COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64068595 RD731 W59 A treatise on orthop RECAP ^1)73 W59 ,>^ in tl)? (Ettii of N^m f nrk ISitUvi^ntt Hihrarg Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseonorthop1901whit A TREATISE ON ORTHOPEDIC SURGERY BY ROYAL WHITMAN, M.D. Instructor in Oethop.'edic Surgery and Chief of the Orthopedic Department of the Vandekbilt Clinic in the College of Physicians and Surgeons of Columbia University ; Adjunct Professor of Orthop.edic Surgery' in the New York Polyclinic; Assistant Surgeon and Chief of Clinic AT the Hospital for Ruptured and Crippled; Orthop.edic Surgeon to the Hospital OF St. John's Guild. Member of the Royal College of Surgeons of England; Member and Sometime President OF the American Orthopedic Association ; Corresponding JIe.mber of the British ORTHOP.iEDic Society ; Member of the New York Surgical Society-, Ktc. ILLUSTRATED WITH FOUR HUNDRED AND FORTY-SEVEN ENGRAVINGS LEA BROTHERS & CO. PHILADELPHIA AND NEW YOKE Entered according to the Act of Congress in the vear 1901, bv LEA BEOTHEES & CO. In the Office of the Librarian of Congress. All rights reserved. TO VIRGIL P. GIBNEY, M.D., LL.D. This Volume is Inscribed AS A Token of Friendship Assured by Long Association, AND OF Appreciation of His Efforts for the Advancement of ORTHOPEDIC SURGEEY '37480- 2* PREFACE. The student of Orthopaedic Surgery is especially concerned with the mechanics of the human machine, with its development, with its capacity at different periods of life and under varying conditions, and with those affections that lead to deformity or that otherwise impair its usefulness. He is concerned, moreover, not only with the local and immediate effects of disease or disability, but with its general in- fluence upon the entire mechanism, and with its ultimate consequences as well. Orthopsedic Surgery occupies a broad field and one of very great and general interest. Its most distinctive advance in recent years has been toward the prevention of deformity, an advance that has been made possible by the better understanding of its predisposing and ex- citing causes. As a natural consequence, treatment has become more direct, more simple, and more effective. It has been the purpose of the author to emphasize this aspect of the subject, which is of the greatest importance to the general practitioner, who so often has the opportunity to recognize disease or disability in its incipiency, when its progress may be checked by timely treatment. He has endeavored to present Orthopaedic Surgery as far as pos- sible objectively, and in a manner that has proved acceptable to stu- dents and practitioners in clinical teaching. Thus the selection of each subject and the space that has been allotted to it has been deter- mined primarily by its relative importance in the actual work of Or- thopaedic clinics. He has been at some pains, also, to outline methods of examination, to explain the phenomena of the symptoms and so to describe and to illustrate the causes and effects of disease and disability as to indicate, in natural sequence, the principles of treatment ; but the particular methods of the application of these principles, which have been described in detail, are always those that have been tested by personal experience. Although this book is designed particularly for students and practi- tioners of medicine, the author has included statistical and other data VI PREFACE. which he hopes may prove of interest to his fellow-workers in this special field. The author desires to express his obligation to the gentlemen who have assisted him in the collection of statistics, and otherwise, whose names are mentioned in the text ; to Dr. L. W. Ely and to Mr. W. P. Agnew for timely photographs, and especially to the Trustees of the Hospital for Ruptured and Crippled, for the facilities that have been afforded him in the preparation of this work. New York, February, 1901. CONTENTS. CHAPTER I. TUBERCULOUS DISEASE OF THE SPINE. Description — Pathology — Etiology — Statistics — General prognosis — Symptoms — Physical examination — Contour and flexibility of the spine — ^Divisions of the spine — Landmarks — The differential diagno- sis of disease in the lower, middle and upper regions of the spine — Treatment by horizontal fixation — by braces — by jackets — by other means. The selection and adaptation of treatment for disease of the different regions of the spine. The complications of tuberculous disease of the spine — Abscess — course — symptoms — treatment. Paralysis — course — symptoms — treatment. Forcible correction of deformity — (Calot's operation) — Gradual correction of deformity... 17 CHAPTER II. NON-TUBERCULOUS AFFECTIONS OF THE SPINE. Syphilis — Malignant disease — Osteomyelitis — Actinomycosis — Inj ury — Traumatic spondylitis — Ehachitic spine — Typhoid spine — Gonor- rhoeal "rheumatism" of the spine — Arthritis — Spondylitis defor- tnans— Osteitis deformans — Neurotic spine — Hysterical spine — Spondylolisthesis — Sciatic scoliosis — Sacro-iliac disease 107 CHAPTER III. LATERAL CURVATURE OF THE SPINE. Description — habitual and fixed deformity, rotation and lateral devia- tion. Pathology — Etiology — Statistics — Varieties — Distribution and effects of deformity — ^Symptoms — Diagnosis — Prognosis-^Pre- vention of deformity— Treatment — by exercises — general exercises — heavy exercises — special exercises — Supports. Forcible correc- tion of deformity — Adjuncts in treatment — Duration of treatment.. 120 CHAPTER IV. DEFORMITIES OF THE SPINE, CONTINUED. DEFORMITIES OF THE CHEST. FUNCTIONAL PATHOGENESIS OF DEFORMITY. Varieties in contour of the spine — Kyphosis — Lordosis — Congenital ele- vation of the scapula — Absence of vertebrae — Flat chest — Pigeon viii CONTENTS. chest — Funnel chest — Absence of ribs — Defective formation of the pectoral muscles — Absence or defect of the clavicle — Acquired lux- ation or subluxation of the clavicle — Asymmetrical development — Tables of height, weight, and circumference of the chest — Func- tional pathogenesis of deformity — (Wolff's law) 181 CHAPTER V. TUBERCULOUS DISEASE OF THE BOXES AND JOINTS. Predisposition — Mode of infection — Latent tuberculosis — Local predis- position — Statistics — distribution of disease — location — side affected — sex — age. Pathology — Varieties of disease — Method of repair — Prognosis — Treatment — operative and mechanical — by drugs — local applications — venous stasis (Bier's treatment) 194 CHAPTER VI. NON-TUBERCULOUS DISEASES OF THE JOINTS. Syphilitic disease of joints — Gonorrhoeal arthritis — Other forms of in- fectious arthritis — Acute epiphj^sitis — Localized infectious osteo- myelitis — Osteo- arthritis — Haemophilia — Hsemarthrosis — Scorbu- tus — Charcot' s disease — Anchylosis 206 CHAPTER VII. TUBERCULOUS DISEASE OF THE HIP JOINT. "Pathology — Statistics — Symptoms — Physical signs, distortion, apparent lengthening, apparent shortening. Causes of distortion — Atrophy — Causes of actual shortening — Measurements — Lovett' stable — Kings- ley's table — Differential diagnosis — Principles of treatment — The traction hip brace — The Thomas brace — The plaster bandage — Vari- ous methods of reducing deformity — The long hip splint — Other forms of apparatus — Double hip disease — Abscess — statistics — treat- ment — Operative treatment — exjjloration — excision — reduction of resistant deformity — Prognosis, mortality, functional results. Sec- ondary deformities of hip disease — Final results 221 CHAPTER VIII. NON-TUBERCULOUS AFFECTIONS OF THE HIP JOINT. Traumatisms at the hip — Acute infectious arthritis — Extra-articular dis- ease — Malignant disease at the hip joint — Cysts of the femur — Ar- thritis deformans 300 CHAPTER IX. TUBERCULOUS DISEASE OF THE KNEE JOINT. Pathology — Etiology — Statistics — Symptoms, primary and secondary dis- tortions — Diagnosis — Differential diagnosis — Treatment — mechan- CONTENTS. ix ical — Extra-articular disease — Abscess — Operative treatment — arthreetomy — excision, amputation — Prognosis — mortality — func- tional results — General conclusions 304 CHAPTER X. NON-TUBEECULOUS AFFECTIONS OF THE KNEE JOINT. Injury in childhood — Synovitis — Infectious arthritis — Osteo-arthritis — Prepatellar bursitis — Pretibial bursitis — Bursse and cysts in the popliteal region — Internal derangement of the knee joint — Con- genital genu recurvatum — rudimentary or absent patella — Con- genital displacement of patella — Slipping patella — Elongation of the ligamentum patellae — Snapping knee — Congenital contraction at the knee — General contractions — Acquired genu recurvatum 324 CHAPTER XI. DISEASES AND INJURIES OF THE ANKLE JOINT. Tuberculous disease — Pathology — Etiology — Statistics — Symptoms — Di- agnosis — Treatment — Prognosis — Tuberculous disease of the tarsus — Statistics — Treatment — Sprain of the ankle — Teno-synovitis — Other affections of the ankle joint 334 CHAPTER XII. DISEASES AND INJURIES OF THE ARTICULATIONS OF THE UPPER EXTREMITY. Tuberculous disease of the shoulder joint — Pathology — Statistics — Symptoms — Treatment — Prognosis — Tuberculous disease of the el- bow joint — Pathology — Statistics — Symptoms — Treatment — Prog- nosis — Tuberculous disease of the wrist joint — Symptoms — Treat- ment — Prognosis — Spina ventosa — Periarthritis of the shoulder joint — Chronic bursitis at the shoulder — Sprain of the wrist — Acute teno-synovitis at the Avrist 348 CHAPTER XIII. CONGENITAL AND ACQUIRED AFFECTIONS LEADING TO GENERAL DISTORTIONS. Rhachitis — Etiology — Pathology — Symptoms, deformities — Prognosis — Treatment — "Late rickets" — "Foetal rhachitis" — Infantile scorbu- tus— ^Fragilitas ossium — Osteomalacia — Osteitis deformans — Secon- dary hypertrophic osteo-arthropathy — Acromegalia 361 CHAPTER XIV. CONGENITAL DISLOCATION OF THE HIP AND COXA VARA. Congenital dislocation of the hip joint— Statistics — Pathology — Etiology — Symptoms — Diagnosis — Differential diagnosis — Treatment — the X CONTENTS. open operation — the Lorenz operation — the intermediate operation — secondary osteotomy — Palliative treatment — Coxa vara — Pathology — Etiology — Statistics — Symptoms — Diagnosis — Treatment — me- chanical—operative. Fracture of the neck of the femur — Trau- matic separation of the epiphysis of the head of the femur 373 CHAPTER XV. DEFOEMITIES OF THE BONES OF THE LOWER EXTREMITY. Bow leg — Knock knee — Statistics — Etiology — The outgrowth of defor- mity — Genu valgum — Description — Attitudes — Secondary defor- mities — Gait — Unilateral deformity — Pathology — Treatment — expectant — mechanical — operative — Genu varum, Varieties — Symptoms — Treatment — Expectant — mechanical — operative — An- terior bow leg — General rhachitic distortions 405 CHAPTER XVI. DEFORMITIES OF THE UPPER EXTREMITY. Congenital dislocation of the shoulder — Obstetrical paralysis — Recur rent dislocation of the shoulder — Congenital deformities of the elbow — Cubitus valgus — Cubitus varus — Subluxation of the wrist — Club hand — Varieties — Club hand associated with defective devel- opment — Congenital contraction of the fingers — Webbed fingers — Trigger finger — Mallet finger — Baseball finger — Dupuytren's con- traction 430 CHAPTER XVII. DISEASES OF THE NERVOUS SYSTEM. Acute anterior poliomyelitis — Pathology — Etiology — Statistics — Symp- toms — Causes of deformity — Deformity in various regions — Sublux- ation — Retardation of growth^Treatment, mechanical, operative... 440 CHAPTER XVIII. DISEASES OF THE NERVOUS SYSTEM, CONTINUED. Cerebral paralysis of childhood — Description — Distribution — Etiology — Pathology — Symptoms — Congenital paralysis — Acquired paralysis — Treatment — Prognosis — Progressive muscular atrophy — Varieties — Symptoms — Hereditary ataxia — Neuritis — Functional affections of the joints — " Hysterical " hip — Differential diagnosis — " Hyster- ical ' ' club foot — ' ' Hysterical ' ' scoliosis — Neurotic joints 459 CHAPTER XIX. CONGENITAL AND ACQUIRED TORTICOLLIS. Description — Statistics— Congenital torticollis — Etiology — Hsematoma of the sterno-mastoid muscle—Acquired torticollis — Varieties — Acute CONTENTS. XI torticollis — Etiology — Symptoms — Diagnosis — Treatment of torti- collis — chronic, acute — Spasmodic torticollis — Etiology — Pathology — Treatment — Exceptional forms of torticollis — paralytic — diphthe- ritic — cervical opisthotonos, rhachitic — ocular — psychical 474 CHAPTER XX. DISABILITIES AND DEFORMITIES OF THE FOOT. General description of the foot and of its functions, the arches, the foot as a passive support, in activity — Improper postures — Movements — Function of the muscles — Strength of the muscles — The foot as a mechanism — The weak foot or so-called flat foot — Description — Anatomy — Pathology — Etiology — Statistics — Symptoms — Diagnosis — Varieties — Weak foot in childhood — Treatment, preventive — Exercises — Support — Construction of brace — The rigid weak foot — Forcible correction of deformity — Subsequent treatment — Adjuncts in treatment — Operative treatment . 492 CHAPTER XXI. DISABILITIES AND DEFORMITIES OF THE FOOT, CONTINUED. The hollow foot — Anterior metatarsalgia — Achillo bursitis — Achillo- bursitis posterior — Strain of the tendo Achillis — Calcaneo-bursitis — Plantar neuralgia — Erythromelalgia — Hallux rigidus — Hallux varus — Pigeon toe — Hallux valgus — Hammer toe — Overlapping toes — Exostoses — Displacement of the peronei tendons — Shoes, effects of improper shoes — Demonstration of the proper shoe 530 CHAPTER XXII. DEFORMITIES OF THE FOOT. Talipes — Description — Varieties — Statistics of talipes, congenital and acquired — Eelative frequency of the different varieties — Congenital talipes — Etiology — Anatomy — Symptoms — Principles of treatment of infantile club foot — Treatment — mechanical — by plaster band- age — by braces — restoration of function — supervision — Treatment ia older subjects — forcible manual correction — tenotomy — Wolff's treatment, reduction of deformity by wrenches — Phelps' operation — Operations on the bones — Mechanical treatment — Other varieties of congenital talipes — varus — equinus — calcaneus — valgus — equino- valgus — calcaneo-valgus — calcaneo-varus — equino-cavus — valgo- cavus — cavus — Congenital talipes associated with defective develop- ment — with absence of fibula— with absence of tibia — with defective formation of the foot — Constricting bands — Congenital amputation — Congenital oedema — Spina bifida and talipes 560 xii CONTENTS. CHAPTER XXIII. DEFORMITIES OF THE FOOT, CONTIXUED. Acquired talipes — Etiology — Diagnosis — Talipes equinus — Description — Etiology — Symptoms — Treatment — mechanical— operative — Talipes calcaneus — Description, development of deformity — Symptoms — Treatment — mechanical, operative — Willett's operation — astraga lectomy — Talipes equino-varus and talipes equino valgus — Other varieties of acquired talipes — Tendon transplantation in the treat- ment of paralytic talipes — Tendon splicing — Arthrodesis 609 Orthopedic Surgery. CHAPTER I. TUBERCULOUS DISEASE OF THE SPINE. Synonym. — Pott's Disease. Pott's disease is a chronic destructive ostitis of the bodies of the ver- tebrae which form the anterior or weight-supporting portion of the spinal column. As the disease progresses the spine bends at the weakened point, and the upper part, sinking downward and forward, throws into relief the spinous processes at the seat of disease ; thus an angular posterior projection is formed. It is called Pott's disease because sucn deformity, slow in formation, accompanied by pain and sometimes by paralysis, was first described accurately by Percival Pott, in 1779. Angular deformity is, ho^vever, simply the evidence of destruction of a portion of the anterior part of the vertebral column. Thus it might be the result of fracture, or of the erosion of an aneurism, or of malig- nant disease, or syphilis or other pathological process ; but deformity from such causes is not now included under Pott's disease, nor is the term now synonymous with deformity. In the modern sense it signi- fies tuberculous disease of the bodies of the vertebrae, of which the early symptoms may be detected and of which the deforming effects may be checked and even prevented by proper treatment. The com- pression and collapse of the affected parts cause the characteristic angular projection at the seat of disease. If one vertebral body is destroyed the projection will be sharp ; if several are implicated it will be less angular, and if one side of a body breaks down before the other there may be a lateral as well as a posterior distortion. The size of the deformity and its effect upon the individual depend in great degree upon its situation. If the disease is at either e;s:tremity of the spine the angular projection must be small because so little of the column remains beyond the destructive process ; or in other words, the area of the spine directly involved in the deformity is small com- pared to that which is free from disease. Thus the characteristic de- formity in the upper cervical region shortens the neck and disturbs the poise of the head ; in the lower lumbar region it shortens the trunk and induces a peculiar attitude and gait. In either case the actual local deformity is usually insignificant and the distortion of the body is comparatively slight. But when the middle of the spine is involved, the opportunity for deformity is great becatise the entire 2 18 TUBERCULOUS DISEASE OF THE SPINE. Fig. 1. column may enter into the formation of the angular kyphosis ; thus the internal organs are compressed and the effect upon the vital mech- anism is disastrous. Pott's disease, as contrasted with tuberculosis of other bones and joints, is peculiar in that it is concealed from view, in that direct sur- gical intervention is of comparatively little avail, in that it lies in close proximity to important parts, the spinal cord behind and the vital organs in front, and finally, in that the effects of the disease and deformity are not limited to the parts directly involved, but influence, to a greater or less degree, the entire mechanism of the body. Pathology. — The minute changes that char- acterize tuberculosis of bone in general are de- scribed in Chapter V. The first indication of the disease is usually found in the anterior part of a vertebral body just beneath the fibro-periosteal layer of the an- terior longitudinal ligament. From this point the granulation tissue advances along the front of the spine and, following the course of the blood vessels, it invades and destroys the adjacent ver- tebral bodies. In other instances the disease may begin in the interior of a vertebral body, most often in several minute foci near the upper or lower epiphysis. These coalescing, gradually enlarge, forming a cavity, surrounded for a time by unbroken cortical substance, which becoming weaker collapses under the pressure of the super- incumbent weight. Occasionally the disease ad- vances beneath the anterior ligament without implicating deeply the substance of the bone, a form of tuberculous periostitis, " spondylitis superficialis." The inter-vertebral discs appear to offer some resistance to the extension of the disease from one vertebra to another, but when the bone is de- stroyed on either side they quickly disintegrate and disappear. The posterior part of the spinal column usually remains practically free from disease with the excep- tion of the pedicles and articulations which may be in direct contact with the tuberculous process. In rare instances the disease may begin in a lamina or spinous process, or one of the small joints may be primarily involved, but such forms of local tuberculosis would hardly be classed as Pott's disease unless the anterior part of the spine were implicated also. The course and outcome of the disease depends upon its type. In one instance the area of primary infection is small and the local re- sistance is sufficient to check its further progress, so that cure without Destruction of the bodies of the first, second and third lumbar vertebrse — with the resulting deformity. (M:6- NARD.) PATHOLOGY. 19 deformity may follow ; or it may advance slowly, accompanied by a process ,6f repair ; the area of active disease is small and the granula- tion tissue undergoes a fibroid transformation or becomes ossified. In such cases deformity may appear and slowly increase, practically with- out symptoms. In most instances however, the tuberculous granula- tions advance more rapidly, destroying the bone or other tissue with Fig. 2. Pott's disease. which they come in contact ; the usual retrograde metamorphosis to cheesy degeneration follows and very frequently liquefaction or abscess formation ; the latter change being caused possibly by secondary in- fection with pyogenic germs. Clinically the liability to abscess is very much increased by irritation or injury and is decreased by abso- lute rest of the diseased part. 20 TUBERCULOUS DISEASE OF THE SPINE. As a rule, in those cases of moderate severity, that come to autopsy during the progressive stage of the disease, one finds on dividing the thickened tissues in front of the spine, a cavity, the walls of which are lined with tuberculous granulations in various stages of degeneration, and containing puriform fluid. The adjoining vertebral bodies pre- sent a worm-eaten appearance and one or more of them is partially destroyed. Small fragments of necrosed bone and "bone sand" may be present, together with larger masses of degenerated tissue ; in rare instances sequestra of considerable size may be found. Occasionally the disease may begin in the posterior part of a verte- bral body, or it may extend backward as well as forward, and, forcing its way into the vertebral canal, it may press upon the spinal cord and involve its coverings, and thus cause paralysis of the parts below. Less often pressure on the cord may be due to the presence of an abscess or to a projecting fragment of bone. The calibre of the spinal canal may be constricted somewhat by the pressure of the superincumbent weight upon the softened and thick- ened tissues at the seat of disease, but as a rule, its capacity is not directly lessened by the angular distortion nor does the degree of de- formity directly influence the frequency of paralysis. Although the disease may begin in multiple primary foci of infection over an extended area, or in two or more distinct regions of the spine simultaneously, yet clinical observation seems to show that it is, in most instances, originally confined to one or two adjacent bodies, one or both of which are partially destroyed ; from this central point the dis- ease may extend in either direction until half the spine may be impli- cated, but in ordinary cases the final area of deformity and rigidity shows that from three to six bodies are more or less involved before cure is established. If the disease is limited in extent, the eroded surfaces of the adjoin- ing vertebree may come into direct contact, but if several vertebral bodies have been destroyed the upper portion of the spine as it sinks downward is often displaced backward so that the anterior aspect of one or more of the upper segments may be apposed to the superior surface of the first body of the lower section (Fig. 3). Less often there may be forward displacement of the upper part upon the lower (Fig. 1). At all stages of the disease resistance to its progress, and efforts at repair are evident in the affected parts. When this resistance over- balances the tendency to degeneration, cure follows. Repair is accomplished occasionally by contact and solid union of the adjoining surfaces of softened bone, but usually the anchylosis is in part fibrous, in part cartilaginous and in part bony, and this union may be further strengthened by a callous formation from the thickened tissues about the seat of disease. In many instances the articular processes, the pedicles and laminae become anchylosed before repair has advanced appreciably in the an- terior portion of the column. Cure may be absolute, as when no vestige of the disease remains ; ETIOLOGY. 21 it may be practically complete, as when the diseased products undergo calcareotis degeneration and are shut in by a layer of solid bone. In other instances the disease becomes quiescent or but slowly advances, showing its presence by exacerbations of pain or by the formation of an abscess, long after active symptoms have ceased. Etiology. — The etiology of tuberculosis of the spine does not differ Fig. 4. DestFuction of the bodies of the third, fourth, fifth, sixth and seventh dorsal verte- brae ; partial destruction of three others. (M:6nard.) The deformity corrected showing the area of the destructive process. (Menaed.) from that of tuberculosis of other bones ; the subject is considered in Chapter V. Relative Frequency. — Tuberculosis of the spinal column is more common than of any other single bone or joint, as might be ex- pected from its greater area. This point is illustrated by the sta- tistics of tuberculous disease treated in the out-patient department of 22 TUBERCULOUS DISEASE OF THE SPINE. the Hospital for Ruptured and Crippled, jSTew York, during a period of fifteen years, 1885-1899. Tuberculosis of the Spine 3,207 cases. " " " Hip 2,230 " " " other joints inclusive 2,408 " Also by similar statistics contained in a recent report of the Boston Children's Hospital, for a longer period, 1869-1893. Tuberculosis of the Spine 1,864 cases. " " " Hip, Knee, Ankle, Shoulder, Elbow and Wrist combined 1,856 " Age. — Pott's disease, although far more frequent in the middle period of childhood, from the third to the tenth years, may occur at any time from earliest infancy to extreme old age. In a series of 1,259 consecutive cases of tuberculosis of the spine collected from the records of the outdoor department of the Hospital for Ruptured and Crippled, 'New York, analyzed for me by Drs. R. T. Frank and C. Gunter, the ages of the patients at the supposed time of onset of the disease appeared to be as follows : Less than 1 year 38... Between 1 and 2 years 176... " 3 " 5 " 627... " 6 " 10 " 234.., " 11 " 20 " 89.., " 21 " 30 " 43... " 31 " 50 " 31... Over 50 " 11.. 3.1 p( er cent. 14.2 50.2 18.3 , 7.2 3.5 2.6 The youngest patient was two months old, the oldest seventy-one years. Dr. Thorndike,^ of Boston, from the records of the Boston Children's Hospital for thirteen years, 1883 to 1896, collected 115 cases of tuber- culosis of the spine in children of two years or less. Seven of these were less than six months, and twenty were under one year in age. Mr. Howard Marsh " has called attention to Pott's disease of the aged, and cites three cases in subjects of sixty or more years of age. Sex. — Sex exercises comparatively little influence on the liability to disease of this region. Of 3,797 cases collected by Mohr, Gibney, Fischer, Taylor and Bradford and Lovett, quoted by HofPa, 2,045 were in males and 1,752 were in females. Of 1,367 cases collected by Frank and Gunter, 708 (52 per cent.) were in males and 659 (48 per cent.) were in females ; and in 2,455 cases tabulated by Knight 1,329 were in males and 1,126 in females. In these combined cases from the Hospital for Ruptured and Crippled 3,822 in number, 53.2 per cent, were in males and 46.8 per cent, in females. The Situation of the Disease. — The dorso-lumbar section of the spine is most often affected. Cervical ostitis is comparatively infrequent. In the series of 1,355 cases from the records of the Hospital for 1 Trans. Am. Ortho. Ass'n, Vol. IX., 1896. 2 Ibid., Vol. IV., 1891. THE SITUATION OF THE DISEASE. 23 Ruptured and Crippled, the attempt was made to locate the origin of the disease by the most prominent spinous process in the tracing. The following are the conclusions. Cervical. Dorsal. Lumbar. Lumbo-sacral. 1st 3 1st 26 1st 94 13 2d 3 2d 43 2d 96 3d 15 3d 42 3d 64 No Deformity. 4th 20 4th 46 4th 57 Cervical 2 5th 13 5th 49 5th 6 Dorsal. 31 6th 22 6th 76 327 Lumbar !22 7th 24 7th 82 -55 loo 8th 97 9th 92 Disease in two regions of the spine. 10th 110 16 11th 71 12th 120 854 Similar statistics are recorded by Julius DoUinger/ of Budapesth, of 700 cases of Pott's disease. Of these the situation of the primary dis- ease could be ascertained in 538. Of this number, in 63 the disease was of the cervical, in 321 of the dorsal and in 154 of the lumbar region. The relative frequency of disease of the different dorsal and lumbar vertebrae, was as follows : Dorsal. Lumbar. 1st 6 1st 59 2d. 7 2d 37 3d 12 3d 31 4th 10 4th 17 5th 19 5th 10 6th 17 154 7th 33 8th 36 9th 36 10th 43 11th 38 12th 64 3"21 The proportionate length of the different sections of the spine at the age of five years is, according to Professor Disse (Skeletlehre, 1896) : Cervical 20.2 Dorsal 45.6 Lumbar 34.2 100.0 If this be contrasted with the percentage of the cases of disease of each section, it will show that the frequency of the disease in the dif- erent regions of the spine does not correspond to the area, as has been suggested, but that it is proportionately much less frequent in the cer- vical and much more frequent in the dorsal region ; a frequency that may be explained by the greater strain to which the middle and lower > Die Behandlung der Tuberculosen Wirbelentziindung. Stuttgart, 1-896. 24 TUBERCULOUS DISEASE OF THE SPINE. part of the spine is subjected, as well as by the relative proportion of cancellous tissue which offers the opportunity for infection! Bollinger. Frank and Gunter. Cervical 11.7 per cent. Cervical 7.6 per cent. Dorsal 59.6 "■ " Dorsal 66.1 " " Lumbar 28.6 '' " Lumbar 26.2 " " Prognosis. — The prognosis in tuberculous disease is discussed in Chapter V. : Pott's disease is the most dangerous of all the tuberculous affections of the bones or joints, as would be expected from the rela- tive importance of the structure affected and of the parts lying in contact with it. It is evident also that the amount of deformity, and its situation, have a direct influence on the prognosis. In the typical " hump-back " deformity, the contents of the thorax and abdomen are necessarily compressed, the blood-vessels are dis- torted and the calibre of the aorta is thereby often much diminished. Respiration is made difficult, and the circulation is impeded, so that the heart is usually hypertrophied and valvular insufficiency is not infre- quent ; thus the vital functions, which are carried on at a disadvan- tage even under favorable conditions, become impossible under the added strain of unfavorable surroundings, overwork or disease. It is a matter of common observation also that few of those who are markedly deformed reach old age. On the other hand, it may be as- sumed that slight deformities, or those which do not as directly inter- fere with the vital functions, exercise but little influence upon the future well-being of the patient. Although the absolute mortality of Pott's disease cannot be accu- rately estimated, it may be stated that at least 20 per cent, of all patients die during the progress of the disease and within a few years after its onset, from causes directly or indirectly dependent upon the local lesion. Some of these die from general dissemination of the tuberculous infection and tuberculous meningitis ; some from exhaus- tion following septic infection and long-continued suppuration, or from amyloid degeneration of the internal organs ; some, from tuberculosis of the lungs, and many, from intercurrent affections that are fatal be- cause of the devitalizing influence of the disease and its complications. The prognosis of Pott's disease, in the individual case, is influenced by many considerations. In one instance the family history is good, the surroundings are favorable, the patient is in good condition and the disease is in the early stage ; one is then inclined to look upon it as ian accident, and hardly considers the possibility of a fatal termination. While in another case, the weakness and under-vitalization of the body are so evident, that the affection of the spine seems but an in- cident of a general degeneration. Symptoms. — The most distinctive sign of Pott's disease is deform- ity. At an early stage of the process there may be but a slight irreg- ularity in the contour of the spine, and if several adjacent vertebral SYMPTOMS. 25 bodies are aifected the projection may be somewhat rounded in out- line. B&t, as compared with other deformities of the spine, that of Pott's disease is characteristically angular, and as its cause is loss of substance, its formation is accompanied by and must have been pre- ceded by the symptoms of bone disease. Deformity is thus the evidence of a destructive process that may have existed for weeks or months even, and only by its early recogni- tion can the ideal result, the prevention of deformity, be attained. For the spine which, although weak, is still straight may be kept straight, but when the deformity is present, it can be remedied only in part, and it may be difficult even to check its further progress. For as the upper segment of the spine sinks forward and downward, the influences of compression and attrition increase the activity of the local process and aggravate its eifects. Angular deformity has been long considered as the essential sign of Pott's disease, and even now, the fact is not generally recognized that the detection of tuberculous ostitis of the spine in the early stage, is both possible and easy by the same methods that serve for the diag- nosis of other affisctions, not attended by such obvious symptoms as external deformity. It is to such application of the principles of dif- ferential diagnosis that attention is especially called. As the spine is the chief support of the body and as it allows a free mobility that accommodates it to every movement of the trunk and to every motion of the limbs even, it is evident that the symptoms of a destructive ostitis must be pain, weakness, and impairment of normal motion. Motion and support are not, however, the only functions of the spine ; it contains the spinal cord, from which branch the nerves that supply the organs and members of the body. This may be im- plicated even at an early stage of the aifection, and the sudden onset of paralysis may overshadow the symptoms of original disease. Or the tumor of an abscess, one of the common accompaniments of tuber- culous disease of bone, may interfere with the functions of important parts lying in the neighborhood of the spine, thus peculiar symptoms, due to this cause, may attract attention before the primary disease is ■ suspected. These are symptoms that may be misleading and it is well, therefore, to consider them apart from those that indicate the primary effect of the disease upon the spine, considered as an elastic support. These direct symptoms usually precede, and always accompany the sec- ondary or complicating symptoms, and upon them the diagnosis depends. The primary and diagnostic symptoms of Pott's disease MAY BE classified AS FOLLOWS : (a) Pain. {h) Stiffness. (c) Weakness. (c?) Awkwardness. (e) Deformity. {a) Pain. — At first thought, one might expect the pain of Pott's disease to be localized at the affected vertebrae, and to be accompanied 26 TUBERCULOUS DISEASE OF THE SPINE. Fig. 5. by sensitiveness to pressure or even by infiltration and swelling of the tissues, but it will be remembered that the bodies of the vertebrae are in the interior of the trunk, practically speaking, as near to its anterior as to its posterior surface (Fig. 9) and that the products of the disease pass downward and forward, rarely backward. Thus sensitiveness to pressure on the project- ing spinous processes is unusual, and palpation, except in the cervical region, is of compara- tively little diagnostic value. The pain of Pott's disease is not localized in the back, in the neighborhood of the dis- ease, because the nerve filaments that supply the bodies of the vertebrae are insignificant parts of nerves that are distributed to distant points, to the head, to the legs, to the front and sides of the body and to these parts the pain is referred; thus "earache" or "stomach-ache" or " sciatica " may be symptomatic of Pott's disease of the different regions of the spine. The pain of Pott's disease is by no means constant, it is induced by jars or by sudden or unguarded movements. It is often worse at night, when after the relaxation of the muscu- lar spasm that has protected the part, the un- conscious movements during sleep cause dis- comfort or pain and the child moans in its sleep, or is restless, and sometimes it wakes with a cry — " night cry." ■^^^ (b) Impairment of Function or Loss of Normal Mobility — Stiffness. — Stiffness of the spine, the result of the destructive ostitis, is in part voluntary, in the sense that the patient adapts his movements and attitudes to the disease and pain and thus avoids, if possible, strain and jar — but the essential and characteristic stiffness of Pott's disease is caused by the involuntary muscular tension and contraction of the muscles about the seat of disease. This reflex mus- cular spasm varies in degree, according to the state of the underlying disease. It may fix the spine or it may be evident only at the extremes of motion, but it is always present, preceding deformity and accom- panying it until cure is established ; thus it is the most important of the diagnostic symptoms of Pott's disease. (c) Weakness. — As the disease affects the most important support of the body, it is a direct as well as an indirect cause of weakness, and the more vulnerable the spine, the more pronounced is this symp- tom ; thus in the young child, whose spine is in great part cartilaginous, evidence of weakness is shown by the "loss of walk," the refusal to stand or the instinctive desire for support, at an early stage of the disease. (d) Change in Attitude — " Awkwardness." — This really suras up the direct deformity; pensatory deformity. V'^ SYMPTOMS. 27 effects of the preceding symptoms, since it is evident that pain, weak- ness, and rigidity must cause a change in the appearance and in the habitual attitudes of the patient. Such symptomatic attitudes may be ahuost diagnostic of the disease and of the part of the spine involved. (e) Change in the Contour of the Spine — Deformity. — The deformities of Pott's disease may be classified as follows : 1. Bone deformity. 2. Muscular deformity. - 3. Compensatory deformity. The characteristic angular projection due to destruction of bone has been described already. Muscular deformity is the distortion due to muscular spasm or con- traction. Of this, the wry neck, symptomatic of cervical disease, and Fig. 6. Normal contour and flexibility of the spine. psoas contraction in the lower region of the spine, are the most familiar ■examples. Compensatory deforniity signifies the more general effect of the local disease and local distortion, upon the spine as a whole. (Fig. 5.) Thus an angula;r projection must be balanced by a compensatory incurvation, and lateral distortion in one direction by lateral distortion in another. These deformities are, of course, nearly related, and they are usually combined, although muscular distortion may precede the stage of bone destruction, while the compensatory changes are not immediately ap- parent. These general and secondary changes in contour may catch the eye before the primary local deformity is detected. Lateral deviation of the spine is not infrequent ; it may be direct distortion at the seat of disease, caused by the destruction of the side of a vertebral body, but more often it is a secondary effect of such 28 TUBERCULOUS DISEASE OF THE SPINE. irregular erosion at one or the other extremity of the spine, or the eflPect of muscular contraction, or it may be clue to simple weakness. Finally, even at a much earlier stage of the disease, there is, almost always, a slight change in the outline of the spine due to local rigidity ; thus the spine no longer forms a long regular curve when the body is bent forward, but as one section remains more or less rigid while the other bends, the outline is broken at or near the seat of the disease. (Fig. 7.) Secondary or Complicating Symptoms. — (a) Abscess. — This may, by its size or situation, cause peculiar symptoms. In the retro-pharyn- FiG. 7. Incipient Pott's Disease. Showing the break iu the contour of the spine, of which the normal flexibility is but slightly impaired. geal space it may interfere with respiration and deglutition. In the thoracic region it might be mistaken for pleurisy or empysema, and when it forms a tumor in the iliac fossa, it may interfere with locomotion, (6) Paralysis. — This is usually a late symptom, but if the disease begins in the center or posterior part of a vertebral body it may im- plicate the spinal cord before deformity is apparent. Abscess and paralysis are symptoms that may be explained by Pott'& disease, but other than by calling attention to disease of the spine as a possible cause of the complication, they do not aid one in determining the diagnosis ; for this reason they are classed as secondary symptoms. CONTOUR AND FLEXIBILITY OF THE NORMAL SPINE. 29 b General Symptoms. — By some surgeons, especial stress is laid upon the diagnbstic value of a slight but constant elevation of the tempera- ture. This is usually present if the disease is active or when an ab- scess is approaching the surface, but the positive value of the symptom in early or quiescent cases, is doubtful. One may expect also that a patient suffering from tuberculous disease of the spine will present some evidence of a painful and depressing aifection, or some evidence of inherited or acquired weakness, yet it must be remembered that the absence of such general symptoms would not exclude Pott's disease. The Contour and Flexibility of the Normal Spine. In the enumeration of the early symptoms of Pott's disease, two have been noted as of especial importance : the impairment of normal mobility and the effect of the disease upon the contour of the spine and upon the attitudes of the patient. Therefore, in the study of the normal spine, the standard with which that suspected of disease must be compared, mobility and contour, at different ages, and under differ- ent conditions, should receive especial consideration. Although the spine as a whole is a flexible column, yet it has a fixed contour ; it curves forward in the upper, backward in the mid- dle, and forward again in the lower region. These curves are, in great degree, the effect of the force of gravity and of the action of the muscles in balancing the weight of the body in the upright attitude. In the adult they are practically permanent ; in early childhood they can be nearly obliterated by traction in the horizontal position ; and in infancy they do not exist. If the newborn infant be placed in the sitting posture the head falls forward and the spine bends in one long backward curve characteristic of weakness. If it be placed on the back and the legs be drawn down from their habitual attitude of semi- flexion, it will be noticed that the range of extension is somewhat limited because of the absence of the lumbar curve and inclination of the pelvis. When the gain in muscular power has been sufficient to enable the infant to raise and control the head the curve of. the neck appears. Later when the child stands the erector spinee muscles hold the body upright against the resistance of the ilio psoas group and of the ligaments of the hip joint ; thus the lumbar curve and the incli- nation of the pelvis result and the normal contour of the spine is established. If from the odontoid process of the axis of a normal individual in the erect posture a line be dropped to the ground, this perpendicular or weight line, about which the weight of the body is balanced, will indicate the curves of the spine, and divide it into sections that corre- spond sufficiently well to function. The cervical curve ends at the second dorsal, the thoracic curve at the twelfth dorsal and the lumbar curve at the sacro-vertebral angle. (Fig. 8.) What has been spoken of as the normal contour of the spine varies considerably in the adult. It is affected by the occupation, and many 30 TUBERCULOUS DISEASE OF THE SPINE. Fig. 8. other circumstances ; of this, the round shoulders of the cobbler or the weaver, the stoop of weakness, of old age and the like are familiar examples : but in childhood, distinct variations from the normal con- tour almost always have a clearly defined pathological cause. As the normal contour is the efPect of the balancing of the body in the upright posture, it is evident that if the outline of one part is permanently changed, compensation for this change must be made in another part. Thus when deformity is well marked, the normal curves of the spine are often completely reversed (Fig. 5), and even at an early stage of the disease, the abnormal contour will often attract atten- tion, long before the characteristic angular projection has become apparent. Although the spine is a flexible column that is constantly changing in outline with every movement and posture yet the range and character of this motion vary greatly in its different parts. In the cervical and lumbar regions motion is extensive, because of the relatively large proportion of elastic inter- vertebral substance, because of the direction of the articular surfaces, and because the center of motion is near the middle of the body. Motion is very limited in the thoracic region, because the intervertebral discs are thin, because of the over- lapping spinous processes and because it forms a part of the rigid thorax. "Where free motion is essential to the habitual attitudes, there disease, which interferes with normal motion, will be earliest apparent, in awkwardness, weakness, and pain, and there, muscular spasm, the chief cause of the rigidity and restraint of normal motion, will be evident on examination. Thus one more often has the opportunity to make an early diagnosis in disease of the lumbar and cervical regions, because in the one the motions necessary in stooping, sitting and standing are constrained, and in the other the neck is stiff, or the head is turned or drawn from the normal line. In the thoracic region, early diagnosis is less often made, because in this section motion is so unimportant that its restraint may escape the attention of the patient or parent. Thus, in consider- ing early diagnosis, and in fact, treatment and prognosis, one must divide the spine into sections. The divisions of the spine. Divisions of the Spine. 1. The neck part, that allows free motion of the head, ending at the third dorsal vertebra. DIVISIONS OF THE SPINE. 31 2. The rigid thoracic part which includes the third and the tenth dorsal seghients. Fig. 9. ^■V> Cross-section of the body of a child at the third dorsal vertebra. (Dwight.) 3. The lower portion made up of the two lower dorsal and the lumbar vertebrae, in which the principal movements of the trunk are carried out. One must bear in mind the distribution of the nerves, because the characteristic pain is referred to their terminations, also 32 TUBERCULOUS DISEASE OF THE SPISE. the parts in relation to the spine at different levels, that may be im- plicated in the disease. Thus, remembering that the symptoms of Pott's disease are in general stiffness, weakness, pain and deformity, one will always apply these symptoms to a particular region of the spine, and will picture to himself the effect of such stiffness, weakness and deformity at this or that vertebra ; the effect of an abscess in this or that situation, and the area of paralysis that might be caused by pressure on the cord at one or another level. Landmarks. — The atlas is on a line with the hard palate. The axis is on a line with the free edge of the upper teeth. The transverse process of the atlas is just below and in front of the tip of the mastoid process. The hyoid bone is opposite the fourth cervical vertebra. The cricoid cartilage is on a line with the sixth cervical vertebra. The upper margin of the sternum is opposite the disc between the second and third dorsal vertebrae. The junction of the first and second sections of the sternum is op- posite the fourth dorsal vertebra. The tip of the ensiform cartilage is opposite the lower part of the body of the tenth dorsal vertebra. The anterior extremity of the first rib is on a line with thf fourth rib at the spine, the second with the sixth, the fifth with the ninth, the seventh with the eleventh. The scapula overlaps the second and the seventh ribs, its lower angle being opposite the center of the eighth dorsal vertebra. The root of the spine of the scapula, the glenoid cavity, and the inter- val between the second and third dorsal spines are in the same plane. The most constant landmark from which to count, is the spinous proc- ess of the fourth lumbar vertebra, which is on a line with the highest point of the crest of the ilium. The umbilicus is near the same plane. The Inclination of the Pelvis. — In the erect attitude the plane of the brim forms an angle of 60 to 65 degrees with the horizon. The tip of the coccyx is opposite the lower border of the symphysis pubis. Length of the Spinal Cord. — In the adult the spinal cord terminates at the lower margin of the first lumbar vertebra. At birth, it extends to the third lumbar and its membranes to the second division of the sacrum. The Intervertebral Discs. — In the adult, the intervertebral discs form 41.9 per cent, of the cervical, 26.4 per cent, of the dorsal, and 44.6 per cent, of the lumbar regions of the spine (Dwight). The Rational Signs. The symptoms of Pott's disease vary decidedly, not only with the region of the spine involved, but also with the age and surroundings of the patient. Like other forms of tuberculous disease it is an insidi- ous chronic affection and its early symptoms may fiiil to attract atten- HISTORY. 33 tion, because they are irregular or intermittent. The child may cry after over-exertion or injury, but afterward it may appear to be in its usual health, perhaps for days or weeks ; but even during this early stage, it will be remembered afterwards, that something was " wrong," that it was fretful and disinclined to play, that it liked to lie on the floor, that it was awkward in its movements, that it was troubled by a cough or indigestion, or by oppression of breathing. One, or many, of such symptoms may have existed for months, but, as a rule, it is not until deformity has made the diagnosis unmistakable, that the child is brought for treatment. It is often after a fall or violent play, that the evidence of pain or weakness can no longer be overlooked, so that injury is likely to occupy a prominent place in the history. History. — The history of the disease as obtained from the parent is usually indefinite and misleading. Certain points may however be set down as of relative importance. One will ask if the immediate relatives of the child have suffered from phthisis or other form of tuberculosis, as this might indicate a predisposition to disease, and thus affect the prognosis. One asks if the child has been robust or the reverse ; if recovery from the ordinary ailments of childhood was prompt or tedious, in order that one may judge of the quality of the patient. One next asks, not " how long has the child been ill ? " for this is usually understood to refer to the duration of the more decided symp- toms, but " when was the child last perfectly well ? " One asks par- ticularly as to the onset of the first symptoms, whether it was sharp and decided, or gradual and ill defined ; if the symptoms were preceded by contagious disease. This latter is an important question, because measles, for example, predisposes to tuberculous infection or at least to its local outbreak, and diphtheria is often followed by paralysis or by weakness, that may simulate certain symptoms of Pott's disease. The character of the injury, that almost every patient is supposed to have received, is then investigated. It should be made clear, whether the injury was the direct cause of the symptoms or if it may have simply aggravated, or brought to light the dormant disease or if, as is often the case, there is simply an indefinite remembrance of an injury which has no connection with the symptoms. To establish injury as the sole and direct cause of symptoms, the patient must have been well at the time of the accident, the ■ symp- toms must have followed immediately and have continued since ; and finally the symptoms must be of such a nature as to be explained by a definite injury. By careful questioning one may usually determine whether the symptoms of which the patient complains are acute or chronic. This is of importance because tuberculosis is a chronic disease, one of the few chronic diseases of childhood, although its exacerbations may re- semble, in symptoms, those of acute disease or even of injury. However important a correct history may be, the actual diagnosis depends entirely upon the physical examination. 3 34 , TUBERCULOUS DISEASE OF THE SPINE. Physical Signs. The physical examination begins on the first sight of the patient, when one notes the general condition and the actions and postures ; but the ultimate purpose is to compare the appearance and mobility of the spine suspected of disease, with the normal standard. Voluntary actions and attitudes show the adaptation of the body to the disease, the conscious and unconscious efforts of the patient to guard the weak part from strain, and from motions that cause discom- fort and pain. But by inspection, palpation, and by the tests of voluntary and passive motion, one may demonstrate and localize the disease. The examination must be purposeful. When one asks the patient to pick up a coin from the floor — the popular test for Pott's disease — one employs it to test the mobility of the lower region of the spine, the region in which the motions of stooping and turning the body are carried out ; remembering that such movements are often not restrained in the slightest degree by disease in the upper portion of the spine. Such tests must not only be purposeful, but they must be adapted to the age and intelligence of the patient. The child that refuses to pick up a coin will often gather up its clothing, because it wishes to be dressed again. If it will not stoop, it will usually rise if placed in the recumbent or sitting posture, which is an equally useful test. A child will walk towards its mother, if placed at a distance from her. It will always turn its head towards her, thus voluntary motion of the cervical region may be tested by changing the mother's position, while the child is held by the examiner. Young children, who strug- gle and resist passive motion if placed on the table, submit quietly when held in the motlier's arms. Various simple and effective tests will suggest themselves to the ex- aminer, who has a definite purpose in view, but much patience may be required in early cases and several examinations may be necessary be- fore the presence or absence of disease can be definitely determined. It is important to remember that in childhood at least, abnormal symptoms always have a cause, therefore a patient should always be kept under observation until the cause is finally discovered. Of all the early signs of Pott's disease muscular rigidity or reflex muscular spasm is the most important, since it precedes deformity and accompanies it, until cure is finally established. It is a spasm that resists motion in all directions ; thus it may be distinguished from the spasm or contraction of certain groups of muscles resulting from irritation or inflammation not connected with the spine. For in such instances motion is limited only in the directions directly opposed by the muscular contraction. True reflex muscular spasm is quite inde- pendent of the will, and thus it may be easily distinguished from sim- ple voluntary resistance on the part of the patient. The muscular rigidity is most marked in the neighborhood of the disease, but it extends to a greater or less distance according to the THE REGIONAL EXAMINATION. 35 acuteness of the local process and the susceptibility of the patient. Even at' an early stage the situation of the disease is usually shown by a slight irregularity of the spine in the center of the area, made rigid by muscular spasm, as well as by the change of contour. This change in outline and in flexibility may be demonstrated by bending the patient forward. If the spine forms a long, even, regular curve and if there be no evidence of pain or rigidity, when such an attitude is assumed. Pott's disease is extremely improbable. If, on the other hand, the outline of the curve is broken ; if the motion of one section of the spine is restrained by muscular rigidity, disease may be suspected, and if other evidence of tuberculous ostitis is present, the diagnosis may be made with certainty. (Figs. 6 and 7.) By a careful physical examination one may expect to detect Pott's disease at any stage and to fix upon its location, or at least upon the point suspected of disease. One will then ask oneself if tuberculous disease of the bodies of the vertebrae of this particular region will satisfactorily explain all the symptoms of which the patient complains ; if for example, the pain corresponds to the distribution of the nerves, if restraint of function will explain the attitudes of the patient, if the change in contour is significant of a destructive process, and the like. The principles of differential diagnosis having been outlined they may be applied to the detection of disease as it appears in the different regions of the spine. The Regional Examination. 1. The Lower Region. — Considering the regions of the spine in the order of liability to disease one begins with the lower section com- prising the lumbar and the two lower dorsal vertebrae, that more nearly correspond in shape and function to the lumbar than to the thoracic division. This is the region of constant and extensive motion, thus the pain- ful rigidity, characteristic of the disease, is often marked long before the stage of bone destruction. The characte7'istiG attitude of the patient is one of what might be called over-erectness and often there is an increased holloumess (lordosis) (Figs. 10 and 12) of the back, so that the prominent abdomen may first attract attention. The walk is careful, and a peculiar tip-toeing step with slight inversion of the feet to avoid the jar of striking the heels is often observed ; this is however not a peculiarity of disease of this re- gion alone, but is rather an evidence that the spine is sensitive to slight jars. More characteristic of lumbar disease is a peculiar icaddle, ex- plained in part by the exaggerated lordosis, and in part by the loss of the accommodative, balancing motion of the lumbar spine, as the weight falls alternately on each leg in walking. The increased lumbar lordosis, so characteristic of the early stage of the disease, is capable of several explanations. It is partly voluntary ; as bending the body forward brings pressure upon the diseased verte- bral body, so bending it backward relieves this pressure. It is partly 36 TUBERCULOrS DISEASE OF THE SPINE. iiivoluntaiy, caused by the contraction of the large muscular masses on the posterior aspect of the spine ; and it is in part compensatory, as the slight psoas contraction which is often present has a tendency to tilt the pelvis forward, necessitating a greater compensatory back- ward inclination of the body. As the disease progresses, the lumbar section becomes straighter, and finally it may project backward in the characteristic angular de- formity. Yet even after the lordosis has been obliterated the back- FiG. 10. Fig. 11. Disease of the upper lumbar region before the stage of deformity, showing abnormal lordosis. The same patient (Fig. 10) five years later showing deformity. ward inclination of the body still continues as a compensation for the change in Ijalance, which the transformation of the forward curve to a posterior deformity has necessitated. (Fig. 11.) Thus over-erectness or Ijackward inclination of the body characterizes the disease of this reo-ion from its beginning to its end in uncomplicated cases. Slight psoas contraction as a part of the general muscular spasm about the point of disease, simply increases the lordosis, but if the contraction is greater, when, for example, an abscess is present which involves the substance of the psoas muscles or forms a painful tumor THE REGIONAL EXAMINATION. 37 in the pelvis, the erect attitude is no longer possible. The legs are drawn toward the body, and the body is inclined forward, to relax the tension. This greater contraction, with the abscess that is usually its cause, is most often limited to one side ; thus the patient inclines the body somewhat forward and toward the flexed leg, " favors it " and the resulting limp is usually mistaken for a sign of hip disease. Fig. 13. Fig. 12. Diseaseof the lumbar region. First symptom, pain in the knees. Disease of lumbar region with right ilio-psoas abscess and psoas contraction. Unilateral psoas contraction is, in fact, so often present when the pa- tient is first brought for treatment, that a limp and the accompany- ing inclination of the body may be considered as characteristic of dis- ease of the lumbar region at a somewhat later stage. The location of the pain depends upon the distribution of the nerves that supply the diseased vertebrae or that pass in its vicinity ; it may radiate over the inguinal region or backward to the loins or buttocks 38 TUBERCULOUS DISEASE OF THE SPINE. Fig. 14. or down the front or back of the legs to the knees. Painful cramp in the leg is sometimes a symptom ; the thigh is spasmodically drawn toward the body and the patient, seizing it with both hands, shrieks with pain. Lateral inclination of the body is often present. It is usually a symptom of unilateral psoas contraction and abscess ; it may be due also to unilateral contraction of the muscles of the back, or at a later stage, it may indicate collapse or destruction of one side of a vertebral body. In other instances it is not a fixed attitude, but is simply a voluntary adaptation to weakness or pain ; thus one may find a large abscess in one pelvic fossa unaccompanied by psoas contraction, while the body is inclined toward the opposite side, the weight being borne habitually on that leg. The stiffness, iceakness and pain, char- acteristic of disease in this region are exemplified in many ways, for example, the child maybe unable to turn in bed; it is slow and awkward in rising in the morning or in changing from an attitude of rest to one of activity. It often pre- fers to stand rather than to sit because in the latter position more weight is thrown upon the sensitive vertebral bodies. When seated, particularly when riding in a carriage or street car, the patient often sits upon the edge of the seat, the shoulders only touching the back, while the hands rest instinctively on the seat, partially supporting the weight and steadying the spine. Stooping, a posture that increases the pressure on the diseased vertebral bodies and which necessitates muscular tension and strain in regaining the erect posi- tion, is particularly difficidt and it is always avoided by the patient if the disease is at all acute. For example when the child is asked to pick up an object from the floor, it either refuses, or it squats on the heels or drops upon the knees (Fig. 14) instead of flexing the spine as in health. Young children, having seized the object on the floor, regain the erect attitude by pushing the body up by the pressure of the hands on the thighs. If the child is placed upon the floor it will, if possible, seize the mother's dress or will crawl to a chair or other object upon which the body may be drawn up by the arms so that the discomfort caused by muscular contraction of the back muscles may be avoided. After the inspection, and the observation of the motions and atti- tudes of the patient, the examination of the range of passive motion is made. The patient is placed at full length face downward on a Lumbar disease. The manner of pick- ing up an object. THE REGIONAL EXAMINATION. 39 table, and the range of extension, and of lateral motion is tested by- lifting tHe legs and swaying the body gently from side to side. (Fig. Fig. 15. Showing the rigidity of the spine before appearance of deformity. 15.) The spine is so flexible in childhood, that rigidity even in the upper dorsal region may be demonstrated by this method, and in test- FiG. 16. Test for psoas contraction. ing the lumbar region, the thorax should be fixed by the hand of the examiner. While the patient remains in this attitude, one should test 40 TUBERCULOUS DISEASE OF THE SPINE. for psoas contraction ; the pelvis is pressed firmly against the table with one hand, while the leg, held in the line of the body, is gently lifted by the other. (Fig. 16.) As tested in this manner, the normal range of extension should allow the knee to be lifted two or three inches from the table. Slight restriction of extension of both thighs, indicating a slight degree of psoas contraction, is very common in lumbar Pott's disease, but when the restriction is marked, and es- pecially if it be unilateral, a deep abscess may be suspected. Such unilateral psoas contraction may be more clearly demonstrated by placing the child on the back, allowing the legs to hang over the edge of the table, when the unaffected thigh will drop below its fellow. As a rule, flexion of the lumbar spine is much more restricted in the early stage of the disease than is extension ; this rigidity and fixa- FiG. 17. A method of demonstrating psoas contraction. tion may be demonstrated by placing the child on its hands and knees, and lifting it from the floor ; when the body, instead of bending over the supporting hands, retains almost its original contour. (Fig. 18.) As has been stated, even at an early stage of the disease one may often detect a slight fullness about the spinous processes or a slight irregularity in their line, about which the muscular spasm is most marked ; this indicates the exact seat of the disease. Deep pressure on the spinous processes at this point will often cause pain, and some- times greater elasticity at the diseased area may be demonstrated. Except in the hands of an expert, it is, however, a test of compara- tively little value ; and it may be again mentioned that local pain and local sensitiveness to pressure on the spinous processes, are not char- acteristic signs of Pott's disease. Finally, one should always examine for pdcic abscess. This may DIAGNOSIS. 41 be suspected when unilateral psoas contraction is present in marked degree, although psoas contraction may be present without abscess and abscess may be unaccompanied by psoas contraction when the sub- stance of the muscle is not involved. The typical psoas abscess, as pictured and described, is the fluctu- ating tumor, that suddenly appears on the inner side of the thigh, although it may have been many months in descending to this position from its original site. Demonstrable abscess is present at some time, in at least 50 per cent, of the cases of lumbar disease, and its early detection is a matter of importance, since its subsequent behavior will Fig. 18. Disease of the lumbar region before the stage of deformity. A test for rigidity. often materially influence the treatment. The child is placed on the side, the thigh is flexed and the hand is pressed gently down into the loin and iliac fossa. Sometimes the examination will be made easier by extending the leg and thus bending the spine forward toward tlie hand. Often, in this manner, one can make out the peculiar sausage- like thickening on one or the other side of the spine, or a larger rounded tumor in the iliac fossa, the presence of which would not otherwise have been suspected. Diagnosis. — If a careful physical examination were made in all suspicious cases, by one at all familiar with the ordinary symptoms of 42 TUBERCULOUS DISEASE OF THE SPINE. Pott's disease, the field for differential diagnosis would be small in- deed ; but it would appear that such examinations are not often made by the physician who is first consulted. One is often told that the child has been circumcised because of pain about the genitals, or be- cause of weakness of the limbs, supposed to be due to " refiex irrita- tion "; or if the patient be an adult, that he has been treated for sciatica, rheumatism or strain, long after the evidence of Pott's dis- ease, even in the angular kyphosis, would have been apparent on examination. Pott's disease is most often mistaken for some one of the following affections. Lumbago — may simulate some of the symptoms of Pott's disease of this region, but it is an acute affection, of sudden onset, usually accompanied by local pain and tenderness of the muscles themselves. Strain of the Back — is often accompanied by stiffness and pain on motion, but like lumbago, its onset is sudden and its cause is known. The pain is usually localized at the point of injury, it is relieved by rest, and the restriction of motion is, in great degree, voluntary. In Pott's disease the pain is neuralgic ; it is often worse at night and the rigidity is due to reflex spasm. Sciatica. — The pain of sciatica is most often unilateral ; it is usually confined to the distributions of this nerve which is often sensitive to pressure throughout its course. The pain of Pott's disease, if it is re- ferred to the legs, is usually bilateral and the nerve trunks are not often sensitive to pressure. In sciatica, movements of the leg that cause tension on the nerve, are often painful, while motion of the spine is free, or but slightly restricted, the reverse of the symptoms of Pott's disease. It is true that lateral deviation and even rigidity of the lum- bar spine are sometimes observed in cases of sciatica of long stand- ing, but if the latter symptom is marked, the diagnosis may be re- garded as open to question. Sacro-iliac disease is far more likely to be mistaken for disease of the hip than of the spine ; the pain and sensitiveness are usually localized about the seat of disease and the motions of the spine are not restricted. Lumbago and sciatica and sacro-iliac disease are extremely uncom- mon in childhood, and if supposed strains or injuries of the back cause persistent symptoms, the appropriate treatment would be similar to that of Pott's disease ; that is to say, fixation and rest of the suspected part, until the cause of the symptoms is made clear. The attitude, characteristic of Pott's disease of this region, the hollow back, the prominent abdomen combined with the waddling gait, may be simulated by Bilateral Congenital Dislocation of the Hip, in which the pelvis is suspended at a point behind its normal position, but in this deformity the gait and attitude have existed since the child began to walk, and are accompanied by the symptoms of bone disease. A similar attitude is sometimes the result of weakness or paralysis of the muscles of the back, as for example in Progressive Muscular Atro- phy, and again in Pseudo-hypertrophic Muscular Paralysis. In this BIA GNOSIS. 43 latter affection there is also a disinclination to stoop, and there may be rigidity of the back, symptoms that, in the early stages, bear a super- ficial resemblance to Pott's disease, but as there are no other signs of disease of the spine, it can be readily excluded. When psoas contraction is present in lumbar Pott's disease, the re- sulting limp, that is often accompanied by pain in the leg, is almost invariably mistaken for a symptom of Hip Disease. It will be remembered that although flexion of the leg caused by psoas contraction is a common symptom of Pott's disease, it is Fig. 19. as a rule not an early symp- tom; thus the history will prob- ably call attention to symptoms referable to the back that have preceded it. Again, the limp of Pott's disease is caused simply by flexion of the leg, a limp that is not, as in joint disease, ac- companied by pain on functional use. When therefore, in the physical examination, the ten- sion of the contracted ilio-psoas muscle is relieved by flexing the thigh still further, the other movements of the hip, flexion, rotation and the like, may be shown to be free and unre- strained. Thus hip disease, in which all motions are restrained in equal degree by muscular spasm, may be easily excluded, except perhaps in infancy. Hip Disease in Infancy. — At this susceptible age there is almost always a sympathetic spasm of the lumbar muscles in acute affections of the hip, and similar spasm of the hip muscles in disease of the lower part of the spine ; so that several ex- aminations may be necessary before an exact diagnosis can be made. In such cases the application of a temporary support to the back and leg, such as a spica plaster bandage which will relieve the secondary spasm, is a useful aid in diagnosis. It has been stated that extension of the thigh is alone restrained in psoas contraction ; it will be evident, however, that the presence of a large and painful abscess in the pelvis or thigh would limit motion in Disease of the lower dorsal region. The earliest indication of deformity. 44 TUBERCULOUS DISEASE OF THE SPINE. other directions as well ; but even in such cases, motion in one or more directions usually remains unrestricted ; thus disease within the joint may be excluded. Secondary Hip Disease. — In Pott's disease of long standing compli- cated by abscess in which the tissues about the joint are infiltrated, or traversed by discharging sinuses, secondary infection of the hip joint is not an unusual complication. In such cases it is not always easy to decide whether it is or is not present, when the limb is distorted and when motion at the hip is limited by the infiltrated and contracted tissues in its neighborhood. Pelvic Abscess. — As abscess is such a common complication of Pott's disease, it will be necessary to consider abscesses of other origin, that may occasionally cause symptoms resembling somewhat those of dis- ease of the spine. Such are the perinej)hritio abscess, and more rarely, that of appendicitis. They diiFer from the abscesses of Pott's disease in that they are, as a rule, acute in their onset and are accompanied by constitutional symptoms and by local pain and tenderness. In such cases the motions of the spine may be restrained, but the restraint is in great degree voluntary, quite different from the rigidity due to disease of its substance. It is true that the pelvic abscess of Pott's disease which has become infected may cause constitutional symptoms, but the history of the disability and discomfort that must have preceded the abscess, together with the probable presence of deformity, will make the diag- nosis clear. Chronic abscess in the pelvis of other than spinal origin, may be the result of disease of the pelvic bones, or of the sacro-iliac articulations, or of the hip joint. It may be caused by the breaking down of lymphatic glands, or it may have its origin in inflammation about the uterine appendages ; and cases of so-called idiopathic in- flammation and suppuration of the ilio-psoas muscle have been de- scribed. In childhood, chronic abscesses in this locality are almost always tuberculous in character, and are caused by disease of bone, either of the spine or of the pelvis. Disease of the spine can be deter- mined usually by the methods already indicated, but if the abscess is of other origin, its exact cause can be decided in many instances only by an operative exploration. Abscesses of this character, of slow and apparently painless formation may finally cause a swelling in the inguinal region or about the saphenous opening, that in the adult is not infrequently mistaken for hernia. In practically all cases, how- ever, the tumor of the abscess may be made out on palpation within the pelvis, while the swelling, although its contents may be in part forced into the abdominal cavity, is very -different in feeling from the complete reduction that is usually possible in the ordinary hernia. In addition some sign of the disease of the spine or pelvis, of which the abscess is a result, is almost always present. Peculiarities of Lumbar Pott's Disease in Infancy. Attention has been called repeatedly to the great importance of the careful observation of the postures and movements of the patient, to PECULIARITIES OF LUMBAR POTTS DISEASE IN CHILDREN. 45 the change in the contour of the spine and particularly to the abnormal lordosis aiid peculiar attitude of over-erectness in the early stage of lumbar disease. But the description of attitudes of standing and walking, and the shape of the spine which is the result of the erect posture does not apply to the infant in arms, nor need the spine be divided into contrasting sections for the purpose of differential diag- nosis. In Pott's disease of infancy the muscular spasm is more intense and its extent is greater. The child screams when it is moved or when the diapers are changed. There is usually no difficulty in de- termining the presence of disease from the evidence of rigidity and pain, but, as has been mentioned, it is sometimes difficult to decide whether the lumbar spine or one of the hip joints is involved. Slight irregularity of the spinous processes indicating the position of the de- structive process is often evident at an early stage and early abscess is not unusual. Pott's disease of infancy might be mistaken for acute rhachitis or scurvy but for the fact that the symptoms of such affections are not limited to the spine but involve to a greater or less degree the limbs and joints, the enlarged epiphyses and other evidences of rhachitis show- ing that the discomfort and pain are due to a general, not to a local disease. The Rhachitic Spine. — The deformity of the spine, caused by rhachitis is not infrequently mistaken for the kyphosis of Pott's disease. It has been stated that a long posterior curvature of the spine char- acterized the weakness of infancy. It is also characteristic of other forms of weakness and particularly that caused by rhachitis in early childhood. During the subacute stage of general rhachitis the child that has never walked or that has " lost its walk " sits much of the time in its chair, or is held in this position on the mother's arm so that the spine is bent backward and a curvature of the lower thoracic and lumbar region is habitual. Soon a slight projection persists, even when the child is lying down ; it usually increases in size and becomes more rigid and permanent, if its exciting cause remains ; thus a some- what rounded and rigid posterior curvature of the dorso-lumbar por- tion of the spine is formed. The diagnosis from Pott's disease should be made without difficulty, because the evidence of general rhachitis is always present so that such deformity is almost as much to be expected as would be distortions of the legs were the child walking. If the patient is placed in its- habit- ual sitting posture it will be seen that the deformity is simply an ex- aggeration of a normal attitude. In this attitude the patient remains contentedly for an indefinite time, whereas if Pott's disease were present, the child would lie on its back or abdomen. Finally, the projection is rounded, not angular, and if the patient be placed in the prone posture the projection may be reduced, in great part, by raising the thighs while gentle pressure is exerted upon the kyphosis ; and although the spine is somewhat rigid, and although such extension and pressure may be resisted by the patient, yet there is complete absence of the muscular spasm characteristic of Pott's disease. 46 TUBERCULOUS DISEASE OF THE SPINE. It may be stated then that the rhachitic deformity is a rounded curvature of the lower part of the spine. Its cause is weakness and habitual posture. The rigidity depends upon the duration of the de- formity. The pain^ if the rhachitis be acute^ is general and is easily explained by the sensitive condition of the bones and joints. It is true that rhachitis and tuberculous disease of the spine may be com- bined, but in such rare instances the symptoms of the more serious local disease will make themselves evident as distinct from those of the general weakness. Recapitulation. — The more characteristic symptoms of disease of the dorso-lumbar region may be summed up as follows : Increased lordosis or over-erectness and a prominent abdomen ; a cautious, constrained or waddling gait ; less often, a lateral inclination of the body, or a limp caused by psoas contraction. Stiffness of the spine, which makes bending or turning the body difficult. Pain, referred to the back, the inguinal region or down the legs, and in more advanced cases, the characteristic deformity. Diagnosis. — The attitude may be simulated by congenital disloca- tion of the hips and by pseudo-hypertrophic muscular paralysis or, more rarely, by progressive muscular atrophy. The limp may be mistaken for that 'of hip disease. The pain and stiffness for sciatica, rheumatism, lumbago or injury. The abscess is to be distinguished from those from other sources. In young infants the symptoms may be simulated by hip disease and by acute rhachitis. Finally the deformity of the subacute form of rhachitis is to be dis- tinguished from that symptomatic of bone destruction. y Disease of the Middle or Thoracic Region of the Spine. The normal motion of this section of the spine, which includes the third and tenth vertebrae is, as compared with those above and below it, slight ; thus, disease of this region may not interfere to a notice- able degree with the general function of the spine. As this part of the column curves backward, the deformity, often unattended by severe symptoms, is not infrequently mistaken for round shoulders. It seems probable also, because of the normal back- ward curve, and because of the leverage exerted by the weight of the head and arms, that deformity quickly follows disease. At all events, patients are not often seen before it is present, so that diag- nosis is usually evident on inspection of the patient. The attitudes are not especially significant. If the lower part of this region is involved, and if the disease be at all acute, they are similar to those of disease of the lower region, viz.: erectness, the peculiar, cautious, in-toeing step, and the disinclination to bend the body forward. If, on the other hand, the upper part is affected, the attitude is DISEASES OF MIDDLE OR THORACIC REGION OF SPINE. 47 often, pavticularly in young children, one of weakness ; there is a slight forward inclination of the body while the head is tilted back- ward or is inclined toward one side. A peculiar shrugging, squareness and elevation of the shoulders is often noticed. (Fig. 21.) In many instances the apparent elevation of the shoulders is in reality caused by the deformity, which shortens the neck and lowers the head. In this connection, it should be mentioned that one of the secondary Fig. 21. Fig. 20. Pott's disease of the middle dorsal region at an early stage, showing slight increase of the dorsal kyphosis. Disease of the upper dorsal region. Characteristic attitude. effects of the disease, the so-called pigeon breast, is, not infrequently, noticed by the parent before the angular deformity of the spine. In the pigeon breast of Pott's disease, the forward inclination of the spine causes a flattening of the upper part of the chest, while the sternum sinks downward and becomes prominent, thus the antero-posterior diameter of the chest is increased, and it is compressed from side to side, so that it resembles very closely the deformity of rhachitis. As 48 TUBERCULOUS DISEASE OF THE SPINE. the pigeon breast of Pott's disease is always secondary to the deformity, its cause, of course, becomes apparent on examining the spine. Of the early symptoms of dorsal disease, pain and labored or '^ grunting" respiration are the most characteristic. Pain referred to the abdomen and to the front and sides of the chest is usually an early and often a constant symptom ; thus persistent " stomach-ache " in a child should always lead one to an examination of the spine. A " spasm of pain " is sometimes excited by Pj(, 22 lateral compression of the chest, as when the child is lifted suddenly by the parent. Of much greater importance, however, is the labored or grunting respiration, which indeed is almost pathognomonic of Pott's disease. This ^'grunting" is caused by the interference with respiration, more par- ticularly with the normal rhythmical move- ments of the ribs. The restraint is, in part, due to muscular spasm, and in part to the voluntary eiforts of the patient. The in- spiration is quick and shallow, in great degree diaphragmatic, and expiration is accompanied by a sigh or grunt. This is apparently caused by a momentary closure of the larynx to resist the escape of air and thus sudden motion of the chest wall. Grunting respiration is, of course, an evi- dence of the more acute type of disease, but even in mild cases in children it will be noticed when the patient is fatigued, or during play. All irritating, aimless cough is often a symptom of disease of the upper dorsal region, and spasmodic attacks resembling asthma are not uncommon. The physical examination will, in most cases, show the characteristic angular ky- phosis, and in the exceptional cases, in which deformity is absent, a slight change in contour will be apparent when the pa- tient is bent forward. In place of the long regular curve of the normal spine, a point where two distinct outlines unite will be observed, one of which may be curved while the other is practically straight. The presence of muscular spasm may be shown by sudden move- ment of the spine, and it may also be demonstrated, in children, by raising the legs and swaying the body from side to side, as illustrated in the preceding section. (Fig. 15.) The change in the rhythm of respiration has already been mentioned ; the restraint does not affect Marked lateral deviation of the spine with rotation. Deformity at the eighth dorsal vertebra. DISEASE OF MIDDLE OR THORACIC REGION OF SPINE. 49 the motion of all the ribs equally, those that articulate with the diseased vertebrae -;are often nearly motionless while the movement of those at a distance may approach the normal. In tracing the neuralgic pain to its origin, the sharp downward in- clination of the ribs must be borne in mind ; thus, the cause of pain in the " stomach " must be looked for between the shoulder blades. As in the lumbar region, slight lateral deviation of the spine is not uncommon, and it may be accompanied by a slight twist or rotation so that the ribs on one side are more prominent. (Fig. 22.) Fig. 23. Double psoas contraction of an extreme degree and paralysis. The arms used as supports. In disease of this region of the spine the spinal cord is more often involved than elsewhere, thus an awkward stumbling gait and finally a " loss of walk " may be the symptoms that first attract attention. This paralysis of Pott's disease and its differential diagnosis are con- sidered elsewhere. Abscess as a complication, can not be demonstrated by palpation unless it has found an outlet between the ribs, but percussion will often show an area of dullness or flatness, extending from the diseased vertebrae toward the lateral aspect of the chest, due in part, however, 4 50 TUBERCULOUS DISEASE OF THE SPINE. to the inflammatory thickening of the tissues in the neighborhood. In rare instances the abscess may press directly upon the trachea or bronchi and cause spasmodic attacks of dyspnoea resembling asthma. Diagnosis. — It is hardly necessary to mention the list of aifections that may cause pain in the chest or abdomen ; it is sufficient to state that such symptoms always require a physical examination. The same statement applies to irregular respiration, to cough and so-called asthma. Occasionally tuberculous disease of the dorsal spine in adolescence, is not only practically painless, but the resulting deformity is rather rounded than angular, so that it may be mistaken for round shoulders. " Round shoulders " is however, as a rule, of longer duration ; some exciting cause of postural deformity, in occupation or otherwise, is usually apparent ; while the rigidity is less marked than in Pott's dis- ease and pain is absent. The situation and shape of the rhachitic kyphosis has been de- scribed. It should be evident, that a more or less angular projection, in the upper part of the spine could not be rhachitic, and yet because of the absence of pain, this diagnosis is not infrequently made, and as a consequence, the activity of the tuberculous disease may be increased by massage and exercises. Lateral deviation of the spine as a symptom of disease, could not be mistaken for the ordinary rotary-lateral curvature, in which pain and muscular rigidity are absent. Acute affections within the chest, pleurisy, pneumonia and empyema are sometimes accompanied by lateral deviation of the spine, but the sudden onset, and the constitutional and local symptoms that accom- pany such affections should make the cause of the deformity and pain evident. It is because these cases are sometimes sent to orthopaedic clinics for braces that such causes of deformity seem worthy of men- tion. The abscess of Pott's disease in this region, as has been mentioned, causes dullness or flatness on percussion of the chest and within this area friction sounds and rales may be heard. If the diagnosis of Pott's disease had not been made or if the pres- ence of the abscess had not been determined by the previous physical examination, it might be mistaken, during an acute exacerbation of the disease or constitutional disturbance from other cause, for pleurisy or empyema, and at other times for phthisis. The tuberculous fluid may remain indefinitely in the posterior mediastinum and the area of flatness may extend beyond the axillary line, yet it may give rise to no symptoms. In all cases then, a careful examination of the chest should be made from time to time in order that the presence or absence of abscess may be recorded. Recapitulation. — Pott's disease of this region is often insidious in its onset, causing no positive symptoms before the stage of deformity. Its most characteristic symptoms are pain referred to the front and sides of the body and the grunting respiration. THE UPPER REGION. 51 If the disease is progressive the ordinary symptoms of Pott's disease — weakness and rigidity — are present ; in the lower thoracic region, the attitude resembles that of lumbar disease ; in the upper, the head is usually tilted somewhat backward and the shoulders appear to be elevated. In differential diagnosis, one will consider the significance of pain, the cough or embarrassed respiration and the affections for which ab- scess or paralysis might be mistaken. Also round shoulders, rhachitic deformity and lateral deviation of the spine as distinguished from the kyphosis of Pott's disease. The Upper Region. The upper region of the spine, which includes the cervical and two of the dorsal vertebne, corresponds in freedom of motion and in the forward curve, to the lumbar region. For the purpose of study, it Fig. 24. Cervical disease with abscess. Characteristic attitude. must be divided into two parts. Of these, the superior or occipito- axoid section is peculiar, in that it contains no vertebral body or inter- vertebral cartilage, and in that the movements of the head are carried out in special joints and are controlled by special muscles. 52 TUBERCULOUS DISEASE OF THE SPINE. Disease at this point is especially dangerous, because displacement or fracture of the weakened vertebrae may cause sudden death by pres- sure on the vital centers. Occipito-axoid disease is comparatively rare, and it is relatively more frequent in adult life than in childhood. Symptoms. — In a typical case, the symptoms are neuralgic pain radiating over the back and sides of the head, following the distribu- tion of the auricular and occipital nerves. The neck is stiff and the head may be fixed in the median line, the chin being somewhat de- pressed, but it is more often tilted to one side, simulating the attitude of torticollis. (Fig. 24.) The attitude and appearance, when normal movement of the neck is cut off by a painful disease is characteristic ; the eyes follow one, or the body is turned, when the attention of the patient is attracted. The patient moves carefully, in order to avoid jar ; often the chin is instinc- tively supported by the hand, and a favorite attitude is one in which the patient sits with the elbows on a table, the hands supporting the head. (Fig. 25.) If the attempt is made to raise the chin, or to ro- tate the head, the patient seizes the hands of the examiner and, if a child, it screams in apprehension. There is often a slight bulging and thickening of the tissues at the seat of disease. The affected vertebrae are usually sensitive to deep pressure, and not infrequently, deep fluc- tuation in the sub-occipital triangle can be made out. The atlo-axoid junction lies just behind the posterior wall of the pharynx on a line with the upper teeth and here abscess often presents itself, occasionally early in the course of the disease, causing symptoms characteristic of obstruction, such as snoring, change in the quality of the voice, difficulty in swallowing, and sometimes spasmodic attacks of so-called croup. When abscess is present and when the disease is at all acute, the reclining posture sometimes aggravates the symptoms, so that " getting the child to bed " is often a tedious and difficult task. In certain cases, one may make out the exact location of the disease in the occipito-atloid or the atlo-axoid articulation, but as both joints are to a great extent controlled by the same muscles, this is often im- possible when muscular spasm is well marked. The uppermost joint, that between the atlas and occiput permits the nodding movement of the head, or flexion and extension on the spine ; while the atlo-axoid joint permits rotation of the atlas about the axis to the extent of about 30 degrees in either direction. If the disease be in the upper joint the nodding movements will be more restricted than those of rotation and vice versa. The motion of the entire cer- vical spine is very free so that to make the test one must grasp the neck firmly, in order to restrain motion except in the joint under ex- amination. Because of this freedom of movement, restriction of mo- tion, symptomatic of disease in the upper region, is often overlooked when it is of the sub-acute variety. The Lower Cervical Region. — The symptoms of disease of the lower cervical section, although similar in character, are often less marked SYMPTOMS. 53 than those of the upper region. The cervical spine becomes straighter and often a slight backward projection or thickening indicates the posi- tion of the disease. The head is usually turned to one side by spasm of the lateral muscles in an attitude of wry neck. (Fig. 26.) The pain is referred to the neck, to the sternal region or down the arms, following the distribution of the brachial plexus. Fig. 25. Cervical disease. A characteristic attitude. In cases of more advanced disease, one's attention may be attracted to the cervical region, because the neck seems short and because the head is tilted backward. The entire back shows a compensatory flat- tening, yet no deformity is apparent until the occiput is raised and drawn forward, when a shelf-like projection may be felt, at what ap- pears to be the top of the spine, but which is really the angular de- formity at the third or fourth vertebra. This emphasizes the importance of a careful observation of the con- tour of the spine and the necessity of explaining to oneself every change from the normal that may be noticed. Disease at the cervico-dorsal junction resembles in its symptoms that of the upper dorsal region. The head is usually tilted backward (Fig. 21) or it may be turned to one side. Disease at this point is often sub- 54 TUBERCULOUS DISEASE OF THE SPINE. Fig. 26. acute in character, and paralysis from implication of the spinal cord sometimes appears before deformity is apparent. The seventh cervical or first dorsal spine is often prominent (verte- bra prominens) in normal individuals and it may be mistaken for the deformity of disease, especially when pain about this point is a symp- tom, as in hysterical or hypersesthetic persons. If such projection is symptomatic of disease there is almost always a slight compensatory flattening of the spine below the point and a certain amount of rig- idity of the surrounding muscles. Diagnosis. — As stiffness and distortion of the neck are the most prominent symptoms of disease of this region it will be necessary to consider first, the forms of Torticollis for which it might be mistaken. In typical torticollis or wry neck, the distortion of the head is caused, almost invariably, by contraction of the muscles supplied by the spinal accessory nerve, the sterno-mastoid and trapezius, so that the chin is slightly elevated and turned away from the contracted muscle. Congenital Torticollis which has ex- isted from birth is not accompanied by pain and it could hardly be mis- taken for a symptom of disease. Acute rheumatic Torticollis, " stiff neck," is sufficiently common to be familiar in its characteristics. It is of sudden onset, " in a single night"; the affected muscles are sensitive to pressure ; the course of the affection is short, and it is of comparative in- significance. A more persistent form of acute torticollis, accompanied by greater muscular spasm and by local tender- ness, sometimes follows of enlarged or suppurating cervical glands; it may follow " earache," tonsilitis or sore throat or any form of irritation about the pharynx. This form of wry neck is not only more painful, but it may last indefinitely, and permanent deformity may result. The onset is usually sudden ; the pain and tenderness are local, and are confined, as a rule, to the contracted part. The sterno-mastoid and trapezius muscles are most often involved, thus the wry neck is typical. If the tension be relaxed by inclining the head toward the contracted muscle, motion of the spine itself will be found to be free and painless, but if traction be made on the contracted muscle, it causes discomfort, thus it is usually resisted by the patient. In disease of the occipito-axoid region, the distortion of the head is, by no means, typical of sterno-mastoid contraction ; it may be tilted up or down or laterally to an exaggerated degree. In other words, Disease of the middle cervical region at an early stage. DIAGNOSIS. 55 the wry neck of Pott's disease is an irregular distortion, not dependent on the 6ontraction of a particular muscle or muscular group. " In torticollis the chin is turned away from the contracted muscle while in Pottos disease it is turned toward the contracted muscle." This is an axiomatic expression of the fact that the distortion of the head symp- tomatic of atlo-axoid disease, depends, in great degree, upon the spasm of the small muscles that directly control these joints, the recti and obliqui and not directly upon the contraction of the sterno-mastoid muscle, as in the ordinary form of wry neck. Again the contraction, symptomatic of Pott's disease, of this or other regions, is the result of muscular spasm, a muscular spasm that fixes the head and prevents painful motion. If the head be grasped firmly by the hands and if gentle traction be made, the muscular spasm relaxes and the patient experiences a sensation of comfort, while if similar traction is made upon the contracted muscles of simple wry neck, the pain is increased and the patient protests. In disease of the middle cervical region, however, the distortion due to the reflex muscular spasm, is similar to that of simple torticollis, and it is sometimes difficult to distinguish one from the other, particularly if the latter is caused by the irritation of inflamed or suppurating glands. For, in such cases, there is usually much sensitiveness to manipulation and a more or less general muscular spasm, so that diag- nosis may be impossible, until apparatus has been applied to rest the part, and to correct the deformity. It has been stated that the head was often tilted backward to com- pensate for deformity in the middle cervical region. It is also, in some instances, drawn backward by spasm of the posterior muscles. Such a case might be mistaken for cervical opisthotonos, in which the head is held in an over-extended position, as is sometimes seen in young infants suffering from exhausting diseases, basilar meningitis and the like. In such conditions, however, the characteristic symp- toms of Pott's disease are, of course, absent. The opposite attitude, viz., a forward droop of the head due to weak- ness of the trapezii muscles, is not uncommon as a sequence of diph- theria or other forms of contagious disease. This droop may be accompanied also by spasm of one of the sterno-mastoid muscles and by pain. In such cases, the history of the preceding affection, the weakness or paralysis of other parts, as of the soft palate, the muscles of accommodation of the eye and the like, together with the general bodily weakness that the patients often present, should make the diag- nosis clear. Injury to the upper segment of the spine, a sprain, contusion, or fracture unless efficiently treated, may cause symptoms resembling very closely those of tuberculous disease ; for example, the pain often radi- ates over the back of the head, and there may be rigidity and deform- ity of the neck, and even infiltration and local tenderness about the in- jured part. Such cases, when seen several weeks or months after the accident, are puzzling, because one may be in doubt whether the symp- 56 TUBERCULOUS DISEASE OF THE SPINE. toms were caused by a simple injury or whether tuberculous infection may have followed or preceded it. In such cases a positive diagnosis cannot be made until the effect of rest and protection has been observed, that is to say, suspicious cases should be treated as one would treat actual disease. If the case is simply one of injury, recovery will be rapid and complete, while if disease be present, the symptoms only, will be relieved. The occipito-axoid articulation may be involved in acute articular rheumatism, or in chronic rheumatoid arthritis, when the diagnosis is of course easily made, but occasionally the joints at the upper extremity of the spine may be the seat of what appears to be an infectious arth- ritis, in which the symptoms are of sudden onset and are sometimes combined with fever and constitutional disturbance, and in which no other joint is involved. The sudden onset and the rapid recovery are the diagnostic points. Abscess in the cervical region is a secondary symptom, and although it may first attract attention to disease by the change in the voice or the difficulty in breathing or swallowing, yet it is always accompanied by some of the characteristic signs of Pott's disease. Whenever the diagnosis of cervical disease is made, one should ex- amine the throat, and whenever a chronic retro-pharyngeal abscess is present one should look for the symptoms of Pott's disease. The diagnosis of the retro-pharyngeal abscess can be made only by inspection and palpation ; therefore, one need only mention the fact, that symptoms of obstruction in the throat, similar to those of abscess, may be caused by adenoid growths and enlarged tonsils. Retro-pharyngeal abscess is by no means always symptomatic of Pott's disease. It may be acute, as one of the sequelae of contagious disease or as a complication of pharyngitis. It is then rapid in its onset and is not accompanied by the symptoms of Pott's disease. Recapitulation. If the disease is of the upper or occipito-axoid region the head is usually fixed in an attitude of deformity, which is sometimes slight and sometimes extreme. In the middle region, the attitude more often resembles that of or- dinary torticollis. In the lower region, there is often no marked spasm of muscles, but the head hangs backward or toward one shoulder. The contour of the cervical spine changes as the disease progresses, the normal anterior curvature is obliterated, thus the head is pushed forward, while the dorsal section of the spine becomes flat or even in- curvated in compensation. The seat of the disease is often shown by an area of thickening or local tenderness to deep pressure. Disease of the joints of the upper or occipito-axoid section is often acute in onset, sometimes a form of synovial tuberculosis, and abscess is a very frequent complication. THE RECORD OF THE CASE. 57 Differential diagnosis of disease in this region will include the con- sideration 'Of the various forms of wry neck, cervical opisthotonos, diphtheritic paralysis, and injury. Retro-pharyngeal abscess must be distinguished from that not connected with the bone, and from other forms of obstruction in the throat. Diagnosis in General. Weakness and the so-called " loss of walk " are well-known symp- toms of Pott's disease, and on this account children suffering from different forms of weakness or paralysis are often sent to orthopaedic clinics for the treatment of " spine disease." Certain forms of paralysis bear a superficial resemblance to some of the symptoms of Pott's disease, for example pseudohypertrophic mus- cular paralysis to the attitude caused by disease of the lumbar region and diphtheritic paralysis to that of the dorsal region. Spastic par- alysis, of cerebral origin, resembles somewhat the paralysis of Pott's disease, but it may be differentiated by tlie absence of pain, by the history and by what is apparent in most cases, the mental impairment. The contractions combined with the weakness and pain that some- times follow cerebro-spinal meningitis may be mistaken for the symp- toms of bone disease, but are as a rule readily explained by the history of the case. Forms of organic disease of the spine, other than tuberculous, as, for example, malignant disease, syphilis and the like, are described in Chapter II. The list of affections that has been considered in the differential diagnosis, is a long one, but it has been made up from actual experi- ence. Most mistakes in diagnosis may be explained by carelessness or ignorance, or because of insufficient opportunity for examination ; but in the earliest stages of the disease, repeated examinations, time for observation and even tentative treatment may be necessary before the diagnosis is confirmed. The Roentgen Ray Photography as a Means of Diagnosis. — The Roentgen ray is of value as a means of determining the exact extent of the disease. If the negative is well defined, the diseased vertebrae are seen to be irregular in outline or they may be lost in a peculiar blur. By counting from above and below the exact extent of the disease may be made out, but inferences as to its character and quality must be made from the rational and physical signs. The Record of the Case. The history and the result of the examination of the patient should be recorded somewhat in the following order. 1. The family and the personal history. 2. The story of the disease with especial reference to its mode of onset, its probable duration, to the noticeable symptoms and to previous treatment, if any. 58 TUBERCULOUS DISEASE OF THE SPINE. 3. The physical examination. This should include the general condition of the patient ; the height and weight ; the attitude ; the character of the disease, whether acute or otherwise, as shown by the muscular spasm and pain on motion ; the presence of abscess as a complication, or paralysis ; and finally, the position and extent of the disease. This is best shown by a tracing, made by means of a strip of lead or pure tin of such thickness that it may be readily moulded on the spine and yet hold its shape when removed. Young's de^dce, consisting of movable pins set in a frame, is a serviceable appliance for this purpose. The tracing should be of the entire spine, made while the patient lies extended in the prone position, and the exact location of the most prominent spinous processes should be marked upon it. In determining the position of the disease it is well to count the spin- ous processes from below upward, beginning with that of the fourth lumbar vertebra, which lies on a line drawn between the highest points of the iliac crests. There are other landmarks that are ap- proximately correct. Sometimes the last rib may be traced to its origin, the scapula covers the second and seventh ribs, the root of the spine of the scapula and the middle point of the glenoid cavity being on a line with the third, and its inferior angle opposite the tip of the seventh dorsal spinous process. The upper margin of the sternum is opposite the interval between the second and third dorsal vertebrae. The vertebra prominens can often be distinguished, as may the spinous process of the axis. Such landmarks are, of course, somewhat displaced in deformity, but they are always sufficiently correct to check errors in counting the spinous processes. The history furnishes a foundation on which treatment is conducted and from which its results are ascertained. The study of final results has become of great importance in orthopaedic surgery, and on this account the record should present the condition of the patient when treatment is begun, in a form that may be readily understood, not only by its writer when details have been forgotten, but by anyone who may in after years consult it. To this history notes during the course of the disease on its complications and incidents and on the changes in the treatment, together with tracings of the spine, are added at regular intervals until the patient is cured. Treatment. The general treatment of tuberculous disease is considered in Chap- ter V. Pott's disease is the most important of the tuberculous affec- tions of the bones, and the importance of proper surroundings, proper food, sunlight, and, within certain limits, exercise in the open air, can hardly be exaggerated. The General Principles of Mechanical Treatment. — Under normal con- ditions the weight of the head and of the thoracic and abdominal TREATMENT. 59 organs tends to bend the spine forward and downward, a tendency that is resisted by the action of the muscles of the back. If the re- sistance is weakened, as in Pott's disease by the direct destruction of the weight-bearing portion of the spine, this tendency toward deformity is, of course, greatly increased. Thus the pressure and strain of the superincumbent weight upon the weakened part that the upright pos- ture entails, are, from the mechanical standpoint, the most important factors in the production of deformity. When the body is bent forward, as in the stooping posture, the in- tervertebral discs are compressed and the pressure upon the vertebral bodies is increased ; so, on the other hand, when the body is held erect or is bent backward, this pressure is lessened, and a part of the weight is transferred to the articular processes and to the posterior parts of the column. In fact, specimens show that the continuity of the spine may be preserved, and that weight may be supported even when a vertebral body has been practically destroyed. The object of a brace or other support used in the treatment of ^ Pott's disease is to hold the spine in this extended position, so that pressure on the diseased vertebrae may be removed. One aims to splint the spine as, for example, one would splint a broken back, in order to relieve the symptoms of discomfort and pain, so depressing to the patient, and to secure the rest that is essential to repair. The effectiveness of a particular splint or support, when applied to a broken leg or to a diseased spine, depends upon the area that it covers on either side of the part to be supported and upon the accuracy of its adjustment, as well as upon the damage that the part has already sustained, and the strain to which it still may be subjected. It must be evident that the body because of its size, shape and contents is not suitable for the accurate adjustment of support, and it is apparent also that the mechanical conditions are more unfavor- able in some parts than in others. For example, in the middle of the back the splint is likely to be effective, because its two extremities, at- tached to the pelvis and to the shoulders, are equidistant from the point to be supported. These conditions are reversed in disease of the upper thoracic region, because the weight of the head and of the arms tends to increase the deformity and because of the insufficient leverage that can be secured for the supporting appliance. The pelvis is the base of support for all forms of splints, and if it be smaller than the abdomen, as in infancy, the adjustment of efficient support is very difficult. Although, in actual practice, the treatment of Pott's disease is in- fluenced by many circumstances, by the age of the patient, the situa- tion of the disease, the duration of the deformity and the like, yet the relative efficiency of braces or other appliances may be decided on purely mechanical grounds. Thus, as the ultimate deformity of Pott's •disease is, in great degree, caused by the force of gravity acting on a weakened spine, the most effective treatment must be fixation in the horizontal position, since only by this means can the strain of use, and 60 TUBERCULOUS DISEASE OF THE SPINE. the pressure of the superincumbent weight be removed completely ; and relief from jars and injury, that favor the extension of the disease, be assured. Horizontal Fixation. — Apparatus for this treatment must be quite independent of the bed on which it may be placed, and of such ap- pliances several forms may be employed. The reclinationgypsbettes of Lorenz ^ is simply a posterior case of plaster of Paris enclosing the head and body. The Phelps bed is somewhat similar. A thin board is cut in the outline of the child's body and extended legs. It is padded with cotton wadding and covered with cotton cloth ; the patient is then placed upon it, and plaster bandages are applied to enclose the body and the legs. Later the front is cut away, so that the patient may be removed from the bed, for an occasional bath and change of clothing.^ The wire cuirasse has been popularized by Sayre ; ^ it is an effec- tive appliance although somewhat cumbersome and expensive. A more effective and more convenient form of support is the Brad- ford frame or stretcher. This is a rectangular frame of ordinary gal-, vanized gas pipe, or better, of the lighter steel tubing. It should be a few inches longer and slightly wider than the patient's body. Over the frame, a cover of strong canvas is drawn tightly by means of cor- set lacings or straps on its under surface. The center of the cover should be protected by a strip of rubber cloth, as will be found to be Fig. 27. Bradford's bed-frame. (Beadfokd and Lovett.) most convenient in the treatment of young children, who wear diapers ; or an interval may be left for the use of the bed pan, as in the illustra- tion (Fig. 27) ; or preferably the cover may be made in three parts, of which the middle section may be removed when necessary, so that the buttocks may not sag into the opening, and thus make the support for the spine less efficient. Several sets of canvas covers may be provided, to allow for frequent washing ; small linen draw sheets may be used to protect them, and a folded sheet or thin hair mattress may be in- serted between the layers of the canvas cover, if the straps or lacings ' Vide Hoffa, Lehrbuch der Orthopadisclien Chir., p. 313. 2 The Phelps plaster-of-Paris bed, Trans. Am. Ortho. Ass'n, Vol. IV., 1891, p. 83. " La gouttiere de Bonnet. K^dard, Chir. Orthopedique, p. 243. TREATMENT. 61 cause discomfort. These refinements are, however, not essential in hospital practice. As has been stated, the position of over-extension is that most favor- able to repair, and this attitude can be assured by bending the bars up- ward from time to time as the deformity recedes, and as the patient becomes accustomed to the apparatus. The spinous processes should be protected by thick pads extending on either side of the spine at the seat of disease. These are sewed to the cover and when properly adjusted they assure better support and fixation. The method of attaching the patient to the frame varies somewhat according to the situation and character of the disease. In ordinary cases a canvas apron, similar to that used with the back brace (Fig. 35), is applied and is buckled to the sides of the frame, while the shoulders are held down by straps crossing the chest, or by axillary straps con- nected by a chest band. If still more effective fixation is desired, as in disease of the upper dorsal region, the anterior shoulder brace, as Fig. 28. The modified stretcher splint, showing over-extension of the spine, with traction for the head and limbs as applied for Pott's paraplegia. used with the back brace (Fig. 33), may be attached to the axillary straps. In disease of the upper and middle regions of the spine re- straint of the legs is not necessary, but in lumbar disease a broad swathe should be passed across the thighs. In disease of the upper region of the spine a certain amount of traction is desirable to aid in the reduction of deformity and to pre- vent the patient from raising the head. This traction is usually ap- plied by means of the halter as used with the jury mast. The straps are attached to a crossbar at the upper extremity of the frame and traction may be made by simply tightening them, or if the upper part of the frame is somewhat elevated the weight of the patient's body makes the proper extension. This position has the advantage, also, of allow- ing the patient a better opportunity to see what is going on about him. In disease of the middle cervical region traction is usually of ser- vice, and fixation of the head is always indicated in addition when the occipito-axoid region is involved, either by sand bags on either side or, preferably, by some form of metal brace. 62 TUBERCULOUS DISEASE OF THE SPINE. In the treatment by horizontal fixation, the child, wearing only the underclothing, is attached to the frame, and after the apparatus has been properly adjusted, he is never allowed to sit up or to turn the body or to raise the head until this form of treatment has been discon- tinued. Children quickly accustom themselves to a restraint that so effectually relieves the symptoms of weakness and pain. Once a day, as a rule, the patient is removed from the support in the following manner : The frame is placed upon a bed and, the straps having been loosened, the child is turned from the frame face down- ward upon the bed by two persons, one of whom supports the head and shoulders and the other the pelvis, in order that the back may be held rigid ; the shirt which opens in front is then removed, the back is rubbed gently with alcohol and powdered ; irritated points are care- fully protected and bed sores are prevented by padding to remove pressure. Usually no trouble whatever is to be anticipated on this score. The frame bed is carefully prepared, the draw sheet is changed and the canvas cover is tightened if necessary. It is of course a great convenience to have two frames so that an immediate change may be made from one to the other. Greater fixation of the spine may be desirable in cases of more acute disease. This may be attained by the use of a light back brace, or a plaster jacket, in connection with the frame. Such support should not be applied however until the recession of deformity, which is to be expected under treatment by the horizontal fixation, has been obtained. As has been stated the child is placed upon the frame wearing noth- ing but the underclothing. The outer garments are made large enough to cover both the body and the frame so that a change can be made without disturbing the apparatus. Thus protected, the child may pass the entire day in the open air. It may be carried in the nurse's arms or a carriage may be arranged for it. In colder weather the patient may be enclosed in a sleeping bag of blanket or skin. Of the conditions that have been mentioned as favorable to the cure of tuberculous disease, but one is lacking in the treatment by horizontal fixation ; this is exercise. Exercise may be in part replaced by mas- sage of the arms and legs, and in any event, beneficial exercise is usu- ally out of the question during the phases of the disease for which treatment by the frame is indicated. Its disadvantages, when properly employed, are in great degree imag- inary, while its positive effects in checking the progress of deformity and in relieving the symptoms of the disease will be apparent at once. The indications for treatment by this method will be considered after the description of the other forms of support. However efficacious the horizontal fixation apparatus may be, it is incomplete in itself since it must be supplemented by some form oi support when the erect posture is again assumed. Such supports are either metallic braces applied directly to the spine or a form of jacket that surrounds the body ; each removes a part of the superincumbent TREATMENT. 63 weight from the seat of disease by holding the body in the extended position and each splints the weakened spine more or less effectively. The Back Brace. — The spinal brace, or spinal assistant, as the orig- inal appliance of Dr. C. F. Taylor was called, consists essentially of two steel bars that are applied on either side of the spinous processes from the top to the bottom of the spine. At the seat of disease pads are placed to provide for greater pressure and fixation, and thus, a fulcrum over which the spine may be straightened or held erect, when the two extremities of the brace are firmly attached to the pelvis Fig. 29. and to the shoulders. The attachment at the lower end is made by means of a pelvic band of sheet steel (gauge 18) from one and a-half to two inches in width, long enough to reach from one iliac spine to the other ; it is placed as low as possible on the pelvis, in other words, just above the upper extremities of the trochanters. To this the uprights are firmly attached at an interval of from one and a-quarter to one and three-quarter inches from one another, so that the spinous processes may pass between them, while pressure is made on the lateral masses of the ver- tebrae. The uprights are made of varying strength, according to the age of the patient, usu- ally about one-half an inch in width (of gauge 8 to 12) and of such quality of steel, that although unyielding to the strain of use, it may be readily •1,1 1 1 xi- "^ The Taylor brace and head support applied for disease bent by wrenches, and thus ^ of the upper dorsal region. accurately adjusted to the back. The uprights reach to the root of the neck, or to about the level of the second dorsal vertebra ; from this point two short arms of metal pro- ject forward and outward, on either side of the neck, reaching to about the middle of the clavicles. To these, padded shoulder-straps are at- tached, which pass through the axillse to a crossbar on the back brace]; thus downward pressure on the shoulders is avoided and increased leverage is assured. (Fig. 29.) Opposite the point of disease, two strips of thin steel about three inches in length are fixed ; these are slightly wider than the uprights 64 TUBERCULOUS DISEASE OF THE SPINE. and are perforated for the attachment of the pressure pads. They may be made of layers of canton flannel or felt, or unyielding material, such as leather or hard rubber, may be used instead. The pads should project from a quarter to a half inch in front of the uprights, in order that firm and constant pressure, to the extent that the skin will tolerate, may be made at the seat of disease. In measuring for this brace the patient is placed in the prone posture and a tracing of the outline of the back is made by means of the lead tape. This outline may be cut in card- board and fitted to the back ; in fact, if the mechanic is unfamiliar with the work, each part of the brace, uprights, pelvic band, etc., may be cut in card- board and attached to one another to serve as a model. Before the brace is finished it should be appliedj to the back and should be carefully adjusted by means of wrenches. The pelvic band is then padded and the parts that come in direct contact with the skin are usually covered with leather. Fig. 31. The Taj'lor back brace. ( H. L. Taylor. ) The Taylor chest piece. Two triangular pads of hard rubber connected by a bar. or, in the treatment of young children, with rubber plaster and canton flannel to prevent rusting. If the brace is applied before the stage of deformity, it should fol- low the exact shape of the spine, but if deformity is already present, particularly in disease of the thoracic region, it should be made some- what straighter, in order to permit a gradual correction of the com- pensatory lordosis in the lumbar region, and for increased leverage above the deformity. As has been stated, a certain amount of reces- sion of deformity can be obtained by rest in the horizontal position, and if practicable this improved contour should be attained before the brace is applied. The apparatus is held in place by an " apron " TREATMENT. 65 (Fig. 35) which covers the chest and abdomen, to which straps are attachec^. Ordinarily this is made of strong linen or cotton cloth, but a canvas front shaped accurately to the body and strengthened with whale bone, is a much more comfortable and efficient support. In ap- plying the brace the pelvic band is first attached to the apron, then the straps in order, from below upward, and finally the shoulder straps. Each strap is tightened until the brace is firmly fixed in proper posi- tion. When a brace is properly applied and properly fitted, it holds its place by friction, but in certain cases, when the disease is low in the back, it is sometimes of advantage to apply perineal straps to hold Fig. 32. Fig. 33. Backward traction on the shoulders fixes the upper dorsal region. The anterior shoulder brace and its attachment. the pelvic band firmly in its place. (Fig. 30.) At first, the brace is removed once a day in order to wash and powder the back, the same care being observed in moving the child as in the treatment by the frame, but when the back has become accustomed to the pressure, the brace should be removed only at infrequent intervals, and thus if de- sirable, only under the supervision of the surgeon. This description indicates the essential qualities of the back brace. It has been modified in various ways ; for example. Dr. Taylor long since discarded the straight pelvic band in favor of one of a \J shape. (Fig. 30.) This makes the brace somewhat lighter and relieves the sacrum from pressure, but it does not add to its effectiveness. The efficiency may be increased however by improving the attachment at 5 66 TUBERCULOUS DISEASE OF THE SPINE. its upper extremity. Taylor has done this by placing two trian- gular pads against the chest as shown in the diagram. (Fig. 31.) Schapps uses in place of the apron an anterior frame of metal, counter pressure on the chest being provided by means of a broad pad of perforated sole leather. At the lower part a band of metal crosses the body and pressure is made directly on the anterior borders of the pelvic bones. Each method is an improvement on the simple shoulder straps of the Fig. 34. The Taylor back brace and head support combined with the "Whitman anterior support. original brace, but neither provides the quality of support and fixation that is required, when the disease is of the upper and middle segment of the thoracic region. In such cases the upper part of the chest is flattened, the inclination of the ribs is increased and the shoulders in- cline forward, carrying with them the scapulae. Thus the weight and the strain of the motion and use of the arms tend to increase the deformity. In health, direct forward or reaching movements of the arms are always accompanied by an increase in the posterior curvature of the TREATMENT. 67 dorsal spine. On the other hand if the shoulders are drawn backward and held in this attitude, the curvature of the spine is lessened and the chest is elevated and expanded. (Fig. 32.) In the treatment of disease of the upper dorsal region it should be the aim, in the application of a brace, to follow this indication and to apply pressure directly upon the extremity of the shoulders to assure the greatest possible fixation of the spine and to restrain the move- ments of the arms, that tend to increase the deformity. The accompanying diagrams (Fig. 33) show how such support may be applied. Two saucer-shaped plates of hard rubber or padded metal Fig. 35. Fig. 36. The anterior shoulder brace. The scapular pads. cover the heads of the humeri and are joined by a rigid bar of steel which passes across but does not touch the chest. On the back brace are placed two triangular pads of similar construction which cover and press upon the scapulae. These pads are however not essential and are often omitted. The back brace is applied, the shoulders are then drawn backwards and the shoulder cups are firmly attached by straps to the neck bars of the brace above and below by axillary bands in the usual manner. By this means the thorax is elevated and the spine is more effectively fixed, while direct movement of the arms forward is made impossible. It would seem that such restraint would be irksome to the patient, but in an extended use of the apparatus this has never been complained of. In many instances, even when the disease is as low as the tenth dorsal vertebra it may be used with advantage but it 68 TUBERCULOUS DISEASE OF THE SPINE. is especially indicated when the disease is in the neighborhood of the seventh dorsal vertebra. In connection with the shonlder brace it is usually advisable to apply a support beneath the chin to prevent the for- ward inclination of the neck and to tilt the head somewhat backward. A very simple and inoflPensive support of this character is a loop of steel surrounding the neck and attached by screws to a back bar on the brace. (Fig. 37.) If a more efBcient brace is required, as when the disease is of the upper dorsal or cervical regions, the Taylor head sup- port should be used. This is an oval ring of steel which may be clasped about the neck Ficx. 38. by means of a lateral hinge. On the front a cup of hard rubber supports the chin and behind the ring fits upon an upright pivot, that may be raised or lowered upon a cross- Ftg. 37. The loop head support. Disease of the middle cervical regioB, show- ing deformity and attitude. This patient had been paralyzed for one year before treatment ■was begun. (See Fig. 39.) bar on the upper part of the brace ; free lateral motion is allowed or it may be checked by means of a screw. (Figs. 34 and 39.) If absolute fixation of the head is indicated as in disease at or near the occipito-axoid region two steel uprights may be attached to the back of the ring and are bent to fit the posterior and lateral aspect of the head closely and a band of webbing is passed from one upright to the other and about the forehead. TREATMENT. 69 In applying the support the chin should always be tilted slightly upward 'in order to throw the weight of the head backward. (Fig. 39.) The adjustment of the head support is made easier if the pivot is attached to the upright by means of a ball and socket joint (Shaffer) (Fig. 29) that may be regulated by a screw and key ; this arrangement is of service when the head is distorted but it is by no means necessary. Fig. 39. FiCx. 40. The Taylor brace and head support, applied to the patient shown in Fig. 38. The Taylor brace with jury mast. When the Taylor head support and similar appliances are used the greater part of the pressure is sustained by the chin which may, after a time, undergo an unsightly recession. It may be of advantage there- fore in certain cases, particularly when restraint of the motion of the neck is desirable to transfer this pressure to the forehead and occiput by extending the back bars upward over the back of the head as in Fig. 47. 70 TUBERCULOUS DISEASE OF THE SPINE. A jury mast may be used to support the head also ; its adjustment will be described in connection with the plaster jacket with which it is usually associated. (Fig. 40.) The Plaster Jacket. — It was at one time claimed that a plaster jacket applied while the body was partially suspended, would actually relieve the weakened area of superincumbent Aveight, by holding the dis- eased surfaces apart. This is not the fact. The jacket supports the spine as does the brace, by holding it in the erect or extended position. One is a circular and the other is a posterior splint. There is this difference however, the brace fits the spine accurately and holds its place by pressure and friction ; the jacket is held in place by the sup- port of the projecting pelvic bones ; it lacks the accuracy of adjustment of the brace at the seat of disease, but on the other hand it provides a sohd support on the front and sides of the body. Each appliance has advantages and disadvantages that become ap- parent in the treatment of certain phases of the disease or conditions of the patient. The plaster bandage is a simple support, whose efficiency depends upon the accuracy of its adjustment to the irregularities of the body, and upon the leverage that it exerts above and below the point of disease. It should be applied while the body is held in the best pos- sible position ; its inner surface should be smooth, and the bony promi- nences that are susceptible to friction and pressure should be protected. A seamless shirt should be worn ; these are made in several sizes and are sold by the yard at a low price. The shirt should fit the body closely and should be long enough to reach to the knees. The patient is then placed upon a stool, and the halter of the suspension apparatus is carefully adjusted ; the arms are extended over the head and the hands clasp the straps or rings ; thus the chest is expanded to its full limit. Sufficient tension is made upon the rope to partially suspend the body and to draw the spine into the best possible attitude ; in most instances the heels should be slightly lifted from the stool. Dr. Sayre, to whom we are indebted for the exposition of this valu- able means of treatment, insists that the sensations of the patient should be the guide, and that traction should be made only to the point of comfort. This is a valuable indication in the treatment of the adult, but it is not often of service in childhood. Before applying the plaster bandage, pieces of piano felting or canton flannel of sufficient size are placed about the anterior pelvic spines, over the upper part of the sternum and a thin strip is some- times used to cover the spinous processes. Finally long strips of saddler's felt, or of other material of sufficient thickness, are applied on either side of the prominent spines to protect them from friction and to provide greater pressure and fixation at the seat of disease. The " dinner pad " is now very rarely used, except in the treatment of adults, and in certain cases of deformity, in which the abdomen is retracted. In childhood the abdomen is usually prominent, and as the jacket expands somewhat after its application no extra space is re- TREATMENT. 71 quired. The pad, which is supposed to represent the space necessary- after a -full meal, is made by folding a small towel into the shape of a sandwich ; this is attached to a bandage and is placed beneath the shirt just below the ensiform cartilage ; when the jacket is com- pleted it may be drawn out, by means of the hanging bandage, leaving the additional space for emergencies. The materials for the jacket should be of the best. Fresh dental plaster should be rubbed by hand into strips of crinoline, free from glue. The bandages should be from three to five inches in width, and six yards in length ; from three to six being required for a jacket, ac- cording to the size of the child. They should be placed on end, in a pail of warm water, one at a time as they are used. No salt or alum should be used to hasten the setting of the plaster, in fact, if such aid is necessary, it is unfit for use. When the bubbles have ceased to rise, the bandage is squeezed gently until no water drips from it and the loose threads are removed from the ends. One person should sit behind the patient, and one in front, while a third may hold the rope and check the swaying of the body. The one who sits behind the patient may clasp the child's legs between his knees and thus assure better fixation of the pelvis. The pads are held in position until they are fixed by the plaster bandages, which should be applied with a slight and even tension. As a rule the jacket should be of uniform thickness throughout. This thickness need not exceed one eighth to one-fourth of an inch and it may be even lighter in certain cases. It is well to make the first turns about the waist and to use the first bandage about the pelvis since the pelvis is the base of support ; and as the most important point for counter pressure is the chest, this part should be made espe- cially strong. During the application of the jacket it should be rubbed constantly, in order that the different layers of bandage may adhere to one another, and that it may fit the projections of the pelvis and body closely. Meanwhile the attitude of the patient should be carefully watched, in order to prevent lateral inclination of the body. In some instances it is possible to lessen the deformity in the dorsal region, by the exten- sion, and by backward traction on the shoulders, while the jacket is hardening. When the jacket is nearly firm, it should be trimmed. In many instances this may be done while the patient is in the swing, but if he is fatigued he may be placed in the recumbent posture. As a rule the front of the jacket should reach from the upper mar- gin of the sternum to the pubes ; behind, from the spines of the scap- ulae to the gluteal fold ; laterally it should be cut away sufficiently to prevent chafing of the arms ; and on either side of the pubes an oval section is cut out, to allow for the flexion of the thighs in the sitting posture. Particular attention is called to the importance of making the jacket as long as possible, so that the abdomen may be contained ■within it, instead of being forced out beneath its lower border. (Fig. 72 TUBERCULOUS DISEASE OF THE SPINE. 42.) After the application of the jacket, the patient should remain in the recumbent posture for at least half an hour. A much longer period of recumbency is always advisable as it does not become absolutely firm for several hours. The shirt is then drawn up over the jacket and is sewed to the neck portion ; this adds much to neatness and cleanliness. The shirt must be drawn tightly about the neck, in order to guard Fig. 41. Fig. 42. The plaster jacket. The plaster jacket suiiporting the abdomen. the body from the crumbs or other objects that may fall beneath the jacket, and in many instances a special protector in the form of a wide collar bib, may be used with advantage. (Fig. 41.) It may be mentioned in this connection that even the slightest ex- coriation or irritation of the skin beneath tlie jacket, can be at once TREATMENT. 73 detected by the peculiar odor. Of this parents should be informed, so that it may be cut down and the source of the irritation removed at once. With ordinary care, " sores," the bugbear of the Fi«- 43. plaster jacket, are of little con- sequence. If the disease is of the mid- dle region of the spine, back ward traction on the shoulders is indicated, by means of the anterior shoulder brace de- scribed in connection with the spinal brace. (Fig. 43.) In many instances a head support is required, and it is of course always indicated in disease of the upper dorsal and cervical regions. For this pur- pose the jury mast is most often employed. The jury mast should be of tempered steel, strong enough to hold its shape under the ten- sion of the halter. (Fig. 44.) Its base should be incorpo- rated firmly in the jacket below the seat of disease ; it should be long enough to reach well above the head and the crossbar should be placed directly over the ears. (Fig. 45.) Fig. 44. The jury mast and the anterior support. Jury mast. The halter should be applied with as much tension as can be borne comfortably by the patient, so that the weight of the head may be at 74 TUBERCULOUS DISEASE OF THE SPINE. least partly supported and the chin should be tilted slightly upward, the aim being to draw the head backward and thus to extend the spine. In disease of the cervical region the crossbar should be fixed to check lateral motion of the head, but this is unnecessary when the disease is at a lower level. The Application of the Jacket in the Recumbent Posture. — The jacket may be applied while the patient lies extended in the prone posture, by the hammoeh method suggested by Davy of London. Fig. 45. The jacket and jury-mast applied. The same patient is shown in Fig. 28. A long narrow strip of cotton cloth is passed under the shirt and the two extremities are drawn tight enough, by means of a pulley, to support the child in the proper attitude. An opening is cut for the face and, if advisable, traction may be made on the arms and legs of the patient. The bandages are then applied in the ordinary manner after which the cloth may be cut short at one end and removed. This procedure is of service in the treatment of weak or paralyzed patients, but the adjustment is somewhat less accurate than by the ordinary method. The jacket may be applied in the supine posture by means of the GoldtJnvalt support. This latter method may be em- ployed with advantage in the routine application of the plaster jacket. (Fig. 46.) TREATMENT. 75 The Application of the Jacket to Patients who have been Treated on the Stretcher Frame. — A very satisfactory method of applying a plaster jacket in young subjects^ whose deformity has been corrected in whole or part by recumbency on the frame in the over-extended position, is the following. The patient is suspended face downward in the hori- -zontal position by two assistants, one holding the arms and the other the thighs ; thus a certain amount of traction is exerted while the weight of the body tends to over-extend the spine. In this attitude a jacket is quickly applied, and the child is at once replaced upon his frame which has been protected by a rubber Fig. 46. The routine method of applying the plaster jacket in the horizontal position by means of the Ooldthwait appliance. The essential part of the apparatus is shown in duplicate in the foreground (A). Upon its upper extremities two thin bands of steel, similar to those used in the Taylor brace, are placed (B), to support the pads which protect the spinous processes at the deformity. The child is placed upon the support, as illustrated in the figure, and the plaster bandages are carried about the body on either side of the support, including the pads. When the jacket is Arm the patient is lifted from the support. By this method a certain amount of leverage is exerted upon the deformity, but less than when the other forms of the appliance are used. See Figs. 58, 59 and 60. sheet. Thus the plaster jacket, during the hardening process, must conform to the habitual posture of recumbency. In addition, the pressure pads of the frame indent the bandage on either side of the spinous processes (Fig. 48) and thus assure better support and fixa- tion. This is a very effective method of applying the jacket in this class of cases, because it is not necessary to retain the child in an un- comfortable position while the bandage is hardening, and because ac- curacy of adjustment in the best possible attitude is assured. As a rule a jacket may be worn for two months, although not infre- quently in hospital practice it may remain for six months, or even 76 TUBERCULOUS DISEASE OF THE SPINE. longer, and yet be fairly efficient. Usually one jacket is removed and another applied on the same day, but if the skin is at all sensitive it is well, after the washing and powdering, to re-apply the old jacket, closing it with adhesive plaster, and allow an interval of a few days before applying the permanent one. The Plaster Corset. — In the stage of recovery the jacket may be re- placed by a corset. A jacket, made and trimmed as already described, is cut down the center and removed from the body. It is carefully Fig. 47. Fig. 48. A fixation support for the head. This may be used with tlie brace or with the jacket. Jacket applied by the stretcher method, showing the depressions in the jacket caused by the frame pads. readjusted to its former shape, bandaged with the cut surfaces in close apposition, and is thoroughly dried or baked. All wrinkles are then cut away from the inner surface, and extra padding is applied if neces- sary ; the shirt is drawn tightly about the borders of the jacket and strips of leather provided with hooks are sewed in front so that it may be laced like an ordinary corset. It may be removed, from time to time, to allow for bathing, but it should always be removed and re- applied while the patient is suspended or in the recumbent position. Corsets are often used in place of the jackets in the treatment of the TREATMENT. 77 active stage of the disease, but they are less effective, since the repeated stretching during their removal and reapplication weakens them and impairs the accuracy of adjustment ; and, in addition, one of the strong- est arguments in favor of the use of plaster of Paris, that treatment is under the control of the surgeon, is nullified. Comparison of the Two Forms of Ambulatory Support. — The most se- vere criticisms of the jacket have been made by those unfamiliar with its use, on theoretical grounds rather than from actual observation. While it is admitted that there are certain objections to its use, yet experience shows that when it is applied in a proper manner under proper conditions it is a thoroughly reliable, efficient and often indis- pensable means of treatment. Indeed, it may be stated that by means of the jacket and the Bradford frame it is possible to treat nearly every case of Pott's disease without the aid of the professional bracemaker, and with success. It is evident, however, that under certain conditions the jacket must be inferior to the brace, in early childhood, for example, when the pelvis is not sufficiently developed for proper support. Again when the disease is low down, at or near the lumbo-sacral junction, the lower border of the jacket does not hold the pelvis with sufficient security to provide the proper fixation. In the upper dorsal region the attachments for accurate fixation may be more readily applied to the brace, and in disease of the cervical region the metallic head support is to be preferred to the jury mast, for the reason that it cannot be removed by the patient as can be the straps of the halter. The traction of the jury mast is very effective when properly used and particularly so, when painful distortion of the head is present, but the tension on the straps is rarely constant and thus it loses in effective- ness. A rigid support is, of course, essential in disease of the atlo- axoid region. The jacket will be found to be most efficient in disease of the spine from the tenth dorsal to the second lumbar vertebra. It is not only effective but it is often a more comfortable support than the spinal brace. It is also more efficient than the brace when lateral deviation of the spine is present ; and from the clinical standpoint, it is often more efficient in relieving the symptoms of pain in this region, when the disease is at all acute. One may conclude, then, that each form of support may be used ac- cording to the indications. The absolute control of the treatment, assured by the use of the plaster jacket will often over-balance the claims of the brace ; in practice among the poor, when choice of means is not always permitted, it is indispensable ; and it may be used with fair success, even under conditions that theoretically contraindicate its employment. Modifications of the Jacket. — Occasionally, the form of the jacket may be changed to meet special indications ; for example, backward traction may be secured by carrying the bandages over the shoulders ; or the head may be fixed in the support, if the jury mast is not at hand (Fig. 78 TUBERCULOUS DISEASE OF THE SPINE. 49) ; or one or both thighs may be included in a spica jacket in painful disease of the lower region, when psoas spasm is a symptom. Such modifications are required rather for temporary emergencies than for continuous treatment. Dr. H. L. Taylor has recommended what he calls the bivalve plas- tic splint of plaster of Paris. " A paper pattern of the posterior valve is made from the patient's back allowing one inch extra around the edge to be folded back. From this pattern eight or ten thicknesses of crinoline are cut of the same size and shape. The patient bemg supported face downward on a rest under the pelvis and Pj(j 49 another under the upper part of the sternum, the crinoline sheets are dipped into plaster cream in a large flat pan, applied to the back, the felt pads being in position ; the edges are folded back for greater rigidity and the whole carefully moulded to the pa- tient and allowed to set, after which the patient is turned on his back and the anterior valve made in a similar manner. " The jacket should be made firm and rigid, especi- ally at the edges, and should reach in front from the pubes to the top of the sternum. Such an apparatus is rigid, removable and adjustable and brings the pressure to bear on definite areas selected with regard to its mechanical ac- tion. The splint may be re- moved to cleanse the back or to note its efficiency, taking the impressions made by the felt pads either side the spinous processes as a guide. If more leverage is needed, the felting may be reinforced or the depth of casing reduced by paring the lateral edges. In other words the jacket has ceased to be mainly a casing and has become a mechanism under the surgeon's control and capable of being manipulated to pro- duce definite mechanical results." Corsets of Other Material than Plaster of Paris. — Corsets of wood, leather, paper, poro-plastic felt or celluloid are sometimes used. These Plaster bandage iucluding the lu-ad to hold the spine in the extended position after the correction of deformity. TREATMENT. 79 are constructed on a plaster cast of the body, a thin accurately fitting jacket being used as a mould. Such corsets have certain advantages of durability and elegance, but none of them has the accuracy of fit of the plaster of Paris corset, which is moulded directly on the body by constant manipulation during the stage of solidification. Corsets of this class are usually somewhat expensive, and on that account are often worn after they are outgrown or no longer fit the patient. Their use is practically limited to the stage of recovery or for other affections than Pott's disease. Fig. 50. The Thomas collar. (Eidlon and Jones.) Of these corsets, one of the best is that used by Weigel, of Roches- ter, made of alternate layers of linen cloth and wood pulp matrix paper, fixed by a mixture of paste and glue. A more durable corset may be constructed of aluminum, as advocated by Phelps. This may be obtained in thin sheets, which may be ham- mered upon the plaster cast into the proper shape. The two halves are attached by hinges in the back and are perforated to allow for ventilation. In the final stage of treatment, the Knight brace, a light steel frame with corset front may be employed (Fig. 132), or a long corset similar Fig. 51. The Thomas collar. A piece of thin sheet metal is cut wide enough to reach from the sternum to the chin and from the back of the neck to the base of the occiput. The edges are turned out and the whole properly covered with felt and fitted. (Eidlon and Jones. ) to that ordinarily worn by women, but strengthened by the insertion of light steel bars along the spine, is often sufficient. Other Forms of Support. — In certain cases of disease of the lower lumbar region of the spine, it may seem advisable to restrain the movements of the thighs, although ordinarily, when this is necessary the patient should be placed upon the frame. Such restraint may be 80 TUBERCULOUS DISEASE OF THE SPINE. Fio. 52. attained by making the back bars of the brace stronger and extending them down the back of the thighs to the knees like a double Thomas hip brace. If the jacket is used, it may be extended to a single or double spica for the same purpose, as has been mentioned. Such appliances are use- ful when psoas spasm and " cramp " are troublesome symptoms. In disease of the cervical region a certain amount of support and fixation may be obtained by collars of poro-plastic felt, plaster of Paris or other material. The Thomas collar is the best of this type of sup- port, but none of them is thoroughly efficient unless used with a brace to control the larger movements of the spine. They are use- ful in emergencies but they are not often required when proper braces can be obtained. Many other forms of appa- ratus of greater or less merit might be described, but space has only permitted a detailed account of three forms that, it would seem, best represent the essential principles involved in the treatment of Pott's disease. The Principles of Treat- ment in Their Practical Ap- plication. — After the descrip- tion of the special forms of appliances used in the routine treatment of Pott's disease, one may consider with advantage the treatment in its more direct relation to the patient. The object of this treatment is to relieve the symptoms, to main- tain and to improve the vital resistance of the patient, to check, to remedy and to prevent deformity. Under favorable con- ditions the death rate is small, and pain is easily relieved, but preven- tion of deformity is often extremely difficult. The effect of treatment must be estimated not simply by its relief of the symptoms of the disease, since deformity may steadily advance in spite of the apparent well-being of the patient, but it must be se- lected and continued or changed with the aim of combating ultimate deformity, and on this standard success or failure must be determined. It is probable that noticeable deformity might be prevented, nearly always, if treatment were applied in season. But practically such opportunity is not often offered, and the local deformity that represents destruction of bone, may be considered as irremediable. There is also a dwarfing and blighting effect of the disease, which, although it is The Thomas collar applied. (Eidlon and Jones. ) PRINCIPLES OF TREATMENT IN PRACTICAL APPLICATION. 81 Fig. 53. usually associated with marked deformity, is always to be feared, par- ticularly when the disease affects the middle or lower region of the spine in early childhood, and is severe and prolonged in its course. By proper treatment one may hope to check the progress of the dis- ease and even to remedy the deformity in great degree, by freeing the spine from the deforming influence of local disease, and by preventing or removing the symptomatic distortions such as psoas contraction or wry neck. Indications for Treatment "by Recumbency. — As has been stated already, the most important influence toward deformity when the spine has been weakened by disease, is the force of gravity ; therefore horizontal fixation is the most efficient means of pre- venting deformity, and it assures the rest for the diseased spine that favors repair. This is then the treatment of last resort, the treatment for emergencies and in many instances the treatment of choice and rou- tine. It is indicated as the routine treat- ment in infancy, and in early childhood up to the age of three years, at least during the acute and progressive stage of the disease, because the structure of the spine offers but little resistance to the extension of the des- tructive process, and because prolonged di- sease and deformity are much more dis- astrous at this age of rapid growth than at a later period. The time that this treatment should be continued is determined by the character of the disease, by the presence or absence of complications and above all by the condition of the patient. A year would perhaps repre- sent the average time that horizontal fixa- tion may be employed with advantage in appropriate cases. When the frame is used in the manner described, and when the child Finai result of luinbar disease; spon- .-, ii'iii •,! taneous absorptioQ of abscess, and IS taken regularly into the open air, the but slight deformity, see Fig. is. general condition almost always improves with the complete relief of the pain, weakness and discomfort that the treatment assures. If the progress of the local disease is toward repair, the patient becomes restless, he no longer lies motionless when he is removed from the frame, but turns and twists the body in a manner that shows the absence of muscular spasm. At this time it is well to fit the back brace that is to be used when the frame is discarded, provided it has not already been used in conjunction with the hori- 6 82 TUBERCULOUS DISEASE OF THE SPINE. zontal fixation ; then little by little the upright posture and ambulation are resumed. Fig. 54. Pott's disease of the middle dorsal region, a type of disease in whicL horizontal fixation is always indicated. H. S., age 14 months. In many instances absolute recumbency may not be required, but the period of activity must be carefully regulated, and must be discon- FiG. 55. H. S. after 14 months of fixation on the modified Bradford frame, shows the recession of deformity, Compare with Fig. 54. SPECIAL INDICATIONS FOR TREATMENT. 83 tinned when there is evidence of discomfort or weakness or pain. If the peri6d of activity must be short, it should be passed in the open air. The passive attitude of sitting, although less strain is thrown upon the spine than during activity, may be even worse for the pa- tient ; thus the reclining or semi-reclining posture should be assumed, as a rule, when the child is in the house, at least during the active stage of the disease. Even if the patient appears to be perfectly sup- ported, the time spent in bed should be long, and a period of rest in the middle of the day should be enforced. The arguments in favor of horizontal fixation in early childhood do not apply to disease in the adult. At this age the structure of the spine is resistant, and deformity is little to be feared, while such con- finement would be irksome and impracticable ; thus local support, supervision and, if possible, a change of climate, must be the treat- ment of selection for the adolescent or adult. In the middle period, from the third to the tenth year horizontal fixation is the treatment for emergencies ; for paralysis, for abscess, for dangerous disease of the atlo-axoid region, for progressive deformity, and for pain that cannot be relieved by the ordinary means. Special Indications for Treatment of Disease of the Different Regions of the Spine. In the selection of treatment, and in the general management of Pott's disease each region of the spine must be judged by itself, since in each there are special difficulties to be met, and complications to be feared, that may influence the prognosis and lead to modifications of the routine of treatment. The Lower Region. — The prognosis is good in disease of the lower region, the symptomatic attitude is favorable, the part may be easily supported, the cases are often seen before the deformity is at all ex- treme, and one may, as a rule, predict recovery without noticeable de- formity or at most a slight shortening and broadening of the body and a peculiar erectness of attitude. Uncomplicated cases may be treated with the brace or jacket. The brace is the better support when the disease is near the sacrum, while the jacket is often more comfortable and more effective than the brace when the middle and upper lumbar region is diseased, par- ticularly when lateral deviation of the spine is present. When- ever the tendency to psoas contraction is, at all marked or when pain or cramps in the legs are complained of, the period of activity should be carefully restricted ; in fact the " night cry " is an indication for a day of rest in bed. The most troublesome complications of this region are psoas con- traction aud the abscess with which it is often combined. As has been stated, psoas contraction changes the attitude of over- erectness, favorable to repair, to a forward stoop that increases the pressure and friction at the seat of disease. If this attitude persists 84 TUBERCULOUS DISEASE OF THE SPINE. and if it becomes fixed by permanent changes such as are likely to follow the burrowing of a pelvic abscess, the result is one of most disastrous deformity, the body and the legs are approximated and the erect attitude is made impossible. In neglected cases of this char- acter, tenotomy and forcible correction or even subtrochanteric osteot- omy may be necessary to overcome the secondary deformity. In ordinary cases of psoas contraction, and when one leg only is flexed, the patient may be allowed to go about using a high shoe on the unaffected side and crutches, so that the flexed leg need not affect the attitude. If, however, the contraction persists, it is well to place the patient on the frame, and to reduce the flexion by traction in the line of deformity, as will be described in the treatment of disease of the hip joint. Persistent psoas contraction is almost always a symptom of abscess about the origin or in the substance of the muscle, and when it is accompanied by pain, it is always an evidence of active disease. Abscess may be expected as a complication in at least 50 per cent, of the cases of disease of this region, but it is by no means always accompanied by psoas contraction, any more than psoas contraction is always caused by abscess. Abscess unaccompanied by contraction more often has its origin above the lumbar region, so that in its descent it passes along the surface but does not involve the substance of the muscle. Attention is especially called to the fact that the bad results of Pott's disease of this region are almost invariably caused by allowing flexion of the legs, whether it be symptomatic of abscess or not, to persist, therefore the importance of preventing and correcting this deformity cannot be over-estimated. It should be stated, however, that in dis- pensary practice, w^hen special care cannot be provided, one often sees psoas contraction that may have persisted for months relax, if the progress of the disease is favorable, without treatment other than the routine fixation of the spine by the brace or jacket. In certain cases, one or both thighs may be fixed by the plaster bandage or by the back bars attached to the brace, when pain and spasm are troublesome, but as a rule rest on the back until the acute phase of the disease has passed is to be preferred. The Lower Dorsal Region. — Disease of the lower dorsal region, the middle of the back, is very favorably situated for effective mechanical treatment, and psoas contraction and abscess are much less troublesome than in the lower part of the spine. The brace or the jacket is an efficient support, and the symptoms are, as a rule, easily relieved. Deformity sometimes increases, almost imperceptibly, by a progres- sive forward bending or lordosis of the flexible lumbar spine below the projection. One must guard against this by applying the jacket firmly while the spine is made as straight as possible, or if the brace is used, the lumbar spine should be drawn firmly against it. If lateral inclination of the body is so marked as to interfere with the proper application of a brace, preliminary rest in bed is indicated. Lateral deviation can be corrected as a rule by the jacket without re- SPECIAL INDICATIONS FOB TREATMENT. 85 cumbency, although this, as other forms of symptomatic distortion, should be treated ordinarily, if not by complete rest, at least by care- ful regulation of the period of activity. Disease of the Middle and Upper Dorsal Region. — This is, from the standpoint of prevention of deformity, the most difficult region of the spine to treat, although the symptoms of the disease may be easily relieved. Deformity is present in nearly all cases when treatment is sought, and, deformity having begun, is very difficult to check, for the reasons that have been already stated. The final result in the majority of cases is what appears to be ex- aggerated round shoulders ; the neck is shortened and projects forward, the chest is flat and the shoulders are high. It is only by an early diagnosis and by efficient and long continued treatment that recovery from disease in this region without noticeable deformity, may be hoped for. In all cases of disease above the ninth vertebra, the anterior brace for backward traction of the shoulders may be used with great advan- tage to secure greater fixation of the spine ; and in all cases above the seventh or eighth vertebra a head or chin support to restrain the for- ward inclination of the neck is indicated in addition. With the plaster jacket the jury mast is employed, with the brace the looped chin rest or the ordinary Taylor support may be used. In disease of the middle and upper dorsal region the brace is to be preferred to the jacket because of the greater accuracy of adjust- ment, and because the halter of the jury mast is rarely retained in proper position when the patient does not, as in these cases, feel the need of such support. In this region of the spine, paralysis frequently occurs as a compli- cation. When it appears after treatment is begun, it is usually a result of inefficient fixation of the spine or of want of caution in regulating the strain to which the diseased part is subjected. Its symptoms and its treatment will be considered later. Disease of the Upper Dorsal and Middle Cervical Region. — This is the most favorable region of the spine for treatment. The disease is usually not extensive because of the small size and compact structure of the vertebrae ; and the mobility of the cervical region is so great that it readily compensates for the local rigidity. Under efficient treatment one may predict recovery without notice- able deformity and in the less successful cases the deformity is not, as a rule, offensive. The shoulders appear high, the neck is short, the head inclines forward while the back is abnormally flat in compensa- tion for the change in contour of the part above. When the case of cervical disease is first brought for treatment, a icry neck deformity, often made more persistent by the infiltration of an abscess or by inflamed cervical glands is almost always present. As a means of correcting this distortion, the jury mast and traction halter, attached to the jacket or brace is a very efficient and comfortable 86 TUBERCULOUS DISEASE OF THE SPINE. support. Under the constant tension the deformity is, as a rule, very quickly corrected, but as a permanent treatment, the brace and head support are to be preferred to the jury mast, because a more exact fixa- tion is assured ; for, as has been stated, although the jury mast, when properly applied and adjusted, is an admirable support, yet under other conditions it is absolutely worthless. The distortion of the head may be overcome also by traction in bed, and it will usually disappear under simple fixation. The use of col- lars of felt or leather has been mentioned. With the brace these are unnecessars', but they may be used with advantage to add to the effi- ciency of the plaster jacket and jury mast. Disease of the Occipito-Axoid Region. — Under efficient treatment the prognosis is good, and recovery without deformity should be the rule. The course of the disease, although it is often accompanied by acute symptoms, is usually short as compared with that of other regions of the spine ; and it may be assumed that, in many cases, it is a primary arthritis, or at least that the primary focus in the atlas or axis is very small. The disease at this point is however in close proximity to the vital centers, and sudden death from displacement of the weakened parts is not uncommon. Abscess is frequent and it is often a trouble- some and dangerous complication. As has been mentioned, wry neck deformity is a very constant symptom, and there is also a strong tendency toward a forward and downward inclination of the head, so that in neglected cases the chin may rest upon the chest. The indications for treatment are to over- come the distortion and to hold the head fixed in the middle line, the chin being somewhat elevated above the right-angled relation with the spine. In the mild cases the jacket-and-jury-mast traction may be used to overcome the distortion, but the metallic head support Avith the fixation attachment, to prevent motion in the diseased joints, is always indicated as the treatment of selection because by such apparatus the danger of displacement may be avoided. When the disease is acute in character, and especially if abscess be present, recumbency on the frame with fixation of the head and slight traction by the weight and pulley, or by the jury mast attachment, is indicated. Traction should not be sufficient to cause discomfort ; counter traction may be supplied by the weight of the body and by slight elevation of the head of the bed. The head sling is of the form used with the jury mast, or a simple band about the head may be used. Under this treatment slight deformity of any part of the cer- vical region will practically disappear, and as a rule the course of the disease is very favorably influenced by it. In certain cases of disease of this region, accompanied by acute symptoms, the attitude of recumbency is extremely uncomfortable. The discomfort is caused apparently by the forward projection of the upper part of the spine, so that when the head is drawn upward and backward in the recumbent attitude the calibre of the throat is lessened, lu other instances the pain may be due to pressure of the atlas against THE COMPLICATIONS OF POTT'S DISEASE. 87 the odontoid process of the axis. In such cases, if recumbency is desiredj'the head must be elevated by pillows to the point of comfort, the support being removed when the child has become accustomed to the position, or when the deformity has been corrected. The Complications of Pott's Disease. Abscess. — It may be assumed that a limited collection of tuberculous fluid is present at some time during the course of Pott's disease in the great majority of cases, but unless it appears as a palpable tumor above or below the thorax or upon the surface of the body its presence is not often detected. Townsend,^ in 380 cases of Pott's disease examined with reference to the occurrence of abscess as a complication, found that it was pres- ent or had been detected in 75 (19.7 per cent.), in 8 per cent, of the cases of cervical disease, in 20 per cent, of the dorsal and in 72 per cent, of those in which the lumbar region was involved. Dollinger,^ in 700 cases under treatment from 1883 to 1895 found abscess in 154 (22 per cent.) ; in 13 of 63 cases in the cervical region (22.6 per cent.) ; in 47 of 403 cases in the thoracic region (11.6 per cent.) and in 94 of 234 cases of lumbar disease (40.17 per cent.). Ketch,^ in 75 cured cases of Pott's disease treated at the N, Y. Orthopaedic Dispensary, selected for the purpose of contrasting the be- havior of the disease in the different regions of the spine found that abscess had appeared in 19 (25.3 per cent.). In the upper region abscess was detected in but one of the 25 cases (4 per cent.) ; in the middle region in 8 of the 25 cases (32 per cent.) and in the lower in 10 (40 per cent.). In 354 autopsies by Mohr, Nebel Bouvier and Lannelongue abscess was found in 281 or nearly 80 per cent. Although cases of Pott's disease that come to autopsy may be supposed to represent a severe type of disease yet it is evident, by contrasting the statistics, that a large proportion of the abscesses escape detection in the living. One may conclude then, that abscess may be expected as a more or less serious complication in 25 per cent, of all cases of Pott's disease, and in at least half of those in which the lower region of the spine is in- volved, the greater frequency here, being explained by the large size and less resistant structure of the vertebral bodies, as compared with those of the upper regions. The tuberculous abscess is separated from the neighboring parts by a limiting wall of more or less thickness, according to its age, the outer layers of which are of fibrous and cellular tissue, the inner of granulation tissue covered with yellowish-gray or pinkish-gray necrotic membrane which is easily separated from the underlying parts. The fluid of the abscess is of a whitish or whey-like color composed of 1 Trans. Am. Ortho. Ass'n, Vol. IV., p. 166. 2 Dollinger, loc. cit. "Trans. Am. Ortho. Ass'n, Vol. IV., p. 200. 88 TUBERCULOUS DISEASE OF THE SPINE. serum, leucocytes and emulsified caseous material and fibrin ; floating in it are larger masses of cheesy necrotic tissue and sometimes minute fragments of bone. This more solid material settles to the bottom of the glass if the fluid is allowed to stand. The fluid of quiescent ab- scesses or those that are in process of resolution is often clear, like serum, but if secondary infection has taken place the pus is of a greenish-yellow color, and is of uniform consistency. At any stage of its progress the abscess may become stationary and its" contents may be absorbed, in fact such an outcome is not unusual ; the fluid of the abscess is usually sterile and secondary infection, before a communica- tion with the exterior of the body is established, is comparatively rare. It has been claimed that abscess formation is always the result of infection with pyogenic germs, but this may be doubted, since the ordinary tuberculous abscess may be sterile or at most contain but a few tubercle bacilli. It is very certain, however, that the formation and increase of the abscess is favored by irritation and injury, and that the most effective treatment of this complication is to support the diseased spine and to relieve it from over-strain. Abscess is a symptom of disease and is, in some degree, an evidence of its character. If it appears early and increases in size rapidly, it usually indicates a destructive and rapidly advancing process, or infec- tion from without. On the other hand, the slowly enlarging or quies- cent abscess has but little significance. In many instances the abscess causes no symptoms whatever, or it may be a source of inconvenience simply because of its size or situa- tion. In other cases, a period of malaise or discomfort or pain is fol- lowed and explained by the appearance of an abscess, but whether the symptoms were caused by the tension of the abscess or by a more acute phase of the disease itself, is not always clear. Large abscesses, which are increasing in size and approaching the surface are usually accompanied by pain, and by elevation of temper- ature, that indicates probably a slight degree of secondary infection, but otherwise the ordinary deep abscess appears to have no other ef- fect than to add, doubtless, to the susceptibility of the patient. The Course and Peculiarities of Abscess in the Different Regions of the Spine. — The tuberculous abscess may remain as a small collection of fluid in the neighborhood of the disease where its presence may be de- tected only by percussion or by deep palpation. As a rule, however, it slowly increases in size, and under the influences of the force of gravity and the tension of its contents it finds its way down the spine or toward the exterior of the body, following the path of least resistance. The abscesses which have passed below the diaphragm or which have originated below this point may follow various paths. Some enter the sheath of the psoas muscle and finally make their appearance on the inner aspect of the thigh, psoas abscess. Others perforate the sheath of the quadratus lumborum muscle and form a lumbar abscess projecting between the twelfth rib and the crest of the ilium at the triangle of Petit. Those abscesses that escape from the fascia of the psoas muscle THE COMPLICATIONS OF POTT'S DISEASE. 89 or that pass downward on the surface of the iliac fascia, the so-called iliac abscesses, often form a tumor over the outer extremity of Pou- part's ligament at the junction of the transversalis and iliac fasciae, or the fluid may follow the course of the iliac artery to the thigh, or, escaping from the greater sacro-sciatic foramen, form a gluteal abscess. Iliac or psoas abscess is most often confined to one side but it may be bilateral, the two sacs communicating with one another by a larger or smaller channel. In the thoracic region the abscess may re- main indefinitely in the posterior mediastinum, where, if large, its presence may be demonstrated by an area of dullness extending toward the lateral region of the thorax or it may perforate the inter- Fig. 56. costal muscles and appear on the posterior or lateral aspect of the chest, or it may pass downward through the aortic opening in the diaphragm and become an iliac abscess. Abscess caused by disease of the occipito-axoid region may force its w^ay forward between the recti muscles and appear behind the pharynx as the retro-pharyngeal abscess, or the fluid may take the opposite di- rection and distend the sub- occipital triangle and then pass forward to the region of the mastoid process. In other in- stances the abscess may dissect its way about the base of the skull or pass upwards through the foramen magnum or down- ward into the spinal canal. Abscesses from the middle cervical region usually pass out- ward between the scaleni and longus colli muscles to the inter- val between the trapezius and sterno-mastoid, perforating the skin about the middle of the lateral aspect of the neck near the anterior border of the latter muscle. These are the paths usually followed by the tuberculous fluid, but occasionally it may enter the spinal canal or break into the pleural cavity or lung or intestine or by the side of the rectum or elsewhere. Treatment of Abscess. — Abscess is by far the most troublesome and dangerous complication of Pott's disease. It may interfere with proper mechanical treatment, and it is often a cause of permanent as well as temporary deformity, especially in the lower region of the spine as Bilateral lumbar abscess. 90 TUBERCULOUS DISEASE OF THE SPINE. has been stated. It prolongs the course of the disease by extending its boundaries and although it is not often a direct cause of death, yet many patients die because of the exhaustion of long-continued suppura- tion that may follow secondary infection and of the amyloid degenera- tion that may finally result. A large abscess is always a source of danger because of the possi- bility of secondary infection of its contents before it finds an outlet and because of the probability of infection, when a communication with the exterior has been established. Abscess is however a symptom and result of disease and in properly treated cases it is as a rule a complication of comparatively slight consequence. If abscess is not present when treatment is begun, one may hope to prevent it by efFec- tive protection of the spine, and if it be present, this protection should be all the more rigidly enforced. The surgical treatment of the abscess of spinal disease is very diffi- cult, not because it is different in character from other tuberculous ab- scesses, but because it is as a rule impossible to remove the disease of which the abscess is a symptom ; and incomplete or ineffective surgi- cal operations should be avoided. As the abscess is a symptom of disease so, as a rule, its treatment should be symptomatic. The retro-pharyngeal abscess demands prompt evacuation because it is likely to obstruct breathing and swallowing, because its sudden rupture may cause death and because an abscess in such close proximity to the vital centers is always a source of danger. In cases of emergency the abscess may be evacuated by an incision in the middle line of the pharynx, but preferably the opening should be from the exterior. An incision is made along the posterior aspect of the sterno-mastoid muscle in its upper third. The abscess tumor is easily reached by careful dissection and drainage is established which has evident advantages over that into the throat. Abscesses from the middle cerviccd region usually point in the lat- eral region of the neck and cause but little inconvenience. Abscesses in the upper thoracic region may, in rare instances, cause dangerous pressure on the trachea or lungs as shown by spasmodic attacks of in- spiratory dyspnoea, " asthmatic attacks." In some instances an area of dullness near the seat of disease demonstrates the position of the abscess, but if it lies in the median line it can not be detected either by auscultation or percussion. If the inspiratory dyspnoea is well marked the symptom may be fairly attributed to this cause and the operation of costo-transversectomy may be undertaken to relieve the pressure. An incision is made, preferably on the right side, to expose the articulation between the transverse process and the rib ; the joint may be resected or a section from one or more of the ribs may be re- moved as in the operation for empyaema ; the finger is then inserted and passed along the surface of the adjacent vertebral body until the abscess sac is reached. It is then opened and drained. (Fig. 9.) In the lower region of the spine operations may be necessary be- cause there is evidence of secondary infection. In this event if the THE COMPLICATIONS OF POTT'S DISEASE. 91 abscess distends the lumbar region or forms a sac on either side of the spine, an opening in the loin on one or both sides of the spine is necessary. This is made as in operations on the kidney, by an incision on the outer side of the erector spinse muscle between the last rib and the crest of the ilium ; the underlying quadratus lumborum muscle is V and if the parts are kept clean and dry, and it is an effective brace for ill! ages? and for all conditions of disease. The Caliper Brace. — The traction may be discarded and the brace may be held in position by a shoulder band, or it may be used as a so-called caliper splint. In this form it was almost exclusively employed by Mr. Thomas in his later practice and at the present time by Hidlon,' the long brace being used simply for a bed splint. As a caliper brace the two bars are cut off and turned directly inward at a right angle, are inserted into a steel tube which is passed through the heel of the shoe. The bars are made slightly longer than the leg so that the patient's heel is lifted nearly an inch from the inside of the shoe when walking ; thus the jar of impact with the ground is prevented. The brace is fixed in position by a leather band beneath the knee and another beneath the calf, and the limb is held exten- ded by pressure pads applied to the thigh and leg, as illustrated. (Fig. 230.) Ridlon uses the brace to reduce deformity by direct pressure backward on the knee by means of bandages, opiates being given to relieve pain. Other braces may be employed, for example the traction hip splint (Figs. 203, 204), but as the Thomas brace answers every requirement, it seems unnecessary to describe others in this connection. Treatment During Convalescence. — During the active stage of the disease the brace must be worn day and night ; during the stage of recovery it may be removed at night, to allow for motion at the knee, and later a form of walking brace (Fig. 205) that will allow a limited motion at the knee, may be of service ; but this is not an essen- tial in treatment. If a certain amount of knock knee remains after recovery, it may be overcome by the use of a Thomas knock knee brace which will also serve as a protective splint. The indications of cure have been discussed under hip disease. In brief, when sufficient time has elapsed to permit of natural cure, when there has been no symptom of active disease for months, when muscular spasm has disappeared, one may tentatively remove the brace in the manner de- scribed. But any symptom of disease and par- ticularly increasing limitation of the range of motion, or a tendency toward deformity, indicates the necessity for continued protection. 'Trans. Am. Orth. Ass'n, Vol. VI. The caliper splint. E, the ring around the upper part of the thigh ; A, pad for backward pressure ; B, bandage ; C, bandage ; F, leather sling for support at the back of the limb ; D, a strip of bandage fastening together the pressure pads to prevent slipping and con- sequent loss of pressure. (Ridlon and Jones.) 318 TUBEBCULOUS DISEASE OF THE KNEE JOINT. If anchylosis be present, supervision and occasional treatment will be required during the period of growth in order to prevent deformity. Extra -Articular Disease. — In certain cases, especially in young chil- dren, the disease about the epiphyseal cartilage of the femur or of the tibia, may find its way to the exterior of the bone before it perforates the capsule. This is suggested by local sensitiveness and swelling over one of the condyles of the femur or about the head of the tibia. In such instances, the thorough removal of the disease is indicated, or if a Roentgen picture shows that the disease is accessible, even though it is not immediately below the surface, an exploratory operation may be advisable. In favorable cases prompt operative intervention may cut short the course of the disease. Aljscess. — Abscess is present as a complication in about one-third of the cases that have received efficient protection, and in a larger per- centage of the cases in which treatment has been neglected. It was present in 51 per cent, of Koenig's cases ^ and in 47 per cent, of three hundred final results reported by Gibney." At the knee as at other joints, the infected abscess is the most dangerous complication of the disease, as is illustrated by Koenig's statistics. Death rate in cases without abscess 25 per cent. " " " " with " 46 per cent. Although in many instances, abscess indicates an extensive and de- structive disease of the bone, yet the exhausting suppuration that is an indirect cause of death, is suppuration from infected areas in the thigh and leg, which may have little direct relation to the extent of the original disease. It should be the aim in treatment to prevent this burrowing of fluid after the capsule has been perforated, and to prevent over-distention of the capsule even, in order to lesson the macerating effect of the tuberculous fluid upon the cartilages. When the fluid within the capsule is of an appreciable amount, and when it is increasing in quantity, it may be removed by aspiration ; or, a better procedure is to incise the capsule. This will allow a thorough removal of its fluid and solid contents, after which the opening may be closed with sutures. Tuberculous abscess which has perforated the capsule may be treated in the same manner, or it may be drained subsequently, according to the indications. Unless the abscess is infected, careful bandaging of the thigh and leg should prevent burrowing. Synovial Tuberculosis. — In the forms of synovial tuberculosis that resemble chronic synovitis the fluid may be evacuated by an incision in the capsule which will allow for exploration and for removal of the fibrinous masses that are often present. Afterwards the interior of the joint may be treated with an application of a strong solution of chloride of zinc, or carbolic acid. This sets up an active inflammation which causes adhesions within the capsule, and exerts a favorable in- fluence on the course of the disease. The injection of iodoform emul- 1 Trans. Am. Orth. Ass'n, Vol. VI. ^Am. Jour. Med. Sci., Oct., 1893. OPERATIVE TREATMENT. 319 sion has been extensively employed in the treatment of tuberculosis of the knese at the Hospital for Ruptured and Crippled, but no decided benefit has been observed. Theoretically its use should modify the in- fectious quality of the tuberculous fluid, and lessen the danger of in- fection with pyogenic germs, and on this ground, rather than because it actually shortens the course of the disease, it may be recommended. (See Bier's treatment, page 203.) Arthrectomy. — When, as in exceptional cases, the disease is progres- sive and shows no tendency toward recovery, and particularly if an infected abscess communicating with the joint makes efficient drainage difficult, the operation of arthrectomy may be indicated. An Esmarch bandage having been applied, the joint is thoroughly exposed by a curved anterior incision passing above or below or through the patella, and all the diseased tissue is removed ; that in the soft parts is cut away, and foci in the bone are removed with the chisel and scoop. If infection be present the joint may be packed with gauze, the leg being fixed in the position of flexion ; but in other instances the wound is closed, with or without drainage as may seem advisable. In a large proportion of cases primary healing may be obtained. By the procedure one may hope to cure the disease, but in all but excep- tional cases the functional result will be anchylosis. The operation has the advantage over excision in that less bone is removed, and that the epiphyseal cartilages, in part at least, remain ; thus the immediate as well as the ultimate shortening is less than after excision. Results of Arthrectomy. — The direct death rate of the opera- tion is small. In 150 cases, reported by Koenig, but 3 deaths were attributable to the operation itself. The final results in 1 1 4 of these cases, in which the operation was performed in childhood, were as follows : Patients cured and living 90 Cured of the local disease but not living at the time of the investigation 10 Practically cured, insignificant fistulse remaining 2 102—89. 5 per cent. Living, not cured 5 Deaths before the cure of the local dis- ease 7 12 — 10. 5 per cent. Thus in 89 per cent, of the cases the operation was successful as far as the cure of the local disease was concerned. In 75 per cent, of the successful cases, immediate cure was attained ; in 25 per cent, fistulse persisted for a longer or shorter time. In 10 cases some motion was retained, but in the others anchylosis followed the operation. In about 70 per cent, of the cases the limb was practically straight ; in 30 per cent, it was distorted. This shows the necessity of continued super- vision during the growing period of all cases in which anchylosis is present from whatever cause. :320 TUBERCULOUS DISEASE OF THE KNEE JOINT. In 48 cases in which the operation had been performed before the tenth year, and iu which the limbs were straight, the influence of the operation on the growth was investigated. Years elapsed Number of Average Shortening since operatiou. cases. in Cm. 2 6 1 3 5 1.6 4 4 1 5 3 2 6-7 19 2 8-13 11 2.5 These measurements indicate that the shortening is not likely to be very great as a result of the operation, certainly very much less than after complete or even partial excision, performed at the same age. Excision. — Excision of the joint Fig. 231. in childhood has been practically abandoned because of the great shortening that follows complete removal of the epiphyses, and be- cause so-called partial excision, that is the removal of thin sections of bone from the surfaces of the femur and tibia leaving the carti- lages, is usually an unnecessary operation, iu the sense that disease that might be cured by this proce- dure might have been cured by conservative methods. Early excision in adult cases is often indicated because it will assure a cure of the disease in a short time, whereas mechanical treat- ment will require years of dis- ability with no certain prospect of absolute cure at the end of the period. If, therefore, the disease has progressed sufficiently to in- dicate that the natural cure would result in anchylosis, or if the time of disability is of importance to the patient, early excision may be ad- vised in the case of the adult, or adolescent, whose growth is nearly completed. The operation is performed under the Esmarch bandage, and the joint is exposed by the anterior incision, as in the operation of arthrec- tomy. All the diseased tissues are cut away and sections of the bones, parallel to the articular surfaces, are removed, sufficient in depth to Deformity and shortening resulting from excision of the knee in childhood. PBOGNOSIS. 321 include all the diseased area. If the sections are so made as to allow the bones to be brought into close apposition, sutures through the periosteum will hold them in position, without nails or wiring. The vessels having been ligated, the wound may be closed with or without drainage, as may be indicated, a plaster of Paris dressing- is applied, and the limb is elevated. Mechanical support is of service in the after-treatment in lessening the discomfort and hasten- ing the cure. Kesults of Excision. — In Koenig's statistics of three hundred excisions, 6 deaths were due directly to the operation, and 23 others occurred during the course of after-treatment; a total of 29 (9.6 per cent.). In 23 instances amputation was afterwards performed because of failure of the operation. The good results are classed by Koenig as 75 per cent., the bad as 25 per cent. In 193 cases, the position of the limb in after years was investigated. It was straight in 175, dis- torted in 18 ; all but one of this latter group being in children. Amputation. — This operation is indicated as a life-saving measure. When the disease is so extensive as to require complete removal of the epiphyses, in early childhood, amputation is the preferable opera- tion, as the limb, aside from requiring constant protection to prevent deformity, will be so short as to be of little practical use. Operations for the Eelief of Final Deformity. — If the joint is anchy- losed in an attitude of marked flexion, the limb may be straightened by the removal of a sufficient wedge of bone from the joint. Slighter degrees of flexion may be remedied by linear osteotomy of the femur. Genu valgum may be corrected by a similar operation. Prognosis. — The most important statistical evidence on the course and the outcome of tuberculous disease of the knee joint in childhood, has been presented by Gibney. The statistics completed in 1892 were the result of an investigation of four hundred and ninety-nine cases treated during a period of twenty years, 1868-1887. In but three hundred of these could definite information be obtained.^ Eighty-seven per cent, of the cases were in children, and 51 per cent, of the patients were less than five years of age at the inception of the disease. The cases were divided into three classes, according to the treatment that had been followed : 1. The expectant treatment. In this class no apparatus was em- ployed or, if employed, it was inefficiently used. 2. The fixation treatment. In this class the joint was more or less efficiently splinted, but not protected from impact Avith the ground. 3. The protective treatment. In this class the joint was both splinted and protected from jar, and the mechanical treatment was effi- cient. 1 Am. Jour. Med. Sci., October, 1893. 21 322 TUBERCULOUS DISEASE OF THE KNEE JOINT. The results were classified as follows : M o a a a * 'm 3 ja s S -B a s a fl*2 £ H W < « & o Expectant 71 5 3 3 9 51 190 39 9 1 35 2 31 11 114 26 300 14 4 40 51 191 Mortality. — The total deaths in the 300 cases were 40 (13.3 per cent.); 26 of these were from causes directly or indirectly connected with the disease (8.6 per cent.), viz. : Operative shock 1 Prolonged, suppuration 16 Tuberculous meningitis 6 Phthisis ._3 26 Intercurrent diseases 14 40 Function. — The functional results, as regards motion, in the cases in which conservative treatment was continued to the end, including the cases still under observation, 242 of 300, were as follows : Expectant Fixation... Protection Total. Motion retained. Anchy- losed. 60 145 37 44 or 7 per cent. 113 "77 " 34 "95 16 32 3 242 191 " 79 51 Of the 191 patients who retained a movable joint 74 had had ab- scess, 3 or more cicatrices being present in 39. f\ I As to the range of motion in 74 it was from 45 degrees to normal and in 41 more than 90 degrees, thus 30 per cent, of the patients re- tained a fair range of motion. Deformity. — In 51 cases anchylosis was present, in 16 of these the limb was practically straight, in 35 it was flexed more than 30 degrees (69 per cent.). These statistics again illustrate the great tendency toward deformity, when during the growing period there is anchylosis at the knee from whatever cause. In the 191 cases in which motion was retained the limb was prac- tically straight in 125 (65 per cent.). In 49 others the flexion was less than 25 degrees and in but 16 could the deformity be classed^ as bad (8 per cent.). In 10 cases only did relapse occur after apparent cure. In but 16 of the 449 cases was there involvement of other joints GENERAL CONCLUSIONS. 323 while the patients were under observation (3.2 per cent.). In 8 of these the spine was involved, in 2, the hip, and in 6 other joints. The influence of age upon the death rate, and the ultimate causes of death, are illustrated by Koenig's statistics, the death rate being much higher, at least in the cases in early childhood, than in this country. According to Koenig's statistics, the death rate, direct and indirect, from disease of the knee joint, was as follows : 323 children (1 to 15 years of age), deaths 65 (20 per cent.) 225 patients (16 to 30 years of age), " 61 (24 per cent.) 68 " (31 to 40 years of age), " 30 (44 per cent.) 74 " more than 40 years of age " 45 (60 per cent.) Causes of Death. Deaths from causes not connected with the disease, 14 (2 per cent.). Deaths following operations, 18 (2,5 per cent.). Deaths caused by tuberculosis, 141 (22.5 per cent, of all cases and 80 per cent, of all the deaths). Tuberculosis of the knee 1 Tuberculosis of the lungs 94 General tuberculosis 30 Tuberculous meningitis 7 Acute miliary tuberculosis 3 Tuberculosis of other parts 6 141 It may be noted that 16 of the 40 deaths in Gibney's cases were due to prolonged suppuration, and that of 51 cases still under observation 26 had been treated for ten years or longer, and were still uncured. This indicates, that in a larger proportion of the cases conservative methods should have been supplemented by more radical treatment. Still, taken as a whole, the results, although the mechanical treatment was, in many instances, far from efficient, are much better than any others that have been presented. General Conclusions. — On this evidence the following conclusions seem to be justified. The death rate in childhood from all causes should be less than 10 per cent. The duration of treatment is from 2 to 5 years. Recovery with a useful range of motion, when the diagnosis has been made at an early stage and when efficient mechanical treat- ment has been employed, may be predicted in 50 per cent, of the cases. Deformity can always be prevented by treatment and by super- vision. Under favorable conditions, radical operations are not often indicated, but when indicated, they should not be delayed too long. Amputation of the limb should prevent death from prolonged suppura- tion. In a certain proportion of cases the disease may be cut short by early exploratory operations, for the removal of foci of disease in the bone before the joint has become involved. Although the benefits of protective treatment are as evident in dis- ease of the adult as in childhood, yet early operation is often indicated in this class, because of the necessity for shortening the period of dis- ability, and because excision assures a straight and useful limb. CHAPTER X. NON-TUBERCULOUS AFFECTIONS AND DEFORMITIES OF THE KNEE JOINT. Strains and Injuries of the Knee in Childhood. Injury of the knee in childhood may cause local discomfort and persistent flexion of the leg, even when but little synovial effusion is present. In this class of cases the application of a plaster bandage is of service in resting the part and preventing further injury. The importance of treating promptly slight injuries of the joints in child- hood, especially in the class of patients predisposed to tuberculous infection, has been mentioned already in the consideration of hip disease. Synovitis. Acute traumatic synovitis is properly treated, immediately after the injury, by splints, by elevation of the limb, by the application of ice bags and the like ; but after the acute symptoms have subsided the absorption of the effused fluid is aided by functional use of the limb, if the joint is properly protected. One of the most efficient methods of treatment is that by means of the adhesive plaster strapping, advo- cated by Cottrell and Gibney. The entire surface of the knee, except a narrow space in the popliteal region, is firmly strapped with over- lapping layers of adhesive plaster, extending from the upper third of the leg to the middle third of the thigh ; and over this a flannel band- age is applied ; or if the leg is swollen, the entire limb should be firmly bandaged with elastic stockinette bandage, from the toes to the upper third of the thigh in addition. (Fig. 238.) The adhesive plaster serves as a support which allows a certain degree of motion, sufficient to stimulate the circulation, and thus to hasten the restoration of the nor- mal condition. If greater compression is desired, the entire joint may be covered with the adhesive plaster as suggested by Hoffmann.^ A pad of cotton is placed in the popliteal space, a close-fitting stocking leg is drawn over the knee and about this circular bands of plaster are drawn as tightly as the comfort of the patient will permit. The adhe- sive plaster strapping is renewed from time to time, as the swelling diminishes and its use is continued until the symptoms have entirely disappeared. Chronic synovitis may be treated in a similar manner, although if IN. Y. Med. Jour., January 27, 1900. PREPATELLAR BURSITIS. 325 the eifusion is persistent the fluid may be removed by aspiration. If the liga!ments are lax, a supporting brace may be required for a time (Fig. 152), and massage and exercises are of service in the stage of recovery. Infectious Arthritis. Suppurative arthritis in this, as in other joints, should be treated by free incisions, and efficient drainage should be assured. Under proper treatment practically perfect recovery is not unusual. Mechanical protection is usually required after the immediate svmptoms are relieved. (See page 208.) RHEUMATOID ARTHRITIS. Osteo-Arthritis. In this disease several joints are usually involved, but occasionally the affection may be confined to the knee. The early symptoms are stiffness, discomfort and pain more noticeable in damp weather, and often creaking sensations in the joint are appreciable to the patient. At intervals the symptoms may be more acute and the joint becomes hot and swollen, as in rheumatism ; as a rule, however, they are sub- acute in character. The progress of the affection is slow, the joint becomes somewhat enlarged and irregular in outline, the range of motion becomes more restricted, and flexion of the limb, after a time, persists. (See page 212.) Treatment. — The general and constitutional treatment of rheuma- toid arthritis does not require especial consideration here. Locally, massage and the hot-air bath, may add to the comfort of the patient and increase the mobility of the joint, in the early stage of the affec- tion, at least. Static electricity has been employed with advantage in certain cases. The application of the cautery and stimulating lini- ments are useful in relieving pain, and the support of a flannel band- age adds much to the comfort of the patient. Prepatellar Bursitis. Synonym. — Housemaid's Knee. A chronic enlargement of the bursa lying over the patella and its ligament, is common among those who have to kneel much of the time, hence the popular name. Occasionally cases of acute bursitis, in which there is considerable effusion into the sac, are seen, and these are sometimes mistaken for synovitis of the knee. Treatment. — In acute cases, strapping the front of the knee with strips of adhesive plaster which will limit motion and provide compres- sion, is an effective treatment. If the effusion is considerable, it may be relieved by aspiration. In chronic cases, cure can be attained only by the removal of the thickened sac. 326 NON-TUBERCULOUS AFFECTIONS OF THE KNEE JOINT. Pretibial Bursitis. Beneath the ligamentum patellae, occupying the space between the tendon and the periosteum of the tibia, is the deep pretibial bursa. It is, according to the investigations of Lovett,^ as wide or somewhat wider than the tendon ; its upper border is on a level with the joint, its lower border reaches to the twbercle of the tibia, and being slightly longer on the outer than on the inner border, it is somewhat triangular in shape. It does not communicate with the knee joint. Enlargement of this bursa is, as a rule, the result of injury, but, as bursitis elsewhere, it may be a complication of infectious disease, rheu- matism and the like. Symptoms. — The symptoms are stiffness at the knee and pain on sudden movement, especially when strain is exerted on the tendon by complete flexion or extension of the leg as in active use. The tubercle of the tibia seems enlarged and is sensitive to pressure, and a swelling on either side of the ligament is usually evident. Treatment. — The aifection, if at all acute, may be treated by re- lieving the strain and pressure on the tendon, by fixation of the limb for a time in a plaster bandage, or other form of splint. Later, the adhesive plaster strapping will provide sufficient fixation and pressure. The absorption of the fluid may be hastened by the application of the cautery. If the swelling is persistent, the fluid may be removed by aspi- ration or incision of the sac. Its complete removal is not often necessary. Enlargement of the Superficial Pretibial Bursa. A small bursa, lying upon the insertion of the ligamentum patellae, may become enlarged, causing an aj)parent hypertrophy of the tubercle of the tibia. It may be treated by strapping with adhesive plaster, and the prominent tubercle should be protected by some form of bunion plaster. Bursas and Cysts in the Popliteal Region. Simple inflammation of the bursa lying between the inner head of the gastrocnemius and the semimembranosus muscle, may cause a fluctuating swelling on the inner side of the popliteal region. Cysts in the popliteal region usually communicate with the knee joint and are complications of rheumatic or tuberculous disease. They are of interest principally from the diagnostic standpoint. Internal Derangement of the Knee Joint. (Hey.) The term internal derangement signifies sudden interference with the function of the joint which may be due to : (a) Loose bodies in the joint ; (6) Displacement of a semilunar cartilage ; (c) Other injury.^ Loose Bodies in the Knee Joint. — Loose bodies in the knee joint may be composed of portions of fibrin, fragments of synovial mem- ' Boston City Plospital Reports, Eighth Series, 1897. 2 W. H. Bennett, Lancet, Jan. 6, 1900. INTERNAL DERANGEMENT OF THE KNEE JOINT. 327 brane or bits of cartilage or bone and the like. In certain forms of synovial tuberculosis and osteo-arthritis, these loose bodies may be present in large numbers, but from the therapeutic standpoint the important cases are those in which the joint is otherwise normal. In this class the foreign body is sometimes detected by the patient as a smooth, movable object on one or the other side of the patella ; but in many instances the first sign of its presence is interference with the function of the joint. After a sudden movement or when the knee has been flexed, as in the kneeling position, or without appreciable cause, severe pain in the knee is felt and the joint may be fixed in the position of flexion. By massage, manipulation, or spontaneously, the foreign body is dislodged from between the surfaces of the bones and movement becomes free and painless, but discomfort remains for a time and in most instances synovial effusion follows. These symptoms recur at intervals and the disappearance of the movable body from its accustomed place at such times demonstrates its relation to the dis- ability. Displacement of a Semilunar Cartilage. — Displacement of a semilunar cartilage is usually of traumatic origin, and it appears to be caused most often by an outward twist of the tibia upon the femur. The patient's limb is fixed in the attitude of flexion, and in certain instances an irregularity may be detected at the inner and upper border of the tibia. To replace the cartilage, the leg should be flexed then suddenly ex- tended and rotated inward. In some instances an ansesthetic may be required. The displacement is followed by discomfort and synovial effusion, and the accident having once occurred, is likely to recur ; the patient recognizing the character of the movements that are likely to cause the displacement, also the proper manipulation for its replacement. Injury. — In other instances, somewhat similar symptoms may fol- low injury at the knee, pinching of the synovial membrane, bruising of the cartilage or a strain of one of the ligaments within the joint, being assigned as causes. In cases of this character in which the symp- toms recur from time to time, the joint becomes weak and insecure, partly because of the repeated synovial effusions and partly because of the muscular relaxation. Treatment. — Immediately after the displacement or injury, the -oint should be splinted for a time, afterwards it may be protected by the ad- hesive plaster strapping, and when the effusion has been absorbed mas- sage and exercises for strengthening the muscles should be employed. In the more chronic cases in which the ligaments are lax, a brace which will permit antero-posterior motion, but prevent lateral mo- bility, may be required. The Campbell brace (Fig. 152) used by Shaffer, is a light and effective support that interferes little, if at all, with the use of the limb. If the diagnosis of displaced cartilage can be verified, and if it is the cause of persistent disability, it should be removed. And the same may be said of isolated foreign bodies, which are known to be the cause of the symptoms. 328 NON-TUBERCULOUS AFFECTIONS OF THE KNEE JOINT. Congenital Genu Recurvatum. Synonym. — Anterior Displacement of the Tibia. Tlie most common of the congenital deformities at the knee is the so-called genu recurvatum, in which the knee is bent somewhat back- ward, or in other words, the leg is hyper-extended on the thigh. The condition is often spoken of as an anterior dislocation, but there is no actual displacement, except in the extreme cases in which the tibia may be turned directly forward on the femur, even to a right angle or less. In the ordinary cases the range of extension is merely ex- aggerated, while flexion is limited or checked, principally by adaptive shortening of the quadriceps extensor muscle. (Fig- 232.) The appearance in well-marked genu recurvatum is very peculiar, it is as if the patient's leg were reversed, for the popliteal depression has Fig. 232. ConjjLiiitil 5,( iiu recurvatum. (Hoffa.) become a prominence and the range of over-extension seems to repre- sent normal flexion. In such cases the leg may be brought to the straight line, but greater flexion is resisted by the retracted tissues, and when the pressure of the hand is removed the leg is drawn back to the deformed position by the contraction of the quadriceps extensor muscle. Other Deformities and Malformations. — Genu recurvatum is not infrequently accompanied by varus or valgus deformity at the knee, more often by the latter, and by laxity of the ligaments. In many instances the patella is absent or is rudimentary and not infre- quently the deformity is accompanied by malformations or defective development of other parts. Seventy-eight cases were collected by Potel.^ In thirty-seven in- stances the deformity was limited to one side, in the others both legs ^ Etude sur les Malformations Congenitale du Genoa. Lille, 1897, Imp. L. Danel. CONGENITAL DISPLACEMENT OF THE PATELLA. 329 were affected. In fiftv cases the condition of the patella was noted, in twenty-Six of these it was absent or rudimentary. Twenty of the cases were accompanied by talipes. Etiolog"y. — The deformity in cases of simple recurvatnm may be explained by an abnormal and fixed position in utero, and in cases seen soon after birth the mechanism is clearly shown by the habitual atti- tude. The thighs are sharply flexed on the body, the dorsal surfaces of the hyper-extended knees are in relation to the abdomen, while the feet may be brought into contact with the face or trunk, according to the degree of deformity. The retarded development of the quadriceps extensor muscle explains the rudimentary patella which is often an ac- companiment of the deformity. Treatment. — The treatment of the hyper-extended knee is very sim- ple. It consists in massage of the atrophied and contracted muscle, combined with more or less forcible manipulation in the direction of flexion. If, as is often the case, the leg seems to be drawn forward by spasmodic muscular action, the methodical massage should be combined with the use of a simple posterior splint. In the more extreme cases manual force may be applied under anses- thesia, and the deformity may be overcome at one or several sittings, according to the resistance of the contracted parts. The leg is then fixed in a flexed position until the tendency to recurrence has been overcome. When the child begins to walk, a light lateral brace may be necessary to insure perfect functional use of the joint, as in many instances laxity of ligaments and muscular weakness may persist for a long time. Rudimentary or Absent Patella. As has been stated, a rudimentary patella is a frequent complication of genu recurvatum, or of any congenital defect or deformity of the knee, or limb that involves imperfect development of the quadriceps extensor muscle. In many cases of this type it is impossible to dis- tinguish the patella during the early months of infancy, but later, a minute patella appears that slowly increases to an approximately nor- mal size. Absence of patella under the same conditions is less frequent, al- though Potel collected one hundred cases from literature. Treatment. — The treatment of rudimentary patella is included in the massage and stimulation of the atrophied or rudimentary muscle with which it is usually associated, and the support that the weak or deformed knee may require. Congenital Displacement of the Patella. The patella may be displaced upward as a result of extreme genu recurvatum, and in rare instances it may be displaced inward or down- ward, but far more often the displacement is outward. Fifty cases of this form are recorded, in most of which it was a complication of congenital genu valgum. 330 NON-TUBERCULOUS AFFECTIONS OF THE KNEE JOINT, Slipping Patella. This term is applied to an abnormal laxity of the supporting tissues that allows intermittent displacement of the patella upon, or to the outer side of, the external condyle. Etiology. — The disability is more common among females than males and is more often unilateral than bilateral. The abnormal mo- bility may be an inherited peculiarity ; it may be due to weakness of the quadriceps extensor muscle, or to imperfect development of the patella or of the external condyle ; or the original displacement may have been due to injury. In many instances, however, the predispos- ing cause is genu valgum, as a consequence of which the patella is car- ried toward the external condyle. Symptoms. — If the slipping of the patella is a frequent occurrence it causes comparatively little pain, but when the parts are less relaxed the displacement is likely to be followed by a certain amount of effu- sion into the joint and by the symptoms of a sprain. It is usually the- result of a misstep or sudden movement when the thigh muscle is re- laxed or of extreme flexion of the leg. As a rule there is a sense of insecurity and weakness at the knee in those who are subject to the accident. Treatment. — The treatment varies according to the condition of the parts about the joint. If the displacement is the direct result of vio- lence the leg should be fixed for a time in a plaster bandage, which may be replaced by the adhesive plaster strapping or a knee cap.. Later massage and muscle training should be employed. In cases in which the slipping has become habitual and particularly when the liga- ments of the joint are much relaxed, a liglit leg brace should be em- ployed to prevent lateral motion and to limit the range of flexion at the joint, if this predisposes to the displacement. Operative Treatment. — If the position of the patella that predisposes to the further displacement is a consequence of genu valgum the recti- fication of the deformity will, as a rule, remedy the secondary disabil- ity. If the displacement appears to be caused by laxity of the capsu- lar ligament, as well as by the abnormal position of the patella, an operation for the purpose of limiting the mobility and restoring the proper relation of parts may be conducted in the following manner : A long curved incision is made about the inner side of the knee, the lower extremity of which crosses the ligamentum patellae. The skin flap having been reflected the capsule may be divided on the outer side without disturbing the synovial membrane. The patella is then forced forward and the redundant tissue on the inner side is folded and sutured, or a section of the capsule may be removed, sufficient in size to hold the patella in its proper position. In extreme cases the tubercle of the tibia, with the attached tendon, may be removed and reimplanted on the inner aspect of the tibia, as performed by Wolff and Walsham. The limb should be held in the extended position for a time, and it should afterwards be supported by a brace or knee cap for several SNAPPING KNEE. 331 months. Subsequently massage, and exercise of the weakened muscle will be df advantage. The operation for the dislocated patella has been performed in child- hood by Pollard/ and in early infancy by Bajardi.^ The method described is that of Bradford.^ Elongation of the Ligamentum Patellae. In certain cases the ligamentum patellae may be abnormally long so that the patella lies habitually above its proper position. This elonga- tion may be one of the evidences of general relaxation of the liga- ments of the knee, and thus a predisposing cause of the slipping pa- tella, or of abnormal mobility at the knee joint. Etiology. — The elongation of the tendon may be a congenital pecu- liarity or it may be acquired. It is often observed as an eifect of an- terior poliomyelitis, or of hemi- or paraplegia. Symptoms. — The symptoms of elongation of the ligamentum patel- lae, as distinct from those of the general laxity of the ligaments, that is often present, are weakness and disability, usually noticeable on walk- ing up or down stairs, or after over-exertion. Shaffer, who first called attention to the disability, thinks that it may be a predisposing cause of displacement of the semi-lunar cartilages.* Treatment. — In this, as in other forms of insecurity or of abnormal mobility at the knee, a brace that allows only antero-posterior motion, will, as a rule, relieve the symptoms. If the ligament is of such a length as to require it, it may be shortened, or the tubercle of the tibia may be removed and implanted at a lower point, as suggested by Walsham.^ Other Congenital Deformities at the Knee. Congenital displacements are uncommon. As a rule they are incom- plete and are caused by laxity of the ligaments and by defective for- mation of the bones or other parts.^ Snapping Knee. A very slight form of partial recurrent displacement, is the snapping or clicking knee not uncommon in early infancy, in which the tibia on sudden extension of the limb springs forward, or rotates outward, on the femur, with an audible snapping sound. This movement appears to be the result of voluntary muscular contraction combined with laxity of ligaments. In some instances the subluxation appears to cause pain or discomfort. The ability to displace the tibia on the femur by mus- cular action, is sometimes found in older subjects. ' Lancet, 1891, Vol. I., p. 988. 2 Archiv di Ortoped., 1894, p. 209. 3 Trans. Am. Orth. Ass'n, Vol. VIII., p. 228. Mbid., Vol. XL 5 Med. Week, February 17, 1893. ^Drehmann, Die Cong. Lux. des Kniegelenks. Zeits. f iir Orth. Chir., Bd. 7, H. 4, 1900. •332 NON-TUBERCULOUS AFFECTIONS OF THE KNEE JOINT. Treatment. — The treatment of congenital dislocations or subluxa- tions of the knee consists in reposition, support and massage of the ■weak part. The snapping knee may be supported by a flannel band- age, or in the more marked type of laxity of ligaments, it may be fixed -for a time in a brace. Complete recovery is the rule. Congenital Contraction at the Knee. Slight limitation of the range of extension of one or both knees is not infrequent. As a rule it is easily overcome by massage and man- ipulation. In the more extreme cases there may be an actual de- formity' of the femur, its lower extremity presenting a forward convex- ity, as in a case reported by Phocas.^ General Contractions. Congenital contraction at the knees of a more marked and resistant form may be combined with flexion contraction at the hip, or it may be one of a series of contractions at other joints. In the latter instance, other congenital deformities or evidences of defective development are usually present. For example, certain joints may be fixed in flexion or fixed in extension. In some instances the contraction or the partial anchylosis appears to be due simply to long-continued fixation in utero, and non-development of the muscles. In others, it appears to be a complication of so-called foetal rhachitis. Treatment.- — The treatment consists in regular massage and manip- ulation, with the aim of increasing the range of motion. Deformity, if present, may be rectified in the usual manner. Prognosis. — The prognosis depends upon the cause of the contrac- tion or fixation. In most instances, under careful and continued treat- ment, the range of motion may be in great degree restored. Acquired Genu Recurvatum. S3monym. — Back Knee. Genu recurvatum, as the name implies, is a deformity in which the knee is habitually over-extended. The congenital form has been de- .scribed. (See page 328.) Etiology. — Acquired genu recurvatum may be a simple local de- formity, or it may be secondary to weakness or distortion of other parts. Local or primary genu recurvatum may be an effect of rhachi- tis, or of disease or injury of the femur or tibia. In this form the femur may be curved sharply forward above the joint, or the upper extremity of the tibia may be bent backward at the epiphyseal junction, and flexion may be limited by the obliquity of the articulating surfaces. More often the deformity is secondary. It may be, for example, an effect of equinus, either congenital or acquired, in which the knee is strained by the effort of the patient to place the heel upon the ground. It may be caused l)y the use of a traction brace in tlie treatment of hip ' Revue d'Oilliopedie, January, 1899. ACQUIRED GENU RECURVATUM. 333: disease, when the knee joint is not properly supported. It is one of the comparatively infrequent complications of disease at the knee joint, in which the leg has been supported by the brace in an extended or over- extended position. In rare instances it is the direct result of trauma- tism, when the leg has been suddenly forced into an over-extended position, and the posterior ligaments, and possibly the crucial ligaments also, have been ruptured or weakened. It is most often, however, an accompaniment of paralysis of the posterior thigh group, or of the gastrocnemius muscle, or both. In the majority of cases genu recurvatum is combined with a vary- ing degree of knock knee. In many instances there is an abnormal mobility at the joint that allows a certain amount of posterior displace- ment of the tibia, and in extreme cases, there may be well-marked subluxation. Symptoms. — The symptoms, aside from the deformity, are weak- ness and insecurity caused by the hyper-extension when weight is borne. If the deformity is extreme, the strain upon the Aveakened parts usually causes discomfort. Flexion is rendered difficult because of the abnormal relation of the joint surfaces and of the accommodative changes in the ligaments and muscles, so that in extreme cases the pa- tient swings the leg along in the extended or over-extended position. Treatment. — If the recurvatum is caused by deformity of the bones^ the normal relations may be restored by osteotomy of the tibia or fe- mur, as may be indicated. Deformity secondary to distortions else- where, may be treated by remedying the primary cause. Traumatic genu recurvatum may be treated by fixation in the flexed position until the repair is complete, afterwards by massage and sup- port, if necessary. The ordinary form of over-extended knee, com- bined with lateral mobility, must be supported by a brace which per- mits only antero-posterior motion to the normal limit or slightly less. Whenever possible, massage and exercises should be employed. CHAPTER XI. DISEASES AND INJUKIES OF THE ANKLE JOINT. Tuberculous Disease of the Ankle Joint. Disease of the ankle is the third in the order of importance, although it is far less common than is disease at the knee. In five consecutive years, 1,788 cases of tuberculous disease of the joints of the lower extremity were treated at the out-door department of the Hospital for Euptured and Crippled. In 54.1 per cent, of these the hip joint was affected, in 36.2 per cent, the knee joint, and in but 9.7 per cent, the ankle joint. Pathology. — The pathology of tuberculous disease at the ankle dif- fers in no essential particular from that of disease of the hip and knee. Tuberculous disease of the ankle and tarsus. A, disease of the ankle and sub-astragaloid joints ; B, cavity in the os calcis containing sequestrum. It does not therefore call for special consideration. It is of interest to note however, that abscess is a more common complication at this, than at the other joints. In 30 final results of disease at the ankle reported by Gibney,^ ab- scess was present in 25, 83 per cent. In 78 final results reported by Prendlsburger ^ abscess was present in 68, 87 per cent., as contrasted with a percentage of 69 and 51 at the knee and hip respectively. This greater liability to abscess is very possibly apparent rather than actual, since the ankle joint is so superficial that fluctuation may be detected lAm. Jour. Obstetrics, April, 1880. ^Lqc. cit. ETIOLOGY. 335 here that would be overlooked at the hip. And because the tissues about the joint readily allow spontaneous opening at an early stage, before sufficient time has elapsed to permit of spontaneous absorption, that is so common in disease of the spine and hip. Situation of Disease. — Otto Hahn ^ has recently investigated the ■cases of tuberculous disease of the ankle and foot treated at Tiibingen 'during the past fifteen years. These cases were 704 in number in •685 patients, in 19 both feet having been involved. In 309 of the cases the disease was of the ankle joint. Of these 51 per cent, were osteal in origin. The primary focus was in the iinternal malleolus in 11, the external in 7, in both in 5. It was in the astragalus in 116 cases. In 16 instances the disease of the ankle was secondary to primary 'infection of the os calcis, and in 5 cases both the astragalus and the os •calcis were diseased. Etiology. — The etiology of tuberculous joint disease does not re- quire further comment. It may be noted, however, that tuberculous disease at the ankle is relatively more common in later childhood and .adult life than is the same affection at the knee and hip. Of 1,000 cases of disease of the hip joint, 12 per cent, were in jpatients more than 1 years of age. Of 1,000 cases of disease of the knee joint, 25 per cent, were in '^patients more than 10 years of age. Of 339 cases of disease of the ankle joint, 30 per cent, were in pa- itients more than 10 years of age.^ .Age at Incipiency of Ankle- Joint Disease in 339 Consecutive Cases Treated at the Hospital for Ruptured and Crippled. 1 year or less 5 23 years old. 2 years old 42 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 19 20 21 22 42 43 24 " 25 " 44 26 " 34 27 " 24 28 " 19 29 " 8 30 " 9 31 " 9 32 " 11 33 " 8 34 " 4 35 " 4 36 " 4 37 " 6 40 " 2 43 " 4 44 " 3 45 " 3 46 " 4 48 " 5 50 " 'Beitrage zur Klin. Chir., Bd. 26, H. 2, 1900. ^ Statistics from Hospital for Ruptured and Crippled. ... 2 ... 3 ... 3 ... 4 ... 4 ... 2 2 .. ... 1 ... 2 .. 1 ... ,.. 2 ,.. 2 .. 4 .. 1 .. 1 .. 4 2 .. 1 .. 1 339 336 DISEASES AND INJURIES OF THE ANKLE JOINT. Of the 339 patients 177 were males (52.2 per cent.) ; 162 were fe- males (47.8 per cent.), cases ; of the left in 166. The disease was of the right ankle in 173 Age of the Patients Treated for Ankle-Joint and Tarsal Disease AT Tubingen. (Hahn.) Males. Females. Total. ItolOyeais 45 28 73 11 " 20 " 149 91 240 21 " 30 " 89 34 123 31 " 40 " 32 28 60 41 " 50 " 37 27 64 51 " 60 '' 35 26 61 61 " 70 " 18 11 29 71 " 80 " 6 17 81 " 1 _0 1 412 246 658 Of 658 patients 412 were males (62 per cent.) ; 246 were females (38 per cent.). In 27 the sex was not stated. Symptoms. — The symptoms are usually subacute in character, and are often mistaken for sprain or rheumatism. In some instances they FiC4. 234. Tuberculous disease (if tlie ankle. appear to follow an injury, but in the majority of cases in childhood no cause can be assigned. The ankle becomes sensitive to sudden move- ments, the patient limps, discomfort after over-use and pain at night BIAGNOSTS. 337 become noticeable. The limp differs in character from that caused by hip or knee disease. The patient walks with the foot rotated outward, bearing the weight upon the heel and upon the inner border, all active leverage being avoided. Deformity. — The primary deformity of ankle-joint disease, in the subacute cases, is valgus, induced apparently by the continued use of the limb in the passive attitude. In more advanced cases it becomes equino-valgus and when the limb is no longer capable of supporting weight, but is held pendant, the equinus deformity predominates, due partly to the force of gravity and partly to the muscular spasm. As has been stated, in the early stage the symptoms are those of a Fig. 235. Tuberculous disease of the sub-astragaloid joint. persistent, somewhat painful disability at the ankle, causing stiffness, limp and at times pain ; later swelling and deformity appear. Physical Examination. — The joint is usually somewhat enlarged. In some instances the swelling is uniform, in others it is localized in front or behind one of the malleoli. This swelling is not, as a rule, like that of simple effusion into the joint, but the tissues have the pe- culiar elastic characteristic of thickening and infiltration. There is usually a perceptible increase in the local temperature, and pressure di- rectly upon the malleoli causes discomfort. The voluntary movements of the joint are restricted and passive movements show the characteris- tic reflex muscular spasm, limiting both dorsal and plantar flexion. 22 Fig. 236. The epiphyses of the lower extremities at the age of s x years, showing the eflFect of operative re- moval of bone at the ankle joint for tuberculous disease at the age of 3 years, in causing subsequent de- formity of the foot and shortening of the limb. (oSS) TREATMENT. 339 SuB-ASTEAGALOiD DISEASE. — If the astragalus is primarily dis- eased, -tMe symptoms are usually first apparent in the ankle joint, but in certain cases the joint between the astragalus and the os calcis is first involved, although this is more often the eiFect of primary disease of the OS calcis. Disease at the sub-astragaloid joint is usually classed as ankle-joint disease, although the swelling is most marked at a point somewhat below the malleoli. (Fig- 235.) Forced lateral motion of the OS calcis causes discomfort, and the range of adduction and abduc- tion of the foot is restricted, while dorsal and plantar flexion may re- main completely free. Diagnosis. — The principles of differential diagnosis of tuberculous disease from other aiFections have been considered in detail in the de- scription of disease of the spine and of the larger joints. In childhood, a chronic, painful disease confined to a single joint in which motion is limited by muscular spasm, and in which there is a tendency to deformity, is almost certainly tuberculous in character. In adult life also the same principle applies, and distinguishes tu- berculous disease from rheumatism, rheumatoid arthritis or other gen- eral affections. Forms of infectious arthritis may be differentiated by the history. Sprains or other injury may be distinguished by the his- tory of the onset and by the absence of local signs of serious disease. In rigid flat foot the symptoms are localized at the medio-tarsal joint. It should be borne in mind, also, that the pain from a weak or injured foot is experienced as a rule only when it is in use, whereas in tuber- culous disease of the bone, pain is common when the part is not in use, and it may be particularly troublesome at night. Treatment. — In disease of this as of other joints functional rest is indicated. This necessitates fixation and stilting of the limb, efficient traction being manifestly impossible. The foot should be fixed in a light plaster bandage, extending from the extremities of the toes to the calf, at a right angle with the leg and in an attitude of slight supina- tion, in order to guard against the tendency toward valgus. This de- formity is very common after the cure of the disease and it often sub- jects the patient to the additional discomfort of progressive flat foot. R'-DUCTiON OF Deformity. — If the foot has become distorted be- fore the patient is brought for treatment, the plaster bandage may be applied in the attitude of deformity, and at the subsequent applications of the dressing, when the muscular spasm is lessened, gentle manipu- lation will gradually overcome the malposition. Although in resistant cases immediate reduction of the deformity under anaesthesia may be required. Throughout the entire course of treatment the greatest at- tention must be paid to the attitude. Deformity is easily prevented, but it is often very difficult to correct, especially during the later stages of the disease, when the tissues are infiltrated and sensitive, and when discharging sinuses are present. Other retentive appliances may be employed, but they are inferior to a properly applied bandage which holds its place by accuracy of ad- justment, which most effectively prevents motion, and which exercises 340 DISEASES AND INJURIES OF THE ANKLE JOINT. a certain degree of compression upon, and general support of, the swol- len joint. The bandage is renewed at intervals of a month, or longer if it is properly protected by a light shoe or slipper. The most satisfactory brace to serve as a stilt in connection with the local support is the Thomas brace, which has been described in the section on disease of the knee joint. (Fig. 229.) A¥hen patients are treated efficiently the discomfort or inconvenience attending the disease is slight. As a rule, the swelling of the joint becomes more localized and finally an abscess appears beneath the skin. It is then advisable to remove the fluid and other contents, by means of a simple incision. In most instances a sinus persists for a time. If the discharge is slight, the part may be dressed with ichthyol, balsam of Peru or other application, and the whole inclosed again in the plaster bandage ; or, if it be more profuse, an opening may be made and the dressing applied outside the plaster bandage. Operative Treatment. — Early operation, especially gouging opera- tions, should be avoided. An effective operation of this character often iuvolves the sacrifice of bone that would be spared in the natural cure, thus it entails an irregularity in the growth, and causes deformity in after life, which may be irremediable. (Fig. 236.) Similar operations in the treatment of fistulse, or abscess, while the tissues are thickened and oedematous, and while the disease within the joint is active, should be postponed until the process of repair is more advanced. During the stage of convalescence, however, cure may be hastened by the removal of persistent foci of disease, or sequestra in the bone, or tuberculous tracts in the overlying soft parts. In the adult or adolescent, and in exceptional cases in childhood, operative removal of the disease may be indicated, and if it is confined to the ankle joint, the removal of the astragalus, which is usually the primary seat of infection, is the operation of choice. The operation is performed under the Esmarch bandage ; a curved lateral incision is made passing beneath the external malleolus from the neighborhood of the tendo-Achillis to the anterior aspect of the joint. The peroneii tendons and the lateral and capsular ligaments are divided, after which the foot may be displaced inward, exposing the joint, the ligament between the astragalus and the os calcis having been separated, the bone may be removed with a little manipulation ; after which all the diseased tissue in the soft parts and in the bone must be removed thoroughly. If the disease has not extended to the tarsus, and if it seems to have been completely removed, the wound may be closed after the peroneii tendons are sutured, but in most cases it should be packed, for a time, with gauze. The after-treatment is conducted as if the operation had not been performed ; support and fixation being continued until it is evident that the disease is cured. Removal of the astragalus does not interfere to a marked extent with the function of the foot, nor does it cause noticeable deformity. As a primary operation, permitting inspection and the opportunity for thorough removal of all disease in the neighboring parts, it should TUBERCULOUS DISEASE OF THE TARSUS. 341 always be performed in preference to extensive gouging, which is, as a rule, of little avail. Prognosis. — Disease at the ankle is not only less common but it is less dangerous than that of the larger joints, because it is remote from important structures and because there is less opportunity for the burrowing of infected abscesses. The duration of the disease here, is, as a rule, shorter than at the knee or hip, and the final results in child- hood, are almost always excellent. Often free motion is retained, and even if the astragalus be fixed by disease, the mobility in the other joints of the foot is sufficient to compensate very effectively for the anchylosis. Shortening of the limb is of comparatively little conse- quence. It is not often more than an inch, and it may be absent. The growth of the foot is retarded partly from disease, and partly because of the destructive effect of the disease upon the tarsal bones. In the 30 cases reported by Gibney, treated expectantly, in which the mechanical treatment was far from effective, (3 patients recovered with normal motion ; 11 with practically normal function. In 7 there was good motion. In 6 there was anchylosis, and in 3 persistent valgus. In all, the limb was efficient. In 20 instances there was no limp, and in but one case was it marked. In no instance was a crutch, cane or other support used. The average duration of the dis- ease was 3 years and 3 months, a minimum of 1 year, a maximum of 6 years. There were 2 deaths, of which but 1 was dependent upon the disease, septicaemia being the cause assigned, though it is stated that practically all the bones of the tarsus were involved. In this case amputation was evidently indicated. Tuberculous Disease of the Tarsus. Tuberculous disease of the joints of the foot, not involving the ankle, is not uncommon. In 386 of the 704 cases reported by Hahn, the disease was limited to the foot. In 141 cases the medio-tarsal joint was involved, in 51 of these the disease was confined to this joint ; in 46 the ankle was involved ; in 29 the disease extended forward to the tarso-metatarsal articulation, and in 16 the three joints were diseased. In 78 cases the tarso-metatarsal joint was involved, in 33 of which the disease did not extend beyond this articulation. Disease of Ixdividual Bones. — In these cases the distribution was as follows : The astragalus 170; disease confined to the single bone in 8 The calcaneum 200; " " " " " "87 The cuboid 116; " '^ '' " " "18 Thescaphoid 82; " " " " " " 2 The cuneiform bones.. 86; " " " " " " 8. Metatarsal bones 45 ; in one-half of these the disease was of the 1st metatarsal, either alone or in connection with the adjoining cuneiform bone or phalanx. 342 BISEASES AND INJURIES OF THE ANKLE JOINT. In a total of 1,231 cases, including these and others reported by Audry,^ Koenig,^ Mondan,"^ Miinch,* Spengler,'* Vallas,^ Czerny '^ and Duniont,^ the relative frequency of the disease in the bones of the foot and ankle appeared to be as follows : Malleoli 96, 7.7percent. Scaphoid 110, 8.9percent. Astragalus 291,23.6 " Cuneiform bones 109, 8.8 " Calcaneus 339, 25.9 " Metatarsus 110, 8.9 " Cuboid 154, 12.5 " Phalanges 22, 1.7 " Peimary Disease of the Asteagalo-scaphoid Joint. — In dis- ease at this point the swelling is localized in front of the ankle on the inner side of the foot. Adduction is restricted and the foot is often fixed in an attitude of persistent abduction. Disease of other bones of the tarsus is indicated by the local swelling and sensitiveness. The disease sometimes involves the shaft of a meta- tarsal bone, or one of the phalanges, causing expansion and destruction, " spina ventosa." (See page 356.) Treatment of Tarsal Disease. — Disease of the tarsus shows a marked tendency to extend from one bone to another until the entire foot is involved. Consequently if an early diagnosis is made of a dis- tinctly localized process, prompt removal of the diseased bone is indi- cated. But in most instances the disease is too extensive to permit of its radical removal. In such cases operative intervention is contra- indicated, and the treatment by protection, similar to that employed in disease of the ankle, is indicated. In childhood the prognosis is very good even when the disease is extensive, but in adult life amputation of the foot may be advisable, especially if there be co-existent disease of the lungs. Sprain of the Ankle. The ankle is, from its position, especially liable to injury, in fact the term " sprain " is popularly associated with this joint. A sprain is most often caused by an unguarded movement, by which the foot is turned suddenly inward or outward, with sufficient force to rupture some of the fibers of the muscles, to strain tendons and tendon sheaths and even to rupture ligaments. If the foot is twisted inward, the injury is most marked on the outer side of the joint ; if outward, on the inner side of the ankle. In the slighter degrees of sprain, the injury may be confined to the tissues about the joint, but in most in- stances there is effusion within the capsule, even hemorrhage when the injury has been severe. Symptoms. — The immediate symptoms of sprain are pain, often in- tense, of a throbbing character, swelling, heat and in many instances, 1 Eevue de Chir., 1891. ^ Ibid., Bd. 44, 1897. ^Schmidt's Jahrb., Bd. 204, 1884. « Deutsche Chir., L. 66. 3 Deutsche Chir., L. 66. ' Volk. S. klin., V., No. 76. * Deutsche Zeits. f. Chir., Bd. 11, 1879. s Deutsche Zeits. f. Chir., Bd. 17, 1882. SPRAIN OF THE ANKLE. 343 discoloration of the surrounding parts, even extending over the leg and fobt. Treatment. — If an opportunity for immediate treatment is offered, the swelling and the effusion of blood may be restrained by the appli- cation of elastic stockinette bandages, from the toes to the knee. As much compression is exercised as the comfort of the patient will allow, and the bandage should be made sufficiently thick to prevent painful motion. If the injury has been severe and if the part is very sensi- tive to motion or jar, the joint having been protected with cotton may be fixed in a light plaster bandage. This may be cut down the front to allow for daily massage of the foot, ankle and leg which is of great service in hastening the absorption of the effusion. The use of hot air, hot and cold water and static electricity, and the like, are of service also in relieving the discomfort and especially in stimulating the circulation of the blood, upon which repair depends. Fig. 237. Adhesive plaster strapping applied for sprain of the ankle. By far the most effective treatment during the stage of recovery and as an immediate application for sprains of slighter degree, is the ad- hesive plaster strapping which has been popularized by Gibney. The plaster may be applied in a variety of ways ; a satisfactory method is as follows. One end of a strip of adhesive plaster about three feet long and three inches wide, is applied to the lateral aspect of the leg just below the knee joint ; it is carried down the side of the leg over the malleolus, beneath the heel and arch, and up the other side to a point opposite the beginning, where it is fixed by a circular band about the calf. If the sprain is of the outer side of the ankle, sufficient tension is made upon the outer half of the plaster to hold the foot slightly abducted. If, as is more common, the sprain is of the inner side, the inner half is drawn firmly beneath the arch, carrying the foot toward inversion so that all strain may be removed from the sensitive part. This band of 344 DISEASES AND INJURIES OF THE ANKLE JOINT. plaster is reinforced by one or more so that tlie lateral aspect of the ankle is completely covered. And in addition the entire ankle, with the exception of the heel, is then enclosed with narrow overlapping strips, which cover all the tissues, well beyond the sensitive area. The foot and leg are then bandaged to assure the adhesion of the plaster. When the joint is firmly held by the supporting plaster, the patient can, as a rule, walk with comfort ; and he is encouraged to do so, for functional use, provided it does not cause additional injury, is the most effective stimulant of the circulation ; thus the patient applying, as it were, an automatic massage, cures himself. As the swelling subsides the plaster strapping wrinkles, and it must be renewed, about three applications being required as a rule, the last of which is allowed to remain until all of the symptoms have disap- peared. It is perhaps needless to state that a preliminary shaving of the part will add somewhat to the comfort of the patient. Gibney ad- FiG. 238. The stockinette baudage. vises the use of narrow, overlapping strips and does not cover the front of the ankle ; the manner of application is, however, of little impor- tance provided that the sensitive part is efficiently supported and com- pressed. Chronic Spraix. — A chronic sprain may be the result of an inef- ficiently treated acute injury, in which an improper attitude originally assumed to spare the sensitive part, finally becomes habitual. In other instances, persistent disability may be the result of fixation of the joint for too long a time in splints. Such disuse cau.ses atrophy of the muscles, while the effused material within and without the joint remains because of the imperfect circulation. The same disability may follow simple disuse of the injured part. It is more often observed in nervous indi- viduals who exaggerate the importance of the injury and the discomfort that it causes. In such cases the limb may be discolored by venous congestion, the foot may be oedematous and the movements may be limited by adhesions or by muscular adaptation to the habitual attitude. TENO-SYNO VITI8. 345 Fig In other instances the original injury may have caused a slight sub- luxatiori of the astragalus, sufficient to throw the foot into an attitude of abduction, in which it has become fixed by the secondary changes in the muscles and ligaments. In some cases of this class the original sprain was at the medio-tarsal or at the sub-astragaloid joint, and its effect has been a traumatic weak foot. Finally, many of the so-called sprains of the ankle are simply injuries of a weak foot and are ex- amples of the rigid or inflamed weak or flat foot. (See the Weak Foot.) Treatment. — Treatment must be conducted with the aim of restoring the normal range of motion and so support- ing the part that normal functional use may be permitted. In many instances when adhesions have formed, and when the foot is persistently held in an ab- normal attitude, forcible manipulation under anaesthesia may be required as a preliminary treatment followed by fixa- tion for a time in a plaster bandage, in the attitude directly opposed to that which had been habitual. And as in this class of cases the habitual attitude is usually one of equi no- valgus, the foot should be fixed for a time in a plaster bandage in a position of extreme varus, and upon it the patient is en- couraged to bear his weight both in standing and walking. When all dis- comfort has disappeared, a support, usually a light leg brace to prevent lateral motion, and if the arch is de- pressed a foot plate also, should be worn for a time. The most effective curative agent is functional use, but massage, hot air, passive manipulation and exer- cises are of service also. Injuries of this class are very amen- able to treatment, conducted with the aim of restoring normal function, when proper support is provided during the period of pain and weakness. Teno-Synovitis. The sheaths of the tendons about the ankle joint, if involved in a sprain rt .1 11 ' j_ 1 • The anterior annular ligament of the OI the ankle, may cause persistent in- ankle and the synovial membranes of the ierference with function ; or strain of fT^Elxux.^TF^^Vk^'rS 346 DISEASES AXn INJURIES OF THE ANKLE JOIXT. The internal annular ligament of the ankle and the arti- ficially distended synovial membranes of the tendons which it confines, i Testut. i (From Gerrish's Anatomy, j a tendon and of its sheatli mav cause symptoms of disability when the joint is uninjured. The symptoms of acute teno-synovitis are discom- fort on motion of the af- FiG. 240. fected tendon and this motion may be accom- panied by a peculiar creak- ing which is apparent on palpation. In many in- stances there is slight local swelling: and sensitiveness to pressure about the af- fected part, and the general movements of the foot that call the muscle into action are painful. The arrangement of the tendon sheaths should be borne in mind. At the ankle joint all the tendons are provided with sheaths ; on the front of the foot are three — the sheath of the tibialis anticus, which ex- tends from a point about two inches above the extremity of the malleo- lus to the scaphoid bone (Fig. 239); that of the extensor longus poUicis, from the annular ligament to the head of the first metatarsal, and the common sheath for the extensor communis digitorum extending from a point about half an inch above the malleoli to about one inch below the annular ligament. Behind the internal malleolus are the com- mon sheaths of the tibialis posticus and flexor longus digi- torum, beginning about an inch above the extremity of the malleolus and extending to the astragalo - scaphoid junction and that of the flexor longus pollicis of about the same ex- tent. (Fig. 240.) Behind the outer malleolus is the sheath of the two peroneii, beginning one inch above the malleolus, divid- ing into two portions for the two tendons and ending just behind the tuberosity of the fifth metatarsal bone. (Fig. 241.) The external annular ligament of the ankle and the artificially distended synovial membrane of the ten- dons which it confines. (Testut.) (From Gerrish's Anatomy.) OTHER AFFECTIONS OF THE ANKLE JOINT. 347 Treatment. — Simple traumatic teno-synovitis should be treated by rest and by compression. An effective treatment is strapping by ad- hesive plaster, so applied as to prevent the movements of the foot that cause discomfort. In more painful and persistent cases the use of a plaster bandage to assure absolute rest may be necessary. Cautery applied over the affected part is of service. Chronic teno-synovitis may follow injury or it may be the result of gonorrhoea or other infec- tious disease. In chronic cases when the palliative treatment is inef- fective, thorough removal of the affected sheath is indicated. Tuberculous Teno-synovitis. — A persistent and increasing swell- ing of a tendon sheath always suggests tuberculous disease. In such instances the sac is thickened and often contains the so-called rice bodies. Prompt and complete removal of the diseased sheath is indi- cated and by this means a permanent cure may be attained in most instances. Other Affections of the Ankle Joint. The ankle joint may be the seat of an infectious arthritis ; it may be involved in an osteomyelitis of the tibia. It may be one of the joints affected in chronic rheumatism or rheumatoid arthritis, and oc- casionally Charcot's disease may appear in this situation. The princi- ples of the treatment of these affections have been indicated elsewhere. CHAPTER XII. DISEASES AND INJURIES OF THE ARTICULATIONS OF THE UPPER EXTREMITY. Tuberculous Disease of the Shoulder Joint. Disease of the shoulder is very uncommon in childhood. In a total of 453 cases of tuberculous disease treated at the Vanderbilt Clinic 210 were cases of Pott's disease. In 6 of the remaining 243 cases, the disease was of the shoulder joint (2.5 per cent.). In 1,883 consecutive cases of joint disease — Pott's disease being excluded — treated in the Out-patient Department of the Hospital for Ruptured and Crippled during the past five years, the shoulder joint was involved in 38 instances (2 per cent.). In 1,900 cases of joint disease treated at Billroth's Clinic, the shoulder was involved in 14, or less than 1 per cent. Fig. 242. \ Section of the shoulder joint, in childhood. (Schuchardt. ) Pathology. — The disease usually begins in the head of the humerus. In 32 observations on adults recorded by Mondan and Andry,^ the primary disease was of the head of the humerus in 23 cases, of the humerus and scapula in 4, of the scapula alone in 1 and in 3 instances it appeared to be primarily synovial. In the majority of cases abscess forms and comes to the surface near the insertion of the deltoid muscles. In advanced cases the tissues of the axilla and of the adjoining thorax may be infiltrated and perforated by numerous sinuses. In other instances the disease is of the form ' Revue de Chir., 1892. SYMPTOMS. 349 called caries sicca, in which there is no swelling, but progressive destruc- tion of the head of the humerus by granulation tissue. This form is charalcterized by extreme muscular atrophy and by practical anchylosis. Statistics. Age at Incipiency of Disease at the Shoulder Joint in 62 Con- secutive Cases Treated at the Hospital for Rup- tured AND Crippled. 1 year or less 1 13 years old 3 2 years old 6 3 " " 4 ii u 5 " " 6 " " 17 u u 9 10 11 12 Males 38, females 24 fi 15 18 19 20 23 26 27 34 48 56 ; rig ht35, 2 1 3 3 5 3 4 1 1 3 2 4 1 fi 1 1 1 5 1 4 24 Total left 27. ."62 Townsend ' made a detailed report on 2 1 cases treated at the Hos- pital for Ruptured and Crippled during the years 1889 to 1893. Ten of these were less than ten years of age, 7 were between ten and twenty, and 4 were more than twenty. The youngest patient was three and a-half and the age of the oldest was thirty-five years. In 5 cases the disease was secondary to disease of other parts ; in one case to Pott's disease, in 2 to hip disease and in 2 to disease of the knee joint. Symptoms. — The history of the case will show the persistent and progressive character of the disability, but the symptoms, characteristic of tuberculous disease, are far less marked at the shoulder than at other joints. This is explained by the fact that the upper extremity is not subjected to the strain of weight-bearing and because the mobility of the scapula upon the thorax lessens the injury caused by unguarded movements of the arm. This double joint at the shoulder masks the interference with the function of the joint, and even when absolute anchylosis is present the patient may think that the movements are but moderately restricted. Finally, the traumatism caused by over-use may be lessened by the voluntary restraint that the patient may exercise upon motion at this joint, without greatly inconveniencing himself. The symptoms of the disease may be classified as pain, sensitiveness, restriction of motion, atrophy. The pain is usually of a dull aching character with occasional neu- ralgic pain referred to the elbow and arm. The discomfort is increased by movements that pass beyond the limits allowed by the mobility of the scapula, especially on attempting to rotate the humerus, as in clothing oneself or brushing the hair. The joint is sensitive to pressure, thus the patient finds that he can not lie on the aft'ected side at night. 1 Trans. Am. Orth. Ass'n, Vol. VII. 350 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. On physical examination the limitation of motion caused by muscular spasm will be evident when the scapula is fixed, so that movement of the joint can be tested. Normally the range between adduction and abduc- tion is about 90 degrees, and between flexion and extension it is some- what less than this. Pressure upon the head of the humerus usually causes pain, and in many instances local heat and swelling are present. The atrophy of the shoulder muscles is often extreme and that of the other muscles of the limb is well marked. As has been stated, abscess is a common accompaniment of the dis- ease, and in such cases the tissues about the joint are swollen and in- filtrated. In other instances there is progressive destruction of the head of the humerus without abscess formation (Caries sicca). In cases of this type the flattening of the shoulder may be so extreme as to be mistaken for sub-coracoid dislocation. Treatment. — The treatment of the disease here as elsewhere is rest. To assure absolute functional rest the wrist should be attached to the neck by a sling, the elbow being flexed to an acute angle ; the arm is then fixed to the thorax by a bandage and all the clothing, including the shirt, is placed outside the affected part. Local rest and compres- sion may be still further assured by strips of adhesive plaster applied over the shoulder and extending to the back and chest ; or a shoulder cap of leather or plaster may be employed. This method of fixing the arm is the only one that assures continuous rest, as a change of the clothing necessitates movement of the joint, which causes discomfort and retards the cure. During the acute phases of the disease, the arm may be supported in the attitude of extreme abduction by means of a triangular splint or pad. This position is often that of greatest com- fort to the patient. Direct traction is not often employed, as support of the pendant limb is usually preferred by the patient. Operative Treatment. — If the focus of disease seems to be localized, an exploratory operation for its early removal may be indicated. Ex- cision of the joint in the adult cases, or arthrectomy in younger sub- jects, may be advisable when suppuration is persistent or when for other reasons it may seem best to attempt to remove the diseased area. Prognosis. — The duration of the disease appears to be from two to five years. The death rate is higher than in disease of the joints of the lower extremity, because a larger proportion of the patients are adults and in this class tuberculosis of the lungs is not an infrequent compli- cation. It is impossible to speak positively of the results of the conserva- tive treatment of disease of the shoulder. The disease is uncommon and protection is almost never applied in the early stage, nor efficiently or persistently employed to the end. The ordinary result is therefore anchylosis, usually of the fibrous rather than of the bony variety. If the disease appears in early life the growth of the limb may be seriously interfered with ; an inch or more of shortening from this cause is not uncommon. TUBERCULOUS DISEASE OF THE ELBOW JOINT. 351 Tuberculous Disease of the Elbow Joint. Tuberculous disease of the elbow joint is the fourth in order of fre- quency, preceding the shoulder and the wrist. Of 1,883 consecutive cases of joint disease treated at the Hospital for Ruptured and Crippled, 56 were of the elbow. Pathology. — The primary disease is in most instances osteal, as in 92.8 percent, of the cases investigated by Scheimpflug, 44 in number.^ The original focus of infection is somewhat more often of the ulna than of the humerus. Of the ulna the olecranon process, and of the humerus the external condyle, appear to be the points of election. Disease of the head of the radius is comparatively infrequent. In 11 9 cases reported by Oilier, the olecranon was involved in 73, the humerus in 33 and the radius in 12 instances.^ And in the cases investigated by Kummer,^ and Middledorpt,^ the ulna was more often the seat of the primary disease than was the humerus, but in 81 cases treated in Koenig's clinic the primary disease was of the humerus in 43, of the olecranon in 36 and of the radius in 2 instances.^ Statistics. Age at Incipiency of Disease at the Elbow Joint in 59 Consecu- tive Cases Treated at the Hospital for Euptured AND Crippled. 1 year or less 2 11 years old 1 2 years old 5 3 " " 4 u u 5 " " 6 " " "7 H U 9 10 Males 28, females 31 5 13 " ( 3 8 14 " ' 2 5 15 " 5 17 " 4 19 " 8 21 " 1 23 " 2 25 " ' 2 5 29 " ' 1 s 31 ; right 27 Total , left 32. 59 Symptoms. — The symptoms are those of a chronic, persistent, de- structive disease. Pain, local sensitiveness and swelling, stiffness, de- formity, atrophy. The pain is usually localized at the elbow. It is increased by sud- den movements, and as the bones are so superficial there is usually local sensitiveness to pressure, most marked over the seat of the dis- ease. In the early stage the swelling is slight and it is of the peculiar elastic character due to thickening of the tissue, rather than to effusion within the capsule, but as the disease progresses the joint assumes the peculiar spindle shape characteristic of white swelling. The degree of elevation of the local temperature depends upon the activity of the > Festschrift fiir Billroth, 1892. ^Karewski, Chir. Krank. des Kindersalters, p. 268. 3 Deutsche Zeits. f. Chir., Bd. 27. * Archiv f. Klin. Chir., Bd. 33. ^Koenig, Lehrbuch Spec. Chir., Berlin, 1900. 352 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. disease. The most important physical sign is the restriction of motion due to the characteristic muscular spasm which becomes evident when the limit of painless motion is passed. The limitation of extension and flexion gradually increases and finally the limb becomes fixed in an attitude midway between flexion and extension, with the forearm in an attitude midway between pronation and supination. This is the characteristic deformity of the Fig. 243. disease. Atrophy of the muscles of the arm and forearm is present, cor- responding to the intensity and duration of the disease and to the functional disability of the joint. Treatment. — The treatment here, as elsewhere, consists essen- tially in placing the joint at rest in the attitude at which anchylo- sis or limitation of motion will least inconvenience the patient, and at the elbow joint, this is ])ractically at right-angular flex- ion. (Fig. 244.) In the treatment of young children the wrist may. be at- tached closely to the neck by means of a sling, with the elbow at an acute angle (the Thomas method) within the clothing. Or a light plaster bandage may be used to fix the joint, together with the sling. This enables the patient to dress himself without moving the part and it protects the joint from injury. Other forms of splints may be employed, but the plaster bandage answers every purpose. It should, of course, extend from the axilla to the hand, and in sensitive cases it may include the hand also. Reduction of Deformity. — In many instances the arm is fixed in the semi-extended attitude when the patient is brought for treatment. In this class of cases a simple and effective means of reducing deform- ity is that suggested by Thomas. When it is impossible to bring the wrist to the neck, one bends the neck toward the wrist and attaches the two by a bandage that the patient is unable to remove. From this uncomfortable attitude the patient can free himself only by drawing the arm toward the neck and thus reducing the deformity. At the next visit the same procedure is repeated, until finally the elbow is flexed to the required degree. A permanent sling may be constructed of a leather wrist band and a tube of leather to pass about the neck, through which Tuberculous disease of the elbow joint. OPERATIVE TREATMENT. 353 the bandage may be drawn ; thus the pressure on the wrist and neck may be.; lessened. In the very resistant cases reduction of deformity under anaesthesia may be required, but this is not often necessary. Prognosis. — If the case is treated at an early stage the prognosis in childhood is good. The duration of treatment may be estimated at two years or more and retention of a fair range of motion may be ex- pected. Anchylosis in the right-angled position does not, however, seriously inconvenience the patient, provided the cure is absolute. The loss of growth is less than when the epiphysis at the shoulder is destroyed and the final disproportion in size depends, of course, upon the age of the patient and upon the degree of function that is preserved. Fig. 244. f Tuberculous disease of the elbow joiut, the stage of recovery. Operative Treatment. — ^^In some instances it is possible to remove small foci of disease from the humerus, or from the ulna, before the joint is involved. The position of the disease may be indicated by sensitiveness or swelling and in older subjects a Roentgen picture may demonstrate its position accurately. Excision of the Elbow. — Excision is often advisable in adoles- cent or adult life, because by this procedure, in most instances, the disease may be cured in a definite time and because a movable joint may be assured. Oschman has recently investigated the final results of the operation 23 354 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. performed on this class at Kocher's ^ clinic at Berne, 1872-1897. In forty of forty-five cases the operation was performed for tuberculous disease. There were no deaths referable to the operation. Of the entire number of cases, fifteen were dead, but eleven of these survived the operation for from five to twenty years. Eight of the deaths were due to tuberculosis, two to other causes and in five the cause of death was unknown. In ninety-six per cent, of the cases the local disease was cured. In sixty-eight per cent, of the cases the patients were able to use the limb at hard labor and in the others it was efficient for light work. In six cases there was subluxation or luxation, in five the joint was not firm. In fifty-nine per cent, the motions were practically normal. In eleven per cent, the joint was anchylosed. The Kocher method of exploring and excising the joint which was employed in the majority of these cases has the advantage of sparing the muscu- lar attachments and affording an opportunity for inspection of the interior. The incision begins upon the outer aspect of the humerus, from three to six cm. above the line of the joint and is carried directly downward over the head of the radius, passing in the interval between the extensor muscles of the arm in front and the anconeus behind. It is then carried inward and downward across the back of the forearm to a point from four to six cm. below the tip of the olecranon, then upward for two cm. on the inner side of the ulna. Thus the mus- cular insertions are spared. The olecranon process is then divided and turned upward and the joint is exposed. If a complete excision is to be performed the olecranon is separated from its muscular at- tachments and the periosteum if possible. The part must be sup- ported until the repair is complete, and in the after-treatment lateral support by means of a light jointed brace will add to the comfort of the patient and prevent distortion. Tuberculous Disease of the Wrist Joint. Disease of the wrist joint is very uncommon in childhood. In a total of 3,105 cases of tuberculous disease treated in the Out-patient Department of the Hospital for Ruptured and Crippled during the past five years, 98 were of the upper extremity and in but four of these was the wrist joint involved. Of 43 cases in which the joint was resected by Oilier, the youngest patient was thirteen years of age. Of 990 cases of disease of the joints in childhood, reported by Karewski, the wrist was involved in 31.- Disease of the wrist in older subjects is less infrequent, although at all ages it is rare as compared with disease in other joints. Tubercu- lous disease of the metacarpus and phalanges (spina ventosa), is, how- ever far more common. 1 Archiv f. Klin. Chir., Bd. 60, H. 2, 1900. ^Chir. Krank. des Kindei'saltei"s, Berlin, 1894. TUBERCULOUS DISEASE OF THE WRIST JOINT. 355 Age at Incipiency of Disease at the Wrist Joint in 18 Consecu- ,TivE Cases Treated at the Hospital for Euptured AND Crippled. 1 1 1 2 years old 6 '' 9 " 12 " 14 " 16 " 17 '' 90 u {, f L ( 2 '?5 i t. 2 '>f; i {. 2 97 1 i 1 Total T8 Males 11, females 7 ; right 12, left 6. Symptoms. — The symptoms of tuberculous disease of the wrist are as in other situations pain, local swelling and sensitiveness, limitation of motion, caused by muscular spasm and atrophy. In advanced cases the hand is usually flexed somewhat upon the arm. Treatment. — The treatment of this, as of other joints, is functional rest, with support in the attitude in which anchylosis or limitation of Fig. 245. Tuberculous disease of tlie carpus. motion will cause the least inconvenience. A light plaster bandage extending from the elbow to the tips of the fingers, applied over a flannel bandage drawn as tight as the comfort of the patient will per- mit, is a satisfactory support ; or a leather splint or other form of ap- pliance may be used. The hand should be held in an attitude of moderate dorsal flexion, which will permit the flexor muscles to close the fingers easily if the wrist becomes fixed by the disease. If flexion deformity is present it should be corrected by degrees, with each appli- cation of the bandage, until the desired attitude is attained. (Fig. 247.) The flannel bandage exercises a certain amount of compression upon the wrist which seems to be of benefit, and in certain instances, this com- pression and fixation may be still further increased by the application of adhesive plaster. When the disease of the joint is quiescent, or in the stage of recovery, the bandage or splint may be shortened to allow the patient to use the fingers. Prognosis. — The prognosis as regards function in cases treated promptly in childhood should be good. In the adult cases, wrist-joint 356 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. disease seems to be very often complicated by disease of the lungs, thus the prognosis as to life is often bad. In this class of cases early excision is usually recommended, with amputation as a final resort. Fig. 246. Tuberculous disease of the left wrist joint. The irregularity and the diminished size of the carpal bones indicate the extent of the destructive process. The patient, the mother of the child (Figs. 10-11) with Pott's disease, died within a year of tuberculosis of the lungs. Spina Ventosa. Central disease of the long bones of the foot and hand is the mosfc common form of tuberculous osteomyelitis. The marrow is the seat of the disease and caseous degeneration is common. While the corti- cal substance is destroyed from within it is often replaced in part by a formation of periosteal bone from without, which in turn may be destroyed by the advancing disease. In the early cases the affected bone is enlarged, spindle-shaped, and is somewhat sensitive to pressure. At this stage repair may take place with but little ultimate change from the normal, but in many instances the bone is perforated and in part destroyed, the neighboring joint is involved and the finger be- comes stunted and distorted. In 159 cases tabulated by Karewski,^ the metacarpal bones were diseased in 65 instances — the phalanges in 57 — the metatarsal bones in 29 — the phalanges of the toes in 8. In a number of instances sev- 1 Chir. Krank. des Kindensalters, Berlin, 1894. SPINA VENTOSA. 357 eral of the bones and larger joints were involved (159 cases in 135 patients). The disease is more common in the early years of life, 84 of the 135 patients being four years of age or less, 38 of these being less than two. Fig. 247. Treatment of tuberculosis of the wrist joint by plaster of Paris, showing the proper attitude. Spina ventosa of the phalanges may be treated by rest and compres- sion, and both splinting and compression may be exercised by adhesive- plaster strapping. If the joint is involved, amputation of the finger Fig. 248. Tuberculous disease of the wrist and knee joints showing the characteristic deformities in neglected cases of a severe type. may be indicated because of the distortion and loss of growth that may be expected. Tuberculous disease, limited to a single bone of the car- pus, or metacarpus, may be treated by operative removal of the disease. 358 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. Periarthritis of the Shoulder. Under the title of scapulo-humeral periarthritis, Duplay ^ in 1872 described a painful aifection of the shoulder induced by traumatism, dependent upon an inflammation of the bursa lying between the del- toid and the supra- and infra-spinatus muscles and the coraco-acroraial ligament. But under this title are now included a number of affections that cause similar symptoms in which it would appear that the interior of the joint is not involved. Symptoms. — In a typical case of so-called periarthritis, the patient complains of a dull pain about the joint and sensitiveness to pressure just below the acromion process or over the bicipital groove. The pain is increased by motion, particularly by abduction or by rota- tion of the arm. In mild cases, only extensive motion causes pain, but in most instances there is a constant sensation of discomfort which is increased to acute pain by sudden movements or jars. The part be- comes sensitive to pressure so that the patient avoids lying on the shoulder at night. In certain instances the pain may radiate down the arm and there may be weakness and numbness of the fingers. Grad- ually the passive movements of the joint are diminished in range, and atrophy of the shoulder muscles appears. These symptoms usually pass as rheumatism, but there is no fever, no involvement of other joints, no swelling, and, as a rule, no general sensitiveness to pressure, as is usual when the synovial membrane of the joint is affected. In certain instances these symptoms follow injury, or exposure to cold or they appear without apparent cause. In one class of cases the symptoms may be due to an inflammation of the sub- deltoid bursa, as in the cases originally described by Duplay ; in others to a TEXO-SYNOViTis of the biceps tendon, that may extend to the sur- rounding parts. This is suggested by local sensitiveness at the bicipital groove, and by the creaking sensation at this point when the muscle is in use. Or the symptoms may be due to neuritis affecting the cir- cumflex nerves, as suggested by Amidon.^ It is probable also that the nerves in the neighborhood of the joint may be secondarily implicated in an inflammation of bursse, or directly injured by the original trauma- tism, if such preceded the symptoms. It is also possible that the bursitis may have been a sequel of gonorrhoea or of other infectious disease. Treatment. — During the acute and painful stage the part should be kept at rest. Cautery may be applied and the joint should be enclosed in adhesive plaster strapping, and if the weight of the limb causes discomfort, it should be supported. In certain instances tension on the sensitive part may be relaxed by supporting the arm in an attitude of abduction. When the acute symptoms have subsided passive move- ments, massage and static electricity are of service. Voluntary exer- cises should be employed when they no longer aggravate the symptoms. ' Archiv Generale de Med., Paris, 1872. 2 Am. Medico-Surg. Bull., March 21, 1896. SPRAIN OF THE WRIST. 359 In the cases of long standing in which motion is very much restricted, apparently by adhesions without the joint, passive movements under anaesthesia may be of benefit. In such cases it may be well to sup- port the limb for a time in the abducted attitude to prevent the for- mation of the adhesions. Afterwards, passive motion, massage and exercises may be employed. If these cases are treated carefully in the early stage, recovery is usually rapid, but if neglected the symptoms may persist indefinitely. Chronic Bursitis. Chronic bursitis at the shoulder joint is comparatively infrequent. The bursse most often involved are the coracoid, the sub-scapular and the deltoid. Of these the last is the most often involved. Sixteen cases have been reported by Blauvelt,' and three others by Ehrhardt.^ The enlarged bursa forms a fluctuating swelling most evident on the anterior and outer aspect of the shoulder, the symptoms being discom- fort, weakness and limitation of motion of the arm. The disease is usually tuberculous in character and it should be treated by incision or by complete removal of the sac, if possible. Sprain of the Wrist. This is a very common accident. The most eifective treatment is the adhesive-plaster strapping applied about the metacarpus, wrist and lower half of the arm. If the pain on motion is severe, sufficient plaster is applied to splint the part and to limit movement to the point of comfort. If the injury is of a slighter grade the compression and support of a single layer of plaster is usually sufficient. This dressing prevents injury and yet it allows a certain degree of functional use which is the most eifective means of restoring a joint to its normal condition, by hastening the absorption of the effused material within and without the joint. Chronic Sprain. — Persistent weakness and stiffness may follow treatment of a sprain by splints, or when for any reason disuse of function has been long continued. In many instances, however, the sprain was in reality a fracture or displacement. All chronic sprains, therefore, should be examined by means of the X-ray in order that the presence or absence of more extensive injury may be determined. The treatment is similar to that of the acute sprain, protection from injury, and functional use to the extent of which the part is capable. With this, massage, hot air and electricity or other form of local stimu- lation may be employed with advantage. The same treatment is indi- cated when the joint is stiff and painful as the result of rheumatism or other inflammation, provided the stage of recovery has been reached. 1 Beitrage zur Klin. Chir., Bd. 22. 2Archivf. Klin. Chir., Bd. 60, 1900. 360 DISEASES OF ARTICULATIONS OF UPPER EXTREMITY. Acute Teno -Synovitis. Teno-synovitis is common at the wrist joint. It is usually induced by strain or over-use of a muscle or set of muscles. Movements of the muscles that are involved cause discomfort and there is usually local sensitiveness and a creaking sensation on palpation over the affected tendon sheath. The adhesive-plaster strapping, so applied as to exert compression and to prevent the motion that causes discomfort, is the most effective treatment. Chronic teno-synovitis, causing progressive enlargement of a tendon sheath with accompanying symptoms of weakness and discomfort, is usually tuberculous in character. In such cases the diseased part should be promptly removed. CHAPTER XIII. CONGENITAL AND ACQUIRED AFFECTIONS LEADING TO GENERAL DISTORTIONS. Rhachitis. Synonym. — Rickets. Rhachitis is a constitutional disease of infancy caused by defective nutrition, of which the most marked efiPect is distortion of the bones. Etiology. — The predisposing cause is constitutional weakness. This may be inherited, or it may be the direct effect of illness, but most often it is the result of improper hygienic surroundings, particularly lack of sunlight, damp rooms, over-crowding and defective ventilation. The direct cause of the disease is improper nourishment. In most in- stances this is due to the substitution of artificial food for the mother's milk, in others to improper diet after the infant is weaned ; in rare cases it may be the result of prolonged lactation, or it may be caused by the defective quality of the mother's milk. The disease therefore begins usually between the ages of six and eighteen months, although it is by no means confined to these limits. In most instances improper surroundings and improper nourishment are combined in the causa- tion of the disease ; thus rhachitis is relatively common in large cities. At the Hospital for Ruptured and Crippled the most extreme cases are observed among the Italian and the colored children. The former are usually nursed but are improperly fed after weaning, while the latter, if nursed at all, are usually allowed a mixed diet even during the early months of life. Pathology. — The manifestations of a disease dependent upon im- paired nutrition are of course general in character. In rhachitis there is a mild degree of anaemia, and a general weakness and relaxation of the voluntary and involuntary muscles. As a result the circulation is impaired and the power of assimilation is diminished, thus congestion and enlargement of the internal organs, intestinal catarrh, bronchitis and the like, are common accompaniments of the disease. The most marked and characteristic changes are found in the bones ; these con- sist in a diminution of the earthy substances and in overgrowth of osteoid tissue. " The essential features of the morbid process are, first, an exagger- ation of the processes immediately preparatory to the development of true bone ; secondly, an imperfect conversion of this preparatory tissue into true bone ; and thirdly, a great irregularity of the whole process." (Erichsen.) 362 AFFECTIONS LEADING TO GENERAL DISTORTIONS. On section of a rhachitic bone it will be noted that the periosteum is increased in thickness, and is more or less adherent to the under- lying softened and spongy tissue. The medullary canal is enlarged and its contents are abnormally vascular. The epiphyseal cartilage, normally a thin bluish line, is much increased in thickness. It appears to be swollen and infiltrated, and it has lost its former translucency. Microscopical examination at this point, where growth is most active, shows marked irregularity in size and shape of the columns of carti- lage cells ; the zone of calcification is lacking or is ill-defined, and masses of cartilage cells are found unchanged in what should be the area of true bone. The same Fig. 249. irregularity of line and shape is observed in the medullary spaces of the newly formed osteoid tissue. As a direct result of the changes that have been de- scribed, the epiphyseal junc- tions are enlarged and the shafts of the bones are thick- ened by the formation of osteoid tissue beneath the periosteum. The indirect effects of the disease, and of the weakness that it causes, are deformities, the nature of which will be indicated under the heading of symptoms. The stage of weakness is followed by that of repair, which sometimes goes on with great rapidity ; the softened bones become ab- normally hard, "eburnated," and premature solidification at the epiphyseal junctions may be one of the more re- mote results of the disease, that accounts in part for the dwarfing of the stature, observed as one of the final results of severe rhachitis. Symptoms. — As the disease is the effect of imperfect assimilation its more pronounced symptoms are preceded by those of indigestion, such as flatulence, constipation and the like. Profuse perspiration, especially about the head, and restlessness at night are common symp- toms. Teething is often delayed or is irregular. The infant is slow in its movements and makes little effort to stand or to walk at the usual time, and if the disease is active, the affected parts may be sen- sitive to pressure. Deformities. — The deformities are in part due to the direct effect of General rhachitic deformities, showing distortions of the arms. DEFORMITIES OF RHACHITIS. 363 the disease. One of the earliest and most constant evidences of rha- chitis is the enlargement about the epiphyses, an enlargement caused in part by the direct hypertrophy, and in part by pressure upon the softened tissues. The enlargements at the junctions of the ribs and the costal cartilages, the "ehachitic rosary," and at the wrists and ankles, "double joints," are almost invariably present in well-marked cases. The more general distortions are in part the effect of atmospheric pres- FiG. 250. Chondrodystrophia of slight degree contrasted with ordinary rhachitis, in sisters. 1. Chondro- dystrophia. Broad, short, very flexible hands, trunk disproportionately long — knock knees. Age 53^ years, height 30^^ inches ; normal height 40 inches. 2. Rhachitis, bow legs, age 4 years ; height 32J^ inches ; normal height 36 inches. sure, in part the effect of the force of gravity and habitual postures, and in some instances muscular action or injury may deform the soft- ened bones. These deformities differ greatly according to the time of onset of the disease, and with its duration and severity. The head may be long and oblong in shape, or rectangular, " caput quad- RATUM," and it sometimes presents prominences in the frontal and parietal regions due to thickening of the bones, and on the posterior aspect depressed and softened areas, " craniotabes." The fontanelles 3()4 AFFECTIONS LEADING TO GENERAL DISTORTIONS. are abnormally large and they may remain open long after the usual time of closure. The thorax is compressed from side to side, the compression being most marked in the middle region where the ribs have the longest cartilages and the least direct support. As secondary results, the back of the chest is flattened and the sternum is thrust forward forming the PIGEOX BEEAST. The lowcr ribs are everted to accommodate the dis- tended abdomen, " pot belly." In well-marked cases the rhachitic chest presents two distinct grooves, one transverse in the axillary line, " HAREisox's GROOVE," and the other passing upw^ard by the side of the rhachitic rosary. These deformities are in great degree caused by atmospheric pressure, but they are increased if the child assumes the sitting posture habitually. In this attitude the body is inclined for- ward, the clavicles are distorted and the spine is bent into a more or less rigid posterior curve, most marked in the lower dorsal and lumbar regions, the " rhachitic spixe." Less often there may be a lateral deviation or scoliosis. The arms may be distorted by the efforts of the child to support the body in the sitting posture, or by active exertion, as in creeping. (Fig. 249.) Occasionally the deformities may be localized at the elbows, and sufficiently marked to merit the name cubitus varus or valgus, cor- responding to genu valgum or varum ; or the principal distortion may be a dorsal convexity of the lower extremity of the radius. The bones of the lower extremity are often distorted, primarily by the habitual postures assumed in sitting or creeping and these defor- mities are usually exaggerated when the erect attitude is assumed. In some instances it would appear that the femoral necks are twisted back- wards somewhat ; this distortion may explain in part the limitation of inward rotation that is sometimes observed in rhachitic children. The changes in the pelvis are of special interest to the obstetrician. These are essentially an increase in the sacro- vertebral prominence, due to the forward and downward displacement of the sacrum, an abnormal ex- pansion of the ilia, caused by pressure of the abdominal contents and, in some instances, a decrease of the lateral diameter, an effect of the pressure of the femora upon the yielding bone. In the milder type of rhachitis in older children, who walk, the defor- mities are often confined to the trunk and lower extremities. In such cases, in addition to the changes in the bones, there is usually a promi- nent abdomen and increased lordosis, combined with slight habitual flexion of the thighs and lower legs, the " rhachitic attitude." If the disease is of sudden onset and is severe and general in its manifestations, it may be accompanied by pain, by sensitiveness of the affected bones and by such weakness of the lower extremities as may simulate paralysis, rhachitic pseudo-paralysis. It is probable, however, that the cases in which the pain is extreme, " acute rhachitis," are, in reality, scurvy or scurvy and rhachitis com- bined, scurvy rickets so-called. Rhachitis, as described, is the type ordinarily seen in hospital prae- TEEATMENT. 365 tice and its manifestations are unmistakable. In its milder form it is not particularly uncommon among the children of the well-to-do, whose hygienic surroundings are good. In such cases the most marked symp- tom is weakness. The child is often fat and well developed, although, as a rule, pale. The abdomen is somewhat enlarged and slight promi- nences at the epiphyseal junctions, particularly at the wrists, may be made out. The legs appear small in proportion to the body and the ligaments are lax, so that if the child stands the feet are flat and as- sume the attitude of valgus. In this class, in which the child is said to have weak ankles, knock knee is common. The most common symptom then of mild rhachitis is the failure of the child to attempt to walk at the usual time, about sixteen months. If a child who is not ill and who has not suffered from exhausting dis- ease does not walk at two years of age, it is probably rhachitic. Prognosis. — The duration of the progressive stage of rhachitis de- pends, of course, upon the age of the patient and upon the treatment. In cases that are untreated and in which the predisposing causes con- tinue, the period of repair may be delayed for several years or longer, as shown by the fact that the child makes little effort to stand ; but, in most instances, the rhachitic child begins to walk at some time dur- ing the third year and at this time the deformities of the lower ex- tremity, knock knee, bow leg, flat foot and the like, usually develop or become aggravated, while those of the upper extremity may become less noticeable. The deformities of rhachitis tend to disappear or to become less marked with growth ; the concavities of the distorted shafts are filled by accretions of periosteal bone, which is again absorbed from the in- terior as the medullary canal straightens itself. The thickened dia- physes and enlarged epiphyses become more symmetrical under the influences of rapid growth and increased functional activity, but traces of severe rhachitis always remain and many of the more noticeable and permanent distortions of the trunk and of the lower extremities are due to this cause. The prognosis as to the outgrowth of rhachitic deformities depends upon the duration and the severity of the disease and upon the func- tion of the deformed part. Rhachitic distortions of the arms almost always disappear. The rhachitic chest is rarely seen in the adoles- cent or adult. The rhachitic kyphosis is corrected or modified when the erect posture is assumed, but rhachitic scoliosis, on the other hand, usually increases with the growth. Distortions of the lower extremi- ties may entirely disappear and in most cases they are less marked in the adult than in the child. Stunting of the growth is a constant effect of severe and prolonged rhachitis ; it depends in part upon the arrest of development during the active stage of disease and in part upon the changes in the bones that cause premature consolidation at the epiphyses. Treatment. — The treatment of rhachitis consists essentially in a re- versal of the conditions under which it developed. It is therefore die- 366 AFFECTIONS LEADING TO GENERAL DISTORTIONS. tetic, hygienic and medicinal. Deformity, the effect of the disease, mav be prevented by guarding the weakened bones from overstrain, or it may be remedied, if it be present, by manipulation or by mechanical or by operative treatment. The more detailed treatment of rhachitis may be found in works on Pediatrics. In general, the diet in the cases developing in early in- fancy should be of milk, especially modified according to the need of the patient. At a later time, corresponding to the normal period of weaning, the diet should be largely animal, to the exclusion of starchy food ; cream and fresh butter being especially valuable. The patient, protected by proper woolen underclothing, should pass as much time as possible in the open air and should sleep in a well- ventilated room. Daily salt baths are recommended for older children and regular massage of the extremities, and of the abdomen, should be employed. Medicinal treatment is of secondary importance. The bowels should be regulated and digestion should be aided by proper remedies. For anaemia, which is usually present, the syrup of the iodide of iron is of value ; cod-liver oil serves both as a food and medicine, when it is readily assimilated. It is unlikely that any drug has a very direct influence on the disease. Phosphorus in doses of 1/200 to 1/100 of a grain is often given and is supposed to lessen the abnormal congestion of the bones, while the deficiency of lime salts may be supplied possibly, by the administration of lime in some form, the syrup of the lactophosphate of lime being a favorite prescription. The prevention of deformity, other than by the means already enu- merated, consists in preventing habitual postures that predispose to deformity, and in daily massage and manipulative correction of begin- ning distortions. Young infants and those whose bones are especially vulnerable should spend much of the time in the reclining posture. The Bradford frame, or similar appliance, is especially useful in the treatment of this class of cases. The treatment of the more advanced deformities, by support or by operation, is described elsewhere. <'Late Rickets." Late rickets is, as the name implies, an aifection presenting all the characteristics of the common infantile form. This, in rare instances, appears in later childhood or even in adolescence; in some cases the affection appears to be a continuation or recrudescence of the infantile form ; in others no history of a preceding affection can be obtained.^ By many writers the term late rickets is improperly used to explain the deformities of adolescence, genu valgum, coxa vara and the like, although none of the distinctive signs of the affection may be present. Local rickets is less objectionable as applied to the same class of cases, although pathological specimens present little evidence of actual local disease. iDrewitt, Trans. Lond. Path. Soc, Vol. XXXIL, 1881. Glutton, St. Thomas' Hosp. Reports, Vol. XIV., 1884. INFANTILE SCORBUTUS. 367 Foetal Rhachitis. Synonyms. — Chondrodystrophia, Achondroplasia. Cases that present the signs of what appears to be severe general rhachitis at birth, are not especially uncommon. The trunk is dis- proportionately long as compared to the stunted limbs ; the head is large, the chest presents a pigeon-like distortion and the epiphyses ap- pear to be generally^enlarged. In some instances the back is curved into a rigid kyphosis^r scoliosis, and restricted motion, or apparent fixation, of many of the joints may be present. Etiology and Pathology. — These cases were formerly supposed to be instances of intra-uterine rhachitis ; chondrodystrophia is not how- ever the result of a disturbance of nutrition, it is due apparently to a congenital defect in the bones themselves or rather of the original cartilage. Rhachitis is characterized by hypertrophy of the epiphyseal cartilages and by delayed ossification. In chondrodystrophia, on the contrary, there is atrophy of the epiphyseal cartilages and abnormal rapidity of ossification. On section of a bone the shaft is seen to be thickened and stunted, the epiphyses are enlarged also and these hyper- trophied and prematurely ossified segments may overhang the diminu- tive cartilage that intervenes. Chondrodystrophia, or an affection resembling it, is sometimes seen (Fig. 250) in a very mild form ; the appearance of the child suggests rhachitis, but the stunting of the growth is greater than is ever the result of rhachitis of corresponding severity. Ceetixism, — Cretinism may cause a similar dwarfing of the stature, and cretinism may be combined with chondrodystrophia, but in most instances the symptoms of mental deficiency that accompany cretinism, are lacking in this affection. Treatment. — The treatment of so-called foetal rhachitis consists in regular massage and manipulation of the distorted parts and of the anchylosed joints. This treatment may extend over several years, dur- ing which the limbs and back must be protected. Rest on the Brad- ford frame during the period of active treatment, is advisable. If congenital cretinism is suspected, the administration of thyroid extract would be indicated. Prognosis. — By persistent treatment the range of motion in the stiffened joints may be regained, but the prognosis is bad. The patients present in later years the abnormally long trunk and stunted extremi- ties that were present at birth. Infantile Scorbutus. Synonyms. — Scurvy, Scurvy Rickets. Scurvy in infancy, as at other periods of life, is a constitutional dis- ease, dependent upon impaired nutrition, caused apparently by the deprivation of proper food. The disease was originally described by Smith and Barlow as scurvy rickets, but it may, and often does, occur independently of the latter affection. 368 AFFECTIONS LEADING TO GENERAL DISTORTIONS. Pathology. — The pathological changes most often found in cases of the advanced type are hemorrhages beneath the mucous membranes and the periosteum. Separation of the epiphyses may occur. Symptoms. — The disease is most often observed in bottle-fed infants from six to eighteen months of age. In some instances the patients are evidently ill-nourished, but in others they may appear to be in good condition. The early symptoms resemble rheumatism. The child shows evidences of discomfort when certain joints are moved, and as the disease progresses it may scream whenever it is turned or lifted. The painful joints are sensitive to pressure and they may be somewhat enlarged, but local heat and redness, as well as fever, are, as a rule, absent. After dentition the gums may be swollen and spongy, and hemorrhages into the skin or beneath the mucous membranes may oc- cur. In extreme cases the swelling about a joint due to effusion of blood and accompanied, it may be, by separation of the epiphysis may be mistaken for the symptoms of infectious epiphysitis or even for sarcoma. Treatment. — The treatment consists primarily in the regulation of the diet, particularly in the substitution of fresh milk, properly modi- fied, for the patent food or sterilized milk that may have been em- ployed. This should be supplemented by orange juice, or that of other fresh fruit. The change of diet usually relieves the symptoms. Dur- ing the painful stage of the disease complete rest in the horizontal posi- tion on a pillow or frame, may be indicated ; later, massage of the limbs and back may be of service in improving the nutrition, and remedying slight deformity. Fragilitas Ossium. Sjmonym. — Idiopathic Osteopsathyrosis. There are many conditions that cause local or general fragility of the bones and thus an increased liability to fracture. For example, the weakness of old age, sometimes called senile rickets ; the atrophy caused by disuse incidental to chronic joint disease, or the weakness that may be caused by certain diseases of the nervous system. Weak- ness of the bones may be general in character, as when it is the re- sult of osteomalacia or rhachitis. Idiopathic fragility or osteopsathyrosis is of congenital origin. The bones appear to be weak simply because of a failure in the formation of periosteal bone. In such cases, there may be distortions at birth, apparently caused by intra-uterine fractures, and in after life, fracture may follow the slightest accident or sudden motion. Blanchard ^ has reported a case in which there were seventy distinct fractures between the ages of two months and twenty-seven years. A similar case was for many years under treatment in the Hospital for Ruptured and Crippled. For a part of the time the bocly and trunk were inclosed in a plaster of Paris casing, to prevent the fractures that followed even 'Trans. Am. Orth. As.s'n, Vol. VI. OSTEOMALACIA. 369 ordinary movements. At the age of fourteen the strength of the bones had increased sufficiently to enable the patient to walk about with the support of braces, but he was, in stature, about the size of a child of seven years. Fractures in this class of cases are attended with but little pain. They unite slowly with but a small callus. It is practically impossible to prevent a certain amount of deformity. With advancing years the liability to fracture may diminish, but as a rule the patient is disabled. The treatment is pro- tective. Massage is of Fig. 251. service in improving nutrition. Medication is of little avail. ^ Osteomalacia. Synonym. — Mollitis Ossium. Osteomalacia is a dis- ease of an inflammatory nature, characterized by an absorption of the earthy substances (de- calcification) of the bones and by deformity. The disease is one of adult life. It is far more common among females than males, and pregnancy, in about half of the cases that have been reported, seemed to be the excit- ing cause. The disease usually begins insidi- osteomalacia. ously. The symptoms are pain on motion referred to the pelvis and to the thighs. This is supposed to be of rheumatic origin until the character of the affection is made evident by the weakness of the limbs and by the deformities. These deformities are of greater interest to the obstetrician than to the surgeon, for when the affection complicates pregnancy, the distortion of the pelvis may be so great as to prevent normal delivery. Osteomalacia in Childhood. — Three cases of osteomalacia in childhood have been reported by Siegert,^ and one case has come under my observation. The patient, one of twelve living children of healthy parents, was nursed by his mother for the usual period, and until the 1 Porak, Bui. et Mem. de la Soc. Obst. et Gyn. de Paris, 1890. Salvetti, Beitr. zur Path. Anat. und AUg. Path., Bd. XVI., 1894. *Munch. med. Wochens., Nov. 1, 1898. 24 370 AFFECTIOyS LEADING TO GENERAL DISTORTIONS. age of four years he appeared to be perfectly healthy. At this time without known cause general weakness of the lower limbs became ap- parent, and at the same time deformities of the lower extremities de- veloped. At the age of six years he was unable to stand. At the present time the condition of the patient, now nine years of age, is shown in the preceding illustration. There is no evidence of rhachitis or of paralysis. The patient has never suffered from pain or discom- fort. The lower extremities are somewhat atrophied from disuse, the bones are abnormally flexible and are distorted to a moderate degree. The epiphyses are not enlarged. (Fig. 251.) Treatment. — As the etiology of the affection is unknown, treatment is symptomatic and palliative. Osteitis Deformans. This disease was first described by Paget ^ in 1877. It is a chronic inflammatory affection of the bones, characterized by hypertrophy and softening. "The bones enlarge, soften, and those bearing weight become unnaturally curved and misshapen." Section of an affected bone shows it to be markedly increased in size, and somewhat in length, by a combination of rarefying and form- ative osteitis. The inner layers become porous, and at the same time new bone is deposited beneath the periosteum. The disease appears to be confined to adult life, and is equally divided between the sexes. Although but a single bone may be afi"ected, as a rule the lesion is symmetrical and more general in its area, the bones of the lower extremity, the skull and the spine being more often involved. Thus, the head progressively increases in size, and the legs become bowed. If the spine is affected it bends forward forming a long, more or less rigid, kyphosis. Aside from the deformities and the characteristic enlargement of the bones, the symptoms are not marked. At times complaint is made of pain usually supposed to be rheumatic until the characteristic changes in the bones appear. The disease is extremely chronic in its course, and as a rule the general health is not seriously affected. In several instances sarcoma of bone finally caused death many years after the onset of the disease. Its etiology is unknown, its treatment is palli- ative. Secondary Hypertrophic Osteo-Arthropathy.- Osteo-arthropathy is an inflammatory disease of the bone character- ized by hypertrophy, clubbing of the fingers and effusion into certain of the joints. The hypertrophy is caused by a deposition of layers of bone beneath the periosteum of the metacarpal and metatarsal bones, the phalanges and the distal extremities of the adjoining bones of the 1 Med. Chir. Trans., Vol. 40 and Vol. 65, 1882. 2 Marie, Eevue Medical, Paris, 1890, X., p. 1. Bamburger, "Wiener klin. Woch., N. 11, 1889. Deutsche Chir., L. 28, 1899. ACROMEGALIA. 371 arms and legs. Less often the area of the disease is more extensive, involving the femora, the humeri and the spine even. Osteo-arthropathy is usually a complication of preexisting chronic disease, most often of the lungs. The patient first notices clubbing of the terminal phalanges and hypertrophy of the finger nails, later an increasing enlargement of the wrists and ankles and of the hands and feet, accompanied by discomfort, sensitiveness to pressure and often by effusion into the neighboring joints, symptoms that would be classed as rheumatic were it not for the evident hypertrophy. The clubbing of the fingers is due, in part at least, to impairment of the circulation and the connection of the disease of the bones with that of the lungs has suggested the theory that it is caused by the ab- sorption of toxines and that its etiology is similar to the amyloid hy- pertrophy of the internal organs that sometimes follows chronic disease of bones and joints attended by suppuration. The treatment is symptomatic and as the affection is almost always secondary to a graver disease, but little is known of its outcome. It is certain, however, that the secondary osteo-arthropathic symptoms become less marked or may even disappear as the patient recovers from the original disease of the lungs or other organs. The affection is very uncommon in childhood, but one typical case having been recorded.^ Acromegalia. This affection is also characterized by progressive enlargement of the hands and feet, but it differs from osteo-arthropathy in that all the tissues are involved in the hypertrophy. The hypertrophy of the bone is limited to the epiphyseal extremities and is slight compared with that of the soft parts. The face is often involved, the tissues of the nose, lips and ears being enlarged and thickened, together with the underlying bones, so that the expression is very markedly changed. Acromegalia is common among those of gigantic stature. The local hypertrophy and the giganticism both being due, it is supposed, to dis- ease of the pituitary gland. Diagnosis. — The three affections that have been described, osteitis deformans, osteo-arthropathy and acromegalia, are rare diseases and they are of little practical interest to the surgeon other than from the standpoint of diagnosis. This might be somewhat difficult if the pa- thological process were confined to a single bone or limb, as is some- times the case in osteitis deformans. The essential characteristics of the three diseases may be summarized as follows: In osteitis deformans the entire bone is increased in size and length, and because of the coincident weakening of its structure, it becomes distorted ; the skull is often involved but the hands and feet are not often affected. It is a disease of middle or later life and there are, as a rule, no symptoms other than those due to the local changes in the bones. 1 Whitman, Pediatrics, February 15, 1899. 372 AFFECTIONS LEADING TO GENERAL DISTORTIONS. In osteo-arthropathy the process is an hypertrophy, but of a slight degree, caused by deposition of periosteal bone especially about the distal extremities of the shafts of the bones adjoining the hands and feet. It is not often accompanied by the weakness or the deformity that is characteristic of the preceding affection ; the skull is not usually involved, but the long bones of the hands and feet are thickened so that these members are markedly increased in size. There is often coincident discomfort and swelling of the neighboring joints. As a rule the local affection of the bones is secondary to chronic disease of the lungs. In acromegalia the marked changes are hypertrophic enlargements of the hands and feet in which all the tissues are involved ; the hyper- trophy of the bones is most marked about the epiphyses, the diaphyses remaining unaffected ; thus it differs from the preceding disease, in which similar enlargement of the extremities occurs. The head is often involved, but the hypertrophy is of all the structures of the face, not of the skull as in osteitis deformans. The disease appears to be confined to early adult life and it is often preceded or accompanied by symptoms of a general nature, headache, mental impairment and the like. The changes in the bones characterizing the affections may be easily demonstrated by means of the Roentgen pictures. CHAPTER XIV. CONGENITAL DISLOCATION OF THE HIP AND COXA VARA. Congenital Dislocation at the Hip Joint. Of all the congenital dislocations or, perhaps, more properly mis- placements, that of the hip joint is by far the most common and the most important. Statistics. — Congenital dislocation of the hip is much more common in females than in males. In 671 cases collected from different sources Fig. 252. Congenital dislocation of the hip showing the elongated capsule and the right angled relation of the neck to the shaft of the femur. (William Adams.) by Lorenz, 589 (87.8 per cent.) were in females and 82 (12.2 per cent.) in males. Of 1,039 cases seen at the Polyclinic in Milan, 867 (83.4 per cent.) were in females, 172 (16.6 per cent.) in males.^ In 500 cases from the records of the Hospital for Ruptured and Crippled, in- ' Bernacchi, Zeits. Orth. Chir., Vol. II., p. 275. 374 CONGENITAL DISLOCATION OF THE HIF. vestigated for me by Dr. C. P. Flint, 413 (82.6 per cent.) were in females and 87 (17.4 per cent.) in males. The dislocation is more often unilateral than bilateral. In Lorenz' series of 671 cases, 421 (64.4 per cent.) were single ; 225 of the right, 196 of the left side. In 245 cases (36.6 per cent.) the displacement was bilateral. Statistics of 500 Cases of Congenital Dislocation of Hip, Eecorded AT the Hospital for Ruptured and Crippled. Males 87 17.40 per cent. Females 413 82.60 " Total 500 100.00 " Eight hip 135 27.66 per cent. Left hip 218 44.47 " Both 136 27.87 '< 489 100.00 " Not specified 11 500 Males. Right hip 25 30.48 per cent. Left hip 32 39.04 " Both 2h 30.48 " ^ 100.00 " Not specified 5 "87 Females. Right hip 110 27.04 per cent. Lefthip 186 55.69 " Both Ill 27.27 " 407 100.00 " Not specified 6 4T3 The dislocation at the time when the patients are brought for treat- ment is almost always posterior, upon the dorsum of the ilium ; in other instances it is anterior, so that the head of the bone may be felt beneath the anterior superior spine. It is possible however that the primary displacement may be in certain instances directly upward. Patholog'y. — The pathological anatomy of the dislocation was first clearly demonstrated by Dupuytren in 1826, and since 1890, when the open operation was first performed, the exact relation and the appear- ances of the different components of the joint have been described in detail by HofFa, Lorenz and other operators. The condition of the joint varies with the age of tlie patient and the strain and friction to which the displaced parts have been subjected. In early infancy it may be assumed that the head of the bone lies in close proximity to what is, in some instances, a practically normal acetabulum ; in others to one that is somewhat rudimentary, often PATHOLOGY. 375 shallow and small, sometimes of an oval but usually of a somewhat triangiilar shape. The acetabulum is covered with normal hyaline cartilage, the ligamentum teres is present and the capsule is of nearly normal structure. At a later time when the joint is exposed at oper- ation at the age of five or more years, the rudimentary acetabulum may be partly filled with cartilage, fat and fibrous tissue, so that it may be almost on a level with the surrounding bone. As a rule, however a well-marked ridge indicating its posterior and upper margin can be made out and in many instances it appears to be of fair size and depth. The CAPSULE is elongated to accommodate the upward dislocation of the femur. It is hypertrophied, especially where it covers the upper part of the head of the bone, and it is often drawn into a shape like an hour glass ; the upper part con- tains the head of the bone, the Fig. 253. anterior wall is drawn tightly across the acetabulum, forming at its upper border a narrow slit- like communication, through which the ligamentum teres passes, if it be present. (Fig- 252.) The interior of the cap- sule is in part lined with syn- ovial membrane, and it often contains more synovial fluid than is found in the normal joint. The LIGAMENTUM TERES, al- though probably present at birth in a large proportion of the cases, becomes attenuated and ribbon- like with the increasing elonga- tion of the capsule, and after the age of five years or at the time when the open operation is per- formed, it is usually absent. According to Lorenz in 52 cases between two and a-half and five years it was present in 17 ; in 48 cases beyond the age of five years it was present in but 4. In rare instances it may be hypertrophied. In ray own experience the liga- ment is present in a very much larger proportion of the cases, although it is often so rudimentary that it might easily be overlooked. A shallow SECONDARY ACETABULUM, formed in part by the direct pressure of the head of the bone through the adherent capsule, and in part the result of irritation of the periosteum, is usually found upon the ilium (Fig. 253), but it is not often of sufficient depth to assure a secure support for the head of the femur ; thus its upper margin gradually recedes or two distinct depressions may be formed one above the other. The upper extremity of the femur is usually somewhat atrophied. The neck is often shorter than normal, and its angle may be lessened, Congenital dislocation of the hip, showing the orig- inal and the acquired acetahula. (Lokenz.) 376 CONGENITAL DISLOCATION OF THE HIP. and in many instances its forward inclination is increased. The head of the bone may be nearly normal although usually it is somewhat flattened on its inner and under surface, or it may be somewhat conical in shape, or again compressed from side to side to an almond shape or otherwise distorted. The abnormalities, in part congenital, become more marked with age, and in adult specimens the head and neck of the femur may be so atrophied and worn away that it has little semblance of normal contour. (Fig. 254.) There are also secondary changes in the bones of the pelvis. In unilateral dislocation the pelvis is usually somewhat atrophied on the Fig. 254. Congenital dislocation of the hip showing the depressions in the ilium and the final effect of pressure and friction upon the femur. (Adams.) affected side, and a lateral inclination of the spine may be present. The final changes in the pelvis caused by the bilateral dislocation, are more important ; its inclination is increased, the lumbar lordosis is ex- aggerated, the sacrum is forced forward and downward so that the an- tero-posterior diameter is lessened ; the tuberosities of the ischia are everted and the transverse diameter of the pelvic outlet is increased. The long muscles of the thigh are sliortened, while those attached about the trochanter are changed in direction and are usually length- ened. There is also a slight general muscular atrophy that is particu- larly marked in the gluteal group. ETIOLOGY. 377 The changes that have been described are in great degree secondary to the displacement. They are in part congenital, in part accommoda- tive and in part due to the influences of attrition and injury, to which the abnormal mobility predisposes ; thus, as a rule, they become more marked with increasing age, and in some of the adult specimens but little resemblance to the normal parts remains. As a rule, congenital dislocation of the hip is not accompanied by defective development or deformity elsewhere : although cases Fig. 255. Fig. 256. Unilateral dislocation showing the inclination of the body toward the shorter leg. The same patient before operation, showing the abnormal lordosis and rotation of the pel- vis. (See Figs. 270, 271. ) are sometimes seen in which a general laxity of ligaments is present or in which the dislocation may be one of a series of deformities and malformations. Etiology. — Nothing positive is known of the etiology of the dislo- cation. In a small proportion of the unilateral cases it may be due to violence at birth, but the fact that nearly 85 per cent, of the patients are females makes it evident that the primary cause can be neither in- jury nor disease. 378 COSGEMTAL DISLOCATION OF THE HIP. Hereditary influence can be established in a few instances. The writer has examined three female children in a family of nine, in each of whom there was dislocation of the left hip, the order being the third, eighth and ninth child. Also twins in another family, one having single and the other double dislocation. And in two instances, con- genital displacement was present in the mothers of patients. Of the various theories that have been advanced to account for the condition, the most reasonable Fig. 257. seems to be defective develop- ment. This defective develop- ment may aifect the entire aceta- bulum or it may involve only its posterior margin, or the cause of the displacement may be an ab- normal laxity of the capsule that predisposes to displacement when the thighs are flexed and ad- ducted. Heusner,^ from an examination of 26 foetuses concluded that the greater liability of females to the dislocation is explained by the disproportionate laxity of the cap- sule as compared with males. It is probable that the disloca- tion, in some cases at least, is at birth a subluxation only, that be- comes complete through muscu- lar action and the use of the limb in standing and walking. Symptoms. — The displace- ment does not as a rule attract attention until the child begins to walk ; although in some cases the mother may have noticed a pe- culiar breadth of pelvis, or a " lump " on the buttock, or a " snapping " about the hip joint, or a peculiar attitude of the limb before this time. UxiLATERAL DISLOCATION. — If the displacement is of one side, a limp is immediately apparent, which becomes more noticeable as the child grows older. The limp is peculiar and its character is explained by its cause ; for the leg is not only shorter than its fellow, but owing to the elasticity of the capsule, it becomes still shorter when the weight falls upon it, so that in walking there is a peculiar lunge of the body toward the short leg, that has been likened to the motion in walking 'Zeits. fiirOrth. Chir., Bd. V., H. 2, 8. Congenital dislocation of both hips, illustrat- ing the separation of the thighs, the abnormal breadth of the pelvic region, and the prominent trochanters. SYMPTOMS. 379 down stairs. The head of the bone is displaced upward and back- ward, iand in compensation the pelvis is tilted toward the short leg and its inclination is increased ; it is thus twisted downward and forward so that the anterior superior spine lies at a lower level, and in advance of that of the opposite side. (Figs. 255, 256.) At an early age the shortening of the leg, due to the elevation of the trochanter, is from one-half to three-quarters of an inch. In ado- lescence, the elevation is from one and one- Fig. 258. half to two inches, and in adult life it may be considerably more. The effect of the displacement is also shown by a flattening of the buttock, and usually the elevated and prominent trochan- ter may be seen as an abnormal lateral pro- jection, on a level with the anterior superior spine which is, as has been stated, somewhat tilted downward. In childhood, mo- tion in the false joint is more free than normal, and the abnormal mo- bility can be demon- strated by alternate traction and upward pressure on the limb, but as the femur be- comes larger and the upward displacement increases, the mobility is restricted ; the range of abduction is much diminished, and not in- frequently the limb be- comes permanently ad- ducted and flexed, thus adding the apparent shortening of adduction to that caused by the dislocation. (Fig. 259.) Bilateral Dislocation. — When the location is bilateral the shortening is, as a rule, equal or nearly so, and as both femora are displaced backward the pelvis is tilted forward ; thus in compensation " the hollow " of the back is increased, the abdomen protrudes, the Bilateral congeuital dislocation of the hip, showing the exag- gerated lordosis. 380 CONGENITAL DISLOCATION OF THE HIP. buttocks are flattened, the pelvis appears to be abnormally wide and the thighs are separated by a considerable interval. (Figs. 257, 258.) The limp characteristic of the single displacement is replaced by an exaggerated waddle, a ''sailor gait." General Symptoms. — In early childhood there are no especial symptoms other than the limp or the waddle but as the child becomes more active it usually complains of discomfort after exertion. It is easily fatigued and at times it may suffer actual pain. These symp- toms are of course more marked in the double than in the single dis- placement, because in the latter case the normal leg is capable of bear- ing more than its share of the strain. The symptoms often increase during adolescence but they may become less troublesome in adult life, when the head of the bone may have found a permanent resting place on the pelvis ; a security assured, however, by a corresponding limita- tion of the range of motion. But the shortening and the secondary effects of the displacement of course remain, so that the individual Fig. 259. .„-«»^ Congenital dislocation in an adolescent, illustrating ttie flexion-contraction in a well-marked case. is, as compared with the normal standard, more or less disabled and deformed. The great majority of the patients are females and because of the less laborious occupations and the distinctive dress, the disability and its effects are less serious than if the displacement were more equally divided between the sexes. Anterior Dislocation. — The symptoms of the anterior disloca- tion in which the head of the bone lies beneath the anterior superior spine, are much less marked because the relation of the pelvis to the femur is nearly normal, so that secondary deformity is slight. The shortening is less and the resistance of the tissues attached to the an- terior superior spine is sufficient to assure a more secure support than in the ordinary form. Diagnosis. — The diagnosis offers no difficulty. The history of the limp or waddle noticed when the child began to walk and yet unac- companied by pain or preceded by injury or disease, is in itself suffi- BIAONOSIS. 381 ciently distinctive. If the displacement is of one side, measurement demonstrates the shortening as compared with the other limb, a short- ening that is explained by the prominence, and the elevation of the trochanter above Nekton's line. Traction and upward pressure on the leg will demonstrate the abnormal mobility of the displaced head ; and finally if the thigh be flexed and adducted to its extreme limit, the neck and head of the femur can be easily distinguished moving under the gluteal muscles when the leg is rotated. Thus it may be differen- tiated from depression of the neck of the femur (coxa vara), in which, althouo-h the trochanter is elevated, the neck and head of the bone can- Fig. 260. Bilateral congenital dislocation of the hip. not be felt, and in which the abnormal mobility, characteristic of the dislocation, is absent. Again, coxa vara is almost never a congenital affection, therefore the history itself would practically exclude it. Upward displacement of the femur not infrequently follows infec- tious EPIPHYSITIS of infancy or early childhood. In such cases a part of the upper extremity of the bone is usually destroyed so that the head cannot be distinguished on palpation. Although the other physical signs are similar to those of the congenital displacement, the scars about the joint show the evidence of former disease, and the history is almost always available for diagnosis, so that as a rule, such disabilities, as 382 CONGENITAL DISLOCATION OF THE HIP. Fig. 261. well as traumatic dislocations or other results of injury or disease, are readily excluded. (Fig. 217.) The double congenital dislocation presents the same local signs as the single form ; it is even more easily recognized by the peculiar appearance and distinctive gait of the patient. The waddling gait may be simulated by that of extreme bow legs, but the hip joints are, in this deformity, normal in appearance and function. The waddle of lumbae Pott's disease is also somewhat simi- lar, but this is an acquired painful dis- ease of the spine, in which the hip joints are normal in appearance and usually so in function. PSEUDO-HYPERTROPHIC PARALYSIS may be mentioned as causing a some- what similar gait and attitude, but here the resemblance ceases. As has been stated, the diagnosis of congenital dislocation can be easily made by physical examination ; the only real difficulty is experienced in early infancy when the dislocation may be incomplete, but opportunity for such early diagnosis is rarely offered. In doubtful cases a Roentgen picture will demonstrate the character of the disability. (Fig. 260.) Treatment. — Dupuytren in 1829, after a careful study of the anatomy of the deformity, made the statement that it was not only incurable but that pal- liation of its effects even was hardly attainable; and for sixty years the state- ment remained practically undisputed. The term dislocation naturally sug- gests that cure can only be attained by replacement of the displaced bone in its proper place, and in 1890 Hoffa of Wlirzburg first performed this operation with success, by opening the joint from behind and enlarging the rudimentary acetabulum to a size sufficient to contain the head of the bone. Since this time the details of the operation have been modified, particularly by Lorenz of Vienna,* who has written the most complete works on the subject. The radical cure of the dislocation can be accomplished by several procedures : ' Patliologie nnd Tlieray)ie der Angebornen Hiift Verrenkung. Wien, 1895. Ueber heilung der Angebornen Jliiftgelenk Verrenkung. Leipzig u. Wein, 1900. Bilateral dislocation in adolescence. This patient was practically disabled by pain and weakness. TREATMENT. 383 1. The open operation with direct enlargement of the rudimentary acetab^ulum. 2. Forcible replacement and gradual reformation of the joint by functional use. 3. The intermediate operation. The Open Operation. — As a preliminary treatment the head of the bone must be drawn down to a point corresponding to its normal posi- tion, so that the trochanter is on the level of Nekton's line or even below it. In the older subjects, traction in bed by means of adhesive plasters and the weight and pulley, as described in the treatment of hip disease may be employed for this purpose with advantage. (See page 269.) From 10 to 40 pounds of weight may be used according to the age of the patient and the resistance of the tissues. In using this strong traction, excoriations must be guarded against by constant supervision and readjustment of the perineal bands, and by lessening the weight from time to time when it causes discomfort. In younger subjects the tissues may be sufficiently stretched by manual force at the time of operation. A folded sheet is passed beneath the perineum, the two ends of which are held by an assistant at the head of the table, and by means of intermittent and continuous manual traction the resistance of the contracted parts is overcome. The traction machine of Lorenz may be used for the same purpose, but, as a rule, the preliminary extension in -bed is to be preferred to the use of extreme force at the time of opera- tion. When the tissues are sufficiently relaxed to allow the trochanter to be drawn down to its normal position, the joint is exposed by a lat- eral incision about three inches in length, extending downward from a point about three-quarters of an inch to the outer side of the anterior superior spine of the ilium, the fascia is divided and the line of junction between the tensor vaginae femoris and the gluteus medius muscles is found. These muscles are then separated and are drawn to either side by retractors, thus exposing the capsule of the joint. The ilio-psoas muscle, which often covers its anterior surface, is separated from it and the capsule is opened by an incision parallel to the neck of the bone. The finger is then passed through the opening, down upon the rudi- mentary acetabulum. A strong cervix dilator is then inserted and the contracted capsule is thoroughly stretched. If the ligamentum teres is present, it is removed ; a large sharp spoon is then introduced by the side of the finger and the acetabulum is enlarged to its normal size by removing from its interior the fibrous tissue, fat and thickened carti- lage. If the acetabulum appears to be of sufficient size, as is not in- frequent in young subjects, this procedure may be omitted, but in such an event the danger of redisplacement is greater and the limb must be fixed in an attitude of flexion and abduction, as described in the func- tional weighting method. (See the intermediate operation.) If the head of the bone is extremely irregular it may be remodeled, but this is rarely necessary. If there is marked anterior rotation of the neck upon the shaft, the head should be replaced in the acetabu- 384 CONGENITAL DISLOCATION OF THE HIP. lum, the leg being rotated inward to a sufficient degree to prevent re- displacement. Later, by means of a simple linear osteotomy below the trochanter minor, the shaft may be rotated outward and the normal relation of the parts restored. In six instances I have found this secondary operation to be necessary. (See osteotomy.) After the head has been replaced the wound may be closed, but if the acetabulum has been excavated a small opening should be left for drainage as the serous discharge is usually considerable in amount.^ A plaster of Paris spica bandage is then applied, the leg being fully ex- tended, somewhat abducted, and rotated as a rule slightly inward, so that the head of the bone may be completely contained within the new acetabulum. The first band- FiG. 262. age usually remains in position for about eight weeks; it is then replaced by one which reaches to the knee only, and the patient is encouraged to bear the weight on the limb. At the end of another month or longer, when it may be supposed that repair is com- plete and when the joint is no longer sensitive to direct man- ipulation, the spica is removed. If possible regular massage and methodical exercises with the aim of stimulating and strengthening the disused and misplaced muscles, should be begun and continued for a year, or longer if necessary. After the open operation the range of motion is at first much limited and forced man- ipulation causes pain. There is also in many instances a tendency toward flexion and adduction. This is due in part to the original traumatism of the opera- tion, in part to the weakness of the abductor and extensor muscles, and in some instances to the depression of the neck of the femur that may be present. This tendency toward deformity must be resisted by massage and manipulation and by the use of apparatus if necessary. A useful form of appliance for the purpose of holding the leg in the proper attitude, is a simple jointed leg brace attached to the shoe and to a pelvic band. (Fig. 263.) If the contraction is resistant forcible manipulation under anaesthesia may be required. 1 Hoffa does not close the wound, but packs it lightly with gauze. Scoops used in the treatineut of congeuital dislocation, also the subcutaneous osteotome. TREATMENT. 385 After the operation the legs may be equal in length, but there is as a rnld a shortening of about a half inch caused by the excavation of the acetabulum and by the depression of the neck of the bone. A limp persists for a year at least and usually longer, the successful functional result being dependent upon the age of the patient and upon the care that has been exercised in the after-treatment. As a rule traces of the former disability will remain in most instances throughout Fig. 263. Fig. 264. Fig. 265. A successful result after the open operation. Shows a useful form of brace to be used in the after-treatment. Eight months after operation by the open method. Bilateral dislocation six mouths after rejilace- ment by the open method. Illustrating the change in the contour of the trunk. life because of the abnormalities of the head and neck of the bone or elsewhere, but in a large proportion of suitable cases, practical cure may be obtained, and in all the progress of the deformity may be checked and the symptoms relieved because the head of the bone has been provided with a secure resting place in its normal position. Re- lapse is unusual if the operation has been properly conducted, unless the neck of the bone is displaced forward in its relation to the shaft so 25 380 CONGENITAL DISLOCATION OF THE HIP. that it may be impossible to retain the head iu the acetabulum unless the foot is rotated inward. The danger of the operation is slight, and the deaths with but few exceptions have been due to infection. Lorenz and Hoffa lost several of their earlier patients from this cause, but with improved technique the danger is slight.^ The bad results of the operation may, as a rule, be accounted for by its improper performance, particularly the failure to replace the femur securely, or by failure to insure asepsis, or by in- efficient supervision and after-treatment. It is perhaps unnecessary to state that operations of this character should not be performed unless asepsis can be assured, unless the oper- ator is familiar with the anatomy of the parts and unless the essential after-treatment can be provided. The prognosis in bilateral displacement is much less hopeful than in the single displacement for the evident reason that the original dis- ability as well as the chances of operative mishap are twice as great. Reduction of the Dislocation without Open Operation. The " Func- tional Weighting Method of Lorenz." — The Lorenz treatment is based upon the theory that if parts about the joint may be sufficiently stretched to allow the head of the bone to be brought into direct con- tact with the rudimentary acetabulum, and if it can be held in this position, the weight of the body, in walking, constantly forcing the bone against the substance that partly fills it, will gradually enlarge it to its normal capacity; thus it is called the "functional weighting" method, and this is its essential and vital distinction from the forcible correction of Paci, with which it is often confounded. The steps of the operation are : 1. Elongation of the limb. — The trochanter must be brought down to the level of Nekton's line or lower. This may be accomplished by preliminary traction in bed with heavy weights, or by manual force at the time of operation, the latter means being efficient in young subjects. The child having been anaesthetized, a folded sheet is passed between the legs and the two ends are held above the shoulder of the side to be operated upon, or the assistant may clasp his hands about the perineum and thus fix the pelvis. One then seizes the thigh and begins a series of alternate stretchings and relaxations, using gradually increasing force for from ten to twenty minutes, or until the resistance of the tissues is entirely overcome. The leg is then as long or longer than its fellow and lies limp in an attitude of abduction. For this preliminary extension Lorenz uses a powerful machine at- tached to the leg by means of a band about the ankle, but I am inclined to think that the manual method is to be preferred if one does not ob- ject to the labor that it involves. 2. Reposition. — One now attempts to force the head of the femur 1 Hoffa has performed the operation 248 times with 10 deaths — 8 due to the opera- tion, the last 132 operations without a death. Lorenz in 260 operations lost 4 patients from septicEemia. — Report of the Thirteenth International Congress, Paris, August, 1900. THE LORENZ OPERATION. 387 over the ridge that represents the posterior margin of the acetabulum and ihrough the opening in the contracted capsule. The thigh is flexed to about ninety degrees in order to relax the cap- sule ; it is then gradually and forcibly abducted under traction to the limit of the range, or slightly beyond even, so that the head and neck of the bone may lie in the same plane with the side of the pelvis ; the thigh is then rotated slightly inward so that the head of the bone may point toward the opening in the capsule, and while trac- tion upon the thigh is continued with one hand the other exerts pres- sure upon the trochanter and head of the displaced bone, Avhich is then lifted and drawn over the obstacle formed by the rim of the acetabulum. If this is successfully accomplished one hears and feels a distinct sound and shock, and the leg remains fixed in an attitude of flexion and ab- duction. From this semi- replacement the bone is at Fig. 266. once displaced when the leg is adducted or extended. 3. Acetabulum For- MATiox. — One now at- tempts to enlarge the open- ing of the acetabular part of the capsule. While the head of the bone is forced against or through the open- ing, the thigh is forcibly rotated outward again and again, and extended to its full limit, in order that the anterior wall of the capsule, which is drawn tightly across the depression, may be distended and the capac- ity of the new articulation increased. Finally, the pa- tient is turned upon the side and direct pressure is ex- erted on the trochanter while the limb is alternately flexed and extended. When the manipulation is completed, the leg is fixed in the attitude of extreme abduction, moderate flexion and inward rotation, by a firm plaster spica bandage extending to the knee, or preferably, slightly below it, the leg being flexed somewhat on the thigh. This longer bandage insures better fixation, and prevents the tendency to outward rotation, although it interferes somewhat with locomotion. At the time of operation one is able to make a fair prediction as to Unilateral dislocation, showing the attitude in the early stage of the Lorenz treatment. 388 CONGENITAL DISLOCATION OF THE HIP. its outcome from the character of the reposition and its stability. In some instances the head of the bone seems to be actually replaced in a sufficient cavity, in others, it appears to slip from side to side with but little indication of fixation. In properly selected cases the operation is free from danger,^ and the Fig. 267. Unsuccessful treatment by forcible correction. (Lorenz operation.) The posterior has been changed to an anterior displacement. Rear view. ' Several deaths from the ansesthetic employed have been reported, three of these by Lorenz, and a number of accidents have been caused by violence in the attempt to reduce the displacement in adolescents. THE LOBENZ OPERATION. 389 pain and discomfort are much less than one would expect after the force 'that has been employed. Occasionally there is some discoloration about the adductor region, but this is practically the only noticeable evidence of the manipulation. As soon as possible the child is encouraged to stand and to walk, the awkwardness caused by the extreme abduction being somewhat lessened by a cork sole, an inch or more in thickness, on the other shoe. The first bandage should remain in place, if possible, for six weeks or longer. When it is removed, one examines the relation of the parts ; if the reposition has been unsuccessful the head of the bone may be felt beneath the anterior superior spine ; the posterior has been transformed simply into an anterior displacement. In such cases the operation may be repeated, but in my own experience the secondary operation has never been successful. If the head of the bone appears to be in its proper position, the bandage is again applied. At the end of another month or more, and with each successive change thereafter, the extreme attitude of abduction may be somewhat lessened, until, at the end of eight or ten months, the normal attitude of the limb is restored. The plaster bandage is then removed, but it is well to re- place it by a simple jointed brace attached to the shoe and to a pelvic band, by this means the foot may be rotated slightly inward and mod- erate pressure may be exerted on the trochanter. (Fig. 263.) During the course of treatment a failure in reposition usually be- comes evident, and in any event success is not assured until after all support has been removed. Roentgen pictures are, of course, of service in showing the true relation of the parts, if they are available. As this operation was first performed in 1895, sufficient time has not elapsed to report definitely upon final results. But in selected cases I am inclined to believe that about 25 per cent, of the patients may be cured by this means alone. The treatment of bilateral displace- ment by this method is less satisfactory. As a rule it is advisable to operate upon but one hip at a time. It should be stated that a method of forcible correction, preceding that of Lorenz, was introduced by Paci of Pisa in 1887.^ Another, and somewhat similar, system is practiced by Schede.^ As these methods are less definite and satisfactory than that of Lorenz, a detailed account of them is unnecessary. If the simple operation is unsuccessful, it must be supplemented by the open method. This will be necessary in the larger proportion of cases, particularly in older subjects, but the second operation will be much simpler and more easily performed because the preliminary treat- ment will have improved the relation of the parts. The great advantage of this treatment is, that it can be applied as soon as the diagnosis is made, for being free from danger and not ne- cessitating a cutting operation or confinement to a hospital, the consent 1 Archiv di Ortop., 1892, p. 420. zArchiv f. Klin. Chir., Bd. 43, 1892. 390 CONGENITAL DISLOCATION OF THE HIP. of parents is readily obtained ; this is certainly not true of the older method. There is also another advantage, in that the muscles become accommodated to the changed relations of the parts while the leg is fixed by the plaster bandage, so that the long-continued supervision and gymnastic training, that are essential after the open operation, may be dispensed with. Even if the operation has merely resulted in Fig. 269. changing a posterior into an anterior displacement, it may be classed as Fig. 268. HlW^ ^ Unilateral disloeatiou. Two years after operation by the Lorenz method. A complete cure. Unilateral dislocation. Eighteen months after operation by the Lorenz method. A complete cure. a half cure, since the deformity of the spine is checked and the short- ening of the leg is much reduced. The Intermediate Operation. The uncertainty of the forcible operation on the one hand and the limitation of motion and distortion that may follow the enlargement of the acetabulum on the other, suggest the desirability of an intermediate REVIEW OF THE TREATMENT. 391 operation which may combine in some degree the advantages of each. Such is the operation of simple replacement by means of open incision. The operation is identical with that described except that the acetab- ulum is not enlarged, and that the further details of the non-bloody operation are followed. The limb is fixed in a position of abduction and inward rotation, although not in as extreme Fig. 270. degree as when the open incision has not been employed. Fig- 271. Secondary Osteotomy. ^ \ If on examination during the open operation the neck of the femur is found to be anteverted to a marked degree, its relation to the shaft must be restored, otherwise the anterior displace- ment is inevitable when the limb is replaced in the proper attitude. To accomplish this the shaft of the femur may be divided by the subcutaneous osteotome just below the trochanter minor, a long slender drill is then inserted through the trochanter into the neck of the femur. This controls the upper fragment and indicates its position. The shaft is then rotated outward to the proper de- gree and a plaster spica bandage is applied, through which the drill projects. In a few days it may be removed. The details of the after-treatment do not differ from those of the ordinary cases. Review of the Treatment of Congenital Dislocation of the Hip. — The prospect of success in treatment stands in direct relation to the age of the patient, since the extent of the pathological changes that make cure difficult or impossible, depends in some degree, as in acquired dislocations, upon the duration of the disability. Conse- quently treatment should be applied as soon as the displacement is discovered, and, as has been stated, there is little excuse for not mak- ing the correct diagnosis as soon as the child begins to walk. The treatment of selection, before the age of six years, is the functional weighting method of Lorenz. By this means a certain proportion of the cases may be cured, and in all instances the posterior may be changed into an anterior displacement, which makes the after-treat- W>^ boXi^ Unilateral disloca- tion. After operation by the Lorenz method. A complete cure. Com- pare with Fig. 255. Unilateral disloca- tion. Two years after operation. Compare with Fig. 256. 392 COXA VARA. raent much easier. If this treatment is ineifective, it should be fol- lowed by the open method. In the younger patients, simple incision and forcible stretching of the capsule may be sufficient, if the acetab- ulum is well formed ; if not, it will be necessary to enlarge it to the normal size. The same system may be followed in older children, but the simple correction is much less likely to be successful although cures have been reported at ages far beyond this limit. As a rule then, in this older class the open operation may be performed primarily, the operation being preceded if possible by traction in bed, so that all con- tractions may be completely overcome. In patients beyond the age of tfen years the prognosis is very doubtful, although the treatment may be attempted in suitable cases. All other methods of treatment, by long-continued traction in bed, by braces for support or pressure — by tenotomy and scarification of the part — by " sclerogenous injection " and the like, have been practically abandoned. For simple palliation a corset which lessens the exaggerated lordosis and provides pressure over the trochanters is of some service in the double dislocation. Some form of brace attached to the shoe by which the weight of the body is supported on a perineal strap as described in the treatment of the convalescent stage of hip disease, and which ex- erts pressure on the trochanter may be employed in the single form supplemented by exercises and by massage. By such means the progress of the deformity may be checked and some improvement in the position and stability of the bone may be assured, although increase of the deformity may be expected when the treatment is discontinued, A " high shoe '' to equalize the length of the limbs, to lessen the limp and to prevent permanent distortion of the spine is indicated also. Over-exertion and laborious occupations should be avoided. This is of especial importance during childhood and adolescence when the ten- dency toward an increase of the disability is most apparent,^ Coxa Vara. Synonyms, — Depression or incurvation of the neck of the femur. Bending of the neck of the femur. The character of this deformity is indicated by the synonyms, while the term coxa vara signifies that its causes and effects are similar to those of genu valgum and varum, the more common distortions of the lower extremities. Genu valgum and varum are common in childhood, but rarely de- velop in adolescence. Coxa vara is, in comparison, not only an infre- quent deformity, but it is peculiar also in that it more often appears in later childhood or adolescence than at the earlier period, doubtless because the neck of the femur is, at the age when rhachitic distortions are common, very short and is relatively stronger than the shaft, while in adolescence the conditions may be reversed. ' The bibliography of the subject may be found in the volumes of the Zeits. fiir Orth. Chir. ETIOLOGY. 393 The distortions at the knee are self evident, but the neck of the femur .is concealed from view, thus the diagnosis of coxa vara may be somewhat difficult ; and in fact, it is only in very recent years that its symptoms have been recognized. Fiorani ^ first described the deform- ity as it had been observed by him in children, but E. Miiller ^ first called attention to the aifection as one of the deformities of adolescence, which, until that time, had been mistaken for hip disease. Pathology. — The term coxa vara should not be applied to depres- sion of the neck of the femur that may be secondary to destructive disease ; for example, to osteomyelitis, arthritis deformans and the like, but it should be reserved for cases of simple local deformity. Fig. 272. In most instances the deformity affects the neck as a whole, in others it is most marked at the epiphyseal junction. A number of specimens have been examined but no changes, other than such as might be caused by the deformity itself, have been found. These are, in brief, congestion and soften- ing of the bone, and evidences of irritation within the joint during the progressive stage of the defor- mity and the general adaptive changes in all the components of the joint that always accompany displacement or distortion. Etiology. — Some writers as- sume that the weakness of the neck of the femur that induces the deformity is the result of local disease such as so-called local rickets, or local osteomalacia. This is however simply a conve- nient hypothesis. Others believe the deformity to be symptomatic of late rickets ; but evidence of general rhachitis is almost never present in the ordinary type of cases. Coxa vara is one of the group of static deformities of the lower ex- tremity caused by a disproportion between the strength of the sup- porting structure and the burden that is put upon it. The support may be disproportionately weak because of inherited delicacy of struc- ture, or it may be weakened by injury or by disease, or over-burdened by weight or strain. Mechanical Predisposition to Deformity. — In many cases the predisposition to deformity is the result of a lessened angle of ' Gazetta degli Ospitale, Nos. 16-17, 1881. 2Beitrao:e zur Klin. Chir., 1889, Bd. 4. 3 Humphrey, Jour. Anat. Pliys., Vol. XXIII., p. 236. Section of the upper extremity of a normal femur at eight years of age ; angle formed by the neck with the shaft 140 degrees. In the normal subject the neck of the femur projects sliglitly for- ward (12 degrees), and upward to form an angle with the shaft of about 125 degrees. In childhood this angle is usually somewhat greater, and in later years it may be somewhat less than 125 de- grees ; in fact a variation between 110 and 140 de- grees may be within the normal limit. ^ 394 COXA VARA. the femoral neck. This slight and predisposing depression which ap- pears to be, in many instances, the effect of early rhachitis, becomes exaggerated to deformity during later childhood or adolescence. The importance of this mechanical factor in the etiology was demonstrated to me by the investigation of a number of cases of simple fracture of the neck of the femur in childhood. In these cases the neck of the femur was, by the original injury, somewhat depressed, and although complete functional recovery followed, yet in a number of the cases, progressive deformity, attended by the symptoms of typical coxa vara, resulted. This could be explained only on the theory that the lessened angle, subjecting the part to greater strain, was the predisposing cause of the later disability. Other factors in the etiology may be general weakness, incident to rapid growth, direct injury or the strain of occu- pation.^ In this connection it may be stated that fracture of the neck of the femur in childhood may cause a deformity which in the absence of a history could not be distinguished from the ordinary form of coxa vara, of which in fact, it is the traumatic form. (See fracture of the neck of the femur.) Statistics. The deformity is far more often unilateral than bilateral and more than three-fourths of the cases are in males. In a total of 109 casea (collected from the literature, including 39 personal observations, 83 were in males and 26 in females ; 85 were unilateral and 24 were bi- lateral. The more important details in the 39 cases that have come uader my observation, are presented in the accompanying table. The points of especial interest may be summarized as follows : In about one-third of the cases there was a distinct history of rhachitis in infancy. The ages at which the symptoms became noticeable ap- peared to be as follows : Adolescents, 12 to 17 20 Later childhood, 5 to 11 13 Early childhood, less than 5 6 Unknown 1 Total M 29 of the patients were males, 10 were females. In 33 cases the deformity was unilateral, in G it was bilateral. In 34 cases the neck of the femur was distorted in a direction backward as well as downward, in 2 directly downward, in 3 forward and downward. In each case of the last group the deformity was bilateral. (See table, page 395.) Symptoms. 1. Mechanical Effects. — The character of the symptoms may be explained by a description of the distortion and of its direct effects upon the function of the joint. When the neck of the femur is depressed, for example, to a right angle with the shaft, ' One case of congenital coxa vara has been reported by Kredel (Cent, fiir Chir. , N. 42, 1896). Depression of the neck of the femur in congenital dislocation of the hip has been mentioned in the section on that affection. SYMPTOMS. 395 .. •! M 0) ^ 6 months Post. p Y Yes 2 Van Orden June 1896 M. R. 4 1 year Post. % No 3 Zeltermann Jan. 1898 M. R. 7 6 months Post. /2 y Yes 4 Vitt Mar. 1897 M. L. 7 6 months Post. 1 1 Yes 5 Tuit July 1899 F. L. ^y^ 6 months Post. Yi % Yes 6 Seeger Mar. 1897 F. L. 8 2 years Post. 1 1 No 7 Rose Jan. 1888 F. D. 8 3 years Post. _ — No 8 Cohen June 1898 M. R. 8 6 months Post. y-i y Yes 9 Kebesky Aug. 1900 M. L. 8 6 months Down'd ^ y Yes 10 Dengher July 1900 M. R. 8 1 year Down'd y^ y^ Yes 11 Hirsch Mar. 1897 M. D. 9 2 years Ant. Yes 12 Reardon Mar. 1898 M. D. 11 6 years Ant. — — Yes 13 Beckmyer Mar. 1895 M. D. 11 8 years Post. — — Yes 14 Brill Mar. 1894 M. R. 11 1 year Post. 1 1 No 15 Greer Jan. 1896 M. L. 12 8 years Post. 1 1 Yes 16 Thomas Mar. 1898 F. D. 12 1 year Ant. R. % ?4 Yes 17 Abrams Mar. 1898 F. R. 13 10 years Post. 2 ? No 18 Rutschmann July 1896 M. R. 13 6 months Post. y-i No 19 Fraad Nov. 1894 M. R. 13 1 year Post. 34 y No 20 Shandley Dec. 1898 F. R. 13 1 year Post. i IK 21 Skid more Nov. 1899 M. L. 13 3 years Post. K 1^ 22 Cords May 1900 M. R. 14 3 months Post. y^ ^y Yes 23 Cunningham May 1897 F. L. 14 1 year Post. Yi ^y No 24 Herbert Apr. 1897 M. R. 14 6 months Post. 1 1 No 25 Bruning Oct. 1897 M. R. 15 2 months Post. y-i 1 No 26 Betz! June 1892 M. R. 15 1 year Post. % 3 No 27 Lawson Oct. 1897 M. R. 15 ] year Post. 9% '^ No 28 Rose Jan. 1896 M. L. 15 14 months Post. % No 29 Allen Apr. 1897 M. L. 16 1 month Post. 1 IK No 30 Puckhaber June 1893 M. D. 16 8 months Post. — Yes 31 Gieger May 1900 M. L. 16 6 months Post. y iM No 32 Schade July 1898 M. L. 16 18 months Post. 1 1 33 Morris Jan. 1900 M. R. 17 6 months Post. 34 S No 34 Jocker Dec. 1899 M. L. 17 1 month Post. ^ No 35 Beck July 1898 F. R. 17 1 year Post. ll 1% No 36 Zimmermann Oct. 1896 M. R. 17 13 months Post. 1 2^ No 37 Fessner Mar. 1894 M. L. 17 6 months Post. % No 38 Enderlich Jan. 1897 F. R. 22 1 year Post. % 1 No 39 Adult Mar. 1896 M. R. 36 Post. 1 IK No the trochanter is elevated to a corresponding degree above N§la ton's line and forms a noticeable projection as contrasted with the normal contour (Fig. 276), a projection that becomes more marked when the thigh is flexed and adducted. (Fig. 275.) In most instances the neck is displaced backward as well as downward, following the line of least resistance, and as the head of the bone remains in the acetabulum the trochanter is thrown forward and the limb is rotated outward. The ability to abduct the thigh is dependent upon the length and upon the upward inclination of the femoral neck (Fig. 154); when, there- fore, this inclination is diminished the range of abduction is lessened, in part by the greater tension that is exerted upon the lower portion of the capsule, in part by the direct contact (Fig. 273) of the rim of the acetabulum with the neck and trochanter and in part by the adaptive contractions that always accompany displacements of this char- acter. It is evident also that the distortion of the neck backward and downward changes the relation of the acetabulum to the head of the bone, so that abduction or flexion tends to displace it from its socket. Thus the range of abduction, of inward rotation and of flexion is limited, while that of adduction, outward rotation and extension, may be increased. 396 COXA VABA. There is actual shortening of the limb dependent upon the upward displacement of the shaft of the femur ; this is not often more than an inch in the ordinary type of adolescent deformity, but the apparent shortening, caused by the adduction and the accommodative upward tilting of the pelvis, may be extreme, from two to three inches is not uncommon, (Fig. 276.) 2. Physical Effects. — The symptoms of coxa vara of the ordinary form, are : Discomfort, awkwardness, limp, shortening, atrophy, limita- tion of motion, deformity. Coxa vara is a more disabling deformity than genu varum or val- gum and its attendant symptoms of discomfort, weakness and pain, are, as a rule, more marked. This is explained by the fact that in Fig. 273. Skiagram of coxa vara, deformity most marked at the epiphyseal junction. This illustrates the me- chanical limitation of abduction caused by the deformity, and the compensatory tilting of the pelvis. The patient is shown in I<"ig. 276. coxa vara, the head of the bone is in part displaced (Fig. 274) from the acetabulum, while in the deformities at the knee the joint surfaces remain in practically normal relation to one another. The symptoms of unilateral coxa vara vary with the degree and with the duration of the deformity. , The patient usually complains of sen- sations of stiffness and weakness, referred to the thigh. These are more noticeable on changing from a position of rest to one of activity and at times, particularly after over-exertion, there may be actual pain. By far the most important symptom and the one that almost always induces the patient to seek treatment, is the limp. This limp accom- panied, as it usually is, by outward rotation of the foot, resembles that caused by fracture of the neck of the femur. On physical examina- OTHER VARIETIES OE COXA VARA. 397 tion the actual shortening, explained by the elevated and prominent trochanter and the peculiar unequal limitation of motion, will make the diagnosis clear. In some instances there may be a slight degree of mus- cular spasm and there is usually some atrophy of the muscles of the thigh. Bilateral Coxa Vara. — If the deformity is bilateral its effect upon the gait and attitude is more marked. The gait is extremely awkward, resembling somewhat that of knock knees, for the limitation of abduc- tion forces the patient to sway the body from side to side in order that the legs may pass one another, and if the deformity is extreme the limbs may be crossed over one another, so that locomotion may be difficult. Bilateral coxa vara is not infrequently accompanied Fio. 274. by other deformities, as, for example, knock knee or flat foot. (Fig. 277.) Other Varieties of Coxa Vara. — In rare in- stances the neck of the femur may be depressed directly downward or even down- ward and forward. In the latter instance the effect of the deformity upon the func- tion of the joint is some- what different from that of the ordinary type. Abduc- tion is limited as in the common form, but inward rotation replaces outward rotation and extension is limited in place of flexion. This type of deformity is almost always bilateral. It is accompanied, usually, by slight permanent flex- ion of the thighs ; thus the lumbar lordosis is exaggerated, whereas, in the ordinary form, it is usually lessened. This description applies to the ordinary types of the deformity as it is seen in later childhood and in adolescence. It undoubtedly occurs in early life, but it is masked by the more noticeable dis- tortions of other parts, and as an isolated deformity that demands treatment, it is rare. One case was observed by the writer in a rhachitic child two and one-half years of age. The symptoms, though slight, were typical, and the diagnosis was confirmed by a Roentgen picture. In other cases seen in later childhood, the history of more or less discomfort for many years, seemed to indicate that the deformity was caused directly by rhachitis. Cross section of the pelvis and the deformed femur. A scheme to show the effect of the deformity in limiting ab- ductioa of the limb. The dotted outline shows the normal relation. 398 COXA VARA. In the majority of cases the symptoms begin insidiously although in many instances they may be ascribed to injury or to over-exertion. If the affection begins in adolescence and is untreated, the period of discomfort during which the depression of the neck may be assumed to be progressive, is from one to three years ; but if the deformity appears at an early age, the symptoms, though remittent in character, may continue indefinitely. When the resistance of the compressed bone Fig. 275. Coxa vara, showing prominent trochanter. Fig. 276. %A^ Case II. Shows the tilting of the pelvis and the apparent shortening of the leg in unilat- eral coxa vara. Actual sliort- ening%inch ; apparent short- ening25^ inches. See skiagram (Fig. 273). becomes sufficient to insure stability, the discomfort ceases and the dis- ability becomes less marked, as Nature accommodates the mechanism to the new conditions. Diagnosis. — In most instances diagnosis may be easily made, and yet coxa vara is very often mistaken for hip disease ; in fact we are indebted to this mistake for most of the specimens of the deformity that have been described. The essential differences between the two TREATMENT. 399 are as follows : In tuberculous disease of the hip the motions of the joint are limited in every direction by reflex muscular spasm, and as a rule, other evidences of the character of the disease are apparent. Coxa vara is a simple deformity ; reflex muscular spasm is absent, except during exacerbations due to injury or over-strain, and movement is not limited in all directions, but only in abduction, flexion and inward rotation when the deformity is of the ordinary type. Actual short- ening is a late symptom of hip disease, while it is present from the very onset of coxa vara. It is a shortening explained by the eleva- tion of the trochanter above Nelaton's line, while such elevation in hip disease is a sign of de- struction, either of the Fig. 277. head of the bone or of a part of the acetabulum. The deformity might be readily mistaken for congenital dislocation of the hip, particularly of the anterior variety, but this would be excluded by the history, since coxa vara is an acquired deformity. The diagnosis between the two affections may be easily made on the physi- cal signs alone. In conge- nital dislocation, if the leg be flexed and adducted to its extreme limit, the head and neck of the displaced bone can be distinguished beneath the distended tissues of the buttock. In coxa vara, nothing but the prominent trochanter can be made out on similar manipulation, while the abnormal mobility, characteristic of the dislocation, is absent. Treatment. — If the deformity were discovered in the early stage, one might hope to check its progress by a change in the surroundings and occupation of the patient. Standing, particularly in the attitude of rest, which throws additional weight upon the weakened part, should be avoided, and work of any kind that induces the familar symptoms of strain should be discontinued. As much time as possible should be spent in the open air, and diet and proper therapeutic remedies should be employed if evidence of constitutional weakness or rhachitis is pres- ent. Locally massage of the limbs and joints and forcible manipula- tion, with the aim of overcoming as much of the adduction as may de- pend upon the secondary changes in the soft parts, should be employed, reinforced by regular gymnastic exercises of the legs, with the object Double coxa vani, of advanced degree, showing the involun- tary crossing of the legs in flexion. 400 COXA VARA. of improving the circulation upon which the repair of the weakened bone depends. In most instances of unilateral deformity temporary support is indi- cated. A perineal crutch (Fig. 204) or, if the circumstances of the patient permit, one of the convalescent hip splints that allows motion at the knee, may pf^^. 279 be used. (Fig. 205.) With support dur- ing the time of greatest strain, that is, when continuous walking or standing may be required, combined with proper exer- cises and massage, the weak part may be- Fio. 278. Unilateral coxa vara, showing the eflfect of slight depression of the neck of the left femur upon the attitude. (bee tig. 279.) The patient, Fig. 278, eight months after cuueiforni osteotomy. An abso- lute cure both as regards symptoms and deformity. See skiagram (Fig. 280). come sufficiently strong to perform its function in a year or more, but supervision will be necessary for a much longer time. Operative Treatment. — When the deformity has advanced so that the leg is permanently adducted, operative treatment is indicated. Linear Osteotomy. — The simplest and most efficient means of overcoming the adduction in older subjects is linear osteotomy of the OPERATIVE TREATMENT. 401 shaft of the femur just below the trochanter minor. This may be per- formed, by the subcutaneous method, as in the correction of the de- formity of hip disease. When the bone has been divided the shaft is rotated inward until the foot is brought to the normal attitude and it is then abducted to the normal limit ; in this attitude a plaster spica bandage is applied reaching from the axilla to the toes. If the deformity is bilateral it is often sufficient to operate on the leg which is most affected. When the fracture is consolidated, mas- sage, exercises and support are employed as has been described. It may be assumed that the increased blood supply necessitated by the repair of the injury will affect favorably the weakened bone as well. Fig. 280. Skiagnuu ofpiitient, Figs. 278 iiud 279. lUuslratiug the ellect. ol' Lhe operiiliou iu repliiciiig the neck of the femur in its normal position. The final result in two cases, in which the operation was performed by the writer, was very satisfactoiy. Cuneiform Osteotomy. — In youistgee patients the deformity may be remedied and its progress checked by removal of a cuneiform sec- tion of bone from the upper extremity of the shaft at the level of the trochanter minor. (Fig. 281.) In childhood the neck of the femur is short and the strain to which it is likely to be subjected slight, thus op- erative treatment may be indicated as a prophylactic measure while in adolescence operative treatment may be deferred until the progression of the deformity has ceased. jJJEn the technique of this procedure there are several points of im- portance. First, all restriction of abduction, of ligamentous or mus- 26 402 COXA VARA. cular origin, must be overcome by vigorous manipulation before the operation on the bone, otherwise it will be difficult to bring the two fragments into proper apposition. The base of the wedge should be about three-quarters of an inch in breadth, directly opposite the tro- chanter minor ; the upper section should be practically at a right angle with the shaft, the lower being more oblique. (Fig. 281, 2.) The cor- tical substance on the inner aspect of the bone should not be divided, but, reinforced by the cartilaginous trochanter minor, should serve as a hinge on which the shaft of the femur is gently forced outward, until the opening is closed by the apposition of the fragments after the up- per segment has been fixed by contact with the margin of the acetab- ulum (Fig. 281 , 3) ; thus the continuity of the bone is preserved. The leg is then held in the attitude of extreme abduction, by means of a plaster spica bandage, which should include the foot also, until the union is firm. The opportunity for treatment of coxa vara, in earliest childhood, is rarely offered. It is usually the direct result of rhachitis and in the early stage, at least, it is probably accompanied by other rhachitic dis- tortions. It would be well, therefore, to examine the hip joints of rhachitic children, especially those who present the deformity of genu valgum with reference to this distortion.^ FRACTURE OF THE NECK OF THE FEMUR. Traumatic Coxa Vara. Fracture of the neck of the femur in childhood, although until re- cently unrecognized, is by no means an uncommon accident, since seventeen cases have come under the waiter's observation during the past nine years. Fracture of the neck of the femur in childhood, how^ever, differs markedly in its symptoms and in its effects from that in later life. In childhood the immediate effects of the injury are far less disabling and the patient is often able to walk about within a few days after the accident, from which it may be inferred that there is, in many instances, a bending and breaking of the neck without actual separation of the fragments. During the period of repair the limp and attendant dis- comfort are usually mistaken for symptoms of hip disease. The diagnosis is usually simple. In all the cases there is a history of injury, usually a fall from a height, which confined the patient to the bed for several days or weeks. On physical examination shorten- ing of half an inch to an inch is found, explained by the corresponding elevation of the trochanter. Motion in the joint is more or less re- strained by voluntary and involuntary contraction of the muscles, but this restriction is much more marked in flexion, abduction and inward rotation than in other directions ; a limitation explained by the nature -The bibliography of the subject, to the extent of 127 references, may be found in a recent article by Wagner in Zeits. fiir Orth. Chir., Bd. Vlil., H. 2, 1900. TRAUMATIC COXA VARA. 403 of the displacement, the neck of the bone having been forced down- ward and backward. The immediate effect of the injury is, as has been stated, less marked than in the adult, but the tendency of the deformity is to increase in later years, because the right-angled relation of the neck to the shaft exposes it to greater strain. In a number of the patients examined several years after the injury, there was an increase of the actual shortening combined with permanent adduction. At this time the de- formity could not have been distinguished, except for the history, from the ordinary coxa vara of a rather extreme degree. The treatment of the fracture of the neck of the femur, if the diag- nosis is made immediately after the accident, should include an attempt Fig. 281. 1, the normal femur ; 2, depression of the neck of the femur— coxa vara ; A, a wedge of bone has been removed ; 3, abduction of the limb first fixes the upper segment by contact with the rim of the acetabulum, then closes the opening in the bone ; 4, replacement of the limb after union is completed elevates the neck to its former position. to replace the neck in its proper relation with the shaft in order that subsequent deformity may be prevented. This may be accomplished, if at all, by forcing the limb into abduction while traction is exerted, and in this position a plaster bandage, reaching from the axilla to the toes, should be applied. After consolidation of the fracture a traction hip splint may be worn for several months or until complete repair has taken place. Massage and forcible manipulation, if limitation of motion remains, combined with the avoidance of over-strain, may prevent the increase of the de- formity. Otherwise the neck of the femur should be replaced in its normal position by the removal of a sufficient wedge of bone from the 404 COXA VARA. base of the trochanter as described under the treatment of simple coxa vara. (Fig. 281.) Traumatic Separation of the Epiphysis of the Head of the Femur. — As has been stated, in traumatic depression of the neck of the femur the bone breaks or bends at about the center of the neck, which in child- hood is but little more than an inch in length. In exceptional cases the head of the femur may be separated at the epiphyseal line. This disjunction is more likely to occur in adolescence and particularly in subjects suffering from coxa vara in the early stage. Thus sudden disability, following slight injury, in an adolescent who has complained of discomfort and limp for some time before and who presents on ex- amination the signs of depression of the neck of the femur, would lead one to consider the possibility of this accident ; but the diagnosis could be established only by a Roentgen picture or by operation.^ The treatment is similar to that of fracture, but the functional de- rangement of the joint is likely to be greater for the reason that the articulating surface of the head of the femur is involved.^ 1 Sprengel, Archiv f. Klin Chir., Bd. 47, S. 805, 1898 ; Clarke, Lancet, Oct. 27, 1900. 2 Whitman, The Medical Eecord, Julv 25, 1893 ; Annals of Surgery, June, 1897. and February, 1899. CHAPTER XV. DEFORMITIES OF THE BONES OF THE LOWER EXTREMITY. Of the distortions of the lower extremity bow leg and knock knee are by far the most common, comprising about 15 per cent, of the total cases in orthopaedic clinics. Of the two, bow leg is the more frequent in all tables of statistics, and it is probable that the proportion of bow leg to knock knee is much larger than would appear from the hospital records ; for genu valgum is generally recognized as a serious deform- ity, while bow leg is known to be of little consequence except from the aesthetic standpoint, so that its rectification is more often trusted to the power of nature. Both deformities appear to be more common in male than in fe- male children, a fact explained perhaps by the greater weight and the greater susceptibility of the former. But here again statistics may be influenced somewhat by the fact that bow legs are considered to be of more consequence to the boy than to the girl because of the conceal- ment that the skirts will insure, if the distortion is not outgrown in childhood. Statistics. — The relative frequency of the two deformities may be in- dicated by the statistics of the Hospital for Ruptured and Crippled for the past ten years. During this time 5,441 cases were recorded, 3,452 cases of bow legs (63.4 per cent.), 1,989 of knock knees (37.6 per cent.). Of the 3,452 cases of bow legs, 2,030 were in males (58.8 per cent.) and 1,422 were in females (42.2 per cent.). The 1,989 cases of knock knees were more evenly divided between the sexes, 1,024 being in males (51.4 per cent.) and 965 in females (48.6 per cent.). Bow Legs. Year. No. cases. Males. Females. Over 21. Over 14. 1 1899 400 236 164 5 2 1898 406 255 151 2 3 1897 467 268 199 4 1 4 1896 356 200 156 1 5 1895 336 200 136 2 1 6 1894 310 170 140 2 7 1893 262 157 105 3 8 1892 306 189 117 2 9 1891 303 174 129 1 10 1890 306 181 125 3 3,452 2,030 1,422 13 21 406 DEFORMITIES OF BONES OF LOWER EXTREMITY. Knock Knees. Year. No. cases. Males. Females. Over 21. Over 14. 1 1899 202 120 82 1 4 2 1898 233 135 98 11 3 1897 222 120 102 2 5 4 1896 232 101 131 5 1895 210 109 101 2 6 1894 212 86 126 7 1893 162 80 82 1 2 8 1892 168 89 79 8 2 9 1891 189 92 97 1 2 10 1890 159 92 67 3 3 1,989 1,024 965 16 29 It will be noted that 45 of the cases of genu valgum were in patients more than 14 years of age, as compared with 34 cases of adolescent or adult bow legs. The writer's personal experience in the clinic enables him to state that a large proportion of the cases of genu valgum actu- ally developed or increased to an extent demanding treatment during adolescence, while most of the cases of bow leg deformity in patients more than 14 years of age had existed since early childhood or were the result of injury or disease. The Etiology of Genu Valg-um, Genu Varum and of Other Dis- tortions of the Bones of the Lower Extremity. — The common pre- disposing cause of simple deformities and disabilities of the lower ex- tremities, in other words those not caused by local injury or local disease, is the erect posture, when for any reason the bones and the joints are unequal to the strain of locomotion and to the task of sustaining the weight of the body. i'" Time of Onset, — At two periods of life the deformities under con- sideration most often develop. The first is in early childhood, when the upright posture is first assumed ; the second is in adolescence, when the rapid growth and other changes incident to this period may lessen the stability of the supporting structures, and when the strain of laborious occupation may be added to that of the increasing weight of the body. The deformities of adolescence are, however, relatively insignificant in number compared with those of early childhood, for in childhood inherited weakness or weakness that is the direct result of malnutri- tion, at once develops into deformity under the strain of standing and walking. Thus, as a rule, the deformities under consideration first at- tract attention soon after the child begins to walk, and the patients are usually brought for treatment during the second or third year of life. If the deformities are severe, the body usually presents the evidences of general rhachitis ; in other instances the distortion of the legs is the only sign of its presence, and in other cases there may be no evi- dence whatever of malnutrition or disease. Predisposition to Deformity. — It is not always easy to explain why weak legs bend in one way rather than in another. In some ETIOLOGY. 407 instances it is probable that a slight degree of deformity is present before"' the child begins to walk. For example, a slight outward bow- ing of the legs is said to be common in early infancy, and the use of heavy diapers might favor a continuation of the distortion. Knock knee may be induced, apparently, by holding the infant on the arm with the knees pressed against the chest, and certain cases of knock knee and bow leg combined appear to be caused directly by this manner of carrying the infant habitually upon one arm. The legs of rhachitic children, who have never walked, are often Fig. 282. Habitual posture as a factor in the etiology of rhachitic bow leg. somewhat distorted and in many instances this may be explained by the habitual postures. (Fig. 282.) A moderate degree of bow leg is not infrequently seen in vigorous infants who stand and walk at an early age. Aside from the deter- mining curve in the bone that may be present before the child be- gins to walk, this predisposition toward bow leg may be explained, perhaps, by the fact that young infants often separate the feet widely in walking and the swaying of the body from side to side may tend to bend the legs outward. In weaker or less vigorous children a slight degree of knock knee is not uncommon, induced, it may be, by weak- 408 BEFOBMTTIES OF BONES OF LOWER EXTREMITY. Fig. 283. ; ness or inactivity of the muscles, as a result of which the child stands with the knees somewhat flexed and pressed together, while the feet are separated and everted, an exaggeration of the so-called attitude of rest. Bow leg is not uncommon in adult life and it is popularly associated with strength and activity. Undoubtedly the attitudes of activity favor the production of bow leg rather than knock knee, so that this tradi- tion may have a foundation of truth. It is said to be common among those who ride constantly and it may be a direct result of injury or dis- ease of the knee joint, but it may be stated that well-marked bow leg in an adult is almost always a deformity that has existed since child- hood. This statement cannot be made of genu valgum, since it may develop or increase during ado- lescence or even in adult life. The predisposing cause is weakness or overstrain, and as has been stated in the popular mind the deformity is characteristic of weakness. The Attitude of Eest. — Genu valgum is an exaggeration of what is known as the attitude of rest or relaxation, in which the weight of the body is thrown in great part upon the ligaments of the three joints of the lower extremity. In the attitude of rest the pelvis is tilted forward, the femora are ro- tated inward upon the tibise and the feet are separated and everted, so that the greatest strain falls upon the inner side of the knees and of the feet. Thus, what is known as flat foot is often combined with knock knee; knock knee may cause flat foot, but more often the flat foot may induce knock knee, or both may be the effect of the same general cause. Genu valgum, in the slighter degree at least, may be induced directly by an improper attitude, but the attitude is, as a rule, the result of over-work to which the mechan- ism is subjected ; thus the knock knee of adolescence is so common among the bakers of Vienna, that " baker's knee " is there synonymous with genu valgum. Genu valgum may be secondary to distortion elsewhere. For ex- ample, compenss^' ory knock knee is usually combined with extreme ad- duction of the thigh ; it may be the result of the inactivity necessitated by the treatment of hip disease ; it may be a direct result of injury, and it is sometimes an accompaniment of osteomyelitis or osteoperiostitis of the ibia, which causes an overgrowth and abnormal lengthening of the leg. A type of deformity in which the prognosis as regards outgrowth is bad. THE OUl GROWTH OF DEFORMITY. 409 The Outgrowth of Deformity. — In considering the treatment of the simple static deformities of the lower extremity which are usually the result of a temporary weakness of structure, one must first answer the question, "Will not the child outgrow it?" This belief in the spontaneous cure of deformity is very strong not only among the laity but among physicians as well ; and it rests upon the common observa- tion that crooked legs become straight, or at least less deformed, with the growth of the child. In fact if one were to judge from the general observation of the effect of growth upon the deformities of this class, or even from the tracings of the legs of rhachitic children taken from year to year, one might conclude that all deformities of this class might be safely left to themselves. As an illustration of positive evidence on the subject, the observations of Kamps,^ on 32 cases of rhachitic dis- tortion of the lower extremity, may be cited. Four and one-half years after the cases were first seen and recorded, examination showed that 75 per cent, were cured, 15.3 per cent, improved, while 9.7 per cent, were unimproved. His conclusions are that such deformities do not, as a rule, require special treatment in early childhood, but that after the age of six years the prognosis for spontaneous cure is unfavorable. Veit ^ photographed a number of rhachitic children seen in the sur- gical clinic of the University of Berlin, and after a lapse of two or three years made another series of photographs of the same patients, who had meanwhile received no treatment. His conclusions are simi- lar to those of Kamps, namely, that surgical treatment is not required for deformity of this character in children less than six years of age. In two classes of cases, however, the prognosis for spontaneous cure is not favorable, those in which the growth has been checked by the rha- chitic process, and in certain cases of extreme bow legs, "O" legs. (Fig. 283.) The rectifying force of nature acts in two ways. Assuming that the deformity reached its limit during the period of original weakness, it must of course become relatively less as the body increases in length and size. In fact the outgrowth of deformity has a direct relation to the rapidity of growth during the early years of childhood. The second manifestation of the power of nature is more positive. It may be assumed that when the deformity is progressive all the tissues are afi^ected by the weakness, consequently the attitudes of the child are those that can be most easily assumed under the abnormal conditions. But when the primary cause of the weakness, in most instances rhachi- tis, is no longer operative, the muscles take on new activity and vigor and the actions and attitudes, in spite of the deformity, become ap- proximately normal. Then according to Wollf 's law of transformation the internal structure of the affected bones begins to change to accom- modate itself to the new conditions of weight and stra*"- induced by the change in action and attitude ; and to this rearrangement of the inter- nal structure, the external shape of the bones must conform in a grad- ual growth toward the normal contour. iBeitriige zur Klin. CMr., Bd. 14, H. 1. 2 Archiv f. Klin. Chir., Bd. 50, S. 130. 410 DEFOBMIIIES OF BONES OF LOWER EXTREMITY. On this theory, it is easily explained how the natural outdoor life of the country has long been celebrated as an effective treatment for this class of deformity. But it by no means follows that deformity is always outgrown, even under favorable conditions. Improper atti- tudes, that favor and cause deformity, are often observed among those who are free from weakness and disability and from the influences of unfavorable surroundings ; and such attitudes are of course more likely to persist in those who were once obliged to assume them be- cause of weakness and defor- FiG. 284. mity. Again, the weakness of structure or function may be an inherited peculiarity, or it may be induced by disease or by improper surroundings, in- fluences that may continue for many years and thus serve to check the natural tendency toward cure. The observations on the outgrowth of deformity have been confined, as a rule, to the period of childhood, and most often they have been made with reference to the more serious grades of distortion, which are the direct result of rhachitis. It must be borne in mind, however, that the true signifi- cance of these deformities in the adult must be judged from the sesthetic, rather than from the medical point of view, and although the extreme degrees of bow leg and knock knee are relatively rare yet in the minor grade both deformities are \e.vy common in adult males and in all probability in adult fe- males also. In 1887 the writer^ noted among 2,000 adult males observed on the streets of Boston, 400 cases of bow leg and 32 cases of knock knee. One may assume then that the legs of about one adult male in five deviate more or less from the line of symmetry, a conclusion that has been confirmed by many subsequent observations. It may be ad- mitted that a certain number of the distortions under consideration are acquired during adolescence, but it is probable that the greater num- »N. Y. Med. Eec, July 30, 1887. Extreme deformities, the result of infantile rhachitis. The leg forms practically a right angle with the thigh. (See Fig. 288. ) GENU VALGUM. 411 ber of those that may be noted in walkers upon the streets represent the incomplete outgrowth of a deformity of childhood. The statement is often made that these distortions of the legs are common in childhood but rare in adult life. Just what the proportion may be in childhood it is impossible to say, but it is not likely to be greater than one in five. One must conclude that statistics, on which such statements are based, have been made up from the records of hos- pitals where it is extremely uncommon for an adult to apply for the treatment of bow leg, to which he has become accustomed since child- hood, unless the deformity is very extreme or is attended by pain. Granting that the power of nature is quite sufficient to modify, or to cure even the more extreme distortions of childhood, still it would seem that this natural force is often ineffective in completing the cure. There- fore in doubtful cases, at least, one should lend assistance in that class of patients likely to appreciate the advantage of symmetry over slight deformity, even though it be unattended by discomfort or disability. Genu Valgum. Synonyms. — Knock Knee, In Knee. In the erect posture the thighs, whose upper extremities are sepa- rated by the pelvis and by the projecting femoral necks, incline slightly inward to the knees, forming an angle at the knee, opening outward. Fig. 285. Fia. 286. Female. Male. The normal iiicliuatiou of tlie I'emuiii. (1'1'I:iffku. ) of about 172 degrees. This angle varies with the breadth of the pelvis, and it is therefore less in adult females than in males. (Figs. 285, 286.) The internal condyle of the femur is slightly longer than the external, thus the inclination of the femur is compensated and the plane of the knee joint is horizontal. 412 DEFORMITIES OF BONES OF LOWER EXTREMITY. Wheu the inward projection of the knees is increased to a noticeable degree the tibiae are no longer perpendicular, their upper extremities incline inward so that in the erect posture the feet are separated when the knees are in contact. (Fig. 287.) In the slighter grades of knock knee, which are due in great degree to laxity of the ligaments, the de- formity is apparent only when the weight of the body is borne, but in more marked cases, although the distortion is increased by the weight of the body, it can not be overcome when this is removed because it depends upon actual changes in the shape of the bones themselves. Fig. 287. Adolescent knock knees. Deformity most marked in tlie tibiae. (See Fig. 290.) As has been stated, the normal inward inclination of the femur is compensated , by the greater length of the internal condyle, and in the deformity of knock knee the plane of the knee joint is still preserved by an apparent elongation of the inner condyle. Formerly it was sup- posed that there was an actual over-growth of this part of the epiphysis, which caused the deformity, but the observations of Mickulicz and Macewen have shown that this apparent lengthening is in reality due, in great part, to a deformity of the lower extremity of the shaft of the GENU VALGUM. 413 femur, which is so bent that the epiphyseal line has an increased obli- quity. • And the hypothesis that bone grows more rapidly when relieved from weight and strain has been disproved by Wollf, who has shown that changes in the bones are the result of accommodation to altered function and attitude. (See page 190.) The deformity is not limited to the femur ; in most instances there is a similar, although usually slighter, irregularity in the epiphyseal line of the upper extremity of the tibia, the shaft being so bent that when it is placed in the perpen- FiG. 288. Skiagram of Fig. 284 showing the deformity to be due to distortions of the diaphyses of the bones while the epiphyses are practically normal. dicular position its internal condylar surface is higher than the external. (Fig. 288.) Changed Relation of the Femur and Tibia. — In addition to the direct deformities of the bones there is a change in the relation of the femur to the tibia. The former is rotated inward and the latter is rotated outward. In some instances there is also a certain degree of over-extension at the knee. This is more often observed in the ado- lescent type in which there is laxity of the ligaments, but in the ordi- nary form of rhachitic knock knee in childhood, the habitual attitude is one of slight flexion at the knees and in extreme cases there may 414 DEFORMITIES OF BONES OF LOWER EXTREMITY. Fig. 289. be actual limitation of the range of extension at the knee, and at the hip as well. The Accommodative Attitude. — When the limb is fully ex- tended, the deformity is most marked because the shortened ligaments and tissues on the outer aspect of the joint become tense, and because the outward rotation of the tibia is increased. As the leg is flexed the deformity lessens, and in the attitude of complete flexion it disappears. (Fig. 290.) This is explained by the fact that the posterior surface of the condyles is not affected by the deformity of the shaft, while the relaxation of the ligaments and the outward rotation of the femora al- low the tibiae to become parallel with one another. This explains the ha- bitual attitude of slight flexion which is so often assumed by patients who thus unconsciously accommo- date themselves to the deformity. Secondary Deformities. — The outward inclination of the leg throws more weight upon the inner border of the foot and tends to de- press it into the attitude of valgus. Thus knock knee in weak children is often accompanied by flat foot, but in the more extreme grades of deformity the efforts of the patient to compensate for the abnormal separation of the feet may result in habitual supination, in fact, con- firmed and extreme knock knee is often accompanied by a slight de- gree of varus that becomes very evi- dent after the correction of the de- formity by operation. Even in the mildest type of knock knee, this compensatory and conservative ef- fort of nature shown by the so-called pigeon-toed walk, may be the first symptom that attracts attention. Gait. — The gait of the patient with well-marked genu valgum is peculiarly awkward and shambling. The knees " interfere " and must be assisted, as it were, in the effort to pass one another in walking. In the slighter cases, the thigh is abducted and rotated outward at the mo- ment of passing its fellow, the movement being then reversed as it, in its turn, suppc.i ts the weight ; but in the more severe type this voluntary effort of the muscles of the leg is not sufficient, and in addition, the body is swayed from side to side and the legs are alternately swung outward and liftgd around one another. Deformity of the femur in genu valgum. (MiCKULICZ.) GENU VALGUM. 415 The deformity" and the effects of the deformity on the gait and atti- tude ^re the most important symptoms, as of other distortions of simi- lar origin. The patient is, as a rule, easily fatigued, and pain during the progressive stage, referred to the inner side of the knee where the ligaments are subjected to continuous strain, is a common symptom, par- ticularly in the adolescent type of genu valgum. Unilateral Knock Knee. — This description refers particularly to the cases in which the deformity is bilateral. Not infrequently it is uni- lateral, the leg being so shortened by the distortion that a well-marked limp replaces the swaying gait. The pelvis is tilted toward the short Fig. 290. Adolescent knock knee, showing the disappearance of the deformity when legs are flexed (See fig. 287.) leg, while the body is inclined in the opposite direction, so that in cases of long standing, a permanent curvature of the lumbar spine may be present. Knock Knee Combined with Bow Leg and with G-eneral Rhachitic Dis- tortions. — Occasionally the unilateral knock knee may be accompanied by an outward bowing of its fellow ; and in the marked distortions of the lower extremity, that are the result of rhachitis, the bones may be twisted and bent in various directions, although the outward expression of the deformity may be genu valgum. For example, the femora may be bent forward and outward above, and inward and backward below, while the tibiae may be bent inward above, and outward and forward below. In other instances, especially in the slighter rhachitic deformities, an outward bowing of the tibiae may accompany a slight degree of knock knees, so that it is difficult to classify the deformity. 416 DEFORMITIES OF BONES OF LOWER EXTREMITY. In the more extreme deformities of the rhachitic type, the shape as well as the contour of the bones is modified, for example, the internal border of the tibia may become very prominent at its upper extremity, and may project beneath the skin like an exostosis. (Fig- 291.) A change in the contour of the fibula accompanies and corresponds to that of the tibia although it is, as a rule, much less pronounced. As Fig. 291. Knock knee and bow leg. has been stated, the internal structure or architecture of the affected bones is changed to accommodate the new static conditions, and ac- cording to Wollf the internal change precedes the external deformity. Pathology. — In knock knee due directly to rhachitis the changes in the bones and in the epiphyseal cartihiges are characteristic of that af- fection, but in the milder grades of deformity, aside from the change in the contour of the bones, the transformation of the internal structure, EXPECTANT TREATMENT. 417 and in some instances slight thickening or irregularity of the epiphyseal cartilage, there is little noteworthy change from the normal. (Fig. 289.) The tissues on the internal aspect of the joint are relaxed, those on the outer side, the lateral ligaments, the capsule and the biceps muscle, are contracted and resist the reduction of the deformity. In the interior of the joint slight changes in the articulating surfaces of the bones, and evidences of chronic irritation of the synovial membrane have been described. Measurements. — There are various methods of measurins: the de- formity. One of the simplest and most practical is to trace the out- lines on paper, while the child is seated with the legs fully extended, the knees being sufficiently separated to allow the pencil to pass be- tween thera. The increase of the deformity, dependent upon the lax- ity of the ligaments and upon the outward rotation of the tibiae, may be estimated by measuring the distance between the two internal mal- leoli when the patient stands, the knees being slightly separated as be- fore and comparing this measurement with that between the similar points in the tracing. In the early stage of progressive knock knee, particularly in the type not caused directly by rhachitis, laxity of liga- ments and the habitual assumption of the attitude of rest, will account for the deformity, which the patient may be able to overcome, in great degree at least, by voluntary eifort. This voluntary control of the de- formity is very suggestive, as indicating certain factors in its etiology and the principles that should be followed in its treatment. Treatment. — The treatment of the deformity under consideration may be classified as : Expectant, mechanical, and operative. Expectant treatment should not be expectant in the sense that noth- ing is to be done to correct the deformity, but expectant in that more positive treatment by braces or by operation is delayed, or avoided if it prove to be unnecessary. During the expectant period the cause of the deformity, if it is consti- tutional, should receive proper dietetic or medicinal treatment as already described in the chapter on rhachitis. And, if possible, the direct ex- citing causes of the deformity must be removed, that is to say, the im- proper attitudes or, in the adolescent, the predisposing occupations should be discontinued. General massage of the limbs may be em- ployed with advantage ; in older children special exercises may be practiced, and in all cases, whether braces are used or not, direct manipulation of the distorted limbs is of the first importance. Manipulation. — In the slight degrees of deformity, more espe- cially of that type in which the distortion appears to be due to simple weakness rather than to rhachitis, the expectant treatment may be tested. The legs should be vigorously massaged at morning and night, and forcibly straightened. The latter procedure is conducted as fol- lows : the patient is seated in a chair, the limb being fully extended so that the deformity is made as extreme as possible. One hand then clasps the knee, the palm lying against its inner aspect ; with the other, the calf is grasped firmly and the leg is then gently straightened over 27 418 DEFORMITIES OF BONES OF LOWER EXTREMITY. the fulcrum formed by the palm of the hand, and is held in the corrected position for a moment. This manipulation should be continued with gradually increasing force, although not to the extent of causing actual pain, for ten minutes, at least twice in the day and oftener if possible. Posture and Exercise. — It has been stated that genu valgum is often accompanied, especially in the rhachitic cases, by flat foot, while in another type the inversion of the feet, or in the more severe cases the actual fixed attitude of varus, indicates the eifort of nature to with- FiG. 292. Fig. 293. The Thomas knock knee brace. Thomas knock knee braces with pelvic band. stand and to compensate for the deformity at the knee. This serves as an indication for making the soles of the shoes thicker on the inner side as in the treatment of flat foot, in order to throw the strain upon the outer border of the foot. The patient should be instructed to walk with the feet parallel with one another, and for older children the tip- toe exercises, in which the body is raised upon the toes as many times as the strength permits, or games or exercises in which the legs are extended should be encourasred. Such exercises are often efficacious MECHANICAL TREATMENT. 419 in the parly stage of adolescent knock knee, for as has been mentioned, genu valgum is an exaggeration of the attitude of rest, therefore its progress should be checked by the assumption of the attitudes proper to activity. A careful record of the deformity should be kept during this tentative treatment and if it improves somewhat, one is justified in delaying the more radical measures. This question may be decided, as a rule, in three months, if instructions are faithfully followed. Fig. 294. Modified Thomas knock knee braces applied. Treatment by Braces. — The most efficient brace in the treatment of genu valgum is the simple straight steel bar or splint extending from the trochanter to the heel of the shoe, without joint at the knee. The greater efficacy of the rigid bar as compared with the jointed brace is explained by the fact that the rectifying force acts constantly when the joint is fixed, and because, in many instances, the patient habitually flexes the knees so that direct pressure cannot be made upon the de- formity by a brace that allows this attitude. 420 DEFORMITIES OF BONES OF LOWER EXTREMITY. Fig. 295. The Thomas Brace. — The simplest and cheapest brace is that of Thomas, which consists of a light steel bar provided with a pad at its upper end for pressure against the trochanter, while the lower rounded extremity is turned inward at a right angle, to pass through the heel of the shoe. The knee is fixed by a posterior bar attached to a thigh and calf band, as illustrated in the figure. When the brace is applied the knee is drawn backward and outward and is attached firmly to the brace by a roller bandage. (Fig. 292.) In the more extreme cases in which the knees and thighs are ha- bitually flexed, the addition of a pelvic band attached to the uprights by a free joint at the hips, adds to the comfort and efficiency of the appara- tus, as the attitude of outward or in- ward rotation can be regulated by twisting the uprights slightly. Or the pelvic band may be divided and attached by means of straps on the front and back. The uprights may be bent somewhat inward at first, and as the legs become straighter they are straightened and finally bent slightly outward to allow for the over-correc- tion of the deformity. (Fig. 294.) Twice a day the braces should be re- moved to allow for massage, manipu- lation and for voluntary exercises of the legs. In most cases the braces are not employed at night, although the rectification of the deformity may be hastened by their constant use. If the deformity is unilateral so that a brace is required for one leg only, the other shoe should be raised by a cork sole about three quarters of an inch in thickness to make walking easier. Children soon become accustomed to the braces and walk easily in spite of the absence of joints at the knees. Another simple and efficient brace is that used at the Children's Hos- pital at Boston. (Fig. 295.) The upper part of the brace is turned backward and upward to lie against the buttock, and the feet can be rotated in or out by lengthening or shortening straps passing before and behind the body. Braces jointed at the knee are sometimes em- ployed, but they are, as a rule, ineffective except in the slighter cases in which the deformity depends upon laxity of ligaments rather than distortion of bone. Duration of Treatment by Braces. — The duration of the brace treatment depends, of course, upon the degree of deformity, the Long braces for genu valgum. (Bradford AND LOVETT.) OPERATIVE TREATMENT. 421 age of the child and upon the efficiency of the apparatus. From six months to one year of treatment by this means is usually required. The cure is assured by the gradual adaptation of the parts to the new static conditions. The contracted tissues of the outer aspect of the joint become lengthened ; the lax ligaments on the inner side con- tract ; the internal structure of the condyles and of the adjoining dia- physis is gradually transformed and at the external contour of the bone becomes correspondingly straighter. When the braces are discarded, attention should be paid to the attitudes, and the exercises that have been mentioned should be continued in order that relapse may be pre- vented. The Plaster Bandage. — When the bones are yielding, as in the deformity due directly to rhachitis in young children, it may be cor- rected rapidly by the repeated applications of plaster bandages, the leg being straightened as far as possible without causing discomfort, at each sitting. This method is rarely employed except in dispensary practice. Operative Treatment. — Immediate correction of the deformity, when it is at all marked, is as a rule indicated after the age of four or five years. It is perhaps needless to remark that the necessity for operation im- plies neglect of proper preventive treatment or the failure of the manipulative and mechanical methods because of their improper appli- cation. While it is possible to correct deformity of the bone by me- chanical treatment in cases far beyond this limit of age, yet the time required and the discomforts of the treatment exclude it in all but very exceptional cases. Osteotomy. — At the Hospital for Ruptured and Crippled, osteotomy is invariably performed in the treatment of genu valgum by means of the small Vance osteotome, the so-called " subcutaneous osteotomy." (Fig. 262.) The limb having been prepared in the usual manner is semiflexed and the inner surface of the knee is placed on a firm sand bag. With the fingers the femur is firmly grasped just above the condyles so that its size and position may be accurately determined, and the sharp osteo- tome about the size of a lead pencil is forced with its cutting edge parallel to the axis of the thigh down to the bone, at a point about one and a-half inches above the external tuberosity. While it is held firmly in position against the bone it is turned to the transverse direc- tion and is then driven through the cortex. When it enters the medullary canal, as is made evident by the lessened resistance, it is partly withdrawn and moved slightly to one side and the other and driven through the cortical substance until by gentle force the bone may be fractured. The osteotome is then withdrawn, the minute wound is covered with a pad of dry gauze, or if the oozing is profuse it may be closed with a catgut suture. The deformity is then slightly over-corrected and a plaster spica bandage is applied. If the de- formity is double both limbs are operated upon at the same sitting. The plaster bandage is continued for from four to six weeks and it is then usually supplemented by a brace which may be worn with ad- 422 DEFORMITIES OF BONES OF LOWER EXTREMITY. vantage for several months, because of the laxity of the ligaments of the knee joint which is usually present in extreme deformity of rha- chitic origin. In less marked cases, the support is unnecessary. Mas- sage and exercises during the stage of recovery should be employed if possible. In some instances the osteotomy of the femur may be performed from the inner side at the same level more conveniently, especially if the deformity is extreme. Incomplete osteotomy and fracture in the manner described has been employed at the Hospital for Ruptured and Crippled in a very large number of cases without a single unfavorable result. The discomfort is insignificant and confinement to the bed after the third day is un- necessary. Cuneiform Osteotomy. — In the more extreme cases of general rhachitic deformity of the lower extremity in which the tibia is im- plicated, it is sometimes necessary to remove a cuneiform section of bone from the inner side of the tibia just below the epiphysis in order to straighten the leg completely. In such cases it is better to perform Fig. 296. The Grattau osteoclast. the second operation at a later time in order that the effect of the fem- oral osteotomy may be observed. In exceptional cases the deformity may be practically confined to the tibia; in such instances it should be corrected by a primary cuneiform osteotomy. Osteoclasis. — Osteoclasis, by means of the Grattan osteoclast, is an effective operation. With this instrument the bone may be broken above the condyles at the desired point, but the force required is con- siderable and it would seem that there might be danger of separating the epiphysis or otherwise injuring the joint, a danger that may be avoided by osteotomy. The adolescent type of genu valgum is not often extreme. As a rule, OPERATIVE TREATMENT. 423 the deformity of the bone is of comparatively short duration, and it is accompanied by considerable laxity of ligaments. In the more chronic cases the osteotomy above the condyles may be performed in the manner described, but in Berlin and Vienna where the deformity is more common than in New York, other procedures are often employed. Wollf's Treatment. — One method is that of Wollf, who by means of the " Etappen Verband " gradually corrects the deformity. The patient is anaesthetized and the limb having been carefully pro- tected with cotton, particularly so about the malleoli, the patella and the inner condyle, is enveloped in a firm plaster bandage reaching from the malleoli to the pubes. When the plaster begins to harden one assistant steadies the pelvis, another holds the inner condyle, while the operator draws the leg inward with moderate but persistent force against the fulcrum formed by the hand of the second assistant and holds it firmly in the partly corrected position until the bandage is firm. About three days later a wedge-shaped section of the bandage about one inch in width is removed from the part that covers the inner half of the knee, the outer half of the bandage being simply divided. The leg is then forced inward until the two sections are again brought into contact. The position is retained by an additional plaster bandage about the weakened part. This procedure is repeated at intervals until the leg is completely straightened, a result that is often accomplished in two weeks. No anaesthetic is required for the secondary corrections. When the deformity has been corrected the patient is allowed to walk about, and for convenience the plaster bandage is divided into a thigh and leg part which are attached by lateral joints incorporated in its substance so that motion is allowed. This apparatus mast be worn for several months and is of course to be supplemented by massage and exercises. LoRENz's Operation. — Another means of correction of deformity without open operation is that employed by Lorenz, what he calls " In- traarticulare modelirerende redressement." In this operation the de- formity is reduced under anaesthesia at one sitting by the gradual ap- plication of force by means of the Lorenz osteoclast. The reduction depends partly upon the stretching of the external ligaments and partly upon the actual bending of the diaphysis of the bone, as in the Wollf method. When the leg has been straightened, or somewhat over-corrected even, a long plaster bandage is applied which is worn for six weeks and is then replaced by a jointed walking brace to be worn for about a year. The operation is not attended by severe pain and the patient is usually allowed to walk about in a few days. Genu Varum. Synonym.^Bow Leg. The term bow legs includes, in its popular sense, all the distortions that cause a separation of the knees when the ankles are in contact with one another. But, strictly speaking, genu varum is the reverse of genu 424 DEFORMITIES OF BONES OF LOWER EXTREMITY. valgum, that is, the cause of the distortion is at or near the knee joint, while bow leg, as the name implies, is a simple bowing of the tibia and fibula, as a rule near the ankle joint. (Fig. 303.) In true genu varum a line dropped from the head of the femur falls inside the knee (Fig. 297), the inner condyle of the femur and the inner tuberosity of the tibia bear the greater part of the weight, the outer condyle is on the same level or somewhat lower than the Fig. 297. internal and the outer tuber- osity of the tibia may be Fig. 298. The genu varum type of bow legs, showiug the outward rotation of the femora. The same patieut, showiug the separa- tion of the malleoli when the knees are in contact. somewhat higher than the internal. The femur is abducted and rotated outward, the tibia is rotated inward. These changes, it will be noted, are the reverse of those found in genu valgum. As has. been stated, the deformity of genu valgum disappears when the legs are flexed, and in genu varum if the legs are flexed and the knees are placed in contact with one another the malleoli may be actually sepa- rated, simulating the deformity of knock knee. (Fig. 298.) This is SYMPTOMS. 425 explained by the inward rotation of the femora, necessitated by placing the kniees in contact with one another. '*' In genu varum the distortion of the bones is not as strictly confined to the neighborhood of the knee joint as in genu valgum, and in simple bow leg there is almost always a certain amount of distortion at the knee, dependent, in part, upon laxity of the ligaments. It is proper therefore to use the two terms synonymously, although one must dis- tinguish a decided difference between the genu-varum type in which the deformity is greatest at the knee, and which is accompanied as a rule by marked laxity of the ligaments (Fig. 299), and the bow-leg Fig. 299. Genu varum of rhachitic origin in an adult. Treated successfully by osteotomy. type in which the deformity may be strictly confined to the lower third of the leg. (Fig. 303.) Symptoms. — As was said of genu valgum, the deformity is the principal symptom. The gait is somewhat rolling because each foot must describe a part of the arc of a circle before reaching the ground ; and because of the inward rotation of the tibiae or because of the in- ward spiral twist of the bone that is sometimes present, patients often toe in, in walking. Except in extreme cases the weakness and awkwardness, character- istic of genu valgum, are absent. This may be explained by the fact 426 DEFORMITIES OF BONES OF LOWER EXTREMITY. that the relation of the bones is such that the general attitude is one of activity, the weight falling on the outer side of the feet, thus flat foot is uncommon as an accompaniment of bow leg, except in the early or rhachitic type. Measurements. — The full effect of the deformity appears only when the weight of the body is borne, but for practical purposes the tracing of the extended legs is the best method Fig. 300. of recording the fixed deformity. In true genu varum the deformity is greatest at the knee and in the distortion the apposed surfaces of the femur and of the tibia participate. In simple bow leg the deformity may be confined to the tibia, which, in addition to the outward bowing, may be twisted inward somewhat upon its long axis. Genu varum may be unilateral or it may be combined with genu valgum of its fellow (Fig. 291), and occasionally slight knock knee and slight bow leg may be present in the same limb. Treatment. Expectant Treatment. — The slighter cases of bow leg in early childhood may be treated by manipula- tion. The leg, grasped firmly at the ankle and at the knee, is straightened with a certain amount of force, over and over again. Gradual correction by this means may be hastened by making the sole of the shoe slightly thicker on the outer border. This aids, also, in correct- ing the secondary pigeon toe, but if the foot is weak, as it usually is in rhachitic cases, this method should not be employed, as it might induce flat foot. Treatment by Braces. — If the deformity is more extreme, or if im- provement does not follow expectant treatment, apparatus should be employed. If the distortion is confined to the lower third of the tibia, a Knight brace may be used. It consists of two uprights attached to a foot plate, the inner bar is provided with a pad at its upper end for pressure on the internal condyle of the femur. The outer bar reaches to the head of the fibula and the two are joined by a calf band. When applied the leg is drawn toward the inner upright by means of a lacing, which passes about it within the outer bar. When the lacing is made fast, the outer bar is bent toward the leg and thus it aids somewhat in supporting it in an improved position. The foot plate may be dis- pensed with and the brace may be attached to the shoe and even the outer bar may be removed, leaving only the upright, which is held in position by the lacing. The apparatus, then, has the appearance of a Long braces for genu varum FORD AND LOVETT. (Brad- OPERATIVE TREATMENT. 427 gaiter and has the advantage of being inconspicuous, although some- what l6ss effective than the Knight brace. By this apparatus, combined mth vigorous manipulation, the deformity may be corrected, in young children, in about six months. If the outward bowing of the knee is marked, another form of ap- paratus will be necessary, and its effectiveness will be much increased if there is no joint at the knee. The outer bar, shaped to the contour of the leg, is attached above to a pelvic band and below to a foot plate, as is the short brace. An inner straight bar extends to the upper third of the thigh and is attached to the outer bar by a thigh band. This inner upright is provided with a lacing of leather or canvas, similar to that of the short brace, which surrounds the knee and upper part of the leg, and thus draws it toward an improved position. The outer bar is then bent slightly inward and serves as an additional support. Another form of apparatus consists of a single upright, attached to the shoe and extending upward as high as possible on the inner aspect of the thigh. At its upper extremity a pressure pad is placed and the knee is drawn toward it by means of straps or bandages. An improved brace of this kind is that in use at the Boston Children's Hospital, in which the upper part of the upright is curved upward and outward just below the groin, to a point on a level with, and behind, the trochanter, and is attached to its fellow by means of a strap passing across the buttocks so that the feet may be somewhat rotated outward if necessary. (Fig. 300.) Operative Treatment. — In children more than five years of age, and in cases of the more extreme type at an earlier age, or when the op- portunity for mechanical treatment is lacking, immediate correction of the deformity is indicated. Either osteoclasis or osteotomy may be employed, and in some instances manual force is sufficient for the correction of the deformity. There is but little choice between the methods. Osteoclasis is somewhat safer possibly, and is to be pre- ferred for the younger patients who may be treated as out-patients. At the Hospital for Ruptured and Crippled, osteotomy is almost invariably performed. The small osteotome is inserted on the inner aspect of the tibia at the point of greatest deformity, and when the bone has been sufficiently weakened, the fracture is completed by manual force. The fibula may be broken at the same time, or, as is usually the case, it may be simply bent outward. The deformity is corrected or slightly over-corrected and a well-fitting plaster bandage, including the foot and extending to the trochanter, is applied. The patient usually remains in bed for a few days, he is then dressed and if he so desires is allowed to stand. Almost no pain or discom- fort follows the operation and in fact, in properly selected cases, it is not only free from danger, but it has a very decided advantage over the simple mechanical treatment. If the child is in good condition, and if the deformity is slightly over-corrected at the time of operation, apparatus will not be required in the after-treatment ; but in many instances some form of support is indicated, usually because slight 428 DEFORMITIES OF BONES OF LOWER EXTREMITY. deformity, due to laxity of ligaments or to deformity of the femur, appears when the weight of the body falls upon the legs. It" has been stated that the deformity of bow leg depends in part upon a deformity of the femur as Fig. 301. well as of the tibia. As a rule, p-_-^— ^j.^----, the correction of the greater de- j X, formity of the tibia will be suffi- cient, but in more extreme cases a secondary osteotomy above the condyles will be necessary. This may be performed simultaneously with that on the tibia, but it is better to defer it until the effect of the primary operation has been observed. Anterior Bow Leg. Synonym. — Anterior Curva- ture of the Tibia. Anterior bow legs. Botli bow legs and kuock kuecs are often seen in children who pre- sent no signs of general rhachitis, but anterior bowing of the legs is almost always combined with general rhachitic distortions of the lower extremity, most often with knock knees ; these in turn are caused by marked distortion of the femora which may be bent forward and out- FiG. 302. Long anterior curvature of the tibia and flat foot. GENERAL BHACHITIC DISTORTIONS. 429 ward above, and inward at their lower extremities, " corkscrew de- formity." In anterior bow legs the tibise are usually flattened from side to side, curved inward or outward and bent forward, the project- ing crests presenting sharply beneath the skin. mgHji"^ ^ Symptoms. — The effect of the anterior bowing is to throw the weight forward upon the foot, thus the heels appear abnormally long and promi- nent, and the patient seems to sink forward at Fig. 303. each step. (Fig. 303.) The knees are usually somewhat flexed, partly as the effect of knock knee with which the de- formity is usually com- bined, and the feet are, as a rule, flat. As has been stated, anterior bow- ing is almost never seen as an independent defor- mity unless it is a relic of the more general distor- tion which has been " outgrown." Treatment. — Anterior curvature of the tibia must, as a rule, be treated by operation. After complete division of the tibia and fibula, the deformity may be overcome by forcing the bones directly backward. In certain instances te- notomy of the ten do Achillis may be required. Cuneiform osteotomy of the tibia permits more perfect correction, but the final result is equally good after simple osteotomy. General Rhachitic Distortions. General rhachitic distortions have been mentioned in connection with knock knee, and with anterior bowleg. A more extended description is hardly necessary. The deformities are usually of the knock-knee type, and they may be treated on the same general plan that has been outlined in the description of the less extreme distortions. Bhachitic anterior bow legs. CHAPTER XVI. DEFORMITIES OF THE UPPER EXTREMITY. Congenital Dislocation of the Shoulder. This may occur in two forms, one in which there is actual mis- placement before birth, and the other in which a dislocation is caused by violence at birth. In either case the displacement is almost always backward upon the dorsum of the scapula (subspinous). Thus the arm is abducted and rotated inward and the head of the displaced bone may be felt in its abnormal position. Cases of congenital dis- placement in other directions are recorded, but these are so unusual as to be of little practical importance.^ True primary displacement of either variety is rare. Many of the reported cases were apparently subluxations secondary to the relaxa- tion of the capsule of the joint and to the muscular atrophy caused by anterior poliomyelitis, or more often to the habitual malposition due to obstetrical paralysis. (Fig. 305.) Treatment. — The only treatment of a dislocation is replacement of the displaced bone, if it be possible. If the displacement wer« dis- covered in infancy, it might be possible to reduce it by manipulation, especially if it were of traumatic origin. As a rule, however, the cases are not seen until later childhood when the accommodative changes are so great as to necessitate the open operation. Phelps, of New York, has reported several cases of congenital dislocation of the shoulder, caused apparently by injury at birth, as most of them were accompanied by paralysis. In the first case (a boy eight years of age) the joint was opened by a posterior incision along the border of the deltoid muscle. The head of the scapula was found to be atrophied and the posterior margin of the glenoid cav'ity broken away. This, together with the contraction of the tissues on the anterior aspect of the joint, made it necessary to cut away a part of the head of the bone in order to replace it. The secondary articulating surface on the scapula was excised and the redundant capsule was removed. The immediate result of the operation was very favorable. Phelps states that he has operated on two similar cases, but a final report of the results has not been presented." It would seem, however, that as in a posterior displacement the con- tracted tissues must be tliose in front of the joint, an anterior rather than a posterior incision, would be preferable. In any event prolonged ' Scudder, Am. Jour. Med. Sci., February, 1898. 2 Trans. Am. Orth. Ass'n, Vol. VIIl. OBSTETRICAL PARALYSIS. 431 Fig. 304. forcible manual stretching of the contracted parts in the manner de- scribed in the treatment of congenital dislocation of the hip should precede the opening of the joint. By this means the writer has re- duced the displacement easily in two cases in early childhood. Obstetrical Paralysis. Partial or complete paralysis of the muscles of the arm may be a re- sult of difficult or protracted labor. This may be due to direct injury of the brachial plexus by the forceps, but most often it is caused by traction on the body or the head and by violent twists of the neck during delivery. The muscles most often paralyzed are those supplied principally by the fifth and sixth cer- vical roots of the plexus, the deltoid, the biceps, and the supinators of the forearm.^ Thus in most instances the arm hangs in an attitude of slight abduction and exaggerated prona- tion. (Fig. 304.) If the attitude is allowed to persist and if the paralysis is permanent, t*he head of the humerus rotated backward beneath the atrophied deltoid mus- cle and held in the abnormal atti- tude by accommodative changes in the capsule and surrounding parts, simulates very closely in later years the true congenital dislocation of the shoulder. (Fig. 305.) Whether cases reported as con- genital displacement of the shoulder are secondary to paralysis or not, it is evident that all cases of obstet- rical paralysis should be carefully examined with regard to a compli- cating dislocation, and that secondary deformity caused by paralysis should be prevented. Treatment. — During the first month after birth, the shoulder of the paralyzed arm is often somewhat swollen and motion may cause pain. In such cases rest is indicated. The arm should be placed against the side, and the hand, with the fingers extended, should be supported on the chest beneath the clothing. When the primary sen- sitiveness has subsided, each of the joints of the extremity should be moved systematically to the limits of the normal range of motion several times in the day. Particular care should be exercised in supinating the forearm to its full limit and extending the wrist and ' Thomas, Johns Hopkins Hosp. Bulletin, Nov., 1900. Obstetrical jjaralysis. Characteristic attitude. 432 DEFORMITIES OF THE UPPER EXTREMITY. fingers, if they are involved in the paralysis. The muscles should be massaged and the arm should be supported by a sling, or otherwise, in proper position. Recovery may be complete, although it is often delayed for many months. As a rule, traces of the injury are evident in atrophy of certain muscles, particularly of the deltoid, and a certain weakness of the arm persists, even though no paralysis remains. In many instances recovery is but partial, the arm is weak, certain muscles are paralyzed, and there is much restriction of movement at the shoulder. The growth of Fig. 305. the member is retarded and the attitude simulates that of pos- terior dislocation, as has been stated. Even in such cases massage and training will the functional disabled part. exercises and often improve ability of the Recurrent Dislocation of the Shoulder. Recurrent dislocation of the shoulder is usually a sequel to traumatic dislocation. The cause of the instability is usu- ally laxity of the capsular lig- ament and weakness of the supporting muscles, the result, it may be, of too early use of the arm after the accident. In rare instances greater de- rangement of the joint, caused by fracture of one or other of the articulating surfaces, rup- ture or displacement of liga- ments or muscles, or perma- nent paralysis of the deltoid muscle may be present. The displacement, which may be partial or complete, recurs at intervals and is a very serious disability. Treatment. — If the patient is seen immediately after a displacement and if the dislocation has recurred but a few times and at long inter- vals, it may be inferred that the disability is the result of simple laxity of the capsule and of muscular weakness. In such cases a period of fixation followed by massage and exercise of the atrophied muscles may result in cure. The patient should be carefully questioned as to the par- ticular movements of the arm that are likely to cause the displacement, Obstetrical paralysis iu adolesceuee. CUBITUS VALGUS, CUBITUS VARUS. 433 which is, as a rule, forward beneath the coracoid process. Most often elevation and abduction seem to be the exciting causes, and these mo- tions should be restrained. A simple and often an eifective means of treatment, is the application of a shoulder cap of canvas that fits closely about the shoulder and upper arm. This is held in place by bands crossing the body and buckled beneath the other arm ; from the lower border of the cap one or more bands pass downward and are attached with the braces to the trousers, so that elevation of the arm is re- strained, before the point of instability is reached. Operative Treatment. — If these milder measures are ineffective an op- eration to reduce the size of the lax capsule may be performed according to the method employed by Burrell. The arm being slightly abducted, an incision is made from the coracoid process downward and outward along the line of the cephalic vein to a point below the upper border of the tendinous insertion of the pectoralis major. The deltoid and the pectoralis major are separated, exposing in the upper border of the wound the coraco-brachialis, and in the lower angle the upper part of the insertion of the pectoralis major. The upper three-fourths of this in- sertion is divided in order to expose the head and neck of the bone. The humerus is then rotated outward and a portion of the insertion of the subscapularis muscle, stretched over the head of the humerus, is di- vided. The capsule is thus laid bare. In Burrell' s second case a portion of the anterior wall of the capsule three-eighths of an inch wide and three-fourths of an inch long was excised, and the wound was closed with sutures. The incised muscles fell into apposition when the arm was fixed to the side. Burrell oper- ated on two patients by this method with perfect success. Similar operations in which the lax capsule was overlapped and sutured without opening it, have been performed, by Ricard in 1892 and by Steinthal in 1895.^ Congenital Deformities of the Elbow. Congenital displacement of the ulna is one of the rarest of deform- ities. The displacement is usually incomplete, and it is associated with laxity of the ligaments. Congenital displacement of the radius is much more common. Thirty cases collected from the literature have been reported by Bon- nenburg.^ The symptoms are similar to those of the traumatic dislo- cation. The deformity is often overlooked in childhood, and as it causes no great disability, treatment is not usually desired. In several instances the head of the radius has been removed with a favorable ef- fect in increasing the range of supination. Cubitus Valgus, Cubitus Varus. Cubitus valgus, in which the forearm is abducted at the elbow and cu- bitus varus, in which it is inclined in the other direction, are occasion- * Burrell and Lovett, Am. Jour. Med. Sci., Aug., 1897. 2Zeits. fiir Orth. Chir., Bd. 2. 2io 434 DEFORMITIES OF THE UPPER EXTREMITY. ally seen as congenital deformities. They are, in most instances, asso- ciated with laxity of the ligaments. Similar deformities are not uncommon during the progessive stage of rhachitis, but they usually disappear when the erect attitude is assumed and when the arms are relieved of the strain of supporting the body in the sitting posture. What may be called normal cubitus valgus, is common among women, and in certain instances it may be exaggerated to deformity. Acquired cubitus varus is usually the result of direct injury. Subluxation of the Wrist. A peculiar displacement of the hand forward and to the radial or ulnar side, described by Madelung ^ as " spontaneous subluxation," is sometimes seen in young subjects whose occupation may require con- stant use of the flexors of the hand and fingers. In these cases the lower extremities of the bones of the arm project on the dorsal surface, the flexor tendons are prominent on the palmar aspect and limit the range of extension of the hand, the wrist may be slightly enlarged and the ligaments seem to be relaxed. The symptoms, aside from the de- formity, are weakness and sensations of discomfort about the dorsum of the wrist. Etiology. — The predisposing causes of the affection are, apparently, relaxation of the ligaments and, possibly, slight preexisting rhachitic deformity of the same character. The exciting causes are occupation or injury. In some instances there is a slight forward bending of the lower extremity of the radius, due, apparently, to irregularity in growth at the epiphyseal junction. Treatment. — The treatment is rest, massage, forcible manipulation in the direction of extension and a support of leather or other material to hold the hand in the extended position until the tendency to defor- mity is checked. Congenital Deformities at the Wrist. Simple congenital dislocation of the wrist is extremely rare. Dis- placement of the wrist and hand is usually associated with defective development of the bones of the arm, and the deformity is usually classed as club hand. Club Hand. Congenital distortions of the hand may be divided into four primary varieties, according to the direction in which the hand is' turned, viz.: 1. Forward or palmar. 2. Backward or dorsal. 3. Lateral to the radial side — radial. 4. Lateral to the ulnar side — ulnar. Lateral and antero-posterior distortions occur also in combination. ■ Etiology. — There are two distinct varieties of club hand : 1 Archiv f. Klin. Chir., Bd. 23. CLUB HAND. 435 1. In which there is simple distortion caused apparently by ab- normal fixation and pressure in utero. 2. In which the deformity is associated with defective develop- ment of the radius or ulna and often with congenital abnormalities of other parts. In the palmar and dorsal distortions the bones of the arm are usually normal. The lateral deviations of the hand are often caused by de- fective formation of the radius or ulna, and thus they correspond to talipes due to absence of the tibia or fibula. According to Hoffa/ 39 cases of the former and but 6 of the latter are recorded ; in but one case was there entire absence of the ulna. Fro. 306. Club hands and club feet. Of the 39 cases of radial club hand 19 were of both sides. These sta- tistics, however, by no means represent the relative frequency of the deformity. From the writer's observation it would appear that radial club hand is nearly as common as the deformity of the foot caused by absence of the fibula, of which, according to Potel, there are 200 re- corded cases. The ulnar form of club hand is less frequent even than the deformity due to defective formation of the tibia. The most important form of club hand is, then, that due to absence or to defective formation of the radius. As in talipes valgus due to absence of the fibula, the tibia is short and often bent sharply forward, so in this form of club hand ihe. ulna is usually short and bent inward. The hand may be perfect in formation, but as a rule the thumb is ab- 1 Lehrb. der Orth. Chir., p. 481. 436 DEFORMITIES OF THE UPPER EXTREMITY. sent or rudimentary and other adjoining bones, together with the cor- responding ligaments and muscles, may be absent also. (Fig. 307.) The hand occupies practically a right-angled relation to the ulna and as this bone is usually bent inward as well, the direction of the hand is often reversed and is parallel to the forearm. As a rule the hand is also somewhat bent forward, so that the deformity might be described as radio-palmar. (Fig. 308.) Treatment. — In those forms of club hand in which the structure is normal the deformity may be overcome as a rule by manipulation, and support by the plaster bandage or otherwise. Massage and mus- cle training are required in the after-treatment. In slighter cases of radial club hand, due to defective development. Fig. 307. Congenital absence of radius and the bones of the thumb. (Weigel. ) it may be possible by manipulation and tenotomy to replace the hand in its normal position, but this is unlikely. As a rule an operation on the ulna will be necessary, together with division of the contracted tissues. Sayre ^ removed a portion of the carpus and implanted the head of the ulna at the point of resection. McCurdy ^ sawed through the ulna, leaving the extremity in relation to the carpus and sutured the proximal fragment and the semi-lunar bone to one another. Thomson ^ replaced the hand by subcutaneous tenotomy and by the re- moval of a cuneiform section of bone from the lower end of the ulna. The operation of splitting the ulna into an ulnar and radial portion 'Trans. Amer. Orth. Ass'n, Vol. YI. 2 Ibid., Vol. VIII. 3 Ibid., Vol. IX. WEBBED FINGERS. 437 aud implanting the carpus between the two, has been performed by Bard^nhauer.^ The immediate effect of the various operative proce- dures was favorable, but no final results have been reported. In any event some form of apparatus must be used during child- hood at least, to support the hand, whether the operation has been successful or not ; and at best the arm will be short, and the thumbless hand Fig. 308. will be weak as compared with the normal. Congenital Contraction of the Fingers. The most common form of congenital contraction is that of the little finger, on one or both hands, which is semi-flexed, apparently, because of deficiency of the skin. In other instances several fingers may be similarly affected. Treatment. — If treatment by manip- ulation and splinting is begun early the deformity may be overcome by length- ening the contracted tissues. In later life the prospect of perfect cure by any method of treatment is slight, because of the strong tendency to recontraction after the finger has been straightened. Webbed Fingers. In the most common form of this de- formity two or more fingers are joined by skin and fibrous tissue to the first pha- langeal joints, but sometimes through- out the entire length of the fingers. In other instances the web may be thicker, containing muscular fibers from the apposed parts and, occasionally, the ,,e feTzld det-med forl'arrsrirs! bones ol the two fingers may be joined to ^^^ '^gs. (Gibney.) one another, even to the finger nails. Etiology. — The cause of the deformity is arrest of development before the fingers have been separated from one another, thus the thumb, which is differentiated from the other parts of the hand as early as the seventy-fifth day of intra-uterine life, is rarely involved, as compared with the fingers which are separated from one another at a later period. Treatment. — In all but the extreme grades of deformity the fingers may be separated from one another ; operative treatment being con- ducted according to the rules of plastic surgery. 1 Verhand. der deutsch. Gesells. fur Chir., 23 Kong., 1894. 438 DEFORMITIES OF THE UPPER EXTREMITY. Congenital Displacements of the Phalanges and Distortions of the Fingers. These deformities are not particularly imconimon. They should be treated by manipulation and by splinting at as early a period as is practicable. Other congenital deformities and malformations of the hand do not call for extended comment. Trigger Finger. Synonyms. — Jerking Finger, Snapping Finger. This affection was first described by Nelaton under the title Doigt a Ressort. On extending the closed hand one finger remains flexed. If the flexion is overcome by greater muscular effort or by passive force the finger flies back to complete extension with a sudden snap or jerk, hence the name. In well-marked cases the same difiiculty and the subsequent snap is experienced in flexing the finger. The middle and ring fingers are more often affected but sometimes the thumb or the fifth finger may be involved. The patient usually complains somewhat of stiffness and pain in the finger but the interference with its function is the principal symptom. Etiology. — The usual explanation of the disability is interference with the motion of the tendon in its fibrous sheath, either because of a reduction of its calibre due to injury or inflammation, or to an enlarge- ment or irregularity of the tendon itself. In most instances the obstruc- tion appears to be in the neighborhood of the metatarso-phalangeal joint. The duration of the affection is indefinite. Treatment. — If the obstruction appears to be of inflammatory or traumatic origin it may be treated by splinting and later by massage. In confirmed cases the tendon and the sheath may be explored in the hope of finding and removing the obstruction.^ Mallet Finger. Synonym. — Drop Finger. This is caused usually by a blow upon the terminal phalanx which ruptures or weakens the attachment of the extensor tendon at the base of the phalanx so that it is habitually flexed to a right angle with the finger. The treatment must be by incision and reattachment of the tendon to the periosteum. Baseball finger (Abbe) is the reverse displacement of the terminal phalanx which is dislocated backward, forming a bayonet-like deformity. If reposition is impossible open incision should be employed to cor- rect the deformity. Dupuytren's Contraction. Dupuytreu's contraction is a deformity of the hand caused by contrac- tion of a part of the palmar fascia and of its prolongations to one or 1 The bibliography is hvrs'e. More recent articles are those of Jamin, Cent, fiir Chir., June 6, 1896, who reports 31 cases and A. Necker, Beitrage zur Klin. Chir., Bd. X., p. 469. DUFUYTBEN'S CON TB ACTION. 439 more of the fingers. The fingers are flexed as a consequence, to a greater or less degree, and in advanced cases they may be drawn to close contact with the palm. The ring finger is most often primarily affected but as a rule two or more fingers are somewhat involved in the contraction. In a large proportion of the cases both hands are involved, but not as a rule simultaneously, the contraction beginning in the second hand several years after the deformity in the first. Pathology. — The characteristics of the deformity are explained by the anatomy of the palmar fascia. This consists of a strong central portion, and two thinner lateral parts that cover the muscles of the thumb and little finger. It is made up of longitudinal fibers continu- ous with the tendon of the palmaris longus and the annular ligament. It divides into four processes that are attached to the digital sheaths, to the integument at the clefts of the fingers and to the superficial trans- verse ligament. Prolongations of the fascia pass along the lateral aspect of the fingers and are attached to the periosteum and to the tendon sheaths of the first and second phalanges. The cause of the contraction appears to be a chronic plastic inflam- mation of a part of the fascia, which becomes hypertrophied, and finally contracts, drawing the finger toward the palm in the manner described. Etiology. — The etiology is uncertain. The contraction is much more common in men than in women and it is practically confined to middle and later life. It is claimed that the deformity is more common among those who are subject to gout or rheumatism. It appears also to be an hereditary affection in certain instances. Injury or irritation of the palmar tissues, incident to cer- tain occupations, would seem to explain the disproportionate liability of the sexes to the affection. Symptoms. — The first symptom is usually the deformity ; the pa- tient finds it impossible to completely extend one or more of the fingers, the tissues about the base of the finger seem stiff, and when it is forcibly extended a hard, elevated cord may be felt extending from about the center of the palm to the second phalanx, most prominent at the metacarpo-phalangeal articulation. To this the skin is adherent, and as the contraction increases it is thrown into elevated ridges. Later, other bands appear if the con- traction affects, as it usually does, other portions of the fascia. In many instances no pain is experienced unless the contracted fascia is forcibly stretched or is pressed upon. In other cases complaint is made of neuralgic pain in the hand and even in the arm and back. Occasionally the first symptom to attract attention may be a sensitive nodule in the skin at the base of the finger. The contraction usually increases slowly until the finger that is most affected is drawn to the palm. Treatment. — The deformity may be overcome by division or prefer- ably by removal of the contracted bands of fascia. The finger is then supported in an attitude of slight flexion until the circulation is adjusted to the new position. CHAPTER XVII. DISEASES OF THE NERVOUS SYSTEM. From the orthopaedic standpoint, only those diseases that directly in- terfere with the function of locomotion or that cause deformity, and for which local treatment is of benefit, are of especial interest. Even this limited class is not often seen in the early or progressive stage and it is rather with the effects of a disease that is no longer present than with the disease itself that the orthopaedic surgeon is especially concerned. The relative importance of this branch of orthopaedic work may be illustrated by the statistics of the Hospital for Ruptured and Crippled. In a period of ten years, 1890-1899, forty-two thousand one hundred and twenty-four new patients were examined in the out-patient de- partment. Excluding cases that cannot properly be classed as ortho- paedic, thirty-eight thousand four hundred and nineteen remain. In two thousand four hundred and forty-one of these the nervous system was involved (6.3 per cent.). Two thousand and twenty-eight of the cases were in young children ; four hundred and thirteen of the pa- tients were more than fourteen years of age and of this number two hundred and sixty-six were adults. Anterior poliomyelitis furnished about 75 per cent, of the total number. In 20 per cent, the cerebrum was involved and 5 per cent, were miscellaneous cases. In 611 cases treated in a period of about two years there were 463 cases of poliomyelitis, 121 cases of paralysis of cerebral origin, 1 6 cases of obstetrical paralysis, 4 cases of pseudo- hypertrophic muscular paralysis and 7 miscellaneous cases. These statistics will explain the selection of diseases of the nervous system for consideration and the order in which they are described. Acute Anterior Poliomyelitis. Synonym. — Infantile Paralysis. Pathology. — Anterior poliomyelitis is an acute inflammatory process of the area of the gray matter of the anterior cornua supplied by the anterior spinal arteries involving both the neuroglia and the cells, and resulting in degeneration and atrophy of the interstitial tissue and of the ganglion cells. ^ In the acute febrile form, comprising about three-fourths of the cases, there is an actual inflammation ; in the other type, in which there are no constitutional evidences of disease, the symptoms may be caused by hemorrhage or by thrombosis. ^ Starr, Loo mis-Thompson, System of Practical Medicine. ETIOLOGY. 441 The minute changes in the cord are characteristic of inflammation, disteiided blood vessels, minute hemorrhages, infiltrating leucocytes and serum. In the early stage the motor cells become cloudy in ap- pearance, later they are swollen and lose their distinct outlines. The degenerative changes aiFect both the cells and neuroglia ; the affected gray matter shrinks and the nerve fibers atrophy, and the cord becomes distinctly smaller at the seat of the disease. When the motor con- ductivity of the cells is cut off, the muscles which are supplied by them are paralyzed and waste away. The circulation in the affected parts is impaired, contractions and distortions appear and growth is retarded. Etiology. — The etiology of the disease is obscure. Exposure to heat, sudden chilling of the body, over-fatigue, injury and the like, are thought to be predisposing causes, while the direct cause of the inflam- matory disease of the cord is supposed to be some form of infection. The disease affects the sexes in nearly equal numbers, and those in perfect health as often as those whose resistance is enfeebled. It some- times occurs in epidemics and there are instances in which several members of the same family have been affected, but usually the cases are isolated and no adequate cause for the disease can be assigned. Age. — Acute anterior poliomyelitis is essentially a disease of infancy. This is illustrated by the combined statistics of several observers tabu- lated by Starr. ^ i CO i i K 00 3 S Seeligmuller 20 17 44 21 16 25 38 92 21 38 18 15 55 25 27 1 4 29 9 9 1 1 9 17 10 2 2 4 4 3 2 2 6 I 4 4 G albraith Sinkler 3 Gowers Starr 3 118 214 140 52 38 12 7 14 8 6 472, 01 77 p 3r cen t., bef ore t\ le f ou rth ye ar. It is far more common during the warm months than at other sea- sons, as is illustrated in 452 cases tabulated by Starr.^ January 8 February 5 March 20 April 9 May 18 June 49^ Ayjl'ust 116 f'^^^' ^^' "^^ P^^* ^^"*-' during the four September ■.■.■.;■.■. 65 J "'^"^^^' ^""^ *^ September. October 42 November 11 December 12 452 ' Loomis-Thompson, System of Practical Medicine. ^Loc. cit. 442 DISEASES OF THE NERVOUS SYSTEM. Distribution of the Paralysis. — The lower extremities are far more often paralyzed than the upper. In 416 of 595 cases, tabulated by Starr, the paralysis was limited to the lower extremities, as contrasted with 53 cases in which the upper extremities were alone involved. Both legs 9 Eight leg 25 Left leg 7 Eight arm 5 Left arm 5 Both arms 2 All extremities 5 Arm and leg same side 1 Arm and leg opposite sides I 2 Trunk i 1 Three extremities I 62 14 15 27 9 4 1 2 2 1 75 107 63 62 5 8 1 35 26 1 22 10 340 40 20 27 7 4 2 5 4 4 3 2 118 170 123 123 26 21 6 47 33 8 26 12 595 Symptoms. — The disease is usually divided into several stages : 1. The stage of onset. This is usually attended by constitutional symptoms, by fever and headache, even by convulsions and delirium ; by vomiting and intestinal disturbance, or occasionally by severe pain. In most instances the elevation of the temperature is not extreme, nor is the constitutional disturbance severe, and but for the paralysis, the attack would be considered as one of the ordinary illnesses so common in childhood. In some cases however the fever is high and there may be convulsions and prolonged unconsciousness, while in others there may be no premonitory symptoms whatever, the child is apparently well at night, but wakens in the morning paralyzed. In many instances the weakness caused by anterior poliomyelitis is not discovered until the child begins to walk, when the awkward gait, or limp, or the distortion of a foot, may make it evident. In a few hours, or a few days, after the first symptoms of the dis- ease the paralysis appears ; its area may extend slowly after it is recog- nized or its extreme limit may be reached at once. This original paralysis is always greater than that which finally persists. The dura- tion of the first stage may be from a few hours to a week. 2. Then follows a stationary period, lasting from a week to a month ; the constitutional symptoms cease, but the paralysis remains. 3. This is succeeded by the stage of partial recovery, lasting from one to six months or longer. The muscles which were paralyzed be- cause of the secondary congestion and exudation about the local mye- litis, recover their power in whole or in part, while those muscles sup- plied from the area in the cord in which the nerve cells have been destroyed, waste away. At this time the contractions and distortions in the paralyzed part appear. 4. The chronic stage. This mav be considered to last until adult DIAGNOSrS. 443 age, or until the ultimate damage to the individual, due to the retarda- tion df the growth and unbalancing of the mechanical equilibrium of the body, may be summed up. The sensation of the paralyzed part is not affected except in the ex- treme cases. The temperature is lower from the first. In many in- stances the limb is not only cold, but it is congested and blue. These circulatory disturbances are caused primarily by the interference with the vaso-motor system, but they are confirmed later by the atrophy of the muscles and by the permanent contraction of the blood vessels. Thus, in general, the impairment of the circulation corresponds to the degree of the paralysis, but not absolutely so. In certain cases the paralysis may be very limited in extent, and yet the limb may be cold and congested, while in others in which the loss of power is much greater the temperature is but slightly lowered and the color remains normal. The same is true of retardation of growth. In most in- stances the ultimate shortening of the limb corresponds to the degree of the paralysis, and consequent loss of function ; but occasionally cases are seen in which the growth is markedly retarded although but few of the muscles are paralyzed. Diagnosis. — It is doubtful if the diagnosis of acute anterior polio- myelitis could be made before the stage of paralysis. But after the paralysis has appeared there should be little difficulty in interpreting the symptoms. It is a disease usually of acute onset, followed by paralysis of certain muscular groups or of entire members. It is a ilaccid paralysis, the reflexes are lost, the muscles no longer contract under faradism and the reaction of degeneration is present ; the tissues waste and the circulation is impaired in the affected parts. It is usual to consider, first, in differential diagnosis the paralyses of cerebral origin, but this is more for the purpose of calling attention to the essential differences between the two, than because they are likely to be confounded by one acquainted with the ordinary charac- teristics of cerebral and spinal disease. Paralysis of Cerebral Origin in Childhood. — In paralysis of cerebral origin, the common form is hemiplegia. It usually follows convul- sions and the intelligence maybe impaired. The paralysis is not com- plete, nor is it limited to groups of muscles ; it is rather powerlessness or impairment of function, due to loss of cerebral control. The reflexes are increased and limbs are stiffened, not flaccid. The electrical reac- tions are not lost or changed in quality. Paralysis of cerebral origin may be also paraplegic or diplegic in its distribution, but in these cases the general characteristics are the same as in the hemiplegic form, ex- cept that the intelligence is more markedly affected. Other Forms of Spinal Paralysis. — Transverse myelitis is very un- common in childhood. In this disease the distribution is equal, the re- flexes are at first increased and sensation as well as motion is lost. Pott's Paraplegia. — In this form of paralysis, also, the distribution is equal, the reflexes are increased and the signs of the disease of the spine are always present. 444 DISEASES OF THE NERVOUS SYSTEM. Rheumatism and Joint Disease. — In orthopsedic practice, anterior poliomyelitis is not often seen in the early stage, unless pain is a prominent symptom, when the disease may be mistaken for rheuma- tism or for some form of joint disease. Cases of this type are not un- common. The muscles are sensitive to pressure and the movements of the joints cause discomfort. In certain instances the paralysis may not be apparent on the first examination ; when it does appear the di- agnosis is, of course, established, therefore the characteristics of disease of the joints need not be detailed. Multiple Neuritis. — Multiple neuritis is usually a sequel of infectious disease, or of metallic poisoning. In the cases due to metallic poison- ing with lead or arsenic, the paralysis usually begins in the extensors of the hands and feet, and is symmetrical in its distribution. This is true also of the limited forms of paralysis following contagious diseases in which the dorsal flexors of the feet are most often involved. In multiple neuritis there is usually local sensitiveness lasting a longer time than in poliomyelitis, and the paralysis is gradual in its onset and the sensation, as well as motion, is aifected. Diphtheritic Paralysis. — Diphtheria is the most common cause of general weakness terminating in paralysis, but in these cases there is usually a history of the preceding disease. The paralysis appears first in the muscles of the throat and neck, and a general and increasing weakness precedes for a considerable interval the complete loss of power. Weakness. Pseudo-Paralysis. — Weakness caused by rhachitis, or so-called pseudo-paralysis, due to this or to other affections, is readily distinguished from actual paralysis by pricking the part with a pin when the muscular contraction will be evident. This test of function is of value in showing the distribution of the paralysis. Loss of power in the tibialis anticus muscle, for example, causes valgus resembling closely the ordinary valgus due to simple weakness. In simple weak- ness the child withdraws the foot from the point of the pin, and the ability to move it in all directions is very evident ; but if the tibialis anticus muscle is paralyzed, the foot is always flexed in the abducted attitude. The same test may be made for paralysis of other muscles or muscular groups. It is a test that is easily applied and that is especially useful in the examination of young children. Obstetrical Paralysis. — Paralysis of the arm is infrequent as com- pared with that of the lower extremities. This form might be mis- taken for obstetrical paralysis, but the history of the disability and its distribution should make the diagnosis clear. Prognosis. — Only in very rare instances does the disease of itself cause death. The prognosis as to function depends upon the area of the destructive disease of the cord, and upon the treatment of the weakened or disabled part. As has been stated the extent of the primary paralysis is very much greater than that which ultimately remains when the inflammatory chans-es about the diseased area in the cord have subsided. CAUSES OF DEFORMITY. 445 The Electrical Test. — During the early stages of the disease the degrefe of final paralysis may be fairly estimated by the electrical reac- tion. Within a week after the initial paralysis the reaction to the far- adic current in the muscles and nerves is lessened and finally is lost. If the faradic irritability is retained in the paralyzed muscles, or if it is merely diminished, recovery may be predicted. The muscles which no longer react to the faradic irritation may still be made to contract by the galvanic current. In normal muscles the reaction is greatest at the closing of the negative pole. In the paralyzed muscles the re- action is slower, it requires greater stimulation and the contraction is greater at the closing of the positive pole. This is known as the reac- tion ol degeneration. The loss of faradic reaction and the change in Fig. 309. Anterior poliomyelitis. Extreme flexion deformity at the hips induciug the quadrupedal attitude. (GiBNEY.) the galvanic reaction indicate that the function of the affected muscle is lost, although certain of its fibers may in time regain their power. The Effects of Paralysis of Dififerent Muscles and G-roups of Muscles upon Function. — The interest in anterior poliomyelitis lies in its imme- diate and ultimate effect upon the functional ability of the individual. These effects may be classified as Deformity of the part directly involved. The general effects of weakness, deformity and loss of growth upon the body as a whole. Causes of Deformity. — The deformities of anterior poliomyelitis are caused : 1 . By the force of gravity. 2. By the unopposed action of the muscles whose power remains. 446 DISEASES OF THE NERVOUS SYSTEM. 3. By functional use. All these and other less important causes of deformity are of course combined in most instances. The relative importance of each factor varies, according to the muscular group that is involved, with the age of the patient and with the work to which the part is subjected. The influence of the different factors can be studied best in the foot. Muscular Action and Gravity. — In by far the larger number of cases, one or more of the anterior muscles of the leg, dorsal flexors of the foot, are involved. This is illustrated by the statistics of ac- quired talipes, tabulated elsewhere, in which the equinus predominates over the varieties of calcaneus deformity in a proportion of three to one. If the anterior muscles are paralyzed in a child before the walking age, the foot drops under the influence of the force of gravity into the attitude of equinus. If this attitude is allowed to persist, the muscles on the posterior aspect of the limb accommodating themselves to the habitual attitude, in time become structurally shortened. In such cases the equinus deformity is caused by the force of gravity ; it is in- creased by muscular action and it is fixed by muscular adaptation. That deformity is not caused directly by muscular action is shown by the fact that it may be prevented by stimulating the paralyzed muscles from time to time with galvinism, or even by passive motion to the limit of dorsal flexion. Deformity is thus prevented, not by opposing muscular action, but by preventing muscular adaptation and structural change, by stretching the active muscles to their full limits from time to time. In the instance cited, gravity and muscular activity are com- bined in the production of equinus, but in other instances, gravity and muscular power may be opposed to one another. If, for example, the calf muscle is paralyzed while the anterior group retains its power, the deformity of calcaneus does not appear until the child begins to use the foot, when the peculiar helplessness calls attention to the disability, if the diagnosis has not been made before. Thus it is that equinus may be present when the child is still in arms, while the opposite de- formity develops much more slowly. Habitual Posture. — There are other cases in which every vestige of muscular power is lost, in which the foot dangles. In this class there is no adaptive shortening of the muscles to fix the foot in the habitual attitude, consequently deformity is slow in making its ap- pearance ; it is not often extreme, and it becomes fixed only by the structural shortening of the inactive tissues, the ligaments and fasciae. There are, of course, other causes for habitual posture than the force of gravity and muscular action, such as, for example, the position of convenience in which a weak or disabled part might be placed, but such causes of deformity may be considered as instances of functional use or rather of adaptation to local weakness. Functional Use as a Cause of Deformity. — Thus far the force of gravity, unbalanced muscular power and the structural changes in the tissues have been considered in the etiology of deformity, as it might develop in infancy. When, however, the patient stands and walks^ THE DEFORMITIES OF AI^TERIOR P0LI03IYELITIS. 447 Fig. 310. existing deformities are exaggerated and distortions are developed and confirmed by the weight of the body falling on the unbalanced part, and by the action of the muscles in the attempt to supply the function of those that are paralyzed. Thus it is that deformity develops far more rapidly when a fair amount of muscular power remains, than when it is completely lost. (See talipes.) Subluxation. — Aside from the distortions due to the causes that have been mentioned, there are others caused simply by weakness ; for example, when laxity of ligaments and the failure of muscular sup- port permits distortion of a limb and subluxation or even displace- ment at a joint. (Figs. 311, 312.) Actual displacement is uncommon and occurs practically only at the hip. In such cases there is usually flexion deformity of the limb. The femur is suspended by the contract- ed tissues attached to the anterior superior spine. This unyielding band forms a fulcrum by means of which force applied at the knee may cause sudden displacement of the head of the femur inward or upward and backward .JJJJ^^§pt?^ Deformities of the Upper Extrem- ity. — Deformities caused by paraly- sis of the muscles of the shoulder and upper arm are usually slight because the part is not subjected to the strain of weight -bearing, and because the force of gravity is opposed to muscular contraction. In these cases the loss of support and the tension on the capsule al- lows a considerable separation of the joint surfaces so that the atro- phied head of the humerus may be displaced forward or backward ; but there is not often fixed dis- placement, and consequently distor- tion due to this cause is very un- usual. Paralysis of the muscles of the forearm and of the hand is followed after a time by deformity of the fingers caused primarily by unopposed muscular action, secondarily by accommodation and atrophy. Deformities of the Neck. — Paralysis of one or more of the muscles Anterior poliomyelitis. Duration seven years. Showing atrophy, and slight lateral cur- vature of the spine. 2J^ inches of shortening. 448 DISEASES OF THE NERVOUS SYSTEM. of the neck may induce a paralytic torticollis. This is, however, ex- tremely rare. Deformities of the Trunk. — Paralysis of the muscles of the trunk may induce distortion and extreme lateral curvature of the spine. This curvature is not usually caused, as might at first appear, by contrac- tion of the active muscles and thus a bending of the trunk with a con- FiG. 311. Anterior poliomyelitis causing genu recurvatum. (See Fig. 312.) vexity toward the weaker side. As a rule, the curvature is, as a whole, in the opposite direction. This is explained by the fact that if the paralysis is extensive enough to cause distortion of the trunk, and if it is limited to one side, the muscles of respiration on that side are also paralyzed or weakened so that the chest wall becomes inactive and collapses while the opposite side increases in volume and lung capacity in taking on the extra work ; thus it expands, drawing the weaker and RETARDATION OF GROWTH. 449 atrophied side into a concavity. The same effect is observed when the a?m and the shoulder muscles are paralyzed, the spine bend- ing toward the side that is still active. Paralysis of the posterior group of muscles, if extreme, might cause a kyphosis. Paralysis of the muscles of the abdomen may induce lordosis, but in this group ot cases the lower extremities are usually involved and the secondary distortions due to posture and to func- tional use mask the direct effect of the paralysis of the muscles of the trunk. And again the over-use of the shoulder muscles in patients whose lower extremities are paralyzed, and the suspension of the body on crutches in walking modify the ultimate effects in these cases in which the paralysis is wide-spread in its area. (See lateral curvature.) Retardation of Growth and Secondary Deformities. — The effects of anterior poliomyelitis are not limited to the paralysis and to atrophy of the muscles, but all the component tissues of the affected limb are involved as well. The bones become relatively atrophied and their Fig. 312. Anterior poliom3'elitis. Paralysis of muscles at the hip allows subluxatiou of the femur. The same patient as in Fig. 311. growth is retarded to a degree proportionate to the extent of the par- alysis and to the functional disability that has resulted. It has been stated however that retardation of growth does not always correspond to the amount of paralysis. In some instances paralysis of a single muscle which does not seriously compromise the function of the part is attended with greater shortening of the limb than in other cases in which the paralysis is far more extensive. Thus it may be inferred that certain cells in the spinal cord are especially concerned in the growth and nutrition of the bones and that interference with the function of these cells may not correspond absolutely to the extent of the de- structive process. However this may be, it is certain that atrophy and retardation of growth are much greater when a limb is not used than when by the aid of apparatus it has been enabled to carry out, in part at least, its proper function. It is evident also that retardation of growth will be more marked during the period of rapid develop- ment ; thus the younger the patient the greater should be the ultimate inequality of the limbs. 29 450 DISEASES OF THE NEBVOUS SYSTEM. Retard ATiox of Growth. — The ultimate shortening varies from one to three inches. In the slighter degrees of paralysis affecting the leg, the shortening may be less than an inch, but when the thigh muscles are paralyzed also, it maybe much more. (Fig. 310.) This inequality is usually very evident in the size of the two feet. When both limbs are paralyzed so that locomotion is very seriously interfered with, the retardation of growth is especially marked and the contrast between the trunk of the patient and the attenuated lower ex- tremities is very striking. Secoxdaey deformities must include besides those already men- tioned the compensatory distortions of the trunk that may follow paralysis of the limbs. Thus a short leg might cause a lateral curva- ture of the spine or great flexion contraction of the thigh might induce abnormal lordosis. As a matter of fact, the final effects of disabilities of this character are very complex and are influenced by many factors of which only a general indication is practicable. Treatment. — The treatment of the acute stage of anterior polio- myelitis is symptomatic. If the diagnosis has been made, such measures as would tend to relieve the congestion about the diseased area should be employed ; cathartics, sedatives, and counter-irritation of the spine, for example. When the acute symptoms have subsided, local treat- ment to maintain as far as is possible the nutrition of the muscles, to pre- vent deformity and to relieve the strain upon the weakened tissues is indicated. The nutrition of the parts may be improved by massage, by muscle beating, by the direct application of heat to the cold ex- tremities, and by the use of galvanism, as long as it will produce con- tractions in the paralyzed muscles. Deformity may be prevented by moving each joint to the limit of the range of motion in all directions several times a day and by sup- porting the limb with appropriate apparatus. Deformity in those parts in which it is favored by muscular action and by the force of gravity, ap- pears much more rapidly than is generally supposed. The indications of equinus, for example, are apparent in a very few weeks after paraly- "sis of the anterior muscles of the leg. The first indication of such de- formity in this class is the discomfort caused by passively moving the foot toward dorsal flexion. This limitation of the range of motion rapidly increases, and as it increases it is confirmed by muscular adap- tation and finally by structural shortening. The Principles of Mechanical Treatment. — The object of a brace is to prevent the deformity due to weakness, to utilize the muscular power that remains and thus to enable the disabled member to carry out its function. As each muscle has an essential function, the paralysis of any muscle must be followed by a certain disability and usually by de- formity. Muscles vary in importance as they do in strength and the ultimate disability caused by paralysis may be predicted very accurately by one who is familiar with this function. Paralysis of the Anterior Muscees of the Leg. — Paral- ysis of the anterior leg group causes the so-called steppage gait, the toes MECHANICAL TREATMENT. 451 C^ <^r33 drag on the floor when the limb is swung forward and this necessitates an awkward lifting of the knee. The result of such paralysis is equi- nus. Slight equinus has a tendency to throw the Fig. 313. Fig. 314. knee backward, "recur- vatum," in order that the patient may place the entire sole on the ground. More marked equinus obliges the patient to bear the weight entirely on the front of the foot and causes flexion both at the knee and hip. If but one of the muscles of the anterior group is paralyzed the tendency to equinus is in so far lessened, but there is an inclination to lateral distortion. Paralysis of the anterior muscles causes an awkward gait and often deformity, but the propelling force of the limb remains. The indication for support is simple, to prevent the foot from drop- ping to the extent that incommodes the patient, or practically to hold the foot at a right angle with the leg. Paralysis of the Posterior Muscles of the Leg. — If, on the other hand, the calf muscles are paralyzed the resistance of the foot is lost and it is simply dorsi-flexed when weight is thrown upon it. Thus the brace must be arranged to prevent dorsal flexion, and strong enough to support the strain which is transmitted from the foot plate of the brace to the front of the leg. The various weaknesses and de- formities of the foot and the means of treating them are described at length elsewhere. (See talipes.) Paralysis of the calf muscles not only affects the foot, but it weakens the knee as well, and genu recurvatum is often a secondary effect. In many instances therefore it will be necessary to support the knee as well as the ankle during the earlier stages of the treatment. Paralysis of the Thigh Muscles. — Paralysis of the quadri- ceps extensor muscle causes primarily a peculiar gait. The patient, unable to extend the leg upon the thigh, throws or swings it forward, then locks the joint by direct contact of the bones and by the resist- ance of the posterior tissues, by inclining the body somewhat forward as the weight falls upon it. In this manner again the knee may be over-extended. Or if extension is checked by shortening of the tissues, The Judson brace for paralysis of the quadriceps extensor mus- cle in connection with deformity of the foot. 452 DISEASES OF THE NERVOUS SYSTEM. induced possibly by habitual assumption of the sitting posture, the pa- tient being unable to lock the joint effectively by complete contact of the bones, often trips and falls because of the insecurity of the sup- port. When in the normal subject the weight is borne upon one leg in the attitude of rest, in which the muscles are thrown out of Fig. 316. Fig. 315 A brace for complete paralysis ol' the limb, sbo win g a form of lock at the knee and a limited joint at the ankle. Anterior poliomyelitis. Paralysis of the ante- rior and posterior muscles. Right leg. action, the knee joint is locked, but the insecurity of this support is illustrated by the school boy's trick of striking the back of the knee with the hand when, the muscles being taken unawares, the person falls to the ground. This insecurity is constant when the extensor of the leg is paralyzed. Paralysis limited to the quadriceps extensor muscle is, however,. MECHANICAL TREATMENT, 453 very unusual. In almost all cases some of the leg muscles are involved also, and the brace usually must serv^e to support the foot as well as the knee. In its ordinary form such a brace is constructed of two lateral upright bars, reaching nearly to the pubes on the inner and to the trochanter on the outer side, joined to one another by bands pass- ing beneath the thigh and the calf, and attached to a light steel foot jjlate. If the dorsal flexors of the foot are paralyzed the ankle joint is arranged to allow dorsal flexion, but to prevent extension beyond the right angle. If the calf muscle is paralyzed a reverse catch is used, or the uprights are attached directly to the foot plate without a joint Fig. 317. Brace for complete paralysis of the anterior muscles of the limb ; before and after covering. (Fig. 314) ; or the so-called limited joint allowing only a few degrees of motion in either direction is used. (Fig. 315.) (See talipes.) In the treatment of young children the joint is also omitted at the knee, the limb being firmly held in the extended position during the active period. (Figs. 314 and 3 17.) This is of advantage because the joint is the weakest part of the brace and soon becomes loose under the se- vere strain to which it is subjected. In older subjects a joint is ar- ranged with a spring catch, the brace being held in the straight posi- tion when the patient is walking about, but allowing flexion when the sitting posture is assumed. This is of course a great convenience. 454 DISEASES OF THE NERVOUS SYSTEM. (Fig. 315.) In fitting the brace the lateral bars should be adjusted to support the limb without uncomfortable pressure, and the joints should be exactly opposite the normal centers of motion. The thigh and leg bands should be properly fitted to the contour of the soft parts so that half the limb is contained within them. These are smoothly covered with leather and the limb is held in position by leather bands that complete the circumference. Other bands are applied across the front or back of the limb, either to support it or to fix it firmly in place. In the ordinary brace without the joint at the knee, there are three anterior bands, one across the front of the thigh, another across the leg, and the third, a wide knee cap, supports the greater part of the strain. (Fig. 317.) Paralysis of the Muscles of the Hip. — The effect of paralysis of the muscles about the hip is difficult to describe, as in these cases many other muscles are usually involved. If all the muscles are paralyzed the thigh dangles. This is however very unusual, for the tensor va- ginae femoris almost always retains its power and is one of the causes of flexion deformity which is so often present in cases of this character. Paralysis of the ilio-psoas muscle makes it impossible for the pa- tient to flex the thigh directly. If the adductors are paralyzed he must lift the thigh with the hand when adduction is desired. Paralysis of the glutei is made evident by the atrophy and by the weakness of the extending power of the limb. The distribution of the paralysis of the muscles of the hip may be ascertained by placing the patient in the recumbent posture ; the leg is then lifted from the table, and by placing the thigh in different po- sitions the ability of the patient to move it may be tested, in older subjects by voluntary effort, in the younger ones by pricking the part slightly with a pin. General weakness of the muscles of the hip causes an awkward, insecure gait accompanied usually by outward rotation of the limb, and as has been stated there is almost always accompanying paralysis of other muscles of the extremity. In such cases a pelvic band must be attached to the leg brace. The pelvic band is made of sheet steel of about 18 gauge, two inches wide, fitted to the pelvis which it encircles midway between the crest of the ilium and the trochanter. At this point it is attached to the brace by a free joint. (Fig. 317.) When the band is accurately adjusted and strapped firmly about the pelvis, the necessary security is assured and the attitude of the limb in walking can be regulated. If greater support is desired a perineal band may be applied as described in the chapter on disease of the hip joint. If both limbs are paralyzed double braces must be used. If the muscles of the lower part of the back are much weakened the pelvic band may be replaced by a corset or some form of back brace. For- tunately these cases are uncommon. Paralytic Scoliosis. — Paralytic scoliosis requires the support of corsets or braces as a rule, such as are used in the treatment of other forms of distortion of the back. (See lateral curvature.) OPERATIVE TREATMENT. 455 Pabalysis op the Aem. — Paralysis of the arm is uncommon and treatment is rarely demanded. In some instances a shoulder support may be of service or a brace to hold the arm at a right angle if the biceps is paralyzed. If the muscles of the scapula retain their power the operation of arthrodesis might be of service in fixing the dangling joint, and the same opera- tion might be useful at the elbow. It is of course evident that one of the lower extremities, although hopelessly weakened, may be braced so that it may serve as a simple prop to bear weight, but as the func- tion of the arm is quite different, extensive paralysis of its muscles makes it practically useless to the individual. Operative Treatment. The Reduction of Deformity. — In a large proportion of the cases of anterior poliomyelitis the patients are not seen by the orthopaedic surgeon until months or years have elapsed since the original attack. They are then brought for treatment be- cause of secondary deformity often of an extreme degree. At least half of the cases of talipes are due to this cause and with the deformity of the foot are often combined other distortions varying in degree with the extent of the paralysis. Many of the patients hobble about on a distorted foot, others use crutches and in a smaller number the only method of locomotion is creeping on all fours. In the cases in which the patient has habitually used crutches allowing the paralyzed limb to " dangle " there is usually marked flexion at the three joints. The thigh is flexed upon the pelvis, the leg is flexed upon the thigh and the foot hangs downward and inward (plantar-flexed) in an attitude of equino-varus. No matter how extreme the paralysis of a lower ex- tremity may be the limb may be made useful as a prop, when properly braced and this prop will enable the patient to dispense with the use of crutches and thus free the arms from unnecessary work. Even if both limbs are paralyzed they may at least serve as supports to enable the patient to stand erect and to propel himself with the aid of crutches. If the limb has been disused for a long time, the atrophy is usually extreme, the bones are fragile and the growth has been greatly retarded as compared with those limbs in which deformity has been prevented and in which the weight of the body has been sustained in functional use. In this class of cases the first step must be the reduction of de- formity : the foot must be brought to a right angle with the leg, the limb must be brought to the straight line, and the flexion at the hip must be overcome in order to enable the patient to stand erect without bending the spine forward into an extreme compensatory lordosis. Acquired deformity of the foot is far less resistant than is the con- genital form and by tenotomy and the proper application of force it may be readily straightened, usually at one sitting. The flexion contraction at the knee may be overcome also by careful and persistent manual stretching combined, if necessary, with division of the contracted tissues on the posterior aspect of the joint. The flexion deformity at the hip is usually fixed by the contraction of the tissues about the anterior superior spine of the ilium, including 456 DISEASES OF THE NERVOUS SYSTEM. the tensor vaginae femoris muscle which is rarely paralyzed. These tissues together with the fascia may be divided subcutaneously, or by open incision if necessary ; after which the deformity may be reduced by gradual forcible extension of the thigh while the pelvis is fixed by flexing the other limb upon the body. When the contraction de- formities are reduced, lateral deviation at the knee is corrected, if it be present, in the same manner, and the bony points having been care- fully protected by padding a long spica plaster bandage is applied to fix the limb. The lesser degrees of deformity may be reduced by other means, for examplp, by repeated applications of plaster bandages under slight cor- rective force, or by manipulation, or by braces and bandaging. Paralytic knock knee may be overcome by the Thomas knock knee brace, and this brace when attached to a pelvic band is a useful form of support in the routine treatment of paralysis of the legs. (See knock knee.) The Thomas caliper knee brace is another cheap and useful support. It is of especial service when there is flexion or lateral deformity of the limb. (Fig. 230.) When distortion has been overcome and when functional use has been made possible by proper support, the development of active mus- cles which had been thrown out of use by the distortions, and of those in which part of the muscular substance has been retained is surprising. In many of these cases the distortions which developed during the tempo- rary paralysis had alone prevented recovery and this latent power may be revived even after years of disuse. Thus in many instances prog- nosis is impossible until the deformities have been corrected and until the limb, properly supported, has been enabled to resume its function. Tendon Transplantation. — This operation is best adapted to the treat- ment of distortions of the foot caused by paralysis of the muscles of the leg, and the procedure is described at length in that section. In certain cases of paralysis of the quadriceps extensor when the sartorius muscle has remained active, if may be utilized to better ad- vantage by attaching it to the insertion of that muscle, as suggested by Goldthwait. Muscle or tendon transplantation may be of service, in exceptional cases, in other situations. Paralysis of the muscles of the arm and hand is unusual. The operation of tendon shortening combined with transplantation of the tendons of one or more active muscles may be of service in the treat- ment of wrist drop, and opportunities may suggest themselves in other situations whenever it is possible to utilize the muscular power to bet- ter advantage. Arthrodesis. — As has been stated of tendon transplantation, arthro- desis is of greatest service at the ankle joint where it may serve to fix the foot at a right angle with the leg. (See talipes.) In exceptional cases arthrodesis or excision at the knee may be advisable in the older patients, but in young subjects the strain upon the long, weak lever formed by the two bones will almost always induce deformity. RECAPITULATION OF TREATMENT. 457 Fig. 318. Arthrpdesis at the hip might be of service in complete paralysis of the pelvic muscles, at the shoulder when the muscles attached to the scapula are active, and in exceptional cases at the elbow and wrist to assure an improved position. Osteotomy. — In rare instan- ces, particularly in the extreme deformities in the adult, oste- otomy of the femur at the hip or knee may be necessary in order to overcome resistant dis- tortion. Recapitulation of Treat- ment. — This consists in support and electrical stimulation of the muscles during the period of re- covery, together with a suitable brace to hold the limb in the best possible position for usefulness when the final extent of the par- alysis has become evident. With the support, any treatment that will improve the nutrition of the part is of service ; massage and muscle beating are of especial value. The limb in which the circulation is deficient should be protected from the cold by pro- per covering, and its nutrition may be improved by the direct application of heat, the hot-air or hot-water bath both being useful. Above all else, func- tional use, which is made pos- sible by apparatus, is of the first importance in preserving and stimulating whatever muscular power remains; and special gym- nastic exercises to this end may be employed if practicable. The prevention of deformity during the growing period is of great importance. Every morning and night the joints of the paralyzed part should be pas- sively moved to the normal limits in all directions in order to prevent the gradual limitation of the range of motion which is the first indica- tion of deformity. Lateral deviation of the limb may be prevented by passive manipulation and by the support that may be exercised by modification of the brace that may be employed. Braces should be strong, and as simple as may be in construction. Elastic bands and springs, applied with the design of replacing paralyzed muscles are of Leg brace with pelvic band. Double uprights. No joint at knee. Foi- paralysis of the anterior thigh and leg muscles. 458 DISEASES OF THE NERVOUS SYSTEM. little practical use, since they are ineffective in action, difficult to adjust and easily disarranged. The parent, when treatment is begun, must be impressed with the fact that a brace must be strong enough to serve its purpose even though its weight be objectionable ; that its period of usefulness is limited and that it must be replaced when it is outgrown ; that the breaking of a brace from time to time is unavoid- able, and that such accidents, in so far as they are evidences of the functional activity of the patient, are favorable indications. Careful supervision of the patient, even though the weakness is not great, will be necessary during the period of growth. The contrast between the development and symmetry, the muscular power and prac- tical utility of a limb that has received this care and supervision, and one that has been neglected, is sufficiently striking to impress any one with the necessity for this tedious and apparently never-ending treat- ment. Thus, in this as in other chronic diseases and disabilities, the char- acter and the duration of treatment, its object and the final results that one may expect to attain by it, should be explained to the parents when the care of the patient is undertaken. CHAPTER XVIII. DISEASES OF THE NERVOUS SYSTEM.— Contimied. CEREBRAL PARALYSIS OF CHILDHOOD. Spastic Paralysis. Cerebral paralysis or palsy is in orthopaedic practice second only in frequency and importance to anterior poliomyelitis. It is however entirely different in its distribution and in its effects. It is a form of disability that is characterized by motor weakness, by stiffness and loss of control, rather than by paralysis. It affects entire members and it results in atrophy, contractions and deformity. It may involve half the body, hemiplegia. It may be limited to the lower extremities, paraplegia. It may involve both the upper and lower extremities, diplegia. In rare instances but one extremity is affected, monoplegia. Distribution. — In 452 cases of cerebral paralysis analyzed by Peter- son,^ 332 were of the hemiplegic type, 73 were of the diplegic type and 46 were of the paraplegic type. In 121 cases observed at the Hospital for Ruptured and Crippled, 63 were paraplegic or diplegic and 58 were hemiplegic. The hemiplegic form of paralysis is usually acquired ; the diplegic and paraplegic forms are usually congenital. Etiology and Pathology. — Cerebral paralysis may be divided into two classes, the congenital and the acquired. Congenital Paralysis. — Paralysis of intra-uterine origin may be the result of mal-development or injury or a secondary effect of intercur- rent disease of the mother. Paralysis caused by injury at birth is usu- ally the result of rupture of blood vessels of the meninges due to pro- longed labor or to the pressure of instruments. Acquired Paralysis. — Acquired paralysis may be due to hemorrhage, embolism or thrombosis or to disease. Sachs ^ presents the following classification of causes and effects. Paralysis of intra-uterine origin. Large cerebral defects — true porencephaly. Hemorrhages of intra-uterine origin. Softening. Agenesis corticalis. Paralysis occurring during labor. Meningeal hemorrhage — very seldom intra-cerebral. Resulting conditions : meningo-encephalitis chronica ; sclerosis ; cysts ; atro- phies ; porencephalies. 1 American Text-book of Diseases of Children. ^ Sachs, The Nervous Diseases of Children, 1895. 460 DISEASES OF THE NERVOUS SYSTEM. Paealysis acquired after birth. 1. Meningeal hemorrhage — very seldom intra-cerebral. Embolism; thrombosis in marantic conditions, and occasionally from syphilitic endo-arteritis. Eesults of these vascular lesions, cysts ; softening ;. atrophy ; sclerosis, diffuse and lobar. 2. Chronic meningitis. 3. Hydrocephalus. 4. Primary encephalitis (Striimpell). General Symptoms. ' Motor. — The effect of the lesion of the brain and of the second- ary changes in the cord is to impair the voluntary control of the limbs supplied from the affected area, Fig. 319. and at the same time the inhi- bition of the higher centers is impaired or lost. Thus, together with the loss of power, there is usually a corresponding exag- geration of the reflexes causing a spastic rigidity of the limbs. This induces distortion, which finally becomes fixed by the adaptive changes in the tis- sues. As the centers for the nu- trition of the paralyzed parts are not involved, the muscles do not waste and the circulation is but little affected. Thus the atrophy as compared with pa- ralysis of spinal origin (anterior poliomyelitis) is comparatively slight, and this together with the loss of growth is due rather to the general effects of the dis- ease and to the loss of function than to the direct influence of the nervous lesion. Mextal. — In this form of paralysis the lesion is of the brain and the direct injury of its structure or the interfer- ence with its development is likely to cause mental impairment. This mental impairment is usu- ally more marked in the paraplegic or diplegic than in the hemiplegic form, because in the latter but half the brain is involved, and because the injury or disease occurs at a later period of its development. So also the mental development is usually less interfered with in the para- Congenital cerebral diplegia. Idiocy. CONGENITAL PARALYSIS. 461 plegic than in the diplegic type. For although both hemispheres were originally involved in all probability, yet the recovery of power in the arms shows that the injury was less extensive than when the weakness persists in one or both of the upper extremities. It is estimated that in 50 per cent, of the hemiplegic cases the patients are feeble-minded, al- though comparatively few (13 Fig. 320. per cent.) are idiotic. In the paraplegic and diplegic forms of paralysis about 70 per cent, of the patients are feeble-mind- ed and from 40 to 50 per cent, are idiotic. (Sachs.) Epilepsy is an accompani- ment of about 45 per cent, of all forms of cerebral paralysis and in 20 per cent, of the cases athetoid or associated movements in the paralyzed parts persist. (Peterson.) Congenital Paralysis. The congenital form of cere- bral paralysis is often seen in orthopaedic clinics, because the effect of the lesion of the brain in retarding both the mental and physical development first attracts the attention of the mother. Thus infants are brought for examination be- cause they are unable to sit or stand or to talk at the usual time. In certain instances the cause of the physical weakness spastic paraplegia. is simple idiocy. In such cases the vacant expression, the inability of the child to recognize even its mother, the extreme weakness and the absence of the spastic rigidity of the limbs, will make the diagnosis clear. In another class of cases the weakness appears to be caused simply by retarded cerebral development. The patient is apathetic and weak. In these cases also there is no evidence of paralysis, but the evident intelligence of the patient distinguishes this type from the idiotic class. In cerebral paralysis the child may be idiotic, or simply apathetic, or apparently normal in intelligence, but it is always weak and in the sitting posture the spine is usually bent backward into a long more or less rigid curve. It makes no effort to stand and when placed in the 462 DISEASES OF THE NERVOUS SYSTEM. Fig. 321. erect posture it will be noticed that the thighs are usually pressed closely against one another and that the feet are extended. The limbs are " stiff." There is a peculiar resistance to flexion at the extended joints, which slowly gives way under steady pressure. This is the characteristic spastic rigidity. (Fig. 320.) Deformities. — These children usually begin to stand, and to walk at about the third year or later with an awkward shuflfling gait ; the limbs are usually flexed, adducted and rotated inward ; the knees touch one another or the legs may be crossed, while the feet turn in- ward in a persistent attitude of slight equino-varus. The equilibrium is very easily disturbed, partly because of the deformities and partly because of direct lesion of the brain. In the majority of the congenital cases the paralysis is para- plegic in its distribution ; perhaps fifteen per cent, are of the hemiplegic variety and in a somewhat larger number the paralysis is diplegic in distribution. (Fig. 319.) As has been stated, in a certain num- ber of cases the intelligence is not im- paired, but more often the patients are dis- tinctly feeble-minded. They are very nervous, easily startled, emotional and are often unable to speak distinctly, yet it is interesting to note that this peculiar emo- tional excitability often passes for an ex- treme degree of brightness of intellect and quickness of perception. In fact parents often remain unconvinced that the child is lacking in mental power until it reaches an age when comparison with other children makes this conclusion inevitable. Acquired Paralysis. As in the adult cases the common form of acquired cerebral paralysis in childhood is hemiplegia. About two-thirds of all the cases occur in the first three years of life ; and in about 20 per cent, of the cases the affection of the brain is a complication of infectious disease. The onset is usually sud- den and is accompanied in the majority of the cases by fever, convulsions and loss of consciousness. When the child regains consciousness the paralysis of the arm and leg is at once evident, and in about 20 per cent, of the cases the face is paralyzed also. Deformities. — At first the paralysis is a simple powerlessness, but *■ Acquired cerebral hemiplegia. TREATMENT OF HEMIPLEGIA. 463 soon the exaggeration of the reflexes is evident. As has been stated, there i^ a loss of voluntary power and an increase of the reflexes or stiffness of the paralyzed members. They are no longer competent to assume the more difficult attitudes and functions, and these are replaced by those that are simpler ; thus flexion becomes habitual. In typical hemiplegia the foot is plantar-flexed and adducted. The leg is flexed on the thigh and the thigh on the trunk, and with the flexion, adduction is usually combined. The arm is held against the body, the forearm is flexed upon the arm in an attitude midway be- tween pronation and supination. The hand is flexed upon the arm and inclined toward the ulnar side and the fingers are clasped over the adducted thumb. Disability. — The loss of power is not absolute ; in most instances the patient is able to walk with an exaggerated limp, dragging the stiffened and contracted leg which serves as a prop rather than as an active support. So also the control of the upper extremities is in part retained ; the patient is able to abduct the arm, to partly extend the forearm, sometimes to extend the fingers and to abduct the thumb, but the power to dorsi-flex the hand and at the same time to extend the fingers is not usually retained in a case of this character. Loss OF Geowth. — The growth of the patient as a whole is usually retarded, and checked to a certain extent, by the lesion of the brain. There is in addition a certain degree of inequality in the growth of the two halves of the body. This inequality is more marked in the arms than in the legs. Shortening to the extent of an inch in the lower ex- tremity is not often exceeded, but the growth of the arm and hand may be very markedly checked. This disproportionate loss of growth in the upper over the lower extremity, although it may be explained in part by the situation of the lesion of the brain, depends more directly upon the interference with function. The lower extremity is rarely disabled to an extent that prevents its use in locomotion, consequently its nutrition is preserved, whereas the same degree of paralysis of the arm utterly unfits it for its more difficult functions and it becomes a useless appendage. With the disuse of function there is a correspond- ing diminution of nutrition and a consequent atrophy and loss of growth. Extreme deformity and disability, as in the type described, is rather unusual. In many instances there is almost complete recovery from the paralysis, only an awkwardness and slowness of movement, com- bined with an increase of reflexes and a slight hemiatrophy of the body persists. In some cases a slight degree of equinus is the only deformity ; in others weakness of the arm may persist although com- plete control of the lower extremities has been regained. The final effect of the paralysis is almost always more marked in the upper than in the lower extremity ; thus when contractions and deformities of the lower extremity are present the arm and hand are often practically disabled. Treatment. 1 . Hemiplegia. — The treatment from the orthopaedic standpoint consists in stimulating the nutrition of the paralyzed parts, 464 DISEASES OF THE NERVOUS SYSTEM. in preventing deformity and in improving the functional ability. The results of treatment are, of course, very greatly influenced by the mental condition of the patient. If the mental power is not impaired one may count upon the eiforts of the patient to aid the surgeon, whereas if the patient is idiotic there is but little encouragement for active treatment. If the patient is seen before the secondary contrac- tions have appeared, deformity may be prevented in great degree by regular massage and by passive movements in the directions opposed to the habitual positions. If the spastic rigidity is slight the control of the movements of the leg may be made easier by the use of a light jointed leg brace attached to a pelvic baud. By this means the move- ments are controlled and the excessive expenditure of nervous energy necessary to guide the limb may be lessened. This support should be supplemented by massage and exercise, and in the milder type of paralysis the control of the limb may be greatly improved. In many instances the patients are not seen until late childhood, when the deformities have become fixed. The foot is nsually turned inward and downward (equino-varus), there is flexion at the knee and often flexion and adduction at the hip, the resistance of the contractions being dependent upon the duration of the deformity. In such cases the distortions must be corrected by force and by division of more re- sistant tissues including often the tendo Achillis, the plantar fascia, and in many instances the hamstrings, and the adductors of the hip. The limb is then fixed in a plaster of Paris bandage for a sufficient time to overcome the more direct tendency to deformity. When the bandage is removed a brace is of service in guiding the limb, and regular massage and forcible passive movements together with proper exercises should be employed whenever practicable. In this class of cases the deformities may be overcome in most instances, but there is a tendency toward flexion at the knee, and stiffness and awkward- ness in movement usually persist. In many of the milder hemiplegic cases the only deformity is of the foot. This should be treated by division of the tendo Achillis and by support for a time until the deformity habit has disappeared. If the arm is but slightly affected proper exercises will greatly im- prove its ability. In the more extreme cases in which the fingers are clasped over one another, treatment is practically useless. In the third class in which the patient has the power of extending the fingers only when the wrist is flexed, the power of dorsi-flexion may be restored or improved by transplanting the flexors of the carpus on the radial and ulna border to the extensors which have been over-lapped and shortened to the proper extent. The transplantation of other tendons may be of service, but the operation is limited in usefulness for the reasons stated.^ Athetoid movements of the hand and arm niay be relieved somewhat by prolonged fixation in a plaster bandage, or by arthrodesis at the wrist joint. 2. Paraplegia. — The treatment of spastic paraplegia is much more iTownsend, Trans. Am. Orth. Ass'n, Vol. XIII., 1900. TREATMENT OF PARAPLEGIA. 465 difficult than that of hemiplegia because the disability is very much greater-and because the mental impairment is usually more marked. In general the treatment in infancy is by massage and by manipula- tion. When the child shows a desire to walk an attempt should be made to relieve the spastic contractions. In certain instances complete correction of all deformities, followed by prolonged fixation of each joint in the over-corrected attitude, may be of service. (Fig. 322.) This Fig. 322. Cerebral paraplegia, second stage iu treatiueut. The long replaced by the short sisica. This pa- tient at the age of eight years was unable to stand without assistance. The spastic contractions and deformities were overcome by tenotomies and by force, and a double long spica bandage was applied. This was worn for eight months. It was then replaced by the bandage shown iu illustration. Six months later this was removed. There is at present no deformity, and the child walks fairly well. may be combined with multiple tenotomies if the contractions are more resistant. The advantage of tenotomy, aside from the simple correction of deformity, is that by elongation of the tendon the response to the exaggerated motor impulses is lessened and an opportunity for more effective control is afforded. Transplantation of tendons from the flexor to the extensor aspect of the limb has been performed in several instances but the value of the procedure is still in doubt. Except in the very mild cases of paraplegia, braces are of little value. The trunk is 30 466 DISEASES OF THE NERVOUS SYSTEM. not as a rule deformed except in the diplegic cases in which the mental impairment is great. Manipulation, massage and posture are of some service in correcting and preventing this distortion. Prognosis. — It is stated by Peterson ^ that the patients in whom the paralysis is paraplegic or diplegic usually die before the twentieth year, and that but few of those in whom it is hemiplegic reach the age of forty. This prognosis applies, it may be assumed, rather to the extreme cases accompanied by mental impairment than to the milder forms. In almost all cases the patient even if idiotic is finally able to stand and to walk. As a rule there is for a time a gradual im- provement in motor power and in mental control as well. It is evident that in a class in which mental enfeeblement is so common and in which epilepsy is present in so large a proportion of cases, simple care and moral and mental training are of great importance. Orthopaedic treatment, although it has no direct action upon the le- sion in the brain, certainly has an indirect efi'ect upon the mental as well as upon the physical condition of the patient. When deformity has been corrected and when contractions have been overcome, func- tional use requires less mental effort ; and motor control may be still further improved by drilling the patient constantly in simple move- ments. Such exercises improve the motor communications and the ability of the paralyzed part as well. Progressive Muscular Atrophy. Progressive muscular atrophy, as the term implies, is a progressive wasting of the muscles, with corresponding loss of power, terminating finally in paralysis and deformity. Under this title are included two varieties of disease. 1. The myelopathic form in which there is primary disease of the spinal cord.. 2. The myopathic form in which the disease is primarily of the nerve terminals and the muscular fibers. The second variety is usually designated as muscular dystrophy to distinguish it from the spinal form. Myelopathic Paralysis or Atrophy. — The myelopathic form of muscular atrophy, the Aran-Duchenne type, usually begins in the small muscles of the hands and spreads from the periphery to the trunk. Fibrillary twitching of the affected and unaffected muscles is fairly constant and the reaction of degeneration may be present. The disease is practically limited to adults and from the orthopsedic standpoint it is of little interest. In another form, the Charcot-Marie- Tooth type, usually classed with the muscular atrophies, the paralysis may begin in the muscles of the legs, causing deformity of the equinus or equino-varus variety. The lesion of the cord in muscular atrophy is of the anterior cornua, and resembles closely that of the subacute form of anterior poliomyelitis. •Trans. Am. Orth. Ass'n, Vol. XIIL, 1900. MUSCULAR DYSTROPHY. 467 Myopathic Paralysis or Muscular Dystrophy. — The myo- pathic form of muscular atrophy may be preceded by apparent hyper- trophy (pseudo-hypertrophic muscular paralysis), it may be primarily atrophic, or the two forms may be combined. It differs from the myelopathic form in several particulars. It is a disease of childhood. It is often heredi- tary and its distribution is different. The affection is divided according to the distribution into two main varieties. Fig. 323. Fig. 324. Progressive muscular dys- trophy, showing the enlargement of the calves and the atrophy of the shoulder muscles. Prdniessivc luuscular dystro- phy, facio-scapulo-humeral type. Extreme lordosis and flexion con- tractions at the hips. 1. The facio-scapulo-humeral type (Landouzy-Dejerine), in which the muscles of the face and shoulder girdle are primarily affected. (Fig. 324.) 2. The juvenile form of Erb, in which the muscles of the back and of the upper arms are first involved. 468 DISEASES OF THE NERVOUS SYSTEM. The etiology, pathology and clinical course of the atrophic does not diifer essentially from the pseudo-hypertrophic form. PSEUDO-HYPERTROPHIC MuSCULAR PARALYSIS. Pseudo-hyper- trophic paralysis is characterized by progressive weakness of the mus- cles of the trunk and of the legs associated with apparent hypertrophy of the calv^es due to a deposit of fat in the wasting muscles. (Fig. 323.) The symptoms are caused by a degenerative atrophy of the nerve terminals and of the muscular fibers and an increase of the connective tissue and replacement of the muscular substance by fat. Diagnosis. — The interest in this latter affection from the orthopaedic standpoint lies in the diagnosis in the early stage of the affection. At this time the patient is evidently weak, he walks with an awkward, shambling gait and climbing stairs is especially difficult. There is usually an increased lordosis and a peculiar swaying or waddle, a disin- clination to stoop and an evident difficulty in regaining the erect pos- ture, and there may be discomfort or pain referred to the lumbar region. If the disease is advanced, the peculiar hard, resistant enlargement of the calves, combined, it may be, with atrophy of the muscular groups of the upper extremity, and weakness of the muscles of the back, makes the diagnosis evident, but in young children the disease may be mis- taken for Pott's disease, simple weakness, or postural deformity. Al- though there is a superficial resemblance to the general symptoms of Pott's disease, yet the specific signs of disease of the vertebrae, pain and muscular spasm, are absent. Weakness, a result of malnutrition or disease, is general in char- acter and its cause is usually apparent ; it is, of course, not accom- panied by local hypertrophy. Retarded cerebral development causes general weakness as far as inability to stand is concerned, but the cause is in this class also usually apparent. Postural deformities in child- hood always have a cause, and as one is not content to treat a deformity without ascertaining its cause, this search will bring to light the pecu- liar symptoms of the disease. Treatment. — In certain instances the discomfort referred to the back, due in part to the lordosis, may be relieved by a light spinal sup- port. Massage and muscle training may enable the patient to utilize the remaining power to best advantage. In the later stages of the disease there may be secondary deformities, most marked in the feet which may be fixed in the equinus or equino- varus attitude. This deformity may be corrected by tenotomy or other- wise, if the patient has not already become so weak that walking or standing is impossible. Hereditary Ataxia. Friedreich's Disease. Hereditary ataxia is an ataxic paraplegia caused by sclerosis of the posterior and lateral columns of the spinal cord. The early symptoms are incoordination and weakness of the legs; later similar symptoms ap- pear in the upper extremities and speech is affected. In well-marked ''HYSTERICAL HIP." 469 cases there is usually distortion of the feet toward equinus or equino- varusj gind occasionally a posterior or lateral curvature of the spine. In one case recently under treatment at the Hospital for Ruptured and Crippled, the rectification of the deformity of the feet was at least of temporary benefit. Neuritis. Localized neuritis after contagious disease or from other causes may result in temporary weakness or paralysis of the dorsal flexors of the foot, cause toe drop and finally deformity. In such cases the foot should be supported by a brace in normal position. This not only prevents deformity, but it hastens the cure by preventing tension upon and struc- tural lengthening of the weakened muscles. The same treatment may be applied for wrist drop from metallic poisoning. The hand should be supported by a suitable brace in the attitude of dorsi-flexion until the muscles have recovered their power. Obstetrical paralysis has been considered under affections of the shoulder. Hysterical Joint Affections and Deformities. Functional Affections of the Joints. So-called hysterical or functional affections may be divided into two groups. 1. Those in which there is no actual disease or weakness. 2. Those in which the symptoms of disease or injury, or of their effects, are exaggerated and prolonged. The first class of cases is small, the second is large. Simulation, whether voluntary or involuntary, of organic disease can deceive only those who are not familiar with the characteristics of the disability that is simulated. Every disease has certain well-defined symptoms which can no more be imitated by a well person than a dis- abled part can suddenly take on the normal appearance and function. "Hysterical Hip." The hysterical hip is supposed to simulate actual tuberculous disease. Diagnosis. — The symptoms of actual disease of this joint are pain, limp, limitation of motion due to reflex muscular spasm,, muscular atrophy, distortion and in the later stages the local signs of a destructive process ; for example, heat, swelling, abscess and displacement of the parts, shortening of the limb and the like. As these later symptoms could not be simulated they need not be considered. In actual disease symptoms and effects follow one another in regular sequence and correspond closely to the pathological conditions that cause them. Pain is not a pronounced symptom ; it is more likely to be concealed than exaggerated and it is usually referred to the knee. Local sensitiveness is not a pronounced symptom, and it is often absent. Distortion of the limb when it occurs in the early stage, before the de- 470 DISEASES OF THE NERVOUS SYSTEM. structive changes are advanced, is caused by reflex muscular spasm and whenever this distortion is great the reflex muscular spasm, which involves every muscle about the joint, is also great ; so that the range of motion in the joint is small, and motion may be absolutely prevented. With the distortion there is always a corresponding atrophy of the muscles of the limb. If pain is present it is usually worse at night than during the day. The hysterical simulation of hip disease is characterized by an ex- aggeration of the symptoms and by absence of the physical signs of disease. There is usually an exaggerated limp, great distortion, marked local sensitiveness and pain, but absence of muscular spasm, atrophy or other signs of disease. The essential differences between actual disease and its simulation may be presented more effectively by contrasting them. Disease. Simulated Disease. Pain, intermittent or absent or Patient often complains bitterly concealed ; referred to the knee, of pain, referred to the hip or to the Often worse at night. entire limb. Worse during the day. Local sensitiveness, often absent Often extreme, caused by the or caused only by deep pressure. slightest manipulation ; the skin is hypersesthetic. Limp, corresponds to the acute- Exaggerated, does not corre- ness of the symptoms or to the dis- spond to the physical signs, may tortion ; slight iu the early stage, be intermittent, but constant. Distortion, slight in the early Often great in the early stage, stage, is dependent on the degree bears no relation to the physical of muscular spasm and upon the signs ; is intermittent, may disap- quality of the disease ; is constant pear at night ; can be reduced by and cannot be reduced by manipu- manipulation, lation. Muscular spasm, always present. Absent. Muscular atrophy, always pres- Slight or absent, ent. Local signs of a destructive dis- Absent. ease, often apparent at an early stage. The age of the patient, the history of the supposed disease and the other evidences of hysteria that are usually present, will confirm the diagnosis. The same principle applies of course to the differential diagnosis of simulated disease at other joints. The knee and the hip are those that are most often involved. Hysterical Deformities. " Hysterical Club Foot." — Local deformity distinct from simulated joint disease is sometimes seen. Several cases of this character in ''NEUROTIC JOINTS." 471 which the foot was distorted have been under treatment at the Hospital for Ruptured and Crippled, recently. The diiferential diagnosis is simple. Talipes is either congenital or acquired. Congenital talipes and all the acquired varieties, other than those of paralytic origin, may be at once excluded from consideration. Paralytic talipes in the vast ma- jority of cases begins in early childhood when it is either caused by anterior poliomyelitis or is one of the deformities of cerebral hemiplegia or paraplegia. When these are excluded, the remaining causes of de- formity are very limited. Every variety of nervous disease has well- defined symptoms. If actual paralysis is present the muscles atrophy and the electrical reactions are changed. In hysterical contractions the muscles do not atrophy and the electrical reactions are unchanged. " Hysterical Scoliosis." — A case was recently under observation at the Hospital for Ruptured and Crippled, in which distortion of the trunk persisted for more than a year, and until a suit for damages was finally decided. In this case there was a most exaggerated lateral twist of the spine so that the shoulder approached the pelvis. The deformity however was not fixed, but it could be completely reduced when the patient was in the recumbent posture. There was no par- alysis, no persistent spasm, no evidence of disease or injury. The de- formity was of a nature that could not be explained by any conceivable lesion, and all the signs of hysteria were present. Treatment. — The principles of the treatment of pronounced hys- teria of which simulated joint disease or deformity are but unusual man- ifestations are considered at length in medical and neurological works, and the subject does not call for especial mention here. It is evident, of course, that an unequivocal diagnosis must be the first and essential step toward cure. In this class of cases apparatus is not often indi- cated unless the deformity has persisted for so long a time that the dis- used muscles have become incapable of performing their proper functions. FUNCTIONAL AFFECTIONS OF THE JOINTS. "Neurotic Joints." In this class, although there is no absolute distinction between it and the preceding variety, there is usually a physical basis for the symptoms, however much they may be exaggerated. The patients are not usually hysterical, in fact hysteria in the ordi- narily accepted sense is uncommon, and although the larger proportion of patients are women, yet men and children are by no means exempt from the so-called functional aifections. It must be borne in mind also that many of these cases are classed as neurotic simply because the cause of the symptoms is not apparent. It is only within a few years that the slighter degrees of weak foot and its effects have been recognized, and it is probable that such cases, together with anterior metatarsalgia, the painful fascia of the con- 472 DISEASES OF THE NERVOUS SYSTEM. tracted foot, achillodynia and the like might be considered as neurotic by one unfamiliar with their symptoms. And it may be inferred that as diagnosis becomes more accurate the more restricted will become the class of cases of purely imaginary disability, in so far at least as the locomotive apparatus is concerned. A " neurotic joint " is often caused by injury. A sprain of the ankle, for example, may have been treated by prolonged immobilization, either because the patient had originally impressed the physician with the severity of the symptoms or because of persistent discomfort. When the dressing is removed there may be congestion and discoloration due to impaired circulation, weakness and atrophy of the muscles due simply to disuse, and a certain degree of infiltration and stiffness caused by the original injury. In cases of this character the disability may be prolonged because the patient or the physician mistakes the effects of disuse for the symptoms of serious injury or disease. When the diagnosis has been made treatment should be directed to increasing the activity of the circulation and thus the nutrition of the part, by counter-irritation, by massage, by passive movements, by voluntary exercises and the like, but cure can only be completed by restoring functional use. If, therefore, the disability is of long standing a tem- porary brace will be required to protect the part from injury, and to increase the patient's confidence. In milder cases it is possible that without support or treatment, other than an assurance of the absence of serious weakness, cure may be accomplished, but this is certainly unusual. What has been said of exaggerated disability at the ankle following traumatism, applies to the treatment of similar affections elsewhere. The knee-joint is very often the seat of so-called neurosis. Injury at this point in nervous children is often followed by a persistent flexion contraction that may continue for weeks after all signs of the injury have disappeared. When the attempt is made to straighten the knee the patient screams with pain and the muscular resistance is very great. In such cases the immediate rectification of deformity and the application of a plaster bandage to hold the limb in the corrected position is indicated. It must be borne in mind that the persistent assumption of a deformed position for weeks or months must be fol- lowed by certain structural changes in the contracted muscles and weakness in the opposing groups. Thus some assistance may be required in the treatment even of the purely hysterical deformities, be- cause of this weakness. In all forms of traumatic neurosis, so called, the possibility of a physical basis for the symptoms should be considered, the location of the pain or discomfort and its connection with certain movements or attitudes should be investigated. If such discomfort is induced or is aggravated always by a certain motion or attitude it is reasonable to infer that this has a well-defined cause, especially as the pain of a neurotic affection is not often of this definite character. In this class of cases limitation of movement for a time to the painless range of motion by some form of support may be indicated. ''NEUROTIC JOINTS." 473 Thus far injury has been considered as the starting point of the symptoias, but in many cases there is no history of injury. In this class the symptoms may have been induced by rheumatism or gout or rheumatoid arthritis, or by neuritis and such possible causes should be investigated and excluded before the diagnosis of simple neurosis is made. In neurasthenic patients or those who are anaemic, or over- worked, the pain and discomfort is often localized in the spine. The " neurotic spine " has been considered elsewhere. In the treatment of all cases of this group the general condition of the patient should receive consideration, and in connection with the local treatment a change of occupation and of scene is often of advantage. It is hardly necessary to insist again that an accurate diagnosis is the first essential of successful treatment. If this is impossible, at least one may by exclusion of those injuries and disabilities and dis- eases which are evidently not present, arrive at a general conclusion as to the character of the ailment, and shape his treatment accordingly. CHAPTER XIX. CONGENITAL AND ACQUIRED TORTICOLLIS. Torticollis. Synonym. — Wry Neck. Torticollis is, as the name implies, a twisted neck ; a distortion caused in most instances by active contraction or by shortening of one or more of the lateral muscles that control the head. Similar distor- tion may be due to disease of the spine, so-called false torticollis, but this should be classed as a symptom of the underlying disease, not as simple torticollis of which the distortion itself is the important dis- ability that demands treatment. Torticollis may be divided primarily into two classes, the congenital and the acquired. Congenital torticollis is a painless shortening of the tissues on one side of the neck, of intra-uterine origin. Acquired torticollis is, in most instances, accompanied in its early stages by local pain and sensitiveness, and by active contraction of the affected muscles. After a time these acute symptoms disappear leaving simply the deformity. Thus from the therapeutic standpoint, torti- collis may be classified as acute and chronic, the latter class includ- ing the congenital form. The sterno-mastoid is the muscle that is usually involved primarily, both in the congenital and acquired forms ; thus in typical torticollis, the head is drawn somewhat forward and is inclined toward the con- tracted muscle while the chin is slightly elevated and turned toward the opposite shoulder, an attitude explained by the normal action of the affected muscle. Irregular distortions of the head, as posterior or anterior torticollis due to contraction of muscles other than the sterno- mastoid, are however not infrequent. These will be mentioned in the consideration of the forms of acquired torticollis. Statistics. — Torticollis is comparatively an uncommon deformity. In a period of twenty-seven years 507 cases were treated at the Hos- pital for Ruptured and Crippled as contrasted with upwards of 5,000 cases of congenital and acquired talipes. Acquired torticollis is by far the more common variety as is shown by the fact that of the 507 cases but 87 were supposed to be of con- genital origin. It is often stated that torticollis is more common in males than in females, and that the right side is more often affected, yet 46 of the 87 congenital cases were in females and the contraction was of the left side in 38 of the 58 cases in which the affected side ^vas specified. Of CONGENITAL TORTICOLLIS. 475 the entire number of cases available for comparison 246 were in fe- males and 198 in males ; in 236 instances the contraction was on the left and in 196 on the right side of the neck. From these statistics it would appear that the deformity is somewhat more common in fe- males than in males and that the left side is more often affected than the right. Congenital Torticollis. In most instances the deformity of congenital torticollis is slight at birth and it may not attract attention until the child sits or walks even. Thus it is often difficult to distinguish the congenital form from the deformity that may have been acquired in infancy, especially as the Fig. .32.5. Left torticollis apparently of congenital origin, sliowiug the secondary distortions of head and face. patient may not be brought for treatment until the distortion has per- sisted for many years. In early infancy slight torticollis may be demonstrated by holding the arm on the affected side and drawing the head forcibly in the op- posite direction, when the shortened muscle becomes prominent beneath the skin, evidently restricting the range of motion. In most instances the sternal division of the muscle appears to be more shortened than the clavicular portion. In exceptional cases the deformity even in infancy may be extreme, and it may be accompanied by well-marked asymmetry of the face and even by distortion of the skull. In this class the shortening may in- 476 CONGENITAL AND ACQUIRED TORTICOLLIS. volve all the lateral tissues, both anterior and posterior. Slight asym- metry may be present at birth, and in the acquired form it is usually evident soon after the onset of the deformity, becoming more marked with its continuance. Its cause is the constrained attitude, the restric- tion of normal use and consequently of the blood supply, combined with the tension upon the tissues of the face, as is evidenced by the fact that it becomes less noticeable after the deformity has been corrected. In the well-marked cases of long standing, whether congenital or acquired, the face is shorter and flatter, the nose and the corner of the Fig. 326. Right torticollis, showing the displacement of the head toward the opposite side. mouth and the eyelids even on the affected side are drawn downward and the skull shows evidence of atrophy and deformity. Secondary distortions also appear in the trunk in chronic cases. These are rotation of the spine to compensate for the lateral distortion of the head and an increase in the dorsal kyphosis, " round shoulders." Among the minor secondary deformities upward bowing of the clavicle caused by the tension of the contracted muscle may be mentioned. (Fig. 325.) In the early stage of torticollis the head is tilted and is displaced toward the contracted tissues, but when the deformity is of longer standing the head following the compensatory convexity of the cervical spine appears to be displaced toward the opposite shoulder. (Fig. 326.) The compensatory deformities that have been indicated are slight in ETIOLOGY. 4:77 infancy but they become more marked in later childhood, for in many instances the shortened muscle ceases to grow ; thus an original short- ening of half an inch, as compared to its fellow may be increased to two or more inches in later years. This fact emphasizes the impor- tance of thorough treatment as soon as may be possible after the distor- tion is discovered. As has been stated the important contraction is usually of the sterno- mastoid muscle, but if the deformity is uncorrected all the lateral tissues become shortened, so that at a later stage complete division of the cervical fascia as well as of the muscles may be necessary before the deformity can be corrected. Typical wry neck caused by shortening of the sterno-mastoid muscle is by far the most common form of congenital torticollis, but occasionally cases are seen in which the head is but slightly inclined to one side and in which the shortening appears to involve the lateral tissues in general rather than a particular muscle. In rare instances, although the deformity resembles that of typical torticollis, the greatest shorten- ing will be found to be of the posterior muscles on one side, particularly of the trapezius and the levator anguli scapulje. Thus the scapular may be elevated and tilted forward. This form of torticollis appears to be one variety of congenital elevation of the scapula, (See page 185.) Torticollis due to defective development of the upper ex- tremity of the spine is a rare deformity that does not require special description. Etiology. — It may be assumed, disregarding the possible influence of hereditary predisposition, that congenital torticollis is, in most in- stances, caused by a constrained or fixed position in the uterus for a longer or shorter time before birth. It is in fact a simple distortion ; and that it has, in the majority of cases, no deeper significance is proved by the fact that it may be easily and completely cured by simple division or elongation of the contracted tissues. It would seem that a deformity to be properly congenital, must be present at birth, yet the theory, first advanced by Stromeyer, that con- genital torticollis is the result of injury at birth has been so generally accepted that it merits further consideration. Hsematoma of the Sterno-mastoid Muscle. — Hsematoma is considered to be, and undoubtedly is, evidence of injury. During difiicult deliv- ery, fibers of the muscle are ruptured, usually in the upper or middle third of the anterior border, hemorrhage follows, which in tlirn is sur- rounded by an encapsulating area of inflammatory material. This forms a firm cylindrical tumor in the substance of the muscle which becomes noticeable two weeks after birth, or at least this is the time when it is usually discovered by the mother. As a rule, the tumor is not sensitive to pressure ; it may or may not be accompanied by restriction of motion in the direction causing tension on the muscle. The tumor remains for from three to six months, when it usually dis- appears, leaving no trace of its presence. The theory of Stromeyer, which until recently was generally ac- 478 CONGENITAL AND ACQUIRED TORTICOLLIS. cepted, is that congenital torticollis is caused by rupture of the muscle and by myositis about the hsematoma. This inflammation may involve and ultimately destroy a large part of the substance of the muscle replacing it with fibrous tissue, which contracting, causes deformity. This theory is extremely improbable for the following reasons : 1. Rupture of muscle elsewhere is practically never followed by myositis and contraction. 2. It has been demonstrated by Heller/ that it is impossible to cause myositis and contraction by any form of injury to the muscles of animals unless it be combined with actual infection with pyogenic germs. 3. Most of the cases of congenital torticollis seen soon after birth present no evidence of hsematoma or injury, viz. : In 7 of 55 cases of supposed congenital torticollis investigated by the writer there was a history of injury at birth. In 48 cases no mention was made of injury. In the seven cases referred to the deformity was accompanied by hsematoma or there was a history of a swelling, apparently of this nature ; but in two of these the hsematoma was coincident wdth intra- uterine shortening of the muscle. 4. Cases of hsematoma of the sterno-mastoid muscle are not as a rule followed by torticollis. Seven consecutive cases of hsematoma were examined by the writer with especial reference to this point. In all the evidence of violence in delivery was clear. Two were delivered by forceps, three were breech presentations and in two version was performed. In one case an arm was broken and in another paralysis resulted from injury to the brachial plexus. Six of the children lived until the swelling had nearly or entirely disappeared and in none did torticollis accompany or follow the hsematoma. 5. In certain cases a congenitally shortened muscle may be ruptured at delivery ; thus the hsematoma is simply a complication of torticollis, not its cause. Bruns ^ has reported such a case, and two others have been observed by the writer, in one of which club foot was present also. 6. Hard tumors of the sterno-mastoid muscle are not always the re- sult of injury ; myositis may be of syphilitic origin apparently occur- ring in intra-uterine life. In other instances tumors of fibrous or sarcomatous nature have been removed from the substance of the muscle. Congenital torticollis in the majority of cases is of intra-uterine origin. If it follows injury at birth it is probably an indirect result of local pain, discomfort and irritation of the nerves or of an actual in- fectious inflammation of the injured part. Pathology. — In the ordinary type of congenital torticollis, as demon- strated at operations on children, the substance of the affected muscle or muscles is simply lessened in amount and there is a disproportionate ' Heller, Deutsche Zeits. f. Chir., Bd. 49, H. 2 and 3, S. 234. 2 Cent. f. Chir., No. 26, 1891. ETIOLOGY OF ACUTE TORTICOLLIS. 479 area of tendinous substance as compared to the contractile tissue. In other instances, the muscle may be almost entirely replaced by fibrous tissue, or it may be traversed by fibrous bands, or patches of scar-like tissue may be distributed throughout its substance. These changes, considered to be evidences of preexisting myositis, are probably more common among the acquired than the congenital form and as a rule they are found only in cases of long standing. Secondarily all the lateral tissues of the neck are shortened to correspond to the habitual attitude, and the compensatory curvatures of the spine in time be- come fixed, so that torticollis may be classed as one of the causes of scoliosis. Acquired Torticollis. Acquired torticollis is an affection of early life, at least 80 per cent, of the cases beginning in the first ten years. As has been stated, congenital torticollis is usually a painless short- ening of the muscles, while acquired torticollis is, as a rule, a painful affection secondary to injury or disease of some of the structures of the neck, which causes peripheral irritation of the nerves and active con- traction of the neighboring muscles. Thus, as a rule, the number of muscles involved in the deformity is greater than in the congenital form ; for example, in the ordinary form of acquired wry neck the trapezius, which receives in part the same nerve supply, is usually involved together with the sterno-mastoid ; and irregular forms of dis- tortion caused by contraction of other groups, are not uncommon. Varieties. — The varieties of acquired torticollis may be classified conveniently as follows : 1. The simple or mechanical form due to scar contraction following destruction of the skin or deeper tissues, as from burns or disease. 2. Acute torticollis caused by direct inflammation of the muscle, by injury, by inflammatory affections of the surrounding parts, combined in most instances with irritation of the peripheral nerves, which causes reflex contraction of certain muscles or muscular groups. 3. Spasmodic Torticollis. — A form of convulsive spasm, " a disorder of the cortical centers for rotation of the head." (Walton.) 4. Irregular forms of Torticollis. — Paralytic, ocular, psychical and the like. The first class, that due to scar contraction, needs only to be men- tioned. Etiology of Acute Torticollis. — The second class is the most im- portant form of torticollis, both as to frequency and as to its effect in causing permanent distortion. Of this group, one of the most com- mon, and at the same time the least important form, is the simple stiff neck, supposed to be due to cold or to muscular rheumatism. Its onset is, in childhood, sometimes accompanied by slight fever and ma- laise ; the affected muscle is somewhat sensitive to pressure and motion or tension causes discomfort. The distortion, in great part voluntary 480 CONGENITAL AND ACQUIRED TORTICOLLIS. Fig. and accommodative, is of short duration as a rule. Strains and direct injury of the muscles of the neck may cause deformity, which usually disappears when the local sensitiveness has subsided. Traumatic hsematomata, similar to those caused by injury at birth, are sometimes observed in older subjects. These usually disappear after a time, leaving no trace of their presence. Another form of torticollis is secondary to cellulitis and to infiltra- tion following the breaking down of tuberculous cervical glands. This may become a permanent distortion if the deformity is allowed to persist or if the tissues of the neck are injured by the suppurative process. By far the most important variety of this class is the acute spastic TORTICOLLIS due to active tonic contraction of one or more of the mus- cles of the neck. The exciting cause of the spasm appears to be irri- tation of the peripheral nerves in the naso-pharynx or in its neighbor- hood, and the muscles most often affected are those supplied in part by the spinal accessory nerve. Thus torti- collis of this form may follow tonsilitis, pharyngitis, measles, diphtheria and the like. It may be preceded by " toothache " or " earache," or it may be an accompaniment of what appears to be the ordinary form of stiff neck, or of enlarged or suppurating cervical glands. In this form the torticollis is caused directly by tonic contraction of the muscles. Reflex spasm of this character is however often associated with the distortion, due primarily to injury of the neck or to some local in- flammatory process, so that a sharp distinction between the divisions of this second class is impossible. Many of the patients are known to be of a nervous temperament and over-study, anxiety, sudden shock and the like are considered to be predisposing causes. This variety of acquired torticollis completely overshadows in importance all other forms, as is indicated by the statistics of 212 cases treated at the Hospital for Ruptured and Crippled in which the cause seemed to be apparent. Of the 212 cases 181 may be fairly assigned to this class. The apparent exciting causes of cases of acquired torticollis treated at the Hospital for Ruptured and Crippled is shown in the following table : Bilateral contraction of tlie sterno- inastoids and trapezii muscles. (See Fig. 328. ) SYMPTOMS OF ACUTE TORTICOLLIS. 481 Enlarged cervical glands 14 Supfturating " " 41 Scarlet fever 14 Diphtheria 7 Mumps 6 Measles 2 Sore throat 8 Suppurating otitis 3 Toothache 6 Cellulitis of the neck 2 Furuncle of the neck 1 Cold in the neck 5 Rheumatism 18 Vaccinia 1 Fever 6 Malaria 5 Injury to the neck 35 Rhachitis 3 Syphilis 1 Cicatricial contiaction 3 Total T81 Torticollis associated with chorea 4 " " " epilepsy 1 '* " " cortical irritation 5 '' ^' " hysteria 1 " " " meningitis 1 hemiplegia 3 Spasmodic torticollis . . . " Functional torticollis Total 31 Fig. P)28. Symptoms of Acute Torticollis. — As a rule the distortion of the neck is slight at first, more noticeable at night than in the morning ; it then gradually increases until the deformity becomes fixed. In other instances the onset is sud- den, sometimes accompanied by fever. In most instances several muscles are more or less in- volved in the contraction, par- ticularly the sterno-mastoid and the trapezius, and in such cases the deformity is more marked and persistent than when the sterno-mastoid is alone aiFected. Less often the contraction is of the posterior group, " pos- terior torticollis," when the head is tilted backward and the chin is turned more toward the opposite side than in the typ- ical lateral form. In other cases the contraction appears to affect the small muscles that control the small joints at the upper extremity of the spine when the head may be tilted forward with but slight lateral inclination, re- sembling closely, except in the history, the symptomatic wry neck of Pott's disease. In rare instances the muscles on both sides of Bilateral torticollis after treatment. (See Fig. the neck may be contracted simultaneously. 31 (Fig. 327.) The con- 482 CONGENITAL AND ACQUIRED TORTICOLLIS. tracted muscles are usually sensitive to manipiilatiou and attempted rectification of the deformity causes extreme pain and is resisted by the patient. The child is as a rule nervous and irritable, it often com- plains of neuralgic pain about the contracted part which is increased by sudden or unguarded movements or strain ; thus " getting the patient to bed " is often a tedious proceeding because of the difficulty of sup- porting the head comfortably with the pillows. In many instances the affection is of short duration ; in others, particularly those in which the reflex spasm is aggravated by local in- flammatory processes, there appears to be but little tendency toward recovery. In such cases, after several weeks or months, the local pain and sensitiveness may subside together with the active spasm, but the deformity remains, caused by actual shortening of the muscles and fascia, aggravated in some instances by the destructive effect of ac- tual myositis. The muscles atrophy and degenerate and present at a later stage the same pathological appearances that are found in the congenital form. Diagnosis. — Torticollis is most often confounded with Pott's disease. This w^ould seem to be hardly possible in cases of the simple painless contraction of chronic torticollis. In the acute form, however, there may be more difficulty in distinguishing between the two. The main points have been mentioned already in connection with Pott's disease. In acute torticollis the affection is of sudden onset, not preceded by the stiffness and neuralgic pain that usually characterize tuberculous dis- ease. The deformity of torticollis is almost always of the regular type, that is, the head is tilted toward the contracted muscles while the chin is rotated in the opposite direction. The spasm and contraction of the affected muscles are very plain and direct tension upon them is painful. If the contraction is relaxed by inclining the head toward the contrac- tion, motion in other directions will be found to be practically un- restricted. In Pott's disease the spasm of muscles is general, the deformity is not of a regular type, since the chin often points to the side toward which the head is inclined. Steady tension with the aim of reducing the deformity is not as a rule painful; in fact it is often agreeable to the patient. Finally the limitation of motion cannot be lessened by inclining the head toward the muscle that seems to be most contracted, for the reflex spasm of Pott's disease limits motion in every direction. As a rule the diagnosis is easily made, but in cases complicated by sup- puration of the cervical glands it is sometimes impossible to exclude Pott's disease until after the effect of treatment has been observed. Disease of the cervical spine, other than tuberculous, is compara- tively rare and resembles in its symptoms Pott's disease rather than torticollis. Acute arthritis of the atlo-axoid articulation that may be a complication of rheumatism or that may follow infectious disease is of sudden onset and sometimes resembles in the symptoms and de- formity the acute spastic torticollis, except that all the surrounding muscles are affected rather than a particular group ; in fact but for TREATMENT. 483 the history it could not be distinguished from tuberculous disease of this region. Although the diagnosis of torticollis is simple, it is not always easy to determine the muscle or muscles involved in the contraction of the acquired form. The effect of unilateral contraction of the different muscles is as follows : The sterno-mastoid inclines the head toward the contraction, elevates the chin and turns it in the opposite direction. The trapezius has much the same action, but the backward inclina- tion and rotation are more marked. The action of the complexus resembles that of the trapezius, but the rotation is less. The splenius inclines the head backward and toward the contracted muscle but does not turn the chin in the opposite direction. The scaleni have the same action except that the head is inclined forward. As has been stated, in acute torticollis several muscles are often in- volved, but the spasm is usually greater in one or in one group than in another. The seat of greatest contraction may be determined by the deformity, by the evident spasm that resists reposition and by the local sensitiveness on palpation. As a rule when the primary contrac- tion is of the posterior group, the deformity is more marked than in other forms. Bilateral contraction of the muscles is rare, but it is oc- casionally seen. (Fig. 327.) Treatment. — The treatment varies according to the cause and with the duration of deformity. Excluding, for the present, the rare and ir- regular forms of wry neck there are, from the remedial standpoint, two forms of torticollis. 1. The chronic form — in which the local pain and sensitiveness are absent, but in which there is resistant and permanent deformity. As has been stated, congenital torticollis is included in this class, 2. The acute form in which the distortion is of short duration and in which permanent contraction may be prevented. The Treatment of Chronic Torticollis. — Congenital torticollis, if of moderate degree, can be overcome in early infancy by methodical stretching of the contracted parts. One person fixes the arm and an- other draws the head gently but firmly in the direction opposed to the contraction, over and over again, meanwhile massaging the tissues of the neck. The procedure should be repeated several times a day; it causes slight momentary discomfort if properly performed, but this ceases when the stretching is discontinued. Care should be taken also that the postures may, as far as possible, favor the reduction of the de- formity; thus while the child is in the mother's arms the head should be supported, and when asleep the pillow may be arranged in a man- ner to prevent the improper position. In this way the torticollis may be entirely corrected or its progress may be checked until more effec- tive treatment is indicated. 484 CONGENITAL AND ACQUIRED TORTICOLLIS. Hsematoma. — The evidence of injury at birth should be treated by massage with some bland ointment ; if it is accompanied by deformity the manipulation already described should be employed. In the great majority of cases of congenital torticollis the patient is not brought for treatment until the deformity has become an eyesore to the parents. The contracted muscle is then usually an inch shorter than its fellow, the disparity increasing as a rule with the growth of the child. In such cases the immediate correction of the deformity is indicated, and this implies in most instances division of the contracted parts by subcutaneous tenotomy or by open incision. If the deformity is comparatively slight and if the contraction seems to be limited to the sterno-mastoid, and particularly to its sternal por- tion, one may hope to overcome the most resistant part of the con- traction by the subcutaneous operation. Aside from the possibility of wound infection, which at the present time is an argument of very little weight, subcutaneous tenotomy has the advantages of simplicity, apparent freedom from the danger which parents associate with an operation, and it leaves no scar behind. It is totally inadequate how- ever for the correction of advanced cases. Correction of Deformity by Subcutaneous Tenotomy. — The patient and the instruments having been prepared as for an ordinary operation, a sand bag is placed beneath the shoulders and the head is inclined so that the contracted muscle is thrown into relief beneath the skin. The sternal insertion of the tendon is seized with two fingers and the teno- tome is inserted beside it and passed beneath it at a point about an inch above the sternum. It is then divided by a sawing motion of the knife. Division of this part of the muscle in this situation is practi- cally free from danger and in the slighter degrees of deformity one can by vigorous manipulation and forcible traction overcome the resistance offered by the other tissues. If bands of fascia resist the correction, they may be divided by superficial nicking with the tenotome in the lateral region of the neck. As a rule, however, in cases of this type the open incision is to be preferred, as it allows the opportunity for free division of the contracted parts with less danger of injury to the blood vessels and nerves in this neighborhood. The Open Operation. — The incision should be made in the line of the muscle midway between the sternal and clavicular insertion. In the milder cases in childhood, it need be little more than an inch in length. A director may be passed beneath the tendon and on this it may be divided. The clavicular insertion and all bands of fascia that resist the normal range of motion may be divided through the incision. In cases of very great deformity in the adult some of the posterior and as well as the lateral muscles must be divided. In such instances the contracted parts may be divided at the upper border of the neck through an incision from the mastoid process backward along the lower border of the scalp, the scar being concealed by the hair. It must be borne in mind that the object of the operation is, by means of division and forcible stretching of the contracted parts, to overcome all THE OPEN OPERATION. 485 restriction to normal motion, and that the failure to accomplish this usually explains the recurrence of deformity, which necessitates the use of apparatus after the operation. Not only should all resistance be overcome by vigorous manipula- tion at the time of operation, but the head should be fixed during the process of repair in the over-corrected position. Thus in the treatment of typical torticollis the chin should be turned to a point over the middle of the clavicle on the operated side and the Fig. 329. head should be inclined toward the opposite shoul- der. In this attitude a plaster bandage should be applied surrounding the head and the thorax. This bandage should re- main until all local sen- sitiveness has disappeared and until the tendency toward deformity has been checked. This fixation in the over-corrected position is very important in child- hood, as an aid in over- coming the deformity habit, but it may be dis- pensed with in the treat- mentof adults. (Fig. 329.) The plaster bandage is retained from four to eight weeks ; when it is remov- ed, massage, manipula- tion and gymnastic train- ing are indicated. Twice a day the head should be forced to the extreme limit of over-correction. Traction on the neck in self-suspension by means of the sling used in the application of the plaster jacket, a regular system of exercises for the muscles of the neck and back and supervision of the habitual postures will usually assure a complete cure. If, however, the deformity habit is strong so that the head has a marked tendency to resume the former attitude some support is indicated. A simple and effective support is the jury mast as used in the treatment of Pott's disease with the plaster jacket or attached to a brace. In the treatment of children a band of elastic tape arranged to draw the head toward the shoulder as sug- gested by Sayre may be sufficient. In the after-treatment of the advanced cases, a support modelled after that of Brown ^ is eflPective and comparatively inconspicuous. ' Bradford and Lovett, p. 588. Torticollis left, showing the method of fixing the head in the over-corrected position. After operation. 486 CONGENITAL AND ACQUIRED TORTICOLLIS. As has been stated the necessity for support, provided the deformity has been thoroughly over-corrected, depends upon the care that is to be exercised in the after-treatruent. When exercises and massage can be efficiently employed, as a rule the support will not be required. In other cases it may be worn for several months with advantage. The principles of the treatment of the chronic or painless form of torticollis that have been outlined apply to the acquired, as well as to the congenital form, after the subsidence of the acute symptoms, when passive shortening has replaced active contraction. Acquired torti- collis is, in most instances, however, a preventable deformity; thus operative treatment would be rarely required had the patient received proper treatment. The Treatment of Acute Torticollis. — The insignificant form of tor- ticollis called stiff neck may be treated by hot applications ; a firm, thick collar of flexible cotton stiffened by several layers of adhesive plaster is an agreeable support in the more painful cases. In true acute spastic torticollis the cramp-like contraction of the muscles is secondary to some irritation elsewhere, which one should always try to remove, and, as has been stated, the general condition of the patient may require treatment as well. But the important indica- tion is to support the head and thus to relieve the pain and to prevent permanent distortion. In the early stage the support of the collar that has been described may be sufficient, but as a rule patients of this class are not seen until the distortion has persisted for weeks or months even, so that a more efficient form of support is required — such is the plaster jacket and jury mast. The elastic tension of this appliance overcomes the spasm and relieves the discomfort and apprehension which have lowered the vitality of the patient. If the spasm is the result of the irritation of enlarged or suppurating cervical glands, as is often the case, the rest afforded by the brace is an effective treat- ment of the cause as well as of its effect, and if suppuration is present this support is most convenient for the dressing that may be required. When the acute symptoms and deformity have been relieved, manipu- lation and exercises may be employed in the manner already described. In cases of longer standing, particularly when the posterior muscles are involved, the deformity may be forcibly corrected under anaesthesia and the head may then be fixed in a plaster dressing in the manner already described. This treatment may be employed at an earlier stage in selected cases. As a rule, when deformity has been allowed to persist for six months or more, its rectification will require division of the more resistant tissues. Spasmodic Torticollis. Spasmodic torticollis, a form of convulsive spasm of the muscles of the neck that is somewhat similar in its general characteristics to writer's cramp,^ must not be confounded with the acute torticollis of 1 Spasmodic torticollis is defined by Walton as a " disorder of the cortical centers for rotation of the head." Am. Jour. Med. Sci., March, 1898. TREATMENT. 487 childhood, in which tonic spasm of the affected muscles, due usually to some' well-defined irritation of the peripheral nerves, is the charac- teristic. Spasmodic torticollis is an affection of adult life. Of 32 cases collected by Richardson and Walton,' but two were in patients less than twenty years of age. The sexes are equally liable to the affection and the contraction is as frequent on one side as on the other. The onset of the affection is usually gradual. The first symptoms are often sensations of stiffness and discomfort in the muscles of the neck; a '' drawing sensation" and a momentary twitching or slight contraction which draws the head to one side. These symptoms in- crease slowly until the head is habitually inclined in the attitude of torticollis. For a time the patient can correct the position voluntarily, or by supporting the head with the hand can restrain the twitching of the muscles, but in well-established cases the head is inclined per- manently to one side and the convulsive spasm is uncontrollable. This latter symptom is the most marked peculiarity of the affection ; at intervals the head begins to twitch and it is finally drawn by the convulsive contraction of the muscles into an attitude of extreme de- formity. As the muscles most often affected are the sterno-mastoid and trapezius the attitude is usually one of typical torticollis. The spasmodic clonic contractions may involve the muscles of the face or of the chest even. They are more marked when the subject is excited or when sudden movements are necessary. As a rule, patients com- plain of neuralgic pain in the head and neck, aggravated by the cramp- like contractions. Etiology and Pathology. — The etiology is obscure. Many of the patients present a neurotic family or personal history, and over-work, shock to the nervous system and the like are cited as predisposing causes. The affection has been compared to writer's cramp as in certain in- stances the spasm appeared to be caused by constrained positions of the head necessitated by certain occupations, aggravated it may be by the strain of defective eyesight. The affected muscles may be hypertrophied from constant activity, and in the later stages of the affection they are, as a rule, permanently shortened. No characteristic changes in the nerves or in the central neryous system have been recorded. Prognosis. — There is little tendency toward spontaneous recovery. As a rule the spasm becomes more constant and other muscles become involved. Treatment. — It is perhaps unnecessary to state that the general condition of the patient and the possible local and general causes of the spasm should receive consideration. As a rule, however, the pa- tient will have exhausted both constitutional and local treatment be- fore coming under observation. In the mild and early cases the avoidance of predisposing causes combined with massage, systematic muscle training and in exceptional ^Am. Jour. Med. Sci., Jan., 1895. 488 CONGENITAL AND ACQUIRED TORTICOLLIS. instances mechanical support may be of service, but in the chronic, severe and persistent cases of this class the resection of nerves sup- plying the affected muscles has alone proved to be efficient. If the spasm is limited to the stern o-mastoid and trapezius muscles resection of the spinal accessory nerve may be sufficient ; but if other muscles are involved or if the spasm recurs after the original operation, the re- moval of the posterior branches of the upper cervical nerves together with extensive division of the contracted muscles upon the same side and sometimes upon the opposite side also, may be required. Resection of the spinal accessory nerve was first performed by Camp- bell de Morgan, of London, in 1866, and since then the operation has been repeated many times by other surgeons with temporary or perma- nent benefit to the patients. According to P6tit of 26 patients so treated 13 were cured and 7 were permanently improved. In five others the benefit was but temporary, one died from erysipelas following the operation.^ The Operation. — The spinal accessory nerve passes downward and backward from the jugular foramen and enters the anterior border of the sterno-mastoid muscle at a point about one and a-half inches be- low the tip of the mastoid process. At this point it should be exposed. Dr. E. Eliot, Jr., from a special study of the course and relations of the nerve, suggests the following method •? " The incision should be generous, for the nerve is situated at a con- siderable depth, and should extend from the mastoid process above, downward to one or two inches beyond the angle of the jaw. The anterior edge of the sterno-mastoid should then be exposed. In the upper part of the wound, the posterior and inferior portion of the pa- rotid gland may have to be drawn forward, although usually it does not overlap the muscle. When this is done, it is comparatively easy to expose by blunt dissection tlie transverse process of the atlas, as it lies directly below the mastoid process above, while immediately in front of this bony prominence, and running downward and forward from the mastoid process toward the angle of the jaw, is the posterior belly of the di'gastric. Behind this lie the main vessels of the neck with the spinal accessory nerve emerging from the jugular foramen and the operator is certain that no harm can be done to these structures as long as he remains superficial to the digastric belly, which in its turn lies at a considerable depth — in fact, at about the level of the trans- verse process of the atlas. " Owen and Petit have drawn attention to the fact that the nerve usually enters the mastoid muscle at a point opposite the angle of the jaw. I have found, however, in a large majority of cases, that on leaving the internal jugular it assumes a definite relationship with the transverse process of the atlas. Never above it, sometimes directly over it, usually a fraction of an inch in front of its most prominent part, the nerve may easily be detected in the small amount of connec- tive tissue that envelops it, and from this point to its entrance into iL' Union M&licale, July 9, 1897. " Annals of Surgery, May, 1895. OPERATIVE TREATMENT. 489 the belly of the muscle it may be isolated with safety, and treated by any suitable procedure. If, exceptionally, it should escape detection, the anterior border of the muscle should be drawn sharply backward at a point opposite the angle of the jaw, the nerve in this way put on the stretch, and by blunt dissection in the adipose tissue that separates the under surface of the muscle from the sheath of the vessels, the nerve may readily be exposed. Usually the nerve passes from under the posterior belly of the digastric, at a point Justin front of the trans- verse process of the atlas, to a point on the deep surface of the muscle just behind its anterior margin opposite the angle of the inferior max- illa. It is sometimes accompanied by a small artery and vein, the latter easily visible, the former a branch of the occipital. Rarely the nerve lies at a considerable distance from the transverse process of the atlas ; in one case as much as half an inch anteriorly. Here the nerve could be found at its entrance into the muscle, the landmark of the transverse process having failed to localize its situation." Richardson suggests that if tlie nerve is not readily found, its posi- tion may be ascertained by drawing the finger nail firmly across the bottom of the wound, a sharp contraction following pressure upon it. The nerve having been isolated a section of an inch should be removed. Richardson advises in addition vigorous stretching of both extremities. After division of the nerve the spasmodic contraction relaxes and the muscles become flaccid, allowing the head to be brought to the normal position, or if the deformity has become permanent the contracted parts may be divided as in the ordinary form. Fixation of the head is not, as a rule, required. The operation should be supplemented by massage and by muscle training. If the spasm has been confined to the muscles supplied by the spinal accessory nerve, the treatment may be perma- nently successful, but in many instances the spasm may recur in other muscles. Of these, the posterior group of the opposite side is more often aifected and a similar operation for resection of the posterior branches of the upper cervical nerves may be indicated. This has been performed with success by Smith of London, Keen, Richardson and others. According to Smith ^ the operation should be conducted as follows : an incision is carried downward from the occiput about three inches in length, parallel to and one inch from the spinous processes. It is continued through the trapezius to the edge of the splenius. The complexus is then divided and the posterior branches of the nerves are exposed ; those of the three upper nerves which supply the pos- terior rotators are then resected. Keen ^ operates in a somewhat different manner, by a transverse in- cision two and a-half inches in length from the middle line of the neck on a level with a point one-half an inch below the level of the lobule of the ear. The trapezius is divided transversely, afterwards the complexus, care being taken to spare the great occipital nerve. The posterior branch of the second cervical nerve is then resected, the sub-occipital nerve is then looked for in the sub-occipital triangle ^Spasmodic Wry Neck, London, 1891. ^^^^als of Snrf>-erv, January, 1891. 490 CONGENITAL AND ACQUIRED TORTICOLLIS. traced down to the spine and divided. The external trnnk of the posterior division of the third occipital nerve is then exposed below the great occipital and divided close to the bifurcation of the nerve trunk,, thus the nerve supply of the chief posterior rotators, the splenius capitis,, the rectus capitis, posticus major and the obliquus inferior is removed. The paralysis that follows even such extensive operations seems to inconvenience the patient but slightly, Avhile the relief from deformity and from the constant spasm is a more than sufficient compensation for whatever weakness or disability may result. The following are the conclusions of Richardson and Walton:^ 1. Palliative treatment, whether by drugs, apparatus or electricity, will rarely prove successful in well-established spasmodic torticollis. 2. Massage may prove of value in comparatively recent cases. 3. Resection affords practically the only rational remedy. 4. Operation on the spinal accessory nerve may afford relief, even if other muscles than the sterno-cleido-mastoid are affected ; on the other hand the affection previously limited to the sterno-cleido-mastoid may spread to other muscles in spite of this operation. 5. No fear of disabling paralysis need deter us from recommending operation, as the head can be held erect even after the most extensive resection. 6. The most common combination of spasm is that involving the sterno-mastoid on one side and the posterior rotators on the other, the head being held in the position of sterno-mastoid spasm with the addi- tion of retraction through the greater power of the posterior rotators. 7. It seems advisable in most cases to give preference to the resec- tion of the spinal accessory as the preliminary procedure. In a later communication Richardson and Walton ^ report very sat- isfactory final results on cases treated by resection of nerves supplying the muscles that were affected by the spasm on one or both sides, com- bined with complete division of the muscles as well, when permanent contraction was present. Kalmus^ has reviewed the literature of the subject. In eleven cases of simple stretching of the spinal accessory nerve, three were cured. In sixty-eight cases the nerve was resected; of these twenty-three were cured and twenty were improved. In four there was no improvement and in one the patient died. In fifteen cases the resection of the nerve was supplemented by division of cervical nerves ; ten of these were cured and three were improved. In two others the sterno-mastoid muscle was divided. IRREGULAR AND EXCEPTIONAL FORMS OF TORTICOLLIS. Paralytic Torticollis. One or more of the muscles of the neck may be paralyzed as from anterior poliomyelitis and thus a deformity, due at first to simple weak- ^ Annals of Surgery, January, 1891. 2 Am. Jour. Med. Sci., July, 1896. •■' Zur Operativ Behand. Caput. Obst. Sjjasticum, Beitrilge zur Klin. Chir., Bd. 26, 1900. PSYCHICAL TORTICOLLIS. 491 ness, and later to the permanent effects of the disability may be the result, s Diphtheritic Paralysis and Torticollis. The muscles of the neck may be involved in paralysis following diphtheria. In this form the trapezii muscles are as a rule involved so that the head hangs forward, but occasionally the paralysis may be accompanied by contraction of one of the sterno-mastoids. The his- tory, the evident weakness, and the paralysis of the soft palate or other parts, which is often present, usually make the diagnosis clear. Cervical Opisthotonos. In the course of certain forms of disease of the nervous system, for example cerebro-spinal or basilar meningitis, the head may be drawn backward by spasm of the posterior muscles. A slight degree of the same deformity is sometimes seen in ill-nourished infants not suffering from serious disease. This and the preceding distortion are of some importance because they may be mistaken for symptoms of Pott's dis- ease and they have been described in that connection. (See page 55.) Rhachitic Torticollis. During the course of acute rhachitis, particularly when the char- acteristic deformity of the lower part of the spine is well marked, the head may be tilted backward usually as a compensatory attitude, but occasionally slight spasm of the posterior muscles may increase the dis- tortion ; so also when lateral deviation of the spine is present due to rhachitis, the neck may participate in the deformity as in other forms of rotary lateral curvature. This is not torticollis, however, in the proper sense. Ocular Torticollis. Several cases have been recorded in which the head was habitually held in a distorted attitude because of defective vision or irregularity in the action of the muscles of the eyes. This is, however, rather an improper attitude than a variety of true torticollis.^ (Fig. 143.) Psychical Torticollis. A distortion of the head, apparently due to the inability of the patient to control the muscles of the neck has been described by Bris- saud.^ The deformity was not due to muscular spasm since it could be corrected by the pressure of a finger on the head. The condition is called by Brissaud a local paralysis of the will, a form of neurosis allied to neurasthenia, epilepsy, and functional spasm. 1 Hobby, Med. News, June 11, 1898, p. 772. 2 These de Paris, 1894. CHAPTER XX. DISABILITIES AXD DEFORMITIES OF THE FOOT. General Description of the Foot and of Its Functions. The function of the foot is two-fold : to serve as a passive support of the weight of the body, and as an activ^e lever to raise and propel it. For the proper performance of these functions, the foot is con- structed to allow elasticity under pressure, and an alternation of atti- tudes under strain, that protect it from injury. The Arches. — The most noticeable peculiarity of the foot is the ar- rangement of its arches. As has been suggested by Ellis and others, Fig. 330. Longitudinal section of the cast of the arch at the point A in Fig. 331 ; A, the astragalo-scaphoid junction ; B, the internal tuberosity of the os calcis ; C, the head of the first metatarsal bone. the construction and shape of the arched part of the foot may be better understood by considering it as half of the arch formed by the two feet. This complete arch may be demonstrated by making an imprint of the apposed feet in plaster of Paris. The plaster cast which repre- sents it will appear in shape somewhat like an inverted saucer, the Fig. .331. Cross section of the cast of the arches of the apposed feet. A. The internal and inferior angle of the astragalo-scaphoid junction. part of each foot that rests upon the ground forming half of an irregular ring. If the plaster cast is sawed into equal sections, it will be seen that the highest or thickest part of each division is at the astragalo- scaphoid junction ; from this point the arch descends sharply to the DESCRIPTION OF THE FOOT AND OF ITS FUNCTIONS. 493 tuberosities of the os calcis and gradually to the outer border, beneath the cuboid bone, and to the metatarso-phalangeal joints. (Fig. 330.) A cross section of the cast will show the contour of what is sometimes called the TRANSVERSE ARCH (Fig. 331), while the section through the long diameter will demonstrate the shape of the longitudinal, arch. In descriptions of the longitudinal arch, it is often divided into two parts, Fig. 332. The bones of the right foot, viewed from the outer side. (Testut. ) (From Gerrish's Anatomy.) of which the outer division is formed by the os calcis, the cuboid, and the two outer metatarsal bones. Of this outer arch, the highest point is at the calcaneo-cuboid articulation (Fig. 332), and although it is normally a permanent arch yet the soft tissues are forced downward beneath it when weight is borne, so that the outer border of the foot makes an imprint throughout its entire length, as contrasted with the Fig. 333. The bones of the right foot, viewed from the inner side. (Testdt. ) (From Gerrish's Anatomy.) inner and deeper arch formed by the os calcis, the astragalus, the scaphoid, the cuneiform and the three inner metatarsal bones. (Fig. 333.) This division, although an artificial one, is of some service in calling attention to the fact that the outer or lower arch is more solidly braced and therefore better adapted to continuous weight-bearing than is the higher and more elastic inner arch. 494 DISABILITIES AND DEFORMITIES OF THE FOOT. The diagram of the longitudiual arch, showing its sharp descent from the highest point to the center of the heel, demonstrates the fact that the heel is well adapted for weight-bearing, while the long anterior pillar composed of several bones is less strong but more elastic ; thus one instinctively extends the foot in descending stairs, for example, to avoid the unpleasant jar of direct shock received upon the heel. Of this anterior pillar, the third metatarsal bone is the most direct sup- port, while the more movable first and fifth metatarsals, more under muscular control, aid in balancing the weight upon the center of the foot. Both divisions of the longitudinal arch are permanent arches, but there are two others w^hich are obliterated under weight ; one of these is that formed by the heads of the metatarsal bones, the anterior METATARSAL ARCH. In the Unweighted foot, the second and third metatarsal bones occupy a higher plane than their fellows, but when the erect posture is assumed, the anterior arch is depressed to allow all the metatarsal heads to bear their share of the weight. The other arch does not rest upon the ground but is formed by the internal border of the foot, which curves slightly outward, so that when the two feet are placed side by side an interval remains between them, widest at the highest point of the longitudinal arch, as is shown in the diagram by the upright section which divides the cast of the two soles from one another, the ixterxal arch. (Fig. 331.) When weight is borne, this curved contour of the foot becomes straighter, or obliterated or even transformed to an arch whose convexity is internal. (Figs. 351, 352.) The Foot as a Passive Support. — The foot is supported by the muscles, by ligaments, and by the strong plantar fascia that covers in the sole. When the foot is actively used, it is in great part supported by the muscles, but when it serves as a passive support, as in standing, the ligaments bear the greater part of the strain, and its normal elas- ticity allows the bearing surface to expand slightly as the arches are slightly depressed. If this normal elasticity is diminished, as is some- times the case, the supports of the arch are subjected to abnormal pressure and the individual may suffer from sensitive corns or calloused skin beneath the bones. Or if the ligaments allow abnormal expansion, the arches may become permanently depressed and as a result the range of motion necessary to the proj»er functional use of the foot, may be permanently restricted. When the statement is made that the foot broadens and that the arches are slightly depressed under weight, it must not be understood that the longitudinal arch is simply flattened by direct pressure and by elongation of elastic ligaments and fascia. Ligaments and fascia are not elastic in this sense and they are not, in the normal foot, over- stretched. The change in contour is the effect of normal motion in the joints of the foot, by which it is placed in the most favorable atti- tude for weiffht-bearino; without muscular exertion — the so-called atti- tude of rest. IMPROPER POSTURES. 495 Of the changes of contour that distinguish the foot used as a passive support from the one that bears no weight, the most significant is the obliteration of the outward curve of its internal border. This change is due to the fact that the astragalus, bearing the leg, rotates inward and downward on the os calcis until it is checked by the resistance of the ligaments and by the interlocking of the bones. The head of the astragalus thus becomes slightly prominent, the inner border of the foot is depressed, and an attitude is attained in which the weight of the body may be supported with but slight muscular exertion. In this attitude of rest, as Von Meyer has explained, there is general fixa- tion of joints of the lower extremity which makes support pos- sible with the least muscular exertion. The pelvis tilts slightly up- ward until tension is brought upon the anterior part of the capsule of the hip joint, the femur rotates slightly inward, so that the tibia is turned outward in its relation to it, and finally the tibia in turn falls slightly inward upon the everted foot. To unlock the joints the pelvis must be tilted forward or the hip must be flexed. The Foot in Activity. — The second function of the foot is as a lever to raise and to propel the body. The calf muscles supply the power and the heads of the metatarsal bones serve as the fulcrum on which the weight is to be lifted. When the foot is used as a lever, it should be held in such relation to the leg that the line of weight, passing downward through the center of the knee and ankle joints, is continued over the second toe or practically the center of the foot. As the body is lifted over the fulcrum the forefoot is turned inward in its relation to the leg or, more properly speaking, the leg is turned out- ward because the inner side of the fulcrum, formed by the first metatarsal bone, is longer than its outer side, thus the strain is directed toward the outer and stronger side of the foot. (Fig. 334.) In the proper walk, which is the best illustration of the leverage function, the feet should be held practically parallel to one another, so that the line of strain may fall through the center of the foot. As one foot is advanced it first bears weight momentarily on the heel, then upon its outer border ; the heel is then raised and the body is lifted over the toes, the great toe giving the final impulse to the step, so that if the walker is looked at from behind, he appears to be in-toeing at the termination of each step. Thus, during the walk, there is an al- ternation of postures, and the foot, under muscular control, assumes the attitudes most opposed to that of passive support. Improper Postures. — The alternation of postures and the leverage action of the foot are by no means necessary to simple progression ; for example, both feet might be fixed in plaster bandages yet walk- ing would be possible, just as it is possible on two wooden legs. In- deed, an approximation to such a manner of walking is often seen, in which the feet are practically held in the passive attitude, the weight being borne upon the heels. Such a walk is necessarily jarring and ungraceful, and if it is not the result of weakness and deformity it pre- disposes to them because of the disuse of the proper function of the foot. 496 DISABILITIES AND DEFORMITIES OF THE FOOT. One means of making the leverage function difficult is the custom of turning the feet outward. Outward rotation of the feet is normal in the passive attitude of weight-bearing, because it enlarges the base of support, locks the joints and throws the strain upon the ligaments to relieve the muscles. On this very account it is the improper atti- tude for activity because the strain falls upon the inner border of the foot, or to the inner side of the fulcrum, and makes the proper exer- cise of muscular power and alternation of postures impossible. In other words the attitude normal when the foot is used as a passive support is abnormal when it is in active use. The Movements of the Foot. — The junction between the foot and Fio. 334. Fig. 335. Illustrates the involuntary adduction of the The improper attitude of outward rotation in which forefoot, due to the obliquity of the metatarsus, there is disuse of the leverage function, in the proper attitude for walking. the leg is made by means of the astragalus, a bone which is not inti- mately connected with either part, since it moves upon the leg and upon the foot, and to it no muscles are attached. The movements of the foot are four in number : Dorsal flexion ; plantar flexion ; adduction ; abduction. Simple dorsal and plantar flexion are confined to the ankle joint, but complete plantar flexion is combined with slight adduction, and dorsal flexion with abduction, because the external facet of the astragalus allows a greater range of motion on the external malleolus than is per- mitted about the internal malleolus. The range of motion at the ankle joint is from sixty to eighty de- grees ; thus dorsal flexion to ten or twenty degrees less than the right THE MOVEMENTS OF THE FOOT. 497 angle, and plantar flexion fifty to sixty degrees more than the right angle. '(Figs. 336, 337.) Adduction and abduction of the foot are carried out in the medio- tarsal and sub-astragaloid joints. Adduction, the motion of turning the foot inward in its relation to the leg, is always accompanied by inversion of the sole or supination, because of the shape of the joint surfaces between the astragalus and OS calcis, where the greater part of the motion takes place. Simple adduction and abduction without supination or pronation is possible to a very limited extent in the medio-tarsal joint. Its range may be tested by fixing the heel, when the forefoot may be moved slightly back and forth upon the astragalus and os calcis. The range of mo- tion in the sub-astragaloid joint is twice as free as in the medio-tarsal Fig. 336. Fig. 337. Voluntary dorsal flexion. Voluntary plantar flexion. In these attitudes the astragalus moves with the foot upon the leg bones, as contrasted with adduction and abduction in which the center of motion is below the astragalus. joint. The character of the motion between the astragalus and os calcis is rotation on an axis passing through the upper and inner part of the head of the astragalus, downward and outward to the outer tuberosity of the os calcis. Thus for all practical purposes, adduction, inversion and supination are synonymous terms : the same is true of abduction, pronation and eversion. Outward rotation is, however, quite distinct, since the center of motion is at the hip joint. In the movement of adduction of the foot, the astragalus is fixed between the malleoli, and upon it the os calcis glides forward and its anterior extremity turns slightly inward ; the sustentaculum tali moves backward, its inner superior surface is elevated and its external sur- face is depressed. Meanwhile the forefoot, following the motion of 32 498 DISABILITIES AND DEFORMITIES OF THE FOOT. the OS calcis, is carried inward about the head of the astragalus ; its inner border is elevated and its outer border is depressed, so that the sole looks inward and downward. In this attitude all the arches are ncreased in depth. (Fig. 338.) In abduction the bones move upon one another in the reverse direc- tion, the curves are lessened and that of the inner border is obliterated. (Fig. 339.) The extreme of adduction is only possible in the position of plantar flexion, because in this position the adduction possible at the ankle joint, in part due to the contour of the astragalus and in part to the Fig. 339. Fig. 338. Voluntary adduction. Voluntary abduction. In these postures the foot moves upon the astragalus which is practically fixed between the mal- leoli. Adduction, the turning of the foot inward in its relation to the leg, is al way?: accompanied by ele- vation of its inner and depression of its outer border, This is known as supination or inversion of the foot. The reverse of this attitude — pronation or eversion — is an accompaniment of abduction as is illustrated in the figures. greater mobility allowed in the joint when the narrow posterior border of the astragalus is alone in contact with the malleoli, is added to the adduction which the joints of the foot permit. Extreme abduction is attained in the attitude of dorsi-flexion, its ex- tent being about one-half that of adduction ; the entire range of motion between the two extremes being about forty-five degrees. In this description the foot is considered as moving on the leg, but in the attitude of rest the foot becomes the fixed point and the astragalus moves upon the os calcis in the manner and to the position THE MOVEMENTS OF THE FOOT. 499 already mentioned in the description of abduction, i. e., it slips down- ward arid forward and turns inward, and at the same time the anterior extremity of the os calcis turns slightly inward and downward, and Fig Fig. 341. The direct dorsal flexors. Tibialis anterior of right side : outline and Peroneus tertius of right side : outline and attachment-areas. (Gerrish.) attachment-areas. (Geerish.) its inner border is depressed. Corresponding to this movement, as the inner border of the foot becomes straight or bulges inward, the scaphoid is forced forward and downward and the longitudinal arch is depressed. 500 DISABILITIES AND DEFORMITIES OF THE FOOT. Fig. 342. Fig. 343. /I / The calf muscle. The plantar flexor. , *. , Gastrocnemius of right side : outline and Soleus of right side : outline and attach- attachment-areas. (Gbkrish.) meut-areas. (Geerish.) THE MOVEMENTS OF THE FOOT. 501 As has been mentioned the turning of the leg inward and the corre- sponding turning of the foot outward in its relation to it, locks in a manner the ankle joint and at the same time throws the strain upon Fig. 344. Fig. 345. Peroneus longus of right side : outline and attachment-areas. (Gereish.) The direct abductors. Peroneus brevis of right side : outline and attachment-areas. (Gekkish. ) the ligaments, so that standing in the erect posture is possible with but little muscular exertion. (Fig. 351.) To put it in a simpler manner, the leg supporting the weight of the 502 DISABILITIES AND DEFORMITIES OF THE FOOT. Fig. 346. N- The most important adductor. Tibialis posterior of right side : outline and attachment-areas. The most of the muscle is represented as if seen through the bones. (Geekish. ) body has a tendency to tilt the foot over toward the inner side and to evert the sole ; thus, under increasing superincum- bent weight, the point of greatest pressure on the sole shifts from its center and outer border toward the inner border. If on the other hand the body is raised upon the toes, the arch is relieved from strain and the weight falls upon the front and outer part of the foot. Plantar flexion and ad- duction represent, as contrasted with the passive attitude of supporting weight, the attitude of activity in which the foot is supported and controlled by the muscles. The Function of the Muscles. — The most important function of the dorsal flexors is to lift the foot as it is swung forward, while the plantar flexors serve in the active propulsion of the body. The difi'erence in function is shown by the rela- tive strength of the two groups, the plantar flexors being five times the stronger; in fact, the calf muscle (gastrocnemius and soleus) alone is three times as strong as all the other muscles of the foot combined. It is prac- tically the leverage muscle, the others serv- ing more especially to fix and to hold the forefoot, or fulcrum, in its proper relation to the leg. (Figs. 342, 343.) The muscles that most directly sup- port the inner arch of the foot are the tibialis posticus and anticus, whose ten- dons meet in their insertion in front of the astragalus in the form of a V. The tibialis anticus supports the internal bor- der of the foot from above, and the posti- cus is the most powerful adductor. (Figs. 340, 346.) The flexor longus pollicis, passing direct- ly beneath the sustentaculum tali, aids in supporting the weak part of the foot and its position demonstrates the importance of the proper functional use of the great toe. (Fig. 350.) The peroneus longus and brevis sup- port the outer arch and the former binds the foot together and holds the great toe firmly against the ground, thus it indi- rectly supports the longitudinal arch against direct pressure. (Figs. 344, 345.) THE FUNCTION OF THE MUSCLES. 503 The relative strength of the muscles and their functions is shown in the following tables : ^ Dorsal Flexors of the Foot : Strength reckoned in kilogrammetebs. Tibialis Anticus 0.871 Extensor Longus Digitorum 0.280 Extensor Longus Pollicis 0. 155 Peroneus Tertius 0.087 1.393 Plantar Flexors. The calf muscle Soleus ....3.256 Gastrocnemius 2.831 Flexor Longus Pollicis 0.218 Peroneus Longus 0. 118 Tibialis Posticus 0.094 Flexor Longus Digitorum 0.078 Peroneus Brevis 0. 055 6.650 Relative Strength of the Supinators of the Sub-Astragaloid Joint. strength. Weight of the Muscles. Soleus 1.021 Gastrocnemius 0.709 Tibialis Posticus 0.337 Flexor Longus Pollicis 0.172 Flexor Longus Digitorum 0.123 2.362 Relative Strength of the Pronators of thk Sub-Astragaloid Joint. strength. Peroneus Longus 0. 282 Peroneus Brevis 0. 192 Extensor Longus Digitorum... 0.164 Peroneus Tertius 0.067 Extensor Longus Pollicis 0.045 Tibialis Anticus 0.021 0.771 123.7 Relative Strength of the Supinators of the Medio-Tarsal Joint. Tibialis Anticus 0.238 Tibialis Posticus 0.078 Flexor Longus Pollicis 0. 034 Flexor Longus Digitorum 0. 033 Extensor Longus Pollicis 0. 030 0.413 Relative Strength of the Pronators of the Medio-Tarsal Joint. Peroneus Longus 0. 162 Peroneus Brevis 0.090 Extensor Longus Digitoi'um 0. 085 Peroneus Tertius 0. 033 370 It will be noticed that the strength of the pronators and supinators 1 Uber die Arbeitsleistung der auf die Fussgelenke Wirkenden Muskeln, E. Fick Leipsic, 1892. 157.0 Grammes. 120.0 39.6 33.2 12.3 362.1 SUB-ASTRAGALOI] Weight of the Muscles, 24.0 Grammes. 16.5 18.2 3.5 12.3 49.2 504 DISABILITIES AND DEFOBMITIES OF THE FOOT. (abductors and adductors) of the medio-tarsal joint is nearly equal, and that the great preponderance of power of the supinators of the sub-astragaloid joint is owing to the fact that the calf muscle is a Fig. 347. Fig. 348. Extensor proprius hallucis of right side : out- line and attachment-areas. (Geerish.) Extensor longus digitoruni of right side : out- line and attachment-areas. (GErrish.) supinator. When the foot is at a right angle with the leg, the power of the calf muscle not being utilized, the pronators are stronger than the supinators. It will be noticed also, that the tibialis anticus muscle. THE FUNCTION OF THE MUSCLES. Fig. 349. Fig. 350. 505 Flexor longus digitorum of right side : outline and attachment-areas. The muscle is represented as seen from in front through the bones. (Gerrish.) Flexor lougus hallucis of right side : outline and attachment-areas. The mus- cle is represented as seen from the front through the bones. (Gerrish.) 506 DISABILITIES AND DEFORMITIES OF THE FOOl. which supinates the medio-tarsal joint, is reckoned among the pronators of the sub-astragaloid joint. The Foot Considered as a Mechanism. — In the study of the de- formities, and particularly of the functional weaknesses of the foot, one must never lose sight of the fact that it is a machine, subject to the same mechanical laws that govern other machines, and that its deformities and disabilities, its relati\"e strength or weakness, may be appreciated by comparing it with the normal standard. As in other machines, marked deformity or distortion is evident at a glance, even Fig. 351. Fig. 352. An attitude that simulates flat foot. (See Fig. 353.) Fig. 352, compared with Fig. 351, will illustrate the Toluntary protection of the foot from over-strain. though the apparatus is not in use, but functional ability can be judged only by the manner in which active work is performed. As has been stated, the foot is, in activity, a lever, by means of which the weight of the body is lifted and propelled. If it is loosely constructed or insufficiently supported by the ligaments, it is evident that it can not be properly controlled by the muscles. If, on the other hand, the muscular power is insufficient, it is evident also that the weight of the body can not be lifted and properly balanced upon it. The structure of the foot may be normal and its muscles may be of normal strength yet the strain placed upon it may be disproportionately THE WEAK FOOT. 507 Fjg. 353. great. This strain may be actual over-weight, or the over-work of a laborious occupation, but more often the machine is over- worked simply because it is subjected to mechanical disadvantages in the performance of its functions, by the assumption of improper attitudes. An improper attitude is one that limits or lessens the range of mo- tion, and the alternation of postures, that protect the foot from over-strain. One of the most common of such attitudes is, as has been mentioned, that of turning the feet outward in walking, thus the ful- crum being displaced outward, the strain falls through the inner and weaker side of the foot. As a consequence of the improper attitude there is usually, to a greater or less degree, disuse of the active leverage function of the foot ; the active lift of the calf muscle is replaced by exaggerated flexion at the knee, the foot being used somewhat as if it were a movable pedestal. (Fig. 335.) This disuse of active attitudes may be unnecessary, just as the out- ward rotation of the feet with which it is associated is a habit, a habit that is often the result of improper teaching. On the other hand, the habitual assumption of the passive attitude may be induced by injury or disease of the foot, or by corns or bunions, or by improper shoes. Under such conditions the strain of the leverage function increases the discomfort, consequently it is discontinued. It must not be inferred that such improper attitudes lead directly to weakness and discomfort, for in most instances, an ungraceful carriage and gait are the only ill effects. The improper attitudes must, however, lessen the power and resistance of the foot and they must be reckoned, therefore, among the predisposing causes of disability and deformity. The passive attitude, it will be remembered, is the attitude of rest, in which the ligaments bear the greater part of the strain and in which the arches of the foot are depressed or obliterated. Typical " flat foot " uf moderate degree, il- lustrating the componeut, elements of abduc- tion and depression of the arch. The Weak Foot. Synonyms. — Splay Foot, Flat Foot. This introduction leads naturally to the consideration of the most important of the acquired disabilities of the foot, a disability whose most important characteristic in the mildest and in the most advanced type is the persistence of the passive attitude, or an approximation to it, in place of active motion and alternation of posture. Disuse of function is followed by restriction of motion, particularly in the 508 DISABILITIES AND DEFORMITIES OF THE FOOT. Fig. 354. Fig. 355. rauge of adduction and plantar flexion, and finally by persistent de- formity, a deformity which is simply an exaggeration of the normal posture assumed when the foot supports weight. (Fig. 351.) This is the so-called flat foot. (Fig. 353.) At first glance^ it may seem that the depression of the arch is the most noticeable peculiarity in a w^ell-marked case of flat foot, and that the popular name is therefore an appropriate term, but on closer examination it will be evident that the normal relation between the leg and the foot is changed. This change, which from the functional standpoint is of far greater impor- tance than the depth of the arch may be analyzed as follows : The Anatomy of the Weak Foot. — 1. The leg is displaced inward so that the weight falls upon the inner side of the foot ; 2. The leg is rotated inward, so that a line drawn through its center, prolonged from the crest of the tibia, instead of falling over the second toe now points inside the great toe, or even over the center of the internal bor- der of the foot. (Figs. 353-356.) It has been stated that under normal conditions in the act of passive weight-bearing, the astragalus rotates downward and inward upon the OS calcis, depressing its anterior and internal border until the move- ment is checked by the strong ligaments connecting the bones, the cal- caneo-scaphoid, the deltoid and the interosseus ; in other words the leg has a tendency to slip downward and inward from off the foot. In the weak foot this inclination has become an accomplished fact, for the normal movement has become so exaggerated by the distention of the ligaments and by the weakness of the supporting muscles that an actual partial dislocation has taken place. The astragalus has rotated and slipped far to the inner side of its normal position and to an attitude of exaggerated rotation and moderate plantar flexion, so that its head can be plainly felt on the internal border of the foot. The os calcis has been forced into an attitude of pronation. Its anterior extremity is depressed and turned slightly inward and its internal border is lowered. (Fig. 355.) The scaphoid bone has been depressed with the head of the astraga- lus, although to a less degree, and has been forced further away from the OS calcis, and with it the entire inner border of the foot is depressed also. Thus the depression of the arch is ahvays accompanied by a bulffinp; inward of the inner side of the foot. The typical flat foot is, as it were, broken in the center (Fig. 366), the posterior division having turned inward and downward ; that is, the astragalus has rotated inward and downward to an extreme degree and has slipped from off the os calcis. The latter bone, although The relatiou of the astragalus to the os cal- cis. The relation of the astragalus and os calcis in flat foot. IHE WEAK FOOT. 509 Fig. 356. forced outward in its relation to the astragalus, still turns inward slightly, while the forefoot in its relation to the leg is greatly abducted. The dislocation may be so extreme that the entire sole of the foot rests upon the ground, and a callus even may be found at the point that usually represents the highest point of the arch, which now supports the greatest burden. In this change of relation between the bones the arched part of the foot, or waist, appears much broader than normal, even broader than the front of the foot ; the heel projects, the external malleolus is de- pressed and carried forward by the rotation of the leg and is much less prominent than normal ; the internal malleolus is more prominent and with the astragalus it overhangs the bearing surface of the sole. The entire ma- chine is twisted and out of gear, its motion is therefore very much re- stricted. It is manifestly impossible for the patient to adduct the forefoot, that is to turn it inward about the head of the displaced astragalus. Plantar flexion is also much limited, because of the permanent position of adduction and plantar flexion that the astragalus has assumed. Dorsal flex- ion, on the other hand, although it is actually restricted, may appear to be abnormally free, because the forefoot is abducted and slightly dorsi-flexed upon the head of the astragalus. (Fig. 353.) The disability and its accompanying deformity, is found in every grade of severity. Pain begins when, the sup- port of the muscles being insufficient, the ligaments begin to give way under strain, allowing the bones to occupy an abnormal relation to one another. It is evident, therefore, that the individual in whose foot the arch is well formed and whose ligaments are firm, will suffer from the symptoms of strain long before the arch has been depressed or deformity has become appa- rent; also that the lateral inward bulging, characteristic of advancing de- formity, must be very great before the arch is completely flattened. In this type the prominent deformity is lateral displacement (valgus). On the other hand, if the individual has inherited a low arch, as is charac- teristic of certain races, or if, as the result of weakness in early life, the arch has been depressed or has never formed, accommodative changes in the bones will have taken place during growth, so that the flat foot Weak feet, showing the inward rota- tion of the legs when the abducted feet are placed side by side. 510 DISABILITIES AND DEFORMITIES OF THE FOOT. Fig. 357. of this type will not be attended with as much change in its relation to the leg, and therefore, disturbance of function, as in the typical case that has been described. This latter class of cases exemplifies the popular type of flat foot that may exist without pain or disability and in which the most noticeable peculiarity is the obliteration of the arch (planus). (Contrast Figs. 357 and 358.) In certain instances, abnormal laxity of ligaments allows deformity of the valgus type when weight is borne, yet the foot, controlled by efficient muscles, may be apparently normal in functional ability, while in other cases in which the ligaments are resistant and yet are sub- jected by insufficient muscular protection to over-strain, disability and pain may precede noticeable deformity. It is very evident that the lowering of the arch is of secondary importance in the deformity and that the popular significance of painful flat foot, as an inherited and irremediable weakness, is most misleading. Yet it seems to have governed the treatment of the dis- ability until very recently. On the one hand, the early cases were overlooked because the foot was not flat, while those in which the deformity was more advanced were simply neglected or were treated by simple supports be- neath the arch or by operation, with- out regard to the loss of function, and therefore without hope of ultimate cure. As has been stated, there is one feature common to every grade of the so-called flat foot ; the foot regarded as a machine is weak, as compared to the normal standard — weak because of the persistence of the attitude of rest and relaxation, as contrasted wdth that of activity and strength, and weak because the proper relation between the power and the fulcrum is changed. Even the inherited flat foot or the flat foot which has never caused symptoms, is weak in the sense that, in use, it lacks the spring and elasticity characteristic of the perfect machine. The term weak foot may be used, then , to indicate all types of the dis- ability. In one weak foot the arch has disappeared (Fig. 358) ; in another weak foot the arch is of normal depth but the foot is abducted or pronated in its relation to the leg. (Fig. 357.) In one case the deformity appears only under weight ; in another the foot is held rigidly in the deformed position by muscular spasm. In one instance there may be great deformity without pain ; and in another, disabling weak- ness and pain without deformity. In one case the foot is unable to perform its functions because of its inherent weakness, in another Weak feet, arch not depressed. ETIOLOGY. 511 the disability may be due simply to the improper use of a normal structure. Pathology. — Supposing the foot to have been normal before it began to break down, it is evident that such deformity could not have been acquired without marked changes in its internal structure, and that its progress must have been attended with symptoms of discomfort and pain. In a general way, these changes are such as have been indicated by the description ; the ligaments on the internal aspect of the foot and of the ankle joint are weak and distended ; the unused portions of the articular surfaces of the joints may be denuded of cartilage, while new facets may have formed to accommodate the changed relations of the bones. For example, the external malleolus may be in direct contact with the OS calcis ; evidences of injury and of abnormal pressure may be found in the thickened periosteum, in formation of osteophytes, while the internal structure of the bones has been changed as well, to adapt itself to the new conditions. The muscles which are no longer used in the leverage function, the plantar flexors and adductors, have become atrophied, a change that is made evident by the shrunken calf. The muscles on the inner border of the foot have been over-stretched, while those on the upper and outer part have become shortened and contracted. Such a foot represents an extreme, it may be an irreme- diable degree of deformity. The machine is completely broken down, it can no longer perform its proper function, it is even less efficient than the wooden foot, because use is attended by discomfort. Etiology. — In all cases the actual symptoms of pain and disability are due to a disproportion between the burden or strain and the ability of the machine to perform it. This theory accounts for the fact that the weak foot, although very common in childhood, does not as a rule, cause troublesome symptoms until adolescence, when the weight and strain put upon it are increased. It explains why the foot, which may be fairly normal in structure breaks down often in later adolescence or early adult life when the con- tinuous strain of regular occupation is undertaken. It is evident also that an occupation that requires the long continuance of the passive attitude, that of waiters, cooks and bar-tenders for example, exposes the feet to greater strain than one which permits alternation of postures and that the symptoms are likely to be more severe and the deformity to be greater among those who are obliged to labor than among those who are not. Over-work or strain, of occupation or otherwise, may be temporarily disproportinate because of general weakness, as for example, during pregnancy or after recovery from exhausting disease ; or because of local injury or disease of the foot itself which weakens it directly or induces improper attitudes. On this theory one may very easily explain what has proved such a stumbling block for students, viz., that there is no constant relation between the degree of deformity and the severity of the symptoms ; for although all flat feet are weak feet yet all weak feet are not necessarily painful feet. Pain is not caused be- cause the foot is flat ; it is a symptom of progressive deformity, of 512 DISABILITIES AND DEFORMITIES OF THE FOOT. strain and injury to the joints ; it shows that the foot is becoming flat or it is a symptom of injury that the weak or flat foot has received. The progress of the deformity may be temporarily or permanently checked at any stage, either by a removal of the exciting cause or be- cause of the resistance of the tissues ; then the pain ceases. On the other hand, this stability may not be attained until the entire sole of the foot rests upon the ground, and even then the patient may suffer from discomfort and pain. This conception of the foot as a machine, of which grades of efficiency may be recognized, has a great advantage since it enables one to per- ceive wherein a foot is weak even though the weakness causes no symptoms whatever. Thus one is enabled to prevent deformity by teaching the patient to avoid the extra strain that improper attitudes entail, and to strengthen the muscles on whose ability its integrity de- pends. Finally from this standpoint one may better appreciate the weakness and deformity that is often the direct result of improper shoes, a subject that will receive more extended consideration elsewhere. Statistics. — A brief analysis of a thousand cases of so-called flat foot treated at the Hospital for the Ruptured and Crippled will represent fairly the points of general interest in this class of cases. The Age and Sex of the Patients. Age. Ten years or less....... Ten to fifteen Fifteen to twenty Twenty to twenty-iive Twenty -five to thirty. More than thirty Males. Females. 68 30 112 87 144 83 94 53 68 41 132 88 618 382 Total. 98 199 227 147 109 220 1,000 Foot aflfected : right, 133 ; left, 138 ; both, 729. In fifty-eight cases the cause of the disability appeared to be injury, and in sixty-five instances it was, apparently, due to rheumatism or to rheumatoid arthritis. The symptoms usually appear first in one foot, and as a rule, they are at all times more marked on one side. Of five hundred and sixty-nine instances, in which the duration of symptoms was recorded, it was six months or less in four hundred and nine. The age of the patients is of interest as bearing on the question of prognosis. Four hundred and twenty-six were between ten and twenty years of age, and seven hundred and eighty were less than thirty. Hospital statistics cannot adequately represent the subject of the weak foot, for as a rule, it was because of disability and pain, not for the deformity or for the milder type of symptoms, that these patients applied for treatment. In the larger proportion muscular spasm and rigidity were present, in two hundred and thirty-four cases to such a degree that forcible over-correction was advised, an operation rarely necessary in private practice. SYMPTOMS. 513 It is in childhood that the prevention of subsequent weakness and deformity is of the first importance, yet but ninety-eight children of ten years of age or less are recorded, and of these a large proportion were brought, not for weakness or deformity, but for treatment of the symptomatic in-toeing. Symptoms. — As has been stated, the symptoms of the weak foot, although similar in type, vary in severity according to the local con- dition and the disturbance of function, the work to be performed, and the susceptibility of the individual. The earliest symptom is usually a sensation of weakness ; the patient begins to recognize as familiar, a feeling of discomfort, of tire and strain about the inner side of the foot and ankle ; sometimes after long standing, a dull ache in the calf of the leg, or pain at the knee, hip or in the lumbar region, symptoms more common in women than in men; or after over-exertion a momentary sharp pain radiating from the point of weakness, thus the patient often dates the history of his trouble from a long walk. After a time the patient may become aware that he is accommodating his habits to his feet ; he rides when he once walked, he sits when he once stood, he no longer runs up or down stairs or jumps off the street car. His feet have lost their spring as he expresses it, which means that the foot is no longer sup- ported and controlled by muscular activity and is no longer used as a lever. Not infrequently, early symptoms are pain and tenderness at the center of the heel, explained in part by the jarring heel walk which is always assumed when the foot is weak, and in part by the strain upon the attachments of the deep plantar ligaments. The patient may complain that he cannot buy comfortable shoes ; the reason is that the weak foot under use is changed in shape, so that the shoe that was comfortable in the morning compresses the foot painfully at night ; thus increasing discomfort from corns, bunions, painful great toe joints, and deformities of the toes is experienced. Coldness and numbness, congestion and increased perspiration, caused by the impaired circula- tion and weakness, are common symptoms in this class of cases. Actual pain is, as a rule, felt only when the foot is in use ; it ceases under temporary rest or relief from disproportionate work, and it is this remittance of symptoms, together with the fact that the discom- fort is usually more marked in damp weather, that leads so often to the mistaken diagnosis of rheumatism. The foot is weak and vulner- able ; the patient recognizes the fact that he has what he speaks of as a weak ankle, or sprain, or gout, or rheumatism, but if he has accom- modated himself to the weakness, but little discomfort is experienced. In many instances such relief or accommodation is impossible, and it is therefore among the working class that one oftener sees the frank and rapid development of the disability and deformity. The range of motion becomes more and more restricted ; the habitual attitude, at first exaggerated to deformity only under the influence of the weight of the body, remains as a permanent displacement of the bones. The weak and dislocated foot is subjected to constant injury, to what may be likened to a succession of slight sprains, so that local congestion, 33 514 DISABILITIES AND DEFORMITIES OF THE FOOT. tenderness and swelling may appear together with muscular spasm, rigidity, and pain on passive motion. Because of this rigidity of the foot, which has lost the power to accommodate itself to inequalities of the surface, the patient dreads to cross a rough pavement, for every misstep is a source of pain. Another symptom, the discomfort felt in changing from a position of rest to activity, which is usually present in slight degree at every stage, now becomes more prominent. The patient, after sitting or on rising in the morning, is unable to walk, but staggers and limps for several minutes, a symptom explained by the fact, that when the foot is at rest, there is a partial reposition of the displaced bones, which must be again forced into the deformed posture that has become habitual. The local tenderness and muscular spasm are increased by use, so that the patient may have difficulty in removing the shoe at night and the symptoms relieved by the rest of Sunday become progressively worse during the week. The pain and discomfort are more general in character, and are often referred to the dorsum of the foot, representing muscular rigidity and tension, and to the ankle wdiere the external malleolus is grinding out a facet in the projecting os calcis. The patient may now complain of discomfort in the feet and cramps in the legs, even when in bed, and the appearance of weakness, awkwardness, and depression of spirits may be so notice- able that the case is sometimes mistaken for serious disease of the nervous system. The appearance of such a foot has already been described, and the effect of the deformity on its function should be evident. The gait is slouchy and cloddy, what has been spoken of as the pedestal walk : the feet are simply pushed by one another, in the attitude of eversion, the knees are slightly flexed and the weight is borne entirely upon the posterior segment of the foot. The muscles have atrophied, the foot is cold and congested from its continued inactivity and it usually is bathed in perspiration. A certain range of motion remains at the ankle joint but adduction is absolutely restricted by the shortened and spasmodically contracted muscles on the outer and upper surface. This type represents, of course, only the severe variety that is more likely to be seen in hospital than in private practice ; and it would seem, were it not for the evidence to the contrary which the histories of the patients present, that the nature of the trouble must be recog- nized at a glance. But in the milder and earlier cases the diagnosis is not always so easily made. Diagnosis. — In all cases of suspected weakness of the foot, a thorough and orderly examination should be made, not only of its ap- pearance, but also of its functional ability and of the manner in which it is used. Such an examination is not merely for the purpose of diag- nosis, which is usually apparent, but in order that the amount and character of the temporary or permanent changes in structure and func- tion may be properly estimated. Attitudes. — One begins the examination by noting the manner of standing and walking. The heel walk, the exaggerated turning out of DIAGNOSIS. 515 the feet, the slouchy gait in which the leg is never completely extended, in which the power of the calf muscle is not applied, and in which the essential postures of the foot are disused, are all elements of weak- ness that should be corrected whether they cause symptoms or not. DiSTRiBUTiox OF Weight axd Steaix. — The distribution of the weight of the body and the habitual use of the foot are often made evi- dent by examining the worn shoe. If it is bulged inward at the arch or worn away on the inner side of the sole, it shows weakness. (Fig. 360.) The same observations are then made on the bare feet, particu- lar attention being paid to the line of strain or leverage; thus a line drawn down the crest of the tibia from the center of the patella, con- tinued over the foot, should meet the interval between the second and third toes ; if it falls over or inside the great toe, it shows that the foot is working at a disadvantage. (Fig. 352.) Contour. — The contour of the foot should then be examined ; its internal border should curve slightly outward, so that if the feet are placed side by side with the toes and heels in apposition, a slight inter- val remains between them ; if this slight concavity is replaced by a noticeable convexity, when weight is borne the foot is weak. (Fig. 357.) This change in contour is the earliest and sometimes the only evidence of deformity. The arch of the foot, properly protected by the muscles and by a proper attitude, sinks but slightly under weight ; there is a slight elasticity only, as the strain is thrown more to the inner side of the median line, and if the depression is marked it shows weakness. Bearing Surface. — The exact amount of bearing surface may be shown by an imprint upon carbon paper or by smearing the sole with vaseline, then as the patient stands upon a sheet of white paper the outline of the foot should be traced, so that the relative size of the imprint to that of the foot may be shown and compared with the normal standard. Another method is that suggested by Lovett. The patient stands upon a square of plate glass fixed in a table, so that by means of a mirror beneath, the bearing surface may be examined under different degrees of pressure and in different attitudes. (Fig. 361.) The Range of Motion. — The balance of the foot, as shown by the range of motion, is next to be tested, for its limitation is one of the earliest signs of improper attitudes and of weakness. This range of motion varies somewhat within normal limits ; it is usually greater in childhood than in adult life, greater in the slender than in the massive foot, and greater in the foot used properly than in one that is not. The first test is applied to simple dorsal and plantar flexion ; the leg must be fully extended at the knee, the line of strain must be in its normal relation, so that the foot may be neither adducted nor abducted and the observation must be made on its outer border. In this position the patient should be able to flex the foot from ten to twenty degrees less than the right angle, and to extend it from forty to fifty degrees beyond the right angle, the range of motion being from fifty to sixty degrees. (Figs. 336, 337.) 518 DISABILITIES AND DEFORMITIES OF THE FOOT. By far the most important test is that of the power of adduction or inversion of the foot, the test of the medio-tarsal and sub-astragaloid joints, a motion in which the os calcis is drawn forward and inward nnder the astragalus, while the forefoot is flexed about its head. With the leo- extended and the patella pointing forward the foot is turned inward as far as possible ; the elevation of its inner border or supina- tion and the turning in of the heel are Avell illustrated in Figure 338 ; the actual range of adduction is somewhat difficult to measure, but it is about thirty degrees. Even the mild and early cases of weak foot usually show some limitation of this most important motion and in many instances it is completely lost, the patient turning the entire leg in the effort to adduct the foot. The less important motion of ab- duction may be tested also (Fig. 339) ; its range is about half that of adduction, so also the range of supination or inversion of the sole is nearly twice as great as that of pronation or eversion of the sole. In other words the internal border of the foot can be raised twice as far from the floor, as can the external border. The range of passive mo- tion is then tested by pushing the foot in all directions. The range of dorsal flexion is from five to ten degrees beyond that of voluntary motion, w^hile passive extension, so far as it applies to the ankle joint, is about the same as the voluntary, although the forefoot may be still farther bent downward at the medio-tarsal joint. The limit of passive adduction is considerably beyond that of voluntary inversion.^ Passive motion serves several purposes ; contrasted with the range of voluntary motion it shows the habitual use of the foot, since the motion least used is most limited. It also makes evident the slight restriction of motion and the presence of local tenderness, which, even in early cases, are usually present. Thus, if pressure is made just in front of and below the internal malleolus, at the astragalo-scaphoid junction, and at the same time the foot is quickly adducted, the patient will complain of pain at the point of pressure and of a feeling of con- striction and tension about the dorsum of the foot, before the normal limit of motion is reached. When the foot is dorsi-flexed the plantar fascia is put upon the stretch, and its condition may be noted, for a contracted and sensitive plantar fascia may cause symptoms of discom- fort, that may induce improper attitudes and thus predispose to further , disability. ^ Varieties of the Weak Foot. — This mode of examination will demonstrate the disability and permanent change in the machine, which must be overcome before a cure can be accomphshed. By it one will learn to recognize several grades of weak foot. 1. The normal foot improperly used, as shown by the manner of standing and walking. 1 As adduction and supination and abduction and pronation are always combined, one term is used to signify the movement inward or outward ; thus, supination means adduction, abduction implies pronation. A fixed attitude of adduction and supination is called varus, a fixed attitude of abduction and pronation is called valgus. Varus and valgus signify, therefore, deformity. Thus the term valgus although it may be properly applied to designate the deformity of weak foot is usually reserved for the more extreme distortion of talipes. (See Figs. 338 and 339. ) EXTREME TYPES OF WEAK FOOT. 517 2. The foot, which because of laxity of ligaments or insufficient muscular support, is forced by the weight of the body into an attitude of deformity ; that is, in which the foot under weight falls into an abnormal attitude of abduction in its relation to the leg, as evidenced by the inward projection of its inner border and by the overhanging internal malleolus, showing that the leg has been displaced inward on the foot. As a rule, there is sufficient laxity of ligaments to allow a depression of the arch, as shown by the imprint, but in other instances, although the arch seems lower because of the characteristic attitude, in which the leg, as it were overhangs the foot, yet the imprint shows that there is no increase in the' area of bearing surface. Indeed this may be even smaller than normal ; thus an individual may suffer from so-called flat foot whose arch is actually exaggerated. 3. The weak foot, which shows typical deformity under use and in which the range of voluntary motion is somewhat limited, particularly in the direction of plantar flexion and adduction. Forced motion causes discomfort and pain, indicating a certain permanent accommodative change in structure, which is not apparent when the foot is not in use. 4. The foot which presents typical and permanent deformity, whether it is in use or not, and in which the range of both voluntary and pas- sive motion is much restricted. In all of these varieties, however, the improper functional use of the foot, in the loss of active leverage, is very evident when the patient walks. Limitation of Motion and Muscula^e Spasm. — Limitation of motion is caused by the accommodative changes in structure to the habitual postures or to the deformity. These are first evident in the muscles and ligaments and finally in the articular surfaces of the bones. Added to this underlying limitation of motion, there is usually a certain amount of muscular spasm, which varies in degree with the local con- gestion, irritation and inflammation of the joints and tissues. In the quiescent flat foot it may be absent but on renewed injury or over-work of the weak structure, it again appears. It depends also upon the irritable condition of the over-worked and contracted abductor mus- cles, practically the only group which retains functional power ; thus the spasm, as has been stated in describing the severe and painful type of weak foot, is greater after the day's use and relaxes somewhat during the night. The degree of muscular spasm and rigidity corre- sponds with the intensity of the symptoms, but by no means with the depression of the arch or with the duration of the deformity. Extreme Types of Weak Foot. 1. Persistent Abduction. — In one type of rigid foot the foot is twisted outward and upward. It may be pronated to such an extent that practically the weight is borne upon the heel and the ball of the great toe. In such instances the astragalus, although rotated inward upon the pronated os calcis, is, of course, not plantar flexed nor is the anterior extremity of the os calcis depressed. The entire foot is simply held in an attitude of extreme abduction and dorsal flexion, by the spasm and contraction of the flexors and abductors, so that the leg must be bent at the knee and inclined 518 DISABILITIES AND DEFORMITIES OF THE FOOT. Fig. 358. forward to brins the sole to the ground. Such extreme cases are un- common. They are often the direct result of injury, so-called chronic sprain, and when the deformity is reduced the arch will be found to be exaggerated in depth. Less extreme types of this class are often seen and they serve to emphasize the statement that the most important dis- ability of the weak foot is due to the change from the normal relation between the leg and the foot and not to the depression of the arch, which is in most instances a secondary deformity. 2. Pes Planus. — As has been stated already, and as is well known, there is a type of painless flat foot sometimes called pes planus in which the flatness of the foot is more noticeable than the other components of the deformity that have been described. This is probably the result of in- herited laxity of ligaments or of rhachitis or other form of acquired weakness in early life, so that a normal arch was never present. Such a foot controlled by normal muscles, may be strong and efficient but it is nevertheless deformed, and it is doubtful if its pos.sessor ever could attain the grace and elas- ticity of gait possible under nor- mal conditions. It is said also, that a low arch is normal in certain races, for example the negro, but it is certain that the American negro is not exempt from the pain and disability incidental to the broken-down foot, whether his arch was originally low or not. It is evident, of course, that the breaking down of a properly shaped foot, provided with normal ligaments, will be attended by greater pain and greater disability than of one in which the arch was originally low and of which the ligaments were weak, because it is during the progression of the deformity and particularly in its early stages, that such symptoms are most prominent. When the bones of the arch rest upon the ground or when final stability has become assured, pain may cease, and permanent accommodation to the new conditions may increase the ability of the deformed mem- ber. Such an outcome might be quickly accomplished in the foot originally flat, while in the other instance, the symptoms although remitting from time to time, might continue during the life of the sufferer. Weak feet and slight knock knees. WEAK FOOT IN CHILDHOOD. 519 Weak Foot in Childhood. There can be no doubt that in many instances, the origin of the weak foot may be traced to early childhood. Certainly, deformities and improper attitudes are very common at this period, and it is much more likely that they are ingrown than outgrown. Actual pain from the weak foot is rare at this age. The child may complain of fatigue and may be weak and awkward, but it is usually because of the very evident deformity, rather than because of symptoms, that advice is asked. In these cases, as in every case, the habitual attitudes and use of the feet are of the first importance. Out and In Toeing as Symptoms of the Weak Foot in Child- hood. — One of the most frequent of the improper postures is that of exaggerated outward rotation of the feet, which is not only an ungrace- ful attitude, but a direct cause of weakness as well. The opposite attitude of inward rotation, the so- called " pigeon-toed " walk, is most Fig. 359. offensive to relatives and friends, and it is for correction of the attitude that the child may be brought for treatment. The attitude is, in many instances, a sign of the weak foot, for on examination the bulging on the inner side, the inward rotation of the leg in its relation to the foot, and the flattened arch, show very plainly that it is the foot and not the attitude that requires treatment ; in fact, the attitude is, in this class of cases, really a safeguard against increasing deformity and it will correct itself when its cause is re- moved. Particular emphasis is laid upon this point, which is very gen- erally over-looked, because the rou- tine treatment of the " pigeon toes " in these cases might be the cause of direct harm. Weak Ankles. — " Weak ankle " is a term popularly applied to the weak foot of childhood, in which the foot is in a position of valgus when in use, so that the shoe is worn away on its inner side. Weak ankles are very common in very young children and are often one of the results of general weakness due to defective assimilation. At this age the foot is, in addition, usually flat (Fig. 358), but in the valgus or weak ankle of later years the arch is often practically normal in outline. Outgrown Joints. — In older children prominent or '^outgrown" joints often attract the mother's attention ; the internal malleoli appear Congenital flat foot. Rigid deformity of an extreme type illustrating the component abduction and obliteration of the arch. 520 DISABILITIES AND DEFORMITIES OF THE FOOT. prominent because of the position of valgus, or because of the eversion of the feet the malleoli may strike against one another, ^'interfere," and thus there may be an actual hypertrophy of the projecting bones from local irritation. Another type is the long slender foot in which the scaphoid bone is prominent because of the strain and pressure put upon it by the im- proper attitudes ; its position is often shown by the point of wear in the leather of the shoe. (Fig. 357.) In the weak foot of childhood, although restriction of voluntary and passive motion may be present, there are, as a rule, but little local ten- derness and muscular spasm, and as has been said, but little actual pain ; thus it differs greatly from the adult type, for the reason that the weak foot in childhood has not been subjected to the strain of con- stant occupation or to the burden of the increased weight of the body. There is another important difference also ; the foot of the adult is obliged to bear greater strain Fig. 360. than any other part, and al- though normal in structure it may be over-strained, so that in many or in most instances the weakness of the foot may be the only disability. But in childhood, when such exciting causes are absent, a weak foot is very often a local indication of general weakness and loss of tone. Gexeeal Weakness. — The direct effects of the weak and painful foot have been de- scribed in detail. It must be borne in mind that the feet are the foundation of the body, and that an insecure foundation affects the entire mechanism. General ftinctional weakness and awkwardness, the flat chest, round shoulders or other curvatures of the spine, are often observed as accompaniments or effects of weak feet. Thus, as a rule, the systematic treatment of any form of postural weakness must include the treatment of the feet as well. Recapitulation. — The disability and deformity of the weak or so- called flat foot are caused by a disproportion between the strength of the foot and the weight and strain to which it is subjected. The foot may be weakened by injury or disease ; it may be over- burdened by the body-weight, or over-strained by laborious occupation, or the broken-down foot may be simply one indication of general bodily weakness. It is unnecessary to enumerate all the various factors that singly or combined lead to this disability. It may be stated, however, that the weak foot is in many, or most, instances the only disability that demands treatment. Its most constant predisposing causes are Flat foot, extreme deformity in cliildliood. TREATMENT. 521 improper shoes, and the mechanical disadvantages to which it is sub- jected 'by the assumption of improper attitudes. All weak or flat feet are mechanically weak, but all weak feet are by no means painful feet. Pain, the symptom of over-strain or injury, bears no definite relation to the degree of deformity. In certain instances, exaggeration of the arch may be combined with persistent abduction of the foot ; . in others, the flattening of the arch may be the most noticeable deformity, but in most cases, the two are combined in varying degree. And as each deformity is an evidence of weakness, it seems hardly necessary to make a radical distinction be- tween the two, except as regards prognosis. For the abducted foot in which the arch is intact is almost always an acquired deformity of short duration, whereas in the case of the foot in which the arch is obliterated the deformity usually dates from early childhood and it is, therefore, much less amenable to treatment as far as perfect cure is concerned. Treatment. — The principles of the treatment which leads to the permanent cure of the weak and deformed foot are very simple, but the application varies somewhat according to the grade and duration of the deformity. The object of treatment is to so change the weak foot that it may conform, not only in contour but in habitual attitudes and in power of voluntary motion to those of the normal foot, because complete cure is impossible unless normal function is regained. The first step must be, therefore, to make passive motion free and painless to the normal limit. In other words the obstructions to the motion of the machine must be removed before the power can be properly ap- plied ; for the increase of muscular strength and ability, on which ultimate cure depends, is not possible while motion is restrained by de- formity or by pain or by adhesions or contractions. The weak foot, because of inefficient ligaments and muscles unable to hold itself in proper position, must be supported, in many instances, until regenerative changes have taken place in its structure. Such support is necessary to retain the joints in proper position, and to hold the weight and the strain in proper relation to the foot, otherwise nor- mal motion is impossible. When these essentials are provided, the patient may cure himself by the proper functional use of the foot, and by the avoidance of attitudes that place it at a disadvantage. It may be well to describe, first, the treatment that must.be applied to all classes of weak foot in which a cure is to be attempted, and which by itself is sufficient in the milder types, before calling attention to the modifications that may be necessary in special cases. The Shoe. — In practically all cases it will be necessary to provide the patient with a proper shoe, for the shoe is usually the direct cause of the minor deformities, and indirectly, in many instances, of more serious disability. Indeed most of the deformities and disabilities of the foot are incidental to civilization and are therefore confined to the shoe-wearing people. The direct effect of the ordinary shoe is to lessen the size and balancing power of the fulcrum by cramping the toes 522 DISABILITIES AND DEFORMITIES OF THE FOOT. Fig. 361. together while the high heel throws more strain upon the arch and the ankle. Indix'ectly it causes deformities, corns, bunions and the like, which serve to make active movement or leverage painful, so that it is replaced by the passive attitude. The proper shoe should contain sufficient space for the independent movements of the toes. This motion is illustrated in the walk of the barefoot child. As the weight falls on the foot the toes expand, and as the body is raised on the foot they contract. The important lever- age action of the great toe and the support afforded by it to the arch of the foot have already been mentioned. The shape of the sole should correspond to the shape of the foot and the heel should be broad and low. (Fig. 361.) The prevention of distorted toes and the discomforts that result from the abuse of the foot is of great importance in child- hood, but unfortunately, little children are often seen wearing shoes of the shape usually assumed at years of discretion. In this regard, girls suffer more than boys as women do more than men. The girl who may have worn comparatively harmless shoes until the age of ten years or there- abouts, changes suddenly to the high heel and narrow sole, and the process of distor- tion begins, the amount of distortion and the degree of discomfort depending on the amount of work required of the foot. Wide soles without heels should be worn as long as possible by children because of the greater stability and because the high heel limits the necessity for, and therefore the use of, the entire range of motion of the foot and ankle. Raising the Ixxee Boedee of the Shoe. — A simple expedient in the treat- ment of the weak foot and an aid in bal- ancing it properly, is to make the inner border of the sole and heel of the shoe slightly thicker in order to throw the weight toward the outer side of the foot. This is of especial importance iu the treatment of the slighter degrees of what is known as weak ankle but it is always of service in the treatment of any grade of weak foot. Attitudes. — When the patient stands, properly balanced in the proper shoe, his attention is called to the three elements of weakness. He is instructed to guard against valgus (Fig. 351) by throwing the weight on the outer side of the foot (Fig. 352) and to guard against The proper relation of the sole to the shape of the foot. A, outline of sole ; B, outline of foot ; C, imprint of foot. SUPPORT. 523 abduction by holding the feet parallel with one another in walking (Fig. §34) ; the significance of the bulging on the inner side of the foot is pointed out to him, how this may be prevented by the avoidance of the postures just indicated and by aiding the arch by the power of the great toe. The importance of leverage is shown him, that he must try to press down the sole of the shoe with his toes and employ the active lift of the calf muscles by fully extending the leg and raising the body on the foot from time to time. (Fig. 334.) Finally, he must avoid long continuance in one position, especially the passive posture, w^hich simulates the attitude and deformity of flat foot. In short he must be instructed in the mechanics of the foot and taught how the weak foot may be protected as well as strengthened. Exercises. — It is important, also, to show the patient the normal range of motion of the foot, motion which, if restricted, must be re- gained by voluntary and passive exercise. Voluntary exercise should be devoted to strengthening the adductors and plantar flexors ; thus the foot should be adducted and supinated (Fig. 338) over and over again at every opportunity. Tip-toe exercises are especially useful ; the patient, holding the feet parallel, raises the body on the toes twenty to one hundred times, resting in the intervals on the outer border of the feet. The best of all exercises is, however, the proper walk, in which the leverage power of the foot is employed and in which it passes through the proper alternation of postures. (Fig. 334.) Treat- ment by massage and special gymnastic exercises is of course of bene- fit, if the patient can command it, although by no means essential to the cure. Support. — In many instances the simple treatment that has been outlined is all that is required and the symptoms of tire and strain are quickly relieved, but in the more advanced type of disability the patient is not able to prevent deformity voluntarily, consequently a support is necessary to hold the foot in proper position and to relieve discomfort. It is usually necessary in the treatment of the weak foot of childhood, because one cannot command the aid of the patient. In selecting a support for the weak foot the nature of the deformity that is to be prevented must be borne in mind ; that the acquired flat foot, for example, is not a direct breaking down of the arch, as is usually taught, but a lateral deviation and sinking — a compound de- formity, as has been already described. (Fig. 351.) Thus a brace, to be efficient, must hold the foot laterally as well as support the arch. But it must not prevent the normal motions of the foot, and thus inter- fere with the increase of muscular strength and ability, on which ulti- mate cure depends. The supports that have been ordinarily used for flat foot do not ful- fil the conditions ; the pads and springs placed beneath the arch are intended to support it by direct pressure without regard to the valgus or the abduction ; they are usually ill-fitting and are often of such length and shape as to splint the foot and thus to restrict its motion. Leg braces which control the valgus do not often hold the foot accu- 524 DISABILITIES AND DEFORMITIES OF THE FOOT. rately, and their weight and unsightliness are fatal objections to their use in the early cases, in which prevention of subsequent deformity is of such importance. A brace should never be applied to a deformed and rigid foot because it is unable to shape itself to the support ; the spasm and rigidity must be first relieved by preliminary treatment, as will presently be de- scribed. The Construction of the Brace. — To properly construct a brace to meet these conditions, it is necessary to provide the mechanic with a plaster cast of the foot, taken in the attitude in which one wishes to support it. Such a model may be easily and quickly made in the fol- lowing manner. The Plaster Cast. — Seat the patient in a chair ; in front of him place another chair of equal height ; on it lay a thick pad of cotton batting and cover it with a square of cotton cloth. Put about a quart of cold Avater into a basin and sprinkle plaster of Paris on the Fig. 362. The attitude iu which the plaster cast should be taken. In the reproduction, the chair upon which the foot is resting, has been removed. surface until it does not readily sink to the bottom ; then stir. When the mixture is of the consistence of very thick cream pour it upon the cloth. The patient's knee is then flexed, and the outer side of the foot, previously smeared lightly with vaseline, is allowed to sink into the plaster and, the borders of the cloth being raised, the plaster is pressed against the foot until rather more than half is covered. THE BRACE. 525 The foot should be at a right angle with the leg and the sole should be in the plane perpendicular to the seat of the chair. (Fig. 362.) As soon as the plaster is hard its upper surface is coated with vaseline and the remainder of the foot is covered with plaster ; the two halves are then removed, smeared lightly with vaseline and bandaged to- gether. The interior is dampened with soapsuds and it is then filled with the plaster cream. In a few moments the Fig. 363. plaster shell may be re- moved, and one has a re- production of the foot, which, when properly made, should stand up- right without inclination to one side or the other. In many instances it will be of advantage to deepen in the plaster model the inner and outer Seo'ments of the a, the astragalo-scapbold joint. The internal flange of the 1 . ^ 1 1 1 brace should rise well above all the prominent bones to a point arch, in order that the about half an inch below the malleolus. arch of the brace may be slightly exaggerated, especially at the heel, so that the depression of the anterior extremity of the os calcis may be prevented. The Brace. — Upon the model the outline of the brace is drawn as illustrated in the diagrams. The best sheet steel, 18 to 20 gauge, cut after the pattern is moulded upon it and tempered, so that, as it is ap- plied for the purpose of preventing deformity, it may be practically unyielding to the weight of the Fig. 364. body. It will be noticed that the brace clasps the weak part of the foot and holds it together ; the broad internal upright portion (Fig. 363) covers and protects the astragalo-scaphoid junction, rising well above the scaphoid ; the external arm covers the calcaneo-cuboid junction and the outer aspect of the foot to a height sufficient to hold the foot securely. (Fig. 364.) The sole part provides a firm, comfortable support, yet, reaching only from the center of the heel to just behind the ball of the great toe, it does not restrain the normal motions of the foot. (Fig. 365.) The brace may be nickel plated and japanned, which makes a smooth finish, or tin plated, or galvanized, which makes a more durable cov- ering. It may be covered with leather, or an inner sole may be placed B, the calcaneo-cuboid junction. The external flange extends from the center of the heel to a point slightly behind the base of the fifth metatarsal bone. 526 DISABILITIES AND DEFORMITIES OF THE FOOT. Fig. 365. on its upper surface ; but this is not usually necessary. As it is fitted to the foot, it finds and holds its own place in the shoe, so that no at- tachment is required ; thus it may be changed from one shoe to another. Not only does it hold the foot laterally and from beneath, but there is an element of suggestiveness in the slight leverage action which is very important. The Positive Action of a Proper Brace. — The patient, instructed to throw his weight upon the outer side of the foot and wearing the shoe which has been tilted in the same direction by thickening the inner border of the sole and heel, presses down the external arm and thus lifts the internal flange against the inner side of the foot, which is instinc- tively drawn aw^ay from the pressure and thus toward the normal contour ; he no longer everts or turns the feet outward in walking, and he is not likely to assume the passive attitude, because of the suggestive lateral pressure of the support ; thus it becomes a positive aid in the physiological cure. The shape of the brace, in general like that of the diagram, is modified in certain cases ; for in- stance, the entire internal aspect of the foot may be weak and must be covered by the internal flange. In very heavy subjects the sole portion must be made larger although this is a detriment, as it les- sens the leverage action ; other slight modifica- tions may be necessary in special cases. If any portion of the rim of the plate causes discomfort, the edge may be turned away slightly at the point of pressure by a wrench. After a few days the patient no longer notices the presence of the brace, and as its presence in the shoe is not evident, it may be worn indefinitely. It is usually necessary for from three months to a year or longer, according to the condition of the patient and the strain to which the feet are subjected. The brace, properly made and adjusted under the proper conditions, causes no more pressure or discomfort than a well made shoe, for its principle is quite different from that of the ordinary sup- ports that are in common use, to which this objection has been made. This brace supports the arch primarily by preventing abduction, con- sequently its pressure is first felt upon the lateral aspect of the foot, a pressure that the patient can relieve by improving his attitude. The brace should afford support when necessary, and at all times suggest and enforce a proper attitude ; it is, however, but one of the essential factors in the general scheme of treatment. In the treatment of children, the foot should be moved in all direc- tions but particularly in dorsal flexion and adduction to the full limit at morning and at night, until the child has regained the normal muscular power and ability. Special gymnastics and massage are al- ways desirable and they may be necessary in certain cases. Bicycling C, the great-toe joint D, the center of the heel. THE BIQID WEAK FOOT. 527 may be cited as one of the best, and roller skating as one of the worst exercisers for the weak foot. A year is about the time required for a cure of the weak foot in childhood, although attention to the shoes and to the attitudes must be continued indefinitely. The Rigid Weak Foot. One may now contrast with these mild types of weakness that have been described, those cases of extreme deformity in which the symptoms are disabling and in which the foot is rigidly held in the deformed position by muscular spasm and by secondary changes in its structure. Such cases, often considered hopeless as regards a cure or even relief, are in reality the most satisfactory from the remedial standpoint, and in no other type of painful deformity can so much be accomplished by rational treatment as in this class. The deformity must be considered as a dislocation in which the astragalus has slipped downward and in- ward from off the os calcis, which in turn is tipped downward and in- ward and into a position of valgus. The remainder of the foot is turned outward, so that the relation of the leg and the forefoot is entirely changed ; in fact the forefoot is almost entirely disused. (Fig. 366.) Corresponding to the duration of the disability, one finds accommo- dative changes in the soft parts and in the bones, but such changes are by no means as marked as those recorded in the reports of autopsies which have been made in cases of advanced and irremediable deformity. In fact, by far the greater number of patients are young adults in whom the extreme deformity is of comparatively short duration, and in whom complete cure is possible. In the treatment of such a condition, one must first reduce the dis- location and overcome the obstacles that contracted muscles and liga- ments may offer to free and normal motion ; then rest must be assured to the injured and congested parts in order to relieve the patient from the pain from which he has suffered so long. Forcible Over-correction. — By far the most effective treatment is forcible over-correction of the deformity, under ansesthesia. When the patient is under the influence of the anaesthetic the muscular spasm relaxes, and it will be seen that this accounts for about half of the re- striction of motion, the remainder being caused by the adaptive changes that have been mentioned. One now endeavors to overcome this resi- dual obstruction ; and to assure the patient against a relapse, by fixing the foot in the position of extreme adduction and supination, the atti- tude directly opposed to that which has become habitual. This is the object of forcible over-correction as the first step in the systematic repair of the disabled mechanism ; its principle must not be confounded with forcible correction carried out with the object of simply remoulding the arch of the foot, or in which the simple cor- rection of the deformity is the object in view. One first extends the foot forcibly, then flexes it to the normal limit, then abducts and adducts, the different motions being carried out over 528 DISABILITIES AND DEFORMITIES OF THE FOOT. and over until the rigid foot has become perfectly flexible. In cases of long standing it is often necessary to draw the patient to the end of the table, so that the foot may be taken between the knees, in order to supply the required force by the thigh muscles. This forcible manipu- lation is accompanied by the audible breaking of adhesions, and the complete disappearance of the deformity. In certain instances it will be necessary to divide the tendo Achillis when, for example, the range of dorsal flexion is limited by resistant accommodative shortening of the calf muscles, or when there has been very great pain and tenderness at the medio-tarsal joint, and it is desired to remove the strain of lever- age completely ; traumatic cases come especially under this head. Tenotomy has one great advantage, it necessitates longer fixation in tlie plaster bandage, and gives the patient the benefit of rest, and the Fig. 366. Fig. 367. The deformed foot before The over-corrected foot, operation. A, the projector! of showing the reversal of the the displaced astragalus and lines of displacement. (See scaphoid ; B, the inner malleo- Fig. 368.) lus ; C, the mediotarsal joint, showing the outward displace- ment before, the inward rota- tion behind, this point. opportunity for prolonged after-treatment. When the passive range of motion has been regained, the foot is turned downward, then inward and upward into the position of extreme varus. By this manipulation the OS calcis is drawn under the astragalus and thrown into the supi- nated position, and the scaphoid is flexed about and under the head of the astragalus, which is then lifted to the limit of normal flexion. The attempt is always made to bring the extreme outer border of the in- verted foot up to a right angle with the leg, which is the limit of nor- mal flexion in this attitude. The foot, thickly padded with cotton, is then fixed in this posture of club foot by a firm plaster of Paris band- age extending to the knee. (Fig. 3(38.) Surprisingly little discom- fort, considering the force that it is sometimes necessary to apply, is experienced after the operation. The familiar and often intense pain, from which the patient has suffered so long, is entirely relieved by the THE RIGID WEAK FOOT. 529 Fig. 368. correction of the deformity ; there is often a sense of tension about the outer «ide of the ankle and dorsum of the foot, but this is not, as a rule, of long duration. Functional Use in the Over-corrected Attitude. — As soon as possible, often on the following day, the patient is encouraged to stand and walk, bearing his weight on the foot. Walking serves two purposes : to still further over-correct the deformity, and to accustom the patient to a posture entirely different from that so long assumed. Meanwhile the contracted tissues on the outer side become thoroughly over- stretched ; the weakened ligaments and muscles on the inner side are relaxed, and the local irritation rapidly subsides under the rest from the constant injury to which the foot has been subjected. The patient is not confined to the bed or house, although if both feet are in plaster bandages, crutches are of course necessary. The time that the feet should remain in the over-corrected position, depends upon the duration of the deformity and the severity of symptoms, or from one to six weeks, the usual time being about three weeks. At the end of two weeks, or whenever the pa- tient can support the weight on the plaster bandage, without a sensation of discomfort, it is removed ; the foot is placed in the normal attitude, and a cast is taken for the brace. Immediately after this is made, the foot is returned to the club-foot po- sition and the plaster bandage is re-applied. When the brace is ready, the plaster bandage is finally re- moved ; the foot is now in good po- sition, and in many instances the arch is exaggerated in depth. For the first few days, prolonged soaking in hot water, or the use of the hot- air bath, with subsequent massage, at intervals during the day, will be found useful in overcoming the swell- ing and local tenderness that may re- main. It is always insisted that a new shoe of the Waukenphast pattern shall be obtained, the sole and heel of which are raised a quarter of an inch on the inner border, to aid in the bal- ancing of the weak foot. The brace is then applied, and the patient is never allowed to walk without its support. When the shoe is re- moved at night, he is instructed to turn the toes in and to bear the weight on the outer side of the foot until it has regained its strength ; in other words, the deformity is never allowed to recur. 34 The forcible over-correction of flat foot. The proper position in the plaster bandage. 530 i DISABILITIES AND DEFORMITIES 01 THE FOOT. Systematic Manipulation. — The systematic treatment is then begun by the surgeon and the patient, the first essential being the attainment of free and painless passive motion in all directions. These motions, which have been so long restrained by deformity, cannot be regained without effort, and during this critical stage, treatment must be carried out by the surgeon himself; if he trusts to the patient or to his friends, a cure is out of the question. At least once a day the full range of motion must be carried out to the normal limit. Three motions, ab- duction, flexion, and extension are usually free and painless ; but the fourth, that of adduction, is almost invariably resisted by the same quality of muscular rigidity that was present before the operation. By far the most effective method of overcoming this resistance is con- ducted as follows : the patient being seated in a chair, the surgeon sits or stands before him. Let us suppose that the left foot is to be adducted or, as the patients express it, twisted. The surgeon places the foot be- tween his knees ; his left hand encircles the heel, the fingers grasping the projecting os calcis and tendo Achillis ; the base of the palm lies against the medio-tarsal joint on the inner aspect of the foot ; the right hand grasps the outer side of the forefoot and toes ; then, by steady pressure of the thigh muscles, the forefoot is forced downward and in- ward (adducted and supinated) (Fig. 338) over the fulcrum formed by the projecting palm, which lies uj)on the left knee, the fingers holding the heel steadily in place. This inward twisting is at first resisted by a mixed voluntary and involuntary muscular spasm, which gradually gives way under steady pressure. When the limit of adduction has been reached, the foot is firmly held until all pain has subsided ; then the patient is instructed to attempt voluntary movements while the foot is guided by the hands ; in other words, the patient attempts to ad- duct the foot while the surgeon supplies the power, which in all cases of this type has been completely lost. This passive manipulation to the extreme limit of normal adduction, plantar and dorsal flexion, is continued from day to day until there is no longer a sensation of pain or tension ; for as long as there is the slightest spasm or painful re- striction, so long is the voluntary motion limited, cure delayed, and relapse of deformity probable. JDuring active treatment the patient, by the use of massage, active and passive motion, is constantly working to one end, namely, to regain the lost power of voluntary adduction. The time necessary to rest the feet, to overcome the local irritation and muscular spasm, to regain, in part at least, the range of passive motion, and to place the patient in the same position, as regards a cure, as that of the milder type of deformity, is from three to six weeks. Usually the patients are told that a month will be necessary, and that at the end of that time they may return to work, free from pain and from the danger of relapse, and that the feet will constantly grow stronger, under the work which was before too great for their strength. The time necessary to reeducate the adductor nuiscles in their proper function depends, in threat degree, ujion the intelligence and persistence of the patient. Although in after-treatment massage and special exer- THE RIGID WEAK FOOT. 531 cises are of benefit, the essentials are very simple ; they are an effective brace, a proper shoe, and the passive manipulation that has been de- scribed, until its object has been attained, and the proper walk, the best and easiest of exercises. Finally, one must force into the patient's understanding the method of protecting the weak foot by the alterna- tion of strain, and by proper postures. Other Varieties of Eigid Weak Foot. — The foot, which is fixed in the abducted position without depression of the longitudinal arch, is simply one variety of the rigid weak foot, which should be treated in the same manner. It may be stated also, that a very large propor- tion of the so-called chronic sprains of the ankle are of this type, and that the disability will yield very readily to treatment, conducted for the purpose of restoring impaired function, in the manner that has been indicated. There are other cases, in which the deformity of flat foot is compli- cated by rheumatoid arthritis or chronic rheumatism, of which the evidence is seen in various joints but in which the pain and discomfort seem to be concentrated, in the feet, which are absolutely stiff and de- formed. In such cases one can hardly expect a complete cure ; but although the function of leverage may not be regained, still one may hope, by overcoming the deformity, to hold the weight of the body in its proper relation to the foot, so that the pain of a progressive dis- location may not be added to the pain of disease. In a number of instances forcible correction has been employed by the writer in cases of this type, and in all, the improvement in the general condition, consequently in the resistance to the disease, after the relief of the local pain and discomfort, has been very great. Between the two classes of cases, the mild and the severe, one finds every grade of deformity. All cases in M'hich there is marked muscular spasm, local tenderness and swelling, require temporary rest ; in many instances, simply rest from functional use combined with massage ; in others, rest in a plaster bandage in the adducted position. In the milder and ordinary class of cases, the use of a brace and shoe will alone relieve spasm and pain, and the range of motion can usually be regained by manipulation, passive motion, and by the proper use of the foot. Occasionally, even in childhood, one may encounter marked limita- tion of normal motion, particularly in dorsal flexion, not due to pain and muscular spasm but to actual shortening of the muscle. This may be the accommodative shortening that is characteristic of long-standing de- formity ; in other instances it would appear to be the result of a slight and unnoticed neuritis or anterior poliomyelitis, which has resulted in muscular inequality. If the contraction does not yield readily to manipulation or to mechanical stretching, forcible correction and if necessary, tenotomy should be employed in the manner already de- scribed ; for whatever may be the theory of its causation, it is again emphasized that obstruction to motion in any direction must be over- come before a complete cure is possible. 532 DISABILITIES AND DEFORMITIES OF THE FOOT. Adjuncts in Treatment. — It must be apparent, that -in many in- stances, the cure of the weak foot is out of the question, either because of the want of energy or opportunity on the part of the patient, or because of the local or general conditions, types familiar in out-patient practice. The Thomas Treatment. — In such cases, raising and strengthening the inner side of the shoe by the wedge-shaped leather sole, as used by Thomas, splints the painful foot and aids in relieving the strain. Plaster Strapping. — If the symptoms are more acute, the adhesive plaster strapping, as advocated by Cottrell and Gibney for the treat- ment of sprains, is often of service, although it is applied in a different manner, and with a somewhat different object in view. One end of a strip of adhesive plaster, about fifteen inches long and three inches wide, is applied to the outer side of the ankle just below the external malleolus ; the foot is then adducted as far as possible, and the band is drawn tightly beneath the sole and up the inner side of the arch and leg, and is stayed in this position by one or two plaster strips about the calf. Narrow plaster straps are then applied about the arch and ankle, in the figure-of-eight manner, and a bandage is applied. The object of the dressing is to aid in holding the foot in the proper posi- tion, by the support and suggestiveness of the plaster, and to provide the firm compression about the arch that is always agreeable to the sufferer from weak foot. This treatment, combined with the built-up shoe, is often very effective in overcoming the acute and disabling symptoms of the weak and injured foot, which are, as has been stated, often the result of extra strain or injury, in other words a sprain of a weak foot. Consequently when these symptoms are relieved, the pa- tient, who has become habituated to the weakness and deformity, con- siders himself cured. Operative Treatment. — The various cutting operations for the relief of flat foot do not call for extended comment. The typical operation, the removal of a wedge from the astragalo-scaphoid region, aims at re- moval of deformity simply; functional cure is made impossible by the destruction of the medio-tarsal joint. It would hardly seem possible that adhesion between the astragalus and scaphoid bones could, for any length of time, withhold a recurrence of deformity of the nature and origin of flat foot, and in all cases that the writer has examined, in which this operation had been performed, there was still local tenderness and muscular spasm and even relapse of the deformity. The operation of advancement of the posterior extremity of the os calcis, as proposed by Gleich, in order that it may be placed in relation to the leg somewhat like that of a Pirogoff* amputation, offers little hope of ultimate cure, because the disability is not due to primary de- pression of the arch, therefore it cannot be cured by exaggerating its depth in this manner. The most innocent and rational of the operations for flat foot is the supra-malleolar osteotomy of Trendelenburg, in which the bones of the leg are divided above the ankle, and the distal extremity turned inward, with the aim of directing the weight THE RIGID WEAK FOOT. 533 upon the outer border of the foot. In practice, the operation is by no means always successful, while the bow-leg deformity that results, if the object is attained, is an unfortunate accompaniment of the treat- ment. It may be mentioned in this connection that fracture at the ankle joint, followed by faulty union in a position of valgus, is a form of traumatic flat foot that may be cured by this operation. In operative treatment, the element of rest, necessary for weeks or months, must be taken into consideration, as explaining in part, the immediate favorable effect of whatever procedure is adopted. An investigation of final re- sults will prove, I believe, as might be predicted from the nature of the deformity and the complex structure of the foot, that there is no short and easy method by which a cure may be attained. In conclusion, the following points are again emphasized : Flat foot in its surgical sense, is a compound deformity, in which the abnormal relation between the foot and the leg, causing the improper distribution of the weight and strain, and disuse of normal function, is of vastly greater importance than the depression of the arch, which has given the name to the disability. The weak and deformed foot can be cured, but only by the applica- tion of the simple principles that any mechanic would apply to a dis- abled machine whose structure and use were known to him ; in other words, there can be no permanent cure of weakness and deformity un- less normal function is regained, or effective treatment unless it has this end in view. The term weak foot has this advantage over others that imply de- formity, in that it may include the earliest indications of disability. Once weakness is recognized, its causes may be analyzed and appreciated at their proper value. Flat foot is a particularly objectionable and mis- leading term, and it should be discarded, or at least used only to de- scribe those cases to which it can properly be applied. CHAPTER XXI. DISABILITIES AND DEFOEMITIES OF THE FOOT. — Continued. The Hollow or Contracted Foot. Synonyms. — Non-deforming Club Foot, Talipes Arcuatus, Talipes Plantaris, Talipes Cavus. The depth of the arch and the corresponding area of the bearing sur- face of the sole of the foot vary greatly in different individuals, and, although marked differences in appearance and function are possible within a normal range, yet, as a rule, the low arch is characterized by a certain relaxation and weakness of structure, while the exag- gerated arch implies a corresponding contraction and loss of normal elasticity. The hollow or contracted foot may be divided into two classes ; the SIMPLE and the compound. In the first class, the simple exaggeration of the arch (talipes arcuatus) is the only change from the normal condition. In the second, the high arch is combined with a certain limitation of the range of dorsal flexion at the ankle joint (talipes plantaris — Fisher). Etiology. — The simple hollow foot may be an inherited peculiarity. The depth of the arch may be exaggerated by the habitual use of high heels (postural equinus), or by excessive use of the calf muscle, as by professional dancers. The compound variety, in which the hollow foot is combined with slight equinus, may be inherited also ; but in most instances, its origin may be traced to a mild and transient form of anterior poliomyelitis or neuritis in early childhood. This causes temporary weakness of the anterior group of muscles of the leg, and thus a slight toe drop, followed by secondary contraction of the tissues of the sole and of the muscles of the calf. In the history of many of these patients it will be found that after recovery from scarlatina or other contagious or infectious disease, the child seemed weak or awkward. These symp- toms became less marked or practically disappeared ; yet a trace re- mained, although not of sufficient importance to call for treatment, until adolescence or adult life, when the greater strain and weight put upon the feet brought to light the latent disability. The affection may undoubtedly develop in later years as the result of neuritis, or of gout or rheumatism. It may be caused by a sprain or fracture of the ankle, and it may be a result of habitual posture to compensate for a leg shortened by injury or disease. SYMPTOMS. 535 Thg exaggerated arch which is a part of a more important deformity, as of eqiiino-varus or calcaneus, or that which is simply a part of the general deformity caused by diseases of the nervous apparatus, does not belong to the class of disability under consideration. Symptoms. — The simple hollow foot often exists without symptoms, in fact it is often considered as a particularly well formed foot rather than a deformity. The usual complaint in these cases is that one is unable to buy comfortable shoes because the ordinary shoe does not support the arch, or because the upper leather exerts uncomfortable pressure on the dorsum of the foot. The convexity of the dorsum of course corresponds to the depth of the arch, and in many instances, the Fig. 369. The coutracted foot of slight degree. cuneiform bones project sharply beneath the skin, and painful pressure points or even inflamed bursse in this locality may cause discomfort. In the well-marked cases in which the weight is borne entirely on the heel and the front of the foot, calluses and corns often form at the center of the heel and beneath the heads of the metatarsal bones. The patient may complain of neuralgic pain about the great toe, the meta- tarsal arch, or in the sole of the foot. The gait is often ungraceful, as the patient walks heavily upon the heels with feet turned outward. In such cases " the ankles may be weak and turn easily." In the more advanced cases of this type, the foot may assume the position of valgus when weight is borne, so that the more noticeable symptoms are those 536 DISABILITIES AND DEFORMITIES OF THE FOOT. of the weak foot or so-called flat foot, even though the depth of the arch is exaggerated. Contracted foot, of the more severe grade, is almost always accom- panied by a certain limitation of dorsal flexion ; and as the shortening of the plantar fascia is often more marked at its inner border, a slight inversion of the forefoot or varus may be present also. When the exaggerated arch is combined with limitation of dorsal flexion the deformity becomes compound. This limitation may be very slight, or it may be well marked ; and a slight degree of permanent equinus even, may be present, Fig. 370. but SO slight that it does not, as a rule, attract attention. This type of the contracted foot was first clearly described by Shaffer in 1885, under the title of " non-deforming club foot " ^ and later by Fisher, of London, as "talipes plantaris." The symptoms are similar to those of the simple hollow foot, but they are almost always more marked. The gait is awkward and jarring, the feet being turned outward to an exaggerated de- gree ; the patient is easily fa- tigued, and often complains of the weakness about the ankle and inner side of the arch, character- istic of the weak foot, and of sensations of tire and strain in the calf of the leg. The discom- fort from corns, the pain referred to the metatarsal region, the great toe, and to the sole of the foot have been described already. On examination the exaggeration of the arch is evident ; and an im- print of the sole shows that the weight is borne entirely on the heel, and on the heads of the metatarsal bones which may be very promi- nent beneath the thickened skin, as if the subcutaneous pad of fat had been absorbed. The anterior metatarsal arch is often obliterated, and the toes are usually habitually dorsi-flexed at the first phalanges, the permanent flexion and thus pressure against the leather of the shoe being shown by a row of corns upon their dorsal surface. (Fig. 370.) The contracted plantar fascia may be demonstrated by forcible dorsal flexion of the foot, when the tense bands, in many instances very sen- sitive to pressure, may be felt beneath the skin. On testing the motion of the foot, the limitation of dorsal flexion, both of the voluntary and the passive range, will be evident. In voluntary flexion, the toes are drawn up and the tendons are plainly 'N. Y. Med. Eec, May 23, 1885. Contracted foot, marked. OPERATIVE TREATMENT. 537 seen qn the dorsum, showing the effort made by the accessory muscles to overcome the abnormal resistance. The limitations of dorsal flexion may be demonstrated in the manner suggested by Shaffer, by asking the patient to flex the feet, while stand- ing erect with the back to the wall, when in spite of the effort made, " the feet remain glued to the floor." Treatment. — In the ordinary form of contracted foot, as has been stated, the disability is much more marked than the deformity ; and the disability is due to secondary changes in the structure of the foot, by which its elasticity is impaired. If this contraction is removed permanent relief will follow. If the simple hollow foot (cavus), or the compound type (plantaris), were discovered in early childhood, massage and methodical stretching would, in all probability, be sufficient to re- lieve the contraction ; but as a rule no symptoms are noticed until later life. Even then, especially in the simple form, they are often slight and may be relieved by a shoe with a broad heel and a high (Spanish) arch or by a foot plate that equalizes the pressure on the sole. In the more advanced cases of the milder type, methodical mechan- ical stretching of the parts by means of the Shaffer ^ " traction shoe " may elongate the tissues sufficiently to relieve the symptoms ; but in the more resistant cases division of the contracted parts and forcible correction of deformity is indicated. Operative Treatment. — The patient having been ansesthetized, a teno- tomy knife is introduced beneath the skin to the inner side of the central band of fascia. This is divided by a sawing motion, and if on forced dorsal flexion other tense bands appear they are divided also. Forcible massage, with the aim of making the foot flexible and reducing the depth of the arch, is then employed. If sufficient force cannot be em- ployed by the hands, the Thomas wrench may be used as in the treat- ment of club foot ; the object being to elongate the foot, to remove the contraction and thus by increasing the area of bearing surface to relieve the painful pressure on the heads of the metatarsal bones. If the con- traction of the tendo Achillis can not be overcome by forcible manipu- lation it may be divided. The foot, held in an attitude of dorsal flexion, is then fixed in a well-fitting plaster bandage, a thin board, shaped to the foot, having been incorporated in the bandage, in order that firm and even pressure may be exerted upon the sole. As soon as possible, often on the following day, the patient is encouraged to walk about, in order that the pressure of the body-weight may be utilized to flatten the foot still more, while its tissues are in a yielding condition. The bandage may be worn for six weeks, or if the tendo Achillis has been divided until its repair is complete. A Avell-fitting shoe should be worn, and methodical massage, and stretching of the tissues should be continued as long as the tendency to deformity remains. By this treatment the symptoms may be relieved and in many instances, a re- turn to the normal shape and function can be assured. IN. Y. Med. Jour., March 5, 1887. 538 DISABILITIES AND DEFORMITIES OF THE FOOT. Weakness of the Anterior Metatarsal Arch. Anterior Metatarsalgia and Morton's Neuralgia. — A peculiar spas- modic pain about the fourth toe was described by Morton of Phila- delphia long before its predisposing and exciting causes were under- stood. For this reason a description of the symptoms may with advantage precede a consideration of the weakness of which they are usually the result. Typical cases of Morton's ^ painful affection of the foot are charac- terized by a sudden cramp-like pain in the region of the fourth meta- tarso-phalangeal articulation. The pain may begin as a burning sensation beneath the toe, as a sud- den cramp or as a peculiar feeling of discomfort about the articulation that increases in severity until it becomes almost unbearable. At first the pain is confined to the neighborhood of the affected joint, but unless it is relieved, it radiates to the extremity of the toe to the dorsum of the foot or up the leg. In many instances the onset of the pain is preceded by the sensation of something moving or slipping in the foot ; in some cases the pain may be induced by sudden movements, missteps or long standing, and in practically all the cases the pain is felt only when the shoes are worn. The frequency of the recurrent cramp varies ; in some cases it is felt only at infrequent intervals ; in others it practically disables the patient. When the cramp habit has been acquired, very slight causes may induce the pain, for example, a thin-soled shoe, a hot pavement, " the sticking of the sock to the foot " and the like, but, as has been stated, except in the very advanced and chronic cases, the pain is never felt except when the shoe is worn. To relieve the pain, the patient removes the shoe, rubs and com- presses the front of the foot, flexes and extends the toes and the like. After the cramp is relieved, a sensation of soreness remains, and occa- sionally slight swelling may appear, but in most instances there are no external signs, although the affected articulation is usually sensitive to deep pressure at all times. The more distinctive term anterior metatarsalgia, a term suggested by Poulosson of Lyons in 1889, may be employed to include Morton's neuralgia, and similar symptoms of pain and discomfort about the anterior metatarsal arch. For in many instances, the cramp-like pain is referred to other points, for example, to several adjoining joints, or the discomfort caused apparently by direct pressure on the bones of the weakened arch may be more troublesome than the irregular attacks of neuralgic pain. Etiology and Pathology. — In seventy-eight cases of anterior meta- tarsalgia in which the location of the pain was noted, it was referred to the fourth metatarso-phalangeal articulation in sixty ; to the third and fourth articulation in six ; to the second, third and fourth in six, and in but six was the fourth articulation free from pain. The pain is most often unilateral, or if the second foot is affected, it is usually after a considerable interval. IT. G. Morton, Am. Jour. Med. Sci., Aug., 1876. THE ANTERIOR METATARSAL ARCH. 539 The affection is more common in females than in males. Of eighty- four cases, sixty-four were in women and twenty were in men. Anterior metatarsalgia is not an affection of early life, the average age in the reported cases being more than thirty years. It is rela- tively more frequent in private than in hospital practice, and not in- frequently the patients are of a distinctly nervous type. The affection is usually extremely chronic. Occasionally the symptoms may cease spontaneously, and in such instances a particular pattern of shoe usually receives the credit of the cure. Morton considered the affection to be a painful affection of the plantar nerves due to compression or pinching by the adjoining fourth and fifth metatarso-phalangeal articulations. This comj)ression was explained by the anatomical construction of the foot, i. e., the mobility of the fifth metatarsal bone Avhich allowed it to roll above and under the fourth, its relative shortness which allowed the head and base of the adjoining phalanx to be brought against the adjoining head and neck of the fourth bone, and finally, by the peculiar distribution of the external plantar nerve between these bones that made it or its fibers more liable to injury. This natural mobility and thus the predisposi- tion to compression might be exaggerated by a sprain, or possibly by rup- ture of the transverse metatarsal ligament, or the pain might be induced by wearing tight shoes, but in many instances, no cause could be as- signed. On this theory, Morton advocated excision of the head of the fourth metatarsal bone to remove the point of counter-pressure. This operation has been performed many times, but practically no patho- logical changes in the resected bone or in the surrounding parts have ever been discovered. In more recent years the true significance of Morton's neuralgia and of similar pains in the front of the foot, has been made more clear by the study of the relation of weakness of the anterior transverse meta- tarsal arch to the symptoms. Attention was first called to this point by Poulosson of Lyons, and again by E,oughton, Woodruff and others, and in a much more thorough and convincing manner by Goldthwait ^ of Boston, in 1894. The Anterior Metatarsal Arch. — If one examines a normal foot, one notices that the two middle metatarsal bones, the second and third, are slightly longer and on a higher plane than their fellows. On the sole of the foot the arch is shown by the depression immediately to the outer side of the muscular projection of the great toe joint. When weight is borne, all the metatarsal bones are on the same plane and the arch is obliterated, but when the weight is removed, the arch reforms with a certain natural resiliency. In walking and standing, the weight is balanced on the head of the third metatarsal bone as is shown by a thickening of the skin beneath its head, but the strain on the metatar- sal arch is relieved somewhat by the balancing action of the muscles about the first and fifth metatarsal bones, the inner and outer supports of the arch, and by the active assistance of the toes themselves. When ^ Boston Med. and Surg. Jour., Vol. 131, p. 233. 540 DISABILITIES AND DEFORMITIES OF THE FOOT. the arch is weak or broken down, this natural resiliency is lost, and, in some instances, the center of the forefoot is not only depressed but it is fixed in this abnormal attitude. In the ordinary type of depressed anterior arch, the deformity may be shown by an imprint of the foot, in which the flabby tissues of the depressed arch encroach upon the clear space representing the longi- tudinal arch, and obliterate what Goldthwait calls the reentering angle to the outer side of the great toe joint, which in the normal foot indi- cates the highest point of the metatarsal arch. In many instances however, the imprint of the foot subject to Morton's neuralgia may be, to all intents, normal and on the other hand depression of the meta- tarsal arch, one of the very common results of improper shoes, may be present, yet unaccompanied by pain or discomfort. Depression of the anterior arch, the result of the loss of the activity of the accessory supports of the arch, predisposes to pain because of Fu;. 371. Position of the fingers corresponding to dorsi-flexion of the toes, an attitude in which lateral pressure causes pain. abnormal pressure upon the persistently depressed articulations from beneath, and it predisposes to pain, as the writer has endeavored ^ to explain, because the metatarso-phalangeal joints of the arch, which is habitually depressed, cannot escape direct lateral compression, if it is exerted by the shoe or otherwise. This point may be illustrated in the hand. When lateral pressure is applied, the hand is folded together and the anterior metacarpal arch is increased in depth, but if the fingers be dorsi-flexed so that it is fixed in a depressed position, then lateral compression causes great pain at all the articulations (Fig. 371) ; or if one finger is dorsi-flexed and the corresponding metacarpal bone is thus forced below the level of its fellows, lateral compression causes pain at the compressed joint. Or if the matacarpal bone of the little finger is made to override the 1 N. Y. Med. Eec, August 6, 1898. ETIOLOGY AND PATHOLOGY. 541 fourth, lateral pressure causes pain usually of a more acute character than at the other joints, because the opportunity for direct pressure is more favorable.' Finally if firm pressure is made upon one or the other side of the head of the depressed metacarpal bone of the dorsi-flexed finger in the palm of the hand, a point of sensitiveness, representing apparently the digital nerve, can be made out. The same experiments may be tried upon the foot with the same results, and it would seem to make clear the mechanism of the pain of Morton's neuralgia, and the allied forms of discomfort at the front of the foot. Anterior meta tarsalgia is in most instances the result of weakness or depression of the anterior metatarsal arch as a whole or in part, and the quality of the pain corresponds fairly to the form of weakness or deformity. If, for example, the entire arch is rigidly depressed, as in certain rheumatic aifections, the discomfort is likely to be caused, in great degree, by the direct pressure of the sensitive depressed meta- tarso-phalangeal joints on the sole of the shoe, or if lateral pressure is exerted as well, the more acute discomfort or pain may be referred to the metatarsal arch in general. If the metatarsal arch is weakened, depressed and broadened but not rigid, the discomfort is often referred, as in the preceding instance, to the center of the arch, and this dis- comfort is increased, in some instances, by a painful callus representing abnormal pressure at this point. If one of the metatarsal bones falls below its fellows, the lateral pressure of a narrow shoe may cause neu- ralgic pain at this joint, but in many instances, in which the anterior arch is depressed the patient makes but little complaint of pain. In certain instances, more particularly those of Morton's typical neuralgia, the foot may appear to all intents normal ; in such cases it may be in- ferred that the sharp and characteristic pain is caused by pressure ap- plied to the over-riding fifth metatarsal bone, just as similar pain is felt if the hand is suddenly compressed while the fifth metacarpal bone is in a similar position. This theory is the more probable when one con- siders the symptoms ; for example, the sensation of something slipping or moving, the necessity for the removal of the shoe to flex and extend the toes and to compress the foot, apparently with the instinctive aim of replacing a depressed arch, or a misplaced bone in the arch. It would also explain how the shoe may be the most direct of the exciting causes of the deformity, in that it compresses the forefoot, and throws more weight upon it by elevating the heel. If the arch is depressed or becomes depressed, or if a bone in the arch over-rides another, this compression causes the symptoms. The Influence of the Shoe in Causing Disability and Pain. — In the etiology of pain and discomfort about the anterior arch, one must recognize the shoe, not only as the direct cause of the pain, but also as the most important of the predisposing causes of weakness of the anterior arch, of which the pain is a symptom, since it compresses the toes, lifts them off the ground by its " rocker sole," and thus, by pre- venting their normal function, throws additional strain and pressure 1 This anatomical peculiarity is well known to school boys. 542 DISABILITIES AND DEFORMITIES OF THE FOOT. upon the arch. In fact in a very large proportion of feet that are supposed to be normal in appearance and functional ability, the toe& are habitually dorsi-flexed in a claw-like attitude, that shows entire disuse of their function both as a support and in progression. Women wear shoes with narrower soles and higher heels than men, and this seems the most reasonable explanation of the fact that they are more subject to the affection. The shoe also predisposes to habitual elevation of the fifth meta- tarsal bone, because this bone almost invariably overhangs the narrow sole, so that the fourth metatarsal bone becomes the outer support of the arch, and is almost always found to be on a lower level than the adjoining bones ; a fact which, together with the natural mobility that may have become increased by injuiyor otherwise, may account for the location of the pain at this point in the majority of cases. Although in certain instances a neuritis may follow direct injury, yet this assump- tion is not at all necessary to explain the symptoms. Nor is it likely that the peculiar distribution of the nerves at this point has any direct influence on the pain, for the nerve supply of all the joints and all the toes is practically identical. Other Factors in the Etiology. — Besides the general effect of the shoe, and the possible influence of inherited predisposition to the affection, which seems evident in certain cases, or of weakness or direct injury of the anterior arch, one recognizes among the causes or complications of anterior metatarsalgia, weakness of the longitudinal arch or flat foot, which may be combined with a depression of the anterior arch. Less often the longitudinal arch may be exaggerated in depth and the dorsal flexion of the foot may be limited by a shortened tendo Achillis, thus more pressure is brought upon the front of the foot. In these cases, the pain may be increased by corns or calloused skin beneath the de- pressed bones and in many instances the discomfort of the depressed arch of the ordinary type is, in great part, caused by a sensitive corn or fibroma at the point of greatest depression, and the patient may be entirely relieved by its removal. (See contracted foot.) Although the symptoms of anterior metatarsalgia may be explained in most instances by the primary effect of improper shoes, by weak- ness and abnormality of the foot itself, and by the local sensitiveness of the parts that are continually subjected to strain pressure and injury, vet in some instances the symptoms can be explained only by local neuritis ; in others, they are aggravated by gout or rheumatism or general debility, and as has been stated in a large proportion of the cases the patients are of a distinctly nervous type. Treatment. — The most important local treatment is to provide the patient with a proper shoe. This shoe must be of proper shape with a thick sole, so broad that no lateral compression of the toes is possi- ble, with a high arch, as suggested by Gihney, in order to remove a part of the pressure from the heads of the metatarsal bones, and a low heel. As an immediate treatment, a firm bandage about the metatarsal re- gion, as suggested by Morton, may aid in supporting the metatarsal TREATMENT. 543 Fig. 372. arch, or better, adhesive plaster strapping may be applied about the metatarsus. Beneath or slightly behind the affected joint or the de- pressed arch, a pad, preferably an oval piece of sole leather, about one inch by three-quarters of an inch in size and one-quar- ter in thickness with bevelled edges, may be fixed to the sole of the foot with adhesive plaster, so that depression of the arch or over- riding of the adjoining bones may be prevented. This pad, suggested by Poulosson and Goldthwait, almost always relieves the pain, and when the exact place has been ascertained, it may be fixed to the sole of the shoe. As a rule, however, a metal support will be found to be more com- fortable and more efficient. This may be constructed of light steel (19 gauge) upon a plaster cast of the sole of the foot, of which the natural depressions, indicating the anterior and the longitudinal arches, have been somewhat exaggerated. The anterior extremity of the brace is made as wide as the foot, and ex- tends forward slightly beyond the metatarso- phalangeal articulations. The brace serves to support the anterior as well as the longitudinal arch. If there is slight depression of the longi- tudinal arch it may be further corrected by rais- ing the inner border of the heel and sole of the shoe, but if it is more pronounced a flat foot brace (Fig. 365) may be employed, whose an- terior extremity is modified to support the met- atarsal arch, as is shown in Fig. 372. If, on the other hand, the arch is exaggerated and if dorsal flexion is limited, treatment with the aim of relieving this deformity will be necessary, as described under " contracted foot." When the immediate symptoms of pain and local discomfort have been relieved, the patient must endeavor to strengthen the natural supports of the arch by proper functional use of the foot, and by regular exercise of the muscles, more especially by metho- dical forced flexion of the toes, as this motion elevates the anterior metatarsal arch. (Fig. 373.) If the anterior arch is rigidly depressed as in some instances, its flexibility must be restored by manipulation or by forcible correction under anaesthesia before a brace can be applied. If the symptoms are very acute, and particularly if they have followed direct injury, the parts should be placed at rest and the anterior arch should be elevated and supported by a properly applied plaster bandage. In chronic and resistant cases, or when conservative treatment cannot be applied, resection of the neck and head of the metatarsal bone at the seat of pain may be performed as advocated by Morton. The op- eration is very simple. An incision is made over the dorsal surface of A brace for anterior metatarsalgia. A iudicates a point beneath the fourth nietatarso-jihalangeal artic- ulation wliich is elevated in order to support the de- pressed articulation. 544 DISABILITIES AND DEFORMITIES OF THE FOOT. the joint, and the bone is separated by bone forceps. The toe is not, as a rule, removed, but after the operation it slowly recedes between the adjoining metatarso-phalangeal joints, causing a rather noticeable deformity. The operation is, as a rule, successful, but in the majority of cases it is unnecessary. The general condition of the patient should of course receive atten- tion, and local applications, electricity and the like, may be of benefit in special cases. A SENSITIVE CALLUS beneath the arch may require removal, and in certain cases its removal may be the only treatment required other than an improved shoe. But as a rule, the cause of the callus is habitual depression of one or more of the metatarso-phalangeal articulations, so Fig. 373. Exercise for the weakened metatarsal arch. that cure can only be assured by supporting the arch and by strength- ening its natural supports in the manner already described. Woodruff^ described a case of what he called "incomplete luxation of the metatarso-phalangeal articulation" in which the symptoms, practically identical with those of Mortion's neuralgia, are ascribed to an upward displacement of the proximal phalanx of the fourth meta- tarsal bone. Another writer, Guthrie,^ described a case in which intense pain followed over-extension of the third phalanx upon the second. Such cases are extremely uncommon and need only be mentioned. Achillo -Bursitis. P^ Synonyms. — Achillodynia, Achillo-bursitis Anterior, Retro-calca- neo Bursitis. Under the title of achillodynia, Albert,^ of Vienna, in 1893 called particular attention to an affection characterized by pain and tender- ness about the insertion of the tendo Achillis, symptoms usually ' N. Y. Med. Eecord, Jan. 18, 1887. 2 Lancet, March 19, 1892. 3Wien Med. Presse, Jan. 8, 1893. ACHILL 0-B URSITIS. 545 caused by irritation or inflammation of the small bursa lying between the insertion of the tendon and the bone. (Fig. 374.) Etiology. — In the acute cases, the cause of the bursitis often appears to be a strain of the tendon or direct injury, as the symptoms appear immediately after running or jumping or after a fall, sometimes after a long walk or bicycle ride. In the subacute cases, the symptoms may begin almost impercepti- bly, so that it may be impossible to assign a direct cause other than the pressure of the shoe, aggravated it may be, by an exostosis of the OS calcis beneath the insertion of the tendon or by concretions within the bursa. In many instances rheumatism, gout, gonorrhoea or one of the infectious diseases, appear to be associated, directly or indirectly, with the onset of the symptoms, or the bursa may be secondarily involved in tuberculous dis- Fig. 374. ease of the os calcis. Symptoms. — In a typical case, pain is felt in the back of the heel at the insertion of the tendon ; the pain is increased by use of the foot, and particularly by the attitudes in which the strain on the part is increased, as, for ex- ample, in descending stairs. There is also ten- derness on pressure about the back of the heel on either side of the insertion of the tendon. In most cases, a slight swelling, often more prominent on the inner than the outer side of the tendon, indicates the situation of the bursa. In the chronic cases, the enlargement of the bursa is very noticeable, and in addition, the en- tire posterior aspect of the heel often appears to be thickened. This is due probably to the secondary irritation about the fibrous expansion of the tendon and the adjoining periosteum. In many cases, the symptoms are pronounced ; pain is often felt in the bottom of the heel or it radiates up the back of the leg. The patient, unable to use the power of the calf muscle, everts the foot in walking, thus subjecting the arch to over-strain, so that the symptoms of the weak foot are often added to those of the original trouble. Not in- frequently however the two affections may be associated from the be- ginning in one or the other foot. The patient complains much of stiffness and weakness at the ankle and sub-astragaloid joints. In the acute cases, or in acute exacerbations there is usually burning and throbbing pain characteristic of acute inflammation, but in the sub- acute form the pain is slight, and is troublesome only after over-exertion. Pathology. — The pathological changes do not differ from those found in and about other bursse under similar conditions. In the mild cases the lining membrane is simply congested and the cavity contains serous fluid. In the chronic cases, the walls are much thick- ened,^ the lining membrane is fringed and reduplicated ; the contents Bursa between the tendo Achillis and the os calcis. 35 lEossler, d. Z. f. Chir., Bd. 42, 1 and 3. 546 DISABILITIES AND DEFORMITIES OF THE FOOT. are semi-solid, and sometimes calcareous masses are present. Similar changes are found however, in the bursse of apparently normal sub- jects, so that the condition of the bursa may not always correspond to the character of the symptoms. Suppuration of the sac occa- sionally occurs, and it may be the seat of tuberculous or syphili- tic disease. In cases of long standing, the parts adjoining the bursa, the expansion of the tendon and the periosteum become thickened so that the bone appears to be increased in breadth and may actually become so. Treatment. — When once established, the affection is usually of a very chronic nature, as is explained by the strain to which the sensitive part is subjected by the use of the foot. It is therefore important to apply efficient treatment at the beginning of the affection if an op- portunity is afforded. Efficient treatment implies absolute rest, and in all cases of any severity, particularly those of acute onset, a well-fitting plaster bandage should be applied to hold the foot slightly inverted and at a right angle to the leg. This should be worn until all symp- toms have subsided. In very mild cases, following immediately on a strain or over-use, simple rest with the application of heat, massage, and pressure, may be efficient. And in the subacute cases, the symptoms may be relieved by the application of a long broad band of adhesive plaster, from the toes over the back of the heel to the upper third of the calf, the foot being slightly plantar flexed. This is firmly fixed by narrow strips of plaster about the metatarsus, the heel and the calf. By this means pressure is exerted upon the bursa, and much of the strain is removed from the tendon. In persistent cases, a brace may be used with advantage, for the purpose of preventing strain upon the tendon. Two lateral uprights with a calf band and padded strap that crosses the upper third of the leg are attached to the shoe, provided with a stop joint at the ankle as used in the treatment of paralytic calcaneus to prevent dorsal flexion. (See talipes.) As the patient is usually sensitive to jar, the heel of the shoe should be replaced by one of thick rubber. In connection with the brace, the stimulation of the cautery and the pressure of the adhesive plaster strapping seem to hasten the absorption of the effu- sion in and about the bursa. If weakness or depression of the arch is present, as a result of the disability or combined with it, a foot plate should be applied (see page 525), and general affections, with which the disability is sometimes associated, should of course^ receive attention. Operative Treatment. — In chronic cases, in which the symptoms are not relieved by treatment, the enlarged bursa may be removed by an incision on one or both sides of the tendon. A plaster bandage is then applied and is continued until the symptoms have subsided. Operative treatment is of course indicated in acute suppurative in- flammation, in tuberculous disease, or if an exostosis beneath the bursa or concretions within the sac are present, as shown by the X-ray photograph. PAINFUL HEEL. 547 Achillo-Bursitis Posterior. Tenderness, pain and swelling at the back of the heel may be due to inflammation of the small superficial bursa that lies between the tendon and the skin. The cause is usually injury or the pressure of the shoe. The symptoms resemble somewhat those of achillo-bursitis anterior, but the swelling is more superficial, and the pain is caused by direct pressure rather than by tension on the tendo Achillis. In the ordinary case, removal of the pressure will at once relieve the symp- toms, but if the discomfort is considerable, a plaster bandage may be worn for a week or more. Sensitive points at the back of the heel are usually caused by the pressure of the shoe ; in rare instances, prominent points, or exostoses of the OS calcis are present, that may require special protection or re- moval. Strain of the Tendo Achillis. Not infrequently, and usually as the result of strain or over-use of the foot, patients complain of symptoms similar to those of achillo- bursitis, but on examination, one finds that the pain and sensitiveness are referred to the tendon itself. There is no swelling at its insertion, or pain on lateral pressure on the os calcis. The sensitive area may be as high up as the junction of the tendon with the muscle, and again, the mid-point of the tendon seems most painful. The cause in some cases may be a direct strain of the tendon or of the muscular fibers near its origin, or inflammation of its fibrous cov- ering due probably to the same cause. The treatment is similar to that of the milder type of achillo-bursitis, by the adhesive plaster strapping, by rest, and later, by massage. Recovery is usually rapid. Painful Heel — Calcaneo-Bursitis. Pain referred to the bottom of the heel, and sensitiveness to pres- sure on standing, are common symptoms of the weak or flat foot. Pain at this point may be one of the symptoms of achillo-bursitis also. In rare instances, the painful point is clearly localized and is confined to a small area in the neighborhood of the inner tuberosity of the os calcis. The cause of the symptoms, in such cases, may be an inflamed bursa lying between the periosteum and the fatty tissue of the heel. Such bursse may contain hard substances or even a fasciculated neu- roma.^ More general pain and tenderness referred to the heel, is often caused by the direct pressure and bruising of the tissues by over-use of the feet. Treatment. — Treatment must be directed to the condition of which the pain is a symptom, and, as has been stated, it is most often one of the symptoms of the weak or broken-down arch. If the tender point is ^Brousses & Berthier, Revue de Chir., Aug., 1895. 548 DISABILITIES AND DEFORMITIES OF THE FOOT. localized, and if the pain is increased by jars, a thick rubber heel com- bined with an inner sole, so cut out as to remove the direct pressure on the sensitive point, will often relieve the symptoms. In persistent cases, in which the sensitive point is distinctly localized, operative in- tervention for the removal of the bursa is indicated. The tissues of the heel may be turned back in a horseshoe-shaped flap which will allow a thorough examination of the affected parts. ^ Sensitiveness due to direct contusion, or bruising of the tissue caused by over-use, must be treated by rest and by change of occupation, un- less a reduction of the body-weight or improvement in attitudes re- lieve the symptoms. Plantar Neuralgia. Synonym. — Plantalgia. Pain referred to the sole of the foot, and sensitiveness to pressure on the plantar fascia, are usually symptomatic of the contracted foot (cavus) ; less often such symptoms accompany the weak or broken- down arch. Pain, tenderness and thickening of the fascia sometimes follow in- jury (rupture of the fascia),^ and a similar condition has been de- scribed by Franke as one of the sequelae of influenza.^ Treatment. — Pain in the sole of the foot, symptomatic of the con- tracted or of the weak foot, may be relieved by the treatment of the conditions of which it is a symptom. In the rare instances in which the fascia is itself injured or diseased, local rest, as afforded by the plaster bandage, is indicated until the acute symptoms have subsided. Erythromelalgia. Wier Mitchell * has described a series of cases characterized by attacks of heat, redness, pain and often swelling of the soles of the feet. Of 27 cases all but two were in women, many of whom were of a nervous or neurasthenic type. The affection appears to be a form of vaso-motor disturbance. Disturbances of the circulation and burning pain in the soles of the feet are common symptoms of the weak foot and of allied affections, but simple erythromelalgia unaccompanied by disability of this character is uncommon. It deserves mention however as a pos- sible explanation of symptoms in obscure cases.^ Hallux Rigidus. Synonyms. — Hallux Flexus, Painful Great Toe. Hallux rigidus is a painful affection of the great toe joint, character- ized by restriction of motion, particularly of the range of dorsal flexion. iDuplav, Clin. Cliir. del' Hotel Dieu. Serie, 1897. ^Lederiiose, Verhand. der Deut. G. fur Chir., XXIII. , Kong, 1894. 3Archiv f. Klin. Chir., Bd. 49, 1895. 4 Am. Jour. Med. Sci., Vol. 76, 1878. 5 Prentiss, Trans. Am. Ass'n Physicians, Vol. XII., 1897, p. 303. HALLUX BIGIDUS. 549 Fig. 375. lu advanced cases, the first phalanx may be slightly plantar flexed together with its metatarsal bone, hence the name hallux flexus, ap- plied by Davies-Colley, who first described the affection. The restriction of motion may be complete, as implied by the term rigidus ; the joint appears unduly prominent or enlarged, usually slightly congested, and pressure or forced movement causes pain. The symptoms of which the patient complains are a burning'or throbbing pain in the joint, increased by standing and particularly by walking, because of the enforced movement of the stiff and painful articulation. In many cases there is no actual deformity of the joint or other change ; the restriction of motion is much less, and the symp- toms are correspondingly slight. Etiology. — Typical hallux rigidus is most common in adolescence, and it is very often associated with the weak or broken-down foot. In such cases, the toe is crowded into the narrow part of the shoe, and is thus subjected to lateral and to longitudinal pressure as well as to the additional strain, that the attitude, characteristic of the weak foot, throws upon it. In some cases the habitual plantar flexion of the toe may be the result of an instinctive eflbrt to support the weak arch (hammer toe flat foot — Nicoladoni). In other instances hallux rigidus is caused directly by traumatism ; as by stubbing the toe, by kicking a hard object, or by other strain or injury. The aflection ap- pears to be, primarily, a form of periarthritis, caused by injury or pressure. The restriction of motion is in part due to muscular spasm, and in part to the irrita- tive and accommodative changes in the ligaments and tendons. In more advanced cases changes in the car- tilage and shape of the articulating surfaces, due to dis- use of function, and to pressure and friction, may be present. Treatment. — If the rigid and painful joint is not associated with the weak arch, it may be relieved by providing the patient with a proper shoe, which ex- erts no pressure on the sensitive part. Motion of the joint may be lessened by increasing the thickness of the sole, or if necessary, it may be entirely restricted by the insertion of a brace of tempered steel between the- two layers of the sole, as shown in the diagram. If, as in some instances, the rigid and flexed joint is associated with rigid flat foot, both defor- mities may be over-corrected, under anaesthesia, and retained in this position by the plaster bandage, as a preliminary treatment. If the milder type of painful joint is associated with the ordinary weak foot, the treatment of the latter condition will usually relieve the symptoms. In this class, particularly among the poorer patients, the shoe may be raised on the inner side, and the sole stifl^ened by means of the wedge-shaped sole recommended by Thomas, as already de- scribed in the treatment of the weak and flat foot. If painful motion The dotted out- line shows the shape of the steel splint that may be inserted in the sole of the shoe for hallux rigidus. 550 DISABILITIES AND DEFORMITIES OF THE FOOT is restricted and the exciting causes of the disability are removed, re- lief of the symptoms is usually immediate. In the chronic cases, in which the pathological changes are more advanced, excision of the joint may be necessary. Painful Great Toe Joint in Older Subjects. A similar condition of the joint is sometimes found in older sub- jects. In many instances the foot is well formed, and the restriction of motion in the joint is very slight ; yet forced dorsal flexion causes pain and long standing or walking causes much discomfort, particu- larly a dull ache in the joint and sharp neuralgic pain referred to the terminal phalanx. In some cases, the onset of the symptoms may be ascribed to a long walk, or " mountain climb," in others to wearing tight shoes, and in some instances, no definite cause can be assigned by the patient. In such cases, the symptoms are often supposed to be ■evidences of gout or rheumatism but although the local discomfort may Fig. 376. Simple congenital varus, adduction without supination — a form of pigeon toe. be aggravated by a predisposition to sucli diseases, yet no relief can be obtained by medication unless it is combined with the local treatment that has been described in the preceding section. The relief aiForded by such treatment alone, proves, in many instances, that the aifection is purely local in its character. (Fig. 375.) As has been mentioned, pain referred to this joint is a common symp- tom of the Aveak foot, and of the contracted foot as well. It is also caused by simple pressure on the joint, and by the use of improper shoes which force the toes into the abducted position. Pain directly beneath the great toe, and sensitiveness to pressure about the sesamoid bones seem to indicate an inflammation of the ten- HALLUX VALGUS. 551 don sheath or local periarthritis. If the discomfort is persistent, the sesamoid bones may be removed. As a rule, such symptoms occur only in combination with pain or deformity of the great toe joint. Hallux Varus. Adduction of the great toe is not infrequent in infancy, and it may be associated with a slight degree of varus deformity. (Fig. 376.) The peculiarity attracts the mother's attention because of the difficulty of drawing on the socks. In many instances the muscles seem abnormally developed, and the toe appears to be somewhat prehensile in its move- ments. Treatment. — The abnormal mobility may be checked by inclosing the toes with a narrow strip of adhesive plaster ; in any event the ordinary shoe may be depended upon to correct any residual deformity of this character. If the adducted toe is combined with varus, it repre- sents a slight degree of club foot that must be corrected in the ordinary manner. (See talipes.) Pigeon Toe, Congenital hallux varus forms one variety of what is known as pigeon toe, or the habitual turning in of the feet in walking. The inward rotation may be due also to bow legs, or it may be an effect of congenital talipes that remains after the cure of the deformity, or of the exceptional variety of coxa vara, in which the depressed necks of the femora are turned forward. In most instances pigeon toe in childhood is symptomatic of weakness either of the arch of the foot or of the knees (genu valgum). In such cases, it is a conservative effort of nature that serves to check further deformity, and it needs no treatment other than that which may be applied to the weakness of which it is a symptom. In the exceptional cases, in which the posture is not symptomatic of weakness or the effect of deformity, the sole of the shoe may be raised slightly on the outer border. This will correct the attitude in the milder type, if combined with instruction and training. In rare in- stances, the in toeing seems to be caused by limitation of the range of outward rotation at the hip joints, a restriction that must be overcome by systematic stretching of the contracted parts. In these and in the more obstinate cases of the simple type apparatus may be applied, sim- ilar to that used in the after-treatment of congenital club foot, to hold the feet in the proper attitude. (Fig. 377.) It must be borne in mind that the proper attitude of the feet is one of parallelism, not of outward rotation, and that slight pigeon toe will as a rule correct itself as the child grows older. Hallux Valgus. Hallux valgus is a deformity in which the great toe is turned out- ward to an exaggerated degree. Outward deviation of the toe is so common, owing to the use of improper shoes, that it is not recognized 552 DISABILITIES AND DEFORMITIES OF THE FOOT Fig. 377. as a deformity^ at least from the popular standpoint, unless the joint appears to be much " enlarged " forming a so-called bunion. Hallux valgus is practically a partial dislocation of the phalanx upon the metatarsal bone. In well-marked cases, the metatarsal bone is adducted or turned inward so that an abnormal interval separates its head from its fellows, while the phalanx is displaced outward and articulates only with the outer condyle. The angle thus formed, or more prop- erly the inner condyle of the adducted metatarsal bone, makes the prominent or "outgrown "joint. (Fig. 382.) This pro- jects sharply beneath the skin, and is ex- posed to injury and to the pressure of the shoe ; thus a bursa develops beneath the skin, while a corn or callus forms on its superficial surface. The projecting bone, covered by the irritated bursa and the thickened skin, makes up the bunion. In many instances the other toes are displaced outward, in the direction cor- responding to that of the great toe, or this may be rotated on its long axis and lie above or beneath its fellows. Pathology. — The pathological changes are such as usually follow deformity, dis- use of function, and injury. The car- tilage on the exposed condyle atrophies, the sesamoid bones, together with the flexor tendon, are displaced outward, the tissues on the outer side undergo accom- modative shortening, while those on the in- ner side are correspondingly lengthened and attenuated. The surface of the bone beneath the irritated periosteum is often roughened and irregular, and exostoses may form about the condyle, and thus ag- gravate the effects of the external pres- sure. Etiology. — The deformity is the direct effect of shoes that are too narrow and of improper shape, and in some instances too short for the foot, so that the great toe is subjected to lateral and longitudinal pressure. The deform- ing effect of the shoe is increased if the arch is weak, so that the toe is forced forward into the narrower part of the shoe when the foot is in use. The deformity may be increased by injury, or by the changes that follow gout, rheumatism, or rheumatoid arthritis, and in rare instances, the distortion may be the direct result of such dis- An appliance constructed of leather bands and elastic webbing for the correction of in toeing. Name of the inventor unknown. OPERATIVE TREATMENT. 553 eases;, but all other factors are of slight importance when compared to the deforming influence of the ordinary shoe. The deformity begins at a very early age ; it advances more rapidly during adolescence, but the symptoms do not often become troublesome until later years. Both toes are affected, as a rule, although the deformity and its accompany- ing symptoms are usually more marked on one side. Symptoms. — As has been stated, the slighter grades of deformity are not recognized as such, and it is usually because of the pain due to the irritating corn or bursa, and incidentally, because of the outgrown joint, that the patients apply for treatment. Treatment. — The symptoms in the ordinary cases may be relieved by providing a proper shoe, by which pressure on the joint is com- pletely removed. (Figs. 361, 378.) The sole should be strong, and it should be slightly thicker along the inner side so that the sensitive joint may be inclined away from the upper leather. In cases in which the deformity is not far advanced, the use of a proper shoe that allows space for an improved position of the great toe, combined with method- ical manual correction of the deformity, and exercise of the disused muscles, while the toe is guided in the proper directions by the fingers, will relieve the symptoms promptly and practically cure the deformity. Several forms of correcting braces have been devised, to be worn during the day, a digitated stocking and special shoe being, of course, necessary. But in the class of cases that can be successfully treated by mechanical correction, few patients will be found who are suffi- ciently interested in the cure of the deformity to submit to the slight discomfort caused by a brace. A simple device for holding the toe in an improved position is the Holden toe post, recommended by Walsham and Hughes. This is a thin piece of metal so fixed in the front and inner side of the sole of the shoe that it separates the first and second toes from one another and holds the former in an improved position. It of course necessi- tates a special shoe and a special shoemaker to fit it in its proper place. Operative Treatment. — In cases in which the deformity is of long standing, and in which the projecting condyle or the exostoses make protection of the sensitive joint difficult an operation is indicated. The primary object of the operation is to remove the projecting bone. This may be accomplished by a slightly curved incision about the inner aspect of the condyle, the center being below the joint, so that the scar will not be subjected to pressure. The flap of skin is raised, the peri- osteum and part of the capsule are lifted from the bone, and the entire condyle is removed with a chisel, so that the surface is made perfectly smooth. Contracted tissues that resist a corrected position of the toe are stretched or divided, and the wound having been closed with sutures, a plaster bandage is applied about the foot and toe. This may be worn with advantage for several weeks, when the parts will have become less sensitive, and the toe will have become accustomed to an improved position. The after-treatment is the same that has been described for the ordinary cases. 554 DISABILITIES AND DEFORMITIES OF TEE FOOT. In most instances, it is well to remove the thickened bursa from beneath the flap of skin. As minor points in the operation, the re- moval of the displaced sesamoid bones has been advised ; and the tendency to recurrence of deformity may be checked according to Weir,^ by dividing the tendon of the extensor proprius pollicis, and sewing jts proximal end to the periosteum of the inner border of the base of the first phalanx. Cuneiform osteotomy of the metatarsal bone is an effective operation if the base of the Avedge includes the projecting bone. Resection of the head of the metatarsal bone is as a rule unnecessary, but it may be indicated if the deformity is extreme. Hallux valgus is often combined with the weak or broken-down arch ; in such cases the foot must be supported by a properly fitted brace. This is of especial importance after treatment by operation. Bunion. — As has been stated, the discomfort of hallux valgus is caused in great part by the irritated bursa and the over-lying corn. These symptoms may be relieved by rest and by hot applications. After- wards the callus or corn may be removed, and the sensitive bursa may be protected by a bunion plaster. Operative treatment should be de- ferred until after the acute symptoms have subsided. Hammer Toe. Hammer toe is a contraction of one of the toes, usually of the sec- ond, in which the first phalanx is dorsi-flexed, the second plantar flexed, while the third may be flexed or extended. The contracted toe is over-lapped by its fellows ; its projecting dorsal surface is subjected to the pressure of the upper leather of the shoe, and the terminal pha- lanx, forced against the sole of the shoe and compressed by the adjoin- ing toes, becomes flattened into a club or hammer-like form. The nail is distorted and often " ingrown "; in most cases a corn or callus forms upon the extremity of the toe and a small bursa and corn over the projecting knuckle, on the dorsal surface. A third corn or callus is often found beneath the head of the metatarsal bone which has been forced downward by the flexion of the toe. Hammer toe is usually bilateral ; it may be congenital, and heredi- tary even, but it is usually acquired, the effect of shoes that are too short and too narrow. The second toe is deformed most often because it is the longest, and because it suffers most from the lateral compres- sion as well. The deformity begins, as a rule, in early childhood, when, the growth of the foot being rapid, it is more likely to suffer from the effects of outgrown shoes, and socks as well. Symptoms. — The symptoms are practically those of the corns or blisters caused by the pressure of the shoe, but they are often suffi- ciently troublesome to interfere seriously, not only with the comfort but with the ability of the patient. Treatment. — The resistance to the rectification of the deformity is 1 Annals of Surgery, April, 1897. DISPLACEMENT OF THE FEB ONE I TENDONS. 555 caused ^,by the accommodative changes that follow habitual malposition. In cases of long standing, all the tissues may be involved in the con- traction, of which the most resistant are the shortened capsular and lateral ligaments of the first inter-phalangeal joint. The congenital hammer toe of the infant may be treated by manipu- lation. When the resistance is overcome, the toe may be held in proper position by narrow strips of adhesive plaster passed over and under it and about its fellows. In older children a digitation in the stocking will often hold the toe in place if the deformity is slight and if a wide shoe is worn. In adult cases, in addition to the manipulation and shoe, a retention apparatus, in the form of a light plantar splint, or stiffened inner sole to which the toe can be attached, should be worn. If the deformity is more resistant, the toe may be straightened by force, aided, if necessary, by the subcutaneous division of the contracted ligaments ; but in advanced cases, the most effective treatment is resection of the joint. Sufficient bone should be removed to allow the correction of the deformity, or in case of its recurrence, to prevent the projection of the joint above its fellows. By this operation permanent relief may be assured. Over-lapping Toes. Over-lapping toes are very common among adults, owing to the pressure of the narrow shoe ; and not infrequently such deformity is seen in infancy and is apparently congenital. Deflected or deformed toes may be treated in infancy by manipulation, and by support with strips of adhesive plaster in the manner described. In childhood ex- ercise and proper shoes will usually correct acquired deformity. In older subjects, an inner sole somewhat like a sandal, to which the toes may be attached by bands of tape, may be employed if the deformity is considered by the patient of sufficient importance to demand treat- ment. Exostoses of the Foot. Simple exostoses of the foot, as distinct from those that are due to disease, as for example, to rheumatoid arthritis, are, in most instances, caused by the pressure upon a projecting bone of a somewhat deformed foot. The common examples are the hypertrophy of the scaphoid, often seen in flat foot of young children, the projection of the cunei- form bones on the dorsum of the hollow or contracted foot, the enlarge- ment of the internal condyle of the first metatarsal bone complicating hallux valgus and the exostoses of the os calcis in achillo-bursitis. As a rule, the treatment of the deformity of the foot and the removal of pressure will relieve the symptoms without other treatment. Operative removal may be required in exceptional cases. Displacement of the Peronei Tendons. Permanent displacement of these tendons forward of the malleolus, is not uncommon as a result of paralytic deformity, particularly ta- 556 DISABILITIES AND DEFORMITIES OF THE FOOT. lipes calcaneus, and in such instances it gives rise to no symptoms. Displacement of one or both of the tendons, or rather a laxity of their attachments, that allows an occasional displacement or slipping from the groove behind the malleolus, may result in serious disability, be- cause of the pain that follows the displacement, and because of the Aveakness and insecurity of which the patient usually complains. The cause of the laxity of the tissues that allows displacement in feet otherwise normal, may have been injury, but as the affection is often bilateral, the predisposition may be congenital. Treatment. — If the displacement is recent, as when it follows injury, the tendons should be replaced and the foot should be fixed in a plas- ter bandage until repair has taken place. If the displacement is habitual, a brace may be applied to restrain those motions at the ankle that induce it. In the chronic cases, an operation with the aim of fix- ing the tendons by deepening the groove in the malleolus, or by sutur- ing the displaced sheath in its normal position, may be indicated. If on examination the cause of the displacement appears to be a shorten- ing of the tendon, it may be divided and lengthened in the ordhiary manner. (Fig. 241.) Shoes. The shoe, as a factor in the etiology of deformity and disability^ has been mentioned several times in the preceding pages, but it is a subject of such importance that it would seem to call for special consideration. The object of the shoe is to cover and protect the foot, not to de- form it or to cause discomfort ; therefore, the one should corre- FiG. 379. Fig. 378. Normal feet. Proper soles for normal feet. spond to the shape of the other. If the feet are placed side by side, the outline and the imprint of the soles will correspond to the accompanying diagram. (Fig- 378.) The outline demonstrates the actual size and shape of the apposed feet, emphasized by enclosing SHOES. 557 them in straight lines. Thus, each foot appears to be somewhat trian- gular, b'eing broad at the front and narrow at the heel. The imprint shows the area of bearing surface, and owing to the fact that but a small portion of the arched part of the foot rests upon the ground, it appears to be markedly twisted inward. The sole of the shoe, if it is to enclose and support the bearing surface, must also appear to be twisted inward in an exaggerated right or left pattern. It will be straight along the inner border to follow the normal line of the great toe, and a wide outward sweep will be necessary in order to include the outline and thus to avoid compression of the outer border of the foot. (Fig. 379.) This demonstration of the true form of the foot is almost an indis- pensable preliminary to an intelligent discussion of the relative merits of shoes, and indeed, it is somewhat of a revelation to those who have thought of the foot only as it has been subordinated to the arbitrary and conventional standard of the shoemaker. The ideal, or shoe- maker's foot, upon which lasts are fashioned, is much narrower than the actual foot ; the great toe is not a powerful movable member, pro- vided with active muscles, but is small and turns outward, so that the forefoot is somewhat pyramidal in form and turns upward as if to avoid the contact with the ground. This imaginary foot, drawn after the shape of the ordinary last, appears in the diagrams. (Figs. 380, 381.) Upon it the sole of the shoe Fig. 380. Fig. 381. has been indicated, to con- trast it with the shape of that necessary to include the outline of the normal foot. The actual foot is thus com- pressed laterally by the shoe until the stretching of the leather, during the " break- ing in" process, allows it to overhang the sole. The great toe is forced outward, and, with its fellows, is com- pressed, distorted, and lifted off the ground by the rocker- shaped sole (Fig. 383), so that normal function is re- duced to the smallest limit. Thus, the foot, according to the age at which the reshaping process is begun and the constancy of the application, gradually approaches the ideal and fits the shoe. (Fig. 382.) This remodelling, however, is often accompanied by such discomfort that the individual rebels and wears a shoe with a square toe, which, from the conventional standpoint, is supposed to show a meritorious effort to follow nature. But the demonstration of the actual foot makes Shoemaker's feet. Shoemaker's soles. 558 DISABILITIES AND DEFORMITIES OF THE FOOT. it evident that it is a properly shaped sole, which serves as a support, not the part which projects beyond the foot, that is of importance. If the shoe with the square toe is wider, and straighter on the inner side than another with a pointed toe, it is in so far an improvement. But, as a matter of fact, one of the worst types of shoe provided for chil- dren, in shape very like the old-fashioned coffin lid, owes its popularity to the square toe. The same comment may be made on the so-called Fig. 382. skiagram of a foot modeled to fit the shoe, illustrating the etiology of hallux valgus. " common sense " shoe, which is well named, since it may be assumed that a properly shaped shoe is an evidence of uncommon sense. The object of the heel is to make walking easier by inclining the body somewhat forward. The high narrow heel is an insecure sup- port, and aids deformity by throwing more strain upon the forefoot and pushing it forward into the narrowest part of the shoe. The heel is of course unnecessary in childhood, and should not be worn, since it SHOES. 559 limits the necessity for, and therefore the use of, the normal range of motion at the ankle joint. The ordinary shoe, by restricting the func- tional use of the foot, favors awkwardness and improper attitudes. It compresses the toes, and is directly responsible for corns, bunions, in- grown toenails, and deformities, and indirectly it causes or aggravates nearly every weakness to which the foot is liable. This assertion does not need support of argument, since in some degree it has been proved by the personal experience of every shoe w^earer. The shape of the proper shoe corresponding to the undistorted foot has already been demonstrated. (Fig. 379.) The sole should be thick enough for protection, but not so rigid as to limit normal motion ; it should follow the imprint of the foot, projecting somewhat beyond the outline of the toes ; it should be flat (Fig. 384), and the upper leather Fig. 384. Fig. 383. The rocker sole. The flat sole. should be capacious. In other Avords, the front of the shoe should be designed to allow and to encourage functional activity, the slight ad- duction of the great toe and the alternate expansion and contraction of its fellows, as may be observed in the barefoot child. Thus the arches may be supported, and the weight and strain properly distributed. The heel should be broad and low. Most adult feet are more or less de- formed, and therefore better suited by an improved than by a perfect shoe. Of this class, what is known as the wide Waukenphast pattern is the best. In selecting the better from the Avorst of the " ready made " shoes, the breadth of sole, the angle of outward deviation of the soles, when the two are placed side by side, and the capacity of the upper leather, must be the determining points. The most effective work for reform can be accomplished by providing proper shoes for children, and thus preventing deformity. The inspection of children's feet shows that atrophy and compression begin at a very early age, and if protection might be assured during the period of rapid growth, serious distortion might be prevented. Socks. — Although of far less importance than the shoes, the socks worn by children deserve special mention as a factor in deformity, since they are often too short and too narrow and are made of unyield- ing material, so that the proper action of the toes is restrained. Theo- retically, the socks, like the shoes, should be rights and lefts, but if they are sufficiently large and of a texture to expand readily to the shape of the foot, but little trouble need be anticipated on this score. CHAPTER XXII DEFORMITIES OF THE FOOT. Talipes. In the preceding chapters, the disabilities of the foot, of which the symptoms of pain and discomfort were of greater importance than actnal deformity, have been described. One now passes to the con- sideration of the congenital and acquired disabilities, of which deformity is the most noticeable feature. Distortions of the foot are, practically, fixed positions in normal atti- tudes, or what are exaggerations of normal attitudes ; in other words the ordinary deformities can be voluntarily simulated and the centers of motion, at which the foot is deformed, are the centers of normal motion. If the foot has been Fig. 385. fixed in the abnormal attitude during the process of formation and rapid growth, or if it has been used for any length of time in the abnormal position, the deformity becomes exaggerated beyond the possibility of imita- tion, and secondary variations in its shape, size and nutrition, follow. The deformities of the foot are grouped under the generic name of talipes, derived from talus (ankle) and pes (foot), signifying, therefore, a form of deformity in which the patient walks upon his ankles. Talipes was thus originally synonym- ous with the popular term club foot, but at the present time it is used simply as a prefix to the descriptive titles of the different distortions, while club foot is usually applied only to the most common of the congenital de- formities, equino-varus, in which the distorted foot is club-like in form. Varieties. — There are four simple varieties of the distorted foot or talipes : Paralytic equinus. Recovery from paralysis, but deformity persists. TALIPES. 561 1. Talipes equinus, the extended or plantar flexed foot. In well- marked cases the patient walks upon the heads of the metatarsal bones, an attitude that suggested the name equinus (horse-like). 2. Talipes calcaneus, the dorsi-flexed foot in which the heel is prominent, and which alone bears the weight in walking ; hence, cal- caneus from calcaneum, the heel bone. In these forms the center of motion is at the ankle joint. Under the terras equinus and calcaneus, are included not only the cases of marked deformity, but also those in which the range of dorsal or plan- FiG. 386. Congenital calcaneus. In this form the arch is obliterated, form it is increased. In the acquired tar flexion is sufficiently limited as to cause a change in the contour of the foot. 3. Talipes varus, the inverted foot. In this deformity the foot is turned in or adducted, and combined with the inward twist there is al- ways a certain amount of supination, or inversion, that is, the inner border of the sole is elevated and the outer border is depressed, so that the weight falls to the outer side of the center of the foot. 4. Talipes valgus, the everted foot. This deformity is the reverse of varus. The foot is abducted and pronated, so that, in use, the weight falls on the inner border. In these forms of lateral deformity, the center of motion is at the medio-tarsal and sub-astragaloid joints. 36 562 DEFORMITIES OF THE FOOT. These simple deformities in which the foot is persistently extended or flexed, or twisted in or out, are comparatively uncommon. Compound Deformities. — As a rule the deformities are combined in varying degree, thus the over-extended or the over-flexed foot is usually twisted inward or outward, making four varieties of compound deformity. 1. Talipes equixo-varus, the extended and inverted foot. 2. Talipes equixovalgus, the extended and everted foot. 3. Talipes calcAjSTeo- varus, the flexed and inverted foot. 4. Talipes calcaxeo-valgus, the flexed and everted foot. In these more important deformities, the arch of the foot may be in- creased or diminished in depth. It is, for example, usually increased in calcaneus and equinus, and it is usually diminished in valgus ; but this secondary or subordinate deformity is not recognized in the ordinary classification. If the arch of the foot is simply exaggerated, the con- dition is sometimes called pes cavus ; if it is lessened or lost, it is called pes planus. These slight degrees of distortion, in which the func- tional disability is usually more important than the deformity, are rarely classed as forms of talipes. Simple cavus, the hollow or con- tracted foot ; and pes planus, one of the forms of the common weak or flat foot, have been described elsewhere. (Chapters XXL, XXII.) Etiology. — From the rem- Yia. 387. edial standpoint, the cause of the deformity is of far greater importance than its form. Thus one divides the distortions of the foot into two groups. 1. The coxgexital form, in which the foot, in process of formation, has slowly grown into deformity before birth. 2. The acquired form, in which the foot, perfect at birth, has at a later time become dis- torted. The congenital club foot may be considered simply as a twist- ed foot, of which the component parts, although distorted to a greater or less degree, are capable of regaining perfect form and function. This is practically true of the great majority of cases, although there are instances in which congenital deformity is complicated by defective for- mation of the foot or leg, or in which the deformity is caused by, or at least accompanied by, paralysis ; as for example, in certain forms of spina bifida or other defect or disease of the nervous apparatus. The acquired deformity is nearly always a consequence of paralysis of spinal origin (anterior poliomyelitis). Certain muscles, or groups of muscles being paralyzed, usually in early childhood, the muscular Congenital valgus. ETIOLOGY OF CONOENITAL TALIPES. 563 force of the foot is unbalanced and it is drawn into a distorted position by the' contraction of the unopposed muscles, and by the influence of gravity. This distortion is confirmed and increased by the accom- modative changes in the structure that accompany functional use and groAvth in the abnormal attitude. Far less often, acquired talipes may be the result of paralysis of cerebral origin, of other forms of spinal disease ; of local paralysis fol- lowing neuritis or injury to a nerve trunk. It may be caused Fie 388. by scar contraction, as after a severe burn, or by direct in- jury to the bone, or by disease that may interfere with sub- sequent growth. (Fig. 236. j Such are, however, extremely uncommon causes, so that the statement holds good that the congenital club foot is a simple distortion capable of perfect cure. Acquired club foot on the other hand is a deformity and disability usually second- ary to disease of the spinal cord ; it is therefore capable only of rectification and not of perfect cure, unless recovery from the original disease, of which it is a result, has taken place. Etiology of Congenital Tali- pes. — As of other congenital deformities, the etiology of talipes is more or less conjec- tural. Occasionally, the in- fluence of inheritance is ap- parent, and again, two or more children with club foot may be born of the same mother, but, as a rule, nothing in the family or personal history will be found that may in any manner explain the deformity. The most rea- sonable explanation as applied to the majority of cases, is the mechan- ical. This is, in brief, the theory that the foot has from some cause remained for a longer or shorter time in a constrained or fixed position, and has thus grown into deformity. It has been claimed by Eschricht, and also by Berg,^ that at about the third month of intra-uterine life the thighs of the embryo are ab- 'Berg, Archives of Medicine, N. Y., Dec. 1, 1882. Congenital club hands and feet, combined witli ancbylosis of nearly all the joints. (Compare with Fig. 389.) 564 DEFORMITIES OF THE FOOT. ducted, flexed and retated outward, the legs are crossed and the feet are plantar flexed and adducted so that the inner surfaces of the thighs, the tibial borders of the legs and the plantar surfaces of the feet, are held in close apposition to the abdomen and to the pelvis of the foetus. Later, there is an inward rotation of the legs so that the feet are turned gradually outward until the soles are brought into contact with the uterine wall, the feet then being in the attitude of abduction and dorsal flexion. According to this theory, there is a regular succession of [attitudes during intra-uterine life. If the inward rotation of the lower extremity is prevented, or if it is incomplete, the foot remaining Fig. 389. The etiology of congenital club bauds, club foot and anchylosis of the joints. The habitual attituij at birth. Photograph at age of three months. (See Fig. 388.) in the original position, becomes deformed. Thus equino-varus being the normal attitude of the early and middle period of intra-uterine life, is not only the most common, but it is the most intractable of the con- genital deformities. But if the constraint or pressure is not exerted until a later period, after rotation has taken place, when the foot has attained or nearly attained its normal size and shape, it will then in- duce the rarer and comparatively slight grades of deformity, such as calcaneus or valgus. This theory, which seems interesting and reasonable, appearsto rest on a very insecure basis. Bessel Hagen states that in embryos of 30 ETIOLOGY OF CONGENITAL TALIPES. 565 mm. in length, the foot is in extreme plantar flexion ; in those of 90 to 100 mm., the foot is at a right angle to the leg ; and from this size to that at full term, the foot may be found in any position, abducted, adducted or dorsi-flexed. He states also that supination is not the usual attitude at an early period but is more common near the termi- nation of intra-uterine life, and when it is present it is more often combined with dorsi-flexion. In other words, there is no time when the foot regularly and normally assumes the attitude of club foot, from which it is changed by the rotation of the legs. Scudder ' after simi- FiG. 390. latra-uterine " amputations." The patieut is a tailor. lar investigations, arrived at practically the same conclusions. He states that there is no necessary relation between the age, the rotation of the legs and the position of the feet. Although the rotation theory may not be accepted, still it would ap- pear that there is, during the process of development, a more or less regular change in the attitudes of the limbs and feet. If they are fixed in one position during this period of rapid growth, distortion must follow ; if the constraint is slight and if its influence is exerted at a late period, the deformity will be slight ; if it occurs at an early period, the deformity will be more resistant. One of the causes of constraint, and thus of ultimate deformity, ap- pears to be the interlocking of the feet. Many museum specimens show this, and in some of the cases of talipes seen during the first week of life, the feet may be replaced in the attitude in which they had been 1 Boston Med. and Surg. Jour., Oct. 27, 1887. 566 DEFORMITIES OF THE FOOT. fixed before birth. (Fig. 306.) Intra-uterine pressure, although not usually the direct cause of club foot, undoubtedly has an influence in aggravating the deformity. The eifect of pressure is not infrequently shown in atrophic areas of skin ; and bursse even are sometimes found over prominent bones. Entanglement in the umbilical cord, the direct pressure of intra- or extra-uterine tumors, and the like, may be men- tioned also as possible causes. Evidence of restraint and of abnormal attitudes of the limbs, is seen not infrequently in connection with club foot ; for example, in hyper- extension or fixed flexion of the knees, and in cases of extreme de- formity, the foot is often smaller than normal, and otherwise asymmet- rical. The distorted foot may be imperfect in structure ; toes may be absent, " spontaneous amputation " (Fig. 390) or constricting bands about the leg or foot may be present. Such abnormalities are usually ascribed to amniotic adhesions. Talipes may be combined with evi- dences of impaired or arrested development ; with hare lip, extrophy of the bladder, spina bifida, and absence of patellae ; or with other de- formities such as club hand and wry neck. Or there may be evidence of intra-uterine disease, as in anchylosis of joints (Fig. 388) or so- called foetal rickets. Finally, deformities of the foot may accompany or are caused by absence of bones, as of those of the foot ; or other deformities and malformations, showing evidently an abnormality in the original make-up of the germ. This latter group, which includes the complications of club foot and imperfection of structure, is com- paratively small, and, as has been already stated, in the great majority of cases, congenital club foot is a simple deformity capable of perfect cure. Statistics. — The most accurate statistics are those compiled from the records of the Hospital for Ruptured and Crippled by Townsend.^ These have been supplemented for me by the later investigations of Dr. N. B. Waller. In the combined statistics are included the data of 3,453 individual cases of talipes. Of these 1,650 were congenital, and 1,803 were acquired. The relative frequency of the congenital and acquired forms of talipes has given rise to much discussion in the past, and statistics on this point are at considerable variance with one another. This may be explained by the fact that acquired talipes is, as a rule, a preventable deformity. At the present time, the extreme degrees of acquired talipes are comparatively rare, and the deformity is usually of a much slighter grade than the corresponding form of con- genital distortion. Sex of Congenital Talipes. Males. Females. Total. Townsend 567 498 348 237 915 Waller 735 ' Total 1065 64.5% 585 35.5% 1650 1 A Statistical Paper on Club Foot, Trans, of the Med. Society of N. Y., 1890. STATISTICS. Sex of Acquired Talipes. 567 Males. Females. Total. 460 515 429 399 889 Waller 914 Total 975 828 45.8% 1803 Percentage 54.1% Congenital talipes is mucli more common among males than among females. All statistics are in accord upon this point. Acquired talipes is more equally divided between the sexes. Foot Affected in Congenital Talipes. Eight. Left. Both. Total. 274 236 256 184 385 325 915 Waller 745 Total 510 30.7% 440 26.5% 710 42.7% 1660 Percentage Unilateral 950, 57.2%. Bilateral 710, 42.7%. Foot Affected in Acquired Talipes. Right. Left. Both. Total. Townsend Waller 384 397 347 421 158 96 889 914 Total Pecentage 781 43.3% 768 42.6% 254 14.1% 1803 In congenital talipes the deformity is nearly as often of both as of one foot, while in the acquired form, unilateral deformity is far more common. In each variety the right foot appears to be more often affected than the left. The Eelative Frequency of the Different Forms of Congenital Talipes. I Townsend. Equino-varus Valgus Varus Calcaneo-valgus Equinus Calcaneus Equino-valgus Calcaneo-varus Cavus Valgo-cavus Equino-cavus Different deformity in each foot. . . Total. 667 87 70 15 35 11 14 4 1 1 1 9 915 Waller. 605 36 15 37 5 17 14 3 4 9 745 Total. 1272' 123 85 52 40 28 28 7 5 1 1 18 1660 Percentage. 77.0 7.4 5.1 3.1 2.4 1.7 1.7 568 DEFORMITIES OF THE FOOT. Eelative Frequency of the Different Forms of Acquired Talipes Together with the Etiology. Spinal. Cerebral. Other forms of par- alysis. Trau- matic. Total. Ante- rior po- liomy- elitis. Hemi- plegia. Para^ plegia. Per- centage. Equino-varus 479 321 219 134 114 76 41 12 22 11 35 1 28 66 3 4 2 1 1 35 46 1 7 5 1 4 3 1 29 26 1 27 3 2 5 2 575 462 224 173 122 78 49 12 24 11 36 2 32.5 Equinus 26.1 Calcaneus 12.6 Valgus 9.7 Equino-valgus 6.9 4.4 Varus 2.7 Calcaneo-cavus Eq uino-cavus 1.3 Calcaneo-varus Cavus 2.0 Varo-ca vus 1465 105 95 8 95 1768 Deformity different on each side 50 Anterior poliomyelitis 1465, 82.8%. Cerebral 200, 11.3%. Traumatic 95, 5.3%. Comparative Frequency of the Different Forms of Talipes, Congenital and Acquired. Congenital. Acquired. Equino-varus 77 per cent. 32.5 per cent. Valgus..... 7.4 " •' 9.7 Varus 5.1 •' " 2.7 Calcaneo-valgus 3 1" '■ 4.4 Equinus 24" " 26.1 Calcaneus 1.7" " 12.6 It will be noted that in three-fourths of the congenital cases the de- formity is equino-varus, and that equinus and calcaneus, rare as con- genital deformities, comprise 38 per cent, of the acquired forms. Occasionally the deformity is different on each foot, far more often in the acquired than in the congenital form (50 of the former or 19 per cent, of the 254 acquired bilateral deformities, as compared with 18 or less than 3 per cent, of the bilateral congenital). In 7 of the 18 con- genital cases, the deformity was equino-varus on one side, calcaneus on the other ; in 3 equino-varus and calcaneo-valgus, and in 3 simple varus and valgus. The 50 cases of acquired talipes represented every combination of deformity. In 31, or 4 per cent., of the 735 cases of congenital talipes in Wal- ler's table, the distortion was combined with other congenital defects or deformities, viz.: In 12 cases with double club hands; in 6 cases with defective development of the hands, webbed fingers and the like ; in 7 cases with spina bifida ; in 3 cases with absence of one or more bones of the leg ; in 1 case with torticollis ; in 1 case with hare lip ; in 1 case with dislocation of the knee and anchylosis of an elbow ; in 2 cases with general rigidity and deformity of the joints. THE ANATOMY OF CONGENITAL CLUB FOOT. 569 The Anatomy of Oong-enital Club Foot. Talipes Ectuino-varus. — CoDgeliital talipes is, in the great majority of cases, the form in which the foot is twisted inward and downward, so that in extreme cases it resembles the club-like extremity that has received the popular name of club foot. The ordinary congenital club foot, in early infancy, is simply a foot held in an exaggerated attitude of plantar flexion, ad- duction and supination. The dorsum of the foot looks forward and slightly outward and upward, the plantar surface is abnormally con- cave and looks backward, inward and downward. The foot often seems somewhat smaller than normal and the heel appears to be ill formed. Upon the outer dorsal surface the prominence of the astra- FiG. 391. Congenital talipes equiuo-varus (club foot). gains and os calcis may be felt beneath the skin, the external malleolus is prominent, while the internal malleolus lies deep beneath the redun- dant tissues of the internal aspect of the foot. The internal structure of the foot is rearranged to correspond to the external contour ; thus the relation of the bones to one another, and the shape of the individual bones even, are more or less altered as the deformity is more or less of an exaggeration of the attitudes that the normal foot is capable of assuming. These changes are most marked in the astragalus and os calcis. The astragalus is somewhat wedge- shaped from without inward ; it is plantar flexed so that a large part of its body protrudes from between the malleoli. Its neck is often some- 570 DEFORMITIES OF THE FOOT. what longer than normal, and it is, as a rule, depressed and deflected inward. (Fig. 392, B.) The os calcis is also in an attitude of plantar flexion ; the internal tuberosity is drawn upward to the vicinity of the internal malleolus, its anterior extremity looks downward and inward, and it is often deflected inward corresponding to the deformity of the neck of the astragalus. Its external surface looks downward and for- Avard, and it lies directly beneath the astragalus, instead of to its outer side, as in the normal relation. The scaphoid bone is drawn inward and upward, and articulates with the inner part of the deflected head of the astragalus ; it lies in close proximity to, and often articulates with, the internal malleolus ; the cuboid is displaced upward and inward, and lies to the inner side of the anterior extremity of the os calcis. The remaining bones are changed in position, but not materially in shape. In many instances the tibia is rotated inward upon the femur, and this inward rotation of the leg may persist after the Fig. 392. deformity of the foot has been corrected ; and in other cases there is often a moderate de- gree of knock knee and laxity of the ligaments. Less often, the tibia is slightly twisted inward on its long axis. The ligaments are altered to correspond to the changed relations of the bones. Those on the short side are more or less resistant, according to the duration of the deformity. The muscles are normal as to their structure and their origin and insertion, but the direction of the tendons as they pass across the foot, is altered some- what. Those attached to the inverted side, the extensor and adductor group, are shortened and are relatively stronger than those on the outer side, which are lengthened and atrophied from disuse. To sum up : all the component parts of the foot participate in the deformity. The most noticeable changes in the bones are in their position and relation to one another, but the astragalus, os calcis, and scaphoid bones are somewhat abnormal in shape as well. The most resistant structures in the deformed foot are the plantar fascia and the ligaments that bind the scaphoid, the os calcis and the internal malleolus to one another. The muscles that are most active in retaining and increasing the deformity are the tibialis anticus, the tibialis posticus, and the combined gastrocnemius and soleus. The changes that have been outlined, which are comparatively slight and which may be easily rectified soon after birth, become more marked as the part develops. And when the child begins to walk, the The deformities of the astragalus in club foot (Adams). A, Astragalus of a normal infant ; 1, from above ; 2, from within ; 3, from without. B, The astralagus in clubfoot in the same positions. THE ANATOMY OF CONGENITAL CLUB FOOT. 571 weight of the body, combined with growth and functional use in the abnorrhal position, increases and fixes the deformity. In the adolescent or adult type of club foot that has remained un- treated, the deformity is so extreme that the patient actually appears to walk on the outside of his ankles, as the term talipes implies. The feet turn directly inward, or even inward, upward and backward, and the peculiar walk, by which interference of inverted feet is avoided, has given another name (reel foot) to the deformity. In such cases, knock knee is usually well marked. This, al- though it may be present at birth, is usually a secondary distortion caused in great part by the accom- modation to the deformity, that is, by the diminution of the base of support and by the interference of the feet. (Fig. 396.) The legs are shrunken from dis- use. Over the outer border of the foot, in the neighborhood of the cal- caneo-cuboid articulation, there is a large callus with an underlying bursa. The foot itself is atrophied and is much smaller than the nor- mal. The changes in the bones are much more marked; only a small part of the articulating surface of the astragalus lies between the malleoli, and this posterior ex- tremity is flattened out to the shape of a wedge. There is con- sequently backward displacement of the leg bones, which is most apparent in the position of the ex- ternal malleolus. In fact, the changes in the foot may be so great as to make the component parts almost unrecognizable. (Figs. 391, 392, 393.) All the bones of the foot are more or less atrophied, and the normal area of cartilage has, to a great extent, disappeared from the proper articular surfaces. In this advanced stage, the normal muscular activity of the foot has disappeared. It is practically a simple rigid support, to which the patient has been so long accustomed that he may walk with compara- tive ease and with no discomfort, other than that caused by the corns and bunions at the pressure points. In these extreme cases, cure, in the sense of perfect functional recovery, is of course out of the ques- tion. But relief of the deformity, that is, replacement of the foot in the Talipes equino-varus in adolesceuce, showing the displacement of the astragalus and its relation to the scaphoid, also the atrophy and distortion of the bones of the leg. 572 DEFORMITIES OF THE FOOT. axis of the leg, at a right angle to it and in the plantigrade attitude, is nearly always possible. Symptoms. — The symptoms of congenital club foot have been, to all intents, included in the description of the deformity. The func- tional disability is of course considerable, although some patients are surprisingly active and are able to walk long distances. Discomfort from club foot is due almost entirely to the corns or inflamed bursse Fig. 394. Fig. 395. Talipes equiuo-varus. The teudons on the front of the foot. Showing the tendons in the sole of the foot and the extreme displacement of the os caleis. over the bony prominences, and its degree depends of course upon the use to which the foot is subjected. Treatment. — In considering the treatment of congenital club foot it is customary to divide it into several classes corresponding to the degree of resistant deformity. The first class would include the very slight or non-resistant cases in which the deformity may be almost entirely corrected by slight manual force. The second class comprises those cases in which a certain amount of varus and well-marked equinus remain, which it is impossible to overcome by manipulation. TREATMENT. 573 The first and second classes include the forms of infantile club foot. The fhird class comprises the cases of more extreme deformity, and those in which the resistance to the correction is great, as in many of the cases in early childhood, or those of later years that have been in- efficiently treated. A fourth class would include the untreated cases in the adolescent or adult. Congenital club foot (talipes equino-varus) treated at the proper time, that is to say, in early infancy, and in a proper manner, in the great majority of cases may be perfectly cured both as to form and function. Club foot in the adult may be made straight, but perfect functional cure is, of course, impossible. The club foot in childhood, in which treatment has been delayed, or in which it has been ineifective, may be cured as to form or function, but the eflFect of the distortion remains in a certain amount of atrophy of the foot and leg, caused by the long disuse of proper function. Although congenital club foot is an eminently curable deformity, yet perfect and permanent cure often requires minute attention to details during the active stage of treatment, supplemented by long-continued and careful supervision after the cure is supposed to be complete. No other deformity presents such a record of failures and incomplete cures, of relapses after apparent cure, of tedious and ineffective treatment by braces, often for many years, and of unnecessary and mutilating oper- ations. Some of the failures may be explained by the neglect of the parents, or by want of opportunity. A few are due to the unusual obstacles in the deformity itself, but by far the greater number must be accounted for by failure of the physician to apprehend the true nature of the deformity, or by his inexperience in the practical details of treatment. Principles of Treatment of Infantile Club Foot. — The infantile club foot is, as has been stated, simply a twisted foot. It is true that there are slight changes in the bones ; but the bones of an infant's foot are represented by yielding cartilage, which will rapidly reform under changed conditions. The ligaments, which are accommodated to the deformity may be easily stretched, together with the more resistant muscles and their tendonous insertions, and when the proper relation of the bones to one another has been restored the joints will become normal. The treatment of club foot may then be divided into three stages : 1. The rectification of the external deformity. 2. The support of the foot in proper position during the process of transformation of its internal structure and until the normal mus- cular power, unbalanced by the deformity, has been regained. 3. The period of supervision. This would include the treatment of possible complicating deformities of the knee, the laxity of ligaments and the like, as well as the over-sight of the functional use of the foot and the leg, during the early years of life. On examining the infantile club foot one will notice the same raus- 574 DEFORMITIES OF THE FOOT. cular activity that characterizes the normal foot. Tlie normal infant moves the foot in various directions, in a more or less regular alterna- tion of postures, but in the club foot, motion is in one direction only, that toward which the foot is turned. The muscles on the back and inner side of the leg, which are alone active, become relatively irritable and hypertrophied as compared with those on the front and outer side, that are disused. Thus, muscular activity of the deformed foot is in reality harmful, because it increases deformity and still further disturbs the muscular balance. For this reason the temporary restraint of motion, necessary during the rectification of the deformity, may be considered rather of advantage than otherwise. When movement is again allowed and encouraged, it must be in the directions opposed to the attitudes of deformity, with the aim of so strengthening the weak- ened group of muscles at the expense of the stronger, that the balance of muscular power may be reestablished. The First Stage of Treatment — Rectification of Deformity. — It should be stated at once, that " rectification of deformity " does not mean ap- parent symmetry, a misapprehension to which the majority of failures in treatment may be ascribed. It means, that when deformity is really rectified, all contracted and resistant parts must have been so elongated, that every passive motion and attitude possible for the normal foot, is equally possible and as easily attained in that which was deformed. This is actual functional rectification, as opposed to the simple straight- ening of deformity. The most important part of the club foot deformity is varus. The foot that is rolled over and jtwisted inward to the attitude of extreme adduction (Fig. 391), must be untwisted and forced into an attitude of extreme abduction or valgus, the so-called over-correction. (Fig. 387.) Until this is accomplished no attention whatever need be paid to the residual equinus. There are two reasons for dividing the procedure into two parts : First, in order that the attention of the surgeon may be concentrated on one and the most important part of the deformity. Second, because"^ by this preliminary untwisting, the os calcis is brought into the upright position, into its proper relation to the astragalus, to the bones of the leg and to the tendo Achillis, so that the true degree of equinus may be appreciated. Preliminary Manipulation. — As a rule, the second or third week of life is as early as mechanical treatment can be undertaken. Until then preliminary manipulation by the nurse, more particularly manual recti- fication of the deformity by gently drawing the foot toward abduction and retaining it in the improved position for a few minutes, as often as is possible, may be of service in overcoming its resistance. As a treat- ment by itself, however, simple manual rectification is tedious and in- effective, although partial cures have been attained by perseverance in this means alone. Mechanical Treatment. — Mechanical rectification is the treatment of choice and routine in infantile club foot. Of this treatment two methods may be described. MECHANICAL TREATMENT. bib 1. By the plaster bandage. 2. By some form of simple splint. The principle of the two is essentially the same. The foot is drawn toward an improved position and retained there by the plaster bandage, or it may be fixed to some form of metal splint or brace whose shape is gradually changed from week to week, as the resistance lessens. Gradual Rectification of Deformity by means of the Plaster Bandage. — In this treatment care should be taken to avoid undue pressure, irrita- tion of the skin or insecurity of the bandage. One should place shreds of absorbent cotton between the toes ; and the outer aspect of the ankle, where the skin is thrown into folds when the foot is straight- ened, should be smeared with vaseline. A narrow strip of Fig. 396. adhesive plaster long enough to reach from the knee to a point an inch or more below the heel, is applied to the outer side of the leg. A thin layer of absorbent cotton is wound about the leg, just below the knee, in order to protect the skin from the hard margin of the plaster bandage, and a similar striji is carried about the toes. The foot is then drawn gently toward the abducted position, oiten as far as the axis of the leg, at the first dressing, without causing discomfort. While it is held in this atti- tude, a narrow flannel band- age is smoothly applied to the leg and foot, the band of adhesive plaster being drawn out between the folds about the ankle. A very light plaster bandage is then applied, from the knee to the extremities of the toes, and into this bandage the projecting strip of adhesive plaster is incorporated, so that no dis- placement of the dressing is possible. The turns of both the plaster and the flannel bandage are made from within, downward and out- ward, so that the tension aids in retaining the foot. When the plaster bandage, which during the hardening process has been constantly rubbed and manipulated so that it may fit the part perfectly, has be- come firm, a long stocking is drawn over it and is attached to the body clothing. At the end «f a week the bandage is removed. The leg and foot are gently bathed with alcohol, thoroughly dried, powdered and protected as before, and the bandage is again applied. At this Neglected club foot, showiDg the secondary knock knee. 576 DEFORMITIES OF THE FOOT. second dressing, the irritable adducting muscles, after the interval of complete rest, will be much less active and the contracted tissues will be less resistant, so that the foot may be easily turned somewhat out- ward, or beyond the line of the leg. After four or five applications of the bandage, at weekly intervals, the foot, in ordinary cases, can be held without resistance in the attitude of extreme equino-valgus. The sole, which at first looked backward, inward and upward will be turned in the opposite direction, forward, outward and downward, and the inner border of the foot, which was con- cave, is now convex. (Fig. 387.) When the varus has thus been over- corrected, treatment is directed to the secondary equinus. At this stage Fm. 397. The first application of the plaster baudage, showing the improved position. (Compare with Fig. 391. ) it is well to cover the bottom of the foot with a foot plate of thin wood (splint wood or cigar box cover) to give the plaster bandage more solidity, and in order that its pressure may aid in fl itenlng the rounded sole. At first, one carries the foot upward (towai ' flot>:il flexion) while it is still retained in the abducted position, but wIk h 'ic right-angled attitude has been attained, it is brought nearer tf> the axis of the leg. The everted position, or the attitude opposed to vnru'^. is retained however, until correction is completed. In correcting ihe equinus a certain amount offeree is required, sufficient to crur>c .^tme discomfort during the application of the plaster, but not sufficient to cause suffering after- wards. The force is applied by means of the sole plate to the entire MECHANICAL TREATMENT. 577 foot, so that the posterior extremity of the os calcis may be drawn down- ward by' actual lengthening of the tendo Achillis, and not, as is often the case, by an over-correction of the forefoot, while the heel remains in its original position of plantar flexion. By the proper application of force the equinus is gradually overcome ; the sharp indentation or fold at the insertion of the tendo Achillis is lessened, and the heel becomes more prominent. The reduction of the equinus may be somewhat more difficult than that of the varus, but it should be entirely corrected in three or four months from the time of beginning the treatment. As has been stated, correction of the deformity implies over-correction. (Fig. 386.) And it is well, when this has been attained, to hold the foot for several weeks, by means of the plaster bandage, in an attitude of extreme pronation and dorsal flexion (calcaneo-valgus) in order to im- press, as it were, the new position upon its structure. This concludes the first stage of the treatment, the simple rectification of deformity. Correction by the plaster bandage has the great advantage of plac- ing the treatment entirely under the command of the surgeon. Prop- erly applied, the support is perfectly fitting and it holds the foot in the desired attitude without undue pressure. The disadvantages of the treatment are almost entirely due to its improper application. For instance, the bandage may be too heavy, or the padding may be so thick that it does not retain its position. Excoriations are usually due to carelessness in the application of the bandage, or because it is not removed in proper season. The fear of compression, of atrophy of muscles, of stunting the growth of the limb, is groundless. At the end of the plaster of Paris treatment, the corrected foot is, as a rule, larger than one that has remained untreated. The stunted foot is the result of non-treatment, or of ineffective treat- ment by braces or otherwise ; not of the enforced rest necessitated by the proper reduction of deformity. The Rectification of Deformity by Splints and Braces. — Of mechan- ical supports, there are many varieties. Complicated appliances should be avoided because they are unnecessary, and because they serve to distract attention from the prime object of treatment, the rapid and systematic cor- rection of deformity. Of the simpler braces, that used by Judson is one of the best and will serve as a type to illustrate this. form of treatment. The method of application may be described in Judson's own words. " The apparatus which I have conveniently used to effect this reduc- tion before the child learns to stand, is a simple retentive brace which acts as a lever making pressure on the outer side of the foot and ankle, at A, in Figs. 398 to 401, inclusive, and counter-pressure at two points, one on the inner side of the leg, at B, and the other at the inner border of the foot, at C. It is advisable to keep in mind that this simple instrument is a lever, because, if we know that we are using a lever with its three well-defined points of pressure, we can make the apparatus more efficient than if we view it, in a more general way, as an apparatus for giving a better shape to the foot. 37 578 DEFORMITIES OF THE FOOT. " I use a little brace made of sheet brass, doing the work with a few simple tools. An advantage of doing the work one's self is that there is no room for doubt as to where the blame lies if the apparatus does not work well. Two curved disks, B and C, Figs. 400 and 401, are riveted to a shank, D, and thus is formed that part of the brace which applies the two points of counter-pressure, while, on the other hand, the point of pressure is brought into action by a third disk, or shield, A, which is drawn tightly against the outer side of the foot and ankle, and held in place by a strip of adhesive plaster E, which includes the limb and the piece which connects the two disks, B and C. The disks are lined with two or three thicknesses of blanket, easily renewed, when necessary, with a needle and thread. These braces are so cheap Fig. 398. Fig. 399 Fig. 400. Fig. 401. Fig. 402. Fig. 403. Fig. 404. Fig. 405. The Judson club foot splint and its application. and easily knocked together that it is nothing to apply new and larger ones, using heavier material for the shank as the child grows. In general, three sizes will be enough, the shanks being 12 gauge, | in. wide; 14 gauge, | in. wide; and 16 gauge, f in. wide. The disks are conveniently made from 22 gauge, 1\ in. wide. The rivets are copper belt-rivets. No. 13. A lip turned on the edges of the disks, with the flat pliers, gives stiffness to the thin brass, and protects the skin from the rough edge. If more easily obtained, tin disks, light bars of iron or steel, and ordinary iron rivets, would doubtless answer. " The brace is applied with three strips of adhesive plaster. The upper and lower pieces, F and G, Fig. 401, are simply to keep the apparatus in place, which they do effectively if ordinary gum plaster TENOTOMY. 579 is used, while, by drawing the middle strip, E, tightly over the shield, and straightening the brace from time to time, the deformity is grad- ually and gently reduced. At each re-application the brace is made a little straighter than the foot at that stage. This may readily be done by the hands, and then the adhesive strip is to be tightened over the shield, till the shape of the foot agrees with that of the brace. After a few days, the brace is to be made still straighter, and again re-applied, and made tight till another point of improvement is gained. The brace is applied very crooked at the beginning of treatment, as in Figs. 399 and 401, and is straightened from time to time, and a longer brace applied as the deformity is reduced and the patient grows. It should be removed every week, or two weeks, and an interval of a few days allowed for freedom from the brace, when the mother is advised to manipulate the foot constantly, using as much force as she will in the direction of symmetry. Manipulating the foot during these inter- vals is of great importance, as cases have occurred in which varus and equinus have been entirely overcome by the mother's hand alone." " By this simple and prosy treatment, carried out systematically and without haste, or violence, or pain, the foot, unless it is a frightful ex- ception, may with certainty be changed from varus to valgus. At the same time the tendo Achillis is lengthened till the position of the foot is near the normal, or at right angles with the leg, as the result of manipulation and giving the brace from time to time a partly antero- posterior action. Figs. 400 and 401 show approximately the shape of the brace at the beginning of treatment, Figs. 402 and 403 when the varus is reduced, and Figs. 404 and 405 when valgus has taken the place of varus. The foot, in this latter stage, may not hold itself valgus, when left to itself, but with almost no force and with one finger it may be pushed into valgus." When the varus deformity is reduced, the equinus is gradually cor- rected by carrying the splint behind the internal malleolus, and finally, if necessary, direct upward pressure may be applied by lengthening the brace and applying it to the posterior aspect of the foot and leg. It may be noted that manipulation and stretching the contracted parts when the brace is removed, is of much importance in the correction of deformity by this or other means. Splints of wood, tin, felt and the like, may be employed, but they present no particular advantage over that which has been described. Tenotomy. — The equinus has been spoken of as the secondary de- formity, but its complete correction is often more difficult than that of varus. The mechanical stretching of the contracted parts by means of the plaster of Paris bandage, or the brace, is often accomplished with ease. But in many instances time will be gained, after the foot has been forced into the position of equino-valgus, by the division of the tendo Achillis, which is the most resistant of the shortened tissues. After division of the tendon, it is often necessary to use considerable force to stretch the other contracted parts, and to force the foot up to the limit of normal dorsal flexion, which is the object of the operation. Occa- 580 DEFORMITIES OF THE FOOT. sionally the obstacle seems to be in the posterior ligament of the ankle, and it is sometimes of service to reinsert the knife and to divide this structure, in part at least, so that it will give way under manipulation. When the foot has been forced into the position of over-correction, it is fixed in a plaster bandage which is allowed to remain for several weeks, until the interval between the separated ends of the tendon is filled in with the new tissue. In many instances, the leg is rotated inward upon the thigh, and the habitual attitude is accompanied by accommodative changes in the liga- ments of the knee joint. During the rectification of the club foot, this secondary distortion may be, in part at least, corrected by forcible manual rotation of the lower leg outward several times daily. Recapitulation. — The management of the first stage of the treatment of infantile club foot is then — manipulation of the foot by the nurse from birth until systematic rectification can be begun — mechanical correction, first of the varus and then of the equinus deformity, termi- nating with a period of retention in the over-corrected position (cal- caneo-valgus). Division of tendons, other than the tendo Achillis, is not often necessary. The time required for the completion of the first stage of treatment, or over-correction of deformity, should not, under favorable conditions, exceed three months. The rapid correction of deformity in the manner described, begun as early as possible and accomplished as quickly as possible, cannot be too strongly urged. In the first months of life the tissues are not re- sistant, the bones are practically entirely cartilaginous, and when the foot in its external appearance is rectified, the rapid growth in the first months of life will change the internal structure to conform to the normal conditions. The fear of atrophy, compression or other harm from the temporary fixation, necessary during rectification, is ground- less, and in fact, exercise so-called, except in the direction opposed to deformity, is harmful rather than beneficial. Correction of deformity may be accomplished by holding the foot in an improved position by strips of adhesive plaster, or by the elastic traction of rubber bands, attached to the leg and foot. As compared with the ease, rapidity, and certainty of correction by means of the plaster bandage, such methods are uncertain and ineffective and they will not therefore be described in detail. The Second Stage of Treatment. Support and Restoration of Function. When the deformed foot has been corrected, in the sense that all normal motions can be carried out by passive force, the first and most difficult part of the treatment will have been completed, and, in some instances, the deformity is actually cured. Such a result is unusual however, for although the foot may be normal in appearance, its mus- cular balance has not been restored. This is shown by the fact that when support is removed, the foot usually hangs downward and inward, and there is little apparent power in the dorsi-flexors and abductors to draw it upward and outward. If at this stage treatment were aban- doned, the deformity would almost invariably recur, at least in part. THE RETENTION BRACE. 581 For thi^ reason, the foot must be supported iu proper position until the slack of the lengthened tissues has been taken up by development in the normal attitude, aided by massage and stimulation of the mus- cles. Practically, support is always necessary until the child has be- gun to walk. The Eetention Brace. — The form of retention brace will vary somewhat according to the indications of the individual case. The best and simplest support is the Taylor brace, the invention of Dr. C. F. Taylor, of New York. (Fig. 406.) This consists essentially of a light upright that extends along the inner side of the leg to the knee, and a thin steel foot plate of the exact size of the sole, with an Fig. 406. The Taylor club foot brace. upright flange on the inner side, rising to a point just above the dorsal surface of the foot, against which the foot is pressed closely so that recurrence of the varus deformity is prevented. The joint at the ankle is provided with a catch that prevents plantar flexion, but al- lows dorsi-flexion. By bending the upright and the sole plate, the foot may be held in slight abduction and e version. The apparatus is applied with straps, as illustrated, and if necessary, its position is further fixed by a band of adhesive plaster, applied on the inner side of the leg to hold the heel firmly against the foot plate. The foot is thus held constantly at a right angle to the leg, or better in the early stage of treatment, in an attitude of dorsi-flexion and val- gus. Occasionally, after complete rectification of the deformity, the 582 DEFORMITIES OF THE FOOT. foot still turns in. In most instances, this is due to an inward rotation of the tibia on the femur at the knee joint, but in some cases, it is Fig. 407. Fig. 408. Taylor club foot brace showing the method of application and attachment. caused by a spiral twist of the tibia itself. In order to correct this secondary deformity, an extension of the upright of the brace is carried Fig. 409. Fig. 410. The Taylor club foot brace showing the adhesive plaster, by means of which the heel is helddown, and the method of attachment. This brace may be used to correct deformity as well as to retain the foot in proper position, as is illustrated by these figures. As a retention apparatus the foot plate should be held at a right angle to the upright by tlie stop joint shown in Fig. 400. METHODICAL MANUAL CORRECTION. 583 beneath^ the leg, provided with a joint at the knee and is extended up the outer side of the thigh. At the hip it is attached by a free joint to a padded pelvic band of light steel. (Fig. 415.) The band holds the upright in the proper relation to the thigh, thus, by twisting the part below the knee, the foot can be rotated outward to the desired degree. In less marked cases the retention bands used for pigeon toe may be employed. (Fig. 377.) Methodical Manual Coeeection. — Several times during the day the brace should be removed in order that the foot may be thor- oughly massaged and forcibly turned, first toward valgus, that is, out- ward at the medio-tarsal joint so that the inner border is made con- vex, and then to the extreme limit of dorsi-flexion and abduction. If the leg is rotated inward, it is forcibly rotated outward on the femur. Even if the tibia is actually twisted on its long axis, the influence of the brace and forcible manipulation will usually correct the deformity. Active contraction of the weak muscles may be induced by tickling the sole of the foot or by the use of electricity ; and finally, the entire limb should be thoroughly massaged before the brace is reapplied. When the deformity shows no tendency to recur, the brace may be removed for a part of the day, later it is used only at night, and finally it may be discarded if the child walks normally. But it is best to continue the daily manipulation, more particularly the systematic stretching or over-correction of the foot, for a long time. Thus one may assure oneself that there is no tendency toward deformity, of which the first symptom is always a slight limitation of the range of dorsal flexion and of abduction. In many instances, the deformity may have been so thoroughly over- corrected by the plaster of Paris bandage or by the brace, and the after-treatment of massage and stretching may have been so efficiently applied by the nurse or parent, that the retention brace may be unneces- sary. On the other hand, the inclination toward deformity may be so marked that a brace may be necessary to hold the foot in slight abduc- tion and valgus for a year or longer. In other cases, the use of a light brace to hold the foot in the over-corrected position during the night is alone required. These are points to be decided by the cir- cumstances in each case. The period of observation and supervision is included in the final stage of the treatment. Third Stage of Treatment — Supervision. — During this period, the at- titudes of the limb and foot of the walking child must be carefully watched, and particularly the signs of wear on the sole of the shoe. If it shows greater wear on the outer side than is usual, it is an indi- cation that the weight does not fall directly on the center of. the foot but to the outer side, and that there is therefore a tendency toward de- formity. This must be counteracted by making the sole thicker on the outer side or slightly wedge-shaped, so that the weight may be de- flected toward the inner border. This third period of treatment, or rather of over-sight of the func- tional use of the foot, must be continued indefinitely. In fact, it is 584 DEFORMITIES OF THE FOOT. the quality of this final supervision that decides in most instances whether the ultimate outcome is to be what is called a satisfactory re- sult, or a perfect cure. The Treatment of Neglected Club Foot. The treatment of club foot, under what may be called the proper conditions, as outlined in the preceding pages, applies practically to all cases before the completion of the first year of life, and mechanical rectification may be successfully employed in cases far beyond this limit of age. As a rule, however, when the patient has walked for any length of time, the resistance of the tissues has increased to such an extent, that more rapid and effective treatment is indicated. The investigations of Wolff have shown that the internal structure of the bones corresponds to their external contour, and that the structure and contour are adaptations to functional use. This internal structure is not, however, permanent, but is readily transformed to conform to changes in form or function. If then, the external contour of the club foot were suddenly reversed, and if use of the foot were per- mitted in this new attitude, a transformation of the internal structure of the bones and at the same time of their shape, would begin at once. This would continue until both structure and shape had become adapted to habitual function. It is upon this natural power of trans- formation that one depends for the final and complete change of the distorted bones to the normal ; and what is true of a resistant structure, like bone, is equally true of the other constituents of the deformed foot. Age as Influencing Treatment. — There is then this very es- sential difference between the indications for treatment in infancy and in childhood. In the first instance, the foot has no essential function. In the walking child, however, the weight of the body and habitual use tend to confirm and to increase the deformity. If walking is al- lowed during the process of rectification of the foot, it must necessarily retard its progress. As a general principle of treatment, walking should not be permitted, until the weight of the body may aid rather than retard the correction of deformity. The great numbers of compli- cated and cumbersome machines that have been used in the treatment of club foot were designed to correct gradually the deformity in walking children. But however efficacious one or another of these may have been in the hands of its inventor, or of one skilled in its use, such forms of apparatus applied under ordinary conditions, simply serve to delay effective treatment and to fix rather than to correct the deformity. The most important function of the brace, aside from its use as a correcting appliance in early infancy, is to support the foot after de- formity has been corrected, and to guide it in its functional use until its normal strength has been regained. And although it may be ad- mitted that rectification of deformity, even in adolescence, by simple mechanical means alone is perfectly possible, yet, only in exceptional FORCIBLE MANUAL CORRECTION. 585 cases \^ould one be justified in selecting a treatment so tedious, which offers practically no advantage over more rapid methods. The Rapid Correction of Deformity. — The principles on which opera- tive treatment is conducted are the same that govern mechanical treat- ment. Thus, the deformed foot must be over-corrected, and it must be held in the over-corrected position, until the immediate tendency toward deformity has been overcome. It must then be supported, until the process of transformation of its internal structure is completed, and until the balance of muscular power has been regained. This general rule of treatment is entirely opposed to the supposition that a surgical operation, no matter how radical, can be, in childhood at least, curative by itself alone. Operative procedures are undertaken simply Fig. 411. Reduction of the varus deformity. (Lokenz. ) for the purpose of making the primary over-correction possible ; and that operation by which this object can be accomplished, with the least interference with the structure of the foot, should be selected. Such an operation is what may be called forcible manual correction. Forcible Manual Correction. — The patient having been anaesthetized, one first attempts to correct the sharp inward twist at the medio-tarsal joint. Supposing the left foot to be deformed, one grasps the heel with the right hand, in such a manner that the projection or muscular part of the palm lies on the outer aspect of the foot, against the most prominent part of its outer border, which is at the junction of the os calcis and cuboid bones. This hand serves as a fulcrum, over which the inverted foot may be bent. The forefoot is then grasped firmly 586 DEFORMITIES OF THE FOOT. by the left hand and one begins a series of outward twists over the fulcrum of the opposing palm, gently at first with alternate relaxation of pressure, but with gradually increasing force as the resistant tissues stretch under the tension. If greater force is required, a triangular block of wood, well padded, may be used as the fulcrum (Fig. 411), one hand pressing on the heel and the other on the forefoot, but there is a great advantage in using nothing but the hands, because one feels sure that no injurious force is likely to be exerted. Under this steady manipulation the foot soon loses its rigidity and its elastic recoil toward deformity — it becomes Fig. 412. 1 latttuiug the sole. (Lokenz.) so limp that with two fingers one can not only hold the sole straight, but can push it or bend it outwards. Thus the first stage of the method- ical correction has been accomplished. One then turns his attention to the supination which makes the outer border of the foot lower than the inner border. The leg is grasped firmly near the ankle with the left hand and with the right the foot is forcibly twisted in a direction downward, outward and ujiward, over and over again, with steadily increasing force as the tissues slowly yield, until it may be forced into a position of extreme abduction, so that the sole may be made to look outwards and downwards — the reverse of the former attitude. FORCIBLE MANUAL CORRECTION. 587 One next stretches the contracted plantar fascia and reduces the cavus which is usually present, by forcing the forefoot toward dorsiflexion, against the resistance of the contracted tendo Achillis, until the sole is made perfectly flat. (Fig. 412.) Finally, the fourth, and often the most difficult part of the rectification, that of forcing the displaced astragalus into its proper position between the malleoli, is attempted. To ac- complish this, the tendo Achillis is first divided subcutaneously, and if necessary the posterior ligament of the ankle is also divided at the same time. The patient is then turned upon his face so that with the knee resting on the table the leg is held upright. This allows one to hook the fingers about the extremity of the os calcis while the hand and arm, lying along the sole of the foot, may be used as a Fig. 413. lever to force it toward dorsal flexion as the os calcis is drawn down- ward. In this manner forcible stretching is con- tinued until the dorsum of the foot can be brought almost into apposition with the crest of the tibia. When the operation has been completed, the foot should be perfectly limp. It is usually somewhat congested from the pres- sure of the fingers, but it is warm and the circu- lation is unimpaired. One may assume that in the change that has taken place from rigid deformity to a limp foot that can be moulded into the desired shape, the component parts of the deformed foot must have been subjected to considerable violence ; that ligaments and muscles must have been stretched, and, it may be, rup- tured ; that new surfaces are now opposed to one another in the articu- lations, and that the bones have been forced into approximately normal position. This method of treatment has a great advantage over the ordinary operative treatment, in that the entire foot participates in the correction, instead of a limited portion, as when, for example, bone is removed by cuneiform osteotomy. It has a second and almost equally important advantage, in that the immediate use of the corrected and yielding foot is possible in the place of the necessary rest that must follow cutting operations. For these reasons forcible massage should Reduction of the equinus deformity. (Lorenz.) 588 DEFORMITIES OF THE FOOT. Fig. 414. be the operation of choice, and preliminary, at least, to more severe procedures in the treatment of resistant club foot in childhood. The only disadvantage of the operation is the actual labor which it necessi- tates on the part of the surgeon, usually twenty minutes or more of rather exhausting work. The foot must now be fixed by a plaster bandage in an over-corrected position. It is first evenly covered with a layer of cotton, and a broad bandage of canton flannel and while it is held by the assistant, the plaster bandages are applied from the tips of the toes to the upper part of the thigh. It is important that the toes should not project beyond the bandage, because of the swelling that sometimes follows. It is important, also, that the foot should be held in the proper posi- tion while the bandage is harden- ing, and that it should not be manip- ulated to any extent after the band- age is applied, in order that no rigid wrinkle may press against the skin. The bandage is applied above the knee in order that the tibia may be rotated outward to its normal position and held there, and because more effective fixation may be as- sured and greater pressure exerted on the foot in walking. To utilize this pressure to better advantage the bandage should be made very thick beneath the sole, and a thin foot plate of wood should be incor- porated in the plaster. When the bandage is applied the position of the foot should be that of over-cor- rection of deformity, flexed beyond the right angle, twisted far outward, and the outer border should be elevated considerably beyond the level of the inner border. (Fig. 414.) One would suppose, after using the force that has been necessarily applied, that much pain and swelling would follow. This is, however, not the case. Often, on the following day, the patients are able to stand upon the foot, and always within the first week if the bandage has been properly applied. The pain following this operation is far more often caused by pressure of an ill-fitting bandage than by the violence that has been used. Thus one should be careful to remove sections of the bandage if it appears to cause undue discomfort. These points are usually the front of the ankle, the back of the heel and the inner border of the great toe. The Importance of Functional Use. — The immediate use of the foot is encouraged, in order that the weight of the body falling on The attitude of over-correction in which the feet are fixed after the opera- tive treatment. THE IMPORTANCE OF FUNCTIONAL USE. 589 the yielding structure may still further correct the deformity. Although only the heel and inner border bear weight directly, yet the pressure of the foot plate on the parts that do not come in contact with the floor is usually sufficient to mould the foot into its proper shape. If greater pressure is thought to be necessary, wedges of wood or cork may be attached to the sole of the plaster bandage so that all parts may bear weight equally. The bandage is covered by a stocking ; a slipper may be worn indoors and an ordinary over-shoe for street wear. The first bandage should be removed at the end of about three weeks as it will have become loose. The foot will then be found to be ex- tremely flexible, and by an enthusiast it might be considered cured. But knowledge of its previous condition should make it evident that a much longer time will be necessary to allow for its consolidation in the new position. At this time almost no evidence of the operation remains, ex- cept, it may be, slight discoloration of the skin. The foot is again held as far as possible in the over-corrected position and another plaster bandage is applied, usually as far as the knee only. This remains for four weeks, or longer if it is still unbroken. The patient uses the foot constantly, and is drilled in the proper method of walking, so that the muscles of the leg may become accustomed to the new and normal attitudes. At the end of another month or more, the plaster is replaced by a brace to be worn inside the shoe, usually of the simplest description, consisting of an upright bar with a calf-band, attached to a steel sole- plate by a joint that will allow dorsal flexion but checks extension at a right angle. This is applied because the dorsal flexors, after years of disuse, only slowly recover sufficient power to resist the action of the opposing group and the force of gravity. The second stage of the treatment is now begun. This may be di- vided into a period of active treatment and one of supervision. The first, or treatment stage, consists in massage of the entire leg and of the foot to stimulate the growth of the atrophied muscles, and method- ical manipulation of the foot several times a day. The important point in this manipulation is to force the foot with the hand to the extreme of the range of motions possible immediately after the operation, viz., eversion, abduction and dorsal flexion, in the same order, as at the time of operation. At the same time the patient attempts voluntarily to carry out these motions by his own muscles, the power being supplied by the hand of the masseur. Slowly the muscles gain in strength and ability and when normal muscular power and balance have been regained the patient is practically cured. But for long afterward supervision is kept up, of the patient's attitude, of the manner of using the foot, of the wear of the sole of the shoe, and the like ; and by constant drilling and stimulation the attempt is made to restore the normal appearance and function. One cannot exaggerate the importance of this after-treatment, and of supervision at least, on the part of the surgeon. The active treatment may often be left to the parents. But constant supervision is neces- 690 DEFORMITIES OF THE FOOT. Fig. 415. sary to keep this after-treatment, which seems so common-place and sim- ple, up to the proper pitch ; to assure oneself that the range of motion regained by the operation does not gradually become more and more restricted, even though the contour of the foot appears to be normal. Forcible manual correction may be employed with advantage from the second to the tenth year, although the limits may be extended in either direction in special cases. In this operation, as described, the tendo Achillis is the only structure di- vided. There is no particular objection to subcutaneous division of other ten- dons or ligaments in connection with forcible manual correction. But in such prolonged manipulation it is much bet- ter if the skin, which itself must be stretched, is unbroken and dry, rather than moist from the bleeding from punc- tured wounds. For this reason it is well to correct the deformity without extensive tenotomy if possible.^ Secondary Deformities. — In cases such as have been described, a certain amount of secondary deformity of the leg is often present. Knock knee rarely requires other treatment than daily manual cor- rection, in connection with the massage of the foot and leg. Hyper-extension at the knee will correct itself during the treatment of the foot, which being fixed in an attitude of dorsal flexion obliges the patient to bend the knee habitually in walking. Inward rotation of the leg upon the thigh is often present. This may be overcome by methodical ma- nipulation and by the use of a brace that is attached to a pelvic band. (Fig. 415.) In many instances, particularly in childhood and adolescence, the patient has so long walked with exaggerated outward rotation of the femur, that after correction of the deformity no inward rotation of the foot appears, even though inward rotation of the tibia be present. In other cases the inward rotation of the foot is caused by a failure to completely replace the astragalus between the The Taylor club foot brace with pelvic band, to prevent rotation of the leg. The brace is shovrn before the covering and straps are applied. ' Forcible manual correction appears to have been described first by Delore. Lorenz employs the method in connection with his osteoclast to the exclusion, practically, of all other treatment. (Heilung des Klumpfusses darch das modellirende Redresse- ment, Wiener Klinik, Nov., 1895. ) The modification of the treatment that has been described has been employed by the author for many years. SUBCUTANEOUS TENOTOMY. 591 malleoli. Occasionally the tibia is actually twisted on its long axis, so that an 'osteotomy may be required in order to overcome the deformity. Malleotomy. — In confirmed club foot, of the type under considera- tion, the chief obstacle to perfect correction is often the astragalus. This is displaced forward, downward and inward, only the posterior portion of its articulating surface being contained between the malleoli. Thus the space between the two bones may have become insufficient for the anterior and wider part of the body of the astragalus. In such cases, even after division of the teudo Achillis and the posterior ligament of the ankle, dorsal flexion still remains restricted and examination shows that the astragalus still projects as before, even though the foot has been forced into a position of apparent dorsi-flexion and abduction. This apparent correction is the result of over-correction at the medio- tarsal joint, of outward rotation of the tibia upon the femur and of backward displacement of the fibula. In such instances the malleoli may be separated from one another by dividing the ligaments that hold them in apposition. A straight incision about two inches long is made directly over the anterior as- pect of the articulation, the ligaments are divided and, by inserting a thin chisel, the bones are pried apart, while the astragalus is replaced in the proper position. This is usually easy if the restraining tissues on the posterior part of the ankle have been divided. The wound is then closed and the foot held in the over-corrected position by a plaster bandage. Complete correction of the varus deformity should, of course, precede this operation. It might seem on first consideration that if immediate correction of deformity could be so easily accomplished in the confirmed cases, it should be employed even in infancy. There are, however, practical reasons against it ; first, because the foot is so small that it cannot be easily manipulated, second, because even after it is corrected it must be supported until the child begins to walk, and third, because the foot can be so easily straightened without an operation, which, even of so slight a character, is sometimes cause of much anxiety to the parents. For these reasons although immediate reduction of deformity is a thoroughly practical and safe operation, it is rarely performed until a later time. Subcutaneous Tenotomy. The division of tendons and other tissues by the subcutaneous method, has been mentioned incidentally but as it has so long occu- pied an important, and even at one time the most important, place in the treatment of club foot, the operation and its effects may be described somewhat in detail. Tenotomy, as has been stated, is performed for the purpose of re- moving an obstacle to the correction and over-correction of deformity. In the acquired or paralytic form of club foot, one or more shortened tendons may be the chief obstacles to reposition. But in the congenital form, in which all the tissues have grown into deformity, the shortened 592 DEFORMITIES OF THE FOOT. tendons are oy no means the only resistant parts, and tenotomy should be considered therefore, merely as an incident in correction. In the ordinary treatment of infantile club foot, tenotomy may often be dis- pensed with, and in the great majority of cases division of the tendo Achillis is alone required. When the tendon has been divided, the deformity is immediately over-corrected ; thus the two extremities are separated to the extent necessary to allow the improved position. At the end of three weeks or more, or at the time when the first plaster bandage is removed, the space will be filled with new material, and in another month the splice, which will be somewhat larger and thicker than the normal, should be strong enough for use. The slight thickening at the site of the opera- tion may be felt for a year or more, but for all intents and purposes, the new and lengthened tendon is perfectly normal, as is the function of the muscle of which it is a part. The process of repair is somewhat as follows : Immediately after the operation the space between the divided ends of the tendon is filled or partially filled with blood ; then leucocytes appear, which with those in the blood clot serve as pabulum for the plasma cells which migrate from between the fasciculi of the tendon and from the tendon sheath. The fibrin and red corpuscles of the clot are absorbed, the extremities of the divided tendon soften and become fused with the new material, which begins to take on the^form and consistency of true tendon, and to separate itself from the adherent sheath. This new tendon, according to Tubby, differs from the normal structure in that the fibrous fasciculi are more irregular and its substance is more like scar tissue, but practically it is perfectly normal in its appearance and function. Since the tendon sheath serves an important purpose in repair, it should be disturbed as little as possible. For this as well as for other obvious reasons, subcutaneous tenotomy of the tendo Achillis, which is so prominent and so distinct from other important parts is to be pre- ferred ; but if more extensive division of other tendons is required, the open operation is often indicated. Division of the Tendo Achillis. — For this operation ansesthe- sis is usually required, preferably by means of nitrous oxid gas, and it is hardly necessary to state that surgical cleanliness, even in so slight a procedure, is essential. The instrument should be small and very sharp so that no force is required in the operation ; the blade should be as long as the tendon is wide. The patient is turned upon the side or to the prone position, so that the foot may be held with the heel upward by the left hand. The position and size of the tendon is ascertained by careful palpation, and the knife is then inserted to its inner side, at about the level of the extremity of the internal malleolus. The flat surface of the blade is held parallel to the tendon, and it is passed beneath it until its point can be felt beneath the skin on the opposite side. The edge is then turned upward and the tendon, being made tense, is divided by a THE CORRECTION OF CONFIRMED CLUB FOOT. 593 sawing ^motion of the knife. Wiien the division is complete, as indi- cated by the separation of the divided ends, the knife is withdrawn, and the minute opening in the skin, from which there is usually slight bleeding, is covered with a pledget of aseptic cotton. The foot is forced into dorsal flexion and is securely fixed by a plaster bandage. In applying the dressing one should take care that no pressure is brought upon the seat of operation, as this might interfere with the effusion of plastic material. As soon as the discomfort attending the operation has subsided the patient is encouraged to stand and to walk. Functional use, far from retarding repair, is, by stimulating the cir- culation, an important agent in assuring firm and rapid union. Division of the plantar fascia is not infrequently necessary and should be performed subcutaneously. The tenotome is inserted be- neath the skin at about the center of the concavity to one or the other side of the central band of the fascia, which is divided by a sawing motion of the knife. The part is put upon the stretch, and other resist- ing bands to the outer and inner side are divided in the same manner ; the cavus is then corrected by manual or instrumental force. The opera- tion like that upon the tendo Achillis is practically free from danger. Division of the tibialis anticus is not often necessary, as this tendon offers little resistance to the rectification of deformity of the ordinary type. The tendon of the tibialis posticus may be divided together with that of the tibialis anticus near the points of attachment. If the oper- ation is required, it may be combined with simultaneous section of the (JALCANEO-SCAPHOID LIGAMENT, with which are blended the anterior part of the deltoid and fibers of the anterior ligament of the ankle. (" The Astragalo-Scaphoid Capsule," Parker.) According to Parker's directions, the foot should be strongly abducted to make the parts tense. The tenotome is entered directly in front of the anterior border of the internal malleolus, its cutting edge being turned forward between the skin and the ligament. It is then turned toward the ligament, and the tissues are divided to the bone. The blade is then made to enter the interval between the astragalus and the scaphoid, and is carried down- ward and forward to divide the inferior part of the ligament and at the same time the tendons of tibialis anticus and posticus. The posterior ligament of the ankle joint may be divided or suffi- ciently weakened, so that it may be ruptured after section of the tendo Achillis by passing the knife directly downward in the middle line upon the upper border of the astragalus. The Correction of Confirmed Club Foot by the Method of Julius Wolff. Wolff's treatment of club foot as described by Freiberg, a former assistant in his clinic, may be summarized as follows : ^ The patient is anaesthetized, and with the hands and by the use of a moderate ' Med. News, Oct. 29, 1892. 38 594 DEFORMITIES OF THE FOOT. Fig. 416. amount of force, the deformity is reduced as far as possible. The foot is held in the improved position by means of strips of ad- hesive plaster, passing from the dorsal surface of the inner border of the foot under the sole and up to the outer aspect of the leg. The leg and foot are then covered with cotton from the tuberosity of the tibia to the tips of the toes and a plaster bandage is applied. As the plaster is hardening, the position of the foot is still further im- proved by pressing the heel inward and the forefoot outward and up- ward. Two fenestra are cut in the plaster at the points of greatest pressure ; one over the external surface of the ankle, and the other over the internal surface of the great toe. If tenotomy is considered neces- sary, it is usually performed as a preliminary operation several days before forcible correction. On the third or fourth day after the operation, a wedge-shaped sec- tion is cut from the bandage on the outer side of the ankle joint and a linear division is made about the ankle, so that the leg and the foot parts of the bandage are separated. (Fig. 416.) The leg being held firmly, the foot is forced outward and upward to the extent that the wedge-shaped opening in the plaster will allow, and the two sections are then united by a covering of plaster bandage. For the secondary correction anaesthesia is not required. At intervals of several days larger wedges are re- moved and the manipulation is repeated until the patient stands with the foot in a satisfactory atti- tude, that is in pronation, abduction and dorsi- flexion. If the deformity is extreme the bandage may be reapplied before the correction is com- pleted with advantage. One should take care that the toes are not compressed, but lie on the same plane, in normal relation to one another. When rectification is complete the plaster bandage is covered with strips of pine shavings, held in place by a crinoline bandage, and painted with carpen- ter's glue. When this is hardened, the whole is covered with a thin silicate bandage ; over this, the shoe is fitted and the patient is encouraged to walk. This form of dressing is used until the trans- formation of the deformed parts may be supposed to be complete, the time varying with the case, from a few weeks to a year. The time required for the primary correction is from a week to a month. When the bandage is finally removed, massage and exer- cises are to be employed. Wolff's treatment has been thoroughly tested at the Hospital for Ruptured and Crippled. It is an efficient means of correction al- though somewhat tedious. It may be more conveniently employed in later childhood and adolescence than at an earlier age. The points at which the bandage is divided and the wedge removed. (Frei- berg.) THE THOMAS METHOD. 595 Fig. 417. Forcible Correction of Deformity by Means of Osteoclasts and Wrenches. In place of manual correction greater force may be employed by means of wrenches or osteoclasts to overcome the deformity. There is this important difference between the two procedures : force may be applied by the hands for as long a time as is necessary without fear of injury, while force applied by a machine must be momentary because of the pressure and strain on the parts where the leverage is exerted. Manual force continuously applied may be supposed to stretch the resistant parts, and although much less power is exerted it is really more effec- tive than the sudden and momentary force of the wrench or osteoclast. By manual rectification the operation may be continued until the de- formity has been over-corrected, while complete correction by means of instruments may necessitate several operations. The Thomas Method.— Of in- strumental correction, that by means of the Thomas wrench is one of the simplest and most efficient. The wrenching may or may not be pre- ceded by tenotomy, a point to be de- cided by the resistance of the parts. As a rule division of the tendo Achillis is alone necessary. The in- strument is a simple heavy monkey wrench, of which the jaws have been replaced by two strong pins slightly bulbous at the ends to keep the covers of rubber tubing from slipping off. The wrench is applied to the in- ner side of the foot and screwed down so that it may " bite " and hold its place firmly, for if it slips it is likely to abrade or tear the skin ; then with considerable force the foot is twisted outward and upward. (Fig. 417.) The "key note" of the operation is to so wrench the foot that it loses its elasticity, and shows no tendency to recoil toward deformity. The foot is then placed in the best possible position and is retained there by the Thomas foot splint or by a plaster bandage. In certain instances one may complete the rectification at one operation, but this not usually at- tempted, the procedure being repeated at intervals of a few days until the deformity has been over-corrected. In very resistant cases, eight The Thomas wrench as used in the correction of club foot. 596 DEFORMITIES OF THE FOOT. or ten applications of force may be necessary. When the deformity has 'been rectified, the foot is held in the over-corrected position for several weeks by the splint or by the plaster bandage. As a walking appliance a simple upright of iron with a calf band is applied to the inner side of the leg, from a point just below the knee to the heel of the shoe into which it is inserted, as is the Thomas knock knee brace. (Fig. 293.) By bending the upright the foot may be kept in slight valgus, and this position is still further assured by mak- ing the outer side of the sole of the shoe thicker than the inner so that the weight falls upon the inner border of the foot. In many instances, the walking brace may be YiG. 418. dispensed with in the after- treatment, but a light brace is usually worn to hold the foot in the corrected position during the night, until the power of the abductors and dorsal flexors has been re- gained. Massage and ma- nipulation are used in the after-treatment in the man- ner already described. Properly applied the treat- ment is satisfactory and free from danger. Sloughing of the tissues caused by the pressure of the instrument or by the plaster bandages has been reported, but such accidents have not occurred in the extensive practice of Thomas and Jones. Correction by Means ,of the Osteoclast. — The late Mr. Grattan, of Cork, used the osteoclast that goes by his name (Fig. 296) to crush and to over-correct resistant club foot. The operation may include beside the correction of the de- formity of the foot itself, fracture of the leg above the malleolus, to turn the foot toward valgus, and a second fracture half-way up the limb, to overcome the inward rotation or twist of the tibia. Mr. Grat- tan's results have been very satisfactory. Other appliances constructed on somewhat similar principles may be employed. Of these, the Lor- enz osteoclast^ and the Bradford^ lever apparatus are the most effective. The Open Incision Combined with Forcible Rectification of De- formity. Phelps' Operation. — When extensive division of contracted Kesistant club foot iu later childhood. (See Fig. 419.) 1 Wiener Klinik, Nov.-Dec, 1895. •Bradford and Lovett, 2d ed., p. 414. PHELPS' OPERATION. 597 Fig. 419. parts is indicated, the open incision is to be preferred because of the opportuiiity thus offered- for the recognition, and for intelligent selec- tion, of structures that require division in the final correction of the deformity. Phelps' operation is essentially simply the division of resistant parts through an incision on the inner border of the foot, combined with sufficient force, manual or instrumental, to over-correct the deformity. It is the most conservative of the more radical procedures, and by it even the most severe type of deformity in the adult can be corrected ; that is to say, the deformity may be overcome and a serviceable foot may be assured to the patient. Perfect functional cure is not possible when deformity has become habitual after many years of neglect. The steps of the Phelps operation are as follows : After proper sur- gical preparation the Esmarch bandage is applied. The tendo Achillis, and usually the posterior liga- ment of the ankle, are divided subcutaneously, and by manual or instrumental force one at- tempts to correct the plantar flex- ion. An incision is then made on the inner border of the foot, just below and in front of the internal malleolus, which is ex- tended directly downward over the head of the astragalus to in- clude the inner quarter of the sole. Through the incision all resistant parts are divided in order, as stated by Phelps. 1. The tibialis posticus, and the anticus, if it offers resistance. 2. The abductor pollicis. 3. The plantar fascia, 4. The flexor brevis digitorum. 5. The long flexor of the toes. 6. The deltoid ligament in all its branches. During the successive division of the tissues, repeated attempts are made to correct the foot, and only those structures are divided that present themselves as tense and resistant tissues when the foot is forcibly abducted. In the adult type of club foot no particular effort is made to recog- nize the different structures, but all the tissues on the inner side of the foot including blood vessels and nerves, the deep ligaments, and oc- casionally the tendon of the peroneus longus muscle, are divided. Even then it is necessary to apply considerable force to correct the de- ■■ KIL^ BHWW||y|i^K->' A**^ pi flfff'^l^j^n 1 1 C^Lfl 1 The deformit}^ (Fig. 418) corrected by Phelps' operation and by cuneiform osteotomy of the os calcis. 598 DEFORMITIES OF THE FOOT. formity. In certain instances the rectification of deformity necessitates osteotomy of the neck of the astragalus, or the removal of a cuneiform section from the os calcis. The object of the Phelps operation is, by the use of force and by division of resistant tissues, to over-correct the deformed foot at one sitting, and as much force and as extensive di- vision of tissues as are required, should be employed by the operator. AVhen the foot can be held in the desired position without resist- ance, the wound is covered with Lister protective, the foot and leg are thickly covered with gauze and cotton, a plaster bandage is applied and the limb is elevated. The Fig. 420. large gaping wound closes by granulation in from one to three months. By this operation the foot, even in severe cases in adult life, may be made straight in appearance. It is evident, however, that in such cases the correction of the defor- mity of the bones is by no means always perfect, for the forefoot may be simply twist- ed outward and upward while the astragalus and os calcis may remain in an approxi- mation to their original de- formity. After thorough over-correction by the Phelps operation the danger of re- currence of deformity in the adult and adolescent type of club foot is not great, and in many instances support other than that of the plaster bandage for several months after the operation may be unnecessary ; but in childhood the ordinary precautions in after-treat- ment to prevent relapse will be necessary. Malleotomy may be employed with advantage in connection with this operation. (See page 590.) Operations on the Bones. Osteotomy of the neck of the astragalus, as a supplementary part of the operation of forcible correction, has been mentioned. In certain instances, particularly in the adolescent or adult type of deformity, the displaced astragalus may oifer such an obstacle to correction that its removal is indicated — an operation first performed by Mr. Lund, of Manchester. Resistant club foot in later childhood. (See Fig. 421.) CUNEIFORM OSTEOTOMY. 599 Astragalectomy. — The astragalus is usually removed by means of an inei^ion passing over its most prominent part, in a direction for- ward and downward from the tip of the external malleolus, between the tendons of the peroneus brevis and tertius. The soft parts are drawn aside, the ankle and astragalo-scaphoid joint are opened and the attachments to the scaphoid, and, as far as possible, those at the inner and outer border, are divided. The foot is then adducted so that the head of the bone may be seized with forceps and drawn upward, the interosseous ligament and the internal lateral ligament may be divided with curved scissors and the bone may be removed. If after removal of the astragalus the deformity can not be corrected, the anterior part Fig. 422. Fig. 421. After forcible correction and astragalec- tomy. (See Fig. 420.) Partially corrected club foot showing secon- dary Icnock knee. of the OS calcis or the external malleolus should be removed as well. A useful movable foot may be obtained by this operation, but it by no means assures the patient from recurrence of deformity. It is never indicated as a primary operation. The varus should be thoroughly cor- rected as a preliminary procedure ; then the resistance that the astrag- alus offers to dorsal flexion, can be estimated. (Fig. 4'2].) Cuneiform Osteotomy. — The removal of cuneiform sections of bone from the outer border of the foot is sometimes necessary, but the operation should be secondary to other methods of correction. The aim should be to lengthen contracted and shortened tissues on the inner border of the foot, to the extent required for reposition ; not 600 DEFORMITIES OF THE FOOT. to remove bone to accommodate these shortened tissues. If this has been shown to be impossible by ordinary means, then removal of bone may be indicated, but this is not often necessary in childhood or even in adolescence. If sufficient bone is removed from the adult foot to allow of perfect correction of the deformity, relapse is not usual ; but in childhood, as has been stated, no operation will take the place of after-treatment. The treatment by cuneiform osteotomy as it is ordinarily carried out is sufficiently simple. In severe cases, the astragalus is usually re- moved and a wedge-shaped section of bone is taken from the os calcis, cuboid, and if necessary it may include the scaphoid bone also. The external malleolus may be removed, if it interferes with reposition. Preliminary fasciotomies and tenotomies are usually performed, but those who favor this method of treatment rarely use force in reposition. In less advanced deformity the astragalus is not removed but a part of its body and neck is included in the cuneiform resection. The foot is retained in proper position until the wounds are closed ; then plaster bandages are employed for several months. Braces are seldom used in the after-treatment. Secondary Osteotomy. — In certain cases of relapsed or ineffect- ively treated club foot, even in childhood, deformity of the os calcis either interferes with correction of the foot or favors relapse. In such instances the removal of a cuneiform section of bone from the anterior extremity, as a supplementary part of over-correction, may be of service. Simple Mechanical Rectification of Deformity in Walking Children and in Later Years. It has been stated that simple mechanical rectification of deformity was possible even up to adolescence, but that the time required for such treatment, usually extending over several years, as a rule ex- cluded it from consideration. The simplest mechanical treatment is that by which the foot is slowly forced from equino-varus into equino-valgus by a brace on the lever principle, which is at first sliaped to the deformity, and is then gradually straightened as the resistance diminishes. "When the mid- point has been passed between varus and valgus the weight of the body aids in the correction of the remaining varus and equiuus. The modification of the Taylor brace used by Judson, an advocate of pure mechanics in the treatment of club foot, will serve to illustrate the type of apparatus which, with slight change, may be employed to correct or to support the weakened or deformed foot. The brace consists of an upright, a flat tapering bar of mild steel, a foot-plate of steel from 18 to 16 gauge, and a strong calf band. The shape of the brace, the method of its attachment to the leg by straps of webbing and its effect in gradually changing the attitude of the foot from varus to valgus are shown in the accompanying figures. The upright is firmly riveted to the foot-plate in the angle of de- formity, so that the patient must walk upon his toes ; as the equinus SIMPLE MECHANICAL RECTIFICATION OF DEFORMITY. 601 Fig. 423. Fig. 424. ^ The Judson brace. Fig. 423 shows the construction of the brace ; the foot plate with the internal flange or "riser," the upright riveted firmly to it, and the calf band. Fig. 424 shows the brace ad- justed to fit the deformed foot. Fig. 425. Fig. 426. Fig. 427. Showing the progressive reduction of deformity. Fig. 42.5 shows the ordinary attitude of the neg- lected club foot in childhood with the adjustment of the brace, it being beut to accommodate the deformity. Fig. 426 shows additional details — an uprightspur useful in holding the heel, and for the attachment of straps ; the spur of sheet brass that maybe bent over the great toe to hold it in position. Fig. 427 shows other details in the method of attachment, a strip of adhesive plaster with two tails in the place of the band of webbing. This aids in fixing the heel. (See Figs. 428, 429.) 602 DEFORMITIES OF THE FOOT. is decreased by the influence of the weight of the body, this angle is lessened. (Fig. 423.) The important points are, that the brace should be strong enough to hold its place under the strain of use, and that the foot shall be firmly secured to it, whether one or many straps of webbing are required, as may be seen in the figures. The use of massage and manipulation is of course combined with the mechanical treatment. By persistent attention to the details of treatment satisfactory results can be obtained by this method in the less resistant cases, even in adolescence. Recapitulation of the Principles of Treatment of Congenital Talipes Equino-Varus. The object of treatment is to overcome and to over-correct the de- formity, at as early a period of life as is possible, and as quickly as possible. The object of over-correction is to overcome all the resist- ance of the tissues that may Fig. 428. Fig. 429. even in the slightest degree limit the normal range of mo- tion in any direction. The foot must be supported in the over-corrected position until the recoil of the tissues toward deformity is no longer present. It must be supported in the proper relation to the leg, and at a right angle with it, until the muscular balance has been reestablished by stimulation of the weaker, and by limitation of the ac- tivity of the stronger, muscles, and until transformation of the internal structure has been completed. If efficient mechanical treatment is applied at the proper time, that is to say, in earliest infancy, no operation, other than division of the tendo Achillis, will be re- quired. If the deformity is not cor- rected or is but partially cor- rected, when the child has begun to walk, some form of operation is as a rule indicated ; but division of the resistant tissues must always be combined with the employment of sufficient force to accomplish the de- sired result, viz., over-correction of the deformity. Forcible manual cor- Showing the progressive reduction of deformity, and illustrating the process of changing the shape of the brace from time to time until it holds the foot in valgus. (See Fig. 425.) CONGENITAL TALIPES VARUS. 603 rection, applied in the manner described, is the most efficient means of attaining this object. No instrument can equal the hand, and the force that can be applied by the hand is sufficient in all the ordinary cases in early childhood, and in combination with subcutaneous division of the more resistant tendons and ligaments, even in later childhood and adolescence. Forcible correction by the Thomas wrench under the same condi- tions, is an efficient treatment, but there is a manifest disadvantage in submitting a patient to a succession of operations, even of so slight a character, if immediate over-correction can be attained by other means. The Phelps operation, which combines thorough division of the re- sistant parts with the application of proper force to over-correct the foot, is the operation of selection for the more resistant cases in ado- lescence, in adult life, and in extremely resistant cases in childhood. Astragalectomy and cuneiform osteotomy are never indicated as pri- mary operations, but one or the other may be necessary for the com- plete rectification of the deformity when other means have failed. Complete cure of deformity, even in the later years of childhood, is possible by means of braces alone, but such treatment is very tedious. It requires not only the continuous supervision of the skilled surgeon, but the intelligent and persistent cooperation of the parents. The re- sults are in no way superior to those attained by more rapid methods, while the disadvantages of long-continued use of braces are sufficiently obvious. To the popular faith in braces as a cure-all of deformity, and to the unintelligent use of braces, may be ascribed now, as in former times, the failure of treatment of this eminently curable deformity. This statement seems justified, even when balanced by the equally fallacious belief, so prevalent among physicians, that a radical opera- tion, if it does not absolutely assure a cure, is, at least, the essential part of the treatment. Rectification of deformity, by whatever means, simply completes the first stage of treatment. Perfect cure can only be assured by attention to the small details of after-treatment, by checking the slightest im- pulse toward deformity, and by guiding the unbalanced foot toward perfect functional use. Other Varieties of Congenital Talipes. Forms of congenital distortion of the foot other than equino-varus are not uncommon, but as a rule these deformities are so slight, and, as compared to equino-varus, so easily remedied that they are relatively of little importance. This distinction does not apply however to ac- quired talipes which will be considered in the succeeding chapter. Congenital Talipes Varus. Eighty -five cases of simple varus are recorded in the table of statis- tics in a total of sixteen hundred and sixty congenital deformities of the foot. 601 DEFORMITIES OF THE FOOT. This deformity often appears to be an incomplete form of equino- varus, but in some instances there is simply a slight inward twist of the foot without supination (Fig. 376) ; in fact, the forefoot seems to be drawn inward by the active movement of the great toe, which, in such cases, seems almost prehensile. (See pigeon toe.) In the more marked form the foot is adducted and supinated, and the tissues are very resistant. The slight grades of deformity may be treated by simple manipula- tion, and if deformity remains after the first year, the shoe will, as a rule, correct it. The more marked varieties must be treated like the varus deformity of ordinary club foot, by braces or by plaster, until the varus has been transformed into valgus. The after-treatment is the same as that for ordinary club foot. Congenital Talipes Equinus. This is a rare congenital deformity, about half as common, accord- ing to the statistics, as varus (40 cases in 1,660). The term equinus implies that dorsal flexion is limited, but that the foot is not deviated to one or the other side (toward valgus or varus). In congenital equinus the deformity is, as a rule, slight, and in many instances it may be overcome by gentle manual force applied frequently. In the more resistant type, mechanical correction, or tenotomy, followed by over-correction and support, may be necessary. Congenital Talipes Calcaneus. Congenital calcaneus is comparatively rare (28 cases in 1,660). As a rule the heel is prominent, the foot is habitually dorsi-flexed, and the dorsum can be easily brought into contact with the crest of the tibia. (Fig. 386.) The exaggerated cavus, that is usually present in acquired calcaneus, is absent. Occasionally the deformity is accompanied by hyper-extension of the knee, and if, as in many instances, there is a his- tory of breech presentation, it may be inferred that the attitude before birth was one of extreme flexion of the thighs upon the abdomen, the anterior surfaces of the extended legs being pressed closely to the ven- tral surface of the body, the feet being fixed in an attitude of dorsi-flexion. As a rule the deformity is slight, and the resistance of the tissues on the anterior aspect of the leg can be easily overcome by massage and man- ipulation. The foot should be gently forced toward plantar flexion several times in the day, and the weak muscles of the calf should be stimulated by massage. Cure may be hastened by the use of some simple form of retention splint to hold the foot in plantar flexion until the posterior group of muscles has recovered its power. Tenotomy or other operative treat- ment is rarely required. In rare instances, the tibia may be bent slightly backward, thus increasing the deformity. In such cases the distortion of the bone may be overcome by manipulation and by apparatus. CONGENITAL TALIPES VALGUS. 605 Congenital Talipes Valgus. Congenital valgus (Fig. 387) is somewhat more common than the preceding varieties (123 in 1,660). Not infrequently it is combined with a slight degree of calcaneus or equinus. The resistance of the contracted tissues is not great and the deformity may be overcome, in most cases, by persistent manipulation. If the muscular power is suffi- ciently unbalanced to warrant it, the foot should be held in the over- corrected position (varus) for some time. Congenital valgus is one form of what is known as weak ankle, and it frequently passes unnoticed until the child begins to walk. If at that time, in spite of massage, the muscles appear weak or the foot inclines outward when weight is borne, it is well to make the sole of the shoe Fig. 430. Congenital calcaneo-valgus. wedge shaped, the thicker part (one-quarter of an inch) on the inner side. In more persistent cases, a brace may be necessary, as described in the treatment of the acquired variety. (See the weak foot.) Talipes equino-valgus is less common (28 in 1,660). This must be treated as the other varieties, by complete over-correction of de- formity, manual or otherwise, and by subsequent massage and support if necessary. Calcaneo-valgus (15 in 1,660), calcaneo-varus (7 in 1,660), equino- cavus (1 in 1,660), valgo-cavus (1 in 1,660), cavus (5 in 1,660), are extremely rare as indicated by the statistics. If treated early, by per- sistent massage supplemented by retention apparatus, these, as well as nearly all slighter grades of congenital deformity, may be corrected and cured even, before the child begins to walk. 606 DEFORMITIES OF THE FOOT. Congenital Deformities of the Foot Associated with Defective Development. Talipes Equino-Valgus Associated with Congenital Absence of Fibula. This is a rare deformity, but the most common of this class. The foot at birth is usually in an attitude of well-marked and resistant equino-valgus. The leg is somewhat shorter than its fellow and the tibia is often bent sharply forward, sometimes to an acute angle, at a point somewhat below the center, as if it had been broken in utero. At the most prominent point the skin may be adherent or it may present Fig. 431. Congenital equino-varus with deformity of the great toes. a dimpled appearance. In some instances the formation of the foot is perfect, but more often one or more of the outer toes, with the corre- sponding metatarsal bones, are absent. Statistics. — Haudek collected from the literature 97 cases ; of these 46 were in males, 21 were in females and in 30 the sex was not re- corded. In 67 (69 per cent.) there was total absence of the fibula. In 30 the defect was partial ; of the lower extremity of the fibula in 17, of the upper extremity in 9, and of the middle in 2 cases. In 27 cases both fibulae were absent or defective ; in 68 one only, the right in 31, the left in 25, and in the others the side was not recorded. In 61 cases toes were lacking, and in these cases it may be inferred that the corresponding metatarsal bones were absent also. The fourth and fifth toes were absent in 27 cases, the little toe alone was missing in 15. TREATMENT. 607 In manv instances, as is usual in cases of defective development, de- formity of other parts was present ; for example in 1 7 instances the patella was absent or undeveloped, and in 11 the upper extremities were defective/ Etiology. — The cause of deformity associated with absence of bone, may be either an original defect in the germ or it may be due to inter- ference with its development. In some instances amniotic adhesions may be one of the predisposing causes ; the sharp bend in the tibia, so often present, may be due to the lessened resistance of the defective part. Treatment. — The indications for treatment are to correct the de- formity of the foot in the usual manner. The bend in the tibia may be straightened by manipulation and splinting, or by osteotomy, if necessary. When the patient begins to walk the foot must be sup- ported. A light steel upright on the outer side of the leg, provided with a T strap to hold the leg against it, will supply the place of the missing fibula. The growth of the tibia is retarded, and a final short- ening of three or more inches may be expected, but with care a useful limb may be assured. Talipes Varus or Equino-varus Associated with Congenital Absence of the Tibia. — Defective formation of the tibia is much less common than that of the fibula. Joachimsthal ^ records 31 cases. Of the 25 cases in which the sex was recorded, 17 were males and 8 females. In 23 in- stances the defect was of one side ; in 8 both tibise were defective. In most cases the femur is somewhat shortened and its lower extremity is imperfectly developed. In a third of the cases the patella was absent, and in many instances other malformations were present. In nearly all the cases there was flexion contraction at the knee and the fibula was dislocated backward. The foot is practically always in an attitude of varus. The toes may be normal, but in a number of instances, the great toe was lacking. In possibly a third of the cases a portion of the tibia, usually the upper extremity, was present. The prognosis, as regards a useful limb is extremely bad. The growth of both the thigh and the leg is much retarded, and it is almost impossible to balance the foot upon the fibula by any form of brace. The ordinary treatment, after the correction of the deformity of the foot, has been to resect the extremities of the femur and the fibula to induce anchylosis. No final results have been reported but it may be assumed that an artificial limb would provide a more useful support than the short and distorted extremity. Congenital Deficiency and Hypertrophy. — The leg bones may be per- fectly formed, but one or more bones of the foot itself may be absent. In these cases, after the reduction of the deformity, a support to hold the defective foot in its proper relation to the leg must be used. 1 Vide also Schworer, Zeits. fiir Orth. Chir., Vol. III., p. 220. Kempke, Zeits. fiir Orth. Chir., Vol. III., p. 93. Gotten & Chute, Boston Med. and Surg. Jour., Nos. 8 and 9, 1898 (128 cases). Mazzitelli, Arch. Ortopedia, 1898, F. 5. Boinet, Kevue d'Orthopedie, Nov., 1899. 2 Zeits. fiir Orth. Chir., Vol. III., p. 140. 608 DEFORMITIES OF THE FOOT. The foot may be divided into two parts, so that it resembles a lobster claw. Supernumerary toes, or deficiency of toes, or hypertrophy of one or more of the toes, with or without corresponding over-growth of the foot or leg, are not extremely uncommon. These deformities must be treated on ordinary surgical principles. Constricting Bands. Tightly constricting bands of scar-like tissue, which cause deep in- dentations in the flesh of the foot or leg, are sometimes seen. These are supposed to be caused by amniotic adhesions. " Spontaneous am- putations " of toes, or of the foot itself, are due to the same cause. (Fig. 390.) |In ordinary cases, the bands require no treatment, but if they inter- fere with the nutrition of the foot, they may be removed. Congenital (Edema of the Feet. In rare instances, sometimes in combination with deformity, the tissues of the feet appear to be oedematous, although the circulation seems to be perfect. The condition is apparently due to obstruction of the lymphatic circulation. It should be treated by massage and by compression. Spina Bifida and Talipes. Talipes, coexisting with spina bifida, should be treated as are other forms of club foot. If paralysis of the lower extremities be present, as is often the case, the corrected feet must be supported as in the or- dinary forms of paralytic deformity.' ^ Uber missbildungen der Menschilichen Gliedmassen und ihre entsteliungsweise, Klausner, 1900. CHAPTER XXllI. DEFORMITIES OF THE FOOT.— Continual. Acquired Talipes. In the account of the cougenital deformities of the foot it was stated that the form known as equino-varus was by far the most common, and that as compared with it, the other deformities were of slight im- portance. In the acquired varieties of talipes, the equino-varus deformity is much less common, the proportion being, in the congenital form, 77 per cent, and in the acquired 32,5 per cent, of the total number. Ac- quired equinus comes next in frequency, 26 per cent., as compared with 2.4 per cent, of the congenital deformity, and every variety and combination of deformity finds its representative in acquired talipes, as may be seen in the tables. (See page 568.) The Etiology of Acauired Talipes. — The cause of acquired talipes is almost always paralysis. In the table of statistics, it will be seen, that in 82.8 per cent, the paralysis was of spinal origin (anterior poliomyelitis). In 11.3 per cent, it was cerebral, the talipes being a part of the deformity of hemiplegia or paraplegia. A few cases were caused by local disease or injury of the nerves, and the remainder, or 5.4 per cent, were of traumatic origin. The distinction between the two forms of talipes, congenital and ac- quired, has already been emphasized. In the congenital form the de- formity is the essential disability, for when deformity has been over- come the most difficult part of the treatment has been accomplished and perfect cure may be expected. In the acquired form, the removal of deformity is but a. part of the treatment, and perfect cure is not to be expected, except in that small proportion of cases in which the primary disease of the spinal cord has caused no permanent injury to its structure, or in which the deformity was the result of some slight or passing disability or disease. Again, congenital deformity cannot be anticipated or prevented. Acquire! talipes is an effect of paralysis only when protective treatment has been neglected. It is a result there- fore that may be foreseen and thus, by proper treatment, prevented. Development of Deformity. — The characteristics of anterior poliomyelitis are described elsewhere. (Chapter XVII.) In its effect upon the foot the usual sequence is somewhat as follows : Immediately after its onset the paralysis is usually widespread, affecting the entire leg for example ; then follows a period of partial recovery, after which the amount of damage that the spinal cord has sustained may be esti- 39 610 DEFORMITIES OF THE FOOT. mated. It is during the period of partial recovery, the six months or more following the attack, that contractions, which lead to deformity, appear. If, for example, the anterior group of leg muscles is paralyzed, th^ foot habitually hangs downward, a position caused by the force of gravity and by the contraction of the unaffected posterior group. If this attitude is allowed to persist, the tissues accommodate themselves to the new position ; the muscles which are never extended to their normal limit, become structurally shortened, while the paralyzed group becomes elongated. Even within a few weeks after the onset of the paralysis, the evidences of advancing deformity are plain. The con- tracted tissues resist passive motion in the directions opposed to the habitual attitude, and the child shows evidence of pain if force is used to increase the limited range of motion. As has been stated already, paralytic talipes is an unnecessary deformity. It may be prevented by supporting the paralyzed part in a right-angled relation to the limb, and by systematic passive exercise throughout the entire range of normal motions ; thus improper attitudes and the secondary contrac- tions that fix the foot in the distorted position may be avoided. Anterior poliomyelitis is most common during the second year of life, or when the child has already begun to walk. When the first and more general effect of the disease has passed away, the child again uses the disabled limb as best it may, thus the distortion of the foot is increased and confirmed by the weight of the body and by functional use in the abnormal attitude. The final deformity, in a particular case, can be predicted from the knowledge of the function of the muscle or muscles which has been lost. For example, paralysis of the tibialis anticus, the most powerful dorsi-flexor and adductor of the anterior group, must result in equino- valgus. If the peroneus brevis and tertius are affected varus will fol- low. Paralysis of the calf muscle will cause calcaneus. Paresis or paralysis of the entire anterior group will cause equinus. If all the muscles are paralyzed, what is called a dangle foot is the result ; the cold atrophied member dangles from the attenuated limb with but little tendency to deformity unless it is capable of use, when it is usu- ally forced into an attitude of equino- varus or valgus. A slight degree of paralysis may cause so little disability that it may be entirely overlooked, and its later effect in causing disability or de- formity may not attract attention for many years. This fact has been mentioned in the etiology of the contracted foot. Differential Diagnosis Between Congenital and Acquired Deformity. — The history itself usually indicates the etiology, for deformity of the foot at birth is never overlooked by the mother. Acquired talipes is practically always preceded by a history of disease, or weakness, or injury, which was soon followed by slight, and afterward by increasing deformity. In paralytic talipes (anterior poliomyelitis), there is evidence of paralysis in loss of function of certain muscles, as shown by electrical stimulation or by pricking the foot with a pin ; later, in the atrophy ACQUIRED TALIPES EQUINUS. 611 of the niuscles and often in the evident change in the nutrition and diminished growth of the limb. Only in neglected and extreme cases of talipes in the adolescent or adult, could there be difficulty in distinguishing between the ac- quired and the congenital deformity. In rare instances, it is true, paralysis may be present at birth, due to intra-uterine disease or to defect in the nervous apparatus. In such cases the cause of the par- alysis is usually apparent (spina bifida, or spastic paralysis associated with defective cerebral development) and the treatment does not differ from that of the acquired form. Acquired Talipes Equinus. In well-marked equinus, the foot is plantar flexed to its full limit and it is held in this attitude by the shortened structures on the posterior aspect of the leg, of which the tendo Achillis is the most important. The patient walks upon the heads of the metatarsal bones, the toes be- FiG. 432. Acquired talipes equiaus. ing dorsi-flexed to accommodate the deformity. The arch of the foot is increased and the tissues of the sole, particularly the plantar fascia, are contracted. The entire foot is broadened and shortened, the breadth being especially increased across the metatarsal region. (Fig. 385.) Corresponding to the exaggerated depth of the arch, the dorsum pro- jects, the cuneiform bones are prominent, and the head and body of the displaced astragalus may be felt beneath the skin on the anterior surface of the foot. In rare instances, and in those cases in which all the' an- terior muscles are paralyzed, the toes may be plantar flexed so that the patient walks upon their dorsal surface. 612 DEFORMITIES OF THE FOOT The cavus or increased depth of the arch is due primarily to the falling downward of the forefoot at the medio-tarsal joint, and in many instances, this dropping of the forefoot is in great degree re- sponsible for the equiniis ; in fact the os calcis is rarely plantar flexed to the degree commonly found in the ordinary congenital equinus. In the slighter degrees of the deformity when the patient still walks upon the sole of the foot, the toes are usually dorsi-flexed, an attitude due, apparently to the over-action of the extensor longus digitorum and proprius pollicis, as aids in dorsi-flexion. (Fig. 432.) The cases of slight equinus combined with cavus have been de- scribed already under the title of the contracted foot. (Page 534.) The exaggerated arch is a secondary and a late result of the paralysis and of the equinus and in the slight degrees of deformity, particularly in the early stage of the paralysis, it may be absent. Etiology. — Equinus in the slighter degrees is perhaps the most common of the forms of talipes acquired in later life, and it is not at all infrequent as a result of other affections than anterior poliomye- litis, although as has been stated, this is by far the most important cause. The nerve supply of the anterior muscles of the foot seems par- ticularly susceptible, and toe-drop, from neuritis of various types, is not at all uncommon. As a sequel of infectious diseases it has been alluded to as an explanation of the slight forms of equinus first noticed after recovery from such aifections. Equinus may be a result of disease of cerebral origin, or even in rare instances, of pseudo-hypertrophic muscular paralysis or locomotor ataxia. It is sometimes the result of habitual posture, as after long confinement to the bed for the treatment of fracture or during the treatment of hip disease by apparatus ; or the contraction may be an effect of voluntary posture, as when the patient habitually walks upon the toes because of a short leg. It is a very common result of neglected disease at the ankle joint, and it may be a result of direct injury, but as of paralysis, so of these less frequent causes it may be said, that equinus need never follow if the foot is properly supported. The changes in the internal structure of the foot are similar to those that follow other forms of deformity ; the tissues on the long side are lengthened and attenuated, while those on the short side become con- tracted. The bones themselves are but little changed in gross ap- pearance, but the articulating surfaces are in abnormal relation to one another ; for example, only the posterior part of the astragalus may be contained within the malleoli in relation to the tibia, while only the lower part of its anterior surface articulates with the scaphoid bone. In all cases of equinus there is a strong tendency toward lateral de- viation to varus or valgus. This is especially true of cases of par- alytic origin. Symptoms. — The effects of the deformity vary. If the leg is ac- tually shorter than its fellow so that the lengthening caused by the ex- tension of the foot is no more than a sufficient compensation ; and if the foot is firmly fixed in the deformed position, surprisingly little dis- TREATMENT OF ACQUIRED EQUINUS. 613 comfort or disability may be experienced, other than from corns or calluses beneath the metatarsal bones. If the leg is not shorter, the additional length caused by the equinus must be compensated by a tilting of the pelvis and lateral deviation of the spine. This often gives rise to symptoms of discomfort in the lumbar region. The gait in this class of cases is always awkward, giving the impression as of stepping over an obstacle. If the foot is not fixed in the attitude of equinns, that is, if it hangs downward when it is lifted, and is forced into a fairly normal attitude by the weight of the body, the gait is very awkward because of the inse- curity and because of the exaggerated flexion of the knee at each step, necessary in order that the pendant foot may not drag upon the ground. If the equinus is extreme, the limb is usually flexed at the knee when in use ; if the equinus is slight the strain resulting from the limita- tion of dorsal flexion is felt at the knee, and in childhood at least, there is often a well-marked tendency to over-extension, or recurva- tura, caused by the eflbrt to place the sole flat on the ground. In the slight forms of equinus, discomfort about the calf is experi- enced ; the limitation of dorsal flexion causes a rather shortened stride and awkward gait, while an unguarded step, that throws a sudden strain upon the rigid heel cord, is felt as a shock and strain through the leg and body. Very often the patient complains of pain about the metatarsal bones (anterior metatarsalgia), and if the equinus is accompanied by a slight degree of valgus symptoms of the weak foot may be present. The prognosis as to permanent cure depends of course upon the cause of the deformity. When it is simply the result of posture or of the ordinary form of neuritis and the like, permanent cure may be ex- pected. In many of the cases that have followed anterior poliomyelitis, recovery, complete or partial, of the original injury to the spinal centers has followed ; yet although voluntary control of the muscles has been regained it cannot be exercised because the foot is held in the distorted position by the contracted tissues. In such instances practical cure may be predicted, if after the over-correction of deformity suflicient time is allowed for the over-stretched and atrophied muscles to regain their proper length and volume. Treatment. — In the rare cases of fixed equinus combined with a short leg, in which the patient suffers no symptoms, it is well to allow the position to remain, a shoe being so built that the heel may support a part of the weight. In the more extreme cases in which the leg is short and the foot is atrophied, an extension foot attached after the manner of an artificial leg may be worn with comfort and with but little evidence of deformity. In the ordinary cases whether permanent cure is expected or not, the rule holds good that the heel should bear the weight of the body, and that the range of dorsal flexion should not be limited when the calf muscle retains its power. If the nervous apparatus has received per- manent injury, the foot must be supported after the deformity has been 614 DEFORMITIES OF THE FOOT. Fig. 433. rectified, but even in this class, the gait may be improved and the discom- fort may be relieved by removing the restrictions to normal motion. The slight degrees of equinus, such as those that are seen soon after the onset of anterior poliomyelitis, may be overcome by simple ma- nipulation and retention in a splint or in a plaster bandage. In more resistant cases, in older subjects, more force may be exerted ; for ex- ample, the patient being seated extends the limb ; the surgeon stands in front of him, one hand holds the leg firmly at the ankle, and the other grasps the foot ; the weight of the body is then thrown against the resistant tissues over and over again with as much force as is consistent with the comfort of the patient. The Shaifer extension brace is also a useful appliance, and especially so be- cause it may be employed to reduce the accompanying cavus at the same time. The weight of the body as a means of overcoming equinus, when the foot is- held in its proper relation to the leg by a brace, has already been mentioned, but this tedious method has but little to recommend it in ordinary cases. The elastic tension of straps and bands at- tached to a brace or to the foot itself by means of adhesive plaster is of some ser- vice in slight cases, but by far the most effective method is the immediate reduc- tion of the deformity, by simple forcible manipulation under anaesthesia, or by tenotomy combined with forcible manip- ulation, or by wrenching. Immediate Correction of Deformity. — Attention has been called to the cavus as an important element in equinus, and whenever one attempts to correct the equinus deformity by force, the exaggerated arch should be reduced to its normal depth, otherwise the foot will appear stunted and deformed. One of the most effective procedures is forcible reduction by means of the Thomas wrench. (Fig. 417.) The resistant bands of the plantar fascia are first divided subcutaneously, the wrench is then fixed to the foot and with sudden force, exerted against the resistant tendo Achillis, the foot may be straightened, the deep ligaments being ruptured or stretched to the proper degree. The tendo Achillis is then divided, a wooden foot plate is placed against the sole, and the foot, having been dorsi-flexed, is fixed by a plaster of Paris bandage. As the patient is encouraged to walk upon the foot as soon as pos- sible, the weight of the body forcing the relaxed tissues against the un- yielding board incorporated in the plaster completes the flattening of the arch. In many of these cases, tlie knee has been over-extended by A brace to prevent foot-drop. One upright is often sufficient. THE TONIC EFFECT OF IMMEDIATE COBBECTION. 615. use in the deformed attitude, so that the habitual flexion necessary io bring the dorsi-flexed foot upon the ground, during the two months al- lowed for the complete union of the divided tendon, is of benefit, as it serves to correct this secondary weakness and deformity. The Tonic Effect of Immediate Correction. — The impor- tance of the tonic effect of immediate relief of the strain of the de- formed position upon the weak anterior group of muscles, together with the complete relaxation of the over-stretched tissues, during the long rest in the over-corrected position, is not generally appreciated. Whenever the weakened muscles, after paralysis, show by tests electri- cal or otherwise, that they have recovered their power in part, this Fig. 434. An effective and inconspicuous support for paralytic toe-drop. An upright of light tempered steel, carefully adjusted to the inner side of the leg and ankle provided with a light calf band. This is strengthened by a posterior support attached to the upright. The lower end of the brace is arranged as a caliper and is fitted to the metal disc of which two views are shown. A depression is cut in the heel of the shoe for the disc as is shown in the diagram. Two strong elastic tapes are sewed to the leather of the shoe. These are attached to the studs on the front of the calf band and thus the toe- drop is prevented. (See Fig. 435. ) treatment should be that of selection. The application of electricity or other form of stimulation to muscles that are unable to exercise their function because of contraction of the opposing tissues is absolutely useless. Nor is any form of artificial stimulation equal to that of the functional use, which is made possible by the removal of the deformity and by the employment of proper support. Equinus, more often than any other deformity, is the result of slight or temporary disability of the anterior group of muscles, and not infre- 616 DEFORMITIES OF THE FOOT. Fig. 435. quently perfect cure seems to have been attained when the plaster bandage is finally removed, usually at the end of two months or more. But even in such cases, the application of a simple support to hold the foot at a right angle with the leg for several months, is of ad- vantage. The after-treatment by massage, muscle-beating, electricity, and the like, combined with methodical passive movements to the limit of dorsal flexion, to guard against recontraction of the calf muscle, should be continued for a long time, or until the muscular bal- ance has been regained. The same form of support is necessary in cases of hopeless pa- ralysis, to hold the foot at a right angle with the leg. The common form is a simple steel sole plate of sufficient size to support the foot and the toes, if their muscles are paralyzed, attached to a light up- right, provided mth a calf-band. The upright is usually applied on the inner side of the leg, where it is least noticeable. At the ankle, there is a " stop joint," which allows dorsi-flexion but prevents the toe-drop. This, when properly fitted, can be placed inside the ordinary shoe, as the paralyzed foot is usually somewhat smaller than its fellow. (Fig. 433.) If the toes do not need support, the up- right can be attached to the out- side of the shoe and the foot plate may be dispensed with. Or, the upright may be concealed by in- troducing it inside the shoe to a joint sunk in the heel ; the toe- drop being prevented by straps passing from the front of the upper leather of the shoe, to the calf-band. (Fig. 434.) Equinus, due to posture or to disease, may be cured by simple cor- rection of the deformity. That due to fracture, when the deformity is caused by displacement of the bones, may be treated by direct opera- tion or by the removal of a cuneiform section from the anterior surface of the tibia above the ankle. (See tendon grafting and arthrodesis.) The same appliance (Fig. 434) provided witli a foot plate of metal or of wood as sfiown in the dia- gram. This modification is useful if the paralysis is complete or if the foot is much atrophied. Acquired Talipes Calcaneus. Acquired talipes calcaneus is much less frequent than equinus and it is practically always of paralytic origin (anterior poliomyelitis), although DEVELOPMENT OF DEFORMITY. 617 Fig. 436. cases o^ calcaneus following injury or disease or distortion of the limb are occasionally seen. There are several varieties or grades of the deformity. In the early stage, and especially if all the muscles of the posterior group have been paralyzed, the foot assumes an attitude of slight dorsi-flexion and the range of plantar flexion is gradually lessened by secondary contrac- tions. This variety resembles closely the congenital form. (Fig. 386.) In the ordinary and typical form of calcaneus, when fully developed, the patient walks, as the name implies, on an elongated heel. The arch of the foot is much increased in depth, and the forefoot is atrophied and useless. Development of Deformity. — The development of the de- formity is somewhat as follows : When the tension of the calf muscle is removed the os calcis gradually assumes an attitude of extreme dorsi-flexion. It stands on end so that its posterior surface becomes inferior. The posterior projection of the heel is lost and it lies in the plane of the atrophied calf. The change in the position of the os calcis increases the distance from the malleoli to the ground, thus calcaneus though in less degree than equinus, makes the leg longer. The turning of the heel on end, thus lengthen- ing one of the terminations of the arch, in- creases its depth and at the same time shortens the length of the foot so that cavus, in more marked degree than with equinus, accompanies calcaneus. The cavus is a later complication of nearly all cases of paralytic calcaneus. In many instances there is no permanent dorsi- flexion or elevation of the forefoot, although in all, the range of plantar flexion is limited. In this class the power in the remaining muscles of the posterior group is probably sufficient to counteract the contraction of the dorsi-flexors. Cavus is thus a direct effect of the displacement of the os calcis. If the entire posterior group of muscles is paralyzed, while the anterior muscles are unaffected, the foot will be somewhat dorsi-flexed and the cavus will be less marked. If the calf muscle only (gastrocne- mius and soleus) is paralyzed, the remaining muscles of the posterior group will counterbalance the dorsi-flexors, and at the same time in- crease the cavus. In some instances the calf muscle is alone affected, in others one or more of the anterior muscles may be paralyzed also, in which case the foot is usually turned toward varus or valgus. The changes primarily caused by the paralysis and by unopposed muscular action become fixed by habitual use, and by secondary adaptation of the tissues. The heel only, is used in walking, and the area of callus which marks the weight-bearing surface becomes much enlarged, while the Paralytic caloaneo-varus. 618 DEFORMITIES OF THE FOOT. forefoot and toes which have bat little functional use become atrophied, a mere appendage to the enlarged heel. (Fig. 439.) Symptoms. — The gait is awkward and inelastic, the patient, who is as it were " ham-strung," stamps along upon the insecure support of the heel in a manner which is easily recognizable by one familiar with the deformity. The changes in the internal structure of the foot, the inevitable adaptations to the deformity do not call for especial de- scription, the disused bones atrophy together with the other tissues, and new articulating surfaces form to accommodate the necessities of functional use. Treatment. — The essence of successful treatment is prevention. When the diagnosis of paralysis of the calf muscle is made, one may predict, unless recovery takes place, a deformity such as has been de- scribed. This deformity may be prevented by proper support, by Fig. 437 Fig. 438. Judsou's brace for calcaneous deformity. massage and methodical stretching of the tissues that have a tendency to contract. The form of brace used for walking and support, should be provided Avith a sole plate, upright and calf-band, as already de- scribed in the treatment of paralytic equinus. If motion is allowed at the ankle it should be in plantar flexion only, the stop being the reverse of that used in equinus, or as this form of check entails much strain upon the brace, the joint may be omitted as in that form used by Judson. (Figs. 437, 438.) Thus the strain, removed from- the weakened tissues, is borue by the anterior surface of the leg. Other forms of braces are sometimes employed, provided with elastic bands to supply the place of the calf muscle, but as a rule the improvement in gait hardly compensates for the trouble in adjustment or the con- spicnousness of the appliance. The most important part of the actual deformity of calcaneus is the WILLETT'S OPERATION FOR CALCANEUS. 619 cavus, in great part due to the changed position of the os calcis ; and in confirmed cases it is practically impossible to reduce this except in part, because the loss of resistance of the tendo Achillis takes away the point of fixation, against which effective force can be exerted. If the deformity is not marked, the foot may be drawn as far as possible toward equinus and fixed in a plaster bandage, the sole part being strengthened by the insertion of a thin board. Upon this the patient may walk, the heel being built up with cork wedges to make the sole level. When the contraction of the anterior tissues has been overcome, the brace is applied and the usual treatment of manipulation and mas- sage is continued. The method of pro- Fig. 439. longed fixation in the atti- tude of equinus by means of the plaster bandage is often very efficacious in childhood and cures of ap- parently hopeless cases by this means have been re- ported.^ Operative Treatment. — In more extreme cases im- mediate reduction of the deformity under anaesthe- sia may be attempted. The plantar tissues, more particularly the plantar fascia, may be divided subcutaneously or by open incision and by forcible manipulation or wrench- ing the sole may be some- what lengthened and the heel pushed somewhat up- ward and backward, so that the foot may be fixed in a plaster bandage in slight plantar flexion. In the reduction of the deformity one must not force the forefoot downward as this would simply increase the cavus, but whatever correction is accomplished should be by means of elevation of the os calcis and elongation of the tissues of the sole of the foot. In some instances the improved position of the os calcis may be confirmed by shortening the tendo Achillis, as first performed by Wil- lett, of London.^ Willett's Operation for Calcaneus. — A Y-shaped incision about two inches in length is made through the tissues down to the tendon. At 'Gibney, Trans. Am. Orth. Ass'n, Vol. XIII., 1900. 2 St. Bart's Hosp. Keports, Vol. XVI., 1880, p. 309. Paralytic calcaneus, showing secondary changes in contour. 620 DEFORMITIES OF THE FOOT. Fig. 440. the lower or vertical part of the iucisiou, which is continued down to the tuberosity of the os calcis, the tendon is dissected free from the sur- rounding parts. It is then divided in an oblique direction from within outwards, and downwards, and the heel having been pushed upward as far as possible, the divided ends are overlapped and sutured ; the flap of skin is drawn downwards at the same time, so that the Y-incision is converted into the shape of a V. According to Mr. Willett's original directions, deep sutures are passed through the skin flaps and through the tendon on either side, so that all the tissues are united. The foot is then fixed in a plaster bandage, and the patient is allowed to walk about wearing a high heel to compensate for the elevation of the sole. The operation is of value in those cases in which some power remains in the calf mascle, which is thus made serviceable. In cases of complete paralysis the position of the foot may be temporarily improved, but unless proper support is used afterward the tissues will stretch under the strain of use ; thus the treat- ment should always be supplemented by a brace of the character already de- scribed. (Fig. 438.) Astragalectomy and Backward Dis- placement of the Foot. — In cases of con- firmed calcaneus or calcaneus combined with lateral deformity, varus or valgus, removal of the astragalus may be in- dicated. This operation permits the direct contact with the os calcis, thus Paralytic varus and valgus. (Gibney.) malleoli to be brought into increasing the security of the foot. The astragalus may be removed by a long, curved, external incision passing from the tendo Achillis just below the outer malleolus to the front of the joint. The peronei tendons are divided, the foot is dis- placed inward and the astragalus is removed. The articulating sur- faces of the leg bones and of the os calcis, are denuded of cartilage ; the tendo Achillis is shortened and to it the peronei tendons are at- tached if the muscles are active. The entire foot is then displaced backward so that the denuded malleoli overlap the anterior extremity of the OS calcis. The object of this procedure is to throw the weight of the body upon the center of the tarsus ; thus the deformity is reduced and the stability of the foot is increased. The wound is closed and the foot is fixed in plaster of Paris. As soon as possible the patient uses the foot in standing and walking. Ultimately apparatus may be dispensed with, but the Judson brace may be used for a time with ad- vantage. This operation has been performed in many instances by Fig. 441. The muscles and tendons on the front of the leg. (Testut. ) From Gerrish's Anatomy. The muscles and tendons on the back of tlie leg. (Testut. ) From Gerrish's Anatomy. 622 DEFORMITIES OF THE FOOT. Fig. 443. the author, for whom it is now the treatment of choice in this type of deformity. (Fig. 438.) By it the usefulness of the foot is greatly increased and its appearance very much improved. Acquired Calcaneo-Valgus and Calcaneo- Varus. In many cases, the foot deformed as a result of paralysis of the calf muscle is in addition turned in a lateral direction, so that the weight of the body falls to the inner or outer side of its center. (Fig. 436.) Calcaneo-valgus in which the foot is turned outward and upward so that the patient walks on the inner side of the heel or even on the inner ankle is not un- common. It is usually a result of more extensive paralysis than simple calcaneus. For example, all the muscles about "the foot may be disabled except the peronei, or in cases of a milder type the tibialis anticus may be the only muscle of the front of the foot that is paralyzed. Treatment. — When the foot inclines toward calcaneo-valgus it is difficult to hold it in proper position. The usual method is to apply the brace, used for ordinary calcaneus, with the upright on the outer side of the foot ; the ankle and arch are then held against it by means of a leather strap. Another form of brace is provided with an upright on either side of the leg, the outer being slightly longer than the inner so that the sole plate is tilted inward, or as it were supinated; thus the weight is guided towards and balanced on the outer side of the foot. It must be borne in mind that other mus- cles of the limb are often paralyzed, so that the deformity of the foot may be but a part of more general distortion, so that the foot brace is often combined with ap- paratus for the support of the leg. (Fig. 314.) In the more extreme cases the deform- ity may be reduced, and the stability of the foot may be increased by the removal of the astragalus in the manner described. Calcaneo-varus is a much less serious affection, since the foot may be more easily supported. A brace, such as is used in the treatment of ordinary varus, without motion at the ankle, or provided with a reverse stop, is ordinarily employed. Tendons in the right sole, From Gerrish's Anatomy (Testut. ) ACQUIRED TALIPES EQUINO-VABUS. 623 ^ Acquired Talipes Equino-varus. Talipes equino-varus is, in the acquired as in the congenital form, the most common of the deformities of the foot. (Fig. 440.) The tendency of simple equinus is usually toward varus, because in plantar flexion the foot is slightly adducted, and because the outer side of the foot is shorter than the inner side so that in walking with the foot extended the tendency of the foot is to turn somewhat inward. Equino-varus is usually preceded by equinus, and the etiology of the one will serve for the other. (Page 612.) In certain cases the varus is more marked than the equinus, as for example when the abductors of the foot are paralyzed while the adduc- tors retain their power ; or in cases of direct injury as in fracture at the ankle ; or when the growth of the tibia has been arrested as the result of injury or disease. A detailed account of the appearance and effect of the deformity is unnecessary. In the early stage of the paralysis it may be reduced easily ; the foot must then be supported by a brace, of which the Taylor €lub foot apparatus is the type. (Fig. 410.) During the night the over-corrected attitude may be assured by a strap running from the up- right to the sole plate. If the deformity is fixed it should be reduced and over-corrected by forcible manipulation under anaesthesia. Division of resistant parts is less often necessary than in the congenital form, but it may be re- quired in neglected cases. The over-corrected position should be re- tained until time has been allowed for the recontraction of the length- ened tissues ; for as has been mentioned in the treatment of equinus, over-correction and rest is by far the most effective treatment that can be applied to a weak or paralyzed part. A support is then used of the character indicated. Astragalectomy and cuneiform osteotomy are rarely indicated, but the latter operation is sometimes of service in checking the tendency toward recurrence of deformity, which is more marked after over-cor- rection in the paralytic than in the congenital talipes. Acquired talipes equino-valgus is much less frequent than the preced- ing deformity. Simple equino-valgus is usually the result of primary paralysis of the tibialis anticus, the most powerful of the dorsal flexors ; thus the foot is drawn somewhat outward when dorsi-flexed, while the metatarsal bone of the great toe, having lost the support of the tibialis anticus muscle, falls downward and is drawn outward by the peroneus longus. In this type one's attention is often attracted by the peculiar appearance of the great toe, which is deformed somewhat like a ham- mer toe by the over-action of the extensor longus pollicis, in its attempt to take the place of the tibialis anticus. The equinus is usually slight and is secondary to the valgus. Treatment may be begun by placing the foot in a plaster bandage in an attitude of varus and allowing the patient to walk upon it until the tendency toward deformity has been overcome. A support with the catch, as for toe-drop, is applied to the 624 DEFORMITIES OF THE FOOT. shoe, and the tendency toward valgus is checked by raising the inner border of the sole or by the use of a sole plate, as in the treatment of the simple weak foot. (Fig. 440.) Acquired simple talipes valgus, from paralysis of the tibialis anti- cus and posticus is rare. Talipes valgus, as when the foot is dislo- cated outward, in cases of complete paralysis of all its muscles, may be considered as a variety of dangle foot. Traumatic valgus and ecLuino-valgus, caused by fracture at the ankle (Pott's fracture) may be treated by osteotomy of the tibia above the ankle. By this means the proper relation of the leg to the foot may be restored in many instances. Equino-valgus of slight degree is not uncommon after tuberculous or rheumatic disease at the ankle or at the astragalo-scaphoid joints. This is practically one variety of the weak foot. Talipes valgus, sometimes called spurious valgus, the simple weak or flat foot, has been described elsewhere (Chapter XX.). Talipes caused by cerebral disease, whether of the paraplegic or the hemiplegic type, is almost always of the form of equino-varus in early childhood. In adolescence the deformity may be equino-valgus or even calcaneo-valgus if there is extreme flexion at the knee. The hemiplegic form of talipes is much more rigid and unyielding than the paraplegic type. The treatment of spastic paralysis, of which the de- formity is a part, is discussed elsewhere (Chapter XVIII.). The deformity must be corrected by the ordinary methods. In many in- stances, when the contractions are not marked, mechanical treatment is unnecessary. Hysterical equino-varus, or other form of deformity, is not espe- cially rare. The diagnosis may be made from the other symptoms of hysteria, from the history of the onset and duration of the distortion, and from the appearance of the deformity, which is evidently merely an assumed posture. (See page 471.) Tendon Transplantation for the Relief of Paralytic Talipes. When one or more of the muscles are paralyzed the unbalanced action of those that remain tends to distort the foot. The object of the brace, in such cases, is to hold the foot so that the muscular trac- tion, however applied, can move it only in the proper directions. The object of tendon or muscle transplantation is to utilize the mus- cular power that remains. Thus by giving an active muscle a new point of attachment where it may be of greatest service the brace may be dispensed with, or made less burdensome. Tendon transplantation is, as the name implies, the operation of at- taching the tendon of a living to that of a paralyzed muscle. The first operation was performed by Nicoladoni in 1882,^ for the relief of paralytic calcaneus. The tendons of the peroneus longus and brevis were divided behind the external malleolus, and the proximal ends 1 Ai-cliiv f. Klin. Chir., .'{, 27, S. 660, 1882. TEND ON TBANSPLANTA TION. 625 Fig. 444. united to the distal extremity of the divided teudo Achillis. The re- sult is said to have been satisfactoiy. The first operation on the front of the foot was performed by Parish/ of New York, for the relief of paralytic valgus, by sewing the tendon of the extensor proprius pollicis to that of the paralyzed tibialis anticus, without division of either tendon. In more recent years the field of the operation has been extended by Drobnik, of Posen," Goldthwait,^ of Boston, and others, to include almost every possible combination of tendons and muscles. Tendon transplantation is most effective from the curative stand- point when but one muscle of the anterior leg group, for example an adductor or abductor, is para- lyzed. The most common form of this milder type is paralysis of the tibialis anticus. As this muscle is the most powerful dorsal flexor and adductor of the foot its loss is followed by secondary equino-valgus. In Parish' s operation the tendon of the adjoining extensor proprius pollicis was simply attached to that of the tibialis anticus, but as the extensor of the great toe is a very weak muscle, its power is hardly sufficient for the double task. A more efficient proced- ure is to split the tendon of the paralyzed muscle. The outer half is then separated from its muscular attachijient, and the distal extremity is carried across the foot and is sutured to all the other tendons. The proprius pollicis is then attached to the inner half. In cases of longer standing and more marked de- formity it is well to reduce the power of the abductors by cutting the tendon of the peroneus tertius from its insertion. This is then drawn beneath the other tendons and is attached to that of the tibialis anticus. All of the tendons on the front of the ankle may then be sutured to one another, so that all may act as direct dorsal flexors. If varus has resulted from paralysis of the peroneus tertius or brevis, or because of weakness of the extensors of the toes, while the Paralytic equino-varus before operation. (See Fig. 4-15.) IN. Y. Med. Jour., Oct. 8, 1892. 2Centb. f. Chir., N. 7, July, 1894. 3 Trans. Am. Orth. Ass'n, Vol. VIII., 1896. 40 626 DEFORMITIES OF THE FOOT. the tibialis anticus retains its power its tendon may be split, the outer half having been separated at the distal end may be passed beneath the other tendons to be attached to the peroneus tertius, or a new attach- ment to the tissues on the outer border of the foot may be made. (Fig. 445.) Every variety of combination has been employed. The tendon of the peroneus longus has been brought across the foot and attached to the tibialis anticus for the relief of valgus. The tendons of the flexor longus pollicis and of the peroneus brevis have been attached to the tibialis posticus and a portion of the inner part of the tendo Achillis has been utilized for the purpose of overcoming the same deformity. Other operations on the back of the leg have been practically that of Nicoladini, the transplantation of the two peronei muscles into the Fig. 445. Paralytic equino-varus cured by operation, showing power of dorsal flexion (one half of the tendon of the tibialus anticus attached to the periosteum of the outer border of the foot). Operation July 19, 1898. The direct union of tendons to periosteum at the most advantageous point, has been urged recently by Lange (Ueber Periostale Schnenverplanzung bei Lahmung, Munch, med. Woch., No. 15, 1900). tendo Achillis ; or, as modified by Goldthwait, the tendon of the per- oneus longus was inserted into the tendo Achillis and the brevis was transplanted into that of the flexor longus pollicis. The operation of tendon transplantation should not be performed until the recovery from the paralysis is considered impossible. The incision should be sufficiently long to expose the tendon and the mus- cular substance. The paralyzed muscle is quite different in color from the normal, being dull reddish yellow, and the tendon is usually dull white in place of the silvery glistening color of the normal tendon. The splitting of the tendon should be begun high up, including, in some instances, muscle substance, and in joining the splices, as much TENDON TRANSPLANTATION 627. surface as possible of each splice should be apposed because the tendons do not readily unite. Fine silk is usually employed for suturing. The tendon sheaths are, as far as possible, closed by fine catgut and the skin incision with the same material. Before the operation is performed, all resistance to normal motion should be overcome by force, and by division of the contracted parts, if necessary. The attachment of the muscles or ten- dons should be made while the foot is held in proper position, and in many instances, it is well to cut and overlap the paralyzed tendons to aid in retaining the foot in the improved attitude. After the operation is completed, the foot should be fixed in a plas- ter bandage, in the over-corrected position, for several weeks or more. Fig. 446. Talipes equino-valgus after treatment by tendon transplantation. The tendon of the peroneus ter- tius was attached to the overlapped and shortened tendon of the tibialis anticus. All the tendons on the front of the foot were then united, so that all might serve as dorsal flexors. As a rule, the foot should be supported by a brace until it is evident that the union of the parts is firm, and until the functional result is assured. The prognosis will depend entirely upon the character of the par- alysis. If the tibialis anticus is alone affected, sufficient power may be borrowed from the other muscles to lift the foot at least suificiently to prevent awkwardness of gait, and to restrain deformity. Even more favorable is the prospect for the relief of varus, caused by weak- ness of the abductors, but it is impossible for weak muscles like the peronei, to supply the place of the great calf muscle or even to restrain the deformity of calcaneus. The power obtained from the peronei however, which has become useless and even harmful because it draws the foot into deformity, may be sufficient to hold the heel in proper 628 DEFORMITIES OF THE FOOT. position and at least to aid the brace in retaining the foot in a normal attitude. The origin and insertion of the muscles, are shown in Figs. 340-350 inclusive. The relative strength of the muscles, as well as their function, should be considered in selecting grafts, and in prognosis also. According to Fick, it is as follows, in kilogrammeters (see page 503) : Back of the Leg. The calf muscle — gastrocnemius and soleus 8.21 Tibialis posticus 0.40 Peroneus longus 0. 44 Flexor com. digitorum 0.37 Flexor longus pollicis 0.82 10.24 Front of the Leg. Tibialis anticus 1.61 Extensor proprius pollicis 0. 39 Extensor longus digitorum 0. 72 Peroneus bre vis 0.31 Peroneus tertius 0. 20 The importance of the calf muscle on the back, and tibialis anticus on the front of the leg, is apparent. The former is nearly four times as strong as the combined posterior group, the latter equal to all the others on the front of the leg. It has been claimed that the transplanted muscle may become hyper- trophied and that its strength may increase sufficiently to carry out its new function, but this is somewhat doubtful. Direct transplantation of muscles on the same principle as tendon- grafting, has also been performed by Drobnik, Goldthwait and others ; for example, the sartorius, the gracilis, or the tensor vaginse femoris may be transplanted into the substance of the quadriceps extensor muscle. Drobnik has suggested the possibility of regenerating the paralyzed muscle by thus engrafting a portion of one that is still active, but this is a possible rather than a probable outcome.^ The principle of the operation applies of course to other parts of the body as well, but the opportunities for its application are far less fre- quent than in the lower extremities. The transplantation of certain of the over-active flexor muscles to the extensor aspect of the limb is sometimes of service in overcoming the deformities of spastic paraly- sis. The operation may be of especial service in the treatment of de- formity of the hand in hemiplegia. (See page 464.) The operation of tendon transplantation is often indicated, as is illus- trated by the fact that it has been employed in fifty-five instances at the Hospital for Ruptured and Crippled during the past year. The author has always employed long incisions to thoroughly expose the muscles and fine silk for tendon sutures. Tendon transplantation has been combined, as a rule, with tendon shortening, and in many instances all 1 It is impossible to formulate rules for tendon transplantation. The fii-st essential is exact knowledge of the degree and distribution of the paral.ysis in the case to be treated, and of the funcHon and strength of the muscles that remain. One may then decide how this power may be best applied, in order to balance the foot and to over- come deformity. ABTHEODESIS. 629 Fig. 447. the tendons on the front of the foot have been sutured to one another, so that all the power might be utilized for dorsi-flexion. In certain cases the transplanted tendon may be united directly to the periosteum on the inner or on the outer side of the foot, instead of to the para- lyzed tendon. Tendon transplantation may be combined also with other operations, such as astragalectomy, cuneiform osteotomy and the like. Texdox Splicixg. — Division and over-lapping of the tendons of para- lyzed muscles may be employed with advantage in certain instances. For example, in complete paralysis of all the dorsal flexors of the foot, each ten- don may be shortened and attached to the anterior ligament, thus the toe-drop may be remedied, or reduced to such an extent that the deformity may in- terfere but slightly with locomotion. As a rule however apparatus must be employed to prevent a recurrence of the deformity.^ Arthrodesis. Arthrodesis, the removal of the car- tilaginous surfaces of adjoining bones and thus inducing anchylosis for the relief of paralytic deformities of the foot, was first performed by Albert, of Vienna, in 1878. As applied to the foot, it is usually limited to those cases in which practically no muscular power remains, the so-called dangle foot. It may be of service also in cases of less disability as in equinus or cal- caneus, when the patient is unable to provide himself with apparatus. The operation consists in opening the joint and removing the carti- lage from the apposed surfaces of the bones, then sewing or nailing them to one another, or simply fixing the parts in a plaster bandage until union has taken place. If the case is one of simple calcaneus or equinus, without lateral deviation, the operation may be limited to the ankle joint which may be opened from the back or front or side, as seems preferable. The cartilage is usually removed with a sharp spoon, and at the same time the relaxed tissues may be shortened after the Willett method, if the deformitv be calcaneus ; or the tendons on the Alirace with a " Jimited " joint allow- ing slight motion at the ankle for paral- ysis or weakness. ' Besides those mentioned in the text, the following are the more important articles on the suhject of tendon transplantation : Hacker, Wiener Med. Presse, 1886. Phocas, Eevue d'Orthopedie, T. 4, 189.3. Winkleman, Zeits. fiir Cliir., Ed. 39, S. 109. Milleken, N. Y. Medical Eecord, Dec, 1895. Ghillini, Zeits. fiir Orth. Chir., Bd. 4, 1896. F. Franke, Arcliiv fiir Klin. Chir., Bd. 52, H. 1 ; Bd. 57. Eulenbiira-, Deutsche med. Wochens., N. 14, 1898. Goelet, Zeits. fiir Orth. Cliir., Bd. 7, II. 1, 1899. Hofla, Berlin, klin. AVochens., X. 30, 1899. 630 DEFORMITIES OF THE FOOT. front of the foot may be similarly shortened with the aim of lifting the toes to the proper level, if they are depressed. If, as in many in- stances, the deformity is equinuo-varus or valgus, the simple fixation at the ankle joint will be insufficient and it must be supplemented by arthrodesis of one or more of the anterior articulations. In cases of calcaneo-valgus, the removal of the astragalus will be found to be a useful operation, since it improves the stability of the joint, and the limitation of motion is usually sufficient to prevent de- formity. If the astragalus is not removed, the operation must include the fixation of the astragalo-scaphoid, and the medio-tarsal as well as of the ankle joint, and, if toe-drop is extreme, of the tarsal joints also. The method of operating depends upon the deformity. In simple arthrodesis of the ankle joint for toe-drop, the joint may be opened by a perpendicular incision over the front of the ankle. For calcaneus, the posterior incision may be employed, if it is in- tended to shorten the tissues after the Willett method in connection with the arthrodesis. Both the ankle and the calcaneo-astragaloid joints can be opened from the back, although the upper one may be more easily reached from the front. If it is necessary to fix the medio-tarsal joint as well as the ankle joint, a curved incision may be made beneath the inner malleolus to the middle of the foot ; or if the foot is in varus, the incision may be made on the outer side. The cartilaginous surfaces of the bones must be completely removed if firm anchylosis is to be obtained. The parts may be fixed with sutures or nails, l3ut this is unnecessary if accurate opposition can be obtained. The foot is fixed by means of a plaster bandage in the line of the leg, slightly dorsi-flexed, and as soon as possible the patient is encouraged to use the part. The improvement in the gait, obtained by the rectification of de- formity and by fixation of the foot, is often very marked, and in many instances support may be discarded. But, in early childhood at least, the patients should, if possible, be kept under observation, in order that support may be applied if the deformity shows a tendency to recur. Arthrodesis is also performed at the knee and at other joints for the purpose of fixing the part in a useful attitude. In certain in- stances, the operation is indicated. It is, of course, limited to cases of hopeless paralysis and it is more suitable to the older than the younger class of patients.^ , ' The move important articles on arthrodesis are the following : Bidone, Archiv di Ortoped., Fase. 6, 1894. Samter, Centb. fur Chir., 1895, N. 21, S. 497. Karewski, Centb. fur Chir., 1895, N. 25, S. 593. Jones, The international Medical Annual, 1895, p. 407. Karasiewicz, Inaug. Diss. Konigsberg, 1894. Broca, Eevue d'Ortho- pMie, Nov., 1894. Roersch, Revue de Chir., 1892, No. 6. Kirmisson, Revue d'Or- thopedie, N. 2, 1896. Popper, Wiener klin. Rundschau, N. 20, 1900. INDEX. ABSCESS in extra-articular tuberculous joint disease, 199 in hip disease, see Abscess in Tuber- culous Disease Hip Joint, 255 pelvic, in lumbar Pott's disease, 40 in Pott's disease, 87 in different regions, 88 treatment of, 89 in sacro-iliac disease, 119 secondary, in tuberculous joint dis- ease, 200 in thoracic region, 49 in tuberculous disease of ankle joint, 334 of hip joint, 285 frequency of, 285 significance of, 286 treatment of, 287 by aspiration, 288 _ . by incision, 288 by injection, 288 of knee joint, 318 statistics of, 318 treatment of, 318 by aspiration, 318 by incision, 318 of shoulder joint, 350 Absent patella, 329 Achillo-bursitis, 544 etiology of, 545 pathology of, 545 symptoms of, 545 treatment of, 546 brace in, 546 operative, 546 posterior, 547 symptoms of, 547 treatment of, 547 Achillodynia, see Achillo-bursitis, 544 Achondroplasia, see Foetal Rhachitis, 367 Acquired genu recurvatum, 332 Acquired talipes, 609 calcaneus, 616 astragal ectomy for, 620 development of deformity of, 617 symptoms of, 618 treatment of, 618 operative, 619 Willett's operation for, 619 development of deformity in, 609 Acquired talipes, differential diagnosis in, 610 equino-valgus, 623 treatment of, 623 equino-varus, 623 treatment of, 623 cuneiform osteot- omy in, 623 equinus, 611 etiology of, 612 immediate correction of de- formity of, 614 Thomas wrench for, 614 tonic effect of, 615 prognosis, 613 symptoms of, 612 treatment of, 613 Shaffer extension brace in, 614 etiology of, 609 Acquired torticollis, 479 Acromegalia, 371 diagnosis of, 371 symptoms of, 372 Actinomycosis of spine 108 Acute torticollis, 479 Amputations, spontaneous, congenital, 608 Anchylosis, 218 etiology, 218 pathology, 218 prevention of, 219 treatment of, 219 by forcible correction, 220 operative exploration in, 220 by passive motion, 220 Ankle joint, tuberculous disease of, 334 sprain of, 342 chronic, 344 treatment, 345 symptoms, 342 treatment, 343 by plaster bandage, 343 by plaster strapping, 343 Anterior bow leg, 428 symptoms of, 429 treatment, 429 Anterior curvature of tibia, see Anterior Bow Leg, 428 Anterior dislocation of hip, 380 Anterior displacement of the tibia, see Congenital Genu Recurvatum, 328 Anterior metatarsalgia, 538 complications of, 542 632 INDEX. Anterior metatarsalgia, etiology of, 538 influence of shoe in causing dis- ability and pain in, 541 pathology of, 538 treatment of, 542 brace for, 543 support in, 543 Anterior poliomyelitis, acute, 440 causes of deformity of, 445 deformities of upper ex- tremity in, 447 of neck in, 447 of trunk in, 448 secondary in, 449 I diagnosis of, 443 | differential, 443, 444 etiology, 441 pathology, 440 prognosis, 444 retardation of growth in, 449 statistics of, 441 tables of, 441, 442 symptoms of, 442 treatment of, 450 mechanical principles of, 450 prevention of deformity in, 450 arthrodesis in, 456, see Talipes osteotomy in, 457 paralysis in, 444 of anterior muscles of leg, in 450, see Talipes paralysis of arm in, 455 electrical test for, 445 muscles of hip in, 454 of posterior muscles of leg in, 451 of thigh muscles in, 451 paralytic scoliosis in, 454 reduction of deformity of, 455 by braces, 456 tendon transplantation in, 456 treatment, operative, 455, 457 Arborescent synovial tuberculosis, 201 Arthectomy in tuberculous disease of knee joint, 319 advantage of, 319 results of, 319 statistics of, 31 9 table of short- ening, 320 Arthritis, acute, of infancy, 211 deformans, see Osteo-arthritis, 212 folloM'ing infectious disease, 210 operative intervention in, 211 treatment of, 211 typhoid fever, 211 statistics of, 211 gonorrhoeal, 208 statistics of, 208 symptoms of, 208 treatment of, 210 varieties of, 209 infectious, of knee joint, 325 Arthritis, infectious, treatment of, 325 puerperal, 210 rheumatoid, of knee joint, 325 of spine. 111 chronic rheumatoid, 113 treatment of, 111 tuberculous, acute, 212 Arthrodesis, 629 description of operation, 629 for toe drop, 630 in treatment of anterior poliomyelitis, 456, see Talipes Astragalectomv in treatment of calcaneus, 620 in treatment of club foot, 598 Asymmetrical development, 189 Ataxia, hereditary, 468 symptoms of, 469 Atrophy, muscular progressive, 466 BACK knee, see Genu Eecurvatum, Ac- quired, 332 lower part of, pain in, 116 treatment of, 116 Bands, constricting, congenital, 608 Bending of neck of femur, see Coxa Vara, 392 Bier" s treatment, see Venous Stasis, 205 Bilateral coxa vara, 397 dislocation of hip, 379 Billroth splint in treatment of tuberculous disease of knee joint, 313 Bow leg, see Genu Varum, 405, 423 anterior, 428 Braces in treatment of lateral curvature of spine, 148, 176 Bradford frame, 60, 271 in treatment of rhachitis, 366 Burs* in popliteal region, 326 Bursitis, chronic, at shoulder, 359 prepatellar, 325 pretibial, 326 pALCANEO-BUESITIS, 547 l_' symptoms of, 547 treatment of, 547 Caliper brace in treatment of tuberculous disease of knee joint, 317 description of, 317 Calot's operation, 101-103 Campbell brace, in treatment displacement semilunar carfilage in knee, 327 Caput quadratum, 363 Cerebral paralysis of childhood, 459 Cervical opisthotonos, 491 Charcot's disease, 217 diagnosis, 217 distribution, 217 pathology, 217 I statistics of, 217 symptoms, 217 treatment, 218 Chest, circumference of, table of, 190 deformities of, 186 1 flat, 186 I treatment of, 186 INDEX. 633 Chest, funnel, 187 pigeon, 186 treatment of, 187 Chondrodystrophia, see Foetal Rhacliitis, 367 Clavicle, absence or defect of, 188 acquired luxation of, 188 treatment of, 188 Club band, 434 etiology, 434 statistics of, 435 treatment of, 436 operative, 436 Club foot, astragalectomv in treatment of, 598 confirmed, correction of, method Julius Wolff; 593 congenital, anatomy of, 569 symptoms of, 572 treatment of, 572 cuneiform osteotomy in treat- ment of, 599 division of the tendo Achillis in treatment of, 592 forcible correction of deformity of, by osteoclasts, 596 by Phelps' opera- tion, 596 bv Thomas method, " 595 manual correction of, 585 hysterical, 470 differential diagnosis of, 471 infantile, principles of treatment of, 573 rectification of deformity of, 574 treatment of, mechanical, 574 bv plaster bandage, ^575 by splints and braces, 577 retention brace in, 581 tenotomy in, 579 malleotomy in treatment of, 591 mechanical rectification of de- formity of, 600 Jiidson brace for, 600 osteotomy in treatment of, 598 secondary treatment of, 600 rapid correction of deformity of, 585 subcutaneous tenotomy in treat- ment of, 591 treatment of, division of plantar fascia in, 593 of tibialis anticus in, 593 posticus in, 593 Congenital absence of fibula associated with talipes equino - val- gus, 606 etiology of, 607 statistics of, 606 treatment of, 607 Congenital absence of tibia associated with talipes var- us, 607 prognosis of, 607 _ statistics of, 607 treatment of, 607 club foot, 569 contraction of fingers, 437 treatment of, 437 at knee, 332 deficiency and hypertrophy, 607 deformities of elbow, 433 at wrist, 434 dislocation of hip, see Hip Joint, Con- genital Dislocation of, 373 ' of shoulder, 430 treatment of, 430 displacement of patella, 329 elevation of scapula, 185 etiology of, 185 treatment of, 186 genu recurvatum, 328 hallux varus, see Pigeon Toe, 551 lateral curvature of spine, 135 oedema of feet, 608 talipes calcaneus, 604 statistics of, 604 treatment of, 604 equinus, 604 statistics of, 604 valgus, 605 statistics of, 605 varus, 603 torticollis, 475 Constricting bands, congenital, 608 Contracted foot, see Hollow Foot, 534 Contraction of fingers, congenital, 437 treatment of, 437 confirmed club foot, method Julius Wolff; 593 Coxa vara, 392 bilateral, 397 diagnosis of, 398 etiology of, 393 mechanical effects of, 394 predisposition to deformity of, 393 pathology of, 393 physical effects of, 396 statistics of, 394 table of, 395 symptoms of, 394 traumatic, 402 diagnosis of, 402 treatment of, 402 treatment of, 399 apparatus in, 400 operative, 400 cuneiforii? osteotomy, 401 linear osteotomy, 400 unilateral, symptoms of, 396 Craniotabes, 363 Cretinism allied to foetal rhachitis, 367 634 INDEX. Cubitus valgus, 433 varus, 433 Cuneiform osteotomy, in treatment of an- terior bow leg, 429 of club foot, 599 of coxa vara, 401 of genu valgum, 422 of hallux valgus, 554 of talipes, 599 Cysts in popliteal region, 326 DEPRESSIOX of neck of femur, see Coxa Vara, 392 Development, asymmetrical, 189 normal, tables of, 190 Diagnosis of Achillo-bursitis, 545 of acquired talipes, 610 of acromegalia, 371 of actinomycosis of spine, 108 of anterior metatarsalgia, 538 of acute epiphysitis at hip, 301 anterior poliomyelitis, 443 torticollis, 482 of calcaneo-bursitis, 547 of Charcot's disease, 217 of congenital dislocation of hip joint, 380 elevation of scapula, 183 paralysis, 461 of coxa vara, 398 unilateral, 397 bilateral, 398 of displacement of peronei tendons, 555 of erythromelalgia, 548 of fractui'e of neck of femur, 402 of functional affections of joints, 472 of gluteal bursitis, 302 of gonorrhosal arthritis, 209 of hallux rigidus, 549 of hollow foot, 535 of hysterical club foot, 470 hip, 469 of injury of spine, 108 of lateral curvature of spine, 141 of malignant disease of spine, 107 of obstetrical paralysis, 431 of osteo-arthritis, 215 arthropathy, 371 of osteitis deformans, 371 of periarthritis of shoulder, 358 of poliomyelitis, anterior, 442 of Pott's paraplegia, 96 of pseudo-hypertrophic muscular pa- ralysis, 468 of rhachitic spine, 109 of rhachitis, 365 of sacro-iliac disease, 118 of sciatic scoliosis, 117 of spondylitis deformans of spine, 113 of syphilis of spine,, 107 of torticollis, 482 of traumatic coxa vara, 402 of tuberculous disease ankle joint, 339 elbow joint, 351 hip joint, 244 Diagnosis of tuberculous knee joint, 310 shoulder joint, 350 of spine, 4l, 50, 54 sub-astragaloid joint, 339 of tarsus, 341 of typhoid spine, 110 of weak foot, 514 Dislocation of hip, congenital, see Hip Joint, Congenital Dislocation of 373 of shoulder, congenital, 430 treatment of, 430 recurrent, 432 treatment of, 432 operative, 433 Displacement of peronei tendons, 555 treatment of, 556 "Double joints," 363 Dupuytren's contraction, 438 etiology of, 439 pathology of, 439 symptoms of, 439 treatment of, 439 Dystrophy, muscular, 467 ELBOW, congenital deformities of, 433 excision of, in tuberculous disease of, 353 joint, tuberculous disease of, 351 Elongation ligamentum patellse, 331 Epiphysis of head of femur, traumatic separation of, 404 Epiphysitis, acute, 211 distribution of, 211 etiology of, 211 prognosis, 212 statistics of, 211 symptoms of, 212 treatment of, 212 Equino-varus, hysterical, 624 Erythromelalgia, 548 Exercise in treatment of lateral curvature of spine, 151, 164 Exostoses of foot, 555 Etxra-articular disease of hip, 301 of knee, 318 FEMUR, bending of neck of, see Coxa Vara, 392 depression of neck of, see Coxa Vara, 392 ' fracture of neck of, 402 Fingers, congenital contraction of, 437 treatment of, 437 distortions of, 438 drop, see Mallet Finger, 438 jerking, see Trigger Finger, 438 mallet, see ^Slallet Finger, 438 snapping, see Trigger Finger, 438 trigger, see Trigger Finger, 438 webbed, 437 etiology of, 437 treatment of, 437 Flat foot, see Weak Foot, 507 Foetal rhachitis, 367 cretinism allied to, 367 INDEX. 635 Foetal rhachitis, etiology, 367 pathology, 367 prognosis, 367 treatment of, 367 Poot, contracted, 534 deformities of, 492 disabilities of, 492 flat, see the Weak Foot, 507 function of the muscles of, 502 general description of, 492 hollow, 534 exostoses of, 555 as a mechanism, 506 movements of, 496 plaster cast of, method of taking, 524 relative strength of muscles of, tables of, 503 splay, see Weak Foot, 507 weak, 507 adjuncts in treatment of, 532 plaster strapping, 532 Thomas treatment, 532 anatomy of, 508 in childhood, 519 out and in toeing as symp- toms of, 519 diagnosis of, 514 etiology of, 511 extreme types of, 517 operative treatment for, 532 pathology of, 511 rigid, 527 other varieties of, 531 treatment of, 527 forcible over-correction in, 527 systematic manipula- tion in, 527 statistics of, 512 symptoms of, 513 treatment of, 521 attitudes in, 522 brace in, 525 exercises in, 523 the shoe in, 521 support in, 523 varieties of, 516 Fracture of neck of femur, 402 Fragilitas ossium, 368 Freidreich' s disease, see Hereditary Atax- ia, 468 Functional affections of joints, 471 causes of, 472 diagnosis of, 472 treatment of, 472 pathogenesis of deformity, 190 Funnel chest, 187 GENU recurvatum, acquired, 332 etiology of, 332 symptoms of, 333 treatment of, 333 congenital, 328 treatment of, 329 deformities accompanied by, 328 statistics of, 328 Genu recurvatum, deformities accompa- nied by, etiology of, 329 Genu valgum, 405-411 accommodative attitude in, 414 combined with general rhachitic distortions, 415 with genu varum, 415 etiology of, 406 gait in, 414 measurements of deformity of, 417 outgrowth of deformity of, 409 pathology, 416 predisposition to deformity of, 409 secondary deformities of, 414 statistics of, 405 table of, 406 time of onset of, 406 treatment of, 417 by braces, 419 duration of, 420 exercise in, 418 expectant, 417 manipulation in, 417 Lorenz's operation, 423 operative, 421 osteoclasis in, 422 osteotomy in, 421 cuneiform, 422 by plaster bandage, 421 posture in, 418 Thomas brace in, 420 Wolff'' s, 423 unilateral, 415 Genu varum, 405, 423 etiology of, 406 measurements of deformity in, 426 outgrowth of deformity of, 409 predisposition to deformity in, 406 statistics of, 405 table of, 405 symptoms of, 425 time of onset of, 406 treatment of, 426 by braces, 426 expectant, 426 operative, 426 osteotomy in, 427 osteoclasis in, 427 Gonorrhceal arthritis, 208 statistics of, 208 symptoms of, 208 treatment of, 210 varieties of, 209 Gonorrhceal rheumatism, see Gonorrhceal Arthritis, 208 of spine. 111 H^MARTHROSIS, 217 Hsemophilia, 216 treatment, 217 Hallux flexus, see Hallux Rigidus, 548 rigidus, 548 636 INDEX. Hallux rigid us, etiology of, 549 treatment of, 549 Hallux valgus, 551 etiology of, 552 pathology of, 552 symptoms of, 553 treatment of, 553 cuneiform osteotomy in, 554 operative, 553 Hallux varus, 551 congenital, see pigeon toe, 551 treatment of, 551 Hammer toe, 554 symptoms of, 554 treatment of, 554 Height, table of, 190 Hemiplegia, treatment of, 463 Hereditary ataxia, 468 symptoms of, 469 ' ' High hip ' ' of lateral curvature of spine, 125 "shoulder" of lateral curvature of spine, 125 Hip disease, see Tuberculous Diseases of Hip Joint, 221 excision of, in tuberculous disease of hip joint, 290 functional re- sults after, 290, 292 statistics of, 289, 291 Hip, hysterical, 469 anterior dislocation, 380 bilateral dislocation of, 379 general symptoms of, 380 congenital dislocation of, 373 diagnosis of, 380 etiology, 377 pathology, 374 statistics, 373 table of, 374 symptoms, 378 treatment of, 382 intermediate opera- tion, 390 Lorenz's operation in, 386 open operation in, 383 secondary osteot- omy in, 391 tuberculous disease of, 221 unilateral dislocation of, 378 Hollow foot, 534 etiology of, 534 symptoms of, 535 treatment of, 537 operative of, 537 Housemaid's knee, see Prepatellar Bur- sitis, 325 Hutchinson's index showing relative depth of cliest, 186 Hysterical club foot, 470 difllerential diagnosis, 471 Hj'sterical equino-varus, 624 hip, 469 diagnosis of, 469 diflerential, 470 symptoms of, 470 scoliosis, 471 case of, 471 treatment of, 471 spine, 115 symptoms of, 115 treatment of, 116 IDIOPATHIC osteopsathyrosis, see Frag- ilitas Ossium, 368 Incidental lateral curvature of spine, 135 Infantile club foot, 573 paralysis, see Poliomyelitis Anterior, 440 scorbutus, 367 pathology of, 368 symptoms of, 368 treatment of, 368 In knee, see Genu Valgum, 405-411 Injury of sacro-iliac articulation, 119 of spine, 55, 108 Intermediate operation, for congenital dis- location of hip, 390 JERKING finger, see Trigger Finger, 438 Joint disease in locomotor ataxia, 218 in affections of nervous system,. 217, 218 Joints, diseases of, syphilitic, 206 acquired, 207 hereditary, 206 later manifestations in, 207 pseudo-paralysis in, 206 spina ventosa in, 207 treatment of, 208 functional affections of, 471 causes of, 472 diagnosis of, 472 treatment of, 472 neurotic, see Joints, Functional Affec- tions of, 471 Judson brace in treatment of club foot, 600 hip brace, 255 KINGSLEY'S table for estimating flex- ion deformity, 244 Knee, congenital contraction at, 332 general contractions combin- ed with, 332 prognosis of, 332 treatment of, 332 displacement of a semilunar cartilage in, 327 cause of, 327 treatment of, 327 Campbell brace in, 327 extra -articular disease of, 318 injuries of, in childhood, 324 INDEX. 637 Knee joint, internal derangement of, 326 loose bodies in. 326 tuberculous disease of, 304 snapping, 331 treatment of, 332 strains of, in cliildbood, 324 Knight brace in treatment, lateral curva- ture of spine, 177 Knock knee, see Genu Valgum, 405-411 Kyphosis, 182 of adolescents, 114 postural, 183 of rhachitis, 109, 183 treatment of, 184 T AMINECTOMY, 98 Li Latent tuberculosis, 194 Lateral curvature of spine, 120 congenital, 135 diagnosis of, 141 mobility tests of, in, 142 posture in, 141 due to occupation, 135 effiects of deformity of, 124 fixed deformity in, 121 forcible correction of defor- mity of, 177 combined with fixation, 178 habitual deformity in, 121 hereditary influence in, 137 the "high hip" of, 125 _ "shoulder" of, 125 incidental, 135 lateral deviation in, 124 occupation as a factor in, 137 pathology of, 126 prevention of deformity of, 146 prognosis of, 143 record of case, 142 rhachitic, 135 rotation in, 123 secondary to deformity else- where, 133 to disease within tho- racic walls, 134 to paralysis, 133 statistics of, 130 age, 131 frequency, 130 sex, 130 symptoms of, 141 treatment of, 147 by braces, 148, 176 corsets in, 177 duration of, 180 exercises in, 151, 164 general, 180 high shoe in, 180 Knight brace in, 177 self-suspension in, 175 Teschner's exercises in, 151 Volkmann seat in, 180 varieties of deformity in, 139 ' ' Late rickets, ' ' 366 Ligamentum patellie, elongation of, 331 etiology, 331 symptoms, 331 treatment, 331 Linear osteotomy in treatment of coxa vara, 400 Lipoma, arborescens tuberculosum, 201 Locomotor ataxia, joint disease in, 218 Lordosis, 184 treatment of, 185 Lorenz operation, for congenital disloca- tion of hip, 386 for genu valgum, 423 reclination gypsbettes in treatment. Pott's disease, 60 Lovett's table for estimating lateral dis- tortion in tuberculous disease, hip joint, 242 Lumbar Pott' s disease in infancy, peculi- arities of, 44 MALIGNANT disease of spine, 107 diagnosis of, 107 Malleotomy in treatment of club foot, 591 Mallet finger, 438 Metatarsalgia, anterioi', 538 etiology of, 538 influence of shoe in causing dis- ability and pain in, 541 pathology of, 538 treatment of, 542 brace for, 543 support in, 543 Metzger-Goldthwait apparatus, 105 Mollitis ossium, see Osteomalacia, 369 Morbus coxae, see Tuberculous Disease of Hip Joint, 221 Morton' s neuralgia, see Metatarsalgia An- terior, 538 Muscles of leg, relative strength of, 628 pectoral, defective formation of, 188 Muscular atrophy, progressive, 466 dystrophy, 467 Myelopathic paralysis, 466 NECK, deformities of, in anterior polio- myelitis, 447, see torticollis, 474 Nervous system affections of, joint disease in, 217, 218 diseases of, 440 Neuritis, 469 treatment of, 469 Neurotic joints, see Joints, Functional Af- fections of, 471 spine, 114 symptoms of, 115 treatment of, 115 Non-deforming club foot, see Hollow Foot, 534 Non-tuberculous affections of the ankle joint, 342 of the hip joint, 300 of the knee joint, 324 of the spine, 107 disease of joints, 206 638 INDEX. OBSTETRICAL paralysis, 431 treatment of, 431 Ocular torticollis, 491 (Edema of foot, congenital, 608 Open operation, for congenital dislocation of hip, 383 Osteitis deformans, 370 deformities of, 370 of spine, 114 Osteo-arthritis, 212 atrophic form, 214 etiology of, 213 ^ of knee joint, 325 symptoms of, 325 treatment of, 325 localized form, 214 multiple form, 213 statistics of, 214 pathology, 212 of spine, see spondylitis defor- mans, 111 case of, 113 symptoms of, 215 treatment of, 215 by apparatus, 216 by forcible manipulation, 216 varieties of, 213 Osteo-arthropathy, 370 treatment of, 371 Osteoclasis in treatment of genu valgum, 422 in treatment of genu varum, 427 in treatment of talipes, 596 Osteomalacia, 369 in childhood, 369 cases of, 369 treatment of, 370 deformities of, 369 symptoms of, 369 Osteomyelitis, infectious localized, 212 of spine, 108 symptoms of, 108 treatment of, 108 Osteotomy for correction deformity of tuberculous disease hip joint, 293 cuneiform in treatment of club foot, 599 in treatment of coxa vara, 401 in treatment of hallux valgus, 554 linear in treatment of coxa vara, 400 secondary in treatment, anterior polio- myelitis, of club foot, 600 in treatment of, 457 of club foot, 598 of genu valgum, 421 varum, 427 Over-lapping toes, 555 PAGET' S disease, 370 see osteitis deformans of spine, 114 Painful great toe, see Hallux Rigidus, 548 joint in older subjects, 550 heel, 547 Pain in lower part of back, 116 treatment of, 116 Paralysis, acquired, 459, 462 deformities in, 462 disability of, 463 loss of growth in, 463 Sach' s classification of causes and effects of, 459 of anterior muscles of leg in anterior poliomyelitis, 450, see Talipes Poliomyelitis, 444 of arm in anterior poliomyelitis, 465 cerebral, in childhood, 459 congenita], 459, 461 deformities in, 462 electrical test for, in anterior polio- myelitis, 445 infantile, see Poliomyelitis, Anterior, 440 muscles of hip in anterior poliomye- litis, 454 myelopathic, 466 Aran-Duchenne type of, 466 Charcot-Marie-Tooth type of, 466 myopathic, 467 obstetrical, 431 treatment of, 431 of posterior muscles of leg in anterior poliomyelitis, 451 in Pott' s disease, 93 pseudo-hypertrophic muscular, 468 diagnosis of, 468 treatment of, 468 spastic, 459 etiology of, 459 pathology of, 459 prognosis of, 466 statistics of distribution of, 459 statistics of mental impairment in, 461 symptoms of, 460 mental, 460 motor, 460 of thigh muscles, anterior poliomye- litis, 451 Paralytic scoliosis in anterior poliomye- litis, 454 torticollis, 491 Paraplegia, treatment of, 93, 464 Patella, congenital displacement of, 329 rudimentary or absent, 329 treatment of, 329 slipping, 330 etiology, 330 symptoms, 330 treatment, 330 operative, 330 Pathogenesis of deformity, functional, 190 Pectoral muscles, defective formation of, 188 Pectus carinatum, see Pigeon Chest, 186 excavatum, see Funnel Chest, 187 Pelvic abscess in lumbar Pott's disease, 40 Periarthritis of the shoulder, 358 symptoms of, 358 treatment of, 358 Peronei tendons, displacement of, 555 INDEX. 639 Pes planus, 518 Phalanges, congenital displacement of, 438 • Phelps' bed in treatment Pott's disease, 60 hip splint, 278 operation for immediate correction of deformity of club foot, 596 Pigeon breast, 364 chest, 186 treatment of, 187 toe, 551 Plantalgia, see Plantar Neuralgia, 548 Plantar fascia, division of, in treatment of club foot, 593 of hollow foot, 537 Plantar neuralgia, 548 treatment of, 548 Plaster bandage in treatment tuberculous disease hip joint, 265, 266 cast of foot, method of taking, 524 corset, 76 jacket, application of, 70 in recumbency, 74 Poliomyelitis, anterior, acute, 440 causes of deformity of, 445 deformities of lower extrem- ity in, 450 of neck in, 447 secondary in, 449 of trunk in, 448 of upper extremity in, 447 diagnosis of, 443 differential, 443, 444 etiology of, 441 pathology of, 440 prognosis of, 444 retardation of growth in, 449_ statistics of, 441 tables of, 441, 442 symptoms of, 442 treatment of, 450 mechanical, principles of, 450 prevention of deformitv _ in, 450 arthrodesis in, 456 osteotomy in, 457 paralysis in, 444 of anterior muscles of leg in, 450 of arm in, 455 electrical test for, 445 of posterior muscles of leg, 451 of thigh muscles, 451, 454 paralytic scoliosis in, 454 torticollis in, 490 reduction of deformity of, 455 by braces, 456 tendon transplantation in, 456 treatment of, operative, 455, 457 Popliteal region, burste and cysts in, 326 Posterior torticollis, 491 Pott's disease, see Tuberculous Disease of Spine, 17 complications of, 87 abscess, 87 in different regions, 88 treatment of, 89 paralysis in, 93 duration of, 95 prognosis, 95 statistics of frequency liability to, in dif- ferent regions, 94 time of onset, 95 symptoms of, 95 treatment of, 97 duration of, 99 operative, 98 forcible correction deformity of, 101 _ statistics of results of, 102 selection of cases for, 102 gradual correction of deformity of, 104 Metzger-G oldthwait apparatus for, 105 local paralysis in, 98 recurrence of, 100 secondary deformities, 100 statistics of, 21 age, 22 frequency, 21 sex, 22 situation, 22 Pott's fracture, 624 Pott's paraplegia, 95 symptoms of, 95 Pretibial bursa, enlargement of superficial, 326 Prepatellar bursitis, 325 treatment of, 325 Pretibial bursitis, 326 symptoms of, 326 treatment of, 326 Progressive muscular atrophy, 466 Pseudo-hypertrophic muscular paralysis, 468 diagnosis of, 468 treatment of, 468 Pseudo-paralysis in rhachitis, 34 in syphilitic disease, 206 Psychical torticollis, 491 Puerperal arthritis, 210 RETENTION brace in treatment of club foot, 581 Ketro-calcaneo bursitis, see achillo-bur- sitis, 544 Rhachitic distortions, general, 429 kyphosis, 109 lateral cdrvature of spine, 135 rosary, 363 spine, 45, 109, 110, 183, 364 treatment of, 110 640 INDEX. Khachitic torticollis, 491 Rhachitis, 361 deformities of, 362 caput quadratum, 363 ' ' craniotabes, ' ' 363 " double joints," 363 pigeon breast, 364 " rhachitic rosarv," 363 attitude, 364 pseudo-paral vsis, 364 spine, 45, 109, 110, 183, 364 etiology of, 361 foetal, 367 cretinism allied to, 367 etiology, 367 pathology, 367 prognosis, 367 treatment of, 367 kyphosis of, 109, 183 pathology of, 361 prognosis of, 365 symptoms of, 362 treatment of, 365 Bradford frame in, 366 prevention of deformity in, 366 Kheumatism of spine, 56, see also Spondy- litis Deformans, 111 Rheumatoid arthritis, see Osteo-arthritis, 212 of knee joint, 325 of spine, chronic, 113 Ribs, absence of, 188 Rice bodies in tuberculous joint disease, 201 Rickets, see Rhachitis, 361 Rigid Hat foot, see Rigid Weak Foot, 527 weak foot, 527 treatment of, 527 forcible over-correction in, 527 plaster strapping in, 532 systematic manipulation in, 527 Thomas, 532 Rotary lateral curvature, see lateral curva- ture of the spine, 120 Rudimentary patella, 329 SACRO-ILIAC articulation, injury of, 119 disease of, 117 abscess in, 119 diagnosis of, 118 prognosis of, 118 symptoms of, 117 treatment of, 118 Thomas hip brace in, 119 Scapula, congenital elevation of, 185 etiology of, 185 treatment of, 186 Sciatica, deformity secondary to, 117, 119 Sciatic scoliosis, see Sciatica, Deformity Secondary to, 117 Scoliosis, see Lateral Curvature of Spine, 120 Scoliosis, hysterical, 471 case of, 471 treatment of, 471 paralytic in anterior poliomyelitis, 454 total," 122 Scorbutus, hemorrhage in, 217 infantile, 367 symptoms of, 368 treatment of, 368 Scurvy, see Scorbutus, Infantile, 367 rickets, see Scorbutus, Infantile, 367 Secondary, hypertrophic osteo-arthrop- athy, 370 Shoes, 556 Shoulder, chronic bursitis at, 359 congenital dislocation of, 430 treatment of, 430 joint, tuberculous disease of, 348 periarthritis of, 358 symptoms of, 358 treatment of, 358 recurrent dislocation of, 432 treatment of, 432 operative, 433 Sinuses in tuberculous disease hip joint, treatment of, 289 Slipping patella, 330 Snapping finger, see Trigger Finger, 438 knee, 331 Spasmodic torticollis, 486 Spastic paralysis, 459 torticollis, 480 Spina bifida and talipes, 608 ventosa, 356 statistics of, 356 in syphilitic disease, 207 treatment, 357 operative, 357 Spine, actinomycosis of, 108 antero-posterior deformities of, 182 kyphosis, 183 postural, 183 of rhachitis, 109, 183, 364 lordosis, 184 treatment of, 185 treatment of, 184 arthritis of. 111 treatment of, 111 changes in antero-posterior contour of, 125 contour and flexibility of normal, 29 variations in, 181 divisions of, 30 injury of, 55, 108 gonorrlia?al rheumatism of, 111 hysterical, 115 symptoms of, 115 treatment of, 1 16 landmarks of, 32 lateral curvature of, 120 congenital, 135 diagnosis, 141 mobility tests of, in, 142 posture in, 141 INDEX. 641 Spine, lateral posture in, due to occupa- tion, 135, 137 effects of deformity of, 124 fixed deformity in, 121 forcible correction of defor- mity in, 177 combined with fixation, 178 habitual deformity in, 121 hereditary influence in, 137 the "high hip" of, 125 "shoulder" of, 125 incidental, 135 lateral deviation in, 124 pathology of, 126 prevention of deformity in, 146 prognosis of, 143 record of case, 142 rhachitic, 135 rotation in^ 123 secondary to deformity else- where, 133 to disease within thor- acic walls, 134 to paralysis, 133 statistics, 130 age, 131 frequency, 130 sex, 130 symptoms of, 141 treatment of, 147 by braces, 148, 176 corsets in, 177 duration of, 180 exercise in, 151, 164 Teschner's, 151 general, 180 Knight brace in, 177 high shoe in, 180 self-suspension in, 175 Volkmann seat in, 180 varieties of deformity in, 139 malignant disease of, 107 diagnosis of, 107 neurotic, ll4 symptoms of, 115 treatment of, 115 osteitis deformans of, 114 osteo-arthritis of, see Spondylitis De- formans, 111 case of, 113 osteomyelitis of, 108 symptoms of, 108 treatment of, 108 physiological movements of, 120 rhachitic, 45, 109, 110, 183, 364 treatment of, 110 rheumatism of, see Spondylitis De- formans, 111 rheumatoid arthritis of, case of, 113 syphilis of, 107 diagnosis of, 107 traumatic spondylitis, 1 09 tuberculous disease of, 17 typhoid, the, 110 41 Spine, typhoid, the, treatment of, 110 variations in contour of, 181 Splay foot, see Weak Foot, 507 Spondylolisthesis, 116 Spondyloze Ehizomelique, see Spondy- litis Deformans, 111 Spondylitis deformans, 111 case of, 113 pathology of. 111 symptoms of, 112 treatment of, 114 traumatic, 109 Spontaneous amputations, congenital, 608 Sprain of the ankle, 342 chronic, 344 of wrist, 359 chronic, 359 Sprengel's deformity, see congenital ele- vation of scapula, 185 Statistics of anterior poliomyelitis, 441 of club hand, 435 of congenital dislocation at hip joint, 373 talipes calcaneus, 604 equinus, 604 valgus, 605 calcaneo-valgus, 605 equino-valgus, 605 associated with congenital absence fibula, 606 varus associated with con- genital absence tibia, 607 of coxa vara, 394 genu valgum, 405 varum, 405 lateral curvature of spine, 130 age, 131 frequency, 130 sex, 130 varieties, 140 of osteo-arthritis, 214 of Pott' s disease, 21 age, 22 frequency, 21 sex, 22 situation of, 22 of results of tuberculous joint dis- ease, 203, 295, 298, 322, 323, 341, 349, 354 of spina ventosa, 356 of synovial disease of joints, 201 of talipes, 566 foot affected, 567 relative frequency of different forms, acquired, 568 congenital, 567 comparative frequency of differ- ent forms, congenital and ac- quired, 568 sex, 567 of torticollis, 474 acquired, 481 table of, 481 spasmodic, 487 642 INDEX, vStatistics of tuberculous disease of elbow joint, 351, 354 hip joint, 224 age, 197, 198, 225 at incipiency table of, 22 deformity in, 248 excision, 289, 291 functional results, 259, 297, 298 mortality, 295 retardation of growth, tables of, 238, 239 sex, 197, 225 side affected, 197, 225 of shoulder joint, 348, 349 of wrist joint, 354 of weak foot, 512 Stemo-mastoid muscle, hsematoma of, 477 Stiffness of vertebral column, see Spondy- litis Deformans, 111 Strain of the tendo Achillis, 547 Symptoms of abscess in Pott's disease, 87 of achillo-bursitis, 545 posterior, 547 of actinomycosis of spine, 108 of acquired genu recurvatum, 333 talipes calcaneus, 618 equinus, 612 of acromegalia, 372 of acute anterior poliomyelitis, 442 torticollis, 481 of anchylosis, 218 of anterior bow leg, 429 metatarsalgia, 538 of arthritis deformans at hip, 302 of bilateral dislocation at hip joint, 380 of bow leg, 423 of bursEe at hip, 302 at knee, 326 at shoulder, 359 of calcaneo-bursitis, 547 of Charcot' s disease, 217 of club hand, 434 of congenital club foot, 572 dislocation of hip joint, 378 of shoulder joint, 430 of coxa vara, 394 of cubitus valgus, 433 varus, 433 of displacement of peronei tendons, 555 of Dupuytren's contraction, 439 of elevation of scapula, 185 of elongation of iigamentum patellae, 831 of epiphysitis, 212 at hip joint, 301 of erythromelalgia, 548 of extra-articular disease at hip joint, 301 of flat chest, 186 of fcetal rhachitis, 367 Symptoms of funnel chest, 187 of genu recurvatum, acquired, [332 congenital, 328 varum, 425 of gonorrhceal arthritis, 208 of- spine, 110 of hsemarthrosis, 217 of haemophilia, 210 of hallux rigidus, 548 valgus, 553 of hammer toe, 554 of hereditary ataxia, 469 of hollow foot, 535 of hysterical club foot, 470 hip, 470 scoliosis, 471 spine, 115 of infantile scorbutus, 368 of infectious arthritis, 210 of injurv of hip, 300 of knee, 324 of spine, 108 of internal derangement of knee, 327 of knock knee, 412 of kyphosis, 182 of late rickets, 366 of lateral curvature of spine, 141 of lordosis, 184 of malignant disease of spine, '107 of mallet finger, 438 of neuritis, 469 of neurotic joints, 471 spine, 115 of obstetrical paralysis, 431 of osteo-arthritis, 215 of knee joint, 325 of osteomalacia, 369 of osteomyelitis of spine, 108 of osteitis deformans, 114, 370 of paralysis, 442, 460 in Pott's disease, 95 of periarthritis of shoulder, 358 of pigeon chest, 186 of plantar neuralgia, 548 of Pott's paraplegia, 95 of prepatellar bursitis, 325 oi pretibial bursitis, 326 of recurrent dislocation of shoulder, 432 of rhacliitis, 362 of sacro-iliac disease, 117 of sciatic scoliosis, 117 of scorbutus, 217, 367 of slipping patella, 330 of snapping knee, 331 of spastic paralysis, 459 of spina ventosa, 356 of spondylitis deformans, 112 of spondylolisthesis, 116 of sprain of ankle, 342 of syphilitic disease of joints, 206 of syphilis of spine, 107 of talipes acquired, 609 congenital, 560 of teno-synovitis, 346 of torticollis, acquired, 479 INDEX. 643 Symptoms of torticolRs, congenital, 475 . spasmodic, 486 spastic, 480 of trigger finger, 438 of tuberculous disease of ankle joint, 336 of elbow joint, 351 of hip joint, 225 of knee joint, 306 of shoulder joint, 349 ■ of spine, 24 of tarsus, 341 of wrist joint, 355 of unilateral coxa va-ra, 396 of weak foot, 513 of webbed fingers, 437 Synovial disease of joints, statistics of, 201 in tuberculous disease of knee joint, 318 treatment of, 318 c a r b o lie acid in, 318 c h 1 o r ide o f zinc in, 318 i o d of orm injection in, 319 venous stasis in, 319 Synovitis, 324 chronic, 324 treatment of, 324 aspiration in, 325 braces in, 325 treatment of, 324 plaster strapping in, 324 Syphilitic disease of joints, 206 acquired, 207 hereditary, 206 later manifestations in, 207 pseudo-paralysis in, 206 spina ventosa in, 207 treatment of, 208 of spine, 107 diagnosis of, 107 TABLE of age at incipiency tuberculous disease ankle joint, 335 elbow joint, 351 hip joint, 225 knee joint, 306 of shoulder joint, 349 of spine, 22 of wrist joint, 355 of patients treated at Tubingen for tuberculous disease ankle joint, 336 Kingsley's, 244 Lovett's, 242 of statistics acquired torticollis, 481 Table of anterior poliomyelitis, 441, 442 of congenital dislocation of hip joint, 374 of coxa vara, 395 of genu valgum, 406 varum, 405 of lateral curvature of spine, 130 of normal development, 190 of talipes, 567, 568 Talipes, 560 acquired, 609 etiology of, 609 development of deformity in, 609 differential diagnosis in, 610 statistics of, 566 foot affected, 567 relative frequency, different forms, 568 sex, 567 arcuatus, see Hollow Foot, 534 calcaneo-valgus, 622 statistics of, 605 treatment of, 622 -varus, 622 statistics of, 605 treatment of, 622 calcaneus, acquired, 616 astragalectomy for, 620 development of deformity of, 617 symptoms of, 618 treatment of, 618 operative, 619 Willett's operation for, 619 congenital, 604 statistics of, 604 treatment of, 604 cavus, see Hollow Foot, 534 statistics of, 605 congenital, 562 etiology of, 563 statistics of, 566 foot affected, 567 relative frequency different forms, 567 sex, 567 equino-cavus, statistics of, 605 valgus, acquired, 623 associated with congenital absence of fibula, 606 etiology of, 607 statistics of, 606 treatment of, 607 statistics of, 605 treatment of, 623 varus, 569 acquired, 623 treatment of, 623 cuneiform osteotomy in, 623 equinus, acquired, 611 etiology of, 612 immediate correction of de- formity of, 614 644 INDEX. Talipes, equinus, Thomas wrench for, 614 effect of, 615 prognosis of, 613 symptoms of, 612 treatment of, 613 Shaffer extension brace in, 614 congenital, 604 statistics of, 604 etiology of, 562 paralytic, tendon transplantation for the relief of, 624 other methods, 625 Parish's operation, 625 plantaris, see Hollow Foot, 534 Talipes and spina bifida, 608 valgo-cavus, statistics of, 605 valgus, congenital, 605 statistics of, 605 varieties of, 560 varus associated congenital absence tibia, 607 prognosis of, 607 _ statistics of, 607 treatment of, 607 congenital, 603 Tarsus, tuberculous disease of, 341 Taylor back brace, 63 foot brace, 581, 582 Taylor hip braces, 256, 279, 281 Tendo Achillis, division of, in treatment of clubfoot, 592 strain of, 547 Tendon splicing, 629 transplantation for relief of paralytic talipes, 624 Kicoladoni's opera- tion, 624 Parish's operation, 625 other methods of, 625 _ in treatment of anterior poliomy- elitis, 456, see Talipes Teno-synovitis, 345 at ankle, 346 symptoms of, 346 treatment of, 347 tuberculous, 347 at wrist, 360 Tenotomy, subcutaneous, in treatment of talipes, 591 Teschner* s exercises in treatment of lateral curvature of spine, 151 Thomas brace, in treatment of genu val- gum, 420 tuberculous disease ankle joint, 340 collar, 79 hip brace in treatment sacro-iliac disease, 119 knee brace in treatment of tuber- culous disease of knee joint, 314 Thomas knee brace, description of, 315 method forcible correction of deform- ity of club foot, 595 treatment tuberculous disease, hip joint, 260 hip splint, 261 wrench in treatment of talipes, 595, 614 Tibialis anticus, division of, in treatment of club foot, 593 posticus, division of, in treatment of club foot, 593 Toes, over-lapping, 555 Torticollis, 474 acquired, 479 statistics of, 481 table of, 481 varieties of, 479 acute, diagnosis of, 482 differential, 483 etiology of, 479 spastic, 480 causes of, 480 symptoms of, 481 congenital, 475 deformity of, 475 etiology of, 477 hsematoma of sterno-mastoid mus- cle in, 477 pathology of, 478 secondary distortions of, 476 following diphtheritic paralysis, 491 ocular, 491 paralytic, 490 posterior, 491 psychical, 491 rhachitic, 491 spasmodic, 486 etiology of, 487 pathology of, 487 prognosis of, 487 statistics of, 487 treatment of, 487 operation in, 488 statistics of, 474 treatment of, 483 correction of deformity in, 484 by subcutaneous tenot- omy, 484 open operation, 484 Traction hip brace, 251 application of, 254 Traumatic coxa vara, 402 diagnosis of, 402 treatment of, 402 separation of epiphysis of head of femur, 404 spondylitis, 109 valgus, 624 Treatment of abscess in Pott's disease,f89 in tuberculous disease of hip joint, 287 of knee joint, 318 of achillo-bnrsitis, 546 posterior, 547 of actinomycosis of spine, 108 INDEX. 645 Treatment of acquired genu recurvatum, 333 of luxation of clavicle, 188 of talipes calcaneus, 618 of equino-valgus, 623 -varus, 623 of equinus, 613 of valgus, 624 of varus, 624 of acute anterior poliomyelitis, 450 of torticollis, 483 of anchylosis, 219 of anterior bow leg, 429 of metatarsalgia, 542 of arthritis following infectious dis- ease, 211 of spine, 111 deformans at hip, 303 of bilateral dislocation of hip joint, 382 of bow leg, 426 of bursse at hip, 302 of knee, 326 of shoulder, 359 of calcaneo-bursitis, 547 of Charcot's disease, 218 of club hand, 436 of congenital absence of fibula, 607 of radius, 436 of ribs, 188 of tibia, 607 calcaneus, 604 club foot, 572 _ contraction of fingers, 437 at knee, 332 defect of pectoral muscles, 188 deficiencies of the foot, 608 dislocation of hip joint, 382 of shoulder, 430 elevation of scapula, 186 torticollis, 483 of coxa vara, 399 unilateral, 400 bilateral, 401 of displacement of peronei tendons, 556 of double tuberculous disease of hip joints, 284 of Dupuytren's contraction, 439 of elongation of ligamentum patellse, 331 of epiphysitis, 212, 300 at hip, 301 of extra-articular disease at hip joint, 301 of flat chest, 186 of foetal rhachitis, 367 of funnel chest, 188 of functional affections of joints, 472 of genu recurvatum, acquired, 333 congenital, 329 valgum, 417 varum, 426 of gonorrhceal arthritis, 210 of spine, 110 of hsemarthrosis, 217 Treatment of haemophilia, 217 of hallux rigidus, 549 valgus, 553 varus, 551 of hammer toe, 554 of hemiplegia, 463 of hereditary ataxia, 469 of hollow foot, 535 of hysterical club foot, 471 hip, 471 scoliosis, 471 spine, 116 of infantile scorbutus, 368 of infectious arthritis, 210 of knee joint, 325 of injury of hip, 300 knee, 324 spine, 109 of internal derangement of knee, 327 of knock knee, 412 of kyphosis, 184 of lateral curvature of the spine, 147 of lordosis, 185 of malignant disease of spine, 108 of mallet finger, 438 of neuritis, 469 of neurotic joints, 471 of neurotic spine, 115 of obstetrical paralysis, 431 of osteo-arthritis, 215 at hip joint, 302 at knee joint, 325 -arthropathy, 371 of osteomalacia, 369 in childhood, 370 of osteomyelitis of spine, 108 of osteitis deformans, 370 of pain in lower part of back, 116 of paralysis, 450, 464, 468 in tuberculous disease of spine, 97 of paraplegia, 97, 464 of periarthritis of shoulder, 358 of pigeon chest, 187 of plantar neuralgia, 548 of prepatellar bursitis, 325 of pretibial bursitis, 326 of pseudo-hypertrophic muscular pa- ralysis, 468 of recurrent dislocation of shoulder, 432 of rhachitis, 365 foetal, 367 of rhachitic distortions, 365 of rudimentary or absent patella, 329 of sacro-iliac disease, 118 of sciatic scoliosis, 117 of scorbutus, 217, 368 of sinuses in tuberculous disease of hip joint, 289 of slipping patella, 330 of snapping knee, 332 of spasmodic torticollis, 487 of spastic paralysis, 463 torticollis, 486 of spina ventosa, 357 of spondylitis deformans, 114 646 INDEX. Treatment of spondylolisthesis, 117 of sprain of ankle, 343 chronic, 345 of wrist, 359 chronic, 359 of subluxation of wrist, 434 of synovial tuberculous disease of knee joint, 318 of synovitis, 324 chronic, 324 of syphilitic disease of joints, acquir- ed, 208 hereditary, 208 of syphilis of spine, 107 of talipes acquired, 613 calcaneus, 618 calcaneo-valgus, 622 -varus, 622 cavus, see Hollow Foot, 535 equinus, 613 equino-valgus, 624 -varus, 624 planus, see Weak Foot, 521 valgus, 624 varus, 624 congenital, 573 calcaneus, 604 calcaneo-valgus, 605 -varus, 605 cavus, 605 equinus, 604 equino-valgus, 605 -varus, 605 valgus, 605 varus, 604 of teno-synovitis, 347 of ankle, 347 of wrist, 360 _ of torticollis acquired, 483 congenital, 483 chronic, 483 spasmodic, 487 spastic, 486 of traumatic coxa vara, 402 separation of the epiphysis of head of femur, 403 of trigger finger, 438 of tuberculous disease of ankle joint, 339 of elbow joint, 352 of hip joint, 249 of knee joint, 311 of shoulder joint, 350 of spine, 58 of tarsus, 342 of wrist joint, 355 joint disease, 204 of typhoid spine, 110 of weak foot, 521 rigid, 527 of webbed fingers, 437 Trigger finger, 438 etiology of, 438 treatment of, 438 Trunk, deformities of, in anterior polio- myelitis, 448 Tuberculosis, arborescent synovial, 201 latent, 194 Tuberculous arthritis, acute, 212 disease of ankle joint, 334 abscess in, 334 situation of disease, 335 deformity of, 336 etiology of, 335 statistics of, 335 age at incipi- ency, table of, 335 age of patients treated at T ii b i n g en, table of, 336 frequency of, 334 statistics of, 334 pathology of, 334 ph ysical examination in, 337 prognosis in, 341 . statistics, final results, 341 symptoms of, 336 treatment of, 339 operative, 340 red ucti on of deform- ity in, 339 by plaster bandage, 339 Thomasbracein,340 removal of astrag- alus in, 340 description of operation, 340 bones and joints, 194 of elbow joint, 351 excision of elbow in, 353 description of operation, 354 final results of, 354 pathology of, 351 prognosis of, 353 statistics, age at incip- iency, table of, 351 situation of, 351 symptoms of, 351 treatment of, 352 operative, 353 reduction of defor- mity in, 352 Thomas metiiod of, 352 general dissemination of, 203 by operation, 203 of hip joint, 221 abscess in, 285 frecpiency of, 285 significance of, 286 treatment of, 287 bv aspiration, "288 INDEX. 647 Tuberculous disease of hip joint, treat- ment by incis- ion, 288 b y injection, 288 actual lengthening in, 238 shortening in, 236 causes of, 236 in the adult, 285 amputation in, 292 atrophy in, 234 Brackett's observa- tions on, 235 causes of, 234 theory of Saborin, 234 theory of Vulpian and Charcot, 234 changes in contour of the hip, 234 in combination, 284 deformities incidental to, 299 diagnosis of, 244 Rontgen ray in, 247 distortions of, 228 apparent lengthen- ing in, 229 shortening in, 230 explanation of, 229 mechanics of, 232 double, 283 treatment of, 284 examination in, method of, 240 physical, 240 excision of hip in, 290 functional r e- sults after, 290,_ 292 statistics o f, 289, 291 _ exploratory operations in, 289 etiology of, 224 general symptoms of, 240 debility, 240 fever, 240 history of, 240 in infancy, 285 local signs of, 244 measurements in, 241 method of estimating degree of dis- tortion in, 242 Kingsley's ta- ble, 244 Lovett's table, 242 of recording case in, 247 Tuberculous disease of hip joint, other deformities incidental to, 299 pathology of, 221 changes in the joint, 223 situation of disease, 223 prognosis in, 294 functional results of, 297 statistics of, 297, 298 mortality, 295 statistics of, 295 progression of symp- toms in, 249 reduction of deformity of, 256, 258' by osteotomy, 293 by plaster ban- dage, -^65 by Thomas splint, 263 by traction brace, 256 by weight and pulley, 268 relative frequency of, 196, 197, 224 retardation of growth in, 238 tables of, 238, 239 sinuses in, treatment of, 289 statistics of, 224 age, 197,^ 198. 225 age at incipiency, table of, 225 of deformity in, 248 sex, 197, 225 side affected, 197, 225 symfitoms of, 225 limp, 226 night cry, 226 pain, 226 reflex muscular spasm, 227 stiffness, 227 treatment of, 249 Bradford frame in, 271 chair for, 278 during convales- cence, 280 splints for, 280, 281 fixation in, 272 "high shoe" in, 254 Jiidson's brace in, 255 lateral traction in, 271 648 INDEX. Tuberculous disease of hip joint, treat- ment, long hip brace in, 276, 277 mechanical princi- ples of, 251 perineal bands in, 254 Phelps' hip brace in, 278 _ plaster spica band- age in, 266 application of, 266 reduction of de- formity in, 256, 263, 268, 293 "stilting" in, 273 Tavlor" s braces for, 276, 279 Thomas' splint in, 261 description of, 261 _ m o d i fi cation of, 264 traction brace, va- rieties of, 252 relative effici- ency of, 257 traction bracein, 251 traction, splinting, stilting, combin- ed in, 273 t racti on straps in, 253 of joints, synovial disease, 201 statistics of, 201 of knee joint, 304 abscess in, 318 statistics of, 318 treatment of, 318 bv aspiration, "318 by incision, 318 actual lengthening in, 310 shortening in, 310 amputation in, 321 arthrectomy in, 319 advantages of, 319 results of, 319 statistics of, 319 table of short- ening in, 320 deformity in, 322 statistics of, 322 diagnosis of, 310 differential, 310,311 etiology of, 305 excision in, 320 description of oper- ation, 320 mechanical support after, 321 results of, 321 selection of cases for, 320 Tuberculous disease of knee joint, func- tional results of, 322 statistics of, 322 general conclusions on, 323 mortality of, 322, 323 operations for relief, fi- nal deformity of, 321 pathology of, 304 primary distortions in, 307 \ prognosis of, 321 statistics of, 321 retardation of growth in, 310 statistics of, 310 secondary deformities of, 308 _ statistics of, 310 situation of, 304 statistics of, 304, 305, 306 age, 305 sex, 305 age at incipiency, table of, 306 symptoms of, 306 synovial disease in, 318 treatment of, 318 chloride of zinc in, 318 carbolic acid in, 205, 318 i o d o form injection in, 319 venous sta- sis in, 205 treatment of, 311 conservative, 312 during convales- cence, 317 forcible correction in, 314 mechanical, 314 Thomiis knee brace in, 314 description of, 315 the caliper brace in, 317 description of, 317 reduction of de- formity in, 312 by the plaster bandage, 313 by traction, 313 INDEX. 649 Tuberculous disease of knee joint, reduc- tion of, by the Billroth splint, 313 of shoulder joint, 348 abscess in, 350 pathology of, 348 prognosis of, 350 results of, 350 statistics, age at in- cipiency, table of, 349 statistics of frequency of, 348 symptoms of, 349 treatment of, 350 operative, 350 of spine, 17 at cervico-dorsal junction, 53 diiTerential diag- nosis, 54 complications of, 87 abscess, 87 in different regions, 88 treatment of, 89 deformity of, 17 effect of, 17 diagnosis in general, 57 etiology of, 21 forcible correction, deform- ity of, 101 Calot's opera- tion, 101 statistics, re- sults of, 102 selection of cases for, 102 gradual correction, deform- ity of, 104 Metzger-Goldthwait apparatus for, 105 history of, 33 local paralysis in, 98 lower cervical region, 52 lower region of, 35 characteristic atti- tude in, 35 difTerential diagno- sis of, 41 increased lordosis in, 35 lateral inclination of body in, 38 location of pain in, 38 pelvic abscess in, 40 treatment of, 90 psoas contraction in, 36 lumbar, peculiarities of in infancy, 44 middle region, 46 abscess in, 49 diagnosis of, 50 Tuberculous disease of spine, middle re- gion, symptoms of, 48 treatment of, 90 paralysis in, 93 duration of, 95 statistics of frequency liability to, in dif- ferent regions, 94 prognosis of, 95 time of onset of, 95 symptoms of, 95 treatment of, 97 operative, 98 duration of, 99 pathology of, 18 physical signs of, 34 principles of treatment of, 80 prognosis of, 24 rational signs of, 32 record of, 57 recurrence of, 100 regional examination in, 35 secondary deformities of, 100 statistics of, 21 age, 22 frequency, 21 sex, 22 situation, 22 symptoms of, 24 diagnostic, 25 general, 29 secondary, 28 treatment of, 58 anterior shoulder brace in, 66 of the different regions, special indications for, 83 horizontal fixation in, 60 apparatus for, 60 Bradford frame, 60 applica- tion of, 62 Phelps' bed, 60 reel i n a t i o n- gypsbet t e s, Lorenz, for, 60 wire cuirasse, 60 jury mast in, 73 mechanical, general principles of, 58 plaster jacket in, 70 principles of, 80 recumbency, indications for, 81 Taylor brace in, 63 measurements for, 64 application of, 64 650 INDEX. Tuberculous disease of spine, middle re- gion, Taylor head support in, 69 _ upper region, 51 symptoms of, 52 Thomas collar in, 79 sub-astragal oid joint, 339 diagnosis, 339 differential, 339 tarsus, 341 disease of individual bones, statistics of, 341 primary disease astragalo- scaphoid joint, 342 prognosis, 342 statistics of situation of, 341 treatment of, 342 wrist joint, 354 prognosis of, 355 statistics of, 354 age at incip- iency, table of, 355 symptoms of, 345 treatment of, 355 caries sicca in, 201 connective tissue in, 200 deposit of fibrin in, 200 diseases predisposing to, 195 etiology of, 194 extra-articular, 199 abscess in, 199 local predisposition to, 195 influence of injury in, 195 osteophytes in, 200 pathology of, 198 perforation of joint in, 200 predisposition to, 194 hereditary, 194 acquired, 194 prognosis of, 202 repair in, 202 rice bodies in, 201 seat of, 196 secondary abscess in, 200 secondary changes in, 200 septic infection in, 202 statistics of, 196 age, 197 distribution, 196 relative frequency, 197 statistics of results of, 203 sex, 197 side affected, 197 treatment of, 204 by drugs, 204 by local application, 204 carbolic acid, 205 iodoform, 204 venous stasis, 205 " white swelling " in, 201 teno-synovitis, 347 Tumor albus, see Tuberculous Disease of Knee Joint, 304 Typhoid fever, arthritis following, 211 Typhoid spine, 110 treatment of, 110 I TNILATERAL coxa vara, 396 U dislocation of hip, 378 genu valgum, 415 Upper extremity, deformities of, in an- terior poliomyelitis, 447 VALGUS, traumatic, 624 Vertebrae, absence of, 186 Vertebral column, stifihess of, see Spon- dylitis Deformans, 111 Volkmann's seat in lateral curvature of spine, 180 WEAK foot, 507 anatomy of, 508 in childhood, 519 out and in toeing as symp- toms of, 519 diagnosis of, 514 etiology of, 511 extreme types of, 517 pathology of, 511 rigid, 527 treatment of, 527 adjuncts in, 532 plaster strapping in, 532 forcible over-correction in, 527 systematic manipulation in, 527 Thomas, 532 symptoms of, 513 treatment of, 521 attitudes in, 522 brace in, 525 exercises in, 523 treatment, operative, 532 the shoe in, 521 support in, 523 varieties of, 516 Webbed fingers, 437 etiology of, 437 treatment of, 437 Weight, table of, 190 White swelling, see tuberculous disease of knee joint, 304 Willett's operation for calcaneus, 619 Wire cuirasse in treatment of Pott's dis- ease, 60 Wolff's law, 190 method of correction of confirmed club foot, 593 treatment of genu valgum, 423 Wrist, acute teno-synovitis at, 360 congenital deformities at, 434 joint, tuberculous disease of, 354 sprain of, 359 chronic, 359 treatment of, 359 treatment of, 359 subluxation of, 434 etiology of, 434 treatment of, 434 Wry neck, see torticollis, 474 y RD 731 W59^cT ^'^^'^'^'^^ '^"'"''^ A ''■eajise on orthopaedic surqer' 2002306735 .1,! 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