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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
[Illustration]
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.
Fragments are sometimes entirely detached at the time of the accident,
and perish at once; or are so slightly connected with the shaft that
they lose their vitality on the first accession of inflammation, become
surrounded by purulent matter, part from their slight attachments, and
come towards the surface. Or the shaft itself may be so bruised by the
violence of the injury as to be incapable of resisting incited action,
though slight. By malpractice, such untoward consequences as the
preceding, and many others beside, are frequently induced.
The uniting medium of separated bones remains soft for some time,
as was already observed; and often, whether from the state of the
constitution, or the circumstances connected with the fracture, the
parts remain long moveable. Pregnancy is said to prevent union; but
I have often seen fractures in pregnant women unite as speedily and
firmly as if the patients had been in that state, and otherwise in
robust health; profuse uterine or vaginal discharges, or determination
to particular parts or organs, will certainly retard union.