COLUMBIA LIBRARIES OFFSITE HeALTMSCieNCESSTANDAHD HX00058955 RECAP |iM;;'ii:i:lvi'>'': f^-^;;:SS.^;: Colombia ^ntto5itt|) Qlolbg^ of Pl|g0trtan0 ant ^txt^otiB JAdi^tmtt ffitbrarg Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/indispensableort01calo INDISPENSABLE ORTHOPAEDICS INDISPENSABLE ORTHOPAEDICS A HANDBOOK FOR PRACTITIONERS BY F. C A LOT CHIEF SURGEON TO THE HOPITAL ROTHSCHILD, HOPITAL CAZIN, HOPITAL DU DEPARTEMENT DE L'OISE, INSTITUT ORTHOPEDIQUE DE BERCK. ETC. TRANSLATED FROM THE SIXTH FRENCH EDITION BY A. H. ROBINSON, M. D., M.R.C.S. AND LOUIS NICOLE ILLUSTRATED VOL. I ST. LOUIS C. V. MOSBY COMPANY 1916 -^, T\")^l C Index of the Coloured Plates. PI. I. The dilTerent appearances of tuberculous pus and the indications to be drawn from them with regard to treat- ment and prognosis 1^3 PI. 11. — Cold abscess on the point of opening. How to save the skin? (See description below the illustration) i53 PI. III. — The same (see PI. 11). The skin is saved (see the des- cription below the illustration) 133 PI. IV. — Suppurated cervical adenitis (condition on arrival at Berck) 88i PI. Y. The same as PI. IV. — After our treatment. The sup- purated adenitis has been cured without a scar 88 1 PI. VI. _ Cervical adenitis. Unsightly effects produced by operation ""^ PI. VII. — Cervical adenitis (The evil effects oi abstention) . . 88i PI, VIII. — Cervical adenitis (Even when a fistula exists, do not operate) 889 ABini)(ii:i) T\BLE OF GOMFNTS (For I In' detailed index, a real recapitulation of the work and for the alphahelical index, see pagea i()G7 lo 1109.) Pkekvce. — J lir lli'valoi^iio, or tlio six conimanflmcuts of orthopir'dics. THREE PRELIMINARY CHAPTERS ON GENERAL TECHNIQUE ^"^''- T. Tethiiique of the apparatus (plaster ami celliilolilj. . . () — II. A word upon anaesthesia in orthopmdics io8 III. Technique of puncture and injection in tuherculosis a) with suppuration, b) dry, c) hslulous ii5 SPECIAL TECHNIQUE. i*^' Part : — Acquired tuberculous orthopoedic affections. Chai'. n . Indispensable notions on the prognosis and treatment of external tuberculoses igi — V, Pott's disease 23q — VI. Hip joint disease 353 — \II. White swellings . . l^SQ a^-i Part : — Acquired non-tuberculous affections. Givp. YIII. Scoliosis of adolescents 56-r IX. Round back and lordosis. 6o3 X. Rickets. Rickety deviations. G08 XI. Genu valgum or varum of the adolescent. Coxa vara. . (1:40 XII. Tarsalgia or painful flat-foot 0:^5 XIII. Infantile paralysis and its deviations GGo 3nd p^j(T . — Congenital orthopoedic affections Chap. XH . Congenital luxation of the hip-joint -n — X^ . Congenital club-foot 82a — XA'I. Torticollis g-jg — XVII. Little's disease 863 4'^ Part": — or Appendix. CiiAP. XVIII. Cervical adenitis 881 — XIX. Other external tuberculoses (cold abcess, osteitis, synovitis, spina ventosa, tuberculosis of the testis and epididymis, tuberculosis of the skin) " ^q^ — XX. ^lultiple tuberculosis 034 — XXI. Syphilis of the bones and articulations g'n — XXII. Treatment of acute and chronic osteomyelitis qoa — XXIII. Practical diagnosis of osteitis or of chronic arthritis . . 961) — XXn . Some malformations of the hand and fingers 97^ — XXV. Some malformations of the foot and toes g8i — XXM. Additional notes on tuberculosis, fistuhe, fractures of the neck of the femur, coxa vara, etc 992 Calot. — Indispensable orthopedics. i PREFACE TO THE 6" EDITION In less than 4 years this hook has reached the 6"' edition and has been translated into 5 languages. Is it not a proof that it has already helped French and foreign practitioners and that it may still further help them? We have doneour best to make it do so. This 6"' edition, carefully revised, has been enlarged by 100 pages and 100 figures on exter- nal tuberculosis, fistulas, the preparation ^ of the liquids and pastes to be injected, fractures of the neck of the femur, coxa vara, etc. Besides, over one hundred of the original illustrations have been replaced by as many new ones, clearer and more explanatory. All our care has also been brought to bear on the material execution of this work which — thanks to the combined efforts of our pvibli- sher, our printer, and our very able illustrator D' Fouchou-Lapcy- rade — has been brought up, we think, to the highest possible degree of perfection that can be attained at the present time. We hope that being so much improved, this 6"' edition will deserve, more even than the preceding ones, the favourable reception given to our book bv practitioners all over the world. PREFACE TO THE 5*'' EDITION This 5"' edition contains nearly ooo pages and ooo figures more than the 4"'> without counting 8 photos in colour. The principal additions bear on the technique of the ajDparatus and punctures, which we have been careful to explain in a clear and detailed manner — not afraid of being too long or of dwelling on too small details. For, having seen at work, during our holiday courses, several hundreds of doctors and students, we are convinced that the double technique (of apparatus and punctures) which was thought to be generally known, is very badly understood and still Avorse applied — with a few rare exceptions. And for any one who does not begin by learning thoroughly the methods of making the plaster and of practising injection it is utterly impossible to treat successfully any of the diseases described in this book. I. According to the metliod of our assistant D>" Fouchet, of Berck. PUb^FACE TO THE 4'' EDITION Tlic o"' edition of this work has received from the medical public Ihc same measure ol' success as the lirsl two. So kind a reception is, for the author, not only a highly valued reward but also a definite encouragement to persevere in the method he has choosen in explaining the orthopedic techniques which are the subject of this book. PREFACE TO THE 3"^ EDITION Let us point out among the additions, the chapter on the pro- gnosis and treatment of external tuberculosis in general, and on the mentality which all doctors entrusted with these treatments ought to have. The object pursued now and always by the author, in his altera- tions and additions as in his first work, is to provide for his colleagues a guide sure and easy to follow and necessary to enable them to institute and successfully complete the treatment of external tuber- culosis and of orthopcedic affections. PREFACE TO THE 2"' EDITION This 2"'' edition, following so rapidly on the former, cannot show anv noticeable clian2:es. Nevertheless everv page of the text has been carefully I'evised and a few even entirely altered, so as to I'ender even clearer the expla- nations of certain especially delicate techniques. The illustrations have been enriched by 3o new ones, Avhile about 3o of the old have been replaced by others more explanatorv. This shows that the author has neglected nothin"- to render the book still more Avorthy of the favourable reception it received from the whole medical press and from practitioners. ALL PRACTITIOERS CAN TREAT PREFACE TO THE FIRST EDITION Nearly every day practitioners are consulted for hip disease, Pott's disease, white s^velling, congenital luxation of the hip, scoliosis, rickety manifestations, in a -word, for a deviation, congenital or acquired. But they know too little about the treatment to dare to institute it or to be able to apply it successfully. How is it that doctors who so often treat fractures and traumatic luxations do not dare, or are unable to treat orthopedic affections which are not, as a rule, more difficult to correct and to maintain? It is because they have not learnt to do it. True, fifteen or twenty years ago, or even only ten vears ago, there Avas no possibility of learning it, for the treatment of most of these affections was then too uncertain, too complex or even absolutely non-existent. Congenital luxation of the hip, for instance, was still the one incurable disease, the disgrace of surgery. Hip or Pott's diseases Avith suppuration ended in death. These three diseases, hopeless yesterday, Ave can noAV cure Avith certainty. And for all deviations the treat- ment has been so much improved that Ave can affirm Avithout much exaggeration that these affections, most difficult to treat barely 12 or 15 years ago, yield to day the most certain and lasting cures. Not only can Ave cure them, but we know how to cure them by simple, harmless and easily applied methods. Their treatment no longer implies great surgical operations nor expensive or complicated mechanical means. In cases of hip or Pott's disease Avith suppuration, punctures only are required, Avhich punctures are certainly easier to perform than those frequently used in ti'eating pleurisy. Incases of congenital luxations and other deviations, the correc- tion is obtained bv simple orthopaedic manipulations and is main- tained up to complete cure by the aid of a Avell made « plaster » . Is it not the Avay we already act in cases of fractures or traumatic luxations ? Thus the treatment of orthopoedic affections has become acces- sible to all practitioners. A beneficient revolution which carries Avith it the most practical results; for 3/4 of the patients, unable to visit the specialists of the large centres, remained until noAv Avholly unat- tended. ()i\iiioi'()ii)i(; AFir:cTiONS at their onset ;> 1)111 Kl llicio he no mlsuiidcrslandlng. ^\ lien I say \oucan treat and line lliose diseases, this is absolutely true only during the first period. I.alcr on>\liat ^ou can do is limited and, in nianv cases, \on are powerless. I should never advise \ou to interl'ere ■with a congenital luxation 1 5 vears old, or w ilh hip disease or a gibhoslty several years old. The treatment is then very difficult, indeed almost liopelesS;, and must alwavs be the work of a specialist. No. What I require from practitioners is to begin treating these diseases from their commencement, because at this period the evil is easy to cure. In fact, is it not \ou, the family doctor, who sees his patients at the onset? Learn then how to utilise this priceless advantage; learn how to take advantage of this period in which the cure is relatively easy, which lasts not merely for a few days, but several months, and even, in the case of certain of these affections, for several years. But, above all, do not take advantage of their long duration to temporize. ^^ by should you wait? A\hen you are in the presence of a traumatic luxation or of a fracture do vou not act at once? If only the practitioners aaIio see these diseases at their onset would do their duty ! But how arc they to know what this duty is?... To give you that knowledge is the purpose of this book. ^^ e have endeavoured to be clear and concise without hoAvever omitting any necessary or useful details. On every page figures illustrate the various periods of the treatment in such a way that any one of you will be able to use any of the approved methods, any where, even without a special installation or a trained assistant. I hope that, thanks to this guide, all doctors so desirous will hence- forth dare to institute and successfully complete the treatment of orthopoedic affections. If it is so, the lime and the m ork spent on this book will not have been w asted ' . I. I wish to thank here my assistant for the last eight rears D'' Fouchou- Lapevrade, whose talent for drawing and deep knowledge of the suhject enables me to illustrate it so cleverlv. DIVISIONS AND PLAN OF THE BOOK Three preliminary chapters : A. Technique of the apparatus. — B. Anaesthesia. — C. Technique of punctures and injections in external tuberculosis. Part I : Acquired orthopcedic affections, of tuberculous origin. — Pott's disease. — Hip disease. — White swelling. Part II : Acquired orthopcedic affections, non tuberculous. — Scoliosis, round Lack, lordosis. — Rickety deviations. — Genu valgum. — Tarsalgia. — Infantile paralysis. Part III : Congenital orthopcedic affections . — Congenital luxation of the hip. — Club foot. — Torticollis. — Little's disease. Part I\ or appendix : Cervical adenitis. — Other external tuberculoses (cold abcesses, osteitis, synovitis, spina ventosa. Tuber- culosis of the testicle). — Multiple tuberculosis. — Syphilis of the skeleton. — Osteomyelitis. — Diagnosis of osteitis or of chronic arthritis . Additional notes : i° On tuberculoses : a) Is it advisable to ope- rate upon them!' b) how to prepare the liquids and pastes to be injected, c) treatment of fistulae. 2° On the treatment of fractures : a) of the patella, h) of the olecranon- c) of the neck of the femur. 3° On coxa vara and its treatment. TlIK IIEXALOGUE OR THE SIX COMMANDMENTS OF ORTIIOPCHilDICS 1. Early diagnosis. 2. /mmef//a/e treatment. 3. Perseverance in treat men t. 4. The preparation of well-jUling plasters. 5. In the correction of tabercahiis deformities, to reduce traumatism to a minimum. 6. To guard against operating upon the tuberculoses; never to open cold abcesses but to puncture and inject them. I Early diagnosis. — Whenever a child is presented to you with a loss of poAver or a pain seated in an}' part of the skeleton, you should never neglect to inspect and examine the child completely nude (palpate, apply pressure, ascertain the extent of the movements). II Immediate treatment. — The diagnosis being made, do not temporize; commence the treatment without delay, for the malady does not wait. Immediate treatment is synonymous (nearly ahvays) with easy treatment and perfect cure. Ill Perseverance in treatment. — Continue the treatment without intermission to the end; the end may be protracted, it may be one or even several years. Warn the parents of this and impress upon them that, just as in your own case, a strong dose of patience is necessary for them. IV To make plasters which fit well. — You should know hoAA" to adapt a plaster Avhich Avill give a good support Avithout being uncomfortable. This is as indispensable a matter in orthopcedics as asepsis is in surgery. It is as easy to make a good plaster as it is a bad one, just as it is as easy for the practitioner to be aseptic as septic. Avoid every useless traumatism. — In the correction of tuberculous deformities, one should proceed gently and rather by set stages. It is more necessary here than in other defor- mities, in order to prevent all danger of generalized tuber- culosis. VI To guard against operating on the tuberculoses. — Never open a focus nor leave it to open. — If the tuber- culous focus has suppurated. — if an abcess has formed, a gland has broken down, an osteo-arthritis suppurated — punc- ture and inject. If the focus has not suppurated, and is easily accessible (this is true for all external tuberculoses except Pott's disease), make, in the focus of these torpid lesions, modifying injections, to produce or to hasten the hardening or softening, after which you puncture as in the first case. Remember that, in tuberculosis, operation rarely cures, it often aggravates and always mutilates; whilst punc- tures and injections are a sure treatment, harmless and practical. THREE PRELlMlNArvY CHAPTERS ON GENERAL TECHNIQUE I" In orthopcedics', those will have ihc best results a\ ho know how lo make the best apparatus. 2" In the external tuberculoses, those will have the best results A\ho know best how to make punctures and injections. AMience the necessity of commencing by a careful study oi the two techniques : of apparatus and of punctures. And as a large number of deformities cannot be corrected without chloroform, we shall study in the third preliminary chapter, this very briefly, the practice of anaesthetics. CHAPTER FIRST THE APPARATUS Every doctor should know how to make a plaster appa- ratus. It is as necessary — and even more often necessary — than to know how to arrest a hemorrhage. Without an apparatus it is impossible to treat a fracture, an arthritis, certain luxations or certain grave traumatisms, etc., etc. This applies to all general practitioners. But what shall we say as to apparatus, for those specially interested in orthopedics? Without apparatus one can do nothing, or next to nothing. AVithout apparatus one can neither prevent nor arrest nor correct a deformity. You can judge of the skill of the orthopedic surgeon by the I . And one may add : in fractures and most ajjcclions of the skeleton. lO APPARATUS >fECESSARY FOR ALL PRACTITIOERS apparatus he makes use of. " Show me your apparatus and I Avill tell you Avhat you are. I THE PLASTER APPARATUS Plaster apparatus are the best, and one may add that plaster suffices for everything and nothing can replace it. Fig. I. — ^yp^ of* plaster apparatus : this is the apparatus one applies for tibio- tarsal arthritis, and for (vaclures of the leg. Plaster is an object of prime necessity, and practitioners should never set out on their daily rounds without having a PLASTI'U AI'I'AIUTl S supply of a few kilos. (It is jusl as imporlanl as an artery forcej)s, a knife, a needle, sutures, a bottle of chloroform, a m itl w ifery forceps . . . ) By itself, plaster alloAvs of the securing different parts of the body hi ^vhatever position desired. For we arc able to maintain that position for (he few minutes required for the setting of the plaster, but Ave cannot do this for the long hours ^vhich are required to dry any other substance than plaster : silicate of potash for instance. Plaster, because it adapts itself as Ave Avish it over any part of the body Avill give us results very superior to all the splints in metal or in Avood, including the Bonnet splint or the appa- ratus of Scultet, AAhich is, besides, much more difficult to fashion than a good plaster. In a Avord, Avith plaster, every one of you can manage to make on the spot, alone, Avithout the aid of any mechanician or Avorking orthopedist, the best apparatus Avhich can be (for fractures or injuries, or orthopedic affections). And I can promise you that you Avill be able to make plas- ters perfect, homogeneous, firm, accurate, comfortable and neat, if you will folloAv very faithfully the directions Avhich I am going to giA'e in this chapter. In the first part of the chapter (Avhich you should read each time you make a plaster), Ave have put together all the indispensable notions. In the second part (Avhich you should read AA'henever you have the leisure), you Avill hnd all the com- plementary details Avhich you can desire of the technique of plaster apparatus. INDISPENSABLE NOTIONS ON THE PREPARATION OF A PLASTER SUMMARY One should prefer, even for the treatment of fracture, circular plas, ters which fit hetter, are more agreeahle to the patient and easier to make than splints. In order to watch over the affected parts, in a circular apparatus, it is sufficient to make an opening over those points, or to convert the plaster into a hivalve. To ensure the good nutrition of the memher under treatment, it is sufficient to be assured of the good nutrition of the extremities of the toes or of the fingers, which should always be left exposed beyond the apparatus. A plaster is prepared with muslin strips impregnated with plaster paste and applied entirely round the region of the body, covered with a casing of soft tissue. One must therefore procure : first a closely fitting casing, secondly some muslin, tlrirdly some plaster. The casing is of cotton : jersey, sock, stocking or sleeve of a jersey — according to the region. This lining is always thinner and more even than cotton wool. It is only in default of such a casing that one ■would use Cotton wool, taking great care to apply it in a layer as even and as thin as possible (of a thickness of not more than i or 2 mm). The plaster bandages are strips of muslin about 5 metres long and 1 5 cm. wide, which have been impregnated with plaster : a) Either they are steeped at the time in plaster paste made with 5 parts of plaster and 3 parts of water, cold, without salt. b) Or sprinkled a little before-hand (one or few hours before) with dry plaster in the proportion of 60 grammes of plaster for each metre of bandage; these strips are then soaked in cold water a few minutes before being used. To prepare a firm apparatus it is Avell to insert a support of « attelles », or strengthening pieces, between the layers of the bandage. These attelles are simply pieces of muslin cut beforehand and soaked for a minute or two, before being used, in the same cream as the strips. IMH^^PENSMUi: N..nnNS ..> TllK I'KKl'A U U K .N ..^ PI.ASI KK I :^ TlK... « alU.llos . .llHT,. an. tun nf II.mu) have a length cciual I., that of the apparatus, a hnsultl, 0,,...! 1. l.aU U.e greatest crcumfcrencc of the apparatu an.l a thickness of one. two or even three sheet o mushn. accor- d n^ as the plaster is a small or a large one, and as U .s or a ehjld or an aJu 1. It it is a pla.l,..- fnr the arm, .hich ought to inchule the shoulder g.rdle, or a plaster lor the lower extremity which shoul.l include the pdvis, a ,Ulnl attelle is introduced in the form of a belt, overlappu.g th. u,.,,-,- mar-in of Ihc two others. The technique of the apparatus. Suppose YOU have to make a plaster for- the leg _ The leg, beeng covered with a easing, is placed xn position an assistant hokUr^ it and raising it by the foot. You apply the first plaster stnp, be nnh- at the toes and the foot, in circular turns overlappmg one third, withou making reverses, .vhich are unnecessary. Take care to apply tbe t ip: «) exactly; 6, without pressure; a flattening .t well so as not Tleave creases. You ascend as far as the upper extremity of the apparatus, where you cut short Ihe strip if it is not used up. „ , , OvJr this first la er of turns of strips, attelles well smoothed down applied, one in fro^t, another, behind. And, over the attelles you apply fuither turns of strips, making thus a third or fourth covering, according as the case is a child or an adult. Between the dilferent lavers of the apparatus and over the la.t one some plaster paste, one to two centimetres in thickness, is applied. And that is all. Then verify and rectifv, if necessary, the position of the limb ; model the plaster over the osseous\,romlnences of the part ^y ,^''^!^'^^' ^'^l^'^. diatly upon, but aroand those prominences; maintain it thus until the complete setlimj of the plaster. A cniarler of an hour later, trim the plaster, strengthen it if need he. Be ore leaving the house, always make sure of the good nutrition of the toe' which will bo a guarantee of the good nutrition ot the entue limb. We will take for a tvpe of our description the construction of a plaster for the leg beg- inning- from the toes and reaching as far as the lower third of the thigh. It is the apparatus which should be used for fractures oi the lee- and for arlhrilis of the inslep. It%hould reach as far as above the knee-joint because, to immobilize well a portion of a limb, it is necessary always to immobilize at the same time as the segment, at least ttic two adjacent arlicnlalions. 1 4 WHAT IS NECESSARY IN ORDER TO CONSTRUCT A PLASTER We ^\l\\ noAv give, a propos of this apparatus, all that part of the technique which is common lo all plaster apparatus, whatever they may be. As to the peculiarities of each region, you will find them indicated in the chapters devoted to the different diseases (for the plaster corset, see the chapter on Pott's disease, and for the large plaster for the lower limb, the chapter on hip disease). A. — WHAT IT IS NECESSARY TO OBTAIN Three things : a) a casing of soft tissue; b) some plaster; c) some muslin. a. The protecting case'. — "^ ou may find this everyAvhere; it should be simply a large stocking reaching up to the lower Fig. 2. — The casing of soft lissae (jersey or " tube '") which protects the skin against direct contact with tlie plaster. third of the thigh, or heller two sleeves of a jersey applied end to end, or even a " lube " of soft tissue. I. ^luch iirefcrable lo cotton aaooI, as "\ve ^^ ill show, p. 62. 1° A cAsiNc. :>" <(t\\\: i'i.ASTi;n, .')" somi; mi -i.i\ i5 If llie tissue of the « tube » or casing is very thin you cniplov two, ihe one over the other. If the lube be too large, make it lit at once by means of sewing. ])) The Piaster. — This is A\hite plaster of Paiis, fine and homogeneous, soft to the touch as starch powder. Preserve it from moisture, and even from the air, in a glass jar, or in a tin box, hermetically closed; because the plaster deteriorates, that is to say, it becomes moist in time, if kept in a bag. even in a place which does not appear to be damp. If you take two samples of good plaster obtained from dif- ferent sources, they may not both set in the same time ; this depends upon their degree of baking. The moment of setting may vary very markedly in the one sample and the other ; and it is to prevent disappointment that I advise you always to test the sample of plaster you are using, belore pieparins' vour apparatus. In order to do this, place in a bowl five spoonsful of j)laster to three of Avater (these are the ordinary proportions), mix them AA"ell together and note hoAV long this (f plaster cream » lakes to set. If you cannot obtain the white plaster of Paris, you may use the grey (as used by plasterers), coarser, often as gritty as fine sand. To ensure the best chance of its being perfectly dry, take it from the middle of the sack and sift it, if it is not homogeneous. This common plaster should be made of a thicker consistence than the Avhite plaster; you must put a third more plaster to the same cpiantity of Avater — remembering that it requires a third more time to set than the Avhite plaster of Paris. You can make good apparatus Avith this common plaster, though less pleasing, provided it has not deteriorated. 1 6 TECHXIQUE OF PLASTER APPARATUS. Finally, suppose in a case of extreme urgency, you have only at hand plaster Avhich is a little deteriorated, that is to say hydrated (white or grey plaster) ; you could dehydrate it and give it back its virtue by baking it for ten or fifteen minutes, in an ordinary oven and in an open receptacle S until no more water vapour is disengaged. The quantity of plaster required. — Take rather too much; say 2 kilos for a child of ten or tAvelve years of age, and three for an adult (for a leg apparatus). c. Muslin. — ■ Ask at the stores for stiff muslin number y or 8, that is, with 7 or 8 threads to the square centimetre (v. fig._ 3). This N° 8 will not be too close nor too loose ; that is the Fig, 3. — The stiff muslin N° 8 used in making the strips and the attelles. (8 threads per centimetre.) kind of muslin used by dressmakers for making the patterns for dresses. I. Wliere can we procure good plaster? Tliis practical information we are often asked for by practitioners. Well, you may obtain the white plaster of Paris at pharmacists, and at some moulders; I dare not say at all, because some use in place of plaster, alabaster, which does not fulfil exactly the condi- tions required. riir. MISI.IN IS CLT INTO STRIPS AND " ATTELKES 17 Procure more llian \ou rcall\ want. Take 7 or 8 metres of the orJinar\ widlli. which is Go or 70 cm.; five metres will be sulficient ibr a child ol" 10 or I a years. Failing stilT muslin, should the case be urgent, you will find plenty oi' old curtains, cast off sheets, from which you can cut off strips of 12 cm. in width, and you can join them together end to end, w ith fme stitchint*- so as nut to lea\e any ridges. Lastly, you should have two or three basins, some cold water without salt, scissors, and a knife. And ask also for one or two large sheets, A\hich you can arrange so as to prevent the spotting and soiling of the carpet, the bed. or the floor, w ith plaster. B. — ASSISTANTS You should have two assistants (one will be sufficient at a push), to make the apparatus for the leg. The assistants may not be medical men, but simply two mem- bers of the family; you should make them understand hoAV to follow well your instructions and assist your movements. With these assistants, you should commence by cutting vour strips and attelles out of the large piece of muslin. C. — PREPARATION OF THE STRIPS AND ATTELLES a. The strips. You separate, by tearing with Nour fingers, a strip of muslin having the folloAving dimensions : Breadth : 12 to 10 centimetres. Length : 5 metres. These are the ordinary dimensions of the plastered strips. Then vou take a second and a third strip from the loll of muslin. Cai.ot. — Indispensable oiihopedics. a lO TECHNIQUE OF PLASTER APPARATUS The number of the strips naturally varies with the build of 'the subject; for a child under 7 or 8 years, one strip may be sufficient; for a child from 8 to i4 years, two strips; for an adult, three strips (always for a leg apparatus). h. The attelles. — These are not indispensable, the appa- ratus could be made Avith strips alone but it is belter to incor- porate attelles or strengthening pieces between the layers of the strips. With these " attelles " the apparatus are firmer, more easily constructed, more quickly made, more compact, more homogeneous, than those made with strips alone, especially if one employs slrips which have been sprinkled with plaster beforehand. The attelles are cut from the remains of the piece of muslin (after having taken the strips from it). The number of attelles : tAvo for each leg apparatus. The Dimensions : the same for the two attelles, namely : Length, equal to that which the apparatus should have (measuring from the upper extremity, above the knee, to the heel, and adding the length of the sole of the foot). Breadth, equal to half the greatest circumference of the region to be covered (that is to say, here, half the circumference of the calf). Thickness, that of two sheets of muslin. It is unnecessary to sew the two sheets together; folded one on the other and flattened with the hand, they will remain in contact. Here then, are your slrips and atlelles cut out of the piece of muslin. But you will not plaster them until you have pre- pared the affected limb and placed it in position. D. — PREPARATION OF THE PATIENT The patient remains in bed, or better, is carried on to a table. I'UEI'AUATIO.N Ol' THE PATIENT i The lANO legs are brought over the edge of the table. The sound leg need not be held, the sound foot rests on a chair. The Toilet of the Skin. The skin is washed with a tampon damped Avith alcohol or ether, and is lightly sprinkled with sterilized talc. If there is a wound, one covers it ^ith a square of aseptic gauze, taking note of the place, (o make there an opening in the plaster a few minutes after its construction — in view of the dressing required afterwards. a. Placing in Position. Two cases : Either the limb is already in good position or, it may be placed so at once (arthritis without deformity, fractures without displacement, or where reduction is verv easv). Or else, the limb is in bad position and its correction requires some time, and often even the use of chloroform (frac- tures or recalcitrant orthopedic deformities). As for the movements required for correction, this is not ihe place to describe them, they will be indicated a propos of each deformity. AA hen this correction has been made, it Avill be maintained by an assistant at the bottom of the table, Avho will seize the foot and pull it more or less, as the case requires. If a very steady, strong traction is needed a second assistant may make counter extension by holding the thigh or the knee with both hands and pulhng towards the upper part of the thigh. Manner of holding the foot. — The right hand of the assistant grasps the fore part of the foot firmly, the palm of the hand being applied to the sole, and the fingers on the dorsal aspect. The left hand seizes the heel and the instep, the palm embracing the projecting heel, the fingers on the lateral aspect. Position of the foot. — i'\ It should be held at 90" of flexion upon the leg. or even at a slightly acute angle, of 80" •20 TECHNIQUE OF PLASTER APPARATUS for instance; 2"''. The middle of the second toe must be in a line with the crest of the tibia. — Sometimes in order to obtain a hyper-correction the foot is carried a httle to the inner side, or a httle to the outer, in an inverse direction to the defor- mity it is desired to overcome; 3"'. The heel should be made to present its normal projection behind (compare it with the sound side). b. Enclosing the limb with a casing of soft tissue. Fig. ^i. — One passes the fourreau or " tube " as one puts on anew stocking, folding it back. Whilst an assistant hokls the Toot by tlie heel, one commences by cover- ina, the forefoot with this folded " tube ". To prevent any discomfort to the patient while ihe fourreau is passed on the foot, the assistant holds the heel with one or both hands, and pulls toAvards him while the fourreau is passed over the toes, gathered up and folded (v. fig. /|); then the fourreau having passed as far as the base of the toes, the assis- tant leaves the heel and takes hold of the toes and instep Avith both hands, while the fourreau is passed over the heel anp now Id PI r ()\ I in: casing of soft tissik 21 k Fig. 5. — The tube OQce passed over the foot, the assistant leaves the heel and seizes the forefoot, then, again, the heel. The fourreau is unfolded to ensheath succes- sively the leg, the knee and the lower part of the thigh. Fig. C. — Placing the patient in position. 22 TECimiQUE OF PLASTER APPARATUS on to the leg (v. fig. 5). The fourreau being in place, the assistant takes hold again of the heel and instep. The upper border of the fourreau is held by a second assis- tant, or by the patient himself, seated. If instead of a tube, a stocking is used, its lo^Yer end should be split to allow of inspection of the naked toes. E. — THE PLASTERING OF THE MUSLIN STRIPS AND " ATTELLES " This is done by simply steeping the strips and attelles in the Plaster cream ^ Fig. rj — Method of preparing the best plastered strips The strip of stiff muslin is rolled in the plaster cream (three cups of water to five of plaster). a. Composition of the Plaster cream. Plaster is mixed with water in the following proportions : five cups of plaster to three of cold water, without salt; there- fore, no hot water nor salt, with which the plaster sets too quickly; with those also the apparatus is too brittle and friable. I. Cover your liand with vaseline before doing this. rLASTEUlNG THE STUU'S AM) ATTKLLES a3 The quantity of the cream lo be |)repareJ (for aa appa- ralus for llic leg) is one cup and a half of Avaler lo two and a half cups of plaster for a child; three cups of water and five cups of plaster for an adult. J'liis (|uanlll\ suffices ampl\ lor an ordinary apparatus for the leg. If, by any chance, you run short of ihc plaster cream in the course of constructing the apparatus, you mav prepare more at once in another basin, or, if you like, in the same one, but after having thoroughly washed it, for the new cream musi not be mixed Avith the debris remaining from the preceding mixture ' . How ought one to proceed to prepare the Plaster cream ? Into a hand basin, first pour all the water required, then all the plaster needed. Stir up at once, rapidly and thoroughly, so as to make a homogeneous cream, without leaving any grit. This mixing of the plaster requires hardly i5 to 20 seconds. b. Impregnation of the strips (v. fig. -). Immediately the cream is ready you steep the unrolled strip or strips of muslin in it. which allows of their being-impregnated " uniformly " and quickly Avith plaster. The first strip being impregnated, you quickly roll it up. and the others Avill be rolled up in the same way by" your assis- tants Avho have seen how to do it. Aon tighten each turn as you Avould in rolling a bandage of ordinary linen, or of linen I. Mix ttie two pastes.'' never I nor will you ever add water lo a cream which is too thick, and has been mixed several minutes; this would "drown " and " kill " the plaster, one would only have " dead " plaster ^to use the technical term). One would •' turn " the cream. To add plaster to a cream too thin is not so bad as to add aa aler to a cream which is too thick, nevertheless it is undesirable and should be avoided. ^\ hen you find, after a few minutes, that you have not sufficient cream, you will make a neAV supply, in a perfectly clean basin. In the same way, if it ever happens after a few minutes, tliat you find your cream is too thin, or too thick, throw it away, wash out the basin and make a new supply, which should be more or less charged with plaster as may be requi- red. 24 TECIOIQUE OF PLASTER APPARATUS soaked in silicate of potash, Avhich nearly all of you have lear- ned to do. In a word, do not tighten too much, nor too little; and the strips Avill thus retain just the quantity of plaster you Avisli, and you Avill be able to apply them one after the other Avilhout having to squeeze them, or at any rate very little. Fig 8. — In the basin on llie right, a bandage has been rolled in the crem, in that on the left, the plaster intended for the preparation of attelles is being stirred. The rolled strips are left in the basin while you go on plas- tering the attelles (Fig. 8). c. Impregnation of the Attelles (v. fig. 9). In a second basin, in Avhich you have prepared a fresh supply of cream, or have poured the excess of that prepared for the strips, but which you have not used, you soak the attelles, one by one, folding and thoroughly impregnating them. The impregnation of the attelles requires scarcely a few seconds (say, 1 5 to 20 seconds). As soon as the strips and attelles are impregnated, they should be applied. But, before indicating the method of making this application, we ought to explain a second method of prepa- IM.VSTKUIMi sriUP^ I'UEI'AIIEI) UKl'dlU- II.VM) 20 ring ihc plaster strips \vliich is found recommended everywhere : lh(> sprinklinjir of llic strips -with dr\ |)lasler, beforehand. Plaster strips, prepared beforehand. This procedure consists in iin[jrciinalin'j beforehand the muslin strips ivUli ilrv phtghT. placing tliem artcr\\ar(ls in reserve, several davs or several ^\eeks. 9. — Method of soaking the attelles in the cream : they should be impregnate 1 a little at a time, piece by piece, and not all at once and en masse. until they are wanted : it is llien sufficient to dip them in Abater a feu- minutes before applying them. les, but remember it is difficult enough for those not accustomed to it, to prepare in this way bandages having the desired charge cf plaster. Now, if too much plastered, they will not allow of being well " soaked and will retain in places gritty particles of hard plaster; when there is not sufficient plaster, the apparatus will be soft and friable, like a •' giileau feuil- lete ". More than that, the plastered strips prepared more or less a long lime beforehand, run the risk of decomposing, that is to say, of deteriorating and becoming h>drated. And this is the reason \a hy I advise you, in a general way, to prepare your strips in the manner first described (in the cream) «hich is moreover the simplest and surest method of obtaining homogeneous and firm appa- ratus. 26 TECHMQUE OF PLASTER APPARATUS Xohvithstanding, I do not absolutely prohibit vour having recourse to the second method; there is one case even where it would be better to use it. This case is when, having need of a large number of strips in order to make a large apparatus for Pott's disease or Coxitis, you have not at your side three or four capable assistants, who after having seen you plaster the first bandage Fisf. lo. — To prepare plastered strips Leioreliand, one sprinkles 60 to 70 grammes of plaster in powder over each metre of muslin ( i5 cm wide); one rolls the strip with the right hand whilst the left hand spreads the plaster in the cream, planter all the others, whilst you yourself apply the first strip (and all the following ones). If vou are alone in making such large plasters or, if you have only one assistant, vou run the risk of being much retarded by this preliminary prepa- ration of all the plastered strips required, and of finding, after having plas- tered the last, that the first one in the basin is already hard and unusable. So that, in this particular case, I recommend you to use bandages already powdered. To produce good ones, you will take tlie following two precautions; rrvsTEHEn srnii'S I'nEi'Anri) hefoui-ham). :>.' 1" The strips will be plaslcreil (o liie proper degree — noillier loo much nor loo lillle — by incorporating 60 to 70 grammes of plaster lo each metre of' muslin (i5 cm in widlli) : altogether, 3oo grammes oi' plaster lo the entire bandage of five metres. Thus, you will divide your pile of 3oo grammes into five small iicajjs and use one of the small heaps witii each metre of slrip. The sprinkling of the strip is very easy : you do just as in preparing a whillug (or frviiig. l-^lo II. — The sprinkled btrip is dipped into a basin of water; some bubbles of gas are at once disengaged : and when no more gas comes off, it is ready for use ; take it out, press it, and apply it. 2. So as not leave the strips to decompose, preserve them in a tightly closed receptacle until you use Ihem, or better still, do not sprinkk' tiiem until a Utile while (1/4 to 1/2 an hoan before you prepare your a^jparatus. When you wish to construct the apparatus, dip two of these strips into a basin of water, so that each of Ihem is entirely immersed (v. fig. ii); leave them soaking until you no longer see bubbles of air on the surface of Ihe water (about a or 3 minutcsj : at that moment, take the first strip, squeeze it thorouglilv and wring it, holding it by the two ends (v. fig. 12) and set about applving it. As tliestrips should not be left toolongin the water, because they nouldhar- den and become useless, care must be taken thai, Adhere a large number of strips are being used, — as is obviously the case in making a plasler corset for an adult, — they arc not all put in the water to soak at the same time, but dip- 28 TECIOIQUE OF PLASTER APPARATUS ped in successively, at intervals as nearly as possible equal to the time taken in applying one strip to the patient. Then, the first strip having been applied, and before removing the second from the basin, you place a third to soak; befcjre applying the third you dip a fourth, arid so on. As to the plastering of the attelles (^vhen the strips have been prepared Fis;. 13. — • Tlie best method of hokling and squeezing the wet plastered strip. by the second method of previously sprinkling) is should always be done in the aboved described manner, soaking the attelles in the cream. F. APPLICATION OF THE PLASTERED STRIPS AND ATTELLES Immediately they have been plastered, as we have said, the strips and attelles should be applied without any delay, for the cream prepared in the proportions indicated above (5 parts of plaster to 3 of water) begins to " set " in about ten minutes. Tin: WAV Ol \ll'I.MN(i THE I'LASTEUED STKII'S ^D The strips and allcllcs must be applied in less than ten minutes in oidcr llial there remains, at the very least, two or ihrce minutes before the setting of the plaster, to correct the posi- tion of the limb and to elTect any '* modelling "'. But let me assure you that you Avill ahvavs find it easy, in llie case of a leg apparatus, to be in time. ^ou Avill have to allo\\ pretty nearly for each First strip : begin at the extremitv of the foot, at Apply without tightening ; spread out the strij le base of llie toes. stage : a) for applying the strips : one to two and a half minutes at the most; b) for applying the attelles, about as much. Altogether, five or six minutes at the most : there are then fully five minutes more ^^vhich is more than you need) to correct the position and effect the modelling'. I. But if it is very easy to finish in good time in preparing a leg appara- tus, it is much less easy to do so in preparing a large apparatus, lor Pott's disease, or even for coxitis, when one is " out of practice ". Consequently for these large apparatus you should prepare a thinner cream (to 5 parts of plaster put 4 parts of water instead of three) that will give you five minutes more margin, that is to sav the setting of this cream will take about fifteen minutes. But we >Aill return to this, a propos of the plaster corset. 3o THE STRIPS MUST BE APPLIED SPREAD OUT ; a. The application of the strips. Take a plastered strip, — Avltliout squeezing it, or scarcely at all — and applv it l)y commencinfj' at the extremity of the toes. Mode of application of the strips. — One makes circular turns Avhich overlap a half or third, but one never" reverses ". That is not necessary ^^itll bandages which are soft and moist : they mould themselves to the contours of the limb and fold Yis- li- — How not lo do it. Do not let the bandage make creases upon the instep as it is doins here. themselves lightly where it is necessary Avithout those folds causing wounds, for they are very small and even smaller than those vou \\ould make ^^ith reverses. These circular turns overlapping one another thus cover the fool, the instep, the leg, the knee, and ascend up to the lower third of the thigh. The topmost turn of the plastered strip should cease i cm. below the upper border of the jersey. 2'* EXACILY, O" WITIIOI T THVCTION OH l'lti;SSI UK At Three recommendations as lo llic mamiei- ol appi viiifr llic strip; spread ll oiil : appl\ il exactly bul without traction. I. The sprcu'liii'/ Old : avuid niakini^ l\\i>ls. Iml willioul l)L'iny' in the nicaiilime concerned about the ine\itahlc (and nciiliyeahlc) small folds occurring in the strip rolled rr)und a region not regularly cylindrical (lig. i4). Rather than make a " lAvlst " cut your strip and spread out the ends. If care be Fig. ij. — The creases which the slrip mav make are effaced by tlie left hand a^ soon as they are made. taken to spread out the strip the apparatus ^^ill not cause any Avound. 2. To apply the plastered strip exactly, folloAv carefully the contours of the region. You can flatten out Avilh the left hand, as you go on, each turn applied hy the right hand (v. fig. 1 5). And in this way you will have a well fitting apparatus, neither loose, nor slack. 3. Do not lighten (a mistake often made by beginners). Avoid causing cedema of the limb (v. fig. i6) : make no Irac- 32 TECHMOUE OF PLASTER APPAllAXUS tion, no pressure. Take care not to pull on the strip, as you would on an Esmarch's bandage. Apply the strip as if you had to take an impression of the contour and the volume of the limb, without adding or curtailing anything, and in this way you will have plasters which Avill cause no discomfort. The first covering having been finished, when with the ban- Yicr, i(j, — What YOU sliottld avoid. Do not pull on the strip for, in pulling, the limb is constricted as is sho>vn liere. dage you have arrived at the upper border of the apparatus, if the strip is not used up, you Avill tear it Avith your hands, or better, cut it with scissors, and keep the remainder to apply later on over the attelles. 6. The application of the Attelles. 0\er the first covering made with the strips, the two attelles are applied (fig. 17, 18 & 19). You take one of them, it does not matter Avhich (they are equal); squeeze it slightly ; spread it out and apply the first one behind. Spread out one of it's extremities, first under the toes where the assistant lakes hold of it and keeps it in position, THE APPT.ICATIOX 0\- TIIK VT'IEI.LES 33 llicn aloiiL; llic sulc aiul upwards under ihe heel, -svliirli j| encl<>ses allerwards, osor llic whole ol' ihe poslerior part ol ijie Yimh, under ihe hack of llic knee as far as the upper border ol' the apparatus A\hercil's cxlrcmilx is held hy someone, or l)\ llir pilient linnself. Fis. I- Posterior attelle : Legin it's application under the sole of [he foot. The other attelle — anterior attelle — is applied in fronl. begining also at the toes'. 1 . If YOU wish to protect tlie toes from tlie pressure of the bedclothes you may alloAA- the lower end of the attelles to project hvo or three centimetres beyond them. If by doing so vour attelle is" too short at the upper part, it is of no consecpience : you will only have to strengthen, by some supplemen- tary strips, this part of the apparatus, where the allelic is wanting. 2. But without going further, without going even as far as their extre- mity, one leaves bare the last joint, in such a Avay as to allow of constant inspection of the skin. You could also take no notice of this recommen- dation during the construction of the plaster, and cover, without hesitation, the dorsal aspect of the toes, provided that you liborale it when you trim tlic plaster. C\LOT. — Indispen-able orthopedics. 3 34 TECm'IQUE OF PLASTER APPARATUS You carry out the application of the attelles. at the same lime spreading out and smoothing down their edges in such a manner as to avoid any sharp projection, Avhich is very easy Avilh attelles so thin as tliese (made, as I said, Avilh one or tAvo sheets of muslin). The edges of the allelles Avill overlap each other at the level of the narroAv parts of the region, Avhich is an advantage. Fjo-. 18. — The application of the posterior atlelle (continued). "While the assistant keeps in place the plaster portion, you spread out the middle portion under the calf. To facilitate and perfect their imhricalion you may incise the edges Avith a cut of the scissors at the level of the malleoli and the heel. Over the attelles a covering is made Avith plastered strips : one uses one or two strips (according as one is dealing Avifh a child or an adult). The strips are rolled from toe to thigh, and then from thigh to toe — until the strips are used up. An important detail. BetAveen the different layers of the apparatus you spread sriiiM) ii.vsri'H (;ui;\M liicTAvicr.N run i.wkus 35 N\illi \niii- liaiiil ,1 l;i\ci' (iiii" (ir Iwn millimolics lliick of plaster cream : Mm uso, lor llial [)inp(ise, wlial remains of ihe cream aller llif plaslerlni^- ol' llie ships and allcllcs; or if none of il remain, von al once prepare a new siij)|)lv. Tliis laxer of plaster cream is llie mortar ' which hinds into a sini^le liomoi^cncons l)locl\ llic difTeienI pails ol llie appaialiis. Fig. 19. — The posterior attelle applied. It encloses half tlie circumfcreace of Ihe posterior aspect of the limb, after the fashion of a casing. Then, over the last strip, spread a final layer of cream, to give a fmishing- touch- to the apparatus. It is now complete. The application of the strips and attelles should occupy from three to four minutes, not more than five. 1. Witliout this mortar one runs tlie risk of having the plaster not homo- geneous (a " gateau feuillete ") especially if it has been jirepared with strips dusted beforehand ^a ith plaster. 2. V^ e will explain further on, p. 79, the methed of polishing the appa- ratus. 36 TECIIMQUE OF PLASTER APPARATUS You Avill have then before the selling of the plaster, several minutes Avhich are necessary for correcting the position and moulding the apparatus. (( Several minutes o, that is the desired margin; not too much nor too little. \ou should have calculated evervthing so Fisf. 20. — The anterior attelle is then placeJ in posilicn. that this may be so; that is to say, you should not only have tesled your plaster beforehand, but more than that, if you are a novice vou should have made a rehearsal and constructed a plaster on the same plan upon a living model. But Avould it not be possible, Avhen you have not settled on vour plan and taken the necessary precautions, to advance or retard slightly the setting on the plasterP To hasten the setting it is recommended in some books, to drv the surface of the apparatus ^^itll hot napkins, or Avith several turns of drv linen bandai,\sii;u •^!) aivli of Mil' liHil. lull ihis is piaclicill \ useless : in arn case, IIm' iiHulilliiiL: will lM'c,i>il\ clleclcd ■\\ illi lliclwo liarids wlilcli j^iasp (lie looi and llio mallei )lar rc;^ioii. Ymi sin mid preserve ihc correction and llie modelling right up to the setting of the plaster, inclusively; il is somelimcs rallier tr\iii^-, bul il is absolutely indispensable, if you A\isli to lose none of tin' Fig. 22. — AVlien the plaster is set you raise tlie lieel so that tlie air passing bencalli tlie apparatus assists the dryinj; (do not confound the setlirifj o( tlie plaster, which requires several minutes, with the drjinr/, which requires several hours and even sometimes several days). . correction obtained. One recognises that the plaster is set by it no longer creasing on the surface ; by it emitting a sound under the finger, when tapped; by it being warm, remembe- ring hoAvever that Avhen it has been prepared with cold water, itAvillnot always be warm to an appreciable extent, even when the plaster is good. AVhen the plaster is set, and then only, you may release the patient's foot and place it on the table, or better still, on the back of a cliair, to hasten the drying of the plaster. l\o TRIMMING THE PLASTER II. — TRIMMING THE PLASTER Ten or fifteen minutes after the plaster is set, you may commence trimming it with a good knife, cutting gently and slowly upon the apparatus, aa hich at this moment, permits of being cut like soft card-board; you cut off the part which covers the extremities of the toes, in such a way, as to expose Fig. 23. — Trimming the plaster by means of a knife or bisloury. the dorsal aspect of the last phalanx. One takes care not to cut into the jersey or stocking, in order to preserve a surplus of the covering Avhich Avill prevent the friction of the plaster over the bare skin. One frees, in the same Avay, the upper part of the apparatus, preserving, here again, 2 or 3 cm. of the soft casing beyond the border of the plaster. Thanks to this trimming of the loAver extremity of the plaster, one is able to make an easy and continuous inspection of the nutrition of the toes. (If all be weU with them, one is assured of the good nutrition of the foot and of the leg). MAki; SI Ki: Of riii: MriuiiDN oi' iiir, i.niis '|i The Iocs oii'^'lil lo be sensitive lo llie [)ricls. of a [)in. rosy, Avarin. ami supple. Voii imisl always look at them before lea\irig the house and it will be sufficient afteiAvards if someone of the family Avatches Fig. 24. — The apparatus complete, trimmed and polislied. them every hour for the first day, then morning and evening on the following days, drawing a pin over the surface of the toes \ I. Anyone may easily perceive the least trouliles or anomalies of tliis kind ; it AA'ill be sufficient for him to compare the results of examination of the affected side with that of the sound side; moreover, in case of doubt, this person should advise you immediately, and in this way, if any trouble ^^ liat- ever should happen, even unexpectedly, during the folloAvingdays, you would alwavs be able to remedv it in time. 42 TECIIMQUE OF PLASTER APPARATUS If the patient is unable to move them voluntarily you should open the plaster by a median slit from top to bottom, until they do move. You split the plaster first on the middle of the dorsal aspect of the foot, afterwards on the anterior aspect of the instep, and Avith a spatula, or even Avith the hands, you Aviden, for one or tAvo centimetres, the still soft edges of the plaster, stopping the instant that the normal sensibility and colour of the toes return. If these do not return, you Aviden more and split the plaster, further and further upAAards, if need be up to the upper border, and raise the edges. Then, everything should return to the normal. You have only then to fix the plaster at this degree of AA'idening Avith a plastered strip, or a simple muslin bandage. In short, provided that you ncA-er depart from this absolute rule of never leaving your patient Avithout haAing positi- vely ascertained that the toes (or the lingers) are rosy, warm and sensitive, I can guarantee that you Avill never have serious trouble Avith nutrition after the application of a plaster, be it the loAAer limb, or the upper limb. After the trimming, the patient is carried to his bed. The Method of lifting and conveying a plastered subject, so as not to injure the apparatus. Take hold of the leg in such a manner as not to make any movement contrary to the position given, or Avhich tends to call into play the articulations fixed by the apparatus. One leaves the plastered leg exposed, the heel raised so that the drying of the plaster may proceed as Avell beloAv as aboA^e (v. fig. 22). Do not confuse this drying Avith the setting; the latter does not require more than ten minutes, Avliile the former requires one or tAvo days, sometimes more ; during that time, one should guard against moving the patient, for the plaster, AFTEft CAIU: ^3 so loiiy as I lie Irasl iiii)isliuc icuiaiiis, is likcl\ lu break; however, if il A\ere lo break, il A\oiild be quite easy to repair if ; AVC Avill ilcscrilie liow in a niDmcnt. Attentions to be paid after application of the plaster The plaster bein,a' construcled, vour iniinedialc laljours arc ended. The patient beinii' returned to bed, a hot water ])oltlc Fig. 20. — If tbe small toe is too much pressed upon, you free it l^y making small slits along the external border of the foot (one frees the internal border of the foot in the sEime way if the great toe be too much pressed upon). may be placed on each side of the plaster to hasten its drying. The toes must be protected against the pressure of the bed- clothes, thus facilitating the circulation of air round the appa- ratus, and helping the drying. It is Avell for this purpose, lo leave the plastered region outside the bedclothes, for the first twenty-four hours. A plaster ought not to cause any more discomfort than a well made boot. At the most, the patient may complain of a sensation of kk TECHNIQUE OF PLASTER APPARATUS uneasiness, similar to that caused by a ne\Y boot. If you call on your patient a fe^Y hours afterwards, or the next day, he will tell you perhaps that he feels some uneasiness at the edges of the apparatus; the two outer toes, the great and the small, may be a little pressed upon by the plaster. In that case, introduce a spatida between the toes and the apparatus, and Fig. 26. — A bi'oken apparatus, which must be repaired and strengthened. try to widen it by a few millimetres. If that is not sufficient, split the plaster a little; do not clip it transversely; no, cut longitudinally the inner or outer side (as the case may be), for a length of one, two, or three centimetres, beginning at the free edge; afterwards Aviden slightly the two lips of the gap, in order to give the toe a little more liberty (fig. 20). And the same in the thigh, if the upper edge of the plaster presses into the soft parts, commence by sliding under the edge a slender and even pad of cotton avooI, and if, in spite of that, the patient still complains, split the apparatus for the length iiiiw I'o mutm; I iii:\ iiii. n.vsrr.H ^i5 (i| a few ceiiliiiii'lrt's. widrii (lie li|).s oC llir y:;\p made, and inlnnlucc a laM'ior colldii \\ool lu prolccl ihe skin IVoni injury. A\ (' will now dt'sciibc : a. The melliod of strengthening llie piaster; 6. The manner of repairing il ; <■. The niclliod of making openings into it; Fig. 27 — How to repair a plaster. — After having slightly moistened the region with very lliin cream, yon apply a large square of muslin, of one thickness only, impregnated with the cream, then a second, then a third. d. The method of removing it and performing- (he toilet of the limb. a. How to strengthen the plaster. If the phister seems too slender, whether it he some minutes, some hours or some days afterwards. }ou strengthen it in tlic folio\Aing manner. It is the whole of the apparatus which needs to be streng- thened, ^ou commence by applying- over the whole surface a 46 IIOAY TO REPAIll A LROXEN PLASTER layer of thin plaster cream (equal parts of water and plaster), then, over this, you spread two attelles (of a single layer of muslin), one of the attelles in front, the other hehind, then a third, and a fourth (always of one thickness only) ; and over all you roll one or two plastered strips. If it is only at one or two points that the plaster is weak you apply, at these Fig. 28. — Over tlia squares, several lavers of pki~terci-l strips are applied. points, going heyond the limits of the Aveak portion, a similar layer of plaster paste, then several squares of muslin (fig. 27), lastly, 2 or 3 turns of plastered strips (fig. 28). b. How to repair the plaster. And when the plaster is cracked, or hroken completely (fissure or fracture) a long or short time after its construction, it is not generally necessary to replace it; one may very well repair it and make it sound again (fig. 27, 28) proceeding in pretty nearly tlie same Avay as in strengthening it. First of all remove the debris of plaster which borders on the crack, then roughen the surface Avith a knife; you hollow IKiW II) CLEANSE A Sf)lLi:i) I'l.ASTEK ^•7 out Utile depressions wilh llic point, as yju piick the ice wilh \our alpensloclv to oljlain a grip; you (lam[) arierwards llic irregular and jagged sur^ace^villl some lliiii plaster (equal parts of plaster and ^\ater). AA hen llic jilasler is soiled, its A\Iiitcness can ho retimed Fig. 29. — How lo make an opening in Ihe plaster. — The piere to be removed is first marked out. then cut with a knife, going through the wliole thickness of the plaster; this piece is lifted out by one corner and removed a'.losether. by the application of a film of paste made wilh these same proportions of plaster and water. \A hen it is softened by urine or by pus, the soiled part is cut out and replaced by squares or attelles held in position by a few turns of plastered strips. Do not use thick paste or attelles of several thicknesses; this is the secret of success in these immediate (or late) repa- rations, Avhicli pass as difficult. If the paste or the attelles are too thick the ne^A pieces will not incorporate with the old plaster, A\hereas in ihe method I have just described, the union /.8 TECHNIQUE OF PLASTER APPARATUS is very intimate and very firm, and yoit will be as expert in repairing the " old " as in making the " ne^\ ". c. How to make an opening in the plaster. To make an opening in the plaster, as in trimming, you cut layer by layer, very gently, until you experience a sensation Fio-, 3o. — "When the piece is removed one cuts the jersey diagonally and folds back the flaps : the skin is laid bare. ol cutting the tissue of the jersey, and no longer the plaster. There is often an indication for the making of an opening: To inspect a projecting fragment of bone, a wound, an abcess, a fistula, etc. One ought to note these different points and protect them by a double square of gauze, Avhen constructing the plaster. Wait, before making these openings, until the plaster is dry (at least 2^ hours), unless however it be a matter of urgency, for example in the case of a wound suppurating freely, which should be dressed the same day, or again, that of a bony projection which ought to be put back as soon as possible, if iiMW 1(1 mam; \n ui'kmnc iv im: i'|,\sti;k ^0 >0U wish to save ihc alrea(l\ llirralcticd >kiii ; in (licso rasos, make the opi'iiiiii;- half an Ikhii- aflei- the plaslci- lias sd. Jusl as in liiniiniiiti', (nic makes use here ol' a knife well sitai-pened; ciil inillimelre hv niilliniclre, unlil Mm come upon llic solt llssuc ol" (lie covering which nou will more easih sliL w il h I he scissors. Fig. 3i. — la Ihe case of a wound : method oi' introducing the dressing beneaht the edges of the opening. You "will not Avoiind the skin if you proceeed cautiously. The security will he still greater il" you have rememhered to cover the skin with a double jersey; it is then that you appreciate the value of this precaution. Another good precaution, when you know beforehand that you may have to make an opening at some points, is to place there (over the jersey, single or doubled), a little square of gauze of two thicknesses, or some fine cotton wool, before applying the first plastered strip. Thanks to this square, one is able, later on. to make an opening- in the plaster at this point, without the fear of wounding the skin. Calot. — Indispen^:able orthopedics. 4 TECH^JIQUE OF PLASTER APPARATUS Fig. 32. — The flups of jersey have been turned do^n over Ihe dressing. The opening, generally square, should exceed by several cen- timetres, in all directions, the point to he watched or treated. Fig. 33. — The dressing is retained by a Yelpeau bandage. now TO ur.Moxi: iiii^ rLAsrcn 01 One i-loscs tlic opcniiii^- willi an ordinary dressing if one is dealing willi a wonnd (lig. ,"ii). or. if one is dealing willi a correction, with squares ol cmIIhii wool ki'[il in position and well llatlened l)\ a lew lavers ol" stiU" muslin, moistened and squeezed; or belter, with a Yelpeaubandage (fig. 32 and .>3). D, How to remove the plaster. The time having arrived for the removal of the plaster* Fig. 3A. — How to remove tlie plaster. — The lines of section. (The plaster has been previously soltened by a bath or by >varm -wet compresses.) it is split in front, in the same manner and Avith the same precautions, as I indicated foi- trimming and making an opening, Avith this difference, that Avhen the plaster has just been cons- tructed it alloAvs of being cut easily (or even some hours or some days afterAvards) ; whereas when some weeks or months older, it does not allow of being cut without some difficulty. For this reason, you should commence by softening the old plaster on a level with the line which the knife is going to follow. You damp it lo or i5 minutes beforehand Avith sponges or Avith linen soaked in hot Avater. This facilitates I. After some Aveeli.s, or may Le months, according as it is a fracture or an orthopedic atrection. 52 TECHXIOUE OF PLASTER APPARATUS very greatly the penetration of the instrument, and Avhen it has cut a little Avay into the plaster, you keep on running some hot Avater along the groove ; then you go on, in this Avay, damping and cutting, right doAvn to the jersey; then you cut the jersey Avith the scissors. But this method of removing the plaster is long and labo- rious ; it is infinitely more simole to plunge the patient, or at Kig 35. — How to cut tlie softened plaster h\ means of a knife : you raise the sides of tlie cleft to avoid wounding the patient. least the plastered limb, into a hot hath, for i5 or 20 minutes, whenever this is possible, that is to say nearly ahvays. As soon as the patient leaves the bath, start upon the plaster Avith a good knife. It will alloAv of cutting as easily as cardboard, and the section and removing Avill occupy one or tAvo mi- nutes (fig. 34 and 35). This prehminary softening in the bath afifords a still greater security : the edge of the soft plaster alloAvs of it being raised sufficiently by means of the fingers for you to be able to slip easily the handle of a spoon betAveen the plaster and the skin, and you can then cut safely upon this improvised iinw Id hi:m(i\i: I hi: i'i,Asri:u :).{ guitlc which you acl\aiice hdle \)\ hlll(; towards llic olhfr extremity of the apparatus. At the instep one is often tielayed in making a coniplcle section by abuttress of plaster A\hich corresponds to the anj,do ol' flexion of the foot (fig. 36). But. if one proceeds with cau- tion, one can divide this plaster obslruction without scratching the skin. As soon as the plaster is thus cul tlirough from lop to Fig. 3G. — At the instep there nearly always exists a buttress of plaster which is awkward to cut. bottom in the median anterior line, one separates and raises the sides and so can remove it Avithout difliculty. At the instep, hoAvever, I Avould advise you to make a second section at right angles to the first, before raising the sides. This second transverse section is ahvays indispensable Avhen the plaster has not been softened by a bath; it proves very advantageous in any case; not only at the instep, but also at the knee (v. fig. 34). 04 HOW TO REMOVE THE PLASTER ^A hen YOU proceed to the separation of the sides (especially Avhen the plaster has not been softened) you should move with prudence and method, making the effort symetrically and ecpially, on the two valves of the plaster. Otherwise one tAvists the limb and, in the case of a debilitated child, or one in whom the skeleton bv disease has a lessened resistance', there is a Fig, 87. — To remove the plaster, an assis ant separates the sides \\hile you raise the limb and pull upon the foot. risk, by such torsion, of bending or even fracturing the bone. A good precaution is to confide to an assistant the task of pulling very firmly on the foot, whilst you proceed, alone or assisted, with the raising and separating of the two valves of the apparatus. The toilet of the skin after removal of the plaster If one need not replace the plaster apparatus again, one is free to make the toilet of the skin in several stages. But, if I. For example in tlic case of a congenilal luxation of the hip. or in one of tuberculosis of tlie member. Tiir loiiKi (II Till. >-kiN VI rnu UKxiowr, oi- rm: i-i. vsir.ii ,).) il is necessary lo re-[)last(r llir lliul). (Uir makes llic toilet at once. One nsos for this warm water and soap, afterwards damping sliglilly the skin with some ether or Eau dc Cologne. If the skin is very scaly you may commence hy rubhing the skin gently, (nv a few minutes, ^^ilh vaseline, anIiIcIi has the elTect of soi'leiiing the scales of epidermis; you wash the skin with a tampon of ordinary cotton wool and pour over it a little ether or alcohol. Then turn the patient gently over, to make the toilet on the other side of the limb. If, as is most unusual, you fmd, after removing the plas- ter, some slight alterations in the skin, eczema, or vesicles, you will attend lo these carefully for a few days before repla- cing the plaster, by applications of oxide of zinc, or talc or, better still, hy radiotherapy. Failing the latter, you may leave the skin, with great benefit, without any dressing, lightly covering it with a piece of gauze, exposing it freely to the air for a few days, or heller still, to the sun for lo mi- nutes the first day. i5 the second, gradually increasing hy five minutes a dav. II SUPPLEMENTARY DETAILS^ ON PLASTER APPARATUS GOOD AND BAD PLASTERS I have said that to know how lo construct a piaster forms part of that minimum of information indispensable to all practitioners and Fig. 38. — A bad plaster. I. Consult that excellent book of my assistant in Paris, D'' Privat, " On plaster apparatus ". (;(Hii) AM) i;ai> i'lasteks 7)- iirxcrllu'li'ss. llicri- arc lew |)r,K(ili()iiois capal)!!' ol' luakiiiL; a i;oo(l plaslt-r ; not llial it is rcallv cliriiciilt. no! Iml il i> mil lauirlil in oni- siliools. Kor that icasoii I 11111-1 explain lo \oii licrc in di'lail, I'lal wliuli makes ^0(h1 ami liad [ilaslcrs. Bad plasters. I mean bv bad plasters', plaslers Avbich arc soft, friable, those apt to lose tlicir shape, heavy, ill liltiiiir. consccpieiillv cpiite inca- pable of riiliiiliiii: ihi'ii- (lieia|)!'ii(ic I'lmclion. Fig. 3(), — Another bad plaster. — These I'.vo figures 38 and 09 show how it should not be done. — Here are two plasters, niu-jh too large and not moulded : veritable floating trowsers. — One easily sees that a plaster made in this way (one saddle for all horses is not fitting better than the glass case over the clock and is incapable of thoroughly maintaining a correction. These plasters, no more moulded, to the bodv than a sentry box to a sentinel, arc nothing more than cache-miseres and deceptions: thev cover but do not support ; thev hide a deformity, but thev do not I. Are die plasters of all " specialists " reallv beyond reproach? Ttiis is like asking : Do all surgeons succeed in procuring a faultless asepsis? — Do ^\e not find among them, some who Avork bv routine, who have indilTercnt principles, and who, alas I are unnilling to depart from them. But, as you know, there is no one so deaf as he \\ho A\ill not hear... And -till, it is not 58 GOOD PLASTERS SUPPORT AND DO NOT INCONVENIENCE correct it. Moreover, they are uncomfortable or painful to bear; they fatigue or injure — like a badly made boot (fig. 38 and Sg). And yet, it is absolutely neces3ary that medical men should know Fig. /|0 and 4i. — Here are hvo good plasters : accurate, well moulded. Compare them with the bad plasters in fig. 38 and oij. how to make good plasters ; for without well made apparatus there can be no good orthopedic cures. Good plasters. The good plaster is that Avhich supports and does not inconve- nience; those are its two essential qualities; if, into the bargain it is elegant, then the plaster is perfect (fig. 4o and 4i )• more necessary to be a professional surgeon in order to he aseptic than it is necessary to be a specialist in order to make good plaster; you will succeed completely if you follow the technique here indicated. SUPE1U(IUI^^ nv nii: cihcli.au i'i.vsiiu ^9 How to make a good plaster (well lllliiiif. coinroilaljlc jurI neat)? Fir-«;t ol' all, il >li()ul(l \>r a circular |ilastcr (made ^\itll strips) ami nol a plastered gutter ( luailc willi ihc classical sixlcca folds ol" nuislin). Tlio superiority ol the circular plaster. — Il is bv far llic most accurate i>iiico il adajils ilsdl to [\\c (Ic^Jri^^Hnis and reliefs ol tlic ^vllolc surface ol llie Ixxlvi; it is llie most confortable to llic [)alicnl (because it snpporU him iiiiil'oiinlv cvorvw licrc i : and il i< the most Fig. !x2. — A bivalve apparatus allowing of complete examination of the limb, if need be, or the dressing of multiple wounds (The two valves are kept in contact by means of a sticking plaster bandage). simple to make ( because, to mould Avell no matter in \\liat region. it is sufficient to roll the plastered strips after the fashion of an ordi- nary muslin bandage, -whilst it is impossible to mould exactly the plastered « gouttiere » made up of i6 folds of muslin, -without ma- kinor coarse ridses which mav wound the skin. But, at once, you ask : a) How do vou inspect- in circular plasters, some bad or suspected point (a fragment of projecting bone, a wound, an abscess or a fistula) ? It is very easy : simpiv make an opening at that point, which ope- ning will not lessen the support, on the contrary, as we use it (this I. The circular plaster is the best for the limbs as weW as for tlie trunk, for fractures as well as for orthopedic alTections. 6o HOW TO MAKE A PLASTER WHICH WILL SUPPORT WELL opening) one can exert more pressure on a certain point , to push back a bony projection, a gibbosity. b) How, -with a circular plaster, can you make a complete exami- nation of a limb, if necessary? First, this complete examination will be rarelv indicated; more- over, could it be better made Avitli a plaster goutticre? And besides, remember that this examination is, in reality, possible (and even easy) -with a circular plaster, seeng that it is sufficient to divide the plaster into two valves which you can take off and reapply as you wish. c) Finally, how are you to inspect the nutrition of the limb, in a circular apparatus? It is sufficient to ascertain the oood condition of the toes and fin- gers, as Ave have already said. Any alteration in their colour, warmth, sensibility, is the danger signal which allows one to know that there is trouble with the nu- trition higher up, and to do at once what is necessary to remedy it certainly ; it is the danger signal upon which you can always rely. Besides, these troubles of nutrition can only arise from some fault in the construction of the plaster, or from the breaking of one of the rules I have given. But do not believe that this clanger does not exist Avith gouttieres. It does. I must even confess that tbe only really serious accident Avhich I have CAcr observed to be caused by a plaster, occurred 20 years ago, in the course of my studies. After the application of a plaster gout- tiere to a fracture of the leg (of an alcoholic subject, it is true), total gangrene of the foot, and even of the lower part of the leg, occui'red beneath a sub-mallcolar bracelet of diachylon. A. — HOW TO MAKE A PLASTER WHICH WILL SUPPORT WELL? In order to support Avell, a plaster should fulfil Iavo conditions : first it, should be sufficiently long, and, secondly, it should be moul- ded to the region. a) The apparatus should be sufficiently long. It is necessary that the plaster should embrace not only the part affected, but also the tAvo adjacent articulations ^ I. I AA"as asked to see, in a large foreign capital, a patient suffering wi\h Pott's disease in the dorso-lumbar region, who had had applied a plaster belt, reaching from the axilla to the iliac crest, the shoulders and the pelvis being entirely free! The patient, as a"ou may well believe, moved about inside it rather like Diogenes in his tub. And still, to sj^eak properly, the formula V^ coNDirioN : Tni: plasteii siioii.u me sufficiemi.y l<»N(; 6i 'l"liii<. Id coiiiplcli'l \ iimiii)l)ili/i' an .illccle'il krirc, iho .'ipparaliis sliould iiicltulo. at llic same liino as tlic knee, the hip and the auklc. Ill order lo hetler iiniiiohili/e the inslep, the knee and the entire fool shoukl he include d. Fig. i3. — The short knee-piece too often made Much too short and loo larire : llie tissues are allowed to be depressed by the edges of the knee-piece and deviation is produced at will. Fig. 4^4. — A longer knee-piece, but again insufficient for the same reasons. Fig. '|5. — The perfect method of immobilizing a knee. Our large plaster takes in, not only the knee, but also the two adjacent articulations. If the plaster does not inchide the two neighbouring articvdations, a deviation within tlie ph\ster, and in spite of it. will appear or reap pear (fig. 43, 44- 4j). And even the formula that the two adjacent articulations should be included is insufficient in manv cases: for example, in a coxitis during the acute stage, one should include below, not only the adja- cent articulation (that is to sav the knee), but even the entire foot. wliich says tliat the two adjacent articulations must be included in the jilasler was here adhered lo : that formula is then insufficient in certain ca-cs. 62 2"'° CONDITION' : THE PLASTER MUST BE CAREFULLY MOULDED Still further : in alTections of the spine, in an osteitis of the tenth dorsal vertebra for example, it >vould be altogether insufficient, and even ridiculous, to include in the apparatus only the two articula- tions next to the affected part. And for orthopedic affections of the back whatever may be the scat, you must include in the apparatus, if not ahvavs the base of the cranium, at least the scapular and pelvic girdles (shoulder and pelvis). We will mention elsewhere, in studying the different maladies, the dimensions to be given these apparatus, in each instance. b) The plaster must be carefully moulded over the region. It should be as exact as if it w ere applied to the skin itself. One mio-ht, strictly speaking, apply the plaster to the skin as is done in the attelles of Maisonneuve, in fractures of the legs. But the plaster adheres to the hair, its direct contact is disagreeable, especially if made with cold water, which is the rule, it might have grave incon- veniences when it is a question of a thoracic plaster; its removal would be also more difficult. For all these reasons, and also to en- sure the cleanliness and good condition of the skin, it is better to cover it Avith a soft tissue, — but with the proviso that nothing be omitted to ensure the accuracy of the apparatus, — a condition AAhich is evi- dently not always fulfilled when, as is often done, coverings of cotton Avool of several lingers in thickness are used. It is impossible, with a plaster applied over such a thick cushion, to control Avith precision a fragment of bone which is pointing, spi- nous processes Avhich project, lips of articulations Avhich tend to be deviated. It is impossible, especially after some Aveeks, or may be months Avhen the cotton avooI has been crumpled, and that, ahvays unevenly. This explains Avell how^ it is that plasters, applied to limbs straio-ht or redressed, generally yield limbs or the trunk deformed (in Pott's disease, hip disease, or fractures). What is to be done ? When you have only cotton wool at your disposal, you may use it, provided that you apply only a very thin layer, as thin as possible, but uninterrupted: say, to fix your ideas, a layer of one and a half to tAvo millimetres, spread out very evenly. But, as you may guess, this is not to be done Avithout difficulty; and it is for this reason that I advise you never to make use of cot- ton wool except in case of necesssity, and to prefer the fourreau of soft tissue. The fourreau you Avill find everyAvherc. It is for the leg (as for the upper limb) a jersey sleeve or two jersey sleeves placed end to A GOOD PLASTEK MUST NOT CAUSE DISCOMFORT 03 oiul ; il is, lailiiii; a jcrscv sIceNC, an oidliiary sociv for llic leg and llic Tool: il is. I'oi' llio liiink. an indiiiary jcrscN. anil Ibr llic large a{)|)araUi.s lor llie lower limb, slill a jersoy, but jhiL on after the manner of a pair of drawers. If (lie fabric of llic fonircan is too lliln, pnlon two'. So niucli for the covering of the skin. Xow for ibc mode of applying the bandages. I have said that il is not sufficient lo apply Ihe strips exactly, thai il Is necessary moreover lo mould the plaster around the projections of the region; this moulding applies especially to plasters of the pelvic region and the Irunk (we ■will return to this a propos of the apparatus for coxitis and Pott's disease). I have spoken also of the nccessitv of maintaining the position of the limb until the plaster has set, but I wish to insist, because this rule is violated every day in the greatest part of surgical practice. Bring to TOur mind what often occurs : The •' chief " refuses to remain any longer, judging that his importance calls him to more noble duties; he hands over the task of maintaining the position to an externe or, to an oblia;ins: friend who is not slow in losing his 'DO O patience in his turn, in front of this plaster which will not dry (too often the plaster of hospitals refuses to dry, being decomposed), and he lets it go before it is " set " : the correction is lost in parts or altogether and thus the final result is lost or compromised. You should keep up the support right up to the setting which will only require a few minutes, if you have taken care to procure good plaster and tested it beforehand, every time you have to cons- truct a new apparatus. B. — HOW TO MAKE A PLASTER WHICH WILL NEITHER BE UNCOMFORTABLE NOR CAUSE INJURY. And first, an axiom : a good plaster must not cause discomfort. On the contrarv, it should give a sense of security and of perfect comfort just, for example, as a well made boot. The patient ought to feel more easv with it than without it! This is true to the letter: children who are taken out of a good plaster are impatient to return to it. I. The tissue of the Pyrenees and the lint recommended in some books are not sul'flcientlv delicate. "4 110V\ TO MAK.E GOOD PLANTERS But let there be no misuuclcrstanding. It may be that Avhcn it is a question of a first plaster, the patient complains of slight discomfort durino- the first few davs, Avithout there being any bad workmanship of the plaster, without auA" other reason than that of being unaccusto- med to it. Thus an adult on whom a large plaster is applied for Fig, !\G. — ANliat is not to be done ; do not pull on the bandage and cause csdema of the limb. Pott's disease is liable to complain of a little discomfort during the first fortA" eight hours, even with a well made plaster. In such a case one does not re-make the apparatus (nothing is to be gained bv it). It is necessary onlv to help the patient Avith soo- thing draughts and a few kind words, to pass the first few rather unpleasant hours. — assuring him that to this discomfort will soon succeed perfect comfort ' . And, even more, Avhen the plaster has been applied for a grave injury or after the laborious or painful correction of some deiormity, the patient mav be expected to experience some pain during the first few I. AVe will describe apropos of the plaster corset, the means of suppress- ing almost entirely this discomfort by making slight temporary modifications in the plaster. Tin; MOSI ACCLR.VTE PLVSTI-K IS THE HEST TOLEU.VTED ()") davs. willioul one iiccossaiih iiircrriiii: llial the plasler is at faiill. Tim jjaiii will pass oil" tjradnallN . w lioreas, //( a bvUv nuvle pldsler tin- pniii would go on increasiiKj . Wc will sec first : Why a plaster incommodes, injures, or causes troubles of nutrition. It is lirsl because it is not accurate. — 'J'lic first condilion Vi'^. '4- and i8. — \Miat it is not necessary to do. Tlie foot is liold in (lie position ofequinus up to the moment of applying the plasler and it is not straightened until immediately afterwards (see explanation of following lisure). Fig. ^8. — The food plastered in extension (vide preceding figure) is carried imme- diately afterwards, before the plaster sets, to an angle of 90°; creases are formed in front of this angle and will nearly certainly bring about a slough, or compro- mise a vessel. \\liicli tlie plaster should lultil in order to be tolerated, is accuracv. One might believe, at first, that a verv accurate plaster would be a troublesome plaster: well, it is the contrary that is true; it is the verv loose apparatus which brings about bv its shaking, its incessant movement, a friction ot" the projecting parts of the plaster against the prominent parts of the bodv, which friction mav possiblv produce a slough. \\ bile, with well modelled apparatus, the reliefs of the bodv are fitted immoveablv into the depressions of the apparatus, and there are no scars, or practicallv none, to be afraid of. But. this need not Cai-ot. — Indispensable orthopedics. 5 66 TO MAKE AN ACCURATE PLASTER BUT NOT TOO TIGHT surprise you since everyone knows that a liorse is injured, not by a tight collar, but by a loose one. We have already mentioned the method of making well fitting plasters, we will not return to it. Second, because it is too tight at one point, or all over. Like a well-made boot, a plaster can and should be accurate ivilhout being tight. The principal cause of tightness in a plaster, is that the bandages have been pulled upon too much when applied. We have mentioned that it is a fault Avhicli beginners commit very often; they have a tendency to pull upon a plaster bandage as they pull upon an Esmarch Fig. 49. — Jn case you should have committed the fault indicated in fig. /17 and /i8, here is the way to remedy the formation of creases represented in fig. -'|8 : you CDntrive a square opening in front over the ankle. bandage. It is necessary then to guard against causing oedema of the limb. Do not think there is need to pull on the bandage in order to apply it exactly. No, it is sufficient to unroll it exactly over the circumference of the limb, as if one had to take an impression of its contour, as it were, without subtracting anything, without adding anything. Therefore do not pull upon the bandages. But there are other reasons for the plaster being too light. 1" Because the assistant who held the foot has drawn or pressed strongly upon the apparatus, before the plaster was set. It seems hardly possible to avoid these tractions or vigorous pressures, Avhen the foot itself has a tendency to deviate. One can do it however, by making it an absolute rule to correct all somewhat obstinate deformities before applying the plaster, and not to add in any way to this correction afterwards. 2° For deformities of the foot, if one tried, after having constru- ted the plaster on the foot in extension, to roughly fiex the foot upon the leg (fig. 47 & 48) a buttress would be produced in front, a plaster ridge, capable of producing a blister, or even of arresting the circula- 1(» \Vi>ll) I'l I.I.IXC L'l'ON l'I,\Sll!:i\KI) HAM)AOES 67 lion in llio loot. I( wdiild sul'lico il is tnio. lo provciil ail annoyance, to make an opi'iiiny in lln- apparal ns in IVoiil, in order to remove this |)ressnre of I lie plaster (li^^ /igj. Aiiollier precaution : the assistant will change places with his hands I'roni lime lo time, change his hold, whilst the plaster is drviny : a conliniious and prolonged pressure al llie same pnini may make a depression in the plaster. Lasllv, it, in spite ol' evervlhing, there remains on the surl'ace ol' the plaster llallened or deep impressions (fig. 5o), caused by the Fig. 5o — During the drying of ttie plaster depressions may be produced liy tlie side of ttie table upon Avhich the patient has been lying, or by the hands -which have been supporting the correction. Here is a specimen of such depressions, application of the hands, one will make, immediately after the setting, openings at these points, replacing afterwards the pieces removed by squares of plastered pads, or bv some turns of plastered bandages (fig. 5i). This is how you can always, or neaily alwavs, prevent the plaster from being troublesome. I say nearly always, for there are excep- tional cases Avhere a plaster, however well made, may cramp or wound the patient, owing to the nature of the lesions or to his generally bad condition. 1*'. Because of the lesion : for example, a pointed gibbosity or a fragment unusually prominent in some fracture of the tibia or of the clavicle may have ulcerated the skin without any fault having been committed in the making of the plaster. 68 TO AVOID PULLIXG UPO>" PLASTERED BAXDAGES But, one can alwavs, or nearly ahvavs save tlie Integument, even in that case, if one takes care to make an opening in the plaster immediately after its completion. 2. Because of the subject; for example, in some paralysed suh- jects, the simple Aveight of the limh may, strictly speaking, cause a slough in the sloping parts, and the mere Aveight of the plaster pro- duce a slouD-li in front. D And you mav see that also, though in a less degree, in verv cachectic subjects. Finally, Ave must say that Ave mav meet Avilh intolerant skins. Fig. 5i. — One raises, as shewn here, or betler slill one picks out the parts crushed in and at once closes the openings by means of square plasters, or a few turns of plastered strips. bearing contact Avith plaster badlv. becoming immediately eczema- tous. But, let us assure vou, that this is met Avith, hardly, once in a hundred cases. The Method of treating wounds or trouble with nutrition of the skin. In pointino- out the causes of these troubles Ave liaA'C indicated at the same time the means of guarding against them, that is to sav. their preventive treatment. If ihese troubles do arise, this is the method of rcmedAing them : First case. — There are troubles with the circulation and the innervation of the limb. These troubles are easily detected; it is sufficient to examine the ro HI-MliDV rilOl IILES OK NLTIUTION AND %VOUNDS 6o Iocs and llial is wlial one slionlii al\\a\s think ol' when a plaster is jnsl linislnHl. Fig. 32. — This plaster was too tiglit ia its whole extent; it has been split from top to bottom and the edges separated. These troubles are due to the fact that the phaster is too tight everywhere. Fig. 53. — This plaster was too large ; a tongue shaped portion has been removed in the median line. In order to relieve the constriction, it is not necessarv to remove the apparatus, it is suificient to loosen it by simply splitting it in the ■JO THE METHOD OF RE-ADJL"STI.\G A PLASTER TOO LARGE median anterior line, in the manner mentioned on page !^l and fig. 52. A\ hen this anterior incision of the plaster and the consequent separation of the two lips have not entirely put matters right, not bringing back, for instance, the return of sensibility, as "well below the toes (or fingersj, as above, vou should open the apparatus behind and? better still, remove it completely and change it, guarding this time against the fault comitted before (of applying the strips too tightly) Fig. 54 — Tiie median tongue has been taken out, the phisler is then readjusted Lv bringing together the sides "which are maintained in contact h\ turns of plastered strips. But, once again, if you are careful never to leave your patients w"ho have had apparatus fitted, without satisfying vourself that the nutrition of the toes and fingers is normal, or is becoming normal again, xou Avill never have anv serious trouble. V^ e will allude, in passing, to the case of the plaster which is too loose. This arises, as we have said, througli the strips not having been exactly applied ^. I . Except however, in the case of fractures with swelling of the limb In that case a plaster fitting on the^ first day, will not do so a week or two afterwards (v. p. 82). WIIAI- l(> IHi WIIKN Till-: I'LASTI.K GALSliS I'AIN -J I Can il !)(• iciiKMruML' \('s, in llic lollowin^ inaiiiior. The manner of readjusting a plaster which is too large. \o\i inalu" an incisuMi aloiii^ llic niidillc I'me in Ironl, culling oul iVoni ono side, ov IVoni holli, Irom lop to botlom, a strip of plaster, one, two. or three centimetres wide; alter that you bring together ihc sides and lix them with a square of plastered muslin, encroaching on Fig. 55. — A slain produced by a slough : this stain is tinted more deeply at the centre than at the periphery; it is not got rid of by scraping the surface of the plaster; on the contrary, it becomes more evident the more deeply the knife sinks into it. the two edges, or else Avith some turns of bandage (fig. 53 and 54)- But, in this case, it is still more simple and more perfect to replace the apparatus altogether. You should replace it in the case of a fracture, after the swelling of the limb has disappeared. Second case. — There exist pain, excoriations, or sloughs. Here the patient complains, one or several days after the construc- tion of the plaster; he indicates a pain at a parlicular point ; at the heel, the malleoli, or the knee. We have said that this ought not to be, that it Avas not in the programme. It behoves you to seek for he cause b\ making an opening in the plaster, at this poml. 72 SIGNS ODICATIVE OF SLOUGHS ; I. FEVER; 2. PAIN: The skin being laid bare; i"*'. One finds nothing abnormal, or, simply that the skin is slightly reddened. In both cases, you powder with talc, and close the opening with a square of cotton wool and a few turns of soft bandage, taking care to inspect it again if the patient complains. 2. There is already a small slough. Sloughs are exceedingly rare, if you have^ made no mistake in Fig. 56. — The first kind of slough ; that which excavates, that which destroys. It is seen especially in cachectic subjects. This variety is less benign than the follow- ing one (fig. 5 7). Its treatment : To stimulate by the application of tincture of iodine, of \igo plas- ter, etc., the vitality of the mortified tissues. the technique. Nevertheless, they may be produced quite apart from any fault in technique, as Ave have said, in cachectic subjects. They may even be produced at any time, by the penetration, beneath the plaster, of a foreign bodv, small particles of plaster or of sand, various articles introduced by the patients themselves, buttons, me- dals, coins, hooks, pencils, etc., or even by the repeated soiling of the skin, with urine, pus, etc. How to discover the slough. One is warned by four signs, which are, in ascending order of frequency ; a) a slight elevation of temperature ; h) a localised pain ; c) a staining apparent on the surface of the plaster ; d) a disagreeable odour emanating from the plaster. o. visiiii.i: siAi\iN(;; 'i . ii/iidiiy oi nn: i'i.\sri:u -j.S It. Snmoliincs, llioii^li vory rarely, il is aniniiinccd I)n a sli'lil riso ol Icmpcralurc. ir, in a plasl(M'('il suhjoct avIio has had no lisc of Icmpornliirc before the applicalidn of (he plaster and has nol liccii redressed nor sustained any serious aecideni, (here occurs a sliij;hl evening fever of P V Fig. 57 Fig. 58 Fig. 67. — The second kind of slough : that whicli fungates (cauliflower). In tlie preceding, there was mortification of the tissues, here there is over-production. This second variety is very benign. — One finds it especially in subjects of good general nutrition. — Treatment : Get rid of the exuberant tissue by caulerizalions of nitrate of silver or the thermo-cautery. Fig. 58. — The second variety of slough (fungating), a stage fuiiiier advanced. It shows itself in the form of a " mushroom " or of " cock's-comb ": sometimes very large with a delicate pedicle. One cuts this pedicle with scissors, or destroys it with a pencil of nitrate of silver, as in this figure. 38° to 38,5° after one, tAvo or three Aveeks, one ought to think of the possibility of a slough having formed. Look immediately and see if you can find a disagreeable odour from any part of the plaster; if you do, make an opening at that point. If you do not, and in case of doubt, — after having Availed eight or fifteen days at the most — cut the plaster in two halves, in order to make a complete examination of the region. And you Avould do the same, if after having found a slough and having dressed it through a small opening, you find fever persist- ing Avhich is not explained bv the said slough: in that case^ cut the plaster in two halves, to assure vour.self there is no slough elsewhere. 74 RAPID TREATMENT AND CURE OF SLOUGHS b. Pretty often, it is the pain persisting at one point, ahvays the same one, (over a malleolus, the heel, the iliac spines, the sacrum, the knee) which discloses the slough. At the seat of the pain, you make an opening in the plaster. c. More often still, you are attracted by the appearance of a brown stain on the surface of the plaster. Do not confuse this with the staining produced by urine, which gives the odour of urine and not of pus : it is rather yellowish and disappears on scraping the surface of the plaster, Avhereas the discoloration produced by sloughing persists in spite of scraping (fig. 55). d. But the most characteristic sign of sloughing, is the dis- agreeable odour emitted by the plaster at one point ; it is a special odour comparable to the odour of pieces of old dressing imprcgnaled with pus*, an odour which makes itself apparent if one puts one's nose near the apparatus. I have an attendant who passes his nose from time to lime over the apparatus and quickly ferrets out, even a commencing slough, to a certainty. Here, smelling is better than seeing. How to treat a slough (fig. 56, 57 & 58). It is not necessary to remove the apparatus, it is sufficient lo make an opening- at the place indicated by the discoloration of the plaster or by the characteristic odour. The slough being exposed and uncovered for three or four centimetres from the edges of the opening of the plaster, you cleanse it, rub over with nitrate of silver the fungating wound, and then treat it with a layer of pow- dered talc, or Avith vaseline sterilized, or with naphthalan pommadc You dress it every day until it cicatrizes, which it does very quickly (in 6,8 or 10 days). 1. And yet, this very disagreeable odour does not signify, absolutely, the existence of a slough; the most disagreeable odours are due to a discharging eczema more often perhaps, than to a real slough. But, in both cases, it is necessary to examine and treat the skin. l^ou treat these eczemas with sterilized talc (rather than with vaseline), or, with daily applications of a layer a millimetre thick, of a black pommade known as naphthalan, and better still, by radiotherapy, or ex^DOsure to open air or the sun. 2. In the exceptional case of multiple sloughs, one turns the plaster into a bivalve, which allows one to make the dressing without neglecting the support of the limb. now ro I'HF.M.M' SA\ r.i.LiMc; oi- the free extremities ~,> Cii\oii lliesc iiuluatious, you should know how (o avoid sloughs, or. if in spile of cvcrylhing, ihcy occur, to recognise them quickly and euro them v(my easily, — in this ^vay a sloupli ought lo he a negligcahle incident. Anolher incident possiljic alter the application of a plaster (and which I wish to [loinl out, hcing desirous of omitting nothing ■which nia\ i)e useful to von ) ; ^\ lieu you have stopped applying a plaster of the lower lind) (or of the upper) for 'a more or less considerahle dis- Fig. 69. — A pla^ler wliicli does not reach to llio exlieuiilv ul it has produced a swelling of the free part. tance from the toes (or fingers) you may possibly see a swelling of the- free extremity of the limb (fig. Sg). What is to be done in that case ? Invariably the parents propose to you to pare down a little of the lower border of the plaster. But if you cut it (or pare it) you will find the swelling will appear higher up. Instead of cutting the apparatus, as the parents request you to do, it would be better to lengthen it ; instead of freeing the limb, it would be better to bandage the free portion, and that is indeed Avhat you will do (fig. 60). You yvill apply, then, over the swollen part of the limb, a cotton wool dressin;?: aentlv introduce a little of this cotton wool (a layer 2 or 3 millimetres thick) bet^veen the lower border of the plaster and nQ INFA>"TS A>D AGED PERSONS MAY BE PLASTERED the skin, and you ^vill afterwards enclose this wool dressing T,vith a soft muslin bandage, or better, with one of Yelpeau bandage, going methodically from the extremity of the limb up to the plaster, and overlapping that ^vith one or tAvo turns of bandage. You bandage the leg in the same Avay from the toes up to the knee, if it is a question of a swelling of the leg or foot, due to an apparatus stopping at the knee. It is the same for the upper limb. Fio-. 60. — In the case of swelling of the free part of the limb, do not pare round the lower border of the plaster, but make a slit longitudinally, following the axis of the limb to the extent of 3 or 4 centimetres, then raise gently the edge of the apparatus in order to pass between it and the skin, a layer of wool; afterwards com- press a little the free part of the limb with a Velpeau bandage, commencing at the toes and rising up to the border of the plaster. Look at it the same evening or the next day and you will see that the swelling has already almost completely disappeared; re- apply the same compressive avooI bandage, and renew it every two or three days, until the tendency to SAvell no longer exists. If it persist, provided it is only a slight degree of swelling, no inconvenience will be caused by continuing this slightly compressive treatment. But, If the tendency is too marked and persists beyond fifteen days, you slacken the plaster by splitting it from top to bottom: you afterwards separate the two edges by 2 or 3 centimetres and keep up this separation after the manner described at p. 68, in the case of a plaster which is too tight. now TO \\oii) \i,i. \ccini:MS w 1 1 ii iiir, i-lastku --y I'iiiallv, dill' last rciiiaik: ii'lirn nn ojicniiKj is made in llic plaster, it iiHisl ahvavs be closed, olliciw isc llic skin would he cut against the sides of the openings, ^ou reclose it 1)n applviny over the exposed part, squares of wool tlie sides of which arc lightly packed betw een the edges of the jilasler and llie skin, and kept in position bv several turns of soil bandage exerting a certain amount of compression. (V. p. 5o). Is there no formal centra-indication against the emploj'mer.t of Plaster. For example, the age of the subject? No : it is pos- sible to plaster the very young (for example for club-foot) as, also, very aged persons (for example, for a fracture). Simply, it Avill be necessary, in those as in the paralysed and cachectic, to make an inspection nearly every day. inspecting the nutrition of tlie toes (or the fingers) by \\Iiich means vou ^^ill avoid any disagreeable surprise. In small children, because of tlie frequent soiling of tlie plaster, it would perhaps be advisable to change the apparatus rather more often — it is onlv a little inconvenient after all. Resume and Conclusions. You see that I have not hidden from vou any of the incidents or accidents possible after the construction of a plaster. I have done so to give you the possibility and facilitv of being on your guard. But. I should have failed in mv object and I sliould have misrepresented things if I had left you Avith the impression that it is a " horribly difficult " thing to succeed Avith a good plaster, and that with the presence of so manv pitfalls to avoid, Avith so many dangerous headlands to double, it would be better not to venture Avith it. Such a conclusion Avould be in reality a complete error, very prejudicial to your patient and yourself so that it is my duty to dissipate it. No : to sum up evervthing, when you have a plaster to make, spread vour bandages accurately, but without pressure or traction ; mould the plaster afterwards bv pressing it around the prominences and not over them: correct bad positions before applying the [)lastcr: maintain this correction Avithout altering it; make an opening in the plaster immediately after it is set if it appears to be too depressed at am poinl; split it from top to bottom, ifyou consi- der, from the condition of the toes, that it is too tight in its entire length. All this is sulficicnt — and there is no " sorcery " in it — to avoid all accidents, or, at least, all serious accidents. 78 now TO MARE ELEGA>T PLASTERS C. _ HOW TO MAKE ELEGANT PLASTERS The ideal as >ve have said, is to make plasters not only comfor- table and accurate, but even elegant; to unite to the into the jucunde. Besides, the t^o things go nearly ahvays together. An accurate plaster could not be ugly, because it reproduces the form of the human bodv. But if, in addition to this regularity you give to the surface a polish and a brilliancy, then it will be perfect. Fig. 6i. — The apparatus in the rough before polishing. And do not think that this prepossession for making elegant plas- ters is of no importance in practice; on the contrary, it is by this that the relatives judge you most often! And by what you Avould expect them to judge you, before a definite result has been obtained, which may require several months, or even years? By what, if not on comfort (or discomfort) due to the apparatus, and by the elegance (or the ugliness) of that appa- ratus? Therefore, train yourself and spare no trouble to make elegant plasters. In place of a clumsv piece of work, strive to make Avhat I mav call iiii; i'iii.iii 1 \( ; oi- iiii: i'i,Asri:u 8i nuHliaii. I1111N1I I lie aiilciior siirlacr ol llic a|)|iaralu>, llallciiiiig il clow 11 alloiwaids and la\iiii; tli(> two flaps ol' llii^ " niilor casing " upon tlio side ol llio piaster, up lo llic middle line heliind, wliei-e \oii cross the superiluous portions ol tlie lateral Haps over (nic anollier. The edge overlaps more or less according as the linih is more or less thin; %\liere the overlapping is excessive, where you have too much mate- rial, lor example, at the instep, cut oil' the exuberant portions Avith the scissors: take care to allow a I'ew cenlimctres I'ni' the two flajis to unite the one with the other. It is all the better to applv the middle ol' the allelic in front, in order that the edges niav be thrown behind, Avherc thev are not seen (no little detail should be disregarded, seeing that we wish to have the apparatus as neat as possible). The application of this supplementary sheet of plastered muslin, serves, among other things, to strengthen the plaster'. Subsequent Polishing of the Plaster. This polishing is done about 48 hours after the plaster has been constructed, when it is dry. You commence by softening the outer plaster glazing with thin paste; one, or one and a cjuartcr, cup of water to one cup of plaster of Paris. Aou pass the hand oyer the w hole surface of the plaster, or you may use a tampon soaked in this Avatery paste. After two or three minutes, a softening is produced: take advan- tage of this for leyelling, with a knife, the surface of the plaster, clearing away all the angles and ridges, after which, over this carefully levelled surface, vou spread a coating or glaze of thicker plaster, made with two cups of plaster of Paris to one cup of water. The best manner of proceeding is : — put half a cup of water into a basin slightly inclined (at an angle of 3o°), then, in the upper part untouched by the w ater, put in reserve a cup full of plaster of Paris. Keeping the basin inclined, take a pinch of plaster between the thumb and fingers, dip the finger ends into the water withdrawing them immediately, still holding the pinch of plaster which has now become a paste. This is spread over a small part of the surface I. Keep lo tills method, and I dissuade you from polishing bv pasting on the apparatus two great placards ol" dry muslin (not soaked in plaster) ; it is a dangerous procedure for you ; it hastens the setting of the plaster and, for that very reason i\ ould not allow you time for making a good modelling. — to say nothing of the fact that this procedure in " quickening "' the selling of the plaster, deprives it in the end of its firmness. Calot. — Inclispensahte orthopedics. 82 ON THE USE OF PLASTER IN FRACTURES of the apparatus, in a laver of about a millimetre in thickness ; afterwards smooth over this surface Avith the hand or Avith a tampon soaked in the water which you find in the tilted part of the basin. Then, take another pinch of plaster Avhich you moisten in the same way, and cover another portion ; smooth it down equally and so on, until the whole of the apparatus has been polished. You get in this Avay a glossy apparatus, and the plaster after a few months, comes to resemble very fine old ivory. We have often been asked for the secret of the composition of the polish employed in obtaining the beautiful plasters of Berck. You see, there is no secret, no mystery ; the polish is simply a layer of plaster paste, with which — if one has a little practice and some dexte- ritv — one can make the most beautiful plaster apparatus in the world ! We mav add that it is easv, when the plaster is soiled, to recover its Avhiteness. This can be done by passing over the surface a tampon soaked with verv thin plaster (equal parts of plaster of Paris and Avaler). A FEW WORDS ON THE USE OF PLASTER IN THE TREATMENT OF FRACTURES First. You should apply your plaster immediately, as soon as you see the patient, without delay, even in the case where the limb is swollen: all vou have to do Avhen the swelling has diasp- Fig. C/|. — Fracture of tibia with projecting fragments; on a level with the fracture an opening is made in the plaster to compress the fragments (with squares of wad ind kept in position by a bandage). METHOD OF DEALING \MTII DISPLACEMENTS 83 pearcd, allfr Icii or Iwelve davs, is to replace the lirst plaster bv a second one more accurate '. Secondly. You must Ircal airvour fraclures, nol \\itli boxsplinls Fig. 65. — Fracture of clavicle with displacement. One com^iresses the projecting fragments through an opening in the plaster. I. If, after the twelfth or fifteenth clay, the plaster seems slightly slack there is no need to change it; tighten it hy cutting off a strip from the ante- rior face of the apparatus as descriljed on p. 70. 84 ox THE USE OF PLASTER I.X FRACTURES but A\itli circular plasters, for the reasons you already understand, that -with a circular plaster, the patient Avill be at once more comfort- able and better supported: you "will obtain the most perfect results. Fig. 66. — RadiogTam ; fracture of femur at the lower third; angu- lar displacement and slight over- lapping of the fragments. y. 6". — Reduction of the fracture has been effected under ana?sthesia ; radio- gram taken through an opening in the plaster apparatus : the displacement remains as before in spite of very powerful traction exerted on the foot. By constructing the circular plaster in the manner explained, by inspecting afterwards the condition of the lingers and toes, you haYe no need to fear for the good nutrition of the plastered limb. a What should be done in the case of a fracture complicated with a wound; Make an opening in the plaster (a few hours after its construc- tion) through Avhich to dress the wounds. iM.ASTr.K i\ lUAcii iu:s (J|- Tin. ll.MI K 85 \[ lliiTc ;iri' several wounds \oii can rosorl ion ol a bivalve plaster. // In (lio lasodla projecting fragment, lor oxainplo in I'rac- turc of llic llljia or clavicle. Exoi'l pressure on I he Craii- ment;; ol' llie lihia. or ol' the chi- \icle, with squares of wadding lield bv strips of adiicslve plas- ter. You exert pressnro in a manner similar to that ol com- pression of a Potts' gibbosity Cv. ch. V). In the case of fracture, the pressnro should be made less over the summit of the projec- tion than upon the adjacent parts of the bonv frairments. the conslruc- Fracture of the Patella. — Treat in the same wav. bv com- pression. Arrange strips of cot- ton wool around the t%vo seg- ments of the patella. Proceed in a similar manner in fractures of the olecranon. Fracture of the Femur. — Here again, >ve make, rather than the generally extolled ex- tension, a large plaster, because with an accurateplaster we obtain results far superior to those formerly obtained by Henne- quin"s extension. This plaster should be very carefully moulded on the pelvis: before setting, one pushes against the ischium from below upwards, while vigorous traction is made on the foot. Bv making an ope- ning in the plaster it is possible Fig. 68 — In this planter an anterior opening has been made opposite the fracture: this arrangement has allowed of a progressive reduction of the dis- placement being effected. For some consecutive days, this progressive re- duction was carried on by compresses of wadding, inwards on the upper fragment, and outwards on the lower fragment and renewed every three or four days. This radiogram was taken after the removal of the plaster, six weeks after tiie accident. Compare with it fig. 60 and 67, it can be seen- that the result obtained is perfect. to perfect the correction in the way 86 ORTHOPEDIC APPARATLS here represented. Here, for example (tig. 67 et 68) is a case of frac- ture of the lower third of the thigh, Avhere the radiogram shows pro- jection of fragments which immediate reduction, made under chlo- roform, Avas not able entirely to efface. We made an opening in the plaster at that point and applied the pads of Avadding, above and outwards at one part, beloAv and inwards at the other, consequenth" in opposite directions, to return little b\ little the two fragments into line. This very energetic compression, Avas kept up by strips of adhesiA-e plaster^ and rencAved everv three or four days. One can see, by comparison of the radiograms (fig. 66, 6'] (a 68), all the steps of the correction, and the perfection of the result ultimately obtained by this method, so simple and benign. Is there another method (surgical operation or extension) AAhich Avould give, I do not sav a better, but as good a result? We do not belicA^e it. For fractures of the arm or fore-arm one should be guided by the ame principles. II REMOVABLE APPLIANCES AND ORTHOPEDIC APPARATUS^ Precious as plaster apparatus are, thev do not suffice for all our needs. We shall see this in studying each deformitv. But, by this time aou Avill haA-e found out that for manv patients the plaster apparatus may be contra-indicated, because it is not mo- vable, noT articulated ; and that in some other cases, it Avill be rejected simplA' because " it is plaster ". I Avill explain myself : First. In certain diseases, the patients require to be supported bv an apparatus, but Avith the possibility of its being taken off from time to time, in order to folloAv some physio-therapeutic treat- ment : massage, gymnastics, bathing, electricity, etc. Example : the scoliotics (and vou knoAv they are legion). Example : patients afflicted Avith infantile paralvsis. I. See, on ttiis subject, the admirable thesis by our assistant at Berck, Dr, J. Fouchet. IIIK IMMCVIIONS lOH TIIKSi: Al'l'AUATUS 87 For some of lliesc, an apparatus ma\ l)o indispensable, lor len or Iwentv Noars, and sometimes I'or lil'e. It cannot be a plasler. Ijul, some liglil apparatus, removable and jointed. Secondly. Tliere arc oilier diseases where the treatment com- mences willi plasler and is terminated >vitli removable apparatus. — — ■ -xi-j- ^' Fig. 60. — Celluloid orthopedic corset, t- . . .1. .,, . ^ fiff. 70. — A laro-e orlhopedic with armature. ^ ' . ,, , . , ' ^ apparatus in celluloid. — For the hip and entire lower limb. Example : tuberculous orthopedic affections (Pott's disease, hip disease, Avhite swelling). The plaster is Avorn up to the perioctof convalescence; but, at this moment, when the patients are alloAved to stand, it is advantageous to replace the plaster by a removable apparatus, which fills in the period between that of strict immobility and that of entire liberty. By taking off the apparatus each night, and even for a little while SUPERIORITY OF CELLULOID APPARATUS each day, the muscles are exercised and strengthened, the joints are loosened, gently and spontaneously. There are other deformities (such as congenital cluh-Toot, genu A'algum, tarsalgia) ^vhere plaster is indicated immediately after the correction, in order to maintain it completely. But, after some Aveeks or even months, the correction ouoht to he preserved hy a lighter apparatus, Avhich mav he taken off at Avill, in order to safe-guard ^the nutrition of the muscles and the plav of the joints. Thirdly. You Avill find many patients, especially among the upper classes, -who ought to Avear a plaster, hut Avho Avill not have it at any price, not for a moment. And Avhy ? Simjjly he- cause it is a plaster, and because they are frightened or rather humiliated, by the prospect of seeing their chil- dren immured for months, perhaps for years , in a "■"block of masonry ". A leg plaster, that may pass; but to be imprisoned in a great " pillory " of plas- ter Avhich takes in the trunk entirely and even also, the head, that, never ! What is to be done? give it up? No. One can still at the last extremity treat them and cure them without plaster, by means of movable apparatus — although it involves a little more trouble and more time. Ah! An apparatus Avhich you can remove Avhen you wish to, that, yes, they will agree to that, or at least, they will consent to try it, inasmuch as celluloid is a more appreciated article than plaster, with its bad reputation. They will try the celluloid, and, what will happen? Very soon — having become accustomed to it — the patients, instead of being tortured, find themselves much better with the apparatus than without it, they no longer Avish it to be removed, they cannot do Avithout it, so that this removable apparatus becomes, as a matter of ^'^S- 7'- — Dorsal aspect of the apparatus sliewn in fig. 70. Tlie two halves of the pelvic portion are joined Ijehincl by two sliding pieces allo^ving of the increase of the diameter of the girdle. (IN I III: I SE Of l'I,A^■llu loK c.r.iriAiiN iiisEAsKS 89 ;kI, iir('nH)\;iM(' ; and so il .noes on lo llir cure: Iml Ihcic was a Fig-. 7^. — An articulated Fig. 72. — The same apparatus '\>itli a >^indo\v apparatus in celluloid for -shutter opening allowing inspection of an tlieliip. A bolt allows the abscess. joint to be fixed or loose ned as may be desired. right Avay to render an apparatus acceptable and this Avas, that it should not be a plaster one. lou see already how numerous are the indications for removable appara- tus. Here are still more. «. You are consulted by a man of very active habits, suffering with Fig. 73. — Thanks to this broadpitch screw adapted to the femoral part of the same apparatus, it is possible to produce a certain amount of traction on the limb. . go MOVABLE PLASTER APPARATUS Pott's disease ; he will not comprehend that he ought te keep at rest in a large plaster, or rather, cannot, he says, having a family dependent upon him. He asks for a movable corset which will admit of his getting about and seeing after his affairs. b. Several times, I have seen these patients with Pott's disease" broken- winded " and bronchitic, asking for a support which would accomodate the thoracic movements. I have sometimes supplied, with this object, a plaster, with a very large opening, but they prefer a moveable corset. Also, through especial anxiety to ensure the frequent toilet of the skin, many ladies of fashion prefer celluloid to plaster, etc. So that, although plaster is always sufficient for the treatment of fractures. rig. 75. — The bolt wliich Gxes the knee-joint in extension for -walking and "which the patient can draw and unhinge, In" means of a cord, in order to bend the knee- joint "when he "wishes to sit clown. it may not be possible, in the treatment of orthopedic affections, to ignore movable apparatus. lou will object that there arc many patients unable to meet the expense •of a removable apparatus, or to procure the help of the " assistance publicpje "', 5till very defective in ovir country districts. W'hat can be done for these patients? One thing only (not sufficient for all cases, but for most of them). That will be, whenever possible, to finish the treatment with a plaster as in the case of treatment of fractures. Come to the w"orst, it can be done for all deviations other than infantile paralysis (and it can be done even in certain cases of infantile paralysis). It can be done in cases of hip disease, "n^hite swelling, Pott's disease; the patient will be allowed to stand and take his first steps still wearing his plaster apparatus. But we will return to this subject further on, d propos of these different diseases. WHAT WILL BE THE MOVABLE APPARATUS? 1 . Removable apparatus in plaster. . ^^hY not make movable apparatus in plaster, which will have SlPEIlIOlti I ^ oi" A UEMOVAIU.i: IT.ASTKIl AI'I'AIIATUS 9' till" .TFERIORlTY OF LEATHER OR SILICATE APPARATUS There remains however cases "where a movable plaster is indica- ted. We will point out all those different cases, as we go along, a propos of each disease. But we may say, for the present, that one uses the movable plaster in all cases of multiple fistulce, or where the skin is verv irritable * and eczematous, requiring daily dressing, or still more in a breathless or very nervous subject, who Avishes to Fig. 78. — A large bivalve plaster for the lower limb. The two valves will be kept in position by bandages or by straps. train himself to wear his plaster, bv keeping it on, at the beginning, onlv a few hours dailv. Movable plasters are useful again in certcin white swellings (of the elboAv, the wrist or the ankle) during the period of injections. To be effective and durable, the movable plaster should be bivalve. But it is not possible to make it of a single piece, that is to say, opening only in front, as in a celluloid apparatus. Plaster is not a sufficiently elastic material for that; made in one piece only, it will crack inside and lose its form almost immediately, after having been taken off and replaced scarcely four or five firnes. I . In tliese two cases, the apparatus will be rapidly soiled and should be renewed very often. It lAill therefore be much more practical here to use movable plasters than celluloid, the frecjuent renewal of which would become far too expensive. ALWAYS PREFER THE APPARATUS IN CEF-IA I.OII) 93 The Bivalve iMovable Plaster. Mflhtid "f ils coiislruction. It is sul'licient to prepare an ordinarv plaster in the inamicr alrcatlv explained; and, when it is dry, altera few hours, or belter still alter a lew davs, it is divided into two valves, by symmetrical incisions at the sides, or before and behind. To obviate the risk of damaging the skin in dividing the plaster, you should use two jersevs — or better, over a single jersev. corresponding Avitli two lines already marked out for two incisions, place bands of wadding three or four centimetres Avide and half a centimetre in thickness — - or better si ill, two strips of zinc, such as one uses in moulding (v. p. 99). The jersev. which remains attached to the inner surface of the apparatus, serves as a natural lining. It is easY. afterw ards, to reapply such a movable plaster. The two halves are replaced in contact by their edges, and kept so by means of straps or a few turns of Velpeau (if one has to take it off every day), and strips of sticking plas- ter, (if taken off onlv now and then) ; or again, one may lace it with hooks stitched to the strips of linen (fig. -9) which have been fixed to the edges of the apparatus with plas- ter paste, or white silicate of potash, or even with ordinarv glue. 2. Removable Apparatus in silicate of potash and leather Apparatus. I only speak of these to dissuade you from using them. Indeed, apparatus in silicate arc too heavy and too friable. As for leather apparatus, they are not firm (they do not keep their shape without an armature), they are heavy, not clean, and are evil smelling. 3. Apparatus in celluloid. Do you wish for an apparatus light, firm, clean, really neat') Then use celluloid. 5. 79. — Removable plas- ter corset ■\vhicli can be laced and unlaced bv nieans of books fixed on tbe edsres. 94 SUPERIORITY OF CELLULOID AP;>AR\TUS Fig. So. — The positive mould (for coxitis). Fig. 8i. — The celluloid has beea constructed upon the mould ; it has not yet been removed from the mould (v. fig. 99.) Fis. 82 Method of constructing a celluloid apparatus (for the hip). Squares of muslin are spread upon the mould ^vith a brush dipped in celluloid paste. Mirnion or constructinc a cei.i.i r.oii) ai'I'Auati;s 9» ('.(•lluldid liikiiii; more lliaii IwciilN-liours lo solidil'v, caniiol be ciHislruclcil, Jiko plaster, on llie suljjecl, who Avould have fiflv times ihe ehaiiee ol h)siiii; llie corrcclioii helorc ihc celluloid became solid, ll shoidd be coustrucled on a mould (\\g. 86). ^(Ml may prepare the celluloid vourself if you ^visll '. Uiir loiistructs it willi squares of niushn impregnated willi cenuloid paste. This paste is made wilh acetone and llic debris ol" ceUidoid (about five parts of acetone to one of celluloid). Instead of using muslin strips, one uses scpiares. Fig-. 83. — Construction of the celluloid corset. On the positive mould, and covering- llie whole of its anterior surface, is applied a square of muslin. (Another square is applied afterwards on the posterior surface). The squares are made of a length equal to half the circumference of the mould. The first square is applied in front, the second behind, the third on the right side, the fourth on the left, alternately, so that the celluloid apparatus has a thickness everywhere of sixteen sheets of muslin or thereabouts. The thickness ranges from 8 to lo sheets (for a hand apparatus) to 20 sheets (for a large celluloid corset for an adult). A brush is used for applying the celluloid. One commences by applying over the mould a layer of oil, then a square of muslin (impregnated with the I. As we used to do formerly, apparatus in France. Indeed we constructed the first celluloid 96 THE CONSTRUCTION OF AN APPARATUS IN CELLULOID paste); one pulls upon it, to adjust the edges, afterwards a layer of the cellu- loid paste, then a sheet of muslin, and so on. One lays on the celluloid and the squares after the manner of bill stickers. One may construct the celluloid apparatus in the rough at [one sitting of about half an hour; after that, over the last sheet of muslin, two or three coatings of paste are laid on, repeating this every three or four hours, until Fi^. 84. — Tlie construction of a corset (continuetl). By means of a brush steeped in the celluloid glue, the square is flattened down, at first in the median portion one reaches the number of 10 or 13 coats; this will give the celluloid polish and brilliancy. After that, leave it to dry for two days, without touching it. Then the celluloid may be taken off for the fitting. To take it off. one cuts along the lines, where, later on, one will lace the elluloid (fig. 81). The fitting having been accompUshcd, it is replaced on the mould; the metal strengthening pieces and joints, if there are to be any, are added. ^ But, if you have not the aptitude for work of this kind, you run THE MKTllol) OF 1 AKINC A MolI.D 97 llic rislv ol lailiii;^; in aii\ ca.-'-i-'^4?'Ai}*J^^,B F ■ V 1 ^^^^^^1 ^B^^^^^2 1 V J 1 t^^' >a^ ^^^t*'" ► , ''^^''-'^H Fig. 85 — The construction of a corset (continued). — The edges of the square are coated over, while vou puU -\vilh the oilier hand to efface the creases. patient, who tlius need not be disturbed, they will trim and finish the celluloid. Thus the whole thing loiU be reduced lo your taking the mould and filling the apparatus, two things very easily done, if you proceed in the followini; manner : I. The Moulding. You have never made one and the very thouiiht of liavinp: to take a mould dismavs vou. Verv well, be reassured: without having I. Sucli as we have at Berck. in the Orthopedic Institute, and as tliere are no\A" almost everv«here in France. Calot. — Tndispensahle orthopedics. " 98 CELLULOID APPARATUS made one, nor having even seen one made, you will succeed at the first attempt, for to take a mould, it is sufficient to construct an ordi- nary plaster on the hare skin, and to remove the plaster after it has set; after ^vhich, the edges of the plaster are brought together, to restore its shape, and thus a perfect negative is obtained . Fig. 86. — Moulding of tlie instep. Cover the skin -witti an ordinary stocking cut off at the toes to allow a strip of zinc being inserted bet- ween the skin and the stocking over which the mould may be cut, in order to remove it. Fig. 87. — Placing the attelles for the moulding of the instep, lou com- mence by applying squares of plas- tered muslin. Over these you roll a plastered strip. The position in Avhich the patient is placed for moulding is, as a general rule, the same as that adopted in constructing a plaster appa- ratus for the same region. For the lower limbs (foot, leg, hip), it should be the horizontal position ; for the trutdv, the vertical position. The patient touching the ground completely with the feet and lightly supported (I do not say suspended, but supported) by the head, by means of the, today, classical strap (fig. 248 and following). — For the upper limb, the upright position. MKIIIOI) <)l" takim; a molld 99 Fig. 88. — Moulding of the knee : the leg is covered with the sleeve of a jersev, underneath ■which has been passed a strip of zinc about three centimetres wide. ButAvc Avill now go into details, There are two precautions lo take. I . In order that the plaster may not adhere to the skin and to the Fig. i>9. — The position of the two strip - in moulding the lower part of the trunk and lower limb (for a small celluloid apparatus in hip disease). lig. go. — ^loukling of the trunk. How to place the strips beneath the jersey. lOO CELLULOID APPARATUS hair, a thin but continuous layer of vaseline is applied over the whole of the region to be moulded. You Avill find in a toAvn Clinic many timorous parents of children Avho dread the contact of plaster with the bare skin. For these you should make a mould over a closely fitting casing (a jersey, a sock, a stocking). This fabric makes a protective lining to the inner surface of the mould, and comes off" with it. So that the adhesion of the covering Avith the plaster may be more intimate, you commence by Fig. 91. — Cutting a mould for the knee. You cut over the zinc strips so as not to -wound the patient. spreading over the outer surface of the covering, a layer of plaster cream before applying the plastered attelles and strips. 2. To prevent all risk of wounding the patient in removing the mould, you place immediately over the skin one or several strips of zinc three or four centimetres wide, upon which you can cut the mould afterwards, as upon a director. The strips being placed in position, you have only to construct the plaster. You do this with attelles and strips of muslin, after the manner of an ordinary plaster. You may introduce some slight variations meanwhile, thus; a. Begin the apparatus by the application of squares or attelles, and finish with plastered strips. PKACTICAI. TI'CIIMOIE 01' \l(»l f.DlNC lOI 6. ']"(i liasU'ii llic (lixiii- of llio |)l;i>|cr, lli;ii is lo say, lo save time, \ou ma\ here use tepid waler, al 'A'y' or /|0", or even cold water Fig- 92. — Cullitig a mould of tiie tliigli. uitli salt (tMO or three tea-spoonfuls of salt in each of the t-wo basins in Axhicli are the attelles and strips). Fig. f)3. — Cutting a mould of Fig. g/,. _ The mould having been removed, tlie the trunk. edges are approximated and held in contact by several turns of soft muslin bandage. 102 CELLULOID APPARATUS This premature drying would have some drawbacks to the firm- ness of an ordinary plaster which has to be kept on for a certain time ; it has none here, for a mould intended to be done away with after a few hours, when it has served as a mould or mannequin. It goes without saying that as soon as you have applied the strips and attelles, before the plaster has set, you verify the position Fig. 95. Fig. 9O. Fig. g5. — A negative mould (of the trunk) placed upon a bench in readiness for the pouring in of the plaster cream, that is to say, for the preparation of the positive (see follo-\ving figure). Fig. 96. — The positive mould obtained from and taken off the negative mould of the preceding figure. of the region to be moulded and you model the articular or periarti- cular prominences. You model as well the edges of the zinc strips. Immediately after the setting of the plaster (or some minutes after) you remove the mould by cutting with a bistoury or an ordi- nary knife over the zinc lathe, and right down to it, that is to say, you cut also the jersey; you then raise the edges of the mould and, thanks to the presence of vaseline, or of the jersey, the mould detaches itself easily from the skin, without any tugging painful to the patient. One proceeds with the removal gently and cautiously, so as not to crack the apparatus. Ill IING THE AIM'AHATIS io3 One IIhmi biings together the edges and one keeps llioni in coiil;iti cither with an attollo of plastered nuislin whicli, encroaching on the two edges, will serve as a '* clasp ", or Avith a band oC soil muslin rolled round the entire mould. In order to construct the " positive " one has only to pour into ^'e- 97- — The celluloid corset finished. ' When it is dry, cut it along the mediaa anterior line and above each shoulder,^in order to remove it and (o carry out the fitting on the patient. this hollow mould some plaster cream ^ But you may avoid this trouble, by employing a worker in celluloid; send him the neo-ative mould, such as it is, and he will reproduce the " mannequin " upon which he will construct the celluloid apparatus. At the end of a few days, as I have already said, he will be able to send you the celluloid so that you may fit it upon your patient. I. I refer you, for all the details, to the thesis already mentioned of my assistant, D' Fouchet. I04 CELLULOID APPARATUS The fitting of the celluloid apparatus. Utility of fitting. — ^ou mav think that the celkiloid, having been constructed on a faithful mould, does not need to be fitted ; nevertheless I advise you to make such fitting whenever it may be practically possible. It will afford you an opportunity of correcting, Avith absolute precision, the length and breadth of the apparatus, the level of the lines of the joints, the situation of anv openings and hollows, etc. Thanks to such fitting, you Avill be able to obtain, still more certainly, a perfect apparatus, that is to sav, without causing any discomfort to the patient, and thoroughlv fulfilling its object. Fitting the apparatus for the foot. The celluloid is sent to vou (bv the constructor) in two pieces, one for the foot, the other for the leg, which are divided on a level with the line of the tibio-tarsal articulation, or rather a little below it, on a level with the axis of movement of that articulation. Without this divisionit wouldbe very difficult to apply the apparatus round theinstep. It goes Avithout saying, that each piece has been split along the anterior median line where the finished apparatus will be laced. The fitting is done upon the skin, bare, or covered with a sock or very thin stocking. The two pieces of celluloid are placed in position in turn, pulling them firmly ajar in front (this mav be done without cracking, thanks to the elasticity of the celluloid). Notice that the anoles of the celluloid, not vet trimmed, are almost sharp, and to prevent them pinching or lacerating the patient's skin, when the apparatus is put on, you should take care to take these angles betAveen your fingers, calling in the help, if need be, of one or tAvo bystanders. Verify the upper and loAver ends of the apparatus, and especially the AAadth of each piece. If thev are a little too Avide, let your assis- tant make the tAvo sides overlap one another, and chalk out froin top to bottom, the line of crossing of the edges, that is to say, the limits of the small strips of celluloid to be removed. If the tAvo pieces are a little too narroAv, you mark, in the same Avay, the distance Avhich separates the tAvo edges, so that the maker may increase, by so much, the Avidth of the fore piece, Avith a flap of soft leather added to it. One does not leave, in fact, the rigid anterior part of the celluloid, Avhich Avould make it difficult to take off and put on the apparatus. One replaces it by tAvo strips of soft leather Avith evelets. FITTING THE CEIXULOIO io5 The loo( iiiul \v'j; being covonHl willi lliclr sIkmIIi oT celluloid, see that llie ])roiniiietices of the malleoli correspond well Asilli llie depres- sion in llie celluloid. This Avill salisly \ou ihal the metallic joints are avcU on a level witli the natural articulations and that the pieces of steel will not exert any abnormal pressure on the bony promi- nences. You can afterwards mark llie limits of llio hollow iiip at (he instep, Fig. g8. — Fitting an apparatus to tlie foot : tlie leg portion and tlie foot portion have been divided opposite the tibio-tarsal articulation and split in front. Avhicli liollo>ving varies Avith the degree of flexion you wish to have. But vou mav be able moreover to dispense with that, for Avith your Avritten instructions, the maker will be able to give the apparatus the amount of play desired. For the rest, in a general wav, restrict vourself to tracing with chalk the slight modifications w hich appear to you necessary, w ithout cutting anvthing off yourself. The maker is furnished with tools to execute more easily and neatly the alterations you require. He supplies afterwards the apparatus with its articulations, the disposition of Avhich Avill enable you to leave them rigid or loose according to vour likino;. io6 CELLULOID APPARATUS But you will apply the celluloid to the patient yourself, and superintend its use. Fitting an apparatus for the leg. In the same Avay, when fitting on an apparatus for the leg, it is necessary to make certain that the depressions of the appai^atus cor- respond Avell Avith the particular pi-omi- nences of the region ; to A'Ci'ify also the length and width, and to mark with a pencil, the level of the line of the knee- joint (the line which corresponds to a horizontal passing through the point of the jjatella); and, finally, you should mark on the celluloid, on a level with the popliteal sjDace, the large piece to he hollowed out on the two leg and thigh pieces of the cellu- loid in order to permit the movements of flexion of the knee, in cases where you wish to preserve those movements. But, as in the apparatus for the foot, you may dispense with that ; the maker should easily know, with your written instructions, how to make the posterior hollows and give the articular play required. Fig. 99. — A small cellul- oid for hip-disease ope- ned and separated from Ihe mould. It is ready for FITTING. Pitting a celluloid for the hip and one for the entire lower limb. The constructor sends you this large celluloid in four segments ; pelvis, thigh, leg and foot, Avhich facilitates greatly the fitting. When the hip or the knee ought to remain rigid, he sends you three segments only. The small celluloid for the hip is in one piece only. See fig. 100 for the method of putting on the apparatus. You commence hy placing in position the pelvic segment, the girdle; then you put on the femoral segment. In order not to injure the patient in doing this, cover the angles Avith cotton avooI or Avith your fingers. The edges are kept in contact either with your hands, or with straps encircling the pelvis and the two seginents of the celluloid. You make certain, here again, that the depressions in the appa- ratus correspond Avith the prominences of the region. You verify the length and Avidth of the celluloid. The thigh of the opposite side should be able to be flexed to FiiriNr; i iir celluloid 107 about an angle of 90"; il is ncccssarv lo remember lliat, in order' lo hollow, if need be, the apparatus at this point. More than that, if it is desired to put on lliis (tlie sound) side a strap of leather or soft Fig. 100. — Fitting an apparatus for the hip. The manner ol putting it on when one is alone. First, open and introduce the pelvic segment, then the femoral. If you have an assistant, you can, wilh his help, open and introduce the two seg- ments at the same time. tissue (to prevent the celluloid from rocking) you should indicate the points of attachment and the length and breadth of the strap. Lastly, the upper edge of the apparatus, in front, over the abdomen, is cut in the form of a crescent, in such a Avav that the middle por- tion leaves the umbilicus uncovered. ^^ e Avill describe, in the chapter on Pott's disease, the method of fitting on the celluloid corset (v. p. 827). CHAPTER II A WORD ON AN>ESTHESIA IN ORTHOPEDICS I. - LOCAL AN/ESTHESIA a. Cocain and Stovain are not often used in Orthopedics. Tliey may be used, of course, to perform a tenotomy, when this tenotomy is the only interference required ; this is very rare ; but in torlicolhs, in congenital club-foot, in old hip- disease, division of the tendon is not the only factor in the correction, and vigorous movements for redressment are indis- pensable before and after the tenotomy. These manoeuvres nearly always require general anaesthesia. h. Ethyl chloride as spray is the ordinary local aneesthetic for puncture of an abscess and for intra- articular injections (v. fig. Ill, p. l32). This anaesthetic is sufficient, provided that it is used with care; one waits, to introduce the needle, until the skin is blanched over an area the size of a five shilling piece. Old patients, always ask for « a little more ethyl chloride ». But avoid the direct and prolonged contact of ethyl chlor- ide with integument which is already reddened and thin, the vitality of which is very low, as the chloride might reduce it still more. In that case produce the anaesthesia on the sound skin, some distance away, and there you will puncture. SOME REMARKS O.N (iENEUAL AN.ESTHESIA 109 II. — GENERAL AN/ESTHESIA This may be pioduced by chloroform, or b\ ether'. If vou are accustomed to ether, you slioukl keep to it; if mil. I advise \ou lo prefer chloroform. Ether is, it is true, a little more easy to administer than chloroform; but it exposes the patient to grave inllammalion of the air-passages, Avhicb mav lead to pulmonary gangrene and abscess of the lung, and more than that, during the whole of the antestliesia, etiier keeps the patient in a state of manifest asphyxia which some- times becomes alarming. Therefore, you should employ chloroform by preference.' There are two remarks to be made on its use in orthopedics. a. The first is that chloroform as a general rule, is much better tolerated by children than by adults, who are nearly always more or less out of condition, or are alcoholic, atheromatous, emphysematous, etc. h. The second is that, in orthopedics, anaesthesia does not need, in an ordinary way, to be pushed to its extreme limit, for example, as far as in abdominal surgery, where it is neces- sary to aAoid the least reflex moyements of the intestines. — So, for the correction of a congenital luxation, a coxitis, or for a club-foot, it is sufficient that the patient is insensible to pain and unable to make any movement of a nature likely to hinder the operator; in other Avords it is sufficient that the muscular resistance is overcome and that the patient does not cry out. You may then, in orthopedics, be satisfied very often with an anaesthesia such as you would use to reduce a traumatic dislocation of the shoulder or perform taxis in a case of hernia. Now, here are some indispensable notions on chloroformisa- tion . I think it is not a digression to give them here, because they are too often violated or misunderstood, and they do not appear to me to be clearly set forth in the large treatises on surger\ . I. I do not see an\ advantage etlivl-ljroinide has over cliloroforni, and I mvself use the latter even for the removal of adenoid vegetations. no GENERAL ANAESTHESIA. PREFERENCE OF CHLOROFORM The absolute criterion, the only one, to know if the sub- ject — Infant or adult — put under chloroform, sleeps suffi- ciently, but not too profoundly, is to see that his corneal reflex is retained. It is necessary, during the whole operation, that the reflex he preserved, whilst the general sensibility and the resistance of the muscles of the limbs are abolished. Fig. 101. — llie ocular reflex. — First stage; the an2Bsthetist has partly opened the eyelids of the patient and placed the tip of his index finger on the eye. By the corneal reflex, one means the contraction, active and immediate, of the eyelids (always appreciable in the upper eyelid), Avhen it is left free, after having been stimulated by touching the cornea of the patient with the index fmger (fig. loi and 102). If the patient is insensible and inert, at the same time that the contractility of the eyelids persists, the anaes- thesia is sufficient for what is to be done; orthopedic correc- tions, and surgical operations. Ancesthesia has then been sufliciently « pushed ». One is certain that it is not too much so, as long as the corneal reflex remains. Security is then complete. THE ONLY CERTAIN CRITERION; Till- COKNEAL REFLEX III During tlie whole of llic opcralion, do nol exceed this degree either on this side or on tlial, Ijiit preserve it hy a few drops ol" clilorolorm athiiinistered from lime lo time. When the patient has lost the corneal rcfle.c, one does not know where one is, and it may he one has gone too far. Apart from tlie corneal reflex, no sign is of absohifc value. Fig. 102 Tlie eve . — The ocular reflex. — Second stage [: anx-thetist, after having touched the cornea, quickly removes his hand to allow the eyelid to close, ought to close firmly, in an active fashion, which can be recognised by the folds which are formed at the commissure. The respiration, the pulse, the color of the face, the dilata- tion and contraction of the pupil, do not signify very much. The respiration may even remain perfect, the pulse normal, the face of a rosy colour, the pupil contracted, and everything, in a word, may appear up to that point satisfactory, Avhen suddenly, without any warning, the respiration and the pulse stop, and then, it may be too late. Rely then entirely on the corneal reflex; it alone will not deceive you. The talent of the ansesthetist consists precisely in attaining 112 CE\ERA.L ANESTHESIA. ITS TECHNIQUE this condition, and in keeping constantly to this degree of anaes- thesia, to take care on the one part, not to allow the patient to awaken, which is evidenced by the movements of defence of his limbs or by his complaining ; to prevent on the other, narcosis becoming too profound, which is ascertained by the loss of the ocular reflex. In the first case, if the patient makes some movements ''of defence (still being unconscious), give him six or eight 'drops of chloroform every eight or ten respirations (do not hurry, do not give the chloroform in large quantity at this moment) until again he is motionless. In the second case, when the ocular reflex has been lost, stop, do not give any more chloroform until the reflex has reappeared : — and so on, until the end of the chloroformisation. 1. The ordinary method of producing sleep. For child- ren who understand, above lo years of age, proceed gradually by slight and continuous closes as you would do for an adult. Every six or eight respirations, throw six or eight drops of chloroform upon the outer surface of the mask, turning it quickly over upon the child's face. 2. The method of producing sleep instantly. If the child is very small, or very nervous, if fear and alarm causes him to cry and struggle violently at your approach, if he resents all your coaxing, if he will not be soothed nor listen to anything, it is better for him that you proceed expeditiously and put him to sleep quickly. Whilst his hands and feet are held, quickly throw fifteen or twenty drops of chloroform upon the mask and apply it quite closely to his face, without allowing the admission of any pure air. His cries Avill at once cease ; the child struggles for scarcely six or eight seconds ; he quickly loses all knoAv- ledge of his surroundings. You keep the mask in position for ten or fifteen seconds only. The child's face is a little INSTANTANEOUS NAUCOSlS IN ClIir.DHOoi) ii3 ooii^oslc'il, l)ul il is already molionlcss, having iiOAvcver the ocular rcllex slill plainly marked. You proceed from lliis moment very gently, Avlth six or eight drops every six or eight respirations, the face regaining its rosy hue in a few seconds. Tf the first whifs of chloroform have not heen sufficient lo Fig. io3. — Withdrawing the tongue ; with the left hand the tongue is drawn out of the mouth ; the index finger of the right hand firmly turning out the labial commissure from the dental arches. abolish the defensive movements in a child of six or seven years, for example, give a second dose, proceeding as Jias been already explained. During narcosis ahvays take care to support the patient's chin with your fingers; that facilitates the respiration greatly. If he vomit, it is because he is awakening. Give him another dose of chloroform, slowly, Avithout too much hurry; thai would be dangerous. If respiration has ceased (but that will not occur until the ocular reflex has been lost, which will not occur if Calot. — Indispensable orthopedics. 8 I 1 4 CHLOROFORMIS ATION carefully Avatched) one should immediately AA'ithdraAV the child's tongue Avith special forceps, or, in default of them, with a safety-pin, keeping- it outside by exerting slight traction on one side, the head being turned and laid on that side, whilst, with a finger introduced into the mouth between the teeth and the opposite cheek, the cheek is raised (fig. io3). This manoeuvre of AvithdraAA-ing the tongue and raising the cheek suffices nearly ahAays to restore the breathing. If it does not suffice, perform artificial respiration. Re- member that in such a case it is the only thing to be done and do not lose time in doing anything else. The anaesthe- tist supports the head, not too much flexed, nor too extended, on the table : toalloAA" it to hang over the table, as advised by some authors, is bad; it might produce too great tension, and consequently a partial closure of the air passages. An assistant holds the legs as a counter-resistance to the traction Avhich you yourself make on the upper part of the trunk, in manoeuvering the arms to produce artificial respiration : but I need not insist on that — you know all about it. The ma- nceuvres of artificial respiration are studied and illustrated in all the treatises on minor or major surgery. I Avish to conclude Avith tAvo observations : a) \Mien you are about to redress a case, you should not alloAv the patient to awaken until the proceeding is quite finished and the plaster « set ». Allow the patient to aAvaken gently. b) Lastly, I Avish to point out that Avhen the patient is ready to aAvaken, he appears sometimes to haA^e lost his ocular reflex and his respiration become all at once silent. Do not be alarmed; press a little harder on the cornea, and you AA-ill see the eyelid react ; moreover, the complexion instead of being- pale, is here as rosy as that of a person sleeping naturally. CHAPTER III THE TECHNIQUE OF PUNCTURES AND INJECTIONS I IN THE TUBERCULOUS SUPPURATIONS Take note from the beginning that this technique is the same for all tuberculous suppurations, equally well hip-disease and Pott's disease as cold idiopathic abscesses. SUMMARY OF THE [TECHNIQUE K A. What it is necessary to obtain. 1° As to instruments : a needle, number 3. a small aspirator, a glass syringe (all these instruments should be capable of being boiled). 2° As to modifying liquids : 2 flasks, one of oil, cresote, and iodo- form toil 70 grammes, ether 3o grammes, creosote 5 grammes, gaiaco! 1 gramme, iodoform 10 grammes). The other of naphthol camphor with glycerin (naphtol camphor 2 grammes, glycerin 12 grammes); this second mixture should be shaken vigorously for a minute and a half and injected immediately, because it is very unstable. These two liqvxids are all that are required. The indications for each : As a general rule, inject the first of them (the oil). — lou may reserve the second (naphthol camphor) for the case where an abscess contains clots blocking the needle, in which case two or three injections of naphthol camphor will soften and dissolve the clots ; after M'hich, you return to the first liquid. The dose to inject is the same for the Uvo liquids, namely; 2 to 12 grammes, according to the age of the patient, for abscesses of a capacity of 20 cm. c. and more. If the abscess is very small, less than 20 cm. c. you inject half as much liquid as of the pus withdrawn. In this way all h^per-tension of the skin is avoided. 3° Have also: a) a tube of ethyl chloride for local anaesthesia and some I. If you are pressed, for time, content yourself with reading this summary where are collected all the leading ideas — returning later to the reading: of tlie entire chapter. ]l6 PICTURES AJJD INJECTIONS IN THE TUBERCULOSES tincture of iodine for sterilization of the skin; b) a small boiled cup, to contain and take from, the liquid to be injected; c) and, lastly a sterilized dressing. B. The Technique. When should you commence the punctures? Immediately the abscess is plainly perceptible, provided you can get at it without danger. (But, this danger only exists for deep abscesses in the iliac fossa; here, you may postpone the puncture until the abscess has become easily accessible). For this technique, there are two recommendations; be very clean and use fine needles only. a. To be very clean; be quite sure of the asepsis of your hands, of the patient's skin, of the instruments, of the liquids to be injected, of the after dressing. b. Employ only fine needles instead of the large trocars generally iised; keep to our N° 3 needle (which has an outer diameter of only one and a half millimetres). Needle N° 4 must only be used when the abscess is far removed from tlie skin and its contents very thick. In no case should a 7ieedle larger than 'N° 4 be used. Other Recommendations. c. Puncture in healthy skin, at a distance of 4 or 5 cm. from the abscess, in such a way that the two orifices in the skin and the abscess are separated by a long oblique track. (/. And at each new puncture, prick the skin at a new point. How many punctures? You may make several punctures and injections (from 7 to 8 and not one only) — for the cures will be so much more certain than with one punc- ture only. At what intervals? When should the second puncture be made ? Ten days after the first. And the others at equal intervals of from 10 to 12 days. After the seventh or eighth sitting, the walls of the abscess are so sound, so healthy, that it only remains to seek for their adhesion. With this object, at the last sitting, after having made a last puncture (without injection) you compress the region, beginning at the extremity of the limb, with layers of cotton wool, held in position by 2 or 3 Velpeau ban- Jages. — Every four or five days one adds over this dressing a new Velpeau bandage which keeps up the pressure to the degree required. On the fifteenth or twentieth day, the dressing is discontinued. The abscess is cured. The duration of treatment of a cold abscess (essential or symptomatic) takes then, from two to three months on an average. All well informed medical men of today know that of the three treatments proposed for the external tuberculoses I" IN Till' TUnEUCl'LOLS SUPPIUATIONS li- a) operation, h) abstention ami c) puncture with injection, llie lasl is the bcsl (we Avill Icll you in Cliai)ler IV why il is llie best). Bui how many know how to apph this best Irealmenl!' Very few. Often times, one may sec, by the side of abscesses opened by surgeons, other cold abscesses which have become fistulous in spite of punctures and injections, or even because of punctures badly made. Does this mean liiat puncture is difficult? No, not exactly, but it must be performed w ith scrupulous care, and no one has ever taken the trouble to teach practitioners. Everything- depends upon the way it is done. A^'ell done, puncture cures; it is a marvellous method. Badly done, it leads to failure, sometimes to accidents, it may even bring about death (in the case of abscess J)y gravitation, of coxitis or of Pott's disease). This is why it is your pressing duty, your « sacred » duty, to study their technique thoroughly. lou may make mistakes in three ways : by instrumentation, by lack of asepsis, by faulty technique. 1° By instrumentation. You may go to Avork (it is unfortunately the rule) with needles or trocars too large; the orifice in the skin does not close, and there remains a fistula. 2" By lack of asepsis. On the pretext that it is not an abdomen to be opened and that the puncture ought to be repeated, only an indiflfereni attention is bestowed to the case; only a very casual asepsis is made of the hands, of the patient's skin, of the instruments, or of the liquids to be injected. And this is particularly serious ; for the liquids remaining for some time in a closed vessel will be under the best of condi- tions for giving birth to microbes. Il8 Pl]?ICTURES AND INJECTIONS. THE MATERIEL 3° By the technique. Too many or too few punctures are made ; at intervals too short or too long, AAitli liquids too active or not active enough, and that is why the abscess persists indefinitely, or even ends by opening spontaneously. These are the mistakes which may be made in the course of Ireatment by puncture. But, the mere fact of my pointing out these faults will help you to avoid them, with a little attention and method. When all comes to all, remember that this technique is at once very delicate and very simple. Very delicate, in the sense that it demands minute care and a strict asepsis. Very simple, nevertheless, and each of you, to do it well, will only need to read, and to remember, that which follows. THE MATERIEL The necessary instruments have been put together by Collin, in a small case which every practitioner ought to possess, as it may prove useful, not only for the treatment of external tuberculoses, but also for punctures and injections in any other disease. i°The needles. — The case includes a set of four needles : nos. I, 2, 3, 4. The needles nos. 1 and 2, serve for simple injection ' without preliminary puncture, that is to say, in cases of dry tuberculosis (which we shall deal with further on, v. p. i6/i). These two needles have no side holes : that would be an inconvenience. I. The dimensions of the needles of our series, as made by Collin are : external diameter internal diameter length. n° I 85/ioo millimetres 65/1 oo 9 centimetres n° 2 ii5/ioo millimetres 75/100 — n° 3 i55/ioo millimetres 1 10/100 n" 4 200/I00 millimetres 1 55/100 — THE ISEEDLK. Ol K ASPIUATOU, fJLASS SYRINGE '•!) On })iinciple, you always take the jincsl needle ihe n'^' i . It suffices for very fluid liquids (iodoformed ether, iodo- formed creosote oil ). The needle n" a is used for liquids which arc rather viscid, such as the gl\cerinaled naphthol camj^hor. Fig. lo'i- — Everything necessary for puncture and injection. Going from left to right : sterilized cotton wool, glycerin, naphthol camphor, Calot case, tincture of iodine, ethyl chloride, Yelpeau bandage, cup, iodoform cresote oil, sterilized gauze, (a basin for pus). For gloves, see fig. io8 and 109, p. 100. The needles N° 3 and 4 serve for punctures, that is to say, in tuberculous suppurations where the injection is always preceded by a puncture. The needles 3 and 4 have side holes, which is an advantage here. Use here in the same way, for puncture, the finer needle (the ^^r-> N-I N?2 N?3 K-A Fig. io4 bis. — These are the external diameters (actual size) of the needles. The n"' 1 and 3 serve for injections; the n°» 3 and 4 for punctures. N° 3) : it will protect you most surely against the risk of a fistula. I20 TECHNIQUE OF PUNCTURES A>D INJECTIONS A needle smaller than N'' 3 might easily be blocked by the more or less clotted contents of an abscess ' . A larger needle exposes you somewhat to a fistula, I repeat it. Fig. 1 00. — Our instruments, A metal case containing ; an aspirator, a glass syringe, one or more needles. And that is why you must use iS° 4, only in case of necessity, I. Nevertheless, when abscesses are very mature, and contain very serous fluid, the needle No. 2 may suffice : try it. FOR PUNCTURE, TAKE NEEDLE N° 3 wUcn you have found N° 3, previously tried, to be blocked bv tlie excessively thick contents of the abscess. You might use N" 4 when dealing with an abscess situated far below the surface of the skin (over five or six cm.) Fig. io6. — Schematic plate (Collin). From left to right : glass syringe, section of the aspirator, needle ?s° 3 with an o, indicating the internal diameter of the needle, a -wire having at its extremity a screw for cleansing the needle. But never, under any pretext, use the higher numbers 5, 6, 7. which you find in some cases : you Avould run a great risk of producing a large fistula. 122 THE PUNCTURE. THE USE OF OUR SMALL ASPIRATOR 2° The aspirator. Our model (v. p. 121) is very easy to regulate, to sterilize and manipulate. a. It is regulated by means of two screws E and V (fig. 106) at the extremity of the glass tube and at the end of the rod of the piston. On tightening the thumb nut V Avhich terminates the rod, the asbestos piston K is enlarged, and Avater-tightness secured. On tightening the other screw E, you ensure the contact of the glass tube with the two washers of india-rubber placed at its tW'O extremities. (In this Avay the vacuum is assured.) The screws are loosened when you wish to take the instrument to pieces. 6. It can be sterilized conveniently by simply boiling (thanks to its piston of asbestos Avhich is not affected by immer- sion in boiling water however much prolonged) . The capacity of the aspirator of the ordinary model is only 10 c.c. But this is quite sufficient in practice, because it is easy, in dealing with a large abscess, to empty and refill the aspirator as many times as may be necessary until the evacuation is complete. And, thanks to its small capacity, it has the advantage of allowing one to evacuate the abscess progressively, and without any danger (or scarcely any) of causing the wall of the abscess to bleed, while that danger exists in using aspirators of larger capacity. This small aspirator, Avith its 10 cm. c. is almost too large for aspirating certain small abscesses, for example, broken doAvn cervical gland; in that case, it would be wise, in order not to draw- blood, to open the cock but very little, so as to draw off the pus drop by drop. And as soon as a depression in the skin is produced showing that the Avails of the abscess have come in contact, or Avhen the pus issues slightly tinged, you immediately turn the cock of the aspirator. All you have to do to make the aspirator ready, so as to create a vacuum, is, the cock being closed, to draAV the stem of the piston up to the end of the barrel and give it a STERILIZATION OF THE MATERIAL USED IX PLNGTURE 123 quarter of a lurn, \\\\en a notch tlierc allo\Ys it to he fixed In that position. 3° The syringe. Tiie glass syringe may easily be boiled; it is adapted like the aspirator, to the flange of the needle. Aspirator and syringe could, in case of necessity, supplement each other, hut it is necessary to have the two, because, in the first place, one is never taken unawares, and in the second, it is much more simple to aspirate with the aspirator, by reason of its cock Avhich allows a vacuum being secured before using it. And it is also easier and more natural to inject with the syringe than with an aspirator, especially when an injection has to be made without a preliminary puncture. Our aspirator being (( in order » (where the vacuum is perfect) you hold it in the right hand, whilst the left hand holds the needle, the evacuation is made without any traumatism; on the other hand, when you aspirate with a syringe which it is impos- sible to exhaust beforehand, you always produce jerks and repeated pullings on the Avail of the abscess. The jerks are painful to the patient, they cause slight hoemorrhage, they inter- rupt, at every movement, the contact between the needle and the syringe. You will find, besides, in the Collin case, one washer of asbestos and two reserve india-rubbers (and you might also ask for the addition of a spare glass barrel for the aspirator, which you could easily adapt yourself). The permeability of the needles is provided for by the addi- tion of a metallic thread (cleaning wire). The cleaning Avire of needles n"^ 3 and 4 has a screw thread cut at its extremity; this allows of its acting as a cleaning brush (each time it is used). The method of sterilizing; the instruments. The aspirator and syringe (previously taken to pieces) are placed with the needles in the small metal case. The case, 124 TECHMQUE OF PLNCTURE AND INJECTION opened, is plunged into a closed fish-kettle full of water, to which has been added some borate of soda, in the proportion of 1 5 to 20 grammes to the litre (this solution boils at io5° to 106°) '. The Avater at the moment you plunge the case into it is cold ; raise it to boiling point — which should be kept up for from half to three-quarters of an hour. Cleansing the instruments. After each time they have been used it is necessary to clean the instruments thoroughly. The grease should be removed first with alcohol and ether. To thoroughly cleanse the needles brush them through with the screw at the end of the wire, already mentioned. After cleansing, boil the instruments again. Afterwards, wipe them with gauze or sterilized wool, or pass them through alcohol or ether, Avhen they will dry spontaneously. Give them a coating of oil, insert the cleansing wires into the needles. Replace the whole in the metal case, which must be always kept perfectly clean. Before each new puncture, boil the instruments again, but this time it may be for five minutes only, if they have been boiled for half an hour after they were last used. I. Note this well. It is generally believed that the instruments must be put into the water when it is already boiling, as without this precaution, th(;y would be tarnished. Well, it is a mistake, we have never seen them tarnished or damaged by placing them in cold water gradually heated to boiling point; moreover in the latter way, all risk of breaking the glass barrel of the aspirator, as is likely to happen if you plunge the instrument suddenly into boilino; water, is avoided. I mvist warn you not to pass the steel needles through the naked flame as it blackens and corrodes them; it detaches the nickle and cjuickly puts them out of use ; and esjJecially because this method of sterilization is infinitely less certain than prolonged boiling for half-an-hour. If you possess platinum needles, you might pass them through the flame without detriment ; but these are very expensive (they cost five or six times as much as the needles of nickled steel. It is then more practical for you to keep to the latter. If the nickelling is good, if they are well cleansed each time after use, then oiled over, the steel needles can be preserved for an indefinite time, in spite of repeated boilings. THE NATURE OF THE INJECTIONS FOR COLD ABSCESS I T.) THE MODIFYING LIQUIDS FOR INJECTIONS There is an inlinilv of medicated agents suggested for the local modification of external tuberculoses. None of these substances is infallible, but there are four or five at least, Avhich are good, with which it is possible to obtain Fig. 107. — The pure camphorated naphlliol in water If you allow a few drops of camphorated naphthol to fall into water, it remains in a state of separated sphe- rules which, if they were introduced into the blood stream, would possibly cause embolism. These spherules are not produced when you throw into the water a few- drops of the mixture of naphthol and glycerin which has been well shaken. a cure, provided that you know how to use them; for the technique is a more important thing than the nature of the injection, and there are medical men Avho will never arrive at a cure with liquids of any kind. I do not mean to say, hoAvever, that all these liquids are equally valuable, far from it, seeing that, after having tried them all, I enjoin you to keep to the two following ones which will suffice for all your needs a) iodoformed oil and cresole, and 6) the glycerinated naphthol camphor. 126 COLD ABSCESS. WE OJECT EITHER THE lODOFORMED But I have already spoken of them and have given the formula at the beginning of this chapter (v. p. ii5). Another word upon the subject of glycerinated naphthol camphor. Before injecting this mixture, you must make sure that it is miscible with water. You throw a drop into a basin of water and shake it. If the drop of the mixture does not disappear in the water, increase the proportion of glycerin, stir well the new mixture and again perform the control experiment in the Avater. (Doctor Cayre, of Berck). A propos of the indications for the tAvo liquids, I would add, that the naphthol camphor should be preferred for an abscess not yet ripe, for example, those large swellings where one AvithdraAVS only a feAV drops of pus, the centre alone being fluid, the rest of the mass being formed of fungosities not yet broken down. In injecting naphthol camphor into the small cavity, the abscess ripens; each ucav injection liquifies succes- sively the several layers of the tuberculosed Avail. And it is for this reason that a fcAV days after injection of naphthol camphor, Avhen making a neAV puncture, one Avith- draAVS a larger quantity of pus than at the first puncture, a larger quantity on the third than at the second, etc. As soon as the softening appears complete, it is better (as I said before) to continue and complete the treatment with the injection of cresoted oil. lodoformed Ether is an active and efficacious liquid, but it is not without drawbacks; it causes pain and is especially liable to cause separation and sloughing of the skin. It ought never to be used in cases where the skin is already thin and red- dened ; it may produce rupture of the skin, by the tension it sets up. True, one may let it run out again partly or wholly; but that mode of procedure is neither very precise nor very certain. In fact, one is never certain that there will not remain, in spite of everything, sufficient ether to distend the skin beyond the limits of its resistance, — without mentioning the cases, rare but nevertheless always possible, where the liquid injected does not return at all, or, it does not return as much as one would wish. (A parallel disaster to this is sometimes seen to follow injections of tincture of iodine into the tunica vaginalis, in the treatment of hydrocele). CREOSOTE, OH Till: CAMl'IK »UATi:i) NAPUTHOL ^V1TII GLYCERIN \ 9.-J There are t\>o cases, cspcciall\ , w here vou should never employ ioJoformed ether : a. The first is in suppurating glands in the neck; with ether you risk seeing the skin give ^^a^, and you know the consequence : a liideous and inellaceahle scar I b. In tiie ahscess by gra\ilatioii of Pott's disease, because iodoformed ether ma\ cause a rupture of the sac ^into the perilonciun or intestine. (1 have known of liiis in several cases.) But on the other hand, you may employ iodoformed ether « here the skin is quite soimd, in the abscess of hip-disease or A\hite s\Aelling, or in an abscess deeply situated in a limb, ^ou might, at anj rate, inject a small quantity, 3 or 6 c.c. of iodoformed ether — a twenty percent solution. ^ou will leave it to run out two or three minutes afterwards, but if per- chance it does not do so, you need not be alarmed, for the quantity injected is too small to bring about any untoward result. It is for this reason that you will never on principle inject more ether than the utmost cjuantity you know for certain can be retained. The tension produced by this quantity of ether is not excessive, and it doubles the certainty of the efficacy of the idoform injected. The proof that the tension produced by the ether is a factor in the cure is that you are able sometimes to cure with injections of pure ether, without the addition of creosote or iodoform, cold abscesses, essential or symptomatic. How do the injections act and how do they cure? The problem has been solved in the laboratory of our mas- ter, professor Robin, by Coyon, Fiessinger and Laurence. They have shewn that the injections do not act as antisep- tics; no, because of the thickness of the wall, of the intricacy of the cavity, of tuberculous infiltration in the neighbourhood and also of the deep situation of the bacilli, the « antisepsis » of tuberculous abscess is as illusory as intestinal antisepsis. The injections act by provoking a great afflux of white cells, of polynuclear cells, afterwards destroying them, thus setting at liberty certain ferments ; the first is a lipolytic ferment having the property of attacking the fatty envelope of the bacillus, later on, a proteolytic ferment (a proteose) having the property of liquefying and digesting albumenoids, that is to say, of des- troying the very substance of Koch's bacillus. The Method of sterilizing the modifying liquids. You may sterilize them yourself, as we are in the habit of doing. 120 PUNCTURE OF AN ABSCESS. THE INDICATIONS FOR PUNCTURE To sterilize the first liquid, the creosote oil, you begin by boiling the oil for half an hour. (If the oil is of good quality, if does not blacken on boiling.) Then you allow it to cool, and throw into it the creosote, the gaiacol and the iodoform, all chemically pure, and lastly you add the ether. For the second liquid (naphthol, camphor and glycerin) you boil the glycerin for tAventy minutes (it boils at i5o°), then allow it to cool, and throw into it the desired proportion of i/6 to 1/7 of naphthol camphor prej)ared aseptically by your pharmacist, under your direction. Itgoes without saying that you will boil the flask and the cups. Lastly you Avill take care to preserve the liquids in well stoppered flasks, keeping them protected from the light. TECHNIQUE OF THE PUNCTURE We have to speak here of the technique only. The dia- gnosis of cold abscess and the study of exploratory puncture (as a means of diagnosis) Avill find their place better elsewhere, (v. chap. XIX). However, we ought to say, now, a few words on the indica- tions for puncture in the treatment of cold abscess. The indications for puncture in cold abscess, a. Is it necessary to puncture every abscess? Yes, if it is an abscess you are able to reach without the risk of wounding some important organ. Suppose you are in the presence of a deep abscess of the internal iliac fossa ; wait to puncture it until it has become superficial. b. Why puncture the abscess instead of trusting to its spontaneous resorption? P'. Because spontaneous resorption is the exception, and by thus Avaiting, you run the risk of seeing the abscess unexpect- edly invading the deep surface of the skin ; after AA^hich you are no longer certain that you Avill be able to prevent its rupt- ure and a consequent fistula. WHEN OlCIir A COLD AliSCI'SS TO HE OI'ICM.I) I2ij :>"'"-^. J>erans('. in llic casculicrc rcabsorpllon lias ocrmrod, il requires a rcry loinj lime (one or several years). 3""J. Because \\ Ikii llie abscess has been reabsorbed, llic cure is not so sure and nol so definite, in a general way, as with llie abscess wlilcli lias been cured by puncture and injcclinn. In fad. wlu'ii \\c sa\ llial a cold abscess is reabsorbed, llial means ihal llicrc is no more liquid, l)ul sniel\ nnl ilmi all (lie infecled and inlccling elements in its wall ba\e disappcan-d. The cold abscess lias perbaps simply returned to its i'oriner condition, tbat of a tuberculoma and al lliis time even ibnugli Ibere is nothing to be felt on palpation, it ma} still retain bacilli Avbicli are quiescent, and in fact, one has often observed the return of these abscesses so called " reabsorbed ". On the contrary, Avhen the contents of such an abscess and the morbid elements in its Avail haAe been got rid of by sue- cessiAe punctures', one can conceiAC, and clinical obserAation confirms it, that the cure obtained should be more complete. 4^'''^. A last reason for employing j^i^^nctures and injec- tions in abscess by gravitation is, that the liquid injected does not act only on the abscess to be cured, but it reaches the bone and the articulation AAhich haA^e caused the abscess, rendering them sound and cicatrising them. — So much so that it may be said in all truth that the patients, provided that aac treat them by puncture and injection, Avill be cured more quickly and surely than if they had not bad an abscess. When ought one to puncture ? Immediately the abscess is recognised (except in the case I. We are in tlieliabit of saying, at tlie familiar causeries in our practice, ttiat it is better to see an abscess in a receiver tlian trust to its absorption into tlie tissues. Ho\vever, A^hcn llic general condition of the patient is very bad. one ouglit to wait a white ; in tlie mean time, do nothing more llian is absolutely necessary in the way of local treatment, to prevent the opening of large abscesses. In such a case, endeavour in every \\ ay to improve itie general condition of the patient. But we shall see about that in tlie cliapter on mul- tiple tuberculoses (chap .xx.j Calot. — Indispensable orthopedics. 9 l3o TECIIMQUE OF THE PUNCTURE OF ABSCESSES already ciled of a deep iliac abscess or a retropharyngeal abscess). It is necessary to begin before the skin has been invaded, before it has become reddened or thin. If not, it will he too late to save the skin already inoculated, already invaded by tubercles in the abscess "wall'; you would not be certain of escaping a fistula and its terrible consequences. And even ^vhen Fig. io8 Fig. 109 Fig. 108 and loq. — Mittens made at llie lime of llie operation, "nilh sterilized com- presses for the case "where vou have touched septic matter. Fig. 108. — The method of making a mitten. Fold a compress inio two, lay the hand flat on the square so made, cut the two thicknesses, following the outline and baste them together or stitch them with the machine following the dotted line. Fig. log. — Afterwards turn them inside out « like a glove » so that the sewing is inside. this red and thin skin does not break, it ^vill very likely be puckered and pigmented; Avhich, in the neck, for example, is always as hideous as a veritable cicatrix. I. In tlie same wav tliat llie skin of the breast may be invaded, after a certain time, by malignant growths of llie subjacent gland. AMlSLl'TiC rULCAL TIU.NS i3i The Puncture. The palient Is lell in bed. or bcllcr slill. placed upon a table, llie region of the abscess Avell exposed. Ilav(^ at hand the necessary objects (v. fig-. lo'i), \\\r case Fii;. 1 10. — An opening arranged in a corset of plaster to allow of the puncture of an iliac abscess. At the moment of puncture, the edges of the opening will be covered with sterilized towels, in the wav she>Yn in the following figure, tig. iii. containing the three sterihzed instruments, the tincture of iodine, the cup, the two flasks of hquid, and the dressing. You proceed to make the toilet of your hands and of the patient, taking as much pains as if \ou were going to open an abdomen. a. Toilet of the hands. — Rub the hands for several minutes wilh a coarse brush in oxygenated water (this is particularly recommended), or, ^vash them thoroughly in Avarm soapy water; after that, rub them with alcohol and ether and steep them in a warm solution of sublimate, one in a thousand. I 32 PUNCTURE OF A COLD ABSCESS It AYOulcl Le better to Avear india-rubber gloves. They are indispensable when you have been touching wounds or matter which is septic. In default of gloves, postpone the puncture until the next day unless there is extreme urgency , (for examjDle in the case of an abscess Avhich is about to open), in which case you might make a puncture, without an injec- Fig. III. — Where you see from periphery to centre : i" the feneslralei compress surrounding the abscess zone; 2. a dark patcli representing the skin painted with iodine, and 3. in the centre of the dark patch, a white area representing the part anaesthetized with ethyl chloride. having smeared your fmgers with tincture of tion, after iodine, or rubbed them Avell with benzole or iodized alcohol, touching the instruments only Avith the hands protected by compresses or large squares of gauze well sterihzed (by boiling) ; or better still, with foiirrecmx similar to infants' gloves or " mittens ", Avhicli have been prepared on the spot, by some one of the family, with tw^o compresses stitched by three of their edges (v. fig. io8 et 109), and afterAvards boiled. b. Asepsis of the patient's skin. — Asepsis is produced noAvadays by simple painting Avith fresh tincture of iodine, by means of a small brush or a piece of cotton avooI (v. fig. iii), without previous Avashing or brushing. I should say, TML: NLLKLi; 1 s MVDi. r<> ii>ii.i»\N \- M ll^ oiti.iiji i; iiuck \'.VA jll,,,,il iiiiiuciliali^ uasliiiii^-. lur a wasliiii-- done llic evciiirif,' before can onl\ be beneficial. 'I'lic riiMiiire oC iodine is ailnwed lo diN forlwoor ibrec uiiiuiles. Painl it uidelv, Fi^. 112. — How not to puncture, for if YOU force the needle through the wall perpendicularly, its course through the soft tissues will be very short, the parallelism of the walls of the small wound would still re- main when the needle is withdrawn ; these conditions facilitate the infec- tion of the abscess bv pus, which niav exude. Fi^. ii3. — How one ought to puncture. The puncture is very oblique ; the track is much Ion- iser (A): on the other hand, the retraction of the soft tissues does away with the parallelism of the sides of the wound, making a track « en chicane » (B). that is to say, over a siuface as large, at least, as twice liie size of the palm of the hand. The advantage of this extensive painting, is to prepare a place for the contact of the left hand, which has to fix the skm Avhilst the right hand pushes in the needle. For the same pur- pose, and as an additional precaution, a large (boiled) compress r34 TECHNIQUE OF THE PUNCTURE OF COLD ABSCESSES is applied over the region, an opening being cut out of the centre, leaving uncovered a square of 6 to 8 cm. wade, in the middle of which is the place chosen for the puncture. All the surface of skin left bare should be painted with tincture of iodine. After the puncture, you remove, with a tampon impregnated Avith alcohol, what remains of the tincture of iodine, for if it is not very fresh it may cause desqviamation or even vesication of the skin . During the four or ten minutes required by the tincture of iodine to dry, you put in order the aspirator, that is to say, you make the vacuum, and you charge the syringe. If you wait to make the vacuum until the needle has been forced in, you may have the pus spurting out and soiling everything, before the aspirator is ready. The aspirator and syringe are afterwards placed in a dish close at hand. The puncture. You use needle n° 3. Where must you prick the skin.^ At a point a^vay from any veins which are visible beneath the integuments, and at a distance of three or four cm. from the cu.taneous zone of the abscess, in such a way as to enter by an oblique track (instead of pricking the skin vertically and going straight into the abscess). This obliquity is advantageous for deep abscesses, and indispensable for „ ^ , , , superficial ones, especially subcuta- Fig. ii/i. — The needle is held -i ' i J between the thumb and second neOUS absCCSSCS (fig. 112). TllOSC fingerservingasguide the first ^\,q^M ucvcr enter except by a finger pushing on the head (or J ± ^ hold it as you would a trocar very obliquc track and almost paral- or ^vriting pen). j^^ ^^ ^^^^ g|^-^_ Thanks to this obliquity (fig. ii3) the lips ot the deep extremity of the needle track will play the part of a valve and TOCOMIRESS TllF. ABSCESS IN OUDF-Il TO lACIMTATE PLNCIUU:£ [A'i \nr\vn[ the ronlciils nl llic al)S("os'< fiDin escai)iii,i:' oulw aidl v, as Fig. 1 1 5. — Abscess of the right iliac fossa : the collection forms a thin sheet in the midst of the depressible soft tissues . the needle is Avithdrawn. Moreover, in pricking the skin four Fig. ii6. — The abscess in the preceding figure. The sheet of pus verv much spread out. or five centimetres from the cutaneous zone of the abscess, one passes through sound skin ; and that is very important. i3G TECHNIQUE OF ABSCESS PUNCTURE Ansesthesia of the skin. — At the place thus selected (fig. Ill) ethyl chloride is sprayed. / ji^io ii-y. — When you proceed to puncture tlie abscess, the needle depresses the skin before it enters the collection. Look at the following figure. As soon as the skin is blanched over an area the size of a live shilling piece, take the n° 3 needle in the right hand Y\a. ii8. — The pressure of the needle (v. fig. 117) drives aside the pus of "which but a little, very thin sheet remains, liable to be traversed by the needle, -without any result. This would be a a ponction blanche )) (a failure), although a great quantity of pus is present. The index finger presses firmly on the head, then the skin is fixed by the index finger and the thumb of the left hand. iio\\ TO MAkf- run am^ckss contents tense '•^7 (fig. ii'i) and lioKl il l)\ llif iiild.lle l)el\\ccii llic llmnih ;iiii| second finger, wliilsl llic iiidix linger presses firmly on llio I'ig. III). — ^^ hat it is necessary to do to puncture this abscess (see the four preced- ing figures). An assistant presses firmly on the peripherv of the abscess. liead ; tlien the skiu is fixed bv the index finger and the thumb Fig. 120. — The assistant in this way (see fig. 1 19) causes the fluid to flow back to a single point where it should be easy to attack it with the needle, by an oblique puncture. of the left hand at one or two centimetres from the point chosen for the puncture ; you could, moreover, direct an assist- [38 PUNCTURE OF TUBERCULOUS SUPPURATIONS Fig. 121. — As soon as anaesthesia is oblained, you sirelcli the skin with the thumb and index finojer of the left hand and thraslthe needle with the ria;ht hand. Fio. 122. — In order to adjust the aspirator to the needle, hold the outer end of the latter between the thumb and index finger of the left hand so as to prevent any dis- placement of the point. This adjustment once assured, the left hand opens the cock of the aspirator. I'lNCTLRE OF llir SKIN. AsiMiiA HON r)i iiii: vi- 1 3f) ant l(^ piisli the abscess tOANards \ou, pressinj,^ it witli one or belli hands on tlie opposite part ol' the region; you then plant Nonr neetlle in the skin, you push A\ith a firm and sustained clTortjSO llial iho integuments are traversed. The congealed skin is sometimes very difficult to pierce, and \ou need to pusli firmly; but it is necessary as soon as the skin has been traversed, to moderate vour force, so as to Fig. 123. — After that, still holding the aspirator and ihe needle in the right hand, the left hand presses gently on the abscess wall. go through the soft tissues gently up to the point Avhere you judge pus Avill be found. AVhen you arrive at the Avail of the abscess, you usually feel a slight resistance; and you should press a little to get through ; but as soon as you are in the sheet of liquid, al resistance has disappeared; you have a special sensation, which you at once recognise. You feel thai the deep extre- mity of the needle moves about with a certain freedom, — which it would not do if it were not in the abscess itself. Fairly often, a small drop of pus oozes from the end of the i4o TECHNIQUE OF ABSCESS PUXCTURE needle. But, generally, the pus does not issue sponta- neously; hence the evident necessity for aspiration, which is infinitely preferable, need it be said, to the rough pressing practised by some practitioners on the region of the abscess, to obtain the discharge of pus; traumatic pressures causing bleeding and creating the risk of inoculation — and, moreover, being very often ineffective in bringing about the evacuation. Fig, i2'4. — When the aspirator is full, the pus is emptied into a small basin. You stop the needle with the left index fmger, right hand takes from the basin the aspirator already which is then adapted to the lumen of the needle. When this adaptation is complete, the left hand valve, the pus immediately fills the aspirator (held in hand) ; you then close the valve and withdraw the from the needle, which remains in its place. Before the aspirator you place and leave a small piece of cotton wool round the needle, to absorb any drops w flow while you empty the aspirator. You empty the aspirator, you exhaust it again while the prepared opens the the right aspirator removing sterilized hich may and you Tin: iMr.crio.N wiiicii i-olluws the en aclaiion or I'u.s i/|i rciula[)l il li> llic needle; and so on aj^aiii and aiiain, niilil ihe abscess is eniplv. One recognises thai llie abscess is empiN l)\ il> having colla[)sed; and, \\hen it is snpcrFicial, h\ its ciilaneous Avail being deepened into a hollow, and 1)n ihcie being no longer any appreciable fluclualion. Is it necessary to try and empty an abscess thoroughly? ..^<}l Fig. 12 5. — Injection. The aspirator is simplv replaced Ijv the cliari;ecl syringe whicti is adjusted to the needle. At the commencement of the treatment, no. so that yon do not run the risk of causing the wall to bleed. Later on, after a series of injections, you may empty it thoroughly, because then, if you should withdraw a few drops of blood, that would cause no inconvenience, the pus being sterile at this time. The abscess being emptied, one avoids washing the parts; it would be prolonging the operation uselessly, and even run- ning a slight risk of infecting the abscess. There remains to be done : The Injection. For this, you simply replace your aspirator by tlie s\ringe already charged, and you push in the injection. 1 42 TECHNIQUE OF THE PUNCTURE OF TUBERCULOUS SUPPURATIONS We have indicated above the liquid which should be chosen : nearly ahvays the creosoted oil; and the quantity which should be^injected : for large abscesses, never more than from ID to i4 c. c. ; and for small abscesses inject less thanio c. c, \ using a quantity equal to a half, or a third of the quantity of pus Avithdrawn. Withdraw smartly the needle attached to the syringe. Immediately, you place over the orifice a tampon of wool or a piece of sterilized gauze, and, by a few to-and- fro movements, you do away with the parallelism of the two orifices in the skin and the abscess wall. Finally you apply lightly a com- pressive dressing, in place of the sim- ple layer of collodion usually employed, which does not sufficiently guarantee against infection. And do not touch it again for several days, until the second puncture. - - ^- j'j?: When should the second punc- Fig. 12G. — Abscess of the left ture be msde? popliteal space. .^.^^-^ ^^^j^^ ^ jj^^^^^ according tO the case. It is best made after about ten days. Why this delay? Because at the end of that time the liquid injected has ceased to act. — This rule applies to ordinary cases, where the skin, before you puncture, was in very good condition ; for if the skin were inflamed and atten- uated, you must inspect it next day, and every following day, to watch it and guard against all eventualities Avhich we will mention a little further on. In ordinary cases, where the skin was in good condition (neither reddened nor attenuated) it is useless to examine it before r IS >ECESSAll\ TO M.Vki: SEVKUAL I'LNCTUUES I 'l.i llie Iciilh (If Iwclflli Jay; at lliat dale, a new piinclure is made, followed 1)\ an iiijcilioii. 'Hie skin is pierced at a new place Fig. 127. — Squares of absorbent cotton wool damped and arranged for the compresion of the abscess on the completion of the series of punctures. g. 128. — Compressive bandage begin ning at the toes and reaching far above the abscess for the purpose of causing approximation of the walls of an abscess of the tliiah or of the nroin. on each occasion, so as to avoid all risk of a fistula occurring. It is preferable to make the second puncture about the t^velfth day than to postpone it indefinitely, relying upon the rc-absorplion of the abscess, a possible occurrence, after a 1 44 PUNCTURE OF COLD ABSCESSES single injeclion. — Our reasons are analogous to those Avliich have urged us to puncture rather than ahstain, namely, that re~ahsorption does not often occur, that in "waiting one loses time, and supposing a case in which this single injection would suffice, the ahscess would not he so Avell cured as it would be Fig. 129. — Abscess of the external aspect of the tliigii. Fig. i3o. — Tiie same abscess after punc- ture and complete evacuation: tlie glob- ular swelling is replaced by a saucer-like depression. after 7 or 8 injections. In the same way an abscess treated by injections Avill he better cured, as avc have said, than that which has re-absorbed spontaneously, without any injection. As to the length of the intervals between the sittings, I know very well there are all manner of opinions ; on the one hand are practitioners Avho propose to repeat the operation every three days; on the other hand there are others aaIio consider the interval should be three moiiths. "S^ell, I consi- THE DIFFERENT APPEARANCES OF TURERCULOUS PUS (AND THE INDICATIONS TO BE DRAWN FROM THEM AS REGARDS TREATMENT AND PROGNOSIS; Cliche J. Foactlou, A. B. C. Non infccte'drpus : Treatment by punctures and injections. A. Serous pus, mahogany colour . 1 In these 2 cases inject iodoformed oil B. Ordinary pus, yellowish green.. ) or ether. C. Clotted pus. — In this case inject camphorated naphtol. D. Sanqinneous pus, without fever, without the odour of pus. — This abscess is not infected but runs a great risk, of becoming infected and of bursting. To avoid this twofold danger, punctures must be performed as rarely as possible, without injections, with slight compression afterwards; by « as rarely as possible », Imean that punctures are to be made only if the skin threatens to give way. E. Claret coloured pus, infected, with fever and the odour of pus. — Treatment : Try to reduce infection and fever by puncturing every day without any injection afterwards. If after i5 or 20 days fever still persists in spite of the punctures (without injections), resign your self to incising and draining this abscess. iiii: iMiuvM.s i!|.i\\i;i;n the injections I |.> (lor llic Irulli lies lirlwccii llic Iwo. IT ihc silliiijj;s are rr[)cal(.'tl loo (iltiii. llnif is a ri-^k nl'llie skin « dc'lcrioraliiig » and of inlVclioii — and Jjrsidc il wuuld faligue llio palienl. If lli(\ £^^ :2?.---^ Fig. i3i. — This is the end of the 8lh aud last puncture; lliis time, instead of a further injection, you apply compression. ^^ hen the evacuation is finished, you apply over the abscess a pad of cotton wool mois- tened and squeezed out; the left hand resting on the pad, the fingers are applied successively the one after the other, commencing at the part furthest removed from the point where the needle entered, causing the last few drops of pus remaining lo ilow in that direction. The aspirator and needle are then withdrawn together, smarlly . are too far apart, the cure of the abscess will take a very long time, and a perfect result is not so certain. Therefore, neilhci- 1* ig. 1 .52. — Then over all a Hat tampon and, lo perfect the compression, some moistened pads of cotton wool placed crosswise over the abscess. too long, nor too short, — and the best rule is to make a sitting every lo or lo days. At the seventh puncture, the liquid you Avithdrau is no longer pus, but a mixture of brownish serosity and Calot. — Indispensable orthopedics. lo 1 46 PUNCTURE OF THE ABSCESS. AFTER SEVEN PUNCTURES ONE of modfying liquid sometimes slightly tinted of a rose co- lour. Very often also, at this time, one notices in the con- Fig. i33. — Two or three weeks after, you remove tlie compress and make an inspec- tion. If, as shewn here (but it is an exception) a small quantity of pus still appears, it is collected at a single point instead of being distributed over the whole wall of the abscess. Puncture at this point without removing the pad of wool, which should remain in position after the puncture, and over it replace the tampons cross- wise so as to renew the compression which should be maintained evenly for three weeks. tents of the abscess, some of the liquid injected, unaltered*. If, after seven punctures and injections, liquid is again Fig. i3i. — The disposition of the moistened tampons for compression of the culs-de-sac about the elbow. I. Tlie bacteriologists explain this (refer to p. 127), by saying that at the beginning, as a result of the first injections, a lipolytic ferment is for- med, having the property of digesting fatty matter (such as the oil of our injections) ; a little later, a proteolitic ferment appears, which digests albumenoid substances, hiit leaves intact the oil of our solution. EXERTS PRESSURE TO AITIU (XIMVTK THE WALLS OF THE AliSCESS I 'l" Iniiued. wliicli is ihc rule. \,.ii will make an eighth jjuiicliirc, l>iil lliis lime without injection. Fig. i35. — Compression of the cul-de-sac of the instep. And you Avill at once compress the region Avith pads ol' Fig. 1 30. — To avoid the vessels, they are marked out tv (he index and second fin- gers of one hand and pushed on one side, while the other hand pushes in the needle two centime'.res outside them. 1 48 PL?yards by pressure of the finger. The needle pushed in at an angle, does not risk injuring the vein. the two screws which serve to regulate it. and aspirate again. But the pus still does not flow. Look for another cause. h) Are you certain you are in the abscess ? neither to one Fig. 109. — An abscess situated behind the vessels. Fig. lie. — A finger is pressed firmly on the skin on the inner side ol' the vein in the direction of the arrow. The abscess is made to protrude on the outer side of the artery : a second finger protects the artery during the puncture. side nor to the other of it!' In order to know this, nou pro- ceed, whilst an assistant holds the aspirator, to make a fresh palpation of the neighbourhood, and ascertain if the level of the abscess corresponds exactly with the point of the needle. AA hen in doubt, push in or withdraw a little the needle l5o PUNCTURE OF ABSCESSES. POSSIBLE INCIDENTS coupled on to the aspirator, you will move about within the Aacuum in the neighbouring parts. But if the pus Avill not flow at all, it is because : c) Your needle is blocked. Generally one feels at once that the needle must be blocked : because one has the sensation, very plainly, of penetrating into a layer of liquid, or because one has already withdrawn a little of the liquid, when all at once the flow is stopped — in spite of the fact that one feels quite well that the abscess is not yet empty. What can you do to clear the needle? There are practitioners who Avould, even in this case, press very firmly on the abscess, to evacuate the engaged clot : a bad manoeuvre which would cause bleeding and bring about innoculations, — the least inconvenience of this method being that it is nearly always useless. You must, on the contrary, drive back the clot into the abscess . To do that, you replace the aspirator by the syringe, and force vigourously into the needle 5 or 6 gr . of creosote oil with iodo- form, or, better still, of sterilised water ; after that Avithdraw the syringe and replace the aspirator, and you Avill see the floAv return. If the needle become blocked a second time, you might force in a new injection or introduce into the mouth of the needle the metallic brush (fig. io6) of Avhich the length is cal- culated so as not to pass beyond a fcAv millimetres of the extremity of the needle. If it is constantly being blocked, do not give it up, do not be unnerved, and, aboA^e all, do not imitate those impa- tient surgeons aa^o immediately cut into the abscess, Avhich « refuses » to be emptied. Too often, this fault, committed Avith a light heart, VA'Ould be irreparable : the fistula produced would never close. No. Content yourself Avith injecting 3 to 6 gr. of naphtol-cam- phor with glycerin, then remove your needle, putting off the puncture for three or four days. AMIAT lO !)(• WIIF.N TIIEIU; IS ItLEK DINf; :> jSi DiiiliiU llicsc few (l.iNs (lie iia|ilil(iUcaiii j)li()i' will Iia\c liail lime lo solieii ihc abscess conlenls ; lliis time y(3u will obtain pus. If. lor some exiraortlinary reason, von slill do not obtain il, Nou should attain inject naplilol Avhicli will at last produce a liquid ta])able of being evacuated, il' not by needle N'\ o. then by needle N°. [\. Avhicli nou would be justified in using under the circumstances. 3. There is bleeding. — You draw blood a\ illi your needle as soon as it is introduced. a) If it is at the commencement of the puncture and there are merely a few rosy streaks in the midst of the hquid, that is nothing; continue to aspirate without fear, and you will notice that at the second aspiration, no more blood is obtained, but only pus. h) On the other hand, if immediately the needle is intro- duced, a jet of blood escapes, you may be certain that you have struck some small vessel of the Avail of the abscess or of the surrounding soft parts : it Avill be better to withdraw your needle at once, then apply pressure for a few minutes Avith a large tampon kept in position by the hand, after Avhich you apply a compressive dressing, postponing the puncture and injection until the next day or the day after, unless it is necessary to empty the abscess immediately, in Avhich case you Avill puncture again, choosing another place for the introduction of the needle, c) At the end of the puncture, after having emptied the abscess, if you see that the pus is slightly tinged with blood, the evacuation is sufficient, make haste to AvilhdraAv the aspi- rator, push in the injection, and AvithdraAv the needle. Here again, you apply pressure for several minutes, then you apply the compressiAe dressing. In all cases Avhcre the abscess has shown traces of blood, do not be surprised at obtaining at the following puncture, some blackish or grayish brown fluid, it is only a mixture of pus and altered blood. l52 PUNCTURE OF AN ABSCESS. POSSIBLE INCIDENTS But now and then at the time of the puncture you with- draw a liquid of reddish or chocolate colour sometimes blac- kish, which is blood more or less altered. You know that this is from the pocket of a cold abscess (and not from a simple Fig. I /(I. — The skin is thin and inllamed at one point. You will puncture by entering the needle "well away from the cutaneous zone of the abscess. traumatic hematoma), by its situation near an articulation or near a bone certainly tuberculous. It will be necessary to empty the abscess but Avilhout injecting anything at once, and to apply a firm dressing; — after that you Avill wait 4 or 5 weeks, and even longer if possible, that is, as long as the condition of the skin will permit, before again performing a puncture. 4. The cutaneous orifice is obstructed after removing the needle, by a drop of pus or some granulation debris. After having withdrawn the needle, you may see a drop of PLATE II COLD ABSCESS READY TO BURST HOW TO SAVE THE SKIN? iSee explanation belo-\v illustration) On her arrival at Berck this girl had a cold abscess"ready to burst ; skin already red and very thin. In this case, to save the skin we made punctures every day or every othei ■ day (without consecutive injections), during 2 weeks. On the lo^h ^lay the skin was saved, as eau be seen in the next plate (pi. III). PLATE III THE SAME (see pi. II). THE SKIN IS SAVED (SEE EXPLANATION BELOW THE FIGURE) The same child as on plate II, alter i5 days of treatment (puncture nearly every day, without injection). One sees here that the skin is saved, it has regained its normal colour. From this time, we made punctures and injections, i. e, the usual treatment for cold abscesses. Tlir SKIN IS AllOlT TO TIltrAK. WHAT IS TO BE IjOM:!' I.').'} pus. or some caseous particles or other debris from the abscess wall, appear in the opening-. ^ ou should remove the debris ^\ilha tampon and wash tlie part with great care, so as to ;i\c>i(| all possible innoculatiun of the skin. Alter all, this little incident rarely occurs if vou use onlv a line needle, N" 3, for puncture, and if you oidy approach the abscess by a long and oblique track, and finally if, in the case of aspiration without injection, you take great care to close the valve before withdrawing the needle while joined on to the aspirator; if you do not. the vacuum still remaining ^\ill draw the clots up to the orifice in the skin. 5. Incidents arising from the bad condition of the skin when the patient is first seen. The skin is reddened and thinned when first seen, this means that the deep surface of the skin is already innoculated and invaded by the tuberculosed wall of the abscess. Can you save the skin.'^ \es and no. It is not always possible and it is on account of this that it is not permissible for the practitioner avIio has the patient under observation from the outset, before any alteration in the skin has occurred, and who has the choice of the moment for intervening, it is not permissible, I say, to postpone the the first puncture beyond a few- days. But if nothing is neglected this skin can oftentimes, even most generally, be saved. At any rate this saving of the skin must always be attempted; the first condition in order to attain this object, is to desire it. Now, most of those who are in favour of puncture and injection believe as soon as they seethe skin already red and thin, that the battle is lost beforehand; thev will not even attempt a struggle. Ahorse still, they at once take the knife and freely open the abscess, judging that a surgical opening is better than a spontanecus opening. Foo- li-li |)olicy I This is quite wrong, there is no reason ever to despair of saving the skin, even when most compromised; especially is it 1 54 PU^JCTLRE OF ABSCESS. POSSIBLE INCIDENTS never advisable to use the knife; it is ten times preferable to fold one's arms : if you do not touch the skin at all, it pre- serves at least a slight chance of saving itself. Unhappily, as to this, practitioners are very difficult to convince, I repeat it, and it happens every day that they, Avho say that they accept the method of puncture, open cold abscesses or tuberculous suppurations, judging that a in this particular case » (^??), which they have had under their eyes, the skin is already too attenuated aud too inflamed to allow of their abiding strictly to the rule. Nay, this rule does not admit of exception. One must ahvays endeavour to save the integument, and one will often be successful. We have cited a number of facts in support of that Avhich Ave advance here (see my book Le^ maladies qii'on soigne a Berck, p. I20, Masson, editeur). How to save skin which is compromised ? There are two indications to fulfil : The first is to do away with all tension of the skin which is so attenuated and offers so little resistance, and, for that, to puncture the abscess every day ; the second is to prevent the march of invasion of the tuberculosis, which calls for injections. But are not the two indications contradictory .►^ If injections are made, secretion by the Avall of the abscess is encouraged and the abscess refills; but wdthout injections, the tuberculosis is not arrested in its march, it will finish by destroying the skin. What is to be doneP There is an alternative. It is to puncture the abscess every day, or every other day and then to inject only a very small quantity of iodoformed creosote oil; 1/2 to i c.c. for small abscesses, 3 to 4 gr. for large ones. Thus, you inject sufficient liquid to modify the granulations on the deep surface of the skin, but not enough to excite a hyper-secretion from the abscess wall, Avhicli Avould still further lessen the vitality of the skin. \\ii\r T(» DO \\iii:n tiii: auscess does not ihu i I'.' ij3 111 siicli a (■;!•<(■ (1(1 iiol neglect, C\|)('ciall\ if dcaliiif;- with ail cKlensive abscess, lo [)lacc llie paliciU in such a position thai tho inllaiiicd part of the skin is uppermost ; anIicr neces- sary make the palieni lie face downwards, may-be for several days and several niglits. He soon becomes accustomed to this position, -which gives us, in many cases, llie best results in helping to sa\e a skin ready to give way. And as soon as the skin has been undoubtedly saved, return to the ordinary treatment of the abscess by puncture and injec- tion, going up to a series of seven injections, the regulation number. B. — CONSECUTIVE INCIDENTS, to one or several punctures or injections. There is the skin, the resistance of which becomes lessened in spite of, or even on account of, treatment. There is the abscess which does not dry up, or which becomes infected, or which bursts open, in spite of everything. a) The skin becomes red and thin after one or several sit- tings. One has established that, alter each puncture and injection, the abscess refdls and before long the increased tension in the abscess creates a danger to the skin. This hvper-secretion from the wall is due lo an excessive reaction caused by the injections. Discontinue them then, for a while, but continue the punctures, without waiting for the lo to 12 days interval (v. p. i45.). Repuncture, were it the day after the preceding puncture, and puncture again every day (without injecting anything) until the red and thin skin has recovered its resistance and its normal colour. At this moment you start the injections again, if the patient has not had the regulation number, but taking care this time, that you inject only half or a third of the dose used before, or make only one injection for two or three punctures. b) The abscess does not dry up. After having continued the punctures and injections for 1 56 PUNCTURE OF ABSCESSES. POSSIBLE INCIDENTS two or three months, the ahscess continues as large as at the commencement of the treatment. This persistance of the abscess is due, most often, to the fact that too many or not enough injections have been made. It is to avoid this double stumbling-block that it is necessary to go up to the number of 7 or 8 injections, but not to exceed that. If it is a mistake to keep to one or t^YO injections, it is a mistake also to continue the injections as long as the abscess reappears; it may happen that, for a few days after the injection, the liquid does not reform, that is the exception; most often, the liquid reforms as long as you continue the injections. Yes, even after the wall of the abscess has been thoroughly cleansed, a fresh injection of the modifying liquid, always a little irritating, sets up a secretion of serum from the wall — amicrobic — a secretion Avhich may persist indefinitely, if injections are continued indefinitely. The injections should be. discontinued after the seventh or eighth, and from that time make only one puncture without injecting, then a compression in the manner described, to effect the approximation of the refreshed wall. If, after two or three weeks compression, fluctuation can still be felt, puncture again and recommence compression and continue it for three weeks longer. At the end of that time, examine again. If the abscess persists with the same volume (or practically the same), empty it again and make compression again for a third period of like duration. The abscess should now be dried uj). If it is not so it is, in this particular case, because the wall of the abscess has not been sufficiently modified by the regulation number of injections. Then you must begin again a complete regular treatment, that is a second series of punctures and injections — after which, a last puncture without injection and compression. But, not oftener than once in ten times, will you be obliged to make thus a second series of punctures and injections, and Tilt; ABSCESS BECOMES INFECTKD. WHAT IS To ItE DONK 1' l7)- nol oflener lliaii once or Iwicc In a Imiidrcd, a lliird series. On llic condition however llial ihe general slale of llie patient is not loi) bad, ami lli.il ihr lucal Irealnicnl of llie causal lesion of the abscess b\ iiravilalion is not loo defeclive. For. one or another of these causes nia\, in fad. iircvcnl the cure uf the abscess. Tlius, for example, you iiia\ ha\e fMllnwcd an unimpea- chable local treatment of liie abscess, the abscess will never- theless go on for ever, if the patient be cachetic, or presents multiple tuberculous foci. Or again, if you do not look Avell after the original condi- tion Avliich has caused the abscess (hip disease. Poll's disease, while swelling); if, for example, you do not put those patients into a position of absolute repose, if you allow them to walk about, and if you do not immobilize them with good apparatus, the abscess by gravitation runs a grave risk of never drving up. And this can be seen in certain cervical adenites ; the abs- cesses persist as long as the bad condition of the mouth and of the tributary territories of the glands causing the abscess continues. And from that the treatment can be guessed. It is to suppress the causes which are producing the suppuration, to seek for every means that will ameliorate the general condition of the patient, to prevent walking, to immobilize him w ith a good plaster, to remove teeth a\ liich are decidedlv bad or not absolutely sound, etc. c) Infection of the abscess occurring in the course of treatment. May we hope that after our numerous recommendations, no one will ever make a mistake in asepsis in the course of punc- ture and injection? and that you will always know hoAv to avoid infection of the abscess. Alas, no!' Errare hiimanuin est! It is necessary then to give here a sketch, a symptomatic table (to which we shall return), of super-added septic infection. The most important sign of infection, is the appearance 1 58 PLJJCTLRE OF ABSCESSES. POSSIBLE INCIDENTS of evening fever with marked morning remission. And this fever is accompanied by the general phenomena with Avhich Ave are familiar: loss of appetite, rapid wasting, insomnia. There are also local changes in the abscess and in the parts around. These local changes present themselves under tAvo different aspects : a) Sometimes, they present a rapid transformation from a cold abscess to an acute phlegmon ; there appear redness, heat, local SAvelling, and pain, either spontaneous or on pressure. Before long, the inflamed skin tends to ulcerate and give way at a point whence issues a thick, phlegmonous, vis- cid, microbe-laden pus, which must not be mistaken for the non-microbic pus of an abscess produced by our solvent injec- tions, or by oil of turpentine when one wishes to produce a stationary abscess. Here are the means of making a diagnosis; in the aseptic abscess, the temperature falls under the efifect of repeated punctures not followed by injections, in the septic abscess the temperature does not yield until after the opening and draining of the abscess. b) The other case is where there are little or no appreciable changes in the skin : it applies generally to deep abscesses ; at the same time, the general phenomena predominate, but the contents of the abscess has changed ; it is no longer true pus, but a saiigiilnolent liquid, the colour of tomato or of wine lees ; it contains sometimes gaseous bubbles and often exhales a fetid odour. Treatment. — One endeavours, by means of daily punc- tures (without injection), to make the temperature fall. — If the infection is very slight, one can do this. It is rare, but I have seen it; then, attempt it. If, in spite of punctures made nearly every day for a certain time — fifteen days, for example — fever persist; if moreover you are certain that the fever is not to be attributed to any intercurrent malady or to a visceral localization of ABSCESSIS \l\\ Iti: IMECTCD AT THE OLTSICT I .')i^ luhen-ulosis, llien. recognise lliat }oii have no alternative l)iil to o[)oii the abscess. Accept the inevitable. ^nu iimsl know also llial M)U shoultl not tielav the openiti'', for W you wail too lonfi', the liver and (he kidncNs run the risk of becoming infccled. and that visceral infection will be Fig, i-'i2. — The skin very much stretched by pus causing it to give wiiy at a point. capable, later on. of spreading on its OAvn account, even after the abscess has been opened. Therefore, if after lo or 20 days, the phenomena of infection and fever have not disappeared, resign yourself, open the abscess and drain it well. And you Avill behave afterwards, as you would in dealing with an infected fistula. Are there not abscesses infected from the very outset, infected before having been interfered with.' ^es, but exceptionally, in the two following cases; l6o PUNCTURE OF ABSCESSES. AVILVT TO DO IF THE ABSCESS OPENS? First case. — That of an iliac or lumbar abscess of Pott's disease, Avhich may, strictly speaking, be infected at the outset by the contiguity of the intestine, fissured or not. This may happen perhaps once in a hundred times, and even here, in these abscesses, the infection, when it exists, comes, 99 times out of a loo, from Avithout, from a fault in the asepsis, or from a fissure in the skin. Fig. i43. — The abscess Las opened extensively. A patcli of skin has given way. The signs of infection and it's treatment are the same as those given above. Second case. This relates to suppurative adenitis in the neck. When there are bad teeth, erosions of the pharynx, or of the ears, or of the nose, or of other tributary territories of the cervical glands, one cannot be sure of being able to prevent, with certainty, the rupture of the skin near a tuberculous abscess, because then, in many cases, it is no longer a question of tuberculous abscesses, but of abscesses infected, little or much, by septic germs coming from without. Therefore, here again, make some reservations as to the chances of saving the skin, if you have seen ulcerations of the now i<) ci.osK AN viiscr.ss which has oi'Knkd si'omamcoi si,\ iGi pliai'Mix. It'clli had oi- iiol absoltileiN sound, rlc. The iiitcction iiiav 1)0 llieu yravc eiioiiyii to lead lo a bursting of llic skin, and al the same lime, not sufficiently so lo cause lever, or at least a fever of more than a lew tenths of a degree. d) Spontaneous opening of the abscess. We have mentioned above tlie case where the rupture of the skin Avas threatening. Imagine the case, still more unfavo- rable, where the opening has been produced at the moment of the patients arrival, or a little before, or even before your eyes, in the course * of treatment, after one or scA^eral injections. What is to be done ? Here again, try and retrieve the condition of things. Ins- tead of enlarging the opening, as alas! so many surgeons do, you should do everything possible to close it. — and you avIH generally succeed. You will succeed especially w hen the opening has not taken place until after a certain number of injections, because then the deep part of the abscess has had a good chance of being so modiQed and refreshed that the cicatrisation may be brought about regularly and quickly, from the deepest part to the peri- phery, (the small superficial wound being, in this case, no longer nurtured by the abscess). The chances of success are decreased, one can understand, if no injections have yet been made, but you may still succeed here A'ery olten. How? I. For, in fact, it may happen (and though the case be rare, I ouglit lo mention it) tliat. in such patient, even when seen in time, with skin still sound, even treated regularly, and without there having been any fault committed in the technique, it may happen that the tuberculosis is, in this case, particularly malignant, that it has been impossible to arrest its pro- gress towards the skin, and that the skin gives wav ; the abscess is open, a small fistula has been produced. But, be re-assured, such evil cases, tuber- culoses so malignant, are scarcely ever met with, say once or twice in a hundred cases. It still remains true that with good general treatment and punctures well performed, you may promise a cure of abscesses « without a hitch ». Calot. — Indispensable orlhopedics. ii l62 PUXGTURE OF ABSCESSES. POSSIBLE INCIDENTS By simple methods ; This, for tuberculous wounds; daily dressings, thoroughly aseptic, or applications of various topical remedies, tincture of iodine, oxygenated water, permanganate of potash, naphtalan, Championniere poAvder, our own pow- der, a drop of lactic acid, iodoformed oil and creosote, ^ igo plaster, neol, etc. Take care to change the remedy nearly every day, for 2 or 3 weeks. Here is the formula of our powder : Aristol 4o grammes. Subnitrate of Bismuth 100 — Grey Quinine, pulverised 3oo — Siamese Benzoin, pulverised 3oo — Carbonate of Magnesia 3oo — Oil of Eucalyptus 3o After 2 or 3 weeks : Either cicatrisation has been accomplished. In that case, if the abscess is no longer perceptible, the treatment is finished. If the abscess persist, you will treat it by punctures and injec- tions, after having waited a few days longer, to give the skin time to strengthen itself. Or else cicatrisation has not occurred, nor anything like it, that is the small wound is kept open by a persistent abscess; it can be closed only by dealing directly with the abscess. For this one makes in the track, and in the cavity of the abscess, some modifying injections, either in liquid form, or in the form of paste. The medicated agents are the same as for the treatment of a cold abscess. If injections of creosote, of iodoform, of naphtol camphor with glycerine, cure the tuberculogenous wall of a closed cold abscess, it is not logical to demand of those injections the cure of the tuberculogenous wall of open abscesses, of cavities, or of fistulous tracks ; the anatomical and bacteriological consti- tution of the wall is identical in both cases, so long as they have not been penetrated through the open orifice by septic germs entering from the exterior. Nevertheless, even when not infected, the open abscess is not in the same condition as the closed abscess, its cure is not so easy, for two reasons; AMIAT TO DO IN THE CASIC OK THE ABSCESS OPEMNO lG3 Tlie first is dial the open abscess constantly runs tlic risk of infection. Tlie second is thai tlic injecletl liquid being not retained, returns immediately — without having time to modify tlie wall of the abscess. Compare with this case that of a closed abscess, where the injection is acting day and night, for several weeks. Fortunately, we are able to put an end to this double difficulty; i"", by means of a very severe asepsis, we can prevent, at least for a certain time, the entry of septic germs from without. 2'"'. In the second place, the modifying liquid may be retained in the sinus and in the cavity. This result is obtained by closing the orifice (immediately the injection has been pushed in), by means of a conical plug of sterilised avooI introduced into the opening, or more simply by a small tampon (of wool) applied over it, and pressing on the cutaneous lips of the fistula, — the plug or tampon being held afterwards by a few turns of Yelpeau bandage. S"'. If you do not succeed in keeping the liquid in its place by this method, there still remains the employment of the same medicaments in the form of paste. These pastes are liquified (by warming to fib" or oo") a short time before injection, and they solidify at the temperature of the body very soon after being injected. We will return to the details of this technique a little fur- ther on, a propos of the treatment of fistula? not infected (v. p. 170 and following). The cure of the cavity of the abscess and of the sinus will lead to that of the small cutaneous fistula which they keep up, and cure is the rule in the recent fistula? of which we are now speaking, occurring in the course of treatment (by punctures) ; for there is here as yet no infection or hardening of the track. The cure is consequently, much easier to obtain than in old fistula?. 11 THE TECHNIQUE OF INJECTIONS IN THE DRY OR FUNGATING TUBERCULOSES Wc will describe elsewhere, in ihe chapters devoted to cervical adenitis, epidydimitis, white swellings, osteitis, etc., that is, a propos of each dry or fangating tuberculosis, in which cases the injection ought to be made. Here, Ave will only describe the technique of the treatment. TECHNIQUE OF THE INJECTIONS A. Instrumentation. a) The syringe, of ordinary glass (v. p. 121). b) Needles N"' i and 2 ; Number one for very fluid liquid, number two for more viscid liquids. Fig. i/j/i. — Needle n" i. Fig. i/i5. — Needle ii° 2, B. The liquids. These are the same, in a general Avay, as for cold abscess, namely ; a) The mixture of creosote, oil, and iodoform, which is (( hardening » in its action. vur. n.iKCTiONS in dry tlherc hoses i05 b) The niixliiic of luiplilol, camphor and frlycerinc, A\liicli is « softening ». Verv much llie same doses arc used here as in the treat- ment of cold abscess. There is anotlier softening agent, 3 or 6 times as active as ihenaphlol camphor and glycerine ; it is a mixture ofequal parts of the four folloxAing liquids: sulphoricinated phenol, camphorated phenol, camphorated naphtol, spirit of turpentine. AA e will describe the indications a little further on, p. i68. The Technique One endeavours to effect, either the hardening of the fungo- sities, or their *"o/'/f/?/nr^ (after which one will puncture them)'. a) To produce hardenin(; Mi\i I hi: 1G9 or S (li(i|)s (if ihis liquid are siiHlciriil lo cffccl ihc sof- leniiii;' oi' llic Liland. This is Ik^n \oii ^\ill use il : In joe I (t or 8 dro[)s inlo llic centre of the filand or luhcr- onlous mass. It', alter 2/1 hours^ the reacliou which follows the injeclion is very active, if there is distinct local pain, insomnia, fever above 38", keepto this one injection. On the other hand, if the reaction is ahnost nil, again inject 6 or 8 drops of the mixture next day or the day after; this time the injection will be nearly always sul'licienl to produce softening. You have only to wait until the softening has taken place, Avhich you recognise by tbe appearance of fluctuation, perceptible at the end of three or four days. Then, you puncture ; you withdraw a viscid pus, the colour of mahogany. If the skin is reddened, do not repeat this, Avait before making another injeclion, until the skin has become normal. If the skin is not reddened, inject again, but this time with naphtol, camphor and glycerine; and repeat the puncture and the injection (of naphtol, camphor and glycerine) every four days; you thus make 6 or 7 punctures, with or Avithout injec- tions, according as the skin is normal or reddened. After the 6th or 7th puncture, you make a last jnmcture, this one Avithout consecutiA^e injection, and then apply pressure. In a Avord, you proceed, as in the treatment of an ordinary cold abscess. If, tAvo or three Aveeks later, there still remains a cres- cent of gland, unaffected by the injection, recommence the injections of softening mixture, and carry on this second treat- ment like the first, Avilh the double purpose of softening the fungous mass and preserving the skin. It is needless to go on fighting against the small remaining vestiges of the tuberculous mass ; they Avill disappear in due course, by themselves, by a process of hardening. Ill THE TECHNIQUE OF INJECTION IN THE TREATMENT OF TUBERCULOUS FISTULy€ We shall study, p. 229, the respective values of the diffe- rent treatments of tuberculous fistula?; surgical operations, expectancy, physiotherapeutic methods, sea-air baths, salt- Fig. 1A7 to i5o. — Our different models of nozzles for injecting into fistulous tracks of different shapes. baths, or sulphur baths, sun-baths, radio-therapy, radium- therapy, modifying injections. We shall see that of all these treatments, the last is ever so INJEcriONS IN TUBEUCULOUS FISTUL.E 171 much (he best, and we will Icll you Avhyit is llie besl. Here, we will speak only ol" the technique of these injections. Fig, i5i. — Nozzle \iilh a cup-shaped extremity for emptying. Substances for injection. Is there anything Avhich has not been injected into tuber- culous fistuhe, from the Villattes-liquor of our grand-fathers to the pommades so much lauded in our own days, passing- Fig. 162. — The syringe, in glass, mounted with its nozzle. by the injections of boiled sea-water, dilute tincture of iodine, weak solution of zinc chloride, tincture of aloes, etc.? Well, I have tried all those injections. And after having tried them all, I have come back, always, to our injections of oil, creosote and iodoform, and naphtol camphor and glycerine. Clinical experience brought me back to them; but reason demonstrated beforehand, that these liquids, already recognised as the best for purifying the wall of cold abscesses sliould also be the best for purifying the fungous wall, almost identical, of TUBERCULOUS FISTULE tuberculous fistulae. These medicated agents are employed in fistulee under the same form, cold liquid, as in abscesses, Avhenever the anatomical disposition of the orifice and of the cavity allows of the liquid being retained in place. This is how to proceed. Make, through the orifice of the fistula, Avith an ordinary glass syringe furnished AA-ith a nozzle of the length and form appropriate to the track, au injection of 4 to lo gr. of one of the tAAO solutions mentioned; block the orifice immediately afterAAards, either AAith a small cone of absorbent cotton avooI forming a plug, introduced into the orifice of the fistula to a Fig. 1 53. — Glass and ebonite syringe for the treatment of fistulas (-which can be used in the absence of the glass syringe of Collin or of Luer). depth of 2 or 3 cm., or, simply AA'ith a tampon of cotton Avool, AAhich, placed flat OA-er the orifice, pushes the lips gently iuAAards — depresses them, in such a AAay as to preA-ent the escape of the fluid introduced; if there are seAxral orifices, an assistant blocks in the same manner the other orifices AA^th small conical plugs of avooI or small tampons. All these tampons are kept in position by a \elpeau bandage carefully applied . The day after the next, giAe another injection, and so on CA-ery other day. Each time, remoA'C the tampon, or the small conical plugs, and alloAA- the cavity to empty : then inject again. If the orifice is gaping, if the daily introduction of the syringe and the contact of a more or less irritating liquid increases the aperture too much for the liquid to possibly remain in its place, it is adAantageous to suspend the injection for a feAv days, Avhich will alloAv the orifice to contract a little. NAIUUE AND lEClINKJl E OF HIE INJECTIONS it3 finds the track between Ihe swollen tissues around the orifice of the fistula. Toward llic twonly-fifth day, llial Is. afler about lo injec- tions, tlio active wall is siiflicienlly modilied and relVcshcd to allow of their closing and to reckon npon the union of llie Avail of the tract. This union is assisted by compressing the parts with small bands of cotton wool placed cross-wise and held firmly by Yelpeau bandage. This is Fig. i5'i. — The nozzle of the syringe not always easy (in the case of inguinal fistula in Pott's disease, for example) ; but it is done whenever possible. If adhesion of the two walls is not obtained at ihe first attempt, if after 20 days, during Avhich compression must be kept up, there is still an oozing, it is necessary to recommence a ucav series of from 8 to 10 injections, ]iroceeding as before. This second series, followed bv compression and a second period of waiting, heals another group of listulfe. If the fistula is still not cured, I advise you to wait 3 or 4 months before making further injections. During these 3 or 4 months of Fig. i55. — intra-fistulous injec- simple ascptic dressings, and of rest, ^ion A strip of damp cotton especially at the sea-side or in the wool IS rolled round the nozzle ^ "^ of the syringe ; the left hand of country, the fistulae close at last, tlie operator firmly compresses nearlv alwavs, evcn thoush thev be the wound with the tampon, ■■ "^ _ '- "^ _ whilst the right hand removes Connected Avitli bone Or a joint, the syringe immediately after provided that One is dealing Avith the injection is completed. ^^ _ '- fistula? not infected (no fever and no albumen being present) (v. p. 2 25). 1-^4 TUBERCULOUS FISTUL/E. INJECTIONS With a little experience and precaution, you succeed, by means of the conical plugs of cotton wool or tampons, in re- taining the liquids in many fistulous tracks. But with most fistulre, it is not so; the orifice, or orifices, are gaping too much to alloAv us to completely close them with the conical plugs or tampons of wool, and to retain com- pletely the liquid in the fistulous tracks. In that case, it is necessary to incorporate the active substances (creosote, iodoform. Fig. i56. — Communicating fistula3. The injection is pushed into one of the listu- laj, while tlie left hand, in order to keep the injected liquid in its place, blocks the other fistula or fistulae by means of a large tampon. naphtol, or camphorated phenol) with a paste which will dissolve in a water-bath at a temperature of /io° or thereabouts, aud which, being introduced in the form of liquid (without scalding the patient) becomes solidified at the end of one or two minutes, at the temperature of the body. We have carried out this method for i5 years (that is, lo years before Beck of Chicago) at our Oise Hospital at Berck, with our assistant P. Pesme, who mentioned our results in his thesis (in 1900). We used at the beginning, a bougie of stearin and naphtol camphor in the proportion of three parts of stearin to one of naphtol camphor. The stearin bougie was previously steri- lized by boiling for 20 minutes over an open fire. Before each injection, we used to dissolve our paste in the water-bath. OUll I'ASTK lOR INJECTION IN GASES Ol' EISTLL/E 1 7;> liiimcdialelv it li(|nilicd,, we iiijccled it and kept il in place with a lani[)on, until it Avas solidified; that occurred after one or two minutes. The injections were repeated every 3 or /| days, until 5 or () injections had been given. Fig. 157. — Tlie dressing after injec- tion. I. Two tampons crossing each other over tlie fistula to pre- serve its occlusion. Fig. 1 58, — 2. An assistant holds the tam- pons Avhilst the bandage is applied, the pressure of -which keeps the liquid in place, until the next injection. We have obtained cures by this method; but we observed sometimes in cases of fistulous passages leading into cavities larger than the tracks, phenomena of retention, such as are noticed as well with injections of paraffin pastes : this is due to the fact that stearic acid and paraffin have a melting point relatively high (60'^ about), and are substances but slightly I'jG TLBERCLLOLS FISTUL.E. INJECTIONS absorbable. That is Avhy we use hardly anything else to day but . the follo\Ying preparations, which give us every satisfaction'. Our paste jn" i. Phenol camphor ) ,, . ,T 1 , 1 1 I aa 6 srammes. jNaphtol camphor ' Gaiacol i5 — Iodoform 20 — Lanoline for spermaceti) lOO — The melting point is about 4o° (slightly above). Our paste y° 2. Phenol camphor } , . „ -- , , ^ , i aa C) grammes. iNaphtol camphor J ° Gaiacol 8 — Iodoform lO — Lanoline (or spermaceti) loo — The melting point is about 4o° (slightly above). The first of these pastes being twice as active as the second, we use it for cavities or fistulous tracks of small capacity, that is, of less than lo cc. in a child, and of less than 20 cc. in an adult. Inversely, we use the paste n° 2 for large cavities, that is, those exceeding the dimensions we have just given. You may inject 10 cc. of the first in a child of ten years, and up to 20 cc. in an adult. Of the second paste you inay inject double the quantity, that is 20 cc. in an infant and /jo cc. in an adult. As a matter of fact we hardly ever reach those figures, but they may be reached w^ithout inconvenience. If you take care not to exceed them, you will never observe a serious accident of intoxication, whilst there have been cases of death Avith the bismuth pastes. Neither will you I. \ou can prepare these pastes yourself, as we have personally done, or you can order them from your pharmacist, if you are certain of his asepsis, or you may inc£uire of Messieurs Ducatte, or Johan, or Gogibusof Berck. THE METHOD OT USING OLll I'A.STi: AS INJECTIONS 77 have anv ac duration, particularly long, ol lliesc affections, is thai ol' one year lor a inininium, and ol'lcn several years^ The obligation resting upon the practitioner to Avatch over his patient, not only during the long period of activity of the disease, but far beyond that, for perhaps one year, tAvo years, three years, in default of Avhich a relapse may occur, and the entire orthopoidic results obtained up to that time, lost. 2. The necessity for all patients to live out of doors from morning until evening, in all seasons and in all weathers", in a perpetual bath of pure air and sunlight. 3. The necessity for keeping at rest in the recumbent posi- tion, of patients afflicted Avith Pott's disease, hip disease or tuberculosis of the loAAer limbs, until the focus is extinguished, that is, in many cases, for several years. ^^ ell, all this you Avill learn in a short visit to Berck. At the same time you Avill see hoAv the tAvo indications for outdoor life and the recumbent position, Avhich are considered by some people to be irreconcilable ^ are in reality easy to recon- cile, eAen for people of small means. The only thing is to put the patients on a " cadre ". 1 . In reality, If, in their common forms, these tuberculoses can be cured in a year, it is only on the condition of their being treated by injections made into the focus. Without injections it will be necessary to reckon three, four or five years. Unhappily, there are cases ^^■here the injections are not practi- cable; for example, Pott's disease A^ithout abscess; the vertebral body, the seat of the lesion, is too far away to be reached by the syringe without uncertainty and without danger. 2. They are clothed in a suitable way, and sheltered if need be. 3. That Avhich makes them, so often, sacrifice the one to the other. The Germans and the English, in carrying out the general treatment before the local treatment, allow their patients to walk alDout, to ensure for them, above all things, life in the open air. The French, on the contrary, give the preference to the local over the general treatment, keeping their patients in bed « in the Avard » (as one sees in many hospitals for children) — Avhich is, perhaps, a worse mistake. The correct formula is. — plenty of air and perfect rest at the same time. nil I'viiiMs \i\i)i: lo i.i\i; IN Tin: open aiu i85 lloie is a verv simple model ol" a wooden bed (cadre) with ""^7 Fis. 162- — T lie bed upon \Yliicli the patients lie. a mattress of horse-hair, designed so that it may be construc- ted everywhere. The patients are laid horizontally and strapped on these l^ Fig. I Go. — The bed is placed on this wooden frame. beds, provided with a handle at each end to allow cf their easy removal into the open air. 1 86 THE NECESSITY FOR REST IN THE RECUMBENT POSITION The patients are thus carried every morning out of doors ; they pass the day, immohiles, either on trestles or on a chassis (about a metre high), or even simply on the ground, or taken out in the small carriages (such as those you see by hundreds furroAving the sands at Berck ' . 4. lou learn also at Berck that, contrary to Avide-spread prejudice, the patients do not pine away, nor are wearied, in the recumbent position. Fio-. iG'i In default of trestles, the bed is placed on two chairs. The first thing Avhich strikes and surprises all the visitors is the very happy countenances, rosy and plump, of all the patients, extended on their beds. Therefore, medical men will be able to reassure parents Avho are fearful, a priori, for the general health of their children, and, as to the effects of the recumbent position kept up for so long a time. HoAv natural and essential this position, Avhich seems so abnormal elsewhere, appears at Berck ! At Berck — owing to the surroundings, and to the example 1 . The same is clone for all afTections (other than the external tubercu- loses) the treatment of which recjriires a long rest (namely rickets, infantile paralysis, congenital dislocation of the hip, osteomyelitis, syphilis of the bones and joints, etc.). TIM". ni.i:i Miii.M' I'osi I ION AI.W \\s W I.I.I. TOI.KUA'n.l) 1 87 i;ii;i:!iiiii'niii'iii;iiiii!L7^i;i:'inm'ia.itj'i;^ Fig. i65. — Thanks to a movable reading desk, the patient is able to read and work. As can be seen, this patient is wearing a large plaster apparatus for Potfs disease. Fig. 1 60. — The patients take their meals in the open air. 1 88 AN EASY MEANS OF RECONCILING THE TWO INDICATIONS set to the new patients by those ah-eady cured — everyone, from the day of arrival, cheerfully accomodates himself to the common regime of rest in the recumbent position. 5. Finally, practitioners Avould learn at Berck that difficult and nevertheless so important thing — not to operate on these patients. They would learn that the knife is the enemy of these affections ' ; that ihe first condition to cure Yiui;hs or di-atii 193 say at once of every cliild stricken witli hip disease or sii|)i)ii- rated Pott's disease. " He is a dead cliiid. But I speak of twenty years ago ! Today this IViiililful niirlitinare is al an end! Evervlliin"- rig. 172. — Pott's disease with fistulae ; the cacheiia is made apparent in this child by an exceedingly large liver. Fig. 178 , albuminuria and fever (v. fig. i~\,- is changed, so thoroughly changed, that the reverse is now true. The late in store for these patients is not death, but cure. \N e like to repeat, in the familiar causeries of our practice, that our profession (especially with regard to us who study external tuberculoses) was at one time the worst of all. the most Calot. — Indispensable orthopedics. i3 194 I. SLOW SEPTICEMIA WITH VISCERAL DEGENERATION depressing, the most demoralising ; that to day it is the most beautiful, the most comforting, that which produces the most numerous and excellent cures, that in which we have the greatest certainty of being useful. What has Avorked this miracle? It should be, here as in Fig. 173. — jNormal outline of the liver. all other departments of surgery, the advent of antiseptics and the perfection of technique. Never! It is not because we perform the operations more asepti- cally, more correctly and more rapidly ; it is simply because we operate upon them no longer. For, by not operating upon the tuberculoses, by not ope- ning the bacillary foci (nor allowing them to open), we close the door to external septic infections, whilst, by operating TO AVOID THIS. NEVER OPEN TUIiERCULOLS lOCl I (JO upon lluMu (however clever the operator) ' a door is opened for llie sccondaiN scplir inleclidns A\liicli conduct the palicnl lo dealli'-. That is wlial we have learned in an experience of twenty years. All that, we have already said ; il' we return to it once more, it is because it is necessary, seeing that so many sur- f^eons or |)h\slcians persist in closing their eyes to the I^i ;fsv frf '±l:±Y^ f -H ■t- i-± '^jy' "-i.. f- A — Fig. ly/i. — Portion of cliart in the case of the child in fig. 172 sulTering with Pott's disease and operated upon (incision and scraping) for an abscess in the right iliac fossa. The patient succumbed in the thirteenth month of hectic fever and degene- ration. light and still transgress, every day, the great command- ment, the fundamental dogma, of never opening tuber- culous foci. The Means of Preventing the first Risk of Death. These means you have guessed at ; they are most simple, and observe that, in reality, it gives us less trouble nowadays to cure our patients than it did formerly to kill them. 1. Tlie great surgeons, aaIio, bv tlieir so-called radical operations, under- take to remove the whole of the trouble, will succeed only in one thing; they A^iil remove everything the patient. 2. « In closed tuberculoses, cure is certain. To open the tuberculoses (or allow them to open) is to open a door by Avhich death too often wil enter. » igG SECOND RISK : THE GENERALISATION OF TUBERCULOSIS What must be done? In the presence of a non-suppura- ted tuberculosis, abstain from any cutting operation ; in the presence of a suppurated tuberculosis do not touch it if the tuberculous foci are difficult to attack, in ^Yhich case they do not threaten the skin ; when they do threaten it and they are then easily accessible, puncture and inject them; Ave have described hoAV to do this (v. Chap. III). Then you Avill cure hip disease and Pott's disease, always, or nearly always. And not only you, but also the second year's student, who knows how to make a puncture and an injection, will cure external tuberculoses infmitely better than the great surgeon Avho is anxious to operate upon them at all costs. As you see, you require only the inclination to be able to suppress this first and great risk of death which threatens patients suffering from the grave external tuberculoses : slow septicsemia and visceral degeneration. 2. The Danger of a Generalisation of Tuberculosis. This risk is much less than the preceding one — it is nearly as little as the first is great. Nevertheless, attend care- fully to Avliat I say. If at Berck we scarcely ever see this generalisation — only perhaps once in a hundred cases — it is because Berck is, Avithout contradiction, the ideal locality for these maladies, and is especially suitable for childrean. It is certain that for subjects — especially adult subjects — living in bad sur- roundings, the risk of generalisation Avill be A^ery real. It is not A^ery rare to find it in the large tOAvns, Avhere patients I. I say nearly always because, in spite of all the efforts made to hinder the opening, one will not be absolutely successful in every case ; for, if the technique of punctures and injections is relatively easy, it is nevertheless very minute, and one may make mistakes in applying it — " errare humanum est ". IS HARDLY KVEU SEEN AT Itl^HCK K)- M'lio have commenced with a Poll's disease, or hip disease, or a white s\Ycning of the knee, finish ^Yilh Inhcrciilosis of (he lunp-. How can the danger be warded oil? The rcmcdv should be to make all these patients live by the sea; but it is impossible, evidently, for most of them to do so, and this is why practitioners, wherever they are, ought to know how to treat the external tuberculoses. (They Avill, I hope, give me credit that I am endeavouring to assist them, and that this book has no other purpose). However, I Avill say to them, your patient cannot go to the sea-side; therefore he is, certainly, a little less well armed against a generalisation of tuberculosis, maybe ; but, at least, you do not accentuate this drawback, nor lessen — by the kind of life you allow him to lead — the very great chances of cure which remain to him. I will explain what I say. AA hat makes the superiority of a sojourn at Berck is not only that the pure air is more tonic than at other places, but that the patients profit more by it. For our patients at Berck — hip cases, Pott's, etc. — live in the open air from morning till evening in all seasons and in all weathers, keeping always at rest, reclining on " cadres ", on the small carriages that promenade the sea-shore (fig. 170). I intentionally insist on this point. But what do you see in the country, and especially in a large town.>^ You see patients affected with hip disease. Pott's disease, white swelling, who, especially if they are at all suffering, are shut up, hidden away in their chambers and in bed with every chink stopped up. This they do for material reasons; because one has not contrived, and one does not know how to contrive, their going out of doors '' in bed "; they have not, as a rule, either a transportable bed nor a carriage. And also, for moral reasons; because the patient himself refuses to go out, and because his parents avoid making him I go GENERAL [SATIO>' OBSERVED I>" THE UMIEALTT MIDDLE-CLASS do SO ; he does not aa ish to be seen, and they do not Avish to expose him. A young- lady afflicted AA"ith Pott's disease, and lying on her mattress in a carriase. said to me. " Imagine mv feelings if I AAere carried about the streets of our little toAAii in this turn-out! At CA^ery step, I shoidd be obliged to submit to Fig. i'j5. — At Berck, our palienl? pass the ^vhole clay on the shore; their carriages are fitted with a leather apron and a hood, which protect them from the glare of the sun and from the rain. the remarks and condolences of strangers, and still Avorse of my friends, and I, in this long Ioaa" carriage, going at a foot pace, should think I AAere on a bier; anyAAhere else, I should be a phenomenon, Avhilst at Berck... I am in the fashion I And this is AA'hy, in the country and in toAAUs, the patients " moulder " in their chambers, Avhich they ncAcr leaAC. Or, they AA'ho ought to be resting on a bed completely horizontal, so as to fulfil the best conditions for the repair of their hip disease or Pott's disease, are unAA'illing to go out, except upright, AAith or Avithout an apparatus. i.N (JUDEU i(» i'iu:\r:\i' it, r.ivi; i\ iiie ori:\ aii; i()() The Remedy for this Risk of Generalised Tuberculosis. As to the remedy, there is only one. for your pMiicnls who are reslricled lo the country or to lowii lile. Fig. 176. — This is what you could do everywhere in the country. AMiite swelling of the knee. The patient immobilised on a bed (the bed of wood, the mattress of liorse-hair) which is carried into the court or into the garden, where he passes the day. Those suffering from hip disease and Pott's disease are laid entirely flat, without a pillow. \ou must take your courage In both hands and impart it to your patients, to triumph together over all the prejudice and all the obstacles Avhich would prevent them living out of doors. In the country this is relatively easy to accomplish. The patient cannot have a carriage, it would cost too much, mate- rially and morally; very well, be it so, he need only be strapped on a large " cadre " and carried in the morning into the garden, Avhere he will pass the entire day (fig. 176). In a town, it is less easily managed, I admit, for those pa- tients who are not able to go away, and who possess no garden 200 ONE ATOIDS IT ALSO BT GOOD LOCAL TREATMENT of their o^AIl; but they might be able often, Avith a little courage and initiative, to be carried into the neighbouring square and remain there for many hours, A^ hen once the habit has been acquired, nothing could appear more simple. If you do this, if you have the necessary energy and courage to carry out your intention, informing your patient and his friends that a cure is the prize to be Avon, you Avould overcome almost certainly the risk of generalised tuberculosis Avhich is the second risk of death. But it is not only by good general treatment that you can accomplish this. It is certain that a defective local treatment may lead to a risk of generalisation; for example, a cutting operation is not only objectionable because it opens the door to septic infec- tions and visceral degenerations, but also because it creates a risk of inoculation of the lungs and other organs. Erasion, the scraping doAvn of tuberculous tissues, Avhich causes hoemorrhage in all such interferences, setting at liberty tuberculous bacilli AAhich may moAe off to colonise far aAA-ay, explains too Avell certain post-operative tuberculous generalisa- tions. I have obserAed it undoubtedly incases in my OAvn prac- tice fifteen or tAventy years ago, at the time Avhen I still operated upon external tuberculoses. Add to all this that operations, in lessening the general resistance of the patient, render the organism still more vulne- rable and more " inoculable ". The non-immobilisation of painful osteo-arthrites, the vio- lent redressment of deformities of the hip. of the back, of the knee, may also favour or provoke the generalisation of tuberculosis. I say that, in order to do aAvay AA"ith these different risks, you must ensure perfect repose of the patient, construct comfortable, that it to say, Avell-fitting apparatus, neither loose nor tight, aA'oid rough redressments, and replace them by redressments Avhich are gentle and progressive. 3"" meningitis; mdiu- haki: at the sea-side than elsevvheue aoi 3. There Remains the Danger of Meningitis. All llial I lia\c jiisl said iiia\ he a|)|trM'd to nicniiigilis. I consider lliat in improving on llic one pari llic resistance oC the subject and on the other by avoiding anything harmful in the way of local treatment, that is to say, any culling operation, any roughness in redressmenl, any painful treatment, by forbid- ding brain work and exercise or premature walking, one puts the patients under the best conditions for preventing the onset of meningitis. This gives me an opportunity of saying something as to the risk of meningitis created in children by sojourning by the sea, in particular by sojourning at the shores of the INorth of France. I believed in it twenty years ago, on the strength of the classical treatises. AA'ell, I do not believe in it any longer, after twenty years experience and personal observation. I will go further than that — I consider to-day that it is the contrary Avhich is true. But first, it is well knoAvn that all children, and with stronger reason, all carriers of external tuberculosis, may have meningitis. And it is still more true of those avIio are debilitated and ill- conditioned. But at Berck, children are better than anywhere else — they eat better, breathe better, grow fatter, become stronger, and one can understand that they must be, on this account, more resistant and more immune against meningitis than they Avould be anywhere else. And this is not a mere fancy nor a matter of opinion — the facts are there. I have scarcely ever seen meningitis — only one, two or three cases a year — less than one in a thousand of the chil- dren afflicted with external tuberculosis Avhom I have treated. But I hasten to add that that has been so for only a dozen years ! I observed a considerable number of cases of meningitis in former years, perhaps ten or fifteen yearly. 202 TO PREVENT IT : ^'O OPERATIO>% >"0 YI0LE:VT REDRESSMENT Do you know why? Because at that time, noAv far off, I operated upon the tuberculoses, or I corrected at a single sitting tuberculous deformities (hip disease. Pott's disease, white swellings) as others did everywhere, and as many still do to-day. AMien, then, certain surgeons put forward that their cases' of forcible redressment of hip disease did not shew a greater tendency to meningitis than those left untouched, I affirmed distinctly to the contrary, basing my opinion on the results of my personal experience. And upon another surgeon practising at a maritime station (notBerck) stating that he believed that he had observed an appreciable number of cases of meningitis at the commence- ment of their sojourn at the sea-side, (that is to say, at the moment when they would especially feel the effect of sea-air, the effect being too stimulating for some children), I replied that I had never seen anything to confirm that opinion; and that, if new patients are more disposed to meningitis, it is due, in my opinion, not to the stimulating effect of sea-air, but, very often, in some marine hospitals, to their being operated upon or forcibly redressed soon after their arrival at the sea-side. But we have already described the grievous influence on the meninges of such mischievous traumatisms.' I could cite instances in support of what I here advance. Without wishing to spend too much time upon the question, I have said enough to draw the following conclusions, which I ask you to remember. Practical Conclusions. There are three risks of death in the external tuberculoses ; — I. Amyloid degeneration of the liver and of the kidneys, which causes nine-tenths of the deaths. This degeneration is due to the opening-up of tuberculous foci. In order to guard against it, it is sufficient to prevent such opening-up. In other words, you ought never to operate upon THEN iiii: TiiurE iusks vnr \r\ni.^ \i.\\ ays piu.vi'.m iiti.i; a. ,1 (/cneralisnlion of litlicrctihisis lo llic lumj, la llic hidney, and lo Ihc li/(i>l(l,T. \i)\i will ;i\nl(l llii-^ iiOiirl\ ;il\\;i\s if llie palicril live out or doors in llic dpcii air ['ir>]\\ im lining lill evening, and 11" you yourself .ihsl.iin IVoni all vidlcnl interference in the general treatment, tliat is to say, llial you perform your redress- ments of hip disease and Avliile swellings, gently and by stages. 3. A Meningitis. You would always avoid this, or nearly ahvays, by increa- sing the general resistance of the patient (and for this object, the sojourn by the sea is evidently the best; which does not, of course, dispense a\ Ith walch being kept during the stay, especially if it is a question of a nervous child), by assuring the cerebral repose of the patients, by your abstaining from all cutting operations and forcible redressments ' . It is possible to promise a cure. And now you know the answer you have a right to give to those parents who, having brought you a patient with external tuberculosis, ask you at once if he will be cured. Yes, you may promise them that he will be cured, or rather that you w ill cure him ; for he wdll not be cured unattended; he will not be cured if he is treated roughly; he Avill be cured because you know what is necessary to be done and how to avoid what would prevent or compromise the cure. 1. Wliich does not mean, I repeat it, that you Avill not do Avliat is neces- sary and sufficient for the redressment of vicious positions. No, you «ould correct them, but in the right manner. Formerly, I used to make forcible corrections after the metliod of Bonnet, of Lyons, Avhich is stitl that of nearly alt surgeons (by movements alternately of llexion and extension, movements carried on for a quarter of an hour). I have not made such corrections for many years now but I succeed as Avell today, Avith mild measures, slow and progressive, in correcting the vicious positions and keeping them corrected. And you will succeed erpially well if you follow the indication-; given in this book for each deformilv. 204 PRI>CIPLES OF LOCAL TREATMENT. 1st, SUPPURATED TUBERCULOSES C, On the local treatment of external tuberculoses. The following considerations are directed not only to the tuberculoses called " orthopoedic " (Pott's disease, hip disease, white sw^elling), hut also to tuherculoses of the soft tissues (ade- nitis, synovitis, epididymitis, etc.). The respective value of the different treatments. I'* In the suppurated tuberculoses. In the presence of a suppurated tuberculosis, what would you do.^ There are three possible treatments : I*** Operation; a""* Abstention ; 3"' Punctures and injections ^ i"' The value of surgical |operation : Without doubt, surgical operation can claim a large number of cures, when it is made very completely, that is to say, in disease of the cer- vical [glands, or in very accessible tuberculosis in the limbs. Nevertheless, you know very well that to go very widely beyond the limits of disease is not an absolute guarantee of its cure ; for a tuberculous inoculation of tissues, up to this time sound but vascular, and brought into contact with bacilli by the operative act iteslf, always remains possible ; this accounts for the fact that, even in superficial accessible tuberculoses, the largest operations often leave fistulee behind. And fistula is the rule (for the same reason and especially, I. I have not mentioned a fourth treatment, the method of de Bier, which, good as I believe it to be, in acute phlegmonous inflammation, whitlows, etc., is of no value, I am sure, against external tuberculoses. THE SIIOKT-GO.MINGS OF SUUGICAL OPERATIONS 2o5 because opcralion li;is not been able to gut beyond ibc liinils of tbc disease), wbcii deep tuberculoses of bones or of joints of limbs are in question, and especially Pott's disease, forwbicb it is always inipossii)le In pci-forni a really complete o[)cralir.ii. Fistula is the rule... Have practitioners tlie least doubt as to ibe miscbief tbey bavc done in transforming tliis Poll's disease or tliat coxitis unopened, into a coxitis or a Pott's opened:' Closed, Pott's disease lias 99 cbances in a liundred of being cured ; opened, tbe proportion is reversed : it is 99 chances in a hundred that the case Avill terminate in death — a little sooner, a little later. That is what the practitioner has done, with a light heart, in opening an abscess by gravitation. It is a door leading to death Avhich he has opened. Through the fistulae, in fact, will penetrate septic germs cau- sing secondary or mixed infections, infections associated with the pure tuberculosis which has existed until then. And if, after that, pus is retained, Avhich it almost constantly is, in the long and tortuous tracks which separate, for example, a focus of dorso-lumbar Pott's disease from a fistula burrow- ing in the thigh — if such retention occur, it will be almost impossible to remedy it; there will be fever and septic absor- ption which will pave the way to visceral degenerations (liver and kidney), culminating in the death of the patient, after one or several years. This is the constant result of surgical operations performed in Pott's disease ; I could quote hundreds of observations of this kind, but each of you will have known such in his own circle. Doubtless, the situation is not the same in the case of superficial tuberculosis, cervical adenitis, iodopathic cold abscess, spina ventosa, ostehis or osteo-arthritis easilv accessible, in Avhich cases, if a fistula remain, the complete drainage of it does away with such retention and reabsorption. But do not conclude that operation may never be seriously harmful in cases of superficial tuberculoses. The danger of secondary infection does not exist here, it is true; but can we 2o6 GENERALISED TUBERCULOSES AFTER OPERATIONS prevent the risk already pointed out of a tuberculous inoculation in the course of an operation, when, by the knife or the cu- rette, the bacilli are brought in contact with vascular tissues thus harrowed and scraped ? Inoculation will be spread by a regional extension of the tuberculosis, or by the creation of a new focus at a distance. Here are some examples taken from a hundred such cases : a. A great Parisian surgeon performed castration lor an epididymitis dating back two years, in a cliild of i3 years. Soon after tlie operation, exactly three months, there appeared a right coxitis, and in the fifth montli the left hip followed suit. b. A little girl had, for three years, a double Spina ventosa of the right hand. It was decided all at once to scrape it : nine Aveeks later Pott's disease appeared at two points (cervical and lumbar). c. A young man 24 years of age was brought to me for left epididymitis by his brother, who is a medical man. I proposed modifying injections (see chap, xix) into the site. The treatment doubtless appeared very simple to my confrere who went the next day to Paris, to consult one of his old masters, a very distinguished surgeon, who performed castration. Two months afterwards, the patient was carried off by meningitis before even the operation wound was cicatrised. And I know of three other cases exactly similar to that. d. Lastly, I hear from one of the surgeons who operate most frequently on appendicitis in Paris, that he has decided not to operate again on appen- dicitis when it is duty recognised as being tuberculous — because, having operated upon six such cases, he had seen two of the patients (the third I) carried off some months after the operation, by the onset of cerebral tuber- culosis. So much for the risk of tuberculous inoculations after ope- ration, a danger I have no wish to exaggerate, which is, I will admit, not very great, but which cannot be denied nowadays, We will take now the cases called " satisfactory", those in which cure is obtained by operation; at what price is that cure obtained? Do the mutilations produced count for nothing? I do not refer to the loss of power left in children, by ope- rations on the skeleton of their limbs, but solely to the results obtained in those superficial tuberculoses which appear the most justifiable for the knife. AHSTENTION PUEl'ERAHI.E TO OI'EKATION -jq-j III ii|»(i;iliiit;- |n|- cci'Nit'al .nlciiilis, \(.ii li,i\c junidrd llie risk (il scplic itilcdion" and luberculdiis inoculalion, \ovi have ohiaincd union hy firsl inloiilion, (if wliirli \ou arc sr» |)iou(l ; lull is il iIrmi iiDJliinL:-. I ask iIkisc siiriicoiis who operate u|)on cervical glands, is il nolhing lliat \ou have left ihal younf girl Avilh horrible cicatrices, persistant stigmata. a\ Inch will remain Avith her, lo ihe end of her davs, a cause of inliriile sadness, A\hich will •• mark " her lor ever, will prevenl her establishing herself and pursuing a normal existence? And it is not a question only of fashionable young ladies; how many shop girls and domestic servants who, by the large cicatrices on their necks are prevented from obtaining situa- tions and gaining a livelihood! Each of us must examine his conscience. AVe ought to think a little more of those children with Pott's disease who have paid w ith their lives for tlie mistake of the practitioner who has opened their abscesses, or even more, of those young women with scarred necks, who have paid for that same error with their beauty and their happiness; I believe that the thought would make us accord, in course of time, rather less credit to cutting operations in the treatment of suppurated tuber- culoses. Remember that taberciilosis does not love the knife which rarely cures, often aggravates, always mutilates. 2°'^ The value of abstention. Do not be astonished after this, if I affirm that to leave suppurated tuberculoses alone, to do nothing except a good general treatment, is far safer, on the whole, than to operate upon them. In other words, syste- matic abstention is preferable to cutting interference at all costs. And I am not alone in this opinion. Has not a Professor of the Faculty of Paris the habit of saying that, in the presence of superficial tuberculosis, it is better to fold ones arms, than to take up the knife? I have heard recently the same language 20b PUNCTURE AND INJECTION, THE ONLY RATIONAL at the Orthopoedic Institute at Milan, where a surgeon said to me : " At -one time we operated upon and scraped every abscess in coxitis and Pott's disease; noAv, Ave never touch them, and our patients have gained much ". Indeed, if one does not touch them, this is Avhat happens : P*, A large number of these tuberculous suppurations are reabsorbed — nearly half of them, a fact certainly not to be overlooked — and it is true, not only in superficial tubercu- loses, but also in abscesses by gravitation in Pott's disease ; it is indeed most frequent in the last case. Nearly half the abscesses in Pott's disease are re-ab- sorbed spontaneously, if you leave the subjects at complete repose with good general treatment. 2"'^ The others open spontaneously may be, but with spon- taneous opening : (a) the risk of tuberculous inoculation is negligible, contrary to what occurs in scraping and cutting- operations. (6) The risk of secondary septic infections is less than in listuloe following on operative interference, that is to say, fistulas in which one has disturbed the tissues very much. This is Avhy the fistulas which are produced in the neglec- ted children of the country are cured much more often than those Avhich are subjected to extensive and learned surgical interferences, fistulae which are very often infected at the onset by the operative act. (c) Mutilation is less after spontaneous opening than after operation. The cicatrix in the neck, which the spontaneous opening of a broken down gland leaves, will never, or scarcely ever, be so unsightly as the large and horrible scars going from ear to chin, or from one ear to other, of which the surgeons are so proud, all the more proud as they are longer. S"^"^ Puncture and Injection. — But let us hasten to say that Ave have fortunately found something better than absten- tion to set against the suppurated tuberculosis. If one sins TREATMENT OF SlITURATED TUBERCULOSES aO() cs[)ccially gravely by commission (in operating), one sins also. bv omission, in leaving an abscess lo open sponlancously. ll is necessar\ not only nol lo opcrale upon or lo open tuberculous snp|)uralii)ns. but still more to prevent them opening, by punduring ibem witli a fme needle. And we will bave already lencicrcd a great service lo our patients if we bave saved ibem IVoni I be risk of mutilation, septic infection and tuberculous iiK iculalion. Tbcrefore lo do nolbing sbould not be your mollo. There is a belter way. If we know bow to profit by tbe presence of tbe abscess cavity in order to replace tiie pus by a modifying liquid which will cure rapidly the tuberculous wall (idiopathic abscess), and which, in abscesses by gravi lation, Avill rise up to tbe source of the pus and cure not only the abscess, but even the affected bone or articulation whence the pus comes, ah! then, it will be truly perfect. AVe shall bave certainly cured our tuberculosis, more surely llian with the best conducted operation, and we shall bave cured it in a few months; Ave shall bave cured it without any danger and without mutilation (tbe most beautiful aesthetic and orthopoedic result). Here then is tlie ideal and dreamt of treatment, until the anti-tuberculous vaccine or serum has been discovered. Well, this treatment is not a myth, it exists, as we have said : it is that of punctures followed by modifying injections, which not only always cure (99 times in a hundred) without risk and Avithout defect, and cure relatively quickly (in 2 or 3 months) ; but more, it offers the advantages of an ines- timable prize, it is very simple and easy ; and it may be applied by all medical men. wherever they may be. This is what one ought not to Aveary in repeating, until all practitioners are convinced, and until the treatment is included in current practice, as it merits to be. All medical men avUI obtain the promised results, provided that they follow exactly the technique AA^e baA^e described. In spite of that technique being easy, there are neAertbeless Cai.ot. — IrulispensaLle ortliopedics. i4 2IO DRY TUBERCULOSES COi\SERVATIVE TREATMENT, some details, the minute observation of Avbicli is indispensable. I very often see practitioners "who wish to treat by punc- tures and injections their suppurated tuberculoses and who, being- unsuccessful, think themselves obliged, in the end, to open or allow to open, the purulent collection. That happens because their technique is defective. You should follow what I have written, in every detail, in chapter III : it Avill give you success invariably. 2"' Dry or fungous tuberculoses. The respective value of the three treatments (operation, abstention and injections) is the same for the dry tuberculoses as for those which have suppurated — Avith this difference however, that in the tuberculoses Avhich have suppurated, injections are of far greater value than abstention^ and extirpation — Avhilst there remain some cases of dry tuberculoses where the conser- vative treatment and surgical operation may be contem- plated although they are not, to my mind, to be preferred. It is not then a question here of proscribing these two treat- ments but simply of considering them as exceptional treatments. We Avill proceed to state, in a few Avords, the exceptional indications . The value of purely conservative treatment. — This treatment may cure a good number of dry or fungous tuber- culoses. It is not Ave, who live at Berck, Avho are going to contest this. But it can only be relied upon AAhen the patients are able to live by the seaside or in the country; and AA'hen it cures, it is not, generally, until after a long time, three, four, five, six years, and even longer; it is an inconvenience that all those AA'ho employ it are obliged to recognize. To sum up, it is too long, consequently too costly, to be carried out in all patients. But especially, it is too uncertain. Even under the best I. Apart from the case of deep abscess in Pott's disease, where one ought to abstain and wait for the spontaneous reahsorption of the ahscess. WllimiT INJECTIONS. M\V WE M'I'IIII) IN A FEW CASES. 211 coiulilioiis, il (Iocs imI curr iiiiicli iiion' tli;m hall tlio cases, III llic ollior hall', llie disease progresses, tlic liihcicuious lesion suppurates or goes on indeliniteiy. These arc sufficient reasons Avh> the " pure " conservative treatment cannot he adopted as a general method of treatment. It ought to be rejected, particularly wiicn [)alients of the woilving-classes are in question, children or adults, and in the case of inliahilants of lariic towns who arc not ahle to leave their unheal tin surroundings. It is acceptable, on the contrary, for a child belonging to a family in easy circumstances, who comes to us, with a tuber- culosis apparently benign, for example, a hard adenitis, or a subcutaneous tuberculoma. The parents are perturbed at the ver\ suggestion of making the least injection; they declare that they are not in the least hurry, and that the question of duration is a secondary consideration to them. They will arrange for the child to live at the sea-side for any length of lime it may be necessary, three years, four years, and more, mider any conditions of hygiene and feeding that may be prescribed. The parents are altogether wrong in dreading injections quite painless, of course; but after all, since thev are not always indispensable for recent and benign tuberculosis, we can abstain at the beginning — we can have recourse to injections, when the families themselves have exhausted their patience, or the malady becoming apparently permanent, the proof will be manifest to everybody of the insufficiency of pure conservative treatment in this particular case. The Value of Operative Treatment. — As to the Opera- tive treatment of dry tuberculosis, a treatment which is still unfortunately that of most surgeons, we must not forget that, if it cure sometimes, it aggravates the condition often and mutilates always. AVe have already pointed out the sad mutilations caused by the removal of cervical glands. Me Avill take another example. 212 DRY OR FUNGOUS TUBERCULOSES that of white swelling of the knee. \A e will not mention amputation, which must be considered as a catastrophe, but only resection. One ought always to reject resection for subjects who have not completed their growth. Everybody will agree that if it is economic, it is insufficient to cure the focus, and that it may, among other things, leave a fistula. Performed extensively, it seriously mutilates the subject by doing away with the arti- cular cartilage, and that mutilation cannot but be aggravated later on. It is thus that subjects, resected in their childhood, present at manhood lo or even i5 cm. of shortening. Although the inconvenience of arresting the growth in an adult does not exist, it remains that, in the adult as in the child, cutting operations performed to get rid of the tuberculosis carry with them the risks of permanent fistula, without counting the slight danger of bacillary generalisation. Nevertheless, operative treatment is admissible in some special cases, for example that of the adult workman suffering with dry and fungous white swelling of the knee. There is here no question of growth, which might arrest us in such a case. On the other hand, this man is obliged to return to his work. Instead of applying to him the ordinary treatment of modifying injections, wdiich would take from eight to tw^elve months to effect a cure, very often with ankylosis, Ave may resect at once ; the resection gives us an equivalent functional result, and reduces the duration of the treatment by one half, pro- vided however, that all goes well, that is, if after having removed the whole of the contaminated tissues, we have obtain- ed re-union by first intention \ I . It would be the same in a case of tul^erculous lesion of the soft tissues, easy to isolate, where extirpation can be efTected very completely without danger of fistula or visible cicatrix (that is, in an unexposed situation ; for example, an axillary or inguinal adenitis, or a subcutaneous tuberculoma in a working man. But it is still preferable, in the last case, to abstain from all operation and to allow matters to go on, keeping the subject under observation; he might oi>i;u\rivt: TUi:ATMt:M' : indications 2ii> Oulsiclo tlicse cxcoplioiKil iiulicalioiis, \vr alwjiys I'all back upon tlie injoclioiis in iIil' Ircalnieul ul" liardaiul runguus luberculosc-s. Injections the best Treatment for dry Tuberculoses. How are injections able to cure dry tuberculoses ? 'riioi'c are t\\o melliods of cure of lubcrculou.s lesions : ibc sclerosing transformation, and the soflening, wilb sabsef[uriiL evacuation. The injections act in bringing about one or other of these modifications. They cure sometimes hke the purely conservative treatment, sometimes like the surgical treatment ; that is, by iiardening the fungosities, or by liquifying them, by which means their expulsion out of the organism is rendered possible (by means of puncture). This depends upon the liquid injected. The llrst method of cure is carried out by injections of the " dry type "; that is, those which do not produce softening; for example, iodoform and creosote. The second by injections of the "■ liquid type " , those which cause softening of the fungosities and the formation of an effusion ; for example, naphtol camphor. The injections of the liquid type are most efficacious and certain, because they permit of the complete evacuation of the tuberculous products by the very small orifice of an aspira ting- needle, without any risk of fistula or tuberculous generalisation which always follows in the train of surgical operations. It is therefore the most rational treatment, that wliicli accords best with the indications of bacteriology and of clinical surgery : the first calls for the expulsion of the tuberculous products out of the body, the second demands that it should be done without any damage to the patient ; — a treatment which has already been put to the test in several thousands of cases — a treatment, simple, although very minute. even continue at liis worli. Either tlae lesion is reabsorijed , or it softens spon- taneously, in which case one would immediately perform the puncture. 2l4 DRY TUBERCULOSES. THEIR ARTIFICIAL SOFTENING Ah, yes! very minute; and we ought to repeat as to the injections what Ave have ah-eady said as to the punctures, namely, that tlie treatment demands, in order to give the promised results, to be done according to a perfect technique and not anyhow, as if the liquid, the dose of the liquid, the number of injections, Avere of no importance. The number of injections may be from 12 to i5 — this means that the treat- ment is somewhat exacting. A slight inconvenience, on the whole, if one has regard to the advantage and the results ! HoAvever, and once again, cure is the prize I And « where there's a aaIII, there's a Avay ». We have already given the details of the technique, Avith all desirable precision, on page i65, and aac aaIII return to it a propos of the treatment of dry or fungous tuberculous arthri- tis (page Boo) and a propos of the treatment of hard adenites and cutaneous or subcutaneous tuberculomata (chapters XVIII and XIX). APPENDIX On our Method of Softening artificially the Dry and Fungous Tuberculoses. (Its Principles ; its Practical Realization.) I. — The Question of Principle. It is admitted that suppurated tuberculosis is essentially of graver import than dry or fungous tuberculosis. We agree with that* ; but on the other hand, it is certain that Ave are to-day better armed against suppurated tuberculosis than against dry tuberculo- sis; so that, in fact, there is more than compensation, and, on the Avhole it Avould be better to have a cold abscess than a tuber- culoma. I. In spite of the fact that this may not be absolute, nor applicable to all cases (as we have already shewn in our hook : Les Maladies^ qu'on soigne a Berck, pp. 70 and 80, to which we refer you for this discussion). SOl'ir.MNt; Ol" l-L.NCiOSlTll-S l!i:iN(; OlilVIM'.l), rL.NCTLUK M.) I w ill explain niNScIf. \ \iiimi; laiK (MUM' lo iiii' willi a sii|)|iiMa I iiii; ailiMiilis ; lliis, \VC kiK^w N\i' tail ciiic (will) |mnciui'cs) in a lew wocks, complclcly, willioiil luutilalioii anil williout cicatrix. \s a set oil', a second young lady came having a " sini|)l(; haril adenitis, lor wliicli A\e notice, as liappens too often, every tliin"- lias been useless; nothing succeeds : neither the sojourn at Bcrclc I'or a year or two. nor the well-known medicines, nor sclero- sing injections of creosote and iodoform. This hard adenitis would not he cured. It remained only to operate upon it, hut o[)eration mutilates, operation leaves an unsightly cicatrix which is, in the eyes of the ^vorld, the infamous and inell'aceahle sign of scrofula. You see, when all comes to all, the fate of the hrst young lady, with her cervical ahscess, is much more enviahle than that ol the second, Avith her hardened gland, so-called more benign. In the presence of this hard, persisting adenitis, one cannot but regret that it would not suppurate. There would have been, bv the fact of its suppurating, more to gain than to lose for a patient treated by a medical man know ing how to make a puncture. But alas! in spite of all our desires the adenitis would not sup- purate at all. Why not force it to do so? Why not force this tuberculous \ liite Swellings, as treated at our Hospital Cazin at Berck). See also " rObservation Clinique " in the Appendix to Chap. XVIII (Adenites) . Tuberculous Fistulas, and Tuberculous Wounds or Ulcers* ^Miat we are about to say here is applicable to all tuber- culous fistulse. As to the peculiarities of each fistula, they will be studied in the chapter devoted to each external tuberculosis (see Pott's disease, white swelling, adenitis, osteitis, epididymitis, etc.). Fistula proceeds from the opening — surgical or sponta- neous — of a tuberculous focus. Fistula is the enemy and the black spot in external tuberculoses : it is the nightmare of all those who are occupied with these affections. If we have condemned operative treatment for almost the whole of the cases of external tuberculosis, it is because opera- tion so often leaves a fistula behind it. If we have described with so many minuticC tlie technique of puncture and injection, it was so that you might be able to avoid fistuUe. 210 TUBERCULOCS FISTUL.E, WOU>DS, AND ULCERS For fisluloe are so difficult to cure that the preventive treatment remains the best. It is for this reason lliat I avouIcI have tlie folloAving ins- cription graved on tlie front of liospitals ^vliere the external tuberculoses are treated : « The cure of closed tuberculoses is certain. To open tuberculoses or to allow them to open is to make a way through which, very often, death will enter. » The danger of death may be but slight, except in the symp- tomatic fistulas of deep osseous and articular lesions (and more particularly in hip chscase and especially Pott's disease). But the superficial fistulas themselves are always troublesome, not only by the unpleasantness Avhich every persistent suppuration causes, but still more by the mutilations and blemishes which they may leave behind them. For example, the hideous and indelible cicatrices left by glandular fistula? in the cervical region, Avithout reckoning the risk of inoculation (if it be but small) springing from the persistence of an active tuberculous focus, even when superficial. Nevertheless, if among fistuke there are certain which kill, whilst others are merely disagreeable (with, between the two, every degree of gravity) a classification of the different varieties has to be made. Classification of Tuberculous Wounds and Fistulse. 1. Tuberculous wounds and ulcerations of the skix\ 2. Symptomatic fistulse or lesions of soft tissues. 3. Symptomatic fistulse of osseous and articular, but SUPERFICIAL, lesions (that is, where drainage is easy). [x. Symptomatic fistulse of osseous or articular lesions, but DEEP (that is, where drainage is difficult). P^ Qroup. — Tuberculous Wounds and Ulcerations of the Skin. — It is a question here of lesions on the surface rather than real fistulae, for there is not any track leading from the cutaneous opening, or, if sometimes, a sinus exists, it ClASSll'ICM ION I. IL lilCHCLI.OUS WolMiS (WllIKH T SINLs) 2 I (J remains siihciilanoons llin)iiL;li ils wlmlc Iciif^lli. il is a siiiipic Fis. Tuberculous ulceration of the tig- 177 ''«• — The process of skin : a large orifice, >Yilh exuberant fleshy granulations protruding; margins of a violet colour, skin delicate, sloughy (a probe has been introduced to raise itj ; the adjoining tissues are uneven, lumpy. cicatrisation ; the ulceration dried, covered with a greyish or blackish crust, which per- sists; the integument around remains for along time lumpy and coloured. undermining of llie skin (rallier than a true fislulous track). Fig. 17S and 178 bis. — Types of syphilitic gummatous ulceration, surrounded kv sharply cut perpendicular edges. These avouikIs follow cutaneous or sab-culaneous tuberculo- 220 TUBERCULOUS FISTULE. -WOUXDs AND ULCERATION'S mala. \o\\ well know the typical characteristics of these wounds, namely : their edges are thin, violet coloured, irregu- lar, undermined, their bases yellowish, with small caseous points or fungosities (fig. 177 and 177 his.). AYhilst syphilitic sores have rounded edges — cut perpendi- Fig. I'jg. — Keloid patcli in the cervical region proceeding from the opening of sub-- cutaneous-bacillary gummata, and sut>-axillary ulcers of glandular origin. The fistula? were produced before the patient's arrival. cularly — punched out — cliiT-like, with a base the colour of ham, or of a gummy appearance (fig. 178 and 178 bis.) But, fairly often, these differential characteristics are much less definite, confusion is possible between the two, so much so, that there are mixed forms, " scrofulates de verole ". Even Avhile still in the domain of tuberculous lesions, one DTAHNOSIS or TlPERClI.Ol S AM) S'il'lllMHC SOKES 221 i-aii see interniedialc I'diius hdwci'ii Itacillarx ulcers of llie skin and lubcrculous liij)us. However, MC will have (lie oji|)orlunil\ in another pari of this wnik (V. chap. \i\) of speaking ahunl iiihiMCiilosis of the skin. 2'"' Group. — In I hi- l:i-i iiip, and in I he fi ijluw ing ones, it is Fig. i8o. — Ulcers following the spontaneous opening of bacillary glands, which occurred before arriving at Berck. The fistula- have been cured in three months bv injection. a question of true fistula*, that is, sores Avliicli are nothing more than small craters through Avhich, coming to open through the skin, are tracks and deep cavities, and ending in tuberculous lesions of the soft tissues or CAen of the skeleton. 222 FISTUL-E PROCEEDING FROM TUBERCULOSIS OF THE SOFT TISSUES The second group is thai of fistuke, symptomatic of lesions of the soft parts. For example, fislulc'e of the neck, of the axilla, of the groin, symptomatic of a tabercidous adenitis (fig. 179 and 180). Or Fig. 181. — Fislul->a5 opening from a tuberculosis of the testicle opened spontane- ously; this figure shows the state of the lesion after a stay at Berck. On his arri- val, the patient had two other fistulsc on the right side of the scrotum still larger and with a graver appearance; we have cured them by the paste injections. Those on the left side " dragged along » hut are in a good way towards cicatrisation and no doubt complete cure without operation . The unusual delay in the cure of these last fistula; is explained by the co- existence in the patient of Pott's disease and a suppurating costal osteitis. But. in spite of the multiplicitv of tuberculous localisations, the patient is so much ameliorated and transformed, that his complete cure is certain and is only a matter of time ; about another year's stav at Berck and local treatment. Let us say on this subject that all the Other scrotal fistulae, C5 fistulae out of •200 cases of tuberculosis of the testicle or of the epididymis (which we have seen during i8 years) have been cured by my injectious in a period which has varied from one month to a year. The case here represented has been by far the longest of all to cure. The cure of this patient is to-day complete. See end of this obser- vation in Additional Xotes, p. loio. , fistulfc of the scrotum, symptomatic of an epididymitis hacillary orchitis (fig. 181). or .">"" IM^^II I r. I'lVDHLCEl) ItY SLIMUl ICIVI, osri;:ri> 2:>:i Or, fislul.r (if llic hand or of llic \\risl, SMiiplomalic of a funrfoiis sviioritia of the tendons, or of a liihcrculosis of llic sy- noriul sheath. The 3' Group comprises the symptomatic fislulac of tuber- culous lesions of (he skeleton, hut superficial lesions, that is, fistuUu with short tracks, \vliicii can be, consequently, easily and completely drained. Fig. 182. — Osseous fistula- and deformity resulting from scraping a spina ventosa the scraping was done by another surgeon . For example, the symptomatic fislula- of a spina ventosa of the fingers or toes; a tuberculosis of the malar bone, of the frontal hone, of the maxillie, of the clavicles, of the ribs, etc. In this group come again the symptomatic fistulae of super- 224 ^Tii PISXUL.E ARISOG FROM DEEP OSTEITIS ficial osteo-arthritis, that is, almost the Avhole of the fistula; of the elboiu, of the lorist, of the instep, of the shoulder, of the knee. This group also includes a certain number of fistuloe of Pott's disease, those which realise, from the point of view of facility of drainage, the conditions aforesaid, namely, fistulas Fig. i83. — Post-operative fistulae following resection of a rib for tuberculosis. Pleu- ral infection consecutive to tbe operation. (The operation had been performed before the patient's admission to our hospital.) which open on the neck, or on the back at, a point very near to the vertebral focus. The 4''' Group embraces the symptomatic fistuke of tuber- culosis of the skeleton, but of a deep tuberculosis, that is. ni()f;N(^sis OK Tin; I(jlu v.viui-iil;s oi i l liLucLi.oL.s itsili. i-; 220 fistula- wilh a loriir sinus — where llie drainage may be nmcli more clillicuU lliaii in llie [)teccding lisluhe. For example, I he symplomalic lislula) of lii[) disease, (he fisUiliu o( Poll's disease, apart I'roiii the exception menlioned above. And, on the other liand, there may be exceptionally placed in this group certain sympto- matic fistula' of white swelling of tbe knee, of tbe shoulder, of the wrist, of the instep — na- mely, those fistuloe Avhich have a long and tortuous track, ren- dering drainage and the dis- charge of pus particularly dif- ficult. Prognosis. The first three are curable, the fourlli nol always — far from it. AAhy.^ It is because fistu- la? of the first three varieties are not " infected ", or because their infection yields easily to the means of treatment, Avhilst the fistulae of the fourth group are very often infecferL infection super-added and so grave that we cannot always master it. Therefore, that which constitutes the gravity of a tuberculous fistula is its possible infection; and the first question to put, in the presence of a fistula, in order to establish its prognosis and its treatment, is Avhether or not it is infected. Infected you may say it is, Avhen the primitive tubercle bacilli are associated with septic germs which have come from without. The tuberculo-septic pus has been retained — which is somewhat rare in fistulce of the first three groups, but very CvLOT. — Indispensable orthopedics. i5 Fig. i8i. — Eslensive fistulous ulce- ration communicating with tlie shoul- der joint (the fistulff existed before the patient's arrival at Berck). 226 TUBERCCLOUS FISTUL.E. PROGNOSIS 1> EACH CASE frequent in the anfractuous and deep sinuses of those of the fourth group — pus, I say, will be reabsorbed by the organism, it Avill cause fever and poison the patient. If the duration of the retention and absorption is short the patient Avill recover. But if it is prolonged, it will lead to a progressive intoxi- Fig. i85. — The same (back view). cation of the organism, a real chronic septicaemia with degene- ration of the liver and kidneys. And the ending of the infec- tion of the fistula will mean the death of the patient, a consum- mation more or less distant, Avhich may be measured by months or even several years. Fortunately, Ave repeat it, all the initial infections do not end in this way. We are able to distinguish three degrees or phases in infection . THE NOX-INFECTKII IISTI F. F. AIIE CL11AHLF, 227 The first degree is characterised by an evening rise of lempe- r.ilurc with morning remissions; the fever has appeared only lor a lew davs or a few weeks ; analysis does not yet reveal any trace of alhumeii in the urine. The second degree is characterised hy the appearance of a t^io-. 1 80. — - Ulceration of the anterior surface of the tibia. The clinical signs on the arrival of the patient, as well as the radiographic examination, suggest almost the diai^nosis of osteo-sarcoma of an osteo-sarcoma, mind you . But the bacteriologi- cal examination (bj M. Noel Fiessinger) revealed the presence of Koch's bacillus. Cicatrisation is now obtained. See end of this observation in additional notes, p. ioi3. little alhiimen; and the albumen appears, as a rule, when the fever persists beyond a few weeks. The third degree is characterised hy the presence of a notable amount of albumen and by an appreciable hypertrophy of the liver, which reaches to at least a fmger's breadth below the false ribs. Fever may no longer exist at this moment. Besides these principal signs there are others, those Avhich constitute the symptomatic cortege of slow intoxication of the organism, namely : loss of appetite, loss of strength, wasting, pallor, a yellow or dirty-white tint of the face, fetor of th ^ pus, the appearance of partial or generalised oedema, etc., etc. 228 INFECTED FISTULE ARE OFTE>f FATAL As to the prognosis of infected Jistahe, this differs according to the degree of infection. The first two degrees are curable, provided that you succeed — by proper drainage — in overcoming the retention of pus. Unfortunately, perfect drainage is not always realisablein Pott's disease or hip disease; it is for this reason that one cannot pro- Fig. 187. — Osteo articular tuberculosis of tlie knee. The coadition of the patient on his arrival at Berck. Lesions extremely advanced, accompanied by profuse and fetid suppuration. General infection of the organism, evening fever, albuminuria, cachexia. Immediate amputation Avas the last chance (a very small one!) of safety to resort to; the parents refused. The little patient returned to his home and suc- cumbed in two months. mise, in an absolute way, the cure of an infected fistula, even of the first degree, symptomatic of hip disease or Potts' disease. Sometimes the fistula will progress, m spite of all our efforts, to the 3''' degree. And, in the third degree, the disease is without remedy, or pretty nearly so, when albumen exists in notable quantity; when the liver extends two fingers' breadth beyond the costal margin, it is too late. Then, even if one drains extensively, even if one succeeds in producing a fall in the patient's temperature, the visceral lesions will continue to progress to their full extent and will finish by carrying off" the patient... always or nearly always. iiil; itKsi I Ki: \ i'\ii;m' or ri ifi.ui:i ijjl.s risrui.r. 220 The Treatment. Every six months you will hear vaunted a new treatment, so-called marvellous, of tul)erculous fistnlu'. Fig. i88. — Operalion sores and fistula? resulting from surgical interference in a case of hip flisease with a closed abscess. The patient liad no fistula' before the opera- tion, which ought to have been, according to tlie promise of the surgeon, « a ra- dical cure »; it has left 28 fisluke (existing since the operation). AVe have already closed i.'i with our injections. Tea months later only three insignificant fistulae remain; the weight of the patient has nearly doubled. (See this observation in (I Additional Notes », p. ioi/|.) All these treatments, neAv and old, may he arranged in four groups : surgical operation, abstention, physio-therapeutic treat- ments and injections. ado TREATMENT OF TUBERCULOUS FISTULE a. Operation. — For a good number of surgeons (for the greatest number, I should say) the only rational treatment of tuberculous fistulee remains, today as yesterday, surgical ope- ration, an operation which they perform very extensively and which they repeat without wearying. Certainly it appears, a priori, logical and rational. But in fact and in practice, experience has proved to us that operation Fig. 189. — Another case of post-operative fistulas. This patient arrived at Berck in this condition with fever, albuminuria (8 or 10 grammes a day) large liver, general cachexia ; he lived two years longer. He succumbed lately after an uraemic crisis. has done twenty times more harm than good. Instead of destroying by a single stroke the tuberculous focus as had been hoped, one might say, as a general rule, they stirred up the focus and thereby opened up tissues Avhich until then were sound; it does not cure the patient, it mutilates him. I say nothing of inoculation far away in the meninges or in the viscera, and of tuberculous generalisations, which opera- tions may bring about. Recall our aphorism : In tuberculosis the knife rarely cures, it often aggravates and always mutilates. At the commencement of my practice, I operated and re-oper- ated upon hundreds of fistulse ; I obtained, doubtless, some ii|'i:u.VTlO\ OUGHT TO ItK \I,\\.V\S ItlMKC IKD :u cures, but uiany more agjiravalions. So much so thai f treat llicm today by (he conservative metliod ; I operate no longer; all llial 1 do now as iiilcrroreiicc, if it may he called a real T-^-ry — ■ - ■— ^^^^^^1 ■r* ^^^^^ ■PS-i T F ; M ^^^^^^^^^^^^__j^ ^^kii.^ Fig. igo. — Fistula communicating with a deep, bony focus (Pott's disease in lumbar region) : the fistulous orifice was found within four inches above the centre of the left iliac crest; an injection of very soft iodoform paste before the photograph was taken shows the different diverticles of the collection. — T. Tampon obstructing the fistulous orifice. — I. Focus and principle cavity of the abscess filled with iodoform liquid. — P. P. P. Secondary pockets. — one of these descends, on the right side, down to the internal iliac fossa; one conceived that there was very poor assurance of perfect drainage with a sinus so anfractuous. If fever appears, or if the cure takes too long, a counter opening will be indicated at the lowest point. interference, is, in the extremely rare case where I find by examination of the sinus a mobile sequestrum, to extract it — without doing more, without touching the sinus. The cures efTected by my conservative treatment today are incomparably more numerous and more beautiful than those obtained by my treatment by operation years ago. 232 OX OPERATION I>" TLBERCULOUS FISTULA The question has been settled, the only treatment of tuber- culous fistula should be conservative. You may rely on our very great personal experience of the tAvo methods. Fig. igi. — These fistula^, of three years' standing, proceeding from a tuberculous pleurisy (empyema) have been cured by a single injection of our naphtol paste. Once again, do not allow yourself to be troubled by the thought that there Avill be small sequestra, an objection which will often be made to you by the advocates of ■' operation at all costs ". First, sequestra here are very rare. I have said so, but supposing they do exist, it is in the two following condi- tions : IIKKi; ol'KIUrioN IS GENEKAI.LY IIAUMrl'L ■a:v6 EitluM' {a) YOii I'md llie sequestrum already completely deta- ched, edsil)' (irccssihle and it is evident, as we have said, that you can and (hiliIiI Io seize il wllli the f()rceps, just as you \\(inl(l aii\ loreiiiii body; but be coiileiiled with that; you can do it Y\itiiout aniesthesia and without causing ha?morriiage. Fig. 192. — Fistulffi proceeding from hip disease; these fistulae, of eighteen months' standing. Ijave been dried up by sis injeclions of our paste in the space of two months. Or, (b) the sequestrum is not mobile or is not easily accessible; well, abstention, in that case, would be better than operation. For sequestra are AAorn aAvay and eliminated by the aid of injections, and even spontaneously in the long run, nearly always. In abstaining, you observe the prirno non nocere. Whilst operation will not be without danger. a) For if you have recourse to a very extensive cutting interference, so-called radical, you run much risk of spreading 2 34 0>f THE BEST TREATMENT OF TUBERCULOUS FISTUL/E (in place of limiting) the region pertaining to the tuberculosis ; it will produce new sequestra and the only result of the ope- ration will be an aggravation, a mutilation. The patient will be mutilated, even when the tuberculosis is superficial. Fig. 193. — Symptomatic crural fistulic in a case of dorso-lumbar Polt's disease. Tiie fistulae which had existed a year and a half were cured in four months by our paste injections. For example : if you curette a finger affected with spina Tentosa, to be quite certain you have reached the limits of the disease you will have to go beyond it and cut into sound tissue ; you will unavoidably go too far, and thus the patient will ■come away from the operation more mutilated than if he had waited for the spontaneous elimination of the deepest Tin; \ Ml i: m \i!-ti.\ iion, i-iumdi mi u u'i;i i m; Miniions :j35 osseous debris present. Nature, in iIh' cimI. will iii;iii,i"-e liiiit'^s iniirli iiiMiv ccoi icalJy than llic .sur^c(jii. />) Abstention, llicii. Is df iikmc \aliic ihaii siir.i^ical 0|)c- ralion. Thai i<. a paliciil placed at rest, in the ^^ood air of tlie connlrx. and especially near (he sea. with good general Ircalnient anil no dllicr hjcal treatment than good aseptic | dressings, has mucii more chance ol" seeing his lisluhe close than hy ojieralion. That is to say, again, that the country practitioner who never operates, will cure a greater numher than the great surgeon who always operates and ohstinatelv re- operates. But I am lea- ching you nothing : have not every one of you seen a great numher of those fistula? cured, which had never been touched .** Fig. if)^.— Poll's fistula situate in tlie proxi- mity of a focus. It was a dorso-luinbar Pott's disease: ttie fistulous orifice \Yas ij centimetres witliout and to the rij:bt of tlie spinous apopliysis of the second lum- bar. The fistula was treated through an opening in a plaster apparatus; it dried up after five injections of our paste in about two months. The cicatrised fistula is seen here through the opening in the plaster corset which the patient still wears. c) Physio-therapeutic Methods. AA hat has iTOt l)een tried, since Bier's method '. the X rays, sunlight cures, violet rays, radium, up to sea bathing at all our shores of the Nord and of the Midi, and salt baths, either mineral or thermal, at all the reputed stations : Salies, Kreuznach, etc., etc. These medications are not without I. Bier's metliod, of wliicli I liave said tliat it has no action against the bacilli, may act favourably against staph\lococcal or streptococcal infection. 236 THE BEST TREATMENT OF FISTUL.E : THE INJECTIONS value, they may succeed in very superficial fistula?, and espe- cially in ulcerations and tuberculous sores on the surface, acting by improving the general condition of the patient, I have tried all these medications, which have sometimes Fig. I go. — Another case of cured fistula in Pott's disease. The patient, aged 52, had a large abscess in Petit's triangle. The abscess had been punctured ai.a injected already three times ^vhen the patient was obliged to leave Berck and sus- pend the treatment for several Aveeks. On his return, the skin was of a violet tint, almost black at two places and a few drops of pus issued through orifices of the calibre of a pin. It was impossible to avert the opening which occurred in about two davs by the giving way of two small scars in the skin ; we recommen- ced our injections: the sores were closed again in about four weeks and have remained so. (This was over six months ago.) effected a cure, but infinitely less frequently than the medicated injections I am about to describe. d) The modifying injections, made wilh the liquids indi- cated, and in the manner described on p. 170. ^\ith these injections cure may be obtained almost always, even in the iiii>L\iL: or nil. iui.aimi.nt iok each ca^k ok ii-ri i.a li.l-j osseous fisliiln-. providetl lliev arc not iiirocicd and proNidcd tliat one does not neglect aii\ of ihe general indications given. ^^e may now indicate tlic Ircatment olearli variety of sore, or tuberculous fistula. I. The Treatment of Tuberculous Sores and Ulcerations. They are cured Avith various topical remedies, varxing their use : the application of our jDOANdcr'. tincture of iodine, peroxyde of zinc, compresses soaked with iodoformed creosote oil, camphorated naphtol with glycerine, permanganate of potash, the application of ^ igo plaster (fresh), nitrate of silver, the thermo-cautery. the galvano-cautery, dressings of oxyge- nated water or naphtalan. Physio-therapeutic treatment. X rays, and high fre- quency currents (these two may hardly ever be used except by specialists), exposure of the sore to sunlight, proceding gra- dually and methodically, sometimes sea-baths, salt baths. In cases somewhat refractory, I have made a circle of modifying injections all round the tuberculous sore (injections of creosoted oil or of naphtol-camphor). 2. Treatment of Fistulae in the Second Group. (Symptomatic Fistulae of Tuberculosis of the Soft Tissues.) Make small injections of oil, creosote and iodoform, or of naphtol-camphor, but making provision for keeping the liquid in position. If the liquid is not easily kept in position, use our paste according to the technique and dosage you already know (p. 176). I. See the formula nl'oiir powder, p. 162. 238 THE TREAT ilENT OF FISTUL.E. I\ EACH CASE 3. Treatment of Fistulse of the Third Group. (Osseous Fistulae with Short Sinuses.) Make the same injections and in the same manner as above. 4. Treatment of deep Fistulae. (Hip Disease, Pott's Disease.) a. If they are not infected, if there is no fever, no albu- men, make modifying injections as above. 6. If they are infected, with evening fever resulting from the retention of pus, try to suppress retention by simple drai- nage. If you do not succeed thus, avoid the injections. Avoid still more carefully the temptation of extensive surgical interfe- rences, so-called radical, which have twenty times more chance of injuring the patient than of improving his condition. Confine yourself to a treatment, perhaps more modest, but incontestably better, which is: ensure the rest and immobilisation of the affected part with fenestrated plasters, asepsis of sores as perfect as possible, and now and then attempt discreetly, and for a short while, some of the physiotherapeutic methods. In addi- tion, a good general treatment. The general treatment, so important here, comprises life in the open air, in the country, or better still at the sea-side; a well-directed dietary, Avhich includes plenty of milk ; and thus you may be able to prolong the patient's life for several years, sometimes you may cure him. We have cured some in this way, even cases of extreme gravity, and Ave have witnessed veritable resurrections. One must never despair. But too often, however, we remain powerless, and death will be the usual termination of these profound infections in hip disease and more especially in Pott's disease. And for that reason, I can never repeat too often the fundamental dogma of the treatment of external tuberculosis " Never open, nor allow to open, the tubercaloiis foci. CHAPTER V POTT'S DISEASE The objective should he to cure without; gibhosity. In order to cure, do not open the abscess. To cure without gibbosity, make good plaster corsets. A reminder of some Anatomical and Clinical Points indispensable in treating Pott's Disease. Pott's Disease is a tuberculosis of tlie vertebral column. The lesion is situated in the anterior part, in the bodies of the verte- brae (fig. 196 to 199). Five Cases. — First Case. Before a gibbosity has appeared (fig. 196). Like all the Avhite swellings. Pott's Disease goes on for some time, several months and even one or two years, without deformity or gibbositv ^ It mav remain unobserved, but generally it makes itself known bv some radiating or local pains, intermitting, or by a functional weakness, caused bv reflex muscular contractions : defective walking, difficultv in stooping, rapid fatigue, etc. Second Case : Gibbosity (fig. 197, 198, 199). Second period ol" the disease. I. Pott's disease mav even never present a rjibboshy, but that is infinitely- rare in children, a little less rare in adults. 24o i^^ CASE : pott's disease without gibbosity But Ave rarelv see children at the first period. Most often, Avhen they are brought to us there is already a gibbosity. This is Fi ^_ ig(5. — Pott's disease before cjibbosily, a tubercle has appeared in the centre of the body of a vertebra ; around this, a zone of rarefaction and softening favou- ring its extension. Yicr, ig8. — The gibbosity accentualed. The tuberculosis has progressed from one vertebra to the others above and belo^v, ^vhich are beginning to soften and to sink. X- 197. — • Beijinninj of the gib- bosity. The tubercle has pro- gressed, perforated the anterior wall of the body and produced an abscess ; the vertebral body collapses, hence the gibbosity is produced behind. pio-. T99. - — Tlie gibbosity has pro- (iressed at the same time as the anterior lesion. Of the first di- seased vertebra only the posterior arc and an insignificant part of the body remain . What is left of it is by degrees pushed backward by pressure of neighbouring ver- tebrae, as is the stone of a cherry when you squeeze the fruit bet- ween your fingers. produced : a) by flexion of the spine; h) by the collapsing ot one or tyvo bodies of vertebrae, softened by the ravages of tuberculosis -, c) sometimes bv sub-luxation of the two spinal segments. '.>^" CASK l'< I I I ^ 1)1^1, \-|. \\ II II (.ijtiwxilY 2^1 At the outset, the gibbosity is ancfiilar, in the middle line, and painful on pressure. Tlio liy^iiics i()7. i(j8 and i(j(j sliow how a ^ibhosilv is producofl. It pro- l:i('sscs: lalcr on appear adaptations, llial is, s(>contlar\ dd'onuilit's ol' olhcr |)ar(s oT the spine, and even of the Ihoiax. oC the pelvis, of the head, all Fig. 200. — Las' sUiie of a gibbf.s'ty. The patient has become a liunch-back (whe I he has not been treate 1 or not well trea- ted.) :,. ^', , fe Fig. 201. — Abscess and tlstula iii I'olLs disease. Abscess by gravitation in tlie iliac fossa. On the left, an abscess has travelled down to the thigh, passing in the shape of a wallet, beneath the crural arch. F. Orifice of a fistula above the crural arch. deformities which contribute to giving to the humps tlicir character- Fig. ao2 to 20'i. — The three principal causes of paraplc-i;iu. Compression of thecord. i" by a projection of hone. 2°'' by an abscess. S"' bv pachymeningitis. istic outline I'v. fig. 200). Cvi.OT. — Inilispcnsable orthopedics. iC 242 3'"' CASE ; pott's disease with abscess. 4™ CASE : FISTULA The o-ibbosity is generally less in Pott's disease of the cervical and lumbar regions than in the dorsal region. Third Case : Abscess. - Fourth Case : Fistulae (lig._20i). — The bacillary focus does not remain localised in the bodies of the Fig. 2o5. Pott'sdisease from ils commen- Fig. 206. — Gibbosity at the fifth cement. Slight projeaion of the spinal dorsal (at the beginning), apophysis of the sixth dorsal vertebra. vertebrae : it may invade the neighbouring soft parts and send pro- longations of fungous granulations more or less far towards the neck, the thorax, the back, but especially to^vards the lowest parts : internal iliac fossa, root of the thigh : — and the softening of_ these granulations constitutes the abscess by gravitation of Pott's disease. .V" CASE : poir's DisKAsi; wim i'vit\i.\sis 2',.S egion, ilinosl Those ahstcsscs, rare in I'oll's disease ol' Ihc upper dorsal n are more rrcciueiil in Poll's disease of llic cervical rcion, and .1 constanllv present in lumbar and doiso-lumbar. 'n.ev mav -n to tlic Icn-ll. of ulceration and breaking dow n o. \\u' -kill, wli.MK'c (lie lorniation o{' Jislnhc which are so easMiy inlec- I.hI : Ihis inleclion is very grave, leading I.. |ho degeneralion of the F.g. 207. — Ordinary type; median and aogular projection ; the attitude in cervical Pott's disease. liver and kidneys and is very often fatal. — Fistula is the greatest danger which menaces the life of these patients. Fifth Case : Paralysis dig. 202, 2o3, 2o4). — The fungous prolongations may be directed also towards the spinal cord The compression produced by the abscess (fig. 2o3) will then give rise to a paralysis more or less complete. The paralysis mav be due also lo a projection ol displaced bone (fig. 202) or to a propagation of the tuberculosis lo the meninges and cord (fig. 2o4) or to some trouble ol the vascular or lymphatic circulation in them. 244 PROG>OSIS ACCORDl>G TO WHETHER IT IS TREATED OR NOT As is the case Avitli gibbosity, paralysis is more frequent in Pott's disease of the dorsal and cervico-dorsal regions than in Pott's disease of the t^vo extremities of the spinal column. It is the reverse with abscesses. Of the three great symptoms, gibbosity, abscess by gravitation, paralysis, the first (gibbosity) is nearly ahvays present; abscess Fis. oos. Ordinarv type ; median and angular gibbosity. exists in about half of the cases, and paralysis only once in 5 or', 6. — The three may exist together, but this is very rare. Generally Fig. 209. — Looking for pain. Succussion ; one seizes between the thumb and fore- finger, the spinous process of the projecting vertebra, pressing upon it with short and quick lateral movements. Avhen an abscess is apparent, there is no paralysis, and vice versa; on the other hand, gibbosity generally co-exists with abscess or with paralysis. Prognosis. This differs entirely accordinij; as the disease is treated or not. A. If the disease is not well treated : a. Tlie gibbosity will develop more and more, and the patient, if he survive, will remain hunch-backed. b. Abscesses are more frequent, more bulky : but especially do they produce fistulte. And fistulous Pott's disease nearly alwavs ends with the death of the patient, sooner or later. c. Paralysis is equally more frequent and is often fatal. B. On the other hand, if the Pott's disease is being well trea- ted : The gibbosity if recent will be not only arrested in it's pro- gress, but effaced. 1)1 It \ I KIN (ii- riii: iiisi.\si: ■>.lxb Ahscessex will ho loss rro([iicn( : ahovo ail tilings. Iliov will cure because tliev will nol be opened or allowed to open. Fig. 2 10. — Dorso-lumbar Pott's disease; typical attitude. Paralysis uill be verv rare and, if it supervene, will be cured 19 times out of 20. Duration of the Disease. The duration depends especially upon the treatment carried out, and slightly upon the particular case, because the tuberculosis maybe more or less virulent. On an average, it is necessary to reckon irora 46 POTT S DISEASE. DIAGNOSIS three to four years, sometimes less, often more. In the case of abscess well treated, the duration of Pott's disease, instead of being prolonged on account of the abscess, is notablv shortened. Dias:nosis. The ordinary case. A child is brought to consult you about a gibbosity- Three times out of four one has only to look at it to see Fig. 211, a 12, : i" stage. The patient flexes his knees instead ol freely flexing the trunk. He uses his right arm to balance liimself in order to preserve his equilibrium. i3. — The patient is asked to pick up an object placed on the floor. 2°* stage. The left knee is in contact -with the ground, the left hand seizes the object. 3"* stage. The patient raises himself by means of his right hand, which takes a point on the thigh as a fulcrum. that it is due to Pott's disease. Indeed, if the parents bring the child to you, it is because they are concerned at the appearance of a prominence in the middle line of the back, and they want to knOAV what it is. i)iA(i.\u.si.> WHEN JiiMu: Is \ (;iiiii(i>ri \ ■yA- How one recognises the gibbosity of Pott's disease. Fig. 2i\. — Esaminini;- the mobility; healthy subject. In hyper-extension, the entire spinal column participates in the movement and forms a regular curve. Fig. 3i5. — In the aEfected subject, the diseased segment (2'' presents rigidity and the spinal column forms a broken line, 1,2, i. (Gg. 197 to 209). We have already said it ; It is median (over 248 POTT S DISEASE. DIAGNOSIS one or two spinous apophvses i, 2"'. it is angular, '6''. it is painful on pressure, and especially on lateral succussion (fig. 209J. Fiff. 216. — Lumbar Pott's disease; there is no o^ibbosily strictly speaking, but tbe physiological lordosis has disappeared, that is sufficient. — Here the diagnosis was confirmed a month later by the appearance of an abscess in the left iliac lossa. Moreover, the attitude is " stiff " (fig. 200 and 2191 and there is rigidity of the spinal column. — The patient ^^ alks all in a block, without anv tlexihilitv 1 fie. 2101. In order to bend down and 1)1A(.\I>-I-- WIIKN Ml (.IIilt(lMI> IS rUliSIiNT ■2'\() nick up ;iri olijcci on llu" i;i(iiind. lie does not bend llic trunk Ircelx : Ik- flexes the legs and kneels down rallier llian stoops (fii^. 21 r , aia, :mo ). ir one raises up llic t'vo limbs and llie pelvis of llie sul)jccl laid on his belly, llie l)ack does not bend in llic cuslomarv \va\ : it resists like a board (tig. ui/j. :u5). Finallv, the general condition is olten below par. and the ordi- nar\ antecedcnl-; ol luberculosis mav be found. Less frequent case. Ao yibbo- sity has appeared. — Once out of four times \ou are consulted onlv for functional Irouliles : nothing is mentioned as being wrong with the back. It is for you to think of it and examine the spine. a. W hen a child is brought o to >ou carrying himself badlv (fig. 2IO), is quickly fatigued, complains of a stitch in the side, or girdle pains, or pains int he limbs, diurnal or nocturnal, ne- ver neglect to completely exa- mine the patient perfectly nude, and. to carefully inspect the back and the lower limbs. If you find a gibbosity, the diasrnosis is easv. • • • 1 Failing that, if you find pain on succussion, stiffness in wal- king, difficulty in stooping, these will suffice to make a diagnosis of Pott's disease. h. Sometimes the patient is brought to you only for an abs- cess — cold pararaclddian — (in the neck, the back, the thigh, or the internal iliac fossaj. Think of Pott's disease and examine the back. Bilateral symmetrical abscess is an indication of Pott's disease 99 times out of 100 : but unilateral abscess should also make \ou think of it. c. More rarelv, it is for paralysis that you are consulted. Think here again of possible Pott's disease, and look for the diffe- rent signs whicb have been uiven \ou about that. l-'i'^ 217. — Itare type : pOTt's DlSli.VSE. DI.VGNOSIS IN Till; CASK OF ABSCESS 2J.i But ho roassnrod, hocouse il is i-;ii-el\ llial I'ult's disease appears under llic loini nl lalciid dfloiinllv or of romid back. Fio. 2 22. — Touch often allo\YS one to distinguish an abscess by rjravilalion in the neck from an idiopathic or glandular abscess. If it is a pharyngeal abscess of vertebral origin ; a hnger laid on the posterior border of the sternomastoid and exercising light but jerky pressure over the deep tissues, will convey the impres- sion of fluid to the index finger introduced into the pharynx, on the left. This sensation would be absent in the case of glandular abscess (c) on the right. Fig 233. — The method of palpating the internal iliac fossa in looking for an abscess ; the pulps of the fingers are firmly pressed into the abdominal wall, pushing aside the intestinal mass. Gibbosity following accident : the diagnosis is bv the history 254 POTTS DISEASE. D1AG->'0SIS IN THE CASE OF ABSCESS of very grave injury, by the sudden appearance of the deformity, with general medullary symptoms, etc. ^ 6. Abscess. — Causes of error in diagnosis. If there is behind the pharynx a cold abscess, one will always think of Pott's disease. One will examine and palpate the cor- responding spinal apophyses ; one Avill look for antecedents, tor- ticollis, intermittent or chronic, radiating pains about the neck, the arms, etc., in such a way as not to mistake a Pott's disease for 2 2 /| . Palpation of the iliac I'ossa ; ihe hand, in pushing aside ihe intestinal mass, comes in contact with the wall of the abscess. a simple idiopathic retro- pharyngeal adenitis. Cervical adenitis is distinguished from abscess by gravitation (of the neck) by the same signs (fig. 220 to 222). When an abscess is situated in the right iliac fossa (lig, 228 and 22Z1) take care not to confuse this Avith a cold appendix abscess, an error which I have seen committed. One Avill distinguish it also from an encvsted collection of peritoneal tuberculoses, from a simple glandular abscess, and especially from an incomplete hernia, an unfortunate mistake I have seen made (v. chap. xix). I . Syphilitic gibbosities are rare ; they are rather of a mixed form, a « scrofulate de verole », v. chap. XXI. The diagnosiswith spondylitis deformans and other ankylosing arthrites of the spine, by the existence of a large curvature, of generalised ankvlosis of the spine, frequently stiffness of the joints at the root of the limbs, etc. POTT S Ml- 1. \si: i>i\(.\ii-i- i\ I in: cAsi; fall hack liulhcr. hiil, under the Fig. 234. — Hie child in (Le preceding figure, five years after commencement of treatment. influence of this conlinuous pushing from behind forwards they return gradually into line. Reason says it and experience demonstrates it. It is enough >M POTT S DISEASE. REDRESSMEXT OF THE GIBBOSITY to look at the examples here given of corrections made by us in this way, to be convinced. (Fig. 227 to 240). Conclusion. In the same way that a fracture suggests plaster immediately, Pott's disease should henceforth suggest Fig. 235. — Lucien B ..., rue de Rivoli, Paris. Gibbosity claling eigbt years. to you the plaster corset. It would even be easy to maintain that plaster is much more indispensal>le in the case of Pott's disease with gibbosity than in the case of ordinary traumatic fracture, where displacement, or even a tendency to displace- ment, does not always exist. POTT S DISKASE. TIIF THEATMENT Ol' ABSCESSES 267 ^1 Cask — POTT'S DISEASE WITH ABSCESS Axiom. — Take care above everythinji: not to open the abscess, nor to allow it to open; lor. if il is opened. Fig. 236. — The same, six years after commencomenl of treatment. it will scarcely ever heal ; a fistula will remain which will become infected and sooner or later, end in death. Here there is no discussion needed as to the treatment 2 68 ABSTENTION IN THE CASE OF DEEP ABSCESSES which should be followed. Opinion is unanimous among well informed surgeons. Even in the case of a retro-pharyngeal abscess in Pott's disease of the suh-occipital region, the abscess must not be Fig. 237. — MarfliaG., Algiers. Gibbosity ten months before arriving at Berck. Opened, but if there should be grave and pressing functional troubles, puncture the collection by Avay of the neck, entering the skin at the side. (Y. p. 344 for details of this technique). The Formula for the Treatment of Abscesses Here it is for the different varieties. a) Leave the abscess alone, if it is not easily accessible, in which case the skin will not be in danger. This is the most frequent case. I'lNCTlUES AM) INJKCTIONS 1-OU S( I'KUI ICIAL ABSCESSES 269 /;) It is permissible, and even indicated, to treat it iCil is easily accessil.le. allli(>ti';li llie skin is not llirealened. Fig. 238. — The cliilcl in the preceding figure, three and a half years after commencement of treatment. c) One ought immediately to treat it Avhen the skin is in danger, in AAhich case it is easily accessible. By treating it, I mean puncture and injection (v. Ch. III). aio TREATME>T OF FISTLL.E /i'" Case. — POTT'S DISEASE WITH FISTULA We have explained (Chap. Ill) the general treatment of tuberculous fistula?. You recollect that : a) If the fistula is not infected (that is there is neither fever nor albuminuria), one must inject into the sinus modifying Fig. 239. — David Ter,-M., Tillis, gibbosity of two year's standing. injections (of creosote and iodoform, or of camphorated naphtol) either in the form of liquid or of paste. h) If the fistula is infected, on the contrary, injections are bad; the treatment, in that case, is summed up in these fev\^ words : make certain of the drainage, rigorous asepsis, rest, general treatment, and patience. J'" CVSE : POTTS DISEASK WITH PUl\r,YSlS 27 I b'" Case. — POTT'S DISEASE WITH PARALYSIS. a) The indication is lo release llic cord Irom pressure and lo modify, if possible, ils circalalinn and its internal nutrition. See figure 202, page 24 1. How are we lo do this ? Fig. 2^0. — Tlie same, three years after redressment. With or ^^itll0ul: operation.^ 6) The treatment /o be carried oat : one fulfds the indications by gently redressing the spine and by exerting afterwards a gentle and continuous pressure over the affected vertebra?, by the only orthopedic treatment ; that is. by the application of a large plaster only, with a dorsal opening. A^ liilst surgical operations are nearly always useless, and even very often, 272 TREATMENT OF THE PARA.LTSIS OF POTT S DISEASE harmful, thev ought to he condemned without appeal in the treatment of paralysis, just as in that of abscess by gravitation. Indeed, operations do 20 times more harm than good, not Fig. 2/10 bis. ■ — Germaine B., aged 7 years, of Santiago, Cliili. — Gibljosity of two and a half years standing. — (This litUe girl was so restless ani intractable that we were obliged to have recourse to chloroform in order to apply the first apparatus. The child was put to sleep and supported in the sitting position; see page 35 1 « on chloroformisation in applying the plaster ». The child having been « made comfortable » by wearing the first apparatus, it was possible to apply the others without the help of chloroform). — see fig. 2^0 ler, the same child after treatment. only because they sho^v a considerable immediate mortality (nearly ^o per cent), but because they leave a fistula, that is, a complication much more formidable, without contradiction, tiil: i,au(;i; I'l.Asiiiii ,m:akl\ ai.w a\s ci hi;s iiii; i '.V11AI.\-I.S 2~'6 than the paralysis, wliicli one wishes locuie. For, |);iralvsis, roineiiibcr. nia\ he cured sponlaneousl\ . hiil especially il niav be cured h\ orlluipi'dic li-ealnienl alone, al\\a\s or Mearl\ ahvays. Fig. 24o ter. — The same 3 i j ■> years after straightening Why not always? Because sometimes it is a question of tuberculous myelitis against which our treatment is less precise and less certain. A ery often one observes a distinct improvement a lew hours Caiot. — In:lispensahle orlhopeclics. 18 2 7-4 TECHNIQUE OF THE TREATMENT OF POTT S DISEASE after the application of tlie apparatus. The two legs may perhaps have been absolutely motionless for more than six months, and behold, on the first evening, they move a little. Two or three days later, the heels are freely raised aboAe the level of the bed. This return of functional activity in the paralvsed part occurs almost regularly. Each week brings about a new impro- vement : in from ,3 tn g months, the paralysis has disappeared, not only from the lower limbs, but also from the bladder and intestine. 2-1 PART. — THE TECHMQUE On the whole, the treatment may be reduced to two things : — A. — The plaster corset. B. — Puncture and injection, when there is abscess. I have laid down in the first part of this chapter what is desirable to be done : I am going to describe in the second part how it ought to be done. .4. — TECHNIQUE OF THE PLASTER APPARATUS How to make a >/ood plasfei' corset, when no specialist is avai- lable, which realises all the required conditions, that is, onew^liich supports w ell and nevertheless does not incommode the patient. A plaster corset is not more difficult to make than a plaster for the leg. which nearly all practilinners can make easily. The only difference between the two is that you liave learned to make the latter, but not the plaster corset. ^A'ell. I have undertaken to teach you. and I promise you will succeed in doing it, if you follow faithfully the technical indications I give you here. Make one or two preliminary rehearsals. — A^hat I ask of you is. as to the first corset you have to apply, to make for yourself (one or tAvo days before) one or tAvo general rehearsals on a " mannequin o. or on some healthy subject of TECHNIQUE Ol' THE FLASTEU COIISET MEDIUM SIZE 270 the same age apprnxlmalcly as the patient. This Avill enable you lo test the ([uality of your plaster, to train yourself, to educate your assistant, ^\ ho may be simply your own domestic, if you cannot secure the aid of a trained nurse. Fig. 2/11. — The medium plaster. Fig. 242. — The large plaster. This rehearsal is always possible in practice, for if, for a fracture, the plaster must be applied immediately, you may, in Pott's disease, put olT for one or two days the application of the corset. In the meantime, the patient should be kept at rest in the recumbent position. Choice of Model of Plaster Corset. There are three models : the large plaster, having the upper 276 pott's disease. TECHNIQUE OF THE MEDIUM PLASTEU part in the form of a funnel or a tray enclosing the base of the skull (fig. 242); the medium plaster, iviih an officer's collar (fig. 2I11), and the small plaster without a collar. They differ only in their upper parts, all of them stop beloAY from 2 to 3 cm. above the great trochanter. The choice of apparatus depends on the situation of the affection. For Pott's disease below the 6*'' dorsal vertebra, and for lumbar Pott's disease, we use a medium apparatus with a straight collar. For Pott's disease of the cervical or upper dorsal regions, above the sixth dorsal vertebra, and for all Pott's diseases with paralysis, Avithout distinction of situation, it is necessary to apply the large apparatus with the funnel-shaped upper part. The small apparatus without a collar ought to be reserved as an apparatus for convalescence, for Pott's disease of the lower dorsal or lumbar regions. /. — The medium apparatus. We jwill describe first the construction of the medium plaster, which is of the three, that most used; we will point out as Ave proceed Aarious peculiarities proper to the other tAvo. Position of the patient. — « Stretch, but do not suspend. » The [apparatus should ^ be made Avith the subject in the upright position ; one supports him only, AA'ithout really sus- pending him. Make, in a Avord, extension only, in such a Avay that the heels do not leave the ground (fig. 243, 244)- This tension is, first, absolutely harmless, as you may guess, even in enfeebled subjects ; second, it is A-ery Avell tolerated by everybody, for the 10 or 12 minutes necessary for the construction of the appa- ratus, including the setting of the plaster. If you adhere to this formula, you have gained everything iiir: PATiiAT I I'UKiiir. TENSION NOT SUSPENSION 277 arnl lost iiolliiiig in making the apparatus in the upright position lallier than in tlie liorizorilal position ' . The suhject will llius Ix' better adjusted willioul being -7 J .T Fig. 2^3. — Strelch and do not suspend. Fig. 24i. In figure 2i3, the cord has not laeen tightened. One sees in fig. 244, that in pulling on the head, one has rectified the attitude and even corrected (slightly) the gibbosity without the feet of the patient quitlimj the fjroimd. fatigued, and you Avill have infinitely more facility for construc- ting your plaster regularly and precisely. (a) The supporting apparatus. — The appliance for supporting the patient should be, in default of a pulley, a simple cord fixed to a hook in the ceiling or in a doorway. The cord I. For paralysed subjects, you \\ould construct the apparatus in the sitting posture, which gives sufficient traction (to free tlie spinal cord) and not too much (lo prevent sudden injury to the tuljerculous focus, and later on, an abrasion of the chin) (fig. 2 45 and 2 46). 2lt PLASTER CORSET. SLPPORTl^SG APPARATUS has at its extremity the centre of a horizontal bar of Avood or Fig. 2^5. — Pelvi-support made up of a bicycle saddle on which is seated the paralysed patient, during the construction of the apparatus. Fig 246. — His thighs are a little flexed in order to free the ischia and render the- support more stable, but not too much flexed to hinder the exact application of the plaster in front. One steadies the patient by pressing on the knees. metal, furnished at each end Avith a groove to retain the two terminal buckles of the occipito-mental straps. But, -without pulley and without hook, you may anywhere improvise a suspensory apparatus, by means of a step ladder THE OCCII'ITO-MENT.VL STR.VI' 279 (fig. 2^7) over llio lop of which you pass the cord sustaining the liorizontal har at a distance from the ground calculated from tlie heiglit of the patient. It is easy, willi or without a pulley, to regulate the height 2^7. — Sustention apparatus improvised with a step ladder. of the horizontal bar, either hy lengthening or shortening the cord, or by approximating or separating the feet of the ladder. (h) The occipito-mental strap. — The patient is bound to the supporting apparatus by a strap or collar-piece (fig. 247)- With an ordinary linen bandage and two safety pins, one makes on the spot a girth Avhich can with advantage take the 280 TECHNIQUE OF THE PLASTER CORSET. THE GIRTH place of all the Sayre's collars, or of those sold by the instru- ment makers. The figures following show the method of procedure. You Fig. 248. — To make a girlh, take a bandage of ordinary linen ao cm. longer than ^ the height of the patient; fold it in two and knot the two extremities together. Fig. 2/ig. — Divide this large loop into three by taking the bandage between the thumb and index finger of each hand at the 2 extremities of its middle third. Fig. 2 5o. — The median portion of the loop should be of such a length, that when applied (the two layers superimposed) on the face of the patient on a level with the nose, the points held by the fingers and thumbs correspond with the auditory meatus. take a bandage of a length equal to the height of the patient measured from the head to the feet (or better still, 20 cm. longer), you fold this bandage into two, and knot the two free THE OCCllTro-MEMM, (ilHTII cxiiviuilies logellior. \n\i have lliiis a large loop (fig. ^.f\8). \(ui then divide this single loop info three secondary loops, one median, lo embrace the base of ihc head (fig. .i\(j and fig. -loo) and two lateral ones (^^hich arc folded upwards as soon as the girth is in position), to hang on the two extremities of tli(^ transverse bar of the sustention ap[)aratus. Viii. 25i. — Tlie lingers are replaced hv two safety pins. The median loop ought to have a circumference equal to twice the distance which separates (in front) the two auditory meatus of the patient. \ou measure the distance between one ear and the other sim- ply with the middle portion of the bandage held thus : (fig. 2/19 Fig. 252. — Placing the girth in position. — The head engaged in the middle loop ought to pass easily, but not too much so : only one centimetre of play must be' allowed on each side (if it is more or less, it drags on the pins and may pullthem out)- and 200) with two lingers on each side. The measure taken, you put two pins transversely in place of your fingers (fig. 25i). So much for the dimensions of the median loop, which is most important. On the other hand, the lateral loops are not of much importance : it is sufficient to have them equal, for their inequality may produce an inclination of the head to one 282 THE OCCIPITO-MENTAL GIRTH Fig. 253. — The two la%prs of the middle loop enclose the chin and the occiput. When the lateral loops are released the pin should be a centimetre above the upper border of the ear. Fii;. 2.14. — lou fix «ifh a ])in one end of the strip to the centre of the posterior handle of the middle loop. (One sees in these figures small squares of cotton wool ■with -which you protect the skin against friction bv the pins. side Fig, 255. — The girth iinished and adapted : a seam has been made instead of a knot. which must he avoided. To adjust a girth you open horizontally the middle loop, intro- ducing it from above do^^n^vards (fig. 262) to the root of the neck, lou adapt the ante- rior layer to the chin and the posterior layer to the occiput, after Avhich you release the lateral loops in order to pass them on to the extremities of the horizontal bar (fastening them to the grooves if there are any). This being done, the middle loop Avill describe a broken circumference, AAhich will prevent its slipping when the patient is pulled upwards, and it will slip all the less as he is pulled upwards (provided that vou have siven it the measurements indi- THE OCCII'ITO-MEMAL Gllll II 283 catcd above). Jiiil if llic patient pulls on the f|^ ^^j.^ ^f t]^g g^pjp ought in its edojes to facilitate its adaptation. / / <• i The right tail is already llattened tO COVCT nearly I / 4 of the prece- down on the shoulder, the left tail is rjirio- turn still raised. — The two tails must go t i ■ • t ^ n round the shoulders in front and unite In thlS Way IS made the first below the axilla at the lateral borders continUOUS COVeHng of the of the attelle (k. /jr. 269). , 1 r\ 1 1 'U fr trunk. One bandage will sullice for a little child ; it may take two or three for adolescents and adults. 3^'^. Application of the Attelles. One then applies the attelles, having taken care to spread them out, after having squeezed them. pott's disease. TECHNIQLE OF THE PLASTER CORSEXJllagS a) One commences with the posterior one or '• cliasuble". 137. J'-^- Fig. 268. — Placing in position the circular at telle of the shoulder and the anterior attelle, of which the inferior third is raised up : that which is represented here is too narrow, it ought to overlap the axillary line by one or two centimetres. Fig. 269. — The attelles in place : one sees the extremity of the superior tail of the " chasuble"' under the axilla, and the inferior third of the anterior attelle raised up over the abdomen : also the attelle for the neck over the woollen neck-piece. The inferior edge is placed at the level of the tip of the coccyx, 294 PLASTER CORSET. APPLICATIO?* OF THE ATTELLES SO that the back is covered by two thirds of the attelle. The upper third, which passes upwards over the scapulae, has been split into two tails of equal width, to go over the shoulders (fig. 266); each tail passes over, then in front of the correspond- Fig. 270. — Modelling the apparatus above the iliac crests. ing shoulder, afterwards under the axilla, and returns to unite with die corresponding lateral border of the posterior part of the attelle. Some incisions, made here and there, into the edges of each tail (fig. 267) facilitate it's appUcation and it's exact adaptation to the circumference of the shoulder. b) One takes afterwards the anterior attelle and applies it first by it's superior border a finger's breadth above the POTT S DISEASE. MODELLING THE PLASTER 29O clavicles; it covers liic tails of the preceding alleile, then descends over the chest and abdomen. The inferior i/3 hangs below the pubes; one folds this apron over the middle i/3, even with the abdomen ; the fold corresponds with the line of the trochanters; this will be the lower border of the plaster (fig. 268, 269). c) The attelle for the neck is applied like a circular cravat (fig. i?68) over the woollen covering. The upper edge of this piece stops at one centimetre below the upper edge of ihe woollen cravat (fig. 269), and the lower edge encroaches upon the upper parts of the two preceding attelles. It is sufficient to roll it without any pressure (nevertheless exactly), to avoid with certainty all constriction of the neck. In a word you apply it as you do your collar ; were it made of sheet-iron and placed directly on the skin, it would not, however, compress your larynx. The three attelles being placed in position, which is very rapidly done (a minute for each if one is assisted by one or tAvo persons), you join them by rolling over them a plas- tered strip in the way mentioned for the under one, that is. in figures-of-8 arid circular turns. One strip over the attelles and one below (tAvo in all) suffice to construct the apparatus for children of less than six years, but 4 or 5 strips (in all) are necessary, as we have said, for subjects of from tAvelve to fifteen years. You may have to use 6 or even 7 strips (Avithout counting the attelles) for adolescents and adults rather big and fat, to give thickness and the required resistance to the plaster. Between the different layers of the strips and over the last, one spreads, as has been mentioned in the generalities, a layer one or two millimetres thick of plaster cream. — It is the mortar Avhich unites into one solid block the different planes of the apparatus. 296 POTT S DISEASE. MODELLING THE PLASTER CORSET 4*. Modelling the plaster. The apparatus is finished. Nothing remains but to model it over the pelvis and around the shoulders (fig. 270 to 272). 1st. Over the pelvis : you model by embracing with both hands, half-closed, the spines and iliac crests, pres- sing the plaster very firmly above the superior border and inwards along the anterior border of the hip- bone Avith the pulp of the fingers (fig. 270) Avhilst the palms of the hands press Ijeliiw the iliac crests. The spines and the crests are thus capped, encased by the apparatus, without any risk of sloughing (fig. 271 ). 2°''. Over the contour of the shoulders, Avhere an assis- tant ' applies the plaster AA'ith very light pressure (fig. 271 ). One occupies, in effecting the modelling, the feAA' mi- Fig. 271. — Modelling the shoulders and iliac ririJ-As which Drecede the SCt- crests, in a large plaster : the modellincr is done in the same way as in a medium plaster, tmg of the plaster, aCCOrdmg — Another assistant models at the same ^q ^\^q calculation laid dOAAn time the sacrum and pubes (that assistant , „ t • i- i has not been shewn here in order to leave before. It IS then, at about the figure more distinct, but see the figure (^q fifteenth miuute, the plas- on the followinsr pase. . i i • terbemg set, that the patient can be remoA'ed from the sustention apparatus. To do this. I. A second assistant makes it fit exacth over the pubes and the sacrum (v. fig. 272). pott's disease. TRIMMlNf; Till- I'LASTER 297 open out llie leot oC the step-ladder, or loosen the cord; llicn pull fonvard, lo disengage the chin piece of the girth. Let the child stand upright for ten minutes more, so as not lo risk hy lying him down too soon, the cracking of the appa- ratus; — then the plaster appearing to he solid, the patient is tig. 272. — Modelling the sacrum and pubes in a large or medium apparatus. The iliac crests are modelled at the same time. (v. preceding figure and its explanation). laid down — placing transversely under his neck a small roll of cotton wool in the form of a log, or, more simply, leaving his head to overhang the end of the table, supporting it with the hand. 5''\ Trimming the apparatus. A quarter of an hour or half an hour afterwards (with the patient lying down) you proceed to trim the apparatus (fig. 278), 2q8 POTT S DISEASE. TECHNIQUE OF THE PLASTER which is done with a bistoury or a common knife well sharpened. The plaster is cut (down to the jersey only) : At the bottom, below the iKac spines, cut little by little, just enough to allow the patient to bend the thigh to a right angle, if it is desired that he should walk about with the apparatus. Cut out less if he ought to remain incumbent; for the legs Avill be thus someAvhat res- trained, and immobilization will be perfect. The plaster is allowed to extend dowuAvards in the sbape of a point over the pubes and also behind over the sacrum. At each side of the shoulders cut away all that goes beyond the scapulo- humeral articulation. The arm holes are freed for 2 c. m. so as to allow of ease in the movements of the arms. The superior border of the collar is pared for a few millimetres to make it even. A small provisional opening is Fig. .7II' Apparatus with offi- ^^^de afterAvards over the front of cer's collar and a provisional the Chest tlirOUgll wllich CaU be opening : the dotted lines shew -, , i , , 1 1 i • r , the limits of the large definite ^^awn the COltOU WOol placed in frOUt opening and the edge of the of the Jersey. Tliis facilitates the apparatus after trimmins. \ ,1 .1 -.i movements ot the thorax, without damaging the soliditv or the precision of the apparatus. Strengthening the plaster. Suppose that the plaster is too Aveak, all over, or at some one point. now TO coNsoi.inA IE the I'I.asteu 299 II may happen in spile til' all llie precautions taken in laying the patient down, llial llie plaster lias cracked during tlie niana^uvrc : it nia\ even crack oi- become crumpled spontaneously. Fig. 27'!. — The medium apparatus trimmed. Permanent anterior opening. Here is the way you remedy this : You pull on the top and the bottom of the apparatus in order to return tlie patient (lying down or upright) to the position desired, and whilst two 3oo POTT S DISEASE. POLISHING THE APPARATUS assistants maintain this position, it is fixed there, by the application of several squares of plastered muslin over the weak places, flattening them out with several turns of bandage. Hold it so until the setting of the new plastered pieces. To succeed in making these repairs, it is well to commence by spreading over the part you wish to strengthen a layer of rather liquid paste (equal parts of water and plaster) and it is over this layer of paste that you will apply the squares of Fig. 275. — Dorsal opening for the compression of the affected vertebrae (m a large apparatus) . plastered muslin, of a single thickness and one by one. This precaution is absolutely indispensable when it is desired to repair a plaster already dry. (For the details, refer to the generalities of the technique of plaster apparatus, chap. I.) Polishing the apparatus. Two days after it has been constructed, one polishes the plaster, which is done after the method mentioned in the gene- ralities, pages 79, 80 and 81. The openings in the plaster. i[\ or 48 hours after the polishing, you vadkelhe, permanent openings. now K) OPEN THE I'EASTEU CORSET 3oi In culling llie openings In llie plaster, as in Uimming, cut layer alter layer, very gently, until \ou have tlie sensation of no longei- touching hard plaster, hul the tissue oi" the jersey. Be careful not lo cut inadvertently through the jersey. With a little practice you Avill easily succeed. But the safest way is to place over the jersey, at the points where \ou intend making the openings (over tlie gibbosity or at any other point), a square of cotton wool 12 cm. in thickness, before constructing the plaster. Thanks to this square, you til hursal opening in a uiediuui planter. will be able to make an opening without fear of wounding the child. The double jersey also gives a greater security. P^. Permanent anterior opening (Cig. 2-fi.) It's dimensions. — Each lateral part of the plaster has a width equal to about a quarter the width of the breast, at the level of the shoulders. But the opening widens very much at the lovyer part, extending from one vertical axillary line to the other. The top piece is 3 or 4 cm. high and the bottom one 8 or 10 cm. 2°''. Dorsal opening. This is made at the same time as the preceding one. In the case of a gibbosity unusually pointed, one does not Avait for 2 or 3 days. Ten or fifteen hours after the plaster 3o2 pott's disease. PLASTER CORSET is made, the dorsal opening is cut out, so as to be perfectly certain that all abrasion of the skin is avoided, (fig. 275). £r;g_ 2']']. — The llaps ol' the jersey are held by an assistant: you place in position the square of cotton wool, >Yhich you carefully spread out at the sides between the skin and the jersey by means of your fingers, or some flat instrument (a spatula). The dorsal opening is indispensable in all apparatus for Pott's disease. I say indispensable. If you remove a piece Fig. 278. — The dome of wool projecting through the dorsal opening. from the dorsal aspect of any corset or apparatus, even if this corset has been applied during complete suspension of the NECESSITY OF THE DORSAL OPENING 3o3 palienl, and ex[)ose llie bare skin, you will see (fig. 276) tliat llic vorlchrcL' do iiol loucli llie inner surface ot" llie corset; tig. 271J. — Compression of the dome by means of a band of strapping. there may even be a gap of from 4 to 5 cm, — which proves that they are not sufficiently supported. This simple examina- Fig. 280. — The compression is completed. tion explains too Avell how, in the ordinary corsets without a dorsal opening, the gibbosities may not only persist, but become aggravated. 3o4 POTT S DISEASE. TECH>'IQUE OF DORSAL COMPRESSION If you "wish the affected vertebrfe to be supported constantly, you see that it is necessary to place there, in very great number, Fjo-. 281. — Schematic sketch of a large apparatus furnished Avith a compressive tampon, before the application of the strapping : C. section of the plaster, interrupted in front by a large anterior opening (which reaches up to the hyoid bone. V. fis;. 2/11); J. Jersey turned aside at the edges of the dorsal opening ; T. squares of ayooI forming a tampon over the gibbosity : — P. direction of the pressure of the strapping -which acts by pushing back the ^vool tampon and the sibbositv to the position indicated by the dotted lines ; — R. Points of counter pressure of the apparatus on a levehyith the scapular girdle: — R' Points of counter-pressure of the apparatus at the level of the pelvic girdle. squares of elastic wool, in order to exert a continuous pressure upon the corresponding vertebral segments. Dimensions of the dorsal opening. — It ought to extend from 3 or 4 cm. on each side of the affected vertebral segment (fig. 275). TREATMENT OF POTT S DISEASE 3o5 The plastered piece is removed, as if it were punclied out, with a bistoury; then you divide diagonally the small square of exposed jersey, raise up the flaps, and proceed to the compression. Technique of the compression. You commence by annointing the skin willi a layer of vaseline of one or two millimetres in thickness. Cut, next, squares of wool a little larger than the opening (fig. 276), Fig. 282. — The gummed bandage applied and partly obscuring the large anterior opening. Fig. 283. — The anterior opening has been freed of the turns of bandage obscuring the opening partly. and of I cm. in thickness. Cut and introduce them at once between the affected vertebrae and the internal wall of the pillars of the opening (fig. 277). Use thusSto lOsquares of wool for the first compression. The wool makes a projecting dome through the opening Calot. — Indispensable orthopedics. 20 3o6 TEGHMQUE OF DORSAL COMPRESSION (fig. 278). The projecting wool is forced into tlie opening until level with the plaster, with one or two strips of sticking plaster, moistened, rolled round the apparatus, and exercising a strong compression over the woollen dome (fig. 279). The dome diminishes by degrees until it is entirely effaced (fig. 280 and 281). The sticking-plaster adheres very soon firmly all round the plaster, and a few hours later, you may cut out and remove the part of the strip which covers the anterior opening : Avhich restores to respiration it's complete liberty (fig. 282 and 288). The number of cotton-wool squares varies according to the case. a. There is no gibbosity; You use 8 to 10 squares (to prevent the appearance of a gibbosity). b. There is a gibbosity; You can then go up to i5 or 18 squares of i cm. not at once, but at the third or fourth compression, Avhen the space Avhich is found betAveen the vertebrae and the plaster has become more pronounced. 18 squares seems enormous, but they adapt themselves in an incredible way, and Ave have never seen any inconvenience from a compression carried to this extent in a gradual way. The gibbosity is by this means, progressively pushed forwards, Avhilst the vertebrae above and below tend, on the other hand, to return towards the posterior wall of the appa- ratus, because of the immobilisation of the shoulders and the pelvis (fig. 281). The condition is comparable to that of a child leaning backwards against a vertical ladder, to which he is firmly attached by the shoulders and pelvis, whilst the middle part of the back is pushed forwards Avith the hand. All this is done sloA\"ly, methodically. So much so that this very efficacious compression, Avhich is as energetic as you Avish, is, nevertheless, extremely gentle and very TREATMENT OK POTT S DISEASE 807 well tolerated. It produces no sloughing ', instead of which, with an apparaUis unopened heliind, sloughing is nearly cons- tant although the [)ressure be inappreciable. //. — The large plastered corset for Pott's disease. The larf/c plaslei' encases the base of iho skull. Fig. 28^. — Oblique occipito-mental era- Fig. 280. — Tiie metliod of rolling the vat and woollen turn, the one as it were first plastered strip round the head the equator, the other the meridian, to at the equator and at the meridian, complete the protection of the head. The posture of the patient, the sustention apparatus, and the occipito-mental girth, are just the same as for the medium plaster. I. Or almost never; v. p. 71 and 74 tlie mean? of detecting and treating slouo:lis. 3o8 THE CONSTRUCTION OF THE (( LARGE )) PLASTER CORSET Here are the differences between the two apparatus. The clothing. — As above, the jersey and woollen pad over the chest. In place of the circular cravat, you use here, to complete the jersey, an oblique woollen cravat, embracing the chin and the occiput, following consequently the occipito- -orj -f7 0-. 286. — Strengthening squares and occipi to-mental attelle placed in position over the first strip for the sub-clavi- cular portion of the large apparatus. J^ Fig. 287. — These two pads are fixed round the head with a plastered strip. mental circumference (fig. 28/i). An assistant holds the two extremities of the cravat over the middle line behind, until the first turn of bandage has been applied. You complete the covering of the base of the skull by two turns of wool one centimetre in thickness, of which one is carried perpendi- cularly to the cravat, as an equator, from the forehead to THKATMENT OF I'OTT S DISEASE Sog the nucha, llie titlier circuhulv round llic neck and the nucha. Preparation of the attelles. — Th( two large pieces for the trunk are the same; but, instead ol the circular cravat, we prepare two square pieces, of Irom i5 to ;?5 centimetres according to the size of the subject (having the usual three thicknesses); these will be placed, one in front, the other behind. Fig. 288. — The upper end of the apparatus has been cut over the forehead and the two pieces turned over at the sides ; remove the lateral pins of the girth which you can thea cautiously pull away by making it slide. But if you have cut the two tails on one side, you have only to pull towards you from the other side ; this second proceeding is much easier. to make the armature of the cranio-cervical portion of the apparatus (fig. 286). The application of the bandages. The first plastered strip is rolled round the head in meridians and in equators, commencing rather by the meri- dians going from the vertex doAvnwards to the jaw (fig. 285). You repass three times and cut the strip. Then you make three 3io TECHNIQUE OF THE « LARGE )) PLASTER, or four turns at the equator, from the forehead to the nucha. Add two or three circular turns, rather loosely round the neck. Afterwards, you roll one or two bandages over the trunk, as for the medium plaster (see above). Application of the attelles. — The two attelles for the trunk are placed as in the preceding apparatus : the two supplementary square attelles are placed the one before, from the chin to the two clavicles,, the other behind, from Fig. 289. — When the child is recumbent, place a bolster under his neck so that the top of the head does not rest on the bed, the vertex to 'the scapulse, encroaching, consequently, more or less extensively upon the large attelles of the trunk (fig. 286). Then you keep in position the two attelles for the head by some turns of bandages in the meridians and equators (fig. 287) as above, and the attelles of the trunk by a bandage rolled in the form of an 8 in circular turns ; lastly, you unite the head and the trunk by a few intermediary circular turns. You use, in the construction of a large plaster, one or two bandages more than for the preceding, — according as you are dealing with a child or an adult. After that you pass on to the modelling, which is done, over the shoulders and the pelvis, in the same Avay as in the first apparatus (fig. 271, 272). IIUMMI.NG TIIK I'LASTEU 3ll It will Hot alwiiNs be necessary to model the plaster with llic hands over the chin and occiput; it models itself sullicientK if each turn of bandage in meridian and equator has been ^vell applied (fig. 287); nevertheless, it is much better to model the jaw b\ passing the hand liorizontally under the chin, in order that the plaster may make there a plateau rather than a funnel. ^ ou then A>ait until the plaster sets. "^'" ~~ ■-■'-•' .■.^.- •-™.^-.- r : After\\ards you relieve the tension by removing the loops of the girth from the bar. At the end of ten minutes, lay the child down, placing the head a little beyond the end of the table, so as not to break the apparatus. Trimming. — Take away (with a good knife), proceeding sloAvly, all the part of the plaster which is above the occipito-mental circumference. This allows of the withdrawal of the girth; to do this, take away the two sub- auricular pins and pull out care- fully the chin portion first, then the other; or, better, cut with the scissors, on one side only, below the ears, the two tails, anterior and posterior, of the girth, and pull it tOAvards you from the other side (fig. 288). It is much better to remove the girth than to leave it in position. At the lower end, the large plaster is trimmed in the same way as the medium. A prov-isional opening is made afterwards (fig. 289) through which you Avithdraw the wool, as in the medium corset. Three days afterwards, make a permanent opening, com- Fig. 290. — The lar^^e apparatus llnished, with its opening, reaching up to the liYoid bone. 3l2 THE CO>"STRUCTION OF A PLASTER O PARALYSED SUBJECTS mencing at the junction of the neck and the jaw ; the larynx being free in front, Avill not then suffer by compression which you may have to exert over the affected cervical vertebrae (fig. 279). Dorsal compression is effected in the same way as in the medium apparatus. The construction of a plaster in paralysed subjects. I have said that, not only Pott's disease of the superior regions, but also all the cases of Pott's disease with paralysis, ^'"- Fig. 291. — Extension of the spine in the horizontal position. An assistant models the apparatus about the pelvis. T-\vo others make extension and counter-extension at the head and the feet, of from 10 to i5 kilograms. are treated by the large plaster. Thanks to its funnel or plateau the extension of the spine necessary for the cure of the paralysis can be better and more exactly preserved than with the medium plaster. The patient places himself in the degree of extension desired (v. fig. 246, p. 27S) for, being unable to support himself on his feet (on account of his paralysis), but only and very imper- fectly on the seat, he ^is somewhat suspended by the girth. If (the plaster being rather slow in drying) the extension becomes too painful towards the end of the sitting, you relieve him by discontinuing the vertical position. You remove him, (at the same time as the bar) and lay him down. Then draw on the head, by means of the bar, with pott's DISE.VSE. TECHNIQUE OF THE PLASTER CORSET 3l3 both hands, with what lorce you wish (lo to i5 kilogrammes goiierallv), whilst an assistant holds liim by the feet (fig. 291). The apparatus is modelled over the pelvis as in hip-disease (v. p. 430). Thon wait in this position for the plaster to set. ///. — The small apparatus. The small apparatus is made in the same manner as the medium, but without the cravat and the neck piece. It is an apparatus for convalescence in Pott's disease of the lower ver- tebra. But in truth, we use it very little even in convalescence. Generally, we make a medium plaster Avith a collar pieced Attention required after the application of a plaster. A^e have spoken of the trimming of the apparatus, of the openings, and of dorsal compression. Sometimes patients (especially adults) are a little distressed for the first two days. You may calm- them by the mere admin- istration of anodynes, for, to this discomfort Avill soon succeed perfect comfort. You will leave the patient afterwards to the care of the parents ; I. Some remarks on the plaster corsets. a. In cases of abscess or oljistiila, make an opening in the plaster. b. Sloughing (strictly speaking possible) : v. p. 35i, the method of recognising and curing it. c. Is the age of the patient AvIth Pott's disease, a contra-indication in the use of plaster? — No, one mav plaster infants of one year (taking care to prevent soiling) just as aged people of more than 5o years. d. One may use chloroform (^exccptionalh ) when constructing the plaster (v. p. 35 1). e. Multiple fislulce or very intolerant and eczematous skins necessitate daily attention ; in such cases, one may convert the immovable corset into a movable one. (v. p. 35o). 2. If the discomfort is too great, you may relieve it by dividing the corset in front in the median line so as to separate the edges by i, 2 or 3 c. m. — but bring them together again and rejoin them tno or three days later, when the patient has become accustomed to the apparatus. 3l4 pott's disease. REMOVING AND CHANGING THE PLASTER the doctor has no need to see him again more than once a month to attend to the dorsal compression Avliich is increased on each occasion hy about i/4 of its amount. Removal of the plaster towards the fourth month. To remove the apparatus. — Place the child in an ordi- nary hath for a quarter of an hour. The plaster softens, and can be cut in a minute or two, ^Yilh any kind of knife. The toilet of the skin. — One makes it with ether or Avith eau-de-cologne, if the skin is neither soiled nor scaly. — In the ordinary case, one rubs gently with vaseline for a few minutes, Avhich has the elTect of softening the epidermic scales; after Avhicli one dries the skin with a piece of fine linen, very gently, and passes over it a little alcohol or eau-de-cologne. One cleanses the front, then the back, turning the patient over. Search for abscess. — You look, by examining the back and the iliac fossae, or, as the case may be, the neck and the pharynx, for any trace of abscess in formation. THE CONTINUATION OF THE TREATMENT IN POTT'S DISEASE AND ITS DURATION Placing the patient on his feet. If no abscess supervene, everything is reduced to making a new plaster every [\ or 5 months. After two year's rest in the recumbent position, the patient is placed on his feet, provided that he is not suffering any pain, either spontaneously, or by pressure on the back, and that his general condition is so good as to allow you to think that the vertebral focus is extinct (or almost so). CONVALESCENCE The apparatus. Then the patient is allowed to get up, wearing the same plaster apparatus. — Hospital cases keep the plaster CONVALESCENCE IN POTT S HISEVSE .Sl5 on ("or :>, or 3 years lonf^cr as a miiiiimini from this time. ■^ ^ 1 1 must be removed only ^^ -*K when, lor the last2 or 3 years, at least, pressure over the verlebne no longer elicits the least tenderness, and the line of the back has not va- ried one millimetre, provided that the general condition of tiie patient is perfect. Under lliese conditions the welding o( Fig. 292. — ^tedium celluloid apparatus. Oae sees the anterior part of the dorsal shutter. the s^lne may be sup- posed to be complele and.de/inite. This can be ascertained by a ra- diogram of the profile whenever practically possible. In the case of town children, it is advan- tageous, when putting them on their feet, to replace the plaster bv removable corsets, Avhich allow of a thorough toilet, are lighter Fig. 393. — Large celluloid apparatus for Pott's disease, cervical or cervico-dorsal. 3i6 POTT S DISEASE. CORSET IN CELLULOID Fig. 29/1. — Celluloid apparatus with large collar, view of posterior aspect. Fig. 295. — An arrangemsQt for fixing the chin piece of the minerva. POTT S DISEASE. COUSET 1> Cl-I.LLLOll) than the plasler, and furnislied. like it. \villi a dorsal opening and a shutter, which allow of continuance of the support and of the compression of the affected vertebra; (fig. 292 and 29'^). Fig. 296. — Tte patient may be dressed in a jersey, — two lathes underneath the jersey. <( Orthopoedic » corsets. The best from all points of view, are the corsets in celluloid (v. fig. 292 to 294)- It is better as I have said, to leave the rather difficult construction of these apparatus to special workers, and so, all that is left for you to do is to make a mould and fit the apparatus 3i8 POTT S DISEASE. CORSET I>' CELLULOID on. This, each of you Avill be able to do quite easily after having read that which follows : Fig. 297. — Placing in position the zinc laths which will serve as a protection when cutting the plaster. Method of taking a mould of the trunk. — The patient dressed in a jersey with laths of zinc in position (fig. 296), TECHNIQUE OF Mol I.HINC. THK TRLNK 6l(Y is supporleJ by ini>aiis of llic yirlli; but be careful liere to j^uard against u stretching » the patient until his heels lose touch Avilh the floor; the tension should be much less, say almost nil. if von wish In have an apparatus in Cflluloid fitting Fig. 298. • — • Application of the posterior attelle. very precisely. Instead of commencing the moulding by means of strips, — as was done for the ordinary plastered corset, begin by applying the attelles. The dorsal attelle is placed in position first (fig. 298); in order that its edges adapt 320 POTT S DISEASE. CORSET IN CELLULOID themselves better over the sides of the trunk, make, if need be, several notches in it. The anterior attelle and the cravat are applied in the same way as is done in the construction of Fig. 299. — The two attelles are in position ; flatten them out carefully over the skin. the ordinary plaster apparatus. Roll one or two strips over the attelles and between each layer of these spread a coating of plaster cream (fig. 3oo). Ml'.riKil) III' I \M\(; A MOI 1,1) OF TIIK TUUNK 'A 21 Tliis will sirongllien your nKnild. This dono, verify and roc- iHn. if iioccssary, lliG posture of the pal ion I. ^ Ou musl,iasll\ , Fig 3oo. — The attelles are held in position and adapted by a plastered strip. whilst the drying is proceeding, model the contours of the pelvis, and to do that, your hand must embrace very exactly the iliac crests, as has been described in the construction ol the plaster corset. Calot. — Indispensable orthopedics. 21 322 POTT S DISEASE. COUSET l.\ CELLULOID When the apparatus is dry, thai is to say at the end of from 5 to lo minutes, you cut it with a knife, following the zinc laths. After it is cut it is easy to withdraw the laths and to Fig, 3oi. — You divide ihe mould upon the zinc strips by means of a knife or a shoe-maker's tool. open the apparatus sufficiently to allow of it's being removed (fig. 002 and 3o3). When the moulding is completed, you carefully bring Ti:ciiMorr oi- moulding tiiiv trunk :wi togcllior' the sides of llic scclidii and keep lliciii in a|i|io-.ll ion eillifi' h\ eiiclosiny- llie avIioIc a|)|)aialns with seNcial luiiis of /^ fi^^ \ \ w \ Fig- 3o2. — The laths liave been removed; you commence to disengage the moukl from the right side of the patient. soft muslin bandage (fig. oo'\), or by applying a narrow plas- tered strip over the slit, covering the two edges. In this case, it is necessary to keep the edges in contact until the ])lastered strip is dry. By this method the form of the trunk will bo reproduced verv exactly. 32/, POTT S DISEASE. CORSET O CELLULOID For greater security, you might — as we have already indicated — pack the interior of the mould with paper or with wood shavings. The mould Avill take 2 4 hours to dry coin- Fig. 3o3. — The mould is taken off as you would take off a ^Yaist-coat. pletely; during that time, you will hang it up, or at least you will support it upright, for should it rest on one of its faces, it will run the risk of flattening and becoming out of shape. ruiAI. OF THE CELr.LI.OII) CORSET :w. MoulilliKI (I ci'l/ii/diil Willi i>i> l^ >i"^ (^^^^ "I" '"'" f'i"«'»^l'l"iES 333 shewing no signs of having bulged, not even by one millimetre, for more than a year. Rcmcnibci- lli.il il is b.Htcr to err by excess ralhcr ll.an by dclaultol-piccaulioas; c.Mitlnue ihcuseofthe apparatus two years too Ion- rather than disconthmc its use two months too soon. \ucl then, when it is taken off, it must be taken off onl.N te.nporarilN. for a dav or two at the commencement; tlierefore look at the patient pretty often, and at the hrst sign, that is Jo say at the first pain or slight visible flexion of the back, replace the apparatus for a fresh period of two years. 6. Old Gibbosities. I have not advised practitioners who are not specialists to undertake in a general way the treatment of extensive and old gibbosities, and have explained why. It does not follow that a specialist can do everything in these cases. He will succeed (but at the price of what efforts!) in effacing, m course of time, 2/3 or 3/4 of the gibbosity, even when it isankylosed. We know in fact, that ankylosis is never complete before a number of vears. On the other hand, experience allows us to aflirm that it is possible, even when ankylosis is complete, to modify, in 3, 4, or 5 years, the shape of the osseous block, provided that the patient is a child whose grow th has not ceased. In fact, the osseous block undergoing from the fact of our treatment, a continuous pressure behind and a relaxation m front will finish by becoming atrophied behmd and hyper- trophied in front. We are able thus, in avery notable degree, to regulate and direct its development, to steer it in a direcl^ion opposite to that it would have followed if it had been left to itself For cases of verv large and old gibbosities, one can say m all truth that the mare the treatment is prolonged, up to the end of the growth of the patient, the nearer it will approach perfection, without of course reaching it. Ihe length of treatment here depends then upon the result we are striving for. In subjects who have arrived at the eal of their growth - 334 POTT S DISEASE WITH ABSCESS when the gibbosity has become welded — there is nothing to look for in correction; one would gain nothing or next to nothing. B. — TECHNIQUE OF THE TREATMENT OF ABSCESS An abscess exists ; you know where and how to find it. I have mentioned in what case to abstain from interfering H.F Fig. 317. — e. i. anterior iliac spine. — e. p. pubic spine. — P. point of election for puncture. with, and in what case one ought to treat, an abscess. To treat it does not mean to open it; that, never ! It is especially when it is a question of abscess due to Pott's disease that it is not advisable to open it nor allow it to open, because here, more than anywhere else, to open it may mean, and most often will mean, death. ESPFCIAM.V NEVEK OPEN ABSCESSES ;^;i5 If Poll's discasL' was so of leu falal in funncr limes, il was because the abscesses Avere opened. And if Poll's disease of ihc luiiib;ir Nciicbr.r was considered as more serious iban Pio-, 3i8. — e. i. anterior iliac spine. — e. p. pubic spine. — i p. pubic sj-mphysis. a. c. crural arch. — c. s. spermatic cord. — v. bladder. — o. urachus. — p. sacral promontory. — i'. ;. iliac vessels. — c. p. pelvic colon. — c. /. lumbar colon. A' A' abscess of wallet shape. — P. point of election for puncture. Pott's disease of the dorsal vertebrte, the former being nearly always fatal, Avhilst the latter was scarcely ever so, it was due onlv to the fact that the first is accompanied by accessible abscess which one Avould hasten to open, whilst the second, presenting no perceptible abscess, would escape the bistoury and it's disastrous consequences. Therefore, the sovereign dogma, the untouchable dogma, is 336 POTT S DISEASE AVITH ABSCESS never to open an abscess in Potls's disease. The results of operative surgerv in such cases are mainlv disastrous. And of Fig. 3ig. — Abscess by gravitation. — On the left side, the abscess has invaded a considerable portion of the internal iliac fossa ; on the right side, the pus has followed the psoas beneath the crural arch and formed a sac on a level with the lesser trochanter. The needle has been pushed against the upper edge of the arch, into the pelvic sac of the abscess. all operators, the most brilliant, the most audacious, the most intrepid, will be here the most dangerous. MO NOT TOUCH DEEV ABSCESSES 337 ^^'llal must be done then? Oh I it is very simple. I Itlir abscess remains deep and not easily accessible, do nolliing, wail. Two things may happen; eitiier it will be reabsorbed spontaneously, oril will grow larger Fi^. 320. — Two abscesses of wallet form. On the right the abscess is gripped under the arch and is pointing at the inner aspect of the Ihigh ; on the left, it has passed through the great sciatic foramen and found its ^YaY into the fossa. To puncture at S S' would not always be sufficient: it would be necessary to punc- ture also at P, on the right side, close to the arch. On the left, treat the sac S' and compress it: if the pelvic sac is not cured, the pus will collect gradually in the internal iliac fossa where vou will be able to attack it in course of time. and become accessible. From this moment, and without Avaiting for it to involve the skin, treat it by puncture and injection. I have only a word to add a propos of the peculiarities which abscesses in Pott's disease present. I" The abscess in Pott's disease may, strictly speaking, be Calot. — Indispensable orthopedics. 32 338 POTT S DISEASE AYITH ABSCESS infected from the beginning, independently of any surgical inter- ference, small or great, independently of any fissure in the skin. The infection then comes from Avithin, from the contiguity of the intestine (fissured or not). But be not afraid for you will Fig. 32 1. — Puncture of an iliac abscess, through an opening made in the plaster apparatus, — one will push aside the flaps of jersey, and carefully protect with compresses of sterilized gauze, the edges of the opening, as was represented in figs III. 122 and i2/|. (chap. IIIJ. scarcely ever see this, as personally, I have seen it but 6 times in 20 years. Signs of infection : Evening fever with marked morning remissions ; the contents of the abscess becoming sanguinolent, of the colour of tomato, or of wine lees. Try to reduce the temperature by punctures without conse- cutive injections. I succeeded once, and in five other cases, to overcome the fever, I was obliged, after some time, to 1)0 NOT PLNCTLKE L .NLK>S TIIi: ABSCESS IS EASILY ACCESSIBLi: 33(» opcii the ahscess. Indeed, tliis opening nuut nol be delaNed too long as llie viscera iniglil. in course of lime, become irre- mediably infected. Therefore, when I lie fever has persisted for 1 3 days, and you are certain it is not attributable to any inter- current malady, do nol wait, open and drain the abscess. Then Iroal a< for infected li"EAR TO BLOOD VESSELS o'^diy \Yhen an abscess presents a principal sac and several diverticula, puncture the sac or diverticulum which is most acces- sible, making sure that you empty the entire abscess. If not, make punctures and injections into the large cavity as Avell as into the diverticula. Peculiarities of Technique according to the seat of the abscess. A. The abscess is situated near to blood-vessels. At the fold of the groin, or in the cervical region (fig. 107 to lAo, p. i/ig). Fig. 828 . — On the right, a large abscess has invaded the whole of the iliac fossa and pushed inwards the intestinal mass so that there is no risk of wounding it by puncture. On the left the needle P. has been pushed in, close by the iliac spine ; its point travels, grazing the bone (following the dotted line), into the puru- lent collection. B. Abscess of the iliac fossa. — You will generally interfere only in the case of very ^superficial bulky abscess, that '2'". ir.l.VC VHSCESSP.S 34 1 is one ill wliicli \i)u can introilucc llie needle williouL having Fig. 324- — Abscess in Petit's Iriaagle (ligured on (he left by cross-liatchins;). anything to fear — I might even say anything to avoid. But it may happen that one is unwilhng to wait T for the collection coming so near the skin, because that requires some- Y\ivvck&[ixoij.fi. )) co-i ■ c\A\\. Fig. 325. — A. Abscess of vertebral origin siluate.l behind the periosteur B. Glandular abscess situated in front of the periosteum. 342 POTT S DISEASE. 2"". ILIAC ABSCESSES times one or several years. It is allowable to expedite matters provided however that the ahscess is ah'eady suffi- ciently large — as large as the closed fist, for example, — and »i- - Puncture of a retro-pharvngeal abscess occurring m the body of he 'third cervical vertebra and not manifesting itself by any clinical sign m the lateral parts of the neck. - M. Inferior maxilla. - L. Tongue. — ^ ^ ^^- tebra. - p. v. n. carotid sheath. - The needle is pushed in front of the transverse process, it grazes the bone, taking first the direction i, then the direc- tion 3. everywhere, is nearly always fatal, death being due to infection. Do not touch them, unless your hand is forced by acci- dents of disphagia or asphyxia — in which case you should not open the abscess, but you should puncture it. You puncture it through the lateral parts of the neck, even when the abscess is not perceptible there. 344 pott's disease. — 4™- retro-pharyngeal abscesses Technique of the puncture of retro-pharyngeal Abscess. To be quite sure of the immobility of the patient, anaesthet- ize him (unless you are dealing with a very reasonable adult). You puncture against and in front of the transverse process Fig. 828. — To show the track the needle follows : we^have made on the cadaver some dissections of the region after the needle was introduced; one sees that it has penetrated within a hair's breadth of the anterior surface of the vertebrae, passing behind the prevertebral muscles ; the carotid sheath which was lying in front of the muscles has been pushed inwards and forwards to allow of the point of the needle being seen. of the axis, or of the 3"^ vertebra, which one feels quite easily (fig, 826); the needle grazes the bone and remains consequently well behind the vessels from which it is separated by the small prevertebral muscles (longus colli, rectus capitus anticus and obliquus superior) and thus arrives at the collection (fig. 827 and 828). Puncture, then inject oil, creosote and iodoform rather than naphtol, because a single injection of oil is often sufficient to cure the abscess 1 uiA I \iK\r in" I'lsri I, i; in i'(>ii'> disease 3/io (iinil N.iu will raivl\ li;i\e to repeal ihls delicate opeialioii ). Duration of treatment of an abscess in Pott's disease. The cure may be oblaincd in two inonlhs ; but il is iiol neces- sary lo go so quickly, lake rallier 3 or 4 months by making a punclureevery i5days(which obviates all fatigue lo the paticul). Will the abscess return ? — No. scarcely ever, provided that the general health is good and that you do not allow the |)a- tient to walk about before 6 or 8 months. If it should return. you would treat it in the same way. What is the effect of treatment and cure of the abscess upon the treatment and cure of the Pott's disease? AMien the abscess is found to be in communication with all the affected vertebral bodies, it is evident that the liquid injected into the abscess cavity will touch all the affected points, penetrating the tuberculous granulations, dissolving them (naphtol), or transfor- ming them into hard tissue (iodoform) and by it's repeated and continuous action, completely improve the condition of the advancing osseous focus and thus ensure the cure of the vertebral focus itself. It is certain then that from the point of view of duration of the disease, one gains something by having an abscess by gravitation. C. — TREATMENT OF FISTUL>€ IN POTT'S DISEASE We have described, page 225, how infected hstulas are distm- guished from non-infected. In the non-infected fistula, make modifying injections of creosote, of iodoform and of camphorated naphtol. in the form of liquid or of paste, — as Ave have explained in chap. Ill (V. p. 17G). In the infected fistula, on the contrary, do not make modi- fying injections, they w^ould be harmful. In such cases, if there is no fever, you must learn to patiently aAvait the closure — with, as the only treatment, aseptic dressings, rest, over-feeding and a sojourn at the seaside. 3li6 TECHNIQUE OF THE TREATMENT OF POTt's DISEASE li the fever exceed 38.5° and persist beyond several weeks, endeavour to reduce it by improving the drainage of the pus. But take care (even if the drainage is not suificient) not to have recourse to great surgical interferences, on the pretence of making radical cures,' because those operations give twenty times more chances of aggravating the infection and the fate of the patient than of ameliorating them. Primo non nocere : an operation, necessarily incomplete here, would redouble the septic absorption and infection. \^'hilst if you do not operate, you leave the patient with a chance of cure. Sometime, indeed, you will see him cured. Too often, we shall be powerless; the fever will persist and Avill, little by little, in several months or several years, cause in those patients visceral degeneration and death. For this reason, I wish to repeat it over and over again, you must do all that can be done to avoid fistulaj — namely ; never open an abscess, and, by every means, prevent it opening sponta- neously. Nevertheless, all the fisluke in Pott's disease have not the same sombre prognosis ; it is much less rare for example, to see those of the neck cured than those of the lumbar region, owing to the relatively superficial jDOsition of the vertebral bodies of the neck, whence the greater facility of complete drainage in that region (v. p. 3 2 5). Orthopoedic treatment of fistulte in Pott's disease. Plaster the patient in order to immobilize the affected focus and to lessen pain, Avhich is often severe. The apparatus should have an opening in it to allow of dressing — or it may be bivalve and removable (v. p. 35o). Medical treatment of symptoms : if there is albuminuria, milk regime. If there is fever, cryogenine, etc. D. — TREATMENT OF PARALYSIS IN POTTS' DISEASE The indication, as I have already pointed out (p. 270), is to remove pressure from the cord. I HE TKEATMENT OK PA UAI.\ SIS. 'ill'] By so dniii-. llit^ causes df lln' paral\ sis cxtriiial Id llic cord are acted on. as well as llic iniliirHin of llic cord ilsdl. Thai is olTecled siiiipix l).\ llic application of a large plasUr. There is already relief IVoni the pressure on the cord by the slight extension made daring the application of the plaster, and Ihis relief isfurlher augmented b) the pressure made afterwards upon the gibbosity. The apparatus should be constructed a\ ilh the Irunk in a vertical position, but supported (v. fig. 246, p. 278), as shewn by my assistant, D"^ Privat, in such a way thai there is not too great traction on the head. Complete suspension would be painful, badly borne, and might give rise to sloughing. If, on the other hand, the patient remain seated, he will not be fatigued, aud you can leave the apparatus to dry with the trunk in the vertical position. That is a good condition for its being correctly applied and producing its full effect, besides causing no injury to the tissues, generally in a poor condition. When the paralysis has reached up to the loins, sores may appear on a level with the pelvic girdle if the plaster is not very exactly applied, and produces, by its roughness, abnormal pressure at certain points. Note that in the case of incontinence of the intestine and bladder, the plaster is easily soiled. It is necessary to take a thousand slight precautions to avoid such soiling and, from time to time, to take off the softened portions and replace them by new strips and new plaster scjuares, by Avhich means it is possible even in the case of extensive paralysis, to preserve the apparatus which is so useful in relieving the spinal cord. Treatment of symptoms. — If there are contractures of the limbs, you may combat them by continuous extension, <5r bv small plaster apparatus. You contend against constipation by suppositories, simple enemata, etc., and against bladder retention, by diuretics, which suffice nearly always, without catheterism (V. p. 7^, the treatment of sloughs). 348 SUB-OCCIPITAL pott's disease SUB-OCCIPITAL POTT'S DISEASE Authors devote a special chapter to the treatment of this particular condition. That seems to me perfectly useless, for there is nothing about it which is not contained in the prece- ding pages, either as to orthopedic treatment (see : large apparatus), or as to the treatment of abscess (see p. ikl retro- pharyngeal abscess), or as to the treatment of paralysis. POTT'S DISEASE IN AN ADULT In the same way we do not see any necessity for adding a chapter on Potts' disease in the adult, in spite of its great frequency (even at an advanced age). It is sufficient to know that the absence of gibbosity is less rare in Pott's disease in the adult that in that of the child, — that the disease is announced more often by spinal pains or girdle pains of terrible acuteness. — that these pains may precede by several months, and even by one or two years, the appearance of the gibbosity, — and that such unexplained sufferings should make you think (even without a gibbosity) of a possible Pott's disease, for the other signs of which you will search. |(see diagnosis p. 246). Think also of Pott's disease, in the presence of every cold paraspinal abscess, or of paralysis supervening without appreciable cause, in an adult as well as in a child. The treatment is the same as in children. It is necessary however for us to accord special attention to these cases of Pott's disease in the adult which go on for eight, ten or fifteen years, with girdle pains or pains in the members, remittent or continuous pains Avhich produce the effect of rheumatic pains. (This form is seen also in children, but much more rarely than in adults). What is to be done against this, fortunately, exceptional form? poll's I)l-r.V>i: l\ I HE ADULT 3^9 N\ (' cannol coiiJl'iuii tliese patients to Ihe rcciimljont po- sitiiin tor fifteen years! Lcl llum walk aboiil, but not without a f;oocl corset, and forbid all fatigue. You will contend directly against the symptoms of pain hy counter-irritation over the spine or over the limbs, by cautery or continuous extension of ihe lowf r limbs, made during the night, etc. AA e shall sec thai these forms of dry caries which persist indefinitely, can be found in other parts of the skeleton. But, in the spine, the pain mav be due to anotber cause. Treatment of gibbosities in the adult. a\ Gibbosity which is in progress (with all the sign* ol' a vertebral focus still in activity) : one arrests and corrects it as in a child. 6) Gibbosity already ankylosed (one which has not increased more than a millimetre lor at least two years, but which offers at the same time the other signs of an extinct Pott"s disease) : there is nothing or almost nothing to hope for in attempting it's correction . — But you will never ihcless put on a corset if tlae patient complains of erratic pains, in order to endeavour to attenuate them; for it is possible even in Pott's disease which is ivelded and extin- guished, to have neuralgias of the trunk and of the members, due to pressure on the nerves at their exit from the spine, — the cause of the pressure persisting for a longer or shorter time after the cure of the tuberculous focus. The bivalve plaster iv. p. 158") renders some service in adults intolerant or emphysematous. POTT' DISEASE CO-EXISTENT WITH OTHER TUBERCULOUS AFFECTIONS (hip disease, etc.) In all tbese cases you Avill treat the Pott's disease by a corset (plaster, at first; celluloid, later). If it is a coxitis v. p. lyl) without pain or deformity, exten- sion will be sufficient to keep the leg in good position. If, on the contrary, there is pain and deformity, make a plaster Avhicb vou Avill join on to the plaster corset. In all other cases (v. p. 667) you will carry out the treatment of the two aflec- tions at the same time. 35o THE REMOVABLE PLASTER CORSET APPENDIX TO CHAPTER V Three additional notes upon the treatment of Pott's disease. 1°' The removable plaster corset. It is very easy to construct. Make an ordinary plaster corset, using cold water without salt, and ^Yllen dry, after a few hours, or the next dav, divide it by symmetrical lateral incisions, into two valves, anterior and posterior, (fig, 329.) To avoid the risk of damaging the skin in cutting the plaster, vou will Fig-. 829. — A medium bivalve plaster. place over the jersey, at the level of the four lines previously chosen for the incisions, woollen strips, or better, zinc strips, the same as those used for moulding. The jersey, Avhich remains adherent to the inner surface of the apparatus, will serve as a natural lining. In order to apply the removable plaster corset, you replace the t\^ o pieces, so that they are in perfect contact at their edges, and you keep them so either A>ith straps, or with some turns of gummed muslin, moist and squeezed out; better still with laces passing round dressmaker's books. These are stitched to strips of linen which have been fastened to the edge of the apparatus ^A"ith A WolU) UPON SLOUGHS 35f (lie [il.i-lor cr.'ain, or w illi silicate, or even nilli oi-Jiiuir\ glue. [I'lg. 288.) ^ nil slioiilil ii-f the rcinovaI)le apparatus only in very limited cases, uamel>. wliea lliere arc numerous fistuhe, or a skin needing daily attention, or again, in an emphysematous or neurotic person who will only be able to become accustomed to the plaster gradually, keeping it on at the ber'inniii"- for a few hours only every day. 2'"'. Upon sloughs. We have described (p. 72) what are their causes, their situation and their treatment. ^\ e have only one more word to add here. If the slough is situated over a gibbosity, do not cease compression for a single day; for, if the compression is regular, it will not hinder the cure of the child, and thus you will have lost nothing froua the point of view of cor- rection of the gibbosity. If the slough is situated at the chin, vou make a Fig. 33o. — Strip of linen with hooks wliich you glue to tlie edges of the plaster. 33 1. — Removable plaster, completely finished. notch in the plaster at this point to allow of its dressing anticipate. All this 3''^. On the use of chloroform in applying the plaster. Sometimes little children throAA themselves about violentlv under the sustension apparatus; to prevent traumatism of the morbid focus, anaesthetise tliem. lou may [>ut them to sleep in the upright position, held by the strap,. d02 NARCOSIS IN THE APPLICATION OF THE PLASTER immobilising firmly tlie head and trunk, during the first whiffs of chloroform. Contrary to what is generally thought, chloroform is wonderfully well tolerated in an upright position, when the chin is kept raised as it is by the i?trap. The last bandage being rolled, you lay the child on the table to dry the plaster, for if it should dry in the upright position, under the ana?sthetic, the trunk AAOuld be too much extended. ^Mience, a little risk of ulterior slough beneath the chin, (if you are preparing a large corset), and the appa- ratus would perhaps be too tight. li ou may also, in order to lessen the traction produced by the weight of the Ijody, put children to sleep, and apply the plaster in the sitting position rather than in the upright. That will be better so. Restless children will (like cases of Pott's disease with paraly sis) be kept seated on a bicycle saddle as represented in fig. 2/15, p. 278. CHAPTER VI HIP-DISEASE A word on the symptoms, the prognosis and diagnosis of hip -disease Hip disease is tuberculosis of the hip-joint. The minute tubercle may rest silently for several months, then, one fine day, it makes itself known by certain pains in the hip or the knee, or bv a slight limp (due to cramp in the peri-articular muscles). Clinical characters. A. Deformities. — The pains and the limp, intermittent at the beginning will soon be almost continual: and a deformity appears, scarcely appreciable at first, then very distinct. There is a saddle-like curve in the lumbar region, produced by a flexion of the thigh; there is a slight lengthening of the leg. produced by abduc- tion of the thigh. Thus, at the beginning of hip-disease, the affected leg appears to be the longer, because it is in abduction. Later, the affected leg ■will appear the shorter, because it -will be adducted. At the last period of the disease it will often be really shorter bv reason of atrophv of the bone and partial destruction, or even complete destruction, of the articular extremities. B. Abscess. — The tuberculosis may break down the barriers of the articulation and be carried towards neighbouring parts, in all directions, leading to abscesses Avhlch, if they are not prevented, will cause ulceration of the skin and open outwardly, producing fistulas. C. Fistulse. — These easily become infected, whence there is danger to life, not so great, however, as in the case of fistulse in Pott's disease. D. Luxations. — Bv reason of the wearing away of bone and the articular dislocation which is brought about by the tuberculous Calot. — Indispensable orthopedics. 25 354 ITS PROGIN'OSIS process, it may produce, not only deformities, but veritable luxa- tion of the femur upwards and backw ards. The disease will thus terminate -with deformity and very ugly Fig. 332. — Normal hip-joint. — The relations of the crural arch and the artery ^Yith the skeleton. shortening unless the patient is carried oflf by the visceral degenera- tions caused by the infected fistulae. What one knows very well, however, is that hip-disease does not follow this course unless it has not been (at least not carefully) looked after, and that, even in the case where it has not been treated, it may be arrested spontaneously at some one of the stages indicated above. Prognosis. But the prognosis of hip-disease changes altogether when it is well attended to. i^'. We can prevent or correct the deformity and thus prevent luxation. 2"'^. We can prevent the opening of abscesses, which means the formation of fistulse ; and in doing away with fistulae we do away also with the great danger to life which threatens the patient. PROGNOSIS ACCOKDING AS IV IS TUEA lEI) Oil NOT 355 3"'. ^^ c can prevent llie tieslruclion of the aiiieular exlivini- tics in liip-discase taken in hand at the bei^'inning. But that whieh wo are unable to prevent absolutely in every case, is tlie slillcning ol" the hip joint, or again, the formation of an A'-' Fig. 333. — The normal liip joint. — Relations of the head of the femur to the vessels. — The stippled part above the accessible zone of the head represents the cotyloid ligament. — The t^vo thick dark tracks are the artery on the outer side, the vein on the inner. — The artery crosses the head at the junction of its inner third and outer two thirds. abscess and the production of a certain amount of atrophy of the bones of the lower limb, the consequence of ^vhich is slight shortening. Nevertheless, shortening and ankvlosis ^vill not supervene, except in neglected patients, and in some cases of hip disease of a serious character: in the other cases we can. if we have attended to the patient very early, secure him a normal or reasonably normal limb: moreover a coxalgic, cured with a shortening of one or two centimetres and a stiff hip joint, is able to walk well (for a length of time and correctly j. 356 HIP DISEASE. ITS DURATIO>" The duration of the disease. It lasts approximately one year in the benign forms ; from two to three years in the ordinary forms ^ , -with or AA'ithout abscess — and 4, 5, 6, 7, years and more in certain forms of dry caries without Pectine. V. fern. Bourrelet. A, fem. Capsule. Psoas. Couturier. Dr. ant. Tens. f. Fig. 334 — Normal hip joint. — Horizontal section of an upright subject through the line A. B. in the preceding figure. abscesses, which progress Avitli an extreme slowness and seem to go on for ever. Diagnosis. It is only difficult sometimes, at the onset of the disease. Aphorism. — When you are consulted Avith regard to a child or an adolescent Avho, without appreciable cause, has been taken with limping or pain in the hip or in the knee, think of the possible existence of hip disease and satisfy yourself of the correctness of your diagnosis, by examining the subject completely naked. I. We shall see that with early injections the duration of hip disease is reduced by more than two thirds. DIAGNOSIS OF COMMENCING COXITIS 357 Make him lie Hal on a table and Unci out if jie has pain on pressure of ihe hip, or a limitation of movement, particularly of the movement of abikiclioii. Fig. 335. — a. Femoral artery. — z. Zone, outside the artery, \Yhere one must press in seeliing for pain on pressure of the head of the femur. Fig. 336. — One presses with the index finger in searching for the pain. 358 HIP DISEASE. DIAGNOSIS. I*\ PAO ON PRESSURE OVER THE V\ Look for pain on pressing the head of the femur (v. fig. 335 to 337). Run your index finger in front of the suspected hip joint, along the fold of the groin, at one centimetre outside the \ Fig. 337. — Examining the sensibility of the head of the femur hy pressure over its outer side. The index finger is pushed inwards at a centimetre above the upper border of the trochanter. femoral artery which you will feel beating. You are right over the head of the femur. Fig. 338. — Tiie second sign of any kind of arthritis of the hip. Here onesees limi- tation of abduction on the right side (affected side) compared with^ extreme abduction on the left (sound) side. Press upon it gently : if the patient gives a cry it is useless to persist ; otherwise, press more firmly, until the patient complains. iiL.vu ui' THE fi:mi'k : •.?"". limitation of abduction 359 Antl find if, on making an idontic;il pressure over the liead of the fonmr of lln- other side, al a svniinelrical point, you provoke an cxacllv similar sensation there . Do this again, if need be, live limes, ten limes, pressing first on Pijr 33f,. — Limitation of movement of flexion represented bv the dotted line. — The Iprinted lines show the extreme normal flexion. the one side, then on the other until \ou are certain whether there is or is not a difference between the two sides. 2"''. Search for limitation of movements (fig. 338, 339, 34o). — Fia. 3^0. Limitation of movement in extension and the manner of making the examination. You fix the pelvis with one hand and with the other you take hold of the knee, the leg being flexed on the thigh, and you move the limb in difl'erent directions up to the extreme limit of movements possible : flexion and extension, etc. For abduction, you commence the movement by a direct flexion of the thigh up to an angle of 90^ ; then, from that "you move the thigh in abduction, as far as possible. 36o HIP-DISEASE AT THE ONSET. DIAGNOSIS Compare the extent of the movements on the two sides : then again Fig. 341. — Lengttening of the affected leg right . Notice there is no longer only arthritis of the hip of some kind, but true coxitis. repeat the proceeding, ten times if necessary. If there is pain on Fig. 3^3- — Atrophy of the thigh, another important sign though not pathognomo- nic), of true coxitis. The thickening of the skin is the indication of this atrophy of the thigh. The cutaneous fold is thicker on the affected side. Fig. 3^2. — Lowering of the fold of the buttock on the side affec- ted indicating also lengthening. On the other hand, the projec- tion of the trochanter is more marked on the sound side. Fiff 34i. — Cutaneous fold thinner on the thigh of the sound side. PATUOOOMOMC SIGN •ENGTHEMNG OF THE I.IMH 30 I pressure, aiitl a limitation of the movement of abduction, }Ou ina\ lie sure llial the hip is diseased. Hul liow do Noii know il is real coxitis? Fi". S.'io. The most Ircquenl conclilion — Lumbar hollowing and flexion oi the knee, verv apparent on the first examination. By the existence of lengthening (apparent) oT ihc ailccled limb. 3'"''. Look for lengthening of the limb. (Pathognomonic sign.) (Fig. 34i and 342.) Fig. 3/|i3. — The same. The hollowing is more pronounced when the knee is pressed upon the dotted line indicates the original hollowing . Without paying particular attention to the position of the two iliac spines, bring the two heels together and see if the internal Fiff. 3/17. _ The same. The hollow disappears on Hexing the knee further ^the dotted line indicates the original hollow "l. malleoli and the heels are on the same level. If there is a difference of a few millimetres, that suffices to confirm the existence of hip- 36: HIP-DISEASE. DIFFERElVriAL DIAGNOSIS disease, at the outset ; for later, we repeat it, there is, on the contrary, shortening of the alTected side. Failing the characteristic lengthening, you will make the dia- gnosis hy the existence of some small glands in the groin of the suspected side, by slight atrophy of the muscles, or thickening of a fold of skin on this side (fig. 343 and 344)> by the absence of any history of injury, or of scarlatina, or of rheumatism, by the insidious onset and the characteristic inter- mittence of the symptoms, by the general condition and the bad antecedents of the patient, etc. In doubtful cases, reserve your diagnosis and ask to see the child again. If then \ou find, after a fcAV weeks, pain on pressure and limitation oi' movement, you "will conckidc it is hip-disease. Differential Diagnosis. a. Diseases not affecting the hip : White swelling of the knee, or sacro-coxitis, or Pott's disease. You must always think of these, that is to say that after examining a hip-joint, \ou ought to examine the pelvis, the lumbar column and the knee. If the disease is situated in those regions, it is there and not in the hip that you Avill find the most apparent characteristic signs ; pain on pressure over the bones, limitation of movement, etc. b. Other diseases of the hip-joint. Osteo-myelitis of the hip begins with great constitutional disturbance and a temperature of from 39° to 4o°, etc. Infantile Paralysis. There is no rigidity (on the contrary abnormal laxity), no pain on pressure. — Atrophy and enfeeble- ment of muscles greater than in hip-disease. The history. Congenital Luxation. The affected leg is not longer but shorter ; Fig. 3i8. — The same. — Riglit coxi- tis. — Abduction and lengtliening very apparent on standing upright; the patient bends naturally the linee on the alTected side. lIll'-DISEASn. DiriEUKN'l lAI. 1)1 AONOSIS S6S llio child N\as laic in walkirii;, lias always had a sliirht limp, a sort of dip; no pain. Von no longer (col the head of iho fomur in froiil a^ainsl ihc arlcrv ; at its usual place there is a void, but one can feel the head more or less displaced, outwards and upwards, against the anterior superior iliac spine (v. fig. 789). Fi^. S.'ig. — Verv marked deformity, in abduction, lumbar 1io11o\y and flexion of the knee. Hysterical Coxitis... But this is so rare!... Do not deceive yourself! it nearly always masks a true coxitis. Rheumatism. In the hip as in the spine, mistrust those mono- articular rheumatisms Avhich seem to last for ever. The same Fig. 35o. — The same. The hollow is elTaced when flexion of the knee is increased. remark applies to the so-called '• growing pains " . How many true hip diseases have been, at the beginning, mistaken for rheumatism, growing pains, sprains ! However, do not exaggerate the difficulties of diagnosing coxitis. In realitv, there is generally none in practice. A\hen you are dealing with a true coxitis you will nearly always notice at your first examination (beside the signs Ave have indicated above) : 364 HIP-DISEASE. THE ANATOMICAL LESIONS i^', a ver\ apparent lameness; — 2""*. a vicious attitude characte- rised by flexion of the thigh and a lumbar hollo^v, together with abduction of the limb (fig. 345, 346, 347, 348, 349, 35o): — 3"^. a fungous puffiness of the region of the joint; — 4"'- fi limitation (more than a half) of the physiological movements; — 5"'. very evident pain on pressure and on movement, etc. ; that means that you will find nianv more signs than are necessarv to confirm the existence of hip-joint disease. A WORD ON THE ANATOMICAL LESIONS BASED LPO-\ RADIOGRAMS IN MY COLLECTION ASD ON THE THESIS OF MY ASSISTANT AND FRIEND D' FOLCHOU Siir la Radiographie dans la Coxalgie, Paris, 1906. All you liaNC to keep in mind are the following ideas : — Placing yourself at the practical point of vicAv, you may consider in hip-joint disease two anatomical forms : one Avhere the contour of the joint and the bony formation are entirely preserved; the other where there is a softening of the head and roof of the cotyloid cavity Icachng to a gradual breaking down of the osseous extremities, in the course of 2, 3, 4, 5 years. The first form terminates without shortening, but the second leaves an inevitable shortening Avhich extends generally to 3 or 4 centimetres. Let us go into details. The first variety comprises the benign and recent cases (see further on upon hip-joint disease ot V' form.) which have been well cared for from the beginning; here, the lesions are always synovial and the bones are scarcely « touched «, if I may say so, by the tuberculous process (fig. 35 1 and 352). The second variety is more frequently the actual condi- tion of things ; it comprises hip-joint disease of the second, third, fourth, fifth and sixth form. The tuberculosis here is more serious, either because from the onset it was essentially more malignant, or, chiefly, because it has not been looked IIll'.rOlNT DISEASE. TlIK AN.VTOMICAL LESIO.NS 365 after from the first hour of its existence, or else, it has been badly looked after. Fig. 35 1 . — Radiogram of a case of left hip-joint disease of the first form, without anv appreciable osseous lesion, in spite of the fact that, clinically, the diagnosis, was not in the least doubtful. It was very probably a coxitis exclusively sj-novial . Fig. 352. Another case of left hip joint-disease of the first form. There is no alteration in the contour of the bone, but only a diffuse decalcification on this side shewn bv a lighter shade. — The femur is in abduction. 366 HIP-JOINT DISEASE. DESTRLCTIO.X OF THE BONY Tuberculosis sometimes excavates one or several small Fig. 353. — Schema of the osseous destruction in the and, 3rd, 'ith and 5th forms of Hip joint disease. From the primitive core, the destruction spreads by successive concentric zones as far as the iliac bone and the upper extremity of the femur. Ihe total wearing away of the two extremities generally measures three or four centimetres and it may attain five or six centimetres or even more in some cases where the head and neck of the bone disappear almost entirely, ^^'^"■y y^ar brings about a mean destruction of from 3 to 5 millimetres in each direction but the softening has a progress more or less rapid. The figures indi- cated here, have, of course, not an absolute value. -caverns on the surface of a bone, but this is rare ; more often it produces tuberculous infiltration which rarefies and softens i:\iiii.Mi rir.s is iiii; nuscii'VL cause ok siioit iKMNf; 30'- (like damped sujiar) iho licad ol (he iViiiiir and llie looC of the acelahulmii. nr pciliaps it is a qucslioti of a rarol'\ iiij,'- oslcilis of the neighbouring parts, \vhi(h is not Inbciculous. hut has been produced round a minute bacilhu\ Incus. From the lad of this softening, the bones do not suddenly break doAvn but are worn away gradually to a depth more or or less great. The wearing aAvay is produced especially if the child walks about, but it is also produced, althoufiih in a less degree, even in children who are kept at rest. There belong to this second form, as we have said : i*\ Cases of Hip-joint disease of the first variety, that is to say, cases of hip-joint disease which come on with spontaneous and very severe pains, or with a displacement of more than 20". 2°'*. All cases of hip-joint disease of the following forms (which are in reality only coxitis of the second form in a more advanced state), namely, cases which have suppurated or are fistulous, and those of the dry carious form. The progress of the lesions and the progressive Avearing away of tissue in the second form may by represented schematically by the figure opposite (v. fig. 353). AAithout reckoning the examples of extreme destruction which fortunately are exceptional, one may say — and this is what I wish you to remember — that at this present time and in more than three quarters of the cases of hip-joint disease cured , we observe a general wearing away of from 3 to U centimetres. There is in this evolution of osseous tuberculosis something special to the hip-joint, and which we have not found in white swelling of the knee, nor of the in-step, where the bones do not decay and always preserve their outline. \A e ought to add that this wearing away of bone is seen especially in the hip disease of children. In the adolescent Avho has completed his groAvlh, the bone Avill resist much better, and sometimes com- pletely, the wearing and destructive process. You will see later on (p. 385 and folloAving) that the only means truly efficacious of altering this cAolution of the tuber- 368 RADIOGRA.MS OF HIP DISEASE AT DIFFERENT PERIODS \ i '^-^^■'^ . i \ 1 1 Fig. 35/1. — Right hip disease at the beginning ; marked rarefaction of the osseous tissue, which appears lighter on the affected side. The articular interline is much less distinct. Fig. 355. — A more advanced type. Right hip disease ; notable -wasting of the head and neck of femur, and of roof of acetabulum. Moreover, outside the trochanter, there is a dark patch, which was found on clinical examination to be a small abscess. Fig. 356. — Left hip disease ; Rad. n° i The superior edge of the aceta- bulum is eroded as if scratched with the nail ; in the eroded space are seen two small sequestra. The epiphysial body is cut in two by a gap which runs from the cartilage to the interline. Fig. 357. — The same patient at the end of a year, after an abscess had appeared. The acetabulum is very much broken down, its superior border raised; the whole of the epiphysis of the head has disappeared. KADlor.RAM or HIP DISEASE SINGLE AM) DOLBLE 3G. Fig. 358. — Olfl hip disease of left side with abscess. Considerable enlargement of acetabulum bv complete wearing away of middle portion of iliac bone. From this destruction a kind of shrinking and telescoping of all the left half of pelvis has resulted. The head and two-thirds of the neck of the femur have disappeared. Fig. 359. — Double Hip disease without appreciable abscess dry caries). On the right. — The head of the femur and the upper half of the neck no longer ejtist. The middle part of the iliac hone, verv much softened, has given wav. causing considerable deformity of the pelvis. On the left. — Disappearance of the head of the lemur and enlargement of the cotyloid cavilv. Calot. — Indispensable orthopedics. 24 370 HIP DISEASE WITH AND WITHOUT ABSCESS Fig. 36o. — Another case on the right side. Erosion of upper part of head of femur. J. 36i. — Right hip disease without abscess (dry caries) . Complete necrosis of femur and considerable enlargement of acetabulum. Fig. 362. — Pseudo-luxation. Necrosis nearly complete of the head and neck, the normal limits of Avhich are marked by dotted line in the figure. There remains only a small stump formed by the infero-exlernal part of the neck. HIP DISEASE WITH ANKYLOSIS WD LUXATION 3-1 b"ig. 3G3. — Anotlier type more advanced; complete necrosis of the head and neck. Of the latter there remains only a small process in the form of a spine >Yhich is still in the cavilv. Fihrous ankylosis. Fig. 364- — Right coxitis. — T^ jps of osseous ankylosis in abducted position (osseous ankylosis is rare in hip disease) . Fig. 365. — True luxation. The head of the femur, or rather the^small stump >Yhich remains of it, is completely outside the cotyloid cavity (the femur is'generally turned round in external rotation;. 372 SIX VARIETIES. WHAT IS TO BE DONE IN EACH ? culous process in the hip and of preventing its destruction is to make articular injections, as soon as hip disease is recognised, that is to say, before the bones have been seriously softened. The ttiree preceding figures summarise for you all the lesions of hip disease. Those which follow are radiograms in some way illustrative of fig. 353. TREATMENT OF HIP JOINT DISEASE The treatment varies with each variety of coxitis,. — All the varieties may be considered with reference to the six following points : — I. Without deformity. 2. Deformity. 3. Abscess. l\- Fistula. 5. Dry coxitis, which maybe protracted. 6. Coxitis which is cured with a defect (shortening, ankylosis, luxation'). We will first define and illustrate in Part I the different varieties, and shew you the treatment suitable for each of them. In Part II we will describe in detail how the treatment must be carried out, that is, how to apply the technique. We will not describe the general treatment of tuberculosis. That you know : life in the open air, in the country or by the sea, for two or three years at least, if possible; good feeding; the 4ise of medicines recognised to be good for tuberculosis, etc. I. — P' PART. CLINICAL. — THE SLX VARIETIES AND THE THERAPEUTIC INDICATIONS IN EACH OF THEM. 1" VARIETY. — HIP DISEASE WITHOUT DEFORMITY Hip disease at the beginning, without deformity and without spontaneous pain (fig. 35i and Soa. p. 365). (Or with very little pain or deformity, for example, only from 10° to 20° of flexion or abduction). For all these patients, you will prescribe rest in the recumbent position for eight or ten months at least. You should never alloio a patient with hip disease to lualk. Patients must not be allowed to walk save alone those of I. We will describe later on double hip disease, coxitis with Pott's l liip disease, to look U>v llic prcservalioii of the arti- cular moveiiienis, when thai is leasible without compromising the cure that is to sax. in rhildnii who are well hjoked after. After Core. — The Irealnieiil once commenced, it will be sufficient for >ou to see the patient ayain once or twice a Fig. 367, — Left coxiUs, and. variety. — Extreme abduction. Cosalgia extremely painful. The child has been anwsHietised ; the redressment is about to be carried out. month. You continue the treatment until the cure, which you may consider accomplished in from six to eight months after the disappearance of all pain, spontaneous or on pressure. At this moment, you get the child up, helping it, in the first exercises in walking, by means of a removable apparatus m celluloid (v. p. 4/4, Convalescence). 376 2""'' VARIETY. HIP DISEASE WITH DEFORMITY 2°^ VARIETY. HIP DISEASE WITH DEFORMITY. Hip disease fully developed, accompanied with a mar- ked deformity (of more than 20"). Deformity occurs either in abduction (fig. 352) at the com- mencement, with lengthening of the limb and some pain ; or, later, in adduction (fig. 368), with shorte- ning of the limb and, most often, without pain. Generally, adduction does not occur until after a period of abduction ; this change of attitude may occur all at once, in one day, with some suffering; but, as a rule, it is pro- duced little by little, in several days, and with- out suffering. In these cases of deformity, there is one treatment only to be adopted, in town or in hospital ; the redressment of the hip joint — in several stages, if the parent object to anaesthesia — but better, with chlo- roform, at one or two sittings, each stage being followed by the application of a large plaster ' . The Functional Result to be sought for in this second variety. — In the diseased hips of the second variety (and in the three following varieties), one abandons the idea of preserving movement. One should have for the objective the cure with a stiff hip-joint, but in a good position. After Care, when corrected. The apparatus is changed about every four months. — The removal of the plaster and the toilet of the child are performed in the way described for Pott's disease. Take the opportunity when making the change to examine the state of the diseased hip-joint. Duration of rest (with the plaster), It will last until all I. For the second variety, as for the first, I advise you to make intra- articular modifying injections before or after the redressment, but more often before (v. p. 384 aVjout these injections). iinipie 5. 368. — S adduction (right hip disease) VARIETY. HIP DISEASE WITH ABSCESS 377 |>aiii liasdisa|)pearo(land even six or ten months from tliat time. The child is then got up, hut with an apparatus (plasterer celluloiil) whiih he will wear day and night until lie no longer has any tendency to a new deformity. But, such tendency still generally exists one and a half or two years after regaining the feet, that is. after the cure of the tuherculous process. \ou must knoAV that, in the second variety, very commonly (horn the twelftli to the twen- tieth month) an articular or peri-articular abscess makes its appearance : the abscess of hip disease. 3 ^ VARIETY. - HIP DISEASE WITH ABSCESS 1. Abscess is produced in about half of the cases taken (( en bloc . It is more generally found in children who Avalk about and whose general condi- tion is indifferent. The abscess does not show itself for nearly a year or tAvo after the appre- ciable clinical commencement of the disease. It is announced nearly ahvays some Aveeks or several months before its appearance , by pains and night crying, occasionally by a slight evening rise of temperature of 87.6 to 38°. Very often it is not announced by anything appreciable, and you should noAv and then look systematically for it, by careful palpation of the ^t?^^:,- Fig. 369. — The abscess is indicated by a swelling limited to the outer reg^ion of the thigh, at a level with the upper third. i.'See figs. 369 and 870, also figs. 355 and 358, pp. 368 and 369. 378 lllP DISEASE MITH ABSCESS entire region of the hip-joint. You should make this complete examination and systematic search for the abscess every month or two months, for example, in those not plastered; you will make it every three or four months in those who are, that is, simply at each change of the apparatus ; this suffices Avell in practice, for an abscess always takes, at a minimum, several ■r X. Fig. 870. — Method of seai'ching for an abscess; successive palpation of all the points with the two index fingers placed thus. months to form, and, reckoning from that moment, still five or six months, at a minimum, before there is a risk of its opening. The abscess may be produced in front or behind (in the buttock), outside or inside of the region, upwards, towards the crural arch, or downwards , towards the middle of the thigh, but especially at the upper third of it, in the anlero-external region. Finally, let us mention that the abscess is generally the index of a serious form of hip disease, in the sense that Ave must expect a shortening of about 3 cm. consequent upon the necrosis of the head of the femur and of the acetabulum, which TIIKHAl'EUTIC IISOICA I'lONS IN CASE or AISSCESS ■)7i) is produccil in nearly cver\ case of suppurated coxitis (v. p. .'iOiS and 069). The softening and necrosis of the bones are less in the varieties without abscess. Not always, however; there are sonic dry forms of hip disease, to which we will return (V. p. 383), which brinf^- about in the long run a necrosis as marked as the cases of hip disease with abscess (v. fig. 859); more than that, these dry caries may continue six, eight or ten years, Avhile hip disease with abscess may be cured very quickly, in a few months from the day it reveals itself, provided that you treat it Avith punctures and injections. This is why it would be preferable for the patient to have an abscess, which hastens the cure. In some of those old dry caries w^e often wish tliat an accessible abscess would shew itself. It is true that formerly suppuration in the hip joint was much more serious than a dry coxitis — because, then, one opened the abscesses and, by this open door, by this fistula, there penetrated into the tuberculous focus septic germs, carried in from Avilhout, which engendered fever, infection, visceral dege- neration (of liver, kidneys, lungs), too frequently terminating, sooner or later, in death. Therefore, for abscesses in hip disease as well as for that in Pott's disease, the first word as to treatment should be not to open an abscess, nor alloAv it to open itself — The second, to treat it by punctures and injections. yS e can summarise in a few words the line to follow in the presence of an abscess : You must not interfere with it until it is easily acces- sible. It is better to deal with it than to abstain from doing so, if it is accessible, which is nearly always the case. It is a pressing duty, if the abscess is threatening- the skin. By interfering with it I mean, I repeat it, puncture, wdth injection afterAvards. 38o 4^ VARIETY HIP DISEASE WITH FISTULA. 4i\ VARIETY. - HIP DISEASE WITH FISTULA If every surgeon, in the presence of an abscess in hip disease, did his duty (in the way we prescribed) there would be no more fistula in hip disease. But there always will be, because — errare humaniim est. W'liat is to be done in the presence of a fistula? We ought to repeat here Avhat we have said of fistulce in general, and of those in Pott's disease (Chap. Ill and Chap. V). We have seen the way to dis- tinguish a non-infected fistula from an infected one, that is, Avith a secondary septic infection added to the bacillary field, but pure at the commencement. The discrimination of the two varieties of fistula is of much importance in prognosis and treatment. a. Non-Infected Fistula. Here, nothing is lost as yet, but it is necessary to hasten the closure of the fis- lula, because, in the long run, it will end by becoming infected (almost certainly). One will make injections after the manner described on p. 174, through an opening made in the plaster. In the infected fistulas, the treatment is summarised in four words : asepsis, fresh air, overfeeding, and patience. 6. Infected Pistulae. Keep to the simple aseptic dressings as long as there is no fever (the absence of fever proves that the pus is discharging well). When fever supervenes and persists for several days or several Fig. 371. — Edouard R., England (Hospital Roths- child] admitted in July, iqoo, with seven infected fistulae and /|0 degrees of continued evening fever. After two and a half years of persevering treatment, closure of all the fistulaj (without surgical opera- tion), then redressment Ac- tually, now January, igog, he walks very satisfactorily. VALUE OF RESECTION IX HIF DISEASE ') '6^1 weeks, one must interfere, for fever is the enemy. It's cause must be retention of pus, and it is necessary to find out Avliere this retention is, and drain at one or several points, hut dmin only with no other desire than to Inin^- ahout a fall of the tempera lure {i\'^. 071). If the fever is overcome in this way by drainage, do not concern yourself about any operation with pretentions to radical cure. Above all, do not make a resection which « ^^ ould carry off everything »... yes, even the patient himself; these great resections give a new impulse to the infection already existing and consequently do more harm than good. Resect'-ii in Hip Disease. So-called complete esection in hip disease is a bad opera- tion ; it cannot cure t^ j tuberculous fistula; indeed, it very often aggravates it. More than that, it mutilates the patient — a patient Avho has been resected preserves (Avhen he is cured ?) a limb much less satisfactory than if he had been treated without resection . It is not necessary to perform resection (incomplete) except to perfect draina§:e : that is the only indication and the only use of resection in hip disease. Believe me, the indication for this operation will perhaps never present itself to you, for, personally, I do not find it necessary to perform even one a year (on an average) out of several hundreds of cases of hip joint disease which I have under treatment. Take particular notice of this indication. In certain ca^es the fever persists in spite of all the drainage provided ; if the fever is not due to a general cause, it is due to infected pus being retained at the bottom of the acetabulum or in the pelvis above the perforated acetabulum, being kept there bv the presence of the head of the femur, which it will be necessary for us to remove entirely or partially. '\ou will perform resection, not with the great idea of doing away instantly with all the lesions — that is impossible — but with the more modest intention of doing away with the 382 HIP DISEA.se. RESECTIOX OF THE HIP-JOINT retention of pus and removing the infected sequestra which may be. of themselves, a cause of fever. At what moment would you perform resection? In such a case, one must know when to interfere — not too soon, hut not too late. Not too soon, that is, not hefore having tried all the other means to make the temperature fall : peri-articular drainage, and drainage below the crural arch, and, if that will not suffice, opening of the articulation or simple arthrotomy. For, resection ought to remain an operation of necessity, it must not be resorted to unless one is morally certain the temperature will not fall Avithout it. It is necessary, however, not to intervene too late : I will explain myself. Fever is a danger vital to the patient, a danger soon fatal if it goes to from 09° to ^o'^. but less imminent if it oscillate about 38°. In these two cases, it leads to a visceral degeneration (albuminuria, fatty liver, enlargement of the spleen, etc.). If one interferes only when these are already produced with a certain intensity, these secondary visceral degenerations following septic absorption, one would not be able to « rescue » the patient, and the visceral lesions Avould from that time develop of their own accord. It is better not to wait until there is albumen in the urine (the urine must be analysed every two or three days). Never- theless, when there is only a trace of albumen, there is still time to interfere, but you must be qnick. It remains always well understood that the cause of the fever is to be found in the hip joint and not in a visceral complication, in which case an operation unavoidably incomplete would merely stimulate the visceral affection and the fever itself. In the course of the operation upon these infected patients you should use anti- septics but sparingly, on account of the kidneys, lou prescribe a milk diet after the operation (and even before) to the same end. If you are in the presence of a subject already profoundly .)'" \A1UEIY. — OI.I) llll' CASES LABELLED (( UlIEUMATISM )) 38.'i infecknl, with a sli^'-lil lingc of jaundice, a notable quanlils ol albumen in llie urine, and a liver projecting beyond the costal margin, llial is, witli all Ihe signs of an infection which has alread\ s|)rcad tliiough the entire organism ; in such a case, it is loo laic to operate; you would not cure your patient, you would have, in operating on him, every chance of sensihh hastening his death. Leave him to die in peace. This leads me to repeat to you in the form of conclusion : A fistula in hip joint disease is infinitely more difficult to cure than to prevent. To prevent it, do not open abscesses and do not allow them to open spontaneously ; that is all. Recall our aphorism : « To open tuberculous abscesses (or to allow^ them to open) is to open a door through which death will too often enter o. 5"'. VARIETY. — HIP JOINT CASES WHICH GO ON INDEFINITELY I wish to speak here of those old hip cases decorated with the name of rheumatism, and which never come to an end ! — Coxitis without abscess, with pains occuring from time to time (due to a dry caries). The patients can get about a little, they have almost returned to their accustomed life, but without ceasing to suffer unmistake- ably in the hip, and they find, from time to time, that their sufferings become so acute as to oblige them to give up walking and return to complete rest for several days or several Aveeks. AYhat is one to do Avith these cases of dry coxitis, Avhich linger on for six years, eight years, ten years, twelve years? One ought to long for the formation of an abscess, as Ave ha\'e men- tioned on p. 3-9. One Avould puncture that abscess and one Avould be rid of it Avith a feAvs months of treatment; Avhilst Avithout an abscess the disease might be protracted for years... But an abscess Avill not come! (This it not so absolute, however — it may come Avhen we are no longer expecting it). 384 TREATMENT OF HIP JOINT DISEASE BY INJECTIONS Here are the three alternatives between which you must choose Either make injections, or wait, or resect, P'. Injections? Yes, but it is particularly difficult to reach all the points of a hip joint affected for so long a time, where the surfaces are adherent, partly or entirely. Try to, hoAvever. I have cured some such patients. If the injections cannot give you, in this case, a rapid cure, they will not be Avithout some advantage. 2°'^. Wait? les; if the injections have not succeeded, wait — placing the patient at rest, at least at relative rest, not allowing any walking without a plaster or celluloid apparatus, making nocturnal extension, etc., and resuming the injections once or twice a year, 3'''^. Resect? There are no indications sufficiently pressing to lead to this operation, which allows, by Avhoever it may be done, so many chances of leaving a fistula, consequently an aggravation instead of an amelioration of the patient's condition. A fistula! Think noAv, if it became infected, it might lead to death, whilst the actual pain of the disease does not, after all, prevent the patient leading an almost normal existence. Resec- tion can be contemplated only if you are a very capable surgeon, full of confidence, and if the patient, quite aware as to what may happen, nevertheless begs you to bring the matter to an end. And even then, make him wait, induce him to reflect upon it for six months or a year longer, before you carry it out. If he continue to insist, you may operate on him, but I think this obligation Avill not occur to you once in twenty times. If you resect, endeavour to obtain, by every means, union by first intention. THE METHOD OP MAKING INJECTIONS IN HIP DISEASE The necessity for injections. Before going further, I will explain myself thereupon. When you have read in the following chapter (Treatment of White Swel- EARLY INTR.V-AUTIGULAU INJECTIONS 385 lings) dial iiijeclions are llie rpgiilar Ireatmcnl of llicse arllirites (where they iiivc I lie same good results as in cold abscesses) YOU will ask wliN I lia\c nol immedialcly recommended this means as ihe invariable treatment in coxitis, wliirli is only, in fact, a white swelling of the co\o femoral joinl. Simply because this method is more difficult of application to the hip than to (he other joints. The articulation does not lend itself to it, anatomically, as the knee for example. It is more deeply placed, the cavity is less accessible to the needle. I do not speak only of the space between the articular surfaces which are fitted together too closely for the needle to be able to penetrate easily the interline, but also of the synovial culs-de- sac, Avliere it is difficult to introduce the injection Avith cer- tainty. The difficulty is especially great in rather old cases of hip disease Avhere the cavity is obliterated by adhesions, or at least very much obscured by bands of membrane. That is why injections are not yet admitted into the current practice in hip joint disease. But how we ought to regret it, and what great benefit they would bring with them ! I do not hesitate to say that it is only with the injections that we are able to alter the prognosis of coxitis, still so grave from the orthopoedic jDoint of view, when other treatments are applied. And if hip disease no longer kills — or, at least very rarely — since practitioners no longer open the abscesses, it still leaves far too much shortening and lameness, in spite of the best fitting apparatus, in spite of the correction of deformities. This is due to the fact that tuberculosis rarefies, softens the articular surfaces of the hip joint, the head of the femur and the roof of the acetabulum, and consequently paves the way to the destruction and shortening which supervene, sooner or later, after one or several years. See under the figures on p. 871 the extent to which this wasting and destruction of osseous tissue goes> But this is not an isolated fact — it is so in more than 3/4 Calot. — Indispensable orthopedics. 25 386 HIP DISEASE. THE ^^ECESSITY OF EARLY OJECTIONS. of the cases taken en bloc : P', in all those accompanied with abscess, which represent already half of the cases of hip disease, and 2"*^, in the case of nearly all dry forms which continue beyond one or two years. That is what occurs nowadays, in spite of rest, immobilisation, general treatment, etc. If practitioners are not willing to do more, they must be resigned to see more than three-quarters o[ their cases of hip disease doomed to a permanent shortening of from 3 to 4 — cm. Fig. Madeleine J. Radiooram on arrival. on an average ; and you know that such a shortening cannot exist without an appreciable lameness. What must be done is to seek for and find the means of preventing this, or better still of preventing the softening and wasting produced by the tuberculous fungus ; the means of destroying it before it has « eaten aAvay i) the head of the femur and the roof of the acetabulum. Does the means of des- troying the fungus or of altering it's development exist ? \es, there is one, but only one; it is to carry a modifying liquid right up to it. The proof has been made in the fungosities of cold abscesses and other white swellings, which do not differ obviously from the fungosities of hip disease. JIECESSITV Of E.VULY I.N.I EGTIO.NS liSi Seeing ihat In lln" disease at ils coiimiciK^'niciit (autopsies of Fig- 873. — The same patieat alter sii moatLs. Radiogram takea at the time the injections ^Yere commenced. Ficf. 87^. — The same patient a vear alter the injections. \o other trace oi' the disease remains except a loss of osseous substance on a level with the superior and internal angle of the neck. — Complete cure \\i[\i all the movements inlact. cases of early hip disease prove it) the lesions are always locaUsecl 388 INJECTING, BEFORE THE FORMATION OF AN ABSCESS in the synovial membrane and on the articular surface of the bones, Ave shall be able by early intra-articular injection to attack the fungosities before they have destroyed the bone. Here, moreover, is a commentary on tuberculosis of the hijJ joint which is very instructive in this respect : Madeleine J., seven years old (from Paris), sent by my very distinguished colleague, D'' Cuneo, arriving at Berck in Sep- tember, igo3. The radiogram (fig. 372) sIicavs that the tuber- culosis has destroyed a good third of the neck of the femur and that there is a sequestrum at that point. This sequestrum it had been proposed to resect by a surgeon avIio affirmed the impossibility of cure without operation ; but the parents refused their consent. As for me, I did not believe in the necessity of a resection ior the cure of the child ; but I feared complete destruction of the neck after a short time by the progress of the tuberculosis, which appeared very virulent; it was excessively painfid, which led me to propose modifying injections, to which the family, unfortunately, objected. Haifa year passed; the child was not better. I insisted again Avith the parents, telling them that, if they refused, Ave should very probably see in a fcAv months, the neck destroyed entirely, the head separated from the diaphysis, and that grave and irremediable infirmity Avould result. M. Cuneo on his part insisted and succeeded this time in convincing the parents. Our fears AA^ere only too deeply realised. A radiogram taken at the time Ave commenced the injections (fig. 373) shoAved plainly that the tuberculosis had destroyed nearly a third of the neck since the first examination and the first radiogram, — and that, in spite of rest, in spite of the plaster and the air of Berck. I made a series of injections of camphorated naphtol after the manner described on p. 166. I softened the fungosities and obtained an appreciable collection of pus at the sixth injection. From that time I made punctures and injections to the extent of ten punctures and ten injections according to my usual technique for the treatment of tuberculous abscesses (see chap. HI). nil' DISEASE : MAKE INJECTIONS IN ALL CASES 380 .V slraiige lliiiig wiiicli shewed thai Ave had reached the alTecletl part of (lie hone was that Ihrough the puncture n('(>dle, small osseous granules, debris of sequestra easily recog- nisable, repeatedly passed out. After this series of injections, which lasted seven weeks, compression was made for three months. \ year later, Ave took a ucav radiogram (fig. 37/1); not onl> had (lie destruction of the neck not progressed, but the neck, on the contrary Avas slightly repaired and the cavern which had appeared Avas partly filled up. More than that, the sequestrum had disappeared. The patient Avas cured. The neck has ever since then become stronger. We saAv the child three years later; she had become perfectly cured Avithout any shortening, Avithout functional damage. Think of the infirmity she AA-ould have had to live through if Ave had not made the injections, or if Ave had Availed longer! This proves, and we have plenty of other cases to the point Avhich also prove (fig. 3^5, 876), that our injections are able to destroy the fungosities and to preserve the bones of the hip joint from rarefaction and eventually destruction. lou see noAv AA^hy I advise you to make intra-articular injections at the outset, in all cases of hip disease, as one constantly does for Avhite SAveUing of the knee.^ And the treatment Avill be even more necessary in the hip joint, Avhere the bones, as experience sheAvs, resist infinitely less Avell than those of the knee, the destructive action of the tuberculosis. II- — Indications for early intra-articular Injections. Because Ave have spoken of making them in all cases of hip disease, Ave do not Avish to say that there are not cases of hip disease essentially benign, Avhere, the lesions having been only synovial and the bones hardly touched by the tuberculosis, there Avill certainly ensue an important osseous destruction if injec- tion is not carried out. No, there are some fortunate exceptions already pointed out; but hoAV are we to knoAv Avhich are the cases Avhich may 3qo TREATMENT OF HIP DISEASE be cured in this wav without subsequent destruction? There is no absohite criterion. There are probably cases of hip disease which come without 1) 'J -^' Fig. 375. — Germaine G., five years of age; left liip disease before injection. The joint -nas threatened -with complete and early destruction. spontaneous pains or deformities, and in which there is not, as shown bv the X ravs, loreaking doAvn nor even appreciable Fig. 3-6. — The same, eighteen months after injeclion. One can see that, thanks to the injections, wasting has not progressed. The tuberculosis has been averted. rarefaction of the bones, cases of hip disease which have been, on the other hand, taken care of from the outset. \es, without doubl ; but remember, however, that there is nothing certain from this point of view, thai nothing can give us precise assu- \\llt:N OUGHT THE INJECTIONS TO HE MADE 3o I rance Ihal. while wo arc keeping l)ack our injections, the tuber- lous process is nol secret I > and silently rarclying and softening the extremities of the bones. Consequently, even in Ihcso cases, and because of the loo F'r- 377. — Radiograui during lil'e after tlie introduclion ol (lie needle; ihe point IS in the interspace. This proves that one can penetrate there, but it is uncertain and difficult. numerous uncertainties whicb we have against us, Ave must make injections : that is, generally speaking, in all cases. III. — When must the injections be made ? Me say, at the very beginning- : as soon as the diagnosis is estabhshed. To wait until there is an abscess, or to interfere only when the coxitis has lasted one or two years, is a mistake, because then it is too bite. In fact, in all hip disease lasting for one or two years the rarefaction of the bones is already too marked, nearly always, for you to be able to save them from Avasting. A'Nlien the hip disease appears before the abscess, with a noticeable defor- mity of more than 20", or Avith severe pains, it may mean Ave are too late, not always, nor even frequently, but in some cases. The principle is to make injections before the bones are — I do not say destroyed — but simply softened. Sgs HIP DISEASE : THE I>'JECTIO>S. Does this mean that no injections must be made in cases of hip disease Avhich are abeady oldP No, they must be made because, with injections, if one is not able completely to prevent destruction (the bone being already too much softened and rarefied), one may still limit it somewhat, since it takes three, four, and five years, and more, to arrive at the full extent of the mischief. (In four cases of old hip disease of two and three years standing, I have been able to save, almost entirely, the osseous extremities Avhich,as shewn in the radiograms, had, on the arrival of the patient, seemed doomed to complete destruction). IV. — The Technique of Intra-Articular Injections of the Hip Joint First, you will carry out the treatment in the same way as for white swellings. You will find in the following chapter Fig. 878. — Dissection of the inguinal region to shew ihe accessible ZOne ot the synovial cavity ; this zone extends Over the whole anterior surface of the neck. — AA', horizontal line passing through the pubic spine; — B, ante- rior surface of the neck; — C, femoral artery; — D, Psoas; — E, Sartorius; — F, Rectus (B, is the point of election for puncture) (p. 097) all about the instruments required, the liquids, the number of injections, their intervals, and you ought to read the entire chapter before making injections into the hip joint. POINTS OF ACCESS TO THE Hll'-JOJ.NT 3y3 V. — The Points of Access to the Hip-Joint. To pcnclratc inlo the cavilv. llic [Mnn[ of election is found in front. Explore the sduiid liip jdini; \(iii will be able to leel below tlio crural arch, between the sartorius and the artery, the head of the femur rolling under your finger when you impart move- UKMifs of rotation to the knee (see fig. 077 and following). In front, the cartilaginous part of the head is directly per- ceptible (thai is, (he part outside the acetabulum) to a height Fig. 879. — Railiogram during life in one of our cases of hip disease, after the injec- tion of iodoformed oil into the synovial cavity ; one can distinguish the shadow of the capsule distended with the liquid. This is the proof that you have penetrated into the joint cavity. of I 1/2 cm. in a child 21/2 cm. in an adult, and we must allow for, in addition, the cul-de-sac formed above this point by the synovial sac. This zone is as broad as it is high, ^^e Sgl\ I>JECTIO>"S : YOU PUNCTURE 2 CM. OUTSIDE THE ARTERY; have there, consequently, an area quite sufficient for the injections. To reach the cavity in this zone, we have only to pass through the skin and the thin muscular lamina of the psoas and iliacus. It is easy to avoid the vessels (artery and vein) Avhich Fig. 879 bis. — Diagram drawn from nature in the course of a dissection, after an injection ^Yitll metiiylene blue of the two hip joints. — On the right side is seen the capsula distended with liquid, between the vessel and the psoas and iliacus. On the left, the capsule has been incised, the head of the femur is shewn, coloured blue. are well out of the way on the inner side, as shewn in fig. 078, As to the anterior crural nerve, it is nearer. Still, it can be avoided quite as easily, because it is in close relation with the artery, and besides, pricking the nerve would not have very serious consequences. But it is necessary to enter into some details. I '/> CM. BELOW A LINE PASSING TlIUOLfill THE PUBIC SPINE 3()5 A\e liavc made more than one Imndi-cd experiments on llie cadaver (injections, followed by control disscclions) and nume- rous radiograms during life, ol" our cases of iiip disease, after injections with iodoform (v. lig. 079), to cstablisii in a precise way the technique of the injections. Here are the practical conclusions drawn from our enquiries. \ou ought not to make injections into the articular interline — Avliich is not impossible (v. fig. 077) although it is difficult to reach. iNeilher must you make them on a level with the cartilaginous part of the head, because the capsule being at this level in close contact with the bone, the liquid would only penetrate into the interstice with great difficulty. You will make the injections into the inferior synovial cul-de-sac at the level of the anterior surface of the neck; this cul-de-sac possesses a certain laxity which renders the penetration of the liquid relatively easy. Here are the points fixed upon. In a child of ten years, you puncture at a point indicated by a small cross in fig. 38 1. at i cm. below (he horizontal line passing through the pubic spine and at 1 12 cm. outside the femoral artery (Avhich can be felt pulsating). In an adult allow respectively i 1/2 and 2 cm. (fig. 38oand 38 1). Puncture directly from front to back. The needle should be pushed in to a depth of from 3 to 4 cm. in a child, and from 5 to 6 cm. in an adult of medium stoutness. In a word, push it in until it is stopped by the osseous plane (the anterior surface of the neck) the resistance of Avhich is characteristic. You will always be stopped by the bone, if you puncture at the right place. One may succeed by leaving the thigh in the extended posi- tion. But the penetration of the liquid is facilitated considerably, as M. Farabeuf has pointed out, by placing the limb in the position of flexion at from 20° to 3o-. with abduction and external rotation of from i5° to 20" (fig. 383). \o\x understand then, that by this slight flexion of the thigh, always possible at the outset of hip disease, the anterior 396 TREATMENT OF HIP-JOINT DISEASE part of the capsule relaxes (as the fingers of a glove are relaxed by flexion of the hand), detaches itself from the bone and comes of its own accord under the point of the needle, which penetrates it easily (v. fig. 38/i and 385). Fig. 38o. — In an adult, puncture I 1/2 cm. beIo\Y the horizontal line passing through the pubic spine, and at 2 cm. outside the artery. Fig. 38 1. — In a child of from 9 to 10 years of age, at i cm. below the horizontal line and at i 1/2 cm. out- side the artery. The injection being pushed home, place a tampon over the puncture and lay the thigh gently doAvn. Then apply a light, compressive dressing. VI. — Conclusion. We will now give the scheme of treatment which you ought to follow in all cases of recent hip disease. The diagnosis being established, you place your patient at rest, in continuous extension or in a plaster, according as the case is that of a town child or a hospital child. If you employ the plaster apparatus, construct it bivalve (fig. 386) in such a way as to be able to remove it easily at each injection, so as to give to the thigh, each time, the slight flexion desired (fig. 383). You commence the injections after two or three days rest. You inject, as we have said, the same fluids, in the same doses and at the same intervals as if you were treating a white THE VALUE OF INJECTIONS INTO THE JOINTS ^97 swelling of the knee, or an ordinary cold a])scess (v. Chap. in). Use a needle (N" 2) bevelled short, like the needle used for injection of cocaine in llie spine and inject oil, creosote and Fig. 382. — Fixed points traced with dermographic chalk; the thigh extended, puncture and penetrate until you feel the bone. iodoform (4 to 10 grammes), rather than naphtol, camphor and glycerine. Fig. 383. — The femur is afterwards put in ilexion at about 3o° ; while this move- ment is made, see that the point of the trocar does not leave its contact with the bone. The nine or ten necessary injections take you two months, after which, for three months, you make pressure with cotton Sq8 HIP-J0I>"T disease. THE USE OF ARTICULAR INJECTIONS wool over the articular region (always together with continuous extension or the plaster). This period having passed, discontinue the plaster, but you Fig. 384. — The incision allocs one to see that, in tlie position of extension of the thigh, the capsule is flattened over the head and neck. must wait four of ftve months before allowing the patient to ed^ get about. Then he is cured ^ Fig. 385. — In Qexmg the Ibigh, the margins of tiie incision gape widely, allowing the space which exists between the capsule and the bone to be seen. I . If this is not so, that is, if pain continues four months after the injec- tions are stopped, which may sometimes happen here as in the other cases of white swellings, you would make a second series of injections. (Consult the note on page 499). EAIU.V INJECTIONS AMLU HIE I'UOGNOSIS •^99 So llial llie cure will be oblaiiied in ten iiutiillis Iruui llie commenrcmenl of ihe treatment (lo to 12 months), instead of the ilircc (ir four years ;*j ref|uircd b\ the ordinary treatment without injections. With the injections, tiie duration ol' hip joint disease will ihus be reduced by two thirds; but, above all, cure Fig. 386. — Bivalve plaster held together hy bandages or by hooks and eyes (v. p. i56\ without shortening and without lameness — complete cure — w ill be the rule, w bile with all other treatments this result w oukl be quite exceptional. Thus the history of the treatment might be written in three lines : — /*' period, that where one used to open the abscess : the patients died of hip joint disease. 2""^ period, that where one punctured the abscess : the result Avas the cure of the hip disease, but at the price of an infirmity. J"' period, that of early intra-articular injections : the hip disease is cured, cured quickly, without lameness and without defect of any kind (see Journal des Practiciens, i\ march 1908; Traitement de la Coxalgie, conference faite a I'hopital Beaujon [service du professeur Robin , par F. Calot). 400 6*'' VARIETY. ANKYLOSIS, LAMENESS AND SHORTENING 6"^ VARIETY. HIP JOINT CASES « CURED ., BUT WITH A DEFECT. (SHORTENING, ANKYLOSIS, LUXATION . I wish to speak here of those cases of hip joint disease cured, or apparently cured for one or several years, which come to you, or come back to you, for some functional defect (fig. 887 and 889). The parents complain that the child is more or less lame, that the limb is shor- tened and is still becoming shorter, that the hack is deformed, at the same time that the loins are becoming hollow ; or simply that the hip is stiff, which causes a difficulty in sitting down and in putting on the shoes. They come to ask you if it is possible to efface these functional defects or ar least to prevent them becoming Avorse. Your reply should be prompted by the two following principles : 1**. If there is simply stiffness of the hip, nothing must be done. 2°''. If there is lameness and shorte- ning, or dorsal deformity, one can and one ought to obliterate as much of this lameness and shor- tening as is caused by the deformity of the hip joint. Fig. 387. — Vicious aak\lo- sis ; flexion, adduction aad internal rotation. Fig. 388. Vicious ankylosis ; hollowing very marked. The deformity removed, do not look for mobility, but endeavour to produce an ankylosis in a good position. I will explain myself on the two rules I have just laid down. I'*. You Avill not interfere in order to « loosen w the hip joint. IIIP-JOINT DISEASE : MEASURE OF TOTAL SlIORTEiNlNG /jO r lumbar hollow ischium spines In Tact, it is cilhcr a question of hip disease without short- ening — (see further back, the hip diseases of the first variety) — and then you will not touch it, in virtue of the priino non nocerc; for, not only would you not have more than one chance in ten of re-establishing the movements, but you Avould run too great a risk, in interfering, of aggravating the patient's condition. Or it is a question of hip disease with shortening — (see further back, hip diseases of the second, third, fourth varieties) — and then it would be rendering a very poor service to the patient to do aAvay with the stifTness of his hip joint (admitting that it were possible to succeed in this without danger to him). As a matter of fact, these patients would not walk so Avell afterAvards as before. It is to their interest to have the hip stiff; this is so true that you must, in the case of persons with hip disease in whom the joint is movea- ble and there is marked lameness, endeavour to stiffen the joint in order to lessen the lameness (which can be done by wearing an immoveable appa- ratus over a long period). 2"'*. Principle : in lameness due Fig. 389. — In oilier to learn the exact functional shortenino-. one ought to efface the lumbar hollow and place the two iliac ■spines on the same level ; this, one does with Ihe patient upright. The shortening is equal to ihe difference of level of Ihe two heels. to shortening, one will do away wdth the amount of it caused by the deformity. But what is this amount.^ That is what Ave are going to determine. A. — Shortening. Its Causes or Factors Very marked shortenings are due to tAvo principal factors : 1. A deformity of the hip joint. 2. Wearing away of the extremities of the diseased bones and atrophy of the skeleton of the Avhole hmb. Calot. — Indispensable orthopedics. 26 402 APPARENT SHORTENING AND REAL SHORTENING Against the first factor of shortening we can do much. Against the second we can do nothing ^ We can only hide it by causing a high heeled boot to be worn. Method of ascertaining the total shortening and the amount of it due to the deformity (fig. 889 to 8961. In order to bring the foot of the affected leg as near as possible to the other, the patient hollows and deforms his back. Fig. 390. — Here the shortening^ is measured with Ihe patient lying down. To make the hollow disappear ones has been obliged to give to the knee this marked degree of ilexion. The total shortening is equal to the distance which separates the heels. By this artifice, he will have less apparent shortening Fig. 391. — An unlikely deformity. The patient walks by supporting himself on his hands. The shortening equals the distance bet\Yeen the heels and even more, for one can see that the hollowing is not entirely done away with and that one would have, in order to obliterate it, to raise the knee still more. and perhaps less lameness ; but he Avill have in addition an I. Except as preventive, by injections (v. p. 38^'. mi> uisi:.vsE la.XGTlONAL SlIOUTEMNG /|o3 nnsig:hllY dorsal dcrormity. ^^llicll \\i\\ not be any bcllcr than a degree more of lameness, especially in the case of a young girl. To demonstrate the real shortening, ihe total shortening interline o the knee malleolu Fig. 892. — Measurement of the limb. — Measure from the centre of Nelaton's line lo the external margin of the sole of the foot (passing by the point of the external malleolus) . iliac spine lumbar hollow Interline tou- } cliing the top of the bone bi malleolar line Fig. 898. — Measurement of the front. (Compare the measure- ments obtained from the two limbs). of the lower limb, you ought to begin by placing the back quite straight and, in order lo do so, you proceed to flex and carry inwards the affected thigh until the lumbar hollow is effaced, until the " loins " touch the table and until the two iliac spines are at the same level (at the same perpendicular to the median axis of the body). This done, you bring the affec- ted heel against the sound calf, and measure from the point ol 4o4 SHORTENING : THE PART PLAYED BY DEVIATION contact to the sound heel (see fig. 890 and Sgi); this distance gives you the total shortening \ What is the share of each of the t^vo factors : deviation and wearing away? It is easy to calculate. Measure the length of the affected limb starting from the centre of Nekton's line (I say from Nelaton's line and not from the upper border of the displaced trochanter); measure from Fig. Sgi-SgS. — Method of measuring the share which is due to wasting of the bone ; — the wasting is equal to the distance which separates the two horizontals (tro- chanter and centre of Nelaton's line). this line doAvn to the external border of the sole of the foot (fig. 392). Take the same measurement on the sound side, from Nelaton's line to the sole of the foot. Compare the measurements of the two sides. a. Wearing away of the skeleton. The difference be- tween the two sides represents the share of the factor which comprises the Avasting of the articular extremities and the atro- phy of the skeleton of the whole limb. The wasting of the I . Measured thus, one sometimes calls the shortening functional, in contradistinction to the real shortening which should be ' ' the loss of svibslance " of the bones in their length; this distinction is an error, or at least demands an explanation; the functional shortening which is, for example, of i5 cm., is the real shortening, in the sense that the patient is really as lame as if he had a shortening of i5 cm., and if one does not remedy it, the patient will remain shortened all his life just as if he had really lost i5 cm. of the length of his limb. AVIIAT IT IS POSSIBLE TO DO AGAINST SHORTENING liOO extremities alone is equal lo llic distance from the superior border of llie trochanter above tbe centre of Nekton's line (v. %. 39 'i, 395). b. Deformity. — The remainder of the total sliortening will be Ihe share of the deformity. Let US suppose the total shortening to be 1 5 cm. (which it frequently is) and that you have found, on measurement in the wav we have mentioned, a difference of 3 cm. between tho two Fis. 396. — Estimation of wearing away and atropiiy in the length of the bones. The small horse-shoe indicates the outline of the troch^inter : the distance from the trochanter to Nelaton's line indicates the -wasting. Fron the trochanter to the point of the patella (interline of the knee-joint; and from that interline to the external malleolus, one has the measure of the length of the bones; compare with the sound side 'the same fixed points). lower limbs. To the deviation will belong in this case, i5 cm. less 3, that is 12 cm. You will be able to promise the parents that you will do away Avith the 12 cm. — that is, four-fifths of the shortening — by your treatment. Instead of actually 10 cm., you Avill tell them that the child will not have more than 3 cm. of shortening. And with only 3 cm. and with a hip joint solidly fixed in good position, he Avill not be noticeably lame. The Reason for Interfering with Shortening. In what case would it be well to interfere :' — At what moment:* and howP I". AVe have said that much can be done against deformity. 4o6 ANKYLOSIS. SIMPLE STRAIGHTENING RATHER THAN OSTEOTOMY Is this a sufficient reason for submitting the cliikl to an interference every time there is a deformity? No. Unless the result is worth it. So I advise you to do nothing, or to use only shght means — traction at night time, weights on the but- tocks, etc. (see fig. 85o and 855), in those cases where there is less than 4 or 5 cm. attributable to the deformity, and if, moreover, this deformity is not increasing. To make sure of it, take the exact measurements every three or six months. On the other hand, it Avould be necessary to interfere each time that at least 5 to 6 cm. are due to deviation, especially if this were increasing. And it happens very frequently that deviation is responsible for more than 5 or 6 and even lo cm. and that it has a certain tendency to increase. How to interfere, that is, by what procedure? That will depend on the degree of stiffness of the hip joint and the variety of the ankylosis — complete, osseous ; or incomplete, fibrous. Direct examination, in revealing lo you very distinct mo- vements, enables you to make a diagnosis easily in the great number of cases. In doubtful cases, when you do not perceive distinct move- ment in the femur (after having fixed the pelvis) have recourse to X rays, which will shew you a continuity between the two bones. In default of radiography, administer a few drops of chloroform to make a rapid examination of the hip, and make certain whether there is movement or not. I can assure you that you Avill nearly always hnd, in true coxitis, afew movements, even in the cases labelled " complete ankylosis of the hip-joint". B. — Ankylosis in Hip Joint Disease P'. Case (frequent). — Incomplete ankylosis. You have perceived (with or Avilhout chloroform) very dis- tinct movement; you will make a simple redressment (without tenotomy if you are not a surgeon — with or without tenotomy if you are a surgeon). 1^'^. Case (rare). — Complete ankylosis. THE TREATMENT OF ANKYLOSIS IN 1111' JOINT DISEASE '107 There are no distinct movements, cmmi under chlorororni ; do not persist, lor, in pcrslsling for lo minutes, you might provoke them very often, because you may happen to separate the two A\ elded articular extremities; you may cause also a great traumatism; do not do it; it would he heller to consider it clinically as one of those cases n| complete ankylosis, Avhere there is not immediately, under chloroform, any appreciable movement. For such cases, you Avill perform a supra-trochanteric osteotomy (linear and sub - cutaneous) or an inter- trochanteric, to be further away from the old focus. I do not Avish to leave you igno- rant of the fact that surgeons prefer osteotomy, even for incomplete ankylo- sis, to simple redressment, because, say they, redressment, by disturbing the seat of the old tuberculous focus, is sure to predispose to a revival of the tuberculosis much more than osteo- tomy, which acts on a point far re- moved from the focus. This objection has scarcely more than a theoretical value, especially if one does not carry out the redressment until the tuberculosis is quite cured and the patient's general condition is good ; it might be necessary to Avait for one or two years on that account. With a redressment done at this moment, methodically, in two stages if you like, you would not run any more appre- ciable risks of re-awakening tuberculosis than by an osteotomy. On the whole, simple redressment remains, in every way, more certainly benign than osteotomy. With redressment you would have no operative complications, Avhilst you might Fia;. Sqy. — Luxation. 4o8 LUXATIOiX OF THE FEMUR IN HIP DISEASE perhaps have them with osteotomy : immediate infection of the small AYOund, or secondary infection of the periosteal ha3matoma. ^or this reason I do not hesitate to recommend to you, practitioners and non-specialists, redressment rather than osteo- tomy for all cases Avhere some movement persists. C. — Luxation of the femur in hip disease. AA'e ought to speak here of complete luxations of the femur, which we must guard against confounding with a simple over-riding of the head in the acetabulum made larger by Avearing of the bone ; over-riding of this kind is as frequent as luxation is rare (fig. 897 and /i7i). You will without doubt never see luxation at the onset of hip disease (I have seen only one case in 17 years) and, if you do see it, you will reduce it without chloroform by the ma- noeuvres one carries out for congenital dislocation of the hip (v. chap. xiv). But you Avill have occasion to see luxations following hip disease in spite of the fact that complete dislocation , as the last stage of the disease, is exceptional if the case has been looked after. The diagnosis is easy to establish by radiography. In the absence of the X rays, it is very delicate, except in the cases where, by palpation, one can distinctly feel the head of the femur in the buttock; but this is rare, because the surroun- ding tissues are hardened, and especially because the head of the femur and even the neck are more or less eroded or des- troyed in these varieties of hip disease. To make the diagnosis in these cases, one may admit that, as a general rule, if the trochanter is more than 4 cm. above Nekton's line, there is a true luxation of the femur; below (i cm. it is a question rather of a simple over-riding of the head in the acetabulum, without the head having escaped from the enlarged cavity. The treatment of pathological luxations of the femur is very difficult, but one is not completely helpless, far from it. DOUBLE HIP-JOINT DISEASE. ITS TREATMENT ^09 ^^'illlOul recUoniny llial one can always corrccl the flexion and adduction Avhich generally accompany dislocation, one may yet manage to correct it, cither by c( reducing » the head, if it is in good condition, Avhich is rare, or, when the head is destroyed, by supporting in the bottom of the acetabu- lum the upper extremity of the trochanter, which is always preserved (v. p. 4 60). HIP-JOINT DISEASE ASSOCIATED WITH OTHER TUBERCULOSES a. Double Hip-Joint Disease. Double coxitis is rare ; fortunately so, because it is very grave from an or thopoedic point ofvicAV. Double coxitis would not be so formidable if the patient would come at the very beginning, and be treated Avith early articular injections; — but that is scarcely ever the case, and then the disease becomes aggravated rapidly; the bilaterality of the coxitis shews already that serious tuberculosis is at work, and serious tuberculosis does not remain at the first degree, neither on one or the other side. It leads nearly always to deformity and to abscesses (vide second and third varieties). And so we are (( caught in a dilemma » ; either the limbs are not sufficiently immobilised in which case the deformity continues to progress, or they are placed in a large plaster, and a double ankylosis will result. But, if ankylosis of one hip only does not prevent the patient Avalking, bilateral anky- losis is disastrous for walking, for sitting down or bending, in a AAord, for all the natural and physiological functions. \ou see that, whatever is done, the orthopoedic prognosis of double coxitis remains bad. Further, abscesses are of fre- quent occurrence, they are more grave, more liable to open than in simple coxitis and there is generally a persisting fistula, the evil consequences of Avhich you know. What is the course to take? When you chance to see a double coxitis at its onset, do 4io HIP DISEASE AIXD POTT S DISEASE not neglect to endeavour to stop the evolution of tuberculosis (by intraarticular injections). As to orthopcedic treatment : rest on a frame with conti- nuous extension well looked after. And. in a general way, prefer extension to a plas- ter, because extension safe- guards the mobility of the joint. If rotation of the limb, exists outwards or inw'ards, meet it by the means sheAvn in the figures 852 to 854- But extension is not always sufficient to prevent deformity being produced or to sooth very troublesome pain . It will then be necessary to have re- course to the plaster for a while. But return to the extension as soon as possible. What can be done against the deformity and stiffness already produced .^^ If the deformity and stiff- ness are next to nothing, leave them alone. If the deformity is very mar- ked (more than 3o°) correct it gently, supporting Avith a plas- ter for two months, then go on with the continuous extension. In the case of stiffness, if there exist at the same time a bad position, correct it (you knoAv how) without troubling to restore mobility. If the hip joints are stiff but in a good position, do not touch them : not that there are no operations proposed for mo- bilising the joints, there are too many I Fig. 398. — Coxitis and middle dorsal Pott's disease. — The plaster is provided with a dorsal opening for compression of the gibbosity, and a pre-inguinal one for articular injections (or for the treatment of an abscess of the hip joint). HIP-JOINT DISEASE : THE TECHNIQUE OF THE TREATMENT '| I I Do not |iorloi-m any of these because, \villi llie besl of them, Mill will inn at least nine chances out of ten of douig more harm than ijood. b. Coxitis with Potts Disease fig. 398;. The prognosis for good walking is very poor, especially Avhen the Pott's disease is situated in the lower part of the vertebral column : which one can understand, because the Pott's disease causing an ankylosis of the lumbar spine and the Hip disease leaving behind it so often a rigid hip, the child w ill be helpless -with this double ankylosis. The treatment. — One encloses in a single plaster the trunk and the whole of the lower limb. If the large plaster is badly tolerated, take ofT the leg por- tion, and hrst endeavour especially to cure the Pott's disease by the ordinary treatment (see Pott's disease); for the hip disease, make simply continuous extension (at the same time articular injections). Afterwards, Avhen the Pott's disease has been cured, you will complete, if need be, the correction of the hip. c. Hip Joint Disease with White Swelling of the Knee on the same side. One treats the two diseases at the same time by making either extension, or a large bivalve plaster, and one endeavours to preserve some movements as much as one can (early injections). d. Hip Disease co-existing with Multiple Bacillary Infections. See Chap, xx, On multiple tuberculoses. II. — 2-'. PART OF THE TREATMENT. TECHXIQUE. The technique of the treatment of Hip Disease comprises : I''. The manner of ensuring rest for the hip in the lying posi- tion, on a frame; 2°''. Continuous extension ; 3"'. The Plaster apparatus ; 4'''. Rediessment of the hip (simple redressment, with or ■without tenotomy or osteotomv); 4t2 HIP-JOI>'T DISEASE : TECHNIQUE OF TREATMENT 5"". Treatment of the abscess of hip disease ; G"". Drainage and resection of the hip joint. REST ON A FRAME Does it not seem useless to devote a chapter upon the way to ensure rest for the hip in the recumhent posture ? Fig. Sgg. — Our frame. — An ordinary frame arranged with a median opening on a level with the seat : the opening is closed at ordinary times by a tampon (T). I do not think so. It seems sufficient, docs it not, to place the patient on a bed :* Yes, doubtless, if the mattress is hard, even, and quite flat; and if the bed can be easily carried out of doors, to allow of the child passing I the whole day in the open air. It is more practical to place the patient on an ordinary board well stuffed and moveable ; or better still on a wooden frame padded with horse- hair, provided on each side with stops for the straps destined to restrain the body ; the straps are fixed at one side and are buckled at the other (fig. Sgg). At the two extremities of the board or of the frame are two iron handles to carry the child into the open air, either into the garden on two chairs, or on a small carriage. The cushioned board or frame may be made anywhere, "iour cabinet maker or upholsterer will make it for you. Fig. tioo. — Our frame. — An utensil in place, seen from above — B. cushioned tampon which serves to take the place of the utensil when the latter is not required. IIEST I I'ON A rUAME ^'.i3 These verv simple means ai-e excellent. But lor the cases lMl;^^l::i:h;i:t!i:l|(:;:ri>v;:;:i::n::::.-::^n:r-''''l''l W Fig. ioi. — Our frame seen from Ijelow «illi its slide. Avhere absolutely perfect rest for the hip is necessary, I object to them, as they allow the child to alter his position and do Fig. 402. . — Our « frame ». — The strap for the legs is fixed by its middle part to embrace the limb in a buckle. not permit of his using the bed-pan without inevitably causing an unnecessary jerk and displacement of the hip. To do away with these avoidable movements, I have had frames constructed with a large median opening, made on a level with the seat (fig. 4oo). When not wanted, the median opening is fdled exactly with a cushion, evenly rounded, pushed in and supported by a board sliding in grooves beneath the frame (iig. 4oi). At the moment of using the bed-pan, you draw the board, take out the cushion and slide in its" place an utensil of suitable 4l4 HIP-JOI.\T DISEASE : SEGUROG THE PATIENT ON A " CADRE size and dimensions, which is thus adapted to the opening; one draAVS the board underneath to keep the utensil in place, in the same way as the cushion, for the necessary length of time. To be assured more exactly of the fixation of the legs, one can arrange the straps for the legs and knees in a double loop for each limb (fig. 402 and 4o3). The fixation of the trunk is effected by two broad straps, Fig. /io3. — Child on his frame. One sees tlie two straps on the legs and thighs, tixed by their middle portion and embracing the limbs in a double loop. Counter- extension is obtained by the weight of the body, provided that the lower end of the frame is raised bv one or two bricks placed under the feet of the wooden supports. or by a waistcoat of ticking passed over the shirt, a waistcoat of Avhich the two shoulders and lower edges are fixed, by lea- thern straps to the sides of the frame. In Bonnet's splint, there is a similar method of fixation ; but Bonnet's splint is dear and not easily obtainable. It has another more serious objection : the Bonnet splint is generally badly constructed, is not sufficiently even and flat; it is easily depressed and put out of shape, and masks the deformity which progresses unobserved, so that '-one very often removes from a Bonnet's splint a deformed child ". I like much belter to employ the ordinary frame as I have modified it. It has the same advantages as the sjDlint without I-1\ATI0N Ol- Tilt: TWO LIMBS /| 1 5 lia\lni: ils inconveniences: it can be made hy any cabinet maker at a ver\ low price; il may 1)C completed by a hard and even mattress made by an upholsterer orevenl)\ ihe child's mother. The mallress ought lobe a liltlc thicker at the level of Ihe seal, to support the pelvis raised up and to prevent hollowing of ihe back. One can adapt to the lower exlremily of ihe frame trans- verse rods, on which, in a groove in place of a pulley, you can pass a cord for continuous extension (lig. /io:^). I prefer the two limbs to be supported for tw o reasons ; the hrst is llial the sound limb being free might, by ils exagge- rated movements, impart slight shocks to the pelvis; the second is that it is important, for the future, thai the two limbs may be placed under the same regime of absolute rest for the dura- tion of the disease, especially Avhen one is trying to obtain a perfect cure, as is here the case. As a matter of fact, the cure could not be perfect if one of ihe limbs — the affected one — were forcibly immobilised — whilst the other — the sound one — could move about unre- strained in the bed. After a year or two of this regime the restrained leg would waste, whilst the free leg would very often have become hypertrophied. When the patient begins to Avalk again he will not be able to do so symmetrically if one leg is feeble and the other very strong. If the two legs are equally feeble, on the contrary, they Avill demand the same effort; they Avill resume symme- trically and simultaneously their power and iheir usefulness. The legs being more equal, Avalking Avill be more regular and the cure more perfect. So as to omit nothing, we may add that the children lying doAvn are generally clothed in long blouses of flannel, open behind from top to bottom. At meal times, one allows the child to raise his head slightly Avhilst his shoulders are steadied by a small cushion. To entertain the children, Ave promenade them once or tAvice a day in small carriages, on a flat field, to avoid shaking. 4i6 HIP- JOINT DISEASE : CONTINUOUS EXTENSION About every six Aveeks, one takes the child from his frame or out of his spUnt, placing him on an ordinary table, which alloAYS one to verify the position and the condition of the joint. The mother will avail herself of the opportunity and make the Fig. Aoi. — Legging made of ticking or of leather for continuous extension. complete toilet of the little patient. This monthly examination helps to prevent the hip joint becoming stiff. 2. CONTINUOUS-EXTENSION You knoAv alreadv well enoush how to make continuous Fig. 4o5. — Extemporised apparatus for continuous extension. The foot is bandaged up" to the malleoli. A strip is placed in stirrup fashion under the sole; the two ends of this strip are applied to the limb up to the groin. extension for fractures of the thigh ; you have only to apply it in the treatment of hip disease. There are manv Avavs of hxinof to the affected limb the lines Fig 4oG. — The two tails of the stirrup are covered to above the knee. They are afterwards turned on each side of the Hmb and the bandage is rolled downwards over them to the malleoli. which sustain the extension Aveights. If you have a method you are familiar Avith, keep to it. TECIIMQUI-: <>l' CONTIMOLS KXTP.NSION ^•>7 11 voii air iisclI I(^ sli'i|is i)( (liacli \ Inn . all is well; makr ihcMi run up In the iipiicr lliinl nf ihc lliiiih so thai lliey act on lliat and nol on ihe ley. If y oil liavo no melliod you prefer, this is wlial I advise, because it nia\ he used everywhere and the parents are in a general way ahle lo I'mk well afler \\\r cliiM In your absence, Fig. ffO-. — Contiauous eitsnsion. — The patient is put to bed and kept tbere with our extension apparatus. Counter-extension is secured by the raising (at llie lower end of the chassis upon which the splint rests. a necessary condition in order that the extension may be pro- perly continued. Extension a) Extension. — Have made in ticking, or better still in soft leather, a long stocking which reaches to the upper third of the thigh, laced in front, with eyelets, and a u tongue » as used Avith boots (fig. 4o4 )- There should be no seam at the heel ; you may even make an opening to avoid any sore at that point. From the calf of the stocking starts, on each side, a leathern thong, Avhich is kept a^vay from the malleoli, in order to avoid all pressure, by means of a Avooden rod placed transver- sely, slightly longer than the breadth of the sole of the foot,. G.VLOT. — Indispensable orthopedics. 27 4l8 HIP JOINT DISEASE : TECHNIQUE OF CONTINUOUS EXTENSION and at each extremity of Avhich is found a hook passing through a hole at the extremity of each leathern thong. At the middle part of the rod is another hook to Avhich the cord for carrying the Aveight is fixed ; this cord passes over a pulley, or, in default of a pulley, over the transverse har at the foot of the bed or of the frame; or even through a hole cut out of the end board of the frame or Avooden bed. Nothing is more easy to adapt. At the extremity of the cord one fixes Fig. 4o8. — Counter-extension is verv easilv elTeeted by placing bricks under the feet of the fore part of the bed or of the chassis which supports the frame. leaden Aveights or sand-bags, weighing 3, 4 kilogrammes according to the age of the child and the result Avhich is aimed at. If you are correcting a deformity, you increase the weight up to 6, 8, ID kilogrammes. The stocking should be laced more or less tightly, in any case so firmly that it is not displaced by the weights. It is a matter of feeling on the part of the mothers, Avho have to watch for the amount the child Avill tolerate. Counter- extension b) Counter-extension. — The most simple method of effect- ing this is to raise the feet of the bed, and fix the patient, that is, restrain the child's trunk on the bed or frame by means of a few Velpeau bandages (v. fig. ^07, 4o8). One CONTINUOUS EXTENSION : COUNTLIl EXTENSION ^•'9 mi'^ht also make counlcr-oxlensioii by placing a skein of very soil xYOol in the groin and ada[)ling ihc Iwo cxlrenniLies of lliis skein lo Iwo rings fixed at llic upper part of the lilllc bed, in such a wav as lo pull from above on ihc corresponding side of the pelvis of the child. If llie Hmb is in abduction, the skein is placed in the groin of the affected side, if the limb is in adduc- Fig. /109. — Uii lai„ [,\\-[,i In lii|i J ji 111 disease. tion, the skein Avill be placed in the groin of the sound side. Steadying the trunk Avith a closely fitting waistcoat of ticking, the ends of Avliich are fixed lo ihe frame, also ensures counter- extension. After a Avhile, a very short time, the care of the extension may be confided to the mother or to a nurse ; that is ^vhy 1 suggest this system in preference to any other, because the prac- titioner himself can scarcely exercise superintendence every moment. By folloAving carefully your instructions and after a 420 CONTINUOUS EXTENSION : COUNTER-EXTENSION little practice, intelligent mothers Avill learn to do much by con- tinuous extension ; but this therapeutic method demands very great care and a certain amount of skill. If you have no one you can rely on, it is better to give it up. Fig. /iio. — The medium plaster. In hospitals where there are many patients, it is not the most practicable system. Lastly, one must not expect more from continuous exten- sion that it can yield. There are some cases of painful hip disease or of obstinate deformities, where it Avill not answer. The pain can only be soothed by a good plaster, and the deformity will only be effaced by correction made under chlor- oform and this correction cannot be completely maintained except by a large, well-made plaster apparatus. HIP DISEASE : THE TECUMQl E OF THE i'LASTER APPARATUS /|2I S. THE METHOD OF MAKING A PLASTER FOR HIP DISEASE. There arc lliiec |)all('iiis of plaster apparatus for the treat ment of hip disease'. Thev diHer only in their lower part. The large plaster reaches from the false ribs to the toes (fig. ^og). The medium plaster slops at the middle of the leg (fig. '|io). The small plaster stops at the Hnc of the knee-joint, and leaves the movements of the knee at liberty (fig. /iii). (., ^' \ '^-^ The Indications for the Large, the Medium and the Small Plasters^ The first is indispensable in the painful cases of hip disease or those having a ten- dency to be deformed; more simply let us say that it is applied to all hip diseases (without distinction) during the period of development of the disease. The second is applied to cases Avhich are cured, when the patient is first allowed to stand. The third is used six months later. It is Avorn for a year and a half at least, until all apparatus are dispensed Avith. For town children, the medium and the small plasters are not often used. Instead of them, Avhen the child begins to walk, he Avears a large celluloid, rigid al the hip joint, but jointed at the knee and at the foot. \A e liaA^e pointed out at length, in our first chapter, the technique of the plaster apparatus and Ave refer you to it for all the generalities. ^\e Avill mention here only AAhat specially refers to the plaster for hip disease. Fig- in. — Tlie small plaster apparatus for walking (applied when the hip disease is cured). I. See thesis of Dr. L. Saint-Beat, iqo6. 4i!2 TREATiIE>"T OF IITP DISEASE There are two conditions to fulfil in order to make a good apparatus for hip disease. The Jirst is, not to interpose betAveenthe plaster and the parts to be supported a layer oi cotton wool, alloAving the bones, when the wool has become uneven, to move in the interior of the apparatus. The second condition, is to carefully shape the upper margin Fig. 413. — Calot table for the construction of plaster apparatus for the lower limb. of the pelvis, to mould the iUac crests by pressing into the plaster with the thumb, above the crests. Without this, they will be able to rise and fall freely and deformity will be repro- duced inside the plaster and in spite of the plaster. Here are a few simple and safe rules w hich must be followed in order to make a good plaster for hip disease at the first attempt. a. As to the covering of the 5u6/ec/, instead of cotton avooI, cover the child with an ordinary jersey — or even tw^o jerseys one over the other (slipped on like pants) : the sleeve will THE TECll.MQLE OE THE I'LASIEK AI'I'AKMT 423 cover llie Icfr. and llie lower borJer nf llic jersey \\ill become tlie iip[)er bonier (iig 4i3). I'or the large apparatus, wbicli readies from the false ribs down lo tlie loes, as tlie sleeve ends al the middle of the leg and does not cover the foot, you will make a sock of the other sleeve of the jersey cut beforehand. T\\e upper brirder of such Fig. /i i3. — By pushing or by pulling (with the control of the dynamometer), one makes abduction or adduction, rotation, external or internal, flexion or hvperestension. sock will overlap the loAver extremity of the other sleeve about as far as the knee. The child thus clothed in jersey, or rather double jersey, in placed upon a pelvi-support of which the plane of support is situated at i5 or 20 cm. above the plane of the table — a pelvi-support Avhich you can improvise everywhere, Avith two boxes, two foot-stools or two piles of books, in such a Avav as to support on the one part the shoulders and the head, and on the other part the pelvis of the patient (v. fig. 4 16). 424 T.REATi\IE>T OF HIP DISEASE The feet are held in the desired position by an assistant Avho pulls on the sound leg, if it is the shorter, or pushes against it if it is longer than the affected leg; a second assis- Fig. /ii_'|. — Our table for hip disease -«Licb may l;e used in the treatment of other orthopoedic aiTections of the lower limbs (for instance the congenital luxation of the hip joint). The pelvis is firmly fixed and the iliac crests are modelled by two cup-shaped pieces or metal splints. The left thigh is found here in the position we have given for the treatment of luxation of the hip joint in coxitis (v. fig. iOi) and also for the treatment of congenital luxation of the hip joint; the left thigh is found in the " first position ", that of the first plaster in the treatment of luxation, while the right thigh is found in the " second position ", that of the second plaster (v. pp. 7/16 and 701 . tant presses upon the knee of the affected leg and upon the pelvis in order to keep up extension or hyper-extension. Keep then, in your practice, to the employment of these improvised pelvic supports. So you see that there is no need to buy beforehand these pelvic supports or those tables which THE TtCllMOLE Ol Till: PLASTEU Al'PARATUS /|25 Fig. /ii5. — The child clothed in his simple or double " tijfhfs worn after the manner of pants. Fig. iiO. — Improvised pelvic-support. 426 PLASTER IN HIP DISEASE. JERSET, BANDAGES AND ATTELLES are invented almost everywhere and Avhich are only " objets de luxe". Vse have had a table constructed ourselves and we give a representation of it here (see fig. /ii2 to 4i4) in order to show you precisely, that its role may be filled as perfectly, and at much less expense, by the improvised support of Avhich 1 have spoken (v. fig. /iio and 4 16), with the help of Fig. !^I-. — Rolling the first bandage. assistants, also improvised, which you Avill find everywhere, in the very surroundings of your patient. b. Construction of the Plaster. You prepare your plastered strips in the way described for the apparatus in Pott's disease, that is, you will prefer plas- tered strips dusted beforehand to strips dipped in the plaster cream (see Chap, i and Chap. v). You apply the strips, observing the recommendations already given. You must spread out the strips, apply them exactly^ APPLY THE JtANDAGES EXACTLY AND WITHOUT PRESSURE /jay bill without pressure. If you spread Ihcm out, there A\ill be no ridyes antl no huiilng. If llic\ arc applied exactly, the apparatus A\ill m.t be too loose. If they are applied Avith- out pressure, the apparatus will not be too tight (fig. 4 17). Circular turns are made over the trunk, without it being necessary to make reverses. At the groin, make a spica, as you would wllh a linen bandage. At the ihidi. at the le? and Fig. 4 1 8. — The last strip. at the foot, again make circular turns exactly applied, without reverses (fig, fiiS). There must be three strips ^ 5 metres long and from 10 to 12 cm. wide, for a plaster for a child of ten years. Remember that the apparatus breaks especially in the inguinal region. Strengthen it at that point by folding the strip several times on itself, or by overlapping several spicas one over the other (fig. 419), or more simply Avith a plastered attelle passed " en cravate " around the hip joint (Fig. 420). I. Ttiree strips suffice, provided that attelles are added. 428 HIP DISEASE. TECHMQUE OF THE PLASTER APPARATUS The Plastered Strengthening Attelles. The apparatus may be made exclusively of strips, but I Avould advise you to make it rather with strips and attelles, as Fig. !iig. — To consolidate the fragile part of the apparatus at the level of the affected groin, one folds the bandage over itself several times which takes the place of the strengthening pads. you did in the plaster for Pott's disease. The plaster is then stronger, more regular and more easy to make. We have described in the Generalities, Chap, i, the method of preparing attelles and plaster cream. For a plaster in hip disease, we introduce four attelles. Fig. .'|2o. — Altelle " en cravale " for strengthening the groin a. The attelle •• en cravate " already pointed out, is made with three thicknesses of tarlatan 12 cm. wide and of a length sufficient for surrounding the hip joint (fig. /iao). b. A circular pelvic attelle to strengthen the pelvic and abdominal portion of the apparatus (three thicknesses of tar- latan : length equal to the circumference of the pelvis, height equal to the distance from false ribs to the line of the trochan- ters, fig. 421). c. and d. Two attelles intended to strengthen, in front and behind, the leg portion of the apparatus. They have a APPMCVTION OF THE I'LASTEUCI) I'ADS ^29 length equal lu the distance from ihe ihac spine to tho loes and a breadth equal to half the greatest circumference of the ihi^di. Fig. /|2i. — The circular attelle for tlie abdomen. \ou may replace these tAvo attelles by a single attelle, like a splint (fig. 421 bis). The respective place of the attelles and the Fig. 421 bis. — Strengthening Attelles : I. As a waist-bell. — 2. " en cravale " at tlie root of the thigh. — 3. As a splint beneath the limb ; this replaces the two attelles, anterior and posterior. strips is the same as for the plaster corset (see Chap, v), that is, you make a first covering Avith the plastered strip, then you 43o HIP DISEASE. MODELLING THE PLASTER APPARATUS place in position the four attelles, and lastly you make, over the whole, a second covering with strips. BetAveen the diflferent layers of plaster, to strengthen them, you spread Avith the hand a layer of i to 2 mm. of paste (true mortar) which binds the whole. e. How to model the supported parts (iliac crests, knee). Fig. /|22. — The apparatus liiiislieil, llie chiltl is replaced on the table. — Carefully verify and rectify the position. — Model the iliac crests. — Enclose the patella between two lateral depressions. The modelling is clone when the child has heen taken down from the pelvi-support and replaced on the table, a few minutes before the plaster sets (figs. 422 to 429). The iliac crests are modelled by making above (not upon the orests themselves, but above) and in front of them, a depression in the plaster with the hands slightly flexed, the thumb in front, the other fingers above. Press doAvn also the plaster below the iliac crests, in such a w^ay as to place them between two depressions; the upper one the deeper, in the iliocostal space, and the lower, less marked, over the external iliac fossa. With the hands, vou lower or raise one of the sides of the MODELLINU llll' I'l.ASltU HOLM) THE i'ELVlS AND Tlli; KNEE '|3 1 pelvis, according lo ihe iritllcalioiis wliicli are present, -^pply llic plaster evenly over llie condyles ol" llie femur and on each side of llie |ial(lla, enclosing consequently the patella between two depressions. There is no other secret iu making perfect apparatus for hip Fig. ^20. Fig. ',2',. Fig. 425. Fig. ^23. — A Ijad apparatus : — apparatus witiiout any depressions, such as are unfortunately too often made. Fig. /|2'i. — In this apparatus the iliac bones can be freely inclined and displaced A badlv made apparatus. Fig. 42 5. — A -well-made apparatus, well modelled over the iliac crests and at each side of the patella. The iliac bones cannot be displaced either upwards nor downwards. The knee cannot turn in the apparatus. disease, and in it all. you see, there is no " Avitchcraft ". AA ith such a plaster, a leg Avhich is in a good position cannot possibly lose that position (fig. :i3o). As to vicious positions, when once rectified and maintained by a good plaster, the correction will not lose even — I do not say centimetres, as is the case with apparatus made by certain careless surgeons — but millimetres. Trimming the Apparatus. — A quarter or half an hour 432 HIP DISEASE. TECHNIQUE OF THE PLASTER APPARATUS after the plaster is " set ", trim and make the edges even by cutting- down to the jersey only. Cut first the upper edge of Fig. 426. — ^lelliod of moulding the iliac crests : — position of the hands for mould- ins; the apparatus upon tlie iliac crests. Fig. 427. — Sketch of an appa- ratus -well modelled above the iliac bones. the plaster over the abdomen, in the form of a crescent, in Fig. /i28. — Schematic sketch of the knee in a badly made apparatus ; the apparatus being circular, the knee is able to turn round in everv direction. g li2T DISEASE. TECH>IQUE OF THE REDRESSME.XT the other the ala of the ilium, he pushes forward the ischium and hrings hack the iliac crest behind upon the plane of the table, in such a manner as to prevent the iliac crest of the affected side tilting forward, ^vhich it ^vill have a tendency to do when you carry the affected femur into good position. 3"' STAGE (fig. \'\o). — Correction. — The pelvis placed in Fig. iio. — 3". stage. Correction. The deformed leg is being carried inwards and dowmvards by the left hand of the surgeon -while the right hand pulls slightly on the foot to facilitate the correction. position and well fixed, you have only to carry the femur into the normal position : With one hand you seize the knee, with the other the foot. With the first hand you pull slightly upon the femur, as if to detach it from the iliac bone; then, Avith a simple pressure of one or two kilograms, you push it directly into the correct position, that is to say, inwards and downwards. It is sufficiently inwards when the knee reaches the prolonged median line of the body, and it is sufficiently downwards when the ham of the affected side touches the table. Having in view the tendency which the leg Avill have later REDRESSMENT OI- A RECENT DEVIATION, IN ABDLGTION ^Z, I on to pass into adduclion. allow an abdudioii df fiom lo" to lb" to persist. On the other hand, one onglil lo go a little urlliec towards deflection and malvc a slight hyper-correction. To do this, carry the pelvis over the loAver end of the table and ower the aflecled knee for 5 or lo cm, below the prolonged plane of the table, pressing on the knee from above do^vn wards. This manoeuvre requires a few seconds. You verif\ the Fig. ^i^r. — Correction iconlinued . The sound leg being placed back in extension, the surgeon, holding the feet, verifies the correction. correction (fig. 44 1) by taking the two feet (the sound flexed leg has been put into normal extension) and comparing the position of the two malleoh and the two heels, Avhilst an assistant, one hand on the knee of the affected side, keeps it in the posi- tion of hyper-extension. There is nothing more to be done but to preserve the cor- rection thus obtained, by a plaster apparatus. 4"". STAGE. — Construction of the Plaster (see above, p. 42o). 5*''. STAGE. — Verification of the Correction a little before the Setting of the Plaster. — The apparatus being finished, 1x1x2 HIP DISEASE. THE REDRESSMENT OF THE DEVIATIONS one removes the child from the pelvi-support, places him gently on the table, the legs projecting over the end to facili- tate the hyper-extension. The correction is again verified, com- pleted if need be, and maintained very exactly in position until the plaster becomes dry. The assistant who models the iliac crests oiiaht to see that '-# " \utk i 1 L of 1 H| ^ ^ l>i - - - - - riassrss ^M m ^H '%:■ i .-...,, :-y.'o.s'or coiifionllal (lislocati()ii(il' (lie lii|), bulyou Avill ranv llirni oiil willi llic lliigh cxIcirIccI. and iiol ilexccl. Ii. Rupture of the adductor tendons (l\'^. l\\-). Two ihumbs pressing crosswise over iho tendinous cord which one or Iwo assistants, pulling llic leg outwards, stretcli to the utmost. Alter a pressure of i or a minutes, one feels under the ihumbs a first tendon give way, then a second, then the others, Avhile the limb is carried oulAvards. Fin. ',00. — Tenotomy of the tlexors. — An assistant pulls on the foot -with one hand and with the other presses on the knee downwards to throw the ilexor tendons into prominence. The tenotome is entered on the inner border of the sarlorius, I 1/2 cm. below the iliac spine. The operator pushes the tendons towards the knife with the fingers of the hand remainino- at libertv. The rupture of the flexor tendons with the thumbs is very difficult and causes a considerable traumatism ; but you W'ill suc- ceed ill stretching them sufficiently by a long and patient kneading. c. Tenotomy. If you are a surgeon, you will prefer tenotomy to rupture of the tendons by pressure of the thumbs. The division is more expeditious and does not require any force. Sub-cutaneous tenotomy is done (fig. 448 and 449) ^^J ^^ incision of a few millimetres, wTiich prevents most surely all chance of infection and is also simpler, Avhatever may have been said to the contrary, than making the section of the tendons by the open method. — If some fibres escape the 452 HIP DISEASE. CORRECTION OF FIBROUS A?fKYLOSES tenotome, they are easily ruptured by making traction, after the tenotome has been withdrawn. This supplementary trac- tion is likewise necessary, though in a less degree, in open tenotomy, as the contraction Avhich affects all the tissues of the region can only be overcome by this supplementary traction. The operation is performed as follows : Instruments. — i", a pointed tenotome; 2'"^ a blunt tenotome, or even an ordinary narrow bistoury may be used. Fig. 45 1. — Another method of tenotomy of the flexors. Here the tenotome is intro- duced outside the tendons ; the left hand of the operator isolates the vessels expo- sing the flexor tendons to the edge of the instrument. a. Division of the flexor tendons near the iliac spine (sartorius, tensor fasciae, sometimes the rectus). The division is made at a centimetre and a half beloAv the anterior superior iliac spine, penetrating inside the tendinous cord and cutting in an outward direction. Position of the assistants (fig. /i5o). — A first assistant holds the sound limb firmly flexed over the abdomen, to immobilise the pehds. A second assistant pulls on the affected knee and carries it dowiiAvards in extension. i". STAGE. — Cutaneous incision. — One makes an incision 4 or 5 cm. long with the pointed tenotome, along the internal border of the prominent tendons, one and a half centimetre TENOTOME Ol- THE VDDUCTOHS A53 beloAv Iho iliac spine, and one introduces llie poiiil to a dcplli of ahiiiil Iwo and a hall" cenlimelres. a'"'. STAGE. — One lunis llic leiiolome so thai ihr culling edge is ouUvartIs; or, one inlroduccs iheblunl tenotome parallel to the incision, to the same dcplli, then one turns it outwards. 3'"''. STAGE. — One cuts Avith a sawing movement, whilst Fig. ^52. — An assistant chaws the leg outwards to make the cord of the adductors prominent. One cuts the tendons from without inwards. The left hand is occu- pied at first in pushing the tendons towards the tenotome, then in raising the skin to protect it from the movements of the knife. the left index fmger brings up the tendon inwards on to the edge of the tenotome. One avoids perforating the skin on the outer side with the point of the tenotome. 4"'. STAGE. — A jerk and a cutaneous depression folIoAv the section of the tendons. The tenotome is Avithdrawn; through the skin you press very firmly on the vessels to ensure hae- mostasis. By your pressure and by some traction by the assistant at the knee the division of the tendons and the correction of the flexion are accomplished. 454 HIP DISEASE. REDRESSMEM OF FIBROUS ANKYLOSES b. Tenotomy of the Adductors (fig. 452 and 453). The operation is based upon the same principles as the prece- ding one, with the few shght modi- fications which one anticipates; the tenotome penetrates outside of the tendons and not on the inner side, the assistants drawing the hmh outwards and not down- wards. The division is made one centimetre below the upper inser- tions along the external border of Fig. .')53. — Tenotomy of the adductors. The tenotome is conducted by the left index finger, the pulp of which pushes the vessels to the outside. Fig. l\b'A. — Haemostasis after tenotomy : one expels the blood by pressing firmly the frno lips of skin, after -which, one makes compression. Fig. Z|55. — Haemostasis. An assistant compresses firmly "with his t"wo hands, furni- shed with tampons, the two small wounds produced by the double tenotomy. the cord made prominent by traction outwards. The operator stands at the outer side of the affected Jimb. TUKATME.NT OF OSSEOUS ANKYLOSIS (vi-KY U.VUIi) ',J5 Tliclefl liiJo\ finger is placed on llic pmminenl cord, wliicli is llien allowed lo ,i-lide inwards — wilhont lenioving the inde\ Cm^vi wliicli Ihen lunches (lie onler border of the tendon. ^^P"ii III'' nail iA' [\\r index finger one places the back of the lenotonic, which is then pushed into the tissues to the deplh desired, and one incises the tendons from without in- wards, avoiding puncture of the skin on the inner side with the instrunienl. One afterwards sees carefully to the arrest of any bleeding, and also lo abduction in order to arrive at the hyper- correction( abduction of from 35" to ^o" at least). Correction in the two cases is kept up by a very firm and Avell modelled plaster apparatus. The compres- sion made to produce has- mostasis should be prolon- ged with the greatest care This ere osteotomy may be perfor- med. — I Cervical, or rather cer\-ico- trochanteric, osteotomy (tiie most useful). 2. Trochanteric (also recommended). 3. Sub-trochanteric (generally done, but ^^rong). until the plaster sets compression is necessary in order to avoid sub cutaneous htematomata Avhich might become infected in course of time. B. —THE CORRECTION OF ANKYLOSES BY OSTEOTOMY I have said (p. 4o6), that you will scarcely ever have to make a section of the bone, because real hip disease is hardly ever followed by osseous ankylosis. I myself do not make more than one or two osteotomies a year although I always have several hundreds of cases of hip disease under treatment. Osteotomy will be sub-cutaneous for the same reason that 456 IIIP DISEASE. OSSEOUS A^^RYLOSES. OSTEOTOMY tenotomy is, because sub-cutaneous interferences are less harmful and offer less risk of infection than those which are done by the open method. The osteotomy severs two thirds or three fourths of the thickness of the bone, and one finishes the section Fig. /.Bg. dinary tome. big. 457. Fig. /i58 Fig. 457. — Cervico-trochanteric osteotomy. Bad transverse direc- tion of the osteotome, ^Yhich would penetrate into the pelvis. Fia;. 458. — Good direction; — should be nearly vertical in some by an osteoclasis, which renders the interference quite harmless. Where should the bone be DivroED? From the orthopoedic point of view, it ought to be done at the level of the angle of the bend (fig. 456). But because of the situation of the old morbid focus which may not, strictly speaking, be entirely defunct, it is better that the rupture should be made a little outside that point. llillMMll M|- v| I'll \-i |;(;,;|| \ \ II |;|i (iv|!i)|ii\n \.)~ Fifif. ItGo. — Osteotomy. — T' sla.jc. — Position of (lie jiaHent. In lliis figure /|0o llie handle of the osteolome is held too higli. It's direction must follow fas in fig. /1C2) the axis of the diaphvsis. ./„. Fig. /|Gi. — Osteotomy. — /" stage. — Tl)e osteotome is introduced into the cutaneous incision down to the bone at the junction of the trochanter and the neck. Then the osteotome is tur- ned go degrees Fig. /|(Jo. See also Fig. 1 1 15 and n iG). 9.^ -,■; I g. A62. — Osteotomy. - — 5"' sla'ye. — The direction of the osteotome is then changed : it should correspond to a bisection of the angle formed by the femoral diaphysis and Ihe bicotylidian axis. ^58 HIP DISEASE. OSSEOUS A^'K1L0SES. OSTEOTOMY It will therefore not be made close to the iliac hone — you would be too near the old focus — hut at the most external part of the neck. In any case do not go below the middle of the great trochan- ter (fig-. 456, 1 or 2) because you AYOuld then be too far from the angle of the bend and die gain by your operation would be much lessened from the point of vicAY of lengthening of the limb; it is for that reason we condemn subtro- chanteric osteotomy AA-hich is recom- mended in some AYorks ; it is somewhat easier, it is true, but it is distinctly less adYantageous. In order to meet the case, you may approach the bone at one or one and a half centimetre below the superior border of the great trochanter (fig. 456, i and a). The section should not be trans- one would run the risk of pene- 463. Yerse trating the ihac bone — it should so- Carry the instru- ment quite near the trochanter, further outside than is shewn in this figure. The osteotome is driven hy a few strokes of the mallet, making a section of two-thirds or three quarters of j^gfin^es be almOSt YCrtical (fig. 458). the bone. ^ "^ _ ' — It will have practically the direc- tion of a bisection' of the angle formed by the diaphysisof the femur and the axis of the acetabulum (fig. 458 to 463). Then, by prolonged pressure, ensure hfemostasis, and fix the limb in hyper-correction (fig. 465). The after-treatment is the same as for simple redressment. One leaves on the large plaster for six months, then one makes the child get up with a small apparatus — which ayIII not be dispensed with for a year and a half later, when the position will be permanently preserved. I. This indication issufficient for practice, because one has never todowith adductions of less than 45 degrees (in osseous ankylosis) . But the indication would no longer be reliable for an extrenme adduction, say of 8o degrees, for instance ; it would be necessary in that case to'perform subtrochanteric osteotonay. TF.CIINKMK Ol >l I'll \- I IKKillAN I r.UIC ( Is I i:( ) I ( )\I V V"'<> Fig. 464- — Osteotomy (continued). The section ol' the hone heing made lor two- thirds or three-quarters, one removes Ihe osteotome and finishes with an osteoclasis. To do this, the thigh is carried very firmly into flexion and adduc- tion as if one wished to exaggerate the existing deformity (this is the first stage of the final osteoclasis. Fig. 'i(J5- — Afterwards (2°' stage^ the thigh is carried into the corrected position, that is, into hyper-extension and forced abduction. 46o HIP JOI>'T DISEASE. OSTEOCLASIS Osteoclasis. Although it is, in reality, a little more traumatising and a little less precise than osteotomy, manual osteoclasis may he of service for children aa hose parents do not wish at any price to hear one or even Fio-. Z|66. — Osteoclasis. — An assistant holds the pelvis (or better, 3 assistants firmly fii the pelvis). The opei-ator seizes the limb (previously straigh- tened bv means of splints tightly strapped) : another assistant seizes the thigh as near as possible to the root, and both of them, the operator and the last assistant, push the thigh downwards and outwards until the bone is broken. speak of osteotomy, nor of blood, norof a hole in the skin. I have performed it under these conditions Avithout accident, Avith an excellent final result. ^cAcrtheless, I do not advise you to have recourse to it except in case AA'here the X rays haA'e demonstrated a neck A'ery much weakened and atrophied — or Avhen you haA^e found, under chloroform, a feAA" obscure movements, but not marked enough to justify an ordinary redressment. TECIIMQL'E or OSTI.OCr.ASIS IH- Till; IIIP .IDINT /|lasloroil as well. Fig. iOg.— 'i'" stage (large plaster;. Fig. '170. — V" >laue. The child can «alk. 462 HIP 30mT DISEASE. OSTEOCLASIS Fig. /iyi. — Luxation of right liip joint. Radiogram on Sept. 2°% 1901. r"^5~^e Fig. /172. — Sept. 23'''', 1 901. One tries to reduce by an abduction of nearly 90 degrees, but without suc- cess. Fig, /173. — Sept. 20"', 1901. In order to induce the femur to enter the acetabulum, it was necessary to place the thigh in flexion at an acute angle on the abdomen, and in abduction of about sixty degrees. Fig. /,75. — Oct. 28'\ 1901. Seeing this, one immediately replaces it in the old position of abduction and flexion; the radiogram shcAvs that, once more, reduction is accom- plished. ;. fql,. _ Oct. 28'*, 1901. A month later, one attempts to les- sen the flexion and abduction The radiogram allows one to see that the femur has a tendency to escape from its cavity. Fig. /17G. ■ — Dec. 2 3"', 1 90 1. New attempt to put the femur in abduc- tion of go degrees. This time the leduction is maintained. One sees that a small bridge of bone has been produced between the edge of the cavity and the femur. TUl-MMKNT OF ABSCESS IN HIP DI^KV'-I. V).'i Fi;;'. .'177. — May (J"', iqo;!. Tlie I'l'imir I' ig. '178. —June 22"', 1902 Abdiiclion of has been replaced in posilion, lillle by about 20 degrees. The reduclion is main- little, in several stages. Tlie re.luc- lained. The small bridge of bone has a lion is permanently mainl.iined. tendency to grow. Tliccliild walks easily. diapliysis by means of four Avooden splints held by straps tiglilly fixed; a veritable apparatus of Scullet (v. fig. ''166). I'''. STAGE \ — One puts tlie Avooden splints in position. 2"''. STAGE, — AA bile tAvo or three assistants hold the pel- vis, pressure is made on the middle of the thigh, until the bone is broken. 4''\ Case. — The Treatment of Luxations of the Femur. I said, on p. '108, that if the head of the femur is in good condition, which is very rare, one makes the reduction as in a congenital luxation of the hip (v. Chap. xn). But if the head of the femur is destroyed (lohich is the usual condition), one may then place the trochanter in the bottom of the acetabulum. — One must be guided here, at every step, by the indications afforded by radiography. — The treatment is difficult and it is reserved almost exclusively for specialists. It is illustrated here (fig. 467 to 478). 5"'. Case — The Treatment of Abscess in Hip Disease The treatment by puncture and injection is the only rational one. AA e have explained the technicpie at length at the commen- cement of this Avork, in Chapter in. Here are some indications relating particularly to the treat- ment of abscess in hip joint disease. I. Afli r being certain tliat anlcvlosis is complete. 464 HIP JOLXT DISEASE. TREATMENT OF ABSCESS A few precautions to be taken accordincj to the situation oj the abscess. When the abscess is at a distance from the vessels, there is no- thing in particular to notice ; but ^vhen the abscess in situated either in front, in the region of ihe femoral vessels, or aboA'e the crural arch, in the pelvis, there are some special points to consider. Fis. 'a'jC^. — Punclure on the outside of the vessels. The operator isolates the vessel with one hand, whilst he punctures with the other hand. a. Beloav the crural arch. (fig. 479)- First palpate the femoral artery Avhich you can feel pulsating; on the inner side of the artery is found the vein, for Avhich you will alloAv a centimetre and a half, lou Avili examine Avhere you ought to approach the abscess, Avhelher it is outside the artery or inside the vein. That depends on the facility with which pressure by the fingers makes the purulent collection bulge more stronglv and more distinctly, on the outer side or the inner side (fig. kSo and following). When you have decided where the puncture is to be made, iiu:vT\ii:.\x oi- abscess i> mi' ihseasi; /|05 Fi"'. .'i8o. — Small abscess in IVonl of llic femoral vein. — Fig. .'i8i. The abscess is pushed inNvards by pressure of the finger. The needle, directed inwards, against the dorsal aspect of the linger, runs no risk of touching the vein. Fig. '182. — i". An abscess situated behind the vessels. — Fig. /|83. — 2°^ A finger firmly presses the skin on the inner side of the vein in the direction of the arrow. The abscess is made to bulge on the outer side of the artery, which is protected with a finger during the puncture. *^ Fig. 484. — Abscess of the buttock. — It is easy to avoid the sciatic nerve which is situated at an equal distance from the trochanter and the ischium. Calot. — Indispensable orthopedics. 3o 466 HIP-JOI>T DISEASE. TREATHEM OF ABSCESS internally or externally, your assistant attempts to pass his finger under the vessels, on the side opposite to that you are going to puncture, and he ^\[\{ push the collection towards you; it Fig. 4S5. — Multiple fislulae (see following figures). becomes, by this manceuvre. more easily accessible. You avoid in this way Avounding the vessels (fig. 48o to 483). Fig. ^86. — Injeclion into the fistulous tracks by the posterior route. The modi- fying liquid, injected through A into the articular cavity returns by the fistu- lous orifices -which one blocks with a large tampon. One has followed here the external route in order to penetrate into the joint instead of the anterior route indicated on p. SgB. — But one may follow also the anterior route. Suppose, however, you do wound them : at once, a jet of blood issues through the needle; v\"ithdraw it immediately and place your fmger over the orifice, pressing for a moment, then, as in dressing a phlebotomy of the arm (it is in fact the same TREATMENT OF ARSCESS IN Mil' DISEASE 467 tiling) apply a lainpon of collon wool over llic bleeding point Avilh some lurns of Velpeau bandage. The slighllv compressive dressing will be removed aflcr five or six days; after wbicli you will recommence your punctures, going a little further aNNay from the vessels, eitlier inAvards or outwards. Fig. ^87. — Diessiag after injection. Fig. '188. — 2"'. An assistant keeps i". Two tampons are placed crosswise hold of the tampons whilst the bandage over the fistula to keep it closed. is applied. This will assure the obli- teration of the fistula from one injec- tion to the other. b. Above the crural arch. An assistant causes the purulent collection to bulge more strongly by pressure exerted from above on the internal iliac fossa. You keep close to the crural arch with your needle, to be sure you avoid the peritoneum, and you keep to the outside of the vessels or inside of them, as tlie case may be (v. also fig. 819 to 822). c. Behind the thigh (fig. /i84). 468 HIP- JOINT DISEASE. TECIIMQUE OF RESECTIO:^ lou Avill avoid the sciatic nerve by remembering that it passes obviously at an equal distance from the trochanter and the ischium . Q'^ Case. — Treatment of a Fistula in Hip Disease. The treatment should be suggested by that described (Chap, in and v) for fis- tulae in general, and for the fistulae of Pott's di- sease (v. fig. 485 to 488). — But here, in the hip Tensor joint, One may do more> Drainage, Arthro- tomy and Resection of the Hip Joint. We have mentioned (p. 38 1 ) the respective indications for these. Drainage is effected, as everyAvhere else, by means of incisions made at all the points Avhere one suspects there is pus retained. Arthrotomy, or the simple opening of a joint, is performed as in the four first stages of resection of the hip joint and is terminated by a thorough drainage. We will proceed to explain the technique of resection. Resection of the Hip joint' (fig. 489 to 495). i^' STEP. — Incision of the skin along a line running from the anterior superior iliac spine to the antero-superior angle of the Fig. 489. — Sketch of tbe incision, either for drainage of the joint, or for resection. One sees, at the bottom of the wound the space which separates the Gluteus Medius from the Tensor Fasciae. I . Tlie indications for which are SO exceptional, as you will not have forgotten (v. p. 38 1). RESECTION (W TIIK 111!' .lOlM' 469 trochanter, exceeding by two centimelrcs in cacli dircclion these two extreme points. 2„,i j..rpp, __ rind Ihc Inlcrral bet\\con the tensor fascias and Ihe ^hilcus medius and sopaialr their luo edges. If the interval Great troch. Fig. igo. — One finds one's way througli the interspace and sees tlie capsule of the joint. is not recognizable, Avhich is the case in old standing suppu- rations about the hip-joint, cut in the direction of the cutaneous incision, through the lardaceous tissues, down to the capsule. ^rd^^^j, _ Exposure of the capsule, ovoi^\hiiisti\\Tema.ms of It. 4th g.j,j,p_ — Opening of the capsule by a crucial incision. — The head of the femur appears. 5ti. STEP. One raises the head without dislocating the femur. If the head is completely necrosed or in a soft condition, as is 470 HIP- JOINT DISEASE. RESECTION OF THE HIP- JOINT frequently the case in hip-joint disease, one removes it entire- ly with a curette, and lays bare the acetabulum. If the head of the femur is not necrosed nor softened, one removes (with the chisel, forced in by the hand or the mallet) only the upper Fig. /.gi. Head ol f. Neck. Caps, opened. Great troch. ( — -J ■j'^i^<-^.-i'<^'^'^- Arlhrotomy. The capsule of tlie joint is opened in its entire length and allows the head and neck of the feniuv to be seen. half of the head and neck, to ensure the discharge of the pus; we will find the half remaining extremely useful from an orthopoedic point of view for preventing ulterior luxations. 6'* STEP. — One makes the toilet with a curette, then with gauze, with which one rubs out the cotyloid cavity and neighbouring parts in order to remove all debris. Then one ensures hsemostasis. I ought to make special mention of the arrest of haemorrhage TEC.HMQLK OT lU'.SEC.I'lON Ol- llli: llll'-.IOlM A7' Fig. iqa. — The upper part of Ihe head and neck have been scraped which is some- times sufficient to ensure the drainage of the cavity. during or after the operation. You should see to this at every step. It is necessary to proceed quickly, — that is understood. But there is one thing of more importance than going quickly ( the tiito hefore the cito) : it is to see that the patient does not lose blood, or loses as little as possible. For this, at each step of the Fig. '193. — Reseclion of upper half of operation, one secures the small }' 'trochanter, of the head and neck, r ' by means of a cold chisel pushed in by vessels which may have been the hand. 473 HIP-JOINT DISEA.se. RESECTION OF THE HIP-JOINT opened. As to the oozing from the surfaces of the soft parts and the bone, one meets that with tampons and ^vith firm pressure upon the parts for one, two, three, four, five minutes, until no more blood flows. I'hen, one proceeds a step further, one compresses again, and so on. II vou have been careful to prevent bleeding, the shock of Great trocli. Fig. liQfi. — Complete ablation of the head and neck. — A cold chisel, worked by hand, divides the neck near its base and nearly perpendicularly to its own axis. the operation will be almost nil, even in an operation of half or three quarters of an hour; on the contrary, the shock will be grave, even after a short operation, if you have not controlled the bleeding well. At the end of the operation, one makes a permanent arrest of haemorrhage by pads placed in the bottom of the aceta- bulum and by energetic pressure, which one keeps up for TI.CIlMdlE OF UESK'niON '.73 iVom 10 to 12 minutes hclMiv pnu-ccdin,- In llir on ic- ilh closirablc prescrNalimi of a jiorlioii of tlic Ik'.mI. or ,il lc;isl the neck. surCu-'uMil lo provide a solid suppoii \'>>y \\u' liml) a level \\ illi llie aiclaludum. Oncloiiclies ihc osseous sniTaces willi a strong solution oi'p nol (one to ten for instance) and, for ten minutes, apply pads w very energitic pressure on llie os- seous surfaces in order to ensure h;e- mostasis before closing the \vound. You will not close it completely but will insert two small drains at the two extremities oftheAvound to prevent the formation of a hicma- toma, which so easily becomes in- fected. The drains are removed at the sixth or eighth day. CONVALESCENCE AFTER HIP-DISEASE AYlien do you place the child on his feet.^^ As a general rule, when the tuberculous focus in cured. One may consider it as cured 6 or lo months after the disappear- ance of the clinical manifestations: fungosities, sol^tening and pain, either spontaneous or on pressure. Then' the child is placed on his feet ; at the beginning, with the support of two crutches (or, better stih, held by the hands) then of two sticks (fig. 497), llien of a single stick or rather of a walking stick held on the side opposite the affected hip. I . From tliis lime, he is permitted to sit up in bed for i or 2 liours a day ; 4 to 6 months later, he will be able to sit in an ordinary chair to take his meals (without the apparatus). Fig. 497. — Tlie sticks which ad- vanlageously talie the place of crutches during convalescence after hip disease. 476 CELLULOID APPARATUS FOR HIP DISEASE He will do his walking exercises from ten o'clock in the morning till six o'clock in the evening. He will Avalk 5 minutes every 2 hours for the first 2 months', 5 minutes an hour for another 2 montlis, then 10 minutes an Fis;. .'198. — Tlie sma'l apparatus in eel- Fig. ^gg. — The same. Poilerior luloid padded and furnished -wilh an aspect, armature of steel. Anterior aspect. hour the 4 months folloAving, after wliich he will have returned to the normal regime. Apparatus for convalescence. i^' CASE. — If the hip has preserved the whole, or the greater part of its movements a removahle apparatus in I. In the interval of these exercises, the child wild rest on a frame or on a couch. CEI.I.l l.'ill) AI'I'All.VTI S IN Mil' hISl'ASE '\-~ collulwid i- wniii h\ llic |);iliciil wlirii he makes his first attempt at walking. Tlic a|.|ui;itiis will he llic mii;iII one stopi)"!!!^ al llic knee (lig. '\\)X. \[)\)). - "i'- li'H' r. llic large apparatus rcacliing lo llie Inoi. hul joiiilcd al the kiicci Fig. Boo. — The large apparatus in cel- luloid jointed at the knee and ankle. Anterior aspect. Fig. 5oi. — The same. Posterior aspect. and ankle (fig. ooo, 5oi). — The patient Avill ^vear it only from lo a. m. to 6. p. m. His hip will he free all the rest of the time as well as during the night. 6 to 10 months later, one will commence to massage the legs gently, electrise them, bathe them; and one teaches the patient to walk properly, methodically, " thinking out " each step. 478 CELLULOID APPARATUS I>i' HIP DISEASE After a year, all apparatus may be put away. 2°"^ CASE. — If the patient has a stiff hip Avith a tendency to deviation, he must wear the apparatus constantly. It should be a small irremovable plaster, or a large cellu- loid reaching from the umbilicus to the foot, jointed at the knee and at the ankle. For how long is the apparatus to be worn ? You will leave on the apparatus until the hip has no ten- dency to deviate, which result is often not attained until 2 years or even longer, after standing-up has been first allowed. When you judge that the time has arrived to leave off the apparatus, you leave it off gradually, first at night, then part of the day, and you will verify very exactly every 8 days that there has been no movement, that is. that there is no return of adduction of the knee nor lumbar hollowing. If you perceive the least deviation, replace the apparatus or, at least, ensure during the night, by the help of Velpeau bandages, attitudes contrary to those Avhich the limb has a tendency to assume. lou will combat adduction, flexion, rotation, in the way mentioned in chap, xiv (fig. 85o to 854). And even in the case where nothing has yielded, apply slight extension during the night, as a preventive measure, so that the limb keeps the attitude and the length you Avish it to retain. Coxalgic children have need, after the cure of the tubercu- losis, of being looked after by the surgeon for one or even seve- ral years, without Avhich they very often again become grad- ually deformed. \ou have cured a child Avithout deA^ation, with no lameness or nearly none; the parents think it is no longer necessary for you to see him, and then, after one, two or three years, a deviation of the hip and a marked shortening- have recurred, causing a A^ery unsightly lameness. Do not give up these children because they haA^e giAen you up too soon. Put them back under treatment and redress the dcAdation, in the Avay Ave have directed for vicious ankyloses in cured hip cases (v. p. 447)- This imroiliinali' ('\(iilii,ilil \ will noi (icciir if \(ui kmih'Iii \)vv III nv'jic llic parents [n show llic child lo you allcr lh( Fig 002. — To take llie measuremenls for a special heel. The patient is phiced upright. The iliac spines at the same level : one places some pla- ster under the sole of the foot -which does not touch the ground. Fig. 5o3. — The foot resting on the spe- cial heel is covered with a stocking, the mould is made over the whole ; one sees the band of zinc over which will be made the incision to take off the nesative mould. Fig. 5o.'i . — Boot for the affected side. Foot pro\ided with"spccial_heel. Fisr. 5o5. — Sound side. apparatus has been left off, at least every 3 or 4 months for several years. 48o HIP DISEASE. RELAPSES AAD RECURRENCES Orthopoedic Boots. A shortening will often remain\ in spite of everything^. If that amounts to less than 2 c. m. it is negligible; the child will walk well, without even the need of a raised boot (provided the position is good and the hip well united). But if the shorte- ning attains or exceeds 3 cm. supply a special heel, not equal to the height of the total shortening, but only half that. The boot should be supple to preserve the easy movements of the foot. Relapses and recurrences'. In stating the precautions to take and the care to be given to patients just allowed to stand again and during convales- cence, we have implicitly indicated the best means of avoiding relapses, that is the return of the tuberculosis. We ought to add some precautions of a general nature, meaning by that, that one must not be in a hurry to send back a child to Paris or to any great city, or to the poor sur- roundings where he was taken ill. One must keep him by the sea or in the country, and attend to his diet and to his hygiene. Keep him from every possible contagion. How many cases of cured hip disease have broken down when prematurely sent back to Paris 1 Do not forget that cured hip disease is an old tuberculosis and the subject of it ought, on this account, to foUoAv a severe course of hygiene, for several years more. Thanks to good supervision, one will avoid relapse, or at least one wall render it as rare as is humanly possible ; for one must admit that a debilitating malady which has unfortunately appeared a short time after the cure, — influenza, diphtheria, I. Particularlv in hip disease "VAith abscess, the tuberculosis having, in these more serious cases, deeply eroded and sometimes destroyed the head of tlie femur and the roof of the acetabulum. 3. Unless you have made early articular injections. 3. What we say here of recurrences in hip disease is applicable to recurrences of other osteo-articular tuberculoses. BELAPSF.S AND REiiT UUF.NCF. iniiiiins. etc. Ilia violciil traumatism over lli<- hip. iua\ [iiecipi- lale a ielai)se. whatever iiia\ have been dour up \o this moineiil. Parents ought lo flee from all foci of coiilagioii and preserve their ehildrcii Avilli the greatest care from all kinds of shocks. What to do in the presence of a patient with hip- disease cured for one or two years, who suffers again in the region of the joint? Assure vourself first of all that it is a question here of a true relapse and not of some passing pains due to a simple sprain — coxalgiques assuredly being liable (as much or even more than anyone else) to a sprain of the hip after a blow or some exaggerated joli.rue — not leading inevitably to a return of the tuberculosis. In case of doubt, always place the child at rest for two weeks. If all pain disappears the same day, replace the child on his feet after those two weeks and send him back again to his ordinary life, but little by little, watching over him very closely, of course. On the other hand, if the pains reappear as soon as he is placed 6n his feet, or if, at the outset, he has been taken Avith acute pains, muscular contractures in the whole of the region, or with noctur- nal pains, or again, if there exist fungosities appreciable on pal- pation, vou will conclude he has a true relapse and will submit the child to the same treatment he underwent at his first attack. Let us mention that the appearance without any pain, of a periarticular abscess, two, three, four years after the child has been sent back to normal life, is not always the sign of a relapse of osteo-arthritis. It is a question very often of an old erratic bacillarv nodule, of a fungosity of the soft parts, having lost for a long lime all communication with the hip, Avhich could have been reabsorbed and remained permanently ignored, and which, instead of that, has softened and produced the abscess of which Ave speak. In a word, it is an idiopathic abscess of the soft tissues, rather than an abscess by gravitation coming from the joint. You will puncture it and inject it. and vou will be able to send back the child almost immediately (after a month or two) to his ordinarv life. Calot. — Indispensable orthopedics. ^' 482 HIP DISEASE. I*''. AN OBSERVATIO>" OX RECENT II IP DISEASE APPENDIX TO CHAPTER III On our results in hip disease. i^'. Specimen of the result usually obtained in cases of recent hip disease fv. figs. 5o6 and 007). The case here iUustrated is that of a little boy, Pierre R... of Paris, Avliom yse treated at Berck for a left coxitis of between two and three months standing. Fig. 5oG. — Child cured of left hip- disease, Pierre R... of Paris who was sent to Berck by my master, ^I. Ja- lajruier. Fig. 507. — The same. Oae sees that he has recovered the -whole of his mo- vements. He is able to flex his thigh at an acute ano;le. These Iwo photographs were taken three years after cure. The diagnosis had been made by my master, M. Jalaguier, who had even commenced the treatment in Paris, before sending the child to Berck. AN ORSRRVATION ON GUAVK HIP DISEASE /,83 Al Bcrtk. llu" lllllc [laliL'iiL I'ollowed llic IreaUncul given in lliis book 1(11- lii[) disease ol' the llrst variety. Al the end of i4 months, he A\as allowed to get up and begin to walk. Here are the photo- grapiis taken three years later. The lirst shews that the child is quite straight (iig. 5oG). No hollowing, no deformily, no shortening. The second shows that he has recovered the whole of his movements. After that, one will not be surprised that the child walks to-day without a shadow of a lameness. He is a normal child. And similar results arc not the exception, they arc the rule in hip disease taken at the beginning and well treated. We can recall a good number of our old cases of hip disease Avho have been able to go through their military service. 2"''. Specimen of the results obtained in old or grave cases of hip disease. The four figures (5o8 to 5io) represent a boy of i3 years of age (A. de N. of Lisbon) who came to us at Berck in 1899, with a left hip joint disease of malignant character dating from about 4 years and still in active progress ; the child complained of very severe pains and presented Iavo large abscesses, one on the buttock, the other in the middle part of the thigh, but not yet opened, fortuna- tely. There was impossibility of movement without crutches, on account of the pain, and of a very marked deviation of the affected thigh, which was flexed at nearly a right angle S with adduction and internal rotation. General condition very indifferent, child pale and miserable. Treatment. — Complete repose in the recumbent position, on a frame. We commenced bv treating the abscesses — punctures and injections — without taking notice of the hip joint disease. At the end of three months, the abscesses were dried up and at the same time the general condition Avas greatly improved. At that moment we commenced orthopoedic treatment, that is, the correc- tion of the vicious ankylosis, proceeding gently, without chloroform, and by stages, in the following way : the trunk of the child being held by two assistants, we made slight traction of about 10 or 1 5 kilograms, on the foot and the leg and after 2 or minutes of this traction, having obtained from 10 to iS'' of correction, we stopped there. Handing over the traction to an assistant, we plas- I. If the thigh appears, in figure 5o8, much less tlexecl, it is because the lumbar hollow is not obliterated, but the flexion attained 80° or 90° Avhen one had taken the precaution of obliterating the lumbar arch (v. p. 48^. fig. 5o8). 484 HIP JOINT DISEASE. AN OBSERVATION ON AN OLD CASE tered the child in this sHghtly corrected position (large plaster going from the umbilicus to the toes). A fortnight later, a second correction (again without chloro- form) of io° to i5", and a second plaster, and so on; every two "weeks a new short sitting for correction, — always gentle, so as not Fig. 5o8. — Left hip disease dating back fourjears, of grave character, and still in active progress. Severe pains, two abscesses, vicious ankylosis. The child unable to move. Such was the condi- tion of child on arrival at Berck. Fig. 5o8 bis. — The same child three years later (the abscess has been dried up and the deviation obliterated in several sittings, by stages). See the text for details of treatment. to fatioue at all the child who bore these very small interferences o ^ admirably. At the end of three months, three fourths of the correction was obtained. To complete the correction we preferred to have recourse to chloroform and perform a tenotomy on the adductors. This very small operation, which lasted barely 5 minutes, gave us not only the complete correction, but even a hvpcr-correction of from 35" to nil TWO AltSCESSES AND VICIOLS ANKYLOSIS /|85 l^o^\ Tlii> liiuc, we Irll llic j)lalcr, whirli slopped al llie kiuM'. in an aiidnclioii of luj" only. For one year more, the cliild wore small plasters: and llien lor nearly riglil nionllis a celluloid Fig. 009. — The same child seen profile (on his arrival at Berck). Fig. 5io. — The same, three years after our treatment. Observe the straigh- tening. The good attitude has been maintained for the last seven vears. apparatus, Avhich makes a duration of about three years for the whole of the treatment. But look at the result obtained. The child Avalks actually without apparent lameness, and this slowlv obtained cure has been perfectly maintained for the last seven years. One can, Avith a treatment well conceived and well carried out obtain results in every way as satisfactory in the immense majority of cases of grave and far advanced hip disease. CHAPTER VII WHITE-SWELLINGS I. — Diagnosis of tuberculous arthritis at the onset. We do not speak of the disease when the diagnosis obtrudes itself, but at the commencement of the disease. You are consulted about a patient -who experiences in one of his limbs a fatigue, or a pain (the pain sometimes only at night), or even a single functional inconvenience, Avhich may be only intermittent. Never neglect to examine completely nude in such cases, the regions of the joints of the suspec- ted member, comparing them constantly Avilli the same regions on the opposite side. — Find out : i^^ If there exist pain on pressure of the articular extremities in the segment over Avhich the patient or his friends dra^v your attention (fig. on). 2"''. If there exist already a commencing deviation, and in default of an apparent deviation, a limitation, however slight, of tlie movements of this articulation. With these two signs you Avill be able to assert that there is " something wrong " in the joint (fig. 5i2, 5i3, 5i4, 5i5). HoAv will vou know that this ' ' some- thing " is tuberculous? i'^ By the history- If the pain and loss of power have super- vened without appreciable cause, without a distinct injury, without rheumatism, Avithout blennorrhagia, without the antecedents of scar- latina or of hereditary syphilis, you should think of a tuberculous Fig. 5i I. — White swelling of the knee. — Look for pain. The painful points (on pressure "with the index finger) may he found either opposite the epiphysial car- tilasres or over the interline. DIAGNOSIS .)l 11 UI.KCLLOUS AUTlllUTlS AT Tllli COMMENCEMENT ^87 ailhrills, cspeciallN il' nou arc doallnj; uilli a delicate cl.ild. or one .-J~F Fi. 5,.. - Umliailoa ofmo.e,nents.-The patient Ivingon l.ls 'j'"; «" tl^e ri.l^a^- ^ed; side, tle.ion oflhe knee is very limited ; on the left .ouud , sule llex.on ., normal. recoverhio- from a debilUatlng disease, an eruptive fever, measles, \\ liooping couuli. etc. ^ddJe) Fig. 5i; Fis. oiA. Fi£. 5i3^. — Lmitalion of movemenl. — A normal knee joint. — Complete extension is possible, Ficr. 01^. — A diseased knee joint. — Complete extension is impossible, it remains at ° a slight degree of flexion. Fio-. 5i5. — Front view. — Globular knee. One notes at the same time a slight decree of srenu valgum. 2"'. By the direcl sirjns. If the patient has no i'cver (or scar- 488 ^YHITE S^VELLINGS DIAGNOSIS AT THE ONSET cely a few tenths of a degree) : if, on palpation of the accessible parts of the synovial membrane, you find thickenings (fig. 5i6, 017), irregular bulgings of the serous cavity, a pastv consistence or pseudo-fluctuation : if there exist an atrophv of the muscles contrast- ing Avith thickening of the folded skin (fig. 342, p. 060). S'"^. By the positive ophthalmo-readion, the value of Avhich seems to me to be real without being pathognomonic. In the cases where vou still have some doubt, have the couraore *:^ Fig. 5 1 6. — ^Normal knee. Tlie osseous prominences and the mus- cles in relief normal condition,. Fig. 517. — Diseased knee. The osseous and muscular prominences have disap- peared ow ing to swelling of the knee. io reserve your diagnosis ; ask to see the patient again : meanwhile, keep him under observation . If vou think there is a possible sprain, massage it; — if rheu- matism, prescribe salicvlate of soda: — if simple hydrarthrosis, puncture it and applv pressure: if hereditarv svphilis, adopt the specific treatment. When, in spite of these different treatments the symptoms still persist for several weeks, namelv, pain on pressure over the ends of the bones, limitation of movements, functional distress, thickening of ouriioioinic iiucAiMKM oi wiiin: s\\i:ij.ings /189 [\\o s\ii()vi;il mciiibraiic, — lIuMi coiicludc [li;il llicrc i> a In IxtiuIoiis iiillirili- and coniiuoiicc llir licalincnl a|)|ii()[)riak' to llial coridiliryn. //. — J*io(ino.'g benign and recent. (Little or no fungosity, AAithout pain and without devia- tion.) In the hospital, and for children of the working class, you will at once apply a plaster (a circular plaster extending to the neighbouring articulations). 4gO WHITE SWELLINGS : CORRECTION OF DEFORMITIES For town children, you may equally well use a plaster; ne- vertheless it is better, in these cases and in this class of people, where you always look for a cure with mobility of the joint, not to apply a plaster, provided the joint affected is kept at rest. Prohibition of walking and rest in the sitting position with the leg stretched out. if the lower limb is affected. The arm in a sling with liberty to walk about, if the upper limb is concerned. The joint in both cases protected with a light protective dressing (cotton wool and A elpeau bandages). Fig. 5i8. — ^^hite swelling of right knee witli marked deviation, ^ncl ^'\ jjjx£ SWELLING DISTINCTLY FUNGOUS OR PAINFUL. Here, in the town as in the hospital, you will immediately apply a plaster which ivill include both the neighbouring joints, so as to ensure more certainly the immobility of the affected joint. 3rd W'hite swelling with deviatio>" (Gg. 5x8). The indication is to correct the deviation : then to preserve the correction with a large plaster. Be prompted by Avhat we have already said (v. Hip joint disease, chap. VI) as to redressment of tuberculous deviations. We ought, as in Hip disease, to distinguish between two varieties of vicious attitudes. i'* : Those at the onset or during the acute period of the OKI iioiMM'Dic lUEATMKM' IN <;ii:M:u.vr, ^9' disease \\lien Llic luhci'culosis is iiiosl \iiuient, ami demands the greatest precautions. •>'"' : The vicious atliliidcs nearly aiivay-'' pfiinless, at the end or at llic " relapsing "' period, vviicn ihc luhcrculosis is nearly extinct or even quite extinct. Here manipulations of a vigo- rous kind are permissible. Fis. Fis;. 52i Fig. 519. Fig. 520. _ _ Fig. 510-522. — Correction of a devialion of the knee by successive stages. a. i^' METHOD. — Without chloroform. Redressment by stages. A new plaster every fortnight. One gains a few degrees each time, Avithout causing pain, as it only amounts to a little traction or a little pressure, which can be effected even after the last plastered strip has been applied. You appeal to the courage of reasonable patients who will tell you freely how far you may go with traction without arous- ing real pain. One attains in this way, in the space of two or three months, surprising corrections and even complete ones, without ma- king any change in the patient's mode of life. 492 WHITE SWELLINGS : CORRECTION OF DEVIATION Figs. 619 to 52 2 represent the correction by stages, made by a series of plaster apparatus, without Chloroform. 6. 2°'^ METHOD. — Correction ivith the help of Chloroform. An apparatus every i5 days, in the way we have just described, is however too much under certain circumstances, for instance in a hospital, for a very busy surgeon. It is simpler, for example, little as one may be familiar with anaesthesia, to give a few drops of chloroform and finish at one or two sittings at the most. Indeed, by the help of chloroform, one accomplishes almost immediately, without danger, without violence, the desired correc- tion which is at once secured by the application of a plastered appa- ratus. The whole affair occupies from 5 to 10 minutes and then three months of rest and perfect comfort is assured for the patient. One sitting suffices for recent vicious deviations. The older deviations require generally two or sometimes three. A gene- ral rule, Avhich it is important not to forget, is to avoid all useless or violent manipulation. We may add that correction is always attained — or nearly always — by simple orthopoedic manipulations, by a simple redressment without having recourse to an osteotomy or even to a tenotomy, B. — TREATMENT OF THE TUBERCULOUS FOCUS. What shall we do to cure the tuberculous focus? A treatment consisting of rest of the joint and its immobi- lisation by a plaster apparatus. Is that all.^ It is all when one is dealing with a focus in Pott's disease. But if, in Pott's disease w^ithout perceptible abscess, the seat being too far removed from the lesions prevents us doing more, it does not follow that our attitude will be the same in articu- lations so easily accessible as the knee, the foot, the shoulder, the elbow or the wrist ' . I. From this point of view, Hip disease stands half way between Pott's disease and white swellings of the different joints. The hip is not so easily THE.VTMEM" OF Tilt: TLHEUCLLOUS Ff)CUS li[i6 Here we may choose between llic lliico ' Inlldw iiii.-- Ircaliiienls i". Mere rest in a plaster: 2'"', Removal ol' (lie aiiicular focus, that is resection; S"', Modifyiiig- iulra-aiiicnl.u- injections. Of these three treatniOTils whicli is the best? Fie (see descriptiou of Fig. 027). To reply to this question, let us go back to the tubercu- lous type of lesion, which is Cold Abscess. In fact, is not white swelling, in reality, merely a cold abscess of the articulation? (fig. oaS to 027.) It is evident, if it is a question of white sAvelling with dis- charge. But it is also true of Avhite sAvelling not yet softened ; accessible; nevcrtlieless you liave seen that it can be reached by following- the method gi\en on page 892. I. The method of de Bier in white swellings X> I do not know this method well enough to be able to express a definite opinion. But Avhat I can sav is that, in some cases well known to me ^^here it has been applied for tuberculous arthritis, it has produced an unmistakable aggravation. Even amputation has been necessary in three cases treated by it; these patients -would certainly have been cured by the treatment we advise. 494 WHITE SWELLINGS : INJECTIONS THE BEST TREATMENT if here the liquid contents of a cold abscess are wanting, on the other hand, we have it's virtual cavity and especially it's cha- racteristic element, the only essential one of the cold abscess, namely, the proliferating and fungous wall. It follows that what has been known to be good for cold abscess will without doubt be good for accessible white SAvel- Fig. 5a5. (see description of Fig. 627). Fig-. 526. lings. And, if there is one thing universally admitted in cases of cold abscesses, it is the beneficient revolution which has taken place in their treatment since one punctures and injects them ; it is the indisputable superiority of punctures and injections over pure conservative treatment (rest and compression) — which is too uncertain and too long — and over surgical operation ivhich rarely cures, often aggravates (by leaving a fistula) and always mutilates^ (fig. 5 28). I. If it is true when one operates on cold abscess, what is to be said of the mutilation left by resections in childhood.^ They inevitably leave a lesion of the articular cartilages, whence a shortening which will increase later on. THE INJECTIONS HAUOEN Oft DISSOLVE THE I'LNGOSI IHCS /|()5 It isexaclly lliesaiiic in w liilc swellings, where tlie Ircatrnent l)\ punclurcs and injeclions is infinitely superior to ihe two others; it is cITicacious, henign, easy to use everywhere and relalivelv rapid ; il cures in a few months, (S to 12, leaving Fig. 527. — Description of figures oaS to 627. — Analogy of suppnraled while swel- lings u'ilh cold abscess : the figures allow us to realize that the synovial membrane (the cul-de-sac under the triceps) may become separated from the rest of the arti- cular cavity (pathological adhesions and form an abscess. The abscess is cured, like all cold abscesses, by punctures and injections. The articular pocket will be cured logically by the same method (as it is of identical nature with the part which has been separated from it), superior orthopoedic results to those of the two other methods'. I do not say that there do not exist some cases of dry or On this account tvpical resections ought to be condemned -withovit appeal, in childhood. I. Injections, Ijv advancing the date of cure, allow us to considerably shorten tlie period of severe immobilisation in plaster; and thus the move- ments have not time to be lost, or, if lost, they may return, — whilst surgeons who do not make injections are obliged to leave the plaster for three long years, whence for their patients, the habitual termination by ankylosis, even after mild arthritis. 496 WHITE SWELLINGS : INJECTIONS THE BEST TREATMENT fungous white swellings calling for either conservative treat- ment (recent or mild arthritis not fungating, the child not pressed for time and able to wait for years) or resection (white swelling of knee completely and easily accessible in an adult Avorking man to whom time means money). But apart from these special exceptional indications, to which Ave will Fig. 028. — An example of the poor result of a resection of the knee : after 5 years, there is a shortening of 11 cm fl) as well as a pseudarthrosis. return, the treatment by injections ought to be the regular treatment of tuberculous arthritis. The method of cure of white SAvellings with effusion, by the method of injection, is easy to comprehend; but how can injections cure a dry or /ungating white swelling? In this way : By making the injections into the large articular cavity and not round about it, Ave reach the fungosi- ties on the internal surface of the synovial membrane and over the osseous surfaces, that is, where they really are. The liquid, placed in contact Avith the fungosities, modi- TFIE INJECTIONS IIAHUEN OU DISSOLVE THE l-llNr;OSlTIES. '|(|- (ics tlieiu III (wo \\,i\s. rilhci- sclerosing ihciii or Mjllcuiiig lliein. Be llic Iraiisloniiiilioii librous or licniilN iiii; llie cure will be thus proiiioled, hastened, assured; if I here is sol n I ion, (li;il is lo say intra-articular cfTusioii arliliciall\ brouglil aboni, one associates the punctures with the injections, as in the case where I'llnsion existed before. A^e iiave liquids which give us sclerosis : that Avhich gives llie best result is creosoted oil with iodoform (the formula is given at p. no); — others which give us solution of the lungosities, the best is emulsion of camphorated naphtol in glycerine (i/6 camphorated naphtol lo 5 6 glycerine; see page no, the dose to be injected). I call those which produce sclerosis, injections of the dry type : when they bring about liquefaction — injections of the liquid type. In a general way. it is better to dissolve than to sclerose. One cures better and more certainly by dissolving all the tuberculous products, so as lo be able to expel them afterwards by puncture, than by transforming them in silu by sclerosis. Bacteriology allowed us to foresee this ; clinical Avork has demonstrated it. One Avill make then, — as a general rule, — injections of camphorated naphtol in glycerine rather than injections of creosoted oil with iodoform. It is a necessitv in the forms, even slightly grave, of articular tuberculosis. As to the benign forms, the injections of creosoted oil with iodoform may be sufficient, and, as they cause, as one can imagine, less inflammatory reaction than the other, one may give injections of the dry type in all town children Avith nervous parents. One cures three fourtlis of the cases in this Avay. AA hen the Avorst comes to the worst in those Avho after 5 or 6 months are not cured, you Avill make a second series of injections, this time of the liquid type. To recapitulate, Avhen white swellings are drv or suppu- rating, the treatment by injections, if it is avcU done, cures more than 19 out of 20 of the patients in the space of from 8 to Calot. — IiicHspensable orlliopedics. 02 IxgS TREA.TMEAT OF WHITE SWELLOGS. INJECTIONS 12 months, with, very often, the preservation of the functions of the joints. This preservation of mobility is obtained especially in town patients whom Ave are able to follow up and who come to us before the period of osseous destruction has set in. STATISTICS To give you an idea of the results of injections in tuberculous arthritis, we cannot do better than place before you here the entire statistics of Avliite swellings treated for lo years, from^ January i8c)5 to January igoS, inthe hospital Cazin at Berck, where all white swellings without exception are treated by intra-articular injections. The number of these white SAvellings amounted to 3ii (176 of the knee, 77 of the ankle, 18 of other articulations of the foot, 8 of shoulders, i5 of elbows, 17 of the wrist or other articulations of the hand.) All these children were cured within a year, by a series of 12 in- jections, except 7 of them Avho were cured «fter 2 or 3 years only, and in whom a new series of injections had to be made (even a third series in four of them). There existed undoubtedly several inde- pendent foci which had not all been reached by the fii'st series of injections. Not one death, no amputation, nor even a real resection. We have not performed in that hospital, for the last ten years, more than three resections of the knee luith a purely orthopcedic object in view. These children have been cured, as we said, In an avei'age of 8 or 12 months, namely, 3 months for the Injections, 3 months of com- pression and rest after the injections, and finally, from 4 to 6 months supervision, still at rest, to be assured of the cure, before returning to the use of the limb. From the point of vieAv of quality of result, not only have we obtained limbs of normal length, position and strength, but, in nine tenths of these cases, the mobility is preserved, but not however in the knee; we must admit that in the hospitals we do nothing to preserve suppleness of the knee, because children of the working I. These statistics of tlie hospital Cazin are the most striking of all those I am able to quote : i'^'. Because in the hospital Cazin, all the swellings have been treated by injection. 2"'^ Because the method has been followed ^^ith the utmost strictness. iNJECiioNs ()i wiiiii; s\\ icij.ixis Willi l;ii iJSioN v.)',) class, Willi little m no siipcrv i^iun ;il tciw aids, liaNc iiioic iiccil lor the limo Ijoiiii; i>\ a strong liml> wliicii remains well cured, than a su|)j)lo joint, wliieli, on account ol it^ verv suppleness, is o\|)0-;ed lo sprains and relapses. It ha[)|)eiis also verv ol'lcn, alter a vear and a half or two years ol wjiitini;. that niobililv in the knee returns of its own accord. TliCII.YInH'J or THEATMENT OF WHITE SWELLINGS BY INTRA-ARTICILAR INJECTIONS. 'I. — White swellings with effusion. Here is the scheme of treatment you should cany out. \ou apply a plaster, ^\ilh an opening for the injections. After that the treatment is identical v\ith that of ordinary cold abscess (v. Chap, iii, Trealinenl of suppurated tuberculoses); the same liquids in the same doses, are injected into the arti- cular cavity. (You will find in the second part of this chapter, the place for injecting each articulations.) Thus one makes from 7 to 8 punctures with as many injec- tions at the rate of one every 6 or 8 days — which extends over about two months. After that, you make methodical pressure over the region with squares of cotton wool introduced through the opening in the plaster and supported by a soft bandage, a compression equal to that required for a gibbosity (v. Chap. v). You leave the limb at rest in the plaster apparatus for three or four months longer. The examination made three or four months later shews that the articulation is free from pain'. From this time, the joint is left without apparatus; but it still requires icst for several months (rest, for the lower limb on a frame ; in a sling for the upper limb). It is during these few I. If, Aery unusually, three or four months after the injections, pain and fungosities still persist, it would he necessary for you to make a second, and if need he, a third scries of injections, leaving three or four months interval hetween the series. This necessity for the second series of injections has occurred to us 3 times in a hundred, and that of a tliird series once in a hundred onlv. OOO ARTICULAR OJECTIOS O DR^ WHITE SWELLINGS months of rest that you usually see the movements return spontaneously by the sole effect of the joint being left at liberty and without any direct treatment ; at the most you will help it by a few baths ( 2 or 3 every week). You should not consider the child cured before six or seven months after the articular extremities have been freed from pain on pressure. This makes for the entire treatment, on an average, from 8 to 12 months. TUBERCULOUS HYDRARTHROSIS. If instead of pus in the joint there is only a sero-fibrinous effusion (do not forget that half of the hydrarthroses of child- hood, in particular those Avhich continue beyond a fcAV weeks, are of tuberculous nature), one will carry out the same treat- ment as for distinctly purulent effusions, with this difference, that five or six punctures and injections, followed by two punc- tures Avithout injections, suffice generally in the case of hydrar- throsis, to ensure the cure. b. — Dry white swelling. One applies here also a fenestrated plaster for 5 or 6 months. We know that here we may look for either sclerosis, or solu- tion of the fungosities. Not only the liquids, but also the number of sittings and their intervals are different in the two cases. i"*' To OBTAIN SCLEROSIS, onc iujects froiii 2 to 12 grammes, -according to the age of the subject and the capacity of the joint, of creosoted oil with iodoform, and one will make only one injection weekly (without punctures, seeing there is nothing to evacuate). One ceases after eight or ten injections. 2°'' To EFFECT THE LIQUEFACTION OF THE FUNGOSITIES, OUC injects the mixture of naphtol and glycerine' (v. p. i65), I. Alone, camphorated naphtol may not give us this liquefaction with certaintv. — Gaiacol, or thvmol or camphorated salol are of incompa- WHITE s\vELLn(;s. — the reactiox puoduced b^ injections 5oi givinp- an injccli'on daily unlil llie arliciilar olTusimi is brou>ilil about. Thai is producctl towards the IViuilli das (sdiiietinu's on llie tliii'd, souielimcs only on llie lil'lh or sixth). As soon as ihc liquid appears, one commences willi a punc- ture and finishes with an injection, loUow ing the technique already studied for white swellings with effusion existing at tlie onset. From this time, spread out the sittings; one only every five or six days, which gives the patient a rest, the daily injections at the lieginning being fatiguing to him. The treatment following the injections is the same as that given above. The reaction caused by the injections. Injections ahvays cause a certain fatigue and a certain reaction ; that is true even with iodoform. You should warn the parents of this. The reaction is more noticeable with injections of naphtol, especially at the commencement, where they have to be repeated each day in order to produce the articular effusion. It is not a question of an immediate reaction, which with our liquid is next to nothing, but of the desired reaction, the following day and for some days afterwards, which is shown by the general and local phenomena of an acute or subacute inflam- mation. One observes a certain malaise, loss of appetite, rably less value (I have experimented with, them, also, for a long time). But camphorated naphtol needs to be employed with considerable cau- tion, that is, in a certain dose and in a fixed form. The dose is from 6 to 3o drops for each injection according as you are treating a child or an adult. The form in which it should be used : never alone, alnays intimately mixed with glycerine in the proportion of one gramme of camphorated naphtol to five grammes of glycerine. Refer to page 120 and to figure 107. Under this form and in this dose, camphorated naphtol is not only inoffensive but is just as efficacious as pure camphorated naphtol, — that is, it produces on the fourth or fifth dav the articular effusion sought for. (See the thesis of Dr H. Saint-Beat, igoS.) 502 WHITE SWELLINGS : THE TREATMENT TO ADOPT sleeplessness, at the same time slight swelling, pain and heat, and occasionally some redness of the neighbourhood of the joint. The temperature reaches 38°, oS'^b, and even sometimes Sg", with the doses we have mentioned. If then after the first or second injection, the temperature rises, it is a good sign, in this sense, that it marks the very near occurrence of effusion in the joint. The pain and other symptoms however should not exceed a certain limit, and the temperature must not remain at say, 39°, beyond a few days. Is is easy besides, to moderate the reaction when loo violent ; it suffices to suspend the injections for one or several days, or even to inject only lialf doses of the liquid. Here is the right formula : provoke sufficient reaction to obtain the articular effusion, but not enough to cause excessive fatigue to the patient. One keeps it at the desired degree, about 38°, by increasing or diminishing the dose of liquid injected, or by spreading out the injections or lessening the intervals between them. The period of malaise comes to an end when the effusion is brougbt about, more especially as, from that moment, the object being gained, one can widen the intervals between the sittings. c. — Injections in white swellings with fistulae. The rule here is the same as in the case of tuberculous fistulcB in general (v. p. 170 and 217). It is only in non-infected fistulje that one makes modi- fying injections (of camphorated naphtol with glycerine or creosoted oil with iodoform). One makes one injection daily for 10 days ; then pressure and rest for three or four weeks. If this series does not suffice for a cure, recommence in the manner described at pages 173 and 180. IN \\lliri£ SWI'I.LINCS WirilOLT EFFUSION 503 CHOICE OF TREATMENT ACCORDING TO THE CLINICAL VARIETY OF WHITE SWELLINGS r' cvsii. — DRY OR FUNGATING WHITE SWELLINGS WITHOUT EFFUSION) ^^ c said dial iiilia articular injeclious are our usual Ireat- ment lor ^^llite s\\ tilings; this in the treatment we apply ahvays.and from the beginning-, in hospital practice. In town work we do not adopt it, neither always nor I'rom the begin- ning, for reasons which you will easily understand. There are timorous parents, who are afraid, instinctively, Avithout knowing why. One must reckon upon their opposition. As moreover, it is indisputable that a tuberculous arthritis has many chances of being cured without injections, in a good environment, although the treatment may be ilve or six times longer, it is true, you may after having AA'arned the parents of this fact, keep to the purely conservative treatment, without intra-articular injections. Leave the child at rest, as in the first case of hip-joint disease, on a frame, Avithout a plaster, Avitha simple cotton avooI dress- ing. He liA-es by the sea or at least in the country for 2 or 3 years. We said that the parents are in no hurry. As long as the joint is not plastered, there is no fear of anltylosis, or of too great atrophy of the limb. After a feAv months of this regime, if the joint has become practically painless on pressure, if there are no more fungosities, if the position is still correct, Ave may expect a cure and Ave Avill continue the same treatment. But if the Avhite SAvelling is stationary and, still more, if it has progressed, if fungosities, pains, or a deviation haAC appeared, there is proof that a cure aaIII not be obtained Avithout injections, or, at least, that it Avill not happen for long years. The duty of the surgeon is then to insist again, AA^th the parents, so that they agree to alloAv the use of modifying 5o4 WHITE SWELLOGS. BEISIGN A>D RECENT injections. Tell them that the injections Avill : V, ensure and hasten the cure, 2"'\ yield a better cure than the conservative treatment would do in a similar case. This point settled, here is, recapitulated in a few words, the course to be folloAved in cases of dry or fun gating AAhite swellings. The three following clinical varieties must be distinouished : Fig. 029. — Diseased knee joint. — Swelling of the joint. — The pa- tella appears projected in front. Fig. 53o. — Healthy knee joint seen on its external surface. a White swellings benign and recent. Practically no fungosities, no deviation, no spontaneous pains (fig. 629, 53o). ]} hen treating a town patient. — If the parents are unwill- ing to have the injections given, place the joint at rest, with or without plaster, and wait. If you have entire liberty of action, make, from the outset, injections of creosoted oil with iodoform after having put on a plaster to be kept on as long as the injections are made, and for a few weeks afterwards. AVIIITK 8\\ KM.INCiS, ILWGATING AM) (iUAVE 5o3 ir von see. after three or four months of waitinf:, that this is not sufficient, if funirosilies or pain on pressure persist, make injections of campliorated naphtol. I1i hen YOU are treafini/ a hospital patient, injccl camphorated naphtol with glycerine from the outset (after the application of a plaster). b. Fungating and grave white swellings with or Avithout devialions, and c. Old and painful white swellings, already several years old and nii.slahen far chronic rheumatism : For these] tAvo varieties (6. and c); from the arrival of the patient, plaster apparatus, after correction of vicious position, if he has one; then, the next day or the day afterAvards, injections of camphorated naphtol. In these old white sAvellings, consisting prohablyof multiple independent foci, one must make similar and simultaneous injections at e\ery point where a tuberculous focus is supposed to exist, and make, if need be, a second and a third series, at three or four months interval the one from the other. It must be unterstood, however, that in dealing with an adidt Avorkman, always in a great hurry, and if you are a sur- geon and Aery certain of your asepsis, you may at the outset, suggest resection ', because it Avould be a saAing of time to the patient. If you are not a surgeon, you may, exen in this case, keep to the treatment by injections of the liquid type, repeated if necessary. They Avill succeed in the end, nine times out of ten, and the orthopoedic cure so often obtained will be at least equal to that Avhich resection aaouH give, — at the cost of a litUe patience and time, it is true (a year or a year and a half instead of from three to iixe months). Avithmit any risk to the patient; this cannot be said of resection. Avhich very often I. Or better, after a series of injections (5 or 6, made in the space of a month), which will much attenuate the virulence of the tuberculosis and Avill ensure union bv first intention. 5o6 WHITE SWELL1?«GS WITH EFFUSION leaves fistuloe, in Avhich case the situation would be very noti- ceably aggravated by operation. 2-1 CASE. — WHITE SWELLINGS WITH EFFUSION, PURULENT OR SERO-FIBRINOUS (TUBERCULOUS HYDRARTHROSIS) (fig. 53i). Always and everyAvhere, in town or in hospital, in adult or in child, there is only one rational treatment : plaster, punctures and injections, either with creosoted oil and iodoform, or, with camphorated naphtol and glycerine (v. p. ii5). 3d CASE. — WHITE SWELLINGS WITH FISTUL>E Read again Avhat we have said (chap. VI) on fistulaj in hip-joint disease. The treatment differs according as the fistulse are infected or not (v. for this difference, p. 225). In non-infected fistulfe, you will make injections and the cure will be obtained, generally, in a fcAV months. In infected fistulse, no modifying injections of iodoform or of camphorated naphtol are made. At the most you will try syringing with solution of per- manganate of potash or with very Aveak carbolised Avater. You must confine yourself to a discreet therapeusis, simple asepsis, and good general treatment : you Avill need abundant patience, for the cure requires i, 2 or 3 years. But at last the cure is obtained, at least in an ideal environment such as that of Berck. So much for the case Avhere there is no fever, or not much. But it is not sufficient Avhere there is fever. You Avill have to drain, to overcome it. If the fever persist in spite of drainage, in spite of arthro- tomy (that is, an extensive opening of the articular cavity and removal of any squestra you may find) and, in spite of resec- tion ; or again, if the viscera, liver or kidneys, shoAV the first lltlvVI \II.M' OF FISTULOIS W III I i: S\\ KM.INCiS ;)()7 si^ns of dof^oiuMarKiii. owinp' In iiifcclion cxlcncling IVom the i)crii)heral foi-iis; or if llu' [laliciil is raclioclic and ihc lungs are begiiinini; lo he liibciciiloscd, resign Nniiisclf to sacrificing the hnih. This is a last resource which we do nol have in hip join! (Hsoasc. liuL you must not have recourse to it except as a last extremitN. thai is, \\hcn you are morally certain that the life of the patient is in immediate damjer and can not be saved irilhoiil aniputation of the limb^ . Neverlheless. amputation issomc- times proposed outside the prece- ding indications, and in the case of a working man whom the necessities of life oblige to return to the unwhole- some surroundings of a large town. His fistula, more or less infected, A\ ilhout for the present endangering his life, has not, nevertheless, much chance of being cured, and causes far too much risk of bringing about in the long run a generalisation of the tuberculosis. It would be better then to amputate. If the lower limb is in question, one would not even attempt, as a preliminary, a very large resection, which would only cure the patient with a limb so shortened that it would be of less use to him than a good stump '. Fig'. 53 1 — AVhite swelling with effusion. — The knee is very swollen ; no osseous reliefs are apparent ; fluctuation quite dis- tinct. I. And on the otiier hand, lo be morally certain that amputation aaIII save him, that is, that the intervention is not too late. ■3. At Berck, I do not perform, on an average, one amputation a year, amongst manv scores of fistulous Avhite swellings in children or adults, 5o8 TREATMENT OF ANKYLOSIS FOLLOWING WHITE SWELLING 4". CASE. — WHITE SWELLINGS CURED OR APPARENTLY CURED WITH ANKYLOSIS Your course, in the presence of an ankylosis, will differ according as it is accompanied AAath a deviation or not. Leave it alone if there is no deviation, or rather you Avill only deal with the ankylosis by very slight methods : very gentle massages; the Baths of Bareges, Bourbonne, Aix, Dax, Salies, or Argeles-Gazost '. On the other hand, if there is a deviation and the func- tions of the limb are seriously affected, you must correct it. No surgical operation for this, not even a tenotomy ; but correction by simple orthopoedic movements with or without chloroform; by stages, one correction every five days, each partial correction being followed by the application of a plas- ter ; 3 or 4 sittings suffice. By this method you will succeed, because the ankylosis is hardly ever really complete, that is, osseous. Never, or scarcely ever, will you need to perform osteo- tomy", nor orthopoedic resection. As for me, I do not perform one per year on an average, although I redress annually a hundred ankyloses folloAving white swellings. As soon as you have transformed the ankylosis with deviation into an ankylosis in good position, you will leave it alone and do nothing to mobilise it^ whom I treat altogether; but tlie patients are not all able to come to Berck, nor wait two years for their cure. This means that you maybe obliged, more often than the Doctors of Berck, to perform the painful task of ampu- tating. 1. See " Argeles-Gazost from a medical point of view " by my old assis- tant, D' Bergugnat. 2. Osteotomy, should it ever seem indispensable to you, is easily and simply performed. See chap. x. as to how it is done at the knee, the supra- condylar osteotomy of Mac Ewen. 3. Doubtless, it is very different for a specialist quite familiar with these therapeutics, and practising in an orthopoedic institution which is fur- nished with all the installations desirable fbalneo-therapy, electro-therapy. DO ?iOT Moltll.lSi: A\ ANkM.o-IS FOLLOW ING W IIITF: S\\ KLLING O09 I lii'ir WDiild l)(' [ou IcNV I'liaiUH's ol ic^li iiinjj im iNcinciit and liio iiimli risk of losing (he good posilioii of llic lindj in endeavouring lo tlo litis. The ciiic of while swelhngis achieved in good position. The patient \\ill ihin have a very useful lind). Be salislii'd wllh lhi< \(i\ hduouraiilr rc^idl. and lake care not lo spoil it, Iroin I he I'unclional point of view, or even lo re-awaken the disease in Uung lo restore tlie articular supple- ness which has heen lost. If I endeavour to warn you, in the course of ihis book, of all that you can and ought to do, I endeavour also to point out that Avhich you cannot, that which you ought not dare to do. mccano-therapy, etc.). Here one can have recourse not only to massaire, but, in certain well understood cases, to the mobilisation, discreet and pru- dent, active or passive, of stiffened joints. l^assive movements are sometimes effected bv mathematically regulated machines, such as our arthromoteur, or by the hands of the doctor. Occa- sionally even, in certain infinitely rare cases, one practises forced mobilisa- tion of the ankylosis under chloroform, to bring back movements; after this the limb is immobilised for i or 2 weeks; then the mobility thus educed from the joint is developped by massage and passive manoeuvres. But these treatments are so special in nature, their results call for so much time and care, they have so few chances of success in the hands of the majority of practitioners, that I do not hesitate to formally advise you not to attempt them. II SECOND PART OF CHAPTER VII, OR THE TREATMENT OF EACH WHITE SWELLING IN PARTICULAR What AA"e have said in the first part of this chajjter is apph- cable to all the Avhite swelUngs. AVe must noAV pass in review the wliite swelhngs of diffe- rent joints, in order to point out the pecuHarities Avhich each of them presents. WHITE SWELLINGS OF THE KNEE ' White SAvelhng of the knee is the most frequent of them all. It is the type of the Avhite swelling, that which Ave have especially in view in our clinical and general therapeutic study of Avhite swellings. We will add only a few things here. 1st. From the point of view of Diagnosis (Tig. 532 to "boi)). a) I have no need to teach you how to find, by looking for the patellar " choc ". the existence of effusion. h) It is here especially that we have to distinguish simple liydrarthrosis from tuberculous hydrarthrosis. If the hydrarthrosis continues for more that 6 or 8 weeks, in spite of puncture and pressure, it is, nearly ahvays, symp- tomatic of a tuberculous arthritis. In the presence of a double liydrarthrosis, Avithout limita- tion of movements, one ought to think of syphilis, if there are I. See the tliesis of : D"' Dulac, 1898; D"^ Cli. Benoit. 1906; D' Gresson, of St-Petersbourg, iqo5. WllllE SWELLING OF 1111. KNLL. l>LVG>OSlS. I'llOGNOSIS 5ll aii\ aiiteccilenls. and even wlicii in (Imiht, Inllow llic s|)('(ili<-, licatiiicul (\. chap, xvi, Syphilis of llic sht'lelnii). c) In ailolcscciits and in adults, an al•tlll■ili■^ of IIk' knee. i'ig. 532 — To search for fangosities. — Schema of the anatomy of the synovial membrane, which is seen tinted in grey behind the patella. which has appeared wilhout apparent cause, is probably due to a blennorrJiagia and one ought ahvays to examine the patient 'with this in view. 2°''. .4^ to Prognosis. Refer to what we said at page 489 on this subject. 5l2 THE FUNCTIONAL RESULT IN WHITE SWELLING OF THE KNEE One can restore a leg straight, strong, and useful, to these patients, but not always the movements. One must note that this mobility is much more difficult to obtain in the knee than elsewhere. With the best treatment Ave succeed in scarcely more than half the cases (in the knee). Moreover, the mobility is not always desirable for the patient, as you Avill see. The functional result to be looked for in the knee. P*. Ill children and in adidts of the upper classes. 1tou will look for cure with preservation of move- ment only when the white swelling is benign and re- cent, and when the position and suppleness are normal or nearly normal. J h ii I t li i'\^ '^fiW'fMi\ '^^'-'^^ ^^^^^ succeed then, I k A ihffll lilll llllllil Hm\ i'^ preserving the mobility, in 0/4 01 tlie cases m children and in half of the cases in adults. This is how )ou will do it : you will not leave the plaster on for more than 4 or 5 months, namely, two months Avhile the injections are being used, and for 2 or 3 months after that; afterwards leave the knee free, with a simple bandage of Velpeau crepe, but still at rest in the horizontal position for 5 or 6 months; that makes lo to 12 months for the total duration of treatment. Fig. 533. — The same seen in front (always tinted grey) exposed to view on each side of the patella. STIFFNESS IN Wlim: SWKI.MNC OF llli; KNFE 5i3 Tlieii ycm iiia\ allow [jalieiils to slaiul on their feet; let iheni -walk with a larj^e ap[)aratiis in celluloid rcacliii)y from llic pelvis to llic foot, but jointed at the hip and ankle. The apparatus is removed during the intervals belwccn the walking exercises, and all night. Remove it entirely after a year's use. Fig. 53'|. — Searcliing for Jluclualion. — Make tlie lluitl move from tiie peripliery to the centre by pressing over the synovial sac, above and below the patella, with the two hands in the form of a horse-shoe i'' step). \ou look for cure by ankylosis, on the contrary, in all cases of rather old Avhite SAvellings (dating back a year or more) Fig. jo3. — 2'"' step; Keeping up the pressure, one brings the hands together and with one of the index fingers, one taps on the patella as one touches the piano: in this way one obtains the patellar « choc ». the sign of the presence of fluid. and of grave character, with a markedly vicious position (flexion of more than 20°, Avith subluxation outwards and backwards). Lock for it also in all cases of the first group where the'move- Calot. — Indispensable orthopedics. 33 5i4 SOME RADIOGRAMS OF WHITE SWELLINGS ments, having been preserved or recovered, the position becomes bad as soon as the patient is left without the apparatus or when Pig 3ih Fig. 537. Ijt, 538 Fig 536. — The fiist radiogram to the left of the reaclei (fig. 53b j is that of the affected side. The second (fig. oSy) that of ihe sound side. — A child of six and a half years — Tuberculous arthritis of four months standing. General tint brighter, the interline more narrow, epiphysial parts more developed over the affected knee. Fig, 538. — White SAvelling of the knee, one and a half years standing (a child of seven years). — The interline is blurred; the diaphyso epiphysial angle of the tibia presents an anterior concavity. Fig. 539 — Osleo-sarcoma of shoulder (had been mistaken for a Avhite spelling). AMirn: swi^llincj of tiii: knee 5i5 Fig. 5^0. — Bonnets apparatus for mobilising the knee. Fig. 54 1. — View of the knee part of the apparatus fig. 5^0. 5l6 FU]\CTIO>'AL RESULT IX AVHITE S^YELLIXG OF THE RXEE he is noticeably lame or incapable of taking a lono- Avalk. To obtain ankylosis, he is made to Avear knee-caps of plas- ter or of celluloid until the knee, " let loose ", for a few days, keeps straight of its own accord, -which sometimes requires three or four years or even more. When the knee has been Fig. 542. — A more simple arrangement for mobilisation of the knee. cured for at least a year, and remains in good position, you may leave off the apparatus. The knee will be stiff but the result remains however, very satisfactory. Especially beware of all forcible mobilisation with or Avithout chloroform. These forcible mobilisations are the causes, as we have said, will IE s\\i:i.Li\(. OF THE km:e 5 17 of lar loo iuan\ tlisa|i[)i)iii(iiiciils to [jracliliuiicrs wliu arc not specialists. Conliiic \ourscir lo massage, to daily baths, saline or sulphu- rous, to some attempts at flexion made by the patient in the bath, by the action of tiic muscles of the leg alone. At the most, and quite exceptionally, and only a year after the cure is unmistakeable, A\ould you alloAV very gentle, very cautious exercises, made Avith graduated machines moved by the patient himself, progressing by only a degree or a degree and a lialf every day (fig. 55o and 542). And you must always be prepared to stop these exercises at the first sign of inflammation, and in that case, to abandon altogether your attempt at obtaining articular mobility. Besides, it very often happens (in more than a third ot the cases), that movement returns spontaneously, without any special treatment, a year or two after the cure of a tuber- culous arthritis. — Everyone has seen examples of this, espe- cially in very young subjects. II. — Children and adults in hospital or of the working class. — After the preceding considerations, need Ave especially mention that, one ought not, in patients of this category, to look for a cure with preservation of movement? Cure them Avith the knee stiff. A'N'hen the knee has remained in a good position, a year and a half or two years after the cure has been accomplished, free the patient from aU kind of apparatus. We have observed in our hospital chidren as well as in private cases, but a little less frequently, that mobility has returned in due course, spontaneously. S--'^ From the point of view of THE CLINICAL ASPECT and of the THERAPEUTIC INDICATIONS. Vse will add jus I one Avord to Avhat has been already said concerning deviations. A lateral deviation (genu valgum or subluxation of the I. See my Traile des tamears blanches, Masson, p. 220. 5i8 PARTICULARS OF ITS TREATMENT tibia outwards and backwards) nearly always accompanies direct flexion of the tibia (fig-. 543, 544)- — As to complete luxation of the tibia backwards (fig. 545, 546), into the popli- teal space, you will doubtless never see it; I have seen it only twice in seventeen years. Fig. 543. — Anotlier type of white swelling. Fig. 54-'|. — W. S\v. with genu valgum. But we must draw your attention to the lengthening of the affected leg Avhich is often produced in these Avhite swel- lings, and is due to the greater fertility of the articular carti- lages of the affected side than of the sound one. This fertility is rarely ever stimulated, and lengthening only exists in benign arthritis; it is often compromised on the contra- ry, in severe wh ite swelling, whence here there is shortening. wimi; >\\i;Li.iNG of the k.M;i: y Kj Li'iiylhi'iiiny, wIktc il exists, is oiii\ lciiii)orar\ ; allor one, two or Ihree years, (he caiiila^yo of llie sound side ovcrlakcs ihe other and llie ei|ualil\ ni' the two Irixs is re-eslahlislicd. Fig-. 5/|0. — Lucieii L... of Pai-is. — Complete luxaliun of tlie lijjia into llie iiuplileal space, existing about live years (radiogram). In the meanlime, for walking, you would have to provide a thick sole for the sound limb. l^ig- 5^6. — The fame, after reduction, without surgicat interference. — The reduc- tion was made November iS"" igo5 (under chloroform). — With the appa- ratus shewn in figures 867 and 868, we made traction on the leg up to 70 kilo- grammes for 1 5 minutes, which pulled down the articular surface of the tibia ft) the level of the surface of the femur. — Then, by pressure downwards on the femur and upwards on the tibia we brought the two surfaces into contact. — Afterwards, a large plaster ifrom the umbilicus to the toes\ In the plaster, we made, the next day, two openings; one in front, opposite the condvles, the other behind, opposite the tibial tuberosities, and by these openings a double cotton-wool compression (as in our apparatus for Pott's disease^ to maintain and further per- fect the reduction. Five months later the reduction persisted. 4'"' From the point of view 0/ TREATMENT. ^^ e will add to what has been s-Aid, in the Generalities, a few words on the apparatus, the correction of vicious positions, the technique of injections and the surgical operations on the knee. 020 APPARATUS IN WHITE SWELLING OF THE KNEE A. — The Apparatus. To immobilise the knee satisfactorily, if it be a question of preventing a deviation or maintaining a correction, it is neces- Fig. 547. Fig. 5/,8. Fig. 549. Fig. 5/17. — The small knee piece very often made. Much too short and too loose ; the soft tissues can be pressed in hy the edges of the knee piece and deviation is produced at will. Fig. 548. — A longer knee piece; but still defective, for the same reason, but in a lesser degree. Fig. 5/19. — The perfect method of immobilising the knee, — Our large plaster, which takes in not only the knee, but also the two neighbouring joints. sary to make a large plaster which includes the two adjacent articulations (hip and ankle). It is sufficient to cast one's eyes on the diagrams above, to see how the classical " knee-piece " is incapable of immobilis- ing the two articular levers, in cases ever so little intractable. The plaster, then, must reach from the umbilicus to the toes i)i:i (lUMi I ii> IN wiiiii: sw 1:1.1. i\(; of riir; knei; aiul \\\\\ be in cvcrv \\;i\ llic same as llic larfrc a[)paralus for hip-joiiil disease (lly. o/j- lo ')^\\)). ^^ hen laif-'e orlliopa?.dic apparatus (celluloiti or leallier) arc used, lliev niav be ailirnlalod ;i( ibc bip ;ind ihe fool, leaving the knee fixed. It is onlN when the lendenc\ to deviation no lon^^er exists that one can dispense Avitb taking in the luo neighbouring joints (fig. 55o). A medium plaster is then used, reaching from the ischium to the toes, and immobiUsing only one of the Fig. 55o. - — The medium apparatus reaching from the ischium to the toes. adjacent articulations, or, even simply the ordinary knee-piece ■which leaves them both free. Finally, let us say that, to immobilise the knee, circular plasters are better fitting and more accurate than splints, and ought, in consequence, to be preferred. The large anterior opening of the circular plaster allows of the examination of the knee and of the articular injections being made without difficulty. B. — The Correction of Vicious Position of the Knee Joint. a. Continuous extension may be of service in private cases Avhere the parents dislike plaster (fig. 552, 553). When it is a question of deviation at the onset, and you are able to attend to it Aery closely, you will in this Avay obtain the correction — Avith a continuous extension arranged by you and looked to every Aveek. But it is simpler to redress than to put on a plaster. 522 DEVIATIONS OF THE RNEE, THE METHOD OF CORRECTING TIIEM h. Forcible redressment of the knee. We have only a little to add to Avhat has been said in the Generalities. Take care to make more trac- tion on the foot than direct pres- sure on the knee (fig. 55/1), which would lead to bruising or fracture of the articular extremities. The traction should be respon- sible here for three fourths of the correction of the bad position, and the pressure for less than one fourth. This applies to the redressment of direct flexions. But one must not forget that, generally, there are lateral devia- tions as well. Scrutinise thoroughly the diffe- rent elements of these complex deviations, of Avliich the tAvo most frequent types are -.flexion and genu valgum , Jlexion and subdaxation of the tibia outwards and backwards. You act upon these different factors at the same time. Thus, whilst an assistant makes traction on the foot to correct the flexion, you yourself exert all your strength on the upper extremity of the tibia, in order to correct the sub-luxa'.ion, forcing the tibia from behind for- wards and from without inwards with one hand, whilst with the other, you push the femur in the opposite direction (fig. 554)- Repeat the movement, persisting for several minutes; it is Fig. 55 1. — Large apparatus «ilh aa opening allowing the treatment by puncture and injections. Tin; v\KM.()>i:s roi.i.ow inc wiiiii. swii.f.inc f»r iiin knee oaS necessary lo persist, because, il'llic dcvialinii he ol old slaiidiuy, there exist osseous ficull lo canv oul. there exist osseous irregularities which render redressment dif- Fig. 552. — Slieep-sklu gaiter and stirrup, for continuous extension of the knee in wliite swelling (see fig. 553). ■ Complete the correction at two sittings, it is easier for yon and better for the patient. In this way you tear nothing. I Fig. 553. — A sand bag is placed on each side of the knee to steady it; a third sand bag is placed over the patella and assists in the continuous extension, for cor- recting the flexion. speak only of the osseous extremities, for injuring the popliteal vessels and nerves is scarcely conceiyable, in spite of what is said in certain books : I have never obseryed it in my own practice. Correction of Ankyloses. Do not interfere with ankyloses in good position. Redress those in bad position — by the method I have just described; it is always (or nearly always) possible to arrive in this way, under chloroform, at a correction of very old standing devia- tions, even those labelled, Ankyloses of the Knee. 524 ANKYLOSIS OF THE KNEE. THE COURSE TO FOLLOW A\hen the patients are anajsthetised, if one examines well, one finds some indefinite movements in the joint; but this very slight mobility is sufficient for one to be able to promise the straightening- of the knee merely by manoeuvres, which sim- plifies matters considerably. Those mana3uvres you already know (fig. 5 54). Fig. 554- — Redressment of a bad position. An assistant makes strong traction in the direction of tLe deviation ; the surgeon applies moderate pressure on the femur and pushes forwards the upper extremity of the tibia. The patient is held firmly by the arm-pits, and by the medium of the limb flexed over the abdomen (fig. /iSg and liko). After having, for some minutes, made gentle traction and pressure, you fix with a good plaster apparatus the partial cor- rection obtained, which is sometimes scarcely appreciable. The traction and pressure are kept up Avhilst the plaster dries, which will be a gain of several degrees — and so you leave it for i5 or 20 days. After which, a second sitting for redress- ment, which will give you a much more appreciable correction. If need be, you make a third correction, and, finally, you have corrected, without surgical interference, deviations for which some other practitioners might have judged a resection or an osteotomy indispensable. ilMI'I.I. IIEDRESSMEM NEAIU.\ AI.WVYS SI FFICIENT Fig. 555. — Osseous ankylosis, of 21 \ears standing, in a woman tiiirty years of age. Notice the complete fusion of the femur and tibia, so complete that there is a medul- lary canal in the osseous bridge which unites them. Shortening ii| cm. ^^ alks with crutches. — The patient asked to be redressed, but without surgical operation. If impossible to effect this without an osteotomy, she would prefer to retain her infirmity, however inconvenient. Given this ultimatnm, we decided upon performing osteoclasis. For that, we strengthened the femur and tibia with wooden splints, '4 on the thigh, i on the leg, held in position by straps (see p. 40o, fig. ^66 ; and (under anesthesia; we applied pressure with all our strength (two of us) so as to increase the flexion of the limb, the femur beins held bv two assistants. After two or three minutes of effort, the limb gave way with a creaking sound and became flexed at an acute angle, then we brought it back into extension. Large plaster for two months. — After effects very slight. Fi". 556. — The same three months after osteoclasis. — We had broken the bona at exactly the spot we wished, opposite the old articulation. One sees the debris of the patella. — The result is perfect. Instead of 19 cm. of shortening, scarcely a centimetre and a half remained due to atrophy). We took great care to do nothing to restore mobility to this knee. — The lameness has disappeared. 526 MHITE S^YELLING OF THE K>'EE. ARTICULAR INJECTIONS You can avoid also division of the popliteal tendons, Avhich is really easy Avith the technique described in Chap. xiii. (And the same applies to the case, rather rare, of osseous ankylosis. It would be quite easy to perform a supra-condylar osteotomy by the method explained in Chap, x.) C. The Injections. S^sss^' The culs- de-sac of the knee-joint are so extensive, so superficial and so accessible that injections here are par- ticularly easy, provided you are not dealing with a chronic Avhite swelling of several years' standing, Avhere the cavityis obliterated or full of adhesions. Remember that the interline of the / . joiiit corresponds with an horizontal ) passing through the apex, or inferior angle of the patella (fig. oSy). The apex of the patella is per- fectly appreciable to the finger. On ;|^'^ each side of it one easily feels a de- pression. A needle pushed into the depression would penetrate the knee- joint. Here already are two points of access to the joint. There are two others, at a centimetre and a half above the base of the patella, and at a centimetre and a half outside (with refe- rence to the axis of the limb) the two superior angles of the bone. If one punctures there, one penetrates into the sub-tricipital prolongation of the synovial cavity. As a general rule, it is into this external part of the sub- tricipital prolongation that I make the injections and I advise you to make them there. One can make the cul-de-sac bulge out at this external point Fio-. 557. — Points of access to the knee-joinl. Willi I ^w 1 I.I i\(. oi' 1 iin KMcr b\ c\<'irniL: |)i('-siiri' oil llic oilier puiiil-., Uial is, ;iI)Oyc and on llic iimrr villi' of (he palclla, and hdnw it, on each side of ihe patellar liganuiil. Pliinire vonr needle inio the snperior exiei-nal cnl-dc-sac. not dii'ecllx backwards, hnl a lillle down- Avards and inwards, in order thai (he poinl enters the inler-condyloid notch, between ihtdeninr and the under surface of the patella. "ion will feel that llir needle is at once enclosed and I'ree bel- Aveen the tAAO bones. \Yhen you baAe this sensation, you are sure to be in the desired position, exactly in the articular cavity. If you puncture the skin too near to the patella, or, if the obliquity of the needle is excessiAe, you run the risk of striking the base of the patella and mis- sing the caA"ity. Therefore puncture at a centimetre and a half, or cAen tAA"o centimetres above and outside the supero- external angle of the patella, and give the needle an inclination of about 45°. You ought to feel the femur Avith the extremity" of the needle; but you avoid driA'ing the point into the bony tissue because this might break it, or obstruct it, Avhich Avould render the passage of the liquid impossible. Consequently, you push the needle firmly and sloAAly through tlie soft tissues up to the femur, and, Avhen you have felt the bone, you gently AvithdraAv your needle for a few^ millimetres; you ought then to feel the point move about betAveen the patella and the femur. At this moment, you should push in the injection Avithout hesitation, and you aaIII see a SAvelling, not only in the sub-tricipital cul-de-sac, but also in the inferior Fig. 558. — Obliquity is gi- ven the nee;lle in order to be sure of penetrating into the joint cavity idem, when one penetrates by the su- pero external cul-de-sac;. 528 SURGICU. OPERATIOX I>' WHITE SWELLING OF THE KNEE lateral culs-de-sac, on each side of the apex of the patella, and YOU will at the same time see the patella distinctly raised. The Injections in Old }]'hiie Swelling of the Knee. In old standing cases, as I have said, it may be that the sub-tricipital cul-de-sac is obliterated or cut off from the general cavity, and that the patella is adherent to the inter-condylar groove. In that case, if you would be perfectly sure that you have penetrated the cavity, or rather what remains of it. puncture on each side of the patellar ligament, exactly in the interline ; puncture someAvhat obliquely, going from the lateral point to the centre, in such a way that the end of your needle reaches the inter-condylar groove, exactly behind the patellar ligament. The liqnid introduced at these points cannot take a false route; it will penetrate between the two articular surfaces — when there are interstices between them. At the same sitting, you should afterwards make a second injection, directly into the sub-tricipital cul-de-sac, so as to be certain that vou have readied the whole of the affected parts. After the classical treatment of injections thus pushed more or less freely into the cavity, should the patient complain of one or more points being particularly painful, either on the outer side, or above the interline, one may infer that some inde- pendent small foci persist, which have not been reached by the injections made into the general cavity. You should then make a supplementary series of injections into the painful points, pusliing the needle up to the surface of the bone, beneath the periosteum. D. Some Remarks on Surgical Operation on the Knee Joint. I will not explain the technique of amputation of the thigh and Avill not delay in describing to you all the surgical opera- lions which have been performed, or proposed, for the treatment of AA'hite swellinff of the knee : erasion. synovectomies, arthrec- -w ri.i.iN;. oi' iiii: KM I.. — imviNAfii; <»i im: .ioim- .r.iItlcr lliese eco- nomic inlcrvciilidiis In he had nperalions. riiesc ()|ioiali(>ns. wliicli dn not reach hcNoiid ihe hmils of the disease, have Man r|\ an\ advantage over rescclion. They have only cured while ^welling entirely at its onset, where the lesions Averc alnmst nil. where treatment by injections or even conservalive treatment woidd have been sulTicieiit. Thai is to say, they are perfectly useless; to their useJessness one must add nearly all the disadvantages of large surgical operations : ihc dangers of lisluhe. ol' luherculous inicctiou, etc. The only surgical operation you will sometimes have to perform is resection of the knee-joint in adult working people; there is no question of this in children, Avliere it would be disastrous from the point of view of shortening of the limb. What you may chiefly have to perform is drainage of the joint for articular abscess which has been, bv mistake or simply by omission, allowed to open. — and, by a second error, has been allowed to become infected. a. Technique of Drainage of the Knee-joint. Take care to open the joint cavity at ils most dependent points (fig. 559 and 56o). lou know that, performed methodically as it ought to be, drainage comprises four " lateral " incisions, parallel to the axis of the limb, two on each side — seven or eight centi- metres in lenslh. The tAvo antero -lateral incisions run along the sides of the patella, the two posterolateral, rather smaller, correspond to the two latero-posterior borders of the condyles. These two last incisions replace posterior drainage directly through the popliteal space, which is more difficult and could only be done by opening the joint freely and extensively. Through each of the anterolateral incisions one inserts a large drainage tube through to the postero-lateral incision. "^ ou will foresee that one could, in the same way. join the CviOT. - — Iiifllspensable orlhopedics. 3.'i 53o TECHNIQUE OF DRAINAGE OF THE KNEE-JOINT two an tero -lateral incisions by two supplementary drains, the one passing above, the other below, the patella. The internal posterolateral incision, made over the poste- Fig. 55g. — Drainage of the knee-joint. — For the two upper incisions and the infero-internal incision, follo^Y the indications in the diagram; but the postero- lateral external incision ought not to be made as it is figured, in a direction perpendi- cular to the axis of the limb ; give it a direction parallel to that axis, so as to be absolutely sure of avoiding the external popliteal nerve. rior border of the internal condyle, does not require very great precision. It is not the same on the outer side, on account of the presence of the external popliteal nerve. Fio-. 5 Go. Knee-joint viewed on the inner aspect. — The different incisions giving passage to drainage tubes which join them together. To avoid it with certainty, one must take as a land-mark the tendon of the biceps, Avhich is easily recognised (fig. 786); the nerve is a centimetre and a half on the inner side of the tendon. One has therefore only to keep always on the outer side of the tendon and stojD the lower end of the incision at the ^Vlll^L; swkm.ing or Tiiii ksee. UI::sEClIO.\ 53 1 arliciilar iiilerlliic (llic iiilerliiio corresponds lo llic apex of the j^alella Avilli llie Icj in llic exicnded posilion). (j. On resection of the knee-joint One will linil the Iccliiiiqne oC reseclion al Icnglli and very well described, in l''aral)enl"s honk, ijiie we will make, on ihis subject, simply some personal remarks wliidi will com- plete Avbat you already know. I'ig. 50i. — Arrest oT liannorrliage al'Icr resection. — /" step : one places, between the t\YO bleeding osseous surfaces, a compress Iblcled in several doubles. lou will use an Esmarcb's bandage, Avhicli gives you greater facility for seeing and removing the diseased parts. lou perform the resection of the two articular extremities with a small saw or a very large chisel, — a resection not too extreme nor too sparing, so as to remove the whole of the diseased parts of the bones, cutting for a fcAV millimetres — not more — into the healthy zone; then you cut away all the suspicious soft tissue, Avitli scissors and dissecting forceps, expending as much attention and lime as may be necessary. 532 WHITE SWELLING OF THE K>-EE The toilet of the bones and soft parts being completed, the exact adaptation of the surfaces of bone Avell ascertained, Fig. 562. — Second step : the limb is afterwards placed in the straight position. place some compresses between the surfaces of the two bones, the leg being carefully held in the flexed position; you place tAvo Fig. 563. — Third step. One or two other compresses are placed over the -wound : the surgeon exercises continuous pressure ^vith both hands whilst his assistant sup- ports the foot and presses the limb up^Yarcls, with the foot applied to his breast. other compresses in front of the bones, between the bones and the corresponding soft parts, and get ready to apply compres- sion, whilst the Esmarch bandage is taken off (fig. 56 1 to 563). lou press very exactly in this way for ten or twelve minutes. That suffices to ensure the arrest of haemorrhage without the application of ligatures. I scarcely ever apply TE(;iiM(ji'i: or uesection or riir. kM:i:-.i(»iNr 533 li"aliucs lo the small vessels, — and llio advaiilafrc is groat Fig. 564. Fig. 505. Fiij. 5o'i. — The method of suturing; the skin (overcasting with cat-gut). Fijj 5C5. — Suture completed; at three different points, strips of cat-gut have been inserted to ensure drainage. in not leaving any foreign bodies in the wound, in order to be certain of obtaining union by first intention. Fig. 566. — Plaster apparatus furnished with an opening which allows of inspection and dressing of the operation wound ; it is closed again after each occasion with a plastered bandage. If bleeding returns after twelve minutes, keep up the pres- sure for five or six minutes longer; it is not time lost. 534 ■WHITE SWELLING OF THE KNEE JOI.XT If, Avhich YOU rarely see, a vessel bleeds again at this time, it is quite open to you to use a cat -gut ligature, but vou will still gain much by prolonged pressure, seeing that, in place of twenty ligatures, you Avill have only one to apply. Iloemorrhage being quite arrested, you pass on to the adaptation of the bones. '\ouAvill have no occasion to suture the bones, thanks to the large plaster which you apply; you suture Fig. 567. — Ordinary sloc- king or sleeve of jersev, and a lath underneath ; for moul- ding the knee. Fig. 5G8. — A celluloid apparatus for walking. The hip and ankle are jointed and moveable. The knee is ri^id or mobile as desired. the skin onlv with an overcast stitch of catgut as figured here (fig. 564). " This suture takes a minute : the twelve minutes lost in compression are regained here. Three strips of cat-gut or three small drainage tubes are inserted, to prevent the accumulation of the sero-sanguineous effusion in the wound (fig. 565). TECHMQLE OF RESECTION OF llll- kNEE-JOlNT 53i: The suture of (he skin ami llic thaina^^e Jiiay ihus be done Avilli l)Oclies winch are entirely capable of being absorbed. The apparatus is here of capital importance and merits the closest altoaliun. It is a large plaster, very well fitting, which reaches from the umbilicus to the foot, as I slicun here (lig. 366). One commences \ I by making the part of the apparatus which extends from the toes to the root of the limb. Fig. 569. _ - ^ Fig. 570. Fig. 56g. — Knee apparatus (in plaster) furnished with a joint. — To render this jointed knee apparatus moveable, it is sufficient to cut it into two plastered sheaths in the anterior median line and to trim the edges. Fig. 570. — Knee apparatus in celluloid, serving at the most to protect the knee but not sufficient to prevent displacement. modelling it well around the knee and the malleoli, then, when the setting of the plaster is completed, or thereabouts (after waiting about five or ten minutes), one constructs the abdominal portion. The patient is placed on the pelvi-support, in order to do this. The junction between the abdominal and leg portions is easy to make, wdth a few turns of plaster bandage applied as a spica from one to the other, and some strengthening squares 536 ^THITE SWELLING OF THE R>"EE. APPARATUS FOR CONVALESCENCE (see p. ^20 for the method of construction of the plaster appa- ratus). A^ hen the h^st bandage has been apphed, one models the apparatus very accurately round the pelvis. This precision prevents even the slightest displacement of the two articular surfaces placed in contact Avith one another; one obtains in this Avav perfect union, in correct position, without mentioning the advantage Avhieh the apparatus has in ensuring arrest of hoemorrhage and the prevention of all inflammation and all pain by the mathematical immobility which it affords. If, which is very unusual, fever should supervene, there is nothing to prevent one making one or more temporary ope- nings opposite the suture, in order to examine the wound and rectify the drainage (fig. 566). On the fiftieth day, one removes the plaster, replacing it by another, or still better, by an orthopoedic apparatus (fig. 067 to 570) with which the 2:iatient will be able to walk, after a week's rest, at about the sixtieth day. But. if need be, the patient will be able, being provided with the large plaster apparatus we have just described, to get on to his feet ten or fifteen days after the operation and walk with the help of crutches. Convalescent Apparatus for White Swelling of the Knee (v. fig. 067 to 570). From the moment of being placed on his feet, the child is supplied with a large apparatus in celluloid (extending from the umbilicus to the toes), similar to that used in the convalescence of hip-disease — with the difference that in hip-disease one leaves the hip rigid and articulates the knee and foot (of the apparatus), Avhilst in AAhite swelling of the knee it is the knee (of the appa- ratus) Avhich is left rigid, the hip and the foot being arti- culated. But a little later one can articulate the knee in its turn. In the case of children of the working class who cannot go to the expense of a celluloid, you will apply, even for the period of convalescence, a plaster knee apparatus, reaching from the trochanter to the malleoli (v. p. 569). wiiiii: --wiii.iM. i>i iiii: WKir.-.ioiM l)lA(iN()>l- :>:'n WHITE SWELLING OF THE ANKLE-JOINT ' a. DIAGNOSIS ITS PECULIARITIES) In adolescents willi allcdious of the auklc-joiul, il is ntcessary lo guard againsl mistaking a simple iarsaUjia lor luljerculous arthritis. It is sufficient lo remember this in Fig. 571. — Skeleton of the ankle- joint, posterior view. 2 cerU:^ — I Fio;. 5t-2. — The same, anterior view: measure- ments to find the places of election in the adult. order to preA^ent error. The conformation of the foot (the bulging on the inner side of the astragalus and scaphoid, the deviation. of the foot on the outer side in abduction, the sole of the foot generally very flat), the absence of appreciable fun gosi- ties, enable one to make the diagnosis (v. also Tarsalgia, chap. xn). I. See thesis of D' Balcncic, igo'i. 538 WHITE SWELLING OF THE ANKLE-JOINT. ^ PROGNOSIS b. PROGNOSIS It is here particularly favourable : cure is nearly ahvays effected with preservation of movements. The functional result to he aimed at. Follow the same general principles as for the knee. They will conduct you to a complete cure. If, in a very exceptional case, the foot become stiff, do not endeavour to alter this, as long as the position is good. Moreover, if the ankle has preserved some amount of movement, but retains a certain equinism, which makes the patient lame, do not hesitate to place the foot at a right angle and keep it so with a plaster as long as is necessary so as to secure a good position, at the risk of ankylosis occuri ng. The play of the neighbouring articulations, the sub-astra- galoid and the mid-tarsal, will supplement, in great measure, this stiffness of the ankle, which may, perhaps, be only tem- porary. c. PARTICULARS OF THE TREATMENT I"' The injections First, some anatomical points to establish the technique of the injections (fig. 671 to 575). The synovial cavity of the ankle-joint permits of the needle entering in front at one of the lateral angles of the interline, and also behind, at the external part by preference, away from the posterior tibial vessels. In front, one will easily avoid the anterior tibial artery and vein, placed in the middle of the anterior surface. It is necessary to use fine needles (n" i, or at most, n" 2, of Collin). The internal angles will be wider if the foot is carried outwards, and, inversely, the external angle will be wider if the foot is carried iuAvards. As a general rule, I make the injections in front, alterna- tely on the inner and outer sides (fig. 57/1) of the interline (over the lateral angles). But if you find, at your first visit, an appreciable swelling \U1ICLI.AU IN.II'CTIONS INTO Till: A NK I.K-.K »INT b'.ii) of llic serous t'avil\ at aiiollicr poinl, it is llicre, in lln' fciilrr of Mil' riini^niis mass, qiiilc accessible, lliat you convey llie moclilying li([irul. It is in fronl, or alniosl as IVcquenlly in llic dependent pail'^ behind, against the malleoli, or even close lo the lendo \('liilli>. dial liiei^c liingous masses arc prod need. W hen ihey become apparent at ihe second, third, or lourth in- jection, the treatment be- Fig. 5-3. — Transverse section of ttie ankle-joint. Fig. 5-3 bis. — One penetrates at tlie antero- external angle of tlie tibio-larsal joint. It is not necessary to pusli tlie needle so far in as is shewn liere. comes much easier. The injection and the puncture, if there is fluctuation, are made at these points. If at the same time there are an anterior and a posterior projection, we will choose the latter by preference, because behind, the synovial cavity is much further removed from the skin than in front and we are all the more secure from the risk of producing a fistula. One may see indeed, sometimes, the skin give way in front, after too great distension of the cavity of the joint in the course of treatment by the injections. 54o WHITE SWELLING OF THE ANKLE-JOINT. INJECTIONS But it is a simple rupture of the skin through excess of tension, ^:^- Fig. 574. — Mew of the external aspect of the joint after injection into the synovial cavitv Fig. 575. — One of the two points of election for penetrating the joint. that is, a non-infected fistula. It is sufficient to discontinue THE APPARATUS lOU I III: A\ kl.K-.IOlM 5^1 llie iiijectioiis ;iiul lical (li(> pari willi gooil asc|»tic dicssiiigs Fig. 576. — Plaster for llie anlvle : position of the surgeon's hands durint; the drvin;< of the apparatus. for a week or two, to see it close. One then returns to the injections, if one lias not already given the requisite number. 2^"' The Apparatus ifig. 57G, 577). This reaches from the toes up to the in- terline of the knee, or at least up above the calf. One must take great care to place the foot exactly at a right an- gle and even at an angle slightly acute, as a pre- ventive measure, becau- se of the natural ten- dency of the foot to take ^^'- '''■ - 'fl- ;ame finished with an opemn, -' opposite llie external malleolous. on extension ; for an analogous reason, in liip-joiut disease, we place the thigh, as a preventive measure, in hyper-extension and slight abduction. 54a ^VHITE SWELLING OF THE ANkLE-JOINT. DEVIATIONS Instead of making an opening at the anterior part, through which to make the injection, we prefer to make a bivalve appa- ratus, anterior and posterior, or lateral, in such a way as to be able to remove it at each new injection (v. fig. 42, p. 59). This allows of a more complete exploration round the joint. The puncture and injec- tion being made, and a slight dressing applied, one re- en- closes the leg and the foot, taking great care to replace the heel very exactly in the most dependent part of the apparatus in such a Avay as to restore it to a rig'ht angle : Avithout this the foot acquires spontaneously a position of equinism. In this way one prevents deviation. One uses these bivalves again in cases where there are multiple fistulas. Deviations. Fig. 578. — Taking a mould of the ankle (v. p. 97). Ordinary stocking split at the ends of the toes A strip of zinc is placed under the stocking upon the skin. If the foot has already become deviated, you will know the way to correct it during the course of treatment by injections. To do that, you Avill make, after each injection (or every two sittings) a new small plaster, Avhich takes two minutes (two bandages to roll) ; before the plaster is set, you endeavour to gain a few degrees of correction by a gentle but sustained pressure of your hand applied to the sole of the foot, while the other hand firmly supports the leg portion of the bandage. As to the deviations observed in a white swelling already cured, the simplest way to obtain the correction is with a \i'i'AU\Tis !-(»ii i'K()Giu>-si\ i: (:()iuu:cTio\ 543 Fig 579. — Mould of llie foot wilb strengthening pieces. Fig. 58o. — Celluloid apparatus with clastic bands for the progressive redressment of the foot. Fis: 58 1. — For the progressive redressment of the foot. Fis:. 082. — Plaster apparalus with a joint. 044 MEDIO-TAJISAL ^VHITE SAVELLOG series of plaster apparatus, such as we have described. One could use, in place of a plaster, an articulated apparatus in celluloid or leather, to the anterior part of which might be attached two elastic bands cross-wise, to approximate the two articular levers (fig. 078 to 583). One might also correct old standing deviations, particularly the lateral deviations in valgus Fig. 583. — Bonnetss apparatus for mobilisation of tlie ankle. But. if vou are not a specialist, keep it for stiff joints, not tuberculous ones. or varus, with the lever boot which we use for club-foot (v. Chap. xiv). In a general way, do not interfere with anky- losed joints which are in good position. WHITE SWELLING OF THE MEDiO-TARSAL AND SMALL JOINTS OF THE FOOT Here. also, take care not to mistake a white swelling for a tarsalgia, and conversely. A"\ e have mentioned liow the dia- gnosis is made (v. also Chap, xii). One treats a medio-tarsal arthritis like an arthritis of the ankle (see above). When one is dealing with the small articulations of the WHITE SWELLING OK llli: SALVLL A UTKULATIONS OF THE EOOT 5/|5 foot, it becomes vcin dil'licult to push llic injecllon into the joints when tliey are so compressed logclher (fig. 5(S/|, .jcSo). Fig. 58^. — Medio-tarsal joint, seen on its external surface; llie point of election is at 2 millimetres in front of the external malleolus (in adults). On the other hand, one must know that by reason of their t • 15 yn I 2i =•/,, Fig. 585. — Tlie same, viewed on the inner side : the point of election is at i5_milli- metres behind the tubercle of the scaphoid ; at 22 millimetres from the tip of the internal malleous. superficial situation, ahnost sub-cutaneous, the skin on the dorsal aspect is constantly in danger, either from punctures which, in course of time, diminish its resistance, or (from C^LOT. — Indispensable orthopedics. 35 546 WHITE SWELLI>G OF THE SMALL JOOTS OF THE FOOT AYithin out) from fungosities. It is necessary then to redouble the precautions to avoid the opening of white swelhngs of these small joints. If there is a prominent spot, for example a projecting fun- gosity, on the plantar aspect, through which you can reach the joints, make use of it; the effusion which you will setup Avill easily find its way between the bones and the fleshy masses of the sole, and the skin will easily be saved. If it is, on the contrary, towards the dorsal aspect of the foot that the fungosities point, especially if they have already com- menced to erode the deep surface of the integument, you are obliged to attack them there. — Then, inject with a fine Pravaz needle (puncturing outside the invaded points) a but slightly ''irritating" liquid, and in a small dose; inject, for instance, a few drops (6, 8, lo) of creosoted oil with iodoform (rather than camphorated naphtol, which Avould occasion a too vigorous reaction). If a liquid effusion is produced with some degree of tension, make haste to evacuate it, either by slight pressure made through the skin, after puncturing Avith a n° i or n" 2 needle, or by means of an aspiration in the ordinary Avay, taking care that you do not use a larger needle than n° 3, — n° 4, Avouldhere endanger the integrity of the skin. Then, again, inject a few drops of creosoted oil, and carry on the treatment by combining the two desiderata of preserving the asepsis of the joint and not causing a fistula to develop. Some succeed where others fail. It is a matter of attention and slightly also of skill. When the skin gives way, if it is not at the beginning, if one has already been able to make some injections of modifying liquid and to partially sterilize the tissues, little harm is done; cicatrisation is generally obtained in five days after the rupture of the skin. In order to secure the healing of the ulcerated skin, follow the treatment indicated on p. i6i. WIIME SWI.LI.ING OK Tlin Ll'I'CU I.IMIl 5/17 WHITE SWELLINGS OF THE UPPER LIMB White swellings ol' (he upper liiiilj are less IVeqiieiil llian lliesc of the loAver limb, because the laller underi-o more Aili'nie Fig. 580. — How to make a plaster apparatus for the upper limb. 7" slep. — Circular turns round the trunk : the plastered bandages are, as in other parts, applied over a vestment which is either an even layer of cotton wool of four or five millimetres thickness or, which is better, an ordinary jersey. than the former; they attain a much less serious degree in the arms, and they are cured more easily for the same reason. It folloAYs again that the deviations are less marked and complex apparatus are less often necessary, or are required for a much shorter time, in the upper than in the lower limb. 548 WHITE SWELLING OF THE UPPER LIMB F^One may ensure the repose of the arm or the fore-arm with a simple sling, adding to it, it goes ^Yilhout saying, a shghtiy compressive wool dressing to protect the affected joint. If, hoAA'ever, the pain is considerable or the nature of the swelling somew^hat serious, it would be quite simple to immobilise more Fig. 587. — How to make a plaster apparatus for the upper limb. 2'"' s/ep. A roller bandage is carried backwards from the axilla of the sound side (i) to the affected shoulder (i bis.); it is then carried down over the anterior surface of the arm making a bend beneath the flexed elbow (2), it passes upwards behind and crosses over the shoulder (3); one then makes several turns of Ihe same spica, the diffe- rent spirals overlapping each other (see the first step in fig. 58(3). completely the affected region by replacing the soft strip of wool dressing by a few plastered strips. It is here that moveable plasters or bivalve plasters are chiefly employed; we have given, page 92, the method of con- structing them. With the plaster apparatus — which abolishes pain at once — the patient is at liberty to Avalk about. The diagrams here given represent the different apparatus which you may apply, according to the case, to the upper limb. TLASTEIl Ari'ARATlS FOIl '1 III: AIlM r^Vj This is the I.ir-^o |il;islci- wliicli sccinvs \\ir ininioliilis.ilion of llic entire liinl), in llie case of |i;iinriil while swelling- nl' ihc sliouldor (fi,i^-. \')S() ti) 590). Fig. 588. — The teclmique of a large plaster for the upper limb 'continued). 3"' step. One makes circular turns round the arm. The large apparatus for white swelling of the elbow is identical Avitli the preceding. Fig. 591 represents the medium plaster for the elbow. One sees by these diagrams tlie position in which the upper limb is immobilised : The arm, in an abduction of from lo" to 20°; 55o WHITE SWELLINGS OF THE UPPER LIMB The elbow in the position of flexion at a right angle or, better, at an angle of 70° to 80" (with the arm). Fig, 58g. — Apparatus for tlie arm (continued). -S"" step. One finishes by circular turns round the arm, the forearm andthe wrist. The wrist, in a straight position, A^dthout flexion, but without hyper-extension. WHITE SWELLING OF THE SMori.DFU . r\\E l\,in(:Tir)NS J I A. - WHITE SWELLING OF THE SHOULDER Technique of the injections. - I'ig. 690 shews llic analomy ol' llie joiul and llie cxlciiL ol' the synovial membrane. %mA Fig. 590. — Apparaius for the upper limb completed, furnished with openings oppo- site the different articulations. There are several points Adhere one can reach the synovia. Keep only to the two following; I'*. On the outer side, in the bicipital cul-de-sac of the general cavity of the joint; 552 WHITE SWELLING OF THE SHOULDER 2"'^. In front, between the coracoid process and the bicipital groove. It is the second route, that is, the anterior route, which I advise you to follow in all cases ^ (fig. SgS). The pointed coracoid process is always easy to feel, even in fleshy subjects (fig. 595), at the antero-internal part of the bony vault of the Fig. 5gi. — Medium apparatus for the upper limb immobilising the elbow and the ■wrist (one can easily make it a bivalve). shoulder. From the bony point of the coracoid process, go horizontally outwards : To half a centimetre of the process, in a child; To one centimetre in an adult; and push in your needle at this point, from before backwards and a little (i5°) upwards. You feel the head of the humerus with the extremity of the needle, and it will be easy, on manipulating the humerus, to assure yourself that you are well upon the head of the bone. That done, you withdraw the needle for one or two milli- metres and then push in your injection. If you inject every day, you will find some fluid collected by the third or fourth day. I . BecavTse it is rather difficult to make the liquid penetrate the bici- pital cul-de-sac. I'lilMS OF ACCESS TO rill- AKIICII.AR CAV1I\ or HIE Mioil.hlll ')')'.\ One sliniiKl know thai il accuinulales at the posterior pari especially, or in llio must depcndcnl pari of llio Joint rallier than in honl. Il is iherolbrc^ in ihc hack |)ntl oC the shonhlcr (or even at Fig. 592. — One punctures at one cenlimetre outside the coracoid process. the posterior part of the axilla) that, from the third or fourth day. you will find fluctuation, although you have made your injections in front. AA hen fl actuation is appreciable at some point, you puncture there. — But if you prefer to puncture only in front, you can cause the whole of the fluid to move towards this point by pressing Avith the flat hand over the opposite dependent part of the collection in the joint. One makes the necessary ten punctures and injections; after which, one empties to the bottom the articular cavity, by two supplementary punctures, without the consecutive injections. During this treatment, as Avell as after it, one supports the ooa TSHITE SWELLING OF THE SHOULDER shoulder merely with a Velpeau bandage. Avliich covers the dressing: and with a sling, which supports the arm. It is only in acutely painful cases that one would apply Fig. 593. — Shoulder joint afler injection of tlie synovial cavity. The sketch she\YS the different points by Avhich one can reach it ^vitli the needle. the large apparatus (in the way indicated above) Avith an opening over the anterior part of the region through which to make the necessary injections. But this plaster apparatus must he removed immediately the pain has disappeared, for instance 1 5 or 20 days after the cessation of the injections. One does not therefore ever make a strict and prolonged immobilisation of the joint. VUIICIIVU INJECTIONS INTO THE SIKH I, HI U .loIM' ;);)a Tlic ;i(l\aiilat:v ol' lliis course is. llial \\\o niovcnienls of the joiiil lia\(' ii(~il liinc lo Ix' losl. at least coin|)letel \ , anc] tlial the\ leluiii ^eiKMalK in the lii>t lew weeks which lolldw the ciul ol' acti\e liealiiieni . Fig. Sgi. — The needle may be forced between the acromial vault and the head of the humerus. They return spontaneously. The patient, when he no longer suffers, instinctively extends the field of movement of the shoulder. A little later, he makes use of his arm for slight purposes, Avithout actually imposing hard w^ork upon it, for several months more. To aid the return of mohility, one orders the patient daily baths : the baths of Bareges, of Argeles-Gazost, of Bourbonne, etc., etc. 556 AXKTLOSIS OF THE SHOULDER FOLLOWIXG WHITE SWELLING The treatment of fistuke presents nothing you do not already knoAY after having read the first part of this chapter. As to function. Stiffness and Ankylosis. AA e have stated that if the arm has not Ijeen strictly immo- bilised bevond a few months — and this Avill not be so bv the Fig. bcjo. — TLe point of election for the injections is found at one centimetre outside the coracoid process, which is always easily felt. treatment with articular injections — the movements will not, as a rule, be lost. If you find yourself in the presence of a complete ankylosis, do not interfere with it; it is safer. lour patient is well cured, thanks to the supplementary and compensatory mobility of the scapula; and you Avould run too much risk of aggravating the situation, instead of improA'ing it, bv undertaking the forced mobilisation of the ankylosis. It is especially the business of specialist surgeons, Avorking in orthopoedic institutions, to undertake, in certain cases, these attempts at mobilisation (fig. 096). AMIITE S\\F.II.1N(; or Till' ELBOW. INJECTIONS JOT Fio-. ogG. — Melliod of fixino: the stump of the shoulder. B. — WHITE SWELLING OF THE ELBOW In the elboAV, as in the knee, the technique of the injections is particularly easy. One enters, either by the radio-humeral interline, which one feelsover the external border of the elbow — making movements of rotation in the fore-arm — or. by preference, a few millimetres above the point of the olecranon, because the route is here wider and more accessdile (fig. 697 to 599). In flexing the fore-arm to a right-angle, one easily feels the point of the olecranon, and above it the tendon of the triceps stretched in this position. It is sufficient to puncture at 3 or !\ mdlimetres above the bony point, and outside of the middle of the tendon to penetrate easily and surely into the joint cavity. After a few injections, the supra-olecranon cul-de-sac becomes distended, and the technique becomes still more easv. The synovial cavity is placed so far from the skin that one here runs no risk of fistula. 558 WHITE SWELLING OF THE ELBOW, BAD POSITIONS Bad Positions. The elboAv ought to be at an angle of from 70° to 80°, in the case where, in spite of every care, ankylosis has occurred (v. fig. 591, p. SBa). If it is not in that position, one must place it there, by stages, Fig. 597. — The elbow joint seen on its external aspect : the radio-humeral articula- tion is found at i8 millimetres from the tip of the epi-condyle. making partial corrections followed by the application of small plasters, recommencing every eight or fifteen days with a ncAV correction. Stiffness and Ankylosis. The movements nearly always return spontaneously, provided that one has not uselessly pro- longed the immobilisation by plaster apparatus. That is why we generally keep it up simply with soft bandages. Leave the movements to return of their own accord — helping them, after five or six months of waiting, by baths or by slight gently passive movements, made by the patient himself, in this way : The arm is held by two straps or by some person's hand, on the surface of a table, the patient being seated. With the sound hand, he takes his stiffened fore-arm and makes slight movements in every direction : flexion and extension, prona- STU-FNF.SS AM) WK'iLUSlS or Till: lOII'.OW. IllKATMENT .ij[) lion and supination. In this \\;i\ we have obtained sonic very excellent cures (sec also fi;.'-. 601). Fig. 098. — The needle strikes Ihe arliculation by (he supero-external angle of the olecranon and penetrates into the olecranon cavity. ^Yhat we are noAv going to describe relates exclusively to incomplete fibrous ankyloses. .-^^ 1 2 cent. ! Fig. 599. — The elbow joint seen on its internal aspect : the ulno-humeral inter- line is found in the axis of the ulna, at two centimetres from the epitrochlea. In the case of a patient coming to you with a complete osseous ankylosis, do not interfere with it if the position is good, that is, if the elbow is flexed at an angle of from 70° to 80°. If the ankylosis is bad (the elbow in complete exlensiou), 56o AVIIITE SWELLING OF THE ELBOW correct it by an iacompiete osteotomy, making use of artificial fracture, or, just as well, keep exclusively to manual osteo- Fig. 600. — Injection into the elbow joint. clasis, which you may perform in the following manner : Some wooden splints are placed round about the arm, and Fig. 601. - Jointed dial apparatus for mobilisation of ibe elbow. To effect flexion, one can join the two levers with elastic cords. STIFFNESS A^D ANKYLOSIS OK THE E^.nO^\ . TUEATMEN'I' 50 1 others around llie lore-arm. \\ luls.1 the arm is firmly held, you seize the fore-arm with bnih hands and cnrrv it in the direction of flexion. Separation takes place at the iiilerhne. The fore-arm heing llexetl at a rip-hl an<^le, you fix it in that position with a plaster Avhich you leave on for two or three weeks; after thai. \ou lake olf the plaster and order haths and massage. As a rule, ankylosis is reproduced, hut in a very good posi- tion. Sometimes you may be fortunate, enough to see useful movement return. A resection might, exceptionally, enable you to restore some amount of movement — but how rarely! — and scarcely ever without prejudice to the strength of the arm — so that, every- thing considered, I dare not advise you to have recourse to that operation — provided that the elboAv is ankylosed at a right angle. Calot. — Indispensable orthopedics. 3G 562 TilllTE SWELLOG OF THE WRIST C. — WHIT£ SWELLING OF THE WRiST AND OF THE SMALL ARTICULATIONS OF THE HAND i^* White Swelling of the Wrist. Anatomy. — The two extremities of the interhne are easily found. The centre of the interhne, in the aduh, is found at from 6 to 7 millimetres above the straight line connecting- the two apophyses (fig. 602). Fig. 602. — The point of elec- tion for injection into the ra- dio-carpal joint is found at 6 millimetres above the centre of aline connecting the extre- mities of the styloid processes of the ulna and radius. AYith this indication you will know how to introduce a fine needle into the interline. Yerv often, you will perceive on the dorsal aspect of the hand some projecting fungosities, developed in the culs-de-sac of the synovial mem- brane. It is by means of these pro- longations of the synovial membrane that YOU will be able to force your liquid into the cavity (fig. 6o3). Remember that the soft parts are rather thin on the dorsal aspect of the wrist, and that one ought, conse- quently, to take every precaution in dealing Avith the skin. AA e refer you to what Ave have already said on this subject Avith regard to the ankle, Avhere the situation is identical. Ankylosis o-f the Wrist. Here again, the best treatment for ankylosis is the preventive treat- ment. If vou treat the Avhite sAvelling by means of injections, Avithout plaster, the Avrist will not become ankylosed. I have never seen ankylosis of this joint since I haA-e treated Avhite SAvelling in this Avay. But a patient, treated elscAvhere, may come to you Avith an ankvlosis alreadv established. If it be fibrous, you Avill treat Wlliri' SWELLlNn OF THE HAM) AM) FINGEUS 503 it by slifihl inclhocls : massage, ballis; ;iii(l yni will leave ihe patient himself to carry out willi his sound liancl some gentle movements (five or six silliugs dails of icn minutes each), the fore-arm being- immobilisetl on llie lable l)\ anollier person, or by means of a slrap. II' the ankylosis is osseous, leave it alone '. 2"' White Swelling of the Hand and Fingers. One sees, at fig. 602, the situation of the interline of the medio-carpal articulation . These s\Yellings ought to be attacked by injections in small Fig. Go3. — Point of penetration of the needle. But one does not need to force the needle so far as is represented here. doses, at intervals, made each time at a different place, and in such a way as to keep the skin Avhole whilst attacking the lesions. Thinking always of the integrity of the skin, it is in this Avay that one ought to treat spina ventosa. 1 mention this in passing, though it does not enter into our present study, since it is, at any rate at its onset, a disease of the diaphyses of the phalanges rather than of their joints (see Spina Ventosa, Chap. xix). 1. Nevertheless, it has happened to me to interfere personally in a case of complete ankylosis in a young lady from Rotterdam, where, by a non- surgical operation (under chloroform) I broke down the osseous adhesions. I saw the movements return completely, thanks, I ought to say, to a conse- cutive treatment of several months; a treatment very gentle and very metho- dical, carried out by a skilful and well-informed masseur, my regretted friend, D' Fourriere. 564 CONVALESCENCE AFTER WHITE SWELLING Ankyloses of the fingers are treated like those of the wrist (see above) . Do not interfere with osseous ankyloses ^ . CONVALESCENCE AFTER WHITE SWELLING Read again Avhat we have said about the convalescence of hip disease, which is merely a white swelling of the hip-joint (see Chap. vi). By what signs would one recognise that a white swelling Fig. 6o4. — White swelling of the wrist. Deformity of the dorsal region. is cured P — By there being no appreciable fungosities, and there being no longer any pain. The disappearance of pain on pressure is the clinical cri- terion of cure. From this time, reckon again from 5 to 6 months as a minimum before thinking of the anatomical cure. After these 5 or 6 months leave the joint to itself to recover its normal functions, by freeing it of all apparatus outside walking exer- cise, unless you wish for ankylosis, in Avhich case you Avill keep I. Here again, nevertheless, I have obtained a complete result in a child from Paris who had an osseous ankylosis of two phalanges of the thumb. Four months after the forcible breaking down of the ankylosis, a good result was obtained, thanks again to D"^ Fourriere. CONVAI,ESCENCE AFTER WHITE SWELLING o(J5 on the apparatus for a long lime. And, it is necessary to look for ankylosis in all cases where preservation of movements gives rise to persistent pain or allows a deviation to be reproduced. AVc repeat that, when it is a question of choosing between a good position and mobility, it is the laller which must be sacri- ficed. To sum up, as lo ^^ hite swellings of ide lower extremity : Do not place your patient on his feet until the tuberculosis is cured, that is, until there is no pain (for six months). You will not discontinue all apparatus until a good posi- tion is preserved naturally. Duties of the Practitioner during Convalescence. Your role is not finished yet. It is, for more than a year, quite as important as it was during the active period of the disease. But, alas ! there are practitioners who take no more interest in the patient when the pain or puffiness of the articular region has disappeared. They do not know that they have still a double duty to fulfil. i" duty. — The practitioner ought to return the patient to his ordinary life gradually, in order to avoid a relapse, or more exactly, a revival of the disease. In order to do that he must watch over the general condition of the patient and the state of the joint. 2"'' duty. — He ought to watch over the functional result obtained; to prevent the good result being compromised or les- sened, and on the contrary, to help on improvement, by all the means in his power. I St duty. — To prevent a Relapse or a Recurrence We can only repeat here what we have said Avith regard to hip-joint disease. One ought to take, for a much longer time, precautions of the general and local order. I mean by pre- cautions of the general order that one must not hasten the return of the cured patient to the city, or to the surroundings, 566 CONVALESCENCE AFTER WHITE SWELLING often unhealthy, Avhere he was taken ill. It is necessary to attend to his diet and his hygiene and to avoid all possible contagion. From the local point of view : one cannot at once impose upon a joint Avhich has just recovered, the same Avork that one would upon a joint Avhich has always- been sound. It is only gradually that its natural functions will return. One realises that the upright position, or walking, if it is a question of the lower limbs, can only be maintained, at the beginning, for a few minutes. In certain cases, it is necessary to help the Aveak joint by enclosing it in an apparatus, plaster or celluloid, Avhich will ensure its rest. The support of two sticks is useful for wal- king, and for six months one may even use crutches, which relieve the knee or the foot of the Aveight of the body. Such are the means of preventing the return of the disease, or at least of rendering a return as rare as possible ; for a debilitating disease, appearing unfortunately soon after the cure, an eruptive fever, bronchopneumonia, etc., or again, a traumatism, a sprain or a bloAv on the joint, might re-kindle the tuberculous focus, whatever has been done so far. The parents should fly from all foci of contagion, and religiously guard the child from all chances of injury and from all fatigue. 2"^ duty. — To maintain and improve the functional result. — Take care, nevertheless, of all unseasonable zeal. Adhere to the simple methods : massage, baths, teaching to walk. At the same time, do not have recourse even to those simple methods until from six to ten months at least after the real cure of the white swelling. COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD731C13C.1V.1 lndispensab|i 2002315424