MULTIPLE DEVIATIONS OF BOTH LEGS IN A 
RHACHITIC CHILD; OSTEOTOMY OF FIVE 
BONES PERFORMED IN ONE 
SEANCE; RECOVERY. 
BY 
CHARLES GREENE CUMSTON, M.D., 
OF BOSTON, MASS. ; 
STUDENT ASSOCIATE OF THE ROYAL ACADEMY OF MEDICINE IN IRELAND ; 
SURGICAL ASSISTANT AT THE BUTINI HOSPITAL, GENEVA, 
SWITZERLAND. 
FROM 
THE M EDICiTtyNE-WSf 
January 27, 1/894. [Reprinted from The Medical News, January 27, 1894.] 
MULTIPLE DEVIATIONS OF BOTH LEGS IN A 
RHACHITIC CHILD; OSTEOTOMY OF FIVE 
BONES PERFORMED IN ONE 
SEANCE; RECOVERY} 
CHARLES GREENE CUMSTON, M.D., 
OF BOSTON, MASS. ; 
STUDENT ASSOCIATE OF THE ROYAL ACADEMY OF MEDICINE IN IRELAND ; 
SURGICAL ASSISTANT AT THE EUTINI HOSPITAL, GENEVA, 
SWITZERLAND. 
C. 1., ten years of age, entered the Butini Hospital in 
November, 1890. The father had always been healthy. 
The mother had had nine children, of which the patient 
and a brother, fourteen years old, were the only ones 
living ; one child died at the age of eight years, from sup- 
purating glands in the neck ; another at the age of three 
years, from pulmonary tuberculosis, while another, at the 
age of two and a half years, died in convulsions. The 
remaining four children were stillborn. The mother’s 
health has always been quite good until the birth of her 
last child (stillborn), about three years ago, which has 
left her an invalid, the disease probably being of a 
nervous nature, affecting the legs ; the patellar reflexes 
are very much exaggerated, especially in the right leg, 
with great loss of strength in both limbs. 
The patient, a little girl, was well developed at birth; 
she could walk when fifteen months old, but. did not 
1 Surgical Clinic of the Butini Hospital, Geneva, Switzerland 
Service of Dr. Kummer. 2 
speak until three years of age, when, after a very 
severe fright produced by a loud noise, she suddenly ex- 
claimed “ Mamma.” From this day she continued to 
talk, but ceased entirely to walk or run. At the time of 
her fright her legs were perfectly straight and well formed. 
As the child could no longer walk, she remained in bed 
for a period of three years, and it was during this time 
that the legs commenced to deviate. For the three years 
preceding the operation, that is to say, since 1887, she 
did not remain constantly in bed, because her parents 
forced her to get up and walk with the aid of crutches. 
When about nine years of age she had a cold abscess 
on the arm, which was opened, and the patient then went 
to Cannes for the purpose of taking sea-baths, in order 
to complete the cure for the abscess. When she returned 
home, after a stay of three months, she was so much 
improved that she could walk a little without crutches. 
However, soon after, the legs became still more deformed, 
and the patient, even with crutches, walked with great 
difficulty, and the parents now decided to have something 
radical done. 
On admission the thorax was slightly deformed. Above 
the nipples there existed an excavation in the thoracic 
frame; nodosities slightly pronounced on the costal 
epiphyses. Auscultation of the heart and lungs revealed 
nothing abnormal. The abdomen was normal. The 
head was large ; the cranium squarely built, the parietal 
protuberances prominent. The teeth presented no signs 
of rhachitis. Both humeri were larger than normal. 
Over the left olecranon was seen an old cicatrix caused 
by the operation for the cold abscess. The submaxil- 
lary glands, and those of the left armpit were increased 
in size. Nothing was noted as to the skin; the sub- 
cutaneous tissue was well-developed, as also the muscles; 
the mucous membranes were of a healthy red. A cica- 
trix of a former spina ventosa existed on the fourth finger 
of the right hand. The urine was of a pale-yellow color, 3 
and transparent; it was not rendered turbid by boiling ; 
mixed with a solution of acetic acid, the gases produced 
by the formation of the carbonates were seen to escape, 
but no turbidity was produced. No albumin or sugar was 
present; the reaction was acid, the density 1010. Both 
legs were found to be greatly deviated, as is shown in 
Fig. I. There was a very decided forward curve of both 
legs, and the right thigh was conspicuous. The curve of 
the thigh took in about equally the entire femur, while 
the curve in the legs was localized in a most evident 
Fio. i. 
manner in the lower third of both tibia and fibula. The 
curve was slightly more pronounced on the right than 
on the left side. There also existed, but very much less 
pronounced, an external curve in the legs, producing a 
genu valgum. Neither the tibio-tarsal nor the tibio- 
femoral epiphyses presented any pathologic condition, 
excepting that the circumference of the condyles of both 
femora were projecting and sharply defined. The dif- 
ferent articulations were normal, and the active and 
passive motions were preserved. The child walked 4 
with great difficulty, was obliged to support herself on 
crutches, was quickly fatigued, and without crutches she 
could only walk a few steps. 
The operation, performed November 18, 1890, con- 
sisted in an osteotomy of the tibia and fibula of both legs 
in their lower third, and an osteotomy of the right femur. 
Dr. Kummer proceeded in the following manner: An 
external incision was made over the lower third of the 
fibula, and then the finger was introduced between the 
extensor digitorum communis longus muscle and the 
peroneus brevis muscle, thus separating them, after 
which they were held apart by an assistant. The peri- 
osteum of the fibula was then divided and peeled off the 
bone, and was pushed aside by an elevatorium placed 
on both sides of the fibula. The transverse division of 
the bone was accomplished by hammer and scissors. 
The hemorrhage was very slight; the incision was closed 
by suture; silk being employed for closing this incision, 
and for all the others as well. The wound was then 
dressed with iodoform-gauze, over which was placed a 
thick layer of gauze sterilized by steam under pressure. 
I would here remark that this is the customary dressing 
employed by Dr. Kummer in the greater part of his 
operations when infection is not to be feared. At the 
same level, an incision was then made over the crest 
of the tibia; the skin, subcutaneous tissue, aponeurosis, 
and periosteum were divided. They were then held 
apart, and a cuneiform excision, with the base situated 
anteriorly, was made in the tibia. The angle opposite 
the base corresponded to the angle of flexion of the leg; 
consequently, after this cuneiform excision, the straighten- 
ing of the leg was attended with no difficulties. The in- 
cision was closed as already described. The same oper- 
ation was then performed on the other leg, and here also 
the straightening was very easily accomplished after the 
cuneiform excision had been made in the lower third of 
the tibia. Above the articulation of the right knee a 5 
linear osteotomy was then performed on the femur. It 
was executed after Macewen’s method, the only modi- 
fication being that the line of section was not transverse, 
but slightly oblique in the upward direction, and from 
the inner toward the outer side of the bone. The 
straightening of the thigh was very easy after this opera- 
tion. The hemorrhage was slight. A plaster-of-Paris 
dressing was then applied, completely covering the lower 
extremities from the toes to the pelvis inclusive. 
The sequel of the operation was perfectly simple. 
Once only, five days after the operation, the temperature 
rose to 38° C., but declined after an enema. The plaster- 
of-Paris dressing was allowed to remain until Decem- 
ber 28th (forty days), when it was removed, and perfect 
consolidation of the straightened bones was found to 
have taken place. Massage, baths and electricity were now commenced. The patient left the hospital perfectly 
cured on February 13, 1891, walking without crutches or 
a cane. She only had a slight deviation of the left leg 
in the sense of a genu valgum. 
We saw the child in February, 1892—that is to say, one 
year after leaving the hospital. Her mother tells us that 
the child has been doing well since the operation, and 
continues to walk without aid. She has been regularly 
Fig. 3. 
at school, a thing that was impossible before the opera- 
tion. The parents and the patient declare that they are 
thoroughly satisfied with the result of the operation. 
However, the child becomes tired a little more quickly 
than the average one of her age, and on examination we 
find that the left sided genu valgum has slightly increased 7 
since leaving the hospital, while on the right side there 
also exists some genu valgum, although in a much less 
degree. On the other hand, the forward deviation of 
the legs, which was so pronounced before the operation, 
has absolutelely disappeared. (See Figs. 2 and 3.) The 
general health of the child has also improved consider- 
ably, this fact being easily explained by the exercise that 
the child has in the open air. 
I have put this case on record, thinking that it might 
be interesting as an osteotomy on five bones, performed 
in one seance, and cured at the end of six weeks by a 
single plaster-of-Paris dressing, without pain or fever, 
and with a good result, which is to all appearances a 
definitive one and is not common. 
My thanks are due to my friend Dr. Vallette, who had 
the kindness to take the second and third photographs. The Medical News. 
Established in 1843. 
A WEEKLY MEDICAL NEWSPAPER. 
Subscription, $4 00 per Annum. 
The American yournal 
OF THE 
Medical Sciences. 
Established in 1820 
A MONTHLY MEDICAL MAGAZINE. 
Subscription, $4.00 per Annum. 
COMMUTA TION RA TE, s7.so PER ANNUM. 
LEA BROTHERS & CO. 
PHILADELPHIA.