ORTHOPEDIC SURGERY: 
DEFORMITIES OF THE LOWER 
EXTREMITIES. 
BY VAN S. LINDSLEY, M. D., 
Professor of Physiology in University of Nashville ami Vanderbilt University. 
Read before Medical Society of Tennessee, April, 1876. ORTHOPEDIC SURGERY—DEFORMITIES OF THE 
LOWER EXTREMITIES. ( > 
By Van S. Lindsey, M. /)., Professor of Physiology in University of Nashville 
Vanderbilt University. 
Thin paper will be confined to that particular kind of deformity usually 
termed Club Foot. I do this from the fact that the subdivision of Orthopedic 
Surgery is comprehensive, elaborate in details, and hut imperfectly treated in 
the general works of surgery which fall into the hands of the general sur- 
geon or practitioner. 
One is struck with the force of the first part of this remark if he examine 
the sj>ecial works on Orthopedics, and the truth of the latter part, if he com- 
pare these sjK*cial treatises with the general works on Surgery, such as Gross, 
Erichson, etc. 
The treatment of deformities is as old as medicine itself, for we can trace 
it hack to the earliest periods of which we have any account. Rut the correct 
methods of treatment are of recent date, and have not yet fully taken hold 
of the profession. 
This class of unfortunates has excited the pity and aroused the sympathy 
of the philanthropic and humane from time immemorial, and alas! in our 
latter day, the cupidity of the designing quack, who with his vain and boastful 
promises of cure, steals from whom God has stricken. 
The deformed have always been peculiarly sensitive to their misfortunes, 
and regarded themselves with a blended feeling of loathing and pity. It 
would make a curious chapter in the history of morbid psychology to note 
the blighting, weird influences and unaccountable effects of club-foot upon 
the characters, acts and writings of distinguished men who have figured in 
the drama of public life, and moulded oftentimes important epochs in the 
world’s history. Byron, who, in the language of his friend, Trelawney, after 
viewing his dead body—“ was an Apollo in form and expression from the waist 
up, with the limbs of a sylvan satyr” is a fit subject for such contemplation. 
Who can say that Byron, with bis shrunken limbs, halting gait, extreme morbid 
sensibility, intense melancholy, a disbeliever in manly honor, and a destroyer of 
womanly virtue, would not have given a different tone and coloring to his 
writings, had he been born with straight feet? There is a secret history here of 
silent but powerfully working influences of which he himself occasionally gave 
us glimpses. 2 
Medical Society of Tennessee. 
We see these influences operating on the Duke of Gloucester in his soliloquy : 
“ I that am curtailed of this fair proportion, 
Cheated of feature by dissembling nature, 
Deformed, unfinished, sent before my time 
Into this breathing world, scarce half made up, 
And that so lamely and un'ashionable 
That dogs bark at me as I halt by them ; 
Why, I, in this weak, piping time of peace. 
Have no delight to pass away the time, 
Unless to spy mine shadow in the sun 
And descant on my own deformity ; 
And therefore, since I cannot prove a lover, 
To entertain these fair, well-spoken days, 
I am determined to prove a villain, 
And hate the idle pleasures of these days. 
But time forbids us pursuing further this interesting aspect of the subject, 
and remands us back to the more accustomed grooves of inquiry as to the 
varieties, cause, seat, and best methods of treatment of club-foot. The di- 
vision into four varieties can not be improved upon, viz: varus (inverted), 
equinus (heel elevated), valgus (everted), calcaneal (phalanges elevated). The 
names are given in the order in which they most frequently occur. Pure varus 
is rarely seen. The cases, so-called, being an inversion of the foot with more 
or less elevation of the heel, and hence we have the name of equino-varus. 
The same thing happens with valgus, eversion of the foot with contracted 
sural muscles, giving rise to the name equino-valgus. There are several other 
sub-varieties, combinations of the original four divisions, which are easily 
recognized when seen, but seldom occur. 
We have often remarked in looking at it, that the skeleton of the human 
foot is one of the most shapeless and unsightly objects imaginable, but when 
bound together by its ligaments, clothed with muscles and tendons, and envel- 
oped with integument, and endowed with its wonderful and varied functions of 
support and movement, it becomes a thing of beauty and inimitable grace. 
In a normal foot the flexors and extensors, the adductors and abductors are 
so harmoniously poised and balanced, that the extremity in a state of rest 
assumes an easy and natural position, and readily responds to the various 
movements of the twelve muscles connecting it with the leg. 
It is the unbalancing of some of these twelve muscles, the disturbance of 
their constant and harmonious tension which gives rise to the great majority 
of the deformities under consideration. 
Derangement of the muscular force acting irregularly and in the wrong 
direction upon the bones, distorts and misplaces them, until we have the disease 
developed into its most hideous and repulsive forms. 
Thus in varus, there is loss of action in the muscles supplied by the peroneal 
nerve, these being the peronei and flexor longus digitorium muscles, leaving 
the tibial muscles and gastroenemius to invert the anterior portion of the foot 
and tilt up the heel. The anterior and posterior tibial muscles, aided by the 
plantar muscles and fascia, continuing to contract without any antagonizing 
influence from the peronei, cause the arch of the foot to take an exaggerated 
curve, and twist the foot inwards at the medio-tarsal and tarso-phalangeal 
articulations, so that the patient walks first upon the outer margin, and finally Orthopedic Surgery, 
3 
upon the dorsal surface of the foot. The foot taking an opjiosite direction in 
valgus, is drawn outwards by the peronei muscles, causing the jierson to walk 
upon the inner margin of the foot. 
CAUSES. 
Although the immediate cause of the deformities under consideration lies in 
the defective action of certain muscles, still we must look further, and in doing 
so, will find the trouble beginH in the nerves supplying these muscles, and some- 
times in the nerve centers themselves. 
It is pretty generally agreed among modern pathologists, that in congenital, 
as well as most eases of acquired talijies, defective innervation resulting in 
motor-paralysis is the primary cause of all these deformities. The older view 
of Cruveilhier and his followers, that the position of the foetus in utero was the 
exciting cause, has but few, if any, adherents to-day. 
Hauer says: “ After mature deliberation I have come to the conclusion that 
the cause in congenital, as well as acquired club-foot, is pre-eminently defective 
innervation, and that there is truly no reason why derangements in the nervous 
system should not take place in the foetus as well as the newly-born child. In 
club-foot (varus) the tibial nerve is the bearer of the difficulty, as must be in- 
ferred from the experiments of Bonnet.” 
“The acquired instances of club-foot are comparatively rare, and they de- 
j*end most unquestionably on imfs'diments and lesions of the spinal cord. Wc 
can discriminate two forms of acquired varus. The active form is the less 
frequent, consisting in reflex action in both extensors and adductors. The ex- 
tensors most usually preponderate, and we see therefore equino-varus and the 
passive form as a Hequel of motor paralysis.” 
“The congenital forms,” says Sayre, in his recent work on Club-foot, “are all 
due to some interference, general or local, with the normal innervation of the 
part. So much has been generally accepted, but the real nature of this nervous 
disturbance has been for the most part misunderstood.” * * * 
“ What has been said above of the lesion in congenital talipes, is to a great 
extent true of the acquired form. Acquired talipes is very generally due to 
the various kinds of “infantile paralysis,” which are the frequent sequela.'of 
scarlatina, diptheria, dentition, and many other diseases in which blood -poison- 
ing exists, and which are attended with great exhaustion.” 
Harwell, Prince, and other orthojadists hold the same opinions with little or 
no variation. 
In what does this defective innervation consist? For just here, the right 
comprehension of this point, gives the key to the proper treatment, and also clears 
away the smoke of battle which has been waged between the tenotomists and 
non-tenotomists. Does the so-called defective innervation of the muscles result 
in spastic contraction, as contended for by some, or in the paralysis of the 
muscles by others ? If we will but take the time to carefully examine a case 
of infantile club-foot, we will find there are certain muscles which have lost 
their power to contract through the natural stimulus of the will, in other words, 
their defective innervation has resulted in motor paralysis. They have ceased 
to antagonize the muscles of the opposite side, having lost not only their ability 
to contract in resjamse to the will, or a stimulus from the spinal cord, but their 
natural tonicity, that normal tension which is so necessary for the harmonious 4 
Medical Society of Tennessee. 
development of all muscular parts. The antagonizing muscles finding nothing 
to pull against, continne to shorten by their natural tonicity until they meet the 
proper resistance from the ligaments holding the bones together, or the bones 
themselves. There is no exaggerated or extraordinary force on the part of the 
muscles, it is only their normal quantum, but it produces an extraordinary 
result in the shape of a deformity, simply because their balancing muscles are 
hors du combat from defective innervation, just as much as if their tendons were 
severed. The symmetrical development and growth of the bones, muscles and 
nerves of the lower extremities, the unerring certainty and perfection with 
which the process advances and is accomplished, is one of the marvels in the 
study of life. Look at that cluster of embryonic cells ! See them segment, now 
assume some rude form ! Is it to be a dog, a cat, or a human being ? From its 
present appearance who cen tell? Upon what pattern is the work being done? 
Where is the artificer? Whence comes the skill and intelligence which guides 
the force acting upon those plastic cells, to push out nodules here and there 
which finally become extremities? In these extremities what varied materials 
and how harmoniously blended and interwoven ? And yet the addition of 
structure upon structure and function upon function has mysteriously advanced 
under the law of development until the process is completed, the work is fin- 
ished, the pattern is worked out, and the result a human foot, a most admirable 
and perfect piece of mechanism. 
In this instance nature has turned out a perfect piece of work. We admire 
it, but how much do we know of the processes? Nothing ! We only judge of 
it by the result. But sometimes nature spoils the job, the pattern is not followed, 
and the result is some one of the forms of club-foot. According to French 
statistics nature in working out her patterns, commits an error in one out of 
every three thousand French inhabitants. Why is there one failure to every 
three thousand perfect patterns? We must look to the physiologist for light. 
For until he can tell us more about the processes employed in the perfect pat- 
terns, how can we detect the hitch which results in a spoiled pattern? The 
causes of defective innervation are still a mystery, they result in paralysis, the 
latter in deformity. 
The main point to be kept in mind by the orthopedist, is, that the principal 
cause of talipes is the paralysis of the muscles on the opposite side of the foot to 
which it is drawn. These weakened muscles being unable to continue the 
contest with their more vigorous antagonists, give way, and the foot is drawn to 
the well side. At this stage of the process, there is no disease of the muscles on 
the side to which the foot is drawn, they are simply performing their normal 
function; the disease is on the opposite side of the foot. In a case of varus, 
the peronei muscles are at fault. How unphilosophical, then, the almost uni- 
versal injunction of general works on surgery to perform tenotomy; in other 
words, to cut the tendons of the well muscles to cure the disease of the weakened 
ones. Is it not more rational to antagonize the well muscles, giving them the 
healthy stimulus of a pull with elastic bands, and in the meantime address 
proper remedies, such as electricity, friction, exercise, etc., to the paralyzed 
muscles to restore their tone and vigorous vitality? We are all well aware of 
the universal physiological law, that when a muscle has been allowed to remain 
contracted for a variable length of time, important nutritive changes take place 
in its minute structure which disqualify it for immediate use as a muscle. After Orthopedic Surr/rry, 
5 
such a change tenotomy becomes a valuable aid in treatment. But as the 
.people are being awakened to the importance of bringing their deformed chil- 
dren early to the surgeon, these cases of permanent contraction are becoming 
less frequent, anti will be of rare occurrence in the future. 
The generic name talipes would seem to indicate, as it really has done to a 
great extent in the minds of surgeons, that the seat of deformity existed solely 
at the ankle-joint, or what is now called the tibio-tarsal articulation. Harwell 
was the first to point out clearly the true seat of talipes, especially in varus 
and valgus, in his little book, “Club-foot without division of tendons.” 
In this he uses the term “ medio-tarsal articulation” to designate the joint 
between the cuboid and os calcis on the outer sider of the foot, and the astra- 
galus and scaphoid on the inner side. He shows that it is at this joint the 
twist takes place inwards in varus and outwards in valgus, instead of at the 
ankle-joint. I have made dissections of the foot, removing all the structures 
except the ligaments, and at first was struck with the great mobility of the foot 
at this medio-tarsal articulation, and with the almost total absence of lateral 
motion between the astragalus and tibia. In fact Dr. Sayre, of New York, 
claims, in his recent work on club-foot, that there is no lateral motion whatever 
of the astragalus. That the internal maleolus formed by the tibia and the exter- 
nal maleolus formed by the fibula lit so closely, and are held so tightly by the 
external and internal lateral ligaments upon the lateral articular surfaces of the 
astragalus, as to prevent »ny lateral movements between the astragalus and 
tibia, and that whatever lateral movements appear to take place at the ankle- 
joint in the normal foot, are really movements at the medio-tarsal articulation, 
together with a sliding of the os-calcis upon the astragalus. Since making dis- 
sections of the foot with special reference to these points, I agree with Dr. Sayre, 
and think that he, next to Harwell, deserves the greatest credit for the light he 
has thrown upon the anatomy of the foot with reference to club-foot. 
And yet Dr. Gross, of Philadelphia, in a letter to Dr. Sayre, “ thanking him 
for his work, which, he states, is of great value to the profession,” adds: “I 
shall continue to make lateral motion at my ankle-joint without rotating my 
hip or revolving the head of my fibula ” 
This is but another example of the tenacity with which some people hold on 
preconceived ideas. In fact I am constrained to say, after a careful examina- 
tion of the section on club-foot by Dr. Gross in his last edition of surgery, that 
he does not come fully up to the advances recently made in this department of 
surgery, as to the causes or seat of the deformity under consideration. Speak- 
ing of the causes, he says: “The most plausible view, perhaps, is that the dis- 
tortion is produced by a defect of nervous influence, leading to a permanent 
contraction of certain muscles with a corresponding retraction and incurvation 
of the bones into which these muscles are inserted. Yrol. ii, p. 1044. 
As we have already shown above, this is just the opi>osite to the expressed 
views of the best orthoj>edista of the present day, based iq>on the most laborious 
investigations of the anatomy and physiology of the normal foot, and also of 
the etiology, pathology and results of treatment of club-foot. 
We do not believe that “a defect of nervous influence” leads first to con- 
traction of certain muscles, but to a paralysis of the opposite muscles, and that 
SKAT OF TAI.IPKS. 6 
Medical Society of Tennessee. 
afterwards it is the normal contraction of the muscles which causes the foot to 
deviate from its proper shape. 
Dr. Gross is very vague and indefinite as to the seat of varus and valgus. 
“ The calcaneum, cuboid, scaphoid and astragalus,” he says, “ suffer more than 
the other bones, which, however, as well as those of the metatarsus and toes 
usually participate more or less, in the deformity.” Yol. ii, page 1047. 
How unsatisfactory when compared with the elaborations of Bauer, Prince, 
Barwell and Sayre upon these points. 
We have the highest respect for Dr. Gross and the splendid work on surgery 
he has given the world. And although we could not expect him to give that 
fullness and detail on special subjects, such as club-foot, as is given by writers 
of special treatises, still we have a right to expect the latest views and most ap- 
proved methods in these general works in the clearest and most concise form. 
TREATMENT. 
If the ground we have taken in the foregoing pages be correct, it will be easy 
to state the main principles of ti’eatment. The object before us will be to tone 
up and reinvigorate nerves which have lost their excitability and conductilitv, 
and at the same time re-awaken the irritability and contractility of the para- 
lyzed muscles, not forgetting to draw out and unravel the contracted fibres of 
those muscles on the side to which the deformed foot is drawn. The discovery 
of Stromeyer in 1831 that tendons and muscles might be subcutaneously divided 
with impunity, gave a wonderful impetus to this department of surgery. Al- 
though cutting the tendons of contracted muscles seemed to cure the deformity, 
yet in time the trouble returned, and tenotomy, though received with great 
enthusiasm and practiced with high hopes, disappointed expectations, and lost 
finally in tire confidence of the people and profession. Experience has assigned 
tenotomy its proper place, and pointed out its true value in those cases in which 
permanent contraction has taken place in the muscle, rendering it incapable of 
responding to the ordinary stimuli generally used. Tenotomy has been disad- 
vantageous to the rapid development of orthopedic surgery, from the fact that 
surgeons have relied too exclusively upon this means to correct the deformity, 
and to the neglect of proper mechanical appliances. Tenotomy should only be 
used when other means have been sufficiently tried and failed. It looks bril- 
liant and gives eclat to seize a knife, divide a tendon or two, and seem to 
straighten a contorted foot at one sitting. This is the temptation, and has its 
fascinations to the surgical mind. If we take the foot of a child with varus in 
the hand, we will find no difficulty by proper manipulation in making the foot 
assume the proper relation to the leg. And if our hands could so remain ap- 
plied day and night for a certain length of time, a most admirable cure would 
be the result. The child would get well without abrasions, serious pressure or 
painful distortions. Bauer, Prince and Sayre, all admit that the human hand 
would make the most perfect apparatus, and that the most desirable instru- 
ments are those which approximate most nearly the actions of the hand. The 
more a club-foot is handled and freely manipulated, the more rapidly will its 
progress towards a cure be effected. And the treatment with the most approved 
mechanical contrivances is slow and imperfect without daily manipulation. 
Surgeons are too apt to think that when they have divided tendons, and applied Orthopedic Surgery. 
7 
Home form of apparatus, tlieir work in done; it ban only begun, and needs to be 
looked after daily with that earnest solicitude which does not fear work. 
All orthopedic surgeons agree that Home kind of mechanical apparatus is 
necessary in the treatment of club-foot, hut the time haa not yet arrived when 
we can all agree as to which is the best. Nearly every writer upon thin subject 
has bin own particular pattern, and in free to claim advantages for it he does 
not discover in others. 
I>r. Bauer in his distrust of modern apjdiances, says, ‘‘There is no mechani- 
cal apparatus, however ingeniously constructed, which could be substituted for 
the hand in the treatment of tali|»es, with any approximate degree of efficiency.” 
In the edition next to the last, Vol. ii, p. 1011, Dr. Gross does not hesitate to 
say, “ It is jterhaps not going too far to affirm that these topics (club-foot) are 
as well understood now as they ever will be.” After reading the last edition of 
his surgery I do not find this sentence, and suppose his larger experience has 
lessened his enthusiasm in the apparatus then used. Dr. Prince is constrained 
to say, “It is ltelieved that in the course of these pages a process will l>e ex- 
plained, which is a pretty adequate substitute for the hand.” Treatise on Or- 
thopedics, p. 171. 
This variety of opinion only proves that these distinguished authors and 
surgeons differ as to their methods, hut arrive at the same result by different 
routes. 
We are decidedly in favor of the extension method, or American plan, as it 
is sometimes called, in which elastic bands of rubber with adhesive strips, and 
sometimes a shoe are used. We do not discard the use of the tenotome entirely, 
but keep it in the back-ground as much as possible. Any case of club-foot, 
which, when placed under the effects of ether, can be brought into its natural 
|K>sition by manipulation of the hand, ought to be relieved by the use of elastic 
bands and the shoe without tenotomy. 
Division of the tendo Achillis is attended with less bad effects than any 
other tendon about the foot, and in cases of equinus, equino-varus and equino- 
valgus, where the foot cannot be brought into j>osition by the hand, I divide the 
tendo Achillis. Tendons which run through long grooves with extensive 
synovial membranes, such as those of the j>eronei and jtosterior tibial muscles 
do not unite well after division, and are liable to destructive inflammation. 
A case of ordinary talijtes equino-varus maybe successfully treated without 
any other appliances than the adhesive plaster, rubber bands and roller band- 
age, after Harwell’s method. “The peculiarity of Harwell’s plan consists in his 
method of attaching the proximal end of his tension apparatus, which is this: 
Starting with the idea of making the artificial tension, the exact complement of 
that of the partially paralysed muscles, he aims to act as nearly as j>ossible upon 
the same bones to which these muscles are attached (and in the same direction), 
by adhesive plaster fastenings, while the points from which the pull comes are 
the origins of these muscles.” A piece of adhesive plaster is cut long enough 
for a piece of bent wire of sufficient strength to be fastened at one end, and the 
other to l>e passed under the sole of the foot and lapped across the dorsal sur- 
face. In varus the wired end of the plaster would be on the outer side of 
the foot for the attachment of the hook connected with the rubber band. 
Another piece of plaster is cut nearly twice the length of the leg between the 
ankle and knee-joint. A strip of tin corresponding in length to the distance 8 
Medical Society of Tennessee. 
between ankle and knee-joint, one inch and a half to two inches in width, a 
little wider at the upper than lower end, is curved to adapt itself to the leg, and 
provided at the upper end and outer side with a wire loop or eyelet soldered on 
for the attachment of the other end of hook and chain connected with rubber 
band. In the supposed case of varus the plaster is placed up and down the leg, 
over the peronei muscles, with the sticking side next to the skin. The tin splint 
is placed on the plaster, but the latter being longest, the upper end is brought 
down over the tin, and a hole cut so that the wire loop may pass through; 
then the lower end of the plaster is treated likewise, and turned up over the 
lower end of the tin, and the whole permanently secured to the leg with a roller 
bandage. A short piece of medium-sized India-rubber tubing, having two small 
chains, one attached to either end, to be fastened to the wire of the foot-piece of 
plaster, and to the wire loop of the tin over the insertion of the peronei muscles 
completes the apparatus. By shortening the chains from time to time any 
amount of pull upon the foot is made which may be desirable. We readily see 
how these appliances can be transferred to the inside of the foot and used in the 
treatment of valgus, or to any of the other forms of talipes. The constant, 
steady pull day and night of the India-rubber finally overcomes the resistance 
of the contracted muscles, and they yield more kindly than they would to 
greater force applied through a shorter time. But this does not restore the 
paralyzed muscles. They must be stimulated daily by friction and the applica- 
tion of the interrupted electric current, so that they may be able in time to take 
the place of the India-rubber tubing and antagonize the formerly contracted 
muscles.