Part 53

Detmold 167 98 69 Bouvier 80 48 32 Martin 61 45 16 Scoutetten 21 13 8 ——- ——- ——- 329 204 125

There are certain facts which would seem to show that club-foot is sometimes hereditary; or, at all events, that it may occur in several members of the same family. Thus, Dr. Detmold states that he has been able to trace the hereditary predisposition to this deformity in not less than eighteen cases, and in all excepting one, to the father’s side. Whether this was a mere coincidence, or obtains generally, it is impossible to say. Mons. d’Ivernois relates an instance in which four brothers were all born with the feet twisted inwards; and another writer, Mons. Helt, speaks of a family, which consisted of six children, all of whom were afflicted with congenital club-foot. In the latter case the disease was probably hereditary, as one of the parents was labouring under the same infirmity. It should be observed, however, that club-footed parents do not always produce club-footed children.

Club-foot may be conveniently divided into four varieties—the inverted, everted, phalangeal, and calcaneal—which differ from each other not only in regard to the character of the distortion and the accompanying phenomena, but likewise in relation to the frequency of their occurrence and the nature of their proximate causes. The most common form by far is the inverted, usually denominated varus, in which the patient walks upon the outer ankle, the great toe being directed inwards and upwards. The muscles of the calf and the adductors of the foot are contracted, and hence there is not only elevation of the heel, but a peculiar inward twist of the foot, analogous to supination of the hand. This alteration occasions the most serious impediment to progression, and when it reaches its highest point imparts a most disagreeable aspect to the affected limb. In the higher grades of the disorder, the sole of the foot is literally scooped out, as it were, as well as deeply furrowed; the instep, on the contrary, is unusually convex and prominent; the small toes generally present in a vertical position, while the big one, separated from the rest, looks upwards and inwards; the outer margin of the foot, which, in conjunction with the corresponding malleolus, chiefly sustains the weight of the body, is almost semicircular in its shape, rough, and callous; and the tendo-Achillis, forced obliquely towards the inner side of the leg, forms a tense, rigid chord beneath the skin.

Sometimes both feet are affected with varus, so that their points form an acute angle with the leg; or approach so nearly as to touch, or even overlap one another. In the majority of cases the thigh and leg retain their natural conformation, being merely somewhat atrophied; occasionally, however, one or both knees project slightly inwards or outwards, owing to the contraction of the hamstring muscles.

The second variety of this deformity, anciently called valgus, may be regarded as the opposite of varus, the patient treading on the internal margin of the foot, while the external is entirely removed from the ground. The sole is directed outwards and slightly backwards, the toes are more or less elevated, and the outer ankle is in a state of semiflexion. The heel is drawn upwards and somewhat outwards, the internal malleolus is uncommonly prominent, the instep is flatter than natural, and the muscles of the calf, together with the adductors of the foot, are permanently contracted. When the disease has attained its highest point, the patient has an unsteady, vacillating gait, from the difficulty which he experiences in preserving his centre of gravity. Valgus is comparatively rare; and, like the first variety of the distortion, it may affect one or both limbs. It is seldom a congenital affection, but is almost always produced by some local injury—as a sprain or blow.

The phalangeal club-foot—the pes equinus of the older writers—is caused by a shortening of the gastrocnemial and soleal muscles, aided, in some cases, by the flexors of the toes. In this species of the deformity the individual walks upon the ball of the foot, the toes, or upon the metatarso-phalangeal articulations, without the heel or any other part of the sole touching the ground. The distance at which the heel is raised varies in different cases, from six lines to four or five inches, according to the extent of the contraction upon which the distortion depends. Considerable diversity is observed in regard to the manner in which the person treads on the ground; most commonly the ball of the little toe bears the brunt of the pressure, but in some instances the weight is thrown upon the great toe, or it is diffused over the whole of the fore part of the plantar surface. In the worst gradations, the heel is so much elevated that the foot forms nearly a straight line with the leg, the toes are much deformed, the instep is unnaturally convex, the plantar aponeurosis is greatly contracted, and the skin above the heel is thrown into dense wrinkles.

In the fourth variety—the calcaneal, recently described by Mons. Scoutetten—the limb rests upon the heel, the toes being drawn upwards, towards the anterior surface of the leg, with which they sometimes form an acute angle. The immediate cause of the deformity seems to be a contraction of the anterior tibial muscle and of the extensor of the great toe, assisted occasionally by that of the common extensor of the foot. The tendons of these muscles form an evident protuberance under the skin, where they present the appearance of tense, rigid chords, which powerfully resist the extension of the limb. The inner margin of the foot, as seen in the cut, is sensibly elevated above the outer, and there is always considerable atrophy of the leg. The distortion, which is almost always congenital, is exceedingly rare. Occasionally the foot inclines slightly outwards, owing to the inordinate contraction of the common extensor muscle.

The changes which the bones, ligaments, and muscles undergo, vary, not only in the different species of club-foot, but in the different stages of the same case. The greatest alteration appears to exist on the part of the tarsal bones, which, although they are rarely completely dislocated, are generally somewhat separated from each other, twisted round their axis, variously distorted, atrophied, or marked by irregular spicula or exostoses. The calcaneum, cuboid, scaphoid, and astragalus, always suffer more than the other bones; which, however, as well as those of the metatarsus and of the toes, usually participate, more or less, in the deformity. The ligaments, in recent cases of club-foot, do not present any material changes, but in those of long standing, or in the higher grades of the affection, they are invariably stretched in the direction of extension, and relaxed in that of flexion. In some instances the original structures are partially replaced by bands of new formation, of a dense fibrous character—the volume and resistance of which vary according to the duration of the disease and the pressure of the parts which they serve to connect together. The muscles also are not much altered in the first instance, except that they deviate from their natural direction, and that, like the ligaments, they are elongated on the one hand and shortened on the other. In ancient cases the whole limb is always considerably wasted, and many of the muscles are remarkably thin and pale, or even transformed into soft, fatty bundles. The cellular substance is condensed and diminished in quantity; the adeps is absorbed; and even the vessels and nerves supplying the affected part are apparently reduced in volume. The skin of the foot, which receives the principal brunt of the pressure in standing and walking, is generally very much thickened and indurated, and large synovial bursæ are often formed beneath it, which are apt to inflame, and thus add to the suffering of the patient. Such is an outline of the more important changes experienced by the different textures in cases of club-foot: to enter more minutely into the subject would be foreign to the design of this article, the object of which is merely to present a general idea of the nature, causes, and treatment of this singular distortion.

The treatment of this affection should be delayed as little as possible. The sooner, indeed, it is attended to, the more probable will be the chances of effectually removing it. This is equally true, both of the congenital and of the accidental form of the disease. The bones in early life and in recent malformations are much more easily restored to their normal position than in youth and manhood, or in cases of long standing; and the muscles also regain much sooner, as well as more completely, their original power. In the worst grades of the disease it is often exceedingly difficult, if the treatment be delayed until after the age of puberty, to accomplish a cure without great carving of the tendons, and the constant employment for months of various kinds of apparatus.

It is still a disputed point, whether, in the treatment of this affection, particularly in infants and young subjects, it is necessary, or even justifiable, to divide, as a preliminary step, the tendons of the muscles which are instrumental in keeping up the distortion. Without endeavouring to settle this question, for which the time has not perhaps yet arrived, I must express my conviction that the present rage for tenotomy is calculated to do a vast deal of harm, not only in individual cases, many of which do not require it, but, what is worse and more deeply to be lamented, in bringing discredit upon an operation, which, if judiciously performed, cannot fail to be of the greatest benefit. In most of the cases occurring in children under two or three years of age, division of the tendons is altogether unnecessary; indeed, one of our most distinguished orthopedic surgeons, Dr. Chase of Philadelphia, seems to trust almost entirely to the employment of apparatus, and to resort to tenotomy only in the worst grades of the disease. Whether this practice will ultimately be adopted by the profession generally, or the division of the tendons be restricted to particular cases, it would be premature to predict; but my opinion is, that much more cutting is now done than is necessary, or than would be done if the treatment of the disease were better understood than it appears to be.

Different kinds of apparatus are in vogue for the cure of this deformity, and it is therefore impossible to determine which is the best, or which should be employed to the exclusion of the others. Every practitioner seems to have his own notions on the subject, and to adopt such measures as whim, fancy, or caprice may dictate. Whatever apparatus be resorted to, the great caution to be observed, on the part of the surgeon, is, that the extension be made in a slow and gradual manner, that the skin be protected from friction and uneven pressure, and that the dressings be steadily retained during the night, as well as during the day, until several weeks after all deformity has disappeared. The object of these directions is self-evident, and too important to be neglected in our curative procedures. The time required for restoring the limb to its normal position must necessarily vary in different cases, and depend upon so many circumstances as to render it impossible to lay down any specific rule. From six weeks to four months, however, may be considered as a fair average, though occasionally a much longer period will elapse. The division of the tendons of the contracted muscles generally expedites the cure by several weeks.

In the operation for dividing the tendo-Achillis the patient may either lie on his abdomen or sit on a chair, and the heel is to be drawn downwards by an assistant with the left hand, the right being placed upon the plantar surface of the toes. The necessary tension being thus given to the part that is to be cut, the surgeon passes a narrow, straight, sharp-pointed bistoury through the skin, from one to two inches above the internal malleolus, flatwise between the tendon and the deep-seated structures. The knife is then pushed on until it reaches the opposite side of the tendon, when its edge is brought in contact with the anterior surface of the chord, which is now completely divided by steady pressure upon the handle of the instrument. The separation of the parts is indicated by an audible snap, and by the immediate cessation of the tense resistance of the tendo-Achillis. Scarcely a drop of blood is lost during the operation, which is almost unattended with pain, and is accomplished in a few seconds. A strip of adhesive plaster is applied over the little puncture, which generally heals by union by the first intention; and the limb, laid in an easy position, should be supported by a paste-board splint and a common roller. The apparatus for keeping up permanent extension may be advantageously employed in three or four days after the operation.

The interval between the divided extremities of the tendon is filled up with coagulating lymph, which is often poured out in considerable quantities. As in other situations, it becomes gradually organised, and is finally converted into a firm, dense substance, not unlike the original structure.

The tendon of the posterior tibial muscle may be cut most advantageously about two inches above and behind the internal malleolus. The operation is conducted upon the same principles as in the preceeding case, and the only particular caution to be observed is to avoid the posterior tibial artery and nerve, which might be endangered by carrying the knife too deeply. The most favourable situation for dividing the anterior tibial muscle, is where it passes over the ankle-joint: the long flexor of the great toe may be cut in the sole of the foot, where, when it interferes with the rectification of the limb, it forms a tense, prominent chord.—ED.]

The phalanges of the toes in general resemble those of the fingers in their diseased actions. Exostosis of the extremity of the distal phalanx, however, has no analogy in the upper extremity; it is by no means an uncommon affection, and usually occurs in the great toe. The growth is generally globular and rough in its extremity, narrow at its origin, attached on the dorsal aspect, projecting obliquely upwards, and always of similar structure with the phalanx. Sometimes they are met with of a size nearly equal to that of the bone from which they spring, but the majority are considerably smaller. The only one I have met with springing from a small toe is here sketched. At first the patient complains merely of pain in the part while walking; soon the pain increases so as to impede progression very seriously; then the nail is found to be raised at its margin, and to cover a hard, unyielding, and tender swelling. The elevation of the nail increases, and the tumour becomes more apparent, covered by hardened cuticle, causing great uneasiness, and almost entirely preventing walking exercise.

It has been recommended to expose the tumour by incision, and remove it at its origin. This affords temporary relief, but the disease is generally in no long time reproduced, and the incision must either be repeated, or the phalanx amputated. The preferable practice, according to my experience, is to remove the phalanx at once. It is less tedious and painful than the incision, produces very little, if any, impediment to progression, and of course is quite effectual in eradicating this most annoying though apparently simple disease.

Of Fractures.—Deformity, shortening, loss of power, unnatural motion on extending and moving the part, pain, and grating, mark solution of continuity in bone, or fracture. Swelling, with spasmodic of these symptoms may be wanting; there is little deformity, and no shortening, when one of two or more action of the muscles, soon takes place. One or several parallel bones is fractured. In fracture of the extremities, extrication of air into the cellular tissue, about the ends of the bone, is not unfrequent, though difficult to account for—giving rise to crepitation, superficial, and quite a distinct sensation from that imparted by the broken bone.

Bones become brittle as age increases, and fragility is also induced by certain disordered and debilitated states of the constitution. In some patients, the bones give way on very slight force being applied, after what may have been supposed a rheumatic attack; the thigh is broken by turning in bed, or by walking from the bed to a chair. In one instance, I had put up a fracture of the thigh with a long splint, and in three weeks afterwards the humerus was broken over the end of the splint during an attempt by the patient at change of posture. In many such cases union either does not take place, or is very imperfect.

In children, the bones frequently contain little earthy matter, bend easily, and often break partially on the convexity of the curve. Even at the age of twelve or thirteen, bending of the bones from injury sometimes occur to a great extent, as of the forearm from a fall on the palm of the hand; in adjusting the parts, a slight crackling is heard when they are brought nearly straight. Complete solution of continuity, though more rare, is occasionally met with in very young subjects.

Fractures are generally the result of great force applied directly to the shaft of a bone, or to its extremity; but they are also not unfrequently caused by twisting of the limb whilst the muscles are in a powerful action. Bones are broken transversely; but more frequently there is a degree of obliquity in the fracture, and the fragments are generally detached. A bone may be split longitudinally, as from a musket-ball striking its shaft in the centre; and fissures often extend from a cross break to a considerable extent, sometimes into joints.

Swelling is often rapid, from extravasation of blood; at other times it is slow, and of a serous character. At first it is soft and yielding, but after a time painful inflammatory tumescence supervenes, the violence and extent of which will depend on the severity of the injury, and very much also on the treatment to which the parts are subjected. If the bones be put as nearly as possible into their original position, and retained so, judiciously—the limb being laid in a comfortable and unconstrained posture, and the bandages, splints, &c., properly adapted—little or no pain or inflammatory swelling will occur; no more action ensues than is required for reparation of the injury. If, on the contrary, the bones are allowed to remain unreduced—perhaps after being well handled—their broken ends, laying among the soft parts, are pulled out by violent spasms, lacerations of the muscles and vessels is increased, effusion, swelling, and violent inflammatory action occur, the pain becomes excruciating, fever and delirium follow; there is an imminent risk of gangrene, and extensive suppuration among the muscles is almost inevitable. If the patient recover, the union is bad, and the limb deformed.

A fracture is said to be simple, where there is no wound of the superimposed integuments. The external parts may be bruised, or the deep structure much injured, with laceration of the vessels and rapid and great swelling; or there may be little or no injury of the soft parts. Great danger may exist without division of the integuments; these, yielding under the force, may remain entire, whilst by great and direct violence the bone is comminuted, the muscles broken up, and the vessels and nerves torn,—the limb is infiltrated with blood, and must become gangrenous as soon as reaction takes place. But usually these untoward circumstances do not exist in simple fractures, the soft parts being but slightly injured.

Fracture is compound when the integuments are divided by the external force, so as to expose the broken bone. But the wound may not penetrate to the bone; and then the accident is termed fracture with wound, not compound fracture. The soft parts are often divided by the sharp end of the bone; this is frequently the case in oblique fracture, occasioned by a fall from a height, the lower fractured extremity being pushed forcibly upwards. The muscles are usually much injured. The wound is either large or small, lacerated or clean.

Fracture, simple or compound, is comminuted when the bone is divided at the broken point into fragments, either small and loose, or large and adherent to the covering of the bone and other soft parts.

Fracture may be complicated with wound or displacement of a neighbouring joint, and with laceration of large bloodvessels and nerves.

Union of divided bones, as of soft parts, is preceded by incited circulation in the part, and effusion of organisable matter. The extent of action is regulated by that of the injury, whether inflicted by accident or by operation. If the soft parts have not been much bruised, if the bone and its covering are merely separated and slightly displaced, and then speedily put in contact, the incited action and the effusion are limited to the divided parts. There is no irregularity afterwards at the point of fracture, the new matter that is not required being absorbed soon after deposition; the bone is smooth and even as before. The deposit of new matter under the periosteum and into the medullary canal is here well exhibited. By this means only is the bone kept together for a very considerable period; afterwards the broken ends are united, and the temporary callus absorbed. If, on the contrary, there is much displacement, and if that is not entirely removed, intense action ensues both in the soft and hard parts, there is great effusion of new matter, or callus, soft and yielding at first, but gradually becoming hard and dense—bony particles being deposited from the vessels ramifying in the extremities, or in the attached fragments, of the old bone. When detached portions of callus are found lying in the soft parts, a piece of old bone which retained its vitality has generally formed the matrix of the deposit. When the ends of bones have been badly placed, and meet each other at an angle or curve, occasionally osseous deposit seems to form in the concavity. This increases in size, unites with the portions of the shaft, and forms a sort of bridge uniting them. This by M. Gulliver has been termed accidental callus.

In badly reduced fracture the swelling is great and hard. The callus is exuberant, much being required for the union of the fractured ends that overlap, and are perhaps far from being in contact; the vascular action and accompanying effusion are great, according to the necessity for them. The bone at the united part is enlarged to perhaps double its original thickness, or even to a greater size. After some time, the ends of the old bone, and part of the new deposit, are rounded off by absorption of the protuberances, and the part becomes more shapely. The canal of the bone and the cancellated texture is again restored. The accompanying sketch of a section of the humerus shows a double fracture. The superior one near the neck, where there is still some thickening, had been well adapted, and the canal is quite perfect. In the other and more recent there is considerable overlapping. The portion of outer osseous shell projecting into the medullary canal would in the end have been removed by the absorbents, and the deformity much diminished.

When the ends of the bone are not well placed, or when they are moved occasionally whilst the uniting medium is still soft, there is danger of a false joint being formed—the callus either giving way, or being all along imperfect, and the extremities at the soft part becoming smooth and moveable on each other; or incited action may run high and terminate in suppuration, with death or ulceration of portions of the bone.