HALLUX VALGUS, 
WITH A 
REPORT OF TWO SUCCESSFUL CASES. 
BY 
ALBERT N. BLODGETT. M.D., 
BOSTON, MASS. 
Reprinted from The Medical Record, 
July 10, 1880. 
NEW YORK: 
TROW’S PRINTING AND BOOKBINDING CO., 
201-213 East Twelfth Street. 
1880. HALLUX VALGUS, 
With a Repokt of Two Successful Cases. 
A great deal of suffering among all classes of peo- 
ple is caused by the continuous and unvarying irri- 
tation and pain produced by comparatively trifling 
causes, which is borne without complaint, either be- 
cause it seems too insignificant to be considered a 
disease and to be treated as such, or because there is 
comparatively little prospect of permanent relief from 
any treatment which can be employed in the case. 
No part of the body is more frequently the seat of 
these affections than the feet and the lower part of 
the leg, and probably no class of diseases is more 
rarely brought to the notice of the surgeon for treat- 
ment. The excessive degrees of these diseases are 
sometimes so serious in their character that the pa- 
tient is brought into a frame of mind to endure any 
operative interference rather than suffer a contin- 
ual martyrdom with no prospect of relief. It is one 
of the diseases of this nature which forms the subject 
of this paper. 
The complaint to which I ask attention con- 
sists in the anatomical element of extreme abduction 
of the great toe, which, instead of forming a contin- 
uation of the line of the foot, is turned outward, is 
rotated upon its axis to a greater or less degree, and, 
in very marked cases, is found lying either under the 
other toes, or compressed into an irregular, deformed 
member, and crowded with the other toes, forming 
a conical projection from the line of the metatarso- 
phalangeal articulation. The other toes are ad- 
ducted, that is, are inclined toward the middle line 4 
of the body, and therefore move in an opposite di- 
rection from the great toe. All the toes are there- 
fore brought closely together and crowded one upon 
another, are altered in shape, and sometimes so con- 
strained in their cramped position that they become 
ancliylosed. The great toe shows a decided tendency 
to lie under the remaining toes, being found in the 
depression beneath the first phalanx, with the other 
toes closely folded down over it and turned down- 
ward, so that their points and the toe-nails rest upon 
the bottom of the shoe. 
The degree of deformity which is produced by this 
disease is much greater than would be expected, and 
the disability which it occasions, both from its me- 
chanical liinderance to locomotion, and from the in- 
tense pain with which it is often attended, is surpris- 
ingly great. 
In connection with the distortion and dislocation 
of the great toe, there is generally much swelling and 
protrusion of the tissues about the head of the ca- 
pitulum metatarsi, which is often the seat of intense 
suffering from pressure upon the prominent joint, 
which tends to aggravate the disease, and sometimes 
induces acute inflammation of the joint itself. 
Prof. Hamilton considers the condition of the ar- 
ticulation to be that of subluxation, in which the first 
phalanx, instead of being simply dislocated outward, 
has partially rotated, so that its proximal end rests 
upon the outer surface of the capitulum. He also 
observes that the articulating surface is prolonged 
outward to a greater or less extent, to form a joint in 
the new position of the phalanx, and that the syno- 
vial cavity becomes obliterated at its internal border, 
both of which facts I was able to verify in the case I 
shall first report. 
Here the articulating surface was displaced out- 
ward and downward, and was limited to an area of 
about six mm. 
In regard to the causation of the disease in ques- 
tion, there can be no doubt that by far the larger 
number of cases are produced in a purely mechanical 
way, by the wearing of ill-fitting shoes. This effect 
may result from two causes: from shoes which are 5 
too narrow, and also from those which are too short. 
Of these two elements of causation in this particular 
disease, it would seem that pressure upon the ends 
of the toes, principally, of course, upon that of the 
great toe, would be the most frequent cause of the 
deformity in question. The great toe would be ab- 
ducted to a powerful degree, while the other toes 
would be adducted, though to a much smaller de- 
gree. The continued action of a short shoe would 
serve to increase the displacement, and at length 
would crowd the great toe beneath the other toes 
and fold them down upon it, so that the ends of the 
smaller toes might rest upon the sole of the shoe. 
This is the condition called “liammer-toes,” and is 
almost always present, to some extent, in cases of 
abduction of the great toe. Of course, the fashion 
of wearing high heels, now unfortunately in vogue 
among the ladies, has a continual tendency to produce 
or to perpetuate this disease, from the tendency of 
the foot to slide toward the toe of the shoe ; and as 
if to furnish no chance of possible escape from 
trouble, many ladies’ shoes are made with a so-called 
“ box-toe,” which does not yield to the foot, but com- 
presses the toes as in a vise, so that some degree of 
deformity is nearly always induced by their continu- 
ous use. 
Another cause which sometimes tends to produce 
abduction of the toe is any affection of the muscles 
which would shorten them, or in any way interfere 
with their functional integrity, thereby rendering 
them unfitted for their normal office. In some such 
conditions, abduction is the inevitable and necessary 
result, and in all there is great probability of its oc- 
currence, as the consequence of an interference wTith 
the motor apparatus of a small and distant member, 
which is exposed to a continual tendency in the di- 
rection of the displacement. Of course, the primary 
disease of the muscles may be due to many causes 
which may be omitted here, since it is with the me- 
chanical effects that we are now dealing. A third 
and frequent cause of the disease, is some lesion 
located in the joint itself, which causes a change in 
the shape of the capitulum, and often in the head of 6 
the phalanx as well. The articulating surface be- 
comes displaced, so as to present no longer upon the 
end of the metatarsal bone, but rather upon its outer 
and inferior aspect, corresponding to which, the toe 
is swung around as on a pivot, and comes to lie in 
a direction nearly transverse to the line of the foot. 
This condition may be caused by a periostitis, due 
to pressure of the boot, or to an injury to this region 
by an accident, and in either case forms a bursa, the 
so-called bunion, in which there is always swelling 
and pain in the tissues about the joint, and often a 
thickening of the bone in the vicinity, sometimes 
even an ostitis. Chronic arthritis is also a frequent 
cause of deformity in this joint, from the distortion 
of the articulating surfaces and thickening of the 
capsular envelopes which so often accompanies it. 
When the diseased condition is once established, the 
motions of the feet in walking, and the weight of the 
body, tend to perpetuate and increase the deformity. 
The muscles, when the toe is out of its normal line 
with the foot, draw upon the toe at an angle, and every 
contraction of the muscle tends to make this angle 
greater, thus, of course, increasing the distortion. 
The distress occasioned by so painful a disease in 
a part continually exposed to pressure and weight, 
and the disability produced by the distortion of a 
part of the foot so important in locomotion, as well 
as the unsightly deformity which is produced by the 
displacement of the toes, all render any measure for 
the relief of this condition a boon to be eagerly 
sought for. 
Various methods of treatment have been tried with 
varying degrees of success, but most of these have 
been discarded as impracticable or useless. Rest in 
bed will sometimes relieve the inflammation about 
the head of the bone, but will do nothing toward re- 
lieving the deformity, and the first attempt at wear- 
ing a shoe provokes the whole trouble anew. 
Tenotomy is often resorted to as a means of re- 
ducing the deformity, but the conditions of the capi- 
tulum and the phalanx are often such as to preclude 
any result from this means, and at best its effect is 
only imperfect and transitory. 7 
Recourse is often had to amputation, which cer- 
tainly relieves the abduction of the toe, but is sub- 
ject to grave objections from the greater deformity 
inflicted upon the foot, the unprotected position of 
the remaining toes, and the disturbance to the equi- 
librium of the body. The diseased head of the meta- 
tarsal bone would necessarily be removed, an osseous 
structure thus be opened, and a risk of greater or 
less degree to the life of the patient would thus be 
incurred. 
A few years ago, Prof. Hueter, in his “ Clinical 
Treatise on Diseases of the Joints,” discussed the 
disease of which we have been speaking, and stated 
that the head of the metatarsal bone had been ex- 
cised for caries with such success as to recommend 
the operation, and he advises it also in extreme 
cases of abduction of the toe from other causes, to 
which condition he gives the name of “ hallux val- 
gus." The operation, as Hueter performed it, con- 
sisted in an incision upon the inner surface of the toe 
in the direction of its axis, which is carried to some 
distance on either side of the joint. The capsule is 
opened, the ligaments are cut, and a subperiosteal 
dissection of the head of the metatarsal bone is 
made, the capitulum is removed by bone-forceps or 
a saw, the toe is brought into a line with the foot, 
and the wound is left to heal by granulation (Hueter, 
p. 341 et seq.). 
So far as I know, attention was first called to this 
method of treatment in America, by a paper, de- 
scribing the operation and accompanied by a report 
of eleven cases, which was read before the Buffalo 
meeting of the American Medical Association, by 
Prof. Frank H. Hamilton, of New York. The cases, 
with two exceptions, were simply those of deformity 
either from mechanical causes or from rheumatic or 
other diseases. Of these eleven cases, six were oper- 
ated upon by Prof. Hamilton, and all resulted in 
cure, with the relief of deformity and restoration of 
the functions of the foot. Five cases were reported 
from other surgeons with a flattering result in four 
cases, and one death. The fatal case was that of a 
gentleman seventy-five years old, who had had ex- 8 
tensive disease of the joint with caries and suppura- 
tion for three years. Esmarch’s bandage was applied 
and the resection was made with a chain-saw. The 
foot was enveloped in a warm-water compress. Gan- 
grene of the toe, foot, and leg ensued, and the patient 
died on the eleventh day. The surgeon who operated 
in this case ascribes the fatal result to the use of the 
Esmarch bandage, which is thought to have delayed 
or even suspended the proper nutrition of the part 
for a time sufficient to destroy the vitality of the tis- 
sues, thus inducing gangrene. That this disastrous 
result sometimes follows the use of the Esmarch 
bandage in debilitated subjects, there can be no 
doubt, and it may easily have been the cause of the 
fatal result in this case. Prof. Hamilton takes great 
care to secure the most favorable conditions for the 
healing of the wound by applying no ligatures or 
sutures after removing the head of the bone, but by 
simply immersing the foot in a bath of hot water, 
where it is kept continuously for a period of from 
five to seven days, when he says “ fomentations may be 
substituted, or the foot may be taken from the bath 
at night and wrapped in wet lint covered with oil- 
silk.” This treatment could be more easily carried 
out in a hospital than in private practice, where the 
appliances for a continuous bath of a certain tempera- 
ture are not always easily obtained. Prof. Hamilton 
adds that “nearly but not quite the same immunity 
to inflammation and other accidents may be obtained 
by continuous warm-water fomentations, and without 
the use of the bath at any period.” In any case he 
advises the use of fomentations for two weeks, when 
they may be replaced by other suitable dressings. 
The incision wras varied in direction by Prof. Hamil- 
ton, so as to form a flap by 2 cm., thus opening the 
joint more easily and completely than was the case 
with the straight incision. The operation was thus 
rendered easier, and the result was equally favorable. 
The cases which I present were of the right and 
left foot respectively of the same person. The 
patient, a middle-aged lady, had long been confined 
to her room, and often to her bed, on account of the 
pain and disability occasioned by the inflamed state 9 
and distorted condition of tlie heads of the first 
metatarsal bones. The history was that of a chronic 
rheumatic arthritis,, no doubt aided materially by 
wearing improperly shaped shoes, though, as is 
usually the case, the patient denies that the shoes 
were ever at fault. She was much emaciated from 
long confinement and suffering, appetite poor, the 
strength greatly diminished, weight between eighty 
and ninety pounds. There was a great degree of 
abduction of both great toes, so that they lay under 
the bodies of the other toes. * 
As before stated, there was great pain and almost 
entire inability to walk; the distal end of the first 
metatarsal bone was very prominent and knobby, 
and the articulation between it and the first phalanx 
was removed from the end of the bone to a point on 
its outer side. The tissues were stretched over the 
head of the metatarsal bone; they were red, abraded, 
and sore. Patient could not wear a shoe, she could 
scarcely get about the house, and was generally mis- 
erable. 
Feb. 2Gth.—Right foot was operated upon by an 
incision extending 2.5 cm. along the axis of the first 
metatarsal bone, and connecting with another in- 
cision transverse to the course of the bone, thus 
forming a right-angled flap. This was turned back 
and the head of the bone exposed. The joint was 
opened and the head of the bone freed from its at- 
tachments to such a degree as to allow a thin steel 
watchspring saw to be passed behind, when the bone 
was quickly sawed off at a point about 2 cm. from 
the distal extremity. There was but little bleeding. 
The wound was washed in carbolized water, and 
three silk sutures were applied by which the flap 
was retained in place. A light carbolized compress 
and bandage were applied. No ligatures were ne- 
cessary. 
Feb. 28th.—Doing wrell. No suppuration. All 
sutures removed to-day. Patient is kept quiet, suf- 
fers but little pain, requires no opiate. Appetite 
good. March 8tli.—Eleven days after the operation, 
wound fully closed. Not much tenderness and no 
pain. Patient is beginning to walk upon the foot. 10 
March 20tli.—Left foot operated upon in the same 
manner as the right. Wound closed with four 
sutures. No ligatures were required. The hone 
was removed a little farther back than in the opera- 
tion upon the right foot and the wound dressed with 
carbolized compress and bandage. March 23d.—All 
sutures removed. No discharge or signs of retained 
fluid. Pain very slight. No swelling. April 3d.— 
Fourteen days—wound fully healed. Patient is 
walking without any pain or discomfort. There are 
no signs of irritation*in the cavity of the joint, and 
motion of the toe is not accompanied by pain. The 
patient is much relieved. Can wear a close-fitting 
boot, which she has not been able to put on for seven 
years. Goes up and down stairs without difficulty. 
The appearance of the feet is much improved. The 
great toe of each foot is brought into proper line 
and the other toes are resuming their normal shape 
and position. 
In regard to the method of treatment advanced by 
Prof. Hamilton, it may be proper to notice a few 
points. He uses no ligatures or sutures, does not 
make any effort to approximate the edges of the 
wound, and is quite urgent in his advice that the 
foot be placed in a bath for some time after the 
operation, for the purpose of preventing sloughing, 
etc. He strongly insists that no bandage be used, 
as being likely to induce gangrene, and his cases are 
invariably left without trying to unite the lips of the 
incision, for the reason that such a wound should be 
left to fill up by granulation. These objections are 
all, doubtless, well grounded, and in some instances 
fully applicable, but they would seem to be more or 
less dependent upon the age and general condition 
of the individual patient and the condition of his 
suiToundings. They were none of them observed in 
my cases, and the result was certainly all that could 
be desired. Union was in both cases entirely by 
first intention ; there was no effusion into the cavity 
left after removal of the head of the metatarsal bone, 
and the recovery was very rapid and complete. The 
only treatment observed other than that mentioned 
above was rest in bed and a moderate diet. 11 
I do not know why Prof. Hamilton considers it 
necessary to observe so many details in the per- 
formance of this operation and in the subsequent 
treatment, or rather the subsequent lack of treat- 
ment, of the patient. The operation is certainly not 
more difficult to execute than many other operations 
upon the extremities, and if the two cases in which 
I have had opportunity to study it form any indica- 
tion, the recovery is not subject to more than the 
average amount of risk and peril. The attempt to 
follow the explicit directions given by Prof. Hamil- 
ton would rob the operation of what, to me, is one 
of its greatest advantages—its simplicity and conse- 
quent ease. To provide the means for constant im- 
mersion of an extremity in a bath of a certain tem- 
perature, with the observance of other unavoidable 
conditions, would render the extensive application 
of this operation outside of large hospitals impos- 
sible, and by just so much tend to limit its useful- 
ness ; for many, if not most of the sufferers from the 
disease we are treating, are found in the humbler 
walks of life. If these inconvenient and costly ar- 
rangements can be safely avoided, it certainly is a 
gain to surgery and to every patient who suffers the 
operation. 
That this may be judiciously advised is proved, I 
think, by the result of my cases, and I consider that 
this operation recommends itself in all proper con- 
ditions as easy, safe, and satisfactory. 
June 16, 1880.—Examination of both feet of this 
patient to-day shows the great toes in normal line 
with the foot, not sensitive, with extensive motion, 
the joints not tender, nor in any way causing her 
any trouble. The other toes have come into ex- 
cellent position, and the appearance of the feet is 
much improved. In fact, both feet are in as good 
shape and proportion as is found in the majority of 
so-called healthy feet. Patient is out walking every 
day, and does a great part of the housework in the 
family, wearing a close-fitting shoe, and being on 
her feet several hours each day. Her general health 
is benefited in almost a similar ratio, and she is loud 
in her commendation of the operation.