Contributions Orthopaedic Surgery

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COXTPvIBUTIOXS

ORTHOPAEDIC SURGERY.BY

A. SYDNEY ROBERTS, M.D.,LATE SURGEON TO THE PHILADELPHIA HOSPITAL, ORTHOPEDIC SURGEON TO THE OUT-PATIENTDEPARTMENT IN THE UNIVERSITY HOSPITAL ; INSTRUCTOR IN ORTHOPEDIC SURGERY

IN THE UNIVERSITY OF PENNSYLVANIA ; OUT-PATIENT SURGEON TO THE EPISCOPALHOSPITAL; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIAAND OF THE AMERICAN ORTHOP.EDIC ASSOCIATION | MEMBER OF THE

PENNSYLVANIA STATE MEDICAL SOCIETY, PHILADELPHIACOUNTY MEDICAL SOCIETY, PATHOLOGICAL SOCIETY,

NEUROLOGICAL SOCIETY, ETC.

WITH A BRIEF BIOGRAPHICAL SKETCHBY

JAMES K. YOUNG, M.D.,PROFESSOR OF ORTHOPEDIC SURGERY, PHILADELPHIA POLYCLINIC ; CLINICAL PROFESSOR OF

ORTHOPEDIC SURGERY, WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA | INSTRUCTORIN ORTHOPEDIC SURGERY, UNIVERSITY OF PENNSYLVANIA ; ASSISTANT ORTHO-

PEDIC SURGEON, HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIASURGEON TO THE HOSPITAL FOR CRIPPLED CHILDREN.

PHILADELPHIA1898.


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n

DORNAN, PRINTER,PHILADELPHIA.


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PREFACE

This work represents all the collected writings of thelate Dr. A. Sydney Roberts except a collection of quota-tions entitled "In and Out of Book and Journal," whichenjoyed a large sale as a popular gift-book.The present collection is undertaken for private distribu-

tion only, for the sole purpose of increasing the interestin the subjects of which it treats, and is prepared by theeditor as a debt of gratitude for many past kindnesses.

Permission has been generously given by Messrs. LeaBrothers & Co., the J. B. Lippincott Co., and Messrs.Wm. Wood & Co.

J. K. Y.


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CONTENTS.

Biographical Sketch of Dr. A. Sydney Roberts. By James K.Young, M.D. 1

Club-foot: Talipes. Roberts and Ketch. Reprint from theReference Hand-book of the Medical Sciences, by courtesyof the publishers, Messrs. Wm, Wood & Co , who havealso loaned the illustrations 23

Pott's Disease. Keating's Cyclopaedia?, Vol. III. . . . 123The Spinal Arthropathies. Medical News, February 14, 1885. 177Clinical Lectures on Orthopaedic Surgery : Club-foot. Medical

News, March 13 and 20, 1886 . . . . . .195Clinical Lectures on Orthopsedic Surgery : Knock-knee and

Bow-legs, with Remarks upon Rhachitis. Medical News,February 4 and 18, 1888 237

Flat-foot : A New Plantar Spring for its Relief. Medical andSurgical Reporter, April 6, 1889 265Chronic Articular Osteitis of the Knee-joint, and Description

of a New Mechanical Splint. Medical News, July 26,1884 283

Deformity of the Forearm and Hands. Annals of Surgery,February, 1886 291


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M E M IOF

DR. ALGERNON" SYDNEY ROBERTS.


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INTRODUCTION.

Each profession has its own manner of honoringits dead.

There is a custom among the members of theBar suggestive of brotherhood. When one dieswho has adorned the profession, a general meetingof the Bar is called, a Judge presiding. At suchmeeting each and every member may pay his tributeto the departedplacing, as it were, a flower uponthe bier of a brother whose victory they had wit-nessed.

In our profession, that of medicine, no such cus-tom obtains. Would it not be well by this or somemeans to inculcate such a spirit of camaraderie f

In lieu of such a custom, it seems highly fittingthat I, as pupil, friend, successor, upon whom insome measure his mantle has fallen, should pay mytribute to the sacred memory of the departed. Whenone of the medical profession whose ability andattainments mark his individuality pre-eminentpasses into eternity, those who linger may takenote of his scholarly attainments and professionalskill, and emulate his many virtues.

Biographies of men of eminence and merit, whilecalculated to please a large class of readers, have a


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4 MEMOIR OF A. S. ROBERTS.greater and more intrinsic value. They present tothose in the heyday of youth a stimulus and encour-agement ; to those in the meridian of their career,the satisfaction that a justifying parallel may bediscovered; while to those who are entering theevening of well-earned rest from labor, a reconcilia-tion may often be found by adopting, as Cooperremarks, "the comfortable self-assurance that thefrowns of fortune or some unlooked-for fatalityhave alone prevented them from enjoying a similardistinction or becoming equally useful members ofsociety."

If in the present undertaking my expressionsoccasionally savor somewhat of enthusiasm, my re-spect for him when a student, my gratitude to himas his pupil, and the affection borne him during mylater association with him, may be offered in apologyof its degree if not in justification of its fault.

I would take this opportunity of expressing mydeep sense of gratitude to those friends who havefurnished me with various data relating to the sub-ject of this history, without which it would havebeen incomplete.

Dr. Roberts was the son of Algernon S., Jr., andSarah (Carstairs) Roberts, grandson of AlgernonS. Roberts. He combined the sturdy elements ofthe Welsh blood with the purest Scotch, his father'sWelsh ancestry having first settled in this countryin 1683, and his mother coming of a long line ofScotch ancestors.He was born December 19, 1855, in Philadelphia.His early education was received at Ilallowell pri-


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INTBOD UCTION. 5vate school, from private tutors, and especially fromMr. Henry Galbraith Ward, now a distinguishedlawyer in New York city. His education and prep-aration for college were completed at an early age,as a private pupil of Professor Thomas Chase, ofHaverford College. The influence of ProfessorChase and Mr. Ward upon the development of hismind is shown in the scope of his medical worksand the character of the literature produced by him.When Mr. Ward first met him he was a slightand rather shy boy, but constantly improving in

strength and confidence. His remembrance of Dr.Roberts is as a very favorite pupil. He was veryregular and faithful in his studies, and gave promiseof a future which he afterward developed in hischosen profession. He was restive under restraint,and school discipline was irksome to him, as helearned more rapidly than many of his companions.Yet, in fact, he did not apply himself closely tostudy until he commenced the study of medicine,which he took up with great earnestness.During his youth he was very fond of drawing,and was very clever with tools, traits which in after

life were of the greatest service to him.His inclination toward the study of medicine as

a profession was first shown while at HaverfordCollege with Mr. Chase, when he wrote to a memberof his family of his desire to study medicine, andasked to have a skull sent to him, adding that he" would like one with all the teeth."

Eminently fitted by nature, environment, andeducation for the medical profession, the decision


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Q MEMOIR OF A. S. ROBERTS.having once been made, he devoted himself to itsstudy with all the energies of his soul, as Gross hassaid of Valentine Mott : " He loved surgery as hismistress, and his constancy merited all the favorswhich she so lavishly showered upon him."With a decidedly artistic taste, his leaning was

toward the study of architecture, and particularlydrawing and similar studies, and he told me histendency always was in favor of the profession ofa railroad engineer, especially bridge-building.

There is no doubt that if he had decided to enterthe profession of engineering his success wouldhave been equally as great as in the one which hechose. In this connection the incident of Dr.Physick recurs to us as being a circumstance ofsimilar kind. Dr. Physick's father was a silver-smith, and it was always the son's regret that hisfather would not permit him to follow in his foot-steps, although, as every one knows, Dr. Physickwas the most distinguished surgeon of his time.

Dr. Roberts was particularly fortunate in thechoice of a preceptor. It was in the office of Dr.Keen that young Roberts first became fully inspiredwith that love for his profession which ever after-ward was a remarkable feature of his career.

Henceforth forever his ambition was not simplyto be the doctor, as Pope would have it,

"Sole judge of truth in endless error hurled,The glory, jest, and riddle of the world,"

but to be a great surgeon.To be a great surgeon is an ambition for which


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INTRODUCTION. 7any one might strive, for, with Gross, I unhesitat-ingly assert, without fear of successful contradiction,that it " requires as much intellect, talent, genius,and knowledge to form a great surgeon as it doesto form a great lawyer, judge, divine, general, orstatesman."

Dr. William W. Keen at this time was laying forhimself the foundation of the enviable reputationthat he now enjoys. From the introductory addressdelivered by Dr. Keen in his course of lectures onanatomy at the Philadelphia School of Anatomythe following year, we gain some idea of the charac-ter of the instruction given by him at that time.As the successor of Dr. Agnew in the old Philadel-phia School of Anatomy, he demonstrated not onlyhis thorough knowledge of this important branch ofmedicine, but also his ability to instruct students,and moreover to entertain them, by his delightful de-scriptions of the early history of practical anatomy.

In addition to the regular winter term in theMedical Department of the University of Pennsyl-vania, Dr. Roberts attended three full spring coursesof lectures in this school, and was graduated there-from on March 12, 1877.

His fondness for the study of pathology led himearly to use the microscope in the pursuit of hisstudies, a somewhat unusual procedure in thosedays, but by virtue thereof he secured honorablemention for his thesis, and subsequently becameAssistant Demonstrator of Histology.Having determined to enter the profession of medi-

cine, Dr. Roberts began his study with all the energy


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8 MEMOIR OF A. S. ROBERTS.of his young manhood. Roused by the earnestnessof his preceptor, Dr. "W. W. Keen, and surroundedby the spirit of enthusiasm everywhere rife in theUniversity, his progress was marked.To thoroughly understand the influence of the

times, one must mark the conditions of the Univer-sity at the entrance of Dr. Roberts.The Medical Department of the University con-

tained at the time bat seven major chairs.The spirit of progress and development that char-acterized the institution from its beginning, in 1740,as a charitable school manifested itself in markedepochs of change.

Dr. Roberts entered the study of his professionin 1873, when every department throbbed with latentlife, only wanting the accepted time to manifest itselfin marked and brilliant change. Daily contact withthis spirit through the formative years of his devel-opment assured the permeation of his character withthe same animation that prompted the actions of hispreceptors.Every energy of his young manhood, every ambi-tion of his life, every demand of his intellectualnature found its response in the spirit of the insti-tution during those years.

Prominent among those who toiled and waitedstood Dr. William Pepper.Recounting the years of progress, and identifiedwith the University, he reviewed the past and fore-cast the future. In his most interesting addressupon " Higher Medical Educationthe True Inter-est of the Public and Profession," he recounts the


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INTROD TJCTION. 9long heroic struggle of the friends of the Universityto obtain an ideal standard. Weeks and months hadlengthened into years, hope had given place to dis-appointment, effort had ended in discouragementtimes over, before the glad day of victory haddawned.

Dr. Roberts took up his lifework at this auspi-cious time, his year of graduation, 1877.

This year marked, according to Dr. Pepper1. The establishment of a preparatory examina-tion.2. The lengthening of the period of collegiate

studies to at least three full years.3. The careful grading of the course.4. The introduction of ample practical instruction

of each student both at the bedside and in labora-tories.5. The establishment of fixed salaries for the

professors, so that they would no longer have anypecuniary interest in the sizes of their classes.

Such standards maintained meant new men innew places. The realms of science with their hiddentreasures awaited the enthusiastic student explorerwho brought to this undiscovered country intelli-gence, enthusiasm, and patient perseverance.The few noble lives that had uplifted the standard

of advance were reinforced by able men in the newlines that diverged from their original centre. Thenumber in the Faculty was increased, a long list ofclinical instructors, demonstrators, and lecturerswas added. Faculties of departments increasedwith each advance. Enthusiasm spread from the


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10 MEMOIR OF A. S. ROBERTS.council chambers of faculty and trustee conferencesto the students in the amphitheatre. The stimulusto mental activity that did not scorn the drudgeryof toil, nor ignore the opportunities of daily doing,developed from the pupils men who became in turnleaders in other circles, representatives of the newdevelopments and expressions of the ideas of theirAlma Mater. Little by little the alpine height ofexcellence was attained until the University stoodpeer with other institutions of acknowledged emi-nence. An expression of the higher manifestationof her influence was exemplified when at her instancethe State Board of Examiners was suggested, andagain the profession felt the fortifying bulwark ofher power. Standards of excellence were demandedthat should protect alike physician and patient.

In the midst of this consuming energy Dr. Robertsstepped into the arena of the profession, full of en-thusiasm and culture, proud to have the lines of lifefall to him in an hour of accepted progress. Stimu-lated to action, he would at once do credit to hisprofession and to his Alma Mater who conferredhis degree. One cannot wonder that then to himcame the ambition that would pay tribute to thepower that had placed him at once upon a plane ofadvanced thought and enrolled his name amongher instructors. To him it was not an ambition tofind place amongst institutions that " sprung up asmushrooms in a night," but he toiled to be worthyat once of position in his profession and University.The class of '77, in which Dr. Roberts graduated

from the University of Pennsylvania, contained


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INTEOD UGTION. 1several men who have since distinguished them-selves in the different branches of their profession.Among them we notice the names of James M.Anders, Joseph Price, Matthew N. Oyer, FrancisX. Dercum, Henry F. Formad, Thomas H. Fenton,Isaac C. Gable, Herman Haupt, Jr., William Hob-son Heath, William C. Hollopeter, Rush S. Huide-koper, Fairfax Irwin, John H. Musser, J. WilkesO'Neil, Andrew J. Parker, and George A. Piersoll.In 1877 he served in the Emergency Corps of theState militia in the coal region riot of Pennsylvania

as volunteer in the First Troop, Philadelphia CityCavalry, being assistant to Dr. William G. Porter,surgeon to the First Brigade, 1ST. G. P. In thiscapacity he served in the West Penn Hospital,Pittsburg, being later removed with the troops toScranton.

Immediately upon his graduation from the Uni-versity of Pennsylvania he was elected to the posi-tion of resident physician to the Blockley Hospital(which position he accepted later), where he servedhis full term and made the acquaintance of themembers of the staff, who were afterward of greatservice to him and whose colleague he soon after-ward became, being very earl}7 appointed surgeonto this institution. At the suggestion of Dr. S.Weir Mitchell, he decided to turn his attention toorthopedic surgery as a specialty. With this inview, he became resident physician in the New YorkOrthopedic Hospital, then, as at the present time,under the care of Dr. Newton M. Shaffer, surgeonin charge. The influence of this training is shown


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12 MEMOIR OF A. S. ROBERTS.throughout his work in this special department ofsurgery which he adorned with so much brilliancy.For two years he practised in this institution. Hav-ing in his mind the old couplet,

"A little knowledge is a dangerous thing;Drink deep, or taste not the Pierian spring,"

he returned time and again to this fountain of knowl-edge, each visit seeming to add renewed energy andskill to. this promising surgeon.With a view to practising his profession in Phila-

delphia, he opened an office at 133 South FifteenthStreet, and at once attached himself to several hos-pitals in the capacity of assistant surgeon. Almostimmediately he was appointed Visiting Surgeon tothe Philadelphia Hospital, Surgeon to the EpiscopalHospital Out-Patient Department, and Instructorin Orthopedic Surgery in the University of Pennsyl-vania. These appointments (with occasional visitsto other hospitals, in consultation with other sur-geons) occupied his time very fully and addedgreatly to his amount of knowledge and his successin this special department.Through his personal exertions the orthopedic

shop of the University Hospital was organized, abuilding erected for the purpose and thoroughlyequipped at an expense of nearly $2000. The con-tin nation of the usefulness of this shop, and thefurnishing of free apparatus to indigent persons,have been secured in perpetuity by the endowmentby members of his family of the A. Sydney RobertsApparatus Fund.


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INTBOD UCTION. 13This was the first, and is still the only shop of its

kind connected with a medical college hospital. Itscontinued usefulness proves the foresight and wis-dom ofDr. Roberts' good judgment in establishing it.

It was at this time that my personal knowledgeof Dr. Roberts began, and during those happy dayswhen I " walked the boards " of the Philadelphiaand Presbyterian Hospitals in company with mypreceptor, Dr. William G. Porter, I had an oppor-tunity of seeing Dr. Roberts at work in theseinstitutions. I was at once impressed with his thor-oughness, his grasp of the subject, and the successhe obtained in the treatment of this neglectedbranch of surgery. The impressions then gainedwere only intensified by more close association withhim in after years.

His experiences at the different hospitals led himearly to desire to be a teacher. The occasion soonoffered itself in lectures delivered at the Universityof Pennsylvania and in the course of clinical lec-tures which he delivered at Blockley upon ortho-pedic surgery, the latter being the first clinicallectures ever delivered upon the subject in Phila-delphia.As a teacher he was thorough, clear, and impres-sive. Without any effort at rhetorical display, heimpressed the students at once with his thoroughknowledge of the subject and of his desire to impartfreely to them all the knowledge he had acquired.

His diagnosis was accurate, and his selection ofthe proper treatment or apparatus was made withthe greatest consideration for the comfort and speedy


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14 MEMOIR OF A. S. ROBERTS.recovery of the patients. If an operation was re-quired the necessity for it was stated in such amanner that it was never refused.His practice was principally among the betterclass of society, and much of it came to him fromconsultations with other physicians and through therecommendation of Dr. S. Weir Mitchell, Dr. Wil-liam W. Keen, and Dr. Newton M. Shaffer, all ofwhom indorsed him in most unqualified manner.His practice was active during the short time hewas engaged in it, and there is no doubt that hadhe continued he would have acquired a large clien-tele and a lucrative income from this source. Whilehis practice was largely among the better and moreinfluential classes, he was as kind to the poor as tothe rich, and I have known a mother, who was toofrail to carry her child to the hospital, advised byhim to bring it to his office to be treated cheerfullyand thoroughly without a fee. Among his paperswere found many letters from poor patients express-ing their gratitude, and many of the nurses on dutyat the Philadelphia Hospital during Dr. Roberts'service have remarked his kind manner to the des-titute.At this time he employed assistants for certain

portions of his work. A large number of black andwhite sketches and colored drawings were made,casts were taken, and his hospital-books were keptmost accurately by Dr. S. R. Jenkins, now of Char-lottetown, Prince Edward's Island, Canada; Dr.William S. Johnson, now of Germantown, and my-self. His manner toward his assistants was always


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INTROB UCTION. \ 5kindly and considerate, and on one occasion I wasmyself the recipient of a trip South through hisinterest in my physical condition.Although his career was brief, he performed a

number of important and difficult operations uponpatients committed to his care. These were alwaysdone in a most thorough and skilful manner, andevery detail was carefully thought out before anyoperation was undertaken. His instruments andapparatus of all kinds were of the finest, and heused them as freely in the treatment of the poorestindividuals as in operations upon the more wealthypatients. Soon after his election to Blockley heseveral times performed osteotomy of the femur(Macewen's operation) with full antiseptic precau-tion and with perfect results. Excision of the kneehe frequently performed, as well as tenotomies of allkinds, after which latter operations he usually em-ployed an apparatus of some kind specially preparedfor the patient.As a surgeon, he was cool, deliberate, and thor-ough, and his success was uniform and phenomenal.His genius was dazzling, burning ever brighter

with a steady flame. His career, like that of Bis-chat, was meteoric, brief, but brilliant; and if themeasure of talent and genius be success, the esti-mate placed upon his career must be great. Thelimits were boundless, but few men ever attain thetopmost round of the ladder of fame, and geniusmust add time to her industry, no matter how steadyand persistent.Some of his lectures before the students at the


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16 MEMOIR OF A. S. ROBERTS.Philadelphia Hospital were afterward published inbook form, and comprised two upon club-foot, twoupon knock-knee, and one upon flat-foot, with adescription of a new plantar-spring for its relief.His writings include a complete article on Pott'sdisease of the spine, in Keating's " Encyclopaedia,"vol. iv, a most comprehensive article. In conjunc-tion with Dr. Samuel Ketch, of New York, hewrote an article upon club-foot in Buck's "ReferenceHandbook of the Medical Sciences." This articlecontains the best bibliography upon this subject ex-tant, and I doubt if anything will ever be written tocompare with it. In 1 884 he read a paper before thePennsylvania State Medical Society upon " ChronicArticular Ostitis of the Knee-joint," with a descrip-tion of a new mechanical splint, which was publishedin the " Medical News," on July 26, 1884. Amongother articles written at this time was one upon thespinal arthropathies, published in the " MedicalNews," February 18, 1885, which attracted con-siderable attention. The photographs collected,illustrative of this subject, but not published tillsubsequently, comprise the best group of photo-graphs upon this subject that has ever been col-lected. About this time he reported a case ofdeformity of the forearm and hands, which waspublished in the "Annals of Surgery," in Feb-ruary, 1886. This contains the pictures of thesplint, modified from that of Dr. Shaffer, of NewYork, and employed by Dr. Roberts in the treat-ment of knee-joint diseases. After his retirementfrom practice he published a volume of selections


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INTROD UGTION. 1from literature, which he called "In and Out ofBook and Journal," which was published by Lipp-incott & Company, and had an extensive sale.His writings are not as large as one would expectconsidering the amount of work which he did. This

is probably due to his dislike to writing and hisattention to more practical matters. His writingsare of the highest order, and reflect great credit uponhim for the amount of research and the quality of thematter contained.He reported many operations before the Patho-logical Society, and exhibited specimens, several ofwhich I now have in my possession.He was a Fellow of the College of Physicians ofPhiladelphia, a Fellow and Yice-President of theAmerican Orthopedic Association, a member of thePhiladelphia County Medical Society, the Patho-logical Society, the Neurological Society, the StateMedical Society, the American Medical Society, anda delegate to the International Medical Congress inLondon.In personal appearance Dr. Roberts was of me-dium height, strongly and compactly built, of a

florid temperament, high forehead, good features,and carrying with him the impression of great re-serve force. His manner was that of a culturedgentleman, and his associations such as would de-velop a manner which was at once kind and firm.His characteristic was a particular sensitiveness.His disposition was quick and impulsive, but kindand forgiving ; a warm and faithful friend. Withtruth it could be said that his friendship was eternal.

2


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18 MEMOIE OF A. S. ROBERTS.The estimate of Dr. John H. Musser, his most

intimate friend, is so thoroughly descriptive of Dr.Roberts' best qualities, that I take the liberty toquote it in full. Speaking of his friend Roberts, hewrites

" Fortunately for me, our friendship was not aloneprofessional. On two occasions I travelled in Europewith him, and on several occasions in this country.Here it could be seen he was a man of affairs. Thiswas the least, however. I constantly marvelled athis wide acquaintanceship with the fine artspaint-ing and painters, sculpture and sculptors, architec-ture, etc. He was familiar with the development ofart in all its phases and of all its schools. Hisearly training in painting taught him to be an excel-lent critic. He could criticise accurately the color-ing or appreciate the value of the thought in thework of art and its development. Furniture, tapes-tries, decorations, metal work, glass, and china hadbeen the subject of study, and their relations toindustrial development. After a visit with profitand pleasure to an art gallery, a museum, a palacewith its art treasures, it was interesting and marvel-lous to go with him to some great mechanical worksor some piece of engineering and see with whatrapturous delight he appreciated it, and with whatknowledge of technical detail he could explain themysteries of the mechanism. When I tell you hewas a critic of no mean order, and a man of exqui-site taste, with an extraordinary appreciation of thebeautiful in art, }Tou can readily see how enjoyablea companion he was.


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INTBOB TJCTION. 1" Roberts also loved nature, and, whether on the

boundless ocean, in the mountains of Switzerland,in the pastoral scenes of England, or the roughercharms of Scotland, he was always full of enthu-siasm and appreciation of the beauties of nature.Roberts's fondness for animals led him to studythem, and he was an excellent judge ofhorse, of cow,of dog. He was fond of out-door sports, and wasan expert in shooting, rowing, and the like. Howalmost unlimited were his sympathies, and howboundless was his knowledge ! He had a most ex-cellent memory, and the history of the countries wetravelled through was at his fingers' ends. Thisadded to the charm of our travels.

" Curiously, although of broad culture Dr.Roberts was not a linguist. Language was notmastered easily by him, although his writings showhe was a master of English ; his conversationalpowers, that he could command it at will.

"Roberts appreciated music. I recall the delightshe showed at the music of the evening service atCologne Cathedral. He was not as familiar with theliterature and development of this art as others."

Dr. Samuel Ketch, another personal friend of Dr.Roberts, has paid tribute to his memory in hisPresidential Address, published in the last volume(1897) of the " Transactions of the American Ortho-pedic Association."His office was neat, plain, and well arranged, andone could see at a glance that it was the office of apractical and progressive surgeon. In office detailshis early education and business qualities were


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20 MEMOIR OF A. S. ROBERTS.everywhere conspicuous. His horses and carriageswere neat and elegant to a degree. His office hourswere from 8 to 11, and were always promptly kept.His stationery was always the same Imperial Bond,of a beautiful marine-blue tint, and his penmanshiphad a style and character that were unmistakable.While in the enjoyment of everything that would

tend to make him happy, and with the prospect ofa great and growing future before him, his healthbegan to fail, and he was compelled to retire frompractice in 1888 and seek change in the country.In resigning his positions at the different hospitals(two of which it was my privilege to receive), a sin-cere regret was expressed in his resignation that hewas compelled to give up practice at this time.

In his letter of November 23, 1888, to me, inspeaking of resigning his position as instructor inorthopedic surgery, he evinced his keen interest inthe future progress of conservative orthopedic sur-gery. " I have to-day," he writes, " sent to theUniversity and to the University Hospital my resig-nations, and hope you may be an applicant for thepositions I vacate, and I trust that if you secure theappointments you will push the work in the interestof conservative orthopedy."Having decided to retire from active practice, he

gave away many of his instruments, the most expen-sive ones to his personal friend, Dr. William G.Porter, to his preceptor, Dr. William W. Keen, andmyself. All of his orthopedic apparatus and all ofhis special books upon orthopedic surgery werereceived by me in this way, and my indebtedness


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INTBOD UCTION. 21to him has already been expressed by the partialdedication to him of my work upon orthopedicsurgery.1Although in feeble health for some time, his death

occurred suddenly and unexpectedly, at Newport,on August 17, 1896. The funeral took place fromhis late residence, at Bala, on Thursday morning,at 11 o'clock, the interment being private. Hisearthly remains were interred in the family vaultat Laurel Hill Cemetery.At the University Club, just before the dinner,

March 11, 1898, when a guest of Dr. De ForestWillard and myself, Dr. Newton M. Shaffer said ofhis friend Dr. Roberts, " Had he practised untilto-day, his reputation would have been national."

Accidental expressions of character in a man'slife many times live after him in enduring form.Near the home of his ancestors, at the side of thepublic highway, it pleased Dr. Roberts to erect afountain at which the hurrying traveller might pauseand drink.The shadows may fall and shut from sight familiar

scenes, the passing throng, the granite fountainwith its cooling stream, but through the darknessunheeded the limpid stream flows on and in themorning blesses the new day.

The years glide on, the shadows fallBut works his hands have wrought live on

1 Treatise on Orthopedic Surgery.


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CLUB-FOOT: TALIPES.


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CLUB-FOOT: TALIPES.

Definition. Under the generic term Club-foot,or Talipes, are included all cases of deformity of thefoot, whether on an antero-posterior or transverseplane, and which are presented in a departure fromthe normal relation of the foot to the leg or of thefoot to itself. This abnormal relation may consistof a flexion, extension, inversion, or eversion.Synonyms. Ger., Klumpfuss; Lat., Pes con-

tortus; Fr., Pied hoi; It., Piede torto; Sp., Pietruncado.Varieties. Club-foot is most conveniently di-

vided into two classes, namely, the simple and com-pound, and of the former we have four typicalforms. These are talipes varus, talipes valgus,talipes equinus, and talipes calcaneus. The firstform, talipes varus, is characterized by an elevationof the inner side of the foot, the sole being turnedinward and the anterior portion of the foot adducted.In talipes valgus, its opposite, the outer side of thefoot is raised and the sole everted. Talipes equinuspresents itself as an elevation of the heel, the footbeing in a position of extension, the patient walkingon the ball of the foot. In talipes calcaneus the toesare raised, the foot being in a position of flexion,and the patient walking on the heel. The two first-


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26 MEMOIR OF A. S. ROBERTS.mentioned deformities occur on a lateral, the twolatter on an antero-posterior plane. To these foursimple forms some authors add other forms : Talipescavus, where the arch of the foot is increased, andtalipes planus, its opposite, where the sole restsupon the ground, the arch being diminished. Re-cently Shaffer, of New York, has described anotherclass, that of non-deforming club-foot. Any com-bination of the simple varieties gives us the com-pound form : talipes equino-varus and equino-valgus,and calcaneo-varus and calcaneo-valgus. Schemat-ically these different forms may be pictured asfollows

' Simple

Varieties . -j Compound

I Other forms

,

f Lateral( Antero-posteriorf Equino-( Calcaneo- .

iCavus.Planus.Non-deforming.

f Varus.{ Valgus.| Equinus.| Calcaneus.] Varus.{ Valgus,f Varus.{ Valgus.

Relative Frequency. In obtaining informa-tion concerning the relative frequency of the differ-ent forms, much difficulty is experienced, owing tothe different nomenclature, notably for varus andequino-varus, used by those making statistics onthe subject. From Tamplin's table, published in the"London Medical Gazette" for October, 1851, andcovering 1780 cases of club-foot, both congenitaland acquired, 764 of the former were recorded to101(5 of the acquired form. By these tables it isshown that by far the larger number were of theacquired variety, the proportion, as stated by


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CLUB-FOOT: TALIPES. 27Adams, being- as 3 : 2. Of the congenital variety,the tables show a preponderance of cases of talipesvarus, but no distinction is evidently made betweenthe simple varus and the compound form, talipesequino-varus. The tables are appended

Congenital.Cases.

Talipes varus 688Talipes valgus 42Talipes calcaneus .19Talipes varus of one foot and valgus of the other. 15

Total 764

Of the 688 cases of talipes varus, 182 affectedthe right foot only ; 138 affected the left foot only363 affected both feet, and 5 cases were complicatedwith other deformities.Of the 1780 cases, 1016 were non-congenital

999 were distributed as follows :Acquired.

Cases.Talipes equinus 401Talipes valgus 181Talipes equino-varus 162Talipes calcaneus and calcaneo-valgus . . ,110Talipes equino-valgus 80Talipes varus 60Talipes varus of one foot and valgus of the other. 5

Total 999

Reeves, in an experience of ten years at the RoyalOrthopedic Hospital, London, gives equino-varusas the most frequent congenital form, and also statesthat the primitive forms of club-foot are rare ascongenital deformities. Sayre, in his work on " Club-


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CLUB-FOOT: TALIPES. 29case in 1903 births. As yet the influences of climateand social position have not been determined. Itprobably occurs more frequently among the poorerclasses.From the foregoing statistics, which have beenconsidered sufficient, the following facts may bededuced

1. The greater relative frequency in males.2. That the varus types are the most frequent.3. That the right foot is affected more frequentlythan the left.4. That both feet are more frequently affected

than a single one.5. That the purely primitive forms are rare.Etiology. There are two classes of club-foot,

namely, the congenital and acquired, and in study-ing their etiology we shall consider the former classfirst. In no department of medicine is there somuch that is mysterious and unexplained as isinvolved in the causation of deformities of congeni-tal origin. From earliest times they have been thesubject of a vast amount of labor and inquiry, andwhile these investigations have resulted in manyspeculations and a few facts, the theories establishedby them still leave much to learn concerning thereal origin of this class of cases. The question isbeset with difficulties from the onset, from the factthat the life of the foetus in utero is not subjectto any direct scientific means of investigation, andwe are compelled to study the subject from suchaids as comparative physiology, embryological data,and post-partum existence and diseases furnish us.


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30 MEMOIR OF A. S. ROBERTS.Could we positively admit the question of diseasesof the fetus, such as pertain to post-partum exist-ence, the problem would be relatively simple. Manyauthors, notably Little, have, from the similarity inthe deformities of the congenital and acquired para-lytic forms, assumed this ground. Outside of thesimilarity in the appearance of the deformities, thisview is not tenable, for it has not been proven thata foetal myelitis or meningitis has existed. Themicroscope has not, as yet, demonstrated changestaking place in the foetal brain or cord, such asoccur in infantile, cerebral, or spinal paralysis. Anelectrical examination shows very markedly differingreactions in the muscles of the two forms, and pa-tients suffering with congenital club-foot can, bythe exercise of volition, use the muscles of the legand foot, while such is not the case in the acquiredform. These differences, together with the externalappearances of the parts affectedthe one cold,flaccid, and atrophied; the other of normal surfacetemperature, plump, and of rounded contourindi-cate an entirely different causation of the deformity.

Heredity, with its mysterious influences, physicaland psychical, also enters into this complex ques-tion, and is undoubtedly a factor in the etiology ofmany cases. Did space permit, many instancesmight be quoted as illustrative of this. From thesewe can as yet deduce no better explanation of itsinfluence than the transmission of personal config-uration.

Arrest of development has also been assigned asa cause for the production of congenital club-foot.


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CLUB-FOOT: TALIPES. 31Although many cases occur in which there is acoexistence of such deformities as spina bifida,hare-lip, and cleft palate with club-foot, yet the feetthemselves show no arrest of development, but onlythe same change of plane as is shown in the casesborn without these coexisting deformities. Changesin the tarsal bones, principally the astragalus andos calcis, have been described by many authors,but by none more thoroughly than by Adams andHueter. These changes consist in alterations inthe form and plane of these bones, but they are byno means constant, and differences of opinion areheld as to their being primary or causative, or secon-dary, as results of the deformity itself. The mostrecent investigations tend to maintain the lattertheory. It has also been found that use of thedeformed foot largely increases the malposition andform of the tarsal bones. A. Luecke also considersthe osseous structure as the seat of primary lesionin club-foot. He and others have shown that at aa certain period all foetuses are club-footed, andLuecke claims that by the constant movement ofthe child in utero the articular surfaces are somodified by the attrition produced as to enable thechild's feet to assume a normal position before birth;any interference with these movements would, how-ever, prevent this attrition, and the child would beborn club-footed. Against this ingenious theory itmay be argued that use increases the deformityafter birth. Why it should act differently before isnot easy to understand. We also know that inacquired cases, such as are due to spastic paralysis,


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32 MEMOIR OF A. S. ROBERTS.for instance, want of use does not so change thearticular surfaces as to cause permanent club-foot,tenotomy in many cases restoring the foot to itsform and function. Perhaps of all the theoriesadvanced, that which ascribes congenital club-footto abnormal intra-uterine pressure, due to lack ofamniotic fluid, has received the largest number ofadherents. Most of the older writers, and manymodern ones, prominently Volkmann, Kocher, Vogt,Banga, and Parker, are among its most noted advo-cates. Here it is maintained that the foetal footis permanently fixed in one position by the intra-uterine pressure, and consequently, at birth, the childis club-footed. It has, very reasonably, been arguedagainst this view, that if a decreased amount ofamniotic fluid and consequent abnormal pressurewere productive of club-foot, other organs whichhad been subjected to the same pressure would alsobe deformed. Yet such is not the fact, clubbedhands, legs, and thighs being among the rarest ofdeformities, very seldom complicating the pedalmalformation. It has also been shown that manychildren have been born club-footed where no appre-ciable difference in the quantity of liquor amnii,judging from previous labors, could be ascertained ;and we have recently seen a case of double equino-varus in a twin, the other child showing no deform-ity whatsoever. Billroth states as follows : " Thetypical form of this congenital deformity appears toindicate that it depends on a disturbance of a typical(symmetrical?) development of the lower extremi-ties ; for if festal disease, disturbance of an irritative


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CLUB-FOOT: TALIPES. 33nature, or abnormal pressure in the uterus were atfault, cases would probably differ." He also quotesEschricht as showing that at the commencement oftheir development the lower extremities lie withtheir backs against the abdomen, the hollows oftheir knees being against the belly ; so during theearlier months the legs must rotate on their axes,and the toes which pointed backward must point inthe opposite direction. If the embryonic extremitieslie so close as to appear united under a commonskin, or be really united, the above-mentioned rota-tion of the limbs cannot take place, and in thisdeformity (siren) the feet are turned directly back-ward. This rotation on the axis, which was arrestedin the above case, does not take place fully in club-foot, the rotation in the foot is not fully accomplished.Billroth states further, that according to this, con-genital club-foot would come among the cases ofobstructed development; about its cause he con-cludes we know as little as we do of other deformi-ties of the same class.H. "W. Berg, of New York, in a very originalarticle, gives failure of rotation as the cause of con-

genital equino-varus. He has studied the subjectfrom specimens seen at the New York Hospital andWood's Museum of Bellevue Hospital, and describesthe changes in the position of the lower extremitiesat different periods of foetal life. He shows that inearly life the whole leg is rotated outward, and thisoutward rotation is accompanied by an exaggeratedvarus, and still later, an equino-varus. This dimin-ishes as the rotation to the normal position pro-

3


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34 MEMOIR OF A. S. ROBERTS.gresses, but he states that even when the rotationof the leg has been entirely completed some of thevarus still remains, and calls attention to the veryslight varus of the new-born. In addition he statesthat equinus is often seen in foetuses of two, three,and four months. This he does not always find,and it disappears in the course of the normal growthof the foot. He concludes that in the early stageof foetal life varus or equino-varus is physiological.He does not think pressure necessary to the produc-tion of the deformity, its cause consisting, in hisopinion, of a non- or retarded rotation inward of thelower extremity. We consider this theory of non-or retarded rotation as of such importance from anetiological stand-point that we quote his account ofits mechanism in full. He says : "As soon as thejoints are formed we find the thigh rotated outwardas far as possible, and flexed upon the body. Theleg is flexed upon the thigh, but not completely, forthis is prevented by the extreme outward rotationof the thigh, which brings the inner border of theleg in apposition with the abdomen of the child.We have, then, the inner border of the thigh andthe tibial border of the leg pressed against the abdo-men of the foetus, the legs crossing each other alittle below their middle. All of the intra-uterinepressure, therefore, is thus brought to bear directlyupon the outer border of the thigh and leg, corre-sponding to the fibular border of the leg, and alsoupon the dorsum of the foot. The result of this isthat the foot is rotated in and extended (equino-varus) until the sole is almost on a line with the


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CLUB-FOOT : TALIPES. 35inner border of the leg, and lies against the body ofthe foetus, while the dorsal surface of the foot is ona convex-curved line with the outer border of theleg, to adapt itself to the concave wall of the uterus.This, I believe, is a stage in the normal develop-ment of every healthy foetus ; and were the extremi-ties to remain in this position, all children would beborn club-footed. But nature provides against thisby the inward rotation of the extremity, whichgradually takes place, carrying the leg away fromits position against the abdomen of the foetus ; andwhen this rotation is completed we find the extensorsurface of the thigh flexed and in relation with thebody of the child, while the legs are flexed uponthe thighs, the inner or tibial borders facing eachother. Now the soles of the feet lie against theuterine walls, and the intra-uterine pressure isexerted directly upon them. This produces extremeflexion of the foot upon the leg, together with anoutward rotation of the foot ; this movement, fromthe constitution of the ankle-joint, accompanyingextreme flexion. Thus is antagonized the varus orequino-varus existing hitherto. It is evident, then,that upon the completeness of the internal rotationor torsion which takes place in the lower extremitydepends the rectification of the early varus of thefoot. Should this rotation not take place at all, orbe incomplete, the foot will continue to maintain itsearly relation to the body of the foetus and uterinewalls, and the child will be born more or less club-footed. If this be so, we should expect to find inclub-footed children that the extremities are rotated


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36 MEMOIR OF A. S. ROBERTS.outward. And this we do find upon examination.In all of the cases of congenital club-foot (equino-varus) which I have seen since my attention hasbeen directed to this subject, I have found that thethigh and leg, as a whole, were rotated out, and thetibia bent at its lower part, so that the feet wereapproximated to each other in addition to being inthe clubbed position. All this is seen to be theresult of non-rotation of the leg." In 1884, twoyears after Dr. Berg's article appeared, Drs. Parkerand Shattuck published a pamphlet on " The Pathol-ogy and Etiology of Congenital Club-foot." Theirtheory, as shown in their argument, is as follows" Our argument is that the feet of the foetus occupyvarious positions during the period of intra-uterinelife, and that this occurs in order that the joint-surfaces, the muscles, and especially the ligaments,be developed so as to allow of that variety of posi-tions and movements which are afterward to benatural to the foot ; and we hold that when any-thing (mechanically) prevents the feet from assum-ing these positions at the proper time, or maintainsthem in any given position beyond the limit of timeduring which they should nominally occupy suchposition, a talipes results. The variety of talipeswill depend upon the date of its production; itsseverity will be in direct ratio to the mechanicalviolence at work. If the inversion of the foot,which is normal during the earlier months of foetallife, be maintained beyond the normal period of time,the muscles and ligaments will, as a consequence,be adaptively short on one aspect of the limb, and


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CLUB-FOOT: TALIPES. 37too long on the other ; a normal position of inver-sion will finally become a deformity. Talipes cal-caneus is, we believe, produced in a similar manner;it occurs, however, later during intra-uterine life,when a flexed position of the foot is normal. Beingthus less fundamental in character, it is also lesssevere as a deformity than varus."To any one who has read Berg's monograph, it

will appear surprising that no mention of it is madeby Parker and Shattuck. This is all the moreremarkable in that Berg had fully anticipated notonly all that they have advanced, but had followedthese data and observations to their legitimate logi-cal conclusions, which for some occult reason Parkerand Shattuck have avoided. Had they cited Berg'spaper, we would have been forced to the conclusionthat the}7 had attempted to prop up the old fancifulmechanical theory with the support of real embryo-logical data.We have endeavored to give as succinctly aspossible the different theories in vogue concerningthe etiology of congenital club-foot. They may bebriefly summarized as follows :

1. The theory of pathological changes affectingthe child in utero.

2. The theory of mechanical forces acting uponthe foetus in utero.

3. The theory of heredity.4. The theory of arrest of development.5. The theory of non- or retarded rotation.In conclusion we would state that it certainly

would seem most reasonable, with our present


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38 MEMOIR OF A. S. ROBERTS.knowledge of the subject, to ascribe the causationof congenital club-foot to the last-mentioned theory,which has at least for its credit the fact of its beingdemonstrable, rather than to those which for theirfoundation either have only the similarity to condi-tions produced by disease after birth, or are entirelyfanciful.

Etiology of Acquired Forms. By far the largernumber of cases of club-foot occur as acquiredforms, and of these infantile paralysis (poliomyelitisanterior) produces the greatest number.Without entering into a lengthy description of

this disease, which can be found in any of the text-books on nervous diseases, and also in anotherportion of this work, it will be sufficient to statethat it usually occurs during the period of dentition,beginning with fever and gastro-intestinal disturb-ance, with or without convulsions, and is followedby paralysis more or less severe. This paralysis isfollowed by a rapid improvement in many of themuscles involved, those of the upper extremity andtrunk usually recovering first, while those of thelower extremity remain unilaterally affected. Theparalysis is followed by atrophic changes, loss ofelectro-muscular contractility, especially to the fara-dic current, and deformities, of which club-foot isthe most frequent. For a long time it was taughtthat the deformities produced by infantile paralysiswere due solely to the loss of power in one set ofmuscles and the preponderating action of theirantagonists. Thus, in consequence of this loss ofbalance in the muscles supporting the leg and foot,


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CLUB-FOOT: TALIPES. 39were produced the altered relations which give riseto the various forms of acquired club-foot. Delpechtaught that a muscle could be in a condition of per-manent or tonic spasm, and the opponents beingparalyzed, the deformities were produced. Thatthis view is faulty has been proven by more recentresearches. Hueter first called attention to the factthat, owing to the position assumed by the paralyzedlimb, its weight caused contractions, and that theso-called antagonistic contractions were not at allmuscular actions, but were due to atrophy and lackof growth. Volkmann, in his now classical lecture,has gone very thoroughly into the mechanism of theproduction of club-foot due to infantile paralysis.He has shown that, owing to the superincumbentweight of the body, the limbs assume positionswhich gradually become permanent; that the so-called tonic retraction does not occur, and that theshortening of the muscles is due not to contraction,but to growth of the limb, the foot remaining in itsdeformed position.A form of paralysis usually designated as spasticor activespastic paralysis (Erb), paralysis with

rigid muscles (Adams), and tetanoid paraplegia(Seguin)is also productive, of club-foot. In thisclass of cases a more general dispensation of theconsequences of the lesion seems to be inflicted.The patients have a silly or semi-idiotic look,although their intelligence seems rather to be re-tarded than obliterated. They frequently squint,and their progression is peculiar and quite charac-teristic. They walk on their toes with their knees


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40 MEMOIR OF A. S. ROBERTS.pressed together, and, in order to maintain theirequilibrium, throw one limb over the other, walkingas it were cross-legged. There is general rigidityand spasm of the muscles, all the reflexes beinggreatly exaggerated. The form of club-foot in thesecases is usually an equinus, and the contractionscan, for the time being, be rectified by continuouspressure, but upon its cessation the feet instantlyassume their old positions. Its pathology wouldseem to indicate, in some cases, a lack of develop-ment, in others a lesion of some portion of themotor tract of the brain, followed by secondarychanges in the lateral columns of the cord. Rup-precht, of Dresden, has studied the nature andtreatment of this condition very thoroughly, andhas shown not only that tenotomy in this class ofcases is often followed by improvement in the posi-tion of the feet, but that in some cases there wasan accompanying improvement in the mental statusof the patient. For further information on thisvery important class of cases the reader is referredto his very valuable remarks in "Volkmann's seriesof clinical lectures. Many authors believe that this,or a similar condition, is an accompaniment ofvarious spinal diseases, acute compression, syphilis,tumors, and caries.Among other conditions due to disturbance ofthe nervous system, pseudo-hypertrophic paralysis,

post-hemiplegic contractions, and neuromimesis areproductive of club-foot. While the two formerclasses are rare as causes of acquired talipes, thelatter or neuromimetic are more frequent, and have


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CLUB-FOOT: TALIPES. 41of late years attracted considerable attention. Ex-amples of these very interesting cases have beencited by Paget, Little, Skey, Shaffer, Weir Mitchell,Haward, and others. They undoubtedly dependupon the neurotic diathesis, and may, by theirsimilarity to the real condition, be very deceptive.Shaffer has devoted considerable space to this classof cases in his work on " The Hysterical Element inOrthopaedic Surgery," a perusal ofwhich will greatlyaid the student in the diagnosis and treatment.Cases due to reflex paralysis have been reportedby Sayre and others, who claim that a functionaldisturbance of the nervous system can cause spasmof certain muscles, which, continuing for a time,while healthy growth is going on in their opponents,so disturbs the balance of power as to produce apermanent deformity. This mode of the productionof club-foot has recently been the subject of muchdiscussion, many authorities altogether disbelievingthe origin of the deformity by this means.The paraplegia accompanying Pott's disease of

the spine is also a cause of acquired club-foot. Itgenerally occurs as an equinus, and is very similarto the spastic cases previously mentioned. It dis-appears as the paraplegia improves.One of the most frequent causes of acquired

talipes is joint-disease of the lower extremity. Hereit may either occur symptomatically or follow thedisease of the articulation. Especially is this trueof the ankle-joint, where, at different periods of theinflammatory trouble, the foot assumes an equinus,varus, or valgus position.


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42 MEMOIR OF A. S. ROBERTS.A very interesting class of cases are those due to

occupation. In these cases, occurring principallyin bakers, blacksmiths, printers, and other trades,the principal factors are the weight of the bodyand long-continued position, and it is in this classthat we often see the inflammatory forms of club-foot. A similar class of cases are those observedin growing boys and girls, and usually occurring atabout the time of puberty. Here the deformity,which is a valgus, is probably due to increasedweight and rapid growth of the body, without acorresponding growth of the muscles and ligamentsof the feet.

Long-continued decubitus, as in the continuedfevers, has been productive of club-foot, generallyan equinus. Volkmann mentions one case in which,after severe typhoid fever, an equinus resulted, andin which a year was occupied in restoring the feetto their normal position by active orthopedic treat-ment.

Traumatisms, resulting in deep cicatrices andburns in the neighborhood of the ankle-joint, arealso causes of acquired club-foot.History aistd Literature. In studying the

history of club-foot it has been thought best todivide the subject into three periods : a Pre-conti-nental period, including the years from 460 to 370B.C. ; a second, the Continental and Early English,including the seventeenth and eighteenth centuries;and a third, or Continental and English, which em-braces the nineteenth century and brings us down1 < i 1 he present day. To render the study more com-


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CLUB-FOOT: TALIPES. 43plete, separate notice is given of American contri-butions, especially valuable for their originality inthe mechanical improvements devised for the reliefof this deformity.

I. Pre-Continental PeriodB.C. 460-370. Theearliest author on the subject of club-foot whosewritings are preserved or accessible is Hippocrates.He mentions very clearly deformities of the articu-lations, and in all his works on ancient surgery,says his translator, there is not a more wonderfulchapter than that relating to club-foot, on which hegives most valuable information. He says: "Thereis more than one variety of club-foot, the most ofthem not being complete dislocations, but impair-ments connected with the habitual maintenance ofthe limb in a certain position." He says further:"Most cases of congenital club-foot are remedial,unless the declination be very great, or when theaffection occurs at an advanced period of youth."For early treatment he relied on bandages, for theapplication of which he gave very particular instruc-tions. He says: " After the application of the ban-dages, a small shoe made of lead is to be bound onexternally, having the same shape as the Chianslippers. This is the mode of cure, and it neitherrequires cutting, burning, nor any other complexmeans." This might imply that he had seen orheard of other means of curing club-foot, but ofthem, if they existed, we have no record.For a period of two thousand years or more the

subject of club-foot was apparently completelyignored, and nothing was added to the knowledge


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44 MEMOIR OF A. S. ROBERTS.collected by Hippocrates and handed down to usby Polybius. It was regarded by all as a subjectof ill omen, and those unfortunately afflicted by thedeformity as being especially the objects of divinewrath. Superstition forbade men from even men-tioning it, much less of devising means for its cure.Celsus, whose writings cover so large a field, doesnot even mention ita fit criterion of the conditionof the times.

II. Continental and Early EnglishPeriodSeven-teenth and Eighteenth Centuries. It was not untilthe middle of the seventeenth century that the ques-tion of club-foot again came into notice.

In 1641 Ambroise Pare, " Les GEuvres" (Lyons),ascribed club-foot to the circumstance that themother, during her pregnancy, had been sitting toomuch with her legs crossed. He also gives a modelof a boot for the treatment of the deformity. Hewas followed in 1643 by Severinus, who wrote ofthe subject. (" De Recondita Abscessum Natura,"Francof., 1643.)In 1658 Arcseus, " De recta curandorum valuerumrational" (Amstel.), describes a process for theremoval of the distortion, and figures an apparatusand a boot by which he treated deformities. Fab-ricius, in 1723, " Opera Chirurgica " (Batavia), pro-poses an iron boot for treating deformities of the feet.In 1741 Andry first used the term orthopedy,and published a work on the subject in two volumes,entitled " L'Orthopedie " (Paris). It is evident fromhis remarks that he does not limit the use of theterm to club-foot, as some authors erroneously sup-


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CLUB-FOOT: TALIPES. 45pose, but, under the derivation dpdbz, straight, andnaedbz, genitive of 7tou


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46 MEMOIR OF A. S. ROBERTS.in twenty-two months. This induced Bruckner, ofGotha, " Ueber ^Tatur, Verfahren und Behandlungder einwarts gekriimmten Fiisse" (Gotha, 1796),and Naumburg, of Erfurt, " Abhandlung ueber dieBeeinkrummung " ( Leipsic, 1796), to use and perfectVenel's method. Wanzel studiedmedicine later, andin his inaugural thesis, " Dissertatio Inauguralismedica de Talipedibus Yaris" (Tubingen, 1798),described the procedure used by Venel. Besidesthe authors already quoted, Ehrmann, of Germany,Tiphaisue and Yerdier, of France, and Jackson,Sheldrake, and Mark Anthony Petit, of England,contributed to the literature and treatment of club-foot.Of these the most important are the writings ofThomas Sheldrake, of London (1798), who consid-

ered the contraction of the ligaments as the essentialcause of club-foot. He aimed his treatment essen-tially at these tissues. His own words are as follows" The essential operation to be performed in curinga club-foot is to produce such an extension of someof the ligaments as, if it happened by accident,would constitute a sprain. It certainly is the dutyof the operator so to conduct this operation thatnone of the consequences which would have takenplace from an accidental operation shall ensue."Mark Anthony Petit, of England (1799), is claimedto have had the first example of tenotomy on record,and to have been the first surgeon to perform it.

This closes the second period in the history ofclub-foot, and while we can see the gradual progres-sion from a purely empirical idea, both of the nature


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CLUB-FOOT: TALIPES. 47and treatment of the deformity, to a broader andmore comprehensive conception of the subject, itwill be admitted that as yet no decided scientificdepartures had been made. The nearest approachwas the operation of Thilenius, which foreshadowed,as it were, the researches which were to follow, andwhich have proved of such invaluable worth to thesufferers from club-foot.

III. Continental and English PeriodNineteenthCentury. More general attention seems to havebeen directed toward the study and treatment ofdeformities at the beginning of this century, andmany master-minds in different countries labored tobring the subject from out of the half mystical, halfempirical atmosphere in which it was enshrouded atthe close of the last century.This period was opened auspiciously by thewritings of Ortlepp in Germany, whose work, " DeTalipedibus," etc. (Jena, 1800), contains many ex-cellent suggestions ; and of Bailly, in France, whowrote under the title "Du traitement et de la cura-bilite du pied-bot invetere " (Lyons, 1802).They were followed in 1803 by Scarpa, of Pavia,who in his work on club-foot, " Memoria chirurgicasui piedi torti congeniti dei fanciulli, e sulla manieradi corregere questa deformita " (Pavia, 1803), main-tained the opinion entertained by Hippocrates, thatthe tarsal bones are not dislocated, but twisted ontheir axes, and only partially separated from theirmutual contact. He contended that the primarydisturbance is in the osseous system, and that, con-sequent on this displacement, the muscles are elon-


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48 MEMOIR OF A. S. ROBERTS.gated or retracted, according to their position. Heproved by dissection the inaccuracy of the supposedcause of club-foot residing in arrest of developmentor malformation. He designed an apparatus, uni-versally known as "Scarpa's shoe," for the mechan-ical treatment of club-foot, the essential principlesof which are retained to the present day, and onwhich most of the apparatus used at present areconstructed. Jorg, of Leipsic, wrote on club-footunder the title, " Ueber Klumpfusse und eine leichteund zweckmassige Heilart " (1803).On the 10th of May, 1806, Sartorius repeated theoperation of Thilenius. The operation, by openwound and " brisement force " combined, ended inanchylosis. In 1809 Michaelis, of Marburg, wrotea treatise " Ueber die Schwachung der Sehnen," etc.He contended that in almost every case of club-footthe tendo Achillis is too short. He operated uponseveral cases of talipes equinus by partial divisionand rupture of the tendo Achillis. He reports thatafter the operation he at once brought the feet intheir natural position. He seems to have operatedvery frequently. In less than one year he had per-formed eight operations of tenotomy: three forequinus, one for varus, three for contracted knees,and one for contracted fingers.

Artopoeus, in 1810, " Sur la torsion congenitaledes pieds des enfans," and Goepel, in 1811, " DeTalipedibus varis ac valgis, corumque cura," werealso important contributors.

In 1816 Delpech, of Montpellier, executed thefourth operation of tenotomy on record. He vir-


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CLUB-FOOT: TALIPES. 49tually did a subcutaneous operation, inasmuch ashe made a small opening through the skin andremote from the tendon. He laid down the fol-lowing important rules for the performance of theoperation

1. The tendon was not to be exposed. The knifewas to be entered at a distance from the tendon,and not through an incision in the skin parallel to it.

2. After section the divided ends of the tendonwere to be brought together, until reunion.

3. Gradual and careful extension was to be madebefore complete union.

4. Complete extension being made, the limb wasto be fixed in this position, and kept there untilunion was perfect.From Delpech's work, " Chirurgie Clinique deMontpellier " (Paris, 1816), and " De l'Orthomor-

phie " (1828), it does not appear that he again per-formed tenotomy.

In 1817 D'lvernois wrote an essay on club-footentitled " Essai sur la torsion des pieds et sur lemeilleur moyen de les guerir."He was followed in 1820 by Palletta, who at-tempted to prove that the primary cause of thedeformity consisted in a deficiency, complete orpartial, of the internal malleolus (" Exercitationespathological.," Paris, 1820).

In 1823 Rudolphi, in his " Grundriss der Phy-siologie," added much valuable information to thepathological anatomy of club-foot. He believed thatclub-hand and club-foot did not depend on extrinsiccauses, but frequently occurred in young children

4


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50 MEMOIR OF A. S. ROBERTS.from irritation and spasmodic action. He also firstcalled attention to the fact that distortions occur inthe embryo as early as the third and fourth monthsof foetal life.From 1823 to 1831 many important contributions

to the study of club-foot were made. Of these themost noticeable were those of Mellet, "Considera-tions generales sur les deviations des pieds ; " JamesKennedy, ofGlasgow, "On the Management of Chil-dren in Health and Disease" (1825); Stolz, in 1826," Memoire sur une variete particuliere du pied-bot ;"Brims, " Dissertat. inaug. de Talipede varo" (1827)Pech, " De Talipedis vari et valgi causa " (1828) ;Cruveilhier, " Anatomie Pathologique " (Paris,1829), who entertained erroneous ideas of club-footand hand, thinking that a cramped position in uterowas the sole cause of these congenital distortionsTortuae, in 1829, " Praktische Beitriige zur Therapieder Kinder-Krankheiten" (Minister) ; Buchetmann,1830, " Diss, inaug. Abhandlung ueber die Platt-fuss" (Erlangen); and Loeb Davides (1830).From the time of Delpech until 1831 it does notseem, judging from the writers just quoted, that theoperation of tenotomy had been placed on such abasis that its performance had been often repeated,or its merits further investigated. In 1821 Stro-meyer not only resuscitated, but established theoperation on a permanent and scientific basis. Byhis discoveries he not only made the operation pop-ular, but, showing the impunity with which musclesand tendons might be divided, opened the field forthe relief of deformities which before had baffled the


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CLUB-FOOT: TALIPES. 51surgeon, and which had condemned the sufferer toa lifelong incapacity. Like all new departures,however, his disciples undoubtedly overdid theoperation, and its applicability was oftentimes lostin the desire to perform it. Thus its proper appli-cation and the counter-indications for its perform-ance have only been the result of experience ; butto Stromeyer and his influence is undoubtedly duethe success attained by surgeons at the present dayin the operative treatment of club-foot. He wroteunder the title " Beitrage zur operativen Ortho-padik" (Hanover, 1838). In 1833 Stork wrotevery learnedly on " De Talipedibus varis." He wasfollowed in 1835 by Vincent Duval, whose writings," Traite pratique du Pied," and u Des Vices Con-genitaux de Conformation des Articulations," con-tain many useful observations. He made manyimportant statistical deductions, and also proposeda classification and nomenclature, which, however,have not come into general use. He is also said tohave been the first operator upon the tendo Achillisin France. In the same year Blance wrote his" Diss, inaug. de novo ad Talipedem varem." Ryan,of London, in his " Practical Treatment of Club-foot" (1835), criticises the three divisions of club-foot into equinus, varus, and valgus, as havingthe merit of being short, but the want of being-exact. Thus, he says, it is necessary that the formof club-foot called equinus should be carried to thegreatest degree of development to give to the pa-tient's foot the appearance of a horse-foot, and anexamination of thirty cases seemed to justify this


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52 MEMOIR OF A. S. ROBERTS.criticism. In regard to the etiology, he consideredgeneral or partial paralysis dne to cerebro-spinaldisease, and the bad position of the child in uteroas the two great causes ; other less important oneshe found in direct injuries, contusions, inflammationof the knee or tibio-tarsal joint, and nerve lesions.He did not think tenotomy a justifiable operation,unless all other means failed.

In 1836 W. J. Little, of London, who was asufferer from acquired club-foot, and who vainlyattempted to have an operation performed in Eng-land, proceeded to Hanover, where he was operatedon by Stromeyer for an equino-varus. In July ofthe same year he himself nerformed the operationin Hanover. He then went to Berlin, and withDieffenbach treated numerous cases of distortion.On February 20, 1837, Little is soid to have dividedthe tendo Achillis for the first time in England,although the honor was claimed by two men beforehim, by M. A. Petit, in 1799, and by Whipple, ofPlymouth, in May, 1836, who states that when heperformed the operation he was not aware that ithad been performed on the Continent, and thatBrodie, to whom he wrote on the subject, discoun-tenanced i ;, but that Liston sanctioned the opera-tion. To Little, however, is undoubtedly due thecredit of popularizing the operation in England,and to his influence the advancement of orthopedicsurgery is largely owing. He is said to have beenthe first to use the term "Talipes" (Talus, an ankle,and pes, a foot) in its generic signification, althoughthe term had previously been used by writers in a


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CLUB-FOOT: TALIPES. 53more limited sense. He saw and described talipescalcaneus, and made extensive researches into thepathological anatomy of club-foot, considering themuscles as the parts primarily attacked. In regardto tenotomy, Little says : " The most favorable timefor division of tendons is a few months before thechild may be expected to walkabout the age ofsix or eight months, until which time mechanicalapparatus should be used." Little wrote his "Trea-tise on the Nature of Club-foot " in 1839, and " Onthe Nature and Treatment of the Deformities of theHuman Frame " in 1853, both being standard workson the subject to this day. Kennedy, of Dublin," Obcervations on Cerebral and Spinal Apoplexy,Paralysis, and Convulsions of New-born Children,"and Martin, " Premier Memoire sur le Pied-bot,"were also among the most prominent publicationsof this year ; the latter ascribing congenital club-foot to deficiency of the liquor amnii. In 1837Sewald (Berlin) wrote his celebrated thesis, " Diss.inaug. de Talipedibus," as also Lode, " Diss, inaug.de Talipedibus varis et curvatura Manus," etc. Inthe same year Pivain wrote his essay entitled, " Surla Section du Tendon d'Achille," etc. Attentionwas also called to the subject of flat-foot, by Never-mann, in an article entitled " Ueber den Platfussund seine Heilung." In 1838 Kness studied thesubject carefully, and embodied his researches in anarticle, " De Talipede Varis," and Wigel in thesame year gave a resume of the operative treatmentunder the title " De Operatione Vari."

In 1839 Velpeau, of Paris, gave much attention


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54 MEMOIR OF A. S. ROBERTS.to the subject of club-foot, and wrote on the sub-ject in his " Nouveaux Elements de Medecine Ope-ratoire." He advised, after division of the tendons,the reduction of the foot, by a powerful instrument,to its normal position, and also its immediate fixa-tion. He called attention to the importance of theposterior tibial tendon, and describes the operationfor its division, its dangers, and advantages.

In the same year Krauss wrote on " The Cure ofClub-foot, Bent-knee, Long JSTeck, Spinal and otherDeformities, with Cases." He was an ardent advo-cate of tenotomy, although he says " in congenitalclub-foot, if advice be early sought, a cure may beattempted by mechanical means alone, but never-theless, in children one and two years old tenotomyis better." Hauser " on Talipes Varus " (Tunice),and De Russdorff, " De Talipedibus," were also im-portant contributors in this year. Between the years1834 and 1840 we find tenotomy practised, and itseffects upon the tendons very carefully studied, bysuch men as Bouvier, of Paris, Pauli, Von Amnion,Phillips, Held, Scoutetten, of Strasbourg, Bonnet,of Lyons, Jules Guerin, of Paris, Dieffenbach, ofBerlin, and Pirogoff. The researches of Bonnet aredescribed in his "Memoire sur la section du tendond'Achillo dans le traitement des Pieds-bots;" Pauliin his essay " Ueber de Klumpfuss und dessenIleilung." The other contributors are : Von Am-nion, who studied the effect of tenotomy very care-fully in his " De Plrysiologia Tenotome ;" Phillips,k% Mibcutaneous Tenotomy in Club-foot;" Held,; ' Sur le Pied-bot;" Scoutetten (Strasbourg), "Mem-


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CLUB-FOOT: TALIPES. 55oir on the Radical Cure of Club-foot;" Bonnet(Lyons), " Trait e* des Sections Tendineuses," etc.;Jules Guerin (Paris), " Memoir upon the Etiologyof Congenital Club-foot;" Dieffenbach (Berlin),"Ueber die Durchschneidnng," and Pirogoff," Ueber die Durchschneidung der Achilles."From the experiments of Bonnet, he was led to

regard the cause of congenital club-foot as residingin the tibial nerve. Pirogoff described two modesof performing tenotomy

1. Introducing the knife between the skin andtendon and cutting inwardly. 2. Introducing theknife between the bone and tendon and cutting out-wardly. The latter operation was always followedby effusion of blood into the sheath of the tendon.

Jules Guerin believed tenotomy was not necessaryfor very young children, and that bandages werealone sufficient for the reduction of varus. He isamong the first to have used plaster of Paris in thetreatment of club-foot.

Scoutetten's mode of treatment was by tenotomyand an apparatus combining fixation with flexionand extension.

In 1840 Coates published his "Practical Observa-tions on the Nature and Treatment of Talipes orClub-foot," etc. (London), and Heine, of Stuttgart,his " Beobachtungen ueber Lahmungszustande derExtremitaten und deren Behandlung," a very scien-tific work on the production of the deformities.

In 1841 Vallin, in his "Abridged Treatise onClub-foot" (Nantes), gave it as his opinion thatmuscular contraction played the most important


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56 MEMOIR OF A. S. ROBERTS.part in the production of club-foot. He say s : " Thecircumstance which has the most influence upon theefficacy of the treatment of club-foot by apparatusis the possibility of acting directing upon the dis-placed bones, and upon the causes which producedtheir displacements."

In the same year Kennedy, of Dublin, wrote his" Observations on Paralytic Affections met with inChildren," which contains many important notes onclub-foot. In 1842 Dunbar writes of the subject inhis "Notes on the Surgery of Deformities, Club-foot." In this year Lizars (Edinburgh), " Opera-tion for Cure of Club-foot," says that " the childmust be old enough to walk before the operation oftenotomy is performed. Two or three years of ageis the earliest time at which tenotomy should bepractised." After tenotomy, he advised a bandagefrom the instep to the toes, and over this a paste-board splint. In 1843 Rilliet and Barthez writelearnedly on the subject in their "Traite clinique etpratique des Maladies des Enfants," and Petitjeanwrote his work " Du Pied-bot." In 1845 Chelius,in his "System of Surgery" (London), devotessome space to the subject. In 1846 the mostimportant work was that of Tamplin, whose " Lec-tures on the Nature and Treatment of Deformities "(London) was long one of the standard works onthe subject, and may be advantageously consultedby the student at the present day. He devisedmany new modes of treatment, and his statistics asto relative frequency are very valuable. Meyer," De Talipede varis," etc., and Muller, " De Valgi


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CLUB-FOOT: TALIPES. 57pedis aetiologia quaedam," also wrote in the sameyear. Morrison, in 1847, " Snr les Pieds-bots," andBerstedt, " De Pedum Deformitatibus" (1848), arevaluable contributions. In 1849 Lonsdale wrotehis celebrated work " On Some of the More PracticalPoints Connected with the Treatment of Deformi-ties " (London).

In 1850 Degaille wrote on the etiology and treat-ment under the title " De l'Etiologie et du Traite-ment du Pied-bot." He was followed, in 1852, byBishop, of London, whose work, " Researches intothe Pathology and Treatment of Deformities in theHuman Body," is a careful summary of the subject.At about this time much attention was given tothe repair of tendons after tenotomy, and, althoughinvestigations concerning this process had beenmade byVon Amnion, Guerin, Pirogotf, Koerner andothers, it was left for Gerstaecker (1851), " Diss.Histol. de Regeneratione Tendinum;" Thierfelder(1852), "Trans. Path. Society" (London, vol. vi.,1855) ; J. H. Boner (1854), " Die Regeneration derSehnen," etc., who performed many experiments onrabbits, but especially Paget, " Lectures on SurgicalPathology " (London, 1853), who has detailedminutely the microscopic changes through all thestages of the reparative process, and to whom weare largely indebted for our knowledge of the sub-ject, to show the exact mode in which the requiredelongation of muscles is obtained in order to curethe deformities for which the operation is performed.Adams, in 1855, also performed experiments uponrabbits in which the tendo Achillis had been divided


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58 MEMOIR OF A. S. ROBERTS.subcutaneously, and has written " On the Natureand Treatment of Club-foot" (London, 1856), anda " Treatise on the Reparative Process in HumanTendons " (London, I860), in which he gives aresume of the published descriptions of experimentson animals, as well as post-mortem examinations inthe human subject. His work " On Club-foot : itsCauses, Pathology, and Treatment," is the mostexhaustive on the subject, and received the Jack-sonian prize for 1864. It has passed throughseveral editions.

Brodhurst, of London, has contributed largely tothe subject of club-foot, the most important of hiswritings being " On the Nature and Treatment ofClub-foot" (London, 1856) and his work " Ortho-pedic Surgery." He was a decided advocate oftenotomy, and employed it to the exclusion of allother means of treatment, considering it better, evenin the most simple cases, to divide the tendons. Hemade numerous experiments upon the reparativeprocess following the section of tendons, the resultsof which were embodied in a communication to theRoyal Society (November, 1859), entitled " On theRepair of Tendons after their Subcutaneous Divi-sion." From 1853 to 1863 many valuable papersupon the subject of club-foot appeared. Amongthe most noteworthy were those of Todd, " ClinicalLecture on Paralysis " (London, 1854) ; Bouchut," A Practical Treatise on the Diseases of Children "(1855); Beckel, " De Pede Yaro" (1856); Vetter,"De cyllopodia cum descript. casus pedi vari;"Ksau, "Beitrage zur Lehre von Plattfuss ;


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CLUB-FOOT: TALIPES. 59Quicken, " De Talipedibus" (1859); Ebner, "DieContracture!! der Fusswurzel und ihre Behandlung"(1860) . In 1863 Barwell, " Cure of Club-foot with-out Cutting Tendons," rendered himself famous byoffering objections to, and strongly opposing, thepractice of tenotomy, which after nearly a centuryof use had, of course, become very popular, andwas supported by all the great surgeons. Histreatment was directed to the restoration of the lostequilibrium in the opposing sets of muscles ; to sub-stituting a force for the paralyzed muscles, to beapplied as nearly as possible in the direction andposition of the paralyzed muscles ; to treating thefoot, not as a whole, but as a compound of manybones ; and to allowing the weakened muscles toregain their power by what might be called passivemotion. This he endeavored to accomplish by theuse of india-rubber bands, also called " artificialmuscles." In his objections to tenotomy he arguesthat the contraction is the result of paralysis in theopposing muscles. When the tendon is cut, allopposition to such contraction is annihilated, andthe muscle itself contracts and the calf shortens.Tonic contraction of the muscle, however, still con-tinues, and the cicatricial contraction will reproducethe same deformity when the apparatus is removed.Non-union occasionally takes place. Weber, " Ueberdie Anwendung permanenter Extension durch elas-tische Strange bei pes valgus" (1863), also advo-cated elastic force. Adams, in 1866, writes thatHeather Bigg had used the same plan several yearsprior to Barwell. Many works appeared during the


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60 MEMOIR OF A. S. ROBERTS.latter end of this period, and the literature of club-foot is now very voluminous. Stoess, in 1866, wroteon "Du Traitement du Varus;" Richter, in 1867,on " De Talipedibus Varis ;" Mezger, in 1868, " DeBehandlung van di Stortistic Pedis mit Fricties ;Hirschfield, in 1869, " Ueber die Behandlung derKlumpfusse ; " Francellon, in the same year, "DeTEtiologie du Pied-bot Congenital." In 1870 Nie-den, " Ueber die Entstehungsweise und Ursache desangeborenen Klumpfusses ;" Volkmann, "UeberKinderliihmung und paralytische Contracturen(Klinisehe Vortrage, ~No. 1), and Marx, " UeberPes Varus." In 1871 James Hardie, " On the Pa-thology of Club-foot and other Allied Affections"(London); A. Luecke, " Ueber den angeborenenKlumpfuss" (Volkmann's Klinisehe Vortrage), andBrodhurst, " Deformities of the Human Body(London). In 1872 Keverchon, " Sur le Pied-bot,"and " Du Traitement des Pieds-bots par le Massageforce." In .1877 Chalot, " Du Pied Plat et du PiedCreu Valgus Accidentels." In 1878 Kocher, " ZurEtiologie und Therapie des Pes Varus Congenitus"(" Deuts. Zeit. f. Chrr.," Bd. ix.), and Bornemann,"Zur Therapie des Pes Varus Congenitus." In,1880 Van Hees, " Ueber Pes Equino-varus." In1881 Kuprecht, " Angeborene spastische Glieder-starre und spaslische Contracturen" ("KliniseheVortrage") ; Dieffenbach, " Ueber Pes Varus undseine Behandlung;" Koutier, "Du Pied-bot Acci-dentel," and Ulcoq, " Du Pied-bot Consecutif a, laParalysie infantile et de son Traitement." In 1882Pascaud, "Of Certain Orthopedic .Vpparatus em-


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62 MEMOIR OF A. S. ROBERTS.on Club-foot," states that the only remedy to berelied upon in the

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