Part 72

In the lower extremity, as in the upper, the _bursæ_ become enlarged, in consequence either of pressure or of external injury. The affection may be acute, following a blow or squeeze, but is most frequently chronic, enlarging gradually and with little or no pain, and caused by habitual pressure on the part. From this, it will at once be understood, why the bursa over the patella should be the one most commonly affected. Its vulgar name, housemaid’s-knee, marks its cause—the avocations of such persons requiring them to rest on one or both knees, frequently, and often for a long time. It also occurs in shop-keepers, and other persons accustomed to shut drawers with their knee, or in other ways to make frequent pressure on that part,—in gardeners, and those employed in similar pursuits. In the acute swelling from injury, local depletion, fomentation, and rest are required, and these are generally sufficient to arrest the swelling, and promote its subsidence; but, in some cases, the fluid is deteriorated and the surface inflames, free incision is required, followed by poultice, and afterwards by simple dressing. In the chronic collection of clear fluid, gentle and continued stimulation of the surface, as by the gum and mercurial plaster, causes gradual decrease by absorption; the causes of the affection being at the same time studiously avoided. The tumour sometimes, as here shown, attains a large size, and from repeated inflammatory attacks becomes consolidated. The cyst is thickened, and lymph is effused into the cavity so as to convert an encysted swelling into one of solid consistence. In such cases as these, the tumour may cause such inconvenience as to make the patient desirous to have it dissected out. This is easily and safely effected; the incisions are made in the direction of the limb, and it is kept at rest in the extended portion for some time, so as to favour the healing of the wound.

Unyielding parts, habituated to pressure, defend themselves by the interposition of a moveable bag containing fluid; betwixt them and the surface the cellular tissue condenses into a cyst, its internal surface assuming a serous appearance, and secreting a fluid resembling the synovial. Such adventitious bursæ are not unfrequent on the ankles and feet, as in tailors, or others usually sitting cross-legged. They may attain a considerable size, and so produce deformity; but they should not be interfered with unless they become inconvenient, as from excited action.

When the extremity of the metatarsal bone of the great toe is large, and consequently the seat of pressure, a bursal formation is produced in the soft parts covering it; this from increase of pressure, or other irritation, may inflame—forming the painful and troublesome disease termed _Bunnion_. Sometimes unhealthy abscess occurs, with thickening, infiltration, and condensation of the surrounding cellular tissue; in such cases, incision and poultice are required, and occasionally it is necessary to destroy the unsound cellular tissue and the degenerated cyst by free application of the caustic potass. The cyst is thus got rid of, healthy granulation takes place, and by afterwards avoiding undue pressure upon the part, a permanent cure is obtained.

It has been elsewhere mentioned, that _cartilaginous bodies_ sometimes form within articulating cavities, occasionally attached by a narrow and slender connection with the secreting surface, but generally loose, seldom numerous, and usually of no great size. They are most commonly met with in the knee-joint, producing inconvenience by impeding progression. Sometimes they are neither painful nor annoying, being small, and seldom becoming interposed between the articulating extremities of the bones during motion; such ought not to be interfered with. But when large, they may be so troublesome as to warrant incision and removal. The foreign body is made to project on one side, and, having been made as superficial as possible at a favourable point, is fixed by the fingers of an assistant. The integuments are then drawn to one side, and an incision made over the body, the capsule is cut to as limited an extent as possible, and removal effected by pressure—or it may be laid hold of by a hook, and extracted; if the cartilaginous substance be attached by a pedicle, this must be divided, but with great caution. The integuments are immediately allowed to resume their natural situation, and so to close the wound of the capsule by overlapping it; the skin is then accurately approximated by adhesive plasters. The limb is kept extended, and not the slightest motion of the joint permitted. The patient is confined constantly to the recumbent posture, purged, and kept on low diet; the utmost vigilance is necessary to prevent inflammation of the synovial apparatus. In some patients on whom I have performed this operation, the wound closed by the first intention, and no untoward symptom threatened, motion and the erect position being resumed in a few weeks. But in the last case which came under my care, though the extirpation was performed with the utmost care, most violent inflammation supervened; the wound opened, synovial secretion flowed out in large quantity, profuse escape of unhealthy matter followed, and exhausting discharge continued for many weeks. At one time the constitutional disturbance was so great as to endanger life; the limb was saved with difficulty, the joint anchylosed. From the result of this case, I am disposed to dissuade operative interference, unless the patient strenuously urge it, and be willing to take the responsibility for the consequences on himself.

[The most common distortion to which the human body is liable is _Club-foot_; an affection which has at all times attracted the notice of the profession, but which has received unusual attention within the last ten years on account of the novel operation suggested for its cure by Dr. Stromeyer of Hanover, in Europe. The lesion is, for the most part, congenital. It may, however, be developed after birth, and even at an advanced period of life, from the foot being accidentally placed in a constrained position, and so retained until the soft structures—particularly the muscles and ligaments—are moulded into a new shape, or until they become fixed in their new situation. Various mechanical causes may give rise to this malady, such as splints and bandages, by which the parts to which they are applied are injuriously compressed, or thrown out of their natural relations. Similar results are produced by convulsions, dentition, nervous irritation, contusions, sprains, fractures, partial luxations, and preternatural laxity of the ligaments. In some instances the defect is occasioned by the presence of a corn, an ulcer, or some other disease which induces the person to walk on one side of the foot, the tip, or the heel, to ward off pressure from the tender parts. A vicious habit is thus established, which, if it be kept up, as it often is, for any length of time, leads to irregular action in the muscles, and to distortion of the bones into which they are inserted.

The formation of congenital club-foot has never been satisfactorily explained. By some—as Meckel, St. Hilaire, Serres, and Breschet—it has been ascribed to an arrest of development. This theory, however, for various reasons, is untenable, and has therefore not been generally adopted by surgical men. Mons. Martin, a recent French writer, thinks it is mainly occasioned by the pressure of the parietes of the uterus on the feet of the infant during gestation, owing to a deficiency of the amniotic fluid; an opinion in which he is joined by Professor Cruveilhier. That the disease may proceed from this source in some instances maybe readily supposed, but that this is the only cause, is what few will believe. The most plausible hypothesis, in my opinion, is that of Mons. Guerin of Paris. He supposes that the primary mischief is in the nervous system, and that the spasmodic and permanent shortening of the muscles of the affected limb is altogether consecutive. He sums up the results of his numerous observations in the following propositions:—1. Congenital club-foot is the effect of a convulsive contraction of the muscles of the leg and foot. 2. In the absence of general or direct traces of the convulsive affection we may almost always discover some immediate characters which indicate the nature of the exciting cause. 3. There are three constituent elements in the retraction of the muscles of the part: namely, the immediate shortening of their substance and tendons; a certain degree of paralysis; and, lastly, a consecutive arrest in the development of their substance. 4. There are no other causes of genuine congenital club-foot than convulsive muscular retraction. The pressure of the parietes of the uterus on the fœtus appears, indeed, in some cases, to produce a deformity of the limbs and feet, similar to but not identical with club-foot. The views of Mons. Guerin are confirmed, in some degree, by the history of those cases which occur after birth; but future observation must determine whether they are correct or otherwise.

The congenital variety of this distortion often affects both feet simultaneously, though rarely to the same extent. In one hundred and sixty-seven cases reported by Dr. Detmold of New-York, the disease was double in nine-three; in forty-one it occurred in the right foot only, and in thirty-three only in the left. Of eighty cases collected from various sources by Mons. Bouvier of Paris, or observed by himself, two-fifths were double; one-third affected the left limb, and one-fourth the right. Of sixty-one cases furnished by Martin, another French writer, twenty-six were double and thirty-five simple: of the latter, eighteen were of the right and seventeen of the left foot. Mons. Helt has published the results of thirty-one cases, in nineteen of which the disease was double; in two it was more distinctly marked on one leg than on the other; and in one instance the calcaneal form of the lesion was united with the inverted. In twenty-one cases observed by Scoutetten, both feet were deformed in nine; and in the other twelve the right limb was exclusively involved seven times; the left five times.

The disease would appear to be more frequent in males than in females, though the relative proportion has not been ascertained. The following table, embracing three hundred and twenty-nine cases, will throw some light on this subject:—

Authors. Number. Males. Females.

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.