Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/deformitiestreatOOtubb DEFOEMITIES A TEEATISE OX OETHOP.EDIC SUEGEEY DEFOEMITIES A TKEATISE ON OKTHOP^DIC SUEGERY INTENDED FOE PEACTITIONEES AND ADVANCED STUDENTS BY A. H. TUBBY, M.S. LoND., F.E.C.S. Eng. ASSISTANT-SURGEON TO, AND IN CHARGE OF THE ORTHOPEDIC DEPARTMENT, WESTillNSTEE HOSPITAL : SURGEON TO THE NATIONAL 0RTH0P.€:DIC HOSPITAL ; SURGEON TO OUT-PATIENTS, EVELINA HOSPITAL FOR SICK CHILDREN ; JOINT HONORARY SECRETARY, BRITISH ORTHOPEDIC SOCIETY ; LATE SENIOR DEMONSTRATOR OF PHYSIOLOGY, GUY's HOSPITAL ILLUSTRATED WITH 15 PLATES AND 302 FIGURES, OF WHICH 200 ARE ORIGINAL AND BY NOTES OF 100 CASES Hontion MACMILLAN AND CO., Ltd. NEW YORK : THE MACMILLAN CO. 189 6 All rights reserved TO MANY FRIENDS AMONGST THE PAST AND PRESENT STUDENTS OF GUY'S HOSPITAL THIS VOLUME IS INSCRIBED BY THE AUTHOR PREFACE This volume is the outcome of several years' work at the National Orthopfedic Hospital, the Evelina Hospital for Sick Children, and for a shorter time in the Orthopaedic Department at the Westminster Hospital. Almost all the cases quoted are from my note-books, and 200 of the illustrations have been drawn from my patients specially for this work. The observations on the " Eepair of Tendons," a subject so ably handled by Mr. Adams several years ago, have been repeated by me from the standpoint of the wider pathological horizon of the present day. It has been my endeavour to make myself acquainted, by direct observation, with the methods of treatment practised in Orthopedic Clinics abroad as well as at home, so that most of the details have been personally verified. The object, however, of this treatise is not only a record of one's own work, but also to give a succinct account of our knowledge on the subject of " Deformities." I have not, therefore, hesitated to avail myself of the writings of Bradford and Lovett, published in America ; of Ptedard in France ; of Hoffa in Germany ; of Adams, Eeeves, Walsham and Hughes in this country. Above all, I cannot omit to express my sense of indebtedness to the many admirable writers who have recorded their experiences in the Transactions of the Amei'ican Orthapedic Association. Some of the material hals from time to time appeared in the pages of the Hospital, and 1 have to acknowledge the permission of the editor of that journal to reproduce it here. viii DEFORMITIES In the matter of Plates and Figures, my best thanks are due to Mrs. E. Davis and J\Ii-. Prendergast Parker, for the care with which they have made the drawings ; to Mv. ¥. Gustav Ernst, for per- mission to make use of many of the illustrations in his work on Orthopa3dic Apparatus ; and to my publishers, Messrs. Macmillan, for the liberality with which they have met my wishes for a fully illustrated volume. To Mr. Vincent Moxey and to Air. W. Spencer Payne I am grateful for valuable suggestions and assistance in seeing the work through the press. The practice of Orthopcedic Surgery in England does not include all phases of diseases of the bones and joints, such as tubercular ostitis and arthritis of the hip and knee, on what grounds it is difficult to understand ; nor in such a work as this would it be customary to write on many congenital deformities, such as cleft palate and hare-lip, which are within the domain of Plastic Surgery. That this volume may l;)e a reliable guide to medical men in the treatment of deformities, and to advanced students in the under- standing of a somewhat difficult branch of surgerv, is the wish of THE AUTHOE. 25 "Weymouth Street, Portland Place, W. June 1896. CONTENTS PAGE Preface .......... vii SECTION I DEFORMITIES OF THE SPINE CHAPTER I CARIES OF THE SPIiS^E OR ANGULAR DEFORMITY Definition — Etiology, Age, Sex, Tubercular Diathesis, Heredity, — Causation — Pathological Anatomy — Natural Methods of Cure — Results of Spinal Caries, Deformity, its Causation, Co-existence with Lateral Deviation, Causes of Increase in Amount of Deformity — Abscess, its Frequency, Direction taken by Pus, Contents, Future Course — Compression -Paraplegia, its Causation, Frequency, Pathological Anatomy, Symptoms, Prognosis and Diagnosis . 3 CHAPTER II CARIES OF THE SPINE (ANGULAR DEFORMITY) {continued) Symptoms of Uncomplicated Caries — Method of Examination — Diagnosis from Rhachitic Kyphosis, Senile Kyphosis, Hysterical Spine, Scoliosis, Malignant Disease of the Spine, Hip Disease, etc. — Prognosis of Spinal Caries without and with Abscess as to Age, Sex, Family History, Social Condition, and Danger to Life — The Prognosis of Abscess as to Region of the Spine involved, Sex, Age, Presence of other Complications and Methods of Treatment . . 29 CHAPTER III THE TREATMENT OP CARIES OF THE SPINE AND ITS COMPLICATIONS General and Local Treatment of Uncomplicated Caries — Treatment of Abscess, and Discussion of the various Methods — Treatment of Compression-Paraplegia, Con- servative and by Operation — Atlo-axoid Disease — Syphilitic Disease of the Spinal Column — Malignant Disease of the Spine — Neuromimetic or Hysterical Spine . . . . . . . . . .49 DEFORMITIES CHAPTER IV SOME POINTS IN THE PHYSIOLOGY OF THE SPINAL COLUMN PAGE General Remarks — Division of the Spinal Column into Anterior or Supporting and Posterior or Protecting Columns — The Four Curves, Cervical, Dorsal, Lumbar, and Sacral, and their Origin- — Existence of a Curve normally to the Right Side — Movements of the Spine — Centre of Gravity of Spine — Contrast between tlie Infantile and Adult Spine . . . . . . .84 CHAPTER V CONDITIONS AFFECTING THE SPINE OTHER THAN POTT'S DISEASE AND CAUSING KYPHOSIS Kyphosis of Infancy, Childhood, Adolescence, Adult Life, Old Age — Hereditary Hump-back — Kyphosis from Rheumatoid Arthritis, Rheumatism, Gonorrheal Rheumatism, Occupation, Osteitis Deformans, Osteo-malacia — Spondylitis — Round Shoulders. . . . . . . . .90 CHAPTER Yl LORDOSIS Static Lordosis — Lordosis of Nerve or Muscular Origin — Compensation Lordosis — Lordosis of Osteopathic Origin — Spondylolisthesis . . . .99 CHAPTER VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE Definition — Distinctions between Lateral Deviation and Rotation — Scoliosis, General Considerations, Clinical Aspects — Varieties of Scoliosis — Classification of Scoliosis — Scoliosis of Adolescents, including "Occupation" Scoliosis — Its Causes, Predisposing and Exciting — Methods of examining a Case of Scoliosis — Symptoms and Course of Scoliosis of Adolescents — Stages of Scoliosis — Morbid Anatomj' of Scoliosis ........ 102 CHAPTER VIII SCOLIOSIS (continued) Pathogenesis of Scoliosis, Experiments of Judson and Others — Congenital Scoliosis — Khachitic Scoliosis — Scoliosis of Nerve Origin — Static Scoliosis — Scoliosis of Cicatricial Origin — Scoliosis associated with Nasal and Naso-Pharjmgeal Obstruction — Diagnosis of Scoliosis in General — Prognosis of Scoliosis . . 141 CONTENTS xi CHAPTER IX THE PREVENTION AND TREATMENT OF SCOLIOSIS PAGE Preventive Measures — General Treatment of Scoliosis — Local Measures — Re- cumbency — Postural Methods — Exercises — Methodical Correction — Supports — Indications for the Various Methods of Treatment at different Ages and Con- ditions of the Spinal Column ...... 162 SECTION II DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES CHAPTER I TORTICOLLIS OR WRY-NECK Varieties of Torticollis — Etiology and Causation — Cases illustrating various Points — Pathological Anatomy — Symptoms — -Prognosis — Diagnosis — Treatment of Congenital Torticollis — Methods of Operating — After-Treatment — Treatment of Spasmodic Torticollis, General and Operative — Section of Spinal Accessory Nerve, and of Posterior Nerve-Eoots ....... 185 CHAPTER II DEFORMITIES OF THE THORAX Congenital Deformities of the Chest, affecting the Sternum, Ribs, and Cartilages — Acquired Deformities arising from Rhachitis, Adenoids, and Spinal Dis- tortions ......... 208 CHAPTER III CONGENITAL DEFORMITIES OF THE HAND AND FINGERS Club-Hand — Congenital Contraction of the Fingers — Supernumerary Fingers — Suppression of the Fingers — Webbed Fingers — Hypertrophy of the Fingers — Congenital Lateral Deviation of the Fingers — Congenital Furrowing of the Limbs 214 Xll DEFORMITIES CHAPTER IV ACQUIRED DEFORMITIES OF THE HAND PAGE Dupuytren's Contraction, Etiology, Causation, Symptoms, Diagnosis, and Treat- ment, Various Methods of Operating — Traumatic Contraction of the Forearm, Wrist, and Fingers — Jerk-, Snap-, or Spring-Finger — Mallet-Finger . . 231 SECTION III RHACHITLS AND THE RESULTING DEFORMITIES CHAPTER I RHACHITIC DEFORMITIES Varieties of Rickets, Congenital, Infantile, Rickets of Adolescence — Etiology — Morbid Anatomy — Symptoms — General Treatment — Deformities of the Skull, Neck, Spine, Cliest, Arms — The Rhachitic Attitmle .... 253 SECTION IV DEFORMITIES OF THE LOWER EXTREMITY CHAPTER I INCURVATIOX OF THE NECK OF THE FEMUR (COXA VARA) General Account of the Deformity — Etiology — Symptoms — Pathology — Diagnosis — Prognosis — Treatment ....... 263 CHAPTER II GEN a VALGUM, VARUM, RECURVATUM, AND BOW-LEGS Genu Valgum, Varieties, Causation, Morbid Anatomy, Symptoms, Prognosis, Diagnosis, and Treatment — Osteoclasis and Osteotomy — Genu A'arum, Causes and Treatment — Genu Recurvatura — Curved Tibia and Fibula — Syphilitic Curvature of Tibia ........ 271 COXTEXTS CHAPTER III CLUB-FOOT GENERAL COXSIDERATIOXS PAGE Varieties and Causation of Club-Foot — Its Frequencj- — A Method of Exainiuing Club-Foot — General Principles of Treatment — The Processes concerned in the Union of Tendon — The Author's Experiments and Deductions . . 306 CHAPTER IV THE VARIOUS FORMS OF CLUB-FOOT Talipes Equinus, Degrees and Varieties, Morbid Anatomy, Symptoms, Prognosis, Treatment — Talipes Calcaneus, Forms, Symptoms, Diagnosis, and Treatment — Talipes Calcaneo- Valgus and Calcaneo- Varus — Talipes Arcuatus and Plantaris (Pes Cavus) — Talipes Varus — Talipes Valgus and Pes Planus — Talipes Equino- Valgus — Clinical Aspect of Union of Tendon ..... 328 CHAPTER Y CONGENITAL AND ACQUIRED TALIPES EQUINO-VARUS Paralytic and Spastic Equiuo-Varus — Congenital Ec^uino-Varus, its Appearances, Morbid Anatomy, Etiology, Obstacles to Reduction, Prognosis, and Diagnosis . 373 CHAPTER VI THE TREATMENT OF CONGENITAL EQUINO-VARUS Treatment of Slight Cases of Equino-Varus by Manipulation and Retentive Apparatus — Treatment of Moderate Cases of Equino-Varus by Tenotomy, Fasciotomy, Use of Retentive Apparatus, and Wrenching — Tenotomy and its Technicpie — Syndesmotomy — Inversion of the Limb and its Treatment . 399 CHAPTER VII TBE TREATMENT OF CONGENITAL EQUINO-VARUS {continued) The Treatment of Resistant Equino-Varus by Gradual Methods, Forcible Measures, Wrenching, Phelps' Operation — Buchanan's Operation and Arbuthnot Lane's Modification — The Treatment of Inveterate Club-Foot hj Forcible Rectification, Tarsotomy, and Tarsectomy — The Forms of Tarsectomy — Astragalectomy — Discussion on the Merits of Tarsectomy — The Treatment of Paralytic and Spastic Equino-Varus — Relapsed Equino-Varus, its Causes and Treatment . 429 CHAPTER VIII ACQUIRED FLAT-FOOT OF ADOLESCENTS AND ADULTS Weak Ankles — General Description of Fiat-Foot — Degrees of Flat-Foot — Etiology — Pathology — Morbid Anatomy — Symptoms — Diagnosis — Prognosis — Treatment, General and Local — Treatment by Rest, Exercises, Apparatus, and by Operation ......... d58 DEFORMITIES CHAPTER IX OTHER ACQUIRED AND CONGENITAL DEFORMITIES OF THE FOOT I'AGE Metatarsalgia, Symptoms, Etiology, Diagnosis, Prognosis, and Treatment — Hallux Valgus or Bunion — Hallux Varus — Hallux Rigidus — Hammer-Toe — Congenital Deformities of the Toes . . . . . . • .489 SECTION V ANKYLOSIS, CONGENITAL DISPLACEMENTS, DEFORMITIES RESULTING FROM CEREBRAL AND SPINAL PARALYSES, ARTHRODESIS CHAPTER I CONTRACTURES AND ANKYLOSIS Definitions — Spurious Ankylosis and its Treatment — Ankylosis, Fibrous and Osseous, Causes, Prognosis, and Treatment — Osteotomy for Bony Ankylosis — Adams' and Gant's Operations for Ankylosis of the Hip . . . 511 CHAPTER II CONGENITAL DISPLACEMENTS (DISLOCATIONS) Congenital Displacements in General — Of the Hip, Frequency, Etiology and Causation, Mechanical Theories, Pathological and Physiological Theories — Anatomy of Congenital Hip Displacement — Symptoms — Prognosis — Diagnosis — Treatment by Recumbency and Extension, Paci's Method, and by Operation — Hoffa's and Lorenz' Operation — Summary of Treatment — Congenital Dis- placements of other Joints ....... f)22 CHAPTER III DEFORMITIES ARISING FROM CEREBRAL AND SPINAL PARALYSES Cerebral Paralysis in Cliildren — Causes — Symptoms, Early and Late — Diagnosis — Deformities and their Treatment — Spinal Paralysis in Children — Infantile Paralysis — Deformities of Arms, Truuk, and Legs — Paralytic Dislocations — Treatment by Mechanical and Operative Measures — Arthrodesis — Other Spinal Paralyses of Children ........ 549 LIST OF ILLUSTRATIONS PLATES PLATE I. Kinking of the Aorta II. Scoliotic Spinal Column III. Congenital Torticollis IV. Do. after Treatment V. Photo-micrograplis of Union of Tendon YI. Do. do. Til. Paralytic Talipes Equinns . VIII. Congenital Talipes Equino-Varus IX. Double Congenital Talipes Equino-Varus X. Congenital Talipes Equino-Varus XI. Do. do. XII. Inveterate Congenital Club-Eoot XIII. Paralytic Talipes Equino-Varus XIV. Ankylosis of the Hip XV. Do. after Treatment (A. H. Tubby) (R. W. Murray) A. H. Tubby) TO FACE PAGE 1.5 119 199 321 324 335 405 407 411 427 440 450 519 FIGUEES FIGIEE 1. Cervico-Dorsal Caries .... 2. Do. Front View . 3. Disease on either Side of Intervertebral Disc, extending to the Bodies 4. Multiple Foci of Disease in the Vertebral Column . 5. Complete Ankylosis of adjacent Vertebrs . 6. Extensive Destruction of the Bodies of the Vertebrte producing Extreme Deformity ...... 7. Caries of the Spine ..... 8. Lateral Deviation of the Spine 9. Extensive Deformity of the Spine from Caries, with much Compression of the Cord ...... 10. Caries of the Spine, with Lateral Deviation (Case 10) 11. Lateral Curvature of the Spine, with ^Marked Prominence of two Spinous Processes ......... PAGE 5 5 7 8 10 12 13 14 24 37 38 DEFORMITIES FIGURE 12. A Case in which the Vertebral Column was affected in two Regions 13. Double Lumbar Abscess from Spinal Caries in a Child, aged 15 months 14. Mr. F. R. Fisher's Bed-Frame for Cases of Spinal Caries (Ernst) 1.5, 16. Phelps' Box for Spinal Caries (after Kedard) 17. Poroplastic Jacket with Occipital Head-Piece (Ernst) 18. Taylor's Brace (H. L. Taylor) ..... 19. Dick's Spinal Apparatus (Ernst) ..... 20. Advanced Dorso-Lumbar Disease with Right Lumbar Abscess 21. A View of the Che.st showing the Changes in its Shape accompanying Caries of the Spine ...... 22. Po.sition assumed by the Head and the Fulness of the Neck in Cervical Caries {Holmes System of Surc/erij) .... 2-3. Odontoid Articulation of the Atlas separated by Ulceration 24. Vertical Antero-Posterior Section of Lumbar Spine showing Deposit of Gumma in the Third and Fourth (after Fournier) 25. Mr. Adams' Spinal Tray for Rhachitic Kyphosis (Ernst) 26. Back-board for Rhachitic Kyphosis (Ernst) . 27. Back View of Case 23, showing long C-curve to the Left, and Prominence of the Spinous Processes in the Dorso-Lumbar Region 28. Side View of Case 23 three Years after Onset of Curvature . 29. Lateral Deviation of Spine from Inequality in the Length of the Legs 30. Back View of Case in Fig. 29 after wearing a Boot with a Cork Sole for a Year 31. Scoliosis. C-shaped Curvature occupying the Dorsal Region, and General Kyphosis ........ 32. Diagram to illustrate the Position of the Ribs when tlie Curvature is to the Right in the Dorsal Region (Redard) .... 33. Illustrating the Alteration in Shape of the Ribs, and Deviation of the Transverse Diameter of the Thorax (Redard) 34. Scoliosis. Long C-curve to Left in Dorsal and Lumbar Regions . 35. Scoliosis. Two Curve.s, one in the Cervical and the other in the Dorsal Region ........ 36. Scoliosis with two nearly Equal Curves and considerable Dorsal Kyphosis 37. Scoliosis. Three Curves ...... 38. Front View of Fig. 37, showing Chest nearly Normal in Shape 39. Scoliosis with Projection of two Spinous Processes at the Intersection of the two Curves ....... 40. Scoliosis, with Reversal of Normal Lumbar Curve, and Posterior Projec- tion of the Lumbar Spinous Processes .... 41. Scoliosis with Reversal of Normal Antero-Posterior Curves 42. Side Views of Faulty and Correct Positions at Desk (after Redard) 43. Back Views of Faulty and Correct Positions at Desk (after Redard) 44. Piano-practice in a Bad Position (after Redard) 45. Piano-^jractice in a Correct Position (after Redard) . 46. Dorsal Scoliosis to the Right, from an Incorrect Position while Writing 47. Do. to the Left ...... 48. Back View of a Case of Intractable Scoliosis (Case 27) 49. Front View of Case 27 ..... . 50. 51. Case of Scoliosis after Measles and Pleurisy 52. Anterior View of the Lumbar Vertebrre from a Scoliotic Spine 53. Dorsal Vertebra from a Case of Scoliosis with the Convexity to the Right Side . . 54. Dorsal Vertebra from a Case of Scoliosis, Convex to the Right Side LIST OF ILLUSTRATIONS XVll from two Parallel and riGUKE 55. Scoliotic Dorsal Vertebra ...... 56. Front A"ie\v of the Bony Framework of the Chest from a Case of Scoliosis 57. Posterior View of Fig. 56 . 58. The Scoliotic Pelvis ....... 59. Effect of the Position in which a Child is held by its Xnrse in })roducin Scoliosis (after Redard) ....... 60. 61. Outlines of Curves ...... 62. Back View of a Child, aged '2 Years, suffering from Ricketty Scoliosis 63. Back View of a Child, aged .3^ Years, suffering from Marked Scoliosis dating from the Onset of Rickets ..... 64. Hysterical Scoliosis (after Redard) ..... 65. Scoliosis of Cicatricial Origin, and Secondary to Empyema (Case 83) 66. Front View of Case 33 ..... . 67. Scoliosis following Pleuritic Effusion .... 68. Scoliosis associated with Adenoids ..... 69. Scoliosis of old-standing and associated with Adenoids 70. A Suitable Desk and Chair for Schools (N. Eng. School Furnishing Co.) 71. An Adjustable Desk and Chair for Schools Do. do. 72. The same as in Fig. 71, ready for Use Do. do. 73. Volkmann's Oblique Seat 74r. Semi-reclining Couch (Roth) 75, 76. The Effect on Spinal Curvature of Suspension Horizontal Bars (Adams) 77. Suspension from a Bar placed Obliquely (Adams) 78. Laced Shield Spinal Apparatus (Ernst) 79. Spring Plate and Laced Shield Spinal Apparatus (Ernst) SO. Adams' Spinal Stays (Ernst) 81. Poroplastic Jacket and Steel Supports (Ernst) 82. Congenital Torticollis. Before Operation (Case 34) 83. The Same, Cured .... 84. Congenital Torticollis to the Left (Case 38) 85. "Ocular " Torticollis from Astigmatism (Redard) 86. Posterior View of the same Patient as in Fig. 85 (Redard) . 87. Torticollis of iledium Severity ..... Very Severe Congenital Torticollis in a Young Child (Redard) Congenital Torticollis, showing Asymmetry of the Face The Same, after Treatment 91. Cervical Collar for Use in the After-Treatment of Congenital Torticolli (Ernst) ........ Sayre's Arrangement for Elastic Traction after Operation for Congenital Torticollis . . . . . . Mr. Adams' Wr3'^-Xeck Apparatus (Ernst) .... Congenital Funnel-Shaped Deformity of the Chest (Redard). Congenital Depression of the Sternum from a Patient aged 12 Years 97. Front and Half-Side Views of a Ricketty Chest Front View of Deformed Chest associated with Adenoids . Side View of the Same Pigeon-breast arising from Adenoids An extreme Condition of Pigeon-breast arising from Xaso-Pharyngeal Obstruction 102. Club-Hand of the Radio-Palmar Variety (Redard) 103. Do. do. (Case 42) 88 90 92. 93. 94. 95. 96, 98. 99. 100. 101. DEFORMITIES FIGURE PARE 104. The Same, after Treatment . . . . . .216 105. Congenital Contraction of the Little Finger of the Left Hand in a Girl aged 15 Years ........ 219 106. Right Hand of the same Patient ...... 219 107. Congenital Contraction of the Ring and Little Fingers in a Boy aged 5 Years . . . . . . . ". .220 108. Contraction of the Hand said to have existed from Birth . . . 222 109. Front View of the same Hand after Section of all the Flexor Tendons at the Wrist ......... 222 110. Congenital Contraction of the Little Finger on the Right Hand, and of the Ring and Little Fingers on the Left Hand (Case 43) . . . 222 111. A View of the Left Hand in Case 43 showing Hyper-extension of the First Phalanges in Congenital Contraction of the Fingers . . . 223 112. The Condition of the Hands in Fig. 110 after Treatment by Operation and Manipulation ........ 223 113. Congenital Contraction of Little Toes in Case 43 .... 224 114. Polydactylism (after Eedard) ...... 225 115. The Bifurcated or Double Hand (after Redard) . . . .225 116. Diagram of Incision and Flaps in Didot's Operation (after Reeves) . 226 117. Transverse Section showing Method of Adjusting Flaps in Didot's Operation (after Reeves) ....... 226 118. Diagram of Incisions and Flaps in Zeller's Operation (after Reeves) . 227 119. Do. do. Norton's Operation (after Reeves) . 228 120. Hypertrophy of the Fingers (Hawkins Ambler) .... 229 121. Congenital Furrowing of the Forearm and Intra-Uterine Amputation of Fingers (after Redard) ....... 230 122. Commencing Dupuytren's Contraction of the Hand and Gouty Arthritis about the Metacarpo- Phalangeal Articulation of the Ring Finger (Case 46) 235 123. A Dissection illustrating the Contraction of the Palmar Fascia in Dupuy- tren's Contraction (Druitt) ...... 237 124. 125, 126. Three Stages in Dupuytren's Contraction (Fig. 126 is after Pedard) ......... 238 127. Contracted Finger from Sloughing of Tendon-Sheath after Whitlow . 240 128. 129. Two Forms of Mr. Adams' Metal Splint for U-se immediately after Section of the Palmar Fascia for Dupuytren's Contraction (Ernst) . 241 130. Extension-Instrument for Use after Section of Palmar Fascia (Ernst) . 242 131. Contraction of the Hand from Pressure of Scar-Tissue on the Median Nerve ......... 244 182. The Same, after Operation ....... 244 133. Mallet-Finger (Abbe) ....... 247 134. The Reverse Deformity to Mallet-Finger, occurring in Base- Ball Players (Abbe) . . . . . . . . .248 135. Ulnar Displacement and Contraction of Fingers in Osteo-Arthritis . 249 136. Late Rickets (Glutton) ....... 254 137. Well-marked Ricketty Chest and Prominent Abdomen . . . 258 138. Ricketty Curve of Radius . . . . . . .259 139. Typical Rhachitic Attitude ....... 260 140. Incurvation of Xeck of Femur (R. Whitman) .... 264 141. Outline of the Deformity in Hofla's Specimen (P.. Whitman) . . 264 142. Incurvation of the Neck of the Femur (R. Whitman) . . . 264 143. Front View of Case 53 (R. AVhitman) ..... 266 144. Back View of Case 53 (R. Whitman) ..... 266 LIST OF ILLUSTRATIONS XIX 147. 148. 149. FIGURE 145. Involuntary Adduction on Flexion of Legs in Case 53 (R. Whitman) 146. Aj)parent Shortening of the Legs relative to the Length of the Body (R. Whitman) ....... Unilateral Coxa Vara (R. Whitman) .... Do. Effect of Flexion of Thigh in increasing Promt nence of Trochanters (R. Whitman) .... Cross Section of Pelvis and Deformed Femur (R. W^hitman) 150. Outlines showing the Effect of Siib-Troehauteric Osteotomy in overcomin the Adduction of the Limb (R. Whitman) 151. Extreme Ricketty Deformity and Knock-Knee 152. Unilateral Genu Valgum arising from Injury 153. Disappearance of the Deformity in Genu Valgum on Flexing the Knee (after Reeves) ....... 154. 155. Knock- Knee before and after Treatment by Apparatus alone . 156. Walking Apparatus for Severe Genu Valgum (Ernst) 157. Osteotomes and Mallet (after Redard) .... 158. Method of grasping Osteotome (after Redard) 159. 160. Genu Valgum before and after Osteotomy . . . 161. Genu Varum of Rhachitic Origin (after Redard) 162. Genu Varum in the Left Limb complementary to Genu Valgum in the Right Limb (after Redard) . . ' . . Epiphysiary Genu Varum (after Redard) .... Genu Recurvatum of Paralytic Origin (after Redard) Curved Tibiae and Fibulfe from Rickets .... Spontaneous Rectification of Ricketty Bone (after Oilier) . Tibial Instrument (Ernst) ...... Side View of Congenital Syphilitic Curvature of Tibise (Case 57) . Front View of the Same ...... 170. Congenital Syphilitic Curve of Tibia (Case 58) 171. Congenital Syphilitic Curvature ..... 172. Suppurative Syphilitic Epijthysitis of Lower Ends of Radius and Tibia 173. Epiphysitis of Upper End of Humerus from Congenital Syphilis . 174. Paralytic Talipes Equinus, before and after Treatment Paralytic Talipes Equinus. Position assumed by the Feet when the}^ ar suspended ........ Paralytic Talipes Equinus. Position assumed by the Feet when th Patient is Lying Down . . . . 177. Infantile Paralysis ....... 178. Walking Apparatus for After-Treatment of Talipes Equinus (Ernst) The same Apparatus, double to Calf (Ernst) Congenital Talipes Calcaneus ..... Talipes Calcaneus from slight Paralysis of Calf Muscles Walking Apparatus for Talipes Calcaneus with Toe-Depressing Spring (Ernst) ........ Z-method of shortening the Tendo Achillis, by the Author 184. Congenital Talipes Calcaneo-Varus in a Child aged 7 Weeks 185. Congenital Talipes Calcaneo-Varus in a Child aged 4 Months 186. Congenital Talipes Calcaneo- Valgus in a Child aged 9 Months 187. Double Congenital Talipes Calcaneo-Valgus in a Child aged 21 Months 188. Talipes Arcuatus in a Boy aged 5^ Years .... 189. The same Foot as in Fig. 188 Restored 190. Contracted Foot ....... 266 163. 164. 165. 166. 167. 168. 169. 175. 176. 179. 180. 181. 182. 183. XX DEFORMITIES riOURE 191. Talipes riaiitaris ....•■ 192. Tracings of Soles of Feet in Case 72 ... 193. Extreme Congenital Valgus from Absence of the Fibube (Meusel) 194. Rhachitic Talipes Valgus in a Child aged 18 Months 195. Rhachitic Talipes Valgus in a Child aged 2i Years 196. Spasmodic Eversion of the Foot after Injury to the Fibula 197. Congenital Talipes Equino- Valgus from Absence of the Fibula (after Redard) ......-• 198. Spastic Talipes Equino-Varus in a Woman aged 35 Years . 199. Extreme Spastic Talipes Ilquino- Varus in a AVoman aged 44 Years 200. Paralytic Talipes Equino-Varus ..... 201. Do. do. Three Views 202. Spastic Talipes Equino-Varus in a Boy aged 17 Years 203. Congenital Talipes Equino-A'arus ..... 204. Do. do. in an Infant aged 7 Weeks 205. Back View of Fig. 204 ..... • 206. Congenital Talipes Equino-Varus in an Infant aged 3 Months 207. Do. do. in an Adult aged 39 Years 208. Do. do. Tracing of the Sole of the Foot from Case associated with Spina Bifida .... Congenital Talipes E(iuino-Varus. Skeleton of Part of a Foot (after Redard) 209 210 211 Skeleton of an Adult Foot Associated with Genu Recurvatum Do. do. Do. do. (after Reilard) ....... 212. Relapsed Talipes Equino- Varus ..... 213. Congenital Talipes Equino-Varus of the First Degree in tlie Right Foot and of the Second Degree in the Left Foot 214. Flexible Metal Splint (Ernst) ..... 215. The Same Applied (Ernst) ...... 216. Mr. Adams' Amarus Splint (Ernst) ..... 217. Little's Rectangular Tin-Shoe (Ernst) .... 218. Tin-Shoe with Quadrant Movement at Heel (Ernst) 219. The Thomas Wrench (Robert Jones) .... 220. Reduction of the Amarus Part of the Deformity l)y the Thomas AA^renc (Robert Jones) ....... 221. Reduction of the Equinus Portion of the Deformity by the Thomas AVrench (Robert Jones) ....... 222. Reduction of the Adduction Deformity at the Medio-Tarsal Joint by th Thomas AVrench (Robert Jones) ..... 223. T-shaped Piece of AVood as used by Hahu to secure Good Position of Foot after Plaster of Paris has been applied (Halin) 224. Mr. Adams' Shoe with divided Sole-Plate (Ernst 225. Little's Double-Hinge Lever Shoe for A'arus (Ernst) 226. AValking Apparatus for the After-Treatment of Congenital Talipes Equino Amarus (Ernst) ....... 227. Little's Concealed Spring (Ernst) ..... 228. Talipes Equino- A' arus witli Excessive Inward Rotation in the Bones of th Leg ....... ■ 229. Congenital Talipes Equino-A'arus ..... 230. Inversion of the Foot remedied by Osteotomy of the Tibia and Fibula 231. Congenital Talipes Equino-A^arus of the Third Degree before Treatment 232. The same Case after Treatment ..... LIST OF ILLUSTRATIOK"S XXI AVhitman) the Treatment of Flat FIGURE 233. Case 89 before Treatment . 234. Case 89 after Treatment 235. 236. Club-Foot Stretcher (Morton) . 237. Congenital Talipes Equino-Yarus 238. Severe Eelapse after Tarsectomy on both Feet 239. Hysterical Talipes Equino-Yarns 240. Relapsed Congenital Talipes Equino-Yarus (Case 90) 241. Back Yiew of the same Feet 242. Case 90 after Treatment 243. Static Flat-Foot 244. Syphilitic Fiat-Foot (Case 91) 245. 246. Static Fiat-Foot, before and after Treatment (Case 92) 247, 248. Pronounced Fiat-Foot (Case 93) 249. Outline of Xormal Foot 250. Outline of Fiat-Foot 251. Outline of Flat-Foot due to Static Causes 252. 253. Outline of von Meyer's Triangle in the Normal and in the Flat-Foot (after Stokes) .... 254. Flat-Foot with Arthritic Changes (after Stokes, 255. Whitman's Valgus Sole-Plate for the Eight Foot (R 256. The Same Applied (R.Whitman) 257. 258. Whitman's Yalgus Plates (R. AYhitman) 259. Mr. Golding-Bird's Sling with Elastic Traction for Foot (Golding-Bird) 260. An Outside Steel Support (Golding-Bird) 261. The Sling in Position (Golding-Bird) 262. 263, 264. Spasmodic Yalgus, with Rigidity of the Communis Digitorum 265, 266, 267. Gleich's Operation (after Stokes) 268, 269, 270. Sir William Stokes' Operation of the Removal of a Wedge Portion of Bone from the Xeck and Head of the Astragalus 271. Morton's Disease. Tracing of the Sole of a Foot 272, 273. Hallux Valgus 274. Spring for the Treatment of Bunion (Ernst) 275, 276. Hammer-Toe 277. Do. 278. T-Spring for Hammer-Toe (Ernst) 279. Hammer-Toe Cured . 280. 281, 282. Lobster-Claw Deformity 283. Partial Suppression of the Fingers 284, 285. Bilateral Congenital Displacement of the Hip-Joint (after Redard) 286, 287. Do. do. 288. Unilateral Congenital Displacement of the Hip- Joint (Redard) 289. Mr. Adams' Extension-Couch for Congenital Displacement of the Hip Joint (Ernst) ..... 290. The Same. Tilted for Meals, etc. (Ernst) . 291. Case 98, fitted with Walking Apparatus and Crutches 292. Case 98, one Year later than in Fig. 291 . 293. Ernst's Walking Apparatus for Unilateral Congenital Displacement of the Hip (Ernst) 294. Thomas' Hip-Splint (H. 0. Thomas) 29.'.. The Same Applied (H. 0. Thomas) Peronei and Extensor Shaped PAGE 431 431 434 436 447 452 456 456 456 459 460 462 464 465 465 467 469 473 479 479 480 481 481 481 483 485 487 490 495 497 501 502 503 504 505 506 526 531 534 536 537 539 539 541 546 546 DEFORMITIES FIGURE I'ACR 296. Infantile Paralysis of the Lowei- Part of the Trapezius and of tlie Serratus Magnus ......... 5.53 297. Infantile Spinal Paralysis of the Lower Extremities with Multiple De- formities (after Redard) ....... 555 298. Infantile Paralysis, with Genu Recurvatum and Talipes Varus on the Left Side ......... 556 299. Apparatus for Complete Paralysis of the Lower Extremities (Ernst) . 558 300. 301, 302. Flail-like Ankle-joint, due to Infantile Paralysis and suitable for Arthrodesis ........ 561 SECTION I DEFORMITIES OF THE SPINE CHAPTER I CARIES OF THE SPINE OR ANGULAR DEFORMITY Definition — Etiology, Age, Sex, Tubercular Diathesis, Heredity — Causation — Patho- logical Anatomy — Natural Methods of Cure — Besults of Spinal Caries, Deformity, its Causation, Co-existence with Lateral Deviation, Cayuses of In- crease in Amount of Deformity — Abscess, its Frequency, Direction taken by Pas, Contents, Future Course — Comjn^ession Paraplegia, its Causation, Frequency, Pathological Anatomy, Symptoms, Prognosis and Diagnosis. Synonyms. — Yin^ish., Angular Curvature (an incorrect expression, and a contradiction in terms), Pott's Disease, Kyphosis, Spondylitis; German, Die Pott'sche Kyphose, Spitzbuckel, or Winckelformige Knickung der Wirhelscmle ; French, Cypliose or Mai de Pott. Definition. — A morbid process occurring in the vertebrae, fre- quently accompanied by destruction of bone and resulting in deformity. Camper and Seyerin directed their attention to this disease ; but to Percival Pott, Surgeon to St. Bartholomew's Hospital, must be ascribed the honour of accurately describing it in 1779. Numerous surgeons in the latter part of the last century and in the present have further depicted it, but have succeeded in adding little to Pott's description. The discovery of the tubercle bacillus, however, by Koch in 1882 placed the whole question of chronic bone disease in a new light. Etiology. — This may be looked at from several points of view. Age. — The disease is most common during the years of active growth, and notably in early childhood; and frequently follows exanthemata. The results of statistics differ considerably, but a review of several collections shows that the larger the total of cases the greater is the preponderance of the disease in children under 5 years of age. Mohr^ found that of 72 cases, 29 per cent occurred ^ Quoted by Bradford and I^ovett,' Ortliop. Surg. New York, 1890, pp. 9 and 10. DEFORMITIES OF THE SPIXE between the first and fifth years. Drachman noted that in IGl cases, 41 per cent occurred at this period of lite, the youngest being eight weeks. Taylor found that of 376 cases, GO per cent were under 5 years. The common occurrence of the disease so early in life, and the rapid diminution of the number of cases up to the age of 25 should not, however, cause us to overlook the possibility of its onset in middle life and old age. It is undoubtedly a rare event in declining years. Mr. Howard Marsh ^ was able to cite only three cases in people over 60 years; one of a man, aged 65, who developed disease of the cervical spine with displacement and projection, followed by an abscess: a second in a patient, aged 64, under Mr. Butlin's care ; a third the case of a clerical dignitary, who died at the age of 72 years. A post-mortem examination in the last-men- tioned case revealed much erosion of the lateral masses of the atlas, the axis, and of the body of the third cervical vertebra, such as occurs in childhood. Sir James Paget speaks of a case in a patient aged 55, and Drachman says he knew of a case in a man aged 77. Such cases are probably instances of a form of " Senile Scrofula," the subject of one of Sir James Paget's Clinical Lectures and Essays. Tlu Sex does not appear to exercise any particular influence. All statistics agree in that, unlike scoliosis, it is quite as frequent in girls as in boys. Nor is this to be wondered at if we remember that girls before puberty exercise their limbs as freely, and often run as nearly equal risks of injury as boys. Tuberculosis. — A very large proportion of cases are either due to, or aggravated by tuberculosis, the hereditary nature of which is universally conceded. Gibney " found a hereditary taint in 7 6 per cent. In 35 per cent this was traced to the father, in 38 per cent to the mother, and in 3 1 per cent to both. In 1 5 per cent tubercular disease existed in other children of the same family ; and in 1 6 per cent the taint was manifested in both parents and children. These and similar observations in the same direction point to tuberculosis as the great factor in the etiolog}", whether the predisiDosition be congenital or acquired. In the latter case the inherent weakness is often traceable to an attack of measles, scarlet-fever, or whooping- cough. Grafted on to the tubercular history is frequently that of traumatism. While admitting freely and without reserve that in the determination of the disease these two causes are often at work in very many instances, I am far from conceding that such universally ' Trans. Anicr. Ortko'p. Assoc, vol. iv. p. 235. ^ Quoted by Bradford and Lovett, op. cit. p. 11. CHAP. I CARIES OF THE SPINE OR AIS'GULAR DEFORMITY 5 obtains. There are few parents who will not think of some slight fall or other accident to their child at the time when the illness was first noticed by them, the recollection of an accident being often un- wittingly assisted by leading questions on the part of the surgical attendant. It appears to me that the question may be summed up by remarking that in a large proportion of instances both factors are at work. Excellent examples are the following cases. Case 1. Pott's Disease following Injury in a Tubercular Patient. — Ethel D , aged 23, a dancer at one of the London Music Halls, came ym. \ 1%,V ^^' \ 1 : 1 \ % Fig. 1. — Cervico-dorsal caries (Case 2). Fig. 2. — Front view of the patient in Fig. 1, show- ing the deformity of the chest in dorsal caries. to me at the National Orthopaedic Hospital in March 1893, complaining of ]jain at the lower part of the back and inability to dance. I found projection of the fourth lumbar vertebra, with rigidity of the spinal muscles and pain, and advancing phthisical mischief in the right lung. Case 2. — Walter H , aged 6 years, came to the same Hospital in June 1893. He fell from the top of an omnibus on his head twelve months previously, and now presented angular deformity limited to the first four dorsal vertebrae, with lateral deviation of the spine to the right in the loAver dorsal and lumbar regions (see Fig. 1). He was sufferino- also from strumous ophthalmia. DEFORMITIES OF THE SPINE In many other cases the history of traumatism is so equivocal or entirely absent ^ that one is forced to infer that tubercular deposits in the spine are solely responsible for the disease. Traumatism. — In a minority of instances however, the absence of hereditary tubercular taint, the distinct history spontaneously volunteered of a severe fall or accident, the subsequent benign pro- gress of the disease unaccompanied by suppuration, and frequentl}' the complete cure, with ankylosis it is true, force us to recognise that simple traumatic ostitis in the adult and epiphysitis in children are alone responsible. A good example of this is the following case. Case .3. Traumatic Foil's Disease. — A. G., aged 40 years, fell from a height, severely straining the back in attempting to save himself from falling. He developed all the symptoms of Pott's disease, and lay recumbent for six years. He completely recovered Avithout complica- tions, and is now well able to bear the fatigue and strain of active exercise, such as mountain climbing, with comparatively little inconveni- ence, in spite of ankylosis of the lumbar spine. Another cause is syphilitic disease of the vertehrcc. It may be acquired or congenital. An instance of the latter form is quoted by Eeeves," who " at the London Hospital had a case of syphilitic caries a few years back, in which the boy coughed up portions of the vertebrfe which had penetrated the lung." In whatever way the disease is acquired, in the structure and functions of the spine there are conditions which predetermine its onset and facilitate its persistence. Such are, the rapid rate of growth of the spine, its liability to frequent jarring, the great amount of cancellous tissue in the bodies of the vertebrae, the pressure of the superincumbent weight of the body, and the exceeding mobility. Pathological Anatomy. — - Localisation. — The region most frequently involved is the dorsal. On this point nearly all authors are agreed. Of a series of 100 cases observed by Eedard at the Dispensaire Furtado-Heine, 6 were in the cervical, 5 in the cervico- dorsal, 62 in the dorsal, 5 in the dorso-lumbar, 20 in the lumbar, and 2 in the lumbo-sacral region.^ E. W. Parker, quoted by Erichsen,^ gives the following figures : cervical, 9 ; dorsal, 82 ; dorso- lumbar, 21 ; lumbar or lumbo-sacral, 37, out of 149 cases. To be ^ Cf. case by Sayre, Orthopedic Surg. p. 277. - Bodily Deformities and their Treatment, p. 133. * Traiti de Chirurgie OrthopMique, p. 232. ■* Science ami Art of Surg. 8th ed. vol. ii. p. 421. CHAP. I CARIES OF THE SPINE OR ANGULAR DEFORMITY 7 more precise as to the individual vertebrae involved, I may perhaps quote further statistics. As there are more dorsal than cervical or lumbar vertebrae, it is natural that the disease should commence more often in the mid-redon of the back. Mohr found that in 6 -" ^^' ^-PJ^ Fig. 3.— Disease on either side of the intervertebral disc, extemliug to the bodies (Guy's Hospital Museum, 102130). adults the twelfth dorsal and first lumbar vertebrae were most frequently the seat of the disease, the second dorsal the next in frequency, then in the fourth dorsal and fifth lumbar nearly as often. My own observations incline one to the belief that the vertebrae from the eighth dorsal to the first lumbar are the most frequently attacked. DEFORMITIES OF THE SPINE Hie Fart of the Vcrtehrcc first attacked. — This is luidoubtedly the bodies, owing to the influence of the superincumbent weight and their cancellous structure. It is stated, although I do not know on whose authority, that quadrupeds do not suffer from spinal caries. A case, however, of spinal caries in a dog was shown by Mr. W. G. Spencer at the Pathological Society, in which two dorsal and four lumbar vertebra; were affected. The intervertebral disc and the adjacent surfaces of second and third lumbar vertebrie were destroyed by ulceration. Siuuses, three on one side and two on the other side of the back, were present during life.^ It is needful to remember that in childhood each vertebra has an epiphysial plate on its upper and lower surface. So that the disease in many cases, reasoning by analogy with other bones of the body, commences as a juxta-epiphysitis, tubercular or traumatic. This is supported by direct observation (Fig. 3). From the epiphysis it invades the intervertebral disc on the one side, or spreads to the body on the other side. Not infrequently the first sign of caries is seen at the anterior aspect beneath the anterior com- mon ligament. It may, however, begin in the centre of the body ; and I am inclined to regard cases so beginning as purely tubercular ; or the disease may commence in the lateral or posterior^ aspect of the body. It is of much importance, however, not to overlook the fact that several foci may be formed simultaneously in different vertebrae (see Fig. 4). The opinion ex- pressed that the intervertebral discs are the starting-jDoints of the disease may be dismissed on histological and pathological grounds, although Luschka ^ states there is a synovial membrane in each disc, and that the lobes of the pulp correspond to Fig. 4.— Multiple foci of disease the villi of a Synovial membrane. This statement I have l:»een quite unable to verify. I have made numerous observa- tions on the intervertebral discs of children, adults, and animals, and in the vertel iral column (Guy' Hospital Museum, 1289'*-'^). 1 Path. Soc. Trans. 1890, vol. xli. p. 341. - Quoted by Erichsen, Science and Art of Surgery, 8th eJ. vol. ii. p. 417. * Cf. case alluded to liy Barker, System of Surg. 3rd ed. vol. ii. p. 404, with plate on p. 403. CHAP. I CARIES OF THE SPINE OR ANGULAR DEFORMITY 9 have seen no trace, either with the naked eye or with the micro- scope, of such a cavity. Undoubtedly the discs soon become invaded secondarily to the bone, and partially or wholly disappear. Affection of other parts of the vertebrte is unusual. The spinous process alone may suffer. A good example of this is quoted by Ashby and Wright.^ Case 4. Necrosis of Cervical Spinous Process. — "E. H., aged 4 years and 5 months. Six weeks ago a hard lump was noticed at the back of the neck, he having a fortnight before fallen on the back of his head ; the swelling had formed gradually, but he had neither pain nor tender- ness. On admission he was well nourished ; there was a large fluctuating swelling in the middle of the back of the neck ; on opening it about three drachms of healthy pus escaped ; the tips of one or more of the spines were bare. The abscess continued to discharge for five months through a small sinus. Subsequently a sequestrum consisting of the spinous process was removed, and he quite recovered." Disease may occur in the costo - vertebral articulations and extend thence to the vertebree. I am unable to quote a case com- mencing in the transverse processes, although it is affirmed in several works that such has happened. No record exists of disease beginning in the articular processes.^ It is stated by Ashby and Wright ^ that disease of the costo - vertebral articulations may simulate spinal caries, " owing to the presence of radiating pain, and the formation of an abscess — possibly some cases of psoas abscess may be due to this cause." The diagnosis is made by the absence of curvature, the unilateral nature of the pain, and the absence of general rigidity of the muscles. To sum up, then, we are enabled to state that the disease starts in the bodies, rarely in the laminas or processes. But with regard to the exact fons ct origo mcdi in the bodies, it frequently happens on the j^ost-mortem table that the destruction has proceeded so far that all trace of the initial lesion is lost. Events of the Inflammatory Process. — Beginning as a carious process, the lesion is always accompanied by the formation of granu- lation tissue.^ The succeeding events vary considerably. In some instances the granulation tissue is absorbed almost as fast as it is formed, the affected bone disappearing gradually without the forma- 1 Diseases of Children, p. 561. ^ j^^-^^, p_ 561. 3 /^^-^^ p_ 572. •^ For the exact processes in caijies of bone, I must refer my readers to works on Surgical Pathology. 10 DEFORMITIES OF THE SPIXE tioii of pus — caries sicca — resulting often in considerable deformity.^ In other cases the granulation tissue breaks down, abscesses form, and make their way to the surface. In more rapid cases before the affected bone has been replaced by granulation tissue, portions of considerable size may be isolated by rarefaction and form sequestra of varying size, the condition then being known as caries necrotica — always a serious event, owing to the rapid destruction of bone, and tlie difficulty of arresting the disease by removal of the sequestra. Oc- casionally, if the area involved be a small one, calcareous degeneration of the granulation tissue takes place, and an encysted nodule forms which remains harmless for years. In rarer instances, true ossification occurs in the inflammatory material, and a rapid and complete cure is effected. An example of this is seen in Fig. 5, where the intervertebral discs and bone have been replaced by granula- tion tissue, which in turn has ossified, the result being complete and perfect bony ankylosis of the adjacent bodies. Such a happy result may usually be 5.-Co.nplete aukylosis of adjacent ascribed to thorOUgh and early treat- vertebrae (Guy's Hospital Museum, ment. with maintenance of good general health from first to last. The ligaments, especially the anterior common ligament, become softened and thickened wdien the disease is situated in the anterior parts of the bodies ; while the surfaces of the neighbouring vertebrae, 1 Cf. Clinical Lecture by Howard Marsh, Lancet, 1893, vol. ii. p. 792. He quotes a case of a young atUilt, aged 19, who had a perfectly distinct angular curvature of the lower dorsal sjnne of which he could give no account. His back was strong, and he was leading an active life, and he could not remember any period at which his spine had given him inconvenience. Mr. Marsh adds, " Clinicalh' such cases are of much importance, because they contradict common experience in two respects ; firstlj', they run their course much more rapidly than the common set of cases ; and secondly, they always end, so far as I know, in firm ankylosis, which the surgeon can do nothing to avert. Firm ankylosis is a result which, unless you can make an authoritative state- ment to the contrary, parents will certainly attribute to your method of treatment by fixation ; but I am quite sure you are justified in maintaining tliat it is not due to this treatment. It would have occurred just the same even if no splints had been employed." CHAP. I CARIES OF THE SPINE OR ANGULAR DEFORMITY 11 together with their periosteum, participate in the inflammatory pro- cess, but to a less degree, resulting in the formation of spiculas of bone, which may subsequently serve as supports to the buttress of new tissue thrown across the chasm. The Natural Methods of Cure. — In non-tubercular cases we may take it that the ostitis induced by injury compara.tively rarely sets up any extensive caries. At the most, it is limited to one or two vertebrfe. And it is in this class of cases that dry caries occurs, and abscess does not complicate the spinal disease. The granulation tissue frequently ossifies, so that a certain amount of localised bony rigidity permanently remains. In tubercular cases what happens is that the affected area becomes encysted -^ and undergoes calcification ; or if the destruction be more extensive, the carious parts are gradu- ally disintegrated, and come away in the discharge either as hrinute spicula? of bone or as sequestra of appreciable size. As the destruc- tion of the bodies proceeds the opposed surfaces of granulation tissue come together, and with the extrusion of all diseased bone, coalesce. Subsequent ossification of this soft material occurs and the gap is bridged over by a buttress of bone, so that the site of the disease is rendered as strong, but with loss of mobility, as before the disease. That most extensive loss of bone is consistent with perfect recovery, numerous specimens in museums testify, notably one from the Peabody Museum, Cambridge, Mass. — a specimen of prehistoric Indian remains in which the whole of the dorsal region has been involved. Results of Spinal Caries. — Bcformity. — Although this is not always present, yet in the great majority of cases it is by far the most marked feature of the disease. Its production is sufficiently explained by the stress of the disease falling on the bodies, and their collapse under the superincumbent weight of the upper part of the trunk and head. It is the onset of deformity that leads patients in many cases to seek advice. Hence the disease often goes un- treated in its early stages. E. Whitman ^ estimates that not more than 5 per cent of the cases are seen before deformity sets in, and the peculiar train of symptoms in spinal disease is such that they may not unskilfully be referred to other slighter causes than caries. The presence of a posterior projection dispels all doubt. The nature and extent of the deformity depends upon the 1 Cf. F. S. Eve, Tatli. Soc. Trans. 1888, vol. xxxix. "Caries without Suppuration," pp. 266-269. - Trans. Amer. OrtJiop. Assoc, vol. iv. p. 240. 12 DEFORMITIES OF THE SPIXE number of vertebra- and the region affected. If but oue vertebra is affected, especially in the dorsal region where the normal physio- logical curve is backwards, a very sharp angle is produced ; if two or three are diseased, the projection is less sharp but very marked. En this case the whole of the spine above and the affected vertebrae are displaced backwards, while the remainder of the spine below is straishtened and its curves flattened out. At the extremities of the spine where the physiological curve is forwards, the displace- ment is less, and is more readily compensated for. Posterior pro- jection can only occur when there is extensive destruction of bone. While the antero-posterior deformity is insisted upon by all authors, we must not overlook the fact that in the early stages considerable lateral deformity may be present (see Fig. 10). When, however, the disease has advanced so far that considerable erosion of the bodies has ensued, the features of the lateral deviation are sometimes merged into, and lost in those of the general displacement of the column. The extent of the erosion and actual destruction of the bodies varies widely. It may be so slight, liowever, that little, if any, deformity is necessarily produced, or it may be so severe that the upper part of the spine is placed at a right angle to the lower (Fig. 6). True dislocation rarely oc- curs, but merely a bending forwards, since the arches and articulating processes are seldom involved and usually maintain their relative posi- tions. AVith the absorption and dis- appearance of the bodies, unless extremely rapid, a widening of the bony walls of the spinal canal results, so that it is very unusual to find the cord compressed by bone. An instance, however, of combined bony and granulation pressure is seen in Fig. 7. So far as the bone is concerned, its loss involves very little danger to the nerve Fig. 6. — Extensive destruction of the Ijodies of the vertebrae produciug extreme deformity (Redard). CARIES OF THE SPINE OR ANGULAR DEFORMITY 13 structures. Widely different in its effects, however, is the production of granulation tissue in the spinal canal. It is the most fruitful cause of " compression " paraplegia. Hereafter we shall deal more particu- larly with this portion of our subject, but the old saying, " The less the deformity, the more the paralysis," has a ring of truth about it. But like all such sayings, it is apt to mislead. In some instances, notably in the cervical and lumbar regions at the commencement of the disease, and due to mus- cular spasm, the normal curves of those parts are exaggerated, and there is in the lumbar spine marked lordosis. In other cases the nor- mal anterior curve is lessened or a " flatness " of the back exists. But wherever the disease may be situated, a slight prominence of any one vertebra, with rigidity of the muscles, should excite grave suspicions and ensure prompt treat- ment. Eeference has already been made to the occur- rence of lateral deformity, and later on the diagnostic signs of this from scoliosis are given (p. 36). Such deviation can only occur when one side of a vertebra is affected more than the other (Fig. 8). It may be noted early in the attack and then disappear, or it may be evident from first to last. Some lateral deviation is seen in the case of Alfred K (Fig. 10). A most excellent article on "The Fig. 7. — Caries of the spine. Compression of the cord partly by displaced bone and partly by granulation tissue (Guy's Hospital Museum). 14 DEFORMITIES Ot^ THE SPIXE Presence of Spinal Distortion in the Early Stage of Spondylitis," by Dr. Bernard Bartow, appeared in the Annals of Surgrrji} The author claims that not only is there deviation, Init also actual rotation, as in scoliosis. But an examination of the figures illustrating the article fails to convince me of the existence of rotation in several of the cases, and it is just in these instances that his diagnosis of Pott's disease seems to me doubtful, at least, judging by the recorded symptoms. In one instance figured - there is undoubtedly lateral devia- ':■) tion. I give notes of a case from Dr. Bartow's article. Case 5. Lateral Deviation in Potfs Disease (Bartow). — "A boy, aged 8 years, had suffered for six months. Dui'ing the latter half of that period there had been three paroxysms of painful spasm of the lumbar muscles, following bending movements of the spine. There was no histor}' of traumatism, but one of family tuber- culosis. Pain was referred to the dorso-lumbar and abdominal muscles, and there was well-marked rigidity of the dorsal and lumbar vertebra? during the execution of ordinary movements. There Avas seen a general deviation of the whole spine to the right, com- mencing in the lumbar region ; eleva- tion of the right shoulder, prominence of the right scapula, and falling away of the right arm from the side, with Lateral deviation of tlic^^spiue approximation of the left arm to the trunk." Fig. 8 (Giiy'.s Hospital Museum, 1004 Some authors are of opinion that the lateral deviation is very common, but during the past four years at the Evelina Hospital for Sick Children and the National Orthopaedic Hospital I have met with only four instances of this' deformity in Pott's disease. It is, however, best seen in advancing cases, and diminishes as the case is getting well. An old -standing antero-posterior deformity is usually rounded, and presents a bursa of considerable size and density over the most prominent points. In advanced cases, especially if in the 1 A'ol. ix. p. 48 d sc'j. " Nos. 5 and 5', ibid. PLATE 1. KiNKrXG OF THE AORTA IX SPIXAL CaRIES Section of the spine showing extensive caries of the vertebi-se with angular deformity. Tlie last four dorsal vertebrae are greatly diseased, the two midtUe are nearly destroyed, and the portions of the iipper and lower have fallen together. The other dorsal vertebrae are also affected on their anterior surfaces. (Guy's Hospital Museum, 1290.) CHAP. I CARIES OF THE SPIXE OE AXGULAE DEFORMITY 15 dorsal region, the shoulders are elevated and droop forward, the sternum prominent, the ribs compressed from side to side, the scapuhe raised, the neck shortened, and the head is thrown forward (Fig. 2). Projection of the head must occur, as a compensation to the displacement backwards of the spine. "With these structural changes considerable alterations in the position of the viscera take place. Thus I have observed the apex beat just at the nipple, and in one instance of eleven years' standing I felt it in the third intercostal space in the nipple line. Hilton Fagge^ drew attention to the " kinking " of the anterior wall of the thoracic aorta (Plate I.), with hypertrophy of the heart in cases of very marked posterior projection of the dorsal spine. The lungs frequently become com- pressed, leading to the peculiar grunting respiration, and later on to the incidence of tubercle ; while the abdominal viscera, notably the liver and stomach, are pushed downwards ; and the abdomen is very prominent in bad cases, with much derangement of digestion. It is essential to keep some record of the deformity from time to time. This is best effected by using a strip of sheet-lead, moderately stout, of not less than one foot in length. With the child lying prone, the lead can be adapted to the curved spine. On removal the lead is turned sideways, and serves as a ruler for an ink tracing on the record sheet. A better plan in place of the ink -mark is to place the lead sideways as before on a piece of cardboard, and use the lead as a guide to cut out the curve in cardboard ; then placing the cardboard against the spine, to see if the outline fits the spinal curve. If not quite correct, it should be gradually trimmed. If the patient is seen early, deformity may be averted in the cervical and lumbar regions ; and in all cases, if already declared, it should be prevented from becoming worse. Some recession of the deformity may, in careful and thorough hands, be obtained." In the dorsal region deformity is almost sure to occur in spite of treatment. " A sudden chafing of the skin, developing under a brace or jacket which has always fitted well, should lead to the suspicion that the deformity may be increasing, although that is not necessarily the case." The conditions which give rise to increase in the degree of curvature are two ; and they occur in two totally different stages of the disease. Firstly, when the excavating process is going on cj^uickly in the bodies, the deformity must necessarily increase ^ Gu3-'s Hospital Reports, 1872. 2 H. L. Taylor. Cf. Kev: York Med. Bee. 8th January ]S87. 16 DEFORMITIES OF THE SPINE sec. i rapidly. Secondly, when active disease has ceased, and healing is taking place, the bodies settle down on the newly-formed tissue, so that a further development of the posterior projection follows. That such increase will occur during treatment, in spite of the most approved appliances, must be pointed out by the surgeon at the commencement of the treatment, otherwise he may incur blame on account of the increased deformity, although in other respects the patient is doing perfectly well. It should be clearly stated that firm union of the affected parts and consolidation of the spine can only be effected in severe cases by apjDroximation of the healthy parts. Abscess. — Briefly it may be stated, from a consideration of the data collected by various authors, that abscess occurs in about one patient in five suffering from Pott's disease. My friend and col- league, ]Mr. E. Muirhead Little, found that among the in-patients at the National Orthoptedic Hosjiital, many being admitted on account of the abscess, this complication was present in 21 of 133 cases; among 133 cases treated as out-patients, only 7 cases of abscess are recorded.^ "W. E. Townsend " tabulated 380 cases of spondy- litis ; 75 were found to have abscess, distributed thus — in the cer- vical region 8 per cent, dorsal 2 per cent, lumbar 7 2 per cent ; these correspond closely with the data given by ]Michael and Parker.^ The latter surgeon found that 8 per cent of his dorsal cases suppurated, 30 per cent of the lumbar, and 70 per cent of the lumbo- sacral. These figures strikingly exemplify this point, that the liability of the various regions of the spine to abscess increases from above downwards. So too do the total range of movements and amount of weight borne. These factors undoubtedly, then, influence the onset of abscess, but there must be others which we are not able to determine so precisely. We cannot determine the exact constitutional equivalent of any one patient ; why in one case there should be entire immunity from, and in another the on- set of profuse suppuration. We can only speak of the individual degree of " recuperative power." An estimation of the severity of the injury does not help us. All we can say is that, given a patient with a strongly-marl^ed phthisical parentage, abscess is more likely to occur than in one free from hereditary taint. Bradford and Lovett ■* remark, " The earlier the treatment is begun, and the more efficiently it is carried out,, the less liable are abscesses to ^ Lancet, 23rd July 1892. - Trans. Anicr. Orthoi). Assoc, vol. iv. p. 164. ■' Roy. Med. CJiir. Soc. Trans. 1884. ^ Op. cit. p. 30. CHAP. I CARIES OF THE SPINE OR ANGULAR DEFORMITY 17 form ; but it must not be assumed that the occurrence of abscess is evidence of incomplete treatment. In many cases an abscess cannot be avoided," In the majority of abscesses having a fatal termina- tion, tubercle is found elsewhere in the bones. On the other hand, while abscess is most frequently the condition which precedes the end, we must not always assume that those cases which do not suppurate are non-tubercular, since, owing to recovery, we have no means of verifying our assumption. While in a few cases abscess may exist without giving rise to definite symptoms,-^ in by far the great majority its existence soon becomes evident. Anatomical Considerations infiuencing the Position of, and Direction tahen hy Spinal Abscesses. In the Cervical Region. — The point of exit of pus is greatly dependent on the disposition and arrangement of the deep cervical fascia. Attached behind to the spinous processes of the vertebrse, it is continuous with the layers of connective tissue investing the trapezius and deep muscles of the neck. It then crosses the posterior triangle, and dividing into two layers, ensheaths the sterno-mastoid muscle. The layers unite at the anterior border of that muscle, and meet the fascia from the opposite side at the median line. A process of the layer beneath the sterno-mastoid muscle passes down in front of the thyroid gland and trachea and depressor muscles of the hyoid bone to the great vessels and pericardium. Pus extending beneath this layer has been known to open into the lungs, trachea and bronchi," notable but rare events. The prse-vertebral fascia covering the muscles of that name, and separating them from the pharynx and oesophagus, may confine the pus for a time, and then by its increase and the pushing forward of the posterior wall of the pharynx, a retro- pharyngeal abscess arises, causing dyspnoea and dysphagia.^ Occasionally tbe abscess bursts into the pharyngeal cavity, or opens into the cesophagus, or it may track down into the posterior mediastinum and open through an intercostal space following the posterior branches of the intercostal arteries. If the pras-vertebral fascia be traced outwards, it is found to form, or become con- tinuous with, the back of the carotid sheath, and is then pro- longed outwards and downwards over the scaleni muscles. Pus arising from diseased cervical vertebrae frequently passes laterally between the longus colli and scaleni muscles, and opens posteriorly ^ Case of A. E. Barker's, quoted in note to p. 62. ^ Cossy, Bull. Soc. Anat. 1877, p. 541 ; and Gamlet, Bull. Soc. Anat. 1878. ^ Cf. case, Hilton's Rest and Pain, 3rd ed. p. 135. C 18 DEFORMITIES OF THE SPINE sec. i to the steruo-mastoid muscle. Occasionally the abscess bursts through the deep fascia, aud appears at the sides of the cervical spinous process. Case 6. Cerviml Caries, Suppuration, Cervical Abscess. — B. H., aged 7, was seen by me at the Evelina Hospital for Sick Children in July 1893. He Avas an undersized sickly boy, one of eleven children. Four years ago his head was jDulled suddenly while playing with one of his brothers. In a few days pain set in, followed by "stiffness of the neck." Subsequently the head was draAAii to the left shoulder, and a large swelling appeared on the left side of the neck. He was then taken to St. Thomas's Hospital, placed in the recumbent position, and the abscess opened. A jacket with an occipital head-piece was applied, and he went out much improved. He was subsequentlj* admitted there for what the mother states was lung trouble, the precise nature of which I was unable to determine. When first seen by me there was rigidity of the neck, some flattening of the normal forward cervical curve, and .slight thickening at the back of the neck over the third and fourth cervical vertebrae, but no posterior projection. About one inch above the clavicle, and in the posterior triangle, there was a dis- charging sinus, from which thin pus was oozing. In November 1893 some minute pieces of bone came away. In Februar}^ 1894 the sinus had healed, although the boy was unable to leave off his support. He is now suffering from phlyctenular ophthalmia. In the Dorsal Region. — The strong fasciee binding the ribs together influence largely the pointing of the abscess. In the upper and mid-dorsal spine pus finds its way between the posterior ends of the ribs, following the posterior branches of the inter- costal arteries and then gives rise to a dorsal abscess. More rarely does a dorsal abscess encroach on the cavity of the chest or the pleural cavities. In lower dorsal and often in mid-dorsal caries pus gravitates either by the sides of the vertebrte beneath the inter- costal fascia, or passes beneath the ligamentum arcuatum internum, and forms a psoas abscess. In some cases the abscess is said to reach the psoas sheath by passing between the anterior spinal ligament and the bone, and then perforating the diaphragm. In the Lumlar Region. — The site of origin of the disease in the bodies of the vertebrae is important as to the course of the abscess, taking into consideration at the same time the pecuHar disposition of the psoas and lumbar fasciae. The sheath of the psoas muscle is a thin layer continuous, above with the ligamentum arcuatum internum, below with the iliac fascia, behind with the anterior lamella of the lumbar fascia, and is attached to the bodies of the vertebras internallv. CHAP. I CARIES OF THE SPINE OR ANGULAR DEFORMITY 19 The lumbar fascia is composed of three layers ; the anterior and middle attached to the transverse processes, the posterior to the s^Dinous processes of the vertebrae. The anterior layer is very thin, and offers but slight resistance to abscess. Pus, following the course of the posterior branches of the lumbar arteries, may track through this layer. J. K. Young ^ has insisted on the importance of this layer of fascia, and would divide spinal abscess into two varieties, internal and external according as they do or do not perforate this layer. The middle layer lies between the quadratus lumborum and multifidus spinse muscles, and gives origin to the trans versalis and internal oblique muscles. The posterior layer completes the sheath of the erector spinas muscle. At the outer edge of the latter structure is a weak spot in the abdominal wall, the triangle of Petit, bounded anteriorly by the posterior edge of the external oblique muscle, and below by the iliac crest. It is in this triangle that lumbar abscesses often point. If the disease begins in the bodies of the vertebrae {a) anteriorly to the attachment of the psoas, or fails to enter the sheath of the psoas, it passes behind the aorta, and thence along the great vessels to the iliac fossa, giving rise to an iliac abscess ; or it may not stop there, but gravitate into the pelvis, and passing out of the great sacro-sciatic foramen, form a gluteal abscess. Ashby and Wright ^ quote a case of abscess bulging at both sciatic foramina, so that fluctuation could be felt across the cavity of the pelvis, (b) If very near or at the attachment of the psoas, it enters the sheath of the psoas, and passing beneath Poupart's ligament, presents either at the inner or outer side of the femoral vessels, or following the course of the internal circumflex vessels, points behind the great trochanter. Earely it may present lower down in the limb ; (c) it often burrows through the anterior and other layers of the lumbar fascia, and appears in Petit's triangle as a lumbar abscess, or {d) rarely wanders about in the fascial layers till it presents in the anterior abdominal wall. It is this persistent burrowing, the irregularity of the abscess cavity, and the difficulty of ensuring efficient drainage that make lumbar abscess so serious a complication. It is remarkable, how- ever, that it seldom bursts into the peritoneum, intestines or bladder.^ But occasionally it invades the spinal canal. ^ Trans. Amer. Orthop. Assoc, vol. iv. p. 175 et seq. ^ Op. supra cit. p. 563. " Instances, however, are recorded. If it burst into the peritoneal cavity a rapid and fatal termination of the case ensues. If into the bladder, so long as the urine remains sweet, the abscess may discharge entirely in this way, and the disease be 20 DEFORMITIES OF THE SPINE sec. i The cuntints of the abscess vary. Sometimes they are serous and sero- purulent fluid with caseous masses. In old -standing cases they are often cheesy. In almost all cases fragments of carious and necrotic bone are found. The wall of the abscess is frequently lined with feeble grey granulations, which may become infected with tubercle before or after the opening of the abscess. Future course of the abscess. It may burst when not under surgical supervision ; and such an event is most disastrous. In too many instances the abscess track becomes septic, and then persistent suppuration, with hectic fever and lardaceous disease, set in — a rapid course to the inevitable end. I am not aware personally of any cases where it has been possible to render the cavity entirely " sweet " again, although such a desirable result has been claimed by Treves and others, and I know of instances to the contrary. Much may, however, be hoped from free incisions, if possible from the lumbar region, and thoroughly scraping and rubbing the abscess wall. It may be duli/ and antisejjticalli/ opened, as detailed under the heading of treatment, with the best results. On the other hand, after opening with all possible care, a discharging sinus is left, which closes only after further operations, or, in some cases, not until necrosed bone has been extruded. In other cases ahsor2)tion occurs, giving immunity from illness to cured. The possibility of tubercular infection of the bladder must not be lost sight of. Bearing upon the interesting question of discharge of bone -abscess with favourable result through the bladder, I may mention the case of Miss H. N. , aged 7 years. In September 1893 I operated upon her for mastoid abscess, secondary to scarlet fever. Whilst it was healing some tenderness developed over the middle of the left iliac crest, but this subsided for a time. On 21st November 1893 I was again asked by Dr. Hayman of Clapham to see her. The day before she had complained of great pain on micturition, and had passed urine containing much pus. On examining her I found a large iliac abscess occupying the whole of the left iliac fossa, and extending below Poupart's ligament, with fluctuation on the outer side of the femoral vessels. Finding that the urine was sweet, and that pus continued to be discharged freely, I advised that we should wait rather than again operate on her ; she had already, before I operated on her for mastoid abscess, been seen by a surgeon for acute cellulitis of the neck, which had necessitated free incision. A plaster of Paris spica bandage was adjusted on 21st November. Dr. Hayman wrote to me in January 1894 to the effect that the urine had remained sweet throughout, that no pus had been passed b}' the urethra for three weeks, and the swelling in the left iliac fossa had disappeared. She is now, March 1894, entirely free from any trouble. I take it that the opening of an aseptic abscess into an aseptic bladder is by no means an event to be deplored. Sweet urine cannot infect an abscess, if the pus directly gravitates into the bladder. In such a case it would have been, I venture to say, very harmful to catheterise the bladder, as the risk of introducing decomposing matter into the bladder, and thence into the abscess cavity, was too gi-eat. CHAP. I CARIES OF THE SPIXE OR AXGULAR DEFORMITY 21 the patient for some years ; but too often it lights up into some other form of tubercular disease. Abscesses occur on both sides in one and the same patient/ and occasionally communicate. In such instances it is best to open both at once, to prevent the possibility of one leaking over into the other. The prognosis, diagnosis, and treatment of abscess receives fuller consideration later. Compression-Paraplegia. — Considering the immediate prox- imity of the spinal cord and nerves to the site of the disease, it is a matter of surprise that this complication does not occur more often. It is equally surprising that so many cases treated on the expectant plan of recumbency, with or without extension, recover. It may at once be said that no very definite relation can be traced between the presence of deformity and paraplegia. On the contrary, the latter may exist without any posterior projection. Nay more, in some cases the signs of bone disease may not be e\ddent imtil some time after the onset of paraplegia. !ISror is paralysis dependent either on the amount, character, or duration of deformity. It is found with equal frequency in large, medium, or slight projections ; it in some cases comes on simultaneously ; in others not till months afterwards ; in yet others distortion appear- ing in early life is not followed by paralysis until adult life. This want of relationship is explained by the morbid anatomy of " com- pression." Very rarely is it due to bone alone. In the majority of cases the active agents are pressure of inflammatory material and pachymeningitis. So that symptoms of slow compression should invariably lead to a very careful examination of the spine, with a thorough inquiry into the patient's antecedents, and any doubtful points carefully considered, especially in the case of children. The formation of an abscess outside the spine often relieves pressure within the canal, either by the breaking down of an inflammatory material or by the gradual removal of carious and displaced bone. If abscess and paralysis coexist for any length of time, the prognosis is necessarily very serious, as the disease must be very exten- sive in both the bones and the vertebral canal, and may be out- side the range of operative procedures. In illustration of these remarks I quote a case recorded by Dr. Swan in the Brit. Med. Journal, 4th February 1893. ^ Cf. a case of bilateral lumbar abscess recorded by J. K. Young, Trans. Araer. Orthop. Assoc, vol. iv. p. 174, which, was successfully aspirated on one side aud opened on the other at one sitting, with complete cure. 22 DEFORMITIES OF THE SPINE sec. i Case 7. A Fatal Case of Compression-Paraplegia. — "xi girl, aged 17, was brought to him with partial paraplegia, marked muscular inco- ordinating movements of the body, hypera^sthesia, and unilateral spasm. The deep reflexes were exaggerated ; an abscess had discharged behind on a level with the lower two dorsal vertebrae. From this a portion of the twelfth rib and an adjoining piece of the vertebral body were evacuated. Soon afterwards complete paraplegia supervened, with loss of the deep reflexes, gangrene of the skin over the projecting points, and ultimately death from exhaustion. The p)Ost-moiiem examination revealed not only the impossibility of drainage, but also the futilit}^ of operation." In by far the majority of cases the spinal cord does not suffer. The reasons are these. Actual dislocation, although one or more of the bodies may be totally destroyed, is rare. "When deformity sets in, the anterior part of the spinal column, the bodies, falls together, it is true ; but this is due to loss of their substance, so that frequently there is widening of the canal at the affected spot sufficiently great to accommodate not only the cord, but a very considerable quantity of inflammatory material and thickened dura mater. Then, too, as the spine is shortened from above downwards, the cord becomes relaxed, and is therefore able more readily to accommodate itself to its altered conditions. The cord is gradually curved, not abruptly bent or displaced. Ascending and descending degenerations set in from " compression." As soon as symptoms of degeneration appear operation is called for. The paralysis is usually bilateral ; in rare cases it is unilateral. It affects the legs generally, although the arms may suffer later ; so both may be paralysed. Dr. Gowers ^ quotes a case of a child of 3, who had presented for two years indications of disease of the cervical vertebrae, and in whom the power of moving the legs was lost in the course of twenty-four hours ; during the second day the left arm be- came paralysed, and at the end of a week the right arm. In instances such as this the cervical vertebrae are necessarily affected, but in the majority of cases the legs alone suffer. Both legs, as a rule, suffer equally. Dr. Gowers, however, gives a case of unequal affection of the legs." Case 8. Compression- Paraplegia, Unequal Affection of the Legs. — "A boy, in childhood, developed angular curvature; at 16 there was an attack of weakness in the legs, which passed away at the end of three weeks; at 17| years the patient sj^rained his back. Pain in it followed ; 1 Dis. of Nervous System, 2nd ed. vol. i. p. 247. " Ibid. p. 248. CHAP. I CARIES OF THE SPINE OR ANGULAR DEFORMITY 23 and six weeks later the riglit leg gradually became weak, and a year and a half later presented intense spastic paralysis, the left leg being very little affected. He ultimately recovered." Frequently the dorsal cord becomes affected ; and if the disease be above the lumbar enlargement, the condition of the legs is gener- ally spastic when the destruction of the cord is not excessive. Dr. T. Halsted Myers ^ has analysed 1570 cases of Pott's disease with reference to the onset of paralysis. Of these 270 were sooner or later paralysed. The site of disease was as follows : 16 in the cervical, 12 in the cervico-dorsal, 105 in the dorsal region about the eighth vertebra, 40 in the lower dorsal, 19 in the dorso-lumbar, 18 in the lumbar, and 9 not stated. The average duration of paralysis in which recovery took place was twelve months in the cervical region, nine and a half in the upper dorsal, six in the lower dorsal, and eight in the lumbar. Eighteen of 218 cases had re- peated attacks of paralysis, viz. two had four attacks, and many three attacks with a good recovery ; but in two cases the patient passed through two attacks and finally died paraplegic. The average duration of the disease before the onset of paralysis was, in the cervical or upper dorsal region, thirteen months ; in the lower dorsal, fifteen ; and in the lumbar, eighteen months. The upper extremities were affected in seven cases ; of these, three were not treated, three were cured, and one died after operation ; of cases affected elsewhere, thirteen recovered without treatment. I have inserted these statistics on account of their great interest. But I am inclined to think that the proportion of 270 cases of compression -paraplegia in 1570 is too great. That they were treated as out-patients at the New York Dispensary may account for this. That one case in seven should suffer appears remarkable to me. It infers that paraplegia is nearly as frequent as abscess in spondylitis. This is certainly not the case. In mixed in- and out- patient practice the proportion is much less. My colleague, Mr. E. Muirhead Little, has collected from the records of the National Orthopsedic Hospital 133 cases, and in only 10 of these was there definite paraplegia. It will be convenient here, before describing the symptoms generally of Pott's disease, to review briefly the pathology, signs, and course of " compression-paraplegia." Pathological Anatomy of Compression-Paraplegia. — Inflam- mation in the bodies of the vertebrae extends, and finally causes a ^ Trcms. Amer. O'rthop. Assoc, vol. iii. p. 209 et seq. 24 DEFORMITIES OF THE SPINE perforation of their posterior surfaces, accompanied by a destruction of their periosteum, and of the posterior common ligament. The epidural space, composed of loose fatty or vascular material situated immediately behind the ligament, is next invaded by the tubercular material, either in the form of granulation material or abscess, or less frequently obliterated by displaced bone. So that practically in most cases a peri-pachymeningitis arises, which is accompanied later by a chronic meningitis of tlie dura mater and other thecal structures — in fact, a pachymeningitis. '"'■^ '■■■ \i For a long time the morbid pro- cess is limited by the tough dura, but ultimately perforation takes place if the patient live long- enough, and then all the symp- toms of acute tubercular menin- gitis with inflammation follow, and the patient rapidly succumbs. More usually, however, the spinal cord suffers slow compression, be- ing flattened by the pressure of granulation tissue, and becomes oedematous and vascular, i.e. softening of the cord occurs with myelitis. This is accompanied by increase of the neuroglia ; sclerosis ensues with partial or entire destruction of the nerve elements and ascending and de- scending degeneration. At the Fig. 9.-Extensive deformity of the spine Same time too the nerve -roots from caries, wth much compression of suffer from pressure and cxudation the cord (Guy's Hospital Museum, 1024*'^). „ , . , -, .-. n of new material around them. The spinal cord may be indented or flattened, as above men- tioned, or cylindrical but much reduced in size. It has even been found as small as a crowquill. Some narrowing of the cord is not incompatible with recession of the paraplegia, since in such cases the cord has been found considerably narrowed, when the patient has died from some other cause. In a case of compression- paraplegia at the National Orthopaedic Hospital, on which I operated, ^ For the description of the microscopical changes in the cord and nerves, standard works on Diseases of the Nervous System should be consulted. CHAP. I CAKIES OF THE SPINE OR ANGULAR DEFORMITY 25 the spinal cord was so much compressed by the arch of the tenth dorsal vertebra that it was impossible to pass a fine probe between the bone and the cord. It was necessary to pick the bone away with a fine pair of bone forceps. So that, to sum up, the six following conditions account for the symptoms : (1) Pressure arises from the gradual formation and squeezing backwards of the granulation material, as the sound bone above settles down to fill up the gap. (2) The nerve-roots are affected by the granulation tissue, and involved in the pachy- meningitis. (3) The cord is suddenly pressed upon by displaced bone. (4) More or less acute myelitis sets in. (5) Acute tuber- cular meningitis from sudden diffusion of infective material in the sub-dural space rapidly carries the patient off. (6) Immediate compression of the cord is very occasionally due to extravasation of blood after an incautious movement, sufficient to rupture a blood-vessel.-*- Sym^ptoms of Compression-Paraplegia. — These necessarily vary with the site of disease. The onset is in some cases very sudden, and is due then to displaced bone, rupture of a blood-vessel, or acute myelitis, or tubercular meningitis. As instances of this rapid loss of functions Gowers mentions several cases. In one of them, a child of 3 years of age, slight weakness existed for three weeks, and then the power of standing was lost in a single night. More often it is gradual, and not without warning in the form of slight paresis. Several of the salient points in the history are illustrated by the following case, which came under my care for in-patient treat- ment. Case 9. Compression-Paraplegia, Ci-adual Eecovery during Recimibency. — J. H. F., aged 5 years, was admitted on 5th January 1892. The back had " grown out " two and a half years previously, and the child had lately become " weaker on its legs." Beyond these details the mother could give no information. On admission the child was pale and weakly, and entirely unable to walk. There was a large posterior curva- ture in the dorsal region, extending from the seventh dorsal to the first lumbar vertebra. The projection was rounded. Partial anaesthesia was ^ Such an event may have occurred in one of Dr. Gowers' cases. " A woman, aged 45, who had suffered from pain in the spine, one day, while walking, sneezed violently three times, and immediately felt ' pins and needles ' in the right knee, and subsequently in the foot. The right leg became powerless during the next three days, the left leg followed suit, and at the end of six weeks both legs were motionless." She died six months later. 26 DEFORMITIES OF THE SPINE sec. i present from the ninth rib downwards on both sides, but sensation to painful impressions was still retained ; he felt slightly the forcible prick of a pin ; as he lay in bed the legs were extended and rigid, with con- siderable adductor spasm and muscular wasting. He could move the legs slightly, making some attempts at flexion and rotation. The knee reflexes were present and exaggerated. There was some incontinence of ffeces when the motions were loose, and imperfect control over the bladder ; at night he passed urine in his sleep ; and in the daytime he must relieve himself directly he felt the desire. Temperature was 9 8 '4° F., and no abnormal signs were found in the chest. The child was placed in bed with an extension-collar beneath the chin and occiput, and the head of the bed raised three inches. It was noted, on raising the child into the sitting position and placing one hand over the lower part of the sternum and pressing with the other firmly over the prominence behind, that there was considerable yielding forwards in the spinal column (" pressure Avith the palm of the hand " test). 26//i January. — The spine was more consolidated, but with no improve- ment in the bladder symptoms, nor in muscular power. 1 1 th Fehruary. — He was now sensitive to touch in both legs. IG/A March. — Could flex knees and ankles freely, and raise the legs two inches from the bed. The fieces were completely retained, and the urine did not escape so freely. \st June. — He attempted to raise himself in bed, the adductor spasm had completely disappeared ; he held his water well, and kicked his legs about in the bed with freedom. The spinal column had increased in firmness, and the child was fatter. 2Mi September. — He could walk a few tottering steps without support, and the back was quite firm. ^th December. — He was quite able to walk alone. He was discharged wearing a poroplastic jacket with a head support, and the extension apparatus to be used at night at home. For convenience of description I have arranged the symptoms, not in the order of their onset, but from a functional point of view. {a) Motor. — The patient complains of getting tired easily, and soon the legs begin to drag, and the toes to catch in walking. With these signs there are loss of equilibrium and complete inability to stand alone, since both legs usually suffer equally ; and finally the child lies in bed, quite unable to move the lower extremities. If the disease is in the cervical region, the arms suffer before the legs. Occasionally it happens that in occipito-atlantal disease the dia- phragm is paralysed, oftentimes suddenly ; and the spinal accessory and hypoglossal nerves too are affected. (h) Sensor3^ — Dull aching pain is common in the early stages, both in the body and limbs. In the body the most usual form is CHAP. I CARIES OF THE SPIXE OR AXGULAR DEFORMITY 27 girdle-pain or pain in the " pit " of the stomach.^ These pains around the body are due to irritation of tlie nerve-roots. Often- times there is no antesthesia, or it occurs occasionally ' without motor symptoms. Sensation is at times regained when motion remains absent. Ansesthesia dolorosa scattered in patches is not uncommon, and hyperesthesia is found above the lesion. (c) Eeflexes. — The superficial reflexes are exaggerated, and so too are the deep, especially the knee and anlde. If the lumbar enlarge- ment is involved, the reflexes are absent. When degeneration has set in they are lost as in disease in other regions of the cord, (d) Sphincters. — Incontinence of urine and fasces occur in severe cases. But I do not share the opinion that they indicate any excessive gravity or inability for recovery. (e) Trophic. — The affected muscles waste, and the " reaction of degeneration " is more or less marked. Before wasting sets in, distinct spasm of muscle is found, notably if the disease is in the dorsal cord. Herpes zoster has been seen along the course of the irritated nerves (Gowers). Acute bed-sores are not uncommon. (/) Vaso- motor. — The limbs are often cold, and sometimes perspire persistently." (g) Special to various regions. — In the cervical region the pupil may be dilated, in the dorsal the intercostal muscles are affected ; hence with diminution of breathing capacity and horizontal de- cubitus, acute bronchitis and broncho-pneumonia form serious com- plications. Diagnosis. — The pain of compression has been referred to all manner of causes, but it avails little to tabulate these. Suffice it to say that it should be an invariable rule to examine carefully the back if any of the above signs are present, and this rule is the more urgent if we are dealing with a child whose history is tubercular. Although a projection may be absent, this should not negative the existence of Pott's disease. It has happened that the paraplegia has disappeared when a projection has formed. As stated above, the nerve symptoms may declare themselves before the bone symptoms. The practical deduction is, examine a child back and front, and so avoid the vexation of having the cause of the paralysis pointed out by a more discriminating surgeon. ^ The Avriter is acquainted with the case of a child who for two years was erroneously- treated for "liver and stomach" trouble. On further advice being sought, a large projection, hitherto unnoticed, was found in the lower dorsal region. - Gowers has seen persistent sweating of one half of the forehead in cervical caries, due to interference with the cilio-spinal centre. 28 DEFORMITIES OF THE SPINE sec. i Prognosis. — The general tendency of the great majority of cases is towards complete recovery without operation. Mere recumbency with extension is often sufficient to induce an immediate change for the better. Some cases, as mentioned previously, recover without any form of treatment. Eecurrent attacks are dangerous, but not so ^:)cr se} Cystitis and bronchitis are grave complications, but I have known some of such cases recover, and the presence of these troubles should not urge one to hasty operation. The value of laminectomy will be dealt with under the general heading of treatment. To complete the list of the complications of Pott's disease, I have only to mention localised pleurisy, due to direct extension of the morbid process from the vertebrse and mediastinal abscess. A general condition of asthenia from the caries itself occurs, in which, however, the reflexes are normal, so determining the absence of true paraplegia. Digestive disturbances are not infrequent, and crises gastriques occur.^ At any time acute tuberculosis in one clinical form or another may arise. ^ Cf. a most instructive case of Gowers, op. sup. cit. p. 248. ^ Cf. the persistent and dangerous attacks of vomiting associated with Infantile Paralysis. CHAPTEE II CARIES OF THE SPINE (ANGULAR DEFORMITY)— (ConiimtefZ) Symptoms of Uncomplicated Caries — Method of Examination — Diagnosis from Bhachitic Kyphosis, Senile Kyphosis, Hysterical Spine, Scoliosis, Malignant Disease of the Spine, Hip Disease, etc. — Prognosis of Spincol Caries without and ivith Abscess as to Age, Sex, Family Histonj, Social Condition, and Danger to Life — The Prognosis of Abscess as to Region of the Spine involved, Sex, Age, Presence of other Complications and Methods of Treatment. The Symptoms of Spinal Caries. — The later conditions having already been discussed under the heading of complications on the ground that deformity, abscess, and compression - paraplegia are rather results than signs, it remains to describe the onset of the disease more particularly. The history may generally be regarded as untrustworthy if it speaks of slight blows ; any severe accident, such as a fall from a height, will always be graphically described, and the date accurately remembered with all the attendant circum- stances. In such instances, if the child be otherwise healthy, reliance may be placed on the account given, but much discrimina- tion must be used if the history is vague. At the same time the careful surgeon will not neglect to inquire into the patient's antecedents, especially as to presence or absence of tuberculosis ; and the replies given, together with his own deductions, will necessarily assist him in forming a prognosis. Method of Examination. — (1) The attitude and mode of pro- gression should first be carefully observed. I cannot do better than quote the graphic description of Professor Sayre -^ : " Wlien walking about the room, the child will reach with his hands from one article of furniture to another, making careful calculation that he shall not be deprived of the support furnished by one article before he receives support from another. If he cannot obtain support by 1 'Op. cit. p. 364. 30 DEFORMITIES OF THE SPIXE sec. i catching hold of various articles within reach, he will rest his hands upon his thighs, in order to transmit the weight of the head and shoulders through the legs to the ground, thereby giving them support without bearing upon the diseased vertebrae." I have often noted, when seeing out-patients, that children in the progressive stage will clutch at once at the writing-table as soon as released from the mother's support ; and on the converse I always take it as a most encouraging sign after a course of treatment when the child, on being brought for examination, stands alone for a minute or two. The mother will often tell one that the child is more readily tired than previously, that he wants to lie down ; or in resting, adopts unwonted attitudes, such as leaning the arms upon a chair or seat, holding the head with the hands, or putting the hands on the front of the thighs and stooping or squatting according to the region affected. The attitude assumed is due to an effort on the part of the patient to prevent any jarring of, or increased pressure upon, the affected part. He places himself, as Professor Sayre says, in a " muscular splint." If the upper cervical vertebrae are affected, the head is oftentimes drawn to one shoulder, and the case may be mistaken for wry -neck, due to contraction of the sterno- mastoid. Error may be avoided by noting that in spinal disease the face is not turned away from the affected side, as it is in ordinary " wry -neck." If the lower cervical or upper dorsal region be diseased, an effort is made to balance the head as much as possible ; the chin is pushed forwards, suggesting " the position of a seal's head when out of water" (Bradford and Lovett). The attitude when the disease is in the mid -dorsal region is described above. An early affection of the lumbar region is often characterised by some lordosis, and a curious sidling gait is not uncommon, due to irritation and contraction of the psoas and iliacus muscles ; but marked contraction of the psoas, gi^'ing rise to persistent flexion, should be regarded as evidence either of distinct psoitis or abscess. In the effort made to avoid jarring, the patient often walks on his toes with flexed knees in a condition of muscular attention. The child should now be stripped; in an adult it is convenient to have a loose skirt hanging from the hips, and put on after removal of the ordinary garments. We may now proceed to test for the other symptoms. (2) Muscular rigiditt/, which causes impairment of the natural mobility of the spine and other parts. Of all signs this is the most valuable. It is present from the first, and can be ascertained CHAP. 11 CARIES OF THE SPINE (AJSTGULAR DEFORMITY) 31 by the following manoeuvre. If in a normal spine the hand be placed palm-wise on several vertebrae, and the patient be directed to bend forwards, the spinous processes move individually, and when the body is brought back to the upright position, the vertebrae are felt to come successively into position. Now in a diseased spine this is not the case. On placing the hand on the spine, and examining it carefully in the manner described, when the affected region is reached, three or four vertebrae are felt to move en bloc ; they move forwards and come back in one mass. With practice this sign serves to detect even the earliest cases. If the muscles on either side be felt, they are noticed to be slightly stiffer and firmer than elsewhere. This rigidity is the " advanced patrol " of disease, and the mobility should always be tested if the patient complain of pain in the abdomen or chest, and no cause be found there. In more advanced cases the rigidity is demonstrable by the common manoeuvre of inviting the child to pick up a small article from the floor. To quote Professor Sayre again, " If the vertebrae are diseased, he will begin by bending the hips and then the knees, and finally will squat down and pick up the object, and rise up in the same careful way that he went down, keeping the back as nearly straight as possible, and allowing no movements in the spinal column which he can prevent." A very noticeable symptom due to muscular rigidity is the short grunting, almost spasmodic respiration of these children when standing or sitting, especially if the disease be in the lower cervical or upper dorsal region. This grunting is at once relieved by laying the child across the surgeon's knees in the prone position, with the arms over one thigh, and the legs over the other. The surgeon then separates his thighs gradually, thus making extension on the patient's spine, and taking off the pressure on the intercostal nerves, with the result that the breathing becomes at once tranquil and somewhat full. On closing the limbs again, the jerky respiration returns.^ In early cases it is advisable to test the extensibility of the spine by laying the patient on his face on a couch and gentli/ lifting the child up by the feet. To test the flexibility of the spine, the child should be seated with the legs extended, and should endeavour to touch the toes with both hands, at the same time flexing the head fully. If the psoas or quadratus lumborum are affected, ^ I consider this is a very valuable sign, and have often proved it ; for this we are again indebted to Professor Sayre. 32 DEFORMITIES OF THE SPINE sec. i extension of the back in the way just mentioned is nearly or quite impossible, and any attempt gives rise to pain. It should not be forgotten, however, that the movements in the lower cervical and upper dorsal portions are naturally limited, and unless careful ex- amination here be made, rigidity may be overlooked. (3) Pain. — Subjectively this is present in the majority of cases. Occasionally it is absent altogether, even with considerable rigidity of the back ; or there may be merely weariness and slight aching. " Eeflected " pain in spinal caries is often a misleading symptom. It assumes the form of headache over the occiput in cervical disease, or of shooting pains in the arms ; of sternal pain or " neuralgia in the side " in dorsal disease ; of dry " belly-ache " or girdle pain ^ in the dorso-lumbar, and of growing pains in the legs in the lumbar form of the affection. These pains are essentially " nerve root " in origin. When they occur the whole course of the affected nerve or nerves must be examined v/ith precision. The pain is sometimes acute, more often sub-acute, but liable to sudden increase ; hence the sudden startings, especially at night ; although it must be admitted that " night cries," or rather " early evening cries," in Pott's disease are comparatively rare as compared with other chronic bone and joint affections. Objectively, pain is elicited by pressure over the individual spinous process. The value of this sign is overrated, and is not to be compared for diagnostic efficiency with rigidity. It is often absent in well-marked cases, while an hysterical girl will complain of pain on being touched ; and if pressure be made on the processes alone, a faulty conclusion will be formed. Another method of testing for pain is to use a sponge wrung out of very hot water ; this being brought over the site of disease gives rise to a sudden sensation of pain. Ice applied is said to do the same. Neither of these latter tests are reliable. Their absence does not exclude caries, their presence is often due to conditions other than caries. It is possible that a very sensitive surface-thermometer might indicate some local rise of temperature, but I have had no personal experience with this method. By gentle movements of flexion, extension and rotation, some pain is often elicited. The method of jarring the spine by sudden ^ Cf. Hilton's Rest and Pain, 3rd ed. p. 93 : "A gentleman whom I saw from the neighbourhood of Norwich with a disease of the spine, in detailing his case to me, said : 'Did you ever see any of those Italian fellows, with monkeys on boards, dancing to music, with a cord or piece of leather strajiped tight around their belly and loins ? That is just how I felt ' ; giving one an idea of the pinched and contracted condition of the abdomen which he had experienced." CHAP. II CARIES OF THE SPINE (ANGULAR DEFORMITY) 33 pressure on the vertex in the erect position is as cruel and un- necessary as the jarring of the extended thigh in suspected coxitis. If disease is present, other symptoms have already decided the issue; if absent, sudden pressure on the top of the head is very uncomfort- able and displeasing to the patient. Ash by and Wright ^ remark : " In a few instances we have found herpes zoster occurring in con- nection with caries of the spine ; and it is worth while to examine the spine in cases of shingles, since they may be a result of lesions starting in the spinal column." A sudden increase of pain is often symptomatic of formation of abscess, increase of deformity, or the beginning of paralysis.^ When treatment is effectual the first result is gradual decrease with final loss of pain. (4) Irregularity of the, Spinous Processes, or Projection of one or more of them. Alternation of the Normal Curvature, either Flattening or Increase. — The advanced conditions of deformity have already been fully dealt with. It remains, however, to speak of slight displacements. If with rigidity of a portion of the spine and pain, one or more spinous processes be unduly prominent and the angle altered relatively to the neighbouring processes, then the disease may be said to have declared itself. The .sharper and more localised the projection, the greater the probability of Pott's disease. A pro- jection of one spinous process is seen occasionally in scoliosis at the point of intersection of two opposing curves (see Figs. 11 and 39). Such a projection is quite unlike the sharp knuckle of a displaced spinous process of caries. The natural prominence of the seventh cervical and neighbouring spines should not be forgotten, nor the difficulty of feeling the bony tips in fat children. In any case the projection of one or more spinous processes is best marked in the dorsal region, as the natural curve has its convexity backwards, while the converse is the case in the cervical and lumbar regions ; considerable displacement often occurs before a spinous process becomes prominent, owing to the thickness of muscles and the natural anterior curve. (5) Thickening around the affected vertchrce is absent in the early stages, but, in my own experience, is generally to be felt when- ever there are one or more outstanding spines. It is useful to recognise it, if any doubt exists as to the diagnosis between Pott's disease and scoliosis ; such thickening is almost unknown in scoliosis. It should always be carefully felt for in every case, as it affords ^ Ashby and Wright, op. cit. p. 567. ^ Cf. Bradford and Lovett, o^j. su]}- cit. p. 21. D 34 DEFORMITIES OF THE SPINE sec. i evidence of considerable extension of the morbid process to the soft tissues. Later in the disease the bones themselves become thickened when repair is taking place. (6) Yielding of the Spine on Pressure. — In the aggressive stages of caries if the palm of the hand be gently and firmly pressed over the posterior projection, the bones are felt to yield somewhat. As repair and healing take place, the yielding is replaced by a distinct resistance, which eventually becomes complete. This sign is of value in the following directions. If the yielding is great, it means that several vertebras are affected and the prognosis will be guarded. When resistance is complete, the treatment may be relaxed and sujDports lessened. To sum up the method of examination. Note the patient's aspect and walk on entering the room ; observe the attitude he assumes at rest ; remove the clothes as far as possible ; test for rigidity, and regard it as the first and most important symptom, the "patrol" of disease; trace pains to their sources; search for any irregularity of the vertebrae ; estimate the resiliency of the spinal column at the affected part ; place little reliance on the history ; and be on the look-out for abscesses and paralysis. Other symptoms are sometimes present. We have dwelt on the peculiar grunting respiration. In addition, cough is not un- usual, dyspncea, gastric disorders, flatulence, obstinately recurring vomiting, and bladder troubles.^ Dilatation or contraction of the pupil has been observed by Charcot and Gowers in cervical caries. The general condition is one of malaise or distinct illness. Loss of appetite, sleeplessness, inability to get about are the cause of this, in addition to the dej)ression of the vital powers, produced in tubercular cases by the production of several distinct foci of disease. The temperature is often raised slightly in the evening, and a hectic appearance may be seen. The onset of abscess aggravates all these symptoms. Diarrhoea and wasting often ensue, and the temperature assumes a pronounced hectic character ; the pain is increased and the general irrita- bility is more pronounced. Dysphagia may follow from pressure on the pharynx and oesophagus ; extensive abscesses in the chest give rise to physical signs such as dulness, etc. ; abdominal abscesses are frequently accompanied by much flatulence and gastric disorder. ^ Cf. Bradford and Lovett, o]). cit. p. 20: "In one notable instance the operation for stone in the bladder — lateral cystotomy — was performed. No vesical trouble was discovered, but at the autopsy caries of the lumbar vertebrai was found." CHAP. II CARIES OF THE SPINE (ANGULAR DEFORMITY) 35 The Diagnosis of Spinal Caries. — When the angular deformity is pronounced, no possible doubt can arise, but in the earlier stages it is possible either to overlook or totally mistake the condition. Experienced surgeons have frequently been at fault, owing, to the peculiar complexity of symptoms in an individual case. Gibney quotes a case in which the malady was first thought to be a sprain, and five months later to be a subacute dorso-lumbar meningitis or coxal neurosis ; two years later it was pronounced to be lumbar caries with psoas abscess, and at the time of writing the diagnosis was doubtful. Eeeves,-^ quoting this case of Gibney's, says, " I mention this case to show not only that the symptoms may be obscure, but that they will vary according to the stage of disease causing it." Herein lies the whole truth. One may tabulate symptoms and give general rules, but cases are seen which set rules at naught and defy calculation. In infancy and early childhood rhachitic kyphosis is not uncommon. But the general yielding of every part of the back, the absence of localised pain, the evenness and disappearance of the curve on suspension or lying down, with the presence of other signs of rickets, are sufficient points of distinction. In young adult life, especially in girls and young women, occasionally in neurotic boys, and in men notably after railway accidents, we find the hysterical or neuro-mimetic sjjine.^ Here there is much pain and not seldom stiffness. But it should be noticed that the pain is " patchy," not following the course of nerves, but limited to certain localised areas with more than one point of special intensity ; it is superficial as well as deep, and may change its seat. There are no spots of anaesthesia. Gowers ^ says, " There is more danger that caries of the spine in a young woman may be passed as hysterical paraplegia than of the opposite error. Especially wdien the subjects of caries present distinct symptoms of hysteria, there is risk, as experience shows, that unequivocal signs of caries may be over- looked." Unsuspected watching of the case, careful and repeated examination of the back are necessary. In any case let the surgeon beware lest he let the words " spinal disease " slip lightly from his lips when seeing neurotic women, if the symptoms at first sight ap- pear doubtful. In those past middle life a natural or senile kyphosis sets in. As previously stated, the onset of Pott's disease is very ■^ Bodily Deformities, p. 138. 2 Sir J. Paget, Clinical Led. and Essays, Lecture v. ^ Op. sup. cit. p. 252. 36 DEFORMITIES OF THE SPIXE sfx. i rare past middle lite, but it has been recorded several times. Syphilitic curvature will be dealt with later. The diagnosis from scoliosis or lettered curvature is generally easy ; the presence of marked rotation from the first, the absence of rigidity and pain are sufficient points of distinction. Lateral deviation (as distinct from curvature) is not so uncommon in Pott's disease. Dr. Bernard Bartow has written an admirable and well- illustrated article on this subject,^ although I am unable to agree with him as to the frequency of rotation. That such, however, does occur is well shown by the following case figured on p. 37. Case 10. Pott's Disease with Lateral Deviation. — Alfred K , aged 10, was seen by me at the Evelina Hospital in April 1894, on account of a projection in the back and pain. Four years ago he fell across the rail of a bedstead, and experienced considerable pain at once. The next day he was taken to St. Bartholomew's Hospital, and some liniment was applied. He lost the pain and was able to get about well until the last few weeks, when he began to suffer, and was noticed to be walking unevenly. On examination, there was a posterior projection extending from the eleventh dorsal to the second lumbar vertebra. The summit of the pro- jection was deviated a half to one inch from the middle line. The lumbar curve below the projection was flattened, while above the prominence a distinct lateral deviation to the right was seen, embracing the whole dorsal region, but best marked from the ninth dorsal vertebra to the site of disease. There was no compensatory curve above. The attitude was erect and military, and there was rigidity of the right erector spince muscle, and he was unable to touch his toes with the knees extended. Pain was felt in the course of the first, second, and third left lumbar nerves, but no "girdle pain " was present, nor paralysis of the lower limbs. Distinct thickening about the lumbar vertebraj was present. He slept well, but could not turn in bed on account of the pain. There Avas no history of phthisis in the family, and no signs of phthisis were present in the patient. A plaster of Paris jacket was applied, and the Ijoy lost the pain and was able to get about well. Lovett,^ in writing on this subject, sums up as follows : — 1. " Lateral deviation is common, especially in advancing cases, but absent in those getting well and those cured ; the early cause is muscular irritation, the later, unilateral absorption of bone. 2. " Eotation is not a prominent factor. o. " The distortion is not that of scoliosis, viz. a sinuous curvature, but a distinct leaning of the body from one side to the other.^ •^ Annals of Surgery, vol. x. p. 48. - Trans. Am. Orth. Assoc, vol. iii. }). 182. ^ The upper part of the bod}', in those cases I have seen, appears to be sliding off the lower at the affected spot. CHAP. II CARIES OF THE SPINE (ANGULAR DEFORMITY "The defornnty of the chest in lateral deviation from Pott's ^;J)-^'^'i^-= s Fig. 10.— Caries of the spine, witli lateral deviation (Case 10). disease does not follow the same rule in scoliosis; in the latter the 38 DEFORMITIES OF THE SPINE ribs rotate backwards on the convex side, in caries on the concave side ; cervical cases show the least lateral deformity. 5. "With the onset of marked lateral deviation a great increase of all the symptoms occurs, and pain is much greater on one side than before, but disappears with the diminution of the deviation under treatment." 6. Bartow specially notes that the patient is unable to overcome the distortion by any effort of his muscles that he is able to exert. 7. Another feature of the de- formity is its reluctance to yield, except in a slight degree, to exten- sion force that is rapidly applied, while the patient is in the erect position. As a rule it may be said that other signs of Pott's disease are present and sufficient to clear up the diagnosis. That at first sight the matter is not so simple as it may appear is shown by Figs. 10 and 11. In both cases there is a limited projection of the lumbar spines, in both there is lateral deviation, in both pain ; but in Fig. 10, the boy with Pott's disease, there was present the " tell-tale " rigidity below the prominent spine and the local thickening ; while in the girl (Fig. 11) this was absent. Curvature in some cases is due to syijliilitic disease. It occurs in adults much more than in children, and affects the upper part of the column rather than the lower. The only clue to the cause of the deformity is the presence of other syphilitic symptoms. Malignant disease of the spine simulates caries in some instances. A fuller notice of cancer in the spine will be given later. The diagnostic differences are as follows, which I take from a clinical lecture of ]\Ir. Howard Marsh ^ : " The symptoms of malignant 1 Lancet, vol. ii. 1893, p. 791, " Bye-ways in the Study of Diseases of the Spine." Fig. 11. — Lateral curvature of the spine, with marked promiueuce of two spinous processes. CHAP. II CARIES OF THE SPINE (ANGULAR DEFORMITY) 39 disease of the spiue bear at first sight a very close resemblance to those of acute Pott's disease. The deformity which occurs is the same, and pain in the column and in the course of the intercostal nerves is also similar in the two affections, yet a closer study will usually disclose certain differences which are sufficient for a correct differential diagnosis. " In the first place, pain is generally much more severe from the first — altogether a much more prominent symptom — in malignant disease, than it is even in the most acute cases of Pott's disease. In some cases it amounts to agony. " Secondly, the disease advances much more rapidly than caries, so that deformity generally makes its appearance very early — in the course of a few weeks — and then very rapidly increases. " Thirdly, paralysis at first of a single limb, or even of a single group of muscles, but soon becoming extensive, is very commonly present within the first few weeks ; and instead of tending to pass off, as is the case in paralysis due to Pott's disease, when the spine is placed at rest, in malignant disease it tends steadily, and often rapidly, to become worse and worse. " Fourthly, incontinence of urine and fseces is soon developed, and bed-sores quickly form. " Fifthly, the patient, instead of improving and gaining flesh, as is the case when he is placed at rest for Pott's disease, rapidly loses flesh, and becomes feeble and cachectic. " Sixthly, the course of the case is a steady and usually a rapid progress from bad to worse ; so that, generally speaking, the patient does not survive for more than six or eight months. " Lastly, there is in many cases evidence of primary carcinoma in the breast or elsewhere ; a circumstance which, in any case, he, who would avoid mistakes, must obviously be determined not to overlook." It may be added to these signs so ably presented by Mr. Marsh, that in malignant disease of the spine, when a projection is found, it is usually more rounded and less sharp than in caries ; neither does a " malignant " projection carry on it a bursa. It is too rapidly formed. In cervical caries the head, as previously mentioned, is dis- placed to one side, and may be confounded with wry-neck. Fortu- nately for the diagnosis, considerable thickening of the soft tissues occurs early in cervical disease, and the back of the neck is flattened. In true wry-neck the head -is rotated to the opposite side, though 40 DEFORMITIES OF THE SPIXE sfx. i drawn down to the shoulder on the affected side. In displacement from caries, the head is fixed laterally, but not rotated ; and the deep muscles as well as the sterno-mastoid are contracted. Move- ment is very limited or absent in caries, whereas in wry-neck it is free in all other directions, save when the shortened sterno-mastoid is pulled on. Then, too, there are the anxious expression, and the attitude and " military " movement in caries ; or in more advanced cases the head is held with the hand supporting the cliin. Hip disease or coxitis may mislead unless careful examination be made. The contraction at the joint and the flexion simulate the psoas-contraction of spinal disease, but special attention to the limitation of movements at the hip-joint, especially flexion, will serve to clear up doubts. In rare instances coxitis and caries coexist. Case 11. Coexistence of Spinal Caries tcith Double Coxitis. — W. B., aged 9, when .3 years old attended Great Ormond Street for double hip- joint disease, and weight-extension was applied. The joints ankylosed, and he afterwards went to the Convalescent Home at Highgate, where he stayed a considerable time. A year ago the mother noticed a pro- jection in the back. I saw him at the National Orthopaedic Hospital in March 1894. His api^earance then was striking; he had the bowed aspect of advanced age ; in the back a projection was seen, composed of the spines and transverse processes of the eighth to the eleventh dorsal \ertebrae. Both hips Avere firmly ankylosed, the right at an angle of .30" and the left at an angle of 35". On examining the spine it was found to be ver}' yielding over the projection, and there was very marked girdle pain and much general distress and illness. A poroplastic jacket was fitted, cod-liA'er oil ordered, and the mother advised to get liim away to the seaside. The case ultimately did well, but there was left very considerable deformity. From sacra-iliac disease the diagnosis is made by the absence of rigidity in the spine, and the persistence of pain over the affected joint, together with the characteristic " sacro-iliac " attitude and the lengthening of one side of the lower part of the body, due to weakening or destruction of the sacro-iliac ligaments. As the disease progresses, swelling appears over the joint, and it may be fluctuation. The latter must not be mistaken for sj)inal abscess. Osteo-arthritis and ostcitis-dcformans cause a general and not a limited kyphosis ; nor do they give rise to reflected pain, unless it may happen — a rare event, I imagine — that the nerves are pressed upon as they issue from the spinal canal. Perinephritis and pevitypMtis, in addition to pain, lla^■e one CHAP. II CARIES OF THE SPINE (ANGULAR DEFORMITY) 41 symptom in common with caries — psoas - contraction. In the absence of abscess the diagnosis is made by a practical acquaintance with the symptoms of the several diseases. Erosion of the spine from aneurism, although it gives rise to dry caries, can scarcely be mistaken for Pott's disease in the ordinary acceptation of the term. Long before any deformity can occur, other symptoms have generally called for careful palpation and auscultation, sufficient in them- selves to render the cause of the persistent pain in the spine e"vddent. With regard to the diagnosis of the cause of the para'plegia, in some instances the latter happens that this precedes deformity, but rigidity and other symptoms of caries are present from the first. As to the other causes inducing paraplegia, such as myelitis, meningeal tumours, gummata in the cord, the reader is referred to the standard works on " Diseases of the Xervous System." The advent of aiscess in caries sometimes complicates the diagnostic problem. Eenal symptoms may occur from abscesses which are spinal in origin. Mr. Jacobsou, writing on the subject of nephro- lithotomy,-'- says, " The great difficulty which may arise in diagnosing between certain cases of spinal caries and renal calculus is not yet sufficiently recognised. G. A. "NYright ^ thus alludes to this matter : ' When a local patch of caries of a vertebral body exists, and especially where deep suppuration occurs and presses upon the kidney, as in a case of my own and one or two others which I have seen, nearly all the symptoms of a calculus have been present. In my own case, without any deformity or tenderness of the spine, there was unilateral rigidity, testicular pain, intermission of symptoms, increased frequency of micturition, nausea during the attacks, and oxaluria with local pain and tenderness. Subsequently an abscess developed, and on exploration a small patch of caries was found, and the kidney was felt exposed on the anterior wall of the abscess cavity. Probably, as in floating kidney, obstruction of the vessels and ureter may arise and cause symptoms, so that pressure of the spinal abscess may disturb the kidney, and quite possibly give rise to hsematuria.' " Erichsen " says : " I have, however, seen an abscess dependent on caries of the vertebras not only assume the perinephritic form, but open into the pelvis of the kidney, thus simulating chronic pyelitis. In this case the diagnosis was made 1 Brit. Med. Journal, 1890, vol. i. p. 117. " Med. Cliron. No. 6, p. 642. ^ Science and Art of Surg. 8th ed. vol. ii. p. 426. 42 DEFORMITIES OF THE STIXE sec. i by a careful examination of the pus, in which molecular masses of carious bone were found. The chemical and microscopical examina- tion of the pus in all cases of doubt should never be omitted." As psoas abscess in the vast majority of cases presents in the thigh, and numerous other fluid swellings are also found there, it behoves the surgeon to attend carefully to the diagnosis of these conditions. Such may be perityphilitic abscess ; iliac abscess arising from disease of the pelvic bones ^ ; localised collections of pus in the muscular and areolar tissue ; intra-pelvic abscess arising from coxitis ; cysts ; femoral hernia with fluid in the sac ; and bursitis. As Sir John Erichsen points out, if the iliac abscess is superficial to the fascia iliaca, it very rarely passes beneath Poupart's ligament, owing to the firm attachment of these structures together. When the collection of pus forms beneath the fascia iliaca, there is nothing to prevent it extending to the psoas and passing down under Poupart's ligament ; and the determination of its origin, whether from disease of the ilium or vertebra? or from a strain, can be made only from the presence or absence of the symptoms of disease of the spine. Psoas abscess also in many cases appears suddenly in the thigh, the patient finding on washing him- self in the morning that he has a large soft tumour in the gToin ; whereas iliac abscess comes on more gradually, and presents in a more diffused manner. From femoral hernia the diagnosis of abscess is not difficult : both give an impulse on coughing, but the gurgling on the return of a hernia and its sudden reappearance when the pressure is taken off are characteristic. There are several other conditions for which spinal disease and abscess may be mistaken, but a thorough examination on the lines already indicated will almost always enable the surgeon to avoid errors. The Prognosis of Angular Deformity and Spinal Abscess. — The existence of Pott's disease must necessarily be of serious import to the general health and life of a patient. The severity of the disease itself; the part affected, the spine being the central axis of the trunk ; the effect of even uncomplicated caries on the general health ; the moderate probability of severe complications, such as abscesses with all their attendant train of evils ; the onset of paralysis : the possibility in tubercular cases of the existence of foci elsewhere, must all militate severely against the attainment of ' Cf. case quoted in note tg p. 26. CHAP. 11 CARIES OF THE SPIXE (AXGULAR DEFORMITY) 43 moderate health, not to speak of longevity. The outlook, however, is not necessarily so very serious. Many patients recover entirely, and may be seen to acquire fresh strength and health after the disease has passed away. They even become vigorous old men in spite of the deformity, just as many sickly children, carefully reared in their earlier years, survive the wear and tear of early and middle life, and seem to preserve their strength even in declining years. At the sea-coast and in healthy country districts an old man, hale though deformed, is not such a rare phenomenon to the medical man as might be expected by those whose practice lies in towns. In the first place, let us consider the prognosis in %incomi3licatecl cases when seen for the first time by the surgeon. The factors to be considered are the family history, the age, the history of the disease, the present condition, and the social status of the patient. We may then pass on to discuss the elements of prognosis as to duration of the disease and the probability of recovery. Having spoken of simple cases, it remains then to speak of the probable results of abscess, paralysis, and visceral lesions. Family History. — In a simple uncomplicated case with or with- out deformity, in which there is no history of tuberculosis in the parents or grand-parents, a favourable opinion may be expressed as to the ultimate cure of the disease, while reserving any definite expression as to the nature of the cure in the direction of deformity and future usefulness of the patient. To quote an example. Case 12. Potth Disease arising from Injurij ; Com.plete Recovery. — A. G., aged 50, when 9 years old climbed up the rain-water pipe on the side of a house, and fell from a height of fifteen feet. He injured his back severely, and considerable pain followed from the time of the accident. This was succeeded in four months by the appearance of a projection limited to tlie upper dorsal region. Notwithstanding the pain, the child was alloAved to get about, and the deformity then became much greater. Subsequently, however, complete cure without abscess followed, and the patient is now perfectly healthy and strong, and able to enter into all the duties of active life. His great-grand- father attained the age of 78, his grandfather 93, his grandmother 85, his father is alive aged 75, and his mother recently died aged 77. Other members of his family are well and strong. On the other hand, a tubercular family history is almost always, if not entirely, an unfavourable element, and minimises the prospect of complete recovery ; while it increases the probability of extensive disease of bone, abscess and' the development of tubercle, visceral 44 DEFORMITIES OF THE SPIXE sec. i or arthritic, under the prolonged strain of the disease itself, and the tedious course of treatment necessary. The Afje. — In children the prognosis is less favourable than in adults ; because phthisis is much more likely to develop in the former than in the latter, and the opinion as to cure of the disease and the length of treatment must be more guarded in children on account of the more extensive bone destruction. In a careful article ^ on Pott's disease and pregnancy, Dr. T. Halsted Myers points out that the gravity of the prognosis is much increased by irrcynancy , even when the caries is apparently cured. The weight of the gravid uterus in active disease increases the probal)ility of abscess - formation, especially when the disease is lumbar. If the disease be entirely cured, the disturbance of the circulation induced by pregnancy tells upon the heart, and some patients succumb from cardiac failure. Dr. ]\Iyers quotes seven cases in which active disease complicated pregnancy. Four were dorsal and three dorso-lumbar. In six of these pregnancy either originated or greatly increased the severity of the disease. In the remaining case, pregnancy and parturition were harmless. The History of the Diseo^se and the ijresent Condition of the Spine. — I have previously advocated that little reliance can be placed upon the history unless it is absolutely clear and circum- stantial, and when the disease dates from a distinct injury of a severe nature in a non-tuberculous child, a more satisfactory prog- nosis may be expressed than in dealing with a tubercular case. With reference to the condition of the spine, the following points should be carefully observed ; the amount of rigidity, the number of vertebrae affected, the state of the spine as to yielding, the size of the projection, and the number of foci of di.sease - ; these will serve as guides in forming the basis of an opinion. The Social Condition. — Much must depend on the amount of care and attention that the patient can command. It may at once be said that the children of the poor, bandied about as they often are from one person's care to another, suffer more acutely, recover more slowly, and stand the strain upon the vital powers less readily than the children of the well-to-do, who can command all those hygienic measures of good food and fresh air which are so essential to their recovery while under surgical treatment. ^ Trans. Am. Orlhop. Assoc, vol. iv. p. 124. ^ In Fig. 12 is seen the representation of a case in which tlie spine is affecteil both in the upi^er dorsal and dorso-lunibar regions ; there is also considerable tubercular affection of both lungs, and the prognosis is therefore very serious. CHAP. II CARIES OF THE SPINE (ANGULAR DEFORMITY) 45 Au opinion will necessarily be sought as to the duration of the case. Each case must be judged on its merits. It is only possible to give the average duration of a number of collected cases. Any statistics bearing on this point should be received with reservation, owing to the likelihood of apparently cured cases creeping in and swelling the total. Some patients must be watched for many years before a __ complete cure can be said to have taken place, and unless one has noted very carefully a series of cases, it is not possible to fully appreciate the frequency of relapse. It may be said that with thorough treatment, the duration of cervical disease (exclud- ing atlo-axial disease) is shorter than dorsal, and dorsal than lumbar, on account of the less size of the bodies of the ver- tebrae, the comparative fragility, and the super- incumbent weight being less in the upper parts of the spinal column. Brad- ford and Lovett ^ re- marked that " relief from symptoms is early ob- tained ; but to establish ^ig. 12.— a case iu which the vertebral column was a complete cure, so that affected iu two regions (Percy E , aged 3 years, National Orthoptedic Hospital). there be no latent disease, requires protection and treatment for years. Eoughly speaking, it is always possible to predict a course of treatment which shall last not less than three years, and probably longer." I take it, these data refer to both complicated and uncomplicated cases, and I do not think that even in the latter hypothesis they are at all beside the mark. The Prohability of Recovery and Danger to Life. — Eeliable * 0]p. cit. p. 50. 46 DEFORMITIES OF THE SPINE sec. i Statistics as to the percentage of recoveries are difficult to obtain, since the cases must be watched through so long a period. Billroth and Menzel report 23 deaths in 61 cases; Jatfe noted 22 deaths in 82 cases; and ]\Iohr, 7 deaths in 72 cases. In autopsies of 702 cases, Billroth and Menzel found tuberculosis of other parts in 56 per cent, amyloid degeneration was present in 15 per cent, and fatty degeneration of the kidney in 22 per cent. Bradford and Lovett quote ISTeidert's ^ investigations on the ultimate cause of death in patients with angular deformity, the result of caries which has been cured. Many with severe deformity die of heart lesions, those with medium-sized curves die of phthisis, while those with slight deformities have a good prospect of life before them. Neidert investigated ol cases, and "the average age at the time of death was 49-^ years : 24 of whom had hypertrophy, some with and some without dilatation of the right side of the heart ; 4 had cardiac muscular degeneration ; 2 had stenosis of the mitral valve ; 1 acute miliary tuberculosis ; 8 died of phthisis ; 4 of pneumonia, and 1 of carbuncle. The occurrence of narrowing of the aorta in Pott's disease has already been noted (Plate I.). Causes of Death. — Tuberculosis is the chief, then come marasmus, exhaustion, lardaceous disease, spinal meningitis, and the fatal results of bursting of an abscess into the trachea, pleura, lung, oesophagus, peritoneal cavity, viscera ; and in one rare case perforation into a large artery. The Prognosis of Abscess. — This question may be considered from the following points of view : the region of tlie spine involved, the sex and age, the extent and position of the bone involved, the presence of other complications, and the influence of treatment. The Region of tlte Sjyine incohed. — In the cervical region abscess occurs less frequently than lower down, and its presence is soon manifest, and therefore ensures jDrompt treatment. It is this call for promptness which is, so to speak, the " saving clause " in cervical abscess, despite the grave possibilities involved in lesions of the cervical cord. In the dorsal and dorso-lumbar regions, the greater movements of the parts, the perpetual action of large muscles, and the lateral force exercised by the thorax in respiration must not only increase the liability to pus formation, but tend to make it .spread in many directions when it is once present. Still more, as we approach the lumbar and sacral regions, the number of foci of diseased bone increase ; and this, together with the peculiar ^ Inaugural Dissert. Munich, 1886. CHAP, II CARIES OF THE SPINE (ANGULAR DEFORMITY) 47 ^^^ ^^S%<^ \ lamination of the fasciee and the fusiform shape of the psoas, affords a wide scope for extension. In the dorsal and lumbar regions of the spine the ribs and transverse processes are some- times involved, and form large sequestra ; while the great depth of the bodies from the surface renders removal of sequestra difficult. In the lumbar region the same remarks apply with increased force, while in both dorsal and lumbar abscess the immediate contiguity of large serous cavities must be borne in mind. Sex and Age,. — Children bear the strain of abscess better than adults. While spinal abscess in a child rarely fails by the urgency of the symptoms to lead to careful examination and early recognition, in the adult it often runs a more chronic course ; and it is not unusual for the patient to go about with " lumbago," the cause of which is found, on examination, to be caries with the coexistence of a large abscess hitherto unnoticed. I am inclined to think, from personal experience of such patients, that their cases run a chronic and often downward course, in spite of the most approved treat- ment. The Presence of other Comiilica- ,s " tions. — The condition of cases pre- . Sentin.o- signs of advancing tubercle Fig. is.— Double lumbar abscess from spinal caries in a child, aged 15 montlis (the mother's hands sujd- porting the child are not showai in the figure). elsewhere, especially in the lungs, unfortunately calls for little comment. So, too, if hectic fever be once estab- lished, the peril is extreme. Next to abscess the most frequent complication is " compression -paraplegia." A i^riori it would appear that the occurrence of abscess during paralysis can have but one effect on the case. A serious view of the matter is not always justified. It often occurs that an intra-sj)inal abscess, the cause of compression, finds its way outside the spinal canal and empties itself into the softer tissues, with corresponding relief to the paraplegia. In cases of extreme deformity, when paralysis is due to the displacement of diseased bone, the onset of extraneous sup- puration by assisting the breaking down of the bodies has relieved the compression. 48 DEFOR.AIITIES OF THE SPIXE sec. i The opposite result occurs when an extra-dural abscess forces its way throu^li the sheath of spiual membraues. In such cases the prognosis is immediately bad. In dorsal caries symptoms of oesophageal obstruction are of grave import. They indicate that the bodies of the vertebne are extensively involved at the anterior aspect, and that the caseating process has extended to the posterior mediastinum, and that there is implication of the glands. The mediastinum is not a situation in which surgical interference is readily tolerated.^ The Method of Treatment. — This must necessarily influence the prognosis very materially, as in all abscesses. But in few is sucli discrimination of methods and zealous care in carrying them out so vitally essential. I allude more particularly to the question of perfect antisepsis from first to last. 1 Cf., however, Mr. "\V. Arbutlinot Lane's cases recorded in tlie Anncils of Surcjerij, vol. xvi. pp. 314-320. CHAPTER III THE TEEATMEXT OF CARIES OF THE SPIXE AXD ITS COMPLICATIONS General and Local Treatment of Uncomplicated Caries — Treatment of Abscess, and Discussion of the various Methods — Treatment of Compression Paraplegia, Conservative and by 0])eration — Atlo-axoid Disease — Sijphilitic Disease of the Spinal Column — Malignant Disease of the Spine — Xeuromimetic or Hysterical Spine. Ix spite of the severe nature of the spinal disease, much good may- be done, and cure often effected. If the case comes under treat- ment in its early stages, deformity may be prevented or reduced to a minimum. In the absence of comjDlications, cure will most readily be obtained in the cervical, lower dorsal, and lumbar reoions ; less readily and with more difficulty in the upper and mid -dorsal regions. The method of cure is by ankylosis, and when the disease is treated early and thoroughly the number of vertebrae aiikylosed is small, the patient having a very useful back. I know of one who is able to climb difficult mountains, despite ankylosis of the four upper lumbar vertebra-. In his case there is no deformity. The treatment may extend over years ; but the ultimate results are often such as to give solid satisfaction to the surgeon. Treat- ment may be described as general and local. General Treatment. — Fresh air and sunshine are most valuable, particularly in tubercular cases. It is the deprivation of them, together v/ith insanitary surroundings and bad food, that renders the treatment of poor patients so tedious. AVhen the necessity for recumbency has ceased, the patient should be sent aw^ay to Margate or one of the East Coast resorts, or failing those, to a somewhat elevated dry place in the country. But Margate air in tuberculosis is nearly a specific in itself Through the agency of various kindly persons we are enabled to secure six weeks or two months in the country from time to time for patients, and the good effect is most E 60 DEFOKMITIES OF THE SPINE sec. i marked. The food should be regular and plentiful, avoiding saccharine and starchy constituents in excess. The stomach and bowels must be regulated and constipation prevented. The best laxative in children is pulv. glycyrrhizie 5ss.-5j. at bedtime. Cod- liver oil, cream, or one of the malt extracts are useful, and we may from time to time give iron in the form of syr. ferri phosphatis CO., or syr. ferri iodidi oj- thrice daily. In tubercular cases such general treatment is essential. In non-tubercular cases it assists their recovery most markedly. Treatment directed to the Spine. — The })rinciples of treat- ment are three in number : — (a) To fix the vertebral column, and to place it in the best possible circumstances for healing. (b) To remove the weight of the upper part of the body from the diseased vertebra?. (c) To prevent, as far as possible, unnecessary deformity by supporting the trunk, especially in front; and if deformity has occurred, to limit its increase. To carry out these principles we have two methods at our disposal, viz. recumbency and the use of retentive appliances. They may be employed separately or in combination in individual cases, but can never be used indiscriminately. The precise value of each varies according to the age, stage of the disease, and the different regions affected. Recumhency. — Indications for : — 1. In all acute cases in which there are considerable pain, distress, and impairment of the general health. 2. When, on employing the " palm- pressure " test to the back, it is found to be yielding anteriorly. 3. When paralysis and abscess are threatened. 4. Particularly in cases of severe cervical and lower lumbar caries. 5. In those patients who become easily tired on their feet, and in those who, apparently well supported mechanically, frequently desire to lie down. 6. In children recumbency may be resorted to with less danger to the general health than in adults. The immediate effects of recumbency are good ; the pain disappears, the nervous irritability is lost, the face loses its anxious aspect, and the patient often puts on fat, although the muscles of the limbs diminish in size. The advantages are thus evident. The relief of pain ; the limita- CHAP. Ill CARIES OF THE SPINE AND ITS COMPLICATIONS 51 tion of the deformity, and in some cases its recession ; the gradual clearing up of any paresis, and the cessation of increase in the size of an abscess, are all good points. The disadvantages are, that in adults there is, after a compara- tively short improvement, a marked decline in the general health ; anaemia and constipation ensue, and wasting again appears. In the case of children these are not marked. Provided the room be airy and sunshiny, young patients bear the prolonged lying down better than adults. But as caged animals are found to be liable to tubercular affections, so children deprived of their liberty v/ill be unable to recover as rapidly as desirable from tubercular troubles. Formerly recumbency was persisted in for years, but now after a time we have the opportunity of giving patients more liberty by the use of plaster of Paris corsets, or some mechanical support such as a poroplastic jacket. It must be clearly borne in mind that when recumbency is demanded, it must be absolute so long as it lasts. The duration of recumlency can scarcely be specified in set terms of months. Each individual case must be judged on its merits. At the National Orthopaedic Hospital I am accustomed to keep children recumbent until all pain has disappeared ; until the palm- pressure test shows the back to be consolidated ; and until, with a little support from the nurse, the child can be sat up carefully for a few minutes, such raising to the vertical position not being accom- panied nor followed by pain. In cases which are doing well, the patient becomes restless, moving his arms and legs freely and fidget- ting constantly, or even attempting to turn over. One finds, how- ever, that unless the case is past treatment, the condition of the spine has markedly improved in three to nine months. Points to he noted in iplacing a Patient in the Recunibent Position. — 1. The mattress should be of horsehair, firm, flat, and not too hard, pillows beneath the head being dispensed with.^ 2. Air-beds or water-beds are best avoided, on account of their ^ Bradford and Lovett, op. cit. p. 55, describe a simple way of arranging a bed-frame so that the child can be moved readily in it and the bed-pan used without disturbance. Dr. Schapps, N.Y. Med. Journal, 21st Oct. 1893, has devised a very cheap and useful form of couch for cases of Pott's disease. The frame of the couch is made of gas-pipe and the body of canvas, stretched as tightly as possible, in which a hole is cut at the point over which the anus will be situated. On each side of the spinal curve, and across the sacrum, small sausage-shaped pads are sewn, to prevent undue pressure on bony points and to steady the body. Straps are also fixed to the bed, which pass over the shoulders from the axillae, and buckle to the bed as near the root of the neck as possible. By means of a weight attached to the ordinary Sayre head-piece, traction is made on the spine. The bed should run on rubber-tired wheels. 52 DEFORMITIES OF THE SFINE instability. They are of doubtful service if the patient is very thin, and bed-sores threaten. These may be obviated by alternating between the prone and supine positions. 3. It is necessary in most cases to employ some retentive arrange- ment to prevent movement. In cervical and dorsal cases a band across the chest, or a knitted-wool strap passing across the chest with circlets for the arms, and fastening to the sides of the bed, is de- sirable. In disease of the lumbar region it is necessary to supple- ment the upper band by a lower one across the abdomen. In older children the band acts as a moral rather than physical restraint. In younger children it is really necessary. An excellent arrange- ment, a bed-frame (Fig. 14) designed by my colleague Mr. ¥. R Fisher, is described in the Lancet, February 1878. It is sometimes .sufficient to pin the night-dress to the .sheet, which is iirmly fixed at the sides of the bed, or to use sand-bags. 4. Should extension be used at the same time ? If it be used with the idea of pulling apart the diseased vertebne, the idea is erroneous, as a very large amount of force is necessary to separate the bodies; but if it be employed to relieve the pres- sure between the adjacent parts of the diseased and partially -collapsed bodies, Fig. 14.— Mr. F. E. FiTher's bed- brought about by the action of irritated frame for cases of .spinal muscles, then its adoption is rational and necessary. In the cervical and upper dorsal forms of disease a leather collar and pulley may be fixed, and a weight of one to two pounds suspended, the head of the bed being raised one to two inches. The weight also serves to fix the head; or sand-bags may be used in addition if the case is an urgent one. In the mid- and lower dorsal and lumbar regions, pads of soft felt may be placed beneath the body in the region of deformity, bearing on the soft tissues at the sides of the median line, and not on the spinous processes themselves ; when the trouljle is lower dorsal or lumbar, extension may be applied to the legs, the foot of the bed being elevated .slightly. Such measures seem to me to answer most requirements, and I have not found it necessary to use Eanchfuss' suspensory cradle, although its merits are largely dwelt on by German and French surgeons. 5. In private cases it is desirable to have a couch or bed whicli CARIES OF THE SPINE AND ITS COMPLICATIONS 53 can be moved and placed in a carriage, so that the patient may obtain fresh air. In poorer patients a Phelps' box (Figs. 15 and 16) answers the same purpose when the acuter symptoms have passed away. 6. The choice of positions — prone or supine ? In the majority of cases, the supine is preferable, although it may be replaced by the prone for a short time, to avoid bed-sores. Obviously in cervical disease where extension is necessary, the supine position alone is available. Eedard ^ strongly advocates the prone position in those dorsal cases where the deformity is commencing, where there is a Fig. 15. — Phelps' box for spinal caries. Fig. 16. — Phelps' box for spinal caries. good deal of irritation and contraction of the muscles, and paralysis is setting in rapidly. He claims that in four out of eight cases he obtained a considerable diminution of the prominence, and in three that the deformity was not increased. He further states that the irksomeness of the position was soon overcome, and the general condition remained good with no loss of appetite. The prone position has certainly the advantage in that it places the congested spine uppermost ; but the disadvantages of it are that a specially- constructed couch is necessary, and more continuous attention to the patient is required. ' ^ TraiU de Chimrgie Ortlioptd. pp. 244, 245. 54 DEFORMITIES OF THE SPINE When the surgeon is satisfied that the severer symptoms have subsided, the spine is firm, and the probability of abscess or other complications is slight, it is well to adopt a combination of the methods of partial recumbency and fixation-appliances. This may be done by using either a double Thomas's hip-splint and crutches, if the disease is low down in the spine, or the patient can be firmly supported by one of the mechanical means to be detailed below. So that at first he is allowed to move about in the upright position for a few minutes daily, and the time is then gradually extended, more locomotion being allowed and less recumbency enforced ; care being always taken that movement stops short of fatigue, and that during the time he is recumbent the hori- zontal position is strictly enforced. Various com- plicated arrangements are figured in books and are in use, but I fail to see that they have any advan- tage either in the amount of movement allowed or support given over the simpler poroplastic or plaster jacket. Susjjcnsion. — A few words are not out of place in dealing with this matter. It is absolutely essential in cervical disease, and can be easily arranged by carrying the plaster bandages of a Sayre's jacket around the neck and forehead, leaving the face and vertex exposed. Naturally this is unsightly and cumbrous, but it affords Fig. i7.-Poropiastic excellent support. Or a iury-mast may be fitted to jacket with occi- '- ^ o J J pitai head -piece plaster or a poroplastic jacket. In the treat- (ErustV^^'^ ^^"^^ ment of out-patients I am accustomed to use a • poroplastic jacket carrying a stem accurately adjusted to the dorsal curve and bearing an occijjital head-rest, with a sling supporting the chin (Fig. 17). Another method is to sup- plement the felt jacket by a helmet and neck-piece, so making a complete cuirass after Walsham's plan. In lower cervical cases which are approaching cure, it is often sufficient to continue the poroplastic material around the neck, and still later a simple felt or Thomas's leather collar may be used. Suggestions as to the UmjAogment of Suspension. — Suspension or support of the head and shoulders is necessary if the disease be above the fourth dorsal vertebra, and support of the shoulders alone if the disease be at or above the eighth dorsal. It is needful to insist upon this point, since one frequently sees cases of disease of the CARIES OF THE SPINE AND ITS COMPLICATIONS upper dorsal vertebrte brought to the hospital \Yith nothiuo- but a jacket on. The resulting increase of deformity is inevitable. In the dorsal region the natural backward curve is aggravated by the erosion of the bodies, and when the disease lies between the shoulder-blades, they are separated from one another, the shoulders are displaced forwards, and the weight of the arms pulls the upper part of the vertebral column rapidly forward. It appears to be a simple matter to speak so decidedly about, but its frequent neglect too often leads to serious consequences. An idea is too prevalent that for spinal disease anywhere except in the cervical reoion a Sayre's or poroplastic jacket is sufficient. Support and, in early cases, backward traction of the arms are most essential to prevent unnecessary deformity of back and chest. Fixation and Supporting Appliances, and their Principles and Tests of Efficiency. — 1. All compli- cated arrangements are to be avoided. In the plaster of Paris jacket properly applied, and to a considerable extent in the poroplastic jacket all the needful requirements are fulfilled. Taylor's brace (Fig. 18) is largely used in America, and has received the stamp of Sir J. Erichsen's approval, and so merits notice. "With the jackets either of plaster or felt I am content. The complexity, weight, and intricate mechanism of the apparatus described in some books would almost make one believe that their designers were about to return to the days of Ambrose Pare's hammered brass cuirass, with steels and springs super- added. 2. They must firmly fix the site of disease. 3. All weight must be taken off the affected region by transfer- ence of pressure from diseased to healthy spots. 4. They must be comfortable, cleanly, and readily removable. 5. Pressure on the skin and chafing must be avoided. 6. The idea that they are to act permanently as extending apparatus as well as fixation, must be avoided. Extension of the normal physiological curves takes place when jackets are first adjusted, and at that time only. Whatever lessening of the actual deformity is sought for, should be previously secured by strictness in enforcing the recumbent position. When the time comes for a Fig. 18. Taylor's brace. 56 DEFORMITIES OF THE SPINE sec. i jacket, the diseased bones should be so firmly consolidated that no extension force short of danger can alter their position. 7. They must be inexpensive and such as can be readily applied by the surgeon himself. More particularly should this be the case in dealing with poor patients. Flastcr Jackets. — These serve merely as fixation appliances, only temporarily and during suspension as a means of traction. To put it more succinctly, the plaster jacket is applied to the patient when suspended and in an improved position. If care be taken that the jacket hardens rapidly, the spine is fixed in the improved position, in so far that the normal and compensatory physiological curves are straightened out ; but the deformity cannot be directly lessened by the jacket. Advantages of Plaster Jackets. — 1. "When properly applied they are efficient in suitable cases. 2. The surgeon is independent of the instrument-maker. 3. They cannot be removed at the whim of the patient. 4. Their cheapness. Disadvantages. — 1. They are uncleanly. This drawback is obviated by sprinkling some insecticide powder beneath them, or by stitching a second vest to the lower hem of that beneath the jacket, and drawing the second garment up into position by pulling on the first. Sayre, by splitting the jackets down the front before they are quite dry, and applying laces to the front, has succeeded in overcoming this difficulty. They thus lose slightly in efficiency but gain in cleanliness and comfort, and can be kept firmly applied to the figure by the lacing. A better plan is to split them longitudinally down one flank, and then lace them. "When removed from time to time they do not so readily break as when they are split in the middle line in front. 2. They are apt to become loose and badly fitting after a time. This can be obviated by care and attention, and seeing that the lower part of the jacket goes sufficiently low on the trunk. 3. They are apt to irritate the skin, especially over the prominences. This may be avoided by careful padding around, but not OA'er the prominence. 4. The condition of the back cannot be watched, nor examina- tion made for the formation of abscess. 5. If a discharging sinus is present, it is difficult to keep it antiseptic with a plaster jacket in position. CHAP. Ill CARIES OF THE SPIXE AXD ITS COMPLICATIOIS^S 57 Experience shows that with due care most of the objections to a plaster jacket may be overcome. Tlic Application of a Plaster Jacket. — The patient's clothes are removed, and a thin tight-fitting seamless vest is put on, a little insecticide powder being sprinkled first over the skin. Pads of cotton wool are made, one to be placed over the abdomen — " the dinner- pad," this is to be subsequently removed ; and others are made to fit round the projection ; the remainder are to be packed over the crests of the ilia to prevent chafing. The patient is sus- pended by the apparatus commonly used in all large hospitals, and care is taken that too much strain is not thrown upon the neck, additional bands passing beneath the axillae. He is raised gradually so that the heels are otf the ground and the toes are just touching. A modification of this method of suspension is to place the patient in a thin cloth hammock, and apply the plaster around the hammock, the ends of the latter being subsequently cut off. Or he may be suspended from the neck, the trunk and limbs resting on an inclined plane.-^ In practice the first method is the most useful. Crinoline muslin is the best material for bandages, and the plaster should be rubbed in evenly throughout the bandage, plaster of the best Cjuality and quite dry being used. A little alum may be added, as the plaster sets quicker. Plaster bandages having been previously put into water till they are thoroughly wet, are then wound smoothly and horizontally around the trunk. There are three fixation-points — the pelvis, the seat of disease behind, the front of the chest above. Therefore begin to put the bandage low down, i.e. well below the crests of the ilia, and make a firm pelvic band first ; now carry the bandage lightly round and round the trunk to beneath the axillae. Now strengthen the jacket by passing the bandage obliquely, at first from the front of the pelvis below to the upper lumbar region, and then with increasing obliquity over the projection and above it, so that two fixation-points are now firmly guarded. It remains to form the third fixation-point — over the front of the chest. This is effected by carrying the bandage to the front of the chest, and passing it obliquely around the trunk from the chest in front to the pelvic band behind, and then with turns of decreasing obliquity around the lumbar region and over the projection, taking care to keep it always thick over the upper part of the front of the chest, the folds of bandage here lying one on another. It may now be ^ Cf. Lorenz's arrangement ; and Redard, lit de pldtre, op. cit. p. 251. 58 DEFORMITIES OF THE SPINE finished off by encircling the whole trunk horizontally from above downwards. Plaster should be rubbed in with the hand from time to time, especially around tlie pelvis, and over the back, and at the upper part of the chest. The patient should then be laid fiat, and the dinner-pad removed. "When the jacket is nearly set, it may be rapidly cut up along tlie front or on one side, removed slowly, and bandaged at once to prevent warping. Laces are fixed across the opening, the patient again suspended, and the jacket finally applied. If the projection is high up in the dorsal region, the folds of plaster should also encircle the axilla? in a figure-of-eight, but then, of course, it cannot be cut up. If this proceeding is neces- sary, shoulder-straps may be fitted in jjlace of the plaster around the axilloe. Poroplastic Jackets. — These were introduced to supersede plaster of Paris. Advantcifjcs.- — 1. Lightness and por- osity. 2. Easy application in skilled hands. 3. Durability ; they last for a year to eighteen months. 4. They permit greater cleanliness, and allow the skin to be watched, and so chafing is prevented. 5. They set more rapidly than plaster, requiring only five minutes, and hence fixation is complete before release from suspension. 6. Their plasticity, taking the shape of the figure exactly, and ensuring a perfect fit. 7. The same jacket can be remoulded as often as necessary. Disadvantages. — 1. They are somewhat costly and out of the reach of poor patients. 2. They require considerable skill in adjustment, as they set so rapidly. 3. They are weak on the anterior aspect of the chest and over the crests of the ilia, i.e. two fixation-points are not sufficiently firm. The felt not being impregnated with resin over the mammie, the lower part of the abdomen, and the crests of the ilia, they are weak at those spots. They are split in front ; hence the weight of the body above the projection bears unduly on the lacing, which stretches considerably and requires careful attention. This may be obviated Fig. 19. — Dick's spiual apparatus. CHAP. HI CARIES OF THE SPINE AND ITS COMPLICATIONS 59 somewhat by carrying up strips of steel behind and firmly fixed to the jacket, and by adding shoulder-straps. Taylor's brace, Fig. 18, "is an apparatus of great utility, more especially in the advanced stages of angular curvature of the spine where ankylosis has taken place between the diseased vertebrse. It has a tendency, in consequence of the upright iron dorsal rods being jointed backwards, to uplift the head and shoulders, and thus often improves the attitude of the patient considerably. But this very advantage in the later stages becomes a source of inconvenience, if not of positive danger, in the earlier periods of the disease, as it tends to separate vertebrae in process of consolidation " (Erichsen). Can Recession of the Deformity lie ohtained f — Taylor, in the New York Med. Record, gives instances in which decrease of the deformity has resulted after the use of the brace. In one instance the spine, which had been bent almost to the right angle, was brought nearly to the vertical position, and no harmful complications ensued. But the brace can only be used in selected cases, and then with great discrimination and judgment, and a correct estimation of the con- dition of the vertebral column. In ankylosed spines the brace can only flatten out the normal physiological curves, and so render the deformity less apparent. When may Treatment he disjyensed -with in Spinal Caries ?■ — 1. The absence of pain is no test, since pain naturally ceases if a sup23ort be worn ; but if pain ensue on removal of the support, the jacket must be put on again. 2. When the spine is firmly fixed and the deformity has remained stationary for some months. 3. If a recession of the deformity has been gained and main- tained for some months. 4. If a compensatory lordosis just below the kyphosis is well established. 5. Dorsal caries is very rarely cured in one year ; cervical and lumbar may require less. 6. If the improvement in the general health is sustained. 7. Supports must always be worn much longer in tubercular cases. If the support has been worn too long the muscles atrophy rapidly. In any case, begin to dispense with the support gradually, especiallv if the patient is increasing in weight (Eyan^). ^ Trans. Ainer. Orth. Assoc, vol. ii. p. 22.3. 60 DEFORMITIES OF THE SPINE The Treatment of Complications Abscess.^ — Abscesses complicating Pott's disease constitute a grave source of danger to life. There can be no doubt that abscesses and their sequeke are the most frequent cause of death in spinal caries. The form of abscess may be psoas, lumbar, iliac, and pelvic. In gravity they may vary from a small collection of pus coming to the surface as directly as possible from the site of bone disease, and readily amenable to treatment, to enormous cavities containing pints, and extending beneath muscles and between planes of con- nective tissue in so devious a manner as to baffle all attempts at radical treatment. When such abscesses burst they form several discharging sinuses. One or more of these occasionally heal, and a new outlet is formed for the pus at some other spot, perhaps not so favourably situated for drainage and antisepsis as the previous opening. There is no type of case so formidable to the surgeon as this. To give details of such an one :- — • Case 13. Exfenm-e Caries, large Abscess tracking in several Direc- tions. — M. P., aged 12. On admission there was extensive angular de- formity occupying the dorsal region from the seventh to the twelfth dorsal vertebrae. The boy was sallow and cachectic. Pus was discharging from one opening in the riglit iliac fossa, and from a second on the outer side of the thigh tAvo inches below the trochanter major. Fluctuation extended on the right side from the crest of the ilium over the buttock to the thigh just above the lower sinus, and laterally from the anterior to nearly as far as the posterior superior iliac spine ; it was also felt over an oval area of about one inch in its long diameter just above the middle of tlie iliac crest, and again doubtfully one inch external and to the right of the last dorsal vertebra. On pressure over the right iliac fossa curd}' pus welled up. An attempt was made to cleanse the discharging sinuses and cavities. The collection in the gluteal region was freely evacuated. Great difficulty was experienced in finding the communication between the smaller collection above the crest of the ilium and that in the gluteal region, but it was subsequently effected. A second incision was made in the space between the last rib and the iliac crest ; but the abscess cavity could not be tracked further. Looking at the large extent of the deformity and its general rounded appearance, it was evident that several vertebrae were extensively diseased. It was probable that pus had made its way downwards from the dorsal spine to the crest of the ilium, and had then extended in two directions, externally into the gluteal region, and internally to the iliac fossa. After opening the posterior collections ^ Reprinted by permission of the editor of the Hospital, from an article on this sub- ject by the author in that journal. CHAP. Ill CARIES OF THE SPIXE AXD ITS COMPLICATIONS 61 freely and rubbing and sponging the abscess walls, the sinuses Avere dressed carefully. It was out of the question to attempt any radical treatment of an abscess extending over such a large area, and with such probable extensive disease of the vertebrae. Cases such as the one I have quoted require great skill in deal- ing with them. Mr. Symonds,^ speaking at the discussion at the British Medical Association Meeting on the " Treatment of Spinal Abscess," quoted the following details. He alluded to a case in which he had opened a large psoas abscess in the thigh, groin, and lumbar region, and obtained primary union. A sinus formed later, and a second abscess was dicovered on the other side. The sinus w^as scraped, the second abscess cleaned out, and the patient became quite well. Lumbar and iliac abscesses constitute a more formidable danger than even psoas abscesses ; the possibilities of their rupture into dangerous regions are greater, and their future course is more uncer- tain. It often happens that they sink into the pelvis, and burst into the rectum or bladder, or in the perinaeum.^ Such is the worst side of the picture. Fortunately there is a more favourable aspect. The methods of treatment open to us are six : — 1. The expectant, leaving the abscess to become encysted or absorbed. 2. Aspiration. 3. Aspiration with the injection of antiseptics. 4. Incision and drainage, with or without washing out the cavity with antiseptics. 5. The method variously advocated by Treves and others. 6. Complete removal of the sac by dissection. Dr. Townsend ^ of Xew York has carefully tabulated the results of treatment of seventy-five cases of spinal abscesses, and I take the liberty of producing his figures in full. The value of the table would have been enhanced if the piosition of the abscesses had been stated. 1 Brit. Med. Journ. 1892, vol. ii. p. 1423. " Michel states that of fortj'-eight iliac and lumbar abscesses, pus was also found iu the pelvis in thirty-nine. Nouvcau Did. dc Med. et CMr. ^ Trans. Amer. Orth. Assoc, vol. iv. p. 169. 62 DEFORMITIES OF THE SPINE Analysis of 75 Cases of Abscesses in Pott's Disease (Townsend) Expectant Metliod. No treatment b}' brace : abscess disappeared . ... 3 ,, „ abscess in statu quo . . . .8 ,, „ abscess increasing, child doing well . 8 ,, ,, abscess increasing, child doing badly . 2 21 Aspiration. Abscesses disappeared after asi)iration . . . . .11 Abscess opened spontaneously after aspiration failed . . .3 Abscess incised after aspiration failed . . • . . .4 Abscess in statu quo after aspiration failed . . . . 1 Number of aspirations in each case from 2 to 6, average 3. 19 Incision and Scrajnnrf of Sac. With use of iodoform emulsion or peroxide of hydrogen . . 14 llesults — Good, 11. Bad, 3. Opened spontaneously . . . . . . . . 21 liesults — Good, 15. Bad, 6. 75 Deaths. Tubercular meningitis ........ 2 Lardaceous disease ......... 2 Suppression of urine ........ 1 1. Absorption of Abscess — The Uxpectmit Flan. — Formerly there were but two methods of treatment : to leave the abscess alone, or to allow it to burst. That abscesses do disappear gradually no one is prepared to deny. Spinal abscesses may or may not give rise to symptoms. A remarkable instance of the latter event is the case given by Mr. Barker.^ We may take it that the course of events in absorption when pus has formed is as follows. The patient is ^ A System of Sii^rg. (Holmes and Hulke), 3rd ed. vol. ii. p. 418. A psoas abscess had become reduced to a dry, tough, cheesy mass, with calcareous plates scattered through it. CHAP. Ill CARIES OF THE SPINE AND ITS COMPLICATIONS 63 placed at rest, the spinal column is fixed, the intervertebral pressure is relieved, and pus ceases to be formed. Gradual diminution of the fluid part of the abscess takes place, and there results a cheesy mass, which becomes firmer and tougher, and may partially or entirely calcify, and be surrounded by a firm fibrous cajjsule. In the non- calcareous parts and in the outlying parts of the capsule numerous tubercle bacilli are found. Their presence always con- stitutes a distinct menace to health and life, and may at any time light up fresh local, or break out into general tuberculosis. The indications for the expectant treatment are — 1. When the abscess is apparently single, and not tracking in two or more directions. 2. When the recumbent position is followed immediately by cessation from pain, and improvement of the general health. 3. The expectant plan should be persevered with, if after a short trial the abscess ceases to enlarge. 4. It is evident that if pus is near the skin and pointing, it is better to open antiseptically, and so avoid the risks of spontaneous opening. 5. A large collection of pus is no hindrance to the trial of this method, provided that the appetite is good and the temj)erature is normal ; in fact in those abscesses which were formerly designated as " cold." At the present moment I am watching the course of a large lumbar and iliac abscess. Case 14. Spinal Abscess hurroioing into Thigh, and evacuated there. Good Result. — A girl, aged 8 years, was admitted to the National Orthopsedic Hospital on 19th December 1893, with a posterior pro- jection of the spine extending from the tentli dorsal to the first lumbar vertebra. A large abscess was felt in the right ihac fossa. It reached internally as far as the umbihcus, and fluctuation was felt on the outer side of the femoral artery in Scarj^a's triangle. She was placed in bed, extension applied, and she Avas given cod-liver oil. On 2nd February 1894 the abscess was found to have diminished sensibly, and did not extend beyond the mid-point of a line drawn from the anterior superior iliac spine to the umbilicus, with corresponding decrease in other dimensions. On 30th April all fluctuation had disappeared from below Poupart's ligament ; the abscess was limited to the iliac fossa. The child became fat and ruddy, and put on fifteen pounds in weight. In October no fulness or fluctuation could be felt in the iliac fossa, but a large collection of pus was found at the outer and posterior aspect of the right thigh. This was opened in three places on the outer side of the thigh, the sac carefully cleansed and rubbed out with iodoform emulsion. Healing by primary union took place. Some pus again 64 DEFORMITIES OF THE SPINE skc. i accumulated in the thigh. It was evacuated, and during the past eigiitecn months the child has been quite welL But unfortuuately good results cm the expectant plan are the exception and not the rule. Apparent diminution in the abscess may take place from the pus sinking into the pelvis. If absorption take place, the result for the immediate present may be regarded as satisfactory, but there is always the possibility of a recrudescence of the tubercular process. In any case, time is gained ; and when the abscess lights up again, as so many do, opportunity is afforded for other and more radical modes of treatment. Personally, I should be inclined, if the indications mentioned above so point, to give the patient the chance of absorption on the expectant plan. One's hand is still free to adopt other measures later. 2. Aspiration. — It is evident that evacuation by this method can only be of service when the contents of the abscess are entirely sero-purulent. But the contents of spinal abscess are very rarely so. In the great majority, large caseous clots are found. Aspiration fails to remove these. All it effects is to remove the more liquid and least harmful part of the pus. It is urged in favour of aspira- tion, that it may favour absorption ; by what means I know not ; and repeated aspiration at one spot may assist the pointing of pus at that spot. The risk run in introducing septic material is by no means small, although theoretically nil. 3. Aspiration ivith Injection of Fluids. — It is difficult to know what can be effected. If the conclusion with regard to aspiration is correct, that its application is very limited and unsatisfactory, in so far that it leaves caseous masses behind, then I fail to see how the injection of carbolic acid, corrosive sublimate, sulphurous acid, peroxide of hydrogen, or iodoform solutions can be efficacious. Can w^e expect that the caseous masses will be rendered inert, and the abscess walls cleansed by applying antiseptics ? I think not. Apart from these speculations, one definite danger is attached to the injection of fluids into spinal abscesses, particularly iliac and lumbar. Bradford and Lovett^ record a death in a boy of 5, after washing a small cold abscess from hip disease with a few ounces of 1 in 40 carbolic acid. I have witnessed dangerous collapse in a man aged 22, who had very extensive iliac abscess. It was aspirated, and a considerable amount of creolin solution injected. The patient, who had hitherto been taking the auaisthetic 1 Op. cit. p. 92. Cf. also Frankel, Wien. Med. JFochcnschr. 1884, p. 34; and Vincent, Med, Press aiid Circ. 1887, vol. xxiv. p. 529. CHAP. Ill CARIES OF THE SPINE AND ITS COMPLICATIONS 65 very well, suddenly became livid and pulseless. After considerable perseverance in methods of resuscitation such as artificial respira- tion and the injection of brandy, the patient was brought round. 4. Incision and Drainage with or witlioid washing out the Cavity with Antiseptics. — The character of abscesses differs very largely. It may be that we have to deal with a localised abscess which is pomting, in wliich the spinal disease is quiescent and the track from the spine healed ; or, on the contrary, we may have to deal with one which tracks beneath fascia, which has numerous pockets connected with it, overflowing from time to time into the main cavity through minute openings, the sinuses being found with exceeding difficulty or not at all at the time of operation ; or finally, some may be almost entirely post-peritoneal and pelvic. The localised forms are readily dealt with, and do well. Of the others, at the best, the outlook is doubtful. One essential point in the treatment is strict antisepsis from first to last. As some abscesses go on discharging for months, and it may be for years, the maintenance of strict antisepsis until the last drop of discharge has ceased is problematical, and in some cases well-nigh impossible. But such a result must be aimed at in all cases, to avoid the deadly risk of septic infection of the abscess walls, with its results of profuse discharge, hectic fever, and lardaceous disease. It is interesting to note that Bradford -^ relates a case of tetanus following incision and drainage. If the abscess be present on both sides, it is better to make a bilateral opening, since a small communication often exists, and pus wells over from the side which has no free exit. Cervical abscesses are best opened from the side of the neck at the posterior border of the sterno-mastoid or the anterior border of the trapezius, unless there is urgent dyspnoea and dysphagia calling for instant treatment from the pressure of a retro-pharyngeal abscess. An exit for pus may then be obtained through the posterior wall of the pharynx, the child being placed face downward, or the head hanging well over the back of the table. Dorsal abscesses should be opened where they point, generally to one side of the middle line of the back. The incision for lumbar abscess is made along the outer side of the transverse processes, and carried down through the quadratus lumborum till the sac is reached. In dealing with iliac and psoas abscesses, it is essential that the incision be away from the groin and upper part of the thigh. In ^ Trans. Amer.' Ortlwp. Assoc, vol. i. p. 11. F 66 DEFORMITIES OF THE SPINE SEC. I children it is almost hopeless to expect to keep the discharge sweet when the incision is near the genitals. Even when fluctuation ...as^:^^ Wk' V. -XT' »^ "H, Wi Jf' //-" "I Fig. 21. — A view of the chest showing the cliaiiges in its shape accompanying caries of the spine. --.K__,i^ ''"'"* 'V-D6t^'^ Fig. 20.— Advanced dor.so-lumbar disease with right lumbar abscess (Grace L , aged 14 months). is present below Toupart's ligament, an opening should be made in the lumbar region, if possible, and pus evacuated there. This CHAP. Ill CARIES OF THE SPINE AND ITS COMPLICATIONS 67 plan has the advantages of securing efficient and safe drainage ; and sequestra, if loose and lodged in the upper part of the cavity, are easily removed. Such a stroke of good fortune as finding large and loose sequestra, is rarely met with even by those who have considerable experience in spinal abscess. The only occasion when an opening near the groin is permissible is in conjunction with a lumbar opening, to aid in clearing and thoroughly cleansing the cavity, the groin opening to be sewn . up before the dressings are applied. Treves has pointed out that the lumbar incision is not possible when deformity exists such as to bring the ribs close to the iliac crest. ISTor is it easy in the case of a very tall and fleshy adult. In adults an opening below Poupart's ligament has the advantage of securing efficient drainage, if the patient progress sufficiently well to be allowed to get up and go about with a jacket on. In any case it is wise, in dealing with children, to cover the dressings, wherever they may be, with waterproof material, to prevent external contamination of them. 5. The Method variously advocated hy Treves, Barker, and others. — The object of this procedure is to place the treatment of spinal abscess on the same footing as that of caries of bone elsewhere, viz, removal of the source of trouble and thorough cleansing of the abscess cavity. In 1882 Israel-^ of Berlin, operating on an abscess in the lumbar region, removed part of the twelfth rib, scraped out the carious portion of the diseased vertebral body, and opened up the vertebral canal from which a quantity of pus escaped. In 1884 Treves read a paper before the Eoyal Medical and Chirurgical Society, urging that psoas abscesses should be evacuated through the loin, and he gave the steps of an operation by which the psoas muscle could be reached at the outer margin of the erector spinse by means of a vertical incision cutting through the sheaths of that muscle and the quadratus lumborum, so reaching the psoas. The psoas sheath is incised and the vertebrae examined by continuing the operation on the deep aspect of the muscle. In one case portions of diseased vertebrae were removed. Treves ^ quoted three operations, after all of which the patients recovered weU.^ The great advances made by Mr. Barker * in the treatment of ^ Berlin, klin. Wochensclir. 1882, No. 10. - Brit. Med. Joicrn. 12th Jan. 1884. ^ Much insistence must be placed, upon the rarity of the cases in wliich it will be possible to remove portions of necrosed bone. * Brit. Med. Jbzmi. 19th Jan. 1889 and 1st Nov. 1890 ; also Mcd.-Chir. Trans. 1889 and 1891. DEFORMITIES OF THE SPIXE cases of tubercular disease of the hip, in which, by means of scrap- ing and flushing with hot water, primary union was obtained, led to the application of this method to spinal abscesses. In his article ^ dealing with the question Barker says : " It is only lately that thorough evacuation has come to mean not only the removal of its fluid contents, but also of all solid and semi-solid caseous or calcareous debris ; and not only of this, but of that lining of half- organised exudation-material which covers the whole inner surface of the abscess formerly called the ' pyogenic membrane.' " The method is as follows : " Taking the case of a large psoas abscess in which the bone lesion is apparently stationary, or, perhaps, healing, but where the pus is steadily increasing, an incision is made over the lower part through sound structures and the liquid pus evacuated. By means of the well-known flushing scoop (Barker's) hot water at a temperature of 103° to 105° F. is sent into the cavity from a reservoir, and carries in its reflux the re- maining contents of the abscess. The flushing scoop is then used as a scraper, to dislodge the more solid portions of the caseous matter which are washed out by the flow of hot water. The walls of the cavity are gently scraped until all the soft lining is removed, and the water allowed to flow till it emerges clear from the cavity. The scoop is withdrawn, excess of w^ater squeezed out from the sac, and sponges on sticks are used to dr}- out the last traces of moisture. Then two or three ounces of fresh iodoform emulsion are poured into the deepest parts of the abscess, sutures placed in position, all excess of emulsion squeezed out, the wound closed and dressed." - Several successful cases are quoted. G. A. "Wright " has dealt with tubercular abscesses on the same lines, except that an ordinary Yolkmann's spoon and solution of perchloride of mercury, 1 in 3000, are used. He gives notes of twelve cases of abscess, nine of tubercular joints, and three arising from spinal caries. The results were favourable in ten, including all the spinal cases. In a clinical lecture delivered by Treves * at the Loudon Hospital, on the " Treatment of Spinal and other Tubercular Abscesses," he gives details of eight cases. By means of the finger and sharp spoon and large quantities of perchloride of mercury solution (1 in 5000) the cavity is entirely cleared and the lining membrane is removed. "After the scraping and flushing ^ Barker, Brit. Med. Journ. 1891, vol. i. p. 27.^. - Abridged from Mr. Barker's account. 3 Bril. Med. Journ. 1891, vol. i. p. 905. * Ibid. 1892, vol. i. p. 1122. CHAP. Ill CARIES OF THE SPINE AND ITS COMPLICATIONS 69 have beeu persevered with until all the lining membrane appears to have been removed, then comes what I believe to be the most important part of the operation — the nibbing of the abscess wall with sponges and the thorough drying of the cavity. ... It is surprising what a quantity of inflammatory material, in the form of the slimy lining membrane, and even cheesy pus, comes away upon the sponges." The evacuation of pus from the spinal canal, and even from the posterior mediastinum and thoracic cavity, has been effected during the performance of laminectomy by Mr. Lane and others, and has resulted in a more rapid cure than would otherwise have taken place. The Memoval of Sequestra. — The diseased bone may with com- parative ease be removed if the laminse, transverse processes, and ribs are affected. But it cannot happen often that large sequestra arising from the vertebral bodies are so accessible and so loose that a pair of forceps or the fingers working through a lumbar incision can dislodge them. Many attempts have been made, notably by Ashurst, to get rid of carious bone by cutting down on to diseased vertebrae and scraping with a Volkmann's spoon. This can only be done in the lumbar region, and then not without exceeding difficulty and danger ; while the operation is not often of much benefit. A few cases are on record attended by brilliant success, but it would be well to have the failures recorded as well. 6. Complete Removal of the Sac hy Dissection. — This is very rarely possible. Mr. Watson Cheyne alluded in a paper on the " Treatment of Spinal Abscess " ^ to a case in which he was able to dissect out the sac and remove the spinous processes, and the wound healed by first intention. Mr. Symonds in the discussion which followed also spoke of a large abscess over the trochanter in which this had been done. To sum up the treatment of spinal abscess. 1. " Eeceding abscesses and quiescent foci are best treated on the expectant plan. 2. Aspiration is to be avoided, unless in the case of a small residual abscess following a previous attempt by the radical method to obtain primary union, and when the abscess is so deeply situated and in such immediate contact with serous membranes and viscera that further scraping is dangerous." 3. Cervical abscesses should be opened through the pharynx 1 Brit. Med. Journ. vol. ii. p. 1422. 70 DEFORMITIES OF THE SPINE sec. i when dyspnoea and dysphagia are urgent, but otherwise at the side of the neck. 4. Psoas and lumbar abscesses are best treated by the method of Barker, Treves, and others. 5. The radical method is more likely to Ije successful if the bone disease be quiescent or healing. 6. Openings in or near the groin are not permissible in children, and drainage tubes are sources of trouble both from the danger of septic infection and the risk of converting the track of the tube into a tubercular sinus. 7. " The merits of the lumbar incision are great, but its appli- cation is limited, and very frequently an incision as for the ligature of the external iliac artery by Astley Cooper's method is preferable. 8. The possibility of removing large sequestra of bone by cutting down on the vertebral column is very problematical ; and in a large number of cases no such proceeding is called for, the diseased bone being simply carious or caseous on its surface." 9. Dissection out of the sac is not often possible, but should be attempted when feasible. The Treatment of Compression-Paraplegia. — Treatment is of two kinds, conservative and operative by laminectomy : a hybrid term and one that might be replaced by rachiotomy, as suggested by Mr. Davies-Colley, or by lamnectomy, according to Lloyd, The Expectant or Conservative Plan. — In estimating the merits of the two plans attention should be directed to the eminently favour- able results of the expectant plan in paraplegia. Dr. Halsted Myers ^ in his account of 218 cases states that the prognosis is distinctly good — 55 per cent were known to have recovered, 26 per cent were not treated at all and passed from observation, presumably well; 3 per cent died of intercurrent disease, and in 16 per cent the lesion was unknown. Of the cases of paralysis studied by Taylor and Lovett the percentage of recovery was 100 when the paralysis came on under treatment ; and in any event more than 83 per cent recover under conservative treatment. So that the necessity for operation is not at all urgent, especially if it be remembered that many cases get well even after very pro- longed paralysis of one to two years' standing, and when the condition has at one time or another appeared hopeless. The conservative treatment requires complete recumbency on a Hat bed. It is better to use some extension, applied either to the ' Trans. Amer. Orth. Assoc. \o\. iii. p. 209. CHAP. Ill CARIES OF THE SPIKE AND ITS COMPLICATIONS 71 head or feet, as it prevents excessive settling down of one vertebra on another and limits pressure on the spinal cord. In severe cases my colleague, Mr. Fisher, uses a suspension couch. This in its essentials is a firmly padded board placed obliquely, and fitted at the top with a suspension apparatus for the head. The apparatus is placed in the bed, and the child rests against, and is supported by, the padded board, while the vertebrae undergo more extension than in the recumbent position, owing to the use of the suspension apparatus. The time needed for recovery varies from a few weeks in paretic cases to a year or fifteen months in severe examples. A second or even a third attack may ensue and yet the patient finally recover. Bed-sores should be carefully guarded against. Rachiotomy {Laminectomy). — This operation has been dealt with by several writers, notably by William White,^ Thorburn,^ Chipault,^ BuUard and Burrell,"* and Arbuthnot Lane,^ and at some length in an article by S. Lloyd ^ of l^ew York, who has tabulated and analysed seventy-five cases, the details of which he was able to obtain, represent- ing all the recorded cases to July 1892.' The article is very exhaust- ive and the subject skilfully handled. For many of the following remarks I must express my indebtedness to Dr. Lloyd's paper. The morbid conditions which give rise to paraplegia in Pott's disease must be clearly borne in mind in discussing the advisability of operation. It is clear that pressure is caused by extra-dural ^ Annals of Surgery, vol. x. p. 1 — "The Surgery of tlie Spine." - "The Surgery of the Spinal Cord," and Brit. Med. Journ. 23rd June 1894. ^ ArcMv Gen. de Med. Oct. Nov. and Dec. 1890. ■* Tra/iis. Amer. Orth. Assoc, vol. ii. p. 241. s Lancet, 1890, oth July ; and Brit. Med. Jo^irn. 1891, vol. i. p. 1227. ^ Amials of Surgery, vol. xvi. pp. 289-335. " Since that date the following eases have been reported, viz. : 6 by Alfred Parkin of Hull : of these, two were brilliant successes, one was improved, two subsequently suffered from psoas abscess, and in one, although power of locomotion was regained, the patient died two months afterwards of tubercular meningitis [Brit. Med. Journ. 29th Sept. 1894). It is, however, permissible to ditfer from Dr. Parkin in the remark that extension and counter-extension of the spine, however carefully applied, have little or no effect on cases of paraplegia. Dr. Andrew Grey {Brit. Med. Journ. 13th April 1895) records a very successful case of laminectomy, in which the arches of the fourth, fifth, and sixth dorsal vertebrje were removed, and sensation and voluntary movement commenced to return a day after the operation. In a very inveterate case of two yeai's' standing of my own, which has not been pub- lished, as the operation was performed as late as January 1896, the return of sensation after laminectomy occupied two months, and at the end of that time there was some return of voluntary movement. But as the case is still under observation, I refrain from giving further details, except that I had six months previously to the laminectomy performed costo-transversectomv without success. 72 DEFORMITIES OF THE SPIXE . sec. i thickening around the cord in the greater number of cases, less often by displaced bone; and rarely by newly-formed fibrous tissue, a con- dition of pachymeningitis (Macewen). Eemoval of the arches has revealed many diseased states of the soft parts. Wright-^ noted that on removal of the prominent dorsal arches a " leathery sub- stance " covered the cord, which did not pulsate after removal of this tissue. Duncan - found the membranes adherent to bone by granulation tissue which was scraped away. Abbe ' removed a dense mass of connective tissue and detritus from the posterior part of the dura mater. Gerster * in a successful case evacuated extra- and sub-dural abscesses, and found extensive thickening of the soft tissues adjoining the intervertebral focus, in which were embedded the anterior and posterior spinal nerve-roots ; the transverse pro- cesses of the fifth, sixth, seventh, and eiglith dorsal vertebr?e on the right, and tlie fifth, sixth, and seventh on the left side were carious and the costo-vertebral joints destroyed. These and the heads of the corresponding vertebrae were removed, together with the bodies of the sixth and seventh vertebrae, which were much disintegrated. Arbuthnot Lane^ in a case, which, so far as the paraplegia is con- cerned, is practically well, found the cord compressed by an abscess, which was very extensive and passed into the chest, where a cavity existed nearly as large as an orange, the walls of which were in great part bony. Lloyd's ^ case revealed the cause of the compression to be due to two firm bands, which were found on dissection to be the thickened interspinous ligaments ; which, in consequence of the separation of the posterior part of the spinal column by the curve, had slipped down until they caused firm compression of the cord. Of 75 cases of operation collected by Lloyd, 20 were adults, 39 were cliildren, and in the remainder the ages were not quoted ; 13 of the adults died, and 16 of the children. In 58 of the cases the region was noted. Of these 53 were dorsal, giving 18 recoveries, 7 improved, 8 not improved, and 19 deaths. There were but 5 cervical cases, 2 of which were cured and 3 died. One case involved the upper dorsal and cervical regions and one the dorso-lumbar, and both died. In the lumbar region there is one case, cured." The question of improvement must necessarily turn 1 Lancet, 14th July 1888, pp. 64-66. - Edin. Med. Journ. 1889, p. 829. "' X.Y. Med. Journ. 24111 Nov. 1S88. •* Annals of Surg. vol. xvi. p. 315. ' Ihid. p. 318. « Ibid. p. 303. ^ Mr. Thorburn, " Lectures on the Surgery of the Spiual Cord and its Appendages," Brit. Med. Journ. 23rd June 1894, estimates that the true ojieration mortality of lami- nectomy is about 20 per cent. He says : " We shall probably obtain the fairest conclu- CHAP. Ill CARIES OF THE SPINE AXD ITS COMPLICATIONS 73 on the presence of and the extent of the myelitis with the resulting degeneration. In Pott's disease this is much less frequent than in injury, as the spinal cord becomes " accustomed " to the pressure, but it is important to recognise its existence before an operation is undertaken. Lloyd came to the following conclusions : — " The operation is contra-indicated — 1. In cases where there are other tubercular lesions. 2. In cases where mechanical treatment has not been applied. It is indicated — 1. In cases where posterior spinal disease is made out as the cause of paraplegia. 2. In cases where the lesion seems to indicate the failure of mechanical treatment. 3. In cases where, during the employment of intelligently applied apparatus, the symptoms continue to increase in severity. 4. In cases where, after a certain period of careful mechanical treatment, say eighteen months, the condition has remained sta- tionary. 5. In cases where pressure-myelitis threatens the integrity of the cord. The first sign of this demands immediate operation. The operation can be applicable to less than 50 per cent of the cases of paraplegia from Pott's disease, as proven by the statistics of Gibney and Myers, and even of this number its application is limited again to those cases where the compression has not produced a complete degeneration of the cord." To Dr. Lloyd's conclusions I might add that the operation is indicated when cystitis and chronic bronchitis are present, while paralysis of the sphincters of the bladder and rectum do not by any means imply a serious prognosis so far as the ultimate recovery of the cord is concerned. The Oiyeration of Laminedomy (Zamnectomij). — Before operating it is well to see, in view of the danger arising from shock, that the limbs are warmly enveloped in wool. During the operation as little as possible of the patient's back is exposed, sions if we refer only to the statistics of a few surgeons, who have reported the whole of their cases, and for this purpose I have added together the cases of Macewen, Horsley, Lane, and myself in this country, and of Abbe, Chipault, and Schede from abroad. We thus find a record of 70 cases, with 12 deaths due to or hastened by the operation, yielding a percentage mortality of 17 "l. This being so, I think I may repeat the con- clusion to which I arrived in 1889, viz. the dangers of the operation are not great, especially in view of the conditions which it is intended to relieve. The cause of death in the great majority we iiud to have been shock." 74 DEFORMITIES OF THE SPIXE sec. i and hot-water bottles may be placed by his side. A subcutaneous injection of brandy during the operation is of value. Ether should be the anesthetic unless bronchitis be present. An incision is made slightly to one side of the median line, to avoid pressure on the scar during after-recumbency. The arches of the vertebrae are laid bare, as completely as possible within the field of operation. Then with a Hey's saw, laminectomy chisel, or fine bone-forcex)S, the laminae are divided and lifted out, and the dura mater exposed. At this stage great care is required. The theca may then be examined, and any inflammatory material or thickening removed, exposing thereby the spinal cord if necessary. The latter may be gently drawn aside with a blunt hook, to seek for caseous material on its anterior aspect. The opportunity should also be taken of removing any sequestra seen or felt, and by taking away the transverse process and the head of a rib, an abscess cavity on the front of the vertebrae may be opened. The amount of haemorrhage is small. The chief difficulty in old-standing cases is to remove the laminae without injury to the cord. In a case of mine the arch of the tenth dorsal vertebra so closely impinged on the cord that tlie bone had to be picked away piecemeal from above. Occipito-Atloid and Atlo-Axoid Disease. — The able writer (A. E. J. Barker) on this subject in the System of Surgery, 3rd edition, has condensed much that is known in a few pages. He points out the following remarkable differences in disease affecting this region of the vertebral column from lesions elsewhere in the spine. 1. " It is a comparatively rare disease now. Xo single instance was found by him among his notes of fifty cases of caries of the spine treated as out-patients at University College. In twenty- five volumes, 1849-1874 inclusive, of the Pathological Society's Transactions the disease has only been brought under notice five times in five of its volumes, only eight ^ cases being presented for consideration. 2. In former times it would appear to have been noted more frequently, perhaps because syphilis was allowed to run on un- 1 Another instance is given in Path. Soc. Trans. 1889, vol. xl. p. 264, by Mr. L. A. Dunn. The anterior and posterior arches of the three upper vertebra were so welded together as to present a slightly undulating but otherwise uniform surface. Mr. Dunn remarks : "The fusion of the three upper vertebra, I take it, results from disease in early life, whilst the changes in the articular processes are probably due to pressure produced by the altered position of the head. However, no history of the case could be obtained." CHAP. Ill CARIES OF THE SPINE AXD ITS COMPLICATIONS 75 checked for longer periods, or was treated too freely with mercury. Thus Eust/ writing in 1817, saw 13 cases. 3. It differs from the commoner forms of disease in being met with in adult life in a large proportion of cases. Thus in 24 cases Mr. Barker had been able to collect, in which the age is indicated, only 6 were under 20 years of age (and 2 of these had reached 18) before the disease had manifested itself, while 18 were adults. 4. It is in many cases more distinctly traceable to injury, and occurs thus in persons to all appearances in good health, without any scrofulous tendencies. 5. It appears capable of advancing very rapidly in destructive change, and under treatment, of repairing itself as rapidly and perfectly.^ 6. The process is more manifestly due here than lower down to syphilis, . . . this syphilitic disease starting in the pharynx or in the vertebrte themselves. 7. The disease affects the joint surfaces of these bones more frequently than the anterior segment." The synv-ptoras are pain in the neck, worse at night, increased by cold, by swallowing, and on deep inspiration. The pain is referred often to the larynx, and radiates over the area of distri- bution of the branches of the second and third cervical nerves.^ It is greatly augmented by movements of the head, especially lateral or rotatory, so that when the patient requires to look round he has to move his whole body. Later, the head droops forward, the sterno- mastoids become prominent, and the expression anxious. The anxiety is increased by any attempt at movement, and the patient takes the utmost care to support the head upon the hands while so doing. Some time before the head has drooped forward, deep palpation immedi- ately below the occiput reveals an acute tenderness. When the head is projected a fulness is noticeable behind, just under the occiput, and in the middle line, caused by inflammatory exudation and the prominence of the spinous processes of the atlas and axis (Fig. 22). Disease in this region of the vertebral column has acquired special significance from its proximity to the medulla, and the •^ Arthro-'kaJcologie, 1817, p. 6. - Hilton, Rest aivH Pain, 3rd edition, pp. 100-107. ■' Cf. Mr. Jacobson's note, Rest and Pain, 3rd edition, p. 95, on the question of pain being present when the sub-oecipital nerve is pressed upon. 76 DEFORMITIES OF THE SPINE fatal result that ensues when softening uf the ligaments occurs and the odontoid process is displaced backwards. Such displacement may be gradual or sudden. As instances of gradual displacement, we may refer to two specimens exhibited at the ]\Iedical and Chirurgical Society ^ ; in one the odontoid process had approached within two lines, and in the other within ^ of an inch of the posterior wall of the canaL Again, some movement causing increased strain on the softened ligaments is immediately followed by fatal results. Such in- stances are recorded by Hilton '" and others. The case of a little child re- corded by the former is particularly striking. Dis- ease in this region had existed for some time be- fore advice was sought. With rest in the recum- bent position for a fort- night, much improvement occurred. " The nurse specially appointed to attend the child, finding that her rest at niglit was now so calm and quiet, that she was so free from Fig. 22. — The position assumed by the head and the pain and fever, that her fulness of the neck iu cervical caries (Holmes' ,-. „ j _ ^c System of Surgery). appetite and power of swallowing were so much improved, as well as her temper, and thinking she was altogether so much better, and willing no doubt to mark lier own penetration, as well as to please the mother by telling her in the morning what had been done by her little charge, instead of giving the child her breakfast as usual, Avithout disturbing the head or neck in the least degree, desired the child to sit up to breakfast. The cliild did so, the head fell forwards, and she was dead." 1 Mecl.-Cliir. Trans, vol. xxxi. p. 259. - Eest and Pain, 3rd edition, pp. 109-112. CHAP. Ill CARIES OF THE SPINE AND ITS COMPLICATIONS 77 Dyspnoea, dysphagia, and a peculiar smallness of tlie voice, due in some instances to the pressure of a retro-pharyngeal abscess, and in others to imjDlication of the pneumogastric, spinal accessory and hypoglossal nerves, are frequent. Erichsen observes that " when the posterior wall of the pharynx is pushed forwards against the posterior nares the voice acquires a peculiar nasal tone." The direction taken by the pus which often forms in the course of the disease has been sufficiently indicated in the section dealing with spinal abscess. If it be confined to the spinal canal it may produce compression of the cord, or set up spmal or cerebral meningitis. When recovery oc- curs, complete ankylosis of the bones accompanies it. Sometimes large portions of the atlas and axis are cast off through the abscess cavity (see Fig. 23). It is remark- able that such severe cases recover. In- stances are recorded by Wade, Keate, Hilton, and Sir J. Paget. The treatment must be conducted on the same lines as in disease of the spine elsewhere. Complete recumbency in the earlier stages, followed later by the use of a plaster of Paris or poroplastic jacket, with a firm occipital head-piece and chin sup- port, are essential Sand -bags efficiently maintain the head at rest during recumbency. The general treatment consists in the administration of tonics and cod-liver oil ; and when practicable the patient should be placed on a specially-constructed carriage and taken out of doors. Syphilitic Disease in the Spinal Column. — In dealing with the causes of Pott's disease much stress has been hitherto laid on the shares taken by injury and tubercidar disease, but there is ample clinical evidence that syphilis may and does give rise to considerable posterior curvature secondary to caries and necrosis. Fig. 23. — Odontoid articulation of tlie atlas separated by ulceration. An atlas is placed below with the coiTespondiug portion broken off to show the relation- ship of the separated part of the anterior arch. The three fragments were exj)elled from the mouth during a fit of coughing (Guj''s Hospital Museum, 1018^^). ^ 78 DEFORMITIES OF THE SPINE sec. i In the cervical region, the part most frequently affected, numerous cases of syphilitic spinal disease are recorded in surgical literature. The frequent occurrence of disease in this part may be due to a spreading of syphilitic ulceration from the pharynx, but more often the process originates in the bodies of the vertebne themselves. A case is recorded and the specimen figured by Hilton ^ in Rest and Pain. The disease was situated between the occiput and atlas, and between the atlas and axis. The probable history of the specimen is that " the man to whom it had belonged had been long the subject of syphilis, had suffered great pain in the neck, and that, after eating his dinner, his head fell forwards upon the table and he died instantly." "^ Another probable instance is recorded by Dr. Dunlop ^ of Jersey. In this case, although the cause is not stated to have been syphilis, yet the occurrence of swellings in the buttock, chest, and back of hand simultaneously with disease in the first and second cervical vertebras and the anterior part of the second lumbar vertebra point to tertiary specific disease. This suspicion is strengthened by the woman's age, 58 years, when she first suffered from pain in the neck and loins. An instance occurring in the dorsal region is given by Mr. Howard Marsh.* Case 15. Syphilitic Deformity of the Spine {Howard Marsh). — " A man, 45 years, came to St. Bartholomew's with tertiary syphilis, from which he had suffered severely at intervals for upwards of fifteen years. He now had several broken-down gummata on the skull, with severe hemicrania and numerous syphilitic scars about his face, trunk, and limbs. He complained of severe nocturnal pains in his back, and said that his spine Avas becoming bent and so stiff that he could not stand uprightly. On examination, the dorsal curve of the spine was found to be considerably increased, so that the shoulders were very round and the head was bent forwards. On iodide of potassium, gradually increased to 20 grains three times a day, he rapidly improved, and the gummata were absorbed. He has had fresh outbreaks of tertiary syphilis since, and each attack has left the spine more arched and more stiff, and when I saw him last he was unable to raise his head above the level of his lower dorsal vertebrae." Eeeves^ mentions a case of syphilitic caries in a boy under his 1 Op. cit. Y>. 111. ' Mr. Jacobson alludes to other instances, one quoted by Collis, Pract. Observ, on the Veiiercal Dis. ; another by AVade, Mcd.-Chir. Trans, vol. xxxiii. « Brit. Med. Journ. 1893, vol. ii. p. 1380. ^ Ibid. p. 793. 5 Op. cit. p. 133. CHAP. Ill CAEIES OF THE SPINE AND ITS COMPLICATIONS 79 treatraeut at the London Hospital, who coughed up portions of vertebrte which had penetrated the lung. As illustrating the incidence of syphilitic disease in the Ivnibar region of the spine, I may cite with advantage the following case of Fournier's.^ Case 1 6. Syplmitic Lesions of the Spinal Column and other Parts {Foxirnier). — A man, aged 56, tall and well developed, was admitted into the Hopital St. Louis in July 1876. "He had been losing health for some time, and suffering from pains in the loins and lower limbs. Examination showed marked evidence of syphilis of long standing, e.g. syphilitic sarcocele, ten cutaneous gnmmata, as also in the muscles, and a gummatous ulceration of the great toe, and a macula on the thigh. In spite of treatment this man's condition soon became Avorse, and he died in October 1876." Post-Mortern. — In addition to the above lesions, there were found characteristic cicatrices in the spleen, a gumma on the fourth lumbar nerve, multiple and considerable lesions of Pott's disease, affecting the lumbar vertebral column, especially the third, fourth, and fifth vertebrte of that region (Fig. 24). These consisted of denudations of bones, thickening or destruction of the periosteal and ligamentous structures, sclerosing osteitis with caseous and purulent infiltration, almost complete destruction of the intervertebral fibro-cartilage, and a vast hollow mass in the lumbar column, also an abscess in each psoas muscle. A careful microscopical examination showed the deposit in these bones to be clearly gummata in various stages of degeneration, also there were gummatous nodules in the nerves passing off from this region. From the details of the cases quoted above we can gather that syphilitic caries of the spine offers a close parallel to tubercular or traumatic caries. In all the varieties of Pott's disease we have similar symptoms. In syphilitic caries the following points are particularly striking : — 1. It begins later in life than other forms of caries. 2. It affects the cervical region by preference, notably the atlas, axis, and third cer\'ical vertebrae. o. It is accompanied by rapid destruction of bone, which in some cases is succeeded very rapidly by repair. ■i. When caries is present, other signs of tertiary syphilis are well marked. 5. It occurs rarely in congenital syphilis. Eidlon, writing on syphilitic spondylitis in children in the Trans. Amer. Orth. Assoc, vol. iv, p. 118, says that " it differs in no way from syphilitic joint disease elsewhere, except that it is ^ Amial. deDermat. wiul de SypJi. Jan. 1881, and quoted by Barker, Syst. Surg. vol. ii. p. 421. 80 DEFORMITIES OF THE SPINE deeply situated, since it usually occurs about the anterior surface of the bodies. Its onset appears to be comparatively rapid; if in the dorsal region, kyphosis soon appears, with a sharp angle and sweep- ing curves above and below. When the disease is well established it follows the rule of all syphilitic lesions, that is, resolution or pus, and the abscess will undergo rapid absorption if the patient is placed under tlie influence of mercurials." He adds, spondylitis associated with joint- disease in young children under three is more often syphilitic than tuberculous.^ The most common associated conditions are bone and joint disease elsewhere ; and the least common are skin eruptions. Treatment. — This must be con- ducted on the same principles as Pott's disease arising from other causes, special attention being devoted to the specific taint. Malignant Disease of the Spine. — The forms of malignant new growth are sarcoma and carcinoma ; these are rarely primary, but commonly second- ary to neoplasms elsewhere. As instances of primary sarcoma, Judson "" quotes three cases which were mistaken for spinal caries. The first case occurred in a boy aged 4-2^ years. Fig. 24.— Vertical autero - posterior the sccoud ill ,a man aged 35 ycars, section of liuubar spines showing i,, ji-i'i ■ iii-, deposit of gimuua in back part ^^^d the third, also lu a man, aged 42 of the third and fourth (after years. In One the Spinal curves were Fournier). i • n i i t i normal, in the second there was doubt- ful alteration of the curves, while the remaining case showed a prominent eighth dorsal spine, forming a distinct angle. Gibney mentions in the Trans. Amer. Orthopedic Association a case of sarcoma in a man aged 40, the growth being situated in the fifth and sixth dorsal vertebrae; and Howard Marsh alludes to a case in a girl aged 7 years. The form of sarcoma is usually " large-celled," and Michel ^ has described these under the heading of " tumor myeloides." ^ This is not according to the author's experience. ■-' Trans. Amer. Orih. Assoc, vol. iv. ^ Nour. Did. de Med. et Ckirnr. xxxix. p. 222. CHAP. HI CAEIES OF THE SPmE AND ITS COMPLICATIONS 81 Examples of primary carcinoma in the spine are sufficiently rare to be pathological curiosities. The majority of cases of malig- nant disease in the spine are clue to secondary carcinoma, following similar disease in the breast, stomach, pancreas, liver, rectum, etc. Hence, if an adult patient complain of excruciating pain in the back coming on suddenly, and he or she be middle-aged, it is always well to examine carefnlly the sites of primary carcinoma. Howard ]\Iarsh, in " Bye- ways in the Study of Diseases of the Spine," ^ Ciuotes a case of secondary carcinoma with angular de- formity. Case 17. Malignant Groidh of the Spinal Column (Hau-ard Marsh). — "I recently removed the breast of a patient who, having found a tumour which she was afraid might be cancer, kept the matter to herself for nine months. During this time the growth steadily increased, and in the last two months she had suffered from very severe pains in her spine at the level of about the fourth dorsal vertebra, and also around the sides of her chest. She had also found great difficulty in walking. AVhen the spine was examined a well-marked angular curvature was found."' ]\Ir. ^larsh, after cpioting this case, dwells upon the fatal reticence of many patients, especially women with cancer in the breast. Other instances might be given, but I commend to the notice of my readers an excellent article on Malignant Disease of the Spine by E. AV. Amidon in the Xcv: YorJc Medical Journal, 26th February 1887, pp. 225-231. The symptoms have been dwelt upon on p. o8 in discussing the diagnosis of Pott's disease. Suffice it to make the following remarks. The disease is insidious, and occasionally is first revealed at the autopsy. The chief symptoms are pain and paralysis. The pain is intense and excruciating, and out of all proportion to any local signs ; but it is nevertheless more accurately limited to the diseased area than in caries. In the latter, local pain is not a prominent sign. The pain of growth is capricious, and it is increased by pressure or motion. It may disappear more or less completely at a later period, according to Edes." Such an instance came under my own notice. Case 18. Cancer of the Spine with Transient Pain. — A ladj', aged 49, who had been t'wice operated on by Mr. Bryant for carcinoma of the breast, in whom extensive recurrence had taken place, Avas seen by me on behalf of a friend on account of agonising pain in the lower dorsal 1 Lancet, 1S93, vol. ii. p. 792. - Boston 3Icd. and Surg. 'Journ. 1886, 17th June, pp. 559-562. G 82 DEFORMITIES OF THE SPINE sec. i region. This had lasted for four days, and various remedies had been tried. I injected lialf a grain of acetate of morphia subcutaneovisly, and the pain soon disappeared. Nor at any other time did it trouble the patient till her death, three months afterwards. At the autopsy a large mass of secondary growth was found, involving the bodies of the tenth and eleventh dorsal vertebrce. Paralysis due to spread of the disease to the meninges, or to compression of the cord, may ensue. Bradford and Lovett ^ state : " The occurrence of oedema from thrombosis in paralysis rather favours the theory of cancer as the cause." The prominence, when it is found, is generally more rounded in malignant disease than in Pott's disease. Unfortunately, nothing can be done for these cases beyond alleviating the pain and distress. When the disease is secondary recognition is easy, but when primary it may be almost impossible. However, intense pain in the liack in a middle-aged or old person, unrelie^•ed by rest and ordinary treatment, and requiring powerful anodynes to combat it, is very suggestive of malignant disease of the spine. Neuromimesis in the Spine, or Hysterical Spine. — Sir James Paget has dealt with this subject in Clinical Lectures and Essays, Lecture \. He writes : " The chief things to study in the spine are pain, stiffness, weakness, and deformity. An angular curvature of the spine — I mean sucli backward outstanding of one or more vertebra as is due to thinning or loss of substance of their bodies or intervertebral discs — is, I believe, quite inimitable by any nervous or muscular disease." Intense pain is frequently complained of by nervous men and women at one or more spots in the column. Frequently it is situated at two spots, between the scapuhe and at the loin. It is described as keen and boring, as though a nail were being driven into the part. Sir James adds : " At these tender spots the nervous patients cannot bear to be touched ; they flinch and writhe when the finger taps or presses them very gently. You may be sure that there is no disease of the spine when you see this, or when the tender parts of the spine are not painful on moving or on coughing or on sneezing. And you may be quite sure, I believe, when a gentle blow or pressure produces more pain than a hard one, or when you find the same pain or flinching if the skin over or near the spine is pinched without pressure on the spine itself. Again, the merely nervous pain is usually variable, though it may be never wdiolly absent." 1 Op. cit. p. 200. CHAP. Ill CARIES OF THE SPINE AND ITS COMPLICATIONS 83 Other signs, which serve to render clear the diagnosis, are the absence of rigidity, alteration in the general health, fever, and tangible lesion of ribs, spine, or nerves after the pain has j)ersisted with varying intensity for months or years. If these patients are carefully watched, they will, when they think themselves unnoticed, turn in bed or bend the back with an ease totally incompatible with any structural disease. Even if hysterical paraplegia supervene, the absence of deformity will generally make the case clear, since it is rare to get paraplegia without some deformity in Pott's disease. The chief importance of these cases lies not so much in the fact that their true nature may pass unrecognised, but that other and graver conditions, such as caries, may be classed as hysterical spine. CHAPTER IV SOME POINTS IN THE PHYSIOLOGY OF THE SPINAL COLUMN General RemarJcs — Division of the Sijinul Column into Anterior or Hiipportincj and Posterior or Protectiny Columns — The Four Curves, Cervical, Dorsal, Lumbar, and Sacral, and their Origin — Existence of a Curve normally to the Eight Side — Movements of the Spine — Centre of Gravity of Spine — Contrast between the Infantile and Adult Spine. The pliysiological role of the spinal column is highly complex. It protects the spinal cord ; it supports the trunk and gives attach- ment to the ribs ; it transmits the weight of the head and upper limbs to the pelvis ; and it is endowed with very diverse movements by the numerous muscles attached to it. It is very flexible, but strong ; it is very firm, though composed of many segments ; it permits of many deviations from the upright position, but at the same time it affords a complete protection to the spinal cord. If the spinal column be more closely observed, it is seen to consist of two chief parts — the anterior, or the column of the vertebral bodies, essentially supporting in function ; and the pos- terior, or column of the arches, whose primary function is the pro- tection of the medullary substance, support being a secondary matter. The importance of thus distinguishing between the two portions is great in the consideration of the deformities of scoliosis, and should be kept carefully in mind. It has been pointed out by A. B. Judson ^ that each vertebra consists of two parts, the body which is free to move laterally in tlie cavities of the chest and abdomen, and the processes which are prevented from the same degree of lateral displacement owing to their being entangled in the posterior parieties composed of ribs, muscles, and fascise. So that in a single vertebra as it deviates in motion from the middle line, the body moves |^ inch and the spinous process ^ inch. ^ Trans. Amer. Orthop. Assoc, vol. iii. p. 96. CHAP. IV POINTS IN THE PHYSIOLOGY OF THE SPINAL COLUMN 85 A vertebra does not, therefore, rotate on its central axis. This statement confirms Adams' observations that the external devia- tion of the spinous process is no measure of the internal dis- placement of the bodies. The length of the adult spinal column, including the sacrum and coccyx, is 26 to 28 inches. Taking the average measurement of the spine at 22 inches, exclusive of the sacrum and coccyx, one-fourth to one-fifth is due to the interposition of the intervertebral discs. To the latter the column owes much of its elasticity and freedom of movement. It is interesting to note the compressibility of intervertebral discs. There seems some foundation for the statement that " when the trunk has been kept in the erect posture during the day, an adult man of middle stature loses about 1 inch of his height, which he does not regain until he has remained some hours in a recumbent position." Eoughly, the spinal column viewed from the front represents a pyramid, the expanded base resting on the sacrum. If the areas of the articulating surfaces be measured from the second cervical to the last lumbar vertebra, they increase from abo\^e downwards, i.e. directly according to the weight sustained. The lohysioloyiccd curves of the spine are four in number — the cervical, dorsal, lumbar, and sacral. The first three pass into each other by a gradual transition, but the junction of the lumbar and sacral is marked by a distinct prominence, the sacro-vertebral angle. The curves vary much with the age, the individual, and the nature of the calling. Many authors assert that at birth the spinal column is straight, but Bouland,^ after very precise research, states there exist at that time (a) a cervical curve with its convexity anteriorly, of which the chord subtending the arc is 42 mm. long : (&) a dorsal curve, concave anteriorly, formed by the ten or eleven upper dorsal vertebrae, of which the length of the chord is 7 8 "5 mm. ; (c) the lumbar curve is generally absent. Bouland asserts that the generally prevailing opinion of the straightness of the infantile spine arises from the fact that the curves described by him are appreciable only in the column of the vertebral bodies, while the arch column is quite straight in the recumbent position. He says that the curves of the body column are due to varying degrees of ossification in front and behind in the cervical and dorsal region ; while in the lumbar region the forward convexity entirely originates from the greater thickness of the intervertebral discs anteriorly. ^ Quoted by Redard, TraiU Pratique de Chirurgie Ortliopklviue, ^. 207. S6 DEFORMITIES OF THE SPIXE sec. i Staffel is of opinion that the sacral curve and the inclination of the pelvis arise at the time when the child attempts to sit up or walk about. In the new-born child the centre of gravity of the trunk is situated well in front of a horizontal line joining the centres of the acetabula. At this time the spine forms a more or less straight line. When the child begins to sit up, the spine is curved so that equilibrium is obtained immediately over the hips. To effect this, there appears a convexity backwards in the dorsal region, followed by compensatory lumbar and cervical curves. With Mr. Treves ^ we believe that, of the four curves, the dorsal and sacral are primary, and due to the formation of the thoracic and pelvic cavities. They appear in fcetal life, and depend upon the shape of the bones. The other two, the cervical and lumbar, are compensatory curves, and depend upon the shape of the inter- vertebral discs. They appear after birth, and are accentuated by the assumption of the erect position. There are two points sup- porting this view. Firstly, if we look at a dried spine from which the discs have been removed, the cervical and lumbar curves are nearly lost, and there is but one curve, viz. in the dorsal region, with its convexity backwards. Secondly, when a child commences to sit, the back invariably assumes a kyphotic position, the kyphosis embracing the whole of the dorsal region, and extending into the cervical and lumbar regions. In rhachitic children this attitude persists as a definite form of kyphosis. In weakly, growing girls there is frequently a prominence of two or three lower dorsal spines associated with a general kyphosis, a condition which by the inex- perienced or inattentive may readily be put down to Pott's disease. There can be no doubt that as the walking powers increase, the psoas and iliacus muscles, passing over the Ijrim of the pelvis to their inferior attachments, accentuate the anterior convexity of the lumbar curve. It therefore follows that, of all positions, sitting at ease, by diminishing the angle of inclination of the pelvis and obliterating the normal lumbar lordosis, and allowing full scope to the development of the dorsal kyphosis, is the most prejudicial in weakly children and adolescents." The presence of a normal lateral curve to the right side has been advanced by some authors as a factor in the production of the ^ Surg. Appl. Anat. 2nd ed. p. 541. - Cf. "Researches in the Spinal Curvatures of Children while Sitting. A Study of the Mechanics of the Sitting Posture." Schultess, Zurich, Zcitschr. f. Chir. Ortli. Band i. Heft 1, 1891. CHAP. IV POINTS IN THE PHYSIOLOGY OF THE SPINAL COLUMN 87 common or right -sided form of scoliosis. But its existence is very problematical, although it has been dwelt upon by Professors Quain and Sharpey, and by foreign observers, Buhring and Hyrtl. The last - named anatomists went even further, and stated that in scoliosis the dorsal and lumbar curves were due to the spinal column being unequally loaded at the sides in different parts, — on the left in the dorsal region by the heart and great vessels, and on the right by the liver. It was therefore proposed to term the ordinary dorsal curve the " cardiac curve," and the lumbar curve the " hepatic curve." They would evidently explain all curves by the deviation of the spine to one side, so as to counterbalance any undue weight on the opposite side. The existence of the right dorsal curve has been attributed to the increase of space required by the heart and great vessels, or to the passage of the thoracic aorta from the left to the median line. Bichat and Beclard attribute it to the preponderating action of the right arm, as in one or two left-handed individuals the dorsal spine was curved to the left, and others to the attitude of the foetus in utero. The latter view is supported by the authority of Volkmann. Amongst others, Sappey, Cruveilhier, Little, and Adams are satisfied that no such normal curve exists, and the French anato- mists Bichat and Beclard state that the utmost deviation they have found is a mere depression at the spot where the thoracic aorta comes in contact with the spine. The movements of the spinal column take place in all directions, but they are more limited than is usually supposed, especially rotation and lateral flexion. These are supplemented by the free play of the pelvis upon the head of the thigh bones, and by the amount of tilting of the pelvis possible without disturbance of the equilibrium. Movements are of two varieties, partial and complete. The former comprise those delicate oscillations, especially in ordinary locomotion, which maintain the head " eyes-front," and serve to break up the shock arising from the impact of the advancing foot upon the ground. These partial movements are not to be confounded with those of oscillation which occur at the hip joint. The complete movements are as follows : — Plexion and extension are most free in the cervical and lumbar region, but in the dorsal are limited by the small amount of inter- vertebral substance and the overlapping of the laminse. The greatest bending backwards is permitted in the cervical, and the greatest bending forwards in the lumbar region, especially between DEFORMITIES OF THE SPINE the fourth aud fifth lumbar vertebr;^. Other movements are determined chiefly Ijv the articuhir processes. In the dorsal region a certain degree of rotation is permitted, owing to the direction of the articular processes ; hence in scoliosis the rotation is best marked in this region. In the lumbar region rotation is prevented, but the articular processes permit of some lateral flexion ; and by a combination of this with antero-posterior flexion, some degree of circumduction is obtained. The cervical vertebrse, owing to the oblique direction of their articular processes, allow of a com- bination of lateral flexion and rotation. Lateral Jlexion of the sjmie heijond a xcrij limited extent is alica/fs combined icith rotation. The limitation of lateral flexion is due to the particular arrangement of the articular processes and ligaments. If more than a slight amount of rotation is required, it can be obtained by a combination of antero-posterior and lateral flexion, and the result of the two movements is rotation of the bodies. Or, to put it another way. The intervertebral pressure caused by lateral movements falls obliquely on the upper planes of the bodies. They therefore tend to glide towards the point of least resistance ; but inasmuch as the bodies are less readily retained by ligaments than the remaining constituents of the column, the arches, the bodies submit to the maximum of displacement, and in doing so necessarily rotate. That lateral flexion beyond a certain point must be accompanied by rotation, is shown by the excellent and instructive experiment by Judson, to which further allusion is made on p. 142. The centre of fjravity of the spine, according to Professor Struthers,^ lies in the upper lumbar region to the right of the median plane. This may explain the great frequency of primary left lumbar curves and secondary right dorsal curves. The contrast between the surgical anatomy of the infantile and the adult spine has been well made by Chipanlt and Daleine." The spine of the foetus and new-born infant is comparatively longer tlian that of the adult, owing to the less development in young life of the lower limbs. In the infant the umbilicus is opposite tlie fourth lumbar vertebra or lower, while in the adult it is opposite the third lumbar spine. The base of the sternum corresponds in the infant to the top of the seventh cervical .spine, and in the adult to the second dorsal spine. The spinal cord descends to the tliird lumbar vertebra in the infant, but only to the first in ^ Edin. MoL Journ. June 1S63, p. 10S6. - Ecv. crOrthoptdic, May 1895. CHAP. IV POINTS m THE PHYSIOLOGY OF THE SPINAL COLUMN 89 the adult. The caiida equina in the infant, instead of forming, as it does in the adult, a cylindrical mass, filling up the whole dural sheath, is arranged in two distinct processes occupying the sides of the canal, separated by an interval of from 3 to 5 mm. The spinal canal may thus be punctured in the third or fourth lumbar space in the infant, without risk of wounding the cauda equina. Laminectomy may be performed under much more favourable conditions on the infant than on the adult. In the former the laminae may be easily resected, as the fatty tissue around the dura mater is much less vascular, and the periosteum can be more readily detached from the bone ; and as it is more plentifully supplied with blood-vessels, it is capable of throwing out fresh osseous tissue, thus repairing with greater solidity the breach in the posterior wall of the canal. CHAPTER V CONDITIONS AFFECTING THE SPINE OTHER THAN POTT'S DISEASE AND CAUSING KYPHOSIS Kyphosis of Infancy, Childhood, Adolescence, Adult Life, Old Age — Hereditary Hump-back — Kyphosis from Rheumatoid Arthritis, Rheumatism, Gonorrheal Rheumatism, Occupation, Osteitis Deformans, Osteo-mulacia — Spondylitis — Round Shoulders. The conditions other than Pott's disease causing kyphosis may advantageously be considered from the point of view of the age at which the deformity in the spine commences. I. Kyphosis of Infancy, due in many instances to feeble muscular development and Rickets. II. Kyphosis of Childhood. — Causes. a. After Rickets. fS. The result of Acute Anterior Polio-myelitis. y. Associated with the late stage of Pseudo-hj'pertrophic Muscular Paralysis. 8. Associated with Chest Deformities such as occur with Adenoids of the Naso-pharynx. e. Hereditary Hump-back. III. Kypjliosis of Adolescence. Round Shoulders. IV. Kyphosis of Advlt Lifr, due to a. Occupation, cjj. cobblers, tailors, and porters. ft. Muscular and Gonorrheal Rheumatism. y. Arthritis Deformans. 8. Osteitis Deformans. c. Osteo-malacia, or MoUities Ossiurn. ^. Progressive Muscular Atrophy. 7/. Bronchitis and Emphysema. Y. Kyphosis of Old Age. KYPHOSIS XOT DUE TO CARIES 91 Fig. 25. — Mr. Adams' spinal tray for rhacliitic kyphosis. From this somewhat lengthy list it will be seen how very diverse the causes and pathology of kyphosis are ; but the classification of the causes I have adopted seems open to the least objection. Another mode of classification is that of Eedard's ^ into kyphosis of ado- lescents, kyphosis of muscular or nerve origin, kyphosis arising from lesions of the bone. Some infants, as the result either of rickets or of general debility,- are unable to sit up long after the period at which children of the same age are accustomed to do so. If these in- fants are habitually nursed in the up- right position, the spine at this period, normally straight, becomes bowled posteriorly, and oftentimes somewhat laterally. Such an instance was the case of C. H., aged 18 months, a very ricketty child in whom both posterior and lateral curves existed, the latter being to the left with much rotation in the dorsal region. The treatment of cases when severe, with the back almost powerless, is recumbency. Mr. Adams' plan of directing the child to be nursed as much as possible in the reclining position, or to be carried about in a padded wicker tray (Fig. 25), is very useful.^ I have proved the efficiency of the wicker tray on many occasions. If the child is able to sit up, but with the spine bent, a back-board of leather, with axillary and periuceal straps attached, is useful (Fig. 26). It gives complete support to the spine and firm fixation. As the spinal curves are not developed till the child begins to walk, it is essential that the back be kept as straight as possible during infancy. The general condition demands atten- tion, and rickets must be appropriately treated. ^ Oj}. sup. cit. p. 213. - In a child aged 1 year and 8 months, who came under m}' care at the Xational Orthopaedic Hospital, there was a distinct history of congenital syphilis, and the posterior curvature of the spine was very marked. I do not suggest that syphilis was the im- mediate cause, but induced rather a general weakness. ^ Led. on Curv. of S^nne, 2nd ed. p. 63. Fig. 26.— Back-board for rhachitic ky- phosis. 92 DEFORMITIES OF THE SPINE sec. i 111 childhood it frequeutly happens that the posterior curva- ture of infancy has heen allowed to persist, or rickets ^ has developed later than usual, with the result that there is muscular and liga- mentous weakness. Such cases are best treated by a combination of recumbency and support. "When the curvature has lessened, frequent douchings and shampooing, with active and passive exercise of the back muscles short of fatigue, serve to correct the deformity and strengthen the muscles. There are two points of importance in connection with this posterior curvature : tlie one is that there is in such cases a predisposition to scoliosis later ; the other that caries of the spine is by no means uncommon in early childhood, and in its early stages is difficult of diagnosis. These latter cases require much care and attention, as the diagnosis is often difficult and uncertain, and not infrequently the termination is destructive disease of the bodies of the vertebne, although at the time of their coming under observation no direct evidence of Pott's disease is obtainable. But if on suspension or recumbency the curvature persist, tlien on- coming Pott's disease should be suspected. Acute anterior polio-myelitis rarely, it is true, paralyses the back muscles ; while the later stages of pseudo-hypertrophic muscular paralysis are characterised by such general loss of power that, if the patient be sat up, the spine yields so much that the chin falls forwards on the knees. In nasal obstruction such as frequently arises from adenoids, considerable posterior and some lateral curvature are not infrequent (Fig. '6^). This matter will be dealt with under the heading of " Deformities of the Thorax." Hrrcditary HnmiJ-hach. — Mr. AV. Adams- has drawn special attention to this form of kyphosis, and quotes a remarkable instance. A man, the father of five children, was " short and dwarfish, with an extreme degree of hump-back. He walked tolerably erect, but his head appeared to sink in between the shoulders, and his chest was • much deformed. The spinal curvature in his case began in child- hood, and was not the result of caries. The eldest son has proved to be the model of his father ; the three next children are free from deformity, but the youngest child exhibited the spinal curvature even at an earlier date than his eldest brother." From the drawing of the cast given by ^Mr. Adams in his book, it is seen that ^ Tampliu noted that in some cases of rickets in which the posterior borders of the scapula? stand out, the occurrence of sub-scai)ular crepitation is due to the bone riding over the headings of the ribs. Reeves, Bodily Def. p. 110. - Led. on Curv. of Spine, 2nd ed. p. 64. KYPHOSIS NOT DUE TO CARIES 93 the curvature affects the whole dorsal region, the natural convexity being greatly exaggerated. I have observed a similar instance in which a parent was affected in this way, and his son showed the bent back as early as the seventh year. It appears to me that but little can be done to remedy this condition. Constant lying down may be suggested by the medical attendant, but he will have a hard task to persuade the parents that such enforced abstinence from exercise and games by an otherwise perfectly healthy child is really needful to prevent deformity. At the onset of puberty the possibility of lateral curvature should be borne in mind. In adult life the causation of kyphosis in tailors and cobblers is sufficiently obvious, and may almost be considered a trade-mark. Nor is it confined to them ; the use of the bicycle has induced the " bicycle-stoop," and I have frequently seen kyphosis in mountain- porters in Switzerland. Eheumatism, gonorrheal rheumatism, rheumatoid arthritis, and osteitis deformans seriously interfere with the natural mobility of the spine and increase the physiological curve in the dorsal region, while reversing them in the cervical and lumbar region. Collectively the condition which these diseases induce is known as spondylitis deformans. Rheumatism affects most frequently the cervical region, more often causing in that situation lateral than posterior deviation, and giving rise to a form of torticollis (posterior torticollis). Gonorrheal rheumatism rarely causes spondylitis. Nolen ^ investigated 116 cases, and found two with arthritis of the vertebrte in addition to other joints. One recovered and one passed from observation before he recovered. So that iDermanent rigidity of the back can rarely be assigned to this disease. Rheumatoid arthritis plays a large part in the production of spondylitis. Bradford and Lovett ^ state that " the spine is in these cases oftenest primarily the seat of the disease, and the other joints become involved later. In the cases seen by the writers the patients have been young adults and children. In this way it offers a de- cided exception to the general behaviour of rheumatic gout. And the affection has been clearly a primary ankylosing arthritis of the vertebral column." I have seen it twice in girls aged 19 and 20 ; in both there was in addition considerable enlargement of the meta- tarso- phalangeal articulation of the great toe, together with the 1 DeutscJi Archiv of Clin. Med. 1882, No. 8, p. 10. - Op. cit. p. 191. Cf. also Adams, Annals of Surg, and Anat. Brooklyn, 1883, vol. vii. p. 6 ; and Brodhurst, Reynolds' System of Med. vol. i. p. 960. 94 DEFORMITIES OF THE SPINE sec i ansemia and mixed gouty and tubercular inheritance characteristic of rheumatoid arthritis. Mr. AV. Arbutlmot Lane ^ has most con- vincingly shown, however, that many cases of posterior excurvatiou of the spine associated with osteo-arthritis are due to pressure on the spine either from the nature of the labour being such as to induce long -continued strain on the spine ("labour changes "), or from pressure of adjacent bodies on the intervertebral discs due to faulty position of the patient causing their partial absorption, together with profound alteration in the shape of the bodies and the structure of the ligaments. The bowed condition of the spine in osteitis deformans is familiar to us all from the lucid description of the disease by Sir J. Paget in the Medico- Chiriirgical Transactions, vol. xlii. p. 77. Bradford and Lovett mention " a rare form of kyphosis seen in osteo-malacia where the whole spine may be bent so that it forms one long arch with the convexity backward. In one case the curve was so great that the chin of the patient rested near the umbilicus." The morhid anatomy of osteo-arthritis of the vertebrae is well illustrated by numerous specimens. Briefly it may be said that the disease is commonest in the dorsal region, especially the fifth, sixth, and seventh vertebne, but sufficiently well marked in the cervical and lumbar regions. The bodies of the vertebra- are flattened from above downwards at their anterior parts, sometimes to a remarkable extent and often present bony outgrowths ; the intervertebral discs are compressed, especially anteriorly, or have disappeared, or been replaced by bone, thus giving rise to complete ankylosis throughout the affected region ; the spinous processes are farther apart than normal and the laminte flattened and shortened. In some cases complete ossification takes place in the ligaments, notably in the anterior common ligament, and between and around the apophyses, also in the intervertebral discs and on the adjacent surfaces of the bodies. Concurrently with the spinal changes the thorax is increased antero-posteriorly and decreased vertically and transversely ; and the sternum is often unduly prominent, while the heads of the ribs in severer cases are firmly fixed by bone to the sides of the vertebrae, and respiration is abdominal. The pelvis is much modified, producing a pelvis similar to the kyphotic variety of obstetricians, being contracted transversely and enlarged in the conjugate diameter. 1 Guy's Hosj). Bej}. 1886, 1887, p. 278; and 1885, p. 321. See also Path. Soc. Trans. vols, xxxvi. and xxxvii. ; and Med.-Chir. Trans, vol. Ixvii. CHAP. V KYPHOSIS NOT DUE TO CARIES 95 The synvptoms of spondylitis are pain in tlie back, slight or severe, and stiffness, which is general throughout the spine with increase of the natural curves. In Pott's disease the rigidity is more localised to the affected part, and the posterior projection is angular in character and appears early in the disease. Immobility of the ribs is pathognomonic of spondylitis ; and the course of the disease is very chronic, curvature appearing gradually, and after pain has been complained of for some years. Treatment. — Unfortunately, when the disease has reached such a stage that deformity is noticeable, but little can be done. In the treatment of osteo-arthritis the essence of success is to begin early and before destructive change has set in. Among the various methods I would advocate complete rest from work and change of air. jSTo measures promise greater success than a course of treatment at Bath or Buxton, with plenty of good nourishing food, avoiding starchy matters and alcohol, and the liberal administration of iron alone or combined with arsenic and iodide of potash, in the form of liq. arsenici hydrargyri et iodidi. If the disease be purely rheumatic, local manipulation and massage of the back may be of some value, but these appear to be of little value in rheumatoid arthritis. In fact, in the latter disease after the first stages the outlook is very hopeless, and the patient gets steadily worse. In osteitis deformans no treatment is of avail. Senile hypliosis arises as the result of debility and wasting of the tissues, with absorption of the intervertebral discs. Or the same change is brought about by the nature of the occupation, as in agricultural labourers and in those whose vocation is such as to produce continued fatigue of the spinal muscles, notably in those " who live by the pen." Mr. Adams says he has observed a severe form of kyphosis in old cavalry officers who have seen a great deal of service in India, and he attributes it to the fatigue of frequent and long marches. In many cases the natural stoop of old age is hastened by rheumatoid affections of the vertebral articulations. In the most severe forms of senile kyphosis the body is bent at a right angle, and the patient can only walk v/ith the assistance of sticks. Such cases suffer very severely from difficulty of breathing, dyspepsia, and interference with the normal action of the heart, as evidenced by persistent palpitation. Beyond careful attention to the position assumed when writing or reading, the avoidance of undue fatigue, and daily exercise with light dumb-bells as pre- ventive measures, but little, can be done. When the curve has 96 DEFORMITIES OF THE SPINE sec. i once formed, efforts must be made to i^reveut its becoming more exaggerated by attention to the points just alluded to. Round Shoulders. — This deformity is the most frequent example of kyphosis of adolescents. As a preliminary condition we have a " weak spine." Bradford and Lovett make the following remarks on this point : " It can be considered under two heads. 1. It is seen in patients young enough to go to school, where the routine is injurious to them, and where cure is to be effected by a proper division of study and recreation, including muscular exercise, good food, and fresh air. 2. In those who have drawn from their stock of muscular or nerve force in the development of their intellect. After freedom from the restraint of school, their time is devoted to a sedentary life or one of undue nervous excitement. In such cases the great muscles of the back are those most called upon, and give out. In several cases the writers have noticed a slight impairment of the faradic contract ibility of the muscles on the convex or weaker side." Some kyphosis and scoliosis often coexist. There can be no doubt that persistent use of the " back-board " in girls' schools in the past generation is responsible for many eases of kyphosis. The treatment of slight cases consists in the application of cold sponges, massage, light muscular exercise, avoidance of late hours and physical and mental fatigue, faradism, and, if necessary, a light support to the back, but not shoulder-braces. The more advanced condition of round shoulders which affects the cervico-dorsal region is referable to too rapid growth, chronic illness, and general debility. These result in general weakness of the back muscles, and the spine, sustained only by its ligaments, bends more and more in the direction of its natural curves, this inclination being increased by the kind of work engaged in. The groups of muscles which are particularly affected are the trapezii, the rhomboids, and the serrati magni. Verneuil has observed the coincidence of kyphosis with flat foot of the paralytic variety. The back shows in the dorsal region an exaggerated curve, the summit being situated about the middle of the dorsal region ; the shoulders are drooping and directed forwards, the scapuhf are prominent, the head is in advance of the body, and the chin approximates to the sternum ; the chest is often flattened or reced- ing. A plumb line through Chopart's articulation passes behind the horizontal line joining the two external auditory meatuses. The diaonosis should not be mistaken for that of Pott's dis- CHAP. V KYPHOSIS NOT DUE TO CARIES 97 ease, which sometimes resembles kyphosis of adolescents at first sight. The treatment of more advanced cases is conducted on two lines. (1) To strengthen the enfeebled muscles; (2) to correct the existing deformity. These courses must often be conducted simultaneously, as they are inter- dependent for success. In addition every care should be taken to avoid those positions which cause undue strain on the weakened muscles. I allude to faulty positions at school desks and in piano practice. In youug girls excessive fatigue from home lessons is often responsible for a curved back. I am not an advocate of the plan of jDrolonged immobility upon the inclined plane, but I think rest for two or three hours daily upon a firm mattress, with a small well-stuffed cushion beneath the loins, very useful. At night it is advisable to place a pillow beneath the summit of the curve, and the head-bolster should be removed, the patient lying supine. To strengthen the back muscles, especially the erectores sj^inae, the latissimi dorsi, the serrati magni, and the trapezii, the application of the weak interrupted current is very useful, so too is massage for fifteen minutes once or twice daily, and douching with tepid water, to be followed by friction with the towel till the skin glows. At the same time due attention should be paid to the general health, tonics and cod-liver oil are often necessary, and a change to the sea-side for neurotic patients is advisable. To correct the existing deformity, the chief reliance must be placed on gymnastic exercises. Artificial supports in the majority of cases are fault}' in theory and pernicious in practice. I allude to shoulder braces, back supports, and jackets. They are to be used only when the kyphosis is so established that no treatment alleviates it, and wdien it appears likely to become worse if the back be left unsupported. Men who are careful of their figures, and are anxious lest their occu|)ation should induce round shoulders, should order from their tailors a very closely-fitting vicuna coat, and be careful to pay a good price for it. The fear of causing the garment to become baggy and ill-fitting and the sensation of tightness across the back will induce them to straighten their shoulders as soon as stooping commences. Exercises. — These are always to be stopped short of fatigue, so that no definite duration can be mentioned, but each case must be taken and treated on its merits, or rather demerits. The exercises should have two objects, viz. expansion of the chest and straightening of the back. H DEFORMITIES OF THE SPINE To e.rpand the Chest. — The patient lies supine on a tirni narrow mattress or a long table covered with a thin flat cushion, in such a way that the edge of the table corresponds with the mid-dorsal region, the shoulders, arms, and head being unsupported and hanging over the sides of the table, and he is then directed to make regular and full movements of inspiration and expiration for Ave to ten minutes. As the pendent position of the head is often irksome at first, the hands may be placed beneath the head, and so better dilatation of the chest is secured. After a few days these exercises may be extended by the attendant bringing the patient's arms above and behind the head, and drawing the shoulders well back, precisely as is done in artifical respiration after Sylvester's method. When the muscles of the shoulder-girdle become stronger, the shoulders may be brought further backwards by dumb-bell exercises in the above-mentioned position. The same results may be effected by fixing two pieces of stout rubber-tubing to hooks on the wall on a level with the patient's shoulders. To the free end of the tubing handles are attached. These the patient, with his back to the wall, grasps ; then the arms being fully extended, he makes steady traction on the rubber for a short time, leaning the body forwards. The tension of the rubber is relaxed by ex- tending the spine, and these manoeuvres are repeated several times. Exercises with light dumb-bells in the standing position are also useful. These with weakly adults should not at first weigh more than one pound, but increasingly heavier ones may be substituted later. Removed of the Kyiihosis. — The simplest exercise is the follow- ing : (a) Let the patient extend the head fully against the pressure of the surgeon's hand applied to the neck. (/3) Then the body being inclined well forwards and the knees being straight, full extension of the whole spine and head is gradually made against the pressure of the surgeon's hand on the nape of the neck. (7) The flexed elbows may be brought as closely as possible into apposition behind the back both passively and actively. These exercises are demonstrated to the patient by the surgeon, and the attendant is enjoined to carry them out systematically, beginning with the easier and less fatiguing, and taking care that both chest and back receive their due share of attention. It is unnecessary to describe the various forms of complicated apparatus devised to carry out the above exercises, as the methods indicated are sufficient in even inveterate cases. CHAPTER VI LORDOSIS Static Lordosis — Lordosis of Nerve or Muscular Origin — Compensation Lordosis — Lordosis of Osteopathic Origin — Spondylolisthesis. Synonyms. — English, Spinal Incurvation or Anterior Deformity; Frencli, Lordose, Dos EnselU, Dos Creux; German, Vorverhiegung der IVirhelsaille. The following varieties of lordosis are considered : — - 1. Static Lordosis. — This occurs normally in the lumbar region in the women of some races, notably in those of Cuba ; and it is present in all pregnant women, and w^hen the abdomen is distended by fat, ascitic fluid, or ovarian tumours. It is also seen in military men, and in those who carry heavy weights on the head. 2. Lordosis of Nerve and Muscular Origin. — The deformity may be due either to contraction or paralysis of groups of muscles, or to general diseases, such as osteo-arthritis, rheumatism, or rickets, affect- ing the spine. As an example of contraction -lordosis, I may allude to a class of cases occurring in infants, in which the head is retracted and the posterior cervical muscles are rigid. I have seen four in practice among my out-patients during the last five years, and the causes in these cases are either partial asphyxia at birth, or reflex irritation due to injudicious feeding. They were cured by a smart purge, such as pulv. scammonii co. gr. iij.-v., attention to diet, and pot. bromidi gr. ij.-v. thrice daily. Such a condition is probably reflex, but it may be mistaken in debilitated infants for the onset of tubercular meningitis. In the cervical region, rheumatoid arthritis and chronic rheumatism also give rise to marked incurvation of the spine. Lordosis of paralytic origin is associated with paralysis - of the sacro-spinal muscles, the trunk 100 DEFORMITIES OF THE SPINE skc. i being allowed to fall back, so as to oppose by its weight the flexor action of the abdominal muscles. Such a condition of lordosis is seen in pseudo-hypertrophic paralysis, progressive muscular atrophy, and as a result of acute anterior polio-myelitis. If paralysis affects the abdominal muscles, the pull of the powerful posterior dorsal muscles not being counteracted by them produces an aggravated condition of lordosis. In the former condition of paralysis of the sacro- spinal muscles the deformity is mainly in the dorsal region, in the latter it is in the lumbar. Rickets, while manifesting itself chiefly in the bones and ligaments, is so frequently associated with muscular weakness that in some infants in tlie sitting posture the weight of the trunk and upper extremities bends the spine backwards. 3. Compensation Lordosis. — In congenital hip displacement the deformity is very marked ; and in acquired hip disease, when the limb is fixed in the flexed position, the patient arches the lumbar spine to bring the aflected limb to the ground. 4. Lordosis of Osteopathic Origin. — In Pott's disease, especially in the cervical and dorsal region, the anterior convexity of the spine is increased to counterbalance the backward projection at the site of disease. Eickets produce lordosis either by simple weakness of the muscles, the body falling into a position, which is more often kyphosis than lordosis. When the child begins to stand, the heavy pendulous abdomen requires a certain amount of counteracting force so that he may stand upright. At the same time too the angle of inclination of the pelvis to the horizon is lessened, and lordosis must follow. Spondylolisthesis, in which a subluxation of the lower lumbar vertebrae occurs, is a rare cause of the deformity nuder considera- tion. Lordosis of the dorsal region occasionally met with in double scoliosis is due to sinking of the spinous processes. It is pointed out by Adams ^ that " it frequently occurs before any lateral deviation of the spinous processes takes place, and therefore before any lateral curvature has become obvious externally. It probably does not amoiint to more than a loss of the natural posterior curvature of the spine in the dorsal region, i.e. a flattening of the back." The treatment of lordosis depends upon the cause. In the majority of cases but little can be done beyond alleviating the general condition. In Pott's disease after ankylosis has occurred no interference with ^ Of. Led. on Curv. of Spine, 2ii(l ed. ji. 56. A case in point is quoted and a drawing of a cast given. LORDOSIS 101 the lordosis is justifiable, but mechanical support is often necessary to prevent the kyphosis and lordosis assuming a more severe grade while the spine is still soft. The lordosis of rickets calls for general treatment, for support while the muscles are weak, and for exercises and massage to improve their tone. CHAPTER VII SCOLIOSIS OE LATEEAL CUEVATUEE OF THE SPINE Definition — Distinctions between Lateral Deviation and Rotation — Scoliosis, General Considerations, Clinical Aspects — Varieties of Scoliosis — Classification of Scoliosis — Scoliosis of Adolescents, including ^^ Occwpation" Scoliosis — Its Causes, Predisposing and Exciting — Methods of examining a Case of Scoliosis — Symptoms and Course of Scoliosis of Adolescents — Stages of Scoliosis — Morbid Anatomy of Scoliosis. Synonyms. — English, Eotanj Lateral Curvature; French, Scoliose, Deviation Latcralc de la Taille ; German, Vcrhierjung, Scitliehe Euckgratsverhrilmmung, Bogenformige Deformitdt der Wir- helsdide. Definition. — Scoliosis is a rotation of the vertebne around a vertical axis, frequently Init not necessarily combined with lateral deviation or bending of the spine to either side. It must be clearly borne in mind, however, that under the term lateral curvature, two different conditions are frequently included, viz. lateral deviation and rotation. Such loose nomenclature leads to confusion in the recognitioir of cases and to errors in treatment. The characteristic points of the two classes of cases, one a functional and the other a structural deformity, will be dealt with on a subse- quent page. Briefly, deviation alone exists in some cases, while in others deviation beyond a certain degree is always associated with rotation, though the deviation of the spine is often no measure of the amount of the internal curvature. General Considerations. — Frcqueneg. — Of all the deformities which are seen at an orthopaedic hospital, scoliosis is one of the most usual. My colleague, Mr. Fisher, states that of 3000 cases which presented themselves for treatment at the National Ortho- paedic Hospital, 353 were affected by scoliosis.^ Drachman examined ^ Ashurst, Internal. Encyclopcedia of Snrgery, vol. vi. CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 103 28,125 children in the public schools of Denmark, and found 368 to be scoliotic. But the occurrence of scoliosis varies much in different places. It is particularly great in large towns. Berend fouud 900 cases of scoliosis in 3000 orthopaedic cases, Langgard 700, and Schilling 600 in 1000 orthopaedic cases seen in clinics in large cities. Of 500 consecutive cases of deformity seen by the writer at the National Orthopaedic Hospital, London, 69 presented either scoliosis or deviation of the spine. Sex. — It is admitted on all hands that the deformity is more prevalent in girls than boys. The proportion differs according to various authors. Eulenberg puts it as high as 1 girls to 1 boy ; Kolliker, 5 girls to 1 boy; and the latter may be accepted as a fair statement. Of the 69 cases mentioned previously as coming under my notice, 1 7 were boys. But, while less frequent in males, I am of opinion that the proportion of severe cases is greater in boys than in girls. Eedard ^ states that, according to his statistics, in children under 5 years of age the proportion is equal in the two sexes, or perhaps is slightly greater in boys. The onset of scoliosis in girls at puberty is associated with much development of the trunk and increase of the adipose tissue, especially in the mammary region, with- out in many cases corresponding muscular development of the spine. Age. — Scoliosis is mainly a disease of adolescence. Taking 1000 cases, Eulenburg found 78 cases from birth to the sixth year, 216 between the sixth and seventh years, 564 between the seventh and tenth years, 107 between the tenth and fourteenth years, and in 35 cases the distortion appeared after the last-named year — i.e. 57 per cent between the age of 7 and 14. Authorities, how- ever, of good repute state — and, I venture to think, correctly — -that a larger proportion than 3*5 per cent appear after 14. Ketch in an analysis of 229 cases put the number at a considerably larger figure. Eedard, who inclines strongly to the opinion that the lumbar curve is primary, remarks that " a large number of primary lumbar scolioses are not recognised because the deformity is not looked for sufficiently often, nor until the compensatory curves have formed." And it seems that he, guided by this opinion, places considerable reliance upon Eulenberg's statistics, which bring out so prominently the early incidence of scoliosis. For my part, I think that if 1000 presumably normal children were examined, the proportion of them showing some deviation of the spine would be large, but I should 1' Op. cit. p. 283. 104 DEFORMITIES OF THE SPINE sec. i not include these as cases of scoliosis, inasmuch as tliey do not develop rotation. And it is always a serious matter to disturb the domestic peace by pronouncing a child to be afflicted with spinal deformity ; rather every effort should be made to minimise than magnify the possibilities of a slight case, both to the parents and in the hearing of the child. A slight spinal deformity is often " treasure trove " to a hysterical lad or girl. Heredity. — In a recent conversation with the writer Mr. Adams expressed himself strongly on this point, as not having the slightest doubt of its hereditary nature. In his Lcdurcs on GuTvatnvcs of the Sjjine ^ he says that among the constitutioiuil conditions should be included an hereditary predisposition to spinal curvature, frequently existing with a consumptive tendency . . . which occurs in girls from 7 to 12 years of age, and sometimes later; in such cases the curvature has a marked tendency to increase rapidly and terminate in conspicuous deformity." As an instance of its hereditary character I quote the following details of a family. Cases 19, 20, and 21. Hereditari/ Sroliosis. — Albert I , itged 11 years ; Frederick I , aged 9 years ; and Annie I , aged 8 years, were seen by meat the National Orthop;edic Hospital between 1890 and 1893. There are four children in the family, and the father has a scoliosis to the right in the dorsal region. The elder boy has a sliglit curve to the left in the dorsal region and the sternum is prominent. The second boy, Frederick, has a long C-curve to the left in both dorsal and lumbar regions ; while the girl has a very tiexible back, which readily assumes any faulty position, and is already developing a curve to the left in the dorsal region. The second boy and the girl proved troublesome cases, and despite rest, exercises, and i)roper support, have developed compensatory curves and some increase of rotation. Case 22. — Harold F , aged 6, came to me at the National Ortho- paedic Hospital in 11th May 1893 with a long C-curve to the left ex- tending over the whole dorsal region, and with the corresponding changes in the scapulae and chest. He sufli'ers much from asthma. A great-aunt, aunt, father, and one cousin are affected with scoliosis. Vogt" goes so far as to say that at least half the cases are hereditary in character. Clinical Aspects of the Deformity.^ — Before describing the various aspects of true scoliosis, it will be convenient to dispose of lateral deviation, since the two conditions may be, and often are, 1 Oj). cit. 2iid ed. p. 230. ^ Quoted by Redard, op. cit. p. 284. •* Reproduced by permission of the editor of the Hospital. CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 105 confused, lateral deviation being called scoliosis ; or a greater error, scoliosis being styled and treated as mere deviation. Pure lateral deviation occurs in those whose spinal muscles are weakened, either from too rapid growth at the age of puberty, V. M.f I'l^d"'' Fig. 27. — Back view of Case 23, showing long C-enrve to the left, and prominence of the spinous processes in the dorso-lumbar region. combined, in the case of young girls of the lower class, with bad food, want of fresh air, and excessive physical work ; or after acute illnesses. In such cases the segmented spine insufficiently supported by the muscles gives way, and insensibly a deviation to one side or the other follows. Still more likely is it to occur in those patients who, from one cause or another, have unequal lower 106 DEFORMITIES OF THE SPINE limbs. In many cases the deviation disappears at once if a cork sole be applied to the boot of the shorter limb. As an instance of the combined effect of heavy trunk and bust, impaired health and overwork, I append the notes of the following case, which, commencing as a lateral devia- tion, subsequently developed in- to scoliosis associated with a prominent posterior curvature. The present state of the case, owing to the girl being obliged to work for her living in spite of the existence of deformity, is seen in Fig. 27. Case 23. Lateral Deviation of the Spine developing into severe Scoli- osis. — A. A., aged 22, has been a nursemaid for the last five years, and has performed in addition the duties of a general servant. She has been accustomed to carry chil- dren on the right arm, and for the last three years has noticed that the back has been growing out. There has been considerable pain in the dorsal region, which was temporar- ily relieved by rest. On examina- tion. — She was a very stout girl, the head and trunk being particularly massive. There was no inequality in the length of the legs. A long C-shaped curve was seen on the left side, extending from the first dorsal to the third lumbar vertebra with but slight compensatory curve. On suspension, this disappeared. She Avas unable to give up work, and, in spite of supports, a large posterior curve occupying the dorsal region formed, and three years afterwards her condition had become steadily worse, an intractable scoliosis resulting (Figs. 27 and 28). Mr. Fisher ^ has enumerated with much clearness the distinc- tions between deviation or " lateral bending " from muscular weak- Fig. 28.— Side view of Case 23 three years after onset of curvature. Internat. Eneydopced. Surge7">j, vol. vi. pp. 1067, 1069. CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 107 ness and scoliosis, and I place the various points in a table for comparison. Distinctions between Lateral Deviation and Lateral Rotation (after F. E. Fisher) Lateral Deviation. Scoliosis. Structural changes in spine and chest Absent Present Effect of flexion of the spine The deviation disappears The deformity is more apparent Horizontal position The deviation disappears The deformity remains Voluntary muscular eflort The spine can be straightened temporarily The spine cannot be completely straightened Eaised shoulder and de- pression just above crest of ilium On opposite sides of the body Generally on the same side of the body Suspension . The deviation disappears Disappearance of the de- formity in initial cases only It is essential, from the points of view of prognosis and treat- ment, that no error should arise from the lateral deviation of Pott's disease. For the characteristic features of such deviation the remarks on p. 36 may he referred to. Having thus excluded simple deviation, let us turn to the varying clinical aspects of scoliosis. Any classification, however convenient, is arbitrary, and cannot cover all the varieties met with ; but many cases may be grouped under the following headings : — Clinical Aspects of Scoliosis. — 1. Cases in icMch the Curvature is mainly Unilateral or C-sliafped. — The curve may be in the lumbar or dorsal region, or in both. It may be of small extent, or involve the dorsal and lumbar reoionsl 108 DEFORMITIES OF THE SPIXE SEC. I In the former case it is frequently seen in the lumbar region, and results in but little apparent deformity. It is convenient to speak of curves as dorsal and lumbar. These terms merely imply that the chief part of the curve is in the region named, not that it is exactly limited to it. / IS Fig. 29. — Lateral ileviation of spine from inequality iu the length of the legs. Some authorities believe tliat iu the majority of scoliosis occur- ring in girls at the age of puberty, the lumbar curve is primary. Benjamin Lee ^ makes the following suggestion : " Proijter ovarium, est mulier. — The menstrual period is associated with considerable backache. To obtain relief from this women lie down, with some- thing hard beneath the back to support the lumbar arch, and so ' Trans. Amer. Orth, Assoc, vol. ii. p. 80. CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPIXE 109 allow the psoas and iliacus to relax. The backache is, therefore, due m the same measure to the reflex irritation of the psoas and iliacus. If these muscles on both sides act equally, then no effect is produced, but if ou one side the muscles are stronger, then curvature ensues.'"' This seems to me far-fetched, but as Bradford and Lovett pertinently say, " Some writers regard the lumbar / Fig. -30. — Back view of case in Fis. 29 after ■vvearins: a boot with a cork sole for one year. scoliosis as the chief curve and as the most common. The question may be regarded as not settled, though for clinical purposes it may be accepted as a fact that the dorsal curve is the one most fre- quently requiring treatment." A single curve ^ or C-shaped curve of large extent is always of ^ For the maintenance of the head iu the erect position there must necessarily be small and somewhat abrupt compensatory curves at the extremities of the chief curve. no DEFORMITIES OF THE SPIXE serious import because of the number of vertebrae implicated, the influence of the weight of the head and upper extremities continu- ally tending to increase it, and the general weakness of the spinal muscles, which make treatment lengthy and troublesome. In these cases, too, the rotation of the spinous processes is well marked, the secondary effects of the deformity are great, and they are likely to run a more rapid and less favouraVile course. Such an instance was A. A., Case 23, quoted on p. 106. Generally the curye is in the lower dorsal and lumbar regions ; less frequently the upper and middle portions of the dorsal region are affected, i.e. the curye may affect the lower or the upper part of the spinal column. A deviation pure and simple may develop into a long C-shaped curve, or more often a double curve forms. Such an instance is the following : — S^'^\ jClt^vii^t/ w'f^ Case 24. Lateral Deviation of the Spine developing into Scoliosis tcith Double Curves. — F. C, aged 15, who came to me Avith a general deviation to the left side in May 1892. In Xoveniber of that year a double cur- vature had formed, the upper with its convexity to the left, and reach- ing from the seventh cervical to the eleventh dorsal vertebra, and the lower convex to the right and in the lumbar region. Fig. 31. — Scoliosis, occupying the general kyphosis, C-shaped curvature dorsal region, and AYhen the chief curve is long the resulting distortion of the body is very considerable, inasmuch as " the vertebral column, like the keel of a ship, is the foundation of the structure of the trunk " (Fisher). The mechanism may be grasped by attention to the accom- panying diagram. Fig. 32, in which the effects on the ribs of twisting of the vertebrae are figured. For simplicity, let us suppose that the chief convexity is to the right, of large extent and occupying the dorsal region, with a secondary smaller curve to the left in the lumbar region. The results on the trunk are as follows : — CHAP. A'li SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 111 (a) General Aiypearance. — The syminetiy of the body is quite lost, the right shoulder being elevated, the left depressed. The right arm is closely approximated to the side and the left falls away at a consider- able angle. The ribs on the right side are bulging, while on the left they are depressed. On the right side there is considerable hollowing out of the flank, with prominence of the hip, while on the left the flank is flattened and the hip is less in evidence than usual. These are due to the rotation of the bodies in the lumbar curve to the left, and the conse- quent pushing backwards of the transverse process on that side, with sinking in of the right process and depression of the Fig. 32.— Diagram to illustrate T • ,1 n ^1 j_ 1 the position of the ribs when muscles covering them. So that, accord- the cm-yatnre is to the ricrht in the dorsal region (after Eedard). ing to the patient's description, the riglit hip is growing out, whereas it is really the flank which is sinking. If, however, the curve is situated so that it extends over the dorsal and upper lumbar vertebrae, then the Fig. 33. — Ilhistrating the alteration in shape of the ribs, and the deviation of the transverse diameter of the thorax (after Eedard). prominent hip and hollow flank are on the left, inasmuch as the right transverse processes are rotated backwards in the lumbar region, while those on the left are rotated forwards and the muscles 112 DEFORMITIES OF THE SPIXE covering them sink in, but, be it observed, are not, as a rule, wasted. (h) The ribs on the right side behind are prominent, with their angles much increased, while in front they are correspondingly depressed, the whole of the ribs being as it were drawn backwards in the planes in which they .u \ '~\ .J\ lie, and compressed from before backwards and from right to left. On the con- cave side the ribs are more prominent anteriorly, but less so posteriorly, and the angle is widened. The altered position of the trans- verse processes sufficiently explains this. On the side of convexity they are more prominent than normal and on the concavity the reverse. In addition the right ribs are more oblique, with the intercostal spaces widened (Figs. 56 and 57). (c) The sccqndce will be found altered from their natural positions. Thus the right scapula, that of the out- growing shoulder, is raised, less vertical than usual, and in severe cases almost hori- zontal, so as to give rise to tlie impression that its in- ferior angle is dislocated. It is also further away from the middle line than normal. The left scapula appears to have sunk, and its position is just the reverse of the right. {d) The clavicle on the right side is much curved, and it has been said that in very severe cases of scoliosis dislocation of the sternal end has occurred. (c) The apices of the spinous j^'^'occsses in the dorsal region are twisted to the left, i.e. away from the convexity. But the deviation 3>^'" Fig. 34. — Scoliosis. Long C-ciirve to the left the dorsal and luinljar regions — Frank H — aged 12 years (Evelina Hospital). CHAP. Til SCOLIOSIS OR LATERAL CURYATURE OF THE SPIXE 113 of these processes is no measure of the deviation of the bodies, which is often much greater, owing to the vertical axis of rotation being situated considerably nearer to the tip of the spinous processes than the fronts of the vertebral bodies. This want of correspondence internally and externally is an important point to bear in mind in forming a prognosis. (/) The transverse processes on the convex side in the dorsal region are prominent, and depressed on the concave side. {g) As pointed out by ]Mr. Adams, the height of the spinal column is de- creased owing to the deviation of the bodies to one side or the other, and to the posterior projection of the spinal column, the result of the general yield- ing. The Mammce. — The left is the more prominent, and the umbilicus is dis- placed to the left, with corresponding- fulness on the right side of the abdomen. The scoliotic pelvis is described on p. 140. Such then are the clinical aspects of a case in which the long curve is mainly dorsal and to the right. Single curvatures in the cervical region are rare, and observed as the result chiefly of torticoEis. But the following case, associated with unequal refractive indices of the cornete, is in- fig. 35 terestino- : — V — Scoliosis. rK*"* Two ciirves are seen, one in the cervical and the other in the dorsal region — W. C. S., aged 12 years Case 25. Unequal BefracMon of Eyes, (Evelina Hospital). Scoliosis. — A. B., aged 15, a feeble Jewish boy, came to me at the National Orthopaedic Hospital on 21st Decem- ber 1893. His general muscular development was bad, the shoulders were advanced, the head was drooping, and he was markedly anaemic. He also complained of inability to see clearly. The seventh cervical spine was prominent, and the whole cervical spine deviated to the right. AVhen the eyes were tested they were found to be unequally hypermetropic. The error in the right eye was + 3 D, and in the left + 5 D. He was fitted with suitable spectacles, and with a change of air, exercises, and after a course of iron, he improved in general health, and the deviation in the neck disappeared. I 114 DEFORMITIES OF THE SPIXE 2. Cases u-itJi two nearly Equal Curves 'present. — As a rule the curves have their convexity to the right in the dorsal, and to the left in the lumbar or dorso-lumbar region. Earely, however, the two curves are situated in the cervical and dorsal portions of the column (Fig. 35). In either of the above conditions the characteristic S- shaped curve appears, one limb of which is primary and the second is compensatory. As to wdiieh is primary it is not essential to determine on mere pathological grounds, except in so far as the question of correct treatment is concerned, but one may usually take it that the less mobile is the more important curve, and therefore demands the more atten- tion. It may happen that in some cases the S-shaped curva- ture is reversed in the respective regions, and tlien the dorsal con- vexity is to the left and the lum- bar convexity is to the right. It is necessary therefore, in depicting the results of the latter malforma- tions, to remember that the dis- tortion will be the reverse of that of the former and more common deformity described below. That the dorsal convexity to the right is more frequent admits of no dispute. The statistics quoted by Mr. Adams fully sup- qu.li port the generally-received opin- ion. Of 569 cases in the dorsal region, 470 were convex to the right and 99 to the left.^ As to the reason of this excessive preponderance of right-sided dorsal curves, I believe it is due to excessive use of the right arm in faulty positions involved in occupations and employments, these being such as to elevate the right shoulder and depress the left. Occupations of this nature are clerking among men, painting and sewing in women, and in school children the very absurd position they are forced to assume ^ Adams, cqj. snj). cif. 2ud ed. p. 160. 1 Fig. 36. — Scoliosis with two nearly curves and considerable dorsal kyphosis (Edith S , aged 14 years). CHAP. VII SCOLIOSIS OK LATERAL CURVATURE OF THE SPINE 115 in learning to write the " Italian hand." The desk is often too low, and the child is compelled to stoop over it, with the right arm raised and rigid to ensure correct and fine upstrokes, while the left arm is depressed so that the hand may fix the copy-book. Such a case of incipient curvature is the following : — Case 26. Scoliosis from Faulty Posture in Sitting. — H. T., aged 14, complained of pain in the mid-scapular region, especially severe -after school hours. His mother brought the boy to me in July 1894, because she had noticed the right shoulder growing out. I ascer- tained that for the last two years he had been sitting at a desk too low for him, and compelled to write in the faulty manner just mentioned. On examination, I found a very tender area extending over the spines of the third and fourth dorsal vertebrse, so sensitive to pressure was it as to make one consider the possibility of the case being one of commencing caries. The legs were equal in length, and the boy was on the whole well developed for his age. There was no rigidity of the back on applying the palm-pressure test during flexion and extension (see p. 34), but there were two curves present, the upper convex to the right extending from the second to the ninth dorsal spine, and the lower from the tenth dorsal into the lumbar region, with the convexity to the left. The natural curve backwards in the lower dorsal region was somewhat lessened, i.e. there was flattening present, and the left side of the chest projected. He was advised to cease attending school, and to employ a combination of rest and exercises. In October 1894 the back Avas nearly straight, the shoulders were almost at the same level, and he had entirely lost the pain. In January 1895 the figure was completely restored and all pain had disappeared. In some cases, however, the scoliosis is due to excessive shorten- ing of one leg, or to the habit of standing mainly on one leg. In such instances the lumbar curve is the first to appear. But as a rule it may be said that the higher in the dorsal region the first curve is, the earlier in life it has appeared. The deformity in the neighbouring parts is seen to be closely analogous to that already described in curves chiefly single. Thus the right scapula is unduly raised, prominent, and altered in direction ; the right shoulder is higher, the ribs stand out even more than when the curve is of greater length, and the hollow of the right flank is also more marked, but the left hip is in these cases of equal curves always the more prominent. The cavity of the chest is more oblique from side to side, owing to the greater projection backwards of the ribs on the convex side; in females the right breast has receded . considerably, and the left is unduly prominent. The greater the- lateral deviation and rotation, and the 116 DEFORMITIES OF THE SPINE more closely it is limited to the dorsal region, the more disastrous are the effects on the shape of the thorax. Another effect is diminution in height of the spinal column, the result of rotation of the vertebme associated with lateral Hexiou. 3, Three or more Curves jjresent. — In some cases three and even four curves are seen, and are variously distributed in the spine. In that form of scoliosis in which there is one large curve present, \vr r' Fig. 37. — Scoliosis. Three curves are present — James P , aged 16 years (Nat. Orthopaedic Hospital). Fig. .38.— Frout view of Fig. 37. In spite of the spinal curves, the chest is nearly normal in shape (see text). there are sometimes two smaller compensatory ones, but this con- dition is distinct from that now under consideration. Here the curves are often of equal length, and it is difticult to say wliich one is primary. The chief point on which a decision must rest is that the first curve is the least mobile when the patient is suspended. When three or even four curves are present, the accompanying distortion in the chest is less, inasmuch as in each curve fewer vertebne are affected (Figs. 37 and 38). But it would only lead to confusion to enumerate all the resulting deformities, even if it CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 117 were possible to do so precisely. Suffice it to say that on the convex side of the curve the changes will be in principle those enumerated above, and that the distortion -effects will be most marked in the chest when the curves are chiefly dorsal. On the concave side the reverse conditions will naturally obtain. 4. Scoliosis associated with Posterior Projection of some of the w Fig. 39. — Scoliosis with projection of two spinous processes at the intersection of the two curves. The flexibility of the back negatived all suspicion of Pott's Disease (Mary W , aged 14 years). Spinous Processes: — This condition is seen when the back presents two curves nearly equal, and the projection is found at the spot where the upper and lower curves intersect (see Fig. 39). The mechanism at work producing the projection is, I take it, as follows : the prominent vertebrae are acted upon by two lateral forces, one above and the other below, i.e. " a couple " of equal and opposite forces is made. The vertebrae at the prominent spot are therefore maintained in the middle line, but undergo consider- 118 DEFORMITIES OF THE SriXE able oblique pressure from above downwards aud from below upwards. In some instances they are forced forwards into the cavities of the thorax and abdomen, but occasionally the undue pressure makes them yield backwards, hence the prominence of the spinal processes. A certain amount of apparent projection is also due to the wasting of muscles at the meeting-point of the curves. Fig. 40. — Scoliosis, limited in extent, with reversal of normal lumbar curve, and posterior projection of the lumbar spinous processes (Henry W , aged 14 years). ) Fig. 41. — Scoliosis with reversal of normal antero-posterior curves. The chief interest of this class of case lies in the following facts. Projection of the spinous processes is a constant accompaniment of Pott's disease, and lateral deviation is an occasional feature ; lateral deviation and rotation of the vertebrse are the distinguishing features of scoliosis, and projection of some spinous processes an unusual occurrence. It therefore happens that at first sight some difficulty may arise in the diagnosis, but the rigidity and fixity of PLATE I J. Fig. 1. The back view of a scoliotic spinal eoluniu, in whicli the spinous processes are seen to ^>e almost in a right line, despite the excessive rotation of the lumbar vertebrae. (Guy's Hospital Museum, 1006'".) PLATE 11. Fig. 2. The front view of the same spinal column, in which the excessive rotation of the lumbar vertebrae and deformity of the vertebral bodies are well seen. (Guy's Hospital Museum, 1006^".) These figures show that the deviation of the spinous processes is no measure of the deviation of the bodies. CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPIXE 119 the affected spinous processes are the distinguishing and diagnostic features of Pott's disease. By way of illustration, figures of Pott's disease and scoliosis with projection are given on pp. 37 and 118. 5. Scoliosis with Oblitercdion or Reversion of the Natuml Antero- posterior Curves of tlie Spine. — Cases of this description present either the less degree of flattening of the back, or the greater one of reversion of the natural kyphosis in the dorsal region, with flattening or some projection in the lumbar region (see Figs. 40 and 41, and compare the two views of a dried specimen, Plate II.). It is evident that such an appearance in the mid-region of the spine is due to two causes. {a) Considerable rotation of the vertebral bodies around a horizontal axis situated near the apices of the spinous processes, and consequent sinking of the bodies of the vertebrce into the cavity of the chest, where they are deficient in support. (&) It arises from the posterior projection of the ribs on the convex side. The flattening in the lumbar region is owing to a compensatory backward pushing of those vertebrse ; and so much displacement may occur that two or three upper lumbar vertebrse near the intersection of the curves actually form a distinct " bow " in the outline of the spinous processes. The clinical importance of recognising this group is considerable, inasmuch as the most troublesome factor of lateral curvature of the spine, excessive rotation, is here present, and the prognosis is dis- distinctly unfavourable. It may be laid down that in such instances the external curvature of the spinous process is no measure of the extent of the internal clisplacement of the bodies (Plate II. Figs. 1 and 2). Varieties of Scoliosis. — From the causal point of view there are many varieties of scoliosis. "A distinction is at once made if we place in the primary class those due to defective conditions in the spine itself, and those to general constitutional causes. "WTiile in the secondary group should be placed those forms which are distinctly traceable to local causes acting from a distance. The varieties then are — I. Primary — a. Scoliosis of Adolescents including Occupation-Scoliosis. b. Congenital Scoliosis. c. Rhachitic Scoliosis. d. Some forms of Scoliosis of Xerve Origin. 120 DEFORMITIES OF THE SPINE sec. i II. Secondary — a. Static Scoliosis. b. Scoliosis due to Cicatricial Contraction such as Empyema. c. Scoliosis in association with Nasal and Post-nasal Obstruction. Scoliosis has also been described as flexible, fixed, and structural. This form of classification has a distinct advantage from a clinical point of view. A tabulation very useful for treatment is that made by Mr. Adams. I. Cases essentially of Constitutional Origin, c.f/. Hereditary Cases, General Weakness, Eickets. IT. Cases dependent upon Constitntional and Local Causes in about Equal Degi-ees, e.g. Bad Position, Certain Occupations, and associated with Debility. III. Cases essentially depending upon Local Causes, e.g. Inequalit}' in the Length of the Legs, Torticollis, Diseases of the Chest, etc. P)Ut to return to the classification I propose to ado]jt. Scoliosis of Adolescents, including " Occupation-Scoliosis." — The term " Scoliosis of Adolescents " is not quite satisfactory, as it conveys no definite idea of cause, but merely implies the date of onset. It is convenient, however, to group under this heading that large number of cases which, commencing in childhood and youth, and being associated often with muscular debility, are induced or aggra- vated by unsuitable occupations. If at the same time the opportunity is taken to discuss the pathogenesis of primary scoliosis together with the symptoms, morbid anatomy and diagnosis in general, much needless repetition will be saved. Causes. — Predisrposing. — The influence of sex and heredity have already been discussed. The others are general feebleness of health, antemia, raj^id growth, and in girls the onset of menstruation, with the cessation of those active habits characteristic equally of girls and boys in childhood. To these should be added the rapid and often excessive development of the breasts in girls, causing increased strain on the back, and the pernicious effects of corsets, together with the weight of long dresses. In the higher classes, girls at the age of puberty, or a little later, commence to imitate the habits of their elders, and exhaust their strength by late hours and sitting in hot " .stuffy " rooms. In the lower classes too the willing girl is often the drudge of all work. Feeble muscular development should be included as a predis- CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 121 posing cause, but a certain proportion of the cases are present in people exceedingly well developed/ and one finds that such instances may be classed in a subdivision as occupation-scoliosis. Injury is not a cause except indirectly and in this way. A weak and liysterical girl has a blow or fall on the back and is told to rest. She " indulges " the back in a faulty attitude and scoliosis begins. Effective. — In illustration, I quote some cases from my notes : — Edith W , aged 14, dressmaker. Long curve, E. dorsal; short curve, L. lumbar. Herbert K , aged 1 8, clerk. Slight curve, R. dorsal. George T , aged 17, bricklayer. Posterior and lateral curve in dorsal region. Ada A , aged 22, nursemaid. Large curves to R. in dorsal and lumbar region (Figs. 27 and 28). Elizabeth G , aged 14, domestic work and nursing. Curve R. dorsal. Lizzie W- , aged 18f, domestic servant. Long curve, R. dorsal. Alice S , aged 22, nursery governess. Curves R. dorsal, and L. lumbar. Minnie R , aged 17, nursemaid. Chiefly R. dorsal. May S , aged 17, housemaid. Curves R. dorsal, L. lumbar. These are illustrations of " occupation-curves." In all cases but one, that of the boy G. T., the muscular development was less than normal. In his case it was above the average. He had carried a hod of bricks on his shoulders up a ladder for three years, and he was particularly muscular. Other occupations in girls are associated with rotary lateral curvature, viz. needlework, book-folding, etc. In various papers ^ Arbuthnot Lane has conclusively proved by direct observation on both the living and dead body the pre- dominant influence of occupation in many cases of scoliosis. He gives drawings of the spine of a brewer's drayman, who carried casks on the right shoulder and front of the right chest. There was a marked scoliosis with the convexity to the right at the seventh dorsal vertebra, together with other changes in the skeleton. Mr. Lane insists that the deformity arising from the habitual performance of heavy labour is " first the fixation and then later the exaggeration of what is a normal physiological attitude, assumed in this particular form of labour," and in other varieties of scoliosis the curvatures are simply " the fixation and subsequent exaggeration of a movement ^ Cf. case quoted by Sayre, oi). cit. p. 395. 2 Med. Chir. Trans. voL Ixvii. ; Path. Soc. Trans. 1884 and 1886 ; Clin. Soc. Trans. 1886 ; Gmjs. Hosp. Rep. 1885-87. 122 DEFORMITIES OF THE SPIXE which is a normal one when the subject occupies a position of rest." He claims that " the double curves of the spine are a normal physio- logical attitude and a position of rest ; and that they only become a deformity when they remain as permanent curves and cease to be Fig. 42. — Side views of faulty and correct ijositions at the school desk. Fio. 43. — Back views of faulty and correct positic at the school desk. The effects of the twisting the legs on the shape of the hack are seen. recoverable, in exactly the same way that the flexion of the dorsal spine is also an attitude of rest, and only becomes a deformity when it persists as dorsal excurvation." These papers are very thoughtful, and repay careful reading. Fig. 44. — Piano-practice in a bad position. Fig. 45. — Piano-practice in a correct position. Certain attitudes are very likely to be followed by scoliosis, e.g. standing on one leg and sitting cross-legged. These cause twisting of the pelvis and rotation of the lumbar spine ; so does excessive horse-exercise by girls without a reversible saddle. The exceedingly CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPIXE 123 faulty arrangement of music-stools and school-desks are responsible for many cases of scoliosis (see Figs. 42-45 ^). The attitude assumed by school-children when writing is not always the same. Sometimes the right arm and forearm are on the table guiding the pen, while only the fingers of the left hand touch the table. The result is depression of the left shoulder, and a rotary curve to the right (Fig. 46). At other times it is the left arm and forearm which bear the weight of the head, neck, and shoulder, and are therefore placed firmly on the table, while the right arm resting lightly, merely guides the pen. The right shoulder is consequently depressed, and there follows a long curve in the dorsal and lumbar region with its convexity to the Fig. 46. — Dorsal scoliosis to the riglit, from au incorrect position Avhile writ- ing (after Redard). Fig. 47. — Dorsal scoliosis to tlie left, also from incorrect position while writing (after Redard). left (Fig. 47). Very often the fault is not in the child but in the desk. It is disproportionate to the height of the child, and the seat is placed at such a distance from the desk that the head and shoulders must be inclined forwards, with the trunk placed obliquely, in order that the pen may reach the paper. Preventive measures are de- scribed on p. 162. The influence of defective accommodation of the eye and errors of refraction in inducing faulty attitudes has already been referred to. A Method of Examination for Scoliosis. — The more severe forms can be diagnosed almost at a glance, but in slight cases it is very easy to overlook the condition. Nor is it the mere recognition that is necessary. We wish to know the amount of rotation and fixation 1 For the use of these blocks I am indebted to the North of England School Furnishing Company, Darlington. 124 DEFORMITIES OF THE SPIXE sec. i of the Spine, the stage of the deformity, and whether it is progressing favourably under treatment, is stationary, or becoming worse. The patient's back should be bared, and it is as well to remove clothes hanging from the waist. To this end it is convenient to have at hand a loose flannel skirt which can be put on by the patient after removal of her ordinary garments, and kept in place around the hips by an elastic band. For the upper part of the body a loose flannel jacket may be j)ut on, with the opening and buttons behind, or a small shawl is sufficient. Then : A. To determine the existence of scoliosis in a suspected case the following points should be noted : — 1. The natural attitude when standing at ease and the angles made by the arms with the body, and the undue prominence of one or other hip. 2. An effort should now be made by the patient to stand in as straight a position as possible, and its effect on the deformity noted. 3. When the patient is at ease, mark out the tips of the spinous processes and the angles of the scapulas with a crayon or aniline pencil, and note the deviation from the normal by taking a string lightly weighted at one extremity and fixed at the other extremity to the tip of the seventh cervical vertebra by a piece of adhesive plaster. The string should reach to the gluteal cleft. Then direct the patient to cross her arms in front of the chest, and measure the distances of the angles of the scapulte from the plumb line, and of the tips of the spinous processes from it at the points of greatest curvature. 4. The relative heights of the shoulders, the asymmetry of the sides of the trunk, and the general contour of the back are then observed. Particular attention in slight cases is necessary to two points — slight alteration in the outlines of the flanks, and flattening or prominence of the erectores spinie. These signs are of great value. The observations are taken when the patient is in two positions, viz. the position of ease in standing, and when she is flexing the back with the arms across the chest and the hands resting on the opposite shoulders. It is remarkable how much greater the deformity appears in the latter position. It " brings it out," as it were, the deformity of the ribs especially becoming evident now that the scapulre are drawn outwards and upwards, and the ribs are uncovered. CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 125 5. In cases of doubt the front of the patient's chest may be examined, and any asymmetry of the breasts or deviation of the umbilicus from the middle line noted. B. To test the flexibility, amount of rotation, and fixation of the spinal column. 1. The flexibility of the spine is tested by causing the patient to bend to one side or the other, keeping the legs straight, while the surgeon fixes the pelvis with his hands above the crests of the ilia ; or, by placing a series of blocks beneath one foot until the patient is no longer able to keep the raised limb straight. The flexibility of the spine may also be tested by direct pressure of the surgeon's hands. If the usual right dorsal and left lumbar curves are present, the right hand is placed over the most convex part of the right ribs, and the left hand with the palm on the left flank. The amount of flexibility is the gauge of the improvement that may he expected under treatment} B. Eoth's ^ " best possible position" as secured by the patient's efforts aided by the surgeon is said by him to be the " keynote " of the exercises necessary for correction. This " best possible position " is obtained in various ways ; sometimes by the patient taking hold with one hand (that on the concave side of the curve) of a horizontal bar placed two or three inches above and parallel with a second bar, which is grasped with the other hand ; when the patient is suspended in this way the weight of the body assists in straightening the curve (Fig. 76). At other times it is sufficient to raise the arms vertically above the head, or to elevate the arm on the concave side of the curve above the head, while that on the convex side is placed at right angles to the body. 2. The amount of abnormal rotation of the vertebrae is estimated not by the deviation of the spinous processes, but by the alteration in the shape of the thorax. 3. The fixation of the spinal column. This is due to osseous changes, and is of serious import. If there be no marked alteration in the curves on placing the patient in the prone position, or on suspension, or in the " best possible position," then fixation changes in the spinal column are present. On the converse, considerable alteration is of good import. An important sign of fixation, and not generally recognised, is this — if, when the patient is suspended, the transverse axis of the pelvis does not become parallel with the ^ Clin. Soc. Trans, vol. xxi. p. 301. 2 Treatment of Lat. Cicrv. of S'pine, p. 13. 126 DEFORMITIES OF THE SPINE sec. i transverse line joining the shoulders, but makes with it an angle of some degrees, then very considerable osseous change is pre- sent. C. To record the progress of the case under treatment. This is best accomplished by photographs, taking care each time to mark out the tips of the spinous processes and the crests of the ilia and angles of the scapula'. An inexpensive and efficient scoliosometer is yet to be in- vented. The apparatus of Schenk and Schulthess are too com- plicated. B. Eoth ^ uses a method which is simple and efficient. " The trunk should be flexed as far as possible, the knees being kept extended and the arms allowed to hang loosely, so that the scapular muscles are relaxed." By these means the ribs are bared of the scapulre, which glide outwards, partly owing to the relaxation of the muscles and partly to the weight of the arms. " The metal tape is made of pure tin, and is 20 inches long, |- inch wide, and about ^^ inch thick, and can be obtained from Messrs. Mayer and Meltzer. I now take a tracing of the ribs posteriorly as follows : I feel for the lower angle of the left shoulder-blade, and fixing one end of the pliable metal tape with my left hand at that point, I carefully mould the tape close to the ribs across the spine to the lower angle of the right shoulder-blade. With a copying pencil I mark the metal opposite the dorsal spine, and then carefully remove the tape, upper edge downwards, on to a sheet of quarto-size paper and draw a tracing inside the tape, marking on the paper the point where the tape crossed the spine. The pencil line is afterwards inked, and the tracing cut out and folded down the middle, opposite the point marking the spine, and we have now an accurate record of the ribs posteriorly. Similarly a record is taken of the loins midway on each side between the last ribs and the iliac crests — that is, opposite the third lumbar vertebra — marking the tape as before where it crosses the spine." To obtain a more complete idea of the deformity, I would suggest that the distance between the points of intersection of the tape with the spine should be ascertained, and the curves laid out on full-sized sheets of paper with the proper vertical distance " between them, and the deviation of the spinous processes marked out on either side of the folded line. It can be quickly estimated by the eye. The method of using a strip of lead ^ Op. sup. cit. pp. 8-10. - Tliis is the more important since it lias been shown that scoliosis diminishes the height of the spinal column. CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 127 to record the deviation of the spinous processes is after all not so accurate as a drawing made to scale from fixed points. Symptoms and Course. — In addition to the curvature and the general effect on the outline and structure of the trunk, . such as elevation of one shoulder, prominence and flattening of the ribs, protrusion of one hip, alteration in the shape of the flanks, and lateral obliquity of the pelvis, there are certain subjective symptoms complained of by the patient, viz. pain, disturbances of circulation, respiration, and digestion, which require to be more fully entered into ; and it will be convenient to discuss these under four headinos, viz. the incipient period, the stage of development, the stage of arrest, and the stage of improvement. I. The Incipient Period. — The particular variety of the deformity we are now discussing, " Scoliosis of Adolescents," is generally sup- posed to begin at the age of puberty, but there can be no doubt its first onset occurs in very many cases earlier than at that time. Pain is as a rule absent, although a feeling of weariness in the back extending to the legs may be complained of. A careful examina- tion of the figure reveals slight elevation of one shoulder, alteration in the symmetry of the flanks, projection of one hip, or faulty habit of standing or sitting. Indeed the child " lolls " about, and is unable to bear any prolonged exertion. II. The Stage of Development. — In cases where the general health is good, and often in children, there is little or no pain. But in weakly girls, with a scoliosis developing at the time of puberty, the amount of pain varies considerably. It may be slight aching pain in the lumbar region, or in some instances may be such as to incapacitate the patient altogether. But it is important to remember that a distinct class of cases exists, viz. the hysterical girl, whose existence is dominated by the idea that she has spinal disease ; an idea which has arisen from an opinion expressed perhaps incautiously, and in her hearing, to the effect that there is some distortion in the back. In such instances localised patches of hyper- and ansesthesia will be felt, together with neuralgic pains in the sides of the chest. Sometimes distinct tenderness on pres- sure over the spinous processes is found, but it is merely, when coexisting with pure scoliosis, an evidence of nervous depression. Cases of this nature are distinguished by the fact that the deformity is not sufficient by pressure and stretching effects to cause such severe pain as is complained of, and it will often happen that the lumbar pain is aggravated by dysmenorrhoea and menorrhagia. 128 DEFORMITIES OF THE SFINE sec. i Hysterical paraplegia may even be present. When the deformity is severe, both local and diffused pain exist. The local pain is, as a rule, on the side of tlie convexity, and in the dorsal region will be found a little below the angle of the scapula on the convex side of the curve, and in the lumbar region, on the opposite side of the middle line near the transverse processes. The diffused pain arises from the altered shape of the thorax and the consequent pressure on viscera. The possible causes of local and diffused pain are : — 1. The increased tension of muscles and ligaments on the con- vex side of the curve. 2. Discomfort and pain arising from the altered position of viscera, and in those cases in which very severe deformity with osseous ankylosis is present, from constant tension of the nerves. 3. From a general hypemesthetic condition due to low vitality. Patients with large single C-curves are very liable to pain, probably owing to the rapid increase in the curve and inability of the affected structures to adapt themselves sufficiently quickly to the altered position. When the pain in such instances is chiefly lumbar and the deformity considerable, it may be due to the contact of the depressed ribs with the iliac crest, and the consequent irrita- tion of the lateral branch of the last dorsal and first three lumbar nerves. Mr. Adams states that " the worst cases of local pain which have come under his observation have been in the most rigid and least flexible forms of spinal curvature, generally of many years' duration, but slowly and progressively increasing." The alteration from pressure in the shape of the individual vertebrae, their bodies and processes, is an indication of the extreme tension on the Ijony j)arts of the column, and is in itself sufficient to account for much of the local pain experienced. That direct pressure of bone on nerves occurs has not hitherto been demonstrated ; and it is improbable, inasmuch as the pain is usually on the convex side of the curve rather than on the concave, while the foramina are normally much larger than the nerves which they transmit. The other symptoms complained of during the stage of development are referable to alterations in the positions of the viscera, and may be tabulated under the heading of — Displacement Symptoms. — These are in evidence during this stage, but are more marked in that later period when fixation has occurred from bony ankylosis. In illustration of the effects upon the viscera, and the symptoms arising therefrom, I will quote two cases. Case 27. Intractable Scoliosis: Considerable Displacement of the Heart. — William H , aged 14, has suffered from curvature of the spine for CHAr. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 129 twelve years. He is thin and the muscular development is feeble. As Siiffff'' /'- ■ y/ Fig. 48.— Back view of a case of intractable Fig. 49.— Front view of William H , scoliosis (Case 27, William H , aged 14 Case 27. Considerable displacement of years). the viscera existed in this case (see text). a child he suifered from rickets, and there is a strong family history of K 130 DEFORMITIES OF THE SPINE tubercle. He now complains of pain in the back, shortness of breath, and of indigestion and constipation. On examination, there is an extensive curvature to the right in the dorsal region, extending from the first to the tenth vertebra, with a second compensatory curve in the lumbar region ; the curves are not lessened by extension ; the legs are equal in length ; the right lower ribs overlap the iliac crest ; the right chest scarcely moves at all in respiration, and its resonance is partially lost; the heart's apex is 2i inches below the nipple, and is displaced somewhat outwards ; there is much pulsation at the inner end of the second and third left spaces ; the right subclavian and common carotid are more prominent than normal, and are seen beating beneath the skin ; the innominate artery Fig. 50. Fig. 51. Two views of a case of scoliosis after measles and pleurisy (Case 28, Daisy C- -, aged 12). rises half an inch into the neck ; the point of origin of the carotid and subclavian can be seen and felt ; the tip of the ensiform cartilage points to the right side, and the umbilicus is displaced to that side ; the lower edge of the liver is 2 inches below the margins of the ribs, and the belly is prominent and tympanitic (Figs. 48 and 49). Case 28. — Daisy C , aged 12, had measles six months before seeing me, and it appears from the mother's description that pleurisy had followed the measles. The patient is weakly and ill, with a long curve to the right from the first to the ninth dorsal vertebra and a compensatory lumbar curve. The right chest is dull, and the heart's apex is just internal to and on a level with the nipple. The abdomen is prominent and tympanitic. On suspension the pelvis twists forwards to the right and upwards^ (Figs. 50 and 51). ^ This tilting may give rise to limping. CHAP, vji SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 131 These cases are examples of the effect of advancing scoliosis upon the position of the thoracic and abdominal viscera. To sum up :— The Lungs. — On the convex side the chest is less resonant, and the vesicular murmur is decreased. On the concave side the note is more resonant, and the respiratory murmur is increased. The total decrease in the respiratory capacity is the cause of the shortness of breath, the frequent and severe attacks of bronchitis, and the increased liability of these patients to tubercular mischief after a pronounced curve has existed for some years. It is possible, too, that deficient aeration and circulation of blood may explain the absence of subcutaneous fat so often seen in these patients. The Heart. — If the concavity is to the left and in the dorsal region, the heart's apex is generally above its normal position and displaced outwards. I have seen the apex beat in an extreme case in the third intercostal space. If the concavity is to the right the heart is pushed well to the right. It is said that the right side of the heart becomes dilated. But from whatever cause it may be, some of these patients are cyanotic ; and many suffer from palpitation, although this may be ascribed to other causes, such as the concurrent dyspepsia. Abdominal Viscera. — The liver, from its large size, is particularly liable to compression and displacement. So, too, the spleen is out of place, while the stomach and intestines are pushed forwards to compensate for the lowered position of the diaphragm. The intestines are distended with gas, an evidence of the general disturbance of the digestive functions. Such is the picture presented by cases in which the spinal distortion has developed rapidly and is becoming extreme.-^ But it should not be inferred that all cases present so much functional disturbance as has been described. Many patients are fairly robust and hearty, and suffer in a slight degree, if at all, from general ill-health. In others their life is rendered miserable by impaired circulation, feeble digestion,^ and limited powers of re- spiration. Following these symptoms, in girls there is general disturbance of the uterine functions. I have already adverted to Benjamin Lee's idea (p. 108) that primary lumbar curves have their •^ The above remarks on displacement symptoms should be read in conjunction with those on the clinical aspect of scoliosis. ^ Adams, op. sup. cit. p. 171, mentions a case of a lady, aged 23, with severe scoliosis, who suffered from severe and periodical attacks of vomiting, but was much relieved by efficient support. 132 DEFORMITIES OF THE SPINE sec. i origin in uterine disturbances, but I do not share his opinion, and fail to see any direct connection between uterine disorders and scoliosis. TJie Ages at v:hich Increase in the Scoliosis occurs. — Briefly it may be said, at three periods, viz. up to the age of 25, from 25 to 40, and in old age. If a slight case commencing at the age of puberty is left un- treated it may become steadily worse imtil growth has ceased, and severe cases may grow^ worse in spite of treatment. The majority of cases, however, may be regarded as having attained the maximum deformity at 25. In a small proportion of cases, as the result of debility, especially that which occurs from frequent child-bearing, a recrudescence takes place, and the curvatures become more pro- nounced between the ages of 25 and 40. The influence of rapidly- succeeding parturitions in this connection should not be forgotten. In a still smaller number of cases, owing to failure of the general health, a scoliosis Avhich has been quiescent for thirty or more years will commence to increase, and cases have been recorded in whiili such an increase took place as late as the sixtieth year. III. The Stage of Arrest. — This stage may be reached spon- taneously, or as the result of treatment. Spontaneous arrest occurs in two varieties of cases : in the slight and in the well marked. There are many people of middle age going about without any apparent external deformity, an examination of whose backs shows them to have suffered from a small amount of distortion of the spine ; and in forming an opinion as to the probable result of a case, this possibility of natural arrest should be borne in mind. By these cases evidence is also afforded that scoliosis is not always so serious a matter as it is sometimes said to be. The other class of cases in which natural arrest occurs present quite a different aspect. The scoliosis is extreme, and has ceased to increase simply because bony ankylosis has taken place, with ossification of the ligaments. These two varieties of natural arrest are at opposite poles. Wlien in the slighter Class of Cases may Natural Arrest he expected ? — I have frequently insisted upon the great tendency of large single C-curves to become steadily w^orse. Conversely we find that the opposite condition of several small curves is particularly favourable to spontaneous arrest, on account of the more complete compensation ; and an earlier arrest may be expected in a case with double curvature if the curves are equal than when they are unequal. Secondly, an important factor in inducing arrest is CHAP. VII SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 133 the attainment of a high level of general health, with increase of muscular power. Thirdly, the nearer the age of completion of growth the patient is when the scoliosis commences, the more likely is it to be arrested before it has become extreme. Fourthly, spontaneous arrest is frequently seen on the cessation of faulty habits of standing or sitting. Evidence of spontaneous arrest is afforded by the loss of pain, fatigue, and discomfort, and by direct measurement. IV. — The Stage of Improvement. — The recognition of this stage is made by observing the gradual diminution of all the signs of deformity enumerated, especially the projection of the ribs on the convex side and the acquisition of symmetry of the flanks. As the ribs return to their normal positions, the shoulders become level. Morbid Anatomy of Scoliosis. — Scoliosis is not a disease, but an alteration in the position, shape, and texture of the spinal structures, dependent on long -continued pressure in an abnormal direction. In the earlier stages of the deformity when it has lasted a year or two, some diminution in thickness of the bodies of the vertebrte and intervertebral discs in the concavity is found, and the ligaments accommodate themselves to their altered positions by shortening. In lateral deviation from spinal weakness it is possible that relaxation of the ligaments is present. The lesions hereafter mentioned exist only in advanced scoliosis. It is essential to remember that scoliosis is not merely a deviation, but an actual twisting of the spine around a vertical axis. The bodies turn to the convex side, the spinous process to the concave side, and the transverse processes are rotated so that the " convex " process stands out, while its fellow is buried. This is a convenient moment to revert to the distinction between the two parts of which the spinal column is composed, viz. : — (a) The anterior, " body-column," or column of the vertebral bodies. (b) The posterior, " process-column," or column of the laminfe, pedicles, and processes. The function of the bodies is essentially supporting, and they suffer proportionately when the pressure to which they are exposed acts in a wrong direction. The processes are altered too, but less so, and the changes in them are secondary and due to the new position they must take. 134 DEFORMITIES OF THE SFINE Changes in the Vertebra'. — (a) The Anteiiur Column, the Bodies. Taking them as a whole, we find that at the middle of the curve they are displaced, being rotated even so far that the line join- ini-)povflnpp Whpn dpviatpd thp right side. Atrophy of the pedicle ^^^ appeal aucc. wncu cieviateci ine on the concave side. The verte- spiuCS twist tOWards the COUCavity. bral body is irregularly oval (after a ■ i t ■ m rri j. • Lorenz). " o'lnnai Ligameiits. — ihe anterior common ligament does not precisely follow the displacement of the bodies. It is somewhat dis- placed, and appears to have slipped to the concave side of the curve. It is no longer centrally placed. On the concave 136 DEFORMITIES OF THE SPIXE sec. i side it presents a thickened border, and on the convex side the edge is indistinct, and conterminous with the periosteum without any line of demarcation. Wlien it has once undergone this change of position and thickness, it acts as the chord of an arc in main- taining the bones in their abnormal position. Specimens of advanced scoliosis show that transformation of the fibrous tissue of the anterior common ligament into bone lias taken place, a condition often synchronous witli ossification of the intervertebral disc. This ossifying change is assigned to osteo-arthritis or osteitis deformans, but I feel sure that in advanced cases of lateral curvature there is a definite formation of bone, especially on the concave side of the curve. There is a specimen in Guy's Hospital Museum showing this. The change has probably been induced by the fixity of the vertebrae. The inter-trans- verse ligaments are stated to be shortened on the concave and elon- gated on the convex side. The Spinal Muscles. — In long- standing cases alone are structural alterations found. Adams says, " In all the dissections I liave had the opportunity of making at late periods, the muscles on both sides of tlie Fig. 55.— a scoliotic dorsal vertebra from spine have been much wasted, re- a case in -which the convexity was to t -. . -, ■ , the left side. Atrophy of the neural duccd HI Several instances to very arch in the concavity is seen (after thin layers, pale in colour, and in more or less advanced stages of fatty degeneration, which probably commences in the muscle on the concavity of the curve, those on the convexity wasting later." Such alterations are due to inactivity of the spinal muscles. The prominence of the muscles on the convex side is explicable by the backward displacement of the transverse processes and increased curvature of the ribs. In early stages the muscles stand out for two additional reasons, viz. their position on the convexity of the curve, and the tension of their fibres resulting from the persistent effort to maintain the body equilibrium. The muscles of the concavity are seldom rigid or prominent. If rigid, it is on account of the shorten- ing they undergo. It is important to recognise that fatty and fibroid changes occur in old-standing cases with fixed curves only. In the early stages the muscles are merely wasted, and rec[uire suitable exercise to CHAP. A-II SCOLIOSIS OR LATERAL CURVATURE OF THE SPINE 137 restore them to their normal size and strength. In still earlier cases, especially those of lateral deviation of the spine, the use of the dynamometer reveals considerable and often unequal loss of power on the two sides of the body. Viscera. — The effects of the distortion on the heart and lungs Fig. .56. — Front view uf the liuny framework of the chest from a case of scoliosis with the convexity to the right in the dorsal, and to the left in the lumbar region (Guy's Hospital Museum, 1006«8). have been mentioned. The trachea, bronchi, and branches of the pulmonary artery are deviated and their diameters lessened. The arch of the aorta is shorter than normal. If the convexity is to the left and of great extent, the thoracic aorta has been observed to cross the line of the vertebral column, and to run down the right side. 138 DEFORMITIES OF THE SPIXE The carotid arteries present sinuous curvatures, and the subclavian, if the curve is chiefly right-sided, is similarly affected. The latter effect is produced by the elevation and forward projection of the " convex " shoulder. Coincidently with this there is sometimes displacement of the inner end of the clavicle. The oesophagus Fig. 57. — Posterior view of Fig. 56. follows the curve of the spine if it be slight, but in pronounced cases it makes a right line for itself. The diaphragm loses its normal shape, and the relative positions of its apertures are considerably changed. The tliorax is profoundly affected in advanced scoliosis. On the convex side the capacity is markedly decreased, and the CHAP. VII SCOLIOSIS OR LATERAL CURA'ATURE OF THE SPIXE 139 tip of the sternum is deflected slightly. On the convex side the Fig. 58.— The scoliotic pelvis (Gny's Hospital Museum, 1006^"). antero-posterior and transverse diameters are diminished ; on the con- 140 DEFORMITIES OF THE SPINE sec. i cave side the depth is lessened, but the diameters are increased. A horizontal section of the thorax shows it to be elliptic in shape, the longest axis being from the most prominent part of the ribs behind to the opposite nipple in front, instead of, as in the normal chest, between the mid-axillary lines, i.e. if the rotatory curve is to the right dorsally, the axis is behind its normal position on the right side, and in front of it on the left (see Fig. o3). The forces at work in the production of the remarkable alterations in the shape of the ribs are two ; the vertebral bodies twisting to the convex side behind, and tlie fixed position of the sternum in front. Under the influence of these two forces, the ribs on the convex side are doubled up at points near the spine, viz. the angles, and on the concave side are unfolded at corresponding points. The pelvis in severe cases is much deformed. In the ordinary deformity to the right in the dorsal and to the left in the lumbar region, the shape of the pelvic cavity is abnormal, the lumbo-sacral angle pointing to the left and encroaching to a marked degree on the left half of the cavity. "With this there is also inward displace- ment of the left acetabulum. The wings of the sacrum and ilium on the left side are thickened, and the crest of the left ilium is lower (Fig. 58). This deformity should not be confused M^ith the flattened jDelvis of rickets. CHAPTEE VIII SCOLIOSIS {Continued) Pathogenesis of Scoliosis, Ex'periments of Jitdson and Others — Congenital Scoliosis — Rhachitic Scoliosis — Scoliosis of Nerve Origin — Static Scoliosis — Scoliosis of Cicatricial Origin — Scoliosis associated tvith Nasal and Naso- Pharyngeal Obstruction — Diagnosis of Scoliosis in General — Prognosis of Scoliosis. The Pathogenesis of Scoliosis. — The space at my disposal will not permit me to review all the theories which have been advanced in explanation of the production of this condition. Indeed it would profit little to do so. They are set forth at length in most of the works on " Orthopaedic Surgery." Suffice it to mention that the many theories may be arranged under three headings, the muscular, ligamentous, and osseous ; and up to a recent date they all had two features in common, the lack of experimental proof and a discordance from clinical and pathological facts. Some of the discordant facts are the following ^ : — 1. Many delicate children with weak spinal muscles, of sedentary habits and a proneness to faulty attitudes, do not develop scoliosis. 2. Some vigorous children leading an active, open-air life, whose spinal muscles seem as strong or stronger than the average, develop lateral curvature. 3. Eight-handed people sometimes develop scoliosis with the dorsal convexity to the left. 4. Some children with considerable difi'erence in the length of the lower extremities do not suffer from scoliosis. 5. A patient with shortening of the right leg, and the pelvis sloping away to the right, may develop a curve with the convexity to the left in the lumbar region. 6. Lateral curvature with extreme rotation may develop with the spine in the horizontal position. A specimen of a mammalian ^ H. L. Taylor, Trans. Amer. Orth. Assoc, vol. iii. p. 136. 142 DEFORMITIES OF THE SFIXE sec. i spiue with scoliosis is to be seen in the Museum of the College of Physicians and Surgeons of Xew York. The lack of experimental evidence has been supplied by American observers. It will be advantageous to detail briefly these experi- ments, as they throw much light on the subject at issue. Judsons Experiment} — A flexible rod is passed through the central canal of a disarticulated vertebral column, and the relative positions of the vertebrte are maintained by spiral springs passing from the spinous process to uprights on either side. "When pressure is made from above on the column, at first lateral deviation occurs, but as the pressure is increased, rotation follows. So that the result is a rotary- lateral curvature. If, while this pressure is still maintained, an attempt be made to bring the spinous process at the most prominent part of the curve into the middle line, a compensatory curve with its appropriate rotation makes its appearance. Bradford and Locctfs Erjperimcnts. — Experiment 1. — The spinal column of a foetus at full term, with muscles and skin intact, but divested of its attached ribs, was first made the subject of observation. The column was found to be more flexible than in children, adolescents, or adults. Rotation, however, was not readily brought about by pressure applied to both ends, although consider- able lateral de\aation ensued, and a curve with the concavity forward was also produced. Experiment II. — Pressure was applied to the whole spinal column of an adult male. The parts experimented on consisted of the spine, from which the larger muscles had been removed, the smaller muscles and ligaments being left, also a portion of the pelvis and the base of the cranium. A box with a rod fixed to its under surface and passing into the medullary canal of the cervical vertebne, was secured firmly to the cranium, and so arranged that it could be moved upwards and downwards, but not laterally. Into the box weights were put. Points observed : («) The spinal column bore a considerable weight without yielding to any appreciable extent. (Jb) As the weight was increased, a curvature with the con- cavity forwards was seen, and this became more marked as the weights were increased up to eighty-four pounds. (c) Xo rotation was observed so long as the weight bore directly downwards, but rotation of the lower dorsal and lumbar vertebne was seen when any lateral deviation was made in the ^ Trans, Amer. Orth, Assoc, vol. iiL p. 96. CHAP. VIII SCOLIOSIS 143 cervical region. The amount of rotation and deviation was much less than is possible in children. Experiment III. — The body of an infant was similarly pre- pared, and by an ingenious arrangement downward pressure was applied to the top of the head and shoulders, the pelvis being firmly fixed. The results were, with increasing pressures : (a) increase of the normal curve backwards, succeeded by (&) lateral deviation of the column with increasing rotation, accompanied by the usual changes in the ribs, viz. flattening on the side of the concavity and projection on that of the convexity. This projection was most marked in the middle and upper dorsal region, but the amount of greatest rotation appeared to be in the lower dorsal region. If the angle of downward pressure were changed, or if the pelvis were so tipped as to cause a curve in the spinal column, the effect of downward pressure was more marked. Careful examina- tion of the method employed showed that, although a well-marked scoliosis accompanied by the characteristic changes in the ribs was produced by downward pressure, yet it was caused by doivniuard 'pressure not exerted in a 'perfectly vertical direction, hut obliquely} If the pressure were directly downwards, then merely increase in the antero-posterior curves ensued. I have abridged the account of these experiments from that given in Bradford and Lovett's Orthopcedic Surgery. The observa- tions of Lorenz on the peculiar oblique striations of the vertebral bodies may be again alluded to in this connection (Fig. 52). It remains to recapitidctte some anatomical and physiological details before concluding. 1. The distinction that exists between the column formed by the bodies, which is supporting in function, and that formed by the arches, which is protective. 2. The bodies project into the thoracic and abdominal cavities. They are therefore free to move laterally ; while the arches and processes are limited in mobility, being entangled in the ribs, dorsal muscles, and fasciae. 3. Very little true lateral flexion of the spine is possible. 4. Lateral bending of the spine beyond a certain point is accompanied always by rotation. This can be readily shown by taking a disarticulated spine, piecing it together, and securing the vertebrae in their relative places by strands of stout catgut, or better, india-rubber, passing through all the bodies and parallel to ^ The italics are the ■writer's. lU DEFORMITIES OF THE SPIXE sec. i each other. If au attempt be made to approximate the axis and sacrum by lateral flexion, rotation comes early into play, and is especially noticeable in the dorsal region. This is better seen in a spinal column in -which the intervertebral discs are retained. The explanation is this. The anterior column formed by the bodies is relatively little compressible, but is very extensile on account of the elastic intervertebral discs. The arches, on the contrary, are held by the processes, notably the articular, at a determinate distance. They are unable to separate, but can glide upon each other. It follows therefore that in lateral flexion of the spine the body column, being capable of extension, is carried to the convex side of the curve, where there is room for that movement to take place, while the arches are carried to that side, viz. the concavity, where they can glide upon each other. 5. When the spinal column is bent laterally, if an individual vertebra be observed, the body is seen to make a wider excursion than the spinous process. The body moves through three-quarters of an inch and the spinous process through one quarter, i.e. the rotation does not take place on the central axis of a vertebra. 6. Bony growth during the period of adolescence follows the path of least resistance ; hence it is that in advanced cases of scoliosis the bodies are thicker on the convex than on the concave side. The same remark applies to the intervertebral discs. 7. According to Vogt there are three periods of rapid augmenta- tion of growth in the skeleton, viz. from the first to the second year, from the seventh year to the approach of puberty, and at and after puberty. In weakly children these periods are associated with general debility and muscular and ligamentous relaxation. And it is just during these periods that the onset of scoliosis is most common. 8. In persons whose growth is finished, and who are generally well developed, the carrying of moderate weights poised on the head results in no deformity, but rather in a perfectly erect and normal spine. To sum up the pathogenesis of scoliosis. We know that any cause which impairs muscular strength, such as rickets, over- fatigue, ill-health, and anaemia, is associated in the first instance with a general yielding of the spinal column in an antero-posterior direction. If any event now occurs to disturb the equilibrium, such as faulty attitudes, inequality of the length of the legs, persistent displacement of the head to one side, as in torticollis ; or CHAP. VIII SCOLIOSIS 145 retraction of one side of the chest, as in empyema ; or a strain is put upon the muscles of one side more than the other, as by ex- cessive use of one arm/ lateral flexion follows. This is owing to the muscles of the weaker side yielding, and to the spine sagging over to that side, hence the convexity of the curve is on that side. Such lateral flexion is only possible within restricted limits, which are undoubtedly larger in weak than in normal spines. As soon as it has passed these limits rotation sets in, and a true scoliosis is developed, with the bodies to the convex, and the spinous process deviated in a less degree to the concave side. As the cause persists and the weight of the head, shoulders, and upper extremities press on the weakened spine, so will the scoliosis increase. The order of events is — {a) Weakening of the spinal ligaments and muscles, followed by (h) antero-posterior flexion, lateral flexion, and rotation of the spinal column. In the first place, weakening of the structures, and, in the second, loss of equilibrium. That such is the course of events is incontestably proved by Bradford and Lovett's experiments. Given, as in their experiments on the flabby spine of a corpse, pressure evenly applied, the result is, firstly, increase of flexion ; secondly, lateral deviation ; thirdly, if obliquely applied, a rotation directly proportional to the super- incumbent weight. In dealing with the subject of scoliosis, it has been thought more convenient to group the appearances, symptoms, morbid anatomy, and pathogenesis of the subject in general under the head- ing of " Scoliosis of Adolescents," inasmuch as the more typical aspect of scoliosis is seen in this particular variety, and the delinea- tion of its symptoms and morbid anatomy include those of the other varieties. A few special remarks, however, directed to the other varieties cannot be out of place. Congenital Scoliosis. — Unfortunately the recorded cases are very few, and the literature of this class is correspondingly scanty. According to the statements of Fleischman and Philippeaux, it mainly exists in monstrosities, and in them it has been chiefly studied. These authors state that it is the consecjuence of the development in a wedge-shape of one or more of the vertebral bodies. Guerin believed it followed muscular spasm secondary to mal-developments of the ^ The case is reported of twin sisters who sat at the same bench at school, and leaned, one on the right arm and the other on the left, in whom curvatures developed in opposite directions. L 146 DEFORMITIES OF THE SPINE central nervous system. In other cases it is said to be due to fcetal rickets. The recorded cases which have come to mv knowledge are 1. A case described by Eokitansky, the specimen being in the Museum at Vienna.^ 2. A child, aged 2 years, admitted into the Eoyal Orthoptedic Hospital under the care of Mr. Adams. - 3. A cast from a similar case in the Museum of the last-mentioned Hospital. 4. A case of a woman aged 31 years, and described by Mr. Willett.^^ Rhachitic Scoliosis. — The first effect of rickets on the spine is to cause a general, not a local increase of the antero-posterior curve of the spine. If the arguments on the "Pathogenesis of Scoliosis" have been followed, it must necessarily result that unless the deformity be arrested or the superincumbent weight of the head and upper extremity be taken off, the antero-posterior curve must develop into a lateral deviation, and Fig. 59.— From a photograph by Redard , . Qmlinsk Tbi^ .showing the ettect of the position in ^^^^n mtO a tlUe SCOilOSlS. lUlS which a child is held by its-nurse in sequence of cvents is assisted by the producing scoliosis. , -, ^ . i -i i general mode of carrying children seated on the flexed forearm of the nursemaid. The forearm is fre- quently placed at an acute angle with the arm, and the child there- fore rests on an inclined plane. Such a position cannot fail to be a powerful auxiliary to the development of scoliosis in rhachitic children. If the child is carried on the left forearm, for instance, he inclines his trunk towards the nurse's chest, and the deviation is thereby accentuated. The effect on the child's spine is well shown in Fig. 59. If the child be carried on the right forearm the effect is reversed. But inasmuch as rhachitic cases more often have the curvature to the left, the frequent use of the left forearm by nurses 1 Path. Anat. Syd. Soc. vol. iii. p. 228, 1850. - Op. svp. cit. p. 228. 3 Bradford and Lovett, op. sup. cit. p. 104. CHAP. VIII SCOLIOSIS 147 ill carrying children may have some influence on its production in this direction. Of 69 consecutive cases seen by the writer at the IsTational Orthopasdic Hospital, 1890-94, 4 were marked examples of rhachitic scoliosis under the age of 2|- years. Of 1070 surgical cases seen at the Evelina Hospital, 8 were examples of this affection at the same age. The affection, however, develops its full intensity be- tween the ages of 2 and 6 years ; but many writers admit the exist- ence of that anomalous disease, " late rickets," a peculiar softening and rarefaction of bone occurring at the ages of 8 to 10 years.^ Last Cervical Vertebra 70th. Dorsal Vertebra Appearance on August 31st. Fig. 60. — Outline of spinal curves at commencement of treatment of Lilian M. H (Case 29). Appearance on November 9th. 1891. Fig. 61. — Outline of spinal curves in the same case after ten weeks' tieatment. The notes of the four cases under the age of 2|- years mentioned above are appended. Case 29. Case of Rhachitic Scoliosis. — Lilian M. H- , aged 2 years, was a very ricketty child, with enlarged epiphyses, deformed chest, bent tibiae, and considerable scoliosis. She was the fifth child'; the others were healthy. She was weaned at the fourth month, and then fed for five months on condensed milk ; now, " she has just the same as we do." On 31st August 1891, the date on which she was first seen, there was a large curve to the right occupying the dorsal region from the first to the tenth dorsal vertebra, together Avith rotation of the ribs and a compensatory curvature in the lumbar region (Fig. ^ For a resume of our knowledge on this subject consult Dr. Goodhart's Diseases of Children. 148 DEFORMITIES OF THE SPINE sec. i 60). She was ordei'ed one drachm of cod-liver oil twice a day, and to wear a poroplastic jacket. Finding, however, on 14th September that the poroplastic jacket was not sufficiently supporting, I had an occipital head-piece added. A marked improvement took })lace, and in ten weeks' time the spine had assumed the appearance seen in Fig. 61. Subse- quently complete restoration of the form of the back occurred. / / / Fig. 62. — Back view of a child, aged 2 years, suflfering from ricketty scoliosis. Case 30. — Clara H , aged 18 months; very rhachitic. Both posterior and lateral curvature were present. There was much rotation of the bodies to the left, forming one large curve in the dorsal region. The curve disappeared on lifting the child up by the arms. The mother stated that the birth was a very difficult one. The child was given one drachm of the extract of malt and cod-liver oil, and was ordered to be carried about on a wicker tray. Considerable improvement followed. CHAP, vin SCOLIOSIS 149 Case 31. — Mabel B— — -, aged 2^ years, was also very ricketty ; the active stage of the disease having subsided, the child was left in a very collapsible state. There was extreme general kyphosis, with much lateral deviation to the right. She was ordered a poroplastic jacket with an occipital head-piece, and soon improved. Case 32. — Winifred A , aged 1| year, presented many of the signs of active rickets. The curvature was to the right and chiefly dorsal. In this instance there was much exaggeration of the curve of the clavicle on the left side, without any evidence of previous fracture. The occurrence of increased clavicular curve on the side opposite to the spinal convexity was an unusual feature. Good results were obtained by the use of a poroplastic jacket with an occipital head-piece. The appearances presented by cases of rhachitic curvature are well shown in Figs. 62 and 63, and may be enumerated. («) A general laxity of the spinal column is present, and, with the scoliosis, kyphosis or, less frequently, lordosis is associated. (h) In young children at the ages of 2 and 3 years, according to Lorenz, the deviation is generally to the left. In older children the deformity appears equally on both sides. (c) The primary curve is dorso-lumbar rather than, as in adults, dorsal or lumbar. (d) The superior limit of the posteriorly-displaced ribs is below the corresponding scapula, i.e. the scapula is not much displaced (see Fig. 62). (c) The alteration in the shape of the pelvis is subsequently very great, and causes considerable difficulty in labour. This class of case has been treated of at some length, but it is not implied that all rhachitic cases are liable to develop true scoliosis. Far from it ; in most instances it does not appear at all. Even when kyphosis is present, but a small proportion develop lateral curvature, as the deformity is averted at this stage by the cure of rickets either spontaneously or under treatment. The morbid appearances of a spine deformed by rhachitic scoliosis is not different to those of the scoliosis of adolescents, except in the unecjual growth of the epiphysial plates of the vertebrae.-^ Scoliosis of Nerve Origin, — After infantile paralysis some deviation of the column, arising from unilateral atrophy of the extensor muscles, is occasionally seen. Scoliosis, however, rarely ensues from this cause alone. More often it is due to the weaken- ing and shortening of one lower extremity. ^ Of. an article by C. B. Keetley on the "Causation of Scoliosis," Trans. Brit. Orthop. Soc. vol. i. 150 DEFORMITIES OF THE SPIXE Distortion similar to that of infantile paralysis follows hemi- plegia, progressive muscular atrophy, and pseudo- hypertrophic paralysis, the chief factor at work -being unbalanced muscular action. ^A i Tift m Fig. 63. — Back view of a child, agerl 3i, suffering from marketl scoliosis, dating from the onset of rickets. The posterior projection of the lumbar spines is worthy of notice. From a case seen at the Evelina Hospital. In locomotor ataxy spinal curvature is very rare. Mr. J. H. Targett ^ says there are not more than six recorded cases. He ^ dut/s Hospital Gazette, 6th Aug. 1895, pp. 133-135. On "Spinal Curvature in Nervous Disorders." CHAP. VIII SCOLIOSIS 151 gives the notes of one case which he had been able to examine, In the dorso-lumbar region, and involving the first lumbar vertebra, was an angular curvature. On either side of the curvature there was much bony thickening. When the patient bent forwards a loud " crunch " could be heard, as " if the spine were broken at a certain level, and the lower end of the upper fragment played in a cavity, formed by the upper end of the lower fragment." In Fried- reich's disease or congenital locomotor ataxy, scoliosis develops late in the disease, and is generally seen to be to the right in the dorsal region, with lor- dosis of the lumbar spine. Gradual weakness of the spinal muscles is the immediate cause, and then excessive use of the right arm deter- mines the direction of the curve. In cases of spastic contraction of the lower extremities with marked adduction of the thigh, deviation is observed about the age of puberty. Accord- ing to Mr. Targett, about half the total num- ber of cases of syringo-myelia show curvature of the spine. It is generally a scoliotic curva- ture with a small amount of kyphosis, but pure kyphosis or lordosis seems to be very rare. j^otes of three cases are given by Mr. Targett in the article mentioned in the footnote on p. 150. Hysterical contraction of groups of muscles in the lower extremities is met with. As a complication, hysterical contraction of the fig. 64 spinal muscles is seen (Fig. 64). It is noteworthy that Charcot states that this is present ordinarily in the dorso-lumbar region ; the appearance of the contraction rapidly follows a slight blow or injury in that region ; both the contraction and the spinal deviation some- times disappear suddenly. They are always effaced under an anaesthetic. Sciatica is stated by Charcot, Babinski, and Ballett to be com- plicated by two varieties of scoliosis, one in which the concavity of the spine is turned to the healthy side, and the other in which the concavity is turned to the affected side. The deviation is dorso- lumbar, and is due to the vicious attitude of the sufferer, arising ^/y Hysterical scoli- osis. A lumbar curve convex to the left is seen, due to hysterical contraction of the lower part of the right erector spinee (after Kedard). 152 DEFORMITIES OF THE SPIXE from coutraction and inability to bear the weight on the aftected limb and resulting in twisting of the pelvis.^ Static Scoliosis. — The most obvious form is that arising from inequality in the length of the lower extremities. This is of two varieties — (a) Due to a congenital asymmetry of the lower extremities. (b) Arising from pathological conditions. Congenital asymmetry is ver}' common, and is, in my opini(Ui. due to unequal growth of bone at the epiphysial line. Measure- ments of a few of the cases seen at my out-patient clinics are subjoined. Name. Age. MEAsrREJiENT.s. CVKVATUEE. . 1. Lily S . 2. Ellen W 3. Sarah M 4. Annie R 5. Margt. G fi Kntp C Right Leg. Left Leg. 14 32 inches, 31l inches. 19 341 ,, 34^ ^, 26 321 ., 331 ., 11 291 ,, 291 ., 20 34 „ 341 ^, 13 1 31| „ 3lf „ 12 29 ,. 291 .. 14 311 ^, 3ol .. 16 331 ,, 33 21 34" „ 34i „ Left lumbar, Right dorsal. Right ,. Left „ Left ,. Right „ Right „ Left Left .. Right „ Right ,, Left „ 7 Alinrl T 8. Ada S 9. Jane T 10. Rose J Cases 2 and 3 are examples of the curious fact that patients may have the lumbar convexity on the side of the longer leg."' The general rule is that the convexity of the lumhar curve is on the side of the shorter Icfj. Measurements of a large number of persons show that inequality of the length of the legs is a constant occurrence. Yet very few such persons suffer from scoliosis, so 'that asymmetry of the legs cannot be a very important factor. We must infer the existence of persistent weakness of the spinal muscles when a mere lateral deviation, the result of tilting of the pelvis from unequal length of support, passes into scoliosis. The faulty attitude assumed must become a fixed position before scoliosis can be said to be present. It is stated by some authorities that the left lower extremity is generally the longer, but Garson states the reverse. The difference 1 For further information ou this subject consult Redard. o'p. cit. pp. 364-367, and Langenbeck's .^i?r/in-, 1889, Article, " Ischias Scoliotica." - Cf. H. L. Taylor, Trans. Amer. Orth. Assoc, vol. iii. p. 136. CHAP. VIII ■ SCOLIOSIS 153 is not proportionately distributed between the tibiae and femora. The shortening is present either in the femur, the tibise being equal ; or the tibia is shortened, the femora being equal; or the tibia on the shortened side is actually longer than its fellow, while the femur is so much shortened as to more than neutralise the lengthening of the tibia. The difference between the limbs varies from ^ to |- inch generally. Asymmetry arising from pathological conditions of the lower extremities is associated, but not necessarily, with scoliosis. Among these conditions are the following : — Coxitis, congenital displacement of the hip on one side, osteo-myelitis and periostitis of the femur and tibia, injuries of and operative interference with the epiphysial lines,""^ genu valgum and varum, ankylosis of the knee, flat feet, the various forms of talipes, especially those paralytic in nature.^ The other conditions giving rise to static scoliosis are to be sought for in the upper extremities and head and neck. In the upper extremity the chief cause is loss of balance, which ensues from infantile paralysis affecting one arm, or in rare instances from amputation of a portion or the whole of the limb. Torticollis is followed by scoliosis, the primary curve being in the cervical region. I have already mentioned a case of hypermetropia and scoliosis. The relationship of vicious positions to scoliosis, which is an undoubted clinical fact, fits in with the experiments quoted on pp. 142, 143. Before pointing out more particularly the relation- ship, I would emphasise this statement : a short leg, a tilted pelvis, a paralysed arm are not necessarily followed by scoliosis. The ex- planation is that the spinal muscles have sufticient tone and equilibrium to maintain the column erect. If the muscles become toneless and weak, then lateral deviation follows, and a temporarily vicious attitude becoming fixed, scoliosis ensues ; the condition of ^ Cf. article by tlie author on "Shortening following Injuries and Diseases of the Epiphysial Line," Lancet, May 1890. ^ In measuring the length of the limbs special care should be taken that the knees are kept fully extended and the limbs parallel. This is a small matter, but if not rigorously attended to, readily makes a difference of \ inch, or even more. Measure- ments are usually made from the anterior superior spine of the ilium to the internal malleolus. It is preferable to take the tape to the external malleolus. The convexity of the muscles of the sound thigh causes an increased measurement when the tape crosses obliquely over it, and the difference in the length of the limbs appears greater than it really is. Especially is this the case in paralytic limbs. By taking the tape to the external malleolus mucli of the source of error is avoided. 154 DEFORMITIES OF THE SPIXE the spine is due to the subsidence of the body into positions of rest. The two factors are a toneless spine and loss of equilibrium/ Scoliosis of Cicatricial Origin. — The cause in this variety is empyema, or repeated attacks of pleurisy. Figs, ^oo, 66, and 67 give the appearances in such a case, and the following are the notes of one case. Fig. 65. — Scoliosis of cicatricial origin, ami secondary to empyema (Case 33). Fig. 66. — Front view of Case 33 showing the position of the discharging sinns after empyema, also the flattening of the chest on that side, and the elevation if the right shoulder. Case 33. Scoliosis secoixdanj to Empycnai. — Henry B- , aged 9 years, came to me at the Evelina Hospital in November 1893. Eighteen months previously he had been an in-patient on account of pleuritic effusion and empyema on the right side. The pus was evacuated at the sixth right space and there is still a sinus left. Through this a little curdy pus escapes from time to time. The right side of the chest is flattened, and there is seen a well-marked spinal curvature in the dorsal region, with its convexity to the left (Figs. 65 and 66). ^ As showing the eflfects of position, there is in the Miitter Museum a cast of the Siamese Twins. In both tliere is lateral curvature, and tlie curvatures are in opposite directions, the shoulders towards eacli otlier being raised. The curvatures are due to tlie fact that in order to give eacli other more room, the twins stood leaning away from one anotlier (Judson, Trans. Amcr. Orth. Assoc, vol. iii. p. 96). CHAP. VIII SCOLIOSIS 155 ■f The aspect of the spiue- is one of deviation more than of scoliosis. The course of events is flattening and obliquity of the ribs on the affected side, and bending of the spine to the sound side. The ribs become flattened owing to the partial collapse of the lung and the cicatricial contraction of pleural bands. Ee- moval of portions of ribs in the late stage of a discharging empyema, while securing the closure of the cavity, is likely, in my opinion, to increase the deviation, a matter then of secondary importance. "To prevent deviation of the spine and deformity of the chest, the great object is to cure the empyema early, and the comparative frecjuency with which one sees this deformed chest appeals very strongly to a more radical means of primary treatment of this disease (re- section of a rib)." ^ In certain cases the deviation passes into scoliosis. Eepeated attacks of pleurisy, by bind- ing down the lung and obliterating the pleural cavity and causing muscular atrophy of the affected side, are factors in the production of scoliosis. Scoliosis in Association with Nasal Obstruction and Adenoids in the Naso-Pharynx. — At first sight it might be asked, What is the connec- tion between these affections ? I shall endeavour to show that the connection is a close one. If a series of cases of adenoids be watched, these facts may be observed. During infancy and early childhood the subject of nasal obstruction shows deformity of the chest alone ; in other subjects, and especially between the ages of 6 and 10 years, kyphosis makes its appearance. Later, from 10 to 16 years of age, scoliosis supervenes on the kyphosis, the abnormal shape of the chest still being very apparent. We have, therefore, this order of events : adenoids, contracted chest, kyphosis, scoliosis. The proof that the deyiation of the spine is dependent on the 1 "W. Arbuthnot Lane, Guy's Hosp. Rep. vol. xliii. p. 372. lP I port to the whole frame; constant pressure is exercised on the convexity of the curve by the spring plate ; the apparatus is self-adjusting by the action of the springs, and, as improvement in the curves takes place by intercurrent exercises and gymnastics, the lacing can be let out ; there is no hindrance to breathing, as the whole of the anterior part of the instrument is soft. That it is efficient is shown by the fact that when a scoliotic patient did not present herself for examination for some months, the curves were found to be over-corrected. The only drawback is the expense, but as the instru- ment lasts with care for some time, this cannot always be considered a serious matter. This instrument is particularly adapted for orthopaedic practice as being self-adjusting, and visits to the surgeon at Fig. 79.— Spring plate au.i laced long intervals only are required. '^''^'^ ^P^^"^ apparatus. A heavier form of instrument, and one requiring care and super- vision in its use, is the spinal support with levers and plate. This, however, is somewhat complex and can be seldom necessary. 1 For a description of this method, vide £.3f.J. 28th Feb.' 1891, 'pp. 461, 462. CHAP. IX THE PREVENTION AND TREATMENT OF SCOLIOSIS 177 stays for cases of commenc- ing curvature, and to be iised as a support when the patient is not exercis- Neither of these patterns of instruments should be employed if the case present fixed osseous curves. Sujjports are indicated in two classes of cases : — (ft) Those in which there is much weak- ness of the spinal muscles, with commencing curvature. In these instances the use of the spinal stays designed by Mr. Adams (Fig. 80), combined with exercises, is valuable. The former are also useful in receding cases when the spinal apparatus alluded to above can be dispensed with, and before the return to simple, light stays. (&) In advanced stages of scoliosis, with fixed deformity arising from bony ankylosis Fig. 80.— Mr. Adams' spinal at some portion of the column, when curva- tures in other parts are increasing and the patient is suffering from pain and symptoms of visceral displacement and pressure, some form of support is necessary. Two kinds are in general use, the poroplastic jacket and the plaster of Paris jacket. The merits and demerits of these have been described on pp. 56-58. In my opinion, the poroplastic jacket is preferable, particularly if it be strengthened by vertical steel bands moulded to the outline of the figure (Fig. 81). When the scoliosis is cervico-dorsal or high dorsal, i.e. above the seventh dorsal vertebra, it is necessary to add an occipital head-piece to the jacket, so as to remove the weight of the head and neck from the spine. Indications for the various Methods of Treatment. — There is no panacea for ■ Poroplastic jacket scoliosis. Eacli case must be treated on and steel supports moulded io-,t i ^■ • • , ■ ^ to the figure, for inveterate definite iines, and a discnmmatmg use made cases of lateral curvature of the means at our command. To recapi- with bony ankylosis. tuiate the means : they are recumbency, postural methods, exercises, methodical correction, and support. With these must be combined constitutional treatment. For practical purposes it is convenient to consider the indications from the point of view of the age, causation, shape, position, number, N Fig. 178 DEFORMITIES OF THE SPINE sec. i and coudition of the curves, as to fixation or not. But tliere can be no hard and fast lines of treatment. 1. In Children under Three Years of Age. — Dependent as scoliosis is at this age largely upon rickets, every effort should be made to remove the rhachitic condition. Prophylaxis consists in the avoidance of the sitting position of the child either on the nurse's arm or lap. It must, if kyphosis or scoliosis threatens, be always carried on a pillow or in a wicker tray. When it is old enough to walk, firm support should be given to the liack by a back-board, poroplastic or leather jacket during the day. The jacket should be removed twice a day to allow the muscles of the back to be douched with tepid water and to be well rubbed to increase their tone, also to permit methodical correction with the hands (p. 175). Particular attention is to be given to the decubitus at night. If mere spinal weakness, the supine is the best : if a curvature be commencing, the child should be taught to lie on the prominent side, with the head low and a pillow placed beneath the convexity. It is too often the case that slight rhachitic curves are disregarded; but from rickets alone some of the most inveterate curves of late adolescence ensue. 2. During tlic first Period of rapid Groivth, from Six to Tvjelve Years of Age. — Prophylaxis consists in careful observation of the child so that she does not fall into faulty positions in sleeping, standing, sitting, or writing (pp. 163, 164) ; that all such conditions as myopia, adenoids (p. 155), and unequal length of the legs are corrected ; and that too great a strain is not put upon her, either mentally or physically. The treatment is to curtail to a great degree the time spent in study, to enforce outdoor exercise, such as walking, or those games which necessitate the use equally of both arms for about one hour or less ; to drill the child for half an hour in the second part of the day, so that she acquires a correct carriage, both forms of exercise being followed by recumbency for one to two hours, prefer- ably on the prone couch (p. 168). Or exercises in the horizontal position on the couch may be enforced, at fii'st for fifteen minutes, and then followed by rest for one hour, twice a day. If the height be out of proportion to the weight, the duration of recumbency should be greater, at least two hours twice a day, and the amount of exercise not more than half an hour twice a day. The ordinary gymnastic curriculum is to be avoided, as it is too long and too fatiguing. In place of drilling, when the curve has become pronounced the less exacting forms of exercises (Set I. p. 170) may be used, the whole time during which they are carried out not being more than half an hour ; CHAP. IX THE PREVENTION AND TREATMENT OF SCOLIOSIS 179 or the use of very liglit dumb-bells, under one pound, for about ten minutes may be combined with the exercises. As the patient im- proves in strength, and the curvatures in flexibility, the more advanced exercises (Set II. p. I7l) may be proceeded with, again not for more than half an hour, and to be followed by recumbency. During the remainder of the day, if there is weariness or fatigue, or the child lapses into a faulty position, a light spinal apparatus with spring plate and laced shield may be employed. Passive manipula- tion (p. l75) is also valuable. Too much attention cannot be paid to commencing scoliosis at this age. The spine is very flexible, and can be moulded in the early stage almost at will by the means described. This element of flexibility is also one of danger ; if the condition be disregarded the deformity progresses rapidly, and the result is lamentable in later years. The duration of treatment cannot be definitely stated, but it will be necessary in most cases for super- vision to be exercised for one to three years. 3. During the second Period ofraind Grotvth, from Twelve to Twenty - one Years of Age. — The signs and treatment of the preceding stage of lateral deviation have been discussed on p. 107. The prophylaxis consists in attention to the general health. Muscular weakness being a predisposing cause, the muscles of the back should be strengthened by tepid bathing, douching, friction, and the use of the constant current. The surgeon satisfies himself that all conditions of occupa- tion, faulty positions, bad habits of standing, and causes of fatigue are removed, and sees that the general tone of the body is raised by fresh air, good and easily-digested food, and the administration of iron. He also inquires particularly into the pattern of chairs, desks, and music-stools, and the duration of music and drawing lessons. The indications for treatment are best arranged according to the stage of the curvature, viz. commencing, established, and fixed. A. Commencing cases, i.e. those in which there are some devia- tion to one side of the vertebra, prominence of the scapula, ribs, and crest of the ilium, with asymmetry of the flanks; or slight cases, where the curves can be made entirely or almost to disappear either by placing the patient in the improved position or by suspension or recumbency. The first question that will be put is, Is it necessary that all the lessons be given up ? In reply it may be stated, it is not essential. Eather they should be curtailed to a quarter or half the usual time, and carried on in the morning, when the 180 DEFORMITIES OF THE SPINE sec. i patient is iu greater vigour than in the afternoon, and followed by adequate rest. If there be no muscular debility, and the scoliosis arises from faulty positions, or defective habits of standing, then the postural method (p. 169) is to be enjoined, and supports are unnecessary. Again, outdoor exercises are to be encouraged, with drilling and athletics, such as swimming, which bring into play all the muscles of the body. The patient should also be frequently exhorted by the parents when any lapse into a vicious position is noticed. If with the scoliosis there is much muscular weakness, then a combination of recumbency, exercises, and support is called for. Eecumbency is specially necessary in primary lumbar curves, and in neurasthenic or overgrown girls. The daily routine should be somewhat as follows : — A tepid bath in the morning, with friction of the back and the exercises of Set I. (p. 170), and after breakfast methodical correction by mani- pulation for half an hour, followed by recumbency, then lessons and outdoor exercise. In the afternoon recumbency for one to two hours. In more advanced cases the exercises should be carried out in the afternoon as well. In the intervals of exercises and recumbency a spinal apparatus which combines support with methodical correction, such as the spring plate and laced shield, is useful,^ or Mr. Adams' spinal stays, if it appear that the muscles are too weak to sustain the body. But it is better, if possible, to dispense with supports. It is also useful to encourage singing and other methods of distending the chest. As the muscular power increases, the exercises in Set II. (p. I7l) may replace those of Set I. But manipulative correction (p. l75) must still be per- severed with, and care be given to the position during sleep. With this treatment cure may be looked for in six months to two years. B. Established or pronounced cases, i.e. those in which the curves may still be greatly improved or modified by the " best position," recumbency and suspension. Here postural methods are useful. The combination of rest, exercises, and support is more urgently called for, and methodical correction should be diligently persevered in. The exercises should be the more advanced, those in Set II., and should be gone through twice a day, and followed by recum- bency for two hours. The daily routine is much the same as in the slighter cases ; and mechanical supports with corrective apparatus ^ Mechanical correction is chiefly of service in the dorsal region, where the plates can act by pressing on the displaced ribs. It is not of much avail in lumbar curvature. CHAP. IX THE PREVENTION AND TREATMENT OF SCOLIOSIS 181 and sufficient rest are necessary. In cases of multiple but still flexible curvatures the general effect of exercises should not be to remove them, but to give strength to the muscles of the back as a whole. If there be slight osseous, fixation, Adams' method of suspension from the two horizontal bars (p. 174) may be employed; and it is stated that Lorenz' method of forcible correction is useful in these slighter cases of fixation,-^ but it is obviously inapplic- able in advanced osseous ankylosis. Of this method I have had no experience, and I merely quote the opinion of writers on the subject. It is well to add that if the curvature be high up, viz. cervical or cervico-dorsal, the head and neck must be sup- ported by an occipital head-piece or jury-mast. C. Fixed or severe cases, where no change in the curves is produced by any alteration of position. All that can be done is to relieve the symptoms — viz. pain, and those arising from displace- ment and pressure on viscera — and, if possible, to prevent the deformity becoming worse. Poroplastic jackets strengthened by steel bands and perforated by a few air apertures, or plaster of Paris jackets, both with or without occipital head-pieces as may be necessary, are the means at our disposal. As the plaster of Paris jacket cannot be so tightly put on as to accurately fit the patient, any straightening of the lesser curves obtained by suspension during its application is rapidly lost. It can merely act as a general support. In Class B some improvement may be looked for, in Class C none. Indeed Walsham ^ states that " even with the use of supports it may, under some circumstances, get worse." ^ Curva- tures arising from empyema are hopeless to attempt to rectify, and so are those associated with destructive nerve lesions, such as acute anterior polio-myelitis, or myopathies, or pseudo-hypertrophic muscular paralysis. In no case is myotomy permissible. Although I have men- tioned above the period during which it is necessary for treatment to be continued, I feel bound to state that in most cases of scoliosis inspection by the surgeon at intervals of one to two months is all that is called for, provided that he can ensure his directions being understood and intelligently carried out. ^ Bradford and Lovett, op. cit. p. 177. 2 St. Bart's. Hosp. Rep. vol. xx. 1884, pp. 195-211, "Notes from the Orthop. Dep. in Treatment of Lat. Curv. of Spine." ^ For a general expression of opinion on the methods of treatment of scoliosis con- sult the Report of the Clin. Soc. Committee on "The Treatment of Lateral Curvature of Spine," Clin. Soc. Trans, vol. xxi. pp. 301-303. SECTION II DEFOEMITIES OF NECK, CHEST, AND UPPEE EXTREMITIES CHAPTER I TORTICOLLIS OR WRY-NECK Varieties of Torticollis — Etiology and Causation — Cases illustrating various Points — Pathological Anatomy- — Symptoms — Prognosis — Diagnosis — Treatment of Congenital Torticollis — Methods of operating — After- Treatment — Treatment of Spasmodic Torticollis, General and Operative — Section of Spincd Accessory Nerve, and of Posterior Nerve-Roots. Synonyms — Latin, Caput ohstipum, Colluvi distorhcm ; French, Torticolis, Cou tortu ; German, Scliiefhals. Definition. — A congenital or acquired deformity, characterised by lateral inclination of the head to the shoulder, with torsion of the neck and face. Varieties. — False and True. False torticollis is not immediately due to muscular or nerve causes, but is a symptom of disease in other structures. For instance, in cervical caries a displacement of the head occurs, and one sterno-mastoid becomes shortened. An error of diagnosis is readily avoided by noting that in spinal caries the muscles are tense and shortened on that side towards which the face is turned, while in the true form the tension is on that side from which the face is turned. The false variety may sometimes be due to cicatrices of skin and fasciae following a burn. True torticollis may be spoken of as acute and chronic. The Acute Form arises from exposure to cold and from rheuma- tism, in fact is the ordinary stiff-neck, and is scarcely worthy of being called torticollis. In children it is apt to be more lasting than in adults, and may give rise to a faulty position of the head more or less permanent. With the deformity there is some tenderness of the muscles. Chronic Torticollis in its true form may be arranged under the following headings : — 186 DEFORMITIES OF XECK, CHEST, AXD UPPER EXTREMITIES sec. ii 1. Congenital or "fixed wry-neck." 2. Acquired. (a) Traumatic and cicatricial, following injuries to the muscles of the neck.^ (h) Compensatory. In scoliosis the head is frequently inclined to the right or left in the effort to maintain the equili- brium. (c) Spasmodic. This may be tonic or clonic in character. The classification, however, of the varieties I have adopted is as follows : — Toiiicollis. — I. False, arising from spinal caries or cicatrices of skin and fascise. II. True. 1. Acute — Rheumatic. 2. Chronic. A. Congenital. B. Acquired. Compensatory. Spasmodic. I have omitted the paralytic form on the authority of Gowers, Dis. of Nervous System, 2nd ed. vol. ii. p. 662. From a pathological point of view, torticollis is spoken of as anterior when the sterno-mastoid is mainly affected, and posterior or retrocollic when the posterior cervical muscles are largely impli- cated ; in the former the deviation is lateral, in the latter there may be backward movement of the head. Etiology and Causation. — The male sex is more liable to congenital torticollis than the female, and it is more frequently found on the right side than on the left. The deformity is a comparatively rare one. Of 2000 patients seen by me at the Evelina Hospital, I have met with it but eight times. Gowers says : " The spasmodic form is more common in women than men. Of thirty-two cases of which I have notes (all those of hysterical nature being excluded), ten were in males and twenty-two in females. It commonly begins in the middle period of life, between 30 and 50 years of age. . . . Cases in females under 30 are often of a hysterical nature, and this is also probably true of the rare cases, in which similar spasm is met with in boys." - The congenital form is said to arise from injury to the sterno- mastoid at birth from traction on the neck. Another cause is shortening of the muscle, following inclination of the fcetal head in ^ Reeves, op. cit. p. 85. - Op. cit. p. 664. CHAP. I TORTICOLLIS OR WRY-NECK 187 the pelvis. This is supported by two facts : congenital torticollis is usually on the right side, and in 75 per cent the foetal head is in the first position, which is associated with flexion of the head to the right shoulder. The shortened muscle may, on account of its inability to stretch, rupture during birth. As to the precise connection of the so-called hematoma of the sterno-mastoid and induration of that muscle with torticollis, the literature is considerable and the evidence conflicting.^ It would appear : (1) that in a certain proportion of cases of congenital torticollis no history of swelling in the sterno-mastoid after birth is obtainable ; (2) in other cases there is a distinct history of such a lesion, these form but a small proportion ; (3) in the majority of cases of hsematoma, torticollis is not developed subsequently ; (4) how far syphilis is a cause of congenital torticollis is not known. Cases undoubtedly occur in which induration of the sterno-mastoid and wry-neck are associated with signs of congenital syphilis. 1 Petersen, Zeitschrift f. Chir. Orthop. Bd. I. Heft 1. (1) No case of wry-neck has been proved to be due to rupture during birth of a normal sterno-tnastoid. (2) Clinical and experimental evidence is against it. (3) The occurrence of intra-uterine shortening is known. D'Arcy Power, "The Relationship between Wry-neck and Congenital Hematoma of Sterno-mastoid," Roy. Med. Chir. Soc. Trans. 1893. His conclusion was that sterno-mastoid haematoma is often followed by torticollis ; see also discussion thereon. Rushton Parker, B. Med. Journ. 1891, vol. ii. p. 1333. Quisling, Centralhlatt f. Gyniik. 3rd Jan. 1891. Royal Whitman, Trans. Amer. Orthop. Assoc, vol. iv. p. 292 — "Observations on Torticollis, with particular Reference to the Significance of the so-called Haematoma of the Sterno-mastoid Muscle." Whitman quotes the opinions of Busch, Volkmann, Stromeyer, Yolbert. He then gives the probable history of congenital torticollis, which consists in torsion of the head and neck, effusion of blood, " encapsulatory inflam- mation " at site of injurj^, then the hard painless tension of muscle, followed by indura- tion. The induration slowly disappears, and is replaced by fibrous tissue, which contracts and gives rise to permanent torticollis. Seven cases are given in which swelling was found after birth in the sterno-mastoid muscle. Nineteen months afterwards, the longest period to which the observations were carried, there was no torticollis. Of thirteen cases, nine were breech presentations and delivered by version, two by forceps, and in two there was no history of interference. Among the fallacies as to hematoma, AVhitman adds that the muscle is shortened in utero, thus presenting a deformity with which induration is a coincidence and not a cause, and refers to such a case reported by Bruns at the Congress of German Surgeons 1891. H. H. Glutton, St. Thomas's Hosp. Rep. vol. xvii. 1888, on "Congenital Sterno- mastoid Tumour or Induration." Eighteen cases are given. In none was there a history of syphilis. Eight cases were breech presentations, two were cases of turning, eight were vertex, and forceps were used in three. In two cases of the eighteen, wry- neck occurred. Cf. also Taylor, Path. Soc. Trcms. vol. xxvi. 1875. H. Arnott, St. Thomas's Hosp. Rep. 1874, vol. v. p. 276. Parker, Brit. Mecl. Journ. 1881, vol. i. p. 515. Golding- Bird, Guy's Hosp. Rep. vol. xlvii. pp. 253-273. 188 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii In illustration of my remarks, the following notes of cases which have come under my observation are given : — Case 34. Congenital Tor- tkollU uifhonf History of Sivellinf/ in Muscle offer Birth. — Ida H , aged 5 years, was brought to me at the National Orthopaedic Hos- pital. For the last two years the mother had noticed that the head Avas drooping over to the right shoulder. The labour was a long and tedious one, and instruments Avere used, but no swelling was noticed after birth. There was no history of syphilis. The appearance presented by the child is seen in Fig. 82, which illus- trates the deviation of the head and the contraction of the sternal part of the right Fig. 82.— Congenital torticollis. Case .34 before opera- Sterno- mastoid. The child tiou. Slight atrophy of right side of face, was operated on by the open method, and the result was successful (see "^ Fig. 83). I \ Case 35. Torti- collis with History of Swelling in Sterno-mas- toul after Birth. — Khoda B , aged 3 years, came to me at the Evelina Hospital in September 1894. The birth was said to be " crossed " and the labour lasted two days, and the child was finally born by the breech ; no instru- ments were used. After birth one hour s_. i was spent in resus- f^'fjS^'- citating the child. Fig. 83.— Case 34 after operation. Fourteen days after y^ '■^^, *-<-'• TORTICOLLIS OR WRY-NECK 189 birth the mother noticed a "band and a himp " in the left sterno- mastoid. The child was taken to a hospital, and the mother was told that it would get Avell. The lump disappeared in nine weeks. The head was noticed to turn over in the second year, and since then has got worse, till it shows the present condition of deformity. The head was drawn down to the left shoulder, and the face was rotated to the opposite side. There was no history of syphilis. Case 36. Gumma of right Sterno-mastoid disappearing binder Treatment — James W , aged 5 weeks, was seen at the Evelina Hospital in April 1893. The mother has had one miscarriage before becoming pregnant with this child. The miscarriage occurred at the end of the third month. This child is the third. It was puny, ill-developed, of an earthy camplexion, and had snuffles, and a' papular and syphilitic rash. On the right side was a distinct localised thickening of the sterno- mastoid, about the .size of a halfpenny. It was firm and apparently painful. The muscle was decidedly tense, but there was no deviation of the head. The swelling in the muscle and the tension disap- peared under the ad- ministration of pulv. hydrargyri cum creta gr. J bis die, and up to December 1894 there was no sign of torticollis. Case 37. Congenital Syphilis, left Sterno-mastoid Induration, and Tmii- collis cured hy Mercurial Inunction. — Jane C , aged 6 weeks, was brought to me at the Evelina Hospital in November 1894. The child was puny, but at the time of birth was a fine large child. The labour was not lingering, but the child was born "feet first." Since birth the child has wasted considerably, and there is now a deep red multiform rash about the nates and vulva, extending doAvn the thighs as far as the knees. The left sterno-mastoid stood out in marked relief from the side of the neck, and was firm and tender. The head was drawn towards the left shoulder, the face was rotated to the right, and the chin raised. The left side of the face was less developed than the right. Under the administration of pulv. hydrargyri c. cret, and rubbing in of hydrargyri oleatis, 2h per cent, the induration of the muscle and torticollis disappeared in two months. Case 38. Left Torticollis, Breech Presentation, Syphilitic Eruption. — Emily A , 5 weeks, was seen by me at the Evelina Hospital 1st December Fig. 84. — Congeuital torticollis to the left (Case 38). 190 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii 1894. She was the third child ; the others were quite healthy, and there have been no signs of syphilitic trouble in them. The mother had one miscarriage nine years ago, but she states that she herself has always been healthy. This child was born feet first after a difficult labour. Present condition. — The left sterno-mastoid is firmer and more tense than its fellow, and stands out in relief. Both its heads are implicated. There is asymmetry of the face, and the left side is distinctly smaller than the right. The head is drawn down to the left shoulder, and the face is rotated to the opposite side (Fig. 84). In the clavicular head of the sterno-mastoid a distinct hard nodule is to be felt. There is a multiform rash on the gluteal region. The child was given grey powder, as the rash appeared to be syphilitic. On 5th January the rash was seen to be undoubtedly syphilitic. Unfortunately I lost sight of this case. Case 39. Indurated Mass in the right Sterno-mastoid, tvith no Contraction of the Muscle. — Joseph D , aged 3 weeks, came to me on 13th July 1895. The head was born first. The nurse had to bring the head through by traction, but no forceps Avere used. It was quite clear to the mother that the child was not born with a lump in the muscle ; she first noticed it when the child was a fortnight old. About the legs and thighs there were some maculae and papules which were suggestive of syphilis, but no confirmation in the history or after-symptoms Avas forthcoming. The right sterno-mastoid was occupied in two-thirds of its extent by a hard olive-shaped mass, which was not tender, and the skin over it Avas of normal colour. The head could be moved freely in all directions. On 27th Jul}' it Avas noticed that the lump Avas smaller, and there A\-as some redness. The case finally did perfectly well, no torticollis appearing subsequently. Case 40. Indurated Mass in right Sterno-mastoid {1 suphilitic), and no Con- traction of the Muscle.— 'Sidney T , 7 Aveeks. The mother states that she has had tAvo miscarriages, one at the fifth month and one at the sixth Aveek. This child had snuffles at birth, and noAv has a feAv papules on the legs and arms and in the gluteal region. The child Avas born by the breech. In the right sterno-mastoid about its centre there Avas a hard indurated mass, Avhich AA^as not tender. The child AA^as given grey poAvder, and the lump became gradually smaller until it finally disappeared. Case 41. Mass in right Sterno-mastoid, Torticollis, Facial Hemiairophy. — Lilian M , 9 AA-eeks. The patient Avas the second child. The mother had been married previously, and there Avas a child by another father. The mother states that she has alAA^ays had good health and has had no miscarriages. The history of the child AA^as as folloAA-s : — The birth Avas by breech presentation, and the labour was hard but short. The child had a rash on the face and in the mouth fourteen days after birth. It con- sisted of red spots, Avhich Avent "right through her and appeared about the loAver parts." The rash lasted for three days, and appears to have been " thrush." The right sterno-mastoid AA^as occupied by a hard irreg- ular mass in the upper tAvo-thirds of its extent. The muscle Avas tense, the head Avas approximated to the shoulder, and the face was rotated to the opposite side. The right side of the face and head Avere distinctly smaller TORTICOLLIS OR WRY-NECK 191 than the left. No treatment was ordered. The child was seen on Sth January 1896, and the swelling had then increased. It was more lobu- lated. Subsequently the patient was admitted to the Westminster Hospital, and I divided the sterno-mastoid by the open method, at the same time removing a small portion of the indurated mass for micro- scopical examination. This showed a great excess of fibrous tissue between the muscle fibres, mRuy of which were broken off short and embedded in cicatricial tissue. There was no excess of small round cells present. The case ultimately did well. To sum up, then, the etiology of wry-neck In my belief, a shortening takes place in the muscle before birth, due either to Fig. 85. — "Ocular" torticollis from astigmatism (after Redard). Fig. 86. — Posterior view of the same patient as in Fig. 85. malposition or congenital syphilis. The labour is lingering and the presentation is often " breech," or vertex requiring forceps ; one case of wry-neck of mine presented a cephalhEematoma as well. Traction may rupture or cause haemorrhage into the substance of the shortened muscle, and shortening follows. Spasmodic torticollis arises from many causes. The spasm is either tonic or clonic, or both kinds may be present. Frequently the spasm is chiefly on one side ; in some cases it is equal on both sides, and when affecting the deep cervical muscles posteriorly is called retrocoUic spasm. The causes are reflex irritation from enlarged glands, carious teeth, otorrhcea ; excessive use of the 192 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii muscles, as in " ocular torticollis " arising from astigmatism ^ (Figs. So and 86); and frequently repeated movements of the head, as in the case reported by Annandale - of a girl, aged 24, a weaver, who was obliged to move her head rapidly first to one side and then to the other, but especially to the left, and in her the spasm developed on the left side. Neurotic parentage, epilepsy, or facial spasm is met with sometimes in the families of those suffering from spasmodic wry-neck. A fall or blow, " habit spasm " (Gowers), malarial poison, are all indicated as causes ; and sometimes it occurs in hysterical subjects, at others in perfectly healthy people. Pathological Anatomy. — In congenital wry-neck Volkmann and Volbert found that in some cases no change was apparent in the muscles ; in others the muscular substance had disappeared, and was replaced by fibrous tissue ; while in a third variety there was fatty degeneration in the muscles, running through them in distinct bands. It is said that similar changes are found in cases of ac- quired torticollis, but this is denied by the best authorities. In the discussion at the Eoyal Medical and Chirurgical Society,^ which succeeded Mr. D'Arcy Power's paper, " Mr. Thomas Smith pointed out that in other parts of the body rupture of a muscle vras followed by lengthening rather than shortening, and he confessed his inability to understand how the retraction and cicatricial changes about the ruptured ends of the muscle fibres in the neck could shorten the muscle to less than its original length. Mr. E. W. Parker stated that in one case of congenital tumour of the sterno-mastoid at the Shadwell Hospital, in an infant 5 weeks old, he cut into one of these swellings and found nothing resembling blood. Mr. W. G. Spencer also referred to a case he had seen operated on by Volk- mann of Halle, in which a hard tumour was dissected from the sterno-mastoid of a girl of 20 years of age, the subject of severe wry-neck. The anterior and posterior layers of the muscle-sheath had been converted into hard masses ^ inch thick, with muscular fibres in the centre, while the general structure of the tumour was ordinary scar-tissue ; the muscle fibre was healthy, and the strain of the injury appeared to have fallen upon the sheath before and behind." But a review of those cases in which inspections have been made are not entirely favourable to the theory of rupture ^ Cf. cases reported by Bradford, Trans. Amcr. Ortli. Assoc, vol. i. p. 46 ; Lovett, ibid. vol. ii. p. 230 ; G. T. Stevens, Archiv f. Ophthalmol. 1887. - Lancet, 1879, vol. i. p. 555. » 24th Jan. 1893. TORTICOLLIS OR WRY-NECK 193 of the muscle fibre.^ It is stated that the sternal head of the sterno- mastoid is more often affected than the clavicular, but occasionally both are shortened, although the outer part of the muscle is less so than the inner. With the deviation of the head, there are also contractions of the fascife and alterations in the cervical spine. The intervertebral discs in old-standing cases are wedge-shaped, the bodies are ankylosed, the anterior common ligament has almost disap- peared, and osteophytes are thrown out.^ These changes result in lateral curvature in the cervical, with secondary curves in the dorsal ^^^• region.^ Witzel has observed asym- metry in the length of the clavicles. In long-standing cases the platysma, splenius, and scaleni are secondarily shortened, owing to the malposition of the head. The asymmetry of the face (Fig. 88), due to delayed development on the affected side, is very noticeable in many cases. On the side of the contraction the line joining the external angular process of the frontal bone with the angle of the mouth is less than on the other side. It may be as much as ^ inch. The nose is also deviated from the sound side, and the cheek is less developed. These changes are 87. — Torticollis of medium severity (after Redard). Fig. 88. — Very severe congenital torticollis in a young child. The asymmetry of the face is well seen present more often on the right side. (after Redard). ^ ^ ^ Liining and Schulthess have published the details of a very interesting post-mortem examination. The case was an infant of 5 months, delivered by the forceps, which showed at the time of birth a swelling at the middle part of the right sterno-mastoid. This was then shortened to the extent of § inch. The cleido-mastoid portion of the muscle was entirely fibrous, with a separate insertion to the mastoid process. On the opposite side the two bundles of the muscles were fused together and the insertion normal. It was impossible in this case to admit contraction of the muscle secondary to traumatism. Zeitschr. f. Orth. CMr. 1891, Bd. i. Heft 1. ^ Lane, Guy's Hosp. Rep. vol. xliii.-p. 370. ^ Betctsche Zeitschr. f. CMr. Bd. xviii. Hefte 5 and 6, p. 335. 194 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii I have heard Mr. Adams say that he has not been able to satisfy himself as to the non-development of one side of the face. He thinks it is only apparent and due to the deviation of the line joining the eyebrows and the obliquity of the nose. By careful measurement with suitable calipers, it is easy to satisfy oneself that the measurement is distinctly less. The causes of the non-development have been variously assigned. Bouvier found in one case an unequal development of the carotids, those on the affected side being the smaller. Dubrueil ^ affirms that there is also nnequal development of the cerebral hemispheres, with asymmetry of the skull. It is possible that impeded blood supply may cause retarded development on one side, but the matter is still in the region of speculation. j\Ir. Golding Bird's opinion is that both the wry-neck and the asymmetry are due to central nerve-lesions. These, however, have not been demonstrated, and the diminution or disappearance of the asymmetry when the cases are operated on early is against this supposition. The pathology of the spasmodic form is obscure. Gowers says : " In no case has a lesion been found that can be regarded as an indication of the morbid process to which the spasm is due. The facts that many muscles are involved, and that when the spasm commences in a single muscle it usually spreads to others, make it probable that the muscular contractions depend on the over-action of the nerve cells, and not on any irritation of nerve fibres." In one case of mine at the Westminster Hospital the torticollis was undoubtedly due to the entanglement of the spinal accessory nerve in the scar-tissue, arising from the healing of suppurating cervical glands. I removed the scar-tissue and a portion of the spinal accessory nerve, and the deformity disappeared. Symptoms. — It will be convenient now to indicate the normal action of the muscles implicated in the various forms of torticollis. The sterno-mastoid inclines the head to the shoulder, rotates the face to the opposite side, and draws the chin forward and slightly elevates it. The trapezius, the highest part of it, rotates the head to the opposite side, draws it backward, and inclines it strongly to the shoulder. The splenitis inclines the head and slightly rotates the face to the opposite shoulder. The trapezii and splenii, acting together on both sides, carry the head backward. ^ :^Um^n.ts (VOrthopidie, 1882. CHAP. I TORTICOLLIS OR WRY-NECK 195 The complexus extends the head, and rotates it to the opposite side. The scaleni flex the head antero-posterioiiy and laterally. The combinations met with are — 1. The sterno-mastoid and trapezius of one side, if implicated, cause great inclination of the head to the same shoulder, and some rotation to the opposite side. 2. The sterno-mastoid of one side and the trapezius of the opposite side, acting in concert, cause much rotation of the head. 3. One sterno-mastoid and the opposite splenius cause extreme rotation of the head. Inasmuch as in wry-neck the head is never rotated to the side of the contracted muscles, it is assumed that the sterno-mastoid and splenius of the same side are not involved. 4. Both splenii acting together cause strong retraction of the head (retrocoUic spasm). In the case of an elderly lady, who consulted me, if the head were at all raised from the chest, such violent action of the splenii took place, and the head was jerked so forcibly backwards, that she felt in danger of suffocation. 5. The sterno-mastoid, trapezius, and complexus turn the head to the opposite side. 6. The scaleni, splenius, levator anguli scapulas, and platysma, if acting together, draw the head to the shoulder. Bearing these points in mind, and assisted by palpation, there will not be great difficulty in ascertaining in which muscles the affection is seated. The symptoms of the so-called acute wry-neck or stiff neck are sufficiently definite. The history of cold, of previous rheumatic attacks, the great tenderness and pain in the muscles, the rapid onset and the limitation of the stiffness mainly to the posterior muscles are characteristic points. Congenital Wry-Neck presents the following sym.j)toms : — In all stages the sterno-mastoid is primarily at fault. In slight conditions it is seen in relief, and felt to be somewhat hard and indurated. Some limitation of movement is present. In severer cases the rotation of the face and lateral flexion of the head are pronounced. The symptoms may be arranged thus : — 1. TJie Deformity. — The head is laterally flexed and the face is rotated ^ to the opposite side. The chin is raised and carried ^ Rotation is greater when the clavicular part of the sterno-mastoid is afifected. Generally the sternal part is the more rigid. 196 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES 8ec. ii forward, especially when an attempt is made to extend the head. The lobule of the ear is therefore inclined to the shoulder, and a vertical line drawn from the tip of the lobule falls just inside the middle of the clavicle, instead of well outside. The shoulder of tlie affected side is raised, owing to the retraction of the sterno-mastoid, and later of otlier muscles, viz. the trapezius and levator anguli scapuliie. The clavicle is more curved. 2. On palpation, the affected muscles are hard, but not painful, and stand in relief. 3. Limitation of movement in advanced cases is great, and pain is caused by attempts to rectify the malposition. 4. Asj/mmdry of tlic Face. — The eyes are not on a level, nor Fid. 89. — Congenital torticollis, showing- asymmetry of the face (Florence A , aged 3 years and 10 months. National Ortliopsedic Hospital). > Fig. 90. — The same case as in Fis after treatment. 89 are the angles of the mouth ; the cheek of the affected side is less prominent, the nose appears smaller than normal, and it is oblique in direction and deviates to the affected side. The measurement from the external angular process of the frontal bone to the angle of the mouth is less on the affected side (Figs. 88 and 89). When the asymmetry of the face is slight, it is more readily observable on looking at the image of the patient's face in a mirror (Golding Bird). The cranium is said, on the authority of Dubreuil,^ to be asymmetrical, and I have seen it so.'' It takes the form of an oblique oval. The parietal eminence is more prominent and the frontal eminence less prominent on the affected side. 5. Cervico-dorsal scoliosis is present in advanced cases, the Gaz Hebd. des Sci. Med. do Montpcllicr - As in Case 41. 1886. CHAP. I TORTICOLLIS OR WRY-NECK 197 convexity of the curve being on the unaffected side. A compensa- tory curve is often present in the dorsal region. 6. In severe cases deglutition is interfered with. 7. Strabismus does not often result from the deformity, as com- pensation is effected in the cervico-dorsal spine. Astigmatism, however, is a cause of torticollis. 8. The surface temperature is lower on the affected side to the extent of two to six tenths of a degree centigrade. This observation was first made by Broca, and has been repeatedly confirmed by Eedard.-^ Spasmodic Wry-Neck, — The symptoins appear in the following order : first spasm, secondly pain. Spasm is gradual in its onset and intermittent in character, at one time greater, at another less, but in many cases increasing. It may remit at times and even cease, but only to reappear with increased force weeks or months later. It is greater when the patient is walking or excited, and ceases during rest. The pain is dull and aching, and when the spasm is most marked it is shooting or cramp-like. The muscles which are affected never waste nor show signs of degeneration. In fact they are, if anything, hypertrophied. The position varies according to the muscles affected, and a glance at the description of the physiological action of single muscles and of muscles in combination will serve, with palpation, to identify them. In the more superficial muscles a distinct hardening can be felt. Sometimes one muscle only is affected. Then it is in nearly all cases the sterno-mastoid, and rotation is a prominent feature. If the muscles on both sides are involved, the head is over-extended (retrocollic spasm). The muscles usually associated after a time with the sterno-mastoid are the trapezius of the same side in its upper part, the platysma myoides, and more rarely the splenius of the opposite side, or the scaleni, levator anguli scapulae, and complexus of the same side. When both splenii are affected the retrocollic spasm is extreme. The points of diagnosis in spasmodic torticollis are : — 1. The affection more often begins on the right side. 2, The sterno-mastoid is the first muscle to take on a spastic contraction, and thence the contraction extends to the deeper and posterior muscles of the same side and later to the opposite side, and even to the muscles of the face and arm. ^ Op. sup. cit. p. 182. 198 DEFORMITIES OF IfECK, CHEST, AXD UPPEE EXTREMITIES sec. ii 3. Paius of various kiuds are present. 4. The spasm may be tonic or clonic in character, and generally gets worse. 5. No wasting of the muscles is present. 6. No asymmetry of the face is developed. 7. Division of the sterno-mastoid is futile as a mode of treatment. 8. It very rarely, if ever, affects children. The irrognosis may be thus summed up. Some cases of spasmodic wry-neck increase up to a certain point, and then remain stationary. Slight contraction may never go beyond this point. Earely the spasmodic form disappears spontaneously. In the congenital form, cure can be effected in the early stage, and the facial asymmetry disappears ; in later stages much improvement can be obtained. The diagnosis is not difficult in any case. The only source of error is cervical caries. The fixation of the head in every direction, the impossibility of moving it at all without causing pain, the per- sistence of the pain, and the presence of thickening around the cervical vertebrae are reliable distinctions. There ought to be no difficulty in deciding whether the case is one of congenital or spas- modic wry-neck. The real difficulties lie in ascertaining the cause of the spasmodic form, and sometimes which muscles are at fault. The Treatment. — In deciding the lines on which treatment is to be placed, it is of course necessary to be fully acquainted with the cause, e.g. the acute or rheumatic form, and wry-neck arising from irritation of enlarged glands, and abscesses, which soon subside when the cause is removed. Fortunately, too, in that form in which there is most induration and fibroid change in the muscles, namely, the con- genital wry-neck, we have in tenotomy a simple and very effective mode of cure. Acute or rheumatic torticollis readily yields to hot fomentations, sprinkled with tincture of opium to relieve the pain, or the applica- tion of linimentum iodi or emplastrum cantharidis, together with the internal administration of sodii salicylat. gr. xv. every four hours for a day or two, and of a brisk purge. Eest of the parts is ensured by the attendant pain. The treaiment of congenital icry-neck is either manipulative, mechanical, or operative. But before commencing it is advisable to ascertain if astigmatism exist ; if so, it must be properly corrected. If in young children congenital syphilis is present, mercury should be given in the form of pulv. hydrarg. cum creta gr. ^ to ^ thrice daily, and a 2^ per cent strength of hydrargyri oleatis rubbed PLATE III, M X~, |« From a photograph of a ease of congenital torticollis uiuler the care of Mr. K. W. Murray of Liverpool, who has kindly allowed me to reproduce this and Plate IV. PLATE IV. ^1 ''■r'M The same patient as in Plate III. after treatment by Mr. Murray. CHAP. I TORTICOLLIS OR WRY-NECK 199 over the tense muscle. The case of Jane C , ISTo. 3 7, quoted on p. 189, is a successful instance of the relief of sterno-mastoid indura- tion and slight wry-neck by these means. ManiiDulatife. — In young infants with slight deformity, the mother should be told to flex the head to the opposite shoulder and turn the chin to the same side several times daily, at the same time rubbing the skin over the affected muscle with some simple ointment such as lanolin, which prevents excoriation. These means will often serve to arrest an incipient wry-neck. As the child grows, a leather or poroplastic collar (Fig. 91) may be worn, to prevent any return of the deformity. Meclianical. — In view of the fact that in section of the sterno-mastoid there exists such a simple and efficient means of cure, the use of complicated apparatus alone is , , , - 1 -c Fig. 91.— Cervical collar for iise much to be deprecated. It very rarely, if iu the after-treatment of con- ever, gives good results. g™ital torticollis, it is also ° . , . . , 1 • 1 1 °^ value in the treatment of Operative. Ihe principles which should cervical caries, when the occi- giiide us in undertaking operative measures p^*^^ head -piece can be dis- ° o J. pensed with. are : — 1. To completely divide the tendinous and fascial bands which prevent the restitution of the head. The method of " open section " has realised to a great extent the possibility of accomplishing these results. 2. After tenotomy to maintain the improved position by means of a simple apparatus, and such as does not interfere with daily manipulations. 3. The after-treatment must permit at the same time effective treatment of the de^dations of the cervical vertebrae. It must be admitted that tenotomy is not always followed by complete reduction of the deformity. This is especially apt to be so when the posterior cervical muscles are adaptively shortened and osseous, or fixed changes have taken place in the cervical vertebra. It is stated that the best age to operate in torticollis is from 4 to 8 years of age. I should not, however, wait till so late, if the torticollis refused to yield to simple manipulation. Then the sooner tenotomy is done the better. A short review of the anatomy of the parts will be of service in considering the merits of subcutaneous tenotomy of the sterno- mastoid and " open section." Division of the sterno-mastoid is 200 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii usually done just above its insertion into the sternum and clavicle. Immediately behind the sternal head is the anterior jugular vein, arching outwards to join the external jugular vein. At the outer border of the clavicular head is the external jugular vein, which receives the suprascapular vein, transversalis colli vein, and a branch from the cephalic vein. The external jugular vein passes into the subclavian. In the triangular space between the two heads of in- sertion of the muscle there is a small branch of the suprascapular artery which is of no surgical importance. A knife introduced into the triangular intersj)ace between the heads and slanting inwards, would wound the common carotid artery, and, slanting outwards, the internal jugular vein.^ Behind the sterno-mastoid is externally a wall of deep cervical fascia, which separates the muscle from the great veins of the neck and marks off the site of operation from the deep cervical and mediastinal spaces ; internally a layer of muscle, composed of the sterno-hyoid and omo-hyoid muscle and portions of the deep cervical fascia, limits the site of operation from the same dangerous regions in the neck and thorax. Suhcutaneoiis Section of the Sterno-mastoid. — Occasionally this has been done in the middle part of the muscle, but on account of the close proximity of the carotid sheath, it ought not to be attempted at this spot. The writer once did it in this place, but felt so impressed by his happy escape from trouble that he is not disposed to tempt fortune again. The muscle is divided generally at the lower end. In some instances it appears necessary to divide the sternal head alone, as it is so very prominent, but experience teaches that when the sternal head has been divided the partial relaxation thereby produced merely serves to demonstrate that some of the malposition is due to the tension of the clavicular head. In most cases it is therefore necessary to divide both at one sitting to secure a good result. The inferior attachment of the sterno-mastoid may be divided subcutaneously in the following manner : — The parts and instru- ments are duly asepticised, the operator stands on the right side in either case. If the right muscle be affected, he enters his knife from the outside, if on the left, from the inside, taking care in either case not to wound the external jugular vein. Some surgeons make ^ A case is recorded of wounding of the internal jugular vein during the open incision. The vein was tied and the patient made a good recovery. Bradford and Lovett, o^). cit. p. 707. CHAP. I TORTICOLLIS OR AVRY-XECK 201 the incision tlirough the skin witli a sharp tenotome, and then pass a blunt tenotome inwards. The tendon may be divided by cutting on to it, or by passing the tenotome beneath the muscle and cutting towards the skin. The former plan is likely to lead one into diffi- culties by wounding the anterior jugular vein, and the latter, by transfixing the muscle, often leaves some fibres imcut, thereby necessitating a further operation. At the moment of section and when the edge of the tenotomy knife is turned towards the skin, the assistant, having previously relaxed the muscle, now makes it tense by carrying the head towards the opposite shoulder and rotating the face to the same side. The muscle is then carefully divided by saw-like movements of the tenotome. This is withdrawn and the puncture is closed by a piece of gauze soaked in collodion or strapped on with adhesive plaster. The exact site of diAdsion should be ^ to 1 inch above the clavicle. It is advised that the skin be drawn downwards over the clavicle, and transfixed there. The skin with the knife in it is then allowed to glide up over the clavicle, so that the site of section of the muscle is at the distance mentioned above the clavicle. The drawing downwards of the skin over the clavicle can only be necessary when section is made from the posterior margin, in order to avoid the external jugular vein. I have not, however, found it necessary, nor is it required in making the incision for ligation of the third part of the subclavian artery. It smacks of surgical " fetish." The old practice was to return the head to the position of deformity for four to five days, and then slowly commence the necessary extension. "With this procedure, extended experience of the open method forces me to disagree. The "Open" Method of Section of the Sterno -mastoid. — Careful antiseptic precautions are necessary in all particulars. The sterno- mastoid is placed on the stretch by the assistant ; an incision is made across its lower attachment, the inner and outer borders of the muscle carefully defined, a director is passed beneath it, and the muscle divided from within outwards. It may equally well be divided by careful movements from without inwards. If any strong and tense bands of fascia are seen, they are severed at the same time. The haemorrhage, which is generally slight, is then stopped, the wound dried, and the edges of the skin incision united by care- ful suturing. The head is then placed at once into the corrected position, and fixed either by a plaster of Paris arrangement or by strapping and bandages. 202 DEFORMITIES OF XECK, CHEST, AXD UPFER EXTREMITIES .xec. ii The advantages and disadvantages of the two methods are as follows : — The advantages of the subcutaneous method are: (1) practi- cally little or no scar is left ; (2) there is less danger of suppuration. Its disadvantages are : ( 1 ) it is often insufficient, as after section of the sternal head the clavicular head and bands of fascia come into prominence, and require more extensive and precise division. It can only be of value when the sternal head is small, well-defined, and can be isolated by the finger. (2) There is distinct danger of wounding the external jugular vein or its connections, with the possibility of entrance of air into veins. (3) On account of the fear of wounding the deeper structures the tendon may be transfixed, and the operation rendered useless. In the old septic days an open incision was, for obvious reasons, avoided. The advantages of the open method are: (1) every step of the operation is seen and abnormal vessels are avoided; (2) complete division not only of the sterno-mastoid, but of tense fascial bands is possible, and the after-treatment is thereby shortened. Its only disadvantage is the resulting scar, but this will be very slight, and after the lapse of years quite unnoticeable if aseptic precautions are observed and the skin sutures carefully adjusted. For my part, I greatly prefer the open method for the patient's safety and my own comfort. To avoid scarring of the lower part of the neck in girls, it has been proposed to divide the muscle at its masto-occipital attachment.^ The incision begins in the skin at the lobule of the ear, coasts close round behind the auricle, and follows the upper limit of the attachment of the sterno-mastoid beneath the hair. Section of the sterno-mastoid by the open method is a very satisfactory operation, and gives good results, but it is necessarily limited in its application. It will not entirely reduce the deformity if many other muscles are secondarily shortened, or when fixation of the spine is present. It has been proposed to remedy the shortening of the posterior cervical muscles, which are too deep and numerous to be tenotomised, by forcible manipulations of the head under an anaesthetic. Bradford and Lovett say : " In correcting this deformity the j)atient should be thoroughly anaesthetised, and an assistant should firmly hold the shoulders, while the patient should be drawn up so that the head projects beyond the end of the operating table. The head should 1 Phelps, X. r. Med. Hec. 4th Aug. 1894, p. 146. TORTICOLLIS OR WRY-NECK 203 be held by the hands and rotated in all directions, considerable force being used." On the authority of these writers, we read that " the danger of fracturing the spine is in such cases of course so slight as to be disregarded, and the deformity can be over- corrected."^ After- Treatment. — The plan of treatment I have adopted, after first seeing it employed by Mr. Longworth Wainwright at the Evelina Hospital, is as follows. The wound is dressed, and the head is put into the over -corrected position. It is then fixed by the following arrangement of plaster of Paris. A piece of house- flannel is cut of such a shape as to cover the back down to the crests of the ilia, the posterior aspect and sides of the neck, and the vertex and side of the head, and reaching over the forehead to just above the supraorbital ridges. This is placed in moist plaster of Paris and quickly adjusted to the back, neck, and head in the over- corrected position, a flannel bandage having been pre- viously placed on the parts to be covered with the plaster. A strip of flannel of sufficient width, which has just been removed from the plaster of Paris, is then passed round the Fig. 92.-Sayre's arrangement for elastic . ^ n p traction after operation for congenital neck, thus ensuring a correct fit of torticollis. the first piece here, and further acting as a collar for the support of the head in its new position. While this is being done an assistant passes an ordinary roller bandage round the chest and abdomen, to keep the large piece of flannel in position, and to adjust it accurately. The whole is left un- disturbed for ten to fourteen days, and the patient is then sent out with a plaster of Paris collar. It is w^ell to divide this anteriorly, and to lace it so that it may be taken off, and daily movements of active and passive manipulation practised. Tlie collar should be worn for four to six months. A more comfortable form of collar is one made of leather or poroplastic material (Fig. 91), and taking its bearings from the thorax and shoulders. In place of plaster of Paris, silicate bandages are used. ^ This is the method advocated also by Lorenz, Wiener Med. Presse, 19th Feb. 1893. He reports twelve cases treated in this way, and all have been completely cured: 204 DEFORMITIES OF KECK, CHEST, AND UPPER EXTREMITIES sec. ii Levrat ^ employs the following method after open section : " The head being enveloped in cotton wool, a silicated bandage is wound horizontally around it at the level of the forehead, and a similar bandage vertically over the crown and under the jaw. Where these bandages meet at the level of the mastoid process on the sound side, a small hook with the concavity looking upwards is inserted. Another silicated bandage is wound round the body below the axillre, and through the thickness of the bandage a hook is inserted in the middle line in front, having its concavity looking downwards. When the bandages have dried, the two hooks are connected by a band of rubber, which assists the sterno- mastoid of the sound side to keep up a continuous traction, and so correct the deformity. The apparatus and dressing are left untouched for fifteen days." Patients who are old and intelligent enough to assist in their own cure, may be treated after Mr. Owen's plan on the following lines : " Open section is performed, and sand -bags afterwards placed on either side of the head to keep it in good position. As soon as the wound is healed, and the patient can get up, he is directed to walk about with a bag of shot in the hand of the contracted side, and told to carry his head to the opposite side many times a day, practising in front of a mirror. At night he is advised to sleep on the affected side, with the head raised on the pillow. In addition, passive manipula- tion is of great value, the movements always aiming at the widest possible separation between the mastoid process and the affected side." By these means both the sterno- mastoid and the other shortened structures are stretched in a way that appears to me safer than the forcible plan combined with the tenotomy, which is recommended by Lorenz, Bradford and Lovett. The less forcible measures suffice to restore the neck to its proper line, unless the operation has been delayed to an advanced age, i.e. twenty years and upwards, and even in these a great improvement may be effected. As mentioned above, the asymmetry of the face cannot be remedied although it may disappear, and the later the operation is performed, the more marked is the facial deformity which persists. Those who prefer the more gradual methods of instrumental correction will find Mr. Adams' wry-neck apparatus of service (Fig. 93). It is complicated and expensive, but it is exact, and can be so made that a spinal instrument with spring plate and laced shield may be fitted to correct any lateral curvature. 1 Lancet 24th Nov. 1888. TORTICOLLIS OK AVEY-XECK 205 TJie Treatment of S'pasmodAc Wry-Xecl:. Non-operative. — In some instances complete mental and physical rest will be followed by subsidence of the spasm, and the pain may be relieved by hot applications or blisters. In other instances nerve tonics such as valerianate of zinc or asafcetida are useful. Sedatives, as succus conii, chloral hydrate, bromide of potassium, give relief. The best of all is subcutaneous injection of morphia, but the evident danger of contracting the morphia habit should militate strongly against its use. Occasion- ally with one or other of these means the spasms will subside. A weak constant current often relaxes the spasm, and if there is much pain from the distorted position of the head a rigid support may be ordered. Operative. — Myotomy of the affected muscles is found to be useless. There remain then stretching, di\dsion, resection or ligation of the spinal accessory nerve, with or without resection of the posterior divisions of the cer\'ical nerves. Operative interference is called for — 1. When treatment by drugs, galvanism, and stipjDorts has failed. 2. When the spasm is increasmg. 3. When it is such as to prevent the patient from attending to his business. 4. If there is much dithculty in deglutition. Eesection of the posterior divisions of the cervical nerves is called for when retrocollic spasm is present and division of the spinal accessory fails to reheve it. Stretchiug of the spinal accessory nerve does not appear in the few cases in which it has been done to have been followed by sticcessful results, and the same remark applies to division of the nerve. Mayo Collier claims to have obtained sttccess by ligation of the nerve.^ Excision of a portion of the spinal accessory nerve is that opera- tion which has given the best restilts. The nerve may be resected Fig. 93. — Mr. Adams' ^tt- neck apparatus. ^ For a resiirae of the literature of this subject up to 1891 a hrochure by Xoble Smith may be consulted — S'pusmodic Wry-necJ: : Elder and Co. Since then the foUoTving papers have appeared : — ■ Petit, Fievv.e cV Ortliopedie, July 1S91. An analysis of 26 cases operated on by the 206 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii at the anterior or the posterior border of the sterno- mastoid. Although the operation is more difficult at the anterior border, yet it is preferable to do it there, since it is at that spot a single nerve- trunk, and has not broken up into its divisions, nor can it be con- founded with other nerves. At the posterior border other nerves issue, viz. the small occipital, posterior auricular and superficial cervical. The steps of the operation are as follows : — The patient lying with the head turned to the opposite side and the parts having been shaved and rendered aseptic, an incision 3 inches in length, commencing at the tip of the .mastoid process, is made along the anterior border of the sterno-mastoid. If the external jugular vein comes in the way, it should be divided and tied. The anterior border of the sterno-mastoid is defined and drawn backwards. With a little dissection the posterior belly of the digastric muscle and the occipital artery come into view. These, together with the prominent internal jugular vein, serve as guides to the nerve, which runs vertically and enters the muscle one inch below the tip of the mastoid process. From a quarter to half an inch of the nerve should be excised. If the nerve is divided at the posterior border of the sterno- mastoid, it can be found almost at the middle point of that border. It is traced forward in the substance of the muscle until it is seen to divide into its branches for the sterno-mastoid and trapezius. About half an inch of the nerve is excised in front of that spot. Immediately the nerve is resected the sterno-mastoid and trapezius are paralysed; but the head does not become straight at once, owing to the shortening which has taken place in other muscles. It is necessary to use an artificial muscle on the lines laid down on p. 204, and to resort to passive movements of the head daily for a period of three to four months. Although successful in some cases, especially in those in which the spasm is tonic in its nature author. Excision of a portion of the nerve was followed by perfect success in 13, much improvement in 7, slight improvement in 2, temporary benefit in 3, and 1 died of phlegmonous erysipelas. Appleyard, "Spasmodic Wry-neck," Lancet, 18th June 1892; also E. Owen on the same subject, ibid. Pearce Gould, "A Case treated by Avulsion of the Spinal Accessory Nerve," ihid. ; Noble Smith, ihid. Keen, " A New Operation for Spasmodic Wry-neck. Division or Exsection of the Nerves supplying the posterior rotator Muscles of the Head," Annals Surg. vol. xiii. p. 44. Gardner and Giles, "Neurectomy in Spasmodic Torticollis and Retrocollic Spasm or Torticolis Posterieur," Australian Med. Journal, 1893. CHAP. I TORTICOLLIS OR AVRY-Is'ECK 207 and confined to the sterno-mastoid, yet resection fails to cure those cases in which retrocollic spasm is present. It then becomes necessary to divide the posterior branches of the cervical nerves. This operation appears to have been devised and carried out for the first time in 1888 by my friend Dr. Gardner, then of Adelaide and now of Melbourne, and to have been closely followed independently by Dr. Keen of Philadelphia in 1889. !N'oble Smith has operated successfully on three ' occasions in this manner. Keen^ gives full directions as to the mode of finding the nerves, but his description is characterised by Gardner^ as un- necessarily complicated. The resection of the spinal accessory nerve should precede by a considerable interval the difficult operation on the cervical nerves, because, firstly, the less operation has been known to be successful even in cases in which movements occurred in muscles not supplied by the spinal accessory nerve, and, secondly, the trapezius being completely paralysed after division of the spinal accessory, time is also given for a more complete study of the muscles involved in the spasm, and in this way unnecessary operations, with their risks and resulting scars, may be avoided. The paralysis which follows section of the sjDinal accessory and cervical nerves is of no moment. 1 Loc. siqj. cit. ^ This writer suggests the follo^ving points as of service : — (a) The incision should be made at a level of half an inch below the lobule of the ear, commencing at the middle line, and carried transversely outwards for 3 inches, and a small vertical incision let downwards between the edge of the trapezius and posterior border of the sterno-mastoid. (6) Define clearly the sub-occipital triangle. (c) The first nerve will be found crossing it ; the second will be seen outside the triangle below the inferior oblique, and the third an inch lower down the neck than that muscle. CHAPTEE II DEFORMITIES OF THE THORAX Congenital Deformities of the Chest, ajf'edincj the Sternum, Ribs, and Cartilages — Acquired Deformities arising from Bhachitis, Adenoids, and Spinal Distortions. The deformities of the thorax are either congenital or acquired. The Congenital Deformities are seldom seen. They consist of cleft sternum, absent sternum, or deficiency in the number of the ribs. A peculiar form of congenital deformity of the sternum is a funnel-shaped depression, situated not at the xiphoid cartilage, as in cobblers, but extending over nearly the whole sternum, and bounded by the ribs on either side, by the abdominal wall below, and the upper part of the sternum above (Fig. 94). This was described par- ticularly by Ebstein and Zucker- handl. The latter thought it to be due to the pressure of the Fig. 94.— Cougenital funnel-shaped deform- inferior nuixilla On the gladiolus ity of the chest (after Kedard). during foetal life. It is Said to be not only congenital but hereditary. Dr. I. S. Haynes ^ classifies the congenital deformities under the headings of deformities of the sternum, ribs, cartilages, and any one or all three parts may be involved. The deformity in the sternum consists of holes, varying in size from a pinhole to openings ^ inch in diameter. Less often the sternum is nearly or entirely cleft throughout its length. Examples of the latter condition are recorded by Dr. Thomas Sinclair^ and Dr. E. H. Martin.^ 1 Amcr. Med. Surg. Bull. 15th Nov. 1894, p. 1356. - Dublin Journ. Med. Science, 1887, p. 557. ■' N. Y. Med. Ilcc. 24th Sept. 1887. DEFORMITIES OF THE THORAX 209 Variation in the Bihs. — Abnormalities consist either of an additional cervical or lumbar rib, or of deficiencies of the ribs them- selves, or there may be fusion of two ribs, usually the first and second, to form the so-called bicipital rib. Variation in the Cartilages. — According to Otto,^ " the attachment of the front end of the ribs is deficient, inasmuch as they are either not connected with their cartilages or they are not connected by them to the breast-bone, or the carti- lages are entirely deficient.""^ The treatment of these cases of cleft sternum or extensive deficiency of the ribs and carti- lages should be to protect the important structures beneath, and at the same time to adjust an apparatus so that it serves to prevent the lateral curvature, which is apt to follow on in adult life. Acquired Deformities of the thorax follow two principal types : " pigeon-breast " and the excavated or depressed sternum, such as occurs in cobblers. The most common form is " pigeon-breast " arising from rickets. In a severe case of rickets the sternum is un- usually prominent, the ribs bend sharply at their angles, the costal ends of the ribs are beaded, the thorax is diminished in measurement from side to side and increased antero-poster- iorly if the decubitus is lateral, but the reverse if it is constantly dorsal. There may be seen three distinct grooves, two vertical, one being at the junction of the ribs and costal 1 Quoted by Bennett, Trans. Acad. Med. of Ireland, 1883, vol. i. p. 163. - Of. Osborne, Archives of Pcediatrics, vol. viii. p. 346. Fig. 91 — Congenital depression of the stenrum, from a patient aged 12 years. 210 DEFORMITIES OF XECK, CHEST, AXD UPPER EXTREMITIES sec. ii cartilages, and the other iu the mid - axillary line ; the third groove is oblique about the level of the ensiform cartilage. The latter is probably produced by the pull of the diaphragm in inspira- tion on the weakened ribs ; while the vertical grooves arise, the anterior from the sinking in of the ribs at that weak spot, the junc- tion of the bone and cartilage, and the lateral from the pressure of the arms on the softened ribs. The alteration in the shape of the chest is due to the external pressure on the chest walls. Rhachitis is frequently associated with spas- modic croup, and the chest deformity is noticeably worse after each attack. Sir "William Jenner has pointed out that /' Fig. 96. Front view of a ricketty chest. Fig. 97. — Semi-lateral view of the same chest as in Fig. 96. in rickets the aperture of the glottis is not sufficiently large to permit air to enter the thorax so rapidly as it expands by the action of the inspiratory muscles. Barlow,^ speaking of scurvy-rickets, states : " During the development of this disease the sternum, with the adjacent costal cartilage and a small portion of the contiguous ribs, seems to have sunk bodily back en Hoc, as though it had been subjected to some %'iolence which had fractured several ribs in front and driven them back. This curious appear- ^ Bradshaw Lecture, ''Infantile Scurvy and Rickets," Brit. Med. Journ. 10th Xov. 1894. CHAP. II DEFORMITIES OF THE THORAX 211 ance, taken in conjunction with the sub-periosteal and other haemor- rhages, is said to be diagnostic of the disease." Another form of " pigeon-breast " is that produced by obstruction to the ready entrance of air. The obstruction arises from adenoids, enlarged tonsils, nasal polypi, and chronic rhinitis. The ac- companying Figs, 98-101 are taken from cases of adenoids which have come under my notice at the Evelina Hospital. The characteristic deformity is well seen. The chest is bulg- ing at its upper and middle fjS-, ,.:,, ; m '-■J^ A-^"' SP<^* Fig. 98. — Front view of chest deformity due to adenoids of the naso-pharynx. Fig. 99.— Side view of the same. part, and retracted in its lower part and excavated. The sternum is not so keel-like as in rickets, and the lateral vertical grooves are absent. The antero -posterior diameter is increased, while the transverse is diminished. The origin of the deformity is, doubtless, the constant sucking in of the lower part of the chest. Unlike the pigeon-breast of rickets, this develops not in infancy, but in adolescents, and that slowly. The sequence of events, nasal and post-nasal obstruction, de- 212 DEFORMITIES OF NECK, CHEST, AXD UPPER EXTREMITIES szr. ii formed chest, kyphosis, and scoliosis, has been dwek upon ah'eady. The proof of their interdependence is in the results of treatment ; removal of the obstruction is followed by rapid improvement in the thoracic and spinal deformities. Other causes of an abnormal shape of the thorax are empyema, .; Fig. 100. — " Pigeou - breast " arising from adeuoids (Sidney N , aged 11 j-ears, Evelina Hospital). Fig. 101. — An extreme condition of " pigeon - breast " due to naso-pharjni- geal obstruction. Pott's disease and scoliosis (p. 138), and certain occupations such as cobbling. The treatment of thoracic deformities consists in attacking the prime causes. Eicketty children require the special treatment for that disease, and later, if the chest remain ill developed, they should be encouraged to take full and deep inspirations many times a day, to exercise the arms, to run about freely in the open air, and the more they shout the better for their chests. To be taught to sing is perhaps the best indoor exercise. Pigeon -breast deformity arising from adeuoids is readily im- CHAP. II DEFORMITIES OF THE THORAX 213 proved or cured by their removal. In all cases of malformed chest the wearing of corsets is to be avoided, and no apparatus for pressing the sternum into position should be used. Ehachitic cases usually right themselves as the child increases in health and strength, and adenoid cases soon improve if attended to. Scoliotic and kyphotic cases of chest deformity are best let alone. CHAPTER III CONGENITAL DEFORMITIES OF THE HAND AND FINGERS CI uh- hand — Congenital Contraction of the Fingers — Supernumerary Fingers — Suppression of the Fingers — TFebbed Fingers — Hypertrophy of the Fingers — Congenital Lateral Deviation of the Fingers — Congenital Furroicing of the Limbs. Club-Haxd Sjnouyms — French, JIaiu bote ; German, KJumpliand. Definitimi. — A congenital deformity of the upper extremity in which the hand is unduly deflected from the forearm. Frequency. — Reeves states that at the Royal Orthopjedic Hospital about three cases of the deformity, generally associated with some other malformations, are seen annually. During the past five years, at the Xational Orthopiedic Hospital, at my out-patient clinic, I have met with four cases, one of which is figured below. Several instances have, I believe, come under the notice of my colleagues, but I do not think as many as three in a year. In his article on " Congenital Absence of the Radii," with which club-hand is usually associated, M'Curdy ^ quotes Kronig,' who re- marks : " There are forty-five recorded cases of congenital absence of the radius, and in twenty-one the defect was bilateral. In only two were the thumb and metacarpal bones well developed. In the great majority of cases the child was both premature and still-born, and seldom lived many weeks. Xearly always other defects were present in other parts of the body." Dr. M'Curdy writes : " Dr. L. H. Sayre ^ reports one case, and Dr. A. E. Taylor has given me a report of one case by letter." Rufus A. Collins^ records a case of club-hand and foot. Dr. Lewis Sayre describes the appearance and treatment of a ^ Annals of Surg. Jan. 1896, pp. 44-47. - Brit. Med. Journ. 10th March 1894. ^ Trans. Amer. Orth. Assoc, vol. vi. ; and X. Y. Med. Journ. vol. Iviii. No. 19. ■* Cliicago Clin. Hevicu; October 1S94. CHAP. Ill COXGEXITAL DEFOEMITIES OF HAND AND FINGERS 215 case in hi3 work on Ortho'pedic Surgery. Malgaigne describes three specimens which exist in the Musee Dupuytren. Compared therefore with club-foot, club-hand may be looked upon as rare. Forms of Cluh-Hand. — For so unusual a deformity the classifica- tion given is somewhat cumbrous. ' But as the forms of affection are many, some arrangement must be adopted. The hand may deviate either to the outer or inner border of the forearm, and be in a position of flexion or extension. Hence we have radial and ulnar club-hand, and palmar and dorsal club-hand. But it is not often that the deformity is so simple, and mixed deviations occur, so that radio-palmar, radio-dorsal, ulnar- palmar, and ulnar -dorsal are the forms met with. Morphologically the cases may be grouped thus : — 1. The skeleton is complete and well formed. Cases of the ulnar-palmar form belong to this class. The malformation consists in a modification of the relations of the articular surfaces, and in an abnormal inclination of them. 2. The skeleton is complete, but various deformities are found. The radius is often shortened and the carpal bones atrophied. This is the most usual variety. 3. The skeleton is incomplete and deformed varieties are generally of this group. There is frequently an absence of one or more bones of the carpus, metacarpus, or of one of the bones of the forearm. When the radius is absent the ulna is shortened, increased in size, much curved, and the lower epiphysis considerably altered. The carpal articulation is abnormal, and there exist in it numerous fibrous bands and tendons, which are not in any way related to the normal structures. Frequently other irregu- larities are present in the body, such as absence of certain groups of muscles, or vascular and nerve defects. Fig. 102.— Club-hand of the radio-palmar form, 's\ith partial absence of the radius and entire absence of the first metacarpal bone and thumb (after Eedard). The radio-palmar Case 42. Congenital Cluh-Eand of Radio-Palmar Variety. — E. J., male, aged 1 month, was brought to me at the National Orthopeedic Hospital in 1895. He was the second child, and, so far as can be ascertained, no deformities liave occurred in his relatives on either side of the family. The rio'ht hand and forearm were deformed. The malformation was 216 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii of the radial-palmar variety. The shaft of the radius was certainly absent, the upper epiphysis being felt, while some doubt existed as to presence of the lower, since the mass of bone felt in that situation might have been the enlarged lower end of the i;lna. The first metacarpal bone Avas absent, and the thumb hung by a loose band of tissue. The ulna was much curved (Fig. 10.3). In other respects the child was quite normal. By way of treatment, a malleable iron splint was placed on the ulnar border of the forearm, and the excessive curva- .^ ture was gradually reduced. Later it is pro- j j | /■ ^.' QnCr (A-^- Fig. 103. — Radio-palmar variety of club-hand, with partial absence of radius and complete supjiression of the first Jiietacarpal lione, illustrating Case 42 before treatment. Fig. 104.— Illustrating the condition in Case 42 after treatment (see text). posed to form a false joint between the base of the first phalanx of the tlmmb and the second metacarpal bone. Etiology. — With reference to this point, less evidence is forth- coming than in tlie case of congenital club-foot. Speculation may be hazarded that the deformity is due to malposition in utcro. It is not possible to understand how that, according to Guerin, a nerve lesion in utcro can be a direct cause of absence of the radius. Symptoms. — In the palmar cases the hand forms with the fore- arm a more or less acute angle, open anteriorly. The lower end CHAP. Ill CONGENITAL DEFORMITIES OF HAND AND FINGERS 217 of the radius is prominent posteriorly, and the carpus articulates with the anterior surface of the radius. There is generally some degree of mobiKty of the hand on the forearm. The electrical reactions of the muscles show them to be either partially paralysed or atrophied. The forearm is small and wasted, owing to the shrinkage of muscles and to the absence of the radius. Treatment. — The means Avhich are adopted to alleviate the deformity are passive movements, massage, the use of retentive apparatus, tenotomy, and operations on the bones. Passive movements and massage are of service only when the patient is very young. But they are valuable in that they prevent aggravation of the deformity by contraction of the tendons on the concave aspect of the wrist. Various apparatus have been devised with the objects of arresting increase of the malformation and to render the hand useful. But they are not very satisfactory, and the patient can use his hand in many cases to better purpose un- fettered by any contrivance. Tenotomy is advocated by Mr. Eeeves, and that writer is at considerable pains to indicate the tendons which should be cut in the various forms. Suffice it to say that those which interfere with the placing of the hand in a right line with the forearm should be divided. He gives hints as to the best means of avoiding important nerves and vessels in their altered relations. In any case, if tenotomy is performed, it should be carried out at the wrist and not at the fingers, for the reason that, if done in the latter position, loss of movement is likely to follow. That complete success can be attaii)ed in cases of acquirecl club-hand by division of the tendons of the wrist, has been shown elsewhere (p. 243). Operative Measures on the Bones. — Bardenheuer,^ in those cases in which the development is suppressed, replaces the defect, at least in its lower part, with bone, and claims to permanently correct tlie deformed position of the hand. The details of the operation are as follows : " By a longitudinal incision the distal end of the ulna and the carpus are exposed, and the former isolated from its attachments. The ulna is then split through its middle into a radial and ulnar section. These are separated by allowing the carpal bones to come up between them. By means of an ivory peg through each side, the ends are fixed to the carpus." A plaster bandage is put on and left for four weeks. This operation has been done by Bardenheuer ^ Quoted by Rincheval in his paper on the "Treatment of Congenital Bone Defects in the Forearm and Leg." An abstract appears in the Annals of Surcjery, February 1895. 218 DEFORMITIES OF XECK, CHEST, AXD UPPER EXTREMITIES sec. ii twice for congenital absence of the radii, in an 18 months old child and in a baby of 7 months. The results in both cases were good. The deformity was permanently corrected and the mobility of the hand was about normal. In one of the cases there was a very pronounced growth of the deformed extremity a year after the operation. Dr. Leroy M'Curdy/ finding Bardenheuer's operation impossible, on account of the shortening of the soft structures, which rendered futile any attempt to shift the end of the ulna across to the centre of the carpus, except by a virtual amputation of the arm, performed the following operation in the case of a female infant aged 5 months : " The ulna was severed at a point where the free end of the upper fragment could be brought to the semilunar bone. The case was of the palmar variety. An incision was made obliquely across the forearm, beginning upon the dorsum and passing upward and around to the flexor aspect, the object being to allow the structures to slide upon each other, and then be sutured in the corrected position, thus avoiding the gap that would otherwise be left after a cross section. The tendons on the radial side were tenotomised, the ulna divided at the point mentioned above, the semilunar connected and drilled, and after drilling the ulna, these bones were adjusted with silkworm gut. Considerable hemorrhage ensued, and several arteries required ligation. The arm was put up in plaster and the wound healed by first intention." Dr. M'Curdy gives figures illustrating his case before and after oper- ation, and the result appears to have been most successful. COXGEXITAL CoXinACTIOX OF FiXGERS This deformity is quite distinct from contraction of the palmar fascia, Dupuytren's contraction, and should not be confounded with it. In infants and children it occasionally happens that the little finger on botli hands is found to be flexed. Generally the affection is limited to the fifth finger, but at times the ring finger, and even all the fingers, are contracted. Three figures are here given showing congenital contraction of the little, little and ring fingers, and all the fingers (Figs. 105 to 108). They are taken, one from a case seen at the National Orthopjedic Hospital, one at the Evelina Hospital, and one from a private case. The affection in question is not only congenital, but is also hereditary. Still more, it is frequently ' Annals of Sxi.rgci~ij, January 1896. CHAP. Ill COXGEXITAL DEFORMITIES OF HAXD AXD FIXGERS 219 associated with congenital hammer-toe, and in that event the second toe is often affected in both feet. Some congenital con- traction of the little finger is not at all uncommon, and it is only when it increases that it comes under the notice of the suroreon. 11^ ^-0 £4^ ^ ' Fig. 105. — Congenital contraction of the little finger of the left hand in a girl aged 15 years. Fig. 106. — A similar deformity in the right hand in the same patient as in Fig. 105. According to Mr. Adams,^ congenital contraction is observed chiefly in girls, and my own observations agree with this. But this writer states that "no deviation is observed in the little finger at the period of birth." On this point it is permissible to differ from Mr. Adams. In the case which is shown in Fig. 110 the infant was 2 months old. Mr. Adams divides the affection into tlirec stages. In the first stage there are observable some flexion of the second and third phalanges of the little finger, and some inclination of these phalanges outwards towards the median line of the hand. Xo Contraction of tTie Fingers and Hariiraer-Toe, 2nd ed. Churchill, London, p. 96. 2-20 DEFORMITIES OF XECK, CHEST, AXD UPPER EXTREMITIES sec. ii contracted bauds of fasciae can be felt, nor is there any shortening of the skin on the pahnar aspect of the fingers. The Hexed phalanges can in many cases be restored by gentle manipulations, but they drop again as soon as the extending force is removed. In the second stage the flexion of the second and third phalanges is increased and permanent, and the first phalanx is hyper-extended. Any attempt to straighten the finger is resisted by the contracted skin and fascia, X \ \ /N S \\ T^ and by the shortened lateral ligaments of the articulations.^ This stage is reached about the seventh to the tenth year. In the third stage, not only is the deformity aggravated in the finger originally affected, but the remaining fingers begin to contract, although the palmar fascia is never involved as in Dupuytren's contraction. In the congenital form, according to Adams, a central longitudinal band of contracted fascia makes its appearance on the flexor aspect of the phalanges. This longi- tudinal band is not a thickening of the digital prolongations of the palmar fascia, which are situated more on the lateral aspect of the phalanges. Oc- casionally in the third stage the third phalanges are hyjDer- ex- tended instead of flexed. With reference to the etiology, but little is known beyond the facts that the affection is both congenital and hereditary. As to its pathology, the one account of a dissection which I have come across is that by Mr. C. B. Lockwood,'- who states that " tlie band in question consisted of a thickening of the digital fascia opposite 1 Mr. "William Anderson, iu his "Lectures on Contraction of the Fingers and Toes," Lancet, July 1891, expresses the opinion that the chief agent in causation is an in- sufficient growth of the lateral ligaments of the interphalangeal joints, their growth not heing pari passu with that of the bones. - Path. Soc. Trans. 1S86. Fi ;. 107. — Congenital contraction of the ring and little fingers in a boy aged 5 years. The palm is seen to be entirely free from contraction. CHAP. Ill CONGENITAL DEFORMITIES OF HAND AND FINGERS 221 the flexor aspect of the proximal interphalangeal joint. Except that it was thickened and shortened, the fascia was perfectly natural." Diagnosis. — 1. From Dupiiytren's contraction. The following table gives the distinctive points : — Congenital Contraction. Dupuytren's Contraction. Age of onset Infancy and childhood. Adult life. Sex . . More often female. More often male. Point of origin Fascia of fingers. Fascia of palm. Parts affected in fingers Central portion of pal- mar prolongation. Lateral portion of palmar prolongation. Position of phalanges . First is hyper-extended, second and third flexed. First and second flexed, third generally extended. 2. From acquired contractions of the fingers other than Dupuytren's. This is generally made clear by a history of injury, or of suppuration, or of some nerve lesion. Occasionally scars will be found about the forearms, wrists, and fingers. Treatment. — In the first stage it is sufficient to straighten the affected fingers by frequent passive movements, and to buckle a small malleable iron splint to the back of the hand and to the finger, so that the latter is retained in the extended position. The splint should be removed three times daily and the fingers passively exercised. As a rule, this treatment removes the slight deformity. But occasionally, even in infants, the contraction has advanced so far that passive movement fails to fully restore the position, and it is necessary then to divide the shortened bands of fascia. This was done by me in the following case : — Case 43. Congenital Contraction of Fingers, Operation, Cure. — Mrs. H consulted me in 1893 with reference to the condition of her child's hand. The abnormal condition of the fingers was noticed shortly after birth, and had increased since. The baby was 2 months old. 122 DEFORMITIES OF XECK, CHEST, AXD UPPER EXTREMITIES sec. ii The fourth and fifth fingers of the right hand were flexed at the first and second interphalangeal joints, and a distinct thickening of the Fig. 108. — Coutraction of the hand saiil to have existed from birth. / I '\jn4 Fig. 109.— Front view of the haud in Fig. 108 after section of all the riexor tendons at the A\Tist. Good movement of the lingers wa.s ob- tained. Fig. 110.— Conseuital contraction of the little finger in the right hand, and of the ring and Uttle fingers in the left hand (Case 43). lateral prolongations of the palmar fascia could be felt at the sides of the phalanges. A similar condition was seen in the little finger of the left hand, and the little toes in both feet were also contracted. The con- CHAP. Ill CONGENITAL DEFORMITIES OF HAND AND FINGERS 223 tracted bands of fascia in the hands were divided, and a malleable iron splint was applied. This was removed every night and the fingers were manipulated. The contraction was thus completely overcome (Fig. 112). In the second and third stages, the fascial bands which are seen and felt to be prominent should be divided and the finger put up in a small malleable iron splint in as full extension as possible. In performing this little operation, the fascia knife should be passed between the skin and the band ; and the latter should be cut transversely. At the same time it is well to turn the knife on to the flat and pass it for a short distance up and down between the skin and fascia, thus severing the fine processes which pass into the skin. As a rule about three punctures are required to each phalanx. Fig. 111. — A view of the left hand in Case 43 show- ing the hyjjer-extension of the first phalanges in congenital contraction of the fingers. n f) / h4-4 7 % \ f^x i \ { '\ J r\ Fig. 112. — The condition of the hands in Fig. 110 after treatment by operation and manipulation. Unfortunately these cases show a strong tendency to relapse, and it is well to warn the patient that after a finger has been straightened a long course of mechanical treatment will be to maintain the' improvement. For this necessary purpose an 224 DEFORMITIES OF NECK, CHEST, AXD UPPER EXTREMITIES .szc. ii apparatus similar to that used after operation for Dupuytreu's contraction may be worn day and night for three months in cases in the second stage, and at night for a further period of three months in cases in the third stage. ^ly colleague, ]Mr. ]\Iuirhead Little,^ has tried forcible extension in a case, but the affected finger showed a marked tendency to re-contract, wdiich he believed would be overcome by the use of a simple metal splint he had designed. In inveterate cases, and in people who obtain their living by Fic;. 113. — The feet iu Case 4-3. showing congenital contraction of the little toes, whicli existed with similar contractions of the fingers. manual labour, the propriety of amjjutating the offending digit may be discussed with the patient. Supernumerary Fingers. — Synonym — Polydactylism. This condition is often hereditary, and may be traced through several generations, and frequently exists both in toes and fingers. There are five varieties of polydactylism. 1. An additional finger is more or less developed, and is generally situated at the ulnar border of the hand, being attached to it by a narrow pedicle." 1 Intcrnat. Med. Mag. May 1S94, "Remarks on Congenital Contractions of the Fingers, and their Treatment by Forcible Extension." - Vide "A Remarkable Case of Polydactylism with Marked Hereditary History," Surgeon-Captain H. E. Drake-Brockmau, Brit. Med. Journ. 26th Nov. 1892, p. 1167. CHAP. Ill COXGEXITAL DEFORMITIES OF HAXD AXD FIXGERS 225 Fig. 114. 2. An additional thumb is more or less developed. It is free at its extremity, and articulates either with the head or the shaft of the metacarpal bone, or with one of the phalanges. Its articulation sometimes communicates with the metacarpo-phalangeal joint. 3. The supernumerary digit, more or less perfect, is closely united throughout its whole length with another digit. This condition is also seen more often in the thumb. 4. A completely developed extra digit is found, and possesses its own separate functions and tendons. In such cases it is evident that the extra power conferred on the hand is a greater advantage than the unsightliness of the deformity is the reverse. So that often no surgical intervention is necessary. 5. The bifurcated hand, which has eight Polydactylism (after Red.rd). fingers and no thumbs. Two cases are reported, one by Murray ^ and the other by Giraldes.- Treatment. — In the first variety, the additional digit should be removed early in life. In the second variety removal is indicated, but care must be taken in so doing to avoid sepsis, as the articulation of the extra / digit frequently communicates with the metacarpo-phalangeal articulation. White ^ records a case where a supernumerary thumb of this variety was twice removed, and each time reappeared in its original form. Even the nail was reproduced. As to the third variety, the propriety of operation is doubtful. If the deformity be removed, a large scar will be left, inas- much as the metacarpal bone must be taken away. In the fourth variety it is advisable not to interfere. Suppression of the Fingers. — These are of interest rather to the teratologist than to the practical surgeon. The fingers may be deficient either in number or in lenoth, owing to the absence of Fig. 11.5. The bifurcated or double hand. 1 2Ied.-CUr. Trans. 1865. ^ 3Ial. CMr. des Mufants, Paris, 1865. ■* " On the Regeneration of Animal Substances. Q 226 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii Fig. 116. — Diagram of the incision and flaps in operation. The dotted line shows the limits adjoining fingers. Didot's of the resource, artificial be pre- tlieir segments,^ or both these conditions may be present. It is not unusual to see rudimentary fingers at the extremity of a mal- developed arm. The forearm, wrist, and metacarpus are totally suppressed, and the rudimentary fingers articulate with the end of the humerus. In these cases but little can be done from a surgical point of view. If the hand is very unsightly or useless, amputation of it is the best and a good hand is to ferred. Webbed Fingers. — Synonym — Syndactylism. There are three varieties, (a) Two fingers, generally those on the inner side of the hand, are united by skin and fibrous tissue ; (b) union is by muscular as well as fibrous tissue and skin ; (c) the bones are fused throughout their entire length, or more often at the second and third phalanges only." Treatment. — In the third variety but little can be done, and the case is often best left alone. In the first and second varieties the chief difficulty after operating is to prevent some re- formation of the web, especially towards Fig. 117. the base of the new cleft. This diffi- culty is overcome in various ways. feet, by Ramsay Transverse section showing the mode of adjusting the flaps in Didot's ojieration. ^ Vide a case of hereditary malformation of the hands and Smith and Stewart Norwell, SriL Med. Journ. 7th July 1894, p. 8. 2 Dr. E. Goldman of Freiberg has published a paper of interest on the suliject of malformations of the hand in the Beitrdge fiir klin. Chirurgie, April 1891. Dr. Goldman says syndactylism may be rightly regarded as an arrest of development, since in certain stages of fcetal existence the fingers are bound together by webs of varying extent. The thumb almost always remains free ; and in most instances two fingers only, usually the third and fourth, are joined together. These facts can be at once explained by referring to what takes place in the development of the hand. As it is known that the thumb becomes detached from the lingers about the seventy-fifth day of foetal life, whilst the four fingers remain bound together for a longer time, it will be seen that the disturbing element must occur at the time when the thuml) has been separated. The subsequent separation of each finger does not take place simultaneously, but as follows, as is seen in the larvre of the triton and proteus. The forefinger, whilst distinct from CHAP. Ill CONGENITAL DEFORMITIES OF HAND AND FINGERS 227 1. The fommtion of a permanent opening at the bottom of the web by transfixing it with a sil^■er pin, or a piece of rubber, or vulcanite, and then division of the web from top to bottom, taking care to keep the raw surfaces apart. 2. Didot's operation. An incision is made along the palmar surface of one finger, and is joined at each end by short transverse cuts so as to form a flap. On the dorsum of the other finger a similar proceeding is carried out, except that the flap is in the opposite direction. The remaining tissues of the web are then divided, and the dorsal flap of one finger covers the palmar surface of the other (Figs. 116 and 117). Points to he observed during and after this operation : — {a) The two fingers are not of the same size, and the flaps should be cut accordingly. (b) The flaps must not be too broad, so as to leave no raw surfaces in ap- position. (c) The sutures must be accurately adjusted at the bottom of the new cleft, so as to leave no granulating surface. (yd) The cleft must be carefully watched to prevent formation of new adhesions. Lastly, the operation is not easy to perform satisfactorily on a small hand, and it should therefore be deferred till the child is six years of age. It is likely to be unsuccessful if the fingers are very closely joined. 3. Zeller's operation. Two incisions A and B are made on the dorsal aspect of the web and fingers meeting at C. They should extend from the metacarpo-phalangeal to the first interphalangeal joints. This triangular flap is reflected towards its base, and the web is divided from C to D. The flap A B C is then carried forward and fixed to the palmar surface and between the clefts, and so prevents contraction (Fig. 118). 4. Norton's -^ operation. Small rounded anterior and posterior flaps are made at the cleft, with their bases at the heads of the metacarpal bones. The web is divided and the flaps joined at Fig. 118. — Diagram of tke inci- sions and flaps in Zeller's operation. the thumb, sends off as a main branch the middle finger, from which the ring and little fingers are sent off as secondaiy branches. ^ Brit. Med. Journ. Aug. 1881. 228 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii their apices (Fig. 119). The following points should he attended to: — (a) The flaps should be thick, so that their vascular supply is good. (h) They should be rather narrow, to prevent bulging. (c) The tissues between the heads of the metacarpal bones should be cut back or removed, so as to allow the flaps to meet well. Fk;. 119. — Diagram of incisions ami flajis iu Norton's operation. (d) The flaps must be long enough to prevent tension. (e) In joining the flaps, small needles and fine sutures must be used, so as to injure the tissues as little as po.ssible. Other points are, that care must be taken that the new web is in a line with the natural one, and that the fingers are kept apart during the healing process. Choice of Operation. — 1. If the web is small and thin, or if the union between the fingers is very close, the formation of a permanent opening at the base of the web is to be preferred. The web may be divided subsequently, and its edges trimmed and sutured. CHAP. Ill CONGENITAL DEFORMITIES OF HAND AND FINGERS 229 2. If the web is extensive, complete and of good width, Didot's operation is the best. 3. If the web is incomplete and reaches but half-way, Zeller's or N'orton's operation is indicated. Hypertrophy of the Fingers. — This condition is sometimes seen at birth in a minor degree, and becomes exaggerated later. ^ ^^R^^^^la' ''|W ^•^^. ^^B ^ i ^^1 ^^^^^^^^^^^^^ ' -: W ^I^H Fig. 120. — Hypertrophy of the fingers, from a photograph by Dr. Hawkins Ambler {Lancet, 4th Feb. 1893). The following forms are described : hypertrophy of all the tissues of the finger ; ^ lymphatic enlargement of the subcutaneous tissue ; a nsevoid condition of all the soft structures (Billroth). In a specimen shown by Mr. Eobert Jones of Liverpool at the meeting of the British Orthopeedic Association in July 1894, the hypertrophy was mainly lipomatous. Pathologically, it is observed that the arteries ^ A case, recorded by Dr. Hawkins Ambler, in a girl aged 12 years, of hypertrophy of both ring fingers, appears to have been of this variety. It was hereditary. Lancet, Itli Feb. 189.3. Dr. Ambler has kindly sent me the photograph of this case for repro- duction here (Fig. 120). 230 DEFORMITIES OF NECK, CHEST, AND UPPER EXTRE:»IITIES sec. ii going to these fingers are larger tlian normal. The temperature of the part is generally raised. Treatment. — Compression of the fingers and ligature of the arteries of the fingers have both been tried, but without success. When the finger l)ecomes a source of annoyance it should be removed. Congenital Lateral Deviation of the Fingers. — Mr. Eeeves figures in liis w(irk n\i BodiJji Di form it lis a remarkable case of congenital deviation of the finger in which the second and third Fk;. 121. — Congenital furrowing of tlie forearm ami intra-iiterine amputation of fingers (after Redard). phalanges are laterally bent on the first, so as to form nearly a right angle. The condition appears to have been imjDroved by the use of a suitaltle instrument. ■ Congenital Furrowing of the Limbs. — These are found more frequently in the leg than tlie arm, and are associated with many other kinds of congenital deformity. They are undoubtedly due either to compression of the limbs by an almormally long umbilical cord, or by amniotic adhesions. In some cases the pressure of the band causes intra-uterine amputation, and the part so separated is ' delivered before or after the fcetus. CHAPTEE IV ACQUIEED DEFORMITIES OF THE HAND Dupuytren's Contraction, Etiology, Causation, Syrnptoms, Diagnosis, and Treatment, Various Methods of Operating — Traumatic Contraction of the Forearm, Wrist, and Fingers — Jerh-, Snap- or Spring-Finger — Mallet-Finger. Dupuytren's Coxteaction Synonyms — English, Contraction of tlic Palmar Fascia ; French, Za Maladie clc Dwpuytren, Retraction cle VA]}on6vrose Palmaire ; German, Die Dvjpuytrensche Contractur cler Finger. Definition. — A permanent flexion of one or more fingers arising from contraction of the palmar fascia, and its digital prolongations. Occurrence and Etiology. — Sc:r.- — -The most extended and valuable statistical table has been compiled by Dr. W. W. Keen of Philadelphia.^ It contains 253 cases, including 70 cases recorded by Mr. Noble Smith.^ Dr. Keen says : " The sex is noted in 2 2 7 cases, of these 180 were men and 40 women." The comparatively large number of women here given is out of proportion with the general experience. But it should be remembered that Mr. Noble Smith's 70 cases included 15 women. Mr. Adams' experience is that the proportion of males to females is about 1 in 15 or 20 cases. He has operated on four or five ladies, and seen it in a few more ; Dr. Keen has seen four, and operated on one. So that the affection must be more common in men. Digits affected. — In 105 cases, in which the finger affected is stated, the analysis gives following result : — ^ Quoted from Adams' ■^a.'m^M.et, Further Observations on tlie Treatment of Dupuytren's Co^atraction, Londou, J. and A. Churchill, 1890 ; also Adams' Finger-Contraction and Hammer-Toe, 2nd ed. p. 85. ^ Royal Med.-Cliir. Trans. 1884. Mr. Smith's cases were obtained by examining 700 elderly people in workhouses. ,0f 400 women, Mr. Smith found 15 cases in which either contraction existed or there was fascial induration with thickenino;. 9 lime 13 .^ 45 5) 88 >5 77 65 232 DEFORMITIES OF NECK, CHEST, AXD UPPER EXTREMITIES sec. ii The thumb was aftected The forefinger was aifected The middle finger was affected . The ring finger was affected The little finger was affected The ring and little fingers together . The phalanges were very unevenly attacked. In To cases, the first phalanx was affected in 15, the first and second in 45, the second phalanx alone in 7, and the third phalanx was also involved in 6 cases.^ In many cases both hands are involved, but not simultaneously nor to an equal degree, but the right hand is not so much more frequently affected than the left, as the theory of the production of the contraction by traumatism would imply. Of 184 cases of Keen's, the right hand only was attacked 58 times, the left 23, and both hands 103 times. Heredity. — Keen found this factor present in 50 of 198 cases; in 3 of them it occurred in three generations and once in four generations." Age. — The deformity is one which comes on in middle or late life, i.e. at the time when fibroid changes generally supervene. Cases are recorded in which Dupuytren's contraction and narrowing of the orifice of the prepuce have been seen in the same elderly person. Although it is generally an affection of late life, I have seen it once at the age of 16 in a girl, and once at 28 years. Occupaiion. — The onset of the contraction has been supposed by some to be due to repeated traumatism of a slight character. In some cases this is undoubtedl}' so, and the following is an instance : — Case 44. Dupuytren's Contraction in a Bookbinder : Operation : Cure. — Bertha G , aged 16 years, came to me at the National Orthopa?dic Hospital complaining of pain in the palm of the left hand, and in- ability to straighten the ring and little fingers. By occupation she was a bookbinder, and she stated that she was accustomed to steady the mass of sheets in the hollowed palm of the left hand Avhile sewing and fastening them. On examination, the inner part of the palmar fascia was felt to V)e thickened, and formed two fibrous cords at the- bases of the ring and little fingers. From each cord a lateral prolongation passed on each side into the ring and little fingers. These were contracted and flexed at the interphalangeal joints. The bands were divided by 1 In congenital contraction of the fingers the first jihalanx is always hyper-extended, and the third occasionally. - And compare Bulley, Jled. Times and Gaz. 1864, ii. 218 ; Madelung, Berl. klin. Woch. 1875, xii. 291 ; Adams, Brif. Med. Journ. 29th June 1878. CHAP. IV ACQUIRED DEFORMITIES OF THE HAND 233 multiple subcutaneous punctures, the fingers extended as much as possible after the operation, and placed in a metal splint until the punctures were healed, when an Adams' apparatus was used. The ultimate result was satisfactory, complete power of voluntary extension being gained. The contraction lias been known to occur in those who use the palm of the hand much in their daily work, e.g. carpenters, drivers, engravers, gardeners.^ But that repeated and slight traumatism is not the sole factor at work is shown by Dr. Keen's tables. In 72 cases where the occupation was recorded, 18 were manual labourers, and 54 obtained their living in ways which could not, without un- duly stretching the imagination, be called manual. Mr. Adams has observed that the majority of his cases were drawn from the professional classes. Medical men, lawyers, writers, and engineers are instanced. The contraction is not unknown in the leisured classes. As far as professional men were concerned, there was one feature common to all, viz. an inheritance of gout. Traumatism. — While statistics are against rather than in favour of repeated slight traumatism as the sole cause, and the point lies in the word " repeated," it is impossible to deny that a single injury is sometimes the precursor of contraction. Dr. Abbe^ instances the following. A patient while climbing a ladder pierced his palm with a piece of frozen mortar, and dated the onset of the affection from that time. In another instance a civil engineer had a long series of stakes to put into the ground, and pressed them hard with his palm. Next day he had a sore palm, and traced the contraction directly back to this date. In 1888 Dr. Abbe operated on A. C, aged 53 years, for Dupuytren's contraction, which he attributed to a strain while turning on a stopcock some years previously, when he heard a snap as if something were breaking in the palm. This part became puffy, and then the swelling slowly disappeared, the palmar contraction following fifteen months afterwards. It is per- missible for me to instance one case of my own. Case 45. Dupuytren's Contraction immediately following an Injury. — Mr. T. E. P., aged 56, two years previously caught the little finger of the right hand in a door. For a time it was very painful and 1 A chemist consulted me for Dupuytren's contraction. In the transverse crease of the left palm and in a line with the ring finger there was a hard nodule, while a band passed down to the ring finger, which was slightly flexed. For many years the spot where the nodule was seen had been pressed on in using the pestle and mortar in pill- making. There was also a strong history of gout. - N.r. Med. Journ. 13th Jan. 1894. 234 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii considerablj'' swollen, but when the swelling had passed off, he noticed " a ' leader ' at the root of the little finger, where there had not been one previously." On examination, a typical Dupuytren's contraction in the early stage was seen, which was relieved by subcutaneous section. As to the explanation of these cases coming after a single injury, it appears to me that Abbe's theory of reflex nerve irritation is the best which has yet been advanced. Causation. — The theories are as follows : — 1. Traumatism, which has already been alluded to. 2. Gout and Eheumatism. 3. Syphilis. 4. Xervous origin (Abbe). 5. Bacterial origin (Anderson). Gout and Rheumatum. — Mr. Adams stated that in his experi- ence at the Royal Orthopaedic Hospital the affection was found to be more common among butlers and indoor servants than in those who performed manual labour. "With reference to the cases occur- ring in the professional classes, he says the only condition common to the whole series is a disposition to gout (Paget's minor manifesta- tions of gout). In illustration of the possible influence of gout, I quote a case and give figure (Xo. 122). Case 46. Traumatism in a Gouty Patient, followed by Dupuytren^s Contraction. — Emma C , aged 25 years, came to me at the Xational Orthop;edic Hospital in April 1893 with this history. Her father and mother had died of chalk gout, and she had "rheumatism" at the age of 1-5. She has one brother and one sister, but they have not suffered from any pains. For twelve years she had been engaged in a laundry as a " starch-pinner." Two years ago she carried her baby for a distance of three miles, mainly on the right arm and hand, and directly afterwards the right hand swelled, especially over that part of the palm which corresponds to the head of the fourtli metacarpal bone. Since then she has noticed difficulty in straightening the corresponding finger. On examination, there is a fluid swelling around the fourth meta- carpo-phalangeal joint, and the head of the matacarpal line is distinctly enlarged. There is no redness about the swelling, but it is painful on pressure. Anteriorly the swelling is not so marked. A well-defined fibrous baud of palmar fascia runs from it to the lower margin of the anterior annular ligament, and the lateral prolongations to the ring finger are thickened. The ring finger cannot be extended at all, and the little finger by passive movement only. There are tophi in both ears. After the administration of citi^ate of potash and vinum colchici, and the local application of bicarbonate of soda, twenty grains to the ounce, the swelling diminished very much. From the history, the tophi, and the ACQUIRED DEFORMITIES OF THE HAND 235 effect of the treatment, it seemed to me a typical example of traumatism in a gouty patient followed bj^ contraction. The theory of a gouty or rheumatic origin receives much support from Keen's tables. Of 48 cases, 42 had either a personal or family history of gout or rheumatism.^ Syphilis. — Eicard and Eicket record cases in syphilitic subjects in which the affection yielded to iodide of potassium. Nervous Origin of the Affection. — Abbe says : " The theory of gout, so far as I can see, is purely an assumption." The sequence of events, according to this writer, is as follows : " First, a slight ^.k, .Nxy ^j!i^^^ Fig. 122. — Commencing Dupuytreu's contraction of the hand and gouty .swelling aljout the metacarpo-phalangeal articulation of the ring finger (Case 46, Emma C , aged 25). traumatism occurs, often entirely forgotten ; then a spinal impression, produced by this peripheral irritation, succeeded by reflex influence on the part originally hurt, producing in its turn pain, hyper^emia, hypertrophy, and contraction of the bands of the fascia; and occasional joint lesions simulating sub-acute rheumatism." The points in favour of Dr. Abbe's theory are the frequent association of neuralgia with the affection, the occurrence of the affection more frequently in people highly sensitive, and the intimate connection of the skin of the palm, full of nerve-endings as it is, with the fascia. A case quoted here from the Edviiburgh Medical Journcd is of interest in this connection. ^ ilr. LockAvood, in the discussion on Mr. Adams' paper at the Medical Society in May 1890, stated that he had made a necropsy in a case in which there was general gouty disease of the joints, and in which the fascial contractions were found to be incrusted with urate of soda. 236 DEFORMITIES OF XECK, CHEST. AND UPPER EXTREMITIES sec. ii Case 47. Dupuytrcn's Cuidradw/i : EpUepsij : Disiqjjjea ranee of Fits after Operation. — Mr. A. G. Miller records the case of a patient, a joiner aged .32, who had become subject to fits ten months before he came under observation. He is said to have been " nervous " ever since ; five rears ago he was arrested in mistake for some one else, but there were no fits until a dispute took place with his parents, after which he left their house and worked very hard at his "bench." This, as already said, was about ten months ago, and it was after this spell of hard work that he noticed a contraction in the palm of his right hand, and almost simultaneously the fits began. These were epileptiform in character apparently, commencing with flexion of the fingers of the right hand. Consciousness, as a rule, was lost, but on one or two occasions the fits had been cut short by forcibly preventing the flexion of the fingers. There was found to be contraction of the palmar fascia of the ring and little fingers of the right hand. The prepuce was also contracted. After the fascia had been stretched and the prepuce slit up, only one fit occurred during the several months that the patient remained under observation. Mr. Miller regards the case as one of epilepsy, resulting from peripheral irritation ; but it is only fair to state that after the operation the patient was under treatment with bromide for some time at least, and the rarity of such a condition arising from such a slight cause makes it A'ery desirable to follow the subsequent history of the patient. Bacterial Theory. — In his Hunterian Lectures, ]\Ir. "William Anderson speaks thus : " The situation of the initial lesions and the peculiar tendency of the new growth to feed like a parasite upon the tissues in which it spreads and which it replaces, have led me to believe strongly that the active agent of destruction is a specific micro-organism which gains access to the subcutaneous tissues through accidental lesions of the epidermis, mostly effected by the finger-nails. This would explain far better than any existing hypothesis the persistent causes of the disease, and its proneness to recur after the most skilfully-devised operations." Mr. Anderson's speculations are by no means so improbable as might at first sight appear. There are many observations bearing on the existence of micro-organisms in the skin. It is only necessary to speak of the parasitic origin and propagation of papillomata, the common wart ; and elsewhere ^ I have hazarded the opinion that the causation of acute infective disorders of the deeper tissues, especi- ally the bone, is to be found in the micrococci which are constantly present in the sweat and sebaceous glands. But until Mr. Anderson's theory is substantiated by careful ^ Tubby, Gutjs Hospital Rejwrts, 1890, "Acute Infective Periostitis." ACQUIKED DEFORMITIES OF THE HAXD 237 observations we must fall back upon the following opinion as to the etiology and causation of the disease. In a patient whose neurotic condition arises from hereditary or acquired gout, slight causes are sufficient to start the fibroid process ; and such, causes are to be found in traumatisms either single or frequently repeated. Morbid Anatomy. — The exact nature of the affection has been made very clear by numerous dissections, references to which are given below.^ The points to be borne in mind are : (1) The affection is primarily a contraction of the fascia, and secondly, of the skin. The tendons have nothing to do with it. (2) The palmar fascia is not a well-defined aponeurosis. It fades off gradually at its edges. (3) It gives off" two sets of processes, the superficial to the skin, and the deep to the lateral aspect of the fingers, passing to the sides of the first and second phalanges, to the periosteum, and to the tendon sheaths. The nature of the change in the fascia is a fibroid hypertrophy. In some cases this appears to be local, and to affect the fascia in the form of small fibromata. In other cases, however, it is a general hyperplasia of one or more bands followed by contraction. On account of the intimate union of fascia and skin, the latter must accompany the ^^*^- 123-— A dissection iiius- ,, . ^ • •. 1 ji rm tratliig the contraction of former m any change m its length. I he the palmar fascia and its pro- longations in Dupuytren's contraction (after Druitt). reason why the ring finger is more often affected is pointed out by Eeeves. In flexion of the fingers, the deepest part of the palm corresponds to the ring finger, and it is this part of the palm which is most compressed in grasping or pushing a round or circular body. Variot found that the fat of the palm had disappeared in one case, . ^ Dupiiytren, Lecons Orales de Clinique Civirurg. 1832, and London Med. and. Surg. Journ. vol. i. p. 267 ; Goyraud, Medicale de Paris, 1835, p. 481, and Memoires de V Academic Royale de Med. torn. iii. and Gaz. Med. 1834, p. 219 ; Partridge Path. Sac. Trans. 1853-54, vol. v. p. 343 ; Druitt, Surgeons' Vacle Mecum, llth ed. p. 301 ; Sevestre, Jov,rn. d'Anat. et de Phys. Paris, 1867, iv. p. 249 ; St. Bartholomew's Hosp. Catalogue, vol. i. p. 177, Churchill, 1882; Lockwood, Path. Soc. Trans, vol. xxxvii. p. 556 ; Ricket, Prog. Mid. 1877 ; Menard and Variot, These de Pa/ris, 1881 ; W. Adams, Finger - Contraction and Hammer - Toe, 2nd ed. 1892, p. 12; Lancereaux ^luoted by Reeves, Bodily Deformities, p. 358 ; Madelung, The Causes and Treatment of Dupuytren's Contraction, Triibner's Translation, 1876. 238 DEFORMITIES OF NECK, CHEST, AXD UPPER EXTREMITIES sec. ii and that the palmar fascia and subcutaneous tissue, the latter beino- thickened, were continuous. He also described hypertrophic changes in the deeper layers of the skin and thickening of the walls of the sweat-glands. Madelung thinks that the disappearance of the fat of the palm is the first stage, and is occasioned by old age, trau- matism, and inflammation. When the fat has atrophied, the palmar Fig. 124. Fig. 125. Fig. 126. Three figures illustrating three stages in Dupuvtreu's eontraction (Fig. 126 is after Redard). fascia is more subject to irritation from iujury or repeated trau- matism, especially over the heads of the metacarpal bones, hence the thickening. Bearing on the part taken by gout in the production, that dissection of Mr. Lockwood's in which he found the fascial contractions incrusted with urate of soda, is of great value. Symptoms. — At first there is a feeling of tightness in the jjalm of the hand and in the ring or little finger, and the patient finds some difficulty in fully extending the fingers, and later there may CHAP. IV ACQUIRED DEFOEMITIES OF THE HAXD 239 be seen some nodular indurations in the palm opposite the heads of the metacarpal Ijones. There is often considerable neuralgic pain in the hand. The skin is at first quite movable on the indurations, but later it becomes adherent, dry, and thickened, and a puckered dimple appears in the transverse crease. The affected fingers then begin to retract in this order ; the first phalanx on the metacarpal, and the second on the first. As a rule the third remains extended on the second, but in the last stage, when the finger is much pressed into the palm, the terminal phalanx is flexed (Figs. 124-126). With the adhesion of the skin in the palm, fibrous bands, like the string of a bow, make their appearance, and often stand well out, and can be traced on to the lateral aspects of the fingers. In some cases the fibrous bands first appear in the fingers. The affection may progress rapidly or slowly. Mr. Adams states that he has known the tip of the finger to be so drawn down as to touch the palm in two years. Prognosis. — Although the affection is slow in its progress on the whole, it is continuous, and a wound in the palm may be caused by the nail of the flexed finger. Earely does it become spontaneously arrested. Diagnosis. — 1. From congenital contraction; the points of distinction have been tabulated on p. 221. 2. From contraction of the tendons, the result of hemiplegia or of nerve lesions in the forearm. Here there are no fibrous bands in the palm, as in Dupuytren's contraction. And in the last-named affection the presence of nodules, adhesion of the skin, and the ex- tension of the third phalanges all serve as distinguishing points. In Dupuytren's contraction the tendons above the wrist may be felt to move freely on passive extension of the fingers. Then in nerve- lesions, wasting of either the thenar or hypotheuar eminences, or both, is present. 3. From flexion of the fingers due to adhesion of the tendons to the sheaths (Fig. 1 2 7). In this event, on attempting passive flexion, the affected tendon is immovable both in the finger and above the wrist. After deep whitlows, if the tendon sheath has been widely opened, the tendon stands up in the palm of the hand. And passive extension obliterates the prominence instead of increasing it, as in Dupuytren's contraction. 4. From contraction of the hand due to osteo-arthritis. The writer has seen all the fingers in this affection bent into the palm, and the whole fascia indurated (the hand of the patient is 240 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES shc ii tigured, p. 249). But there were not in this case distinct bundles of fascia, and no one portion of the fascia was more affected than the other. Treatment. — When the affection is at all marked, the only measure available is an operation on the fascia. Attempts have been made by gradual me- chanical extension to over- come the contraction, but these have always been painful and unsuccessful, and the contraction appears to have increased after- wards. In the mildest cases extension of the fingers may be practised by the patient, but only with the hope of deferring, not avoiding, operation. Oiyerative Treatment. — This may be either subcu- taneous or open. Of the subcutaneous methods, the best is that of Mr. Adams. It consists in making mul- tiple subcutaneous divisions of the fascia and its pro- longations. That surgeon " introduces a fascia knife with a straight cutting Fig. 127. — Contracted finger from adhesion of tendon ed^'C terminatin"" in a point, to its sheatli, after whitlow (Rosa F , aged ° . •, i , 29). and carrymg it between the skin and the con- tracted cord, which is divided by cutting downwards very slowly and cautiously, taking care not to dip the point nor divide any of the structures except the contracted band of fascia. The first puncture should be made in the palm of the hand, a little above the transverse crease and where the skin is not adherent to the fascia. The second puncture should divide the same cord as the first, thus leaving the contracted band isolated in the palm of the hand. The third and fourth punctures divide the lateral bands, whicii pass to the fingers, taking care not to divide the nerves and ACQUIRED DEFORMITIES OF THE HAND 241 arteries. Pressure is made after each puncture by a piece of porous india-rubber or German felt." After the operation Mr. Adams brings the finger as nearly as possible into the fully-extended position without using any force, and keeps it thus by a well-padded metal splint (Figs. 128 and 129), applied to the flexor aspect. Full extension is not always possible, on account of the risk of tearing the skin in severe cases, and the intense pain set up by the traction on the digital nerves. In these cases it is better to make many punctures, twenty or thirty. Fig. 128. Fig. 129. Two forms of ]Mr. Adams' metal siDliut for use immediately after section of the palmar fascia for Dnpuytren's contraction. and gradually to extend the finger. The after-treatment advocated by Mr. Adams is the constant use of the metal splint for three or four days, and then the wearing of the extension-instrument (Fig. 130), at first night and day for a fortnight. When the extension is com- plete it should be worn at night only for about six months. Mr. Adams' operation is most satisfactory, and with care and attention to details, the results are all that can be wished for. In nine cases I have found the results very good. Open Methods of Operating.^ — All the forms of open operations should be done with antiseptic precautions. Dupuytren's method is simply a transverse incision through the skin and contracted fascia ^ For the respective merits of the subcutaneous and open operations, a paper on "The Treatment of Dupuytren's Contr'action of the Palmar Fascia," by J. Macready, in the Brit. Med. Journ. 22nd Feb. 1887, may be consulted with advantage. R 242 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sEf. ii in two or three places. Goyraud ^ incises the skin longitudinally over the fibrous bands, freeing the skin from the latter, dividing them transversely and placing the fingers in extension. Eicket modified this plan by making short transverse incisions at the end of the longitudinal one, dissecting up the small flaps thus formed as far as was necessary, and then dividing or excising the bauds. Busch's ^ operation consists in making a triangidar flap with its base in the transverse crease of the palm, and the apex at the highest point of the hand. The flap, with as much subcutaneous tissue Fig. 1-30. — Extension-instrument for use after section ^S pOSSlbic, IS dlSSectcd Up, of palmar fascia. thus Severing all the pro- cess of fascia attached to the skin. The offending bands are made prominent by pulling on the fingers, and are then freely divided. The disadvantage of this operation is the great retraction of the flap, which leaves a large surface to granulate up. If several fingers are involved, an oval incision, with its convexity to the wrist, answers better than a triangular flap. Choice of Operation. — In all cases it is my opinion that Adams' operation, when done carefully, and, if necessary, in two or even three stages in very severe cases, and with steady perseverance in the after-treatment, will meet all requirements. The advantages of the open method are that it is possible, by actually seeing the fascia, to divide all contracted bands, and, if need be, to dissect them out. The disadvantages are their greater severity, their unsuitability to aged patients — Bradford and Lovett point out that many patients with Dupuytren's contraction have sugar in the urine — the longer time involved in healing, the possibility of drainage of the wound being required, and the occasional necessity of skin-grafts to cover the granulating surfaces left by the retraction of the divided skin or flaps. Recurrence of the Deformity cfter Operation. — This is most fre- quently due either to persistence in that form of occupation from which the conditions arose, or to want of persevering and watchful after-treatment. As a rule cases once thoroughly and efiiciently treated are cured permanently. 1 Cf. a modlBcation of this operation by Mr. Hardie of Manchester, Med. Chronicle, vol. i. p. 9. - Berliner klin. Wochensc.hr. l.o and 16, 1875. ACQUIRED DEFORMITIES OF THE HAND 243 CONTEACTION OF THE FOEEARM, WeIST, AND FiXGEES In this place it is proposed to speak briefly of those forms which arise from traumatism affecting the nerves of tlie upper extremity, leaving other instances which arise from cerebral and spinal lesions to be considered in the chapter on " Deformities the Eesult of Cerebral and Spinal Paralysis." As examples of traumatic contraction of the forearm and hand, the two following cases which came under my notice, in one of which, JSTo. 48, a novel method of treatment was adopted, are given : — Case 48. Contraction of Hand after Pressure on Median Nerve : Section of all the Flexor Tendons at the Wrist : Cure. — Edith B , aged 4, came to the National Orthopaedic Hospital, presenting this history and these symptoms. A year ago she fell down and hurt her forearm. This was all the history that could be obtained. She was taken to the German Hospital, and the following account was kindly sent me. On admission, there was a lacerated wound at the upper part of the flexor aspect of the right fore- arm. Some crepitus was present, and compound fracture of the coronoid process of the ulna was diagnosed. The wound suppurated, and healing was delayed by " pocketting " of pus at the lower part of the forearm. When she came to me the forearm was in this position. It was flexed at the elbow and pronated. The wrist was flexed, and the thumb, first and second fingers were contracted. There was anaesthesia of the flexor aspect of the two outer fingers and thumb. The hand was com- pletely useless. At the upper part of the front of the forearm a depressed cicatrix was seen. With the history and the appearances presented, it seemed that the median nerve was irritated by scar-tissue at the point where it passes through the two heads of the pronator radii teres. It was therefore decided to free the nerve, and "\\dth this object, an incision was made in the centre of the anterior aspect of tlie elbow joint, and the median nerve found ; but on tracing it downwards to the pro- nator radii teres, the nerve was seen to be quite healthy. It was then thought that the lesion was nearer the wrist, and so the incision was lengthened. The nerve was traced beneath the flexor carpi radialis. This muscle, being in the way, Avas divided at its middle and the ends turned upwards and downwards. Continuing the incision more towards the wrist, and separating the muscles, about .3 inches above the wrist the median nerve entered dense scar-tissue. From this it was freed, and the scar-tissue dissected away. The nerve was then seen, for an inch of its length, to have lost its translucent appearance, and to be of about half its normal thickness. The anterior interosseous branch Avas also carefully examined from its origin to the upper border of the pronator quadra tus. The ends of the flexor carpi radialis were united by sutures, and the wound closed. It completely healed by primary union within a week. 244 DEFORMITIES OF XECK, CHEST, AXD UPPER EXTREMITIES sec. ii As the immediate result of freeing the nerve, the fingers were capable of being passively extended without pain, whereas before the operation this had not been possible. Six weeks afterwards, feeling that no more movement was to be ex- pected, in spite of massage, the use of the batter}' and passive movements, and on the ground that considerable adaptive shortening of the flexor muscles had taken place, the following i)rocedure was carried out. The incision Avas carried down to the wrist, and the median nerve separated from the tendons in contact with it, and kept out of danger by a probe Fig. 131. — Contraction of hand from pressure of scar- tissue on tlie median nerve in the forearm. This Fig. shows the condition in Case 48 before operation. Fig. 132.— Tlie same hand as in Fig.l 31, after free- ing the median nerve and siibcutaueously dividing all the flexor tendons at the wTist. passed beneath. Then with a blunt tenotomy knife (/// the flexor tendons at the wrist were divided, by cutting through them straight down to the bones. The fingers Avere then found to be capable of complete extension. The edges of the Avound Avere united, the tendons not haA'ing been drawn together by sutures. The limb AA^as put up in a malleable iron splint, with the AATist and the fingers and thumb flexed, and left so for five Aveeks. At the end of that time, finding good union of the tendons had taken place, the child left the hospital Avearing a plaster of Paris gauntlet, which maintained the flexion of the Avrist, but left the fingers and thumb free. She Avore this gauntlet for a year, it being remoA^ed from time to time for the application of the interrupted current to the part. At the end of a year the functions of the hand Avere completely restored, Avith the exception of a little Aveakness in the index finger ; otherAA^se flexion CHAP. IV ACQUIRED DEFORMITIES OF THE HAND 245 and extension were perfect. She could write on a slate, pick up a pin, and use the right hand as well as the left. The success of the case I ascribe to the absence of any pus after either operation, and to the main- tenance of i/he wrist in the flexed position for so long a period as a year, thus preventing any undue stretching, by over-action of the extensors, of the soft band of union between the ends of the divided flexor tendons. The condition of the forearm and hand before and after the operation is seen in Figs. 131 and 132. The next case is an example of paralysis of the musculo-spiral nerve, arising from vicious union after separation of the lower epi- physis of the humerus. Case 49. Contracted Hand after Miisculo-Sjnral Faralysis : Operation. — A. S., aged 8, sustained two years previously an injury to the lower part of the right arm, "the bone being broken." It was set, but the hand was not of much use to him. On examination, the right hand was dropped and the fingers were flexed. There was anaesthesia of the outer three and a half fingers on their dorsal aspect, and the forearm was pronated. At the outer border of the humerus, and at its lower end, a large bony projection was felt. The child was admitted to the National Orthopaedic Hospital, and an incision was made doAvn to the bony projection. The musculo-spiral nerve was found to be tightly stretched at this spot by the displacement outwards of the viciously-united lower epiphysis. The projecting portion of bone was chiselled off", and the tension on the nerve thus removed. Considerable imj)rovement in the power of the supinators and extensors followed, but, unfortunately, the case was not kept under treatment by the parents sufficiently long to secure a thoroughly good result. Jerk-, Snap- or Spring -Finger^ The description of the affection is that, if the patient closes all the fingers on the palm, on opening them he finds that one remains shut. It can only be extended by the other hand, when " it flies ^ Au excellent accoiTnt of this atfection is found in Mr. H. A. Reeves' Bodily De- formities, pp. 373-382. He gives numerous references to the subject, which inay with advantage be reproduced here. The}'' are : Notter, Archives Gen^rales de Med. 1850, series iv. torn. 24, p. 142 ; Busch, Lehrhuch der Chir. Bd. ii. p. 143 ; Hahn, " Ein Fall von Federnden Finger," Ally. Med. Centralztg, 1874, No. 12 ; Menzel, "Ueber Schnellenden (Federnde) Finger," Centrcdblatt f. CJiirurgie, 1874, No. 22; Berger, "Ueber Schnel- lenden Finger, " Dci^fec/ie Zeitsch. filr Tract. Med. 1875, No. 718 ; Zieber, "Ueber den sogen. Schnellenden Finger," Wien Med. Blatter, Nos. 14-17, 1880 ; Vogt, Bie Chirurg. Krankheitcn der ohen Extremitaten, 1881 ; Felicki, Ueber der Schnellenden Finger, 1881 ; Bernhardt, " Beiti'ag zur Lehre von Schnellenden Finger," Centralhlatt filr Neukranlc, No. 5, 1884. Mr. Reeves also briefly describes three cases on p. 375 of his work. Abbe, "Surgery of the Hand,"^V. F. Med. Journal, 13th Jan. 1894, also describes the affection, and gives illustrations of five cases. 246 DEFORMITIES OF NECK, CHEST, AND UPPER EXTREMITIES sec. ii open like a knife-blade with a snap " (Abbe). ^Sometimes there is difficulty also in flexing the finger, which is accompanied by a small jerk. According to Eeeves, the affection is more often seen in the thumb, and there is often a circumscribed swelling to be felt some- where in the course of the tendon, and the obstruction is almost always near the metacarpo-phalangeal articulation. Aljbe figures his cases, and the affection is seen to be in the ring and little fingers. As to the pathology of the affection, it appears to be due to some obstruction of the flexor tendons as they pass through the osseo-fibrous groove formed by the transverse ligament of the palm at the metacarpo - phalangeal articulation. This obstruction may be due either to narrowing of the groove, or to the tendon being enlarged, or thickening below the groove, and its passing with diffi- culty through it. The narrowing of the groove appears in some instances to be due to the formation of ganglia in the sheath of the tendon. Especially is this so in the case of the index finger. A description given by Mr. Battle ^ of what seems to be this aliection, although it is not specifically so stated, is that " a patient will sometimes come for relief on account of a painful place on the palm of the hand, and usually of the right one, perfectly well localised and much increased by an attempt at grasping anything, such as the handle of the door in order to open it. The pain will have existed for a variable time. On examination, if the finger be flexed, and careful examination made where most tenderness is felt, a rounded body will be found, not so large as a pea, well defined, very hard and attached to the deeper parts just at the point where it is known that the sheath of the flexor tendon of the index finger terminates in the pahn. If these apparently solid bodies be cut down upon, they will be found to permit of easy separation from surrounding parts, excepting when the pedicle is attached, pear- shaped and cystic." It is therefore evident from this descrip- tion that a flexor ganglion may, by the thickening it causes in its growth, narrow the groove. ISTelaton was of opinion that the hard movable body the size of a pea felt in the metacarpo-phalangeal articulation was the cause of spring-finger. It is easy to under- stand how teno-synovitis might give rise to the affection. So much then for the probability of thickening of, or obstruction in the tendon sheath as a cause. Xow as to the tendons, IJeeves states that he has found small 1 Cf. W. H. P>attle, "Some Surgical Affections of the Hand, Flexor Ganglion," Brit. Med. Jonrn. 8tli April 1893, pp. 783, 784. CHAP. IV ACQUIRED DEFORMITIES OF THE HAND 247 ganglia on the flexor tendons. There, too, thickening of the vascular fringes of the vincula accessoria tendines, from teno- synovitis, would readily explain the symptoms. Treatment. — If a ganglion can be felt, the finger should be opened and the ganglion excised. If teno-synovitis has preceded the symptoms, blistering, and later, passive movement under an ansesthetic are to be recommended. If there should be no informa- tion forthcoming as to the cause, then fixing the finger in a metal splint, with pressure over the spot where the movement of the tendon is arrested, will cause the affection to disappear. Mallet-Finger This affection, a rare one, is variously described as " mallet-finger," " drop-finger," " subcutaneous rupture of the extensor tendons." As to the cause, Morris -^ states that the deformity is not un- common among men who engage in athletic sports. When the extensor tendons of the fingers are tense, a blow upon the end of a finger transmitting force in a direction which would ordinarily flex the finger, results in an injury to the extensor tendon, where it is attached to the dorsal surface of the last phalanx. According to this writer, the injury consists, not in a bodily separation of the tendon from its points of attachment, but rather in a thinning of the tendon on the proximal side of the principal point of attachment to the phalanx, and of the fibres which form the posterior ligament of the last phalangeal articulation ; a few fibres are undoubtedly ruptured, but most of them slide away from each other, very much as the threads fig. 133.— Mallet or of a textile fabric separate when the fabric is Sef"'' ^''^*^' violently stretched, but are not torn. Abbe, who calls it " drop-finger," gives two cases, and both arose from slight causes. Case 50. Case of Drop- Finger (Abbe). — A lady was taking off a 1 Some references to tins subject are : Abbe, N. Y. Med. Journ. 13th Jan. 1894, "The Surgery of the Hand," and the affection is described under the title of "Drop- finger" ; R. T. Morris, "Mallet-Finger," Medical News, 19th Sept. 1893; M. E. Schwartz, ArcMv. G&nirales de Med. May 1891, under the title of "Subcutaneous Rupture of the Extensor Tendons of Fingers," quoted in Brit. Med. Journ. Supp. 20th June 1891. •248 DEFORMITIES OF XECK, CHEST, AND UPPER EXTREMITIES sec. ii stocking, and pushing it down the side of lier leg with the tips of her fingers, suddenly found the end joint of her ring finger had given wa)-, and hung at right angles to the finger powerless. With the other hand she could straighten it, but was unable to support it. It appeared to have notliing but skin over the joint to hold it up. Case 51 — Cose of Droji-Finger : Ope mf ion: Cm re (Abbe) — Avas that of a prominent ai'chitect, whose ring finger dropped useless at the last joint, from the slight pressure of his finger-tips pushing across a paper from which he was brushing some bread-crumbs. An operation was performed two weeks later. A linear cut was made on the back of the knuckle, and the torn end of the tendon was sutured to the periosteum of the base of the last phalanx. The result four years after was most admirable. Abbe mentions that in base-ball players the reverse deformity to " drop-finger " is frequently seen. The last phalanx is violently dislocated backward, and cannot be replaced on account of the flexor tendons wi^apping themselves round the head of the second phalanx, which slips through a liutton-hole in the capsule. Eeturning to the subject of mallet - finger, /! V_— ^U Schwartz gives three cases. In two the injury /j L -^ \ occurred to the little finger, and in one to the middle finger. Symptoms. — Immediately after the occurrence of the injury to the tendon, the last phalanx occurring in base- assumes a semi-flcxed position. Tliere are slight Abbe).'^" '^'^^ ^ ^^ swelling and ecchymosis over the last interphalan- u'al joint, a circumscribed tender spot on the dorsum of the last phalanx, just below the joint, and inability of the patient to extend the last segment of the injured finger, all other movements being unimpeded. The anatomy of the affection is either partial or complete, tear- ing away the attachment of the extensor tendon to the base of the last phalanx. As the result of experiments on the cadaver, Delbet was of opinion that the rupture was partial and not complete. If the case be left to itself, the last phalanx becomes fixed in the flexed position, and the use of the injured finger is much impaired on account of the formation of adhesions in the joint. Treatment. — In the first place, the treatment should consist in the application of a straight splint to the front of the finger, so as Fig. 1.34. — Tile re- verse deformity to mallet - finger, CHAP. IV ACQUIRED DEFORMITIES OF THE HAND 249 to keep the terminal phalanx fully extended. If at the end of three or four weeks the power of full extension has not returned, the surgeon should cut down, and stitch together the divided ends of the tendon, or the tendon to the periosteum at the base of the last phalanx. Morris prefers to make a linear incision, to divide the tendon longitudinally into its two principal fasciculi, then sever each transversely on the proximal side of its thinnest part, and to advance each fasciculus to a point upon its own side of the finger near the base of the finger-nail. At this point the fasciculus is sutured to the under surface of the skin, with a suture which passes O"^' Fig. 135. — Ulnar displacement of hand and contraction of tlie fingers in osteo-arthritis (H. .J. L., aged 23 years). through the skin and is tied upon the outside. This is done Ijecause the tendon makes as good union with the soft parts as it would if sutured to the periosteum, and the hold is firmer. The finger-nail is sometimes temporarily lost, as the result of encroach- ing on its matrix. When the advanced fasciculi are sutured in place, the last phalanx is sometimes over-corrected, and extension at the first inter-phalangeal articulation is caused. But this is merely temporary, and disappears in a few weeks, leaving a perfect finger. Other Acquired Deformities of the Hand Amongst these there may be mentioned the contraction and ulnar displacement of the fingers occurring in osteo-arthritis. Fig. 250 DEFORMITIES OF XECK, CHEST, AND UPPER EXTREMITIES sec. ii 135 is an example in a watchmaker, aged 23. This condition improved very considerably after the internal administration of arsenic and iodide of potassium, with frequent soaking of the hands in water containing bicarbonate of soda. Another affection due to osteo-arthritis is Hutchinson's " last joint " arthritis. In these cases, mostly females, the last of the terminal phalanx is much enlarged and nodular, and the phalanx is deviated laterally. The subject of scarring of the hands after severe burns belongs to the domain of general surgery, and it is not possible in this place to discuss its bearings. A. Poncet ^ of Lyons has described a defoi-mity of the hands which attacks glass-blowers. It is a severe hindrance to the useful- ness of the hands, and has often been a cause of exemption from military service. The deformity consists in permanent flexion of the fingers upon the hand, the ring and little fingers being more flexed than the middle and index. The thumb is free. The flexion is mainly at tlie first interphalangeal joint, and is said to be due to contraction of the flexor sublimis tendon. There is no thickening of the fascia nor contraction of the skin. The fingers deviate to the ulnar side. The deformities arising from cerebral and spinal lesions will be considered in the chapter dealing with those matters. ^ Annals of Surg. vol. viii. p. 151. Abstracted by C. R. B. Keetley. SECTION III KHACHITIS AND THE EESULTING DEFORMITIES CHAPTER I RHACHITIC DEFORMITIES Varieties of Rickets, Congenital, Infantile, BicJcets of Adolescence — Etiology — Morbid Anatomy — By^nptoms — General Treatment — Deformities of the Skull, Neck, Spine, Chest, Arms — The Bhachitic Attitude. Synonyms. — English, BicJcets ; Latin, Morlus Anglicus, Articuli Duplicati ; German, Die Englisclie Kranhheit, Doppelglieder, Zwiewuchs ; French, Rhachitisme, Maladie Anglaise ; Italian, Rhachitide. Definition. — A constitutional disorder, which occurs usually in children, is associated with malnutrition, and manifests itself chiefly by changes in the bones and disorders of the digestive system. Although a full description of rickets is out of place here, yet it is necessary to briefly give the main points of the disease before discussing the deformities. Varieties of Rickets. — These are congenital, infantile, rickets of adolescence or late rickets, and scurvy rickets. Senile rickets alluded to by Eeeves is probably osteo-malacia. As to the existence of congenital rickets Virchow is agreed, and cases have been brought forward by Shattock,^ Henoch, and others."^ Infantile rickets usually commences after the sixth month, and is most frequently seen be- tween that date and the second year. Late rickets comes on about puberty,^ and is associated with albuminuria. Glutton * has reported two cases. 0. B. Keetley ^ reports a case in a woman aged 2 years. She had noticed for some time a marked swelling of the 1 Path. Soc. Trans. 1881. ^ T. C. Railton reports and figures a case in the Brit. Med. Jcnhrn. 16th June 1894, p. 1299. ^ L\icas, Lancet, 9th June 1893. 4 St. Thomas's Hospital Report, 1884, p. 103. ^ Ilhost. Meet. News, Sept. 1888, and Ann. Surg. vol. ii. p. 308. 254 RHACHITIS AXD THE RESULTING DEFORMITIES right hip. This was variously diagnosed as dislocation, periostitis, and tumour. From the slow progress of the disease, and the sudden development of a superadded scoliosis, Mr. Keetley diagnosed rhachitis adolescentium. A wedge of bone was removed from the convexity of the femur, the bone snapped across, the adductor longus divided, and the limb straightened. Microscopical examination of the bone removed showed the changes characteristic of rickets.^ With reference to scurvy rickets, it has been thought by some to be scurvy and by others rickets. The factors in the causation of the disease are anaemia and an intensification of those errors of feeding which produce rickets. The symptoms are swelling of the limbs, due to sub -periosteal or intermuscular extravasa- tions of blood, purpuric spots on the skin, spongy gums, htemorrhage from the kidneys, and spontaneous fracture of the bones." Ashby and Wright ^ thus sum up the identit}' of the disease : " Drs. Cheadle and Barlow both incline to the view that they are really examples of scurvy brought on by im- proper food, more especially by the absence of fresh milk for the dietary. . . . Others incline to the opinion that the condition is rather an Fig. 136.— Late rickets, exaggerated or excessive form of the ansemia, ?in ciutWslLe!^"^'' which is usually present in severe rickets, and {By permission of Messrs. in our Opinion there is much to favour this Cnssell and Co.) . „ View. Etiology. — Heredity plays no part in the production of rickets, nor does syphilis. The younger children of a numerous and rapidly- begotten family are very likely to suffer. Other factors are want 1 Dr. E. Cautlej' records a case in a girl, aged 11. A very full description is given. It appears that the child suffered from rickets at the age of 4, that the disease had become quiescent, and then reasserted itself at the age of 10. Dr. Cautley in his article f/ives other references to recrudescent or late rickets, e.g. Ransford, Brit. Med. Journ. Ts87, vol. i. p. 1213 ; Palm, Pract. vol. xlv. 1890, pp. 275-320 ; Duplay, Gaz. des Hopitaux, Paris, 1891, p. 1397. Mr. Robert Jones showed a case at the Liverpool Medical Institution, Brit. Med. Journ. 7th Feb. 1896, p. 341. - Cf. Cheadle, Lancet, vol. ii. 1878, p. 657, and vol. ii. 1882, p. 48. Barlow, Med. Ohir. Soc. Trans, vol. Ixvi. p. 159 ; and Lancet, vol. ii. 1894, p. 1075. ^ Diseases of Children, 1st ed. p. 326. CHAP. I RHACHITIC DEFORMITIES 255 of fresh air, sunlight, and deficient personal cleanliness. The tuber- cular diathesis, in so far as it is a cause of general weakness, and predisposes to digestive disturbances and diarrhoea, may be considered a factor. But the chief cause of all is hand-feeding and the use of artificial foods,^ together with the ingestion of starchy foods, such as potatoes. A proper proportion of animal fat, proteid and earthy salts, such as exists in the mother's milk, or in properly-prepared " artificial human " milk, is absolutely essential during the first years of life. But an insufiicient quantity of milk or an excessive amount of starchy foods does not explain all cases, since a large number of children brought up in a haphazard way do not suffer.^ The disease is most prevalent in temperate climates and in the older countries of the world, and is very marked in great cities where fresh air and sunshine are notably absent. Various theories have been advanced. The production of lactic acid in the intestines by excessive fermentation of the amyloid constituents of food was at one time assigned as a cause. It was conjectured that the lactic acid dissolved the calcium salts from the bone, and further acted as an irritant to growing bone. This enticing theory has been disproved, and at present there is not one which will bear searching examination. Morbid Anatomy. — The bones in severe cases pass through three stages : (1) Stage of congestion ; (2) stage of softening ; (3) stage of sclerosis. It is in the first and second stages that the deformities occur, which in the third stage become fixed. In stages 1 and 2 restitution is obtainable by manipulation and the use ■^ Dr. Cheadle, in introducing the discussion on rickets at the meeting of the Brit. Med. Assoc, in August 1888, stated that the food factor is the only factor which is any- thing like constant. - Beneke has studied the predisposing causes of rickets from an anatomical stand- point. He found that in rhachitis the heart is of average size, but the arteries are abnormally large. Jacobi aptly says, "As it is not probable that a chronic disorder in its slow progress should work a rapid change in the blood-vessels, the inference is a sound one, that if the disorder cannot have altered the blood-vessels, these must have given rise to or be connected with the nature of the disorder." This, by the way, is in support of Beneke's observations. The large size of the arteries explains the existence of the hypersemic condition of the bones, especially at the epiphysial junction, and of the increase of development and thickening of the bones after the morbid process ceases. The large arteries induce a low blood pressure, and therefore thei'e is retardation of the circulation both in bone and muscle, and the latter becomes flabby and feeble in con- sequence. Regarded in these lights, it would seem that Beneke's observations are very important in elucidating the predisposing causes of rickets (Abstract from a paper by C. N. D. Jones on Rhachitic Deformity, Annals Surg. vol. ix. pp. 241-271). 256 RHACHITIS AND THE RESULTING DEFORillTIES sec. hi of mechanical apparatus. In stage o operative interference in the case of the long bones is called for. The bones are affected in two places, tlie periosteum and the epiphysial lines. The affection consists of diminished deposition of lime-salts, v/ith irregular and excessive calcification of the cartilaginous matrix in which growth of the bone takes place. The periosteum is thickened, red, vascular, and does not peel cleanly oft' the bone, but fragments of softened bone adhere to it. Beneath it is soft, red spongy bone, arranged in layers, and in severe cases entirely replacing the normal compact tissue. It is easy to understand, then, how readily ricketty bones bend and yield, and greenstick fractures are caused. At the epiphyses a ring of thickening is felt at the growing line, and later the whole epiphysis is enlarged. " To the naked eye the cartilage is semi-transparent or gelatinous-looking, reddish from abnormal vascularisation, and irregular at the periphery, in place of maintaining the normal even line. Microscopic examina- tion shows the deeper or osteogenetic layer of the periosteum to be chiefly affected, and the layers of spongioid bone beneath to consist of calcified islets arranged radially to the surface of the diaphysis. Beneath the islets of the bone are large red medullary spaces." ^ The cartilage of the epiphyses under the microscope shows excessive and irregular increase of the cells and loss of definition in the columns. In the spaces between the columns much vascular round- celled material exists. Away from the growing line masses of calcified cartilage are seen, and still further much embryonic bone is present. Symptoms. — Among the earliest are tenderness of the bones, the cluld crying out when moved, disordered digestion, sweating of the head, and bronchitis. The child, if it has commenced to walk, is " taken off its feet," " and some bending of the bones may be seen at this stage. The complexion is of a peculiar earthy tint, and the child sits in a heap. At this time, too, " beading " of the ribs and enlargement of the radial and ulnar epiphyses are found. The disease is often complicated by laryngismus stridulus and convulsions. The spleen and occasionally the liver are felt to be enlarged, and the abdomen is distended. Dentition is delayed, and when the teeth appear, they are craggy and pitted, deficient in enamel, soft and prone to decay readily. ^ G. H. Makins, Treves' System of Surgery, vol. i. p. 365. - Dr. Gee says, "A child who is not idiotic or weakened by some recent disease, and who cannot walk at the age of IS months, is either ricketty or paralysed." CHAP. I RHACHITIC DEFORMITIES 257 The chief difficulty in diagnosis is to differentiate between congenital syphilis and rickets. The certain signs of syphilis in infants are cicatrices around the mouth, the presence of condy- lomata, the rash, and tlie existence of nodes on the shafts of the bones. Separation at the epiphysis implies syphilis. Fracture of the shaft of a bone implies rickets. When a clear history of syphiHs, however remote, in the parents is forthcoming and the bones are affected before the sixth month, the presumption is in favour of congenital syphilis rather than of early rickets. Pseudo-paralysis, arising from epiphysitis, is more often seen in syphilis than in rickets, but cranio-tabies is proper to both diseases, although more common in rickets. The deformities of the skeleton will be considered more fully, but an outline of the treatment can be conveniently placed here. General Treatment. — The great points are first of all a change of air, either to the seaside or into the country, and alteration of the diet. All starchy foods should be prohibited, and care should be taken that the milk has sufficient cream in it ; also that the milk given does not contain excess of casein, but is well diluted with whey. A teaspoouful or more of finely-divided semi-cooked meat is of advantage twice a day after the seventh month, if diarrhoea is not present. If that should exist, the juice of under- done meat mixed with barley-water is of value, and when these fail to agree, white -wine whey may be substituted. Either cream or cod-liver oil, or maltine and cod-liver oil, will be called for, while iron is necessary when the ansemia is marked. The preparations of iron which agree well are the vinum ferri, the compound syrup of the phosphate, and the tartrate. Osseous Defoemities in Eickets The Skull. — The circumference of the head is often much increased,-^ in some cases owing to hydrocephalus. If the hand be passed over the scalp, the position of the sutures, especially of the coronal, is defined by a thickening of the bony margins. The fontanelles are of large size, and may remain open as late as the fifth or sixth year. The defective development of the bone, especially in those parts exposed to pressure, results in more or less circumscribed areas which are yielding to the touch, and give the ^ In the discussion on rickets at the Pathological Society in 1881, an opinion was expressed that rhachitic heads are smaller than the normal, but extended experience disproves this. S 258 RHACHITIS AND THE RESULTING DEFORMITIES impression of the so-called " egg-shell crackling." The condition is known as cranio-tabes, and is met with also in congenital syphilis. In a case which came recently under my observation at the Evelina Hospital the whole vault of the skull was so softened, that pressure at any part produced an indentation. That cranio-tabes is due to the effect of pressure on softened bone is supported by two facts. It is generally seen in the occipital region in infants, i.e. where the head presses on the pillow ; while in ricketty monkeys the thinnest bone is met with in one or other parietal region, owing to the habit these animals have of resting in the sitting position, with one side of the head against a support. A prominent, square fore- head, with fulness of the lateral aspect of the frontal bones, obliquity of the upper wall of the orbits, and prominence of the eyes, are characteristic of rickets. In the parietal regions the emi- nence on the central part of those bones is exaggerated, and taken with the enlarged frontal emi- nences, the natiform appearance results. This is, however, better marked in congenital syphilis. In the face the chief error of development is in the lower jaw. Makins ^ observes the " defective development of the outer wall of this bone interferes with the acquisition of the proper arched form by the body, the incisor teeth being arranged transversely, and from them the remaining teeth diverge obhquely backwards, the alveolus being somewhat inverted posteriorly, so that the teeth point inwards. The lower margin of the body is inverted (Fleischmann). The teeth appear late, and are defective in enamel, readily becoming carious." Rhachitic Torticollis.— Phocas " of Lille reports • three cases of torticollis in ricketty children of 10, 15, and 18 months. The head was strongly inclined to the left, the chin was elevated, and the face turned a little to the right. There was no contraction 1 Treves' System of Surgenj, vol. i. p. 368. - Eemic d'Orthopidie, January 1894. Fig. 137. -Well-marked ricketty chest aud proniiueut abdomen. CHAP. I RHACHITIC DEFORMITIES 259 of the sterno-mastoid, and the head was easily replaced, but resumed its vicious attitude when support was withdrawn. Later, the head was thrown back, and this backward tilting was harder to prevent than the lateral. Pain was not severe, but the children were peevish and resisted examination. The lateral deformity lasted about three months, and the posterior also disappeared after a time under appropriate general treatment, and the use of a rubber collar to keep the head in position. An explanation is suggested, viz. softening of the vertebrae and weakening of the muscles and ligaments, as the cause of the trouble. It is also possible that foetal rickets may be the cause of some cases of congenital torti- collis. Spine. — The changes in the spine, which becomes at first kyphotic, and often scoliotic at a Fig. 138.— Ricketty curve of radius (Lily B , aged 2^ years). later date, are de- scribed in Section I. Chapter V. Lordosis is not uncommon in rickets. (jliest. — This subject, too, is discussed in Chapter I. Section II. on deformities of the chest. But two points in connection with this region are worthy of notice, viz. exaggeration of the curves and the occurrence of sub-luxation of the inner end of the clavicle in rhacliitic children. With displacement of the bones there is frequently some scoliosis, and inasmuch as the sub-luxation is on the " convex " side of the scoliotic curve, it is probable the scoliosis may be the immediate cause, owing to the forward and upward tilting of the shoulder on the convex side, thus pushing the inner end of the clavicle out of place. Gibney,-^ in a clinical lecture, alludes to several cases, and says, " Lately we have a way of curing these that is very good. My attention was first called to it by Stimson, who had injected alcohol around the articulation, binding the parts with a roller bandage. Two or three injections serve to set up an inflammation aroimd the joint. Several success- ful cases have been reported." Rhachitic Deformity of the Arms is seen in severe cases. In the accompanying Fig. 138 the radius is seen to be prominent at 1 Int. Clinics, vol. iv. 1893, p. 239. 260 RHACHITIS AND THE RESULTING DEFORMITIES its upper part. More frequently both bones are bent just above their inferior extremities. In the latter case the deformity is due to the habit of crawling in young children who are unable to walk. By way of treatment, daily manual efforts to arrest the curve should be made by the parents. Splints are of little use. The Ricketty Pelvis has these characteristics. The conjugate diameter is decreased owing to the prominence of the sacro- vertebral angle. In consequence of the in- ward thrust of the head of the femur at the acetaljulum on each side, the lateral aspect of the pelvis is flattened and the pubic arch is diminished. The tubera ischiorum approxi- mate unduly, while the ventera iliorum are expanded by the weight of the viscera upon them in their softened state. The effects of these deformities of the pelvis on labour are fully discussed in obstetric works, and suitable means are there suggested of neutralising them. But in extreme cases the operation of symphysiotomy, recently taken into favour, seems to be preferable to procedures such as craniotomy, cephalotripsy, which sacrifice the life of the child, or C;tsar- ean section, which results occasionally in death of both mother and child. Rhachitic Deformities of the Long- Bones of the Lower Extremity are of great importance, and are discussed in Section IV. Ehachitic flat-foot is described in the chapter on Talipes. The Rhachitic Attitude is an exaggera- tion and a persistence of the attitude of the to walk. The rhachitic child stands with the Fig. 139. — Typical rhachitic attitude. infant when learninf^ feet wide apart, the thighs flexed, the knees bent, the back arched, and the shoulders thrown back (Fig. 139). Much light is thrown upon the cause of this attitude in a paper written by Arbuthnot Lane in the Gwjs Hospital RcpoTts, vol. xxix., especially on p. 32. But some of the lordosis is due to the prominent abdomen of rhachitic children, in addition to the causes mentioned by Lane. SECTION IV DEFOEMITIES OF THE LOWER EXTREMITY CHAPTER I IXCURVATIOX OF THE XECK OF THE FEMUR (COXA VARA) i General Account of the Deformity — Etiology — Symptoms — Pathology — Diagnosis — Prognosis — Trea t m en t. This condition was described in 1889 by E. Miiller,^ who presented four cases, in patients aged 16, 17, 18, and 19 years. In all the deformity was one-sided. In 1890 Eotter^ detailed to the Medical Society at ]\Iunich a boy of 15 with bending of the neck of both femora. Hoffa,^ as the result of resection of the hip-joint, obtained a specimen showing very great deformity. Whit- man, in his article in the Transactions of the American Ortliopceclic Association, gives four cases with photographs, some of which he has kindly allowed me to reproduce here. Before ]\Iiiller de- scribed the affection in 1889, bending of the neck of the femur in the otherwise healthy bone of adolescents had been observed,-'' and Iveetley's case of rhachitis adolescentium alluded to on p. 253 was, in all probability, an example of the affection under con- sideration. But incurvation of the neck of the femur is not met with in ^ Much of the information on this subject has been obtained from an excellent paper by Royal Whitman, "Observations on Bending of the Xeck of the Femur in Adol- escence," Trans. Amer. Orth. Assoc, vol. vii. pp. 270-293. - " Ueber die Yerbiegung des Schenkelhalses im "Wachtthumsalter, Ein neues Krank- heitsbild," Beitrage zxw Klin. Chir. 1889, Bd. iv. s. 137-148. ^ "Ein Fall von doppelseitiger rhachitischer verbiegung des Schenkelhalses," Munchener Klin. TFochenschrift, 12th Aug. 1890. * " Zur Casuistik der Yerbiegungen des Schenkelhalses," von Julius Schultz. Zeitschrift fiir Orth. Cliir. Bd. i. s. 55. ^ Thus Whitman, loc. sup. cit. p. 287, mentions Roser, Schmidt's Jahrhucher, 5 Supplementband, Leipzig, 1843, p. 257 ; Zeis, 1851, Beitrage zur Patliologischen Anat. unci zur Pathol, der Hilftgelciiks, No. 1; Richardson, 1857, "Deformity of the Neck of the Thigh Bone simulating Fracture, -with Ossific Union," Trans. Philadelphia Path. Sac. 264 DEFORMITIES OF THE LOWER EXTREIMITY adolescence only. Lauenstein ^ had in his possession specimens taken from a child, aged 6 years, who died after osteotomy for other rhachitic deformities in the lower limbs. Both femoral necks in this case were much bent. Nelaton " had previously noticed elevation of the tro- chanters in rhachitic children. Two cases have recently come under my own obser- FlG. 140. — Incurvation of the neck of the femur. Out- line of the depressed neck of the femur in Miiller's specimen, contrasted with the normal position shown by the dotted line (after Royal Whitman). Fig. 111. — Incurvation of the neck of the femur. Outline of the deform- ity in Holfa's specimen. The dotted line shows the normal position (after Royal Whitman). vation at tlie National Orthopaedic Hospital, one in a child of 4, and the other in a child of 7. In the first-mentioned case the affection was bilateral, and the trochanter was half an inch above Nelaton's line. In the second case the left hip only was affected, and the trochanter was three-fourths of an inch above Nelaton's line. In neither was there any of the downward movement of the trochanter on traction of the leg, so character- istic of congenital hip displacement, a con- dition with which coxa vara has been often mistaken. AVith reference to the etiology, in the majority of cases coxa vara is due to rickets, infantile and adolescent. If the latter, the disease is then said to be " local " in its manifestation. With this opinion Whitman in his article agrees, but he thinks that in some cases the bending Fig. 142. — Incurvation of the neck of the femur. From a photograph by Dr. Royal Whitman of Case 52, show- ing the apparent shortening of the right leg, the pro- minence of the trochanter, the adduction and coni- pensatory tilting of the pelvis. 1 " Bemerkungen zu dem Neuguugsworkel des Sclienkellialses," Archiv fur Jdiii. Chir. Bd. xi. s. 244. - Art. "Rhachitisme," Xoxivcaii did. clc vied, ct de Chir. vol. xxx. p. 382. IXCURA'ATIOX OF THE XECK OF THE FEMUR 265 of the neck is the result of over-weight, acting especially at the time of pubert}'. Symptoms. — E. ]\Iilller described them as follows : " In adol- escence without apparent cause, or following slight injury, the patient begins to limp, and to complain of fatigue and pain about the affected joint on exertion. Shortening of the limb is soon apparent, and is caused by elevation of the trochanter above Nekton's line. The limb is usually extended or flexed to a few degrees and somewhat rotated outward. The motion of the joint is slightly diminished, particularly in abduction. There is no local tenderness on pressure." To these symptoms Eotter added an awkward rolling joint due to adduction of the thighs, with fatigue and pain on exer- tion. Eoyal AVhitman carefully details the symptoms of the four cases mentioned in his paper,-^ and I quote two of them here briefly. Case 52 (Royal AVhitman). — "A boy, aged 15 years, was seen with Ih inch actual shortening. This amount of shortening had all come on within one year, as at the age of 14 'he was in perfect condition.' After that age he noticed a gradually increasing limp, and the application of a cork sole became necessary. Flexion, extension, and rotation remained free, but abduction became entirely restricted. In the figure presented by Whitman adduction of the right leg, tilting of the pelvis, and scoliosis are seen (Fig. 142). It should be added that there was no up-and-down movement of the head of the femur in the acetabulum. All treatment w\as refused." - Case 53 (Royal Whitman). — "The boy was aged 16 when he came under Dr. Whitman's observation. In infancy he was said to have had weak ankles and flat-feet. For two years he had been working as a grocer's boy, standing and carrying heavy weights. Lately there had been soreness and stiffness about the right hip, which were attributed to 'growing' pain. On resting, these symptoms disappeared. When he resumed work they reappeared in an aggravated form, and were in- creased by extra work, but diminished by rest. On examination, the trochanters were found to be slightly elevated above Xelaton's line, the gait was rolling in character, and abduction at the hip was Hmited to a third of its extent, and more marked on the right side than the left. The treatment, consisting of rest and gymnastic exercises, was neglected, and three months later he again came to the hospital, walking with much effort, the rolling gait being most marked and abduction of the legs limited ' at the line of the body.' Crutches were now ordered. Four months later the patient was seen. The adduction as the patient moved on crutches was so great that the legs were crossed, ' scissor-legged de- 1 Trans. Amer. Ortli. Assoc, vol. vii. pp. 270-293, '-Observations on Bending of the Neck of the Femur in Adolescence." ^ Petit. Les janibes en ciseaux. Cong, francais des Chir. 1892, p. 733. 266 DEFORMITIES OF THE LOWER EXTREMITY Fio. 143. — Incurvation of the neck of the femur. The Fig. shows the prominence of the trochanter.s in Case 53 (R. Whitman). Fig. 144. — Mark view of Case 53, showing the relative pro- minence and elevation of the trochanters, and the absence of the normal lumliar lordosis (R. Whitman). / ^ / Jl \ <0a \ ^jA '4 \ Hr-— (iM 'ym ? ^^&^m[ Fig. 145. — From a third photogi-aph of Case 53, showing the involuntary crossing of the legs in Hexing the thighs on the body (R. Whitman). IXCURVATIOX OF THE XECK OF THE FEMUR 267 formity.' On flexing the right thigh the limb crosses that of the opposite side, and with the thigh at a right angle with the trunk, outward rotation is such that the heel is in a line with the opposite anterior superior spine. With the limbs parallel and extended, separation of the knees to 3^ inches only is possible. Flexion at once crosses them. The trochanters are now Ih inches above Xelaton's line. Dr. "Whitman, in the belief that the bending of the necks of the femora had nearly reached its limit, proposed to divide those bones below the trochanters so as to obtain sufficient abduction" (Figs. 143-146). Cases 3 and 4 of "Whitman's presented symptoms similar to those in case 52 and those enumerated by E. Miiller, Case 3 of Whitman's was relieved by absolute rest, regular g}Tnnastic exercises, massage, and stretching of the affected hip and knee ; case 4 by a "traction" hip -splint, massage, and exercise. I have ventured to give the chief points of these cases, as they afford us a good description of a deformity but recently re- cognised and understood. To sum iqj, the symptoms are : — 1. Age — generally adolescence, less often childhood. 2. Class of patients — those who carry weights or do much walking, and are subject to prolonged fatigue. 3. Onset, peculiar stiffness of the hip referred to " gTowing " pains. The stiffness is worse on rising after sitting for a time, but is relieved by complete rest. 4. Limping, if one side is affected ; waddling, if both sides are affected. 5. Shortening, amounting to as much as \ Fig. 146. — From a photo- grapli of Case 5-3, taken 6 moutlis after Fig. 143, and showing tlae apparent shortening of the legs relative to the length of the body (Pu Whitman). l^- inch. 6. Prominence of the trochanters, especially on flexing the thighs. 7. Displacement of the trochanter above Xelaton's line and backwards as well. 8. Eotatiou outwards of the limb, and eversion of the foot. 9. Limitation of inversion and final loss of abduction, with, in 268 DEFORMITIES OF THE LOWER EXTREMITY an extreme case, " scissor-legged " progression and inability to walk without crutches. 10. Tilting of the pelvis and consecutive scoliosis. 11. Ehachitis in some cases has occurred in childhood. ^^ ,r^ Fig. 147. — Unilateral coxa vara. There are seen promiueuce of the left trochanter, slight tilting of the pelvis, and genu valgum on the right side (R. Wliitman). Fig. 148. — L iiilateval coxa vara. The effect of flexion of the right thigh in increasing the deformity is well seen (R. Whitman). Ncgatirehj : 1. Xo local swelling (except that presented by the displaced trochanter) or tenderness on pressure. 2. Absence of the up-and-down movement on traction charac- teristic of congenital hip displacement. 3. Suppuration never occurs, nor thickening of the trochanter. Pathology. — Hoffa's case (Fig. 141) showed that the neck of the femur had bent in such a way downwards and backwards that the INCURVATION OF THE NECK OF THE FEMUR 269 head of the bone rested on the trochanter minor at an angle of 60° with the shaft, as contrasted with the normal of 28". On section there was no evidence of previous disease, but the structural arrangement of the cancellous tissue differed from that which is usual. The femur was also rotated outward, the trochanter was raised and pushed nearer to the middle line of the body. The difficulty in flexion of the limb arises from the trochanter coming into contact with the prominent upper and posterior margin of the acetabulum. Local rhachitis may be a cause, but the incidence of the disease in patients liable to much standing and prolonged j,^'^ 149. -doss-section fatigue, together with absence of deformities in other of the long bones, points to the chief factor in production being over-weight acting upon a slender neck of the femur. Diagnosis, — 1. From congenital displace- ment of the femur. The symptoms are much alike in respect of the prominence of the trochanters, and their displacement upwards and backwards, the waddling gait and the shortened limb ; but in congenital displace- ment the limb can always be lengthened by trac- tion, and the gain thus obtained is at once lost on ceasing traction, while the head of the bone is felt not to be in the acetabulum. 2. From coxitis. Bruns of Tubingen ^ has observed about thirty cases of coxa vara, and con- cludes that of a large number of cases diagnosed as incipient coxitis, several were examples of in- curvation of the neck of the femur. 3. From fracture of the neck of the femur, upper part of the shaft, or separation of the of the iDelvis and de- formed femur. A scheme to show the effect of the deformity in limiting abduction of the limb. The dotted outline shows the normal relation (R. Whitman). \ Pig. 150.— Outlines epiphvsis. In these cases the history and crepitus showing the etiect . of sub-trochan- afford a guide, teric osteotomy m Profifnosis. — Rest Quicklv relieves the pain, overcoming the ® ± ^ i. adduction of the and the depression of the head and neck of the man) ^^'' ^^^"' ^^^^^^ ^easc. If left to itself, the miserable condi- tion detailed in the second case of Whitman results. Treatment. — In the early stages entire rest, local massage, and 1 23rd German Surg. Congress. Quoted in Med. Week, 27th April 1894, p. 193. 270 DEFORMITIES OF THE LOWER EXTREMITY sec. iv passive motion in the direction of the limited movement will efiect much. Failing these, complete recumbency and the employment of traction to the limb are of service. If the depression of the neck has apparently reached its limit, infra-trochanteric osteotomy, re- moving a wedge-shaped portion of the bone will do much to restore the power of abduction and inversion. The subsequent use of a cork sole will be necessary, on account of the shortening, if the affection is unilateral. CHAPTER II GENU VALGUM, VAEUM, RECURVATUM, AND BOW-LEGS Genu Valgum, Varieties, Causation, Morbid Anatomy, Symptoms, Prognosis, Diagnosis, and Treatment — Osteoclasis and Osteotomy — Genu Varum, Causes and Treat- ment — Genu Becurvatum — Curved Tibia and Fibula — Syphilitic Curvature of Tibia. Genu Valgum Synonyms. — English, In-hiee, Knock-knee ; Latin, Genu Introrsum ; German, Knickhein, X-hein, Bdckerhein, Ziec/enhein, Kniebdhrer, Knieng, and Schimmel- hein ; French, Genou cagneux, Gendu en dMans; Italian, Ginoc- chio torti alV indentro. Definition. — Genu val- gum is a deformity of the lower extremity in which, when the legs are fully extended on the thighs, an angle obtuse externally exists at the knee-joint. Varieties. — 1. Rhachi- tic Genu Valgum. — This occurs in early childhood between the first and fourth years, although in severe cases of rickets it may be seen during the first year, and, according to Dittel (quoted by Bradford and Lovett), even at birth. 2. Static Genu Valgum, or genu valgum adolescentium. The. onset of this form occurs between the twelfth and eighteenth year. Fig. 151. — Extreme ricketty deformity and knock-knee. 272 DEFORMITIES OF THE LOWER EXTREMITY By some the pathology of this variety is to be found in an attack of " late " rickets. But this supposition is gratuitous, inasmuch as other signs of rickets are absent, and the knee-joints are often the only parts affected. 3. Traumatic Genu Vahjum. — The causes of this are, (a) after operation for genu varum, when the correction has been excessive ; (b) from lateral bending of the bone after excision of the Fig. 152. — Unilateral genu valgum arising from injury (Case 54). knee ; (c) from fracture of the lower end of the femur or upper end of the tibia, and from separation of the epiphyses in that situation. Fig. 152 represents a case of traumatic genu valgum which came under my notice in 1893. Case 54. Traumatic Genu Valgum after Injury to Lotcer End of Femur, Osteotomy. — John M , aged 12 years, was run over three years ago, and taken to Guy's. It was there found that the lower end of the femur was fractured. He was discharged with fair union. Since then the leg has been getting weaker, and now presents the condition seen in Fig. 152. CHAP. II GEXU VALGUM, VARUM, EECURVATOI, AXD BOW-LEGS 273 He was admitted to the Xational Orthopaedic Hospital, and I performed au osteotomy. The result was satisfactory. 4. Infiaramatory Genu Valgum. — This arises from acute inflam- matiou in the shaft of the femur, or epiphysitis at the lower ex- tremity of that bone, or from tubercular disease of the knee-joint. In the last-mentioned disease there has been destruction of the ligaments and erosion of the joint surfaces, followed by displacement outwards and backwards of the tibia, and eventually ankylosis. 5. Paralytic Genu Valgum, occurring as a complication of talipes valgus or calcaneo-valgus after acute anterior polio-myelitis. The first and second varieties are of importance, and constitute nearly the entire number of cases met with ; while the third, fourth, and fifth varieties are seldom seen, and it is beyond the scope of this work to discuss them at any length. Causation of Genu Valgum. — Inasmuch as bending of the shafts of the bones constantly occurs in rickets, and many cases of knock - knee are rhachitic, it was readily taken for granted by some writers, especially before the recent and more exact observations on the subject, that the explanation of knock-knee was to be found in bending of the diaphysis. But unequal gTowtli of the epiphysial lines is known to occur in rickets. So that the production of the deformity was assigned either to bending of the shaft or inequalities at the epiphysial line. While this statement fails to account for cases of knock-knee at all ages and under all conditions, it is certainly true so far as those early cases, occurring in the course of an attack of rickets, are concerned, and particularly so when weight has not been borne on the feet.-^ The assumption, however, of the erect position brings another factor into play. This is the position assumed by the lower extremities in the " attitude of rest." Subordinate to tliis, but acting simul- taneously with, and influencing the question of the ultimate degree of the deformity, are other conditions, which are comprised under the term " muscular weakness." Such a state of weakness arises from over-fatigue, the bearing of heavy weights, constitutional debility, or, in childhood, the persistence to a late date of rickets. We have then before us three causes of genu valgum, viz. (1) bending of the lower part of the shafts of the femur and upper part of the tibia; (2) unequal growth of the epiphysial line; (3) ^ C. X. Dixon-Jones draws attention to tlie fact that in crawling along the floor the weight of the body is thrown on the knees and inner arches of the malleoli, thus tending to produce a genu valgum. Amials of Surgery, vol. ix. p. 255. T 274 DEFORMITIES OF THE LOWER EXTREMITY sec. iv mechauical causes. The tiist and second causes are purely rhachitic, and have their origin in structural alterations from the beginning. The third cause is " static " in its inception. To discuss more fully the influence of the " attitude of rest." In standing on both feet, a perpendicular line drawn through the centre of the head of the femur passes through the knee-joint, nearer the external than the internal condyle, and the wider the pelvis is in proportion to the height, the more is this line displaced outwards ; so that normally greater weight is transmitted through the external condyle of the femur than the internal. But to com- pensate for the obliquity of the femur, and to bring the articular surfaces of the knee-joints horizontal, the internal condyle is normally ^ to ^- inch longer than the external. In standing for any length of time, the muscles tire and considerable strain is thrown upon the ligaments. In the lower limb the ligaments which in the " attitude of rest " bear the greatest strain are the Y-ligament of Bigelow, the internal lateral ligament of the knee-joint, and those ligaments which sustain the arch of the foot. The " attitude of rest " in standing on both feet is therefore one in which the thighs are extended on the body, the knees on the thighs, and the feet separated widely in order to give a firm base of support to the body with the least muscular fatigue. The wider the feet are separated, the greater is the pull on the internal lateral ligament of the knee, and the greater the pressure between the external condyle of the femur and the external tuberosity of the tibia. For a time the internal lateral ligament sustains the strain, but it gradually yields and knock -knee commences. At the same time with the persistence of the strain, the arches of the foot give way, and the foot is everted. The last-named complication aggravates the strain on the internal lateral ligament, and increases the pressure on the external condyle of the femur. At the same time the internal condyle, being relieved of the normal pressure on it, undergoes lengthening, which in its turn perpetuates the deformity. That this is the explanation of static genu valgum under the influence of a vicious " attitude of rest " is supported by two facts, viz. : — («) In the early stages of genu valgum a distinct space exists in the knee-joint between the internal condyle and the correspond- ing tuberosity of the tibia. If the limb be extended, the two parts may, by lateral pressure on the leg, be made to meet with a distinct click, and the deformity be temporarily rectified. CHAP. II GENU VALGUM, VARUM, RECURVATUM, AND BOW- LEGS 275 (&) If specimens of knock-knee be examined, a distinct depres- sion, deeper tlian the normal, is seen on the upper surface of the external tuberosity of the tibia, pointing to atrophy from pressure. I fail, then, to see how genu valgum can be accounted for by primary lengthening of the internal condyle. Secondarily, however, lengthening of this part does occur. The Results are as follows : 1. The gait is shambling and awkward, partly on account of the weakness of the ligaments, partly because the knees tend to cross, and in some measure on account of the coexisting flat-foot. 2. Contraction of the biceps tendon, ilio-tibial band, and external lateral ligament ensue. The biceps tendon and ilio-tibial band are felt as firm cords on the outer side of the limb, and in many instances act as hindrances to the reposition of the limb. 3. The tibia is rotated outwards. This comes partly from the contraction of the biceps, and partly from the obliquity of the bearing surface of the femur. The patella undergoes sub-luxation outwards, and in severe cases is on the outer aspect of the limb. 4. The lateral mobility is often extreme, rotation of the ex- tended leg is often possible through an angle of 45° to 60°. When it reaches the last-named degree, some hyper-extension of the knees will be noticed on standing. 5. In those cases in which the affection is unilateral, or more advanced on one side, obliquity of the pelvis is present and one limb is shorter. Particularly is this so if genu varum exist in the other limb. Scoliosis is often a result of the inequality of the limbs. 6. The occurrence of flat-foot has been mentioned, but occasionally in severe cases of genu valgum the feet became permanently in- verted on account of the efforts made by the patient to prevent spreading of the feet at the base of support. Bow-legs are some- times present with knock -knee, and if the convexity is antero- internal, increase the deformity and the dif&culty in walking. Morbid Anatomy. — -In purely rhachitic cases a curvature is seen in the lower fourth of the femur and upper part of the tibia. According to Volkmann, quoted by Eeeves,-^ the lower epiphysis of the femur may also be twisted or rotated out. In some rhachitic cases there is said to be overgrowth of the cartilage at the inner side of the growing line. This is possibly secondary to the diminu- tion of pressure through that part of the epiphysial line. ^ Bodily Deformities, p. 241. 276 DEFORMITIES OF THE LOWER EXTREMITY The internal condyle is longer than the external, and the inequality is readily seen if the patient be placed in the supine position, with the legs fully flexed. The external condyle is atrophied and flattened, and its articular cartilage is thinned. Sometimes the normal depression on the upper surface of the external tuberosity of the tibia is increased, while that on the internal tuberosity is shallower than natural. Eeeves mentions that " an osseous spiculum is frequently present near the in- sertion of the internal lateral ligament in bad rhachitic examples." The elongation of the tendons and ligaments on the inner side and the contraction of them on the outer side have been already alluded to. Hypertrophy of the inner part of the growing line in non-rhachitic cases at puberty is described by Mickulicz. The hypertrophy is on the shaft side of the epiphysial line. But while Mickulicz is inclined to look upon it as the primary cause, I venture to think it is the result of insuflicient pressure on that part, and is a secondary matter. The "attitude of rest" and its results in persons of weak muscular development explain, it seems to me, very fully the changes in the joints and ligaments of knock-knee at the time of puberty. I fail to see how the supposed existence of late and local rickets can have much to do with the matter. If so, where are the constitutional symptoms which normally accompany rickets ? Symptoms. — Those which are complained of by the patient are few, and consist of difficulty in rapid progression, pain and tenderness over the internal lateral ligament, and a disposition to become readily tired. On looking at the patient when standing, the acute angle formed by the legs, the rolling gait with swinging of the pelvis, and the eversion and abduction of the knees and feet are at once seen. In advanced cases the gait is a combination of a roll and a jerk, the latter movement arising from the yielding of the internal lateral ligament as the full weight of the body bears on each lower extremity. The outward rotation of the tibia and displacement of the patella have been noticed ; but in some severe cases the tibia is rotated inwards, the explanation of the latter event being obscure. Separation between the malleoli varies from a few inches to 18 or more, and three lines drawn one through each tibia, and one uniting the two malleoli, may make an equilateral triangle. It is well known that on flexion of the legs in genu valgum the deformity disappears. Several theories have been advanced in CHAP. II GEXU VALGOI, A' ARUM, RECURVATUM, AXD BOW-LEGS 277 explanation. Bradford and Lovett ^ remark : " It would seem to be most easily accounted for by the fact that the posterior surfaces of the condyles of the femur were not so much affected, but that the deformity was produced by an alteration of the lower surfaces of the condyles alone, and that when (on flexion) the facets of the tibia ceased to articulate with the latter, the abnormality ceased — a state of affairs which coincides very well with the static theory of the production of the deformity." This expression of opinion is very similar to that of Gueniot. Mr. Eeeves advances Busch's explanation, which is that the disappearance on flexion is due to the downward displacement of the internal condyle caiising an oblic|uity of the articular line, and a consequent oblic|ue axis of rotation on flexion. Mr. Pieeves illustrates it by the mechanical arrangement of a rule jointed at a, d, with its limbs h and c forming an obtuse angle (Fig. 153). So long as the limbs h and c are in the same plane there is an angle prominent at d, but when c is bent on d to 180" the two limbs of the rule become parallel. Unfortunately for this explanation the joint at a, d. is straight, and the illustration is not applic- able to crenu valo-um in which the line of articulation between the bones of the knee-ioint is admittedly .„ ^ , '' -' Fig. 1 0-3.— To il- Oblique. lustratethedis- It seems, then, that no valid explanation is appearance of _ -^ _ tlie deformitj^ forthcoming which will satisfy all the mechanical iu genu valgum conditions of genu valgum. The importance, how- °^ flexmg the p c r > ^ knee (Reeves). ever, of this disappearance of the deformity on flexion has a distinct bearing on treatment, viz. that to rectify the deformity by mechanical appliances the knees must be kept in the extended position. Methods of estimating the Degree, of Deformity. — 1. The simplest is to place the patient in the standing position, taking care that the knees do not quite touch,^ and that the condyles are not rotated inter- nally, and then note the distance between the malleoli. 1 Op. cit. pp. 647, 648. 2 Xormally with the malleoli in contact on standing, the knees are separated by an inch or more. In order, then, to ensure a correct estimate of the deformity in genu valgum, the same relative position of the internal condyles should be obtained. Thus, in the case of an adult, it is well to place a book 1 inch in thickness, and in a child one of i inch, between the knees. It is a faulty and deceptive way of measuring to place the knees touching one another. The measurement at the malleoli is thereby reckoned at from 1 to 2 inches less than it really is. 278 DEFORMITIES OF THE LOWER EXTREMITY sec. iv 2. Another method is to sit the patient upon a sheet of white paper with the toes pointing upward, and trace the outline of the limbs with a pencil. The objection to this is that the separation of the malleoli in sitting is no measure of tlie separation in standing, since the laxity of the ligaments at the knee-joint varies much in different individuals, and it is exactly the standing position which emphasises the real extent of the deformity. 3. Mr. Eeeves measures the height of a perpendicular drawn from the base to the apex of an obtuse triangle formed by the femur, tibia, and a straight line joining the great trochanter and external malleolus. The perpendicular is drawn opposite to the knee-joint. It seems to me that tlie first plan is open to the fewest objections when properly carried out. Prognosis. — This question may be considered from two points of view. Will the child grow out of it ? Will an operation be necessary ? In answer to the first question it may be said that if the case be a slight one, i.e. merely a little separation of the malleoli in walking, and the general health be good, recovery will ensue without treatment. But with any failure of the general health or excessive fatigue in walking or standing, the case will l)ecome rapidly worse. As to the question of operation, there can be no doubt that extreme degrees of genu valgum, even with as much as 18 inches separation between tlie malleoli in an adolescent, can be rectified by instrumental treatment. But the duration of recumbency is so great, and this method of treatment so tedious, that in a case in wdiich the bones no longer spring on bi-manual pressure, or if the child is over 5 years of age, osteotomy should be advised in order to save time and expense. Diagnosis. — There can be no difficulty in recognising a case of genu valgum ; the chief point is to assign the appropriate cause. The traumatic form is known by the history ; the pathological by the altered outline of the joint, loss of mobility, and other signs ; and the paralytic variety by other signs, such as wasting elsewhere in the limbs. Care should also be taken not to assign late rickets as a cause, unless other signs of that disease are present. Treatment. — The three stages which bones affected with rickets undergo have been stated to be : — 1 . Congestion. 2. Softening. 3. Eburuation. CHAP. II GEXU VALGUM, VAEUM, RECURVATUM, AXD BOW-LEGS 279 In considering the treatment of genu valgum arising from rickets, these three stages should be borne in mind, as the line of treat- ment in any particular case must depend upon the state of the bones. In static genu valgum there are two stages, viz. — 1. Eelaxation of ligaments and muscles. 2. Osseous deformities arising as the result of relaxation. As in rickets, these stages afford us guides in treatment. I take it that neither in the softened stage of the bones in rhachitic genu valgum, nor in the early stage of relaxed muscles and ligaments in the static variety, ought an osteotomy to be performed, inasmuch as there are at our command other and less severe measures. The treatment of genu valgum may be placed under three headings : — 1. General Treatment; Eest and Local Manipulation. 2. Mechanical and Manipulative. 3. Operative. But before discussing these points the question may be asked, Do slight cases of genu valgum rectify themselves ? This has been touched on in dealing with the prognosis. Mr. Eushton Parker ^ thinks that cases of slight knock-knee show a strong tendency towards recovery if the child be prevented from walking — a very difficult matter. Then again, how small is the number of adults with knock-knee who present themselves for treat- ment for the first time at hospitals compared with the number of children who are seen with this affection. Whitman - observed the proportion of knock-knee cases in 2000 adult males seen consecu- tively in the streets of Boston. He found only 3 2 cases. Gibney ^ in six years noted 276 cases of genu valgum ; of these, 255 occurred in children under 14 years of age. This and the preceding observa- tion seem to bear out the contention that as the patient attains adult life the slighter cases of knock -knee undergo spontaneous rectification. Taking my experience of the three hospitals to which I am attached, I notice that it is only severe and moderate cases which are brought for treatment, the slight forms not presenting themselves. We may then take it that in a certain proportion of cases, notably the ricketty ones, the deformity disappears spon- taneously. 1. Cieneral Treatment ; Best and Manii]}v2ation. — If the case is that of a ricketty child, the dietary and hygienic measures detailed ^ Liverpool Med. Cliir. Journ. Jan. 1887, p. 119. " N. Y. Med. Rec. 30th July 1877. ^ IMd. 29th Nov. 1884. •280 DEFORMITIES OF THE LOWER EXTREMITY sec. iv on p. 257 should be attended to. A change of air to the country or seaside is of special value, and the child should, as far as possible, be kept off his feet. If difficulty arise in so doing, a long outside splint, reaching from the pelvis to 4 inches below the external malleolus, and with the whole length of the limb, especially the knee, well bandaged to it, is effectual. In addition, by keeping the knee extended, recovery is accelerated. Not only has " splinting " the advantage of keeping the child at rest, but if for any reason the patient pass from observation, it anticipates, so to speak, any increase of the deformity. Manipulations are best carried out as follows : — The splint, if any, having been taken off, and the limbs having been douched with tepid water, the knee is pressed outward with one hand and the tibia inward with the other hand of the nurse, the legs being extended on the thighs. The pressure is maintained for a few seconds and then relaxed, the movement being repeated several times. At no time should pain be caused, but the pressure must be uniform,, and at each sitting some improvement will be noticed. Afterwards the patient's limbs are well rubbed by the nurse. This simple procedure may be carried out night and morning. When the muscles have become larger and firmer, the child should be taught to stand and walk with the feet straight in front, and must not be permitted to assume the " stand-at-ease " position. In the slighter static cases, rest and manipulation, with douching and shampooing the limb, wiU soon remedy the deformity. 2. Mechanical Treatment. — The scope of this form of treatment is limited by two anatomical conditions, viz. absence of eburnation of the bones in children, and, in adult cases, relaxation of the liga- ments without marked elongation of the inner condyle of the femur and contraction of the biceps and ilio-tibial band. It cannot, how- ever, be denied that good results have been obtained in even extreme cases by mechanical arrangements which have a rack opposite the knee-joint. The apparatus is put on the outer side of the limb, and is accommodated to the deformity. It is then screwed up from time to time until the genu valgum is overcome. I have seen a case in which there were 14 inches of separation between the malleoli cured in this way. But there can be no question that the treatment is extremely tedious, often painful, and detrimental to the patient's general health, on account of the long confinement. The princijjlcs upon which mechanical treatment is based are very simple, viz. traction upon the knee from a stiff rod or splint CHAP. II GENU VALGUM, VARUM, RECURVATU.M, AXD BOW-LEGS 281 taking its bearings from the great trochanter and the onter side of thigh and legs ; continuous extension of the leg ; no interference with walking beyond the limitation of the knee movements. There are various apparatus in which these principles are attained, but in this place only a few can be mentioned. The simplest arrangement is two padded wooden splints reaching from the pelvis to the external malleoli. A broad band of webbing attached to the upper end of each splint and buckled around the pelvis keeps them in position above, while each is secured to the Fig. 154. — Kuock-kuee before treatment by apparatus aloue. Fig. 155. — Knock-knee after treatment by apparatus alone. outside of the limb by bandages or broad strips of webbing, care being taken to make lateral traction outwards on the knees. In place of bandages or webbing at the knees, a leather knee-cap may be fixed to each splint in such a way that it can be buckled firmly at that spot. Bradford and Lovett use a simpler and less unsightly arrange- ment than the above-mentioned. Their apparatus consists of " a light steel rod attached below to a steel sole plate, and jointed at the ankle. It runs up the outside of the leg as far as the tro- chanter, and then the rod is bent backward and upward, to lie against the upper part of the buttock, and to serve as an arm by 282 DEFORMITIES OF THE LOWER EXTREMITY which the leg can be inverted if the child toes in or out in walking. The knee is drawn upon by a square leather pad pulling from the sliaft opposite the knee. The upper ends of the apparatus should be buckled together posteriorly by two straps, one connecting the tips of the posterior arms, and sometimes another may be needed running across the lower abdomen connecting the shafts. By length- ening or shortening these straps, it is evident that any desired degree of inversion or eversion of the foot may be produced. Often the posterior strap alone is all that is needed." This arrangement commends itself strongly, on account of its simplicity, utility, and comparative cheapness. A more complicated and costly arrangement is. figured below (Fig. 156). It is suitable to those cases in which ligamentous relaxation is pronounced at the hip and ankles in addition to the knees, and to those in which the bones of the limb readily yield to lateral pressure through their whole extent. The principles of this instrument are sup- port to the limb, stretching the external lateral li'rament and ilio-tibial band, and taking the strain off the internal lateral ligament, thereby enabling it to contract to its normal length. At the same time, the removal of excessive pressure allows the external condyle to grow. The diffi- culties of the mechanical treatment are the dura- FiG. 1,56. — Walking ap- , • .-, • t j.i • i. n j -c paratusforsevere<^enu ^^*^'^' ^"® pam, II the case IS at all scvere, and, it valgum, not suitable elaborate apparatus is used, the costliness. The duration of treatment may be shortened by divi- sion of the hieeps and ilio-tibial hand. These little operations present no difficulty, and cocaine is a sufficient anaL'sthetic. The patient lying semi-prone flexes the limb, the movement being resisted by an assistant, so that the tendon becomes tense. The part having been rendered aseptic, the surgeon passes the knife on the flat about 1 inch above the joint vertically on the inner side of the biceps tendon, and as close to it as possible. Care is taken to guide the knife around the tendon, and the edge of the knife is turned towards it ; the assistant then extends the limb, and the tendon is severed. The external popliteal nerve is in no danger if these precautions are observed. Care, however, should be taken not to transfix the tendon, as a re- introduction of the knife is embarrassing, nor should the point be CHAP. II GEXU VALGUM, VARUM, RECURVATUM, AXD BOW-LEGS 283 dipped too deeply. If it is, the superior external articular artery may be wounded. The ilio-tibial band is readily divided on the outside of the limb. Should any doubt exist as to the exact position of the structures, the ilio-tibial band should first be identified by making it tense, and tracing it down to the head of the tibia ; the structure next behind and somewhat internal is the biceps tendon, while the external popliteal nerve is internal to the biceps, and lies deeper than it. So long as the point of the knife is entered on the inner side of the tendon, and follows closely round in getting be- neath it, no danger to the nerve can ensue. 3. Operative Measures. — They are : — {a) Osteotomy. (b) Osteoclasis. (c) Forcible manual rectification by Delore's method. {d) Erasion of the knee or arthrodesis, which is suitable only for some cases of paralytic genu valgum. It is convenient, in the first place, to speak briefly of osteoclasis and forcible reduction, leaving osteotomy for fuller considera- tion. Osteoclasis as a means of treatment of genu valgum has found some advocates, especially since instruments have been designed to break the bone with precision. It is held in favour in France ; but, appreciating the brilliant results of Sir William Macewen's work, English surgeons have not practised osteoclasis to any extent. In France, Delens, Demons, EoUin and MoUiere advocate it, and the last named have designed an osteoclast which " will fractm-e the lower end of the femur 2 inches from the joint without injuring the articulation." ^ Dr. Grattan of Cork has also designed a form of osteoclast which fractures bones with much certainty and cleanness. It seems to me that osteoclasis has but one advantage, viz. a simple fracture is produced, whereas in osteotomy a compound fracture results. But there are varieties of compound fractures. If the fracture is transverse, completely aseptic, and the external wound is so slight as to heal within a few days, as occurs in osteo- tomy, the lesion is but little or no more serious than a simple fracture. Whereas in osteoclasis it cannot be denied that ecchy- mosis of the soft parts, splintering of the bone, separation of the epiphysis, and rupture of the -external lateral ligament have occurred. So that the one advantage of the fracture being a simple one is a ^ Bull, et Mem. de la Soc. de CMr. Paris, 1883, voL ix. p. 885. 284 DEFORMITIES OF THE LOWER EXTREMITY sec. iv poor set-off against these serious contingeucies.^ I slioiild not myself perform osteoclasis in preference to osteotomy for genu valgum. One American writer " thus forcibly expresses himself : " The osteoclast is an instrument of tremendous and brutal power, which I hope will never be generally adopted by American surgeons." As some one well puts it, " The osteoclast should become an historical surgical reminiscence ; while Macewen's chisel should be canonised as the ideal scientific corrector of bone deformities," Forcible Manual Rectification. — The chief advocate for this pro- cedure is Delore, but what has been said as to the disadvantages of osteoclasis applies with equal force to forcible manual rectification. The method has been before the profession for several years, but has never commended itself to the general notice of surgeons. In ex- perimenting on the cadaver, separation of the epiphyses of the femur and tibia, rupture of the periosteum, and laceration of the external lateral ligament have been produced.^ In one case, which died twenty-nine days after the operation, Delore found that the external halves of the joint surfaces were not in contact with each other. He admits that frequently the external lateral ligament is ruptured. It appears to me that forcible manual rectification for genu valgum is unscientific* ^ Redard, Chirurgic Orthopedique, p. 588, thus tabulates the points respecting osteoclasis and osteotomy : — Osteoclasis. Osteotomy. 1. Requires a special apparatus. ' No special apparatus needed. 2. Simple fracture is produced. Compound fracture is caused. 3. If the osteoclast is not correctly applied. Unless properly carried out, in fractur- the fracture is not transverse ; splinters and ing the remainder of the bone, the splin- fissures are caused. ters may cause damage. 4. The sequelse are mild, demanding little The sequelte are also mild ; there is watching, but some ecehymosis and limita- rarely effusion into the joint. tion of movement in the joint may occur. 5. Duration of treatment shorter. Duration of treatment longer. But it seems to me that from a perusal of his conclusions, Redard is liolding a watching brief on behalf of osteoclasis, and is not a thorough advocate of it. ^ C. N. Dixon-Jones, Annals of Surg. vol. i. p. 257. ^ Barbier, " Etude sur le Genu Valg.," Tk^se de Paris, 1874. * Mohring {Zcitschr. f. Orthopddische Chir. vol. iii. p. 201) reviews A. Zuffi's method of forcible manual correction of genu valgum. "The method is safe and sure, and re- lapses are rdre. In 800 cases the external lateral ligament was never ruptured." The method is as follows: "The jjatient is laid on a table, with the affected side up, and the hip and knee of the opposite side well Hexed. A block with a raised edge is placed under the internal femoral condyle. One assistant stands in front of the patient, and fixes the pelvis by grasping the upper iliac crest with one hand and the flexed knee of the opposite side with the other. Another assistant stands behind and presses over the great trochanter, to prevent injury to the hip, and over the external condyle, to give CHAP. II GEXU A'ALGOI, VAROI, RECUEA'ATUM, AXD BOAV-LEGS 285 Osteotomy. — Indications : — 1. AVhen the bones are ebiirnated. 2. In children over 4 years of age, if separation is greater than J: inches and not due to ligamentous weakness. 3. When mechanical measures have been tried and ha\-e failed, either owing to pain or hardness of the bones. 4. If mechanical mea- sures are inadmissible on account of the patient's want of means. 0. When there is con- siderable elongation of the internal condyle, or much bending of the shaft of the femur or tibia. The forms of operation in vogue are : — 1. Maceweu's Supra- Condyloid Osteotomy from the Inner Side. II. Division of the Shaft from the Outer Side. III. Oblique Division of the Internal Condyle (Ogston) with Eeeves' Mo- dification. lY. Osteotomy below the Knee. Y. A combination of the above. The first three will be described in full. I. Macevjens Supra- Condyloid Osteotomy. — The skin is duly cleansed and a carbolic compress j)ut on over-night. Xo Esmarch bandage is necessary. The patient lies on his side, and the leg is flexed with a sand-bag beneath it. Two osteotomes should be at hand, one -J- inch and the other |- inch wide. purchase to the operator, who, grasping the leg hy the calf with one hand, and above the ankle by the other, gradually forces the leg into the correct position, taking care to keep it fully extended. The leg is put up somewhat over-corrected in a plaster dressing." Fig. 15 -Osteotomes and mallet. 286 DEFORMITIES OF THE LOWER EXTREMITY SEC. IV The point of incisiou throiigli the skin is on the inner side of the thigh, ^ inch in front of and above the adductor tubercle. A long narrow-bladed knife is entered on the fiat at this spot, and carried straight down to the bone. With the heel of the knife the incision is enlarged longitudinally to a little more than the width of the osteotome. Along the knife as a director, the osteotome is introduced and is passed to the bone, the knife being then with- drawn. The osteotome is then turned at right angles to the limb. By successive blows of the mallet the osteotome, held firmly, is driven through the inner two-thirds of the bone. Mr. Jacobson -^ says : " The direction of the bone incision is most important. The surgeon must cut transversely across the femur on a level with a line drawn ^ inch above the tip of the external condyle. Otherwise, as in a valgus limli, the whole internal condyle is lowered, a line drawn trans- versely from the adductor tubercle might land the opera- tor low down in the external condyle. The osteotome must be driven at first from behind forwards and to the outer side. It is then made to move for- wards along the inner border until it comes to the anterior surface, when it is directed from before backwards and angle of the femur. By keep- After Fig. 158. — Method of grasping osteotome. towards the outer and posterior ing on these lines, there is no fear of injuring the artery." each blow of the mallet, the handle of the osteotome must be moved laterally, so as to prevent locking. It is in the latter connection that the employment first of a large and then of a small osteotome is to be commended. When three-quarters of the bone have been divided, the limb is extended, and with one hand just above the wound and the other holding the middle of the leg, the limb is carried steadily inwards until the femur is felt to give. Difficulty often arises owing to the external or posterior aspects of the femur not having been sufficiently divided. The osteotome must then be re-introduced, but it is a bad proceeding ; owing to the retraction of 1 The Operations of Surgery, 1st ed. p. 1091. CHAP. II GENU VALGUM, VARUM, RECURA^ATUM, AND BOW-LEGS 287 the soft parts, it is often by no means easy to make the osteotome enter the incision in the bone. The wound is gently syringed and dressed, and the limb put up in splints in the straight position. Personally, I prefer to place a back and two side splints on for the first week, and then after rectifying any fault in the position, to encase the limb in plaster of Paris bandages. No change of dressing is, as a rule, needed. Six weeks after the operation the plaster is taken off' and the patient allowed to walk on crutches. Any difficulty in bending the knee should be rectified. In some cases, simultaneous division of the biceps or ilio-tibial band is needed to obtain good position, and in extreme cases it may be necessary to divide the tibia below the upper epiphysial line. Accidents. — 1. Septic Infection. — Sir W. Macewen ^ collected 1384 cases, of which 820 were his own. Three cases died after operation, of which two were due to septictemia. 2. Hemorrhage. — M'Gill' reported a case in which the popliteal artery was divided and was subsecjuently ligatured. Langton ^ recorded a case of wound of the popliteal artery by a sharp spicule of bone projecting from the articular end ; considerable haemorrhage occurred and the artery was ligatured. Gangrene set in and ampu- tation of the thigh was performed. Unfortunately, however, death ensued. Mr. Howard Marsh ^ wounded the anastomotica magna artery, and was compelled to cut down and ligature it subsecpiently. Gibney ^ also speaks of a case in which the anastomotica magna artery was wounded, and he has met with severe hsemorrhage from the bone. The causes of the haemorrhage are : (a) the use of too broad an osteotome ; (&) not dividing the posterior part of the bone with the cutting edge of the chisel pointed forwards ; (c) allowing the chisel to slip ; {d) abnormal course of the anastomotica magna artery. 3. The external popliteal nerve has been divided. II. Division of the Shaft from the Outer Side vnth Scnu or Chisel. — This is the procedure advocated by Sir William MacCormac. The writer uses this method almost invariably, and performs the section with an osteotomy saw. The mode of performing this operation is as follows. The limb is duly asepticised and rotated inwards, a sand-bag being placed 1 Lancet, 27tli Sept. 1884. "- Ihid. 17tli May 1884. ^ jj^-^^^ 29th March 1884. •* Ihicl. 17th May 1884, p. 891. Brit. Med. Jov.m. 1884, i. 665. 5 N.Y. Med. Journal, 6th Dec. 1884. 288 DEFORMITIES OF THE LOWER EXTREMITY beneath it. The knife is entered at a point on the outer side three fingers' breadth above the top of the patella when the limb is extended. It is passed straight down to the bone, and cuts firmly on to its anterior and outer surfaces, so as to divide the periosteum. With the heel of the knife the wound is slightly enlarged backwards. Along the knife, now turned on the flat, the saw is introduced. At first the handle should be dropped a little so as to divide the outer wall of the compact tissue. It is then raised somewhat and cuts through the anterior wall. In this way Fig. 160. Genu valgum. These figures illustrate the condition of the limbs before and after osteotomy. In this case the osteotomy was done with the saw from the outer side. In Fig. 160 there is seen to remain more curvature of the tibia, which was remedied l)y suljseiiuent osteotomy. at least two-thirds of the bone is divided. By carrying the limb inwards the thin inner wall readily gives way. The wound is gently syriuged and then dressed. For the first seven days the writer places the limb in a back and two side splints. At the end of that time the position is finally rectified and the limlj placed in a Ci'oft's splint or plaster of Paris bandage. The plaster is removed at the end of the sixth week, and the patient is allowed to get about on crutches. Advantages. — Mr. Jacobson ^ states that the advantages are : " 1. The femur is divided at a much narrower part than in the 1 Op. sup. cit. pp. 1089, 1090. CHAP. iL GEXU VALGUM, VARUM. RECURVATUil. AXD BOV'-LEGS 289 supra-conclyloid operation of Macewen, and thus it is most easily and quickly done. 2. The bone section is farther away from the epiphysis and the line of synovial membrane, in case subsequent inflammation takes place. 3. There are no important blood-vessels near." III. Obliq^ux Division of the Internal Condyle. — The limb is flexed and supported on a sand-bag. A narrow-bladed knife is entered at the mid-point of the inner aspect of the thigh and 2 inches above the adductor tubercle, and is then carried downwards and outwards firmly on the bone, until the point is felt in the intercondyloid notch. As the knife is withdrawn the skin opening is enlarged. Using the knife as a director, an Adams' saw is passed along it and the edge of the saw turned backwards. The internal condyle is then nearly sawn offl AYhen the saw approaches the posterior part of the bone, it is withdrawn. By carrying the knee firmly inwards, the internal condyle is detached and slips up somewhat on the inner surface of the femur. The wound is dressed and the limb is placed either in wooden splints or plaster of Paris bandages. Advantage. — The operation is of value in very severe cases of knock-knee only, when the deformity is due entirely to great elon- gation of the internal condyle, and it is evident that a linear osteo- tomy will not be sufficient to rectify' it. Disadvantages. — 1. Stiffness of the joint has followed. 2. The knee is freely opened and its structures considerably disturbed. 3. The risks involved in any want of care in securing perfect asepsis are very serious. 4. Genu varum may follow, owing to the position of bone chiselled away becoming too much displaced upwards. Mr. Eeeves claims that by his modification of Ogston's operation, the joint is not opened. He adds, however, '•' G-r anting, for the sake of argument, that the joint is always opened in these cases, experience has abundantly shown that practically it matters not, and in this sense the operation is properly called extra-articular." ^ Division of the tibia as well as of the femur can only be required in very exaggerated cases, and the improvement obtained is not so great as might be expected. To sum up the treatment of genu valgum. 1. Cases under 4 ' Bodily Deformities, pp. 274, 275. Dr. G. Melloni of Rome has declared his pre- ference for Mr. Reeves' operation over^Iacewen's, as it completely avoids the difficul- ties arising from the vicious union of fragments or from incomplete union, which, according to Dr. Melloni, sometimes occur in the latter operation. X. Y. Med. Rec. May 1894, p. 638. U 290 DEFORMITIES OF THE LOWER EXTREMITY years of age should be treated by manipulation, splints, and mechanical appliances ; operative interference is not called for. 2. Cases over 4 years of age fall into two classes : (a) Those in which malposition of the limb is entirely due to relaxation of the ligaments, with but little overgrowth of the internal condyle. (&) Those in which the internal condyle is much enlarged, or the lower end of the femur twisted inwards, and the bones are eburnated. In division («) rest, splints, and walking apparatus will effect a cure. In division (b) treatment by mechanical means is possible but tedious. It is better to operate, and to perform an osteotomy Fig. 161. — Genu varum of rbachitic origin (after Rertard). Fig. 162. — Genu varum in the left limb comple- mentary to genu valgum in the right limb (after Redard). of the femur from the outside, with section of the biceps and ilio- tibial band if necessary. Genu Varum Synonyms — English, Bandy-legH, Out-hiec ; Latin, Genu Edrorsiim ; Frenclj, Gcnoii en dehors ; German, SicJicIhcin, Sdhelhcin, O-Bein. Definition. — Genu varum is that condition of the legs in which a line drawn from the head of the femur to the middle of the ankle- joint falls inside the centre of the knee-joint (Macewen). Causation. — 1. In the majority of cases, rickets is the chief cause, and genu varum is, in such instances, constantly found associ- ated with curved tibice. Indeed, the so-called genu varum is not limited to the knees. There is a general outward convexity of the CHAP. II GENU VALGUM, VARUM, RECURVATUM, AND BOW-LEGS 291 femur and tibia, and as the knee happens to be situated very nearly in the mid-length of the limb, it is the most prominent part of the convexity (Fig. 161). 2. Complementary. — This variety of genu varum is unilateral, and is the antithesis of genu valgum in the opposite limb (Fig. 162). 3. After Operation for Genu Valgum. — I have seen cases in which the primary deformity has been over-corrected, and genu varum has resulted. 4. Oeeupation. — The folio wiug is an example : — Case 55. Genu Varum from Occupation. — A young man, aged 19 years, came to me at the National Orthopsedic Hospital. The left leg alone was affected, while the right was quite straight. He had worked for five years at a printing machine, standing on the right leg and using the left exclusively for the treadle. When he became fatigued, instead of working with the leg in a vertical plane, he was accustomed to allow it to lapse outwards, thus economising the calf muscles by substituting for them the weight of the everted limb falling on the treadle. 5. After Excision of the Knee. — As a rule, if the limb ankylose in a vicious position, the deformity is antero-posterior, but in the following case it was external : — Case 56. External Deformity of the Lower Limb after Excision: Operation. — Edward P , aged 13 years, came to me at the Hospital in August 1891. The history is that, when 6 years old, he hurt his left knee, and two years afterwards he underwent an operation in Dublin. From the appearance now presented by the limb, there is no doubt the joint was excised, as the patella is absent, and there is the transverse scar of an incision across the position of the lost joint. His present condition is this. At the site of operation firm ankylosis has taken place. Above this, and about the lower end of the femur, numerous scars are seen, indicative of old bone mischief. The lower end of the femur is bent inwards, but not to such a degree as the shaft of the tibia, which is so much curved that when the boy stands on the right leg the left heel crosses the crest of the right tibia and can- not be brought to the ground. There are 2| inches shortening on the left side. He refused operation, and was fitted with an internal support, extending from the left tuber ischii to the internal malleolus. He did not present himself for two years. During that time he had grown considerably, and now the left foot was 4 inches off the ground and still more thrown across the right leg. On account of the disability he asked that an operation might be performed. It was pointed out there was some risk of the bone affection lighting up, but he consented to run that risk. Two osteotomies were performed, one at the lower end of the femur and the other at the upper part of the tibia, and the limb was straightened. Considerable difficulty was experienced in sawing 292 DEFORMITIES OF THE LOWER EXTREMITY through the lower end of the femur. The time occupied in doing so was three-quarters of an hour. Tliis was owing to the exceedingly sclerosed condition of the bone. The limb was put up first in wooden splints and then in plaster of Paris. When the left tibia had been brought immedi- ately beneath the left hip joint, the shortening was 2^ inches instead of 4, so that with a cork sole he walked well. 6. Occasionally genu varum is seen iu adults arising from relaxed ligaments alone. Age. — The rhachitic cases occur under 4 years as a rule, and, in the writer's opinion, are more common in girls. Clinical Varieties. — 1. The form of genu varum usually met with is that in which the prominence of the knee is but a regular part of the arc of the circle formed by the bending of the femur and tibia outwards. 2. In rare cases the deformity is at the knee, or just above it, owing to the effect of rickets, or other causes on the ligaments of the knee, or lower third of the shaft of the femur. In such cases the external condyle elongates, and the internal atrophies, as it bears most of the weight. The external lateral ligament is also stretched. Fig. 163.-Epiphysiary genu varum. 3. Epiphysiarygcnu varum. Redard^ The outward curve iu tiie right describes a form wliich has hitherto limb is most marked about the . • o upper epiphysis of the tibia, and received but scant attention from authors. Redardf''^*^ '"'^ *°'^''°° ^""^^^^ "^^ ^^^^ ' " ^^' ^°"^^^ °^ rapidly in patients of 12 to 16 years, especially girls, and is associated with the marked activity of the epiphyses above and below the knee at this time of life." In many cases Eedard has noticed local pains. The outward curve of the bones is most marked about the upper epiphysis of the tibia, and is combined with torsion (Fig. 163). Degrees of Genu Varum. — These vary from a slight external projection of the knees to complete bowing of the whole extremities, so that a circle may be described within the limits of the pubes and lower limbs. It is difficult in rhachitic cases to explain the out- ward bending of the knees. It is suggested - that the ricketty ^ 02). cit. p. 591. - Bradford and Lovett, o^;. cit. p. 674. CHAP. II GENU VALGUM, VARUM, RECURVATUM, AND BOW-LEGS 293 attitude is a factor in the production. A child with rickets stands with the lumbar spine lordosed and the thighs flexed slightly. When the latter occurs the knees are separated and the femora rotate outwards on their own axes. The line of gravity, therefore, instead of falling outside the knees, falls inside, and any softening of the bone encourages yielding externally. This explanation is plausible but unsatisfactory. With a similar ricketty attitude, genu valgum, the opposite condition, is more often seen. I venture to think genu varum arising in rickets is more likely to be due to unequal growth at the epiphysial line, i.e. the outer portions are more active than the inner, and in genu valgum the reverse occurs. Symptoms. — The nature of the deformity is at once seen on look- ing at the patient. The line of the knee is oblique and the external condyle is longer than the inner. The deformity, if situated at the knees alone, disappears on flexion as in genu valgum. The patient walks with more security than in the latter affection. It is necessary, however, having an eye to treatment, to ascertain the condition of the ligaments and bones as to relaxation and elasticity. Treatment. — It is conducted on the same lines as genu valgum. In cases in which the bones are soft and the ligaments relaxed, inside splints, with manipulation and massage, are sufficient. When the bones are eburnated, osteotomy at the point of greatest curvature in the limb is necessary. Genu Eecurvatum Synonyms — English, Back-knee ; French, Genou en arrihre. Definition. — A deformity characterised by hyper-extension of the knee-joint. Occurrence. — It is seen associated with other conditions, viz.: — 1. Congenital club-foot, e.g. equino- varus and valgus. 2. Paralytic club-foot (Fig. 164). In an extreme case I saw, the patient could balance herself on the under aspect of the condyles of the femur with the legs hyper-extended. 3. Eickets, on account of the relaxation of the muscles and ligaments. 4. Deformities of one limb where an excessive strain has been put upon the sound limb. 5. Charcot's disease. 6. As a primary condition, it is seen in congenital displacement of the knee, and is often present in infants who are otherwise perfect. 294 DEFORMITIES OF THE LOWER EXTREMITY Back-knee as the Result of Irregular Growth of the Upper Epiphysis of the Tibia. — Sir G-. Humphry, Kirmisson, and others ^ have described a peculiar condition of back-knee, in which a bending of the upper part of the tibia exists in the situation of the epiphysial cartilage. The deformity is often present on both sides, and follows chronic inflammation of the knee or upper part of the tibia, and arises from excessive growth of the posterior part of the upper epiphysial line of the tibia. At first the impression given by this lesion is that of a dislocation back- wards of the knee ; but carefid exami- nation shows that the tuberosities of the tibia are in perfect contact with the articular surface of the femur, and that the cause of the deformity is the formation of a forward angle of flexion at the upper epiphysial line of the tibia. Corresponding to the depression in front in this situation, is a promi- nence which can be felt in the lower part of the popliteal space. The shaft of the tibia is consequently directed forwards and downwards, instead of directly downwards. In the absence of any chronic inflammation of bone or joint in this region, it is presumed that irregular growth of the epiphysial line has occurred. If the deformity is a hindrance to progression, a walking apparatus with a flexion sj)ring at the knee-joint should Ije worn. Fig. 164. — Geuu recurvatum of para lytic origin (after Eedard). Curved Tibia and Fibula TIJow-Legs) Alterations in the shape and outline of tlie tibia and fibula arise from rickets, syphilis, osteitis deformans, and osteo-malacia. The fibula follows the tibia in the direction of the deformity, so that the shape and outline of the tibia are the main points at issue, and it ought, therefore, to be understood that when the tibia is mentioned the fibula participates in the same kind of changes. ^ See a paper by R. Whitman, an abstract of which appeared in the Amrr. Med. and Surg. Bull, loth March 1894. CHAP, n GEXU VALGUM, VARUM, RECURVATUM, AXD BOV'-LEGS 295 Ricketty Curvature of the Bones. — Of all the deformities arising from rickets, bow-legs are the most common and the least serious. The pathological changes in the bones have been described on p. 256. To the touch the bones are tender and unusually elastic. The three stages of osseous rickets, viz. congestion, softening, and eburnation, are best seen in the bones of the leg. If one feels the crest of the tibia, the outline is sharp and the crest itself is deflected. The inner surface of the tibia is concave, and the curvature is rarely purely anterior, being antero-lateral, either externally or internally. The tibia is flattened from side to side, and the curve is generally most marked at the lower third. The medullary canal is often narrowed in the middle of the shaft, and enlarged at the extremities ; but occasionally it is dilated through- out its whole extent When the curvature is very marked, the medullary canal is eccentric, being nearer the convexity than the concavity of the bones. It may be so near the surface of •the convex portion as to be separated from it only by a thin layer of bone, or it may actually open on the surface of the bone (Beylard). On the concave side the bone is much thickened by sub-periosteal deposit, which acts as a supporting buttress to the arch of the concavity. Frequently genu varum and curvature of the femur are present as well, but the chief curve is in the tibia. Seldom are curved tibise associated with genu valgum. The most common coexisting deformity is flat-feet. The age of onset of the deformity is between the first and second year. In rare cases it appears as early as the tenth month, or as late as the third year. But taking the average age of 500 cases brought to me at hospital, I find it to be 2 years and 2 months. In private practice the attention of the medical man is drawn to the deformity in the children of the well-to-do much earlier than in the case of the poorer classes. The tibia may be curved in almost any direction, but apart from genu varum and curvature of the femur,^ the following types are found : — 1. An external curvature, and generally situated at the junction of the middle and lower third of the leg. AVith this there is some- times a twist in the bones, the lower third of the leg looking inwards ^ The pi'esence of curvature in tliis bone may be shown by crossing the legs and. bringing the condyles as much as jiossible side by side without rotation, and then noting if an elliptical space exists between the thighs. 296 DEFORMITIES OF THE LOWER EXTREMITY and forming a well-marked angle, externally, with the remainder of the diaphysis (Fig. 165). In other cases the curve is cliiefly at the junction of the upper and middle thirds of the legs, and the angle is promiuent internally. The feet are flat and the knees are apparently close together. This variety is often mistaken for primary Fic;. 165. — Curveil tiliire. from rickets in a child aged 2^ years. genu valgum. But if the case be watched from the first, the curvature of the tibia precedes the approximation of the knees. 2. A more or less anterior curvature of the tibia, occupying the whole length of the bone, or only the upper or lower third. The heel is often raised, the foot pointed, and in walking it is in a position of equino-valgus. 3. An internal curvature is present, with flattening of the bones and the feet in a varoid position. Of these three types the first is common and the third rare. Occasionally one sees an internal curve in one leg and an external in the other. CHAP. II GENU VALGUM, VARUM, RECURVATUM, AND BOW- LEGS 29? Prognosis. — In bow-legs there is always an inclination to spontaneous rectification.^ This in slight cases is often complete, but in severe cases only partial. It is therefore unwise to allow any case to pass untreated, since, if the bones are soft, slight cases may very quickly become severe. The method of spontaneous rectifica- tion can be readily understood from Fig. 166 after Oilier. Treatment. — The line of treat- ment depends upon the condition of the bones, whether soft or eburnated, the direction of the curve, and the age and social status of the patient. In the case of the neglected children of the poor, osteotomy is called for in less severe cases, and earlier than in children of the well-to-do, who obtain efficient supervision and suitable ap- paratus. All forms of curvature except the marked anterior are amen- able to mechanical treatment when the bones are soft. The question of treatment may be discussed under three headings : — 1. Constitutional Treatment with Local Manipulation. 2. Constitutional Treatment with Manipulation and the Application of Splints or Walking Apparatus. 3. Operative. 1. Constitutional Treatment with Local Manipulation. — This form of treatment is advisable for babies who ^ Kampe {Bruns. Beitrage z. Tclin. CMr. xvi. 1) is of opinion that the greater number of all cases undergo spontaneous cure. The process lasts two to four yeais. If the curvatures begin in the first or second year of life the legs are quite straight by the fourth or fifth. CC a)A CC Fig. 166. — Scheme to illustrate spon- taneous rectification of ricketty bones during growth (after Oilier). The small figure on the right represents a ricketty tibia in a young child. The large figure represents the same bone in an adolescent. The small figure is inscribed within the large. DA, Place occupied by the shaft of the primitive bone which has disappeared in the progress of develojiment ; CA, CA, the addi- tional bone due to ossification at the eijijjhysial lines, which were in a right line with the shaft during the attack of rickets. This new bone CA, CA forms two cones of which the summits correspond to the extremities of the diaphysis of the infantile bone. They enlarge pari passit with the growth of the bone. OP, Periosteal bone, by means of which the bone becomes thicker, and the former shaft is gradually enclosed ; EE, epiphyses ; CC, epiphysial line. 298 DEFORMITIES OF THE LOWER EXTREMITY have not yet walked, as it is a fact that curvature of the tibia and fibula is sometimes present before the child has attempted to walk ; for children who are not weighty in the body ; for those in whom the bones are not unduly soft, and the curve is a general rather than a localised one. The usual constitutional means of alleviating rickets must be carried out fully, while the legs should be bathed and rubbed night and morning, and the nurse instructed to hold the leg at the knee and ankle, and using the tluimbs as a fulcrum to make gentle attempts to straighten the leg. This manipulation should be performed night and morning. A record of the curvature, by means of either photographs or tracings, as described in genu valgum, ought to be taken from time to time, and if tlie curve show any increase, mechanical supports are required. 2. Cotistitutional Treatment with 3fechanical Siqjports and Maiiipidation. — This form of treatment is called for when a curve originally slight is becoming marked ; when a child is weiglity, and cannot be kept off his legs ; when tlie curve is located in one part of the bone more than another ; and when the child is luider 4 years and the bones are not hardened. The question arises, Should the form of apparatus be such as to entirely prevent the child walking? I think not in any case. All the forms of apparatus act on the principle of taking their fixed points from two bony prominences and drawing the curve towards the support. Provided this is efficiently done, the cliild should be allowed to use his legs, as free movement by them encourages that improved nutrition, which more than counter- balances any of the l)ad effects of the body-weight. The simplest form of apparatus is an inside wooden splint from the internal condyle to the internal malleolus for external curvatures, and the reverse for an internal curvature. But in many cases the deflection of the bone is as much anterior as lateral. The single splint is then inefficient, and the difficulty may be overcome by using a trough splint of the following construction. Two straight pieces of wood or tin, of suitable lengtli and width, are joined together so as to make an elongated rectangular splint. If the curve is antero-external, the splint is put on the inside and the back of the leg only. By the pressure of the bandage the antero-external curvature is drawn towards the angle of the splint. The same principle exists in the less cumbrous but more expensive tibial instru- CHAP. II GEXU VALGUM, VARUM, RECURVATUM, AXD BOV'-LEGS 29 9 ment (Fig, 16 7), in which there are rigid lateral and. posterior rods fixed to the boot and knee piece, with straps passing round the leg. In those cases where a marked anterior curvature exists, with elevation of the heel, mechanical appliances are of little or no value. 3. Operative Ifeasures, viz. — 1. Osteoclasis : ^Manual or Instrumental. 2. Osteotomy. 3. Eemoval of a Wedge from the Bone. Operative interference is called for when the bones are so hard that mechanical treatment is out of the question : in children over 4 years of age ; in cases of severe anterior curvature ; and in marked instances of lateral curvature. With regard to the choice of operation, the majority of surgeons prefer osteotomy, but some elect to perform osteoclasis. Personally, the writer's preference is for osteotomy, because it is a more precise operation, and less damage is done to the bone and soft tissues by a clean saw-cut. It will be urged that in osteoclasis the fracture is simple, but with correct antiseptics the dangers of sepsis after osteotomy are very remote. Certain it is that osteoclasis is inadmissible: (1) if the curvature is very near a joint or epiphysis; Tibial instrumeut for bow-leg. (2) if the bone is very hard or firm; (3) if there are several curves in a limb ; (4) if the curve is anterior. I cannot help thinking that, despite guarded assertions to the contrary, considerable damage may be done to the soft tissues by the use of osteoclasts. In France the Colin's osteoclast is much employed, and in this country Dr. Nicholas Grattan, of Cork, has perfected an instrument of extreme power and, according to its inventor, of great precision.^ 1. Manual Osteoclasis. — Mr. E. W. Murray," of Liverpool, who has 1 Grattan. "Twenty-seven Cases of Deformities of the Extremities treated by Means of the Screw Clamp," Brit. Med. Journ. Srd May 1890, p. 1006. All these did well. Occasionally, however, laceration of the soft parts occurred. A simple may thus be converted into a compound fracture, and this occumng in a limb not prepared aseptically for such an event, with an instrument which has not been sterilised in all probability, is apt to be disastrous. - "The Treatment of Ricketty Deformities by Means of Osteoclasis," Brit. Med. Journ. 2oth Aug. 1894, p. 413. 300 DEFORMITIES OF THE LOWER EXTREMITY sec. iv had very extended experience of this method, having straightened no less than oil legs in one year by it, gives the following directions : " If it is a simple curve, to break the bone at its greatest convexity, one should not attempt to break it as one would a stick ; but grasping the limb, say it is the right leg, firmly at the point at which you wish to produce the fracture, and keeping the left hand perfectly steady, using the thumb as a fulcrum, slowly over-correct the deformity with the right hand until the bone is fractured. It is important that the bone should be fractured and not merely bent, for the tendency of the bent bone to resume its former position is so great that the bandages are apt to become tight and the foot to swell, or the child's delicate skin to blister at the points where the splint presses. If, however, in attempting to straighten bone, one has to use so much force as to render it un- certain where the fracture will take place, then, as the object is to straighten the bone and not simply to break it, you had better desist, and perform an osteotomy." In no one of his series of cases has ^Ir. Murray had a mishap. It appears, then, that manual osteoclasis is a safe procedure, and saves the trouble and time involved in an osteotomy. But with regard to osteoclasts, if the bone requires that great amount of force to fracture it which these instruments are capable of exercising, the writer would prefer osteotomy. 2. Osteotomy. — The operation is a simple one. The leg is duly asepticised and supported on a sand-bag. If it be the left leg, the surgeon stands on the left side and passes an osteotomy knife on the flat through the skin over the crest of the tibia, and at the most prominent point of the curve, down over the inner surface of the hone, and then tm^ning it at right angles, firmly grooves the periosteum. Along the knife the saw is introduced, and as the knife is withdrawn, the skin incision is enlarged to prevent the heel of the saw^ abrading it. "With short movements the tibia is di\-ided, taking care not to wound the structures posterior to it. There is no necessity to divide the fibula with the saw, since, when the section of the tibia is nearly complete, a firm movement inwards or outwards, as the case may be, will fracture the fibula and the remaining portion of the tibia. A counter-opening may be made for drainage. The wound is dressed and the limb is put up in plaster of Paris, and kept so for six weeks. 3. Removal of a Wedge from the Bone. — An open wound is necessary in this case. Tlie size of the wedge to be removed should CHAr. II GENU VALGUM, VARUM, RECUR VATUM, AXD BOW -LEGS 30] be determined previously by drawing an outline of the leg on paper, and then removing with scissors a sufficient wedge of the paper, so that the model is made straight. In this form of operation the osteotome is desirable, as it is easier to remove the wedge with it than with the saw. Some difficulty may be experienced, after excision of the piece of bone, in settino- the lecc straio-ht. This arises from two causes : — k 4 Fig. 168. — Congenital sj^hilitic curvature of tibiae (Case 57). Fig. 169.— Front view of Fig. 168, showing entire absence of any lateral bendiug of the bones when the curva- ture is due to congenital syphilis. (a) The periosteum on the pos- terior surface of the tibia is imper- fectly divided. (&) In cases of great anterior curvature the tendo Achillis is too short, and prevents apposition of the fragments. It should there- fore be divided. JSfon- Union after OjJerations. — This is so rare an event, consider- ing the enormous number of osteotomies performed, that it is of little practical moment. A case of non-union came under the notice of my colleague, Mr. Little.^ He first tried freshening the ends of the fractures, and then, at my suggestion, placed living rabbit's bone in. But this failed, and Mr. Little was forced to amputate. Below the site of non-union there was most extensive fatty degeneration of all the tissues of the lower part of the leg and foot. Syphilitic Curvatuee of the Tibia This variety of curvature is met with in congenital syphilis, and occasionally in acquired syphilis. 1 B(yy. 3fed.-Chir. Trans. 1891. 302 DEFORMITIES OF THE LOWER EXTREMITY In the congenital form the appearance is quite diagnostic. The affection is frequently symmetrical, and occurs mainly in children under 6 years of age. I have met \\dth six cases during tlie last five years. The following descriptions are of two cases which came before me at the Xational Orthopaedic Hospital. The appearances are seen in Figs. 168-171. Case 57. — C'on;/enital Syphilitic Curcature of the Tibicc. — ]\I. E., aged 5, came to me in October 1892. Thei'C are five children in the family, Fig. 170. — Congenital syphilitic curve of tibia (Case 58). and this is the second child. The mother has had no miscarriage, but she suffered from a rash after the birth of this patient, who had snuffles at birth, and " red spots " on the bod}' up to 3 years of age. There is now a peculiar earthy pallor, with the high-arched palate and the scoring round the mouth associated Avith the congenital taint. The mother states that this child was born at the eighth month. It should be added that the next child has also shown signs of congenital syphilis. The deformity is shown in Figs. 168, 169. On looking at the child from the front but little abnormality is observed, except some genu valgum. A lateral view, however, shows a remarkable anterior curvature CHAP. II GENU VALGUM, VARUM, RECURVATUM, AND BOW-LEGS 303 of 'both legs, nearly symmetrical, and aflfecting the middle rather than the lower third. The curvature in both cases is directly anterior, and not antero -lateral. The crest of the tibia is very rounded, and the internal and external surfaces of the bone are convex. Right leg, outer side. Eight leg, inner side. Left leg outer side. Fig. 171. — Congenital syphilis, with marked curvature of the tibiae. The drawings are taken from a male infant aged 3 months, who was seen at the Evelina Hospital in October 1895. Case 58. Congenital Syphilitic Curvature of the Tibice. — A. J. S., aged 6, came to me in February 1896. The mother has had six children, and two miscarriages, both at the seventh month. Of the six children, two died in infancy, but the Cause of death is unknown. There is no history in A. J. S. of spots nor of sores round the mouth, and no sign of keratitis. On examination, the child is fairly healthy-looking. The right 304 DEFORMITIES OF THE LOWER EXTREMITY tibia is thickened at the middle third for 6 inches, the crest lost, and the surfaces rounded. The leg is hot and red. There is anterior but no lateral curvature. The left leg is affected to a less degree than the right. Tenderness has been noticed for eight or nine months. The patient cannot walk. The teeth are very deficient, dome-shaped and irregular. In March 1896, after the patient had been taking grey powder for three weeks, the redness and tenderness disappeared, and the forward curvature in both legs had decreased. Fig. 172.— Suppurative syphilitic epiphysitis at lower ends of radius and tibia in an infant aged 1 mouth. The child died shortly after the drawings were made, and the epiphyses were found lying loose in purulent cavities. Fig. 173. — Epiphysitis of upper end of humerus from congenital syphilis. The upper epiphysis is seen to be separating from the shaft (Guy's Hospital Museum,! 105). As to the diagnosis from rhachitic curve, the following table serves to show the points of contrast : — Rhachitic curve. Acre . . . . Generally under 3 History Direction of curvature Signs of rickets pre- sent Antero - external or antero-internal Syphilitic curve. Occurs up to the ninth year Syphilis in parents and other signs of congenital syijhilis in child Purely anterior CHAP. II GENU VALGUM, VARUM, RECURVATUM, AND BOW-LEGS 305 Ehachitic curve. Syphilitic curve. Position of crrve . . Generally in upper or In middle of shaft lower third Crest of tibia . . Sharp . . . Smooth and rounded Surfaces of tibia . . Flat or concave . Convex These points afford sufficient guides in distinguishing between the two forms of curvature. If a syphilitic curve be viewed from the front there is no lateral deviation to be seen. The form of congenital disease in this event is osteo-plastic (Parrot). In the acquired form of syphilitic disease of the tibia the affection is a localised swelling or node rather than a curvature, and is rarely symmetrical. The treatment is anti-syphilitic ; splints and manipu- lation are of no avail. With reference to other forms of curvature, such as those arising from osteitis deformans and osteo-malacia, special monographs should be consulted. X CHAPTER III CLUB-FOOT— GENERAL CONSIDERATIONS Varieties and Causation of Club-Foot — Its Frequency — A Method of Examinin(j Club-Foot — General Principles of Treatment — The Processes concerned in the Union of Tendon — TJie Autlwi^s Experiments and Deductions. Synonyms — Latin, Talipes, Pes Contortus ; French, Pied Bot, Stn^phopoclie , Kyllopodie, KjjUose ; German, Klumpfuss. Definition. — The term club-foot comprises those deformities in which there exists an abnormal anatomical relation of the foot to the leg, or of one part of the foot to the other. By some the meaning of club-foot is restricted to the deformity known as talipes equino-varus, but by the greater number of surgeons it is used in the wider sense just indicated. Inasmuch as the foot is capable of extension, flexion,^ adduction with inversion, abduction with eversion, and talipes is associated either with over-action or loss of action of one or more groups of muscles affecting these movements, so we have — 1. Talipes equinus, or the over-extended foot; ) the centre of motion be- 2. Talipes calcaneus, or the over-flexed foot ; J ing at the ankle-joint. 3. Talipes varus, or the adducted and inverted ^ ,, , j. ,• i .-' ' the centre of motion be- , rr I- ' 7 xi 1 1 i. J 1 i. 1 r hi" at the raedio-tarsal 4. lalipes valgus, or the abducted and everted . ? ^ foot; I J""^*^- Further, the convexity of the plantar arch undergoes at each contact of the foot with the ground a diminution, and when the foot ^ In the following pages, when the term "extension" of the foot is used, it implies pointing of the toes ; and when " flexion," raising of the toes, with depression of the heel, is meant. This is not morphologically correct, but long usage gives sanction. But the term "extension" is better replaced by " dorsi-flexion," and "flexion" by "plantar- flexion." CHAP. Ill CLUB-FOOT GENERAL CONSIDERATIONS 307 is raised, a restoration. Hence two more varieties must be added, viz. — 5. Pes carus, in which the convexity of the longitudinal arch of the foot is increased. This it is better to subdivide into talipes arcuatus and talipes plantaris, according as the front part of the foot is on a level with or below that of the heel ; it being understood that in each case there is a distinct increase in the convexity of the arch. 6. Pes planus, in which the arch is dropped to a varying degree. Clinically it is found that such a simplicity of arrangement does not always prevail. Frequently the deformity is compound in its character. Thus talipes equinus and varus are often combined, and talipes calcaneus and valgus. The compound forms in their order of frequency are — 1. Talipes equino-varus. 2. Talipes calcaneo-valgus} 3. Talipes equino-valqus. 1 -^y , „ j/ ^, ^ } Uncommon. 4. lahpes calcaneo-varus. j Taking 150 consecutive cases of club-foot wdiich have come under my care at the iSTational Ortbopasdic Hospital, and 50 which I have treated at the Evelina Hospital, or 200 cases in all in five years, talipes calcaneo-varus of the congenital variety w^as seen once, viz. in a child of 2, and in the left foot, while the right foot was an example of talipes calcaneus ; congenital equino-valgus was seen twice, and paralytic equino-valgus five times. The Causes of Club-Foot may be summarised : — I. Congenital. II. Acquiird. 1. Paralytic, as a result of acute anterior polio -myelitis (infantile paralysis). 2. Spastic, as a result of hemiplegia, primary lateral sclerosis, or reflex irritation from teething and dys- pepsia, giving rise to convulsions ; or from partial asphyxia at birth. Other causes of reflex irritation ^ Bonnet classified "club-foot" into two divisions — the club-foot internal-popliteal or talipes equino-varus ; and the club-foot external-popliteal, or talipes calcaueo-valgus — founding his theory on the supposition that in the first variety the muscles supplied by the internal popliteal nerve, and in the second variety those by the external popliteal nerve, were affected. But in talipes equino-varus the tibialis anticus, which is supplied by a branch not of the internal but through the external popliteal nerve, is implicated. Then, again, we meet with rarer forms, such as equino-valgus and calcaneo-varus, which cannot be included in Bonnet's classification. 308 DEFORMITIES OF THE LOWER EXTREMITY sec. iv are an abscess in the calf or inflammation in the ankle-joint.^ 3. Cicatricial, the result of burns. Talipes calcaneus is seen to follow deep burns on the front part of the foot. 4. Traumatic: (^0 Injuries to bones, e.g. fractures and separa- tion of the epiphyses." (Z>) Injuries to joints. Schwartz ^ alludes to unreduced dislocation of the ankle-joint as a cause, (p) Injuries to tendons. A ruptured tendo Achillis badly treated results in talipes calcaneus."* {(]) Injuries to nerves. A case is recorded, if memory serves me correctly, in which talipes resulted after accidental section of the posterior tibial nerve. 5. Inflammatory. After acute osteo-myelitis of one of the bones of the leg, the rate of growth is arrested in one bone, while in the other it is normal, and the foot is turned into the position of either A'algus or varus. Chronic osteitis has been known to i^roduce a like result, but in a different way. The growth in the healthy bone is normal, while in the diseased bone it is excessive. Such an instance came under my notice some years ago. 6. Talipes decubitus — a spurious form of contraction wiiich occurs in bedridden patients from the " dropping " of the feet and the weight of the clothes. It is best marked and most intractable in alcoholic paraplegia. 7. Hysterical paralysis or contraction. Of the acquired forms the paralytic and spastic varieties are ^ As to the possibility of reflex irritation from an elongated and adherent prepuce causing talipes, I have not been able to convince myself. L. H. Sayre's views on the question are well known. Cf. Orthopedic Surgery, Lecture III. In justice to Sayre it should be added that he terms this condition "reflex paralysis," and argues that the deformity is not due to contraction. It is diSicult, however, to believe that if Sayre's cases were paralytic, recovery could have been so rapid. In one case the child was able to walk fourteen days after circumcision ; op. cit. p. 15. - I have twice seen cases of valgus following fracture of the lower end of the fibula in young subjects, in whom the natural rate of growth at the lower epiphyses was arrested, while the tibia continued to increase in length, and pushed the foot outwards. ^ " Des diffurentes especes de pied bots et leur traitement," These (Vagreyat. Paris, 1883. '' I have also seen four cases of calcaneus which followed equinus, and due to ex- cessive elongation of the tendo Achillis after division. The usual history is that the patient was allowed to walk about "a week or two " after the operation. CHAP. Ill CLUB-FOOT GENERAL CONSIDERATIONS 309 more immediately due to abnormal muscular action, and are common ; while the others are rare, and amongst the curiosities of surgical literature. These latter may be termed s^Durious talipes. In the pro- duction of talipes we must remember that the role of the muscles presents itself under two very different aspects. (a) In congenital and spastic cases a group or groups of muscles are in over-action, while their opponents are of normal or slightly less strength. The foot is therefore pulled into an abnormal posi- tion corresponding to the action of the more powerful muscles. If an attempt be made to replace the foot, it is either entirely resisted, or partial restoration alone can be effected. When the force is removed, the foot "flies back" to the deformed position. In these cases then the direction of the deformity is in the line of action of the affected muscles, e.g. talipes equino-varus from contraction of the calf and tibialis anticus muscles. (/3) In paralytic cases a group or groups of muscles are para- lysed, while their opponents are of normal strength. The foot is therefore pulled in a direction opioosite to that of the affected muscles. In early cases the foot " flops about," and complete restoration can be effected. In paralytic cases the direction of the deformity is opposite to the line of action of the affected muscles, e.g. paralysis of the muscles on the front of the leg and of the peronei causes talipes equino-varus. Frequency of Ckib-Foot and its Varieties. — Club-foot is a common deformity. Mr. F. R. Fisher -^ has tabulated 3000 consecutive cases of deformities which have come under his notice. The analysis showed that club-foot occurred in 581 cases. But taken in comparison with other surgical affections, it is of rare occurrence. Eedard " estimates that in 1000 surgical cases, 4 of club-foot are met with. Dieffenbach admits that one instance of congenital club-foot is found in every 800 to 1000 cases. In 23,932 new-born infants Chaussier found 132 deformities, and of these 35 were cases of talipes. Of 15,229 births occurring at La Maternite de Paris, Lannelongue^ noted 108 cases of deformity, and 8 of these were club-feet. It is said that congenital club-foot is more common than the acquired, but this I venture to doubt. Of 200 consecutive cases under my care, 8 3 were congenital. Sydney Eoberts' ^ statistics support my view, viz. 173 congenital cases against 223 acquired. 1 Ashurst, Encyclo]}. of Surg. vol. vi. p. 1003. ^ Op. cit. p. 622. ^ "Du pied hot. cong.," These (Vagr6gation, Paris, 1869. * "Club-Foot," Phil. Med. News, March 1886. 310 DEFORMITIES OF THE LOWER EXTREMITY sec. iv Sex. — Congenital club-foot is more frequent in boys than girls, and the same is true of the acquired varieties. Hcrcditi/. — Many surgeons have observed that club-foot runs in families. Quite recently I had under my care a middle-aged man suffering from advanced flat-foot, which by treatment was much improved. Six months after ceasing attendance his wife bore him a son, who had talipes equino- varus of both feet. Adams ^ mentions a case in which the deformity persisted through three generations, and Eedard refers to a similar instance. Not only is club-foot hereditary, but the particular form reproduces itself in the children. With congenital club-foot other deformities are frequently found, such as polydactylism, club-hand, hare-lip, and spina bifida. There is now under my care a case of congenital talipes calcaneus as- sociated with spina bifida. In dealing with talipes it is necessary to determine the form, and then to ascertain the cause. A description will therefore be given now of a method of examining club-feet. A Method of Examining Club-Feet. — To some a club-foot is a club-foot and nothing more. But it is imperative before com- mencing treatment not only to ascertain which form of club-foot is being seen, but also to be precise as to the cause. It is therefore my endeavour to draw out a rough plan of the usual method of examination, and to give illustrations in point as far as possible. The various steps of the examination are :. — 1. The history. 2. The gait on entering the room. o. The position of the foot and limb on standing and sitting. 4. An outline or impression of the sole of the foot. 5. General examination of the affected limb or limbs as to shape, size, muscular development, diminished or excessive mobility of the joints, the temperature of the limb : the condition of the skin as to colour, integrity, and the presence of corns or thickened skin over the heels and beneath the balls of the toes. The boots should also be looked at, and any unequal wear at one or more spots noted. 6. The passive movements which may be effected by the surgeon, and the directions from which resistance is felt. 7. Localisation of the resistant ligaments and fascicle, and of 8. Contracted or paralysed muscles. This is effected by touch, by movement on the part of the patient, and by 1 Op. cit. p. 218. CHAP. Ill CLUB-FOOT — GENERAL CONSIDERATIOXS 311 9. Electrical reactions. 10. Signs of abnormal and arrested development, especially of bones. To proceed to details. 1. Tlie History. — The first question asked is, When was the deformity noticed ? Of course in congenital cases, if the deformity is at all marked, it is seen immediately after birth. In slight cases difliculty may arise. Mr. Eeeves ^ says regarding the normal form of the foetal foot : " In it the plantar arch is but little formed, the sole of the foot is turned in, and the anterior part shghtly adducted, but the peronei are capable of turning the sole outwards. To distinguish the former natural positions from slight cases of club- foot, the infant should be placed near the fire ; and if the foot be normal the child will flex the thighs upon the abdomen, the legs upon the thighs, and turn the feet out ; but in equino-varus it will not be able to evert the foot." Congenital club-foot is as often double as single. Paralytic club-foot is more often single. In the latter case the information will often be volunteered that the child was quite well until about 18 months old, and then it was feverish and had a convulsion ; and next morning it was unable to move the limb. In spastic cases, which are often bi-lateral, some history of asphyxia at birth, or of symptoms of meningitis, or an account of a fall, blow, or sudden shock is fortlicoming. Inquiry should also be made as to rheumatism, and, if an adult, as to gout in the family. The mode of delivery is often of interest ; many congenital cases have been breech presentations or one of twins. Some cases of congenital club-foot are distinctly hereditary. 2. The Gait on entering the Boom. — The "tiptoe" forward gait of spastic cases is characteristic. In infantile paralysis, if the case be one of equinus, the toes are dragged and the heel is raised ; if the affection be calcaneus, the heel is brought to the ground with much emphasis, while the front part of the foot flaps somewhat as the patient advances to take the next step. Some shortening is frequently present in paralytic cases, and evidence of this is seen in the halting gait and the drooping of one side of the pelvis and one shoulder. In congenital club-foot it should be noted which part of the foot comes into contact first with the floor. In equino- varus considerable turning in of the foot and raising of the heel is seen. Weakness of one leg, with the arm held rigid and the forearm pronated -and flexed, are suggestive of infantile hemiplegia. ^ Practical Ortliopcedics, p. 152. 312 DEFORMITIES OF THE LOWER EXTREMITY sec, iv 3. The Position of the Foot and Limb on Standinrj and Sitting. — It is essential that the patient be examined in both positions, otherwise errors may be made. For example, in right-angled con- traction of the tendo Achillis, when the patient is sitting he can bring the heel to the ground because the calf muscles are relaxed, but on standing with the leg fully extended and the calf muscles tense, the heel may be an inch or more off the floor. Again, some cases which appear to be equino-valgus when the patient is standing, resolve themselves into equinus if the sitting position be adopted with the leg placed at right angles to the knee, for the reason that in order to bring the heel to the ground in standing, with a somewhat short tendo Achillis, the foot is abducted or adducted at the ankle, and the difficulty arising from the shortness of the tendon is thus obviated. Cases of varus should be examined with the patella to the front, and the true position of the foot ascertained. 4. An Outline or Impression of the Sole of the Foot. — This may be obtained in several ways : either by applying printers' or ordinary ink to the sole, and directing the patient to place his foot firmly on a sheet of white paper, or by taking a sheet of smoked glass and telling the patient to stand on it ; or if an outline only be desired, the sole of the foot may be M'ell moistened with water, and the foot planted iirmly on a sheet of brown paper. The outline may he rapidly put in with ink before the impression on the brown paper dries. It is valuable in cases of arcuatus and flat-foot to obtain an impression or outline at the commencement and at the end of treatment. 5. General Examination of the Affected Limb. — The shape of the limb, especially as to muscular wasting, and its development as compared with its fellow should be noticed. Thus in congenital and spastic cases the " swell " of the calf is at a higher level than in the healthy limb. In infantile paralysis wasting of the anterior or the posterior muscles will readily be seen, so too in the late stages of spastic cases ; wdiile the enormous calves of pseudo-hypertrophic muscular paralysis will not escape attention. Tlie bones are often felt to be of less thickness, and not only the leg, but also the foot, is shorter than normal. An excessive mobility at the knee-joint, especially if rotation is free in the extended position, is a factor of importance in the prognosis and treatment of club-foot, both of the congenital and paralytic varieties. Much of the inversion in talipes equino-varus CHAP. Ill CLUB-FOOT — GENERAL CONSIDERATIONS 313 is due to it, and it needs methodical correction. In infantile paralysis a flail-like condition of one or more of the joints will be evident, and the knee may be hyper-extended. The temperature of the surface of the limb and the colour of the skin, often dusky red or blue, with the presence of chilblains and other signs of imperfect circulation, are characteristic of anterior polio-myelitis, and of some congenital cases in which spina bifida is present. The presence of corns and false bursas indicate that undue pressure exists at the spots where they are found. Thus in right- angled contraction of the tendo Achillis a row of corns will be found beneath the heads of the metatarsal bones, and the same condition is seen in talipes arcuatus and plantaris. In old-standing cases of equinus the heel is feebly developed and small, and the skin over it quite thin, thus showing that it has not at any time come into contact with the ground. It is well to look at the boots and see if they are worn unequally, especially in the cases of so-called weak ankles. 6. The Passive Movements ivhicli may le effected ly the Surgeon. — In most cases of club-foot the nature of the deformity is evident. But it will happen that iu slight cases it is difficult to decide by merely looking at the foot if adduction or abduction is too free, and similarly with extension and flexion. The foot should then be moved passively in all these directions, and it should be noticed in which of the positions it can be placed with the greatest ease. These movements should be carried out with the child both standing and sitting. 7. Loealiscdion of the Resistant Struetures. — The heads of the metatarsal bones being drawn away as far as possible from the heel, any bands of plantar fascia standing unduly in relief may be seen and felt. If any doubt exist, the position of the band may be localised accurately by pressing gently the forefinger-nail on it, and its tension thus quickly ascertained. On account of their depth from the surface, it is often impossible to identify the con- tracted ligaments. 8. Localisation of Gontraetecl or Paralysed Muscles. — This may be roughly determined by sight and touch. But in cases of infantile paralysis and in spastic and congenital cases it is advisable to put the patient through a kind of drill. Thus, when paralytic equinus is present, it is needful to ascertain if any and what degree of power remains in the extensor muscles. The patient, if sitting, should be told to try to raise the toes towards the surgeon's finger, placed at 1 or 2 314 DEFORMITIES OF THE LOWER EXTREMITY sec. iv inches above them. Then the dorsal flexion of the great toe may be tried in the same way, in order to see if the extensor proprius pollicis have escaped or not. Similarly in calcaneus an attempt may be made to touch the surgeon's fingers held an inch or two below the toes. To estimate the power of abduction and adduction in the foot, the finger should be placed 1 or 2 inches to the outside or inside of the foot. In paralytic cases it is essential to know if any paralysis of the quadriceps extensor be present. To do this it is not sufficient for the surgeon to hold his hand at the level of the patient's knee and tell him to tovich the hand w4th the toes. With one hand holding the condyles of the patient's femur, the thigh should be fixed, while the other hand is held out for the patient to touch with his toes. If there is any paralysis of the quadriceps extensor, and the femur is not fixed when the patient is told to extend the leg, it will be noticed that he first flexes at the hip, and raises the thigh off the chair, thus getting a start, so to speak, and then extension of the leg is made. So that this flexion at the hip tends to mask slight weakness of the quadriceps extensor. 9. EU'drical Bcadions. — In cases of spastic paralysis the affected muscles react to the constant current with less current than normally. While in paralytic cases not only is more current required than normally to obtain a contraction from a given muscle, but if the muscle be hopelessly damaged, no reaction at all is obtained. In those muscles which are less affected the reaction of degeneration is seen, and the muscle responds for a time more readily to the galvanic current, while stimulation of the nerve gives little or no response ; and both the muscle and the nerve fail to respond to the Faradic current. Then, too, in the reaction of degeneration, instead of the order of ease of contraction being K.C.C. A.C.C. ] T equal A.O.C. K.O.C. A.C.C. may equal K.C.C, or A.C.C. may exceed K.C.C, and K.O.C. may exceed A.O.C. 10. Signs of Abnormal or Arrested Development of the Bones. — In the case of congenital club-foot the direction of the head of the astragalus and the presence of excessive inward rotation of the bones of the leg are points of importance. Absence of the fibula or tibia,^ or parts of those bones, and a rudimentary patella are ^ I have au example of this in a little girl now under my care at the "Westminster Hospital. CHAP. Ill CLUB-FOOT GEXEKAL CONSIDERATIONS 315 occasional accompaniraents. In paralytic feet excessive prominence of the cuboid in eqnino-varus is a point of importance in estimating the time to l3e occupied in treatment. General Remarks on the Treatment of Club-Foot. — A distin- guished orthopcedic surgeon (E. H. Bradford of Boston), writing on the treatment of club-foot/ remarks, " The literature of the treat- ment of club-foot is as a rule that of unvarying success. It is often brilhant ; . . . and yet in practice there is no lack of half-cured or relapsed cases, — sufficient evidence that the methods of cure are not universally understood. In club-foot half- cures are practically no cures at all. The great test of the cure of club-foot is the position of the foot in walking. There should not be the slightest attempt to return to deformity at any period." - " Xone of us claim to cure club-foot in a short space of time." ^ " Cases of club-foot should be watched a long time before jDronouncing as to absolute cure." ^ Such are the opinions, succinctly expressed, of our American confrtres, to whom we owe so many advances in this branch of surgery '" ; and such opinions are felt to be correct by all workers in this subject. Eapid results are the exception, and, indeed, are not to be aimed at, nor are they often, in the very nature of the cases, possible. While any undue delay is earnestly to be deprecated, the chief object in view must be the permanency of the cure. If this object can be rapidly and satisfactorily achieved by wide division of soft tissues, or ablation of offending bony prominences, so much the better. If not, then the older and well-proved ortho- paedic methods are still deserving of full recognition, and demand practical knowledge on the part of those whose lot it is to treat cases of deformity. In undertaking the treatment of club-foot, the objects are two : to remove the deformity, so far as the shape of the foot is con- cerned : to completely restore the functions of the foot and limb permanently. These two objects are not identical, inasmuch as a foot perfect ^ Trans. Amcr. Orth. Assoc, vol. i. p. S9. - Bradford and Lovett, o}). sicp. cit. p. 460. ^ Gibney, Annals Surg. toI. ix. p. 181. * Roberts, Trans. Arner. Orth. Assoc, vol. i. p. 35. ^ I might allude id passing to the value of Phelps' operation, and the extensive use of the wrench in the cure of club-foot. At the same time the successful meetings of the American Orthopsedic Association, and the high tone of their published Transactions, bear testimony to the acknowledged position which orthopaedic surgery has acquired "on the other side." 316 DEFORMITIES OF THE LOWER EXTREillTY sec. iv in its shape and relations to the leg may be nearly useless for easy progression, as in the case of tarsectoniy I allude to later. In the process of restoration to shape, the foot may lose so much of its elasticity as to be of little use in walking. After treatment, then, not only should the foot be shapely ; it must be also elastic, painless, bearing a due proportion of the body - weight on heel and toe, external and internal border, and capable of a moderate amount of exercise without weariness. Above all, no, case begun in infancy or childhood can be looked on as perfect in its result unless in adult life normal and easy progression is maintained. This ideal result is not possible in all cases. It appears, however, convenient, in the first place, to briefly discuss in the abstract the methods at our command for treatment, and then in separate sections to apply them to the various forms of club-foot. These methods are : — 1. Mechanical. 2. Physiological — such as douching, shampooing, the proper use of the electric current. 3. Operative. 1. Mcclianical Methods. — The employment of these methods, mainly before the era of tenotomy, for all degrees and varieties, and the failures naturally resulting from an imperfect knowledge of anatomy, rightly brought discredit on the exclusive use of apparatus. Since the introduction of subcutaneous tenotomy, and more especially of the antiseptic treatment of wounds, the tendency has been, aided by better anatomical knowledge, to become less and less "mechanical," if I may use the term, and to expedite the cure by operations, sometimes of a severe character and involving risk of limb and life. There are, however, certain degrees of all forms of club-foot to which mechanical methods are applicable. Who, for instance, would divide tendons in the foot of a new-born infant, which, slightly inverted, is yet replaceable by the hand ? Or who, in a case of rhachitic valgus, would sever the peronei tendons when the arch can be readily restored by the use of suitable apparatus ? In the earlier degrees of club-foot of all forms, then, the use of retentive apparatus is a valuable adjunct to active and passive exercises. After operations of all kinds on club-foot, the employ- ment of apparatus of some form, whether it be plaster bandages, metal splints, elastic traction, Scarpa's shoes, or the many kinds of CHAP. Ill CLUB-FOOT GEXERAL COXSIDERATIOXS 317 walking instruments, commonly called " irons," is essential to complete the case and to prevent relapse. Even the advocates of tarsectomy employ some retentive apparatus, despite the confident assertion that nothing whatever will be needed once the operation is performed, as '"' its merits are so great and its success so far- reaching." The mere enumeration of the various apparatus woidd read like an instrument-maker's catalogue, and I shall content myself with a brief description of some of them in the proper place, and a mention of the principles on which their construction is based. 2. Physiological Methods, including icell-dirccted Exercises, Douch- iTig, and Shainpooing, and the 'jj'^oper Use of the Electric Current. — Dr. Phelps has well said that " the best orthopcedic machine ever devised is the human hand ; guided by intelligence it applies forces for the correction of deformity more deKcately and perfectly than any inanimate object ever invented." ^ In the early treatment of cases of club-foot skilful manipulation can accomplish more than mechanical apparatus. But as it is necessary to retain the advantages daily gained by manipulation, some form of retentive apparatus must be used. The proper manipulations and exercises for each form of talipes will be subsequently described. Valuable adjuncts, especially in paralytic cases, are well rub- bing of the limbs, douching with hot and cold water alternately at least once a day, and the use of the constant current in preference to the interrupted or Faradic. One of the chief difficulties in the treat- ment of deformities appears to be that of adequate nursing. In general hospitals nm'ses have not the time to pay adequate atten- tion to manipulations and the relief of pressure by instruments — details which, slight in themselves, are essential to success. Xor, owing to the demand on the resources of a large hospital from the urgent nature of so many cases, is it possible to keep cases of deformity under that prolonged observation which they undoubtedly rec^uire. Then, too, the frequent advent of new " dressers," often of unequal merit and patience, who, before they have fully learnt one class of work, pass on to other portions of their curriculum, must aggravate the difficulty. It is scarcely a matter of wonder that with all these difficul- ties to contend with, surgeons have been led to adopt more radical procedures, such as tarsectomy, in obstinate cases. But I would repeat that it does not suffice for a patient to leave the hospital with a shapely foot. It must be not only useful for locomotion at 1 New York Med. Journ. 4th March 1895, p. 387. 318 DEFORMITIES OF THE LOWER EXTREMITY sec. iv that time, l)ut continue so for many years. This necessitates pro- longed individual attention over a very long space of time. 3. Oijerative Measures. — In the majority of club-feet some form of operative procedure is imperative. These are either tenotomy with fasciotomy, wrenching, tarsotomy or tarsectomy. As tenotomy is by far the most frequent form of operation practised, I have experimentally inquired during the last two years into the methods by which tendons unite, and in the following section I give the results of my experiments with a view to the determination of these points. The Processes coxcekned in the Union of Tendons, with ORIGINAL Investigations by the Author. The earlier history ^ of tenotomy is fully set forth by Mr. Adams in his work on The Reparative Processes in Human Tendotis after Division. Mr. Adams has therein gone so fully into the matter up to 1860 that it is needless to repeat it. His own researches are so thorough that had it not been for improved methods of preparation and staining of specimens, together with the wider pathological horizon of the present day, I should not have undertaken any experi- ments in this subject, nor ventured to have submitted them to the reader. Air. Adams has come to the following conclusions : — 1. That tendons are capable of perfect reproduction, except that the new material does not acquire the opaque pearly lustre of old tendons. 2. That new material is formed in two to three weeks. 3. The perfection of the process is in direct proportion to the absence of extravasated blood, and the continuity of the tendon sheath is all -important in the regenerative process; since, wdien consisting of loose areolar tissue, it furnishes the matrix in which the nucleated blastematous or proper reparative material is developed. Dembowski endeavoured to ascertain the origin of the early reparative material. By injecting Berlin blue into the jugular vein, he formed the opinion that it was really composed of wandering leucocytes. This special point has been more fully studied in tendon by Grunhagen, Beltzow, Flemming, and Ponfick ; in areolar tissue, by Messrs. Ballance and Sherrington ^ ; and in the light of the re- searches of the last-named observers, by myself in tendon.^ ^ Mr. Adams gives a complete rtsume of the literature of tlie subject in his work. - Journ. of Fhysiolorjy, October 1889. 2 Tubby, Guy's Hospital Eejmrts, 1892, aud Path. Soc. Trans. 1892. CHAP. Ill CLUB-FOOT GEXERAL CONSIDERATIONS 319 The views of the majority of the more recent observers, while coinciding on certain points, differ unduly in the following respects : — 1. What is the influence of effused blood on the healing process ? 2. Is the tendon capable of perfect regeneration ? 3. By means of which kind of tissue is the union brought about ? As to this point, Korner and Beltzow declare it is the tendon corpuscles which alone induce the healing. Which tendon corpuscles do they mean ? There are several kinds. Busse ^ has attempted to solve this point, but from his experiments I cannot glean any absolute information. In my experiments I have directed particular attention to this matter among others. And to the above queries I would add : — ■ 4. Do the leucocytes take a principal or subordinate share in the regeneration ? 5. What is the influence of the tendon sheath ? 6. Can primary union of tendon be obtained ? Before discussing these points it is necessary for me to describe my methods of experiment and examination. The tendines Achillis of full-grown rabbits were divided with antiseptic precautions from the outer side. The punctures were closed with a sealed dressing of sublimate gauze and iodoform. An attempt was made to fix the legs by plaster of Paris, but the animal generally succeeded in eating it away. The only precaution adopted against excessive movement was to limit closely the space in which the animals were confined. They were kept for the following periods after the operation : 3, 7, 14 days; 4, 5, 8, 9, 13, and 33 weeks; and one for 13 months. For microscopical examination, the tendon with the sheath was removed, and placed at once in Flemming's fluid (weak) of chromo- aceto-osmic acid for 24 hours, which sufficed to harden as well as to fix it. Some were then, after having been washed in water for 24 hours, stained in a mixture of alum-carmine and osmic acid (Zoltan V. Eoboz' formula), as recommended by BoUes Lee.^ This stain has a very direct selective action on protoplasm ; active chromatin is stained red, resting chromatin purple, and the remainder of the cell brown. The pieces of tendon were then embedded, some in parafhn and others in celloidin. In other cases, after washing out in water, the masses were embedded at once in celloidin, cut, and stained in Delafield's hsematpxylin and eosin, at the instance of my 1 Prize Essay, Greifswald, 1891. ^ Microtomist'' s Vade Mecum, 2ncl ed. p. 85. 320 DEFORMITIES OF THE LOWER EXTREMITY sec. iv friend, Dr. Ijcueke of Brunswick. A point worth noting, if the tendon be embedded in paraffin, is its great liabiHty to become so hard and brittle that it will not cut. This difficulty can be over- come by soaking it in cedar oil for three full days before placing it in the paraffin bath, and by clearing the cut section in cedar oil also. Before describing the microscopical appearances of divided tendons undergoing union, it will be advantageous to briefly sum- marise the structure of normal tendons. In them there are, as is well known, white connective-tissue fibres, tendon cells, blood-vessels, and lymphatics, the whole bound up in a fibrous sheath, varying considerably in density and somewhat in structure. White fibrous tissue is readily recognisable under the microscope by its parallel, wavy, unbranched fibres. The tendon cells, according to the latest observations, are of three kinds : (a) the large fixed tendon cells seen, in section parallel to the long axis of the tendon, as oblong- bodies ; and in transverse section to be of irregular outline, with processes extending into the connective -tissue spaces. The cells are uni-rnicleated, and the nuclei are so placed that they face each other in neighbouring cells ; (h) migrating cells are seen, which wander freely through the inter-fibrous and lymphatic spaces. Cer- tain of these cells have distinctive features. They are known as the " plasma cells of Waldeyer." In size they are larger than the leucocyte, they possess one or more processes, they liave a large oval nucleus, and present a granular cell substance. Several cells often aggregate and form clumps. These migratory cells are very important in the process of union of tendon, (c) Small round cells, which are indistinguishable from ordinary leucocytes except by special stains, and then they are seen to be more eosinophilous than tlie leucocyte of the plasma. Blood-vessels are found in tendon in parallel systems, but they are more numerous in that part which is attached to bone. In observations on the healing of tendon it has been noted that the process is always further advanced in that portion which is nearer the bone. The lymphatics of tendons consist, in the first place, of inter-connective -tissue spaces lined by flattened epithelial plates, and containing particularly the plasma cells ; and, in the second place, of definite lymphatic vessels containing some elastic tissue in their walls. The structure of the tendon sheath varies according to the region, but generally it consists of white fibrous tissue, yellow elastic PLATE V (Photo-micrographs). Union of Tendon Fig. 2. Fig. 3. Fig. 1.— Is-lets of plasma-cells appearing iu the uniting material. The islets are seen as dark spots on a white background (Expt. 3). Fig. 2.— Collections of plasma-cells (vasoblasts) in the uniting material forming the boundaries of branched vacuolated spaces (Expt. 2). Fig. 3.— Branching collections of plasma-cells (vasoblasts) about to form capillaries. CHAP. Ill CLUB-FOOT GENERAL CONSIDERATIONS 321 tissue, and has an ample supply of blood-vessels, the latter being of considerable importance in the healing process. It is known that the tendon is most intimately continued into the bone. In young subjects, especially at the insertion of the ligamentum patellte, numerous cartilage cells are found between the fibres. From the ossification of such cells prominences of bone, such as the tubercle of the tibia, the adductor tubercle, and others of like nature are formed. Excessive proliferation of these cells gives origin to enchondromata and exostoses. In the normal condition we can readily understand that the tubercle will part company from the tibia before rupture of the tendon occurs. In specimens of normal tendon comparatively few round cells are visible either between the fibres or between the fasciculi. On division of the tendon it is soon seen that the number of cells is greatly increased. At the point of section the fibres are pushed apart by the rapid development of cells, and present a frayed-out appearance. These groups of cells are in all probability the latent cells, or " schlummernde Zellen " of H. Schmidt,-^ described by him as becoming visible in fibrous tissue, after prolonged stimulus, such as "the vascular changes, induced by traumatism." But more on this point anon. f Experiment 1. Ai^pearances immediately after Division of a Tendon. — The ends of the tendon are cleanly cut. The tendon stiunps are embedded in a complete cap of effused red and white corpuscles, the latter being few in number. In places the tendon bundles are slightly separated from each other by red blood corpuscles and a few white. It should be stated that a few droj)s of blood were effused at the time of operation, both externally and, as was afterwards found, in the subcutaneous tissue. Corresponding to the ajjerture in the skin was a minute puncture in the sheath, which, distended by blood, retained its circular outline. The" tendon stumps were five-eighths of an inch apart. Experiment 2. Three Days after Division. — About ten drops of blood escaped from the wound at the time of operation. The skin was adherent over the point of operation. The sheath was thickened, especially on its outer and posterior aspects. It had a reddish tinge, and showed to the naked eye minute blood-vessels. The tubular outline was still preserved, and it was well filled with uniting material, which was of the same diameter as the cut ends of the tendon. The stumps were separated seven-eighths of an inch and were slightly bulbous. The uniting material was soft, semi-fluid and deep red, and ad- herent to the sheath. The posterior parts of the tendon were more retracted than the anterior part. Microscopically. — The tendon sheath is seen to be about twice its noniial thickness, and is adherent to the tendon by the new material which extends beyond the divided ends upwards and downwards for half an inch. The vessels ^ Vii'chow's Archiv, Bd. cxxvii. p. 96, and Bd. cxxviii. p. 96. Y :322 DEFORillTIES OF THE LOWER EXTREillTY sEr. iv of the slieatb are widely dilated. The tendon ends are becoming rapidly infil- trated with large cells, and plasma cells, which obscure the undivided fibres. The effusion between the ends consists of numerous red blood discs, whose out- lines are now ill-defined. Fibrin filaments are observable between the cells. There are also many longitudinal vacuolations, some with clear-cut and others with fading margins. A few are surrounded by a continuous layer of plasma cells with well-defined nuclei — future vasoblasts — the general impressions given being that of a branching capillary vessel, but lacking the flattened endothelial lining (Plate I. Figs. 2 and 3). Occasionally the vacuolations are seen to branch, and between them are dividing plasma cells. Many of the latter have become oval, while a few are fusiform or irregular in shape (fibroblasts). Leucocytes are jiresent in abundance. The fixed tendon cells show little or no change. The nucleus is found more towaixis the centre of the cells, and is less regular than normal Many new uni-nucleated cells (latent-cells), smaller than plasma cells or leucocytes, are appearing between the bundles of the fibres. Experiment 3. Tendon Seven Days after Divmon. — At the operation about twenty drops of blood escaped. On examination, the wound in the skin and sheath is quite healed. The latter is red but not of uniform thickness, being of greater diameter below, and tapering upwards for 1 inch until it is only half the size of the upper end of the tendon. It then becomes thicker. The sheath is firmly adherent to the uniting material. The tendon ends are separated to the extent of l| inch, and the distal stump is more bulbous than the proximal. At the lower end the line of section is not traceable, and to the naked eye the parts are semi-gelatinous and reddish. The uniting substance is pink at the ends, red and diffluent in the centre, and adherent to the sheath. Microscopically. — The clean-cut appearance of the tendon ends has now quite disappeared. The stumps are ragged, and several isolated portions of tendon substance are seen surrounded by fibrin filaments. Just above and below the point of section there are on all sides numerous plasma cells undergoing rapid division, congregated into groups, and some are bipolar in shape. Leucocytes are by no means so abundant in the regenerative material as formerly, and now most of the red corpuscles have been absorbed. A very important point in the union of tendon is the following process, which can still be observed as on the third day in the uniting material. Plasma cells are grouped together in large islets, and are surrounded and supported by a faintly-staining, somewhat homogeneous material, consisting of fibrin (Plate I. Fig. 1). In the immediate neighbourhood of the islets of plasma cells, around them and at times in their centre are masses of smaller deeply -stained uui- nucleated cells, leucocytes. It would appear that at such spots plasma cells are appearing in the fibrinous and cellular remains of the old clot, and, what is more to the point, multi- plyiny at the expense of the leucocytes tihich are ingested by them, and now resemble "giant cells" (Plate YI. Fig. 1). This appearance has been described by Messrs. Sherrington and Ballance in their observations on areolar tissue. ^ The leucocytes thus play a subordinate part in the process. They simply form a medium in which the plasma cells multiply, and are absorbed by the latter. From plasma cells arise later two varieties of cells, vasoblasts and fibro- blasts. The former are now seen to take on their functions in this manner. The vacuolations, present on the third day, and due to fatty degeneration of parts of the clot, have now disappeared, and in their place elongated masses of plasma ^ Joumai of Physiology, vol. ix. p. 571. CHAP. Ill CLUB-FOOT GENERAL CONSIDERATIONS 323 cells are now evident. The masses are noted after a short distance to twist, and may be seen coursing freely through the new tissue, to become connected with the vessels in the muscle above and bone below, and further with those in the tendon sheath in the following way. The " latent " cells, which were small and arranged in clumps between the fibres, are now much enlarged and similar to plasma cells, and are arranging themselves in line between the tendon fibres at a short distance from the point of section. There they are continuous with the elongated masses of plasma cells in the effusion. Subsequently in the masses of latent cells between the tendon fibres and in the elongated masses of plasma cells in the effusion small channels appear whose walls are composed of a single layer of oval or rounded cells. These channels are the precursors of new blood and lymph channels for the nutrition of the scar-tissue, and eventu- ally unite with the blood-vessels of the muscle and bone. Before this connec- tion is complete the cells receive their nutrition from lymph exuding from the dilated blood-vessels of the sheath. The well-defined outline of the fixed tendon cells is obscured, and they tail oflf occasionally. The nucleus is still single, of normal size and shape, and is not dividing. In some sections taken from another animal at this date fatty areas may be recognised in the scar tissue. The sheath is many times thicker than normal, and active division of its plasma cells is occurring, especially opposite the centre of the gap between the tendon -ends, and an intimate vascular and fibrous connection between the sheath and uniting material has been established. It is at this sjaot that the beginnings of new vessels in the effusion are best marked, corresponding to the extreme dilatation and tortuous character of the vessels of the sheath. Experiment 4. Tendon Fourteen Days after Division. — ^To the naked eye the only changes are that the sheath is opaque and white, not red. The uniting material is of considerable strength, faintly fibrillated and firm throughout, and adherent to the sheath by fine filaments of tissue. Microscopically. — The ends of the tendon have lost all form and shape, and are blending imperceptibly with the scar tissue which is dovetailed into them. The formation of new vessels between the fasciculi is further advanced (Plate VI. Fig. 2), but the fixed oblong tendon cells show no further change. Islands of plasma cells are prominent, and many of the cells are elongating rapidly to form new fibres, which have an inclination to arrange themselves parallel to the long axis of the tendon. This appearance is visible only near the tendon stumps ; but at the farthest part from them there is only a confused mass of faintly fibrous ground substance, islets of j)lasma cells and leucocytes as on the third day. All the red blood corpuscles and fibrin filaments have disappeared and given way to a fine ground substance formed by the processes of plasma cells. Amongst the latter, giant-cells containing four, six, and eight nuclei are seen. These nuclei are ingested white blood corpuscles. Experiment 5. Tench Achillis One Month after Division. — The uniting material is 1 inch long and as thick as the normal tendon, but not quite so firm. Under the microscope the thickening of the sheath is not so marked as in Experiment 4, and there are fewer vessels in it. The band of union shows a beautiful series of looped vessels passing down and up from the tendon stumps, and it is possible to demonstrate the direct continuity of vessels from muscle and bone to tendon, and thence to scar tissue forming anastomotic loojas, which are best marked where the rounded ends of the stumps are traceable. No small round cells are visible between the tendon fasciculi, while now that blood- 324 DEFORMITIES OF THE LOWER EXTREMITY sec. iv vessels have completely formed, plasma cells are less in evidence. All trace of leucocytes is lost ; while the processes of the plasma cells from the scar tissue are insinuating themselves in all directions between the old fibres, which have lost their parallel arrangement and become wavy. Experiment 6. Five Weeks after Division. — The only point of interest in the experiment lay in the fact that in dividing the tendo Achillis the neighbour- ing artery was wounded and a considerable quantity of blood lost, and 'post- mortem the sheath was found extremely adherent and the ends were separated more than an inch. Under the microscope and near the stumps the uniting l)and is more like ordinary fibrous tissue. At these spots short fibres are seen arranging themselves more or less parallel to the axis of the tendon. Many of the plasma cells which were previously swollen and slightly spindle-shaped have, after division of their nuclei, assumed a very elongated .shape, and in some cases the nuclei have disappeared. The sole change visible in the fixed cells is that they are elongated slightly in places, but they are not attempting to form fibrous tissue. Experiment 7. Tendo Achillis Seven Weeks after Division. — The tendon sheath is of nearly normal thickness, but is still white and opaque. A few fine adhesions are seen between it and the tendon. Microscojncalhi. — The sheath is now seen to be partially separated from the scar tissue. In the latter the wavy fibrillation at the ends nearest the stumps is better marked, and is proceeding towards the centre of the band. All stages of the transformation of the plasma cell into fibrous tissue, viz. from the round to oval, and thence to the fusiform nucleated cell and non-nucleated fibre, are visible. The number and size of the vessels in the scar has decreased. Experiment 8. Tendo Achillis Eight Weeks after Division. — One point is worth recording in a section taken from this tendon, viz. that the process of fibrosis is be.st marked in the neighboiirhood of the vessels in the scar. Experiment 9. Tendo Achillis Thirteen Weeks after Division. — Sections taken from tendons at this date show the process of disappearance of the blood- vessels. The walls lose their sharp definition and the lumen becomes filled with a number of small round cells, which in transverse section appear as circumscribed masses of cells. The nuclei of the fixed tendon cells have now divided, and the bodies of the cells are broader and flatter, while their ends tail oft', but there is no further evidence at this or at sub.sequent periods that these cells give rise to fibrous tissue. Experiment 10. Nine Weeks after Section. — The liand of uniting material is 2^ inches long. It is opaque and dull white, lacking the semi-transparency of tendons. The minute appearances are much the same as in Experiment 9. Experiment 11. Thirteen Weeks after Section. — The ends are separated 3 inches, united merely by a dull -looking fibrous cord, which to the naked eye is quite avascular. It should be mentioned that the animal had been quite unable to extend its foot for some time. Some slight adhesions are still present between the tendon and the sheath. The latter is almost of normal thickness, but is rather matted where the opei^ation has taken place. Micro- scopically the conversion of plasma cells into fibrous tissue is more marked throughout the band of union, and the vessels are entirely occluded. In some places they are represented by a mere line of fibrous tissue, in others by a thick band of the same variety of tissue, i.e. the small round cells described in Experiment 9 as filling the lumen of the vessels have given place to fibrous tissue. PLATE YI (Photo-micrographs) Fig. 1. Fig. 2. Fig. 3. Fig. ]. — Masses of giant-cells containing ingested leucocji:es. From these giant-cells or enlarged plasma-cells, both va,soblasts and fibroblasts are formed. Fig. 2. — Complete capillary formed in the uniting material from plasma-cells (vasoblasts) (Expt. 4). Fig. 3. — Appearances at junction of nev,- and old tendon material, eight months after section of tendon. CHAP. Ill CLUB-FOOT GENERAL CONSIDERATIOlSrS 325 Experiment 12. Thirty -three Weeks after Section. — The band of union is 2 inches in length and the sheath is distinct from the tendon. Microscopically, the whole of the uniting material is more closely assimilated to that of normal tendon, and the young fibres are more regularly arranged, the oval and fusiform cells being more or less in procession. But the following differences are noticeable. The fibres are by no means strictly parallel, and the spaces between them are much greater than normal ; the individual fibres branch, and some of the remaining cells arising from the plasma cells resemble the fixed cells of the tendon stump in tlieir disposition between the fibres, their more geometrical outline, and the presence of a single round nucleus. The masses of cells (the occluded blood-vessels) are very much smaller, and their outer zones are forming fibrous tissue. Experiment 13. Tliirteen Months after Section. — The uniting band has by this time ceased to elongate and the sheath is quite free. It is interesting to note that although there is such elongation of the band of union as to render the muscle of little use, yet there are no evidences of degeneration of the muscular fibres. Microscopical sections show, too, that the apjaearance of normal tendon is not perfectly regained. While many of the new fibres are parallel, some wander freely, and there is still a confusion of pattern. In addition, some blood-vessels, irregularly distributed, are seen running tortuously in the scar, and not arranged between definite fasciculi as in normal tendon. Many of these tortuous vessels are becoming gradually occluded, as shown by injection from the main artery of the limb. Some of the cells derived from the plasma cell resemble fixed tendon cells, but they are not oblong in longi- tudinal section. We may therefore infer that perfect regeneration may be possible, but that it is far from complete at the end of the thirteenth month. It is my opinion, however, based on a study of these and other sections, that the uniting band remains scar -tissue, and nothing else, however long a period be allowed to elapse. With respect to the processes in human tendon, they are substantially the same as in rabbits' tendon. From a study of Adams' ^ and other observers' work on human tendon, it is my belief that in man it is not perfectly regenerated even as late as three years after division. The processes concerned in the union of tendon may be summarised thus : — ^ Re'parative Process in Human Teiulon, p. 65. 326 DEFORMITIES OF THE LOWER EXTREMITY Normal Texdon (Destination of the Elements in tlie Uniting Process). Fibres (dovetail into new fib- rous tissue). Fixed cells. No share in formation of new fibrous tissue. Leucocytes mi- grate into new material, and act as pabulum for plasma cells in addition to leu- coc3'tes from the blood clot. Plasma cells between fasciculi. I Fibroblasts. Inter-fascicular Yasoblasts. (Latent cells.) I Plasma cells. Yasoblasts. Fibrous tissue of New inter-fascicular Inter-fascicular scar. vessels running to vessels in ten- supply uniting ^^on stumps, material. TENDON DIYIDED, with blood clot between end.s. Red corpuscles absorbed. Fibrin absorbed. Leucocytes form a pabu- lum for new plasma cells, which migrate from the vessels of the tendon sheath and from between the fasciculi of the tendon stumps. New i)lasma cells (see above). Fibroblasts. I A'^asoblasts. Fibrous tissue of Yessels of unit- uniting ma- ing material, terial. I Cells remaining uni- nuclear and somewhat square, like fixed ten- don cells. A few permanent in scar. Majority transformed into fibrous tissue. The slieatli thickens and becomes adherent to the uniting material. Its dilated vessels supply lymph to the j^lasma cells in the uniting material, and later communicate with the new vessels in that material. Subsequently the communications are closed, and the adhesions between the sheath and the scar tissue of the tendon disappear. The questions which were asked before the experiments were described may now be answered. 1. What is the influence of effusion of blood in the healing process ? As the vascular tendinous sheath is wounded in all cases, some blood must be effused, and the white corpuscles in the clot CHAP. Ill CLUB-FOOT GENERAL CONSIDERATIONS 327 are useful in forming a pabulum for the plasma cells. The red blood corpuscles and the fibrin are of no direct service. They are simply absorbed. Excessive effusion is to be avoided, since time is consumed in its absorption, and the energy of the plasma cells is manifested in that direction rather than in the formation of scar tissue. If the parts be unduly stretched before absorption has taken place, the uniting band is weak and feeble. Sufficient blood and no more should be effused to fill the sheath and maintain it of the same diameter as before the operation. 2. Is the tendon capable of perfect regeneration? In my opinion, it is not ; in fact the destruction of the Malpighian layer of the skin is a parallel instance in so far that, if once destroyed, it is not reproduced. The whole thickness of the epidermis is never replaced if it is lost over a large area. 3. By means of which kind of tissue is union effected ? It is by the plasma cell found in the connective -tissue spaces of the normal tendon, and by plasma cells which migrate from the dilated vessels of the inflamed sheath into the clot. 4. What share is taken by leucocytes ? An entirely subordinate and temporary one, as they are soon absorbed by the plasma cells, forming their pabulum as they develop. 5. What is the influence of the tendon sheath? For quicker union of the tendon ends and subsequent smooth working of the regenerated cord in its sheath, it is essential that the sheath be interfered with as little as possible. If freely divided or removed, much adhesion of the uniting material to the fascise, ligaments, muscles, and bone occurs, cf. Experiment 6 ; and if contraction of the muscle recur, it is correspondingly difficult to remove by a second tenotomy. Erom the vessels of the sheath many of the plasma cells come, and their importance in the process has been freely insisted on. 6. Can primary union of tendon be obtained? Busse's experi- ments point to the impossibility of obtaining this. Some stretching of the band of union always followed, even if dovetailing of the divided ends be carefully carried out. CHAPTER IV THE VARIOUS FOEMS OF CLUB-FOOT Talipes Equinus, Degrees and Vaiieties, Morbid Amitonuj, Symptoms, Prognosis, Treatment — Talipes Calcaneus, Forms, Sxjmptoms, Diagnosis, and Treatment — Talipes Calcaneo-Valgus and, C'alcaneo- Varus — Talipes Arcuatus and Plan- taris {Pes Cavus) — Talipes Varus — Talipes Valgus and. Pes Planus — Talipes Equino-Valgus — Clinical Aspect of Union of Tendon. Talipes Equinus Synonyms — French, Fied hot cquin ; German, Pferdcfuss, Spitzfuss. The essential features of this variety of deformity is an inability to place both the toes and heels on the ground at the same time, and the patient walks on the heads of the metatarsal bones. Subsequently contraction of the soft parts in the sole of the foot ensues, and necessitates division of the plantar fascia, and it may be of the deeper structures. Degrees of Talipes Equinus. — The foot should normally be capable of dorsi-flexion on the leg to the extent of 18^ beyond the right angle. Any condition in which this angle is diminished at the ankle-joint without inversion or eversion is rightly called talipes equinus. A few degrees of diminution are not of import, but if the foot cannot be flexed beyond the right angle, then there exists The First Degree, or Right-angled Contractio7i of the Tendo Arhillis. — In the examination of these cases it is essential to note that in estimating the angle of flexion of the foot, the knee must he kept fully extended, since shortening of the tendo Achillis is readily compen- sated by flexion of the knee. Unless the whole foot can be brought squarely to the ground with the heel in complete apposition, without pain or force in the fully erect position, the first degree of talipes equinus is present. THE VARIOUS FORMS OF CLUB-FOOT 329 The results of this slight deformity are: 1. The formation of corns beneath the heads of the metatarsal bones.^ 2. Slight lameness and shortening of the stride. For ease in walking complete flexion at the ankle is necessary, and if the knee be kept slightly flexed in walking the stride is necessarily lessened. 3. Some eversion and inversion of the foot occur, especially in paralytic cases, as the calf muscles become shorter. To diminish flexion at the knee as much as possible in walking, and at the same time to bring the heel to the ground, the foot is twisted inwards or outwards at the ankle, so that the muscles and tendons Fig. 174. -Paralytic talipes equinus, before and after treatment (Charles M , aged 3 years). may take as short a course as possible from the points of origin to their insertions. Many cases of so-called talipes varus or valgus are found to be equinus when carefully examined with the knee fully extended. The Second Degree. — The heel is raised well off the ground, and a transverse crease is seen above it. Progression takes place on the heads of the metatarsal bones, and decided lameness is present, due 1 It is a good clinical point that if a row of corns be found in this situation, either right-angled contraction of the tendp Achillis, or contraction of the plantar fascia, caus- ing talipes arcuatus, is present. If one or two corns are found under the heads of the second, third, and fourth metatarsal, and not on the first and fifth, then Morton's dis- ease may be suspected. 330 DEFORMITIES OF THE LOWER EXTREMITY partly to the extended foot and partly to large and inflamed corns. In congenital and spastic cases a broadening of the front part of the foot, owing to the " spreading " of the heads of the metatarsal l^ones and separation of the toes, is seen. This appearance is all the more r^^' w^-;^^'A Fig. 175. Paralytic talipes equiuus ; the positiou assumed by the feet when they are suspended. striking from the ill-developed state of the heel. Here the skin is quite thin and shows no signs of pressure ; the tuberosities of the os calcis are absent, so too is the natural pad of fat. The great toe is drawn towards the middle line of the body, and the inner border of the foot is concave. This appearance simulates that of slight varus, but in the latter case the site of deformity is at the medio- THE VARIOUS FORMS OF CLUB-FOOT 331 tarsal, and not at the metatarso-phalaugeal joint, as in the former. The limping gait in paralytic cases and the jerky step in spastic are characteristic. The plantar fascia is frequently contracted in this stage. Noticeably in paralytic cases, and to a less degree in spastic, the head of the astragalus forms a distinct prominence on the dorsum of the foot (Fig. 174). The Tliircl Degree is an exaggerated condition of the second. * \ ^1^" Fig. 176. — The same patient as in Fig. 175, showing the position assumed by the feet when the patient lay down. So much extension is present that locomotion takes place on the dorsum of the foot. It is bent completely backwards, and the toes are, as it were, " tucked underneath." If one foot alone be affected in the second or third degree, the patient is often able to hobble about fairly well. But when both feet are deformed, walking may be impossible. Occurrence and Causation.— Talipes equinus is the rarest of 332 DEFORMITIES OF THE LOWER EXTREMITY seh. iv congenital deformities. Little, however, has recorded two, Brod- hurst " one or two," and Adams three cases. The writer has met with one case in a child aged 4 months, who presented pure equinus in the left, and equino-varus in the right foot. As an acquired deformity of the foot, equinus is the most frequent of all varieties. The causes of it are : — (a) Spastic, viz. hemiplegia, spastic paralysis. (b) Paralytic, from infantile paralysis and sometimes hemiplegia. (c) Traumatic, injuries to the ankle-joint and anterior tibial nerve. (d) Cicatricial, from burns on the back of the leg, or laceration of the calf-muscles. (c) Eeteution of the foot in a vicious position, e.fj. the pointed feet of bedridden patients — talipes decubitus. (/) Associated with other deformities, such as shortened limb from coxitis, fracture, and separation of the epiphyses. (ff) Inflanmiation, rheumatic or tubercular of the ankle. Practically we have to consider two classes, the spastic and paralytic. There are essential diferences in the feet according as sjMsm or paralysis is present, viz. : — In both the congenital and spastic cases the heel is much raised, the arch somewhat deepened, but the foot is in a direct line with the leg, and there is no falling away at the medio-tarsal joint. Whereas in paralytic cases the heel and posterior part of the foot do not appear so much raised, as that the front part of the foot is dropped. In this event the head of the astragalus and dorsal surface of the scaphoid are very prominent {vide Plate VII.) The toes in a spastic case are hyper-extended at the metatarso-phalangeal, and flexed at the first inter-phalangeal joint, and so present a claw- like appearance. In paralytic cases of the first degree they are extended fully on themselves, and in the second degree they are hyper-extended at the metatarso-phalangeal joint, while in the third they are entirely flexed into the sole. In all forms of club-foot the following points hold good in the diagnosis of congenital, spastic, and paralytic talipes. In the congenital cases the deformity is present from birth, and is frequently bilateral. In the majority of cases it is either equino- varus or varus. Much resistance is offered to any attempt to straighten the foot ; there is little or no interference with the nutrition of the foot in early cases. In the silastic variety one or CHAP. IV THE VARIOUS FORMS OF CLUB-FOOT 333 both feet are affected. Equinus is the most common deformity ; the affected muscles are tense, rigid, and resistant ; the nutrition of the limb becomes ultimately affected, and the contracted muscles atrophy : the reflexes are increased. In the imralytic cases very often one foot only is involved ; the affected muscles are lax and flabby, and give the reaction of degeneration ; the reflexes are diminished or lost ; the limb is wasted, and shorter than its fellow ; its temper- ature is diminished, and it is cold and blue, and trophic lesions of the skin may be present. The Morbid Anatomy of Talipes Equinus. — Inasmuch as the foot is not deflected laterally, and the permanent condition is one that can be nearly assumed by the normal foot, the alterations in the bones and soft parts are not marked, nor are they sufficient to prevent the foot from being restored to complete usefulness. Tlu Bones. — A case is recorded by Adams -^ of a man, aged 2 5 years, whose foot showed no " material change " in the form of the bones. They are altered in position and direction, but not in out- line. The OS calcis is either slightly elevated or remains horizontal. In congenital forms elevation of this bone is present, in paralytic cases it is absent. Earely it may happen that the upper surface of the OS calcis comes in contact with the posterior part of the articular surfaces of the tibia and fibula ; such au occurrence, however, has been described. The head of the astragalus is directed downwards and forwards, and often stands out prominently on the dorsum of the foot ; subluxation occurs at the astragalo-scaphoid joint. In severe instances the scaphoid and os calcis articulate. Eeeves ^ says that the base of the fifth metatarsal bone may be nearly in contact with the os calcis. When this is so, the arch of the foot is greatly exaggerated, and there is much adaptive short- ening of the soft structures in the sole. In paralytic cases the equinus is seen to depend chiefly upon a dropping away of the foot at the medio-tarsal joint, so that the cuboid and scaphoid are also lowered in position, and displaced from the OS calcis and astragalus. The metatarsal bones assume a vertical position, or are directed backwards, and are spread out at their distal extremities. In paralytic cases the compact bone-tissue is thinner and lighter than normal, and the cancelli and medullary cavities are filled with fat. Loss of cartilage occurs in those articulations which are the site of partial subluxation, e.g. from the 1 Path. Soc. Trans, vol. iii. p. 468, 2 Oj). cit. p. 209. 334 DEFORMITIES OF THE LOWER EXTREMITY SEr. iv head, superior and lateral articular facets of the astragalus, and the heads of the metatarsal bones. Ligaments. — The dorsal ligaments are stretched, especially the superior calcaneo- cuboid and calcaneo- scaphoid, and the anterior part of the lateral ligaments of the ankle. The plantar structures are much contracted. The fascia is first affected, and then the inferior calcaneo - scaphoid and the calcaneo - cuboid ligaments are shortened. So too are the posterior parts of the lateral ligaments and the posterior ligament of the ankle. It is necessary to recognise the existence -of shortening of the last-named ligament. In severe cases of long standing section of the tendo Achillis is not sufficient to reduce the deformity and to permit sufficient dorsi-flexion at the ankle. As a rule such a state of affairs is due to shortening of this ligament. Muscles. — In paralytic feet the extensors undergo fatty and fibrous degeneration, while their opponents are shortened from want of opposition. In spastic cases Guerin says that fibrous degeneration is present. Tendons. — In addition to the tendo Achillis, the plantar fascia and the long flexors and the peroneus longus are shortened and tense. Later the short plantar muscles retract. Skin. — Corns and adventitious bursse are present. In severe cases the former suppurate, and leave perforating ulcers. The skin in the sole is shortened, but after division of the deeper structures will stretch. Prognosis. — In congenital and spastic cases, so far as the deformity is concerned, the outlook is good, as, for example, in the following case : — Case 59. Spastic. Talipes Eqiiinus. — Eva P , aged 2, was brought to me in 1895. The history was that the child was quite healthy at birth, and nothing Avas noticed until she was 1 year old beyond the fact that she did not use her left arm properly. The case was evidently one of infantile hemiplegia. The left forearm was flexed and pronated, the wrist flexed, and the thumb and fingers contracted. The left knee was also somewhat flexed, and the foot in a state of equinus. I advised that the right arm should be tied up, so that the left might be used more freely, and that section of the tendo Achillis be performed. This was done with good results. But the ultimate value of the limb for locomotion in spastic cases must depend upon the persistence of the central cause of the spasm. PLATE VII. Fig. 2. — After treatment. Paralytic Talipes Equinds (Case 60). CHAP. IV THE VARIOUS FORMS OF CLUB-FOOT 335 111 paralytic cases we have to consider the prognosis from two points of view : («) the ultimate shape of the foot ; (&) the acquisi- tion of voluntary power in the affected limb. As to the first point, the removal of the deformity does not prevent any great difficulty. It may be said that a shapely foot is, as a rule, obtainable, as in the following case : — Case 60. Severe Paralytic Talipes Equinus : Operation: Cure. — Walter E , aged 9, came to my out-patient room at the Evelina Hospital with the foot in the condition seen in Plate VII. Fig. 1. The deformity was evidently due to infantile paralysis, as the limb was 4 inches shorter than its felloAv, cold, and wasted. The boy could only limp. He was admitted, and the tendo Achillis and plantar fascia were divided, with the successful result seen in Plate VII. Fig. 2. By the aid of a cork sole, the patient could get about fairly well. Nor, as in the case of talipes equino-varus, is age any bar to success. Instances are recorded of cure of the deformity at the ages of 54 and 60 years. The second factor in prognosis, the acquisition of voluntary power in the affected muscles, is a different question. In in- fantile paralysis we must be guided by the number of affected muscles, and the extent to which power is lost. But it should not be forgotten that greater recovery of muscles or fibres of a muscle takes place under appropriate treatment than could at first be anticipated. If the deformity of the foot be removed, it is a matter of surprise how much power and usefulness muscles, apparently in a hopeless state of degeneration, regain, especially if, in addition to active exercise, they be douched, rubbed, and galvanised. When the deformity arises from causes such as prolonged decubitus, we may say briefly that it presents a favourable prognosis, since there is no degeneration ^ of muscle and no ankylosis. In those cases which arise from inflammation of the ankle-joint, generally of a tuberculous or rheumatic nature, the outlook is the reverse of favourable. Diagnosis. — Pure talipes equinus presents in the second and third stages no difficulty in recognition. It is only in the first stage of right-angled contraction that it is likely to be overlooked. Under the title of " non-deforming club-foot," Shaffer " has described an affection in which the heel can be placed on the ground, but the anterior part of the foot cannot be raised. It appears to be a state of imperfect flexion at the ankle and medio-tarsal joints. ^ Except Avhen the equinus is due to nerve-lesions. - Bradford and Lovett, op. cit. p. 746. 336 DEFORMITIES OF THE LOWER EXTREMITY sec. iv It is often difficult to be sure of the cause of talipes equinus, but a careful inquiry into the history as to the mode of onset, the presence of tonic contractions elsewhere — especially of the adductors of the thighs — the absence of extreme muscular wasting, and of coldness and the excessive reflexes in spastic cases, will serve to distinguish them from paralytic cases. In the latter, if of moderate severity, before contraction of the sole has set in, it will be noted that when the foot is raised the dropping away of the front part of the foot is very apparent (Fig. 177); but this sign in some cases entirely disappears when the foot is placed firmly on the ground. The Treatment of Talipes Equinus. — The treatment of paralytic equinus is conducted on the following lines. In cases of the first degree, or right-angled contraction, manipulation and exercises may be employed. Walsham and Kent describe some exercises which they have found " especially useful." " The patient stands with the soles flat on the ground, and then bending the knees and hips whilst holding the body erect, with the arms close to the side, endeavours to touch the ground with the finger-tips. This exercise should be per- formed, say, six times a day at regular intervals. Fig. 177.— From a and for five or ten minutes at a time. It may be case of infantile varied bv placing a wedge-shaped block of wood paralysis. The , . ,,- • i -. i o • i dropping of the or Other non-yiclding material, Zf to 6 inches foot owing to the |^- | beneath the fore part of the foot, and then paralysed condi- ^ ' ^ tion of the anter- in like manner, whilst bending the knees and hips' Irvel'^'t "areut'' ^^^^ keeping the body erect, endeavouring to touch the ground with the tips of the fingers." A walk- ing apparatus with toe-elevating spring and a " stop " at the ankle- joint to prevent undue plantar flexion, is necessary by way of after- treatment, and the application of a tin -shoe at night must be enforced. But time and trouble may be saved by division of the tendo Achillis. If there is any contraction of the plantar fascia, this should have been severed previously. In equinus of the second degree division of the plantar fascia, followed by tenotomy of the tendo Achillis, is called for. It is advisable to make sure that the front part of the foot and the heel can be placed in one horizontal plane before the tendo Achillis is divided. The condition of the toes varies. Sometimes they are in THE VARIOUS FOKMS OF CLUB-FOOT 337 a straight line with the metatarsal bones, at other times they are " clawed.'' If this condition of " clawing " ^ be present, and the extensor muscles show by electrical tests but slight signs of de- generation, the extensor tendons should be divided at the roots of the toes at the same time that the plantar fascia is severed. The immediate after-treatment consists in the use of Scarpa's shoe or plaster of Paris, according to the inclination of the surgeon. Great attention must be paid to active and passive exercises, and the use of the induced current. As soon as the union of the tendo Achillis is formed, a walking instrument may be ordered. According to the degree of paralysis of the leg muscles, so should the walking ap- FlG. 178. — Walking apparatus, single to the calf, -with toe- elevating spring, for the after- treatment of paralytic talipes eqiiinus. Fig. 179. — Walking appara- tus, double to the calf, ■«ith toe-elevating spring, for the after-treatment of paralytic talipes equinus. paratus be single or double to the knee (Tigs. 178 and 179): and if there is laxity of the knee-joint ligaments, o^ing to paralysis of the extensors of the thigh, the instrument should be carried to the upper part of the thigh, or to the pelvis, if the affection is sym- metrical. Double knee-caps and a ring-catch joint at the knee are helpful and convenient, and the shortening of the limb renders an additional tliickness of sole necessarv. One of the best means of 1 The "claw-like" state of the toes is said to be due to paralysis of the interossei. This rests on the authority of Duchenne of Boulogne, who formulated the theoiy as the result of tests with the induced current. I am not aware that he verified it by actual dissection. In Walsham and Hughes' work the authors state, in a specimen of equinus with clawed toes, the interossei were healthy. Z 338 DEFORMITIES OF THE LOWER EXTREMITY SEr. iv restoring the muscles when the functions are in partial abeyance, is that of walking exercise, and this can only be obtained after a division of all those structures which prevent the restitution of the foot to its normal position and the application of a suitable instrument. In the third degree time must be given for the inflammation of the skin around corns and false bursse to subside, and then the foot is gradually unfolded, beginning with the front part, and finally letting down the heel by section of the tendo Achillis. After this there may remain considerable plantar flexion at the ankle, and the wrench may be called for. Should the use of this instrument not be sufficient, then astragalectomy is preferable to the other forms of tarsectomy. But in paralytic cases open operations are to be avoided, if possible, owing to the low vitality of the tissues. By the gradual methods the degree of deformity which may be over- come is very considerable indeed. The after-treatment, both immediate and remote, is similar to that in the second degree. Congenital cases are treated on the same lines. The Treatment of Spastic Cases. — In these cases the amount of comfort obtained by tenotomy is considerable, and lasts for some years, and is permanent when the spastic process has ceased, so that the writer would perform tenotomy of the tendo Achillis. The same remark applies to cases of pseudo- hypertrophic paralysis. And in the pointed foot, the result of prolonged decubitus, especially after peripheral neuritis, tenotomy of the tendo Achillis is called for. Talipes Calcaneus Synonyms — French, Pied hot talus ; German, Hackenfuss. Cctusation. — This is an infrequent deformity. It is met with arising from congenital, paralytic, and other causes, such as want of proper supervision after section of the tendo Achillis, feeble union of the divided tendon, wound of the calf involving the tendon or posterior tibial nerve, contraction of a scar from a burn on the anterior .part of the foot. A'p2^earanccs. — The feature of this distortion is the undue de- pression of the heel, with or without elevation of the toes. If the latter are elevated, the sole of the foot is not unduly concave. But when the anterior part of the foot and the toes are nearly, if not quite, on a level with the heel, then the concavity of the arch is CHAP. IV THE VARIOUS FORMS OF CLUB-FOOT 339 greatly increased, and one form of pes cavus, or, as it is better named, talipes arcuatus, is present. Frequently in long-standing cases, on the posterior aspect of the leg and just above the heel, a prominence is seen. It is formed by the lower ends of the tibia and fibula, which become conspicuous as the astragalus and foot are drawn forwards and downwards. Congenital Talipes Calcaneus. — Examples of this kind are not often seen. During the past five years I have met with nine cases. The notes of one case are as follows : — Case 61. Spina Bifida, Hydrocephalus, Talipes Calcaneus. — Robert M , aged 21 months, was admitted into the Evelina Hospital on 29th October 1894 for a perineal abscess. The family history was good. There are nine children in the family, and the mother has had no miscarriage. The patient was a full-term child, and was born with a "lump" on his sacrum, which, from the present puckered appearance, was probably a spina bifida. This seems to have become spontaneously cured by ulceration. There was no history of syphilis. He has had " water on the brain " ever since he was born, but has had nothing else the matter with him until the perineal swelling appeared. Both feet were in the position of pure calcan- eus, the angle in both cases between the dorsum of the foot and the leg being 30°; and this angle could not be increased without pain, owing to the tonic contraction of the exterior proprius pollicis Fig. 180. — Congenital tali- 11 TV rpu i. 1 pes calcaneus (Artliiir and longus digitorum. ihe appearances presented |, ^^^^^ - weeks) by the feet were similar to those in Fig. 180. Under chloroform the contracted tendons were divided, and the feet placed at once in right-angled shoes. They were kept in this form of splint for three weeks, and the child went out, but it is feared that the walking power will not be good, owing to some contraction of the adductors of the thighs. At present (February 1895) the feet remain in excellent position, and the adductor spasm is much less. It is stated by Adams to be the rarest of all forms of congenital club-foot ; but it may be permissible for me, from my own observa- tions, to doubt this. I am aware that in infancy the flexion of the foot upon the leg is much greater than 18°, but in the four cases mentioned above there was distinct difficulty in bringing the foot to the right angle. It is stated that caries of the ankle-joint is associated with a flexion of the foot simulating talipes calcaneus. A$p)ect of the Foot in Congenital Calcaneus. — The foot itself is 340 DEFORMITIES OF THE LOWER EXTREMITY sec. iv perfectly iionual in shape, but it is dorsi-tiexed upon the leg, and fixed by contraction of the shortened extensor muscles at an acute angle. There is no increased arch of the foot ; indeed, if the cases are seen and treated before walking has commenced, the sole of the foot is flat. Occasionally slight deviation of the foot to the one side or the other occurs, and then calcaneo-varus or calcaneo-valgus exists. There may be transverse folds on the dorsum of the foot. The complica- tions of calcaneus are genu recurvatum, varus of the opposite foot, absence of bones, viz. complete or partial absence of the fibula, tibia, tarsal bones, or deficient and defective toes. Spina bifida, hydro- cephalus, and cleft palate are sometimes associated with the deformity. There is little or no displacement or alteration of the bones in the foot. The anterior ligaments of the ankle-joint are shortened and the posterior lengthened.^ The muscles contracted are of course the extensors of the toes. Lonsdale - has described a rare complica- tion of this form of club-foot, viz. rigidity of the knees in an extended position, with flexion of the thighs. These cases have always been breech presentations. The prognosis is good as a rule, and the cases are readily curable. When the child commences to walk, the calf muscles acquire considerable power, pull up the heel and bring the front part of the foot to the ground, so as to ensure a more perfect balance. In the treatment of these cases it is sufficient, when the infant is very young, to extend the foot daily several times and to shampoo the posterior muscles, or the foot may be extended under an anaes- thetic, and placed in a retentive apparatus. Probably the best form is the soft iron splint, which can be removed before rubbing the leg and its angle altered as the case requires. Tenotomy and after-extension of the foot by means of a metal splint, or by Scarpa's shoe, or by plaster of Paris, are necessary if the child is over 1 year, ^ Dr. J. Griffiths of Cambridge, Brit. Med. Jouni. 30th Dec. 1893, describes a case of " Symmetrical Talipes Dorsalis in an Acephalous Foetus." There was a spina bifida extending from the skull to the mid-lumbar region. In this instance the deformity at first sight resembled that known as talipes calcaneus, but in the sketches accompanying the article the heel is seen not to be drawn up and the os calcis is horizontal. The whole foot is sharjily bent upwards at the medio-tarsal joint, so that the dorsum is applied to the anterior surface of the leg and there exists extension at the ankle, with hyper-extension at the medio-tarsal joint. Dr. Griffiths' contribution is interesting as showing the evolution of congenital calcaneus. It is possilde that the unbalanced action of the extensor acts first by hyper-extension at the medio-tarsal joint, and then secondly at the ankle-joint as development proceeds. - Lancet, Sept. 1855. THE VARIOUS FORMS OF CLUB-FOOT 341 au and if the foot cannot be extended beyond the right angle unde anaesthetic. Acquired Calcaneus. — Aspect of the Foot in Paralytic and other ^ Forms of Acg_uired Talipes Calcaneus. — The appearances presented are totally different from those in the congenital form, and are essentially- dependent, in the first place, npon dropping of the os calcis from lengthening of the tendo Achillis ; and in the second place, upon con- traction of the plantar fascia and deeper structures of the sole. The heel is abnormally lengthened and ball-like, owing to the tuberosities being prominent. This appearance is accentuated by the large pad Fig. 181. — Talipes calcaneus of the left foot from slight paralj-sis of the calf muscles. of fat and thickened skin which forms over the tuberosities, the result of undue pressure. The front part of the foot is raised, and cannot be brought to the ground at the same time as the heel. It is said that the foot is more or less everted, but in the few cases I have seen this has not been the case. At first the arch of the foot is not increased, but when the deformity is allowed to persist, the toes and the heels are approximated, so that the arch is much deepened, and talipes arcuatus (pes cavus) follows. A deep trans- verse groove therefore forms in the sole of the foot. The legs, especially the calves, are very much wasted in paralytic cases, and the tendo Achillis is thin aud membranous. ^ I have seen one case of spastic talipes calcaneus associated v.'ith hammer-toe. The cause could not be ascertained with certainty. 342 DEFORMITIES OF THE LOWER EXTREMITY hec. iv The different appearances in congenital and paralytic talipes cal- caneus depend upon the following points. In the congenital form the deformity is at the ankle-joint only ; in the paralytic it is at both the ankle and medio -tarsal joints. In the congenital form the posterior tibial muscles are normal in strength and prevent the dropping of the os calcis. In the paralytic form these muscles, being powerless, can neither prevent tlie heel dropping nor counter- balance, through the os calcis, the action of the long anterior muscles which are attached to the toes. The os calcis therefore drops, and is at the same time pushed out of its place by the extensors acting on the toes through the ankle and other joints. Partly by the pull of the extensors approximating the front and back of the foot, and partly owing to the effort made by tlie patient to bring the front of the foot to the ground, the deepening of the arch is progressive. So long, too, as the deformity is allowed to exist, the fascite and short muscles of the sole tend to contract, and to bring 'the head of the metatarsal bones nearer the heel. Hence the arch is increased, and is possibly represented by a deep groove.^ Syiiqdoms. — While in the congenital forms tlie muscles are not wasted, nor is the leg cold, but the gait is awkward, slow, and un- gainly ; in the paralytic variety there is often lameness, and the heel strikes the ground first, while the fore part of the foot flops down. The foot can be much dorsi-flexed, and the calf is wasted, with the tendo Achillis in a lax condition. Case 62. Talipes Calcaneus after Section of Tendo Achillis for Equinus. — Harold E, , aged 15, suffered from infantile paralysis affecting the left leg when 2 years of age, and talipes equinus resulted. Five years ago the tendo Achillis was divided and the boy sent home under local supervision. He was allowed to walk about three weeks after the operation. When seen by me the left heel was exceedingly prominent, the arch of the foot much increased, and the distance from the ^ On the connection between paralytic equinus and calcaneus, contrary as they may seem, Walsham and Hughes, p. 365, are very explicit. "In cases of infantile paralysis in which the anterior muscles and the peronei, as well as the superficial and deep muscles of the calf, are affected — that is, when all the muscles of the leg are paralysed — the foot, by reason of its weight, falls into the position of equinus, so that in calcaneus there must always be some power left in the anterior muscles or in the peronei to maintain the OS calcis in a position of dorsal flexion and depress its posterior extremity. In brief, therefore, when the anterior muscles entirely escape, the foot is dorsi-flexed (calcaneus) ; when they are only to some extent affected, the anterior part of the foot drops forwai'd, and more or less cavus is produced according to the extent of the paralysis of the anterior muscles ; and when they are entirely paralysed, equinus, and not calcaneus, is the result." CHAP. IV THE VARIOUS FORMS OF CLUB-FOOT 343 tip of the great toe to the inner tuberosity of the os calcis was Ih inch less on the left than on the right. There was some contraction of the plantar fascia. The fascia was divided, and he was ordered to wear a walking instrument with a toe-depressing spring in the daytime, and a Scarpa's shoe with an outside steel support at an obtuse angle and uplifting movement in the sole plate for night wear. Some improvement resulted, but as it is not sufficient, I intend to shorten the tendo Achillis and dove- tail the cut ends. Morbid Anatomy. — Bones and Joints.— The long axis of the OS calcis is oblique and in extreme cases vertical, walking taking place on its posterior surface. The position of the astragalus is altered too. It is displaced as a whole posteriorly, and the back part of its superior articulating surface may even project somewhat ; while the neck and head point forwards and upwards. At the medio- tarsal joint the scaphoid and cuboid are slipping downwards and forwards from the posterior portion of the tarsus ; and in early stages there is undue movement at this joint. At the ankle-joint extension is scarcely possible, owing to the contraction of the anterior tibial muscles and shortening of the anterior ligaments. The posterior ligament is correspondingly lengthened. Muscles and Fasciae. — Much wasting and fatty degeneration of the calf muscles ensue in paralytic cases, while their opponents are shortened and tense. The short muscles and ligaments of the sole and the plantar fascia are retracted. Skin. — Corns and adventitious bursse are seen on the heel, while under the balls of the toes the skin does not show the natural thickness and hardness. In paralytic cases the integument is also cold, blue, and liable to chilblains. Prognosis. — In all cases, when the heel is much dropped and the arch of the foot unduly concave, especially if contraction of the plantar structures have ensued, the outlook is bad. The shape of the foot may be restored by section of the fascia and short muscles, but the chief difficulty consists in keeping the heel up. This is especially the case when the cause is infantile paralysis. The results of recent methods of shortening the tendo Achillis by dove- tailing and in other ways are not generally regarded as successful, although some cases have done well in Willett's and Walsham's hands -^ by an operation which consists of division of the tendo Achillis obliquely from above downwards and from before backwards, and then sliding the cut ends past one another until the necessary 1 Brit. Med. Journ. 31st May and 14th June 1884. 344 DEFORMITIES OF THE LOWER EXTREMITY shortening is obtained. Care is taken to stitch the two parts firmly to each other and to the skin. Treatment. — That of the congenital form has already been al- luded to on p. 340. But if the case is of a severe nature and refuses to yield to manipulation, the following tendons should be divided, viz. the extensor proprius ]3ollicis, the extensor longus digitorum, with the peroneus tertius and the tibialis anticus. The foot is then retained in good position by some form of apparatus. Either the malleable iron splints, Scarpa's shoe, or plaster of Paris are efficient. The drawbacks to the Scarpa's shoe are its complexity, expense, and the difficulty of satisfactorily adjusting it, unless well accustomed to its use, so that j)ressure sores may be avoided. In the treatment of talipes the simpler the apparatus the better. In the case of Eobert M^ , aged 21 months, described on p. 339, the tendons were divided and malleable iron splints applied, and the foot was successfully restored. Such is the usual result if the case is seen early. -^ Acquired calcaneus, especially of the para- lytic variety, is more difficult to treat on account of the alteration in the arch of the foot. The paralytic form may arise in two ways, either as a direct result of infantile paralysis or from excessive lengthening of the tendo Achillis after section for paralytic equinus. The measures at our command for treat- ment are physiological, mechanical, and operative. In whatever condition the calf muscles are, they must be assiduously massaged, and the constant current applied daily until they regain as far as possible their tone. Mechanical Treatment. — The objects are to raise the heel, to bring the toes in contact with the ground a little before the heels, and to keep the arch of the foot as flat as possible. These are effected by a walking instrument (Fig. 182), which may be single. Fig. 182. — Walking appar- atus for talipes calcan- eus with toe - depressing spring. ^ In the Rtvvc cV Orthopdidie for Sept. 1892 Larabrie details a case of congenital calcanens in a male, aged 17, in ■whom division of tendons failed to reduce the deformity. After removal of the scaphoid and other offending portions of bone, the sole of the foot could be placed firmly on the ground, whereas, before the first operation, merely the outer and posterior part of the foot came into contact with the ground. CHAP. IV THE A'ARIOUS FOEMS OF CLUB-FOOT 345 or double to the calf iu severe cases, having a toe-depressing spring, with a three-quarter stop at the ankle-joint, i.e. the joint stopped a little over the right angle to prevent the heel dropping. In most cases a rubber band or accumulator should be attached from the garter- piece to the heel of the boot, and a steel support should be placed on both the inside and the outside of the leg. For night wear a tin shoe Avith a quadrant is necessary. The C[uadrant must be so adjusted that the sole-piece is at an angle of 110" with the calf- piece, and some extension is thus obtained. One point in fixing this shoe deserves attention. The heel is first fixed firmly in .its place, and then, with the left hand drawing the heads of the metatarsal bones forwards and slightly upwards, the surgeon straightens out as much as possible the structures in the concavity of the plantar arch, and finally fixes the front part of the foot in position by a bandage. The use of walking apparatus is advisable in these cases for some years.^ Operative Measures for Acquired Calcaneus.— They are of various kinds, viz. (1) section of the contracted fasciae, muscles, and tendons of the sole of the foot ; (2) measures designed to shorten the tendo Achillis ; (3) attaching the healthy peronei muscles to the lower stump of the tendo Achillis — Xicoladoni's method; (4) arthrodesis. 1. Section of the plantar fascia and some of the short muscles in the sole is useful as a preliminary to mechanical treatment, so that the distance between the toes and the heel may be increased, and the patient acquire as flat a sole as possible to walk on. Section in the sole may be suj)plemented by forcible stretching with the hand or wrench. 2. Shortening of the Tendo Achillis. — This cannot be accom- plished by simply cutting across the tendon horizontally in two places, and removing a giA^en length. Although the stumps may be closely united by sutures at the time of operation, yet the tendon after a time becomes as long as before, and the heel drops. The recurrence of the deformity after such an operation is due, it appears to me, to two causes — continued stretching of the paralysed calf muscles, and yielding of the band of union. Various devices are practised to overcome these objections. The methods of shortening the tendo Achillis are by (a) Willett's Method. - (h) Gibney's Method. ^ Judson's apparatus is also of value. 346 DEFORMITIES OF THE LOWER EXTREMITY sec. iv (c) The Z-Method. (d) Transplantation of the Tubercle of the Os Calcis. (a) Willett's Method} — "A Y-shaped incision some 2 inches in length is made over the lower end of the tendo Achillis down to the tendon. At the lower or vertical portion of the incision, the dissection is continued until the tendon is fully exposed over its superficial and lateral surfaces for the space of 1 inch in length, its deep connections being left undisturbed. The tendon is now cut across at the point of junction of the oblique portions of the wound with the vertical. Next the proximal portion of the tendon is raised, with its superficial connections to the integuments intact, to the extent of fully |^ of an inch by dissecting along its deeper surface, i.e. by reversing the dissection made upon the distal segment. A wedge - shaped slice of the tendon is now cut off from both segments, that from the proximal being removed from the deep surface, whilst from the distal it is taken from its superficial ; in both instances the faces of the wedge-shaped portions removed being at the point where the tendon has been divided. The heel being now pressed upwards, the proximal portion, including both skin and tendon, is drawn down and placed over the distal, thus bringing the prepared cut surfaces of the tendon into apposition. In this position they are held by an assistant, whilst four sutures, two on either side, are passed deeply through the integument, then through both portions of the tendon, and again out through the integument and fastened. When the operation is completed the united edges of the wound assume a V-shaped appearance, owing to the angle of the proximal portion being now attached to the terminal point of the distal portion of the original incision." As Walsham points out, and it is in accordance with the ex- perience of others and myself, plastic operations on the tendons of muscles, which are affected witli infantile paralysis, are successful only when some healthy fibres are present in the muscles. It is useless to perform this or the other forms of tenectomy if the calf muscles give no reaction to electric stimulation. Elongation of the degenerated muscle -fibres will follow some months after the operation. (h) G-ihneys Method.- — A Y-shaped incision is made. The ' St. Bartholomews Hosp. Rep. vol, xvi. 1880, p. 309. ^ Vide the paper by Y. P. Gibney in Ann. Burg. vol. xi. p. 241. Cf. twenty-eight cases treated by his method, seventeen with a good result, eight a fair result, and three a poor result. THE VARIOUS FORMS OF CLUB-FOOT 347 tendon is divided by a very oblique incision passing from below upwards and from behind forwards. The upper portion is then sutured as low down as possible on the lower, and the foot is placed well in plantar flexion. (c) Tiie Z-Method. — The tendon is exposed by a vertical incision over it. If necessary, the skin may be divided horizontally at the upper and lower ends of the vertical incision. The tendon, for example the right one, is divided thus. The knife is passed hori- zontally into it at its left edge, and half - way through it. The edge of the knife is then turned downwards, and the tendon split vertically for a variable distance according to the extent of shortening required. At the lower end of the vertical incision of the tendon the edge of the knife is turned to the right, and cuts horizontally through the remaining portion of the tendon, thus — Fig. 183. — To illustrate the Z-methocI of shorteuing the teudo Aclyllis, by the aiithor. From the rectangular part ABC a portion marked out by AB A'B' is removed, and from the second rectangular part BCD a portion C D CD is removed. Each part cut out is equal in length to one-half of the amount of shortening required. The part at A'B' is united to AB and C^D^ to CD, and the two sides of the vertical incision BC are sutured. By this operation the tendon is satisfactorily shortened, and there is not the same probability of stretching of the band of union as in some of the other operations.^ ^ Phocas, Revue d,' Orth) They cannot be fuUy dorsi-flexed when they are straightened or everted. ^ Mr. Adams says : "The liability to interruption of treatment from infantile com- plaints is much less to be feared within the first few months than at a later period ; and when the foot has been completely cured, I have never seen the defonnity return in consequence of a few weeks' illness. " It is of the utmost advantage to complete the treatment of the club-foot before the commencement of dentition, when children are generally fretful and become liable to so much illness that interruptions from this cause may really be feared. Moreover at a late period children are so much stronger that they often resist all treatment with great violence, and in a passionate child I have known hei-nia produced from this cause." {Club-Foot, 2nd ed. p. 233.) CHAP. VI THE TREATMENT OF CONGENITAL EQUINO-VARUS 401 f^^ Such cases can be treated by manipulation alone, or by manipu- lation combined with massage and retentive apparatus. Method of Manipulation. — The movements to be practised are abduction and eversion at the transverse tarsal and sub-astragaloid joint, and flexion and extension of the whole foot at the ankle, finishing up with circumduction. In all these movements care should be taken that the grasp of the left or fixing hand of the surgeon is made by the thenar eminence and the whole length of the opposing fingers, and not by the tips alone. By so doing more pressure can be borne by the infant than if the latter are dug into the foot. To abduct and evert, the foot is firmly taken in the surgeon's left hand at and below the ankle-joint in the way in- dicated above, and holding the front part of the foot firmly but lightly with the right hand, the foot is gradually abducted as far as it will go without causing pain. It is held in that position for a few seconds, and then allowed slowly to return to its original position. This man- oeuvre should be repeated for five minutes, and supplemented by eversion at the transverse tarsal joint. Then flexion and extension at the ankle-joint are practised for another five minutes, and finally circumduction a few times. Twice or three times a day these exer- cises should be repeated, and the surgeon should see that the mother or nurse is fully competent to carry them out ; simple massage of the foot and leg, especially of the anterior tibial and the peronei muscles, should be further enjoined. It is perhaps a small matter, this of exercises, but one more point remains to be noticed. If the movements are rough and sudden and cause pain, reflex contraction of the contracted muscles sets in, and little can be accomplished at that sitting, or at any other, as the infant soon becomes fractious. Treatment by manipulation alone calls for a considerable amount of intelligence and persistence, is very tedious, and requires to be 2 D Fig. 213. — Congenital talii^es equino-varus of the first degree in the right foot, and of the second de.gree in the left foot (E. L. S., aged 5 weeks). 402 DEFORMITIES OF THE LOWER EXTREMITY sec. iv supplemented by some form of retentive apparatus. As an adjunct manipulation is also extremely valuable in the after-treatment of the more severe degrees. Manipulation combine.d vnth Retentive Apixiratvs. — At the National Orthopaedic Hospital it is largely the custom to employ the flexible metal splint (Figs. 214 and 215). It is a straight well-padded piece of soft iron, strong enough to neutralise the contracted muscle, but 'sufficiently flexible to be bent to any angle. The method of appli- cation is as follows. The splint is first bent so as nearly to fit the outer border of the leg and foot. It is then, by three or four turns of a bandage, fixed to the leg, and the foot is slowly abducted to the splint and held in position by other turns of the bandage. Gradu- FiG. 214. — Flexible met;il splint. Fig. 21.5. — Method of applying flexible metal .si)lint. ally the angle of the splint can be diminished until the foot can be fixed in a straight line with the leg without pain. This suffices to control the varus. For the equinus the splint should be bent to the right angle, and fitted to the back of the leg and sole of the foot. In this stage it is better to employ two splints, one in the manner just mentioned, and a second on the outer side of the leg and foot. The splints are to be worn night and day, being removed for a short time when manipulation is practised, and immediately re-applied. Careful attention, should be given that undue pressure on the malleoli and other bony prominences is avoided, otherwise sore places will result. More efficient, but more expensive than the above, is Mr. Adams' varus splint (Fig. 216). It consists of a thigh-, calf-, and foot-piece, jointed at the knee with a free joint, and at the ankle by a single rack- and-pinion movement. The extension above the knee is very useful in CHAP. VI THE TREATMEXT OF CONGENITAL EQUINO- VARUS 403 controUiug inversion, which is frequently found to- exist at the knee or in the leg in these cases. On the outer side of the foot-piece is a toe-wire, with a strap for overcoming the inversion of the foot. By it and the rack-and-pinion movement at the heel the deformity can be overcome. It is best to partially reduce the varus in the first place by the flexible splint, and to use the varus splint later. For slight cases of equiuo- varus, and in the after-treatment of talipes equinus, Little's rectangular tin- shoe (Fig. 217), or the tin-shoe with a quadrant movement (Fig. 218) at the heel, is useful. Bradford and Lovett ^ speak highly of Taylor's varus shoe and of a modification of Bell's apparatus for the mechanical cure of club-foot. In place of the above apparatus a simple splint can be made of gutta percba, poroplastic felt, or papier mache. The em- ployment of plaster of Paris, with repeated fixation of the foot held in it as nearly in a corrected position as possible at each applica- tion of the bandage until the plaster is firm, has some merit. It is especially applicable to that class of patients wbose parents are too Fig. 216. — Mr. Adams' varus splint. Fig, 217. — Little's rectangular tin-sLoe. Fig. 218. — Tiu-shoe with quadrant movement at heel. poor to obtain apparatus of any kind. Among these people, too, there is reason to believe that the surgeon's instructions will not be 1 op. cit. pp. 464-468. 404 DEFORMITIES OF THE LOWER EXTREMITY sec. iv carried out, and it is better to put ou some form of apparatus which cannot be readily removed. A point in the application of plaster is that after the tiannel bandage or cotton wool has been put round the leg, the first figures of eight of the plaster bandage should be very wide ones, reaching from tlie toes to the upper part of the leg, and passing from the inside below to the outside above, thereby increasing the outward leverage on the foot. Care should be taken not to indent the plaster with the fingers while holding the foot in position during setting. The bandage must be re-applied at least twice weekly, the foot being manipulated, massaged, and additionally corrected each time. This method requires much effort and per- sistence on the part of the surgeon. It is only the lightest cases of congenital club-foot which are permanently cured by manipulation and retentive apparatus. Duration of this Form of Trccdment. — The \arus can be reduced in three to six weeks, and the equinus in another month ; but con- siderable care and the use of retentive apparatus are necessary for some years if relapse is to be prevented. The Treatment of the Second Degree. — The deformity in this degree is of the following nature : — The foot cannot be fully everted nor brought into a straight line with the leg. In attempting to do so the tendons of the tibialis anticus and posticus, the flexor longus pollicis, and perhaps that of the extensor proprius pollicis become tense. Contraction of the tendo Achillis exists, and the heel cannot be brought to the ground when the knee is fully extended, nor can the foot be dorsi- flexed beyond the right angle. Cases of this kind may be cured by — 1. Tenotomy, with the after-use of shoes and apparatus ; or by 2. Tenotomy, followed by wrenching on two or three occasions, and putting the foot up in plaster of Paris after each partial correc- tion. 3. The after-use of retentive apparatus. As this degree is usually found in children under 4 years of age, and the bones and ligaments are still elastic and partially cartilaginous, it is not necessary to resort to more serious measures. By such are meant Phelps' operation, or the various kinds of tarsectomy. Tenotomy and Fasciotomy. — The object in congenital club-foot is to bring about an equal balance of the opposing structures. This is effected in most cases by tenotomy in two ways — the lengthening PLATE VIII. Fig. 1. Cougeiiital talipes I'qiii no- varus before treatineut (Cyril S , aged 4 years). ^ ^t^tiSaSr^^'^ 'f% f D*w.^- z: /2 ^■'z Fig. 2. The same case after treatnieut liy tenotomy, instrumental rectification, and manipulation. CHAP. Ti THE TREAT:ilEXT OF COXGEXITAL EQUIXO-VARUS 405 of the tendons, and the rest given during healing to the contracted muscle. There can be no doubt that, according to the views now held as to the nerve mechanism of the deep reflexes, a tightly con- tracted tendon acts as a perpetual reflex stimulus to its muscle, pro\rLded that the nervous arc through the spinal end is intact. Tenotomy in General. — "With reference to the tenotomy knives, they may be either sharp- or blunt-pointed, the former being employed for burrowing through the more superficial structures towards the tendon, and the latter for insertion along the side of the sliarp-pointed knife, which is then withdrawn. The section of the tendon is made by the blunt-pointed instrument. It should be used when there is fear of wounding a neighbouriug artery, such as the posterior tibial, or a larse vein, as in subcutaneous section of the sterno-mastoid. But to those practised in tenotomy one knife, the sharp-pointed one, is all that is needful except in division of the sterno-mastoid. The point of a tenotomy knife should correspond to the centre of the blade, and the cutting edge be slightly convex. " Slender points, on account of their liability to break, are to be avoided." The cutting edge must always be keen, and not extend more than an inch from the point, and the back be strong and rounded so as to offer sufficient resistance to a tough tendon. Tenotomy may be performed subcutaneously or by the open method (« del ouvert). Generally the subcutaneous method is to be preferred, except if the sterno - mastoid, and perhaps, the biceps and other hamstrings are to be divided, where important vessels and nerves are so near as to be liable to injury. In other cases there appears to be no object in making the open incision. It is a needless procedure, and, in my opinion, may result in adhesion of the tendon to the skin. The importance of injuring the sheath in division of tendon as little as possible may readily be understood by referring to the experimental details of the process of union. It has been abundantly shown that from the sheath the new material receives lymph at first, and later a plentiful supply of blood-vessels. All tenotomies should be performed with full antiseptic pre- cautions. "When these have been neglected suppuration has followed, although rarely (see '' Accidents after Tenotomy "). Anesthetics in Tenotomy. — For all varieties of tenotomy nitrous oxide gas is sufficient, except for that of the sterno-mastoid, where the convulsive movements ■ of the neck muscles from the partial asphyxia seriously embarrass the operator. The eflects of nitrous oxide can be prolonged by admixture with oxygen, a proceeding 406 DEFORMITIES OF THE LOWER EXTREMITY sec. iv most successful in the hands of my friend and colleague, Dr. Prederic Hewitt, to whom must be assigned the credit of having brought the simultaneous employment of these gases to high perfection. Ether is useful as an annesthetic w^hen tenotomies are combined with wrenching, or if they are performed by the open method ; its administration is more pleasant if preceded by nitrous oxide gas. Some surgeons deem a general amesthetic unnecessary for tenotomies, and indeed this is the case in young infants. As a rule chloroform, except in operations about the neck, is best avoided, since ether is practically free from risk. Local anaesthetics are of little service. The injection of cocaine is not always effectual, and is occasionally followed by alarming symptoms of collapse. If it be used at all, not more than a quarter of a grain should be given. It is stated that the injection is more successful' if it be made in the direction of the arterial stream. Accidents during aiul after Tenotomy, ami Causes of Failure. — In the performance of tenotomy the chief risks are wounding arteries and veins, and the severing of nerve trunks. As to the arteries, it is not uncommon in dividing the tibialis posticus for a jet of arterial blood to follow the withdrawal of the tenotome, and section of the plantar fascia and short muscles of the sole, if at all deep, must involve the internal plantar vessels and nerve. Such events in the extremities are of little moment. A pad firmly applied suffices to arrest all haemorrhage. It is better to divide a small artery com- pletely rather than to puncture it, as the risk of aneurism is less. Operations in the neck in the neighbourhood of the internal jugular and subclavian veins demand every care, and my preference here is for the open method. In dividing the biceps tendon behind the knee the external popliteal nerve has been wounded and divided. An accident of this nature is deeply to be deplored, and if any doubt exists as to the identities of the tendon and the neighbour- ing vessels and nerves in important situations, the open method is safer. Accidents after Tenotomy. 1. Siqjjncration. — This event I have not seen, but that it is a real danger is evidenced by the following remark of INIessrs. Walsham and Hughes ^ : " We may say at the outset that the only troubles, we have ourselves had, have been suppuration in one case after division of the tendo Achillis, and a traumatic aneurism after division of the plantar fascia." It is much to the authors' credit that they record these accidents, as they 1 Op. cif. p. 191. PLATE IX. Fig. 1 )le cougunital talipes equino-varus (Cyril D- aged 6 weeks). \, Fig. 2. To show the completion of the first stage o treatment, viz. leiluction of the varus de forniity, leaving the teudo Achillis intact am the feet in the equinus position. ^ '^x.^^ Fig. 3. Completion of treatment by section of tendo Achillis, and the position of the right foot at the age of 4 years. CHAP. VI THE TREATMENT OF CONGENITAL EQUINO-VARUS 407 serve to impress upon us that so slight an operation as tenotomy is not unaccompanied by danger.^ 2. Aneuris77i. — In addition to aneurism of the internal' plantar artery mentioned above, two cases of aneurism of the posterior tibial artery have come to my knowledge. They were both readily cured by the pressure of a pad and bandage. 3. Teno- synovitis may result from septic infection of the wound, and cause extensive adhesion of the uniting material and tendon to its sheath, with considerable risk of sloughing of the tendon. 4. General infective diseases, such as erysipelas, septicaemia, and pyaemia, may complicate tenotomy, as after any simple wound not accompanied by full antiseptic precautions. 5. Hce7norr]iage. — After wounding the anterior or the posterior tibial artery free hsemorrhage occurs for some time, if firm pressure is not maintained ; but if this ordinary precaiition is taken, little blood will be lost. A'^olkmann and Owen record instances of wounding of the internal jugular vein when dividing the sterno- mastoid subcutaneously. Both patients, however, recovered. 6. Non-union of tendon results from suppuration or from an interval of too great an extent being maintained between the tendon stumps, especially if a patient be allowed to walk within a month " ; after section of the tendo Achillis non-union may occur, especially in a case of infantile paralysis, where the tendon is often small and badly supplied with blood. Such an unfortunate event has come within my knowledge. Causes of Failure in Tenotomy. — 1. Imperfect division of a tendon. This event occurs occasionally in the case of the tendo Achillis, which may be either transfixed, leaving the deeper part intact, or a small portion of the superficial part may remain un- divided for fear of " coming through " the skin. 2. Missing the tendon, as, for instance, in the case of the tibialis posticus in a fat infant. This mistake has been verified by subse- quent dissection. 3. Clumsy division with extensive laceration of the sheath and ^ It has been pointed out that during the recent prevalence of influenza suppuration has occurred after tenotomy to an unusual degree. - It is well known that Syme allowed his patients to walk on the third day after section of the tendo Achillis. The weight of modern opinion is strongly against this plan. It has been shown that in the experiments on rabbits, if the foot be left entirely uncontrolled, the tendon ends separate gradually as much as 2i inches, and the stretch- ing goes on for several weeks. 408 DEFORMITIES OF THE LOWER EXTREMITY sec. tv soft parts, causing matting and firm adhesion of the tendon and neighbouring structures. Tlie Question of Immediate and Gradual Hcjiositio/i of the Part after Tenotomy. — There are several factors to be considered. The first is the position of the tendon. On the attachments of the sheath, its elasticity, and its capability of retraction, when divided more or less completely, much must depend. In some instances, as described on p. 370 imder the title of "Functional Prognosis of Tendon Suture," the tendon stumps retracted 2^ inches, in other cases not more than half an inch. Again, an interval of 1 inch in the tendo Achillis will not interfere with firm union, while the same amount in the flexor tendons of the hand will seriously impair the functions of the part if the extensors are not efficiently controlled. Then again, it is advisable before deciding the question to consider the strength and tension of the affected muscles and their opponents. In a spastic or congenital case, the interval after division will be greater than in a paralytic case, since the tendons of the affected muscles are in a state of greater tension than normal, and the ends fly apart more on division. Their opponents, too, having a normal amount of contracting power, act vigorously through the neighbour- ing articulation, and so pull the ends farther apart. Some tendons, again, " fly " more than others. This is especially the case in the extensor longus digitorum of the foot, and the extensors of the first and second phalanges of the thumb, if divided just below the wrist. Then, too, if an artery has been pricked, htemorrhage is less likely to occur if the limb be returned to the deformed position temporarily until a firm clot has formed in the artery. There are some cases, then, in which immediate rectification as far as possible is admissible, and there are many others in which it is not advisable. But inasmuch as gradual reposition is in all cases safer, and the same end is gained, I fail to see any reason for strongly advocating the immediate reposition. Above all, the gradual method has the advantage that the length of the band of new material can be regulated to a nicety, as the uniting substance is during the first three or four weeks capable of considerable extension without in any way affecting either the subsequent thickness or strength of the band. Another point is this. If the tendon be immediately lengthened to its full extent, and the case pass rapidly from obser- vation from some cause or another, so that the union is not kept under full control, the band becomes unduly long and weak, and in the case of the tendo Achillis, talipes calcaneus has followed. CHAP. VI THE TREATMENT OF CONGENITAL EQUINO-VARUS 409 Structures requiring Divisio7i in the Second Degree of Congenital Chtb-Foot. — ^They are portions of the plantar fascia, the tibialis anticus and posticus, the flexor longus digitorum, perhaps the extensor proprius poUicis, and certainly the tendo Achillis. Now in a compound deformity such as equino-varus it is evident that the obstacles to complete reduction are situated in two centres of movement, the medio-tarsal and the ankle-joint. In operating on such cases we must recognise this fact. To reduce the varus there must be some fixed point to take purchase from. Such a point already exists at the os calcis and astragalus, owing to the contracted tendo Achillis fixing those bones firmly in the mortice of the tibia and fibula. If the position of this fixed point be prematurely disturbed by section of the tendo Achillis, much of the leverage which can be exerted from that part on the front of the foot is lost ; and further, the foot can be rotated at the ankle and sub-astragaloid joint in such a way as to give an appearance of reduction of the varus long before it is complete. It is therefore most strongly advocated that the treatment of eqioino- varus should he conducted in ttvo stages. I. Complete reduction of the varus portion, leaving the tendo Achillis untouched. II. When the varus is overcome, division of the tendo Achillis to reduce the equinus. The importance of preserving the integrity of the heel cord until this second stage is begun cannot be over - estimated. I am fully aware that some surgeons divide all resistant structures at the same time, but with much deference I cannot help thinking that in such cases there are two risks, the one of incomplete reduction of the varus, and the other of an unduly long tendo Achillis, resulting in a pernicious form of talipes calcaneus. In support of these remarks, it is well to add that such ill results have come under my notice. The varus part can usually be overcome after division of the tibialis anticus and posticus and sometimes of the extensor proprius pollicis, fiexor longus digitorum, plantar fascia, and anterior fasciculus of the internal lateral ligament. Section of the Plantar Fascia. — In slight cases this is not necessary, but if in attempting to reduce the concavity of the sole any tight bands be felt,^ then fasciotomy should be done. The bands to be divided are on- the inner side of the sole and on the ■^ The best way to feel and to localise these accurately is to use the edge of the fore- finger nail. It is more efficient than roughly palpating them with the tip of the finger. 410 DEFORMITIES OF THE LOWER EXTREMITY .SEf. iv iiiuer border of the foot itself. The latter band is often missed, and gives rise to delay in reducing the deformity, especially of that peculiar appearance which we have mentioned, the adduction of the great toe. A practical point is that after division of the superficial bands deeper ones come into prominence, and necessitate wider section than at first seemed necessary. Frequently the short muscles of the great toe will require attention. Division of the plantar fascia is sufficiently simple. The parts having been antisepticised, the patient is put under nitrous oxide gas, after being placed in the lateral or semi-prone position. If the division is to be made on the right side, the right leg is extended, and the foot turned as much on the dorsum as possible ; the left leg is flexed at the knee, and the left foot is thus out of the way. The assistant, by fixing the heel with one hand, and carefully making upward pressure on the ball of the great toe, renders the fascia prominent,^ so that the bands are clearly felt. If necessary, the surgeon may define them with his finger-nail. The assistant now relaxes the tension on the bands, and a knife is passed in. The spot to select is one-third nearer the attachment to the os calcis than to the roots of the toes. Posteriorly the fascia has not split into several divisions, and it is more completely divided. Again, if section is required a second time, more elongation will be obtained by bisecting the anterior two-thirds of the space between the toes and heel, than by quartering the whole space, as must occur if the first section has been made in the middle of the fascia. The classical method is to pass the knife— a strong-backed fascia- knife — on the flat deeply to the band. The fascia, previously lax, is then made tense by the assistant, and by careful sawing movements of the knife, the edge of which has been turned upwards, the bands are severed. It is the practice at the Xational Orthopaedic Hospital to .enter the knife between the skin and fascia, and cut towards the bones. The attachment of skin and fascia is so close that, if the latter is divided in the classical way, considerable difficulty will be experienced in completely severing all the strands without cutting through the skin. Section from the skin downwards has another advantage, in that the deeper bands and short muscles can be divided ' An inexperienced assistant will sometimes hold the liall of the toe so clumsily that the bands are not well defined, nor are they rendered tense at the moment of division. His thumb and fingers should firmly but lightly hold the head of the metatarsal bone of the gi-eat toe in such a way as by slight movements downwards, inwards, or out- wards, to render those bands prominent whicli need division. PLATE X. Fig. 1. Fig. 2. Cougenital taliiies equino-varus before treatment. Side view of the same foot as in Foreshortened view (Ivy H , aged 2 years). Fig. 1 liefore treatment. Fig. 3. Tlic same foot after completion of treatment. CHAP. VI THE TREATMENT OF CONGENITAL EQUINO-A^ARUS 411 without altering the direction of the knife's edge. If any contracted fascia is present on the inner border of the foot, it can be relieved by a section made from the same skin puncture. The small wound is then dressed with gauze and a bandage ; as a rule no splint is necessary. Immediately after the operation some surgeons stretch the sole of the foot either with the hand or the wrench. But it is better to wait for two weeks until the blood effusion has disappeared, and then to stretch. It seems that less cicatricial tissue is formed, and consequently less matting of the parts ensues. At any rate the resulting cicatrix is always less painful. It is advisable to inform patients that after this operation some pain may persist at the site of operation for several weeks, and is liable to recur on walking, but this inconvenience does not last more than two or three months, and its disappearance may be hastened by careful friction to the sole. The less the foot is stretched for the first fourteen days, the less is the after-pain. Careful dissection out of the contracted fascia in the sole, as for Dupuytren's contraction of the palmar fascia, has been suggested and practised, but in ordinary cases it is not needed, and sutticient elongation can usually be secured by subcutaneous section and the use of the wrench. Mr. Arbuthnot Lane ^ has introduced an extension of this operation, viz. wholesale subcutaneous division of all the structures in the sole of the foot, without respect to arteries and nerves. This is practically a subcutaneous Phelps', and for the degree of deformity now uuder^ consideration is not necessary. Tenotomy of the Tibialis Anticus. — This presents no difficulty. It is well to remember that the tendon is often displaced somewhat internally, but it can usually be felt. The patient lying supine, the tendon is accurately defined on the dorsum of the foot, and the tenotome, held fiat, is passed underneath it, and from without inwards, so as to avoid the dorsalis pedis artery. The tendon is made tense by the assistant abducting the foot and rotating the sole inwards, and the edge of the knife being turned towards the tendon, a slight movement severs it. The knife is withdrawn on the flat. If the tendon cannot be readily felt, owing to the amount of fat present, a point just below the middle of the ankle-joint and slightly to the inner side localises it. Successful division is evidenced by a 1 Lancet, 1893, vol. ii. 19th Aug. In addition to subcutaneous section of all the soft tissues in the sole of the foot, Mr. Lane divides all the resistant structures behind the internal malleolus. 412 DEFORMITIES OF THE LOWER EXTREMITY sec. iv suddeu loss of resistance to the knife and a diminution of the inver- sion of the foot/ Tenotomy of t!ie Extensor Longus Pollicis. — This is usually done on the dorsum of the foot midway between the ankle and the first interdigital cleft, the knife being passed from without inwards. Immediately on section the great toe becomes flexed. Tenotomy of the Tibialis Posticus is performed either above the internal annular ligament, i.e. above and behind the internal mal- leolus, or below the internal annular ligament. As a guide to the tendon, text-books speak of a small, prominent spine, the posterior tibial tubercle, on the posterior edge of the internal malleolus, and at the junction of this process with the shaft. It is suggested that the knife should be entered immediately behind this point, and that the tendon be there divided. There are several objections. Firstly, the tendon is entering the synovial sheath in the annular ligament, and complete division is difficult ; secondly, this point of bone is absent in children ; thirdly, the leg is sometimes too fat for the tubercle to be felt. The best method is the following, especially in operating on infants. If, for instance, the right foot is the affected one, the child is turned to the right lateral position, so that the outer aspect of the leg lies as flat as possible on the table. The left knee is flexed, and the left foot is thus out of the way. The operator stands on the left side of the patient (if for the left tibialis posticus, on the right side), and the assistant faces him, holding the foot extended, inverted, and adducted, so that the tibialis posticus and flexor longus digitorum are relaxed. The surgeon now marks a point with his eye, 1 to 2 inches above the tip of the internal malleolus, and exactly midway between the anterior and posterior margins of the leg. Holding the knife vertically and with the flat of the blade parallel with the long axis of the tibia, the point is passed in perpendicularly to the skin, and is carried on steadily until the inner edge of the tibia is met. This is the guide to the tendon. If the edge is not felt, the knife must be used as a probe until it is. The edge of the knife is turned backwards toward the tendon. The assistant now dorsi- flexes, everts, and abducts the foot, thus rendering the tendon tight. This movement is in infants often sufficient to make the section, 1 In many cases I turn the edge of the blade away from the skin, and sink the point until it is just in front of the tip of the internal malleolus, and then cut firmly down to bone, thus dividing all bands and fascia and the anterior fasciculus of the internal lateral ligament, as in Parker's syndesmotomj-. CHAP. VI THE TREATMENT OF CONGENITAL EQUINO-VARUS 413 without any effort on the part of the operator. In older children a gentle sawing movement is made, and the tendon gives with a sudden jerk, which is felt by both assistant and operator. If the flexor longus digitorum ]. is divided at the same time a double jerk is felt in the foot. No doubt should exist as to the section of the tendons ; if properly performed the foot at the time will immediately be found to be capable of more eversion. In thin legs, too, a gap may be felt between the ends of the tendon. If on withdrawal of the knife a jet of bright blood follows, with sudden blanching of the foot, the posterior tibial artery has been wounded. Oozing of dark blood indicates puncture or division of the internal saphenous vein, but neither of these events is of much importance. Those who are anxious on these points, however, or who are not practised in the operation, should use the sharp tenotome to oj)en the tendon sheath, and then substitute the blunt knife for the tenotomy. But if one frequently performs the operation, there is little or no risk of wound- ing the artery with the sharp tenotome. A pad of gauze is placed over the wound, and kept in place by two pieces of American -rubber plaster fixed crosswise, but not passing entirely round the leg. A second pad is placed over the site of the wound, and a turn or two of bandage lightly applied keeps all in place. A flexible iron splint adapted to the deformed position is then fixed along the inner side of the leg and foot. Division of the tibialis posticus, flexor longus digitorum, and flexor longus pollicis simultaneously may be accomplished thus. The astragalo- scaphoid joint and the tibialis anticus tendon are defined. The knife is entered flat just external to the tibialis anticus tendon, and passed beneath the skin. The edge is turned towards the bone, and the foot being everted and flexed, the tendons are divided by cutting firmly towards the bone. Division of the Feroneus Longus and Brevis can be readily effected about 1-|- inch above the external malleolus. The patient is placed on the opposite side, and the foot held somewhat everted so that the tendons are relaxed. The knife is then passed from behind forwards beneath them at a distance of 1-|- inch above the external malleolus, where they are prominent and close to the fibula. The foot is then forcibly inverted and the tendons are severed. In the case of hyper-extended toes due to contraction of the extensors, it is often best to sever the tendons at the root of the toes. Section of the Tenclo Achillis. — This section should, in my opinion, ^ To include the tendon the knife should be buried a little deeper in the leg. 414 DEFORMITIES OF THE LOWER EXTREMITY in cases of congenital equino-varus, be done at a later period than those of tlie tibiales anticus and posticus, for tlie reasons given on p. 409. The method is as follows : The parts are rendered aseptic, and the patient, after the administration of the anaesthetic, is turned into the prone position. The spot selected for division is at the narrow part of the tendon, a short distance above its insertion. If the knife be entered higher np, tliere is risk of w^ounding the posterior tibial artery, greater thickness of tendons to divide, and the possiljility of not including the plantaris in the section. The foot is held by the assistant so that the tendon is relaxed, and the knife is passed through the skin with the blade fiat from the outer ^ side, and close beneath the tendon. The tendon is then made tense by the assistant, and by gentle saw- inf movements section is accomplished. At that moment a snap is perceptible, and a gap between the ends can be felt beneath the skin. The assistant should now extend the foot so as to prevent the knife coming through the skin. Section of the tendon nmst be complete. When I have watched novices perform this small operation, I have noticed that the division has been sometimes incomplete, arising, I believe, from two causes : {a) want of boldness in dipping beneath the tendon, so that it is transfixed, and only the superficial part divided; (b) a small band, possibly part of the plantaris tendon on the inner side, escapes section. After the operation a pad of gauze is fixed with strapping over the puncture, and further kept in place by a bandage.^ A flexible iron splint is put on the front of the leg and dorsum, so that the foot remains extended. Sijndesmotomy : Division of the Ligaments — Subcutaneous Section of the Astragal o-Sca'plwid Capsule (E. W. Parker). — This operation is called for when there is very considerable obliquity of the neck of the astragalus, but is very rarely necessary in cases of club-foot of the degree we are now considering. It is convenient, however, to ^ It is genei-ally recommended that the knife be entered from the inner side. In equino-varus the posterior tibial artery is displaced towards the tendon, and the latter is frequently deviated inwards. It appears that there is a risk of puncturing the artery if the dip with the knife is made from the inner side. Should there be any doubt, both the sharp and blunt tenotomes may be employed. It is better to divide the artery than to i)uncture it. In the latter event, there is more likelihood of aneurism. 2 Both strapping and bandage should be loosely applied in order that the skin may not be pressed between the tendon ends, and jiavtially block the sheath. For perfect union the sheath must be well distended with blood. CHAP. Yi THE TREATMEXT OF COXGEXITAL EQUIXO-VARUS 415 give tbe steps here amongst the slighter operative measures for club- foot. The operation presents this advantage that with the ligaments the tendons of the tibialis anticus and posticus can be divided at one stroke on the inner side of the foot. The astragalo- scaphoid capsule^ is, according to Parker, "an unyielding capsule of great strength made up above and internally of the superior astragalo - scaphoid ligament vpith fibres from the anterior ligament, the anterior portion of the deltoid ligament of the ankle-joint, and below with fibres from the inferior calcaneo- scaphoid ligament. To these are united fibrous expansions of the tendons of the anterior and posterior tibial muscles." Mr. Parker's directions for division of the capsule are as follows ^ : " The teno- tome, being held vertically with the edge forwards, should be entered immediately in front of the anterior border of the internal malleolus, the blade being kept as far as possible between the structures to be divided and the superjacent skin. In the next stage the blade is turned towards the surface of the ligaments, and by means of a gently sawing motion, is made to divide them. As the superficial fibres are divided, deeper ones come into play, and must in their turn also be cut until the bones are reached. By keeping the knife close to the bones and directing its point to the plantar aspect of the foot, the calcaneo-scaphoid part of the ligament can be easily divided." During section the ligaments should be made tense by forcibly abductincr and everting the foot. Division of the internal lateral ligament of the ankle may be performed subcutaneously from the small wound made in dividing the tibialis anticus tendon. Care should be taken to keep close to the tip of the internal malleolus, and not to wound the posterior tibial artery. Si'Mutaneous Section of the Posterior Ligament of the Ankle. — -This is not a successful operation. In the first place, it is difficult to make sure that all the fibres are divided ; and secondly, contraction of this ligament is rarely the sole factor in the persistence of the equinus. The two causes of intractable equinus are, downward deflection of the neck of the astragalus and tilting forwards of that bone, so that its superior articular part cannot be replaced in the mortice of the tibia and fibula. One other operative measure, applicable to this degree of club- foot, remains to be mentioned. This is vrrenching, which may be effected more especially in this degree by manual force, and in the severer degrees by special apparatus. If rapidity of treatment 1 Congenital Club-Foot, p. 63. ^ Op. cit. p. 83. 416 DEFORMITIES OF THE LOWER EXTREMITY ill the second degree of clul)-foot is aimed at, there is no method so quick and so safe as that of wrenching, combined with tenotomy. When wrenching is carried out with the hands, the movements are the same as those practised in manipulation (p. 401), but they are made under anaesthetics and with more force, plaster of Paris being Fig. 219. — The Thomas wrench (Robert Jones). afterwards applied. After a fortnight the plaster of Paris should be removed, and the foot again forcibly manipulated, the opportunity bein^r taken to massasie the foot and les; thorouCThlv. ^^..^-^^ Fig. 220. — Reductiou of the varus part of the deformity by the Thomas wrench (Robert Jones). Wrenches and their Use. — Some wrenches are formidable and powerful instruments. Others are simple and handy. The best form for the treatment of club-foot is the Thomas wrench (Fig. 219). Other useful forms are Vincent's modification of Eobin-Molliere's tarsoclast, which I have seen in use at tlie Hopital de la Charite CHAP. VI THE TKEATMEXT OF COXGEXITAL EQUIXO-VARUS 417 at Lyons, and Bradforcrs lever. Phelps' apparatus and Grattan's osteoclast are complicated.^ My friend Mr. Eobert Jones of Liverpool, who has had great Fig. 221. -Kednction of the equiuus portion of the deformity by the Thomas A\Teuch (Robert Jones). experience in the use of the Thomas wrench, has, at my request, most kindly described his mode of using it, and allowed me to insert the accompanying figures. After preliminary tenotomy and syndesmotomy, Mr. Eobert Jones writes : "■' In the inversion-deformity of varus the pins of the wrench should grasp the foot on the inner side, and should be suffici- ently tightened to prevent all danger of slipping. The upper pin should be against the astragalus (Fig. 220) and the foot forcibly rotated out- wards, counter pressure being supplied by the operator's hand, which is placed against Fig. 222.— Overcoming the adduction deformity at the lower end of the fibula. the medio-tarsal joint by the Thomas ^^Tench (Puobert Jones). For the equinus deformity the position of the wrench is the same, but the handle should be ^ Full descriptions, with figures of the various forms of tarsoclasts, are to be found in the Traite cU Cliirurgie OHhopedique (Piedard), and in the Deformities of the Human Foot (Walsham and Hughes). 2 E 418 DEFORMITIES OF THE LOWER EXTREMITY sec. iv made to work in the flexion axis of the aukle-joint (Fig. 221). To correct the adduction deformity at the mid-tarsal joint, the upper pin should be placed against the cuboid, and the lower behind the first metatarso-phalangeal joint (Fig. 222) ; the structures on the inner side should then be stretched. The twisting and bending is done quickly and forcibly, and the foot immediately released. Holding the foot in the bite of the wrench too long may result in a pressure sore.^ The key-note of treatment consists in the extent to which the stretching is carried. It should be to such a degree that the foot is temporarily paralysed, and lies limp in the hand. A retentive splint is then applied. After two or more days, depending upon the degree of the deformity and the severity of the wrenching, the resiliency of the foot begins to return, and the wrenching is repeated. To anticipate the inward rotation of the tibia and fibula, one hand grasps the leg below the knee and fixes it, while the other grasps above the ankle and attempts by a twisting movement to overcome the rotation of the tibia. This manoeuvre should be practised frequently. The foot must be over-corrected." Dangers of Wrenching. — These remarks apply not to the Thomas, but to the more formidable varieties of wrench. 1. Tearing of the Skin. — When the concavity on the inner side is considerable, and the foot is resistant, the skin, being much shortened and bound firmly to the plantar fascia, may give way in an oblique direction from near the tip of the internal malleolus to the middle of the sole more or less. This event should be antici- pated by rendering the foot aseptic before the operation, and met by suitable dressings when it occurs. It is, according to many ardent advocates of the wrench, of no great importance — in fact it is only an involuntary Phelps' operation. Sloughing of the skin from pressure must be guarded against (see note 1 below). 2. Gangrene. — This arises not from the wrenching, but from the plaster bandages, which may be put on tightly, allowance not being made for the subsequent swelling of the foot."- 3. Separation of the Epiphysis is a lamentable accident, and may seriously impair the efficiency of the limb. Every care should be taken to avoid it. 4. Fracture of the Bones of the Leg. — This event is not so serious. 1 This can be obviated by placing a strip of rubber or a thickness of wet cloth between the pins and the foot. - Vincent (of Lyons) states that "he has had to deplore one case of gangrene from this cause " (Private Pamphlet). CHAP. VI THE TREATMENT OF CONGENITAL EQUINO-VARUS 419 In some cases, if excessive inward rotation of the leg is present, a fracture is sometimes made of set purpose to overcome the in- version. In the less degrees of club-foot so vigorous a treatment cannot be necessary, but in severer cases, and those which have relapsed, wrenching is of great value. The Treatment of the Limb and Foot after Operation. — The methods in use are — • A. Immediate Rectification of the Deformity. — The foot is over- corrected by tenotomy, followed by manipulation and wrenching, and is at once put up in plaster of Paris, with a good padding of cotton wool or thick flannel bandage beneath. The bandage is best applied from without inwards, and must be carried from the roots of the toes well up the leg. Care should be taken not to indent the plaster Avith the finger while it is hardening. This may be obviated by using a T-shaped piece of wood after Hahn's pattern (Fig. 223). The advantage of this method of immediate rectification consists in economy of time. The disadvantages are — 1. While suitable for slight cases, in severer cases it Fig. 223. — T-sliaped piece of wood as used by Hahii to secure good position of foot after plaster of Paris has been applied. involves risk of bruising of the parts, on account of the force required at the time of operation. 2. Extreme care and watchfulness after the operation must be observed, in order that the pressure of the plaster or other fixation apparatus may not cause sloughing, and this care necessitates re- tention of the patient in a hospital for one or two weeks. 3. Interference with the circulation has occurred, and gangrene followed. 4. Pain is often extreme,- partly from the violence to which the foot is subjected, and partly from the pressure of the retentive apparatus. So that the foot must be " taken down," some of the 420 DEFORMITIES OF THE LOWER EXTREMITY sec. iv deformity allowed to return to relieve the pressure, and the hope of immediate rectification foregone. As a compromise the next method is much in vogue. 5. Eelapse occurs from time to time. B. Bajjid Rectification of the Foot. — After the operation the foot is placed nearly in its corrected position, and plaster applied. This is renewed at intervals of three days, and the foot is corrected a little more each time until it is in good position. The wrench may be used once or twice afterw^ards, but to a less degree than at the first sitting. Before each re-application of the plaster the foot and leg should be well rubbed. C. Gradual Rectification of the Foot. — In the opinion of many the ideal result, except in two points, viz. the length of treatment and the expense involved, is gained by the slower methods, especially in severe cases. There is less tendency to relapse, the foot is more elastic, no pain results, and there is an absence of the risks involved in imperfect supervision. In the case of the poorer patients especi- ally, when the parents see the foot put straight in a short time by the rapid methods, they are apt to imagine that no further care is needed, and the case is promptly allowed to relapse. In illustra- tion, I quote the following letter I received from a friend who consulted me about a case : " I tenotomised as you advised, and did a good deal of good temporarily ; however, the plaster of Paris was not kept on, and when the child began to walk it got much worse again, and is now as bad as ever. The child is over 2 years of age, and walks on the external malleolus. What further to do I don't quite know% and write to ask 'whether you cannot take the boy in somewhere and help him. His parents are very helpless, and if it can go wrong after his return, it will." Desirable as rapidity of treatment is, and ideal as it may be to the surgeon, yet if ultimate success is thus to be discounted by relapses, it seems that after all the slower may be the surer way. In place of plaster, silicate of potash, gum and chalk, or dextrin and starch may be used, but are not so easy to apply. The restoration of a deformed foot is not merely a question of dividing easily accessible tendons and fasciae. It is more. The bones must be brought into position, and moulded till they assume a normal shape, and the ligaments on the concave side stretched, and on the convex side allowed time to shorten. Thus the whole foot is gradually brought into good position. Short of wide-cutting operations, which are unjustifiable in this degree, there is no method CHAP. VI THE TREATMENT OF CONGENITAL EQL'INO-YARUS 421 Fig. 224. — Mr. Adams' shoe witli divided sole-plate for the after- treatment of talipes equino- varus. SO certain and sure, but tedious witlial, as that which I mention, viz. the Pinfolding of the foot at first in its anterior part, using the posterior as a fulcrum, and then reducing the deformity in the latter. Doubtless much time may be saved by wrenching, and during the first stage of treatment it should be employed ; but the foot needs time to adapt itself to the new position induced by tenotomy and the wrench, and for this purpose mechanical aids, especially some form of Scarpa's shoe, seem to me to be the best. - The Gi^aclual Method. — The plantar fascia, the tibialis anticus and posticus are divided, and the extended foot is placed in a malleable iron splint, which is bandaged on the outer side from the toes upwards. The splint is so adjusted to the outer side that the position of the foot remains in a less deformed position than before the operation. After three to four days the foot is slowly " brought out " in infants by means of the varus splint (p. 403), and in children over one year by Adams' modification of Scarpa's shoe. Adams Modification of Scarpa'^ Shoe. — "The modern Scarpa's shoe, or, more strictly speaking, Adams' extension shoe (Fig. 224), is de- sisjned to meet the anatomical requirements by placing the me- chanism for extension opposite to the joints where it is obtained, viz. the ankle and transverse tarsal joints. The shoe consists of a heel-piece and sole-plate, and a trough or calf portion. The heel- piece is connected to the calf-piece -Little's doubie-hiuge lever shoe j^y ^ doublc-action rack movement, for varus. -^ -, n • having lateral, flexion, and exten- sion movements. This is invariably placed on the inner side of the shoe, for the reason that, as the outer border of the foot requires raisino- the mechanical centre of movement for this should have as Fig. 221 422 DEFORMITIES OF THE LOWER EXTREMITY sec. iv long a radius as possible. The lieel-piece and sole-plate are con- nected by three rack-and-pinion movements, having lateral move- ment, uplifting, and rotation ; these corresponding to the threefold deformity. By means of these movements the appliance can be adjusted to the severest condition, and gradually unfolded as the treatment progresses." Dr. Little's varus shoe is nearly as eflicient and not so ex- pensive (Fig. 225).^ Manipulation of the foot must be most assiduously carried out once and, if possible, twice daOy. It should not be done in a perfunctory manner, nor left to the care of an untrained nurse, but the surgeon must see that it is thoroughly done. Xo factor in this stage of treatment is more important. The movements in manipulation are described on p. 401. Elastic Traction. — In place of and after tenotomy, efforts have been made to overcome the deformity by means of elastic traction, and it is claimed by some surgeons that cases of this degree can be thus completely reduced. The method consists in applying adhesive strapping and bandages to .the leg and foot, and fixing hooks in the strapping at the upper and outer part of the leg and at the outer side of the heel and front part of the foot. The hooks are then joined by elastic tubing or accumulators such as are used for closing doors. The idea is that the india-rubber takes the place of the weaker muscles, and so acts in a physiological manner. Plausible as this is in theory, in practice it does not act well. It is difficult, in the first place, to make the plaster and bandages sufficiently firm with- out causing some impediment to the circulation ; in the second place, much irritation of the skin is caused by the strapping ; and thirdly, the force not acting through the centres of movement, cannot eftectually control the deformity. When the inversion is fully corrected the tendo Achillis is divided, and the heel is gradually brought down in the Scarpa's shoe. Duration of Active Treatment by the Gradual Method. — The deformity in the front part of the foot can be reduced by teno- tomy and the Adams' shoe in about six weeks ; in less time if wrenching be employed. The reduction of the equinus takes from four to six weeks more, but occasionally this proves to be obstinate. Flexion of the foot can be effected by means of passive exercises, 1 Details of the instruments employed in England will be found in "Walsham's work, already referred to in America and on the continent in Bradford and Lovett's work. CHAP. VI THE TREATMENT OF CONGENITAL EQUIXO-VARUS 423 or by using a foot-exercising apparatus. It is of especial value in rigid and relapsed cases, where adhesions frequently exist in and around the ankle-joint. While speaking of this matter of obtaining due flexion of the foot, it is well to add that when the foot can be dorsi-flexed to a little over the right angle with the knee fully extended, it is sufficiently corrected. There is no greater error in the treatment of equinus and equino- varus than excessive elongation of the tendo Achillis. As stated on a previous page (344), calcaneus of a peculiarly troublesome variety follows. When sufficient flexion has been obtained, a walking instrument should be worn during the day, and a rectangular tin-shoe at night. After- Treatment of Congenital Equino- Varus. — It may be certainly said that unless efforts are made to neutralise by manipulations the vicious tendencies of the affected muscles, fig. 226.— Walking appar and means be taken to control the foot during the period of active growth, relapse is certain to follow cases of any severity. For one to three years after active treatment has ceased, some form of walking apparatus is required. Slight cases and those before the child has walked are controlled by a light boot and spring (Fig. 227). "The chief merit of this instrument is a convex long spring, which is attached to the sole of the boot, and extended to the calf. The boot is first laced on and the spring then brought into position. By the convexity and position of the spring the foot is forced to assume the position of valgus, but if this be too marked, the power of the spring can be easily reduced by a controlling strap. The foot has perfect mobility, there being a free movement at the ankle." Little's concealed varus spring (Fig. 227) answers the same purpose. When the child is over 2 years of age, and begins to walk, it is desirable, taking into account the increased weight in the feet, that some firmer support should be provided. A good walking apparatus is that shown in Fig. 226, in which a noticeable atus for the after-treat- ment of congenital talipes equiuo-varns. Fig. 227.— Little's con- cealed spring for ab- ducting or adducting the foot in varus or valgus. 424 DEFORxMITIES OF THE LOWER EXTREMITY feature is the varus T-strap which is fixed to the outer part of the sole, and Ijeing buckled round the upright on the inner side, maintains the foot in a slightly inverted position. The sole-piece of the instrument must be so fixed as to evert the foot ; a " stop " at the ankle is sometimes desirable to check excessive dorsi-Hexion. For children of 4 years of age and older, it is advisable to have a second upright, on the outer side, so that the foot may be held under complete control. If after one to two years the foot, being uncovered and the child standing firmly on it, remains quite straight or slightly everted, then a boot with a concealed varus spring will suffice. As to when instruments may be entirely dispensed with, it is difticult to fix a precise date. The best criterion is the steady maintenance of the foot to the front in all j^ositions, whether stand- ing, sitting, or lying. Then instruments may be gradually dispensed with from the thigh or knee downwards. During the after-treatment a rectangular night - shoe should be worn, and constant manipu- lation of the limb be carried out in all cases. Treatment of the Complications, especially Inversion, of the whole Limb and Genu Recurvatum. — Inversion may Fig. 228.— Talipes equino- varus exist ((() in the shaft of the tibia, i.e. it is \vith excessive inward rotation ^^^july twistcd iuwards ou a longitudinal m the bones of the leg. _ -^ .... axis, or, as some authors maintain, it is not sufficiently twisted outwards in development, and in that respect resembles the anthropoid apes, in which the external malleolus is normally in front of the internal ; (h) at the knee-joint, a very fre- quent condition, and frequently associated with lax ligaments and genu recurvatum ; (c) in the axis of the femur ; (d) at the neck of tlie femur in such a way that the anterior margin of the great trochanter looks somewhat forwards and inwards. The existence of inversion of the leg may be ascertained by taking two points, the inner side of the great toe and the inner edge of the patella. In the normal limb these two points should be in one plane which is parallel to the median vertical plane passing through the body from front to back. Xom*, when the foot is put at right angles CHAP. VI THE TREATME]S^T OF CONGENITAL EQUINO-VARUS 425 to the leg, and the great toe placed dh-ectly pointing forwards, if the inner edge of the patella is outside the vertical plane passing through the great toe, and the anterior surface of the patella looks outwards : or if, when the patella is brought to the front, the foot, though perfect in itself, remains twisted inwards, then inversion is present. To decide as to the cause of the inversion, the following manoeuvres should be employed : — As the faulty position is mostly due to relaxation of the ligaments of the knee, it is well to eliminate this cause in the first place. Therefore extend the thigh and leg, grasp the former with the left hand, the patella pointing directly forwards, and the leg with the right just below the knee-joint, and attempt to rotate the leg outwards. If the ligaments are lax at the knee, the inversion can be readily overcome. If, however, the inverted foot cannot be brought to the front by this manceuvre, then the cause is generally rotation inwards of the tibia and fibula. Inversion may, however, be due to excessive inward twisting of the femur on its longitudinal axis. In this event, the outer surface of the great trochanter will have its normal direction, but the limb below will be inverted ; and the two points, the inner edge of the patella and the inner margin of the great toe, though lying in the same plane, Avill be inside their normal position. Should the inversion exist in the neck of the femur, the outer surface of the trochanter will look for- wards, and the foot and knee may be brought to the front by rotating at the hip-joint. While it is easy to distinguish between inversion of the tibia and fibula, and inversion at the knee-joint, yet rotation in the axis of the shaft of the femur and its neck are frequently combined in varying degrees. Fortunately, however, the treatment of the two last-mentioned causes is the same (see below). Having thus ascertained the cause of inversion, it remains to overcome it. 1. If it be in the bones of the leg, and the child is young, it is often sufficient, as Mr. Eobert Jones recommends, to grasp the leg below the knee with one hand, and above the ankle with the other, and give the leg a few firm twists outwards. In older children this procedure will not suffice, and it occurred to me that linear oste- otomy of the tibia and fibula' would overcome the difficulty. This idea I was able to put into practice in a case in which manipulation, free division of tendons, fascia, and the internal lateral ligament of 426 DEFORMITIES OF THE LOWER EXTREMITY the ankle had failed. The foot itself was perfect in shape, but it still remained inverted in its relation to the leg.^ Case 87. Congenital Equino-Varus tvith ^narked Inversion of the Bones of the Leg — diversion Believed hy Osteotomy. — Agnes H , aged 2 years, came under my care in November 1894, suffering from marked congenital equino-varns of the left foot. The varus was first reduced, and then y Fig. 229. — From a case of congenital talipes Fig. 230. — The inversion of the foot equino-varus in which the deformity in the remedied by osteotomy of the tibia foot had been rectified, but inversion jier- and filjula. sisted on account of the excessive inward The + indicates the middle point of the rotation in the bones of the leg (Case 87). patella in both figures. the equinus. Although the foot was then perfectly straight, with the heel well on the ground, yet the inner border of the foot remained at right angles with the front surface of the patella (Fig. 229). When the ^ This case I brought to the notice of the British Orthopedic Association at Liver- pool in May 1895. Almost simultaneously an article by Mr. Swan of Dublin appeared in the British Medical Journal, 15th June 1895. It is entitled "A Method of Treating Inversion of the Limb subsequent to the Cure of Talipes Equino-Varus." Linear oste- otomy of the tibia and fibula is recommended. PLATE XI. Fig. 1. Condition of the foot in Case before operation. Fig. 2. Completion of the first stage of treat- ment in Case 88, viz. reduction of the varus deforndty, leaving the foot in the position of equinus. Fig. 3. Complete restoration of the foot in Case CHAP. Yi THE TREATMENT OF CONGENITAL EQUINO-VARUS 427 foot was brought to the front, the anterior surface of the patella looked externally. There was no laxity of the ligaments of the knee-joint. I therefore decided to perform an osteotomy in the lower third of the tibia and fibula to remove the excessive internal rotation in these bones. This was done, and the foot came well to the front, with its inner margin and that of the patella in one right line when the child walked (Fig. 230). Ill place of osteotomy, osteoclasis is preferred by some, notably Dr. Grattan of Cork.-^ 2, Inversio7i dice to Relaxation of the Ligaments of the Knee- Joint. — -The best means of overcoming this is the use of instru- ments continued up to the thigh or pelvis according to the degree of laxity of the ligaments. If but slight laxity exist, then the thigh-piece is sufficient, but it is not possible to indicate in definite figures when it is necessary for the instrument to be carried up to the pelvis. The knee-cap is very useful in preventing the free antero-posterior movement in that joint which, in addition to undue lateral movement, is so often seen in these cases. The arrangement when the instrument is carried to the pelvis is seen in Fig. 226. 3 and 4. Inversion arising from Twisting in the Axis of the Shaft of the Femur, and at the Neck of the FemMr. — To control this the instrument to the pelvis must be used (Fig. 226). An ingenious instrument is Dr. Doyle's spring rotator, but it has very little control over the limb. Among other apparatus designed for this purpose are Bonnet's, Matliieu's, and Sayre's. The treatment of genu recurvatum is tedious but not difficult. I am accustomed to maintain the knee slightly flexed by locking the free-joint in the instrument at the knee in such a way that an obtuse angle is formed, and the knee is kept permanently flexed at about 30°. After a few weeks of fixation of the knee, much of the tendency to recurvation disappears. A Thomas knee splint, slightly bent, or a plaster of Paris bandage applied to the flexed leg, or a bent malleable iron splint placed behind the knee, will answer the same purpose. When the patient walks, it is advisable either to have the free-joint at the knee locked, or the instrument supplied with a " ring-catch," an ingenious piece of mechanism which main- tains the knee rigid in walking ; while by shifting it upwards the joint is released, and the knee can be flexed, a great convenience 1 Fide the discussion following on, E. G. Brackett's paper, "On the Treatment of Infantile Club-Foot," Trans. Amcr. Orth. Assoc, vol. v. p. 232. Also Grattan, "The Treatment of the more severe Forms of Club-Foot by Osteoclasis," B.M.J. 2nd May 1891, p. 96, etc. 128 DEFORMITIES OF THE LOWER EXTREMITY sec. iv iu the sitting posture. To overcome the geuu recurvatuin will take one to two years by these means. Nevertheless, I have only seen one case in which excision of the knee could be said in any way to have been justifiable. In any case the great point in the treatment of this complication is the prevention of over-extension of the knee for a considerable time. Case 88. Congenital Talij)es Equino - Farns of the Second Degree — Restoration of the Shape of the Foot. — Herbert C , aged 6 weeks, Avas brought to me in 1895. The foot was inverted, adducted, and the heel raised. The deformity could not be entirely reduced by the hand, and attempts to do so caused considerable pain. The appearance of the foot is seen in Plate XL Fig. 1. The structures which appeai'ed to be at fault were the tibialis anticus and posticus, and the tendo Achillis. There was no history of club-foot in the family, and the birth was a normal one. The bones of the leg were of normal shape. The treatment consisted in the first place of division of the tendons of the tibialis anticus and posticus, and the foot was put into a malleable iron splint bent to an obtuse angle, and applied to the outer aspect of the leg and foot. Tlie angle of the splint was gradually reduced, the mother being enjoined to remove it twice daily, and manipulate the foot out- wards. In four weeks the varus had disappeared, leaving the foot in a state of pure equinus (Plate XL Fig. 2). To overcome this, the tendo Achillis was divided, and the foot placed in a rectangular tin-shoe. The deformity was thus completely reduced (Plate XL Fig. 3). But as the child was not old enough to walk, the wearing of the tin-shoe at night was continued, and the daily manipulation carefully attended to. CHAPTER VII THE TEEATMENT OF CONGEXITAL EQUINO-VARUS {Continued) The Treatment of Resistant Equino-Varus by Gradual Methods, Forcible Measures, Wrenching, Phelps' Operation — Buchanan's Operatio?i and Arbuthnot Lane's Modification — The Treatment of Inveterate Club-Foot by Forcible Rectification, Tarsotomy, and Tarsectomy — The Forms of Tarsectomy — Astragalectomy — Dis- cussion on the Merits of Tarsectomy — The Treatment of Paralytic and Spastic Equino- Varus — Relapsed Equino- Varus, its Causes cmd Treatment. The Treatment of the Third Degree, Rigid or Resistant Club- Foot. — lu this variety the deformity is of the same character as in the second degree, but is more exaggerated. The adduction of tlie foot is more marlced, tlie inversion of the sole is considerable, the inner border is more concave, the outer is more convex and bears traces of pressure in tlie skin, the heel is more raised, the in- ternal malleolus is buried, and the external is unduly prominent. But the chief characteristic of these cases is that on manipulation in various directions the foot is very resistant. The deformity can be diminished to only a slight extent, and any attempt causes pain. The impression given to the hand of the surgeon is as if the structures of the foot were partially glued together. The same parts are involved as in the second degree, but the changes in the articulations and bones described on p. 384 are well marked and evident from external examination. Thus the tip of the internal malleolus closely approximates to the scaphoid, and the cuboid is very prominent. On trying to replace the foot, the inner and middle bands of plantar fascia are tense, the tibial tendons and that of the extensor proprius poUicis stand out, and the tendo Achillis is tight. Cases of this degree are seen from the ages of 4 to 1 2 years, i.e. after the child has walked for a considerable time. The best form of treatment for these rigid feet is, in my opinion. 430 DEFORMITIES OF THE LOWER EXTREMITY a gradual one. There is uo course that answers so well as the following : — Take the patient off' his feet for two to three weeks and give him complete rest. By so doing time is allowed for the pain- ful reflex spasm of the muscles to pass away, and the foot soon becomes less rigid. The disappearance of the latter condition is much assisted by soaking the feet for fifteen to thirty minutes in warm water at night. If any sores or tender places are present, they should be allowed to heal before the soaking is commenced. The degree of suppleness which returns to the foot is surprising. Fig. 2-31. — Congenital talipes equino-varus of the third degree, before treatment. Fig. 232. — The same ease after treatment. Tenotomy of the plantar fascia and the tibial tendons is now per- formed, and the foot is put up for four days in a malleable iron splint. Tlien treatment by Scarpa's shoe is begun. Notv the essence of uUimate success hy this method is to proceed gently, and on this point the writings of my colleague, Mr. Fisher, may be quoted with advantage. Speaking of the use of Scarpa's shoe in these cases, he says ^ : "It is a powerful instrument, but no attempt must be made to drag the foot into shape with the full 1 Lancet, 27th May 1893, p. 1248, "The Causes of Failure in the Treatment of severe Club-Foot. " CHAP. VII THE TREATMENT OF CONGENITAL EQUINO- VARUS 431 power it can give ; if this is done, a source of failure will again confront us. The skin will certainly become abraded, and pressure- sores will result, which will prohibit the further use of the instru- ment ; the mechanical treatment will thus be interrupted, and, in the meantime, the divided structures will re-unite before sufficient length of material has been obtained. The utmost gentleness must be employed, the foot being, as it were, coaxed, and not forced, into position; proceeding on these lines, it is extraordinary how rapidly a very severe distortion may be reduced. Eough handling and rude '%] \ n:(J: Fig. 233.— Case 89 before treatment. Fig. 234. — Case 89 after treatment, b\^ tenotomy, mechanical rectifi- cation, and manipulation. attempts to break through the resistance that the distortion may offer will cause irritation about the seat of operation, with exudation of inflammatory products, and that condition of adhesion to the surrounding structures which accompanies . . . too rapid stretching immediately after tenotomy." When the varus has been fully reduced, the tendo Achillis should be divided and the heel brought down. Some resistance at the ankle may be met with, but this can be overcome by manipulation and the use of the foot-exercising apparatus. Illustrations and notes of a case which has been treated on these lines are here presented. Case 89. Double Congenital Equino-Vanis of a Marked Character, the Feet being Eigid and Resistant. — Elizabeth M , aged 10 years, a 432 DEFORMITIES OF THE LOWER EXTREMITY sec. iv nervous, delicate girl, the subject of this deformity (Fig. 233), was brought to me in 1894. The manner of birth was natural, and no other cases of similar deformity had occurred in the family. On examination, both feet were equally affected, the child being obliged to get about on crutches, and propelling herself partly by these, and partly by bearing the body-weight on the outer borders of the feet. The feet were adducted, inverted, and rotated, so tliat the outer borders could alone come into contact with the ground. The heels were much raised. The striking point about the case was the extreme rigidity of the parts. No temporary replacement by manual force was possible. The plantar fasciae and the tibial tendons in both feet were divided, and the varus gradually over- come by the use of Mr. Adams' varus shoe. Subsequently the ten dines Achillis Avere divided. As there Avas considerable rotation at the knee- joints, she left wearing a walking-instrument to the thighs, but was able to put both feet squarely on the ground, and to Avalk with comfort (Fig. 234). The length of treatment Avas six months. Happily successful as treatment on these lines is, the length of time occupied, often twelve months, has induced surgeons to devise other means of overcoming the difficulties in restoring the foot. The means adopted are radical in their nature, and require operative interference. They are--- 1. Forcible Eectification or Wrenching. 2. Phelps' Operation. 3. Free Subcutaneous Division of all Eesistant Structures. 4. Tarsal Osteotomy. 5. Tarsectomy. Forcible Rectification or Wrenching. — This is a most valuable resource in rigid and inveterate club-foot. When the deformity has reached this stage all the tissues of the foot are implicated, and many of the structures are out of easy reach of the knife, so that forcible rectification, which affects all the tissues, is the one method Avhich is eminently successful, and is therefore coming more into general use. In " A Eeport on the Treatment of Club-Foot by Means of the Thomas AVrench," by V. P. Gibney,-^ the author describes liis procedure, and gives the result of twenty cases treated by this method. He says : " The object of wrenching is, in the first place, to convert an equiuo-varus into an equiuo-valgus by the Avrench, and then to reduce the equinus by tenotomy and manual force, and leave the foot in position in plaster long enough for the bones on the outer side to become atrophied, and to hope for some hypertrophy of the ^ Annals of Sicrgery, vol. ix. p. 101 ; and Trans. Amer. Orth. Assoc. \o\. i. p. 74. CHAP. VII THE TREATMENT OF CONGENITAL EQUIXO-A'ARUS 433 inner side when pressure is removed." Dr. Gibney succeeded in the majority of his cases in getting the feet into excellent j)Osition, but the date of publication of the paper was so soon after the operations that its author regrets that he is unable to report final results. In the discussion which followed, Dr. Bradford of Boston thought that the instrument was not powerful enough for the severest cases, particularly in correcting the equinus deformity. The question of sloughing subsequently to the operation was raised, and Dr. Eidlon stated that there had been none in his cases, the thick rubber tubing on the arms of the wrench protecting the soft tissues completely. He thought that the skin would bear a great deal of pressure if it were but momentary, and therefore it was of importance that apparatus of the kind and osteoclasts should be so constructed that the grip could be instantly released when the work was done. Eedard of Paris has used several thicknesses of wet cloth as padding to obviate sloughing. Professor Konig of Gottingen,^ in speaking of forcible reduction, states that he has treated during the past five or six years all cases of club-foot by this method. He has, on account of his bad experi- ence, abandoned the bloody operations, which have for their object the removal of a part of the bony skeleton. In only very excep- tional instances have heavy instruments for reduction, which grasp the foot, been used. These have been abandoned in favour of the hand of the operator with the aid of a point of support. He does not accomplish everything at one sitting, but three or four are necessary. The most favourable cases for his mode of treatment are in patients from 5 to 20 years of age. The procedure con- sists of two acts ; firstly, the adduction is overcome, and secondly, the foot is brought into dorsal flexion and abduction. In the intervals of forcible rectification a plaster bandage is applied. Bradford and Lovett figure an instrument termed a club-foot stretcher,- the object of which is to exert pressure under control of the operator in three directions, and to enable him to twist and raise the front of the foot. Tenotomy and manual correction are first employed, and if not sufficient the instrument is then used, and the foot wrenched into an over-corrected position. An anaesthetic is, of course, required, and correction will be done gradually rather 1 Beilagez. Centrhl.f. Cliir. 2oth November 1S90. 2 Op. cit. Figs. 470 and 471. Dr. ilorton, the inventor of the club-foot stretcher figured by Bradford and Lovett, has now discarded its use. In severe cases he prefers astragalectomy. 2 F 434 DEFORMITIES OF THE LOWER EXTREMITY than by any sudden tear. The extent to which the force can be applied is with difficulty defined ; it may be said, however, that experience shows that a much greater pressure can be used than would at first be thought feasible — in a majority of cases enough force can be used to convert the foot from the position of varus to valgus, and to correct the equinus position. Bradford and Lovett further state that the risk of sloughing is not so great as would be thought. Afterwards a plaster of Paris bandage is applied by them. The authors give as their opinion that forcible rectification is able to correct and cure the severest forms of club-foot. Morton's club- FiG. 235. Fig. 236. Two views of a club-foot stretcher. foot stretcher (Figs. 235 and 236) has the disadvantage that traction is applied through straps, and these are yielding, so that the exact amount of force cannot be accurately estimated. Dr. Morton's " Eemarks on Instruments for the Forcible Correction of Club-Foot " ^ are worthy of attention. To return to the Thomas wrench. The most prominent advocate of its iise in England is, perhaps, Mr. Eobert Jones, of Liverpool, who has kindly furnished me with the account on p. 417 of the manner of its employment. In my opinion it is a very valuable instrument, and I have used it with success at the AVestminster Hospital. Opinions still differ widely as to the best method of treat- ^ Trans. Amer. Orth. Assoc, vol. i. p. 31. CHAP. VII THE TREATMENT OF COXGENITAL EQUINO-VARUS 435 ing resistant club-foot, but it would appear that the time is not far distant when the severer varieties of the deformity will be submitted to forcible rectification in all cases. Phelps' Operation, or Treatment by Open Incision. — This operation was brought to the notice of surgeons in 1881, and has therefore had a fair trial. The details are as follows : — An Esmarch's bandage is first put on, and the foot having been previously rendered aseptic is placed on its outer side. An incision is then made from the mid-point of a line drawn from the top of the internal malleolus to the tuberosity of the scaphoid. The in- cision extends downwards and outwards into the sole until the inner two-thirds have been cut across. The superficial and deep fascia and the abductor hallucis are divided. The internal plantar nerve and artery are spared if possible. The tendons of the tibialis anticus and posticus are then cut through, together with the internal lateral ligament and the calcaneo- scaphoid ligament (Parker's astragalo - scaphoid capsule). The head of the astragalus is thus exposed, and the foot is forcibly redressed. In Phelps' original operation the tendo Achillis was divided subcutaneously at the same time. Many operators prefer, however, to leave that to a subsequent sitting. The result of the open incision is a deep wound, which must heal by granulation. In the meantime the foot is kept in its new position by plaster of Paris, or it may be fixed in a Scarpa's shoe until the wound is healed. It is stated that one dressing is sufficient, and no further application is necessary. This has not, however, been my experience. One difficulty which arises after the operation is a tendency for the edges of the skin to become inverted, and to form the shelving sides of a deep depression. This I have obviated by dissecting up the skin for -g- to 1 inch on either side of the incision from the deeper structures. To overcome the inconvenience arising from the cicatrisation of a wide and deep granulating surface, Mr. Arbuthnot Lane ^ applies a large skin-graft over the wound on the second day. The graft should be of such a size as to allow for its subsequent shrinkage. T. H. Kellock ^ trans- plants a flap of the whole thickness of the skin in the following manner : — The usual operation having been carried out, " A flap of the whole thickness of the skin about an inch wide is then cut on the outer side of the foot by two parallel incisions reaching from the upper end of the operation wound to the sole, and dissected ofl:' the underlying structures, the skin being brought together under- 1 Lancet, 19tli Aug. 1893. ^ jj^i^i 30th March 1895. 436 DEFORMITIES OF THE LOWER EXTRE^MITY neatli it by sutures. Five or six days later, the Hap appearing to be well nourished, the lower end is divided and, leaving the upper end still attached, is turned across and secured by one or two horse- hair stitches into the deep wound on the inner side of the foot, which is by this time mostly covered with granulation tissue, and the foot and leg fixed in plaster of Paris." I believe I am right in saying that a similar idea occurred independently to my colleague, Mr. Muirhead Little, and was carried out by him with success. My friend, Dr. William Gardner ^ of Melbourne, has modified Phelps' operation with promising re- sults, "A wedge-shaped plate of decalcified bone is inserted into the gap between the astragalus and sca- phoid, to which bones it is wired, and by this the lengthening of the inner side is maintained until the plate is replaced by fibrous tissue. There is thus a minimum of interference with the tarsal articulations, and the arch of the foot is not destroyed." Dr. Gardner mentions a suggestion of Dr. Cherry, which is that the scaphoid should be divided vertically, and a plate of decalcified bone inserted be- ''-'-■ tween the parts, thus preserving the astragalo-scaphoid joint, although add- ing a false joint to the foot. Phelps' operation is not necessary in the less severe degrees of club-foot, Fig. 237. — Congenital talipes equino- • .1 t i i ^ . varus ^vith well-marked rigidity of suice they Can be curcd by tenotomy the foot, in which Phelps' operation and suitable manipulation, and the was subsequently performed with ,. . , ,^ , . c success. question arises as to the extent of its usefulness in resistant and in- veterate club-foot. In dealing with the anatomy of the advanced degrees of club-foot, it has been shown that very extensive alterations of shape and position are present in the bones, joints, and ligaments. Now Phelps' incision leaves the bones untouched. It is confined to the soft parts, and although for a time the inner border of the foot may be lengthened, yet the deformity will very Australian Medical Journal, 15th Sept. 1893. CHAP, vii THE TREATMENT OF CONGENITAL EQUINO-VARUS 437 probably recur later.^ It has been claimed that after the opera- tion it is possible to slide the scaphoid and cnboid outwards on the calcis. Walsham and Hughes ^ remark that " as regards the cuboid and os calcis it appears to us, inasmuch as the plane on the cuboidal facet on the latter bone looks in the talipedic foot forwards and inwards, that, if the cuboid is carried into a line with the leg, it must be at the expense of the separation of the contiguous articular facets on their inner side. . . . We have found that rectification in the dissected foot after division of the short liga- ments and tendons on the inner side was here only accomplished by the actual separation of the articular surfaces." So that in the severer cases of club-foot, especially with old-standing displacement of the bones, Phelps' operation is likely to be followed by relapse, as, unless the ligaments on the inner side are very freely divided, the essential part remains untouched, and, further, the scar is very likely to contract. It appears, however, that Phelps' operation is useful in relapsed cases not of a severe degree, in which the bony distortion is not much marked, but where the soft parts on the inner side are matted together by previous tenotomies and syndesmotomies.^ Free Subcutaneous Division of all Resistant Structures. — This procedure was initiated by Professor Buchanan. Mr. Arbuthnot ^ I have seen three cases of relapse of the foot after Phelps' operation. I think it fair to add the relapse was due to ignorance and want of perseverance on the part of the patient in the after-treatment. 2 Op. cit. p. 216. ■^ A few references on the subject of Phelps' operation are the following: — "The Phelps' Method of Treating Club-Foot," by A. Phillipson, Arcliiv f. klin. Chir. Bd. xxxii. s. 989, and Annals of Surg. vol. viii. p. 459. " Results of Orthopa?dic Surgery in Pes Varus," by G. Krauss, Deutsche Zeitschr. f. klin. Chir. Bd. xxvii. Hefte 3 and 4, and Annals of Surg. vol. ix. p. 306. The author concludes that the weight of opinion tends to hold in an unfavourable light the operation of cuneiform resection of the tarsus. The talus extirpation is also unsatisfactory. The operation of Phelps is too young to command any positive opinion as to its true position. "The Treatment of Severe Cases of Club-Foot," by Noble Smith, Lancet, I7th Dec. 1892. He says : " Before we can accept Phelps' treatment we ought to compare it very carefully as regards the permanent results with other methods, and especially with forced reduction." Also, "Thirteen Cases treated by Phelps' Operation for Talipes Equino- Varus," by B. E. Mackenzie, Trans. Amer. Orth. Assoc, vol. iv. p. 48. Also, "A Comparison of the Operative Methods in the Treatment of Club-Foot," by De F. Willard, Trans. Amer. Orth. Assoc, vol. V. p. 225. He does not advocate Phelps' operation, since the same amount of division can be done subcutaneously. The disadvantages of Phelps' operation are that — (1) The wound must close by granulations. (2) The time of healing is long. (3) The resultant scar makes a furrow in the foot more ill-looking than that of mere sub- cutaneous division. Also Phelps' remarks. Trans. Amer. Orth. Assoc, vol. v. p. 232. He states that in 90 per cent of cases it is possible to straighten club-feet without operating on the tissues. 438 DEFORMITIES OF THE LOWER EXTREMITY sec. iv Laiie has extended the operation, and has advocated it with vigour.^ Speaking of the open method, Mr. Lane remarks : " The result which is obtained by this operation is apparently most satisfactory, but when the patient begins to walk on it the result, in my experience, is very unsatisfactory, since there is an absolute loss of continuity of all the soft parts in the sole of the foot. I have never obtained by this method a result with which I was satisfied, nor have I yet seen one. The other operation, or that of complete subcutaneous section, is the one that recommends itself most strongly to me." The mode of operation is as follows : " An india-rubber bandage is applied above the knee to control the circulation, and by means of a strong-bladed, sharp-pointed tenotomy knife everything beneath the skin that opposes the placing of the foot in a position of moderate abduction upon the astragalus is divided. This includes the several divisions of the plantar fascia, part of the internal lateral and annular ligaments, the superior internal calcaneo-scaphoid ligament,^ the inferior calcaneo-scaphoid, and the long and short plantar ligaments, together with the tibialis anticus and all the tendons, vessels, and nerves in the sole of the foot. I do not hesitate to make many punctures, only taking care that tlie knife is entered in such a direction that the forcible fixation of the foot in a position of abduction does not cause the wound made by it to gape, a point of considerable importance. By spending some time, and by exercising a moderate amount of skill it is possible to divide all the soft parts opposing the abduction on the astragalus, and to leave the skin intact except for the punctures produced by the tenotomy knife. After this has been done, I pass a knife between the skin and tendo Achillis and divide it. If the foot does not become square, I cut all the soft parts except the peronei, carefully dividing the posterior ligament of the ankle-joint. The disadvantage of the operation is that in bad cases the skin for a time affords an obstacle to the foot being returned to a good position, and necessi- tates an application of a plaster of Paris bandage about every three or four weeks, the foot and leg being fastened to a back splint and foot-piece, the inner margin of which forms an angle of 25° with the vertical. Its great advantage is that the foot which results is a useful one, and one on which the patient can walk gracefully." ^ "The Treatment of Severe Cases of Congenital Talipes Varus in Infancy," Lancet, 19th Aug. 1893, p. 432. Although described as an operation suitable for infantile cases, I have ventured to place it among those which might be considered suitable to maturer years, on account of its very radical nature. - Cf. Mr. Lane's description, Gmjs Hospital Reports, 1886, p. 250. CHAP. VII THE TREATMENT OF COXGEXITAL EQUIXO-YARUS 439 Eor infantile cases it must seem that such a procedure is un- necessarily severe, and for older cases it is difficult to see wherein the special merit of the operation consists as compared witli Phelps' operation. Mr. Lane admits that the skin which is left more or less intact is a disadvantage, and it is on this point that his pro- cedure differs chiefly from Phelps'. It is to be wished that ]\Ir. Lane had appended a table of cases treated by his and other methods for comparison. Personally I should hesitate before performing so drastic an operation — a veritable " panotomy " (if I may coin a word) — at one sitting. ISTo mention is made of any ill results from after- hsemorrhage, yet it seems a very possible event. AYalsham and Hughes ^ mention that relapsed cases of free subcutaneous division have come for further treatment to St. Bartholomew's Hospital. Those operations which attack the bones are more suitable for the severest" degrees of club-foot, and under the heading of in- veterate club-foot I propose to discuss them. But to sum up the three forms of operation, forcible rectification, Phelps' open incision, and the free subcutaneous division of all resistant structures, it must, I think, be admitted the forcible rectification alone answers all the demands, inasmuch as it is rapid, comparatively safe, bloodless, and reaches all the affected structures, both bones and soft tissues. The after-care of these cases is all- important. There is the same choice of retentive and walking apparatus, but the need of constant supervision is still more impera- tive. Particularly so is this the case after Phelps' operation, as its designer pointed out when he introduced the operation to the notice of surgeons. The Treatment of the Fourth Degree, or Inveterate Club- Foot. — Here the distortion is exaggerated to its utmost limit, and the foot is fixed, feeling as if it were set in plaster of Paris. The heel is much raised ; the toes point forwards and upwards, and are almost in contact with the inner side of the leg; progression is either on the outer side or partially on the dorsum, on which are seen false bursce lying over the prominent cuboid and fifth metatarsal bones. The plantar surface shows the longitudinal and transverse creases in a very marked degree. The affected leg and foot are smaller than the other, and the foot is boat-shaped, the outer border bearing the whole weight of the body. Such a case is that of Annie E , aged 39 (Plate XII.), who came to me at the hospital in 1891, but who refused to go under treatment of any kind, saying that 1 Oyj. cit. p. 214. 440 DEFORMITIES OF THE LOWER EXTREillTY sec. iv she could hobble about well enough in a boot of a peculiar make and shape she was wearing. Treatment. — This resolves itself into the following methods : — 1. Forcible rectification. 2. Tarsotomy and tarsectomy. 3. The older orthopaedic methods of tenotomy and gradual rectification by means of Scarpa's shoes. "With reference to this it may be said that the certainty of curing the feet by these means has been proved many times, but the extreme length of time is a great disadvantage. As to forcible rectification (p. -1:32), it is the measure which, combined with tenotomy and free fasciotomy, should be tried ; and, failing that, in these exceptional cases tarsotomy or tarsectomy may be resorted to. For the reasons stated above, it does not seem that Phelps' operation will effect a cure. The illustration (Fig. 202) is from a case of mine in which Phelps' operation failed to cure the trouble. A slight improvement only was made. According to Bradford and Lovett,^ the various forms of tarsotomy and tarsectomy are — 1. Picmoval of the cuboid, 2. Eemoval of the astragalus. 3. Eemoval of the astragalus, cuboid, and scaphoid, •i. Section of the neck of the astragalus. 5. Eemoval of the astragalus and external malleolus. 6. Osteotomy of the lower ends of the tibia and fibula. 7. "Wedge-shaped resection of the tarsus. Speaking of these the authors say : " The results from the first method have not been altogether satisfactory, and the fourth may be said to be insufficient, and against the third and sixth it may be urged that too much mutilation is required. Authorities differ in advocacy of the second and seventh methods." To the list should be added Fitzgerald's operation,^ in which some of the bones are crushed and others divided. Also complete tarsotomy with a chain-saw is advo- cated by Mr. H, P, Symonds of Oxford. "With reference to the last procedure I may quote the remarks of ]\Ir. Walsham, in a paper on " The Treatment of Severe Club-Foot," read in the Section of Diseases of Children at the meeting of the British Medical Associa- tion, 1892: "Tarsotomy or transverse division of the tarsus is of 1 Op. cit. p. 492. - A Xev: Procedure for the Cure of Congenital Talipes Varus and Equino-Varus, Melbourne ; Stilwell and Co. 1889. PLATE XII. Inveterate form of congenital club-foot. The longitudinal and transverse gi'ooves in the sole of the foot are well seen. CHAP. VII THE TREATMENT OF CONGENITAL EQUINO-VARUS 441 service where the varus is the chief defect. In extreme cases simple transverse division of the tarsus has not, in my hands, been sufficient for thoroughly dealing with the deformity, and a second or oblique section has had generally to be made, thus removing a wedge of bone. In short, the tarsotomy has had to be completed as a tarsec- tomy. My tarsotomies have been done with a chain-saw passed beneath the extensor tendons through a small incision on the outer and inner side of the foot. The line of section has been planned to divide the neck of the astragalus on the inner side of the tarsus, and the anterior end of the os calcis on the outer side. The ultimate results have not been so uniformly good as in the cases where the astragalus has been removed." Indeed, when the multiple nature of the deformity in inveterate club-foot is considered, it is not likely that a mere sliding outwards of the anterior on the posterior part of the foot will correct displacements consisting of adduction, inversion, and excessive plantar flexion. The twist in the axis of the os calcis, the displacement downwards and forwards of the astragalus, the insufficient adaptation of this bone to the space between the malleoli, the atrophy of the scaphoid, and the overgrowth of the cuboid all remain untouched by the operation. Astragaloid Osteotomy. — After the structures on the inner side have been divided and stretched, the deformity of the astragalus in inveterate cases remains. Bradford and Lovett -^ say that in a great majority of cases, if the deformity is rectified and the foot held for a sufficient time in good position, and a proper walking shoe used for a year, a new facet will be formed for the scaphoid on the anterior aspect of the astragalus in place of that on the inner side, by means of which the bones articulate in long-standing club-foot, and a cure will be effected. The method of doing astragaloid osteotomy is this. Fasciotomy, tenotomy, and division of the ligaments should be done, and the foot brought by forcible manipulation into as good a position as possible. An incision from the tip of the internal malleolus to the base of the first metatarsal bone, and parallel with the tibialis anticus tendon, is then made ; and by stretching the inner margin of the foot, the scaphoid is drawn away from the internal malleolus, and the neck of the astragalus exposed. With an osteotome the neck is divided, and, if necessary, that portion of the OS calcis near the calcaneo-cuboid articulation may be divided. The foot should be put up at once in the corrected position. Drs. 1 Op. cit. p. 494. 442 DEFORMITIES OF THE LOWER EXTREMITY sec. iv Bradford and Lovett have had four cases. In one case the result was " most excellent, curing at one operation an inveterate case in a boy of ten." In three other cases " the result was not so good." But it is pointed out that the operation is too young to form a definite opinion of its merits. They do not claim it to be " a sub- stitute for tarsal resection, but it will be found useful in cases where the astragalus is prominent and the twisting of its neck evident." It will be asked, In what respect is this operation superior to tarsotomy ? I take it that with an open incision it is possible to divide the neck of the astragalus and the os calcis in such a plane that the equinus deformity may be fully rectified. That is to say, astragaloid osteotomy is valuable when equinus is a greater feature than varus. Astragalectomy {Lund's ^ Operation). — An incision is made on to the bone from the tip of the external malleolus downwards and for- wards, passing between the peroneus tertius and brevis. After raising the soft tissues with an elevator, the ankle and astragalo-scaphoid joints are opened. The astragalus is then freed from its ligament- ous attachments, and is removed. Mr. Walsham " states : " The only difficult part of the operation is the division of the internal lateral ligament, but this can be overcome without much delay by cutting freely round the inner side of the astragalus with the curved bone scissors." It is advisable that " the astragalus be seized with lion-forceps, and drawn now this way and now that as the remaining fibres are divided." If any difficulty arise in bringing the foot to the right angle, the anterior extremity of the os calcis or a piece of the external malleolus must be removed. The wound should be closed entirely, and the foot put up in plaster of Paris for a month, and tlien passive movement employed so as to obtain mobility at the ankle. Twenty-one astragalectomies were performed at St. Bartholomew's Hospital from 1882 to 1893; all did well. In two only was there any suppuration. T. G. Morton ^ is in favour of astragalectomy, if there is much distortion of bone, on these grounds — 1. The resulting freedom of the ankle. 2. Immediate and permanent correction of the deformity follows. 3. No mechanical after-treatment is necessary. 1 Brit. Med. Journ. 19th Oct. 1872. The operation was also done by lilr. Thomas and Prof. John Wood, Lancet, 16th March 1878, p. 359. - Brit. Med. Journ. 18th Feb. 1893, p. 342. ^ Trans. Amer. Orth. Assoc, vol. iii. p. 119. CHAP. VII THE TREATMENT OF CONGENITAL EQUINO-VARUS 443 4. There is no possibility of recurrence. 5. The operation is not difficult. Dr. MenseP of Gotha has removed the bony nucleus of the head of the astragalus, by splitting open the cartilage, in a case in which slight gangrene had followed forcible rectification and the application of plaster of Paris. That the after-history of operations on the astragalus is not uniformly satisfactory is evidenced by a case of Dr. Mason ^ of ISTew York, who was obliged to amputate after unsuccessfully excising the astragalus and a portion of the external malleolus. Tarsedomy.^ — The operation presents no difficulty. It is very tempting if a foot is too short on the inner side, and too long on the outer, to saw away a piece of bone and pull the foot straight ; but it does not appear to be a very scientific proceeding. The cause of the trouble is in the inner segment of the longitudinal arch, and there the deformity should be rectified. The result of the trouble is on the outer side, and to attack the result and leave the cause does not appeal to one's judgment. But as the operation is performed frequently by some surgeons, it should be described. The foot and leg are rendered aseptic, and an Esmarch's bandage put on above the knee. Strict antiseptic precautions are essential. An incision is made from the middle of the os calcis over the prominent outer border of the foot to about the middle of the fifth metatarsal bone. The size of the incision will vary somewhat according to the amount of deformity, but in any case it should be too large rather than too small. The knife cuts straight down to 1 Beilacje z. Ccntr. f. Ghir. No. 25, 1890. 2 N. Y. Med. Rec. 14th July 1877. ^ The following references may be of interest in this matter: — Little, Practical Observations on the Treatment of Cluh-Foot, 3rd ed. p. 305. The operation was suggested by Dr. W. J. Little, and carried out by Mr. Solly. Verbelzi, "Removal of Astragalus in a Child of 5 J Years," Centralblatt fur Ghir. No. 24, 1877. Davy, Lancet, 14th Feb. 1888, and "On Improvements in the Treatment of Equino- Varus," Lancet, 14th Oct. 1893, p. 921. Davies-Colley, Medico-Chir. Trans. 2nd series, vol. xliii. 1877. Konig, Centralblatt f. Chir. 1880, No. 13. Rupprecht, Ibid. 13th March 1880. Mensel, Ibid. No. 11, 1880. Hartley, "Operative Treatment of Club-Foot, " ^?maJs of Surg. March 1894. De F. Willard, "Comparison of Operative Methods in the Treatment of Club-Foot," Trans. Amer. Orth. Assoc, vol. v. p. 225. Bradford, "Treatment of Con- genital Club-Foot," Trans. Amer. Orth. Assoc, vol. i. p. 89. A. C. Ramsay, "Cuneiform Osteotomy for Congenital Talipes Varus," seventeen cases given, Annals of Sv^rg. vol. xii. p. 423. V. P. Gibney, "Cases of Cuneiform Osteotomy for Relief of Double Con- genital Varus," Annals of Surg. vol. xi. p. 334. Ewens, "Osteotomy Generally, with Special Reference to Tarsectomy in Advanced and Intractable Cases of Talipes Equino- Varus," Brit. Med. Journ. 17th Oct. 1891, p. 842 ; eleven cases are alluded to. 444 DEFORMITIES OF THE LOWER EXTREMITY sec. iv the boue. A second incision at right angles, and about 1 inch long, either extending upwards to the dorsum of the foot or, prefer- ably, into the sole, is made. With an elevator the soft parts and periosteum are reflected over tlie bone which is to be removed. Then with either chisel or saw a wedge-shaped piece is taken from that portion of the foot which is most prominent, and of such a size that the foot can be brought into position without any undue force being used. The base of the wedge should at least equal that of the outer border of the cuboid, and be thicker above than below. In Mr. Davies-Colley's original case this was done " irrespective of the articulations." The wound is then sewn up and dressed anti- septically, and placed at once in plaster of Paris in the corrected position, and retained so for a month to six weeks. Even after tarsectomy it is necessary in most cases to use some kind of mechanical apparatus, otherwise there is danger of relapse, in spite of all that is said to the contrary. Eelapsed cases after tarsec- tomy are not so uncommon. Eemoval of the astragalus, scaphoid, and cuboid involves ex- tensive mutilation of the foot. If the case be so severe, a doubtful matter, as to appear to require this procedure, it may well be that amputation is to be preferred. A shortened, rigid foot, although of normal shape, is of little good, and an artificial substitute will often enable the patient to walk with greater ease. Comjjariscm of the Efficiency in Treatment of the Older Ortliopcedic Measures, combined with Wrenching, and the Various Forms of Tar- sectomy. — In the first place I would quote the opinion of some authorities on this subject. Bradford and Lovett, after detailing some admirable results of tarsectomy, remark : " Such results corre- spond with those of others, but it cannot be denied that much of the foot is sacrificed, and that the severest cases can, as a rule, be perfectly corrected without such radical proceeding. The method does, however, save time in treatment, and when time and expense are to be considered, the procedure should be regarded as efficient and without risk." ^ Mr. Walsham, whose great experience must entitle his opinion to much respect, says - : " What is the ultimate condition after excision of the astragalus, and, if necessary, other portions of the tarsal bones ? Well, at the most, it is only making the best of a bad job. But the foot is plantigrade and respectable in shape, and if healing by the first intention is ensured, and passive ^ Op. cit. p. 494 and Trans. Amer. Orth. Assoc, vol. i. p. 89. - Brit. Med. Journ. 18th Feb. 1893, p. 342. CHAP. VII THE TREATMENT OF CONGENITAL EQUINO-VARUS 445 movements are subsequently kept up, a fairly movable ankle-joint is obtained. Further, the patient's walking powers are much im- proved, and he can, as a rule, dispense with instruments. I say as a rule, because, as all are aware, the severe deformity of the foot which calls for astragalectomy is often, after all, merely part of a general malformation of the whole limb." Krauss' ^ opinions on the points at issue are as follows : — " 1. The different methods of resection of the tarsus impair the form of the foot and the stability of its osseous arch, with a conse- quent impairment of mobility and usefulness. " 2. Eesection as an operation is not free from risk. " 3. Eesection removes all chance of future restoration by orthopaedic treatment. " 4. There is no conceivable form of club-foot in which tarsal resection is justifiable, except it be in the case of one that is per- sistently painful in an old subject, and in which there is no prospect of a good result from orthopaedic treatment. " 5. Equally good and more rapid cures can be effected by bloodless ' redressement ' of the foot, this being possible not only in the deformed feet of children, but also of adults." These then are the opinions expressed by authorities on the matter. There is, perhaps, no subject on which so many diverse opinions are held as the respective merits of tarsal resection and the bloodless methods. It seems that unless the case be one of exceptional difficulty, the solution is found in the social status of the patient. If time can be spent in the cure, many surgeons prefer the gentler methods, whereas the stress upon hospital beds is so great in large cities that the quicker method of tarsectomy is resorted to. It may not be amiss to examine the question at issue under the headings of the risk involved, the efficiency of the operation and the utility of the foot, the time taken in the cure, the possibility of relapse, the availability of future orthopfedic treatment, and the necessity of employing apparatus after active treatment has ceased. General Considerations on Tarsectomy. — 1. The Bisk Involved. — By the bloodless methods there is practically no danger, provided that the foot be not secured too tightly in fixation apparatus. Tarsectomy is by no means uneventful in its history. Suppuration is not unknown. V. P. Gibney " relates two cases of cuneiform oste- otomy for relief of double congenital equino-varus. One did perfectly well, but the other — a most inveterate case, aged 32 years — after ^ Trans. Fifteenth German Surg. Congress. ^ Annals of Surgery, vol. xi. p. 334. 446 DEFORMITIES OF THE LOWER EXTREMITY sec. iv removal of parts of the os calcis and the neck of the astragalus, com- bined with Phelps' operation in the right foot, suffered from septicaemia. The left foot was subsequently operated on, and healed very nearly by first intention. " There did remain in both feet fistulous sinuses, from which bits of necrotic bone were removed from time to time." Now that tarsectomy is so widely advocated, we cannot but express our admiration at the courage shown by Dr. Gibney in relating this case. Mr. Walsham ^ records suppuration in two of twenty-three cases. Mr. Eichard Davy, in a clinical lecture delivered by him in 188.>, gives an analysis of twenty-two operations, all successful except one on a man aged 20 years, who died of septicemia. Mr. Ewens " of Bristol says that, " Of fifteen cases performed by him and his colleagues we have no fatal case to report, but in two or three instances suppuration has taken place." So that tarsectomy is not free from risk, as tliese cases show. They are isolated cases, it is true, and culled from surgical literature after some search ^ ; but they are none the less telling (see Dr. Wilson's statistics at the foot of the page). 2. The Efficiency and Utilitif of the Foot. — After the bloodless methods the foot, even if not always shapely — and form is not everything — is at least elastic and useful. After astragalectomy, or removal of a wedge, the member, although perfect in outline, is frequently shortened and inelastic, with imperfect or no movement at the ankle and medio-tarsal joints. At a meeting of the British Orthopaedic Society in December 1894, Mr. Keetley alluded to a case of a man the subject of double cougenital club-foot. One foot had been subjected to tarsectomy and the other left untreated. The patient found the untreated foot of greater use to him in progres- 1 Brit. Med. Journ. 18th Feb. 1893, p. 341. - Ibid. 17th Oct. 1891, p. 844. ^ Dr. H. A. Wilson {Amer. Med. -Surg. Bull. 1st Feb. 1894) has analysed 435 bone operations for the correction of club-foot performed by 108 operators. There were seven deaths — three from septiceemia, three from diarrhcea, and one from carbolic acid poisoning. In one case the foot had to be amputated for gangrene, and two cases are described as failures without explanation. The age of the patients ranged from 3 weeks to 47 years ; 29 operations were done on patients under 2 years, 126 under 6, and 234 under 10. Simple excision of the astragalus was done 156 times, and 68 forms of bone operation were practised on the remaining cases. The results of operation are given under numerous heads, but 231 may be grouped as good or excellent, 135 as not definitely stated, and 42 as not benefitted, including two amputated for pain and seven deaths, as before stated. The author, in accord with recent experience, states his belief that cases of congenital club-foot properly treated from birth will never require tarsectomy, and that even in relapsed and neglected cases tlie percentage suitable for bone excision is extremely small. Twenty-nine surgeons reported that they had never done any bone operations for club-foot. CHAP. Yii THE TREATMENT OF COXGEXITAL EQUIXO-A'ARUS 447 sion than the tarsectomised foot, which, though perfect in shape, was entirely inelastic. 3. The, Time occiqyied in Treatment. — In inveterate cases there can be no doubt that tarsectomy carries the dar. The ratio of time Fig. 238. — Severe relapse after tarsectomy on both feet. The + marks the centre of the patella. occupied respectively by tarsectomy and the bloodless methods may, as a general rule, be reckoned by weeks to months. 4. The Possibility of Rela/pse. — The very nature of congenital club-foot is one of relapse. It has been claimed for tarsectomy that relapses are not possible. Neither should they be if the 448 DEFORMITIES OF THE LOWER EXTREMITY sec. iv restored foot is retained in good position by apparatus. But I have seen sad casas of relapse after tarsectomy done some years previ- ously. These patients have presented themselves at the National Orthopedic Hospital for further treatment (cf. Fig. 238), which in several instances has not been possible to any satisfactory extent, owing to the matted condition of the soft parts and the firm ankylosis at the joints. It is not claimed that the bloodless methods are never followed by relapses, Ijut fortunately then there is room for further treatment. 5. The Availahility of Further Treatment. — From what has been said it appears that a tarsectomy, which has failed, leaves no room for complete cure by future treatment. Indeed, it would seem that an artificial foot would be preferable in some cases to the rigid, distorted, useless member I have seen. 6. The JVe^essity of Aijparatus after Active Treatment has Ceased. — If relapses are to be prevented both after tarsectomy and the bloodless operations some mechanical appliance is necessary. In the accounts of cases after tarsectomy it is specially noted that the patients could walk without any instrumental aid. I may be wrong, but I venture to think that if such cases had been seen, say three years afterwards, the foot would not be in perfect position. To sum up ^ : — 1. The cases in which tarsectomy is necessar}^ are very few, and form a very small percentage. 2. Tarsectomy is entirely inadmissible in infants and children under 12 years of age. Their feet can be restored by the bloodless methods. 3. In the majority of cases of severe nature in adolescents and adults a cure may be obtained by the bloodless methods. 4. Tarsectomy should only be done when orthopaedic treatment has been tried and failed, when progression is impossible owing to severe pain and the pressure of inflamed corns and bursre and ulcer- ated skin ; or if any marked developmental deformity is present." ■^ The generalisations on the treatment of club-foot made by Bradford and Lovett {o2). cit. p. 504) are excellent and to the point, and coincide with the author's opinion. ^ The usual deformity exists in the astragalus and the lower ends of the tibia and fibula. The varus can be overcome, but all attempts by ordinary means to remove the equinus' are futile. The upper articular surface of the astragalus refuses to lit be- tween the malleoli. In such instances astragalectomy is practised. My colleague, Mr. Muirhead Little, writing "On the Treatment of Resistant Talipes in Adults and Ado- lescents" {Brit. Med. Journ. 19th Oct. 1895, p. 965), describes the removal of a wedge Avith the base upwards from the neck of the astragalus and front part of the os calcis with much success in an obstinate case. He thinks that sufficient flexion can be obtained in this way, and that astragalectomy is unnecessary. CHAP. VII THE TREATMENT OF CONGENITAL EQUINO-VARUS 449 5. Only those who are perfectly sure of their a,ntiseptic methods should undertake tarsectomy. Comparison of the Forms of Tarsectomy. ^ — The favourites are astragalectomy and removal of a wedge from the outer side of the foot ; and according to the statistics of Augustus Wilson,"^ who has collected 435 cases of operations on the bones of the foot, astra- galectomy is preferred. Dr. Frank Hartley has published an excellent paper on " The Operative Treatment of Club - Foot," ^ in which details of fifteen patients, the subjects of the severer forms of congenital club-foot, are given. In all, twenty-six feet were operated on. Speaking of astragalectomy, he says : " The extirpation of the astragalus would seem to be indicated when the chief deformity in the foot is due to the astragalus, and the flexion at the ankle-joint cannot be carried beyond a right angle with the foot, on account of the prominence of this bone anteriorly." He claims that astragalectomy causes less interference with the arch of the foot than tarsectomy, and interferes less with the growth of the foot. He adds, however : " If the ankle-joint can be brought to a right angle or more, and the dis- tortion of the foot is principally in the medio-tarsal joint, cuneiform osteotomy is the slightest and easiest method of treatment. The principal disadvantages of this method seem to be that the supina- tion in the calcaneus remains, that the arch of the foot is broken, and that the growth of the foot is interfered with in the younger class of cases." In concluding his article, Dr. Hartley says : " I wish to state that I do not believe in any routine operative treat- ment for club-foot. Each case is to be studied for itself, and with the idea of restoring the function and relieving the deformity." ^ In both resistant and rigid club-foot, massage, douching, and electricity need to be used as in the less severe degrees. Teeatmext of Paralytic Talipes Equixo-Varus In considering the treatment of this form of club-foot, the following special points should be borne in mind : — 1. The deformity is due to loss of power on the part of certain ^ Trans. Amer. Orth. Assoc, vol. vi. 1894. ^ Annals of Surgery, vol. xix. pp. 257-288. ^ Barton Hopkins of Philadelphia has contributed to the Annals of Surgery, April 1895, "A Note on a New Method' of correcting Inveterate Talipes Varus by the Artificial Production of Pott's Fracture Deformit}^," and gives three cases in which success appears to have been achieved. 2 G 450 DEFORMITIES OF THE LOWER EXTREMITY sec. iv muscles ; they are functionally absent, and in the majority of cases cannot be restored. They can only be to a certain extent replaced by artificial apparatus. 2. Restoration of form is not so difficult, since the ligaments and bones become fixed only in inveterate cases. Generally the condition is one of absence of power on the part of muscles and groups of muscles which are over-balanced by the normal strength of their opponents, therefore over-correction is to be avoided. 3. The disease, after it has fully declared itself in the spinal cord, is not progressive. It is rather the reverse. IMuscles which at first appeared to be hopelessly paralysed often show signs of partial recovery. 4. Trophic changes in tlie parts {e.g. fatty degeneration of the bones) are well marked. Thus they do not lend themselves to radical operative procedures. 5. Physiological methods such as douching, rubbing, electricity, active exercise, play a very important part in the after-treatment of these cases. In slight cases manipulation is all that is necessary, and the use of a walking instrument with an inside steel support and a varus T-strap, with a tin-shoe for night wear, is required. In some marked cases division of the plantar fascia and tenotomy of the tibialis anticus and posticus are called for ; and when the varus deformity is corrected, either by Scarpa's shoe or by plaster of Paris, the tendo Achillis is divided, if the foot cannot be dorsi-flexed to the right angle. Every care should be taken that in the after- treatment the tendo Achillis is not allowed to become too long. A walking instrument, with both inside and outside steel supports to the knees, toe-elevating spring, and varus T-strap, are necessary for some years. If there is paralysis of the thigh muscles, the instru- ment must be carried up and secured around the pelvis by a girdle, and a ring-catch fitted at the knee, so to fix the leg in extension while walking, and to allow flexion on sitting down. In most cases a cork-sole will be required to compensate for the shortening. A more sightly arrangement is the O'Connor extension boot. The question of arthrodesis will be referred to in the chapter on Spinal Paralysis. An ingenious operation has been devised and carried out once by Winkelmann,^ with the object of saving the patient the inconveniences of arthrodesis, while making it un- necessary for him to use an apparatus. The operation is designed ^ Deutsche Zeitschr. f. Chir. xxxix. pp. 1, 2. PLATE Xm. Fig. 1. Talipes equino-varus from infantile paralysis, in a child aged 4^ years. The same case at the completion of treat- ment, viz. reduction of the varus deformity. This was effected by tenotomy, followed by mechanical and manual rectification. Y<^'^y. — 1. The attention of the surgeon is called to a patient's foot on account of the pain suffered. Frequently it is intense and paroxysmal, and renders movement impossible. Xor is it confined to the foot, but starting aljout the head of the third and fourth metatarsal bone, is reflected up the limb. As a rule no redness is present, but I have seen very considerable congestion in one case. In that instance, while at rest the patient would suffer little or no inconvenience, and started on a walk feeling no discom- fort. Shortly afterwards tlie pain would com- mence, and become worse on going into a warm room, the feet feel hot, and he was un- able to move. His one desire was to remove the boot, and hold the front part of the foot firmly. On two occasions, during a severe attack of paroxysmal pain, I found redness present over the first and second interspaces. Pain, however, is not always of this acute character, but is occasionally of a chronic nature. 2. Deep tenderness is present about the sole from a "case of I'^ads of the third and fourth metatarsal bone. Morton's disease. A 3. The affected foot is broader across the bulging instead of a re- , , „ , ^ , . , . , entering angle is seen 'icads 01 the metatarsal bones than is normal, behind the ball of the and, as Stated above, some degree of flat-foot great toe. . '^ may exist. 4. On examining the sole, a large corn may be seen over the heads of either the second, third, or fourth metatarsal bone, which are felt to be prominent in this situation. This prominence of the head of one of the metatarsal bones, taken in conjunction with the character and starting-point of the pain, is diagnostic of the disease. 5. A peculiar twist is present in the foot. The portion in front of the tarso-metatarsal articulation is twisted inwards, so that the base of the fifth metatarsal bone is exposed to the pressure of the boot, and the patient complains of constant pain at that spot. In fact, in some instances, and these are early cases, the patient seeks relief from this alone. CHAP. IX ACQUIRED AXD COXGEXITAL DEFORMITIES OF THE FOOT 491 6. The impression of the foot is typical. There is a bulging instead of a re-entering angle behind the ball of the great toe. Fig. 271 is from a case of Morton's disease.^ In illnstration of these points I may quote three cases : — Case 93. Case of Mortoris Disease. — Mr. C , aged 39, a bank- cashier, and standing most of the day, consulted me for pain on the outer side of the foot, which became so bad as to necessitate his giving up his position at his desk in the latter part of the day. His father had suffered from gout, but he himself had not at any time had an acute attack. On examination of the right foot I noticed at once the pecuhar inward twist, and the base of the fifth metatarsal bone was prominent, very painful, with a false bursa over it. He complained also of dull aching pain about the head of the third metatarsal, but it had never been paroxysmal. The arch of the foot was somewhat lowered, and on ex- amining the sole, a corn was found over the head of the third metatarsal bone, which seemed to have dropped away from the others. The boots he had been wearing were narrow in the tread and very pointed. I advised that he should rest the foot entirely for a fortnight, and mean- Avhile a pair of low-heeled boots should be made, with a valgus pad beneath the instep, and so arranged as to fit tightly across that part, and to leave ample room across the heads of the metatarsal bones in treading. It seemed to be highly probable that the displacement of the head of the third metatarsal bone arose from the pressure of narrow boots on tliat part of the transverse arch. To relieve the pain over the base of the fifth metatarsal bone. I suggested that the leather of the boot should be blocked out over that spot. A month afterwards he expressed himself as much relieved. Case 94. — Mr. N , aged 32, consulted me for paroxysmal pain in the front part of the right foot, which became so severe at times as to entirely prevent him moving about. He played much cricket, and had frequently been struck with the ball on the dorsum of the foot. The boots he was wearing were fashionable, and no doubt contributed to the JDerpetuation of the pain. The latter was always worse in the evening, and occasionally became agonising in a warm room, and was accompanied by considerable redness and extreme tenderness in the first interspace. Relief Avas temporarily obtained by removing the boot. On examination I noted that the arch of the foot had given, the base of the fifth metatarsal bone was prominent, the anterior part of the foot twisted inAvards, and there Avas depression and enlargement of the head of the second metatarsal bone. Relief AA^as obtained by boots constructed on the same plan as in Case 92. He Avas also advised to soak the feet in hot water containing a drachm of bicarbonate of soda to the pint, and citrate of potash Avas given . internally. After some Aveeks the pain 1 Taken from GoldthAvait's article, Brit. Med. and Surg. Journal, cxxxi. Xo. 10, p. 253, 492 DEFORMITIES OF THE LOWER EXTREMITY sec. iv lessened and disappeared. I .should state that I haA-e stibsequentl}' seen one of Mr. X "s sisters on account of osteo-arthritis. Case 95. — Mr. J. D , aged 25, consulted me in July 1895 with reference to pain and difficulty in walking. He could only hobble, on account of the pain, and had tried all sorts of boots. The history of gout was well marked in the family. Pain was complained of in both feet, al)out the head of the third metatarsal l)ones and over the base of the fifth metatarsals. In the soles of both feet the head of the third metatarsal was very prominent with a large corn on it, and in the right foot smaller ones were present over the heads of the second and fourth. The arch of the foot was much increased, and the toes of both feet were hyper-extended. At times acute attacks of pain, lasting on and oft' for a fortnight, occurred, and completely laid him up. The inward tAvist of the foot was Avell marked. So extreme was the displacement of the heail of the third metatarsal bone on the right side that I advised its removal. As he objected to this, and was anxious to try other treatment, I advised bathing in hot Avater every night, and boots closely fitting over the instep and very broad in the tread. In XoA^ember 1895 I heard that a con- siderable improvement had occurred. Fdthohxjy of this Affaiion. — The explanation given by Morton is the folloAving: — The heads of the first three metatarsal bones are nearly on a line and less movable than the remaining ones. The head of the fourth is ^ inch behind that of the third, AA-hile tliat of the fifth is nearly ^ inch Ijehind the head of the fourth. Between the heads of the fourth and fifth branches of the external plantar nerve pass ; Avhile the anterior extremity of the fifth metatarsal, and to a less degree the fourth, is A'erv mobile. When the transverse arch is compressed the head of the fifth metatarsal bone and its proximal phalanx come directly into contact with the head and neck of the fourth metatarsal, and consequently the nerves are compressed. While this anatomical explanation suffices in the case of the fourth and fifth metatarsal, it does not explain instances of meta- tarsalgia beginning betAveen the second and third, and third and fourth bones. In such instances the explanation appears to be this. When the transverse arch gives Avay at the heads of the metatarsal bones, and tight boots continue to be Avorn, the heads of the metatarsal bones are rubbed together, and pre.s^ure on the nerv^es Avith pain ensues. One head is pushed out of place at the spot Avhere pressure is greatest, and the nerve is compressed between the adjacent heads and the depressed one, and pain is most marked there. In other cases of an osteo-arthritic nature the digital nerves are compressed by osteophytic projections. This hypothesis is CHAP. IX ACQUIRED AXD CONGENITAL DEFORMITIES OF THE FOOT 493 supported by the co-existing enlargement of the base of the iirst phalanx of the great toe, which is notably affected in osteo-arthritic cases. The Diagnosis. — It has to be made from flat-foot chiefly on account of the pain. I ha\'e already said that in many cases of Morton's disease flat-foot of a minor degree is present, but it is rarely so marked as to explain the acute and agonising pain of metatarsalgia. The cases may be considered to partake more of Morton's disease than flat-foot when the pain begins about the heads of the metatarsal bones, and is of the paroxysmal nature already alluded to. In other instances not a trace of flat-foot exists, but the arch of the foot is exaggerated (cf Case 95). So that no confusion ought to arise in the latter class of case. The Prognosis should be guarded in all cases. Even with com- plete rest, the acute pain diminishes slowly for a few days, and for weeks afterwards exacerbations may take place when the patient walks. The effects of treatment are displayed slowly, and the patient should therefore be warned that the trouble is likely to be a tedious one. Treatment. — In all instances evidences of rheumatism, rheuma- toid arthritis, and gout should be sought for, and treated with the usual, but frequently inefficacious, constitutional remedies. The acute attacks of pain are relieved by removing the boot and soaking the foot in hot water. Bradford and Lovett suggest the alternate use of hot water and ice. But these applications I have not tried, and as far as ice is concerned, I should hesitate to use it in a gouty case. The application of the oleates of morphia and atropin temporarily relieve the pain. In most cases relief may for a time be obtained by grasping the instep and sole, or by tightly compressing the bases of the metatarsal bones with a flannel bandage.^ The first thing is complete rest of the foot for two or three weeks. Then some walking may be allowed. But no boot should be worn for a time, merely a canvas or rubber shoe with a bandage around the proximal ends of the metatarsal bones. When all pain has subsided the following description of boot should be ^ Thei'e may appear to be a contradiction here. One of the causes given is narrow- ness of the boots, and yet relief is gained by gi'asping the instep and the sole. But the discrepancy is only apparent. .Gibney, Journ. of Nervous and Mental Diseases, Sept. 1S94. p. 592, has observed that if the bases of the metatarsal bones be tightlj' grasped the distal ends are separated and the nerves are no longer compressed, hence the relief obtained. 494 DEFORMITIES OF THE LOWER EXTREMITY sec. iv worn, viz. one with a high instep and A'aJgus pad, if flat-foot is present, with a heel coming well forward beneath the instep and of moderate height. The boot should also be made to fit closely over the instep, and be broad in the " tread " so as to give plenty of room to the lieads of the metatarsal bones, and the soles must be thick.^ In severe and long -continued cases not relieved by the above treatment, Morton advised excision of the head of the fourth metatarsal bone. But when there is undue prominence of the distal extremity of either the second or third, rather than of the fourth, I should certainly excise that one which could be most plainly felt from the sole, and had the largest corn over it ; and this I have done in the case of the head of the tliird metatarsal bone with complete relief Deformities of the Toes Synonym — Hallux Extrorsus, Bunion. Hallux Valgus. — The proper direction of the great toe is the subject of a paper contributed to the Paris Societe de Biologic by M. r. Regnault." He agrees with the observations of anthro- pologists and surgeons that, in persons who go barefooted and use their feet only for walking, the great toe and inner border of the foot form a right line. In some cases tiie great toe is even slightly adducted, and this is more marked among savage races, who use their feet as prehensile organs. Abduction of the toes is an artificial condition, and arises from wearing boots, and is exaggerated by the demands of fasliion. Hallux valgus is largely due to the use of improper boots, not necessarily of tight ones, but of those which are pointed and often too short. In some cases it may be traced to osteo-arthritis and gout.^ These diseases, however, merely give a faulty direction to the great toe, which is accentuated by narrow-pointed boots. The feature of the deformity is displacement of the great toe outwards, with prominence of the base of the proximal phalanx and the head of the first metatarsal bone. Both these portions of bone are often enlarged and covered by a bunion or false bursa. The ^ For this idea of the construction of a suitable boot in these cases I am indebted to Dr. Gibney. The boot is fully described in the article referred to in the preceding note. ^ An abstract of his observations appeared in the Xcu- York Med. Journ. 19th ilay 1894, p. 638. ^ Anderson, Lancet, vol. ii. 1891. CHAP. IX ACQUIEED AXD COXGEXITAL DEFORMITIES OF THE FOOT 495 enlargement is specially noticeable in cases of osteo-arthritis, and I have on several occasions felt grating in the first metatarsal- phalangeal joint. The Anatomy of the affection is as follows : — The o-reat toe is Fig. 272. Fig. 273. T"^vo %-iews of case of hallux val?u.'; displaced outwards so as to leave part of the head of the meta- tarsal bone uncovered. A subluxation occurs, with the result that the internal lateral ligament is stretched, and is in some cases thinned, but more often thickened. According to Eedard,-^ it is ^ Traite Pratique de Chir. OHh. p. SoO. 496 DEFORMITIES OF THE LOWER EXTREMITY sec. iv occasionally perforated. The external lateral ligament is shorter and thicker than normally. Those muscles the tendons of which are inserted into the inner side of the base of the first phalanx are .stretched, and those which are inserted into the outer side are contracted. On the dorsum the tendon of the extensor proprius pollicis is displaced externally, and Ly its new position takes an important part in maintaining and increasing the deformity. The skin on the inner side, beneath the ball of the great toe, is in early cases reddened, and later becomes thickened. Beneath it, in the subcutaneous tissue, a false bursa or buuion forms, which, according to "Walsham and Hughes, is sometimes multilocular. It is very liable to inflammation, and suppuration may cause cellulitis. Il" pus make its way into the joint, disorganisation occurs. Corns situated in and on the bunion are extremely painful, and often of large size. In one patient, from whose foot I dissected out a large painful bunion with a painful corn on top of it, I found, on subsequent section of the part removed, that the corn extended through the whole thickness of the buuion, nearly an inch. Where the head of the metatarsal bone is not covered by the base of tlie phalanx, the cartilage is tliinned or has entirely dis- appeared, and much osteophytic enlargement of the head of the metatarsal bone is present, while lipping of the base of the proximal phalanx can frequently be felt through the skin. The Si/nqytoms are sutiiciently plain. In most people some displacement outwards of the great toe is present, but not enough to cause pain. It is for this symptom that the surgeon's attention is called to the part, which is seen to be inflamed and prominent. In old-standing cases the altered direction of the great toe, the presence of a fluctuating swelling and corns over the inner side of the head of the metatarsal bone suffice for tlie diagnosis. Occasion- ally the affection is mistaken for gout, but a little care will dis- tinguish an inflamed bunion hum an acute attack of podagra. As the great toe is being displaced, it rides over the second toe, and depresses the second and third phalanx, so that hammer-toe com- plicates the deformity. In cases of liallux valgus or extrorsus, flat-foot is often present as well. Women suffer more frequently than men, — three times as frequently, — and both feet are often simultaneously affected, though not in the same degree. Treatment — Prophi/hictic. — Pointed boots must be absoluteh' forbidden. It is not of much avail to discuss with the patient CHAP. IX ACQUIRED AND CONGENITAL DEFOEMITIES OF THE FOOT 497 whether the boots he is wearing are pointed or not. An outline of the sole of the boot he should wear must be given to him, and he should be directed to go to a rational bootmaker who will carry out instructions. The sole of the boot should be as broad as the sole of the foot when it is placed on the ground and the weight of the body is being borne on it. If any displacement exist, the inner side of the upper leather should be blocked out, so as to give ample room to the great toe and to the prominence of the metatarso-phalangeal joint. Curative treatment in slight cases consists in wearing the boots made on the lines just suggested, the application of cold and soothing lotions to the inflamed and thickened skin, and in the use of some arrangement whereby the great toe is kept away from the second toe. In early stages nothing answers so well as a divided (digitated) sock, with a separate stall for the great toe. Some advise the use of a " post " between the first and second toes, but I have not found this answer well in practice, as it is difficult to bring the great toe into the proper place for it. Pulling inwards of the great toe night and morning, if per- severed with, soon brings the toe into better position. , n , , • 1 Fig. 274. — Spring for the treatment An excellent arrangement is made of bunion, by Ernst for these cases, viz. a leather cap or thimble fitting over the great toe, secured by a tape which passes along the inner border of the foot and around the heel by an elastic insertion which is fastened at the outer border of the foot. A more elaborate apparatus consists of a metal plate adjusted to the foot at the instep (Fig. 274). At the lower part of the plate a spring is jointed and curved convexly towards the toe, having a division of the spring over the bunion to obviate pressure. When the patient is unable to afford a special apparatus, a wedge- shaped pad of lint fixed between the toes is of service, and the first toe may be further separated from the second by drawing it away by strapping secured round it, and passing back towards the heel. Or a splint of rubber or pasteboard may be fixed to the inner margin of the foot and toe, thus pulling the latter inwards. When the deformity is severe, the bursa large and painful, and subject to recurring attacks of inflammation, operative procedures are necessary. I may here detail my proceeding in the following case : — 2 K 498 DEFORMITIES OF THE LOAVER EXTREMITY sec. iv Case 96. Bunion, Removal of Bursa, Chiselling off Bony Prominences around the Joint, Complete Belief. — Maria B , aged 42, with a gouty history, had suffered for some years from a large bunion and halhix valgus on the right side. When seen by me in 1891 the bursa was much inflamed. I cut down on it and dissected it out, but as she then objected to any interference Avith the joint and bone, I was obliged to content myself with dividing the extensor proprius pollicis and the external part of the capsular ligament, and forcibly manipulating the great toe inwards. After the wound healed she Avore one of Ernst's bunion springs. In 1894 this patient again came to me Avith the great toe more abducted than Avhen I first saAv her, and a new and much-inflamed bursa Avas present. So great was the pain that she was anxious to haveAvhatever I thought necessary done. I therefore made a longitudinal incision down to the bone, cutting through the bursa, Avhich contained pus. The bursa Avas removed, and the cavity so left was Avell Avashed out Avith carbolic lotion. The joint Avas opened freely, the capsular and other ligaments being divided as completely as possible. With a chisel a large slice Avas taken aAvay from the inner and under surfaces of the head of the metatarsal bone and base of the phalanx, and the extensor proprius pollicis diA'ided. With a little force the great toe AA^as brought into position, and, after closing the Avound, it Avas firmlj^ held in position by a malleable iron splint applied along the inner side of the foot. The Avound healed rapidl}-, and the patient left the hospital Avith a movable joint of normal size and shape, and Avalking very comfort- ably. Another ready Avay of curing these severe cases is to excise the head of the metatarsal bone. Mr. Davies-Colley prefers removal of the base of the first phalanx. The latter procedure does not, however, o'et rid of the enlaroed head of the metatarsal bone. Mr. Barker excises a Avedge-shaped portion from the neck of the metatarsal bone. Other surgeons perform a linear osteotomy of the bone. Amputa- tion of the great toe is necessary in fcAv cases, viz. if much suppura- tion is present, if the skin is riddled Avith sinuses, and the joint destroyed. In the treatment of simple bunion, the AA^earing of suitable boots and the application of Scott's ointment, or of unguentum ammoniaci cum hydrargyro, give relief. If acutely inflamed, hot boracic fomenta- tions may be applied, and if suppuration folloAv, the bursa should be freely opened and dissected out. Hallux Varus or Pigeon-Toe This deformity is met with frequently in congenital equino-varus. After the treatment of varus, it may remain as an obstinate feature CHAP. IS ACQUIRED AXD COXGEXITAL DEFOEMITIES OF THE FOOT 499 of the deformity. It varies in extent, aud the angle of inward dis- placement may be ■45'' or more.^ The treatment consists of manipidation and the use of a light splint to press the toe outwards. Hallux Eigidus Synonyms — Hallux Doloroms, Hallux Flexus, Painful Cfrea.t Toe. As described by Mr. Davies-CoUey, the deformity consists of a forced flexion of the proximal phalanx of the great toe through 30" to 60", aud some extension of the second phalanx with the toe held rigidly in that position. Other writers differ in some respects. Thus Walsham and Hughes ^ state : '" In many cases we have met with, beyond the pain in movement, ■ there has been little or no flexion, and practically no rigidity." Bradford and Lovett^ agree with Mr. Da^4es-Colley's description. Mayo Collier "^ gives the following account of it founded on nine cases, seven males and two females : " The affected foot presents a peculiar characteristic appearance. In the first place it is a long foot ; it is an abnormally long foot for the size of its owner. Xext the foot is nearly always cold, damp, aud blue. The distortion of the foot is characteristic and peculiar, and is due to the fact that any pressure between the head of the metatarsal bone and the sesamoid bones on the tendons of the short flexor cannot be tolerated. The metatarsal bone is flexed on the tarsus, and is adducted to the mid -line from its fellows. With this the proximal phalanx is slightly flexed. . . . The head of the metatarsal bone appears through the skin to be enlarged, and there is found sometimes some lipping of the cartilage of this bone at its under and lower aspect in the neighbourhood of the sesamoid cartilages. In early cases pain is not usually com- plained of until the end of the day, and then mostly after long standing or much walking, but as the disease progresses the pain is continuous. The joint is never red, painful, or tender to the touch, except on manipulation. . . . Flexion of the joint is generally readily permitted, but any attempt at extension elicits opposition and evidence of acute pain on the part of the patient." It seems to me that the discrepancy as to the position of the parts is explic- 1 Anderson, "Contraction of Fingers and Toes," Lancet, voL ii. 1S91, mentions a case in which the angle was nearly 90'. - Op. cit. p. 512. ^ Op. cit. p. 756. ^ Lancet, 1894, vol. i. p. 1614. 500 DEFORMITIES OF THE LOWER EXTREMITY sec. iv able ou the supposition that the cases recorded are various stages of one affection. The disease is more commonly seen in males than females, and in young males under 20 years of age. It is generally associated with flat-foot ; and, according to Cotterell, its origin is to be sought in a combination of flat-feet and short boots. The great toe is thus cramped, the proximal phalanx becomes flexed, and the head of the metacarpal bone depressed. Pressure then follows between the last- named structure and the sesamoid bones. As to the anatomy of the affection, Mr. Davies-Colley found the plantar fibres of the lateral ligament and the tendinous tissue connecting the sesamoid bones to be contracted, so that extension of the toe was limitfed. Mayo Collier found " caries with marked absorption from pressure existing on the under aspect of the head of the metatarsal bone at the points of contact with the sesamoid bones. The cartilage was almost completely worn off the points of contact, leaving the subjacent bone bare and congested. There was also some lipping of the adjacent margin of cartilage, and at spots invasions of granulations passing in from the synovial membrane. The cartilage of the rest of the bone, as well as of the proximal phalanx, was healthy. The treatment is to remove the causes, viz. flat-foot and too short boots. In the majority of cases this is successful. But in inveterate cases excision of the head of the metatarsal bone is the surest means of relief. Ham:mer-Toe Synonyms — French, Orteil en martcau, Orteil en Z, Ortcil en cou dc cygne, Orteil en griffe ; Germau, Haminerzelie. Definition. — A deformity usually affecting the second toe, and consisting of dorsi-flexion of the first phalanx, plantar flexion of the second, and extension of the third phalanx.^ Etiology. — 1. Congenital. — A small proportion of the cases are ^ Hammer-toe must not be confused witli the contracted and claw-like toes met with in various forms of talipes. In the latter cases all the toes are afl'ected, and the follow- ing forms of contraction are present : — («) In talipes equinus all the toes may be dorsi-flexed at the metatarso-phalangeal joint, and plantar-flexed at the first interphalangeal joint. A condition similar to this is met with in talipes arcuatus and plantaris. {b) The toes may all be plantar-flexed from the metatarso-phalangeal joint, so that the dorsal surface of the toes is in direct contact with the ground. CHAP. IX ACQUIRED AND CONGENITAL DEFORMITIES OF THE FOOT 501 distinctly congeuital. lu these instances the second toe is usually affected, and in both feet. In the same patient congenital con- traction of the fingers, especially of the fourth and fifth, may be seen. 2. Heredity. — Of all the deformities to which the foot is liable, this is the one in which heredity is most marked. Mr. William Anderson has traced this in at least a fourth of the cases which have come under his notice, and in the Lectures on the Contraction of the Fingers and Toes'^ he alludes to an instance in which the deformity had occurred in four generations.^ I have met with two j^V'-" 1 1) £'-«''' >^ Fig. 275. Fig. 276. Two views of a case of hammer-toe. examples in private practice of its perpetuation through three generations. 3. Acquired Causes. — In many people the second toe is longer than the first, and by some this is believed to be the normal state. Whether the first or second be the longer matters little, if tight and pointed boots be worn, so far as the production of hammer-toe 1 Lancet, vol. ii. 1891, p. 213. 2 Mr. Warrington Haward showed six dissected specimens at the Pathological Society in 1893. These toes had been amputated on account of the pain they caused. Mr, Haward was unable to accept the theory of ill-fitting boots to explain all the cases. "Many were distinctly hereditary, and occurred in neurotic people" {Lancet, 6th May 1893). 502 DEFORMITIES OF THE LOWER EXTREMITY sec. iv is coucerned. In either case, the great toe, not having sufficient room, is subluxated outwards and the other toes become clawed. As the displacement of the great toe persists, it rides over the second toe, and the second and third phalanges of the latter being main- tained in constant plantar flexion, adaptive shortening of the long tendons and the lateral and glenoid ligaments follows, with hyper- extension of tlie first phalanx. The Appearances of Hammer-Toe. — On tlie dorsal aspect of the first interphalangeal joint a painful corn is frequently present. Beneath this is a bunion, which from time to time inflames and suppurates. On the under surface of the joint a deep groove is noticeable. The skin is contracted, and at the bottom of the groove the long flexor tendon can be felt. The first phalanx is in a state of extreme dorsal flexion, so that the head of the metatarsal bone is un- covered below to about half its extent. The second phalanx is always plantar-flexed, while the third may be either plan- tar-flexed, dorsi-flexed, or in a line with the second. As a result of the squeez- "" ing of the tip of the Fig. 277. — Hammer-toe. atiected toe downwards, its tip is often broad and flat, hence the term " hammer-toe." The second toe is in the majority of cases affected, and in both feet, but to a variable degree. I am inclined to think that the deformity is more common in women than in men. Morbid Anatomy. — To Shattock and Adams must be ascribed the credit of first having correctly described the anatomical conditions in an advanced case. Whatever may have been the original cause, the great obstacle to reduction is found to be in the shortened lateral ligaments and the contracted glenoid ligament. The flexor and extensor tendons are undoubtedly contracted, but division of them is not sufficient to remove the deformity. The lateral ligaments must be severed. As a result of the displacement neither the lower part of the head of the metatarsal bone nor the upper CHAP. IX ACQUIRED AXD COXGEXITAL DEFOEMITIES OF THE FOOT 503 half of the head of the first phalanx is covered by the bone articulating with it, and the cartilage of the uncovered portion of bone is thin and atrophied. On account of infiammation extending from the bursa, ankylosis between the first and second phalanx has been met with. Treatment. — In slight cases attention to the boots, and the various measures for remedying outward displacement of the great toe detailed on p. 497 are of value, especially if care be taken to straighten the affected toe several times night and morning. By fixing at night a malleable iron splint suitably bent to the sole and to the affected toe, the condition will often be improved. Ernst makes a useful T-spring for slight cases (Fig. 278). This is also of service after operation. Operative. — In cases of medium severity, forcible reposition with the fingers under an ansesthetic is often suc- cessful. A distinct snap or crack is felt indicating rupture of the lateral ligaments. If the shortened skin prevent complete resti- tution of the toe, the skin may be divided by a V-shaped incision. Division of the Ligaments. — Mr. Adams Fig. 278.— T-spring for ham- , p T J 1 • . • 1 . 1 mer-toe. The spring is has periormed this operation subcutaneously applied to the sole of the for several years with much success. I foot and the under sm-face of the affected toe, which have treated a very large number of cases is extended on it. on this plan with good results in every case except one. In this instance there was free hgemorrhage from the digital artery, and I applied a strip of gauze firmly around the toe. By a misunderstanding this was left on too long and the skin of the toe remained in a sloughy condition for some weeks. The patient's general condition was unhealthy, and as the toe was exceedingly painful, I thought it better to remove it. Subcutaneous Section is performed under all aseptic precautions in the following^ manner : — An assistant holds aside the first and third toes, and the surgeon, steadying the second toe with his left hand, enters a fine, narrow-pointed, strong-backed knife into the mid- point of the groove on the under aspect of the first interphalangeal joint. Passing the knife upwards, beneath the skin, and avoiding the digital arteries and nerves, the edge of the knife is turned to- ward the bone, and the lateral ligaments severed. By continuing the division on the under aspect of the joint, the long tendon and the glenoid ligament are divided. Without removing the knife ^.04 DEFORMITIES OF THE LOWER EXTREMITY from the skin pimcture, it is passed down to bone throngh the remaining lateral ligament. Mr. Adams is of opinion that the joint is not usually opened. I venture to think that it is and must be. After free division of the ligaments and tendon, the toe can be brought into good j)osition. If not, a little force suffices to rupture any of the ligamentous fibres which may have escaped division. In some cases it is as well to sever the contracted extensor tendon as well. Should the toe, however, not come into good position, the puncture on the under surface may be enlarged to Fig. 279. — The cure of hanimer-toe by subcutaneous section of the flexor tendons and of the ligaments. This is the same foot represented in Figs. 275, 276, and 277. a transverse incision, the head of the first phalanx protruded and removed with bone forceps. After the operation and dressing, the toe is placed in the cor- rected position in a malleable iron splint, until the wound is healed. A T-splint is then worn for some time until the toe shows no disposition to return to its former state. Complete excision ^ of the joint by a lateral incision is practised, and cures the patient, saving, too, a considerable amount of time in ^ Acting on the suggestion contained in Mr. Anderson's Lectures, Surgeon-Captain Rowan successfully removed the heads of the first phalanges in a bilateral case in which tenotomy had been tried and failed [Brit. Med. Journ. 10th June 1893). CHAP. IX ACQUIRED AXD COXGEXITAL DEFOEMITII :S OF THE FOOT 505 Fig. 281. Fig. 280. Fig. 282. From three photographs taken loy Air T f Rn.v ii + -i, ^ Lolxster-CIa^-DeLmitvof theFe^tmlParH^^^^^^ illustrate the author's "Cases of markable Hereditary ffistory '' Suppression of the Finapr. ,,-ht. „ r... Suppression of the Fingers, with a Ee- 506 DEFOE:\nTIES OF THE LOWER EXTREMITY sec. iv treatment. Amputation is rendered unnecessary if the foregoing- plans be efficiently carried out, and, indeed, it is an unnecessary mutilation. Abnormal conditions of the toes other than those described above are met with. They are, syndactylism, polydactylism, Fig, 283. — Partial suppression of the fingers (from a photograph by Mr. L. C. Burrell). The woman in the illustration is the aunt of the children seen in Figs. 280, 281, and 282. suppression of tlie toes, or wide departures from the normal con- dition.-^ Syndactylism is treated on the same lines as in the hand. 1 Vide "A Case of Lobster-Claw Deformity of the Feet and Partial Suppression of the Fingers, with a Remarkable Hereditary History," with photographs, by the author. Lancet, 17th Feb. 1894. This case is that of a boy, aged 3 years, who was seen by nie at the Evelina Hospital. I must express my thanks to Mr. L. C. Burrell, late of Guy's Hospital, for the great trouble he took in tracing the genealogical history of the deformities, and for his kindness in taking photographs. The patient was one of a family all of whom presented abnormalities of the hands and feet. In his case the abnormalities may thus be described. The feet, which were nearly symmetrical in appearance and size, gave one the idea of a lobster's claw. The second, third, and fourth toes were entirely suppressed ; the great toe was much lengthened, there being two phalanges, but no nail. The fifth toe was also overgrown, and seemed to have three phalanges, while a well-grown nail was found on it. Between these digits a wide sulcus was present, closely similar to that found between the forefinger and the thumb in a normal hand ; but the most remarkable point was that the well-developed first toe pre- sented, in addition to the ordinary movements of fiexion and extension, the power of opposing itself to the remaining toe, so tliat in its action and grasping movements it CHAP. IS ACQUIRED AXD COXGEXITAL DEF0E3IITIES OF THE FOOT 507 Polydactylism, often persistently hereditary, may call for amputation of one of the supernumerary toes, preferably one of the outer ones. Lateral deviation of the toes, the result of iDad boots, may be resembled the thumb of man and the opposing toe of the quadrumana (see Figs. 280 and 2S1). With this severe deformity the feet were, however, perfectly useful for walk- ing, and in so doing there was no sign of lameness. The hands had but one finger, corresponding in position to the fifth finger, the thumb, first, second, and ring fingers being entirely suppressed, while the metacarpus was normal. In the case of the younger child, a girl, the feet presented the same appearances as in this patient's case, while there were two fingers on each hand webbed together (see Fig. 282). Two other children, who were males, were deformed similarly to my patient. An aunt, who brought the child to the hospjital, was another example of precisely similar deformity. Her hands are shown in Fig. 283. The table of family relationship is very interesting. The deformity has persisted nearly constantly through four generations, and in the later generations is more marked than in the earlier. The ancestors, J. G. and his wife, were perfectly formed in the hands and feet, while the abnormalities were trans- mitted indiscriminately through males and females, although in no instance was there any relationship between husband and wife in any one generation. It was not possible to trace any cousinship. The curious shape of the feet is mtich more persistent than the suppression of the fingers; of twenty-two descendants of J. G., thirteen had but two toes on each foot, with the prehensile movements of the great toe ; one had but one toe on each foot, and one had one toe on the left foot and two on the right foot. The family table is given below. James G — — — • Married ; both normal ; not cousins. I James. Two fingers each hand and two toes each foot. Married Mary ; nonnal. I James. One finger each hand ; two toes each foot. Married Harriet ; normal. Thomas (normal). Married ; wife nonnal. I Two sons ; normal. Mary. Married ; hands normal ; two toes each foot. i Male. One finger each hand ; two toes each foot. ] Edward. Married ; wife normal ; two fingers each hand ; two toes each foot. Maria. Married ; Edward nor- mal ; one finger each hand ; two toes each foot. Female patient in Fig. 283. Male. Male. Isaac. Normal. Xormal. One finger each hand ; two toes each foot. Henry. Harriet. Lucy. Thomas. Joseph. Harriet. One finger each ^Tormal. Three fingers left ^STormal. One finger each Two fingers hand ; one toe hand ; four fingers hand ; one each hand ; each foot. riahtihand ; stump toe left foot ; two toes each in" place of thumb two toes right foot, projecting into foot, palm ; two toes each foot. Edward. One finger each hand; two toes each foot. Eiehard (patient). Absence of all fingers, except the last on both hands ; two toes on each foot ; nail on last toes ; no nail on first, which in its move- ments resembles a thumb. Figs. 2S0and2Sl.- Mary. Two fingers each hand — these are webbed together ; two toes each foot. Fig. 2S2. James. Exactly same defoim- ity as Richard. 508 DEFORMITIES OF THE LOWER EXTREMITY sec. iv remedied by manipulation and wearing a digitated sock, or by the use of a sole-plate with slots in it. In extreme cases amputation is necessary. Hypertrophy of the toes, generally of the hallux, is seen from time to time. The hypertrophied toe is frequently displaced inwards or outwards. It may attain an immense size. The hypertrophy may affect the skin, subcutaneous and fatty tissues, or these and the bones may be uniformly enlarged. In most cases partial or com- plete amputation is required eventually. SECTION V ANKYLOSIS, CONGENITAL DISPLACEMENTS, DEFORMITIES RESULTING FROM CEREBRAL AND SPINAL PARALYSES, ARTHRODESIS CHAPTER I CONTRACTURES AND ANKYLOSIS Definitions — Spurious Ankylosis and its Treatment — Ankylosis, Fibrous and Osseous ; Causes, Prognosis, and Treatment — Osteotomy for Bony Ankylosis — Adams' and G ant's Operations for Ankylosis of the Hip, Synonyms — English, Stiff -Joint, Fixed Joint; French, Eaicleur articulaire, Ankylosc ; German, Gelenkverivaclisnng. Derivation — Greek, djKvXo^, crooked or hooked ; aparatus the patient could walk with comfort without crutches or sticks. ]\Ir. Adams' operation is by no means so easy to perform as might appear from the description aiven by its author. The neck of the femur is not easy to " hit " with the knife, and the tendency is to make the section at the junction of neck and great trochanter. In that event, the time occupied in section varies from a half to one hour, especially if the bone is sclerosed. In the case of Miss A. J., I found it Ijetter to make an incision about 1 inch long above the trochanter, and to burrow with the finger down to the neck of the bone, guiding the saw into place. The difficulties of the operation can thus be readily overcome. The operation is not suitable in children, in whom the neck of the femur is ill-developed and, it may be, is partially destroyed by ulceration. The best results are obtained for ankylosis after rheu- matic fever and acute suppurative arthritis. Ganfs Operation, or Infra-TrocTiantcric Osteotomy of the Femur. — An osteotomy knife is passed to the outer part of the anterior aspect of the bone at the base of the great trochanter. The saw is entered along the knife, and the outer two-thirds of the femur divided. The remainder is then snapped by carrying the limb inwards. When practicable, it appears that Adams' operation is preferable to Gant's, especially when the deformity is rectangular or nearly so. Operating by Gant's method for a deformity for this severity is apt CHAP. I CONTRACTURES AXD AXKYLOSIS 521 to leave a very ugly angle iu the shaft of the bone, and may be followed by non-union. For osseous ankylosis of the knee, a linear osteotomy in moderate cases, and removal of a wedge-shaped portion of bone in severer cases, with division of the flexor tendons, will serve to remedy the deformity to a considerable extent. CHAPTER II CONGENITAL DISPLACEMENTS (DISLOCATIONS) Congeiiital Displacements in General — Of the Hip, Freqiunci/, Etiology and Causation, Mechanical Theories, Pathological and Physiological Theories — Anatomy of Congenital Hip Displacement — Symptoms — Prognosis — Diagnosis — • Treat- ment by Becumhency and Extension, Pad's Method, and by Operation — Hoffa's and Lorc'n£ Operation — Summary of Treatment — Congenital Displacements of other Joints. The word " dislocation," as commonly accepted, implies separation of those parts of a joint which have been normally in contact. If through an error in development such contact has at no time occurred, I take it there cannot exist a dislocation. Therefore the word " displacement " is more correct. Long usage has sanctioned the expression " congenital dislocation," hut, I venture to think, with- out a due appreciation of the contradiction therein implied. As an example, congenital displacement of the hip may be taken. The pathology of veritable cases teaches us that there has been no perfect acetabulum formed from which the head of the femur could have been dislocated. Congenital displacements of nearly all joints have been described, Vint the chief interest centres about that at the hip, on account of its greater frequency, and the serious interference with locomotion it gives rise to. Congenital Displacement of the Hip It is necessary to clear the ground a little before the subject is entered upon. Thus unskilful or violent delivery in breech pre- sentations resulting in dislocation at the moment of birth, cannot be classed as congenital. That such accidents may happen is shown by some experiments of Melicher at Vienna upon women who had died undelivered. In six trials he found that with the fnioers or CHAP. II CONGENITAL DISPLACEMENTS (DISLOCATIONS) 523 hook it was possible to produce the luxation. In two instances in which the displacement was unilateral, the dislocation was in that hip to which greater traction had been applied as the presenting part. Eeduction in these cases was effected with the greatest difficulty. Such are acquired, not congenital, displacements. In these instances the acetabulum was perfectly formed, and no great difficulty would have been subsequently encountered in deepening it sufficiently to again receive the head of the femur. But with ordinary care I doubt if it be possible to produce a dislocation of the head of the femur from a normal acetabulum. If, however, the cotyloid cavity be deficient, especially as regards the upper part of the rim, as is stated to be the case, in some instances, by Lockwood, then displacement of the head of the femur at birth by breech presentation is very probable. Frequency. — Parise ^ examined the hip-joints of 332 infants who died in L'Hopital des Enfants Trouves, and found congenital dis- placement in three cases. Chaussier,^ in 23,293 infants delivered at the Maternite, found it present once only. But it must not be forgotten that congenital displacement is often not recognised until the child begins to walk. In 2000 cases of children coming before my notice at the Evelina and Orthopaedic Hospitals, I have seen it seven times. Kronlein's ^ statistics, based on 7 7 cases of Drachmann, 107 of Pravaz, and 90 of his own, found that of 274 cases, 35 occurred in males, and 239 in females, i.e. 12-4 per cent in males, and 86-6 per cent in females. Of these cases, 111 were bilateral and 163 were unilateral. The right hip was alone affected 83 times, and the left 80 times. It is thus seen that the affection occurs with greater frequency in girls than boys, and is more often unilateral than bilateral. Etiology and Causation. — With regard to the causation of the lesion, a large number of theories have been propounded, but there is one only which is confirmed by scientific observation. The theories may be arranged under three headings — the Mechanical, Patho- logical, and Developmental. Theory of Mechanical Causation. — Under this heading the follow- ing possibilities have been cited, viz. unskilful and violent delivery of breech presentations with the hook or fillet, falls on the part of the mother, malposition of the foetus in utero. 1 Bull, de la Soc. de Cliir. 1866, vol. vii. p. 331. 2 Chaussier, quoted by Kronlein, Deutsch. Cliir. B. 26, p. 83. ^ Quoted by Redard, op. cit. p. 498. 524 ANKYLOSIS, CONGEXITAL DISPLACE:\1EXTS, ETC. sec. v With reference to the first we may say that such cannot be considered as congenital, if they are produced at birth by violence. This supposed mode of origin could be A'erified by the sensation of the bone leaving the socket, and the presence of hiematoma ; as to the second, there is a case of dislocation of the xiphoid cartilage in an infant whose mother fell at the fifth month of pregnancy, but this fact cannot throw any light on the production of displacement at the hip ; with reference to the third, the fact that many of the cases have been breech presentations may give colour to it. Yet this alone cannot be the real factor, because of the large number of such pre- sentations in which no displacement of the hip is found to exist, and, secondly, dislocation of the hip cannot occur from a normal acetabulum unless the force used in delivery be extreme. With Bowlby ^ we believe that it is not possible for displacement to occur when the thighs are flexed on the abdomen in utero, if the cotyloid cavities are perfect. Theory of Patliohiiiical Cavsation.- — The following conditions have been assigned : — {a) Muscular Contraction, due to some central nervous lesion (Guerin, Melicher, Carnochan), but unfortunately no central nervous lesion has been discovered, and tlie muscular contraction may, with more probability, be assigned to the displacement of the head of the bone rather than its cause. (h) Paralysis of the Peri-trochauteric Muscles. — In Adams' cases there was no paralysis of the muscles, and the displacement arising from paralysis appears at a period too remote from birth for the lesion to be considered congenital. (f) A Morbid Condition of the Articular Apparatus, viz. softening and other alteration of the ligaments (Sedillot, Stromeyer), hydrarthrosis (jMalgaigne, Parise), tubercular disease of the synovial membrane (Broca), and of the articular surfaces (E. Barker). Against the view of the causation of congenital displace- ment by hip disease in the foetus, Bowlby - brings forward the following facts : — " 1. The patients in whom the deformity occurs are commonly healthy, and show no evidence of tubercle or struma. (2) Suppura- tion is never seen in these cases. (3) Ulceration of cartilage, caries, and necrosis have never been described. (4) The limb develops in. a normal manner after l»irth, the displaced femur equalling its ^ Pafli. Soc. Trans, vol. xxxviii. p. 297. - Ibid. p. 297. CHAP. II COXGENITAL DISPLACEMENTS (DISLOCATIOXS) 525 fellow iu length, conditions which are commonly reversed when hip disease occurs in infants. (5) Disease of the joint does not explain the abnormal development of the acetabulum." Dcvelo'jjriicjital Causes. — This theory is supported by pathological observation, and is therefore the only one which can be accepted. Originally advanced by Palletta, it has received confirmation by the work of DoUinger,^ Grawitz," Bowlby, W. Adams,^ and Lockwood.* Dollinger considered that premature ossification of the Y-cartilage at the bottom of the acetabulum was the cause, while Grawitz, from his observations of twelve specimens of congenital hip displacement from seven new-born children, concluded that it was due to arrested development of the acetabulum. Bowlby ° describes the appearances of the acetabulum iu a unilateral case of this nature taken from a girl, aged 13 years, thus : " In the position of the normal acetabular cavity is a triangular depression, which, although it evidently represents the acetabulum, is far too small to have accommodated the head of the femur at any time. . . . The edges of the depres- sion are scarcely raised above the level of the surrounding bone. The upper portion of the normal acetabulum, the iliac segment, appears to have been suppressed, so that the ill-developed acetabulum represented by the above-mentioned triangular depression is formed merely by the coalescence of the pubic and ischiatic segments." Another case shown at the Pathological Society by Mr. J. H. Morgan ^ revealed a triangular acetabulum with the base directed outwards, the height of which was 1 inch, the breadth ^ inch. Mr. Shattock ' also mentioned another probably congenital case from a girl, aged 16 years, in whom both acetabula were triangular. The two specimens in the Hunterian Museum also show the same unusual appearance of the acetabulum. Mr. Lockwood has demon- strated that in one case the margin of the acetabulum was deficient.^ The development of joints is touched on by him, and he states that " the hip-joint is not at first a pelvic socket in which the head ^ Archivf. klin. CJiir. 1877, Bd. xx. ^ Virchow's Ardiiv, 1878, 74, i. 3 Path. Soc. Tram. vol. xxxviii. pp. 300, 301. ■* Jbul pp. 303-311. ® Loc. sup. cit. ^ Ihid. ~ Ibid. . * Loc. sup. cit. In this case the head of the femur was displaced on to the dorsum ilii. There was also ectopion of the abdomen with protrusion of several viscera, dis- placement of the head of the I'adius on to the front surface of the carpus, and the carpus towards the flexor aspect of the radius and ulna, and forward displacement at the knee- joints. Mr. Lockwood cites another case of absence of the margin of the acetabulum without displacement. 526 ANKYLOSIS, COXGEXITAL DISPLACEMEXTS, ETC. of the femur lies, but the acetabulum is formed by a growth of pelvic cartilage up and round the head of the femur. By the third month of intra-uterine life this process is far advanced, and the acetabulum is a deep cup." In these observations then we have the etiology and causation of congenital disijlacement at the hip. It is well to bear in mind, in view of the various operations for deepening the acetabulum, tliat it is originally shallow, is smaller than normal and of unusual shape, and that in truly congenital cases the rim is deficient. C cbtr'Ur., Fig. 28-t. — Front view of a case of bilateral congenital displacement of the hip-joint (after Redard). Fio. 285. —Back view of Fig. 284 (after E.-dard). These facts alone must throw a shadow of doubt on the reported success of some operators. Are all the cases which are stated to be congenital, and which have been operated on, really congenital, and not traumatic or paralytic ? There is a hereditary tendency in some cases of congenital dis- placement. Bradford and Lovett quote Dujjuytren,^ who had met with three families where the affection was present in several ^ Lecons Orales de Clin. Chir. Paris, 1832, tome ill. Art. xiu. CHAP. II COXGEXITAL DISPLACE^^IEXTS (DISLOCATIOXS) 527 members. Cases have been recorded by Bouvier/ Yernenil," and Yolkmaun." The Anatomy of Congenital Displacement. — Unfortunately, there exist but few authentic specimens in museums in this country.'^ The luxation is said to be complete or incomplete ; and in the latter case, according to Guerin, it becomes complete when the child walks. As to the position assumed by the head of the femur, it is stated that the displacement is nearly always dorsal, and rather postero-superior than directly superior. It is said to be exceptional for the head to come forward and to be found in front of the pubis or at the obturator foramen. According to Bouvier,^ they are the greatest of rarities. But of seven cases I have had under my care, three were anterior. At a meeting of the British Orthopa;dic Society in July 1895, Mr. H. A. Eeeves drew attention to tlie fact that, in congenital cases, the displacement was more often anterior than was generally supposed. In his practice Mr. Eeeves had met with several cases. It will be convenient from the point of view of treatment to describe the appearances met with at three different periods, viz. — 1. At birth. 2. In young children who have walked. 3. In adults. 1. Ap]pearances at Birth. — The acetabulum is in its normal position, but it is abnormal in shape, being either triangular, oval, or elongated. A'ery seldom indeed, if ever, has it been found com- pletely absent. The cartilaginous rim may be wanting, as in the case described by Lockwood, and the mass of fat at the fundus of the acetabulum, the gland of Havers, is much hypertrophied. When the cotyloid border is defective, the canity is almost continuous with a flattened surface on the iliac bone, sometimes covered with cartilage, which indicates the new position taken by the displaced head. Grawitz has shown by microscopical observation ^ Leeons Clin, sur le,s mcdad. cJiron. de Vo.pp. lowraotcur. - Gaz. des Ropitaux, 1868. pp. 68 and 76. ■* Kranklieiten des Beicegv.ngsorgane. ^ Some of these are : an authentic one (described by Bowlby, Path. Soc. Trans. ) and a doubtful one (described by D'Arcy Power) in St. Bartholomew's Hospital Museum, one in Charing Cross Hospital Museum,, two in St. Thomas's Hospital Museum, a doubtful one without any history in the Middlesex Hospital Museum, one in Guy's Hosptital Museum, and four in the Hunterian Museum, including Carnochan's. •5 Archiv. Gen. de Med. xiv. p. 439. 528 AXKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. sec. v that the edges of the Y-shaped eartihage are much hypertrophied, and that the bone developed at the margins is very thick. The head of the femur is round, or irregular or flattened, and is said to have been absent. The neck is short and conical, and forms an angle, less obtuse than tlie normal, with the diaphysis. The round ligament is flattened, slender, and of greater length than natural. It is sometimes softened and, exceptionally, it may, according to Ziegler, be of greater thickness than in a normal joint. The capsule which is inserted around the margin of the original acetabular cavity is elongated, thinned, its capacity much increased, and it is sometimes distended with fluid. The muscles are often atrophied and retracted. Lockwood, in the case he described, states that " the muscles which surround the joint participated in the disturbance of position, and the obturator externus and quadratus femoris were especially dragged upwards by the ascent of the femur. The ilio-psoas lay in a deep groove, which was situated just below and internal to the anterior inferior spine of the ilium, and tlie tendon of the psoas wound backwards in an exaggerated way to reach the lesser troclianter." In an autopsy on an infant, the subject of congenital displacement on the left side, the muscles on that side were shorter and less developed than on the right. 2. In Children iclio have Walkal. — The acetabulum is seen to remain small, shallow, and triangular. Above and posterior to it and around the new socket there is sometimes found a growth of bone which forms a partial rim for tlie latter, and to which the capsular ligament is attached. In Bowlby's case, a girl, aged 13, there was " a slightly depressed surface of bone covered b}^ dense fibrous tissue which was continuous with a fibrous capsule around the neck of the femur. No attempt had been made at the forma- tion of a new socket, either by the absorption of the ilium or by the development of new bone. The ilium itself is abnormally smooth, all the ridges for attachments of muscles being very slight." Occasionally where the head of tlie femur has rested the bone is hard, flat, and ivory -like. As an effect of the body-weight the femoral head moves further away from its proper place. Palletta in one case observed on the ilium three slight but distinct impressions, which appearance he interpreted as indicating that the head of the femur had occupied three successive positions. The head of the femur is small, conical or flattened at the part CHAP. II COXGEXITAL DISPLACEMENTS (DISLOCATIOXS) 529 where it comes into contact with the ilium, if. superiorly aud posteriorly. The cartilage is present iu most cases, but wanting in a few. The neck may be shortened or absent, and then the head is supported directly by the shaft. The capsular ligament is elongated, dilated, in some cases thinned, and in others much thickened. It sometimes has a curious hour-glass shape,^ and its cavity is obliterated at the middle. According to Pravaz, this condition is only seen when the round ligament has disappeared. The upper insertion of the capsular ligament embraces both the new and old cotyloid cavities. The round ligament has been found in various conditions, occasionally thick and solid,- as if it had helped to support the body-weight, more often elongated and attenuated, and frequently absent (Bowlby, Adams), or merged into the joint-capsule.^ The muscles are stated by Yolkmann and Kroolein not to be contracted during infancy, but to become so during adolescence. In the history of a specimen shown by Mr. Shattock, probably congenital, from a girl, aged 16 years, it is stated that both thighs were flexed and the muscles appear to have been permanently contracted during life. According to Hoffa and others, muscular contracture is undoubtedly present in some cases in infants. The importance of determining the presence or absence of muscular contraction during the early years of life in these congenital cases is great in view of the extremely thorough division of muscles advocated by some iu their operative procedures. 3. Ill Adults. — All the above conditions are much exaggerated. The displacement of the femoral head becomes greater, the capsule is now much thinned, or is sometimes pushed at its upper and posterior part between the caput femoris and the ilium, and may form a sort of bursa between the bones.^ Eedard, to whom I am indebted for much information on the jjathology of congenital dis- placement, says : " In certain cases in adults the capsule wears away and the round ligament is destroyed ; the caput femoris then comes into immediate contact with the periosteum of the ilium, and forms a new and sufficiently perfect cavity for the reception of the ^ Carnochau. A*. F. Journal of Med. 1848; Holmes Coote, Lancet, 1860; Cautou, Jlcd. Gaz. sli. - Adams' Todd's Encycl. vol. ii. •' Bouvier, ArcMv. Gen. rfe iled. xiv. p. 439. ^ In Mr. Canton's specimen, described by Mr. J. H. Morgan, it is stated that "'the head and neck of the femur were found on the dorsum ilii, while a large bursa existed between the capsular ligament {and /) which immediately covered the head of the femur like a hood." Path. Soc. Trans, vol. xxxviii. p. 298. 2 M 530 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. sec. y head, with definite margins, while the old cavity Ijecomes more and more distorted.^ The new cavity is placed more or less above or behind the old cavity, sometimes in the middle of it (Coudray)." Bradford and Lovett remark " that the new cavity is often deep enough to form good support. The pressure of the head of the femur in its new position causes absorption of the periosteum and joint-capsule in that place, and the capsule finds a new attachment in the osteophytes, thrown out to form an upper rim to the cavity in favourable cases." It is very interesting to know what becomes in adult life of all the cases of congenital hip disease which are seen in childhood. Some shrinkage of the capsule and fixation must take place and the condition thus improved, or else more would be heard in later years of these cases. The muscles are, according to Eedard, much altered, some are contractured, and their points of attachment are approximated. Xronlein and Bardeleben assert that they undergo fatty and fibrous degeneration. The muscular contractures are best seen in adults ; and they are no doubt due to the abnormal position of the head of the femur," and to the slight flexion and rotation of the thighs. Considerable shortening is found in the psoas and iliacus and in the peri-trochanteric muscles, while the adductors and internal rotators are affected to a less degree. The pelvis undergoes considerable change. The crests of the ilia approach each other, while the tubera ischii are separated and everted, and the ramus of the ischium becomes somewhat twisted. The transverse diameter of the true cavity of the pelvis is increased, while that of the false pelvis is diminished. The changes arise from the heads of the femora in their new positions on the dorsa iliorum pushing the alw together somewhat. The effect of these alterations on the pelvis is to facilitate parturition rather than to prevent it. Symptoms. — A. In bilateral cases. 1. Mudt of Progression. — Very frequently the deformity escapes observation until the child commences to walk. Then he is seen to waddle, and to be the subject of lordosis. Pravaz thus describes ^ In specimen 742 in tlie ]\Iu.sw Dupuytien the original acetabuluni is nearly obliterated, and partially replaced by a prominence of bone. - J. H. Morgan described the head and neck of the femur m.s being on the dorsum ilii, the former having passed beneath the external rotators. Path. Soc. Trans. voL xxxviii. p. 29S. CHAP. II CONGENITAL DISPLACEMENTS (DISLOCATIONS) 531 -^ / r I Fig. 286. — Back view of a case of bilateral congenital displacement of the hip-joint (M. A. F , aged 8^ years). Fig. 287.— Side view of Fig. 286. 532 ANKYLOSIS, COXGKXITAL DISPLACEMENTS, ETC. sec. v the mode of progression : " The patient tirst raises himself some- what on his toes and inclines the upper part of the trunk towards that foot which is chiefly supporting the weight of the body ; then the other foot is slowly carried forward. At that moment the trochanter of the limh, on which tlie weight of the Lody mainly falls, can be felt to move upwards towards the crest of the ilium, and then resumes very nearly its former position when the weight is taken off that side." When running, the waddling effect is not so marked. 2. Lordosis is present on account of the disturbance of the equilibrium of the trunk. The vertical line through the centre of gravity of the body falls behind its normal position, and the trunk tends to fall backwards. To compensate for this, the lumbar region is arched and the abdomen protruded. 3. A disproportion of the lower limbs to the general bodily development is at once observable (Fig. 286), and when the patient's hands are placed by the side, they reach lower down on the thighs than in a well-proportioned individual. The muscles of the lower extremities are small and ill-developed, and the appearance is exaggerated by tlie want of proportion between the size of the peh'is and lower limbs. The pelvis appears broader than natural. -i. The great trochanters are unduly prominent when the child stands, and they are nearer the crests of the ilia, or on tlie pubes, being displaced upwards to the extent of ^ inch to 2 inches. The gluteal muscles form a cone whose base is at the ilium and apex at the great trochanter, so that the tubera ischii are not covered by muscle. o. The heels are rotated inwards, while the toes point outwards, and the knees are brought close together. Abduction of the limb is limited in dorsal displacements. 6. On the patient lying down, the lordosis disappear.s, and the tops of the great trochanters are not so near the crests of the ilia as when the patient is standing. The upper borders of the trochanters are, however, still above Xelaton's line. 7. Measurement of the limit from the anterior superior spine of the ilium to the internal malleolus .shows that it is shorter than normal. But if the measurement be taken from the upper margin of the great trochanter on the affected side in a unilateral case, the actual length of the affected limb is but little, if any. less than is natural. 8. ]\Iuch of the shortening may be made to disappear in infants CHAP. II COjSTGEXITAL displacements (dislocations) 533 and children by steady traction on the affected limb. If, while making traction, one hand of the surgeon be placed on the prominent trochanter, it can be felt to descend and almost touch Xelaton's line. This is a most important point in diagnosis. B. In a unilateral case. In walking a very decided limp on the affected side is seen, the shoulder on that side is lower than the other, while the trunk inclines to the sound side. The disproportion in size of the affected limb, the wasting of the muscles, the prominence of the trochanter, the upward displacement of its head, and the dimin- ished measurement from the anterior superior spine are readily appreciated by comparison with the sound side. Xegatively, there is a total absence of pain, no limitation of movement in young children, and but little in adolescents. Importance of Early Recognition of these Cases. — 1. As to the possibility of cure. The earlier the treatment is commenced the more likely are mechanical methods to effect a cure. Especially is this so if treatment is begun before the child has walked, and before the caput femoris has become much displaced, with the accompanying elongation of the capsular ligament. 2. Unjust accusations have been made against nurses and others in charge of children, the subjects of the deformity, of their having been allowed to fall. A careful examination of the case at the time will readily disprove any such accusation. 3. On account of the want of early and complete recognition, an incorrect diagnosis is made, and the patient may be wrongly treated for some time. Diagnosis. — The first thing to be clear about is that a displace- ment of the head of the femur is really congenital, and not due to traumatism. In the history the points which assist the formation of an opinion as to the congenital nature of the deformity are the possibly hereditary nature of the affection, the onset of limping or waddling without pain when the child commences to walk. One must be careful not to readily accept the assertion of the parents that the child has had a fall. The main features of congenital displacement are as stated above, the displacement of the head of the femur above ISTelaton's Line, the ease with which the head may be pulled downwards when the patient is recumbent, and the great mobility of the parts without pain. A. When the affection is hilateral, it is easier to form an opinion 534 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC than when it is unilateral. But even in tlie former case mistakes have been made, and confusion lias arisen with the following conditions. 1, Coxa Vara. — In this deformity, although the great trochanter is displaced above Nelaton's line, it cannot be drawn down l)y traction on the limb, and the head of the bone can be felt in its normal position. The waddling gait and the prominence of the trochanter in coxa vara, together with the difficulty in abducting the limb, have caused the two affections to be confounded. 2. In cliildren the lordosis and the imperfect balance of the l)ody occurring in pseudo - hypertrophic paralysis have given rise to some difficulty in dis- tinguishing it from congenital displace- ment. But again, in pseudo-hypertrophic paralysis the head of the bone is in its normal position, the trochanter is not ex- cessively prominent, many of the muscles, y\ "^ff/ /l ) such as the gastrocnemius, and extensors m. liwi W^ of the thigh are seen to be hypertrophied, wliile others, such as the lower part of the pectoralis major, tlie latissimus dorsi and teres major are atrophied, and the peculiar movements of the child affected with this form of paralysis on rising from the horizontal to the vertical position are diagnostic. As is well known, the child climbs up himself in rising from the couch Fig. 288.— Unilateral congenital to the Standing position. displacement of the hip-joint ,, n ^- t -i j i r-c ^ ■ ^i (after Redard). breneraily in bilateral anections the diagnosis is easy, but in slight cases of displacement, and especially in young children, the lordosis and undue prominence of the gluteal region are not marked, and it is difficult to be sure if the upper margin of the trochanter be on Nelaton's line or not. B. When the displacement is unilateral. The difficulties of diagnosis are much increased, especially in slight and early cases, but great reliance must still be placed on the abnormal position and rounded shape of the head, its excessive mobility, and the ease with which it can be made to move over the external surface CHAP. II COXGEXITAL DISPLACEMEJiTTS (DISLOCATIOXS) 535 of the ilium, or, in cases of anterior displacement, over the pubes : the absence of pain in ^valking and the freedom of the movements at the hip, together with the disappearance of shortening on gently drawing on the affected limb. The diagnosis has to be made from : — 1. Coxitis, especially when the head of the femur has undergone pathological dislocation. But a careful inquiry into the history of the affection in this case, its progress, the presence of abscesses or sinuses, the painful limitation of the movements of the joint, the existence of adduction of the thigh rather than abduction, and finally, if doubt still exist, an examination under an antesthetic will render the case clear. 2. From Parahitic Dislocation of the Hip. — If the child has not walked, the difficulties are great. According to Yernenil, niany so-called congenital displacements are really paralytic. And confusion is the more likely to arise because the caput femoris is very mobile, and the great trochanter is much displaced, while moderate traction brings the head back into its position. But the muscles should be very carefully tested for signs of degeneration secondary to anterior polio-myelitis. By careful and skilful move- ments, the head of the femur may be replaced in the acetabulum, while in congenital displacement it cannot. 3. From Traumatic Dislocation. — Although the head of the bone is full and rounded, and is in a new po.sition, yet the rigidity of the limb, the history of the case, and, if recent, the bruising of the parts will render the diagnosis sufficiently clear. Prognosis. — In untreated cases the outlook is bad. Much will depend upon the extent of the displacement, taken with the age of the patient when first seen. In some cases a more or less perfect acetabulum is formed or the capsule shrinks, and the joint becomes firmer, but the lordosis, prominence of the gluteal region, and the rolling gait persist. It remains to be seen later to what extent the deformity may be remedied by treatment. Treatment. — The methods of treating congenital displaceinent of the hip are three, viz. — 1. Extension either in the Piccumbent Position or by Appar- atus. 2. Forcible Eeduction. 3. Eeduction by Operative Measures. 1. Extension citJier in the Becicmheat Position or ly Apixn-atas. — The oldest form of treatment is by continuous extension. Among 536 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. its advocates are Travaz, father^ and sou,- Buckminster Brown,^ aud "William Adams.* But to Buckminster Brown should be ascribed the credit of having been the first to treat cases in this way with considerable success. He subjected his patient, a little girl, aged 4 years, to complete recumbency with extension for thir- teen months, and then allowed her to get about for a year in an arrangement by which she could imitate the movements of walk- ing without bearing the weight on the legs. At the end of two years and three months the troelianters were in place, the lordosis had disappeared, and the child was able to run about normally. This is a classical case, and is extensively quoted by the advocates of this line of treatment. But as the question of treatment is still r-rr^- FiG. 289. — Mr. Adams' extension-coiicli for cases of congeuital ilisplacement of the liip-joiut. The part on which the jiatient lies is detachable, and can be placed iu a carriage. sub judicc, it would be very interesting to trace this case, and to ascertain if after a lapse of nine years there is any sign of recur- rence of the displacement." Dr. Post '^ treated successfully, under an autesthetic, a case of unilateral displacement by placing the head of the femur in a young child as nearly in the normal position as possible, and then immobilising the parts in plaster of Paris for a year, allowing the child to get about on crutches. 1 Bull, dc VAcad. de Med. vol. iii. p. 438. - Bi'Il. dcla Soc. de Chir. 1864, p. 218. •' Boston Med. and Surg. Journ. 4th June 1SS5. •* Brit. Med. Jonrn. 23rd April 1887, and 22nd Feb. 1890. " This has taken place, according to Dr. Myer.s, Annals of Surg. Aug. 1894. ^ Boston Med. and Svrg. Journ. No. 23. In 1894 this ease had suffered a slight relapse. CHAP. II CONGENITAL DISPLACEMENTS (DISLOCATIONS) 537 In this country Mr. Adams has advocated this line of treat- ment, and has carried it out in two cases with satisfactory, results, the remaining four being under observation. Of Mr. Adams' six cases, two were double and four single displacements. But in the two cases given by him,^ we are not told that the patients were able to get about ultimately without apparatus of any kind. In connection with this method it is interesting to inquire what are the objects of treatment by recumbency for so prolonged a time as two years, and what changes may be effected in the parts by it ? Fig. 290.— The extension-couch tilted for meals, etc. The couch may also be tilted the reverse way, so that the weight of the body acts as counter-e.xtension. According to Mr. Adams, if the treatment is begun under 2 years of age, the gradual displacement of the head of the femur by the elongation of the capsular ligament will be prevented, and further he thinks there will be "adapted growth of the capsular ligaments and all the surrounding muscles and fibrous structures," when the head of the femur is retained for so long a time in as nearly as possible its normal position ; and as a result " a circular flattened depression will be formed in the bone near the acetabulum, and this, together with the adapted growth of the capsular ligament and fibrous structures, will keep the head in position. The upper 1 Brit. Med. Journ. 22nd Feb. 1890. 538 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. sec. v portion of the capsule we may also hope will contract." ^ That something of this kind does occur is shown by another case quoted by Mr. Adams of a young man, aged 19 years, who had Ijeen treated by recumbency for twenty-six months at the age of 6 to 8 vears. At the nineteenth vear there was only 14- inch shorten- ing, and witli a cork sole the limp in walking was very slight, and he could take any amount of exercise. This may be considered satisfactory, seeing that if the cases go untreated, the shortening at the age of 19 is usually 2 to 3 inches or more. In any event, the result of Buckminster Brown's case has encouraged many surgeons to pursue the same line of treatment. Schede ■ has, since 1880, treated cases of congenital displacements, in whom no secondary changes have been caused hy urdl-iny, by simple traction, slight abduction, and moderate lateral pressure on the trochanter, by which the head of tlie bone is retained in the acetabulum. He holds that in many cases the condition is by no means so incurable as it is supposed to be, and it can be not only greatly improved, but brouglit to a complete cure. But after tlie child has commenced to walk, the prognosis is less favourable. By the end of the second year, certainly in the third, the changes in the joint have become so marked that intermittent extension no longer suffices to reduce the deformity. But in such cases the employment of continuous extension by means of weights for a few w'eeks or months so restores the position that, with abduction and pressure over the great trochanter, the head of the bone may be made to go back into its place, and remain so firmly fixed that pressure upon the sole of the foot no longer causes it to ride out. Schede's apparatus is essentially an outside steel support from the pelvis, with an abduction screw, by turning which pressure may be made on the trochanter. This is employed during the day, and extension of four to five pounds at night " till a cure is effected." Schede reports 43 cases treated by his method. Of these 1 was entirely and absolutely cured,^ 13 almost cured, 15 greatly improved, 10 but slightly improved, and 4 lost sight of He also reports 4 cures by operation. 1 Cf. the changes wliich are described on p. r'29 in the outline and density of tl]e capsular ligament, and notabl}' the hour-glass contraction which has been seen. 2 VcrlmmUuiKjen der Deutsch. Gcsdsch. fur Chir. xxiii. Congress, 1894 ; and Aiviials of Sunjery, March 1895, pp. 347-3;)l. * Dr. T. H. Mj-ers says {Annals of Surgery, Aug. 1894) that Dr. Schede has written him to say that lie has completely cured four cases by this method. CHAP. 11 CONGENITAL DISPLACEMENTS (DISLOCATIONS) y39 Yolkmann also obtained good results by these methods of exten- sion with abduction. I have tried the treatment by recumbency and extension in two cases with a great measure of success, and I here give the details. Case 98. Congenital Displacement of both Hips treated hy Recumhency and Extension for Two Years. Subsequent Retention of the Heads of the Fig. 291. — Case 98 : congenital ilisplacenient of the hip, fitted with walking apparatus and crutches. Fig. 292. — Case 98 : photograph taken one year later than in Fig. 291. The boy is able to walk without cratches, and all lordosis has disappeared. Femora in Good Position. — Edgar M , aged 7 years, came under my care at the National Ortliopsedic Hcspital on 4th April 1892. He was the first child, and was born by the breech, but no instruments were used. On admission he was seen to be a well -nourished boy, but the lower limbs were small in proportion to the rest of the body. There were the typical lordosis on standing, and waddling gait in walking, and the prominence of the trochanters was marked. In the horizontal position it 540 ANKYLOSIS, COXGEXITAL DISPLACEMEXTS, ETC. sec. v was noted that the heads of the femora were displaced dorsally, and were nearer the crests of the ilia than is normal. By measurement it was found that the upper border of the right trochanter was f inch above Xelaton's line, and the left i inch, but both could be brought into proper position by traction on the limb. The boy was i)laced on a couch constructed hy Ernst on Mr. Adams' model (Figs. 289, 290), and sufficient extension applied to bring the trochanters downwards to their normal position. No attempt was made to reduce the displacement on either side. On 11th July 1892 it was noted that when the exten.sion was removed the upper margins of the trochanters were not more than h inch above Nelaton's line, improvement therefore being greater on the right side. The recumbencv and extension were maintained till May 1894, and he was then fitted with an apparatus (Fig. 291) by Ernst, which allowed him to move with the aid of crutches, while at the same time the feet did not touch the ground, extension lieing kept up by pressure on the tubera ischii, and over the great trochanter. At night the extension was maintained by a .stirrup and weights. In January 1896, as there was no sign of the upward movement of the great trochanters when the apparatus was removed, moderate force was applied upwards in the long axis of the limbs, and failed to cause any shortening, and the boy was allowed to dispense with his crutches, the instrument being altered so that he used his feet in walking (Fig. 292). After two months there was not the slightest upward deflection of the tro- chanters. So far, then, tiiis case mav be considered satisfactory, and in about six months I intend to dispense altogether witii apparatus. Case 99. Double Cougenifal Duplarement nf hoth Hijjs, treated as in Case 98. — Mary Ann F , aged Sh years, came to me at the National Orthopaedic Hospital on 6th December 1893. Her appearance then is seen in Figs. 286, 287. The sj'mptoms were similar to those in Case 98, except that the displacement above Nelaton's line was 2 inches on the right side and 2^^ inches on the left, and the displacement was not dorsal but pubic,^ and there was some tension of the adductor nuiscles. She was treated by continuous recumbency and extension, with the limbs some- what abducted, for two years. In Jarniary 1896 the heads of the femora were almost fixed, and it would have required a strong pull to draw the limbs downwards h inch, and more so on the left than on the right. She left the hospital wearing the extension -apparatus and walking on crutches. I do not claim that these cases are cured, but so far there is every indication of it, and I shall take an opportunity of reporting their condition two years after they have cea.sed to wear any apparatus. It is evident that treatment on these lines is tedious to a degree, and difficult to carry out, and some parents will strongly object to ' Phelps, Trans. Ariicr. Orth. Assoc, vol. iv. p. 1.32, quotes a case of Ridlon's, and gives two of his own of forward dislocation. CHAP. II CONGENITAL DISPLACEMENTS (DISLOCATIONS) 541 it. lu such cases I liave, following Mr. Adams, carried out a mode of treatment which is a compromise, and in one instance with great success. The method is for the patient to wear an extension instru- ment with a cork sole on the boot of the sound limb by day, and to have a weight applied at night. The following is an example : — Case 100. Congenital Dis- placement of Left Hip. Treatment hy Means of a Walking App)aratus, and Extension at Night. — Ethel E , aged 4, was seen by me on 11th October 1893, in con- sultation with Dr. Herron. For the past two years it had been noticed that the child limped, halting on the left leg. There was no pain, either in standing or walking. Tlie birth was by the vertex. On examination, the movements of the leg were free in all directions, the head of the femur was displaced on to the pubes, the left leg was 1 inch shorter than the right, and the great trochanter was 1 inch above N6laton's line. It could be pulled down ^ inch by traction. Tiieie was scoliosis in the left lumbar and right dorsal region. She was ordered to wear one of Ernst's extension apparatus by day, and to have a weight of 2h pounds applied to the leg at night. In April 1894, with the instrument removed, the top of the great trochanter was | inch above Nelaton's line, and it could be pulled down so that the shorten- ing entirely disappeared. On 8th ^1^. 293.— Ernst's walking apparatus for uni- December 1894 the left leg was lateral congenital displacement of the hip. ^ inch shorter than the right, and the trochanter could not be displaced upward by any reasonable amount of force. She walked without any perceptible limp, and the scoliosis had entirely disappeared. This is the modification of Buckminster Brown's plan I should recommend in children under 4 years of age, when the method of 542 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. sec. v prolonged recumbency, described above, is impracticable.^ It is not to be wondered at, then, in vie\v of the length of treatment, the necessity of selecting cases in which the displacement is not excessive and in which the children are not too old, that surgeons have attacked the matter in other ways. 2. Forcible Ecdnction. — Paci has brought this method into prominence. Ijy his manoeuvres he does not claim to put the head into its normal position, but to make it descend into the neiglibour- hood, with the idea of securing a new joint in that situation, and thus relieving the patient of the shortening, lordosis, and waddling gait. Professor Post of Boston has tried this method, and both surgeons claim to have cured some cases. The nianamvres of Paci are as follows : — The patient is placed recumbent, and the surgeon flexes the leg fully on the thigh, and the thigh on the pelvis, thus carrying the head of the femur down- wards. The thigh is now abducted slightly (too much abduction may cause anterior displacement), and the limb is strongly rotated outwards,"^ and then extended fully. By the last-named movement the head is brought as near to the acetabulum as possible. As a rule an antesthetic should be given for this proceeding. Afterwards the limb is put up in silicate or plaster of Paris bandages for a month, followed by continuous extension for three months. Then walking may be commenced on crutches. It seems that this method of Paci's has commended itself to Professor Lorenz, one of the pioneers in the operative treatment of congenital" luxation. " After much thought and careful observation of the cases operated on, Lorenz resolved to alter his treatment in 1895, and since that time has treated thirteen cases with perfect success and witliout 1 With the idea of exciting the formation of a bony growth at the spot where the head of the femur rests in recumbency, Laniielongue {La Scmaine Med. 1891, p. 510) injects a few drops of 10 per cent solution of cliloride of zinc. In a child of 3 years he made eight punctures, and in each deposited two drops of the solution. Three weeks later he deposited twenty drops, and he states that five weeks from the first injection there was a bony growth apparent below the crest of the ilium and above the great trochanter. The result appeared to be good, and it was reported to the Congress of Surgeons iu 1891 as a cure. Coudray {Bull, et Mei/wircs de la Soc. de Chir. Paris, 1891, xvii. p. 770) reports the cure of a case treated by Paci's method, injections of chloride of zinc solution, and continuous extension for live months. Jewell {Ann. d'Orthopedic, December 1893) reports three cases treated by these injections, repeated from two to live times. Tw'o were cured, one of them a bilateral displacement. (Quoted from an article by T. Halsted Myers on "Congenital Dislocations of Hip," Ann. Surg. Aug. 1894). - If the displacement be anterior, the limb should be adducted and rotated inwards. CONGENITAL DISPLACEMENTS (DISLOCATIONS) 543 cutting." -^ Lorenz states, however, that the bloodless reposition is unsuitable in cases where the child has been allowed to continue to walk untreated till the seventh or eighth year, and the rudimentary acetabulum has become effaced. Paci has by his method achieved success in ten of eleven cases, and Eedard ^ in three of five cases. 3. Operative Treatment. — This mode of treatment is at the present time (March 1S96) still on trial, and it is difficult to express any decided opinion about it, as we wait to be convinced that, even with the most recent and improved forms, the removal of the deformity is complete and permanent, since sufficient time has not yet elapsed. Many forms of operation have been practised, and their aim seems to be naturally either to diminish the size of the caput femoris so as to make it fit the deformed acetabulum, or to increase the size and depth of the latter so as to make it receive the head. Among the earlier operations is that of decapitation of the femur, which ]\Iargary proposed after an unhappy attempt to form a new acetabulum. Margary's efforts have been imitated by numerous surgeons, viz. Motta, Vincent of Lyons, and Ogston,^ but I fail to find any examples of permanent success by these means. The last- named surgeon has proposed and carried out a method in which the head of the femur is removed by a horizontal section through the neck, and a wedge-shaped piece cut out of the os innomiuatum at the site of the acetabulum, with the intent that the femur may fix into the mortice thus left. The futility of such an idea is at once apparent, as is show^n by reference to the diagrams accompanying his paper. At the present day the operations which command attention are Hoffa's method and Lorenz' modification. Hoffa's Operation} — The joint is opened by Langenbeck's, or ^ Med. Press and Circ. 19tli Feb. 1896, p. 191 ; aud here the details of Lorenz' most recent procedure are given. "^ Op. sup. cit, p. 528. " Annals of Surgery, vol. viii. p. 161. '^ See Anncds of Surgery, vol. xii. p. 463, and articles by E. H. Bradford, also by T. Halsted Myers, Annals of Surgery, Aug. 1895. From Dr. Myers' article many of the points dealing with Hoffa's operation are taken. In the Med. Week, 27th April 1894, p. 194, is an account of an autopsy in one of Hoffa's cases, which died from diphtheria six months after operation, together with a discussion on the subject. Hoffa states that the autopsy showed that the result of the operation was the formation of a completely new acetabulum, the articular surfaces being everywhere covered by hyaline cartilage, as was seen by microscopical observation. The cotyloid cavity was deep, furnishing a good support for the head of the femur, and everywhere perfectly invested 544 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. sec. v the posterior incision, and the capsule is divided at its insertion with the neck of the femur. Tlieu the muscles are peeled from the great trochanter by a periosteal elevator. Hofta finds that in children under 5 years of age it is almost always possible by flexion of the thigh and direct pressure upon the head to bring it into the old aceta1)ulum,^ and there is no need to deepen the latter. When the head of the femur is replaced, the hip and knee are often seen to be flexed. This is overcome by holding the head firmly in the acetabulum while an assistant gradually extends the leg on the thigh, so stretching the muscles attached to the tubera ischii. In children of G years and upwards, Hoffa divides the last- named muscles before opening the joint (on Lorenz' recommenda- tion). The limb is now abducted, and the adductors subcutaueously divided. It is then hyper-extended, and the soft parts attached to the anterior superior spine of the ilium, and the fascia lata divided by the open method to better control the hiemorrhage. The joint is now opened and the head freed so completely that it can be brought out of the wound. The ligamentum teres is now extirpated. The acetabulum is deepened and broadened by using a bayonet- sliaped Volkmann's spoon ; and its cartilage, fat, and a good portion of spongy tissue scraped out, but the margins of the cavity are pre- served as much as possible. Eeduction of the head is now possible. Hoffa puts the limb afterwards in moderate inversion to prevent the escape of the head from its new position, and after a few weeks brings it into its normal position. Care is taken to keep the limb abducted and extended. The first fixation dressing is kept on four to five weeks, and the massage and careful passive motion are carried out. After that time the child can stand and walk in an apparatus which allows motion at the hip, but prevents the head escaping from the acetabulum. This is worn for weeks or mouths " until the joint is fully consolidated.^ by cartilage. Further, it was obvious from the great tliickness of bone tliat a deep cavity can be formed without danger of perforation ; and even if perforation shoukl occur in the course of the operation, the consequences are not so bad as thej' have been alleged to be, but Kirinisson's two deaths in which perforation had occurred should be noted in this connection. ^ How ca:n this be so, if, as tlie pathological observations show on p. 52S, the triangular or oval acetabulum is too small to receive it .' - Surely a weak point in Hoffii's operation, since but little time is gained on the recumbency and extension method, and cure is by no means certain. ^ In the "Epitome of Current Med. Lit." B.M.J. 14th July 1895, p. 5, there is an abstract from an article of Hoffa's in the Berliner klin. JFochenschr. detailing the results of his operation. The results of 112 operations on 82 patients are given ; 30 of them CHAP. II CONGENITAL DISPLACEMENTS (DISLOCATIONS) 545 Lorenz' ^ Modifications of Hoffas OiJeration. — Loreuz states that liis operation comprises these stages : formation of a femoral head, which does not always exist, reduction of the head of the femur, enlargement of the cotyloid cavity, and fixation of the head into the cotyloid cavity. He rejects Hoffa's opinion that the muscles inserted into the greater and less trochanters are shortened, and states that they are actually lengthened. Lorenz, therefore, does not sever them. The parts which are shortened are the outer part of the fascia lata, some bundles of the adductor magnus, the sartorius, and the hamstrings. The details of Lorenz' operation are division of the tensor vaginae femoris through a longitudinal incision starting from the anterior superior spine of the ilium, and to the first incision is added another, passing transversely inwards at the level of the trochanter. The anterior wall of the capsule is then denuded, and the capsule opened by a crucial incision.^ The acetabulum is hollowed out, and the head of the femur re-formed, if necessary. After which it only remains to pull on the latter until it is brought down to a level with the cotyloid cavity. Much assistance is now afforded by the section of the hamstrings. Lastly, the limb is put up in a position of slight abduction. In four weeks' time massage and gymnastic exercises are begun, and these must be continued for a year. The advantages of this opera- tion consist in causing but comparatively little interference with the muscles. Lorenz has operated on sixty-three children, and in some cases thus treated eighteen months ago, " the result obtained is really brilliant," it being impossible to detect the slightest trace of the dislocation which formerly existed. Comparing the two forms of operation, one unhesitatingly prefers Lorenz' method when one decides to operate. The severity of Hoffa's operation is very great ; it is almost amputation at the hip-joint, with the femoral artery and vein, the anterior crural and the sciatic nerves alone left intact. Personally I may add that I had bilateral and 53 unilateral displacements. Death occurred in 3 cases, being due in 2 of them to prolonged anesthesia, htemorrhage, and shock, and in the third to iodoform poisoning. In 9 cases, ankylosis of the hip followed, and return of the luxation in 11. These statistics, in view of the severity of the operation, are not encouraging. 1 Centralhl. f. Cliir. Aug. 1892; Ann. Surg. vol. xvi. p. 582: Brit. Med. Journ. Sept. 1892; ibid. 6th June, 1893; Wien. med. Presse, No. 11, 1892; 3fod. Week, 13th April 1894 ; Annals of Surgery, Aug. 1894. - Bradford insists upon the necessity of free division of the Y-ligament of Bigelow in these cases. Annals of Surgery, Aug. 1894. 2 N 546 ANKYLOSIS, COXGEXITAL DISPLACEMENTS, ETC. should Strongly dissuade a patient ^vitll congenital displacement from being subjected to Hofta's procedure, because — 1. The Danger. — Dr. Halsted Myers ^ states that he has notes of 177 cases of Hofta's operation or some of its modification, and among these are six - deaths due directly to operation." To these may be added one that Lorenz mentions as having occurred from septicaemia, and Kirmisson states that he " knows of a few fatal cases in the hands of other surgeons, which lie is not authorised to mention." ^ And if all the cases which have been operated on by Fig. 294.— Thomas' hip-splint. Fig. 295. — Thomas' hip -splint applied. The patteu ou the left foot is uot very clearly shown. this method were reported, it is certain that other deaths will be found to have occurred. 2. Tlie Prolability of Cure. — Hoffa himself states that he wishes it to be distinctly understood that these children cannot be com- pletely cured, since there is always left some shortening of the limb. In bilateral cases, however, he can reduce the w^addling gait to a minimum, and can almost completely overcome the lordosis. '^ Loc. sup. cit. - Bradford and Lovett, loc. svp. cit. mention another. ^ Viz. 3 of Hoffa's, 2 of Kirmisson's, 1 from ha-morrhage and peritonitis eight days after the operation, following perforation of the acetabulum, and 1 from septicfemia, following perforation of the acetabulum, and 1 of Broca's. ^ Bradford and Lovett, loc. si(p. cit. p. 130. CHAP. II COXGENITAL DISPLACEMENTS (DISLOCATIONS) 547 These points have made most surgeons discountenance operations of such severity, and even Lorenz, the originator of a much less severe form of operation, has, " after much thought and careful obser- vation of the cases he has operated on, resolved to alter his procedure in 1895 in some cases, and has carried out bloodless reduction in thirteen cases with perfect success and without cutting." To sum up the Treatment. — 1. Of the non-operative methods of treatment, it seems that Paci's is the best, and should undoubtedly be tried in the first place.-^ The great advantage of this method is the immediate reduction of the displacement in the sense that the head is placed either on or in the acetabulum, while the traumatism caused by the movements may give rise to inflammatory exudation, which fixes the head of the bone. It is essential that sufficient rest, extension, and support to the limb should be given for some months afterwards. 2. The well-tried method of complete recumbency, extension and abduction for a period of many months, should not be abandoned. It is of special value in children under 2 years, and may effect a cure. In older cases the symptoms are much improved. The chief objection to it are its duration, tedium, and the possibility of dis- appointment, owiug to recurrence of the deformity at a later period in some instances. 3. As a compromise, in slight cases with not more than ^ inch shortening in young children, the use of an extension-apparatus for walking, and pads over the trochanter, with traction by weights at night, is often very effective (cf. Case 100). 4. Operative measures cannot be necessary if the displacement is recognised early. In cases which have gone untreated for several years, when the bloodless methods have been tried and failed, and an operation is demanded, the best form is that of Lorenz, but surgical intervention can never be regarded as a routine method of treatment. If it is undertaken, the following points, excellently summarised by Eedard, must be clearly put before the patient : — {a) The number of perfect cures by operation is small. (&) Cases are, however, frequently much improved, (c) Lameness persists to a slight degree, and the limb remains more or less shortened. (rf) The formation of a complete new joint is very rare. 1 He reports fifteen cases, which are almost perfect a year or more after operation. They have been examined by many surgeons, wlio liave expressed themselves as greatly pleased with the results {ArcMvio cli OrtopecUa, Anno IX. No. 6, and Anno X. No. 1). 548 ANKYLOSIS, CONGEXITAL DISPLACEMENTS, ETC. sec. v (c) The lordosis is generally corrected. (/) The danger of operating by Hoffa's method is considerable, and complete cure is problematical. Other Congenital Displacements^ Of the Loiccr Jaic. — Imperfect development of the jaw with partial displacement has been seen. Frequently some other con- genital deformity is present, such as the persistence of the brancliial clefts, malformations of the ear, macrostoma, etc. A double dis- placement forwards and another backwards have been described. Of the Spine. — In monstrosities the cranium is sometimes seen to be displaced forwards or backwards on the vertebral column. Of the Joints of the Upper Extreviity. — The clavicle has been seen congenitally displaced at both extremities (Guerin). The shoulder ^ : the head of the humerus may be displaced forwards or backwards on the scapula. I have met with an example of the latter condition at the Evelina Hospital. Occasionally a downward displacement is seen, sub-gienoid. The elbow : both bones may be displaced backwards, or the head of the radius forwards or backwards. The wrist: in club-hand there are met with anterior, posterior, inward and outward displacements at the wrist. The fingers : Chaussier instances a fcetus in which the outer three fingers were displaced at the metacarpo-phalangeal articulation.^ Of the Loiucr Extremity. — The hip : the description of the forms is set forth in the preceding pages. The knee : a forward displace- ment partial or complete is met with, associated with congenital talipes varus and valgus. Hibon ^ collected 1 1 cases. The patella : this is generally outwards, and is partial or complete.^ Bajardi describes a case in which the patella was partially displaced outwards on the right, and completely on the left side. He had collected 34 other cases.® The ankle : complete luxations are very rare. The partial displacements are seen in congenital club-foot. ^ Vide the treatise of Kronlein in the Deutsche Chirurgie. - Cf. M. Smith, Dublin Journ. of Med. Science, 1839 ; and Stirason, Treatise on Dis- locations, p; 107. 3 Cf. also Berard, Diet, de Med. Art. "iJain," voL xviii. * "Luxation du tibia en avant," These de Paris, 1881. 5 Bajardi, Archiv. di Ortoped. Ann. XL vol. iv. •^ Sclion {Ucjcskrift for Laeger, 17th Nov. 189-3) reports a case of congenital dislocation of the left patella. The patient's mother and one sister had similar deformities. CHAPTER III DEFORMITIES ARISING FROM CEREBRAL AND SPINAL PARALYSES Cerebral Paralysis in Children — Causes — Sijmptoms, Earhj and Late — Diagnosis — Deformities and their Treatment — Spinal Paralysis in Children — Infantile Paralysis — Deformities of Arms, Trunk, and Legs — Paralytic Dislocations — Treatment by Mechanical and Operative Measures — Arthrodesis — Other Spinal Paralyses of Children. Cerebeal Paralysis in Children Under this somewhat vague term are included two conditions : — Infantile Hemiplegia. Spastic Paralysis. And associated with them is frequently an idiotic condition both of mind and muscle. Osier ^ has stated the causes of infantile hemiplegia to be — 1. Haemorrhage occurring during violent convulsions, or in the course of whooping-cough/ or at birth (meningeal), and due to pressure of the forceps, also meningeal htemorrhage following a fall. 2. Post-febrile processes resulting in embolism,^ endo- and peri- arterial changes and encephalitis. 3. Thrombosis of cerebral veins.'^ To these might be added microcephalus, which is so frequently found associated with defective and abnormal development of the brain. A case of this latter description has been under my care at the Evelina Hospital, partly as an in- and partly as an out-patient since 1893. I performed linear craniectomy on him in 1894, but with no relief to the hemiplegia, and no improvement in the mental 1 FMlad. Med. News, 11th Aug. 1888, p. 143. ^ ^gs^_ j/gf^_ p^.^g^ ^^^^^ qi^.^^ 1887. ^ Landouz}' and Soredey, Rev. de Med. 1885. * Gowers and Handford, Brit. Med. Joiorn. 1887, vol. i. p. 1098. 550 ANKYLOSIS, COXGEXITAL DISPLACEMENTS, ETC. sec. v condition, which has remained idiotic. Of three other cases on which I performed craniectomy, two were in no wise benefitted, and one died a week after operation, and 'post-mortem there was found sclerosis of the whole left cerebral hemisphere, with great dilatation of the ventricular cavity, and a large abnormal fissure ex- tending obliquely through the cortex into the lateral ventricle. The date of onset varies. In some cases hemiplegia exists from birth, and it is then due to mal-development of the brain, asphyxia neonatorum, or trauma in deliver}- ;. in others it commences at the age of 5 or 6 years, and in a third class at the time of the second dentition. Symptoms. — Early. — 1. Convulsions frequently usher in the di.sea.se, either after a blow on the head or a fall, or in the course of an acute illness, or with whooping-cough. 2. The paralysis is unilateral. The face is paralysed on one side, but the orbicularis palpebrarum usually escapes. Strabismus, often external, is very frequent. The arm suffers more than the leg. As a rule the facial paralysis disappears first, and in most instances completely. The arm remains more completely and permanently affected than the leg. 3. Sensation on the affected side is as a rule unimpaired. 4. Aphasia is commonly seen at the beginning, but is often temporary. 5. The reflexes are generally exaggerated. 6. Unilateral sweating has been seen during an attack. Late. — 1. Eigidity of the limbs sets in at an uncertain period after the attack, and varies in degree. It is sometimes so extreme that it is not possible to obtain any reflex contraction of the muscles. It disappears during sleep and under an anaesthetic, but is in- creased on any effort being made to overcome it. In rare cases the limbs remain completely paralysed and limp. 2. Athetosis or spurious chorea develops after a time in a pro- portion of the cases. 3. The mental powers are defective. This is not so in all cases, many of these patients being quite up to the ordinary standard of intelligence. 4. The affected limbs become wasted, blue and cold. They are frequently shorter and more slender than natural, owing to delayed development of the bones. 5. Deformities of a most persistent and intractable nature ensue. The arm is, as stated above, more affected than the leg. CHAP. Ill DEFORMITIES FROM CEREBRAL AND SPIXAL PARALYSES 551 The position assumed by the arm is quite typical. In this member flexion predominates. The shoulder is sometimes raised, and sometimes lowered. The upper arm is generally kept parallel with the trunk, or is a little advanced and adducted by the contracted pectoralis major. The forearm is flexed at a right angle, and is generally in apposition with the lower part of the chest or upper part of the abdomen. It is almost invariably pronated, very rarely supinated. This pronation of the forearm is most difficult to diminish. It is the position which in slight cases is the first to become fixed in the forearm, and is the last to yield to treatment. The wrist is also strongly flexed and the hand is adducted. The thumb is adducted and flexed into the palm. The fingers are firmly contracted. The leg is in a condition of extension and the foot assumes a talipedic form, either equinus or equino-varus. In one case of infantile cerebral paralysis which came under my notice, both thighs were somewhat flexed and adducted, both knees were bent at an acute angle, and the feet were in a position of equinus. By suit- able tenotomy, fasciotomy, and the use of extension apparatus, the deformity was completely overcome, so that the girl was ultimately able to walk well. 6. The Mode of Walking. — The heel is raised and the foot is lifted from the ground with dilficulty. The toes scrape along the floor. Diagnosis. — The following conditions should be carefully eliminated : — 1. Paralysis arising during delivery or obstetrical paralysis. As a rule this is limited to single nerve-trunks, e.g. paralysis of the facial nerve due to pressure of the forceps, or injury of the brachial plexus arising in delivery of " arm-posterior presentations." 2. From spastic paralysis the result of primary lateral sclerosis. There is no doubt that cases of spastic paralysis in both legs do occur in which there are no cerebral symptoms present, but ex- amination of these cases shows no lesion in the spinal cord. 3. From certain forms of congenital contracture (p. 511) in which no nerve-lesions are present. Prognosis. — When deformities have occurred the prognosis, so far as they are concerned, is far from favourable. In some instances the spastic condition improves, but by that time the affected limbs have become stunted and dwarfed, and fixed in various positions. On these grounds parents should be warned that 552 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. sec. v no great improvement is likely to take place if the spastic condition when first seen is at all well marked. If athetosis, mental de- ficiency, or epilepsy be present, then the ontlook is decidedly bad, in so far as the dnration of life, usefulness of the patient, and correction of the deformity are concerned. Treatment. — Every eftbrt must be made, if the case is seen early, to prevent the onset of deformity. Yov this purpose the limbs shovild be "well rubbed and manipulated, and passive move- ments of the joints of the affected parts freely carried out in all directions. The patient should also be well drilled, and taught, so far as the mental condition will permit, to use the affected limbs as much as possible. For instance, in hemiplegic contraction of the arm it has been found advantageous to tie up the unaffected arm, and to insist upon the hemiplegic arm being used. In the case of the leg, every encouragement by precept and practice should be given, so that the affected limb may be used in walking ; and passive movements of the hip, knee, and ankle carried out, especially abduction of the hip, extension of the knee, and dorsi- flexion of the ankle. ]\Iuch improvement may be expected in slighter cases. With reference to the use of retention-apparatus, my experience is that directly they are removed the spasm returns. As to operative measures, I have found it to be absolutely useless to divide the tendons of the rigid muscles in the upper extremity. I have performed section of tlie biceps, flexor carpi radialis, pronator radii teres, and of all the flexor tendons of the wrist at one sitting without any permanent benefit. In the lower extremity the results have been less disappointing. In one case the adductors of the thighs, the hamstrings, and the tendo Achillis were divided, with permanent benefit to the patient so far as locomotion was concerned. The point, I take it, is this : Walking is impossible not so much on account of the loss of muscular power, but because of the abnormal position of the parts, the patient being unable to plant the foot on the ground as the heel is so much raised. Similarly, the adductor spasm prevents free movement. If by section of appropriate tendons the malpositions can be rectified, then the locomotion is much improved, and in some instances becomes moderately good, if care be taken to keep the limbs in normal ]iosition for several months afterwards.^ ^ Of. Gibney on the "Treatment of Spastic Paralj'sis," Amcr. Journal of Nervous and Mental Disease, Aug. 1890. CHAP. Ill DEFOE:\nTIES FEO:\r CEEEBEAL AXD SEIXAL EAEALYSES 553 Spiral Paealysis ix Childeex Acute Anterior Polio-Myelitis or Infantile Paralysis. — On this subject much has been written in dealing with paralytic club- foot, and it is not necessary here to go freely into detail concerning the causation, onset, and diagnosis of the disease, but rather to deal with some varieties of deformity which have not been treated of in previous chapters. It is sufficient to say that the disease presents three stages : («) an acute stage, characterised by febrile symptoms Fig. 296. — Infantile paralysis of the lo-wer part of the trapezius and of the serratus magnus (H. H., aged 11 years). and the development of paralysis : (h) a period of convalescence, which commences when the paralysis is at its height, and from which a partial recovery of the affected limb or limbs dates ; (c) a period when deformity sets in, which arises from two conditions — paralysis and atrophy of the muscles, and atrophy and shortening of the bones. The nature of the affection is peculiar in that it is very selective in its effect on the muscles. Xot only are groups of muscles paralysed, but individual muscles, and even separate fibres, are, as it were, picked out.^ ^ Cases of acute anterior polio- myelitis are liable from time to time to distressing attacks of vomiting, independently of any recognisable cause, and lasting two or three days at a time. The son of a medical friend was an instance of this. 554 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. sec. v As a rule, the muscles of the terminal portion of the extremities are more paralysed than those nearer the trunk, and the legs more than the arms. In the upper extremity the deltoid is often paralysed either alone or with other muscles. But the distribution of the paralysis maybe very unequal; thus in a case (Fig. 296) which came to me at the Xational Orthopedic Hospital, the whole serratus magnus and the lower part of the trapezius below the spine of the scapula and deltoid were paralysed, while the teres major and minor had escaped ; the scapula was seen to have undergone considerable displacement. In the leg, the extensors of the toes and the peronei suffer more than the flexors and the adductors of the foot. The muscles of the face are almost invariably imaffected, while those of the trunk are occasionally involved. Thus lateral curvature sometimes arises from unilateral paralysis of the erector spinte. When the abdominal muscles are involved, the lordosis is extreme, and the trunk appears to be falling backwards. The onset of deformity is from four to six months after the ap- pearance of the purely nervous symptoms, but is occasionally more ra]3id. It is during this interval that every effort should be made, by suitable splints or mechanical apparatus, with attention to posture, to prevent deformity. As to the immediate causation of deformity, it is found in partial paralysis of a limb, due to the more powerful action of unopposed muscles and to the eff'ect of position. Deformities of the Arms.- — It is rare for the whole upper ex- tremity to be paralysed. As stated above, the deltoid is generally affected, and there results, not infrequently, a paralytic subluxa- tion at the shoulder-joint, with loss of roundness there. Such a case I have met, in which it appeared that there were at least 1^ inches between the articular surfaces, and the head of the humerus could be made to assume any of the forms described in traumatic dislocation. Earely, as in the " forearm type " of Eemak, the ex- tensor muscles are paralysed, while the supinator longus escapes. Wrist -drop then results. Occasionally the adductor muscles of the thumb are affected. Deformities of the Trunl-. — These are scoliosis, kyphosis, and lordosis of paralytic origin. As a result of inequality of the lower limbs, the pelvis is frequently tilted, and static scoliosis results. Deformities of the Lower Extremities. — When the whole limb is affected, it is small, cold, bluish, perfectly limp, and swings like a flail in all directions with the patient's movements (Jaml^e de jjolichinelle — Charcot). The joints are lax, and the segments of the CHAP. Ill DEFOKMITIES FROM CEREBRAL AXD SPIXAL PARALYSES 555 limb may be caused to assume almost any position. There is, how- ever, one important point worthy of notice. In those instances in which at first sight it appears as if all the functions of the part were entirely lost, careful examination of the muscles of the hip shows tliat the psoas and iliacus have escaped either partially or entirely, and that some flexion is left. It is important to be aware of this, for so loncj as some power is left in these muscles, the patient can be made to walk by the aid of instruments after deformities lower down in the limb have been rectified. In partial paralysis of the limb the antero-internal muscles of the thigh are the most severely affected, and extension of the leg upon the thigh is lost. "With this condition there is fre- C[uently considerable abduc- tion of the tliighs and lordosis. The knee is flexed more or less, and later on, if the hamstring muscles are not involved, contracture of them takes place with subluxation backwards. If the hamstrings, however, are paralysed, or when the .' ligaments of the knee give, the latter becomes hyper- extended, and one form of fig. 297 genu recurvatum results. In old-standing cases there are outward rotation of the tibia and eversion of the foot. The deformities of the foot have been fully considered in the chapters on talipes. Parahftic SvMuxations in the Lovjer Zimh. — These occur at the hip, knee, and ankle. The Hijx — They have been studied by Yerneuil, Eeclus, and Infantile spinal paralysis of tlie lower extremities Tvitli mtiltiple deformities (after Eedard). 556 AXKYLOSIS, CONGEXITAL DISPLACEMEXTS, ETC. Karewski.^ The forms are anterior and posterior dislocation, more usually the latter. Associated with the displacements is paralysis of the o'luteal and thio-h muscles. The war in which the disloca- tions come about is as follows : — In the case of the dorsal form, the gluteal and peri-trochanteric muscles being paralysed, the support which they naturally give to the capsular ligament is withdrawn, and further the head of the femur is gradually pushed out of place by the tonic action of the adductors until it rests against the upper and posterior part of the cap- sule. This gradually yields, and finally the caput femoris lies on the dorsum ilii. In the case of the anterior disloca- tions, the adductors and the psoas are paralysed, so that the glutei and peri-trochanteric muscles gradually push the head out of place. In dorsal displacements the lower extremity becomes fixed in the position of adduc- tion and inversion, and external rotation and ab- duction are impossible, reverse obtains. If the Fig. 298. — Infantile paralysis with genu recurvatnni, anil talipes varus on tlie lelt side (Mary D . aged 16 years). In anterior or pubic dislocations the displacement is recent, the head may be replaced, but it is difficult to do so in old-standing cases. But under an anaesthetic replace- ment is often possible, and the difficulty then arises of keeping the head in its proper position.^ ^ Drutsche med. TFochenschr. Xo. 6, 1889, and Annals of Surgery, vol. x. p. 226. He gives two very interesting cases ; one was sub-pubic and the other was on the ramus of the pubes. In the second case, after section of the muscles attached to the trochanter major and incision of the capsule, the head of the femur could be replaced in the acetabulum. - Cf. a case of Bradford and Lovett's, oiJ. cit. pp. 552, 553. A figure, Xo. 565, is given of this ca.se in their work on Orthopedic Surgery. CHAP. Ill DEFORMITIES FROM CEREBRAL AND SPINAL PARALYSES 557 As stated in writing on congenital displacement of the hip, difficulty may arise in distinguishing it from paralytic displacement, but the differential signs are given on p. 535. The Knee is subluxated backwards, so that the tibia moves in a plane posterior to that of the femur. The Ankle. — Various subluxations are seen, viz. forwards with talipes equinus, backwards with calcaneus, inwards and outwards with varus and valgus. The Treatment of Paralytic Deformities.^ — In the first place, every effort should be made from the time of onset of the paralysis to retain the limbs in as nearly normal a position as possible, parti- cular attention being given to the fact that the feet do not assume the equinus position. Electrical stimulation of the nmscles, friction and massage should be assiduously persevered with. The active treatment of these deformities must be of two kinds, mechanical and operative. The object of mechanical treatment is twofold : — "1. To support and protect the paralysed limb in such a way that the muscles shall work to the best advantage, and that the joints are supported and controlled. By doing this the occur- rence of contraction-deformities is prevented, and the nutrition of the limb is kept in the best possible condition by enabling the limb to be used in a comparatively normal way. " 2. To overcome by means of suitable apparatus deformities which have already occurred, and to prevent their recurrence " (Bradford and Lovett). In order to make the mechanical treatment clear, it will be well to arrange the details under the following heads : {a) Paralysis below the knee, (h) Paralysis below the hip. (c) Paralysis in- volving the pelvis and parts below. In paralytic cases no instru- ment should be fitted until all distortions have been corrected by tenotomy, and a cork sole is nearly always required on account of the shortening. {a) Mechanical Treatment in Paralysis heloiv the Knee. — The most usual forms are talipes equinus and calcaneus. In talipes equinus the lost power of the extensor muscles may be replaced by a toe- uplifting spring, so that in such cases the apparatus which is to be ordered is the following, a walking : apparatus, double {i.e. with steel supports on the inner and outer side of the leg), from ground to calf, with toe-uplifting spring and three-quarter " stop " at ankle- joint. But inasmuch as some degree of varus or valgus is frequently 558 AXKYLOSIS, COXGEXITAL DISPLACEMENTS, ETC. present, it will be necessaiy to add a varus or valgus T-strap, and if much valgus exist, a valgus pad. Eectangular tin -shoes for night-M'ear should be ordered. In the case of calcaneus, the appar- atus extends from the ground to the calf, has a toe-depressing spring, and a small accumulator passing from the garter-piece above to the heel below, so as to prevent the latter coming into contact with the Fig. 299. — Apparatus for complete paralysis ot the lower extremities. ground too soon. A half " stop " at the anhle-joint is desirable. The tin-shoe should be put on at night, and care must be taken that the sole of the foot is placed in the shoe as Hat as possible. (h) Paralysis Mou: the Hij). — The instruments just mentioned should be extended to the upper part of the thigh on either side of the limb. They should be fitted with a double knee-cap and ring- catch joint at the knee. The object of the latter is to make the apparatus rigid from the hip to ankle in walking, while in sitting it can be slipped up so as to allow of flexion at the knee. CHAP. Ill DEFORMITIES FROM CEREBRAL AND SPINAL PARALYSES 559 If there is much tendency to inversion or eversion, it is always better to carry the apparatus up to the pelvis by a continuation of the outside steel support to a pelvic band. A joint is made opposite the hip. (c) From the Pelvis cloivnvjard. — The instrument which is of most service in these cases has the following technical description if applied to both sides : a walking instrument for both legs, double from ground to thigh, single to pelvis, movable joint at hip, double knee-caps, ring-catch joint at knee, with toe-elevating or toe- depressing spring according as equinus or calcaneus is present, and with varus T-strap or valgus T-strap and pad, according as varus or valgus are combined with equinus or calcaneus (Fig. 299). So long as the ilio-2JSoas muscle retains part or all of its 'poimr, i.e. so long as some flexion at the hip is present, good results from the use of this instrument may be expected. To give an example, a case came under my observation of almost total paralysis of both limbs with double talipes equino-varus, contraction at both knees and hips, but with power left in both the psoas muscles. The child could merely go along on its gluteal region and hands, but some power of contraction remained in the ilio-psoas. By suitable tenotomies the limbs were unfolded from below upwards, and w^ere made parallel. The apparatus described under heading (c) was applied, and so much power returned to the limb that the child was able to walk, supported by the apparatus but without crutches, for two miles. In the case of paralytic dislocation at the hip, the head of the femur must be drawn into its proper place by weight-extension in the recumbent position, and the vicious position of the thigh corrected by traction. The improvement so gained can be maintained by the use of a leather splint or poroplastic spica, the child being allowed to go about on crutches. After a time a walking apparatus with a joint at the hip may be ordered. Operative Treatment. — There are the following : — Tenotomy and Fasciotomj^ Osteotomy. Arthrodesis. With reference to tenotomy, in the case of paralytic affections of the knee and ankle, the manner of section has been fully described in the preceding chapters, and it is not necessary to reiterate it. In the case of the hip, the section may require to be very extensive and deep, even including part of the capsule of the joint. It is 560 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. sec. v always better then to perform open section, as difficulty may arise from hiemorrhage. In some cases it is not possible to reduce all the deformity by operation at one sitting, on account of the great tension on the vessels and nerves. It is better in this case to be content at first with partial reposition, and to apply extension by weights for a time, and then proceed again with the division. Osteotomy. — When there is extreme fiexion at the hip, and the section of the soft tissues must necessarily be very deep and ex- tensive, it is better to perform Gant's operation of sub-trochanteric osteotomy. In some cases of paralytic knock-knee, osteotomy may be required. Arthrodesis. — This term is defined as an operation designed to fix a joint in a paralytic case. The object of it is ankylosis, either fibrous or osseous. The latter condition is obtained by com- plete removal of the articular cartilages. The history of the operation is recent. It was first performed by Albert of Vienna, on 20th July 1878, although his claim to priority is disputed by von Lesser. Subsequently Winiwarter, Eied, Ewinger, Eeyhier, Wolff, Kirmisson, Rochard, and Eobert Jones have done the operation. At the International Medical Congress at Berlin in 1880 the subject was discussed by Petersen, Lesser, and Bessel- Hagen, wdio proposed various methods. Arthrodesis is performed either on the ankle or knee - joint, generally the former. Indications for Arthrodesis. — 1. When the paralytic condition is very severe. 2. In poor patients who are unable to provide themselves with apparatus. 3. When the wearing of an apparatus is badly tolerated and causes pressure sores. 4. It should never be done in spastic cases ; nor in paralytic cases after acute febrile disorders, as paralysis, secondary to zymotic diseases, shows a strong tendency to recovery. 5. When two joints in a limb are hopelessly flail - like, it is advisable to fix one or both of them. Method. — At the ankle. Considerable difference of opinion exists as to the most convenient incision, whether it should be anterior, posterior, internal, or external. But the consensus is in favour of the external incision as for excision of the ankle. Against the anterior incision there are urged : the section of the artery, depriva- tion of a foot of a part of its scanty supply of blood, and the CHAP. Ill DEFOE]*IITIES FROM CEEEBRAL AND SPIXAL PARALYSES 561 difficulty of getting the tendons to unite satisfactorily. The joint should be freely opened, and all the articidar cartilage removed with a curette or sharp Volkmann's spoon, if osseous ankylosis be desired. It is not necessary to carefully dissect away the synovial membrane, since in those cases in which it has been left its presence has not interfered with tlie formation of bone, but no loose pieces -^ Fig. 300. I 1 "V Fig. 301. '^.j J Fig. 302. Three views of a flail-like ankle-joint, due to infantile paralysis and suitable for arthrodesis. of cartilage are to be left in the wound, and none attached to the bone-surfaces. The bones are fixed together by Albert and Zinsmeister with catgut or kangaroo tendon ; by Petersen with nickel needles ; by Karewski with ivory pegs. Albert and Zinsmeister have left plugs of iodoform gauze between the bone-surfaces, so as to excite suppura- tion. But Mr. Howard Marsh has shown that suppuration is not 2 562 ANKYLOSIS, CONGENITAL DISPLACEMENTS, ETC. sec. v always followed by bony ankylosis. It is better, if no plugs are .to be left in, to arrest all haemorrhage, and close the wound at once. In the case of the knee, the technique does not differ from that of an ordinary arthrectomy, care being taken, however, that all the cartilage is excised. As to results. In one of Albert's cases ankylosis followed after a few months. In "Winiwarter's, AVolff's, Lessor's, and Kydygier's the success has been complete. Eobert Jones has reported ^ fifteen cases in which he has ankylosed the knee or ankle. Considerable improvement in the use of the limb was noted in nearly all the cases. Various deformities are met with as the result of other spinal lesions ; thus there are cases of bilateral paralysis in which the legs are in a spastic condition, and unaccompanied by any cerebral symptoms or affections of the upper extremities. These seem to be analogous to the cases of primary spastic paraplegia met with in adults. In Ijoth instances section of the tendines Achillis enables the heels to be brought to the ground and the patient to walk with much more security than previously, and the same remark applies to pseudo-hypertrophic paralysis before the complete paralytic stage has set in. I had the privilege of assisting Mr. Adams at an operation on a man, aged 24, the subject of pseudo-hypertrophic paralysis, and the patient's powers of locomotion were much improved. Other spinal diseases such as cervical pachymeningitis, syphilitic myelitis, amyotrophic lateral sclerosis, Friedi-eich's disease, syringomyelia are associated with deformities which cannot unfortunately be remedied by orthopedic surgery. 1 Prov. Med. Jouni. Dec, 1894. BIBLIOGEAPHY OF AETHEODESIS Albert — Lehrhvxli der Chir. Bd. ii. s. 254. Beit rage z. Operat. Chir. 1888, Bd. ii. p. 88. Wiener med. Press, 1882, Xo. 23, p. 725. Centralblattf. Chir. 1881, No. 48, p. 766. " Falle von Kunstlicli. Ankylosis bild. An paral. Gliedmassen," Wien. med. Press, 1882, Xo. 23" Braatz — Internal. Congress, 1890. CocHOX — "Contrib. a I'etude d'arthrodese," TJtese, Lille, 1892. CoTTERELL — Lancet, 13th May 1893, "On Artlirodesis,'"' etc. Daraigxez — "Contrib. a I'etude d'arthrodese," J7ie.se, Bordeaux, 1891. Defoxtain'e — BuU. de la Soc. de Chir. 29 Mai 1889, p. 453, et Gaz. des hopitaux, 1891, No. 23. DEftCHAJiPS — "Arthrodese pour pied bot paral." Bull. Soc. Chir. 29 Mai 1889, et Gaz. des hop. 1889, No. 93. Dollixger — "Arthrodesis bei der Kinderlahmung," Centra.lhlatt f. CJrir. 1891, No. 36. EuLENBURG — " Paral. spin, subaigue avec relachm. paral. de Tartic. de I'epaule. Arthrodese," Berlin, klin. JVoch. .January 1890, No. 3. Edrixger — "Ein Beitrag z. Arth. paral. Gelenk. v. Muskel," Med. JFoch. 1889, No. 6. GiORDAXO — "Contrib. alia cura Artodesi," Arch, di Ortop. 1890, p. 22. Heussxer — Archiv f. Idin. Chir. t. xxxi. 1885, p. 66. HoFFA — Munch, med. Woch. February 1889. HoLTiiEiER — "Ueber Arthrodesis," Inaug. Dissert. Greifswald, 1888. Jalaguier — De V Arthrotomie, Paris, 1886. Jones (Robert) — " 15 Cases of Arthrodesis," Prov. Med. Journ. December 1894. Karew.ski — Soc. med. de Berlin, 1889, 20th November. "Ueber Operativ. an paral. Gelenk." Deutsche med. Woch. 1890, Nos. 4 and 5 ; Congress internal. Berlin, Section der Chir. Orthop. 1891. KiRirissox — " Lecons Clinicpies surlesmalad.de I'appareil locomoteur, 1889," Bull. Med. 189i, p. 601. Lampugxaxi — Centralhl. f. Cliir. 1886. Les-ser — Ibid. 1879, No. 31, and 1886, No. 46. /*^ LoREXZ — Allgem. med.. Zeitg. 1887, Nos. 12, 13, and 14. MoTTA — "Due casi di Artrodesi," Acad, di med. di Torin, 24th -April 1891. Riforraa med. 1st May 1891. Natraissox — Th. Doctor, de Paris, 1892. NicoLADOXi — Archiv f. Tdin. Cliir. t. xxvi. p. 488.- Petersex — Ibid. t. xxxvii. p. 235 ; Internal. Congress in Berlin, 1890. 564 BIBLIOGRAPHY OF ARTHRODESIS Phocas — Contj. ed-frame for spinal caries. 51 causes of distortion in flat-foot, 469 diagnosis of flat-foot, 475 duration of spinal caries, 45 experiments on scoliosis, 1 42 fatal wasliing out of abscess of hip, 64 forcible correction of wry-neck, 202 formation of new joint in cong. displ. of hip, 530 genu valgum, symptoms of, 277 glycosuria and Dupuytren's contraction, 242 hallux rigidus. 499 incidence of abscess in spinal caries, 16 osteoarthritis of spine, 93 paralytic dislocation of hip, 556 prognosis of compression-paraplegia, 70 prognosis of scoliosis, 158 round shoulders, 96 sloughing after wrenching, 434 splint for genu valgum. 281 suitable desk and chair for school use. 166 tight boots and weak ankles. 459 Broca, (?) arthritis in cong. displ. of hip, 524 death after Hofla's operation, 546 surface temperature in cong. wry -neck, 197 Brodhurst, B., rheumatoid anhritis of spine, 93 cong. tal. eqninos, 332 Brown, Buckrainster, cong. displ. of hip treated by recumbency, 536 Bruns, c-ases of coxa vara, 299 Buhring and HyrtL natural curves of spine, 87 BuUard, laminectomy, 71 INDEX 567 Bulley, Dupuytren's contraction, 232 Biirrell, laminectomy, 71 Buscli, jerk-tinger, 245 operation for Dupuytren's contraction, ■ 242 Butlin, H., caries of spine in the aged, 4 false ankylosis after fracture, 513 Camper and Severin, 3 Canton, cong. displ. of hip, 529 Carnochan, muscular contraction in displ. of hip, 524 Cautley, Dr. E., late rickets, 254 Charcot, dilatation of pupil in cervical caries, 34 hysterical scoliosis, 151 jamhe de iMlicliindle, 554 peroneal paralysis, 374 Chaussier, cong. displ. of fingers, 548 frec|uency of cong. displ. of hip, 523 Cheadle, scurvy-rickets, 254 use of foods in rickets, 255 Cherry, modification of Phelps' operation, 436 Chipault, infantile and adult spine, 88 laminectomy, 71 Clutton, cong. sterno- mastoid tumour or induration, 187 late rickets, 253 Cochon, arthrodesis, 563 Collier, Mayo, hallux rigidus, 499 ligation of spinal accessory nerve, 205 morbid anat. of hallux rigidus, 500 Collins, R. A., cong. absence of radii, 214 Collis, syphilitic disease of spine, 78 Coote, Holmes, cong. displ. of hip, 529 Cossy, 17 Cotterell, arthrodesis, 563 hallux rigidus and flat-foot, 500 Coudray, cong. displ. of hip, 530 injection of chloride of zinc in cong. displ. of hip, 542 Cruveilhier, interosseous space obliterated in cong. tal. equino-varus, 390 intra -uterine position and cong. tal. equino-varus, 392 natural curves of spine, 87 Daleine, infantile and adult spine, 88 Dana, metatarsalgia, 489 Daraignez, arthrodesis, 563 Davies-Colley, 70 anat. of hallux rigidus, 500 hallux rigidus, 499 Davies-Colley, removal of base of first phalanx for bunion, 498 tarsectomy, 443 Davj', extirpation of scaphoid for flat-foot, 485 improvements in treatment of equino- varus, 443 septicaemia after tarsectomy, 446 Defontaine, arthrodesis, 563 Delbet, mallet-finger, 248 Delens, osteoclasis, 283 Delore, manual rectification in genu valgum, 284 Demanke, pes planus in epileptics, 358 Dembowski, origin of uniting material in tendon, 318 Demons, osteoclasis, 283 Deschamps, arthrodesis, 563 Dittel, cong. rickets, 271 Dollinger, arthrodesis, 563 developmental causes in cong. displ. of hip, 525 premature ossification of Y-shaped car- tilage, 525 Drachman, age in caries of the spine, 4 frequency of cong. displ. of hip, 523 frequenc}' of scoliosis, 102 Drake-Brockman, polydactylism, 224 Druitt, Dupuytren's contraction, morbid anat., 237 Dubreuil, asymmetry of head in wry-neck, 194 reunion of tendon, 369 Duchenne, clawed toes, 337 griffe 2ned creiix, 353 paralysis of interossei, 352 pes cavus, 352 spastic tal. valgus, 363 Duncan, condition of spinal membranes in caries, 72 Dunlop, probable syphilitic disease of the spine, 78 Dunn, L. A., disease of cervical spine, 74 partial absence of fibula, 359 Duplay, late rickets, 254 Dupuytren, Dupuytren's contraction, morbid anat., 237 heredity of cong. displ. of hip, 526 Ebstein and Zuckerhandl, funnel-shaped sternum, 208 Edes, pain in malignant disease of spine, 81 Eulenburg, age of onset of scoliosis, 103 arthrodesis. 563 DEFORMITIES Eulenbnrg, sex in scoliosis, 103 Euiinger, arthrodesis, 563 Eve, F. S. , spinal caries without suppura- tion, 11 Ewens, tarsectomy, 443 Fagge, Hilton, kinking of aorta in spinal caries, 15 Fayrer, J., rupture of popliteal artery in straightening knee, 518 Felicki, jerk-finger, 245 Fere, C, pes planus in epileptics, 358 Fisher, F. R., bed-frame, 163 bed-frame for spinal caries, 52 causes of failure in treatment of severe club-foot, 430 distinctions of latei-al deviation and curvature of spine, 107 frequency of scoliosis, 102 rate of development of scoliosis, 161 suspension-couch, 71 tal. arcuatus and plantaris, 354 Fleischmann, cong. scoliosis, 145 osseous deformities in rickets, 258 Flemming, regeneration of tendon, 318 Fournier, syphilitic disease of spine, case of, 79 Friinkel, danger of washing out spinal abscesses, 64 Galtox, law of height in children, 160 Gamlet, 17 Gant, infra-trochanteric osteotomy of femur, 520 Gardner, W., first resection of cervical nerves, 207 modification of Phelps' operation, 436 Gardner and Giles, neurectomy in spasmodic wry-neck, 206 Garson, asymmetry in length of legs, 152 Gee, symptoms of rickets, 256 Gerster, condition of membranes in spinal caries, 72 Gibney, V. P., case illustrating difficulty in diagnosis of spinal caries, 35 cuneiform osteotomy for double cong. varus, 443 flat-foot and ingrowing toe-nail, 468 general treatment of club-foot, 315 metatarsalgia, 493 method of shortening tendo Achillis, 346 non-operative treatment of metatarsalgia, 489 Gibney, V. P. , osseous deformities in rickets, 259 sarcoma of spine, 80 septiciemia after tarsectomy, 446 spontaneous recovery from genu valgum, 279 suitable boots in metatarsalgia, 494 treatment of club-foot by Thomas' wrench, 432, 433 treatment of spastic paralysis, 552 tubercular heredity in spinal caries, 4 Giordano, arthrodesis, 563 Gleich, transplantation of posterior part of OS calcis, 486 Golding-Bird, apparatus for flat-foot, 481, 482 cong. wry-neck, 187 cause of, 194 extirpation of scaphoid for flat-foot, 4S5 flat-foot and high-heeled boots, 467 method of estimating degree of flat-foot, 462 pes cavus, causation of, 353 treatment of flat-foot, 477 Goldthwait, obliteration of anterior trans- verse arch of foot, etc., 489 Gosling, T. P., severance of tendons, opera- tion, reunion of tendon, 369 Gowers, "\V. R., alteration of pupil in cervical caries, 34 flat-foot and locomotor ataxy, 468 habit spasm in wry-neck, 1 92 on hysterical spine, 35 paralysis of all four limbs in spinal disease, case of, 22 paralysis, unequal affection of legs, case of, 22 patholog}' of spasmodic wry-neck, 194 rapid onset of compression-paraplegia, 25 s])asmodic wry-neck, more in females, 186 Gowers and Handford, cerebral thrombosis in children, 519 Goyrand, Dupuytren's contraction, morbid anat., 237 operation for Dupuytren's contraction, 242 Grattan, X., osteoclast, 283, 299 osteoclasis for inversion of bones of leg, 427 Grawitz, abnormal development in cong. displ. of hip, 525 Gre)', A., on laminectomy, Griffiths, J., symmetrical tal. dorsalis in an acephalous fcetus, 340 Grunhagen, regeneration of tendon, 318 INDEX 569 Gueniot, genu valgum, 277 Guerin, anat. o*' cong. displ. of hip, 527 cong. displ. of clavicle, 548 cong. scoliosis, 145 muscular contraction in cong. displ. of hip, 524 Gwynne, arthrodesis in tal. calcaneo-valgus, 348 Hahn, jerk-finger, 245 T- piece, 419 Hardy, treatment of Dupuytren's contrac- tion, 242 Hare, modification of Ogston's operation, 485 Hartley, J. W., astragalus, inclination of neck, 384 comparison of forms of tarsectomy, 449 morbid anat. of cong. tal. equino-varus, 383 nearthroses in cong. tal. equino-varus, 387 operative treatment of club-foot, 443 Haward, W., hammer-toe, 501 Haynes, I. S., cong. deformities of chest, 208 Heine, frequency of cong. tal. equino-varus, 379 Henoch, cong. rickets, 253 Heussner, arthrodesis, 563 Hibon, cong. displ. of knee, 548 Hilton, John, dysphagia, etc., in caries of spine, 17 necrosis of atlas and axis, 77 pain in caries of spine, 32 suddeii death from disease of axis, 76 syphilitic disease of spine, 78 Hofla, arthrodesis, 563 case of coxa vara, 268 coxa vara, 263 method of operating in cong. displ. of hip, 543 muscular contraction in cong. displ. of hip, 529 Hopkins, B., production of Pott's fracture deformity for inveterate tal. varus, 449 Horsley, V., cases of laminectomy, 73 Hueter, obliquity of neck of astragalus, 384 obliquity of neck of astragalus and cong. tal. equino-varus, 393 pathology of flat-foot, 468 Humphry, Sir G., genu recurvatum, irregular growth of upper epiphysis of tibia, 294 Hutchinson, J., last joint arthritis, 250 Israel, method of evacuating spinal abscess, 67 Jacoei, observations on pathology of rickets, 255 Jacobson, "W. H. A., accidents after Adams' operation, 519 advantages of osteotomy from outer side, 286 false ankylosis after fracture, 513 osteotomy of femur, 286 pain due to pressure on sub-occipital nerve, 75 sj'philitic disease of spine, 78 Jaffe, percentage of deaths in caries of spine, 46 Jalaguier, arthrodesis, 563 Jenner, Sir W., narrowing of glottis in rickets, 210 Jewell, injection of chloride of zinc in cong. displ. of hip, 542 Jones, C. iST. D., genu valgum, 273 osteoclasis and osteotomy, 284 ricketty deformities, 255 Jones, Eobei't, arthrodesis, 560, 562, 563 inversion in bones of leg, 425 late rickets, 254 lipomatous hypertrophy of fingers, 229 method of using Thomas' wrench, 417 Thomas wrench, use of, 434 Judson, A. B., experiment in scoliosis, 142 movements of vertebra, 84 primarj' carcinoma of spine, 80 scoliosis in the Siamese Twins, 154 spine, experiments on, 88 Kampe, spontaneous rectification of bow- legs, 297 Karewski, arthrodesis, 560, 563 paralytic dislocation of hip, 556 Keate, necrosis of atlas and axis, 77 Keen, W. W., etiology of Dupuytren's con- traction, 231 flexor tendons at wrist, operation on, 372 resection of cervical nerves, 206 Keetley, G. B., case of tarsectomy, 382 causation of scoliosis, 149 coxa vara, 263 glass-blowers' deformity, 250 late rickets, 253, 254 Kellock, T. H., transplantation of skin, Phelps' operation, 435 Ketch, age of onset of scoliosis, 103 570 DEFORMITIES Kirmisson, arthrodesis, 560, 563 death after Hoffa's operation, 544 genu recurvatuni, irregular growth of upper epiph3-sis of tibia, 294 Kocher, normal and talipedic astragalus, 384 Kiilliker, sex in scoliosis, 103 Kimig, forcible reduction in club-foot, 433 Korner and Beltzow, iinion of tendon, 319 Krauss, comparison of methods of treatment in cong. tal. equino-varus, 445 Phelps' operation, 437 Kronig, cong. absence of radii, 214 KriJnlein, condition of muscles in cong. displ. of hip, 530 cong. displacements, 548 frequency of cong. displ. of hip, 523 LAitPUGXAXi, arthrodesis, 563 Lancereaux,Dupuytren's contraction, morbid anat., 237 Landouz\^ and Soredey, cerebral embolism in children, 549 Lane, "W. Arbuthnot, cong. wry-neck, 193 empyema and scoliosis, 155 evacuation of pus from spinal canal, 69 labour changes in spine, 94 laminectomy, 71 positions of strength and weakness of foot, 468 ricketty attitude, 260 scoliosis, occupation in, 121 skin-grafting, Phelps' operation, 435 subcutaneous division of all sti'uctures in sole of foot, 411 treatment of severe cases of cong. tal. varus in infancy, 438 Langenbeck, ischias scoliotica, 152 Langgard, frequency of scoliosis, 103 Lannelongue, injection of chloride of zinc in cong. displ. of hip, 542 Larabrie, removal of bones for cong. tal. calcaneus, 344 Lauenstein, coxa vara, 264 Lee, B. , origin of lumbar scoliosis, 108 Lesser, arthrodesis, 563 sweating feet and flat feet, 461 Levrat, after-treatment of cong. wry-neck, 204 Lickroth, school-desk, 166 Liebreich, school-desk, 166 Little, E. M., cong. tal. equinus, 332 Little, E. M., forcible extension in cong. contraction of fingers, 224 frequency of abscess in spinal caries, 16 frequency of compression-paraplegia, 23 natural curves of spine, 87 removal of wedge from astragalus, 446 tarseetomy, 443 transplantation of skin in Phelps' opera- tion, 436 Little, W. J., concealed spring for varus or valgus, 423 morbid anat. of cong. tal. equino-varus, 383 tin-shoe with quadrant movement, 403 Lloyd, S., cases of laminectomy, 72 laminectomy, 71 Lockwood, C. B. , abnormal develo[)ment in cong. displ. of hip, 525 condition of muscles in cong. displ. of hip, 528 deficiency of rim of acetabulum, 523. 525 dissection of cong. contraction of fingers. 220 Dupuytren's contraction, dissection, 238 morbid anat., 237 necropsy of case, 235 Lonsdale, cong. tal. calcaneus with rigidity of knees, 340 Lorenz, arthrodesis, 563 causes of distortion in flat-foot, 469 cong. displ. of hip treated by forcible reduction, 542 forcible correction of scoliosis, 175 forcible correction of wry-neck, 203 method of applying plaster jacket, 57 operation for cong. displ. of hip and results, 545 position of metatarsal bones in flat-foot, 472 school-desk, 166 Lovett, R. "W., lateral deviation of spine in caries, 36 Lucas, R. C. , late rickets, 253 Lund's operation, how done, 442 when done. 442 Liining and Schultess, cong. wry-neck, 193 Luschka, affection of intervertebral discs in caries of spine, 8 MacCormac, osteotomy of femur from outer side, 287 Macewen, Sir W., conditions of membranes in caries of spine, 72 supra-condyloid osteotomy, 285 INDEX 571 Mackenzie, B. E., Phelps' operation, 437 Macready, J., treatment of Dupuytren's contraction, 241 Madelung, Dupuytren's contraction, 232 first stage, 238 morbid anat., 237 Makins, G. H., description of bones in ricket:^, 256 osseous defoi-mities in rickets, 258 Malgarine, cong. absence of radii, 215 hydrarthrosis in cong. disph of hip, 524 Marsh, H., anlvylosis, 514 ankylosis in spinal caries, 10 carcinoma of spine, 81 caries of spine in the aged, 4 diagnosis of caries and cancer of spine, 38 distinction between false and true anky- losis, 512 pathology, etc., of bony ankylosis, 514 sarcoma of spine, 80 syphilitic disease of dorsal spine, 78 Martin, E. H., cleft sternum, 208 cong. tal. equino-varus due to deficiency of amniotic fluid, 393 Mason (of New York), amputation after astragalectomy, 443 M'Curdy, cong. absence of radii, 214 operative treatment of club-hand, 218 Melicher, experiments on displ. of hip, 522 muscular contraction in cong. displ. of hip, 524 Melloni, G., treatment of genu valgum, 289 Menard and Variot, Dupuytren's contraction, morbid anat., 237 Meusel, case of absence of fibulse, 360 causes of death in caries of spine, 46 false ankj'losis after fracture, 513 jerk-finger, 245 percentage of deaths in caries of spine, 46 removal of head of astragalus, 443 Meyer, A^ou, condition of calcaneo- scaphoid ligaments in flat-foot, 471 triangle of foot, 469 Michael, frequency of abscess in spinal caries, 16 Michel, sarcoma of spine (tumor myeloides), 80 Miekulicz, morbid anat. of genu valgum, 276 Miller, A. G., Dupuytren's contraction, epilepsy, 236 Mohr, age in caries of the spine, 3 percentage of deaths in caries of spine, 46 vertebr* affected in caries of spine, 7 Mohring, osteoclasis and osteotomy, 284 Molliere, osteoclasis, 283 Morgan, J. H., appearances in cong. displ. of hip, 525 Morris, E. T., mallet-finger, 247 Morton, T. G., astragalectomy, 442 astragalectomy in club-foot, 433 club-foot stretcher, 433 excision of head of metatarsal bone for metatarsalgia, 494 instruments for forcible correction of club- foot, 434 metatarsalgia, 492 painful aff"ection of fourth metatarso- phalangeal articulation, 489 Morton, T. S. K., metatarsalgia, 489 Motta, arthrodesis, 563 Miiller, E., cases of coxa vara, 267 coxa vara, 263 suppuration in ankylosed hip after manipu- lation, 518 symptoms of coxa vara, 265 Murray, bifurcated hand, 225 Murray, K. W., osteoclasis, 299 Myers, T. H., cong. dislocation of hip, 542, 543 frequency of compression-paraplegia, 23 influence of pregnancy on caries of spine, 44 prognosis of compression-paraplegia, 70 results of Hoffa's operation, 546 Nateaissox, arthrodesis, 563 Neidert, causes of death in caries of spine, 46 Nelaton, coxa vara, 264 jerk-finger, flexor ganglion, 246 morbid anat. of cong. tal. equino-varus, 383 Nicoladoni, arthrodesis, 563 method of shortening tendo Achillis, 348 Norwell, Stewart, hereditary malformation of hands and feet, 226 Notter, jerk-finger, 245 Ogston, osseous flat-foot, 465 resection of astragalo-scaphoid joint, 484, 486 Oilier,' spontaneous rectification in bow-legs, 297 Openshaw, T. H., etiology of flat-foot, 4/0 modification of Ogston's operation for flat- foot, 486 Osborne, variations in costal cartilages, 209 572 DEFORMITIES Osier, causes of infantile hemiplegia, 549 Otto, variations in costal cartilages, 209 Owen, E., after treatment of cong. wry-neck, 204 wounding of int. jugular vein, 407 Paci, forcible reduction of cong. displ. of hip, 542 Paget, Sir J., caries of spine in the aged, 4 false ankylosis after fracture, .513 hysterical spine, 82 minor manifestations of gout, 234 necrosis of atlas and axis, 77 osteitis deformans in spine, 94 Palletta, condition of parts in cong. displ. of hip, 528 developmental causes in cong. disjd. of hip, 525 Palm, late rickets, 254 Parise, frequencj' of cong. displ. of hip, 523 hydrarthrosis in cong. displ. of hip, 524 Parker, R. W., abnormal uterine position and cong. tal. equino-varus, 392, 393 astragalo-scaphoid capsule, 388 cong. wry-neck, 187 foetal astragalus, 384 frequency of abscess in spinal disease, 16 localisation of caries of spine, 6 morbid anat. of cong. tal. equino-varus, 383 d scq. morbid anat. of wry-neck, 192 syndesmotoni}', 414, 415 talipedic astragalus, 384 Parker, Rushton, spontaneous recovery in genu valgum, 279 cong. wry-neck, 187 cases of laminectom}', 71 Parrot, cong. syphilitic ciu've of tibia, 305 Partridge, Dupuj^tren's contraction, morbid anat., 237 Pearce Gould, spasmodic wry-neck, 206 Petersen, arthrodesis, 563 cong. -wry-neck, 187 Petit, spasmodic wry-neck, 205 symptoms of coxa vara, 265 Petters, pathology of cong. tal. equino-varus, 379 Phelps, cong. displ. of hip forwards, 540 operation, value of, 315 section of sterno-mastoid at upper attach- ment, 202 Phillipeaux, cong. scoliosis, 145 Phillipson, A., Phelps' method of treating club-foot, 437 Phocas, arthrodesis, 564 method of shortening tendo Achillis, 347 rhachitic torticollis, 258 Piechaud, arthrodesis. 564 Poncet, artlirodesis, 564 glass-blowers' deformity, 250 Ponfick, regeneration of tendon, 318 Post, cong. displ. of hip treated by recuin- benc}', 536 by forcible reduction, 542 Pott, Percival, caries of spine, 3 Power, D'Arcy, specimen of cong. displ. of hip, 527 ■wry-neck and cong. hrematoma of sterno- mastoid, 187 Pravaz, cong. displ. of hip treated by re- cumbency and extension, 536 fre(juency of cong. displ. of hip, 523 QuAix and Sharpey, natural curves of spine, 87 Quisling, cong. wry-neck, 187 Railtox, T. C, cong. rickets, 253 Rammallay, arthrodesis, 564 Ramsey, A. C, cuneiform osteotomy for cong. tal. varus, 443 Ransford, late rickets, 254 Reclus, paralytic dislocation of hip, 555 Redard, age of onset of .scoliosis, 103 classification of kyphosis, 91 cocain in flat-foot, 476 condition of int. lateral ligament in hallux valgus, 495 condition of muscles in cong. displ. of hip, 530 cong. tal. varus, 373 definition of ankylosis, 511 epiphysiary genu varum, 292 forcible reduction in cong. displ. of hip, 543 how to use wrench in club-foot, 433 lit de pidtrc, 57 localisation of caries of spine, 6 osteoclasis and osteotomy, 284 pes planus in cong. displ. of hip, 358 position of metatarsal bones in flat-foot, 472 prone position in caries of spine, 53 sciatic scoliosis, 152 sex in scoliosis, 103 tarsoclasts, 417 INDEX 573 Reeves, H. A., aftection of ring finger in Dupuytren'j contraction, 237 ease of cong. syphilis of spine, 6 coug. lateral deviation of fingers, 230 coDg. tal. equinus, 359 contraction of plantar fascia in tal. arcu- atus, 352 diagnosis of caries of spine, 35 frequency of club-hand, 214 genu valgum, measurement of, 278 morbid anat. of, 276 sj'mptoms of, 277 jerk-finger, 245, 246 ganglia on flexor tendons, 246 normal form of fcetal foot, 311 position of caput femoris in cong. displ. of hip, 527 senile rickets, 253 syphilitic disease of dorsal spine, 78 tenotomy of club-hand, 217 Eegnault, proper direction of great toe, 494 Remak, forearm type of paralysis, 554 Renault, arthrodesis, 564 Reyher, false ankylosis after fracture, 513 Re3-hier, arthrodesis, 560, 564 Ricard and Ricket, Dupuytren's contraction from syphilis, 235 Richardson, coxa vara, 263 Ricket, Dupuytren's contraction, morbid anat., 237 operation for Dupuytren's contraction, 242 Ridlon, cong. displ. of hip forwards, 540 how to use wrench in club-foot, 433 syphilitic disease of the spine, SO Ried, arthrodesis, 564 Roberts, S. , frequency of cong. tal. equiuo- varus, 379 general treatment of club-foot, 315 Rochard, alteration in direction of tendons in talipes, 389 arthrodesis, 560, 564 morbid anat. of cong. tal. equino-varus, 383 Roersch, arthrodesis, 564 Rokitansky, cong. scoliosis, 146 Rollin, osteoclasis, 283 Roser, coxa vara, 263 Roth, B., "best possible position" in scoli- osis, 125 method of registering scoliosis, 126 Rotter, coxa vara, 263 symptoms of, 265 Roughton, E., metatarsalgia, 489 Rowan, excision of head of first phalanx for hammer-toe, 503 Rupprecht, tarsectomy, 443 Rust, syphilis of spine, 75 Ryan, when spinal supports dispensed with, 59 Rydygier, arthrodesis, 560, 564 Sappey, natural curves of spine, 87 Sayre, L. H., caries of the sj)ine, 6 symptoms of, 30, 31 cong. absence of radii, 214 elastic traction in wry-neck, 203 muscular development in scoliosis, 121 paralysis of tibialis anticus in flat-foot, 470 plaster of Paris jacket, 54, 56, 57 suspensory apparatus and scoliosis, 174 Schapps, bed-frame for Pott's disease, 51 Schede, apparatus for treatment of cong. displ. of hip, 538 cases of cong. displ. of hip treated by recumbency and extension, 538 Schilling, frequency of scoliosis, 103 Schmidt, H., " schlummernde Zellen," 321 Schon, cong. displ. of fingers, 548 Schreiber, arthrodesis, 564 Schultess, cong. wry-neck, 193 mechanics of sitting posture, 86 Schultz, Julius, coxa vara, 263 Schussler, arthrodesis, 564 Schwartz, arthrodesis, 564 subcutaneous rupture of extensor tendons of finger, 247 Schwartz et RifTel, arthrodesis, 564 Scudder, adult, fcetal and talipedic astragalus, 384 Sedillot, (?) arthritis in cong. displ. of hip, 524 Sevestre, Dupuytren's contraction, morbid anat., 237 Shaffer, non-deforming club-foot, 335 Shattock, S. G., appearances in cong. displ. of hip, 525 cong. rickets, 253 cong. tal. equino-varus, morbid anat., 383 hammer- toe, morbid anat., 502 Sherrington, regeneration of areolar tissue, 318 Sinclair, cleft sternum, 208 Smith, M., cong. displ. of shoulder. 548 Smith, Noble, etiology of Dupuytren's con- traction, 231 spasmodic wry-neck, 205 treatment of severe cases of club-foot, 437 574 DEFORMITIES Smith, Ramsey, hereditai'v malformation of hands and feet, 226 Smith, Thomas, cong. wry-neck, 192 Spencer, W. G., caries of spine in a dog, 8 morbid anat. of wry-neck, 192 Staffel, spinal curves, 86 Stokes, Sir W., osseous flat-foot, 465 operation for flat-foot. 486 remarks on flat-foot, 465 Stromeyer, (?) arthritis in cong. displ. of liip, 524 Struthers, centre of gravity of spine, 88 Swan, fatal case of compression-paraplegia, 22 osteotomy for inversion of limb in tal. equino-varus, 426 Syme, early movement after tenotomy, 407 Symington, condition of calcaueo- scaphoid ligaments in flat-foot, 471 Symonds, C. J., treatment of spinal abscess, 61 Symonds, H. P., tarsotomy, 440 Tamplin, frequency of cong. tal. valgus, 359 Targett, J. H., scoliosis in locomotor ataxy, 150 in syringo-myelia, 151 spinal curvatures in nerve disorders, l.'>0 Taylor, A. E., cong. absence of radii, 214- Taylor, H. L., brace, 55, 59 caries of spine, age of onset, 4 hajmatoma of sterno- mastoid and wiy- neck, 187 recession of deformity in caries of spine, 15 static scoliosis, 152 Teissier, false ankylosis after fracture, 513 Thomas, astragalectomy, 442 kneespint for genu recurvatum, 427 Thorburn, laminectomy, 71 surgery of spinal cord, 72 Tooth, H. H., peroneal paralysis, 374 Townsend, W, R., frequency of abscess in spinal disease, 16 results of treatment of spinal abscess, 61, 62 Treves, F., natural curves of spine, 86 open division of hamstrings, 518 spinal abscess, 20 method of evacuating, 67 Tubby. A. H., case of ankylosis of hip remedied by Adams' operation, 519 frequency of scoliosis, 103 lobster-claw deformity of foot, 506 shortening following injuries and diseases of the epiphysial line, 153 A^AKIOT, Dupuytren's contraction, morbid anat., 237 Verbelzi, astragalectomy, 443 A'erneuil, heredity in cong. displ. of hip, 527 kyphosis and flat-foot, 96 paralj'tic dislocation of liip, 555 Vincent, danger of wasliing out spinal abscesses, 64 Vincent (of Lyons), gangrene from tiglit bandaging after wrenching, 418 Virchow, cong. rickets, 253 Vogt, heredity in scoliosis, 104 jerk-finger, 245 periods of rapid growth of skeleton, 144 Vogt's operation, 485 Volbert, morbid anat. of wry-neck, 192 Volkmann, cartilaginous ankylosis, 515 cong. displ. of hip treated by recumbency and extension, 539 heredity in cong. displ. of hip, 527 morbid anat. of cong. tal. etpiino-varus, 383 morbid anat. of wry-neck, 192 oblique seat, 169 wounding of internal jugular vein, 407 Wade, necrosis of atlas and axis, 77 syphilitic disease of spine, 78 Wainwright, W. L. , plaster of Paris in wry- neck, 203 "NValdeyer, plasma cells, 320 AValsham, astragalectomy, 442 estimation of degree of flat-foot, 461 lateral curvature of spine, 181 method of shortening tendo Achillis, 348 osseous flat-foot, 465 shortening of tendo Achillis, 372 suppuration after tarsectomy, 446 tarsectomy, 444 treatment of severe cUib-foot, 440, 441 AValsham and Hughes, apparatus for flat- foot, 482 connection between tal. calcaneus and e(piinus, 342 downward deflection of neck of astragalus, 384 exercises in tal. equinus, 336 hallux rigidus, 499 importance of tendo Achillis in treatment of tal. equino-varus, 454 morbid anat. of tal. equino-varus, 383 multilocular bursa in bunion, 496 Ogston's operation, 486 Phelps' operation, 437 position of astragalus in flat-foot, 471 INDEX 575 Walsham and Hughes, relapse after Buchanan's operation, 439 suppuration after tenotomy, 406 White, William, laminectomy, 71 reproduction of supernumerary thumb, 225 Whitman, R., attitudes of strength and weakness of foot, 476 chronic spasm of foot, 468 coxa vara, 263, 267 deformity in caries of spine, 11 genu recurvatum, irregular growth of the upper epiphysis of tibia, 294 h?ematoma of sterno-mastoid, 187 persistent abduction of foot, 468 positions of strength and weakness of foot, 468 spontaneous recovery in genu valgum, 279 symptoms of coxa vara, 265 Willard, De F., comparison of operative methods in treatment of club-foot, 437 Willett, A., cong. scoliosis, 146 forcible rectification of flat-foot, 483 hot-air bath in contracture, 512 method of shortening tendo Achillis, 346 shortening of tendo Achillis, 372 Willett and Walsham, operation for acquired tal. calcaneus. 343 Wilson, analysis of 435 tarsectomies, 446 Winiwarter, arthrodesis, 560, 562, 564 Winkelmann, operation for paralytic tal. equino-varus, 451 Wolff, arthrodesis, 560, 563, 564 suspensory cradle, 168 Wolter, functional prognosis of tendon suture, 370 Wood, J., articulation of os calcis with fibula in iiat-foot, 471 astragalectomy, 442 Woodrufi", C. E., incomplete luxations of metatarso-phalangeal articulations, 489 Wright, G. A., condition of coverings of cord in caries of spine, 72 method of treatment of tubercular ab- scesses, 68 Young, J. K., case of bilateral spinal ab- scess, 21 lumbar fascia and abscess, 19 Zeis, coxa vara, 263 Zieber, jerk-finger, 245 Ziegler, condition of ligamentum teres in cong. displ. of hiji, 528 Zinsmeister, arthrodesis, 564 Zoltan V. Roboz' formula, 319 Zufl], manual osteoclasis, 284 576 DEFORMITIES INDEX OF SUBJECTS Abbreviations :—Aiiat.= anatomy ; tal. =talipes ; cong. = congenital ; int. = internal ; ext. = external ; displ. =displacenient ; fds. = forwards ; bwds. =backwarils. Abscess, cervical, where to open, 65 dorsal, 18 where to open, 65 extra-dura], opening into theca, 48 iliac, 19 lumbar, 19 psoas, IS retro-pharyngeal, 77 spinal, absorption of, 20, 62 anatomical conditions influencing direc- tion of, 17 bearing of age upon, -17 bearing of region involved on prog- nosis, 46 bilateral, 21 burrowing of, 60 bursting into viscera, 46 caries in, 16 cervical fascia in, 17 contents of, 20 danger of injecting, 64 diagnosis from other abscesses, 42 dissection out of sac, 61, 69 effect upon compression-paraplegia, 47 expectant treatment, 61, 62 future course of, 20 general summing up of treatment, 69 importance of complete antisepsis in, 48 incision of, and drainage, 65 indications for expectant treatment, 63 injection of, 61, 64 involvement of posterior mediastinum, 48 Israel's method of evacuating, 67 mistaken for renal abscesses, 41 opening into abdominal viscera, 19 trachea, lungs, etc., 17 prognosis of, 46, 4S retro-pharyngeal, 17 treatment of, 60 treatment by aspiration, 61, 64 Treves' method, 61, 67 Absence of bones in tal. calcaneus. 340 Accidents in tenotomy, 406 Acetabulum, deepening of, in cong. hip displ., 544 perforation of, 544 Acquired club-foot, 307 flat-foot of adolescents and adults, 458 Acute miliary tuberculosis in s^jinal caries, 46 rheumatism and flat-foot, 466 Adams' double horizontal bar, 173 extension instrument for Dupuytren's contraction, 241 metal splint for Dupuytren's contraction, 240 modification of Scarpa's shoe, 421 operation on neck of femur, 519 ,, ,, when done, 520 spinal stays, 177 spring jdate apparatus, 176 varus splint, 421 Adducted foot {sec Talipes varus) Adenoids and pigeon-breast, 211 and scoliosis, 155 Age of onset of bow-legs, 295 of scoliosis, prognosis, 159 of spinal caries, bearing on prognosis, 44 Albuminuria in late rickets, 253 Alteration in gait in flat-foot, 474 Alum-carmine, 319 Amyloid degeneration in spinal caries, 46 Aufemia and flat-foot, 466 Anaesthetics in tenotomy, 405 Aneurism after tenotomy, 407 Angular curvature (siv Spine, caries of) deformity of spine [sec Spine, caries of) Ankle, fibrotis ankylosis, treatment of, 518 paralytic dislocation, 557 Ankylosis, 511 after nou-suppurative arthritis, 514 after suppurative arthritis, 514 bony, treatment of, 518 causes of, 514 Charcot's di-sease, 515 complete, 514 IXDEX 577 Ankylosis, cong. tal. equino-varus in, 388 deformity in. 511 diagnosis of, 515 fibrous, 514 treatment of, 516 by extension, 517 by gi-adual movement, 516 by manipulation, 516 good position, 515 of knee and scoliosis, 153 osseous, 516 of knee, treatment of, 521 pain in fibrous, 515 partial, 514 prognosis, 516 spurious, 512 symptoms, 515 vicious position, 515 Antisepsis, importance of, in spinal abscess, 48 Aorta, effect of scoliosis on, 137 narrowing of, in spinal caries, 46 Appearances in rhacbitic scoliosis, 149 Arcb of foot lost in flat-foot, 459 Arras, paralytic deformities of, 552 position of, in infantile hemiplegia, 551 ricketty deformity of the, 259 Arteries, efi'ect of scoliosis on aorta, 137 ,, ,, carotid, 138 ,, ,, pulmonary, 137 ,. subclavian, 138 Arthrodesis, 560 indications for, 560 in paralytic club-foot, 450 in tal. calcaneus, 348 methods, 560 of ankle, 560 of knee, 562 results of, 562 Articular process of vertebrte, altered in scoliosis, 135 Asphyxia at birth and cong. tal. equino- varus, 392 Astragalectomy, 440. 442 for flat-foot, 485 for relapsed varus, 456 Astragaloid osteotomy, 441 Astragalo-scaphoid capsule, division of liga- ments, 414, 415 Astragalus, extended in ankle-joint in cong. tal. equino-varus, 383 foetal, 384 head of, rotation in flat-foot, 459 Astragalus, neck of, importance in main- taining deformity, 454 neck of, opposing reduction, of talipes, 391 obliquity of neck, 384 ;, ;; of, au d coug. t al. c qulu 0- varus, 393 "point," 470, 488 position of, in flat-foot, 471 prominence of head of, 331 section of neck of, 440, 441 talipedic, 384 adult — head, 385 neck, 385 new facets on, 385 prominence of head, 385 shape of body, 385 facets, 385 head of, 385 interosseous gi'oove, 385 sui-faces of, 385 twisting of neck of, 383 Asymmetry of face in cong. wry-neck, 193 of legs in scoliosis, 152, 153 of skull in cong. wr3'-neck, 194 Athetosis, 550 Atlo-axoid disease, 74, 75 treatment of, 77 Attitude of rest in genu valgum, 274 Author's experiments on union of tendon, 321-325 Back-kxee {see Genu Recurvatum) irregular growth of upper epiphysis of tibia, 294 Bandy-legs {see Genu Varum) Blood-vessels in tendon, 320 Bodily health in scoliosis, influence of, on prognosis, 159 Bones, development of, 314 of foot, position of, in flat-foot, 471 Bow-legs, 294 age of onset, 295 constitutional treatment with local mani- pulation, 297 constitutional treatment with mechanical supports and manipulation, 298 manual osteoclasis, 299 operative measures, 299 osteotomy for, 300 pathological changes in bones in, 295 prognosis of, 297 2 P 578 DEFORMITIES Bow-legs, removal of awedge from bone in, 300 ricketty curvature of bones in, 295 stages of osseous rickets in, 295 treatment of, 297 types of, 295 Bronchi, effect of scoliosis on, 137 Bronchitis in scoliosis, 131 Buchanan's operation for cong. tal. e(|uino- varus, 437 Bunion, 494 amputation of great toe when done, 498 bursa multilocular, 496 dissected out, 498 excision of head of metatarsal bone, 498 improper boots, 494 in flat-foot, 474 mistaken for gout, 496 more often in women, 496 operative treatment of, 497 suitable boots in, 497 symptoms of, 496 treatment of, 497 of prophylactic, 496 Bursse in, cong. tal. equino-varus, 382 flat-foot, 460 suppuration of, in cong. tal. equino-varus, 383 Calcaneo-astiiagaloid ligaments, condi- tion of, in flat-foot, 471 Calcaneo-scaphoid ligaments, condition of, in flat-foot, 471 "Canoe-shaped" foot, 459 Capsule of hip-joint, hour-glass shajie in cong. dispL, 528, 529 Carcinoma of spine, 80 Caries of spine {sec Spine, caries of), 3 duration of, 45 Cartilages costal, variations in, 209 Cartilaginous ankylosis, 515 Causation of genu varum, 290 tal. equinus, 331, 338 Causes of, ankylosis, 514 club-foot, 307 failure in tenotomy, 406 metatarsalgia, 489 scoliosis, effect in prognosis, 158 spasmodic wry-neck, 191 tal. arcuatus, 352 tal. plantaris, 352 Cephalhematoma, 191 Chairs, defects in, 164 suitable, 165 Charcot's disease, associated with genu re- curvatum, 293 Cheek, defective development of, in wry- neck, 193 Chest, abnormal, due to occupations, 212 due to Pott's disease, 212 due to scoliosis, 212 treatment of, 212 acquired deformities of, 209 appearances in nasal obstruction, 211 cong. deformities of, 208 osseous deformities in rickets, 259 rhachitie, treatment of, 213 ricketty, 209 Chinese ladies' feet, 352 Chromatin-filaments, 319 Chronic torticollis, 185 Cicatricial scoliosis, 154 tal. equinus, 332 Classification of scoliosis, 120 Clavicles, effect of scoliosis on, 138 asymmetry in cong. wry-neck, 193 Clawing of toes, 337 Cleft palate and tal. calcaneus, 340 Club-foot {sec Forms of talipes) acquired, 307 after inflammations, 308 causes of, 307 cicatricial, 308 congenital, 307 definition of, 306 frequency of, 309 gait in, 311 hysterical, 308 method of examination, 310 muscles affected, 309 paralytic, 307 spastic, 307 traumatic, 308 treatment of, general remarks, 315 unfolding of, 421 various forms of, 328 Club-hand, 214 definition, 214 etiology, 216 forms of, 215 radio-dorsal, 215 radio- pal mar, 215 ulnar-dorsal, 215 ulnar-palmar, 215 frequency, 214 morphological conditions in, 215 symptoms, 216 INDEX 579 Club-hand, treatment — operative, on bones, 217 passive manipulations, 217 tenotomy, 217 Cobbler's chest, 212 Colin's osteoclast, 299 Comparison of gradual treatment of club- foot and tarsectomy, 444 less severe methods of treatingclub-foot,439 wrenching and tarsectomy, 444 Compensation lordosis, 100 Compression-paraplegia, 21 anaesthesia, 27 conditions accounting for symptoms, 25 diagnosis, 27 duration of treatment, 71 effect of abscess in relieving, 21 girdle-pain, 27 herpes zoster, 27 hyperfesthesia, 27 laminectomy, 71 morbid conditions, 72 onset, 25 pathological auat. , 23 ■ prognosis, 28 proportion of cases of spinal cai'ies affected, 23 rarely due to bone, 21 recovery during recumbency, case of, 25 spastic symptoms, 23 sphincters, condition of, 27 sweating in, 27 symptoms, 25, 26, 27 treatment, expectant, 70 operative, 71 unilateral, 22 Congenital absence, of radii, 214 club-foot, 307 associated with genu recurvatum, 293 contraction of fingers, 218 diagnosis, 221 etiology, 220 pathology, 220 relapse, 223 stages of, 219 treatment, 221 bj' forcible extension, 224 with hammer-toe, 218 contracture of knee, 511 dislocation, misnomer, 522 displacements, 522 et seq. of ankle, 548 clavicle, 548 Congenital displacement, of elbow, 548 fingers, 548 hip, 522 et seq. knee, 548 associated with genu recurvatum, 293 lower jaw, 548 patella, 548 shoulder, 548 spine, 548 wrist, 548 rickets, 253 scoliosis, 145 syphilis distinguished from rickets, 257 syphilitic curvature of tibia, 302, 303 tal. calcaneus, 339 equino-varus, morbid anat., 383 rotation of front of foot, 379 valgus, absence of fibula and intra- uterine fracture of tibia, 360 and curved tibia, 360 Contracted toes, 500 Contraction, acquired, of fingers, 245 forearm, 245 wrist, 245 definition, 511 lordosis, 99 of hand from muscular spinal paralysis, 245 from pressure on median nerve, 245 Contracture, 511 causes, 512 conditions for manipulation, 512 definition, 511 treatment, 512 Corns in flat-foot, inflamed, 474 tal. equinus, 329 cong. tal. ec^uino-varns, suppurating, 383 Corsets and scoliosis, 164 Coxa vara (incurvation of the neck of the femur), 263 chief factor in production, 269 diagnosis, 269 etiology, 264 pathology, 268 prognosis, 269 symptoms, 265, 267 treatment, 269 Coxitis and scoliosis, 153 Craniectomy, 549, 550 Creases in sole of foot in cong. tal. equino- varus, 382 Cuboid, removal of, 440 talipedic, adult, fcetal, 386 580 DEFORMITIES Cuneiform bones, talipedic, 387 Curved tibia and fibula {see Bow-legs) Dangeii to life in caries of spine, 45 Death after, Hoffa's operation, 546 tarsectomy, 446 Definition of, ankylosis, 511 club-foot, 306 club-hand, 214 contraction, 511 contracture, 511 Dupuytren's contraction, 231 flat-foot, 458 genu recurvatum, 293 genu valgum, 271 genu varum, 290 metatarsalgia, 489 rickets, 253 scoliosis, 102 wry-neck, 185 Deformities, from cerebral paralysis, 549 of one limb associated with genu recurva- tum, 293 Degree of scoliotic curve, prognosis, 161 Delafield's hematoxylin, 319 Desks, defects in, 164 suitable, 165 Diagnosis of, ankylosis, 515 caries of spine, 35-40 cong. contraction of fingers, 221 cong. tal. equino-varus, 397 coxa vara, 269 flat-foot, 475 genu valgum, 278 infantile hemiplegia, 551 metatarsalgia, 493 rickets, 257 ricketty curve from syphilitic curve of tibia, 304 scoliosis, 157 spasmodic wry-neck, 197 spinal abscess from other abscess, 42 tal. equinus, 335 Diaphragm, effect of scoliosis on, 138 Didot's operation, 227 Digestion, impaired in scoliotics, 131 Dinner-pad for plaster jackets, 57 Disease of cervical spine, 74 Distinction between false and true ankylosis, 512 Division of, all the tendons of the wrist, 243, 370 biceps cruris, 282 Division of, ilio-tibial band, 282 tendons at inner ankle simultaneously, 413 Dorsum of foot, rounded appearance in paralytic tal. equino-varus, 376 Doubly-twisted foot, 379, 381 Douching in club-foot, 3] 7 Doyle's spring rotator, 427 Drop-finger, 247 Droppingof os calcis in acquired tal. calcaneus, 342 Dumb-bells, value in scoliosis, 172 Dupuytren's contraction, age, 232 bacterial tlieory, 236 choice of operation, 242 definition, 231 diagnosis from, adhesion of tendons, 239 cong. contraction of fingers, 239 contraction of tendons, 239 osteo-arthritic contraction of hand, 239 digitis aftected, 231, 239 fibrous bands, 239 gout and rheumatism, 234 heredity, 232 hyperthroi^hic changes, 238 morbid anatomy, 237 nervous origin, 235 nodular indurations, 239 occupation, 232 of the hand, 231 pain in, 239 prognosis, 239 recurrence of deformity, 242 sex, 231 spontaneous arrest, 239 subcutaneous section, 240 symptoms, 238 syphilis in, 235 traumatism, 233 treatment, after operation, 241 by open method, 241 mechanical, 240 operative, 240 Duration of treatment in cong. club-foot, 397 Elastic traction in club-foot, 422 disadvantages, 422 Elbow, fibrous ankylosis, treatment of, 517 Electric current applied in club-foot, 317 Electrical reactions, 314 Electricity in treatment of cong. tal. equino- varus, 399 Empyema, and scoliosis, 154 effect on prognosis of scoliosis, 159 IXDEX 581 Encephalocele and cong. tal. equino-varus, 392 Epiphysial separation and talipes, 365 Ernst's apparatus for complete paral3'sis of lower extremities, 558 boots for flat-foot, 479 laced-shield apparatus, 176 T-spring for hammer-toe, 503 ■ walking apparatus for cong. displ. of hip, 541 Etiology of, club-hand, 216 cong. contraction of fingers, 220 coxa vara, 264 flat-foot, 466 hammer-toe, 500 rickets, 254 wry-neck, 186 Everted foot {see Talipes-valgus) Examination of club-foot, 310 Exercises for, club-foot, 317 convalescent scoliosis, 171 early scoliosis, 317 flat-foot, 477 later scoliosis, 171 scoliosis, 170 et seq. tal. equinus, 336 treatment of scoliosis, 167 "extension" of foot, 306 Extensor longus pollicis, 412 proprius pollicis, tenotomy of, 412 tendons of foot, functional prognosis after , section, 371 tendons of hands, functional prognosis after section, 370 tendons of thumb, functional prognosis after section, 370 Extensors of toes, tenotomy of, 413 External lateral ligament in flat-foot, 471 popliteal nerve, wounded in tenotomy, 406 Family history in caries of spine, importance of, 43 Fascice, condition of, in flat-foot, 471 over flexor tendons at wrist isolating suppuration, 371 Fasciotomy in cong. tal. equino-varus, 405 Fatty changes in muscles in scoliosis, 136 degeneration of kidney in spinal disease, 46 Felt-collar in cervical caries, 54 Femoral artery, wounded in Adams'- opera- tion, 519 Femur, inversion in axis of shaft, 424 of neck, 424 Fibroblasts, 322 Fibroid changes in muscle, 136 Fibula, abnormalities of, in cong. tal. valgus, 361 partial or entire absence in cong. tal. valgus, 359 Fingers, cong. contraction, 218 cong. lateral deviation, 230 fibrous ankylosis, treatment of, 517 hypertrophy, 229 treatment, 230 subcutaneous rupture of extensor tendons 247 supernumerary {see Polydactylism), 224 suppression, 225 webbed, 226 First metatarsal bone, hypertrophy of base 474 Fitzgerald's operation, 440 Fixation-points of plaster jacket, 57 Fixation and supporting appliances and tests of efficiency, 55 Fixed joint {see Ankylosis), 511 Flat-foot, 458 after acute rheumatism, 466 after exanthemata, 466 age of onset, 466 alteration of gait, 474 and adolescence, 465 ,, an£emia, 466 ,. excessive standing, 467 , , feeble health, 466 ,, genu valgum, 467 ,, gout, 467 ,, injury, 467 ,, locomotor ataxy, 468 ,, scoliosis, 153 ,, sweating foot, 461 ,, unsuitable boots, 467 appearances of, 459 appropriate boots in, 477 arthritic changes, 474 associated with syphilis, 461 - causes, exciting, 468 predisposing, 468 condition of extensor communis digitorum 462 of peronei tendons, 462 definition, 458 degrees, 463 how estimated, 461, 462 diagnosis, 475 due to paralysis of tibialis anticus, 470 582 DEFORMITIES Flat-foot, etiology, 466 first degree, 463 fourth degree, 465 general description, 459 Gleieh's operation, 487 morbid anat., 471 oedema in, 474 Ogston's operation, 484, 486 oncoming, 463 osseous, 465 treatment of, 484 pathology, 468 post-rhachitic, 466 Pott's fracture from, 467 prognosis of, 475 pronounced, 463 prophylactic treatment, 476 rectified, forcibly, 483 gradually, 484 relief of pain, 476 rest in, 476 rhachitic, treatment, 475 rigid, 464 second degree, 463 spasmodic, 462 static, causes, 467 Stokes' operation, 486 sweating of foot, 475 symptoms of, 472 tailor-position in, 477 third degree, 464 treatment, 475 by bandages, 478 Ernst's apparatus, 479 exercises, 477 general, 475 local, 475 pads, 479 rest, 477 supports, 478 Whitman's brace, 479 treatment of first degree, 477 second degree, 477 third degree, 482 fourth degree, 484 wearing of Thomas' boots, 478 wedge - shaped excision of astragalus, 486 Flattening of sole of foot, 474 Flemniing's Huid, 319 Flexion of foot, 306 Flexor longus digitorum cruris, tenotomy, 413 Flexor tendons in fingers, functional prog- nosis after section, 371 in palm, 371 at wrist, prognosis after suture, 371 Foods, value of, in rickets, 255 Foot, defectively modelled in talipes, 383 exercising apparatus, 423 outlines of, 312 perfect, 394 position of strength, 468 of weakness, 468 Forcible rectification of club-foot, 440 Form of scoliotic curve, effect on prognosis, 160 Fracture of bones of leg in wrenching, 418 for inward rotation, 419 Frequency of club-foot, 309 of cong. tal. equino-varus, 379 Friedreich's disease and tal. arcuatus, 352 Functional prognosis of tendon-suture, 408 Gangrkne after rectification of club-foot, 419 Gant's infra-trochanteric osteotomy, 520 Gastrocnemius, grafted on peronei, 451 General tuberculosis and caries of the spine, 46 Genu recurvatum, 293 and Charcot's disease, 293 ,, cong. club-foot, 293 , , cong. displ. of knee, 293 ,, cong. tal. equino-varus, 391 definition of, 293 effect on prognosis of cong. tal. equino- varus, 394 occurrence of, 293 paralytic club-foot in, 293 ricketty, 293 tal, calcaneus in, 340 walking apparatus for, 294 Genu valgum, adolescentium, 271 and flat-foot, 467 ,, scoliosis, 153 ' attitude of rest in, 274 awkward gait, 275 causation — bending of femur, 273 mechanical, 274 unequal growth of epiphysial line, 273 contraction of biceps, 275 of ext. lateral ligament, 275 definition, 271 IXDEX 583 Genu valgum, diagnosis of, 278 division of int. condyle, 289 advantages, 289 disadvantages, 289 flat-foot in, 271, 275 flexion of knee in, 276 inflammatory, 273 lateral movement of knee in, 275 lengthening of int. condyle, 276 Macewen's operation, 285 manual rectification, 284 measurement of, 277 method of manipulation for, 280 morbid anatomy, 275 obliquity of pelvis in, 275 osteoclasis in, 283 osteotom}', 285 after-treatment of, 287 from outer side, 287 indications for, 285 methods, 285 paralytic, 273 pressure on ext. condyle, 274, 275 prognosis, 278 relaxation of int. lateral ligament, 274 results of, 275 ricketty, 271 section of biceps cruris, 282 of ilio-tibial band, 282 static, 271 symptoms of, 276 traumatic, 272 treatment of, 278 by manipulation, 279 ,, rest, 279 mechanical, 280 principles of, 280 summing up of, 289 varieties of, 271 walking apparatus for, 282 Genu varum, 290 after excision of knee, 291 ,, operation for genu valgum, 291 age, 292 and scoliosis, 153 causation of, 290 clinical varieties of, 292 complementary, 291 definition, 290 degrees of, 292 elongation of ext. condyle, 292 epiphysiary, 292 from occupation, 291 Genu varum, ricketty, 290 symptoms of, 293 treatment of, 293 Glass-blowers' deformit}', 250 Gluteal abscess, 19 Gonorrhceal rheumatism and flat-foot, 475 of spine, 93 Gout and flat-foot, 467 and pes planus, 359 Gradual method of treating club-foot, dura- ation of, 422 method of treating tal. equino - varus, 421 rectification of inveterate club-foot, 440 Great toe, partial power of opposition in cong. tal. equino-varus, 378 proper direction of, 494 valgoid, in flat-foot, 461 Griffe pied creux, 353 H.a;MATOiiA of sterno-mastoid, 187 Hsemorrhage after tenotomy, 407 intra-cranial in children, 549 Hallux dolorosus {see Hallux rigidus), 499 extrorsus [sec Bunion), 494 flexus {see Hallux rigidus), 499 rigidus, 499 anatomy of, 500 and flat-foot, 500 symptoms of, 499 treatment of, 500 valgus {see Bunion), 494 anatomy of, 495 and flat-foot, 467 improper boots, 496, 497 symptoms, 496 varus, 498 associated with tal. varus, 498 treatment of, 499 Hammer-toe, 500 acquired, 501 how produced, 501 amputation to be avoided, 503 and congenital contraction of fingers, 219 ankylosis of first and second phalanges, 503 appearances in, 502 congenital, 500 definition of, 500 etiology of, 500 excision of first interphalaugeal joint, 504 forcible reposition, 503 heredity, 501 584 DEFORMITIES Hammer-toe, morbid anat., 502 phalanges, position of. 502 shortening of glenoid and lateral liga- ments, 502 subcutaneous division of ligaments and tendons, 503 treatment, 503 operative, 503 palliative, 503 Hand, bifurcated, 225 deformity of, in osteo-arthritis, 249 Hare-lip and cong. tal. equino-varus. 391 Heart, dilation of, in spinal caries, 46 displacement of, in scoliosis, 128. 131 hypertrojihy of, in spinal caries, 46 muscular degeneration of, in spinal caries,46 stenosis of mitral valve in spinal caries. 46 Heel, foreshortened in flat-foot, 460 Hemiplegia, and scoliosis in, 150 Hereditary hump-back, 92 Heredity, effect on prognosis of scoliosis, 159 not in rickets, 254 Hip, cong. displ. of, 522 auatomj' of, 527 in Hoffa's case, 543 causation, 523 condition in adults, 529 of capsule, 528, 529 round ligament in, 528 developmental causes, 525 diagnosis of, 533 from coxa vara, 534 ,. coxitis, 535 ,. paralytic dislocation, 535 .. pseudo- hypertrophic paralysis. 534 . . traumatic dislocation, 535 due to muscular contraction, 524 etiology, 523 forcible reduction. 542 frequency, 523 head of femur, shape, 528 importance of early recognition, 533 mechanically produced, 523 morbid anat. in children. 528 appearances at birth, 527 :io arthritis in, 524 operation, Hoffa's, 543 Loi'enz', 545 paralysis of peri-trochanteric muscles, 62 4 pathological causes, 524 pelvis in, 530 positions of head of femur in, 527, 540 Hip, cong. displ. of, positions of head of femur, 527, 540 prognosis of, 535 recumbency and extension , objects of, 537 symptoms of, in bilateral cases, 530 unilateral cases, 533 treatment, 535 by extension, 535 by oi^eration, 543, 545 by recumbency. 535 by walking apparatus and night ex- tension, 541 summed up, 547 fibrous ankylosis, treatment of, 517 paralytic dislocation of, 535, 555, 556 anterior, 556 posterior, 556 History.in club-foot, 311 Hoffa's operation for cong. hip displ., 543 and Loreuz' operations compared, 545 operation, danger of, 545 probability of cure, 546 results, 544 Hollow-foot {sec Talipes arcuatus and Plan- taris), 351 Hot-air bath for contracture, 512 Hydrocephalus and talipes calcaneus, 340 and cong. tal. equino-varus, 392 Hypertrophy of toes, 508 Hysterical scoliosis, 151 Iliac abscess, 19 Incurvation of the neck of the femur (see Coxa vara), 263 Indian clubs, use in scoliosis, 172 Infantile hemiplegia. 549 causes, 549 date of onset, 550 diagnosis, 551 leg, position of, 551 position of arm in, 551 prognosis, 551 section of adductors, 552 of biceps cubitis, 552 of tendo Acliillis, 552 of wrist tendons, 552 symptoms, 550 treatment of, 552 operative, 552 Infantile paralysis, 553 onset of deformity, 554 scoliosis in, 150 Infantile rickets, 253 INDEX 585 Inflammatory genu valgum, 273 , Influenza, suppuration after tenotomy, 407 Ingrowing ankle, 467 toe-nail and flat-foot, 468 Injury and flat-foot, 467 In-knee (see Genu valgum) Internal jugular vein, wounding of, 407 lateral ligament of ankle in flat-foot, 471 opposing reduction of club-foot, 391 section of, 415 plantar artery wounded in fasciotomy, 406 saphenous vein, wound of, 413 Inversion, in bones of leg, 425 in bones of leg, treated by osteotomy, 425, 426 of limb in tal. ecj^uino-varus, 313 of lower limb, site of, 424 treatment of, 425 Inverted foot {sec Talipes varus) Inveterate club-foot, appearances in, 439 Inward rotation of lower limb in coug. tal. equino-varus, 390 Jeek-fingee, 245 narrowing of tendon groove, 246 thickening of tendon, 246 treatment of, 247 Jury-mast in spinal caries, 54 Knee, cong. contracture of, 511 fibrous ankylosis of, treatment, 518 hyper-extended, 313 -joint, excessive mobility of, 312 lax ligaments in, 424 laxity of ligaments in cong. tal. equino- varus, 391 paralytic dislocation of, 557 Knock-knee {see Genu valgum) Kyphosis, 3, 89 due to infantile paralysis, 92 due to nasal obstructions, 92 due to pseudo-hypertrophie paralysis, 92 in adults, 90 of adolescence, 90 of childhood, 89 of infancy, 89 paralytic, 554 rieketty, 91 senile, 90 Laminectomy, 71 contra-indicated, 73 indicated, 73 method of performing, 73 Lamnectomy {see Laminectomy), 71 Lane's modification of Buchanan's operation, 438 advantages, 438 disadvantages, 439 "Last joint" arthritis, 250 Late rickets, 253 and scoliosis, 147 rigidity, 550 "Latent cells," 321 Lateral curvature of spine {see Scoliosis) deviation of spine, 105 Leg, position of, in infantile hemiplegia, 551 Legs, how to measure, 153 Leucocytes, function of, in tendon union, 322 Ligaments, condition in flat-foot, 471 of foot in cong. tal. equino-varus, 388 of spine, effect of scoliosis on, 135 Limbs, cong. furrowing of, 230 surface temperature of, 313 Limping in cong. displ. of hip, 533 Little's double-hinged lever shoe, 421, 422 Liver, displaced in scoliosis, 131 Lobster-claw deformity of foot, 506 Localisation of affected muscles in tal., 313 Locomotor-ataxy and flat-foot, 468 scoliosis in, 150 Long bones of the lower extremity, rieketty deformities of the, 260 Lordosis, 99 compensatory, 100 from polio -myelitis, 100 from progressive muscular atrophy, 100 from pseudo-hypertrophie paralysis, 100 in cong. hip dislocation, 532 of nerve and muscular origin, 99 osteopathic, 100 paral}'tic, 99, 554 rheumatoid, 99 rieketty, 100 static, 99 treatment of, 100 Lower extremities, paralytic deformities of, 554 Lumbar abscess, 19 fascia, layers of, and lumbar abscess, 19 incision for spinal abscess, 65 Lymphatics of tendon, 320 Malignant disease of spine, 80 paralysis, 82 symptoms, 81 Malleoli, position of, in flat-foot, 472 586 DEFORMITIES Malleoli, relative position in cong. tal. equino-varus, 387 Malleolus, ext., position in cong. tal. equino- varus, 3S0 int., position of, in cong. tal. equino-varus. 380 int., prominence in flat-foot, 400 Mallet-finger, 247 anat. of, 248 symptoms, 248 treatment of, 248 Mamma; in scoliosis, 113 Manipulation in cong. tal. equino-varus, 399 method of, 401 .scoliosis, 167 Manual osteoclasis, method of, 300 Meningocele and cong. equino-varus, 392 Metal splint, flexible, 402 Metatarsal bones, position of, in flat-foot, 472 bones, talipedic, 387 neuralgia {sec Meta tarsalgia), 489 Metatarsalgia, 489 broadening of foot in, 490 causes, 489 corns in, 490 deep tenderness in, 490 definition, 489 diagnosis of, 493 due to ill-fitting boots, 490 due to pressure on digital nerves, 489 excision of head of metatarsal bone, 494 flat-foot in, 490 gout in, 489 osteo-arthritis in, 492 pain at third interspace, 489 at fourth interspace, 489 character of, 490 pathologj^ of, 492 prognosis of, 493 prominence of head of metatarsal bone, 490 rest, necessity of, 493 rheumatic diathesis, 489 suitable boots in, 494 symptoms, 490 traumatism in, 489 treatment of, 493 twist in foot, 490 typical impression of foot, 491 Microcephalus, .t49 and spastic tal., 375 Morbid anat. of, cong. wry-neck, 192 Dupuytren's contraction, 237 Morbid anat. of, flat-foot, 471 genu-valgum, 275 hallux rigidus, 500 hallux valgus, 495 hammer-toe, 502 paralytic tal. equino-varus, 376 rickets, 255 scoliosis, 133 tal. calcaneous, acquired, 343 tal. equinus, 333 tal. varus, 357 Morton's disease {see Metatarsalgia), 489 Movements, of spine, 87 passive, in tal., 313 Muscles, conditions of, in flat-foot, 471 of spine, efi'ect of scoliosis on, 136 Music-stools, 123 Nasal obstruction and scoliosis, 155 polypi and pigeon-breast, 211 Xearthi'oses in cong. tal. equino-varus, 387 Nerve, ext. popliteal, 282 and vessels, position in cong. tal. equino- varus, 390 Neuromimesis in spine, 82 Neuropathic scoliosis, 149 Non-deforming club-foot (Shaff"er), 335 Non-union after osteotomj', 301 North of England School Furnishing Desk, 166 Norton's operation, 227 Nose, deviation of, in cong. wry-neck, 193 Nursing in club-foot, 317 OBJECT.S to be attained in treatment of cong. tal. equino-varus, 399 Obstacles to reduction of cong. tal. equino- varus — in adult, abnormal shape of joints, 391 ,, new joints, 391 ,, ligaments, 391 ,, skin, 391 in infant, fasciie, ligaments, neck of astra- galus, 391 Occii^ital head-piece in spinal caries, 54 Occipito-atloid and atlo-axoid disease, 74 Occupation, eflfect on scoliosis, 160 -scoliosis, 120 Occurrence of genu recurvatum, 293 O'Connor exten.sion-boot, 450 (Edema in flat-foot, 474 (Esophagus, effect of scoliosis on, 138 Ogston's operation for flat-foot, 484, 486 INDEX 587 Oncoming flat-foot, 463 Os calcis, elepation, rotatiou in cong. tal. equino-varus, 383 position of, in flat-foot, 471 talipedic, adult, 386 facets, 386 fcetal, 386 position, 386 rotation, 386 surfaces of, 386 sustentaculum tali, 386 tuberosities feebly developed, 330 Osmic acid, 319 Osseous deformities in, rickets, 257 flat-foot, 465 rickets, stages of, in bones of leg, 295 Osteitis deformans, 305 and ankylosis, 514 Osteo-artliiitis of spine, 93 morbid anat. , 94 symptoms, 95 treatment, 95 . Osteoclasis for inversion of bones of limb, 427 Osteo-malacia, 305 Osteophytes in scoliosis, 135 Osteotome, use in removal of wedge from bone, 301 Osteotomy, for bow-legs, 300 for inversion in bones of leg, 425, 426 from outer side, advantages, 288 in paralytic deformities, 560 non-union after, 301 of femur, accidents, 287 division of ext. popliteal nerve, 287 hfemorrhage, 287 septic infection, 287 Out-knee {see Genu varum) Over-extended foot {see Talipes equinus) Over-flexed foot {see Talipes calcaneus) Pain, following immediate rectification of club-foot, 419 of fiat-foot, causation, 473 character, 472 position, 473 of scoliosis, 128 Painful great toe {see Hallux rigidus), 499 Palmar fascia, contraction of {see Dupuy- tren's contraction) Palm-pressure test in caries of spine, 31 Paralytic club-foot, 307 club-foot associated with genu recurva- tum, 293 Paralytic deformities, treatment, 557, 559 dislocation of hip, 555, 556 genu valgum, 273 tal. equinus, 332 Pathological changes in bones, in bow-legs, 295 tal. equinus, 332 Pathology of, acquired tal. valgus, 362 cong. contraction of fingers, 220 coxa vara, 268 flat-foot, 468 metatarsalgia, 492 spasmodic wry-neck, 194 Partial absence of fibula in equino-valgus, 360 Pedicles, altered in scoliosis, 135 Pelvis, hemi-atrophy of, in cong. tal. ec[uino- varus, 391 in cong. displ. of hip, 530 kyphotic, 94 ricketty, 260 scoliotic, 113 Peroneal paralysis, 356, 374 Peronei tendons, condition in flat-foot, 462, 471 position in flat-foot, 482 Peroneus longus and brevis, tenotomy of, 413 longus, position on os calcis in tal. equino-varus, 386 Pes cavus, 307 {see Tal. arcuatus and plan- taris), 351 Pes planus, 307, 358 and cong. displ. of hip, 358 in epileptics, 358 normal in certain races, 358 normal in infants, 358 Phelps' box for caries of spine, 53 operation, 435 failure if neck of astragalus deflected, 454 indications foi', 436, 437 in tal. varus, 358 method of, 435 relapse after, 436 Phthisis, death from, in caries of spine, 46 Physiological measures in cong. tal. equino- varus, 399 Pied creux valgus, 352 Pigeon-breast, 209 due to post-nasal and nasal obstruction, 211 Pigeon-toe {see Hallux varus), 498 Plantar fascia, contracted, 331 588 DEFORMITIES Plantar fascia, dissection out, 411 section of, 409 after-treatment, 411 Plasma-cells in tendon, 320 Plaster jackets, advantages, 56 disadvantages, 56 Plaster of Paris, jacket in scoliosis, 177 and relapsed club-foot, 455 in after-treatment of club-foot, 419 in tal. equinus, 337 splint, 403 Pleurisy and scoliosis, 154 Polydactylism, 224 and cong. tal. equino-varus, 391 in foot, 506 treatment, 225 varieties, 224, 225 Poroplastic jacket, advantages, 58 disadvantages, 58 in scoliosis, 177 in spinal caries, 54 " Post " in boots, for bunion, 497 Posterior ligament of ankle, retracted in cong. tal. equino-varus, 388 section of, 415 Posterior tibial artery, wounded in teno- tomy, 406 wound of, 413 Postural methods in treatment of scoliosis, 167 Pott's disease {sec Caries of spine) fracture, causing flat-foot, 467 Pregnancy, influence on caries of spine, 44 effect on scoliosis, 132 Prevention of scoliosis, ] 62 Prognosis of acquired tal. calcaneus, 343 acquired tal. valgus, 366 ankylosis, 516 bow-legs, 297 cong. tal. calcaneus, 340 cong. tal. equino-varus, 394 cong. tal. valgus, 361 coxa vara, 269 Dupuytren's contraction, 239 flat-foot, 475 genu valgum, 278 infantile hemiplegia, 551 metatarsalgia, 493 paralytic tal. equino-varus, 377, 451 relapsed varus, 457 scoliosis, 158 spasmodic wry-neck, 198 spastic tal. equino-vanis, 377 Prognosis of spinal caries, 42, 46 tal. arcuatus and plantaris, 356 tal. equinus, 334 Progressive muscular atrophy, scoliosis in, ; 150 ' and peroneal paralysis, 374 Prone position in caries of spine, 53 Pronounced flat-foot, 463 Psoas, importance of, in infantile paralysis, 555 abscess, IS where to open, 65, 66 Pseudo- hypertrophic paralysis, calves in, 312 scoliosis in, 150 Kachiotomy, 71 Kate of growth, effect on scoliosis, 160 Reaction of degeneration, 314 Recovery in caries of spine, 45 Recumbency, in scoliosis, 167 in spinal disease, 50 advantages, 50 disadvantages, 51 duration, 51 indications for, 50 special directions, 51 Reel-foot {sec Tal. equino-varus), 373 symptoms of, 382 Relapse, after Buchanan's operation, 439 after immediate rectification of club-foot, 420 in spastic tal. equino-varus, 378 of tal. equino-varus, want of sufficient after-treatment, 455 Relapsed club-foot, possibility of, 397 equino-varus, 452 tal. equino-varus, treatment of, 455 varus, 452 causes, 453 prognosis, 457 treatment, 455 Removal of a wedge of bone in bow-legs, 300 Reproduction of tendon, 318 Resection, of rib, eff'ect of scoliosis on, 155 of tarsus, argument against, in children, 384 wedge-shaped, 440 Rest in flat-foot, 477 Results of genxx valgum, 275 Retro-pharyngeal abscess, 77 Rhachitic attitude {sec Ricketty attitude) chest, grooves in, 210 deformities {sec Rickets), 253 INDEX 589 Rliachitic deformities of the long bones of the lower extremity {see Ricketty) scoliosis, 146 torticollis {see Ricketty torticollis) Rhachitis, effect on prognosis of scoliosis, 158 Rheumatism, and contracted i^lantar fascia, 353 and pes planus, 359 in spine, 93 Rib, bicipital, 209 cervical, 209 lumbar, 209 variations in, 209 Rickets, associated with genu recurvatum, 293 congenital, 253 definition, 253 description of bones in, 256 diagnosis, 257 distinguished from cong. syphilis, 257 etiology, 254 general treatment, 257 heredity not in, 254 infantile, 253 "late," 253 in genu valgum, 272 morbid anat., 255 osseous deformities in, 257 arms, 259 chest, 259 long bones of lower extremity, 260 pelvis, 260 skull, 257 spine, 259 scurvy, 254 senile, 253 stages in bone disease, 255 sj'mptoms, 256 theories of cause, 255 tubercular diathesis in, 255 use of foods in, 255 varieties of, 253 Ricketty attitude, 260 curvature of bones in bow-legs, 295 deformities, 253 of the long bones of the lower extremity, 260 genu valgum, 271 genu varum, 290 kyphosis, 35, 91 pelvis, 260 torticollis, 258 valgus, 364 Right-angled contraction of tendo Achillis, 312, 328 Right arm, excessive use of, and scoliosis, 164 Rigid flat.foot, 464 causes, 482 Rigidity in cong. tal. equino-varus, 395 Ring- catch, 427 Round-shoulders, 96 exercises for, 97 treatment, 96 Rotation of front of foot in cong. tal. equino- varus, 379 Sarcoma of spine, 80 Scaleni, action of, 195 Scaphoid, extirpation of, for flat-foot, 485 subluxated, in cong. tal. equino-varus, 383 talipedic, adult, 387 foetal, 386 Scarpa's shoe, 337, 422 " Schlummernde Zellen " of H. Schmidt, 321 School-desks, 123 Sciatic scoliosis, 151 Scoliosis, 102 adolescent, 120 causes, effective, 121 ,, predisposing, 120 age of increase, 132 age of onset, 103 alteration in outline of chest, 115 in position of transverse processes, 113 in position of vertebras, 112 in shape of bodies of vertebrae, 134 of ribs, 111 and enlarged tonsils, 156 appearances of flanks. 111 arrest of, 132 aspect of spine, 155 Bradford and Lovett's experiments, 142 cardiac displacement, 128, 131 C-curve, 107 importance of, 110 centre of rotation in spinous processes, 135 changes in vertebrse, 134 cicatricial, 154 clavicle in, 138 alteration in curve, 112 clinical aspects of deformity, 104 condition of muscles, 136 congenital, 145 definition, 102 diagnosis in general, 157 590 DEFORMITIES Scoliosis, discordant facts, 141 displacement symptoms, 128 due to torticollis, 113 effect of pregnancy on, 132 effect on abdominal viscera, 131 on spinal ligaments, 135 equal curves, 114 errors of accommodation of eye, 113, 123 examination of cases for. 123 faulty attitudes, effect of, 122 faulty position in writing, 115 frequency of, 102 from adenoids, 155 ,, empyema, 154 ,, infantile paralysis, 150 ,, hemiplegia, 150 ,, nasal obstruction, 155 ,, nasal obstruction, characters of, 157 ,, pleurisy, 154 ,, progressive muscular atrophy, 150 ,, pseudo-liypertrophic paralysis, 150 ,, sciatica, varieties, 151 ,, torticollis, 153 ,, wry-neck, 193 general appearance in, 111 general treatment of, 166 height of spinal column, 113 heredity in, 104 hysterical, 151 improvement in, 133 incipient period, 127 in locomotor ataxy, 150 Judson's experiment, 142 lungs, effect on, 131 mainly unilateral, 107 niamma», 113 mammalian spine affected with, 141 morbid anat., 133 myotomy, 181 natural arrest of, 132 obliteration of natural curves, 119 of nerve origin, 149 pain in causes, 128 paralytic, 554 pathogenesis of, 144 summing up, 144 position during sleep, 163 posterior projection of spinous processes, 117 prevention of, 162 prognosis, 158 discussed under headings, 158 puberty, effect of, 120 Scoliosis, rate of development, 161 respiratory capacity in, 131 results on trunk, 111 rhachitic, 146 age, 147 appearances, 149 faulty position in carrying child, 146 scapulie, ijosition of, 112 S- curves, 114 sex, 103 stage of development, 127 stage of, effect on prognosis and treatment, 157 static, 152 due to asymmetry of limbs, 152, 153 striations on vertebral bodies, 134 symptoms, 127 three or more curves, 116 tieatment, 166 ct seq. by accumulators, 174 apparatus, 176 double horizontal bar, 174 exercises, 170 forcible correction, 175 jacket and occipital head-piece, 177 jury-mast, 168 manipulation, 175 plaster of Paris, 177, ISl poroplastic jacket, 177, 181 postural methods, 169 rachilysis, 175 recumbency, 168 suspension, 173 suspensory cradle, 168 wicker tray, 169 daily routine, 180 during sleep, 168 indications for various methods, 177 value of singing exercise, 172 varieties, 119 wedge-shape of vertebral bodies, 134 with reversion of curves, 119 writing in fault}' attitudes, 123 Scoliosometer, need of, 126 Scoliotic pelvis, 140 Scurvy-rickets, 254 appearance of chest, 210 symptoms, 254 Senile kyphosis, 95 rickets, 253 Septicaemia after tarsectomy, 446 Serratus magnus, paralysis of, 554 Sex, scoliosis, prognosis in, 159 INDEX 591 Shortening of lower limbs in cong. displ. of hip, 532 Shoulder, accidents after breaking down, 517 bony auk3'losis of, treatment, 518 fibrous ankylosis of, treatment, 517 paralytic luxation of, 554 Singing, value of, in scoliosis, 172 Site of scoliosis, prognosis, 160 Sitting, faulty position in, and scoliosis, 164 Skin, condition in cong. tal. ef|uino-varus, 390 Skin-gi-afting in Phelps' operation, 435 Skull, deformities in rickets, 257 osseous deformities in rickets, 257 Sleep, position during, and scoliosis, 163 Snap-finger, 245 Social condition, influence of, on prognosis of caries of spine, 44 Spasm in flat-foot, 463 Spasmodic flat-foot, 462, 464 Spastic club-foot, 307 paralysis in children, 549 tal. equinus, 332 Spina bifida and cong. tal. equino-varus, 391, 392 and tal. calcaneus, 340 Spinal accessory nerve, resection of, 206 incurvation (see Lordosis), 99 stays in scoliosis, 177 Spine, abscess of, 16 dissection of sac, 69 summing up of treatment, 69 anterior deformity of (see Lordosis), 99 cardiac curve of, 87 caries of, 3 abscess in, 10 absence of bony pressure, 12 absence of true dislocation in, 12 acquired, 6 acute miliary tuberculosis in, 46 advantage of recumbency, 50 age of onset, 3 alteration of pupil in cer\'ical caries, 34 bursa over projection, 14 compression-paraplegia, treatment, 70 congenital, 6 danger to life, 45 definition, 3 deformity in, 11 diagnosis, 35 from coxitis, 40 ,, hysterical spine, 35 ,, malignant disease of spine, 38 Spine, caries of, diagnosis from osteo-arthritis and osteitis deformans, 40 from perinephritis and perityphlitis,40 ,, rhaehitic kyphosis, 35 ,, sacro-iliac disease, 40 ,, scoliosis, 36 ,, senile kyphosis, 35 diet in, 50 disadvantages of recumbency, 51 displ. of apex beat of heart, 15 displ. of viscera, 15 due to aneurism of aorta, 41 duration of recumbency, 51 etiology, 3-6 evacuation of pus from spinal canal, 69 events of inflammatory process, 9 extension in, 52 fixation and supporting appliances in, 55 flatness of back, 13 flattening of normal curves, 33 general treatment, 49 grunting respiration in, 31 herpes zoster in, 33 increase of deformity, 15 jury-mast, 54 kinking of aorta, 15 lateral deformity, 12, 13 localisation, 6 method of examination, 29 muscular rigiditj^, 30 how estimated. 31 myelitis, 24 natural methods of cure, 11 necrotica, 10 night-cries, 32 cesophageal obstruction, 48 pachymeningitis, 24 pain, 32 reflected, 32 subjective and objective, 32 "palm-pressure" test, 34 part of vertebrte first attached, 8 Phelps' box in treatment, 53 plaster jacket, 54, 56, 57 advantages, 56 application of, 57 disadvantages, 56 poroplastic jacket, 54, 58 position during recumbency, prone or supine, 53 pressure on nerve-roots, 24 principles of local treatment, 50 probability of recovery, 45 592 DEFORMITIES Spine, caries of, prognosis, 42 of uncomplicated cases, 42 proportion of cases affected with com- pression-paraplegia, 160 Rauchfuss' suspensory cradle, 52 recession of deformity, Ifi, 59 recumbency, indications for, 50 special points to be observed, 51 retentive arrangement for use in, 52 sicca, 10 suspension, 54 symptoms, 29 syphilitic, 6 thickening around affected vertebra?, 33 Thomas' splint, 54 tracing of projection, 15 traumatism, 4, 6 treatment, 49 discontinuance of, 59 tubercular meningitis, 24 tuberculosis as a factor, 4 yielding of, on pressure, 34 centre of gravity of, 88 cervical caries, case of, 18 diagnosis from •vvry-neck, 39 cong. syphilis of, rarity of, 79 contrast of infantile and adult, 88 curves of, 85 existence of nonnal lateral curve to right, 86 extension of, 87 flexion of, 87 gonorrheal rheumatism, 93 hepatic curve of, 87 hysterical, 82 lateral curvature of {see Scoliosis) deviation of, 105 flexion in, 88 length of, 85 malignant disease of, 80 deformity in. 39 pain in, 39 movements in, 87 osseous deformities of, in rickets, 259 osteo-arthritis, 93 osteo-malacia, 94 physiologj', 84 rheumatic aS"ections, 93 rheumatoid arthritis, 93 rickets in, 146 rotary lateral curvature {see Scoliosis) rotation, 88 spondylitis, 93 Spine, syphilis in, 74, 77 Spinous processes, altered in scoliosis, 135 Spurious ankylosis, 512 conditions for manipulation, 513 treatment, 512 flat-foot {sec Flat-foot), 458 Splay-foot {see Flat-foot), 458 Spleen, displaced in scoliosis, 131 Splenius, action of, 194 Splints, dextrine and starch, 420 felt, 403 gum and chalk, 420 gutta-percha, 403 poroplastic, 403 silicate of potash, 420 Spondjditis, 3 of spine, 93 Spondylolisthesis, 100 Spreading of toes, 330 Spring-finger, 245 Stages of bone disease in rickets, 255 of osseous rickets in bones of leg, 295 Standing position and scoliosis, 163 Static flat-foot {see Flat-foot), 458 genu valgum, 271 scoliosis, 152 Sterno-mastoid, action of, 194 divided at upper end, 202 by "open" method, 201 in middle, 200 tenotomy or subcutaneous section, 200 Sternum, depressed, 209 effect of scoliosis on, 139 funnel-shaped, 208 perforated, 208 Stiff-joint {see Ankylosis), 511 Stiff-neck, 185 Stokes' operation for flat-foot, why preferred, 488 Strabismus in infantile hemiplegia, 550 Subcutaneous section of all flexor tendons at wrist, 369 case of, 370 Supernumerary fingers {see Polydactylism), 244 Supports in scoliosis, 167, 177 Suppression of fingers, 225 Suppuration after tarsectomy, 445 Surgical soles, 479 Sweating feet and flat-feet, 461, 475 of foot in flat-foot, 461, 475 "Swell" of calf in cong. club-foot, 312 Swelling of feet in flat-foot, 474 INDEX 593 Symptoms of, acquired tal. calcaneus, 342 acute wry-Deck, 195 ankylosis, 515 bunion, 496 club-hand, 216 cong, displ. of hip, 530 et seq. cong. tal. equino-varus, 382 cong. tal. valgus, 361 cong. wry-neck, 195 coxa vara, 265, 267 Dupuytren's contraction, 238 flat-foot, 472 ■ genu valgum, 276 genu varum, 293 hallux rigidus, 499 malignant disease of spine, 81 mallet-finger, 248 metatarsalgia, 490 rickets, 256 scoliosis, 127 scurvy rickets, 254 spasmodic wry-neck, 197 Syndactylism, 226 and cong. tal. equino-varus, 391 in foot, 506 Syndesmotomy, 414 in tal. varus, 357 Syphilis, cong., distinguished from rickets, 257 in Dupuytren's contraction, 235 Syphilitic curvature of tibia, 301 treatment, 305 disease of spine, 77 points of distinction, 79 Talipes and scoliosis, 153 Talipes arcuatus, 307 and calcaneus, 352 ,, contraction of peroneus longus, 352 ,, Friedreich's disease, 352 ,, plantaris, prognosis of, 356 appearance of foot in, 351 causes, 352 connection with tal. plantaris, 355 due to zymotic diseases, 354 from paralysis of interossei, 353 in tal. calcaneus, 339 pain in, 354 paralytic, 352 treatment, 356 Talipes-calcaneo valgus, 307, 348 appearance of foot in, 349 Talipes calcaneo-valgus, paralytic, 349 Talipes calcaneo-varus, 307, 348 appearance of foot in, 350 Talipes calcaneus, 306, 338 after section of tendo Achillis, 342 appearances of foot in, 338 causation, 338 different appearances in cong. and ac- quired, 342 from lengthening of tendo Achillis after section, 409 prognosis, 340 Talipes calcaneus, acquired, 341 appearances of foot in, 341 arcuatus in, 341 difficulty of keeping heel up, 343 Judson's apparatus in, 345 morbid anat. of bones, 343 fascise, 343 joints, 343 muscles, 343 skin, 343 prognosis, 343 symptoms, 342 treatment, 344 by arthrodesis, 348 Gibney's method, 346 Nicoladoni's method, 345 section of plantar fascia, 345 Walsham's method, 348 Willett's method, 346 Z-method, 347 Talipes calcaneus, congenital, 339 aspect of foot in, 339 complications — absence of bones, 340 genu recurvatum, 340 hydrocephalus, 340 spina bifida, 340 toes, deficiency of, 340 morbid anat., 340 treatment, 340 Talipes decubitus, 308, 332 Talipes equino-valgus, 307, 368 treatment of, 368 Talipes equino-varus, 307, 373 causes, 373 Talipes equino-varus, acquired, 373 action of muscles in, 374 articular, 373 causation, 374 from dislocation, 373 ,, fractures, 373 ,, inflammatorv conditions, 373 2 Q 594 DEFORMITIES Talipes equino- varus, acquired, from epi- physial separation, 373 paralytic, 374 spastic, 374 traumatic, 373 Talipes equino-varus, congenital, 373 abnormal development of bones of foot, 393 after-treatment of, 423 appearances in adult life, 381 in infancy, 380 arrested development of bones of leg, 392 bones, condition of, 384, 385 characters, if resistant, 421 complications — absence of bones, 379 absence of fingers, 379 amputation (intra-uterine) of limbs, 379 meningocele, 379 polydactylism, 379 syndactylism, 379 creases in sole, 382 degrees, first, 380 second, 380 third, 381 fourth, 381 diagnosis from hysterical scoliosis, 398 from paralytic variety, 398 ,, spastic variety, 398 etiologj' of, 391 free subcutaneous section of structures, 437 frequency of, 379 gait in, 382 gradual rectification of foot in, 420 immediate rectification of foot in, 419 importance of leaving tendo Achillis un- touched till last stage, 379 ligaments, condition of, 388 mechanical causes, 392 muscles, condition in, 389 nature of deformity, 378 nearthroses in, 387, 388 nerve lesions, 392 obstacles to reduction, in adult, 391 in infant, 391 outline of tread, 383 prognosis, 394 rapid rectification of, 420 sites of deformity, 378 symptoms, 382 tendons affected and their direction, 3S9 treatment by open incision, 435 by Phelps' operation, 435 Talipes equino-varus, congenital — treatment in two stages, 409 of first degree, 400 second degree, 404 structures requiring division, 409 third degree, 429 by gradual metliods, 430 fourth degree, 439 genu recurvatum in, 427 inversion of limb in, 424, 425 walking ajjparatus for, 423 when commenced, 400 Talipes equino-varus, paralytic, 373 astragalus, position of, 376 condition of muscles, 376 morbid anat., 376 OS calcis, position of, 376 prognosis, 451 special points in, 449 substitution of healthy for paralysed muscles, 451 treatment of, 449 by manipulation. 450 by tenotomy, 450 Talipes equino-varus, spastic, 373 appearance of foot, 376 muscles affected, 374 prognosis, 377 treatment, 451 Talipes equinus, 306, 328 astragalectomy in, 338 causation, 331 congenital, 332 degrees of, 328 diagnosis of, 335 first degi'ee, 328 second degree of, 329 third degree, 331 treatment of, 338 morbid anat., 333 bones, 333 ligaments, 334 muscles, 334 skin, 334 tendons, 334 prognosis of, 334 section of plantar fascia, 336 of tendo Achillis, 336 spastic V. paralytic, 332 treatment, 336 use of wrench in, 338 walking apparatus for, 336 Talipes plantaris, 307, 352 IXDEX 595 Talipes plantaris, appearance of foot, 351 causation, 352 lameness in, 355 paralytic, 352 treatment, 356 Talipes valgus, 306, 358 Talipes valgus, acquired, 361 appearances of foot in, 362 pathology, 362 bones, 362 fasciae, 363 ligaments, 362 muscles, 362 skin, 362 prognosis, 366 Talipes valgus, congenital, 359 appearances of foot, 359 associated with other deformities, 359 convexity of tibia in, 361 curvature of tibia in, 361 prognosis, 361 treatment, 366 Talipes valgus, false {see Flat-foot), 458 Talipes valgus, hysterical, 365 Talipes valgus, paralytic, 363 two forms of, 363 treatment, 367 Talipes valgus, pathological, 366 ti-eatment of, 367 Talipes valgus, spastic, 365 special points of, 363 treatment, 367 Talipes valgus, traumatic, 365 treatment of, 367 Talipes varus, 306, 356 Talipes varus, congenital, 356, 373 due to cicatrices, 356 due to relapse of equino-varus, 357 from infantile paralysis, 356 general appearance of foot, 357 in progressive muscular atrophy, 356 morbid anat. of, 357 spastic, 357 treatment, 357 Tarsectomy, comparison of forms, 449 conclusions on, summing upi, 448 considerations on, 445 duration of treatment, 447 efficiency of, 446 necessity for apparatus after, 448 - possibility of relapse, 448 risk of, 445 in tal. varus. 357 Tarsectomy, methods of, 443 Tarsotomy, 440 Tender points in flat-foot, 473 Tendo Achillis, excessive elongation of, 423 functional prognosis after section, 371 incomplete division of, 414 last tendon divided in cong. tal. equino- varus, 379 lengthening of, 341 possible interval for union, 370 section of, in pseudo-hypertrophic paralysis, 562 shortened in acquired tal. calcaneus, 345 shortening in cong. tal. equino-varus, 389 tenotomy of, 413 thin and membranous. 341 transfixed, 453 Tendon, cartilage cells in, 321 latent cells in, 321 Tendons and their directions in cong. tal. equino-varus, 389 imperfect division of, 407 longandweakin cong. tal. equino-varus. 390 missed, 407 new material, how formed, 318 non-union of, 407 normal structure of, 320 plasma-cells in, 327 possibility of perfect regeneration, 327 union of, author's experiments, 321 et seq. clinical aspect of, 368 influence of effused blood, 319, 326 of tendon-cells, 319 leucocytes in, 319, 327 primary imion of, 319, 327 share of tendon-sheath in, 327 summary of processes, 326 Tendon-sheaths, effusion into, in flat-foot, 474 influence of, on imion of tendon, 319 structure of, 320 Teno-synovitis, after tenotomy, 407 Tenotomy, accidents, 406 auiesthetics in, 405 aneurism after, 407 antiseptics in, 405 causes of failure, 406 general remarks on, 405 gradual reposition of foot after, 408 hemorrhage after, 407 immediate reposition of foot after, 408 in cong. tal. equino-varus, 404 inveterate club-foot, 440 tal. varus, 357 DEFORMITIES Tenotomy, knives, 405 non-union of tendon, 407 open method, 405 subcutaneous, 405 suppuration after, 406 teuo-synovitis after, 407 Thigh atrophied in cong. tal. equino-varus, 391 Thomas' wrench, 434 correction, of adduction deformity, 418 equinus deformity, 417 tiat-foot, 483 inversion of foot, 417 relapsed club-foot, 456 tal. varus, 357 leather collar, 54 Thorax, effect of scoliosis on, 138 Thrombosis of cerebral veins in children, 549 Tibia, abnormalities of, in cong. tal. valgus, 359-361 absence of, in cong. tal. equino-varus, 392 cong. syphilitic curvature of, 302 diagnosis of ricketty and syphilitic curves, 304 inversion of, 424 syphilitic curvature of, 301 treatment of syphilitic curve of, 305 Tibia and fibula, inward rotation, correction of, 418 osteotomy of, 440 Tibialis anticus, paralysis of, in flat-foot, 470 tenotomy of, 411 Tibialis posticus, position of, in fiat-foot, 471 tendon imperfectly divided, 453 tenotomy of, 412 Tiptoe gait, 311 Toes, clawing of, 337 deficient in tal. calcaneus, 340 hyper-extended in tal. plantaris, 355 lateral deviation of, 507 suppi'ession of, 506 Tonsils, enlarged and pigeon-breast, 211 enlarged and scoliosis, 156 Torticollis {sec Wry-neck), 185 ocular, 192 producing scoliosis, 113 ricketty, 258 Trachea, eff"ect of scoliosis on, 137 Transverse processes altered in scoliosis, 135 Trapezius, action of, 194 paralysis of, 554 Traumatic genu valgum, 272 tal. equinus, 332 tal. valgus, 365 treatment, 367 Treatment of, atlo-axoid disease, 77 bony ankylosis, 518 bow-legs, 297 bunion, 496 club-foot, general remarks, 315 methods — mechanical, 316 objects in, 315 operative, 316 persistency in, 396 physiological, 316 club-hand— operative on bones, 217 passive movements, 217 tenotomy, 217 cong. contraction of fingers, 221 deformities of chest, 209 tal. calcaneus, 340 tal. equino-varus, 399 coxa vara, 269 Dupuytren's contraction, 240 fibrous ankylosis, 516 fourth degree of tal. equino-varus, 439 general, of rickets, 257 of spinal caries, 49 genu valgum, 278 genu varum, 293 hallux rigidus, 500 hammer-toe, 503 hypertrophy of fingers, 230 infantile hemiplegia, 552 inveterate club-foot, 439 jerk-finger, 247 local, of spinal caries, 50 lordosis, 100 mallet-finger, 248 metatarsalgia, 493 paralytic deformities, 557 mechanical, 557 operative, 559 pathological tal. valgus, 367 polydactylism, 225 relapsed tal. equino-varus, 455 tal. varus, 455 rigid flat-foot, 482 scoliosis, 166 spasmodic flat-foot, 482 wiy-neck, 205 spastic tal. equino-varus, 451 IXDEX 597 Treatment of spastic tal. equiuus.. 338 tal. valgus, 367 syphilitic curve of tibia, 305 tal. arcuatus, 356 calcaneus, 34:4 equinus, 336 plantaris, 356 valgus, congenital, 366 valgus, paralytic, 267 varus, 357 wry-neck, 198 Trunk, paralytic deformities of, 554 Tubby's method of treating bunion, 497 Tubercular diathesis in rickets, 255 Types of bow-legs, 295 Uxiox of tendon, 313 author's method of experiment, 319 TALOrS AXKLES, 458 Varieties of genu valgum, 271 rickets, 253 wry-neck, 185 Varus, imperfect cure of, 453 relapsed, due to imperfect division of soft structures, 453 Vasoblasts, 322 Voice, partial loss of, in retro-pharyngeal abscess, 77 Vomiting, attacks of, in infantile paralysis, 553 "Walking apparatus for acquired tal. cal- caneus, 344 for tal. equinus, 337 Walsham's cuirass for caries of spine, 54 glycerine pad for flat-foot, 479 Ward's reclining chair, 168 "Weak ankles, 458 position of parts, 458 Webbed fingers, choice of operation, 228 treatment, 226 varieties, 226 Wedge from bone, removal of, in bow-legs, 300 Whitman's brace, 479 valgus plates, 480 Wicker-tray of Adams, 91 Wrenches, Bradford's lever, 417 Grattan's osteoclast, 417 Phelps' apparatus, 417 Thomas', 416 Vincent's, 416 Wrenching, dangers of, 418 for resistant club-foot, 432 in club-foot, 416 Wrenching foot, separation of epiphyses, 418 gangrene, 418 tearing skin, 418 Wrist, fibrous ankylosis, treatment, 517 Writing, faulty position in, and scoliosis, 164 Wry-neck, 185 acute, 185 symptoms, 195 treatment, 198 causation, 186 chronic, 185 classification, 186 combination of muscles, 195 complication by scoliosis, 193 cong., after-treatment, 203 anat., 192 asymmetry of cerebral hemisx^heres, 194 of clavicles, 193 of face, 193 author's cases, 188-191 causes of defective development of face, 194 changes in vertebrae, 193 contraction of fascife, 193 defective development of cheek, 193 deformity in, 195 deviation of nose, 193 due to injury at birth, 186 etiology, conclusion as to, 191 forcible correction, 202 generally in males, 186 hcematoma of sterno-mastoid, 187 induration of sterno-mastoid, 187 on right side, 186 sternal head more often affected, 193 symptoms, 195 syphilis, influence of, 187 treatment, 198 by manipulation, 199 mechanical, 199 open section, advantages, 202 disadvantages, 202 operative, 199-203 tenotomy, advantages, 202 disadvantages, 202 definition. 185 etiology, 186 spasmodic, 186 causes, 191 diagnosis, 197 598 DEFORMITIES "Wiy-ueck, spasmoiUc, from astigmatism, 192 from epilepsj', 192 habit spasm, 192 more iu women, 186 myotomy, 205 pathology, 194 prognosis, 19S resection of spinal accessor}' nerve, 206 Wry -neck, spasmodic, 195 symptoms, 197 treatment, 205 operative, 205 treatment, 198 et scq. varieties, 1S5 Zeller's operatiox, 227 retrocollic spasm. 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