in his upper jaw, left side, beginning about the second bicuspid tooth. Dr. Y., of Louisville, removed an exostosis from the lower jaw, thinking this might be the cause of the pain. The part was so sensitive that the wind blowing on his mustache excited excruciating pain. Removed the infra-orbital nerve February 6, 1877. Immediate relief followed. The face became very painful and much swollen. Three days later the old pain returned for a short time. During this time he suffered pain in the wrists and knees, recurring every four hours. Pain both in the face, wrist, and knees, disappeared after the use of large doses of quinine. A year later severe pain returned, but in the inferior dental nerve. September 5, 1879, removed the inferior dental nerve. For a week or ten days had slight pain, but of a different character and associated with soreness from the operation. Had no pain to the time of his death from pneumonia, December 14, 1879.

CASE XII.-William K, aged 43; been suffering seven years; severed but failed to completely remove the inferior dental nerve in May, 1878. Remained well seven months. Operated again January, 1879, drilling the bone in two points. Was free from pain one year. January, 1880, pain returned, and a third operation was performed. Is well at the present time, May, 1880.

CASE XIII.-W. A. K., aged 32 years; pain in the superior maxillary, beginning six years ago. One morning while washing his face, he suddenly felt a severe pain under the right eye. Pain was so severe and the shock so sudden, that he came near falling. Lasted but a few moments, then disappeared. Second attack four months later. Attacks involving the branches of infra-orbital have been very frequent since that time and lasting usually about five minutes, the longest interval between the attacks being two months. In winter the attacks usually have been less severe than in summer. Operated May 24, 1880, cutting the infra-orbital nerve: the removal was not satisfactory, but the patient is entirely free from pain at present, May 26, 1880.

THE MECHANICAL TREATMENT OF SOME OF THE MORE COMMON ABNORMAL CONDITIONS OF THE FOOT.

BY CHARLES F. STILLMAN, M.D.,

NEW JERSEY.

EVERY surgeon in large practice has many cases brought to his notice of weak ankles, inverted feet, and the commoner forms of clubfoot, which are not sufficiently grave to need operative procedure, and for which our mechanical contrivances have hitherto been crude and insufficient, because not strictly physiological.

It will be my aim in this short paper to lay before you a plan of treatment differing in many points from any in use, avoiding all pathological and anatomical descriptious, except those which are necessary to the proper understanding of the mechanical treatment, as this department alone is embraced by our subject.

WEAK ANKLES.

The foot is made up of twelve bones, which in the normal condition are held closely and harmoniously together and may be considered, as far as the ankle is concerned, as one piece, since only one of its bones-the astragalus-comes in contact with the bones of the leg, this articulation constituting the anklejoint. This joint permits of two free and two limited movements of the foot, "extension and flexion, and inward and outward rotation." The foot is retained at its proper angle by a series of muscles, so exquisitely adjusted that a perfect balance of power exists between them; but let this balance be destroyed, and the harmony of the arrangement is lost and deformity occurs.

This loss of power in the muscles may be limited to one, or several, or may embrace them all. The greater number of cases, however, are those in which the anterior muscles of the leg are impaired, the predominant symptom being a dropping of the

foot-the anterior half more than the posterior-with diminution of power to keep the foot at a right angle, or to lift the toes while walking. When this is not complicated with changes in the structure of the foot, the latter may either invert or evert as chance may direct, but the tendency is to invert in the majority of cases.

The external and internal supports are also weakened, and the ankle gives way laterally, especially externally, on the smallest provocation.

The treatment of the uncomplicated condition is mechanical and physiological. The mechanical treatment consists in supplying, as far as possible, the muscular power of the anterior of the leg, treating the foot as a whole, giving, at the same time, lateral support.

It is then necessary to use a brace, which will allow all the motions of the ankle-joint, and yet be provided with constant elastic power of sufficient force to keep the foot at a right angle when at rest, and afford the extended muscles a chance to contract and revive under the influence of the physiological treat

ment.

Fig. 1.

I have devised for this purpose a brace which fulfils these conditions, and fulfils them perfectly, and supplies a want long felt in orthopaedic surgery, for an apparatus which can be worn with the patient's ordinary shoes, and yet be detachable at pleasure. (Fig. 1.)

It consists of a steel strip parallel with the leg and worn externally, so as to interfere less with locomotion, and be op posed to the side towards which flexion takes place; connected above with a leg girth and extended below at an angle to the back of the heel, where it is hingejointed with a horizontal strip whose anterior extremity is connected with the ver tical strip above the point of divergence by an elastic cord, which may be lengthened or shortened at will.

The horizontal strip is riveted to a strong strip passing under the instep, perforated in the centre to allow the insertion of an

oblong pin attached to a plate fastened into the arch of the shoe. This pin may be turned around after such insertion, and then forms both a firm attachment and a pivot, and is situated in the centre of motion of the foot.

The points for which I assume originality and excellence in this arrangement, are: 1st. Placing the hinge joint at the back of the heel, instead of over the ankle-joint as in every other form of apparatus, thus greatly increasing the leverage, and in connection with elastic power anteriorly, which may be augmented as desired, preventing the toes from dropping beyond a desired line, producing a constant elastic power vertically, which causes the foot to assume any desired angle with the leg. 2d. Making the brace and shoe distinct and connecting the brace with the shoe, only by a detachable pivot in the centre of motion of the foot, and to the leg by a girth allowing them to be removed at pleasure.

The pivot insertion below allows the foot to be everted or inverted at will, without in the least impairing the support of the ankle; and any apparatus like those now in use, which allows motion of the foot only upwards and downwards, does not fulfil the indications.

The phrase "centre of motion of the foot," deserves a little explanation. If you stand upon one foot, and raise the other from the floor sufficiently to

suspend it from the hip, rotating it slowly inwards and outwards, both heel and toe describe arcs of circles, of different diameters. Now, while the foot is rotated ontward, pass an imaginary line bisecting it longitudinally, and when inward, pass another imaginary line bisecting it, and the point of intersection of those two bisecting lines is the centre of motion of the foot (Fig. 2); a line passing through this

Fig. 2.

point and the hip-joint, being the line of direction of the leg, so that the centre of motion is the proper point to place a pivot,

if you wish lateral or rotary motion of a foot in the highest degree, with no opposition; and, therefore, the pivot of our brace is placed in that position.

INVERTED FEET.

This affection is an exceedingly common one among children who are usually designated as pigeon-toed, and causes an extremely awkward gait. It is due to a weakened condition of the peronei muscles, which possess the power of everting the foot, and may be either congenital or non congenital, the former being much the more common and difficult to treat. In its more advanced stages it constitutes the various types of talipes varus. In simple uncomplicated inverted feet, the deformity is

slight, the patient being able to wear an ordinary shoe, the

weight of the body keeping it in shape, but the toes point inward and downward, both at rest and in motion.

While the impaired muscles are being treated by electricity, friction, etc., to restore their tone, it becomes necessary for us to use a mechanical appliance to restore the balance of power, to