1 - /T - 3 . * pbvjuy at ^atm-rw. ^P/.,f/ ■ i life ... <&fot£4t^M UNITED STATES OFAMERICA. 1H4* ORTHOPEDIC SURGERY. ^HHM^^H MANUAL OF ORTHOPEDIC SURGERY, BEING A DISSERTATION WHICH OBTAINED THE BOYLSTON PRIZE FOR 1844, ON THE FOLLOWING QUESTION: IN WHAT CASES AND TO WHAT EXTENT IS THE DIVISION OF MUSCLES, TENDONS, OR OTHER PARTS PROPER FOR THE RELIEF OF DEFORMITY OR LAMENESS?" BY HENRY JACOB BIGELOW, M. D " Eripiunt omnes * * ** * * sine vulnere nervos." Otid. Remed. Amoris, V. 147. BOSTON: WILLIAM D. TICKNOR &, CO CORNER OP WASHINGTON AND SCHOOL STREETS, MDCCCXLV. — 9 N rP CO 5 bo L © H "5c p O fee 2 as h3 P - Pa< 3 partly open ~f> p* p ,p 02 rQ s P* "c3 p 1-1 ■1* STAMMERING. 51 (1.) The letter v though formed between the front upper teeth and the under lip, is identical with the sound produced by a slight separation of the lips ; as in the Spanish Habana, pronounced like the English Havana, though formed by the lips. In the latter case, it is somewhat exaggerated. (2.) Were the palate flat, it is probable the sound th would be produced by the position of the tongue which now forms 5 ; to avoid which, its extremity is advanced to the teeth. (3.) The concavity of the palate, with the similar opposing one of the tongue, produces the whistling s and z, A short distance farther back it is more diffused, and becomes the hissing sh, and French j, as mj arret. (4.) That r is a vibration, is shown in its exag- geration in the Italian language ; thus giorno ; aver for avere. (5.) L is an irregular sound, produced by a partial but firm interception of the current of sound, by the tip and edge of the tongue applied to the palate. (6.) Ch in the German nacht, is perfectly analo- gous to ph and th in English. It will be seen that this table refers only to the enunciation of the consonants, which may be con- sidered as the interruptions and interceptions of the vowels, and therefore more immediately concerned in the defect of stammering. The original sound produced by the vocal chords, is modified, but not intercepted, during the production of a vowel. A 52 STAMMERING. complete interruption occurring after the sound has left the larynx, forms a consonant. If stammering, in its common forms, be a spas- modic contraction of the muscles concerned in the mechanism of articulation, it is probable, although direct proof is wanting, that it may exist at either of these four points, and that each may be the seat of a variety of the affection, which it becomes im- portant to distinguish from the rest. Some indica- tion of the character of the affection, may be drawn from that of the sounds emitted. But this is an uncertain test. An anterior portion of the mechan- ism, if deranged, will be liable to interfere with that behind, and vice versa. Thus p masks t, and t interferes with the articulation of p. When in confirmation of these views, w T e consider the dif- ferent degrees of this affection, from the simple lisp, to the confirmed stammer accompanied with dis- tressing convulsions of the whole countenance, it is evident that the lesion is a complicated one, and that in its different forms, it demands a different treatment. We cannot but wonder at the temerity of surgeons, who when the patient stammered, at once condemned him to the knife, and indifferently divided the genio-glossi muscles, or subjected the entire tongue to a bloody bisection, with a vague intention of modifying its nervous condition. An adjustment of the machinery of articulation, can be based only upon a thorough analysis of its complicated action. An outline of this analysis may be found in the foregoing table, and such must be the HISTORY. 53 groundwork of any future efforts to identify the dif- ferent forms of this affection. The remainder of this article, will be devoted to an account of the different operations, which have been of late years practised in this affection. HISTORY. • The French Journal des Debats of January 2d, 1841, contained the following original announce- ment at Paris, of the operation of Dieffenbach. " We read in a German paper, that a discovery of Professor Dieffenbach, excites at Berlin, general attention. This surgeon has found the means of curing stammering by an incision of the tongue. The operation he has performed, has completely succeeded. According to Dieffenbach, stammering arises from an impossibility of applying the tongue to the palate. His method consists in putting an end to this inconvenience." These indications were not lost upon the French surgeons. Some of them laid claim to previous ver- bal suggestions of an operation. Others, adopting the principles hinted at by Dieffenbach, sought to discover his method ; and hence resulted what is known as the French operation. It was announced nearly simultaneously by Amussat, Phillips, Baudens and Velpeau. It subsequently appeared, however, that the surgeon of Berlin employed a different me- thod. With the intention at once, of enabling the patient to antagonize the tongue with the roof of the 54 STAMMERING. mouth, and of " changing the innervation," he prac- tised a deep transverse section, sometimes with loss of substance, at the root of this organ. The French method had reference only to the liberty of the tip of the tongue, and consisted in the division of the genio-glossal muscles and other parts beneath. The different French operations are essentially the same, and the literature upon this subject re- lates chiefly to the operation, and is, for the most part, polemic in its character. METHODS OF DTEFFENBACH. The theories upon which DiefTenbach founded his operation, are explained in the following quota- tions. 1. " Shortening of the muscular substance" 1 It is especially upon this last method, (excision of a piece of the tongue,) " that I have founded the great- est hope ; because it had for its result, the shorten- ing of the tongue, and enabled it to touch the su- perior wall of the buccal cavity ; a movement, the developement of which is especially sought." * * * (P. 436) " The patient, after operation, has a sen- sation of a shortening of the tongue, and of an elevation of the point against the palate." 2. Change of Innervation. " As I thought that the derangement in the mechanism of language i Dieff. in the Annales de la Chirurgie Fran^aise et Etrangere. Paris, 1841. t. i. p. 422. METHODS OF D1EFFENBACH. 55 which produces stammering, had a dynamic cause, which I regarded as a spasmodic state ^of the air tubes, which resided especially in the glottis, and which was communicated to the tongue, to the muscles of the face, and even to the neck, I ought to conclude that, by interrupting the innervation in the muscular organs, which participate in this anormal state, 1 should succeed in modifying it, or in causing its complete cessation. " It is for this reason that the transverse section of the muscular substance of the tongue, seemed to be an enterprise worthy of being attempted, and of which the success seemed to be infallible ; like the efficacy of the transverse section of muscles, in a great number of spasmodic affections." To accomplish these ends, Dieffenbach employed successively, three different methods. 1 . A horizontal transverse section of the root of the tongue. 2. A subcutaneous transverse section of the root of the tongue, preserving the mucous coat. 1 3. A horizontal section of the root of the tongue, with excision of a triangular piece, in its entire breadth and thickness. A. Method of Excision. The patient is seated, his head supported against the chest of an assistant. The tongue is protruded and seized upon its edge, by the teeth of a " pince de Museux." Thus laterally compressed, it gains in thickness, a con- 1 Lettre a l'Acad. Roy. des Sciences ; printed at Berlin. 56 STAMMERING. dition favorable to the operation. Being then car- ried forward and a little to the right, by one aid, while another draws apart the angles of the mouth with blunt hooks, the root is seized by the thumb and fore-finger of the operator's left hand, laterally compressed, and raised. The blade of a bistoury, edge upward, is entered at the left side of the root, penetrates to the opposite surface, and cuts its way out from below upwards. The posterior edge of the wound being fixed by a strong suture, the ante- rior border is seized with toothed forceps, laterally compressed, and cut off with a narrow bistoury. The piece thus removed is wedge shaped, the base about three-fourths of an inch in breadth, correspond- ing to the mucous surface, and has been compared to a slice of melon. The posterior edge is then brought forward by means of the suture and a small hook, and united to the anterior edge by six strong points of suture, which, traversing the bottom of the wound, impede hemorrhage. In subsequently removing the first ligature, if it be followed by an oozing of blood, it is an announce- ment that the cicatrization is not yet solid, and the surgeon should desist. This fact, and the manner of arresting the hemorrhage by deep sutures em- bracing the mass of the tongue, may serve as hints for other operations upon these parts. B. The Simple Section of the root of the Tongue resembles the preceding method, without the re- moval of the wedge shaped mass. C. Subcutaneous Section of the root of the FRENCH OPERATION. 57 Tongue. In this operation, the upward section terminates, before dividing the mucous coat upon the superior surface of the tongue. DiefFenbach thus speaks of the dangers of the operation : " The loss of the tongue by gangrene or by ex- tensive suppuration, or even by the want of dex- terity of the assistant who may easily tear it, are considerations which require to be maturely weighed, and which, joined to the difficulties which it pre- sents, will hinder operators of little experience from wishing to attempt it." FRENCH OPERATION. The propositions of the French surgeons em- braced the principal points presented by DiefFen- bach. The conditions supposed to accompany stammering, indiscriminately in all its varieties, are thus enumerated. 1. Slight deviation of the tongue to the right or left. 2. Impossibility of pressing the tip of the tongue against the upper lip, without the aid of the lower jaw, which advances to support it. 3. Spasmodic agitation of the tongue during the act of phonation. To these Velpeau, Amussat, and others, added a fourth proposition. 4. A remarkable developement of the genio-glos- sal muscles, the frenum being strong and hard. 8 58 STAMMERING. The division of these muscles is the aim of the French operation. The different methods are sub- joined. Method of Phillips. The patient is seated, as in the operation of Dieffenbach. The surgeon seizes the frenum at its angle of reflection upon the tongue, with a hook, bent at right angles, that it may not impede his subsequent manipulations, and confides it to an aid. He then implants a second small hook in the frenum, at a half line distance from the ducts of Wharton, and between the two hooks, divides largely the mucous coat, with scis- sors. Laying aside the scissors, he introduces by the wound, a blunt hook edged upon its concavity, and collecting upon it " all the muscular mass of the tongue," divides it with a sweep of the instru- ment. Phillips, it is seen, severs the muscle near its fanlike expansion in the tongue. The other methods deal with a point nearer the jaw, where the muscle is less voluminous and less vascular. Methods of Velpean. 1. The tongue is held by the left hand, armed with a linen, and drawn aside. A puncture is made with a lancet, at the right of the frenum near the under jaw. A tenotome is plunged in the aperture, to the depth of three-fourths of an inch, and the genio-glossal muscles are divided, without enlarging the incision of the mucous mem- brane. 2. In another case the section was made with scissors. FRENCH OPERATION, 59 3. In a third patient, M. Velpeau removed a tri- angular mass from the point of the tongue, and the wound was brought together by sutures. 4. In a fourth, the anterior pillar of the velum palati, which contains the palato-glossus muscle, was divided, but without success. 5. At a subsequent operation, this surgeon stran- gulated by ligature a mass, resembling in size and position, the wedge removed in the operation of Dieffenbach. The tongue being drawn forward, was traversed at its root by a needle, armed for strength with four threads. Two were tied over the back of the tongue. The two others were tied in the same way, a little in advance of the first, thus insulating a portion of the tissues, which sub- sequently sloughed away. Method of Amussat. The surgeon first divides the frenum, with the mucous membrane on each side, and the salivary glands, avoiding the ducts of Wharton. If no advantage is gained, the genio- glossal muscles are divided near the apophyses. If, during this process, the tongue be thrust for- ward and upward, the muscles spontaneously offer themselves for section, and are easily divided with knife or scissors. Of Baudens. This surgeon employs pointed scissors bent at an elbow near the pivot, like Roux's scissors for the operation of staphyloraphy. Slightly opened, they are thrust to some depth astride the genio-glossal muscles, which are then divided at a 60 STAMMERING. single stroke. The genio-hyoid muscles are some- times included in the section. Of Lucas of London. The mucous membrane and cellular tissue, are dissected to the extent of an inch, in the method of this surgeon, for the purpose of exposing and avoiding the ranine arteries, the large veins, and a branch of the lingual nerve, which borders the outside of each muscle. The muscles are divided, and a triangular fragment whose base corresponds to the surface, is detached. Subcutaneous Operation. M. Bonnet has pro- posed a puncture beneath the chin, at the distance of an inch behind it. A tenotome is introduced, and thrust upward, its edge toward the bone. When it is perceived beneath the mucous mem- brane, the surgeon feels for the insertion of the genio-glossal muscles, and cuts to the right and left. By keeping the edge of the tenotome against the jaw, and acting only upon the superior part of the convexity of the bone, upon a median line, the insertions of the genio-hyoid muscles are avoided. ACCIDENTS AFTER THE OPERATION. Hemorrhage. The vascularity of the parts, the size of the incision, and the difficulty of command- ing the bleeding vessels, are conditions which give rise to formidable hemorrhage, with difficulty arrest- ed by means more painful than those employed to remedy the stammering. It is obviously difficult to amass evidence upon this point. At a time when ACCIDENTS AFTER THE OPERATION. 61 surgeons emulated each other in reporting success- ful results from the operation, various motives in- duced misrepresentation. But the danger of hem- orrhage is not altogether concealed. DiefTenbach says of his own subcutaneous method, " The blood gushed with abundance from the two lateral wounds, as if it escaped from a large arterial trunk ; and the tongue soon became tumefied, by the mass of blood which accumulated in the interval of the sub- cutaneous section." The books allude to a student at Berlin operated upon by this surgeon, who died from the profuse bleeding attendant upon the opera- tion. Phillips says of this method, "It is surrounded with too many dangers to be retained in practice. The hemorrhage is always very abundant, and we possess no means to arrest it, unless by a second operation, more painful and more cruel than the first." And in another place, " The hemorrhage which follows this operation is of long duration ; and I felt the greatest anxiety, after having operated upon a young man of Liege. The section of the muscles was made at eleven o'clock in the morning. At eight o'clock in the evening, the blood still gush- ed, as from the mouth of an open artery." Again, " I have seen patients, in my practice, lose blood seven or eight hours after the operation, without the possibility of arresting it." M. Guersent, surgeon of the Hopital des Enfants, has published a remarkable case of this kind, in which the patient, a child of twelve years, was pre- 62 STAMMERING. disposed to hemorrhage. After the operation, by Amussat's method, the hemorrhage commenced, and was renewed at intervals for ten days. During this time every means were employed to arrest the bleeding ; styptics, balls of charpie, cold lotions, and finally the actual cautery, which was renewed seven times. At the end of ten days the patient presented a state of almost complete anemia, from which it slowly recovered. At the end of three weeks, the child stammered as before, the tongue being much shorter after the operation. The bleeding is promoted by the inclination which patients have, to suck blood from the wound. The hemorrhage should, in common cases, be treated by the injection of iced water; tamponne- ment ; plugging with balls of lint, wet with alum or some other styptic solution. In the operation of DierTenbach, the bleeding is impeded by deep sutures, which are drawn tight, thus compressing the mass of the tongue. The hemorrhage is usu- ally arrested, by the formation of a more or less voluminous clot, w T hich should not be disturbed. Phillips alludes to two cases of obstinate hem- orrhage, following the removal of the coagulum. Tumefaction of the Tongue. The enlargement of the tissues, often considerable during the in- flammatory action, is sometimes such as to hazard the life of the patient. 1 " Everybody knows the deplorable story of 1 Phillips, Tenot. sonscut, p. 392. ACCIDENTS AFTER THE OPERATION. QS a young man operated upon, whose tongue ac- quired a considerable volume. It formed upon the lower wall of the mouth a vast valve. During the night, the symptoms became more and more alarm- ing, and the result was finally enveloped in a pro- found mystery. How many other examples have had the same fate ! " In the Gazette des Hopitaux, (Juin 1, 1841,) M. Amussat has avowed one case of death. The subject had been operated upon, in presence of a commission named by the Academy. The same journal contains also the history of a man who came near dying of asphyxia, by the enlargement of the tongue. The tongue, left to itself after the section of the genio-glossal muscles, exercises a great force of re- traction, and has a tendency to turn back upon the glottis, an accident which it has been shown may be fatal. A similar accident is to be apprehended from the posterior portion of the tongue, in the transverse dorsal incision of Dieffenbach, and hence the care requisite to secure it during the operation, by means of a suture or a hook passed through its substance. APPRECIATION OF THE DIFFERENT METHODS. In estimating the comparative value of the differ- ent methods, a first ground of comparison, unques- tionably the most important, is their efficiency in relieving the imperfection of articulation. The 64 STAMMERING. inadequacy of the operation in a majority of cases seems generally to be conceded. It has been shown theoretically, that in its application to a part only of the articulating machinery, it is incomplete. But such an avowal is not to be looked for in papers upon this subject ; the aim of most of which is to herald the success of a new operation, and to give noto- riety to its advocates. To this remark there are exceptions. DiefFen- bach considers the operation inapplicable in certain cases, and allow r s that in what concerns the indica- tions of the operation, they are much more difficult to determine than in the operation for strabismus. Of the French operation, Phillips thus speaks. " Among true stammerers, there are some who re- double the 6, p, d, t, and who pronounce for ex- ample b, 6, b, 6, a, &c. These may be improved by the section of the genio-glossi, but not radically cured ; the lips play a too considerable role in the articulation of this letter. Those who redouble the t, and the a, may be radically cured by the sec- tion of the genio-glossi, if there is not at the same time some defect in the respiration. Stammering upon s and z may be also diminished by the opera- tion ; but if it bears upon the h, k, and m, the opera- tion is without effect. I have never, up to the present day, been able to appreciate the least change upon these letters after the operation." These observations are cited, as confirming the analysis of sounds laid down by the writer in the beginning of this article. APPRECIATION OF THE DIFFERENT METHODS. 65 The articulation of the consonants mentioned by Phillips, as affected by the section of the genio- glossi, will be found referred in that table to the tip of the tongue, and consequently directly influ- enced by the liberty of that part of the organ. M. Chassaigne, 1 another writer upon this sub- ject, in opposing this theory of Phillips, cites a case in which the pronunciation of the sentence " Maman m?a mande" was facilitated by the sec- tion of the genio-glossi. It is probable that in this case the affection existed, not in the labial muscles, but in those of the tip of the tongue, the spasmodic action of which, masked or impeded the labial ar- ticulation. Such mistakes have arisen from an insufficient study of the varieties of the affection. In most reported cases, it sufficed that the patient was unable to articulate certain test words, like those alluded to, or " Kakoski, Colonel des Cos- saques" "hippopotamus ," " concupiscence ," and he became a subject for the operation, according to the method then in vogue. If after this lesion of the buccal cavity, the spasmodic action of the mus- cles ceased for a time, the operation was proclaimed satisfactory in its result. Such has been the opera- tion I have often witnessed in the Paris hospitals, and such are the majority of printed observations. Authors seem to allow to Dieffenbach, a greater share of success than to other surgeons. No means of estimating the value of his assertions upon this 1 Trait6 du Strabisme et du Begaiement. Paris, 1841, p. 140, 9 i3 STAMMERING. point are at hand. It is however difficult to give full credit to statements like the following. 1 " I have within a short time operated upon fourteen stammerers, in removing a triangular piece of the tongue, and in all, the stammering has entirely ceased." It may be suspected that at the end of a longer period it returned, at least in some of the cases. It is easy to imagine that in promiscuous opera- tions upon the different varieties of the affection, the section of DiefFenbach, which involves all the lingual muscles, should more readily alter the func- tional conditions of the tongue, than the division of the genio-glossi alone. But if the division of muscles be its object, this method attacks indiscrim- inately the interweaving fibres of all the fasciculi, without bearing directly upon the body of either of them. On the other hand it is difficult to establish how far it may alter the innervation of the part ; neither is this proved to be the essential end of the operation. If the previous length of the lingual surface interfered with the power of opposing the tip to the palate, the removal of a portion of the dorsum might tend to obviate this difficulty ; but much less directly than the division of the genio- glossal muscles. Until the applicability of the German operation be clearly indicated, and its efficacy shown, the profuse and dangerous hemorrhage, the tumefac- tion, and other inflammatory accidents to which it is liable, are insurmountable objections to it. 1 Dieff. Gazette des Hopitaux. Mars. 18, 1841. STATISTICS. 67 The same is true in a less degree of the French method, which however probably applies to a greater number of cases, and is less objectionable, when the point of section approaches the jaw-bone, as in the subcutaneous section of Bonnet, which is confined to the tendinous insertions of the muscles. The analogy of this method to the simple section of the frenum in tongue-tied children is obvious'. It is sometimes employed with advantage where the tongue is not confined, where the spasmodic condition of the genio-glossi muscles can be clearly demonstrated. The method of Velpeau, by ligature, offers a smaller chance of hemorrhage, but is even more sub- ject to violent inflammatory accidents. The removal of a triangular mass from the anterior part of the tongue and from the genio-glossal muscle, the divis- ion of the genio-hyoid and other equally fanciful sections, are evidently experimental. Authentic statistics of the results of these differ- ent operations will not be expected, when the unscientific character of most of the papers upon this subject is considered. The following results, those of Dieffenbach ex- cepted, refer to the French method. M. Baudens says, " we count at this time twenty-one persons operated upon by our method. All have obtained, if not an absolute cure, a notable amelioration." It is sufficient to add, that of strabismus, the same author remarks, " of eight hundred squints that we have operated upon, * * * in every case we have 68 STAMMERING. succeeded ; let skeptics put us to the test ; let them give us the most desperate cases, and when we have failed once, we will yield to the evidence." Such assertions need no comment. Dieffenhach has been elsewhere quoted, " four- teen cases operated upon, among all of whom the stammering has entirely ceased." Chassaigne, among seventeen cases, gives seven cured, five ameliorated, and five without beneficial result. Finally, Phillips concludes his essay as follows : " of one hundred individuals speaking badly, called improperly stammerers, we find only five subjects really stammering ; and these alone are fit to be operated upon with success. Of these five individ- uals, we count two or three who stammer only upon the lingual letters. In these cases the opera- tion is brilliant in its results ; the stammering ceases entirely. The two others stammer upon linguals and labials, and then the operation affects the stammering of the linguals alone, and hardly modifies the stammering of the labials. " I have seen in the service of M. Velpeau a case of brilliant success, after an operation upon a sub- ject who stammered, i. e. redoubled the linguals. " The ninety-five other individuals do not stam- mer, but speak badly ; either because they shut the mouth in trying to talk, or because they do not breathe, or because they cannot or do not know how to make use of the tongue to aid articulation, or finally because they have nothing to say." TENOTOMY. The division of tendons is an operation of ancient date. Tulpius, in 1685, refers to Isacius Minim, as having practised it. It was at that time consid- ered a grave and dangerous operation, and de la Sourdiere in 1742, terminates a memoir in the fol- lowing words. " The section of tendons ought then to be avoided." In 1782 or 1784 Lorenz divided the tendo-Achillis at the request of Thilenius, a physician of Frankfort ; and Michaelis soon after effected, though incompletely, the same section. Until recently, it was the custom of surgeons to incise the integuments with the tendon, the severed extremities of which were freely exposed to the air. In these conditions, the divided tendinous surfaces remain for a length of time pale. Slowly they be- come vascular, granulate, until the vegetations fill the surrounding void, and finally heal, with a dense 70 TENOTOMY. firm cicatrix, which involves cellular tissue, apon- euroses and integuments. The sliding of the ten- don is thus impeded, and in its restricted move- ments, it bears with it the surrounding and adher- ing tissues. The restorative process is in such cir- cumstances tedious ; and the constitutional reaction, and consequent hazard to the patient considerable. At the present day, the division of tendons is a trifling operation, and almost divested of danger. Delpech first proposed a section which should not denude the tendon. A bistoury was passed beneath the skin, which it traversed at two points, as if for the passage of a seton. The incision was extended to the length of about an inch, and the tendon was divided. Stromeyer and before him Dupuytren, according to Velpeau, indicated the method by simple punc- tures. The latter surgeon confined himself to a single orifice, which gave admission to the instru- ment, taking care not to wound the integuments of the opposite surface. This is essentially the method of the present time, and the most simple which sci- ence now possesses. It has undergone two modi- fications, referred respectively to Stoess and Bouvier. In the method of Stoess, the knife is introduced beneath the tendon, which is divided from within outwards. Bouvier enters the instrument beneath the skin, and divides the tendon from the surface towards the deep seated parts. The field of subcutaneous operations, effected by a simple puncture of the integuments, and applied DIVIDED TENDONS. 71 to muscles and aponeuroses as well as tendons, has been widely extended by various surgeons ; among whom Dieffenbach and Guerin are conspicuous. The exclusion of air, is the aim and characteristic of this method. A degree of vitality is thus retain- ed in the injured parts, and even in the effused blood, which favors in a remarkable manner their restorative action. The functions of absorption and secretion are carried on with a rapidity, to which the presence of the atmospheric fluid seems fatal. An entirely new class of operations by this method, has sprung into existence, to which the remainder of this paper will be devoted. SUBCUTANEOUS CICATRIZATION OF DIVIDED TENDONS. It is well known that a tendon, when divided beneath the skin, is disposed to retract, leaving an interval between its extremities, at the point of sec- tion. In most cases the interval is obliterated, and the continuity of the tendon reestablished, by the gradual deposition of an intermediate fibrous tissue. Observers differ with regard to the manner in which this tissue is formed ; and experiments have led to apparently opposite results. Stromeyer, in attributing the deformity of certain club-feet to muscular contraction, asserts that the length of the newly formed tendon, which he com- pares to a thick ring, is alone insufficient to account for the redressment of the deformity ; and supposes 72 TENOTOMY. that the muscle, once relieved from the stimulus of tension, elongates itself, until the divided tendinous surfaces are brought into contact. On the other hand it may be urged, that the interposed mass is often considerable. In one experiment of Bouvier, its length was nearly two inches at the end of twenty-four days. It is possible that the tendi- nous end, enlarged at its point of union with the newly deposited matter, may have been mistaken by this surgeon, for the entire substance of the cicatrix. One class of observers, among whom are Held and Bouvier, suppose that the tendinous sheath, with its surrounding cellular tissue, undergoes a gradual transformation into fibrous matter, with agglutination of its walls, and obliteration of its cav- ity. Others, leaning to the theory of Hunter, assert that the cavity of the sheath is a receptacle of blood and of lymph, which is afterwards organized and converted into tendinous fibre. Such, are Amnion, Guerin, Phillips, Duval. The result of the detailed experiments of Bou- vier x on one side, and Amnion 2 on the other, ren- der it probable that the restorative action varies in different circumstances, and accommodates itself to the pathological conditions of the parts. In the ex- periments of Ammon, the effusion of blood was con- stant ; and was probably due to a laceration more 1 Mem. de l'Acad. Roy. de Med. t. vii. 2Exper.,t. I., p. 155. DIVIDED TENDONS. 73 or less extended, of the fibrous envelope and sur- rounding cellular tissue. This hemorrhage was of rare occurrence in the cases of Boavier ; and we infer that care w T as taken to divide the tendon, with- out injury of the neighboring parts. Whether with Guerin we consider the effused coagulum to be a condition essential to the process of restoration, or with Velpeau view it as an accidental complication, it is evident that such a body of fibrin, interposed between the divided tissues, must modify the pro- cess which nature sets up where no such foreign body exists. The experiments alluded to, seem to establish the following propositions. When the fibrous sheath is little injured, and when there is a free communication between the divided ends of the tendon, the tissue of the sheath becomes dense and indurated by the deposition of fibrous matter, and layers of cellular tissue are suc- cessively impacted upon its exterior. In the mean time, its cylindrical cavity, strangulated at the cen- tre, gradually contracts ; lymph is exuded in its in- terior ; the extremities of the tendon assume a coni- cal form, and uniting with the sheath, the whole mass finally acquires the character of a dense fibrous cord. But when the surrounding tissues are divided, and a coagulum is deposited in the wound ; when, instead of the fibrous sheath ready at hand, to be converted into tendon, a foreign body, as it w r ere, is interposed between the divided surfaces, the 10 74 TENOTOMY. process of restoration is different. While the wounded surfaces exude lymph, the coagulum plays the chief part in the formation of the new tendon. It becomes gradually organized. Its substance is penetrated with vessels, which, in their turn de- posite plastic matter, until the severed extremities are at length united by a few filaments. These increase in size, acquire a compact texture, and are fused in time into a fibrous resisting mass. GENERAL CHARACTERS OF DEFORMITY. It is probable that all congenital distortions of the trunk and limbs, are the result of muscular contraction, originally induced by an affection of the nervous centre or its branches. At the period when the surgeon is called to operate, it is no longer active, and he deals only with its results, as presented by certain modifica- tions of the muscles, fibrous tissues and vessels. The original affection, being a spasmodic action of the muscular fibre, has received from Guerin the name of contraction ; wrrle the consequent and permanent lesion, as exhibited in the partial or en- tire change of the muscular into a fibrous tissue, has been called by the same writer, retraction. 1 The duration of the state of simple contraction is in- definite ; and during this period, the soft parts may 1 To this condition. Little has applied the term, " structural short- ening.' Lancet, Dec. 9, 1843. p. 39. GENERAL CHARACTERS OF DEFORMITY. 75 be elongated by proper means. But the fibrous change is attended with rigidity, unyielding in pro- portion to the extent of the transformation. Most cases of club-foot present these characters, and date either from foetal existence, or from some convulsive affection of early life. Their leading and distinctive feature, is a tenseness of certain tendons, which become especially evident beneath the integuments, when an attempt is made to cor- rect the deviation. They are then rigid and salient, and manifestly interfere with the normal position of the limb. Retracted muscles are generally found upon dis- section, to be pale, atrophied, and partially con- verted into fibrous tissue. They are more or less completely paralyzed, and their developement has been arrested. The fatty transformation is more rare, and of less importance to the surgeon. It has been doubted whether it be possible to detect this lesion through the integuments. When it interferes with the restoration of the limb to a normal posi- tion, it is generally more or less combined with the fibrous change. Guerin has laid down two rules, with regard to the change which the muscles undergo, when thus permanently contracted. 1. In all chronic deformities, the muscles, instead of continuing their primitive relations with the distorted portion of the skeleton, tend to become shorter, and to direct themselves in a straight line, between their two points of insertion. 76 TENOTOMY. 2. The transformation of muscles is fatty or fibrous ; fatty, when the muscles are compressed, and left to themselves ; fibrous, when they are sub- mitted to exaggerated traction. 1 The tendons and ligaments seem rather arrested in their developement, than changed in form. In a state of repose, the fibrous cords become more compact, and are not unfrequently changed into bony matter. Guerin supposes that this osseous deposition only occurs, when the muscles become fatty ; but the position has been disputed by other surgeons. The arteries do not follow the muscles in their deviation. They are neither shortened nor tense and straight. " They accompany the muscular curves when they are attached to these muscles, and become tortuous when free ; the more so as the distance they traverse is more limited." 2 The nerves tend to diminish in length, and to adapt themselves like the muscles, to the cord of the curve produced by the deformity. This dispo- sition to retract, is attributed by Guerin to the fibrous tissue of the neurilemma. The veins dilate and increase in number ; modi- fications, supposed by Guerin to explain the fatty transformations of the tissues in general. The tendency of the skeletons of deformed limbs to exude a greasy matter is well known. 1 Vues. Gen., etc. p. 23. Paris, 1840. 2 Op. cit. p. 25. INSTRUMENTS AND MANUAL. 77 INSTRUMENTS AND MANUAL OF THE OPERATION. The instruments contrived for subcutaneous ope- rations are exceedingly numerous, and the more important ones will be alluded to in another place. Many of them offer useless complications and re- finements. The sections may all be effected with one or two tenotomes. The most useful consists of a blade, about an inch in length by one eighth of an inch wide, pointed, and slightly convex. At- tached to a short cylindrical shank, it serves to divide the larger tendons. Probe pointed, straight on its edge, and with a longer shank, it may be used for the broad or deeper-seated fibrous tissues. (Figs. 8, 9.) The tension of the tendons, is by far the most important of the indications for their division. When it is ascertained that their retraction inter- feres with the normal position of the part, it is expedient, as a general rule, to divide them ; be- ginning with the most rigid and salient. The manual of the operation is briefly as follows. The region being placed in a convenient position, the tendon to be divided is made tense, and if pos- sible evident, beneath the integuments. This is effected either by the position of the patient, by voluntary contraction of the muscle, or by external force properly directed. Guerin pinches up, immediately over the tendon, a fold of skin, one end of which is confided to an 78 TENOTOMY. aid, and introduces the tenotome flatwise at its base. He then releases the integuments, and the puncture recedes to a distance from the point of section, while the blade retains its position near the tendon. The tendon is now made tense by active or passive flexion or extension, and divided by a slight sawing movement of the knife. It is unimportant whether the section be made from without, or within the tendon, if there be no especial indication, such as the neighborhood of large vessels, to guide the operation. A place of section should be chosen, where the tendon is sur- rounded by cellular membrane. It is rarely possi- ble to obtain union, in the cavity of a synovial sheath ; and permanent deformity has resulted from division of the tendon in this position. At the moment the section is completed, a noise is heard as the two ends suddenly recede from each other ; modified and exaggerated, if it be near the region of the thorax. The instrument is with- drawn as it was entered, the integuments being compressed as the knife recedes, to hinder the ad- mission of air. As the blade leaves the puncture, the finger arrives at and covers it, until it is effec- tually sealed by a bit of adhesive plaster. HEMORRHAGE. If the hemorrhage be considerable, a tumor occupies the seat of the effusion, and the blood is to be expelled by the puncture as far as practicable. MECHANICAL TREATMENT. 79 It is more frequently distributed in the cellular membrane, and left for subsequent absorption. Alarming hemorrhage is rare, as the larger vessels are not involved in the operation. In some experiments of M. Amussat, which I saw at the Abattoir Montmartre, the open vessel, even when of considerable size, if completely divided, occupied the centre of a coagulum, the walls of which acquired such tenacity, as to confine the fluid nucleus, and arrest the effusion. 1 In deep sec- tions additional security is offered, by the flexibility of the vessels, which yield to the edge, while the resisting tendon is divided. Hence it is better in such positions, to avoid as far as possible the saw- ing movement of the instrument, and to divide the tendon by force perpendicularly applied to it. MECHANICAL TREATMENT. It is now generally allowed, that an immediate application of mechanical force is not indicated. Inflammation, re-opening of the puncture, admission of air and suppuration, were not unfrequently the sequence of the operation in past years. These accidents have become less common, since atten- tion has been directed to the cicatrization of the integuments, before beginning the mechanical treat- ment. i These results have been since generalized, by farther observa- tions upon hemorrhage in the human subject. Amussat. Common, a VAcad. des Sciences. Oct. 28, 1844. 80 TENOTOMV. The principle of the various machines contrived for this purpose, is simple. Their object is to direct and maintain a permanent effort, against the curve of the deformity. A separate part of the appara- tus is adjusted to each detached portion of the skeleton, while the centres of movement of the machine, correspond to the articulations, and are fixed by ordinary mechanical expedients, such as a ratchet-wheel, rack and pinion, or best by a per- petual screw. (Figs. 16, 17, 18.) Of mechanical treatment without division of the tendon, little need be said. It is often efficient in infancy, and in certain cases of spasmodic and of slight deviation. But in a common case of chronic deformity, two elements oppose the return of the parts to a normal condition ; the distortion of the bone, and the tension of the unyielding fibrous tis- sue, which approximates its extremities. In sever- ing these fibres, we remove one of the chief im- pediments to the restoration of the part ; as is evi- dent from the sudden separation of the divided extremities. It has been abundantly proved that, under proper restrictions, the operation is safe, and that while the duration of the treat- ment is abridged, there is less chance of a return of the deformity, than when unaided mechanical treatment is adopted. CLUB-FOOT. Certain rare cases of this distortion result from idiopathic malformation, or other lesion of the bony tissues ; but by far the most numerous class is due to muscular agency. Club-foot has been defined to be the result, " of 1 inequality in the antagonizing muscular forces, and of the permanent retraction of certain mus- cles." CAUSES. Its causes may be considered in two classes, with reference to the period of their influence. 1 ; Con- genital. 2 ; Consecutive. 1. Congenital. Among the probable influences supposed to act during the foetal state, are the fol- lowing. 1 Traits pratique du Pied. Bot. par Vincent Duval. Paris, 1843. 11 82 CLUB-FOOT. a. An intrinsic muscular contraction, due to the agency of the cerebro-spinal system. As the most frequent cause of club-foot, it is by far the most important to the surgeon. It produces a large majority of the cases with which he is called upon to deal. b. The mechanical pressure of the uterine fibres, or the bad position of the child. The first of these causes has been investigated bv Guerin, who considers convulsive muscular con- traction as the essential cause of the congenital form of the distortion. His theory is founded, 1. Upon dissections of foetal monstrosities and deformities, where lesion of the nervous centre or its ramifica- tions was evident. 2. Upon the fact that it often accompanies strabismus and other deformity, man- festly due to convulsive action, in different parts of the system. In confirmation of this position he offers, with other evidence, the following remarkable" observa- tion. Twin infants were affected with double con- genital club-feet, which at the end of six months had assumed a natural position, under treatment. At this time, one of the infants was seized with convulsions, accompanied with a return of the club- feet, which were treated anew with success. At the end of a year, fresh convulsions occurred, and the distortion was again reproduced in one of the feet, though in a less degree. 1 An unequal pressure of the uterus has been as- 1 Etioloorie Generate des Pieds bots congrenitaux. 1843. CAUSES. 83 signed as a cause of fetal distortion ; but this ex- planation admits of doubt. The presence of the water of the amnios would tend to counteract such pressure ; upon which ground Breschet rejects the theory, while Guerin, on the other hand, maintains that a certain lateral, but uniform flattening of the foot, may result from this force. Duval offers a number of observations, tending to show that cer- tain positions of the child during uterine life, may induce deformity. In these observations, the club- foot was accompanied by distortions, which were evidently exaggerations of the natural position ; such as a permanent folding of the arms, the thighs being flexed upon the pelvis. They seem rather to indicate a general tendency to muscular contrac- tion, than a distinct cause of the development of club-foot. c. Guerin discards the doctrine of an arrest of developement, advanced by Breschet, as an original cause of distortion, but admits the influence of this principle as a consequence and aid of muscular retraction. 2. Consecutive. These sources of distortion are more readily appreciated. Among them are, wounds of the leg or plantar surface, blows and sprains. That variety which results from wounds, or from disease of the bones, generally bears marks of the lesion which has provoked the deformity ; and cicatrices and contractions of the integuments, supply the place of the distinctive marks of re- traction. 84 CLUB-FOOT. It is generally allowed that the paralysis of cer- tain muscles may produce distortion, by permit- ting the unopposed contraction of the antagoni- zing muscular forces. The subsequent transform- ation of these muscles, then permanently confines the limb in its new position. The majority of operators advocate tenotomy in such cases, when the distortion materially interferes with the con- venience or comfort of the patient. The deviation once corrected, the traction of the healthy muscles may be counteracted, and the normal position main- tained, by springs, or other mechanical contrivances. In this way the condition of the patient is often very considerably improved. Both in the congenital form, and in chronic cases which result from spasmodic action, occurring at a period subsequent to birth, we meet with the con- ditions of retraction before described. The mus- cular fibre has given place to a more or less fibrous tissue. It has become pale and atrophied ; its developement has been arrested, and the points of its insertion are approximated. Beneath the in- teguments, are found a series of tense, salient cords corresponding in position to the tendons, and es- pecially evident, when an effort is made, to restore the foot to a normal position. VARIETIES. Most authors recognise three varieties of club- foot ; viz : Equinus, Varus, and Valgus. VARIETIES. 85 1. Eqainus. When the heel is drawn towards the calf, and the patient walks upon the toes or metatarsal extremities, like the horse, which gives the name to the distortion. 2. Varus. When the plantar surface is turned inward, and the limb rests upon the outer edge of the foot. 3. Valgus. When the sole is directed outward. To these are added a rare variety called Talus. Here the toes are drawn upward, upon the front of the leg, while the heel alone remains upon the floor. It is directly opposed to Equinus. Modern writers have proposed other divisions. Duval proposes the general term strephopodie (oTQi-cpw-Tzovq) for deviation of the foot, and varies its application by the insertion of the prepositions, tvdov, ££co, vno, a^co, jcdrcu ; — thus streph-endopo- die, — exopodie, — ypopodie, — anopodie, — ocato- podie, for deviation inward, outward, under, up- ward and downward. The division of Bonnet is more worthy of atten- tion. He divides 1 club-feet into two classes. 1. Those forms produced by the retraction of muscles supplied by the external popliteal nerve. 2. Those produced by the retraction of muscles, to which the internal popliteal nerve is distributed. Thus the internal popliteal club-foot includes the varieties Equinus and Varus ; while the external, much less frequent, consists of the different degrees of Valgus and Talus. i Sect. tend. 1841, p. 432. 86 CLUB-FOOT. The amount of distortion is marked by degrees. Thus Dieffenbach divides each of the three ordinary varieties into five degrees. Phillips and Guerin into three. Bonnet subdivides his two varieties, each into five degrees. I adopt the most familiar classification, and shall describe three degrees f each form of the affec- tion. EQLINUS. The first degree of equinus, consists of a direct elevation of the heel from the floor, due to the gas- trocnemii. In the second, this action is exagge- rated, and often complicated by the action of other muscles. In the third, the toes are bent backwards under the foot, and the bony frame-work is more or less distorted. First Degree. The subject walks upon the ex- tremity of the affected foot, of which the toes are more or less extended towards a right angle. The calcaneum is carried upward, and the astragalus slightly dislocated forward. The retracted muscles are those attached to the tendo-Achillis, and occa- sionally the extensor of the great toe. The foot is slightly arched, and shorter than its fellow. It presents upon its plantar surface two callosities, cor- responding respectively to the heel and ball of the foot, the latter being well developed. The toes are elevated, partly by the weight of the body, and partly by the contraction of their tendons. EQUINUS. 87 Second Degree. The mode of walking is an exaggeration of the last ; the foot often inclining to one or the other side, when the muscular tension is unequal. The skeleton presents a similar position of the calcaneum and astragalus, the former of which sometimes touches the tibia, while the ex- tension of the toes, throws the weight of the body upon the articulating extremities of the metatarsals. Besides the retracted muscles of the calf, the extensors, and in some cases the flexors of the toes, begin to appear beneath the integuments. The foot is shorter and broader, the heel and toe being drawn together, as Guerin supposes, by the retracted fibres of both surfaces. Hence also its arched form. The great toe is occasionally raised by its own re- tracted tendon, while the other toes are sometimes flexed upon themselves, in their position of exten- sion. The skin of the plantar surface is wrinkled, and presents a rough callus at the metatarsal ex- tremities. That of the heel, if it no longer touches the ground, becomes smooth and delicate. Third Degree. As the contraction increases, the extremity of the foot gradually passes beyond the perpendicular. The toes are directed back- ward, until the dorsal surface is beneath, and plays the part of the sole. At this period, it is rarely uncomplicated with one of the other varieties. The bones yield to the forcible retraction of the muscles, and to the superincumbent weight. The metatar- sals are curved backwards, and slightly separated from the cuneiform bones. The ligamentous artic- 88 CLUB-FOOT. illations of the tarsus become lax, and the astrag- alus is almost entirely dislocated. The gastrocnemii, the flexors and extensors of the toes, and the plantar aponeurosis, are concerned in this degree of equinus. Lateral complications involve other muscles. The foot has become great- ly distorted. The skin of the sole is thin, while that of the inverted upper surface has become hard and rugous. Flexion and extension are prohibited, and the arched instep exhibits in its cavity the sa- lient and retracted fibres. The toes are often inter- laced, the calf much reduced in size, and the knee somewhat flexed. VARUS. The turning inward of the foot, is characteristic of this complex form. In the first degree the inner edge of the foot is raised from the ground. In the second, the patient walks upon the outer edge, while in the third, the sole is directed upwards, and the dorsum fulfils the functions of a plantar surface. In simple varus, the foot is raised upon its exter- nal edge, while the sole, looking inwards, is directed forwards and backwards. It is rare. Guerin ob- served but seven cases in four hundred club feet ; or less than two in one hundred. l It is more frequently complicated with equinus ; which has led the same 1 Mem. sur. les Difform. du Corps Humain. Paris, 1843, p. 320. VARUS. 89 author to make the divisions of varus, varus equinus, and equinus varus, as the one or the other variety predominates ; each of the two last being subdivided into three degrees. The inward inclination of the foot, is sometimes due to the unaided action of the gastrocnemii, but more commonly results from the traction of other muscles. The distortion of the skeleton may be resolved into two elements ; adduction and extension. Adduction. The astragalus forms a centre, for the movements of the calcaneum and scaphoid bones. The cuboid moves upon the calcaneum, the cuneiform upon the scaphoid, while the toes follow the cuneiform in their progress inward. The calcaneum presents its inferior face to the opposite foot, but its attachments to the astragalus undergo little modification. The cuboid is carried inward wdth the scaphoid, and exposes a small portion of the surface by which it is articulated with the cal- caneum. The scaphoid undergoes a more consid- erable displacement. It is even partially dislocated. Passing inside the head of the astragalus, and de- scending from its upper part, its position is oblique. The head of the astragalus, at its external and upper part, is salient beneath the integuments, while a new articulation is formed upon its internal sur- face. Extension. The pulley glides through its socket, and is exposed in front of the tibia and fibula. A number of new articulations result from this forced extension. The scaphoid, at its superior internal 12 90 CLUB - FOOT. part, comes in contact with the internal malleolus. Behind, the tibia, and finally the fibula, are articulated to the calcaneum. The displaced articular surfaces become gradually ossified. The head of the astrag- alus is depressed internally, and the anterior facette of the calcaneum, absorbed upon its internal surface, becomes oblique. The walk, in varus, is difficult. In the exagge- rated form, the patient often requires a crutch or cane. The skin of the dorsal surface, before it ac- quires a power of resistance, often takes on inflam- matory action at its point of contact with the ground. The knees are inclined inward, and the affected foot swings over its fellow, or describes curves to avoid it. The muscular action is compli- cated. The elevation of the heel is due to the muscles of the calf. The chief agents of adduction are the tibiales, posticus, and anticus. As the foot deviates inward, the tendo-Achillis begins to act in the chord of the arc described by the leg and heel, and exerts an important influence in adduction. The flexor of the great toe now begins to draw, and the foot yielding to the combined action of this muscle and the flexors of the sole, curves upon itself. In other cases, the common flexor of the toes, and the adductor of the great toe, are refracted, and both the flexors and extensors of the foot, acting as adductors, from the change in the direction of their insertions, promote the distortion. The curve of the foot is aided, in this position, by the retraction of its dorsal muscles and the plantar aponeurosis, VALGUS. 91 while the tension of the long peroneal, compresses it laterally. In its later stages, this variety yields with dif- ficulty to surgical treatment. The relations of the bones are much altered, and the shape of the foot is sometimes little modified after section of the ten- dons. In cases of extreme distortion the foot re- sembles a huge fist. The toes are flexed and inter- laced, and the dorsal surface, if in contact with the ground, is occupied by a rough callus. Large and remarkable bursse are sometimes found under the cuboid bone, when the deformity has existed for a series of years. * The now delicate skin of the sole is much wrinkled ; the leg is more or less atrophied, and often permanently flexed upon the thigh. VALGUS. This form, in which the sole is turned outward, is opposed to varus. The first degree, is what has been called flat foot, and is characterized by obliteration of the arch, with occasional retraction of the extensors of the toes. In the second degree, the sole is raised from the ground, and the w T eight of the body is thrown upon the inside of the foot. The third presents different characters, due to the retraction of different muscles. The relations 1 Liston on diseases of the Bursae. Lancet, Oct. 21, 1843. 92 CLUB-FOOT. of the bones of the tarsus and metatarsus are altered. First degree. The skeleton is little modified. The ligaments and muscles which unite the ex- tremities of the arched sole, are relaxed, while in some cases, the retraction of the extensors aid in elevating its anterior extremity. The foot is close- ly applied to the ground, and rotated outward. Second degree. The astragalus is partially lux- ated backward, and the cuboid and scaphoid dis- placed externally. The peroneals and extensors of the toes raise the outer border of the foot, the anterior part of which is carried upward and out- ward, the toes being elevated by their extensors. Third degree. The scaphoid sometimes aban- dons the internal surface of the head of the astrag- alus, which then becomes inarticular. The bones of the tarsus separate one from another, yielding to the retracted muscles. The peroneals, the exten- sors of the toes, the abductor of the little toe, and the accessory muscles are retracted. The metatar- sals sometimes leave the anterior articulating fa- cets of the cuneiform, to take a position upon their superior surface, at an acute angle with the leg. If the tendo-Achillis be also contracted, the pa- tient walks upon the central portion of the sole, with the heel and toes raised. In this exaggerated form, a small surface is applied to the ground, and the skin not unfrequently becomes inflamed and ulcerated. The form of the foot varies with the permanent forces applied to it. TREATMENT WITHOUT SECTION OF TENDONS. 93 It is difficult to imagine that the unaided muscles of the external surface of the leg, should overpower the force exerted by those of the inner side. Gue- rin affirms that a pronounced valgus is an indication of a more or less complete paralysis of the gastroc- nemii, tibiales, and flexor of the toes. Mr. Little suggests that another reason for the greater fre- quency of varus, is the fact that the flexors and ad- ductors are earlier developed in the foetal state, than the extensors and abductors. TALUS. Talus is a name applied to a rare deformity nearly allied to the last, and directly opposed to equinus. The foot is in forced flexion ; and the pulley exposed posteriorly. The retracted muscles are those of the anterior part of the leg and dorsum of the foot. According to Guerin, this affection also implies a paralysis of the antagonizing muscles. The toes are in contact with the front of the leg, and the weight of the body is thrown upon the heel. In all these forms, the original distortion is rather due to the muscles than to the aponeuroses and ligaments, which undergo subsequent retraction. TREATMENT WITHOUT SECTION OF TENDONS. Before the introduction of the subcutaneous ope- ration, it was common to treat club-foot by the unaided force of machines. Although this princi- 94 CLUB - FOOT. pie is still maintained by certain orthopedists, it cannot be deduced from a scientific consideration of the subject. It is now a well established fact, that in certain cases of distortion, the tissue of the short- ened muscles undergoes a fibrous transformation ; and it is highly probable if not equally certain, that this transformation is in proportion to the degree of tension to which the muscular substance has been subjected. In an old case of varus, for example, the leg and foot form a sort of bent bow, of which the ex- tremities are united by a cord of fibrous tissue, which at once becomes tense, when an attempt is made to straighten the limb. It seems obvious, that the first step towards straightening the bow, is to sever the string which aids in keeping it flexed ; and this treatment is in fact indicated, unless it can be shown, either that the operation is attended with danger or inconvenience to the patient, or that unaided mechanical treatment is equally efficacious. Now it is well known that the subcutaneous divis- ion of a tendon, when properly performed, is attend- ed with trifling pain, and that there is little or no chance of subsequent inflammatory accidents. On the other hand, very severe pain often accompanies the attempt to elongate a retracted tendon by simple extension. And while few at the present day will dispute, that the time occupied by this process is much longer, the deformity is liable to re-appear at a subsequent period. It is not here implied that all cases of distortion demand an indiscriminate division of tendons. On TREATMENT WITHOUT SECTION OF TENDONS. 95 the contrary, there are certain cases of recent de- formity, and of disease originating in the joint and not in the muscles, where the tenotome may not be required. In such cases the surgeon should be guided by a knowledge of the original lesion and its effects. If, however, a single rule were required, applicable in a large majority of cases, it should be the following : When in distortion of long standing, while a certain degree of motion still remains in the joint, a tendon evidently hinders the limb from assum- ing a normal position, it should be divided. Upon this subject Bonnet (de Lyon) thus re- marks : 1 " Among children it is often possible to cure club-feet by machines alone, by friction, etc. ; but as, in easy cases, the section of the tendons in- sures success, abridges the treatment, and avoids pain ; as it is, besides, perfectly innocent, I believe that recourse should always be bad to it, unless children are to be treated during the first months which follow their birth. It is then so easy to bring the foot into the normal position, that friction and machines, which, at a more advanced period of life, are only accessories of treatment, are then its prin- cipal feature, and are alone adequate to produce the desired effect." The same distinction is made by Guerin, be- tween the treatment of the conditions of contraction and retraction. 2 1 Traite des Sections Tendineuses, etc. Paris, 1841, p. 567. 2 Vues Generates, 4-c. Paris, 1840, p. 73. 96 CLUB-FOOT. " Simple contraction permits us to hope for the immediate elongation of the muscles, by means proper to effect it ; extension, kneading, (massage) frictions, &c. ; while veritable retraction, shorten- ing with fibrous degeneration, implies the impos- sibility of a return of the muscles to a normal length, or the impossibility of a sufficient mechanical elong- ation, and demands in consequence the aid of a cutting instrument. Thus, recent deformities by contraction, torticollis, flexion of the limbs, may be often successfully treated by mechanical and medi- cal agents, w r hile old deformities by retraction de- mand, peremptorily, surgical means." For simple mechanical treatment, different meth- ods have been devised. In the apparatus of Venel the action is lateral. In varus, for example, upon the external side of the leg, and the internal surfaces of the foot and heel. Delpech employed two machines ; the first, to bring the foot straight, the second, to attain the horizontal position. Dieffenbach and Guerin have employed plaster for the same purpose. The foot placed in a box, is brought as far as possible towards a normal posi- tion, and covered with plaster, which is allowed to set. It is subsequently renewed at intervals of two or three weeks. A small hole broken in the mass, exhibits the condition of the tissues during treat- ment. Guerin especially recommends this method, when the delicate and irritable skin of young sub- jects, refuses to submit to the pressure of bandages. SECTION OF TENDONS IN CLUB-FOOT. 97 The force is equally distributed, while the cuticle is softened by the retained transpiration. Mechanical aid is occasionally useful, for the pur- pose of rendering the tendon tense and salient before section. The apparatus requires continued care, and frequent re-application, especially in infants, where the tissues, compressed by the straps, diminish in volume, and the foot becomes loose. SECTION OF TENDONS IN CLUB-FOOT. Different varieties of the deformity demand the section of different fibrous fasciculi. For the elevation of the heel, the tendo Achillis. For the foot raised upon its outer edge, the tibialis anticus ; turned upon its internal edge, the pero- neus tertius, and all or part of the extensors of the toes. For adduction, the tibialis posticus, for ab- duction, the peronei longus and brevis. For the curvature of its internal border, the ad- ductor of the great toe. For the permanent flexion and extension of the toes, their corresponding mus- cles, both long and short. And finally, when acces- sory to the distortion, the plantar aponeurosis, and any of the tendinous and muscular fibres of the foot and leg. For the different varieties of the distortion, M. Guerin has commonly divided the tendons as fol- lows. For equinus, the tendo Achillis, and some- times the flexor proprius of the great toe. For pure varus, the tendo Achillis, and tibialis posticus. 13 98 CLU3-F00T, For varus-equinus, the tibiales anticus and posti- cus, the tendo Achillis, the extensor proprius and adductor of the great toe, and sometimes the pero- neus longus. For valgus, the peroneus tertius, and the longus and brevis. For talus, the tibialis anti- cus, the peroneus tertius and the common extensor of the toes. And finally, the plantar aponeurosis ; and other muscles, in less common varieties. Before the volume of Bonnet, (de Lyon,) pub- lished in 1841, I believe no writer had minutely described the manner of dividing the different ten- dons of the leg. Operations upon the tendo Achil- lis and tibialis anticus, were already the subject of various memoirs ; but the tibialis posticus, and the peroneals of the ancle, had not at that time been divided upon the living subject, although their posi- tion was indicated by Velpeau, with a view to their section. Duval in his second edition published in 1843, gives certain details upon this point. The manual of the subcutaneous operation has been before indicated in general terms. The ten- don is made salient if possible. A fold of skin be- ing pinched up at one end, between the thumb and finger of the operator's left hand, the other end is confided to an aid, and the tenotome introduced by a simple puncture at its base. The fold is released that the puncture may recede to a distance from the point of section, and the tendon is divided by a sawing motion. Tendo Achillis, The patient commonly lies upon SECTION OF TENDONS IN CLUB-FOOT. 99 the belly, though Dieffenbach prefers a kneeling position. The place of section is of importance. Duval and some other writers, merely indicate a point an inch or two above the calcaneum. The distance evidently varies with the dimensions of the limb, and certain other considerations, but as a general rule, the most salient point should be preferred. While the muscular fibres are to be avoided, above, the want of vitality in the tissues forbids a section too near the bone of the heel. When the tendon is contracted, it sometimes ap- proaches the posterior tibial artery and veins, which we avoid in receding from the heel. Scoutetten describes a bursa mucosa near the cal- caneum, the puncture of which might liberate the synovial secretion, in sufficient quantity to interfere with re-union of the tendon. Authorities are divided upon the direction of the section. Stromeyer, Scoutetten, Duval, cut from the bone towards the surface ; while Bouvier, Dieffenbach, Guerin, and many other surgeons, enter the knife beneath the integuments, and in- cise toward the bone. It is, in general, a matter of little importance whether the section be com- menced upon the anterior or posterior surface of the tendon. When, however, the tendon so nearly approaches the posterior tibial artery, with its ac- companying veins and nerve, that it is difficult to engage it alone upon the blade, it is evidently bet- 100 CLUB-FOOT. ter to cut toward the bone, that the edge may repel the yielding vessels. If a pointed tenotome be employed, it should be hindered from piercing the integuments of the op- posite surface. The safest plan is to employ a blunt tenotome, a puncture being first made with a lan- cet or pointed knife. Most surgeons prefer to make this aperture upon the inside of the heel ; a preference for which no strong reason is offered. The integuments are somewhat more lax, and the tendon is occasion- ally more voluminous, upon that side, while the slender tendon of the plantaris is there more directly beneath the instrument. A fold of the integument being pinched up, and the tenotome being introduced at its base, the foot is extended by the operator, and the tendon, when tense, severed by an alternate movement of the blade. The moment of section is accompanied with a noise, and with the separation of the extrem- ities in most cases, although the bones are some- times so distorted, or other tendons so retracted, that this separation is inconsiderable. The air be- ing carefully excluded, and the blood expelled, as far as practicable, the wound is closed with adhe- sive plaster. The division of other tendons may precede or follow that of the tendo Achillis. Velpeau divides, in the same operation, all the retracted tendons. Phillips, Duval and others, seek to reduce the com- plicated varieties of the deformity to the simple SECTION OF TENDO>- IN CLUB-FOOT. 101 form of equinus, for which the tendo Achillis is subsequently divided. Both methods recommend themselves by their results, but the latter is more generally adopted. Tibialis Anticus. This muscle is best divided at its most salient point, a few lines below the an- nular ligament. Beneath, is the articulation of the astragalus with the tibia and fibula, which might be endangered by too deep a section. M. Bonnet asserts that the division of the tendon of the heel often relaxes this tendon, and obviates the neces- sity of its section. Tibialis Posticus, Certain cases of exaggera- ted distortion, have been supposed to demand the section of this tendon, though the operation is com- paratively rare, and of difficult execution. Behind the tibia, it is enclosed in a sheath, in the neigh- borhood of an artery of considerable size. Some anatomical knowledge is required to reach its posi- tion below the ankle, since it is rarely salient, and its section is unattended with perceptible separa- tion of its extremities. In cases of complicated equinus, when the scaphoid is at a distance from the external malleolus, the following method of M. Bonnet may be adopted. The eminence of the head of the scaphoid being found, the tenotome is entered at a quarter of an inch above, and a lit- tle in front of it, and advanced till it meets the astragalus. The instrument is then slid along against the bone, until its extremity arrives at a point four or five lines beneath the prominence of 102 CLUB-FOOT. the scaphoid. If the edge of the tenotome be now raised until it reaches the skin, the tendon is with certainty divided. This method is inapplicable in the more marked degrees of varus. The extensors of the toes should be severed at their most prominent point, commonly at the artic- ulation of the metatarsals with the phalanges. Peronei longus and brevis. These tendons are enclosed in a fibrous sheath, above or below which they may be divided. Above, they are occasion- ally quite prominent. The position to be chosen below, is about half an inch in front of the ankle, and as was indicated for the tibialis posticus. The surest method consists in introducing the pointed tenotome behind the tendon, and cutting from within outward. This point less endangers the articulation, and allows the instrument to pass free of a protuberance situated upon the external side of the calcaneum. Flexor communis and flexor longus pollicis : The depth of these tendons renders their section difficult, elsewhere than on a line with the first phalanges of the toes. The blade is slid beneath, and advanced to the surface. The short flexors may be included in the section. The Plantar Aponeurosis is often retracted, and requires division. The tenotome should be intro- duced at the inner edge of the foot, where the fibres are in strong relief; commonly at a point near the articulation of the first with the second MECHANICAL TREATMENT. 103 range of the tarsus. The section should not be carried so deep as to wound the articulation. This is perhaps the most painful of these operations. The narrow blade being carefully withdrawn without enlarging the puncture, the blood and any accidental bubble of air are expressed. The finger is kept upon the wound, until a bit of adhesive plas- ter is made ready and applied, so as hermetically to seal the orifice. The foot may be then enveloped for an hour or two with a wet compress, which relieves a local burning pain, sometimes experienced by the patient. A re-division of the tendon is occasionally re- quired during the mechanical treatment, and is in- dicated by the resistance and prominence of the tendon. In this way the tendo Achillis has been unjusti- fiably divided, upwards of twenty times upon the same individual. A twice or thrice repeated section is not uncom- mon, nor is it objectionable. The new division should be effected a short dis- tance above the cicatrix, which occupies the posi- tion of the previous section. MECHANICAL TREATMENT. It has been a question, whether force should be immediately applied after the section of tendons, or whether it should be delayed to a subsequent period. Velpeau gives preference to immediate mechanical 104 CLUB-FOOT. treatment. Duval, while he recommends the foot to be at once placed in a machine, to retain any advantage that may have been gained by the sec- tion alone, deprecates immediate extension. I be- lieve that many of the inflammatory accidents so frequently reported as results of tenotomy, are to be attributed to a too hasty application of force. It may be asserted that a large majority of Euro- pean orthopedic surgeons, follow the example of Stromeyer, and wait for the cicatrization of the puncture, before applying extension to the limb. In this country, this practice was recommended by Dr. Hayward, 1 of Boston, as long since as 1841. At the end of forty-eight, seventy-two hours, or even a much longer period, when the integuments are united, and the tendon has set up a restorative process, force may be gently applied. The adjustment of a machine requires much immediate and subsequent care. A gradual and long continued force, alone will induce the foot to resume its normal position. The foot is unequally covered with tissues, and a slight pressure, even of a strap, a lump of cotton, or a fold of bandage, be- comes painful where the bone projects. This is especially true of thin subjects. The pain is in general dull, though sometimes insupportable. In equinus the great toe and in- step are more frequently the seat of pain, while in the treatment of varus it occupies the external i Bost. Med. and Surg. Journal, 1841, p. 313. MECHANICAL TREATMENT. 105 border of the foot ; is lancinating, and exacerbated by the warmth of the bed. If the pressure be continued, the skin becomes red, hot, and exhibits a gangrenous vesicle, fol- lowed by slough and ulceration. At other times the foot is much swelled, while the limb, especially in scrofulous subjects, becomes more or less cede- matous. When the pain is local and permanent, the appa- ratus should be removed, and the skin, if red, soothed with emollient and narcotic lotions. At the end of a few hours, the machine may be re- applied, the spot being well protected with cotton. In case of an eschar, the ulcer should be allowed to heal, before any attempt to re-commence mechani- cal treatment. The first application of a machine is always in- effectual. The tissues require time to accustom and adapt themselves to their new position. They are impatient of force, or are so depressed, that the foot becomes loose in the machine. When it is necessary to change the apparatus, it is impor- tant to maintain the foot in its new position during the process. If allowed to escape from the hand for a moment, it tends to resume its recent form, a movement accompanied with great pain. The part should be kept cool. During the first ten or twelve days, it is well to examine the apparatus once or twice a day. It is better also to increase extension in the morning rather than the evening, when the consequent pain sometimes hinders the 14 106 CLUB-FOOT. patient from sleeping. A want of attention to these details may involve the necessity of suspend- ing the treatment, when the progress of several days is sometimes lost in a short time. MACHINES. It remains to describe some of the principal ma- chines, employed in the treatment of club-foot. The principles and aim of most of them are the same. They offer different mechanical combina- tions, which belong rather to the mechanician than the surgeon. It is this peculiarity, together with assiduous care required in the use of the apparatus, which has led to the establishment of institutions devoted to the treatment of deformity, and has cre- ated a class of specialists known as orthopedists. The machines may be described as consisting of a series of pieces, each adapted to a corresponding detached portion of the skeleton, and united by joints, the movements of which represent those of the articulations. The apparatus should be capable of conforming itself to the curve of the distorted limb, and is pro- vided with screws, or other mechanical contrivances, for forcibly restoring the parts to a normal position, (figs. 16, 17, 18.) EQUINUS. When the deviation is slight, it suffices, after section of the tendons, to confine the foot in a com- EQUINUS. ] 07 mon boot^the leg of which is of stiff cowhide, and laced in front. The starched bandage is also em- ployed with success for this purpose. If the distortion is great, these methods are in- sufficient, and it becomes necessary to employ a certain amount of force. The machine of Stro- meyer, and the boot of Scarpa, may be regarded as the type of such apparatus, and have undergone various modifications. The Machine of Stromeyer, (fig. 14,) employed by Dieffenbach, consists of two bars of wood, ex- tending from the ham to the ancle, on each side of the leg, and united by cross-pieces at top and bot- tom. A third sliding cross-piece, capable of being fixed by screws, serves as an axis of flexion and ex- tension to a piece of board which corresponds to the sole of the foot. The flexion of this wooden sole is effected by two cords, which, attached to its upper corners, traverse pulleys at the upper part of the parallel bars, and return to a roller governed by a ratchet, at the lower extremity. The calf of the leg rests upon a sheet of leather attached to the parallel bars, and is secured by straps. Scarpa' } s Boot, (fig. 15,) which has been mod- ified by Guerin, Phillips, and others, presents a sort of shoe open at top, and united by straps. At the ancle, it is articulated with two lateral uprights of metal, which are bound to the leg at intervals, by wadded straps. The flexion of this joint is gov- erned by a screw fixed by its extremity to the sole, and passing obliquely to one of the metal uprights. 108 CLUB-FOOT. The sole itself is sometimes jointed, and admits of a lateral movement, which accommodates it to the lateral varieties of club-foot. It is governed by a screw upon its edge. l The machine of Stromeyer is possessed of greater force than the boot of Scarpa, while the latter is more portable. The boot, worn to advantage dur- ing the day, may be replaced by the machine of Stromeyer at night. VARUS. The treatment of varus is more difficult, the re- sistance of the skeleton in the exaggerated forms, being often great. In young children, it sometimes suffices to sever the tendo Achillis, and apply subsequently the starched bandage. For older children, the boot of Scarpa may be employed. Phillips, Duval, and Little, prefer, when the deviation is great, to attack the distortion of adduction, and to convert the form of varus into simple equinus, before dividing the ten- do Achillis. If this method be adopted, the result may be attained in the following way. The leg, w 7 hen the punctures are healed, should be enveloped in wadding which is confined by a roller, (fig. 19.) A long splint, morticed at its extremities, is cush- ioned, and applied to the external surface of the leg, extending from the knee to about six inches 1 Modifications of these joints will be found in the drawings. VARUS. 109 below the heel. The superior extremity is fixed to the head of the fibula by a band, which, after passing through the mortice, is continued around the leg to the heel, and starched. The splint be- ing thus bound to the leg, its lower and projecting extremity serves as a point of attachment to a band, which is fixed by several turns to the end of the foot, and serves to draw it outward. The varus is thus gradually converted into equinus. An ingenious method of Dieffenbach, (fig. 20,) applies to certain cases of slight deviation. The middle of a yard of starched band, looped round the inside of the hee], crossed on the outer ancle and adhering to the calf, tends to draw the heel outward. A similar loop, not starched, is allowed to hang loose a few inches below the inner ancle and sole, and is bound by a roller to the internal surface of the leg. A long splint, terminated by a lateral notch, which is engaged in this loop, is now bound to the external surface, as high as the knee ; and the apparatus is complete. It will be observed, that the splint acts as a lever over the outer ancle, which serves as its fulcrum, to draw the sole out- ward, by means of the loop round its extremity. If the patient walks, the splint is driven upwards and outwards, and the foot necessarily follows it. Among the machines which conform to the devi- ation of the foot, that of Bouvier and Duval may be mentioned. The Machine of Bouvier consists of a jointed sandal attached to a lever, which, acting over the HO CLUB-FOOT. ancle, carries the foot outward, as its superior ex- tremity approaches the leg. The Apparatus of Duval, (figs. 22, 23,) is com- plicated in appearance ; but is little more than the sandal of Scarpa's boot, attached by a universal joint to a leg-piece. The joint is governed by two perpetual screws. An upright, which extends from the inner side of the sole to the ancle, is furnished with a cushioned metal plate, which may be ad- vanced against the heel by screws behind it. (fig. 22, 6.) The apparatus of Little is taken from the Lancet, Feb. 24, 1844, and will be readily understood from the drawing, (fi^. 21.) VALGUS. In the simpler forms of valgus, a starched bandage sometimes suffices, after section of the tendo Achil- lis. If complicated, the splint may be used to re- duce it to the form of equinus, as was indicated for varus. The splint should here be applied on the internal surface of the leg. OTHER METHODS. The treatment of club-foot by means of a plas- ter mould \ has been already alluded to. In the less exaggerated varieties of distortion, and espec- ially in children, the foot may be gradually brought down by a sole, or sort of shoe, attached to bands of wrought iron, so thin as to allow of being bent GENERAL REMARKS. HI to the required position, and stiff enough to re- tain it. While the common expedients of mechanical treatment have been described, it is obvious that its purpose may be equally effected by a variety of combinations, the details of which are here unne- cessary. GENERAL REMARKS. Before submitting the limb to the action of a machine, especially of the more powerful ones, it is of great importance that it should be adequately protected. It should be enveloped in a soft roller, and afterwards covered with cotton, especially at the points of puncture. The salient parts being then wadded, and the cavities carefully filled, the cotton should be kept in place by another roller. Any fold or inequality is now to be arranged, and the whole covered with a stocking. The limb thus swathed is placed in the machine, carefully surround- ed with cotton, and the straps successively fastened. In general the apparatus should be at first loose- ly applied. As the foot becomes accustomed to pressure, the straps may be drawn tighter, while the force is gently augmented. When the patient complains of pain, relief is sometimes afforded by loosening the straps and inserting fresh wadding. A continuance of the pain, demands that the foot should be removed from the apparatus, and the skin exposed, with a view to the local treatment else- where described. TORTICOLLIS. The division of the sterno-cleido-mastoid muscle with the adjacent integuments, was performed by surgeons of the last two centuries. The operation bj a simple puncture is of more recent date. Dupuytren practised this method in 1822 ; and in 1826 and 1830, Stromeyer 'and Dief- fenbach published similar observations of their own. In France, the method was reproduced by Amus- sat, Bouvier and Guerin, in the years 1836, '37 and '38. The latter writer has since materially modi- fied the operation, and has thrown much light upon the affection for which it is practised. CAUSES. The agents of this distortion may be considered in two classes. The one including the varieties in which the contraction or retraction of the sterno- cleido-mastoid muscle, is the chief source of the CAUSES. 113 affection, while to the other are referred all other causes. To the former, the operation about to be considered, is in most cases applicable ; to the lat- ter, much less frequently. 1 . Among this class are a. caries of the bone ; indicated especially by the history of the lesion. b. An inflammation of the synovial capsules and fibrous tissues of the cervical vertebrae, which Bou- vier has called articular torticollis. It is either acute or chronic. Distortion results from the long con- tinued efforts of the patient, to relieve the tense and painful ligaments, by displacing them in a direction which the head ultimately retains. c. Abscesses and cicatrices in the cervical region. d. Tumors and glandular engorgements, so con- siderable as to force the head for a length of time from its normal position. To this last class Duval attributes thirty out of * sixty cases treated by him- self, in which the disease was followed in two or three months, by permanent shortening of the mus- cles. e. Paralysis of the muscles of one side, the head yielding to the unantagonized force exerted by the opposite side. The cervical column is not curved, but the last cervical is inclined upon the first dorsal vertebra. In efforts to bow the head, the chin flies to the paralyzed side. In this form, the distortion, if exaggerated, may be partially relieved by a sec- tion of the healthy muscle. 1 Op. cit., p. 513. 15 114 TORTICOLLIS. 2. The principal causes which directly affect the muscle are, a. Active muscular contraction, with subsequent retraction, atrophy and fibrous transformation. To this agent, most cases of congenital torticollis are due. b. Muscular rheumatism of the sterno-cleido-mas- toid muscle, and the retraction which may result from it. c. The action of forceps during labor. The mus- cle is torn, and blood effused, much as when sub- cutaneously divided. Simple contusion sometimes suffices to produce inflammation, followed by re- traction. The deviation is more frequent to the right than to the left. According to Phillips, two-thirds of the cases of this distortion due to muscular contraction, are directed to this side ; and in connection with the last cause of the lesion, it is affirmed that in seventy per cent of ordinary labors, the head is presented in the first position. The form of torticollis, about to be considered, recognises muscular retraction as its immediate cause. The muscles are either idiopathically affect- ed, or are retracted at a period subsequent to the original lesion ; so that the head, for a length of time displaced, by glandular enlargement or other- wise, is retained in its abnormal position by the mus- cular fibres, which accommodate themselves to their new relations. STERNO-CLEIDO-MASTOID MUSCLE. 115 SYMPTOMS. The head deviates in various degrees, to the right or left of the normal position. In the exaggerated forms, the chin is raised in the air, while the head is rotated, and depressed upon the shoulder of the affected side. In this situation the face changes its expression ; the features of the depressed side become in a measure atrophied ; the brow falls and the cheek becomes less prominent. In the region of the sterno-cleido-mastoid muscle, a dense cord is felt, which becomes more promi- nent and resisting, if force be applied to the head in a direction opposed to its action. The shoulder of the contracted side is drawn upward and forward, so that the sternum and the centre of the thorax, being no longer upon the same plane with the shoulder, are apparently depressed. Much pain with a sensation of dragging, is some- times experienced in the affected side, increased by atmospheric influences, after exertion, and in bed. STERNO-CLEIDO-MASTOID MUSCLE. M. Guerin considers this a double muscle, of which the two parts, endowed with different func- tions, may be separately affected. The following are his propositions : 1 i Memoire sur une Nouvelle Methode de Traitement du Torticolis ancien, Paris, 1843, p. 186. 116 TORTICOLLIS. 1. The sterno-cleido-mastoideus consists of two distinct muscles, the sterno-mastoideus and the cleido-mastoideus. 2. The sterno-mastoideus and the cleido-mas- toideus are possessed of separate functions. The first is especially a motor of the head, the other is essentially an inspirator muscle. 3. In torticollis, till now attributed to the short- ening of the entire sterno-cleido-mastoideus, the sternal portion of the muscle may be alone primi- tively affected. 4. In the treatment of chronic torticollis, due to the shortening of the sterno-mastoideus, the section of the sternal portion, may suffice for the disappear- ance of the essential cause of the deformity. The division of the sternal insertion of the mus- cle, is in certain cases, followed by a more or less gradual restoration of the head to a normal position. Such cases are reported by Duval and other writers. In other cases it is insufficient, and it is necessary to divide also the clavicular portion. Bonnet : re- marks that it is far from sufficing in all cases ; and that four times out of five, he was compelled to di- vide at a later period the clavicular fasciculus, be- fore the distortion yielded. VERTEBRAL COLUMN. The head being carried out of the centre of grav- ity, the vertebral column institutes a series of curves 1 Op. cit,, p. 582. TREATMENT WITHOUT SECTION. H7 with a view of restoring the equilibrium. They are of two kinds. The first is general, and is due to all the vertebral articulations. The second, described by Guerin, is local, and occurs at the intervals of the last lumbar vertebra with the sacrum ; of the eleventh and twelfth dor- sals ; and of the seventh cervical and first dorsal. From this inclination of " locality" which is an ex- aggeration of the normal movements of the articu- lations, results a series of reentering angles, com- mon to the spines of all subjects affected with chronic torticollis, and continuing after the division of the muscles of the neck. TREATMENT WITHOUT SECTION. Before the disease assumes a chronic form, while the muscle is yet in a state of simple contrac- tion, the deformity sometimes yields to medical treatment ; such as kneading, alternate flexion and extension, and friction. M. Guerin especially recommends local friction with the tartar-emetic ointment ; the developement of the pustules being sometimes simultaneous with the restoration of the head to a normal position. It should be remarked, that the sterno-mastoid muscle is not the sole cause of distortion in chronic cases. Other cervical muscles participate in the affection, and a prolonged treatment is re- quired to counteract their efforts, even after the division of the fibres of the sterno-mastoid. Neither 118 TORTICOLLIS. is the exaggerated form of distortion completely relieved by surgical aid. A certain inclination of the head often continues, and the features and facial bones, atrophied upon the depressed side, rarely regain their normal outline. The age of the patient is another important con- sideration. M. Bonnet places the limit at fifteen years-; after which a perfect restoration of the parts, in the chronic form of the lesion, can no longer be expected. SECTION OF THE STERNO-CLEIDO-MASTOID MUSCLE. Before the adoption of the subcutaneous opera- tion, it was common to divide the integuments transversely ; after which the muscular fibres were severed, layer by layer. Such was the operation practised by Brodie, Warren, Roux, and others. Of late years the subcutaneous method has been generally adopted. Although the section of one, commonly of the sternal insertion, sometimes suffices, it is often nec- essary to divide both tendons. Guerin, who for a time sustained the former theory, has since divided, in many cases, both fasciculi. It is usual first to attack the more prominent of the two tendons, after which the other becomes more tense and may be divided either immediately, or at an interval of a few days, as suggested by Bonnet. In certain cases the muscle may be divid- ed at once. SECTION OF MUSCLE. 119 There has been much discussion upon the mer- its of different sections. It has been doubted, whether the puncture should be made from within outward, and the section from the profound to the superficial parts, or vice versa ; and much unneces- sary importance has been attached to these differ- ences. As a general rule, the point of section is at a short distance above the sternum. Guerin gives the distance of six or eight lines ; Phillips an inch ; Duval half or three-quarters of an inch. This length evidently varies in different subjects. It occasionally happens that the tendon makes no prominence near the clavicle, and it becomes necessary to divide it at its most salient point, two or three inches above. The hemorrhage which follows a muscular section is sufficient reason for proscribing this point when it can be avoided. The section of the superior extremity, has long since been abandoned. The following are the principal methods : Method of Dieffenbach. The patient being seat- ed, an aid behind draws the head to the side opposed to the deviation, while a second aid depresses the elbow and shoulder of the affected side. The mus- cle being thus made tense, the operator pinches it up between his thumb and finger, and passes be- neath it, at a short distance above the sternum, a small curved bistoury. When the point is felt be- neath the skin of the opposite side, the knife is 120 TORTICOLLIS. slowly withdrawn, and the muscle being pressed against its edge, is in this way severed. DuvaVs Method. The patient is placed in the position just indicated, and the tendon made salient. The tenotome is introduced at its posterior surface, for the sternal insertion, from within outwards. In this case, the surgeon being in front of his patient, the right hand is employed for the right muscle, and the left hand for the left. For the clavicular inser- tion, the knife is introduced behind the most salient edge, whether external or internal, and the tendon is divided, from the deep to the superficial lay- ers. When the tendinous fasciculus is not marked beneath the skin, a puncture is made with a lancet, by which a blunt tenotome is carried to the opposite border of the muscle. On three occasions, M. Duval divided the whole muscle, by the aid of a single puncture at the inter- nal border of the sternal insertion ; and once, by a puncture at the external border of the clavicular extremity. Guerirts Methods. Stemo-mastoid. 1. The pa- tient lies upon a bed, the upper part of which is elevated. An aid draws the head, so as at once to oppose the inclination, and exaggerate the existing rotation. In this way the muscle is extended, and by the last movement carried into an anterior plane ; detached as it were from the subjacent parts. A fold is raised parallel with the muscle, and the ten- otome introduced flatwise, beneath the skin, at a point corresponding, when the skin is relaxed, with SECTION OF MUSCLE. 121 the external border of the muscle, and six or eight lines above its insertion. The fold is released, and the edge previously turned upward is pressed upon the muscle, which is divided. The tenotome here employed, is peculiar, and concave upon the edge, (fig. 12.) 2. In the second method, less effectual than the last, and less employed, a convex tenotome is intro- duced beneath the tendon. A grooved director is here objected to, upon the ground that it traverses the tissues with difficulty. Cleido-mastoid. The muscle being put in ten- sion, and a fold raised, the instrument is introduced upon its inner border, eight lines above its inser- tion, and the division is effected from the skin towards the centre ; so that the two insertions may be successively severed in opposite directions by means of a single puncture in their interval. There is little danger of wounding the larger vessels, especially in the methods of Guerin. It has been shown how the muscle is carried into a plane anterior to these vessels. By making the punc- ture near the clavicle, we avoid the anterior jugular vein in its passage to the subclavian. The primi- tive carotid-artery and internal jugular vein are pro- tected by the sterno-hyoid and sterno- thyroid mus- cles, and correspond in both sections to the base of the blade of the knife. In dividing the cleido-mas- toid, the anterior jugular, when it exists, may be left between the back of the instrument and the skin, if the knife be introduced in a position per- 16 122 TORTICOLLIS, pendicular to the muscular fibres, and not flat- wise. Should a second section become necessary at a subsequent period, certain precautions are requisite. The adhesive action and subsequent cicatrix may displace the larger vessels, and Duval suggests, that an interval of six months should be allowed to elapse, before the section is repeated, in order that the newly formed substance may completely insulate itself from the surrounding parts. The complete division of the muscle, in all these methods, is attended with a slight explosion, deep- ened by the proximity of the chest, and also by a sudden separation of the two ends of the divided muscle, and a corresponding movement of the head. As soon as the knife is withdrawn, the blood is to be expressed from the wound, and the puncture hermetically sealed with a bit of adhesive plaster of the size of a shilling. A compress and roller com- plete the dressing. Great care is requisite to pre- vent the admission of air into the wound. Pus in this region sometimes infiltrates the anterior medi- astinum. Once formed, the pus should be allowed to escape ; although when fluctuation is just per- ceptible, compression sometimes favors the absorp- tion of the fluid. For this purpose, a ball of lint is placed upon the tumor, and being covered with com- presses, is maintained by long strips of adhesive plaster, extending from the back upon the chest. With a little attention however to diet and repose, espscially if the air has been excluded from the MECHANICAL TREATMENT. 123 wound, these accidents are avoided. The wound commonly heals by the third day, and mechanical treatment may be then commenced. SECTION OF OTHER MUSCLES. The division of the sterno-cleido-mastoid muscle sometimes relieves the deformity but incompletely. It is then important to ascertain whether other mus- cular fibres aid in retaining the head in its anormal position ; in which case they become tense, oppose any effort to replace the head, and require division. Portions of the trapezius, and platysma have been thus divided. MECHANICAL TREATMENT. The aim of mechanical treatment is twofold. 1. To adjust the head in a normal position. 2. To correct the curves of the vertebral column. When the deformity is slight, the spinal distortion is also inconsiderable, and attention should be chiefly directed to the position of the head upon the cervi- cal vertebrae. In older patients, and in the exag- gerated varieties, it becomes necessary to apply force to the vertebrae, both in the cervical and dor- sal regions. The apparatus is then complicated. Among the more simple means of commanding the head, are the following : 1. A cravat of pasteboard, or boiled leather, as employed by Guerin, is simple, and almost univer- 124 TORTICOLLIS. sally adopted in ordinary cases. Its height may vary at different points. A substitute is a circle of stiff wire, so bent as to correspond with the edges of such a cravat. 2. A band carried around the head horizontally and united to vertical bands over the crown from before backward, and from ear to ear. A band fastened to the first, at the mastoid process of the healthy side, is drawn down in front and attached upon the chest or at the waist, so as to aid the ac- tion of the healthy muscle. A cap may be substi- tuted for the bands upon the head. 3. The temporo-axillary bandage of Mayor. The base of a triangular handkerchief is applied to the temple of the affected side, and the extremities brought, one round the forehead, the other round the occiput, to be united below the axilla of the sound side. A horizontal band may be added to this bandage. The two last methods tend rather to increase than diminish the cervical inclination, and are therefore only applicable in slight deviation, or as temporary substitutes for other apparatus. A complete machine, the force of which is adapt- ed as well to the spine as the head, is complicated and expensive. Various models have at different times been contrived for this purpose. They are adapted either to the horizontal or upright position. The former have received the name of orthopedic beds, and are chiefly modifications of those of Shaw and of Guerin. MECHANICAL TREATMENT. 125 The apparatus which admits of locomotion recog- nises its leading features in the Minerva of Dela- croix, and takes its point of counter extension upon the pelvis or the shoulders. The Apparatus of Bouvier, modified from the Minerva, consists of a wide metallic belt resting upon the hips and haunches. To this is fastened a steel up- right in the form of a T, which occupies the region of the spine and scapulae, and is retained by shoul- der-straps. A firm point of counter-extension is thus obtained between the shoulders, to which is attached an upright bar, from which the head is suspended. The head is secured by a horizontal metallic band, descending upon the mastoid processes, which gives attachment to vertical straps for the crown and chin. The iron rod by which it is attached to the steel plate between the shoulders, is so contrived as to admit of elongation, extension, flexion, rota- tion, and lateral inclination, in any of which posi- tions it may be fixed, (fig. 24.) Cravat of Phillips. A large triangular piece of sheet iron, well cushioned, is adapted to the back of the chest, the base corresponding to the shoulders. A strap secures it around the hips. The chief sup- port is derived from broad wadded suspenders, which secure it over the shoulders. To this triangle is fastened an upright of iron, capable of being raised or depressed, and terminated above by a tooth, corresponding in position, and use, to the odon- toid process. Upon this rotates, by means of a 126 TORTICOLLIS. socket, a stuffed collar of iron which supports the chin. This contrivance is cheap and effectual, (figs. 25, 27.) The orthopedic bed of Guerin is modified from that of Shaw. It consists of the divided bed, of which the superior point of division corresponds to the union of the cervical and dorsal regions, instead of corresponding to the central dorsal region, as in that employed for lateral curvature of the spine, (figs. 31, 34.) The body is secured upon the bed, and appropriate lateral force is applied. The head is confined in a casque, and is secured by a collar adjusted to the chin. The movements of this hel- met, which are thus communicated to the head, are universal, and graduated. l An inclined plane, to the head of which the chin is attached, by a handkerchief passing under it, is serviceable in certain cases. Extension is then effected by the weight of the body. i The details of the machinery, obvious to an ingenious mechanist, but requiring a long description, may be found in the last edition of Torticollis, Paris, 1843. I am not persuaded that the mechanism is the simplest and most effectual. FALSE ANCHYLOSIS OF THE KNEE-JOINT. The division of tendons is much less effective in deformities of the knee, than in those of the foot. While club-foot depends in a majority of cases upon muscular retraction, without lesion of the synovial surfaces, distortion of the knee rarely originates in this cause. It commonly results from disease, either of the cavity of the joint, or of its investing mem- branes. Duval refers fifteen cases in twenty to sub- inflammations of this articulation. The change in the form and character of the tissues is then so considerable, as often to render it difficult to restore the normal shape of the limb or its functions. Most cases, however, are susceptible of amelioration from treatment, and it is sometimes possible, both to straighten the limb and to renew its suspended movements. 128 KNEE-JOINT. CAUSES. Congenital retraction. This variety of the affec- tion is analogous to other congenital deformities, and is accompanied with the fibrous transformation of the retracted muscles. As in the operation for club-foot, their section then facilitates the subse- quent mechanical treatment. Muscular retraction materially interferes with the developement of the bones and other parts, in early life ; and the limb rarely or never regains its normal length and out- line, if the operation be deferred till adult age. As an idiopathic affection of the knee, it is, however, comparatively rare. Permanent flexion. In this position of the leg, the muscles become, after a time, passively retracted, and require, equally, division. It is unnecessary here to inquire what agents contribute to this posi- tion, so common in chronic diseases of this articula- tion. By the flexion of the knee, most of the muscles are relaxed ; it is the natural position when the patient lies on the side, and the necessary one, when the synovial cavity is distended with fluid. It is also sufficient to know, that in a large ma- jority of cases of long standing, resulting from both these causes, adhesions are formed between the articulating surfaces ; and in this connection it is unimportant, whether they presuppose synovial in- flammation, or whether, as Hunter supposed, and as seems to follow from the recent investigations of PATHOLOGICAL ALTERATIONS. 129 M. Teissier, 1 a simple state of rest may cause vas- cularity of the synovial, and the deposit of false membranes. Serious lesion of the Joint, The most common form of false anchylosis, is that in which the artic- ulating surface is materially altered ; where chronic inflammation, ulceration and the lesions commonly accompanied by the white swelling, have occasioned long continued suppuration, cicatrices and change in the form of the cartilaginous and bony extremi- ites. The following are the principal changes which result from long continued flexion of the joint, in disease of this sort. PATHOLOGICAL ALTERATIONS OF THE TISSUES AND THEIR CONSEQUENCES. The entire limb is commonly withered and atro- phied. Spontaneous luxation. The weight of the flexed leg resting upon the heel in a horizontal position, aided by the action of the flexor muscles, incline the head of the tibia backward, and the joint tends to open behind ; while the distended condition of the lateral and posterior ligaments finally permit this bone to glide back upon the posterior surface of the condyles of the femur, which are often atro- phied at that part. i Gaz. Med. t. ix.,p. GOO -26. 17 130 KNEE-JOINT. Rotation. The powerful action of the biceps flexor, the shape of the condyles, the disposition of the crucial ligaments, and the position of the leg, which the patient supports upon the outer side of the heel, tend to impress upon it a movement of rotation outward, often considerable. Duval refers to a case in which the internal condyle of the femur was received into the external concave surface of the tibia ; there being a semiluxation of the tibia upon the femur. These partial luxations according to Bonnet, accompany three-fourths of the cases of angular anchylosis of the knee. Outward luxation of the patella generally accom- panies rotation of the tibia. Change of form in the articulating extremities. The parts in contact undergo ulceration and absorp- tion. The pressure of the condyles of the tibia, often ulcerated themselves, occasion extensive ab- sorption of the posterior part of the condyles of the femur, w 7 hich are sometimes excavated to the depth of half an inch or more. The pressure of the patel- , la upon the external condyle in front, destroys its convexity. Adhesions. The patella is sometimes glued to the anterior part of the femur, and sometimes to the interval between the femur and tibia, in which case it is impossible to straighten the limb. The cartilages of the anterior part of the femur are some- times absorbed, and the two bones become inti- mately united by fibro-cellular bands, in a way to obliterate the anterior half of the cavity of the syno- DIAGNOSIS. 131 vial membrane. 1 Finally, masses of fibrous tissue surround the joint, occupying especially the popliteal region, where they envelope the vessels and nerves, and form a compact mass. A dissection was ex- hibited by M. Chassaignac to the Anatomical Society of Paris, in which the popliteal artery was so con- tracted by these adhesions, and imbedded in them, that any attempt at sudden extension of the limb must have produced its rupture. DIAGNOSIS OF THE DIFFERENT ORGANIC LESIONS. While the disease is in an active state, besides the constitutional symptoms, the knee is often much enlarged ; it may present the peculiar doughy feel which sometimes accompanies sub-inflammatory action in this region, or may be distended with fluid. There is generally more or less pain upon movement, however slight. When the nerve is retracted, probably by virtue of its fibrous sheath, it is of manifest importance to distinguish it from the tendons, which present a similar elevation in the ham. Their relations, how- ever, are different. While the tendons may be traced to the condyles of the femur, the nerve trav- erses the area of the popliteal triangle and gains the space between the condyles. The position of the bones is easily detected. The luxation and rotation of the tibia is indicated by the i Bonnet, p. 560. 132 KNEE-JOINT. corresponding and evident modification of the out- line of the limb, and by the outward direction of the toe, when the anterior part of the thigh is made to look directly forward. The absorption or disintegration of the articulat- ing surfaces is difficult to be detected, and must be inferred from the duration of the disease, the posi- tion of the limb and of the patella, and from the amount of suppuration. The existence of fibrous tissues is to be inferred from the resistance of the soft parts and the cica- trices of fistulous passages. Adhesions are less difficult to be recognised than ulcerations of the articulating surfaces. The union of the tibia and femur is indicated by the absence of all movement. The adhesion of the patella should not be confounded with its immobility re- sulting from the tenseness of the ligaments when the leg is flexed. When the patella is adherent, we may always infer the obliteration of the anterior part of the cavity of the joint. ■ It is however in some cases difficult to distinguish true from false anchylosis ; the bony, from the fibrous union of the parts. The pain produced by the forced flexion of the joint is an uncertain test. Perhaps the surest indication that the union is false, is the possibility of still producing a cer- tain amount of flexion beyond the point at which the knee is stationary, and hindered from exten- i Bonnet, p. 571. DIAGNOSIS. 133 sion by the retracted muscles. The limb can then in most cases be straightened. But when the joint is entirely deprived of the power of flexion, it is probable that the anchylosis is bony ; and in such cases even when the osseous deposit is inconsider- able, it is doubtful if the degree of flexion has ever been diminished. It is of less importance to dis- tinguish true anchylosis, imperfect though it be, from the complete fibrous union of the synovial surfaces, which sometimes follows rheumatic affec- tion, since this lesion also offers serious obstacles to mechanical treatment. Passive flexion of the joint is sometimes dimin- ished or entirely prevented, during the examination of the patient, by the active contraction of the mus- cles ; so that capability of motion may exist where it is not detected. In such cases, if the attention of the patient be diverted, the muscles become re- laxed, and a certain power of movement is found still to exist. As was before stated, it is commonly in the direction of flexion ; extension being pro- hibited by the passively contracted muscles. In examining the limb, the alternate forced movement, which stimulates the contraction of the muscles, may be replaced, by measuring, as Duval recom- mends, the distance between the ischium and heel, in each position, the pelvis being fixed. If there is a difference in the measurements, the union is false. 134 KNEE-JOINT. TREATMENT. The treatment of false anchylosis of the knee-joint, may be considered under three general heads. 1. The division of the tendons which oppose ex- tension. 2. The extension of the limb. 3. The reproduction of its normal movements. The evidence of the results of treatment is far from satisfactory. Thus, in the serious lesion of the joint already alluded to, Bonnet maintains that the section of tendons is never practised with suc- cess ; Phillips is less decided as to the efficiency of treatment, while Duval offers numerous observa- tions of distortion from lesion of this sort, accom- panied with suppuration and subsequent cicatrices, in which treatment produced a straight and service- able limb. The results of these cases seems to have varied, not only with the character and degree of the lesion, but with the nature of the mechanical treatment ; and it is therefore important to estimate the value both of the indications for treatment and of the dif- ferent methods of applying mechanical force. Of the former, one of the most promising is the pos- sibility of still executing a certain degree of flexion. Duval does not hesitate to affirm, that by means of sub-cutaneous sections, its entire extension can always be obtained, provided the anchylosis is false or incomplete. But it is evident that without the indication afforded by the capability of flexion, TREATMENT. 135 it is difficult, if not impossible, to establish this im- portant point. There is little or no recorded evi- dence to show that the limb has ever been reduced when the joint was entirely destitute of the power of motion, that is, of flexion ; while on the contrary it frequently happens, that all efforts fail to produce any modification in the outline of the limb. The cavity of the joint has then become the receptacle of organized lymph, which has soldered together the articulating surfaces. 1 In time, this lymph is trans- formed into bone and the anchylosis is complete. But it does not theoretically follow, in the absence of facts, that treatment must be unavailing, because there is no movement in the joint, even at a period when the lymph presents some traces of osseous de- posit. Nor are the experiments 2 of M. Bonnet upon the dead subject conclusive. The organized false membrane, while endowed with vital proper- ties, must tend to yield to a permanent and pro- portionate force ; to be relaxed by gradual traction, and to be absorbed by pressure. In this way, con- tinued mechanical force is capable of producing ef- fects upon the living tissues, which the passive re- sistance of the dead and inert fibres would render impossible. In such cases, experiment alone can 1 I have examined a knee in this state, in which there was no possi- bility of producing movement, though as yet no osseous particles had been deposited. 2 In these attempts to straighten the limb, it was found necessary not only to divide the tendons and fibrous tissues, but afeo to open the joint behind, in order to allow the posterior edge of the articulating surface of the tibia to recede from the femur. Op. cit., p. 563. 136 KNEE-JOINT. decide upon the propriety or the capabilities of treatment. Interarticular adhesions are not the only obstacles to the successful treatment of this deformity. An equal, and according to some writers, a greater dif- ficulty exists in the distortion of the articulating surfaces. Nor is the amount of this distortion indi- cated by the degree of flexion of which the joint is capable ; for, as Duval affirms, the joint may enjoy this power to a considerable extent, where the al- teration of the articulation is sufficient to interfere materially with treatment. When the luxation is great, and when the condyles are partially absorbed, it sometimes happens that all attempts at extension are fruitless ; either because the adhesions are too firm to be overcome, or because the patella has en- gaged itself between the tibia and femur, and can- not be displaced. J The condition of the articulation also exercises an important influence upon the shape of the limb after treatment. This, however, depends not only upon the degree of luxation and rotation of the tibia, upon the amount of ulceration and absorption of the cartilage and bone, but also upon the direc- tion and adjustment of the mechanical force em- ployed during the treatment. The tendency of the tibia to backward luxation has been referred to. If in permanent flexion of this sort, an extending force be applied to the foot, i Phillips, Op. cit., p. 201. TREATMENT. 137 the head of the tibia does not glide forward on the condyles of the femur, as in the normal condition of the joint, but tends to remain stationary behind it. The anterior margin of its articulating surface forms, against the femur, a fulcrum by which the posterior edge is gradually lifted away from the condyles ; so that when the limb is straight, the perpendicular of the tibia is behind that of the femur, and the weight of the body resting on the femur, bears upon a point anterior to the tibia. This is the condition of the leg in a large pro- portion of the cases mentioned by Duval. Mr. Little seems to have obtained better results ; the tibia being made to occupy a position more directly beneath the femur. The advantage in the treat- ment adopted by the latter surgeon, is mainly due to the distribution of force in the machines em- ployed. While that of Duval merely extends the limb, the apparatus used by Little aims both at ex- tension and at the reduction of the head of the tibia ; which is lifted into its place, by an effort applied directly to it. In fact, without this arrange- ment, the previously existing luxation is liable to be exaggerated, and even to be rendered complete. The degree of movement permitted to the joint after reduction also depends chiefly upon the de- gree of the lesion, but also partly upon the treat- ment. In Duval's cases, six patients in ten were left with a stiff joint ; but it should be remembered that this surgeon considers the treatment complete, when the limb is brought down and the patient is 18 138 KNEE-JOINT. able to rest his weight upon it. Little, on the con- trary, here commences a third stage of treatment, with the view of re-establishing the movements of the articulation ; and he seems, in some cases, to have obtained this desirable result. When the deformity occurs at an early age es- pecially when it is congenital, and depends upon muscular contraction, it is of great importance not to delay treatment. The retracted muscles pre- vent the bones from attaining their normal length, and irremediable deformity is the consequence. In May, 1838, M. Bouvier exhibited to the Acad, des Sciences, a specimen which demonstrated these consecutive changes of bones and ligaments, and the necessity of early action to anticipate these al- terations. Duval fixes the average duration of treatment at six weeks, and the maximum at three or four months ; while Little places the average in adults at two months ; a shorter period being required for children. The process of restoring mobility varies from three months to a year. MEDICAL TREATMENT. It is sometimes well to fortify the general health of the patient, who is often of a scrofulous consti- tution ; and also to reduce, if necessary, the local inflammation, before submitting the limb to surgi- cal influences. Duval recommends for this purpose a course TREATMENT. 139 like the following. Salt-water baths every two days ; if practicable, in the open air and sun. Three or four cups daily of infusion of hops, with ten grains of bi-carbonate of soda, or a dozen pas- tilles of lactate of iron. Claret wine, diluted with infusion of hops at meals. Broiled or roast meat. No milk nor fruits. In short, a tonic and anti- scrofulous regimen. At night, a poultice to the knee, made with a narcotic decoction. Every morning, on removing the poultice, fric- tion of the joint with a bit, of the size of a filbert, of the following ointment. Simple Cerate g i i Bromide of Iron 5 i i Extr. Hemlock ) . . . Camphor ) For the bromide of iron may be substituted eight grains iodine, with a drachm of hydriodate of po- tassa, if slight irritation of the surface be desired ; or 5 i i of the iodide of lead as a simple resolutive producing no cutaneous irritation. SURGICAL TREATMENT. Under this head will be successively considered, 1. Treatment without tenotomy. 2. The section of tendons. 3. Sudden extension. 4. Gradual extension after the inflammatory symptoms have subsided. 5. Tenotomy and extension during the existence of local inflammation. 140 KNEE-JOINT. TREATMENT WITHOUT TENOTOMY. What has been already said upon this point, in connection with Torticollis and Club-foot, applies equally to False Anchylosis. The resistance of the muscles, when recently contracted, may undoubt- edly be overcome by simple extension. According to Little, we may succeed without tenotomy in effectually straightening the limb, in a favorable case of false anchylosis in the adult, after the lapse of five years ; but it is rarely possible in a child, unless of very lax fibre, permanently to relieve by mechanical means, a severe contraction of similar duration. The fibrous transformation is more rap- idly effected in children ; partly because the func- tions are in general more active, and partly perhaps because the muscle is subjected to increasing ten- sion, as the bones are developed. THE SECTION OF TENDONS. The tension of the muscles, and the resistance which they offer to extension, is of course the im- mediate indication for tenotomy. In the con- genital form, tenotomy is especially indicated. When the retraction is only passive, and the se- quence of permanent flexion, the duration of the lesion will give some indication of the probable de- gree of fibrous transformation, and the propriety of tenotomy. In most chronic cases, extension is SECTION OF TENDONS. 141 facilitated and the treatment is abridged, by divid- ing the tendons of the ham ; but the more impor- tant element of prognosis, the condition of the articulation, must be taken into the estimate, in deciding the question of treatment. The section of the tendons which oppose the extension of the leg, seems to have been first effect- ed by Michaelis. Dieffenbach operated in 1830, Duval in 1837, Bouvier in 1838, and Guerin in 1839. The chief varieties in the method of operating are those of Dieffenbach and Bouvier ; the former of whom divided the tendons from the deep to the superficial regions ; the latter in the inverse direc- tion. Method of Dieffenbach. The patient, supported by an aid, is placed upon his knees in a chair, while a second assistant confines the thigh of the affected side. The operator first divides the tendons of the semi-membranosus and semi-tendinosus in carry- ing the instrument beneath the skin and beneath the tendons. The biceps is divided in the same way. The extension is then increased to bring into view any fibres which may yet oppose the straightening of the limb, and these are successive- ly divided. The punctures are carefully closed, and the other conditions of subcutaneous wounds as far as possible fulfilled. Method of Duval. The patient lies upon his belly, and the leg is extended. The tenotome is introduced at the level and towards the anterior 142 KNEE-JOINT. face of the tendons, the most prominent of which is first to be divided. The leg is then farther ex- tended, and other tendons become in their turn sa- lient. The first is commonly the biceps, the second the semi-tendinosus, then the semi-membranosus. For the former, the instrument should be intro- duced from the hollow of the ham outwards, and as far down as possible, to avoid the lesion of the ves- sels and nerves. Two punctures suffice ; one for the biceps, the other for the two other muscles. The knife should not be allowed to perforate the opposite surface. It is made to bear directly upon the anterior part of the tendon, which is divided from its profound to its superficial and cutaneous surface. The pain is slight, a few drops of blood only escape, and the punctures heal in two days. Method of Bouvier. Longitudinal punctures are made upon the eccentric border of the tendons to be divided. A blunt tenotome is introduced flat- wise beneath the skin, while the finger of the left hand of the operator apprises him of the progress of the instrument. It is then turned upon the tendon, which is divided from without inward. The edge of the instrument should be so short as neither to enlarge with its base the external aper- ture, nor in dividing the biceps, to wound with its extremity the external popliteal nerve. From the puncture of the outer surface the biceps is divided; from the internal puncture, the semi-tendinosus, semi-membranosus, and if required, the rectus in- ternus. SECTION OF TENDONS. 143 According to M. Bonnet, it is necessary in cer- tain cases to divide not only the rectus internus and sartorius, but the gastrocnemii, which last is effect- ed by severing the tendo Achillis. From the dissections of this surgeon, it appears also that the nerves are sometimes so retracted as to resemble tendons. They may be distinguished, as was before stated, by their position in the centre of the lower part of the popliteal space, from the tendons, which pass to a point just inside the con- dyles of the femur. The larger vessels are deeply seated ; but the proximity of the popliteal nerve to the outer ham- string is sufficient reason for prefering the method of Dieffenbach, which protects it with the back of the instrument, to that of Bouvier which exposes it to the edge. In certain cases, the section of the biceps alone suffices, especially in the variety complicated with inward deviation ; but it not unfrequently happens that the semi-tendinosus and semi-membranosus become prominent a week or two afterwards and require division. From the internal puncture may be successively divided the semi-membranosus which is deepest, then the semi-tendinosus, and finally the rectus in- ternus. Resting here, we avoid the section of the internal saphsena nerve, but in dividing the sarto- rius, this nerve and vein are necessarily comprised in the section. It is asserted by Little that it is better to divide 144 KNEE-JOINT. the superficial and cutaneous nervous filaments which traverse the surface of the gastrocnemii. They may be distinguished from fibrous filaments by the peculiar pain, sometimes severe, occasioned by their tension, especially during treatment. Prof. Froriep of Berlin, reports a case in which the fascia lata, and fascia cruralis required division. Such cases are comparatively rare. MECHANICAL TREATMENT IN THE CHRONIC FORM. Two kinds of mechanical treatment have been applied to false anchylosis. 1. Immediate and violent. 2. Gradual and progressive. Among the first are to be ranked the methods of DiefTenbach and Louvrier. The second includes the methods of Duval, Bou- vier and others. SUDDEN EXTENSION. The method of DiefTenbach diners from that of Louvrier. While the former divides the tendons and then violently flexes the limb, Louvrier directs the effort to its extension, and without section of the tendons. In the one case, the punctures of the integuments are liable to laceration ; in the other the tendons are almost of necessity ruptured. Method of Dieffenbach, Immediately after the division of the resisting tendons and fibres, and SUDDEN EXTENSION. 145 also of any profound cicatrices which offer impedi- ment to extension, the operator places one hand upon the thigh of the patient, and with the other seizes the foot and forcibly flexes the limb. It is then alternately flexed and extended, the principal effort bearing upon the flexion. To effect this the united force of two or three men is sometimes requisite. The rupture of the adhesions is attended with cracking explosions. The punctures covered during the operation by the fingers of the operator, to ex- clude the air, are now closed with sticking plaster, the limb enveloped in a roller, and placed in a splint. It sometimes happens that the limb constantly returns to a state of flexion after extension ; a movement due to the retraction of the lateral liga- ments. The external ligament is commonly the one affected, and is then perceptible beneath the skin, and requires division. Method of Louvrier* The barbarous method of M. Louvrier needs only an allusion. The limb is confined in splints, hinged at the knee. The patient is placed in recumbent a position, and forcible ex- tension is applied at two points, by means of cords wound around a roller. By one the foot is drawn down, while the other simultaneously depresses the knee towards a straight line. Extension is thus effected in twenty-five or thirty seconds ; but not without rupture of the skin, and of the tendons of the ham, denudations of the vessels and nerves, 19 146 KNEE-JOINT. gangrene, and in one instance suppuration and death the twenty-second day. In another case, the artery was ruptured, gangrene ensued, and am- putation was rendered necessary. The method of Dieffenbach is not exempt from these accidents. Duval 1 reports a case of fever, lo- cal suppuration and delirium following the operation. Such results peremptorily forbid the adoption of these methods in chronic cases, especially as equal advantage is to be derived from a gradual and much less painful application of force. In recent cases, of not more than three or four months standing, and the result of acute inflam- mation, circumstances may render it expedient to break the adhesions by sudden force, but even then gradual extension is to be preferred in a majority of instances. In such a case, when the inflamma- tion has subsided, manual force may be applied as described by Bonnet. For this purpose, the flexors of the leg are re- laxed by a horizontal position of the patient. An aid confines the pelvis, while another supports the foot. The surgeon now with one hand carries forward the head of the tibia, to prevent its back- ward luxation, while with the other he depresses the inferior extremity of the femur. The leg when reduced is placed in a hollow splint, and enveloped in a starched bandage. Slowly progressive extension. In this method, l Op. cit., p. 455. SUDDEN EXTENSION. 147 the two portions of the limb are confined in splints, hinged at the knee, and brought into a straight line by long continued traction or other mechanical means. The process is often completed in less than a month after the division of the tendons. In exceptional cases it requires three or four months. In the construction of these machines, care should be taken to distribute and equalize the force. It has been elsewhere shown, that the tibia is disposed to backward luxation, and often re- quires to be urged forward at the moment exten- sion is applied. Perhaps the best machine is that described by Little. The apparatus of Bonnet, which resembles the apparatus of Louvrier, and imitates the manner already described, of applying manual force, is also efficient. The punctures are allowed to cicatrize, and the limb is well protected with cotton before being submitted to the machine. A flannel roller is then applied, somewhat tighter at the knee than above or below, to aid in counteracting the tendency to flexion. Extension at first progresses rapidly, even when the flexion is considerable, to the extent of thirty or forty degrees in a week ; but is subse- quently more gradual and laborious. When the knee becomes painful and engorged, Duval advises local friction, with the ointment of Iodide of lead, already alluded to ; and compres- sion by means of a flannel roller. The machine is then re-applied. Pain is always an indication for the removal of the apparatus and examination 148 KNEE-JOINT. of the limb, as in the treatment of club-foot. When the sections are recent, a slight movement of the limb is apt to occasion great suffering. It should, therefore, be well supported while the appa- ratus is changed. It is sometimes at the option of the patient, whether the limb shall be entirely reduced, or w T hether it shall remain flexed at a slight angle ; the latter position being undoubtedly the most con- venient, especially in ascending a hill, or going up stairs. Different machines will be found described in the plates, (figs. 26, 28, 29, 30.) RESTORATION OF MOBILITY. At this stage, Little commences a new treatment for the purpose of restoring the mobility of the joint. The method consists of passive movements, frictions, vapor baths, &c. ; with the occasional flexion and extension by means of a machine applied to the leg. This difficult process requires a period vary- ing from three to six, and even twelve months. MECHANICAL TREATMENT WITH TENOTOMY DURING IN- FLAMMATION. Certain cases of anchylosis must be considered as a favorable termination of the disease. To inter- fere with the process, would renew the inflamma- tion. Little considers tenotomy inapplicable, until MECHANICAL TREATMENT. 149 two or three years after the termination of active inflammatory symptoms ; and cites a case in which disease was renewed, apparently from a neglect of this rule. M. Duval maintains an opposite theory, and while he deprecates, in such cases, unaided mechan- ical treatment, he maintains, in a memoir addressed to the Academy of Sciences, in December, 1841, that " club-feet and false angular anchyloses of the knee, may be cured during the course of the inflam- matory maladies which produced them." The following passage more fully illustrates this point. 1 " When there is an inflammation of the knee, the seat of which is shown by the nature of the pain to be in the soft parts ; 2 which is not diffused, but circumscribed ; localized, so to speak, in the interior region of the articulation ; when the flexion is due to the permanent retrac- tion of the muscles ; when, I say, there is this combination of circumstances, and the inflammation has resisted all common therapeutic means, I be- lieve that everything is to be expected from the section of the retracted muscles, whatever be the local disorders of the articular parts. By this op- eration, we shall avoid also, the chance of anchylosis in a bad position. " Supported by numerous facts, I believe I may announce the following doctrine. Pain, inflam- 1 Duval, p. 438. 2 It may be remarked that little indication of the seat of the lesion can be drawn from the character of the pain. 150 KNEE-JOINT. mation, alteration of intra and extra-capsular parts, or of the teguments, phlegmonous swelling, oe- dema, numerous cicatrices, suppurating surfaces ; all these circumstances, which seem to be so many contra indications, ought not to arrest the operator ; but are, on the contrary, indications to induce him to act. All prejudices which might have previously arrested him ought to yield to facts." The tendons being divided, gradual extension is applied to the limb. This principle is based upon a number of facts ; and is supported upon the ground, that extension, while it brings in contact new and less diseased parts of the articulating surfaces, separates the posterior and ulcerated portions from each other, and by relaxing the muscles, diminishes the pres- sure of the patella upon the anterior surface of the femur. Extension applied before section of the retracted flexor muscles, would evidently counter- act these indications in bringing the inflamed sur- faces more forcibly in contact. M. Guersent, of the Hopital des Enfans, asserts 1 that in white swelling of the knee it is almost always advantageous to practise tenotomy, the moment circumstances are tolerably favorable for its performance ; that is to say, when the tumor is not extremely painful ; when the inflammatory symptoms begin to diminish in intensity. M. Ribes, a French writer of some note, ex- 1 Gazette des Hopitaux, Juillet, 4, 1844. MECHANICAL TREATMENT. 151 presses himself as follows : 2 " Medical art is rich in therapeutic remedies for the relief of white swell- ing of the knee-joint, but in almost all cases, from a simple cause, they have proved utterly inefficient. This cause is the permanent and forced contraction of the flexor muscles of the leg. Eh bien ! Why should we not perform, at the proper time, the sub- cutaneous section of the tendons of the semi-mem- branosus, semi-tendinosus and biceps muscles which keep up this uneasy state of things ? By this easy operation we may rationally hope not only to relieve the existing pain and distress, but also very mate- rially to promote the formation of anchylosis, and consequently the cure of the disease. This simple and safe operation is already admitted and recog- nised by surgeons. 5 ' It is unnecessary to say that great caution is to be exercised in accepting evidence of this sort, and especially in experimenting upon a lesion suffi- ciently grave to hazard the life of the patient. 2 Med. Chir. Rev. Oct. 1844, p. 469. RICKETTY KNEES This variety of distortion, commonly known as knock knees and how legs, accompanies in many cases a ricketty diathesis in young; subjects. It re- sults in part from the flexibility of the bones. In the former variety the joint also becomes distorted, either from the relaxation of the internal ligament or the arrest of developement, or shortening of the external lateral ligament. The tibia is then di- rected obliquely from above downwards and from within outwards, while the femur forms another side of a triangle of which the summit is the knee. The articulating surfaces of the knee joint become oblique in the line of a perpendicular let fall from the summit upon the base of this triangle, and the extremities of the bone are often enlarged. Medical Treatment. — In infants, a tonic treat- ment often suffices to rectify completely the devia- tion, especially the outward curvature. The fol- TREATMENT. 153 lowing formula will give an idea of the treatment of Guerin, in the case of a child of two or three years of age. 1 1. Three salt water baths a week with the ad- dition of one pound of gelatine to each. 2. Fric- tion and massage* morning and evening. 3. Every other morning, fasting, a table-spoonful of syrup of gentian alternating with cinchona. 4. For ha- bitual drink, infusion of chicory (slight laxative and bitter) with one third Eau de Vichy and one third old Bourdeaux. 5. Light but substantial diet ; fresh eggs, simple soup ; cooked leguminous vege- tables and fruit ; but neither raw fruit nor milk. 6. Country air. 7. No walking for some months. The above course of treatment was prescribed by M. Guerin for an infant of two and a half years of age, whose limbs, previously affected with the out- ward curvature, became straight at the expiration of a few months after its adoption. A simple change of air and diet often produces the same effect. Surgical Treatment. — When the child has at- tained the age of six or eight years, the firmness of the external lateral ligament in the imvard devia- tion, renders it expedient to divide it, rather than to attempt its extension. In certain aggravated 1 Writer's MS. of Guerin's lectures. 2 The term massage may be rendered in English by the word Sham- pooing. It consists of friction combined with pinching and kneading of the muscles, and with the gentle alternate forced extension and re- laxation of their fibres. 20 154 RICKETTY KNEES. cases, the tendon of the biceps is retracted, which is then to be divided. M. Guerin does not hesitate to divide the external lateral ligament, thus opening the articulation. He asserts that no ill effect results from this operation, (which I have often seen performed by him,) pro- vided the rules for subcutaneous perforations of the articulations are strictly adhered to. 1. The section should be made in the position of extension. M. Guerin has endeavored to show that, in certain positions of the joints, a sort of vacuum is established in the articular capsules ; which aids the effusion of the synovial fluid from the secreting surface, by a sort of action of suction. If this be established it becomes a matter of impor- tance not to divide the capsule, when the joint is in such a position as to tend to draw into its cavity atmospheric and other surrounding fluids. 2. The air should be carefully excluded. 3. Perfect subsequent rest of the limb should be enjoined. With the subsequent and long continued use of an apparatus, as M. Guerin affirms, the internal portions of the oblique articulating surfaces become absorbed, the leg occupies a perpendicular, and the deformity is permanently relieved. Protracted mechanical treatment is required, to produce the requisite modification in the joint. Bon- net states, that he has never been able to obtain from this method a satisfactory result. 1 I Op. cit., p. 575. PERMANENT FLEXION OF THE HIP-JOINT. The principles of treatment of false anchylosis of the knee, by gradual extension, apply equally to per- manent flexion of the hip. It is, however, more difficult to appreciate in this lesion the amount of change in the articular structures. The distortion is corrected by mechanical force, either alone or combined with the section of tendons. A year or two after the cessation of active inflam- matory symptoms, gradual reduction may be at- tempted, by the traction of a weight, spring, or other mechanical power. If the tendons resist the effort, the tenotome should be employed. The tendons which have been divided for this af- fection, are those of the adductor longus and magnus, rectus femoris, sartorius, pectineus, and, lastly, the tendon of the psoas and iliacus. The two last muscles have been divided by M. Guerin and by Dr. Sargent of Worcester. In the operation of the 156 HIP- JOINT. latter surgeon upon a boy of ten years of age, in whom the deformity, of three years standing, was the sequence of apparent cerebral affection, the tenotome was introduced, about three inches below the anterior superior spinous process of the ilium, and carried in a direction parallel to Poupart's liga- ment, up to the edge of the femoral artery. The ten- don being extended, the knife was carried to the bone, when the tension yielded. Profuse hemorrhage followed the withdrawal of the knife, only arrested by compression sufficient to produce an eschar two inches in length. But the patient, who before the operation was a cripple, confined to his bed or walking upon his hands and knees, recovered, in a great measure, the use of his limb, and now walks erect without a cane. Jt should be mentioned, that the puncture was first made, at a point about one inch and a half be- low the spinous process of the ilium ; and above the position of the profunda and recurrent arteries, which would have then escaped division. It proved however, that the cicatrices of previous sections, had condensed the tissues to a degree which ren- dered them impervious to the tenotome, which was then introduced still lower down. The crural nerve was divided. The proximity of the tendon of the psoas to the large vessels, will hinder less dexterous surgeons from attempting its division, notwithstand- ing the eminently satisfactory results of this case. 1 1 N. E. Quarterly Jour, of Med. and Surg. July, 1842. ANCHYLOSIS Little need be said upon this point. It is rare that a case of simple deformity justifies the surgeon in hazarding the life of the patient to a degree, which the operation proposed for anchylosis de- mands. The integuments and soft parts are widely incised, and the bone, after being exposed, is sawed apart. The patient is left in the conditions of a severe compound fracture. Dr. J. Rhea Barton first performed this operation upon the hip in 1827. 1 The neck of the femur was divided, and a serviceable joint was reestablished ; which, however, became again anchylosed at the end of six years. A similar operation w r as performed by Dr. Barton, upon a knee anchylosed at an angle, in May, 1835. 2 The integuments were divided, and a wedge-shaped 1 North Am. Med. and Surg. Jour., April, 1827. 2 Am. Jour. Med. Sciences, Feb. 1838. 158 ANCHYLOSIS. mass of bone was removed from the femur just above the condyles, the base of which, corresponded with the anterior surface of the bone. The limb was gradually straightened, the bone united, and the patient was enabled to walk without a cane. The first of these operations was to establish a joint, the second to correct the deformity of the limb." The latter operation was repeated with success by Professor Gibson in 1341, 1 and the former by Dr. Rodgers 2 in 1843, with like result. DiefFenbach proposes, in his last work, to break down the osseous union of the knee-joint with an instrument, and Malgaigne suggests the employ- ment of a chisel and mallet for the same purpose. 1 Am. Jour. Med. Sciences, July, 1842. 2 Ibid., Feb. 1843. LATERAL CURVATURE OF THE SPINE. The treatment of lateral, spinal curvature, has re- ceived much attention in France, and has recently been discussed at length, and not without warmth, in the Academy of Medicine. The principal advo- cates of the opposite modes of treatment, are MM. Guerin and Bouvier x ; the one insisting upon the 1 The following are the conclusions of M. Bouvier : 1. That the section of the sacro-lumbalis, longissimus dorsi, spi- no-transverse muscles, &c, is not immediately followed by diminution of spinal curvature. 2. The changes which the curves undergo during the succeeding mechanical treatment, are exactly identical with the changes produced by this treatment alone, when it has not been preceded by the section of the muscles. 3. The time necessary to obtain these changes is the same, whether we have recourse to orthopedic means alone, or practice also section of the muscles. 4. In a word, dorso-lumbar tenotomy has no kind of influence in remedying lateral deviation of the spine, properly so called. M. Bouvier further concludes : 1. That the majority of lateral cur- 160 CURVATURE OF THE SPINE. necessity of muscular section in certain cases of this distortion ; the other maintaining, that no ad- vantage is to be derived from it. The question relates to the duration and effi- ciency of the mechanical treatment, alone, or ac- companied with section of the muscles, and can only be satisfactorily determined by the analysis and comparison of a considerable number of cases, subjected to each method. The operation being attended with little pain, or chance of subsequent accident, is hardly to be taken into the estimate, if any advantage is to accrue from it. I believe M. Guerin has shown, as far as he is able, that the treatment is abbreviated in certain cases, by the division of the muscles* If it is established, that these tissues are liable to undergo the fibrous change in the region of the spine as w T ell as the extremities, as it undoubtedly is, they must offer a certain amount of resistance to any attempt to ex- tend them. That this resistance is not insur- mountable, that the spinal column can be extended in spite of its influence, will be readily conceded by those who have seen the tense and undivided muscles of the ham slowly yielding to the gradual application of mechanical force ; but this treatment is often accelerated by the section of the tendons vatures of the spine are not owing to muscular contraction. 2. That the etiology of the distortion, pathological anatomy, and clinical ex- periments proscribe the section of muscles of the back in the treat- ment of these curvatures. VARIETIES OF THE LESION. 161 in the popliteal regions, and many are ready to ad- mit, that the same advantage is to be obtained by the division of the tense dorsal muscles upon the concave side of an exaggerated spinal curvature. The two modes of treatment need farther investi- gation ; but in rejecting the exclusive views of the partisans of either method, the evidence ren- ders it highly probable, that the treatment of lat- eral curvature is often accelerated by dorsal my- otomy. 1 1 This subject has been revived in the Academie de Medicine by M. Malgaigne. After a tedious and excited discussion upon the value of dorsal myotomy, the matter was referred to a committee, of which Roux and Velpeau were members. The report of this committee was read to the Academy, 12th November, 1844 ; and may be con- sidered as embodying all that is yet settled upon this point. The fol- lowing are extracts from this report : " Although it should be proved that tenotomy was unavailing in the cases cited by M. Malgaigne, we should have no right to deny, for that reason, that the operation was ever efficacious." * # * a \y"e do not admit, that spinal curvatures are unaccom- panied with muscular contraction in all subjects." * * * " But it is important not to deceive ourselves upon the value of tenotomy in such cases, and not to decide upon it unless we can establish materially the existence of unyielding or tense cords upon the concave side of the deviation ; not during the influence of certain active positions, but when we try to straighten the curve by foreign force." And among the conclusions, " 6. Nothing at present justifies the opinion of those who attribute the majority of lateral curvatures of the spine to convulsive or active retraction of the muscular system. " 7. But, the secondary shortening of certain muscles in the con- cavity of the curves, ought to hinder us from rejecting, a priori, and absolutely, spinal myotomy." The question thus stands much as it did before. 21 162 CURVATURE OF THE SPINE. The pathology of the lesion has been thoroughly reviewed by M. Guerin, whose opportunities have enabled him also to investigate manv practical con- siderations connected with the treatment. The following is a brief exposition of the views of If. Guerin, with such additions as embrace the more important suggestions of other writers. CAUSES. A lateral deviation of the spine presents certain alterations in the conformation, structure and rela- tive position of the vertebral column and surround- ing tissues. The advanced age of the patient, the long duration, or the exaggerated degree of this dis- tortion, are conditions which give rise to secondary alterations, and place such deviations beyond the reach of art. Tuberculous and other disease of the bones, anchylosis and osseous transformation of the fibrous structures, are also cases foreign to the class about to be described. Certain forms are eminently adapted to receive aid from an operation ; greater in proportion to the youth of the patient and the inconsiderable degree of distortion. In such cases, the muscles, which form the chord of the principal curvature, are either primitively or consecutivelv contracted ; and dis- play themselves in certain positions of the body in the form of a resisting fasciculus, which hinders the vertebral column from assuming a normal posi- CAUSE OF THE CONGENITAL VARIETIES. 163 tion. This muscular retraction is identical with that of club-foot and wry-neck. As a primitive lesion, and a cause of osseous dis- tortion, lateral deviation is congenital or non-con- genital. CAUSE OF THE CONGENITAL VARIETY. That the congenital variety is due, like other congenital deformity, to muscular spasm, resulting from nervous influence, is shown 1. By the frequency with which deviations of the spine and other articular deformities, such as exaggerated distortion of the superior and in- ferior limbs at their different joints, and also of the hands, feet, &c. coexist in fcetal monstrosi- ties, which offer evident alteration of the brain and spinal marrow. These cases present marked mus- cular traction in the direction of each deformity, proportioned in degree to the intensity of the le- sions of the nervous centres. 2. By congenital deviations of the vertebral col- umn observed in the living subject, and accompa- nied either with strabismus, club-foot, torticollis, or other distortion of the skeleton, or with appear- ances of convulsions in the face, irregularity of the two halves of the cranium, or diminution of force and even paralysis in certain parts of the muscular system ; or, finally, with veritable congenital spas- modic affections, such as epilepsy, hemiplegia, par- aplegia, with or without muscular contraction. 164 CURVATURE OF THE SPINE. In the non-congenital form, it is equally shown by cases of spinal deviation, dating from a period subsequent to birth and immediately following cer- ebral or cerebro-spinal affections. It is accompanied as in the two preceding forms, with a great number of other deformities, such as strabismus, torticollis, club-foot, deviations of the knee, all dating from muscular convulsions, and ac- companied with retraction of the muscles exactly in relation with the form and degree of the deform- ities. In these three varieties, the essential characters of the disease are the same, and identical with those in which the deviation alone remains to indicate the existence of a similar cause at some previous period. MUSCULAR RETRACTION. Muscles* The anatomical characters of the re- tracted tissues accompanying spinal deviation are the same as those of retracted muscles in other regions. At first, in a state of spasmodic contraction, they become in a measure paralyzed, their developement is arrested, and degeneration commences ; fibrous if they are submitted to traction ; fatty in a state of repose. The condition of active contraction differs from that of passive retraction. In the former, the mus- cle is tense, acts as the immediate cause of the ver- MUSCULAR RETRACTION. 165 tebral curve and limits its extent. In the latter condition, it merely accommodates itself to the dis- tance between the extremities of the curve, and is less forcibly extended. In both cases the shortened tissue is moderately resisting. In the former or fibrous change, the tissues are felt beneath the skin, a hard, fascicu- lated mass, occasionally giving the sensation of fibro-cartilage, if the column be extended. The muscle is found to be diminished in size, retracted, paler, of a whitish yellow, of an eminently fibrous or fibro-fatty texture, contrasting strongly with the regular form, red color, and fleshy consistence of the corresponding normal muscles. The longis- simus dorsi is occasionally so fibrous that its apon- eurotic and tendinous portion acquires a double length at the expense of the muscular portion. In the fatty degeneration, the muscle becomes somewhat softer than natural, and retains its orig- inal volume. After the section of muscles thus retracted, the extremities reunite by means of an intervening por- tion, of adequate length ; this tissue regains its normal character, and becomes, in a word, muscle. Vertebrce. Upon the convexity of the curvature, both the vertebrae and their intervening flbro-carti- lages increase in thickness, while the concavity is marked by a corresponding absorption and di- minution of substance of the same parts. They thus acquire, individually, a wedge shape. Ligaments, In cases of long standing or of 166 CURVATURE OF THE SPINE. great deviation, the ligaments may become re- tracted and even ossified, in consequence of which the vertebrae tend to become anchylosed. Thorax. The ribs follow the deviation of the spine, and in exaggerated examples the thoracic cavity is distorted and compressed, and the con- tained viscera are modified in position, form and structure. Portions of the lungs may become in- durated, and even acquire a fibro-cellular struc- ture. 1 The progress of this sort of deviation is chiefly due to mechanical causes. The column once bent is powerfully acted upon by the weight of the body in a vertical position, to a degree which slackens the extended cords, and renders it difficult to detect them beneath the skin. They are not for this reason less efficient in retaining the spine in its anormal position ; and an upright posture commonly restores their tenseness and indicates their locality. In a young and recent subject this tenseness may be made apparent by suspending the body by the head. The amount of retraction is sometimes consider- able, amounting to a third of the length of the mus- cle, and is always proportioned to the curvature. In some cases the muscles, situated on the convex side of a curvature, slip over the spinous processes to occupy a position upon its concavity. iDiff. du Syst. Oss., p. 26. NON-CONGENITAL VARIETIES. 167 CAUSES OF NON-CONGENITAL VARIETY. Among the causes of the non-congenital form of spinal deviation, are 1. The convulsions of infancy. 2. Local or general spasmodic action occurring at a later period of life. These causes, recognised as producing distortion of the limbs and neck, have also their influence upon the muscles of the vertebral column, which is thus suddenly curved, though the resistance of its surrounding tissues may render the deviation so inconsiderable, as to prevent its immediate de- tection. Wounds of the muscles of the back, and blows or other violence to these tissues, may be an immediate cause of their permanent con- traction. Other causes are, a want of general muscular and ligamentous force ; an inequality in the antag- onizing power of opposing muscles ; the paralysis of some of them ; an abnormal inclination of the plane of support ; a primitive inequality of the two halves of the skeleton ; ricketty or scrofulous ten- dencies ; any of which suffice either to create a deviation, or to occasion a pre-disposition to curva- ture, which the agency of slight causes developes. The superincumbent weight of the body, and the tendency of the muscles to accommodate their length to the distance between the approaching extremities of the arc, augment the curve in pro- 168 CURVATURE OF THE SPINE. portion to their force, and the inability of the parts to resist their influence. CURVATURE AND TORSION. A lateral deviation of the spine consists of two elements, to be separately considered. 1. Curva- ture.- 2. Torsion. Curvature is of two kinds. The one occupies the immediate seat of the lesion ; the other is an accompanying and compensating deviation. The trunk always tends to maintain an upright position. As soon as a part of the vertebral column deviates from a perpendicular, another portion institutes a curve in an opposite direction, by way of restoring to the mass its centre of gravity. For this reason, a single curve never exists alone. It is rare that two are found unaccompanied by a third. Three are very common, and four occasionally met with. The position of the spinous processes is not in all cases an indication of the extent or direction of the deviation. In a pathological specimen exhib- ited to the Academy of Medicine, the column viewed from behind, offered a single curve, while the bodies of the vertebrae in front, presented four. This apparent anomaly is due to torsion, which ac- companies all cases of deviation. The principle of torsion is illustrated by an at- tempt to bend a blade of grass, or a flat, flexible stick, in the direction of its width. The centre immediately rotates upon its longitudinal axis to CURVATURE AND TORSION. 169 bend flatwise in the direction of its thickness. In the same way the spine, laterally flexed, turns upon its vertical axis to yield in its shortest or antero- posterior diameter. The centre of rotation or torsion is a vertical line through the summits of the spinous processes, which remain, in consequence, comparatively sta- tionary, while the bodies of the vertebrae rotating around this centre, tend to occupy the outside of the convexity. For this reason it often happens that the principal curve alone can be detected by the direction of its spinous processes, and writers have been thus led to admit the existence of single curvature. Each vertebra of a curve is laterally bent upon its antero-posterior axis ; and the spinous processes are thus inclined towards the transverse, upon the convexity of the deviation. The vertebrae of transi- tion from one curve to another are alone to be ex- cepted from this rule. Other elements of the mechanism of torsion, are, 1. The disposition of the articulating surfaces; which, in the cervical and dorsal regions, are oblique, while in the lumbar region they are nearly transverse. 2. The resistance of the lateral muscles, which become subsequently retracted. Among the prin- cipal, are the costal insertions of the longissimus dorsi, the inter-spinales, and the inter-transversales muscles and ligaments, which confine the summits 170 CURVATURE OF THE SPINE. of the processes, while the bodies of the vertebrae yield to the effort of flexion. GIBBOSITY. To the action of torsion is due the prominence of the ribs, muscles, scapula and shoulder upon the convex side of the curve and the corresponding de- pression upon the concavity. This deformity, com- monly termed gibbosity, is constant in cases of pa- thological deviation. CURVES — THEIR POSITION AND MECHANISM. It is rare to find two vertebral columns, pathologi- cally distorted, which offer precisely the same charac- ters. Nevertheless certain curves are more frequent than others. A convexity to the right, above, and to the left, below, is more common than the reverse. The principal curve, commonly occupies the dor- sal, or dorso-lumbar region ; a circumstance ex- plained by the fact, that the centre of the move- ments of totality, of the vertebral column, and of lateral flexion in particular, is situated at the point of junction of the dorsal and lumbar regions. It is due to the following anatomical disposition of the articulation, uniting the eleventh and twelfth dorsal vertebras. 1. "The articulating facettes are more perpen- dicular and transverse. 2. "A sort of notch is formed by a prolongation CURVES. 171 upwards and forwards of the superior tubercle of the transverse process of the twelfth dorsal vertebra, which is recurved like a hook, so as to convert into a transverse groove, the space comprised between this appendix and the superior articulating process of the same vertebra. In this groove is received the inferior edge of the articulating facette of the eleventh dorsal vertebrae, which slides there without the least of obstacle during the movements of lat- eral flexion of the column. Besides this circum- stance, certain muscles, the quadrati-lumborum, the common mass of the sacro-lumbalis, longissimus dorsi and semi-spinales, which are the agents of lateral flexion, are, to a certain extent, circum- scribed in this region, and belong especially to it." A similar conformation, but less marked, exists in the neighboring dorsal vertebrae, which gradually lose this peculiarity in receding from this point ; so that the natural curve, in the lateral movements of the spine, decreases from the loins upward. A single principal deviation once established, curves of compensation immediately follow, as the result of subsequent active muscular contraction, and the trunk is restored to a perpendicular. These secondary curves are sometimes hardly ap- preciable. That occupying the cervical region is often slight, and when masked by the action of torsion, is sometimes not indicated by a correspond- ing curve of the spinous processes. As was before remarked, an evident alternate deviation of the bodies of the vertebrae of the entire column, some- 172 CURVATURE OF THE SPINE. times presents no appreciable variation from a per- pendicular, when viewed from behind. A dorso-lumbar deviation is always arrested in the dorsal region to give place to a curve of com- pensation. Though more frequent at the junction of the lumbar and dorsal vertebrae, the distortion may occupy any portion of the vertebral column, and is attended with a general prominence of the parts upon its convexity, and a corresponding de- pression in its concavity. Exaggerated deviation is accompanied by ivrin- kles of the skin, corresponding to the concave side of the most considerable curve ; often a short dis- tance below the axilla. The trunk, supported by alternate curves, is very slightly, or not at all, inclined ; the hip, never ele- vated, if the legs be of equal length ; and the sub- ject does not necessarily walk lame. The muscles, which are commonly retracted in the principal or dorso-lumbar curvature, are the common mass of the sacro-lumbalis and longissi- mus dorsi ; in the central dorsal region, the same mass, with the spinalis and semi-spinalis dorsi ; at the cervico-dorsal curve, the complexus, cervicalis ascendens and transversalis colli. The lesion may occupy other positions. Certain portions of the trapezius may be retracted and fibrous, by the side of other portions, paralyzed, atrophied and membranous, and by the side of other healthy muscle. All the muscles of the back are sometimes retracted, producing great distor- TREATMENT. 173 tion. The long dorsal may be alone retracted, by the side of the sacro-lumbalis, passively affected ; or a simple fasciculus of one of these muscles, may offer a state of tension in the midst of healthy tis- sues. In such cases it is amply proved, that the extended muscular bands, when subjected to tor- sion, may become retracted ; in other words, their developement is arrested ; they are, in a measure, paralyzed, and more or less transformed into fibrous tissue. In such conditions they fulfil, with regard to the spine, the functions of a string in a bent bow. TREATMENT. Distortion of the spine is less amenable to treat- ment than other deformity ; chiefly, perhaps, from the difficulty of applying to it a permanent and properly directed mechanical force. A first diffi- culty presents itself in the necessity of flexing the entire body, in order to affect corresponding flexion of the vertebrae. The mass is unwieldy, and a lateral effort can be applied only through the inter- vention of the ribs, shoulders, or pelvis. Nor can this power be maintained for a length of time. The respiration is impeded, the posture is constrain- ed, the integuments are irritable, and the trunk impatient of confinement. The mechanical treat- ment must be frequently suspended, and in these intervals, various influences, among which the ver- tical weight of the trunk is not the least, tend to 174 CURVATURE OF THE SPINE. reproduce the deformity. The subsequent exer- cise of the muscles, so important in orthopedic treatment, can only be accomplished in the region of the spine, by exaggerated and comparatively fa- tiguing movements of the whole trunk. It is obvious, that such conditions are far less promising than those which commonly attend the treatment of club-foot ; where the whole distortion is embraced by the apparatus, which maintains an unremitting and progressive force, as long as it may be required, and where the gentle exercise of walking subsequently secures the advantage ob- tained from the use of a machine. The results of the treatment of spinal curva- tures are, as might be expected, much less satis- factory than those of most other distortions, while the time required is longer ; and hence the dif- ficulty of deciding between the claims of different methods. The deformity is often inconsiderable and sta- tionary, and requires no treatment. At other times the constitution of the patient is to be fortified with change of air, and food, with salt baths, cold douche, frictions and massage. Exercise in the open air is important, and the mechanical treat- ment of this deformity is always combined with gym- nastic exercises. These should be so contrived as to strengthen the muscles upon the convexity of the principal curve, and to elongate those upon its con- cavity. Such are, climbing the under-side of a spiral ladder; turning a crank above the head and on SURGICAL TREATMENT. 175 the side of the concavity, in the horizontal posi- tion ; a lateral rocking horse inclined towards the side of the concavity ; which will serve as exam- ples of a great variety of contrivances, obvious to a machinist. A bag of sand or shot, carried upon the head, while the patient walks, is an excellent method of exercising the dorsal muscles. 1 But when the pa- tient is at rest, its vertical weight would obviously tend to exaggerate the curvatures. If, however, in certain postures of the patient, a tense fasciculus appears beneath the skin, upon the concave side of the principal curvature in the posi- tion of a chord, uniting the two extremities of the arc, there is little doubt that the progress of me- chanical treatment will be accelerated by its subcu- taneous division. Were the section of muscles un- necessary, the operation is attended with no dan- ger and with little pain or hemorrhage. It offers no impediment to subsequent mechanical treatment, which is the same in every respect except in its duration, whether the muscles be severed or not. SURGICAL TREATMENT. In such a case, the exact position of the re- tracted fasciculus is ascertained by placing the pa- tient in a vertical or horizontal position ; or by 1 The straight backs of negroes, and people accustomed to carry weights upon their head, are proverbial. 176 CURVATURE OF THE SPINE. making extension, if requisite. Parallel extension is sometimes used to effect an elongation of the muscles preparatory to their section. OPERATION. M. Guerin nowhere indicates the manual of the operation. In those I have seen performed by him, amounting to a dozen or more, the patient was laid upon his belly upon the table. The hands being extended by the side, the patient was desired to raise his head ; an action by which the dorsal muscles were brought into play and their re- tracted fibres made tense. A fold of skin was then pinched up at the outer edge of the extended fas- ciculus, and, a puncture being made, the myotome was introduced flatwise at its base, at a point which afterward receded to the distance of an inch from the external border of the muscle. The knife being then turned upon the mass, the fibres were divided by a sawing motion communicated to the convex edge of the blade. By reason of its fibrous character, the resisting cord is divided with precision and at once ; and its complete section is attended with a sharp and dis- tinct explosion, as the extremities recede one from another. On the other hand, non-retracted mus- cular fibres are soft, and yield to the instrument, which is unable to effect either a clear or a rapid division of their substance. Immediately after the operation, certain elements MECHANICAL TREATMENT. 177 of the deformity disappear at once ; and what is important, other fibres rise to take the place of those which have been severed. They often oc- cupy nearly the same position, and their section is attended with an additional correction of the devi- ation. The same phenomenon sometimes appears at the end of six or eight months after the commencement of mechanical treatment. When in such a case the curvature remains undiminished during several months, the re-division of the muscles is attended with a new diminution of the curve, generally rapid during the first days after the operation. MECHANICAL TREATMENT. Mechanical treatment is effected either by por- table apparatus, which allows the patient to move about, or by mechanical beds, in which force is ap- plied horizontally. In the former, a broad metallic belt embraces the hips, and serves as a fixed point, from which exten- sion is applied either to the head or more com- monly to the shoulders. The inconvenience of the latter method is apparent. The shoulders and scapula yield to the force, while the vertebral col- umn is unaffected by it. The apparatus ofHossard, modified by Tavernier, does not aim at extension. It consists of a belt of wadded leather, four or five inches broad, and fixed around the pelvis by horizontal and perineal straps. 178 CURVATURE OF THE SP1JNE. Behind, a steel upright reaches to the height of the shoulders, and is attached to the belt by ratchet work, which admits of its lateral inclination tow- ards the shoulder of the concave side of the curve. From its summit a broad strap winds spi- rally downward round the convexity of the curve, which it presses towards a perpendicular, and is fixed to the belt in front. The trunk being thus thrust from its centre of gravity, tends, in recover- ing itself, to correct the spinal deviation. The strap should traverse the most salient point of the ribs behind, while a second strap passes, if required, in the contrary direction around the lumbar curve. This efficient apparatus does not forbid active exercise. Its great advantage is, that the correct- ing force is purely muscular ; and derived from the efforts of the body to regain the perpendicular from which it is thrust by the machine. On the contrary, the shoulder supports ; and the Minerva already described, 1 which exercises traction upon the head, are substitutes for muscular action, which they enfeeble, in supplying its place. 2 Marshall Hall proposes to take a plaster cast of the body, in an upright position, and to deposit upon it, by the galvanoplastic method, a coating of copper. The whole is sawed in two, vertically, and a pair of copper corsets are thus produced ex- actly fitted to the trunk. The idea is ingenious, 1 See page 124 and plate, fig. 24. 2 Lancet, Feb. 3, 1844. PARALLEL EXTENSION. 179 but the principle of support is open to the objection just mentioned. Various orthopedic beds have been devised for the purpose of effecting horizontal extension. In these the force is best applied in one of two ways. 1. In a direction parallel to that of the spine. 2. In a direction perpendicular to it. PARALLEL EXTENSION. Parallel extension is effected by fixing the pelvis and applying an extending power to a series of straps passed round the chin and head. This is best effected by the machine about to be described for the second method. This method is applicable in old and very pro- nounced curvatures, where the extent of the curve gives power or purchase to this simple traction. Also in the deviations with four curves, or where two closely follow each other in the dorsal region. It is then impossible to apply perpendicular force to each curve separately, on account of their proximi- ty. Continued force of this sort is liable to pro- duce a relaxation of the ligaments, which predis- poses the spine to a recurrence of the deformity. It also tends to efface the natural antero-posterior curves. Many young people treated in establish- ments where these beds are exclusively employed, have their backs flattened ; the shoulders and other regions of the vertebral column being reduced to the same plane. These ill effects are to be com- 180 CURVATURE OF THE SPINE. bated by suitable gymnastic exercises alternating with extension. Horizontal extension also acts but indirectly upon the wedge-shaped conformation of the vertebrae, its power diminishing as the curve becomes less marked. SIGMOID EXTENSION. The method which Guerin has called sigmoid extension consists of several elements. The first of these is parallel extension, the head and pelvis being respectively attached to the top and bottom of the bed. The second is a lateral force applied to a point upon the side of the trunk corresponding to the convexity of the curve, and in a direction perpen- dicular to it. The action is analogous to that of straightening a bow, when the extremities are held in the hands, and the knee is applied at an intermediate point of the convexity. It has several advantages over parallel extension. The power is applied to greater advantage ; and a temporary curve in the opposite direction is substituted for the original curve ; as in the attempt to straighten a bow. This feature of sigmoid extension is of great im- portance. To effect it, two uprights are placed upon opposite sides of the bed, one above the other, at points which correspond with the convexity of each curve ; and are capable of being advanced towards a median line and fixed in that position. PARALLEL EXTENSION. 181 This simultaneous application of the power to the extremities and convexity of the double curve or S, suggested the term sigmoid extension. It is the more efficient, as many deviations have their prin- cipal curve at the level of the dorso-lumbar region, which answers to the articulation already described of the eleventh and twelfth dorsal vertebrae ; a dispo- sition which greatly aids the action of the machine. A third peculiarity is the combination of flexion and extension. It is effected by placing the cen- tres of rotation of the upper and lower portions of the bed upon opposite sides. In illustration of this, provide a strip of board, and a pair of compasses, the length of which is equal to the width of the board. Saw the board across, and placing the shut compasses horizontally in the interval of division, attach a leg to each of the sawed surfaces. The joint of the compasses forms a lateral centre of ro- tation for the boards ; and in flexing one board upon the other, the triangular interval of separa- tion gradually increases. If the board be again sawed and provided with a similar joint upon the opposite side, this arrangement will represent the orthopedic bed, employed by M. Guerin, in which a joint corresponds to each of the two principal curves. The body of the patient fixed upon it is at once flexed by the joints, and extended by the increasing intervals of separation. A helmet is united to the apparatus by a uni- versal joint, and serves for the mechanical treat- ment of torticollis. It is capable of being fixed in 182 CURVATURE OF THE SPINE. any position which the cervical vertebrae in their normal state, are capable of assuming, and serves as a point of counter-extension to the pelvis, which is attached by a belt and straps to the foot of the bed. It should be remarked, that the extension of the head is in reality effected, not by the helmet, but by a stuffed collar of iron suspended from its lower margin. M. Guerin finds it inexpedient to flex simulta- neously, the upper and lower tables of the bed ; and when there are two principal curvatures of nearly the same degree, they are treated alternate- ly in different parts of the day. When there is a single principal curve for which the muscles have been divided, M. Guerin directs attention to this, to the exclusion of the less marked curves of compensation. In such a case, the body being extended, is thrust to the side of its concavity by the aid of the uprights alone ; one of which is applied to the convex point, while the op- posite supports the pelvis. The tables of the bed are then not flexed. In certain scrofulous and other deviations with- out muscular contraction, simple flexion may be required, without extension. It is effected by a bed like that described ; but possessing but one division, with its axis of lateral flexion at a point equi-distant from the two sides. The apparatus will be better understood by re- ferring to the annexed drawings, (figs. 31, 32, 33, 34.) CONTRACTION OF THE HAND AND FINGERS. The section of tendons in the hand is much less uniformly productive of good results than in many other regions, and its propriety has been disputed. The indications for the operation are not yet clear- ly pointed out. It has been performed by most orthopedic surgeons, but it is doubtful if it is ever efficacious, while it is certain that the fingers are sometimes disabled by the operation. CAUSES. The distortion is sometimes due to diseases of the bone. That form which is the effect of contraction of the tendons, or which is accom- panied by this symptom, recognises a variety of exciting causes. It is occasionally, but rarely, congenital. It results from cutaneous eruptions, fractures, wounds or abscesses. It also follows 184 CONTRACTION OF THE HAND AND FINGERS. paralysis of antagonizing muscles. In the variety thus accompanied by active or passive muscular re- traction, which alone oners conditions for tendinous section, the tendons are resisting and in high relief beneath the skin. The deviation is rarely due to a single set of muscles, and it commonly presents a combination of the various movements of the hand. Flexion of the hand is sometimes accompanied with extension of the fingers or with a lateral inclination, and with flexion of the phalanges. The muscles of the arm not unfrequently participate in the affection, and the fore arm is more or less flexed or pronated. It has been demonstrated by Froriep of Berlin, that the palmar aponeurosis, when retracted, may aid in the flexion of the phalanges, by means of fibres which it supplies to each side of the fingers. In certain cases the joints are partially anchylosed, and require forcible extension. The section of the flexor tendons of the fingers is frequently, if not in all cases, followed by a loss of power in the hand. The phalanges can no longer be flexed. It has therefore been a question whe- ther their division should ever be attempted. In support of the affirmative, it is urged that the de- formity is in a great measure relieved ; and that in unsuccessful cases the hand yet retains sufficient power to grasp large objects. But it is probable, that were the chances fairly represented, few pa- tients would consider the shape of a hand an in- ducement to hazard the loss of its use ; and the CONTRACTION OF THE HAND AND FINGERS. 1 85 histories of cases like that of M. Doubouvitski, 1 will deter most surgeons from attempting the division of the tendons in this region. OPERATION. For the deviation of the entire hand, which is rare, it suffices to divide the palmaris longus and brevis, and perhaps the flexor carpi ulnaris if there be a lateral inclination of the hand. These ten- dons are subcutaneous, and easily divided. The motions are generally restored, when the contrac- tion is not due to paralytic affection of the antago- nizing muscles. 2 More commonly, the flexors of the 1 In this well known case, many tendons of the forearm and hand were divided by M. Guerin ; among them, the deep flexor in the fingers and the superficial flexor tendons in the forearm. The pa- tient, who was before able to retain an object in the contracted fingers, lost all power of flexing the phalanges, and the hand became in consequence, comparatively useless. Similar instances are not wanting. The case of Jenny Wilson re- ported by M. Guerin to the Acad, des Sciences, to illustrate the inno- cuity of the division of thirteen tendons, was examined by M. Phillips, a year afterwards at the Salpetriere. He sums up the anatomical details as follows : " This patient remained during nine months in the service of M. Guerin at the ' Hopital des Enfants.' She bitterly de- plores, as well as her mother, the results of all the operations she has undergone. Before these sections she could make a move- ment with the fingers which permitted her to hold a needle, which she then seized with the mouth to be again taken by the fingers. By these movements she could sew fast enough to make shirts. Now, this sole resource no longer remains ; she is condemned to vegetate in a service of incurables at the 'hospice de la Salpetriere.' The thirteen sections were made in the forearm, in the two legs, and two feet." — Annates de Chirurgie. Paris, 1841; t. ii. p. 130. 2 Little in Lancet. Dec. 16, 1843. 24 186 CONTRACTION OF THE HAND AND FINGERS. fingers are also retracted and the phalanges drawn toward the palm. The first phalanx often remains straight, while the two last are flexed upon it. After dividing the flexors in the forearm, the hand may be more or less extended, but when, as it often happens, the fingers are stiff and unyielding, the surgeon is called upon to decide upon the expedi- ency of additional sections in the palm and fingers. In such a case, extension may be sometimes effected by force, but it should be previously ascertained that the resistance is not due to the retraction of tendons or palmar aponeurosis. As was before stated, the division of the tendons of the palm and fingers is rarely successful. The section of the deep flexors at the level of the second phalanges allows the extension of the fingers but paralyzes their power of flexion. The tendon is drawn back through the bifurcation of the super- ficial flexor, and an interval is thus formed between the divided surfaces, which are hindered from unit- ing by the presence of the synovial fluid. In the present state of knowledge upon this sub- ject, it may be affirmed that the superficial flexors of the fingers should never be divided at the base of the first phalanx, but rather in the forearm. The proximity of the median nerve at the wrist, compels us to divide the deep-seated flexors in the palm, if at all ; but the reunion of their tendons is uncertain. The operation is indicated only when a single finger is permanently flexed, and interferes with the movements of the rest. CONTRACTION OF THE HAND AND FINGERS. 187 The flexors of the toes are sometimes retracted, and may be divided in the sole, the reestablish- ment of motion being here of comparatively little importance. Little benefit is obtained in most cases from a simple division of the cicatrices consequent upon burns, especially upon the palmar surface. MECHANICAL TREATMENT. Immediately after the section, the patient is apt to experience severe and deep-seated dragging pain in the arms, due to the forcible contraction of the muscles. The pain is alleviated by frictions and steaming. The hand being well protected, is confined in contact with a straight splint, extending from the elbow to the extremities of the fingers. The splint may be provided at the wrist with a hinge regu- lated by a screw or other mechanism, so contrived as to fix it at any required angle. The whole may be supported in a sling. CONGENITAL DISLOCATIONS. Numerous well described cases of the different varieties of congenital luxation are to be found in the papers of various writers, especially since the subject has received general attention. Although interesting, in an anatomical and pathological point of view, they are generally to be referred to the principles laid down by Guerin in his memoir upon this subject, which is the groundwork of the fol- lowing chapter. CAUSES. Certain forms of congenital dislocation are due to the paralysis of certain muscles. Luxation resulting from disease of the bone is unaccompanied with active muscular retraction, and easily distinguished. The affection is due in a large majority of LOCALITY AND PROGRESS. 189 cases to muscular retraction ; and resembles in this respect club-foot and wry-neck. It accom- panies these distortions, and is found in acepha- lous and other anormal conformation of the nervous system. LOCALITY AND PROGRESS. Any joint in the body is liable to dislocation from muscular retraction. The luxation may be partial or complete. At an early period of foetal life, the articulating cavi- ties are imperfectly formed, and the articular ex- tremities easily extend the yielding ligaments, and escape from their normal positions. At a later pe- riod, when the sockets are more completely devel- oped, the dislocation is commonly partial. The progress of the luxation is due to the arrest of the developement of certain muscles ; to the physiological contraction of others ; and to the su- perincumbent weight of the body. These forces in the end complete a dislocation which was at birth partial. In such cases, an indeterminate length of time is required to complete the luxations. The femur in such cases rarely escapes from the aceta- bulum in less than three or four years after birth ; and surgeons have been thus led to suppose the affection non-congenital. An essential step towards the reduction of the dislocation, is the division of the retracted muscles, whether actively or passively affected. 190 CONGENITAL DISLOCATIONS. CONDITION OF THE MUSCLES AND SOFT PARTS. The muscles originally concerned in inducing the luxation are actively retracted. Others, pas- sively retracted, merely accommodate themselves to the approximated points of insertion. Their di- rection is often changed. Their texture is either fibrous, when tense ; fatty when exempt from traction ; or hypertrophied when tasked with the duties of inefficient muscles. Muscles primarily retracted, require division. Those passively shortened may be, in certain cases, mechanically extended, but sometimes require divis- ion. The fatty tissue opposes no obstacle to the normal position of the part. The arteries become flexuous and retain their length, but decrease considerably in volume. The veins increase in number and in size. The nerves are shortened, probably through the agency of their fibrous sheath ; and their mechanical extension, during treatment, is attended with pain. The cellular tissue increases in quantity, fills up depressions, and takes the place of the atrophied muscular fibre. The skin adapts itself to the conformation of the subjacent parts, being often cushioned in depres- sions, by adipose matter. The ligaments and capsules, like the muscles, are changed in form, dimensions, and texture. They may be actively retracted as well in con- genital dislocation as in other deformity. In ex- CONDITION OF THE MUSCLES. 191 treme adduction of the foot, the internal lateral ligament of the tibio-tarsal articulation and the astragalo-scaphoidean ligament are sometimes re- duced to a third or a quarter of their normal length. In the same way the external lateral ligament of the knee offers an obstacle to the correction of in- ternal deviation of this joint. The ligaments are also subject to passive retraction, merely accommo- dating themselves to their approximated points of insertion. When extended, they become thinner and longer. Like the muscles they are subject to fatty trans- formation when in a state of continued repose, though in a less degree. In conditions which pro- duce the fibrous transformation of the muscles, the ligaments tend to become ossified ; a condition which is also the occasional effect of rest alone. The articular capsule of the femur when extend- ed gradually, acquires the form of a double cone united at their summits. In fine, the ligaments and capsules when retract- ed, offer invincible obstacles to reduction by unaid- ed mechanical force ; and when elongated, they constitute a serious impediment to any efforts to maintain this reduction. The cavity of the capsular ligament of the head of the femur, has been found to be obliterated in old subjects ; a fact upon which has been founded an argument against attempts at reduction. This condition does not exist in young subjects ; and is rarely a serious obstacle to reduction until the pa- 192 CONGENITAL DISLOCATIONS. tient attains the age of twelve or fourteen years. The communication has been found to exist even in subjects of twenty, twenty-five, and thirty years of age. Alterations of the articular extremities. The head of the femur, for example, is diminished in size, while its neck becomes shorter and more horizon- tal. - It may be flattened or grooved, by pressure against the edge of the socket, or other neighbor- ing parts. When no longer lubricated by the synovial fluid, its surface loses its polish, and becomes rough, while the cartilage gives place to bone. Articular cavities. The cotyloid cavity is especial- ly the seat of alteration. It tends to become at once superficial, and triangular, in a manner correspond- ing to the triple formation of the os innominatum. The articular cavities tend to become obliterated, in proportion to their original depth, and the date of the lesion. This is effected in two ways. 1st. By the rising up of the bottom of the socket, which seems to result from the absence of pressure. 2. From the production of a cellular fatty tissue, ap- parently the hypertrophy and degeneration of the normal tissues of the base of the cavity. When the luxation is partial, the cavity yields to the continued pressure of the head of the bone in the direction of the force which it exerts. These conditions may be thus summed up, with reference to the reducibility of the luxation. 1. When the head of the bone has escaped from its CONDITION OF THE MUSCLES. 193 socket, and no new socket has been formed, both the articular extremity and cavity proportionately diminish in size. This circumstance, while it facil- itates reduction, impedes subsequent movement. The reduction, however, tends to induce the parts to resume their normal size. 2. If the head of the bone has formed a new socket, it retains much of its original dimensions, a condition which hinders it from entering the atrophied socket, and prevents its reduction. 3. The grooves and other irregularities in the conformation of the articulating extremity, inter- fere both with reduction and subsequent move- ment. 4. After reduction, the articular deformities, and the relaxation of the capsules, facilitate the recur- rence of luxation. The changes both of bones and soft parts is gradual and slow, so that though these luxations become after a time irreducible, they are not so at first. Guerin has reduced congenital dislocation of the femur, of ten years' standing, and M. Guil- lard has reported a similar case of permanent reduc- tion of a scapulo-humeral luxation, in a girl of six- teen years of age. Congenital Dislocation is not due to a simple arrest of developement of the bony structure. If the bones be examined at an early period after lux- ation, they are found unchanged. 25 194 CONGENITAL DISLOCATIONS. ALTERATIONS OF PARTS IN THE NEIGHBORHOOD OF LUXATIONS. New articular cavities are sometimes formed, and sometimes not. They are rarely developed before the age of twelve or fourteen, but the period of their formation varies. In an old woman of seven- ty-three with double congenital luxation of the hip, one new cavity was formed, while the other side presented merely a slight depression. With regard to the conditions which aid in es- tablishing the new socket, M. Guerin declares it to be a law that such cavities are formed, only when the capsular ligament is ruptured, and the head of the bone is placed in contact with the bone upon which it lies. When the new joint is formed, the ruptured capsule contracts firm adhesions, which preclude all chance of displacing the bones, except by un- justifiable violence. When there is no new joint, the head of the bone is finally bound down by fibrous cords, which require subcutaneous division. Alterations of the skeleton. These are especial- ly observed near the hip. Contrary to the opinion of Dupuytren, the pelvis often suffers in these cases, as has been shown by M. Sedillot. When one femur is luxated upwards and out- wards, the pelvis of that side is carried upward, backward and outward. The whole pelvis is flat- INDICATIONS FOR REDUCTION. 195 tened obliquely, the pubis being carried beyond the median line towards the healthy side. The os innominatum of the affected side be- comes more perpendicular, and that side of the pel- vis is elevated. INDICATIONS FOR REDUCTION. From examinations of the pathological confor- mation of the parts, in different stages of lesion, it results, that congenital luxations are reducible in certain conditions ; that they are less so in propor- tion to the degree and long standing of the deform- ity ; that they are wholly irreducible when very old, and principally when accompanied with new artic- ular cavities ; and, finally, that the permanence of the reduction is in proportion to its facility. MEANS OF PREPARING FOR, EFFECTING, AND CONSOLIDAT- ING, REDUCTION IN ALL ARTICULATIONS. 1. Preparatory and continued extension, which counteracts the displacement due to superincum- bent weight, and brings into view the retracted muscles. 2. The subcutaneous section of muscles which refuse to yield to extension. 3. Continued extension of the ligaments; and their subcutaneous section if required. 4. The reduction of the luxation. 5. The consecutive treatment ; of which the in- dications are 196 CONGENITAL DISLOCATIONS. 1. Apparatus of extension to elongate the mus- cles and ligaments not divided, and to extend those which have been divided. 2. Force so supplied as to maintain the articu- lar surfaces in contact, and to exercise continued pressure upon the part destined to form a new socket. 3.' Gradual motion in imitation of the normal movement of the part ; to wear away as it were a depression for the articulations, and to establish its functions. 4. An indication derived from the fact that the capsule must be ruptured, and the bones placed in contact before a new articulation can be estab- lished. M. Guerin therefore practices subcutaneous per- foration of the capsule, and scarification of the liga- ments, to promote an inflammatory action, which may induce their firm adhesion. In this way M. Guerin reduced the congenital dislocation of the sternal extremity of the clavicle in a girl of thirteen years of age, which had been repeatedly reduced, without success. M. Guerin scarified the capsular ligament, and repeated the operation at the end of ten days. The extremity of the bone was confined in its place, and in a month the ligaments were firmly retracted, and the arm was capable of executing its normal move- ments without luxation of the clavicle. RECENT AND CHRONIC DISLO CATIONS. The tendons not unfrequently form a serious impediment to the reduction of accidental disloca- tions of long standing, especially of the humerus and olecranon. They have been not unfrequently divided in these cases, by the subcutaneous opera- tion, and the limb has been thus replaced with comparative ease. The pectoralis major, latissimus dorsi and teres major and minor muscles, have been thus divided for the purpose of reducing a dislocation of the shoulder of long standing. I have seen M. Berard divide the tendo Achillis, for the purpose of facilitating the reduction of a recently dislocated foot. The foot was easily re- placed, and the patient subsequently recovered its use. Several similar cases are reported in the journals by this surgeon, and by other writers. 193 DISLOCATIONS. In the reduction of a dislocation of the foot, of long standing, accompanied with the formation of an artificial tibia tarsal joint, M. Bonnet divided the tibialis posticus, the extensors of the toe, and of the great toe, and finally all the fibrous tissue of new formation. SECTION OF MUSCLES IN LOCKED JAW. Certain rare forms of this affection are due to bony anchylosis, for which M. Berard has proposed a section near the condyles analogous to that prac- tised in Barton's operation for anchylosed hip. The more common form results from muscular contraction. For such cases M. Bonnet 1 proposes the section of the masseter and temporal muscles, as an aid to ordinary mechanical means for sepa- rating the teeth. The masseter is best divided according to Bonnet, in its superior fifth. Below this point, it adheres to the lower jaw and is cover- ed behind by the parotid gland. The tenotome is entered at the anterior border of the muscle, just below the zygomatic arch, and carried behind it as far as the coronoid process of the lower jaw. The muscle is then divided from within outward. 1 M. Bonnet effected the division of the masseter muscle, Oct. 16, 1841. It had been performed by Dr. Schmidt of New York, the 8th of the same month. — Boston Med. and Surg. Jour., July, 1842. 200 LOCKED-JAW. The temporal muscle may be divided above or below the arch. It is best divided below, unless, as in old patients, the coronoid process is so long as to impede the progress of the knife. The mus- cle may be always divided above the arch, but its substance is less tendinous, and the hemorrhage from the deep seated temporal artery is consid- erable. In the section beneath the zygomatic arch, the tenotome is entered at nearly the same point as for the section of the masseter, and directed towards the tuberosity of the superior maxillary. The blade is then passed backwards, between the ex- ternal pterygoid and the temporal muscles, until it reaches the articulation ; when the muscle is di- vided from within outwards. The coronoid pro- cess is occasionally an insurmountable obstacle to the section in this region. Above the malar bone the blade is entered just in front of the temporal artery, and carried to the bone, in contact with which it remains until it reaches the posterior part of the malar bone. The edge is then turned outwards and the muscle di- vided. Both the muscles may be simultaneously divided. In one case in which M. Bonnet applied these methods, a slight amelioration was obtained. The patient was old, and the affection of long standing. The operation of Dr. Schmidt was followed by immediate relief in locked-jaw of twelve years standing. SUBCUTANEOUS SECTION OF THE ORBICULAR MUSCLES. These muscles have been subcutaneously di- vided, with good results, for various affections. That of the mouth, for deviation of one of the an- gles, which assumed, after operation, its normal po- sition. 1 That of the eye, by Cunier, for ectropion. The sphincter of the anus, by Blandin, Brachet, and others, in cases of fissure of the anus. M. Phillips affirms that the orbicular muscles are not formed of circular, but of straight fibres, ob- liquely situated, and attached by one extremity to a median line, and by the other to an aponeurotic circle which surrounds them. This he infers from the irregular form of the mouth in the spasmodic action of its orbicular mus- cle, and from the fact that, in drawing upon the 1 Phillips' Tenot. Souscut. p. 204. 202 ORBICULAR MUSCLES. fibres, in any direction, the orifice is distorted and a chord instead of an arc is produced by the trac- tion. The relief obtained by the division of the orbic- ular muscle of the eye, in the case of ectropion above referred to, seems to confirm this theory. APPENDIX. In the treatment of deformity, it is common to take at the outset, a cast in plaster of the distorted region, which may be afterwards compared with a cast taken at a subsequent time. The result of orthopedic treat- ment is in this way readily appreciated. In casting entire limbs some little dexterity is requi- site. The tendency of the dried or anhydrous sulphate of lime to set, or form a solid hydrate when mixed with water, is well known, and most people are familiar with the general features of the process of casting in plaster. But there are some details connected with manipulation, in casting large masses, and in taking moulds from the living subject, which deserve to be mentioned. I have therefore written out the following description of the process, most of which I obtained, one morning, from the ' mouleur ' attached to Guerin's establishment. 1. No tools are a substitute for the hand, which is in contact with the plaster during the whole process. The only utensils required are a stiff spatula of wood, or better of iron, a bowl, a chisel and mallet. 204 APPENDIX. * 2. The necessary quantity of plaster must be mixed at once. It is evidently better to exceed than to fall short of the required amount. 3. The most convenient vessel is a basin or common earthen pan with flaring sides. Into this, water at the temperature of about 100 degrees 1 is first poured. The calcined plaster is then taken in large handsful, sup- ported by the open palm and fingers which are slightly separated, and gradually sprinkled into the water by a sort of successive undulating movement of the fingers. In this manner the water attacks each particle as it falls, and hinders the formation of lumps which are after- wards difficult to break up. The powder is equally distributed until it is so heaped up that it begins to ap- pear above the surface. Half a minute is then allowed to elapse to enable the water to penetrate it thoroughly, after which the mass is stirred with the spatula until it assumes, at the end of a minute, a uniform consistence of the density of thick syrup. It is then ready for use. The plaster is placed in contact with the object, of which a cast is desired, and when hard is removed. It then constitutes a mould into which a fresh quantity of plaster is subsequently poured. The last should pre- sent, when withdrawn, a fac-simile of the original. It is evident that solid objects require a mould of several pieces, which multiply in proportion to the com- plicated form and unyielding material of the model. Flesh and other soft tissues yield to the projecting an- gles of the mould ; and the number of its pieces is thus considerably diminished ; so that it is rare that a human limb or trunk requires a mould of more than two pieces. i Cold water subjects the patient to unnecessary exposure. APPENDIX. 205 The divisions are made by means of a strong thread which is applied to the limb before the plaster is laid on ; and being withdrawn by its loose ends when the plaster is half hardened, it cuts its way out and bisects the mould. The position of the string as a general rule is as follows : 1. On the leg, from the superior insertion of the rec- tus muscle over the patella, along the tibia to the outer side of the great toe, and by the centre of the sole, heel, and ham, to the tuberosity of the ischium. A better di- vision is from the great trochanter to the head of the fibula, centre of the external malleolus, thence on the external edge of the foot to the edge of the little toe, and the end of the great toe ; then back to the internal malleolus, the internal condyle of the femur and the superior insertion of the adductor muscles. 2. The arm is divided by a line from the region of the pectoral on the side to the styloid processes of the pronated radius and by the radial edge of the hand and the tips of the fingers to the styloid and coronoid pro- cess of the ulna and the region of the deltoid. If the fingers be separated, the string is to be carefully carried to the base of each, upon the edge which separates the palmer and dorsal surfaces. 3. Upon the trunk, the line passes over the back of the neck a little before one shoulder to the great tro- chanter on one side, and behind the other shoulder to a point just behind the trochanter of the opposite side. The action of respiration commonly breaks the mould upon the anterior surface of the trunk, and the pieces are to be subsequently put together. 4. The mould of the head requires but two pieces, separated before and behind on the median line, or, which is better, by a line through the vertex passing 206 APPENDIX. before one ear and behind the other. Such an oblique division obviates the difficulty presented by correspond- ing prominences on opposite sides of the original. They are thus distributed between the two halves of the mould. The hair is covered by an oiled napkin and the ears are plugged with cotton. The head is commonly included in a cast of the neck ; a perpendicular position is necessary. The soft plaster then flows off from the sides of the nose without ob- structing respiration. In the horizontal position, quills or paper tubes are adapted to the nostrils. A perpendicular position is required to display the action of the muscles of the neck or trunk, while the limbs may be cast horizontally. When permanently flexed, the plaster is kept in contact with their inferior surface, by a sort of bed formed by a sheet of stiff paper supported by straw. As a slight motion breaks the plaster before it is hard- ened, young children require to be confined during the process. If a leg for example, is to be cast, the plaster is pre- pared as before indicated, some of the thinner plaster is then applied with the hand to the external and internal surfaces of the limb, and by means of this the string is made to adhere, care being taken to bring it in con- tact with the skin at every point. The limb is then gradually covered, and the plaster as it thickens, is ap- plied with the hand till it attains a depth of from one to three inches. The string is withdrawn while the plaster is yet soft, and the mould thus divided is allowed to harden. The mass grows warm j and it is just be- fore its maximum heat, when a fragment pressed be- tween the thumb and finger breaks as if dry and brittle, that it is to be taken off, If the plaster by accident APPENDIX- 207 becomes too hard, so that the string breaks, the mould is to be broken with a chisel and mallet, and the frag- ments are subsequently united, by a layer of plaster applied to the outside. In casting the back, the model is seated upon a table and the hairs of the neck being matted together with soft soap, the plaster is applied with the hand to the upper part of the neck and shoulders and allowed to stream down the back. As it attains consistence it ad- heres to the skin and may be built up. The interior surface of the mould thus formed is im- mediately painted over with a mixture of soft soap and water, and when saturated, the superfluous soap is re- moved, and a thin coat of oil applied. If composed of pieces, these are united and the mould is then ready for the cast. Plaster is prepared as before, without delay, poured into the interior, and allowed to set. At the expiration of fifteen minutes the mould must be broken off in small fragments with a chisel and mal- let, and is hence said to be lost, {stampa persa.) Du- ring this operation the cast is held in the lap, and the blows should be given in the direction of the axis which presents the greatest inertia. The mould is thus readily detached ; its entire superior surface being removed before the base is attacked. If the cast be not immediately made, the mould be- comes dry and must be soaked in water before the ap- plication of the soap. If the operation be delayed for several days, the plaster of the mould becomes so hard as to be with difficulty broken. If the cast be allowed to remain a few hours in the mould the oil is absorbed and the surfaces are with difficulty detached. If a duplicate cast be desired, a permanent mould {stampa buona) is made upon this first cast, which then 208 APPENDIX. serves as the model. The model is well oiled and plas- ter is applied in small masses each capable of being de- tached from its various curves and angles. The first piece is detached and its edges squared with a sharp knife after which it is oiled and replaced to aid in the formation of the next. These fragments are numerous when the model is complicated. Drapery, and the stat- uettes, which are common in the shops, sometimes re- quire several hundred, which are kept in place by an outer covering or garment (camisia) of plaster in large fragments. When dry the mould is heated and satu- rated with boiled linseed oil at a high temperature. This gives tenacity to the plaster, and presents when cold a polished surface, which needs only to be oiled when a cast is required. The pieces are detached in the inverse order of their formation, and such a mould yields an indefinite number of casts. REFERENCE TO PLATES, STRABISMUS. Fig. 1. Speculum for upper or lower Lid. " 2. Hook for Conjunctiva. " 3. Double do. for Sclerotic. " 4. « Crotchet-bistouri ' ot Baudens with porte-sponge. " 5. Blunt Hook of Dieffenbach. '.* 6. Tenotome of Guerin, (see p. 26.) " 7. Side view of do. " 13. Snowden's blephareirgon modified. TENOTOMY. Fig. 8. Common pointed Tenotome. " 9. " blunt do. " 10. Myotome for Dorsal Muscles. " 11. Front view of do. " 12. Guerin's Tenotome for Sterno-Cleido-mastoid Muscle. " 13. Self-acting Speculum for Lids. CLUB-FOOT. Equinus. Fig. 14. Foot-board of Stromeyer. (see p. 107.) " 15. Scarpa's Boot, (see p. 102.) Sole of do. «' 16. \ " 17. \ Graduated Movement. " 18. ) Varus. «• 19. Contrivance for reducing Varus to Equinus. (see p. 108.) " 20. Dieffenbach's do. (see p. 109.) 27 Hs-.l. tsr u E Talse Amckjlosis of Emee Join* lateral €wTw&itmn'e 6 Eiff. 31