The influence of growth on congenital and acquired deformities

Front matter

r>

V >

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Preface

The original intention of writing a paper which should call attention to the influence of growth has led to the preparation of this book. Certain features have been included which, although not entirely novel in themselves, are yet presented in a new light which gives them importance as matters that will repay close attention in practice. Among the subjects thus treated are: the application of the weight of the body for the reduction of club-foot, the use of the equine position of the foot to increase the length of a shortened limb, the adoption of symmetrical movements and correct rhythm for removing deformity and excluding lameness, and the manner in which misleading tumors are produced by the rotation of lateral curvature. It is difficult to overlook entirely the element of growth when patients are with few exceptions children, and in view of the fact that the word orthopaedic is derived from two Greek words carrying the ideas of straightness and juvenile development. A. B. Judson.

New York, January, 1905.

Table Of Contents

PAGE

Introduction 1-4

CHAPTER I. Congenital Club-foot

Treatment at an early stage. — Mechanical details. — Early use of adhesive plaster. — Treatment at a later stage. — " Stamping a foot straight." — Club-foot of spastic contraction. — Neglected, relapsed, and inveterate cases. — Subcutaneous tenotomy. — Measurement of degrees of deformity. — Mechanical disadvantages of the human foot. — Hat-foot. — Minor ailments of the feet, . . . . 5-32

CHAPTER II. Deformities Caused by Infantile Paralysis

Exemption of the upper extremities. — Paralysis of thigh muscles. — Of leg muscles. — Talipes calcaneus. — " The Human Wheel." — The strain on the tendo Achillis. — Congenital calcaneus. — Paralytic varus. — Valgus. — Mechanics of locomotion.— Deformities of locomotor ataxia and Friedreich's disease.— Importance of treatment during growth. — Details of treatment. — Recognition of mechanical surgery. — An orthopaedic laboratory. — Apparatus not only prosthetic, but also preventive and therapeutic — Orthopaedic surgery as a specialty, . . 33-63 vin CONTENTS.

CHAPTER III. Tuberculous Joint Disease

PAGE

An affection of childhood. — Predisposing causes. — Operative and mechanical treatment. — Intelligent expectation. — Deformity. — Fear of ankylosis. — Favorable outcome depending largely on early diagnosis, 64-72

CHAPTER IV. White Swelling of the Knee

Removal of bodily weight imperative. — By recumbency.— By axillary crutches. — By ischiatic support. — Arrest of motion by leverage of pressure and counter-pressure. — Deformity reduced by the same instrument. — Ultimate mobility compromised by unreasonable fear of ankylosis.— Treatment throughout the growing period. — Subluxation. — Abscesses.— Knock-knee.— Bow-legs. — Ankle disease, .... 73-86

CHAPTER V. Treatment of Hip Disease

Basis of mechanical treatment. — Historical notes. — Use of adhesive plaster for traction. — Practical inferences from morbid anatomy. — Correlation of traction and fixation. — The American splint. — Details of application in the third stage. — Weight and pulley. — Paradox in treatment of hip disease and fracture. — Ultimate mobility promoted by fixation. — Management of apparatus at home. — Joint disease in the upper and lower limbs. — Weight of the body as a factor. — Comparative importance of traction and protection. — Tuberculous disease of wrist, elbow, and shoulder. — The ischiatic crutch. — Its use as an artificial limb. — In ununited fracture. — Discontinuing treatment. — Overexertion to be avoided after recovery, . 87-129

CONTENTS. ix

CHAPTER VI. Abscesses of Hip Disease

PAGE

Absorbed, cold, and inflamed abscesses. — Without effect on duration and results of disease. — Their origin, significance, and deportment. — Location of sinuses. — Question of operation or expectation, 130-14 1

Chapter VII

Diagnosis, Prognosis, and Appre< iation of Results of II ii' Disease.

Symptoms and signs. — Reflex action the most valuable early sign. — Three diagnostic signs of established disease. — To test for antero-posterior and lateral mobility. — Structural shortening.— Found also in acute epiphysitis, diastasis, infantile paralysis, congenital dislocation, and coxa vara.— The synovitis of continued fever.— Good results depending largely on diagnosis before pain appears.— Good functional results after the third stage.— Amount of motion less important than position of limb. — Manikin demonstrations. — The goniometer. — Ready methods of estimating shortening, . . . 142-169

Chapter VIII

Causes and Prevention of the Deformitv of Hip Disease.

Real " less important than " apparent " shortening. — Faulty position of the limb. — Fixation the result at first of muscular contraction, afterward of ankylosis. — The neuro-muscular element. — The movable-immovable joint. — Faulty position unconsciously assumed for convenience. — Method of inducing its surrender. — Illustrations of favorable and unfavorable results.— Difficulty of direct mechanical reduction. — Over-

Contents

PA(

coming structural shortening. — Local hyperemia and anaemia. — Extension shoe. — Equine foot. — Definition of lameness in general. — Normal and abnormal rhythm. — Influence of growth on correction of deformity, ijo-il

CHAPTER IX. Pott's Disease of the Spine

A disease of childhood, but occurring also in the aged.— Signs and symptoms. — Local pain and disability often absent. — Varying effects of cervical, lumbar, and dorsal disease. — Compensating lordosis. — To make a diagnosis before appearance of deformity. — Recovery through reaction and consolidation.— Recumbency.— Mechanical support. — Arrest of motion. — Transference of weight. — Incidental improvement of figure during growth.— A practical rule and mechanical details. — Plaster-of-Paris jacket. — Abscesses. — Paraplegia. — Reduction of stature. — Caries of sternum, . . . 189-216

CHAPTER X. Lateral Curvature of the Spine

Rotation. — Its cause. — Its effect on torso overlooked in art. — Diagnosis obvious, but incidental effects of rotation not always recognized. — Tumors. — Sciatica. — Sacro-iliac disease. — General health and ability not compromised. — Rotating curvature a physiological manoeuvre.— Incidental and typical curvatures. — Importance of treatment.— Braces. — Treatment based on clinical observations. —Recumbency, suspension, rest, chest expansion. — Sequence of causes, . . .217-244

THE INFLUENCE OF GROWTH

UPON

Congenital and Acquired Deformities,

Introduction

I venture to present to the reader a new volume on orthopaedic subjects, not because there is any lack of excellent systems and text-books, but rather to emphasize what seems to lie at the base of practice in this specialty, the fact that prevention and cure arc to be lOiind in so managing a case and equipping a patient that natural growth will be the principal factor in recovery. Mr. Hilton said : " Repair is but the repetition of growth. The same elements, the same kindred conditions are necessary to the same results." This view is far from including all there is in orthopaedic practice, but the thought thus expressed should. temper the consideration of all procedures, whether operative or mechanical, which have for their object the removal of deformity.

The average length of a new-born baby is nineteen and a half or twenty inches. During the first six months he grows from four to five inches, and in the second six months from three to four inches. During the second year he grows from three to five inches; during the third year from two to three inches and a half; and during the fourth year from two to three inches. By the end of the fifth year the child has generally doubled his original length. After that his average annual growth is from one inch and two-thirds to two inches, with a slight acceleration in the years just preceding puberty. This period of gradual increase in size, covering nearly a quarter of the three score years and ten, may not be neglected in intelligent efforts to banish deformity and promote physical ability, refreshing the significance of Andry's designation of orthopaedic surgery as the "art of making a child grow straight." If the surmise is correct that the rate of growth is not uniform from year to year, but is now rapid and again slow, it would be well if fluctuations in the rate could be recognized or foreseen, making possible especial orthopaedic efforts when growth is rapid and comparative relaxation of treatment when it is progressing more slowly.

The methods of diagnosis, prevention, and treatment herein presented are put on record as having proved useful and as likely to be at least suggestive in the practice of others. These pages probably contain very little that is new or presented for the

INTRODUCTION. 3

first time. So-called new observations and inventions in medicine and surgery have generally been made before and recorded on some page which for some reason or other has not been read. In regard to " new truths," it has been wittily said that " what is true is not new and what is new is not true." In all departments of industry improvements are planned some time before they are realized or tested, becau>e unfavorable conditions have to be first changed by improvements in other departments. Imagination walks ever in front of the advancing line of the arts and sciences, and no member of the band may progress except in company with the rest. In orthopaedic surgery methods have improved, not because something new has been learned about disease and principles of treatment, but rather because general knowledge has increased and difficult mechanical effects have become convenient through improvements in and novel applications of such materials as adhesive plaster, gypsum, and steel. The fine adjustments which Fayette Taylor made by ingeniously constructed joints in his " spinal assistant " are now more readily made in Bessemer steel. Conditions of advance are not only physical, but are also found in mental attitudes which are liable to change in response to reason and experience. When the fear of wounding a tendon was overcome, subcutaneous tenotomy was accepted. The fear of ankylosis may in course of time subside, and the views of the surgical world may in due order turn in favor of intelligent expectation in the management of joint diseases, thus making good Mr. Hilton's additional words: " Rest is the necessary antecedent to the accomplishment of repair and growth. This is surely the natural suggestion of a means toward an end which should never be lost sight of by the physician or surgeon."

Chapter I. Congenital Club Foot

The effect of natural growth on deformity is very evident in a case of congenital club-foot. A baby gains in length from seven to nine inches in the first year, in which period the deformity becomes more obvious and obstinate with each added month; but if the foot is held in a good position, growth introduces symmetry and facilitates restoration.

TREATMENT AT AN EARLY STAGE.

This deformity cannot receive attention too early. Dr. Willard says: "The time for beginning the treatment of congenital club-foot is at the hour of birth." The limb should at once begin to grow straight instead of growing crooked. Ready to yield, the little foot seems to be held out in an appeal for the application of a lever, making points of pressure and counter-pressure in the directions indicated by the arrows in Figs, i, 2, 3, and 4. A plaster-of-Paris dressing observes the same points of action. The brace shown in Figs. 3 and 4 may be made of brass or other convenient metal. The thin discs are softly

GROWTH AND DEFORMITY.

padded. The brace is applied with three strips of adhesive plaster and very gradually bent to different shapes, as seen in Figs. 5, 6, 7, and 8, the foot taking on corresponding shapes until it occupies the concavity of the brace where valgus is seen instead

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

<J

Fig. 5.

Fig. 6.

Fig. 7.

Fig. 8.

Figs. i-8. — Points of Pressure and Counter-pressure in the Early Stage of Treatment, and Changes made in the Brace and in the Shape of the Foot.

of varus. These successive changes took place and were carried farther in Case I., as is shown in Fig. 22, on page 22. Correction cannot well be overdone in this stage. The details of this application are presented more clearly in Fig. 9, which shows the right foot of a boy six months old in process of correction.

COX(' r EX I TA L CL L r B-FOO T.

The plaster 'surrounding the leg and the upper shield

and that surrounding the foot and the lower shield are lightly applied as they simply hold the apparatus in place. The middle plaster, after being securely fastened by several turns around the upright, receives the unattached middle shield and surrounds the lower part of the leg and the brace.

While one hand reduces deformity by forcing the limb and brace together, let the other hand secure the middle plaster after repeatedly carrying it around the limb and the upright of the brace, being ever mindful of the pressure made by the middle shield, which is the key to the application. It is needless to say that careful attention is required to secure comfort and efficiency, which follow the skill born of repetition. Under advice and instruction the successful carrying out of the necessary details depends on the intelligence found in the patient's home. Reduction is assisted by the position of the babe " in arms,"

Fig. 9. — Details of Application.

where no part of his weight interferes with the mechanical force used. One or two days in each week may be given to freedom of the foot and manipulation in order to maintain flexibility. Without haste, violence, or pain, the foot, having doubled its size by growth, will be found valgus when resting undisturbed, and the tendo Achillis, as an incidental effect and without especial attention, will be sufficiently lengthened to permit a right-angled position of the foot. This, the first stage of treatment, should be concluded long before walking begins.

Early Use of Adhesive Plaster.— In the case of a new-born babe, before a brace can be prepared, the trouble may be met by surrounding the foot with a strip of adhesive plaster in such a manner as partly to correct deformity, the improved position being secured by making firm traction on the long end of the plaster and attaching it to the outer side of the leg. This method was advocated in 1850 by Dr. S. D. Gross, at that time one of the faculty of the New York University. The same material had, however, been used, although in a different way, many years before in the treatment of this affection. In 1740 Mr. Cheselden wrote : " The first knowledge I had of a cure of this disease was from a professed bonesetter. I recommended the patient to him, not knowing how to cure him myself. His way was by holding the foot as near the natural position as he could and then rolling it up with strips of sticking plaster, which he repeated from time to time as he saw occasion, until the limb was restored to a normal position." In orthopaedic practice the material or method is often of less importance than the skill and enthusiasm of the physician. If he has invented or improved an instrument, the attendants of the patient, inspired by his confidence, unite with him in overcoming the inconvenience and trouble inseparable from mechanical treatment and thus succeed where others meet with disappointment.

TREATMENT AT A LATER STAGE.

When the patient, with his foot now in good shape, learns to walk a critical stage of treatment begins. If left to itself the foot will relapse at once tinder the weight of the body, which develops a distinct boundary plane dividing varus from valgus as the foot presses the ground. By way of illustration, place the ulnar border of the hand on a table and it will be seen that pressure, with alternations of pronation and supination, will in turn produce full pronation, corresponding with valgus in the foot, and full supination, corresponding with varus. Applying pressure equal to twenty-five pounds brings to light the fact that the weight of a child will, if properly directed, insure a normal foot, or if misdirected confirm de-

GROWTH AND DEFORMITY.

formity. Advantage of this may be taken by the use of a brace that holds the foot, even a little, on the right side of the plane between varus and valgus.

Fig. io.— Flexible Paralytic Club-foot of the Patient seen in Fig. 17

Fig. ir. — Brace for Foot shown in Fig. 10.

The child may thus, with increasing weight and activity, achieve recovery by stamping the foot straight. Fig. 10 shows the deformed but flexible foot of a child four years old. The brace used in this case is shown in Fig. n. Its weight is thirteen ounces. It is made of soft steel and has a band, an upright, and

CONGENITAL CLUB-FOOT. u

a foot-piece composed of a tread and a riser. The foot-piece is lined with adhesive plaster to prevent rust and a piece of truss leather fastened with two copper rivets. More or less valgous in shape, the instrument makes pressure on the outer side of the ankle, while counter-pressure on the inner side is found at the upper part of the brace and along the riser of the foot-piece. The sole of the foot finds on the tread an inclined surface like that of the inner side of the sole of a shoe whose outer border has been thickened in order to precipitate valgus, an effect which is seen in Fig. 12. This favors the leverage by which the foot is held on the right side of the plane.

Dr. Cook ingeniously sought to combat varus by providing the sole of a common shoe with an ample steel extension directed outward in order to reduce deformity with the descent of the body, in imitation of the method by which quadrupedal gait is modified by the application of a horseshoe forged with a lateral or antero-posterior ex-

Fig. 12. — Tread

tension. His experience proved that of Brace with the such an application would probably be effect of a Built "

more effective in club-foot if a coalition were practicable between the foot and shoe, such as is found in veterinary practice.

The upright of the brace may be inclined backward ten or fifteen degrees with a corresponding extension of the foot. This increases the length of the lever applied against deformity. Thus arranged, the tread will cut the sole of the shoe, which may be protected by a steel in-sole (about an inch wide) lying between the brace and the shoe, or else cut to fit the anterior part of the sole and fastened inside the shoe by a screw. The strap which spans the front of the leg carries a sliding pad to allay the friction transferred

to this point from the toe, as in the treatment of talipes calcaneus (p. 47). This arrangement is otherwise useful in relieving the front part of the foot from part of the weight of the body, which seriously interferes with the correction of deformity. It also seems to have an entirely unexpected tendency to lengthen the heel cord. The action of the brace may be improved by the use of adhesive plaster applied as in Fig. 13, a strip encircling the foot and buckled to the riser at A ; or a window, D, may be cut in the junction of the tread and riser, as seen in Fig. 14, through which the plaster C, passes to the buckle F, on the under side of the tread. The plaster may be conveniently doubled, as at A in Fig. 15, the remainder of the facing, B y

\V y /

J

•

Fig. 13

— Adhesive Strip

Applied to Untwist Anterior

Part of Foot (1887).

CONGENITA L CL ( T B-FOO T.

i3 being removed at the time of application. The prehension and traction made by this material admirably imitate the action of the hand, making pressure

Fig. 14. — Window for Exit of Adhesive Strip

in the selected directions, untwisting the anterior part of the foot and keeping the toes from surmounting the riser.

Fig. 16 shows the brace applied to the foot, and Fig. 17 the child equipped for stamping her foot straight, increasing activity and weight and juvenile growth combining to secure a good result. Applied

Adhesive Strip Ready for Application.

under or over the stocking, the brace is worn inconspicuously and without inconvenience for many months, a larger one being made when required by

GROWTH AND DEFORMITY.

the patient's growth, which being rapid at this age is a welcome ally. By the end of the fifth year a child has doubled his original length, an increment that has perforce a positive effect for benefit or injury.

Fig. i 6 — Brace seen in Fig. n, Applied to Foot seen in Fig. 10.

Fig. 17. — Brace Applied and Foot Dressed.

Nothing especial is needed in the way of shoes, the mate of the other shoe answering every purpose. If necessary the capacity of the shoe may be increased by cutting it down in front and adding more eyelet holes. With this instrument treatment may be concluded. The result should be normal ability, practically not impaired by a heel cord somewhat shorter than normal. This tendon with the other fibrous structures would doubtless yield to direct mechanical treatment, but it is found to adapt its length to the requirements of walking and running without especial attention in the course of treatment.

Inversion, commonly seen at an early stage, may not cause anxiety as it takes place at the hip, and disappears under instruction when the child learns, in due time, the necessity of making a good appearance. Parental impatience sometimes leads to cessation of treatment after the brace has been worn for several months with apparently full recovery; but when a relapse to varus is indicated by the reappearance of a callus and the rapid wearing through of the outer border of the sole of the shoe, treatment is necessarily resumed for another period. Success implies perhaps uncommon intelligence in the parents, who should possess the difficult quality of patience and be able to give appreciative attention to the case at home. On the other hand the surgeon has no easy task who makes the frequent necessary mechanical adjustments and cannot escape ultimate responsibility for the home management.

The Club-foot of Spastic Contraction. — Correction of deformity by the weight of the body properly directed is illustrated in the equino-varus seen in a case of spastic contraction. The muscles being readily overcome by continuous leverage, the corporal weight holds the foot in the normal position, which continues when the brace is laid aside after a period of treatment in which growth has made some progress. A patient thus aided to walk enjoys a general improvement which seems to react favorably on the nervous disorder.

NEGLECTED, RELAPSED, AND INVETERATE CLUB-FOOT.

While it is thus easy to remedy congenital club-foot when taken early and treated systematically there is great difficulty in the restoration of neglected, relapsed, or inveterate cases, of either congenital or acquired origin. Operative treatment is necessary in nearly every case of this kind, and judgment will be required lest an improvement in appearance is gained at the expense of locomotor ability, which is good in many cases even of severe deformity. Bradford and Lovett's treatise records the surprising locomotor skill and agility acquired in certain cases in which deformity had gone uncorrected. A moderately severe resistant club-foot is seen in Fig. 18. In such a case the application of a brace which forcibly holds the varus partly corrected gives excellent ability in walking and running, and is

CONGEXITAL CLUB-FOOT. i;

often and very excusably preferred by the youthful patient to an operation which would lessen the strength and ability of the foot, although improving its appearance. Worn in this way the brace is a purely prosthetic appliance. Its effect would, however, be therapeutic and ultimately curative if the patient could be induced to relieve the foot from the weight of the body by wearing in addition a pair of crutches or an ischiatic support for the time necessary to bring the foot around to that position in which the weight of the body would assist in completing the reduction of the deformity. It is of course far better to ,

J FlG. iS.— Resis-

foresee these troubles in the very early tant Paralytic youth of the patient when complete res- ( l lub ; foot ' Age

J *■ t len ^ ears.

toration is easily practicable.

Double Club-foot, — The recumbent position is necessary if the affection is double, unless one limb be treated at a time, in which case— as when only one foot is affected — resort may be had to crutches, or, better, to ischiatic support, with a high sole under the other foot, as in hip or knee disease, until the straightening of the brace and the foot and continuous leverage lead the way to the vantage-ground where the weight of the body may be enlisted as a corrective force.

i8

GROWTH AND DEFORMITY.

Subcutaneous Tenotomy.— If the tendo Achillis fails to meet the requirements of locomotion after reduction of deformity by this method, as a last re-

Fig. ig.

maining defect it may be divided. In 1831 Dr.Stromeyer (1804-76) made his first section of this tendon, an operation which has been said to " mark the beginning of the whole system of subcutaneous sur-

CONGENITAL CL ( 'Il-FOOT.

gery and of all really successful orthopaedic treatment." Five years later Dr. Little (1810-94) visited Stromeyer and against the advice of friendly medical authority submitted to tenotomy for talipes equino-varus (left), following an attack of infantile paralysis at the age of four years. The result in this and other cases " caused a revulsion of feeling in favor of subcutaneous tenotomy/' which was first performed in

GROWTH AND DEFORMITY.

England by Dr. Little himself in 1837. In that year Dr. Detmold (1808-94), coming to New York, " introduced orthopaedic surgery into America," making one hundred and eighty divisions of the heel cord in two years. In current medical opinion Stromeyer is credited with the discovery of subcutaneous tenotomy, Little with having widely disseminated a knowledge of it, and Detmold with its introduction into this country. Not a few of the advances of surgery have been due to previous misconceptions oi the danger of invading certain regions or wounding certain tissues. Stromeyer's discovery greatly encouraged the study and practice of orthopaedic surgery. With further advances in general medicine and surgery it is probable that other changes of mental attitude will be seen and other modifications will be accepted in the methods of this branch of practice.

The Goniometer. — The flexion of the foot on the leg may be conveniently measured by the goniometer. With the knee flexed in order to relax the gastrocnemii and the tendo Achillis, and the foot held midway between varus and valgus, one arm of the instrument may be held parallel with the crest of the tibia, and the other with the plantar surfaces of the heel and the ball of the foot. The degrees of flexion may then be read on the scale. After club-foot it is difficult without impairing the power of the limb to give to the heel cord the length which normally permits flexion of fifty or sixty degrees. But flexion of twenty or twenty-five degrees, which is acquired in the course of routine treatment, practically secures full ability without defect of gait.

Case I. — Double Congenital Club-foot. — Without previous attention, treatment was begun September 5th, 1896, at the age of three months, the shape of the boy's feet at that age being seen in Fig. 22, which

GROWTH AND DEFORMITY.

also shows the progress made in the case until the child was five years old. The natural increase in size was clearly an important element in correction.

Fig. 22. — Case I. Reduction Begun by Leverage, Promoted by the Favorable Action of the Weight of Body, and Aided by Growth.

The outlines were grouped and reduced en bloc in the camera and were thus made to present their relative proportions. The first stage of treatment occupied twelve months, in which forty-three visits were made to the office. The appearance and lateral flexibility being normal, treatment was then sus-

CONGENITAL C L ( r B-FOOT.

pended. At the end of five months, in which nothing was done, the child had learned to walk, and it was noticed that the outer borders of the soles were becoming callous. Braces were therefore applied like the one seen in Fig. n, larger ones being substituted as the child grew. In this stage forty-two visits were made in twenty-two months, and treat-

FlG. 23.— Case I., Corrected Double Congenital Club-foot. Age of patient, seven years.

ment finally ceased when the patient was four years old. A year later the last outlines seen in Fig. 22 were taken. At that time the left ankle was flexible

GROWTH AND DEFORMITY.

twenty-five degrees, and the right thirty degrees. When walking or running the boy had no defect in his gait. Two years later calluses were absent and

Fig. 24. — Case I., Corrected Double Congenital Club-foot.

the toes were not inverted in walking. The limbs are seen in Figs. 23, 24, and 25. He was doing what other boys of his age do, with no indication that his feet had ever required especial attention.

An operation is often a desirable resort in club-foot. Some visits to the physician may thus be escaped. The statement that to operate for club-foot is a confession of failure is too sweeping. Operations must, however, be supplemented by mechanical treatment.

A general view of the subject shows that congenital club-foot, being an affection easily responsive to treatment, is as a rule well and promptly corrected by the method and with the instruments and materials most conveniently under the control of the physician responsible for the case. To insure sue

Fu

-Case I.. Standing with Toes Raised.

however, all expectation of a speedy cure should be frankly abandoned at the outset, and preparation made for dilieent treatment be^un soon after birth and continued until growth is well advanced. Better results are reached by patiently relying on slow methods and natural growth than by resorting to forcible correction repeated whenever the deformity becomes offensive through neglect. There is, moreover, one source of disappointment which should be borne in mind, and that is the idea that wearing a brace is all that is necessary. A brace in itself is entirely inefficient. It must accomplish a constant definite purpose, which it can be made to do only by the presence and alertness of an intelligent mind. The most faithful and anxious parent requires frequent advice and supervision, not to mention the readjustments and alterations of apparatus repeatedly required with the lapse of time and changes in the foot. In the history of a case thus managed there will be intervals of considerable length, when treatment may be suspended, to be resumed with the first sign of returning deformity.