have excluded from the table the more easily remediable cases of knee-contracture induced by spasm, paralysis, burns, &c., as these do not fall within my definition of ankylosis.* The results of the application of tenotomy to knee-ankylosis will, as shewn by these cases, bear comparison with the results of therapeutics applied to an equal number of any other diseased conditions incidental to the human frame. In no case did the operation aggravate the patient's condition, in no case did it fail to afford relief; in two, which were the least benefited, locomotion was, in the one (Case VIII.), effected with greatly diminished fatigue; in the other (Case IX.), the patient, who had been unable to walk since occurrence of the ankylosis, was rendered able to do so without assistance even of a cane. In the remaining fourteen cases, some acquired a greater degree of mobility and a more perfect joint than others; all were enabled to walk, unaided by crutch or stick, and the younger individuals with scarcely a trace of lameness. Although an observer, critically conversant with the elegance, flexibility, and strength characteristic of the movements of this part of the frame in the normal condition, might not fail to perceive some defect in the attitude or gait of these fourteen former subjects of knee-ankylosis, their condition so nearly approached the normal state, that I shall venture to designate them cured.†

period discovered the source of error in diagnosis described page 27. Tenotomy was successful in relieving false ankylosis of the opposite ankle of this patient.

* The only other case of false ankylosis excluded is one formerly related in my Treatise on Club-Foot and analogous Distortions, 1st edition, 1839.

The term cure is commonly employed by physicians and surgeons in a relative and not in the absolute signification. How rarely the condition of individuals justly said to be cured of inflammation or disease of any organ will bear a comparison with that of individuals who have never been the subjects of disease! The cured condition is relative to the previously diseased state; and the value of the medical or surgical treatment is determined, not by comparison of the cured individual with those who have never suffered, but with his previous condition. The cure, in the ordinary point of view, is the restoration of the structure and function of an organ to that condition which enables the individual

CASE XXIII.*

FALSE ANKYLOSIS OF THE ANKLE IN THE EXTENDED POSITION.

; on

SEPT. 4, 1837. Miss ***, aged 27, informs me that when about seven years of age she was attacked with scrofulous disease in the right leg, accompanied with numerous abscesses, ulcerations, and fistulæ, the last of which closed twelve years since. During the continuance of this protracted disease she was unable to walk its subsiding, the extended position assumed by the foot for so long a period had produced a permanent elevation of the heel to its greatest extent. This position had arisen from the anterior muscles of the leg being overbalanced, in the absence of the exercise of volition, by the superior power of the gastrocnemii and other posterior muscles, combined with the gradual contraction of the numerous cicatrices. The patient now walks upon that part of the sole of the foot corresponding to the metatarso-digital articulations (as in fig. 31), which is covered with the usual painful corn investing the cutis when subjected to undue friction or pressure. The heel is drawn upwards by the contracted muscles of the calf to the extent of five inches this distance is retained even when the entire weight of the body is thrown upon the affected limb, or when the patient endeavours to force it down; so rigid, indeed, is the contraction, that no efforts to force up the toes effect the least alteration in form of the foot. No actual deformity of the foot beyond the fixed state of so-called extension exists. The whole of the muscles of the affected thigh and front of the leg are weaker than those of the opposite side; those of the back and outside of the leg are bound down to the bones by ten or twelve indented cicatrices, some of which exceed the length of three inches. She is incapable of exercising voluntary power by the action of the anterior muscles, through their being constantly kept on the stretch; and is also unable to exercise the posterior muscles, some of them in various parts being firmly adherent

to pursue the ordinary avocations of life with ease and comfort, although the restoration may not be so complete that the organ will endure the same wear and tear as an organ never affected.

* Cases XXIII. and XXV. have been already published in my Treatise on Club-Foot and analogous Distortions (edit. 1839); but as they are properly cases of false ankylosis, I have republished them here in an abbreviated form.

to the bones, and the remainder being already contracted to their

Fig. 31.*

The letters ta indicate the tense

tendo achillis; p t, posterial tibial tendon; h, the heel ele

vated to the utmost.

fullest extent. The entire extremity, owing to the fixed straight position of the foot, is rendered longer than that of the opposite side. The tibia and fibula, however, from the long continuance of the scrofulous disease, not having kept pace in growth with those of the opposite limb, are about one inch shorter, and consequently diminish to that extent the excess in length of the affected extremity. This, in addition to the studious efforts of the patient to conceal her deformity, by walking leisurely, and as much as possible upon the toes of the sound leg, renders the lameness less than that which usually results from a deformity so considerable. She cannot stand or walk for any great length of time, particularly if the pavement be sloping or uneven, without much pain and fatigue. She is urgent for the performance of an operation, which has succeeded in the case of an acquaintance, also one of my patients, whose deformity was of twenty-five years' standing. The non-existence of true ankylosis of the joint is evident from the lateral motion given to the astragalus and tarsus by alternately moving the toes inwards and outwards.

Sept. 7. Divided the tendo achillis. I punctured the skin on the inner side of the limb, opposite to the part where the tendon was least engaged by the adhesions, and as far from the anterior

* This figure illustrated another case in the same treatise; but as it perfectly resembles the cast of the foot here described, I have availed myself of it on the present occasion.

surface of the tendon as compatible with the safety of the posterior tibial nerve and vessels, one side of the knife being directed towards the latter. The edge was then directed backwards against the tendon, the point being made to describe a quarter or third of a circle, the centre being that part of the skin where the external puncture was made. By this cutting backwards and circular motion of the point of the knife, the tendo achillis, and nearly all the adhesions (which I found to be fibro-cartilaginous) between the edge of the knife and the skin, were divided in the same manner I usually adopt for cutting the former only, without puncturing the skin of the opposite side of the leg. After the withdrawal of the knife, two small portions of fascia, or bands of adhesions, were felt through the integuments unsevered, which were cut by the reintroduction of the bistoury. Cicatrisation immediately followed.

After a few days, extension was commenced, and the apparatus was slowly tightened, but with little amendment in the state of the ankle-joint. The patient complained of restless nights, and took a few doses of tinct. opii. The pain endured from the apparatus was not referred to the situation of the ligamentum deltoideum and fibulare posticum, to the former of which, after the operation for clubfoot, patients usually point as the part where they feel the process of extension, but to the back of the fibula, two inches above the malleolus. On the eighth day of the extension I found, to my disappointment, that the foot was nearly in the same position as before the operation, the heel having but slightly descended; it was therefore evident that some unusual impediment existed to the bending of the ankle. At the place where the patient complained of pain and of having felt the process of extension, close to the tendons of the peronei muscles, a cicatrix adherent to the bone was observed somewhat inflamed, appearing as if it had been on the stretch. I now suspected that these tendons might be implicated in the cicatrix, and adherent to the fibula, although before the operation I believed them to be free; I therefore resolved that if, on subsequent examination, this suspicion were confirmed, I would divide them below the cicatrix. The bandages and apparatus were removed, and the spiritlotion directed to be constantly applied to the ankle, and a dose of laxative medicine to be taken, in order to accelerate the removal of oedema of the parts, which obstructed an accurate examination.

On the eighteenth day after the division of the tendo achillis, all swelling having subsided, I was enabled to satisfy myself of the precise state of the parts. No adhesion of the peronei tendons at the cicatrix was present; for on moving the ankle-joint as far as the deformity would admit, I found that they were rendered, both above and below the cicatrix, alternately tense and lax. The cicatrix was still slightly œdematous and red, accompanied with a sensation of pain on attempting to press the toes upwards, ranging from the cicatrix to the posterior extremity of the os calcis. By careful manipulation I discovered what I believed to be a firm band, passing from the os calcis, or from the inferior portion of the divided tendo achillis, to this cicatrix of the fibula. Pain was felt in the direction of this band on pressure, and also on endeavouring to force the toes upwards.

My friend Mr. Herring of Sun Street, who attended the case with me, coincided in the opinion that this fibrous band constituted the impediment to bending the joint; I therefore determined to divide it between the cicatrix and its connexion with the lower part of the tendon, which was effected after the manner of dividing the tendo achillis, with the exception of the introduction of the knife on the outside of the limb. The wound at the part healed the second day; but a minute puncture, made by the curved point of the knife in the posterior median line, cicatrised a day or two later. Stromeyer's foot-board was then immediately re-applied, and the same degree of extension which had previously produced great pain and uneasiness was now borne with comparative ease. The heel gradually descended, and on October 9th, fourteen days after the second operation, she was able to put the heel and entire sole to the ground, which had not been done for twenty years. A lighter modification of the apparatus was subsequently worn for three weeks, to support the joint when walking, and (although the foot had now acquired to the eye of a cursory observer a perfectly natural form) to endeavour to bend the ankle beyond a right angle with the leg, and thus obtain the full extent of natural motion. This instrument did not occasion the slightest uneasiness; on the contrary, it proved a source of ease; for when the foot was allowed to hang unsupported, she felt, as is usually the case for a short time after the operation, pain from motion of the recently elongated ligaments of the joint.