'^^2. i,-^ i^-j CUfllumbta Hmn^rsttg in X\\t Oltty of Nrm fork S^fj^r^nr^ IGtbrarg TREATISE ON ORTHOPEDIC SURGERY BY EDATAED H. BRADFORD. M.D. Surgeon to the Boston Children's Hospital ; Consulting Surgeon to the Boston City Hospital; Professor Orthopedic Surgery, Harvard JJedical School AXD ROBERT ^\, LOYETT. M.D. Surgeon to the Infants' Hospital and to the Peabody Home for Crippled Children; Assistant Surgeon to the Boston Children's Hospital ; Assistant in Orthopedic Surgery, Harvard Medical School THIRD EDITION ILLUSTRATED BY FIVE HUNDEED AND NINETY-TWO ENGRAVINGS NEW YORK WILLIAM WOOD AND COMPANY MDCCCCVII .J) i Copyright, 1905, By WILLIAM WOOD AND COMPANY )l^)bll i- TO Cbarles TKIlilliam leUot PRESIDENT OF HARVARD UNIVERSITY, THIS BOOK IS DEDICATED. .IX EXPRESSION OF RESPECT FOR THE MOST STi:in:LATIXG OF EDUCATORS. PREFACE TO THE THIRD EDITION. In preparing the third edition of this work it has been necessary to rewrite entirely several portions, to make extensive alterations in others, and to rearrange chapters and subjects. These changes have been made in the endeavor to offer to the reader a description of the present condition of orthopedic surgery with its notable progress since the pub- lication of the second edition in 1 899. The most marked difference between the second and third editions will be found in the chapters treating of congenital dislocation of the hip, of scoliosis, of traumatic and non-traumatic coxa vara, and of non- tuberculous diseases of the joints, as it is in the study of these subjects that the greatest advances have been made. Many original illustra- tions have been added and many of the old ones have been improved, making them more illustrative of the subjects mentioned in the text. A chapter giving the details of orthopedic apparatus, with descrip- tions and drawings of appliances found to be of practical efficiency, is added in the hope of giving to the general practitioner technical infor- mation which is of use in the treatment of orthopedic affections. The authors are greatly indebted to friends and colleagues for many helpful suggestions and for their ready permission to make use of their illustrations and clinical material. Boston, April ist, 1905. Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/treatiseonorthopOObrad CONTENTS CHAPTER I. PAGE Tuberculous Disease of the Joints, i CHAPTER n. Tuberculous Disease of the Spine, i6 CHAPTER in. Tuberculous Disease of the Hip, 84 CHAPTER IV. Tuberculous Disease of the Knee, 147 CHAPTER V. Tuberculous Disease of the Ankle and other Joints, . .171 CHAPTER \ I. Infectious Osteomyelitis — Infectious Synoxttis and Arthritis, . 186 CHAPTER Vn. Arthritis Deformans, 196 CHAPTER VIII. Other Affections of the Bones and Joints, 224 CHAPTER IX. Rickets, Knock-knee, and Bow-legs, . . . . . . 271 CHAPTER X. Coxa \'ara and Coxa \\alga, 30S CHAPTER XL Lateral Curvature of the Spine, . . . . . . .322 V vi CONTENTS. PAGE CHAPTER XII. Other DEFORmTiES of the Spine and Thorax, , . . -375 CHAPTER XIII. Torticollis, 392 CHAPTER XIV. Anterior Poliomyelitis, 406 CHAPTER XV. Spastic and other Paralyses, . 445 CHAPTER XVI. Functional Affections of the Joints, 467 CHAPTER XVII. Unilateral Atrophy and Hypertrophy, 476 CHAPTER XVIII. Congenital Dislocations, 479 CHAPTER XIX. Talipes, 518 CHAPTER XX. Flat-Foot and Other Deformities of the Foot, • . . . 559 CHAPTER XXI. Practical Details of Apparatus, 601 ORTHOPEDIC SURGERY. CHAPTER I. TUBERCULOUS DISEASE OF THE JOINTS. Pathology. — Etiology.— Prognosis. — Principles of Treatment. Orthopedic surgery deals with the prevention and correction of deformity, and demands not only a study of the deformities of the hu- man body, but also some knowledge of the affections which produce them. Of these the most important are the tuberculous diseases of the joints. Bone tuberculosis has been called strumous, scrofulous, and fungus disease, caries of bone, etc., and various theories as to the predisposing cause have been presented. It is known to be the result of the inva- sion of the tubercle bacillus, which frequently finds a favorable soil for development in the spongy bone of the growing epiphyses. PATHOLOGY. Articular tuberculosis begins as an affection of the spongy tissue of the epiphysis, generally near its line of junction with the shaft, occa- sionally near the articular cartilage. It occurs usually as a localized disease, appearing in one or more distinct foci; a simultaneous tuber- culous infiltration of the whole epiphysis, however, rarely happens. The common form of tuberculous infection of the epiphysis is the one spoken of as focal or encysted, when the first change is the forma- tion of single or multiple foci of tuberculous degeneration. On section of the diseased epiphysis the first noticeable change consists in a local hypersemia of some part of the spongy tissue. There then appears in this hypersemic area a small, grayish, translucent spot, almost as small as one can see, which grows more gray and increases in size, while a zone of hyperaemic tissue develops around it and the neighboring bone looks boggy from an excess of the transuded fluid. At first usually there is no synovitis ; it is purely a localized ostitis. The tubercle bacilli, being lodged in the marrow of the bone, cause a multiplication of the surrounding cells, probably by the action of a toxin, and a typical tubercle is formed. Such an area consists of a cen- tral mass of giant and epithelioid cells surrounded by a zone of lym- ORTHOPEDIC SURGERY. phoid cells. As the tuberculous area increases by multiplication of the cells, the centre degenerates, forming a necrotic mass in which fat drops may be seen. Sometimes the tubercle bacillus can be found, usually in small numbers, in the giant cells, or in the epithelioid cells, or between them. The process extends by the formation of other tu- bercles, apparently due to the multiplication of the tubercle bacilli and their diffusion through the tissues. New ne- crotic areas like the first are found, which coalesce and form a mass of caseous mater- ial. Around the tuber- culous area there appears a zone of non- tuberculous granulation tissue early in the proc- ess. During the later and reparative stages of the process this area becomes less vascular and is converted into denser fibrous tissue. As the individual tubercles meet and co- alesce, they form, in the marrow of the bone, ir- resfular caseous masses. i^S^ MOd' •". ■^^1 ^Jv^v^v_wQ ,,;#- y, in tnis way large areas *^' )' ■•;'^* '■^i*=**€'*'- of bone may be involved by peripheral enlarge- ment of the tuberculous area. This area may soften and a tubercu- lous bone abscess may result, the purulent ma- terial containing bone fragments like sand. Instead of forming a " bone abscess " the process may result in the formation of a sequestrum composed of necrotic trabeculae retaining their shape and lying in a cavity in the bone. x-\bout the sequestrum is a layer of granulation tissue. The sequestrum may take the shape Fig, -Section of Tuberculous Synovial Membrane. (Nichols.) TUBERCULOUS DISEASE OF THE JOINTS. of a wedge having its base toward the joint, in which case it is known as a " bone infarct." As the diseased focus grows larger it looks more yellow in spots, and shows at its centre a tendenc)- to cheesy degeneration, and later in the history of the affection one finds nodules, varying in size from that of a pea to a hazelnut, which are filled with a putty-like substance, such as the cheesy material found elsewhere in the body, except that it contains spicules of bone from the trabeculae, and in the larger foci pieces of dead bone of considerable size are found. Later in the history of the affection the tuberculous nodule may break down into purulent material. Generally the original focus is sur- rounded by smaller tubercles, which aid in its extension ; but the chief work is done by the erosive action of the granulations, which take the place of the progressively rarefied bone. From the stage of tuberculous infiltration the process may follow any one of three courses : the diseased focus may be absorbed and so Fig. 2.— Tumor Albus. Small focus in upper epiphyseal line of tibia. Synovitis of joint, but no tuber- culous process apart from focus- as noted. Death from miliary tu- berculosis, a. Epiphysis; b, pri- mary focus; c, shaft. (Nichols.)- Fig. 3. -Tuberculous Epiphysis. Vertical section through the head of the radius, a. Shaft of radius; b, epiphyseal cartilage; c, epiphysis; d, joint surface; cartilage; <", tuberculous primary focus; /", perforation of joint cartilage and infection of joint; £', tuberculous '■ pannus " extending over joint cartilage. (Nichols.) cured ; it may extend to the periphery of the bone and break through the periosteum and empty itself there ; or, lastly and probably most commonly, it may extend to the joint and infect that. OR TH OPEDIC S UR GER V. 1 . The absorption of the diseased focus is theoretically possible up to a late stage in the process, so long as the disease remains strictly local and no sequestra of an}- size have formed ; the pus ma}' become cheesy and calcified. 2. The next most favorable termination to the disease is when the focus does not infect the joint, but breaks through the periosteum and discharges into the periarticular structure. This happens when the focus is so situated that the line of least resist- ance takes it to another part of the bony surface away from the joint, there forming probabl}' an abscess which must be evacuated externally or break. Sometimes this ends the disease; the granulation tissue be- comes fibrous, and then osseous, and the disease is over. This, according to Krause, is most likely when the focus is in the upper or lower end of the tibia or in the olecranon.' It is not likely to occur in the hip on account of the extensive distribu- tion of the capsule. 3. Probably the com- monest course for this localized ostitis to pursue is to break into the joint cavity, and the ease with which infection of the joint from the epiphysis is produced will be readily understood b}' considering the pathological conditions. The seat of the disease in the beginning is ordinarily not far from the cartilage. At first it excites no joint inflammation, but when it reaches a certain stage, even before it breaks into the joint, inflamma- tory reaction in the joint begins." The inflammation of the joint at ' Krause : " Tub. der K. und Gelenke." 1S91. - Lannelongue : " Co.xo-tuberculose." Paris. 1S86. Pig. 4. — Section of Tuberculous Synovial Membrane. Numerous tubercles with giant cells. Between these, oedematous granulation tissue with many lymphoid and plasma cells. (Nichois.) TUBERCULOUS DISEASE OF THE JOINTS. 5 first is non-tuberculous, the synovial membrane appearing thick and cedematous, the cavity of the joint being filled with a serous inflamma- tory exudate. This process may be very extensive. Perforation of the joint by the tuberculous focus is the next step in the process. When the tuberculous focus underlies it, the cartilage of the joint begins to disintegrate and appears softened and yellow, and •i * Fit;. 5.— Tuberculous Knee, Process of Repair Advanced. Small focus persists, i?, Tibia ; /', tuberculous softening ; r, femur ; d, patella. (Nichols.) finally breaks through. The perforation frequentl)- occurs near liga- ments. The tubercle bacilli, having entered the joint, are quickly dis- seminated by movement of the articulation, and the synovial membrane becomes infected. The synovial membrane then appears thick, smooth, and shining, and sometimes nodular; the surface is studded with small .specks not larger than the head of a pin. The yellow tuberculous areas increase and soften, and tuberculous ulcers of the synovial membrane form. The thickened synovial membrane extends as a pannus growth over the 6 ORTHOPEDIC SURGERY. edge of the articular cartilage, sometimes covering the whole cartilage. At the same time the tuberculous process may extend between the car- tilage and bone. The cartilage beneath the pannus layer is destroyed and disintegrated, while the free surface of the cartilage becomes fibril- lated and ulcers appear in it also. When the tuberculous process ex- tends beneath the cartilage the latter is eroded and destroyed. Large areas of cartilage may be detached from the underlying bone, and sometimes the entire cartilage may be loosened, as in the hip-joint. Under these conditions the denuded end of the bone is seen to be co\- ered with nodular granulation tissue filled with tubercles, caseous and otherwise. As the disease goes on the cartilage is destroyed or cast off in flakes, and the denuded bones are attacked by the tuberculous proc- ess and are eroded. As a result of this, articular cavities are enlarged and distorted, and distortions and subluxations may occur. The tonic muscular contraction accompanying joint disease tends in certain joints to crowd together the softened ends of the bones and hasten the wear- ing away. Microscopical examination of the diseased area at any time before all structure is lost shows a typical granulating tuberculosis. Thickening of the capsule, infiltration of the periarticular tissues, and thickening of the ends of the bones are clinical manifestations, and abscess formation and all the other complications are ready to follow. About the affected joint is formed a layer of granulation tissue which may be converted into fibrous tissue. This process may be very extensive and accounts for such phenomena as the ovoid swelling in tu- mor albus and the thickening of the trochanter in hip disease. This fibrous tissue may be oedematous, and the spaces may contain a fluid reacting to stains like mucin. Repair is brought about by the formation of fibrous tissue, probably arising from the layer of non-tuberculous granulation tissue which grows into and replaces the tuberculous material. Caseous material is largely absorbed, and the inspissated remainder is replaced by fibrous tissue or is calcified and encapsulated. Fibrous, cartilaginous, or bony ankylosis may result from the process of repair. It is most important to note that the process of repair may be in- complete, and that small areas of tuberculous material encapsulated by fibrous tissue may persist for a long time and under favorable condi- tions may become active and cause a recurrence of the disease. This fact must alwa}-s be borne in mind in forcibly manipulating convales- cent tuberculous joints. Or the repair may be complete and the previ- ously inflamed tissue be converted into cicatricial bone — usually more firm than the original structure. Certain variations of this process must be described as other t3'pes of synovial affection from that described are found at times. TUBERCULOUS DISEASE OF THE JOINTS. 7 Arborescent tuberculous synointis is the name given to a condition in which the synovial membrane is covered with branching arborescent tags frequently coated with fibrin. Sometimes a large amount of fatty tissue may be present, constituting the " lipoma arborescens." • Solitary tuberculous nodules of the synovial membrane are described. Nodular and even polypoid growths with little tendency to caseation Fig. 6.— True Ankylosis of the Hip Joint. CJoachimsthal.) project into the joint. Although at first the rest of the synovial mem- brane is but little affected, it becomes involved later. Hydrops articiilonmi tuberculosus was a name given by Konig to a chronic effusion of joints said to be primarily synovial. In these there is said to be at first no marked thickening of the synovial membrane. Later the membrane assumes the typical character of tuberculous syn- ovial inflammation. A similar condition of joints with a purulent effu- sion is described as "empyema tuberculosum." It has always been asserted by writers on bone tuberculosis that primary disease of the synovial membrane occurred. Volkmann, how- 8 ORTHOPEDIC SURGERY. ever, as early as the writing of his classical monograph, said : " The fungous inflammations of the joints begin generally, and in children almost without exception, not at all as an arthropathy, but as a pure osteopathy, with a very circumscribed caseous or tuberculous ostitis." ' Nichols,- in one hundred and twenty tuberculous joints examined from children and adults, man}- from excisions, a considerable number from autopsies or amputations, did not see a joint in which, if all the bones entering into the joint were sawed open, one or more old bone foci were not found. Complete examination of a joint at operation is usually difficult and oftenest impossible, so that conclusions as to the absence of primar}- bone disease based upon such examinations must be accepted with caution. Although primar}' tuberculosis of the synovial membrane is de- scribed by those whose statements carr)- great weight, the results of Nichols' investigations must be borne in mind, which are positive and not negative conclusions. And it may be assumed for clinical purposes, until the contrar}- is proved, that practically all tuberculous joint dis- ease has its origin in bone. Cold Abscesses of Joints. — If the tuberculous process in the bone reaches the surrounding tissues by perforation of the cortex and peri- osteum or by rupture of the joint capsule, an abscess is likely to occur. The area of tuberculous softening in the periarticular tissues is formed by the coalescence and caseation of tubercles. Sun-ounding the soft- ened area is a la3-er of tuberculous tissue, about which is another layer of oedematous and vascular granulation tissue. This process may ex- tend until a large cavity has been formed. The contents of these abscesses are composed of caseous material from the degeneration of the tubercles and exuded serum with necrotic pieces of bone. In the fluid are poh^morphonuclear leucoc3"tes, often taking up little or no stain on cover slips. Pyogenic organisms are ab- sent unless present by secondar\^ infection. The fluid ma)' be like true pus ; it may be so thick that it will hardly flow ; it may be thin and water}' and contain coagula, or it mav be red or brownish from hemor- rhage. Microscopically tubercle bacilli may be found in the abscess, but they are to be identified, even after prolonged search, in onh- about .one-third of the cases. In such cases inoculation experiments must be relied upon to establish their presence. The wall of these abscess cavities is composed of an inner layer of tuberculous tissue, outside of which is a layer of secondaiy inflamma- tory" tissue. The inner laver may be granular or necrotic and ulcerated. The abscess extends by peripheral enlargement m the line of least re- ' Volkmann : Klin. Vortr.. v.. p. 1405. -Nichols: Orth. Trans., vol. xi.. p. 3S3. TUBERCULOUS DISEASE OF THE JOINTS. 9 sistance. The walls of tuberculous sinuses consist of an inner layer of tuberculous tissue, outside of which is a zone of oedematous granulation tissue. Tubercle bacilli in the tissues are frequently found, though not in- variably, as in the process of decalcification necessar)' to cut sections of bone for microscopic examination tlic\- ma\- become so disorganized as to stain with difficulty or not to stain at all. Inoculation of animals with tissue from bones and joints affected by this type of disease produces general tuberculosis,' and the disease may be experimentally produced in animals.' General viilieiry iiiberculosis of bone occurs in connection with gen- eral miliary tuberculosis. The marrow is studded with miliary tuber- cles; necrosis and inflammatory reaction are slight or are absent.^ ETIOLOGY. Heredity. — That heredity is a factor in causing tuberculous joint disease has long been claimed. Whether the tuberculous virus can be directly transmitted as such from father or mother to the offspring must still be held open to question,' but that the surroundings of cer- tain families weaken the resistance and favor tuberculous invasion ap- pears not improbable. Figures which attempt to show what proportion of children with joint disease inherit a tendenc}" to these diseases are notoriously un- trustworthy. In the class of hospital patients from whom most of these statistics come, anything approaching accurate information with regard to the diseases of which relatives have died cannot be expected. There is also an inclination on the part of parents to deny the existence of tuberculous disease in their parents and relatives. In this wa-\- pa- rents of all classes are much more anxious to establish some traumatic cause for the affection of the joint than to have it supposed that the child inherited any constitutional taint. Again, it must be remembered that in a community in which approximately ten per cent of all deaths are from phthisis, phthisis must necessarily appear in the family histo- ries of a certain proportion of any group of individuals whose antece- dents are inquired into. For these reasons the statistics cannot be '- Cheyne : British Med. Jour.. April. 1891. -Deutsch. Zeit. f. Ch.. 1S72. xi.. 317.— Schiiller : "Exp. unci histol. Unter- suchungen," Stuttgart, iSSo. — Cent. f. Ch.. 1SS6. Xo. 14. ^ Konig : Archiv f. klin. Chir.. 26. p. 822. — Caumont : Deutsch. Zeit. f. Chir., XX., 137. — Krause : Deutsch. Chir.. Lief. 28a. — Deutsch. med. Woch.. 18S6. 9-13.— Cent. f. Chir.. 1887. p. 52.— Quoted by Barber: Brit. r\Ied. Jour., June 23d. 18S8.— Pfeiffer: Fort, der Med.. 1888. Xo. i. p. 33.— For further detail the reader is re- ferred to the article of Nichols (Trans- Am. Orth. Assn., vol. xi.), which has been freely used by the writers. ■* Cheyne : " Tuberculous Disease of Joints." p. 97. 10 ORTHOPEDIC SURGERY. regarded as other than inaccurate, and only approximating the truth, but the error is hkely to lie always on one side, in making the propor- tion of inheritance too small.' Traumatism. — Experimentally it has been shown that trauma to the joint of a tuberculous animal may cause tuberculous joint disease, but that it does not do so in the healthy animal. It has been established that contusions and wrenches cause the effusion of blood in the spong}^ tissue of the bone. Cases are seen in which tubercles develop directly from the clot, just as in a syphilitic individual a gumma may develop at the site of an injury to the bone. "There are cases in which the swelling from the fall merges into the tuberculous swelling." - It would therefore seem rational to assume that trauma caused tuberculous joint disease in children who inherited a constitutional taint. But it becomes evident at once that this is not all, for every surgeon of experience must have in his mind cases in which joint disease of a tuberculous type has followed injur}" in children whose family histories were excep- tionally good. From one-sixth to one-half of all cases would appear from the col- lected statistics to be traumatic. In certain cases traumatism alone must be accepted as the causative factor, while in some cases no cause can be assigned. The cxantJicniata must be mentioned as being the cause of tubercu- lous joint disease in a certain proportion of cases, probably a larger proportion than has been suspected. Measles and scarlet fever are the most common eruptive diseases to be followed by these sequelae. There are very few figures bearing upon the subject. The effect of the exanthemata in causing other forms of joint disease will be alluded to later. The entrance of the bacilli is apparently most often through the respiratory and digestive tracts. It is probable that whatever continuously diminishes the power of resistance and of repair in growing children increases what may be termed the vulnerability of the epiphyses, and furnishes the soil for the development of tubercle bacilli and the consequent results. Age. — Tuberculous joint disease is pre-eminently a disease of child- hood. It is not congenital, and under one year it is not common. The majority of cases occur between three and ten years of age." ' Gibney : " Strumous Element in Joint Disease." N. Y. Med. Jour.. Jul}-, 1877. — From preface of German translation of " ' le Mechanical Treatment of Pott's Disease." — Croft: Clin. Soc. Transactior London, vol. xiii. — Nichols: Orth. Trans., xi., p. 358. -Konig: Deutsch. Zeit. fiir Chir., 1S79 ^i. "X. M. Shaffer: "Am. Clin. Lectures," vol. iii.. 141: Sonnenberg: Arch, f, klin. Chir.. iSSi, xxvi.,789: Lannelongue : Loc. cit. — "Hip Disease in Child- hood." p. 2. — L. A. Sayre : " Orthopedic Surgery and Diseases of Joints." TUBERCULOUS DISEASE OF THE JOINTS. II The liability of the aged to tuberculous joint disease must not be overlooked.' The patients may be seventy-five or ninety, and cases of hip disease present the same pathological appearances here as in young children. The course of the disease is more rapid and destruc- tive than in the young, and its etiological relations are decidedly more obscure. The reasons why tuberculous joint disease affects children to so great an extent are as follows : In the active period of growth more change is going on and there- fore more instability exists and consequently greater liability to disease. Children are more liable to falls and injuries, which are such a fertile source of joint and bone lesions. It is not till after puberty that the process of natural selection has eliminated the weaklings from the stock. Children are kept quiet less easily than adults, and a slight in- jury ma)" develop into a formidable disease. Tuberculosis in general is common in childhood. Sex is not a factor of any prominence, but there is a slightly larger proportion of tuberculous joint disease among boys than among girls."^ Distribution of Chronic Tuberculous Joint Disease. — The relative frequency with which tuberculosis attacks the various joints in children may be estimated from the following figures: At the Children's Hospital, from 1869 to 1903 inclusive, 5,950 cases of tuberculosis of the joints were distributed as follows: spine, 2,867; hip, 2,281; knee, 375; ankle, 394; elbow, 33. These practically all occurred in children under the age of twelve. In 211 cases of joint tuberculosis among the out-patients occurring in children under two years, there were 120 cases of Pott's disease, 61 of hip disease, and 29 of tuberculosis of the knee-joint." Judson has called attention to the great preponderance of joint dis- ease in the lower extremity as contrasted with the upper limb. Ana- lyzing the reports of two orthopedic institutions in New York City, he found that in a single year the following number of cases of disease of the different joints were treated: Hip-joint di.sease 577 Knee-joint disease iSi Shoulder disease 6 Elbow disease S or 758 patients had disease of the joints of the lower extremity, while in the same time there appeai ^ only 14 cases of joint disease in the upper extremity. In joint disease, when one r more articulations are involved, any ' " Clinical Lectures and Essays. Senile Scrofula." 2d ed.. p. 345. -Gibney: Loc. cit.. p. 206. ^Thomdike: Orth. Trans., ix., p. 196. 12 ORTHOPEDIC SURGERY. combination may be found ; but the most common are hij) disease and Pott's disease, knee disease and Pott's disease, and double hip disease. Disease of the knee- and hip-joint at the same time is not common, and double tumor albus is unusual. DIAGNOSIS. The recognition of tuberculous joint disease is to be based upon cer- tain general phenomena modified by the anatomical conditions of the joint affected. These diagnostic signs are considered in connection with the individual joints. The use of tuberculin as a means of diagnosis is open to the criti- cism that its results are attended with so much uncertainty that its value in the individual case is always open to question and cannot be assumed to be a reliable demonstration that tuberculosis is either pres- ent or absent in that case.' It has been demonstrated that in a certain per cent of well-marked cases of pulmonary or other tuberculosis, tu- berculin gives a negative result, while in other cases, presumably non- tuberculous, a certain percentage of positive results is obtained. The great frequency of tuberculous invasion has been shown by the autop- sies of Babes," for example, who found lesions of the bronchial glands in more than one-half of his autopsies on children ; and those of Nae- geli,^ who found, in 508 consecutive autopsies, that 97 to 98 per cent showed evidences of tuberculosis. Under these circumstances tuber- culin must necessarily be unreliable in demonstrating joint tubercu- losis.^ The inoculation of material from suspected joints into guinea-pigs forms a reliable means in the diagnosis of tuberculosis of the joints. The x-ray is an aid in the diagnosis of joint tuberculosis where the process is sufficiently advanced to have caused the absorption of lime salts in the affected area or to have destroyed any part of the bony structure. In early cases the radiograph may be normal when disease is present. PROGNOSIS. The destructive process which is so prominent a feature of joint tuberculosis is almost from the first accompanied by a reparative proc- ess tending to limit the destruction, protect the surrounding tissues, and prevent generalization. The prognosis depends in the individual ' F. \V. White: Boston ^led. and Surg. Journal. August 5th. 189S (with bibH- ography). — Schliiter: Deutsch. med.Woch., 1904. viii..3o. p. 272 (with literature). Brit. Med. Journ., 1903, vol. ii., pp. 48, 96. '■'Babes, quoted by Burrell : "Surg. Tub.." Trans. Mass. Med. Soc ,xix., 1903. •'Naegeli : Arch, fiir path. Anat., vol. clx. •*" Indirect Tuberculin Reaction." Bull, de ITnstitut Pasteur, t. ii., April 30, 1904. p. III. TUBERCULOUS DISEASE OF THE JOINTS. 13 case upon which of these two processes prevails over the other. The former is favored by inel^cient local treatment, bad inheritance, poor general condition, unfavorable surroundings, and, in general, what may be termed poor resistance to the tuberculous process. The reparative process is favored by the reverse of these conditions, in the majority of all cases of joint tuberculosis, properly treated at a fairly early stage, the outlook is favorable. The prognosis is more favorable in children than in adults. TREATMENT. Since bone tuberculosis has been shown to be one manifestation of tuberculous infection and not the result of an unknown evil, the prin- ciples of treatment are more clear. Resistance to the infection by the tubercle bacillus is furnished when the individual is in a normal state. The antidotes to be relied upon to check its advance after it has found lodgment are not only good air and food, but such general activity as will promote normal metabol- ism. Tuberculosis is prevalent and fatal among caged animals — a fact Avhich is to be borne in mind in the treatment of bone tuberculosis. The treatment is both general and local. The general treatment consists in giving the patient the best possible environment and in fur- nishing such conditions that normal activity will cause the least possi- ble, injury to the part locally affected. In tuberculosis of the lung the patient is in constant danger of self- infection or increase of the process from the inhalation of infected material. In bone tuberculosis no such danger exists. Strong, well ossified bone does not offer suitable soil for the bacillus. Bone tissues when invaded resist the advance of tuberculous infection by surround- ing the diseased area with a thick enveloping mass of tissue and by subsequently repairing the invaded region by the development of strong bone. Traumatism, which injures this bone construction and furnishes unde\'eloped cells instead of firm bony structure, favors the spread of the tuberculous process. The treatment of bone tuberculosis, therefore, consists in promoting such general conditions as will favor repair (general treatment) and the protection of the parts from injury during the disease (local treatment). General Treatment. — The patient should be placed in the most fa- vorable environment available in the matter of food, home surround- ings, air, sunlight, proper clothing, exercise, avoidance of fatigue, and similar requirements. Outdoor Treatment. — Of these requirements outdoor air is of the utmost importance, and the open-air treatment of surgical tubercu- losis ' is nowhere more beneficial than in joint disease. The outdoor 'Burrell: Comm. Mass. Med. Soc, 1903, xix., 11, p. 303. 14 ORTHOPEDIC SURGERY. method recognized as of such value ' in the treatment of pulmonary tuberculosis is advisable.-' During the day the patient should be out of doors or in a room with one or more windows open. In winter proper protection against cold should be obtained by warm clothes rather than by heated rooms. Such patients should sleep out of doors in tents or well-aired sheds. During the summer this offers little diffi- culty, and in the winter such treatment is available even in a New England climate. From Christmas, 1903, through the winter, the pa- tients at the Convalescent Home of the Children's Hospital at Welles- ley, with Pott's disease and hip disease, lived and slept in an unheated shed with skylights or doors open. Properly protected by woollen caps and heavy blankets, they suffered no discomfort, and the beneficial effect on the local process was evident. The importance of the treatment by fresh air and sunlight has been recognized in Europe in the establishment of seaside sanatoriums for children with tuberculous joint disease. It is being recognized in America that a convalescent home in the country is an almost neces- sary part of a surgical hospital for children. Drugs. — The writers are of the opinion that drugs, except tonics when required, are of little or no value in the treatment of joint tuber- culosis. Local Treatment. — Fixation, distraction, and protection, along with operative treatment, are considered in speaking of the individual joints. Other local measures are occasionally of use, in addition. Biers congestive treatment ^ depends upon hypersemia as a thera- peutic agent, and in connection with proper mechanical treatment it may be of benefit in the knee, ankle, elbow, or wrist. A congestion of the affected joint is induced by bandaging above and below the joint with cotton webbing or rubber bandages and allowing the con- gestion to continue for an hour daily. The congested parts should feel warmer than the normal skin, but the process should never be pushed to the degree of causing pain. X-ray treatmeiit consists in an exposure of the affected joint to the x-rays for a certain period every day or every second day. In a fairly large number of cases of joint tuberculosis under mechanical treatment treated in this way in addition, checked by cases under similar condi- tions not so treated, the writers have not been able to detect any bene- fit from the use of the x-ray. Counter-in itation, inunction, zgnipuncture, and similar measures ^ Aled. Record, November iSth, 1902, p. 736. Am. JNIed., March 21st, 1903, 440. Miinch. med. Woch., 1902, xlix., 1081. -Zeitsch. f. Tub. und Heilstatt., July, 1902, pp. 366 and 369. ^ Frieberg : Am. Journ. Orth. Surg., August, 1904. ii.. 150. — Luxembourg: Miinch. med. Woch., 1904, 10. TUBERCULOUS DISEASE OF THE JOINTS. 15 have fallen into more or less disuse since the better appreciation of the pathology of joint tuberculosis and the essentials of its treatment. Massage, manipulation, hot-aii' baths, doncJics, and similar measures to stimulate the local circulation are to be avoided during the acute stage of the process as essentially undesirable. In late convalescence they may prove of much value. CHAPTER II. TUBERCULOUS DISEASE OF THE SPINE. Definition. — Histon-. — Pathology. — Occurrence and Etiology. — Symptoms. — Complications. — Diagnosis. — Differential Diagnosis. — Prognosis. — Treat- ment. Definition. — Pott's disease is the name applied to a destructive path- ological process which attacks the bodies of the vertebrae. The other names by which the affection is known are as follows : Spondylitis, Malum Poitii, Caries of the spine, Kyphosis, Angular curvature, Tu- berculosis of the vertebrae, and Spinal curv'ature. In German it is known as Die Potfsche Kyphose, Spitzbnckel, Winkelforinigc Kiiicknng der Wirbelsdule, and TnbcTcnlosc Wirbclcntziindung ; in French as CypJiose, Mai de Pott, and Mai Vertebral. History. — Antero-posterior curvature of the spine is an affection which was described by the ancients, and was known to Hippocrates and Galen, who attributed its cause to tubercle '" within and without the lungs."' Ambroise Pare wrote of it and used a metal cuirass in its treatment, but it was not until the time of Percival Pott, in 1779, that any accurate description of the disease was given.' In honor of that surgeon the disease is chiefly known by his name. The existence of the disease in prehistoric times in North America is proved by a speci- men in the Peabody Museum, Cambridge, Mass. PATHOLOGY. Pott's disease represents the result of a destructive ostitis affecting the spong}' tissue of one or more of the vertebral bodies. This ostitis is tuberculous in type and follows the same course as tuberculous ostitis occurring at the epiphyses of the long bones, as in hip disease, tumor albus, etc. The first appearance noticeable to the naked eye on examining a ■section of a diseased vertebra at an early stage of the disease is a small hyperaemic spot in some part of the spongy portion of the body of the vertebra, generally near the anterior surface of the body. This spot grows larger and more red as the process extends, and finall}' the cen- tre becomes opaque and grayish, while a zone of hyperasmia surrounds 'Pott: "Remarks on that Kind of Palsy Affecting the Lower Limbs." etc., London, 1779. 16 TUBERCULOUS DISEASE OF THE SPINE. 17 it. A focus of tuberculous ostitis is present. If this process extends, the opaque spot becomes larger, and finally cheesy degeneration of its centre takes place. At other times both caseation and degeneration into tuberculous pus take place, and a localized abscess of bone exists, probably encapsulated in a membrane of inflammatory tissue, which sur- rounds the focus, endeavoring to protect the surrounding healthy bone Fig. 7.— Pott's Disease Involving the whole Dorsal Region. Prehistoric Indian remains. (Peabody Muse^im, Spec. 17,223.) from the erosive action of the focus. Microscopical examination shows a mass of tubercles in a rarefied spongy bone tissue, and in the tuber- cles are to be found tubercle bacilli. The focus of tuberculous material may either be absorbed or calci- fied, or, as happens much more commonly, the ostitis may increase until it has destroyed a large part or the whole of a vertebral body. In its course of enlargement it may include portions of bone, the nutrition of which is cut off by the adjacent inflammatory destruction. Such portions necessarily become necrosed, and with caseous matter, granu- lation tissue, and the products of inflammation constitute an area of altered and degenerated structure in the vertebral body. If this dis- eased area has become large enough, the vertebral body gradually be- comes incapable of sustaining as much pressure as before. From the i8 ORTHOPEDIC SURGERY. ])eculiar weight-bearing function of the vertebral column, the pressure upon each vertebral boch' is always considerable when the vertebral col- umn is in the erect position. If one vertebral body is becoming exca- \-ated, a point will be reached where it can no longer sustain the weight, but must give way slowly or suddenly. A forward tilt of the whole vertebral column above the seat of disease is then inevitable, with a certain amount of backward angular deformit}- at the diseased vertebra. This is the mechanism of the production of the knuckle in the back. Fig. 8. — Lower Dorsal Region. One intervertebral disc destroyed. E.k- tension of process backward to dura and formed along prevertebral liga- ments. Moderate knuckle hardened in upright position, so that gravity pressed diseased vertebrae together. a. Tuberculous softening- (Nichols.) b-' Fig. q. — Lower Dorsal Region. Opposite half of specimen rested on knuckle while hardening, so that gravity extended the spine. Marked separation of diseased vertebrae, a, Tuberculous disease beneath prevertebral ligaments; b, cav- ity between diseased vertebrae. (Xichols.") It is, in brief, a softening and crushing of one or more vertebral bodies and a giving way of the column at that point as a necessary mechanical result. This process is limited, as a rule, to the vertebral bodies ; the trans- verse, articular, or spinous processes are rarely affected secondarily or primarih", their structure of hard bone apparently protecting them from tuberculous invasion. The intervertebral eartilage between the diseased vertebrae becomes fibrillated and disintegrated and disappears. There may be two or more foci in one \-ertebra, or the whole body may be equally affected ; the disease ma}" be limited to one spot, forming TUBERCULOUS DISEASE OF THE SPINE. 19 a localized abscess of the bone, or it may extend so as to involve the adjacent \-ertebrcc. If the disease remains limited to the centre of the vertebra, l^ut little deformity ma}' result. Primary disease of two ver- tebral bodies in different, non-adjacent parts of the spine is rare. But an extensive destruction of two or more adjacent vertebrae from pri- mary disease of one ma_\- be said to be the rule in Pott's disease. In some instances this destructive process may be limited to the surfaces of a large number of vertebral bodies; in others a few contiguous ver- FiG. 10. — Spine, Lower Dorsal and Lumbar Region. Extreme knuckje. Lower ribs rest on pelvis. Chang-e in angle of ribs due to continued deformity. Calibre of spinal canal not diininished. ct<>^. Abscesses, however, may burst into the mouth, trachea, bronchi, medias- tinum, oesophagus, or pleura. They may rupture into the intestines, blad- der, vagina, rectum, or the abdominal cavity ; and one case is reported in which a spinal abscess simulated a fis- tula in ano. Abscesses may also burst into the spinal canal or the hip- joint. Occasionally they burst in the alimentary canal, not so rarely in the lungs, and exceptionally in the peritoneum or larger vessels. Abscesses in the lung give rise to less disturbance than would be supposed ; in reality they present the rational and physical signs of a low form of localized pneumonia, of a chronic or subacute type. The bursting of an abscess into the bronchi is characterized by the discharge of a large quantity of pus, which is coughed up, the amount of dysp- noea, collapse, and danger from suffocation being dependent on the size of the abscess. The sudden discharge of pus is the indication of rupt- FlG. 42. — Lumbar Abscess. 42 ORTHOPEDIC SURGERY. ure into the oesophagus, intestines, and bladder ; rupture into the ves- sels will necessarily be fatal. No symptoms can be relied upon to give warning of the impending" danger. The course of an abscess is toward absorption or increase. It may remain stationary in size and quiescent for a long time — a condition of Fig. 43.— Cervical Abscess. things which may be compatible with fair general health. Instances are not uncommon in which adults have been able to attend to active work and children to play about, although suffering from large cold abscesses. When absorption takes place the fluid contents disappear, and the caseous and purulent detritus, if present, in all probability be- TUBERCULOUS DISEASE OF THE SPINE. 43 comes encapsulated. This sometimes happens even in large psoas- abscesses. Abscess is most frequent in disease of the lumbar region, moderately frequent in the dorsal region, and least frequent in the cerxical region.' DIAGNOSIS. The ordinary clinical history of a case is of little value as an aid in establishing the presence of the disease. It maybe significant enough to create a strong suspicion of the existence of vertebral disease, but without definite physical signs a diagnosis of Pott's disease can- not be made. Too much impor- tance must not be allowed to the tendency of the parents to at- tribute the condition to trauma- tism. It should be mentioned that the absence of pain can in no way be assumed to show the absence of Pott's disease. The diagnosis, then, must be made wholl}' from the phys- ical examination. The chief phys- ical signs upon which one must rely can be divided into two classes: {a) those occurring from bony destruction ; and (Jf) those dependent upon muscular spasm. (c?) Signs due to Bony Destruction. — Since these are made evi- dent by the presence of angular deformity of the spine, which is the result of bony destruction, they are so conspicuous that they can scarcely be overlooked. And the prominence of one or more of the vertebral bodies, associated with muscular spasm, is a positive sign of the presence of the disease, unless it is the result of a fracture of the spine, or in adults the outcome of malignant disease, aneurism of the aorta, or some similar affection. In the larger number of cases, as they come to the surgeon, this bony deformity has occurred, and the diagno- sis can be made at a glance ; but the most important class of cases, so far as the diagnosis is concerned, are those in which bony destruction has not yet begun, and in which the need of an early diagnosis is evi- dent, in the hope that it may lead to treatment which may be sufficient to prevent the occurrence of deformity. ib) Signs Arising from Muscular Spasm. — These are: I. Stiffness of the spine in walking and in passive manipulation. ^ Townsend : Orth. Trans., vol. iv.. i66.— Ketch: Orth. Trans., vol. iv.. 200. — Dollinger: "Die Bhdlg. der Tub. Wirbelentz.." etc.. Stuttgart. 1S9S. Fig. 44. — Retropharj-ngeal Abscess. 44 OR THOPEDIC S UK GEK Y. 2. Peculiarity of gait and attitudes assumed, according t(j the loca- tion of the disease. 3. Lateral deviation of the spine.' For all examinations children should l)e stripped. I. Muscular Stiffness. — On examining for muscular stiffness of the spine, the child is most conveniently laid face downward on a table or bed, and lifted by the feet. In a normal back the lumbar and lower dorsal spine can l^e markedly bent, and a general mobility of the whole column is seen. In patients in whom Pott's disease is present the re- gion affected is held rigidly by muscular contraction when manipulation ■ ■ B '4£li^i^»nn WM ^^^H^t^ ■ I I ^^B^^^^^^ 'Ji ■ \ 1 M- m ^^H ^^^H ^ p.1^^^^^^^1 ^^1 1 flH ~~^^^B m ^*te»\^ 1 Fig. 45. — Jiigidity of Spine in Pott's Disease. (Children's Hospital Report.) is attempted. In certain instances the erector spinae muscles stand out like cords when the child is lifted, and it is questionable how much im- portance should be attributed to this sign ; it occurs in cases of hip dis- ease and in certain instances in excitable children in whom no joint disease is present. Lifting the patient by the feet in this way will show the existence of lumbar or lower dorsal rigidity, but it does not detect high dorsal Pott's disease. In lumbar Pott's disease lateral mo- bility of the spine, as well as antero-posterior flexibility, is lost. 2. Peculiar Gait and Attitudes. — In considering the gait as a diag- nostic symptom of Pott's disease, one must be prepared to find any of the characteristic features absent. In general the walk is careful, steady, and military, and the steps are taken with such care that jars to the spine are avoided ; in other instances, however, the child walks ' Boston Med. and Surg. Jour., October 9th. 1890. TUBERCULOUS DISEASE OF THE SPINE. 45 with comparative freedom, e\"en when tlK' presence of the chseasc is manifest, and the well-known test of havin','' the child i)ick up objects from the floor may fail to detect anything. Assuming, then, the extreme importance of the early diagnosis of the disease when practicable, it becomes necessary to consider in detail the deviations from the normal signs, according to the region of the spine affected. Cervical Pott's Disease. — The most common s)'mptom (;f the disease in this region, due to muscular rigidit}', is the occurrence of Fig. 46. — Xormal Flexibility of Spine. (Children's Hospital Repoi't.) Avrv-neck with stiffness of the muscles of the back and neck. This is often accompanied by distressed breathing at night and intense occipi- tal neuralgia. The head is held sometimes in a much distorted posi- tion ; the most characteristic attitude is when the chin is supported in the hand ; and when the patient turns sideways to look at objects, the whole body is turned. In severe cases one notices flattening of the back of the neck, with sometimes bony deformity. When spinal dis- ease occurs in this region the early symptoms are most often confused with sprains, muscular torticollis, and inflammation of the cervical lym- phatic glands. In disease of the upper cervical vertebrae the head, however, ma}' 46 ORTHOPEDIC SURGERY. \ be held sharply flexed and sunk upon the chest. It may be hyperex- tended with the occiput resting on the upper part of the spine, or it may be held laterally bent. From sp7'ains the immediate diagnosis is almost impossible. In the early stages of sprains of the neck the head is often held stiffly and to one side ; motion is resisted and is painful, muscular spasm is present, and in the case of children of unintel- ligent parents the history cannot be accepted as valid. From true muscular z^ny-ncck the diagnosis is often extremely difficult. In congenital torticollis manipulation is generally not painful, and one muscle is firmly contracted while the rest are relaxed. In congenital cases the head and face are distorted, and the eyes often are not upon the same plane. In Pott's disease, on the other hand, the muscular fixation involves all the muscles, and movement in any di- rection is resisted, and is more apt to be painful. This applies fairly well to cases of anterior wry -neck; but in cases in which the true muscular tor- ticollis is of the posterior variety, and is due to a contraction of the deeper muscles, the diagno- sis is much more dif- ficult, for no one muscle is contracted and movement is lim- ited by a general muscular resistance. The differential f J N Fig. 47.— Child with Dorsal Pott's Disease Picking up Object from Floor. diagnosis can be most easily made by putting the patient tt) bed and seeing if the application of extension is sufificient to over- come the distortion, as it will do in the course of a few days if due to Pott's disease. RJicuvmtk torticollis simulates cervical Pott's dis- ease so closely that the physical signs are not sufficient at first to differ- entiate the affections. Inflainnu-itiou of the lymphatic glauds of the neck may give rise to a position of the head simulating wry-neck, associated with muscular spasm. TUBERCULOUS DISEASE OE THE SPINE. 47 Upper Dorsal Pott's Disease. — In this region detection is the most easy because any bony destruction at once results in angular de- formity, on account of the posterior curve of the spine in this part, and it is on this deformity that one must depend rather than on symptoms due to muscular stiffness. The shoulders are, however, held high and squarely, the gait is mili- tary and careful, and lateral deviation is almost certainly present. In Pott's disease, paralysis may exceptionally be the first perceptible symptom. From round shoulders, Pott's disease is generally to be distinguished Fig. 48.— Xormal Child Picking up Object from Floor. by the fact that in the former the spine is flexible and the deformity rounded and not angular. The distinction is generally easily made. Lumbar Pott's Disease. — Vertebral disease in this region of the spine is difficult of detection on account of the anterior curve of the spine in the lumbar region, so that in any moderate amount of destruc- tion of the lumbar vertebral bodies no posterior angular curvature is de- veloped, and it is only in the later stages of the disease that any angu- larity becomes prominent. The occurrence of deformity is preceded by a flattening of the lumbar curve. The attitude is that of lordosis, which in some cases becomes very marked ; the gait is military and careful, and lateral deviation is generally present, sometimes to a very marked degree. It is in this region of the spine that it is most conspicuous. 48 OK THOPEDIC S UR GER Y. In many instances of lumbar Pott's disease the first noticeable symptom is a limp, which is due to unilateral psoas contraction, the result perhaps of abscess or perhaps only of psoas irritability. Psoas contraction must be set down as one of the common s}'mptoms of lum- bar Pott's disease. If the child is laid on its face and an attempt is made to flex the lumbar spine, it is found to be entirely rigid. Any attempt to hyperextend the leg in this position leads to the detection of the slightest psoas irritability. Lumbar Pott's disease is occasionally mistaken for single or double hip disease, or is regarded as a rhachitic curvature. The differential diagnosis between lumbar Pott's disease and Jiip Fig. 49. — Altitude Assumed in Dorsal Pott's Disease when Rising' from Floor. disease is at times difficult, although it is not generally considered so. When the hip symptoms are due to Pott's disease and are caused by psoas irritability, the restriction of motion in the hip is simply in the loss of hyperextension, while abduction and internal rotation are free and not affected. This limitation of motion in only one direction is generally sufficient, in connection with the other symptoms, to establish TUBERCULOUS DISEASE OF THE SPINE. 49 the presence of Pott's disease. On the other hand, in some cases the hmitation of the hip's motion is in all directions, and simulates very closely the limitation of true hip disease. Another element which leads to the confusion of the two affections is the rigidity of the lumbar spine which often occurs as an accompani- ment of acute hip disease. If a child with hip disease is laid upon its face, and an attempt made to fiex the lumbar spine by lifting the feet from the table, the irritability of all the muscles is so great that often the lumbar spine will appear to be completely rigid, and only a very careful examination will show that this is secondary to the hip dis- ease. RJiachitic deformity of the spine is a posterior curvature often so sharp as to be angular. It occurs at the junction of the dorsal and the lumbar regions. This junction is also a frequent site of Pott's disease. Muscular stiffness may not be present. Fig. 50. — Examination fcr Psoas Contraction. (Children's Hospital ]y the Perma- nent Flexion Deformity Resulting from Double Hip Disease. TUBERCULOUS DISEASE OF THE HIP. 99 ease. The later course of the disease is marked by much greater uni- formity, but even then temporary improvement may be quite marked. Temperature. — Chikh-en with hip disease under treatment by ambu- latory measures have as a rule a higher afternoon temperature than normal. In 627 observations made on cases of hip disease and Pott's disease at the Out-Patient Department of the Children's Hospital a rise of temperature of one or two degrees was common. Ninety per cent of all cases, acute or chronic, mild or severe, had an evening tempera- ture of at least 99°, and a rise to 103° or 104° in severe cases was not necessarily an indication of ab- scess. Double Hip Disease. — The dis- ease seldom begins in both hip- joints at the same time, and the second joint may become inflamed while the patient is under treat- ment in bed for the first joint. The course of double hip dis- ease would appear to vary some- what from that of single hip dis- ease. It is, as a rule, of a severe t\pe and tends strongly to ank}-- losis. The amount of pain suf- fered in the joint last affected is usually less than that of the first joint, probably because there is less jar or motion when two hip- joints are affected than when one alone is attacked. Malpositions are more than usually troublesome and may be differ- ent in the two hips. Recovery without deformity and with as much motion as possible is most important in double hip disease. Progression in a Case of Severe Double Hip Disease. DIAGNOSIS. The diagnosis of hip disease may be easy or difficult ; ' in the earli- est stages errors in it are sometimes made, and care is necessary for a positive diagnosis in any stage. The most common error is the belief that the presence of pain or tenderness is necessarily present in hip disease, and that its absence excludes the possibility of hip disease. Another error often made is to look for " grating " in the joint as a sign of the disease. That sign is to be obtained only by the use of an anaesthetic, by which means the muscles guarding the joint are re- ' R. W. Lovett: " The Diagnosis of Hip Disease." Boston Med. and Surg. Journ., August 14th, 1902. lOO ORTHOPEDIC SURGERY. laxed, and then only in advanced cases when two bony and eroded sur- faces lie in contact. The diagnostic symptoms in hip disease which should be borne in mind in making a diagnosis of hip disease are as follows: 1. Muscular spasm (stiffness of the joint or limitation of its motion). 2. Lameness. 3. Attitude of the limb in standing, walking, or lying (adduction flexion and abduction of the limb), and shortening. 4. Atrophy. 5. Swelling. These symptoms \'ary in prominence at different stages of the dis- ease. It may be said that the early diagnosis must be made chiefly by the symptom of muscular rigidity and by palpation of the joint. _ The ab- FlG. 103.— Method of Examining the Hip. sence of pain or sensitiveness counts for nothing and atrophy is not significant of anything more than inflammation of the joint. The limp is peculiar, but a similar one is present in other conditions. I. Muscular Spasm. — The chief diagnostic sign in hip disease, upon which the main reliance must alwa}-s be placed, is i]ic presence of stiff- ness of iJie joint or limitation of its proper arc of motion when the limb is passively manipulated. Except in the very earliest stages there can be no hip disease without a perceptible limitation of motion, unless the focus of disease is remote from the joint. This limitation of motion is TUBERCULOUS DISEASE OE THE HIP. lOl not the result of adhesions or beginning ankylosis in early hip disease, but it is the result of a tonic contraction of the muscles controlling the joint, and disappears under anaesthesia in the early stages of the disease. In the detection of this most important diagnostic sign it should be borne in mind that some care is required to discover slight limitation of motion in very young children, who are apt to resist thorough examina- tion. The voluntary resistance to manipulation due to fright is, how- ever, always resistance to all motions of the limb; if by slight force this Fig. 104. — Method of Determining the Limitation of Extension in Hip Disease. is overcome, resistance to any especial motion will not be encountered unless hip disease is present. A comparison of the resistance of one leg with that of the other will reveal abnormal resistance. The normal amount of abduction is, however, slight, and resistance to motion in this direction, therefore, is an early test of importance. Extreme abduction Fig. 105.— Lordosis Resulting from Bringing the Flexed Leg in Hip Disease Parallel to the Other. and rotation of the thigh flexed at right angles to the body are tests likely to reveal the smallest degree of limited motion. In young and frightened children the tests for limitation of motion at the hip-joint are best made with the children lying on the mother's lap or leaning on the mother's shoulder. In examining older children for muscular stiffness, the clothes should be removed and the patients should lie upon a hard surface rather than on a bed. Attempts to I02 ORTHOPEDIC SURGERY. move the limb should be made gradually, gently, and persistently- rough force only exciting resistance and making a delicate examination impossible. It is advisable first to put the normal leg through the same manipulations which are to be made on the affected side. The most convenient order of motion in examination is first flexion, then abduc- tion and abducting rotation with the thigh flexed, then extension. The suspected limb should be held at the ankle or knee with one hand, while the other hand will grasp the pelvis to ascertain when motion in the joint ceases and movement of the pelvis begins. Examination under anaesthesia shows less than the examination mentioned, at the early stage of hip disease, as muscular spasm, the most important diagnostic sign, has been overcome and is absent. If the limb is extended so that the popliteal space be placed upon the hard surface on which the patient lies, normally there will be no alteration of the position of the back; if, however, there is a limitation in the normal extension of the limb, the back will be arched up as the popliteal space is pressed down. This limitation of extension can also be determined by examining the patient lying upon the belly. If one hand be placed on the sacrum and the thighs be alternately raised from the surface on which the patient lies, a difference in the amount of motion at the hip without moving the sacrum can easily be determined. The limit to the amount of abduction or adduction is determined by placing one hand on the anterior superior spine of the ilium on the sound side, and with the other hand gently abducting or adducting the suspected limb ; when limitation is present the pelvis, of course, moves with the diseased limb. For detecting limitation of rotation the thigh should be flexed to a right angle and rotation tested in that position. The motions most often limited in early hip disease are abduction, hy- perextension, and rotation when the thigh is flexed to a right angle. The loss of motion in this group is always suggestive. Careful inspection in the early stages of hip disease during manipu- lation will sometimes show fibrillary contraction of the muscles of the thigh, especially the adductors, on sudden or unexpected movement of the limb. In the later stages of hip disease complete stiffness of the joint may be present. If this is due to muscular spasm it disappears, in a meas- ure at least, under complete anaesthesia. An ankylosis of the hip-joint is as stiff under full ansesthesia as without it. Any catch in the motion of the joint in any part of its arc is exceed- ingly suspicious, no matter how slight it may be. II. Lameness. — ^At the earliest stages the limping may be intermit- tent and not constant, and, again, it may be so slight that it is practi- cally imperceptible, so that its absence does not exclude hip disease. The diagnosis cannot be made alone from watching the child walk. TUBERCULOUS DISEASE OF THE HIP. 103 III. Attitudes. — Abnormal positions of the diseased limb at an early stage of the disease are caused by the action of the muscles holding the limb stiffly in a distorted position. Neither adduction nor abduction of the limb is usually recognized by the patient as such, but the complaint is made that the limb seems longer or shorter than the other. The pelvis is tilted, which gives a practical lengthening of the limb if ab- duction is present, and in the same way the limb appears shorter to the patient if adducted. The tilting of the pelvis can be recognized by drawing a line from the anterior superior spine of one side to that of the other. This should normally be at right angles with the long axis of the body. In this way have arisen the terms of apparent or prac- tical shortening and lengthening, which have given rise to some obscurity, being often con- fused with real or bony shortening. The accompanying diagrams will explain the matter. The normal position of the pelvis in relation to the limbs is shown in heavy lines in Fig. I, where both legs are at right an- gles to the pelvis, the normal position for standing and walking. If, however, the right leg is fixed by muscu- lar spasm in an ad- ducted position, A E, the relation is changed, and when the patient stands erect the legs must be made parallel to permit walking or standing on both feet, and this can be done only by tilting the pelvis to the position shown in Fig. 2. It will be seen by the tilt- ing that the leg A C is carried up with that side of the pelvis, and to all appearances the leg A Cis shorter than the leg B D, when the patient stands or lies straight. Thus adduction results in apparent shortening of the adducted limb as compared with the other when the patient lies straight. In the same way in Fig. 3, if the leg A C\s ab- ducted to the position A F, the pelvis must be tilted in the opposite direction to make the legs parallel, because the angle FA ^ is a fixed quantity, and so the pelvis is tilted, and A C for practical purposes is Fig 1. . 1 « ■Tl, Z \ \ \ " Fig. 106.— Diagram Showing Practical Shortening from Adduction. Fig. 107.— Diagram Showing Apparent Shortening and Lengthening of Leg due to Tiltin"- of the Pelvis. 104 ORTHOPEDIC SURGERY. longer than B D, and the amount of apparent lengthening depends upon the amount of abduction. A patient then with fixation of one leg in a position of adduction has a deformity which results in a lifting of that leg from the ground when he stands or walks, for the tilting of the pelvis has caused a prac- tical shortening of that leg. In the same way abduction causes the opposite tilting of the pelvis and a practical lengthening of the diseased leg. So that the terni apparent or practical shortening can be applied to the inequality of the legs noticed in walking or standing, which results from the tilting of the pelvis. Practical shortening can be esti- mated by measuring from the umbilicus to each malleolus when the patient lies or stands straight. Real or bone sJioiiening is different from apparent shortening. It results from the retarded growth or atrophy of the affected limb or from the destruction of bone in the hip-joint. Real shortening is meas- ured by a tape from the anterior superior spines of the ilium to the malleolus on each side. The amount of enlargement of the acetabulum and absorption of the head of the femur which has taken place may be estimated by de- termining the amount that the trochanter of the femur has risen above its normal position. If the patient lie upon the well side, and Nelaton's line (from the anterior superior spine to the most prominent part of the tuberosity of the ischium) be drawn over the affected hip, the thigh being somewhat flexed, it should pass just above the upper margin of the trochanter ; if the trochanter is above this line, it is an evidence of destruction of part of the head of the femur or enlargement upward of the acetabulum. Estimation of Adduction and Abduction. — The amount of de- formity due to adduction or abduction or flexion of the limb is an im- portant index of the progress or activity of the disease and should be carefully estimated. A simple method has been devised by which it is possible to esti- mate with the tape measure alone the angle of either abduction or ad- duction present. In measuring patients it is found that real and practical shortening of a leg are often not the same in the same patient, and that the differ- ence between them varies in proportion to the amount of deformity present. This was taken as the basis for constructing the following working table. The mathematical process by which it was made is given in full in the original article.' To measure by this method, the patient is made to lie straight, with the legs parallel. Real shortening is measured with the ordinary tape measure, and apparent shortening is obtained in the same way. It may be repeated that real or bony short 'R. W. Lovett: Bost. Med. and Surg. Journal. March Sth, i8SS. TUBERCULOUS DISEASE OF THE HIP. lO: ening is measured from the anterior superior iliac spines to each malle- olus, and that practical shortening is found by a measurement taken from the umbilicus to each malleolus. The difference in inches be- tween the two kinds of shortening is seen at a glance. The only addi- tional measurement necessary is the distance between the anterior superior spines, which is taken with the tape. Turning now to the table, if the line which represents the amount of difference in inches between the real and apparent shortening is followed until it intersects the line which represents the pelvic breadth, the angle of deformity will be found in degrees, where they meet. If the practical sJioTtcning is greater than the real shortening, the diseased leg is adducted ; if less than real shortening, it is abducted. Take an example : Length (from anterior superior spine) of right leg, 23; left leg, 22^; length (from umbilicus) of right leg, 25 ; left leg, 23 ; real shortening % an inch, apparent shortening 2 inches; difference between real and practical shortening, ly^ inches; pelvic measurement, 7 inches. If we follow the line for i^ inches until it intersects the line for pelvic breadth of 7 inches, we find 12° to be the angular deformity; as the practical shortening is greater than the real, it is 12° of adduction of the left leg. If apparent lengthening is present its amount should be added to the amount of actual shortening. Table I. Distance between Anterior Superior Spines in inches. bi) 'A H I 2 2% 3 3X Z% iX 4 3 3 J ^ 4 4/2 5 S'A 6 ey 7 7>2 8 8>^ 9 9>^ 10 II 12 13 5^ 4' 4' 3 3° aj 2= 2 2^ 2° 2'" 2° 2° 2° 1° i"' 1° 1' i" 10 8 7 6 5 5 4 4 4 4 4 4 4 3 3 3 3 2 ■Ji 14 12 II 10 8 8 7 7 6 6 5 5 5 4 4 4 3 3 38 32 29 27 25 23 21 20 19 18 17 16 14 13 12 U 42 35 32 29 27 -5 23 22 21 19 18 iS 16 14 13 39 36 32 30 27 26 25 ■^2 21 20 19 17 15 14 40 35 33 30 28 26 24 23 22 21 19 17 16 i^ inches, it represents 31° of flexion deformity of the thigh. Table II. In. Deg. In. Deg. In. Deg. In. Deg. 0-5 I 6.5 16 12.5 31 1S.5 50 I.O 2 7.0 17 13.0 2)2i 19.0 52 1.5 3 7-5 19 13-5 34 19-5 54 2.0 4 8.0 20 14.0 36 20.0 56 2-5 6 8.5 21 14-5 37 20.5 58 3-0 7 9.0 22 15.0 39 21.0 60 3-5 9 9-5 24 15-5 40 21.5 63 4.0 10 10. 25 16.0 42 22.0 67 4-5 II 10.5 27 16.S 43 22.5 70 5-0 12 II. 28 17.0 45 23.0 75 5-5 14 "■5 29 '7-5 47 23-5 80 6.0 15 12.0 39 18.0 48 24.0 90 If the leg is so short that it is impracticable to measure off twenty- four inches, one can measure twelve inches ; ascertain from here the 1 G. L. Kingsley : Bost. Med. and Surg. Jour., July 5th, 1S88. TUBERCULOUS DISEASE OF THE HIP. 107 distance to the surface on which the patient is lying in a ]:)erpendicular hne in the same way, then doubhng this distance and looking- in the table as before, the amount of flexion is found. Thomas' test for flexion is one which is sometimes of use for a rough estimation of the amount of flexion deformity. The patient lies on the back and the well thigh is flexed on to the abdomen and held there. This places the pelvis in the correct position, with the lumbar spine in contact with the table, and the diseased thigh is by this naturally Fig. 109.— Thomas' Test for the Estimation of Flexion of the Diseased Leg in Hip Disease. thrown into a position of flexion if such deformity exists. It is not suitable for use in cases in which the hip is sensitive, nor, as a rule, in the case of adults. IV. Atrophy. — Atrophy is a symptom of great significance. Its absence in real hip disease is most unusual, its presence suggestive but not diagnostic, for it exists in acute joint inflammation of any type. The measurement for atrophy is made with a tape measure by tak- ing the circumference of both thighs and both calves at the same level on each side. The conventional places for such measurements are at the middle of the thigh and the middle of the calf. V. Swelling. — The existence of deep thickening over the front of the hip-joint or behind the trochanter is of great significance, and of the signs mentioned is the one least likely to be present in cases simu- lating tuberculous hip disease. It is not easily recognized. Thicken- ing of the trochanter major is a diagnostic sign of assistance. Pain. — The significance of pain has been mentioned. " Night cries " characteristic of hip disease have already been mentioned ; they are extremely significant in pointing to the probable existence of seri- ous joint disease, but they may exist in cases which do not prove to be real hip disease. It is no sign of the absence of hip disease when one I08 ORTHOPEDIC SURGERY is able suddenly to jam the head of the femur into the acetabulum without causing pain — a diagnostic method sometimes relied on. Its violence makes it unjustifiable as well as untrustworthy. DIFFERENTIAL DIAGNOSIS. Some affections commonly mistaken for tuberculous hip disease in practice desen.'e notice. I. Synovitis of the hip, jf traumatic, infectious, or rheumatic ori- gin, or from no assignable cause, may occur in children, but it presents Fig. no. — JS'-Ra— . Femoral disease. Slight atrophy of femur and pubic borse. head of fenmr. Thickening of neck of femur. Ercsion of the symptoms of beginning hip disease and a diagnosis is iwi practica- ble in the earl}- stages ; the fact that the svmptoms occur after a fall must not be allowed too much weight as arguing in favor of synovitis. It is distinguishable from true hip disease only by its relatively briefer course. In s}Tiovitis the usual joint s\-mptoms, such as atro- phy, muscular spasm, night cries, etc., ma}- be present.' Marked thickening about the joint is less noticeable in the early stages than in hip disease. 'Boston ^led. and Sur^^. Journal. cxsAii. . i6i. TUBERCULOUS D IS EASE OF THE J I IP. 109 In adults, synovitis of the hip may come on ciearl}' after a fall; there is no history of preceding" disability, and muscular spasm and wasting' are present. 2. Lumbar Pott's disease ma)' have for its first symptom a limp and a restriction of motion in one leg. This is due to the descent of pus in the psoas muscle or to an irritation and contraction of its fibres. As a rule, this limited motion is only in the direction of loss of hyper- e.xtension, but it may take occasionally the form of a general restriction of motion and the joint may be sensitive to manipulation. The point to be determined is whether rigidity of the lumbar spine is present; if so, Pott's disease is to be suspected, l^ut sometimes in hip disease at a sensitive stage the tenderness of the joint is so great that on at- tempted fle.xion of the spine the erector spin?e muscles are also spas- modically contracted and lead to the appearance of rigidity of the lum- bar spine. The diagnosis may sometimes be a very difficult one, and an opinion must be withheld and the case kept under observation until characteristic symptoms of one affection or the other develop. Later in the histor)' oi lumbar Pott's disease a psoas abscess will often de- scend and may irritate the hip-joint on one or both sides; this may again so closely simulate hip disease that it is hard to tell whether the psoas muscle is causing all the trouble or whether the hip-joint is really involved. A test of the arc of abduction of the hip may be valuable in this connection, as this motion is impaired or lost at a comparatively early stage of hip disease. It is an excellent rule never to make a diag- nosis of hip disease without examining the spine to see if Pott's disease is present. 3. Chronic arthritis deformans, morbus coxae senilis, which in many cases remains purely a synovitis without ostitis, begins sometimes idio- pathically without the history of even slight injury. A diagnostic point relates always to the age at which the patient is attacked, it being- much less common in childhood, except in extensive cases in which other joints are affected. The presence of arthritis may, of course, be demonstrated in other joints. The .I'-ray is of value in showing bone proliferation. 4. Acute Infectious Inflammation (Osteomyelitis) of the Hip Joint. — The S3-mptoms are more acute than in hip disease, the swelling is greater, and the temperature higher as a rule. In young children the diagnosis is often obscure until operation is rec^uired by abscess. In Konig's collection of 758 cases of hip-joint inflammation there were 568 tuberculous cases and no of acute infectious coxitis.' 5. Anterior Poliomyelitis. — At the stage of onset of infantile par- alysis there may be for a short time, in rare instances, marked pain and tenderness, with immobility of one limb ; ordinarily these s}-mptoms ' Konig- : "Die spec. Tub. d. Knochen und Gelenke," pt. ii., p. 123. no ORTHOPEDIC SURGERY. are not accompanied by other symptoms of hip disease, but are ac- companied by loss of power of the rest of the hmb as well as a loss of its normal warmth, rapidly followed by atrophy in the whole limb. In the late stages of infantile paralysis there is no stiffness at the hip- joint, but we note abnormal mobility in all directions and other evi- dences of infantile paralysis, such as distortion of the foot and knee, coldness, atrophy, and marked loss of power of certain muscular groups which make an error in diagnosis very unlikely. 6. Congenital Dislocation. — Congenital dislocation of the hip-joint need not be mistaken for hip disease, as the clinical history of the former is of continued limp since the child commenced walking. The trochanter is above Nelaton's line. There are no symptoms of muscu- lar stiffness or limitation of motion of the hip in congenital dislocation ; in fact, no symptoms of hip disease except the limp in gait. Patients with congenital dislocation, however, at times have slight attacks of synovitis of the hip due to the imperfect mechanism of the joint, but these symptoms subside after a short rest. 7. Hysterical joint affections, as they are to be diagnosticated from organic joint disease, will be considered more fully under the head of functional joint disease. It may be said here that the symp- toms of functional and organic hip disease may be much the same, the characteristic of the former being that they are variable in their inten- sity and not consistent with one another. 8. Coxa vara, a distortion of the neck of the femur, gives rise to shortening and limping. The trochanter is higher than Nela- ton's line. There is either good motion at the hip-joint or the limita- tion is in the direction of abduction, while the flexion is free. The amount of limitation of motion is less than would be expected from the history of the case, which is of long duration. The diagnosis is aided . by a skiagram. 9. Knee-joint Disease. — Hip disease is often diagnosticated as "knee trouble," so that it seems worth while to call attention to the well-known fact that pain in hip disease is in most cases referred to the inner side of the knee. Examination will show which affection is present. 10. Miscellaneous Conditions.— Perinephritis and appendicitis have been mistaken for hip disease. Such an error, however, must be rare. In the chronic forms of these affections there may be slight psoas contractions and the presence of iliac abscesses. In these affec- tions the limitation to motion of the thigh at the hip-joint is not general nor does it affect abduction, but it is most marked in the direction of limitation of extension. Periarticular disease, which has not yet attacked the joint or the epiphyses of the joint, is recognized with difficulty. Under the TUBERCULOUS DISEASE OF THE HIP. in head of periarticular disease may be included inflammation of bursas and lymphatic glands, psoas abscess, or psoas muscular spasm from caries of the lumbar spine (psoitis). Sarcoma of the hip may be mistaken for hip disease or hip dis- ease for sarcoma. The ,r-ray may give assistance in the diagnosis and a piece of the growth should, of course, be removed for examination. Separation of the Epiphysis of the Femur. — Separation of the epiphysis or fracture of the neck of the femur, with the resulting distortion, which may be termed traumatic coxa vara, can be distin- guished from hip disease by the history aided by an .^'-ray examination. PROGNOSIS. Under favorable surroundings the disease is one which tends to recovery in a majority of cases with more or less deformity. It is the duty of the surgeon to see that the chances of recovery are as favorable as possible, and when recovery occurs that it shall result with the least deformity and the most useful limb possible. Mortality. — The rate of the mortality due to the disease in hip dis- ease is greater among the poorly nurtured hospital cases than where after-treatment can be carefully looked after. Cazin ' reported, in 80 cases of suppurative hip disease treated at the hospital at Berck, in the course of five years, 55 per cent were cured; 12.5 per cent died; 25 per cent were not cured; 7.5 per cent were improved when removed. Of 288 cases collected by Gibney there was a mortality of 12.5 per cent from exhaustion, meningitis, and amyloid degeneration. In the Alexandra Hospital, London, there were 100 deaths out of 384, a mortality of 26 per cent; of these, 260 were suppurating cases, and the death rate of these was 33.5 per cent. Forty-two per cent were reported cured. C. F. Taylor, of New York, has reported 94 cases in private practice, with only 3 deaths ; of these 94, 24 were suppurating. Hueter reports the mortality of hospital cases at 27 per cent, and Billroth at 31 per cent. Jacobson reported a mortality rate of 73.2 per cent in 63 suppurating cases. The mortality rate from the disease alone has been generally considered to be about 30 per cent. Shaffer and Lovett investigated 51 cases of cured hip disease which had been discharged from the New York Orthopedic Dispensary at least four years previously, and found that 41 had remained cured. Of the remaining 10, 4 had died and 6 had relapsed, although 4 of the latter had been apparently cured a second time.'" Causes of Death. — ^Death may occur from (i) the generalization of tuberculosis in the form of phthisis, tuberculous meningitis, and gen- ' " Statistique des Coxalgies suppures," Bull, de la Soc. de Chirurgie, No. 5, 1S76.— Shaffer and Lovett: N. Y. Med. Journ., May 21st, 1SS7. ■N. Y. Medical Journal, May 21st, 1S87. I 12 ORTHOPEDIC SURGERY eral tuberculosis ; (2) from amyloid degeneration of the viscera; (3) from exhaustion; (4) from intercurrent disease; (5) from septicaemia and exhaustion after suppuration. Functional Results. — Spontaneous cure may result in hip disease, but as a rule with little motion and with marked deformity.' Recovery with complete motion after tuberculous hip disease is rare, but occurs even in hospital cases. From this condition to com- plete loss of motion the cases range according to the thoroughness of treatment, the severity of the disease in the individual case, and the resistance of the child. The earlier that treatment is begun the better Fig. III. Fig. 112. Figs, m and 112.— A Case of Hip Disease under Ambulatory Treatment. Result .s:ood. Motion to right angle. CChildren's Hospital Report.) the outlook. A cure by ankylosis would be expected by the writers in perhaps a quarter or a third of hospital cases who followed out treat- ment properly. Some amount of motion would be expected in the majority of cases. The amount of joint motion is likely to diminish rather than increase in the years following treatment. The prognosis in hip disease in adults is less favorable than in chil- dren, as the process is generally of a severer type. 'New York Med. Rec. I\Iarch 2d. 1S7S.— Trans. Am. Orth. Assn., vol. xi., p. 256. TUBERCULOUS DISEASE OF THE HIP. 113 If a cure with ankylosis takes place, an important practical point, as regards the use of the limb and locomotion, is the position in which ankylosis occurs.' Length of Time for Treatment. — It may be stated that at least from two to three years will probably be needed in the treatment of a case of hip disease taken at an early stage, while protection to the joint will be ad- visable for two or three years more. The early discontinuance of treatment is a serious mistake, as re- 'N. Y. Med. Record, March 2d, 1878.— British Med. Journ., August 3d, 1889. Fig. 113.— End Result in Patient with Hip Disease under Traction Treat- ment. Traction two and one-half years. Trochanter on Nelaton's line (see Fig. 114). 114 ORTHOPEDIC SURGERY. lapses are likely to occur when everything seems quiet. In the same way too early a discontinuance of the convalescent splint will often cause trouble. It is therefore much safer to err on the side of keeping on an apparatus unnecessarily long than to run what would seem to be a considerable risk of relapse. Even when a relapse does not occur, the too early discontinuance of treatment may lead to an in- crease in the flexion or adduction deformity. Distortion The prognosis as to distortion, however, does not necessarily imply permanent dis- tortion ; for at the present time, after recovery from hip disease (the deformity still existing with severe flexion and adduction) these disfigurements can be en- tirely and permanently relieved by subtrochanteric osteotomy. It is, however, much more desir- able to correct malposition of the limb whenever it occurs than to allow it to become permanent, when its correction is a much more serious matter. The prog- nosis as to lameness will depend on the amount of malposition of the limb, the amount of motion present, and the degree of short- ening. Shortening. — Some shorten- ing will be present in a majority of cases if the disease continues for any time, but for practical use in locomotion the actual shortening is of much less moment than the position of the limb. At the close of the disease an average amount of shortening would be from half an inch to two inches, if one considered the severer cases. There may be no shortening, but if the head of the femur is dislocated it may be a shortening of from three to five inches. Actual shortening due. to arrest of growth of the limb is beyond the control of the surgeon; but shortening from subluxation or dislocation of the head of the femur or enlargement of the acetabulum may be said to be due to a lack of thoroughness of treatment by traction. Perfect treatment may in some instances be impossible, from circumstances Fig. 115. — Cured Case with Marked Permanent Flexion, showini? Lumbar Lordosis. TUBERCULOUS DISEASE OF THE HIP. 115 beyond the control of the surgeon; but he should persistently bear in mind that subluxation and distortion from that source can be prevented by thorough treatment of the disease. Atrophy is never entirely cured in severe cases, but in the calf mus- cles it diminishes very much after the use of the leg is resumed. Abscess. — The significance of abscess is not very great; it does not affect the ultimate amount of motion in the joint nor does it seriously increase the shortening.' When abscesses occur in cases under careful mechanical treatment, the outlook is worse than in suppurative hip disease in general, because the careful treatment prevents the occurrence of abscess in all but the W()rst cases, so that in these the death rate is necessarily high. In a series of 63 cases of abscess from the Boston Children's Hospital,- the death rate was 40 per cent. Abscess occurred in 18.7 per cent of 574 cases of hip disease under out-patient treatment which were analyzed.^ The amount of sensitiveness of the hip and pain in cases which are well treated should be slight, though nocturnal cries may persist for a while in the early stages. The reoccurrence of night cries late in the disease, or of acute sensitiveness of the joint, is most often a sign of inadequate treatment or of trouble coming in the joint; most frequently it precedes the occurrence of abscess. Under conservative treatment carried out for a sufficient time one may expect a good functional result in the majority of cases. In few diseases is the benefit of thorough, skilled, and long-continued treat- ment more clear, and in few surgical affections can the surgeon attempt to check the progress of disease and influence recovery with greater probability of success than in hip disease ; but the surgical care and supervision should not be limited to the more acute stages of the affec- tion, but should be continued during the convalescent stage if the best results are desired.' TREATMENT. General Considerations Influencing Treatment, It is to be remembered that the hip-joint differs from the other joints in that it is surrounded by strong muscles. These, in case of acute inflammation of the joint, develop a condition of exaggerated irri- tability analogous to the blepharospasm in ulceration of the cornea. This condition needs surgical consideration, as unless checked it will ' Shaffer and Lovett : Loc. cit. '^Boston Med. and Surg. Journ., November 21st, 1SS9, p. 503. ^ Lovett : " Dis. of Hip," p. 1 17. •*The report of certain representative cases, with the results obtained in them, will be found in the second edition of this book, p. 241. They are omitted in the present edition as unnecessary. Ii6 ORTHOPEDIC SURGERY. develop deformity and destruction of the joint. The means at the sur- geon's disposal besides operative measures may be classed as means of fixing the joint, distracting the joint, and protecting it from injury, and involve a consideration of methods of (i) fixation, (2) traction, (3; pro- tection. The treatment of tuberculous ostitis of the hip-joint is based upon the same principles that are of importance in the treatment of tuber- culous ostitis of other joints, modified by the special anatomical condi- tions of the hip. The Principles of Treatment by Fixation and Traction. The object of fixing any joint affected with ostitis is to prevent an aggravation of the inflammation of the bone by the injury incident to motion. In an acutely inflamed condition the slightest motion involves joint injury and is to be avoided while the acute stage persists. In many joints it is necessary merely to secure firmly the bones forming the joint, and injury to the joint is prevented. In the hip-joint, hov/- ever, two factors militate against the efficiency of the ordinary methods of fixation : 1. The difficulty met in securing the upper portion of the joint, viz., the pelvis, which, owing to the mobility of the lumbar vertebrae, is not secured by fixing the trunk. 2. The muscular spasm of the strong muscles about the hip-joint. These muscles are in hip-joint inflammation in a state of reflex irrita- bility or of tonic spasm, and either crowd the head of the femur against the acetabulum by a continued muscular contraction or inflict upon the joint the injury of a sudden muscular contraction of all the muscles around the hip. The amount of this injury can be easily es- timated in even the weakest of children by an examination of a cross- section of the muscles. Adults who have experienced these attacks of muscular spasm liken the sensation to that of a blow of a sledge-ham- mer upon the hip. The importance in the treatment of hip disease of this increased ar- ticular pressure is shown by pathological evidence, which demonstrates the destruction of the bones forming the joint in the direction of such pressure and the absence or diminution of such destruction where this exaggerated pressure has been diminished. The effects of traction, when thoroughly carried out, can be seen in the specimens shown in the figures. A comparison of such specimens with those of severe hip disease in which traction was not used speaks most emphatically for the thorough use of the method. But although these facts have been recognized, there has been a lack of exact knowledge of the amount of force necessary to counteract TUBERCULOUS DISEASE OF THE HIP. 117 ex:^gge rated intraarticular pressure and when to apply it. To deter- mine this, a series of investigations were made by the writers,' which demonstrated that in healthy joints an appreciable amount of distrac- tion was possible in children by a traction force of twenty pounds ; but in certain cases this distraction did not take place immediately on the application of the traction force, which served at first as a stimulant to the muscles. In children suffering from hip disease in the chronic sup- purative stage, with disorganization of the articular ligaments, a trac- tion force of ten pounds caused distraction. In the late stage of hip disease, when the cicatricial contraction of the capsule and tissues has taken place, distraction is not effected by a traction force. In suppu- rative cases of hip disease with extensive disorganization of the cotyloid ligament, a slight traction force of a few pounds causes distraction. This can be easily demonstrated when a joint disorganized by hip dis- ease is cut down upon and the finger inserted into the joint. Although under attempts at fixation of the hip-joint without traction the violence of the spasm of the muscles of the hip-joint diminishes, it is impossible to prevent entirely injurious muscular spasm without traction, and it will also be found that cases treated by so-called fixation alone will mean a greater danger of pressure destruction of the head of the femur and wandering of the acetabulum than when traction is efficiently ap- plied. It would appear that no thorough fixation of the inflamed hip-joint is possible without traction, and that when a patient is suffering from an acute condition of tuberculous ostitis to such an extent that all mo- tion is injurious, it is also necessary to provide for protection of the joint from injurious muscular spasm. The consideration of the treatment of hip disease for practical pur- poses may be divided into : A, The treatment of the acute stage ; B, the treatment of the subacute stage ; and C, the treatment of the conva- lescent stage. A. The Treatment of the Acute Stage. — Treatment at this stage demands arrangements which will prevent movement of the joints and pressure from muscular spasm. To prevent movement of the hip-joint, the ordinary gas-pipe bed-frame (Chapter XXI., 9) already described will be found of practical value. The child is placed upon the back upon this frame, and the shoulders, pelvis, and unaffected leg are se- cured by means of straps. Traction is then applied to the length of the leg by a pulley attached to the foot of the bed. This pulley is arranged in such a way that it pulls upon the diseased leg in the line in which it is held when the pelvis is placed square upon the frame. If flexion is present the pulley is elevated, and if adduction or abduction is present the leg is pulled in or out. If the leg is pulled in a position of flexion, ' Children's Hospital Report, 1S9S. ii8 ORTHOPEDIC SURGERY. it is held irx position by an inclined plane or by folded sheets placed under it. The amount of traction force to be used is a question of judgment in each case, but as much weight should be applied as can be borne without discomfort by the patient. The foot of the bed should be raised to furnish counter-traction. If the patient is too sensitive to be placed upon the bed-pan without discomfort, a hole should be cut Fig. ii6. — Method of vSecuring Child to Bed Frame for Recumbent Treatment of Hip Disease without Deformit5'. in the covering of the frame to allow the bed-pan to be placed under the frame without disturbing the patient. The patient should be turned once a day to have the back rubbed with alcohol, and this should be done with extreme care. Traction should be made upon the leg hill Ik. i n^mmjrmm-'- ^% ■HK.::^ H L HHHH ng 1 ■M M Fig. 117. — Traction b}' Inclined Plane. when the patient is turned and the hip-joint should not be moved dur- ing the process. In cases in which traction efficiently used does not afford relief, lateral traction may be added. This is furnished by means of a cloth band passing around the inner side of the upper part of the thigh which runs straight out, and is attached to a weight hang- ing over the edge of the bed. Resistance to this pull is furnished by TUBERCULOUS DISEASE OF THE JJI/>. 119 another cloth band running around the iHum on the diseased side, pass- ing around the patient, and over the other side of the bed to be attached to another weight. The amount of these weights is to be determined by the comfort of the patient. Traction during the acute stage may also be furnished during recumbenc}- b}- the application of a long trac- tion splint, which is used in place of the weight and pulley traction. In this case the patient lies upon the bed-frame wearing the traction splint. The use of the weight and pulley during recumbency without the use of the bed-frame is ineffectual, as the patient lies upon a sag- ging mattress and fi.xation is not afforded to the diseased hip. B. The Treatment of the Subacute Stage. — During the subacute stage of the disease it is desirable that the patient should go about as Fig. iiS. — Latei-al Traction in Hip Disease. far as is compatible with the welfare of the diseased hip. The most efficient mode of treatment during this stage is to be found in the use of the traction splint, which furnishes not only traction, but also some restriction of motion. Unrestricted activity is not desirable at this stage. The patient's day should be a short one, broken by a period of recumbenc}-. Wliile wearing the splint the patient should sleep upon the bed-frame arranged in the manner described in speaking of the acute stage of the disease. Traction Splixts. Traction splints exert their power upon the joint by virtue of pull- ing down the leg against a counter-point of pressure furnished by the perineum. A number of appliances have been devised for the purpose of traction, the principle of which is practically the same, viz., perineal resistance with a pulling force exerted on the limb. 120 ORTHOPEDIC SURGERY. The traction splint (^Chapter XXL, 10) in common use is developed from the traction splint originally devised by Dr. Henry G. Davis. The modifications by Dr. C. F. Taylor and Dr. L. A. Sayre were, how- ever, of great importance in establishing the usefulness of the appliance. A traction appliance consists of an outside steel upright reaching from the trochanter to below the foot ; at the upper end is a horizontal rigid pelvic girdle in which the patient is secured by one or two perineal straps ; to the bottom of the shaft is attached some appliance for exer- cising traction upon the limb, the latter being held to the bottom of the splint by means of webbing attached to adhesive plaster straps. The adjustment of traction is easily provided for in se\'eral ways. One is by means of a sliding rod moving within a tube, the extension of the splint being controlled by means of a key and ratchet, a catch securmg the rod when in the proper position. The lower end is furnished with a broadened piece, bent so as to pass under the foot, and straps are attached to it which can be buckled into buckles secured to the adhesive plaster on the patient's leg. A cheaper arrangement for traction can be furnished by means of a small windlass on the footpiece of the splint, turned by a key with a ratchet. Perineal Bands. — These may be made of webbing covered with Can- ton flannel or chamois skin. Leather sewed smoothly around a leather strap is the cleanest perineal band of all ; but in the hands of careless persons it becomes hard with the constant wetting from urine, and is liable to chafe. Two perineal bands are better than one, as furnishing better coun- ter-resistance to traction and checks to adduction of the limb. The perineum should be kept powdered, and it should be bathed in alcohol daily. When an excoriation appears the perineal band should be covered with linen which is well spread with vaseline or zinc oint- ment and changed often. If the chafed spot becomes worse, the peri- neal band on that side should be removed and the other band entrusted with the whole weight ; or the child should be put to bed, the splint removed, traction by means of a weight and pulle}^ in bed being used for a short time until the perineum is healed. Ordinarily, with proper care and cleanliness, the perineum is able to bear after a short time all the pressure needed. Traction Straps". — The readiest wa\" to obtain the hold upon the limb for an extending force is by means of adhesive plaster applied as indi- cated in the diagram. It should be applied firmly to the thigh above the knee. If applied to the leg alone, traction falls upon the knee and may cause relaxation of the ligaments of that joint. Efficient plaster should be used, of a kind that will adhere readily without being heated. A plaster prepared with a combination of oxide of zinc will be found TUBERCULOUS DISEASE OF THE HIP. 121 to irritate the skin less than the ordinary surgeon's adhesive plaster. The plasters should be changed every three or four weeks, or oftener if they cause irritation. They can readily be removed, if the skin and plasters be thoroughly moistened with benzin or ether. If any portion of the limb is chafed by the plaster, it may be protected by means of a Fig. 119.— Traction Hip Splint Applied, Front View. Fig. 120.— Traction Hip Splint Applied, Back View. cloth covered with ointment placed over the part, and the plaster be applied over the cloth and the whole limb ; or if the chafing is exten- sive, the whole limb can be covered with zinc ointment and protected b\- a smooth bandage, and the plaster put on over the bandaged limb. This will require frequent renewal, but will answer temporaril)-. A bandage applied over the plaster impedes the circulation and increases 122 ORTHOPEDIC SURGERY. the danger of eczema or chafing. If a bandage is apphed over the plaster and worn for a few hours after it is first put on, sufficient adhe- sion of the plaster will be secured if proper plaster is used. In certain cases an obstinate eczema is occasioned by the adhesive plaster, and it Fig. 121.— Traction Hip Splint Applied, Side View. Fig. 122. -Traction Hip Splint, High Sole and Crutches Applied. is necessary to have recourse to some other means of extension. Sub- stitutes for plaster are to be found, gaiters applied to the ankle or straps above the knee. These, however, will slip if more than a slight traction force be applied, and are not as a rule satisfactory. Another form of traction strap can be made in the following way : Cloth is cut TUBERCULOUS DISEASE OE THE HIP. 12 to fit the thigh and leg accurately ; webbing straps and buckles or lac- ings are attached, which when tightened give a hold upon the thigh above the knee. If stra])s are sewed to this leather or cloth legging, they can be made to furnish fairly efficient traction ; but they are likely to slip, and are inferior to the simple ad- hesive plaster as a means of traction. Application and Use of the Traction Splint. — The traction splint is applied by having the child lie on the back while gentle traction is made on the leg by the hand to steady it. The pelvic band is passed around the child, buckled around the waist, and the perineal bands are fastened. The traction straps below the foot are then attached Fig. -Double Uprig-ht Hip Splint Applied. (Dane.) Fig. 124. — Leather Spica Trac- tion Splint. to the windlass or whatever extending apparatus is used, and as much traction applied as the child can comfortably stand. The straps around the leg are then fastened. When it is necessary to remove the splint or loosen the traction to care for the perineum, traction should be made upon the leg by the hand. Crutches. — With an efficient traction splint thoroughly applied, a sufficient amount of restraint of motion at the hip-joint can be furnished 124 ORTHOPEDIC SURGERY. to enable a patient not in the acute stage of the disease to move about with tlie aid of crutches, the well limb being elevated by a raised shoe. In cases with any tendency to acuteness, however, thorough traction is essential, and walking on a traction splint without crutches is liable to cause perineal chafing and less efficient traction, as at each step on the splint the traction force is somewhat diminished, on account of the yielding of the perineal straps. In cases in which convalescence has been established, crutches may be dispensed with and less traction exerted. Modified Traction Splints. — Various modifications of the traction splint have been made, in the hope of securing greater fixation in con- nection with the traction and in this way to enable free locomotion without endangering the joint. The splint devised by Dane (Chapter XXI., 13) and the combination of the traction splint with a plaster or leather spica represent the most efficient forms of this apparatus. The objection to such appliances is that they neither fix the joint nor do they permit as efficient traction as that furnished by the traction splint without a modification. The arm extending up to grasp the pelvis or thorax acts as a lever which jars the hip as the trunk moves, and the greater the traction used the more injurious is the lever action. A plaster-of-Paris bandage over the trunk and affected limb (as far as the knee), over which a traction apparatus is applied, the traction straps being placed on the limb before the plaster bandage is put on, furnishes probably the most effective combination of traction and par- tial fixation. Less cumbersome than the plaster, but not as easily fur- nished, is a moulded leather spica splint made over a cast by a similar process of manufacture to that described in speaking of leather jackets (Chapter XXI., 3). Still another arrangement can be furnished if a cloth corset with lacing be made, enclosing the trunk and limb and attached to a Thomas hip splint (Chapter XXI., 13). If this is laced snugly to the patient the child can be lifted with but little jar to the hip, and a traction splint can be applied wdth but little additional diffi- culty. This combination is of service in exceptional cases in which the acute stage is longer than usual, but it is not necessary in ordinary cases in which a comparatively short thorough treatment by recumbency is followed by a subacute stage where the limitation to the hip motion is furnished by a well-applied traction splint. Fixation Splints. Ambulatory treatment by means of so-called fixation appliances without traction has been tried in many cases for many years at the Boston Children's Hospital. The results in comparison with those obtained where traction was efficiently and carefully applied to sim- ilar cases justify a strong statement as to the superiority of the em- TUBERCULOUS DISEASE OF TIJE HIP. 125 ployment of traction in the subacute stages of hip disease, not only on theoretical grounds, but because of the superiority of the results obtained as observed in a large number of cases carefully treated and carefully recorded. Ambulatory treatment by partial fixation without traction may be needed when but little nursing care can be furnished, and the surgeon should be familiar with the best methods of its employment. It is manifest that thorough hip fixation cannot be given if the patient is allowed to move about, as the pelvis cannot be thoroughly secured by any bandage or appliance. It is also true that the method, although imperfect, is better than no treatment. Through its use patients may be relieved of the acute symptoms. Plaster-of-Paris Splint. — The hip-joint may be fairly well immobil- ized by a plaster-of-Paris spica reaching from the axillae to the heel. Fig. 125. — Application of Plaster Spica Hip Bandage. It is made more efficient if the other limb is included by a double spica, which, however, prevents locomotion. With a bandage applied to one leg alone the patient can go about on crutches wearing a high shoe on the other foot. This forms the routine of treatment in many Euro- pean clinics, but the amount of effective fixation furnished is limited. The aim of this treatment is well expressed by a representative French surgeon writing as follows : " It is ankylosis in good position that we pursue as the ideal of a cure in coxalgia." ' What has been said of the plaster-of-Paris spica, even when so applied as to hold the thorax and the other leg, is true of metal and leather splints, which do not so completely hold the joint as that does. These lack fixative power by virtue of the little hold which they have upon the pelvis, and although in many cases of hip disease they serve a ' " Late Excision of the Hip." Boston Med. and Surg. Journ., July ist, 1897. 126 ORTHOPEDIC SURGERY. therapeutic purpose in acting as an incomplete means of fixation, they cannot be advocated for general use. The Thomas Splint. — The Thomas hip splint (Chapter XXI., 13), invented by H. O. Thomas, of Liverpool, is an appliance much in use in England. It is a very simple apparatus, easily made, and having many points of usefulness. It consists of an iron bar extending down the back of the body and the diseased leg to a little above the ankle ; the upper end of this is attached to a chestpiece which is at right angles to the upright and en- circles the chest, fasten- ing in front. There are two circlets of iron which grasp the thigh and calf. The appli- ance is kept in place Fig. 126.— Plaster SpicaHip Bandage. Fig. 127. — Thomas' Splint Applied, Posterior View. (Ridlon.) by a wide chest band and a bandage around the limb, and can be bent to fit any degree of flexion existing in the diseased leg and applied to it in that position. The apparatus requires much skill in adjustment, as it is hard to fit and keep in place. There are two points in the use of the splint upon which Thomas laid much stress. The patient must not go about while muscular spasm and joint irritability are present, and the limb must not be disturbed even for purposes of examination unless absolutely necessary, and then only at intervals of TUBERCULOUS DISEASE OE THE HIP. 127 months. The appHance prevents motion of any great amount, enables the patient to be Hfted without jarring the hip, and prevents and cor- rects flexion of the thigh. In certain acute cases the pain ma)' be in- creased by the Thomas sphnt, from the fact of the imperfect fixation furnished. For motion at the hip cannot be prevented as the leg and thigh are firmly held by the fiat rod to which they ai^e bandaged, and, as this rod extends up the trunk, to which it cannot be so firmly fixed as to prevent all motion when the patient turns in bed or moves. The upper end of the rod acts as the long arm of a lever, moving with every respiration if tightly applied, and on moving jarring the hip. A double Thomas splint is more efficient as a means of fixation, but it does not permit locomotion. In a single Thomas splint a raised pat- ten is put under the shoe of the well foot and crutches are used. Immobilization and Ankylosis. — Much has been written in reference to the danger of ankylosis incurred by the immobilization of diseased joints. That fixation of a healthy joint even for prolonged periods does not cause ankylosis has been demonstrated.' The most common cause of ankylosis in diseased joints is, of course, in the cicatrization of the inflamed tissues. Any measure which tends to limit inflammation tends materially to limit rather than increase the ultimate impairment of motion. Treatment of the Stage of Convalescence. — Protection of the joint from the whole or part of the jar in walking is useful in the convales- cent stage of hip disease. The need of this will be readily understood if it is remembered that in ordinary walking the whole weight of the body falls upon the hip when the limb is straightened and the heel strikes the ground. A tuberculous hip may be sufficiently cicatrized to resist slight injury, while the frequent impact of a weight of upward of forty pounds may in time produce a condition of congestion which will furnish a cause for lighting up a quiescent focus of tuberculosis. The simplest way to protect a joint is with the use of crutches, the sound limb being raised by means of a patten on the shoe of the sound limb, enabling the affected limb to swing free of the floor. Protection Splints. The ordinary "traction " splint, as described, can be used as a pro- tecting splint, as it is longer than the limb and passes under the foot, enabling the weight to be borne upon the splint instead of on the pa- tient's foot. Protection without traction (Chapter XXI., 11) can be furnished by omitting the sliding rod, and continuing the upright rod below the foot, and expanding it at the bottom into a crutch bottom to be shod with a rubber tip running down at the outside of the foot, or 'N. Y. Med. Jour., May 17th, 1S90. 12! ORTHOPEDIC SURGERY. by inserting' it into a socket in the boot. Tlie upright of the splint should be long enough that the patient's heel should not touch the sole of the boot, though the ball of the foot may do so. The greatest jar in locomotion comes as the heel strikes the ground at the com- mencement of the step. If this jar is broken by the splint, the remain- ing jar to the hip in the step will be diminished at the ankle and knee, and the hip sufficiently pro- tected, except during the acute stasres of the disease. Fig. 128.— Crutch Tip Convalescent Hip Splint, Applied. Fig. Jointed Convalescent Hip Splint, Applied. The ordinary protection splint should be, like the long traction splint, an outside steel upright with a horizontal pelvic band at a level with the trochanter carrying perineal straps. It should be slotted below into a steel sole plate screwed to the bottom of the sole, and when the splint is in place and the perineal band buckled, the patient's heel should not touch the heel of the shoe, but hang an inch or less above it. A protection splint can be made hinged at the knee, and, if prop- erly adjusted, patients can walk about readily with but slight discom- TUBERCULOUS DISEASE OE THE HIP. 129 fort. In this way reliable protection is secured during the long period of convalescence necessary for the thorough recovery of the affected epiphysis.' If proper protection is neglected and not continued long enough, the jar of locomotion — the whole weight being thrown upon the epiphysis previously diseased — is sufficient to prolong the stage of irritability, to prevent complete cicatrization and ossification of the inflamed bone tissue, to promote contraction of the limb and distortion, and in many instances to give rise to relapses. It is not necessary in young children that the splint be jointed at the knee in a protection splint ; this is, however, of advantage in adults. As the patient's condition improves, the splint can be shortened and jar gradually be allowed to come upon the limb. Protection is needed for some years after the subsidence of active symptoms. The need for the reapplication of protection is indicated by a reappearance of stiffness or increased limping on removal of the splint. The older the patient and the more active the process the longer protection will be needed. Relapses. — Hip disease is not ended when the acute symptoms have subsided ; a process which requires so long a time for its development requires also much time for its disappearance. It is safer not to dis- continue traction and begin simply protective treatment as soon as the pain and acute symptoms are gone, and it is safer not to discontinue protective treatment until a long time has been given to the joint in which to recover itself. Termination of Treatment. — Patients apparently cured in childhood of hip disease, but with fixed or partially fixed joints, may suffer in later life from painful attacks from overstrain of the ligamentous attach- ments of the joints; this is especially true if any distortion remains un- corrected and the patient becomes heavy. This painful stage yields to the treatment by protection for a short time. If, however, much deform- ity persists, correction of the deformity is often necessary. Recur- rence of the tuberculous process in adult life in a hip which has been thoroughly cicatrized since childhood is rare. When ambulatory treatment is attempted it is desirable that every precaution against jar to the hip be taken. As it becomes clear that the danger of motion or jar at the hip has diminished, crutches can be laid aside for part of the time, with the continuance of traction as long as there is a tendency to contraction of the limb or muscular spasm. Later traction may be discontinued, but protection still maintained. Traction should be given up only after the muscular irritability elicited by gentle manipulation has been absent for some weeks, until pain and night cries have been absent for months, and until there is ' " Mechanical Treatment of Hip-joint Disease," C. F. Taylor, New York ; and E. G. Brackett : Boston Medical and Surgical Journal, October 6th, 1887. Q 130 ORTHOPEDIC SURGERY. every reason to believe that the process is quiescent and only partial stiffness of the joint remains, due to inflammatory adhesions and not to muscular spasm, and that protective treatment should then be pursued for two or three years at least and discontinued gradually. Summary of Mechanical Treatment. — A systematic and graded treatment of hip disease is in this way provided, capable of meeting the successive indications in the usual course of a typical acute hip disease in its progress from an early destructive stage to recovery, first, by thorough fixation with protection of the joint from muscular spasm and traumatism; second, by locomotion with a minimum of motion at the hip and protection of the joint from jar, with a check to exaggerated intraarticular pressure from muscular spasm ; and third, by freer motion at the hip, but with protection of the hip from the jar incidental to walking and a check to the development of deformity. As cases vary, the treatment will be changed to meet the variations according to the judgment of the surgeon. The period of fixative recumbency, which should be as short as possible, will in some cases be longer than others, owing to the activity of the inflammatory process. In some cases ambulatory treatment can be begun at once without the stage of thorough fixation with recumbency. This course of treatment is inadvisable while deformity or acute spasm is present, but may be demanded by the necessity of the case. In some instances an increased risk to the local lesion may be justified to improve through greater activity the general condition. The application of traction in hip disease to be of benefit needs to be carefully directed. As in aseptic surgery vigilance and efficiency on the part of attendants are necessary, while as in aseptic surgery a par- tial adoption of the method is better than its total rejection, yet the method is injurious if its imperfect use blinds the surgeon to the neglect of other essentials. A surgeon is not employing the aseptic method of treatment if he washes his hands in sterile solutions and poisons the wound with septic dressings. In a similar way the use of a traction splint in the case of a child with hip disease is not only not beneficial, but becomes injurious if it leads the surgeon to neglect the necessity of protecting an inflamed joint from undue motion. The care required in the application of traction splints and the un- satisfactory results following apparent treatment by traction splints in out-patient clinics have led many surgeons to abandon the use of the so-called traction splints, allowing the patient to walk about with crutches, with the thigh, leg, and trunk supported by fixation appliances. The Treatment of Complications. Abscess. — Abscesses due to hip disease may in the early stages be absorbed in some cases under prolonged treatment by recumbency. TUBERCULOUS DISEASE OF THE HIP. 131 Abscesses may also be left to enlarge and break if for any reason this seems desirable in any individual case. If abscesses are well local- ized and increasing in size, and burst spontaneously, they often are thor- oughly evacuated, leaving a sinus which, after discharging for some time, finally heals. Often, however, the abscess is not completely evacuated. Some residue remains, and, gravitating along the lines of fasciae, it gives rise to the development of another abscess, until several collections of pus may be developed about the joint. The experience of the writers in treatment by aspiration and the injection of germicidal solutions has not been favorable for the same reasons as those mentioned in speaking of Pott's disease.' Incision under strict antiseptic precautions is to be advised in all cases in which absorption seems unlikely; exploration of the joint cav- ity should be made if the abscess communicates freely with it, and pos- sibly softened bone may be scraped out. The abscess cavity should be examined for pockets, wiped out with dry gauze, and drained. Sinuses,, as a rule, persist for months or years after operation." When efficient treatment is carried out, abscesses as a rule appear only in the severer cases, in which drainage is likely to be of benefit to the disease. The closure of abscess cavities by suture after the evacua- tion of their contents, while in rare instances it leads to permanent union by first intention, is not to be advised, as breaking down gen- erally occurs subsequently. It must be remembered that the tubercu- lous infection is not confined to the wall of the abscess, but extends into the surrounding tissues. Night Cries. — This troublesome complication usually disappears quickly after the establishment of thorough treatment by recumbency and strong efficient traction. It is indicative of an active condition of the process of epiphyseal ostitis. In some instances it persists for sev- eral weeks even under treatment. In such cases an abscess is usually developed. The employment of phenacetin and salicylate of soda '' has appeared to be of some efficiency in diminishing night cries. Although opiates, chloral, and bromide of potassium in large doses will often give relief, the use of them is to be avoided if possible. Deformity. — The deformities occurring are flexion, abduction, and adduction, or any combination of these. In the early stages of the dis- ease when malposition occurs it is best corrected by putting the patient to bed and making traction in the line of the deformity. Correction by the Traction Splint. — Slight cases of deformity can be corrected by the use of traction splints, which allow the patient ' N. Y. Med. Jour., March 2d, 1889. ■Boston Med. and Surg. Jour., September iSth, 1S90. — Orth. Trans., vol. ii., p. 87. ■R. \V. Lovett: Boston Medical and Surgical Journal. April. 1S89. 132 ORTHOPEDIC SURGERY. to go about with the aid of crutches. The traction splint naturally antagonizes adduction of the limb by virtue of its pulling the leg against a counter-point in the perineum which tends to abduct the leg to which the splint is applied. Correction by Recumben'CY. — In the severer cases rest in bed hastens correction. If the patient is allowed to roll about in bed, or sit up, or hold the limb flexed at the knee, it is manifest that no proper traction force is being used. It is obvious, therefore, that the patient should be fastened to a bed frame and traction made in the line of deformity. As the Fig. 130.— Diagram to illus- trate the performance of sub-trochanteric osteoto- my for the correction of ankylosis of the hip in a deformed position. The solid line indicates a linear osteotomy ; the dotted and solid lines tog'ether, a wedge-shaped osteotomy. Fig. 131. — Adduction Deformity Resulting from Hip Disease before Correction. (C. F. Painter.) malposition of the leg diminishes under treatment, the line of the pull is made gradually more in the long axis of the body. The ill effect of a pulling force not in the line of the deformity in the acute stages of hip disease is evident. If an attempt is made to force the limb down in a case of flexion, and a pull be made in the line of the axis of the body, the head of the femur is crowded upward to the ante- rior edge of the acetabulum by the force applied at the end of the lever, viz., the femur, the contraction of the flexor muscles (holding the limb flexed) furnishing the fulcrum. In milder stages of the disease this is not so important as in the acuter stages, but it is a mechanical error in TUBERCULOUS DISEASE OE THE HIT. 133 any stage to attempt traction except in the line of the deformity. This error is often the occasion of increasing the pain and sensitiveness in cases of hip disease. Correction Under an An/ESthetic. — In cases of resistant defor- mity treatment by traction is tedious and in the more obstinate cases in- effectual. In cases of this character the use of judicious force under an anaesthetic is advisable. Care must be exercised not toinfiict a trauma upon tuberculous bone, but where resistance is firm, cicatrization of the diseased area can be supposed to have taken place, and often but little force is necessary to secure correction. Division of the con- tracted fascia lata and adductor muscles will be of assistance in some instances. After correction the limb should be fixed in a plaster-of-Paris spica bandage, a corrected position with slight ab- duction. When firm ankylosis is present manual correction will not be sufficient and recourse to oste- otomy will be needed. Correction by Osteotomy. — The operation in common use was devised by Gant ; ' in this the femur is divided below the trochanter minor. The anatomical reasons which he gave for this step were that the resistance of the psoas and iliacus muscles was set free and that a return of the flexion was not therefore to be expected, as when the bone was divided above the attachment of these muscles. He also called attention to the fact that in operating for ankylosis, after hip disease, it was desirable, if possible, to make the section through healthy bone and as far as possible from the original seat of the disease ; in this way dimin- ishing the liability of rekindling the old joint inflammation. Tcchniqjie of Operation. — The osteotome is a chisel, which should possess a temper about halfway between that of a cold chisel and a car- penter's cutting tool, so that the QdgQ of it will not be turned by the hardness of the bone. The cutting edge should be sharp and the width ' Lancet, December, 1872, p. 881. Fig. 132.— Adduction Deformity Resulting from Hip Disease after Correction. (C. F. Painter.) Same patient as Fig. 131. 134 ORTHOPEDIC SURGERY. of the blade about half an inch. The blade should be marked with a line every half or quarter of an inch from the cutting edges, so that one can tell how deeply the osteotome has penetrated. A fair-sized wooden carpenter's mallet answers better than any of the lead or steel ones found in the instrument-shops. In the performance of the operation the patient lies on the side with a sand pillow between the legs, and the skin is sterilized carefully. The chisel may be driven in through the sound skin about an inch or an inch and a half below the great trochanter, according to whether one is operating upon an ado- lescent or an adult. The chisel should at first be held with the blade in the long axis of the limb and turned when it reaches the bone until its edge is at right angles to the axis of the limb. The osteotome should then be driven into the bone by sharp blows with the mallet, turning the cutting edge first forward and then backward, so as to cut obliquely through the whole shaft. If the osteotome be- comes wedged it should be loosened by lateral motions and a thinner one substituted if possible. Any attempt at pry- ing with the osteotome may re- sult in breaking the blade and should be avoided. When the spongy tissue has been traversed by the blade of the chisel, it will come in contact with the opposite wall of solid outside bone and will at once be felt to be driven with greater resistance. Then the osteo- tome acts as a probe as well as a cutting instrument. The bone should not be entirely divided, but when it seems evident that only a shell is left, attempt should be made to fracture the femur — very little force is needed, and if the bone does not yield easily the chisel should be again driven in still farther — always loosening it after each blow of the mallet and directing the blade in a new direction. After the bone is broken, in most cases the flexed leg can be ex- tended and the adducted one brought straight, and no unnecessary Fig. 133. — Ankylosis at a Right Angle following Hip Disease, before Gant's Osteotomy. (C. F. Painter.) TUBERCULOUS DISEASE OF THE HIP. 135 manipulation of the bone should be made. If the osteotomy has been efficiently performed little force is needed to correct the deformity. There is little bleeding and a small skin wound, unless it is necessary, as sometimes happens, to make a cut in the anterior surface of the upper thigh, to divide bands of contracted fascia which prevent full extension of the thigh. The patient should then be fixed in a carefully applied plaster spica bandage, which should secure the hip firmly in the corrected position. The anterior spines, the patella, and the vertebral Fig. 134. — Same Patient as Shown in Fig. 133, after Osteotomy. (C. F. Painter.) Fig. 135.— Double Thomas Splint Applied. Hip spines should be well protected by padding to prevent sloughs. When plaster-bandage fixation is undesirable, on account of the condition of the skin, the patient should be placed on a bed-frame and a traction weight applied, pulling in the desired direction. Confinement to bed should last between five and six weeks. If it is desired to compensate for bone shortening it can be done by put- ting up the shortened leg in an abducted position. The latter will be found of assistance where the shortening is great, as the resulting tilt- ing of the pelvis adds to the practical length of the limb. The risks 136 ORTHOPEDIC SURGERY. attending the operation are slight. Hemorrhage is very rare — although accidents have been reported from pressure on the femoral vessels by- sharp edges of bone.^ Marked improvement in the general condition of the patient often follows the operation.^ After-Treatment. — After the cessation of bed-treatment, fixation in a plaster-of-Paris spica should be continued for at least six weeks more. If fixation in the improved position is abandoned too early the deformity may recur. Deformity occurring during the acute stage of the disease should be rectified as it occurs and prevented from recurring. The ultimate functional results following the operation are excellent. Although there may be no motion at the hip-joint, the lumbar vertebrae are usually more movable than normal. The operation is indicated in all cases of severe deformity in which the distortion interferes seriously with locomotion. Shortening of the Limb. — Shortening of the limb after hip-joint dis- ease and after excision occurs in a certain number of cases ; nothing can be done to prevent it when it is due to arrest of growth. Preven- tion of the development of the disease and such use of the limb as is compatible with the safety of the joint, inducing proper circulation in the limb, may be regarded as the only means at our command. The shortening due to subluxation is in a large measure prevented by efficient treatment. Patients with much shortening of the diseased leg vary a great deal in the relief afforded b}- a high shoe; sometimes they find it of the greatest possible benefit, while at other times it is a constant annoy- ance. The shoe can be raised by a cork sole, or more cheaply by an iron or wooden patten, or by an arrangement in which the foot, like the stump of an amputated limb, fits into the socket of a specially con- structed elongated boot, which conceals the shortening. Double Hip Disease. — During the acute stage of the disease recum- bency on a bed-frame and efficient traction by weight and pulley or by two traction splints is the best treatment. After the stage of spasm has passed, the patient can be carried about in a double Thomas splint and when convalescence is established, locomotion with traction or pro- tection splints and crutches is possible. The chief difficulty in treating double hip disease is in the prevention of deformity, not so much dur- ing the active stage of the disease, but after convalescence has been established. Deformity will probably not occur if patients are kept recumbent for a sufficiently long time to establish a perfect cure. If, however, they are allowed to walk or move too soon, before the joints are thor- 'Post: Ann. Anat. and Surg. , January, 1SS3. and Rev. de Chir., December, 1S81. — C. T. Poore : " Osteotomy and Osteoclasis," New York, 18S4. • Goldthwait : Orth. Trans., vol. xi., p. 2S0. TUBERCULOUS DISEASE OF THE HIP. 137 oughly strong, weight must necessarily fall upon the affected limbs in walking. If these are not sufficiently recovered to sustain the weight, deformity may ensue. Even with very little motion in either hip-joint locomotion is often possible, although the gait is necessarily restricted. OPERATIVE TREATMENT. Curetting and Drainage of Tuberculous Areas in Hip Disease. — In cases of tuberculous ostitis of the hip, when the process is limited to sharply defined foci surrounded by firm bone, the condition may be said to resemble that presented by an abscess, and drainage of such a focus is desirable when the part affected is easily accessible, as in the knee or OS calcis. But when the acetabulum or the epiphysis of the femoral head are attacked, it is difficult to secure satisfactory drainage and the removal of all diseased tissue ; nor is it, as a rule, easy in this region to determine, by means of a skiagram, the existence of a sharply defined focus. It has been shown ' that tuberculous changes may exist in bone in an early stage of development and on the borders of apparent tuber- culous cavities, and yet not be demonstrable in ,t'-ray pictures taken of living subjects, especially when taken in the deeper structures. This procedure is most satisfactory when the process is situated near the trochanter, which may be trephined or tunnelled for the removal of de- tritus or sequestra.^ When this is attempted for foci in close proximity to the hip-joint, it excites increased reflex irritability and exaggerated muscular spasm, and should in treatment be followed' by thorough trac- tion to overcome the injury following increased intra-articular pressure. When this cannot be provided, or when the localization of the disease is not sharply marked, the method is of doubtful value in affections of the hip-joint proper. The operation is performed by exposing the part of the bone in which the focus has been located and removing it by thorough curet- ting. The cavity is then carefully dried and wiped out with strong car- bolic acid and alcohol or a 2.5-per-cent solution of formalin, and the wound closed, with the exception of a temporary gauze wick. The operation should be performed with as little unnecessary traumatism to the joint as possible. The operation is followed by traction in the re- cumbent position. Excision of the Hip- Joint. — This method of treatment is based upon the opinion that, when a tuberculous affection exists, repair is hastened by the eradication of the diseased portion. Excision is less to be advo- cated at the hip than at the knee or ankle, for the reason that it leaves ' Feiss : Journal of Med. Research, 1904. -R. T. Taylor: Am. Journ. Orth. Surgery, vol. i., p. 232. — A. M. Phelps: N. Y. Med. Journ., September 5th, 1900. 138 ORTHOPEDIC SURGERY. a poor joint for weight-bearing purposes and because it is difficult and dangerous to remove the acetabulum, frequently primarily diseased in hip disease. Bardenheuer ' has excised the acetabulum in twenty-six cases, eighteen of which were suffering from tuberculous ostitis and nine from osteomyelitis. He concludes as follows: that the complete resection of the hip-joint, including the acetabulum, is a severe but not fatal operation, though skill is required. It is indicated in all cases with septic involvement of the acetabulum and all cases of acetabular caries where conservative treatment has failed. The operation is performed by means of an incision made along the crest of the ilium, extending from the sacro-iliac synchondrosis to the anterior superior spine. The bone is to be cleared of muscular at- tachments down to the acetabulum. By means of a Gigli sa\v, the acetabulum is separated from the ramus of the pubis, the connection of the ilium, and the descending ramus to the tuberosity of the ischium. It is easier to remove the acetabulum without opening the joint, which can be opened later and the head of the femur saved. If the head of the femur is involved it is re- moved, being sawn off at the neck. The wound should be closed and traction applied to the limb, placed in a slightly abducted position. Excision in the early cases is not justified when conservative treat- ment can be carried out for a sufficient time and with thoroughness. The removal of the head and neck, moreover, removes from the socket one of the supports on which the trunk rests, and the hip is more mutilated than after the cure by the natural process of gradual absorp- tion, repair, and cicatrization, which leaves a firm though possibly anky- losed hip. After excision the hip is necessarily mutilated. The oper- ation is therefore reserved for the severer cases. Method of Operation. — Of the incisions in ordinary use the straight external incision is the one most commonly used and the most service- able. The incision should begin at a point midway between the anterior superior iliac spine and the great trochanter, the knife being pushed •directly to the bone. The cut should curve to the top of the trochan- ter and then downward and forward, the length of the incision being from four to eight inches.^ 'Bardenheuer: Festschrift d. Akad. f. prakt. Med. in Coin, 1904. 2 Brit. Med. Jour., July 20th, 1889, p. 119. Fig. 136. — Straight External In cision for Excision of tin Joint. TUBERCULOUS DISEASE OF THE HIP. 139 The tissues should be incised down to the bone, the soft parts should be divided, and the capsule opened. It is best to incise the peri- osteum of the trochanter, and if possible with a periosteum elevator to free it wdth its muscular attachments from the bone. Sometimes the whole trochanter can be uncovered in this way. After having made the cut down to the trochanter and separated the periosteum on the outer side so far as practicable, the next step is to separate the soft tissues from the bone on the inner side, stripping back the periosteum as far as it exists as such. In advanced cases of hip disease, however, it will be found that all that it is practicable to do is to clear the periosteum from the outer aspect of the trochanter and then to separate the muscular attachments from the neck of the bone, keeping the knife as close to the bone as possible. Then passing the finger around the femur and adducting the leg slightly will raise the head of the femur out of the acetabulum, and the capsule can then be divided and the head of the femur thrown out into sight and sawed off, or the section can be made by a small saw or osteotome before dislocat- ing the bone if the finger is kept inside of the neck of the femur as a guard. If the head of the bone is dislocated, it is more easy to see the limit of diseased bone and to make the section well in the healthy tis- sue. The objection to dislocating the head of the bone before section is that fracture of the diseased and atrophied shaft of the femur may occur if it is done roughly, and also that periosteum may be stripped up fron. the inner aspect of the shaft and cause necrosis. When the head is adherent, it should be curetted or chiselled from its place. The acetabulum should be examined and any sequestra removed and any carious surface should be scraped with a Volkmann's spoon. If the acetabulum is perforated, the edges should be chipped off until the point is reached where the periosteum lining the pelvis is attached to the bone. After the operation a tube or a strip of gauze should be left in the most dependent angle of the wound and the rest may be sewed up if the tissues are not too much infiltrated with the products of inflamma- tion. A heavy antiseptic dressing should then be applied and the hip should be fixed either upon a frame with light traction or in a plaster- of- Paris spica with the limb in an abducted position. As soon as it is practicable the child should be allowed to move about with crutches, wearing, as an appliance to prevent subsequent deformity, a traction splint. It is impossible to remove all of the tuberculous material in excision of the hip ; and this must necessarily lead to relapses and imperfect results in many cases. The mere removal of the head of the bone is a very incomplete measure for the eradication of the disease in those cases in which the tuberculous material has mfiltrated all the tissues m I40 ORTHOPEDIC SURGERY. the neighborhood of the joint. In many cases of extensive disease it is not easy to do a subperiosteal operation. In the severer cases the capsule is lax and partially destroyed, so that the finger when first introduced in the wound finds the head of the bone only loosely in con- tact with the acetabulum and dislocation is easily accomplished. The ultimate results in cases in which excision was performed only after mechanical treatment had failed are as follows : Fer cent Cases, of Deaths. Children's Hospital, Boston,' . . . .50 44.0 Hospital for Ruptured and Crippled, New York (Townsend '), . . . . . .99 51.5 The causes of death after excision of the hip are, aside from the small per cent caused by the shock of the operation, due to the same causes as in hip disease not treated by excision, and it is certainly not Fig. 137. — Late Excision. Poor result. No motion. Hip painful. Walks with splint. Three years since operation. (Children's Hospital Report.) true, as has been claimed, that excision of the hip is a preventive of sys- temic infection. That general tuberculosis and tuberculous meningitis supervene in a certain proportion of cases of hip disease is a fact well known. Mr. Barker, an advocate of excision, in a lecture at the Royal College of Surgeons in 1888 on the treatment of tuberculous joint dis- ease, said that in no less than ten per cent of all deaths following excis- ion " rapid miliary tuberculosis supervened in such a way as to suggest strongly, if not to prove, that the surgical interference was the cause of the generalization of the disease." The statistics of Wartmann, based upon 837 resections, show that at least 10 per cent of all the deaths are caused by rapid general miliary tuberculosis, coming on in such a way that it is strongly suggested that the surgical interference stood in a causative relation. This point has been of late often alluded to, and the lesson to be drawn is that in excisions the work should be done cleanly, with as little tearing of tis- sue and opening of lymphatics as may be, with the most careful and constant irrigation. ' Orth. Trans., vol. x. TUBERCULOUS DISEASE OE THE HIP. I4[ Mortality. — It may be stated then, in brief, that resection of the hip- joint as an operation is attended by an immediate fatahty of about 7 per cent. The mortality of the disease after the operation cannot be estimated as less than 20 to 30 per cent, and when cases are followed up for several years it is higher still. Functional Results.— After excision of the hip-joint the mechanical conditions are not favorable to the formation of a firm joint. After operation the head of the femur is gone and part or all of the neck. The capsular ligament is destroyed, and the upper end of the femur lies loosely against the ilium — perhaps at the acetabu- lum, perhaps somewhere else, and out of this very uncertain contact a new joint must be formed if there is to be one, or else a union without motion. A new joint is established in suc- cessful cases. In these cases a synovial sac may develop, and the head of the bone is bound firmly to the ilium so that a comparatively useful hip-joint remains. But the use- fulness of the limb after success- ful excision is less than after recovery under non-operative treatment. In some instances a limb which was in excellent condition immediately after the operation becomes ultimately en- tirely useless. An illustration of this was reported by one of the writers ' in a patient seen five years after excision. In Cul- bertson's tables" the case is reported as follows: "(No. 464.) — Re- covered in six and two-thirds months ; one-half inch shortening, almost perfect motion. Last heard from six and two-thirds months." Though the limb at the time of the patient's reported condition of cure was in a favorable condition, five years later the boy could only touch the floor with the toes of his affected limb, and was unable . ' N. Y. Med. Jour., April, 1879. '■^Transactions Am. Med. Assn., 1S76, p. 142. Fig. 138. —Result of Suppurative Hip Disease Treated by Traction after Three Years' Treatment, Showing Extreme of Possible ilotion. 142 ORTHOPEDIC SURGERY. to walk without crutch or cane and could bear little or no weight on the affected limb. It is difficult to determine definitely how large a proportion of useful limbs ultimately result in cases in which recovery has taken place after excision of the hip.' In a series of 50 cases of excision of the hip done at the Children's Hospital from 1877 to 1895 it was possible '■' to report on the condition of 10, four years or more after oper- ation. The interval ranged from four to fourteen years. One had his hip amputated later, a second was in poor general condition, but with the exception of the ampu- tated case no one of the patients used a cane or crutch ; one had 6 inches of shortening, one 5, one 4, one had 2 inches, and three had only I inch. The amount of mo- tion in flexion in those of the 10 cases in which it was recorded was as follows: None, 25°, 40°, 45°,6o°, 65°, 80°. Indications for Excision. — The indications for excision can be stated as follows : 1. When conservatism is im- possible owing to lack of facil- ities for thorough treatment and the affection is rapidly progress- ive. 2. When a progressive destruc- tive process has continued in the hip-joint unarrested by the most favorable conditions. 3. When the process is so acute that it threatens not only the destruction of the joints but en- dangers life. 4. When an extensive sequestrum is present. It must be borne in mind that results as to mortality after early excisions (before extensive destruction in the bone has taken place) are ' Cent. f. Chir. , 1879, No. 2. — Med. Times and Gaz. , November 3d, 1877.— Orth. Trans., vol. vi., p. 124. -Lovett: Orth. Trans., vol. x. Fig. 139. — Late Excision of Hip. Motion prac- tically perfect. (Same case as Fig. 140.) TUBERCULOUS DISEASE OE THE HIP. 143 much more favorable than after late excision.' The results of careful conservative treatment, if carried out for a long time, are superior to those after excision in a majority of cases, and when conservative treat- ment is practicable it should be preferred. In large hospitals or among a poor and unintelligent class, conservative treatment is sometimes impracticable, and in such cases excision is resorted to earlier than would otherwise be justifiable, and the results gained are more satisfac- tory than when the operation is deferred. It must be evident, in com- paring the mortality and the results of excision of the hip with the Fig. 140.— Late Excision of Hip. Motion practically perfect. mortality and the results of conservative treatment, that excision has no place in the routine treatment of the disease, because its mortality is higher and its functional results are inferior. The operation has, however, a decided usefulness in late cases of hip disease, when it becomes distinctly a life-saving procedure, and in severe cases at an early stage when no home treatment or adequate hospital treatment for a long time is practicable. 'Cent f. Chir., 1894-96.— Congres de Chir., Proc. verbale, 4S1. — " Coxalgie Tuberculeuse," Paris. — Journ. de Med. et de Chir., Annales, iv., 3, 261. — Congres Fr. de Chir., 1S95, ix. , 153. — Jalaguier: These d'Ag., Paris, 18S6. — Archiv f. klin. Chir., xxiv., 4, 719. 144 ORTHOPEDIC SURGERY. Although the writers have been able to gain thoroughly satisfactory results after excision of the hip, and in a few instances have had reason to regret not having resorted earlier to excision in cases in which con- servative treatment proved unsatisfactory, yet after years of careful experience in the treatment of hip disease by both conservative and operative methods they would unhesitatingly record their opinion that the conservative method of treatment is preferable to the operative and that resection is needed only in exceptional cases.' Amputation. — The question of amputation of the diseased limb alone remains for consideration. The mutilation which results is the chief objection to the operation, and is but partially met by an artificial limb. An undoubted reformation of bone has taken place in the case operated upon by one of the writers.'^ Absolute economy of blood — of the utmost importance in all hip amputations — is vital in cases reduced to the physical extremity seen in cases of hip disease undergoing this operation. The limb 'should be elevated and stripped of blood, and an elastic bandage is doubled and passed between the thighs, its centre lying between the tuber ischii of the side to be operated upon and the anus. A pad in the shape of a roller bandage is tied over the external iliac artery ; the ends of the rubber are drawn tightly upward and outward (one in front and one behind) to a point above the centre of the iliac crest of the same side. The front part of the band passes across the compress ; the back part runs across the great sciatic notch and pre- vents bleeding from the branches of the internal iliac. The ends of the bandage, are tightened, and should be held by the hand of an assistant placed just above the centre of the iliac crest. The danger of hemorrhage may be still further diminished by trans- fixing the thigh from side to side above the line of incision and securing pressure with a steel skewer passing under the vessels. If rubber tub- ing be passed tightly around the ends of the skewer over the anterior surface of the thigh, the front vessels can be compressed and the same method can be applied to the posterior vessels (Wyeth's method). The operation in this way can be performed without the loss of any appreciable amount of blood, and there is time for due deliberation, as there is no danger of a death upon the table by a sudden gush of hem- orrhage. The operation of amputation at the hip-joint has been performed three times at the Boston Children's Hospital in extensive disease of * E. H. Bradford : " Operative Dislocation and Drainage of the Acetabulum in Articular Disease." Boston Med. and Surg. Joum., 1901, cxlv., 240. - Wyeth: Ann. of Surgery, xxv., 1897, 127. — Levison : Jour. Am. Med. Assn., June 24th, 1899, p. 1428. — Erdman: Ann. of Surgery, September, 1895. — Lancet,- May 26th, 1883. TUBERCULOUS DISEASE OF THE HIP. 145 the hip and pelvis, with operative success in all, but with ultimate death from amyloid disease in two cases. Ultimate recovery took place in one who grew to manhood and at twenty wore an artificial limb fitted to a stump in which reformation of the bone took place from the peri- osteum. The following conclusions would appear to be justified: amputation at the hip-joint, in hip disease, should be regarded as the very last resort, contraindicated by extensive amyloid degeneration of the viscera or a moribund condition of the patient. The chances of mortality are not greater than those in amputation of the thigh in general, and the chances of a permanent cure (barring the mutilation) would appear to be greater than after excision at the hip-joint. The amputation should be done subperiosteally whenever it is possible. Summary of Treatment of Hip Disease. It is difificult to summarize the treatment of hip disease, for the reason that cases differ greatly in severity ; some needing recumbency for a very long period, owing to a severe degree of sensitiveness or to the activity of the ostitis, while in other cases ambulatory treatment with proper appliances is sufficient without recumbency. The proper treatment of hip disease is, therefore, not the exclusive use of any splint, but the use of such means as may meet the indica- tions as they are present. During the acute stages, the hip-joint should be fixed efficiently in bed. This implies the use of thorough traction. Continued confinement to bed is not beneficial to the general condition of tuberculous patients, except temporarily during the acute stage ; and as soon as the acute symptoms have subsided the patient should be allowed to go about with the hip thoroughly protected against jar and spasm. This can be done by means of a traction splint, if efficiently applied, with at first the additional protection from crutches. If the acute symptoms return under this method, thorough rest in bed is again indicated in addition to efificient traction and fixation. If the acute symptoms diminish and there is less muscular rigidity at the hip-joint, greater freedom can again be allowed, and eventually traction discontinued, and the joint merely protected from jar. This should be continued so long as there is any danger of recurrence of active symp- toms or tendency to contraction. In brief, the hip should be fixed as long as it is sensitive, should be protected and distracted as long as there is muscular spasm, and pro- tected as long as it is weak. The best results are attained only by thorough treatment for a year at least, and careful supervision and protection for two or three subsequent years. Distortions of the limb should always be corrected as they occur. In many cases some motion can be saved at the hip-joint if treatment is not discontinued too soon. 146 ORTHOPEDIC SURGERY. Abscesses can be treated on general surgical principles. Radical operative measures are needed only in exceptional cases if thorough conservative treatment can be secured. Out-of-door air, the best ob- tainable surroundings, with as much activity as the local conditions of the joint justify, stimulating the circulation by exercise, and improving the appetite and the metabolism, are the antidotes at present available to the tuberculous condition. These, if combined with such surgical treatment as will protect the affected bone from frequent traumatism, may be relied upon to effect a cure in the greater number of cases of hip disease. CHAPTER IV. TUBERCULOUS DISEASE OF THE KNEE. Definition.— Pathology. — Clinical history. — Diagnosis. — Differential diagnosis. — Prognosis. — Treatment, (a) conservative, (d) operative (excision,— arthrectomy, — amputation). DEFINITION. The other names by which this affection is known are tumor albus^ white swelhng, scrofulous disease of the knee, chronic purulent or fun- gous synovitis of the knee, etc. The knee-joint differs in anatomical structure from the hip, in that the joint surfaces forming the knee are nearly flat and the facets in the tibia shallow. Owing to this fact, the tibia is easily drawn backward and flexed by the hamstring muscles, the flexors of the leg being much stronger than the extensors ; at the same time it is rotated out- ward, the combination constituting the common and troublesome de- formity which is the characteristic one after severe tumor albus. The course of the disease in the knee does not differ in general from that in the hip, but the measures necessary for preventing deformity in the two joints are somewhat different. PATHOLOGY. Tumor albus, as it is seen in children, begins oftenest, if not always, as an epiphyseal ostitis of the tuberculous type. Like other forms of tuberculous disease, it is oftenest limited to certain portions of the epiphysis, and either the femoral or tibial epiphysis may be attacked primarily. Cases are occasionally seen, however, in which the primary focus is in the patella or in the head of the fibula. Li children it is not uncommon to see an acute, apparently traumatic effusion gradually absorbed, leaving an infiltrated and thickened synovial sac. In the greater number of cases, however, the bone symptoms clearly precede the effusion. The pathological appearances of tuberculous joints have been so fully described in speaking of the pathology (Chapter L) that it is not worth while to enter upon them here to any extent. In the severer cases a destructive, fungous, or purulent synovitis 147 148 ORTHOPEDIC SURGERY. generally develops, which becomes the characteristic feature of the process. This may end in a complete destruction of the joint or in arrest and recovery by absorption and cicatrization. CLINICAL HISTORY. The affection begins, as a rule, insidiously, with stiffness and limp in gait. The disease may be limited for a long time, and be manifested by an enlargement of the con- dyles or head of the tibia, or it may extend and involve the whole joint; occasioning severe pain, swelling of the periarticu- lar tissues, effusion into the joint, periarticular abscess, and distortion of the limb {i.e., flex- ion and subluxation), and end- ing in a natural cure with fibrous or bony ankylosis and a distorted limb, which may be more or less serviceable, according to the distortion; or the affection -may result in such extensive sup- puration as to endanger life from septic or amyloid changes. Sometimes in cases of moderate severity an attack of severe pain supervenes, and an acute stage is reached, when the limb is flexed at the knee, hot and tender to the touch, and sen- sitive to any jar. Under proper treatment this stage gradually subsides, and there may be left impairment of motion. En- largement of the bone, if it persists for any length of time, is characteristic of chronic epiphysitis of the knee. In the milder cases, arrest of the disease may occur at any time with more or less complete restoration of the joint. In the severer cases suppuration may follow, with the establishment of sinuses. The de- structive process may become so extensive that excision or amputation is required. In general, the affection is favorably affected by proper treatment. Fig. 141. — Tumor Albus. Joint shows general tuberculous process, without visible connec- tion with the primary focus ; a cavity in head of tibia of three centimetres diameter, filled with cheesy material, a, Tuberculous focus m femur. (Xichols.) TUBERCULOUS DISEASE OF THE KNEE. 149 In tumor albus the most noticeable symptoms are heat, swelling, tenderness, and joint distention ; while in hip disease, the joint being less accessible, a different class of symptoms, restriction of motion, limp, and distortions of the limb, are more to be depended upon. Fig. 142.— Right Knee-joint Bent. Sagittal section. Joint surface slightly separated, show- ing the infra-patellar fat pad, and the bursa under the patella tendon as well as the ex- tent of the joint synovial membrane. (Fick.) Swelling. — In tumor albus the knee will be seen to have lost its defi- nite contour, the depressions on the sides of the patella have become filled out so that there is an indistinctness of outline which is as per- ceptible to the touch as to the sight. Most often the patella seems to be raised from its position by a semi-solid mass and the whole knee I50 ORTHOPEDIC SURGERY. seems surrounded by a boggy infiltration. Later it assumes a spindle shape and the distention causes the skin to be somewhat anaemic in the more severe cases, whence the name of tumor albus. The swelling at the knee, unless suppurative synovitis is present to a marked degree, differs from that of synovitis with effusion, in that the swelling is of the bone and soft periarticular tissues, and is not alto- gether within the joint. If the effusion is large, as in chronic serous synovitis, the patella, when the muscles holding it are relaxed, can be depressed by pressing on it, and be felt to hit against the bone as it floats above the fluid within the joint. In effusion the shape of the swelling is characteristic. When effusion is the characteristic feat- ure, it is most prominent on both sides of the patella, and is lim- ited by the tendon of the quadri- ceps extensor muscle and by the ligamentum patellae. In some instances, one of the condyles — usually the internal condyle — is enlarged more than the other, causing knock-knee. Atrophy. — Atrophy of the muscles, both of the thigh and calf, is present, and reaches a seri- ous degree inacute cases. It is more equally distributed between the muscles of the thigh and those of the leg than in hip disease. Shortening. — Shortening is a much less important factor than in hip disease, and until late in the affection does not appear to any extent, and this late shortening comes as a result of the faster growth of the well leg oftener than as the out come of bone destruction. During the course of the disease kngthoiing of the affected leg may occur. The hyper- aemia occasioned by the inflammation induces the overgrowth in all directions of the tibial and femoral epiphyses, so that they outstrip for a while those of the other leg. In measuring a child with tumor albus it is, therefore, not uncommon to find the diseased leg half an inch longer than the other. Later in the disease, the trophic disturbance Fig. 143. — Tuberculous Knee in Adult. Gen- eral synovial tuberculosis. Large irreg'ular area of tuberculous softening in epiph^-seal end of femur, extending- into joint along crucial ligaments. (Nichols.) TUBERCULOUS DISEASE OF THE KNEE. I ;i which occurs in all these tuberculous joint affections makes itself felt and the diseased leg falls behind the well one in its growth. Pain. — The pain of the affection is, except during the acute exacer- bations, not severe, though pain on jarring the limb is common. Night cries are much less common than in hip disease, but they occur. When, however, the patient does suffer from an acute exacerbation, the pain and tenderness are excessive. From the exposed condition of the d— Fig. 144.— Tuberculous Knee, Process of Repair Advanced. Small focus persists, a, Tibia ; 5, tuberculous softening ; c, femur ; d, patella. fNichols ) joint jars and twists are very common, and the suffering may be ex- treme. Tenderness is very common, especially over the inner surface of the head of the tibia. In certain cases, however, the knee is held rigid by muscular spasm, and any reasonable manipulation fails to occasion any pain. Heat. — Heat of the affected joint is present and is a most valuable index of the progress of a case. It can be easily felt with the hand as long as the disease is active, but when it becomes quiescent it disappears, to return if anything goes wrong. It can be felt to diminish if treatment 152 ORTHOPEDIC SURGERY. is successful in quieting the condition of the joint, and is a most urgent indication for protective treatment so long as it exists in any degree. Lameness. — Lameness is a constant symptom. It varies with the sensitiveness of the joint and is much influenced by the amount of flexion present in the diseased knee. Muscular Fixation. — Muscular fixation is a symptom of this as of all chronic tuberculous ostitis, but is less prominent than in the hip. In the early stages it may be practically absent. The joint may be held perfectly rigid in full extension or in partial flexion, or a certain arc of mo- tion may be permitted, and then the muscles quickly catch the joint and prevent it from going farther. Persis- tent muscular spasm results in the characteristic malposi- tions of the affection : flexion, and subluxation of the tibia. Deformity. — Malpositiojis of the limb result from the greater power the flexor mus- cles of the thigh possess in contrast to the extensors. The limb becomes gradually flexed almost from the first, and if the affection goes on without treatment, flexion may reach a right angle, and this is the tendency of the disease throughout and a marked obstacle to its suc- cessful treatment. Even when the affection is nearly cured or after a slight injury of the joint flexion may return, which is accompanied by increased heat and tenderness. Together with the flexion, and as a result also of the predominance of the flexor muscles of the thigh, subluxation of the tibia backward occurs at a later stage of the affection; this is due to the shape of the joint sur- faces and the persistent contraction of the hamstring muscles always pulling the tibia backward. If the leg has assumed this distortion Fig. 145.— Bony Ankylosis of the Knee-joint, with Ankvlosis of Patella. TUBERCULOUS DISEASE OF THE KNEE. 153 and is straightened without an attempt to correct the subluxation, the tibia will lie in a plane back of that of the femur, and the part of the knee formed by the femur and patella will be unduly prominent. Fig. 146. — Subluxation in Tumor Albus. Another result of long-continued muscular spasm is the external rotation of the tibia upon the femur, which accompanies severe grades of flexion and persists after straightening of the leg if such is accom- FiG. 147.— Position of Deformity in Tumor Albus. plished. In the same way a certain amount of knock-knee is apt to be present in the corrected limb after severe grades of tumor albus. Abscess. — Abscess appears either as a purulent distention of the cap- 154 ORTHOPEDIC SURGERY. sule, which ma)' point at any part of the surface and discharge by sinuses for an indefinite time, or abscesses form in the periarticular tissues as in hip disease. As a rule abscess formation is accompanied by an acute degree of the affection. DIAGNOSIS. The diagnostic symptoms and signs in tumor albus are an intermit- tent lameness; a general enlargement of the knee-joint, with a feeling of stiffness and pain on using the limb ; heat over the joint; and the presence of local tenderness and muscular stiff- ness in manipulation of the joint. The character of the enlargement of the knee-joint is of great importance. DIFFERENTIAL DIAGNOSIS. Gross errors in diagnosis in affec- tions of the knee are not common, as a thorough examination of the joint is readily made. The distinction between a synovitis with effusion and a chronic ostitis is based on the size and shape of the swelling. The diagnosis is often aided by an A'-ray examination. By the test of aspiration and guinea-pig inoculation, a diagnosis can be estab- lished. Synovitis. — Sluggish cases of syno- vitis in young children should be re- garded with very great suspicion, inas- much as they are likely to eventuate in tumor albus at any time, if the con- dition is not already that. Periarticular Disease — Periarticular disease (inflammation of bursse and periarticular abscesses) is to be distin- guished from true articular disease in that there is little or no joint stiffness, and in that the swelling, if present, does not bear the relation to the patella that occurs when there is fluid beneath the patella ; the distention be- ing clearly outside of the joint sac. Functional disease (hysterical, neuromimetic) of the knee is to be recognized by the absence of objective symptoms and the prominence Fig. 148. — Tuberculosis of Right Knee- joint, with Marked Bony Enlarge- ment at Inner Side of Knee. TUBERCULOUS DISEASE OF THE KNEE. 155 of subjective symptoms. Heat is generall}- absent, limitation of motion and tenderness may be excessive, and swelling' and alteration of the joint contour are absent. Arthritis Deformans. — A diagnosis between a tuberculous affection Fig. 149. — Severe Tuberculosis of Knee-joint with Marked Swelling-, Flexion, and Sinus. and that form of arthritis deformans with synovial infiltration and change is difficult and can often be made only by a careful study of the case with the aid of the inoculation test. It is to be remembered Fio. 150. — Tuberculosis of Knee-joint with Extreme Flexion Deformity. that tuberculous disease is more common in childhood than is arthritis deformans. Haemophilia may cause an inflammation of the knee closely resem- bling tumor albus. The diagnosis must be made by establishing the existence of the bleeder's diathesis and by the course of the case. 156 ORTHOPEDIC SURGERY. PROGNOSIS. Tke prognosis of tumor albus is similar to that of the same affec- tions of the other large joints. The functional results after conserva- tive treatment are in av' erage cases excellent ; sometimes perfect motion is restored, but in general only an incomplete arc remains with occa- sionally complete rigidity. The earlier that treatment is begun and the more faithfully it is carried out, the better is the outlook as to functional result. In advanced cases disability necessarily follows, and in neglected cases deformity of the limb, flexion at the knee, subluxation of the tibia, and the formation and discharge of abscesses are likely to occur, ending Fig. 151. — Old Tumor Albus Recovered, Showing Degree of Possible Flexion. either in a complete destruction of the joint or in a cure with ankylosis. A liability of the dissemination of the tuberculous disease to the brain or lungs exists in this as in other similar affections. In all severe cases there is a danger of permanent distortion of the limb. This may be so severe as to render the limb useless. Flexion of the limb is a constant result in severe cases unless treated with great care. Shortening is less likely to exist to a troublesome extent than in hip disease. As in all cases of epiphyseal ostitis of the larger joints, the progno- sis as to the tmie of requisite treatmen.t depends not only on the time needed to check the inflammation, but also for the re-establishment of sound bone tissue capable of bearing weight without danger of relapse. This in growing children demands a long time. Protection is generally TUBERCULOUS DISEASE OE THE KNEE. I57 necessary for from one to two years, and perhaps even longer, after the acute stage is ended. TREATMENT. The treatment may be classed as conservative and operative. Conservative Treatment of Tumor Aldus. What was said in regard to the treatment of hip disease may be Fig. 152.— Old Tumor Albus Recovered with Motion, Showing' Subluxation of Tibia. repeated in speaking of epiphysitis of the knee-joint. The treatment should be thorough and persistent, and should meet the indications, and fixation and protection are the most important indications in diseases of the knee, while traction is less so. The employment of protection should be continued until it is probable that the epiphysis is normal, which is a matter of judgment in every case. Protection should be dis- continued gradually and tentatively ; if discontinued too soon, recur- rence will take place, or the deformity of the limb will increase. Fixation should be used so long as there is any activity of the inflammation ; this is 158 ORTHOPEDIC SURGERY. indicated by pain, muscular spasm, or tenderness. Efficient fixation of the knee does not require confinement to bed except in ver}' acute cases, in abscess, and in deformity. In cases in the acutest stage the patient is kept in bed with the hmb hekl by weight and pulley traction and the foot and limb steadied by sand bags or side splints or by a splint plaster bandage. Ordinarily this acute stage is absent or is brief, and ambulatory treatment is both possible and desirable. Fixation.— It is manifest that the most thorough fixation is made if the fixing appliance is as long and extends as high as possible. The leg and femur, if much longer than the appliance, will have a greater mechanical advantage than if the splints are suffi- ciently long. It should also be borne in mind that, owing to the fact that the thigh is well covered by soft tissues, a cer- tain amount of motion is pos- sible owing to the yielding of the soft parts. Fixation by stiff bandages is an efficient method of treatment when the bandages are properly applied. They should reach from the groin to the ankle, in the acute cases in- cluding the foot, and as firmly as possible grasp the muscles of the limb. Plaster of Paris is the most available material for use. The method does not give in all cases certain, definite sup- port. Judson says in regard to it : "It may be an exaggeration, but it conveys the idea, to say that a plaster-of-Paris or silicate splint, applied to the leg and thigh, contains a mass of jelly in which the femur is but little restrained from motion." And in a degree this is true of all stiff bandages. The figure shows the inefficiency of a loosel)' applied plaster band- age so far as fixation is concerned. Other stiff bandages are of silicate of potash, leather, celluloid, wood pulp, papier mache, etc. The}- may be cut down the front and laced so as to be removed at any time. Fix- ation without protection is inadec|uate treatment when locomotion is Fig. 15 -Tuberculosis of Knee-ioint with Abscess. TUBERCULOUS DISEASE OF THE KNEE. •59 desired. For this reason it is insufficient to apply a stiff splint to the affected leg and to allow the patient to walk without further protection of the limb. Fixation as a means of treatment so far has been considered only as applicable to the limb in its straight position. Much more often a Fig. -Radiograph of Old Tuberculosis of Knee-joint, Showing Destruction of Joint Sur- faces and Bone, Flexion and Subluxation of Tibia. degree of flexion is present to complicate matters, the treatment of which will be considered later. Protection. — Protection can be furnished by means of crutches and raising the sound limb by a thick sole which allows the affected limb to swing clear of the ground. Better protection is furnished by means of a splint with perineal support and longer than the limb, which passes below the foot so as to take the jar of locomotion. The best of these splints is one similar to that already described as a protective splint in hip disease. It will be described more fully in speaking of the treat- ment of flexion in tumor albus. Thomas Knee Splint. — A simple appliance is the Thomas knee splint i6o ORTHOPEDIC SURGERY. (Chapter XXL, 14) which consists of a padded iron ring fitted so as to surround the thigh at the perineum, and fastened to two rods on each side of the Hmb, longer than the hmb and secured at the bottom to a metal plate below the foot or bent to fit into a slot under the shank of the boot. The bar at the bottom of the splint can be utilized as a means for using traction if adhesive plaster is applied to the leg and webbing sewn to the lower ends; the webbing straps are buckled tightly around the bar, and a certain amount of traction can be exerted. The idea of Pig. 5.— Imperfect Fixation of Knee-joint by Loose Plaster Bandage. Fig. 156. — Imperfect Fixation of Knee-joint by Plaster Bandage of Improper Length. using traction is not in accordance with the views of the inventor of the splint. The leg can be fixed by means of bandages and leather bands attached to the splint. With this splint applied, the patient sits in a ring supporting the perineum, while uprights run below the foot and bear the body weight. In cases requiring less rigid protection and in the case of adults the inner half of the perineal ring is cut away and from the two extremities of the cut ring is slung a leather perineal band on which the patient rests in the same manner as in a hip splint. In acute cases and cases tending to flexion the use of a plaster-of- Paris splint in addition to the Thomas splint is desirable, as better fixa- tion is secured than by bandages. Traction is necessary only in very TUBERCULOUS DISEASE OF THE KNEE. i6i acute cases ; a stiff bandage to the knee in addition to the Thomas splint contributes better fixation than is possible with the splint alone. The Thomas splint is slung from the shoulder by means of a strap, and the well limb is raised by means of a cork, wooden, or steel patten. Crutches are not necessary in connection with the Thomas splint. Calliper Splint.— When the condition of the limb has improved so much that spasm and sensitiveness are absent or in mild cases the Thomas splint (Chapter XXI., 15) can be shortened and the ends slotted into the sole of the shoe at such a place that the splint is too long for the heel to touch the ground, and in this way the patient walks about suspended largely by the perineal ring and bearing but little Fig. 157.— Wire Splint for Gradual Correction of Knee Flexion. weight on the diseased joint. Then gradually after some months the use of the splint may be discontinued. When convalescence has been further established and protected motion at the joint is possible, the knee splint may be jointed with a spring catch and check to limit the amount of motion. Blisters, cauterization, and counter-irritation are beneficial only in relieving the symptoms of pain temporarily. The treatment by passive hyperaemia and dry heat is useful if at all in the milder and more chronic cases. • Treatment of Complications.— Z>£/(?;'w//j'. — Flexion of the knee is commonly seen even in the early stage of the affection, associated in the early part of the disease with an acutely sensitive condition of the 1 1 l62 ORTHOPEDIC SURGERY. joint, but later in the history it may come on insidiously and without pain. The means of straightening a knee-joint flexed by acute disease may be classified as follows : I. By traction in the line of the deformity applied {a) in bed; {U) while the patient goes about. 2 By simple fixation by means of a succession of plaster-of-Paris bandages. 3. By straightening under ether. I («). In sensitive cases it may be necessary to confine the patient to bed. Traction by weight and pulley can be applied to the leg by means of adhesive plaster applied below the knee, the leg being supported by a firm cushion under the knee arranged so that traction comes in the line of the deformity. After a diminution of the spasm, which follows very soon upon the appli- cation of traction, the limb can be made straight gradually and fixed in a straightened position, and ambulatory treatment can be begun. )^ I ib'). Traction in the line of the defoi'viity 'J can be applied to the limb while the patient goes about, by one of several appliances which are more or less expensive. The best splint is one already alluded to, similar to the protection splint described for hip disease (Chapter XXI., 16).' It is furnished with a perineal band which takes the body weight off of the leg, and at the knee is a lock joint which can be set at any angle. The bottom of the splint goes far enough below the foot to protect the limb from jar in walking, and ends in a traction bar. The splint is set at an angle corresponding to the angular deformity of the affected knee, and traction is made up- ward above the knee by means of adhesive plaster attached to the thigh and buckling on to the splint, and extension is made downward below the knee by a plaster extension pulling down to the traction bar at the bottom of the splint. The leg is fixed in the splint by leather lacings for the thighs and calf, which are adjusted after the extension is tightened. A simpler appa- ratus has been described," made of plaster of Paris and serving the same purpose except that it does not allow weight bearing on the affected leg. Fig. 158. —Thomas Cal- liper Splint, with Pads, Applied. (Ridlon and Jones ) Lovett : Orth. Trans., vol. v H. L. Taylor: Orth. Trans. vol. P- 53- TUBERCULOUS DISEASE OF THE KNEE. 163 2. Rcdiictioji of Flexion by Fixation Bandages. — A very simple way to straighten a knee-joint acutely flexed by disease, when apparatus cannot be afforded or is impracticable, is by simple fixation of the knee- joint by means of a series of plaster-of-Paris bandages. These should be applied to the knee in its deformed position without any attempt to extend it. It will be often found in the lighter cases that the limb can be made straighter at each successive bandage, so great is the sedative action of complete fixation. It is hardly necessary to add that no weight should be borne upon the limb during the process of straighten- ing. 3. Forcible Reduction of Flexion. — In cases without adhesions the knee is easily put in a correct position with the use of little or no force Fig. 159.— Reduction of Flexion Deformity by Traction in Recumbenc}\ under complete anaesthesia. If the leg is allowed to remain in the flexed position, angular ankylosis will probably occur, as shown in the figures. When firm adhesions have been formed at the knee-joint, cor- rection by means of appliances will be found tedious, painful, and some- times impossible, and generally forcible correction of some sort will be necessary to break down the adhesions. One way is to break down the adhesions by forcibly flexing the leg, and then by forcible extension to straighten it. The danger of rupturing the popliteal artery, which has occurred, is in this way diminished. Many appliances have been devised to give greater power in forcible correction. One procedure not requiring the use of apparatus is as follows : The patient is placed upon the floor upon the back and the surgeon stands over the patient, holding the flexed knee with both hands, the fingers being placed 164 ORTHOPEDIC SURGERY. under the popliteal space. The whole weight of the surgeon's trunk can be thrown upon the end of the lever furnished by the patient's leg, the hands of the surgeon, pulling upon the popliteal space, furnishing resistance. After the limb has yielded and the adhesions are broken, it can be straightened if the pa- tient is turned upon the face; a downward force being applied to the heel, resistance being fur- nished by a cushion placed under the patient's knee. When sub- luxation of the tibia is present it must be corrected. This can- not be done so well by this method as by the instrumental method to be described. After Fig. 160. — Jointed Traction Knee Splint Applied. Fig. i6r.- -Goldthwait's Genuclast Applied. correction, the limb should be well surrounded with sheet wadding and a stiff bandage applied, the limb being held straight until the plaster has become hard. The procedure is sometimes followed by pain, and opiates may be necessary for a few days. Such measures are not required except in resistant cases. The dangers incurred by this pro- TUBERCULOUS DISEASE OF THE KNEE. 165 cedure are not so great as would be supposed. The danger of rupture of the artery can be avoided by care. Separation of the epiphysis of the femur ma)- take place, but is cured by the fi.xation requisite to treat- ment, and should not occur if the force is carefully applied. P>acture of the femur and tibia can be avoided by care. If the deformity, flexion, remains uncorrected in severe ostitis of the knee-joint, a subluxation of the tibia backward takes place, due to the contraction of the hamstring muscles. This is due in part to the spasm of the hamstring muscles, which have pulled the tibia backward, but chiefly to the fact that owing to adhesions the flexed tibia is unable to slide forward over the condyles of the femur, as happens in normal extension. Attempts to straighten the leg simply crowd the anterior edge of the tibia into the condyles. To obviate this the head of the tibia should be pressed forward and upward to the same degree that the leg is raised. The most efihcient method of accomplishing this is by the use of the apparatus shown in the figure called by Goldthwait,' who modified it from the original apparatus, the "genuclast." Pressure forward on the head of the tibia is exerted by turning the handle; this, by means of a screw force, pushes a plate forward against the tibia, working through a band. The calf muscles protect the artery and nerve from injurious pressure. Counter-pressure is secured by means of leather straps, which are passed respectively over the knee and leg, protected by a thick layer of saddler's felt. Several straps will be needed at the knee to prevent loss of counter-pressure, as the limb is made straighter. Another strap, under the leg, secures the lower part of the leg. The side bars, bands, and plate of the apparatus should be of strong steel. The apparatus is put on the limb in a flexed position (after ruptur- ing adhesions by forcible flexion if that is needed), the head of the tibia is pushed forward as far as is advisable, and, by means of the end of the appliance, which serves as a handle, the leg is extended ; the press- ure forward of the head of the tibia can be increased, and the counter- pressure regulated if necessary, by loosening such of the straps as extension of the limb may tighten too much. In some cases the reduc- tion may be accomplished at one time, while in others successive appli- cations of the apparatus are necessary. Adhesions of the patella to the front of the femur may constitute an obstacle to reduction without cutting. The treatment of cases resisting this method will be consid- ered in the section of this chapter on operative treatment. Experiments on the cadaver which were conducted by one of the writers at the Harvard Medical School, through the courtesy of Drs. C. B. Porter and T. Dwight, showed that by means of this appliance ' Boston Med. and Surg. Jour., September 7th, 1S93. 1 66 ORTHOPEDIC SURGERY. the tibia could readily be pushed forward to any desired extent. On normal joints, the tibia can be pushed forward to a considerable dis- tance without rupturing the ligaments. In general, correction of flexion deformity under ether is the best method except in slight cases. Abscess. — The treatment of abscess is the same that is recom- mended for the treatment of abscesses at the hip, except that they are generally more superficial and can be opened earlier. They do not dissect about between the muscles to the extent that hip abscesses often do. Operative Treatment of Tumor Albus. The operative measures to be considered are : 1. Excision. 2. Arthrectomy and erasion. 3. Amputation of the leg. I. Excision of the knee-joint is to be undertaken in those cases in which conservative treatment has failed to arrest the progress of the disease ; in which originally the disease is too extensive to warrant con- servative treatment ; in which the general health is failing and the dis- ease failing to improve under efficient conservative measures. In adults it is to be undertaken earlier than in children, as the progress of the disease is in the former less favorable than in the latter. Excision is inferior to conservatism as a treatment of knee-joint disease in children, because the functional results are not so good. Excision of the knee is also performed to correct the deformity caused by bony ankylosis at an angle of flexion. It would be fair to assert that in patients between fiv-e and twenty, the mortality from the operation, near and remote, would not be far from ten per cent, being less rather than more than this percentage. The functional results after excision are, however, inferior to the results after conservative treatment. Ankylosis is to be hoped for after excision and is complicated by a tendency to flexion of the apparently ankylosed joint. It may be said with regard to the amount of shortening after excis- ion in cases in which the epiphyseal lines are saved that it is likely to be only moderate, although even then it is more than after conservative treatment." Operation. — -The operation of excision of the knee-joint is per- formed as follows : The leg should be carefully prepared for an aseptic operation. The use of the Esmarch bandage and tourniquet is advisable. The joint is opened by a free anterior incision passing from the inner to the outer 'Arch. f. klin. Chir., 1S85, iv.. 32. TUBERCULOUS DISEASE OF THE KNEE. 167 side of the joint slightly below the patella, the ligamentum patellae is divided, the periosteum and muscular attachments are cleared from the ends of the bones, the ligaments are cut, and the articular end of the femur protruded through the incision and as much as seems desirable sawed off. In the same way the tibia is cleared and protruded as a safeguard against injuring the popliteal vessels. The patella should be removed if it is diseased. In children it is desirable to avoid removing bone below the line of the epiphysis — a precaution not necessary in adults. It is best at first to remove a very thin section, just enough to take all the articular surface of both bones, and then to remove another section if the disease is very extensive, or if only foci of disease are seen to scoop them out extensively with a sharp spoon. It is of the utmost importance to at- tend carefully to the plane of section which the saw makes in removing the articular surfaces. If these planes are ever so slightly oblique, the whole axis of the limb is distorted and the line of weight-bearing is wrong and tends to cause angular de- formity at the knee. In the femur the plane of section should be parallel to the articular surface and not perpendicular to the shaft of the bone, which would make it oblique at the joint. As soon as sec- tion of the bones has been made, the new surfaces should be placed in con- tact and the line of the limb carefully ob- served. To secure fixation the bones may be wired together or fastened to each other by wire nails or pegs of ivory or bone. A wire posterior splint may be used, but, in general, a plaster-of-Paris bandage reinforced by a steel bar and with a window cut for dressing, the bandage includ- ing the foot, furnishes the best means of fixation, the bones having been fixed accurately in position by some of the means mentioned and the limb after that handled very carefully. The only objection to it is that in the profuse discharge of serum which takes place necessarily from so large a wound within the first twenty-four hours, the plaster is likely to be stained through and may have to be changed. But if a suffi- ciently heavy dressing is put on, this will ordinarily not happen to any extent, or if it does a light dressing can be applied outside to protect Fig. 162.— Osteotomy for Deform- ity with Ankylosis. (After Hoffa.) 1 68 ORTHOPEDIC SURGERY. the stained spot. Occasionally the plan is useful to dress the limb after operation in a heavy dressing and on the next day to redress it and apply the plaster. In this way one may be almost sure of a dress- ing which can be left on almost indefinitely, provided the operation has been aseptic. There are two precautions to be observed in putting the leg up in splints or in plaster: first, the tendency to eversion ; and second, the tendency to dropping backward of the head of the tibia. With moder- ate precautions these deformities may be avoided. When the bones are wired together, if the holes which are bored in the tibia for the insertion of the wire are placed well backward and the corresponding holes in the femur well forward, much will be done to counteract this backward displacement of the leg upon the thigh. A protection splint is to be worn for some time to prevent the recur- rence of flexion. It is much the wiser course to have the patient wear a perineal crutch (in the form of a Thomas knee-splint), which shall prevent bearing any weight on the leg until several months after oper- ation. If this precaution is neglected, permanent flexion of the limb is likely to occur or a lighting up of the original disease. Excision of the Knee for Angular Ankylosis. — When excision of the knee is done for angular ankylosis, the only modification of the operation which is necessary is the removal of a wedge of bone large enough to allow the ends of the bone to come together, so that the angularity is obliterated. Osteotomy of the femur is a measure which may be used to correct flexion deformity at the knee too strong to be overcome by forcible straightening. The osteotomy should be linear and as near the joint epiphyseal line as possible. This can be employed in place of a wedge- shaped excision for angular deformity, as not involving shortening. The osteotomy is followed by careful straightening of the limb. The advantage of this method lies in the fact that any motion remaining at the joint is not destroyed as it must be in excision. Its disadvan- tage is that the condyles of the femur are necessarily displaced for- ward to form an angle with the shaft. i\ linear or wedge-shaped oste- otomy of the upper part of the tibia has been described by Konig for • the same purpose. 2. Arthrectomy. — As a substitute for excision, what has been termed arthrectomy or erasion has been employed. Arthrectomy consists of the removal of all palpable and obvious portions of diseased tissue, whether in the synovial membrane or else- where, leaving what appears to be healthy tissue. Two advantages are claimed for this operation over excision: (i) That it does not interfere with the growth of the limb, and (2) that mobility of the joint may be preserved. It may be added that the latter is an exceptional event and TUBERCULOUS DISEASE OE THE KNEE. 169 not altogether so desirable or safe an ending under the circumstances as bony ankylosis. The objection to the operation is that it is not thorough, and oftener than excision fails to eradicate the disease. The operation offers advantage over excision only in the case of chil- dren and chiefly before the disease has made extensive progress. It is easy to see that, if any extensive disease of the bone is present, any measure short of thorough removal must necessarily fail. The opera- tion is, therefore, not suited to cases in which there are many sinuses and bone enlargement, but to milder cases as a less severe operation than formal excision. In the matter of risk there is little to choose between this operation and excision, for the immediate death rate under proper precautions is very small in both operations. The risk of operative tuberculous in- fection, alluded to so often in speaking of operations upon tuberculous joints, is present in arthrectomy as in excisions. Operation. — The operation itself may be described as follows : The joint is opened as in cases of excision and the tuberculous synovial mem- brane as far as possible should be dissected out ; if diseased spots are found in the bone or have been previously located by the ,f -ray, these foci should be removed by the curette or chisel, and the cavity left in the bone wiped out v^ith pure carbolic acid and alcohol, and the joint sewed up or drained according to the extent of the disease and the general aspect of the case. If the whole epiphysis is diseased, excision is of course unavoidable. Instances of excellent recovery with complete healing occur after this operation, and success has followed the procedure in many cases in the practice of the writers. The most thorough removal possible of all tuberculous tissue in the affected joint is essential, neces- sitating sometimes complete dissection and removal of all of the syno- vial membrane, as well as careful curetting of the bone. The patella should be removed or left, according to its condition. The parts of the knee-joint to be most carefully investigated for diseased foci are the synovial pockets and the epiphyseal lines of the femur and tibia at their lateral aspects. Here one may find foci of tu- berculous material extending into the epiphysis, without, however, in most cases crossing the epiphyseal lines. The after-treatment should be like that of excision, except that wir- ing or nailing the bones together is not necessary, as the ligaments should be preserved so far as possible. Flexion of the limb may follow arthrectomy as well as excision ' in cases in which protection to the joint has been discontinued too early, so that the after-treatment should be as careful and as prolonged as after excision of the joint. 3. Amputation. — In cases of extreme disease of the knee-joint ' Hofmeister : Abst. in Arch. f. Orth , i., 2. I/O ORTHOPEDIC SURGERY. amputation of the thigh is necessary as a hfe-saving measure. As for the indications determining a choice between excision and amputation, it can be said that when the patient's reparative power is slight an am- putation is to be preferred. The question is largely one of individual judgment ; if excision is first tried and fails to arrest the disease, and finally amputation has to be performed, the patient's chances are, of course, injured by the choice of excision in the first place. In the adult extensive removal of the bones may be accomplished by excision with- out any danger of arrest of growth, and few patients can be brought to consent to amputation of a limb so long as any other method of treat- ment holds out the faintest prospect of relief. In children amputation should be deferred to the last moment and excision given the prefer- ence, unless the eradication of the disease would necessitate the re- moval of so much bone that a useless leg would result from that. In children, therefore, the operation could be advised only when the joint was hopelessly disorganized and so much of the shaft of the long bones was evidently diseased that an excision was not practicable. Summary. The treatment of tumor albus should consist m. fixation of the dis- eased joint by plaster of Paris or some suitable splint, with traction in cases in which the muscular spasm is very marked. If ambulatory treatment is to be undertaken (which is almost invariably to be advised), protection is also necessary. This is furnished by the Thomas splint, a high shoe, and crutches, or by the use of a protection splint similar to the one used in hip disease, etc. fixation can be discontinued at the close of the acute stage, but protection is advisable for a much longer time. Excision is not in children an advisable method of treatment until mechanical measures have proved inefficient after a faithful trial, and the same is true of arthrectomy. The latter is not suitable for adults. Deformities should be corrected as they arise. CHAPTER V. TUBERCULOUS DISEASE OF THE ANKLE AND OTHER JOINTS. ANKLE. Ankle (Symptoms. — Diagnosis. — Prognosis. — Treatment). — Shoulder (Symp- toms. — Treatment). — Elbow (Symptoms. — Treatment). — Wrist (Symptoms. — Treatment). — Sacro-iliac disease (Etiology. — Symptoms. — Diagnosis. — Prognosis. — Treatment). The seat of the disease may be in the articular end of the tibia or in the astragulus; and other adjacent bones may be involved secondarily or independently, as the os calcis, the scaphoid, cuboid, and cuneiform bones. The pathological process does not differ from that already described, but on account of the numerous synovial sacs in the tarsus and the proximity of the bones to each other, extension of the disease is favored. Symptoms. — Pain and tenderness of the whole joint to pressure and motion may or may not be present. Tenderness, as a rule, is present over the joint capsule in front, and perhaps under the malleoli, and swelling and heat are invariable accompaniments of the affection. Mus- cular rigidity is marked in most cases. Lameness is an early and a marked symptom. Sometimes it is pro- duced by the pain which weight-bearing causes in walking, but more often by the muscular stiffness which will not allow the ankle-joint to bend. The swelling consists of a boggy infiltration of the soft parts around the ankle, along wath a distention of the joint capsule by gelati- nous granulations. Li character it is oedematous. This swelhng is uniform around the ankle, except when an abscess is pointing on one side. The depressions in the contour of the ankle in front and behind the malleoli disappear in the swelling. The foot in affections of the ankle-joint usually assumes a position with the toes pointing downward, and in chronic cases with the foot slightly rolled outward (in the posi- tion of equino-valgus). This, however, is not the only malposition, for the foot may assume the position of pure talipes calcaneus. These malpositions are brought about by the abnormal tonic muscular contrac- tion, and these deformities yield of themselves and the foot returns to its normal position when the irritation is quieted in the joint by proper treatment. 171 172 ORTHOPEDIC SURGERY. Wasting of the thigh and calf muscles occurs. Abscesses may occur. When the disease attacks the medio-tarsal or tarso-metatarsal joints, the anterior part of the instep appears swollen and is hot and tender. Fig. 163. — Tuberculous Ankle-joint. Diffuse tuberculosis of tarsus. Primary focus lost in the area of destruction, a, Tuberculous infiltration of soft parts ; b, tuberculous soften- ing of tarsal bones. (Nichols.) Motion at the ankle is but little restricted, but motion in the anterior part of the foot is attended by pain and is usually lost. The location of the affection is evident from examination. If the os calcis is attacked Fig. 164.— Tuberculous Ankle, tf, Lower end of tibia; b, tuberculous cavity in tibia; t, tuberculous disease of calcis : se affected are individuals of feeble physique. Other cases of knock-knee are produced as a late result of muscu- 2 84 ORTHOPEDIC SURGERY. lar paralysis. Fractures about the joint and destructive ostitis of the knee are also causes of knock-knee in their late history. Mechanical Production of Knock-knee. — While the chief cause of the deformity seems to be a static one, due to the superimposed body weight, pressure from faulty position and abnormal strain, as has been shown by Dane, may be a factor in the production of bony curves. Other causes are to be found in peculiar gait, distributing the weight and strain in an unusual manner. The normally formed human being in the upright position stands with a certain amount of knock-knee. The femurs form an angle of 15° with each other and sometimes more, and, as a result of this oblique direction, the inner condyle of the femur must be longer than the outer. When a normally formed person stands erect with the heels to- gether, if a plumb line be dropped from the head of the femur it will be seen to fall outside of the centre of the knee-joint ; and this will happen to a greater extent in the female than in the male. It is therefore evident that the external con- dyle of the femur and the corresponding facet of the tibia transmit more body weight than do the corresponding internal articular surfaces, because the centre of gravity lies outside of the centre of the joint. To maintain an erect position with the feet together requires muscular action. If the stand- ing position is to be maintained for a long time, or for a short time in the case of children or feebly developed adults, the instinctive disposition is to substitute ligamentous for mus- cular support. This can be accomplished by keeping the knee extended and separating and everting the feet. It is the attitude assumed by children learning to walk and by tired adults. This attitude is often spoken of as "the attitude of rest." From this position more weight than before is transmitted through the external condyle and less through the internal one. If angular deformity takes place finally, all the weight is transmitted through the external condyle. Two results may follow from this : stretching of the internal lateral ligament and atrophy of the external condyle. The stretching of ligaments when subject to undue tension is too familiar a pathological process to require comment. The atrophy and retarded growth of bone, and especially rhachitic bone which is sub- jected to pressure and strain, are well known.' ' Lane : Guy's Hosp. Rep., vol. xxviii. Fig. 230 — Axis of a nor- mal leg, and of one Affected with Knock- knee. RICKETS, KNOCK-KNEE, AND BOW-LEGS. 285 Flat-foot ordinarily coexists. Sometimes it must stand in a causa- tive relation to knock-knee ; sometimes it is more the result than the cause, but commonly they are both the results of the same faulty atti- tude, assumed as a result of muscular fatigue and weakness. Flat-foot is more easily produced than knock-knee, and is more common. It is proper to recognize the class of cases when the femur is appar- FiG. 231.— Slig-ht Knock-knee. Fig. 232.— Moderate Knock-knee. ently normal, but the articulating surfaces on the head of the tibia are oblique. In still a third class of cases the deformity is due not so much to primary joint obliquity as to a bend in the diaphysis of the femur or the tibia just above or just below the joint.' There are, then, three bony deformities likely to be found in cases of knock-knee, viz.: ' Arch. f. klin. Chir., 1S79, xxiii. 286 ORTHOPEDIC SURGERY. (a) Difference in the size of the condyles of the femur. {b) Inequality in the articular facets of the tibia. {c) Bending of the diaphyses of the bones above or below the joint. In severe cases the tibia is found to be rotated outward. The internal ligaments are hypertrophied, and the muscles and ten- dons on the inner aspect of the leg are, of course, stretched. The pa- tella lies farther outside than it should do. In some it may be seen that the outward rotation of the tibia is so marked that a sort of compensatory inversion of the feet has been acquired almost to the condition of varus to aid in keeping balanced. Fig. -Severe Knock-knee due to Rick- ets. Seen from behind. Fig. 234. — Slig-ht Knock-knee Resulting- from Tuberculous Disease of the Left Knee. Now cured. Symptoms. — Subjective symptoms in knock-knee are almost always absent. Children and adults tire more easily than they should when they have knock-knee, and sometimes pain and sensitiveness are com- plained of over the internal lateral ligament of the knee ; as a rule those with knock-knee are clumsy and have a poor sense of balance. In young children with knock-knee and active rickets locomotion is gen- erally difficult, while in adult cases there is less difficulty in walking, RICKETS, KNOCK-KNEE, AND BOW-LEGS. 287 even in severe cases, than would be expected from the degree of the deformity. In the standing position it is noticed that the knees are unduly prominent on the inside aspect of the leg, and that the tibi?e diverge sO' that the feet are perhaps only a few inches apart, or, again, in severe cases, a considerable distance. In cases in which the angular deform- ity is very great, the patients find the easiest position for standing is- with one knee behind the other, so that in this way the feet may be brought together. If the child stands with the feet together one knee is generally a little hyperextended and the other slightly flexed, so that they appar- ently come together. The gait of a patient with double knock-knee is distinctive. The- gait is a rolling one, consisting of a series of slight lurches, which are, however, not nearly so marked as in bow-legs or congenital dislocation of the hip ; while what is particularly noticeable is the outward throw of the leg when it is being brought forward. The gait is, moreover, slightly modified by the fact that in severe cases the thighs and consequently the knees are slightly flexed. " Toeing in " is common, even in the slighter grades. When the deformity is unilateral the limp is less marked. Lateral curvature is sometimes induced by the unilateral deformity. On manipulation, the knee-joint is often movable in a lateral plane through an arc of several degrees. In these cases the deformity is, of course, increased when weight is put upon the affected leg, so that in walking and standing it reaches its maximum. The angular deformity disappears when the knee is flexed to a right angle, except in cases in which the chief deformity is in the tibia. But if the knee be flexed while the hip-joint is still extended, the deformity does not entirely disappear, though it is very much diminished. The practical point is, that as the deformity is most severe when the leg is in the extended position, all mechanical treatment applied to the correction of knock-knee must be to the fully extended leg. When the leg is fully flexed the inequality in the length of the condyles is most evident, as seen in outline from the anterior surface of the thigh. This may be registered by shaping a lead strip to the lower sur- face of the femur when the knee is fully flexed, and drawing an outline on paper from the lead strip, which should be stiff enough to keep its shape. Occasionally one sees a combination of knock-knee and bow-legs in the same subject. Loose Knees. — In young children beginning to walk, who have grown rapidly or who have perhaps the mildest degree of rickets, there is often developed a laxity of the knee-joint which may require treat- 288 ORTHOPEDIC SURGERY. ment. On account of the mechanical conditions explained above they stand with the knees prominent inward, but the deformity disappears on lying down and no overgrowth of the internal condyle is to be found. The knees can easily be hyperextended and are abnormally movable laterally. Such children are unsteady on their feet and the apparent knock-knee is noticed. The treatment consists of the measures to be described in speaking of the mildest cases of knock-knee. Fig. 235. — Bow-leg- of Right Leg, Knock-knee and Flat-foot on Left. Fig. 236. — Hyperextended Position of the Knees, Frequently Seen in Con- nection with Knock-knee. Measiirevie7it of the Deformity. — The simplest and most reliable method of registration is to have the patient sit upon a sheet of brown paper with the legs extended and the feet pointing upward ; and then, with a pencil held perpendicularly to the paper, to trace the outline of the legs. No other method can give so accurate an idea of the degree and character of the deformity present, or can afford so delicate a means of watching and recording the progress of the case. Diagnosis. — The diagnostic points which mark the affection known RICKETS, KNOCK-KNEE, AND BOW-LEGS. 289 as knock-knee are an inward angular deformity at the knee which disap- pears on flexion of the leg' upon the thigh. There is also in the latter position to be noted a relative prominence of the internal condyle of the femur in nearly all cases. In children the large proportion of all cases are rhachitic and static, while in adults the purely static cause must be assigned. It is not, in general, justifiable to assume rickets as the cause of knock-knee in cases in which there are no distinctive signs of rickets. Paralytic knock-knee occurs only in severe grades of paralysis. Its diagnosis is evident from the wasted and contracted condition of the paralyzed limb. Knock-knee from destructive disease of the knee-joint is a re- sult of severe tumor albus and not of the lighter grades. Traumatic knock-knee is of two kinds: {a) Resulting from osteotomy for genu varum and overcorrection of the deformity; {y) resulting from fractures of the condyles of the femur or of the articular facets of the tibia, which are liable to cause lateral malposition of the knee. The ,i'-ray is of use in defin- ing the chief location of the de- formity when necessary. Prognosis. — In severe cases it is evident that so much harm has been done already, and the bones have come into such faulty apposition, that spontaneous improvement is not to be expected. Chil- dren with a slight degree of knock-knee which is not progressive will probably outgrow it without any treatment if in vigorous health. But if the deformity is moderate or severe, the chances are strong that the affection will remain stationary or more probably will become worse as time goes on, unless active treatment is begun. Treatment. — The treatment of knock-knee falls into three divisions: I. Expectant. II. Mechanical. III. Operative. I. The expectant method of treatment relies upon nature's efforts to repair the deformity ; efforts which are aided on the part of the sur- geon by keeping the child off of its feet to a greater or less extent, and by constitutional treatment and by massage and corrective manipula- ^9 Fig. 237. — Case of Knock-knee, Showing also the Tracings of the Legs at an Interval of Four Years with no Treatment. 290 ORTHOPEDIC SURGERY. tion. In mild cases there is a tendency to outgrow the deformity, but this tendency is at a great disadvantage mechanically, nor is it a safe proceeding to wait for this spontaneous cure in any marked case of knock-knee. The difficult question in the whole matter is to decide which cases can be left to themselves — a question which cannot be an- swered categorically. An argument for the spontaneous outgrowth of knock-knee is found in the rarity of adult cases which present themselves at clinics. When the expectant method is chosen in rhachitic knock-knee, the child should at once be put upon the constitutional treatment for rick- ets. If the knock-knee is merely the outcome of a feeble general con- dition, the patient should be most carefully looked after in the matter Fig. 238. — Manipulation in the Treatment of Knock-knee. of hygiene, and tonic treatment and gymnastics should be given, the aim of which should be to strengthen the leg muscles. As much as possible the patient should be kept off of the feet, and a change to country air is capable of effecting great local improvement in feeble children. The legs should be rubbed and manipulated each night. The rub- bing should be the same as that described under infantile paralysis, and the manipulation, in cases of knock-knee, should be directed to the gentle correction of the deformity by repeated mild manual pressure. With one hand the manipulator presses the knee outward, while with the other he presses the lower part of the tibia inward. Even with a very slight degree of force a certain yielding can be felt in the direction of improvement, and then the pressure should be relaxed and the limb allowed to resume its first position. This manipulation should be re- peated many times, continuing each pressure only a few seconds. Nor should it ever be done forcibly or long enough to make the child cry. This manipulation faithfully carried out is an important adjuvant, not only of expectant but of mechanical treatment. RICKETS, KNOCK-KNEE, AND BOW-LEGS. 291 In no case should expectant treatment be considered when the child is not under sufficiently close observation to be seen every few weeks, and to have tracings taken to determine whether the deformity is improving or is stationary. It is advisable in early knock-knee to raise the inner border of the foot in order to bring the line of weight bearing at the knee as far out- side as possible. For this purpose felt pads shaped to support the arch of the foot are of use, or the inner border of the sole and heel of the Fig. 239. —Knock-knee, Irons Applied. Front view. Fig. 240. — Knock-knee, Irons Applied. view. Side shoes may be made one-eighth or one-fourth inch thicker than the outer border in order to accomplish the same object. II. Mechanical Treatment. — Treatment by apparatus aims at the gradual correction of the deformity, commonly by making counter- pressure against the internal condyle to prevent the further giving way of the knee and to pull it outward to a fixed point furnished by an out- side upright. Upon this principle all modern apparatus is constructed. In children in whom the change known as eburnation has succeeded rickets, the bones are so hard and unyielding that it is almost hopeless, by means of such mild traction as can be exerted, to pull the knee back into place. In general terms, it is not probable that mechanical treat- 292 ORTHOPEDIC SURGERY ment will be of use after the age of four years has been reached except in slight cases ; nor is osteotomy or osteoclasis likely to be considered before that time. Under this age in moderate degrees of deformity the Fig. 241. Fig. 242. Figs. 241 and 242.— Knock-knee. Mechanical treatment for one and one-half vears. Fig. 243. Fig. 244. Figs. 243 and 244. — Knock-knee Cured in Three Years b}- the use of Simple Out- side Upright. A good average result. outlook is good with mechanical treatment, and the younger the patient the better the outlook. Former orthopedic methods are exemplified by methods of recum- bency, a method which has practically be- come obsolete. In the ambulatory treatment of the affection, a form which has been in use for some years at the Children's Hospital (Chapter XXI., 18) has proved itself effi- cient in practical use. It is 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 trochanter, and then the rod is bent backward and up- ward, to lie against the upper part of the buttock and to serve as an arm by which the legs can be everted if the child toes in in walking. The knee is drawn upon by a square leather pad, pulling from the shaft opposite the knee. There is no advantage in carrying the outside uprights to a rigid waist band, as is done sometimes. Braces are worn until the line of the leg becomes practically normal. III. Operative Treatment. — The modern operative treatment of knock-knee is comprised under the simple operations of osteotomy and osteoclasis. Osteotomy.— T\\Q. operation consists in the division of part of the Fig. 245. — Line of Cutting in Oste- otomy for Knock-knee. The pict- ure on the left is the ordinary Macewen operation. The one on the right shows the removal of a wedge of bone required only in the severest cases. RICKETS, KNOCK-KNEE, AND BOW- LEGS. 293 bone by the chisel, and the completion of the procedure by fracture of the partly divided bone. The operation is performed as follows : The patient's leg is rendered aseptic; the patient lies on his side with the leg extended, the outer side of the knee resting on a sand-bag. The skin and underlying tis- sues may be divided with a knife over the point of division of the bone, or, what is more simple, the chisel is driven through the sound skin into the bone without any incision. This diminishes the bleeding and Fig. 246. — Proper Position for the Hand and Osteotome in Performing Osteotomy. simplifies the operation. The use of an Esmarch bandage is unneces- sary. The point selected for fracture is the point at which the chisel is to be inserted. This should be as near to the joint as is practicable with- out injury to the joint. The chisel can be inserted on the inner or outer side of the femur. There are no especial advantages of either side for the point of entrance of the chisel, which is determined by the custom of the surgeon. The place most commonly selected is that recom- mended by Macewen,' on the inner side, a short distance above the tu- bercle of the adductor tendon. The distance varies with the size of the patient. In children it should be but little above; in older cases, where the width of the bone is to be considered, a point one-half inch above 'Brit. Med. Journ., June 30th, 1S88, p. 1377. — Lancet, April 21st, 1SS9. 294 ORTHOPEDIC SURGERY. the tubercle is the point of election. The osteotome is driven into the bone with the blade at right angles to the long axis of the femur, and by successive blows with the mallet the operator cuts nearly through the whole thickness of the bone. The osteotome is likely to become wedged very firmly unless the precaution is taken to move the handle of the chisel laterally after each blow. In this way alone can one cut from the front to the back of the bone, for driving the chisel straight through in one line accomplishes but little. When the chisel has dis- FlG. 247. — Moderate Knock-knee Before Operation. Fig. 248. — Same Case After Macewen Oste- otomj-. appeared to a depth indicating that three-quarters of the bone has been divided, it should be withdrawn and an attempt made to fracture the thigh by gentle bending. If this cannot be done, the osteotome should cut further, for the common mistake is a failure to divide the anterior and posterior borders of the femur. Some skill is required in the use of the osteotome, which is made to serve not only as an instrument for dividing the bone, but as a probe which enables the surgeon to determine what portion of the structure RICKETS, KNOCK-KNEE, AND BOW- LEGS. 295 he is dividing. The bone being in its different parts of different hard- ness, the resistance varies, and the locaUzation of the part cut is not difficult. As little injury as is possible should be done to the bone, and little is inflicted if the osteotome divide the outer cortex for the width of an inch on the side entered and undermine the cortex of the re- maining side, cutting through the spongy portion. The insertion of different sized osteotomes is not necessary. The osteotome should be held firmly and its direction carefully attended to by the surgeon. When the bone has broken, unnecessary manipulation should be avoided, but the limb should be put in a corrected position after having been overcorrected, and, after an aseptic dressing has been applied, a plaster-of-Paris bandage should be put on to hold the leg in a corrected position. But little pain follows the operation. No change of dressing is needed ; the plaster may be removed in three or four weeks, another reapplied, and in six weeks or more the patient allowed to stand on the limbs. In correcting the deformity it is manifest that in one place a gap is left to be healed by blood clot, and in another place the divided frag- ments will be pressed firmly together. As the periosteum is but little damaged, firm union takes place, as has been shown clinically in a large number of cases and by pathological specimens of cases dying a year or more after the operation. The operation, when properly per- formed, is devoid of danger, and non-union need not be anticipated in cases suitable for operation. Sometimes, when the deformity lies chiefly in the head of the tibia, the operation of osteotomy might be performed there either alone or in connection with femoral osteotomy. The removal of a wedge of bone is rarely necessary from either the femur or tibia in cases of knock-knee. Much care is needed in the application of the retaining plaster bandage. After the wound has been properly protected by aseptic dressings, the limb should be carefully covered with cotton, not only to allow for shrinking of the tissues, but to prevent undue pressure on any projecting points. If the limb has been properly corrected, which is essential to the success of the operation, the application of the bandage differs in no way from that employed in the treatment of ordinary fractures. The danger of sloughing under the plaster is not great, but if the surgeon desires to examine the bone a window can be cut in the plaster. The bandage should not be removed or the corrected position interfered with until union takes place. Osteoclasis. — The forcible fracture of bone by instrumental or man- ual means in knock-knee is decidedly inferior to osteotomy, inasmuch as it lacks the precision of that method ; more splintering occurs, and rupture of the external ligaments and epiphyseal separation are apt to 296 ORTHOPEDIC SURGERY. occur, as in redressement force.' It is therefore better to limit the use of osteoclasis to the correction of bow-legs, where the instrumental or manual force can be applied to the shaft of a long bone. BOW-LEGS. Bow-legs is the name applied to the opposite deformity to knock- knee, which is an outward angular deformity of the knee, or a general Fig. 249.— Child Sitting Turk Fashion, Pro- ducing, at Junction of Lower and Mid- dle Thirds of Legs, Anterior and Lateral Bowing. (Children's Hospital Report.) Fig. 250. — Child with Bow-legs in Ordinary- Sitting Position, Showing Fitting of One Leg to the Other. (Children's Hospital Report.) outward bowing of the legs, so that when the patient stands erect with the heels together the knees are a greater or less distance apart. The condition is also known as genu varum, genu extrorsum, out- knee, bowed legs, or bandy legs. In German one speaks of it as Sabel- bein, Sichelbein, O-bein, and in French as Genou en dehors. It is single or double, generally the latter, and may exceptionally exist in one leg when knock-knee is present in the other. ' Codiilla : Zeitsch. f. orth. Chir , Bd. xi. RICKETS, KNOCK-KNEE, AND BOW- LEGS. 297 Occurrence. — The deformity is almost always the result of an out- ward yielding of the long bones of the leg, especially of the tibia. At times, however, it is clearly due to an obliquity at the knee-joint, where the external condyle appears the larger of the two. The anatomical changes found are those of rickets. The bending of the bones is in most cases, like the other deformities of rickets, a simple yielding, without fracture or destruction of bone tissue. Causation. — -Bow-legs is essentially a rhachitic deformity in chil- dren, and true bow-legs can occur only in a child whose bones are soft enough to bend, easily. It occurs in the first three or four years of life, and ordinarily in connection with general rickets ; sometimes, however, other rhachitic manifestations are absent ; but the yielding of the bones in a child of this age must of itself be accounted sufficient evidence of rickets. Bow-legs of a marked type are seen in children who are too young ever to have borne their weight upon their legs. To account for this, one must assume a lateral press- ure from carrying and from the sitting position, along with the possibility of some distor- tion from tonic muscular pull. Early walking, so much talked about as a cause of bow-legs, is not to be accounted a factor of any importance in their pro- duction unless rickets in some degree is present. Why the bones should bend outward as they do is a question which is by no means settled. The child with rickets stands with thighs flexed and the lumbar spine arched forward; once given this condition, it is easy to see how bow-legs arise. As the thighs flex the knees are separated and the femurs rotate outward on their own axes; as a result of this the line of gravity, instead of falling outside of the knee-joint, as we have seen was the case in the normal erect position, falls inside of it ; and any yielding of the bones, of course, must take place in the outward direction. With the yielding of the bones the line of the legs falls farther and farther outside of the line of gravity, and the body weight continually acquires better leverage to bend the bones. Antnior ciirvaUire of the thigh and the leg bones is manifestly the result of body weight coming upon a flexed limb, conjoined perhaps to the action of the most powerful muscles in the body (the flexor muscles of the thigh) pulling in the same direction. Symptoms are absent, except, of course, those of rickets. But the Fig. 251. Fig. 252. Fig. 251. — Bow-legs, Gradual Curve Involving" the Whole Leg. Fig. 25-2.— Bow-legs, Curve mostly in Tibia. 298 ORTHOPEDIC SURGERY. deformity is plainly evident, and even in the milder cases the gait is modified in a characteristic way. The child walks with a distinct wad- dle and generally with the feet wide apart and a tendency to invert the toes. The gait in bad cases bears a resemblance to the waddling gait of double congenital dislocation of the hips. The line of the leg lies so much outside of the line of the centre of gravity that in bearing weight Fig. 253. -Standing- Position of Child with Moderate Bow-Legs. Fig. 234. — Curve Involving Whole Leg. on the left leg, for instance, the body must be thrown decidedly over to the left to bring it over its line of support ; it is in a measure the re- verse of the gait in knock-knee. This lurching is inevitable with each step, and, other things being equal, is in a degree proportionate to the amount of curve present. The deformity is almost always more conspicuous in the standing position, both because these children stand with the legs so far apart RICKETS, KNOCK-KNEE, AND BOW-LEGS, 299 and because the knee-joints generally yield somewhat in a lateral direc- tion when the body weight is superimposed. The curve is most often a gradual and uniform bowing of the femur and tibia, so that with the feet together the outline of the legs forms an oval which in severe cases approaches a circle. A second class of cases presents a bowing chiefly in the lower third of the tibia which is more angular in character, and the femurs are practically normal ; a third class presents, either alone or in conjunction with the other de- formities, a bowing forward of the tibia and sometimes of the femur- also. These are the three common types of the deformity. At times Fig. 255. — Severe Anterior Bow-leg-, Seen from the Front and Side. (H. L. BurreU.) the deformity lies chiefly in the knee-joint and the bones are compara- tively straight. Occasionally the condition of knock-knee and bow-leg existing in the same leg is seen. An inward rotation of the lower part of the tibia exists in bow-legs which causes " toeing in " in walking. This is apparently a part of the process of side bending, as a three-cornered weight-bearing body like the tibia, in bending to the side, finds less resistance in bending and twist- ing than it does in bending alone. Diagnosis. — The condition of bow-legs is evident on inspection. Macewen's definition applied to this deformity would be, that it was a condition in which a line drawn from the head of the femur to the mid- dle of the ankle-joint would fall inside of the centre of the knee-joint. 300 ORTHOPEDIC SURGERY. It is often difficult to determine how much of the deformity lies in the tibia and how much in the femur. If the legs are crossed until the insides of the knees are together when the child is in a sitting position, it will be seen whether the femurs include an oval space between them or are parallel to each other. Prognosis. — The prognosis in out- ward bow-legs is favorable ; in anterior bow-legs, less favorable under expectant or mechanical treatment. The prospect of spontaneous outgrowth of the de- formity is better than in knock-knee, and in young children rational mechan- ical treatment offers almost sure relief. The prognosis of bow-legs, when un- treated, will be considered more in de- tail in speaking of the treatment by expectancy. Operative treatment can ameliorate almost any condition of de- formity and often entirely rectify it. When the deformity is extreme or the bones are eburnated, it is not, of course, likely that the child will outgrow the bow-legs. Treatment. — The treatment of bow- legs, like that of knock-knee, is to be considered under three heads: I. expec- tant, II. mechanical. III. operative. I. The expectant tj-eatnicnt is suited to a large percentage of cases of the deformity, and its range of applicability is wider than in knock- knee. The me- chanical conditions are not so much in favor of the increase of the de- formity as in knock-knee, and the tendency in slight cases is toward rectification in the course of growth. In general, when the curve is uniform, involving femur and tibia alike, the chances are more favor- able for spontaneous cure than if the deformity is localized in the tibia and more angular. During expectant treatment the general condition should be most carefully attended to and rickets treated from the first. The child should be encouraged to be off of his feet as much as possible, and the legs should be massaged and manipulated each night, being gently bent toward a straight direction. Fig. 256. — Anterior Bow-legs. RICKETS, KNOCK-KNEE, AND BOW-LEGS. 301 In all cases tracings should be taken at least once each month, to determine if the deformity remains stationary or is improving, and if after two or three months no improvement is evident, mechanical treatment should be begun. 1 1 . Mcchaji ical treat- ment is based upon the principle of drawing the knee inward to a rod which has counter- points for sustaining outward pressure at the upper part of the thigh and at the ankle. Here, as in knock-knee, trac- tion from a rigid rod is more definite and more satisfactory than from an elastic one. The form of apparatus used is of little consequence so long as it answers the indications and holds the knee extended (Chapter XXI., 31). It is no longer custom- ary to treat these cases by recumbency. The apparatus shown (Chapter XXI., 19) is the one generally in use at the Chil- dren's Hospital in Boston, and is serviceable. It consists of a steel upright, which is attached below to the sole plate of the shoe. It runs up nearly to the origin of the adductor muscles, but it must fall a little short of them or it will ex- coriate the skin in walking. The upright is then bent for- ward and upward, and curved to fit into the groin and come up as far as the posterior part of the dorsum of the ilium. In this way a lever is provided with which to evert the feet to any extent by altering the curve of these arms and strap- FiG. 257.— Bow-legs Affecting Chiefly Bones of Lower Leg. Fig. Fig. 259. Fig. 260. Figs. 258, 259, and 260. — Case of Bow-legs. Prog- ress in three years under expectant treatment. 302 ORTHOPEDIC SURGERY. ping- them together behind. Pads for the outside of the legs are made of leather and buckled by two or three straps to the upright, opposite the greatest convexity of the curve. Anterior tibial curves are not susceptible of improvement or cure by mechanical treatment except in slight cases in which the bones are soft. In these cases it is useful to apply to the foot (Chapter XXI., 20) a modification of the brace de- scribed above (Chapter XXI., 19). The mechanical treatment of bow-legs should be advised in cases in which the deformity is severe or sufficiently obstinate to make it doubtful whether spon- taneous outgrowth of the deform- ity will occur, because braces do no harm and do not retard spon- taneous improvement. After the age of three or four it is not gen- erally worth while to begin me- chanical treatment. In the case of babies the ex- pectant plan of treatment is the one to be followed at first. III. Operative Treatment. — Os- teoclasis. — In the case of bones still soft or in very young chil- dren, if it is desired to operate at that stage, manual fracture has a place in the operative treatment, but even then manual fracture presents no advantage over the osteo- clasts. Mechanical fracture is made feasible by the use of osteoclasts, of which the one of Rizzoli is the simplest. The appliance is easily under- stood from the accompanying illustration. The instrument is made of heavy steel, and the rings and the screw pad all slide on the bar so as to be adjustable to any length of leg. The parts of the apparatus which come in contact with the leg are padded so that the edges shall not cut. The instrument is applied to the bared limb, the rings being adjusted as far as is possible from the point at which fracture is desired. In placing the rings of the osteoclast on the limb, care should be taken not to put them too near to the joints of the ankle or knee, as the epiph- yses might be separated by carelessness. The screw is to be adjust- ed so as to press at the point of election for fracture, which is at the point of the greatest convexity of the curve. Pressure is increased until Fig. 261. — Bow-leg. Brace Applied. RICKETS, KNOCK-KNEE, AND BOW-LEGS. 303 fracture of the bones takes place. The fibula generally breaks first, the tibia shortly afterward on continuing the screw pressure. The fracture of the bones is evidenced by a loud snap which can be heard anywhere in the room. The bone will usually be found to bend before fracture occurs. If the instrument is well padded there will be no danger of injury of the skin from the temporary pressure necessary for fracture, although the amount of this pressure may be very great. The skin will become blanched or congested, but after the removal of the osteoclast the color will be found normal, with but slight evidence of pressure. The fract-, ure will be found to have taken place opposite to the screw-pad plate. An excellent osteoclast, devised by Dr. R. T. Taylor, of Baltimore, has the advantage of working more rapidly. It is, however, somewhat more elaborate than the Rizzoli and not so easily carried about. After the bone has been broken, the osteoclast should be removed, the fragments placed with the hand in the desired position, sheet wad- ding carefully placed around the leg, and the limb fixed in a plaster bandage and held in a carefully corrected position. The bandage Fig. 262. — Rizzoli's Osteoclast. should reach from the toes to the hip, and the limb should be held in the corrected position until the plaster has hardened thoroughly. When there is a rotation of the tibia as well as a curvature, care should be taken to see that this also is remedied and that the limb is fixed in a normal position. Experience has shown that the procedure is ordinarily free from risk, and in properly selected cases the danger of non-union after fract- ure may be disregarded. The fracture is a transverse one and there is no danger of splintering the bone A number of experiments upon 304 ORTHOPEDIC SURGERY. the cadaver were made by the writers with reference to this point, and it was found that although spHntering will take place in dry bone if subjected to fracture by an osteoclast, yet bone undried, as found in the dissecting-room, will break transversely ; the fracture takes place as a sharp linear fracture half-way through the bone. The part of the bone nearest the side of pressure breaks with an irregular line of fracture, as if torn. The amount of force required for the fracture of an adult bone is very great, so much so as to make osteotomy in most instances a preferable procedure. Osteoclasis near the joints is difficult, but in the shaft of the tibia the operation is an excellent one, yielding satisfactory results with but little discomfort to the patient. Cases should not be operated upon unless the bones are fairly Fig. 263. —Method of Applying Osteoclast. Strong — that is, not if the rhachitic process has not been well arrested, as recurrence of the deformity may take place. As a rule, the operation should not be performed before the age of four. The limb should remain in a fixed bandage for four or five wrecks, and no appliance is needed as an after-treatment. Osteotomy should be employed in place of osteoclasis in cases of bow- legs (i) when the curvature is so near the joint that osteoclasis is not practicable ; (2) when the bone is so strong that osteoclasis is not feasible ; (3) when several curves exist in the same leg ; (4) when the curvature is anterior; (5) in cases of bow-leg in which the distortion is largely m the lower epiphysis of the femur; (6) in cases m which it is desired to locate the fracture very accurately, as in badly united fractures of both bones of the leg with displacement. RICKETS, KNOCK-KNEE, AND BOW-LEGS. 305 Osteotomy for bow-legs is a similar operation to that for knock- knee ; the division of bone is made wherever it appears most necessary, and no formal operation can be laid down. In young children the fibula need not be cut with the osteotome, but can be broken manu- ally. Anterior Bow-Legs. — In the treatment of anterior bow-legs, i.e., where the curve is forward and not to the side, the tibia may be broken by the osteoclast applied in the usual way, and after the fracture has been loosened by the hands the leg may be set straight. Tenotomy of the tendo Achillis aids this attempt and is generally necessary. Oste- otomy, however, as a rule is more satisfactory in these cases. In ante- riorly curved bow-leg in children, a linear osteotomy can be employed dividing the posterior two-thirds of the tibia and using the anterior por- tion as a hinge with the interlacing broken fibres and uninjured perios- teum to promote healing. The osteotome is inserted in the side of the Fig. 264.— The Lever Osteoclast of R. T. Taj-lor. tibia. By this procedure the shortening caused by removing a wedge is avoided. Considerable manipulation is necessary after the osteotomy to free the fragments from the shortened posterior tissue which is nec- essary to give a corrected position. The gap caused will, as in the oper- ation for knock-knee, heal by blood clot. In older cases a wedge- shaped excision may be necessary. After osteotomy it is not necessary to wire the fragments of bone together ; if they are placed in apposition and fixed, union can be ex- pected to take place. Ultimate Results of Osteotomy mid Osteoclasis. — J. E. Goldthwaite traced out twenty-eight cases of knock-knee and bow-legs operated on in the Children's Hospital, not taking into account any case operated within a year and a half of the beginning of his investigation. There were eleven cases of Macewen's osteotomy for knock-knee and eleven of osteoclasis for bow-legs, while there were five cases of anterior bow- ing of the tibia treated by osteotomy. The average length of time after the operation was four years, and of these cases only one had re- 20 3o6 ORTHOPEDIC SURGERY. lapsed. That was a colored boy, four and one-half years old, who pre- sented a condition of extreme rickets. He had both knock-knee and bow-legs, and osteoclasis and osteotomy were done and the knock-knee had recurred somewhat since operation. Cases will be met when several curves are present, and the judg- FlG. 265. — Bow-legs of Moderate Degree Before Operation. Fig. 266. — Same Case After Osteo- clasis. ment of the surgeon will be exercised in a choice of what bone is to be attacked and if more than one shall be operated upon at one time. In the hands of a surgeon skilled in these operations and working rapidly, several bones may be corrected at one sitting. The surgeon's purpose should be to correct those deformities which most interfere with normal gait, and leave others to the correction of growth. It may be said that the results in the treatment of these deformities in childhood are exceedingly satisfactory as a rule, the surgeon aiding nature, and nature completing the efforts of the surgeon, so that little or no trace of the previous deformity will remain in after-life. It is not advisable to operate in either bow-legs or knock-knee before the age of four years. RICKETS. KNOCK-KNEE, AND BOW-LEGS. 307 RHACHITIC CURVES IN THE UPPER EXTREMITY. These rarely present themselves for treatment, and but little further need be said except that by means of osteotomy the curves of the upper extremity can be treated as readily as those of the lower. IMPROPERLY UNITED FRACTURES, The same method can be applied in the correction of improperly united fractures of the upper and lower extremities. In this class of affections, however, vicious callus may be present in such a way that more than linear osteotomy may be needed. The principles of treat- ment for the correction of these curves, in the main, are those consid- ered in the treatment of rhachitic curves. In deformity following badly united fractures, however, the employ- ment of a narrow osteotome applied freely at such points as may be necessary to weaken the callus will be found useful. CHAPTER X. COXA VARA AND COXA VALGA. Coxa vara and traumatic coxa vara. — Etiology. — Pathology.— Symptoms. — Diag- nosis. — Prognosis. — Treatment. — Coxa valga. It has been demonstrated by Dwight that the normal range of va- riation in the angle between the neck and the shaft of the femur is much greater than has been ordinarily supposed. When these varia- tions are slight no clinical symptoms follow, but disturbance of the function of the hip is likely to result when this angle is diminished be- yond a certain point. The name coxa vara is applied to the condition in which the neck of the femur is bent downward sufficiently to give rise to symp- FiG. 267.— Specimen of Severe Coxa Vara. (Robert Jones.) toms. This bending may reach such an extent that the neck forms with the shaft a right angle or less, instead of the normal angle of 120° to 140°. ETIOLOGY. Coxa vara may be unilateral or bilateral, and affects males more often than females. It is, in general, an affection of growing bone, and is seen most often in adolescents, and next most frequently in children. COXA VARA AND COXA VALGA. 309 although adults are not exempt. The more frequent affection of ado- lescents is explained because the disability is more noticed by them than by children, because the strain coming upon the growing femur is Fig. 268. — Radiograph of Same Specimen. (Robert Jones ) greater the larger the individual, and because the neck of the femur is relatively longer in them than in young children.' The affection may be congenital.'^ PATHOLOGY. The shape of a growing bone is in general determined by the rela- tion between the strain coming upon it and the resistance of its struct- ure. If these relations are normal, the usual shape of the bone will be preserved ; if the resistance is diminished or the strain increased, mod- ifications in shape are likely to occur.' The causes of coxa vara are, therefore, to be sought in increased strain or diminished resistance in the neck of the femur. Coxa vara is to be found in connection with rickets, osteomalacia, acute osteomyelitis, and ostitis deformans. The changes resulting from the destructive processes of arthritis deformans and tuberculosis 'Whitman: "Orth. Surgery," 2d edition. - Krebel : "Coxa Vara Congenita." Cent. f. Chir. , October 17th, 1S96. — Joa- chimsthal : Zeit. f. orth. Chir., xii , i and 2, 52. ■Frieberg and Taylor: " Wolff's Law." Orth. Trans., vol. xv. 310 ORTHOPEDIC SURGERY. of the hip may cause a changed relation between the head and shaft of the femur, simulating coxa vara. Coxa vara may exist in cases presenting no clinical or pathological evidence of any condition causing a softening of the bone. In certain marked cases the change in shape ma}- be clearly seen without other evidence of disease. In addition to the downward displacement of the head and neck of the femur, there is generally also present a yielding of the neck in the horizontal plane. The most common bend of the neck is that with the convexity forward, so that the leg is rotated outward and the foot everted. In other cases, less commonly seen, the neck is bent with the convexity backward, and the foot and leg are inverted. In still other cases the depression of the head and neck in relation to the shaft may be directlv downward without forward or backward bendinsr. In these Fig. 269. — Specimen of Coxa Vara, no Clinical History. (Warren Museum.) cases neither eversion nor inversion will be marked. The changes may be most evident at the end of the neck of the femur nearest the tro- chanter or at the end nearest the epiphysis. In exceptional cases there may be bending of the upper part of the shaft of the femur. COXA VARA AND COXA VALGA. 31 1 Traumatic Coxa Vara. (Fracture of the neck of the femur, epiphyseal disjunction, infraction of the neck of the femur, Schenkelhalsbriiche, etc.) Described under these various names is a changed relation between the head of the femur and its shaft, which may be classed with coxa Fig. 270. — Specimen of Severe Double Coxa Vara from an Adult Female (No. 3821 in the Vienna Pathological Anatomical Museum). (Albert. 1 vara of non-traumatic origin. It is clearlv traumatic in origin, follow- ing slight or severe accidents. It exists chiefly in children and is often overlooked. The pathological change consists most often of a displace- ment, partial or complete, of the epiph^"sis downward, and a consequent elevation of the trochanter in relation to the head of the bone. At other times the injur}- results in a real fracture or infraction of the neck of the femur, the junction of the epiphysis and shaft apparently escaping injury.'' •Hofta: Zeitsch. f. orth. Chir., xi., 3. 52S (with bibliography^ — Whitman: Am. Journ. Orth. Surgerj-, ii., i. 312 ORTHOPEDIC SURGERY. In some instances, while no evidence of trauma is clear, enough strain coming upon the epiphysis to modify the growth of the bone may have existed without giving rise to characteristic symptoms of fracture Fig. 271.— Coxa Vara and Bending Outward of the Upper Shaft of the Femur. (Albert.) or epiphyseal separation. In other cases a fracture of the neck of the femur in adolescents or children, sufficiently severe to necessitate thorough treatment by the usual methods, may be followed months after by yielding of the neck of the bone induced by the softening of the neck incident to callus formation. COXA VARA AND COXA VALGA. 313 SYMPTOMS. The early development of coxa vara is not likely to be accompanied by marked symptoms, the earliest signs noted being generally referred to the hip-joint, which is the seat of vague discomfort and slight irrita- bility and pain, and walking is avoided. The characteristic symptoms when the deformity is established are as follows: Shortening exists in unilateral cases and the trochanter is raised above Nelaton's line in both unilateral and bilateral cases. In children Fig. 272.— Sagittal Section of Coxa Vara, Showing Rearrangement of Trabeculje to Com- pensate for Cross Strain. (Abbott.) the shortening may be slight. The trochanter in marked cases is more prominent than normal. Limitation of motion of the hipfoint is most marked in the direction of abduction, which is due not only to a shortening of the abductors, but to the pressure of the trochanter against the ilium when the leg is abducted. Joint irritability is generally present and may be severe enough to cause limitation of motion in other directions than abduction. Lameness 2x\di pain m. the joint after exertion are fairly constant symptoms. If the affection is unilateral, a limp is noticeable; if bilate- ral, a waddling, restricted gait takes its place. When a backward twist of the trochanter exists, the foot will be everted and flexion of the thigh will be accompanied by ez'ersio7i and 3H ORTHOPEDIC SURGERY. ubductio7i. When a forward twist is present, inversion of the foot is found. In severe cases the thighs may be crossed in front of the body in full flexion. Scoliosis may result in unilateral cases. In bilateral cases the dis- tance between the trochanters will be greater than normal. DIAGNOSIS. The recognition of coxa vara is not difficult. The top of the tro- chanter is higher than normal, being above the line drawn from the anterior superior spine of the ilium to the middle of the tuberosity of the ischium (Nekton's line). Short- ening is present if the affection is unilateral. A femoral twist is recog- nized by determining on deep palpa- tion the direction of the trochanter rel- atively to the cross axis of the pelvis when the leg is straight and the patella faces directly forward. The trochan- ter points forward or backward, accord- ing to the existing twist. In marked cases limitation in abduction is present, and in cases in which the hip is strained from inability to bear the strain inci- dent to locomotion, symptoms of joint irritation {i.e., pain and slight stiffness on passive motion) may be present. The diagnosis can be aided by a skiagram. Cases of coxa vara have been re- garded as suffering from hip disease and from congenital dislocation of the hip. Such mistakes can be avoided by a thorough examination of the case. In cases of ]iip disease of long duration the joint stiffness is greater than is seen in coxa vara. The stiffness af- fects all motions, and not chiefly ab- duction, and the trochanter is not elevated above Nelaton's line, ex- cept after considerable bony destruction, which wall be accompanied by deep thickening about the joint and by marked muscular spasm. In congenital dislocation on deep palpation the head will be discovered ■outside of the acetabulum. On rotating the limb in congenital dis- location of the hip, the excursion of the head will be greater than that Fig. 273.— Traumatic Coxa Vara of Right Leg, from an Accident Occurring when Patient was Four Years Old. (Hoffa.) COXA VARA AND COXA VALGA. 315 of the trochanter, the reverse being true in coxa vara. In coxa vara the distance between the trochanters is wider than normal, but this is Fig. 274. — Outline of Depressed Neck of Femur in Muller's Specimen. Contrasted with normal (m dotted line). (Whitman.) not the case in congenital dislocation of the hip. In coxa vara, if the patient stands upon the affected limb and raises the other from the Fig. 275.— Cross Section of Pelvis and Deformed Femur. A scheme to show the effect of the deformity in limited abduction. Dotted outline shows the normal relation. (Whitman.) 3i6 ORTHOPEDIC SURGERY. floor, the cross axis of the pelvis is held firmly at a right angle with the line of the leg and thigh or somewhat above it, while in congen- ital dislocation of the hip the pelvis drops. PROGNOSIS. In connection with general rickets, when coxa vara exists with other marked rhachitic deformities, the prognosis does not differ from that of knock-knee or bow-legs. In other cases there seems no reason to look for spontaneous cure. Remissions in the symptoms follow the rest ne- cessitated by the joint irritability and may be of considerable duration. TREATMENT in coxa vara is either expectant or operative. Conservative Treatment. — In the stage in which the bone may be regarded as congested and not sufficiently strong to support super- imposed weight, crutches or an apparatus which will remove weight Fig. 276. — Double Coxa Vara Showing Eversion of Feet and Outward Rotation of Legs. (J. E. Goldthwaite.) from the head and neck of the femur can be employed. A convales- cent hip splint (Chapter XXI., 11) or a Thomas knee sphnt (Chapter XXI., 14) can be used in unilateral cases. In bilateral cases hip-trac- COXA VARA AND COXA VALGA. 317 tion splints with an abducted position of the limbs are indicated if the symptoms of joint irritation demand such thorough treatment. Mas- sage is of benefit in stimulating the circulation. When the deformity Fig. 277.— Case of Double Coxa Vara. This case was reported by Dr. George H. Monks in the Boston Medical and Surgical Journal, November i8, 1886. The photograph here shown is a recent one, having- been taken for Dr. Monks three or four years ago. is slight, such measures may be relied upon not only to check an in- crease of the deformity and to allay the condition of hip sensitiveness which may follow overstrain, but also to favor correction by a more normal growth. Operative Treatment. — If the deformity is sufficiently severe to occasion disability, operative measures are indicated. These may be directed to restoring to the patient free motion in the direction of ab- duction or to the correction of deformity. Forced abduction may suffice in young children and can be accom- plished by abduction of the limb under anaesthesia with or without fas- ciotomy, and fixing of the limb for a month or more by a plaster spica 3i8 ORTHOPEDIC SURGERY. bandage in an abducted position. After this, massage and stretching exercises should be prescribed. Protected use should then be resumed. Osteotomy can be either linear or cuneiform. In linear osteotomy the bone is divided by an osteotome, cutting across the femur below the trochanter minor, as described in hip disease. The limb is strongly abducted, the shaft being rotated in or out to correct the twist of the Fig. 278,— Fracture oE Hip Four Years after the Accident. Shows eversion. (Whitman.) Fig. 279.— Fracture of Hip. Projec- tion and elevation of trochanter. (Whitman.) neck. Plaster fixation with the limb abducted should be maintained for from four to six weeks. In linear osteotomy a surgeon familiar with the procedure can divide the shaft as in osteotomy for knock-knee without a skin incision, using the osteotome to divide the skin. Linear osteotomy requires the exercise of some skill in its performance, with the expectation of an excellent result. After this, if the limb is Drought into the straight position, the former depressed angle of the neck will be changed to a normal oblique inclination. The bone gap caused by COXA VARA AND COXA VALGA. 319 the rectification will, as is observed in Macevven's operation for knock- knee, fill by healing by blood clot and subsequent ossification. The advantage claimed for cuneiform osteotomy, or the removal of a wedge-shaped fragment from the femur just below the level of the lesser trochanter, is the certainty of a sufficient gap of bone to correct the deformity. The disadvantage is that the operation requires more dissection and destruction of tissue and causes shortening. In cuneiform osteotomy a three-inch incision is made on the outer side of the femur, from the top of the great trochanter down. The tis- sues are separated, and by means of an osteotome a wedge-shaped sec- FiG. 280.— Radiograph of a Severe Rhachitic Coxa Vara in a Patient Six Years Old. (Joachimsthal.) tion of the femur is removed. The apex of the section should be at the cortex of the femur opposite the lesser trochanter, which should not be divided. The upper section of the bone should be at right angles with the axis of the shaft and the lower section made at an angle, the base ORTHOPEDIC SURGERY. of the wedge being three-quarters of an inch wide, the exact amount varying with the size of the bone. After the section has been made and the wedge of bone removed, the uncut inner surface of the femur is broken. The splintered fragment and the periosteum act as a hinge and no wire sutures are needed, the cut bone surfaces being placed in apposition, the top of the great trochanter being pressed against the ilium by abducting the limb. The limb should be fixed in a plaster spica bandage, holding the pelvis and femur securely. Afti-r-TrcatmcJit. — After the removal of the plaster bandage the motion of the limb should be encouraged without weight bearing by passive movements, massage, and going about on crutches. After this it is a matter of judgment in each case w^hether the patient may be al- lowed unrestricted activity or whether the neck of the femur may still possess too little resistance, in which case a protection splint should be worn. Traumatic Coxa Vara. — In cases seen long after the accident the treatment does not differ from that described for- ordinary coxa vara. In recent cases, seen so soon after the accident that con- solidation has had no time to occur, the leg should be abducted and fixed in that position by a plaster-of -Paris spica. Traction may be required in exceptional cases. Unprotected use of such a leg should not be allowed for a year after the injury. Coxa Valga. Coxa valga is the name applied to the condition which is the re- verse of coxa vara. In this the angle between the neck and shaft of the femur is increased above 140°. In connection with this deformity also twists of the neck of the femur may occur. It has been recorded as occurring in connec- tion with infantile paralysis, in connection with atrophy following old ankylosis of the knee-joint, in osteomyelitis of the pelvic bones, in severe rickets, and in osteomalacia.' It has been recorded following 1 Turner: Zeitsch. f. orth. Chir., xiii.. 11.— Albert: "Coxa Vara und Valga," AVien. 1899. Pig. 281.— Radiograph of a Sagittal Sec- tion of a Specimen of Coxa Valga, Amputation of the Thigh having been Done in Childhood. (Turner.) COXA VARA AND COXA VALGA. 321 a severe fracture of the lower end of the femur and knee-joint. A congenital case ' has been reported of double coxa valga in which ap- parently neither rickets nor trauma was present as an antecedent cause. When symptoms have been reported they consist of an a.b- FiG. 282.— Radiograph of a Case of Coxa Valga. (David.) ducted position of the leg with eversion, and adduction and inward ro- tation are limited. The gait is not unlike that in double coxa vara. A satisfactory treatment of the condition has not been formulated. ' David: Zeitsch. f. orth. Chir. , xiii., ii. and iii., 360 (with literature). 21 CHAPTER XI. LATERAL CURVATURE OF THE SPINE. Definition.— Frequency.— Sex.— Age. — Patiiology.— Etiology.— Symptoms.— Di- agnosis.— Methods of record.— Prognosis.— Preventive measures. — Treat- ment. DEFINITION. By this term is understood a constant deviation of the spinal col- umn, or a portion of it, to either side of the median line of the body, with a resulting distortion of the trunk. The affection has also been called scoliosis and rotary lateral curvature. In French it is known as ScoHose, deviation laterale de la taillc, and in German it is called Seitliche Riickgratsverkrimwmng, and Kyphosco- liose. Lateral curvature is either congenital or acquired. The former va- riety, hovi^ever, is rare ; when present, it is a result of imperfect or de- fective development.' FREQUENCY. The affection is a common one, but its prevalence can only be esti- mated, as statistics gathered vary apparently according to the standard of the observer. Drachmann reports scoliosis in lYi per cent of 28,125 school chil- dren in Norway, while in Switzerland ' 24.6 per cent among 2,314 school children are reported to have had lateral curvature, in Moscow 29 per cent of scoliotics among 1,664 children were found by Hagemann, and in St. Petersburg 26 per cent among 2,333 by Kohlbach. Berend reports 900 scoliotic patients in 3,000 patients ; Langgaard 700 in 1,000 cases; Schilling, 600 in 1,000 (Schreiber). Whitman re- ports that scoliosis was, next to bow-legs, the most common deformity at the out-patient department of the New York Hospital for Ruptured and Crippled Children. The distortion is seen more frequently in girls than in boys, but statistics as to the comparative frequency of the deformity in females as compared with males vary. It is placed by different observers at from seven to four females to one male. ^Vogt: " Moderne Orthopadik," p. 75.— Schreiber : " Orthopadische Chi- rurgie," p. 118. - Annales Suisse d'Hygiene Scolaire, 1901. 322 LATERAL CURVATURE OF THE SPINE. 323 //5 JIO m i\ ^1 19 n It is possible that if parents were as solicitous as to slight variations in the figures of their boys as of their girls, the statistics would show a greater proportion among boys than has been reported. In the lateral curvatures of young children (under five), the males are said to equal or to outnumber the females. When school children are observed, the proportion of males is very much greater than when the statistics are taken from patients coming for treatment. Some of the most severe forms are to be seen among males. Age. — Although it is probable that the dis- tortion exists to a slight extent at an earlier age, the majority of cases brought to the surgeon for treatment are from ten to sixteen years of age. Whitman reports 39 per cent under fourteen years of age, 48 per cent between fourteen and twenty-one; Eulenberg, over 50 per cent between seven and ten years of age, and 10 per cent be- tween ten and fourteen. Lateral curvature, an abnormality in the shape of the trunk by which its symmetry is lost, is characterized by a curve and twist of the spinal column, causing an undue prominence of one side and other irregularities of contour. The deformity is more readily understood if the pathological changes are examined. 2J T~ 15^^0?-'/0(/-3]0-35^-30f PATHOLOGY. Fig. 283. — Diagram show- ing the Progressive In- crease of Scoliosis dur- ing School Life. The lowest grade in school is placed on the left. The lower figure shows the number of children investigated in each grade and the figure at the top the number of scolioses found in each grade. (Scholder.) The pathological changes in true lateral curv- ature are not those resulting from destructive disease of the vertebrae, but are the alterations of bone induced by abnormal pressure and strain. The spinal column, as a whole, is bent and twisted, and the individual vertebrae are in places altered in shape as well as misplaced from their normal relation to the vertical plane of the trunk. The ribs and pelvis may be altered in shape. The muscles and liga- ments are altered in their tonicity and length, and internal organs may be displaced. Characteristic of the deformity is the combination of a side curve of the spinal column with a twist, the spinous processes as a rule pointing away from and the vertebral bodies being turned toward the convexity of the curve. This rotation is the result of the structure of the spinal column, which cannot bend to the side without twisting. 324 OR THOPEDIC S UR GER Y. The changes seen necessarily vary according to the stage of the affection and the degree to which the deformity has developed. In the earliest stage of scoliosis slight if any anatomical change will Fig. 284. — Longitudinal Section of the Ver- tebral Column of a New-born Child, Show- ing the Absence of Ph\'siolog'ical Curves. (Schulthess.) Fig. 285.— Side View of the Vertebral Column of an Adult Man. (Schult- hess.) be found in the bones, ligaments, or muscles ; but in the stage of fixed curves and in the latest phases of the affection, marked distortion of LATERAL CURVATURE OE THE SPINE. 325 the whole spinal column, as well as the individual vertebrsc, is to be observed. Wherever a side curve with rotation of the spine tias taken place, the bodies are crowded together on the concave and separated on the convex side of the curve. Growing bone adapts itself to altered press- ure, and in time the vertebral bodies will be found thicker on one side than the other, and changes in shape of the articulating and transverse processes will also take place. The transverse Fig. 286. — Torsion in Lateral Curvature, bar.) (vSchrei- FiG. 287.— Distorted Pelvis in Lat- eral Curvature. processes are out of the normal plane; the ribs follow the transverse processes, and show a characteristic projection on one side and flatten- ing on the other. If the column is curved laterally in two or three directions, rotation necessarily takes place in different parts of it in opposite directions. The projection of the ribs is naturally more noticeable than the projec- tion of the transverse processes without ribs, so that in the lumbar region the rotation seems slight when compared with that of the dor- sal region. The intervertebral cartilages necessarily twist with the vertebrae and are compressed on one side more than on the other in cases of marked curves ; in severe cases they will be found on measurement thicker on the side of convexity than of concavity, so that instead of being flat they are wedge-shaped from side to side. In some cases the rotation is more marked than the curve, the line of the spines being nearly straight, while the bodies are found badly out of line, the axis of rotation being near the spines. Wolff's Law. — The adaptation of bone to pressure has been formu- lated in what is known as Wolff's law, which is as follows: "Every change in the formation and function of the bones, or of their function 326 ORTHOPEDIC SURGERY. alone, is followed by certain different changes in their internal archi- tecture and equally definite secondary alterations of their external con- formation in accordance with mathematical laws." The relation of bone structure to strain, however, was understood and described by Sir Charles Bell in his treatise on "Animal Mechanics," and was also described by Jeffries Wyman, of Cambridge/ Fig. 288.— Method Used for Producing Deformitj- of Head by Flat-Head Indians. (From Sketcii from Lewis and Clark.) Fig. 289. — The Flat- Head Indian. An old man. There is necessarily a torsion of the spinal column whenever it is bent toward the side, and when a curved condition of the spine becomes habitual or constant the changed pressure in the spinal column pro- duces in time alterations in the shape of the vertebral bodies and in the articulating surfaces. It has been shown that not only do the bodies of the vertebrae give evidence of torsion around the axis of the spinal column, but there is, in advanced cases, evidence of torsion of the bodies themselves in oblique and spiral longitudinal striations on the bodies in the place of Fig. 290. — Transverse Section of a Scoliotic Thorax. (Albert.) the usual vertical marking, and in a twist of the spinous process and lamina in its relation to the vertebral body.^ The bodies lose their nor- [902 ^"Animal Mechanics," by Sir Charles Bell and Jeffries Wyman, Cambridge, - Lorenz : " Scoliosis," Wien. LATERAL CURVATURE OF THE SPINE. 327 mal symmetrical shape ; the spinal canal becomes irregularly oval in shape, and the transverse and articular processes are altered according to the position of the vertebrae; those on the crowded side being broader and lower than on the convex side. The changed vertebrae vary according to their relative position in the curve and to the direc- tion in which they receive the superincumbent pressure, those at the site of the greatest curve changing the most. On section the structure of the bones will be found normal, except that abnormalities in bone density and in the trabeculae will be ob- served, and irregularities in shape and growth. The ribs are not only displaced, but altered in shape. They are Pig. 291. — Horizontal Section of a Normal Dorsal Vertebra. (Dolega.) also altered in the line of their obliquity, being lowered on the side of the concavity of the curve. The contour of the thorax is changed from the altered shape of the ribs ; the clavicles remain, as a rule, unchanged, but the tip of the ster- num may be deflected from the median line. The ribs project back- ward at the angle on the side of the convexity of the curve and forward on the side of the concavity. A cross section of the thorax shows an alteration of the diagonal axes of the chest, and in the ordinary dorsal right convex curve the diagonal axis from the left front side to the right back side of the thorax is longer than on the other side. The different halves of the thorax, 32 8 ORTHOPEDIC SURGERY. on cross section, should be symmetrical normally, but in lateral cur- vature the portion on the convex side is smaller than that on the con- cave side, owing to the flattening of the ribs. The vertebral bodies are also crowded into this half of the thorax, so that there is less room Fig. 292.— Section of the Ninth Dorsal Vertebra in a Case of Right Dorsal Scoliosis. (Dolega.) for expansion of the lung on that side than on the other side. In the severest cases of distortion, the lower ribs on one side may rest upon the crest of the ilium or sink into the pelvic cavity. The muscles of the spinal column in an early case of lateral curva- ture are unaffected, except in cases of a purely paralytic nature. In dissections of advanced cases the muscles are found to have degen- erated. The muscles in the concavity of the curve are found neither prominent nor rigid. The prominence and rigidity of the spinal mus- cles in the lumbar region frequently seen on the convex side of the lum- bar curve often convey to the touch a doubtful sense of fluctuation, and have sometimes led to the suspicion of an abscess. In advanced cases of lateral curvature, the ligaments on the concave side of the spinal column are shortened and those on the convex side are elongated. This is the result of adaptive shortening, and is not found in the early stages of the affection. Distortion of the Pelvis in Cases of Lateral Curvature of the Spine. — The pelvis is not necessarily distorted in lateral curvature of the spine, but the bones of the pelvis may, if not sufficiently un3delding in their structure, become altered by abnormal pressure or strain. The pelvis may assume the appearance of obliquity from a prominence of one hip due to the uncovering of the crest of the ilium by the over-pro- LATERAL CURVATURE OF THE SPINE. 329 jecting ribs, but true obliquit}' is exceptional. When there is irregu- larity in the length of the legs, obliquity of the pelvis necessarily exists. The spinal cord is not affected by lateral curvature. The spinal nerves, in consequence of the large size of the foramina, are not liable to suffer compression, but symptoms of nerve-root pressure are at times observed in advanced cases. Influence of Lateral Curvature in Causing Displacement of Abdomi- nal Viscera. — The abdominal viscera are less likely to be displaced, even in severe cases, than the thoracic organs, though the liver ma}- be out of place and altered in form, according to the direction and extent of the spinal distortion. The spleen may suffer some compression, and the aorta is necessarily displaced. The lung on the convexity of the curve is much more compressed and flattened, and the thoracic cavity on the concavity of the curve is always found to be much larger Fig. 293.— Experiment on Cadaver Showing the Causation of a Right Curve %vith Rotation from Oblique Superincumbent Weight. than would be expected. The lung on the concavity of the curve may be altered in form, but is not diminished in bulk as on the side of con- vexity. The heart is generally found displaced toward the concavity of the curve in severe cases. 330 ORTHOPEDIC SURGERY. ETIOLOGY. When bone was reg^arded as a structure which was unchanged in shape except by accident or destructive disease, the phenomena of lat- eral curvature were not easily understood. No evidence of disease or traumatism is found, and, although the bones are abnormal in shape, they are not defective. It is now known that bone, like other portions of the human frame, muscle, and skin, is a structure which adapts itself to conditions, being changed in shape and strength under pressure and strain. Bone can be deformed by abnormal pressure without injury to the health, as is shown by the flat-headed Indians, whose skulls were shown by Clark to have been distorted by pressure mechanically applied for a long period in infancy. The foot of a Chinese lady is another illustration. The shape of the bone, as is well known, alters in differ- ent occupations. These alterations in bone, studied as they have been by Bell, Wyman, and Wolff, may be regarded as the result of altered conditions. The phenomena of lateral curvature, curve and rotation, have been produced experimentally on the cadaver of infants (Bradford and Lov- ett, ist and 2d eds.. Chapter "Lateral Curvature"), and in animals by Wullstein,^ who produced scoliosis by securing for six months the spine of a growing dog by a stiff bandage in a bent position. Growing chil- dren, obliged to retain an abnormal position through paralysis, often acquire scoliosis, and the Siamese twins, prevented from normal atti- tudes, developed similar deformities. It is not necessary to seek for remote causes in studying the etiology of scoliosis. To explain the development of scoliosis it is only necessary to as- sume the existence of a constantly applied force exerted upon the spinal column in abnormal directions. As the resistance offered by the bone differs in different portions of the spine, a certain type of deformity results from abnormally applied superimposed weight, and, as individ- uals differ, similar conditions do not produce the same deformity in different individuals. Whatever favors abnormal distribution of the superimposed weight favors the development of the deformity, as is also true of conditions which diminish the resistance of bone. Of the fac- tors favoring abnormal distribution of superimposed weight, the follow- ing may be mentioned : 1. Faulty attitudes in standing or sitting. 2. Inequality of the length of the limbs or other causes tilting or twisting the pelvis. 3. Occupations which produce faulty attitudes. 4. Paralysis or weakness of the muscles of the back. 5. Congenital defects, absence or defects of the ribs or vertebrae. ' Wullstein : " Die Skoliose," Stuttgart, 1902. LATERAL CURVATURE OF THE SPINE. 331 6. Torticollis or inequality of vision in the eyes. 7. Contraction of the chest following empyema. 8. Sacro-iliac disease. 9. Asymmetry of the pelvis. Lateral curvature is also favored by causes which will diminish the resistance of bone to abnormally applied weight. Apart from disease of the structure of bone, these are: (i) rickets and osteomalacia; (2) abnormal lack of bone resistance of the spinal column, from rapid, ex- cessive, or ill-nurtured growth. SYMPTOMS. Early History. — The deformity of scoliosis is developed during the growing years, becoming arrested, as a rule, at the end of the period of growth. The affection is ordinarily discovered by the patient's mother at the age just previous to puberty, although it is developed earlier than this in a majority of cases without being recognized. The symptoms are so slight in the earliest stages and the deformity is so easily overlooked that the surgeon is rarely consulted. The patient suffers no inconven- ience at this stage, and as the child is at an age (five to ten) when the figure is not carefully scrutinized, little attention is paid to the slight elevation of the shoulder or projec- tion of the hip. Upon superficial ex- amination but little else is to be seen, and these symptoms disappear on re- cumbency or suspension. A careful examination often discloses a pecul- iarity in standing or sitting. In a majority of cases when the surgeon is consulted, well marked de- velopment of the distortion has al- ready taken place, with more or less structural change. The muscular system may or may not be well developed, but in a majority of cases the muscles are not large or strong. In the early periods of the development of the affec- tion there is rarely any symptom complained of except the annoyance of the curvature, due to a distortion of the figure. In a few instances Fig. 294. — Front View of Lateral Curva- ture, Showing: Prominence of Left Mamma in Right Dorsal Convex Curva- ture. 332 ORTHOPEDIC SURGERY. of growing girls with marked impairment of strengtii some thoracic pain may be felt, and fatigue on exertion in walking or standing. The period during which the curvature of the spine may develop is in- definite, as well as are the rate and extent of the development. It is impossible, in the present stage of our knowledge, to predict the amount of in- crease or the permanency of arrest. The liability to increase is greatest during the growing years. But cases of severe curvatures will be seen in which de- velopment has slowly con- tinued during the years of younger adult life. While it is certainly true that the time when a curve may be regarded as arrested is not easily recognized, an examina- tion of a large number of untreated cases justifies an opinion that spontane- ous arrest takes place in a very large number of the slighter cases, without fur- ther development of the deformity. Even in many of the severer types of the deformity patients will be observed who go through adult life without any increase of, or inconvenience from, the deformity. The symptoms of lateral curvature zro. pain, impah^fnent of general condition, and deformity. Pain. — Painful symptoms are not common in the affection, except in the severest cases. The symptoms of pain are of three classes : I St. Those due directly to the altered muscular or ligamentous strain. 2d. Those due to the abnormal pressure from distorted ribs upon. the nerves or ilium, or by vertebrae upon nerves, or to alteration of the size and shape of the thorax, and displacement of viscera. 3d. Neurasthenic symptoms from a lack of vitality, superinduced by the limitations as to exercise and activity, consequent on the deform- FlG. 295. — Right Lateral Curvature. (Weigel.) LATERAL CURVATURE OF THE SPINE. 333 ity, and to the impairment of circulation and res]:iiration by the deform- ity of the chest. Impairment of General Condition. — Interruption in the functions of the liver, stomach, and intestines is occasionally seen in severe cases. Shortness of breath also occurs, as well as pain in the stomach, loss of appetite, and indigestion. In the severest cases a lack of deposit of fat in the subcutaneous tissue will be noticed, and the patients are thin, even though they may be in relatively good health. Deformity. — The chief symptom of lateral curvature is the distor- tion. This, as has been explained, is not limited to a simple lateral Fig. 296. — Severe Lateral Curvature (Un- treated). Fig. 297.— Right Dorsal, Slight Left Lumbar Curve. curvature of the spine, but to this is added a twisting of the trunk ; or, in other words, there is both a curvature and a rotation on a vertical axis. The curves of the spinal column vary in degree, situation, and ex- tent. There are, however, common types, which it is convenient to bear in mind in considering" the subject of treatment. Lateral curvature either involves the whole spine in one curve, termed by some writers total scoliosis, or it is chiefly confined to a re- gion or regions of the spine, and the curvature is called cervical, dojsa/. 334 ORTHOPEDIC SURGERY. or lumbar scoliosis. These are defined right or left, according to the direction of the convexity of the curves. What is termed double scoliosis is met when an upper curve is found in one direction and a lower in the opposite. If one lateral curve occurs in the middle region of the spinal col- umn, one or two other compensating curves are of necessity developed in opposite directions, to preserve the patient's balance, above or below the deformity, in order that the head be kept erect and in the median line. These compensating curves may or may not be of pathological significance. In some instances one of the compensating curves is of an equal prominence with the so-called primary curve ; in which case the spinal column will pre- sent the S-shaped curve which is characteristic. In other cases what is termed the compensating curve may become more marked. The curves are rarely limited exactly to definite portions of the spinal col- umn ; the upper curve may be so long as to include all of the dorsal and upper lumbar vertebrae. Again, the lower curve may be so long as to invade nearly the whole of the dorsal region, the com- pensation taking place in the upper part of the cervical re- gion. In all varieties of curves except the total, compensat- ing curves, so called, are necessarily present. They may be so slight as not to attract attention. Furthermore, when the curves are in the flexible stage it is difficult to de- termine which is the more important one ; but after osseous changes have taken place, the most important curves become fixed, and these are the curves which demand most attention. This is partly due to the attitude in which the column is placed, and partly, probably, to a lack of resistance of tissues of certain parts of the spinal column. Fig. 298. — Severe Right Dorsal, Left Lumbar Curve Showing' Marked Lumbar Rotation on the Left. LATERAL CURVATURE OF THE SPLNE. 335 Cervical Curvature. — The cervical or cervico-dorsal curves are the least common form of lateral curvature, except when associated with torticollis. This curvature may, however, occur primarily ; when it does, it is most commonly accompanied by a long compensatory lower curve. There is invariably elevation of one shoulder and an inclination of the: axis of the head to the side of the concavity of the cervical curve. Dorsal Curvature. — The most common dorsal curve is with the convexity to the right. In these cases the right shoulder will be raised, the right shoulder blade will project backward more prom- inently than the left, and will be at a higher horizontal level and farther from the median line of the trunk. The back, just below the scapula, will be more rounded backward on the right side and more flattened on the left, and the left shoulder will be held down. In front, in well-marked cases, the breast and front of the chest may be more prominent on the left than on the right side. In addition to the curve there may be a tendency to displace- ment of the whole trunk to the right side. When this is the case, the right arm, when hanging,vvill be free from the side, while the left arm, when hanging dovvn, necessarily strikes the hip. There is also, unavoidably, a change in the outline of the sides of the back. The sides, instead of being symmetrical, as seen from the back, will be different; one side of the outline will be unnaturally straight, and the other more than normally hollowed. The normal backward physiological curve in the dorsal region may be diminished so that the upper back is abnormally fiat, or it may be increased so that the dorsal region is abnormally bowed. The latter condition is spoken of by German writers as kyphoskoliose. Lumbar Curvature. — Lumbar dorsal or lumbar curvature manifests itself by a prominence of one of the hips ; the one on the side of the concavity of the curve appears in the contour of the trunk higher than Fig. 299. — Right Dorsal, Left Lumbar Curves with Displacement of Body to the Right. 336 ORTHOPEDIC SURGERY. on the other side, as it is less covered by overlying tissue. It is often termed a "high hip," but incorrectly; measurement shows no differ- ence. In well-marked lumbar curvature there is also a fulness in the back on the one side, above the crest of the ilium, and a corresponding flattening on the other. In front the umbilicus is at the side of the median line. A marked difference in the outlines of the two sides of the back, already mentioned, is seen in this form of curvature. A combination of lumbar and dorsal curves in opposite directions, or compound curves as they have been termed, will present the features of both varieties, but the distortion of the most pronounced curve predomi- nates. Limping. — In severe cases of curves involving the lum- bar region the distortion of the vertebral column is so great that the pelvis is second- arily tilted, and by this one leg is rendered shorter than the other for practical purposes and a more or less marked limp may be caused. Structural and Postural Curves. — Curves will be found to vary not only in their local- ization and their amount of rotation, but also in their ri- gidity. This variation is due to the variation in the amount of structural change. For clinical purposes it is conveni- ent to apply the term struct iiral curves to those with evident changes in the tissues, and pos- tural to iho's,^ curves wdthout definite structural changes. The latter are flexible and easily corrected by the patient's effort, by lying down or by suspension. In the latter, rotation is not a prominent symptom. These curves have also been designated as fixed or habitual. The Xoxvcva primary and secondary curves are also used to define the relative clinical importance or severity of the two curves present. This appli- cation of the term is preferable to the use of these terms to designate the one first formed, as it is impossible to determine this in many cases. Fig. 300.— Left Total Curve Showing Elevated Left Shoulder. LATERAL CURVATURE OE THE SPLNE. 337 Rotation. — As is explained under the head of pathology, it is impos- sible for any curvature to take place in the spinal column without being accompanied by rotation. The prominence of rotation in lateral curvature is a measure of the severity of the case. The amount of rotation may be much greater in some cases than would be expected by the slight amount of apparent lateral deviation of Fig. 301. — Right Dorsal Curvature Follow- ing Empyema of the Left Side. Fig. 302. — Right Dorsal Curve, Showing Ele- vation of Right Shoulder, Prominent Left Hip, and R.otation of Right Chest Back- ward. the spinous processes, as if the vertebras yielded more by twisting under superincumbent weight than by curving to the side. Rotation, as has been shown, is always toward the convex side of the lateral curve ; but in childhood the so-called total scoliosis often shows a general backward prominence of one side. The backward projecting shoulder will often be found on the concave rather than the convex side. This occurs only in a flexible spinal curve, where the compensa- tory curve is not easily recognized or entirely established. It is per- haps the initial stage of the ordinary type of scoliosis, the long curve being afterward divided into two sections. Relative Frequency of Curves — The lateral curvature most com- 22 338 ORTHOPEDIC SURGERY. monly seen by the surgeon is the right convex dorsal curve. To this is frequently added a lower curve with the convexity to the left. If the ■ trunk is displaced to the right, as is often the case in long dorsal curves, the left hip is uncovered and appears more prominent than the right, the reverse being the case when the trunk is displaced to the left. When school children are examined irrespective of symptoms complained of, many postural curves not brought to the surgeon for examination Fig. 303. — Lateral Curvature Due to Empy- ema of Right Chest. Five months after operation. Fig. 304.— Congenital Lateral Curvature As- sociated with Absence of Ribs. are seen. Of these, total curves will be found the most common, and of these, the one with the convexity to the left is the most frequent.' VARIETIES OF LATERAL CURVATURE. Rhachitic Lateral Curvature. — This form occurs in rhachitic chil- dren, but it is not so common a curve as the simple posterior curve which appears as a backward prominence in the lumbar region in so many cases of rickets. In some varieties of lateral curvature there may also be an exaggerated antero-posterior curve due to yielding of ' Liining and Schulthess: " Orth. Chir. ," Munich, 1901, p. 246. — Zeitsch. f. orthopadische Chir., 1902, Bd. x. LATERAL CURVATURE OF THE SPINE. 339 the bones under the unusual distribution of superincumbent weight. It is probable that if cases with rickets were more carefully examined, scoliosis would be more frequently observed. Truslow ' found it in 15 per cent of 201 cases of lateral curvature, and Mayer" found scoliosis in 217 out of 220 rhachitic children. Difference in Length of Legs. — A slight difference in the length of the lower limbs is the rule. But development of lateral curvature directly from this cause is not invariable, as is evident from the fact that in cases of scoliosis a notable difference in the length of the lower limbs is detected, in about the same proportion of cases as in nor- mal children. In children with marked inequality in the length of the legs and with diminished resistance in the vertebral column, sco- liosis will follow. Paralytic Lateral Curva- ture. — In a certain number of cases of paralysis of the muscles of the back lateral curvature of the spine is found. When the muscles of the back are weak, the patient instinctively assumes an at- titude in which the spine is balanced with the least action on the part of the weakened muscles. The curvature may be toward the side of the paralyzed muscles or away from them.^ The bones of the spine may be distorted (if lacking in a power of resistance) by a constant vicious attitude, and a fixed lateral curvature result. This form of lateral curvature is most commonly developed after infantile paralysis, as this is the most common form of paralysis occur- ring in the growing years ; but the effect of other palsies, if influential ' Whitman : " Orthopedic Surgery." ^Bulletin Medical, June 15th, 1901. ^ Arnd : Arch. f. Orthopadie, vol. i.. No. i. Fig. 305.— Left Lumbar Dorsal Curve. 340 ORTHOPEDIC SURGERY. in weakening certain muscles of the back, would be the same, and the distortion may be seen after spastic paralysis, progressive muscular hy- pertrophy, syringomyelia, and other affections weakening the muscles of the spinal column. Torticollis. — Affections causing unequal muscular contraction of the muscles of the back will throw the spine out of balance. In this cate- gory torticollis is to be mentioned, as lateral curvature always follows this affection unless it is corrected. Inequality of vision and hearing Fig. 306.— Severe Curvature due to Rickets. and congenital conditions causing the head to be held to one side (T. Dwight) are possible causes of scoliosis. Lateral Curvature from Contracture of the Chest. — Lateral curva- ture may follow empyema, and some deviation of the spinal column is likely to follow severe forms of empyema. In the purest forms of this type the spine is pulled to one side, the ribs being flattened, i.e., fixed obliquely at a lower angle than normal, from the cicatricial contrac- tion of the kmg which prevents expansion of the lung on that side and leads to an increased expansion on the other. In certain cases the altered position so induced has its effect upon the growth of the spine. LATERAL CURVATURE OF THE SPINE. 341 It has been said that a curvature followed in some instances pneu- monia, phthisis, and organic heart disease. Lateral curvature may follow sarcoma of the ribs and lung.' Lateral Curvature from Occupation. — Any occupation which neces- sitates faulty attitudes for long periods daily, favors the development of spinal curve, but lateral curvatures of severe type due to ordinary oc- cupation are not, as a rule, common, for the reason that laborious occu- pations are not, in general, entered upon until an age when the spinal column has a sufficient amount of resistance to withstand the superim- posed weight without developing great structural change. Slight lateral curves may be seen, analogous to the kyphosis of those employed in occupations requiring stooping. In clerks one Fig. 307. — Severe Case of Spastic Paralysis in a Patient who had never Walked and who from Childhood had Sat to One Side. The patient is now an adult. shoulder is often higher than the other from the attitude of writing, and it is said to be true also in blacksmiths. Severe forms of this class are sometimes seen in adolescents whose occupation habitually twists the spine, as in carrying baskets or trays.' Scoliosis in nursing women, from carrying infants too frequently upon one side, is also recorded, and the same attitude in one-armed per- sons. Scoliosis seen in school children is in reality generally an occupa- tion deformity, resulting as it does from the constant assumption of faulty attitudes, which produce abnormal pressure and strain upon growing spinal columns lacking in structural resistance. Congenital defects in the spinal column with misshapen vertebras ' Boston Med. and Surgical Journal, January loth, 1889. -Zuppinger: Zeitsch. f. orthopadische Chir. , xi., p. 280. 342 ORTHOPEDIC SURGERY. is a cause of congenital deformity, but it is impossible in the absence of reliable statistics to determine how commonly this occurs. Alteration in the shape of the vertebrcz from disease (Pott's disease, osteomyelitis of the spine, and spondylitis deformans) may cause lateral curvature. It may also occur in Pott's disease and sacro-iliac disease as the result of muscular spasm. Ischias scoliotica, referred to also as scoliosis neuromuscularis, or neuropathica or ischiatica, is a term which has been applied to lateral curvature in the lower part of the spinal column occurring in connection with s'^iatica. It is severest in cases in which the lumbar nerves are involved. The curvature may be to the side of the affected nerve, or the reverse, or it may alternate. The condition is most easily relieved by fixative appliances. DIAGNOSIS. A diagnosis of lateral curvature, in a se- vere case, is so simple that an inspection of the patient is all that is required. In the less-marked cases, however, the recognition of the true nature of the de- formity is not so easy, and a careful examina- tion is necessary, not only for the exclusion of other affections of the spine, but also for an estimate of the progress of the lateral curvature and the amount of rotation and bony change in the spinal column. The method of examination of a case of lateral curvature is as follows : The patient's back should be bared in ordinary cases to the level of the trochanters, and the arms should be allowed to hang- free. The most natural attitude in standing should be noted and also the position of the patient in an attempt to stand in as straight a position as is pos- sible ; the tips of the spinous processes are to be marked with a skin pencil, and also the ends of the scapulae. To determine the central line a string, to which a slight weight is attached, is hung from the sev- enth cervical vertebra (to w^hich it can be fixed by a piece of adhesive plaster), the string being long enough to hang below the cleft of the buttock ; or the string should be used as a plumbline to show a perpen- dicular, erected from the middle of the pelvis. In this case it hangs in Fig. 308.— Lateral Curvature due to Infantile Paralysis of Mus- cles of Trunk. LATERAL CURVATURE OF THE SPLNE. 343 the cleft of the buttock, and the deviation of the spine from this verti- cal line can be noted. The distance of the tips of the scapulae (the arms being crossed in front of the chest) from this central line should be measured, and also the distances from this line to the points of greatest curvature of the line of the spinous process. These points be- ing noted, the slope of the shoulders, the outlines of the sides of the trunk, and the contour of the back, as well as any lack of symmetry or unilateral fulness, should be carefully recorded, both when the patient is standing and in the stooping position, with the back well arched. If a side deviation of the line of the spinous processes is observed, a lack of symmetry of outline, or a unilateral projection of the ribs or scapulae, in the erect position, it should be recorded and the patient should be suspended by means of a head sling and also made to lie in a recum- bent position upon the face. A marked alteration of the curvature, contour, or outlines following removal of the superincumbent weight is of particular importance. If the curve disappears under these conditions, it is to be classed as postural. If it does not disappear, it is to be considered structural. The patient should then bend forward with the knees straight and the arms hanging until the trunk is horizontal. In the normal spine the two sides of the back will be on a level when viewed in this posi- tion. Rotation of the ribs or lumbar vertebrae due to structural changes is shown by a greater upward prominence of the side of the back which has rotated backward. This may be measured, if desired, by a plumbline hanging from the angle between the arms of a pair of calipers. This plumbline records the variation from the horizontal in a protractor fastened at the angle of the calipers, or the apparatus (^Nivclliertrapez) of Schulthess ' may be used for the same purpose. The flexibility of the spine should be tested by causing the patient to stand first with one foot and then the other upon a series of blocks half an inch in thickness, and testing what height can be placed under the patient's foot without preventing her from standing upon both legs with the limbs straight, without flexion at the knee; this tests the lat- eral flexibility in the lower part of the spinal column. In testing the flexibility higher up, the patient should be seated on a stool, and one hand of an assistant be placed upon her side, above the crest of the ilium, while the other hand should be placed upon the crest of the ilium of the opposite side. The patient should then be directed to bend sideways toward the side of the higher hand, and the amount of this motion, without tilting of the pelvis, is to be noted. The lateral flexibility can also be readily seen by directing the pa- tient to bend to the side with the hands behind the head and the feet apart, keeping the legs straight and avoiding twisting the pelvis. ' Liining and Schulthess: " Orth. Chir ," jMiinchen, 1901, p 153. 344 OR THOPEDIC S UR G ER \ \ It is not always necessary to examine the front of tlie patient's trunk in the case of older patients. When this is done, the projection of the ribs in front, and the difference in the prominence or flatness of the two breasts, the deviation of the tip of the sternum and of the um- bilicus from the median line are of importance, as indicating the amount of structural change which has taken place. The asymmetry of outline is always to be more clearly seen from the front than from the back of the patient. The strength of the muscles of the patient's back may be tested, if desired, by means of a dynamometer, or spring balance, and the height and weight should be recorded and compared with the normal standard for the age as given. A diagnosis of lateral curvature in the early stage is to be made by Fig. 309.— Measurement of the Rotation of the Ribs in the Horizontal Position \iy the Levelling Trapezium of Schulthess. (Schulthess.) observing in any case an habitual lack of symmetry in the outline of the sides of the trunk and the slope of the shoulders, in the unnatural projection of one shoulder blade or a portion of the trunk on one side or of one hip, and on a constant deviation of the line of the spinous processes from the vertical line. The accidental assumption of a faulty attitude does not justify a diag- nosis of lateral curvature ; but the habitual assumption of such a posi- tion, when the patient stands in the attitude of ease and greatest com- fort, indicates an abnormal condition. The existence of slight grades of lateral curvature is made more evident by allowing the patient to stand for a minute before beginning the examination, in order to obtain the relaxed position due to beginning muscular fatigue. The amount of structural change is indicated by the amount of stiff- ness and by the slight change in the curves and asymmetrical symptoms LATERAL CURVATURE OF THE SPINE. 1 A r" as the patient alters the position by standing, lying, bending, twisting, and hanging. In this way it is possible to determine the amount of progress the distortion has made and the stage of the affection. Lateral curvature is not infrequently confounded with Pott's disease through ignorance of the nature of either affection, both being classed as chronic spinal affections. In pro- nounced lateral curvature, the lateral twist and the rotation are essentially different from the curve of Pott's dis- ease, w^hich is chiefly an antero-pos- terior curve. In the former, rotation is an unmistakable symptom ; in the latter, it is absent or slight. In the slighter cases of lateral curvature the spine is flexible and the lateral curve diminishes or disappears on recum- bency ; and there is never a sharp angu- lar projection. In Pott's disease the spine is not flexible but stiff, the curve is angular, and it does not disappear on recumbency. Lateral curvature oft- en exists in Pott's disease, but is a lean- ing of the whole body to one side and is associated with the signs of destruc- tive disease. Methods of Recording Lateral Curvature. For clinical purposes a careful record of lateral curvature is necessary. In recording lateral curvature it is desirable to note the flexibility of the spine, the curve, and the amount of twist or rotation, as well as the attitude and contour. Photography, if carefully em- ployed, is of assistance.' For this pur- pose the spinous processes should be marked; and a line drawn from the sev- enth cervical spine to the cleft of the buttocks, which marks the median line of the body. The patient if standing should be placed squarely before a camera and photographed with an arrangement of light to prevent strong shadows. The rotation can be photographed if the standing patient stoops and the camera is ' Spelissy : Trans. Am. Orth. Assn., vol. xv. Fig. 310. — Apparatus for Recording' Lateral Curvature. (Feiss.) 346 ORTHOPEDIC SURGERY. focussed on the portion of the back showing the greatest rotation of the spine. A more ready but less reUable means of record can be furnished by the following measurements made and recorded from the spinous proc- esses to the line connecting the two ends of the spine : First, the dis- tances between the line from the seventh cervical spine to the cleft of the buttock and the points of maximum curve of the line of the spines in the upper and lower curve if both exist are recorded ; second, the distance from the spine of the seventh cervical vertebra to the point where the line connecting the ends of the spine crosses the line of curve. A simple apparatus devised by H. O. Feiss, of Cleveland, gives a fairly accurate record of the deformity by means of series of horizontal Ltanf.Su/t.s/tiney f/ Bf. anisu/t.spme iter J^^ n \\ s Fig. 311.— Tracings of a Case. The unbroken line representing the tracings at the level of the anterior superior spines and the broken line the tracing at the level of the tenth dorsal vertebra. (Feiss.) tracings of the trunk at different levels, superimposed on each other in a constant relation to the median plane of the body. The patient stands on a platform, from the back of which projects a square, vertical • upright, upon which slides a horizontal arm carrying at its ends two horizontal arms projecting forward. The patient stands back to the upright, and one horizontal arm is behind him and one is on each side. The anterior superior spines are marked by a pencil. By means of holes in these arms, through which a skin pencil can be inserted, three marks on the patient's skin are now made at the level of the anterior superior spines, one on the patient's back and one on each side. The upright is then pushed up to the level of the greatest deformity, and by using the same holes in the uprights three more marks are made on LATERAL CURVATURE OF THE SPINE. 347 the skin in the same vertical planes as the others. Points are marked in the same way at other levels if desired. Horizontal contour tracings of the back and front of the patient at the levels of the marked points are made by means of a "draughtsman's adjustable rule." The poste- rior lower tracing is taken first and the points on the skin are marked on the tracer, and this tracing is reproduced on paper ; the anterior part of W 28 20 -19 12 -2* Fig. 312.— Apparatus for Recording Lateral Curvature. This machine records the antero- posterior curves, the line of the spine and outline of the body in the lateral plane and the horizontal contour of the back at any level. (Schulthess.) the tracing is then taken and laid out on the paper. The anterior and transverse lines of the apparatus are represented by lines drawn by a T-square. The second tracing is taken in the same way and drawn upon the paper, the marked points being made to lie over the same points in the first tracing drawn. A series of tracings is thus graphi- 348 ORTHOPEDIC SURGERY. cally recorded, which bear the same relation to each other as the con- tours of the patient do at the recorded levels.' Records taken in this way will serve for clinical purposes, but they lack scientific precision, as the possibilities of error on the part of the recorder are too great to be neglected. The methods answer for. the use of a single observer, but not for a comparison of results in the prac- tice of different surgeons. The best and most accurate method of record is that to be obtained by the apparatus of Schulthess. The patient stands in a frame with the pelvis secured, and, by means of a pantagraph working from a bridge sliding up and down in the frame, an accurate record of the lat- eral deviation of the spinous processes, the antero-posterior curve of the spine, and the amount of rotation at different levels is obtained. The apparatus is expensive and complicated." PROGNOSIS. Two errors in prognosis are common. First, that the disease is of the most serious nature ; second, that it is a trivial affection and will be readily outgrown by the patient. The fact is, that in the larger number of these cases the affection is a self-limited one, occasioning slight deformity, which persists through life, causing no trouble and recognized only by the dressmaker or by some near relative. In other cases, however, the disease becomes decidedly worse as the deformity increases, and a pitiable distortion follows, causing a marked deformity and perhaps neuralgic pain. It is impossible to state positively in what instances an increase of the curve will take place and when they can be relied upon to remain stationary. It may, however, be said that when the physical condition during the growing period remains constantly below the proper stand- ard, and when the patient's growth is rapid, an increase of curve is to be apprehended. The decrease or diminution of lateral curvature from simple growth without treatment is not to be expected. Sometimes the disease may remain to a slight extent during girl- hood and early womanhood, developing an increase at a period past middle life. Such cases are dependent upon a loss of general health •and upon trophic changes occurring at this period of life. In determining the prognosis the probable rate of growth is to be borne in mind. This can be ascertained by the patient's height, the hereditary ten- dency toward height as ascertained by the height of the parents and the parents' families. The general opinion is that completion of growth exerts a powerful influence in arresting progress of the curvature. 'H. O. Feiss : Boston Med. and Surg. Journ , 1905. - Liining and Schulthess: " Orthop. Chir.," Miinchen, 1901, p. 147. LATERAL CURVATURE OF THE SPINE. 349 In general it may be said that if a patient has gained full height and development in figure, any increase in growth is not often to be ex- pected, and that an increase in curve is not probable after the osseous system has become thoroughly formed and the strength of the spinal column established. The normal height and weight of male and female are here given for the sake of reference. Table of Height and Weight of the Human Body. Male. Aa-e. At birth 1 year 2 years 3 ■' 4 " 5 " 6 " 7 " 8 " 9 " lo " 12 " 14 " i6 " i8 " 20 " 25 " 30 " 40 " Height in Feet and Inciies. I ft. in. (o, " (o, " (o, " (o 6 10 3 6 8 9 9 8 496 m. 696 ^' 797 " 860 ■' 932 " 990" 046 " 112 ■' 170 " 227 " 282 " 359" 487" 610 " 700 " 711 " ,722 " 722 " 713 " Weight. lbs. 29 33 36 39 44 49 53 57 68 89 117 135 143 150 152 151 ( 3 20 (10 00 ( 1 2 . 00 (13 21 (15 07 (16.70 (18.04 (20.16 (22.26 (24.09 (26 12 (31 00 (40.50 (53 (61 (65 (68 (68 (68 Female. Age. At birth 1 year , 2 years 3 4 5 6 7 8 9 10 12 14 16 18 20 25 30 40 Height in Feet and Inches. ft. 6 in. (0.483 m, 3 " (0.690 " 6 " (0.780 " 9" (0.850" . . .(0.910 " 2 " (o 974 •' 4 " (I 032 " 7 " (1.096 " (I. 4 9 II 139 200 248 327 447 500 562 570 577 579 555 Weight. 6 20 25 27 31 34 37 40 43 50 53 67 84 98 "7 120 121 121 129 lbs. ( 2.91 kgm, ( 9-30 •' (11.40 " (12.45 " (14.18 " (15 50 " (16.74 '• (18.45 " (19 82 '' (22 44 " (24.24 " (30 54 '■ (38 10 " (44.44 " (5310 " (54 46 " (55. oS ■' (55 14 " (58. 45 " 350 ORTHOPEDIC SURGERY. Prognosis under Treatment. Theoretically, lateral curvature is a deformity which can not only be prevented, but if treated in time can be cured. Practically, cases are often brought to the surgeon after structural changes have taken place and the tissues have become resistant. They are often in the condition of cases of humpback after a cure has been established with a persis- tent deformity, ,when a complete rec- tification of the curve is not advisable on account of the severity of the treatment. If cases of scoliosis have little structural change, improvement can always be obtained, and often this can be made a permanent cure. In cases wdth evident structural change in the growing years, diminution of the curve is to be expected to follow thorough treatment. In rigid cases an improvement of condition and car- riage can be hoped for. The pros- pects of treatment are, of course, better when it can be carried on dur- ing the period of growth. Fig. 313. — A Record Made by the Machine Shown in Fig. 312. At the left is the outline of the upright spine. Below are the contours of the back at three dif- ferent levels. (Schulthess. ) PREVENTIVE MEASURES. As faulty attitudes exert an in- fluence in causing lateral curvatures, the avoidance of these is of importance in preventing curves. Attitude at School. — The attitude assumed dur;ng school w^ork de- serves careful consideration, as the injurious effect of improper attitude has been proved by statistics which show the prevalence of curvature among school children, and by the increase of the deformity in school years.' The prevalence of faulty attitudes in school has been shown by Scudder" and others. In an examination of the attitudes of 1,484 school children seated in the schools of Boston and its neighborhood, sixty-seven per cent were found to be in incorrect position at the time of observation.^ An examination of the attitude assumed in waiting by sixty-seven healthy adult males, while writing in a three-hour w^ritten examination, 'Scholder: " Schuleskoliosis." Archiv f. ortliop. Chir., i., 2.— Freeman : Ar- chives of Pediatrics, June, 1904 -Report Boston School House Dept. . 1904. ^ L. M. Towne : " Physical Education Review." LATERAL CURVATURE OF THE SPINE. 351 y t \ J* showed at the end of two hours that in all the paper was inclined slightly, so that the written line formed an angle with the cross axis of the thorax. This angle varied from ten degrees to a right angle. The inclination of the paper was always such that the right upper corner was in front of the left. In a large majority of the writers the left side of the hip was in front of the right, the left shoulder in front of the right, but the left ear Avas usually slightly lower than the right and somewhat behind it. .In all cases, therefore, there was a slight rotation of the spinal column. The trunk in three-fourths of the writers was inclined to the left, in about one-quarter to the right, and in the re- mainder it was held erect. It may be fairly assumed that, if a twist of the spinal column is invariable in writing in strong men, faulty atti- tudes will be equally common in weakly children. School Furniture. In the prevention of scoliosis proper school furniture is essential. Seats. — Chairs used by children rarely support the back muscles adequately, which may be unduly stretched and thereby weakened. Children often assume faulty attitudes simply for the reason that proper support is not furnished the lower part of the back. They are apt to sit sideways, the trunk being sup- ported on one tuberosity of the is- chium. The seat of the chair in which the child is to sit for any length of time should not be deeper than the length of the thighs or higher than the length of the legs ; its back should not be above the shoulders and should be arched so as to fit in the hollow of the back. If this is not done, the large muscles of the back will be unduly strained, as they are inserted into the broad fascia which is attached to the sacrum and iliac bones, and faulty attitudes will be instinctively fig. 3i4.-Diagram of the Adjustable School assumed by the patient. This is 'iSt!:^^^ ^ Tc^^ ""°°"°''" shown if tracings be taken of the back of a child in the various attitudes of sitting, leaning forward, back- ward, and sitting unsupported. The back of the chair should slope backward slightly, forming an angle of 100° to 110° with the seat. The back of the chair should be arched with the convexity forward, the greatest convexity correspond- i 352 ORTHOPEDIC SURGERY. ing to the physiological curve in the hollow of the back. The back of the chair should be constructed so that it will serve as a support to the spine when the child leans backward, and especially to that portion of the back which is in most need of support and subject to the greatest strain, i.e., the lumbar region. The backs of most chairs simply touch the shoulders of children in the upper dorsal region. The following measurements are adapted from Staffel:' I. II. III. IV. 6-9 9-12 12-15 Adult, years. years. years. Height from seat to floor 33 cm. 37 cm. 41cm. 47 cm. Height from seat to middle of lumbar pro- jection of chair 21 " 23 " 25 " 27 " From edge of seat to vertical line drawn from lumbar projection to seat 26 " 30 " 34 " 3S " The writing-table should be at a height proportionate to the height of the person sitting. The distance from the top of the seat to the top Fig. 315 -School-room Fitted with Adjustable School Chair in Use in the Newer Boston Schools. (Report of Boston Schoolhouse Commission, 1904.) of the table should be one-eighth of the height of a girl, and one-seventh of that of a boy. The height can also be determined in the following ready way : The distance from the olecranon of the bent arm to the seat with two inches added should be the distance from the seat to the top of the desk. The edge of the table should be just over the edge of the chair. The inclination of the top of the desk should be a slope of two inches in a breadth of twelve. Adjustable school furniture is of 1 Staffel: Centralblatt f. orthop. Chir., May ist, 1SS5. LATERAL CURVATURE OF THE SPINE. 353 great importance in furnishing to school children suitable desks and seats. The chair adopted by the Boston School Commission after experi- mentation and measurement, and adopted for use in 1903 in all new and refitted school-rooms, is one meeting most of the requirements and one which has proved practically of use.' A chair furnishing support to the back and permitting a change of position without loss of support has been devised by Professor Miller of the Massachusetts Institute of Technology and Dr. Stone, of Boston.'.. Attitude in "Writing. — That the development of scoliosis may be influenced by a twisted attitude in writing would appear from the dif- FiG. 316.— School-room Shown in Fig. 315, Showing Scholars Seated. Cl'ieport of Boston Schoolhouse Commission, 1904.) ferent percentage of spinal curvatures found in different schools in dif- ferent cities, where the oblique and vertical writing are taught : ^ Oblique Writing. Vertical Writing. Per cent. Per cent. Nuremberg 24 15 Zurich 32 12 Munich 24 15 Furth.. 65 31 Wurzburg 28 8 Although too much credence can easily be given to statistics with ' Reports of Boston School Commission, 1903 and 1904. -'Trans. Amer. Orthopedic Assn., vol. xii. ■^ Schulthess : "School Scoliosis," Hamburg, 1903. — Scholder : Arch. f. orthop. Chir. , i., 3. 23 354 ORTHOPEDIC SURGERY. such variation of percentages, it would appear to be probable that in oblique writing especial pains will be needed to prevent a twisted atti- tude in writing. The proper attitude during writing is with the transverse axis of the trunk parallel with the edge of the writing table. The forearms should rest at least two-thirds of their length upon the table. The trunk should be held erect, the legs should be straight before the trunk. School Hygiene and School Gymnastics — ^Proper lighting of school- rooms and the correct placing of blackboards are essential in favoring proper attitudes. The avoidance of long sitting periods by introducing gymnastic exercises and changes of position is of importance.' It is evident that gymnastic exercises are of little benefit if not carefully and efficiently supervised. Correct Carriage. — Faulty attitudes are frequently assumed in walk- ing and in standing, especially by young children. The inclination to stand upon one leg is usually a habit, but in some cases it may be due to a muscular weakness of one limb or of a knee or ankle. The habit is to be corrected by drill or by muscular exercise, and by encourag- ing activity with the necessary constant change of position. Incorrect habits in sitting at home are to be remedied by insisting that the chil- dren with curvature shall not sit curled up or bent over in reading, but that they shall sit in suitable chairs and hold the book correctly. Attitude during Sleep. — The most common attitude in sleep is upon the side, but decubitus upon the back is more common than on either single side. The right side is more commonly lain on than the left, but the difference is slight ; young children and men not infrequently lie upon the belly, but the attitude is not assumed by women or growing girls. The fact that a right-sided decubitus is to be avoided in a right dor- sal convex curve makes these facts of value. In ordinary cases the precautions at night which should be observed are that the patient should not be allowed to sleep with many pillows and that the bed should be a firm one. The child should not be al- lowed to assume a twisted position, but should lie upon the back or the side of the greatest concavity. In threatening cases measures are nec- essary to preserve a proper position. This can be done by means of bed frames, described under Pott's disease. Proper Clothing. — Much has been said about the injurious effects of corsets, and there is no doubt that the muscles of the trunk are weak- ened by the wearing of them.' The injury from compression may be made less by elastic lacings and by the use of waists instead of corsets. 'Report National Committee on Education, Washington, 1S94-95, p. 449- — Ibid., 1S95-96, p. 1 174. -Hutchinson: New York Medical Record, April 27th, 1S89, p. 464. LATERAL CURVATURE OF THE SPINE. 355 That growing girls should be furnished with clothing which does not constrict the trunk needs no argument. The use of side garters, which fasten tightly drawn long stockings to waists dragging upon shoulder straps and shoulders, is to be avoided. This can be done by the use of round garters or attaching the garters to properly constructed .shoulder straps independent of the waist and designed to draw the shoulders backward and not forward. Heavy petticoats should not be attached to waists with shoulder straps dragging upon the shoulders of growing girls. This can be avoided by the use of union suits for underwear and light petticoats. TREATMENT. Several difficulties are to be met in treating lateral curvature. As the affection is active during the period of growth, treatment, to be efficient, must be carried on for a long time, and is tedious to the sur- geon and irksome to the patient. Furthermore, as the disease is one that does not threaten life and is slow and uncertain in its outcome, it is sometimes difficult to enforce the proper treatment for the requisite length of time. Again, danger of increasing deformity varies at differ- ent periods of the trouble, and consequently methods which are neces- sary at certain stages of the affection are not needed at others. Cases will be brought to the surgeon's care presenting varying degrees of deformity and needing different grades of treatment. Cases, how- ever, can be grouped in two classes : I. Those with slight structural change and curves in the main flexi- ble. The treatment of this class is directed to improving the patient's attitude, in the expectation that if faulty attitudes are rarely or never assumed there will be no danger of an increase in the structural changes of the curve. The treatment is e.\i\\&r postural, directed to the forming of correct habitual attitudes ; or gymnastic, directed to strengthening weak muscles and thereby favoring correct carriage. II. Those with structural change and curves which are fixed. In these cases corrective treatment is directed primarily toward correcting existing curves. I. Treatment of Flexible Cases. Postural Treatment. — The postural treatment consists in the cor- rection of faulty habits, the development of weak muscles, and the re- tention of proper attitudes. As a raw recruit is taught the position and carriage of the soldier, so children, if faulty habits of attitude are present, are to be drilled into standing and walking in correct attitudes. This method is suited for the simplest cases of beginning curvature. To be thoroughly carried out, it requires that the patient should daily be exercised in walking, standing, and sitting properly for a specified time under the direction of some competent person. The principles of 356 ORTHOPEDIC SURGERY. the " setting-up " drill of recruits in all armies are applicable, with mod- ifications, to patients of this class. When resting during the hour of drill the patient should remain recumbent. After the drill is over, such precaution should be taken as will prevent the persistence for any length of time of a faulty attitude. This should not be done (out of the drill time) by constant correction, but by the proper arrangement of the play hours and a super- vision of the chairs when reading and studying. Walking, running, and active games should be encouraged, while read- ing, except in proper position, should be discouraged. The treatment is strictly Fig. 317.— Seat Elevated on One pOStural. Side for Changing Lumbar jj^g ^g^j^l ^^^ habits of position are as Curves. . follows : Standing on one leg, sittmg at too low a table, sitting in a twisted position, and sleeping always on one side with too high a pillow for the head. Gymnastics.- — In many early cases the faulty attitudes are clearly the result of muscular weakness. The increase in height has not been accompanied by a corresponding development in muscle. This condi- tion is frequently met in rapidly growing children, and is one of the most common causes of lateral curvature. Here proper gymnastics are indicated, but they should be prescribed and carried out with much care. In the more marked cases the children are unable to bear much exercise without fatigue. Those exercises, therefore, chiefly needed in correcting the deformity should be the only ones prescribed. The usual class-work of gymnasium is to be avoided, as such cases require the individual attention of a competent person, who will see that no faulty position is taken during the exercises. Each case may be regarded as far as exercises are concerned as a separate problem to be worked out individually. Light Gymnastics. — It is not a difficult matter to devise simple and practicable exercises to develop the muscles chiefly at fault, viz., the muscles of the back and loins. The strength of a patient's back muscles can be determined in a ready way by attaching a cord to the front of a cap tied to the head, and fastening this cord to a spring bal- ance. The patient, seated and strapped to a seat at the proper distance from the spring balance, held firmly by an assistant, is directed to bend backward, keeping the back straight so far as is possible. This exer- cise is repeated as many times as advisable. The patient stands with the heels, back, and occiput against a pro- jecting corner (of furniture or doorway), and places the elbows (the arms being flexed) as far back as possible. LATERAL CURVATURE OF THE SPINE. 357 The patient, seated on a stool or chair, should place the feet behind, and on the inner side of, the front legs of the chair, and slowly bend sideways ; the assistant, resisting on the head, determines the strain on the muscles of either side. General developmental exercises for the back, shoulders, and abdo- men, when taken with the spine straight and the carriage of the body correct, constitute the best general scheme for the treatment of such cases. Cases will be seen of such feeble muscular strength that it is advis- able to begin with those which demand the least muscular effort in Fig. 318.— Trunk Bending Apparatus, Raising the Weight and Localizing the Movement. (Schulthess.) maintaining a symmetrical attitude. For these cases exercises with the patient recumbent are desirable, such as the following : 1. The patient lies upon the back with arms at the side, the feet are held, and the patient raises the head and chest. 2. The patient lies on the face and raises the head and chest. 3. The patient takes i and 2 with the arms behind the head and the elbows squared back. 4. The patient lies on the face with the trunk projecting over the edge of a table and the hands on the hip, and raises the trunk to a hori- zontal position. 358 ORTHOPEDIC SURGERY. The same exercises, if repeated with the arms extended above the head, require more muscular effort. If the patient has gained sufficient strength, a series of Ught dumb- bell exercises with bells weighing from one to five pounds can be pre- scribed, carried on with the patient recumbent, similar to those just mentioned. Care should be taken that they are correctly performed. After this, follow light symmetrical dumbbell exercises with the patient standing in a correct position. The work of the patient should be tabulated and carefully graded. This is to be followed by heavier work of the same general type. Heavy Gymnastics. — The method of muscular development by means of the use of heavy weights has been employed with advantage in cases of scoliosis. This was first thoroughly carried out by Tesch- ner, of New York,' and in many cases has been followed by excellent results. The patient should exercise daily with light dumbbells weighing from one-half to five pounds, and three times a week exercises under supervision with heavier weights should betaken. The weight of these heavy bars and bells and the amount of the exercise depend upon the strength, capacity, and endurance of the individual. Each patient is put to his limit of work at each visit, and this limit is extended at each visit. This increase is largely dependent on correctness of posture and precision in the work. Bells weighing from five pounds to twenty and thirty pounds each and steel bars and bar-bells w-eighing twenty-six pounds and upward ■can be used. The exercises are as follows: Bells are pushed from the shoulders above the head alternately as often as the patient's strength permits. The patient swings a heavy bell with one hand from the floor, above the head and down again, the elbow and wrist being fixed and the motion repeated as often as possi- ble in a systematic manner; then with the other hand the same number •of times, and later with both hands. This exerts all the extensor mus- cles from the toes to the head in rapid succession. When a heavy ball is pushed or swung above the head on the side opposite the scoliosis, the action of the back muscles is such as to cause the curved spine to approximate a straight line. A similar result is produced when a heavy weight is held by the side of the erect body on the scoliotic side, the arm being at full length. When a heavy bar is raised above the head with both hands, the patient must fix the eyes upon the middle of the bar to maintain the equilibrium. This necessitates the bending of the head backw^ard, the straightening and hyperextending of the spine, and consequently cor- ^ Annals of Surgery, August, 1S95 ; Orth. Trans. .vol. ix. — Erich: N. Y. Med Journal, October 7th, 1899 LATERAL CURVATURE OF THE SPLNE. 359 recting a faulty position with a weight superimposed. The heavier the weight put above the head, whether with one hand or with two, the more the patient must exert himself to attain and maintain a correct or an improved attitude in order to sustain the equilibrium. When a patient lying supine upon the floor raises a heavy bar above the head so that the arms arc perpendicular to the floor, the weight of the bar, the position and weight of the body, and the action of the muscles tend to broaden the entire back and shoulders, and a Fig. 319.— Paper Jacket, Hinged. (Weigel.) slow downward movement tends to widen the entire chest, and most markedly the shoulders. Pushing the bells above the head, swinging them with each hand and with both hands together, raising a bar above the head standing and lying down, and the exercises above enumerated constitute a day's work. Whether light or heavy exercises are used, persistence is necessary for success. It is needless to add that the patient should exercise under careful supervision, rest being prescribed as a part of the daily treatment, the amount of work being regulated each day. 360 ORTHOPEDIC SURGERY. Asymmetrical Gymnastic Exercises. — Exercises formulated with the expectation of isolating certain weak muscles in the back will, as a rule, be found impracticable, for the reason that it is difificult to deter- mine the weakness of any individual muscle, and because in a lateral curve it is difficult if not impossible to exercise a weak muscle on the convexity of a curve without the danger of exercising also the strong muscle of the compensatory curve. As a rule, symmetrical muscular exercises with the body held as symmetrically as possible are the most practicable in lateral curvature. A few asymmetrical ones may be used if marked difference in the strength of one arm or leg is present, and an increased amount of work can be given to the weaker limb or side. Fixation Appliances. — It is manifest that during the formative period of growth faulty attitudes are to be avoided. Recumbency being inap- plicable for a long period, and gymnastics being possible only for a lim- ited portion of the day, some form of appliance which checks faulty positions is often desirable. Corsets made of plaster-of-Paris, leather, paper, and celluloid, or cloth stiffened with steel, act as supports and limit faulty positions. Weakening of the muscles from the use of such appliances must be combated by systematic gymnastics. These appliances should be re- movable if designed simply as means of preventing faulty attitudes, and are made in the same way as removable corsets for the convales- cent stage of Pott's disease, except that they are modelled to correct certain positions and not to fix the spinal column. In general, support of this sort is indicated when the patient shows no marked improve- ment under gymnastic work, but drops back after each exercise period. It is evident that under these conditions no satisfactory progress will be made without support. When side inclination of the trunk exists to such an extent as to make the lumbar curve the chief curvature, raising the pelvis (by plac- ing an increased thickness under the sole of the shoe on the apparently lower hip, and a pad under the lower buttock in sitting) will serve as partial correction. II. Treatment of Structural Cases. Corrective Measures. — When shortened ligaments and muscles are situated so that they serve as a check to the free movement of the spine, purely muscular exercises are not sufficient for corrective stretch- ing. Gymnastics alone are therefore inadequate as a system of treat- ment in cases of this class, although useful as an adjuvant and as a pre- vention of relapse after correction by other means. It has been proved by clinical experience and by experiments on cadavers that pressure upon certain parts of the thorax — that is, on the ribs — is effective in correcting the distortion of the spinal column in such structural cases. LATERAL CURVATURE OF THE SPLNE. 361 This corrective force needs to be adequately and correctly applied, and is analogous in its aim to the repeated correction used by those train- ing themselves to become contortionists or dancers. It is also true that bending the trunk to the side by force moder- ately applied will often place the spine in an improved and corrected position. Such procedures as these increase the flexibility of the spinal column in the desired direction and make improved attitude possible. It is manifest, however, that if a corrective force is to be beneficial in scoliosis it must be made effective on the curved and not on the normal portion of the spine. The spinal column above and below the curved part where the corrective force is to be applied must be secured ; oth- erwise the more flexible and normal part of the spine will be more affected by the corrective force than will the abnormally rigid, curved, and twisted part. This is true not only of corrective force applied by pressure, but of attempts to correct the curve by posture and exercises which have as their aim the stretching of shortened ligaments. Pressure to the ribs for this purpose should be applied as near their attachment as possible, in order to spend as much of the force as possi- ble in correcting the deviation of the spine and as little as possible in bending the ribs on the spine. Corrective measures are either applied intermittently in the milder cases or continuously in the more resistant cases. Intermittent Correction by Exercises. — These can be given with much precision by means of elaborate appliances devised for the purpose, of which those used by Schulthess are the best. Simpler forms can be employed with benefit if care is exercised in localizing carefully the correcting force. These involve some mechanical restraint of a portion of the patient's trunk and swinging or stretching the rest of the trunk in a direction to straighten the curve. Great care is nec- essary in these exercises, which are flexibility exercises and not prima- rily designed to strengthen the muscles. There is a danger of increas- ing the flexibility of the wrong portion of the column and increasing the compensatory curves. A few exercises of this type may be men- tioned. Any loss or impairment of spine flexibility, local or general, should be remedied, as a normal flexibility in all directions is an im- portant matter. Symmetrical stretching is of use in such cases. As examples of this may be mentioned : 1. Hanging by the arms or suspension by the head in a Say re sling. 2. The patient stands with the head and shoulders in a Sayre sling; the feet are fastened to the floor, and the patient rotates the trunk through a circle, first in one direction and then in the other. 3. Sitting or standing, the patient rotates the trunk from right to left, and then from left to right. 4. The patient hangs from a bar and by a muscular effort rotates the 362 ORTHOPEDIC SURGERY. pelvis and legs, first in one direction and then in the other. This ex- ercise should be done with some force. If round shoulders, contracted chest, or pronated feet coexist with the lateral curve, suitable exercises should be added. As examples of asymmetrical exercises to increase flexibility, the fol- lowing may be men- tioned : 1. The patient sits or stands with the legs apart and bends to the side of the convexity of the curve, or, with the arm of the concave side across the top of the head and the arm of the convex side around in front of the abdomen, the patient bends to the convex side through the ribs and not through the waist. 2. The patient lies on the face with the feet held. With the hands behind the head and the elbows raised, the body is raised and swayed toward the convex side, the pa- tient trying to " puck- er in " the bulging ribs and not to bend in the lumbar con- cavity. 3. The patient stands with the convex side leaning against the padded edge of a table or a padded roll, and bends over the pad which presses against the convexity. 4. The patient stands with the feet apart and, in a right dorsal, left lumbar curve, the right hand is placed against the convexity on the ribs with the elbow out from the side, and the left arm on top of the head or on the left side of the pelvis, according to the position which Fig. 320. — Apparatus to Afford Resistance to the Left Shoul- der, which Pushes to the Left Against the Pad Raising the Weight on the Right Side of the Apparatus. The pelvis is fixed. (Schulthess.) LATERAL CURVATURE OE THE SPLNE. 363 seems to give the best correction. The right hand then presses the convexity to the left, using as much force as possible. Fig. 32i.-Apparatus for the Forcible Correction of Lateral Curvature in Suspen (Weigel.) spension. 5. Remembering that a twist to the right causes a left lateral curve, beginning below above the lumbar region, a twist to the right may be 364 ORTHOPEDIC SURGERY. used as an exercise for antagonizing a curve to the right in that region. The patient sits back to the surgeon, the hands behind tlie head and the elbows squared back, and, while the pelvis is held, twists the head and shoulders as far to the right as possible. The variations to be made in these exercises are many, but compli- cated exercises are undesirable, as it is not possible to analyze their anatomical effect, and the risk necessarily involved in asymmetrical work of inducing or increasing compensatory curves is increased. Such exercises should be given with great care, with the back exposed to view as a rule, and should be followed by a period of rest. In order to make such exercises effective in the spine the pelvis should in all cases be fixed during the exercises. The rules for the simultaneous use of supporting appliances are the same as those given in speaking of flexible curves. Intermittent Stretching by Appliances. — Intermittent correc- ti\'e force may be applied passively for stretching at frequent periods by means of appliances to be men- tioned in speaking of the use of cor- rective jackets. This procedure is advisable when free standing or other exercises need to be reinforced temporaril}" by more accurately local- ized stretching. The same procedure is advisable in many cases as a pre- liminary to the application of cor- rective jackets, in order to obtain beforehand greater flexibility in the direction of correction. Corrective Measures — Continuous Use of Force. — In certain cases the curves are too resistant to be altered materially by intermittent cor- rection. In suitable cases attempts can be made to correct the curves by a method of constant pressure, as it has been demonstrated that the shape of bone is altered by constant pressure. This is shown not only in dentistry in the success in altering the shape of the jaw, in the cor- rection of congenital club-foot with congenital bone changes, but also pathologicallv in the artificial development of structural changes in bone seen in the Chinese lady's foot,' Wullstein's experiments in the ' P. Brown: Journal Med. Research, December, 1903. Fig. ^22. — Corrective Plaster Jacket with Head-piece Applied for the Correction of Scoliosis. (Wullstein.) LATERAL CURVATURE OF THE SPINE. 36; artificial development of lateral curvature already mentioned, in the pro- duction of lateral curvature in different occupations/ and in the altera- tion of the jaw from scar contraction after burns and the alteration of the shape of the face in torticollis. For the application of this method, plaster jackets should be applied to the patient in a corrected or over- corrected position. It is evident that this method of correction is chiefly applicable dur- ing the growing period. Corrective plaster jackets can be applied, as for caries of the spine, with the patient in a standing or sitting position or recumbent, either lying on the face or back. Jackets are applied as for caries of the spine, but much more skill is required, as the amount of correcting force and method of applying require the exercise of judgment. If a good Fig. 323. — Diagram of Plaster Jacket. Fig. 324. — Slipping of Plaster Jacket. deal of force is employed, the patient may be exposed to subsequent discomfort. It is usually preferable to use correcting force without an anaesthetic and apply jackets at short intervals. Suspension or a traction force is manifestly of less value than in caries of the spine, as the affected portion of the spine in lateral curva- ture is always the most resistant portion, while in caries the curve, if in a stage suitable for treatment, is less resistant. The most economi- cal application of force in straightening a stiffly curved stick is by bending it over a resistant pressure rather than b}' pulling each end. Experiments on cadavers show that this is applicable to the human trunk." If the patient is seated or standing, a head sling will be of assistance, with some suspension force to steady the upper part of the trunk. Traction force may be used in the recumbent position, though it is rarely needed. ' Lane: Guy's Hospital Reports, xxviii. - Lovett: American journal of Anatomy. 1904. 366 ORTHOPEDIC SURGERY. The relative advantages of the different positions of the patient in the appHcation of a corrective jacket are as follows : With the patient standing or seated it is much easier to apply the bandage on all sides of the patient than when the patient is recumbent, and for this reason is preferable in applying jackets to the neck and shoulders. In the upright position the position of the head relative to the thorax is that usual in locomotion, while in recumbency an altera- tion in the normal thorax takes place. Recumbently applied jackets are therefore less comfortable to the patients than those applied with the patient upright. If the patient is seated it is easier to correct lordosis or any torsion of the pelvis than if the patient is standing, but in the seated position Fig. 325. — Apparatus (Kyphotone) for the Application of Forcible Jackets in Scoliosis during Recumbenc)' on the Back. (R. T. Taylor.) the surgeon needs to take especial pains in arranging the seat so as to enable him to apply a jacket which will hold the pelvis firmly. Much greater correcting pressure can be applied with the patient in a recumbent position, as the superimposed weight is not an influence to be opposed. In recumbency on the face lordosis can be overcome more readily than if the patient lies upon the back. It is less easy, however, to secure a desirable expansion of the chest and arching backward of the spine in the dorsal region in face than in back recumbency. Where there is much rotation to be corrected, the recumbent position is to be preferred. Where side deviation is the more important feature, the upright position is to be considered also. The simplest method of application of a corrective jacket is for the patient to sit or stand in the centre of a four-upright frame. The head is secured in a head sling with moderate traction. Webbing straps pass from the different uprights and can be made to exert press- ure in different directions as desired. These are included in the jacket, the emerging portions being cut off. A more complicated appliance, with more precision in the application of the force, is one furnished LATERAL CURVATURE OF THE SPINE. 367 with circular steel bands connected with the uprights. From these adjustable bands screw pressure rods can be made to exert pressure on all desired parts of the trunk. In the recumbent position the patient may be placed with the back supported on a frame with uprights similar to that used in the applica- tion of corrective jackets in Pott's disease, except that the pressure points are applied in the back, not upon the transverse processes, but upon the backward prominence of the ribs. Correction of lateral devi- ation can be furnished by horizontal traction, if necessary, or by side pressure. Felt padding is needed over the portions of the body which Fig. 326.— Apparatus for the Application of Plaster Jackets during Recumbency on the Face, are but little protected by fatty tissue ; the plaster bandages should be applied high up under the drooping shoulder and over the shoulder from behind, across the neck. When the plaster is sufficiently hard- ened the patient can be lifted, the detachable plates which are thor- oughly padded remaining in the jacket. A simple method of application of a corrective jacket in an inclined or recumbent position is to secure the patient firmly in the centre of the four-upright frame used for applying a jacket in the upright posi- tion and inclining the whole frame backward. The correcting straps. will need readjustment for proper correcting force when the patient is changed from the upright to the recumbent position. An effective appliance for corrective jackets in face recumbency is in use at the Boston Children's Hospital, devised by Dr. Z. B. Adams. The apparatus consists of a heavy gas-pipe frame, three by four feet. The patient lies face downward on two webbing strips, running from end to end of the frame, with the legs flexed. Near the bottom of the frame is an adjustable crossbar bent to fit into the flexure between the ;68 ORTHOPEDIC SURGERY. thighs and the pelvis, on which the patient rests the lower part of the body. Sliding on this bar are two arms, which slide in and clamp down on the buttocks, holding the pelvis steady on the crossbar. This bar is movable from side to side in order to induce or correct curvature in the lumbar region when necessary. There are three vertical transverse rings, two feet in diameter, fastened to pieces on the sides of the frame LATERAL CURVATURE OE THE SPLNE. 369 so that they can be moved to any desired point along the frame. These rings are also movable from side to side, and by an independent move- ment they can also be rotated through a half circle. Any one of these movements can be checked at any point by turning a screw. The shoulders are held by a pair of axillary straps fastened together by a strap across the chest in front. These straps are suspended from the ring nearest to the top of the frame and can be made to hold the shoul- ders in any desired degree of twist by a rotation of the ring. Each ring is provided with two long screws at the two poles of the ring. These screws are adjustable upon the ring and can be set at an)- desired angle to it. By rotating the ring and adjusting the angle of the 24 370 ORTHOPEDIC SURGERY. screws they can be made to screw down or up upon any part of the back or chest. For the apphcation of the jacket the patient hes on the face on the two webbing strips, the lower part of the trunk resting on the cross rod and the bars clamping the buttocks; the feet rest on the floor and the arms are extended above the head. The rings are then adjusted at the two levels where it is desired to make correction, generally in the dorso- lumbar and the dorsal regions. For side correction a webbing strap is fastened to one side of the ring, carried around the patient's side over Fig. -Lateral Curvature Before Correction. Fig. 330. — Lateral Curvature Three Weeks After Correction. a heavy pad of felt and back to the ring. The same is done to the other ring at the other level where side correction is desired, while the top ring controls the shoulders. The rings are then pulled to one side, the bandages around the patient tighten, and any endurable degree of side correction is obtained. When the side correction is made the screws are then screwed down on to the patient, their points being protected by sheet-iron pads, two by three inches, which are covered with heavy felt. These pads are incorporated in the jacket. The shoulders are controlled by the axillary pads attached to the upper ring along with screw pressure up or down as desired. In the correction each level is separately attacked from below upward. LATERAL CURVATURE OF THE SPLNE. 371 A plaster jacket is applied to the patient held in this way with a great amount of force at the operator's disposal. In applying corrective jackets it is to be remembered that there are two elements of the deformity demanding correction — one, the lateral curve, to be corrected by side force; the other, the rotation, to be cor- rected by a twisting force. Any use of force, to be effective, must be Fig. 331.— Case of Scoliosis before Operation Showing Lateral Deviation of Spine. (Michael Hoke.) met by counter-points of resistance or the whole spine will be pushed to one side or twisted as a whole. High dorsal curves are not likely to be much improved by correc- tive jackets, because no satisfactory point of counter-pressure can be found above the curve. Lumbar curves are also generally better treated by other means, because there are no ribs to exert side pressure on this region and direct side force cannot be exerted. 372 ORTHOPEDIC SURGERY. Corrective plaster jackets should embrace the shoulders and, in cases of high dorsal curves, the neck, and should not be removable. Windows can be cut in the jacket over the portion of the trunk where pressure is undesirable. At first the patient will need supervision, but later can go about freely. Jackets should be repeated at short intervals, preferably two or three weeks, and applied as long as cor- Pig. 332. — Case of Scoliosis Before Operation Showing Rotation. (Michael Hoke.) rection can be obtained. This stage of treatment is followed by that of removable jackets and gymnastic exercise. The amount of correcting force used is a matter of judgment, as is also the time when corrective pressure treatment should be discontin- ued. Supporting jackets are necessary for many months after correc- tion has stopped, and should be discontinued gradually. Adult Cases. — When the bones have become hardened by growth, marked correction is not possible either by intermittent or by constant pressure. The treatment must be palliative and consist of gymnastics, massage or electricity to relieve symptoms, accompanied or not, ac- LATERAL CURVATURE OF THE SPINE. 373 cording to circumstances, by corsets as a partial support to superim- posed weight. Treatment bv Operation. Operative attempts consisting of resection of the projecting ribs, performed by Volkmann in 1889 and Hoffa ' in a few instances, have been made in cases in which the distortion of the ribs resulting from Fig. 333. — Case of Scoliosis After Operation, (ilichael Hoke.) rotation is so severe as to preclude the possibility of correction by other means. The success obtained was not great. Hoke " has utilized this method, carefully executed, as a preliminary to later jacket correction, on the theory that in some cases with marked distortion of the thorax the ribs constitute an impediment to correction of the rotation. The success obtained by Hoke was satisfactory in the case in which the treatment was reported. ^ Zeitsch. f. orth. Chir. , 1S96, 401. ^ Amer. Jour, of Orthop. Surgery, vo!. i.. No. 2. 374 ORTHOPEDIC SURGERY. Braces mid Corsets. — Treatment by the use of spinal braces and spinal corsets alone, other than the temporary use of plaster jackets applied under corrective pressure, is not advisable. These serve only as an adjuvant to other treatment. Summary of Treatment. If the back is flexible and no observable osseous change has taken place and the curvature disappears during suspension or recumbency, the treatment should be postural and gymnastic. The gymnastics should as a rule be "light," symmetrica] work. Asymmetrical exer- cises may form a subordinate part of the treatment. Corsets are needed in the more marked cases where exercises alone do not effect improvement. When the curve is somewhat fixed but fair flexibility remains, the treatment should consist of corrective stretching by gymnastics or appliances and heavy and light symmetrical gymnastics. Supports will be required under the same conditions as those mentioned for flexible cases. In structural cases with rigid curves, gymnastics are of use only as an adjuvant, and corrective force intermittently exerted by appliances and gymnastics or continuously exerted by means of corrective jackets are the modes of treatment to be considered. The latter is the proper method for the severer cases. Severe structural cases have been oper- ated upon with fair success. Severe structural cases in adults are best treated by support, massage, and exercises to secure a better general carriage. The length of time needed for treatment varies necessarily. In general it may be stated that growing children wdth a tendency to faulty attitude need careful inspection during the years of growth. The inspection need not be frequent, and will vary from three months to six months according to the rate of growth. In light cases a few weeks' supervision of gymnastics, followed by monthly or quarterly in- spection, is all that is necessary. In severer cases the treatment will require at first frequent attendance and later, observation for a period of months followed by inspection at longer intervals. CHAPTER XII. OTHER DEFORMITIES OF THE SPINE AND THORAX. Kyphosis (Round shoulders. — Causes.— Symptoms. — Prognosis.— Treatment). — Lordosis. — Spondylolisthesis (Pathology. — Etiology. — Symptoms. — Treat- ment). — Deformities of the Thorax (Pigeon Breast. — Funnel Chest. — Con- genital Deformities).— Congenital Elevation of the Scapula. At birth the spinal column is straight and does not present the physiological curves constant in later life. Physiological curves begin as soon as the child attempts to sit and stand. The cervical curve differs from the others in that it can be obliterated by a change in the position of the head, while the other curves are, after early childhood, in part at least, permanent. These curves var}' according to the habits, occupation, muscular system, sex, and figure of the individual. The normal curves are for- ward in the cervical region, backward in the dorsal, and forward in the lumbar. The limits of movement in the spine are set by the shape of the vertebrae, the length of the ligaments, and the tonicity of the muscles. Muscles weakened by disease, by overuse, by too rapid growth, or from any cause, which are unable thoroughly to do the work expected of them, do not prevent an increase of these curves. The spine is longer in recumbency than in the erect position,' and the amount of this change will be seen by referring to the accompanying table of measurements of the height of eleven people standing, and their length when lying upon the floor on their backs ; ten of these were adults and one was a child. The difference was relatively greatest in the child. Number. I 3- 4- 5- 6. 7- 8. 9- 10 1 1 . Age. 40 38 15 29 30 22 31 35 Heiglit in Erect Position. 5 ft. 6 " 5 " 5 ;■ 5 5 [; 5 5 " 6 " 5 " 3 '■ 8i _3_ 1 1; 8 m Length in Dorsal Recumbency. 5 ft. 6 " 5 " 5 " 5 " 5 " 6 " 5 " 6 " 8^ 9 5X3 Difference. 4 TIT ' T. A. Storey: Am. Phys. Education Review. 1904. :7 5 376 ORTHOPEDIC SURGERY. The term kyphosis is used to designate an increase in the backward dorsal physiological curve, and the term lordosis to describe an increase in the forward physiological curve in the lumbar region. KYPHOSIS. An increase of the backward curvature of the spine, being an exag- geration of the dorsal curve, is most noticeable in the upper part of the spine, although it may practically involve the whole column. It occurs Fig. 334.— Round Shoulders. Curve of dorsal and lumbar regions. Marked forward displacement of shoulder. Fig. 335. — Round Shoulders. Kyphosis involves whole spine. (Round back.) (i) as a static deformity, which is the commonest form seen, and is known as "round shoulders"; or {2) as the result of an abnormal con- dition of the bones or as a result of paralysis. OTHER DEFORMITIES OF SPINE AND THORAX. 177 I. Round Shoulders. The term round shoulders is generally applied to the stooping atti- tude which results from the muscular relaxation due to rapid growth, to the assumption of improper attitudes, and to poor general condition. Fig. 336. — Round Shoulders with Forward Dis- placement of Scapulas. Back comparatively flat. • Fig. 337. — Round Shoulders with Increased Lumbar Lordosis. It is generally seen in children and is likely to be observed at any time after the age of five or thereabouts. Causes. — The affection is to be regarded as a static one connected with improper muscular support. The common causes are as follows: Improper position at school and at home. The stooping position necessitated by improperly fitted school furniture used, by the attitude assumed in writing, and the curled-up position assumed by children in reading at home are important factors in the causation of round shoulders, and what has been said in regard to the causation of school scoliosis applies equally well to round shoulders. Rapid growth, long hours at school, insufficient food, improper 378 ORTHOPEDIC SURGER\r arrangement of clothing, and too long an active day are causes inducing muscular debility and therefore favoring round shoulders. Symptoms. — The attitude of round shoulders is well known and the name itself is descriptive. The head is not carried erect, but is run forward somewhat, the shoulders slope forward, the scapulae are unduly Fig. 338.— Sitting Position in Marked Round Shoulders. The spine is flexible and can be straightened by muscular effort. prominent behind and may be noticed through the clothing in severe cases, and the whole shoulder-joint seems to be forward of its normal position, the chest is narrow and flattened, and the expansion deficient. The lumbar spine may present an increased forward curvature, so that the patient stands with an abnormally hollow back, or the lumbar spine may be involved in the backward curve and the lumbar curve dimin- ished or lost. The patient's trunk is carried back and the abdomen thrust forward. The pelvis is forward of its normal position. Some degree of flat-foot is likely to coexist, and beginning lateral curvature accompanies many of the cases. \\lth the persistence of the attitude of round shoulders the muscles and ligaments in front of the shoulders become shortened and those at the back stretched. The muscular development is generally poor. If OTHER DEFORMITIES OF SPINE AND THORAX. 379 the arms are carried to a vertical position above the head, it is done by arching the spine forward in the lumbar region, which is made neces- sary by the contraction of the muscles connecting the arms and upper chest, such as the pectoral muscles. Pain is not often complained of, but ma)' be present in nervous children, especially girls. The attitude maybe partially corrected temporarily by the voluntary muscular effort of the patient, but the faulty attitude will be again assumed almost immediately, as the muscles are unable to maintain the corrected position. The types of variation in the physiological curves of the spine are described^ under four heads: i. Flat back. 2. Flat hollow back. 3. Round back. 4. Round hollow back. The first two are rather indi- vidual variations from the normal of no especial significance, and will be understood from the figures. The last two are the two variations roughly grouped as round shoulders. Prognosis. — The prognosis without treatment is not good, so far as recovery from the deformity is concerned, and it may be carried over into adult life practically unchanged. With proper treatment recovery is to be expected. Treatment. — In the treatment of round shoulders the patient should, of course, be put in the most favorable surroundings possible. Incorrect Fig. 339. Round Back. Fig. 340. Round Hollow Back. Fig. 341. Flat Hollow Back. (Modified from Stafifel to show onh- upper part of figure.) attitudes at school and at home should be corrected so far as possible. Errors in vision are to be investigated and remedied if they exist. Undue fatigue and a very long active day are to be avoided. ' Staffell: "Die mensch. Haltungstypen." etc.. Wiesbaden. 1SS9.— See Lovett: "Round Shoulders." etc. (with literature 1. Boston Med. and Surg. Journ., November 6th. 1902. 38o ORTHOPEDIC SURGERY. Arrangement of Clothing. — It is a common custom to fasten a child's clothes, including the garters, to a waist which is kept from slipping down by two straps over the shoulders. These straps do not pass over the root of the neck, but most often over the tips of the shoulders, where they obtain increased leverage to pull the shoulders Fig. 343. — Deformity of Shoulders due to the Pressure of Cervical Ribs. (Dr. C. F. Painter.) downward and forward. The constant drag of this not inconsiderable weight upon structures little suited to support it is a most important factor. The arrangement of clothing should be improved and round garters should be worn, and the stockings should not be fastened to the waist. The trousers and skirts should, if possible, be supported by a belt, and the waist to which the clothes are ordinarily fastened should be relieved of as much weight as possible. The shoulder pieces of the waist should consist of two straps passing close to the root of the neck and not running over the tips of the shoulders. In this way the constant drag of the clothing upon the tips of the shoulders will be avoided. In the more marked cases it is some- times advisable to use a support of firm webbing, one inch wide, which runs transversely across the back at the level of the axillary line, passes OTHER DEFORMITIES OF SPINE AND THORAX, 381 through the axilla on each side, and over the front of the shoulders, crossing diagonally in the middle of the back. These straps should be sewed where they cross in the back. To the bottom of these straps may be fastened the clothes, if necessary, and their weight will serve in a measure as a somewhat corrective backward pull.' Gymnastics. — The gymnastic treatment of round shoulders con- sists in stretching the contracted tissues and in drilling the child in the maintenance of a correct position. The stretching can usually be accomplished by simple measures. Suitable exercises for this purpose are as follows : 1. The patient hangs from a bar by the arms. 2. The patient lies on the back with a hard roll under the scapulae, while the arms are extended and stretched by an assistant pulling them above the head upward and backward. 3. The patient sits on a stool with the hands behind the head and the elbows squared, and the elbows are pulled backward while the knee Fig. 344.— Sohulthess' Apparatus for Correctiun of Round Shoulders. (Schulthess.) of the manipulator presses forward against the spine on a level with the shoulders. The restoration of flexibility before giving corrective work is essen- tial. The use of a greater degree of force is sometimes necessary to accomplish the desired stretching. This may be accomplished by the 'J. E. Goldthwaite : Amer. Jour, of Orth. Surg., vol. i., No. i, p. 65. 382 ORTHOPEDIC SURGERY. application of plaster jackets ' covering the shoulders and pulling the shoulders back with any desired degree of force, or by any form of stretching apparatus which pushes the dorsal region forward while holding the shoulders back. As soon as flexibility is restored, postural light gymnastic work directed to the muscles which it is desired to de- FlG. 345.— Apparatus for ytrelchiug uf Round Shoulders. velop should follow. The demands of the cases are not essentially dif- ferent from those of early scoliosis so far as the gymnastic treatment goes, the object in each case being to cultivate a correct attitude. Apparatus (Chapter XXI., 23). — In cases of marked round shoul- ders, when the children are unable to maintain for any length of time a corrected position, some mechanical assistance to the extensor mus- cles is needed. A useful brace consists of a posterior horizontal pelvic band, grasping the pelvis at the level of the anterior superior spines. From this run up, at a distance of one inch or less from the spinous processes, two tempered steel uprights, which are turned out on the flat at their upper ends and terminate just below the root of the neck well toward the axillary line, where they are furnished with an axillary straps, which run through the arm-pit and fasten to a transverse cross- bar on the brace. This brace is furnished with an abdominal band, ' Amer. Tour, of Orth. Surg . vol. ii.. No. 3. OTHER DEFORMITIES OF SPINE AND THORAX. 383 which runs from the upright around the abdomen, to assist in the main- tenance of the correct position. A modification of this brace has been made by Thorndike C Chap- ter XXL, 33), by adding movable shoulder-pieces, so that the patient has a freer use of the arms. Static Kyphosis from Occupation. This type of deformity occurs in adults and in children. In adults it is either the result of a condition acc^uired in childhood carried over into adult life, or it is acquired by some habitual position connected with the occupation of the individual. It is also seen in workmen who carry heavy loads upon their shoulders. The investigations of W. A. Lane ' would seem to indicate that the form of deformity caused by occupation is due, not only to a change in muscles and ligaments, but to a real alteration in the shape of the bones. In the same way, as has Fig. 346. —Patient with Round Shoulders Before Stretching. Fig. 347.— Patient One Month Later After Treatment by Stretching. been seen in scoliosis, the persistence of an exaggerated curve of the dorsal spine in a growing child would be likely to lead to a structural change in the bones, resulting in a permanence of the condition. Round shoulders from occupation are noticed in tailors who sit cross- legged with the spine bent, cobblers who bend over their work, clerks 'Practitioner. May. 1901. 384 ORTHOPEDIC SURGERY. who sit continually bent over a desk, and in men performing heavy work, such as blacksmiths, who work continually bending over a bench or an anvil. The exaggerated curve of the dorsal spine acquired by children who bend over their desks at school is also to be classed in a measure as an occupation curvature. Kyphosis may also occur in (2) Pott's disease, (3) spondylitis defor- mans, (4) scoliosis, (5) osteomalacia, (6) rickets, (7) ostitis deformans, (8) paralysis of the back muscles, (9) old age, acromegal}-, and sec- ondary osteoarthropathy. LORDOSIS. Lordosis is the name applied to the increase of the physiological curve forward in the lumbar region. This exists in various abnormal conditions, and the amount of curve, of course, varies in normal indi- viduals from those who have a very flat back in the lumbar region to those who have a very markedly hollow back. In certain cases in which the individual is perfectly normal, a very marked lumbar curve exists. It is hardly necessary to do more than mention the various ■conditions in which lordosis exists. 1. Lordosis often exists in connection with the kyphosis of the dor- sal spine spoken of in connection with round shoulders ; here it is com- pensatory to the dorsal curve and the result of muscular weakness. 2. Lordosis also exists in pregnant women and often in persons with large abdomens, due to accumulation of fat or to distention, as in ascites and abdominal tumors. In these cases it is simply the balanc- ing of weight by which the centre of gravity is brought over the centre of support. 3. Increased lumbar curve also exists as the result of training in professional gymnasts, especially in backward contortionists. Such persons habitually walk with a marked degree of lordosis. 4. In conditions in which the abdominal or the back muscles are paralyzed, the attitude of lordosis is the result of an attempt to balance the weight of the upper part of the body without bringing a strain upon the muscles. In paralysis of the abdominal muscles lordosis exists. 5. In Pott's disease of the lumbar region apparent lordosis may be one of the first symptoms to be noticed. 6. In cases of double congenital dislocation of the hip lordosis gen- erally exists, because the point of support of the femur on the pelvis is oftenest back of the acetabulum; consequently the pelvis rotates on a transverse axis, carrying the lumbar spine forward. 7. Lordosis exists in many cases of severe rickets on account of the rotation of the pelvis on a transverse axis, as will be described in speak- ing of rickets. OTHER DEFORMITIES OF SPINE AND THORAX. 385 8. In hip disease, in which on account of muscular rigidity or ad- hesions one leg is held in the position of flexion, lordosis is present. In double hip disease with flexion deformity the lordosis may be exten- sive. Contraction of the hip, for any reason, as in infantile paralysis, causes lordosis. 9. Lordosis may exist in coxa vara, both secondary to the distortion at the hip and as another manifestation of the rhachitic change. 10. In spondylolisthesis lordosis is very marked. TreatDicnt.- — The treatment of these curves is necessarily dependent upon the causative conditions and attendant circumstances. SPONDYLOLISTHESIS. The name spondylolisthesis (^-o>(J;j/(^9, a vertebra, and o/.'^t^t^Vj^^, a gliding) refers to a forward subluxation of the body of one of the lower lumbar vertebrae, with the exception of one recorded case in which the upper part of the sacrum was displaced forward. This displacement has ordinarily been described as a dis- location ; in most instances it hardly reaches a greater degree than may Fig. 348.— Small Pelvis of Prague (Median Sec- tion). Instance of slight forward displacement of fifth lumbar vertebra. (Neugebauer.) Fig. 349. — Breslau Specimen. Instance of slight forward displacement of the fourth lumbar vertebra. (Neu- gebauer.) be described by the name subluxation. Even this name is incorrect anatomically, because the body of the vertebrae is chiefly affected, while the laminae and spinous process remain practically in place.' ' Neugebauer: " Spondylolisthesis et Spondylizeme," Paris, G. Steinheil, 1S92. Critical review, description of specimens and cases, complete bibliography. — Kil- lian: "Comment, anat. de Sp.," Bonn, 1853; " Schilderung neuer Beckenformen," Mannheim, 1854. — Blake: American Journal of the Medical Sciences, 1867, cvii., p. 285.— V. P. Gibney: Medical Record, March 30th, 1SS9.— Lombard : Boston Medical and Surgical Journal, August 20th, 1885.— Lovett : Trans. Amer. Orth. Assn.. 1S97. 25 386 ORTHOPEDIC SURGERY. Pathology. — The essential part of the condition seems to be the slipping forward of one of the lower lumbar vertebral bodies, while the vertebral arches remain practically in place. This implies, of course, Fig. 350. — Pelvis of Moscow (Median Section). Instance of extreme forward displacement of fifth lumbar vertebra. (Neugebauer.) Fig. 351.— Specimen from the Museum of KoUiker at Wurzburg, Showing Double Defect of Vertebral Arch. iXeug'ebauer.) an increase in the distance between the body and the spinous process of such a vertebra. The commonest form of the displacement is subluxation of the fifth lumbar vertebra in relation to the sacrum. The displacement of the Fig. 352.— Spondylolisthesis due to Vertebral Disease. (Dr. H. B. Gushing, Johns Hopkins Hospital. I fourth lumbar vertebra in relation to the fifth is next in frequency. The displacement forward of the first sacral vertebra in relation to the rest of the sacrum has been recorded once only (H. von Meyer, Zurich specimen). The displacement may be slight or extreme. OTHER DEFORMITIES OF SPINE AND THORAX, 387 Etiology. — Spondylolisthesis is recorded as affecting women more frequently than men, and comparatively few male cases have been recorded. It occurs almost always at puberty or in young adult life, and the majority of all cases give the account of a severe traumatism, occurring most often during childhood or near puberty. The deformity may follow immediately upon the accident, or it may develop in after- FlG. 353.— Case of Spond_vlolisthesis. Woman, thirty years old. (Breisky.) years, just after puberty or during pregnancy. Other cases are to be accounted for only by frequency of pregnancy or by very hard work. In some cases no assignable cause can be found. Symptoms. — The symptoms by which the diagnosis must be made are as follows : A disturbance of equilibrium resulting in a faulty car- riage, which is shown chiefly by a sharp increase in the lower lumbar curve in even the mildest cases. The spine curves forward sharply from the sacrum, and this gives undue backward prominence to the crest of the ilium and the buttocks. The appearance at first glance is the same as that in cases of double congenital dislocation of the hip. Lateral deviation of the spine may be present. With this lordosis goes 388 ORTHOPEDIC SURGERY. a diminution of the obliquity of the pelvis, which causes flexion of the thighs. Vaginal examination shows, of course, a prominence high up on the posterior wall of the pelvis. The trunk is shortened in relation to the legs on inspection, and the thorax tends to approach the pelvis. The affection is not one characterized by excessive pain. The differential diagnosis must be made from Pott's disease, double congenital dislocation of the hip, and rickets. Rickets must be recog- nized by its general diagnostic signs. Treatment. — The most successful treatment consists in fixation of the lower spine by a jacket or brace until the fracture, if such has oc- curred, has united and the products of the injury have been absorbed; Fig. 354. — Side View of Case of Spond\-l- olisthesis. (Braun v. Fernwald.) Fig. 355, — Back View of Same Case. or, if heavy weight-bearing has been the cause, until the stretched and weakened tissues have resumed as normal a position as possible. This period must, of course, last for months, or in cases of great deformity it would seem as if a fixation support must be permanent. OTHER DEFORMITIES OF SPINE AND THORAX. 389 DEFORMITIES OF THE THORAX. Pigeon Breast (chicken breast, Huhnerbrust, pectus carinatum or gallinatum, poitrine en car^ne, poitrine de pigeon, etc.) is a deformity more or less common in children, characterized by a prominence of the sternum and cartilages of the ribs and accompanied by an increase in Fig. 356. — Traumatic Spondylolisthesis in a Young Man of Eighteen. Fig. 357.— Funnel Chest. (J. S. Stone.) the antero-posterior diameter of the chest and a diminution in the lat- eral. The deformity is generally most marked in the median line, but in many cases the prominence affects chiefly the ribs of one side, mak- ing a unilateral prominence on one side of the sternum. It is due to rickets and is associated often with nasal or pharyngeal obstruction in growing children. It is also seen in a marked degree in dorsal Pott's disease, in which it is due to the sinking forward of the upper dorsal spine, carrying with it the ribs. In slight cases the deformity is prob- ably outgrown spontaneously, but in the severer cases it may last into adult life. 390 ORTHOPEDIC SURGERY. The treatment consists in children in a combination of gymnastic and respiratory exercises to expand and develop the lateral parts of the chest. As a type of these exercises may be mentioned a useful one, in which the patient lies on the back and, with strong pressure made downward on the deformity, deep inspirations are taken. Funnel Chest (funnel breast, Trichterbrust, pectus excavatum, tho- rax-en-entonnoir) is a name applied to a deformity in which the sternum and costal cartilages are depressed below their normal level. The de- FiG. 358.— Congenital Elevation of the Scapula. formity is as a rule asymmetrical, and in its lighter degrees is not un- common. It is more marked in males than in females, and but little is known of the cause of the affection. In many cases it apparently is congenital, and in a mild degree is sometimes seen in connection with Pott's disease. No satisfactory treatment has been formulated beyond general gymnastic measures, among which may be mentioned forced inflation of the chest. Congenital Deformities. — Other deformities of the thorax of con- genital origin need only to be mentioned. Among these are absence or a defective formation of the ribs, a condition generally associated wath lateral curvature of the spine, the presence of cervical ribs, and anomalies OTHER DEFORMITIES OF SPINE AND THORAX. 391 or absence of the pectoral and other muscles. Defective formation or absence of the clavicle has been reported, and malformation of the scapula is sometimes seen. Congenital Elevation of the Scapula (Sprengel's deformity, ange- borener Hochstand des Schulterblattes). — This condition is a somewhat unusual congenital deformity, in which one scapula is raised in its rela- tion to the thorax and clavicle and also to the opposite scapula. The scapula is not only raised, but generally so rotated that its lower angle approaches the spine. Scoliosis is likely to exist in connection with it, and in some cases asymmetry of the face and skull has been noted ; the affection is rarely bilateral.' One or more of the scapular muscles may be absent and bony anomalies are frequent. In one class of cases a bridge of bone connects the scapula and the vertebral column ; in an- other class there is a long piece of bone projecting upward from the superior border of the scapula, but not articulating with or attached to the vertebrae. In other cases there is no bony outgrowth and no defi- ciency of muscles. In some cases the projecting upper border of the scapula is so noticeable in its elevated position that it is mistaken for an exostosis." The etiology is obscure. Certain of the cases are evidently to be classed with other congenital malformations. The theory of intra-uter- ine pressure and the persistence of a position of the scapula natural to a certain period of foetal life have been urged as the cause of some of the cases. ^ In cases seen during childhood extensive division of the shortened muscles holding the scapula in its abnormal position is to be advised, and the removal of any bony bridge or projection. Marked improve- ment may thus be obtained. In older cases no operative treatment is advisable.^ ^ Centralbl. f. Chir. , 1902. -Wilson and Rugh : Annals of Surgery, April, 1900. ^Hibbs and Correll — Lowenstein : Zeitsch. f. Orth., xi., i, p. 40. ■* Freiberg: Annals of Surgery, May, 1889. CHAPTER XIII. TORTICOLLIS. Definition. — Etiology. — Pathological anatomy. — Symptoms. — Diagnosis. — Prog- nosis. — Treatment (Mechanical. — Operative). DEFINITION. The name torticollis is given to that distortion of the head which causes it to be held awry, and this condition is either constant or inter- mittent. The other names by which this affection is known are wry -neck, caput obstipum, collum distortum, cou tortu, Schiefhals. ETIOLOGY. Torticollis may be congenial or acquired.' I. Congenital Torticollis. {a) It may exist in connection with other deformities, such as club- foot and similar malformations. In these cases it seems proper to at- tribute its existence to those intra-uterine conditions causing other de- formities. {b) Abnormal pressure of the uterus seems to be accountable for another class of cases in which the cranium and face on the affected side are smaller at birth. {c) Amniotic adhesions are spoken of as a cause. (d) Inflammation of the muscles seems to be proved by the patho- logical findings in certain cases and must be mentioned as an occasional cause. {e) Arrest of the development of the muscles due to an affection of the nerves or nerve centres must be spoken of as a cause often ad- vanced to account for torticollis.^ (/") Rupture of the sterno-mastoid muscle occurring at birth has ^ Trans. Am. Orth. Assn., iv.. p. 293. — P. Redard : " Le Torticolis," etc, Paris, 1898 (full bibliography). -Osier: N. Y. Med. Journ., December 12th, 1S91.— Golding Bird: Guy's Hosp. Rep., 1890. — Shaffer: Trans. Am. Orth. Assn.. vol. iv., p. 305. 392 TORTICOLLIS. 393 been mentioned ' as a cause of torticollis, and undoubted cases have been observed where torticollis has followed partial rupture of the sterno-mastoid at childbirth. Experiments, however, upon rabbits producing hrematomata of the sterno-mastoid gave negative results. Furthermore, torticollis has not followed the hsematomata from rupture of the sterno-mastoid at birth in a number of cases carefully watched by several observers. (V) Imperfections in the atlas and cervical vertebree have in some reported cases been the cause of congenital torticollis. 2. Acquired Torticollis. As the causes of the affection may be mentioned : {a) Cicatricial contraction of the skin or deeper tissues. {b) Traumatism to the neck and head. ( Goldscheider : Zeit. f. klin. Med., xxiii., 1893, p. 494. — Dauber: Zeit. f. Ner- venlieilkunde, vol. iv. — Siemerling: Arch. f. Psychiatric, xxvi., 267 (with literature to 1894). ■■ Von Kahlden : Cent. f. Path., September 14th, 1S94 (Charcot's view). ANTERIOR POLIOMYELITIS. 409 columns of Clarke disappear and the anterior nerve roots become smaller than those of the other side. Atrophic changes soon take place in the paralyzed limb. Some- times the atrophy affects the bones, which become shortened even to the extent of affecting the length of a limb by several inches. At the same time the affected limb grows comparatively smaller in circumfer- ence than that of the opposite side. This is frequently the result of Fig. 368. — Anterior Poliomyelitis. Chronic stage; section through sixth cervical segment ; diminution of anterior gray matter and of entire half of right side. (Sachs.) retarded growth rather than of real wasting, but both factors at times enter into the change. In other instances, even in severe cases, the bones seem but little affected, while the atrophy of the muscles is very marked. The epiphyses are stunted, and the ligaments become thin and loose, and dislocations and distortions of the joints are favored. It is in the muscles that the most notable changes are found. These waste rapidly and become flabby to the touch, and microscopic examination shows a loss of striation followed by a granular degeneration of the fibres until little is left beyond muscle corpuscles and fat granules con- tained in sarcolemma. This, of course, is clearly more than the atro- phy of disuse.' That poliomyelitis represents an acute inflammatory condition of the anterior gray matter of the spinal cord is conceded on all sides, but the question arises what the origin of such inflammation may be. The only satisfactory explanation at the present day is to suppose that the inflammation is the result of an acute infection which happens to be located in the spinal cord, just as other infectious diseases show a predilection for other sites in the body. The microbic origin has not yet been satisfactorily demonstrated, but all the clinical facts point toward this view, and the close dependence of the myelitic process upon the distribution of the blood-vessels lends further color to this theory." ' Gowers : "Dis. of Nervous System," vol. i..253. — Jacob v. Heine: Loc. cit. ^ Sachs: "The Nervous Diseases of Children," New York, 1S95. 410 ORTHOPEDIC SURGERY, SYMPTOMS. In general the clinical history of the disease falls into three stages : {a) The onset, to which stage belong the acute febrile symptoms and the development of paralysis. (b) The stage of convalescence, which begins at the time of the full development of the paralysis, and is followed by a brief stationary period, and finally rapid and then slower improvement until a stationary period is reached. (<:) The stage of deformity, in which wasting of the affected limb is present and static, paralytic, and contraction deformities have super- vened. No arbitrary subdivision of the classes of symptoms will be made, because in reality the stages run into each other so gradually that it seems unjustifiable to divide them practically. Infantile paralysis is oftenest ushered in by a mild or severe febrile attack, which presents no definite characteristics to distinguish it from any ordinary attack of cold or indigestion. The elevation of tempera- ture is not excessive, commonly from ioo° to 102° F., sometimes even 104°. With this fever are apt to be associated vomiting, convulsions, giddiness, or other cerebral disturbance, sometimes even delirium. Older children complain of pain in the back and limbs. There is, as a rule, no warning of the attack, although Seeligmiiller has noted at times a disinclination to walk or stand as much as usual for some days preceding — a fact quite in accordance with Lange's theory that over- exertion of the muscles has much to do with the production of the dis- ease. Convulsions may be present, and when they occur they are usually followed by a period of unconsciousness. The feverish attack at the onset may, however, be very severe, at times lasting two or three days (or even weeks) before the paralysis appears. More commonly, however, it is very slight and scarcely noticed. In certain rare cases, two or even three attacks of fever are noted, each followed by an in- crease in the paralysis. Pain of a rheumatic character in the back and limbs is a common initial symptom. In certain cases all feverish and other symptoms are absent at the onset, and the child is suddenly dis- covered to be paralyzed in one or more limbs. Such paralysis comes on oftenest in the night, but it has been observed to come on quietly in the daytime, while the child was at play. In these cases there may be no succeeding illness, and the paralysis is the only symptom through- out. Diarrhoea, vomiting, general hyperaesthesia, and much nervous irri- tability are other symptoms which often accompany the onset of the paralysis. During the first few days there may be paralysis of the blad- der with retention or incontinence of urine, but it disappears after a ANTERIOR POLIOMYELITIS. 411 few days or weeks. Pain is a symptom but little noted in infantile paralysis, but it is not uncommon, nor does it indicate of itself the presence of any additional pathological process. The paralysis itself very quickly becomes manifest and reaches its maximum within a few hours of the attack, or within a day or two, except in rare cases. Having reached its maximum and remained sta- tionary for a short time, improvement almost invariably begins. In rare cases improvement begins immediately after the attack and pro- ceeds to complete recovery. These are the cases which are spoken of as " temporary spinal paralysis." The more common course is for the paralysis to remain nearly stationary for a time varying from two to six weeks, and then to improve, at first rapidly and then more slowly, for three or four months. After six months have passed, further sponta- neous improvement is unusual. Vascular changes become very marked. The temperature of the limb is much lower than that of the other. The limb is generally blu- ish, with a superficial stagnation of the blood, on account of an atrophy of the blood-vessels and consequent diminution of their calibre, and when the blood is pressed out of the surface capillaries by the finger it returns slowly. On account of this vascular sluggishness ulcers may form, which are slow to heal and very painful. The limb even very early loses its normal appearance, and the flaccid undeveloped look of the foot or hand is most noticeable. Atrophy of the affected muscles begins to be perceptible a few weeks after the onset of the paralysis, while the loss of striation in the muscular fibres can be detected with the microscope within two or three days of the attack.' The muscles may be tender to the touch during the time that they are wasting so fast, especially in adults and older children. Muscles seriously affected are toneless and flaccid from the first, and in the late stages of wasting scarcely any volume of muscles seems left when the limb is grasped with the hand. The paralysis is a purely motor one, and although tingling and for- mication may be present, sensation is very rarely affected. The reflexes are abolished in the affected limb if the implication of the extensor muscles of the thigh be enough to do away with the knee jerk of the affected side. Sometimes after an attack the paralysis may seem to be general, but the probabilities are that after improving in general, the loss of power will eventually be localized in one limb, and that if one limb orig- inally is paralyzed the likelihood is ver}' great that a certain amount of power will be regained, leaving only certain groups of muscles perma- nently paralyzed. ^H. W. Berg: Wood's " Ref. Handbook." vol. v., p. 504. 412 ORTHOPEDIC SURGERY. Distribution. — The paralysis in its distribution is monoplegic in about half the cases, as the tables taken from the cases of Duchenne, Seeligm tiller, Sinkler, and Starr will show: Both legs, 170 One leg, 246 Both arms, 6 One arm, 47 All extremities, 47 Arm and leg, same side, 33 " opposite sides, 8 Trunk 26 Three extremities, 12 595 The great preponderance of paralysis of the lower extremities is to be noted, and the liability to paralysis increases even from the thigh to the foot, and when improvement begins in a case in which both an upper and a lower extremity are paralyzed, the improvement begins first in the arm. Commonly certain groups of muscles are attacked, and when adjacent muscles are affected they seem to be selected at random oftener than by functional or anatomical association. In the leg, the extensors and the peronei are the muscles oftenest affected. The glu- tei are never affected alone, but they commonly share in any extensive paralysis of the leg.. In the arm the deltoid suffers oftener than any other arm muscle, either alone or in association with other muscles. The " upper-arm type " of paralysis, which Erb has described, consists of the simultaneous affection of the deltoid, supra- and infraspinatus, the biceps, and the supinators. There is also a "forearm type "de- scribed by Remak,' in which, as in lead paralysis, the extensor muscles of the hand are paralyzed while the supinator longus is spared. The serratus magnus is sometimes affected as well as the trapezius and pec- toralis major. The neck muscles are very seldom affected and the mus- cles supplied by the cranial nerves only rarely. The muscles of the back may be paralyzed and the patient be una- ble to sit erect, or lateral curvature may result — a state of affairs often made worse by allowing the patient to sit erect while the muscles are still weak. The diaphragm is occasionally paralyzed. In those rare cases of paralysis of the abdominal muscles, the patient leans back to a very marked degree, missing the restraining action of the abdominal muscles. There are, finally, cases of universal paralysis in which death soon takes place from interference with respiration. The sequelae of the disease are few. ^Remak: Arch. f. Psych., Band ix. , 1S78-79, p. 510. ANTERIOR POLIOMYELITIS, 413 Deformities. — The deformities whicli come on after infantile paraly- sis are late events in the history of the disease and rarely develop until at least some months after the attack. They are, as a rule, progressive in their character and the end results are often such extreme distor- tions that the affected limb is useless. The deformities fall into two chief classes: (i) deformities due to trophic changes, such as bone shortening, etc. ; (2) deformities due to muscular paralysis. (i) The first class is comparatively unimportant; shortening of the paralyzed arm or leg may take place with atrophy of the bone in every direction, so that a liability to fracture is of course a necessary conse- quence. Shortening of the arm is comparatively unimportant in itself, but shortening of the leg is likely to induce lateral curvature of the spine from the necessarily tilted position of the pelvis ' due to the un- equal length of the legs. (2) The deformities of the second class, which are the result of muscular paralysis, are manifold and form the great bulk of the cases of deformity in anterior poliomyelitis. As a rule they do not appear earlier than two or three months after the onset and more commonly not for many months. For clinical consideration they fall into two groups: deformities caused by contraction, and deformities due to laxity of the muscles and ligaments. Volkmann, on the ground of Hiiter's investigations, ex- plained nearly all the deformities on mechanical grounds, urging that the deformities were developed partly by reason of the weight of the limbs concerned and the position which they assumed when at rest, and partly because of the muscular insufficiency of the affected limbs which allowed the articular surfaces to be subjected to an excessive pressure when brought into use, which had the effect of gradually pressing them into abnormal position. The earlier idea had been, however, that they were brought about by the unopposed action of the muscles which were not affected. Probably both factors are active in the causation of de- formity. A word should be said in regard to the reason of the more severe affection of the anterior leg and thigh muscles than of the posterior muscles in nearly all cases. The theory has been advanced that, after a paralysis of the leg, the limb lies flaccid and nearly powerless, the toes drop, and, if the sitting posture is assumed, the knees flex and the legs hang heavily down. As a result of this, the anterior muscles are always pulled upon and slightly stretched, while the posterior ones are lax. If all the muscles are equally affected, this very factor may be enough to make a great difference in the ultimate usefulness of the two groups. Stretched muscles are notoriously at a disadvantage, so far as 'Bradford: "Etiology of Lateral Curvature," Boston Med. and Surg Jour, 1886, cxiv. 414 ORTHOPEDIC SURGERY. recovery goes, in any diseased condition, and muscles at rest are much more favorably situated. So that this very point may determine in a measure the relative amount of recovery in the two groups. Moreover, muscular contraction and consequent deformity occur only in cases in which a muscle has been allowed to remain for a long time in a shortened or stretched condition. For this reason it is highly important to support and restrain the affected limb in a normal po- sition (the foot at a right angle to the leg, etc.). The common deformities from infantile paralysis which come to the orthopedic surgeon for treat- FlG. 369.— Kyphosis in Advanced Paralysis of the Back Muscles. Fig. 370. — Infantile Paralj'sis. Contract- ures of right leg. (.Weigel.) ment are those of the lower extremity. Considered in detail, it is best to begin with deformities at the hip-joint and then to pass on to the consideration of knee-joint deformities and distortions of the foot. Deformities of the Leg. — Paralysis may be complete and a flail-like leg be the result, with wasted muscles and loose, distorted joints, inca- pable of motion or bearing weight. Such a limb is spoken of as " jambe de Polichinelle." But more commonly the paralysis is partial rather than complete. ANTERIOR POLIOMYELITIS. 415 The muscles of the thigh commonly affected are the internal and ante- rior groups. This constitutes a serious combination and renders walk- ing difficult ; not only is the leg abducted with a tendency to eversion, but the extensor thigh muscles cannot hold the knee rigid as is neces- sary in walking, the leg giving way whenever weight is put upon it. The glutei are generally implicated in this paralysis, and the contraction Fig. 371. — Paralj'sis of the Left Leg-, with Talipes Equinus and Involvement of the Internal Rotators and Abductors of the Leg, Resulting in a Position of Abduction and Eversion. which is likely to result from this paralysis is flexion of the thigh alone or with abduction of the leg, a condition always associated with flexion of the knee and talipes equino-varus. Flexion deformity at the hip produces in time a most marked lordo- sis in the back. When the patient stands with the leg dangling, the weight of it drags upon the pelvis and rotates it on a transverse axis, a compensation which makes it possible for the leg to hang as nearly as possible perpendicularly. This deformity is marked and troublesome. 41 6 ORTHOPEDIC SURGERY. At the knee, contraction in the flexed position (with often a ten- dency to subkixation of the tibia backward) is found, and in the more severe cases decided knock-knee. At other times when laxity rather than contraction predominates, hyperextension of the knee is observed and sometimes lateral mobility also exists. In severe cases of this type Fig. 372. — Severe Double Paralysis with ^larked Knock-knee and Distortion of Feet. This patient was unable to walk. in which the deformity has been rectified by mechanical or operative means, the tibia lies in a plane decidedly posterior to that of the femur. The same may be said of the knock-knee which results from the greater prominence of the internal condyle of the femur. The flexion may have been overcome, but still a decided degree of knock-knee may re- main in the corrected leg. Hyperextension of the knee may also increase to a very marked degree and is commonly associated with talipes valgus. This hyperex- tension results in cases in which the anterior muscles are weak and fail to hold the knee extended when walking is attempted. In these cases the patient throws the weight of the body upon the fully extended knee ANTERIOR POLIOMYELITIS. 417 and the strain falls upon the ligaments rather than on the muscles. The posterior ligaments yield in time to this repeated weight and the patient obtains for a time a better bearing. The same deformity is favored by a tendency which these patients have to lean with the hand upon the knee when rising from a chair. There is a tendency to outward rotation of the tibia upon the femur in cases of long-standing paralysis of the leg. In this case the eversion of the foot in walking is a troublesome complication. Inasmuch as paralyses of the anterior tibial muscles and the peronei are the most frequent,' the deformities that one sees oftenest are talipes Fig. 373.— Hyperextension of the Left Knee due to Paralysis of the Limb. Varus deformity of the right foot. equino-varus, or, if the peronei are intact, talipes equinus. Pure talipes varus from this cause is not common. It will be seen that hyperextension of the knee is favored in cases in which talipes equinus exists, as by that means alone the foot can be placed flat on the ground. Talipes calcaneo-valgus and pure flat-foot are favored by lax liga- ments, and the latter may be a progressive deformity, which increases until a stage is reached in which the inner malleolus almost touches the ground and the foot can be flexed until the dorsum touches the skin ' Ross: " Dis. of Nerv. Syst. ," William Wood & Co., 187S, p. 942. 27 4i8 ORTHOPEDIC SURGERY. over the tibia. The bearing of body-weight on a foot, the Hgaments and muscles of which are weak, tends to produce flat-foot. Pure talipes calcaneus seems to be the result of the paralysis of the posterior calf muscles combined with the action of gravity and super- incumbent weight. What is known as pes cavus is more common than pure talipes cal- caneus. The order of frequency of the different forms of deform- ity from anterior poliom}-elitis is as follows : (i) talipes equino- varus; (2) calcaneo-valgus ; (3) equinus; (4) calcaneus or pes cavus. Deformities of the arms are not common as the result of infantile paralysis. The least infrequent of these results from the paralysis of the deltoid. In addition to the inabilit}' to raise the arm from the side, there are present a flattening of the shoulder and a prominence of the acromion process, and the shoulder presents an angular rather than a rounded outline. The ligaments are loosened, and the arm hangs loosely, so that in some cases a wide gap may be observed between the acro- mion and the humerus. An}- distortion of the arm and hand further than the flaccid condition resulting from the paralysis is quite rare. If con- traction does occur, it follows the type to be seen in adult hemiplegia : flexion of the elbow, hand, and fingers. The commonest paralysis of the hand is one affecting the adductor muscles of the thumb, as a re- sult of which the thumb is drawn back to a level with the other fingers and the power to oppose it to the other fingers in grasping is thus lost. Infantile paralysis of the sterno-mastoid muscle is recognized as an occasional cause of wry-neck. Paralysis of the intercostal muscles rarely causes deformity, but Gowers saw a case in which a permanent depression in one side of the thorax resulted from such a paralysis. Fig. 374. — Paralysis of Both Legs, Severest in Right. Knock-knee and flail-like legs. This patient was unable to walk without crutches. ANTERIOR POLIOMYELITIS. 419 Paralysis of the erector spinas muscles results in a permanent arching- of the spine and inability to sit erect. Paralysis of the abdominal mus- cles causes lordosis. Lateral curvature of the spine results from infantile paralysis in one of three ways : (i) From the inequality in the length of the legs (due to paralysis of one leg), causing tilting of the pelvis. (2) From the unilateral paral- ysis of the muscles directly controlling the vertebral column, which might be either a paralysis of the intrinsic spinal muscles or of the erector spinae group on one side. (3) From faulty spinal attitudes as- sumed in consequence of some paralysis elsewhere, as in paralysis of one arm, or of the serratus magnus, or even of the sterno-mastoid. These cases have been more particularly considered under the head of lateral curvature. Dislocations from Infantile Paralysis. — Dislocation, complete or partial, belongs to the more uncommon of the complications of infantile paralysis and characterizes severe cases. Dislocation of the hip is the one most commonly met and it takes place either spontaneously or in consequence of weight being borne Fig. 375.— Paralysis of the Back Muscles, Causing- Saddle- back Deformity. upon a limb which is improperly supported by its ligaments. It occurs chiefly in cases in which the paralysis is severe and of long standing, and it may disable the leg on account of the laxity with which the femur articulates with the pelvis. A shortening of one or two inches may be present, as the dislocation is generally on to the dorsum of the ilium ;, 420 ORTHOPEDIC SURGERY. but sometimes it takes the form of a laxity of the joint in all directions, so that the head may be thrown into any position by manipulation of the shaft. Most dislocations of the hip are inconvenient chiefly be- cause of the shortening and insecurity which follow the displacement of the head of the bone. But the head of the bone in a year or two becomes often quite firmly fixed in its new position, and such legs are some- PiG. 376. — Paral\-sis of the Left Arm Muscles, Del- toid and Serratus Magnus. Fig. 377.— Moderate Degree of Talipes Valgus, Right Foot. times nearl)' as serviceable as they were before. Dislocation may, however, occur before any weight is borne upon the affected limb, by the spontaneous action of the muscles, as in a patient eighteen months old, in the experience of one of the writers, in which dislocation of one h^p took place at the age of three months. In this case the dislocation was reduced under an anaesthetic, and by the application of a plaster- •of-Paris bandage the head of the femur was permanently retained in the acetabulum. These dislocations are rarely attended by much pain and are often overlooked by the parents. Laxity of the knee-joint, so that the joint surfaces slip by each other in the motions of the joint, is a less common affection, but is sometimes seen. In these cases the joint is subluxated at each step. ANTERIOR POLIOMYELITIS. 42 1 The subluxation of the tibia in severe cases of knee flexion and the dislocation of the shoulder after paralysis of the deltoid muscle have been already mentioned. DIAGNOSIS. In typical cases the diagnosis of infantile paralysis is not difficult. But in other than typical cases the recognition of the disease may be extremely difficult, and it is never easy to establish a positive diagnosis in the initial stage. At that time the occurrence of localized pain may be a misleading symptom, and sensitiveness of the affected limbs may suggest rheumatism. The occurrence of convulsions and unconscious- ness may divert the attention to the brain, and all sorts of side issues may be suggested by the manifold symptoms of the onset of the disease. The affection is often wrongly classed as cerebrospinal meningitis at the earliest stage, as the head is sometimes drawn backward in severe cases. The diagnostic points upon which the practitioner must rely are the sudden onset, a motor paralysis, rapid muscular wasting, the distribu- FlG. 378.— Talipes Varus, Right Foot. tion of the paralysis (mostly monoplegic and very rarely hemiplegic), and the loss of the tendon refiex. Diagnosis by the determination of the electrical reaction of the muscles requires especial training and skill, although it is distinctive and the most reliable test at our command. Electrical Condition of the Muscles. — The electrical reactions in infantile paralysis are clearly marked and characteristic when they can 422 ORTHOPEDIC SURGERY. be obtained. Faradic irritability of the affected muscles and nerves begins to diminish within a day or two of the onset of the paralysis, and in muscles severely affected the electric irritability disappears entirely ; in the muscles less seriously involved it is merely diminished. This constitutes a valuable symptom in prognosis, as in muscles which are completel}' parah-zed faradic irritability is permanently lost by tJie sec- ond week. But even in later years it may be possible to find in such muscles a trace of irritability to the faradic current by thrusting a hy- podermic needle into the muscular substance and transmitting the cur- PlG. 379. — Flexion Deformity of the Hip, Knee, and Ankle, due to Contractions. Fig. 380.— Dislocation of Hip, the Result of In- fantile Paralysis. In this position the head of the femur (left) is in place, but with ab- duction it slips out again. rent through that. But the change in reaction to the galvanic current is even more important. Normally when this current is passed through ner\'e and muscle, a quick, sharp muscular contraction takes place at the opening and closing of the current, and the muscular contraction ANTERIOR POLIOMYELITIS, 423 should be greater at the closing of the negative pole than when the positive pole is closed. The cathodal closing contraction should be normally greater than the anodal closing contraction. When nerves and muscles affected by anterior poliomyelitis are examined, not only a Fig. 381. — Same Case as Shown in Fig. 380, with Hip Dislocated. Fig. 382. -Old Paralysis of Left Leg- with Slight Knock-knee and Talipes Varus. slow wave-like response to electricity instead of a sharp quick jerk is found, but the electrical formula is reversed and tJie closure of tJie posi- tive pole gives the greater contraction. In general a much stronger gal- vanic current is needed to produce a contraction in these paralyzed muscles than in normal ones. These qualitative and quantitative changes in reaction to the galvanic current constitute what is known as the "reaction of degeneration," and this affords the most definite ground for the diagnosis of infantile paralysis. But such an examina- tion to be of any value requires practice and special skill in the use of electricity. In young children the examination often yields no results even to a specialist in nervous diseases on account of the child's con- stant activity, and although it is the most definite means of diagnosis that we possess in obscure cases, its use is attended with many difficulties. 424 ORTHOPEDIC SURGERY. The only affection which may not be distinguished by electrical ex- amination from anterior poliomyelitis is peripheral paralysis caused by interruption in the course of some nerve. DIFFERENTIAL DIAGNOSIS. The leading points which are to be depended upon in the differen- tial diagnosis are these : Infantile paralysis is purely a motor affection and sensation is never permanently impaired. The reflexes are gener- ally diminished or lost. Wasting is rapid and extreme and the leg is cold and blue in severe cases. The " reaction of degeneration " is pres- ent in electrical examination. Cerebral paralysis generally begins with a sudden onset, and often convulsions are present and the child is found to have lost the use of one side of the body. It differs from infantile paralysis in these points : its distribution is hemiplegic and facial paralysis is common, the tendon reflexes are increased from first to last, faradic excitability is not lost, and the galvanic formula is normal ; later the intelligence is generally affected and atrophy is neither so marked nor so rapid as in infantile spinal paralysis, but similar contractions of the joints of the affected limb come on. These contractions are, however, often spastic in char- acter. Allusion must be made to the importance of electricity in mak- ing a differential diagnosis, which is often attended with much difficulty. A hemiplegic distribution of infantile spinal paralysis is rare, but cases have been reported in which the facial nerve was involved.' Table of the Differextial Diagnosis of Infantile Paralysis and Cerebral Paralysis. Age. Onset. Distribution of paralysis. Rei^exes. Electrical reaction. Mental ment. impair- Infantile Spinal Paralysis. Sharply limited to children in first dentition. Sudden, but severe convul- sions not often present. Oftenest monoplegia or para- plegia ; rarely involves fa- cial nerve. Lost generally. Faradism, diminished or lost. Galvanism, formula reversed (reaction of degeneration). Absent. Spastic condition absent. Cerebral Paralysis (HemipleT^a). Not sharply limited to young children. Sudden, and severe convul- sions generally present. Hemiplegia ; generally involv- ing facial muscles on one side. Increased. Faradism, normal. Galvanism, normal. Likely to come on. Spastic condition of one or both lears often follows. Progressive muscular atrophy in childhood is a very rare affection, but it has been observed, sometimes beginning in the legs. Its onset Henoch: Loc. cii., p. 203. — Barlow: Loc. cit., p. 76.— Seeligmiiller. ANTERIOR POLIOMYELITIS. 4^5 is gradual, and the faradic excitability remains so long as there is any muscular substance left and the galvanic formula remains normal. The reflexes are not lost until all muscular substance has gone. Acute transverse myelitis of the dorsal region causes paralysis of the legs when it occurs, but unless the lumbar enlargement is involved there is no loss of electrical irritability. Reflex action after a day or two is much increased and ankle clonus can be obtained. There is generally paralysis of sensation, and bed-sores develop with much ra- pidity, while any wasting is very gradual. There is no change in the electrical formula. A paralysis much like that in anterior poliomyelitis has been de- scribed by Bullard following cerebrospinal meningitis } In such cases pain and tenderness of muscles persist longer than in infantile paraly- sis. There is a tendency to spastic contraction in the early stages, which becomes less later. The knee-jerks on the whole are less affected than in infantile paralysis ; they may, however, be absent en- tirely. Diphtheritic paralysis may offer serious difficulty in diagnosis, be- cause anterior poliomyelitis may occur in the course of a diphtheritic attack as in any other infectious disease. The paralysis of diphtheria affects oftenest the muscles of the palate and fauces, the electrical reac- tions remain normal, and severe atrophy is not present. Pseiido-hypertrophic paralysis in its early stages is not likely to be confused with infantile paralysis, for it is generally characterized by much increase in the size of the muscles, which is extensively distrib- uted and comes on very gradually and is not accompanied by any marked electrical changes. Late in the affection marked muscular atrophy occurs, but it is generalized and the history would clearly differentiate the condition from anterior poliomyelitis. Paralysis may result from lesions of a peripJieral neive, as in instru- mental delivery at childbirth, from tight bandaging, etc. But its dis- tribution is limited to a single nerve or group of nerves, and it is char- acterized by a concomitant affection of sensibility. The electrical reaction would be the same as in infantile paralysis. The so-called rhacJiitic paralysis might offer some difficulty of diag- nosis. But it occurs in the acute stage of rickets and is not a paraly- sis so much as a disinclination to use weak and tender limbs. It is accompanied by general tenderness and to a certain extent by the diag- nostic signs of rickets, the reflexes are normal, and its onset is more gradual. It is, however, so early a complication of rickets that its recog- nition may offer difficulty. Infantile paralysis of one leg may produce a limp in gait which sug- gests congenital dislocation of the hip, but only on a superficial exami- ' Boston Med. and Surg. Journ. , vol. i., p. 159, 1S99. 426 ORTHOPEDIC SURGERY. nation. In congenital dislocation the trochanter would be above Nek- ton's line, atrophy would be very slight, and the electrical reaction normal. With hip disease, infantile paralysis is at times confounded in prac- tice. The onset of the paralysis may be accompanied by joint pain and tenderness, and, on the other hand, hip disease is accompanied by mus- cular atrophy and a modification of faradic irritability of the muscles. But the distinguishing feature of hip disease is muscular fixation, and that is not present in infantile paralysis, in which muscular laxity is the prevailing condition. The onset of hip disease, although generally gradual, may at times be apparently sudden. PROGNOSIS. So far as danger to life is concerned, the outlook in infantile paraly- sis is very favorable, for few patients die in the acute attack. When death does occur it is generally at the end of a week or ten days. Con- tinued cerebral symptoms, however, are of grave significance. In cases in which the deformity is only of moderate extent, it is not probable that life will be shortened by it. It is not likely that the paralysis will increase if it has been station- ary for twenty-four hours. Second attacks are very rare, and when they do occur, they come on within a day or two of the original attack and are made evident by an increase of the existing paralysis. The tendency of the paralysis, as we have seen, is toward improve- ment and partial recovery. The law of Duchenne suggests a more exact prognosis in the fact that all the paralyzed muscles in which the faradic irritability is only more or less diminished, but not completely lost, during the course of the second week, do not remain permanently paralyzed, the restoration being more prompt and complete the less the faradic irritability has been diminished. In general, when the faradic irritability is lost at once, paralysis will be severe and to a certain ex- tent permanent. When the irritability is lost later, the paralyzed mus- cles will improve slowly and nearly recover. When faradic irritability is not lost at all, recovery will take place in a few weeks or months. W^ithout the use of electricity one has to wait much longer before giv- ing any more definite prognosis than a general promise of improve- ment. When untreated, a case of infantile paralysis will almost invariably improve for one or two months at a rapid rate, then more slowly for two or three months more, and then after a stationary period, contrac- tions, looseness of the joints, and malpositions are likely to begin, which may increase indefinitely. Under treatment the prognosis is much more favorable and the limit of possible improvement extended by many years. ANTERIOR POLIOMYELITIS. 427 It should be remembered that even in mild cases of infantile paral- ysis bone shortening' may follow. Certain severe cases escape with but little, while a mild case of talipes valgus may show, with the wasting of the leg', a shortening- of one or two inches in the limb of the affected side, or, in exceptionally severe cases, shortening of several inches. A large measure of success in the orthopedic treatment of infantile paralysis in the stage of deformity can be expected in a large percen- tage of cases, exclusive of the hopeless class where a large portion of the body is permanently paralyzed. If correction of the deformity, mechanical treatment, massage, dry heat, and all practicable use of the limb aided by apparatus be begun at as early a stage as possible, devel- opment of the strength of many muscles not completely paralyzed, but weakened from disuse after the original onset of the disease, can be expected, materially benefiting the patient. This can be supplemented if necessary by tendon transference or arthrodesis. By thorough sur- gical care what would be a condition of hopeless affliction can be con- verted into a slight or endurable disability. TREATMENT. The treatment of infantile paralysis varies according to the stage at which treatment is to be undertaken, and is either stimulative to check the paralysis, or corrective to prevent or improve deformity. For the latter purpose it is either mechanical or operative. The Stage of Onset. — If the fact that paralysis is present is estab- lished during the febrile attack, which is usually the first symptom of the disease, vigorous treatment should be at once begun, to limit, if possible, the destructive process in the cord. Cathartics should be given at once, the patient should lie on the side or the belly, to prevent stasis of the blood in the spinal cord, and counter-irritants or cups should be applied over the spine. Ergot should be administered in doses of ten drops of the fluid extract, three times a day, for infants of six months, and half a drachm for children of one or two years. Bro- mide of potassium and of sodium and strychnia are recommended. The general condition of the child should in every way be kept as good as possible. Antipyretics may be indicated. The Stage of Paralysis. — But few cases are seen by the surgeon until the stage of paralysis is present, when treatment by medicine is manifestly of little avail. The question that then presents itself is in regard to the treatment of the paralysis, in order that the ultimate amount of muscular power may be as great as possible. It must be remembered that the tendency of the paralysis is at first very strong toward spontaneous improvement. It is therefore manifest that in the first few weeks treatment should be directed toward producing condi- 42 8 ORTHOPEDIC SURGERY. tions which shall be as favorable as possible for that improvement to attain its maximum. The object of treatment in this stage should therefore be, first, to support the affected limb in a normal position, and most carefully guard against the stretching of joints and ligaments and muscles; and, sec- ondly, by the use of electricity, massage, and systematic exercise to keep the nutrition of the affected muscles in the best possible condi- tion. In this way only, by beginning the treatment at the first, can the best possible ultimate result be obtained. It has been seen that what may be called protective treatment should be begun at once, and from the first the diseased limb should be placed and retained in a normal position, so that the affected muscles and joints maybe supported and kept at rest and relaxed. In this way the enfeebled muscles are placed under the best possible conditions for their recovery. To allow attention to be diverted from these very important measures to pursue a medical treatment whose utility is doubtful, is manifestly irrational. In paralysis of the legs the feet should be supported from the first at a right angle, in their normal posi- tion, by some simple splint or similar appliance, and the weight of the bed clothes should be kept off of the toes. The appliances needed to maintain in a proper position the limbs of a patient with paralysis will vary according to the parts affected and will demand some ingenuity on the part of the surgeon. In severe and extensive cases light bed frames may be very useful to allow the patient to be carried about, while retaining the limbs in a proper position. So far as possible in such cases bandages should be avoided, and straps should be used instead, as the surface circulation is feeble and likely to be impeded by bandages. When the arm is paralyzed, a sling should be worn to prevent drag- ging of the arm upon the shoulder-joint ligaments and the weakened deltoid muscle, or, if the deltoid is chiefly affected, the arm may be sup- ported on a frame holding it at right angles to the trunk. Electricity is a most useful therapeutic measure in the early stages of the paralysis. Treatment should be begun as early as the spinal irritation seems to have disappeared, probably about the end of the first week, and continued indefinitely, but not to the exclusion of proper mechanical treatment. The galvanic current is used ; a very gentle cur- rent is passed through the affected muscles and nerves for a few min- utes each day, and muscles which contract only feebly to faradism should be daily stimulated by the application of the faradic current. ^Muscles which will not contract to faradism can sometimes be much improved by applications of the interrupted galvanic current. The chief use of electricity, it is to be remembered, is to stimulate to con- traction the paralyzed muscles, thereby affording a sort of gymnastics. ANTERIOR POLIOMYELITIS. 429 Probably electrical treatment receives much cieclit in the treatment of this disease, which is not improperly clue to it, for it is employed at a time when marked improvement is almost certain, and very much the same results can be obtained by methods about to be considered. One sees cases in which it has ceased to benefit the child and has been per- sisted in to the exclusion of more rational treatment for that especial case. But even in the late stages of the disease, when wasting and deformity have come on, the use of electricity may at times lead to an improvement of nutrition. Dry warmth and rubbing are measures which seem of equal, if not of greater, value in the stage of simple paralysis. Heat is easily ap- plied by having the child sit in front of a fire or stove with the leg Fig. 383.— Clawed Toes and Pes Cavus following Infantile Paralysis. thrust through a hole in a sheet of pasteboard. This serves as a screen to the rest of the body, while the affected member is allowed to become thoroughly warmed once or twice a day either in this way or by a hot- air oven. During the day, especially in cold weather, the paralyzed limb should be protected by two thick stockings and a warm boot. Any treatment which stimulates the circulation of the paralyzed limb aids in its recovery by improving the nutrition of the muscles, and dry heat very effectually accomplishes this end. A paralyzed leg should be thoroughly heated for an hour before it is rubbed at night. Massage is another most important element of treatment in this as in any stage of infantile paralysis after the initial irritation has quieted down. Skilled massage, when it can be obtained, is of course better than friction at the hands of the parents, but the latter is a simple and efficient treatment, which lies within the reach of most people. In the place of the usual manual massage, mechanical massage of the limbs has been employed by means of carefully constructed appli- ances. This, however, will be within the reach of but few. 430 ORTHOPEDIC SURGERY. Active muscular exercise of the paralyzed limb is a most desirable tonic to the affected muscles, however it is obtained, provided the mus- cles be not overtaxed. With the assistance of the parent's hand, a foot which naturally drops forward from paralysis of the anterior leg mus- cles can be flexed, and with each repetition of the exercise the muscle may be found able to accomplish more. It is impossible to lay down any series of exercises. In each case the problem must be met differ- ently. The aim should be so to assist the affected muscles that if they have any power left they may be enabled to use it daily for their own advantage. And with this in view, assistance should be rendered by supporting and aiding the affected limb in its movements in the way most likely to call into use these paralyzed muscles. Such exercise forms a most useful adjunct to the massage. It should be repeated each night just before or just after the massage. H. L. Taylor, in an excellent paper on the hygiene of reflex action, says : " In the neuromuscular degenerations following acute anterior poliomyelitis, it is especially important to restore to the paretic extrem- ities, so far as possible, the stimuli of locomotion and other normal associated movements without the inhibition of insecure footing and strained tissues— and it is for the specific purpose of restoring to the damaged cord and muscles the cutaneous, muscular, and articular stim- uli of locomotion that apparatus is constructed." Mechanical Treatment. The mechanical treatment of infantile paralysis is twofold in its ob- ject. The first and simplest use of apparatus is to support and protect the paralyzed limb in such a way that the muscles shall work to the best advantage and that the joints may be supported and controlled. By doing this the occurrence 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. The second function of mechanical treatment in infantile paralysis is to overcome by means of suitable appliances deformities which have already occurred and to prevent their recurrence ; it may often be nec- essary to attempt both objects with one apparatus. The Indications for Mechanical Treatment. — Whenever a paralyzed limb is unable to bear the weight of the body which falls upon it in locomotion, some mechanical help is manifestly advisable. This is not only needed when the paralysis is complete, but also when, owing to incomplete muscular strength, more strain is borne on the articular lig- aments than is normal. Moreover, when the bearing of the body-weight or the act of walking throws the foot or the leg into any abnormal po- sition, the use of some appliance is indicated. It is difificult to describe ANTERIOR POLIOMYELITIS. 43 1 the various appliances needed in the treatment of infantile paralysis^ and much must be left to the ingenuity of the surgeon m each case. Paralysis of the Leg. — When the muscles of the leg are paralyzed, those which help to control the ankle-joint in standing and walking are rendered inefficient and the ligaments may become relaxed, so that in the standing position the ankle of the affected side cannot sustain the body-weight as it should, and the foot is apt to roll in or out, causing an inversion or eversion of the foot amounting to a degree of talipes varus or valgus. In any apparatus which is to sustain the foot in its weight-bearing function, accuracy of support is indispensable, and a simple leather boot, however stout it may be, soon yields and the foot slips away from the rest of the apparatus, and the efficiency of the brace is impaired ; a rigid sole is, therefore, essential for any apparatus which is to control the ankle properly, and this can easily be accomplished by having a thin steel plate inserted between the layers of the sole of the boot. When no contraction or deformity exists at the ankle, but there is simply a tendency of the front of the foot to drop on account of the affection of the anterior muscles of the leg, locomotion can be made much more easy by preventing this. A common appliance for this lat- ter deformity is an ordinary shoe fitted with lateral steel uprights and a posterior steel calf band (Chapter XXI., 28). There is a right-angle stop catch at the ankle which keeps the foot from dropping. The same end can be better accomplished by the application of a walking appliance, described under club-foot as an equino-varus shoe,, which should be provided with a right-angle stop at the ankle which will not allow the ankle to be extended to more than a right angle (Chapter XXL, 37). When in bearing weight upon the leg the ankle assumes a varus position, a varus shoe will correct the tendency to de- formity (Chapter XXI., 30). If the foot rolls out and is everted into a valgus condition when the body weight is borne upon the leg, an outside shoe is to be applied, in construction like the varus shoe, but which should have a broad leather strap which should pass around the inner malleolus and support it (Chapter XXL, 31). This apparatus is a difficult one to render quite comfortable to the patient, as much weight must necessarily come upon the strap which supports the inner malleolus. As flat-foot is almost always present in these cases, it is well to arch the steel sole plate of this apparatus so that it serves as a valgus plate as well as a support- ing appliance. If calcaneus is present the apparatus spoken of for equinus is used, with the stop catch reversed to prevent dorsal instead of plantar flexion (Chapter XXL, 39). Pes cavus may be treated by inserting a steel sole in the sole of the 432 ORTHOPEDIC SURGERY. boot and passing a strap from the sole over the dorsum of the foot. This treatment is made much more efficient if combined with prehmi- nary division of the plantar fascia. Mechanical treatment alone is likely to be unsatisfactory. Talipes calcaneus may be treated by fixing the foot for months in a position of talipes equinus by means of a plaster bandage. At the end of this time a shortening of the muscles at the back of the leg will be found.' It is manifest that the simpler and lighter these appliances are and the less unsightly, the more serviceable they will prove. For this rea- son they should be carefully fitted and the uprights made to follow the outline of the leg. In very slight cases, in which there is only a slight eversion of the foot with a small degree of valgus, a common valgus plate (Chapter XXI., 32), such as would be applied for flat-foot, will often answer every purpose in correcting the deformity, and it should be applied as in simple flat-foot. In severe cases of paralysis of the muscles of the legs and foot, the thigh muscles may be involved. The same appliance will often have to support the knee and thigh as well as to correct deformity at the ankle. But this involves merely an extension of the apparatus up the leg. Paralysis of the Thigh Muscles. — When the muscles of the thigh are involved in the paralysis, the limb becomes unable to sustain the weight thrown upon it and the knee flexes and the limb drops forward Avhen weight is borne upon it. The knee-joint does not bend to one side or the other, as the lateral ligaments retain much strength. In a few instances the knee will drop backward to more than a straight line, but, owing to the strength of the crucial ligaments in infantile paraly- sis, it never falls so far back as to be unable to sustain weight. For the practical purposes of locomotion, therefore, it is only essential that the knee be prevented from dropping forward, and this can be done by means of any appliance which will press the knee backward. The sim- plest way of doing this is by the use of two steel rods reaching from the back of the thigh to the bottom of the shoe (Chapter XXI., 25), connected at the top by a posterior steel band, which furnishes a coun- terpoint of pressure by which to hold the knee. If a strap is passed in front of the knee, it is impossible for it to drop forward when weight is thrown upon the leg, and the patient can stand upon the limb. The appliance supplies the check normally exercised by the muscles. Be- low it should be fitted to a boot, or, if the muscles of the leg are also involved, to one of the appliances such as the varus or valgus shoe men- tioned above. Instead of being applied by means of a steel sole plate, the appara- tus may be fastened to the sole of the boot (Chapter XXI., 26). In ' Gibney : Medical News, 1900, Ixxvii., 399. ANTERIOR POLIOMYELITIS, 433 addition to the bands shown in the figure, leather lacings to retain the thigh and calf will probably be needed to give the apparatus greater stability, as the lacings, by covering a large area of skin, substitute sur- face pressure for the point press- ure given by narrow straps. This is a matter to be considered in all supporting apparatus. Fig. 384.— Supporting Splint for Infantile Paralysis of the Leg. Fig. 385.— Supporting- Splint for Use in In- fantile Paralysis. It prevents ilexion of the knee in standing, but is provided with a lock-joint at the knee. If the knee tends to drop backward and become hyperextended, it can be remedied by a similar appliance with a strap passing behind the knee, with an upper band encircling the thigh. In practice this appa- ratus can often consist of a single outside upright hinged at the knee. It passes to the inside of the leg just below the knee to become attached to a varus shoe. This answers as well as a double upright in 28 434 ORTHOPEDIC SURGERY. many cases. The apparatus can be hinged at the knee for convenience in sitting down and should be furnished with leather lacings for the thigh and calf (see Figs. 384 and 385). Other cases, in which the paralysis is more severe, require the two uprights, as they furnish a more definite support. The foot is easily Fig. 386. — Jacket Attached to Caliper Splints Applied to a Case of Paralysis of the Trunk aud of Both Legs. retained to the steel sole plate by straps or a piece of leather lacing over the instep. The fenestrated knee cap is the most comfortable method of holding the knee extended. Although in walking it is generally necessary to have the knee kept extended by the splint, yet in sitting down it is a great comfort to the patient to be able to flex the knee, and for this reason nearly all splints should be hinged at the knee. A great variety of hinges can be applied at the knee with different catches, enabling the patient to bend the limb b}^ loosening the catch or locking it when it is desired that the limb should be stiff. The sim- plest and most economical of these is the simple drop catch shown in the figure. When the limb is straightened, the ring falls down and ANTERIOR POLIOMYELITIS. 435 locks the splint in the extended position, but it can ])c pulled up at any time, allowing the knee to bend. In another and more expensive form the splint is self-locking, and the bending is made possible by pressing a handle at the outside of the knee. When the adductor muscles are affected, little or nothing can be done to supplement them by mechanical means without employing heavy apparatus, inasmuch as their loss of power occurs only in exten- sive paralysis. Little can be done to remedy paralysis of the glutei muscles, but when paralysis of the legs appears to be complete, a cer- tain amount of relief may be given by attaching the leg uprights to a leather or silicate jacket. The common Thomas knee splint (Chapter XXI., 14) may be joined to a leather jacket (Chapter XXI., 3) by lat- eral uprights jointed at the trochanters. The muscles of the back are rarely if ever paralyzed, except in con- nection with palsy of some of the muscles of the leg. Complete paral- ysis of the muscles of the trunk indicates an extent of disease which is most distressing. When the muscles of the back are but partiall}-- affected, help may be afforded by the use of corsets or other supporting appliances, such as are employed in the deformities of the spine. These can be connected with the leg appliances and will afford assist- ance in standing. Cases of this sort may be so severe as to require the use of crutches for rapid locomotion, but much assistance may be afforded by appliances in many cases. The abdominal muscles are sometimes, though rarely, affected, giv- ing a protuberant abdomen and a position of much lordosis in standing. Waist bands or corsets will serve to correct the malposition of the trunk to a certain extent. The mechanical treatment of infantile paralysis of the arm is not a question which arises often enough to make it worth while to enter upon any discussion of it, save to mention that the principles of treat- ment are the same as those already considered. The use of elastic bands to supply the place of the disabled muscles is thought in some instances to be sufficient to compensate for the action of the paralyzed muscles. It will, however, be found that an elastic support, inasmuch as it is not of certain tension, is necessarily a varying support and adds to the complicated nature of the appliance rather than to its efficiency, nor is it possible to gauge accurately the force or pressure exerted at any time. It is generally, therefore, a much less efficient form of apparatus than the rigid forms here advo- cated. Mechanical Treatment as Applied to the Correction of the Deformity. — Whether the deformity shall be corrected by purely mechanical means or by operative interference depends not only upon the nature 436 ORTHOPEDIC SURGERY. of the distortion, but also upon the time at the disposal of the patient and surgeon. Many of the distortions of this sort can be cured in chil- dren without any operative interference, as all that is required is the stretching of the fasciae and the contracted tendons. These distortions are either flexions at the hip or knee or some distortion of the ankle. The less severe of these distortions yield readily upon the application of efficient force. Deformity at the hip, which is generally flexion, with perhaps abduc- tion, is the hardest of all the deformities of infantile paralysis to correct by mechanical means, on account of the difficulty of securing a fixed hold upon the pelvis, by which a point of resistance can be secured in overcoming the flexion of the thigh. A simple apparatus which is often of use is furnished by two caliper Thomas knee splints (Chapter XXI., 15), or one, as the case may be, attached to a leather jacket by side irons hinged opposite to the hips. To the posterior and upper parts of the splints are attached straps which buckle to the back of the Fig. 3S7. Fig. 38S. Pigs. 387 and 3S8.— Supporting- Apparatus in ParaU-sis of Anterior Thigh Muscles. jacket, and while by the jacket as firm a hold as possible is taken on the pelvis, when the straps are buckled the caliper splints pull the legs backward and tend to overcome the flexion at the hips. During this time the child should go about on crutches. But the contraction is sometimes resistant, and it is necessary to confine the patient to the bed and to employ traction of a considerable amount and such measures as have already been described in correc- tion of the flexion deformity of hip disease. ANTERIOR POLIOMYELITIS. 437 Attempts to use the weight oi the leg to correct this flexion in se- vere cases are of little use. It might be imagined that if the knee were straightened by a ham splint, and the patient allowed to go about on crutches with the leg projecting in front of him, the weight of it by- dragging upon the shortened tissues would stretch them and the flexion at the hip would be dimin- ished. But the leg hangs almost perpendicu- larly in these cases, owing to a compensatory lordosis in the lumbar spine, which takes place at once. This is due to the rotation of the pelvis upon its transverse axis, which occurs under the influence of the weight of the leg and which oc- casions no inconvenience to the patient. A sim- ilar proceeding occurs when a weight is applied to the patient's leg lying in bed, so that it be- comes inefificient also. In the severer cases op- erative treatment is indicated. Flexion of the knee is due to a contraction of the hamstring muscles. The deformity in chil- dren, except in severe cases, can be corrected by bandaging the leg to a splint which takes press- ure above on the under side of the thigh and below is fastened to the heel. The appliance is similar to that described above as a support to the knee. In resistant cases some pain is expe- rienced in this procedure, but the pain is not great. Patients with severe deformity should be confined to bed during the application of this method of treatment, but in the milder cases they may be allowed to go about. The simplest of all forms of correction in contraction of the knee is the Thomas knee splint (Chapter XXL, 14) or a modification of it, but jointed splints will be found convenient in some instances of the sever- est type. If the Thomas knee splint is applied, a bandage should be applied in front of the thigh and behind the calf; by tightening these a decided extension force is exerted upon the knee. A more complicated brace for correction of the knee is one similar to the simple supporting brace with two uprights already described (Chapter XXI., 26), except that it is jointed at the knee and furnished on one side with a worm screw and ratchet, so that by the use of a key the splint can be set with any desired angle at the knee. A leather knee cap is sometimes necessary to obtain counter-pressure against the knee in front, but in other cases the thigh and calf lacings are sufficient to obtain any desired leverage. These leather lacings should fit with Fig. 389.— Splint with Sin- gle Upright for Infantile Paralysis of Right Leg with Varus Deformity of Ankle. 43 S ORTHOPEDIC SURGERY. especial accuracy in this form of appliance. To be applied the splint should be flexed to fit the contracted knee and put on and laced firmly. Then with the key it should be extended nearly to the point of endurance and worn as straight as it can be borne for an indefinite time. At first these sub-joints may prove sensiti\'e and painful, but they soon become used to the tension and then rapid progress can be made. The exten- sion of a contracted knee may in the case of an adult be a matter of many months, but in children it requires less time, unless it is severe, when operation ma\" be required. The deformity shows a strong ten- dencv to recur when the apparatus is removed. Correction b}" the repeated application of plaster bandages to the knee, extended as much as possible, will often be found satisfactory and pamless to the patient. This can be facilitated by inserting a hinge joint in the plaster at the knee, and b}" cutting awa}' the plaster around the leg at the Ie\'el of the hinges it may be used as a straight- ening appliance. The method, however, is a slow one in resistant de- formities. Deformities of the Feet. — The mechanical correction of deformities of the foot caused by infantile paralysis is so much more tedious than Avhen operative measures are used that the majority of surgeons much prefer the latter method. In the less resistant cases, however, correc- tion of paralytic cases can be effected by plaster-of-Paris bandages re- peatedly applied to feet forcibh' held in as near a corrected position as possible. Slight paralytic deformities of the feet can also be corrected by fixing the feet in the walking appliances used for the various forms of talipes, arranged so as to prevent motion in the direction of contrac- tion, but allowing motion in other directions. The weight of the patient at every step acts as a correcting force. OPERATIVE TREATMENT. The object of operative interference in paralytic affections is two- fold : I St. To correct existing deformity. 2d. To render the paralyzed limb more efficient. For a\-erage cases of post-paralytic deformity, forcible manual cor- rection with or without the aid of tenotom}", with muscle-stretching and perhaps fasciotomy, are sufficient for correction. The deformities to be corrected are flexions at the hip and knee, and the distortions of the feet classed as the different forms of talipes. The latter can be corrected by the various procedures described in the chapter on *' Club- foot. ■"■■ Paralytic talipes, however, is much less resistant and yields to much less radical measures than are often needed in congenital club- foot, and subcutaneous tenotomy and fasciotomy with manual correc- tion will suffice in almost all cases. ANTERIOR POLIOMYELiriS. 439 Flexion at the knee may require tenotomy of the hamstring muscles, which is more thoroughly performed by means of an open incision than subcutaneously, as frequently the shortened fasciae need division as well as the tendons. In order to prevent a gaping wound after correc- tion, a Y-shaped or longitudinal skin incision should be used. An open incision is necessary if the contractions \\\ flexion of the Jiip are resistant. These are usually superficial and involve the fascia lata, but the intramuscular septa of the deep mus- l *.^ cles may also need division and the operation \ '\ "v may have to be extensive. In the older cases in which alteration in the shape of the bone exists, osteotomy or even excision may be needed. The latter is rarely indicated, as linear osteotomy near the joint will enable Fig. 300. — Transplantation of Sartorius to Quadriceps Tendon. CGoldthwait.) Fig. 391. — Elongation of Tendo Achillis. (Berger and Banzet.) the surgeon to straighten the limb with less destruction of tissue. The measures above mentioned do not aid the paralysis, but aid locomotion with or without the necessary appliances. Tendon Transference.' — Measures maybe undertaken for the direct ' O. A'ulpius : "Die Sehneniiberpflanzung." etc.. Leip.sic, 1902 (with bibli- ography). 440 ORTHOPEDIC SURGERY. purpose of aiding the paralyzed muscles with the view of making loco- motion possible without the need of appliances. The most important of these are the operations on the affected muscles. Tendon transplantation or tendon anastomosis, first introduced in 1 88 1 by Nicoladoni, consists of a procedure by which the proximal ends of healthy or partially affected muscles are inserted in or attached to the distal ends of the tendons of paralyzed muscles or to the perios- teum, and the action of the healthy muscle is transferred to the attach- ment of the paralyzed one or to a more ef^cient insertion.^ The transference of one tendon to another, as originally intro- duced, has been extensively employed and has been followed by a cer- tain amount of success, but in a large percentage of cases the ulti- mate results have not been so beneficial as is to be desired. It was found that the functional strength of the transplanted muscle was rarely equal to the required work. Improvements in the methods have been made recently, however, which have increased the efficiency of the procedure. Periosteal tendon transference, as it may be termed, is a pro- cedure which can be relied upon to give a reasonable amount of perma- nent success. It is impossible at present to give the statistical value of the procedure. So much depends upon the amount of strength re- maining in the transferred muscle that the cases are difficult to group. For success it is essential that the muscular balance in the paralyzed limb be restored, and for this it is necessary that the transferred mus- cle pass as directly as possible from its origin to its new insertion ; it is essential that the transferred muscle should not be relaxed and that it should have a firm and an effective attachment. The transferred ten- don should be given a periosteal attachment, if possible, at such a point as will give on muscular contraction the functional result of the re- quired motion. When the tendon is not long enough to reach to the desired point of insertion, it can be lengthened by the use of strands of braided silk, which are quilted in the end of the transferred tendon, and at the distal end sewed into the periosteum or attached to the proximal end of the paralyzed tendon. Lange, who originated this method, has demonstrated not only that in this way a permanently useful tendon can be furnished, but that ap- parently fibrous tissue forms about the silk strands. The application of the method varies necessarily with the deformity and the part para- lyzed, whether it is for a paralytic talipes equino-varus, a valgus, equi- nus, calcaneus, for paralysis of the extensor cruris, or for other paral- yses. In eqinno-vai'HS, egtiino-valgns, or eqiiimis the procedure is some- ^ Codivilla : Zeitsch. f. orth. Chir., xii. — Vulpius : Ibidem. — 'Ldiage., Schanz, and Reiner: Ibidem. — Koch: Miinch. med. Woch., July 19th, 1904. ANTERIOR POLIOMYELITIS. 441 i what the same. The operation is more conveniently done after the hmb has been made bloodless by the Esmarch method, and the deform- ity of varus, valgus, or equinus must be forcibly corrected with tenoto- my and fasciotomy if necessary. The correction of the deformity should be preferably done a few days before the tendon operation. A long incision is then made over the middle of the ankle or the part of the ankle where the tendons to be operated on are situated, extending to the dorsum of the foot. The muscle to be transferred is then se- lected and the tendon isolated and cut off as near its insertion as possi- ble. The end is then secured by a long, stout, silk suture. The muscular portion is freed above sufficiently to permit a transferrence of the direction of the mus- cle in a nearly straight rather than a curved course. The desired point of in- sertion is then selected, which should be as far forward on the tarsus as is prac- ticable. The silk attached to the freed tendon is then stitched securely to the periosteum at the selected point, the tendon pulled tightly into its new posi- tion, and firtnly tied. If the tendon is too short to reach, its length can be pieced out by the strong silk strands of the suture or it may be stitched into the paralyzed tendon near its insertion, but a periosteal insertion is much to be pre- ferred. All the extensor tendons of the foot, if relaxed, whether paralyzed or not, are to be shortened. If they are paralyzed they can be used as a stay in the corrected position, and if not paralyzed they can only be effective if sufficiently tight. The tendo Achillis should, of course, be divided when necessary. It is evident that the length and the site of the skin incision varies with the surgeon's judgment and with the muscle to be transferred. Whether the tibialis anticus or the peroneus longus is selected depends upon the location of the paralysis and will affect the position of the skin incision. When the anterior group of muscles are all paralyzed, as in talipes equinus, a portion of the tendo Achillis and one of the pe- ronei can be brought forward to the front of the foot and given an an- terior attachment on the tarsus. In this procedure a posterior as well as an anterior incision is needed, and the transferred tendon is passed subcutaneously forward from the posterior to the anterior incision. The operative reduction of calcaneus or calcaneo-valg7is is not per- manently accomplished by simple shortening of the tendo Achillis, be- V Fig. 392. Fig. 393 Fig. 392. —Transplantation of Ten- don. (Berger and Banzet.) Fig. 393. — Side Incisions in Tendon to Permit Elongation without Loss of Continuity. (Berger and Banzet.) 442 ORTHOPEDIC SURGERY. cause, being paralyzed, the tendon will again stretch and the deformity recur. If the posterior part of the os calcis is set up toward the ankle, a better relation of the foot to the leg is obtained. The operative pro- cedure is as follows : The side of the os calcis is exposed by an incision sufficiently long and an osteotome is used to loosen the posterior part of the OS calcis from the front part. The line of separation begins above, just posterior to the astragalus, and runs downward and forward obliquely. When this part is separated the heel is set up by pressure on the tuberosity of the os calcis. The tendo Achillis is then exposed and reefed until it is tight with the foot in its corrected position. If an element of valgus exists with the calcaneus, some of the ten- dons of the common extensor should be cut and given a periosteal in- sertion into the scaphoid or cuneiform. It may also be advisable to change the insertion of one of the peronei muscles to the inner border of the foot. In pes cavns the plantar fascia is to be tenotomized, the foot forci- bly stretched, with an osteotomy of the tarsus in extreme cases. Oste- otomy of the OS calcis is also to be considered in pronounced varus and valgus with distortion of that bone. The proceeding is similar to that in congenital club-foot. Paralysis of the Exteiisor Cniris. — This paralysis can be improved if the hamstring muscles are sufficiently strong. The tendcTn of the bi- ceps (or a portion of it) and the semimembranosus are freed near their attachments by incision at both sides of the leg, and are brought for- ward under the skin and stitched securely into the ligamentum patellae close to the patella. It is necessary that the muscles should be freed sufficiently high up from their attachments so that the muscles can be brought to the front of the leg without being curved. Transplantation of the sartorius into the conjoined tendon of the quadriceps can be performed, but, as the muscle is not a strong one, as much effective strength cannot be expected from its transferrence as from that of the hamstring. This procedure sacrifices a portion of the power of flexion of the limb at the knee — a loss which is compensated for by the greater usefulness of the limb. Pai'alysis of the Upper Extremity. — A portion of the trapezius can be transferred to the insertion of the deltoid in paralysis of the latter. Tendon transferrence in paralysis of the wrist is of value. The same principles of procedure are necessary in the upper as in the lower ex- tremity. It is almost needless to state that suppuration diminishes the pros- pect of benefit from tendon and muscle transplantation, and the meas- ure should not be undertaken except by an adept in thorough asepsis. After-Treatment. — After the operation the limb should be protected by sufficient cotton padding and fixed in the desired corrected position ANTERIOR POLIOMYELITIS. 443 in a plaster-of-Paris bandage, arranged so as to allow the required in- spection after dressing. After six weeks the plaster bandage is to be followed by a retention apparatus, such as has already been described, and the gradually increasing use of the limb allowed, along with mas- sage and passive exercises to develop the transferred muscles to their new work. Arthrodesis. — Where the paralysis is total or nearly so tendon trans- ferrence is useless, and the disability of the limb, except by mechanical assistance, would be unavoidable were it not for the procedure of ar- throdeses, which is devised for the purpose of stiffening the flaccid joint. This is more commonly applied to the ankle-joint and is at- tempted by opening the joint freely and exposing the astragalus, which should be denuded of cartilage on all its articular surfaces, as well as the lower end of the tibia and fibula. It is necessary that the os calcis should not be free to move under the astragalus, and the joint surfaces of the calcaneocuboid articulation are also to be denuded in very lax joints to prevent a subsequent distortion from the loosening of that joint. In cases of severely relaxed ankle-joints it is of use to shorten the anterior or other groups of muscles, in order to have them serve as stays to the newly stiffened joint in its resistance to strain. Arthrodesis can be employed in stiffening the knee and has been employed to fix the shoulder and hip. In the latter joint, however, the operation has hitherto been of doubtful benefit. After operation the joint should be fixed in a correct position for two months, after which gradually increasing use is to be allowed. Nerve-Twisting. — It is possible in some cases, where very slight power remains in some muscles of a limb, to increase and distribute that power better by a division and twisting of the main nerve of the limb. The nerve is dissected out and sutures are passed through the sheath in such a way that, when they are tightened after the nerve is cut, the distal end is rotated on the proximal end through one-third of a circle. The nerve is cut after the sutures are passed, the sutures are tied, and the wound is closed. Decided improvement in function has been re- ported.' Nerve Transplantation. — It has been demonstrated experimentally by Spitzy " that nerve impulses may be given new directions by nerve anastomosis; that is, connecting the proximal end of one nerve with the peripheral end of another and transferring its motor impulse. Peckham ^ transplanted in two cases two branches of the internal pop- liteal nerve into the external popliteal ; in both cases there was some 'Verbal communication from Dr. W. S. Baer, of Baltimore. -American Jour. Orth. Surgery, August, 1904. '^Providence Med. Journal, January, 1900. 444 ORTHOPEDIC SURGERY. restoration of power in the extensor muscles. J. K. Young, of Phila- delphia/ has since reported a case of successful nerve transplantation in the leg. The technique has been elaborated experimentally by Spitzy.- Osteotomy may be required to correct severe flexion deformity at the hip, and at the knee to correct the knock-knee and flexion at the same time. At the hip it does not differ from the ordinary Gant oper- ation, and is necessary only in cases in which division of the soft parts is not enough to allow sufficient extension of the thigh on the pelvis. At the knee a simple transverse division of the femur is made just above the condyles, allowing correction of both flexion and knock-knee at the same time. These operations, of course, have no effect upon the paralysis as such, but merely serve to place the limb in a position suit- able for weight-bearing. After operation mechanical support is usually necessary. Excision. — In other cases resection of joints is to be considered on account of the extreme bony deformity which they present, as in severe paralytic knock-knee, in which a stiff knee rather than a movable one is desired. If the latter is preferable an osteotomy rather than excision should be done, as excision leaves a stiff joint. The deformity of knock-knee or flexion at the knee can, of course, be corrected by the plane of the bone section in excision. ^ Am. Journ. Orth. Surg., August, 1904. -Zeitsch. f. orth. Chin, xiii. CHAPTER XV. SPASTIC AND OTHER PARALYSES. Spastic paralysis. — Congenital. — Acquired. — Symptoms.— Idiocy. — Etiology of ac- quired spastic paralysis. — Pathology. — Diagnosis. — Prognosis. — Treatment. — Pseudo-hypertrophic paralysis. — Progressive muscular atrophy. — Hereditary ataxia.— Obstetrical paralysis. SPASTIC PARALYSIS. The condition is known under tlie following names : Spastic paraly- sis, spastic hemiplegia, Little's disease, spastische Gliederstarre, etc. The affection is more common than was formerly supposed. At the Children's Hospital 310 cases of cerebral paralysis came under treat- ment, while 987 cases of infantile paralysis appeared during the same period. ; Motor disturbances in children which are due to cerebral lesions are manifested clinically in one of three ways: (i) As a single hemiple- gia; (2) as a diplegia; (3) as a paraplegia. Contractures, choreiform movements, mental impairment, aphasia, epilepsy, inco-ordination, etc., may be the accompaniments of any one of these forms. The distribution of paralysis in 225 cases analyzed by Peterson and Sachs was as follows: Right hemiplegia, 81 ; left hemiplegia, 75; diple- gia, 39; paraplegia, 30. Total, 225. Congenital Spastic Paralysis. It is usually not recognized at birth, as it consists of a lack of mus- cular co-ordination common in infancy, which persists in certain mus- cles during life. The origin of it is to be found in cerebral defects, intra-uterine cerebral hemorrhage, and lack of development of the brain. Acquired Spastic Paralysis. Symptoms. — The form most commonly seen is that acquired during or after labor. The onset may resemble very closely that of infantile spinal paralysis; it often begins with an illness of some sort. Fre- quently paralysis develops in the course of an infectious disease, some- times after an attack of what seems to be indigestion or a slight feverish attack, sometimes after a fall or a slight blow on the head. 445 446 ORTHOPEDIC SURGERY. Commonly the onset is marked by convulsions. Delirium or screaming spells may accompany the onset. Sometimes, however, though very rarely, the disease develops suddenly in perfectly healthy children without any febrile or other disturbance, or it may develop insidiously without disturbance enousrh to attract attention. From the second Fig. 394.— Case of Right Hemiple.aria At- tempting to Walk. Fig. 395. -Attitude in Attempted Walking, Spastic Paraplegia. year, for the first six or seven years of life, the liability ver}' gradually diminishes : the number of cases, however, rises slightly at the time of the second dentition. In this respect it offers a sharp contrast to in- fantile spinal paralysis. When the paralysis is noticed, it is found to be most often hemiple- gic in distribution. Monoplegia is rare. The face is paralyzed in a moderate proportion of all cases, and the arm is always affected more severely than the leg and recovers more slowly. The facial paralysis ordinarily is not complete and does not affect the muscles that close the eyes. It disappears first of all the paralyses, and often recovery is complete. Strabismus is very common. The paralyzed side is power- less, but sensation is generally unimpaired ; coldness and vascular slug- gishness are present m some of the severer cases. The reflexes of the SPASTIC AND OTHER PARALYSES. 447 affected side are much increased from the first — a sign which is of the greatest assistance in diagnosis. As in the hemiplegia of adults, rigid- ity of the affected muscles comes on in about seventy-five per cent of all cases at a varying time after the onset of the paralysis. The rigid- it)-, when present, is increased by any attempt to use the limb ; it is excited by passive manipulation and it disappears during sleep and usually under an anaesthetic. Post-hemiplegic movements follow in a certain proportion of cases. Hemianopsia may be present. Aphasia accompanies probably a certain proportion of cases of cere- bral paralysis, but it is often transitory. It is always motor aphasia, and may accompany either right or left hemiplegia. Mental enfeeblement, varying from complete idiocy to simple back- wardness, develops in a large proportion of all cases. In the 26 cases- in the Children's Hospital series ' only 6 had what was classed as aver- age intelligence, and i of these was aphasic and i stuttered very badly. Of the rest, 7 were idiotic, 8 feeble-minded, and 4 very backward. Sachs found idiocy present in 35 per cent of all diplegias and in 60 per cent of paraplegias, while it occurred in but 13 per cent of hemiplegias. Such chiklren as escape mental deterioration in childhood often develop psychoses later in life. Epileptic attacks appear in the paralyzed limbs and thence become generalized in one-quarter to one-half of all cases reported. Ordinarily they come on in two or three years after the paralysis, but they may be delayed, and ten or even thirty years may elapse sometimes; on the other hand, they may begin within a few weeks of the onset. The mind may, however, remain perfectly clear in spite of a severe hemiplegia, and no sign of mental deterioration may be present in the early or the late history of the disease.^ To the later history of the affection belong the atrophy and contrac- tions of the limbs. In hemiplegia the affected side rarely recovers en- tirely, and often the growth of the bones is retarded. The muscular atrophy, as a rule, is not so great as in infantile spinal paralysis, but in certain cases the muscles waste very much. In severe cases there is. marked arrest of growth in the bones. In the Children's Hospital series one case showed a shortening of two inches in the arm after the paralysis had lasted seventeen years, and three other cases of four, seven, and eight years' standing showed a shortening of one inch. This points to some trophic lesion. The permanent contractions that come on are most noticeable in the arm, and as a rule are of one type in the arm and leg. In the former the arm is held close to the side, the elbow is flexed strongly ' Lovett : Boston Med and Surg. Journal, cxviii., 641. -' Spiller; "Spastic Spinal Paralysis." Philadelphia Med. Journal, June 21st, 1902. 448 ORTHOPEDIC SURGERY. and firmly, the hand is flexed, and the fingers are drawn into the palm, usually embracing the thumb. The humerus is rotated inward, and outward rotation is resisted by muscular contraction. Supination and extension of the fingers are resisted. These contractions are very firm and resisting. The leg in bad cases is adducted and flexed at the hip, the hamstring muscles of the knee have contracted, and flexion of the knee has resulted, and the foot is in a position of talipes equino-varus or simple equinus. In other cases only the finer movements of the hand may be lost, and the leg movements may be impaired only enough to cause a bad limp. Post-Paralytic Disorders of Movement. — In certain cases of hemi- plegia, single and double, a disturbance of motion occurs at a later stage, which is spoken of under many different names, such as atheto- sis and chorea spastica; while what is called "congenital chorea "in many cases is the same affection. Spastic Condition of the Muscles. — At times the tonic spasm of the muscles becomes the most prominent feature of the case, and there is a persistent stiffness and constant spasm of the muscles of the legs and "Fig. 396. — Atrophy of the Hand in a Case of Hemiplegia of Several Years' Duration. (Knapp.) sometimes of the arms; the legs are straight and rigid, and the feet are extended, and when an attempt is made to walk the child stands on tiptoe, and often the spasm of the adductor muscles is so great that the legs are crossed. The walk is almost characteristic — a clinging gait, in which the feet are scraped along the floor with much effort and straining at every step, if indeed the spasm is not so great that walking at all is out of the question. In general this affection is the result of a cerebral lesion and a de- scending degeneration of the lateral columns of the spinal cord. This grade of affection in the majority of cases represents the result SPASTIC AND OTHER PARALYSES. 449 of a larger brain lesion than takes place in hemiplegia. For this rea- son, these children are for the most part feeble-minded or idiotic — as one might reasonably expect as the result of so extensive a brain lesion occurring at so early an age. However, one not uncommonly sees children of more than average intelligence affected with spastic paraplegia, so that the existence of spastic paralysis is by no means evi- dence of mental inferiority. Often these children have strabis- mus, a stupid, idiotic face, the saliva drips from the mouth, and the teeth de- cay very early. In the milder cases the difficulty in walking lies in the fact that Fig. 397.- ■Attitude Assumed in Kitting by a Feeble-Minded Child. Fig. . — Spastic Paraplegia in an Adult. any effort to use the limbs increases the muscular spasm and tends to throw the leg into the position of extreme adduction, with extension of the foot and generally slight flexion of the knees with talipes equinus. It is often impossible to demonstrate the increased tendon reflexes either at the knee or at the ankle on account of the great stiffness of the legs, because the muscles are continually at their maximum of contraction. The electrical reaction in these and in the hemiplegia cases is unchanged. In certain cases the spasm is so great that the patient is unable to 29 45 O ORTHOPEDIC SURGERY. stand alone. When supported, the thighs are adducted very closely and the toes pointed and crossed. The mental disability may be manifested in the milder cases by an excessive irritability and a disposition to do mischief and perhaps to destroy playthings wantonly. Furious outbursts of temper are not uncommon. It seems as if spastic paralysis of the legs were occasionally a sequel of simple hemiplegia coming on after some years. Inco-ordination or Idiocy. — This condition may be the accompani- ment of cerebral palsy or it may be the result of other causes. The classification of Sachs is as follows : 1. Hereditary idiocy -] ^,/ , ^. ' , ■' ' (^) developmental. I after traumatism. 2. Acquired idiocy -j after convulsions. I after infectious diseases. 3. Myxoedematous idiocy. The only excuse for its introduction here is the very close outward resemblance that these conditions present on superficial examination to the spastic cases already considered; but definite paralysis and spastic rigidity of the muscles are absent, and idiocy obscures everything. If patients are seen seated, the stupid cross-eyed look, the drooping head, HMH ^" • 1 ^j3P^ s Al ^ ^^M^^^K^-^i^^^ ' ^jMk B s Fig. 399. — Severe Infantile Spastic Paralysis. and the drooling are exactly what is seen in the severe mental enfee- blement of spastic paralysis or hemiplegia. But put the child on his feet and the difference is at once evident. Either his muscles are so lax that he will be unable to bear his weight at all, or he will stand holding his parent's hands with his feet wide apart, his knees bent, and SPASTIC AND OTHER PARALYSES. 451 his trunk leaning forward. The whole body sways to and fro with an oscillating movement, and the sense of equilibrium seems almost want- ing; if he is let alone, he walks in a staggering, uncertain way, with many falls. From this the condition grades off to a disability so great that the child cannot even sit up; when it is propped up the head lops on to one shoulder, the vertebral column fails to support the trunk and bends to a marked degree, and every muscle seems limp and useless. There is no suspicion of muscular rigidity or localized paralysis. Sensory disturbances are not uncommon, and often a pin can be thrust through the skin without pain. The reflexes are sometimes nor- mal a,nd sometimes increased, while the legs are generally flabby and cool, and the hands and feet often undeveloped. Every grade of the condition is seen from that described above to complete helplessness. Etiology of Spastic Paralysis. — The etiology of prenatal cases of , cerebral palsy is obscure. Such cases may occur in neurotic and epi- leptic families. Traumatism to the mother during her pregnancy, severe illness of the mother, severe fright, and hereditary syphilis are among the causes. The etiology of cases dating from birth is better formulated. Asphyxia at birth, prolonged labors, and instrumental de- liveries are frequent causes. In cerebral paralysis acquired after birth there are certain well-for- mulated causes.' Acute infectious diseases play their part, cases hav- ing occurred after measles, scarlatina, typhoid fever, smallpox, tonsil- litis, pneumonia, pertussis, cerebrospinal meningitis, gastro-enteritis, mumps, diphtheria, dysentery, typhus fever, and syphilis. Fright and trauma are two other accepted causes." In a large number of cases the disease seems to affect perfectly healthy children without any assignable cause. The indigestion attacks, the fever, and the convulsions attending the onset cannot fairly be as- signed as causes. The disease is about evenly divided between the sexes. Pathology. — The pathological condition is much the same in hemi- plegia, diplegia, and paraplegia. These conditions in general are due to embolism or hemorrhage, and the resulting retardation of growth of the affected portion of the brain, together with the secondary changes in the spinal cord. Autopsies made later in the disease show pathological changes which are more extensive and less definite in their character. Wasting and sclerosis of a greater or less part of the brain and the con- ' Phila. Med. News, 18S7, ii. — Parvin : American Journ. Med. Sci , 1S75. — Sinkler: Med. News, 1S85, vol. i.— McNutt: Am. Jour, of Obst , 1SS5.— Parrot : " Clinique des Nouveau-nes," Paris, 1877. -Obstet. Trans., London, vol. xxvi. ; Boston Med. and Surg. Journal, June 2Sth, 1888.— Osier: Phila. Med. News, July 14th, 18S8.— Abercrombie : St. Barth. Hosp. Rep., xvi., p. 35, and Brit. Med. Journ., June iSth, 1887. 45- ORTHOFEDIC SURGERY dition known as porencephalus are what one finds in these later cases. These seem to be the late results of the destructive change mentioned above, which have occurred in a growing brain and have retarded its growth and have produced an extensive scar formation in the place of cerebral tissue. Porencephalus occurs as a loss of substance in the fomi of cavities or cysts. The pathology of the condition ' is a lesion of the motor tract of the brain with consequent atrophy and retarded development of the affected portion, and descending degeneration of the pyramidal tracts and lateral Fig. 400. — Distorted Brain in Case of Infantile Spastic Paralj'sis. columns of the cord. From the extensive atrophy found in young chil- dren at autopsy, it seems that unquestionably sometimes the disease originates in defective development of the nervous centres, especially the pyramidal tracts, rather than in an acute cerebral hemorrhage or embolism. The theory that the condition was due to a poliencephalitis similar ' E. H. Bradford : Am. Joum. of Orth. Surgery, vol. i.. p. 375. SPASTIC AND OTHER PARALYSES. 453 to poliomyelitis has not received confinnation nor the support of mod- ern neurologists. To enter upon a discussion of the pathological condition in the cases of inco-ordination spoken of above would be to introduce the very ex- tensive subject of the pathology of idiocy.' Diagnosis. — Spastic paraplegia is characterized by tonic contraction of the muscles which yields to steady resistance, except in the advanced stages where fibrous changes have taken place. The galvanic reaction is normal. At times the muscular rigidity is so excessive that the ex- aggerated knee-jerk and ankle clonus cannot be obtained. In estimat- ing the child's mental condition, very little weight can be attached to the parents' account of the patient's capacity. The differentiation of cerebral paralysis and infantile spinal paraly- sis has been dealt with. Obstetrical paralysis might be mistaken for a cerebral lesion, but a careful examination would determine the paralysis to be limited to the distribution of some especial nerve or group of nerves. It occurs in the distribution of the facial nerve after the use of the forceps, but it occurs as a rule in the shoulder in consequence of the stretching of the nerve trunks in the manual extraction of the child's body. Cerebral tinnors may cause the symptoms of hemiplegia, and a diag- nosis of this condition from the lesions generally causing paralysis would ordinarily be impossible. Tumors of the pons or cerebellum would cause symptoms of bilateral rigidity (spastic paraplegia) if the}'- compressed the motor tracts. Pseudo-h\"pertrophic paralysis, the pseudo-paralysis of rickets, s}"phi- lis of the spinal cord, and hereditary spastic paralysis are possible sources of an error of diagnosis in obscure cases. Certain cases of chorea prove on investigation to have their origin in a slight cerebral paralysis. The same may be said of epilepsy. Prognosis. — The prognosis in these cases should be most guarded, and is dependent upon the extent of the central lesion, not always easily recognized. When epilepsy or idiocy is present little benefit can be expected from surgical treatment. The spastic muscular condition is to be regarded as a difficulty in addition to the epilepsv or idiocy which especially needs treatment. When no mental impairment is present much benefit can be expected from suitable surgical treat- ment. In formulating the prognosis it is to be remembered that epilepsy develops in about half of the cases. ^ Osier: Med. News, Phila.. August nth. iSSS. p. 143. — Landouzy and Sire- dey : Rev. de Med.. 1S85. — Jendrassik and Marie: Arch, fiir Phys., 1SS5.— Cow- ers and Handford : Brit. Med. Journal. 1SS7. i.. 1098.— Seibert : Arch, of Pe- diatrics, March, 1SS8, 16S. 454 ORTHOPEDIC SURGERY. Treatment. — In spastic paralysis it is at times possible to accomplish much by muscular training and exercise. The muscles which are most strongly contracted are the thigh adductors and the calf muscles. Such a patient should be given exercises calculated to develop the ab- ductor muscles and the dorsal flexors of the foot, which by increased power will in a measure counterbalance the muscles which are too pow- erful. The patient should lie on the back on a hard table, and should separate the legs as far as possible at first without being touched, and then against slight resistance. The legs in the extended posi- tion should be rotated outward, while the heels are kept to- gether. In walking the patient should be cautioned to go very slowly, to lift each foot well off of the ground, and to turn out the toes with much care. In connection with massage and rubbing, this method of treat- ment is capable of accomplishing a decided change in the method of walking, and, while the walk may be stiff and unsteady, it has lost the characteristic scraping and dragging of the spastic gait. Such patients walk with much less fatigue than before and feel much more steady upon their feet. The disappearance of the aphasia is aided by systematic training and it always proves more tractable than in the adult. Apparatus is suited to the treatment of the milder deformities only. Talipes equino-varus of a mild degree may be temporarily corrected by a proper appliance (Chap- ter XXI., 37). The muscles furnish sufficient support to the affected limbs, but, owing to the increased reflex excitability and to imperfect motor impulses, the muscles are in a state of spasm and of useless- ness from the distorted position. In general the deformities are to be treated as in infantile paralysis. The deformity, however, returns immediately on removal of the appliance, so that, apart from the tem- porary rectification, apparatus is of little advantage in cerebral par- alysis. Retentive apparatus, however, is of use in retaining the limbs Fig. 401. — Spastic Paralj^sis before Operation. SPASTIC AND OTHER PARALYSES. 455 in proper position after operation (Chapter XXI., ^5). Post-hemi- plegic movements are at times relieved by placing the member at rest for some weeks or months under restraint. Operative Treatment. — Tenotomy, Myotomy, Fasciotoiny. — Clini- cal evidence has proved that tenotomy, especially of the tendo Achillis, in this class is of great benefit in suitable cases, not only in improved walking, but sometimes in improvement of the general condition and diminution of the general irritability, from the benefit of increased ac- FiG. 402. — Spastic Paralysis after Operation. tivity. The orthopedic surgeon will meet a certain number of cases of this class with pronounced equinus deformit}' of one or both feet. Lo- comotion is difficult for the reason that it is impossible for the patient to bear the weight upon the whole sole of the foot. This increased difficulty is sometimes suificient to deter the patient from efforts at lo- comotion and always adds to the unsteadiness of gait. If tenotomy of 456 ORTHOPEDIC SURGERY. the tendo Achillis is done, the contraction ceases, and though the strength of the muscle is not lost in a number of cases which have been watched by the writers for several years, there is little tendency to a reappearance of the equinus deformity/ In instances of this sort a practical cure may be gained by tenotomy. This treatment is especially suited to those cases in which there is lit- tle or no mental disturbance. Division of the hamstring tendons by open incision should be done when they are suffiicently contracted to prevent the full extension of the knee. This operation is preferable to subcutaneous tenotomy be- cause it offers a better chance to divide contracted tissues other than tendons. In the severer cases with adductor spasm division of the adductor tendons is also of benefit, as the adductor spasm often causes the knees to knock together in walking and is a serious obstacle in progression, and even the weakening of the muscles spasmodically contracted by removal of a portion of the muscular bellies is often of use. Gibney ^ has removed the tensor vaginae femoris with benefit to correct the inversion of the limb not infrequently met. In many instances, how- ever, if the intermuscular septa and the intermuscular fasciae are thoroughly divided in the spasmodically contracted muscular area, the remaining portion of the muscle can be overstretched. After-Treatment. — After the operation the limb is to be fixed in an overcorrected position by means of plaster-of-Paris bandages or retentive appliances for several weeks. This is to be followed by muscle training, gradually increasing exercises, with limbs held by ambulatory retention appliance (similar, as a rule, to what are to be used in infantile paralysis) until the proper muscular balance has been established, when appliances are to be discarded. It is to be remembered that the affection is not strictly a paralysis, but a disability from imperfect muscular co-ordination, increased by muscular contraction in certain muscles. The treatment consists in not only restoring the muscular balance, but in muscle training to re- establish the proper muscular co-ordination. Care is necessary during the process of muscle training with apparatus not to overstretch the divided tendons, as, for example, after division of the tendo Achillis, as locomotion with stiffened knees, necessary in the earlier stages of after- treatment of a contracted limb, brings unusual strain upon the tendo Achillis. It is advisable, therefore, in tenotomy of this tendon (where hamstring contraction exists), to perform plastic tenotomy. This is done by dividing half of the tendon at different levels and on different ^ O. Vulpius : "Die Sehneniiberpflanzung." etc., Leipsic, 1902, p. 197 (with bibliography). -American Journ. of Orth. Surgery, vol. ii., No. i. SPASTIC AND OTHER PARALYSES. 457 sides, and by stretching the tendon, elongating it without leaving a gap entirely across. Tendon transferrence has been recommended in this affection, especially of the hamstrings forward, to reinforce the lengthened ex- tensor curis by a procedure similar to what is employed in poliomyelitis. This would avoid the need of muscle training, with, however, a loss of the muscular balance which is always desirable. The procedure should be reserved for the more severe cases. Tendon transferrence, however, is of great advantage in the spastic contraction of the forearm. Arm and Ha7id. — The pronator radii teres may be converted into a supinator,^ and the carpal flexors may be converted into carpal exten- sors." In the first operation an incision, two or three inches long, is made in the middle of the front of the forearm. The upper and corner borders of the pronator are cleared and the tendon with its periosteal attachment is freed from the radius. The tendon is then passed through the interosseus membrane close to the radius and the tendon reinserted on the outer side of the radius, if possible at the site of its former insertion ; if not, at a new roughened place on the radius. In the other operation " the flexor carpi ulnaris is divided just above the annular ligament and inserted into the tendon of the extensor ulnaris, and the flexor carpi radialis divided at the same level and attached to the radial extensor. Operations upon the Brain. — It is natural that exploratory trephin- ing should be attempted in cerebral paral^'sis when the lesion can be well localized. Little benefit, however, has as yet followed this procedure in spastic paralysis, for the reason that the degenerative changes following the congenital defect are such as are not relieved by operative inter- ference. It is possible, if the operation could be performed at an early stage shortly after birth, that benefit might result. There are certain motor disturbances affecting children which come under the notice of the orthopedic surgeon so frec|uently that a brief 'A. H. Tubby: Brit. Med. Journ.. September 7th, 1901. -Robert Jones: Tubby and Jones, "Surgery of Paralyses." London. 1903, p. Fig. 403.— Tran.splantation of the Pro- nator Radii Teres in Spastic Paralysis of the Arm. 458 ORTHOPEDIC SURGERY. mention of their characteristics deserves a place here. These affec- tions are: I. Pseudo-hvpertrophic muscular paralysis. Progressive muscular atrophy. II. Hereditarv locomotor ataxia. I. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. Definition. — Pseudo-hypertrophic muscular paralysis is an affection of the muscular system characterized by a diminution or loss of the functional energ}' of certain muscles and an abnormal increase in their size, which, together with diminution in the size of other muscles, is pathognomonic. The affection is also known as muscular pseudo-hy- pertroph\", lipomatous muscular atrophy, diffuse muscular lipomatosis, mvopachynsis lipomatosa (Uhde) ; Paralysie myosclerosique, paralysie musculaire pseudo-hypertrophique. Modern classification places the affection among the progressive muscular atrophies. Etiology. — The etiology of the affection is not known. The disease develops usually during childhood, but in exceptional instances its ap- pearance is delayed until the age of eighteen or twenty years. It affects males more commonly than females in about the proportion of four or five males to one female. The disease is more apt to occur in familv groups than in isolated cases, and the hereditary element is marked. Pathology. — The pathological condition consists in the overgrowth of the connective tissue in the muscles and the wasting of the muscular substance proper, "while a deposit of fat takes place to a greater or less extent. No constant or characteristic pathological condition is found in the spinal cord, although various changes have been described, and the condition is at present still regarded as a primary affection. Symptoms. — The first symptoms to attract attention to the child's condition are muscular feebleness and peculiarity of gait. These gener- ally precede any noticeable enlargement of the muscles. Such children tire \Qx\ easily in walking and they have especial difficulty in going up and down stairs. They fall often and in rising from the ground they adopt a procedure which is one of the most characteristic features of the disease. Inasmuch as on account of muscular weakness they can- not straighten the back or extend the knees without assistance, they rise from the ground in the manner shown in Figs. 406, 407, using the muscles of the arms to accomplish what the leg and back muscles cannot do. These children tend to walk with legs apart, and at times an awk- ward gait and a tendency to fall are for a long period the only symp- toms of the affection. SPASTIC AND OTHER PARALYSES. 459 Such patients learn to walk late and depend much m their progress upon the assistance afforded by the furniture, upon which they lean heavily. In kneeling on the hands and knees at times there may be noticed a characteristic saddle-shaped depression of the back, which is due to the weakness of the erector spinas muscles. This is not an early accompaniment of the disease, but is a characteristic of the late stage when much lordosis is also present in standing. In walking these children throw the centre of gravity of the body well over each leg in turn as it sup- ports the body-weight. In this way they save muscular effort. The result is a waddle more or less Fig. 404.— Kj'phosis in Pseudo-h^-pertro- phic Paralj-sis. Fig. 405. — Case of Pseudo-hypertro- phic Muscular Paralysis. marked. They may stand with marked lordosis of the lumbar spine, chiefly due to a weakness of the lumbar muscles. The lordosis disap- pears when the patient sits down and a bowing backward of the whole vertebral column takes its place. Mental enfeeblement is associated with the disease in many cases. The enlargement of the muscles is usually most marked in the calves of the legs. On this account the parents generally feel no anxiety because the child walks late or feebly, inasmuch as the development of the legs seems so remarkably good. 460 ORTHOPEDIC SURGERY. Fig. 406.— Series of Photographs Showing Method of Getting up from the Ground in Pseudo-hypertrophic Muscular Paralysis. (Curschmann.) The affected mus- cles are hard and re- sistant to the touch, but at times the sen- sation in handling them is like that of a fatty tumor. Atrophy of some of the muscles of the upper extremity is apt to be present. The scapular muscles, the serrati, the latissimus dorsi, and the pecto- ralis major are often wasted. Talipes equinus and flexion of the knees and hips may occur from muscular contraction. Lateral curvature of the spine may follow, and at other times a perma- nent flexion of the spine occurs from w^eakness of the erec- tor spinae muscles, and the child sits bowed forward. But these deformities mark only the late stage of the affection, which is more often character- ized by a helplessness more or less complete. Neither the re- flexes nor the elec- trical reactions are modified in any degree until the muscles have reached a marked stage of atrophy. Then they are dimin- SPASTIC AND OTHER PARALYSES. 461 ished in proportion to the muscular wasting, and finally they are lost. The reaction of degeneration is not present. Very often the skin over the af- fected limb is mottled and subject to vascu- lar changes, indicat- ing some vasomotor disturbance. Diagnosis. — In well-defined cases the affection in its later stages is not likely to be mistaken for any- thing else. The pe- culiar gait with the feet wide apart and a reckless disregard of falls, the characteris- tic method of rising from the floor, the age of the patient, and the progressive char- acter of the disease, all suggest this affection. If examination shows enlargement of the calf muscles and nor- mal or diminished re- flexes, the diagnosis may be considered as established. Yet of even greater diagnos- tic importance than the enlargement of the calf muscles is the combination of en- largement of the in- fraspinatus and wast- ing of the latissimus dorsi and pectoralis Fig. 407.— Series of Photographs Showing Method of Getting up from the Ground in Pseudo-hypertrophic Muscular Paralysis. (Curschmann.) 462 ORTHOPEDIC SURGERY. major muscles — a state of affairs to which great diagnostic importance is to be attached. The gait in early hypertrophic paralysis, and that in idiocy, spastic paralysis, in the paralysis of rickets and Pott's disease, and in simple weakness have very much in common. Prognosis. — The prognosis is as unfavorable as possible. Recovery is all but unknown/ and arrest of the disease is rare." The course of the disease is essentially chronic. The earliest stage is made manifest by muscular feebleness, and passes on to a stage in which hypertrophy of the muscles becomes evident. This stage is pro- gressive and at the end of it the pseudo-hypertrophy reaches its maxi- mum and the disease becomes stationary and remains so for two or three or perhaps several years. Then comes a time of increasing fee- bleness and extension of the paralysis. The muscles waste and the power of movement is lost in the legs and arms. In this deplorable condition the patient may live on until death comes from increasing exhaustion or some intercurrent disease. Treatment is practically without benefit, and there is no reason to believe that drugs have any effect in retarding its progress. Electric- ity, massage, and gymnastics are sometimes of benefit in connection with other treatment. Tenotomy is of use as soon as the heels are drawn up. Often walk- ing may become impossible, chiefly on that account, and division of the tendo Achillis on both sides may restore for a time the power of walk- ing; also tenotomy of the hamstring tendons at the knee may be indi- cated in severe cases. PROGRESSIVE MUSCULAR ATROPHY. Progressive muscular atrophy is an affection characterized by a wasting of the voluntary muscles, and a consequent diminution in their power, which pursues a chronic course and attacks successively indi- vidual muscles and groups of muscles. Etiology. — In muscular atrophy as it occurs in children, the only cause assignable is a congenital tendency, often inherited. But at times isolated cases are met, and in adults other causes are to be taken into account. Males are more often affected than females, and the time of onset of the disease is most variable ; it may begin as early in life as at the age of three years or as late as sixty, but its development in advanced life is rare. ' Duchenne : Arch. gen. de r^Ied., 1S6S. i.. pp. 5 and 6. -Donkin: "Note on a Case of Pseudo-hypertrophic Paralysis. Recoverj'." Brit. ?vled. Journal, April 15th, 1882. SPASTIC AND OTHER PARALYSES. 463 Progressive muscular atrophy has, since the days of Aran and Du- chenne, been subdivided into different types. 1. In the Aran-Duchenne type the atrophy begins oftenest in the small muscles of the hand, spreads to the forearm and perhaps the shoulders and back. It may begin in the muscles of the thighs. The atrophied muscles show fibrillary contractions, and the reaction of de- generation is present. The affection has a pathology and is of spinal origin. The changes found are a sclerotic and pigmentary atrophy of the ganglion cells of the anterior cornua, an inflammatory condition of the neuroglia, and cellular proliferation. The anterior nerve roots are affected secondarily. 2. The hereditary form is of the same general type as the preceding. It is very unusual and may occur in more than one member of a family. 3. The peroneal form or leg type of progressive muscular atrophy affects in most cases the lower extremities. The extensor muscles of the toes are first affected, then the small muscles of the feet, and finally the entire leg. Talipes equinus or equino-varus is a common result. The development of double club-foot with progressive wast- ing of the lower extremities is very suggestive of this type of the af- fection. It may affect the upper extremities first and then the lower. Sensory changes are generally present. The reflexes in the lower extremities may be diminished or lost if the disease is sufficiently ad- vanced. The electrical reactions, as a rule, are altered both quantita- tively and qualitatively. Cases of club-foot occurring in this type may be successfully operated on.' The changes in the muscles consist in atrophy of the fibres, a loss of transverse striation, and a proliferation of the nuclei. Degenera- tions of the nerves are present, but changes of importance in the spinal cord have not been established. The two remaining types along with pseudo-hypertrophic paralysis are to be classed as primary myopathies or primary muscular dystro- phies, in that they are not associated with demonstrable lesions \\\ the spinal cord. 4. Erb's type. The juvenile form of progressive muscular atrophy is very rare and is characterized by progressive wasting of certain groups of muscles. These are the muscles of the shoulder girdle, the upper arm, the pelvic girdle, the thigh, and the back. The forearm and leg muscles remain, for a long time at least, intact. There are no fibrillary contractions, no reaction of degeneration, and no sensory dis- turbances. 5. The Landouzy-Dejerine type or the facio-scapulo-humeral variety occurs at times in children. The muscles of the face are first affected and the atrophy spreads to the shoulder and arm muscles. In excep- ' Sachs: Loc. cit., p. 413. 464 ORTHOPEDIC SURGERY. tional cases this type may begin in the arms or legs. The reaction of degeneration and fibrillary twitching are never present. Treatment. — The medical treatment of all these affections is hope- less. When muscular contractions occur tendons should be cut and deformities rectified. Rest to the atrophied muscles, massage, and electricity are useful. HEREDITARY ATAXIA. Hereditary ataxia deserves mention as a serious motor disorder which is sometimes met in children. It is dependent upon a family predisposition, but is not often directly inherited, but more commonly appears in several members of one generation. Hence the name of family ataxia. It is also known as Friedreich's disease. Other names are hereditary ataxic paraplegia and degenerative ataxia. The cases are rare. Etiology. — Aside from the influence of a congenital tendency the cause of the disease is as yet unknown.' The disease develops most often early in life. The sexes seem equally liable to the affection. Pathology. — In examining sections of the cord in these cases, a de- generation of the lateral columns, with a more intense and plainly marked sclerosis of the posterior columns, is found. This is similar to the lesion of locomotor ataxia. Symptoms. — The symptoms resemble very closely those of locomo- tor ataxia, except that the lightning pains of the early stage and crises Fig. 408.— Deformity of the Feet in a Case of Friedreich's Disease. Hyperextension of the toes and club-foot, (^larie.) are not so marked as in the latter affection. Hereditary ataxia, more- over, involves the upper extremities more severely and earlier in the course of the affection. The patient notices a feeling of weakness and uncertainty in walk- ing, and soon it becomes apparent to others that the motions of the legs are not properly co-ordinated. The feet are placed wide apart in standing, and in walking the gait is practically that of locomotor ataxia. 'Gowers: Vol. i., p. 3S0.— Shattuck : Bost. Med. and Surg. Journal, vol. cxviii., 7, p. 168.— Smith: Boston Med. and Surg. Joum., October 15th, 1885. SPASTIC AND OTHER PARALYSES. 465 The movements of the hands become irregular and inco-ordinate, and a jerky irregularity develops in the movements of the head and neck, so much so that it may assume the aspect of an irregular tremor. Speech may also be impaired. The knee-jerk disappears, but the plantar reflex remains. Sensa- tion is affected in var)'ing degrees in different cases, and trophic disturbances of the skin are not present. As a rule the sphincter mus- cles are not affected. Nystagmus is often present; the Argyll-Robert- son pupil is absent. Deformities are apt to come on in the later stages of the disease. Lateral curvature may be present ; talipes equinus or equino-varus and permanent flexion of the knee are likely to occur. Diagnosis. — In a clearly marked case the walk is characteristic and resembles that of ordinary locomotor ataxia. The deep reflexes are diminished or absent and there is a certain amount of disturbance of sensation; the electrical reactions are normal. Isolated cases occur rarely, and a history of some such affection in other members of the same family aids very much in the diagnosis. Prognosis The disease is essentially progressive, and the progno- sis is bad in proportion to the rapidity of progress. Death usually occurs from intercurrent affections, but sometimes the disease lasts for thirty years or more and does not seem to have shortened life. It is not likely to cause death inside of ten or twelve years at the least, and nothing can be expected from treatment. Treatment. — ^The treatment should be similar to that in common use in locomotor ataxia. The gen>«ral hygiene of the patient should be most carefully regulated, and skilful massage sometimes accomplishes much in keeping up the nutrition of the muscles and thus diminishing the patient's disability. Electricity in the same way is of use, but it is distinctly second in importance to proper massage. Deformities should be corrected by tenotomy, etc., as they occur. Among similar affections are the cerebellai' type of hereditary ataxia described by Marie, differing chiefly in having exaggerated reflexes and ocular symptoms in addition to those described above. OBSTETRICAL PARALYSIS. Obstetrical paralysis of the shoulder is an affection which is fairly common and often results in a disabled arm. It occurs most often after difficult labors when traction is made upon the head in head pres- entations, or upon the trunk when the head is delivered last. It may occur, however, after normal labors.' The injury appears to be due to injury to the two upper roots of the 'Boston Med. and Surg Journal, 1S92. 30 466 ORTHOPEDIC SURGERY. brachial plexus. It has been found experimentally that the two upper roots give way first when traction is made, becoming very tense when the shoulder is pulled down, while the three lower roots remain lax under the same conditions/ The paralysis is of Erb's type and the nerves involved are the circumflex, suprascapular, musculo-cutaneous, and musculo-spiral. The condition is made manifest immediately after birth by an inabil- ity to use one arm ; it hangs powerless at the side, with the palm turned backward, and often the fingers are flexed tightly. If the arm is lifted from the side it falls lifelessly back into place, and although movement of the fingers is generally present, it is impossible to use the arm to any extent on account of the paralysis of the shoulder muscles. The p'ogiwsis in the severer cases is not good as to recovery. The ireatincnt should consist in the use of a sling or supporting bandage at first to prevent stretching of the joint capsule and muscles. Later massage and electricity are likely to be of use in lighter cases. The muscles should not be allowed to acquire a permanent contraction, but should be kept lax by daily manipulations of the joint. External rotation and supination are the most difficult motions to preserve. In cases with contraction, myotomy of the pectoralis major muscle followed by retention of the arm in a position to prevent contraction of the scar, is of use. When the paralysis affects only certain muscles, as is not infre- quently the case, operative measures, referred to in the chapter on "Spastic Deformities," viz., muscle transferrence, will be of assistance. Portions of the trapezius can be transferred to the deltoid, and other muscular transferrence can be performed in the forearm if any strong muscles remain. If the biceps is paralyzed and no triceps can be utilized, the arm can be made more useful by a procedure suggested by Jones, of Liverpool, viz., a flap plastic operation in the bend of the elbow, the skin and re- sulting scar tissue serving to hold the arm in a slightly flexed position, which is more useful than a straight one. Arthrodesis can be per- formed for the same purpose at the elbow. 'J. S. Stone: Boston Med. and Surg. Journ., 1899. CHAPTE^'XVI. FUNCTIONAL AFFECTIONS OF THE JOINTS. Definition. — Etiology. — Occurrence. — Symptoms. — Spine. — Hip. — Knee. — Ankle. — Diagnosis. — Prognosis. — Treatment. DEFIiSriTION: Functional disorders of this class are also termed hysterical and neuromimetic. The affections of this class most often involve the spine, hip, knee, and ankle, although the other joints can hardly be considered exempt. These disorders are probably dependent upon a disturbed nervous condition, perhaps due to a disordered blood supply, brought about by nervous exhaustion from overgrowth, from disease, nerve strain, or from trauma. They are here termed functional, because there is no evidence, clinical or pathological, of organic disease. Ordinarily these disorders are seen in persons of an excitable, emotional temperament, but exceptionally the most aggravated type of functional affections may be seen in persons of calm and composed demeanor manifesting no ex- aggeration in statement or manner. . ' ■" ETIOLOGY AND OCCURRENCE. A study of the etiology of this class is disappointing. As a predis- posing influence, an emotional temperament, which enters largely into the exaggerated statement of all subjective symptoms, must be consid- ered in all cases. The influence of home training and discipline in the development of this temperament is important, as well as is heredity. Persons broken down in health by suffering or chronic disease become naturally in time incapable of bearing pain, and the statement of such patients is exaggerated and the endurance lessened. Trauma is a frequent exciting cause. In certain cases the pain caused by a synovitis, for instance, seems to be perpetuated after its legitimate cause has disappeared. This is due to the patient's abnor- mal sensitiveness and self-concentration. Such sensations are to be classed as "habit pains." Again, slight sources of peripheral irritation, too slight to be an inconvenience to normal persons, may be a cause of severe symptoms in neurasthenics. Among such causes may be mentioned a short leg 467 468 ORTHOPEDIC SURGERY. or a weakened foot of slight degree, some degree of thickening of the synovial fringes in the knee, etc. This condition of hypersensitiveness is sometimes to be seen in young girls about the time of puberty, and in elderly women at the time of the menopause, rarely in young children. Wom.en in young and middle adult life are the most frequent sufferers. How far sexual irri- tation enters into these cases as a causative influence cannot be said with certainty, but in some cases it appears to be one of the disturbing factors which make up the disease. The statement cannot be too strongly made that, although these affections are seen mostly in young women at or after puberty, it must not be overlooked that they occa- sionally occur in young children, in boys, and also in men. Why a dis- turbance of the nervous centres should result in the manifestation of a group of symptoms so closely resembling those of serious joint disease is but one of the many unexplained phases of this disorder. The same may be said of the direction of these symptoms to any particular joint; except that traumatism is in many cases the cause which determines the concentration of the attention upon some one joint. SYMPTOMS. These affections may begin gradually or they may be seen following accident. Again they may be the outcome of a protracted convales- cence from some joint injury. The symptoms presented are usually much exaggerated and out of proportion to the local signs. There is usually a condition of hyperaesthesia, especially of the skin, which manifests itself most clearly when any manipulation of the affected part is attempted. Although this is a very important factor in the de- termination of this class of affections, the absence of this hyperaesthesia must not be taken as sufficient evidence to exclude the disease. An- other characteristic feature of these disorders is the fact that the objective signs vary from time to time. The stigmata of hysteria accompany many of these cases and when present are of great diagnostic importance. Organic and functional disease are frequently associated. A young woman with some joint affection of a mild character will sometimes so exaggerate and emphasize her symptoms that the case may appear to be of the most acute sort, but careful examination will perhaps show that the disease is convalescent and that the real condition is very favor- able. This can be detected only by a careful examination showing that the muscular stiffness varies much with the attention of the pa- tient and that much pain is attributed to the slightest manipulation which can easily be performed without suffering or muscular spasm when the attention of the patient is diverted, while the muscular rigid- FUNCTIONAL AFFECTIONS OF THE JOINTS. 469 ity of chronic joint disease is a constant and not a variable resistance to passive manipulation. Atrophy may be considerable, but it is not more than can be ac- counted for by disuse. Distortions of the affected limbs have nothing characteristic about them, except that they may or may not follow the malpositions of the limb which occur in real joint disease. The hysterical knee-joint is often flexed, and the hip may be flexed and perhaps adducted or ab- ducted. In short, the symptoms of functional joint disease have one distinc- tive characteristic, they are chiefly subjective, and objective signs of structural trouble are absent or nQt prominent. A familiarity with the objective signs of disease of the various joints is of course necessary^ in making the diagnosis of functional troubles, and the foregoing chapters have dealt with those objective signs. Symptoms often associated with functional disorders are ovarian tenderness and pain, baso-occipital headache, a feeling of suffocation as if a lump were lodged in the throat, and symptoms of this class. The association of uterine disorders is common, and also another frequent accompaniment is found in the presence of errors of refraction in the eyes. The surface temperature may be increased, local sweating may oc- cur, and neurologists describe some swelling as an accompaniment of certain cases of functional disorder of the joints. The correction of all sources of peripheral irritation is of course a matter of much importance. Spine. The condition in this location is also described under the names of irritable spine, hysterical spine, spinal irritation, functional affection of the spine, weakness of the spine, neuromimesis, etc' The affection may occur spontaneously or most often as the result of some trauma, either mild or severe. It appears as a sensitive and painful condition of the spine, manifested by sensitiveness most often over the spinous processes of the vertebrae, pain in motion and manipulation ; and in most of the cases is associated with a certain amount of general neurasthenia. Pain and tenderness are frequently found at the base of the neck, between the shoulders, in the lower dorsal region, or at the end of the spine. This pain is usually subacute, it is aggravated by fatigue, and it may be accompanied by much hyperassthesia, which is usually local- ized in a comparatively small area where there is a complaint of a burn- ing sensation, while no curvature or projection can be seen on inspec- 'Friedberg: Schmidt's Jahrb., 1897.— Bruns' Beitr., xi., 1894.— Willard and Spiller : " Concussion of tlie Spinal Cord." N. Y. Med. Jour., March 6th, 1897. 470 ORTHOPEDIC SURGERY. tion of the back. In the extreme cases, patients are unable to bear any weight upon the spine in sitting or standing, and they present the symptoms that suggest a hyperaesthesia of the hgaments or of the fas- ciae of the back muscles. Ordinarily the patients are able to go about freely, but suffer great pain, especially when their attention is turned to the subject of themselves. In a few instances of the severest sort the back is held stiffly, and any conscious attempt at bending is avoided by the patient; but unconsciously, when the patient's attention is di- rected in another way, the back will be seen to move with comparative freedom. A gait which is very similar to that of Pott's disease may be pres- ent, and also rigidity of the back in rising or stooping. As in that affection continued standing and walking may cause pain, the patient is very sensitive to any jar and may be relieved from discomfort in the recumbent position. A careful examination of the patient usually shows that the symp- toms of stiffness are more from an apprehension of possible pain of movement than from the unconscious muscular spasm seen in the acute stages of early Pott's disease. Pain on movement, moreover, is usually much greater than is seen in early Pott's disease. Some deviation from the normal attitude in standing is seen in most cases.' This may be a slight lateral deviation of the spine due to a short leg. It may be a rounded back from lack of muscular support, or it may be a position of lordosis and leaning back in an effort to balance. Such patients generally are poorly developed muscularly. Whatever defects exist should be corrected. Certain cases of backache of this type result from flat-foot or con- tracted foot. An examination of the feet should always be made. Sprains of the vertebral column occur at times after falls. Stiffness and pain may reach a considerable degree and render the diagnosis from Pott's disease impossible for a time. In the cervical region wry- neck may be present from muscular spasm. The pain may be very severe. This condition of sprain may persist for months, and in neu- rasthenic persons may merge into the so-called hysterical spine. PIip. The symptoms which may present themselves under these condi- tions at the hip-joint may resemble hip disease in many particulars. There is often complaint of a severe pain in the limb, and any attempt to move the hip elicits expression of pain. There may be an absence of atrophy, and the pain is more likely to be localized at the hip than at the knee, which is the reverse of what happens in true hip disease. ^ Lovett : "The Neurasthenic Spine." Am. Medicine, November 30th, 1901 ; N. Y. Med. Journal, May 30th, 1903. FUNCTIONAL AFFECTIONS OF THE JOINTS. 4/1 Unconscious movements at the hip-joint may be made more freely than in the painful stages of hip disease. In some instances marked fixation at the hip-joint may constantly be present, but usually the stiffness in examination of the hip is great, but unconscious movements at the hip as in stooping are freer. The stiffness is more the stiffness of apprehension than the limited mo- tion of early disease of the joint. The affection in children is not common, but by no means exceptional. The de- formity may be marked and persistent, recurring quickly after reduction. Knee. Functional disease of the knee- joints often simulates either chronic synovitis or ostitis. Pain and tender- ness may be present, creaking is noted as an occasional symptom in func- tional affections, and at times there seems to be present an increase of surface temperature. More commonly the surface temperature of the af- fected side is reduced. The knee may be flexed, but during sleep that posi- tion may be involuntarily abandoned or the leg can be easily straightened, offering but little resistance. Con- traction of the knee is often absent. A moderate degree of muscular atro- phy is present, especially if, as is usu- ally the case, the knee has been tightly bandaged for some time. In rare instances some swelling of the periarticular tissues around the knee is observed in this class of cases. The swelling is transitory and does not involve the joint proper. Nowhere does the diagnosis present greater difficulty than at the knee, where traumatism may loosen the semilunar cartilages to a slight degree or do some similar injury. The diagnosis of functional disease can be made only after the careful exclusion of all organic pathological conditions in both knee and foot. As our knowlege of abnormal con- ditions in the knee-joint becomes more exact fewer cases are classed as functional. Fig. 409. — Attitude in Walking in a Case of Hysterical Affection of the Joints of the Leg in a Girl of Thirteen. 472 ORTHOPEDIC SURGERY. Ankle. A functional disturbance in the ankle is not infrequent. It is most commonly met as a result of sprains which have been treated for too long a time by rest and fixation. A condition of muscular weakness, enfeebled circulation, and apprehension at slight pain ensues, and no attempt at the proper means of securing recovery is made, for the rea- son that the first attempt to use the disabled joint is painful and pain is regarded as a symptom indicative of inflammation. In functional disease of the ankle an attitude similar to talipes varus or of flat-foot may be seen. The distorted attitude in both the knee and the ankle may be so constantly assumed as to cause a contraction of the hamstrings or tendo Achillis. At the ankle most cases of functional affection are either the out- come of trauma or are associated with some abnormality of the foot. The functional affections of the other joints present no points worthy of especial mention. DIAGNOSIS. The symptoms are often those of organic joint disease, but the groups of objective physical signs are deficient and inconsistent with one another. The objective signs vary and are not so severe as the symptoms would lead one to expect. Pain is the prominent feature, and muscular rigidity and similar symptoms are of varying severity, according to the concentration of the patient's attention. The pres- ence of superficial hyperaesthesia and of signs characteristic of hysteria with an emotional temperament are facts which should excite attention. In examining patients in whom a functional affection is suspected, much information can be gained by watching the movements of the patient in getting out of bed, moving in bed, etc. The limbs or back should be bared, and the unaided movements watched. Those suffer- ing from organic disease of the hip or spine show a constant stiffness or attempt to guard or protect the affected limb, which is not displayed to so marked a degree in purely functional affections. The diagnosis to be of value must in practically all cases be made by a process of exclusion. Again it must be remembered that func- tional and organic disease may exist in the same joint, that is, legiti- mate symptoms may be so exaggerated as to constitute a functional affection. X-ray examinations are of assistance, as they show the absence of organic change in the bone structures which would be present in tuber- culous disease of a prolonged or acute course. FUNCTIONAL AFFECTIONS OF THE JOINTS. 473 PROGNOSIS. If left to itself, a true functional affection of the spine or joints may improve gradually without special treatment, or it may remain un- changed until the joint function becomes really impaired by the con- tinued inaction. In some cases a sudden and profound mental impres- sion may prove stronger than the idea of local disease and a cure is effected. It is this that the surgeon strives to accomplish in certain cases, it is this that may be brought about by faith cure or charlatanry, and rational treatment of a similar sort can likewise win excellent re- sults if properly carried out. The age of the patient and the duration of the affection are impor- tant in determining the outlook. The older the patient and the longer the course of the disease the less favorable is the prognosis. The existence of some peripheral source of irritation renders the immediate prognosis perhaps more favorable. TREATMENT. In few disorders is a routine treatment of less use than in functional affections of the joints or spine. Especially important, from the out- set to the end of the treatment, is an established diagnosis, on which the surgeon can rely. To attempt to follow out a treatment which shall be suitable to either functional or organic disease is fatal to a suc- cessful issue. Temporizing on the part of the physician at once makes successful treatment almost impossible. A definite plan of treatment must be formulated and adhered to. The disorder usually manifests itself as a disability of a limb, the object of treatment being to overcome the disability. Various meth- ods will be needed to effect this. It is first necessary that the patient be brought into as nearly nor- mal a general condition as possible. The improvement of the local condition is then to be considered and estimated, and finally the patient is to be trained to regain the use of the disabled limb or spine. In cases in which the spine is involved, rest to the back must be secured by recumbency for part of the day. Elaboration of treatment is desir- able in many cases and a rigid adherence to a careful and continuous routine of exercises, feeding, and medication must be insisted upon. This class of cases cannot be successfully treated unless due attention is given to regulating and improving diet and general condition, and correcting sleeplessness. For the treatment of the local condition, the physician has to decide between the necessity of correcting any existing distortion or local im- proper conditions of circulation or muscular weakness of the limb or 474 ORTHOPEDIC SURGERY. back, and the danger of increasing the expectant attention of the pa- tient by too great attention to the local condition. It is for this reason that counter-irritation and the cautery are to be avoided. It is essen- tial that the local condition should not be made light of by the surgeon, and the reality of the symptoms must be accepted and the disability recognized. A probable hypothesis explaining the condition must be assumed, and treatment based upon this should be carefully and con- sistently carried out. Any statement that the affection is a trivial nervous disorder or that it can be overcome by exercise of the will is in most cases an error. An important part of local treatment is the improvement of the cir- culation in the part affected, and strengthening of the surrounding muscles. This can be done by massage, local hot-air baths, electricity, and gymnastics. In general the beneficial effect of the local measures adopted must be insisted on, and by a graduated amount of enforced exercise pro- gressively increased, the patient may be surprised into finding herself daily doing more without feeling more pain. Sometimes it may be only practicable to make the patient take two steps a day, but the advance to three and four steps is an important gain. It may be repeated that without a certainty on the physician's part that he is dealing with a functional affection, and without a rigid adherence to his formulated plan of treatment, success is not often to be obtained. Great benefit can be obtained by graduated exercises in this class of cases. Another useful way of accomplishing this result is by means of mechanical passive and active exercises according to the method introduced by Zander. Appliances as a rule should be avoided, but in some cases they are temporarily needed to enable the patient to go about more freely when there is marked muscular weakness. They should be discarded as soon as is practicable. In the spine the tempered steel uprights (Chap- ter XXI., 32) spoken of in connection with round shoulders are of use temporarily in aiding in the maintenance of the upright position. In functional affections of the hip, knee, and ankle it is sometimes necessary to employ crutches in order to give locomotion and exercise. Crutches should be used sparingly, and only temporarily, inasmuch as there is danger of the patient becoming habituated to them. When contractions and malposition of the limbs are present, these should be corrected either by operation or by mechanical means. Op- erative measures are usually simple, as under an anaesthetic the limb can be pulled readily into normal position, while only in severe cases is tenotomy of the resisting muscles needed. Appliances will probably be required to retain the limb in the corrected position. Light cases of functional affection of the hip will be best treated at FUNCTIONAL AFFECTIONS OF THE JOINTS. 475 first by the use of crutches and the elevated shoe to che well foot, aided by gymnastic exercises for the limb of such a character as the patient can endure. The elevated shoe should be lowered and removed gradu- ally, and in the same way crutches should be shortened and replaced by a cane, and finally all support discarded by gradual stages. The use of a hip splint will not often be found advantageous on account of its weight. Traction by weight and pulley is rarely needed, but is sometimes advisable. Much judgment is required to determine what cases of functional affection of the hip, knee, and ankle joints are to be treated by rest, by protection of the limb, or by use. Rest in bed is to be avoided unless the patient is in a marked neu- rasthenic condition needing quiet, but confinement to bed is generally unavoidable during the correction of deformity. Whatever the methods of treatment to be instituted, it is absolutely essential that the physician should h^ve complete control of the man- agement of the case without interference of friends or relations. Often it is therefore necessary to take the patient away from home for the time being. In many cases the home influence is a most important factor in inducing and keeping up this condition. It is of importance for the physician to obtain the patient's co-oper- ation in the treatment prescribed. It is a mistake to belittle the symp- toms or to treat them as imaginary. They are not only real to the patient, but in fact are probably the result of some unrecognizable cen- tral vasomotor disturbance causing functional disability, and not of the ■patient's fancy. The disability is usually increased by the patient's apprehension or self-will. These are not overcome by contradicting the patient's statements. As the local symptoms of hyperaemia, anaemia, congestion, atrophy, and muscular weakness are diminished by rest, support, careful exercise, application of heat or cold, hot air, vibratory massage, manipulation, or whatever measure may be employed, the use of the limb should be gradually increased with each day's task prescribed. The gradual gain, even if slight, brings encouragement to the patient. Cases vary in difficulty and often tax the physician's efforts to the ut- most in meeting the varying symptoms, but in many instances such efforts are essential as necessary to save the patient from hopeless invalidism. In cases in which functional symptoms are superadded to an organic lesion, much skill and judgment are required in treatment. In all these varieties of functional affections, the principle of treat- ment is the same — temporarily to protect the affected part from strain and painful use, to improve the circulation and increase the muscular strength, and as the condition improves to train the patient to the gradual resumption of the normal use of the limb. A combination of muscular training with mind cure constitutes the treatment. CHAPTER XVII. UNILATERAL ATROPHY AND HYPERTROPHY. Cases of unilateral difference in the growth of the body are of prac- tical interest. Hunt/ of Philadelphia, in 1879, made observations which led him to state that bilateral symmetry as to the length of the lower limbs was exceptional. Since then several observers have corroborated the views of Hunt. Dr. Cox ^ measured the lower limbs in fifty-four healthy per- sons, and in only six were the limbs of the same length. There was no uniformity with regard to which side was the longer. The variation in length was from one-eighth to seven-eighths of an inch. Wight ^ gives the measurements of sixty persons, and concludes "that the greater number of limbs, comparing the limbs of the same person, show a dif- ference in length. About one person in every five has limbs of the same length." The difference is usually from one-eighth of an inch to an inch. In one case the difference was as great as one and three- eighths inches. Callender * measured forty individuals, and found the limbs of equal length in all but two, in whom the variation was slight. He used a simple tape. All the persons measured happened to be Englishmen. Roberts ' and Dwight " have attempted to settle the question by obser- vation on the bones of skeletons. Roberts found asymmetry the rule in femora and tibiae in eight skeletons. Dwight reported measurements in eleven skeletons; in five the femora were equal; in one case the difference was three-quarters of an inch. Tibiae were equal in only two cases. In some cases the longer femora and tibiae were on the same side, and in some cases on different sides. Dr. J. Garson,' of London, published the results of the measure- ments of seventy skeletons. The lower limbs were equal, he says, in only ten per cent. 'Am. Journal Med. Sciences, January, 1879. -Am. Journal Med. Sciences, April, 1875. ^Archives Clin. Surg., vol. i.. No. 8, February, 1877. ■* St. Bartholomew's Hospital Reports, vol. xiv., 1878, p. 187. 5 Philadelphia Med. Times, August 3d, 1S78. ''Mass. Med. Soc. Communications, 1878, p. 175. 'Journal of Anat. and Phys., vol. xiii., p. 502, 1879. Nature, January 26th, 1SS4. 476 UNILATERAL ATROPHY AND HYPERTROPHY. 477 Morton ' has made many measurements and found that among 513 boys 292 presented inequality in the length of the lower limbs varying from one-eighth of an inch to one inch and five-eighths. In 241 there was no appreciable difference in length. In none of these cases had there been previous fracture or any bone or joint disease which might have accounted for the defect. Three of the boys, including those that exhibited the greatest shortening, were aware of the fact that one limb was deficient in length. Burrell ' reported three cases of marked unilateral atrophy only noticed when the children began to walk, when it became manifest by a limp. Broca ' relates the case of a boy of eleven who appeared " as if the two halves of the body were differ- ent-sized persons joined together." Paget ' found that there is often a difference of volume as marked as is the difference in length, and it is often difficult to say which of the two unequal limbs is the better or the more appropriate to the other parts of the body. In Hartwig's studies of the upper ex- tremity the bones of the right arm were found to be the longest, cor- responding with Hyrtl's results. Poncet ' reported a case of alter- nate inequality, the right arm and the left leg being better de- veloped. The conclusions reached by all have been nearly identical, namely, that throughout the long bones of both extremities there exists often a certain amount of asymmetry in regard to length. The very important theoretical and practical bearing of this is easily seen. The relation that short limbs may bear to cases of lateral curva- ture ' has been discussed. Fig. 410.— Case of Multiple Plexiform Fibro- ma. Causing Hypertrophy and much Lengthening of Left Leg. (H L. Burrell.) ^ " Asymmetry of the Lower Limbs," etc. Phila. Med. Times, July loth, 1S86. -Boston Med. and Surg. Journal, vol.' cvi., p. 462. ■^Canstatt's Jahresbericht, 1859, vol. iv., p. 6. ''Am. Journal Med. Sciences, January, 1886. = Lyon Me'dical, January 29th, 188S. " Revue de Chirurgie, April loth, 1888. 47 S ORTHOPEDIC SURGERY. The progressive facial hemiatrophy is of interest from an etiological standpoint. The etiology of these different forms of atrophy or hypertrophy is obscure. In the cases of injury to the joints Nicoladoni suggested a premature synostosis of the epiphyseal cartilages. The facial hemi- atrophy is thought to be a trophic neurosis of certain nerve ganglia or nerves — or a simple vascular disturbance of the part has been sug- gested as a possible cause. It is probable that certain of these cases are the result of a slight former hemiplegia, which has manifested itself chiefly in retarding the growth of the affected side without any distinct loss of motor power. Symptoms and Treatment. — Long-continued slight and oftentimes severe backaches, with lumbar and pelvic pain, involving the distribu- tion of the sciatic nerve, are often due to asymmetry of the lower limbs. Such symptoms are at times at once relieved upon correcting the asymmetry b}' increasing the height of the shoe of the shortened limb. A person in previous good health may from some depressing physical condition begin to have the above symptoms of pain localized as stated, and upon examination unequal limbs will be found in very many cases. Morton said that United States pension-examining surgeons stated that many applications for pension have been made for disabilities de- scribed as lumbago, supposed to have been caused by exposure or by injuries contracted during the war for the Union. In nearly all such cases an examination revealed a previously unrecognized asymmetry, and the symptoms were probably induced by this defect in develop- ment. Symptoms of inequality of the lower limbs may simulate coxalgia. In such cases the legs should, of course, be measured. Children com- plaining of backache, or so-called growing pains, should be carefully examined for any such anatomical defects. The medico-legal bearing of the fact of asymmetry has been called attention to by Hunt in the paper already referred to. Hypertrophy of the limbs may occur either from dilatation of the vessels (as in angioma), from disease of the lymphatics, and from con- genital anomaly.' '"Clinical Report Children's Hospital Service." Boston Aled. and Surg. Journ.. cxliv., 14. p. 329. CHAPTER XVIII. CONGENITAL DISLOCATIONS. Congenital dislocation of the hip. — Frequency and occurrence. — Etiology. — Pa- thology. — Symptoms. — Diagnosis. — Differential diagnosis. — Prognosis. — Treatment. — (Reduction with aid of mechanical force. — Tenotomy, fasciotomy. — After-treatment. — Relapses. — Osteotomy. — Treatment of older and adult cases. — Summary.) — Congenital dislocation of other joints. — Knee. — Patella. — Congenital absence of the patella. — Ankle. — Shoulder. — Elbow. — Wrist Cubitus valgus, cubitus varus. — Spontaneous subluxation of the wrist. CONGENITAL DISLOCATION OF THE HIP. Congenital dislocation of the hip is neither a common affection nor one of very great rarity. Among 6,969 orthopedic patients apply- ing at the out-patient department of the Children's Hospital, there were 152 cases of congenital dislocation of one or both hips. Chaus- sier, in 23,293 infants born at the Maternite, found only i case of con- genital luxation. But it is probable that it occurs in reality much oftener than it is recognized clinically. Parise dissected the hip-joints of all children d3dng while he was interne at the Hopital des Enfants trouves, and in 332 he found congenital dislocation of one or both hips in 3. The distribution of the affection between the sexes and in one or both joints can be seen from the following tabulation of collected cases : Single Number. Boys. Girls. Right. Left. Double. Drachmann 77 10 67 24 24 29 Pravaz 107 11 96 27 29 51 Kronlein 90 14 76 32 22 31 N. Y. Orth. Hosp. and Disp 25 2 23 5 10 5 Boston Children's Hospital ' 24 o 24 7 11 6 Prahl iS 31; GO o 341 40 301 93 96 122 The affection is much more common in girls than in boys, 301 of these 341 cases (88 per cent) having been observed in females. No satisfactory explanation has been advanced to account for this prepon- derance in girls. Etiology.^The etiology of the affection is not known. True con- genital dislocation without doubt is an affection of uterine life, congeni- tal dislocations having been found in the foetus. It would seem also 479 48o ORTHOPEDIC SURGERY. that it is not an arrest of development like harelip, but like congenital club-foot rather a perversion of it, a malposition of bones with the re- sulting structural changes of the soft parts. Violence at birth alone, is not considered the cause of true congenital dislocation. The theor}" that the deformity is due to intra-uterine pressure at a period of foetal development is held by many.' This theory, however, does not explain the fact that the affection is much more frequent among girls than among boys. The lack of complete development in the acetabulum Fig. 411. — Lordosis and Prominence of Tro- chanters in Congenital Dislocation of the Hip. 0- S. Stone.) Fig. 412. — Unilateral Dislocation of the Hip. (Fiske Prize Fund Essaj'.) described by many writers will be found after thorough examination of pathological specimens to be explained by the malposition of the parts during a portion of the period of foetal life rather than by a structural arrest of development. ' A specimen was described by Air. Jackson Clark in which in uterine Hfe the thighs were flexed for so long a period without extension as to cause firm contrac- tion of the anterior portion of the capsule. Later extension of the limb, possibly from an increase of the amniotic fluid or from any cause, would, in a shallow acetabulum, cause dislocation of the hip (Brit. Ortho. Trans., vol. i.). CONGENITAL DISLOCATIONS. 481 There is, undoubtedly, a tendency to heredity in congenital hip dis- location. Dupuytren relates the case of three families in which the affection was present in several members, and cases are related by Bouvier,' Verneuil, Stadfeldt, Caswell, and Volkmann. It has been observed in two instances at the clinic of the Children's Hospital. In each instance two sisters were similarly affected. Pathology. — The changes in the anatomical structures seen in con- genital dislocation are found in the capsule, in the muscles, and in the Fig. 413. — Prominence of Trochanters in Double Congenital Dislocation of the Hip. (Fiske Prize Fund Essay.) Fig. 414. — Lordosis in Double Congenital Dislocation of the Hip. (Fiske Prize Fund Essay.) bones. The changes in the capsule are such as would naturally follow a prenatal dislocation before the joint structures were formed. Nor- mally the capsule passes from the rim of the acetabulum to the neck of the femur, the head being placed well in the socket. In congenital dis- location, when the head lies out of the socket and above the acetabu- lum, the capsule is stretched. Furthermore, the weight of the body, as soon as the individual walks, rests not on the head of the femur ' Bouvier : " Leq. Clin, sur les Mai. chron. de TApp. locomoteur." 31 482 ORTHOPEDIC SURGERY. \ placed under the acetabulum, but falls upon the capsule, which stretches like a strap from the acetabulum to the trochanter, and this capsule necessarily becomes thickened. As it is stretched across the acetabu- lum it becomes adherent at the rim and to a portion of the ilium, so that the acetabulum seems obliterated, being covered by thick, strong, fibrous tissue, reaching from rim to rim. This portion of the capsule is entirely shut off by adhesion from that which surrounds the head, save for a small opening at the upper portion of the rim. This open- ing may be, and usually is, smaller than the head, and not easily stretched, as the tissues lose their elas- ticity owing to the fibrous bands which form from the use of the capsule as a weight-bearing structure. f The muscles are changed in conse- quence of the altered position of the head. Some of the muscles are shortened, others are lengthened. The muscles which are shortened are the adductor group, the psoas and iliacus, and the muscles reach- ing from the tuberosity of the ischium to the leg, i.e., the hamstring muscles. The glutaei muscles are not shortened, and the group of muscles which pass from the pelvis to the greater trochanter, the ob- turators, gemelli, etc., are lengthened. The capsular and periarticular ligaments adapt themselves to the position of the deformity, and those which are attached to the lesser trochanter are particularly strong and firm to prevent the pushing of the head upward, when weight falls upon the leg. It is these tissues which oppose any attempt at reduction, and unless they are stretched or divided the deformity can- not be corrected. The' alteration in the bone consists of a flattening or alteration of the shape of the head, a twist of the neck, the consequence of mal- position of the head, and in the shape of the acetabulum, which is sometimes triangular in shape and shallow. Three varieties of congenital dislocation, classified according to the position of the head, are mentioned, viz., backward, upward, or forward. The backward or dorsal is much the most common. If the point of suspension is directly over the proper place for the acetabulum, the patient's pelvis is hung in a comparatively normal M -**' Fig. 415. — Rroadening of Perineum in Double Congenital Disloca- tion of the Hip. (Fiske Prize Fund Essay.) CONGENITAL DISLOCATIONS. 483 plane, but if much behind it the pelvis is tilted and severe lordosis re- sults,' the latter being the more common condition.^ Symptoms. — The deformity usually attracts no attention until the child learns to walk at the age of two or even three years. Then it is noticed to stand ordinarily with its back very much arched and to wad- dle most markedly when walking is well begun. This waddle is char- acteristic and very marked. When the dislocation is only unilateral, the waddle becomes an exaggerated limp ; in stepping on that leg the child leans to the affected side, and the leg seems to have grown sud- denly shorter; the child recovers itself at once and goes on with this sudden giving way whenever the affected leg is stepped upon. In Fig. 416.— Congenital Dislocation of the Hip in Full-term Foetus. (Warren Museum.) double dislocation, in young children, the prominence of the trochan- ters is not marked enough to attract attention ; in older persons, how- ever, the prominence of the trochanters and buttocks is most notice- able. There is no complaint of pain by children suffering from this affection. Diagnosis. — The diagnosis rests chiefly on one point, the position of the trochanters above Nelaton's line, which is drawn from the ante- rior superior spine of the ilium to the tuberosity of the ischium. In small, plump children it is sometimes difficult to determine accurately whether the trochanter is on the line or very slightly above it. The displacement of the trochanter upward varies from half an inch to one ' The pathological condition of congenital dislocation has been recently most thoroughly investigated by Dr. E. H. Nichols, of Boston, to whom the writers are indebted for information on the subject (Trans. Am. Orth. Assn., 1896). 484 ORTHOPEDIC SURGERY. or two inches, according to the severity of the case, but on careful pal- pation the head of the femur can often be felt on deep pressure if the limb is rotated, as moving in an abnormal excursion outside of the ace- tabulum. As the child lies on its back, the perineum is noticed to be unusu- ally broad in double dislocation, the legs will perhaps be everted, per- haps in normal position, and on manipulating them they will be found in young children to be unusually movable, especiall}' in the direction of eversion. On pulling the leg with gentle force the trochanter will be felt Fig. 417. — Congenital Dislocation of the Hip in Full-term Foetus. Capsule re- moved. (Warren Museum.) Fig. 41S. — Specimen of Congenital Dislocation of Hip. A^ Capsule stretched around distorted head ; j9, portion of contracted capsule ; C, cap- sule leading to acetabulum. drawn down, if the other hand is placed upon it, and to slip back when the leg is released, and a measurement will show that the leg has been lengthened temporarily bv the traction force. The muscles, although not normally developed, are not paralyzed, and the children are ordinarily healthy ones. In unilateral dislocation, the leg of the affected side is slightly smaller than the other. In larger children and adults the conformation and outline of the hips are so distinctive that the diagnosis may be made almost at a glance ; but in young children palpation or a skiagraphic examination is often necessary. CONGENITAL DISLOCATIONS. 485 Trendelenburg has called attention to an important diagnostic symptom. When a normal child stands upon either limb and flexes the other at the knee and thigh, the opposite buttock will be seen not to drop. In the case of congenital dislocation of the hip, however, the opposite buttock will be found to drop to a noticeable degree if the patient takes this attitude. This is to be explained by the fact that in congenital dislocation of the hip, owing to the fact that the head of the femur is not in the socket, the muscles from the great trochanter and the pelvis (which serve to keep the pelvis level) when supported on one side have no purchase and are therefore inefficient. In small children with fat buttocks it is sometimes difficult to find Fig. 419. — Congenital Dislocation, Child of Ten. Femur sawn and sides reilected, showing dislocated position of the femoral head, the capsular pouch, the capsular hy- men in front of the acetabulum, the acetabular cavity, and capsular constriction at the mouth. (Warren Mu- seum.) J \ - Fig. 420. — Congenital Dislo- cation of the Hip. Cross section of femur and ace- tabulum (femur tttrned back), showing capsular constriction at mouth of acetabulum. Child three 5"ears old. (Warren Mu- seum.) with certainty the dislocated head. The diagnosis is aided by remem- bering that when the head of the femur is in the acetabulum, rotation takes place with the acetabulum as the centre, and the neck as the ra- dius of the arc of motion; when the head is out of the acetabulum, the trochanter is the centre of motion, and the looser head describes the arc. A skiagraphic picture is of great value in diagnosis, and if accurate is conclusive. Differential Diagnosis. — The following affections may be confounded 486 ORTHOPEDIC SURGERY. with congenital dislocation of the hip in smaller children : coxa vara, distortion following infantile paralysis, separation of the epiphysis, de- formity following early arthritis of infancy, traumatic dislocations, and the deformities of hip disease. In all these affections, with the exception of the first, viz., coxa vara, there should be a history of previous injury or illness; and in all, with the exception of coxa vara and infantile paralysis, the freedom of motion of the femur seen in early congenital dislocation is not found. Coxa vara, or the distortion of the neck of the femur, which short- ens the limb and raises the trochanter above Nekton's line, may be Fig. 421. — Femur in Congenital Dislocation, Showing Alteration in Angle of Neck. confounded with congenital dislocation. The mistake can be avoided if the fact is borne in mind that in coxa vara the head is in its normal socket, while in congenital dislocation the head is to be felt outside of the acetabulum. Coxa vara is only very exceptionally noticed as early as three years of age. The affection of congenital dislocation is occasionally regarded as a disease of the spine, as marked lordosis is always present, and in many instances spinal corsets have been applied with the idea that this is the chief source of the trouble. CONGENITAL DISLOCATIONS. 487 Prognosis. — The disability caused by this affection in childhood is slight. The limp is noticeable, and, in double congenital dislocation, may be distressing. As the patient becomes older and the weight increases, some annoyance may be caused in adolescence; but this ordinarily is not great until middle life or old age. In single disloca- tion the defect in adults may be only an inability to engage in active occupation, accompanied by occasional attacks of severe muscular pain, with muscular cramps. These attacks subside under rest, but if the patient becomes heavier or feeble they may necessitate the use of crutches and cause severe disability. When the dislocation is on the dorsum the disability is greater than when it is anterior or above the Fig. 422. — Old Cong-enital Dislocation of Hip with Alteration of Neck of Femur to Shape of Acetabulum. (Warren Museum.) acetabulum. Muscular patients suffer less than those with feeble mus- cles. In double dislocation the trouble is increased. No strong acetabulum develops around the dislocated head, and with the body suspended from the femurs by a loose capsular ligament, the patient goes through life walking with discomfort and effort at each step, always preserving that most characteristic swaying from side to side. It may be said that in general the tendency of these cases when untreated is to remain stationary or to grow somewhat worse. The pelvis, although altered in shape, does not appear to be changed in such a way as to interfere with childbirth. 488 ORTHOPEDIC SURGERY. The prognosis in cases which are treated will be considered under that head. Treatment. — Attempts at reduction without operation have proved unsuccessful, although cases by Pravaz, Buckminster Brown, and Adams were thoroughly treated by traction for a long period and ap- parently benefited at first. The ultimate results were, how^ever, en- tirely unsatisfactory, and the method cannot be recommended. Operative measures- when first attempted without a thorough Fig. 423.— Congenital Dislocation, Showing Dropping of Pelvis when Patient Stands on the Affected Limb. Fig. 424. — Coxa Vara, Showing Elevation of Pelvis when Patient Stands on Affected Limb. knowledge of the pathological conditions also failed, but through the valuable work of Hoffa and Lorenz successful operative methods have been developed and a reasonable and increasing percentage of success is obtained in suitable cases. Mechanical treatment and the treatment by traction continued for a long period, advocated by Pravaz, Adams, and Buckminster Brown. have not given results which were permanently successful. The operative methods may be termed : 1. Reduction by open incision. 2. Reduction by forcible manipulation. CONGENITAL DISLOCATIONS. 489 Reduction by Open Incision. To Hoffa belongs the credit of having first presented to the pro- fession an operative method of value. This has been modified by Lorenz and himself and may be described as follows : The patient is to be placed upon the back with the limbs slightly Fig. 425. — Double Congenital Dislocation Unreduced. abducted and rotated outward. The incision is made in a line drawn from in front of the anterior superior spine, obliquely downward and Fig. 429.— Fourth Step. Fig. 426.— Line of In- FiG. 427.— Second Fig. 428.— Third cision for Opera- Step. Step, five Reduction. backward, crossing the femur a short distance below the top of the tro- chanter. The incision should be along the outer edge of the tensor vagina femoris, between this and the anterior border of the glutseus 490 ORTHOPEDIC SURGERY Fig. 430. — Congenital Dislocation Reduced. CONGENITAL DISL O CA TIONS. 491 medius. The incision should pass well below the top of the femur, and should cross it slightly above the level of the trochanter minor. The tensor vaginse femoris is retracted and the fascia lata divided by a straight incision, and, if necessary, by an additional cross incision. The glutsEus is also retracted, and beneath the tensor muscle the rectus femoris will be found, with a reflected tendon passing outward, to be attached to the ilium above the acetabulum. If the muscular tissues are well retracted the capsule will be uncovered and can be split, this Fig. 431.— Congenital Dislocation. Reduction bj- incision. Osteotomy of shaft to correct twist of neck. should be done by an incision in the direction of the original skin incis- ion, and should be free enough to expose the whole head and neck as far as the trochanteric line, and, if necessary, a cross incision is made. An assistant should flex the thigh to a right angle to the trunk, and the attachments of the capsule to the neck and the trochanteric line, including the lesser trochanter, should be thoroughly freed both on the anterior and posterior surface of the neck to such an extent that the surgeon can pass his finger completely around the neck. The head can then be thrown out, the ligamentum teres having been divided, if pres- 492 ORTHOPEDIC SURGERY. ent. The head of the femur can then be pulled aside and a clear view of the capsule covering the acetabulum, as well as the acetabulum, can be had. If the capsule is constricted above the acetabulum it can be cut with a herniotome or stretched with a dilator or enlarged with a curette. It is important that the bony edge overhanging the acetabu- lum should project sufficiently to furnish a firm socket after the head is reduced. It is sometimes difficult, if the tissues are imperfectly divided, to find the socket, for the reason that a portion of the capsule lies flat across the socket and is adherent to the edges, the surgeon feeling only the upper edge and a mass of connective tissue ; but when this difficulty is met it is necessary to enlarge the incision, as it is essential that the head be placed well in the socket. It is not infrequently necessary to Fig. 432. — Double Congenital Dislocation of the Hip. Reduction on left side by open incision. Relapse on right side after attempted manipulative reduction. Capsular constriction at mouth of right acetabulum. Death six months after operation. deepen the acetabulum by means of a curette or gouge. This is neces- sary if the acetabulum is abnormally shallow. It is sometimes necessary, if the head of the femur is conical in shape, to remove a portion ; but if the cartilage on the acetabulum is removed and the head of the femur freed from its cartilage, ankylosis is liable to result. It is particularly necessary that the capsule should not be folded in attempted reduction in such a way as to prevent the free entrance of the head into the acetabulum, and it is especially impor- tant that the connection between the acetabulum and the femur at the trochanteric line and lesser trochanter should not be so firm as to pre- vent the easy reduction of the head into the socket. When it is found that the head when reduced into the socket will not remain there if the leg is adducted or extended, some remaining fibres of the capsular at- tachments on the anterior surface, passing from the ilium to the lesser CONGENITAL DISLOCATIONS. 493 trochanter and its adjacent parts, will be found to exist. After the acetabulum has been deepened sufficiently, the reduction of the disloca- tion should be performed. After the reduction the redundant capsule can be closed, with a wick for drainage, or packed, according to the judgment of the surgeon. Fig. -Diagram of Section of Capsule in Normal and in Congenitally Dislocated Hip. Drainage is to be regarded as of importance, as the cavity is a deep one and may be shut off. Furthermore, in this region the danger of infec- tion from urine, in small children, is to be considered. The experience at the Boston Children's Hospital has, however, been in favor of clos- FIG. 435. Fig. 434. Figs. 434 and 435.— Diagram Showing Difficulties in Reduction, i, In the capsule covering the acetabulum ; 2, in the shortened capsule between the acetabular rim and the lesser trochanter. ing the wound at the time of operation, leaving only a gutta-percha tissue wick, to be removed in a short time. When absolute confidence can be placed in thorough asepsis, closing the wound in this way at the time of operation saves for the patient a long period of wound- 494 ORTHOPEDIC SURGERY, healing. The hmb should be flexed by means of a plaster-of -Paris spica reaching from the thorax down to the foot, holding the limb in a strongly abducted position. The position of the limb can be gradually brought to normal by later application of plaster-of-Paris bandages. Reduction by Forcible AIaxipulatiox. This method, requiring necessarily the employment of an anaesthetic, was first attempted by Post, of Boston, without a permanent successful result. Paci, at the International ]\Iedical Congress in Rome, showed several cases successfully treated by a manipulative method of reduc- tion under an anjesthetic. This has been elaborated by Lorenz, of Vienna, who has extensively demonstrated the details of the method. Fig. 436. Fig. 437. Figs. 436 and 437. -Diagram Showing Pelvi-trochanteric and Pelvic Muscles in Congenital Dislocation of Hip. The method of manipulative reduction is based on the fact that in many instances the head can be placed in the acetabulum after all the ob- structions caused by the contracted soft parts are overcome by stretching, and that this can be done satisfactorily by using the femur as a lever. Complete anaesthesia is necessary. The child's ankle is grasped firmly and a strong pull exerted, counter-pull being furnished by an as- sistant who presses upon the perineum or, in the more resistant cases, pulls upon a folded sheet, one end of which is passed under the peri- neum. The limb should be rotated forcibly to both the outer and inner side, and then forcibly abducted both with the knee flexed and straight. It is essential that the adductor group of muscles should be over- stretched or torn, and this can be aided by forcible massaging or by striking with the hand the belly of the long adductor. After the limb has been brought to a right angle with the axis of the trunk, and in some instances twenty degrees beyond, the knee being straight, it should be again brought in a line of the axis of the trunk and then forced upward with the knee straight, until the thorax is touched by the CONGENITAL DISLOCATIONS. 495 front of the thigh, thus stretching the hamstring muscles. The child should then be turned upon its face and forcible hyperextension used, both with the leg abducted and straight. The child is then placed upon its back and reduction attempted, the surgeon holding the patient's limb just below the knee, which is flexed with one hand, the other hand being placed upon the pelvis, the palm pressing on the crest of the ilium and the thumb passing behind and beneath the trochanter. The thigh is then flexed and abducted, and with the limb in this position the operator should press the head of the femur downward with the exer- FiG. 438. — Dissection Showing Tendinous Insertion of the Lower End of the Adductor Magnus. else of strong force, to stretch the lower border of the capsule. The child is then turned upon its face and hyperextension exerted, both with the limb abducted and in a line with the body. The child is then placed upon its back and an attempt at reduction made. If the tissues have been sufficiently stretched by the above- 496 ORTHOPEDIC SURGERY. mentioned manoeuvres, the reduction can be easily made. The surgeon holds the patient's limb just below the knee with the hand, abducts the limb strongly, flexing it at the knee. The other hand is placed upon the pelvis, the palm of the hand resting on the anterior spine, and the thumb being placed under the trochanter, while an assistant steadies the pelvis by pressing upon the opposite side. The patient's knee is pressed downward from the plane of the operating table, while the tro- chanter is pressed upward and slightly forward. In successful cases the head will be felt to slip into the acetabulum with a sudden move- ment characteristic of the reduction of a dislocation. It is often necessary to give slight rotary motion to the limb and slight manipulation is often necessary. The surgeon can use the head Fig. 439. — Manipulati%'e Reduction in Congenital Dislocation of the Hip. Traction and reduction. of the femur to determine the size and depth of the acetabulum, and the firmness with which it is held in the acetabulum is also to be noted. In the more resistant cases a padded, wedge-shaped block placed behind the trochanter will be of assistance, serving to push the tro- chanter and head of the femur forward, while the patient's knee is pressed downward. When the head of the femur is well in the acetab- ulum it can be felt on careful palpation, lying under the point of inter- section of a line following the femoral artery, with a line crossing the pelvis at a level with the top of the symphysis pubis. A tightening of the hamstrings will usually be observed on reduction of the hip. After the reduction has been made, the limb should be carefully brought into a straight position, i.e., parallel with the long axis of the trunk. If dislo- cation occurs during this manipulation the tissues must be stretched still further and the head again placed in the acetabulum. CONGENITAL DISLOCA TIONS. 497 Reduction with the Aid of Mechanical Force. In the younger cases little difficulty will be encountered in stretch- ing the shortened muscles by the use of manipulation as described, but in older cases much force is necessary, which involves danger of fracture of the femur or pelvis, both of which accidents have occurred in manipu- FiG. 440.— Manipulative Reduction. Forced abduction stretching the adductors with blows upon the adductor attachment. lative reduction. A difficulty encountered where manual force is em- ployed is in holding the pelvis. This is essential to the accurate em- ployment of force, and the accurate employment of force is of the greatest importance if much force is to be used. It is for this reason that mechanical aids have been advised in the reduction of congenitally dislocated hips. One of the most efficient of apparatus for the purpose is an appliance devised by Mr. Ralph W. Bartlett, of Boston.' It consists of a perineal resistance plate, traction 1 <5«- Si Fig. 441. — Manipulative Reduction. Forced flexion with leg straight at knee. rods, and cyhnders, which press on the pelvis at and above the tro- chanters. The traction rods are attached to the cyhnders, and moving about each cylinder is a metal collar controlled by a handle. The collar is armed with a plate which can be made to press the trochanter down- ' Jour, of Med. Research, new series, vol. v., December, 1903, pp. 440-448,. 498 ORTHOPEDIC SURGERY. ward and forward. The cylinder is pivoted upon an eccentric pin, and when moved by a wrench can be made to increase the pressure of the trochanteric plate. The patient is placed in the apparatus with the perineum pressing on the perineal plate; the trochanteric cylinders are adjusted to press Fig. 442. — Manipulative Reduction. Hyperextension. upon and above the trochanters. The patient's ankles, protected by saddlers' felt and leather, are connected to the windlass at the bottom of the traction rods by means of rawhide straps. With the aid of this Fig. 443.— Manipulative Reduction. Head of femur pressed into acetabulum by manipulation after all contracted tissues are relaxed by overstretching-. mechanism, traction to any extent can be applied, and in connection with it a strong abducting force, with, in addition, a force which will press the trochanter and head downward when the limb is strongly CONGENITAL DISLOCATIONS. 499 abducted. The danger of fracture is diminished, as the replacing force is applied when the head is pulled away from the pelvis. This appliance has been used at the Boston Children's Hospital for the past two years, after careful experiments upon cadavers, and its effi- ciency proved in a series of thirty cases, some of these of the more resistant type. The Bartlett machine is to be regarded as a stretching appliance rendering the manipulative reduction easy after the thorough stretch- ing. In some instances a reduction takes place by the aid of the appa- ratus alone, rotation of the stretched limb being sufficient to lift the femoral head into the acetabulum. In the more difficult cases, however, the child is to be removed from the stretching apparatus and the ordinary manipula- tions applied. Tenotomy, FasciotOxA-iy. — The most important tissues other than the cap- sule which need to be stretched to en- able the surgeon to replace a congen- itally dislocated femoral head are the adductor group of muscles, the ham- strings, and the fascia lata, including the ilio-femoral band. The adductor group of muscles can be stretched with comparative ease, with the exception of the fibres of the ad- ductor magnus, which pass from the tuberosity of the ischium and are col- lected into a tendon of considerable size, which is inserted in a tubercle above the internal condyle of the femur. These fibres are not of importance in limiting the adduction of the limb and are not s-tretched by forcible abduction. They do serve, however, as a check to lengthening the lim.b, and in re- sistant cases offer the strongest resistance to a traction force needed to pull the head of the femur down to the level of the acetabulum. This resistance can be readily overcome by tenotomy of the tendon at the lower end of the adductor magnus. If a small incision is made on the inner side of the internal condyle of the femur, this tendon can be easily found, a director or hook passed underneath it, and a divi- sion of the tendon made without difficulty by a scalpel or scissors. It will be found that no other tissues in the adductor group will Fig. 444. — Plaster Fixation after Reduc- tion of a Congenitally Dislocated Hip. Foot raised to improve locomotion. 500 ORTHOPEDIC SURGERY. offer serious obstacle to the stretching movements preliminary to reduction. The ilio-tibial band which offers the strongest resistance to elonga- tion of the limb can be readily divided by a tenotome inserted beneath the skin a short distance above the external condyle. The band is from an inch to two inches in width, and can be easily felt beneath the skin on the outer side of the leg when traction is applied to the ankle. ■t m.r,und. ^•,ttcf,tf.c fi—,t- C J) arm ^-«ii,„p •> % a.$.re ''.c-AoH^tr Pig. 443. — Details of Bartlett Machine, Showing Effect oi Eccentric Movement. In double congenital dislocation of the hip where lordosis is well developed, the anterior portion of the fascia lata offers an obstacle when traction is applied, this force acting rather to increase the lordosis than to pull down the femoral head. This obstacle can be overcome by dividing the fascia near its attachment to the anterior superior spine. If a small incision is made through the skin a short distance below the anterior superior spine and the skin is retracted the fascia can be divided freely. Althousfh the hamstrins: muscles offer considerable resistance to CONGENITAL DISLOCATIONS. 501 pulling down the dislocated femoral head, tenotomy of their tendons, though easily performed, is rarely necessary, for the reason that the resistance of these muscles can be readily eliminated by flexing the thigh and knee. After the reduction it is important to stretch these muscles that the limb should be placed in a normal position without dislocating the head. This can usually be accomplished by forcible straightening of the limb with the knee extended after the head has been reduced. The above-mentioned procedures need not be considered except in the more resistant cases. Xo other resistant tissues are of importance, with the exception of the capsule. These measures are usually not needed, as the tissues can be stretched without resort to tenotomy in ordinary cases. Accident s.~T\\Q. method of reduction of congenital femoral disloca- tion by manipulation is not without danger and requires the exercise of considerable judgment. Fracture of the femoral head, fracture of the Fig. 446.— Bartlett Machine. Reduction of congenital dislocation of the hip. pelvis, death from shock, rupture of the femoral artery, temporary and permanent paralyses have all followed the injudicious use of force in correcting this deformity. These accidents can be avoided if the method is limited to the less severe cases. Slight paralyses not infrequently follow manipulative reduction, but pass away without treatment in a short time. From the experience at the Boston Children's Hospital it would appear that the danger of injury in forcible reduction is diminished by the employment of a mechanical appliance similar to the Bartlett ma- chine. Great care, however, and judgment are necessary in the use of this as of all powerful aids. After-Treatmext. — After the hip has been placed in the acetabu- lum, it is necessary that it should be held in the socket until the capsu- lar tissues are sufficiently strong to prevent a relapse. The child, while still under the anaesthetic, is placed upon a pelvic support and a firm plaster bandage applied to the thigh and pelvis, pro- tected by stockinet, felt, and cotton. The thigh should be flexed and abducted so that it is held at a right angle with the long axis of the body and with the inner cond}-le on the same plane as the symphysis pubis or a little lower. In this position the muscles are at a disadvan- tage in exerting a dislocating force ; the neck of the femur points for- 502 ORTHOPEDIC SURGERY. ward and the head is pushed forward. This position renders difficult a relapse in the direction of a backward dislocation and favors the cica- trization of the posterior capsular tissues. It favors anterior displace- ment, however, and the contraction of the tissues which check the bringing of the limb to the normal straight position. The position should be changed as soon as danger of a relapse in a backward direction is past. If it is necessary to retain the limb in the Fig. 447.— Six and One-half Years Old. Congenital dislocation of left hip. One year after reduction by ojjerative mechanical stretching and manipulation. Strongly flexed and abducted position for several months, the limb should be rotated daily while still in the plaster, to check the contrac- tion of the pelvic trochanteric muscles. After the danger of a relapse to a posterior dislocation is past, the limb can be fixed in the second posi- tion. For the second position the limb is brought down to a position of abduction of forty-five degrees. In cases with a well-developed socket and well-reduced head the limb can be placed in this position imme- CONGENITAL DISLOCATIONS. 503 diately after operation. It is the practice of some surgeons to allow the patients to walk about immediately after reduction, placing a high block under the flexed foot, in the expectation that the use of the limb will favor a deepening of the socket. For this the plaster needs to be cut so as to allow motion at the knee and free motion at the well hip. It. is safer, however, to fix both the hip-joint and the knee of the affected side for a few wrecks after the forcible reduction, carrying the Fig. 44S.— Showing Strength of Reduced Hip by the Trendelenburg Test. Motion and gait of reduced hip normal. plaster well down the limb and around the opposite perineum. After the tissues have recovered from the laceration of reduction, "the plaster can be shortened so as to allow the patient to enjoy more freedom. The length of time during which it is necessary that the plaster band- age should be worn varies, with each case, from two to six months or even a year In order to prevent the contraction of the muscles when the limb is placed in the plaster-of-Pans spica, it is desirable not only that the 504 ORTHOPEDIC SURGERY. child should walk about as freely as possible after the first few weeks following the operation have passed, but that the limb be rotated inside the plaster-of-Paris spica by an attendant, who, holding the patient's ankle, endeavors to straighten the limb at the knee and gently turns the foot inward. After the time has passed when plaster fixation is no longer necessary, daily exercise should be given, directed to increasing the motion at the hip-joint. It is necessary to stimulate the muscles which are not being used, and to stretch by gradual exercise the mus- cles which may remain contracted. The patient should be given both passive and active exercises. In the passive exercises the manipulator should place one hand upon the pelvis with slight pressure above the trochanter, and with the other move the femur in the direction of flex- ion and adduction, the patient being recumbent. Movement should also be made to straighten the limb at the knee and turn the foot in- ward, bringing the limb gradually in the direction parallel with the other. Similar active exercises can be undertaken and conducted with care daily. Relapses. — Although it may be claimed that a large number of cases of single congenital hip dislocations under ten )-ears of age can be reduced (with or without the aid of mechanical force), it must be ad- mitted that a considerable number of apparently cured cases relapse. The results have been divided by Lorenz into anatomical and functional cures, the latter term being applied to the cases in which the femoral head is near but not in the socket. But for the sake of accuracy it is desirable to avoid classing with successful cases those in which a failure in the attempted surgical procedure has resulted, even if the patient's condition may have improved. While perfect results can be obtained in a considerable percentage of cases by forcible manipulative reduction, the causes of relapse need consideration. One of the most common is wdiat may be termed im- perfect reduction, i.e., a reduction into the acetabulum with the folds of the enlarged capsule crowded into the socket in front of the femoral head. In some instances an hour-glass contraction of the capsule exists in congenital dislocation of the hip, too great and too firm to permit the passage in attempts at reduction of the femoral head through the con- stricted portion. It has been thought that the use of the limb in walk- ing in the after-treatment enables the pressure of the femoral head to wear through the folded capsule. Evidence to support this is lacking, and, considering the toughness and nature of the folded capsule and the large percentage of relapses, it is probable that when this condition exists (a condition verified by pathological evidence and where open incision has follow^ed attempts at forcible reduction) relapse is inev- itable. Relapse may follow where the capsular tissue fails to hold with suf- CONGENITAL DISL O CA TIONS. 505 ficient firmness in the acetabulum the reduced head after reduction. This takes place when a cotyloid ligament is not developed, and when the muscles are not sufficiently strong to keep the femoral head in place, or when tissues, contracted in the flexed and strongly abducted 5o6 ORTHOPEDIC SURGERY. position of after-treatment, prevent the placing of the limb in the normal position without causing displacement. Care in after-treatment may prevent relapses in many instances of 'V^i ■1 F this class. Careful examination of the cases during after-treatment by manipulation and with the skiagraph, the use of gymnastics, and mas- CONGENITAL DISLOCATIONS. 507 sage will be of advantage in restoring the muscles to their normal con- dition. Relapses result also from abnormality in the shape of the femoral head and in the shape of the acetabulum. It is impossible by manipu- lative reduction to place securely a distorted femoral head into an equally distorted and smaller acetabulum. Permanent reduction is also made difficult by the twist of the femur, which gives an abnormal direction to the femoral neck and consequent abnormal muscular rela- tion. The importance of the femoral twist in causing relapse after con- genital dislocation has been exaggerated. It has been found by the investigation of Mikulicz and also by Soutter that a femoral twist may exist to a considerable extent without causing noticeable disability. When a femoral twist of ninety degrees is present, it is impossible for Loiiq apcis neck. TraTJSveyse axis condvlea. Fig. 451.— Twist of Xeck in Congrenitall}- Dislocated Femur, Looking- from Above Downward. the patient to walk normally with the femoral head in the socket. Under these circumstances an osteotomy of the femur is necessary. Osteotomy. — When osteotomy is necessary it can be performed by the use of an osteotome or a chisel, dividing the femur beneath the lesser trochanter by a linear osteotom)'. If this operation is performed shortly after reduction, it will be found that some danger is incurred of displacing the reduced head by the use of the mallet and the osteo- tome. This danger can be avoided by the division of the femur a short distance above the condyle, employing a Gigli saw. This is easily ac- complished by passing a large, curved needle around the femur, care being taken that the needle should be kept close to the bone on the inner side and thus avoid any danger of injuring the artery or nerve. No difficulty will be encountered in placing the wire, and, although the skin and muscular tissue maybe somewhat injured in dividing the bone, the injury is no greater than that met in an ordinary osteotomy. It is safer to divide by the saw the greater part of the bone, leaving a por- tion to be broken that the remaining portion may serve as a splint to steady the fragments. The treatment after correcting the rotation by rotating the foot outward is the same as that of an ordinarv fracture. 5o8 ORTHOPEDIC SURGERY. As a guide to prevent the twisting of the upper fragment, a small steel wire can be driven into the trochanter during the operation. Any twist of the upper fragment will be readily noticed. Prognosis After Treatment. The results obtained in the treatment of congenital dislocation of the hip show a gratifying increase in the percentage of permanent cures Fig. 452.— Untreated Case of Double Congenital Dislocation. Unable to walk without crutches. as the knowledge of the pathological conditions of the deformity has been more thoroughly understood and as technical skill has increased. The results obtained at the Children's Hospital in the treatment of congenital dislocation of the hip from 1884 to 1903 inclusive will serve as a commentary on the progress made in the treatment of the affec- tion and will define the prognosis. I. From 1884 to l8g6—2T cases. Treated by mechanical appliances without operation, 7; by incision and curettage (Hoffa's early opera- CONGENITAL DISLOCATIONS. 509 tion), 12; by manipulation under ether (Post), 2. Successful, o; un- successful, 21. II. FTonil8g6 to ig02 — ^^ cases. By open incision, 34 : Successful, 11; unsuccessful, 6; result unknown, 17. By manipulation, 20: Suc- cessful, i; unsuccessful, 7; result unknown, 12. III. Cases operated in ig02 — 22 cases. By incision, 2 : Successful, o; unsuccessful, 2. By manipulation, 20: Successful, 8; unsuccessful, 2 ; relapse, 3 ; anterior transposition, 7. IV. Cases operated in IQOJ — JJ cases. By mechanical stretching and manipulation, 24: Successful, 16; unsuccessful, 3; transposition, Fig. 453.— Double Cong-enital Dislocation of Hip. Child aged four. Untreated. 5. By manipulation, 8 : Successful, 6; unsuccessful,:; transposition, i. By incision, i: Unsuccessful, i. These figures indicate the development of the treatment of the affection from the earlier attempts at treatment without operation until the recognition of accepted methods of treatment. The results reported as obtained in the year 1903 were carefully examined by a committee of surgeons six months or a year after operation, and may be regarded as representing the permanent condition.^ ^ "Report of the Orthopedic Staff of the Boston Children's Hospital, Based upon Observations in One Hundred and Forty-six Cases." Boston Med. and Surg. Jour., vol. cli., No. 4, p. 85, July 28th, 1904. 5IO ORTHOPEDIC SURGERY. It is difficult to determine from statistics the exact percentage of success to be expected from the open incision and from manipulative reductions. Statistics, however carefully compiled, vary in accuracy and in standards of success. An examination of the later statistics shows conclusively that the method of reduction by operative manipula- FlG. 454.— Same Patient, Age Twenty-eight. Untreated case. Patient able to walk actively with little limp. tion (the so-called bloodless reduction) may be expected to give perma- nent anatomical cures in from ten to twenty per cent of the cases, and improved, i.e., functional cures, in at least sixty per cent of the cases. The claim that a greater percentage of cures can be obtained by open incision carefully performed with the latest improvements in tech- CONGENITAL DISLOCATIONS. 511 niqiie is probably justified, although the results of the earlier attempts at open incision were not satisfactory. The statistics offered by Hoffa of later results from the open incis- ion with improved technique are highly satisfactory. Treatment of Older Adult Cases.— Baer, of Baltimore, has operated with success upon an adult patient of twenty-five years of age with double congenital dislocation. The reduction was accomplished by means of an open incision with deepening of the acetabulum. The second hip was operated upon two years after the first. Although a satisfactory result was obtained in this instance, such success cannot be anticipated in a majority of instances, and the risk of stiffenino- the Fig. 455.-PIaster-of-Pari.s Fixation after JlanipulatLve Reduction of Double Dislocation, Showing Amount of Ecchymosis. joint is considerable. Some benefit is obtained by manipulative treat- ment, with or without an anaesthetic, in increasing the arc of motion and the usefulness of the limb. As a rule, however, the best treat- ment in adult or older cases is by gymnastics, which will strengthen the muscles in the lumbar and gluteal regions. The use of a stiffened corset holding the hips and the dorsal region firmly, either made of stiffened leather or of cloth stiffened with steel, will be found of benefit in many of these cases in furnishing support to the back. Summary. Surgeons will vary somewhat in their choice of methods of opera- tion, according to their experience and success with the methods of reduction by forcible manipulation or by open incision, but these facts may be said to be generally accepted : As a rule no attempt at reduction is advisable under two years of age, as the tissues are not sufficiently developed to prevent relapse. In the early cases, from two to five years of age, reduction is easily accomplished by forcible manipulation. 512 ORTHOPEDIC SURGERY. In older cases, from five to ten, except in children with weak mus- cles, although reduction by forcible manipulation is often not difficult, reduction is much easier after stretching by the Bartlett machine, and in some cases the reduction is impossible without the aid of the Bart- lett machine. In cases older than ten, as a rule, reduction by open incision is to be preferred ; and in resistant cases under ten, where there is reason to be- lieve alteration of the shape of the head and acetabulum or a firm and narrow hour-glass contraction of the capsule exist, reduction by open in- cision after a thorough stretching of the muscular tissues is advisable. In cases of doubt as to which method to employ, the surgeon can regard it as a safe rule to follow if reduction is first attempted by forcible manipulation, employing open incision if relapse follows. Al- though the operation by open incision cannot, if performed with skill, be regarded as more dangerous than that of forcible manipulation, as a rule it is less acceptable to parents of patients. Where the acetabulum is too shallow to hold the reduced head, it should be deepened if a lasting reposition is to be expected, but no sur- geon should attempt this procedure or the reduction by open incision unless assured of complete asepsis in every surgical detail . The length of time needed in after-treatment must be determined by the condition found after reduction, and must be left to individual judgment in each case. Double cases are to be regarded as more than twice as difficult as single. Attempts at reduction by forcible manipulation should be made on both hips at the same time, but if open incision is employed, as a rule two separate operations are necessar}". KNEE. Congenital dislocation of the knee is seen with greater frequency than that of some of the other joints.^ It occurs most often in the form of hyperextension of the leg on the thigh, which has been considered by some writers a displacement rather than a true dislocation forward. In some cases the lower epiphysis of the femur is bent forward on the shaft.- It is in any event a congenital affection of importance when it occurs. It is frequently double, and the displacement may be directly forward or forward and to one side. The leg forms a right angle with the thigh, the apex of the angle being backward, and the cond)-les of the femur can be felt in the popliteal space ; the patella is often small and occasionally absent, and lateral mobility may be present. Modifi- cations in the shape of the bone, ligaments, and cartilages in the knee- ^ Drehman : Zeitsch. f. orth. Chir., vii.. 22 (98 cases). - Delan^lade : Rev. d'Orthopedie, May, 1903. CON GEN I TA L DISL O CA TIONS. 5.13 joint, even to the point of ankylosis, have been recorded in some of these cases. The deformity may be associated with malformation- of Fig. 456.— Congenital Dislocation of the Knees Forward in a Yonng Adult. Other parts, and the cause can be given no more clearly than that of other congenital deformities. Forward displacement of the leg at the knee is to be treated by manipulation in the direction of correction and the application of a solint to the knee to hold the leg in a corrected position. Following Fig. 457.— Congenital Dislocation of the Knee. (Genu recurvatum with club-foot.j these measures apparatus should be applied to limit the lateral motion if it is present, restricting the amount of hyperextension and increasing the amount of flexion. Apparatus must be worn, of course, till the 'h'h SH ORTHOPEDIC SURGERY. structures about the joint have adapted themselves to the new condi- tion. Posterior dislocation of the tibia on the femur occurs at times. Lateral subluxation may be found in connection with other congenital deformities.^ PATELLA. Dislocation of the patella is among the more common of the con- genital dislocations ; many cases reported as congenital have, however, been doubted. The type most frequently seen is outward dislocation existing with some degree of knock-knee. It may be displaced inward or upward, in the latter case being associated with lengthening of the patella tendon. There may be, in connection with the dislocation outward, absence or flattening of the outer condyle of the femur. The disability may be slight or there ma}^ be marked impairment of the extension power of the leg on the thigh. Treatment by operation would be similar to that described in speaking of slipping pat-ella. Congenital Absence of the Patella. - The patella may be absent or tardy in its development. If it is absent the knee appears broad and flat and there may be marked im- pairment of the function of the knee. In other cases the knee is FIG. 458.-ConKenital Dislocation of bo.h Knees ^^^^^^^_ Jt ^^^y COCxist with Other with Club-foot. (Remer.) -' malformations of the knee, espe- cially genu recurvatum. It is often bilateral and is frequently associ- ated with club-foot and similar deformities. The treatment consists of apparatus to support the defective joint and massasre and muscle trainino; to the extensor muscles. 1 Cone : Am. Medicine, November 5th, 1904, p. S12 (with literature). -A. Thorndike : Orth. Trans., vol. xi. CONGENITAL DISLOCATIONS. 5.15 ANKLE. Inward and outward congenital dislocations of the ankle have been recorded in connection with absence of the tibia or fibula.^ SHOULDER. True congenital dislocation of this joint is rare, and many cases re- ported as congenital have proved on investigation to be dislocations due to paralysis or due to injury to the shoulder at birth, resulting most often in a separation of the epiphysis. The dislocation found is the subspinous, but other varieties have been recorded, such as the sub- coracoid and subacromial. Double dislocation of the shoulder has been described and in some cases associated with other malformations. In one case two children in one family were similarly affected. The glenoid cavity is likely to be malformed, as in a case reported by Smith, where there was hardly a trace of the normal glenoid cavity. In other cases it is approximately normal. The limitation of function is similar to that in traumatic dislocations. Cases of dislocation of the shoulder- joint in young infants have been reduced with or without incision, with improvement in the usefulness of the arm; cases of true congenital dis- location, however, improved by operation are fev/. Cases were oper- ated on by Phelps by doing what was practically an arthrodesis through a posterior incision, and the redundant capsule was removed. Some similar cases have been reported, but most of them are open to the sus- picion of not having been congenital. The chances of successful re- placement would be greater in cases with a normal glenoid cavity and in cases undertaken early in life. In later childhood the prospect is less good. In addition to the operative reduction, reduction by manipulation is to be considered, following the lines indicated in the operation for con- genital dislocation of the hip. After replacement the arm should be held by a plaster bandage for some months in a position of abduction and outward rotation." ELBOW. Congenital dislocations of the elbow are very rare and of compara- tively little practical importance. The reported cases do not conform to any one type, following a wide range of variation. I. Both bones maybe dislocated forward or backward. This condi- tion is extremely rare. ' Freiberg : Amer. Jour, of Orth. Sur. . vol. i., No. 4, p. 335. -Whitman: " Orthopedics," second edition, p. 473.— Porter: Orth. Transac- tions, xiii., 1898.— Cumston: Amer. Jour, of the Med. Sciences, June, 1903.— Kir- misson: "Traite des Mai. chir. d'Origine Congen.," Paris, 1898, p. 485. 5i6 ORTHOPEDIC SURGERY. 2. The displacement of the head of the radius is a more frequent form of dislocation and may occur on both sides. The dislocation may be backward, forward, or outward, with or without abnormality of the other bones of the arm. 3. Backward dislocation of the radius and partial dislocation of the ulna with imperfect development of the external condyle have been recorded. The displacement may or may not be seriously disabling. In cases requiring radical operation, the head of the radius or the entire elbow-joint may be resected. Cubitus Valgus— Cubitus Varus. In connection with congenital dislocation of the elbow may be men- tioned a deviation from the normal line of the arm occasionally seen. If the arm of the adult hangs at the side with the palm of the hand directed forward, the line of the forearm should form with the line of the arm an angle of about 169 degrees with a variation of 10 degrees in either direction. The outward deviation of the forearm is a few degrees greater in women than in men. Cubitus valgus is the name applied to the condition in which the forearm is displaced too far to the radial side; cubitus varus, the condition in which it is displaced to the ulnar side. Trauma is the most frequent cause of the marked varieties. They are also associated with rickets and the element of inheritance apparently plays a part. In case either deformity should be severe enough to require operative treatment, an osteotomy may be done simi- lar to the Macewen operation for knock-knee. WRIST. Pure congenital dislocation of the wrist is extremely rare. The ordinary form in which it is seen is in connection with club-hand. Spontaneous Subluxation of the Wrist. A displacement of the wrist has been described by Madelung,^ in which the hand is displaced to the palmar side of the forearm and prob- ably to either the radial or the ulnar side laterally, generally to the former. In such cases the lower border of the radius and that of the ulna are prominent at the dorsum of the wrist, and the bones are somewhat sep- arated from each other. The wrist is much increased in thickness and the function of the hand is impaired. Active and passive dorsal flexion are affected and some pain may be present, especially in dorsal flexion. The hand can be replaced only in the lighter grades of the affection. There is excessive mobility of the intercarpal joint and there may be slight forward bending of the lower extremity of the radius. ' Archiv f. klin. Chir. , Bd. xxiii. CONGENITAL DISLOCATIONS. 517 Aside from the pain which may be present, the symptoms are weakness and sensations of discomfort about" the wrist. The causes of the affection are given as relaxation of the Hgaments, stretching of the muscles by hard work, irregularity of growth at the lower end of the radius, and possibly a malposition lasting over from rickets. The treat- ment is at first hyperextension of the joint by means of bandages and splints, the use of massage and similar measures, and osteotomy in cases with bony deformity sufficient to require it. CHAPTER XIX. TALIPES. Talipes equino-varus (Club-foot). — (Pathology. — Etiolog}-. — Symptoms. — Diag- nosis. — Prognosis. — Treatment. ) — Talipes equinus (Varieties. — Etiology. — Pathology. — Symptoms. — Treatment). — Talipes calcaneus (Varieties. — Symptoms. — Treatment). — Talipes valgus. — Talipes varus. ^Talipes cavus. Club-hand (Varieties. — Etiology. — Symptoms. — Diagnosis. — Treatment). The name talipes signifies a deformity of the foot, and, although it was originally used to indicate a form of talipes now known as equino- varus or club-foot, the present use of this word is as a prefix to the de- scriptive adjective designating the variety of the deformity which exists. Of the pure forms of talijDes one finds described talipes equinus, the plantar-flexed foot ; talipes calcaneus, the dorsally flexed foot ; talipes cavus, the foot with increased arch; talipes valgus, the everted foot; and talipes varus, the inverted foot. Talipes equinus may exist with either valgus or varus, being then spoken of as equino-valgus or equino-varus, the elements of two de- formities being present. Talipes calcaneus may exist in connection with valgus or very rarely with varus, being then known as calcaneo- valgus or calcaneo-varus. TALIPES EQUINO-VARUS (CLUB-FOOT). The term club-foot is popularly applied to a deformity characterized by an inversion, torsion, and depression of the front part of the foot with an elevation of the heel. In walking on a foot thus deformed, the weight of the body is borne, not by the sole of the foot, but by the outer side, and in extreme cases by the dorsum of the foot. The distortion is also known as "reel" foot — pes contortus, Klump-Fuss, pied bot, etc. The deformity is either congenital or acquired. Frequency. — Club-foot is by no means an uncommon distortion, and was mentioned in literature even in the days of Homer. ^ In 6,969 orthopedic patients applying at the out-patient department of the Chil- dren's Hospital, Boston, there were 488 cases of club-foot. Congenital club-foot is by far the most frequent of the congenital deformities of '"Iliad," i,, 599; xxi., 331. 518 TALIPES. 519 the foot. It affects males more frequently than females, and the right foot is more frequently affected than the left. It is as often double as single. Acquired club-foot affects males and females in about equal proportion, the right foot is most often affected, and it is more fre- FIG. 459. -Section of Foot and Leg in Club-foot. Fig. 460. — Section of Foot and Leg, Normal. quently unilateral than bilateral. Chaussieur, among 22,923 newly born infants, reports 37 cases of club-foot. Lannelongue, among 15,229 births at the Paris Maternity Hospital, found 8 cases. Pathology. — The deformity is a dislocation inward of the anterior part of the foot, the dislocation taking place at the medio-tarsal articu- lation. All the tissues are necessarily affected by the abnormal posi- tion, and the skin, muscles, tendons, and fasciae are all altered. In all cases of congenital club-foot, even in that of a full-term foe- tus, the scaphoid bone will be found articulating with the side of the Fig. 461.— Relation of Astragalus to Os Calcis. (Whitman.) Fig. 462.— Relation of Astragalus to Os Calcis in Flat-foot. (Whitman.) head of the astragalus rather than with the anterior surface. The articulation is also more toward the under side of the astragalus, the head of which is thus uncovered. The scaphoid may be so far distorted to the side as to articulate at one end with the tip of the internal malleolus. The cuneiform bones, being intimately connected with the scaphoid, follow the displacement of the latter, and the same is true of the metatarsal bones and the pha- 520 ORTHOPEDIC SURGERY. langes, so that the long axis of the front of the foot forms a right angle, or even an acute angle, with the axis of the leg. The cuboid is neces- sarily displaced to the inner side and does not articulate with the front of the OS calcis, the facet of which also inclines obliquely to the inner side. In fully developed cases, and in older children or adults, there is a more marked and important alteration in the shape of the bones. The OS calcis, by the elevation of the tuberosity, is drawn from a horizontal into a position approaching the vertical. It is also more or less rotated on its vertical axis, so that its anterior extremity is directed outward and the posterior extremity inward, and thus the anterior artic- ulating facet is oblique to the axis of the bone. The cuboid bone main- FiG. 463. — Dissection of Club-foot. tains its connection with the os calcis, but follows the inward direction of the anterior extremity of the foot. There is no rotation of the astragalus on the vertical axis, but, as has been stated, it is depressed forward on its horizontal axis, so that only the posterior portion of its superior articular surface is in contact with the inferior articular surface of the tibia, and the anterior part of its anterior facet projects beneath the skin of the dorsum of the foot. Besides this displacement, the shape of the bone is altered by the twisting inward of the head and neck, so that the anterior articular sur- face looks inward instead of forward, and the disposition of the carti- lage at the articulating surfaces of the head of the astragalus is neces- sarily altered. The three cuneiform and the three metatarsal bones, being closely connected with the scaphoid, are more twisted to the in- side than is the case with the cuboid, though the metatarsals are not all TALIPES. 521 equally involved in the rotation from without inward and are spread out something as the branches of a fan, in such a way that the anterior part of the foot is enlarged more than normal. Besides these alterations in the position of the foot others take place secondarily, depending on pressure and the effect of locomotion on the distorted bones. The different tendons assume an abnormal direction and in general are carried farther to the inside than is normal ; this is especially true of the tibialis anticus, the common extensor of the toes, and the long extensor of the great toe. Synovial bursse may form on the outer Fig. 464. — Double Congenital Club-foot. edge and back of the foot, which may become inflamed and suppurate ; corns and callosities are also formed on the skin, from the pressure of walking. No change has been found in the nerves or the spinal cord in cases of club-foot. In extreme cases there may be slight alteration in the shape of the femur and a laxity at the knee-joint; the tibia has also been found al- tered, and the same is true of the fasciae. The muscles are never found paralyzed in congenital club-foot, but the contracted muscles seem more developed than the lengthened muscles. The muscles of the leg atro- phy from disuse, and the leg is much smaller and the foot shorter than normal. 522 ORTHOPEDIC SURGERY. In addition to the faulty shape of the bones there is a change in the ligaments and fasciae, and this is not confined to the severe and most inveterate cases, but is always present. Not only are the plantar liga- ments and fasciae contracted, but the internal lateral and posterior liga- ments are also contracted. Etiology. — In regard to the etiology of congenital club-foot, various theories have been advanced in explanation of the deformity. A popular idea is that the distortion is due to maternal impressions, but no conclusive evidence in regard to this has been obtained.^ Heredity, on the part of both the father and mother, has been established without doubt in a certain number of cases, but in a very large majority no trace of similar deformity in ancestors can be found. The chief theories which have been advocated to explain the de- formity in uterine life are as follows : First. — Abnormal compression in the uterine cavity. Second. — Retraction or paralysis of muscles depending or not on lesion of the nervous system occurring in utero. Third. — A malformation depending upon arrest of development of the foot. With regard to these theories it may be said that abnormal com- pression of the uterine walls may be a factor in producing the deformity, that evidence of muscular paralysis is wanting, and that the evidence that club-foot is due to a retarded rotation of the foot - and is the persis- tence of a foetal condition is not supported by good evidence.' It may be said that we are entirely ignorant of the causation of club-foot, and unable to give a reasonably satisfactory explanation of the phenomena of its development." Symptoms. — Club-foot gives rise to great inconvenience in walking. In uncorrected cases, however, the amount of skill and agility patients acquire in locomotion is surprising, even though the deformity remains unchanged. Bursae and callosities form over the unprotected portions of the foot, and may inflame and cause much discomfort, limiting the amount of the patient's activity. A laxity of the knee-joint is some- times developed in consequence of club-foot. The gait of these patients is characteristic. In double cases the feet are lifted one over the other as a step is taken, giving a peculiar appearance, and perhaps suggesting the popular name of "reel" feet. The tendo Achillis is firm and hard to the touch ; the plantar fascia ' Dabney : '" Cyclopedia of Diseases of Children," vol. i. -Brit. Med. Journ., 1886, ii. 10; Archives of Med., New York, Dec. i, 1882; Boston Med. and Surg. Journ., Oct. 27, 1887.— Wolff : " Ueber die Ursachen, etc.. des Klumpfusses," Berlin, 1903. ^Bessel Hagen : " Die Path, und Therap. des Klumpfusses," Heidelberg, 1899. ■*R. W. Parker and Shattuck : Brit. Med. Jour., May 24th, 1SS4. p. 998. TALIPES. 523 will be found short and hard on palpation. The front of the foot pro- jects to the inside of the vertical axis of the leg, the posterior end of the OS calcis is raised and turned inward, the leg is turned outward, and the head of the astragalus and cuboid project under the skin. There is usually atrophy of the muscles of the leg. The external mal- FlG. 465. — Cong'enital Club-foot. Cured club. Twenty-four years after correction in infancy by tenotomy, manual force and retention, walking appliance worn for two j'ears. Patient able to walk without limp or discomfort twenty miles a day. leolus is prominent and the internal malleolus not readily felt. The foot is more or less rigid in the deformed position, resisting gentle attempts at correction. Diagnosis. — There is no difficulty in recognizing the deformity of club-foot. In infancy, a true club-foot is sometimes thought to exist when the trouble is simply a temporary spasm of the tibialis muscles which turn the foot in. This passes away in a short time and should occasion no anxiety. The history of the case establishes a diagnosis between the congeni- tal and non-congenital forms of club-foot. The paralytic form can be 524 ORTHOPEDIC SURGERY. recognized by the evidence of paralysis of the muscles on the anterior and external surface of the leg. Paral) sis, it may be added, is the only common cause of acquired club-foot. The severity of cases of club- foot cannot be determined always by the apparent distortion. Cases resembling each other in outward appearance may pro\'e less or more difficult of treatment. As a rule, however, it may be said that the younger the patient the less resistant the deformity, and it is often con- venient to consider the cases as : I St. Infantile — i.e., infants in arms. 2d. Walking cases — i.e., cases in young children in which the feet have been walked upon before the deformity has been corrected. Fig 466. Fig 467. Fig. 468. Fig. 466.— Diagram Indicating- Mid-tarsal Articulation in Club-foot and the alteration in the positions of the sci.phoid and cuboid in their relation to the astragalus and os calcis— with alteration in the shape of front of os calcis. Fig. 467.— Diagram of a Normal Foot. Fig. 468.— Diagram of a Club-foot Partially Corrected, Leaving the Projection of Front of Os Calcis Unchanged, and the Consequent Imperfect Reduction of the Cuboid. A relapse necessarily follows. 3d. Resistant or relapsed cases — i.e., those which have resisted treatment, or in which treatment has been inefficient, and in which the deformity has recurred. 4th. Neglected cases, in which the feet have grown for years in a severely distorted position. Prognosis. — In regard to the prognosis of the deformity, it may be said that the distortion does not correct itself, and, if left uncorrectea, remains the most obstinate of malformations. The deformity is one which is essentially curable; in fact, it may be said that it is always curable, provided care and attention can be given by both surgeon and nurse. TALIPES. 525 The amount of time needed for treatment varies according to the method employed. Formerly much time was needed in the treatment of inveterate cases, but since the introduction of open incision and tarsal resection, when necessary, correction can be accomplished in a short time. In infantile cases the time required for correction is relatively short, but retentive appliances are needed for a longer time. It may be said in general that the older the cases and the larger the foot the more difficult the correction, but the less the danger of relapse after correc- tion. In regard to the permanence of the cure and the danger of relapse, it may be said that if perfect correction is attained relapse is excep- tional, if moderate care is used in the employment for a sufficient time of retentive appliance.' But it must be borne in mind, especially in the case of young chil- dren, not only that the correction must be complete, but that efficient appliances for keeping the proper position of the foot in walking (reten- tive or walking appliances to be described) must be worn until the gait and attitude are perfect. In club-foot half-cures are practically no cures. Relapsed cases are invariably resistant and difficult to correct. Treatment.— The object of treatment is the correction of the distor- tion and the retention of the foot in a corrected position until any re- turn of the deformity is impossible, the tendency to relapse being very strong. The treatment should be purely mechanical, or both operative and mechanical. The treatment of club-foot, therefore, requires : 1. A rectification of the misplaced bones and a lengthening of short- ened and contracted tissues. 2. A retention in a normal position until the abnormal facet of the astragalus and the other tissues become, under the pressure of new po- sition, normal. At the present time few procedures in surgery are as precise in their indications and as certain in their results as the methods for the cor- recting of club-foot. The correction of club-foot should be divided into two steps, whether the treatment is mechanical or operative. I St. Correction of the varus deformity. 2d. Correction of the equinus deformity. In other words, the front of the foot should be twisted out and after- ward be raised. This will be found of practical importance, as the foot is more easily twisted before than after the equinus deformity is over- come. 1 Trans. Am. Orthop. Assn., vol. i., " Club-foot." 526 ORTHOPEDIC SURGERY. . Operative treatment in some form is the method to be selected in cases of congenital club-foot, except in young infants and in older chil- dren when some contraindication to operation exists. The mechanical procedures for correcting club-foot are as follows : Manual manipulation. Plaster-of-Paris bandages. Apparatus. The operative procedures which are to be considered in treating club-foot are : Tenotomy. Division of the ligaments. Open incision. Forcible correction and osteotomy. Mechanical Correction. Manual. — The simplest method of correction is by the use of the hands, and in the case of a new-born infant with club-feet the mother may be directed to manipulate the foot, and having rectified the de- FiG. 469. — Double Club-foot in Plaster Bandages After Operative Correction. formity by gentle force several times daily, to hold it as straight as possible for a minute or two each time. This process continued daily over a period of months is in intelligent hands capable of restoring the foot to its normal mobility and position, after which retention treat- ment should be besfun. TALIPES. 527 Plaster-of-Pai is Bandages. — Another method in correcting club-foot is by repeated fixation in a plaster-of-Paris bandage, the foot being held as nearly in a corrected position as possible at each application of the bandage until the bandage hardens. The application of a plaster-of- Paris bandage must, however, be made with care and skill to prove effi- cient, whether applied for correction without operation or to maintain the overcorrected position obtained by op- eration. The foot should be wound with plenty of sheet wadding, pads should be Fig. 470. — Congenilal Double Club- foot Walking Before Operation. Fig. 471. —Double Club-foot. Two months after correction b}'- forcible manipulation, wearing walking retentive appliances. Same case as Fig. 470. placed between the toes, and the foot should be held overcorrected from the first during the application of the bandage by an assistant, who shifts the fingers from place to place to keep out of the way of the bandage, yet who maintains the overcorrection. To overcorrect the position of the foot when the plaster, is setting is to cause folds of the bandage to turn in and either compress or cut the tissues after the plas- ter is set. It is important to keep the inner end of the foot part of the bandage long, to press outward the front of the foot, and thus antago- nize the varus. 528 OR THOPEDIC S UR GER 1 '. The circulation of the toes must be carefully watched after the ap- plication ©f such a bandage. An extension of this method is to be obtained after the plaster has set by removing an elliptical piece of the plaster bandage over the an- terior and outer aspect of the ankle and dividing the rest of the band- age at the same level by a circular cut. By crowding the front of the foot-piece up and out and holding it in the improved position by fresh bandages applied over the old plaster, further correction is obtainable. Fig. 472. — Splints for Equino-varus Applied. The bandage should reach above the knee, where the limb should be slightly bent to prevent the plaster bandage (which should be re- newed ever}' two or three weeks) from rolling around the limb, and to prevent the child from kicking it off. In the case of small children with plump legs, and in resistant cases, it will, however, be found diffi- cult to prevent the heel from being drawn away from the bandage, and stretching of the tendo Achillis will by this method be tedious. This method has the disadvantage of being tiresome, but it has many advantages in being a practical method, readily applied, and not leaving details of application to the patient's parents. It is evident that TALIPES. 529 correction in this way, if persistently applied, is possible, but, except in very young children, it is advisable to perform tenotomy first. If the Chinese^ can produce an extreme deformity by bandaging the children's feet, the same method could be emploved for the correction of deform- ity. ^^^/^m/z/j.— Mechanical correction fwithout tenotomy) by means of appliances has been successfully employed in very young cases. The method, however, requires much persistence on the part of the surgeon if a perfect cure is expected, and is not to be advised. Although treatment by apparatus is not sufficiently effective to cure any but the mildest forms of congenital club-foot in young children, it is often enough to bring about a cure in acquired club-foot of moderate severity. The form of apparatus is the same whether used as a correc- tive or as a retentive appliance, and will be described here. The object of such apparatus is to retain the tarsal bones in proper position until the muscles and ligaments have adapted themselves to the normal posi- FIG. 473.-Taylor Shoe in Process of Adjust- FiG. 474.-The Upright Brought into Place inent. The sole plate applied and the foot and Acting as a Lever, Turning the Foot strapped to the sole plate. to the Outer Side. tion, and until articular facets have been formed in the proper directior, or the astragalus and os calcis have assumed, under altered pressure, a relatively normal shape. Corrective apparatus is essential after the desired position of the foot has been obtained by other means. The corrected foot tends to relapse in two directions— inversion and elevation of the heel. If this is unchecked and walking is done in im- proper attitudes, hurtful pressure and strain fall upon the bones and ligaments of the foot, and relapse takes place. This should not occur if proper retention and walking with a proper attitude of the foot are cared for. As these appliances are to be worn a long time, they should be light, readily adjusted by the nurse, not unsightly, and m no way limiting lo- comotion, walking, or running. The best are worn within the shoe. ' Percy Brown : Journal of Med. Research. 1904. 34 530 ORTHOPEDIC SURGERY. It is unnecessary to describe all the various appliances that have been used. Mention will here be made of one which has been found of service in the writers' experience, after a careful trial of the usual \'ari- eties of appliances designed for the purpose. It is to be remembered that in all appliances it is necessary that the pressure preventing a faulty position of the foot should be applied pre- cisely, pressing the front of the foot and tip of the heel outward, the front of the foot, especially the outer edge including the cuboid, upward, and the back of the foot, i.e., the end of the os calcis, downward, and the outer dorsum of the foot inward. Inward pressure should be exerted upon the outer edge of the front of the OS calcis and astragalus, and not upon the cuboid, as is too com- monly done in inefficient apparatus. As the latter bone is in front of the mediotarsal joint, inward pressure upon it not only fails to correct the deformity but tends to increase it. This explains the occurrence of many relapses. The apparatus (Chapter XXI., 27), which is a modification of Tay- lor's varus shoe, consists of a sole plate small enough to fit in a shoe secured to a jointed upright furnished with a stop to prevent the plate from dropping into the equinus position. The foot is secured to the plate by means of a strap which, secured to the inner side of the plate, passes from the inside of the great toe obliquel)- to the outside of the foot so as to press upon the anterior outer surface of the os calcis and through a loop at the outside, and then is brought across the ankle through the metal loop and secured in the clasp. A cross strap to keep the toes down, and a cross ankle strap to keep the heel down, are sometinies necessary in addition, with a back strap behind the heel. The appliance can be worn inside of a shoe, opened like a bicycle shoe well down to the toes. A combination of operative and mechanical methods of treatment is at present the most common mode of treating club-foot at all ages. The -operative interference most frequently resorted to is tenotomy and subcutaneous division of the fasciae or ligaments. Operative Tre.\tment. — Tenotomy. — The structures to be di- vided are, of course, those which hold the foot in its deformed position. The tendons may be divided by entering the tenotome under the skin and cutting the tendon from without inward, or by passing the tenotome under the tendon and cutting outward. The advantage of the former is that there is no danger of making a large skin incision by a slip of the tenotome. There is, however, danger of incomplete cut- ting of the tendon. The tendon which is most frequently divided in equino-varus is the tendo Achillis. Section of the Tendo Achillis.— The patient should lie upon his face or side and an assistant should bold the foot ; the surgeon enters the TALIPES. 531 knife parallel to the border of the tendon, passing the tenotome flatwise between the tendon and the skin. This having been done, the blade of the knife is turned toward the posterior surface of the tendon and the assistant raises the end of the foot so as to stretch the tendo Achillis slightly. The left index finger presses on the skin over the back of the tenotome, and in this way the sensation of the cutting of the tendon can be felt. The only precaution necessary is to be assured that the tendon is completely divided. When the operation is done, the extravasated blood IS squeezed out of the opening and a small amount of aseptic gauze is placed over the wound. The operation should be done aseptically and an aseptic dressing applied. Section of the Tibialis Posticus. -S^zWoxx of the tibialis posticus is done m the following way: If the muscle is divided in the leg the foot IS placed on its external border. The surgeon divides the' skin by ^'*5- 475. Fig. 476. Fig. 476.— Imprint of Normal Foot. means of a pointed tenotome 2 cm. above the tip of the internal malle- olus and on a vertical line situated half-way between the posterior bor- der of the malleolus and the corresponding border of the tendo Achillis The tenotome should be directed perpendicularly downward to the depth of I or 1.5 cm. Then the handle of the instrument should be turned so as to describe the arc of a circle and the tendon divided ver- 532 ORTHOPEDIC SURGERY. tically inward. The assistant at the same time turns the foot forcibly in the direction of abduction. If the incision is made too near the mal- leolus, the internal saphenous vein and nerve may be cut. If the inci- sion is made too near the tendo Achillis, there is danger of dividing the tendon of the long flexors of the toes and the posterior tibial artery and nerve. The writers can record the puncture of the posterior tibial artery by the point of a tenotome and the formation of a small aneurism which required ligation, but caused no subsequent annoyance. The Tendon of the Tibialis Anttcus.—ThQ tendon of the tibialis an- ticus is divided more easily. For this purpose it is sufficient to be Fig. 477.-Relapsed Resistant Congenital Club-foot in a Boy of Eight. Front view. guided by the prominence of the tendon put on a stretch by abducting the foot. To avoid the wounding of the deep parts, it is better to enter the tenotome under the tendon. Division of the Plantar Fascia.— \X. is often necessary to divide also the plantar fascia, preferably before division of the tendo Achillis, as the latter acts as a means of support for stretching the foot when the plantar fascia is divided. The plantar fascia is divided in the same way TALIPES. 533 that the tendons are incised. The most prominent portion of the fas- cia is the point of election for subcutaneous incision. The fascia, it must be borne in mind, is not a narrow band, but a broad Hgament needing a long subcutaneous incision. The tenotome should be inserted on the inner side of the sole nearly half-way between the os calcis and the ball of the foot, but nearer to the os calcis. The tenotome is to be pushed subcutaneously nearly across the sole, the edge of the knife Fig. 47S.- Same Case. Three weeks after forcible correction, immediately after removal of plaster retention bandages. turned toward the fascia, and the knife drawn across the fascia, which will be felt to give way as it is divided ; an assistant should make up- ward pressure upon the ball of the foot, in order to put the fascia on the stretch. As the artery lies deeply, there is no danger of injuring it, if ordinary care is used. The tenotomes used should be strong at the neck, and the cutting edge should not be too long, as the skin is necessarily divided if they are too long ; infantile cases require a much smaller instrument. The blunt-pointed tenotome is but little used now, and the sharp-pointed ones are used for all subcutaneous work. Tenotomes as furnished by instrument-makers are ordinarily much too large, and though serviceable in myotomy, are better for tenotomy in children if smaller. The Repair of Divided Tendons}— ^]\q\\ a tendon is divided, the ^Seggel: Beitr. z. klin. Chir., xxxvii., i and 2. 534 ORTHOPEDIC SURGERY. cut ends are separated to a variable extent, depending upon the retrac- tion of the muscle to which it belongs, upon the position in which the limb is placed, and upon the surrounding attachments of the tendon. Extending beneath the ends of the tendon is its tubular sheath of con- nective tissue, and it is this which chiefly furnishes the reparative mate- rial. The sheath becomes vascular and succulent, and after the absorp- tion of the blood that has been effused within it, the interval between Fig. 479. — Relapsed Resistant Congenital Club-foot in a Bo_v of Eight. Rear view! the divided ends of the tendons becomes filled with lymph, which grad- ually becomes fibrillated and forms a firm bond of union between them. The new material so closely resembles the old tendon and is so in- timately blended with it that for a time it would be difficlilt to distin- guish them, except for a certain translucency which is possessed by the former, and is not natural to the latter. By this means the divided ten- don is increased in length to the extent of the interval by which its ends are separated, and elongation will vary according to the amount of separation. If after the operation treatment is carried out with ordinary care and skill on a healthy subject, a useful muscle is obtained. TALIPES. 535 Adhesions may, and doubtless often do, form between the divided tendons and the surrounding structure, but in ordinary cases they are not of consequence, for they give way in the use of the foot, and do not interfere with the function of the muscle. Much undeserved opprobrium for a time fell upon the procedure of tenotomy. In half-cured and relapsed cases atrophy and functional dis- ability of the muscles will be found ; but there is no evidence to de- monstrate that tenotomy, when properly performed, exerts an unfavor- able influence upon the muscle. Division of the Ligaments. — Division of the ligaments ^ is of use in the correction of club-foot. For division of the astragalo-scaphoid ligament, the skin and soft tissues should be punctured down to the bone by the insertion of the Fig. 480. — Soles of Relapsed Resistant Congenital Club-foot in a Boy of Eight. tenotome. It should then be inserted in front of the internal malleolus and pushed directly to the underlying bone, and swept subcutaneously around the bone, keeping close to it. The knife should be kept between the skin and ligaments, and the latter divided by a sawing motion of the tenotome. This division, if satisfactorily and thoroughly made, may serve in certain cases as a substitute for the division of the tibialis ten- dons. The calcaneo-cuboid ligament should also be divided in severe cases. The tenotome should be inserted a short distance behind the head of the fifth metatarsal bone, near the articulation of the os calcis and cuboid, which can be felt on palpation. The sharp-pointed tenotome should be inserted to the bone, and then by careful motion the whole ligament should be divided. ' London Path. Soc. , British Med. Jour., 1886, vol. ii., p. 10. 536 ORTHOPEDIC SURGERY. Subcutaneous tenotomy of all the parts which obstruct the complete restoration is performed. This in most cases consists of division under an anaesthetic of the plantar fascia, the ligament of the scapho-astraga- loid joint, and last, the tendo Achillis. After the tenotomy of the first three the foot is forcibly corrected by the hand, and a division of the resisting parts carried to such a point that the foot can be easily brought beyond the normal plane, after which tenotomy of the tendo Achillis is done and the foot placed in plaster in an overcorrected position. In case the restoration has not been perfect, as sometimes happens with more resistant feet, it is well to remove the plaster at the end of ten days and apply the brace which is to be w^orn, reapplying the ap- paratus every two or three days. In this way, before complete consol- idation has taken place, a certain amount of gain can be made and over- correction be obtained at the end of a few weeks, which at first was impossible. If, however, the restoration has been complete it is better to keep the bandages on for from six to twelve weeks, in order that the foot may not be disturbed from its overcorrected position. When the bandages are removed great care should be taken that the foot is not allowed to drop from its overcorrected position, and thus make traction on the ligaments and soft parts in which contraction is desired. When the plaster bandages are removed the retention appliance, described above, is to be used so long as there is any tendency to an incorrect position. The permanence of the correction depends on the establishment of an accurate balance of the antagonism of muscles and other soft parts when the foot is in normal position. The after-treatment by retention must be persisted in until the child is able, without special effort, to walk with the foot in a natural position; otherwise a relapse will occur. The sooner the foot is corrected the better, provided the patient's general condition is satisfactory, and that treatment is not liable to be interrupted by intercurrent infantile disorders; practically, treatment should be undertaken as soon as an infant is nursing well and is in rea- sonable health. The use of retention apparatus will be necessary for some years and should be discontinued gradually. The parent may aid in the treatment by daily manipulating the feet into the overcorrected position. The treatment described covers in general all that is necessary for infantile club-foot. The length of time during which the appliance is needed in after- treatment varies and is in general in inverse proportion to the size of the foot or the difficulty of correction, infants in arms needing a reten- tion appliance relatively longer than is necessary in adult cases, in which, if correct gait with proper weight-bearing upon the sole is se- cured for a few months, relapses are not to be expected. TALIPES. 537 Summary of Mechanical Treatment. — In simple cases one may attempt correction (i) by manual manipulation repeated several times daily, (2) by plaster bandages applied at intervals of two or three weeks, (3) by the use of a corrective brace constantly worn, (4) by the subcutaneous division of tendons, fasciae, and ligaments followed by immediate overcorrection in a plaster bandage. Without after-treat- ment relapse will follow in practically all cases. After-treatment con- sists in the use of a retention brace and daily manipulation of the foot. Operative Correction. In cases too resistant to be corrected by the means described the following radical measures may be employed : I St. Open incision. 2d. The use of extreme force. 3d. Tarsal osteotomy. Open Incision. — The chief difficulty is in obstinate cases to stretch the contracted tissue on the concave side of the distortion. Phelps' open incision on the inner and plantar surface is of use in these cases. The advantage of open incision in club-foot is the facility of com- plete and thorough division of all the soft tissues to the bone. The method by which this is done is as follows : The skin is divided along the inner side of the foot, from the tip of the malleolus well down on the inner edge of the first metacarpal bone. After the skin is incised, the other tissues are cut with care, using a director if necessary. The insertion of the tibialis tendon is found and cut across. The artery can be spared by careful dissection, but if necessary it can be divided and tied. The plantar fascia on the sole of the foot should be divided by the use of a tenotome, or long, thin knife. A cross incision toward the sole of the foot from the middle of the long incision is sometimes nec- essary, but it is desirable to avoid this if possible. A triangular incision with its apex upward toward the ankle, instead of the cross-cut of the skin and fascia, is equally efficient and diminishes the gap after correct- ing the foot.^ Forcible Manipulation. — Even if tenotomy and thorough open incision are done, a certain amount of resistance remains from the in- terosseous ligament connecting the tarsal bones. Considerable force is often necessary to bring the foot into an overcorrected position. This can be done either by manual force or by the aid of mechanical force. Several wrenches for this purpose have been devised ; that of Thomas is the simplest and is sufficiently efficient when no bone ob- struction exists. The foot is then brought into as normal a position as possible, thorough aseptic dressings are applied, and the foot is then ^ Jonas : Annals of Surgery, April, 1897, 449. 538 ORTHOPEDIC SURGERY. fixed in a plaster-of-Paris bandage reaching above the knee and holding the well-padded and aseptically dressed foot in an overcorrected posi- tion. If the dressing is provided with efficient protectors and sufficient dressings, no change in the bandage need be made for a fortnight or longer. If necessary, however, a window can be cut in the plaster over the wound and the dressings changed. After the plaster of Paris is discarded the retention shoe is to be w^orn. The use of manual force without any previous cutting operation will rectify the deformity in club-foot, and such a method is in use. The inward twist of the foot, at the mediotarsal joint, is first corrected by Fig. 481. -Thomas Club-foot Wrench, Modified. (Hoflfa.) grasping the heel in one hand and the forefoot in the other and stretch- ing the inner side of the foot, either by the hands alone or by bending it over the padded edge of a triangular block of wood. The inversion of the sole of the foot is then corrected by a similar series of manipulations, until the sole of the foot is everted and will stay in that position without the use of force. The plantar fascia is next stretched and the height of the arch re- duced by flexing the foot dorsally against the force of the tendo Achillis. The reduction of the astragalus to its proper position between the malleoli is next undertaken. The tendo Achillis is divided by a teno- tome, and, if necessary, the posterior ligament of the ankle-joint. TALIPES. 539 The child is now turned on the face, and the front of the thigh hes on the table with the knee flexed and the leg vertical. The operator hooks his fingers around the os calcis while the hand lies on the sole of the foot to force it into dorsal flexion. This is done by a series of forci- FlG. 482. — Manipulative CorrecLiou of Club-foot. (After Lorenz.) ble pressings downward on the sole of the foot, until the dorsum of the foot nearly touches the tibia. The foot is now limp and can be held in an overcorrected position without the use of force. In this position a plaster bandage is applied. The disadvantages of the operation lie in the unnecessary violence used to obtain a result which can more easily be reached by cutting re- sisting structures. The use of manipulative force is a well-recognized and useful preliminary to all forms of operation for club-foot. The experience of the writers has led them to prefer the removal of a wedge A Q Fig. 4S3. — Lever Correction Apparatus TApplied), of bone to the use of extreme force in cases which are still resistant after the use of the measures just described.^ In applying the bandages, it is of course important that the foot should be held in an overcorrected position until the plaster becomes hard, as no further correction can take place under the bandage. In the majority of cases perfect correction or overcorrection is possible, ' Phillipson : Deut. Zeitschr. f. Chir., xxviii. 540 ORTHOPEDIC SURGERY. and the foot can be held in proper position for the apphcation of the fixation bandage without much force. Osteotomy. — When but a slight amount of osseous distortion is present forcible correction aided by tenotomy or open incision will be sufficient to overcome the deformity, but in the more resistant cases. Fig. 484.— Double Congenital Club-foot Before Operation. changes in the shape of the tarsal bones forming the mediotarsal joint prevent perfect cure, and operation upon the bones is necessary. Astragaloid Osteotomy. — hx\ examination of the anatomy of resist- ant club-foot shows that the facet of the astragalus in the astragalo- scaphoid articulation is on the side instead of in front. There is also some obliquity of the neck of the astragalus. If this obstruction of the bone can be corrected and the front of the foot brought into place, there would be less tendency to relapse. It is essential, in every inveterate case of club-foot, that if the foot is to be unfolded, the shortened tissues in the arch of the foot and in the inner side of the foot be stretched, torn, or divided. This can be done safely by means of tenotomy, forcible stretching, or open incision ; TALIPES. 541 but the deformity of the astragalus still remains. In many cases, even if somewhat resistant, if the deformity is rectified and the foot held a sufficient time in the proper position, and a proper walking shoe used for a year, a new facet of the astragalus will be formed and a cure effected. In a few cases this is not the case, and in such instances os- teotomy of the neck of the astragalus suggests itself as a suitable oper- ation. The procedure will not be found a difficult one. Tenotomy or open incision and division of the fascia and ligaments should be done, and Fig. 485.— Same Case Six Weeks After Operation by Forcible Correction. the foot stretched and manipulated into as nearly normal a position as possible. An incision through the skin is made from the tip of the malleolus to the inner side of the head of the first metatarsal, which will be found in severe cases close to the malleolus. The incision is close to and nearly parallel to the tibialis anticus tendon, and in the direction of the metatarsal. The incision should be made to the bone and the foot straightened, as the metacarpal bone is separated from the malleolus. The scaphoid will be seen before the astragalus is encoun- tered, if the deformity is great, and it will be first within the reach of the knife in all cases. If the foot is still further stretched, the scaphoid begins to uncover the side of the astragalus, and the neck of the astrag- alus is seen ; a small osteotome is entered and placed upon the neck of the astragalus, to the proximal side of the scaphoid articulation, and the 542 ORTHOPEDIC SURGERY neck of the astragalus divided or nearly divided. The foot is then for- cibly straightened, and the neck of the astragalus unchiselled is fract- ured. The result is similar to that in Macewen's operation for knock- knee, and the distortion at the neck of the astragalus is removed. It is manifest that the line of section of the bone at the neck of the astraga- lus should be transverse to the axis of the bone, and at such a plane that when the equinus deformity is corrected the resulting gap at the section should not be greater than necessary. The foot should be fixed in an overcorrected position. A wedge-shaped resection of the neck of the astragalus through a skin incision in the outer and upper surface of the foot has been performed, but linear osteotomy would seem to be preferable. Osteotomy of t/ic Head of tJie Os Ceilcis. — The relation of the cuboid to the os calcis is frequently masked, lying deeper than that of the scaphoid and astragalus, and it may in treatment be but par- tially corrected. The distortion of the os calcis at its anterior aspect, if not corrected, increases and forms an obstacle to the complete restoration of the cuboid to the normal position, although the rest of the deformity may have been corrected. When the cuboid is cartilaginous and the liga- ments are well stretched, the defect at the anterior portion of the os calcis can be overcome by forc- ibly correcting the foot and retaining it in the corrected position by means of a plaster-of-Paris bandage, care being taken, however, that the cuboid be restored to place, and in time it will be found that the cartilaginous abnormality in the shape of the os calcis is grad- ually changed under corrected pressure. When distortion of the head of the os calcis is great, no amount of mechanical treatment can overcome the obstacle, if it is of bone and if the ligaments are strong, binding the bones in a distorted position. It is manifest under these circumstances that the rational treatment is a removal, not of the astragalus or cuboid, but of a part of the projecting portion of the head of the os calcis. After complete stretching or division by tenotomy, force, or open incision of the contracted tissues on the inner and under side of the foot, tendons, ligaments, and fasciae, if it is found that the front of the foot cannot be brought to a perfectly corrected or overcorrected posi- tion, an incision should be made on the outer side of the foot, passing from behind the external malleolus forward and downward. The incis- ion should be a curved one, and the chief convexity should be at the forward portion of the os calcis. This incision should reach to the Fig. 486.— From Photo- graph after Removal of Astragalus of Left Foot for Club-foot. TALIPES. 543 Fig. 487.— Sole Imprint after Removal of FiG. 488.— Sole Imprint of Case of Club-foot Astragalus for Club-foot. Corrected by Tenotomy, without Contrac- tion but with Inversion of the Foot. bone and should expose the peroneal tendons. These can either be drawn to the side or divided to be stitched later. The upper portion of the incision should reach behind the external malleolus, and should ex- FiG. 489.— Imprint of Left Foot before Opera- Fig. 490.— Imprint of Left Foot after Opera- tion, tion. 544 ORTHOPEDIC SURGERY. tend far enough up to allow sufficient retraction of the flap to give room for the osteotomy. After the bone has been reached, and the periosteum divided and pushed aside, an osteotome should be inserted far enough back to remove a sufficient amount of bone. The direction of the inser- tion of the osteotome should be such as to allow the placing of the cu- boid, after the bone has been removed, in a normal position. This step of the operation requires some nicety and judgment, as it is of impor- tance that the front plane of the bone, after the wedge has been re- ^ n i!iJp JHRh K^ J y^ Fig. 491.— Case of Bad Relapsed Congenital Club-foot in a Woman of Thirty-four, Corrected by Force with the Use of a Wrench. Photograph taken three months after correction. moved, should be in the direction of the normal facet of the front of the OS calcis. A ^vedge-shaped portion of bone should be removed from the anterior and outer part of the os calcis, and the cartilaginous ends saved in order to allow a proper amount of motion between the cuboid and the OS calcis after recovery. The wedge-shaped portion of bone that should be removed should be ample and- enough to allow the replace- ment of the front of the foot in a normal or overcorrected position and the restoration of the proper direction of the os calcis. The wound should be carefully washed out to remove any frag- ments of bone that may have been left, and subsequently stitched ; the tendon of the peroneus longus, if divided, being stitched. The foot should then be dressed with proper dressings and fixed in an overcor- TALIPES. 545 rected position by plaster bandages according to the ordinary rules in osteotomy. Whether this operation should be done in connection with an oste- otomy of the neck of the astragalus, and with an open incision at the same sitting, is a matter of judgment in each case. Imperfect results are due to neglect of thorough asepsis, failure to remove a sufficient amount of bone, failure to remove it in such a direc- tion as to cure the deformity, and lack of care in placing the foot in an overcorrected position after operation. While the plaster is hardening the cuboid is pressed upward and outward, and the front of the foot pressed outward and upward, counter- PiG. 492.— Case of Bad Relapsed Congenital Club-foot in a Woman of Thirty-four, Corrected by Force with the use of a Wrench. Photograph taken three months after correction; showing cicatrix of the tear of the skin caused by correction. (See Fig. 491.) pressure being applied on the astragalus on the outer and upper side, and the os calcis twisted into its normal position. Treatment can be carried out with a plaster-of- Paris bandage until the foot is thoroughly healed, and also until locomotion has been re- established. After this the use of the club-foot shoe is advisable for at least some months. Relapses. — No error is greater than a common one, namely, that tenotomy alone is sufficient to correct club-foot. In fact, tenotomy is only the beginning of a course of treatment. If the foot is rectified and held in place for a month, it is supposed by some surgeons that a cure has been effected. But such is by no means the case. 35 546 ORTHOPEDIC SURGERY. Moreover, it must always be borne in mind that relapses will inva- riably occur unless the distortion is overcorrected, and little reliance can be placed on the curative effect of time. Efforts at correction should be continued until the foot can be easily abducted beyond the median line, and while slightly abducted, can be flexed so that the dor- sum of the foot shall form less than a right angle with the leg, the sole of the foot being flat, and there being no twist in the front of the foot. After this the correction appliance can be gradually omitted while manipulation of the foot is still carried on, and the case should be kept under observation. Relapses occur in a certain number of cases simply from the care- lessness of the parents, who are not aware of the necessity of retaining the corrected foot in the proper position for a long time. In such cases a second operation is advisable. Relapses in older children are clue to incomplete correction, either from a lack of thoroughness or from the existence of an unusual amount of distortion of the astragalus or os calcis not suspected, and demand- ing osteotomy, or from too early removal of the fixation or retention appliance. ■ In some instances of resistant club-foot it is found difficult, in cor- recting the foot, completely to overcorrect the equinus deformity, and to enable the foot to be brought to within a right angle with the leg. If this is not done, inconvenience is felt by the patient in taking a long step, and the foot is turned in to facilitate this. The smaller the foot the greater this danger. If this is not corrected, it may, in some in- stances, seriously interfere with the excellence of the result. It should always be borne in mind that a distortion in the neck of the astragalus or in the head of the os calcis exists, even in infantile club-foot, and that the feet are not permanently corrected until the alteration of the facets into a normal position has taken place. This is independent of bringing the foot into a normal position, and demands fixation in an overcorrected position for some time. In some cases this is more needed than in others, probably because the alterations of the facets of the astragalus are in some instances slight. Too great overcorrection of the deformity and the development of a splay-foot have sometimes resulted from overzealous treatment. The danger is, however, not great ; and instances are rare, and are to be overcome by the treatment for a valgus foot. Inversion of the foot, after cure of the club-foot, may in a few in- stances be observed from imperfect strength of the outward rotatory muscles at the hip. This, however, causes but little disfigurement, the inversion usually being slight, and correcting itself by the normal devel- opment of the muscles. A marked toeing-in of the foot in running per- sists a long time in some instances in which the foot is entirely cor- TALIPES. S47 rectecl and the walking is normal. It disappears wiih the increase of muscular strength. In such cases the ordinary Taylor shoe should be carried up to the hip by means of an upright on the outside of the leg and a posterior arm carried back from the level of the trochanter, as in the knock-knee splint. By tightening this, eversion is secured. A relaxed state of the knee-joint causing inversion of the tibia is not uncommon in infantile club-foot ; it usually corrects itself in the devel- opment of the child after correction of the foot. In rare instances, however, it may persist, requiring the longer use of a walking appliance. The muscles retarded in club-feet by disuse need development be- fore a complete cure is effected. Ordinarily the muscles develop of themselves after complete correction, if the limbs are actively used. In some cases the development is slow and massage and electricity are advisable. Generalization as to Treatment. — The literature of the treat- ment of club-foot is too often that of unvarying success. It is some- times as brilliant as an advertising sheet, and yet in practice there is no lack of half -cured or relapsed cases — sufficient evidence that methods of cure are not universally understood. Surgeons differ somewhat in regard to the method of treatment of club-foot, but the following statements are regarded by the writers as worthy of acceptance : FirsL — It is possible to correct completely infantile cases of con- genital club-feet without the help of any operative interference, even tenotomy. Second. — Tenotomy, however, even in infants is of assistance, and in older cases is in almost all instances necessary for a perfect cure. Te- notomy properly done is not followed by any unfavorable results to the muscles. 77^zr^.— Certain resistant cases can be corrected and cured without operation upon the bone, but in such cases considerable force must be used. Fourth. — In resistant cases, however, when there is deformity of the bone, osteotomy or a wedge-shaped resection of the astragalus or os calcis is necessary. Fifth. — Congenital club-foot is a thoroughly curable deformity, pro- vided the pathological conditions existing are thoroughly understood, and the resisting structures overcome. Sixth. — For cure, overcorrection of the deformity is necessary and retention in an overcorrected position until the normal relation of the parts has been established. Seventh. — The best retention appliance is one which mterferes with the normal motion the least without permitting the distorted position of the foot. 548 ORTHOPEDIC SURGERY. Acquired Club-Foot — Paralytic Deformity. The most common form of acquired talipes equmo-varus is that fol- lowing infantile paralysis which is described in another chapter. The prognosis of paralytic club-foot is necessarily more unfavorable than that of the congenital form, although the distortion is more readily - corrected ; it is impossible to restore the affected muscles to a normal condition, and the prolonged use of some form of appliance may be necessary. In some instances, however, after thorough correction and retention for a while in a corrected position, if the foot is of sufficient size, relapse does not take place, or does so only in a partial degree, and a useful and but slightly distorted foot remains. The correction of paralytic club-foot is to be conducted on the same principles as that of the congenital type. Correction is, however, much less difficult, as osseous changes are present only in the old severe and neglected cases. Tenotomy of the contracted and healthy muscles can be done as in congenital cases, though overcorrection after tenotomy is to be avoided. Immediate correction and fixation in a corrected position are to be used after tenotomy as in the congenital form. Tendon transferrence and arthrodesis as applied to this affection are discussed under infantile paralysis. The walking appliance to be used in paralytic cases is in general the same as that which has been described in congenital cases. TALIPES EQUINUS. (Pes equinus, Horse heel. Pied bot equin, Pferdefuss, and Spitzfuss.) Talipes equinus is the name given to a condition in which the foot is held in a position of plantar flexion and cannot be dorsally flexed to the normal extent (twenty degrees beyond a right angle). Varieties. — Talipes equinus may be congenital or acquired. Con- genital equinus is an uncommon deformity, constituting about five per cent of all cases of equinus. In i,66o congenital deformities of the foot there were 40 cases of equinus. Its origin is no more clear than that of other similar congenital deformities. The congenital form of the deformity is generally not severe. Acquired Talipes Equinus. In the acquired forms all degrees of deformity are met, from the slight condition in which the foot cannot be flexed dorsally beyond a right angle with the leg, to one in which the foot and leg form practi- cally a straight line. TALIPES. 549 Etiology. — The causes of acquired talipes equinus are as follows: 1. Infantile paralysis of the anterior muscles of the leg. 2. Cerebral (spastic) paralysis, hemiplegia, pseudo-hypertrophic paralysis, neuritis, and similar affections causing either loss of power in the anterior muscles of the leg or an overbalancing of these muscles by the contraction of the posterior group. 3. Shortening of the leg after joint disease or fracture may lead to Fig. 493. — Talipes Equinus of Marked Degree. This represents the ■weight-bearing position. Fig. 494. ^Talipes Equinus of Left Foot Resulting from Paralysis. an adaptive talipes equinus which serves to make the legs of equal length for walking. 4. Talipes equinus may be a symptom or result of disease of the ankle-joint. 5. Long confinement to bed may cause talipes equinus, which is merely the result of the long-continued plantar flexion of the foot. 6. Fractures may result in talipes equinus either from injury to the ankle-joint or from fixation during repair in a plantar-flexed position. 550 ORTHOPEDIC SURGERY. 7. Hysteria may be a cause. 8. The contraction caused by posterior cicatrices or the loss of power due to division or injury of the anterior muscles and tendons of the leg may cause the deformity. Pathology. — The structural changes in talipes equinus are slight. In a large number there is simply a shortening in the Achilles tendon or muscles, with a consequent alteration in the shape or relation of the bones and soft tissues of the foot. Some cases, however, are due less to the raising of the calcaneum than to a depression of the head of the astragalus, which may be depressed nearly in a vertical line, and the arch of the foot increased by a strong flexion at the medio-tarsal joint. Symptoms. — The deformity in its slighter degrees is not particularly disabling. In its severer grades it is the cause of a severe limp and at times of much discomfort. A slight degree of the affection may be enough to cause a limp in walking, as in carrying the leg back at the end of the step the foot should be bent to more than a right angle. Corns and calluses of a severe grade are frequently found on the sole at the front of the foot. They may be a source of severe discomfort. In cases of moderate severity the weight of the body is borne on the distal end of the metatarsals in walking, the toes being hyperextended. In the severest forms of all the foot is bent on itself, so that the sole is directed backward and locomotion takes place on the dorsal surface of the metatarsus and toes. The arch of the foot is generally higher than the normal, and the condition which will be described as pes cavus may coexist with the equinus. In the severer forms there is a marked projection on the dorsum of the foot formed at the site of the calcaneo-cuboid and astragalo-scaph- oid articulations. As locomotion occurs only on the ball of the foot, this part becomes abnormally wide, and in time the plantar fascia con- tracts and resists the reduction of the malposition. The spastic form is most commonly met in spastic paralysis or after hemiplegia. As this is due to the contraction of the muscles of the tendo Achillis, the position of the foot in this differs from that follow- ing paralysis. The heel, in the spasmodic form, is drawn upward and the whole foot depressed in consequence. There is, therefore, less ten- dency to the formation of an angle in the medio-tarsal or tarso-metatar- sal joints. The form often met in shortened limbs, as after recovering from hip disease, fracture, etc., is the result of the maintenance of the foot for a long time in a partially extended position, in the act of walking and standing. In these cases it is a compensatory arrangement, inasmuch as it tends to keep the pelvis level, and not to be regarded as objection- able except in its appearance. The detection of talipes equinus is a simple matter. The normal TALIPES. 5 5 I foot should be capable of flexion about twenty degrees beyond a right angle, and any cause which restricts this flexion is a degree of talipes equinus. Treatment. — The division of the tendo Achillis will relieve the de- formity in all cases except those in which bony deformity exists at the ankle, as in the cases following fracture and tuberculosis of the ankle- joint. In such cases or in extremely severe instances of deformity from other causes, a wedge-shaped osteotomy of the tarsus might be required for rectification, but this would be unusual. The deformity should be at once corrected after tenotomy and a plaster-of-Paris bandage applied. If a retention appliance is required after operation, a modification of the club-foot shoe, with the ankle-joint arranged to stop extension at a right angle, will be found to be effect- ual and simple. Or a simple foot-piece joined to two uprights and a posterior band may be used, which is jointed in the same way at the ankle. This prevents the foot from rolling in or out and thus makes the act of walking a force to pull upon the tendo Achillis at each step (Chapter XXI., 28). Acquired talipes equinus is in most cases due to anterior poliomye- litis, and the treatment of that form has been discussed there. In cases due to ankylosis of the ankle-joint or to severe acquired distortion of the bone from prolonged neglect, a wedge-shaped osteotomy might be necessary. TALIPES CALCANEUS. (Pes calcaneus. Pied bot calcaneen, and Hackenfuss.) Talipes calcaneus is the name applied to a condition in which the foot is held in a position of dorsal flexion. Varieties. — The deformity may be congenital or acquired. It is a comparatively rare congenital deformity, about two-thirds as common as congenital equinus (28 cases in 1,660 cases of congenital deformity of the foot). The hollow in the sole of the foot so often present in the acquired variety is likely to be absent in the congenital. It may be noticed only as a slight downward prominence of the heel or it may be so severe that the dorsum of the foot may be laid against the anterior surface of the tibia. Its etiology is practically the same as that of the other congenital deformities. Acquired talipes calcaneus is less common than acquired equinus. It presents the same characteristics as the congenital form, except that an increased hollowness in the arch of the foot is likely to coexist, in which case the deformity may be spoken of as talipes calcaneo-cavus. The cause of the acquired deformity is in most cases paralysis of the muscles of the calf of the leg from anterior poliomyelitis. It may occur in chronic disease of the ankle as a symptom of muscular irritability. 552 ORTHOPEDIC SURGERY It exists sometimes in hysteria, and it may result from rupture or divis- ion of the posterior muscles of the leg, from cicatrices in the front of the ankle, and from ankylosis of the ankle-joint in a faulty position. The pathology of the affection is manifested by the changes incident to the maintenance and use of the foot in this abnormal position. Stretching of ligaments and muscles are found on one side, with short- ening on the other and changed relations between the bones, resulting perhaps in the development of new articular facets. Symptoms.— The patient walks upon the heel and the gait is inelas- tic, because the spring of the foot is absent and the patient walks bear- FlG. 495. — Talipes Calcaneus. ing the whole weight on the os calcis. The diagnosis presents no diffi- culty, except that it must be remembered that the association of the deformity with both \'algus and cavus is frequent. Treatment. — In congenital cases the foot should be daily manipu- lated by the parents into a position of plantar flexion. As soon as the anterior muscles are stretched, it is advisable to put the foot up in a position of plantar flexion, to bring about adaptive shortening of the posterior muscles. In the severer cases the application of a series of corrective plaster bandages holding the foot in plantar flexion may be necessary. Tenotomy of the anterior tendons is rarely required. When the foot can be plantar-flexed to the normal amount, a retention shoe preventing dorsal flexion may be applied, but in slight cases this is not necessary (Chapter XXL, 29). TALIPES VALGUS. Talipes valgus is the name given to a condition which is not in all cases to be clearly differentiated from what has been described as flat- TALIPES. 553 foot. Talipes valgus may be congenital or acquired. As a congenital deformity it is one of the more common of the congenital deformities of the foot. In i,66o cases of congenital deformity of the foot there were 123 of congenital valgus. The bones in congenital flat-foot even in severe cases show but little alteration in shape. The astragalus is turned obliquely to one side and downward, and the angle of the artic- ulation faces more to the side than is normal. The end of the os calcis may be slightly raised. The sca- phoid is turned to the outer side and is rotated on its central axis, so that the outer side is slightly raised and the inner side is lowered — the Fig. 496. — Moderate Degree of Talipes Valgus, Right Foot. Fig. 497.— Talipes Varus, Right Foot. arch of the foot is obliterated and the inner border is often convex rather than concave. It may exist by itself or in connection with other defects of the bones of the foot or leg. It may exist alone or associated with calca- neus or equinus. The deformity of congenital valgus is likely to be extreme and the sole of the foot may present a downward convexity. The three elements mentioned in flat-foot — abduction of the front of the foot, eversion of the sole, and lowering of the arch — may be fully developed. The changes of the bones do not differ essen- tially from those described in acquired flat-foot. The deformity may 554 ORTHOPEDIC SURGERY. be spoken of as congenital flat-foot, from which it is not to be dis- tinguished. Acquired Talipes ]^algits is a condition characterized by eversion of the sole of the foot or abduction of the front of the foot in relation to its long axis, or by both. It differs from acquired flat-foot in the ab- sence of a distinct dropping of the arch of the foot. This distinction is not to be made in all cases nor is it of great importance, but, in gen- eral, cases presenting the two first conditions mentioned are to be classed as valgus, and cases with the dropping of the arch also as flat- foot. The most common cause of acquired' talipes valgus is anterior poliomyelitis. It also occurs in hysteria, following inflammation of the ankle-joint, and in certain cases of spasm of the peroneal muscles. The symptoms, as contrasted with those of flat-foot, are generally char- acterized by less pain, and the modification in the gait produced by the abnormal position is in general more prominent than pain. The treatment of the condition consists in the application of an ap- paratus (Chapter XXI., 31) to correct the rolling inward of the ankle, combined generally with some support to the arch of the foot. In the milder cases the application of a flat-foot plate would be sufficient treat- ment. TALIPES VARUS. Talipes varus is the name given to a condition in which the sole of the foot is turned inward. Simple talipes varus occurred eighty-five times in sixteen hundred and sixty congenital deformities of the foot. In its congenital form the deformity is apparently an incomplete vari- ety of ordinary club-foot in which the element of equinus is not marked. In the acquired form it results from infantile paralysis and is at times seen as the result of severe knock-knee. As associated with talipes equinus it is the commonest of congenital deformities of the foot. Treatment. — In the congenital form the treatment is practically the same as that of equino-varus, except that it may not be necessary to cut the tendo Achillis. In the acquired form retentive apparatus is useful, preventing eversion of the foot (Chapter XXI., 30). TALIPES CAVUS. {Hollow foot. Pes cavus. Pes arcuatus or excavatus, Pied hot talus. Pied creux, Hohlfuss.) Talipes cavus is the name given to a condition in which the arch of the foot is increased and the anterior part of the foot is approximated to the heel. It is not necessarily associated with any other deformity, but may occur in connection with talipes equinus, calcaneus, valgus or TALIPES. 555 varus. It is rarely congenital in its severe forms,' but a markedly high arch to the foot may be an inherited peculiarity sometimes suf- ficiently marked to justify classing it as pathological. In the acquired form it exists in most cases as the result of anterior poliomyelitis, and is also to be classed as a shoe deformity. The pathological changes show nothing besides the effects of a continued malposition of the bones. The deformity varies more or less in degree. The most marked form is to be found in the foot of the Chinese lady of high rank, in which the heel and front of the foot are approximated by bandaging in early youth, and a degree of pes cavus is induced which does not exist except under these highly artificial conditions. From this ex- FlG. 498. — Pes Cavus with an Element of Calcaneus. treme grade all degrees of the affection are seen, the slightest being an increased elevation of the arch not accompanied by symptoms, in which the foot rests upon the ground in standing, touching only on the heel and ball of the foot. It is less disabling than pes calcaneus, and is fre- quently associated with the other deformities mentioned. The two types commonly seen are, first, those resulting from anterior poliomye- litis, in which a paralysis more or less extensive has involved the foot and leg. In a second form, generally milder in grade, it apparently de- velops as a shoe deformity in middle childhood, and appears to be the result of wearing too short a shoe or of a shoe narrower than the front ' Redard : " Chir. orth.," p. S39. 556 ORTHOPEDIC SURGERY. of the foot ; the front of the foot being held back by the front of the boot, the tendency in weight-bearing is to approximate the heel and the toe, and in this way to approximate the front of the foot to the heel. In the slightest grade it apparently forms one of the varieties of the condition described as contracted foot. The plantar fascia is contracted and bands may be felt under the skin. The symptoms in the slighter varieties are those of a sprain of the arch of the foot and the muscles of the leg, owing to insecure balance of the foot in standing. Corns and callosities may develop in the front of the foot ; the elasticity of the gait is impaired. The treatment of the slighter forms, in which the symptoms are due to the imperfect balance of the foot, consists in the use of a boot with sufficient room in front and of proper length, which is pro\-ided with a high arch or artificially high shank, to give the foot a correct bearing surface and to contribute to its stability. If any element of equinus coexist, the gastrocnemius muscle must be stretched.' In cases of average severity in young children a flat steel plate running the length of the boot may be inserted between the layers of the sole, and the dorsum of the foot strapped down to it by a strap running over the top of the foot and fastening to the plate. This will tend to stretch the contracted tissues in walking. Operation is required in the severer cases. The plantar fascia is thoroughl}' divided by a subcutaneous te- notomy and the foot put up in a plaster bandage which should flatten the arch of the foot as much as possible. When walking is begun, which should be as early as possible after operation, the steel sole plate and strap described above should be adjusted to the shoe. CLUB-HAND. In German the distortiDU is known as Khnnphaud, and in French as main bote. Congenital club-hand is a rare condition, which is in man}' cases analogous to congenital club-foot. The name is applied to a deviation of the hand, at the wrist, from the line of the forearm ; this deviation is almost always in the direction of flexion. It occurs at times without malformation of bones, in which cases there may be also stiffness of the shoulder- and elbow-joints of the affected arms, with imperfect development of the muscles. At other times there is associated with the club-hand an absence or defective development of the radius or ulna, often associated with other malfor- mations. \\\\h the defective development of the bones of the forearm are likely to be associated muscular defects and anomalies. Varieties. — The modern classification of the distortion is to speak of the cases as palmar and dorsal club-hand, as the deformity is toward ' Shaffer: X. Y. Med. Jour., March 5th. 1SS7. TALIPES. 557 flexion or extension ; or as radial, and ulnar or cubital, as the deviation is imvard or outward at the wrist. Mixed forms are the most common, and are spoken of as radio-palmar, etc. The dorsal forms are rare. The bones of the arm may be normal, but more commonly they are deformed, or the radius may be wanting" wholly or in part. The carpus may be normal, or incompletely developed, or almost entirely wanting. When the radius is deficient, the lower end of the ulna is enlarged to Fig. 499. — Club-hand Due to Congenita] Absence of Radius. (Sayre.) articulate with the carpus. A variety of anomalies of the muscles, ves- sels, and nerves may occur. Etiology. — No satisfactory etiological cause can be assigned for the occurrence of club-hand, beyond the usual explanations urged to ac- count for congenital deformities in general. Symptoms. — In looking at the palmar varieties of club-hand it is seen that the wrist is sharply flexed, and that perhaps the lower end of the radius may be covered by the skin and traversed by the extensor tendons, while the carpus articulates with the under surface of the radius. The forearm is wasted, and if the radius is absent it appears to be very slender indeed. The hand possesses a certain degree of mobil- ity at the wrist, and when it is partly replaced the flexor tendons can be felt to be rendered tense, and stand out under the skin. 558 ORTHOPEDIC SURGERY. The diagnosis is evident, and any pathological process \Yhich is ac- companied by this malposition is classified as club-hand. Treatment. — In the mildest cases, particularly if the bony structure is normal, treatment should consist of manipulation to stretch the con- tracted tissues and retention in the correct position by means of a splint. Tenotoni}' is to be done only if reposition is impossible without it. After retention in the proper position for a sufficient time, massage and muscle training should be begun. Where bony defects are present and the case is not to be rectified by the measures described, some operation on the bone may be per- formed. R. H. Sayre ' performed an osteotomy of the ulna to correct its curve, and later removed two of the carpal bones and the styloid process of the ulna and inserted the end of the ulna into the gap in the carpus. Thompson" removed a wedge from the lower part of the ulna. McCurdy divided the ulna across and sutured the distal end to the semilunar bone.^ Bardenheuer ^ has split the lower end of the ulna longitudinally and implanted the carpus between the two parts of the ulna separated. The reported results of these operations have been favorable, but it must be evident that the joint under these conditions must be an im- perfect one.' 'Trans. Am. Orth. Assn., vol. vi.. p. 208. "Ibid., vol. ix.. p 165. '^ Ibid., vol. viii., p. 8. •'\'erhandlung der deutschen Gesellschaft f. Chir.. 1894= ^Kirmisson: "Mai. Clin. d'Origine Congen ," 189S. CHAPTER XX. FLAT-FOOT AND OTHER DEFORMITIES OF FOOT. THE Flat-foot (Definition. — Patliology. — A'arieties. — Causation. — Frequency. — Sj'mp- toms. — Diagnosis. — Prognosis. — Treatment). — Anterior metatarsalgia. — Hal- lux valgus. — Hallux varus. — Hallux rigidus. — Hammer toe. — Clawed toes. — Painful heel. — Post-calcaneal bursitis. — Synovitis of tendo Achillis. — Exos- toses. FLAT-FOOT. Definition. — The term "flat-foot" is applied to a deformity usually of a static type — that is, one due to superimposed weight. Thisdeform- FlG. 500. — Print of Child's Foot in Mocca- sin, Showing Weight- bearing Portion of Foot. Fig. 501. — Foot of Japanese Bronze. (Boston Art ^Museum.) ity resembles in many respects talipes valgus, and has been consid- ered by many wTiters a variety of that distortion. There is, however, sufficient difference to warrant a consideration of flat-foot by itself. 559 56o ORTHOPEDIC SURGERY. The abnormality of flat-foot is best understood by a comparison with the normal standard. Normal Foot. — If the foot of a yoang infant is examined it will be Fig. 502.— Feet of Charioteer Fig. 503. — Egyptian Statue. seen that there is muscular power in the movement of all of the toes. The great toe can voluntarily be drawn to the inner side, and the fifth FLAT-FOOT AND OTHER DEFORMITIES. 561 toe can be drawn to the outer side by voluntary muscular exertion. The toes can be flexed readily. The second toe is, when stretched to its full length, frequently longer than the first. The third is of the same length as the first, the fourth is somewhat shorter, and the fifth, though shorter, is but slightly so. None of the toes remains perma- nently curled, though when in a relaxed condition the terminal phalanx drops somewhat and the smaller toes curl. A separation between the first and second toe is normal. When the muscles are active the great toe is drawn to the inner side frequently. The line of the extremities of the toes presents a gradual curve with the greatest forward con- vexity at the tip of the second toe. The line of the inner edge of the foot is always straight except when there is contraction of the muscles. Fig. 504.— Left Foot of Child Eighteen Mouths Old. (Dane.) If the undistorted adult foot which has never worn shoes be exam- ined, it will be found to present many of the characteristics of the infant's foot, but there is greater muscular power in the toes and foot and relatively less fatty tissue. The flexibility of the front of the foot is great, and can be increased by training, especially in the power of separating the great toe from the next, which is utilized as an aid in prehensibility. If in comparison the foot of an adult who has always worn shoes is studied, a loss of flexibility in the movements of the toes, often some distortion of the front of the foot, and an impairment of muscular power of the muscles of the foot are seen. The effect of this impairment is to favor the development of the deformity generally known as flat-foot. Pathology. — In light cases of flat-foot the anatomical changes show very few alterations in the shape of the bones. There is simply an altered relativ^e position.' ^"Statik und Mechanik des menschl. Fusses," Zeit. f. orth. Chir., 1894, iii., 243.— R. W. Lovett and F. J. Cotton: Trans. Am. Orth. Assn., vol. xi.— Peter- sen : Arch.f. Orth. (abst.), i., 3. — Riedinger: Centralbl. f. Chir., 1897, No. 15. — v. Meyer : " Ursache und Mechanismus der Entstehung des erworbenen Plattfusses," Jena. 1883. ^.6 562 ORTHOPEDIC SURGERY. The nature of the mechanism of the deformity will be better under- stood if the normal action of the foot in standing and walking is borne Fig. 505. — Savage Feet. in mind. If an individual with normal feet stands with both feet placed together and pointed forward, the weight in each foot falls upon a point midway between the outer and inner edge, passing through the FLAT-FOOT AND OTHER DEFORMITIES. 563 ankle and astragalus and being distributed to the rest of the foot. If now, the superimposed weight is made excessive by havmg the individ- ual stand upon one foot, the body inclines to that sMde to preserve the =*^ Fig. 506.— Longitudinal Section of Foot. (Fick.) balance and to prevent side strain. When the weight upon the foot comes in such a way that it cannot be brought directly over the middle of the foot, a movement takes place whereby the side strain is dimin- ished. This represents the position of muscular strength when exposed to the strain of excessive superimposed weight. In this movement the 564 ORTHOPEDIC SURGERY. astragalus and ankle are pulled sideways to the outer side of the foot, the ball of the foot and the heel being placed firmly on the ground and the astragalus being held firmly from lateral motion by the tibia and the fibula. This motion, which is made possible by the many articu- lations of the foot, occurs in the midtarsal joint chiefly. The scaphoid, the inner cuneiform, and the posterior end of the first metatarsal are Pig. 507. -Posterior View of Foot, Showing Ligamentous Support and its Weakness to Strain Inward. (Fick.) "brought upward and to the outer side, the great toe and the head of the first metatarsal are pressed firmly on the ground, and the os calcis and the cuboid move with the astragalus. In contrast with this movement of strength and muscular support must now be con%\dQ\-&d the position of relaxation and ineffectual sup- port. When the patient is standing, if the muscles moving the great toe and the head of the first metatarsal or those regula'ting the outward and upward movement of the inner side of the scaphoid are weak or FLAT-FOOT AND OTHER DEFORMITIES. 565 inefficient or do not act with strength, the midtarsus drops to the inside when superimposed weight falls upon it, and the movement is the re- verse of that described above. The astragalus rotates inward; the scaphoid, the cuneiform, and the proximal end of the first metatarsal move downward and inward ; and the front end of the os calcis and the cuboid follow the astragalus to the side. This involves a twisting of the whole limb, which rotates at the hip-joint. The astragalus moving with the leg on the bones of the foot, the inner malleolus will in conse- quence be seen to move downward, inward, and backward. Up to a certain limit this movement occurs in relatively normal feet, but be- FlG. 508.— Pr.nt of Arab Foot. Fig. 509.— Plaster Cast of Dental Wax Foot Impression in Sand, Showing- Weight- bearing Portions of Foot. yond this what must be regarded as a pathological condition is reached, attended by symptoms of pain and disability, and is the first step in the formation of flat-foot. The deformity, strictly speaking, is not a flattening of the foot, but consists of an exaggerated midtarsal drop and twist, occurring, as has been said, normally under certain conditions. The deformity is a com- bination of inward rolling and dropping to the inside of the middle of the foot, with an outward deviation of the front of the foot. Normally in the standing position, if the patella faces straight to the front, the foot should be directed also straight ahead ; but in flat-foot the front of the foot turns to the outside when the leg is placed with the patella 566 ORTHOPEDIC SURGERY. and ankle squarely to the front. The deformity has for this reason been termed pronated foot, as the deformity somewhat resembles pro- nation. It is also called weak or weakened foot. Fig. 510. — Casts of Civilized and of Savage Feet. There is necessarily a variation in the relative prominence of the different factors of the deformity in individual feet: i. The inward Fig. sii.— Voluntary Plantar Flexion (Nor- mal). (Whitman.) Fig. 512.— Voluntary Dorsal Flexion (Nor- mal). (Whitman.) movement of the midtarsus, " the dropping in " of the foot, may be the characteristic of some cases. 2. The dropping down of the arch may FLAT-FOOT AND OTHER DEFORMITIES. 567 be the most prominent feature in others. 3. The abduction of the front of the foot, resulting in a change of the angle between the front of the foot and the axis of the heel, may characterize still other cases. And these three factors may be present in varying proportions and Fig. 513.— Weakened Foot without Breaking Down of Arch. relations. The recognition of the relative prominence of these elements is of much importance in treatment. Alterations in the shape of the bones are noted, in severe cases the Fig. 514. — Meyer's Line in Average Foot. Fig. 515.— Meyer's Line in Normal Foot. external malleolus being at times somewhat flattened and rounded. The chief distortion in the bones occurs in the astragalus, os calcis, scaphoid, and cuboid. In extreme cases the astragalus has dropped from above to the inside of the os calcis, the latter being rolled to the 508 ORTHOPEDIC SURGERY. inside with a deviation of its forward end to the inside. The front of the foot is turned outward, the scaphoid and cuboid being practically I'lG. 510.— iable wiLu (jiuss Top for Examining Feet. Fig. 517.— Glass Table for Examining, in Use with Mirror. dislocated. At the outer side the cuboid may be displaced upward. Changes in the direction of the metatarsus and of the phalanges are found. Exostoses are frequently developed. There is a loss of the normal play of the bones in the tarsal articu- FLAT-FOOT AND OTHER DEFORMITIES. 569 lations from loss of elasticity of the ligaments, and changes in the shape of the bones result from abnormal pressure. The muscles are changed in their strength, the tibialis being weak- ened and the peronei contracted. The plantar ligaments are stretched and displaced, and those bear- ing strain are thickened. Varieties. — As has been already mentioned, talipes valgus resem- bles flat-foot, and they are often classed together. For clinical rea- FlG. 51S. — Type of Tracing Described as Normal. sons it is more convenient to consider the subjects separately. The same is also true of congenital valgus, sometimes called congenital flat- foot. Infants were thought to be flat-footed, but this has been shown to be apparent rather than real.' Causation. — In general terms it may be said that the deformity is caused by a disproportion between the weight to be borne and the mus- cular power which bears it. Among the determining causes may be mentioned : 1. Boots of improper shape or size. 2. Weakness or insufficiency of the muscles, resulting from ill health and especially following confinement. ' Dane: Trans. Am. OrtliOp. Assn., 1898. — Spitzy : Zeitschrift f. orth. Chir,,, xii., 4, 777. 570 ORTHOPEDIC SURGERY. 3. Prolonged standing. 4. Rapid growth. 5. Rapid increase in weight. 6. Accident or disease, causing disuse of Hmb and muscular weakness. Fig. 519. -Flat-fool Occurring in a Young Rhachitic Child. 7. Excessive weight-bearing, as in the case of professional strong men and jumpers. 8. A shortened condition of the gastrocnemius muscle, as described Fig. 520. — Outline Drawing (from Photo- graph), Showing Inward Excursion of Internal Malleolus in Pronaiion. Fig. 521. — Composite Photograph, Showing Excursion of Malleolus and Arch with and without Weight-bearing. (Dane.) by Shaffer. Unless dorsal flexion of the foot beyond a right angle is possible, it is difficult for a person to complete the step with the leg straight behind him and the foot pointing forward. Eversion of the FLAT-FOOT AND OTHER DEFORMITIES. 571 foot is necessary, and a completion of the step by rolling over on to the inner side of the foot. 9. Rickets, distorting the bones of the foot. 10. Infantile paralysis. 1 1 . Spastic paralysis or other disturbances of muscular balance. 12. Trauma and inflammation. The most common of traumatic causes is Pott's fracture, m which a deformity is the result of inefficient treatment or of a very severe and intractable fracture. As a result of ankle-joint disease accompa- nied by considerable destruction of tissue, one sometimes sees very marked flat-foot, which does not tend to grow worse, because there is generally firm ankylosis in the ankle; but the deformity may be severe. Acute arthri- tis, especially of gonorrhoeal origin, is a not infrequent cause of flat-foot. Causation.— Flat-foot has been mentioned as a race pecul- liarity, negroes and Jews being mentioned as especially afflicted ; but facts do not warrant the statement, which has been found not to be true of the native negroes of Africa.' Many of the barefooted races have been considered flat-footed simply because of the strong development of the muscles of the sole, careful examination showing excellent arches. The most common cause is the weakening of the muscles of the foot by shoes. Shoes as worn by the leisure class or by the class that gain their livelihood (as is the rule in cities) by occupations which re- quire standing rather than strong and vigorous walking, compress the front of the foot. This part of the foot, from compression and from resulting weakness, cannot adapt itself as greater weight is thrown upon the foot, and the medio-tarsal twisting takes place, which in the strong bare foot is prevented chiefly by the action of the tibial muscles ^ Freiberg: Am. Journ. of Orth. Surgery, vol. i. Fig. 522. — Composite Photograph, Showing Lateral Excursion of Lower Leg and Foot with and without Weight-bearing. (Dane.) 572 ORTHOPEDIC SURGERY. and by the muscles of the first metatarsal and its phalanges. People the front of whose feet has been compressed stand and walk with a greater angle of divergence of the axes of the feet, which increases the danger of the development of the deformity by bringing greater strain upon the inner side of the foot and favoring the inward rolling which frequently develops flat-foot. Flat-foot is not developed among moc- casined savages who use their feet actively as hunters, using the mus- cles of the front of the foot freely. Symptoms. — Flat-foot is a deformity characterized by a flattened appearance of the sole of the foot. The deformity is also called splay-foot, pes planus, and spurious val- FiG. 523. — Tracing of a " Flat foot." No symptoms. gus; in German, Plattfuss; and in French, pied plat. It is also some- times called pes pronatus. It can for convenience clinically be divided into two groups : 1. Flexible flat-foot or zucakencdfoot, where little or no structural changes have taken place and the foot assumes the flattened position only when weight falls upon it. 2. Rigid flat-foot or flat-foot proper, in which the distortion is per- manent, some structural change in Hgament or bone having taken place. In Blodgett's ' series of one thousand cases the females predomi- nated, and two-thirds o^ the cases were under forty years of age. 'W. E. Blodgett: Am. Journ. of Orth. Surgery, vol. ii., No. 2. FLAT-FOOT AND OTHER DEFORMITIES. 573 Deformity. — In the severer cases, instead of the normal arching upward of the inner border of the foot, this border is either less arched than normal or is in contact with the ground. The foot has the appear- ance of being not only broad but abnormally long. It is more or less everted, and in severe cases the head of the astragalus and the scaphoid tubercle form a marked bony prominence at the middle of the inner border of the foot. The internal malleolus is more prominent than normal and is thought by the patient to have enlarged. In the milder cases, which are often too slight properly to deserve the name flat-foot, there is the beginning of a similar process. This beginning abnormal- FiG. 524. — Flat-foot of Moderate Degree. ity of position, although sufficient to cause symptoms, may be so slight as to escape observation except on the closest inspection. There is a tendency of the inner malleolus to be more prominent, the foot is slightly everted, the weight is borne more on the inner border than is normal, and the arch of the foot may appear to be somewhat lower than normal. This condition might perhaps be better spoken of as a strained than as a flattened foot; from this condition to that of a com- pletely flattened foot every degree is to be seen clinically. Marked flat-foot may be present without causing symptoms. It is not infre- quently seen in athletes and occurs as a perfectly useful foot m a cer- 574 ORTHOPEDIC SURGERY. tain small proportion of persons. In such cases the foot is flexible; when structural changes have taken place in the ligaments, muscles, or bones, and stiffness is present, painful symptoms are generally seen. Flat-foot is more frequently double than single, and as a rule the Fig. 525.— Severe Double Flat-foot. symptoms in one foot are more severe than those in the other. The symptoms are frequently worse in the foot showing the least deformity. Pain. — The first SN-mptom complained of is a sense of discomfort in the feet after standing or walking. This may increase until pain of greater or less extent is present during and following use of the feet. In the milder cases pain ceases when the weight is removed, but as the condition be- comes more advanced the pain not only becomes more severe, but continues after the use of the feet is stopped, and in the severer cases persists during part of the night. The severity of the pain may be greater than is to be ex- pected from the amount of distortion. The pain is most frequent in the neigh- borhood of the scaphoid ; it occurs also in the front of the foot, in the centre of the heel, behind the inner malleolus, and on the outer border of the foot. Pain is also complained of in connection with flat-foot in certain cases in the leg, knee, back, or hip. Tenderness. — Tenderness is seen over Doints of ligamentous Fig. 526. — Outline Drawing (from Pho- tograph) in Normal and Pronated Position. Showing Forward Excur- sion of Mark over E.xternal Malleo- lus in the Pronated Position. FLAT-FOOT AND OTHER DEFORMITIES. 575 strain ; it occurs under the scaphoid, under the centre of the heel, be- hind the internal malleohis, at the outer border of the foot, and in the great toe-joint. It is rarely absent and may be found in one or more of these situations, according to the type of the distortion. Muscular Spasm. — In very acute cases there may be irritability Fig. 527.— Displacement of Little Toe. (H. L. Burrell.) and contraction of the peroneal muscles holding the foot in the position of abduction ; in this case there is apt to be tenderness over the origin of the peroneal muscles. Irritability of the gastrocnemius frequency a J) Fig. 52S.-a, Flat-foot ; b, Flat-foot with Eversion. (Children's Hospital Report.) exists, and tenosynovitis of the tibial and peroneal muscles is occasion- ally seen. Stiffness.— Congestion of the foot and swelling of the foot and leg are frequent symptoms. Stiffness or loss of flexibility is a symptom which is gradually developed, and it involves at first and most promi- 576 ORTHOPEDIC SURGERY. nentiy the mediotarsal joint. The stiffness is such that the front of the foot cannot be adducted actively or passively as much as it normally should be. This is an important matter to recognize, as it prevents an assumption of a correct position by voluntary muscular effort until the proper flexibility is restored. There is also, especially in the later his- tory of the case, some limitation in the plantar and dorsal flexion of the foot at the ankle-joint. •■ In severe flat-foot, owing to the change in the form of the bones, there is a limitation in the amount of motion at the ankle-joint. The normal amount of motion, which should be 80°, in flat-foot may be re- stricted to 30° or 40°. Gait. — The gait becomes modified as the affection progresses and becomes in a measure characteristic. The feet are generally more everted than normal, and in painful cases it will be noted that in standing the patient deliberately throws the foot over, so that the weight is borne more upon the inner border than is normal. There is a lack of elasticity to the gait, and this is a symptom often complained of by the more intelligent patients, who find their feet stiff and clumsy. After the patient has been sit- ting for some time and on rising in the morning the feet are likely to be stiff and clumsy. Contracted Foot. — Mention should be made of a type of painful affection of the foot often seen in practice, in which the symptoms of muscular irritability and con- traction predominate. It may be an accom- paniment of mild flat-foot or it may exist in connection with a highly arched foot. Such feet cannot be dorsally flexed beyond a right angle, and perhaps motion may be restricted in other directions. Pain and irritability in walking may be noticed in the calves of the legs as well as in the arches of the feet, and even backache may be present. This variety of irritable and strained foot is probably one of the affec- tions described as " contracted foot " ' or " non-deforming club-foot." "" It is apparently due to the strain and bad balance induced by wearing improper and ill-fitting shoes. It is most commonly seen in women of the upper classes. ^Lovett: Art. "Orthopedic Surgery," Park's "System," 2d ed.— Whitman: " Orth. Surgery," 2d ed., p. 699. ■^Shaffer: N. Y. Med. Rec.,May23d, 1885; N. Y. Med. Journ., March 5th, 1887. Fig. 529. — Boot for Left Foot Worn by Patient with Severe Flat-foot, Showing Character- istic "Treading- Over " of Shoe. FLAT-FOOT AND OTHER DEFORMITIES. 577 Symptoms in Children.-Ih young children the symptoms are somewhat modified. Pain is not a common symptom, and rigidity in the deformed position is rare. The amount of flattening is on the aver age greater than in adult cases when the child is in the standin- posi- Fig. 53°-— Radiograph Showing: Compression of Left Foot by Boot. tion. The child tires easily, is not steady in walking or light on the feet m movements requiring balance, and falls frequently. Associated with the flattened foot there is often to be found in young children an abnormal lateral mobility of the knee-joints.' ' Journ. Am. Med. Assn., April i8th, igoi 37 ^' 5/8 ORTHOPEDIC SURGERY. Diagnosis. — The recognition of a static disturbance in the foot suffi- cient to give rise to pain is to be made partly from the history of the case, and partly from the examination of the foot. The characteristic symptoms have been already indicated. For examination of the feet, the shoes and stockings should be re- m ^^.: 1' ^'^ . Fig. 531.— Radiograph Showing Right Foot Uncompressed by Boot. moved and the patient should stand facing the surgeon upon the floor or upon a plate of glass with a mirror underneath. The relation of the foot to the leg should be noted, whether the in- ternal malleolus is unduly prominent and the foot rolled over on to its inner border. The height of the arch of the foot is of importance, and FLAT-FOOT AND OTHFR DEFORMITIES. 579 any lowering of the inner border is significant. The rolhng of the foot further on to its inner side or the lowering of the arch after the patient has stood for a minute indicates muscular insufficiency under weight-bearing. If, in addition to its outline, the sole of the foot is inspected by means of the mirror, the normal foot will show an evenly distributed anaemic area, the weakened foot will bear more weight at its inner sur- faces at the front and back of the foot, and will roll over further under the influence of muscular fatigue. The impression of the weight-bearing foot is of interest, but not of great diagnostic value. In the tracing as ordinarily taken the non- weight-bearing position of the foot is recorded first and then the weight- bearing position, the two being superimposed. The abnormal and the Fig. 532. — Xormal Motion of the Front of the Foot. normal imprints are shown in the accompanying illustrations. The impression of the foot is taken by having the patient step on a piece of cardboard blackened with camphor smoke. The degree of flexibility should be examined by attempting to ad- duct the forefoot gently with the hands and to flex the foot dorsally with the patient's knee extended. Loss of the first of these move- ments is of diagnostic importance. The presence of tender points in the sole of the foot, either under the heel or under the scaphoid, generally indicates static disturbance of the foot. The range of variation in the contour of the foot and in the height of the arch in individual feet is so marked that from inspection it is not possible to say that a foot may or may not be the seat of symptoms. A foot apparently anatomically sound may give rise to symptoms, while, on the other hand, one excessively rolled in may be perfectly useful.' Differential Diagnosis. — Rheiiinatisin and Arthritis Deformans. — The diagnosis of " rheumatism " in the feet should be made with very great care and only in connection with distinctly rheumatic manifesta- ^ Lovett: " The Occurrence of Fiat-Foot among Trained Nurses." Am. Journ Orth. Surgery, vol. 1,. i. 58o ORTHOPEDIC SURGERY. tions in the upper extremities. Pain in the knees, hips, and back may be purely secondary to a static disturbance in the foot. The frequency with which this diagnosis is made by practitioners unfamiliar with flat- foot makes it important to lay much stress on this point. The fact that no dropping of the arch of the foot can be detected by the eye by no means establishes the diagnosis of rheumatism. An ,r-ray examination is of assistance in determining any displace- ment in the relation of the bones to each other occurring in the severer grades of the affection and not present in the lighter grades. It is also of value in giving information as to the presence of arthritis defor- mans and the existence of spurs of bones. Prognosis. — After a time the foot may become accustomed to its altered position and painful symptoms cease. In other cases, however, the painful symptoms continue and become worse rather than better. The condition may persist almost indefinitely, a constant source of pain and disability. The results of treatment are as a rule satisfactory. In cases with little permanent distortion but great muscular weakness, benefit and cure can be expected from careful treatment. In cases of average severity, relief can almost always be given by very simple measures. A spontaneous cure is not to be expected. Even after deformity of the bone takes place and the distortion is confirmed, a useful foot may be obtained if the muscular developrnent of the leg is good. Severe deformity can be corrected by operative measures, with the restoration of normal function by after-treatment. Treatment. — The treatment of the conditions described will depend upon the nature of the deformity, its severity, and its duration. The principles of treatment are simple. They consist of the sup- port of the foot in a proper position (if support is needed) and the de- velopment of the strength of the muscles and tissues until they are sufficiently strong to maintain the normal attitude. Where fixed dis- tortion of the foot is present, it is to be corrected by mechanical or operative measures. Supporting Treatment. — Plates. Indication for Support. — When the strength of the foot is inadequate to sustain the weight of the body without discomfort, mechanical support is needed. Flat-foot plates (Chapter XXI., 32) are indicated in such cases even when the lower- ing of the arch is not marked to the eye, but when the symptoms of strain are sufficiently characteristic, as described above. Plates are not likely to be of use in rigid and deformed flat-foot where it is not possi- ble to obtain an improvement in position by gentle manipulation. In such cases the restoration of a more correct position should precede the use of plates. Casts for Plates. — For the construction of a properly fitting plate a FLAT-FOOT AND OTHER DEFORMITIES. 581 cast of the foot is necessary. This is made from a plaster mould of the foot placed in as near a correct position as is possible. The patient is seated and the foot is placed in a pan of plaster of Paris and water of about the consistence of melted ice cream. No weight is put upon the leg during this proceeding, and the plaster is heaped up around the inner side of the ankle and is allowed to harden. The foot is then re- moved from the mould, which is greased with vaseline and filled with plaster-of-Paris cream. When the latter hardens it is removed from the mould and gives a representation of the patient's foot in a somewhat corrected position. As this cast furnishes a somewhat sharp contour of the sole of the foot, a plate shaped exactly to it would be likely to present rather sharp contours and not be so comfortable as a somewhat modified shape. It is therefore necessary for the surgeon with a sharp knife to cut away something of the lower surface of the cast in order to insure in the plate an even, well-distributed bearing surface, pressing most on the points where pressure is desired. It must be remembered that the plate should furnish support to the hard tissues of the foot and not to the soft, and in fat feet more modification will be necessary than in thin ones. It is also necessary, if the plate is to be properly balanced and set evenly, that the surgeon should cut the cast where the front and back edges of the plate come, in such a way that they should be flat and approximately in the same plane ; otherwise a rocking plate or one with uneven edges will result. Another method of preparing casts for plates is to model them from moulds of the foot made in dental wax. If a sheet of quickly hardening dental wax is softened in hot water and placed upon the bot- tom of the foot, a mould can be taken. When it is hardened it can be removed from the foot, and can be cut and moulded to any desired shape by immersion again in hot water. In this way a wax flat-foot plate is made fitted to the boot. A plaster-of-Paris cast can be taken of this, and reproduces exactly the shape and size of the plate desired. Manufachire and Material.— TYiQ. best all-round material for the manufacture of plates is a spring tempered steel of a gauge varying from eighteen to twenty, according to the weight of the patient. For the manufacture of plates from this material, the services of an instru- ment-maker or of a skilful blacksmith are necessary. The cast should be furnished to him and the plate forged to fit the cast exactly. It should then be tried on the patient, before or after which it should be tempered. For final use the plate should be copper-plated and nickel- plated. In other cases it is more convenient to cover it with leather, but the moisture of the foot is more likely to rust it under these con- ditions than when it is nickel-plated. Galvanizing furnishes a perma- nent protection against rust, but the process destroys or impairs the temper of the plate. A galvanized plate should therefore be made 582 ORTHOPEDIC SURGERY. heavier than others. Of other material used for the manufacture of plates should be mentioned phosphor bronze, which is malleable and more easily fitted, but plates made from it are much heavier than of tempered steel. Sheet celluloid may be used for the manufacture of plates, but in order to support weight it has to be very thick, and even then is inclined to bend or break. It has the advantage that the sur- geon can make and shape his own plates. The celluloid is cut of the desired shape and is bound on to the bottom of the cast by rubber tub- ing, which is wound round both cast and plate on the stretch ; it is then immersed in boiling water, which softens it until it takes the shape of the bottom of the cast. The edges should be smoothed with a file. Another efficient but somewhat clumsy use of celluloid may be made by the surgeon. A celluloid paste is made by dissolving celluloid chips in acetone ; this is then painted on to several layers of gauze laid on the cast, between which strips pieces of steel wire are incorporated. The wires are laid on in different directions, giving strength as desired. When the celluloid has hardened, the edges of the plate should be trimmed. Shape of Plates. — Judgment is necessary in determining the proper shape of the plate in each case, as the deformity varies both in degree and in kind. The shape should be determined by the part of the foot which needs corrective support. In the milder cases all that is needed is to furnish support to the sustentaculum tali. In other cases the scaphoid, cuneiform, and proximal end of the first metatarsal need to be raised. In some cases the tendency of the os calcis to rotate to the inner side of the foot is to be checked, and in other cases side pressure is needed on the head of the astragalus, scaphoid, and cuneiform, with counter-pressure on the outer side of the foot. The most practical way of determining what shape of plate is desirable is to have the patient stand, and by pressure with the hand to see in what place the force accomplishes the best result. In general, a plate should be higher along the inner part of its surface than on the outer, but it should not be made so sloping that the foot continually slides off. If this is the case a counter-point of pressure may be furnished by turning up the outer flange at the outer edge of the plate. Ordinarily it is advisable to have the plate support nearly the whole width of the sole, ending in front behind the sesamoid bones of the great toe and at the back end just anterior to the weight-bearing surface of the heel, or, if desired, running to the back of the weight-bearing surface of the heel. If the anterior part of the foot is broken down, support to it should be furnished by raising the front of the plate in a dome-shaped rise, sup- porting the part of the foot behind the heads of the metatarsals. In flexible feet a shorter plate can be used than in rigid feet. The need of an inner flange and its height will be determined by the require- FLAT-FOOT AND OTHER DEFORMITIES. 583 ments of the case; the same is t'-ue of the outer flange. The plate at its outer border should not project beyond the outer edge of the shank of the boot, or it will push out the leather and destroy the shape of the boot. Fitting and Use. — The plate should be shaped in such a way as to act as a prop to the portions of the feet which drop to an abnormal po- sition when weight is thrown upon them. In the practical fitting of the plate, if the plate is rightly shaped, the foot when not bearing weight should lie smoothly against the bottom of the plate, not springing off at the front or back. If it springs off, it will exert more pressure than is generally comfortable. When the plate is placed in the boot and the patient stands upon it, there should be a sense of even, well-distributed pressure, and not a feeling as if the patient were standing on a ridge or lump, which will be the case if the plate is too high. If an inner flange is used it should not press too much upon the foot when weight is borne upon it. If sensitive points in the foot are present and cause pain when weight is borne upon the plate, it will be necessary to lower the plate opposite these points. When the plate is first applied it should be worn only for so long a period as is consistent with the com- fort of the patient, and should then be taken out to rest the foot if nec- essary. If the plate is persistently a source of pain it will not give the desired relief, but will cause irritation and must be lowered until it is comfortable. No point is more commonly neglected than this, and the very common use by patients of ill-fitting supports bought at shoe-stores brings much discredit upon the use of plates. The plate should set firmly in the shoe and should not rock, and the front and back ends should be in contact with the sole of the boot. Misuse of Plates. — The danger of injury to the feet by the too con- stant use of plates is to be borne in mind. The plate is to be regarded in the same light as is a crutch or cane in the case of any joint unable to bear the strain of use, and is to be discarded when the normal strength has returned and the irritability has disappeared. To continue the plate after the indications for its use have disappeared is to hamper the muscles of the feet and to prolong the unnatural condition. Discontinuance of Plates. — When the symptoms of irritation have disappeared, a trial of the strength of the foot is to be made by discon- tinuing the plate for a short period and by teaching the patient to hold the foot by muscular effort in the corrected position. When the plate is first left off, prolonged standing and walking are to be avoided, and if symptoms of irritation follow its discontinuance it should be reap- plied. It is a mistake to discontinue the plate suddenly or for the pa- tient to continue to go without it if symptoms of strain are present. Pads. — The use of felt or leather pads supporting the arch of the foot is sometimes of use temporarily or under exceptional conditions. 584 ORTHOPEDIC SURGERY. Such pads may be cut of the desired shape and worn outside the stock- ing by being fastened on temporarily by a tape passing round the foot or by being incorporated in an inner sole of leather. If they are worn for any length of time the weight of the foot stretches the leather of the boot and breaks down the shank and they cease to be of value. Felt or leather pads are frequently of use in persons with mild flat-foot who have to exercise or stand in gymnasium shoes. TJie Oblique Sole. — Palliative treatment is often attempted in cases of flat-foot by making the inner side of the sole and heel of the boot one-eighth or one-fourth of an inch thicker than the outside. The weight is in this way thrown more to the outer side of the foot and the strain on the inner side is somewhat relieved. The thickness of the wedge which is necessary may be determined experimentally by build- ing up the inner side of the boot till the desired position is obtained, as determined by the diminution in the projection of the internal malle- olus. The objection to the method is that the foot slides on the incline of the sole if an effective elevation in the sole of the boot has been made and the boot is distorted by the stretching of the leather over the outer side; in addition to which, the pressure of the outer side of the foot against the boot is uncomfortable. It is to be remembered that in the correction of flat-foot not only should the body weight fall well on the outer ^(\gQ. of the foot, but the great toe and head of the first metatarsal should perform their normal functions in locomotion. The method is sometimes useful in the flat- foot of children and in connection with the use of plates; in the latter case a slight elevation will sometimes diminish the strain on the inner side of the foot. Of itself, however, it must be regarded as a very im- perfect method. The raising of the inner edge of the heel of the boot without changing the sole has the advantage of checking somewhat the inclination of the os calcis to roll to the inside. M.\ssAGE, Gymn.\stics, ETC. — The supportive treatment of flat-foot should be reinforced by measures to stimulate the local circulation and to strengthen the muscles of the foot. Massage is of the first impor- tance, but should not be pushed to the point of irritation. The use of alternating hot and cold douches or of a local hot bath followed by a cold douche is of much value. Vibratory massage, electricity, and the use of hot air may be of use in especial cases. Exercises to increase the power of the deficient muscles are sufificient, in connectioji with the measures already mentioned, to correct many of the milder cases. They form an important part of the treatment of all cases, mild or severe, whether or not used in connection with support to the arch, and are to be regarded as essential to treatment of any form. The toeing-out habit in standing and walking should be corrected. Individuals with strong and untrammelled feet stand and walk with but little diversfence FLAT-FOOT AND OTHER DEFORMITIES. 58; of the angle of the feet. The greater the angle of divergence in walk- ing and standing, the greater the tendency to strain of the tissues and to falling of the foot to the inner side. Shoes.- — Typical flat-foot, being a static deformity, is in general to be prevented if proper precautions are taken. Of these the most im- FlG. 533.— Showing- Shoe Constriction of Front of Foot, with Normal Foot in Shoe Before and After Removal of Upper. portant is footwear which does not distort or interfere with the free movements of the foot. In infants beginning to walk, in whom the body weight may be too great for the muscular strength, trouble may be averted by massage and manipulative treatment, the avoidance of great fatigue, and the use of proper footwear. In older children with the same defect, gymnastic development of the muscles of the feet should be followed out and faulty shoes avoided. The adoption of proper footwear is essential not only to protect a foot under treatment for flat-foot from relapsing to its deformity, but 586 ORTHOPEDIC SURGERl also as a preventive measure in young children. The object of a boot should be to hold the foot in an approximately correct position and not Pig. 534. — a, Drawing of Normal Position of Bones of Foot. 1^, Fashionable Shoe, c, Tracing of Skiagram of Foot in Shoe, Indicating Cramping and Downward Pressure on the First Metatarsal. to interfere with the normal function of the foot in walking. It is ob- vious that the great toe should have room to help support the inner Fig. 535.— a, Photograph of Humped Foot, d, Tracmg of Skiagram of Humped Foot with Irritation Exostosis of the Metatarso-cuneiform Articulation. border of the foot ; that the forefoot should not be cramped, but should have room to be placed properly on the ground, in order to perform its FLAT-FOOT AND OTHER DEFORMITIES. 587 weight-bearing function ; and that the toes should be given room and opportunity to touch the ground in their proper relation and thus be of use in walking, and that the outer edge of. the foot should have an op- portunity to exert its normal function in supporting the body weight. These requirements necessitate that the boot or shoe should have a straight inner line, that the shank should be as high as the shank of the individual foot when bearing slight weight. This should not be too stiff, permitting the normal play of the first metatarsal inward and Fig. 536. — Tracing of Skiagram of Foot in Shoe Before and After Removal of Upper. downward, and should be slightly higher at its inner than its outer bor- der. The forward part of the boot should be as wide as the weight- bearing foot at that point, and the toes should have room to be placed individually on the ground. The forward part of the sole should not be rolled up, but should be flat, to enable the toes to finish the step in walking; neither should the lower surface of the sole be convex from side to side, but should set squarely on the ground. The heel should not be high. The forward part of the boot should be at somewhat of an angle to the line of the long axis of the heel, that is, the forefoot should be slightly adducted on the posterior part of the tarsus. Since the position of the weakened foot is one of abduction of the forefoot, and the position of the foot under muscular support is one of adduction of the forefoot, it is obvious that the support of the foot in the former 588 ORTHOPEDIC SURGERY. condition is corrective in character. The upper should not be shaped too snugly upon the dorsum of the foot or be so inelastic as to prevent the flexible action of the toes. The shape of the shoe has become conventionalized to such an ex- tent that the general use, among the leisure class, of shoes of the shape of the normal foot is not practicable. The people of the city streets will not be shod as hunters. It is, however, practicable to limit the use of fashionable shoes for leisure hours and working boots for working hours. The boots should be adapted to the gait and use. People who use the front of the feet in locomotion, "front-foot" walkers, and those walking on uneven ground need more room in the front of their boots than heel walkers or those who walk on an everi surface. Individuals Fig. 537-— a Shoe Arranged so as not to Cause as much Pressure on the Dorsum and Pre- venting the l^istortion. with any tendency to flat-foot should have walking boots as well as dress boots, and the feet should be rested as much as possible in san- dals and moccasins. The Treatment of Painful Cases. — In certain cases the symp- toms of local irritability reach so high a grade that especial treatment is needed. Spasm of the peroneal muscles may be present, holding the foot in an abducted position and resisting movements of rectifica- tion. In this case temporary fixation of the foot in a plaster bandage is the most efficient measure. In other cases great irritability is caused by a tenosynovitis from joint inflammation incident to strain, and in these cases the treatment described for sprain of the ankle is necessary. Irritated flat-foot, however, is not so favorably affected by massage as the ordinary sprain of the ankle. Support to the Leg and Foot.— In the severe forms, when there FLAT-FOOT AND OTHER DEFORMITIES. 589 is decided eversion of the foot, a support holding the leg is needed. Such may be afforded by means of a steel sole plate, with an upright passing up on the outside of the leg, with a supporting strap around the inner malleolus described in speaking of infantile paralysis, or as a sim- ple upright attached to the outer side of the sole of the boot, with a leather support over the inner malleolus secured to the upright (Chap- ter XXI., 31). ^ Forcible Correction.— In cases in which it is not possible to place the foot in an approximately correct position on account of stiffness and muscular contraction, it is generally unsatisfactory to attempt Fig. 5-,8.-Deformity Caused by the Con.striction and Confinement of the Foot. the use of a support until the position of the foot has been corrected. Such patients should be anaesthetized and the foot forcibly twisted into shape. It must be remembered that there are two elements of deform- ity to be corrected: first, eversion of the foot; and, second, abduction of the forefoot. This can be done manually in many cases, but in severe cases such an appliance as the Thomas club-foot wrench will be of use in giving better leverage, or the foot can be manipulated over a padded wooden wedge. The foot should be overcorrected if possible, or in any event placed in the best obtainable position and held by a plaster bandage. It then follows the course of an ordinary sprained ankle, generally of slight de- gree. As soon as the patient can walk without pain, supports should be applied. 590 ORTHOPEDIC SURGERY. In less severe cases correction can be gradually accomplished by the repeated application of plaster-of-Paris bandages. In extreme cases osteotomy of the neck of the os calcis and astrag- alus may be needed. The removal of a wedge-shaped piece of bone from the inner side of the midtarsus has been recommended, but should not be undertaken unless it is certain that the chief obstacle to correction lies in the dis- torted shape of the astragalus, scaphoid, and os calcis. In a majority of cases, even the severe ones, forcible correction will be found more efficient than wedge-shaped exsection, as the distortion will be found to be distributed in various parts of the foot, and extensive removal of bone will be followed by weakening of the foot. The operative details Fig. 539.— Forcible Correction of Valgus on Wooden Block. (Berger and Banzet.) for osteotomy and wedge exsection are similar to those to be regarded in operating on club-foot, it being remembered that the deformity is the reverse of club-foot. The most notably deficient muscles are the tibialis posticus, the tibialis anticus, the flexor longus hallucis, and the short muscles of the sole of the foot. The following simple exercises will be found useful : The patient walks on the outer edge of the foot with the inner edge raised. The patient attempts to separate the great toe from the second toe laterally and to hold it in that position while walking. The patient flexes the toes while the foot is free and grasps objects in them by their plantar surface. The patient walks with the front of the foot directed inward. The patient sits with the leg extended and resting upon the assist- ant's knee. Forcible adduction of the forefoot is then made while the assistant resists lightly with one hand steadying the tibia and the other pressing against the ball of the great toe. The patient should be taught to rise on the toes at the end of each step, finishing the step with the toes. FLAT-FOOT AND OTHER DEFORMITIES. 591 The patient should place the feet together in a parallel position, rise upon the toes as far as possible, and turn the heels, and, with the feet in this position, lower the body by bending the knees. Such exercises as the surgeon directs should be performed an in- creasing number of times each day. Certain other painful affections and acquired deformities of the feet are sufficiently allied to fiat-foot to be considered in this connection. METATARSALGIA. (Anterior metatarsalgia, Morton's disease.) This name is used to describe a cramping pain more or less spas- modic, situated between the distal end of either of the outer three metatarsal bones. It was first described by T. G. Morton,' of Phila- delphia, in 1876. Causation — The pain is due to a disturbance in the normal relation of the anterior ends of the metatarsal bones, causing a pinching of the external plantar nerve between the ends of the bones, or to pressure of the metatarsals on other digital nerves, or to abnormal strain upon the ligaments connecting the metatarsal heads." The affection is thus due to the disturbed relation in the position of the metatarsals caused by faulty footwear. Normally the head of the first metatarsal bears a large part of the weight which comes upon the front of the foot. If footwear is worn which gives insufficient room for the toes and at the same time exerts a crowding pressure upon the metatarsals, the heads of the first and fifth metatarsals are unable to drop to the normal plane below the level of the other metatarsals, owing to the narrowness of the shoe. The weight therefore falls unduly on the heads of the other metatarsals, which are crowded downward as the foot slips forward in the boot. Symptoms. — The condition is characterized by a more or less severe pain, which radiates down into the toes and often up into the leg. The pain usually appears when the patient is walking. It occurs generally between the third and fourth or fourth and fifth toes. It may be pre- ceded by a sensation of slipping between the ends of the metatarsals, or the slipping may occur without the pain. It ordinarily comes on when the boots are on, but may sometimes be occasioned by rising on the toes in the stocking feet. The patient seeks relief instinctively by removing the boot and manipulating the foot, which relieves the acute pain. Some soreness may remain afterward and a tender spot is often found at the seat of the pain. The attacks of pain may become gradually more frequent and more ' Amer. Journ. Med. Sciences, 1S76. -Jones: Liverpool Med -Chir. Journ., January, 1S97. 592 ORTHOPEDIC SURGERY. severe until a condition of disability is established, the patient dreading walking. Spontaneous recovery may occur, but is uncommon. The foot may be normal, so far as can be ascertained on inspection. Oftener, however, one or more of the following variations from the normal may be detected. 1 . The foot may be weakened and the standing position show slight dropping of the arch. 2. The anterior arch of the foot, or the arch normally formed by the heads of the metatarsal bones, if looked at in a cross section of the foot, is relaxed and flattened. The heads of the second, third, and fourth metatarsals are on a lower level than normal. 3. Dorsal flexion of the foot may be limited on manipulation. Callosities may be found under the heads of the metatarsals, and one or more of the metatarsal heads may be felt unduly prominent in the sole of the foot. Motion of the toes, especially in severe cases, is apt to be limited in the direction of plantar flexion. Diagnosis. —This affection is frequently diagnosticated as neuralgia, for which only general treatment is prescribed, yet the diagnostic symptoms are perfectly well marked and definite and not like those of any other affection. The prognosis without treatment is not good; the attacks as a rule become more frequent and painful, though spontaneous recovery does rarely occur. With proper mechanical treatment most patients recover, but occasionally very obstinate cases are seen which resist all the ordi- nary methods of treatment. Treatment. — It is obviou-: that if any static deformity of the foot exists it should be corrected. If the weakened foot is present a proper plate should be applied, brought well forward with an elevation behind the distal ends of the metatarsals. If the anterior arch is relaxed and flattened, a felt or metal pad should be placed under it behind the heads of the metatarsals. In short, measures should be adopted to relieve the front ends of the metatarsals from pressing down on to the sole of the foot in finishing the step \\\ walking. Proper boots with a broad sole should be worn, and compression of the front of the foot by boots should be avoided. The normal flexibility of the toes should be cultivated by proper exercises. In some cases, however, compression of the shafts of the metatarsals for a time affords relief. In these cases it can be afforded by adhesive plaster, by band- aging, or by a boot made tight over the shafts of the metatarsals. Re- moval of the distal end of the fourth metatarsal has been advo- cated as a measure of treatment, but it is not often necessary to resort to this. FLAT-FOOT AND OTHER DEFORMITIES. 593 HALLUX VALGUS. This name is applied to the outward displacement of the great toe. In the normal foot, as seen in children and people who do not wear boots, the long axis of the great toe vyhen prolonged backward passes through the centre of the heel (Meyer's line). Causation.— This deformity of the great toe, however, is not neces- sarily the result of tight shoes, for the deformity may come in people who have worn only comparatively loose ones. The upper leather of shoes, being more yielding than the sole, stretches under the pressure of use, or is stretched to avoid pressure upon the metatarso-pha- langeal articulation. The boot is not stretched at its extreme end Fig. 540.— Hallux Valg-us. Great toe unde FIG. 541. -Hallux Valg-us. Great toe over. and it inevitably becomes, in a degree, conical in shape on this account, being broader across the ball of the foot than at the tip end. In the act of walking the foot necessarily slips inside of the boot to a certain extent, and if the shoe slips backward and the foot forward, a certain amount of pressure will come upon the inner side of the end of the great toe, tending to displace it outward. This deformity may also be occasioned by short boots, and the ordi- nary pointed-toe boots, or any boot which does not give more room for lateral spreading at the toes than at the metatarso-phalangeal articula- tion, would necessarily give rise to the trouble. Stockings are also a factor in its production. 594 ORTHOPEDIC SURGERY. Symptoms. — When the deformity continues for any length of time, alteration in the relation of the bones of the metatarso-phalangeal joint takes place. The head of the metatarsal is partly uncovered as the phalanx is pushed to the outer side, and the head of the metatarsal may become enlarged from growth of the bone due to periosteal irritation. The skin over this prominent joint may grow thick and a bursa form over it. This may become inflamed, giving rise to an extensive cellulitis, Fig. \';,';;jire, and {c~) an occipital piece of steel. (a) The chest and shoulder piece is a U-shaped piece of wire bent to rest on the shoulders and on the chest, not bearing on the clavicles. The U-piece which is applied to the chest and shoulders is meas- ured from the level of the xiphoid cartilage to one inch posterior to the anterior border of the trapezius. These strips are vertical. The width of the bottom of the U-piece is the horizontal distance between the middle of the clavicles. It is bent to follow the lateral contour of the chest, and from below up- ward lies closely against the chest and shoulders, but is bent out over ^i°- 551 the clavicles. (7;) The other piece of wire, the chin-piece, is bent to follow the outline of the chin and the ramus of the jaw. The posterior ends of the chin-piece are bent vertically downward just back of the ramus of the jaw, and welded or soldered to the chest-piece at points posterior to the clavicle on each side. Anterior Head Support. (See Fig. 77.) 6 14 ORTHOPEDIC SURGERY. (c) The occipital piece consists of a strip of cast steel wire, one- quarter of an inch thick, running horizontally behind the head and bent around the wire upright on one side to form a hinge and secured to the opposite wire upright by a hook catch made by bending over its end. The length of the anterior horizontal portion is the distance from just behind the ramus of the jaw to the tip of the chin. Its width is the distance between the outer surface of the mastoid processes plus one-half of an inch or less on each side. The height of the vertical portion of the chin-piece, where its posterior ends are bent down to unite with the shoulder-piece, is measured from the tip of the ear to the point where the highest portion of the shoulder-piece passes over the shoulder. This vertical portion slopes outward from the ramus of the jaw to the shoulder part of the U-piece. The measure of the occi- pital part of the brace is the distance between the tips of the ears measured as a curve, not touching the skin, at a level just below the occipital protuberance. To prevent chafing of the skin, pads are attached under the tip of the chin, as described in the oval ring. The occipital piece is padded behind with thick felt covered with leather. To the portions of the U- piece of the brace passing over the shoulder and across the sternum are soldered strips of thick machine steel, three-quarters of an inch wide and one-quarter of an inch thick, curved to fit the brace, perforated at their edges with small holes, so that there may be stitched to the pos- terior surface of these steel pieces felt pads covered with chamois or kid. The material used for constructing this head-piece is cast steel, one-quarter of an inch in diameter. The support is fastened to the back brace by means of strips of webbing, one inch wide, riveted to the upper part of the U-piece. These straps, which should be padded, pass over the shoulders and are fastened to buckles riveted to the upper ends of the antero-posterior support. Similar webbing straps are also attached to the lower angles of the U-piece and pass horizontally around the sides of the chest, to be fastened to buckles attached to the middle of the antero-posterior support. If it is desired to give greater security to the head, upright strips of steel may be attached to the posterior part of either of the forms of support just described, the oval ring or the antero-posterior support.' These strips are bent to conform to the posterior contour of the head, and pass upward one inch behind the mastoid processes to the level of the parietal eminences. They are made of spring steel, one and one- quarter inches vride and one-sixteenth of an inch thick, forming a padded plate at the top riveted on to the upright. The length of the upright, made of one-quarter of an inch round cast steel, is the distance from the horizontal ring to the parietal eminence. They are provided PRACTICAL DETAILS OF APPARATUS. 615 at their upper ends with buckles, which are riveted to them, which serve to secure a padded webbing strap passing forward round the forehead from one upright to the other. They are also provided at the level of the mastoid processes with a buckle facing inward on each up- right, which serves to secure a supporting strap passing behind the oc- ciput. The tightening of these straps steadies the head, and, with the chin-piece, holds it firmly. 7. THOMAS COLLAR. The original Thomas collar consisted of a strip of calf skin folded on itself to the depth of from four to six inches, the two free ends being stitched together in an irregular curved line. In the centre of the por- tion to be placed under the chin the stitching was from four to six inches below the upper border. At the point below the ear the stitching was two inches from the upper bor- der. At the posterior portion the lower border of the stitching was three inches be- low the upper border. Sawdust was pressed ^^''■'''%'^^i^^^^'^''''^"' in between the folds of leather held below by the stitching and above by the folded top of the leather. Straps and buckles were attached to the posterior portion of the collar stitched around the neck. A greater or less amount of sawdust was packed into the cavity, in order to increase or diminish the amount of support. This collar, which can be made by any saddler, is somewhat awkward in shape but readily made. As a substitute for this, a collar stock can be made of stiffened leather similar to what is used for leather jackets, reinforced by steel or phosphor bronze and padded with felt. The length of the collar or stock should be sufficient to encircle the neck and fasten behind without overlapping. 8. QUADRILATERAL BACK BRACE.' The design of this brace is to combine with the antero-posterior leverage action of the Taylor back brace the power of checking rotation obtained in the plaster-of-Paris jacket. The entire upper chest is left free from the pressure of the apron, and the shoulder girdle is used as a point of counter-pressure for the axillary straps. This is made pos- sible by the fastening of the scapulae under the widely separated up- rights, which restrict their motion upon the thorax within very narrow limits. It consists of {ci) a pelvic band; (/;) two uprights; (r) a top bar; (^) a pad plate bar; (r) an apron. 'John Dane: Trans. Am. Orth. Assn., xiii., 70. 6i6 ORTHOPEDIC SURGERY. id) T\iQ pelvic band is, made of No. 15 gauge sheet steel, and is bent to fit the curve of the pelvis, circling it behind at a point just above the trochanters. Its anterior ends reach to the anterior superior spines. {b) The uprights, made of No. 12 gauge cast steel, and riveted to the pelvic band a little outside of the posterior superior spines. They extend upward to one-half of an inch above the spines of the scapulae. To their ends are riveted the descending arms of the top bar. These uprights are bent so as to follow the curve of the flanks, but not to rest upon the skin until they pass over the scapulae, from which point they should press upon the skin when the shoulder-straps are tight- ened. {c) The Top Bar. — This is made of the same size of metal as the uprights. Its length is the diameter of the back, taken from one-half of an inch inside the glenoid rim of the scapulas, when the shoulders are pulled backward. Each end of this bar is bent at a right angle downward and continued for one inch. To these descending arms the upper extremities of the up- rights are riveted. {d) The Pad-Plate ^^7-.— This is a horizontal bar, No. 14 gauge sheet steel, fastened to the uprights by means of a flat-headed screw at the level of the kyphos. Its central portion is curved sharply backward so as to clear the spinous process of the vertebrae. On the slope of this curve on each side are riveted the pad plates. These are flat strips of No. 1 8 gauge sheet steel, one-half of an inch wide and from one and one-half to three inches long. The distance between them is enough to insure their pressure falling upon the transverse processes of the vertebrae. To facilitate adjustment of the pad-plate bar the opening for the screws that hold its ends to the uprights is made in the form of slits, one-half of an inch in length. Three buckles are riveted to the uprights, one on each side, the upper one just below the axilla, the others equally spaced below. One more pair of buckles are riveted to the ends of the pelvic band. One -Quadrilateral Back Brace. PRACTICAL DETAILS OF APPARATUS. 617 end of a padded strap is riveted to the outer end of the top bar on each side. The frame of the brace is wound with canton flannel or covered on the side next the skin with leather. Each pad plate has a felt pad, three-eighths of an inch thick, sewed to its anterior surface. These can be frequently changed as occasion may arise. {/) The Apron. — This is cut from sole leather, one-sixteenth of an inch thick. Its length extends from the level of the ensiform to the top of the pubis in the median line ; from the level of the ensiform to the anterior superior spines on the sides. Its width is the diameter be- tween the anterior spines. Straps of webbing are sewed to this on each side opposite the lower buckles on the brace, the upper pair of buckles taking the ends of the padded straps that come from the top bar of the brace. Quadrilateral Back Brace with Head Support. The brace is similar to that just described, with the addition of a second horizontal bar connecting the uprights from one to two inches below the top bar. In cases of very high deformity the pad-plate bar can be made to take its place. The head support consists of: ia) Two uprights; ((^) the occipital strap ; (c) the frontal strap. ia') The uprights. Starting as flat forged steel bars, one-half of an inch wide and one-eighth of an inch thick, from one inch below the second horizontal bar, they are carried straight upward to a point one inch below the occiput ; then as round rods they are curved upward and outward to a point one inch above and one-half of an inch behind the ear ; then forward close to the head as flat bars to the level of the pos- terior part of the forehead. As they pass around the occiput behind they are one-half of an inch from the head. These uprights pass through guides riveted to the posterior surface of the top and second bars of the brace. The guides on the second bar are perforated with holes and finished with screws for holding the uprights in position. The width between the guides should be a little less than the trans- verse diameter of the patient's neck. The horizontal flanges are cov- ered with leather on their inner sides where they grasp the head. A buckle is riveted to the anterior end of each horizontal flange. {b) The occipital strap is made of a thin strip of brass, one-quarter of an inch wide, covered with calf-skin. On one end it is prolonged forward for one-half of an inch as a right-angled arm. This is riveted to one of the uprights at the angle where it becomes horizontal. Its other end is free. This strap is padded on its inner side with thin felt and covered with leather. On the free end this leather is prolonged as 6i8 ORTHOPEDIC SURGERY. a strap and passes through a buckle riveted to the outer side of the other upright at the angle where that becomes horizontal. (