WITH THE AUTHOyS COMPLIMENTS. 
CARIES OF THE ANKLE 
IN CHILDREN. 
THE RESULTS OF EXPECTANT TREATMENT FROM 
A STUDY OF THIRTY CASES. 
BY 
V. P. GIBNEY, A.M., M.D , 
Of the Hospital for the Ruptured and Crippled, New York 
[A Paper read at the New York State Medical Society February 
3d, 1880.] 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XIII., No. II., April, 1880. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1880. CARIES OF THE ANKLE 
IN CHILDREN. 
THE RESULTS OF EXPECTANT TREATMENT FROM 
A STUDY OF THIRTY CASES. 
BY 
\/ 
V. P. GIBNEY, A.M., M.D , x 
Of the Hospital for the Ruptured and Crippled, New York. 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XIII., No. II., April, 1880. 
NEAV YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1880. CARIES OF THE ANKLE IN CHILDREN 
THE RESULTS OF EXPECTANT TREATMENT FROM A STUDY 
OF THIRTY CASES. 
BY 
V. P. GIBNEY, A.M., M.D., 
Of the Hospital for the Ruptured aud Crippled, New Y ork 
No less than thirty-four amputations were performed in 
England alone in one year, and that, too, recently, for caries of 
the ankle, wrote Mr. Hancock in 1873.1 
I have been unable to get accurate statistics from hospital 
reports as to the number of children who are annually sub- 
jected to the loss of a foot for disease of this jont, yet in St. 
Bartholomew’s alone I find that, in a period of nine years 
(1870-1878 inclusive), seventeen amputations of the foot were 
performed for caries of the ankle in children—under sixteen 
years of age—and that of this number two died. 
I take it that London occupies a high position in conserva- 
tive surgery, indeed I have heard American surgeons condemn 
the surgery of London as being too conservative. The incom- 
pleteness of hospital reports as published in our own country 
has prevented the compilation of statistics regarding amputa- 
tion ; still, I do not believe that the general surgeon on this 
side of the Atlantic hesitates longer than our English brother as 
to the disposition to make of a limb when an extensively dis- 
eased ankle-joint presents. 
Dr. Gross, in his last edition (vol. ii., pp. 1092, 1093), ex- 
presses his preference for amputation when the astragalus is 
involved ; yet he advises a free, bold incision when other bones 
of the foot are implicated. He states, what is very true, that 
we never know how many may participate in the carious 
process. Even of the calcaneum—that bone which one would 
think could be diseased and .easily removed without fear of 
other bones being diseased—he speaks rather discouragingly 
1 Anatomy and Surgery of the Human Foot, London, 1873. 4 
Gibney : Results of Expectant Treatment in 
of the efforts to get a useful foot, and amputation is reported 
as having followed excisions. It is true, that since excision and 
evidement have become popular, the sacrifice of the foot lias be- 
come much less frequent, but it is likewise true that many cases, 
wherein these operations fail to arrest the disease, are subse- 
quently condemned to amputation. 
Sedillot, in 1867, made a strong plea for Idevidement des os 
(scooping out the interior of the bone—partial excision), and 
published many cases that appeared to be remarkably good 
results from this method of treatment. Yet the operation was 
condemned by Hancock and others, so that Vdvidement fell into 
disrepute, and one does not often hear of any other operations 
about the foot than excision and amputation. 
Excision had its warmest advocate in Mr. Hancock, who 
became intolerant of anything save a complete excision. In 
fact, one reading carefully his arguments in favor of this opera- 
tion can but feel that his zeal in a warfare against amputations, 
so stoutly advocated by Mr. Syme, led him to overlook facts, 
and to take for granted as proven that which was by no means 
well established. He did a good work when he raised his voice 
so powerfully against the sacrifice of the human foot; yet he 
did not know, I am sure, how many carious ankles get well 
in children, whose parents remove them from hospitals and 
from their medical advisers, to place them under the care of 
some old woman who uses a mysterious kind of salve, or of 
some professional bone setter, or to take them to some shrine 
where the laying on of hands and a prayer, followed by a pe- 
riod of time varying between one and three years, serves to 
effect a cure. 
We have yet much to learn of the pertinaciousness with 
which children hold out against chronic diseases. Vulnerable 
they may be, yet their powers of resistance, at times, are 
simply marvellous. 
I am quite sure that many a reader of this paper can recall 
to his mind a case of joint-disease, for instance, in a child 
where amputation was advised, and seemed indeed imperative, 
where the parents declined absolutely to have the operation 
performed, and where the patient subsequently made a recov- 
ery with a useful limb. Some of the most brilliant results in 
orthopedic surgery have been observed in just such cases. Thirty Cases of Caries of Ankle in Children. 
5 
To show what excision promises, I have had recourse to 
that monument of human industry—the Prize Essay of the 
American Medical Association, for 1876. I refer to the work 
of Dr. H. Culbertson, on “ Excision of the Larger Joints.” 
On pages 302 and 303 is his summary of the 108 cases 
excised for disease of the bones entering into this articulation. 
I have collected from his table all wherein the disease devel- 
oped prior to the sixteenth year of life, and the number is 
thirty-eight. The results are as follows, and are given in 
the order of usefulness:—Five (Nos. 117, 152, 256, 265, 267) 
recovered with a “ perfect limb ; ” one (No. 233) walked with- 
out lameness; five walked easily, though with a limp; in 
thirteen, the “ result good,” although no mention was made of 
the gait; in six, the result was doubtful; six walked without 
support; in two, amputation was subsequently resorted to. 
The average period at which these thirty-eight cases were “last 
heard from” was 221 months. The five perfect results were 
reported by the following: 
1. No. 147.—Textor, Jr., of Germany, in Heyfelder’s tables. 
The excision included the “ends of tibia, fibula, and astragalus,” 
the result given as “ very good, mobility perfect,” and the 
patient was last heard from four months after the operation. 
2. No. 152.—S. F. Statham, London, reported in Hodge’s 
tables; the “ astragalus and part of the calcis ” were removed, 
and at the end of ten months there was “ complete mobility,” 
and the patient “ walks and runs without pain.” 
3. No. 256.—T. G. Morton, of Philadelphia, reported in Am. 
J. Med. Sc., N. S., lxi., p. 424. The “ astragalus and os calcis ” 
were removed, and at the end of seven months “ very perfect 
recovery followed as to motion and to usefulness of foot.” 
4. No. 265.—A. G. Walter, of Pittsburgh, Pa., reported 
to Dr. Culbertson in a letter. There were twro operations: 
“ 1st, lower surface of tibia and slice of astragalus ; 2d, removal 
of sequestrum through involucrum ; ” the result, “ at fourteen 
months able to work in a glass factory; perfect usefulness of 
joint in every respect; joint and foot normal in shape; ” wras 
heard from thirty months after the first operation. 
5. No. 267.—The same, and reported in the same manner. 
There were removed “ 6 inches of fibula; f inch of tibia; entire Gibney : Results of Expectant Treatment in 
6 
astragalus ; almost all of the calcaneum ; all of the os navicu- 
lare, and part of the cuboid.” The patient recovered in “ seven- 
teen months,” had less than one inch “shortening;” got “an 
admirable limb and foot; useful to the fullest extent, without 
any deformity, save the scars ; ” was last heard from “ twenty- 
eight months.” 
The above statistics appear to be the facts in connection 
with excision of the ankle-joint in children, and it were useless 
to record opinions and theories ; yet Mr. Hancock is so good 
an authority that I shall quote him. On page 294, in arguing 
for excision, he says : “We know that diseased ankle-joints do 
not invariably recover.” Witli equal force could lie predicate 
the same of excised joints. 
Speaking of excision, Mr. Bryant1 says, “ I have had no ex- 
perience of this operation, having in majority of cases of dis- 
organized ankle-joints obtained good results by the expectant 
treatment and by free incision. . . . Where excision may be 
expected to be successful is where the disease is limited to the 
articular surfaces of the bones, and it is in such that the 
treatment by incision and the expectant principle is so suc- 
cessful.” 
“My own impression is,” says Mr. Macnamara,2 “that the 
longer we deal with cases of advanced tuberculous disease of 
the bones, the clearer we appreciate the importance of time 
and hygienic conditions as affecting their issue.” 
Dr. Frank Hamilton, discussing the relative merits of excision 
and amputation, says, “ Nor must it be forgotten that, with 
strumous children, rest alone, with proper hygienic measures, 
is often competent to effect a cure, without the interposition 
of any strictly surgical interference.” 
Farther on he says, “ Excisions at this articulation for 
chronic disease of the joint [ankle] is seldom, if ever, advisable, 
since inflammation is prone to propagate itself downwards 
through the tarsal bones, leading, eventually, to the necessity 
of amputation, if it does not result in death.” 3 
There is a plan of treatment very popular with Dr. Sayre, 
of New York, viz., the passage through the joint of setons of 
1 Practice of Surgery. Philadelphia, 1873, p. 786. 
2 Diseases of Bone. Macmillan & Co., London, 1878, p. 129. 
3 The Principles and Practice of Surgery. New York, 1873, pp. 398, 399. Thirty Cases of Caries of Ankle in Children. 
7 
oakum and the use at the same time of a splint for securing 
fixation and extension, the foot being first placed in normal 
position by means of force or tenotomy. 
I find in his work on Orthopedic Surgery, 1876, the records, 
of four cases in children, and the results are as good as those 
of excision, infinitely better than those of amputation-. 
They are as follows: I quote from pages 176 et seq. 
1. “The motions are almost perfect, and she can walk with- 
out pain.” 
2. “ It is now twenty-one years since this case was operated 
on, and she is as well in one leg as the other, and the motions 
are almost perfect,” and a little farther on in the same para- 
graph it is stated of the same patient, “ The motions are 
equally perfect; in fact she is the prize skater of the city.” 
3. Twenty years after the operation (on page 180) : “ This 
motion has very materially increased and is now almost as 
perfect as the other. The foot is smaller than the other 
and about half an inch shorter, but he supplies the deficiency 
by a thick sole inside his boot and can run and skate without 
the deformity being detected.” 
4. On page 184: “ Perfectly well without deformity and 
in robust health.” The mobility is not stated and from the 
photograph on page 183, one recognizes a slight degree of 
valgus (splay foot), which indeed is recorded as existing three 
months earlier. 
We see that the disease ran its usual course; in one about 
two and a half years; in another about three years; in another 
a little over three years; and in still another nearly two years. 
Dr. Sayre does not claim for a single one a joint absolutely 
perfect, but he does get, as we all get, highly useful joints. 
Besides, the treatment was not materially shortened. Further- 
more, we have no fears of amyloid degeneration in prolonged 
suppuration about this joint as we have when it is in the 
neighborhood of the other larger joints. 
True, one of the cases, in my analysis to follow, died of 
septicemia or pyemia (the differential diagnosis was not 
made); yet I have no less an authority than Bilroth for the 
following: “ Recoveries take place under all these modes of 
treatment, but I think there are more recoveries and cer- 8 
Gibney : Results of Expectant Treatment in 
tainly fewer deaths from pyemia under the expectant treat- 
ment.” 1 
With one or two exceptions, all the children whose cases I 
•am about to analyze owe the usefulness of their limbs, I am 
glad to state, to the conservatism of Dr. James Knight, the 
founder of the Hospital for the Ruptured and Crippled. 
I have not included a single case in my table about which 
there can be any doubt as to the final condition of the foot. 
I have made it a point to examine every one personally, or, 
when that were impracticable, to have them examined by some 
one on whose accuracy of observation I could implicitly rely. 
To trace out patients in New York, when years sometimes 
have passed since one last knew their whereabouts, is a task 
by no means agreeable. 
I have been careful to give the minutest details as to func- 
tion, and when details were wanting, I have been careful to so 
state. These thirty cases do not, by any means, comprise the 
whole number we have had under treatment. There are several 
still under treatment, a few have died of intercurrent diseases 
totally disassociated from the hone disease, wherein the sinuses 
were not closed ; many have passed from our hands into those 
of surgeons who have performed various kinds of operations 
before the disease was arrested; some I have been unable to 
find after prolonged and diligent search. It is very difficult 
to find thirty cases in New York City, whereon an operation 
has not at some time been held. 
I shall not, in this paper, report all the cases, but only about 
one-half, and these shall be reported as briefly as possible. 
For the other half I would refer such of my readers as are 
desirous of studying them more thoroughly to a report by my 
friend, Dr. T. E. Satterthwaite, to the Therapeutical Society of 
New York, in December last, and published in the New York 
Medical Journal for March or April, 1880. Tn the Medical 
Record, January 31st, 1880, p. 126, is an abstract, and the 
definition of expectant treatment is given by Dr. Satterthwaite 
as follows: 
1 Surgical Pathology. 4th Ed. Translated by Hackley, N. Y., 1879, 
p. 476. Thirty Cases of Caries of Ankle in Children. 
9 
“ If the joint is inflamed, entire rest is ordered; if abscess 
form, it is opened; if loose bone be detected, it is simply re- 
moved as if it were a foreign body interfering with the process 
of healing; if, in the further progress of the case, malposi- 
tion of the parts is found, a support or brace is given to rectify 
the deformity.” This I accept as the expectant plan of treat- 
ment. Of course, the health is attended to on general prin- 
ciples. 
Case II.—A frail, phthisical-looking girl in her seventh year, 
began to walk lame, and some swelling without heat or pain was 
observed about the right ankle. Her family was tuberculous and 
no exciting cause could be found. The invasion was almost im- 
perceptible; little attention was given to the foot, and six months 
afterward she first began to have pain. Later she had a fall 
which aggravated the disease, and just fifteen months after the 
first symptom, she entered the hospital, April 4th, 1871. 
She walked badly, and usually got about by hopping on the 
left leg. The natural depressions about the ankle were effaced, 
and there was a pulpy feel imparted to one’s finger as the parts 
were handled; the joint was not tender on concussion, but on 
passive motion, which was very limited, there was much pain. 
The right calf was 7£ inches, left, 9£ inches; over malleoli, right 
side, 7£ inches, left, same; heel and instep, right side, 9 inches, 
left, 9£ inches. 
The expectant treatment was adopted in this as in the other 
cases, and for a long time no change was observed. She got bet- 
ter in time, no suppuration ever occurred, the malleoli continued 
tender, although the patient walked with very little if any lame- 
ness by the 30th of April, 1873, when she was discharged about 
cured, i. e., there was no tenderness on rough handling, no swell- 
ing, and the movements were nearly normal. The foot, however, 
was three-quarters of an inch short. I saw and examined the 
case on December 3d, 1879, six years and six months after the 
date of discharge. She was in good health, was walking without 
any lameness, though at times, when weather is changing, she has 
a little halt, could flex foot beyond 90°, though not to full extent, 
could extend the front of the foot, the heel moving very little, 
and could in- and evert over about one-half the normal arc. Both 
malleoli appeared to be expanded. Measurements: right, calf, 11 
inches; malleoli, 8£ inches; heel and instep, 10£ inches; foot (in 
length), 8f inches; left, same points, 12£, 8£, 11, 9£ inches. She 
never had any suppuration and never any relapse. 
Case XIV. was not fully reported in Dr. Satterthwaite’s 
report to the Therapeutical Society, inasmuch as I had failed, 10 
Gibney : Results of Expectant Treatment in 
at the time said report was made, to find the child. I shall 
now give the case briefly, in order to record the last examina- 
tion made quite recently. 
This case, then, was a girl whose family history was wretched, 
and who contracted disease about the left ankle when two years 
of age, supposably from a fall. It could not be definitely learned 
when suppuration began, but on admission to hospital, fifteen 
months after the first symptoms, December 28th, 1875, there was 
an open sinus, surrounded by a cicatrix, over the external malleo- 
lus. 
There was, likewise, much tumefaction in this neighborhood, 
the child was not very lame, movements were not limited to any 
great extent, and there was very little deformity of the foot. At 
the end of two months, the old abscess sac had refilled and 
broken, leaving an ulcer about three-quarters of an inch in diame- 
ter, and separated from a similar condition on outer side by a 
healthy strip of integument. By the end of May, however, both 
ulcers had healed, and on September 27th, 187G, the case was 
discharged as cured. 
May 22d, 1877, was re-admitted on account of the recurrence 
of a large abscess on the inner aspect of the ankle, of short dura- 
tion. The pain was so great that child was carried in on a 
pillow. Three days later, the abscess was opened, but the skin 
sloughed, leaving an ulcer about the size of a silver quarter of a 
dollar. This healed by the middle of July, and the case was 
again discharged, cured, on August 3d, of same year. 
January 21st, 1880, I succeeded in finding the child, and learned 
that no more relapses had occurred, that she had been very active. 
She was not lame, could flex and extend perfectly, and could in- 
and evert over nearly the normal arc. Long cicatrices existed 
about each malleolus and the internal malleolus was elongated 
about one-half inch. The measurements are given in the ap- 
pended table. 
Case XV. was admitted to the hospital February 7th, 1878. 
The patient was a boy, whose right ankle became diseased in his 
second year, and now one and a half years had elapsed. There 
was no history of any exciting cause, but •the paternal family was 
tuberculous. The little fellow on admission walked quite lame, 
everting the foot, and there was very marked tumefaction over 
each malleolus. The joint movements were nearly abolished, 
the calf was 6 inches against 7 inches for its fellow, the circum- 
ference over malleoli was 6£ against 5£ for that of opposite side. 
At the end of a month an abscess had developed about the inter- 
nal malleolus and was incised March 2d, an ounce of pus being 
evacuated. A sinus remained, yet the boy suffered very little 
from pain. May 14th, 1879, a small spicula of bone was exfo- 
liated and removed through the sinus, after which the discharge Thirty Cases of Caries of Ankle in Children. 
11 
ceased, the opening closed, only to re-open again by August 26th, 
when another piece of bone was removed as it protruded from 
the sinus. This was the last, and on December 3d it was re- 
corded that he walked without any lameness, that the sinus had 
been closed for three months, that all movements were normal 
except extension, and this was nearly normal, that the limbs 
were of equal length, the right calf 7 inches, left inches; the 
internal malleolus a little enlarged, the circumference here being 
6§ against 5f for opposite side, and that the case was regarded 
as cured. Has been seen quite recently, and the condition 
remains the same. There is no deformity. 
Case XVIII.—On June 23d, 1876, there was admitted to hos- 
pital a strumous-looking girl with the history of chronic epiphy- 
seal ostitis at the right, ankle, two years standing, beginning when 
the child was two years of age. It was reported that she got a 
blow, yet no swelling or stiffness followed until a long time after- 
wards. There was gradually increasing soreness and lameness. 
At the time of admission she walked very lame, the foot being 
markedly everted and receiving the weight on the heel; there was an 
elastic tumefaction over each malleolus, and the movements were 
almost nil; the calf measured 7 inches, the other one 8 inches, 
the three ankle measurements were 5£, 7£, inches against 5£, 
7f, 6 inches. There was very little tenderness on moderare 
handling of the foot, and no sign of suppuration. Massage was 
employed and an effort made by medication to restore the health. 
Slow progress was made toward increasing the motion at the 
joint, and nothing occurred to relieve the monotony until Janu- 
ary, 1878, in which month a small patch of strumous naso-facial 
erysipelas appeared, soon passing off. In April had varicella. 
In May it was thought that some motion had been gained, and 
no inflammation had been excited by a pretty severe passive motion 
twice daily. By November 15th, it seemed that the movements 
were better, yet the deformity and the lameness were about the 
same, and at mother’s request child was discharged. 
January 28th, 1880, Dr. A. M. Vance, of our staff, found 
the case for me, and learned that the patient had not had any 
treatment since leaving the hospital. He examined the limbs 
carefully and the calf measured 7£ inches against 8£ inches, the 
ankle 5f, 8£, 6 inches against 6, 6£ inches, the foot 6£ inches 
in length, against 7 inches, the limbs were equal in length; the 
child did not walk lame at all, flexion, extension, in- and eversion 
and rotation were perfect, in fact, the cure was complete. There 
was never any suppuration. 
Case XIX.—A pale-looking girl, ten years of age, was brought 
to the out-door department of the hospital, May 26th, 1873, for 
disease about the right ankle of one year’s standing, coming on 
shortly after a varicella. It had been very insidious in its de- 
velopment, presenting the usual remissions and exacerbations, 12 
Gibney : Results o f Expectant Treatment in 
The family history was both rheumatic and scrofulous. The 
child, on her appearance at the hospital, could scarcely walk, and 
an abscess was already forming. The treatment was purely ex- 
pectant, and within a few months the abscess had opened, a sinus 
remaining. The case ran a tedious course, if we take into account 
the resulting deformity, talipes equinus. This was being treated, 
when in July, 1875, without known provocation, a caries of the 
lumbar spine developed, femoral abscess right side followed, and 
the thigh became much deformed. The equinus was, however, 
eventually relieved, and the case, so far as this joint is concerned, 
long since cured. The patient is still under treatment for the 
spinal disease, but the movements at the ankle are perfect, 
except in flexion. She uses crutches with a high shoe on left 
foot, and gets about quite freely. 
Case XX.—Of this patient we did not have full notes; in fact, 
none were made until August 12th, 1875, the girl being then 
five years of age, and the note related to a marked valgus which 
had resulted from a caries of the ankle, left side. The child at 
this time had chronic phlyctenular conjunctivitis and blepharitis 
and presented about all the signs that go to make up a strumous 
habit. The familv history was so interesting that I made the 
following notes: maternal grandfather died of cancer, the 
grandmother of “disease of the womb,” at the age of forty- 
eight years, after an illness of nine months, one uncle at the age 
of twenty-seven years of hemoptysis, and another of “spasms” 
of some kind, and an aunt (who has since died) was marked 
with cicatrices of old glandular abscess and had a convergent 
strabismus; the father suffers much from a chronic hacking 
cough, the paternal grandfather died of consumption, the grand- 
mother of pneumonia (kind not ascertained), and an uncle was 
very low with consumption. 
A cicatrix was found back of the external malleolus. A spring 
was applied, and the case was seen a few times, then lost sight 
of. Dr. Vance found it, however, January 28th, 1880, and 
learned from the mother that, when the child was one year old, 
disease of the ankle came on, and that Dr. Knight treated her 
as an out-patient, for about a year continuously, that in that 
time abscess formed, ulceration supervened, and that as the case 
improved she discontinued her attendance, returning two or 
three vears later, when the valgus became so marked. Since 
1875, however, there has been an uninterrupted progress toward 
recovery. The child is not lame at all, and can walk any dis- 
tance without harm to the ankle. Movements, active and passive, 
are perfect in all directions; the limbs are equal in length, the calf 
is one inch smaller than its fellow, the foot is one-half inch short, 
while the measurements over malleoli are the same as those of 
opposite side. A deep and long cicatrix is present, and there is 
just a perceptible amount of splay foot. 
Case XXI.—A girl, set. 2 years, presented at the out-patient Thirty Cases of Caries of Ankle in Children. 
13 
department December 31st, 1875, with disease at right ankle, of 
six months’' standing. An abscess was already forming over external 
malleolus. The ease was not seen again until January 25th, 1876, 
when it was noted “ integument and subjacent tissues have 
sloughed, leaving a large, deep, ragged-edged ulcer inch); 
charcoal and flaxseed poultices ordered.” By February 5th, the 
edges of the ulcer had healed, and the general appearance of the 
foot was vastly better. There Avas some constitutional disturb- 
ance, howe\rer, and a decoction of cinchona, gentian, and serpen- 
taria was ordered. The case was not seen again until January 
28th, 1880, when Dr. Edward Swasey, of our staff, visited the house 
and found the child in good health, walking and running with 
great ease, though perceptibly limping. There is never any pain 
unless occasionally in damp weather, movements in all direc- 
tions about one-third normal, a large cicatrix over external mal- 
leolus; 1 inch atrophy of calf, f inch enlargement over malleoli; 
foot, \ inch short. The mother continued to employ the poul- 
tice, and after six months’ time, the ulcer was healed, sinus closed. 
It re-opened again a few months later, but soon closed. The case 
has been regarded as cured for three years. 
Case XXII.—On the second of March, 1876, A. C., a maleaet. 
21 years, called at the office, and from him we obtained a history 
as follows: 
At the age of ten years he suddenly felt one day a sharp stick- 
ing pain in the left ankle, and about four weeks thereafter, a 
swelling appeared just below the internal malleolus, which swell- 
ing gradually extended toward the outer side, and an abscess 
opened spontaneously, immediately above the external malleolus, 
six months later. The discharge was profuse, and the relief from 
pain was great. An ulcer appeared, and eight months after the 
opening, a small piece of bone, honeycombed in appearance, was 
found one day in the dressings removed. At this time, the ulcer- 
ation was so deep that the tendons and muscles here were exposed, 
and the foot was condemned to amputation by some prominent 
surgeons. lie came uiyler Dr. Knight’s care, and expectant treat- 
ment was employed. The ulcer soon healed, but a sinus remained, 
which ultimately closed permanently. There was observed a long 
deep cicatrix over external malleolus, and on January 29th, 1880, 
he called by request, when the calf was found 2 inches smaller 
than the right; the foot 1 inch shorter; the limbs of equal length; 
the foot anchylosed at a right angle with the leg. He can “walk 
five miles without pain,” is on his feet constantly, and is a machin- 
ist by occupation. 
Case XXIII.—A boy, set. 1£ years, came under treatment as an 
out-patient July 6th, 1878. There was an elastic swelling over 
the external malleolus left side, lameness, pain, and stiffness of the 
joint; all of three months’ standing. The exciting cause was not 
learned. An anklet was applied, a liniment ordered, and moder- 
ate rest enjoined. Syrup of the iodide of iron was also prescribed. 14 
(jtibney : Jiesults of Expectant Treatment in 
August 23d, the swelling had diminished a little, and the boy 
could walk more freely. October 25th, not seen since date of 
last note, and now there is an abscess over the malleolus. This 
is opened, a small quantity of pus evacuated, and simple dress- 
ings ordered. January 9th, 1879, an ulcer formed, but is now 
about healed, the discharge is very slight; movements perfect in 
all directions, and boy walks without lameness. February 7th, 
sinus closed; no induration; about cured. April 4th, sac of old 
abscess refilling within past few days; cold water dressings and 
rest. Ordered, also, dialyzed iron and cod-liver oil. April 25th, 
inflammation has subsided. May 7th, a little thickening; noth- 
ing more remains. 
January 28th, 1880, in looking up the case to-day, I found the 
mother who reported that the child died on May 9th of malignant 
scarlet fever; was taken violently ill the evening of its last visit to 
the hospital, and attended by the family physician. 
Case XXIV.—A cachetic-looking girl, aet. 5 yeai’s, came under 
treatment April 22d, 1878, for a lameness of three months’ dura- 
tion. There was a small elastic tumor at instep just over the 
astragalus, the circumference at this portion of the foot being 
nearly £ inch greater than at corresponding portion of other foot; 
the movements were imperfect. The bone was tender on press- 
ure; the child tired easily, and at times was quite lame. The 
exciting cause was not ascertained. Cod-liver oil, an alterative 
tonic, a liniment, and an anklet were prescribed; the patient was 
seen a few times afterwards, and then ceased to attend. Dr. 
Swasey visited her home January 28th, 1880, and learned from the 
mother (the child was at school) that the patient fell into other 
hands, a spring was used until about six months ago, since which 
time the case has been considered cured. She admits, however, 
that there is a perceptible lameness, though never any pain. 
There was never any suppuration. 
Case XXV.—A girl at the age of 5 years fell while at play, and 
was thought to have strained her right ankle, though there was no 
symptom until two or three months later. Then she walked 
lame, and “swelling and soreness came and went.” An elastic 
anklet was employed for a time, but the child continued lame, 
and suffered more or less pain. She came under our observation 
August 18th, 1876—three years after the initial symptom. There 
was a boggy swelling over the external malleolus; the calf was 1 
inch smaller than its fellow; and the movements at the tibio-tarsal 
joint were but little impaired. We advised that patient be admitted 
to the hospital, but the mother declined to leave the child, and I 
saw nothing more of the case until January 28th, 1880; 1 found 
the child perfectly free from lameness and deformity, able to 
extend, in- and evert and rotate the foot to the normal extent, 
but unable to flex to quite the full extent. The external mal- 
leolus was a little enlarged, and just above this was a depression Thirty Cases of Caries of Ankle in Children 
15 
—a remnant, most likely, of an old sac—the contents of which 
had been absorbed. There had never been any suppuration. The 
calf was £ inch smaller than its felloAV, and the foot £ inch short. 
The child had been regarded as cured for nearly three years; 
never had any treatment after the date of our last note. 
Case XXYI.—A hearty-looking hoy, get. 3 years, was admitted 
to hospital February 12th, 1874, for the relief of a diseased foot and 
ankle of two years’ standing. The mother died of consumption, 
and the boy became lame without any exciting cause, so far as 
known. The onset was very slow, and it was a long time before 
the affection attracted any special attention. On admission he 
was totally unable to walk, there was marked tumefaction across 
the instep; the skin was red, and from a small ulcer over the 
scaphoid sero-pus exuded. There was also much swelling about 
the malleoli, and the foot was quite tender The right calf was 
fif inches; the left, 7|- inches; the right foot, 7| inches; the left, 
5£ inches in circumference. The mobility was not tested. The 
treatment consisted of cleanliness, simple dressings, tonics, and 
rest. February 15th, spontaneous opening over the middle third 
of the foot, inner aspect, with a discharge rather profuse. Little 
was recorded of the case until December 1st, when it was noticed 
that the ulcers have healed; all sinuses have closed, and the foot 
appears comparatively sound. The boy walks well, though with 
marked valgus, for the relief of which a spring is applied. Feb- 
ruary 20th, 1875, the spring has caused no return of the ulcera- 
tion, and the valgus is much less marked. April 15th, examined 
pursuant to discharge. Stands and walks with foot in valgus, 
and limps perceptibly. There is no open sinus. Within past few 
days a little tenderness has developed over scaphoid and in the 
joint, and it is decided to keep him in the hospital a week or two 
longer. May 1st, is discharged this date, although not regarded 
as cured. lie is to continue an out-patient. 
He did not return, and was traced by Dr. L. E. Holt, who 
found him free from lameness, able to extend and flex the foot to 
the full extent with ease, hut unable to invert or rotate the foot. 
He could evert a little, yet this was not perfect. The disease 
seemed to have involved chiefly the scaphoid, and in this locality 
he found three cicatrices, two of which adhered to the bone. 
There was still a moderate degree of valgus. There was £ atrophy 
of calf, and £ inch shortening of foot. The aunt reported 
the boy had been regarded as cured for three years, and had not 
had any other treatment after leaving the hospital. 
Case XXVII.—A girl, aged 11 years, was admitted to hospital 
August 6th, 1873. with disease at right ankle, induced, it was 
thought, by a strain two years before. She was quite lame when 
she came in, the internal malleolus and scaphoid were enlarged 
and tender to pressure, yet there was a fair degree of motion pre- 
served. No suppuration had ever occurred, and there was now no 16 
(tlbnky : Results of Expectant Treatment in 
sign of abscess. A little rest, with massage twice daily, soon relieved 
her, so that on the 29th of August she was able to walk without 
lameness. She was allowed home on the 18th of September, 
walked to excess, and came back very much worse—scarcely able 
to walk at all. From this time to May 15th, 1874, there was 
nothing special to record, save exacerbations of pain, swelling and 
lameness, caused by exertion, and periods of apparent cure. On 
this date she was discharged cured, and continued without any 
relapse (so she reported) up to the 21st of December, 1879, when 1 
made an examination at her house. There was on that date a 
slight halt, almost imperceptible. She works all day standing, and 
is able to dance without pain or inconvenience, unless she dances 
to excess, then she has a little pain about instep. The arch of 
foot is a little deeper than that of its fellow; there is no bony en- 
largement, but a little tenderness on pressure over medio-tarsal 
joint. No cicatrices anywhere; flexion and extension are perfect, 
and in- and eversion nearly normal. Calf is } inch small, and 
foot l inch short. 
Case XXVIII.—On May 8th, 1876, a girl, aged fourteen, came 
to the hospital, seeking relief from a slight strain of her right 
ankle, which on examination proved to be an old carious ankle 
long since cured. There was a deep cicatrix one inch in length 
to the outer side of the tendo Achillis and spreading out over 
the external malleolus, a small one in front of this process, and 
another still, one inch above. The foot was at a right angle with 
the leg, could be extended fairly, but notfiexed beyond 90°, and as 
this was done one could feel a roughening within the joint. There 
was no swelling, tenderness, or pain on handling, yet as she walked 
there was some pain; this, however, was recent. The calf was 
atrophied two inches, and the foot was one-half inch short. The 
history was, that five years before this examination she fell down 
eight steps, spraining her ankle, that within a year or two abscess 
formed, ulceration of the soft parts followed, yet no pieces of bone 
were exfoliated, that the treatment was chiefly constitutional, 
that the discharge ceased about one and a half years later, and 
that she had considered herself as long since relieved. I heard 
from her on the 28th of January, 1880, and the report was that 
she was not lame, had about perfect use of the foot, and was in 
excellent health. 
Ca.se XXIX.—A boy, aged eight years, was admitted to hospital 
August 16th, 1878, for the relief of a deformity resulting from 
disease at the left ankle. When six and a half years of age, dur- 
ing a tardy convalescence from measles, he had multiple abscesses 
over body—about twenty in number—and four months later the 
ankle swelled, boy was lame, and three months afterward was ad- 
mitted to Mount Sinai Hospital, where he was treated by local 
applications and rest. Improved, became very active, was im- 
prudent, and finally became worse than ever; abscess formed, was Thirty Cases of Caries of Ankle in Children. 
17 
incised, and rest again resorted to. On admission he had talipes 
valgus, and the skm about the ankle was seamed with cicatrices, 
lie has been under treatment a long while for the deformity which 
is now about overcome. Yet he walks without the normal 
springiness to the arch. An examination, made January 29th, 
1880, finds two inches atrophy of the calf, a half-inch shortening 
of the foot, and movements limited to about one-half the normal 
extent. A roughened condition of the joint can be perceived as 
one employs passive motion. 
Case XXX.—A boy at the age of two years began to walk lame 
and to complain of pain at his left ankle, marked tenderness be- 
ing evinced by stepping on anything irregular. The parents 
knew of no exciting cause. There was very little pain, however, 
during the first six months. He came under treatment in the 
out-patient department, May 19th, 1876, just twelve months after 
the beginning of the disease. 
There was at that time an elastic swelling over both malleoli, 
and the foot was in talipes calcaneus; there was considerable 
muscular rigidity, and extension could not be made to a right 
angle. The calf was three-quarters of an inch smaller than its 
fellow. The treatment we advised was not carried out, but the 
case was treated for a while with a plaster-of-Paris bandage which 
is reported to have excoriated, then it came under domestic 
treatment. Dr. Vance found the boy, January 31st, 1880, and 
examined the limb carefully. There was anchylosis at the tibio- 
tarsal joint at a right-angle; two cicatrices back of the external 
malleolus, and one in front of and below the same; one-inch 
atrophy of the calf, one-half of an inch shortening of the foot, 
the limbs of equal length. The boy walked decidedly lame and 
had no spring to the arch of his foot. He was very active, how- 
ever, and there was no sign of active disease about the joint. 
Some of the cases I have reported recovered with joints more 
or less anchylosed. This could have been obviated, I am sure, 
if we could have had an opportunity of employing passive 
motion and using an apparatus during the stage of repair. 
The results as summarized from the appended table are as 
follows: 
Age.—The disease developed in 14 cases prior to the fourth 
year of life; in 11 between four years and nine years, and in 
5 between the ages of nine and thirteen years. It is thus 
seen that this, like all other joint diseases of a tuberculous 
nature, is peculiar to early childhood. 
Bones Involved.—He who has had much experience in 
caries of the bones entering into the ankle and medio-tarsal 18 
(tibntey : Results of Expectant Treatment in 
joints, will readily appreciate the difficulty of definitely locat- 
ing the disease. It is well known that the ostitis rarely 
limits itself to a single bone. Those who resort to operations 
can have a better opportunity of learning what bones are in 
volved. In my tables I have endeavored to locate the carious 
process approximately, and hence my statements in this con- 
nection must be taken, not as of facts, but as of opinions. 
In 14 of the 30, the lower epiphyses of the tibia and the 
fibula, and one or more bones of the tarsus were involved, the 
astragalus especially. In 10, or one-third, the tibia and fibula 
seem not to have been implicated, but the tarsus alone was 
the seat of disease. In 4, the tibia and fibula were the only 
bones carious, and in 2 the os calcis alone. 
Suppuration in 19 was extensive, i. e., at times profuse and 
long continued ; in 6 it was moderate, and in 5 there was- 
none. It is worthy of note that in three of those wherein 
resolution took place, the joint has continued more or less 
tender, and at times a little lameness is manifest. 
Two of these have made perfect recoveries, so far as the func- 
tion of the joint is concerned, one after years, the other 
after 3 years. The atrophy of the calf still persists, and with 
this single exception one could not believe from personal 
inspection that there had ever been any disease. 
Treatment extended over a period less than 6 months in 5 
cases; between 6 months and 1 year, in 9; between 1 and 2 
years, in 12; and between 2 and 3 years, in 4. The average 
duration was one year and three months. 
The Duration of the Disease was one year for the min- 
imum, and six years for the maximum. The average was 
three years and three months. 
The Interval between the Cure and the Last Examina- 
tion was such as to enable me to speak with absolute certainty 
of the great majority of all included in my analysis. 
One died of scarlatina about a week or two after the closure 
of a sinus that had been merely oozing for a long time, and 
the boy was regarded as cured; one died during the progress 
of the disease. 1 saw and examined six cases, six months 
after a cure had been pronounced. This was the shortest inter- Thirty Gases of Caries of Ankle in Children. 
19 
val. The longest was thirty-two years. The average was 
three years and ten months. 
Shortening of Limb.—In 9 eases this was not ascertained, 
in 8 there was no shortening; in 7 there was no apparent 
shortening; in 3 there was i inch, and 2 it was from | to 1 
inch. 
The Foot was not shortened at all in 3 instances, was less 
than F inch in 16, less than 1 inch in 4, and in 7 the difference 
was not ascertained. 
In only one case was there no atrophy of the calf, and this 
was one wherein the os calcis was alone diseased and 32 years 
have elapsed since the cure was complete. 
Lameness.— Of the whole 30 cases tabulated, 20 or two- 
thirds came out without any lameness; 7 had a slight halt in 
their gait, yet could walk long distances and felt no fatigue 
on account of the limb; in one only was the lameness marked. 
Not a single one walks with a crutch, a cane, or a high shoe 
even. One girl, it is true, goes now on crutches, but she does 
so, not because of any lameness of her ankle, but because of a 
lumbar Pott’s complicated with great deformity of the hip and 
thigh consequent on femoral abscess. She can and does, at 
times, walk without any support, but we have insisted on her 
using the crutches, with a high shoe on the foot of the sound 
limb. 
As to Mobility.—Five were normal, i. e., can Hex, extend, 
invert and evert and rotate the foot perfectly. Two of these 
had disease in the os calcis alone, two in the tibia or fibula, 
suppuration not occurring, and the other one had disease of 
the scaphoid alone. 
Six patients got well with a complete restoration of motion 
in eversion and inversion, while there was not perfect flexion 
or extension. This defect could be made out only by careful 
comparison. 
Five were normal in flexion and extension, while there was 
a limit to complete inversion or eversion, or both. 
In seven, careful comparison was not made, but it was 
decided that there was “ good motion.” 
In two, there was complete anchylosis at the tibio-tarsal 
joint. Yet, in these there seemed to be an exaggeration of 20 
(tikney : Results of Expectant Treatment in 
motion at the medio-tarsal, which compensated in a measure 
for this condition. 
In four, there was limitation to normal motion in all direc- 
tions, yet the limb was useful. 
In three, there was splay foot, yet not enough to cause any 
marked inconvenience. 
During the progress of the disease, talipes equinus would 
frequently arise, yet this was overcome by apparatus in due 
time. 
From the foregoing analysis, and from the facts I have gath- 
ered concerning the results of operative procedures in caries 
about the joints of the foot, I am fully warranted in drawing 
the following conclusions: 
1. Many children annually undergo amputation of the foot 
for caries of the ankle, when, by conservatism and a proper 
amount of respect for the vis medicatrix natures, the member 
could be saved, the child be spared the mortification of being 
thus hopelessly maimed, and surgery itself be ennobled. 
2. Excision as a rule is not attended with as good results 
in children as authorities have led us to expect; and is rarely 
ever justifiable. 
3. Partial excisions, the passage of tents through the joint, 
and other operative procedures offer no advantages over the 
expectant plan. 
4. Nature herself, unaided by art, gets useful limbs, but, as 
a rule, anchylosis varying in degree and deformity more or 
less marked. 
5. The expectant plan of treatment, fully carried out, assures 
us of more results that are perfect, and more limbs that are use- 
ful without the aid of support, than does any other plan known 
to the profession. 
The accompanying statistics are deduced from the table 
appended, and have already been summarized. 
CONCLUSIONS. Thirty Cases of Caries of Ankle in Children. 
21 
6 
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Tibia and 
Moder- 
2 yrs. 
3 yrs. 
7 yrs. 
None. 
£ inch. 
1£ in. 
None. 
Flexion and extension 
tarsus. 
ate. 
nearly normal; inver- 
sion and eversion per- 
fect; no pain unless he 
walks to excess; is 
very active. 
2 
7 
Tibia, fib- 
None. 
2 “ 
-** 
CO 
6f “ 
None. 
f “ 
H “ 
None. 
Extension and eversion 
ula, and 
not quite normal; flex- 
astragalus 
ion and inversion per- 
feet; no pain except at 
weather changes; mal- 
leoli expanded but not 
tender. 
3 
3 
Fibula and 
Exten- 
i “ 
6 “ 
4 “ 
2 “ 
None. 
“ Good motion at joint;” 
no deformity of foot; 
tarsus. 
sive. 
no tenderness. 
4 
4 
Tarsus. 
Moder- 
1* “ 
4 “ 
4 “ 
2 “ 
None. 
Movements accomplish- 
ed with ease; no de- 
ate. 
formity, pain, or ten- 
derness. 
5 
12 
Tarsus. 
Exten- 
If “ 
3 “ 
7* “ 
No ap- 
3 .. 
14 “ 
None. 
Can dance well but can- 
About two years ago a 
sive. 
parent. 
not skate well; flexion 
relapse of two months’ 
perfect; extension, in- 
version, and eversion 
about one-half normal. 
duration. 22 
Gibney: Results of Expectant Treatment in 
o 
7, 
AGE WHEN DIS- 
EASE BEGAN. 
BONES 
INVOLVED. 
SUPPURATION. 
DURATION OF 
TREATMENT. 
DURATION OF 
DISEASE. 
INTERVAL BE- 
TWEEN CURE & 
LAST NOTE. 
SHORT 
LIMB. 
ENING 
FOOT. 
ATROPHY OF 
CALF. 
LAMENESS. 
RESULT AS TO MOBILITY 
AND USEFULNESS. 
REMARKS. 
6 
6 
Tibia and 
Moder- 
% vrs. 
2A yrs 
64 yrs 
None. 
A inch. 
1 inch 
None. 
Very slight extension; 
Fibula. 
ate. 
flexion nearly normal; 
inversion and eversion 
normal; malleoli en- 
enlarged, and a little 
tender on pressure. 
13 
1 “ 
2 “ 
u “ 
Very 
No deformity; mobility 
M 
tarsus. 
sive. 
slight. 
not recorded, though 
apparently normal. 
8 
1 
Tibia and 
Exten- 
2 “ 
3 “ 
2j “ 
£ inch. 
None. 
j inch. 
None. 
Flexion to 90 : extension 
Wearing apparatus for 
tarsus. 
sive. 
normal; inversion one- 
the deformity. 
half normal; eversion 
normal; a slight valgo- 
9 
10 
Tibia and 
Exten- 
i “ 
3 “ 
4A “ 
£ “ 
A inch 
a “ 
Slight 
Inversion normal: ever- 
No lameness except after 
tarsus. 
sive. 
sion and extension 
prolonged exertion. 
one-half normal; very 
slight flexion ; stands 
much; no pain. 
10 
13 
Os Caleis. 
Exten- 
i “ 
H “ 
32 “ 
No ap- 
None. 
None. 
All movements perfect; 
Had caries of spine at 
sive. 
parent. 
never any pain, or 
same time, and was 
sign of relapse. 
treated by Mr. Colies of 
Dublin. 
1 1 
91 
Tarsus. 
i “ 
2 “ 
Died from septicemia. 
Autopsv showed nearlv all 
sive. 
2 
tarsal bones diseased. Thirty Cases of Caries of Ankle in Children. 
23 
12 
11 
Tarsus 
and meta- 
tarsus 
both feet. 
Exten- 
sive. 
1 yrs. 
1 yrs. 
fyrs. 
None. 
None. 
£ inch.1 
None. 
Slight valgus both feet; 
all movements nor- 
mal; no pain. 
■ 
Began in both feet at same 
time, and ran about 
same course in each. 
A later examination 
shows valgus to be re-» 
lieved by treatment 
with apparatus. 
13 
7 
Os Calcis. 
Exten- 
sive. 
3* “ 
5 “ 
2 “ 
None. 
None. 
£ inch 
None. 
No loss of function; 
movements in all direc- 
tions normal; walks 
and runs any distance 
without pain. 
14 
2 
Tibia and 
tarsus 
Exten- 
sive. 
1st, 1 
year. 
2d, 
3 mos 
3 “ 
2± u 
~4 
None. 
inch. 
i “ 
None 
No deformity; flexion 
and extension perfect; 
inversion and eversion 
nearly so; lower epi- 
physis of tibia a little 
elongated. 
15 
2 
Tibia and 
tarsus. 
Moder- 
ate. 
Hyrs 
3 “ 
6 mos. 
£ inch. 
i '* 
i “ 
None. 
Extension nearly nor- 
mal ; all other move- 
ments normal; no de- 
formity. 
16 
1 
Tarsus. 
Exten- 
sive. 
U “ 
6 “ 
Hyrs. 
i “ 
h “ 
h “ 
None 
Flexion and extension 
normal; inversion and 
eversion about one-half 
normal; no pain ; no 
deformity. 
Valgus nearly relieved 
by treatment. 
17 
6 
Scaphoid 
and prob. 
other tar- 
sal bones. 
Exten- 
sive. 
1 “ 
2 “ 
4 mos 
No ap- 
parent. 
j “ 
k “ 
None. 
Flexion and extension 
normal; inversion and 
eversion nearly so; a 
slight valgus remains. 24 
(tibney : Results of Expectant Treatment in 
cc . 
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RESULT AS TO MOBILITY 
REMARKS. 
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18 
2 
Tibia and 
None. 
2Jyrs 
5 yrs. 
1 year 
No ap- 
£ inch. 
J inch 
None. 
Movements in all direc- 
9 
fibula. 
parent. 
tions normal; no defor- 
mity; no pain even af- 
ter long walks. 
19 
Tarsus. 
Moder- 
2 “ 
3 “ 
4 “ 
Flexion not quite nor- 
mal; other movements 
Caries of lumbar verte- 
brae with femoral ab- 
ate. 
perfect; bears most of 
her weight on the foot. 
scess on right side, and 
deformity of this limb; 
walks on crutches ; the 
right ankle the one for- 
merly carious. 
20 
1 
Tarsus. 
Exten- 
2 “ 
3 “ 
6 “ 
None. 
i inch. 
1 inch 
None. 
Movements in all direc- 
sive. 
tions normal; a very 
slight valgus; never 
21 
Tibia, and 
Exten- 
3 mos. 
2* “ 
3 “ 
None. 
i “ 
1 “ 
Slight 
any pain. 
Movements in all direc- 
probably 
sive. 
tions about one-third 
22 
10 
tarsus. 
Tibia and 
the normal; girl quite 
active on the foot. 
Exten- 
Hyrs. 
3* “ 
10 “ 
f inch. 
1 inch. 
2 
Slight 
Anchylosis at tibio-tar- 
astragalus 
sive. 
- 
sal joint; excessive 
movements in medio- 
23 
n 
Fibula and 
Slight. 
tarsal joint (can walk 
5 miles without pain). 
10 
1 “ 
None. 
Mother reported that 
movements of this foot 
tarsus. 
mos. 
Died of scarlatina. 
were as good as those Thirty Cases of Caries of Ankle in Children. 
25 
24 
5 
Tarsus. 
None. 
8 mos. 
2 vrs 
6 mos. 
Slight 
of the other ; no defor- 
mity. 
Mother reported, the 
child as cured, and as 
walking lame only af- 
ter much exertion; 
movements not ascer- 
tained. 
35 
5 
Fibula. 
None. 
2 mos. 
3 “ 
84 vrs. 
No ap- 
parent. 
4 inch. 
J inch 
None. 
Flexion not quite nor- 
mal; other movements 
normal; never any 
pain; no deformity. 
26 
1 
Scaphoid. 
Exten- 
sive. 
2£ “ 
54 “ 
2 “ 
No ap- 
parent. 
1 “ 
4 
* “ 
None. 
Flexion and extension 
normal; inversion and 
eversion imperfect; 
never any pain; a 
slight valgus. 
27 
9 
Tarsus. 
None. 
9 mos 
3 “ 
54 “ 
No ap- 
parent. 
* - 
2 << 
4 
Slight 
Flexion and extension 
perfect; inversion and 
eversion one-half nor- 
mal; is on her feet 
much of the time; 
dances well. 
28 
9 
Fibula and 
astragalus 
Exten- 
sive. 
1 “ 
4 “ 
5 “ 
1 “ 
4 
2 “ 
None. 
Reported as having a 
perfect foot, though 
mobility of joint not 
definitely ascertained. 
Is wearing apparatus to 
overcome deformity. 
29 
6* 
Tibia, fib- 
ula, and 
tarsus. 
Exten- 
sive. 
2 “ 
3 “ 
4 mos 
1 inch. 
1 “ 
2 “ 
Slight 
Movements over one- 
half normal; lacks the 
springing motion of 
the foot in walking. 
30 
2 
Tibia and 
tarsus. 
Exten- 
sive. 
2* “ 
34 “ 
1 vr. 
None. 
* “ 
1 “ 
Mark- 
ed. 
Anchylosis; slight varus: 
walks without pain; 
natural spring being 
lost, however. 
Never under any regular 
course of treatment. 26 
(tibney : Expectant Treatment in Caries of Ankle. 
AGE. } EXCITING CAUSE. 
BONES INVOLVED. 
SUPPURATION. 
Under 4 years 14 None known 20 
Between 4 and 9 years 11 1 Fall or blow 10 
“ 9 and 13 “ 5 
Tibia, or Fibula and Tarsus. 14 
Tarsus 10 
Tibia and Fibula 4 
Os Calcis 2 
Extensive 19 
Moderate 6 
None 5 
DURATION OF TREATMENT. 
DURATION OF DISEASE. 
SHORTENING OF LIMB. 
SHORTENING OF FOOT. 
Under 0 months 5 
Under 1 year 2 
Between 6 raos. and 1 year. 9 
“ 1 year and 2 years. 12 
“ 2 “ “3 “ . 4 
Between 1 year and 2 years. 4 
a 2 “ « g it jg 
“ 3 “ “ 4 “ 4 
“ 4 “ “ 5 “ 2 
“ 5 “ “ 6 “ 4 
Died 1 
One-half inch 3 
None 8 
No apparent 7 
Not ascertained 9 
Lengthening of tibia 4 inch 1 
“ “ 4 “ 16 
None. 3 
Not ascertained 7 
ATROPHY OF CALF. 
INTERVAL BETWEEN CURE AND 
LAST EXAMINATION. 
MOBILITY. 
Between l and 2 inches 8 
“ « “ 1 “ 7 
One-half inch 8 
Not ascertained 6 
None 1 
32 years. . 1 
10 “ .. 1 
7 “ .. 4 
6 “ .. 1 
5 “ .. 2 
4 years.... 2 
3 “ .... 2 
2 “ ... 6 
1 “ .... 3 
* “ •••• 6 
Normal 5 
“ except flexion, extension, or both 6 
“ “ inversion and eversion 5 
“ “good motion” 7 
Anchylosis at tibio-tarsal joint 2 
Motion in all directions, but limited 4 
LAMENESS. 
One died of intercurrent 
disease a week or two after 
cure was pronounced. One 
died of septicemia. 
None 20 
Slight 7 
Marked 1 
Not ascertained 2