•iTr-r '^^^^ri^^^yi^P'^'iSSr HX64068994 RD731 B72 a treatise on orthop RECAP pft ■..^ »V- ,. f- El.. I.. -'•' :^.'-;^if .^ ' V ^ ■ l^^k. ;V ;':^^; ►+■ -v^f,.'* ..T^^!r -d-'^ r- ----1---! " mtfjfCitpotiHrttifork College of ^fjpgicianjf anb ^nrscons: iLibrarp B ,->--' Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseonorthop1890brad A TREATISE ON Orthopedic Surgery EDWARD H. BRADFORD, M.D., Surgeon to the Children's Hospital, Boston City Hospital, and Samaritan Hospital ; Instructor in Clinical Surgery, Harvard Medical School; AND ROBERT W. LOVETT M.D., Surgeon to the Samaritan Hospital; Assistant Out-Patient Surgeon to the Children's Hospital: Out-Patient Surgeon to the Carney Hospital ; formerly Assistant Surgeon to the New York Orthopedic Dispensary and Hospital. ILLUSTRATED WITH 789 WOOD ENGRAVINGS. NEW YORK WILLIAM WOOD & COMPANY 1S90 Copyrighted, 1890, WILLIAM WOOD & COMPANY. /,- S~SQ ELECTROTYPED AND PRINTED BY THE publishers' PRINTING COMPANY 30 & 32 WEST 13TH STREET NEW YORK PREFACE The writers of previous works on Orthopedic Surgery have con- fined themselves to a consideration of the treatment of existing deformities, such as club-foot, lateral curvature, and bow legs. The only conspicuous exception to this is found in the excellent book of Dr. Sayre. But the term Orthopedic Surgery, if it is properly defined, should include the prevention as well as the cure of de- formity. For this reason the diseases of the joints have been con- sidered by us at considerable length, inasmuch as they are among the most common sources of deformity and disability. We have endeavored throughout to include such subjects as are likely to come to the attention of those who interest themselves in the practice of this branch of surgery, without perhaps adhering too closely to the definition of the term orthopedic surgery. In this way, besides the consideration of joint disease and Pott's dis- ease, we have added a brief description of some disabling and de- forming nervous affections, which we have only attempted to dis- cuss in their practical surgical aspect. The deformities resulting from fractures, dislocations, and burns are so fully treated in works on general surgery that they have not been considered here. Edward H. Bradford. Robert \V. Lovett. Boston, May 15th, iSgo. TABLE OF CONTENTS. PACE Preface, ■ . . . iii CHAPTER I. Pott's Disease. Definition. — History. — Pathological Anatomy. — Occurrence and Eti- ology. — Symptoms. — Diagnosis. — Differential Diagnosis. — Prog- nosis. — Treatment 1-102 CHAPTER II. Lateral Curvatures of the Spine. Definition.— Frequency.— Predisposition as to Sex.— Clinical History. — Stages of the Aftection. — Symptoms. — Pains. — Distortion. — Cur\^a- ture. — Torsion. — Varieties of Lateral Curvature. — Etiology. — Path- ology. — Diagnosis. — Prognosis. — Preventive Measures. — Treat- ment, . . 103-183 CHAPTER III. Other Affections of the Spine. Curvatures of the Spine. — Physiological Curvatures. — Scoliosis. — Kyphosis. — Round Shoulders. — Rheumatism of the Spine. — Lor- dosis. — Weak Spine. — Spondylolisthesis. — Affections of the Tho- rax. — Malignant Disease of the Spine, 184-201 CHAPTER IV. The Pathology of Chronic Joint Disease. Diseases Affecting the vSynovial Membrane ; Anatomy of Sj'novial Membranes ; Chronic Serous Synovitis ; Chronic Purulent Syno- vitis. — II. Jomt Diseases Affecting the Cartilage; Hypertrophy and Atrophy; Primary Inflammation of Cartilage; Secondar\- Inflammation of Cartilage ; Loose Bodies in the Joints. — III. Joint Diseases beginning in Bone ; Tuberculous Ostitis ; Gummatous Ostitis ; Formative Ostitis (Arthritis Deformans) ; Exostoses ; Tumors of the Joints; Miscellaneous Minor Affections of the Bone. — IV. Joint Diseases beginning m the Peri-articular Struc- vi TABLE OF CONTENTS. I'AGK tures; Ligamentous Afifections ; Peri-articular Abscess ; Bursitis — other Affections Impairing Joints, ....... 202-230 CHAPTER V. The Etiology, Course, and Termination of Chronic Joint Disease. Etiology. — Chronic Serous Synovitis.— Chronic Purulent Synovitis. — Inflammation of Cartilage. — Joint Manifestations in {a) Tubercu- losis, (b) Syphilis, {c) Rheumatism, (d) Arthritis Deformans, {e) Gout, (/) Acute Infectious Diseases, {g) Miscellaneous Conditions. — Tabes Dorsalis. — Haemophilia. — Growing Pains. — Acute Arthritis in Infants. — The Distribution of Chronic Joint Disease. — Course and Termination of Chronic Joint Disease.^Ankylosis. — Treat- ment of Chronic Joint Disease, 231-254 CHAPTER VI. Hip Disease. Definition. — Pathology. — Clinical History.— Diagnosis. — Differential Diagnosis. — Prognosis. — Treatment (Conservative — Operative), . 255-359 CHAPTER VII. Other Diseases of the Hip-Joint. Chronic Synovitis. — Symptoms. — Diagnosis. — Treatment. — Arthritis Deformans. — Pathology and Etiology. — Symptoms. — Diagnosis. — Treatment. — Charcot's Diseases of the Hip-Joint. — The Acute Arthritis of Infants. — Syphilitic Disease of the Hip. — Periostitis of the Hip. — Malignant Disease of the Hip. — Loose Cartilages in the Hip-Joint. — Interstitial Absorption of the Neck of the Femur, . 360-365 CHAPTER VIII. Tumor Albus of the Knee-Joint. Definition. — Pathology. — Clinical History. — Diagnosis. — Differential Diagnosis. — Prognosis. — Treatment, («) Conservative, {B) Operative (Excision — Arthrectomy — Amputation), 366-397 CHAPTER IX. Other Diseases of the Knee-Joint. Chronic Synovitis. — Intermittent Hydrops Articulorum. — Arthritis Deformans. — Loose Bodies in the Knee-joint. — Internal Derange- ment of the Knee-joint. — Bursitis. — Cysts about the Knee-joint. — Charcot's Disease. — Dislocation of the Patella. — Primary Dis- ease of the Cartilages. — Rupture of the Patella Tendon, . . 398-417 CHAPTER X. Diseases of the Joints of the Ankle and Foot. Diseases of the Ankle-joint. — Simple Synovitis and Ostitis. — Symp- toms. — Diagnosis. — Treatment. — ^ Arthritis Deformans. — Diseases of the Scapho-cuneiform Articulation. — Diseases of Metatarso- phalangeal Articulation. — Bursitis of the Ankle, . . . .418-428 TABLE OF CONTENTS. vii PACE CHAPTER XI. Diseases of 'vwv. Siioui.dick, Eeijovv, and Wrist JfjiNTS. Shoulder-Joint. — Acute Synovitis. — Chronic Serous Synovitis. — Os- titis.— Chronic Rheumatoid Arthritis. — Periarthritis. — Charcot's Disease. — Synovial Cysts and Bursse. — Treatment of Shoulder-Joint Diseases. — Elbow-Joint.-— Synovitis.— Ostitis. — Chronic Rlicuma- toid Arthritis. — Urethral Arthritis. — Charcot's Disease. — .Syphilitic Disease. — Peri-articular Disease and Stiffness of the Elbow. — Treatment of Elbow-Joint Diseases. — Diseases of the Wrist-Joint. — Ostitis. — Teno-Synovitis. — Rheumatoid Arthritis. — Treatment of Wrist-Joint Disease 429-444 CHAPTER XH. Diseases of the Sacro-Iliac and other Joints. Diseases of the Sacro-Iliac Joint. — Diseases of the Phalangeal Articu- lations. — Diseases of the Temporo-Maxillary Articulation. — Dis- eases of the Sterno-Clavicular and Acromio-Clavicular Joints. — Diseases of the Articulation between the Pieces of the Sternum. — Diseases of the Sacro-Coccygeal Joints. — Diseases of the Sym- physis Pubis, 445-449 CHAPTER XIII. Club-Foot. Frequency. — Anatomy. — Causation. — Symptoms. — Diagnosis. — Prog- nosis. — Treatment, 450-508 CHAPTER XIV. Congenital Dislocations. Congenital Dislocations. — Occurrence. — Congenital Dislocation of the Hip.— Frequency and Occurrence. — Etiology. — Pathology. — Symp- toms.— Diagnosis. — Differential Diagnosis.— Prognosis. — Treat- ment. — Congenital Dislocations of other Joints than the Hip, . 509-526 CHAPTER XV. Congenital Deformities of the Fingers and Toes. Club-Hand. — Supernumerary Digits. — Deficiency of the Fingers and- Toes.— Hypertrophy of the Fingers and Toes.— Webbed Fingers and Toes. — Congenital Contractions and Tumors of the Digits, . 527-537 CHAPTER XVI. Infantile Spinal Paralysis. Definition. — History. — Etiology.— Pathology. — Symptoms. — Diagno- sis. — Differential Diagnosis. — Prognosis. — Treatment, . . . 538-577 CHAPTER XVII. Cerebral Paralysis of Children. Symptoms. — Hemiplegia. — Spastic Paralysis. — Incoordination of Idiocy— Etiology of Cerebral Paralysis. — Patholog}^ of Cerebral Paralysis.- -Diagnosis. — Differential Diagnosis.— Prognosis.— Treat- ment '" , 578-599 viii TABLE OF CONTENTS. PAGE CHAPTER XVIII. Pseudo-Hypertrophic and other Paralyses. Pseudo-Hypertrophic Muscular Paralysis. — Progressive Muscular Atrophy. — Hereditary Ataxia, 600-611 CHAPTER XIX. Rickets. Definition. — Pathological Anatomy. — Occurrence and Etiology. — Symptoms. — Diagnosis. — Differential Diagnosis. — Prognosis. — Treatment, 612-638 CHAPTER XX. Knock-Knee and Bow Legs. Knock-Knee. — Occurrence and Etiology. — Symptoms. — Diagnosis. — Prognosis. — Treatment. — Expectant. — Mechanical. — Operative. — Bow Legs. — Occurrence. — Causation. — Symptoms. — Diagnosis. — Prognosis. — Treatment. — Expectant. — Mechanical. — Operative, . 639-690 CHAPTER XXI. Torticollis. Definition. — Etiology. — Varieties. — Pathological Anatomy. — Symp- toms. — Diagnosis. — Prognosis. — Treatment. — Mechanical. — Opera- tive, 691-71 1 CHAPTER XXII. Unilateral Atrophy and Hypertrophy. Atrophy and Hypertrophy, 712-714 CHAPTER XXIII. Dupuytren's Contraction of the Fingers. Definition. — History. — Pathology. — Etiology and Occurrence. — Symp- toms. — Diagnosis. — Prognosis. — Treatment, 715-726 CHAPTER XXIV. Flat-Foot and other Affections of the Feet. Talipes Valgus.— Congenital Talipes Valgus. — Acquired Valgus. — Varieties and Frequency. — Causation. — Pathological Anatomy. — Symptoms. — Diagnosis. — Prognosis. — Treatment. — Talipes Equi- nus. — Non-Deforming Club-Foot. — Talipes Calcaneus. — PesCavus. — Deformities of the Toes. — Hallux Valgus. — Hallux Varus. — Hallux Rigidus. — Hammer Toe. — Deviations of the Small Toes. — Morton's Painful Affection of the Foot. — Teno-Synovitis. — Other Minor Afl'ections, 727-760 CHAPTER XXV. Functional Affections of the Spine and Limbs. Definition. — Etiology. — Frequency. — Occurrence. — Symptoms. — Spine. — Hip. — Knee. — Diagnosis. — Prognosis. — Treatment, . . . 761-773 ORTHOPEDIC SURGERY. CHAPTER I. POTT'S DISEASE. Definition. — History. — Pathological Anatomy. — Occurrence and Etiolog)'. — Symptoms. — Diagnosis. — Dififerential Diagnosis. — Prognosis — Treatment. Definition. — Pott's Disease is the name applied to a pathological process which attacks the bodies of the vertebrae. This disease was first clearly described by Percival Pott in 1779, and in recogni- tion of this fact it is now commonly called by his name. The other names by which the affection is known are as follows : Spondy- , litis, Malum Pottii, caries of the spine, kyphosis, angular curvature, and spinal curvature. In German it is known as Die Potfsche Kyphose, Spitzbuckel^ and Winkclforniige Knicknng der Wirbelsdulc; in French as cypJwse, and inal de Pott. History. — Antero-posterior curvature of the spine is an affection which Was described by the ancients, and was known to Hippo- crates 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 Perci\^al Pott 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 evidenced by the picture of a specimen from the Peabody i\Iu- seum, Cambridge, Mass. Pathological Anatomy. Pott's Disease represents the result cjf a destructive ostitis affect- ing the sporigy tissue of one or more of the vertebral bodies. This ostitis is tuberculous in type and follows the same course as * Pott, "Remarks on that Kind of Palsy Affecting the Lovver'Limbs," et-c., London, 1779, I 2 ORTHOPEDIC SURGERY. tuberculous ostitis occurring at the epiphyses of the long bones, as in hip disease, tumor albus, etc. A detailed account of the histological character of tuberculous ostitis will .be given in Chapter IV. Nothing more than a very brief account of the process as it occurs in this especial region will be attempted here. 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 hypersemic spot in some part of the spongy portion of the S'^ Fir. I. — Pott's Disease Involving the whole Dorsal Region. Prehistoric Indian Remains. (Peabody Museum, Spec. 17,223.) body of the vertebra, generally near the anterior surface of the body. This spot grows larger and more red as the process ex- tends, and finally the centre becomes opaque and grayish, while a zone of hyperaemia surrounds it. A focus of tuberculous osti- tis 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 pus take place, and a localized abscess of bone exists, probably encapsul- ated in a membrane of inflammatory tissue, which surrounds the focus, endeavoring to protect the surrounding healthy bone from J'OTT'S DISEASE. 3 the erosive action of the focus. Microscopical examination shows a mass of tubercles in a rarefied sponj^^y bone tissue, and in the tubercles are to be found tubercle bacilli. From the fact that these characteristics are to be found in nearly all the specimens examined, the affection is spoken of as tuberculous ostitis. The focus of caseous 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 includes portions of bone, the nutri- tion of which is cut off by the adjacent inflammatory destruction. These portions necessarily become necrosed and with caseous mat- ter, granulation tissue, and the products of inflammation constitute an area of altered structure in the vertebral body. If this dis- FiG. 2. — Bone Sequestrum. Fig. 4. Destruction of Part of Two Vertebrae with Consequent Deformity. Fig. 5. — Cheesy focus in the Body of a Vertebra, showing also Patency of Spinal Canal. (Schreiber.) eased area has become large enough, the vertebral body gradually becomes incapable of sustaining as much pressure as before. From the peculiar weight-bearing function of the vertebral column the pressure upon each vertebral body is always considerable when the vertebral column is in the erect position. If one vertebral body is becoming excavated, 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 deformity at the diseased vertebra. This is the mechanism of the production of the knuckle in the back. It is, in brief, a soft- ening and destruction of one or more vertebral bodies, and a giving way of the column at that point. This process is limited, as a rule, to the vertebral bodies; the transverse, articular, or spinous processes are rarely affected sec- ORTHOPEDIC SURGERY. ondarily, and, so far as is known, never primarily, their structure of hard bone apparently protecting them from tubercular invasion. The disease is therefore in no sense an articular affection, al- though pathologically it resembles the epiphyseal and juxta-epiphy- seal ostitis classed among the joint diseases. There has been much discussion as to the possibility of primary tubercular disease of the intervertebral cartilage, some authorities affirming its impos- sibility, and denying the reliability of the pathological observations Fig. 6.- -Spinal Column in Well-marked Caries of Spine. (Warren Museum.) Fig. 7.— Primary Disease of Two Different Parts of Spinal Column. cited as proof to the contrary. The facts are, that the interverte- bral cartilage is absorbed at an early stage in the disease, but that a few cases have been reported by reliable observers in which there would appear to be no doubt that the cartilage alone was affected, as has been observed in a few rare instances of primary disease of the semilunar cartilages of the knee-joint. Various portions of the vertebral bodies may be affected. There may be two or more foci in one vertebra, or the whole body may be equally affected; the disease may be limited to one spot, form- POTTS DISEASE. 5 ing a local'ized abscess of the bone, or it m-ay extend so as to in- volve the adjacent vertebrae. Primary disease of two vertebral bodies in different, non adjacent parts of the spine is rare, though it has been recorded. But an extensive destruction of many ad- jacent vertebrae from primary disease of one may be said to be the rule in Pott's disease. In some instances this destructive pro- cess may be limited to the surfaces of a large number of vertebral bodies: in others a few contiguous vertebral bodies are completely destroyed. The number of vertebrje involved necessarily varies; in some instances the bodies of twelve or even more have been Tig. 8.— Pott's Disease with Two Foci of Dis- ease, Dorsal and Lumbar. Fig. 9. — Extensive Dorsal Caries Causing Large Angular Deformity. destroyed, producing a deformity which involves almost the whole of the spinal column. A superficial ostitis of the anterior surfaces of the bodies, without involving the inter-vertebral cartilages or impairing the Aveight-bearing function of the vertebrae, has been observed, though it is rare. In certain cases the formation of pus is a characteristic of the disease from the first, and in these cases abscesses are apt to be a conspicuous feature. The pus finds its way, after the destruction of the body of the vertebra, into the surrounding tissues and gravi- tates downward. It appears usually in the course of the sheath of the psoas muscle when the disease is situated in the lower half of the spine, but the site of the abscess necessarily depends upon the place of the original disease, and may be in the mouth — as in re- OR THOPEDIC S URGER V. tro-pharyngeal abscess — in the neck, in the axilla, or in the back, lungs, abdomen, or groin. In certain cases meningitis and myelitis are present in the cord opposite the, seat of disea.se, accompanied sometimes by what is virtually the destruction of the cord at that point. The pathological condition of the spinal cord and its membranes in the paralysis accompanying Pott's disease of the spine has been well described by Charcot, Michaud, Courjon, Echeverria, and others. It has been shown by these writers that the paralysis is very rarely caused by direct pressure of bone, as it is uncommon for even very marked deformi- ties of the spine to narrow the spinal canal to any great ex- tent. Moreover, paralysis some- times occurs before there is any deformity, and it often recov- ers while the deformity gets worse. Many cases with ex- treme deformity are never par- alyzed at all. Autopsy shows that in cases of paralysis the process ordinarily begins as an external pachymeningitis. The caries of the vertebrae, by con- tiguity or by irritation, causes this meningitis, and there is a deposit of inflammatory mate- rial in the dura, a consequent thickening of that membrane, and compression of the cord by this thickened dura at the point of irritation. The compression probably at once starts a myelitis, and it is this myelitis that is the cause of the paralysis. As the seat of the caries is in the bodies of the vertebrae, the meningitis is ordinarily anterior, and the myelitis is most severe in that part of the cord, especially at first, but it varies in extent from, a mere infil- tration to a complete disintegration of the cord. It may be more or less unilateral, it may extend up or down the cord, but pres- sure-myelitis causes the paralysis, which will vary with the extent and seat of the lesion. Ascending and descending secondary degenerations follow in time, when it is of any considerable ex- tent. If the myelitis ceases, it leaves a certain amount of scle- rosis of the cord at the seat of the disease. This, again, may be very slight, or the cord may be reduced to a fraction of its for- FiG. lo. — Patency of Spinal Canal- in Pronounced Caries of Spine. (Warren Museum.) POTT'S J) IS EASE. y mer size, and yet serve well enough to transmit healthy nervous impulses. But meningitis is not the only cause of coini^ression-myelitis in this disease, although it is the common one. There may be a direct strangulation of the cord by the vertebral arches, obliterat- ing the canal; or an abscess from carious bone may be a source of pressure within the canal. A caseous deposit from the vertebrae and a loose piece of bone have been found as sources of pressure. From the autopsies it seems probable that pressure from any source at once gives rise to a mild myelitis. Dr. Elliot has made a most careful pathological and experimental study of the pressure paralysis of Pott's disease, and has reached the following conclusions : that the lesion begins as a simple me- chanical pressure on the cord in the form of abscess products, thickened dura, or bone, that the inflammatory process in the dura is a limited one, and that the medullary surface of the dura is almost always normal. As there is no tendency of the cord to be involved by the specific carious process going on in the bone, the cord lesion is purely the result of pressure. That the presence of sclerotic tissue at the site of the cord lesion in cases of long standing is not an evidence that the process was originally an inflammatory one, and experimental physiology gives no evidence of an inflammatory lesion following experimental com- pression of the cord. And pathological findings in recent cases reveal but few instances where the original lesion seems to have been inflammatory. In short, his research would lead to the con- clusion that the original cord lesion is not, as a rule, inflammatory.' Fig. 1 1 (from Gowers) shows a series of sections of the spinal cord at different levels in a case of pressure myelitis from caries of the spine. In proportion to the extent of the disease and the number of vertebrae involved, an angular deformity of the spine may be pres- ent to any extent. In severe cases this angular deformity leads to many secondary pathological changes. The shape and capacity of the chest is necessarily very much altered, and the ribs sometimes sink into the pelvis. A.s a result of these changes in chest capac- ity, hypertrophy of the heart, often accompanied by valvular dis- ease, is common. In examining thirty-one post-mortem specimens of Pott's disease in adults, Neidert^ found hypertrophy of the heart in twenty-four, muscular degeneration of the walls of the heart in four, and mitral stenosis in two. Lannelongue^ found a very marked narrowing of the calibre of the aorta in many cases. Sometimes it was even reduced to a mere slit. ' N. Y. Medical Journal, June 2d, i88S, p. 599. =■ Neidert, Inaug. Diss. (Munich, 1886). 3 Rev. de Chin, Aug. loth, 1SS6, p. 671. ORTHOPEDIC SURGERY. Phthisis is of course common from diminished chest capacity as well as from the ever-present inability of the dissemination of tuberculosis from the bone focus. Fig. Fig. 12. — Complete Absorption of Vertebral Body. (Warren Museum.) Fig. 14. — Complete Bony Anky- losis. (Warren Museum.) Fig. 15. — Section of Such a Union of Vertebrae. Fig. II. — Compression of the Spinal Cord and Pressure Myelitis. D, Mid-dorsal region near the point of compression; C, one and one-half inches higher up, showing a slighter degree of myelitis; B, first dorsal, slighter myelitis, ascending degeneration; E, one and one-half inches below pressure point, general my- elitis ; F, two inches lower down, descending degeneration of pyramidal tracts and " comma- shaped '' descending degeneration in anterior part of posterior external column; G, lowest part of dorsal region^ only" descending degeneration of pyramidal tracts. POTTS DISEASE, c, A cure, however, is possible even in cases with very advanced deformity. This cure can come about in one cjr two ways: (i) by ankylosis between the surfaces of the bodies of the diseased ver- tebrae — a very slow process, whicli requires years for its comple- tion ; (2) by the ossification of the inflammatory material, thrown out around the column and by the action of the formative ostitis which accompanies the destructive process, the vertebral column is supported, as it were, in surrounding bone. This ossification is more marked around the articular and transverse processes than at the seat of the disease.' Occurrence and Etiology. Sex. — Sex does not appear to be an important factor in causing Pott's disease, though statistics vary somewhat. Gibney found in 2,455 cases, 1,329 males and 1,126 females. Mohr found females slightly more numerous than males. Fisher, in 500 cases, found Fig. 16. — Healed Kyphosis in Dorsal Region. 261 males and 239 females. Taylor in 412 cases found 234 boys and 177 girls. Of 294 cases treated at the Children's Hospital in the last four years there were 152 boys and 142 girls. Age. — The disease is more common in childhood. Mohr found, in 72 cases, that the disease occurred between the first and fifth years in 29 per cent ; between the sixth and tenth years in 22 per cent; between the eleventh and fifteenth years, 22 per cent ; be- ' Alexander, Liv. Med. Chir. Journ., July, 1SS7, p. 367. lO ORTHOPEDIC SURGERY. tvveen the sixteenth and twentieth years, i6 per cent; and above the twentieth year in ii per cent. Drachman found, in i6i cases, 41 per cent between one and five years; 36 per cent between five and ten years; 13 per cent between ten and fifteen years; 5 per cent between fifteen and twenty years; 4 per cent between twenty and twenty-five years. The oldest case was seventy-seven years of age, and the youngest eight weeks. Gibney found that 87 per cent were under fourteen years of age; 7 percent between fourteen and twelve ; and 4 per cent over twenty-one. Taylor found, in 375 cases, that 226 were under five; 68 between five and ten; and 24 between ten and fifteen (N. Y. Med. Record, August 13th, 1881). Freqziency of Occurrence. — Jaffe found, in the post-mortem exam- ination of 317 cases of tuberculosis of bones and joints, that there was caries of the spine in 26 per cent of the cases; in bones of the feet in 21 per cent; in the hip-joint in 13 per cent; in the knee- joint, in 10 per cent; in the hand, in 9 per cent; and in the elbow, in 4 per cent. The erect position of the body is a factor of importance in caus- ing disease of the spine, or, in other words, that position which necessitates superincumbent pressure upon an injured vertebral body. Caries of the spine is said not to be found in quadrupeds. Localization. — The mobility of the spine — that is, the forward bending of the spine — appears to influence to some extent the localization of the disease, although this is a matter not fully de- termined. Any of th2 vertebrae may be attacked, but in varying frequency. Statistics are of uncertain value, as they are chiefly based upon autopsies and, therefore, from adults. Mohr, in fifty-six autopsies of caries of the spine, found that the disease is most com- mon in the thoracic region (thirty-three in fifty-six cases), next in the lumbar region (twenty-seven times), and next in the neck (twelve times). The sacrum was diseased in one case. As there are more dorsal vertebrae than either cervical or lumbar, it is natu- ral that the number of cases of dorsal disease should be greater than in the other regions. In adults Mohr found the first lumbar to be the one most frequently diseased, the second lumbar the next; the fourth dorsal, the twelfth dorsal, and the fifth lumbar were attacked nearly as frequently. Billroth and Menzel found, in autopsies, the first and second cervical vertebrae the ones most fre- quently attacked, and next to these the sixth, the fourth, and the eighth dorsal, the fourth and the fifth lumbar, the tenth and the ninth dorsal, and the third cervical, in the above order. The ver- tebrae least frequently attacked were, according to Mohr, the ninth, the tenth, and the eleventh dorsal, the fourth lumbar, and the fifth and the sixth cervical. Billroth and Menzel found the fifth and POTTS DISfiASK. U the sixth cervical, the first and the second dorsal, tlic first lumbar, the vertebra least often attacked. Jaffe found, in the exam- ination of living subjects, that the sixth and the seventh dorsal were the vertebrae most freciuently attacked ; and he found, also, that the lumbar vertebra; were less frequently, and the cervical more frequently, the seat of disease than had been supposed from post-mortem examination. Taylor found, in an examination of 300 living patients with caries of the spine, that the points of greatest liability to the disease arc first, the sixth and the seventh cervical ; second, near the eightli dorsal; third, the second and the third lumbar. The points of least liability to the disease are from the first to the fourth dorsal an'd the eleventh and the twelfth dorsal, besides the two extremi- ties of the spinal column. Although, as is seen, the locations of relative frequency given by the different observers do not agree, it would appear that certain portions of the spine are more liable to attack than certain others, and that the theory advanced by Taylor was a plausible one — viz., that the regions most liable to the dis- ease were those which were the most exposed to jars or increased pressure; and that the disease would be more frequent where the hinges of motion at the spinal column came, varying to a degree according to age and occupation, or where there was the greatest exposure to the effects of violent jars. In short, it may be assumed that the determining cause of caries of spine is jar or superincumbent pressure; the influential cause that physical state which is incapable of resisting slight trauma, exposing the tissue probably to the invasion of the tubercle bacillus. How Pott's disease is caused is not yet definitely determined. That the disease is of a tuberculous nature is frequently asserted and seems probable, and, as is often the case, some fall or injury can be regarded as an exciting cause. Gibney, in an examination of 185 cases, found a hereditary tuberculous taint in 'j^ per cent. In 35 per cent this was inherited from the father; in 38 per cent from the mother; in 31 per cent from both. In 15 per cent it existed in other children of the family, and in 16 per cent the taint was manifest in both parents and children. In 45 per cent a weakened condition from previous sickness was found; and in 22 per cent both an inherited and an acquired diathesis were found. Taylor, in 845 cases, found 53 per cent with a history of preceding trauma; in 15 per cent there was disease of the lung in nearer or more distant relatives; in 19 per cent so-called scrofula was asserted, and in 34 per cent a sickly diathesis. 12 ORTHOPEDIC SURGERY. In general it is more common than not to find phthisis present in the family history, near or remote, or some decided cause for the affection in the child's own history, such as measles, scarlet fever, or some wasting illness, and whooping cough is said by some writers to be an etiological factor of importance in Pott's disease. In certain instances this would seem, from the history of the cases, to be probable. The etiology of tuberculous affections of bone is considered at length in Chapter V. Symptoms. Few affections have a clinical history which varies so widely and appears under such different guises as that of Pott's disease. In the cervical region the disease may appear to be an idio- pathic torticollis, while in the lumbar region it often simulates hip disease so closely as to render an immediate diagnosis impossi- ble. The one constant symptom, however, which accompanies all cases of Pott's disease and must often form the chief reliance in diagnosis is muscular rigidity at the affected portion of the spine. Just as joint fixation is the constant symptom of chronic joint dis- ease, so is restricted motion between the diseased vertebrse the con- stant accompaniment of Pott's disease, in its early stages or later. Typical cases of Pott's disease are so characteristic in their symptoms that the diagnosis is evident alm.ost at a glance. The guarded character of all the movements is perhaps the most strik- ing feature. In Avalking, in stooping, or in lying down, the spine is most carefully guarded against jar and against motion, attitudes are assumed which relieve the vertebral column of some of the weight of the body, and a glance at the naked child shows unnatural modes of standing and walking. A prominence of the vertebrse is ordinarily present as early as at this stage, and oftener than not pain is acute and aggravated by motion. Constitutional disturbance is also very likely to be pres- ent when the disease has been of even a few months' duration. Peculiarity of attitude, muscular stiffness, and referred pain are the most prominent of the earlier symptoms, and they may be present before a projection has been noticed. The importance of these early symptoms can hardly be overstated, as it is on an early recognition of the affection that the hope of a ready cure is to be based. Attitude. — The peculiarity in attitude noticed early in the disease is due either to reflex muscular spasm — similar to that seen in joint-disease (notably that of the hip-joint), — or to an unconscious effort on the part of the patient to prevent jar or any increased J'OTT'S JJ/SKASK. 13: pressure upon the affected vertebral bodies. These attitudes nec- essarily vary according to the point of the spine attacked. In dis- FiG. 17. — Posterior View of the Position in Cer- Fig. 18. — Attitude in Cer- Fig. 19. — Attitude in vical Caries, Showing the Tilting of the Head vical Caries of only Moder- Severe High Dorsal which so often Simulates Torticollis. ate Seventy. Caries. ease of the upper cervical region, the most common attitude is that of wry-neck. This is sometimes confounded with idiopathic torti= ,ij^ST5«t Fig. 20. — Position of Head in Cervical Caries. Fig. 21.— Frequent Position of Head in Cervical Caries. 14 ORTHOPEDIC SURGERY. collis, and patients in some instances have been subjected to teno- tomy under a mistaken diagnosis. When the disease is in the lower cervical or upper dorsal region, the chin is held som.ewhat raised, to balance the weight of the head on the articular facets, suggesting the position of a seal's head when out of water. The spinal column below the point of disease is abnormally straight, and in some instances curved slightly forward^ while in the lower dorsal region an exaggerated backward projection of the spinous proces- ses may be seen ; this projection, due to a compensating curve, is sometimes so marked as to sug- gest that the disease has attacked / . \ \ another part of the spine. / K / \ Fig. 22. — Attitude of Head and Elevation of Chin in Cervical Caries. Fig. 23. — Elevated Shoulders in Upper Dorsal Disease. In the middle dorsal region, the attitude to be noticed most fre- quently is an elevation of the shoulders. Sometimes one shoulder is held for a time higher than the other, and temporarily a slight lateral deviation of the spine is to be seen. In the lumbar region, the patient in the early stage frequently will be noticed to lean POTT'S ]) IS EASE. '5 backward, like pregnant women or adults with large abdomens. A peculiar position and characteristic sidling gait, which is sometimes seen at a comparatively early stage of disease in the lower dorsal or lumbar region, is due to a slight contraction of the psoas and iliacus muscles. In a late stage, when psoas abscess is present, a marked contrac- tion of these muscles takes place ; but even when there is no evi- FiG. 24. — Lordosis in Lumbar Pott's Disease. Fig. 25. — Attitude in Pronounced Dorsal Caries. dence of existence of suppuration or of a psoas abscess, slight in- flammatory irritation of the muscles will produce a limitation to the arc of extension of the thigh on the trunk. This may be so slight as to be noticed only by placing the patient on the face and attempting extreme extension of the thigh. If more muscular re- sistance is met on one side than on the other, or than is usually encountered, it may be assumed that the increased tonicity is the result of irritation of some of the muscular fibres extending the this;!!. l6 ORTHOPEDIC SURGERY. In addition to the square position of the shoulders, the pecuHar position of the head, and the erect attitude of the upper part of the spine, which prevents the superincumbent weight of the trunk and upper extremities (above the diseased portion of the spine) from faUing forward upon the diseased vertebral body, the gait is peculiar; the patient walks more on the toes than on the heels, and with the knees slightly bent — in such a way that all possibles springs may be brought into play to diminish jarring the spine. These peculiarities of attitude and position vary in severity ac- cording to the severity of the disease ; they may be at one time more noticeable than at another. Characteristic also at this stage of the disease is a muscular stiffness, which becomes more marked after the patient has been quiet for a while (during sleep). The stiffness of the limbs diminishes or disappears after the patient has moved about. A certain amount of muscular rigidity of the mus- cles of the back will be felt on palpation in affections of the middle dorsal and lumbar regions; stooping which involves arching of the back forward is difficult or impossible, and in attempting to stoop in order to pick up any article from the floor the patient will keep the spine erect and reach the floor, lowering himself with an erect trunk, by bending the knees (Fig. 27), It will often be noticed that children become tired more easily than usual, and after playing about for a time will desire to lie down, to rest their arms upon a chair or seat, or to support the head with their hands, or the trunk by holding on to the thighs, according to the part of the spine affected (Figs. 26 and 28). The amount of muscular stiffness, rigidity, and difificulty in main taining the spine erect is in a measure an index of the degree of activity of the disease. In early cases the muscles on either side of the area of the affected vertebrae will often, on bending the back, be seen to spring out in relief, acting like physiological splints to the diseased vertebral column. Attitude in Psoas Contraction. — Various modifications of charac- teristic attitudes are at times produced. The most common of these probably is the flexion of the thigh which results from psoas contraction, usually the result of psoas abscess. The contraction of the muscle is both the warning and the accompaniment of the abscess. The results may be seen in Figs. 31 and 32. In the first only in a slight degree; in the second case to such a degree that the 'leg cannot be put to the ground in walking and the use of a crutch is necessitated. An attitude necessitated in the more acute cases of psoas abscess is seen in Fig. 29, where a large psoas abscess was present. The detection of mild degrees of psoas contraction is accom- POTT'S DISI'lASE 17 Fig. 26. — An Occasional Attitude Assumed in Acute Pott's Disease, Especially when the Dis- ease is in the Cervical Region. Fig. 27.— Characteristic Attitude in Stooping. Fig. 28.— Attitude Assumed by Children with Acute Pott's Disease, and in Other Cases Ne- cessitated by Psoas Contraction. Fig. 29.— Attitude in Severe Pott's Disease with Psoas Contraction and Abscess. ORTHOPEDIC SURGERY. plished by the simple manipulation shown in the figure, by which one at once appreciates the loss of the hyperextension of the thigh. . Lateral dirvatttre of the Spine in Potfs Disease. — Lateral de- viation of the spine is ah occasional attitude to be found in Pott's disease and is discussed at length in its relation to lateral curvature under the head of diagnosis. As a rule the lateral curvature of Pott's disease is char- acterized by very slight, if any, rotation of the spinal column on a vertical axis. Dr. Bartow,' in a recent very interesting article on the subject, however, advocates the view that rotation is much more com- mon than has been supposed. He says: " Pathological spinal rotation is always associated with the early stage of spondy- litis in the regions that I have mentioned (dorso-lumbar)." The experience of the writers would lead them to believe that generally rotation of the spinal column was imperceptible in these cases. Dr. Bartow's article is illustrat'ed to show most admirably the characteristic attitude apart from any question of rota- tion. The lateral deviation has no espe- cial significance except in indicating a certain modification of treatment to be considered later. It is sometimes the first symptom of Pott's disease and one which has attracted but little attention. Pain. — In certain cases of Pott's disease pain is absent altogether, but it is often present to a most distressing degree, and it forms a more prominent symptom than it does in hip disease or tumor albus, for instance. In a measure it tends to mislead both parents and physician, for the pain is rarely complained of in the back, but referred to the peripheral ends of the nerves, and thus described as being felt in the abdo- men, chest, or limbs. Abdominal pain passes for "stomach ache," and pains in the limbs for " growing pain." In general, it may ':uJ Fig. 30. — Lateral Deviation of the Spinal Column in Lower Dorsal Disease. Annals of Surgery, July, il POTTS J)JSJCASK. 19 be said here that persistent k^calized pain in the case of a child is a symptom demandint; very threat attention. The sleep of these children is apt to be much disturbed by pain, Fig. 31. — Mild Degree of Psoas Contraction, the Result of Abscess. Fig. 32. — Severe Grade of Psoas Contraction. Fig. 33. — Method of Examination for Psoas Contraction in Pott's Diseise. 20 ORTHOPEDIC SURGERY. for the suffering from Pott's disease, like all the pain of bone dis- eases, is more severe at night. In the milder cases this is manifested by simple restlessness, while in more severe cases it takes the form of crying spells. This may even be the case where the children can walk about without pain during the day. " Night cries " are occasionally present in Pott's disease, although very rarely, if one compares their infrequent occurrence here with their prevalence in hip disease. When they are present, however, they are distinc- tive. The child falls asleep only to wake with a sharp scream and perhaps to fall asleep again by the time that the parent reaches the bedside. This may be repeated several times each evening, and as a rule it does not occur by any means so commonly later in the night. The early evening is par excellence the time when " night cries " are heard in any form of joint disease. The pain is usually subacute, and may be only occasional. At times the attack may be very severe, accompanied by intense hy- perassthesia, so that the pressure of the bedclothes cannot be toler- ated, and patients in this condition have been supposed to have intense peritonitis or pleurisy. The subacute form is more com- mon, and this, together with muscular stiffness, often gives rise to a diagnosis of rheumatism, sciatica, or neuralgia. The pain in these cases is due to a compression of the nerves by inflammatory products as they pass out of the spinal canal. Analogous to these attacks of pain are disturbances of the functions of other nerves — manifested in cough, a peculiar grunting respiration, dyspnoea with cyanosis, gastric disorders, obstinate and recurring vomiting, and troubles of the bladder, with or without pain at the end of the penis. Patients suffering in this way have been treated for bron- chitis, pneumonia, gastritis, or cystitis. In one notable instance the operation for stone in the bladder — lateral cystotomy — was performed. No vesical trouble was discovered, but at the autopsy caries of the lumbar vertebrae was found. These periods of suffering may become intense — constituting acute attacks, subsiding after rest, and recurring at intervals with- out apparent exciting cause. Dilatation or contraction of the pupil, existing for some time, has been noted in cervical caries of the spine, with compression of the cord (Charcot). It is to be expected that pain will be diminished and generally controlled by efificient mechanical treatment. Certain cases, how- ever, are from the first so intractable that pain persists in spite of all that can be done. Fortunately such cases are not the rule, and in general it may be assumed when pain comes on in the course of treatment, that the apparatus does not fit, if mechanical treatment POTT'S JUS EASE. 21 is used, or that the parents are not careful in the nursing of the child or in carrying out treatment thoroughly. In a few instances it will be found that pain can for a time not be entirely checked by treatment. A sudden and violent increase of pain should lead one to suspect an approaching access of the disease — with increase of the deformity — the formation of an abscess, or the beginning of paralysis. Paralysis. — Considering the fact that the spinal canal, containing the spinal cord, is so near the scat of disease in caries of the spine, it is not strange that paralysis is so common a symptom in Pott's disease. This complication is more frequent the higher the portion of the spinal column which is affected, for the reason that the cord is larger and the vertebral bodies smaller the higher we ascend in the column. But as a rule it is not the result of a direct compression of the cord by the bony arches of the spinal canal, but it is caused by a compression myelitis and meningitis set up by the contiguous in- flammation. The paralysis does not always occur in the severest or the sharpest deformities, nor is it proportionate to the degree of angular curvature. Mr. Pott, in his original treatise, wrote : " Since I had been particularly attentive to the disorder, I thought that I had observed that neither the extent nor degree of the curve had in general produced any material difference in the symptoms, but that the smallest was, when perfectly formed, at- tended with the same consequences as the largest and that the use- less state of the limbs is by no means a consequence of the altered figure of the spine, or of the disposition of the bones with regard to each other, but merely of the caries." The paralysis, as we have seen, is due to a thickened condition of the cord membranes inducing a compression of the cord and a certain degree of consequent transverse myelitis. The mischief is sharply limited as a rule to the seat of disease, unless the process has reached so severe a degree that descending secondary degen- eration of the cord is present. The clinical picture is what one would expect from a considera- tion of the pathological condition ; a paralysis of motion mild or severe, followed, if the case gets worse, by a paralysis of sensation, which is said by Courjon never to become complete. The motor paralysis varies from mere muscular weakness to complete loss of power. It begins as a sense of fatigue, a dragging of the feet ; then there is inability to hold one's self erect. Unless the disease is in the lumbar region, the reflexes are exaggerated, and muscular spasms often start from the least irritation ; they frequently appear spon- taneously. The muscles are flaccid and the legs are powerless. 22 ORTHOPEDIC SURGERY. With the secondary degenerations in the cord rigidity sets in; first the legs are rigid in the extended position, then flexion accompa- nies the permanent contracture. The bladder and rectum are par- alyzed toward the end of all very bad cases, and whenever the lumbar enlargement is involved ; in milder cases they escape. It is hard to explain why the arms are paralyzed in certain cases of dorsal caries, for an ascending secondary degeneration of the cord should give rise to no symptoms, and we have to assume an ex- tended myelitis or meningitis. Of the sensory paralysis below the lesion there is less to be said; it is apt to begin as paraesthesia ; anaesthesia afterward comes on to a greater or less extent, and when this occurs it means a pretty extensive transverse myelitis. Trophic disturbances and loss of electrical contractility are not to be seen unless in exceptional cases, where other parts of the cord than those usually affected have become secondarily changed. The wasting of the muscles and diminution of electric contractil- ity are usually only such as disuse would cause; if, however, the lumbar or cervical enlargement is attacked, emaciation of the mus- cles and the loss of faradic contractility, with the reaction of de- generation, are to be noted. In a few instances affections of the joints, supposed to be sec- ondary to lesions of the cord, have been noted, and instances are mentioned in which herpes zoster, apparently due to the same cause, was present. Many patients with Pott's disease, especially children, are bed- ridden, or at least non-ambulatory, without being paralyzed. When the disease runs its course unchecked, asthenia is often pro- found, and although there may be no trace of paralysis, the patient frequently has no desire or strength to walk or even to sit up. Another cause which sometimes keeps patients off their feet, inde- pendently of paralysis, is psoas contraction of a severe grade, espe- cially if it be bilateral. Still another reason is a preponderating mental impression of inability to walk or stand. Many cases per- sist in walking when paralyzed to a degree which ought to preclude it, and which would ordinarily do so, while others are bedridden with little or no paralysis, or remain so after the paralysis has totally disappeared, having recovered without being conscious of restoration. This accounts for the suddenness of invasion, and particularly of recovery, in some of these paralyzed cases. So great is the general weakness induced by Pott's disease in severe cases that an inability to walk results from weakness alone without any affection of the cord. The limbs are generally wasted, but the reflexes are normal, and on this one must depend to differ- entiate the affection from compression myelitis. POTTS DISEASE. 23 Paralysis is rarely an early symptom in caries of the spine, though it has been observed before the stage of deformity; it is sometimes partial; it is usually preceded by paresis; it may in rare instances precede deformity. The frequency of paralysis is indi- cated by the figures collected by Gibney. Out of 295 patients with caries of the spine, paralysis was noted 62 times; in 189 cases of caries of the upper dorsal and cervical region, paralysis occurred in 59 ; in 106 cases of lower dorsal and lumbar disease, paralysis occurred in only three. Paralysis is usually bilateral; it may, however, be unilateral, and in some unusual instances it occurs above the point of deformity. Taylor and Lovett found in an examination of 59 cases (out of 445 cases of Pott's disease) that the location of disease was as follows: I cervical, 7 cervico-dorsal, 37 dorsal, 7 dorso-lumbar, 4 lumbar, 3 unclassified. The deformity was large in 20, medium in 10, small in 17 (in 12 unclassified). The paralyzed cases presented no worse deformity than that seen in average cases. In 26 the outline of the deformity was rounded and gradual; in 16 it was distinctly sharp. The paralysis occurred on the average about two years after the beginning of the disease. It came on immediately after a fall in 4 cases, in 8 cases it appeared within one year, in 26 within four years, in i within five, in 29 within eleven, and in 10 within twenty-eight years. The duration of the paralysis was never, in the cases reported, over three years, except in i case, where it persisted with but little improvement for six years ; in 2 cases it lasted three years; in 5 cases it lasted two years. A recurrence of the paralysis was noted in 6 cases, 4 having two attacks and 2 having three. Out of 72 cases of caries of the spine watched by Mohr, there was paralysis in seven per cent; and of 61 cases of autopsy in deaths from caries of the spine, alteration and disease of the cord was found in eleven per cent. Paralysis is an affection of rare occurrence in Pott's disease under efficient protective treatment. It occurs without regard to the amount or character of the deformity, and is often preceded by much pain ; on the average it lasts a little less than a year. Its prognosis is extremely favorable in mild cases, or in severe ones if they can be treated early. Recovery, when it occurs, is generally complete, no trace of the disability of the limbs being left. In- complete recovery is uncommon, but incomplete paralysis often is present. In fact the early commencement of efficient treatment will often seem to render abortive an attack of paraplegia, and change what threatened to be a complete loss of power to a com- paratively trifling disability which is merely enough to prevent walkinsf for a few weeks or months. Fig. 34, — Rounded Outline of Deformity as seen in Cured or Convalescent Pott's Disease. Fig. 35. — Sharp Angle of the Acute Stage. Fig. 36. — Slight Projection of Dorsal Region. Early Caries of Spine. Fig, 37. — Projection of Dorsal Region in Caries of the Spine. More advanced than that shown in Fig. 36. J'OTT'S JUS EASE. 25 Deformity. — The most characteristic feature of Pott's disease is the deformity — that is, the projection backward of one or more spinous processes. This is occasioned by the destruction of the vertebral bodies which form the anterior support of the spine. When this is re- moved, the spinal column above the dis- ease falls forward, throwing the spinous processes out of the vertical line, and caus- ing a projection at the diseased point. The projection is primarily of the affected vertebrae; but following this other verte- brae are more or less involved, and the curve increases, with the establishment of secondary curves. The sharper the pro- jection, as a rule, the more acute is the process; but this rule, however absolutely Fig. 38. -Extreme Kyphosis. true in the upper dorsal region, has occasional exceptions in the lower dorsal and upper lumbar regions. It may be stated that in - old cases there is, as a rule, more of a curve and less of an angle. Fig. 39. — Method of Takiag Tracings of the Spine. It is not absolutely true that the greater the amount of the disease the greater the deformity, for there may be extensive disease on the front of several bodies without diminishing the weight-bearing 26 ORTHOPEDIC SURGERY. function ot all of them; but, generally, the more vertebrse in- volved, the greater is the pro- jection. It is most important to keep a record of the deformity in each case under observation. This record is most easily taken by the simple method shown in Fig. 39- A strip of sheet lead half an inch wide, of the quality known to the dealers as " four pounds to the foot," is made straight by pressing out the curves, and is laid along the spinous pro- FiG. 40.— Tracing Outlines of Spinal Curves, showing Change in the Progress of Disease. The eailiest tracings are on the right. Fig. 41. — Tracings of Different Varieties of Kyphosis. cesses of the child, who lies on his face with his hands at his sides, and his head turned to one side. With the fingers the lead is pressed against the spinous processes, and when it is Fig. 42. — Outline of Back in the Adult in Exten- tensive Lumbar Pott's Disease. Fig. 43.— High Dorsal Pott's Disease showing also the Deformity of the Chest. POTT'S DISEASE. 27 removed it is stiff enough to keep its shape. The curve is then drawn upon a piece of cardboard by means of this lead strip, placed on its side and used as a ruler. The card-board curve is cut out with scissors and the concavity is then applied to the child's back to see if it fits accurately. If not, it should be trimmed with the scissors until it does. The slightest change in the outline of the back can then be detected at any subsequent visit, because any increase or diminution of the deformity will prevent the cardboard cutting from fitting perfectly the outline of the back. If the deformity is left to itself, its tendency is to increase until a spontaneous cure results or death ensues. In many cases in dor- sal Pott's disease this result is reached only after an enormous deformity has occurred. In cervical and lumbar Pott's disease spontaneous cure is more likely to occur, and, when it occurs, is accompanied by much less deformity than in the dorsal region. When this spontaneous cure occurs, the change takes place grad- ually and does not cause narrowing of the spinal canal; the inter- articular facets become united, and the bodies may be welded together so as to form practically one bone; in cured cases the curvature which has been sharp becomes rounded into a curve with a relatively long radius. In the cervical region, however, this rounding is not as marked as in the other regions. The gibbosity is most marked in caries of the upper dorsal region ; the curve in the lumbar region is an arc with a longer radius than is found elsewhere in the spine. The secondary curvatures are, in cervical caries, a dorsal incurvation below the disease, with a slight lumbar excurvation; in dorsal disease an increased hollowing in above and below the gibbosity of the disease ; in lumbar caries a long curva- ture with convexity inward above the disease. The neck becomes shortened and thickened in cervical caries; the trunk is shortened in disease of other parts of the spine; there may be also a diminu- tion of an uncertain origin in the growth of the whole body. In severe cases the limbs more usually grow to the normal amount, and are necessarily out of proportion to the length of the trunk. An alteration in the shape of the lower part of the face takes place in marked dorsal disease, with a facial expression which is charac- teristic. A spontaneous arrest of the disease without much deformity may take place in cervical caries, although instances must be un- common ; the same is true of lower dorsal and lumbar disease; the curvature, however, is necessarily larger and the cases less common than in cervical caries. When the deformity is under treatment, it is to be hoped that it will be prevented from growing much larger. In the mid-dorsal 28 ORTHOPEDIC SURGERY. Fig. 44. — Showing Shortening of Trunk in Pott's Fig. 45. — Square Shoulders of Pott's Disease and Slight Disease of Moderate Grade. Lateral Deviation of the Column. Fig. 46. — Tracings from Cases of Pott's Disease showing the Recession of the Deformity under Mechanical Treatment. POTTS jjjsi-:ase. 29 region, however, it is generally impossible to prevent it from in- creasing slightly, whatever be the treatment; and, especially if the treatment is incomplete on the part of either parents or surgeon, the deformity in this region is likely to increase considerably. In certain cases the disease is so acute and the process of destruction so rapid that even with the most careful treatment increase of the deformity is not to be prevented. The accompanying figure shows the progress of the disease in one of these very acute cases in which the care at home has been perfect and the brace is thoroughly ef^cient. Recession of the deformity is at times the result of careful mechanical treatment, but such a result is exceptional and only to be obtained under the most favorable conditions. Fig. 46, showing the tracings in some of the cases, is from the ad- mirable article by Dr. Henry Ling Taylor.' Cases in Avhich the deform- ity is rapidly increasing are as a rule characterized by much pain. In general it may be assumed that a sharp and angular deformity indicates active and progressing dis- ease. A sudden chafing of the skin which develops un- der a brace which has always fitted well, should lead to the suspicion that the deformity may be increasing, although that may not be necessarily the case. Deformity of the chest is a constant accompaniment of dorsal Pott's disease. The vertebral column cannot give way and form an angular deformity without altering the position of the sternum and ribs. The deformity is usually a thrusting downward and for- ward of the sternum with a lateral flattening of the chest. In short, it results in the formation of a pigeon-breast so closely re- sembling that caused by severe rickets as to be often mistaken for it at times. There may, however, be a prominence of the ribs on both sides of the sternum, as is shown in the figure, where a depres- sion of the sternum is seen. Sometimes the pigeon-breast is the first symptom to attract the attention of the parents, and for that alone the children are brought to the surgeon. ' Med. Rec, Jan. 8th, 1SS7. Fig. 47. — Depression of the Sternum in Dorsal Pott's Disease. 30 ORTHOPEDIC SURGERY. Abscess. — In many cases of Pott's disease the whole course is run without any evidence of suppuration, but in others abscesses form a distressing comphcation. The earHer treatment is begun and the more efificiently it is car- ried out, the less liable are abscesses to form, but it must not be assumed that the occurrence of abscesses is evidence of incomplete treatment. In many cases an abscess cannot be avoided. The causes of the development of an abscess are the same in Pott's disease as in caries elsewhere. What the abscess-determin- ing influences are, which, in some instances, give rise to profuse suppuration, and the absence of which, in other cases, allows an Fig. 48. — Psoas Abscess. immunity, is at present conjectural. They may be supposed to be dependent on the amount of constitutional or local power of resist- ance on the part of the patient ; the extent of the bacillary invasion and resulting suppuration; the severity of a previous injury ; and the individual degree of recuperative power, or of reparative tissue- development. If we consider the situation of the vertebral bodies (the point of origin of abscesses) — projecting into the cavities of the thorax and abdomen, surrounded by the lungs and intestines, close to the large vessels and the oesophagus — it will seem extraor- dinary that the formation of an abscess does not more frequently lead to a fatal termination. In fact, however, the fluid contents of the abscesses follow in the line of least resistance, and the layers of rorr's disease. 31 fascia;, in most cases, protect tlic larger cavities of the trunk from invasion ; the pus generally extends along the sheath of the mus- cles and comes to the surface at points distant from its origin, ap- pearing in the neck, the back, the axilla, in the lumbar region, in the groin, or in Scarpa's triangle. These purulent collections arc classified respectively as lumbar, iliac, and psoas abscesses. Of these classes psoas abscess is the most common. It is very rarely met with in children unless in connection with vertebral dis- ease, but in general it is an almost pathognomonic sign of dorsal or lumbar Pott's disease. Shaw describes its formation as follows: *' When the abscess is connected with diseased dorsal vertebrae, it encounters in its descent the diaphragm. But the barrier is over- come by a particular process. As the abscess comes in contact with the diaphragm and compresses it, adhesive inflammation is set up in their respective surfaces. The consequence is that they become united over a considerable area; an opening is next formed by absorption within the boundaries of the adhering structures; the abscess then protrudes; and extravasation of pus at the mar- gins is prevented from taking place by the firm union of the parts en- circling the opening. . . . The abscess comes into relation with the heads of the psoas muscle. . . . But as it travels downward, it is pre- vented from enlarging in the fore part, by the resistance from the ligamenta arcuata, and at the back by that of the spine and the lowest rib; hence it forces its way in the line of the psoas muscle." In this way the muscles may become involved in the suppuration and constitute a part of the abscess. The abscess tends to enlarge more on its outer than on its inner side because the fascia is less resistant there. It finally reaches Poupart's ligament and bulges in the groin. The pus may, how- ever, travel as far down as the insertion of the psoas muscle. There is then a swelling both above and below Poupart's ligament and fluctuation may be detected between the two by placing one finger above the ligament and the other below it. Pus may find its way to the iliac fossa either from a psoas abscess or by finding its own way there directly from the diseased bodies. At times a collection of pus will work over the crest of the ilium and point in the gluteal region. A lumbar abscess is the outcome of disease of the lumbar verte- brae. It appears as a swelling on one side or the other just outside the quadratus lumborum. At times it is associated with dorsal caries and not with lumbar. Abscesses may accumulate in the inguinal region above Pou- part's ligament. Before passing down the sheath of the psoas muscle, they may enlarge in the abdominal cavity beneath the 32 ORTHOPEDIC SURGERY. peritoneum, constituting a layer of subperitoneal abscesses. In time these abscesses descend down the thigh, but they may remain for a long time large, threatening, abdominal tumors. Before the Royal Medical and Chirurgical Society Mr. R. W. Parker ' said that out of one hundred and eighty-three cases of caries of the spine, he found nine cervical, eighty-two dorsal, twenty-one dorso-lumbar, thirty-seven lumbo-sacral, and in forty-two cases the position was not noted. In about eight per cent of his dorsal cases suppuration ensued, while it was found in thirty per cent of his dorso-lum- bar cases and in seventy per cent of the lumbo-sacral. Abscesses, however, at times point in all sorts of places. They may burst into the mouth, trachea, or bronchi,^ in the Fig. 49. — Lumbar Abscess, Fig. 50. — Retro-Pharyngeal Abscess, showing Character- istic Expression and Attitude. intestines, bladder, or the abdominal cavity. Dissecting behind the pharynx they cause dyspncea, the result of the bulging of the posterior wall, and are recognized as retro-pharyngeal abscesses. Occasionally they burst in the alimentary canal, not so rarely in the lungs, and exceptionally in the peritoneum or larger vessels. Sometimes apparently the sac descends on both sides of the spinal column, developing two abscesses. ' British Medical Journal, January 12th, 1884, p. 58. ^Cossy, Bull. Soc. Anat., 1877,541, and Gamlet, Bull. Soc. Anat., 1878. POTT'S niSI'lASI']. 3,3 The contents of abscesses vary. Usually they are filled with serous or sero-purulent fluid, with caseous masses. Soinetinnes the contents may be entirely cheesy. Often they contain fra^'ments of necrotic bone and small calcified masses with large shreds and flakes of gelatinous material from the suppurating tissues. This is of practical importance in the question of aspiration of these ab- scesses, for the shreds and flakes in the pus are likely to form an obstruction to the passage of the pus through any needle save a very large one. Pallor, impairment of strength, or an increase in the number of the white corpuscles, with a diminution of the number of red, justify, if existing for some time, an opinion of the existence of a collection of pus. The local symptoms presented by abscesses vary with the locality. Retro-pharyngeal abscesses cause dyspnoea and dysphagia. 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 dyspnoea, collapse, and danger -from suffocation being dependent on the size of the abscess. The sud- den discharge of pus is the indication of rupture into the oesopha- gus, intestines, and bladder; rupture into the peritonenm or com.- munication with large vessels will necessarily be fatal, and there are no symptoms which will 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 con- dition of things which may be compatible with fair general health. Instances are not uncommon where adults have been able to attend to active work and children to play about, although suffering from a large cold abscess. When absorption takes place, the fluid contents disappear, and the caseous and purulent detritus, if present, in all probability be- comes encapsuled. This sometimes happens, even in quite large abscesses. When the abscess is evacuated, there is as a rule but slight gen- eral disturbance, provided it bursts in such a way, and the abscess itself is in such a condition, as to give complete drainage; if it is only evacuated in part, and if the cavity of the abscess is large, ex- tending upward to the spinal column by means of a long circuitous channel which does not admit of complete drainage, fever, with septic changes, usually follows the evacuation of the abscess, vary- ing in different cases in amount and extent. 3 34 ORTHOPEDIC SURGERY. Michel found, in 48 cases of abscess, the locahzation to be as follows: In 39 the abscess was about the pelvis ; in 6 it was in the neck, and in 3 it was in the dorsal region; of the 39 in the pelvis 13 were about the groin, 14 occupied the iliac fossa (2 of these occupied the upper outer part of the thigh in addition), and i appeared near the anterior superior spine of the ilium ; 7 were in the lumbar region; i in the perineum; of the 6 in the neck i was in the supra- clavicular fossa, 3 at the sides of the neck, and 2 were post-pharyngeal. The 3 ab- scesses in the dorsal region appeared near the middle line and by the sides of the dis- eased vertebrae. Abscesses may burst directly into the spinal canal, or into the hip-joint, giving rise to hip-disease, or may appear in the ingui- nal canal, simulating hernia. Parker {Brit. Med. Jotir., January 12th, 1884, p. 78) found, in an examination of 82 dorsal, 21 dorso-lumbar, and 37 lumbo-sacral cases of spinal caries, abscesses in eight per cent of the dorsal cases, in thirty per cent of the dorso-lumbar cases, and in seventy per cent of the lumbo-sacral. As a rule abscesses which burst spontane- ously are very likely to discharge from pouting sinuses, for an indefinite time, often for years. This tendency seems to be di- minished by thorough operative treatment of the abscesses, establishing perfect drain- age, but even then the seat of disease is often inaccessible and for a long time the abscess cavity may discharge from sinuses. Furthermore, a tuberculous condition of the sinus wall may be developed and the sinus itself may become a tissue secreting pus. General Condition. — Pott's disease produces a more profound im- pression upon the general condition than do the other tuberculous joint and bone diseases. Children with Pott's disease may be noticeably retarded in the growth of their trunks and may become dwarfed. The arms and the legs seem abnormally long, and the head also seems unusually large. These children are frequently fretful and capricious, made so either by the disease and by ill- health or by injudicious petting on the part of the family. They are also often precocious and their mental development is superior Fig. 51. — Showing Disproportion of Head and Trunk. J'OTTS J)/SJ':/1SJC. 35 to healthy children of the same a^^e. Tlicy arc, moreover, delicate, take cold easily and seem especially liable to slight attacks of pneumonia. Heart disease also seems frequent amon^ them, and disturbances of the digestion— ^mvj' gasti'icpics. Patients with Pott's disease are of course liable to attacks of tubercular menin- gitis, but the experience of the writers would lead them to believe that the liability to this was less than in hip-joint disease. The temperature in Pott's disease is in general higher than in health. In hip disease the same holds true, and the number of cases considered in that connection is larger than the number noted here. The following temperatures were taken in cases of Pott's disease treated without recumbency, in all stages of the dis- ease, when the affection was at all marked. The hectic appearance of these children as seen late in the afternoon suggested the likelihood of a higher temperature than normal. The temper- atures were all taken with a standardized thermometer. 99.5°, 100.3°, 997°> 100.9°, 99-3°» 99-3% 100.5°, 101.1°, 99.3°, 98.7°, 100.9° F. Healthy children under the same conditions had normal tem- peratures. Diagnosis. The recognition of Pott's disease in the later stages is easy, but before the presence of the sharp projection, or while that is still small, the affection is often overlooked. In examining a Rigidity of the Spinal Column in Pott's Disease. suspected case in the early stage a diagnosis is to be based on the presence of the following symptoms: i, stiffness in the back; 2, peculiarity of attitude or gait; 3, seat and localization of pain and 36 ORTHOPEDIC SURGERY. nervous symptoms ; 4, irregularity of outline of the row of spinous processes, or abnormal projection of individual spinous processes. The child should be entirely undressed for examination and made to stand on a table or upon the floor and to walk across the room. This proceeding will perhaps reveal some peculiarity of gait or position which will not be evident in any other way. The child should then be carefully inspected as to the outline of the spinous processes and made to pick up some object from the floor. During the movement the surgeon should note the rigidity of the back, if any such symptom present. The patient should then be laid upon his face on a table or bed and the outline of the spinous processes examined with the fingers. The flexibility of the column should next be tested by lifting the child by the feet while it lies face downward on a table. In Pott's disease the back is rigid, as shown in the figure, taken from a case of moderately acute Pott's disease in the dorsal region. Gen- erally the erector spinae muscles can be seen standing out like cords on both sides of the spinous processes endeavor to hold the Fig. 53. — Normal Flexibility of Spinal Column. The normal flexibility of the column is shown in Figs. 53 and 54. Psoas contraction is looked for by placing one hand on the sacrum and hyperextending one leg and then the other (Fig. 33). When cervical caries is suspected, the movements of the head must be tested. With adults this examination has to be modified to a certain degree and voluntary movements on the part of the patient must in a measure be substituted for passive manipulation. I. MiLsailar Stiffness. — In the very early stage of Pott's disease the most reliable diagnostic signs must always be the rigidity of POTT'S JJ IS EASE. 37 the vertebral column at the seat of disease. This may often be brought out by passive manipulation when the characteristic atti- tudes have not yet been assumed. If the child walks with unusual stiffness or keeps the back stiff in stooping or j^resents even a very small angular prominence, the diagnosis is all the more clear, but observant parents bring children to the surgeon before these things have occurred and the recognition of muscular rigidity becomes a matter of prime importance. To recognize this it is important to know the amount of normal flexibility of the spinal column. This varies to a degree in indi- viduals, and in children is much greater than in adults. Little dif- ficulty is met in recognizing muscular stiffness in the cervical region. The normal flexibility of the spinal column can be tested as follows : The child should sit upon a lounge with legs bent slightly at the knee, and touch the toes with both hands, at the same time placing the chin upon the sternum; or, stand- ing with straight legs and arms stretched out above the head, the child should en- deavor to touch the floor with the hands, curving the head upon the chest as far as is possible. To determine stiffness of the qUadratUS lumborum and ^'^- 54.-Normal Flexion of Spinal Column. psoas and iliacus muscles, the child should be placed upon the face and an attempt be made to raise the thighs. Normally the spine can be bent to a marked degree, the back sagging as the thighs are raised in this way; in diseases of the lower dorsal or lumbar region the whole trunk will be lifted as if made in one piece, on lifting the thighs ( Fig. 52). Stiffness of the back is an early and a well-marked symptom ; it may be unrecognizable in the earliest stages of lumbar caries, if the disease is localized in a small focus, not yet involving the carti- lage or whole of the vertebral body. Stiffness may be confined to a few of the adjacent vertebrae and not involve the whole back, i.e., patients with cervical or upper dorsal caries in a subacute stage may be able to stoop to the floor quite freely, without indicating any lack of mobility in the lumbar or lower dorsal region. Stiff- ness of the upper dorsal vertebrae, if limited to a small region and slight in amount, is with difficulty noticed, as normally there is not much flexibility in the upper thoracic region ; but for practical purposes, in the usual cases which present themselves for 38 ORTHOPEDIC SURGERY. examination, the amount of stiffness is such that it admits of no mistake. In such a case when a child is Hfted by the heels, as shown in the figure, the erector spinae muscles will often stand out on each side of the spine as indistinct and very firm columns. In cervical, and occasionally in upper dorsal, disease the spasm of the muscle produces a torticollis which is sometimes with difB- culty distinguished from pure torticollis (independent of any dis- ease of bone). In torticollis from caries the posterior muscles rather than the sterno-mastoid are usually involved, and there is more spasm than is usual in simple torticollis. The patient, in lying down or in sit- ting up suddenly, usually steadies or supports the head with the hands as a protection against jar or violence. If there is pain, it is in the back of the head or shoulders. In pronounced cases there is little difBculty in recognizing cervical caries — ^there is a thicken- ing and a projection in the outline of the neck, the back is flattened between the shoulders, or even hollowed in, with a compensatory projection in the spine in the lumbar region; sometimes in upper cervical disease a projection of the pharynx is to be felt in the mouth. In examining for peculiarity of gait, attitude, and movement, as mentioned above, the child should be watched narrowly as it runs about, rises from a recumbent position, stoops, etc. In the earliest stages the variation from normal movement may be slight at times. The nervous disturbances are, as has been mentioned, those de- pendent on irritation of the nerves issuing from the column at the affected point, and on a transverse meningitis or meningo-myelitis, They consist of pseudo-neuralgias, cough, grunting respiration, or dyspeptic attacks. 2. Peculiarity of Attitude and Gait. — The peculiar attitudes and gait of persons with Pott's disease have been so fully considered already in their diagnostic bearing that there is no occasion to repeat them here. They are early symptoms of the disease and they precede the formation of a knuckle in the back, but they fol- low muscular rigidity, which is the earliest symptom of all. The diagnosis must not rest on attitude alone in a doubtful case, unless it is confirmed by muscular stiffness at the affected part. At other times too much stress must not be laid upon the absence of charac- teristic attitudes. One occasionally sees children with well-marked kyphosis who do not present any characteristics of gait or attitude. 3. Seat and Localization of Pain and Nervous Symptoms. — Pain is not a necessary accompaniment of Pott's disease ; when it oc- curs it is generally referred to the back of head, shoulders, chest. POTT'S 1) 1ST: ASK. 30 abdomen, or legs, rather than to the back. It is increased by jars and by the erect position. It may occur in the form of "night cries," and at other times it may appear as a spasmodic abdominal pain during the daytime, much resembling cramps. Sometimes it is excited if the child be lifted, as described above, to see if there is muscular stiffness present, but in other cases with perfect stiff- ness of the back, pain is wholly absent. The test of pressing down on the child's head to see if pain is caused in the back is a brutal and irrational one. Tenderness on pressure over the spine is almost never present, although it is spoken of in many text-books as characteristic of the disease. This is so much the case that ten- derness when present is more an evidence of a functional neurosis, or hysterical spine, than it is of caries. A tenderness in the spine may occasionally be present in Pott's disease, from a hyperesthe- sia of nerves, but even this is rare. Paralysis, as another nervous symptom, is sometimes the first to be noted. This is not a common event, but sometimes in a doubt- ful case the occurrence of paralysis is suf^ficient to settle the ques- tion of diagnosis. A recognition of the beginning of paralysis is usually possible, from the fact that it is generally preceded by an increase of pain in the abdomen, and an increase of the deep re- flexes of the knee and ankle, and by muscular cramps. The paral- ysis usually begins gradually, and is first indicated by the patient's dragging one of his legs. But even before that it is generally noticed that the patient becomes tired very easily and seems weak. A peculiarity in breathing is particularly noticeable in upper and middle dorsal caries in the acute or subacute stage. The patient breathes as if unable to take a long breath, and while talking or breathing rapidly will hold the breath momentarily. The respira- tion has been defined as a grunting respiration, which expresses the condition well. 4. Irregularity of Outline of the Roiv of Spinous Processes or Ab- normal Projection of the Individtial Spinojis Processes. — The recog- nition of a projecting knuckle in the earliest stages of caries of the spine is not so easy as might be supposed. In very young children, when fat, the spinous processes are not easily felt, and furthermore, a projection may sometimes be seen normally, in thin subjects, of the spines of the sixth and seventh cervical, occa- sionally of the first dorsal and also of the last dorsal and the first and second lumbar vertebrae. These normal projections differ from the sharp projection seen in caries, in that they are in conformity with the projections of the other spinous processes — and more like a longer spinous process and less like a spine projecting at a wrong angle. Any projection 40 ORTHOPEDIC SURGERY. beyond the line of the other spinous processes of a spine in the middle dorsal region, must be regarded as presumptive evidence of caries, inasmuch as a physiological projection in the upper and middle dorsal regfon (below the first two dorsal) has not been observed in children. Irregular and pathological projections in the upper cervical region are in the early stages difficult to recognize, owing to the thickness of the overlying muscles; a diagnosis is here rather to be based on the position of the head and the muscular spasm. The shape of the back varies in adults physiologically — the back of a cobbler is different in curve from that of a soldier, and projections in the lower dorsal and upper lumbar regions may be seen in healthy backs. The Diagnosis of Abscesses. — Abscesses may remain some time without being recognized, when in the thorax or abdomen. Ordi- narily, however, they pass down the sheath of the psoas muscle, and the irritation excited by the presence of inflammatory invasion causes muscular spasm and a contraction, more or less marked, of the psoas muscle ; this is shown by a peculiarity in gait and by limitation in extension of the thigh. Induration and fluctuation can be felt in the lower abdomen above Poupart's ligament, on deep pressure, often before a swelling is noticeable to the eye. The formation of an abscess may be suspected when pain sud- denly increases, and a patient who has been doing well loses flesh and shows other signs of general disturbance. Retro-pharyngeal abscesses are recognized by the symptoms of dyspnoea, and on palpation a fluctuating projection will be felt in the pharynx. The occurrence of swelling should be watched for in such cases. In Pott's disease of the dorsal and lumbar region this is likely to appear in the lumbar region or the groin, and it may be noted that contraction of the psoas muscle, and consequent inability to ex- tend the leg fully, is frequently a precursor of this condition. The amount of the psoas contraction in these cases and its oc- curence probably depends somewhat upon the course of the abscess, and the consequent irritation of the psoas muscle. In some cases the contraction is very severe and occasions a distressing deform- ity. In other instances the contraction can be determined only by careful examination. The character of the deformity has already been alluded to in speaking of attitude. Hernia is sometimes suggested by the appearance of a psoas abscess in the groin. Such purulent collections sometimes appear very suddenly, are egg-shaped and not hot or tender. They can sometimes be much diminished in size by gentle pressure, but they POTT'S J) IS EASE. 4 1 at once refill and present none of the characteristic features of hernia. They lie outside of the femoral vessels in general and the signs of Pott's disease are always present. The finer diagnostic points are needed in less pronounced cases, of Pott's disease, but ordinarily the disease presents itself witii well-marked characteristics, even in the earlier stages. The patient, usually a child, is brought for examination with the statement that there are occasionally sharp pains in the belly, colicky pains, or rheumatism in the legs, that this pain is increased by jar, that riding aggravates the symptoms ; there is stiffness after getting up out of bed, or after sitting for a while, and it requires some little running about before the stiffness passes away. The child will occasionally stop in its play, and will lie down or com- plain of pain, which may be only temporary. On examining the child without clothes, it will be found that there is a peculiarity in gait or attitude ; the child walks stififly, with short steps, bent knees, with head erect, chin thrust forward, and shoulders raised ; sits rather than stoops in picking anything from the floor. The child leans against a chair as if tired, and supports the head with the hand; if lying down it gets up slowly and carefully, and stands with its hands on its thighs. There is often a grunting respiration and monosyllabic speech, as if deep breathing jarred the spine, a symptom almost pathognomonic of the disease. An abnormal projection of one or two of the spines of the vertebrae, with stiff ness, completes the diagnosis, and to this is often added spasmodic action of the muscles of the back, which start out on jarring the spine and are quite noticeable on inspection. History. — The question of diagnosis in Pott's disease must not be dismissed without a word as to the little dependence that can be placed upon the previous history of the case as presented by the average parent. There is an almost universal tendency to refer the disease to some slight accident and to date the beginning of the disease from that. Often enough it is evident that the disease is of long standing and that the recent accident has only served to direct the parent's attention to a condition in the back which was present in a considerable degree before that. The diagnosis must be made and can usually be made from the physical signs. The history of the case, as often given, cannot be allowed undue importance. Noble Smith calls attention to the frequency with which Pott's disease is overlooked by the medical man, and tells of some re- markable specimens to be found in the London Hospitals, where extensive destruction of the vertebrae had taken place, and yet when the symptoms during life had been most insignificant. Nota- 42 ORTHOPEDIC SURGERY. bly that of Dean Buckland, whose symptoms were those of " mel- ancholia," where after death there was found extensive caries of the first three cervical vertebrae. Differential Diagnosis. It is difificult at times to differentiate a strain of the vertebral coliLvin from Pott's disease. After a fall in which the back has been wrenched, a child begins to walk stiffly and to complain of pain- in the back and perhaps in the legs. Attitudes char- acteristic of Pott's disease are assumed, the trunk is supported Fig. 55. — Rhachitic Curvature of the Spine. with the hands upon the thighs, the back is kept stiff in stoop- ing, and passive manipulation shows that muscular rigidity is present. This condition has, perhaps existed for ten days and an opinion is requested as to the existence of serious trouble. At this stage a diagnosis is sometimes clearly impossible. But in strains of the back the tendency is to a recovery, and the result establishes the diagnosis. Severe strains of the back are comparatively rare in childhood, but in adult males engaged in laborious occupation cases of strain are more common than cases of Pott's disease. The diagnosis is one which should be made in childhood with very great reserve. Rhachitic curvature of the spine is often with difficulty distin- guished from Pott's disease. It will be noticed in the figures that POTT'S J)ISEASE. 43 the bend, usually described as involving the whole column, may be almost angular and present the closest resemblance to a yielding of the column produced by carious softening. Rhachitic curva- ture, however, occurs in young children, who present more or less marked signs of general rickets, although they may be slight. It is situated at the junction of the lumbar and dorsal regions and involves several vertebra;. Muscular rigidity is not so common or so marked as in Pott's disease, but it may be present to almost complete fixation, all statements to the contrary notwithstanding, and muscular stiffness cannot be relied upon as a sign that what seems to be a rhachitic curvature is really Pott's disease. Lateral curvature of the spine is an entirely different affection from Fig. 56. — Rhachitic Curvature of the Spine. Pott's disease. It is not the result of a carious destruction of bone, but is the result of a distorted and abnormal process of growth. It is characterized not by an angular projection of the spine back- ward, but by a gradual shaped curve of the spine laterally with a rotation of the vertebral column on its long axis, as described in Chapter II. Pain is not present, and the recognition of the affection is generally due to an alteration in the outlines of the trunk, and a prominence of the shoulder or hip, as mentioned in Chapter II. Lateral deviation of the spine which accompanies Pott's disease is not so much characterized by rotation of the ribs. It may be present as an early symptom, but it often occurs late, and other symptoms of the disease are generally well marked, and as a rule 44 ORTHOPEDIC SURGERY. it accompanies severe and painful cases. It is much diminished by recumbency, and the other signs of Pott's disease are present. Pott's disease and true rotary lateral curvature practically never coexist, and in most cases the diagnosis is not at all obscure. But in the course of Pott's disease at an early stage a lateral deviation may be present, which may be mistaken for lateral curvature. On a careful examination it will, however, be found that a stiffness of the back is present which is never to be seen at an early stage of Fig. 57. — Front View of the Lateral Deviation in Pott's Disease. Fig. 58. — Lateral Curvature from Severe Pott's Dis- ease and Psoas Contraction of Right Side. lateral curvature. In some instances careful and repeated exam- inations are needed to establish a positive opinion. A lateral deviation takes place also sometimes in old cases of caries of the spine in connection with an old kyphotic curve. The condition is, however, so easily recognized that a mistake in diag- nosis is not possible. Wry neck may be a symptom of cervical Pott's disease, and the diagnosis between true muscular wry neck and the distortion which is only symptomatic of bone trouble is one which often requires the closest attention. At other times one has to wait for the de- POTT'S DISEASE. 45 velopment of farther symptoms. True wry neck is caused chiefly by the contraction of certain muscles of the neck, tlie other mus- cles being unaffected. Movement of the head is free in all other directions, there is no pain and no resistance to passive motion on the part of the other muscles. On the other hand, wry neck due to caries resembles at first sight the condition just mentioned very closely, but pain is gener- ally present and the head is held firmly in its abnormal position by all the muscles. In fact the deep muscles seem more firmly set than the superficial ones. Any attempt at passive motion of the head excites resistance of all the muscles of the neck, which all guard the position and render further movement painful. When torticollis is merely sym.p- tomatic, the gait is often stiff, and the head is perhaps held with the hand under the chin. The back of the neck is also flat- tened, and in general the other symptoms of cervical Pott's dis- ease coexist. Hip disease under certain con- ditions may be confounded with lumbar caries of the spine. In certain cases of hip disease in an acute stage there is muscular re- sistance to motion in the lower dorsal and lumbar region, just as a prevention of motion at the ' hip joint analogous to the psoas F1G.59 and lumbar stiffness is found in lower Pott's disease. In hip disease this stiffness is also to be found to a marked degree in the adductor muscles of the thigh, while in Pott's disease, unless a psoas abscess has directly invaded the periarticular tissues of the hip joint and is irritating the peri- articular muscles, motion is no more limited in the direction of the adductor than in any group of muscles. In brief, it may be said that in hip disease, even at the earliest stage, there is restricted motion in all directions of the normal movements of the hip joint — a symptom not present in lumbar caries. In the latter, however, stiffness of the back is always pres- ent, while the resistance at the hip is usually to the motion of ex- tension of the thigh to a greater degree than to that of flexion or abduction. Lateral Distortion of the Column in a Severe Case of Dorsal Disease. 46 ORTHOPEDIC SURGERY. In some cases repeated and careful examinations are needed to establish a diagnosis. HypercestJietic spine, also termed the hysterical spine, the neuro- mimetic spine, is characterized by tenderness in certain portions of the back, sometimes accompanied by pain or ache. This condi- tion is more common in neurotic persons, but may be seen in others who have been suffering from nervous exhaustion from any cause. The tenderness may be intense and manifestly exagger- ated, or it may be only slight, and confined to small spots in the lower cervical and upper dorsal or in the upper lumbar region. As a rule, no real stiffness in the back is present, but in severe cases, or in cases which have remained in bed for some time, mus- cular stiffness may be present. This condition is sometimes seen after railway accidents. In the cases that are termed " railway spine," abnormal projection or deformity in the spine does not exist. Referred pains, or the attitude and gait characteristic of Pott's disease, are absent. A hyperaesthetic spine occurs in adults, and especially in young growing girls ; it may exceptionally be seen in children. Malignant disease of the spine presents, when a projection is found, a more rounded and less sharp projection than is seen in^ the beginning of caries. Carcinoma of the spine is usually second- ary. The symptoms, however — pseudo-neuralgias, paresis and par- alysis, .muscular stiffness — are the same in both, and sometimes only a conjectural diagnosis can be made. Carcinoma never occurs in childhood, and primary sarcoma of the spine in childhood must be the rarest of disorders. Much the same may be said of the curvatures of the spine caused by aneurism, except that the diagnosis is usually made by auscultation or by the rational symptoms before the spine is noticeably affected. A diagnosis of the meningeal tumors within the spinal canal would necessarily be difficult; the symptoms would, however, be nervous symptoms which would not affect the gait or attitude, except through paralysis, unless the pressure of the tumor should cause absorption of the vertebrae. This would not happen until a late stage of the affection, and a recognition of the affection would be made easier by the clinical history. Besides gummata of the spinal cord, a syphilitic destruction of the spinal vertebrae is among the medical possibilities, though it has hitherto escaped record. If it were limited to the bodies of the vertebrae, the symptoms would in every way resemble those of caries of the spine; the clinical history, however, and the age of the patient might serve as guides to an idea of the true etiology. POTT'S DISEASE. 47 Sensitiveness of the skin over the spine, or pain in pressin^^ on the spinous processes is not a symptom of I'ott's disease and it is the chief feature in hypercesthesia. Stiffness and constrained at- titudes may be present, but of course angular deformity is absent and stiffness is variable in amount. In the diagnosis one must depend largely upon the general aspect of the case, the presence of ovarian tenderness, the hysterical "globus," and the other symptoms of that ill-defined condition, hysteria. Rheumatoid arthritis (chronic articular rheumatism, spondylitis deformans of the spine) is an affection of adult life characterized by stiffness and some arching of the spine; there is usually little muscular spasm, and no unusual projection of the spinous pro- cesses ; in some instances the ribs are ankylosed to the spine, so that no expansion of the chest is possible. Patients suffering from this affection may have neuralgic or pseudo-neuralgic pains of the nerves issuing from the spine at the affected part. With regard to the symptoms of sacro-iliac disease, perinephritis and perityphlitis, it may be said that a mistake in diagnosis can happen only through a lack of acquaintance with the symptoms of these affections. It should, however, be borne in mind that in perityphlitis and in perinephritis, when an abscess is present, a con- traction of the thigh may occur resembling that seen in psoas abscess. The absence of a projection or irregularity of the back, and the power of muscular movement of the back in these cases, will help to establish the fact that they are not due to caries of the spine. The same is true of caries of the sacrum. Prognosis. Pott's disease will always be regarded as one of the most for- midable of diseases; its long course, the deformity often entailed, the severity of the complications (abscess, paralysis), and of the symptoms at times; and the occasional termination in death, coming only after years of suffering, or often in a crippled state, gfve both to the surgeon and to the non-professional public a nat- ural dread of the affection. These inferences are, however, drawn from the severer cases, and facts show that the disease has a ten- dency to spontaneous recovery, that in certain parts of the spine deformity can be prevented, and that in few affections does the Avork of the surgeon give greater relief than in Pott's disease. Mortality. — No statistics of value exist as to the percentage of mortality and recovery. Billroth and Menzel report 23 deaths in 61 cases; Jaffe 22 deaths in 82 cases; and Mohr, 7 deaths in 72 cases. In a disease having so long a course, a number of patients 48 ORTHOPEDIC SURGERY. should be watched for a long number of years in order to obtain statistics of value. The percentage of mortality would be greater in adults than in children. In a certain number of cases spontane- ous recovery has taken place in early childhood. Many specimens, in museums also exist, which show complete bony union, with entire cessation of the carious process. Billroth and Menzel found, in autopsies of 702 cases, tuberculo- sis of other parts of the body in more than one-half (fifty-six per cent). Amyloid degeneration was found in fifteen per cent of the cases, and fatty degeneration of the kidney in twenty-two per cent. Mohr, however, found the latter in only six per cent of the cases, collected by him. Mohr found tuberculosis of the lungs in only eight out of sixty-one autopsies. Neidert has investigated the cause of death in patients with, angular deformities of the spine, the result of Pott's disease which has been cured. Patients with severe deformities die of heart fatigue ordinarily, patients with medium-sized curvatures die often- est of phthisis, and die young, while those with small deformities- have nearly as good a prospect of long life as men with normal spines. These results were obtained from the investigation of thirty-one specimens in the Munich Pathological Institute. The average age of the patients at the time of death was forty-nine and one-half years. Twenty-four had hypertrophy, with or without dilatation, of the right side of the heart, four had muscular degen- eration of the heart walls, and two had stenosis of the mitral valve, one showed acute miliary tuberculosis, eight died of phthisis, four of pneumonia, and one of carbuncle. (" Causes of Death in Deform- ities of Vertebral Column," Inaugural Dissertation, Munich, 1886.) Lannelongue, speaking of narrowing of the aorta in Pott's dis- ease, says that in his autopsies he has noted that a very marked narrowing of the calibre of the aorta was not uncommon. In one specimen the aorta only measured sixteen millimetres before the origin of the brachio-cephalic trunk; twelve millimetres after the carotids had been given off, and only eight millimetres in the region of the second lumbar vertebra. In another specimen the lumen of the aorta was reduced to a mere slit. These changes are consequent upon the abnormal curves given to the vessels, and their existence explains the production of certain rapid and pecu- liar paralyses which come on in spinal caries and which are not due to compression of the cord. Cause of Death. — Michel gives as causes of death in 44 cases of spinal abscess: in 14, tuberculosis of lungs; in 16, marasmus; in 5, sloughing of limbs from oedema; in 4, pyaemia; in 2, arachnitis;, in 2, pus in the medullary canal; and in i, pneumonia. POTTS. DISEASE. 49 Mohr, in 9 cases of fatal abscess, found perforation into the •oesophagus in 2 ; pleura and lungs in 2 ; pleura alone in i ; i^eri- toneum in i ; spinal canal in 2. Perforation into a large artery has been noted. Death has occurred from the rupture of a spinal abscess, which discharges into the bronchi. Abscess. — The frequency of the complication of an abscess varies somewhat according to the locality of the disease; this is most common in the lumbar, and least common in the cervical, region. Mohr found, in 61 cases at autopsy, thirty abscesses. Of these but one was of cervical caries; and the number of lumbar cases with abscess was twice that of dorsal. In life, abscess existed in but 9 of 72 cases. Cases of recovery after rupture or. evacuation of abscess are not ;SO rare as to be exceptional, but abscesses in adults must be looked upon as much more unfavorable as to prognosis than in children. The prognosis will depend largely upon the situation of the abscess, the completeness of evacuation, and the amount of drain- age possible. The occurrence of psoas abscess and contraction of the thighs will add much to the difificulty and the length of treatment. Ab- scess in itself does not make the prognosis much more grave, al- though, as a rule, abscesses characterize severer grades of cases. The discharge is likely to be prolonged and exhausting, and the sinuses are likely to continue open for a long time, perhaps for months and years. Age. — The prognosis in the case of adult? is not nearl}' so favor- able as in the case of children, and it should be very guarded both as to ultimate recovery and the permanent benefit to be derived from treatment. Phthisis is much more likely to develop than in children and the local process seems to possess an activity greater than in young children. Deformity. — The tendency of the deformity is to increase, and this is especially marked in the upper dorsal region ; instances of arrest without marked deformity are not so very rare in upper cervical disease, and in lower dorsal disease; but in the upper and middle dorsal regions the tendency is for an increase of the de- formity proportionate to the extent of the disease. It has been frequently stated that a recession of the deformity does not take place. Such instances are rare, but have been ob- served. The lost parts of the vertebral column are not regained, but growth takes place in the normal vertebra and is arrested in the ankylosed vertebree; the projection is then proportionately less, and practically less prominent. As a rule, however, the pro- 4 50 ORTHOPEDIC SURGERY. jection increases somewhat during the growing years, and with it there is necessarily an increase in the compensatory curves. In some cases, an arrest of the growth of the whole child takes place apart , from the loss of vertebral substance. A peculiarity in the shape of the jaw and face is also observed in cervical and upper dorsal caries. Prognosis as to Time in Recovery. — No reliable statistics exist as to the amount of time necessary to establish a cure in Pott's dis- ease. The disease varies greatly as to its self-limitation in individ- uals, and according to the situation and extent of the disease. Necessarily there will be a difference in individual cases in the result of treatment. Relief from symptoms is often easily obtained, but to establish a complete cure, so that there be no latent disease, requires protec- tion and treatment for years. It may be said that, as the bodies in the cervical region are smaller than those in the lumbar, the time required for self-limita- tion here is shorter than in the lumbar region. In the latter region,, also, the superincumbent weight is a more important factor than in the upper part of the spine. Roughly speaking it is always possible to predict a course of treatment which shall last not less than three years and probably longer. Until one has seen the frequency with which relapses occur in cases which are apparently cured, when treatment has been discontinued too early, it is impossible to appreciate the true danger in an early discontinuance of treatment. The occurrence of bony ankylosis firm enough to support the column in its weight -bearing function must be a process requiring a long time for its completion, to judge from it as observed else- where; and nowhere is protection more urgently demanded during convalescence than in the vertebral column. This is especially true in growing children. Cases of supposed cure of caries of the spine have re-developed symptoms of caries at the period of rapid growth at the approach of puberty. It should especially be borne in mind that protection to the spine may be needed at this period. Paralysis in Pott's disease shows a remarkable tendency to re- cover, as has been already stated — a fact that many authorities have overlooked, taking their statistics from incurable hospital cases. The cases investigated by Taylor and Lovett gave the following results : Of the 59 cases analyzed, 39 wholly recovered, 3 recovered in part, 5 died of intercurrent affections, and in 12 cases the termina- tion is unknown. That is to say, in the whole number of cases POTTS DISEASE, 5 1 where the termination was known, cit^iity-thrcc per cent recovered wholly from the paralysis; and this percentage is undoubtedly too low, for, of the cases which died, 2 were recovering and 2 others were probably over their paralysis when they died, although they cannot be so counted. Of the deaths, 2 were due to pneumonia, i to acute phthisis, i to the opium habit, and i to acute cerebral meningitis. The termination was unknown in so many cases because they came only for consultation, or disappeared from observation after a little while, or were discharged for neglect. The bladder and rectum are noted as having been paralyzed in 8 cases, and here the per cent of recoveries fell to fifty-seven, in the cases in which the result was known. The arms were affected in 3 cases. Of these, I recovered wholly and the other 2 partly. Muscular rigid- ity is noted in 5 cases, of which 2 recovered wholly, but it was un- doubtedly present in many others. The latter symptoms mean much damage to the cord, and the wonder is that any recover from them. Where the paralysis came on while the patient was under treatment (19 cases), the percentage of recoveries was one hundred in the 17 cases whose termination Avas known. Of the 2 cases where the termination was doubtful, i was recovering power quite fast at the end of six months, and the other was still para- lyzed when two years had gone by. Neither has been heard from since. The average duration of all these cases was a little less than one 5^ear. When the paralysis came on under treatment, the average duration was only seven months. The disappearance of the paral- ysis wa3 gradual — the sensory part recovered first, then the motor, and last of all the tendon reflexes became normal. In three or four cases the recovery followed in a few days or weeks after the evacuation of an abscess, and in one case the recovery was sudden and occurred during an attack of measles, after the paralysis had lasted two years. A recurrence of the paralysis was not uncom- mon, having occurred in 6 cases— 4 patients had two attacks, and 2 others had three. The intervals between these recurrences varied from a few weeks to some years. Recovery may take place after complete motor paraplegia with marked sensory impairment. In a few cases the paralysis recurs. Treves quotes a case of recovery after complete paralysis of the lower limbs, with loss of power of the upper extremities and in the bladder. He mentions a case of two attacks of paralysis, occur- ring in the same patient in two years, which were followed by re- covery; and another of three attacks of paralysis in eight years, in a man of twenty-four. The presence of marked paralysis of sensation indicates an ex- 52 ORTHOPEDIC SURGERY. tensive myelitis involving the posterior as well as the anterior columns of the cord. Some impairmenf in sensation is found in all cases of paralysis in Pott's disease, but it is usually so slight as only to be "recognized by the most delicate tests and for a short time. Paralysis of sensation may be complete and yet recovery result, as in a case in the experience of the writers where the loss of sensation was so great that a bandage was accidentally pinned to the skin, without pain to the patient. Complete recovery from paralysis of sensation and motion, however, occurred in a year. But paralysis of sensation, especially if combined with paralysis of the rectum and bladder, makes the prognosis less favorable. Prognosis is necessarily made much less favorable by the exist- ence of amyloid disease of the viscera, which frequently follows long-continued suppuration. Although the prognosis in Pott's disease is, as in all diseases, in a measure uncertain, it is possible to promise almost certain im- provement from proper and careful treatment, and in many cases to anticipate ultimate cure. The final course of the disease must in many cases remain uncertain, but it is the experience of the writers that the uncertainties of prognosis are no greater in this than in other grave chronic disorders. Instances of spontaneous . complete recovery from well-advanced Pott's disease have been undoubted. The prognosis of average cases coming under thorough treat- ment is by no means unfavorable. But treatment must be thor- ough and long continued in all cases of any severity. The prog- nosis in adult cases is necessarily much more unfavorable than in children. Treatment of Pott's Disease. After considering the pathological appearances of a disease which is at times as severe as Pott's disease, it is natural that the surgeon reading the recorded facts should be appalled at the formidable complications and alarming terminations which are possible. But extended experience will give a much more favorable view of the matter. The course of Pott's disease is necessarily a long one and the treatment should be continued through many years, but in few affections can results more satisfactory to the surgeon be gained than in the treatment of this affection, for these results are gained only by thorough treatment and the exercise of good sense and judgment. Whether the surgeon shall use the methods of recum- bency, whether he shall employ braces, or corsets, and whether he shall interfere surgically must depend not only upon the surgical conditions of the case, but also upon the surroundings of the patient. POTT'S J) /S /CASE. 53 He will be able in all cases to alleviate pain, and in a majority of cases to effect a cure, and this cure will result with or without a deformity according to extent of disease, its situation, anrl also according to the thoroughness of treatment and the care and nurs- ing given to the patient. In a large number of instances the cure is permanent and the patients are able to carry on active occupa- tions throughout life. Cases of cervical caries are usually treated with the greatest satisfaction, as their course is shorter. The symptoms, however, at times may be alarm- ing and the pain may be great. Cases of the upper dorsal region are the most difificult of treatment, as the preven- tion of deformity requires much thorough- ness of treatment and in some cases this is impossible. Patients with disease in the Jower dorsal region are treated with great satisfaction. The accompanying picture will illustrate the results Avhich may be obtained in severe cases if persistently treated. It is that of a boy of the age of eleven who five years before presented a sharp angular curvature in the lower dorsal region. A large ab- dominal abscess was formed on the left side, which was opened by incisions in the groin and back. The patient was fixed in a recumbent position and remained so for nine months. A second abscess formed on the right side, which was also incised, the sinuses discharged for two years. At the end of seven months the patient was fitted with an antero-posterior support and was allowed to go about using crutches. These latter were discarded at the end of a year and at the present time the boy is to all appearances well, is as well able to play as other children and enjoys perfect health. It cannot be claimed that results of this kind can be gained in every case, but this case represents a class Avhich is by no means uncommon, and such results can be fairly anticipated where good nursing and persistent treatment are possible. Principles of Treatment. — The principles of treatment of caries of the spine are simple, though their practical application is attended with difficulty. The diseased vertebral bodies should be protected from jar and pressure until a cure is accomplished. As in ostitis elsewhere, Fig. 6o. — Result in a Severe Case of Dorsal Pott's Disease. 54 ORTHOPEDIC SURGERY. there is always an effort toward repair, and everything should be avoided which would hinder this reparative process. The jars which come upon the spinal column are chiefly those received in bending the column forward, and pressure upon the vertebral bodies comes from the superincumbent weight of the head and trunk. In treating a diseased vertebra, therefore, the superim- posed weight should be removed from the part affected, so far as is practicable, and all bending forward avoided, the spinal column being fixed so as to secure rest for the vertebral bodies. Furthermore, as the inevitable tendency of the spinal column, weakened in front, would be to fall forward, deformity will take place if the vertebral column is left unsupported, and in treatment every effort should be made to limit the increase of that deformity, or if possible to prevent it. It will be readily understood that thorough treatment of caries of the spine involves much time, partly because the disease is rarely discovered until much progress has been made, and partly" also because the reparative process in bones of the size and situa- tion of the vertebral bodies is necessarily slow. A cure cannot be considered as having taken place, in a structure which has to bear so much weight as the spine, until it is able to sustain, without injury, any jar which may come upon it; otherwise a relapse is apt to occur. It is because so much time is required that surgeons are sometimes obliged to be satisfied with what must be considered imperfect results. Given perfect conditions, it is theoretically as possible to bring about a cure without, as it is with, an increase of deformity, provided a cure can be effected at all. Practically, it is difficult to secure the requisite conditions of com- plete fixation and ideal position, and perfect results are rarely attained ; but it has been shown, by reliable clinical evidence, that prevention and recession of the deformity are sometimes won ; that prevention of increase of the curve and cure may in many cases be expected to follow thorough treatment ; and that relief and benefit are always to be looked forward to as a reward for careful treat- ment. Methods of Treatment. — The methods which have been used to remove from the spine the superimposed weight are, first, recum- bency, and, second, suspension and fixative appliances, such as braces and corsets. They constitute the methods of treatment, and have respectively certain advantages and disadvantages which should be clearly understood by the surgeon. Treatment by Recumbency. — If the patient lies upon his back, or upon his face, on a hard surface, there is no superincumbent weight pressing upon any portion of the spine. If the patient lies POTT'S DrSEASIC. 55 upon his back upon a spring-bed, and the bed sags, the spine is, of course, bent, and pressure upon the vertebrae, proportional in amount to the extent of the curve, results. This can readily be demonstrated by measuring the length (jf a person lying flat, and comparing it with his height as he stands. It will be found that there is an increase while the person is recumbent, of from one to one and a half inches, due to the obliteration of the curves of the spine. If a small pillow is placed under the back so that it is curved with the convexity forward, the bodies are separated in proportion to the amount of the curve. In thorough treatment by recumbency it is not suf^cient that the patient be placed in bed; he should not be permitted to sit up, lie upon one side (twisting the spine), or bend forward while on his side. The patient, however, can lie upon his face. The patient, if unruly or restless at night, can be prevented from sitting up by pinning the shoulders of the night-dress to a sheet which Ts secured to the sides of the bed ; or, better, by straps in the following way: A soft cloth strap is placed across the bed at the height of the patient's shoulders, and secured at the sides; it is also prevented from moving down by a cross-strap secured at the top of the bed; if the patient's shoulders are secured to the straps by loops around the axillae (these loops being fastened to the straps), the patient can neither sit up nor roll to one or the other side to any extent. A belt about the hips, secured by side- straps to the sides of the bed, will prevent the pelvis from moving sideways, and the patient is thus held suf^ciently secure. Sand- bags placed at the sides of the patient also aid in preventing side movements. An excellent means of retention has been described by Fisher {^Lancet, February, 1878.) The bed should be flat, and the patient should use no pillows. This way of securing the patient, however, does not enable him to be lifted or moved readily, and is objectionable on that account. In children this can be obviated by arranging a bed-frame in the following way : If four stout steel bars, one-half inch wide and one-fourth in thickness, be fastened together so as to make an oblong frame of the patient's height and width, and over this stout sheeting be wound and fastened, the patient can lie on this, if it be placed upon the bed, as comfortably as upon the bed; straps across the shoulders, fastened to buckles secured to the frame, and others about the hips, will secure the patient in a recumbent position, while the frame and child can be lifted and carried about easily. The sheeting can be readily changed when soiled ; no padding is needed. The sheeting should be cut out at the reeion of the but- 56 ORTHOPEDIC SURGERY. tock, so that the bed-pan can be used. Traction of the spine can be employed by attaching an arm at the head of the frame to secure the sling. This arrangement is more comfortable and much cheaper than a Bonnet's wire cuirass, and can be made as efficient in fixing the spine. The same can be used in older persons, but it requires a stouter frame, and there is more diflficulty in lifting the patient. One of the chief advantages of this apparatus is the ease with which the patient can be carried about and be taken out of doors, thus avoiding the evils of long indoor confinement. Traction, so much used by the earlier French orthopedists, can hardly be thought to separate directly the diseased vertebrae, as was originally supposed, except when applied in the cervical region. Experiment has shown that great force is required to pulL the normal vertebrse apart. Traction, or extending weights ap- plied to the trunk, may, however, diminish the physiological curves, and thus diminish pressure. This extending force is readily ap- plied by means of belts about the pelvis and thorax. These belts are supplied with straps and cords, which pass to the foot and head. Fig. 6i. — Frame to Secure Recumbency and Fixation, and to Allow Patient to be Moved About. of the bed respectively, and running over pulleys, exert force by means of attached weights. In some acute cases this system affords relief, probably as a correction of muscular spasm, and also as a means of fixing the patient, and possibly, in directly diminish- ing inter-vertebral pressure. The pressure of the adjacent vertebrae can be diminished by pads placed under the body, pressing the spine forward. They should be thick enough not to flatten to such an extent as to be inefficient, and soft enough to be comfortable. It will be found that curled hair or the best of felt will meet the requirement ; they should be so arranged that, as the patient lies on his back, the pressure should come over the sides of the vertebrae, and not upon the spinous processess. In disease of the cervical region traction will be found of great assistance in acute cases, the relief afforded being often very marked. It is obtained by securing the head in a sling, similar to that used for suspension, which passes under the chin and occiput; to this is attached a cord which runs over a pulley, and is supplied with a light weight (one-half to one pound). Counter-extension is POTT'S J) IS EASE. 57 supplied by the weight of the patient's body, if the head of the bed is raised. Traction in the lumbar region may also be applied by employing extension by weight and pulley (as in I^uck's extension for frac- tured thigh) to both legs, and raising the foot of the bed. Treatment by recumbency will be found of service, either alone or in conjunction with other methods, in cases with acute symp- toms, in cases of severe cervical caries, and in caries of the lower lumbar region. In children the irksomeness of the confinement passes off readily; but in adults the imprisonment constitutes a serious obstacle to the employment of the method. Patients who have been suffering will often be found to gain flesh after the relief afforded by recumbency, though the muscles in the limbs diminish in size. Treatment by. recumbency, if used, should be thorough. Half measures have the evils of the imprisonment without the benefit of fixation. The limit of its usefulness is usually marked by the restlessness of the patient. The objections to treatment by recumbency are evident. Pott's disease is a tubercular affection and close confinement is injurious to patients with a tubercular taint. Patients of this sort need all possible help from fresh air and exercise, and the method of treat- ment by recumbency for years, formerly the only thorough method possible, is not now regarded as necessary in all cases. It is impossible to define precisely in what cases or at what stage recumbency is needed. In the acute stages recumbency is abso- lutely necessary, and where paralysis or abscess is threatened, re- cumbency for a few months will bring about more favorable symp- toms. In cases causing much anxiety, recumbency should for a while form an essential part of the treatment. In cases needing this treatment it will be found that the patients begin to improve in appetite, flesh, and general condition after a week's recumbency. If recumbency is continued for too long a period, the patient's condition ceases to improve and the tonic of improved circulation and activity is required. After some experience a surgeon Avill learn to estimate for what cases recumbency is most advisable. It may in general be stated that such patients as become easily tired when on their feet and those who, though well-supported mechan- ically, frequently desire to lie down, will improve if all weight can be taken from the spinal column. This can be most thoroughly done in a recumbent position, with thorough mechanical support, and with suspension appliances, or, in dorsal and lumbar caries, patients who are recumbent for a greater part of the time may be allowed some activity with the aid of crutches, for a short time each day. The amount of time should be increased as the patient 58 • ORTHOPEDIC SURGERY. improves, with the use of the frame or with the " gouttiere " (to be described under the treatment of hip disease) patients (if children) can be moved about readily and given the benefit of fresh air. A combination of the treatment of recumbency and mechanical fixation will be of advantage in the severer cases, and at times relief from pain may be afforded by recumbency combined with a light weight attached to each leg by a plaster extension, by allow- ing the body to act as a counter-extending force mild traction is exerted upon the diseased part of the vertebral column which exerts a sedative effect upon the irritated muscles. It has semed to the writers that in this as in other forms of tuberculous joint disease the tendency to tuberculous meningitis is favored by too prolonged or ill-judged confinement in bed. In cases convalescent from paralysis and in another class of cases where the general prostration is extreme, exercise may be ob- tained by the use of one of the appliances shown in Figs. 62 and 63. Treat-ment by Suspension. — The pressure upon the diseased verte- brae by superimposed weight can be removed by suspension. Suspending a healthy person by the head obliterates the physi- ological curves (cervical and lumbar lordosis, dorsal kyphosis), and the spine becomes straight so far as its formation will allow. The spine of a new-born child becomes straight by suspension, but in an adult the changes in the shape of the bones and the strength of ligaments, and the tension of the muscles, prevent the spinal column from becoming perfectly straight. In suspension by the axillae or arms the strain comes upon the latissimus dorsi muscles, and though the superimposed weight which would fall upon the lower part of the spinal column is re- moved, yet the curvatures in the upper part of the spine are not made straight. In suspension, in old caries of the spine, it is only the physiologi- cal curves which are obliterated ; the sharp kyphosis is held too firmly by inflammatory adhesions to permit of correction; in earlier cases with movable vertebrae, the intra-vertebral pressure must be, in a measure, diminished at the point of disease by sus- pension, but suspension does not cause a disappearance of the sharp angular projections at the point of disease, and in cases that present themselves for treatment the deformity cannot be cor- rected in that way. Complete suspension as a remedial agent can necessarily be used only temporarily, in holding the trunk in a better position while corsets and appliances are fixed to the spine. Partial suspension is also used, applied by means of chairs and wheel-carts, or by a sliding pulley attached to a bar in the ceiling, enabling the patient POTT'S DISEASE 59 to sit up and walk about without allowing the full superimposed weight of all on the spine. In patients suffering with the symp- FiGS. 62 and 63. — Appliaaces Allowing Locomotion and Relieving Superincumbent Weight. G Fig. 64.— Jury-mast before Incorporation. Fig. 65. — The Jur>--mast Applied. toms of Pott's disease, relief will be afforded by suspension without causing much discomfort by the pressure of straps on the head and 6o ORTHOPEDIC SURGERY, neck. The amount of time that complete suspension can be used varies with the size and weight of patients. Suspension will be found to be more ef^cient in disease of the cervical and upper and middle dorsal regions than in that of the lower part of the spine, for the higher the disease the less is the superimposed weight, and the less the difficulty met with in apply- ing to the head an efficient suspending force. The only practical application of continued suspension in the treatment of Pott's disease is found in caries of the cervical region, when suspension can really be obtained by a jury-mast running up from a plaster jacket as a base, in the manner soon to be described. Traction may be ex- erted by the elasticity of the bent iron rod forming the up- ward continuation of the jury- mast. A simple appliance for a head rest with the plaster jacket is shown in the simple bent-wire head piece by which extension may be obtained. The head rest opens at the back and when the head is in place buckles behind the neck. The lower part of the head piece runs down on to the chest and buckles by webbing on to the upper part of the jacket, so that by tightening the straps the whole head piece may be raised (Fig. G"]^. A most thorough and exhaustive investigation of the effect of suspension in caries of the spine has been published by Anders {ArcJiiv f. klinische Chiriirgie, 1889, 38 Bd., 3d, p. 558). His con- clusions coincide with those of previous investigators, but his re- searches are more thorough than have previously been reported. He proves conclusively that the effect of suspension in caries of the spine is not to separate the diseased vertebrae, or in fact to directly affect the projection. The flexible portion of the spine is altered by suspension, as it can also be altered by recumbency, the prone position, or different attitudes The undoubted beneficial effect of plaster jackets is due, not to the separation of the affected vertebrae, but to a fixation support Fig. 66.- ■ Sayre Head-piece for Suspension in Pott's Disease. POTTS J)ISEASE. 6i in an improved position. In short that pLastcr jackets afford an excellent antero-posterior support. Treatment by Means of Fixative Appliances. — The irksomeness of the method of treatment by recumbency, and the practical impos- sibility of carrying Out thorough treatment in a large number of cases during the whole period of time necessary for complete cure (i.e., until the spine has been restored to its ability to bear weight without likelihood of relapse), has always justified attempts to Fig. 67. — Plaster Jacket with Bent-wire Head Piece. Fig. 68. — Jury-mast and Plaster Jacket. secure fixation of the spine, permitting locomotion. From the days of Ambroise Fare's hammered brass cuirass to that of the plaster jacket, the corset has been a favorite form ; but crutches, springs, and steel supports have been employed in a great variety of ways. The tests of an appliance are its efficiency, its convenient use, and the little discomfort felt by the wearer. A large number of appliances used are of no value, simply because they do not meet the conditions indicated by the disease, which, varying in different cases, remain the same in principle, viz., the fixation of the spine 62 ORTHOPEDIC SURGERY. in such a position that the jar on the vertebral bodies shall be re- duced to a minimum or entirely removed. This position (aside from recumbency and suspension) would be, if possible, with the Fig. 69. — Diagram showing Spinal Column with the Usual Relation of the Bodies in Caries of the Spine. Fig. 70. — Position of Diseased Bodies made Worse by Flexion of Spinal Column. Fig. 71. — Diagram of Ca- rious Spine Straightened by Mechanical Support. spinal column bent backward (concavity backward), so that the point of disease would be in front of the line of superincumbent Fig. 72. Fig. 73. Figs. 72 and 73. — Modified Jury-mast Before and After the Sling is Tightened. weight, rather than behind it. This (as the diseased portions are the vertebral bodies in front of the hinge of motion, viz., the POTT'S J)/SJwlSK 63 articulation) would tend to piy the diseased bodies apart if the spine were flexible, or diminish the superimposed pressure. "To straighten the spinal column in such a manner that the weight of the body is borne on the transverse processes, and not by the bodies of the vertebra;," as has been proposed, is not possible if any disease exists sufficient to cause a projection. This has been proved in experiments on the cadaver, and in suspension of patients the projection at the diseased portion does not disappear. It is possible, however, to diminish, by suspension, recumbency, or cer- tain positions, the amount of inter-vertcbral pressure at the point of disease, and to fix or nearly fix the spine in the corrected posi- tion. Practically the choice comes down to one of two appliances : the plaster jacket and its modifications, and the posterior steel brace, which acts on the transverse processes of the vertebrae as a lever to modify the pressure between the diseased vertebrae. In the cervical region the various collars come in for consideration. Other appliances are numberless, and are .chiefly modifications of one or the other of these standard methods of treatment. TJie Treatment by Plastej' Jackets. — The most ready method of fixation is by means of Sayre's plaster jacket, which may be applied while the patient is suspended or recumbent. It was originally supposed that a jacket could be applied so as to serve as a means for holding. the diseased vertebrae apart, i.e., as a means of distraction. Suspension having pulled the vertebrae apart, a jacket which takes its base-bearing on the pelvis and a purchase on the thorax, would keep these portions from coming together by a vertical support. These ideas are erroneous. Sus- pension straightens the spinal column as far as possible and re- moves antero-posterior curves, and the application of a plaster jacket prevents the column from bending forward. Plaster jackets are efficient not as a means of fixation alone, or of distraction, but as a means of securing comparative fixation in an improved posi- tion. The treatment by plaster jackets requires care, for a poor jacket does harm rather than good by deceiving the physician and the patient. For the proper applying of plaster jackets, moreover, a careful attention to detail is necessary. Bandages are prepared by rolling loose-meshed cloth in dry plaster-of-Paris. The cloth to be chosen is that capable of carry- ing the most plaster-of-Paris, and presenting as little cloth-fibre as possible. Crinoline muslin will be found to answer this purpose. The plaster is to be rubbed in smoothly and to be freed from lumps or unevenness. The patient's clothes are removed and a thin, tightly-fitting undershirt applied, made so as to present no 64 ORTHOPEDIC SURGERY. wrinkles. The patient is then suspended ; the head is secured in a sHng, which is attached to a strong cord playing in a pulley, or series of pulleys, fastened to a strong point above the patient's head. An assistant pulling on the cord raises the patient so that the heels, and if necessary the toes, are free from the floor. It is desirable to diminish the strain upon the neck, and padded loops Fig. 74. — Application of Plaster Jacket. connected with the bar, which is raised by the cord and pulley, can be passed under each axilla, or handles may be held in each hand, connected with cords which play over pulleys. A pull on the cords pulls up the arms, raising the patient. It should, however, be remembered that strain upon the arms or scapulae, connected as they are to the spinal column by the trapezius and the latissimus dorsi, does not tend to straighten the upper part of the spinal column. Pads are placed over the crests of the ilium, and a large, J'OTTS J)fSI':ASE. 65 soft pad over the abdomen. This latter is to be pulled out when the jacket has become hard, and prevents too great pressure on the abdomen. The bandages are placed singly on end in water and kept im- mersed until they are thoroughly wet {i.e., until air-bubbles no longer rise in the water from the immersed bandage) and are then wound smoothly around the patient. If the plaster is fresh and of the best quality, it should harden in from five to ten minutes. The hardening can be hastened by putting salt or alum in the water, but this makes the plaster some- what more brittle. After the plaster is hard or nearly hard, the patient is to be placed on a soft flat surface, care being taken not to crack the plaster in so doing. The abdominal pad is then re- moved, and the edges of the bandages are smoothed down and cut off if they press uncomfortably on the thighs or axillae. It is important that the jacket should be strong in front as well as behind, and should be wound as high as possible in front, in order to prevent the spinal column from falling forward. If the jacket become broken, it should be removed, and another applied. Chafing can usually be prevented by careful padding on each side of the prominent vertebral process and over the hips. For the former, the stuffed finger of a kid-glove will often answer, but saddler's felt, cut of the appropriate thickness, will answer better. It is important that the proper material should be used for the bandages. Too close-meshed a cloth cannot retain enough plaster in its fibre, and holds the moisture too long to admit of rapid hard- ening, which is an essential of a suitable jacket ; and a too coarse- meshed tissue, as mosquito-netting, while allowing rapid setting, makes a jacket which is liable to chip and is not sufficiently durable. Felting has been prepared which, when subjected to heat, be- comes soft, but stiffens on cooling. This has been used as a sub- stitute for plaster-of-Paris corsets. (Cocking: Brit. Med. Journal. 1878, p. 283.) If the disease is in the cervical region, the plaster bandages can be carried up around the back of the head and neck, leaving the face and upper part of the head exposed, and so fixation and support may be obtained in that part of the vertebral column. This method of fixation has certain manifest disadvantages in lack of cleanliness, clumsiness and unsightliness, but it is thorough and furnishes an excellent support and is by no means uncomforta- ble for the patient. With the proper application of the plaster jacket began a new era in the treatment of Pott's disease, and for this much honor is due to Dr. Sayre, who was so influential in bringing this useful 5 66 ORTHOPEDIC SURGERY. measure to the notice of the profession. It brought a ready means of treatment within the reach of thousands of patients who Fig. 75.— Appliance for Suspension. Fig. 77 — Beely Method of Suspension Fig. 76.— Suspension Sling, German Pattern. Fig. 78.— Schreiber's Method of Suspension. POTTS DISJiASJ':. 67 could not have been helped by tlie prevalent methods of treat- ment. Plaster jackets have certain great advantages when ijro[)crIy applied. In appropriate cases they are efficient and the surgeon is in no way dependent on the instrument maker; they cannot be loosened at the whim of the patient and remain as the surgeon leaves them. On the other hand, plaster jackets not being remova- ble are uncleanly and to many patients uncomfortable on that account; occasionally an obstinate eczema will develop underneath the jacket. Plaster jackets can be applied to patients lying in a recumbent Fig. 79. — Finished Plaster Jacket Cut and Laced. Fig. So. — Silicate of Potash Bandage Jacket. position slung in a thin cloth hammock. The bandage is wound about hammock and patient and the ends of the hammock cut off; or several sheets of crinoline wet in plaster may be wound layer by layer about the patient while recumbent or when suspended. The usual way, however, will be found to be the readiest. Plaster jackets may be split, furnished with lacings and applied and removed at will ; they lose thereby a part of their efficiency, as they may be improperly reapplied by the patient. But with careful parents and attention plaster jackets lose but little of their efficiency if they are carefully split down the front and removed before they dry. They should at once be placed in 68 ORTHOPEDIC SURGERY. the same shape that they were in before removal and tightly- bandaged to keep them from warping, as they will if let alone. In one way they gain in efificiency by being laced, because as the jacket becomes somewhat worn it can by tighter lacing be made to fit the back more closely. As applied by Dr. Sayre the present plaster jackets are split and laced, and by this they gain wonder- fully in cleanliness and comfort. The neatest and most acceptable form of jacket is one applied over a seamless woven shirt. These shirts are made very long and reach the knees; one of them is put on the patient and the jacket applied over it. The lower part of the shirt is then turned up Fig. 8i. -Beely's Felt Jacket with Double Jury-mast. Fig. 82. — Owen's Felt Corset with Head Attachment. over the outside of the jacket and reaches to the top of it. It is there stitched to the upper part of the shirt along the upper edge of the jacket. This, however, is not done until the jacket has been removed, by splitting it down the front and gently springing it open. The edges of the cut are stitched with leather and a row of hooks is provided on each side with which to lace it together. A jacket is thus provided, which is covered inside and outside with soft woolen material, which can be removed for purposes of clean- liness and reapplied to the patient, who should be, of course, sus- pended for each re-application. A plaster jacket is only ef^cient in disease below the seventh dorsal vertebra; if the disease is situated higher up than this the addition of a head piece is necessary. As a substitute for plaster jackets, corsets are made of leather,. POTT'S DISEASE. 69 felt, or glue. The plaster jacket, which is applied in the usual way, is removed with care, so as to preserve its shape. A plaster mould is taken, and on this as a form a corset is made of sole leather (which when wet can be stretched tightly over the form), by winding bandages or strips of paper soaked in silicate of potash or glue about the mould. Felt impregnated with glue has also been used. After this has be- come hard, it can be split and furn- ished with eyelets and lacings; it can then be applied on the patient, who is suspended, as in the application of a plaster jacket. The leather jackets for heavy patients need the reinforcements of strips of steel, which should be accurately fitted to the mould and firmly secured on the jacket. These corsets are more neat and more durable than plaster jackets, but require more time in their manufacture. The figure shows the leather jacket made and used by Dr. Vance, of Louisville. It is so simple in its manufacture and construction that it can be made by the physician if need be. Fig. 83.— Walsham's Felt Cuirass. Vance s Leather Jacket. -Cloth Corset. A cloth corset reinforced with wire and strips of steel has been used, and it has been found of relief and benefit in certain cases ; but when perfect fixation is required, the arrangement is not as reliable as firmer corsets. In the upper dorsal and cervical region, it is necessary either to add to the plaster jacket an appliance for securing the head (the 70 ORTHOPEDIC SURGERY varieties of which will be mentioned later), or to carry the plaster jacket over the shoulders and neck. A plaster collar applied simply to the neck, and not to the trunk, does not give, sufficient support except in disease of the upper cer- vical vertebra, though it has been occasionally used. The figures illustrate methods of supporting the head in cervical caries devised by Dr. Benj. Lee, of Philadelphia. . An antero-posterior support, devised by Dr. C. Fayette Taylor, is suitable for use in emergencies. It consists of several thicknesses Fig. 86. Fig, 87. Fig. 86 and 87. — Lee's Method of Suspension in Cervical Caries. of blotting paper, saturated in shellac and moulded to the patient's back. The shape of the paper should be similar to that of the back of a man's vest. When the shellac is dry, buckles can be attached. These buckle on an apron in front, and pad plates of blotting paper can be added inside. For permanent wear the jacket is not suitar ble. The shellac is softened by the perspiration. The jacket is, moreover, very hot and induces profuse sweating of the back, so that it requires constant repainting with shellac, without that it becomes soft, and unless it be carefully looked after, smells offens- ively. j'OTTS nisiCAsi-:. 71 In all forms of head supports, if worn for a long time, a cer- tain amount of recession of the chin takes place. The nature of this is not clearly understood, but the growth of the lower jaw is in a measure temporarily interfered with, and the front teeth in the lower jaw can in severe cases not articulate with those of the upper. The distortion results from the continued use of any form of head support, and is more liable to occur the more efficient the support. The jaw gradually resumes its shape after removal of the head support. Objections to the Plaster Jacket. — The theory of the plaster jacket seems founded upon a misapprehension, namely, that the deform- ity is partly obliterated by suspension. There is a certain amount of lengthening of the spine produced by thorough suspension, but it is obtained by the obliteration of. the physiological and compen- satory curves and not by any decided change in the outline of the deformity. The deformity is often greater when the patient is in the upright position than when he is lying on the face or suspended from a suspension appliance. Even if it were possible to distract the diseased vertebrae, it would not be desirable by this or by any other method, because it would separate the diseased surfaces and leave an angular gap be- tween them which must be filled by some solid material before any weight-bearing function could be resumed by the column. It is rather desirable than otherwise to keep the diseased surfaces to- gether if undue pressure can be overcome, though it is advisable to reduce the pressure from superincumbent weight as far as is possi- ble which crowds together the inflamed and softened vertebr^E. But suspension can be depended upon to modify the pressure between the diseased vertebra. Unfortunately, however, the plas- ter jacket does not of itself, by its hold upon the thorax, maintain a continued extension, but the jacket and the thorax so adapt themselves to each other that active suspension ceases. The jacket, however, does act as an antero-posterior support until it becomes loose and inefficient. The practical objections to the plaster jacket are : First. — It becomes loose and fits badly after being worn for some time, and furnishes at the best an inaccurate support to the diseased column. Every change in the size of the abdomen affects its bearing upon the back, and the size of the abdomen changes at every meal. One has only to examine a plaster jacket which has been worn for some time to see how loosely it fits in parts. Often, indeed, the hand can be inserted between the jacket and the chest. Second. — It is hot and dirty unless it is so made as to be remov- 72 ORTHOPEDIC SURGERY. able, and that requires considerable pains on the part of the sur- geon. Moreover, when a patient is careless, bread crumbs, food, and vermin find their vi^ay under the jacket. Third. — The jacket is very liable to chafe. Sometimes it causes deep ulcers under it. Especial pains should be taken to remove the jacket at once if the child should have an eruptive disease, such as measles or scarlet fever, for ulcers are very likely to form under it during these diseases. In a word, the theory of the jacket is based upon a misapprehension. It is in reality an antero-posterior brace which lacks much of being perfectly efficient, and it is dirty and hot and liable to chafe the skin underneath. But, on the other hand, it must be said that it is the best and most efficient mode of treating certain cases. When a lateral deviation of the spinal column is present with Pott's disease, the jacket is preferable to any brace. In disease which is very low down, the jacket is often a more efficient and comfortable mode of treatment. For careless and ignorant patients a jacket which is not removable is far preferable to any apparatus which they can misuse. Moreover, the cheapness of the jacket brings it within reach of many people who would otherwise have to go without treatment. The experience of an Italian surgeon, Motta,' is of interest with regard to the use of the plaster jacket. He has applied the Sayre jacket some 1,200 times and he reports most satisfactory results from its use. The time required for treatment was from eighteen months to two years. Treatment by Means of Braces. — Besides the objections to fixed plaster corsets mentioned, this adverse criticism may be urged, viz., that the back cannot be readily inspected nor the pressure easily altered from day to day, if the spinal column has become altered in shape or if the appliance has slipped. For proper treatment by fixation of the spinal column, it is important that there should be little or no forward and backward movement near the diseased ver- tebrae. To obtain this the spinal column should be made as nearly straight as is possible, and the trunk prevented from bending for- ward by means of backward pressure on the upper and lower part of the trunk, and forward pressure on the spinal column at the dis- eased point. It will be seen that if the corset slip, the back changes in shape, so that the pressure will come in such a way that the spinal column is pushed forward above the point of disease, and the appliance will then be an injury. A brace should work on the principle of a lever, the fulcrum being the diseased point of the ' Annual Univ. Med. Sci., 1889, Vol. iii., pp. 5-7. POTTS J) IS EASE. 73 spinal column, and the power should be applied so that the part above the diseased vertebrae is held back as far as possible, thus diminishing the inter-vertebral pressure at the diseased point. This is true, whether the appliance is a steel brace or a plaster corset, but the regulation and inspection of the fulcrum are more readily- attained in a brace, if properly constructed and allowing adjust- ment, than in a corset, the manufacture of which involves much labor. The construction and application of a brace should be superintended di- rectly by the surgeon. The details rel- ative to the future result are fully as important as the application of a splint in any fracture, for the result will, in a Fig. -Diagram of Antero-posterior Support ; Side View. Fig. 89. — Diagram of Antero-posterior Support ; Back View. great measure, depend on the accuracy of adjustment. For the construction of a splint a tracing of the back should be made. This is done as follows : The patient lies upon a hard surface, and a strip of flexible metal (lead or a mixture of lead and zinc) strong •enough to retain its position, and pliable enough to be readily bent, is laid upon the back, from the neck to the sacrum, so as to accu- rately fit the lines of curve presented by the spinal column. The lead is removed, laid on its side upon a piece of stiff card-board and the inner outline traced. This not only serves as a record, but can he used for a sfuide in the construction of the brace. 74 OR THOPEDIC S URGER V. Different forms of appliances have been recommended for the treatment of Pott's disease. The first efificient and thorough adap- tation of the principles of treatment by proper antero-posterior supports has been accomplished by Dr. C. Fayette Taylor, of New York. Since the use of appliances advocated by him some modifi- cations have been introduced, but the principles under which he worked have remained much the same. Fig. go. — Antero-posterior Back Brace of Ordinary Pattern. Fig. 91. — Brace with Band at Bottom instead of V piece; also applied with Swathe. The simplest antero-posterior apparatus consists of two uprights of annealed steel, three-eighths or one-half of an inch in width and thick enough to be rigid. The gauge numbers of the steel as to thickness should be eight to twelve. These uprights should reach from just above the posterior superior iliac spines to about the level of the second dorsal vertebra. The uprights are joined to- gether below by an inverted (J-shaped piece of steel which runs as far down on the buttock as possible without reaching the chair or POTTS niSlwlSE. 75 bench when the patient sits down. Or the brace may end in a waist-band, as is shown in the fij^ures. The uprights are joined above by another U-shaped piece, the upper ends of which should pass over to the anterior as^ject of the elevation of the shoulders, or rather to the root of the neck. The uprights should be far enough apart to support the transverse processes of the vertebra;, and not the spinous processes. They should be bent according to a cardboard tracing of the back, taken as described, and then adjusted to the back. The neck and bottom pieces should be cut out in cardboard in pattern. The whole should then be riv- eted together and tried on the patient, who should be lying on his face in the recumbent position. Any alteration nec- essary in the curves of the steel, in order to have the ap- pliance fit closely to the back along its whole length, can be made with wrenches. The brace can be wound with strips of canton flannel, faced with hard rubber, and covered with chamois, or be covered smoothly with leather. An accurate fit is essential, the covering is merely a matter of detail. Pad plates covered with felt or hard rubber, are needed. In some instances, at the points of greatest pressure (the fulcrum of the lever, etc.) the bars of the brace, if well pad- ■ded, answer every purpose. Buckles are needed at the ends of the neck piece, at a level with the axilla, opposite the middle of the abdomen, and at the lower end of the brace. If properly designed the appliance will press firmly at the ful- crum. I.e., the pad-plates and pressure should be uniform at this Fig. 92. — Antero-posterior Support Applied. Tavlor. y6 ORTHOPEDIC SURGERY. point and closely fitted to the contour of the curve. The appliance will also touch necessarily at the top and bottom, but the chief pressureshould be at the points designed as fulcrum. Variations from this type of construction will naturally be of use. The sim- plest is the following: Instead of an upright of a single piece to which a pad-plate is attached, an upright of three pieces may be used, the pad-plate being separate, and fastened to two steel strips extending above and below. This arrangement allows the sections to be taken apart and carefully adjusted, but is somewhat more complicated. Instead of the band at the bottom, a curved piece of steel is sometimes of advantage, in avoiding pressure in the middle of the sacrum and allowing careful adjustment. Nicety of work- manship in the manufacture of a brace is of relatively secondary importance. The essential is that it should be mechanically effi- cient in meeting the indications of fixation. The construction of the brace does not necessarily involve expensive workmanship, and need not be anything beyond the skill of a village black- smith. It should be borne in mind that, besides accuracy of fit and proper design, it is of importance that the apparatus be stiff enough so as not to yield as the weight of the trunk falls upon it, inasmuch as yielding involves inter-vertebral pressure. This is true not only of the uprights, but also of the band. A stiff appliance, if properly fitted, can be made as comfortable as a yielding one, and is much more efficient. . It is surprising how small an error in the direction of inac- curacy of fit will excite pain. Moreover, it is necessary that the patient should be seen often enough to keep the brace fitting ac- curately, for the deformity may increase or diminish at any time. In such a case the brace becomes inefficient. It is, of course, essential that the trunk be properly secured to the brace. This can be done by means of an apron, which covers the front of the trunk, the abdomen, and the chest, reaching from the clavicles nearly to the symphysis pubis. The apron is provided with webbing (non-elastic) straps, which are fastened into buckles attached to the brace. Padded straps, passing from the top of the brace around the arms, under the axillae, and attached to buckles in the middle of the brace, help to secure it; but the scapulae, being movable, cannot be relied upon alone to fix the trunk, and the apron must be furnished with straps at the top, which pass over the shoulders to buckles in the top of the brace. In adults it is often convenient to have the apron split down the front and provided with webbing straps and buckles. It can then be adjusted by the patient himself without touching the straps at the back which secure the apron to the brace. POTTS DISl'.ASE. 77 A useful addition in certain cases of dorsal caries is found in tlie use of Dr. Taylor's chest piece, which is shown in the fi^^ure. \^y means of hard-rubber pads a definite counter point of pressure is furnished at the upper part of the chest which keeps the brace closely against the back. The pads of the chest piece may be made Fig. 93. — Apron for the Antero-superior Support. of hard-rubber and fit in below the clavicles, where they cause no discomfort and restrict the chest movements less than the apron, beside affording more definite support. The brace should be worn day and night, and removed daily that the back may be bathed. While the brace is off, the patient should lie on the face or the back. On no account should he sit erect. The back, after being washed, should be rubbed with alcohol and then powdered with face powder, corn starch, or Pear's fuller's earth. The brace should then be applied and buckled tightly into place. Chafing of the back is some- times unavoidable in summer. When a severe chafed spot forms, the brace must be removed for the time and the child lie flat in bed until the ulcer heals. Dr. Judson formulates a gen- eral rule which may serve as a guide in the treatment of Pott's disease by rigid apparatus, espe- cially in all forms of the Taylor brace. The rule reads : " The apparatus maybe considered as having reached the limit of its effi- ciency if it makes the greatest possible pressure on the projection compatible with the comfort and integrity of the skin." Certain braces have a tendency to " ride up," and the neck pieces, instead of lying closely to the shoulders, project upward in a most Fig. 94. — Taylor's Chest Piece. 78 ORTHOPEDIC SURGERY. unsightly way. In general, this does not occur in braces which fit accurately. Sometimes, however, it is most troublesome, and in these cases padded perineal straps can be added which are attached to the apron in front and to the lower end of the brace behind. They are, however, a source of much annoyance to children, in urination especially, and are to be avoided if possible. The apron will sometimes be found to cut over the anterior-superior spines of the ilium and also under the arms, and must be properly padded. In applying the brace the patient should lie upon his face, and the apron be spread under him. The brace should then be placed in position upon the bare back, or upon a thin, smooth cloth per- mitting no wrinkles, and the apron strapped to it as tightly as is possible. The more tightly the two are strapped together, the more thorough is the fixation. The position of the straps and their number will vary in cases accord- ing to the situation of the disease, etc. By means of wrenches and a vice the uprights can be bent so as to secure pressure in the proper place, and a proper adjustment is not difficult. A troublesome complication in the use of the antero-posterior brace is the presence of a late- ral curve in the vertebral column, this has been m.entioned as an oc- -Cocking's Poro-piastic casioual Complication of Pott's acket with Jury-mast, ^igease. The bracc fits when the child lies down, but when he sits up, the column leans to one side again, and it is of course impossible for the brace to fit as before. Fortunately, this symptom passes slowly away as ef^cient support is afforded to the column, and then the brace fits again. Mean- time it is best to apply the brace, bending up one neck piece and bending the other down to make the top of the brace set squarely; it is also best to keep the patient in a recumbent position as much as possible until the deformity improves. The application of the therapeutic principle of fixation in the best possible position varies according as the disease involves the upper, middle, or lower parts of the spinal column. In the upper region, as elsewhere, it is desirable to prevent the Fig. 95. — Nebel's Jury-mast. POTTS /) IS /CASK. 79 weight of the head from falling upon the diseased bodies of the vertebrae. This can be done in the cervical region by suspension in a sling, similar to that used in ordinary suspension for the appli- cation of plaster jackets. The sling passes under the chin and occiput, and is connected by means of straps to a bent rod, which arches above the head and is bent around the head and neck, being attached below to a plaster, felt, leather, or wire corset. The jacket is kept from slipping down by means of pressure on the hips, if the hips are large enough (which is rarely the case in chil- FlG. 97. Figs. 97 and Beely's Felt Jacket — Cervical Caries. dren), or by means of straps passing over the shoulders; the weight of the head is thus transferred to the shoulders or hips. The amount of pressure under the chin and occiput would in some in- stances be such that it would be impossible for the patient to open his mouth; but a reduction of the weight of the head on the cer- vical vertebras is easily effected in this way, Avhich also prevents the head from bending forward. A thoroughly efificient arrangement is one used by Dr. C. F. Taylor, of New York; an ovoid steel ring passes around the neck, made so that it can open, and be secured when closed, and ar- ranged so that it can serve as a rest for the chin, and so that pres- 8o ORTHOPEDIC SURGERY sure can also be exerted on the occiput. This collar at the back plays on a pivot, allowing lateral motion of the head. The pivot is attached to the usual back-brace, and can be raised or lowered, as it is desired to increase or diminish the upward pressure on the head. The back-brace should be supplied with pad- ded cross-pieces, which will effect counter- pressure on the shoulders. This appliance requires care and skill in application, and is useless unless properly fitted. The problem of supporting the head in cer- vical caries is always a difficult one to solve. The brace just described is an apparatus which is fitted only with much trouble and which easily transfers so much. of its weight to the shoulder pieces that chafing is inevitable. Other forms of head support have been tried from time to time. Some of them have been useful. The one shown in the figures is a continuation of the two uprights Fig. 99. — Head-rest for An- tero-posterior Support. Fig. 100. — Antero-posterior Brace with Taylor Head-piece. Fig. ioi. — Antero-posterior Support Applied. on the back of the head. By the head piece the head and neck are held firmly back against the forks of the brace. It is a service- POTT'S J) [SEAS E. 8i able brace when there is considerable deformity in the back of the neck or the head tends to fall backward, as it sometimes does. The chief objection to it lies in the fact that it is a m(jst difficult mat- ter to so shape the forks that they will follow the outline f;f the head and not be painful by undue pressure upon any one point. A separate chin rest of the pattern seen in the figures is often used. It consists simply of a bent wire stout enough to support some weight and a tin pad plate bent to fit the curve of the chest. ■;?=»«i Fig. I02.— Front View of Antero-posterior Support for Cervical Canes, Showing Apron. It is adjusted by straps running to the brace under the arms and above to the ends of the neck-pieces. It is worn with the ordinary steel antero-posterior support, and is a very useful and inex- pensive addition in cases where the chin tends to drop upon the chest, in cases of cervical caries, or in high dorsal caries, where a support to the head seems indicated. A brace has been devised by Dr. J. E, Goldthwaite, formerly House Surgeon at the Children's Hospital, which affords most ex- cellent fixation in cases of cervical caries. Its construction is evi- 6 82 OR THOPEDIC S UR GER V. dent from the figure, and it seems likely to be serviceable in cases where there is excessive sensitiveness of the spine. Collars of various sorts, unattached to any other appliance, have been used, which, pressing on the chin and occiput above, and on the sternum and shoulders below, transfer the weight in part from the intermediate cervical vertebrae and check the forward bowing of the cervical region. These collars can be made of plaster of Paris, but are cumbersome and unsightly; leather collars, stuffed Fig. 103.— Form of Head Support for Cervical Caries. with sawdust, as used by Mr. Thomas, of Liverpool, will be found more convenient. A convenient way of making these collars of Mr. Thomas is by taking a piece of stout webbing, long enough to go loosely around the neck, and winding it with sheet wadding or oakum until it is padded sufficiently. Then it should be covered with a bandage outside and the ends of the webbing should be buckled together. The patient wears the collar a few days and then as the padding becomes matted down, new padding is added, until the collar is the desired size and shape. It is then sent to a harness maker to be covered with leather. In this way a much more satisfactory re- sult is obtained than by sending measures to a harness maker in the first place. A collar made of wire netting, moulded to the shape, and rein- POTT'S PfSlwlSli 83 forced by strips of steel, is much more sightly. This collar was devised by Dr. If. L. liurrell, of Boston. It is made of li^dit brass gauze netting and paper patterns cut of a];j)roximately the re- Fig. 107. — Thomas's Leather Collar, Fig. ioS. — Fonn of Head Support for Cervical Caries. 84 ORTHOPEDIC SURGERY. quired size and shape. Then the netting is shaped to the neck in two pieces and sent to the instrument maker. When completed it buckles arouiid the neck, and is useful either alone or as the head piece to a modified brace, as is shown in the figure. Collars, however, lack in steadiness, and, in order to secure ac- curate fixation of the head, they should be connected with uprights which extend below and are attached to the trunk. The combina- tion of a collar and Taylor back brace may be seen in the figure. • It is hard to say just when the need for a head support begins. Fig. 109. — Back View of Head-rest. Fig. no.— Head-rest for Transferring the Weight of the Head to the Shoulders in Cer- vical Pott's Disease. In general, if the disease is above the fourth dorsal vertebra, a head piece is indicated. Sometimes, if the disease is lower down, pain makes it evident that a head support is needed there also. In the lower cervical and upper dorsal region it is difficult to apply suspension efificiently or to fix the spine completely, and the treatment of caries of the spine in this region requires particular care for the arrest or prevention of deformity. The means to be used are the same as those employed In cervical caries. The mechanical treatment of disease in the middle region is quite satisfactory; the principle of leverage can be applied with thoroughness, and excellent results obtained. POTTS DISEASE. 85 In the lowest region — i.e., in the lumbar region — it is difficult to prevent entirely the forward bending of the spinal column, and in severe cases absolute recumbency is the best treatment; but ex- cellent results are often obtained by the mechanical treatment alone of these cases, for the reason, probably, that the bodies in the lumbar regions are large, and in some cases but a relatively Fig. III. — Burrell's Brass-wire Collar. Fig. -Burrell's Wire Collar Attached to Antero- posterior Support. small portion may be affected. The reconstruction of bone is more readily established, and all that is needed is a certain amount of mechanical support ; the applicance should reach as low as is possible. It will be found that the lateral deviation observed in caries of the spine, unless well-pronounced change in the shape of the ver- tebrae has taken place, will disappear without difficulty under an efficient antero-posterior support. 86 ORTHOPEDIC SURGERY. H. L. Taylor gives nine cases where recession of the deformity- has taken place under treatment by the Taylor back-brace. He states, first, that " the average ultimate result in Dr. C. Fayette Taylor's private practice, using his antero-posterior leverage sup- porting and protective apparatus, thoroughly and for a sufficient length of time, has been, under favoring conditions of attendance and home attention, the definite arrest of the deformity at, or near the point it had reached before such protection was furnished." In certain cases, however, he notes that the deformity will increase in spite of all care. The straightening of the curved back to which he refers, is not merely the obliteration of the compensatory curves, but a real diminution or disappearance of the angular projection. The cuts that accompany his article show that plainly enough. Of the nine cases, one was dorsal disease, three were dorso-lum- bar, five were lumbar entirely. In five, the knuckle completely disappeared, while in the others the improvement was very marked. The time for disappearance ranged from three to ten years after the beginning of treatment. The case of dorsal disease recovered wholly. The cases are given in full in the article. The chief objection to the use of mechanical appliances as a method of treatment is, that care and special skill are required, not only in the application of braces, but in the inspection and manage- ment of the case. Faulty Appliances. — Unless an appliance works in the way the indications of the disease demand, it is inefficient, and it is on ac- count of faulty construction that appliances have often been found of so little use. A most common fault is that, in order that the appliance may be light, the steel uprights are flexible and give under pressure. It is evident that any appliance which allows bending forward of the spine at the point of disease does not re- lieve the pressure when relief is most needed. A second fault is that the trunk is often not thoroughly fixed by the straps, etc., of the appliance. If this is the case, the brace becomes simply a frame of steel laid upon the back, and not a therapeutic agent. The exact situation of straps must vary; they should, however, make pressure as high up and as low down on the trunk as possi- ble. If elastic straps are used, the value of the appliance is im- paired in proportion to the elasticity. It is of the greatest importance that the fulcrum of the brace should be applied to the right portion of the spine. It is not neces- sary that the uprights should be applied closely to the whole back, but it is important that at the point of the disease, and for some distance below, the pressure should be thorough, indicating that as POTT'S J)ISI<:ASE. 87 the appliance is worn but little motion of the spine at that j;oint is possible. The pad-plates should be arranged so that they may make pressure on each side of the spines, as near as is feasible to each other; pressure directly on the spines cannot be borne. The use of a crutch attachment to a brace is very common, and originated from the fact that patients often lean upon tables, or support themselves on their arms. To be efficient, a crutch should have a firm base, but, attached as it is to a steel waist-band, it af- fords no certain support, and is therefore of doubtful advantage. If a crutch is to be used, it should reach to a firm base, as the floor. Ordinary crutches (a wheel-crutch) act in this way; but the pelvis of a child is too small to furnish a steady base. If the brace is too long below, the patient will sit upon the ends when he sits down and force it up at the neck. Objections to the Steel Antero-Posterior Support. — Although the brace is one which can be made by any blacksmith, the directions for its construction and its application after it is made require a definite knowledge of its structure and uses on the part of the sur- geon. It is not an apparatus which can be bought of an instru- ment maker: it must be made for the individual case. Many braces are furnished by the stores which in outward appearance resemble this apparatus, but either fit so badly that they are of no value or are entirely wrong in the principle upon which they are constructed. Often the uprights are made of tempered steel and are so elastic that they furnish no fixation whatever to the diseased vertebrae. The utmost care in the fitting and use of the brace is demanded both on the part of the surgeon and the parents. The brace can be fitted easily with two monkey wrenches, but it requires a certain amount of painstaking. On the part of the parents, the brace must be daily applied with care and the patient must be watched to see that the straps are kept constantly tight. The back of the patient must be carefully looked after to prevent chafing, which is sure to occur in the careless use of the brace. Chafing often is, inevitable in children with tender skin, but much can be done to prevent it if the back is washed daily, rubbed with alcohol and kept carefully powdered during warm weather. Selection of a Method of Treatment. — In the selection of mechani- cal supports the choice will lie between some of the fixed corsets of plaster of Paris (or the variations of that form of corset fixation) and the antero-posterior supports of steel. The experience of the writers would lead them to prefer the type of appliance classified as the steel antero-posterior support whenev^er its use is practicable. Some skill is required in the adjustment of appliances of this sort, 88 ORTHOPEDIC SURGERY. but not more than can be readily acquired by a short experience with this class of cases. The great advantage of the antero-pos- terior support is that it can be more accurately adjusted to the back and kept fitting more efificiently. It has been said that the steel supports are not ap,plicable to the treatment of the ambulatory class of patients, such as is seen at hospital clinics. The experience at the Boston Children's Hospi- tal does not support this view. Plaster jackets, which were formerly much used there, are being discontinued in most cases in favor of the more adjustable steel appliances. In this class of cases it has been found possible to secure in most instances the intelligent use of the antero-posterior support. The chief difificulty is to obtain the frequent attendance of the patients, so that the brace may be carefully looked after and made to fit the back. The plaster jacket is, however, often within reach in practice when it is impos- sible to obtain a brace. It is an efificient apparatus, moreover, and gives much relief. In this, as in all other questions of surgical methods, much de- pends upon the surgeon's facility. A surgeon whose acquaintance with surgical appliances is simply such that he is able to direct his patient to an instrument maker who can sell the most marketable in- strument, will hardly have successful results from mechanical treat- ment. If he has more acquaintance with the application of plaster corsets, they would prove preferable in his hands. A slight amount of experience, however, will be sufificient to enable him to familiar- ize himself with the principles of thorough mechanical treatment by proptr appliances. The circumstances of the parents will often determine the choice of a method of treatment, inasmuch as they may be unable to bear the expense of even a cheaply made antero-posterior support. In these cases it is evident that one must use plaster of Paris, and with plaster of Paris a perfectly good result is to be obtained. If recumbency is necessary in such cases, a cheap oblong bed- . frame can be made out of light gas-pipe and covered with cheap cloth, and the expense is insignificant. In this way the proper treatment of Pott's disease can be brought within the reach of even the poorest of families. The choice- of the proper head support and the judgment as to when a support is needed are both difficult in certain cases. In general, when the disease is above the fourth dorsal vertebra, some form of head support is always indicated, and often in cases when the disease is situated a little lower down, as at the sixth or the seventh dorsal vertebra, some head support is usually of much benefit, especially if the deformity is a large one. roTT's j)isi-:ASii. 89 The so-called jury-mast is efficient as a cliin and head su[Ji;ort, but it is unsightly, and patients are anxious to be freed from it in upper dorsal disease, earlier than is desirable. Less unsightly but more dif^cult to adjust is the Taylor oval ring. This latter can be made a most efificient appliance. A Thomas collar is more readily adjusted and is cheap ; it answers admirably in cases of cervical disease. When there is a tendency to throw the head backward, a high rest at the back of the head is desirable. If the opposite ten- dency is present, a wire chin-rest, such as has already been described, is advisable. The choice of treatment in a given case, the need of recumbency during the severest stages, and fix- ation in a recumbent position (which may be temporarily necessary), fol- lowed or supplemented by the ap- plication of mechanical supports — must all be a matter of judgment. When recumbency is needed it should be thorough, and this is not simply done by placing the child in bed. No superincumbent weight should be allowed to fall upon the unprotected spine, and the appli- ance or corset should be worn night and day. Having had a somewhat ex- tended experience in the treatment of Pott's disease by both the plaster jacket and the antero-posterior support, the writers are desirous of expressing their preference for the latter in all cases where it is obtainable, except in some cases of low dorsal caries and in cases with a serious lateral deviation of the column, as previously explained. In saying this, they do not intend in any way to throw discredit upon the plaster-jacket treat- mnt, which is a very efficient one and only suffers by comparison with a more efificient method which is to be found in the antero- posterior support. Fig. 113 — Plaster Jacket with Jury-mast Applied. Treatment of Complications. Abscesses. — Lumbar and iliac abscesses constitute a most formid- able complication in caries of the spine, even more so perhaps than psoas abscesses, as the possibilities of dangerous rupture are greater, 90 OR THOPEDIC S UR GER Y. and the future course more uncertain. They present a mass of tuberculous matter, which either remains permanently in the body, a source of possible future tuberculous infection, or they extend, bursting internally or through the skin, in the latter way often ex- posing the patient to the danger of septic absorption through the imperfect drainage of a large cavity. The frequency of pelvic abscess is shown in Michel's figures. Out of forty-eight cases he found thirty-nine in the pelvis (" Nouveau diet, de med. and chir.," and Parker, Brit. Med. Journal, Jan. 12th, 1884, P- 78), in an examination of eighty-two dorsal cases, twenty- one dorso-lumbar, and thirty-seven lumbo-sacral cases of caries of spine, he found that there were abscesses in eight per cent of the dor- sal cases, thirty per cent of the dorso-lumbar, and in seventy per cent of the lumbo-sacral. (See also Lachaniere, Boston Med. and Surg. Journal, April 24th, 1884, p. 397.) This may fairly illustrate the fact that the problem of the treatment of iliac abscess is one frequently presented to us. Exactly in what way the question should be met is well worthy of discussion, as authorities range from the point of view of ex- treme expectancy and conservatism to that of early and radical operation. Treatment of the spinal column, fixation, and relief of interver- tebral pressure will always be regarded as essential, and in many cases will be sufficient to promote the absorption and disappear- ance of the abscess. Whether this takes place will depend in all probability on the amount of injury that has been done to the vertebrae before treatment was begun, the extent of the lesion of the bone, the size and contents of the abscesses, whether they are chiefly caseous or contain bony sequestra, or whether the propor- tion of serous fluid is large. Even if absorption does not immedi- ately take place, the mass may become encapsulated and be appar- ently of little account except as a threat. But frequently, as is well known, such abscesses extend, burst, and give rise to much trouble. Expectancy offers a thoroughly recognized method of treatment, well sanctioned by authority, and backed by excellent results in many cases. One of the most noticeable of these was presented by a young gentleman of twenty, who had been a patient of Dr. C. F. Taylor, of New York. His Pott's disease began when he was a child of three, and for a number of years he was under constant treat- ment. At the time that the writer had an opportunity to examine him he was twenty years of age, and had for several years been free from any symptoms of his disease and was apparently entirely well. He had been without a support for the spine for some time. There ]\)TTS J) IS EASE. 91 was a kyphotic projection in the middle dfjrsal region, and healed cicatrices in botii groins — the remains (jf five successive sinuses which followed double iliac abscesses. He was in good flesh and health. The abscesses had opened themselves, and the sinuses had remained open for years, but had finally closed and had remained so continuously for a long time. Abscesses may, however, be absorbed even after they have pre- sented the signs of fluctuation and have appeared as distinct swell- ings, as in the following case seen by the writers. A boy of five presented Pott's disease in the lower dorsal verte- bras and a fluctuating swelling in the right groin, with the charac- teristics and accompanying symptoms of iliac abscess of a small size. It was decided by the mother not to undertake any treat- ment, and he was not seen until four years later. According to the mother's statement, the swelling in the groin increased grad- ually and descended down the thigh, but finally grew smaller and disappeared. At the time of the second examination the boy presented the usual appearance of a patient who had recovered from a case of Pott's disease : i.e., a rounded kyphotic projection and small stature. No trace of an abscess could be found. It cannot, however, be inferred that absorption or encysting of a large abscess is the rule, either with or without treatment. Cases hke the following are unfortunately not exceptional: J., a girl aged sixteen, of good flesh and apparent health, but Avith a distorted hip, from a hip disease of early childhood, presented signs of lower spinal caries, and developed a left inguinal abscess, which after- ward became a psoas abscess, and finally burst, giving rise to hectic and eventually death from septicaemia and exhaustion. In how many cases expectant treatment may be relied upon as safe and in how many the result is disastrous, it is impossible to state, as statistics, are wanting. We may, however, accept the statement of Treves, that the most frequent cause of death in Pott's disease is from abscess and its sequelae. (See " International Ency- clopaedia of Surgery," art. Pott's Disease.) In fine, it will be readily admitted that the treatment of abscess by expectation has its limits. The methods of treatment, apart from that of expectancy, are : 1. That of repeated aspiration. 2. That of injection of fluid to promote absorption. 3. That of incision. The former wall be found to be unsatisfactory in many cases, for the reason that the aspiration does not remove the caseous clots, but only the serous and sero-purulent fluid — the least dangerous 92 ORTHOPEDIC SURGERY. part of the contents of the abscess, and that easily renewed by subsequent effusion. It is probable that aspiration favors absorption. Repeated as- piration, in weakening the wall of the abscess at one point, favors pointing and discharge where absorption does not take place. In regard to the question of the cure of an abscess by the injec- tion of fluid, there is but little as yet definitely known in cases of large abdominal abscesses, as the method has been in use but a comparatively short time. Hyperdistention with carbolic-acid solution, proposed by Mr. Cal- lender, is dangerous from the possibility of carbolic-acid poisoning. The writer recorded a death in a boy of five after washing a small cold abscess from hip disease with a few ounces of one to forty solution of carbolic acid. {Bost. Med. Journal, 1880, Vol. VII., p. 578; Frankel, Wien. Mediz. Woch., 1884, p. 34; Vincent, Med. Press, aud Circ, 1887, Vol. XXIV., p. 529.) Whether iodoform or corrosive sublimate or sulphurous acid can be used w^ith safety, is not yet decided. If, however, there is dan- ger, in all probability in iliac and lumbar abscesses it will be at its greatest, owing to the sinuous channel and pockets of these ab- scesses, and the liability of retention of a larger quantity of injected fluid than was intended. The question of incision would theoretically be easily answered. An abscess is an abscess wherever it is situated — a source of dan- ger to the patient. When it is not absorbed, it should be incised and the contents evacuated. In opposition to this aphorism we have the teachings of the older surgeons, which come to us as a tradition, that large cold abscesses are to be left to nature; the manifest dread most sur- geons seem to have in opening a large pus cavity ; and the fact that experience in many cases of incision would show that opening the abscess would sometimes appear to be injurious and in fact to hasten death. This dread has been materially diminished since the introduction of antiseptic surgery, but even under careful precau- tion it is difficult to guard for months against possible sepsis. And in many of these cases of lumbar and iliac abscess it is impossible to obtain primary intention, as it is impossible to reach the origi- nal focus of disease. Cold abscesses from caries of spine differ from cold abscesses elsewhere in this, that, to reach the surface of the body, the chan- nel is long and often tortuous. It follows from this that the exter- nal appearance of the abscess may give no indications of the state of the original disease, or of the existence or non-existence of sacs along the course of the channel leading to the original caseous. POTT'S J )I SKA si:. 93 lesion of the spine. These sacs may be entirely separaterl by layers of fascize, except perhaps through a small opening found with difficulty at the time of operation; and in evacuating one the other may be imperfectly drained. In certain cases, therefore, the incision of the abscess at the surface is not followed by relief, and may be the prelude to the patient's decline and death. In many cases where the abscess is quite thoroughly localized, the incision is little more than the lancing of a boil. The abscess has worked its way thoroughly to the surface, and the channel connecting the abscess with the spine is closed or nearly closed, and the original point of disease in the vertebra is in a quiescent stage. The matter is an entirely different one when we are dealing with large abscesses projecting into the abdominal cavity, and which may be termed abdominal abscesses. These may not differ in ap- pearance, under inspection or on palpation, from perityphlitic ab- scesses or other collections of pus underneath the peritoneum and pressing into the peritoneal cavity. A certain number of these abscesses remain encysted, and occa- sion no trouble. Others end in a spontaneous rupture, bursting in various directions. The overflow comes to the surface of the skin or intestine, discharges, and leaves a sinus, which may heal, per- haps, or remain with a slight discharge. The main body of the abscess has meanwhile discharged its overflow in another direction, leaving another sinus, and so seteral sinuses are formed. In some instances, following the abscess in one groin, a second may appear in the other, — two outlets from the central abscess around the dis- eased vertebral bodies. The spontaneous rupture into the rectum or intestine is not often the occasion of any disturbance; and in some instances the abscesses have entirely evacuated themselves in this way, and given rise to no further disturbance. The records of the autopsy-room, however, show that so fortu- nate a termination is by no means the rule, but it is easy to see that the termination of the case is largely iniluenced by the size and character of the abscess which is present. As it will be readily admitted that in certain severe cases treat- ment by expectancy in large abdominal abscesses is followed by disastrous results, there is no need of argument in favor of pre- ventive measures, if any may be regarded as effective and safe. Free radical incisions have been advocated by Konig, Treves, Andrews, and others, and in many cases are strongly indicated on account of the serious symptoms which the abscess may set up by the effects of its pressure. Lacharriere has collected twenty-eight cases treated by antisep- 94 ORTHOPEDIC SURGERY. tic incision dressed with strict antiseptic precautions. Of these five died, fourteen were healed without sinuses, and in nine the result was uncertain. Twenty-one cases were treated by curetting the abscess ^alls, and of these two died, fourteen were healed, and in five sinuses were left. This latter procedure is not possible ex- cept in abscesses of the lumbar region and of the back. In psoas or iliac abscess such a treatment is not only not always possible but in certain cases dangerous. If an operation is done with proper precautions it is attended with no risk of sepsis. It is not to be expected, however, that simple incision and drainage will close the abscess in most cases. On the contrary, their tendency is to discharge almost in- definitely, and this must be borne in mind in advocating operation where it is not urgently indicated by pressure effects and the dis- tention of the abscess. Very often an abscess which has advanced so far as to appear as a swelling in the groin may be opened in the back and no second opening may be necessary. An incision is made along the side of the lumbar vertebrse just outside the transverse processes and carried down through the quadratus lumborum muscle until the abscess sac is reached. It can usually be distinguished without difficulty and is made tense by pressure in the groin. It is evacu- ated by an incision at the bottom of this wound and perfect drain- age is secured. In opening the abscess in this way at the seat of the disease it may be possible with a curette to remove a part of the diseased body of the vertebrse. This, however, must be done with very great care. To be of any use it must be thorough. A retro-pharyngeal abscess is best opened by passing into the mouth a bistoury wound to within half an inch of its point with cotton, and cutting freely, using the finger as a guide. The child should be held face downward in order that the pus may not enter the trachea, and plenty of swabs should be at hand to keep the mouth clear, for the gush of pus is sometimes considerable. When the abscess bursts. into the lungs or the intestines, there is nothing to be done beyond the usual expectant treatment. Treatment of Psoas Contraction. — When flexion of one or both thighs has come on, it is not likely to diminish spontaneously, and if the deformity is allowed to go untreated, such contractions are formed that the condition may become permanent. A permanent contraction of one or both psoas muscles with the thigh flexed is a serious deformity. If it exists on both sides, the patient can walk only with the trunk held nearly horizontal. If it is unilateral, it leads to a very serious disability, requiring in most j'OTTS j)isi-:asI':. c/y cases the use of a crutch, for the spine cannot be flexed to allow the foot to reach the ^n'ound in walkin^^ as it docs when right- angled flexion of the thigh exists as a result of hip disease. For these reasons it is desirable to attack psoas contraction with very vigorous measures, which afford a prospect of averting any perma- nent contraction. In the early stages the child should be put to bed on a frame. A light extension should be applied to the leg, and the jjulley should be gradually lowered until the leg is straight and the flexion gone. In cases where the flexion has only existed a few weeks or months, this is generally easily accomplished in one or two weeks. If not, or if a more rapid method is desired in the first instance, the child should be anaesthetized and the leg straightened by force and retained by plaster of Paris or some retentive apparatus. If this cannot be done with the use of moderate force, it is better to divide and cut the fascia and the contracted bands — an operation which cannot often be done thoroughly subcutaneously, for there are many deep bands. The deformity is almost sure to return if the patients are allowed to go about, and they should either be kept on a frame, or an arm should be extended down from the brace or the jacket to keep the thigh fully extended. Finally, subtrochanteric osteotomy may be necessary in severe cases, but it should not be applied until after recovery from caries. Paralysis. — ^The treatment of paralysis is at present chiefly expec- tant. Medication is that employed in meningitis and compressive myelitis. Ergot, iodide of potash, bromide of potash, strychnia, physostigma, have been used and recommended; local application of blisters, cautery, ice, hot water, have been recommended, and the use of the cautery is especially advised by neurologists. The natural course of the paralysis is toward recovery, and in many cases this comes unexpectedly; so that a careful estimate of the effects of different agents is difficult. Recovery takes place in a large majority of cases under any treatment, but it is hastened and made almost sure by the early adoption of efficient mechanical measures. The actual cautery is a tradition of the neurologist, based on theoretical grounds and founded on improvement noticed in a few cases. In view of the very satisfactory results obtained without the use of the cautery, so barbarous a means should not be em- ployed, unless supported by stronger claims than can at present be urged. It is, however, best to put the patient at once upon his back, as in this way the full development of the paralysis may be prevented g6 ORTHOPEDIC SURGERY. and its course shortened. Gibney ' and others recommend iodide of potash in large doses for the treatment of this form of paralysis, but the writers have not seen any noticeable benefit from its use. Recumbency and extension by weight seems at times to hasten recovery. Operative Treatment of Potfs Disease. — It is only within a few years that the possibility of direct surgical interference in Pott's disease has been considered. Israel/ in 1882, in opening an ab- scess in the lumbar region of a patient thirty-four years old, with scoliosis persisting since boyhood and suddenly accompanied by paralysis, found extensive disease of the bone. He resected a diseased portion of the twelfth rib, and scraped out the carious portion of the diseased vertebral body, penetrating into the verte- bral canal, from which a quantity of pus discharged. The patient did well for five weeks, when an empyema resulted and death fol- lowed. The operative interference had no effect upon the paralysis. Some years ago Mr. Treves read a paper advocating direct inci- sion in cases of lumbar caries and in certain cases of dorsal caries where collections of pus have formed. A vertical incision is made near the outer edge of the erector spinae muscle ; the sheaths of that muscle and of the quadratus lumborum are cut through; the psoas muscle itself is incised and the vertebrae are reached by con- tinuing the operation along the deep aspect of that muscle. The vertebrae can then be inspected and any diseased bone removed. Treves 3 reported three operations, after all of which the patients made a good recovery. Since then the field of operation has been somewhat extended. Podres" cut down upon the vertebral column in a case of cervical caries Avhere there was evidence of a deep collection of pus. He made an incision of two inches along the posterior border of the sterno-mastoid muscle and then with a blunt instrument followed up the brachial plexus until he reached the vertebral column. The sixth and seventh cervical vertebrae were found superficially ulcer- ated. The abscess was curetted and the wound dressed aseptically. A sinus remained for six months and the vertebrae had to be curetted again; after that the wound healed. Boeckel, Reclus, Ashhurst and others have since practised the plan of cutting down on to the diseased vertebrae and removing as far as possible the carious bone with a gouge or Volkmann's spoon. As a rule the results of the operation have not been successful, the * Medical Record, October 24th, 1S85, p. 453. = Berliner klin. Woch., 1882, No. 10. 3 S. Treves, Brit. Med. Journ., Jan. 12th, 1884. 4 Podres, Cent. f. Chir., No. 38, 1886. rOTT'S J) IS EASE. 97 benefit in most cases bcinj^ only tcmpcjrary and tlie outcome nrjt uncommonly fatal. Practically the bodies of the vertebrae are very hard to reach except in the lumbar region, and when once reached the accurate and thorough removal of the diseased tissue is a prob- lem of much difficulty. Removal of the Lmnincc for the Relief of Pressure Paralysis. — The operation of laminectomy, or trephining of the spine, is one which to-day excites much interest. It is undertaken for the relief of pressure upon the cord, and although it is still in its early in- fancy, it is an operation which seems likely to come more widely into vogue, temporarily at least, so that it is worth while to inquire somewhat carefully into the present status of the operation. The excellent articles of Dr. Willard ' and Dr. J. W. White ^ on the sub- ject have been largely drawn upon by the writers in presenting the subject. The tolerance of animals to operations upon the spinal column was shown by the experiments of Maydl,^ who found that it was possible to cut down upon the cord, suture the dura, and even resect the cord without killing many of the animals. He was led by these experiments to operate successfully upon a case of trau- matic Pott's disease in a man twenty-six years old. In this case he removed the arches of the ninth, tenth, and eleventh vertebrae and thus relieved the pressure upon the cord. To Macewen undoubtedly belongs the credit of resuscitating the operation of systematically searching for and removing any exist- ing lesion, although from the time of ^Egineta, Bell, and Cooper it has been discussed. Only a few years since it was denounced as unjustifiable.'* Macewen justly claims that he has demonstrated that " the spinal membranes and the cord itself can be exposed, and that neoplasms and encroachments upon the lumen of the canal may be removed therefrom without unduly hazarding life. The old objections that such operations were full of danger from hemorrhage and were unprofitable and unsuccessful, have certainly been thoroughly disproven, and we are now able to offer a measure of success to a class of hitherto hopeless cases." = The operation consists in cutting down upon the spinous pro- cesses in the region of the deformity, the incision being slightly to one side of the centre, so that the resulting cicatrix will not be unduly pressed upon during recumbency. All the soft tissues are then stripped bare with a periosteal knife, until the entire lamina is exposed. One-half or the whole of the arch may be removed as ' De F. Willard, Trans, of Coll. of Phys. of Phila., March 6th, 1SS9. " Annals of Surgery, July, 1889. 3 Wiener Med. Presse, 1S84., 42. 't Ashhurst's " Encycl. Surgery," vol. iv. s British I\Ied. Journ., Auo-. nth iSSS. 7 g8 ORTHOPEDIC SURGERY. necessary, but even an opening upon one s>ide gives ready access to the canal. A half trephine, a saw with cutting edge upon its convex surface, a chisel, or a pair of angular cutting bone forceps or rongeur forceps may be used for making the section. When cut through the lamina can be lifted off, and then the . theca lies exposed. Sometimes the cord can be seen pulsating in its bony canal; again, it lies shrunken. If the pressure has been due to an inflammatory growth, the connective-tissue neoplasm may be dissected away with scissors from the theca, or the latter may require removal with the growth. Should the pressure have been due to bony growths, the ossific material will probably lie in front of the cord and should be searched for as far as safety permits, the cord being lifted with a blunt hook. All discovered portions of dead bone should be re- moved, and thorough drainage secured laterally, if possible. Even when the anterior bony projection can be neither discovered nor removed, the pressure upon the cord will be very greatly relieved, by the freedom allowed to it for expansion posteriorly. Much of the benefit derived from the operation is doubtless due solely to this relief of pressure. Erosion of diseased bone should be prac- tised, if possible, and the most thorough antiseptic precautions during operation and in subsequent dressings observed. The su- perficial tissues should be sutured separately from the deeper ones. Hemorrhage may be controlled by pressure forceps, by ligation, or by packing with iodoform gauze. Immediate improvement is not to be expected. In one of Macewen's cases motion was first noticed on the eighth day, in another it returned much more slowly. Macewen operated May 9th, 1883, on a case of sensory and motor paralysis with incontinence of urine and feces, removing three laminae. The patient made a brilliant recovery. His series of cases includes four others, two of which were successful. Horsley has operated on a large number of patients already, but only reports one case as yet where shortly after operation the paralysis was disappearing. Abbe ' reported a case of extra-dural tumor of the spine (which White interpreted as a case of Pott's disease) where slight improve- ment followed operation. Mr. Wright^ has recently attacked a case of dorsal Pott's disease by this operation, in the hope of relieving a severe and progressive paralysis. The disease was in the mid-dorsal region and an incision was made over the spines along the angular prominence. The ^ Medical Record, February gth, 1889. = Wright, Lancet, July 14th, 1888, 64. POTTS DISEASE. 99 laminae on each side were divided and with their spinous processes were removed, exposing the cord, which was found surrounded by a buff-colored, tough, leathery substance. This was cut away with scissors and the muscles and skin brought together over the wound. Healing took place by first intention and slight temporary im- provement followed, but the patient soon fell back to the same condition in which he was before operation, and this condition persisted. The most recent and one of the most successful operations upon the diseased vertebrae is the one reported by Lane [Brit. Med. /ourna/, April 20th, 1889) in which a paralysis from mid-dorsal curv- ature improved perceptibly within four days of the time of resec- tion of the laminae, and in a month the boy was moving his legs freely and had improved very much in his general condition. At the time of operation the boy was seven and one-half years old and had had the curvature between one and two. years, and the paraly- sis for several months. Duncan reported in May, 1889 {Edin. Mcd.Jo7irnaL),7i. case where paraplegia which had existed a year was cured by the removal of the laminae of the fourth, fifth, sixth, and seventh vertebrae. Dr. H. L. Burrell, of Boston, recently reported to the American Orthopedic Association an operation done for the relief of paraly- sis in a case of advanced dorsal caries. The patient was in a very bad general condition before operation and died soon afterward. Considering then the published cases, there are eleven operations on record as follows: Macewen, five, three successful; Horsley, one reported, doubt- ful; Abbe, one, slight improvement; Wright, one, no permanent improvement; Lane, one, successful; White, one, fatal; Duncan, one, fatal; Burrell, H. L., one, fatal.' That is of twelve operations on record, four have been success- ful. Mr. Horsley's unreported cases are said to have been more favorable. Of the successful cases, in one case paralysis had existed for two years and involved both motion and sensation, and the sphincters of the bladder and rectum were affected, while spastic contractures of the muscles were present. In this case recovery Avas so good that five years later the patient was able to play football. In the second and third cases sensation and motion were both lost at the time of operation and the sphincters wxre involved. The fourth case is that of Mr. Arbuthnot Lane already related in full. ' British Med. Journ., August nth, iSSS, ii., 30S, 323; Glasgow Med. Tourn., 1SS4, xxii., 65 ; Glasgow Med. Journ., 1886, xxv., 210; Med. Contemp. Napoli, 1SS4. i., 520; Lancet, July 14th, 1888, 264; Internal. Journ. Surgery and Antiseptics, October, iSSS, 225 ; Brit. Med. Journal, April 20th, iSSg. lOo ORTHOPEDIC SURGERY. Of Mr. Lane's case it may be said, however, that, in view of the usual clinical history of pressure paralysis from caries it is possible that speedy recovery would have taken place without operation ; and this criticism may perhaps be made of some of the other suc- cessful cases. Once more it may be allowable to call attention to the fact that in the cases of paralysis studied by Taylor and Lovett the recovery percentage was lOO when the paralysis came on under treatment, and that it is very favorable ; in any event more than 83^ of all the cases recover under conservative treatment. Operations for the relief of traumatic perssure upon the cord have been collected and arranged by Ashhurst (" International Encyc. of Surg.," 2d Ed., Vol. IV.) The objections to the operation are stated by Willard as follows: " I. It endangers life, and a certain percentage of cases will die from shock that would otherwise live for years and might even recover. " 2. It is uncertain in its relief, since when the compression is an- terior it may be impossible to remove the cause. " 3. It weakens the only support of the head and shoulders, in the portion of the column upon which alone dependence is to be placed, since the anterior support — i.e., the bodies of the vertebrae — has been already disintegrated. " This weakening process must throw additional strain upon both muscles and diseased bone, and the operation, if done before de- cided consolidation had occurred, would leave the trunk without any support, thus increasing the risk of sharp flexion and deformity." It may be said, therefore, that resection of the laminae of the vertebral column is an operation which is attended with some risk of a fatal issue — a risk which cannot yet be stated numerically. But that at the same time several brilliant successes have followed the operation, so that it holds out the hope of relieving cases of paraplegia which would otherwise have been hopeless. The ope- ration, however, has no place in the treatment of Pott's disease until the conservative measures have been faithfully tried over a sufifi- cient period of time — measures which in most cases will prove efficient and successful in the relief of the paralysis. Constitutional Treatment. — Means for improving the patient's gen- eral condition are important, and are such as are em.ployed in patients with the tuberculous state elsewhere in the body: Care as to diet, proper nutritious food, tonics, and digestives, and such medicines as are regarded as reconstructive (cod-liver oil, the hypo- phosphites of lime, and soda, iron, quinine, etc.). As in all chronic diseases, medication should vary with the patient's condition. The patient should be weighed from time to time and an estimate POTT'S J) I SEAS E. ^ lOI formed as to whether his condition needs fattening or restricted diet, and whether the amount of exercise allowed should be in- creased or diminished. Exercise and fresh air, the best of tonics, are to be directed in such cases, and to such an amount as the acuteness of the symp- toms, and the danger of access of disease by possible falls and jars permit. It should be borne in mind that no appliance can be used which will be so thorough a means of fixation that injury may not follow violent falls, and also that, to favor the reconstructive pro- cess essential to the arrest of caries, a certain amount of exercise, sunshine, and freedom from the imprisonment of the sick-room, are of the greatest advantage. Judgment as to the relative importance of these different dangers constitutes the treatment of the disease. Summary. — The proper treatrrient of caries of the spine is not the application of any method, the use of any corset or brace, but the employment of such means as are most efficient for carrying out the object aimed at. A brace is useless in the case of persons unable to adjust it, a plaster jacket applied about the trunk is use- less and brutal surgery in disease of the cervical or high dorsal region. Recumbency, carried to a point of depressing the patient's mental and physical condition, is as much of a mistake as to drag a pati'ent about who is anxious to lie down. In the treatment of these cases, the surgeon should be familiar with the advantages to be gained by all methods, and should em- ploy each as the case may demand, and for such a length of time as the circumstances of the case may require, or combine the dif- ferent methods as may be advisable. In a general way he may formulate to himself that : In acute, painful cases absolute recumbency with fixation, combined with extension in disease of the upper part of the column, is the best method until the active stage of the disease is passed ; in middle and lower dorsal caries an immovable plaster jacket, without head attachment, in the case of negligent people. In disease of the cervical, dorsal, and upper lumbar regions some mechanical appliances must be used if the patient is not recumbent. The choice will be directed by the circumstances of the case (amount of care, expense, sensitiveness as to appearance) between a plaster bandage (holding neck and trunk), collars, braces, etc. In the lowest lumbar region recumbency, with or without fixa- tion by extension, constitutes the most thorough method of treat- ment. Braces or corsets are of value as a help for fixation during recumbency or in the stages of convalescence, and where recum- bency is unadvisable. 102 ORTHOPEDIC SURGERY. Properly constructed braces, designed so as to apply thorough antero-posterior support, with fixation in an improved position, form a method of treatment most satisfactory to the surgeon capa- ble of controlling and inspecting his patient. For such treatment, however, care on the part of the attendant of the patient, and ready facilities for the adjustment of braces, are necessary. Whether recumbency for a time is required, or whether ambula- tory treatment with fixation appliances is sufficient, are questions of judgment in individual cases. CHAPTER II. LATERAL CURVATURES OF THE SPINE. Definition. — Frequency. — Predisposition as to sex. — Clinical history. — Stages of the affection. — Symptoms. — Pains. — Distortion. — Curvature. — Torsion. — Varieties of lateral curvature. — Etiology. — Pathology. — Diagnosis. — Prognosis. — Pre- ventive measures. — Treatment. By this term is understood a constant deviation of the spinal column, 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, Scoliosc, deviation latci'ale de la taille, and in German it is called SeitlicJie Riickgratsverkri'nnnmng. Lateral curvature is either congenital or acquired. The former variety, however, is exceedingly rare ; when present, it is either a result of foetal rickets or it is an accompaniment of imperfect de- velopment, and inequality in the formation of the different sides of the trunk (Vogt, " Moderne Orthopaedik," p. 75 ; Schreiber, " Ortho- paedische Chirurgie," p. 118). Ketch (^New York Medical Journal, April 24th, 1886), generalizing from 229 cases, concluded that lateral curvature usually begins from the 8th to the 15th year. In 52 per cent of the cases the distortion began between the 1st and 1 2th year. In 41 per cent from the 12th to the i8th, and 3 to 4 per cent from the i8th year upward. Eulenburg in 1,000 cases, noted: 78 between birth and the 6th year. 216 " the 6th and 7th years. 564 " " 7th and loth years. 107 " " loth and 14th years. 35 above the 14th year. Mr. Willett has described a congenital case of this deformity in a specimen examined by him. The dorsal spine was altered by a slight anterior and left lateral curve ; four and a half of the dorsal I04 ORTHOPEDIC SURGERY. vertebrae were missing, five ribs on the right side and four on the left were absent, the left clavicle was out of shape, and_the scapula was connected by a bridge of bone with the sixth cervical verte- bra. The deformity is, in his opinion, due to an early defect in the elements forming the vetebral and lateral plates in the embryo. This malformation was found in an adult woman who had given birth to a living child, and who died of pericardial effusion in her thirty-first year. The specimen is almost unique occurring in a person oi this age, a list of specimens in the English museums giving only one other similar case in an adult, sixty-four years old. Shakespeare, often accurate in medical details, was probably un- aware of the infrequency of congenital scoliosis. These are the words of Gloster describing his distorted back : " I, that am curtailed of this fair proportion, Cheated of feature by dissembling nature, Deformed, unfinished, sent before my time Into this breathing world, scarce half made up." Frequency of the Deformity. The frequency of scoliosis may be estimated by Drachmann's figures, who found in 1884, on examining 28,125 school children in Denmark (16,789 boys, 11,386 girls), 368 cases of scoliosis, one and one-third per cent. Fisher states that of 3,000 cases of deformity brought to the National Orthopedic Hospital of London, 937 were affections of the spinal column, and 353 were lateral curvature. Berend reports, 900 scoliotic patients in 3,000 patients ; Lang- gaard, 700 in 1,000 cases; Schilling, 600 in 1,000 (Schreiber). These figures, however, taken from foreign authorities, do not necessarily represent the numbers to be found in American hospi- tals. The writer had occasion to observe the great number of adults with distorted spines to be met with in Dresden, and for eleven successive days noted the number of these deformities among the first 300 adult persons met. Only those on the same side of the street who were passing in an opposite direction were counted. The counts were made during walks at noon in the crowded part of the city (Alt Markt and Schloss Strasse). No opportunity was taken to examine these deformed persons, some of whom were probably cases of cured Pott's disease. Cases of light curvature and those not easily recognized at a glance were not noted. The count, which consisted only of the severest type of distortion, re- sulted as follows : LATERAL CURVATURES OE THE SPINE. lO: In different 300 people met Aug. 1, 1872, there was i scoliotic. 2 ' ' were 3 3 4 5 6 " 4 " 3 " 2 " 2 7 8 ' was I " 9 10 " " II ' ' were 2 12 ' TO ' ' was I 13 were 3 August 8, six cases were seen on the other side of the street, but not noted. A later observation for two successive days in 1883 gave similar results. Similar observations in other localities visited have indicated the same frequency of deformities. A count in the city of Boston made at noon on a pleasant day in summer, at a part of the city filled with the persons visiting the shops, gave as a result : One slight case of scoliosis ; one dwarfed person where a slight curve was suspected. No cases of the sever- est form of deformity in 1,000 passers. Predisposition as to Sex. — The distortion is more common in girls than in boys, and in the proportion of from four or five to one. Ketch found 189 females and 40 males. Kolliker found 577 females and 144 males. But of the most severe forms of the disease there were more males than females, and it is probable that if parents were as solic- itous as to slight variations in the figures of their boys as of their girls, that the statistics would show a greater proportion among boys than has been reported ; an opinion which is held by Vogt. In the lateral curvatures of young children (under five) the males are said to- equal or to outnumber the females. Bernard Roth found in 200 cases, 183 girls; Wildberger, out of 120 cases, loi girls; Berend in 896 cases, 773 girls. Out of 173 cases collected by Adams, 151 were females, 22 were males. Drachmann found the proportion of girls to boys, that of eight to two. The percentage of cases which are girls as compared to boys, has been stated by Eulenburg as ten to one, and by Kolliker as five to one. Io6 ORTHOPEDIC SURGERY. Clinical History. It should be distinctly borne in mind that true lateral curvature is not a disease in any true sense of the word, but a distortion of growth. The deformity appears and is developed during the growing years ; becoming arrested, as a rule, at the end of the period of growth, and its subsequent changes are simply those which occur elsewhere in the osseous system as a result of the wear and tear of use. The affection may be divided into three stages: 1. Initial stage. 2. Stage of development. 3. Stage of arrest, or quiescence. Initial Stage. — The affection is ordinarily discovered by the pa- tient's mother at the age just previous to puberty. It has, how- ever, been shown that it has developed earlier than this in a ma- jority of cases, but is not recognized. Lateral curvature is not usually seen in it earliest stage. At this period of it, the symptoms are so slight and the deformity so easily overlooked that the surgeon is rarely consulted. The patient suf- fers no inconvenience at this period, and as the child is at an age (seven to ten) when the figure is not carefully scrutinized, little attention is paid to the slight elevation of the shoulders or projec- tion of the hip. Upon examination, but little else is to be seen, and these symptoms disappear on recumbency or suspension. Tests as to the strength of the muscles, sometimes show a comparative lack of muscular force, but this is frequently not the case. A care- ful examination usually discloses a peculiarity in standing or sit- ting. A disposition to bear weight in the attitude of rest on one side more than on another is frequently noticed, and also an inclin- ation of the trunk to one side of the vertebral line. State of Development. — In a majority of cases when the surgeon is consulted, well-marked development of the distortion has already taken place. The curves are either flexible curves, that is, nearly disappearing on recumbency of the patient, or when the patient is suspended; or dive fixed, when little change of the curve takes place in removing the weight from the spinal column. Cases vary greatly in the rate of progress made. 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 affection, there is rarely any symptom complained of except the annoyance of the LATERAL CUK VATUA'JlS Ol' 7'/fK SPINE. 107 curvature, due to a distortion of the fi^^ure. In a few instances of growing girls with marked impairment of strength, some thoracic pain maybe felt, and fatigue on exertion of walking or standing. In addition to this, sensitiveness and burning sensations of the back maybe found, thougli these latter are more pr^jperiy attribut- able to a disordered condition of the nervous system, classed as neurasthenia, than directly to the lateral curve. The period during which the curvature of the spine may develop is indefinite, as well as is the rate and extent of the development. It is impossible, in the present stage of our knowledge, to predict the amount of increase or the permanency of arrest. The liability to increase is greater during the growing years, and there is some ground for a belief that the chief danger of increase is during this period. But cases of severe curvatures will be seen where development has slowly continued during the years of adult life. Stage of Convalescence, Quiescence, and Arrest. — While it is cer- tainly true that the time when a curve may be regarded as arrested is not easily recognized, an examination of a large number of un- treated cases justifies an opinion that spontaneous arrest takes place in a very large number of the slighter cases, without further development of the deformity. Even in many of the severer types of the deformity, patients will be observed who go through life without any increase of, or inconvenience from, the deformity. No sharp distinction as to stages of development and arrest can be made, but the classification of this sort has its value in consider- ing treatment. In general, it may be said that the initial stage corresponds to childhood and the approach of puberty; the stage of develop- ment extends from the period of commencing puberty to the es- tablishment of growth, and the stage of arrest, or quiescence, in- cludes a period after completion of osseous development. Symptoms. — Pain. The symptoms depend, in general, upon the amount of distortion, but this rule is not an absolute one, as in cer- tain individuals slight irritation produces a greater amount of pain than in others less deformed. Symptoms are as a rule not com- mon in the affection. The symptoms of pain are of three classes: 1st. Those due directly to the altered muscular or ligamentous strain. 2d. Those due to the abnormal pressure from distorted ribs or 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 I08 ORTHOPEDIC SURGERY. by the limitations as to exercise and activity, consequent on the deformity. Cases of shght curves are practically free from symptoms of pain, and in the milder types of the deformity, at the stage of quiescence or arrest, no symptoms are complained of if the patient is in good health; if, hoAvever, the health becomes enfeebled, slight neuralgic pain in the sides of the thorax is occasionally felt. This is, usually, accompanied by paraesthesia, or hyperaesthesia in certain parts of the back, in the upper dorsal or lumbar region ; but in the severest types of the deformity, symptoms directly due to the distortion may be observed, viz., neuralgic pains from abnormal pressure upon nerves and from undue strain upon ligaments and fasciae, occa- sioned by distorted attitudes. The pain, which is usually located in the lumbar region and down the thighs, is worse after fatigue, and is relieved in a measure by removing the superincumbent weight, but it is often impossible to determine whether these symptoms are due directly to the curva- tures or to a concomitant neurasthenia. Tenderness on pressure is never present in pure lateral curvature, and when found it is an evidence of nervous depression. General Symptoms. — Interruption in the functions of the liver, stomach, and intestines, is mentioned by Adams, as 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. The neurasthenic symptoms are chiefly manifested by indisposi- tion to exertion, vague complaints of pain and discomfort, and ten- derness in the back. These symptoms are rarely as marked in lateral curvature as in the pure forms of spinal irritation, but they may be added to the symptoms directly due to the distortion. In many of the severest forms, the patients' lives are made mis- erable by a variety of symptoms probably referable to impaired circulation, feeble digestion, lack of energy, and limited powers of respiration. The symptoms are, in part, due to the mechanical compression of the deformed thorax; and in part, to a lowered con- dition of the nervous system, as is seen in ordinary cases of neuras- thenia from mental anxiety and the limitations of the surroundings. Distortion. — The chief symptom of lateral curvature is necessa- rily the distortion, which, even when not severe enough to occasion discomfort, is aways a source of mortification and annoyance to the patient. The distortion is not limited to a simple curvature of the spine„ LATERAL CURVATURJCS OF THE S/'/NE. 109 but, as will be described later, to this is added a twistiii^ of the whole trunk; or, In other words, there is both a curvature and a torsion on a vertical axis. Curvature. — The, curvature of the spinal column varies in degree, situation, and extent. The variations are so great that no two curvatures are precisely alike, as is evident from the accompanying illustrations. There Fig. 114. — Projection of Shoulder in Right Convex Dorsal Curvature. Fig. 115. — Upper Dorsal Curvature. are, however, common types, which it is convenient to bear in mind in considering the subject of treatment. If one lateral cuvre occurs in the middle region of the spinal column, it necessitates two other compensating curves in opposite directions, one above and one below the deformity, in order to keep the head erect and in the median line. These compensating curves may or may not be of pathological significance. If not, the lateral curvature consists of a single curve, which may be situated in different parts of the column. In some instances one of the compensating curves is of an equal prominence with the no ORTHOPEDIC SURGERY. so-called primary curve; in which case the spinal column will pre- sent the S-shaped curve which is characteristic and which is illus- trated in the accompanying pictures. In other cases, what is termed the compensating curve may become more marked. The curves are often termed either dorsal or lumbar, but they are rarely limited exactly to these portions of the spinal column ; in most instances, also, the curves are not typical ; the upper curve may be so long as to include all of the dorsal and upper lumbar vertebrae, so that the prominent hip, due to the sinking away and rotation forward of the lower ribs on the side of the concavity, may not be the right, but the left hip; although the right shoulder is raised. Again, the lower curve may be so long as to invade Fig. ii6. — Curvature in the Cervical Region. Fig. 117. — Dorsal Curvature. nearly the whole of the dorsal region, the compensation taking place in the upper part of the cervical region. In both these varieties of curves, compensating curves, so-called, are necessarily present. They may be so slight as not to attract attention, or they may constitute a curve of equal severity with the upper or lower curves, forming a double curve. Furthermore, when the curves are in the flexible stage it is diffi- cult to determine which is the more important one; but after osse- ous 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 certain parts of the spinal column. LATERAL CURVATURES OF 77/ A' SI'/NE. I I I Cervical CiirvaULrc. — The cervical or \\\^'\ dorsal curves arc the least common forms of lateral curvature, except when associated with torticollis. This curvature may, however, occur primarily ; when it does, it is more commonly accompanied by a long compensatory lower curve, as in the accompanying picture. There is invariably elevation of Fig. ii8. — Projection of Hip in Lumbar Curvature. Fig. iig. — Front View of Lateral Curvature, showing Promi- nence of Left Mamma in Right Dorsal Convex Curvature. 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 promi- nently than the left, and Avill 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. 112 ORTHOPEDIC SURGERY. In front, in well-marked cases, the breast may be more prominent on the left than on the right side. In addition to the curve there may be a tendency to incline the Fig. I20. — Antero-postenor Curvature in Lateral Curve. Fig. 121. — Dorsal Curvature. Fig. 122. — Low Dorsal Curve. Fig. 123. — Low Dorsal Curve. LATERAL CURVATURES ()/' TJ/E S/'JNI-: "3 whole trunk to tlic rit^lit side. VVIicrc tliis is tlic case, the ri^ht arm when hanging, will be free from the side, while the left arm, when hanging down, necessarily strik'es 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, the left side of the outline will be un- naturally straight, and on the other more than normally hollowed. Fig. 124. — Lateral Curvature — Long Right Convex Dorsal Curve. Fig. 125. — Double Lateral Curvature. Lumbar Curvatitre. — The lower dorsal or lumbar curvature mani- fests itself by a prominence of one of the hips ; most frequently the right, sometimes the left. In well-marked cases there is also a ful- ness in the back on the left side", above the crest of the ilium ; and a corresponding flattening on the left side. In front the umbilicus is at the side of the median line. The most common lumbar curve is with the convexity to the left. A difference in the outlines of the two sides of the back, already mentioned, is also seen in this form of curvature. 8 114 OR THOPEDIC S URGER V. A sharp clinical distinction between lumbar and lower dorsal curves is not practicable, as they resemble each other in regard to Fig. 126.— Slight Double Lateral Fig. 127.— Double Curvature. Curvature. Fig. 128. — Double Curvature. Fig. 129. — Lower Dorsal and Lumbar Curvature. Fig. 130. — Double Curve. the resulting distortion. A combination of lumbar and dorsal curves will of course present the features of both varieties, but the LATERAL CURVATURES OE THE SJLNE. 115 distortion of the most pronounced curve predominates. If the curves are equal, a double curvature is said to exist, in which case the leaning to one side is not as marked as in long, single, dorsal curves. The curves maybe reversed; but the more common ones are those indicated with the upper convexity to the right and the lower convexity to the left. When this is the case, the distortion will be correspondingly altered. Localization. — Some writers regard the lumbar scoliosis as the chief curve, and as most common. The question may be regarded as not Fig. 131. — Left Convex Dorsal Curvature. Fig. 132. — Sharp Left Convex Dorsal Cur\-e. settled, though for clinical purposes it may be accepted as a fact that the dorsal curve is the one most frequently requiring treatment. Limping. — In certain very severe cases the distortion of the ver- tebral column is so great that the pelvis is secondarily 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. In 721 cases, Kolliker found one prominent lateral curve in 466 cases.' 'Centralbl. f. Chir., No. 21, 1SS6. Il6 ORTHOPEDIC SURGERY. In the number examined, 391 were in the dorsal region; 208 of these were with the convexity to the right and 183 with the con- vexity to the left. 222 cases showed double prominent curves, and of these 172 were with the upper curve a convexity to the right and the lower curve convex to the left. 42^ per cent of the number examined by Drachmann; 92 per cent of those reported by Eulenburg; 84 per cent accord- ing to Adams, and 81 per cent according to Heiner, presented curves in the upper dorsal region with the convexity toward the right. Lorenz and Drachmann think that the lumbar lateral curv- ature with the convexity toward the left is more frequent than has been thought. Lorenz found in 163 cases, 62 lumbar curves and 64 dorsal; and Klopsch found 71 lumbar curves in 121 cases. Lat- eral curvature with the convexity toward the left is more com- mon in young children. Out of 569 cases in the Royal Orthopedic Hospital of lateral curvature, 470 cases presented curvature with convexity toward the right side, 99 to the left side. Of Adams's and Lonsdale's 173 cases, in 149 the convexity was to the right side, and in 24 the convexity was to the left side. Some discussion has taken place as to which is to be regarded as the primary and which the secondary curve in cases of double scoliosis. Bouvier, Malgaigne, and most French writers claim that the dor- sal curvature toward the left is the one which is first formed and that the lumbar curve is generally much smaller, with the concav- ity to the right and secondary (see Malgaigne); this is denied, however, by many surgeons, notably Alexander Shaw, who consid- ers that the lumbar curve is the primary one and that the dorsal curve is secondary. According to Shenk, the lumbar curve is the most common primarily, but the dorsal curve is most commonly brought to the attention of physicians on account of the greater deformity due to a torsion of the ribs. Torsion. — As is explained under the head of pathology, it is im- possible for any curvature to take place in the spinal column with- out being accompanied by torsion of the vertebrae, or rotation, as it is frequently termed. The prominence of torsion in lateral curvature is a measure of the severity of the case. It is to this torsion of the vertebra that is due the necessary alteration of the position of the ribs, the ■prominence of the shoulder blade as well as the flattening of the chest on one side, the difference in prominence of the breasts, and of the hips, and also the lumbar fulness. LATERAL CURVATIIKKS OF 77 /K S7'7N7':. 117 These symptoms of torsion may be present before any curvature can be determined in the line of the spinous processes, the projec- tion of the shoulders, or of the hip, constituting the first evidence of lateral curvature. Torsion presents the most characteristic and distressing symp- tom of lateral curvature, for it not only causes the projection of the /^ %^ Fig 133. — Left Convex Dorsal Curve. Fi(, ij4 — I u<.r J )ii-.al Lur\ature. shoulder and the hip — the most disfiguring part of the deformity — but it is from torsion and its consequences that the greatest con- traction of the chest and resulting disturbances are due. The amount of torsion may be much greater than would be ex- pected by a slight amount of apparent lateral deviation of the spinous processes, as if the vertebrae yielded more by twisting under superincumbent weight than in a sideway curve. Varieties of Lateral Curvature. The varieties of lateral curvature are in all probability not as numerous as some Avriters would lead us to suppose, but as there are many different causes which may produce the distortion, a number of varieties may be readily classified. A lateral deviation is sometimes seen in an early stage of caries of the spine, and at the later stages in untreated or neglected cases when the consolidation of the carious bone has taken place irregu- larly. ii8 OR TH OP ED It S UR GER V. This distortion may, naturally, follow fracture or dislocation, and is occasionally seen in the rare affection, spondylolisthesis, de- scribed in another chapter. In sacro-iliac disease a curvature of the spine due to the pecu- FiG. 135. — Low Dorsal Curve. Fig. 13?. Fig. 137. Fig. 136 and 137. — Rhachitic Lateral Curves.' liarity of the attitude is quite constant, and in torticollis scoliosis necessarily follows. RliacJiitic Lateral Ctirvatiire. — This form occurs in rhachitic chil- dren ; but it is not so common a curve as the antero-posterior curve which appears as a back- ward prominence in the lumbar region in so many cases of rickets. The pure rhachitic lateral curvature has, ac- cording to Lorenz, its greatest curve in the mid- dle of the spinal column, and is more likely to be characterized by convexity to the left. Guerin claims that rhachitic children show a lateral curvature in 9.7^ of cases. Eulenburg found that in rhachitic scoliosis, the period of development of the curve was in the first six months in 54^ of the cases, and that the per- centage diminished to nothing at the seventh year. The affection is as common in boys as in girls. The distortion may or may not be ac- companied by other evidences of rickets, but in most cases the other signs of the disease are marked. In some varieties of lateral curvature there may also be an exag- gerated antero-posterior curve due to yielding of the bones under the unsual distribution of superincumbent weight. Fig. 138. — Lateral Curvature in Sacro-lliac Disease. LATERAL CURVATURKS 01' Till': Sl'fNE. IKj Static Lateral Curvature. -T\\\'~> term is ai)[jHc(l to that form due to inequality of the Icn^4h of the le^s. A slight difference in the length of the lower limbs is the rule, as will be shown under another heading. But development of lateral curvature directly from this cause is exceptional, as is evident from the fact that in a comparatively small number of cases of scoliosis, a noticeable difference is detected in the length of the lower limbs. i^^miwrnf/ Sklifosowsky found in 21 cases of lateral curvature, inequality in the length of the limbs in 17 {Ccntralblatt Fig. 139. — Slight Lumbar Curve Accompanying Knock Knee and Resulting Shortening of One Limb. Fig. 140.— Lateral Cur\'ature Following Marked Inequality m Length of Legs. /. Chir., 1884, p. 43). Staffel found in 230 cases of scoliosis the left leg shorter in 62 cases. H. L. Taylor found 28 cases of shortening of the left leg in 32 cases of scoliosis. Furthermore, from only a comparatively small number of cases of clearly defined shortened limbs from infantile paralysis, hip dis- ease, etc., does true scoliosis result. In a certain number of cases, however, of shortened limbs from these affections, a marked lateral curvature is found in some cases characterized by rotation of the ribs. 120 ORTHOPEDIC SURGERY. That curvature should develop in some instances and not in others, is probably due to the fact of the existence in certain of these cases of less resistance of the spinal column to unfavorable conditions. Paralytic Lateral Ciirvatiirc. — 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 attitude in which the spine is balanced with the least action on the part of the weakened muscles. The bones of the spine may be affected (if lackirig 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 occurring in the growing years; but the effect of other palsies, if influential in weakening certain muscles of the back, would be the same, and the distortion may be seen after spastic paralysis, pro- gressive muscular hypertrophy, and other affections weakening the muscles of the spinal column. Lateral curvature may follow empyema and some deviation of the spinal column almost necessarily follows severe forms of em- pyema. In the purest forms of this type there is no true scoliosis, the spine not being twisted to a noticeable extent, but simply pulled to one side, the ribs being flattened, i.e., fixed obliquely at a lower angle than normal, from the cicatricial contraction of the lung which prevents expansion of the lung on that side and leads to an increased expansion on the other. In certain cases, however, the altered position so induced has its effect upon the growth of the spine, and a true lateral curvature with torsion takes place. It has been said that a curvature followed in some instances pneumonia and phthisis, but this is not, according to Mr. Adams, commonly the case. Lateral curvature in a case of sarcoma of the ribs and lung has been reported by Shattuck {^Boston Med. and Surgical Jojtrnal, Jan. loth, 1889). Lateral Curvature from Occupation. — Lateral curvatures of severe type due to occupation, are not, as a rule, so common as other forms, for the reason that laborious occupations are not, in general, entered upon until an age when the spinal column has a sufificient amount of resistance to withstand the superimposed weight. Slight lateral curves may be seen, similar to the kyphosis of those employed in occupations requiring stooping. Scoliosis in school children is, in fact, a curvature from occupation in a true LATERAL CURVATUKI'lS ()/' '/'J/IC S/'/NJC. 121 sense, though the tenn as (jrcliiiarily used is not so aijplierl. in clerks one shoulder is often higher than tlie other from the at- titude 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 bas- kets or trays. Mr. Arbuthnot Lane has called special attention to this fact, and has also observed that the shape of the lateral curve varied in a measure with the occupation. Fig. 141. Fig. 142. Figs. 141 and 142. — Lateral Curvature Following an Attack of Infantile Paralysis. In short, occupations which require constant one-sided attitudes, as in the clerk, artist, blacksmith, etc., may, in certain individuals, develop a lateral deviation of the spinal column as the natural result of this constant position. Scoliosis in nursing women, from carrying infants too frequently upon one side, is also recorded, and the same attitude in one-armed persons. Lateral curvature from a peculiar position in sitting has also been noted due to inequality of eyesight. 122 ORTHOPEDIC SURGERY. A twist in the lower part of the spinal column is seen in some forms of sciatica.' Physiological Cu7've. — What has been termed a physiological curv- ature has been described by Bouvier. Such a curve is usually found with the convexity to the right in the dorsal region ; it is sometimes seen at autopsy, but not in young children. It is sup- posed to be due to the Aveight of the heart, or to the greater use of the right arm or right side of the body. The importance of Fig. 143. — Lateral Curvature Following Empyema. f IG. 144.— Slight Flexible Upper Dorsal Right Convex Lateral Curvature. this curve is not as great as is supposed by some writers. In fact the existence of this curve as a physiological curve has been denied by many authorities. Flexible, Fixed, and StriicUiral Curves. — Varieties have been made by some writers who wish to classify lateral curvatures as flexible or fixed according to their disappearances or persistence on a change of attitude. Structural curves are described as those where a change in the structure and shape of the bones has taken place. ' Ischias Scoliotica, Langenbeck, Archiv, i^ LATERAL CUA'VATUAL-'.S ()/' 77//': S/'/N/i. 123 These terms are convenient in describinj^ a condition of tli<; spinal column according to the stage of progress of the affection and the amount of ligamentous or osseous change that has taken place, but they should be used in no wider sense. Etiology. A great deal has been written on the subject of the causation of lateral curvature, and the question is still a vexed one, although at present the weight of authority favors the opinion that the de- formity is chiefly brought about by mechanical influences. The theories advanced to explain the phenomena of lateral curv- ature are the following: I. That the distortion is due to unequal muscular action, as is true in torticollis. 2. That the cause is to be found in an inequal- ity of growth of different portions of the vertebrae, as if the affec- tion were to be classed as a localized unilateral hypertrophy. 3. That the distortion is the result of superincumbent weight acting upon a faulty condition of the spinal column. One of the most notable causes alleged for those cases in the first group is that of active muscular contraction, which was advo- cated by Jules Guerin, who believed that lateral curvature was caused by the spasmodic contraction of certain muscles, in the same way that the head is twisted in torticollis. As a result of this belief, myotomy of muscles on the concave side of the curve Avas recommended by Guerin, and in one case he performed thirty or forty muscular divisions. Both this method and theory have fallen into discredit at present. The. facts, as seen clinically, do not substantiate such a theory. In the cases of true lateral curvature at an early stage, not only is there no spasm but no contraction even of the muscles on the con- cave side of the curve ; and the contraction seen in the later stages of pronounced curves can be explained by the supposition of the adaptive shortening of the muscles. It may be assumed, that although in exceptional cases there may exist an active contraction of certain muscles, as a cause for lateral curvature (as is the case in torticollis and in some instances of caries of the ilium or lumbar vertebrse), yet these cases are so ex- ceptional as to be insufficient to establish a rule for the treatment of scoliosis. Stromeyer and Barvvell have spoken of the contrac- tion of the serratus muscle as a cause of this deformity. This, however, has not found general acceptance. A much more probable presentation of the muscular theorv is that which has received the able advocacy of Eulenburg and which 124 'ORTHOPEDIC SURGERY. has met with acceptance from many authorities and been the foundation of a system of treatment. The theory may be stated as follows: Continuous muscular action is necessary for holding the trunk erect. If all the muscles are not in continuous action they must be constantly on guard to prevent any deviation from the normal position. If any of the muscles are weakened the spinal column will tend to bend, the deviation falling with the convexity on the side of the weakened muscles; the side of the concavity being that of the normal mus- cles. In weak individuals, habits of attitude, continued for a long time, will weaken certain muscles, by over-stretching them, and will cause distortion to ensue. The objection to this theory is that it cannot satisfactorily ex- plain all the facts. No diminution in the strength of the muscles has in the early cases been demonstrated, and such as has been found is in the severe cases and is only such as would result from the long-continued disuse of the muscles. Furthermore, lateral .curvature is often developed in individuals of apparently strong muscles. There is, moreover, also no proof that muscles are weak- ened by the slight over-stretching which follows the habits of standing or sitting seen in children. As Lorenz has justly observed, the habits of sitting or standing on one leg should, if Eulenburg's theory is correct, develop an abnormal attitude of the hip, knee, or elbow, from muscular action. Of this there is no proof; and, moreover, in lighter cases of scoliosis, no diminution in the muscu- lar power of the different sides can be demonstrated. Eulenburg's theory can, however, not be readily dismissed. Even if the purely mechanical theory of lateral curvature due to static influences be accepted, it is presumable that the faulty atti- tudes frequently assumed by children in sitting and standing, may be due to a lack of strength of certain groups of muscles, either inherited or acquired by accident; although it is not possible to demonstrate such impaired muscular strength of these muscles. In other words muscular weakness may be regarded as a predisposing influence, if not an actual cause of the deformity. With this in view it is alleged that the distortion is probably due to disturbed muscular conditions involving impaired muscular power on one side. The muscles primarily affected are probably not the external muscles moving the spinal column, but the inter- nal group which pass from vertebra to vertebra, and act on the column in segments. The second theory, that of abnormal growth, is advocated by Hueter and Engell, who believe that in some cases there is an LATERAL CURVATURES OE Tllk SJLN/C. 125 abnormal growth of one side of the thorax, including the ribs and the vertebrae, similar to the unilateral atrophy or hypertrophy seen elsewhere; and that there is an abnormal ossification at the ends of the ribs in early childhood from which cause the thorax is twisted and developed asymmetrically. Delpech and Bouvier think that faulty attitudes, instead of being the cause, are the result of lateral deviation, which are themselves due to asymmetrical development of the bodies of the vertebra;. The position of the heart on the left side of the body has been explained to be an exciting cause for lateral curvature with the convexity toward the right. This, however, cannot be construed as true, as in the case of Beclard, where there was transposition of the viscera on the right side and still a lateral curvature to the left side existed. And in left-handed persons the left shoulder is fre- quently found higher than the right. Many objections can be urged against this theory; but the most important is, that it does not correspond with clinical facts. If a series of cases be collected and arranged according to their severity, it will be found that in the lighter cases (differing appar- ently only in degree from the severer ones), no abnormality of growth in the spinal column is present. No evidence has been ad- vanced to support the theory of a freak of growth in the ordinary cases of lateral curvature ; the exception to this statement being only the rare instances of congenital imperfection which develop a distortion at first somewhat resembling lateral curvature. Fur- thermore, against this theory it may also be urged that in the early stages of the affection these curves disappear in recumbency and that they only become permanent after a long tim.e. Lorinser has advanced a theory of subacute inflammatory changes in the structure of the bone, but there is little to be said in support of such a view. Lesser urged the view that the unequal action of the different halves of the diaphragm through unilateral paralysis of the phrenic nerves gave rise to the deformity. The doctrine of faulty innervation as a cause of scoliosis has been advanced, but it has not yet received any acceptance. The third theory is that of superincumbent weight. The ma- jority of authorities favor this theory, which is urged by Roser and Volkmann, who consider the deformity as the result of the gradual mechanical force of the superincumbent weight falling upon the spinal column which is not held erect, and which is in- capable of resisting the pressure which falls upon it. The clinical facts conected with lateral curvature may be briefly stated as follows : 126 ORTHOPEDIC SURGERY. The distortion occurs chiefly in childhood and fully develops in adolescence. In the earliest types there is an habitual distorted attitude which can be corrected by removing the superincumbent weight ; in the later forms the distortion can only be slightly over- come by removing this weight and in the most severe forms no change can be effected in this way. It remains, therefore, to investigate whether the anatomical changes found in cases of the severer type are such as can be caused by superincumbent weight. As has already been stated, these changes are chiefly a twist of the spinal column, with such alterations of the different vertebrae as would follow such a twist, provided the bony structures were unable to sustain such a down- ward pressure. To demonstrate that superincumbent weight could cause this twist the following experiments were tried. Observation I.' The spinal column of a full-term infant was removed, leaving the skin, superimposed muscles, and ligaments in- tact, but removing the ribs. It was found that although the column was more flexible than in children, adolescents, or adults, rotation was not readily brought about by simply pressing the two ends toward each other, holding each end in the hand ; the amount of lateral deviation, that is, curving sideways, without rotation of the bodies, was not great, though much greater than in well-grown spinal columns. The most noticeable effect of pressing the upper part downward was to cause a bending with the concavity forward; bending with the concavity backward was possible only to a com- paratively slight degree. Rotation was easily produced by twisting the spine. Observation II. The body of a young female adult was hung by the head with the head fixed and the body free from the floor; the skin of the back having been dissected off, long pins were driven in the occiput and in the spinous processes of the different verte- brae; a thread with a weight was hung from the pin in the occiput, long enough to touch the floor, and a second thread with a piece of chalk attached was hung successively from the pins inserted in the different spines and from the sacrum. The pelvis was then twisted forcibly and the arc marked off on the floor by the piece of chalk, as suspended from the different pins, was measured from that point in the circle indicated by the plumb line, hung from the pin inserted in the immovable head. The figures are as follows, measured from the line from the occi- put : ^ The writers are indebted to Prof. Dwight and Drs. Mixter, Conant, Newell, and Burrell of the Harvard Medical School for their assistance in their experiments. LATI'IRAL CUA'VATUA'KS ()/' Till-: S/>/NK. 127 Arc described by a line from sacrum, 150" " " " " axis, 66' first dorsal, 83^ third dorsal, 100° sixth dorsal, 1 18'-' " . " " twelfth dorsal, 130^ third lumbar, 136^ While these figures are only approximate, as the amount of force used in the successive twistings was not measured and presumably not the same, yet they indicate that the amount of rotation possi- ble is greatest in the dorsal region, leaving out of account the twist- ing possible in the atlo-axoid articulation. The three or four upper dorsal vertebrae moved together; the greatest rotation appeared to be in the third lower dorsal; lateral deviation (that is, without rota- tion) was possible only in the lower dorsal vertebrae. Pressure made on the floating ribs appeared to have little effect in twisting the vertebrae, but pressure on the thoracic ribs appeared in a mea- sure to affect the line of the spinal column. Some play in the costo- vertebral articulation existed, but beyond that point pressure ex- erted on the ribs was transmitted to the column. Volkmann' found that in life the greatest possible twist of the whole body, including that occurring in the hip joints, was 144°, so that the figures here given are overstatements of the possible phy- siological limits of rotation. This is also somewhat greater than that indicated by the facets of the disarticulated vertebrae, which would show that if the joints were firm there would be absolutely no rotation in the lumbar region, little in the cervical, except in the atlo-axoid articulation, and not much in the dorsal region. A certain amount of laxity in the articulation allows more play than would be supposed by the structure of the bones. This was evident on forcibly twisting the cadaver. The amount of forward and backward motion possible in an adult is much less than would be supposed. This is apparent on inspection, and has been accurately measured by Meyer.- Observation III. The whole spinal column of an adult male, a dissecting-room subject, was taken, including a portion of the pelvis, and the base of the cranium. The larger muscles were re- moved, but the ligaments and smaller muscles were kept. The pelvic sacrum was firmly held in a vice and a box was secured on the cranium by passing a rod, firmly secured to the box down into the medullary canal of the cervical vertebrae ; the box was then ' Virchow's Archiv, 1872. ^ "Die Statik und Mechanikdes Menschlichen Knochengerustes," p. 210. Virchow's Archiv, Bd. xxxv., page 225. Ibid., Bd. xxx\n., 1S66, page 144. Ibid., xxx\-iii.. page 15. 128 ORTHOPEDIC SURGERY. secured so that it would move up and down, but not laterally ;^ weights were placed in the box. It was found that the spinal column could bear a considerable weight without yielding to any noticeable extent. As the amount was increased a curvature with concavity forward was seen, which increased as the weight was increased up to eighty-four pounds. No rotation of the vertebrae was observed as long as the weight bore down directly, but rotation of the lower dorsal and lumbar region was seen when any lateral deviation was made in the cervi- cal region; the amount of rotation or deviation was, however, very small as compared with that possible in children. None of these experiments approximately reproduced the condi- tions to be found in life, as the attachments of the ribs had been severed and the viscera removed. Furthermore, the spinal column in the adult is much less flexible than that of a child or adolescent, when lateral curvature is usually observed. Observation IV. The body of an infant of a year was prepared in the following way: The thighs were amputated near the hip- joints and the pelvis fixed upon the remaining stumps and secured by means of nails on a board, long pins were passed laterally through the pelvis and secured to the board by means of hooks, and the whole pelvis then imbedded in plaster-of-Paris. The board to which the body was secured was then placed on a stand with four upright rods attached at the four corners, to which rods a flat board was attached so that it would slide smoothly up and down. The child's trunk therefore was placed between two boards, one being fixed and the other pressing down upon the child's head. To keep the head in place it was inserted in a tightly- fitting tin cylinder which was fastened to the under surface of the board. Weight placed upon the upper board (sliding as it did freely upon the uprights) brought a downward pressure upon the child's head and shoulders. To make the latter more even a wooden collar was placed around the neck resting on the shoulders. Long pins were then inserted in the spinous processes of the ver- tebra; so that rotation could be more readily noticed. To check the falling forward of the neck, a cord was placed around the neck and fastened at the side to the uprights, acting as a check, just as in life the longer muscles of the back would act in keeping the body erect. Downward pressure upon the upper board caused the child's back to bend backward (convexity backward). When carried be- yond a certain point the column would bend sideways with marked rotation, with the changes usually noticed in the ribs, flattening on the side of the concavity and projection on the side of the convex- LATERAL CURVATURES UE 77/ E SPINE. 129 ity. This projection was most marked in the middle and upper dorsal region, but the amount of greatest rotation api)cared to be in the lower doi'sal regicjn. If the angle of downward pressure was changed, or if the pelvis was tipped so as to cause a curve in the spinal column, the effect of downward pressure was more marked. Rotation of the vertebrae was, of course, readily produced by lateral pressure twisting the spine; and on removing all downward pressure, by placing the cadaver in a horizontal position rotation Fig. 145. — Experiment to Demonstrate Causation of Lateral Cur\-ature. and curvature in the dorsal region was easily made by twisting the pelvis and holding the head fixed, or vice versa, the axis of the head and pelvis being kept the same. Although a well-marked scoliosis was thus artificially produced, attended by the characteristic flattening of the ribs on the side of the concavity and projection on that of the convexity, yet a more careful examination appeared to show that although this was the result of downward pressure, it was downward pressure not exerted in a perfectly vertical direction ; for although the force was applied properly, yet it was not possible to prevent some play in the cervi- 9 I30 ORTHOPEDIC SURGERY. ilii cal region, from which it resulted that the force fell obliquely upon the under portion of the spinal column, causing curvature and necessarily rotation. The accompanying illustration indicates the lateral curvature produced in the experiment. It is drawn from a photograph. The photograph of a case of lateral curvature in a grown child shows the similarity of the shape of the back in true lateral curva- ture to that of the experiment. If it were practicable to apply a force directly downward and -^. transmit it through the cervical and upper dorsal region without deviation, the effect upon the lower dorsal region would be to cause an antero-posterior curva- ture. The lateral curvature therefore results from downward pressure, but downward pressure applied obliquely upon some portion of the spinal column. Rotation fol- lows from the anatomical struc- ture of the interlocked vertebrae, it being possible for them to ro- tate slightly, while the amount of tipping sideways (without twist- ing) which the articular facets permit is much less. Rotation takes place with the vertebral bodies directed toward the convexity and the spine to the concavity for the reason that the former being larger, are un- able to be crowded into the smaller space of the concavity, and are pushed in the direction where there is more space. Perhaps also, as has been pointed out by Judson, the fact that the bodies are free while the spines are held by muscles may give the former more freedom in movement. From the above facts the following generalizations may be made :. The effect of the weight of the thorax on head and shoulders would be, if applied in a vertical direction, to bend the spinal column forward and backward, but in flexible spines the superin- cumbent weight rarely falls directly, and curvature follows. This is at first a physiological process, but it subsequently becomes, by = £ Fig. 146. — Dorsal Right Convex Curve. LATERAL CURVATURES OF 77//'; SI'fNE. 13 r the alteration in the shapes of the bones under altered pressure, a pathological change. The extent of th-e curvature, and the situation of the curve w ill be determined by the attitude habitually taken by the individual, and perhaps also by a difference in the resisting power in different parts of the column. The injurious effect of superincumbent weight in curving the spine, is increased by the obliquity of the pelvis, or the inclination of the shoulders so frequently taken by persons of weak muscular systems in sitting sideways and leaning. The curve is usually in the dorsal region, with the right shoulder raised, as the majority of people are right-handed. The distortion is one of growing years, and is more common in girls than boys, for two reasons, namely, that at the age when lateral curvature is usually seen first, girls grow more rapidly than boys, and their muscular system is less well developed, from the customary life habits of girls in society. The effect of superin- cumbent weight upon a yielding spine in adult life, after the verte- brae have ceased to grow, is to cause an increase in the antero- posterior curve O'f the back. The lack of normal resistance of the bony structures of the spinal column, in part or in whole, may be supposed to exist in certain individuals without the supposition of any pathological change of sufificient gravity to be classed as rickets. During the age of growth, complete ossification of the different vertebrse has not been attained. It is well known in certain cases, that in rapidly growing persons, the ossification of the spine does not make equal progress with the ossification elsewhere. Alexander Shaw mentions two preparations of the spine in the Museum of the Middlesex Hospital, where such a condition of things exist (vide Holmes's " System of Surgery," Vol. HI., Ameri- can Edition). An analogue of this condition is found in the knock-knee de- veloping about the time of puberty, and the accompanying cut from the Warren Museum may serve as an illustration. This view would be supported by Vogt, who calls attention to the fact that the development of ordinary lateral curvature comes at periods of the physiological increase of the process of ossification of the whole skeleton. Vogt describes three periods of increase of growth: ist, includes the first two years; 2d, the beginning of the second dentition in the seventh year to the approach of the time of puberty; 3d, the period of puberty. Fisher writes that atten- . tion should be especially directed to the fact that mere constant bending of the spine to one side will not induce a structural change; 132 ORTHOPEDIC SURGERY. Fig. 147.— Rhachitic Lateral Curvature of Spine. From Specimen in the Warren Museum. LATERAL CURVATURES ()!■ THE S/'/NE. [33 that there must exist, also, within the column itself, some con- tributory defect, without which lateral curvature will not become developed. Adams and Fisher believe that this contributory defect is in the structural relaxation or weakness of the ligaments, rather than in a lack of resistance of the bones, Fisher, however, himself com- pares the condition to that seen in knock-knee, which is now gen- erally regarded to be due to an osseous rather than a ligamen- tous defect. The constitutional influence in the development of lateral curva- ture is little understood. Drachmann found that only a small por- tion of the anaemic and scrofulous children in the 28,000 scholars examined were scoliotic. An hereditary predisposition to spinal curvature frequently co-existing with a consumptive tendency, is mentioned by Adams as occurring in girls from seven to twelve years of age or later; and in those cases the curvature tends to in- crease rapidly and terminate in a conspicuous deformity; but lateral curvature of the spine according to Adams rarely co-exists with consumption. Eulenburg found 25 per cent of scoliotic patients showed some hereditary tendency toward the affection. Vogt found it in one-half of his cases. While Rupprecht ' considers ordi- nary lateral curvature as rhachitic, Lorenz thinks that weakly chil- dren have ipso facto a disposition to lateral curvature; but he is unwilling to say that in cases where it occurs the children are always rhachitic ; for the lack of resistance of a rapidly-growing bone may be sufificient, under certain static conditions, to develop the lateral distortion. It has already been said that the most common curve is that which raises the right shoulder and causes a convexity in the mid- dle dorsal region to the right ; but the most rational explanation of this fact may be found in the usual habit of greater use of the right arm. In the case noted of two girls (twin sisters) who sat at the same bench at school and leaned habitually one on the right arm, the other on the left, curvatures were developed in opposite directions. Sigfried Levy^ thinks that there are two distinct etiological fac- tors in the production of habitual scoliosis: one, " an anomaly of nutrition," a purely organic matter; secondly, certain mechanical causes — faulty positions of standing and sitting. Neither one of the factors can cause it alone; both must be present at the same time. In support of this view, he speaks of a case which he saw, where a girl of three years had a resection of the knee, and grew up with ' V. Centralb. f. orthop. Chir., 1SS6, 2. = Also Busch, Berl. Klin. Wochenschrift, iSSo, p. 106, vol. i. 134 OR THOPEDIC S URGER Y. one leg nine centimetres shorter than the other. The pelvis was always tilted, but there was no suspicion of scoliosis until she was twelve years old, when she began to have headache, pain in the side, malaise, etc., and in spite of all precautions, a typical lateral curvature rapidly developed. He has seen three other such cases; and in over a hundred cases of habitual scoliosis which he has ob- served, in every case symptoms of general disturbance (as in the case related above) accompanied the development of the deformity. As is well stated by Fisher, the causes of lateral curvature are the predisposing and the proximate. 1. Predisposing causes, which are constitutional, such as debility, rickets. 2. Proximate causes (essentially local), which disturb the equilib- rium. These are vicious positions, sitting positions, faulty atti- tudes, empyema, or any long-continued irregular distribution of weight. Pathology. The pathological changes in true lateral curvature are not those resulting from any disease of the vertebra, but simply the altera- tions of bone yielding under pressure in an abnormal direction. The changes are chiefly to be noticed in the spinal column, viz., the bodies of the vertebrse, the articulating processes, and the spines; but in severe cases all the bones of the trunk may be altered and also the pelvis. The muscles and ligaments are altered in their tonicity and length, and internal organs may be displaced. The changes seen necessarily vary according to the stage of the a;fTection and the degree to which the deformity has developed ; and consist chiefly of a curvature and a torsion. In the flexible stage of scoliosis no anatomical change will 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 the vertebral bodies is to be observed. Wherever a lateral curve of the spine has taken place, the sides of the bodies are crowded together on the concave side and sepa- rated on the convex side of the curve. Growing bone adapts itself to altered pressure, and in time the bones of the convex side will grow more than on the concave side and the vertebral bodies will be found misshapen, thicker on one side than the other; and changes in the shape of the articulating and transverse processes will also take place. As has already been stated, a twist takes place in the spinal column and consequently the transverse processes are out of the normal plane ; the ribs follow the transverse processes, and a LATERAL CURVATURES OE 'THE S/'/NE. 135 characteristic projection on one side and flattening on the other occur. If the cokimn is curved laterally in two or three directions, rota- tion necessarily takes place in different parts of it in opposite direc- tions, and the projection of the ribs is naturally more noticeable than the projection of the transverse processes without ribs; but in the latter case the lumbar muscles are thrown forward, or recede, giving a characteristic alteration in the contour of the trunk. The inter-vertebral cartilages necessarily twist with the vertebrae and are compressed on one side more than on the other in cases of marked curves; but in severe cases they will be found on measure- FiG. 148. — Torsion in Lateral Curvature. Fig. 149. — Torsion in Lateral Curvature. ment 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, as has been shown by Adams and others, the tips of the spines in severely rotated columns may be on a straight line, while the bodies are badly distorted, the axis of rotation being near the spinous processes. For an understanding of this torsion, it is Avell to bear in mind that the structure of the spinal column is such that a bending to the side without any twisting of the column is only possible to a limited extent. The pure sidewise motion of the column, the only motion possible in fish, is fully developed in reptiles and in some animals, but is limited in man. In old people it may be almost wanting, though in foetal life and in infants it is much more free. 136 ORTHOPEDIC SURGERY. A detailed anatomical description of the structure of the verte- brae is hardly necessary for an understanding of the phenomenon of torsion. The individual vertebrae rotate on each other to a limited extent; the amount of possible rotation varying according to age, and the condition of the spine. The various parts of the spinal column permit a different amount of rotation ; the upper cervical region permitting the most, and the lumbar region the least. Where the demands of the individual require more mo- tion to the side than would be possible by the purely side- way bending of the column, this can be gained by a tor- sion of- the column so that the Fig. 151. freer antero-posterior movement of it may aid the limited side motion. Some discussion has taken place as to whether the torsion is primary to the curve or secondary. ^z^xxmAt {Centralblatt f. Chir., Nov. nth, '82) is of the opinion that the torsion is primary, as there is always a curvature if torsion exists, but slight curvature may take place without torsion. Dr. Judson's excellent experiment to demonstrate the phenome- non of rotation is well known, and can be understood by a glance at the accompanying illustrations (Figs. 150, 151).' A flexible rod is LATERAL CURVATURES (>/' '/'//A' SJ'JNE. 137 passed through the disarticulcd vertebra; of a spinal column, placed in their normal order, one above another, and kept in relative position by means of elastic straps, secured to uprights. Increase of downward pressure demonstrates rotation and lateral curvature. There is, therefore, necessarily a torsion of the spinal column, whenever it is bent toward the side to any considerable extent ; and when a curved condition of the spine becomes habitual or con- stant the changed pressure in the spinal column produces in time alterations in the shape of the vertebral bodies, and in the articulat- ing surfaces. Lorenz has clearly shown that not only do the bodies of the ver- tebrae 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 spinal -longitudinal striations on the bodies in the place of the usual vertical marking. Besides the rotation, as has been stated, the bodies grow in the direction of the least pressure; consequently the bodies lose their normal symmet- rical 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 shape of the vertebrae is indicated in the accompanying picture, but it must be borne in mind that the vertebrae vary necessarily according to their relative position in the curve and the direction in which they receive the superincumbent pressure. The alterations of the bones in the vertebral column are not to be studied in the individual vertebrae. The whole column is twisted and all the bones are necessarily altered according to the abnormal positions, as a result of those atrophic changes in bone which always result from abnormal pressure or Aveight bearing. The ribs are not only rotated, but altered in shape, as is seen in the accompanying picture. They are 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, and the clavicles remain unchanged ; but the tip of the sternum may be deflected from the median line. The ribs project backward at the angle on the side of the convexity of the curve and forward in the line of the concavity. A cross section of the thorax shows an alteration of the diagonal axes of the spine, which should normall}' be equal, but in the ordi- nary dorsal right convex curve the diagonal axis, from the left front side to the right back side of the thorax, is longer than the other. 138 ORTHOPEDIC SURGERY. The different halves of the thorax, on cross section, should be symmetrical normally, but in lateral curvature the portion on the Tig. 152. — Individual Vertebra Altered in Lateral Curvature. mm Fig. 154. — Individual Vertebra Altered in' Lateral Curvature. y^/ Fig. 155. Torsion in Lateral Curvature. Fig. 153. — Change in Shape of Bodies of Vertebras. Fig. 156. — Torsion and Curvature in Lateral Curvature. convex side of the line from the spine to the sternum is smaller than that on the concave side, owing to the flattening of the ribs. The vertebral bodies are also crowded into this half of the thorax, LATERAL CURVATURICS Ol' 77/ A' S/'/N/C. 139 so that there is less ro(MTi for expansion of the lun^ on that side than on the other side. In the severest cases of distortion, the lower ribs on one side niay rest upon the crest of the ilium or even sink into the pelvic cavity, and an alteration of the shape of the pelvis may be caused in this way. The muscles of the spinal column in an early case of lateral curvature are unaffected, excefit in cases of a purel}' paralytic nature. Adams found in dissections of advanced cases that the muscles on both sides of the spine " were much wasted, reduced to very thin layers, pale in color, and in more or less advanced stages of fatty degeneration, which probably commences in the muscles in Fig. 157. — Alteration in Angle of Ribs in Lateral Curvature. Fig. 15S.— Distortion of Ribs and Thora.x in Lateral Curvature. the concavity of the curve, those on the convexity wasting at a much later period." (The muscles in the concavity of the curve are found neither prominent nor rigid.) In advanced cases of lateral curvatures, 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 shorten- ing of them, 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 distorted in lateral curvature of the spine ex- cept in cases of general rickets, for, as a rule, obliquity of the pelvis does not exist in lateral curvature. The pelvis, however, assumes the position of obliquity from a prominence of one hip due to the uncovering of the crest of the ilium by the over-projecting ribs. Where there is irregularity in the length of the legs, obliquity of I40 ORTHOPEDIC SURGERY. the pelvis necessarily exists. The prominence and rigidity of the spinal muscles in the lumbar region frequently seen on the con- vexity of the sharp lumbar curve often conveys to the touch a doubtful sense of fluctuation, and is frequently laid to the suspicion of an abscess. The spinal cord is not affected by lateral curvature. The spinal nerves in consequence of the large size of the fora- Fig. 15-5 — Displacement of Ribs in Lateral Curvature. Fig. 160. — Distortion of Ribs in Lateral Curvature^ Fig. 161. — Distorted Pelvis in Lateral Curvature. Fig. 162. — Scoliotic Pelvis. mina are not liable to suffer compression except in cases of great severity. Infliience of Lateral Curvature in Caiising Displacement of Abdom- inal Viscera. — The abdominal viscera are less likely to be displaced, even in severe cases, than the thoracic organs, though the liver may 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 neces- LATERAL CURVATUKJ'IS OF 11 IE S/'/jVE. J41 sarily di.spkvced ; tlic thoracic cavity on the side of tlie convexity of the curve is flattened, and diininislied in size to a much larger extent than on the concavity in consequence of the flattening of the ribs on the convexity of the curve. Adams reports a case where at a 2)ost-mortem examination, he was barely able to pass the hand between the bodies of the verte- brae and the ribs. The lung on the convexity of the curve is, therefore, much more compressed and flattened, and the thoracic cavity on the concavity of the curve is always found to be much larger 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 convexity. The heart is generally found displaced toward the concavity of the curve in severe cases. Adams claims that consumption or a consumptive tendency fre- quently exists as a complication of lateral curvature of the spine; but he admits that he has no statistics to support this view, and it is not in accordance with the experience of physicians who make a specialty of diseases of the lungs, who claim that they rarely find cases of consumption in patients with lateral curvature. Diagnosis. A diagnosis of lateral curvature, in a severe 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 deformity is not so easy, and a careful examination is necessary, not only for the exclusion of other affections of the spine, but also for an insight into the stage and 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 to the level of the trochan- ters, 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 possible; the tips of the spinous processes are to be marked with a crayon and also the ends of the scapula. To determine the central line a string, to which a slight weight is attached, is hung from the seventh cervical vertebra (to which it can be fixed by a piece of adhesive plaster), the string being long enough to hang to the cleft of the buttock. 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 142 ORTHOPEDIC SURGERY. of greatest curvatur.e ®f tke line of the spinous process. These points being noted, the slop© of the shoulders, the outlines of the sides of the trunk, and the contour of the back, as well as any lack of symmetry orunilateral fulness, should be carefully recorded, both when the patient is standing and in the stooping position, with the back well arched. If a devi4tion of the line Fig. 163. — Torsion of Ribs in Lateral Curvature. Fig. \t -Projection of Ribs seen in a Stoopinc Position of Back. of the spinous processes is observed, a lack of symmetry of outline, or a unilateral projection of the ribs or scapulae, in the erect posi- tion, the patient should be suspended by means of a head sling and also made to lie in a recumbent position upon the face. A marked alteration of the curvature, contour, or outlines follow- ing removal of the superin- cumbent weight is of parti- cular importance. The inspection of the arched back, stooping from a sitting position is import- ant ; any rotation of the fixed ribs due to osseous change is easily detected in the lack of symmetry and projection of one side more than the ®ther. 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 thick- ness, anci testing what height can be placed under the patient's foot without preventing her from standing upon both legs with the limbs straight and without flexion at the knee; this tests the lateral flex- FiG. 165.— Projection of Side of Thorax in Lateral Curva- ture, seen when Back is Bent. ■ LATERAL CURVATURI'lS UF THE SJ'LVE. 143 ibility in the lower part of the spinal column, in testing the flex- ibility 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. 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 be often readily seen by directing the patient to bend to one side, keeping the legs straight and avoiding twisting the pelvis. The amount of possible rotation of the spine may also be of im- portance ; in which case the patient should sit upon a revolving stool with the shoulders held firmly by an assistant, when the amount of possible revolution of the stool in one direction or an- other, without turning the shoulders, can be approximately esti- mated. It is not always necessary to examine the front of the patient's Fig. 166.— Diagram of Normal Thorax, Fig. 167.— Diagram of Thorax, Lateral seen from Above. Curvature, seen from Above. trunk. 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 umbilicus from the median line are of importance, as indicating the amount of struc- tural change which had taken place. The strength of the muscles of the patient's back may be tested 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 on the habitual lack of symmetry in the outline of the sides of the trunk, the slope of the shoulders, or contour of the back, in the unnatural projection of one shoulder blade or of one hip; and on a constant deviation of the line of the spinous processes from the vertical line. An accidental assumption of any position with the prominence of these symptoms does not necessarily constitute lateral curva- ture; but the constant habitual assumption of such a position when the patient stands in the attitude of ease and greatest comfort 144 ORTHOPEDIC SURGERY. must be regarded as a lateral curvature either of a flexible or fixed type. Adam's and Fisher claim that a distinction should be made be- tween deviations and curvatures of the spinal column, and state that much of the confusion regarding causation and the results of treatment is from a lack of this important dis- tinction. This distinction, however, is not always a practical one, as in the early stage of lateral curvature before fixation has occurred permanent rota- tion is not always recognizable. Mr. Fisher figures three cases of so-called curvature of the spine; and only one of these, he claims, is a curvature of the spine, the two others being devia- tions of the spinal column. In a cur- vature of the spine he considers that there is rotation of the bodies of the vertebrae, whereas in a deviation of the spinal column there is no rotation. He suggests the term, lateral bending, for a class of cases which occur in young girls who are overworked and under- fed, the servants of the lower classes, girls educated at " cheap establish- ments for young ladies," those working in the second-rate drapery shops, and so forth ; it is also met with in those who have suffered from long illness of an exhausting nature, and in those affected with that defective condition of health commonly described as gen- eral debility. Frequently accompanying this de- formity is that mental condition which tends to exaggerate any bodily de- rangements. The hysterical complica tion generally appears at a late, and not at an early, stage of the affection, which must not be con- founded with the so-called " hysterical spine." The amount of fixed rotation is best indicated by the amount of unilateral projection of the ribs at the level of the shoulder or in the hollow of the back when the patient bends forward or is recumbent. Fig. -Lumbar Flexibility of the Spine. LATERAL CURVATURES OF THE SPINE. H5 The amount of osseous and ligamentous change is in proportion to the change in the amount of the curves and asymmetrical symp- toms, as the patient lies or is suspended. In this way it is possible to determine the amount of progress the distortion has made, and the stage of the affection. A notable error in the diagnosis of lateral curvature is recorded by Mr. Adams in the practice of surgeons of the last generation, which seems hardly possible at the present time. The relaxed muscles in the lumbar region in a case of severe lateral curvature were mistaken for a deep abscess, and operative measures were Fig. 169. — Lateral Flexibility of '1 runk Fig. 170. — Lateral Flexibility of Trunk. advised by several surgeons of prominence. The subsequent re- sult proved the swelling to be purely the deep muscular tissue in the loin made prominent by the rotated transverse vertebrse on the convexity of a lumbar curve. The writers can record a large dorsal lateral curve with severe rotation of the ribs which was mistaken by a physician (a skilled specialist in diseases of the chest) for an obscure form of pleural effusion. Lateral curvature is not infrequently confounded with caries of spine through simple ignorance of the nature of either affection, both being classed as chronic spinal affections. No differential diag- 146 ORTHOPEDIC SURGERY. nosis could be simpler than that between these two affections In pronounced lateral curvature, the lateral twist and the rotation are essentially different from the curve of Pott's disease, which is chiefly an antero-posterior curve. In the former rotation is an unmistak- able 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 recumbency; and there is never a sharp angular projec- tion. In Pott's disease the spine is not flexible but stiff, the curve is not lateral but angular, and it does not disappear on recumbency. Methods of Recording Lateral Curvatiire. — Several methods of recording lateral cur- vature have been recommended, the sim- plest being the measurement of the tips of the scapulae from the vertical line already mentioned, and a measurement of the dis- tance of the point of greatest convexity from the median line. Tracings of lead outlines of the sides of the trunk are of value if accurate, but Fig. 1 71. -Diagram of Lines of Dis- they are not readily taken with accuracy. tortion in Lateral Curvature. Casts of the trunk are not readily taken with accuracy and are bulky and also inaccurate. The most reliable method will be found to be that of photo- graphing the patient's back. The back should be marked with crayons on the spinous processes and the tips of the scapulae, and the patient should stand with the arms crossed in front of the body while a photograph is taken. Several appliances have been described designed to record cor- rect measurements, of which Buhring's and Mikulicz's and Schult- hess's should be mentioned. Buhring's apparatus consists of a glass plate 16 by 20 inches fixed in a frame. The patient stands in front of the glass plate, a tracing on paper is made from the outline of the back which is projected upon the glass plate. Mikulicz's scoli- osometer consists of a vertical and horizontal arm, the latter mov- ing upon the former. The vertical portion is fixed to a pelvic band, and to the end of the vertical portion is fixed a goniometer so arranged that every torsion of the body marks a deviation on the indicator {Centralblatt f. Chir., 1883, p. 305). Schulthess's ap- pliance {Centralblatt f. OrtJiop. Chir., 1887, No. 4) is said to be effi- cient but is expensive.' ' A much cheaper appliance and apparently equally efficacious has been devised by Dr. C. L. Scudder, of Boston. LATERAL CURVATURES OF THE SPINE. 147 Proc;nosis. No accurate data are in existence wliich enable us to form a definite prognosis in this peculiar affection. Two errors in prog- nosis are common. Plrst, that the disease is of the most serious nature; second, that it is a trivial affection and will be readily out- grown by the patient. The fact is, that in the larger number of these cases the affection is a self-limited one, occasioning slight Fig. 172. Fig. 173. Figs. 172 and 173. — Schulthess Appliance for Recording Lateral Cur\-ature. deformity, which persists through life, causing no trouble and recognized only by the dress-maker or by some near relative. In other cases, however, the disease becomes decided!}- worse as the deformity increases, and a pitiable distortion follows, causing a great deal of neuralgic pain and a pitiable deformity. Sometimes the disease may remain to a slight extent during girlhood and early womanhood, developing an increase at a period past middle life. Such cases are rare, and are dependent upon a loss of general health. It is impossible to state in what in- stances an increase of the curve will take place and when they can be relied upon to remain stationary. 148 ORTHOPEDIC SURGERY. It may, however, be said that where the physical condition dur- ing the growing period remains constantly below the proper stand- ard, and where the patient's growth is rapid, an increase of curve is to be apprehended. The decrease or diminution of lateral curva- ture from simple growth without treatment has never been seen. In determining the prognosis in any given case the following facts must be ascertained and borne in mind : First, the probable rate of growth. This can be ascertained by the patient's height, the hereditary tendency toward height as ascertained by the height of the parents and the parents' families. The general opinion is that completion of growth exerts a power- ful influence in arresting progress of the curvature. In a girl of health at the age of twenty, with only a slight degree of curvature, this may remain without increase for life, or for a while; but there remains a liability to increase, and Adams notes a case where a patient, with a slight curvature up to the age of forty, developed a very severe curvature at sixty, owing to failure of general health. The physician should bear in mind certain facts as to the rat.e of growth of children. Malling-Hansen,' as director of the Royal Deaf and Dumb Institution, has examined 130 children, weighing them at different times. The boys were weighed at 6 a.m. and 9 P.M. The girls were weighed once a day, at 2 P.M. He found that a child might weigh from one to two pounds heavier at night than in the morning, and be more than one pound and a half lighter in the morning than it was in the evening before exercise. Bathing did not influence the weight. There was always an increase after a full meal. He found that there were three periods in which the weight varied : first, a period of decrease from the middle of May in each year to the middle of July; a period of increase of great importance from the middle of July to the middle of November; and then a period in which the child's weight increased slightly, but often remained sta- tionary, and might even diminish, from the middle of November to the middle of May. Temperature had an effect upon increase and decrease, increase of temperature being accompanied by increase in weight, and vice versa. Boys consumed one-fifth more than girls. The patient's occupation also is influential, as it may be said that if a patient has gained full height and development in figure, any increase in growth is not to be expected, and an increase in curve is not probable after the osseous system has become thoroughly formed, though such an increase may occur if there is a failure of health and strength. The normal height and weight of male and female are here given for the sake of reference. ^ Brit. Med. Journ., Sept. 20th, 1884. LATERAL CUA'V A TUNICS OL 77/ A' SILXK. 149 Tahi.k )V \\vm;\\:\ and WKKiirr Atak. Ilr.MAN P.OIA-. Age. At birth,' I 2 3 4 5 6 7 8 9 10 12 14 16 iS 20 25 30 40 year, years, Height in Feet and Inches. I ft. 7 in, 3 " (0.496 m. (o. 696 ' ' (0.797 " (0.860 " (0.932 " (0.990 " (1.046 " (1. 112 " (1.170 " (1.227 " (1.282 " (1-359 " (1.487 " (r.6io " (r.700 " (1.711 " (1.722 " (1.722 " '(1-713 " Weight. 7 lbs. ( 3.20 kgm.) 22 " (lO.CX) ' 26 " (12.00 ' 29 " (13.21 ' 33 " (15-07 ' 3^' " 116.70 ' 39 " (18.04 ' 44 " (20.16 ' 49 " (22.26 ' 53 " (24.09 ' 57 " (26.12 ' 68 " (31.00 ' 89 " (40.50 ' 117 " (53-39 ' 135 " (61.26 ' 143 " (65.00 ' 150 " (68.29 ' 152 " (68.90 ' 151 " (68. 91 ' Female. Age. Height in Feet and Inches. At birth, 1 year, . 2 years, 3 4 5 6 7 9 10 12 14 16 18 20 25 30 40 I ft. 6 in. (0.483 m.) 2 " 3 " (0.690 " ) 2 " 6 " (0.780 " ) 2 " 9 " (0.S50 " ) 3 " . . . (0.910 " ) 3 " 2 " (0.974 " ) 3 " 4 " (1.032 " ) 3 " 7 " (i.og6 " ) 3 " 9 " (1-139 " ) 3 " II " (1.200 " ) 4 " I " (1-243 " ) 4 " 4 " (1.327 ") 4 " 9 " (1-447 " ) 4 " II " (1.500 " ) 5 " I " (1-562 " ) 5 " 2 " (1-570 " ) 5 " 2 " (1-577 " ) 5 " 2 " vi-579 " ) 5 " I " (1-555 ") 6 lbs ( 2.91 kg m.) 20 " ( 9-30 ' 25 " (11.40 ' 27 " (12.45 ' 31 " (14.1S ' 34 " 37 " (15.50 ' (16.74 ' 40 " (1S.45 ' 43 " (19.82 ' 50 " (22.44 ' 53 " 67 " 84 " 98 " (24.24 ' (30.54 ' (3S.10 ' (44-44 ' 117 " 120 " 121 '• (53- 10 ' (54.46 ' (55-oS ' 121 " 129 " (55-14 ' (58.45 ' The conclusions of Pravaz are well expressed, who considers that " the patient's general condition is of great importance in the prognosis of lateral curvature. Chlorosis and imperfect nutrition are unfavorable to the re-establishment of the figure. In general, recovery of the figure is more to be expected in younger than in older patients, but the writer wishes to warn against the prevalent idea that patients will grow out of a curve of the spine. The prog- nosis in curvature following" phthisis is unfavorable, and distortions ISO ORTHOPEDIC SURGERY, due to disturbances of muscular action are often very difficult to treat, and rickety distortions are more unfavorable for treatment than those due to a loss of flexibility of the spine in children at the time of the second dentition or puberty. Curvatures submitted to treatment at an early stage, even when quite pronounced, may be- come corrected provided the patient's general condition is good, the prognosis depending in a large measure upon the amount of rotation of the vertebrae present, rather than on the amount of the curve. Curvatures in the lumbar region are less favorable than those in the dorsal region, and curvatures with a long radius are more readily straightened than those with a short." The lateral curvature seen in early Pott's disease is easily cor- rected by the proper treatment for caries of the spine. The de- formity which comes on in the later stages and is dependent on osse- ous change is irremediable. Preventive Measures. As faulty attitudes exert an important influence in causing lat- eral curvatures, the avoidance of these is of importance in prevent- ing curves. The attitude assumed in sitting is necessarily of great importance. The accompanying pictures depict the attitude usu- ally taken by children in writing, as well as the desirable attitude. Fig. 174. — Faulty Attitude. Fig. 175. — Corrected Attitude. Schenk (" Zur .Etiology der Scoliosis," Berlin, 1885) has studied the attitude in writing assumed by 200 school children. In 160 the trunk was found inclined with a convexity of a lower dorsal curve in 160 cases. In 34 the trunk inclined toward the right, but the body twisted toward the left. In only 6 was there no twist of the body. In only 38 was the transverse axis of the body parallel with the LATERAL CURVATUKl-S ()/■- Till-: SriNE. 151 desk, and in the others the pelvis was twisted obhquely tfj the right. The writers have taken the opixirtiinity to examine the attitude as- sumed in writini,^ by 67 healthy adult males, while writinc; in a three- hour written examination. At the end of two hours the attitudes were observed. In all the paper was inchned 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 th« left ear was usually slightly lower than the right and some- what 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 remainder 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 attitudes will be equally common in weakly children. The proper attitude during writing is with the transverse axis of the trunk parallel with the edge of the waiting table. The fore- arms should rest at least two-thirds of their length upon the table. The trunk should be held erect, the legs should be straight be- fore the trunk, and the feet should rest upon a sloping cricket which rests and steadies the legs. Scats, — Chairs used by children frequently do not properly sup- port the back muscles, 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. The. accompanying pictures show the profile of a proper support for a school chair designed by Liebreich, and also a reclining chair. A fruitful source of faulty attitudes in sitting is furnished ^by chairs, which, not fitting the child or supporting the back properly, induce the patient to sit sideways, the trunk being supported on one tuberosity of the ischium and on one elbow. 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; or if this is not practicable, hard cushions or false chair backs made of leather stiffened with steel should be placed in the back of the chair so fitted as to act as a proper support. For children with weak backs it is advisable that the lower part 152 ORTHOPEDIC SURGERY. of the back should be well supported. 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 assumed by the patient. The back of the chair should slope backward slightly, forming an angle of ioo° to iio° with the seat. The back of the chair should be arched with the convexity forward, the greatest convexity cor- responding to the physiological curve in the hollow of the back. The back of the chair should be constructed so that it will serve Fig. 176. — Diagram showing Imperfect Support of Back in Badly Fitting Chair. Fig. 178.— Liebreich's Chair and Desk for School Children with Weak Back. as a comfortable support to the whole spine when the child leans backward. The backs of most chairs simply touch the shoulders of children in the upper dorsal region. Liebreich's school chair is designed to meet this end. Staffel has advised the use of a lumbar back rest, which can be secured to a chair at a proper height; it should be narrow enough to fit into the lumbar region. The following measurements are adapted from Staffel:' 6-9 years. Height from seat to floor, • 33 c.m. Height from seat to middle of lumbar pro- jection of chair, 21 " From edge of seat to vertical line drawn • from lumbar projection to seat, . . 26 " II. g-T2 years. 37 cm. 23 " 30 " III. 12-15 years. 41 cm. IV. Adult. 47 cm. 27 34 38 Staffel, Centralblatt f. orthop. Chin, May ist, 1885. LATERAL CURVATUKES OR THE SRLXE. 153 Fig. 179. -School Bench and Seat with Support for Hollow of Back. These pictures illustrate a f(;rin of school chair whicli will be found to support the hollow of the back. 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 of the table should b e one-eighth of the height of a girl, and one- seventh of that of a boy. The height can also be determined in the fol- lowing ready way: The distance from the olecra- non of the bent arm to the seat with two inches added should be the dis- tance 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. Attitude During Sleep. — The attitude during sleep is of import- ance. To determine the attitudes usually assumed by children, the accompanying observations were made by Dr. E. G. Brackett, who was allowed, by the courtesy of the Superintendent, Dr. Heath, to examine the decubitus of the children in the Marcella Street Home, Boston. 320 healthy children were observed with reference to the decubitus while asleep. Of this number 156 were boys, 164 girls. The majority w^ere between 6 and 14 years of age, and all be- tween 4 and 16. It was noted whether the child was lying on the back, side, or stomach. In many instances the decubitus was so nearly dorsal that it was a question under what head it should be placed, but none were considered as h'ing on the side unless the position was such that the pressure was borne on one side of the thorax. In about three-fourths of the number seen, the position was easy, the body straight, and head on the pillow, exposed. In several the head was so thoroughly Fig. iSo. — School Bench and Seat with Support for Hollow of Back. 154 OR THOPEDIC S URGER Y. wrapped in the blanket, that it could not be removed without almost shaking the child out. Among those not lying on the back, the favorite position was on the side, with the knees drawn up nearly to the abdomen, and the head bent forward toward the thorax. Among the girls, this position was more common and more extreme. One position was seen closely resembling that of the foetus in utero. The child, a boy of five, was sitting on the right buttock, with the body thrown forward and to the right side, with the knees in apposition to the thorax, and the feet crossed. The head had fallen forward, the face resting on the knees, one arm lay across the chest, the right seemed to be under the side. In this position the child was soundly asleep, and required a shak- ing to be roused. The figures show the positions to be about equally distributed among the three — back, right and left side, except with the boys from lO to 14, among whom there were a majority on the back. In the others the age did not seem to influence the tendency. Boys, 4-7 " 10-15 Girls, 4-8 8-10 . . 8-12 9-14 Back. 21 41 62 13 12 7 51 R. 24 20 44 14 17 20 59 L. 15 39 15 12 16 49 Stomach. 4 7 II 2 I 5 Dr, Hare, of Boston, examined the decubitus of the healthy in- mates in one of the penal institutions of Boston, recording the positions observed after 10 P.M,, that is from one-to two hours after the time the inmates went to bed. The results were as follows : Lay on Back. Lay on the Right Side. Lav on the Leftside. Stomach. Total. Men, Women Boys, 536 136 68 384 74 73 321 56 15 24 8 1292 266 164 Totals, . . . 767 531 392 32 1722 The decubitus of the boys in this table is to be noticed. The frequency of the decubitus on the right side is quite marked, and is explained by the fact that the boys were all required to lie upon the right side when they went to sleep to prevent conversa- LATERAL CURVATURES OF TJIE SJ'FNE 155 tion, two hours later some had turned on tlie face, some upon the left side. It will be seen that the most common attitude in sleep is upon the side, but that 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 difTerence 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 dorsal convex curve makes these facts of value. Faulty attitudes are fre- quently assumed in walking and in standing, especially by young children. The habit of standing upon one leg is usu- ally 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, if possible, by drill or by muscular exercise. In ordinary cases the pre- cautions at night which should be observed are that the pa- tient should not be allowed to sleep with many pillows, and the bed should be a firm one. The child should not be al- lowed to assume a twisted po- sition, but should lie upon the back or the side of the great- est concavity. In threatening Fig. iSi.— Faulty Attitude of Child, Laterally Curving Spine. cases measures are necessary to preserve a proper position. This can be done by means of bed frames, described under caries of the spine. Much has been said about the injurious effects of corsets, and there is no doubt that the muscles of the trunk are weakened by the wearing of corsets (Hutchinson, N. Y. Med. Record, April 27th, '89, p. 464), The custom is at present so prevalent that it is difii- cult to prevent patient^ from wearing corsets unless under fear of immediate injury. The injury from corsets may be made less by seeing that the lacings are elastic and the waist boneless or fur- nished with slis^ht steels. 156 ORTHOPEDIC SURGERY. Treatment of Lateral Curvature. Several difficulties are to be met with in treating lateral curva- ture. As the affection is active during the period of growth, treat- ment, to be efficient, must be carried on for a long time and this is tedious to the surgeon 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, the dis- tortion and danger vary at different periods of the trouble, and consequently methods which are necessary at certain stages of the affection are not needed later on. As has been said above, lateral curvature is a curve and torsion of the spinal column, due to the superincumbent weight falling irregularly upon a weakened spinal column which is constantly held out of line. There are, therefore, three ways in which an in- crease of distortion can be prevented : 1. By removing the superincumbent weight. 2. By strengthening the weakened spinal column. 3. By preventing the spinal column from being held constantly out of line. I. Removal of Superincumbent Weight. — Recumbency is the only practical way in which removal of the superincumbent weight can be applied for any length of time, as suspension must be a tempo- rary measure and recumbency constituted the chief method of treatment of the older orthopedic surgeons. At present, however, we cannot consider that this is a method of treatment which commends itself for continuous use for any length of time in the treatment of lateral curvature, for, if prolonged for any great length of time, it necessarily injures the patient's general condition, weakens the muscles, and does not promote the forma- tion of solid bone in the spinal column, so that the weight can be borne without the yielding of the column. In cases of very rapid growth, where there is much fatigue, as in neurasthenic cases, re- cumbency, either on the back or in the prone position, may be advisable if carried out to the extent of rest for several hours of the day. The use of a distracting force, which is described in the works of the older orthopedic surgeons with the intention of obliterating the curve by a direct pull, is inefficient, as the amount of force that can be applied for any length of time is not sufficient to effect as much as the simple position of recumbency. This has already been demonstrated in spondylitic curves and is equally true of the fixed curves of scoliosis. LATERAL CURVATURES UE THE SPINE. 157 The ternporary use of suspension by the head can be added as a means of daily exercise, and can be i^erformed by means of the head sling attached to a sliding bar in the ceilinc,^ or to a wheel carriage, as indicated in the accompanying diagram. The employ- ment of this method for the sole and continuous treatment of lat- eral curvature is of course impossible, as the disease ordinarily runs its course through several years, but in extreme cases such methods maybe applied temporarily. 2. To Strengthen the Weak- ened Spinal Cohinin. — Any attempts to strengthen the bony structure in the pres- ent state of our therapeu- tic knowledge must be lim- FiG. 182. — Position for Application of Plaster Jacket. Fig. 183. — Pulley for Attachment of Self-sustaining Appliance. Fig. 184. — Means of Fixation of Pelvis in Application of Plaster Jacket. ited to the administration of tonics, and an improvement of the digestion, assimilation, and encouraging exercise and fresh air as far as it is practicable. The spinal column, however, can be strengthened in its practical power of resistance by increasing the strength of the muscles which hold it erect, as will be seen under the description of gym- nastics. 158 ORTHOPEDIC SURGERY. 3. Prevention of Faulty Positions of the Spinal Column. — There are three methods by which this can be accompHshed : The postural, The gymnastic, and The mechanical. Postnral. — The postural treatment is that method where correc- tion is sought by instruction in proper attitude. As a raw recruit is taught the position and carriage of the soldier, so children are to be drilled into standing and walking erect. This method is suited for the simplest cases. 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. When resting during the hour of drill the patient should remain recumbent. After the drill is over, such pre- caution 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 arrange- ment of the play hours, and a supervision of the chairs when read- ing and studying. Walking, running, and active games should be encouraged, while reading, except in proper position, should be dis- couraged. A certain amount of time should be given to proper rest of the back. The usual bad habits of position are as follows: standing on one leg, sitting at too low a table, sitting in a twisted position, and sleeping always on one side with too high a pillow for the head. In most early cases the faulty attitudes are clearly the result of muscular weakness. The growth in size has not been accompanied by a corresponding development of muscle. This condition is fre- quently 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 cases of gravity, 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 the gymnasia 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. Mr. Bernard Roth, of London, has devoted much time and at- tention to the development of proper simple gymnastics, combined with postural treatment, the efificiency of which he has demon- strated by a series of successful cases. He has pointed out that in each individual a certain attitude can be voluntarily assumed by the patient, which is the nearest approach to the normal. This attitude varies to a degree in each case, and must be ascertained LATERAL CURVATURES OE TIIIC S/>/j\E. 159 by experiment. The first step I'n treatment should be to determine this position, which he calls the " k-ey-note " position. All exer- cises should be made in such a way as to develop the muscles involved in this attitude, or while the attitude is maintained. The following are the exercises which he prescribes, varying in a mea- sure in individual cases : 1. Lying on the back, arms by the side, hands supinated, very slow deep inspirations by the nose, expiration by the mouth. 2. The same, with arms extended above the head. 3. Position the same as No. i, head rotation, lateral flexion of head. 4. Position the same, simultaneous circumduction of both shoul- der joints from before backward, elbows and wrists extended. 5. Position the same, one hip circumducted both ways (knees extended). 6. Lying on back, simultaneous extension of both arms upward, outward, downward, from a position of the elbows flexed and close to the trunk. 7. Lying prone, one hip circumducted both ways, knee kept ex- tended. 8. Sitting on couch, with the back at an angle of 45°, ankle cir- cumducted in, up, and out, while the toes are inward the whole time. 9. Lying on back with arms extended upward by the sides of the head, flexion of both arms (surgeon resisting). (The patient's knees, flexed over the end of the table, fix the trunk.) 10. Patient astride a narrow table, with the arms down and hands supinated, trunk flexion at lumbar vertebrse (patient resist- ing), followed by trunk extension (surgeon resisting). 11. Patient, with arms extended upward, leans against a vertical post with pegs on each side ; these he grasps. The surgeon gently pulls the patient's pelvis forward by his hands on the sacrum (patient resisting), also pelvis rotation on its axis to right and left alternately (surgeon resisting), with the hands on each side of the pelvis. 12. Lying on back with head and neck projecting beyond the end of table, the head is gently flexed by the surgeon's hand on occiput (patient resisting).' It is not a difificult matter to devise simple and practicable exer- cises to develop these back muscles. 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 ^ British Medical Journal, May 13th, 1882; and also Walsham, St. Bartholomew's Hospital Reports, vol. .xx. , 195. l6o ORTHOPEDIC SURGERY. to a spring balance. The patient, seated 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, and the amount of the pull is inidcated upon the dial/ A record of this registers any increase in the strength of the patient, and as a clinical fact it will be found that an improvement in carriage will correspond to an improvement in the indicated strength. The management of cases of this sort may be described in a general way as follows : After a careful inspection of the deformity, and a diagnosis as to the flexibility of the curves, and examination of the faulty attitudes, the child's height and weight should be taken and a comparison made with the standards established by Bowditch's tables,^ or the tables of measure for weight and height mentioned under the head of prognosis, in order to determine whether any excess of growth in height or deficiency in weight exists. It should be considered that if a child has grown with unusual rapidity, or if the height had increased without a proportionate increase of weight, greater care should be exercised in the management of the case. The patient should then be directed and taught to sit and stand and walk in as nearly a normal position as possible, and be drilled to assume this position. It should be the object of the attendant to see that all exercises taken during the exercise hour should be done without an assumption of a faulty attitude. The exercises assigned should vary in each caes. In addition to those already mentioned the following will be found of use: 1. The patient sits facing the assistant who holds a strap passing about the patient's occiput (prevented from slipping by a cross strap around the head and chin). The patient bends forward and back, keeping the spine straight. The backward movement is re- sisted by the assistant. 2. Same as above, except that the straps cross the shoulders. These exercises may be carried on with a weight and pulley, or rubber exercising tubes instead of the resistance of the assistant, but the amount of force is less readily regulated. The assistant should correct any arching of the back. 3. The patient stands facing a wall at arm's length from it; places the left hand upon the wall at the height of the chin, the hand being in a direction across the body. The patient,' supported by the arm, slowly brings the face toward the arm, bending at the ' By fastening a spring balance to the wall, and an arrangement with pulleys and cord connected to straps fastened to the patient, the actual amount of force in different move- ments can be estimated. ^ Reports of the Mass. State Board of Health. LATKEAL CURVATUI^I'lS Ol' 77//': S/'/N/L i6l ankles, kccpiriL; the wlic^le !)()(ly in line; the face slioiihl be turned so that the left ear touches the hand, and tlie standin^^r pfjsition slowly resumed, the body bein<^ still kept from bendint^ at the hijxs. 4. The patient stands with the heels, back and occiput against a projecting corner (of furniture or doorway), and places the elbow (the arm being flexed) as far back as possible. 5. The patient, seated on a stool or chair, should i)]ace 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, deter- mines the strain on the muscles of either side. For children accustomed to stand upon one leg, the best exer- cise is to drill them to stand upon the other for a specified number of minutes, and standing on one leg to lower and raise the body, bending at the knee. Exercises carrying out the principles advocated by Roth, have been recommended by Dr. R. H. Sayre {N. V. Med. Journal, Nov. 17th, 1888, p. 538), who describes them as follows: In beginning the exercises a mat or thick shawl is laid on the floor and the patient lies prone, the arms at right angles to the trunk, palms down, face turned to the convex side, and the back as straight as possible. The patient supinates the hands, throws the scapulse well back, raises the hands from the floor, and lifts the trunk, while the surgeon holds the feet doAvn. This is repeated three times; later on it can be done oftener. The breath should not be held during any of these exercises, but the patient should breathe naturally. If necessary to secure this, make them count out loud while exercising. With the hands behind the head, the patient raises the elbows from the floor, and raises the trunk as before, the feet being held by the surgeon. With the hands behind the head and the elbows raised, the body is swayed toward the convex side, the patient trying to " pucker in " the bulging ribs and not to bend in the lumbar concavit}'. The feet are fixed as before. With the arm on the side of the convexity under the body, the other arm over the head, the heels fixed, the patient raises the trunk from the floor. Sometimes the arm on the side of the concavity is put on the opposite buttock while the patient raises the trunk. Sometimes the arm on the convex side is put on the buttock, and in cases of marked lordosis, with great stooping of the shoulders, both hands are put on the buttocks while the patient raises the trunk. The patient now lies on the back, arms at the sides, palms up, and lifts first one foot in the air, while the surgeon makes resist- II 1 62 ORTHOPEDIC SURGERY. ance graduated to the patient's power; repeated, say, five times. The same is done with the other foot, and then with both. The feet are next separated and then brought together once more while the surgeon resists. Each leg then describes a circle, first from within out, then from without in. If there is special weakness at the ankles, with a tendency to flat- foot, the patient flexes the foot and extends it against resistance, and turns the sole of the foot toward its neighbor, the surgeon re- sisting, and it is then forcibly everted again by the surgeon, the patient resisting. The patient now lifts the arms from the sides, passing perpen- dicularly to the floor till they are stretched as far beyond the head as possible and then going at right angles to the trunk and parallel with the floor, returns them to sides palms up. While the heels are held, the patient rises to a sitting position, hands at the sides ; then she rises from the floor with the hands behind the head and the elbows at right angles to the trunk. The patient now stands with the heels together; toes turned slightly out, hands behind the head, elbows at right angles to the trunk; then rises on tip-toe, bends the knees and hips, keeping the back as straight and erect as possible, and rises up once more. With the arm on the concave side high above the head, the arm on the convex side at right angles to the body, she rises on tip-toe,, bends the hips, knees, and ankles so as to squat, then rises and stands. All this time care must be taken to push the body as straight as possible, and gradually educate the patient to hold it so, without wiggling during these movements. Let the patient practise walking in these positions, both on the flat-foot and tip-toe, and also step high as if walking up stairs. With the palm of the patient's, hand on the convex side against the ribs, pushing them in, the hand on the concave side, she pushes a slight weight up in the air while the body swings so as to straighten out the curves. Sit behind the patient, fix her thighs with your knees, while she holds both arms above the head and bows toward the floor, keep- ing her knees stiff while you keep her ribs as straight as possible with your hands. 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. The patient sitting with the back toward the surgeon, the latter pushes one hand against the most prominent part of the convexity, and with the other hand passed around the shoulder of the concave LATERAL CURVATURLS OJ' LJII-: SPINE 163 side, straightens out tiie curve as much as possible, the hand on the "bulge" acting as a fulcrum in straightening the curve. The patient sits on a stool in front of the surgeon, who fixes the Fig. 185. — Elastic Strip witli Handles. Fig. 186. — Exercise for Strengthening the Back Muscles. li Fig. 187. — Exercise for Back and Abdominal Muscles. Fig. iS -Exercise for Gluteal and Back Thigh Muscles. Fig. iSg. — E.xercise for Trapezius and Back ^Muscles. pelvis with his knees. The patient then twists the projecting shoulder to the front, while the surgeon holds the elbows, which are at right angles to the trunk, the hands being behind the head, 164 ORTHOPEDIC SURGERY. and makes resistance. In the same position the patient swings forward and back, swinging through the hips, keeping the back stiff and "not bending in the waist. The patient pushes in the ribs on the convex side with the hand, and pushes up with the hand on the concave side, the same as when standing. She also Hfts the arm of the concave side at right angles with the body while holding a weight. Where gymnastic appliances can be had they will be found of help. An endless variety of these can be employed, but the accom- panying will serve as the simplest and in the reach of those need- FlG. 191. Figs. 190, 191. — Sayre's Exercises for Lateral Curvature. ing home gymnastics. Efficient home appliances can be made by the use of rubber exercising tubes, which may be had at any estab- lishment for furnishing rubber goods. Better than these are the weight and pulley appliances which can readily be procured. The exercises should be such as develop the muscles of the back, in- cluding the neck; the glutaei muscle and muscles about the hip usually also need exercising, and the abdominal muscles also in many cases (Figures 185, 186, 187, 188, 189). Suspension as a means of muscular exercise is in all probability of little value, as the muscles which are brought into play are chiefly the arm muscles. The temporary relief of the superincum- bent weight which is afforded by suspension, may correct the curve LATERAL CURVATURI'.S OF TJ/L S/'/NL. i6; in a measure, but the effect cannot be lasting. Suspension will, however, help to relieve for a while in some severe cases of lateral curvature the sense of discomfort caused by badly distributed weight falling upon a distorted s[jine. The same may be said of trapeze and ring exercises. Gymnastics, as ordinarily prescribed for lateral curvature in gymnasia, consists in trapeze and hanging, ring exercises. Of these the same can be said as of ordinary suspension, viz., that they temporarily correct faulty attitudes without strengthening the muscles which physiologically are needed to hold the trunk erect. In prescribing exercises it is rarely practic- able to strengthen in double curves and in most single curves the muscles of the convexity without giving some exercise to those of the concavity. It is more practicable to oblige the patient to assume the most erect attitude possible and ex- ercise the large muscles of the back in this atti- tude. This can be done by rubber exercising tubes or better by the simple weight and pulley appliances. A few light dumb bells, and a few uprights, can be made to constitute a useful gym- nasium. The muscles of the lower parts of the back will be found particularly weak in most feeble chil- dren, and this is frequently a cause of faulty attitude. Fig. 192. — Self-suspend- ing Appliance. Mechanical Method of Treatment. The mechanical means used are for the purpose of either {a) limiting, checking or preventing faulty attitudes ; {b) for exerting direct pressure upon the projecting ribs or hip ; or for (V) abso- lutely untwisting the curves. To understand the first it is desirable to bear in mind the faulty attitudes most frequently assumed by patients with flexible lateral curves, as follow^s: (i) the elevation of the shoulder, the dropping of a shoulder; (2) the tilting of the pelvis, raising one hip; (3") lean- ing the trunk to one side. The appliances used vary in effectiveness from simple straps or springs to fixed corsets or heav}- braces. (i) For the first purpose, that is, prevention of the elevation of 1 66 ORTHOPEDIC SURGERY. the shoulder, a suitable shoulder-strap will be sufficient. This can be furnished by an ordinary cloth or soft leather strap which, pass- ing around the elevated shoulder above, is buckled below to a belt Fig. 193.— Seat Elevated on One Side for Changing Lumbar Curves. Fig. 194. — Strap for Correcting Elevation ot one Siioulder. which is kept down by straps secured to the stockings. (2) Ordi- narily, in light cases, the prevention of the raising of one shoulder will check the dropping of the other. If, however, it is not suffi- Fig. 195. — Crutch under Arm. Fig. 196. — Volkmann's Oblique Seat. Fig. 197. — Bandage Swathe in Lateral Curvature. cient, a simple crutch can be employed in connection with the shoulder strap to the opposite shoulder. For prevention of tilting of the pelvis the seat higher at one side, so often recommended, will be found of some use; it has LATERAL CURVATURI'S ()/• TIfK SI' /NIC. 1^7 little influence on the upper or middle dorsal curve, but it is un- questionably of use in cases of lower dorsal or lumbar curvatures. More easily carried about than a cushion is a thick pad of sad- dler's felt, which can be worn (secured to the waistband and drawers under the skirts) on one buttock. Mr. Barwell has recommended the use of ela.stic bands wound about the body so as to exert pressure on the desired points. They can be made to be of use in some instances to check faulty atti- tudes. Barwell's method has been recommended by Dr. Sayre in cer- tain cases. This method has lately been advocated by Fischer' who applies it in the following way: A band is placed around the shoulders like a figure of 8, bandages crossing behind and connected to an elastic strap which passes downward from the right side and forward over the breast and belly to a perineal band passing around the upper part of the left thigh. In this way the right shoulder will be pulled forward and down, and the left hip up — as is desired in the correction of the ordinary form of lateral curvature. If the curvature is of the opposite type, the straps should be placed pulling from the left instead of from the right shoulder and to the right instead of the left hip, and if the curve is a single instead of a double curve, namely, if the right shoulder is raised and the right hip lowered, the strap should pass around the front of the body and the left side and be connected to a perineal band on the right thigh. Corsets. — Corsets of some sort have always formed a common mode of treatment in lateral curvature. Where the faulty attitude is one of leaning to the side, lateral supports of some sort are of course needed. Many different varie- ties of corsets are in vogue — ^plaster-of-Paris jackets and their sub- stitutes, glue, felt, silicate of potash, wood pulp, woven wire, leather made on moulds taken from the jackets, and cloth corsets rein- forced by steel. In choosing the proper corset one has to be guided not only by the medical conditions of the case, but by the circumstances of the patient, and the importance of sightliness and comfort, as well as of ef^ciency. The matter of personal custom of the surgeon often dictates the choice of the material employed. Leather corsets, formed by being stretched on moulds of plaster jackets, the leather being reinforced by steel strips, will be found efificient and convenient. In light cases the leather corset need not completely encircle the trunk, but may simply be made in two lateral halves, connected by lacings or straps. * Centralblatt f. Chirurgie, 24, p. 17. i68 OR THOPEDIC S URGER V. Leather corsets may be furnished with broad inner leather strips which, sewn at one end to the inner side of the corset, pass through openings in the corset and are tightened and buckled into straps Fig 198 — Swathe in Lateral Curvature. Fig. igg. — Corset with Straps for Lateral Pressure. on the side of the corset, so that tightening these straps exerts lateral pressure. The place on the corset for the re-enforcement by steel strips varies in a measure in each case, but they should be so placed as Fig. 200.— Corset with Straps for Lateral Fig. Pressure. Cross section. Di. — Diagram of Plaster Jacket. Fig. 202. — Slipping of Plaster Jacket. to check the dropping of the shoulder if there is a tendency to this, as well as to check a habit of bending the spinal column to one side. Lateral supports should be as low on the side of the pelvis as possible. LATERAL CURVATURES OE TJIE S/'/NE 1O9 Corsets of this sort, or of any sort, are incaijable of entirely pre- venting leaning to one side. They serve rather as checks or re- minders. As a type of the stiffest corsets the j^Laster-of-Paris jacket may be taken. But it will be seen that although the trunk may be made straight by suspension, and a plaster jacket applied on a patient in this position, it is impossible to prevent a certain amount of slipping of the corset on the patient. If the corset slips upward, or if the pelvis alters its position, the bearing of the corset on the pelvis is loosened, and the corset tips and is pressed to the side by the trunk. This, of course, is also true if the corset is loosened or is made of a less stiff material. Besides this objection to the use of plaster jackets, it can be Fig. 203. — Removable Corset. Fig. 204. — Ambroise Fare's Beaten Brass Jacket. stateri that the method cannot be relied upon as the proper method of treatment in lateral curvature in all stages. The objections against the use of immovable plaster jackets have been forcibly expressed by Mr. Adams.' Plaster-of-Paris jackets, he thinks, fail as a curative agent ; the gain in height by extension is quickly lost ; the spinal muscles are weakened, and gymnastic exercise is impossible ; respiratory movements are restrained, and active exercise prevented ; the treatment is unnecessary at night, and bathing is interfered with. Poroplastic jackets, being remov- able, are free from the disadvantages of plaster, and in many cases of incurable curvature serve as a light retentive support. Mr. Adams' objections do not apply to the use of removable plaster corsets (corsets split at the front), these, however, are not as dur- able as those made of felt or leather, silicate or glue. Medical Times and Gazette, June 5th, 1880, page 623. I/O ORTHOPEDIC SURGERY. "Noble Smith, in speaking of the treatment of lateral curvature, records himself as not in favor of the perforated felt jacket. "(i.) Because felt jackets compress the walls of the thorax, and thus interfere with respiration. Fig. 205. Fig. 206. Fig. 207. " (2.) Because felt jackets do not thoroughly control the upper part of the spine, "(3.) Because the use of such corsets hinders the free develop- ment of the dorsal and other muscles. Fig. 208. Fig. 209. Figs. 205 to 210. — Beely's Corset. Fig. "(4.) Because he finds it better, if a support is needed, to use a light instrument which does not interfere with muscular exertion, but which acts as a support directly the muscles become too tired LATERAL C (./ A' V A T U ALCS ()/•• VJ/JC SJ'JXE 171 to keep the spine in an uprij^dit ])osition, and which prevents the subsidence of the spine into abnormal curves." It may be added that the use of corsets in lateral curvature is as old as Ambroise Pare — the accompanying cut representing the beaten brass corsets used by him (Fig. 204). Corsets should extend well down on to the hips for the purpose of securing a firm hold on the pelvis; even then it is difficult to A. B. Fig. 211 A and 211 B. — Stiffened Cloth Corset Applied to a Severe Case. entirely prevent tilting of the jackets and leaning to the side, as has been shown above. The accompanying illustrations shows Beel}-'s corset, which may serve as a good type of the light corset-form of appliance. This needs no description beyond the statement that it is made of stout cloth strengthened by strips of tempered steel and aided by straps (Figs. 205-210). Flexible corsets can be made of woven wire, or brass wire twisted spirally. Corsets, as has been said, can be made readily by modelling from 172 ORTHOPEDIC SURGERY. moulds taken from plaster jackets, applied to patients suspended or in a corrected position. Casts of the trunk can also be made by inclosing the trunk in a hard-rubber bag, into which wet plaster-of-Paris is poured. The ordinary method of applying a plaster jacket, with the self- suspension of the patient, aided perhaps by an appliance for steadying the pelvis, will be found most convenient. Mechanical Appliances. — Besides the various forms of corsets, a large number of heavier appliances have been in use designed to exert pressure upon the projecting ribs of the trunks and to im- prove the figure. Fig. 212. Fig. 213. Fig. 214. Figs, 212, 213 and 214. — Method of taking a Plaster Cast of the Trunk without Bandage. These supports -have fallen into disrepute at present, largely,, perhaps, because too much was expected from them, and as they have fallen short in actual accomplishment, are cumbersome and expensive. These appliances cannot be expected to untwist a rotated spine. They work at a mechanical disadvantage in that one of the chief factors in causing the rotation, viz., the superincumbent weight, is not relieved during the greater part of the day. Pressure also is applied not directly upon the spinal column, but on the ribs, and it has been urged that such pressure will simply increase the LATERAL CURVATURliS OJ'' /'//A' S/'/NF. 173 amount of motion in the costo-vcrtcbral articulation without affect- ing the spine. But as the chief deformity h'es in the projection of the ribs, anything which will check or diminish the amount of this projection, will be of advantage. In any appliance which is designed to exert pressure ujjon or correct the attitude of the erect trunk, it is essential that the base of the support be fixed. This can be done in several ways : 1st, by straps connected with the base of the support, passing under the perineum and secured in front. The support is, there- fore, checked if it tilts to the side. 2d. By straps at the base of the support which pass from front to rear on both sides over the rim of the pelvis and prevent tilting of the appliance. 3d. By attaching to the pelvic band of the support pieces of steel which pass down the outer side of the thighs and are strapped to them at the lower end, and at the upper end are secured to the pelvic band by a strong joint. Flexion of the thighs is possi- FiG. 215. — Points for Lateral Pressure in Deformity of Thorax. ble, but any leaning to the side of the appliance is checked in pro- portion to the strength of the steel and the length of the lower lever applied to the thigh. This fact is overlooked in a large number of appliances as will be seen in many of the illustrations. It is manifest that unless this fact is borne in mind, lateral pressure simply tilts the appli- ance without affecting the curve of the spine. In fact it may be said that unless the pelvic band is thoroughly prevented from tilting, the apparatus is useless. If the pelvic band is secured as far as possible from tilting, a base line is secured, steel arms can pass upward to the side of the trunk, and serve either as a point of attachment for straps, or for movable plates adjusted by a screw pressure. The points for lateral pressure and counter-pressure vary in each case, and with each curve. The accompanying diagram (Fig. 215) shows the points of pressure and counter-pressure in an extremely deformed thorax, and if there is also a tendency for the trunk to lean to the side, a side pressure is also needed. Pressure may be 174 ORTHOPEDIC SURGERY. needed on one side in the upper part of the thorax and in a differ- ent direction in the lower portion of the trunk. In describing the great variety of apphances recommended and Fig. 2i6.— Appliance with Lateral Screw Force. Fig. 217. — Appliance with Screw Force and Plates for Lateral Pressure. in use, it is impossible to describe the details in all. They may be classified as follows: I. Those exerting force by means of screws and levers. Fig. 218.— Jointed Back Upright. Fig. 219. — Appliance with Screw at Base for Altering Angle of Upright. 2. Those working by means of straps and buckles. 3. Those acting on the principle of leverage. Appliances with Screw Force. — Uprights are connected with a LATERAL CURVATUNLS ()/■' 77/ JC .V/'/yW:. 175 pelvic or waist band, and so adjusted tliat by means of a screw and worm the angle of the uprights can be altered. It is of course, as has been said, essential that the pelvic band be firmly secured, and this can be done by means of perineal straps, straps over the pelvis, or by connecting the band with steel rods which are fastened to the thighs. In the accompanying illustration straps over the pelvis are those relied upon to prevent tilting. An example of this form of appliance is given in the accompany- ing illustration (Fig. 216). aa is a pelvic band furnished with straps which pass over the crest of the ilium and prevent dropping of one side of the pelvic band, c is an upright for the back to which are attached arms Fig. 220. — Lateral Pressure by Plate and Strap. Fig. 221. — Appliance for Fixation by Strap. Fig. 222. — Appliance for Pressure by Straps. moved by a worm and screw and furnished with plates at dd. Crutches, bb, which pass under the axilla are designed to steady the appliance. The second illustration shows a more powerful appliance fur- nished with two uprights. Still another form is represented in Fig. 218, where the adjust- ment is secured in a less expensive way. Instead of the worm and screw, the upright is broken and parts can be moved laterally by means of a pivot, and secured in the altered position by means of a set screw. In another form the lateral motion is secured by means of a long screw on the pelvic band. The number of appliances which can be devised on the principles 176 ORTHOPEDIC SURGERY. of screw force is manifestly very great. The simplest form will be the best, provided it is also efificient. Appliances with Straps. — Forms of appliances attempting to secure correction hy means of lateral pressure through straps or lacings connected with an immovable upright, are usually lighter than those trusting to screw power. They are also simpler, but the power is not as carefully regulated and adjusted. The accom- panying illustrations show the various vyays in which straps should be adjusted. Appliances Relying on Leverage. — Lateral pressure can be exerted by means of the principle of leverage as is seen in the accompany- FiG. 223. — Appliance for Pressure by Strap. Fig. 224. — Appliance for Pressure by Straps. Fig. 225. — Appliance for Lateral Pressure by Straps. ing figure. This appliance is more useful in preventing faulty atti- tudes than in correcting existing deformity. Another form of appliance is made by which pressure upon the projection ribs can be effected on the principle of leverage in the following way. Arms are constructed so as to straddle the pelvis on each side. The two arms are connected behind by a joint and clasped in front; on both sides at the bottom these arms are furnished with straps, which press upon the sides of the hips. At the top one of these arms is furnished with a pad plate, on tightening the hip strap on that side lateral pressure can be exerted. A light crutch can be furnished to the arm on the other side. It must be admitted that the amount of benefit as yet obtained by heavy appliances is small. As a means of correction they can hardly be called successful, and for checking an increase of the LATERAL CURVATURLS OF THE SPJNE. 177 curve they may be of assistance, if tliorouj^hly carefully ai^plied and conscientiously worn for a lon^ period. The proper adjustment and choice of appliance, the judgment as to when it is to be worn and the length of time for the use of the appliance are matters on which authorities differ. No fixed rules can be prescribed and the cases need to be looked upon indi- vidually. MetJwdical Forcible Correction. — Lorenz, in a valuable work upon the subject, has suggested the advisability of correcting the dis- tortion of lateral curvatures by twisting the patient over a pad- FiG. 226. — Appliance for Lateral Pressure. Fig. 227. — Lever Principle for Lateral Pressure. ded bar, for several weeks, daily. This method is a tedious one, but if tried it will be found to be the most efficient means for cor- rection in cases with slight osseous curves ; but is manifestly un- suited for advanced cases. The arrangement depicted in the accompanying diagram, which is slightly modified from the appliances described by Lorenz and Beely, will be of service. Daily use of this Avill be found to cor- rect distortions which simple suspension or recumbency will not correct. The effect of sucli correction is only temporary, unless the gain be improved upon by fixative appliances. This Lorenz reports to have done successfully. Where correction is possible it 12 178 ORTHOPEDIC SURGERY. is evident that this can be done to the best mechanical advantage if the exciting cause, superincumbent weiglit, is removed. Suspen- sion, as has already been said, accomplishes this; but the effect of this mode of correction cannot be localized. By Lorenz's method this is more readily done. If the spinal column be arched backward the rotation can be made to disappear, and if slight bony or ligamentous change pre- vents the entire disappearance of the rotation, force can be applied to greater mechanical advantage when the patient is recum- FiG. 228. — Lorenz Method of Correction by Pressure. Fig. 229. — Twisting Appliance for Correction of Lateral Curvature. bent or the weight is taken off the spinal column, than when the patient is erect, by means of appliances. The treatment of lateral curvature in the early portion of the stage of development should be therefore an attempt to increase the backward flexibility of the spinal column, especially in that portion where the curve is the most pronounced. In short, there should be in these cases of lateral curvature an attempt to develop backs similar to those seen in the class of gym- nasts and contortionists, known as backward contortionists, who have developed an unusual amount of backward flexibility of the spinal column. In addition to the appliance employed by Lorenz is a simpler one, which can be used by patients at their homes. LATKKAI. CUKVyV/'l/A'/CS i)l' Till': SPINE. '79 The appliance, which should be placed upon a flat lounge, con- sists of a board a little wider than the patient and long enough to hold the greater part of the patient's trunk when recumbent. At the end of the board should be a wooden bar covered with a padded leather pillow. This bar should revolve on two pivots secured to the board, and the patient should lie with his shoulders Fig. 230.' — Twisting Appliance for Methodical Correction of Lateral Curvature. upon this padded bar Avhich should be raised about ten inches from the plane of the board. An assistant should gently pull the patient so that the shoulders will project beyond this roller, and should then direct and assist the patient to raise the arms above the head and bend the head and arms and upper portions of the neck and back, as far backward as possible. The patient should then be directed to take deep inspirations and expand the chest as far as he is able: he should now turn so as to lie chiefly upon the pro Fig. -Side Twisting of the Spine in iNIethodical Correction. jecting shoulder, the assistant pressing upon the projecting ribs in front and the patient breathing as deeply as possible. If the chief curve is in the lumbar region, the lower portion of the back should be placed upon this roller, the legs held down by an assistant, and the patient directed to bend backward as far as he can conven- iently do so. i8o ORTHOPEDIC SURGERY. Forcible rectification under anaesthesia is a method which has been recommended, but not appHed. Mr. Barwell {Lancet, April 27th, 1889, p. 831) recommends a method of forcible correction by means of exercising with straps, which he terms rachilysis. The method is a practical one, but hardly as efficient as that of Lorenz. Fischer has also advocated much the same plan, recommending that the patient should exercise by wearing weights hung upon the neck by means of a padded collar, the patient assuming such attitudes as may be required to bring the pressure in a proper direction. Lorenz has recommended the application of plaster corsets to patients held in a position twisted to the side, as is illustrated in the accompanying diagrams. The writers have made a thorough Fig. 232. Fig. 233. Figs. 232, 233 and 234. — I.orenz' Fixation Plaster Corset. Fig. 234. trial of this method, but have been unable to satisfy themselves that it presented advantages over the ordinary method of applica- tion of jackets. The exact value of methodical correction can hardly yet be de- termined, as the method is new, but from the cases reported by Lorenz, it would seem to be of value. This would be the opinion of the writers from their experience in the method. Operative Measures. — No methods of operative interference are of use in lateral curvature. Forcible correction under an anaesthetic has been suggested, but never deemed advisable. Myotomy and fasciotomy, advised by Guerin, have not been accepted as proper treatment. Sayre and Volkmann have both performed myotomy, but the latter has rejected the method [Centralblatt f, Chir., No. 30, p. 483, 1880) and the former no longer employs it. LATERAL CURVATURES Of' THE SEINE. /8f Correction in a Recumbent Position. This is a method formerly much employed and at present in all probability too much neg- FlG. 23s.— Reclining Couch with Lateral Pressure and Traction. Fig. 237.— Reclining Couch with Traction by Weight. Fig. 23S.— Side View lected. The accompanying picture illustrates forms of a reclinino- couch for lateral pressure and a traction force. The latter is 0I httle advantage, except as a means of securing the patient. I82 OK THOPEDIC S UR GER V. Spinal couches present a wearisome method of treatment, but in cases which are rapidly becoming worse, they offer the most tho- rough means of treatment. They can be employed for a certain number of hours a day. Choice of Methods. If the methods of treatment mentioned be recapitulated, they maybe summarized as follows: i, postural; 2, gymnastic; 3, by recumbency; 4, methodical correction; 5, mechanical. These are severally suited to different classes of cases, and the selection of the proper method or methods will vary according to the patient's condition and the state of the curvature. If the back is flexible and no osseous change has taken place ; if the curvature entirely disappears when the pa- tient is recumbent or suspended, and is appar- ently dependent upon habits of attitude, stand- ing, or sitting, the postural method is applicable, coupled with careful selection of school seats, desks, and home chairs. If to this condition of habitual faulty attitudes, muscular weakness of certain groups of muscles is added, proper gymnastics should be employed. If the curves are threatening to increase, and the patient gives evidence of nervous exhaus- ^^^ , tion, recumbency for several hours a day should V « ^F ^^ enforced; and in the worse cases, recumbency Fig .39 -Fixation Board should be aided by fixation in improved position with Lateral Pressure. by mCanS of appHanCCS. When the curves are somewhat fixed, but some flexibility still remains, the method of methodical correction carried out for sev- eral months will be found helpful, in addition to gymnastics and postural exercises. Of appliances, removable plaster jackets or corsets of that type, will be found the most available, as they are of service in prevent- ing or checking the assumption of faulty attitudes, and as checks to torsion and growing out of the ribs. Appliances, however, should always be regarded as to be supple- mented by gymnastic treatment, and should only be used tempo- rarily during the period of the greatest increase of the curves. It cannot be asserted that the use of appliances or corsets can in all cases be dispensed with. They are needed in cases where the curve threatens to increase, and among negligent people where LATERAL CURVATURES UR TJIR SPINE. 183 gymnastic treatment cannot be well carried (jut, while there is a pressing clanger of increase of the curve. Corsets and mechanical appliances necessarily weaken the mus- cles of the back, and are to be avoided if possible, and when they are used, massage is advisable in addition to gymnastics. The amount of time needed for treatment varies necessarily. In general it should be stated that growing children need careful in- spection during growing years. The inspection need not be fre- quent, 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 inspection, is all that is necessary. In more threatening cases, methodical correction and the use of appliances under supervision for several months are desirable. In the severest types of rigid curves, no corrective treatment is advisable, as the symptoms can be relieved by stiff corsets, or suspension, recumbency, massage, and electricity. The subject of treatment has been well summarized by Walsham : (i) All lighter cases should be treated by gymnastics. (2) Appli- ances can be combined with gymnastic treatment. (3) Even in the severer cases gymnastics should be employed, and in event of fail- ure, corsets can be employed. (4) Corsets alone, however, never result in cure, rarely in improvement, and sometimes do not pre- vent an increase of deformity. CHAPTER III. OTHER AFFECTIONS OF THE SPINE. Curvatures of the Spine. — Physiological Curvatures. — Scoliosis. — Kyphosis. — Round Shoulders. — Rheumatism of the Spine. — Lordosis — Weak Spine. — Spondylolisthesis. — Affections of the Thorax. — Malignant Disease of the Spine. Physiological Curvatures of the Spine. As the spinal column is composed of several segments bound together by ligaments and muscles, it is frequently curved in a variety of ways. The amount of possible curvature is checked by the shape of the vertebrae, the length of the ligaments and the tonicity of the muscles, and this amount can be somewhat increased by practice, as in acrobats (Thomas Dwight, Scribners Magazine, May, 1889) and varies in degree and kind according to age, occupation, and physiological capabilities. The anatomical researches of the Weber brothers, Henke and Meyer, and others have fully explained the physiological curves of the spine, and little need be said here farther than to state that in infants the spinal column is straight. When the child begins to sit, the back bends, the convexity of the curve being backward, but on standing and walking the pelvis is rotated from the position necessarily assumed in the sitting and lying position, and the spine becomes curved forward just above the pelvis, making the so-called hollow of the back. In this way are developed the so-called physiological curves of the spine, which are constant and characteristic, but vary to a degree according to the habits, occu- pation, sex, and shape of the individual. The curves are as follows : a long curve, involving nearly the whole of the dorsal region, with the convexity backward ; above this the spine is bent in another curve in the cervical region with the convexity forward, and in the same direction in the lumbar region. Fig. 240. — Physi- ological Curves of Spine. Fig. 241. OTHER AFJ'l'lCTlONS Ol' 77 /K S/'/N/C. 185 The long dorsal curve becomes changed and exaggerated in persons who habitually bend forward from habit or occupation, and the hollow of the lower part of the back varies greatly in dif- ferent individuals. The effect of superincumbent weight upon the spinal column is to exaggerate the physiological curves, and as is well known, there is a diminution in the height of the body at the end of the day of from thirteen to fourteen millimetres. As a proof that muscular action does not cause the physiological curves of the spine, a rare instance may be cited of that condition, where owing to malformation or disease, the acetabulum was want- ing, and the weight fell upon the hip-joint paced forward of the nor- mal position.' In this case the pelvis tipped backward more than normal and the lumbar curve was obliterated, so that the lumbar region was filled and the hollow of the back disappeared. Mus- cles act as a check to the bending of the spinal column and it is a combination of this with the fact of gravity and the necessity of keeping the head erect which gives rise to the curves which are always found in the erect figure. Muscles weakened either by disease or by too rapid grow^th, which are unable thoroughly to do the work expected of them do not prevent an increase of these curves. The same is true of cer- tain occupations as that of cobblers and tailors as compared to that of soldiers. It will also be found that there is a difference in length of the spine according to the patient's attitude, the spine being longer in the recumbent position that when standing. The amount of this change will be seen by referring to the ac- companying 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 a child. The difference was rela- tively greatest in the child. Age. Height in Erect Length in Dorsal Difference. Position. Recumbency. I 28 5 ft. 8 ^ in. 5 ft. 9 ^ in. , ■-| in. 2 40 6 " I/, - 6" 2Je" H" 3 38 5" 7-^i" 5" 83!," 1^" 4 15 5" A" 5" lA" M" 5 22 5 " S " 5 " m " 10" T6 6 29 5" Sif" 5 " 9 " ^" 7 30 5" iixr' 6" ^" A" 8 22 5" "A" 5" iiH" 1*6" 9 31 6 " 2 " 6" 2if" ' 12 a 10 35 5" 4lf" 5 \\ S^ \\ A" II 3i 3" lA" H" Result same in eight other cases in which measurements were not recorded. ^ Monks, Boston ]\Iedical and Surgical Journal. Nov. iSth, 1SS6. l86 ORTHOPEDIC SURGERY. Age. Erect. Recumbent. Difference. 35 ■ Evening, lo P.M. Morning, 7 a.m. 5 ft. 4H in- 5 " 5A " 5 ft. 5/^ in. 5 " 511 " if' The curvatures of the spine demanding orthopedic treatment apart from the curvatures from caries of the spine already de- scribed, are of three kinds : 1. Lateral curvature ; scoliosis. 2. Curvature with convexity backward ; kyphosis. 3. Curvature with the convexity forward; lordosis. These are frequently combined. Scoliosis. Lateral curvature of the spine has been considered in the pre- ceding chapter, and will not be discussed here. Kyphosis. The curvature of the spine with the convexity backward (kypho- sis) is either the physiological curve increased to an unusual degree, or it represents a curve incident to pathological states. . The first variety usually is situated in the upper part of the spine between the shoulders, and constitutes what is ordinarily termed round shoulders. This is due either to a habitual bending forward of the head and neck, or in addition to this, to a position of the shoulder blades, which are dropped forward instead of being held back nearer to the spine as in the normal position. Ordinarily this condition is the result of a relative muscular weakness, the head being bent forward from a diminished muscular tonicity. This condition of things is seen more frequently in rapidly-growing chil- dren. The curvature may also result from habit or occupation in perfectly healthy persons, as the round shoulders of cobblers or tailors. Another and marked form is seen in the rounded shoulders so common in old age, when with the general wasting of the tissues, partial absorption of the intervertebral discs takes place, and the vertebral column assumes a greater curve in the dorsal region. This is noticed in nearly all persons who reach sufficient age to establish the process of the absorption of subcutaneous fat and the general condensation of tissue characteristic of that period. The intervertebral discs in the dorsal region in the aggregate are some- what thicker at their anterior than at their posterior part, so that they maintain the dorsal spine in a less curved condition than 'Boston Med. and S. Jour., Sept. 13th, 1883, 245. OTHIlR affections of Till': SPINE. 187 would be the case if the bones were in contact with each other. Consequently tiie wasting of these discs causes {greater dorsal curv- ature. A similar dorsal kyphosis, associated with ri<^idity, is seen in rheumatoid arthritis of the spine due to a process similar to the senile change just alluded to. A rare form of kyphosis is seen in osteo-malacia, where the whole spine may be bent so that it forms one long arch with the convex- ity backward. In one severe case examined by the writers, the curve was so great that the chin of the patient rested on the um- bilicus. No difificulty is met in recognizing this form of kyphosis, as the other symptoms of osteo-malacia, the brit- tleness of the bones, etc., make the diagnosis clear. A most common form of kyphosis is that seen in children with rickets. This is usually situated in the lower dorsal re- gion and always involves two or three vertebrae. The curve is rounded and usually disappears or diminishes as the pa- tient lies UDOn the face Fig. 242. — Kyphosis in Advanced Paralysis of the Back Muscles. though this is not always the case. A very marked form of kyphosis of nearly the whole spine is sometimes seen in cases of paralysis of the back muscles, either after anterior polio-myelitis or in the advanced stages of pseudo- muscular hypertrophy or progressive muscular atrophy. In these cases' the patient sits with the head resting almost on the knees with the whole back forming one curve with the convexity back- ward. The kyphosis of caries of the spine has already been considered. A recognition of the condition of kyphosis presents no difificulty, and the recognition of the causes which produce the curvature is ordinarily easy in the recognition of the pathological state. ■ Caries of the spine, cancer of the spine, infantile paralysis, rick- ets, chronic vertebral rheumatism, and arthritis, are all recognizable affections, and when kyphosis is present with these affections, the cause is evident, and kyphosis resulting from different occupations is also recognizable, a ready inference from the knowledge of the occupations. 1 88 ORTHOPEDIC SURGERY. Round Shoulders. — What may be called an exaggerated phy- siological kyphosis, round shoulders, is recognized by the flexibility of the spine and the evident muscular weakness. The latter can be determined by the dynamometrical muscular tests. These ^re obtained easily by the use of a spring balance screwed to the wall against which the patient pulls by means of a cord attached to a head cap. The patient sits on a stool facing the balance and bends backward, using the back muscles. The condition of round shoulders is sometimes mistaken by anxious parents for spinal de- formity, but is readily distin- guished from that by the differ- ence in the projection of the shoulder blade, and by the rounded outline of the kyphosis. In high cervical caries, however, a condition is sometimes seen in the dorsal spine, which closely simu- lates round shoulders. The spine is flexible in round shoulders. This condition in very young children has no especial signifi- cance, but in older children it indicates a lack of strength of the spinal column, and to an ex- tent a predisposition to lateral curvature. Treatment of Kyphosis. — The forms of kyphosis requiring" treatment are the rhachitic, and that due to muscular weakness. ^_ The kyphosis of caries of the lar Weakness of Back. spine has already been spoken of. The kyphosis of rickets is ordinarily in the lower dorsal region, and requires no treatment except anti-rhachitic treatment, aftd the avoidance of the sitting position to a large extent even in the milder cases. In severe cases of young children in the acute stages, it is, however, desirable to oblige the patients to maintain the recumbent position, supporting the back by a corset or frame. The bed frame described for Pott's disease is the most convenient ap- pliance. Light braces and corsets are of use as checks to increase of the curvature, but they are of little use in infants, owing to the small size of the patients, and in older children with rachitic curves gymnastic exercises are more suitable. Former orthopedic methods Fig. 243. — Back Support Formerly Applied in Muscu- O'/'J/JCR AJ'I'-I<:CTI0NS OF 77 /JC S/'/NK. 189 are exemplified in the figure. Where supports are needed tliey arc of the same kind as tliose needed for the orch'nary round slioidders. The mechanical and gymnastic treatment needed in round shoul- ders has been well described by Stillmann, of New York, in a paper read by him before the American Orthopedic Association. Still- mann directs that the patient should lie upon a lounge with the head and upper extremities lying over the end of the lounge, and should bend the head, neck, and upper part of the body as far backward as possible. Dumb-bell exercises should be carried out in this position. Exercises can also be carried on by means of weights and pulleys, while the patient is leaning on a board arched backward, the board be- ing so arranged that the patient is recumbent. The lighter cases can best be treated by gym- nastics. For other cases, mechanical appliances should be used made of light steel on the princi- ple of the ordinary an- tero-posterior support, or in case the head is thrust badly forward, it should reach high enough to support a cravat or stock which, encircling the neck, is fastened be- „ . ^ . „ cu ,j c ' _ fiG. 244. — Antero-posterior I* IG. 245. — Shoulder Straps to hind to the steel upright Support for SUght Kyphosis. Hold Projecting Shoulder-blades i. j-l- u 1 A „„ on Jjoth Sides. at the back. A very con- venient and efficient appliance in all but severe cases is found in tempered steel uprights which lie against the transverse processes of the vertebrae and terminate in shoulder loops ; below they take their origin from a rigid steel waist-band. The condition of round shoulders is usually accompanied b}- a tendency to allow the shoulder blades to drop forward; this can be checked by means of straps applied as in the accompanying dia- gram. The continued use of any supporting appliance Avithout careful gymnastics is likely to lead to weakness of the muscles of the back. Mr. Roth has pointed out another possible result from shoulder braces.' ' Trans. Am. Orth. Association, Boston, 1SS9, vol. i. IQO ORTHOPEDIC SURGERY. " I have observed in numerous instances where shoulder-braces have been worn for several months or longer, and where from mis- placed perseverance and severity they have been worn extra tightly, that the unfortunate wearer has tried to obtain relief from the excessive pressure of the straps over the coracoid process and adjacent clavicle on each side, by throw- ing the whole upper trunk backward by undue arching of the loins, with the result of producing severe lumbar lordosis in ad- dition to the dorsal "Fig. 246.— Faulty and Correct Position. kyphosis for which the apparatus was being worn. I am quite aware that dorsal kyphosis is generally accompanied by compensatory lumbar lor- dosis; but in these cases to which I refer, the lumbar hollow is much severer than usual, and causes an exaggerated thrusting for- ward and prominence of the abdomen. Of course I am referring to the kyphosis of muscular debility, and not to that due to spinal caries. In spite of these facts, ninety-nine out of one hundred medical men of the present day are in the habit not only of allow- ing but even of advising patients to wear these instruments of tor- ture. I understand that large fortunes are being made by the sale of those popular American and other shoulder-braces which are so largely advertised at the present time." Dumb-bell and weight exercises will improve the condition by strengthening the trapezius muscle. Care should be exercised in supporting the Fig. 247.— Faulty and Correct Position. back by properly fitting chairs, and by the avoidance of faulty attitudes already mentioned under lateral curvature. The kyphosis in ostitis of the spine (Pott's disease), malignant disease of the spine and aneurism, is easily recognized and charac- teristic, and in all of these affections it presents much the same characteristics. OTIU'IR A/'-FJ-:C77()NS OJ'' 7J//-: SI' I NIL 191 Another form of kyphosis is from chronic rheumatic arthritis of the spine. Rheumatism of the Spine (Spondylitis Deformansj. Ankylosis of the spine early follows rheumatism or occurs as a manifestation of rheumatic gout (arthritis deformans). The affec- tion is one which has attracted little attention, but which presents certain characteristic features. It occurs as a complication of gonorrhoea in its rheumatic mani- festation and separately as a complication of arthritis deformans. In gonorrhoeal rheumatism the spine is rarely involved alone, but in a few instances this condition has been observed. In one hundred and nineteen cases of gonorrhoeal rheumatism collected in the article on Rheumatisme Blennorrhagique (" N. Diet, de Med. et Chir.," Blennorrhagie), the spine is not mentioned as having been involved. In the one hundred and sixteen cases carefully investigated by Nolen {^DeutscJics ArcJiiv f. Klin. Med., No. 8, 1882, p. 120) two are mentioned as having had, in combination with affections of the other joints, an arthritis of the vertebrae; one is mentioned as having recovered, and the other as not being entirely well at the time that he passed from observation. Ferron ("These de Paris," 1868, No. 211), without giving any clinical facts, states that all the joints of the body may be affected, even " those of the jaw and vertebrae." Instances, therefore, of a permanent stiffness of the back from this exciting cause, without any accompanying impairment of the functions of other joints, must be regarded as exceptional. Chronic rheumatoid arthritis of the spine is an affection which presents the same features as the gonorrhoeal form just mentioned. The spine is in these cases oftenest primarily the seat of the dis- ease, and the other joints sometimes become involved later. In the cases seen by the writers the patients attacked have been young adults and children. In this way it offers a decided excep- tion to the general behavior of rheumatic gout. And the affection has been clearly a primary ankylosing arthritis of the vertebral column, accompanied by manifestations of a disease which resem- bles rheumatoid arthritis. Adams,' in his classical monograph on rheumatic gout, mentions spinal rheumatism as occurring in severe cases affecting other joints, the distortion sometimes being so severe as to interfere with locomotion. Annals of Anatomy and Surgery, Brooklyn, 1SS3, vol. vii., p. 6. ig: ORTHOPEDIC SURGERY. Paget has recently described a chronic inflammation of the bones (Medico-Chirurgical Transactions, 1879, 2d series, vol. 42, 1877, p. '^'j) which he has named osteitis deformans (also called Paget's dis- ease), " the spine, whether yielding to the weight of the overgrown skull or by change in its own structure, may sink and seem to shorten with greatly increased dorsal and lumbar curves." Similar is the arthritis deformante du rachis, described by Ley- den, 1874, and by Braun ("Klin, und Anat. Beitrage z. Kenntniss d. Spondylitis Deformans," Dr. Julius Braun), and also in an arti- cle in the Transactions of the London Clinical Society, 1879, P- 204. Rosenthal (" Diseases of the Nervous System," American trans- lation, 1879, p. 225) states " that the principal phenomena in deform- ing vertebral inflammation of a chronic course (also called verte- bral gout) consists of a difificulty in the movements and stiffness in the corresponding vertebral articulations combined with pe- ripheral pains. The loss of motion is most marked in the cervical column. Thickening and nodosities are sometimes observed in certain parts of the neck if the cervical vertebrae are affected, or in the abdominal region when the lumbar vertebra are involved. At times well-marked creaking is observed in rotary movements of the neck." The deformities of the vertebral column following spondylitis deformans may sometimes exercise compression upon the cord. Putzel (" Functional Nervous Diseases," p. 133) mentions the fact that the affection is scarcely mentioned by writers on orthopaedic surgery. Two cases of ankylosis of the spine with stiffness of the other joints are reported by Brodhurst (Reynolds' " System of Med- icine," vol. i., 960), and one case of ankylosis of the spine is men- tioned by Delpech (" L'Orthomorphie "). Syniptoiiis. — The symptoms of the affection are pain in the spine, sometimes aggravated by every jar and paroxysmal in char- acter. It is described as being very distressing and these patients move with the greatest possible care to avoid being shaken. In other cases pain may be a subordinate symptom, and may be little complained of. Stiffness of the spine is the characteristic symp- tom. The normal curves are slightly exaggerated, especially the dorsal curve, and perhaps very much increased, and the patient walks somewhat bent over by the dorsal kyphosis with a gait some- what like that of Pott's disease. In stooping the motion is entirely from the hips. In lying down the curves are not affected or oblit- erated. In short the spine is stiff from the sacrum to the occiput in the worst cases and permits no more motion than would an iron rod. In the severer cases the ribs are ankylosed at their junction with the spine, and the chest wall scarcely moves in inspiration, or OTiii'iR AJ'in'icTioNS ()]■ Tiir: SI' INI-:. 193 it may be entirely stationary and of course tlie breatln'n^^ is wholly abdominal. The cervical vertebra; are usually the last to be affected, and motion of the head is possible after the dorsal and lumbar regions have become rigid. There are no other characteristic symptoms of the affection. In less severe and advanced cases the sj)ine is not involved to the whole extent, but marked stiffness without angular projection exists in a portion of the column. The course of the disease is chronic in the extreme, and its duration covers many years. The bone inflammation has no de- structive tendency and accomplishes nothing more than stiffen- ing tlie vertebral column. The impairment of the general health consequent upon this is generally not so severe as one would anticipate. The diagnosis of the affection can be made by recognizing the rigidity of the entire vertebral column without the angular promi- nence of Pott's disease, nor does the latter affection so stiffen the whole column, but only the diseased region. Pott's disease involv- ing the whole or a large portion of the vertebral column would soon lead to very marked results in its destructive tendency. The immobility of the ribs is a pathognomonic sign of the affec- tion and the involving of other joints would merely confirm one's opinion of the character of the affection. The early stages of the affection have never been seen by the writers and have not been satisfactorily described. It need hardly be said that the prognosis is unfavorable. The harm done is irremediable and the prospect of checking the general disease almost hopeless. The dorsal curvature will probably in- crease, and if the other joints are involved, the patient's condition is deplorable. Treatment. — In the matter of treatment very little can be said. The general measures useful in rheumatoid arthritis ordinarily should be faithfully tried. The outlook in this affection is no bet- ter than in the other manifestations of these diseases. Electricity to the spine may be of some use in altering the con- ditions of the local circulation. It is useless to try to ward off the approaching ankylosis by manipulation and the measure is harm- ful and painful. Hot application and hot baths sometimes mitigate the symptoms. When pain is present on motion, mechanical support is indicated. In a case under the care of the writer excessive pain was caused by the jar of walking and by any sudden movement, although the spine was anchylosed except in the cervical region. A steel antero- 13 194 ORTHOPEDIC SURGERY. posterior head support with a chin rest was appHed, and the patient obtained relief from its use, and a decided irritabihty of the cervical muscles was quieted and he was able to move his head more freely than before. The use of the apparatus in this case was a pure experiment, but it justified the hope that some relief may be afforded to the painful cases of this unfortunate class. After wearing the brace for some months, the patient was able to discontinue its use gradually, without any return of the pain. An acuter form of rheumatic inflammation of the vertebral artic- ulations has been mentioned, but such a form must be rare. Lordosis. Lordosis of the spine, with the convexity forward, is, like kypho- sis, either due to an increase of the normal physiological curve, or to the pathological states already described. In caries of the spine a compensatory lordosis below the carious point is not un- common. In paralytic conditions, the attitude is often the result of an attempt to balance the weight of the upper part of the body without bringing a strain upon the back mus- cles; the attitude character- istic of pregnant women, and large-bellied persons, the so- called " attitude of the alder- man." This is also true of the lor- dosis from muscular weak- ness. Lordosis also exists in pregnant women, in persons with large fatty abdomens or abdomens distended from any cause, such as ascites and abdominal tumors. In these cases it is merely a balancing of weight by which the centre of gravity is brought over the centre of support. The deformity also exists as a result of professional training in professional gymnasts, especially in the class of gymnasts who- Fig. 2, Extreme Lordosis. OTIU'lR AJ'1'1<:CTH)NS ()/'- Tlll'l S/'/NE. '95 have been trained as backward contfjrtionists and are able to bend the spine backward to an unusual decree. These contortionists habit- ually walk with a naarked degree of lordosis, A compensatory lordosis is seen in cases of congenital dislocation of the hip, and when contraction of the hip joint in a flexed posi- tion has occurred, as the result of hip disease or for any other reason. Lordosis is also present in many cases of rickets on account of the rotation of the pelvis on a transverse axis as described in Chapter XIX. Lordosis will also be seen in cases of infantile paralysis, pseudo- hypertrophic paralysis and muscular debility, when, owing to the weakness of the back muscles, the erect position cannot be main- tained through ordinary muscular, tension alone. In these cases the back is hollowed out, so that the body weight falls further back and the muscles which keep the spine from bending are not needed; a ligamentous support being sub- stituted for a muscular one. A very common cause of lumbar lordosis is found in hip disease, whenever by muscu- lar rigidity or by adhesions the leg is flexed ^ upon the pelvis. In order to enable that leg to be put on the ground, the lumbar region bends, allowing the pelvis to rotate and the flexed leg to come into the same plane as the other. In this way the patient Fig. 249.— Appliance for Lordosis. is able to stand or lie with the legs in the same plane. As recov- ery from hip disease with a leg slightly flexed is not uncommon nor an altogether undesirable position for the leg, if ankylosis must be present, this form of lordosis is one which is commonly met. For the same reason when the hip is flexed for any other reason, as by the contractions following infantile paralysis, lumbar lordosis is equally common. In the gymnastic treatment of lordosis, the exercises mentioned for the strengthening the muscles of the back in lateral curvature will be of use. In certain cases, supports may be of assistance. Either the form of corset used for lateral curvature, or an appliance which presses on the sacrum below [e), and shoulders above and exerts counter- pressure upon the abdomen by means of a belt band (d) secured to the back uprights (a and b). 196 ORTHOPEDIC SURGERY. Weak Spines. A class of spinal troubles due to strain of position is not infre- quently met. It can be considered under two heads: (i) It is seen in patients young enough to go to school, where the routine is injurious to them, and where cure is to be effected by a proper division of study and recreation, including muscular exercise, good food, and fresh air. (2)' Those who have drawn from their stock of muscular or nerve force in the development of their intellect. After freedom from the restraint of school, their time is devoted to a sedentary life or to one of undue nervous excitement. In such cases the great mus- cles of the back are those most called upon, and give out either from want of nutrition or excessive tension. The equilibrium which is maintained by concerted action of the muscles of each side is lost, and neuralgic pains and backache follow. In several cases the writers have noticed a slight impairment of the faradic contractility of the muscles on the convex or weaker side. In these cases the attitude is usually that of an increase of the physiological curves, slight kyphosis and lordosis and also often a lateral curvature. The spinal column is flexible and there is often local hypersesthesia. The daily use of the faradic current is advisable. Cold sponging, friction, massage, light gymnastic exercises, and the application of a light support made of cardboard, wet and moulded to the back, and secured by a bandage, and worn at times, are to be included in the treatment.' Spondylolisthesis. This is an unc®mmon affection, sometimes confounded with caries of the spine. It is characterized by a great increase of the forward curvature of the spinal column in the lumbar region. Franz Neugebauer,^ in a most excellent paper upon the subject, arrives at the following conclusions : That the deformity is not so rare as has been supposed. That it may and does occur in both sexes, and is not confined to any particular age. That it is an acquired deformity, occurring in extra-uterine life, without the concurrence of a primary dyscrasia or inflammatory disease of the bones (rhachitis, osteomalacia, caries, ostitis). ^ Keating-, Philadelphia Medical Times, February 26th, 1881. = Archiv filr Gynaekologie, Bd. xix., xx. OTHER AFFECTIONS ()/■' TJ/E S/'/NE. 197 That althoLich it may occur in those early subjected to the carrying of heavy weights, and in women exposed to early and frequent pregnancies, yet in the majority of cases it has a distinct traumatic origin, and is to be looked upon as a surgical deformity. Schroeder' has reported nine cases which are discussed from an obstetrical standpoint. Rokitansky" has described two cases. Gibney^ recently reported a case of a man of twenty-nine years of age, previously healthy, who was thrown from a horse-car, strik- ing upon his back. Several ribs were fractured, as were also sev- eral of the spinous processes of the vertebrae, and there was a luxation forward of the lower lumbar vertebra upon the sacrum. Unsuccessful attempts were made to reduce this dislocation. The chief feature in these cases, consists in the separation of the body of the last lumbar from the first sacral vertebra, and the con- sequent sinking of the lumbar spine into the pelvis, so that the in- ferior surface of the last lumbar rests on the anterior surface of the first sacral vertebra. The anterior surface of the last lumbar ver- tebra is directed downward; the surfaces of the fourth, third, and second lumbar vertebrae form an arch, the most prominent part of which being nearest to the symphysis, takes the place of the normal promontory. The result of this displacement is a considerable short- ening of the antero-posterior diameter of the inlet of the pelvis. The gradual sinking of the vertebrae is accompanied by an atro- phy of the intervertebral cartilages and by a bony union between the lumbar and sacral vertebrae. The weight of the body con- ducted through the spine is now transmitted to the anterior surface of the sacrum instead of to its base, which tends to throw the pelvic centre of gravity forward. This is compensated for invaria- bly by lessened inclination of the pelvis, the anterior portion being slightly tilted upward. The backward pressure upon the base of the sacrum forces the posterior iliac spines wide apart, while the apex of the sacrum is thrown forward, thus encroaching on the antero-posterior diameter of the outlet. Since Kilian, in 1853, first drew the attention of obstetricians to the spondylolisthetic pelvis through the specimen known as the Prague pelvis, no new light had been thrown on the condition until Neugebauer in 1884 propounded his views in the Aiuialcs dc Gy- ndcologie. Until then, the views of Rokitansky and Kilian that the lesion originated in caries of the vertebrae were generally accepted, ' " Lehrbuch der Geburtshiilfe," S. 576. ^ " Nouv. Dictionaire de Medecine et de Chirurgie Prat.," vol. xii. , p. 132. 3 New York Med. Record, March 30th, 1879, p. 347. 198 ORTHOPEDIC SURGERY. some, however, holding that the deformity was due to rickets, osteomalacia, tuberculosis, or hydrorrhachis. There .are seventeen specimens of this deformity known to exist in museums and elsewhere, and Neugebauer concludes from an ex- amination of ten of these that spondylolisthesis may exist : (i) On the ground of congenital lateral defect in the ossification of one or both sides of the arch of the fifth lumbar vertebra, espe- cially in the interarticular portion of the arch (spondyloschizis inter- articularis congenita, arcus vertebralis). (2) On the ground of a primary fracture : {a) Of the sacral articular processes, if the posterior transverse span of the arch of the fifth lumbar vertebra is displaced forward, and its inferior articular process exhibits a corresponding antero- posterior elongation, {b) Of the interarticular portion of the arch of the fifth lumbar vertebra, if the posterior transverse span of the arch is not dis- placed forward, but has remained in its normal position, and whether the lumbo-sacral joint is ankylosed or not. Etiology. — The primary cause of this deformity is a separation of the articular surfaces of the last lumbar from the first sacral verte- bra, which may be brought about by fracture of the transverse processes; caries of the transverse processes induced by trau- matism, or by. traction upon the articular ligaments sufficient to produce luxation (as from the too early carrying of heavy weights). Several cases due to the latter cause have been reported by Arbuthnot Lane, Diagnosis. — Aside from the recession of the lumbar spines, one notes a prominence of the same with widening of the iliac bones. Breisky ' calls attention to the peculiar figure of persons with spondylolisthetic pelvis. The thorax and extremities are normal, while the abdomen is unusually short and appears to have sunk between the prominent iliac crests. The pelvic inclination is les- sened, the crests of the ilia are wide apart, and the gluteal region abnormally steep. It is often very hard to distinguish this condition from caries of the spine, and at times the diagnosis is impossible. Rickets has also been confounded with spondylolisthesis, but in any case where the rhachitic changes were enough to cause this same prominent lumbar lordosis, similar rhachitic changes would be present in other parts of the body. Prognosis. ^T\v& prognosis, of course, has to do largely with the effect of such a deformity upon parturition. Treatment. — The chief importance of this affection is in its effect '^ Breisky: Archiv f. Gynaek. , Bd. ix., 1876, p. i. OTJ/KA' .U'/'ECT/ONS OF nil': S/'/N/C. 199 upon jjarturition, and tliat asjjcct of treatment docs not belong here. The reduction of the dishjcation might be attempted in recent cases where the cause was clearly traumatic, but, as in Gibney's case, it is hkely to prove unsuccessful. In general it may be said that the condition is irremediable. Malignant Disease of the Spine. This condition needs little more than mere mention in this con- nection. Sarcoma and carcinoma of the vertebral column are oc- casionally met, and in their origin they may be either primary in this location or secondary to some deposit elsewhere. Sarcoma is often primary, and in several reported autopsies has been found to be of the large-celled type. Michel ' has described these under the head of "tumor myeloides." Cysts or cavities, with fluid or semi-fluid contents, are frequently found, and he has suggested a relation between this and hydatid cysts, but this can hardly be sustained. Carcinoma is more likely to be secondary, and has been noted following similar disease of the breast and testicle, and less fre- quently of the liver and stomach. The occurrence may be from direct extension, or from general infection. The disease usually begins as an infiltration of the spongy tissue of the vertebral bodies, which is gradually replaced by the malig- nant growth. There may be but little change in the appearance of the bodies, but these will be found converted into a soft, friable mass. Destruction of the bone substance with deformity may occur. Small growths external to the vertebrae are sometimes seen, and are likely to be mistaken for malignant disease of the vertebral column. The disease may pursue an insidious course, and not be suspected until found at the autopsy. This, however, is rare, and a serious affection is usually evident, even though no diagnosis is made. The chief symptoms are pain and paralysis, and both are the result of the encroachment of the growth on the spinal nerves and cord. Considering the course of the former and the intimate relation to the diseased bone, it is not surprising that pain should be an early and prominent symptom. It is usually increased by pressure and motion. The location of the pain will depend on the site of the diseased vertebrae, and will be accordingly in the arms, trunk, or legs. Edes"" states this symptom may disappear more or less com- pletely at a later period. The paralysis usually follows a disturb- '" Nouv. Diet, de Med. et deChir.,"39, 222. ^Edes, Bost. M. S. J., June 17th, 18S6, 559. 200 ORTHOPEDIC SURGERY. ance in sensation and is due to compression from extension of the disease, or from involvement of the meninges. It may be partial or complete, as a rule does not occur suddenly, and may, as in one case reported by Edes, show the result of the extension of the pressure to different parts of the cord. The occurrence of oedema from thrombosis in paralysis rather favors the theory of this disease as the cause. Tenderness over the spine is an uncertain sign, and probably has no more diagnostic importance than in ordinary spinal caries. When deformity occurs it will be found to present a more rounded prominence than is usually seen in Pott's disease. It is stated that in secondary disease the course is more rapid than in primary. Hemorrhage from the bowels or hematuria has been observed in several cases. Charcot ' gave the name of " paraplegia dolorosa " to the condi- tion which he had observed to follow infiltration of the vertebrae, more particularly those cases seen by him after cancer of the breast, and which revealed the existence of this disease, which was other- wise latent. These symptoms consist of pain, chiefly in the lumbar region, and radiating through the lower limbs.. In character these pains are lancinating. There is formication, sense of constriction about waist, no anaesthesia, but on the other hand there is frequently hyperaesthesia. Walking is usually interfered with, but complete paralysis does not occur. The bladder and rectum are not affected, and there is no marked vaso-motor disturbance, as shown by the tendency to rapid formation of bedsores, etc. When following malignant disease elsewhere, which can be rec- ognized, the diagnosis should present no special difficulty, but in other instances is usually hard or even impossible. It should be distinguished from aneurism of the aorta, and cervical pachymen- ingitis and Pott's disease. The prognosis needs no comment, a fatal end is only a matter of time. Distortion of the Thorax. A distorted condition of the thorax presents itself either as a congenital affection or as a result of pathological change in bone. A partial absence of the sternum has been reported in a small num- ber of cases and is interesting chiefly as a freak of nature. The prominence of the sternum results in a certain number of rhachitic cases and is secondary to the flattening of the back which by elevating the ribs makes the sternum more prominent. ' Charcot. Comptes rendus de la Soc. de Biol., 1865, 28. OTHF.R AFFECTIONS OF 77/ F S/'/NF. 2OI Where this is accompanied by a sinking in of ihr. ribs near the junction with the sternum, the deformity popuhirly known as "chicken breast" (pectus carinatum) follows. A sinking in of the lower part of the sternum accompanied by the [projection of the lower part of the ribs is also to be observed and a deep hollow at the end of the sternum will be seen which, if accompanied by large pectoral development, presents a deformity whicii may be alarming in appearance but without pathological significance. A widening at the lower part of the chest and a prominence of the lower rih)s in front, as if pressed outward by a distended abdomen, is some- times to be seen. These deformities require no treatment. Slight deformities of the chest acquircd-by continued obstruction to clear breathing have been described by Dupuytren, Robert, Hooper,' and others. Pigeon Breast Deformity. — This name has been given to a pro- trusion of the sternum and cartilages of the ribs. The antero-pos- terior diameter of the chest is enlarged. This distortion is more common in young children than in adults, which probably indicates that the patients often out-grow the deformity. The origin of this distortion is not known, but it is supposed to be due to an imper- fect expansion of the lungs from some obstruction occurring at a time in childhood when the bones were soft and flexible. Dupuytren has stated that patients with this deformity have previously suffered from enlarged tonsils. This is also the opinion of Mr. Timothy Holmes. Certain cases of dorsal Pott's disease are characterized by much deformity of the chest due to the sinking forward of the upper dorsal part of the spine, carrying with it the ribs. They have been discussed in Chapter I. ^ " Boston City Hospital Reports," fourth series, 66. CHAPTER IV. THE PATHOLOGY OF CHRONIC JOINT DISEASE. I. Diseases Affecting the Synovial Membrane ; Anatomy of Synovial Mem- branes ; Chronic Serous Synovitis ; Chronic Purulent Synovitis. — II. Joint Diseases Affecting the Cartilage ; Hypertrophy and Atrophy ; Pri- mary Inflammation of Cartilage ; Secondary Inflammation of Cartilage ; Loose Bodies in the Joints. — III. Joint Diseases beginning in bone ; Tu- berculous Ostitis ; Gummatous Ostitis ; Formative Ostitis (Arthritis De- formans) ; Exostoses; Tumors of the Joints; Miscellaneous Minor Affections of the Bone. — IV. Joint Diseases beginning in the Periarticular Structures; Ligamentous Affections; Periarticular Abscess; Bursitis — other Affections Impairing Joints. The pathology of chronic joint disease is a very extensive sub- ject, the Hterature of which is very extensive, especially in this transition period. For no part of the pathological domain has ex- perienced greater or more radical changes in the last few years, and to-day one has no accepted classification and no definite path- ological system; a great deal has been written, but it has yet to be crystallized into some definite scheme. No attempt will be made here to treat exhaustively the very ex- tensive subject of the pathology of chronic joint disease ; but sim- ply to present it in its practical, surgical aspect, and in its very important clinical relations. The pathology of chronic joint dis- ease can be best considered under the following simple headings: I. Diseases affecting the synovial membrane. II. Diseases affecting the cartilage. III. Diseases affecting the bone. IV. Diseases affecting primarily the periarticular structures. The consideration of acute joint disease will not be undertaken, as it cannot, by any construction, be considered as coming into the domain of orthopedic surgery. I. Diseases of the Synovial Membrane.— \t may be best to review very briefly the construction and function of synovial mem- brane before considering the diseases of that structure. Synovial membranes approach so closely to the serous mem- branes that they are often classified with them. But, although structurally much the same, they differ from the serous membranes Tin: PATJIOLOCV Ol' (.7/A'()N/C Jo/N'f I > IS EASE. ^ 203 ill sccrctini,^ a peculiar fluid, synovia, and tlicy arc not, like the peritoneum, etc., closed sacs, in all joints wliere motion takes place (diarthrodia) a lubricatinij fluid is necessary, and tliis fluid is furnished by the so-called syn(jvial membrane. Every diarthrodial joint is lined with a layer of synovial membrane, excej^t in the places where the articular cartilages arc in contact. Here there is no membrane,' except at tlie edL,^^; of the cartilages, which the syn- ovial membrane may overlap for two or three millimetres,- before merging into the cartilaginous structure. Fasciculi, and folds of the capsule, the internal ligaments, and fatty internal protrusions are all covered by the membrane. Synovial membrane is thin and elastic. Externally it merges into the tissue of the joint-capsule, while its inner surface is smooth and moist. Histologically the structure is a basement tissue of elastic and connective-tissue fibres, upon the inner surface of which lies a single layer of endothelial cells (His). In gross the inner surface of a joint presents a smooth and shining surface, inter- rupted, especially where the membrane folds to pass from one sur- face to another, by the synovial fringes (plicae synovialesj — villous structures of varying size and length, somewhat resembling intes- tinal villi, the largest being perhaps one centimetre long. They are richly supplied with blood-vessels, for each villus contains the con- voluted twig of an artery. Some of the fringes, however, are merely hernia-like protrusions into the joint of small masses of fat, covered by membrane; these fill up unoccupied spaces. The nerves are derived from the same nerve-trunks that supply the muscles of the limb. The nerve-filaments terminate in small plex- uses, unequally distributed, under the synovial membrane. The lymphatic network is not easily demonstrated, but that it exists is evident from the fact that coloring matter injected into the joint disappears very quickly, to reappear in the lymphatic channels of the limb. Synovia is a clear, alkaline fluid, much like the white of &^^ in general appearance; when rubbed between the fingers it imparts an oily sensation. It is largely secreted by the cells which cover the synovial fringes. In structure it contains albumin, mucin, some fat, leucocytes, and epithelial cells. A fluid identical in com- position with synovia can be produced by rubbing up a portion of the epidermis in a weak alkaline solution. This fact suggests ^ that most of the mucin is derived from the endothelial cells soaking in the weak alkaline fluid secreted by the fringes, and this view is ^ Cornil and Ranvier : " Path. Hist.," 227. Philadelphia, iSSo. = Cadiat et Robin : " Diet. Encyc. des Sc. Med.," ix. , 3, 549. ^ Barwell : " Diseases of the Joints," p. 22. London, 1S81. 204 ORTHOPEDIC SURGERY. strengthened by the fact, discovered by Frerichs,' that, when joints are quiet, the synovia in them contains only half as much mucin as when they are in motion. Chronic inflammations of the synovial membrane begin as such, or they represent the continuance of an acute synovitis affecting the joint. In general these inflammations are characterized by an increased secretion or perversion of synovia and a structural change in the membrane which often goes on so far that it invades other structures, and the cartilage and bone become secondarily affected. Chronic synovitis appears under one of two heads: chronic serous synovitis or chronic purulent synovitis, according to the character which the synovial fluid assumes. Chronic serous synovitis is also known by the names of dropsy of the joint, hydrarthros, hydrarthrosis, hydrops articulorum chron- icus, etc. As a rule, pathological changes are present in the syn- ovial membrane of a character about to be described; but certain cases show no pathological changes beyond this increase of fluid for a long time, and these are the cases which have given rise to the names hydrops, hydrarthron, etc. These cases were at first thought to be dropsical, and non-inflammatory, like hydrocele ; but, such a view is maintained at present by few. On the other hand we have Blandin,- Bonnet,^ Billroth,-* Volkmann,^ Cornil and Ran- vier,^ and Marsh, who place it among inflammatory affections. It must be said, however, that the fluid in the joints resembles the fluid of hydrocele in color and consistency; but it contains mucus, which is not the case in hydrocele, and as compared with the fluid of simple dropsy it contains more albumin. As opposed to the view that this is a dropsical affection it may be said that femoral aneurism and other obstructions to the leg circulation do not cause joint distention even in extreme oedema, and even in the cases of primary hydrops articulorum (which are not so common as those where it is secondary to acute affections) the view is now held that it is an inflammation of low grade, with slight tissue change. The most common form of chronic serous synovitis is where it succeeds one attack or a series of attacks of acute synovitis, and here the pathological changes are evident, although they are at first very slight. One sees in the commencement only a slight increase of vascularity and a tendency to thickening of the membrane which begins, perhaps, to look boggy from soaking in the excess of joint ^ Frerichs : Wagner, " Handworterbuch der Phys. ," iii., i, 446. ^ " Diet, de Med. et de Chir. pratique," 8, 89. 3 Bonnet: " Mai. des Artie." Paris, 1845. •* Arch. f. kl. Ch., ii., 408. * Billroth: " Surg. Path.," 1883, Am. ed., p. 578. * Cornil and Ranvier's " Plistology." THE J'ATHOLOGV OF CHA'ON/C JO/NT DISEASE. 205 fluid. This fluid may be insij^niificant, or very lar^Uj in amount; it is ordinarily yellowish or colorless, but at times it is red from blood originally effused. Increased vascularity and thickening of the membrane arc fol- lowed by an hypertrophy of the synovial fringes, described above. This hypertrophy varies from a slight and almost imperceptible hyperplasia to a condition where the fringes are transformed into a mass of fibrous polyj)i, so that the synovial surface may be fairly shaggy. At other times they are translucent, seeming to be (as they often are) fat globules '"nclosed in a delicate capsule. Meantime, the subsynovial tissue has hypertrophied, and in some cases it is known to have increased to an inch in thickness, and if the fluid has been long in the joint the synovial membrane and the parts below it look light yellow, pulpy, and boggy. If the effusion has been extreme the capsule has either become enormously thick- ened or has given way and become much distended. If so, the lateral and internal ligaments, weakened by the continual tension and soaked by the contained fluid, have also stretched, and lateral motion may be found in the knee-joint, even to the extent of 60"". There may, however, have been, instead, a development of cysts in connection with the joint, practically herniae. These occur oftenest in the popliteal space in connection with the knee-joint (Baker ') . The synovial membrane in certain cases begins to encroa upon the cartilage. Normally, it runs into the cartilaginous border for two to three millimetres, but now the hypertrophied membrane sends out processes which creep in still further, as pannus does on the cornea. These cases Hueter calls syiiovitis Jiyperplastica pan- nosa. It is simply an extension of the process that we have con- sidered above. It may go on to the formation of granulation tis- sue, but it is not likely that it will. Purulent cases generally follow another type, as will be seen, and after changes in the synovial membrane have reached this grade, secondary changes in the car- tilage are likely to begin. These are fatty degeneration of the car- tilage cells, fibrillation of the hyaline substance, and consequent disorganization of the structure. If it falls away and leaves the ends of the bones bare, eburnation and enlargement of the ends of the bones results. The outcome of simple serous synovitis is in absorption or suppuration, or a persistence of the condition with a continually increasing disability of the joint.. The Jiydrops articiiloru)>i tJibcrculosus of Konig is a peculiar form of serous synovitis that must be mentioned. This is a primary tuberculosis of the synovial membrane, and Konig accounts for ' St. Barth. Reports, xiii. 2o6 ORTHOPEDIC SURGERY. its existence by the supposition that the irritation caused by the tubercules' growth is not enough to produce its ordinary man- ifestation, in fungous granulations. It occurs most often in a dif- fuse tuberculosis of the synovial membrane ; sometimes in that form of chronic synovial inflammation characterized by the enor- mous connective-tissue formation described above; the class of cases which Hueter calls synovitis hyperplastica tuberosa;' and thirdly, in some cases of fungous synovitis in children, to be de- scribed later. The effusion has more of a serous than of a purulent character. The tubercles may be found present in a synovial membrane almost unchanged by inflammation where there were no symptoms of note before death. Ordinarily, however, the mem- brane is thickened and succulent, and studded with tubercles even into the subsynovial tissue. The surfaces tend toward granula- tions; if these are fully developed t>he effusion is generally purulent rather than watery. The exudation is often fibrinous, so that coagulation products of many shapes are present in the form of loose bodies, like melon-seeds, rice, etc. ; and, although formerly it was held that such bodies did not occur in tuberculous affections, Konig and Riedel"" now consider that the finding of these loose bodies in the hydrops of a joint or a tendon, increases the likeli- hood that the affection is tuberculous. This tuberculosis of the synovial membrane ordinarily coexists with a tuberculosis of the neighboring bone, although there is no communication between the two, and, from their appearance, neither is secondary to the other. ^ There is, finally, a form of chronic serous synovitis where the effusion is so scanty that the affection goes by the name of dry synovitis, or arthrite plastique ankylosante. At times this appears as an acute affection ; but again, and perhaps more often, it is found as a distinctly chronic joint disease generally in connection with some infectious cause, such as gonorrhoea. The effusion is so small as to be imperceptible, but it is so rich in fibrin that the ends of the bones are fairly soldered together directly by the organized exudation, although the changes in the cartilage are slight. •* Chronic p7ir7ilent synovitis is also called in English, white swelling,, fungous joint disease, gelatinous arthritis, pulpy degeneration of synovial membrane, strumous arthritis, etc. In German, Fungose Gelenkentziindung, Die granulirend tuber- culose Gelenkentziindung and Gliedschwamm ; in French, Tumeur ' Bohm, R. : " Beitrage zur Norm, and Path. Anat. der Gelenke," Wurzburg, 1868-69.. ^ Riedel : Deutsche Z. f. Chir., Bd. x. 3 Konig: " Die Tuberc. der Knochen und Gelenke," S. 22. Berlin, 1884. ^ Gaz. des Hop. Jan. 23d, 1881. THE I'AT1I()IA)(}Y Dh' CI I Ni)N IC J( )/ XT J )/S/':,IS /■:. 207 fongucusc, and tlic Latin names of the affection are Synovitis hyperplastica fungosa (Hucter), I'yartiirosis, lilmpyeina articuloruni, and last and most widely known of all, Tumor albus. The name tumor albus was originally given by Wisemann to practically all classes of chronic joint-disease characteri/x-d by swelling, and Brodie was the first to restrict its application to that class called by him " pulpy degeneration of the synovial membrane." Since that time it has stood as the name for tliat pathological con- dition, being especially applied to the knee-joint, until of late years the terms strumous and tuberculous have come to be applied to it. Like chronic serous synovitis, chronic purulent synovitis is either the continuance of an acute affection or it begins as a chronic dis- ease, insidiously and perhaps without assignable cause. At other times, however, it is the result of chronic serous synovitis when that terminates in suppuration. The first stage in chronic purulent synovitis, when it begins as such, is an increase of vascularity in the synovial membrane and perhaps an extension of it on to the cartilage. The synovial fluid is increased in amount and the peri-articular tissues are more or less infiltrated with serum. From this stage the membrane becoiries velvety, the cartilages look yellowish, and the synovia has been replaced by a fluid, vary- ing from turbid serum to laudable pus. It is possible to say in advance what a continuation of this condition would lead to, and the later changes found in chronic purulent synovitis represent this continuance. The hypertrophied and infiltrated synovial membrane takes on still greater activity; cell formation and vascular supply become very much increased, and the result is a typical but rather low- grade granulation tissue, Avhich is yellowish or pinkish, and admir- ably described by the terms pulpy and gelatinous. Microscopically it does not difTer in any way from granulation tissue as found else- where, except that it often contains in its structure small white specks, which are visible to the naked eye, and which are the struc- tures described by Koster {Virch. Archiv, Bd. 48) as tubercles. They were almost constantly found by him embedded in this tissue around the edge of the joint, and later in the disease generally through the fungous tissue. The proof of the identity of the struc- tures is well enough established ; Koster considered them true miliary tubercles {Arch, dc PJiys., 1870, p. 325), Brissaud {Rev. Mens, tie Med. et de Chi?'., June loth, 1879") thought that although joint fungus undoubtedly occurred without the occurrence of tubercles, there is abundant microscopic proof that tubercle is the 2o8 ORTHOPEDIC SURGERY. chief element. In this view, that the structures found are true tubercles, Konig {Deutsch. Arch. f. Chir., 1879, XL, 317 and 350), Friedlander, and Ranke agree. Bacilli are found in a certain pro- portion of caSes, as will be seen later. When the granulations are fully developed they secrete of course a purulent fluid, and they may melt into pus very rapidly or very slowly, and in certain parts of the joint the process may be much more advanced than in other parts. But this stage of disease in the synovial membrane will not have been reached without accompanying changes in the cartilage and bone. The cartilage becomes yellow and loses its opalescence, and if one tries to lift from it the synovial hypertrophies where they have grown over on to it, they often cling to it, and if they are pulled away leave a red and eroded surface of cartilage under them. The cartilage may, however, become granular first in other places, especially where the opposing surfaces are in contact, and notably does this occur when the limb is in malposition and parts of the cartilage not altogether used to it become roughly pressed together by the tonic muscular contraction. Often the whole de- generated cartilage may be detached and cast off from the bone, or it may be disintegrated in flakes. When, by the disintegration of the protecting cartilage, the granulations reach the bone they at- tack the tissue of the epiphysis in all directions. Hypersemia of the ends of the bones has already been present for some time, accompanying the joint inflammation, and the bone structure is readily destroyed by the action of the granulations. There is now no limit to be set to the destructive processes; the ends of the bones, softened and embedded in a mass of jelly, are crowded against each other by the muscular contraction, and a sinus is probably draining off the products of the destruction. The ligaments, infiltrated, degenerated, and over-stretched, have given way, and dislocations, complete or partial, have probably already occurred, generally as a result of the predominance of the flexor muscles over the extensors. The formation of intra-articular abscesses and their escape to the surface through the degenerated, capsule needs no explanation ; a fistulous track, lined with the same gelatinous material, marks their path. Sometimes the abscess has been extra-articular and results from the breaking down of the periarticular cellular infiltration, which contributes so much to the enlargement of the joint. On the other hand at any period of the affection reparative pro- cesses may set in. The granulation tissue then becomes less suc- culent; the areolar tissue in it more prominent, and the cells less numerous; in time fibrous tissue forms in its place and from this THE J' ATM O LOGY OF CHRONIC JOINT DISEASE. 209 may result complete or [);irti;il ankylosis; if these fibrous bands become ossified so-called true ankylosis is the result, if the car- tilages have not been extensively destroyed, or if the affection has been chiefly synovial, any degree of restoration, even complete mobility, may result. It is not uncommon to find associated with fungous joint disease, tuberculosis of the lungs, of the meninges, or general miliary tuberculosis. ' The division of the affection into stages has no justifiable patho- logical bass. II. Joint Diseases Affecting the Cartilage. — Such affections are known by the name of chrondritis, ulceration of cartilage, degen- .'iration or fibrillation of cartilage, etc. Cartilage is a tissue of low grade, non-vascular and sluggish in all its reactions, and it is to this that we must turn for the explan- ation of the extreme rarity of primary inflammatory disease of the cartilages of the joints. Surrounded on one side by synovial membrane and on the other by bone, this tissue lies in the neigh- borhood of far more irritable tissues than itself which react to any trauma or constitutional irritant long before the cartilage does. Hyaline cartilage is a bluish-white, opalescent structure of great density, which covers the ends of the bones in all diarthrodial joints. It is non-vascular and derives its nutriment from the bone and synovial membrane, which furnishes another explanation why secondary affections are so common. It consists of hyaline sub- stance and corpuscles which lie embedded in it and contain one or more nuclei. These corpuscles lie near the joint-surface in layers parallel to it, but deeper, near the bone, in columns perpendicular to the cartilaginous surface, which accounts for the readiness Avhich the cartilage shows to be chipped vertically. Externally the carti- lage is attached to the bone by the perichondrium, and the internal sui-face lies free and moist in the joint. Fibro-cartilage, when present, appears as a cross between fibrous and cartilaginous tissue. It appears in three forms — intra-articular ; circumferential, as around the acetabulum ; and, lastly, as the con- necting substance in joints which do not move (amphiarthroses\ as in the symphysis pubis. Histologically it consists of fibrous tissue intermixed with cartilage-cells and it possesses far greater tough- ness and elasticity than hyaline cartilage. Hypertrophy and atrophy of the joint cartilages are pathological processes occasionally alluded to, the former is seen in the margi- nal ecchondroses ' of arthritis deformans, and in children where ossification has been delayed the articular cartilages may appear to ' Cornil and Ranvier: " Path. Hist.," Phila., iSSo. p. 236. 14 2IO ORTHOPEDIC SURGERY. be very thick. Atrophy' of the cartilages occurs to a very sHght extent in the joints of old people, and sometimes where joints are subjected to very great pressure- decided atrophy of the cartilage (as of all the articular structures) takes place.^ The degenerative changes in cartilage follow a type which is peculiarly constant. The phases are many, but the process is es- sentially the same. It is, in a word, a cell multiplication, and fatty or granular degeneration of the corpuscles with a fibrillation of the hyaline substance. Whether we have in question primary or sec- ondary inflammation, the results of injury, or the degeneration of gout, it will be seen that the cartilage in its behavior follows very closely the type of degeneration described above. Primary inflammation of cartilage is a rare disease, and in the great majority of so-called cases the affection of the cartilage is secondary. In fact the existence of primary disease is denied by such men as Hiiter, Barwell, etc., but there have been recorded from time to time certain cases which seem to establish the fact that primary erosion of the cartilage does occur. The writer in Holmes' "Surgery" says: "Inflammatory ulcera- tions of the cartilages, unaccompanied by disease of any other joint-tissue, x^-A.y possibly take place, though cases of it are not easily met with ; " and that seems a fair statement of the situation. Years ago the discussion was not as to primary disease, but as to whether inflammation was present in cartilage at all, and whether the changes found were not the result of the other tissues acting on it. The researches of Redfern," Goodsir,^ Virchow, and Weber* estab- lish the active character of the changes well enough, and give the story of the controversy. As to the existence of primary disease, Brodie' reported some cases that he considered primary cartilage disease ; but, looked at in the light of modern pathology, there seems but little doubt that they were cases of primary disease of bone. The same is true of a case called " acute idiopathic ulcera- tion of cartilage " reported by Mack,® where the bone " was exten- sively carious." Panas' claims to have found erosion and ulcera- tion of cartilage without disease of other tissues. Bauer reported a case in 1871, where there seemed little doubt that it was a case ' Barwell: " Dis. of Joints," p. 408. ^ Holmes' " Syst. of Surg.," vol. iii., p. 55. 3 Arbuthnot Lane: St. Barth. Hosp. Reports. t Redfern: Month. J. Med. Sci. 5 " Anatomical and Pathological Researches," Edinburgh, 1845. * Weber: Virch. Archiv, 1878. ■* Brodie, Benj. : Quoted in Holmes' " Surgical Diseases of Children." ® Buffalo Medical and Surgical Journal, 1850, v., 385. 5 Article, Articulations, " Nouv. Diet, encyc. de Med. et Chir. " Paris. THE J'A'niOLOifV ()/■' CHRONIC JOINT iJ/SIiASIC. 211 of primary cartihic^inous disease of tlic intervertebral discs, and at autopsy the eight upper dorsal discs had been destroyed, while the cervical discs had become soft and pulpy. The patient was fifteen years of age, and the disease had lasted six years; there was prob- ably a traumatic origin. Other cases of suppurative inflammation of the intervertebral discs are recorded by Ogle," Broca,-= and Chas- saignac,^ where ulcerative changes were found in one or more of the intervertebral discs, which varied from a small perforation to complete disappearance of the disc. Kocher ■* reports three cases of circumscribed fungous disease of the internal meniscus in the knee-joint. • Secondary I nflavDiiation of Cai'tilagc. — As a result of the inflam- mation of synovial membrane or bone, secondary inflammation of cartilage is very common. The number of nuclei in the cells, and the number of cells in the corpuscles, multiply very fast. There is a certain amount of fatty degeneration of the cells present, and striation of the hyaline substance goes on to fibrillation, and local or general disintegration of that. The cells break from the cor- puscles and infiltrate the whole cartilage; it becomes yellowish and soft. If the process is very acute the hyaline substance is disintegrated without having time to undergo much fibrillary de- generation and the production of leucocytes is the prominent part of the process. If it is slower, fibrillation is more marked. At any rate, disintegration generally comes on, and where the carti- lage is gone (generally where the pressure is greatest) an ulcer with a granulating base and clean-cut edges is seen, of greater or less extent. The base of the ulcer consists of typical granulation- tissue, and in this way the entire cartilage may quickly disappear, or these ulcers may go on to cicatrization and heal by the forma- tion of a connective-tissue scar. At times when ostitis is the cause of the secondary inflammation of the cartilage the inflammation of the bone may have cut off the nourishment supply of the cartilage, and it undergoes necrosis and is cast off into the joint, where the yellow opaque pieces lie loose, or are disintegrated into pus. What is known as the " fatty degeneration of cartilage " is merely the regular degeneration of cartilage, and when the fibrillation is slow and fatty degeneration of the cells predominates it does not cause ulcers, but the degenerated fibres are tough and resistant and attached at one end and they lie with the other free in the joint-cavity. Intermingled with the fibres are fat-globules and a ' Path. Soc. Trans., xv., 1863, p. i, and vol. iv. of same, 1S53, p. 27. - Gaz. Hebdom., 1864, p. 29S. 3 Gaz. des Hop., 1S5S, p. 156. ■• Cent. f. Chir. , November 5th, i83i. 212 ORTHOPEDIC SURGERY. few leucocytes and the cartilage-corpuscles are either disintegrated or filled with fat-globules. The fibres may wear away and leave the bare ends of the bone, not ulcerated and covered with pulpy granulations, but white and eburnated. Fatty degeneration of car- tilage is considered to be analogous to the arcus senilis of the cornea in its etiology and pathology. In other cases the process is known by the name of the " fibril- lary degeneration of cartilage." Fatty degeneration and cell-multi- plication in the cartilage-corpuscles assume a subordinate place, and fibrillation of the hyaline substances becomes the all-impor- tant part of ihe degeneration. The fibres are well-marked, and where pressure occurs they are worn away, evenly or unevenly. Where they are worn away again we see white bone thickened and ivory-like; and calcareous degeneration occurs in the patches of the degenerated cartilage. It is "the ossification of cartilage." Around the edges the cartilage is covered by the synovial mem- brane, probably hypertrophied, and here cell-formation and fibril- lation begin as well as elsewhere ; but the cells cannot escape, having no free cartilaginous surface, and they are retained and become active in the form.ation of cartilage, and the marginal ecchondroses of which we have spoken are formed, so Marsh ' says. In time calcareous deposits occur in these as well. Sometimes they break off, and form one kind of the " loose bodies " in the joint. The deposition of urate of soda in the hyaline substance may, perhaps, be called the gouty degeneration. It is not a different process from the others — cell-multiplication and fibrillation go on as before. This urate deposit is simply superadded in the cartilage, where it is sometimes seen (in very acute cases) as a simple superfi- cial layer, then later, in white patches which are larger below the surface, where on more careful examination it is seen to have left the corpuscles free and to have settled in the hyaline substance around them. Still later it also invades them, and disintegration goes on. A simultaneous deposit of urate of soda occurs in liga- ments, bones, and the periarticular structures. Loose bodies in the joints come in for consideration more aptly under the diseases of cartilage than they do elsewhere. The other names for the condition are, loose cartilages, joint mice, floating or movable bodies in joints, mures articulorum, corpora libera artic- ulorum, etc. They can be divided into three classes, according to their structure, as follows: {a) Fibromatous, {b) Lipomatous, (<:) Chondromatous. These bodies lie free in the joint or attached by a slender pedicle. They vary in size from a small pea to a horse-chestnut or larger, 'Marsh: " Diseases of Joints." THE PATll()U)i}Y OF CHRONIC JOJN'r /J/S/wUS/C, 213 and are of all shapes. .The smaller ones are most often shaped like melon-seeds, or irregularly round, while tlie larger ones are more regularly round, concavo-convex, or spherical. Sometimes they are facetted and crowded together like the carpal bones, and then again they are mulberry-shaped or pyriform. In (me joint they may appear singly or in great numbers, and they may vary a great deal in size in the same joint. Mr. T. Smith removed recently over four hundred from one knee-joint.' The knee-joint is by far the most apt to be affected, and Harwell estimates that nine-tenths of all cases occur in that joint.- Next in frequency comes the elbow,' and all of the larger joints are liable to contain these bodies. In external appearance they are whitish or yellowish, and vary from a soft consistency to a bony hardness. On section they show either a plain fibrous structure, or a fibrous sheath inclosing a mass of fat. Again, the structure is of hyaline or fibro-cartilage, ordinarily with- out corpuscles, or of bone tissue, most often without Haversian canals. Frequently they present a combination of two of these forms. They are often found in connection with the changes known as arthritis deformans, and also in the form of chronic synovitis, already alluded to as synovitis hyperplastica tuberosa, where the .synovial fringes become much hypertrophied ; sometimes these hypertrophies are pedunculated, and if the stalk breaks the syno- vial tuft is left free in the joint as a loose body. Again, they originate in severed enchrondromata or osteophytes which have grown into the joint and been broken off; and some- times cartilaginous or bony plates develop in the synovial fringes or the joint capsule and are separated and lie loose in the joint. At other times the free body seems to be only the remains of a blood clot from a preceding acute synovitis or the consolidated residue of an effusion very rich in fibrin. Lastly, there is certainly a class of traumatic cases Avhicli have been much discussed. Formerly it was held that these free bodies (of the chondromatous class) were the result of the direct forcible tearing off of pieces of cartilage by wrenches or strains or blows, and Hiiter supports that view* as does also Virchow.^ The more modern view is represented by Konig, who does not deny the pos- sibility of this tearing off of bits of cartilage, but he insists upon its rarity and shows the great force necessary to detach them in ' Howard Marsh: " Diseases of Joints," p. 1S3. = Harwell : " Diseases of Joints," p. 26S. London, iSSi. 3 Konig : Arch. f. klin. Chir., 1SS8. 4 Cf. Erodhurst: St. George's Hospital Reports, 1S67, ii. s,, 141-144, and Volk- mann: Deutsche Klinik, 1867. No. 48. s " Die Krankhaften Geschwi'ilste," p. 450. Berlin, 1S63. 214 ORTHOPEDIC SURGERY. this way. Rather, he says, consider that theSe pieces are so bruised and injured by the trauma that their necrosis follows, and then a spontaneous osteochondritis desiccans takes place which leads to their detachment and sets them free in the joint. Cases in which the traumatic origin of these chondromatous free bodies is beyond question, are given by Mr. Marsh; ' notably one where, three weeks after a wrench to the knee, a free body was removed by Mr. Simon, which Mr. Shattock pronounced to be a piece of the articular sur- face.^ • There seems reason to believe that in spite of the lack of blood- vessels these bodies are nourished, after being set free in the joint ; not only does ossification of them take place after they are freed, but the case of Recklinghausen ^ would seem to show that growth is also possible. III. Joint Diseases Beginning in Bone. —The chief chronic disease of bone which ultimately involves the joints as well, is a patholog- ical process which is distinctly a degenerative ostitis; a certain amount of formative activity accompanies the process; but the general type is distinctly degenerative. In general terms the process is as follows: there is a hyperaemia of the vessels and infiltration from the distended capillaries and consequent absorption of the trabeculae, which leads to the forma- tion of the enlarged spaces known as the lacunae of Howship. The bone cells degenerate into fat and are finally replaced by embry- onic tissue, and when this stage has been reached of course the mechanism is at hand for any amount of destruction of bone tissue. The greater part of degenerative ostitis of the ends of the bones, especially in children, whom this form chiefly affects, follows one distinct type which is to-day classed as tubercular. The evidence which supports this view will be presented, and, in advance it may be said that this evidence is of such a character that it lends much support to the view that this chronic degenerative ostitis is really a tubercular affection. This disease, perhaps most correctly known as tuberculous osti- tis, is identified with a large number of other names. In English, scrofulous joint disease, tuberculosis of joints, chronic articular ostitis (of which most cases are tubercular) and in general the term of " caries " of the joints. German, scrofulose Caries, tuberculose Caries, Knochen-Nekrose,. Knochen-Abscess, scrofulose Gelenkentziindung, and fungose Ar- thritis. ' Howard Marsh: British Medical Journal, April 14th, 1888. ^ Pathological Society Transactions, xv. , p. 206. 3 ' De Corp. Liberis Articulosum." Regimonti, 1864. THE r ATI 10 LOG V 01'' CHRONIC JOINT DlSICylSli. 215 Latin, Caries mollis sivc fungosa, fungus arliculi, caries sicca, etc. French names aim at greater precision in speaking of osteo-pd-ri- ostite tuberculose chroni(|ue and tubcrculose articulaire, not to mention such fine distinctions as tubercule tardif a evolution rapide' and osteite aigue. In whatever joint it appears it presents itself in much the same form, as an affection of the spongy tissue of the epiphysis, most often near its line of junction with the shaft; but sometimes near the articular cartilage, and rarely in the periosteum. It occurs mostly as a localized disease, appearing in one or more distinct foci (encysted tubercle of Nelaton); a simultaneous tuberculous infil- tration of the whole epiphysis (the infiltrated tubercle of Nelatonj, however, rarely happens. Fig. 250. — Juxta-epiphyseal Ostitis of the Hip. Fig. 251. — Abscess of the Epiphysis. The common form of tubercular infection of the epiphyses is the one spoken of as focal or encysted, where the first change is the formation of single or multiple foci of tubercular degeneration. On section of the diseased epiphysis the first noticeable change con- sists in a local hypersemia of some part of the spongy tissue. There then appears in this hyperaemic 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 hyperjemic tissue develops around it and the neighboring bone looks boggy from an excess of the transuded fluid. There is no synovitis, it is purely a localized ostitis. As the diseased focus grows larger it looks more yellow in spots, and shows at its centre a tendency to cheesy degeneration and later in the history of the affection one finds nodules, varying in size ' Keiner and Poulet: Arch, de Phvs., 1SS3, p. 224. 2i6 ORTHOPEDIC SURGERY. 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 breaks down into pus, and it is said that at this stage absorption has occurred, leaving nothing but a cavity filled with limpid serum.' Generally the original focus is surrounded by smaller tubercles which aid in its extension ; but the chief work is done, as we shall see, by the erosive action of the granulations (rarefying osti- tis). Sometimes a sequestrum of considerable size may be found in these cavities ; the granulations have cut off the source of nourish- ment from a certain area of bone, and it has died and is loosened from the sounder parts, and lies loose in the cheesy or liquid pus; or a piece of bone too large to be contained in the cavity may die and be detached as a wedge-shaped piece as at the end of the tibia. Usually these larger pieces are of a wedge shape, with the base at the. end of the bone, the ordinary shape of an infarction. Even the whole epiphysis of the femur may be detached. It should be noted that the cavity is sometimes sharply marked and lined by more or less of a pyogenic membrane, which at first is soft and gelatinous, later it becomes more resistant and tougher. From this stage of the process any one of three courses is possi- ble : the diseased focus may be absorbed and so cured; it may extend to the periphery of the bone, and break through the peri- osteum and empty itself there ; or, lastly, and probably most com- monly, it may extend to the joint and infect that. 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 any size have formed ; the pus may be- come cheesy and calcified, or less frequently it may be absorbed as mentioned above, leaving a cavity filled with serum. This termin- ation, of course, is one which only comes to the knowledge of the pathologist accidentally, and so it is accounted very rare. The next most favorable termination to the disease is where the focus does not infect the joint but breaks through the periosteum, and discharges into the peri-articular structures. This happens when the focus is so situated that the line of least resistance takes it to another part of the bony surface away from the joint. Volk- mann showed clearly that this was no very uncommon occurrence. As it reaches the periosteum the latter thickens and inflames, and finally softening, allows the pus from the original focus to pass into the peri-articular structures, there to form an abscess which must be ' Vincent's Article, Ashhurst's " Encyclopaedia," vol.'vi., p. 908. THE J'ATJ/OLOGV UJ'' CJIRONJC JOINT DISJCASE. 217 evacuated externally or break. Scjmetiines this ends the disease; the granulation tissue becomes fibrous, and then osseous, and the disease is over. Probably the commonest course for this localized ostitis to jjur- sue, is to break into the joint cavity, and the ease with which in- fection of the joint from the epiphysis is produced will be readily understood by co' .idering 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, inflammatory reaction in the joint begins. This is perfectly well established. Take one of Lannelongue's early autopsies,' e.g., in a case of early hip disease a focus the size of a pea was found in the epiphysis two millimetres from the cartilage; it was caseous and did not in any way communicate with the joint, yet although there was no effusion the capsule was thickened, the synovial mem- brane in parts reddened and fungous, and the round ligament already vascular and softened. The cartilage in certain parts was thinner and losing its elasticity. One other of his autopsies, and the early resections of Volkmann- show the same point, the latter finding even more advanced joint changes than Lannelongue's autopsies showed, for increase of synovial fluid, swelling of peri- articular structures, and thick and red synovial membrane were present, before the pus had entered the joint. It should be remembered that opportunities to study the early stages of joint affections are very rare, but it would seem then as if often the joint were involved and inflamed in the first place by contiguity rather than direct infection, and by its inflammation and the softening of cartilage over the diseased spot of bone rendered the more ready for the direct invasion of the pus and caseous material from the primary focus. " The danger to the joint begins with the softening of the cheesy masses " (Volkmann). When once the pus has broken through the softened and degenerated cartilage and has reached the synovial membrane, a purulent synovitis is at once started up which speedily assumes a fungous and destructive character and a " panarthritis " has begun. Thickening of the capsule, infiltratiofi of the peri- articular tissues, and thickening of the ends of the bones follow quickly, and abscess formation and all the other complications are ready to follow. It matters little now whether the process began in the synovial membrane or the bone, as this stage is the same in its clinical appearances and its capability for evil. Any amount ^ Lannelongue: "Coxo-tuberculose," Paris, 1S86. ^Volkmann: " Samml. Klin. Vortr.," No. 52. 2i8 ORTHOPEDIC SURGERY. of destruction is of course easily possible: erosion of the articular surfaces; spontaneous subluxations and luxations of the joints; cold abscesses of any extent reaching the surface and continuing to discharge by many sinuses ; and, worst of all, from the local dis- ease the dissemination of general tuberculosis or tubercular menin- gitis or phthisis. Microscopical examination of the diseased area at any time be- fore all structure is lost shows a typical granulating tuberculosis. Within the low-grade granulation tissue one finds numerous and characteristic tubercles with epithelioid and giant cells (Konig)^ but with the increase of cheesy degeneration the typical tuber- culous structure becomes more and more obscure. The tubercles are found in a dense plasma composed of a great quantity of amorphous matter, fatty and calcareous granules and leucocytes. Outside of this one sees enlarged bone spaces, atrophy of the trabeculae, and fatty degenerated bone-cells, becoming embry- onic tissue as one nears the seat of disease. In short these are the changes which accompany long-continued hypersemia in bone and constitute the rarefying ostitis of French writers. There seems little doubt that the original infection comes most often by means of the blood-vessels (Konig, Miiller, Vincent, Zieg- ler). Sometimes, probably, the lymph-channels are to be blamed, but the beginning of the process is, in general, understood to be of the following character, although, of course, it is partly conjectural.'' Bacilli or micrococci become heaped up in the capillary of a Haversian canal, cut off the blood-supply, and start up in the neighborhood an endarteritis of the type known as tubercle, an in- filtration of leucocytes, the formation of a lacuna of Howship, and the formation and continual increase of embryonal or granulation tissue. The trabeculae grow thin, and the bone-cells undergo fatty degeneration and disintegrate, while their place is taken by the embryonal tissue-cells, which continually extend and melt away the bone substance. Hence the formation and extension of the dis= eased focus. Sometimes, however, the seat of disease is surrounded by a condensing rather than a rarefying ostitis. Kiener and Poulet make three stages of the process, which, perhaps, will explain the sequence a little more fully: (i) fibrous or embryonal transforma- tion of the marrow; (2) appearance of the follicles with condensing and rarefying ostitis ; (3) caseation of the marrow and eventual necrosis of the trabeculae. ' Kiener and Poulet (in Arch, de Phys., 1880) have demonstrated that the cells of the inner walls of the capillaries of the diseased region hypertrophy and undergo hyaline de- generation, form a giant cell which fills the capillary ; the other coats of the vessels are infiltrated, the follicle is formed, and the vessels closed. 77/ A" rATIlOJJ)GY OF CI I RON IC JOI NT D/SJwlSf:. 219 When the absorption of a tuberculous ff)cus takes place, the spot of diseased tissue becomes cheesy and the granulation-wall sur- rounding it changes from its erosive to a formative action, having a tendency to send processes into the cheesy mass, which processes become fibrous and ultimately bony tissue, but the tendency is to incomplete scarring, a bit of tuberculosis granulation remains behind, perhaps for years, and explaining in a measure the ten- dency to later relapses in this class of disease. The entire absorp- tion of large sequestra is very doubtful (Konig). Primarily or secondarily, the periosteum is quite sure to be af- fected. If primarily, a tuberculous focus is seen under the peri- osteum and the bone destruction around it is superficial, it is " eine periphere Caries ; " but if the periosteal focus is secondary, it communicates with the original point of disease in the marrow. The periosteal foci, like the others, become cheesy or melt down to form abscesses. But even before the tubercular focus is deposited in the periosteum, increased periosteal activity begins ; sometimes with absorp- tion of the deposited inner layers, as in spina ventosa, where the whole circum- ference increases, yet the marrow cav- ity increases more all the time ; while in other cases osteosclerosis (a forma- tive ostitis) takes up the whole bone. F.g. 252.-Diffuse Epiphyseal Ostitis. The second and rare form of tuberculous inflammation may be considered very briefly. When simultaneous infiltration of a whole epiphysis occurs it is characterized by the deposit in the meshes of the spongy tissue of a gray substance like brain tissue, Avhich is in gross appearance like the focal lesion just mentioned, without limit or boundary. Yellowish pus collections are to be seen in spots, which ultimately extend, and the whole affair soon assumes the aspect of a true purulent osteomyelitis, and it is this stage that is ordinarily found on section. The true tuberculous infiltration presents a different appearance from the subsequent puriform in- filtration, which is characterized by a dull yellow surface and an absence of blood-vessels. Having considered the pathological appearances in this so-called tubercular form of joint disease it now becomes necessary to inves- tigate wifh care the evidence presented in favor of considering it a tuberculous affection. Microscopic examination shows a typical granulating tuberculo- 220 ORTHOPEDIC SURGERY. sis. Even in the cases where large seq-uestra form in the ends of the bones without any evident tuberculous foci, one can ordinarily find, without trouble, tubercles in the granulation layer between the sequestrum and sound bone. With Koch's discovery of the bacillus of tubercle in 1882, there came in a new criterion in the determination of whether or no cer-. tain microscopical appearances really represented tuberculosis. By improved methods the presence or absence of bacilli can be deter- mined by a simple microscopical examination. They are most often found lying in the giant cells, and sometimes in the other cells ; they are few in number, and hard to find. Koch ' discovered them in two cases out of four in fungous joint disease. Since then various observers have found them in varying proportion of all cases examined. Schuchardt and Krause investigated all cases of " fungous and scrofulous joint disease " coming to Volkmann's clinic for some weeks, some forty cases altogether, in all of which they found the bacilli of tuberculosis; but they were very few in num- ber, and very hard to find. A modification of Ehrlich's method was used. In one cold abscess twenty sections were required to find two bacilli. Kanzler,^ in 15 cases of bones and joints exam- ined, found bacilli in only 8. Miiller^ examined some 39 cases, using the pus for the most part, and in a few cases he was unable to find the bacilli, although he would examine most carefully perhaps twenty preparations. He believes, on the strength of this, that it is possible to have tuberculous joint disease without the presence of bacilli. Castro Sofifia,"* in a great number of clinical cases of bone tuberculosis examined for bacilli, was always able to find them. Ros- well Park 5 in a systematic examination of detritus and pus from this class of cases extending over a period of two years was able to find tubercle bacilli in nearly all instances. Reuben,* in five cases of spina ventosa, otherwise free from tuberculous disease, found the bacilli in all cases, looking for them in the granulations, and, moreover, inoculation was successful. In general, the results of later years are more positive than the earlier results, probably from perfection of methods. The evidence presented seems to justify the conclusion that in most cases of chronic joint disease of the character just described, tubercle bacilli are present, but that the examination for them is difficult; and, moreover, that they are present in smaller numbers at the late stage, when most examinations are ^ Fortsch. der Med., 1883, 9. Bd. i.,- S. 277. ^ Kanzler : Berl. klin. Wochenschrift, 1884, 2, Jan. 14th. 3 Mtiller : Cent. f. Chir., 1884, p. 33. '■ These de Paris, " Recherches exp. sur la Tuberculose des Os," 1885. s Med. Press of West N. Y., Jan., 1887. ^ Baumgarten's " Jahrbuch," 1886, ii., 230. THE PATHOLOGY OJ'' Clfh'OjV/C JO/A'T D/SlwiSE. 221 made; probably in the staf^c'of invasion examination of tlic tissues would show many more. Experimental research has proved tiiat substances containing the bacilli of tuberculosis are capable of producing tuberculosis when introduced into the general circulation. It has also been proved with equal certainty that substances in which they are present, if inoculated into animals, under proper precautions, will produce local and general tuberculosis, as is also, of course, true with regard to pure cultures of the bacillus. It may be mentioned in passing that it matters not whether the tissue for inoculation is taken from a scrofulous joint or a phthisical lung, the result is the same — nothing could testify more strongly than this in favor of the iden- tity of tuberculosis and scrofula. The importance of inoculation experiments in establishing the identity of this form of joint affection is very great. Arnold in- serted into the anterior chamber of a rabbit's eye a small fragment from a scrofulous joint or gland, and in six days the bacilli of tubercle were present in great numbers in the corneal tissue, and soon after that, young tubercles were found. In about five weeks tubercles could be demonstrated in the kidneys, and general tuber- culosis caused the death of the animals. The same results were obtained by the inoculation of pure cultures.' Another point in the chain of evidence is to demonstrate the susceptibility of the human species to tubercular inoculation. Lehmann- relates the tubercular infection of ten children (fatal in seven) who were circumcised by a phthisical rabbi in a small con- tinental town. The prepuce became the seat of tubercular ulcera- tion and the inguinal glands enlarged and suppurated. Similar cases are related by Elsenberg,^ Mecklen, and Hoist, ■• where the presence of bacilli in the affected tissues was demonstrated. A case related by Pfeiffer deserves especial mention. A veteri- nary surgeon of good antecedents and in sound health punctured the joint of his thumb with a knife, while dissecting a tubercular cow, a synovitis of the tubercular type followed and he died in a year and a half of phthisis. His thumb joint showed typical tuber- cular structures in which bacilli abounded. ^ With the understanding of these facts it becomes necessary to consider inoculation experiments as they bear directly upon the question of joint disease. ' Baumgarten: Cent. f. d. Med. Wiss., 1SS3 ; Baumgarten : Zeit. f. Kl. Med., Bd. 9 and 10; W. Cheyne: Practitioner, 1SS3. => Deutsch. Med. Woch., 18S6, 9-13. 3 Cent. f. Chin, 18S7, p. 52, ^ Quoted by Barber: Brit. M. J., June 23d, 18SS. « Pfeiffer: Fort, der Med., iSSS, No. i, p. 33. 222 ORTHOPEDIC SURGERY. Hueter injected sputa from phthisical patients and detritus from tubercular glands into the joints of dogs, and found that it excited in them a synovitis hyperplastica granulosa, as he terms it, of the same type that one finds in tumor albus, etc., of the human sub- ject. From this focus a general tuberculosis often developed, and caused the death of the animal.' Also, he introduced the granula- tions from a human tumor albus into the circulation of several dogs, and caused, with much regularity, general miliary tuberculo- sis. Schiiller^ threw further light on the relationship between joint affections and general tuberculosis by the following experiments: Guinea-pigs and dogs were rendered tuberculous by inhaling solu- tions of phthisical sputa and tuberculous detritus for half an hour a day for several days, and by the occasional injection into their lungs of the same solutions. The knee-joint of each was then wrenched or violently contused, and, with a few exceptions, a syn- ovitis granulosa hyperplastica of a purely tuberculous type followed in the injured joint, while but few tubercles were found in the lungs. Similar injuries to healthy animals caused no such joint disease. Barwell^ takes exception to these experiments, and con- siders that Schiiller's experiments conclusively prove " that a tuber- cular state of the body does not produce joint disease. In other words, the earlier phases of joint disease are not tuberculous," chiefly on the ground that in only six of the twenty-four animals were structures like tubercles found in the granulations of the diseased joints, and these structures Barwell considers as purely inflamma- tory. He is, however, the only author of note who rejects Schiil- ler's very careful work, and his article is not convincing or modern. Miiller'* showed very clearly the channel of infection by which the bacilli enter. Tubercular material was injected into the femoral artery of sixteen rabbits with no results, next into the crural arte- ries (whence come the bone nutrient arteries) of ten other rabbits, and in some were found tuberculous bone lesions. Finally, the nutrient arteries were found, and into them alone the tuberculous material was injected in twenty goats, and some dogs and sheep. The goats alone yielded positive results, most of those whose arteries were injected showing typical focal tuberculous disease of the ends of the bones. One young goat was well for four months, then he began to limp, and at the end of thirteen months his knee- joint showed a typical fungous joint disease, beginning as a cheesy focus in the bone with a wedge-shaped sequestrum and several tuberculous foci around it. ' H. Hueter : Deutsch. Arch. f. Chir. , 1879, xi., 317, ^ Schiiller : Cent. f. Chir. for 1878, v., p. 43. 3 Lancet, August 2d, 1884. 4 Cent. f. Chir., No. 14, 1886. THE PATHOLOGY OF CHRONIC JOINT DISI'.ASE. 223 Sternberg,' on the other hand, failed to produce tuberculosis in animals by the injection of inorganic material into their circulation. Garr6,^ using the pus from cold abscesses, nujstly of joint origin, found specific bacilli present in only a small number, and attempts at cultivation in these gave no results; but this pus injected into animals caused general tuberculosis. More recently still, Triconi^ put phthisical sputa and pus from this class of diseased joints into the epiphyses and diaphyses of the bones, with the result of start- ing up a disease like bone tuberculosis in the human being, and once a bone injection caused also a synovitis. Burdon Sanderson and Klein have obtained practically the same result from inoculation experiments,^ and those of Villemin are historical. So much for experimental inoculation in animals ; the generaliza- tion of tuberculosis from a diseased joint in the human subject is a process unfortunately of such common occurrence that it can be passed over very briefly, and it shows even more clearly than ex- perimental inoculation the relationship of tuberculosis and this class of joint disease. A few figures may show the great liability of this. Bilroth found that fifty-four per cent of patients dying with this form of joint disease, die of acute miliary tuberculosis; Jaffe, that fifty-three per cent of the deaths are from general tuber- cular infection. Grosch's^ extensive statistics show that in hip disease tuberculosis is, in spite of antiseptic precautions, the com- monest cause of death. Nor does the removal of the diseased joint seem to diminish this liability very much. Konig^ did 117 resec- tions for this class of joint diseases, and of 25 deaths found 18 due to general tuberculosis, and 9 more patients hopelessly tubercu- lous; and he has more recently called attention to the danger of " operative tubercular infection," where, by opening the lymphatic and blood channels in an operation which at the same time stirs up the focus of disease, tuberculous material is carried over the body, and general tuberculosis results. Caumont ' found no preventive effect in resection, for in twenty- six cases of hip disease, treated expectantly, one-fifth died of gen- eralized tuberculosis, while twelve others were resected and one- third died of the same cause. Yale^ says, in quoting it, " Others ^ N. Y. Medical Journal, p. 325, 1SS4. ^ Garre : Deutsch Med. Woch., No. 34, 1886. 3 Triconi : Baumgarten's Jahresbericht, ii., p. 229, 18S6. 4 Quoted by Dennis, N. Y. Med. Ass. Rep., ii., p. 331. 5 Grosch : Cent. f. Chir., 228, 1SS2. ^ Konig : Archiv f. Klin. Chir., 26, p. 822. 7 Caumont : Deutsch. Z. f. Chir., xx., 137. ^ Yale : N. Y. Medical Journal, November 2Sth, 18S5. 224 ORTHOPEDIC SURGERY. may have had better results, but the prophylactic effect cannot be very decided, if such marked exceptions occur." Esmarch agreed with Konig as to the small preventive value of resection. This is the evidence for considering this form of chronic ostitis as tubercular; and there seems no need of any extended argument to demonstrate that such is the fact so far as modern pathology can guide us to any conclusion. Gunimatoits Ostitis. — Beside the tubercular form of degenerative ostitis, one finds a form characterized by the formation of gummata. It is the less common form of degenerative ostitis which affects the subjects of tertiary and hereditary syphilis. This is character- ized by the formation of gummata, in the spongy tissue of the epiphyses, or more commonly in the periosteum; but a much more common location still is in the shaft of the bone, so that it does not appear as a joint disease at all in most cases, but as an affection of the shafts when it occurs at the ends of the bones. It is not common for the epiphysis to be affected before the synovial membrane, but it does occur, although synovitis is much more common from this cause. On section the bone shows, most often in the periphery, a yellowish-gray focus of disease, in appear- ance strikingly like the early stage of focal tuberculosis. But from this latter it may be distinguished, according to Schiiller, by the absence of any surrounding hyperasmia or infiltration, which, he says, always goes with tuberculous disease. Often, of course, these gummata exist along with much synovitis of a characteristic type, and a much thickened and diseased periosteum. Gummata in the periosteum appear as elastic swellings, rich in fluid, poor in cell- elements; later they degenerate to stuff like pus and by fatty de- generation and absorption a cheese-like substance and scar-tissue,, and finally only a thickening remains. Secondarily to these periosteal and bone lesions come the capsu- lar and synovial thickening, and the cartilage degenerations noted above. One special form of syphilitic disease deserves mention, syphilitic osteochondritis with accompanying epiphyseal periostitis and peri- chondritis, as Ziegler calls it. Before the joint is infected, one finds a circular swelling around the epiphysis ; this is a periostitis with much spongy tissue under the periosteum, which later affects the joint perhaps with a destructive purulent synovitis,' as a subacute or chronic synovitis with much effusion and thicken- ing.^ Occasionally the inflammatory process is of such a character ' Langenbeck's Archiv f. Chir. , 28, Heft 2. ^Somma: Giornale Internazionale di Sc. Mediche, 1882; Cassell: Archiv f. Khde., 1884-85. THE PATHOLOGY OF CHRONfC JOINT DISEASE. 225 that the epiphysis is loosened from the shaft by the destructive process. To make the diagnosis of syphilis and tuberculosis from the pathological appearance of the bone alone might occasionally be difficult, but aided by clinical characteristics there would not often be much difficulty. The microscopical structure of the focus of disease in these cases shows a typical gummatous structure. ArtJij'itis Deformans. — Leaving the question of degenerative osti- tis as it affects the joints, one comes to a joint disease secondary to the opposite condition, formative ostitis. This affection is known by a multiplicity of names, of which the following are the principal ones. Rheumatic gout, chronic rheumatic arthritis, arthrite seche, ar- thritis deformans, osteoarthritis, nodosity of the joints, rheumatoid arthritis, nodular rheumatism, dry arthritis, proliferating arthritis, malum senile, chronic articular rheumatism. The name arthritis deformans will be adopted here, inasmuch as it describes the con- dition and involves no etiological theory. It is a question just where this form of joint disease belongs in the present classification, for the condition has been asserted to have its origin in the .bone,' the synovial membrane (R. Adams and Brodie, Volkmann, Cruveilhier), and the cartilage (Marsh, Orth, Billroth, Cornil and Ranvier). And although weight of modern authority places its ordinary origin in the cartilage or the cartilage and synovial membrane, the bone changes ultimately assume so great prominence that it seems best to consider it here. There is a thickening of the synovial membrane, a hypertrophy of the fringes, and finally the development of the shaggy surface already spoken of. The changes in the cartilage are of the usual type of cartilage inflammation, only more severe. The hyaline substance becomes fibrillated, and where there is pressure it is worn away in small patches or large surfaces, exposing the bony lamella, which speedily becomes polished and ivory-like from the friction. The same process of cartilage degeneration taking place atvthe periphery of the joint results differently. There is sufficient free- dom from pressure to wear away the degenerated substance, and the covering of synovial membrane retains the proliferated corpus- cle cells, which remain and, taking on a formative activity, make the marginal hypertrophies or ecchondroses already mentioned ; but sometimes these perforate the synovial membrane and become intra-articular, and often break off to form loose bodies ; at other ' Barwell, loc. cit., p. 3S5. ^5 226 ORTHOPEDIC SURGERY. times they grow laterally, and do not encroach upon the joint. Inasmuch as these ultimately oseify, an explanation of the extreme changes in the shape of the ends of the bones is afforded, easily transforming a globular to a flat end, and so limiting very seriously the arc of motion of the joint. The changes in the bones are in the first instance the result of the wearing away of the cartilage covering the ends, and the con- sequent friction and eburnation of the articular ends with an irrita- tion of them. This irritation results in hyperaemia which is neces- sarily attended by a slight degree of rarefying ostitis. But after the enlargement of the Haversian canals, and the de- generation of the bone-cells, a formative activity springs up in the periosteum and in the endosteum covering every one of the cancel- lar walls, and a compact, " eburnated " layer is quickly made which covers the exposed end, under which layer a formative activity is going on while the polished surface is always being worn away; and to this constant wearing away is due the " worm-eaten " ap- pearance so generally spoken of, which is due to the exposing of the ends of the Haversian canals. But while pressure and friction are wearing away the centre of the articular ends of the bones, the margins, where pressure and friction are slight, are rapidly prolif- erating. Hypertrophy of the cartilages here affords a field for the deposit of lime-salts, and the hypertrophic bony enlargement is closely bound up with the development and increase of the margi- nal ecchondroses so often alluded to, their growth goes on super- ficially, while ossification takes place in the deeper layers by a process similar to physiological ossification. These lumps inter- nally, then, are bony, superficially they are cartilaginous. Growing out with surprising rapidity, they form a buttress-like growth which speedily restricts the motion of the joint, although true ankylosis rarely or never takes place, the stiffness and loss of joint movement being due to this ensheathing bony growth. Degeneration of the ligaments occurs early in the affection ; they become inflamed and then thickened, and finally they degenerate into a condition where they resemble fibro-cartilage or elastic tis- sue, and in virtue of this, the affected joints may show decided lateral mobility. Finally, at the attached border of the capsule as well as in the ligaments themselves, there begins a dense bone formation which contributes to the ensheathing bony mass. The osteophytes are more rounded and flat than one is accustomed to see in bone for- mation after fractures, e.g., and from the fact that ossification is not preceded by any especial vascularity, the new-formed bone is more dense and compact than normal; the tissues ossify just THE J'ylTHOLOGV OF CHRONIC JOINT JJ/SJiAS/C. 227 as they are. The muscles controlhng the joint atrojjliy from dis- use, and the tendons are " absorbed " as well as the intra-capsu- lar ligaments. "The absorption of tendons is best illustrated in the shoulder, where that part of the long tendon of the biceps which lies within the capsule is often found displaced from its groove and frayed out, or completely worn through, and its two ends, separated by a considerable interval, are adherent to the subjacent bone." ' Synovial effusion is often present for a while at the beginning of the affection, but it never occupies more than a subordinate place and suppuration practically never occurs. In the late stages there is apt to be peri-articular oedema of the affected joint, and the skin, even before that, becomes thin and drawn, and shoAvs most plainly the deformed outline of the joint. Exostoses. — Apart from the changes of arthritis deformans there sometimes occur exostoses about the articular ends of the bones, which are very rarely large enough to impede the motion of the joints, at other times they are troublesome by involving tendons in their growth. They are of two kinds. First, small spur-like processes or rounded projections, the result either of an inflammatory process, or of a simple hypertrophy; and several large lobulated, spongy masses of bone called diffused osteoid tumors, which occasionally involve and destroy a joint, as in the cases of Paget'" and Lance- reaux,3 where the knee-joint was so badly involved by the growth of one of these osteoid tumors from the tibia and femur that am- putation was necessary. In structure they all show typical bone formation, and both classes belong rather to the order of patho- logical curiosities. Ttcmors of the Joints. — Tumors involving the joints are malignant or benign. In the latter class are to be named exostoses, cartilag- inous tumors, angioma, aneurism, and echinococcus. The last three are only pathological curiosities; exostoses have been con- sidered under formative ostitis. Cartilaginous tumors grow from the peripheral or central part of the bone, they occur chiefly on the joints of the hands. Malignant tumors are of vastly more importance. There is a tendency among certain writers (Billroth, Marsh, etc.) to identify all malignant joint tumors with sarcoma, ignoring the existence of carcinoma. The existence of primary cancer of bone is, however, attested by Virchow, Volkmann, Forster, Paget, and Barwell. Sar- coma is, however, vastly more common, and it occurs in many his- ' Howard Marsh : " Dis. of Jts.," p. 59. 1SS6. ^ " Surg. Pathology," vol. ii., p. 506. 3 Holmes' " Surgerj-," iii., S25. 228 ORTHOPEDIC SURGERY. tological forms, round and spindle-celled, myeloid, partly cartilagin- ous and (rarely near the ends of the bones) partly ossified, as the osteo-sarcoma. The growth originates occasionally in the synovial membrane, ordinarily in the bones from the endosteum or perios- teum. The latter infil- trates soft parts of bone, and on section appears fleshy and mottled, be- ing most often com- posed of myeloid or giant cells. The endos- teal form, however, is ordinarily the spindle- celled form and grows less rapidly, absorbing the bone and having the ap- pearance of having a cap- sule, which it really does possess. Joint sarcomata chiefly young subjects from fifteen to twenty or twenty- five years of age. The joints commonly affected are the knee, the shoulder, and the wrist. The condition of the perios- teum must be alluded to before leaving the subject of joint dis- ease beginning in bone. There is, of course, a certain amount of periosteal thickening as the result of the hyperaemia and gen- erally heightened nutrition of tuberculous and gummatous os- titis. Primary disease of the periosteum is very rare as the beginning of joint disease, but it may occur in both tuberculosis and syphilis. Periosteal thick- ening is so constant an accom- paniment of epiphyseal ostitis that in hip disease, e.g., it forms an important diagnostic sign. Before leaving the subject of ostitis as the beginning of joint dis- ease, one or two of the less common, but still possible varieties, must be mentioned. Fig. 253. — Tumnr of the Bone Involving thejoint. ^From a Photograph.) THE I'ATJ/OLOGV OF CHRONIC JOINT DISEASE. 229 Simple 07' ti'aninaiic ostitis secondarily affecting the joints is very unusual. In the traumatic form, one finds blood effused and in- flammatory processes beginning, of the kind described above as typical, the periosteum is infiltrated, and the bone marrow filled with a fluid cellular exudation. Then it depends upon circum- stances whether absorption will take place, or whether pus forma- tion will begin, and the trabeculae will be absorbed and the bone broken down, or whether the whole affair will take on the tubercu- lous type and run the course of that affection. If no infection comes, wounds, tears of the joint capsule, fractures, etc., result in only a serous or fibrinous or bloody effusion into bone, joint, and capsule; but where the bone is opened to infection, destruction and necrosis is only too apt to result. Lastly there is acute infections osteo-inyelitis, which sometimes affects the epiphyses of the long bones, and in that way seconda- rily infects the joints. It begins in the bone marrow or the perios- teum. The marrow becomes hyperaemic, the periosteum infiltrated and thickened ; soon in both are seen beginning foci of pus, and sometimes hemorrhages in their tissue; soon pus formation ob- scures everything, and the bone fairly melts away; large collections of pus may form between bone and periosteum. Ordinarily this affects the shafts of bones, but sometimes the epiphysis, and sec- ondarily the joint, become infected when the foci of disease are near the joint; like the tuberculous foci, they tend to infect it. Cocci are constantly found,' most often staphylococcus pyogenes aureus and albus, and extensive necrosis results. IV. Joint Diseases Affecting Primarily the Peri-articular Structures. Ligamentous Affections. — It was formerly thought that diseased lig- aments were often the cause of chronic joint disease. William Adams wrote : " Strumous joint disease commences most frequently in some of the ligaments of the joints." To-day we know that the commonest beginning of chronic joint disease is in the bones, yet the fact remains, a wrench or sprain causing evidently injury to a ligament (of perhaps ever so slight a character) is sometimes the starting point of a chronic joint affection. Ligaments are pecu- liarly slow to inflame and slow to repair ; when they are found in a state of inflammation they are thick and pulpy and softened. In gout they may be the seat of the deposit of tophi before other localities are affected. Peri-articular Abscess. — Suppuration in the peri-articular cellular tissue and subsequent affection of the joint, may start from an open skin-wound which has been infected, or from an injury to the ' Rosenbach : Fort, der Med., iii., 1885 ; Garre : " JNIikro-org-anismen b. d. "Wundin- fektions-Kkhten.," Wiesbaden, 1SS4 ; Mliller : Schmidt's Jahrb., vol. cc\'i., p. 2S4. 230 ORTHOPEDIC SURGERY. limb where cellulitis has come on in consequence of the trauma. Again, in children of feeble type, peri-articular abscess of a slow and chronic character is not unlikely to arise after slight bruises, and sometimes after no perceptible injury at all. Any of these abscesses, if they are not at once evacuated, are, of course, likely to infect a neighboring joint; occasionally, the abscess from one dis- eased joint burrows a long distance, and in its course, either opens into another joint or passes so near to it that infection of the second joint takes place. This may occur in psoas abscesses, where the pus travels near enough to the hip to infect it. This explains a certain number of the cases of hip disease secondary to Pott's disease. Bursitis. — The inflammation of bursae is a question which seems rather to belong to general surgery, but certain of the bursas com- municate very closely with important joints, and it seems worth while to mention some of them. It is not difficult to see that an inflammation of one of these may easily lead to an affection of the joint. For example, the large bursa between the neck of the glenoid process and the subscapular muscle is ordinarily in connection with the shoulder-joint, as is the case more rarely with the bursa under the deltoid. The bursa beneath the triceps tendon is most often a prolongation of the elbow synovial membrane. The bursa under the psoas and iliacus tendon frequently communicates with the hip-joint, and the bursa in the popliteal space often communicates with the knee-joint. These are the common communications, but at most this is an infrequent cause of joint disease. As other causes of impairment, rather than disease, of joints, may be mentioned the following: cicatrices after burns, wasting of muscles and ligaments after infantile paralysis, and muscular contractions causing malpositions of the joints after hemiplegia, etc. CHAPTER V. THE ETIOLOGY, COURSE, AND TERMINATION OF CHRONIC JOINT DISEASE. Etiology. — Chronic Serous Synovitis. — Chronic Purulent Synovitis. — Inflam- mation of Cartilage.— Joint Manifestations in (a) Tuberculosis, (d) Syph- ilis, (c) Rheumatism, (d) Arthritis Deformans, (e) Gout, {/) Acute Infec- tious Diseases, (g-) Miscellaneous Conditions. — Tabes Dorsalis. — Haemo- philia. — Growing Pains. — Acute Arthritis in Infants. — The Distribution of Chronic Joint Disease. — Course and Termination of Chronic Joint Dis- ease. — Ankylosis. — Treatment of Chronic Joint Disease. The etiology of chronic joint disease is a question of much prac- tical importance in some of its aspects, especially in regard to the chronic tuberculous joint diseases of children. The consideration of the whole subject will be undertaken so far as possible under the same divisions which were used in speaking of the pathology of joint disease. Chronic serotis synovitis which begins as such and is not the result of the acute affection is a disease about whose cause very little is known. At times it is impossible to determine the cause, while at other times it must be assigned to some poor systemic condition. The affection occurs oftenest in young adults, especially young men, and it is far more frequent as the outcome of one or a series of attacks of acute or subacute synovitis. When it begins as the chronic affection it is not as a rule associated with the rheumatic or any other diathesis beyond a poor general condition. Some authors consider it an obscure form of osteo-arthritis,' but such cases are most often marked by the occurrence of marked hypertrophy of the synovial fringes, and a tendency to connective- tissue formation. One phase of the affection is represented by the intermittent form described by Seeligmiiller= where thirteen cases are detailed. In only two cases could any constitutional cause be assigned, and these suffered from intermittent fever. The affection has no established pathology beyond this.^ ' Marsh, Howard : " Diseases of the Joints," p. 76, 1SS6. " Deutsche Med. Wochschft., 18S0, v. and vi. 3 Nicolayson : Cent. f. Chir. , June 4th, 1887. 232 ORTHOPEDIC SURGERY. Certain classes of cases of chronic serous synovitis, however, have a definite pathological basis, and such are instances of the common form of chronic serous synovitis, where it remains from the primary affection, caused by a blow, wound, a strain, or exposure to cold and over-exertion, or in those obscure cases where no cause is to be assigned, which are sometimes called rheumatic, on very insuffi- cient evidence. Here the appearance is that modified appearance of the acute form described above. Next comes the rheumatic variety, the result of a primarily rheumatic synovitis with its ten- dency to relapse and to ankylosis, and a rheumatic form without any primary stage, occurring as a sequel or complication of clearly marked rheumatism. These forms are both marked by hypertro- phy of the fringes, and a tendency, in long-continued cases, to bone enlargement and tissue formation ; and allusion is made to pure chronic rheumatism, not to rheumatic arthritis, which will be de- scribed by itself. Syphilis as a cause of this form of synovitis ap- pears in two phases, one in the secondary stage, where it simulates the rheumatic form very closely and is ordinarily acute, but some- tirries it is chronic and persistent. At times it is markedly inter- mittent. If it persists it leaves the joint enlarged, indurated, and subject to subsequent attacks. The second form is encountered in the tertiary stage, where it appears as an infiltration of the synovial membrane and sub-synovial tissue of a gummatous type (Lance- reaux '), with a varying amount of effusion, and a tendency, if con- tinued, to enlargement of the bones, but not especially to stiffening of the joint." Richet^ called this " syphilitic white swelling." " The effusion may be purulent, but it is also at times serous. Chronic serous synovitis occurring in hereditary syphilis is often secondary to bone or cartilaginous affection,^ especially a bilateral painless form, which attacks children from eight to fifteen years of age. It does not tend to go on to destructive changes, though primary forms are described.^ Gout and arthritis deformans both are occasional causes of chronic synovitis. Lastly, gonorrhoea is to be mentioned as a more or less common cause of joint effusion of a chronic character, ordinarily as a se- quence of an acute or subacute synovitis of long-drawn-out course, and in the fluid gonococci are to be found.' The attack ordinarily occurs in the second or third week of the discharge, and simulates sometimes the course of rheumatism and sometimes that of pyae- ' " Traite Hist, et Prat, de Syph." Paris, 1873. ^ Follin : " Traite de Path, externe," p. 714. 3 Richet : Mem. de I'Acad., 1853. 4 Bumstead and Taylor: "Venereal Diseases," p. 837. * Schtiller : Cent. f. Chin, 1882, ii., p. 32. ^ Clutton : Lancet, 1886, i., 391. ^ Ziegler : " Path. Anat." 1887. ETIOLOGY, ETC., OE CIIRONIC JOINT J)ISEASI:.^ 233 TTiia; women are rarely attacked by it. The discussion of the eti- ology of the tuberctdous affection will be postponed until the con- sideration of the more common forms of joint tuberculosis, those occuring primarily in the bone. Chronic purulent synovitis is sometimes the result of an acute serous or purulent synovitis, but the tendency of acute synovitis in healthy individuals is not to run on to this form ; when this occurs it is most often in adults of feeble constitution and in chil- dren of the feebly resistant type described as strumous, tubercu- lous, and scrofulous. It occurs primarily in a very large number of cases as a chronic affection. The etiology of primary inflanniiation of cartilage is extremely obscure. In some of the cases reported it was traumatic in origin, in others no cause was assignable. . Some patients were old, others young; in fact, there seems nothing to indicate the cause. The etiology of secondary inflammation is to be sought in the cause of the primary affection — ^trauma, tuberculosis, a penetrating wound of the joint, or whatever may be at the root of the synovitis or ostitis. Reyher described a change in the cartilage due to dis- use of the joint characterized by a slow inflammatory process, which he produced by immobilizing for weeks the limbs of some dogs. Fatty degeneration of cartilage is an ill-defined process accom- panying the later stages of chronic synovitis, occurring in old age and as a subordinate process in rheumatoid arthritis. But here fibrillary degeneration is the characteristic form, along with the in- creased bone-formation, but fibrillary degeneration pure and simple is the expression of the general morbid condition known as rheu- matoid arthritis.' Certain constitutional pathological conditions have a most im- portant part in the causation of chronic joint disease. The chief ones are : {a) Tuberculosis. {b) Syphilis. {c) Rheumatism. {d^ Arthritis deformans. {e) Gout. (_/) Acute infectious diseases. (_^) Miscellaneous conditions. In these the joint disease seems to be merely the local expression of a general condition. {a) Tuberculosis. — Formerly it was supposed that joint disease of a tuberculous charactei took its origin in the synovial mem- ' Zeitschrift fi'ir. Chir. , iii., iSg. 234 ORTHOPEDIC SURGERY. brane, but of late years, in consequence chiefly of the work of Volkmann and Konig it has been learned that tuberculosis of the joint begins usually in an inflammation of the bone. This is invar- iably the case in children, according to Volkmann. Miiller' analyzed 232 preparations, mostly from resections, with the following result : Bone-origin. Syn. origin. Indefinite. Total. Knee 69 47 42 33 3 10 16 II I 118 Hip 61 Elbow 53 Total 158 46 28 232 Age. Three to fourteen years. . Fourteen to thirty years. . Thirty years and upward. Bone. 50 64 39 Svn. 18 12 Of 71 other cases analyzed by Konig,"" 47 were osseous, and the distribution was as follows: Bony. Syn. Hip 8 17 II 3 8 7 6 Knee Foot. Shoulder 7 I Elbow 2 Volkmann ^ believes that fungous joint diseases begin usually,, and in children always, as a localized ostitis limited to a spot in the epiphysis. Unhappily figures bearing on the subject beyond those given above are very scanty. The whole classification of this class of diseases had been very imperfect until recently the dis- covery of tubercles in fungous joint disease has revived the term tuberculous, common among French writers but discarded until the discovery of the tubercle bacillus in the fungous granulations of these affections. The histological identity of the structures found in chronic fun- gous joint disease has been abundantly established. The frequency with which these are found has been more fully discussed in speak- ing of the pathological appearances. The reasons for considering these affections tuberculous have been fully given in the preceding chapter. Heredity in the Causation of Tuberculous Joint Disease. — In the ' Miiller-Konig : " Die Tuberc. der Knochen und Gelenke." Berlin, 1884. ^ Konig: D. Z. f. Chir., xi., 1879. ' "Samml. kl. Vortrage," 168 and i6g. ETIOLOGY, ETC., OF CHRONIC JOINT DISEASE. 235 causation of this form of joint disease, characterized f;y the forma- tion of tubercles, much stress has always been laid upon the inher- itance of what has been called a "scrofulous tendency," an inher- ited vice of constitution. The use of the word "scrofula" has intentionally been avoided here, and the reader is referred to Mr. Treves' " Manual of Surgery " for a discussion of the relation of scrofula and tuberculosis. Recent writers maintain (although this is by no means generally accepted) that tuberculosis is a chronic infectious parasitic disease, and that scrofula- — although presenting certain modifications arising from the difference of the tissues in which it is seated — is, from a pathological point of view, identical with tuberculosis (H. Marsh, " Disease of Joints," p. 97). Experimental investigation has shown clearly enough the possi- bility of the transmission of tuberculosis .from parent to offspring. Landouzy and Martin,' taking a six and one-half months' foetus born of a phthisical mother, found it to all appearances perfectly free from tuberculosis; yet a piece of its lung put into a guinea- pig's stomach caused general tuberculosis in four months, and in- oculation was then carried through five animals. The cardiac blood from another foetus caused the same tuberculosis in other guinea-pigs. Again, one of these tuberculous guinea-pigs gave birth to a litter, and a young one two days old was killed and ap- peared perfectly healthy ; yet pieces of its viscera inoculated into other guinea-pigs caused general tuberculosis. And finally, the semen of a guinea-pig thus rendered tuberculous was removed from the vesiculae seminales with much care, and being inoculated into other guinea-pigs, caused tuberculosis. Figures which attempt to show what proportion of children with joint disease inherit a tendency to these diseases are notoriously untrustworthy. In the class of hospital patients from whom most of these statistics come, anything approaching accurate informa- tion with regard to the diseases of which relatives have died Can- not 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 way parents 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 consti- tutional taint. Again it must be remembered that about \ofo of all deaths are •from phthisis, and that phthisis must, therefore, necessarih' appear in the family histories of a certain proportion of any group of in- dividuals whose antecedents are inquired into. For these reasons the following statistics cannot be regarded as ' " Faits clin. et exper. pour servir a I'hist. de I'heredite de la tuberculose." 236 ORTHOPEDIC SURGERY. Other than inaccurate, and only approximating the truth, but the error is likely to lie always on one side, in making the proportion of inheritance too small. Gibney' analyzed 596 cases of different tubercular joint diseases, and has found tubercular disease in one or both parents in sixty- eight per cent, and what he calls an " acquired diathesis " in thirty per cent more; and of the whole number, after a close investiga- tion, he could only find one case which did not present an acquired or hereditary diathesis; but he represents an extreme point of view in the matter. C. Fayette Taylor,"" in the analysis of 845 cases of Pott's disease, found thirty-four per cent where there was tubercu- lar or so-called scrofulous disease in the parents, and in sixty-six per cent the disease came on in patients of a sickly diathesis. In 401 cases of hip disease from the Alexandra Hospital reports, twenty-four per cent had phthisis in the family history ^ and thirty- five per cent were classed as traumatic. Albrecht, tabulating 325 cases of tuberculous disease of various joints as to etiology, classed thirty-three per cent as " associated with scrofula." The chief opponents of the point of view that these joint diseases are oftenest the results of inheritance, are those who hold that the common cause is an injury to the joint. Experimentally it has been seen that trauma to the joint of a tuberculous animal will 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 spongy tissue of the bone. Konig has seen cases where tubercles developed directly from the clot, just as in a syphilitic individual a gumma will develop at the site of an injury to the bone. " There are cases where 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 where joint disease of a tuberculous type has followed injury in children whose family histories were exceptionally good. Konig estimates half the cases as traumatic ; Albrecht, one-sixth ; Croft, thirty-five per cent ; Gibney, forty-two per cent (of which seventy-two per cent were also hereditary) ; Taylor, fifty-three per cent (in 845 cases) ; and Sayre still represents the extreme view on ' Gibney : " Strumous Element in Joint Disease," N. Y. Med. Jour., July, 1877. ^ From preface of German translation of "The Mechanical Treatment of Pott's Dis- ease." 3 Croft : Clin. Soc. Transactions, London, vol. xiii. ■♦ Konig: Deutsch Z. fiir Chir., 1879, xi. ETIOLOGY, ETC., OE CHRONIC JOINT EJShlA^^E. 237 this side in maintaining that practically all arc traumatic. Gibney observed 845 cases of spinal paralysis (a class of children subject to constant falls and injuries), for several years, and found only 4 complicated with joint troubles. Roser ' observed lOO children at Marburg with fracture of the elbow, and in no case did tubercular disease follow. Shaffer- says, " Experience proves that traumatism excites only acute disease, as a rule. In those constitutions strong enough to resist and repair the injury, these acute troubles soon subside. Under reverse circumstances they are apt to be followed by a chronic form of inflammation which may end in suppuration," Adams, Agnew, Bauer, Sayre, Petit, represent the advocates of traumatism. S. D. Gross believed that this joint disease could not exist without a vitiated constitution. Volkmann says, " Individuals with fungous joint disease spring, practically without exception, from families in which scrofula and tubercle are hereditary." That such is the rule, but that exceptions are common, is the view held by Sonnenberg,^ Konig, Howard Marsh, Roser, and the majority of modern writers. In view of all this the safest view to take is that, in the' greater proportion of children an inherited vice of constitution is present, and that in these cases traumatism is most liable to be followed by chronic disease, but that in certain cases traumatism alone must be accepted as the causative factor, while in other cases the disease seems to have originated spontaneously. It is in these last cases that one finds the most marked signs of ill health and "scrofula." The exanthemata must be mentioned as being the cause of tuber- culous 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. Croft estimates that about 7^ of chronic tubercu- lous joint disease in children follows the exanthemata, but there are very few figures bearing upon the subject. The effect of the ex- anthemata in causing other forms of joint disease w^ill be alluded to later. 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 bacillus and the consequent results. Age. — Tuberculous joint disease is pre-eminently a disease of childhood. It is rarely, if ever, congenital,-* and under one year it ' Berl. Klin. Wochenschrift. ^Shaffer, N. M.: "Am. Clin. Lectures," vol. iii., 141. 3 Sonnenberg : Arch. f. Klin. Chir., iSSi, xx^^., 7S9. '' Lannelongue, loc. cit. 233 ORTHOPEDIC SURGERY. is not common. Of Gibney's 860 cases, so often alluded to, 84^ per cent of all cases occurred before fourteen. Of 619 cases of hip disease tabulated by Mr. Wright,' there were : and Under 6 years, . From 6 to 10 years, " 10 to 15 " 15 to 20 " 20 to 25 " 25 to 30 " 30 to 35 " 35 to 40 " 40 to 50 Above 54 years, Total, Two years and under, From 2 to 5 years, 5 to 10 " " 10 to 14 Total, . . Mr. Bryant has tabulated 360 cases as follows Under 4 years, . ... From 5 to 10 years, . " II to 20 " . " 21 to 30 " . " 31 to 40 " . Above 40 years, .... Total, 40 cases, no 129 66 39 17 9 4 3 I 418 cases 28 cases 62 a 81 (< 30 (( 201 cases 126 cases 97 86 27 13 II 360 cases. Taking Mr. Wright's and Mr, Bryant's cases, and adding 365 others. reported by Dr. Sayre,' we have 1,344 cases of hip disease, of which 1,000 occurred under fifteen years of age. This is natural enough, for these tubercular diseases affect chiefly the epiphysis, and the epiphysis during its period of greatest activ- ity when its blood supply is largest and its tissue changes most rapid. The records of the New York Orthopedic Dispensary show the liability at different ages in the cases of joint diseases of the lower extremity treated for the years 1884-1I " Hip Disease in Childhood," p. 2. L. A. Sayre : " Orthopedic Surgery and Diseases of Joints." EriOLOGY, ETC., UJ'' CHRONIC JO/NT PfSEASE. 239 Under 3. 3 to 5. 5I010. kjIojs. 151020. (Jvcr2o. Hip 115 316 509 140 47 5' Knee 43 69 ' 94 28 22 63 Ankle 12 18 24 18 4 7 170 403 627 186 'J I 121 The liability of the aged to tuberculous joint disease must, how- ever, not be overlooked. The fact that people over sixty are more often " scrofulous " than people between thirty and fifty, is noted by Sir James Paget/ The patients may be seventy-five or ninety, and cases of hip disease present the same pathological appearances here as in young children. Paget speaks of the affection as one which he frequently meets. The course of the disease is more rapid and destructive than in the young, and its etiological rela- tions decidedly more obscure. The reasons given why tuberculous joint disease affects children to so great an extent are formulated as follows by Mr. Wright, in speaking of Hip Disease: I. Because in the active period of growth more change is going on and therefore more instability exists and consequently greater liability to disease (Barwell). II. That childern are more liable to falls and injuries, which are such a fertile source of joint and bone lesions. III. That it is not till after puberty that the process of natural selection has eliminated the weaklings from the stock. IV. That children are kept quiet less easily than adults and a slight injury may develop into a formidable disease. V. That tuberculosis in general is common in childhood. Sex is not a factor of any prominence, but there is a slightly larger proportion of tubercular, joint disease among boys than among girls. Of 619 cases of hip disease collected by Wright, there were 371 males. Holt,- in 2,307 cases of hip disease, found 1,178 males and 1,129 females, but the preponderance is very slight, and Mr. Bryant thinks one sex as liable as the other. Barwell thought that the presence of phimosis in a measure accounted for this pre- ponderance of males in hip disease, at least, and in 100 cases of hip disease he found 83 in a condition of more or less complete phimo- sis. Wright examined 63 cases taken at random, 12 of which were hip disease, and he found, that in the hip disease cases sixty-seven per cent had phimosis, while in the others only fifty per cent. Dr. Sayre is an advocate of phimosis as an exciting cause of hip dis- ease. ^ "Clinical Lectures and Essays. Senile Scrofula." 2d Ed., p. 345. - Gibney, loc. cit., p. 206. 240 ORTHOPEDIC SURGERY. There is hardly any need of figures to call attention to the fact that phimosis is a most prevalent condition in small boys both healthy and diseased. The figures of Dr. Roswell Park,' however, show this in a series of observations which he made on 150 boys of all conditions in private and hospital practice. Number. Per cent. Class I. Cases permitting easy and perfect re- traction of the prepuce, ..... 30 19.62 Class II. Cases of slight or partial adhesions with little or no retained smegma, ... 48 31-37 Class III. Cases of complete or nearly complete adhesions without stenosis, .... 36 23.53 Class IV. Cases where retraction was impossible, 39 25.48 153 100 From this it is easy to see how phimosis might easily come to be assigned as the cause of any pathological condition. As regards the social status of these patients, it is said tubercular joint disease is an affection attacking the lower classes more fre- quently than children of well to do and better-fed parents. Figures, however, to establish the statement cannot be said to be of value, and statistics are taken chiefly from hospital practice. The disease, however, is unfortunately not uncommon in people of excellent or luxurious surroundings. The Distribution of Chroitic Tuberculous Joint Disease. — The fre- quency with which different joints are affected can only be learned by the consideration of large groups of cases. Schiiller'' gives the following table from 439 cases of Socin and his own: Knee, 35.8; hip, 15.9; elbow, 12.7; tarsus, 11. 8; foot, 9.6; hand, 6,2; shoulder, 4.1 per cent., etc. Billroth and MenzeP in 1,996 cases found the distribution as follows: Vertebral column, 35.2; knee, 11.9; head bones, 10.2; hip, 9.4; sternum, clavicle, ribs, 9.2; ankle and foot, 7.5 per cent. Of 421 cases observed at Basle,-* 265 were classed as "caries," and 156 as " fungous disease," and their location was Caries. Head, .... 8.3 per cent. Pelvis, .... 33.6 " Upper extremities, 22.3 " Lower extremities, 33.6 " Multiple, ... 2.2 " Fungous Disease. Upper extremities, 25.6 percent. Lower extremities, 74.3 " Hip, 41 Knee, .... 50 " Foot, . . ; . 25 " ' Chicago Med. Jour, and Exam., 1880, p. 561. ^ " Die Path, und Ther. der Gelenkentziindungen," Wien und Leipzig, 1887. 3 Arch, f, Chir., xii., 1871. ♦ Deutsch. Z. f. Chir., xi., 1879, 350. ETIOLOGY, ETC., OF CUKOXIC JOIXT D/SEASE. 24 1 Gibney, in 614 cases, mostly in children, found 209 cases of spinal disease; 271 cases of hip disease; 103 cases of knee disease; 31 cases of ankle disease. Five hundred and thirty cases of chronic joint disease of this type in children have been observed in the surgical out-patients of the Boston Children's Hospital, in the last three years, and they have been located as follows: Hip, 220; knee, 64; ankle, 36; verte- bral column, 202; shoulder, 3; elbow, i; wrist and fingers, 4. At the New York Orthopedic Dispensary, dealing also almost wholly with children, from 1884 to 1886, inclusive, there were ob- served 2,644 cases of chronic joint disease of this type, in which there were, 1,178 cases of hip disease; 1,024 of vertebral disease; 83 of ankle disease; 319 of knee-joint disease; 7 of wrist disease; II of elbow disease; 11 of shoulder-joint disease; 11 of multiple joint disease. Dr. Judson' has recently called attention again to the great pre- ponderance of joint disease in the lower extremity as contrasted with the upper limb. Analyzing the reports of two Orthopedic Institutions in New York City he finds that in a single year the following number of cases of disease of the different joints were treated; Hip-joint disease, . . » . . . 577 Knee «' " 181 Shoulder " . . . . . . . 6 Elbow " 8 or 758 patients had disease of the joints of the lower extremity, while in the same time there only appeared 14 cases of joint dis- ease in the upper extremity. The conclusion that Judson dra^^■s should be presented in his own words : *' The practical lesson to be drawn is the necessity of imitating in the lower the mechanical environment of the upper limb. The lower extremity should be made a pendent member by some form of crutch, axillary or perineal, from the earliest recognition of the disease till its resolution." In joint disease where one or more articulations are involved, any combination may be found, but the most common are hip disease and Pott's diseafse, knee disease and Pott's disease, and double hip disease. Disease of both the knee and hip joints is not common, and double tumor albus is very unusual. {b) Syphilis. — Joint inflammations in syphilis occur at three stages of the disease: (i) in the early secondary stage; (2) in the tertiary stage ; (3) in hereditary syphilis. Each of these forms must be mentioned separately. ' N. Y. JMed. Record, May i8th, 1889. 16 242 ORTHOPEDIC SURGERY. (i) Coincident with the skin eruptions, the sore throat, the iritis, etc., of the early general manifestation of the disease, there is oc- casionally, though not commonly, noted a simple serous synovitis. No post-mortem examinations of joints in this condition are re- corded. The" joints most commonly affected are in the order named: the knee, hand, elbow, foot, and fingers. (2) In tertiary syphilis there are two manifestations of what is practically the same pathological process. The development of gummata in the periosynovial tissues with chronic hyperplastic synovitis, and later cartilage destruction. And secondly, the de- velopment of gummata in the bone and a secondary affection of the joint, as we have seen under degenerative ostitis. (3) The joint manifestations of hereditary syphilis fall under four classes, which are sufificiently well marked to be considered sepa- rately. A simple serous synovitis attended with much effusion, and a tendency to cartilage necrosis in spots; the capsule may be more or less thickened, but the epiphyseal cartilage remains normal. An osteochondritis with an accompanying epiphyseal periostitis and perichondritis, as already considered under degenerative osti- tis, with its accompanying chronic synovitis and, worst of all, its tendency to separate the epiphysis from the shaft of the bone. A chronic serous hyperplastic synovitis, with papillary growths and gummatous changes of the synovial membrane. And lastly, joint inflammation, the result of syphilitic ostitis, periostitis, and osteomyelitis of the long bones. The classification followed is practically that of Max Schtiller. Syphilitic joint disease attacks oftenest the knee, then the elbow, the small joints of the fingers, and the toes, the metarcarpo-and metatarso-phalangeal joints, then the joints of the hand, the hip- joint, the ankle, and the sterno-clavicular joints in the order named. In 61 cases of syphilitic joint disease collected from various authors, the distribution was as follows: knee, 22; joints of hands and feet, 20; the elbow, 12, and the remainder about equally distributed among the joints mentioned above. (c) Rheumatism is an affection which receives credit for the causation of much joint disease with which it has really nothing to do. The manifestations of arthritis deformans are confused with the truly rheumatic affections, and as in simple acute synovitis of the knee where no cause is assignable the disposition of many prac- titioners is to consider the affection as " rheumatic," so in joint disease in general, obscure cases are liable to be placed in this class. In true rheumatic joint affections the structure attacked is chiefly the synovial membrane, which secretes much fluid and takes on ETIOLOGY, ETC., OE CHRONIC JOINT DISEASE. 243 the appearances of chronic proliferating inflammation, with a ten- dency to connective-tissue formation. In long-continued cases the cartilage shows the signs of chronic inflammation; thickening of the ends of the bones is not uncommon. The whole tendency is away from suppur^ition and toward connective-tissue formation. One form, which Schiiller calls arthritis rheumatica ankylopoetica, shows but little or no effusion, but a tendency to the formation of fibrous, and later bony, ankylosis. This ordinarily occurs in people of lowered vitality through want, or use of improper food. Rheumatic joint affections attack oftenest the knee, then the foot, elbow, hand, shoulder, hip, etc. They are monarticular or polyarticular, and are either the outcome of an acute joint rheu- matism, or an affection beginning spontaneously, or more rarely they result from some injury. For the most part, purely rheumatic affections attack youths and people of middle age. (d) Arthritis deformans (or rheumatoid arthritis) is characterized by the clearly marked series of changes described as the chief group in formative ostitis. In its manifestations it is both monar- ticular and polyarticular, oftenest the latter, and its victims are selected from those who are between the middle age and old — retro- grade changes in nutrition seem to be essential for its development. Hoy/ much of the disease is of nervous origin, and how much is rheumatic, is entirely unknown. Joints are attacked in the follow- ing order: knee, hip, shoulder, elbow, hand, foot, etc. (Schiiller); others place the hand and finger-joints first in frequency. It is more common among men than women, and women whose cata- menia have ceased early are especially prone to the disease. It is not unknown, however, among children, perfectly typical cases oc- curring in childhood. The affection may seem to be the result of injury, by dampness, or insufficient food, and often no cause at all can be assigned for it. Attacking the hip, it is known as "malum coxse senile," a per- fectly well-defined affection clinically. {e) Gout. — The joint affection, which is the manifestation of the constitutional malady known as gout, ordinarily begins as an acute attack, and is followed by a chronic inflammatory process, increased by constant exacerbations. The synovial membrane first presents the appearances of acute inflammation ; the cartilage also shows a tendency to inflammatory degeneration and erosion, and on its free surface and in its tissue appears a deposit of urate of soda, as well as in its capsule and periarticular structures, which localized deposits are known as " tophi." Bony ankylosis may ensue, and there is but little tendency to suppuration, unless the calcareous 244 ORTHOPEDIC SURGERY. deposits ulcerate through the skin by pressure and so open the periarticular tissue. The common seat of the affection is the metatarso-phalangeal joint of the great toe (Scudamore found one hundred and forty out of one hundred and ninety-eight cases lo- cated there), and from that joint it tends to invade the other joints of the foot, the joints of the hands, and the knee and elbow.-joints. Gouty affections attack chiefly men of middle age in the upper classes who have lived upon highly nitrogenous food and have not taken a large amount of exercise. In consequence of the departure from the normal condition, uric acid forms in the blood, which is deposited in the tissues as urate of soda, from the presence of which joint symptoms arise. (/") Acute Infectious Diseases. — The acute infectious diseases in which joint complications occur are as follows: measles, scarlet fever, small-pox, typhus fever, typhoid fever, cerebro-spinal men- ingitis, pneumonia, dysentery, diphtheria, erysipelas, epidemic parotitis, pertussis, puerperal fever, pyaemia, septicaemia, malaria, gonorrhoea, and after the use of catheters and sounds. The pathological appearances are those of acute and chronic serous or purulent synovitis of one or several joints. Sometimes the inflammation assumes a pseudo-membranous character, as oc- casionally in scarlet fever and puerperal fever. The infectious ma- terial ordinarily reaches the joint through the circulation, but sometimes (as in puerperal fever, acute infectious osteomyelitis, or erysipelas) from separate foci of disease, either by the lymph- channels or by direct extension. These diseases are now almost universally attributed to the pres- ence in the joints of micro-organisms of infectious character. Such theories as that of William Ord, e.g., that gonorrhoeal synovitis is the result of reflex nerve disturbance, have not enough in their favor to make them acceptable in the present tendency of pathol- ogy. Micro-organisms are found in the diseased joints, and in serous synovitis their character differs from those in puru- lent synovitis; it seems as if the question of whether the syno- vitis were to be a mild serous one, or a violent destructive puru- lent form, was determined by the kind of micro-organism reaching the joint, rather than on the especial infectious disease present. In serous effusions, organisms which characterize the especial dis- ease present are found, and in greater or less number different forms of pyogenic cocci; but in purulent and phlegmonous pro- cesses one finds exclusively such organisms as staphylococcus and streptococcus pyogenes in enormous numbers.' These facts have ' Arch. f. klin. Chin, xxxi., Heft 2; Huebner : " Zierassen's Hdbch.,"2 Auflage, ii., p. 546; Cent. f. Chir., 1884; Sitzungsber. d. Cong. f. Chir., 1884. ETIOLOGY, ETC., 01' CHRONIC JOINT DISIIASE. 245 been established in tlit: joint diseases of scarlet fever, acute infec- tious osteomyelitis, puerperal fever, etc. It is su^^^^ested that the synovitis of rheumatism is of the same character, but no evidence in support of the theory is to be adduced. Gonococci have been found in gonorrhfjeal synovitis.' The fact that synovitis occasion- ally follows urethral irritation, were gonorrhoea is not present, is well established,'' e.g., after dilatation for stricture. Joint complications come oftenest during the full course of the general disease, when they are apt to be polyarthritic, but in scar- let fever they generally come on at the time of desquamation, and in small-pox in the suppurative stage. In other affections they are commonest toward the end of the disease, as in diphtheria, after weeks or months of gonorrhoea, and late in dysentery as well. Of course, they only occur in a very small proportion of all cases ; coming late in the disease they are much more apt to affect only one joint. But little is known of the general liability of the different joints; the knee is, however, clearly the one most often attacked. With regard to scarlet fever, Thomas^ found the small joints of the ex- tremities oftenest attacked, while Gerhardt, in his collected cases, found the larger joints of the upper entremity most liable.'' Nolen 5 collected, out of literature, 118 cases of gonorrhoea! joint affections (iii men and 7 women), which affected 308 joints, in the following relation: knee, 86; foot, 52; shoulder, 29; hand, 26; fingers and toes, 17; metatarso-phalangeal, 16; hip, 15; elbow, 13, etc. One joint alone was affected 21 times; two joints were affected 12 times; three joints w^ere affected 12 times; many or all joints were affected 15 times. ig) MiscellancoiLS Conditions. — In tabes dorsalis (locomotor ataxia) a definite pathological condition of the joints is clearly rec- ognized. The affection is known as Charcot's disease (having been first demonstrated by him), spinal arthropathy, tabetic arthropathy, etc. Arthropathy of the same type occurs also in acute myelitis, hemiplegia, disseminated scleroses, the paralysis of Pott's disease, progressive muscular atrophy, in certain cases of tumors occupying the gray substance of the cord, and in certain traumatic lesions of ■' Petrone : Rivesta Clinica, 1SS3, No. 2; Kammerer : Cent. f. Chir. , 1SS4. No. 4; Sonnenburg : Veroffentl. der Gesellsch. f. Heilk., Berlin, 1S86, p. 52; Petrone : Spallan- zani, 18S5, X. and .\i. == Re\nllout : Gaz. des Hop., 1S75-89. 3 Thomas : " Ziemssen's Hdbch. der Spec. Path.," ii. , 2. ■» Gesellsch. f. Innere Med., July, 1SS6. s Archiv f. klin. Med., 1882, xxxii., p. I20. 246 ORTHOPEDIC SURGERY. the cord. In short, it may occur in any cord lesion which involves the cells of the anterior gray cornua.' The joint affection appears generally at an early stage of the cord affection. The swelling of the joints may be quite large, and con- sists of an effusion in the joint, and an oedema of the whole limb. This often appears suddenly, and may subside, in part, with equal rapidity. There are, of course, severe and milder types. In the severe cases, the synovial membrane is pale and covered with gran- ulations, the capsule is thickened and covered by a deposit of lime, and in the severest cases the capsule is entirely absorbed, and the ends of the bone are distorted, hypertrophied, or atrophied. The effusion is rarely purulent, and if so, it is due to violence. Luxation and spontaneous fracture may occur. The affection is, by Virchow and others, considered to be due to predisposition in the bones to faulty cellular change, resulting from the nervous disease of the spinal cord ; ^ though others regard the affection as due to the im- pairment of sensation in the joint. Injuries which would ordinarily cause pain and necessitate rest in tabetic individuals do not, and the resulting and repeated inflammations eventually injure the joint. Pathologically, the morbid changes do not differ greatly from those of formative ostitis (arthritis deformans), except that the process may be much more extensive. The clinical course is" ordinarily chronic, but it may become rapid and be attended by complete disability of the joint. The affection attacks the joints in the following frequency: out of 107 cases, the knee was affected 78 times; the hip, 31 times; the shoulder, 21 times; the tarsus, 13 times; the elbow, 10 times; the ankle, 9 times; the wrist and jaw, each 2 times, and the spine once. A. Sydney Roberts,^ in a paper on spinal arthropathies, deduces the following practical facts : First, regarding the period of devel- opment. The tabetic arthopathies may occur independently, or precede the active symptoms of locomotor ataxia. Then, again, they may develop suddenly, late in the course of a posterior spinal sclerosis. He considers that the peripheral expression of central nerve irri- tations is characterized by the following changes found in the structures of the various articulations: (i) A chronic asthenic hyperaemia of the synovial membranes; a hydrarthrosis. (2) An interstitial atrophy of the epiphyses. (3) A fungous or rarefying ^Charcot: Vol. i., p. 121, "Arthropathy m Progressive Amyotrophy"; Mitchell: Am. Jour. Med. Sciences; Michaud : " Sur le meningite et la myelite dans le mal uest," Paris, 1871; Gull: Guy's Reports, 1858; "Arthropathy in Hemiplegia," Scott Allison; Dann : Lancet, ii., 1831, p. 235. ^ Centralblatt f. Chir., October 15th, 1887; ibid., No. 22, 3887; ibid.. No. 25,1887, p. 5. 3 Phila. Med. Times, Feb. i8th, 1885. EriOLOGY, KTC, ()/■' CIIKONJC JOINT /J/S/wlS/C. 247 epiphyseal liypcrtrophy. (4) The formation (A osf,(.f)j)liytes and bony stalactites. These various joint expressions characteristic of spinal arthropathies naay exist separately, but are usually combined in the same subject. They may readily be distinguished from the common inflamma- tory lesions by the total absence of the reflex neural phenomena, that is, of pain, both reflex and local, the apprehensive state re- garding joint-movements, and the reflex or tetanic spasm of the muscles, always associated with joint arthritis. There is some dif- ficulty in differentiating the affection from malignant disease, but a careful inquiry into the history and course of the lesion, and the presence or absence of central disturbances, are our most reliable guides. The progress of the arthropathies is most often essentially chronic. Occurring not infrequently early in the history of a tabetic lesion they slowly increase, with occasional exacerbations, and years elapse before fully matured. A rapidly developing arthropathy may be associated with the later stages of an ataxia. Their course is self-limiting, though never reparative. Hcsmophilia is another condition in which a peculiar and charac- teristic joint-affection is occasionally met ; hemorrhage from the synovial membrane of the joints, as well as from the serous mem- branes in other parts of the body is found. This comes on either spontaneously or in consequence of some injury, and affects most frequently the knee, elbow, and ankle. Fresh dark blood is poured out, and the cartilage, ligaments, and synovial membrane are stained by it, and the cartilage shows a tendency to degenerate. Micro- scopical examination of the cartilage in the case reported by 'Wx. Legg, showed only the ordinary early changes of inflammation. All the changes seem purely the results of synovial hemorrhage. Certain pathological conditions do not easily come under the heads of this or any classification and must be considered inde- pendently. Groiviiig Pains. — A joint affection incident to growth has been described by Bouilly, and has long been known but unclassified by practitioners, and popularly considered to be incident to growth — " growing pains." There is slight pain chiefly in the juxta-epiphy- seal region, most commonly near the lower epiphysis of the femur. This pain is brought on by fatigue, strains, or exposure. In the lightest cases the symptoms pass away in a few hours. In severer forms they may last for several days, and the pain be accompanied by slight fever. In the severest form the affection may continue for months. There may be slight effusion in the joints, but recov- 248 ORTHOPEDIC SURGERY. ery eventually takes place. It may occur during the ages between five and twenty-one/ A great amount of harm is done in referring to this class the pains of beginning chronic joint disease. Growing pains proper are neither severe nor permanent. Analogous to this may be mentioned what has been termed by French writers maladie de la croissance — which is in reality a hyperaemia and sensitiveness of the epiphysis in adolescents — anal- ogous to what is seen occasionally in rickets. Acute Arthritis in Infants. — English writers have described, un- der the term of acute arthritis in infants, a form of acute epiphy- sitis or juxta-epiphysitis occurring in infants from two months to two years of age. It is of a particularly severe form. It is ex- tremely fatal, death occurring in 13 out of 27 cases. Several joints may be attacked. The knee, hip, and shoulder are the ones most frequently involved. The joint at first is stiff, pain and swelling follow, and later an abscess is formed. Out of 27 cases, the hip was attacked 14 times, the knee 11, the shoulder 5, the ankle and elbow 4 times each, the wrist once. Out of the 27 cases, in 20 the affection was monarticular.- TJie Distribution of CJironic Joint Disease. — Of 2,002 cases of all kinds of joint disease collected ^ from the clinics of Volkmann,"* Langenbeck,^ Hueter,^ and Socin,^ IjSS/ were of the lower extrem- ity, 615 of the upper. The distribution of all the various forms among the special joints was as follows: knee, 711; hip, 333; foot, 234; elbow, 183; hand, 172; shpulder, 166; finger, 94; tarsus, 78; toes, 31. Of 834 cases collected by Schiiller, showing the frequency of the various kinds of joint disease, there were 240 cases (28.7 per cent) of acute serous synovitis; 26 cases (3 per cent) of acute purulent synovitis; 67 cases (8 per cent) of simple chronic synovitis; 138 cases (16.3 per cent) of arthritis deformans; 343 cases (43.5 per cent) of scrofulous or tuberculous joint disease. Schiiller estimates the general relation of acute to chronic joint disease as 4 to 6 in general, although hospital clinics would set it as 3 to 7, because acute joint rheumatism and metastatic inflammations are not seen here. Two or more joints may be attacked at the same time, not infre- ' Gaz. des Hopitaux, 1883, p. 1034. ^ Ploward Marsh : " Diseases of Joints." 3 Arch, fiir klin. Chir. , xxi. , Berlin, 1877. 4 Beitrage zur Chir., p. 152, Leipzig, 1875. s Jahresberichte (i877-]884) des Spitales zu Basel. ^ Hueter : " Gelenkkrankheiten," i., 164. 7 Schiiller : " Die Path. u. Ther. der Gelenkentzlindungen," p. 33. ETIOLOGY, ETC., ()/■' CHRONIC JO J N'J' DISEASE. 249 quently in the affection known as chronic rheumatoid artlirilis, but also in tuberculous diseases. Course and Termination. — The clinical course of the different dis- eases of the joints, while varying somewhat according to the ana- tomical surroundings of the different articulations, preserves the types sufificiently, so that a description of the disease in one joint will serve for that of another within certain limits. Tlie ?jest type of a serous joint effusion will be found in effusion of the knee-joint, while for typical tubercular ostitis of the joints, the history of the larger joints, hip or knee, will serve ; and the same is true of chronic rheumatoid arthritis. It will therefore be simpler to describe the clinical course of the affections of the joints under the heads of the special joints. Joint affections terminate either in, a cure with more or less perfect motion of the articulation, or in destruction of the joint with a resulting deformity or loss of the limb, or in ankylosis. Synovitis, whether serous or purulent, is a much less destructive affection than ostitis and follows a milder course. Its results are therefore much more favorable. Chronic serous synovitis is chiefly harmful in its weakening action upon the articulations which it affects. The lateral ligaments of the knee loosen and lateral motion may be present in the joint. Added to this is a loss of control over the joint motions and a constant feeling of insecurity on the part of the patient. This may lead to almost complete disability of the joint. Chronic purulent synovitis is more destructive, although it may resolve and leave unimpaired motion; but more commonly motion in the affected joint is ultimately restricted and complete ankylosis results at other times. Epiphyseal ostitis, again, may be cured Avith perfect restoration of joint motion, but these cases are exceptional and more commonly one must expect decided impairment of motion or complete anky- losis, or on the other hand the process may never reach so desira- ble a state as ankyolsis, but it may go on to disintegration of the joint or almost endless suppuration. The impairment of motion comes oftenest from the formation of adhesions which represent the organization into connective tissue of the morbid products present in the joint during the disease. Cure with perfect motion may result even after joint abscess has occurred, but as a rule any destruction of the articulating surfaces results in restricted motion. In the less favorable cases destruction of the joint is likely to occur in tuberculous ostitis of all kinds if the process is not checked. All the tissues of the joint may be'come involved and destroyed, and the periarticular tissues may be invaded. From 250 ORTHOPEDIC SURGERY. this stage of pan-arthritis any degree of destructive change can easily result. Dislocation of the bones and disortion of the limbs develop,, the tissue about the joint becomes brawny and infil- trated, the purulent process extends up and down in the shafts of the long bones as an osteomyelitis, the limb becomes oedema- tous from obstructed and diseased blood-vessels, and operative in- terference is demanded. Under proper treatment in by far the greater number of cases the affected joints will not reach the con- dition just described. In certain cases, however, the disease is not checked by treat- ment. With so grave a local condition as is seen in the severest forms of joint affections the general system does not escape serious im- pairment. Amyloid degeneration of the liver and other viscera at times accompanies this condition of prolonged suppuration, it is not, however, a v^xy common affection. Septicaemic changes, such as cloudy swelling of the viscera, phthisis, tubercular meningitis, etc., arc other consequences of long-continued suppuration, and frequently follow the graver forms of the disease. Ankylosis is the last termination of serious joint disease to be considered. The loss of mobility may vary from a small diminution in arc of motion to a complete obliteration of all movement. Some of the pathological processes that we have considered are perfectly capa- ble of destroying the articular surfaces and replacing them by granulations. The granulations in turn are replaced by connective tissue " organized " directly from the granulation tissue. Conse- quently it is easy to see how fibrous bands of greater or less extent are formed, running from one bone surface to the other, and these in turn may ossify and a solid bony mass may be formed \vhere there was at one time a joint. Oftener fibrous and bony ankyloses are found associated with each other. In the form of synovitis characterized by a small fibrinous exudation (dry synovitis) the formation of fibrous bands between the joint surfaces is accom- plished without the intervention of granulation tissue. Other causes of the loss of motion in joints, besides fibrous and osseous ankylosis of the joint surfaces, are: i, cicatricial contrac- tion of the articular capsule and ligaments; 2, adhesions between the folds of the synovial sac causing restriction of joint motion, and secondarily degeneration of the cartilages, in consequence of inaction; 3, the buttress-like osteophytes in formative ostitis; and 4, in pathological luxations, the result of destructive bone inflam- mation causing loss' of substance in the ends of the bones, and con- sequent malposition of the articular ends of the bones. ETIOLOGY, ETC., ()/■' CIIKONJC JO/NT JJ/SEylSE. 351 Bony ankylosis is of course oftcncst tlic result of supimrative syn- ovitis primary or secondary, hut not necessarily the result; for, of thirty-five cases of hip-joint disease analyzed with reference to the ultimate amount of motion in the joint in suppurative and non- suppurative cases, it was found that the presence or absence of ab- scesses had no effect upon the ultimate amount of motion left to the joint.' Marsh found bony ankylosis present in an ankle-joint one month after suppuration began. On the other hand, as we have seen, true bony anchylosis may occur without suppuration at all. But as a rule bony ankylosis is only present after the disease has been quiescent for years. And many errors of treatment are made by assuming that it has taken place within a short time of the cessation of the disease. Treatment. — On the subject of treatment of chronic diseases of the joints, it may be said that in cases influenced by constitutional states, such as tuberculosis, syphilis, gout, or rheumatism, constitu- tional treatment is manifestly indicated. It is self-evident that the better the patient's health is, the better the chances of recovery, even in affections comparatively localized. In tuberculous joint affections the benefit of fresh air and exercise is particularly to be borne in mind. The general methods for surgical and local treatment of chronic diseases of joints may be enumerated as follows: i, local applica- tions (counter-irritation, cauterization, inunctions, frictions, mas- sage, subcutaneous injections); 2, compression; 3, fixation; 4, pro- tection from jar; 5, traction (extension). In addition to these the operative measures, aspiration, incision, excision, and amputation, are needed at times. Local Applications. — The benefit to be derived from local applica- tions comes chiefly from an alteration in the circulation of the parts and a relief of a condition of congestion, if such exist. Blis- ters, counter-irritation, and cauterization play less of a part in modern therapeutics than formerly, but in certain cases they ap- pear to afford relief. Friction and massage, apparently, in improving the circulation, improve the condition of the joint in certain cases. It is probable that in this way galvanism is beneficial. Ignipuncture in joint affections has been recently recommended by Kolomin, for epiphyseal ostitis, especially in the foot and wrist in children. In cases of chronic synovitis with absence of pain and tenderness, it is not recommended by the advocate of the method. 'New York Medical Journal, May 21st, 1S87 : "Ultimate Results of Mechanical Treatment of Hip Disease." 252 ORTHOPEDIC SURGERY. An anaesthetic should be used, and a Paquelin cautery should be the instrument employed, and either superficial punctures, burning the soft infiltrated tissues round the joint, can be made, or deep punc- tures extending to the bone and marrow, the latter after trephin- ing the sound bone. Antiseptic dressings should be applied. Either a number of punctures can be employed, or a few deep ones, according to the condition of the disease.' The method has also been used by Oilier, who divides the skin and sound tissues with a knife, and if necessary the bone should be exposed and thorough antiseptic cleansing should be carried out. Oilier and Vincent re- gard the method of more use in certain diffuse cases of tubercular epiphysitis than the curette.'' The benefit of inunctions is probably that of frictions generally, namely, the establishment of an improvement in circulation and the diminution of congestion. The application of moist heat, as poultices or the wet-pack, is often agreeable. And if there is in- flammatory heat in the part, cold compresses, irrigation, or the ice-bag are advantageous. The subcutaneous injection of solutions of iodoform into tuber- cular granulation tissue has been recommended in fungous diseases of joints, but the results reported have not brought the method beyond the experimental stage. In the view of imitating the spontaneous cure of fungous granulations in tuberculous joint dis- ease by calcification, Kolischer has in a number of cases injected subcutaneously a concentrated solution of calcium phosphate at the seat of the disease. The solution is as follows: 75 grains of neutral phosphate of calcium are dissolved in twelve ounces of water, and enough phosphoric acid is added until a perfect solution is obtained. Nine minims of dilute phosphoric acid (Austrian Pharmacopoeia) are added with 3 ounces more of water. The whole solution is sterilized by boiling and injected into the fungous tissue by means of a syringe with a platinum needle. The joint is dressed with gauze wet in a solution like the above, except that 90 minims more of dilute phosphoric acid should be added. There is a great deal of pain after the injection and morphia is usually nec- essary. Fever and induration of the tissues follows. Kolischer reports successful cases.^ The injection of solutions of iodine into the joint cavity is a remedy formerly occasionally used, which fell into disuse. Of late the irrigation of joints with aseptic solutions has been advised and practised. Solutions of carbolic acid, i to 20, or of ^ See Boston Medical and Surgical Journal, April 26th, 1883, p. 392. ^Vincent : "Arthrotomie Ignee." Revue de Chirurgie, January loth, 1884. 3 Wien. Med. Presse, No. 22, 1887. ETIOLOGY, ETC., OF CHRONIC JOINT DISEASE. 253 corrosive sublimate, i to 1,000, are used. Jla^^er rejjorts the injec- tion through a small trocar of such stjlutions with benefit in cases of relaxation of the shoulder and of the temporo-maxillary joint.' Coinprcssio)i. — Compression promotes absorption of fluid in fedc- matous tissues and effusion. It can most readily be applied to the knee by means of rubber bandages or other elastic compresses. Dried compressed sponges bandaged around a knee and then wet, will, by expansion, produce pressure in cases of chronic synovitis. Fixation. — Fixation, i.e., the prevention of motion at a joint, is indicated in all active inflammatory conditions of a joint. In sub- acute conditions of inflammation a limited amount of careful motion is not injurious, the amount of motion varying according to the state of the joint. Sudden, violent, or jerky motion is, how- ever, injurious. Verneuil has called attention to the danger of too frequent and early use of forcible passive motion, and has laid great stress on the undue fear of the formation of ankylosis (ankylophobia, as he terms it) from fixation of the limb. He claims that ankylosis results from inflammation, and that the best way to prevent anky- losis is to check inflammation, most readily done by rest and fixa- tion; that ankylosis does not invariably take place simply from rest, as in the limbs of hemiplegics, wdiere immobility is unavoid- able. Ankylosis does not result, except when chronic rheumatic arthritis is combined; but in the joints stiffness results after too long fixation in fractures, partly from traumatic inflammation, partly from periarticular contraction. - Protection. — Protection from the jar incidental to locomotion is of importance in ostitis of the joints of the lower extremities, except in the latest stage of convalescence. The importance of protection is often overlooked in the supposition that, if a knee or ankle is fixed by a stiff bandage, the patient can bear weight upon the limb, forgetting that in an ostitis jar to the inflamed epiphyses is more injurious even than motion. The simplest method of protection in affections of the lower extremity is by the use of crutches, but, as will be seen under the headings of individual joints, other more convenient means can be used. Protection from jar in joints of the upper extremity is readily effected by the means used for fixation. Traction. — The "traction " of the bones forming a joint, that is, the pulling them apart, is manifestly desirable when the inflamed epiphyses are being crowded together, either by jar or muscular pressure. Exaggerated pressure of two inflamed bony surfaces of ' American Journal of the Medical Sciences, April, iSSS. ^ MouUin : " Sprains," p. 116, London, 1SS7. 254 ORTHOPEDIC SURGERY. a joint upon each other increases the danger of necrosis, and the extent of the destructive ostitis, by diminishing from pressure the blood-supply proper to the separation of the inflamed parts, and by thus retarding the development of the formative or cicatricial ostitis from which a cure is to be expected. In certain joints, as the elbow, sacro-iliac, symphysis pubis, traction is impracticable. In pure synovitis, where there is no danger of extension to the bone, there is little need of traction. This, however, is a rare con- dition in the larger joints, if extensively inflamed. The operative procedures, aspiration, arthrectomy, and arthro- tomy will be considered severally under the headings of each joint, where they are to be borne in mind as therapeutic methods. The employment of these several methods varies not only in the different affections of the joints, but also in the different joints, for the anatomical conditions vary so widely. It will, therefore, be necessary to leave any more detailed consideration of the subject until speaking of the separate joints. CHAPTER VI. HIP DISEASE. Definition.— Pathology.— Clinical History.— Diagnosis.— Differential Diag- nosis. — Prognosis. — Treatment (Conservative — Operative;. The affection which is commonly known as Hip Disease is by far the most frequent affection of the hij^ joint, and by common usage the general nam.e of " Hip Disease " or " Hip^joint Disease '"' has become limited to that especial affection of the joint which comes now for consideration. It is known also by the names of morbus coxarius or morbus coxse, coxalgia, chronic articular ostitis of the hip, and coxo-tuberculose (Lannelongue). The pathological condition most commonly found is a chronic tuberculous ostitis of the epiphysis of the head of the femur. Pathology. The pathology of hip disease has already been considered in its general aspect along with the other forms of tuberculous joint dis- ease in Chapter IV. It will be remembered that it was then dem- onstrated that the affection begins most often as an ostitis, and that hip disease originates as a synovitis rarely. The point of original disease has been by various writers believed to be in the synovial membrane, the ligamentum teres and other ligaments, the cartilages, and even the subsynovial tissue, and at the present time authors are not quite agreed as to the most common initial site of the affection. It is not worth Avhile to catalogue the views of various authors; but it may be briefly stated that the evidence is strongly in favor of the osseous origin of the disease in children, while in adults an initial synovitis is more common. Among the surgeons who hold this view are Bryant (who esti- mated nine-tenths in children as osseous in origin), Barwell, Rust, Gross, Marsh, Annandale, Konig, Volkmann, Gibney, and Lanne- longue ; but Sayre, Billroth, and others favor the theory of a syno- vial origin ; and one still finds advocates of the ligamentous origin of the disease in Owen, Holmes, Adams, and Coulson. 256 ORTHOPEDIC SURGERY. Miiller' analyzed the specimens of 61 hip excisions, and found that the disease began in the bone in 47 cases, in the synovial mem- brane in 3, while in 1 1 it was impossible to state where it originated, Konig investigated with regard to this 71 preparations from all the joints and found 47 of osseous origin.'' Wright bases his opinion upon 100 excisions of his own and the examination of specimens removed by other surgeons, and believes " that in true chronic morbus coxae, such as we ordinarily see, and also in the acute and rapidly destructive cases, the disease begins almost invariably in the bone." ^ There are certain early autopsies which have showed the matter very plainly; one was the case mentioned by Gibney in his book on diseases of the hip, where both joints were affected; and in one case the focus was in the head of the femur, and in the other in the acetab- ulum. Lannelongue has reported four early autopsies; but autopsies early enough to reveal the primary condition are not common. Although in most cases the head of the femur is the primary seat of dis- ease, there is no question that in others the floor of the acetabulum is first affected, while in still others the acetab- ulum becomes involved in the progress of the disease. In Wright's 100 cases the acetabulum was necrosed or per- forated in 27, in 14 of which there seemed reason to believe that the fe- FiG. 254.— Acetabular Coxitis. mur was first affcctcd. In 49 other cases, however, the acetabulum was superficially diseased. Habern has asserted that primary acetabular hip disease is much more common than has been supposed, and he supports his views by the following analysis of 132 hip resections from Volk- mann's clinic* In 50 of these a caseous focus of the acetabulum was found with a sequestrum in 31 ; in 23 there was a focus in the femoral head, neck, or trochanter; in 7 there were such foci in both acetabulum and femur; and in 29 cases the disease was so far advanced that it was not possible to find the primary focus of disease. In 23 cases ' Konig- : " Die Tuberc. der Knochen and Gelenke," Berlin, iS = Konig : Deutsch. Z. f. Chir. xi., 1879. 3 G. A. Wright : " Hip Dis. in Childhood," p. 17. 4 Cent. f. Chir., April 2d, 1881. ////' D/SKASE. 257 the disease appeared to have hccii jjiiinnrily synovial. J^eyorid this there is really no definite infonnation to he given, the experi- ence of all operators being largely the same, namely, that in a few cases the acetabulum presents evidence of having been primarily diseased, but that in a greater number it becomes secondarily af- fected in the course of the disease which has begun in the head of the femur. When once the acetabulum has become diseased, a curious en- largement of it is apt to take place. The irritated pelvic femoral muscles which are in a state of tonic contraction crowd the head of the femur against the upper border of the acetabulum ; under this continual pressure absorption of that jDortion of the rim of the acetabular cavity takes place with an actual enlargement of the cavity from below upward. This enlargement is shown in the ac- FlG. 255. Erosion of the Head of the Femur. Fig. 256. companying figure. This so-callfd migration of the acetabulum is the cause of shortening of the limb, in many cases, and measure- ment will show that the trochanter lies above Nelaton's line. The changes in the head of the femur are chiefly the result of ostitis and pressure. There is alteration in the shape of the head of the bone, inasmuch as it is worn away by the pressure induced by constant muscular spasm and destruction of the articular surface. The appearance of the cartilage, as described under the pathology of that structure, often suggests ulceration, and hence arose the theory that the original seat of hip disease was to be found in the cartilage. There are cases which show that in an early condition there may be hyperaemia and ulceration of the ligamentum teres ; such a case is figured by Homes in his " Surgical Diseases of Chil- dren," and other instances are reported by Martin and Collineau. The condition may be due to a primary tuberculosis at this point, but the cases cited do not demonstrate the fact conclusively, and it is more likely that ulceration of the ligament in hip disease exists 17 258 ORTHOPEDIC SURGERY. either as an extension of the disease from the epiphysis or secon- darily to the ostitis and contiguous synovitis, as is the case with the crucial ligament at the knee joint in disease of that joint. " Dislocation " of the hip in hip disease is a term often used which is, perhaps, misleading. True dislocation very rarely occurs, but partial destruction of the softened head of the femur in the manner just described leads to a shortening of the limb and to an elevation of the trochanter above its proper level. The wearing away of the acetabulum produces the same result and both these deformities occur ; but true dislocation is rare, because, even if the head of the bone is almost entirely destroyed, there is so much in- FiG. 257. — Diffuse Epiphyseal Ostitis, Fig. 258. — Pathologically Enlarged Acetabulum. flammatory tissue deposited about the joint that the head of the bone is retained partly in place. Fracture of the atrophied and degenerated shaft of the femur may occur in occasional cases. A typical specimen from a fairly advanced case of hip disease shows a reddened and thickened synovial membrane, perhaps even broken down into granulations ; the cartilage is gone from the head of the femur or hangs in tags or shreds, and the general appearance of the end is often spoken of as " worm eaten," a term which de- scribes it very well ; and sometimes the whole cartilage may be lifted from the bone by a layer of granulations. The epiphyseal portion of the head of the femur has probably disappeared in part or altogether, and a ragged, carious end of bone will articulate with the acetabulum if the cartilage has entirely disappeared. Much importance has been attached lo the presence of sequestra ////' niShlASI'l. 259 in the diseased bone. Tin: wliolc epipliysis may form one seques- turm, but this is not common. Sometimes a sequestrum hes in the epiphysis, but more connnonly it extends on bf^th sides of the epiphyseal line; while sometimes tlie dead bone extends some little distance into the diai)hysis. The acetabulum at this same stage is generrdly lined with <(ranu- lation tissue; the cartilage, wln'ch may be large in amount, has either disappeared or it is rough and eroded. Perforation of the floor of the acetabulum may take place, but this generally is to be seen only in advanced cases of hip disease. Inside of the pelvis a dense wall of fibrous tissue and thickened periosteum shuts off the head of the femur or the contents of the joint from the pelvic cavity. In cases where the disease has gone on as far as this, extensive dis- ease of the pelvic bones is likely to coexist. In the other direction, when once the disease of the femur has passed the epiphyseal line, there is no limit to be set to its course or its extent of destruction. Abscesses appear externally if the disease of the joints extends to the peri-articular tissues, or where a separate focus of disease formed outside of the joint spreads to the surrounding soft parts. Suppuration inside of the pelvis is not a very uncommon condi- tion in the acetabular form of the disease-^in the femoral form it only accompanies advanced disease. It arises most commonly from perforation of the acetabulum or from inflammation inside the pelvis excited by the bone disease in the neighborhood ; or again the pus may ascend to the brim of the pelvis, either in the sheath of the psoas muscle or in other tissues and then gravitate down the inner wall.' A natural cure results in one of twow^ays: by the absorption or calcification of the tuberculous tissue at an early or a late stage of the disease ; or by the purulent degeneration of such tissue and its evacuation by an external opening and discharge. But a spon- taneous cure is not the natural tendency of the disease in the early stages. The suppuration which comes later seems to be nature's effort to eliminate the diseased material, and it is the common method by which spontaneous cure results when it does occur. This late stage of the disease is not likeh- to have resulted until malpositions and shortening of the limb have come on and much impairment of the general condition has resulted. It is this state of affairs that makes the spontaneous cure of hip disease unlikely and imperfect. When spontaneous cure does occur it is almost invariably with an ankylosed joint. The articular surfaces have been destroyed by the disease and being melted into pus have been carried away and, ' R. W. Parker: Chir. Soc. Trans., iSSo. 26o ORTHOPEDIC SURGERY. in part of the joint at least, eroded and hyperaemic bone surfaces are in contact, and motion between these would be impossible. At first, these are connected together by the organized granulation tissue, which solidifies into tough fibrous tissue which in turn be- comes the seat of the deposit of lime salts, and a solid mass of bone exists where once there was a joint. In these cases, however, one sometimes finds at autopsy an in- cluded cheesy focus which still presents some signs of activity. It is to these foci that one looks for an explanation of the late relapses of the disease and the very great harm which is sometimes done by forcible manipulation of these joints and consequent relighting of the original tuberculous disease. In a case of cured hip disease under the writers' observation, where there had been ankylosis and freedom from symptoms for some years, fatal tetanus suddenly developed without any assignable cause, and autopsy showed an ankylosed hip joint in which was included a large tuberculous focus which was the only peripheral source to which the tetanus could be assigned.' Ifi other respects the pathology of hip disease has been described under the general pathology of joint disease. Clinical History. Early Symptoms. — The beginning of the affection is most often gradual and insidious, but at times it begins so abruptly, according to the parents' account, as to suggest a traumatic origin. The child will be noticed to limp at times and at other times to be com- paratively free from lameness. This lameness increases, and it will be found that the patient is inclined to strike the ball of the foot rather than the heel in walk- ing; although the heel can be put down to the floor, yet instinct- ively the knee is slightly bent and the heel raised when the weight of the trunk falls on the hip. There is a certain amount of stiff- ness of gait apparent in the morning when the patient first gets out of bed, and after sitting for a while; this passes away after the patient has Avalked or played about. At night, as a rule, the limp is less than in the morning. The limp can, perhaps, best be de- scribed as a very slight stiffness and dragging of the affected leg in walking. If the child be inspected it will be seen that, although able to run about and play freely, there is a noticeable limp, and in stand- ing the knee of the affected side is usually flexed slightly, the pelvis being tipped, and the thigh slightly abducted. The tilting of the ' Trans. American Orthopedic Association, vol. i. ////' i)1si:asi: 261 pelvis and abduction of the tliii;li may he so slight that it is scarcely noticeable, except by the tleviation from the median line of the fold between the two buttocks. In girls the vulva on the affected side will be seen to be lower than f)n the other side. With regard to pain at this stage it is very often absent and if present, is noted as night cries, to which allusion will be made. It has been customary to divide hip disease into stages and to Fig. 259. — Position Assumed in Standing with slight Abduction of the Right Leg. Fig. 260. — Tilting of the Pelvis and Abduction of the Thigh in Hip Disease. ascribe to these stages certain definite symptoms. There is little agreement among writers on the subject as to what these stages should be, and from a clinical and pathological standpoint it is not desirable to attempt any such division, for even if such a classifica- tion is made, it is hard to identify the stages clinically and they are often so ill-defined that much confusion results. In the early part of the disease, pain at night, stiffness, and limp- ing are the chief symptoms. Then folloAv malpositions of the limb, 262 ORTHOPEDIC SURGERY. more severe disability, and greater pain and sensitiveness perhaps. Abduction of the diseased limb is a little the most common of the malpositions of the early stage, but adduction is by no means un- common as an early symptom. Later in the course of the affection adduction is much more frequent than abduction. Succeeding the deformities which have just been described, one finds abscess formation and the development of sinuses; and this stage of the affection will hardly have been reached without con- siderable constitutional deterioration, which may become extreme, and in a few cases caused death by amyloid degeneration of the viscera. Lameness. — From being at first scarcely perceptible, the lameness increases and the limp becomes very noticeable. In very acute cases, Fig. 261. The Gait in Hip Disease. Fig. 262. pain may become so severe that the child will refuse to use the leg, or malposition of the leg may come on rapidly and the limp may on that account become excessive, but in general the child walks with- out pain, though perhaps limping badly. Until the very late stages of the disease lameness is not due to bone shortening. The accom- panying figures shows the appearance presented in walking by a boy with a fixed and sensitive hip joint. Pain. — As the affection progresses, pain in the knee and sensi- tiveness to jarring the limb may become prominent symptoms, the pain being located by the patient in the knee in the great majority of all cases. The adductor muscles of the thigh will be found near the symphysis pubis to be prominent and contracted, and frequently there is a thickening; of the tensor vag-inae femoris noticeable on ////' nisi'iASi'.. 263 palpation. An unconscious prolcction of the joint will be noticed in the movement of the patient, the focjt of the well limb will be placed under the lower part of the other le^ when it is to be sud- denly lifted by the p9.tient, as from the floor to the bed, or from the bed to the floor, or in moving from one side of the bed to the other. In walking, the patient instinctively avoids resting weight upon the limb, except for as short a time and with as little jar as is possible, the thigh being slightly flexed, tlie knee being bent, and the heel raised so that the shock upon the acetabulum from pressure of the head of the femur \whcn the weight of the body is thrown upon the limb) may be broken at the knee and ankle joints, which serve as springs. This attitude of the limb — flexion of the thigh — be- comes habitual and characteristic ; to it is added in the earlier and more acute stages adduction, abduction, and outward rotation of the limb. In manipulating the leg at this stage pain may follow the slight- est jar to the joint, or, on the other hand, the joint may be perfectly stiff by muscular spasm and yet manipulation may be wholly pain- less. In other cases a certain arc of motion can be described with- out causing pain, but when the limits of this arc are reached, fur- ther motion becomes painful and is prevented by muscular fixation. The sensitiveness of the joint may become so great, when an acute stage supervenes, that the slightest movement of the patient, or jar of the bed or room, causes extreme suffering. The limb is flexed at the thigh, everted, and abducted. This stage may come suddenly and gradually pass away, the pain diminishing by degrees under the enforced treatment of rest, or it may be pro- longed for months. The patient will gradually become able to move the limb, or steady it with the sound limb or with the hands; a characteristic position is frequently taken by the patient, who places the well foot on the dorsum of the foot of the affected limb, exerting pressure away from the acetabulum. Pain may be absent at any or all stages of the disease, and is not a diagnostic sign for or against the presence of hip disease ; and it should be ah\'ays borne in mind that tenderness or sensitiveness at or about the joint may be absent, consequently the absence of these symptoms does not indicate the absence of well-pronounced disease. The joint may be firmly held by muscular spasm, allowing restricted motion on manipulation, while sensitiveness may be absent, upon which, however, at any time a sensitive condition of the joint ma}* super- vene. The pain is often remittent, and here, as in all the symptoms of this affection, the most marked remissions may occur. The loca- tion of the pain is variable, but is generally referred to the inside 264 ORTHOPEDIC SURGERY. and front of the thigh near the knee or directly at the knee joint. The intimate relations and anastomoses of the sciatic, obturator, and anterior crural nerves seem to furnish the best explanation of this, although Bonnet thought it due to the position of the pa- tient, lying in bed with the leg rolled over on its outer side, a con- sequent strain being put upon the external lateral ligaments. There are various explanations offered beside these, one of which is that of Dr. Sayre, to the effect that the pain is a result of the struggle between the adductor muscles and the distended capsule. The causes as enumerated by Wright ' seem to explain the "re- flected " pain most satisfactorily. These are, first, the supply of both hip and knee by the obturator, sciatic, and anterior crural nerves ; second, sympathy between the ends of bones or direct ex- tension of the inflammation ; third, muscular spasm. Attempts have been made to differentiate the varieties of hip disease by the location of the pain, but little or no reliance can be placed upon such a system. Erichsen, for example, believes that pain in the knee is most marked in " femoral coxalgia," from stretching of the obturator nerve over an abscess or from its being involved in the thickened tissues about the femur. Pain in the joint he interprets as " arthritic coxalgia," while pain in the iliac fossa or side of the pelvis would mean "acetabular coxalgia." In general the pain is referred to the whole front of the lower thigh or to the inside of the knee over the inner condyle. In a minority of cases the pain is referred to the joint itself. In the more acute cases sensitiveness to pressure on the trochanter and to any manipulation of the leg is present. But again the whole course of disease may be gone through without the development of local tenderness. Night Cries. — At an early stage of the affection the symptoms of " night cries " often appear. They occur in the early part of the night, usually, and may become an exceedingly annoying symp- tom. After the patient is asleep, and to all appearance entirely unconscious, sleep will be interrupted by a loud cry as if of severe pain, followed by moaning or crying for a few seconds ; the child being unconscious or only half conscious of the cause of the pain. These do not occur when the patient is entirely awake, and are caused by the spasmodic twitching of the muscles abnormally irri- table from irritation reflex to the inflammation of the joint. These cries may vary from a short moan to a piercing shriek, and may in the severest cases be repeated fifteen or twenty times during the night. They do not occur in the later stages of the disease, and may be entirely wanting in the mildest cases. They resemble ' G. A. Wright: " Hip Disease in Childhood," p. 39. jiir j)isi-:asi-:. 265 somewhat the cry in the " ni'L^ht terrors " of nerv^ous children, but differ from those in tliat there is greater evidence of extreme pain, and no connection with unpleasant dreams, apprehension, or fright. From the testimony of j)atients old enough to explain symptoms, the pain is reported to be extremely sharp and severe, suddenly in- terrupting sleep and awakening one, and leaving an ill-defined sense of an aching in the tliigh and hip as if the hip had sustained a blow. MiLScidar Fixation is always ]:)resent in some degree, restricting the joint's normal arc of motion. This will be discussed more fully under the head of diagnosis. Here it may be said that rest to the joint and thorough treatment tend in time to restore motion to the diseased part, and that if a child is taken under treatment with a perfectly rigid joint it is to be expected that under treatment the joint will become more movable unless the disease is very acute and progressive. Increased stiffness appearing in the course of treatment is a sign of inefficient treatment or of extension of the disease. The amount of motion in the joint gained at the close of treatment in most cases diminishes somewhat in after years with- out any evidence of relapse; but in some cases of adults who have entirely recovered from hip disease in youth, nearly normal motion at'the hip joint may be found. This muscular rigidity is the most important feature of the disease, for not only is it the chief reliance in the matter of diagnosis, but it is the cause of the malpositions of the limb, of the wearing away of the acetabulum and of the head of the bone, and it lies at the root of much of the pain. It fur- nishes the most accurate .index of the progress of the case, and im- proves or becomes worse as the case becomes better or worse. The importance of recognition and accurate study of this symptom cannot be over-estimated. At this time percussion of the patella tendon shows an increased knee-jerk on the affected side. A symptom of acute hip disease which has not received due at- tention is a muscular irritability of the lower erector spin^e muscles as well as of the muscles directly controlling the hip joint. If a child with severe hip disease be laid on his face and lifted by the legs with a view to determining the flexibility of the lumbar spine, one can often notice the lumbar muscles stand out like cords, and hold the lumbar spine quite rigid. This often gives rise to the suspicion of the coexistence of Pott's disease. This symptom is present only in the severe forms of hip disease. AtropJiy. — A marked atrophy of the muscles of the thigh and of the glutsei is characteristic. It is supposed to be reflex to the dis- ease of the joint,' and if the muscles of the thigh are tested for ' Emile Valtat : " L'Atrophie INIusc. dans les Mai. Articulaires."' Paris. 266 ORTHOPEDIC SURGERY. contractility to the irritation of the faradic current, it will be found that the contractility is markedly diminished. Atrophy of the muscles controlling an inflamed joint begins early and may be very marked, even in a simple acute synovitis. In five cases, seen by Valtat from the eighth to the eleventh day of the synovitis, muscular atrophy was present in all to the extent of at least two or three centimetres. The character of the joint disease seems to matter but little in the production of this phe- nomenon. Traumatic or simple, acute or chronic, serous or puru- lent synovitis, all show muscular atrophy, and the more acute the disease, the faster the wasting goes on. That this is something more than the mere atrophy of disuse is shown by the fact that it begins so sharply and so early, that it is greater in the diseased limb than in the well one, even when the patient has been in bed from the first, and that the muscles, although atrophied, are not soft and flabby, but tense. Sir James Paget says : " I wish I could explain it better than by calling it reflex atrophy," and Brown- Sequard's experiments lead him to think that the trouble is an irritation of the nerves, and independent of the trophic centres. Valtat injected the joints of guinea-pigs and dogs with irritant solutions, mustard oil and ammonia, and found that muscular atro- phy came on quickly. In one case, in eight days there had been a loss of thirty-two per cent by weight, in the anterior thigh-muscles, and twenty-four percent in the anterior calf-muscles; in another case it reached forty-four per cent, and in all cases the extensors wasted more rapidly than the flexors. He attributes much influ- ence in the matter to the amount of pain present, a point already clinically noted by Paget. Valtat also calls attention, in this con- nection, to the paralysis of the muscles of the affected limb often accompanying acute joint disease. In a case of knee-joint synovitis, which he mentions, there was complete paralysis of the flexors of the leg at the end of twenty-four hours. Such a paralysis, to a greater or less degree, seems to precede the wasting of the muscles. This atrophy will sometimes be absent for weeks and months, although generally it can be easily appreciated at an early stage of the disease by grasping the muscles in the hand or by measurement with a tape. The difference in the circumference of the two thighs will be, perhaps, one-quarter of an inch to an inch, and the differ- ence in the size of the calves is generally about half of the thigh difference. In children who can use the leg fairly well, there is rarely any calf atrophy at the first examination. The obliter- ation of the^fold of the buttock on the affected side is a result partly of muscular atrophy and partly of the periarticular swelling which accompanies the disease. It is a common but not a constant ////' D/S/'lylS/C. 267 symptom at the early staj^^cs of the (hseasc. It is also partly due to the flexed attitude of the limt), which naturally diminislies the prominence of the buttock on that side. Malpositions of the Limb. — The fixation of the diseased limb in a distorted position is one of the common- est incidents of the affection. This is due to the tonic muscular contraction so often alluded to. These malpositions arc in a position of flexion, of adduction, of abduc- tion, and of eversion. Flexion of the thigh was originally supposed to be due to an effu- sion in the capsule of the hip-joint, but it is seen along with adduction and abduction in cases where no effusion has taken, place. It is chiefly due to the muscular contraction, which is constant in chronic disease of the joint, and partly to an unconscious effort on the part of the patient to assume a position most comfortable for the joint and most protected from jar.' In double hip disease flexion produces a terrible deformity. As the disease progresses, adduction or abduc- tion of the limb takes place, and the attitude of flexion and adduction is characteristic of the last stage of the affection. Abduction and adduction of the diseased limb are present in most cases sooner or later. Nei- fig. 263— Flexion and Abduction, theris characteristic of the early stage, al- (From a Photograph.) though abduction is often stated to be, but many cases begin and continue as adduction. These deformities generally disappear under treatment by rest or traction ; but again, they appear in cases Fig. 264. — Severe Abduction and Eversion occurring in a very acute case. under treatment, and they go hand in hand with a sensitive con- dition of the joint which may be the precursor of abscess. » Lannelongue : " Coxotuberculose," Paris, 1885; Hilton: " Rest and Pain," London. 268 OR THOPEDIC S URGER Y. Bonnet, of Lyons, investigated this question of malposition in inflammation, making some experiments which have become classi- cal, and until lately his theory met with universal acceptance. Joints in the cadaver were injected with fluid by means of an ordi- nary hand syringe, and Bonnet found that the limbs assumed the same positions as when inflamed during life. He concluded that the limb simply assumed the position in which the joint would hold the most fluid. But certain objections were urged against this theory. Bonnet's injections had been made with so much pressure that the condition of affairs in the joint was not to Fig. 265. — Adduction. be compared with that in acute synovitis. There are two very forcible clinical objections — certain cases of knee-joint disease, for example, with an extreme amount of effusion, present little or no flexion, and in the whole class of chronic tuberculous joint diseases, where the malpositions are most marked and most constant, effu- sion is most often absent or very slight in amount. All this, of course, points to some second factor in originating and maintain- ing these positions. The explanation of Hilton represents the other point of view; he says " that the irritated or inflamed condi- tion of the interior of the joint (say the knee-joint), involving the whole of the articular nerves, excites a corresponding condition of ////' niSI'lASE. 2G) irritation in the snmc trunks wliicli supply both sets of muscles, extensors and flexors; but that tlie flexors, by virtue of their superior strength, compel the limb to obey them, and so force the joint into its flexed condition." This i)hase of the question is elab- orated a Httle more fully by Liicke, who says that the extensors are lighter in color, and are not so well supplied with blood, and that impairment of motor functions, after fatigue from electrical stimulation, is more marked in the exten- sors than in the flexors. In summing up, Liicke offers practically tlie same expla- nation that Hilton does, saying that the patient finds it most comfortable to hold the limb in this position, all the muscles being tense and set, but at present, the question of position of the limbs in in- flamed joints is not thoroughly under- stood. Fig. 266.— Adduction of the Left Leg in Acute Hip Disease. Fig. 267. — Stanam^ PoMtion assumed in Right Hip Disease where Flexion and Abduction are Present to a Moderate Degree. The occurrence of abduction or adduction in the course of the disease is a very common and very troublesome matter. As a rule, the symptom indicates that the disease is not arrested, or is progressing, and the occurrence or increase of malposition is almost always accompanied by an increase of muscular fixation, and often, as will be seen, this precedes abscess formation. If the malposition is allowed to become permanent, the final result can never be so 2/0 ORTHOPEDIC SURGERY. good as where ankylosis takes place in a more normal position. The limp in an ankylosed limb depends more upon the amount of adduction than on anything except perhaps the bone shortening. It is, therefore, of much importance to be able to estimate with reasonable accuracy the amount of malposition present. When adduction is present in both legs, as in double hip disease, an'd ankylosis of both hips has occurred, cross-legged progression. Fig. 268. — Crossed Leg Progression, the Result of Double Hip Disease. Fig. 269. — Position assumed in Standing and Walking where Flexion of the Right Hip is Present. as shown in the figure, is made necessary on account of the inability to separate the legs. It is, of course, an extremely awkward way of walking, but persons afflicted with the deformity are, neverthe- less, not entirely incapacitated from going about. The position in standing and lying is modified by the occurrence of these malposi- tions ; abduction or adduction causes tilting of the pelvis and char- acteristic postures which are seen in the figures. In the same way flexion causes a marked lordosis of the lumbar spine in standing with the legs together; by standing with the diseased leg some- ////' J)lSh:ylSlL. 271 what flexed the lordosis can be overcome. The fij^ure sh(;ws the effect of flexion in producing lordosis <~A the lumbar spine when the flexed leg is made straight. This occurs when the patient lies on a table and the flexed leg is brought down or when he stands erect, with knees together. The recognition of inaljjosition is not of great diagnostic importance, because the muscular s]nism which causes it ^ Fig. 270. — Moderate Flexion in Right Leg but Fig. 271. — Position assumed m Standing in Right Obliteration of the Lordosis in the Lumbar Hip Disease where Fle.xion is more Severe, showing the Spine by not attempting to place the Right Foot IMarked Lordosis of the Lumbar Spine owing to the on the Ground. placing of the Right Foot on the Ground. is of so much more significance, but the presence of malposition has a most marked effect in modifying the treatment of the affection. Pcri-articnlar Syviptovis. — A tenseness in the superficial tissues over a diseased hip which the other side does not possess is often found at a comparatively early stage of the affection. Behind the trochanter the deep tissues are resistant and the fossa existing there is filled out, and the great trochanter may be apparently 2/2 OR THOPEDIC S URGER Y. thickened, but no very great importance can be attached to this, although Wright considers it pathognomonic of suppuration in the joint. The inguinal glands of the affected side, in fact of both sides, are often enlarged and they may be so much distended that they obstruct-the venous return and the skin is marbled with super- ficial veins. They are at times the seat of superficial abscesses. In very severe cases the upper part of the thigh and the tissues in the vicinity of the hip may become swoljen generally — an oedema of the periarticular tissues takes place, similar to that seen in the knee in the so-called "tumor albus; " this may disappear or be- come localized in the fornnation of an abscess. A thickening over the tensor vaginse femoris is often to be felt. Abscess. — In quite a large proportion of cases suppuration takes place, and the severer forms are accompanied by much pain. The site and course of the abscesses vary according to the seat and size of the original focus of the ostitis, whether in the femur or acetabu- FiG. 272. — Lordosis Resulting from bringing the tlexed Leg in Hip Disease Parallel to the Other. lum. Abscesses may be entirely peri-articular, if the initial lesion of the epiphysis extend in a course outside of the joint ; or they may come from suppuration within the joint ; or having been peri-articular, they may later involve the joint. The invasion of the abscess is frequently without constitutional disturbance, as is not infrequent in cold abscesses in general. There may, however, be a slight fever. As the abscesses enlarge they are usually accompanied by the pallor incidental to suppura- tion — the suppurative leucocythsemia characterized by an increase in the number of white corpuscles. This condition may not inter- fere with a fair appetite and more or less satisfactory general health, but as a rule the appetite is capricious. Abscesses may be absorbed spontaneously or discharge themselves. They may evac- uate themselves nearly, the residual fluid following along the course of the sheaths of the muscles and the fasciae, reappearing later as secondary abscesses, the same abscess causing five or six fistulous openings. These openings discharge pus and serum for ////' J)/SJCASE. 273 months and years in most cases. With tlic; bursting of an ab- scess, and the discharge of any considerable quantity of pus the patient's condition may rapidly deteriorate or the condition may be only temporary and be followed by marked improvement. When the pus has left the joint it generally burrows between the thigh muscles to reach the skiii, where it appears as a tense swelling of varying size. Pluctuation is usually marked. As the abscess invades the skin the latter becomes thin and red, and ulcerates in one or two places, evacuating the abscess. The contents of the abscess may, however, in a few instances be \ absorbed even at a stage v/hen fluctuation is marked, and the swelling may disappear, leaving a depression beneath the skin. The pus most commonly reaches the skin at the anterior border of the tensor vaginse femoris muscle, it may, however, gravitate backward and open back of the great tro- chanter or at the lower border of the glu- teus maximus; it may come around to the ' inner side of the thigh and perhaps open in front of the adductor tendons or even dis- charge into the rectum: finally it may as- cend the sheath of the psoas muscle and point above Poupart's ligament, or it may descend in the thigh muscles and point in the popliteal space. It has been said that the seat of the primary disease can be in- ferred by the situation of the abscess; but enough facts have not yet been obtained to z^ justify such generalization. "'^ Probably abscess is very often the result of ^/n inefficient treatment. As a rule, it does not ^^ at ./- t ►■ ' r IG. 273. — Most Common J^ocation come on in cases of hip disease, which are of Hip Abscess. doing well, when muscular fixation is slight and motions are pain- less ; but it comes in cases where malposition of the limb is present with, perhaps, complete muscular fixation and often a painful con- dition of the joint. The waiters are inclined to believe from their experience that malpositions very generally precede abscess forma- tion. This opinion has been sustained by an investigation of the records at the Children's Hospital for the last five years. Formerly cases of hip disease were onl}' admitted to the hospital wards when abscess appeared, or when such serious malposition of the limb occurred as to render further ambulatory treatment impossi- ble. Of late the manner of admission of these patients has been \ 274 ORTHOPEDIC SURGERY. SO modified that now the occurrence of adduction, abduction, or flexion under treatment has been considered as an indication for admission to the hospital, and an attempt at gradual reduction of the deformity by bed extension. While this modification of the plan of treatment has been coming about, the number of hip ab- scesses has been steadily diminishing, although the number of cases of hip disease treated has steadily increased until, in 1888, there were only eleven hip abscesses operated on in 300 to 400 cases of hip disease treated by ambulatory methods in the outdoor depart- FiG. 274. — Hip Abscess, with Deep Fluctuations at the Anterior and Upper Part of the Thigh. Fig. 275. — Adduction and Bone Shortening with Atro- phy of the Right Leg. Fig. 276. — Shorte genital Dislocation ning in Con- of the Hip. ment of the hospital. And all abscesses which occurred were ope- rated upon with but two exceptions.' Shortening. — -The effect of persistent muscular spasm of muscles about the hip-joint characteristic of hip disease, is to crowd the femur against the acetabulum. The amount of the force may be estimated as relatively great, if we bear in mind the strength of the affected muscles. The result of this force is to produce the pseudo-luxation characteristic of hip disease, viz., the enlargement ' Boston Medical and Surg. Journ., Nov. 2ist, 1S89, p. 503. ////' DISEASE. 275 • of the acetabulum and the absorption of the head of the femur, with resulting shortening of the limb; and in certain cases the actual escape of the head of the femur from the socket. In addition to the shortening produced by absolute destruction of bone in the femur or the acetabulum, there is a decitied trophic disturbance of the limb which results, as has been seen, in wasting, and which also has an effect in retarding the bony growth and probably causes at the same time a certain amount of bone atro- phy; retarded growth of the affected limb becomes evident in the early months of the disease, and is a permanent condition which is not outgrown as years go on, for the affected limb always lags behind the other in its growth. In studying the general effect of shortening, it is found to exist principally in the femur, though the tibia shares in it to a less extent also. The shortening of the thigh is ordinarily about two- thirds of the whole, but sometimes it is less, and it may be wholly in the femur. When there is much shortening of the leg, the foot of the affected side is also smaller than the other. The difference in the length of the legs almost always increases slightly after the disease is cured, as was shown in the series of cured cases of hip disease analyzed by Shaffer and Lovett.' In these cases at the time of discharge from hospital treatment and supervision, care- ful measurements were made and recorded in twenty cases. At that time the shortening varied from half an inch to an inch and a half, and in only four cases was it as much as two inches. Several years afterward these cases showed, almost wathout exception, an increase in the amount of shortening. In five cases it was an inch or less, and the rest showed from one and a half to two and a half inches difference. The legs had grown meantime five, ten, or e\-en fifteen inches, so that the shortening was not in any case excessive. It also seems that the shortening does not increase indefinitely, for, in the cases where eight or ten years had elapsed between the two measurements, there was no greater shortening than when three, four, or six yeaps had elapsed. The amount of shortening, as after excision, may be supposed to depend, in a measure, upon the de- struction by the disease of the epiphysis, but this can onh- partially explain the facts, as limitation in the growth of the tibia and foot also occurs in some instances. General Condition. — Children with hip disease are often robust at the beginning of the afTection and sometimes the general condi- tion continues good to the end, but these cases are exceptional. More often, after some months the child becomes pale and the appetite fails at times; often it does not go any further than this; ' N. Y. Med. Journal, May 21st, 1SS7. 276 ORTHOPEDIC SURGERY. but at other times decided constitutional disturbance results. Any account of the symptoms of hip disease would be incomplete with- out speaking of the remissions in the course of the affection which have attracted but slight attention. In the early stage this is es- pecially noticeable, and a case may to outside appearances entirely recover from the symptoms of pain, lameness, and discomfort for some days or weeks. Then the symptoms return with increased vigor, perhaps to disappear again in a short time. The muscular stiffness does not wholly disappear at these times, although it may improve along with the other manifestations of the disease. The later course of the disease is marked by much greater uniformity, but even then slight temporary improvement may be quite marked. Temperature.— Vc seems probable that the temperature of chil-' dren with marked hip disease is somewhat higher than has been supposed. The following table shows the result of taking the tem- perature in a consecutive series of cases of hip disease of all sorts and stages, as they attended the out-patient department. They were taken late in the afternoon with a standardized thermom.eter, and no cases wefe omitted. The cases, it may be emphasized again, were not selected for their severity, but were both light and severe and represented a very fair average. Table Showing the Temperature of Children with Hip Disease. 99.8 100.2 99.1 100.5* 100.3 100.9* 100.2* IOI.2 99-3 102.4* lOI.I* 100.5 I0I.8 99.2 102. 99.9 997 98.7 997 100.7''- 101.9 As a check to this observation the following temperatures were taken of healthy children at the same clinic under the same condi; tions. 99-3 98-5 97-3 98. 99.3 99.3 99.3 98. 99.1 99.1 98.1 97.3 98.3 98.5 97.3 Double Hip Disease.— ^\dXon states that the disease seldom begins in both hip joints at the same time and that the second joint may become inflamed while the patient is under treatment in bed for * Cases marked with an asterisk had discharging sinuses. ////' niSI'lASE. 277 the first joint, showin^^ that traumatism inay be cxchidcd as a cause of the disease. This corresponds witli tlie experience of tlie writers, who have observed several cases of double hip disease where the second joint was affected during the careful treatinent by fixation of the first. The course of double hip disease would appear to vary somewhat from that of single hip disease. The amount of pain suffered in the joint last affected is usu- ally less than that of the first joint, probably because there is less jar or motion when two hip-joints are affected than when one is Hip disease, like all dis- eases, is a self-limited one. A natural cure takes place in a majority of cases, but the cycle of invasion, efflor- escence, convalescence, and cure, always consumes a long period of timiC. The natural cure in the lightest cases leaves a slight limitation of motion in the hip. This is accompanied by a slight limp. More frequently there is practical stiffness at the joint, with fibrous or eventual bony an- kylosis at the hip-joint, and prob ,,Q . J 11 .• Til ^\G. 277.— Permanent Position necessitated bv ably HeXlOn and adduction Ot the the Flexion Deformity resulting from Double Hip limb with practical shortening. Disease. Subluxation of the femur with shortening of the limb is a common result of the natural cure, and an arrest of growth with actual short- ening of the bone. A most distressing deformity may follow the natural cure of double hip disease. This may leave severe flexion of both femora, or flexion and adduction so that the limbs are crossed. Diagnosis. The diagnosis of hip disease ma}^ be easy or difificult ; in the earliest stages, errors in it are sometimes made, and care is neces- sary for a positive diagnosis in any stage. The most common error is the belief that the presence of pain or tenderness is neces- sarily present in hip disease, and its absence excludes the possibility of hip disease. Pain or tenderness are not, however, early symp- toms in a majority of cases. Another error often made is to look 278 ORTHOPEDIC SURGERY. for "grating" in the joint as a sign of the disease. That sign is only to be obtained by the use of an anaesthetic by which means the muscles guarding the joint are relaxed. In any event bony grating can be obtained only in advanced cases when two bony and eroded surfaces lie in contact, and rub upon each other when the joint is manipulated. The diagnostic symptoms in hip disease which should be borne in mind in making a diagnosis of hip disease are as follows: 1. Stiffness of the joint; tonic muscular spasm. 2. Lameness ; limp in gait. 3. Attitude of the limb in standing, or walking, or in lying, ad- duction and abduction of the limb. 4. Atrophy. 5. Pain. 6. Swelling, These symptoms vary in prominence at different stages and activity of the disease. In brief it may be said that the early diagnosis must be made chiefly by the symptom of muscular rigidity. The absence of pain or sensitiveness counts for nothing and atrophy is not charac- teristic. The limp is peculiar, but a similar one is present in other conditions. The diagnostic importance of the other symptoms will be con- sidered in detail. Stiffness ox tonic muscular spasm, the chief diagnostic sign in hip disease, upon which the chief reliance must always be placed, is the presence of stffness of the joint or limitation of its proper arc of motio7i when the limb is passively manipulated. Except in the very earliest stages there can be no hip disease without a percep- tible limitation of motion, and even then Valette ' 'claims there can be no hip disease if the motions at the hip-joint are perfect. In one case examined in the very earliest stage, which afterward proved to be hip disease, the motion at the hip-joint on one examination appeared to be perfect ; but on a second examination the next day, after a little exercise, it gave evidence of slight limitation of motion. This limitation of motion is not the result of adhesions or begin- ning 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 lim- itation of motion in very young children, who are apt to resist ' " Nouveau Diet, de Med. and Chir." ////' DISEASE. 2/9 thorough examination. Tlic resistance to motion due to fright is, however, always resistance to all motions of the limb; if by slight force this is overcome, resistance to rotation of a flexed thigh, or to extreme flexion, will not be encountered. A comparison of the resistance of one leg with that of the other will reveal abnormal resistance. Limitation to motion at the hip-joint, in the early stages, is at the extremity of the arc of normal movement, i.e., flexion, extension, abduction, or adduction. The normal amount of abduction is, however, slight, and resistance to motion in this direction, therefore, is an early test of importance. Extreme ab- duction, or adduction, and rotation of the thigh flexed at right angles to the body, is also a delicate test. 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 exam- ining the patient for muscular stiffness, the clothes should be removed and the patient should lie upon a hard surface (except in the case of an infant in arms, as above mentioned). At- tempts to move the limb should be made gradually, gently, and persistently — rough force only exciting resistance and making a delicate examination impossible. The most convenient order of motion in examination is first flexion, then abduction and abduct- ing 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 nothing, at the early stage of hip disease, as muscular spasm, a most important diagnostic sign, has been overcome and is absent. A limitation to flexion is determ.ined by flexion of the normal limb on the abdomen to its utmost limit, and afterward a repetition of the motion of the suspected limb. If the limb is then 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 contraction of the psoas and iliacus muscles, i.e., a limitation in the normal extension of the limb, the back will be arched up as the popliteal space is pressed down. This limitation to extension can also be determined by examin- ing 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 l^Fig. 2'jZ\. The lim.it to the amount of abduction or adduction is determined by placing one hand on the anterior superior spine of the ilium on 28o ORTHOPEDIC SURGERY. the sound side, and with the other hand gently abducting or ad- ducting the suspected limb, where limitation is present the pelvis of course moves with the diseased limb. Careful- inspection in the early stages of hip disease will some- times show fibrillary contraction of the muscles of the thigh on sudden or unexpected movement of the limb. In the later stages of hip disease practical ankylosis of the joint takes place, there being no motion at the hip-joint. This is due to muscular spasm and disappears under complete anaesthesia, unless a permanent degeneration of the muscle has taken place, or a fibrous ankylosis of the hip-joint has begun to be developed. A limitation to rotation at the hip is not so readily detected in the earliest stages of hip disease. Often the foot can be turned in and out with apparent normal freedom ; if, however, the thigh Fig. 278.— Method of Determining the Limitation of Extension in Hip Disease. be flexed upon the abdomen, and an attempt be made to rotate the femur and at the same time abduct it, at a very early stage, ' unusual resistance to this motion will be found on the affected side as compared to the normal side. It is not possible to say just what degree of fixation spasm on the part of the muscles can be accepted as evidence of disease of the joint. Any catch in the motion of the joint in any part of its arc is exceedingly suspicious, no matter how slight it may be. And any considerable degree of fixation may be regarded as almost pathognomonic of hip disease, especially when it is a loss of abduc- tion, of hyper-extension and of external rotation, the first motions as a rule to be restricted in true hip disease. Lameness. — Another diagnostic sign of value is a limp in gait, which is an early symptom, in fact the earliest symptom. It may be said that no hip disease can be present without giving rise to it. At the earliest stages, however, the limping may be intermittent and not constant, and again, it may be so slight that it is prac- ////' DISEASE. 281 tically imperceptible, so tliat its absence does not exclude liij; dis- ease. Its character has jjeen ah'eady descrijjed, and tiie fact that it is worse in the morning than at iiigiit, but these are not alto- gether distinctive and the diagnosis cannot be made alone from watching the child, wafk. Only lately a case came under the ob- servation of the writers where the limp of hip disease was perfectly simulated by a child who had a very slight infantile paralysis of the muscles of one leg, and a similar walk is seen in other conditions, such as sprains of the hip. Attitudes and Shortening of the Limb. — Abnormal positions of the diseased limb are caused by muscular contraction holding the limb stiffly in distorted position. Neither adduction nor abduction of the limb are 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, 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 be at right angles with a line from the umbilicus to the symphysis pubis. In this way have arisen the terms of apparent or practical shortening and lengthening which have given rise to some obscurity. The accompanying diagrams will explain the matter; The nor- mal position of the pelvis in relation to the limbs is shown in heavy lines in Fig. i, where both legs are at right angles to the pelvis, the normal position for standing and walking. If, however, the right leg is fixed by muscular spasm in an adducted position, AE, 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 only be done by tilting the pelvis to the position shown in Fig. 2. It will be seen by the tilting, that the leg AC is carried up with that side of the pelvis and to all appearances the leg AC is shorter than the leg BD, 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 AC is abducted co the position AF, the pelvis must be tilted in the opposite direction to make the legs parallel, because the angle F A B, is a. fixed quantity, and so the pelvis is tilted, and AC, for practical purposes is longer than BD, and the amount of apparent lengthening de- pends upon the amount of abduction. A patient then with adduction of. one leg has a deformit}* 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 practical shortening 282 OR THOPEDIC S URGER V. 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 term 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 estimated by measuring from the umbilicus to each malleolus when the patient lies or stands straight. Real or bone shortening is entirely different from apparent short- ening. It results from the retarded growth of the affected limb or from the destruction of bone in the hip joint, and is independent of the amount of adduction or abduction. Real short- ening is measured by a tape from the anterior superior spines of the ilium to the inner malleolus on each side. It is important, in an examination for hip disease, to determine the amount of permanent injury which the disease has already inflicted. The amount of en- FiG. 280. — Diagram showing Practical Shortening- of the Right Leg from Adduction. largement of the acetabulum and absorption of the head of the femur which has taken place, may be estimated by determining the amount of subluxation. If the patient lie upon the well side, and a line (Nelaton's line) be drawn over the suspected hip, the thigh being somewhat flexed, from the anterior superior spine to the most prominent part of the tuberosity of the ischium, it should pass just above the upper margin of the trochanter; if the trochan- ter is above this line, it is an evidence of subluxation. The amount of deformity due to adduction or abduction or flex- ////' nrshiASii 283 ion of the limb is an important index of the progress or activity of the disease and should be carefully estimated. Estimation of Adduction and Abduction. — This estimation of the amount of adduction or abduction present has ordinarily been made by the use of the goniometer, the instrument shown in the figure. The horizontal arm is laid on the anterior superior iliac spines and the other arm is then laid in the line of the diseased leg and the index shows the angle of deformity. This instrument is clumsy and inaccurate and not always at hand. A simpler method has been devised by which it is possible to estimate with the tape measure alone the angle of either abduction or adduction present. Fig. 281.- Goniometer. In measuring patients it is found that real and practical shorten- ing of a leg are often not the same in the same patient, and that the difference between them varies in proportion to the amount of deformity present. This was taken as the basis for con- structing the following working table. The mathematical pro- cess by which it was made is given in full in the original article,' the results are all that concern us here. 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 re- ' R. W. Lovett, Bost. Med. and Surg. Journal, ]\Iarch 8th, iSSS. 284 OR THOPEDIC S URGER V. peated that real or bony shortening is measured from the anterior superior iliac spines to each malleolus, and that practical shorten- ing is found by a measurement taken from the umbilicus to each malleolus. The difference in inches between the two kinds of shortening is seen at a glance. The only additional measurement necessary is the distance between the anterior superior spines, which is taken wath 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 shortening is greater than the real sJiortening, the diseased leg is addiictedj if less than reed 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, i^ inches; pelvic measurement, 7 inches. If we follow the line for i^ inches until it intersects the line for pelvic breadth of 7 inches, and we find 12° to be the angular de- formity, as the practical shortening is greater than the real, it is 12° of adduction of the left leg. Distance between Anterior Superior Spi nes in inches. 4 i f I li li If 2 2i 2i 2f 3 3i 3* 3i 4 3 3^ 4 4i 5 5i 6 b\ 7 1\ 8 8^ 9 9i 10 II 12 13 5° 4° 4° 3° 3° 2° 2° 2° 2° 2° 2° 2° 2° i" 1° 1° 1° 1° 1-. 10 8 7 6 5 5 4 4 4 4 4 4 4 3 3 3 3 2 £/} 14 12 II 10 8 8 7 7 6 6 5 5 5 4 4 4 3 3 1) 19 17 14 13 II 10 9 9 8 7 7 7 6 6 6 5 5 4 Oh < 25 21 iS 16 14 13 12 II 10 9 9 8 8 7 7 7 6 6 30 25 22 19 17 15 14 13 12 12 II 10 10 9 9 8 7 7 "ca 36 30 26 23 20 18 17 15 14 13 13 12 II 10 10 9 8 8 Pi 42 35 30 26 23 21 19 18 16 15 14 14 13 12 12 10 ID 9 1) a; 40 34 30 26 24 21 20 19 17 16 15 14 14 13 12 II 10 Si 39 34 29 27 24 22 21 19 18 17 16 15 14 13 12 II 3S 32 29 27 25 23 21 20 19 18 17 16 14 13 12 42 35 32 29 27 25 23 22 21 19 18 18 16 14 13 C 1) 39 36 32 30 27 26 25 22 21 20 19 17 15 14 40 35 33 30 28 26 24 23 22 21 19 17 16 38 35 32 30 28 26 25 23 22 20 18 17 42 38 35 32 30 28 26 25 23 21 19 18 ////' niSI'lASE. 28s As to the practical accuracy of tlic im.tliod : it has been used by the writer and others in a larj^c nimihcr of cases of hip-joint dis- ease in the Surgical Out-patient Department of the Children's Hospital, and afterward a very careful measurement has been taken independently with a fairly accurate goniometer, and the results have always coincided within one or two degrees. Estimation of Flexion. — The flexion deformity of the thigh may be measured by a similar method.' The patient lies upon a table flat on his back and the surgeon flexes the diseased leg, raising it by the foot until the lumbar vcrtebr.x- touch the table, showing that the pelvis is in the correct position. The leg is then held for a minute at that angle, the knee being extended, while the surgeon 'A c Fig. 282. — Estimation of Flexion. measures off two feet on the outside of the leg with a tape mea- sure, one end of which is held on the table (so that the tape measure follows the line of the leg) (AB). From this point on the leg (B) where the two feet reaches by the tape measure one measures per- pendicularly to the table (BC), and the number of inches in the line BC can be read as degrees of flexion of the thigh, by consulting Table 11. For instance, if the distance between the point on the leg and the table is 12}4 inches it represents 31° of flexion deform- ity of the thigh. Table II. In. Deg. In. De«. In. Deg. In. Deg. 0.5 I 6-5 16 12.5 31 1S.5 50 I.O 2 7.0 17 130 33 19.0 52 1-5 3 7-5 19 13-5 34 19-5 54 2.0 4 S.o 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 lO.O 25 16.0 42 22.0 67 » 4-5 II 10.5 27 16.5 43 22.5 70 5-0 12 II. 28 17.0 45 23.0 75 5-5 14 II. 5 29 17-5 47 23-5 So 6.0 15 12.0 39 iS.o 4S 24.0 90 ' G. L. Kingsley : Bost. I\Ied. and Surg. Journ., Juh' 5th, iSSS. 286 ORTHOPEDIC SURGERY. If the leg is so short that it is impracticable to measure ojff twenty-four inches, one can measure twelve inches; ascertain from here the distance to the surface on which the patient is lying in a perpendicular line in the same way, then doubling 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 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 lum- bar spine in contact with the table, and the diseased thigh is by this naturally thrown into a position of flexion if such deformity exists. Fig. 283. — Thomas' Test for the Estimation of Flexion of the Diseased Leg in Hip Disease. The figure makes the method plain. It is not suitable for use in cases where the hip is sensitive, nor, as a rule, in the case of adults. Atrophy. — Atrophy of the muscles is an early symptom, and is determined by measuring the circumference of the thigh, or by in- spection or palpation of the muscles. The obliteration of the fold of the buttock mentioned in the older writers is due to this atro- phy, but it is not always one of the earliest symptoms. The mus- cular atrophy is greater, as a rule, than that of simple disuse of the muscles; yet in the earliest cases the atrophy may be so slight as to escape detection by the tape measure, but usually it rapidly becomes more marked than when seen in simple disuse, as is noticed by a comparison of cases of hip disease with cases of sim- ple motor paralysis, as after apoplexy without trophic disturbance. The measurement for atrophy is made with a tape measure by taking the circumference of both thighs and both calves at the same level on each side. In cases where accuracy is desired, the ////' nisF.ASE. 287 level at which the circumference is t(j be taken should be measured from some bony point on both sides, such as the anterior superior spine, the patella, or the malleoli, to insure takin nisi'iASE. 323 The splint advocated by \)x. A. B. Judson is shown in the fi^^ure. It is more a protective than a traction appliance and is rather a perineal crutch than an apparatus for exerting much traction. The shaft is so tapered that the weight of the splint is centred near the upper part, and it is thus easier to manage in w.alking than the ordinary splints. It is finished above in a rigid pelvic arm which is covered with hard-rubber. 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. Consequently it is safer not to discontinue traction and begin simply pro- tective treatment as soon as the pain and acute symp- toms are gone, and it is safer not to discontinue pro- tective treatment until a long time has been given to the joint in which to recover itself. It has been the experience of the writers several times to see a relapse started up by a change to pro- tective treatment even when the symptoms of hip disease had been quiescent for months and there seemed every reason to believe that the change was a safe one. It is impossible to lay down rules as to the contin- uance of treatment further than to say that traction and partial fixation should be continued until all acute symptoms have subsided and have been quies- cent for months 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. Fig. 312. — judbon's Perineal Crutch. The Treatment of Complications. Abscess. — In certain cases of hip disease the epiphysitis is either so diffuse or so slight that the cicatricial process follows the inflam- matory process of the bone without undue cell proliferation; but in others the tuberculous focus is neither encapsulated nor ab- sorbed, but is sloughed out and causes an irritation and an abscess follows. This again may be absorbed, or it may require treatment. Simple cold abscesses secondary to hip disease can with safetv be left to themselves, if they do not cause constitutional disturb- ance or increase rapidly. It is desirable, however, that pus should be prevented from burrowing or extending in a great varietv of 324 ORTHOPEDIC SURGERY. directions. This can, in a measure, be done by bandaging the limb, and is done if a traction splint is worn efficiently ; the pus being checked from extending along under the fasciae by the resistance caused by the perineal strap and the pressure of the padded plates. If the abscess extends, it is well localized in a large majority, of cases, and can extend only outwardly. If abscesses are well-localized and increasing in size, and they are left to burst spontaneously, they often are thoroughly evac- uated, 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. It is better in such cases to open the original abscess freely, so that thorough drainage is furnished — large incisions being better than small. The pyogenic membrane should be dissected off or curetted, and if that is done, with thorough asepsis, and proper dressings applied, it is not uncommon, when active disease of the bone has subsided, for such abscesses to heal up entirely by first intention, without recur- rence or sinus formation. To gain such results two things are es- sential, viz., thorough drainage of the Avhole abscess and perfect asepsis. It is, of course, necessary that thorough treatment for the ostitis be not interrupted. Certain surgeons, however, believe in non-interference in hip abscess, unless the symptoms are so acute as to render it necessary, urging the danger of septic or tubercular infection in opening them, and also calling attention to the fact that these abscesses may be absorbed. The danger of sepsis should not be present, although there is a certain danger of tubercular infection. This point of view is very ably stated by Dr. A. B. Judson in a paper recently read.' He says, " I should not omit to give my reasons for failing to see the importance of incision, scraping, and antiseptic closure of the abscesses in question. Incision is a tardy and fruitless pro- cedure. The most painful stage in the history of the abscess is long past. It was present when the pus was collecting under the periosteum and in the cells of bone. If we could interfere early with the bistoury and knew where to direct its point, we might relieve the' pain, and perhaps, in favorable circumstances, shorten the case and save bony tissue by dividing the thickened periosteum or breaking the shell of compact bone. But when the pus is in the cellular structures or the cavity of the joint, I do not see that the progress of the case can be materially affected by interference. If the abscess is cold, there is no painful tension to be relieved. If ^ N. Y. Med. Jour., March 2d, 1889. ////' DISEASE. 325 it is phlegmonous, tension is the result of inflammatory infiltration and can be relieved only by extensive and multi[jle incisions. If we operate in either case, we substitute artificial for natural closure, and with the best antisepsis we gain nothing by operating unless we reach and scrape out the purulent depot or the interior of the joint, and then nothing unless we remove the eroded cartilage and exfoliating bone and excavate the focus, and then nothing in many cases unless we remove large quantities of bone or excise the joint. And if we operate in the manner described we do not avoid the necessity of bringing to bear the best mechanical treatment and hygienic control, which, if they are supplied, will bring about a re- covery, whether we operate or not, by the slow but sure process of natural repair, with the better result the less we interfere with the soft parts, as a general rule." In general, however, modern surgical opinion inclines to advo- cate the incision and antiseptic evacuation of collections of pus in connection with the hip-joint as well as elsewhere in the body. The practical fact seems to be that in many cases incision, cleans- ing and drainage will cause the speedy closure of an abscess which might otherwise have been incompletely evacuated and which would have discharged for months; for in many cases the temper- ature will fall and the general condition immediately improve after the opening of the abscess. When, however, an abscess has developed gradually, gives no discomfort, and is not increasing, and the patient is free from ele- vation of temperature, it can be left undisturbed. Absorption may occur even after fluctuation has become distinct and the abscess is apparently superficial. Rapid or constant increase of size and fever at night should be considered indications for incision. An acute abscess causing pain and discomfort should be opened with- out delay. Pelvic Abscess. — Habern ' classifies these abscesses as follows: (i) Those which are dependent upon disease or perforation of the acetabulum. (2) Those from the rupture of the capsule in purulent coxitis on the inner and upper insertion. The pus passes over the pubic bone into the fossa iliaca. (3) That form which results from an extension upward of an abscess formed between and beneath the adductors, and spreading along the ilio-psoas muscle into the pelvis, (4) Para-articular abscesses without communication with an in- flamed joint. Habern classifies his results as follows : Of those not operated " Centralblatt f. Chir. , April 2d, iSSi. 326 ORTHOPEDIC SURGERY. upon in three years 19 per cent had recovered; 15 per cent died; 66 were not well. In four years, 26 per cent had recovered; 17 died; 57 not well. In five years, 24 per cent had recovered ; 21 had died; 55 not well. Taking all the cases (those operated and not operated), at the end of five years, 13 per cent were well without operation; 37 were resected, with a mortality of 51 percent; 11 per cent had been amputated, with a mortality of 60 per cent ; and 29 per cent had remained not well. Aspiration of abscesses is generally an exceedingly unsatisfactory measure, but occasionally (not commonly) an abscess will be ab- sorbed after one or two aspirations. As a rule it refills again and again, with greater or less rapidity, until the method is abandoned. A large needle must be used in these aspirations and often the pus will not flow through that on account of the flakes contained in the pus of cold abscesses. Continued aspiration at one point will so weaken that part of the abscess that a spontaneous opening will probably occur there and incision may after all be required. Injection, after aspiration, of the abscess cavity with iodoform and glycerin or iodoform and ether, is sometimes useful. With the latter one must provide a vent for the volatized ether, for the heat of the body is enough to cause the conversion of the ether to vapor and in a closed cavity the distention produced may be pain- ful and even dangerous. The hyper-distention of the cavity with carbolic-acid solution is unsafe on account of the risk of fatal poi- soning, which is not unlikely in young children. The writers would record as a warning the death of a patient with a cold abscess of hip disease, from carbolic-acid poisoning, following the washing out of a small abscess cavity with a few ounces of a i-to-40 solution of carbolic acid. As a rule, if it seems desirable to adopt any opera- tive measure in the treatment of a hip abscess, incision is the safest and most satisfactory. Night Cries. — A troublesome complication in the early stages of hip disease is often the nocturnal cry. These usually disappear after thorough fixation with traction. In some instances, however, the cries persist for weeks or months, but they are certain to dis- appear after the subsidence of the acute stages of the affection. The application of blisters back of the trochanter, the use of poul- tices, and the compression of the thigh muscles by a tight bandage, have been advised as a means of diminishing the sensitiveness of the joint. The administration of salicylate of soda in large doses ' is frequently efificient in checking night cries and sensitiveness of the joint. It should be given in doses of the same size which would be used to control acute articular rheumatism, and it will rarely fail ' R. W. Lovett : Boston Medical and Surgical Journal, April, i88g. jur nish.ASi-:. 527 to give at least temporary relief. Although opiates, chloral, and bromide of potash in large doses will often give relief, the use of them is to be avoided if possible in liip disease, as the pain they are to check is momentary, and the effect of the narcotic persists and is injurious upon the appetite and nervous system. Stretching the sciatic nerve, trephining the head of the femur, and direct incision of the joint have been advised and tried with success in aggravated cases of this sort. The most efficient means for correcting night cries is absolute fixation of the joint in the line of deformity if malposition is pres- ent. When traction is used, it should be employed with the limb elevated so as to avoid stretching the psoas and iliacus mus- cles ; the limb should be well supported and traction made in the line of the deformity if any is present. Night cries will often sub- side quickly and not reappear. Malpositio)is of tJie Limb. — Distorted attitudes of the limb are in- cidental to the clinical history of hip disease, and the correction and prevention of them form an essential part of treatment. In the earlier stages of the disease there is little difficulty in correcting the existing deformities due to abnormal muscular contractions or malpositions of the limb, the ordinary treatment of hip disease being sufficient to correct deformity. If traction is applied in the line of the deformity, it will be found, in a few days, in the early stages of the disease, that the limb can be placed in a more nearly normal position until it eventually becomes straight. The deformities occurring are flexion, abduction, and adduction. Flexion can be corrected by thorough traction in the line of the deformity, as already mentioned. It will be found that a traction splint is more efficient for this purpose that the simple weight-and- pulley traction ; the patient should be fixed in bed, a traction splint applied, the flexed limb raised to the angle of deformity so that the back is flat, and attaching, if necessary, to the traction splint the weight and pulley to give additional fixation to the limb. It will be found in a majority of cases that each day the angle of de- formity is less and the limb can be lowered. Flexion can also be corrected by means of the Thomas splint bent to fit the flexed limb and gradually straightened. Slight cases of deformity can be corrected by the use of appli- ances such as traction splints which allow the patient to go about with the aid of crutches ; but in the severer cases rest in bed hastens correction. The traction splint naturally antagonizes ad- duction of the limb by virtue of its pulling the leg against a coun- ter-point in the perineum which tends to abduct the leg to which the splint is applied. 328 OR THOPEDIC S URGER Y. Deformities in the early stage of hip disease may be corrected by anaesthetizing the patient and placing the limb in a normal posi- tion, holding it in a corrected position by means of plaster of Paris splints. There is but slight danger following careful cor- rection in this way, but the method is rough and inferior to the gradual methods. Abduction usually corrects itself under the ordinary treatment for hip disease, or is changed to adduction in the natural course of the disease. The same may be said of adduction, but this latter distortion is often more persistent. It can generally be corrected by the ordinary weight-and-pulley method, with fixation in bed. The most satisfactory method to pursue is to put the patient to bed with a weight and pulley exerting traction upon the leg in the line of the deformity and gradually restoring the leg to a more Fig. 313. — Fixation Frame, with Inclined Plane Attached. normal position, as can be done with surprising facility day by day. The same end can be accomplished by confinement to bed and the application of a traction splint to the leg supported in the line of the deformity and changed daily toward a normal position, which will be found more efficient, the traction in the line of the deformity serving as a sedative to quiet the muscular irritability and thus enable the limb to be restored to a more correct position. Mr. Howard Marsh has employed an excellent method, which is easily applied in cases of adduction, using the ordinary weight-and-pulley traction on each limb, that applied to the adducted limb pulling downward toward the foot of the bed and that on the normal limb pulling upward toward the head of the bed. In the correction of adduction a most efficient appliance is one recommended by Dr. H. L. Taylor, of New York (Fig. 314).' It is used during recumbency and is particularly suited to the correction ' New York Medical Journal, November igth, 1887. ////' j)/sjwisj':. 329 of the relapsed and difficult cases occurring in the late stages of the disease. In later st^iges of severe deformity, forcifjle straightening under an anaesthetic (with or without division of the adductor tendons and the division of the fascia lata by open incision), or osteoclasis, or osteotomy have been advised,' and are of use. In the older cases of deformity, where there is probably fibrous but not bony ankylosis, much can be done in the way of correction by confinement to bed and traction with considerable weights. In this way the writers were able to correct an ad- duction deformity which could not be rectified under ether with the use of any justifiable amount of force. And again a case of right-angled flexion of one hip was corrected in a young girl, who was not willing to have an operation, by con- tinued confinement to bed and traction; the well leg being flexed (as in Thomas's test for flexion) to furnish a resistance to the traction force and prevent lordosis of the lumbar spine. Forcible Correction of Deformity. — Where the deformity is not to be corrected by mechanical means or by simple reposition of the limb under ether, operative measures can be re- sorted to. These are : 1. Brisement force with one or more sittings followed by fixation. 2. Tenotomy, myotomy, and fasci- otomy as a prelude to brisement force. 3. Osteoclasis. 4. Osteotomy. Forcible maniial correction is often efifica- cious, and is not attended by as much risk as might be supposed in the cases of children or adolescents. There is some danger of fracture of the bone in resistant cases and also the risk of lighting up the disease by the force to the joint. This might easily happen by setting free an encapsulated focus of tuberculous ma- terial which had ceased to be active. Tenotomy and JMyotomy Folloived by Forcible Straightening. — The skin, as Volkmann has shown, is not of much importance in maintaining the contraction of the hip-joint, but the fascia lata is troublesome and particularly the intermuscular ligament between ' Rosmanit: Archiv f. klin. Chir., 1SS2, Bd. 2S. i. Fig. 314. — Taylor's Adduction Splint. 330 ORTHOPEDIC SURGERY. the rectus and tensor vaginse femoris muscles. Froriep has shown that in the contraction of the hip and knee the muscles are not as powerful in fixing the distortion as the connective tissue. Wini- warter has- recently revived and Billroth performed the open in- cision of the soft tissues in contractions' of this sort. A V-shaped incision is made from Poupart's ligament to the front of the thigh, the size depending upon the amount of contracted tissue. After the division of the skin and fascia, attempts should be made to straighten the limb, which sometimes can be done without division of the muscles; this, however, can safely be done even down to the capsule of the joint. After the limb has been straightened it should be fixed either by plaster of Paris or by extension, with fixation Fig. 315. — Apparatus for Fixing the Pelvis in Osteoclasis of the Hip. of the pelvis, the choice depending upon the experience and pre- ference of the surgeon. Osteoclasis. — -Where there is osseous ankylosis or very firm fibrous union within the joint, either osteoclasis or osteotomy are to be resorted to. Manual osteoclasis is sometimes done in attempts at brisement force, but it is rarely, if ever, now used intentionally. Mechanical osteoclasis has been successfully performed by Dr. C. F. Taylor, of New York, and appliances have been used to aid in fixing the pelvis as a help to manual osteoclasis. There is, how- ever, a lack of precision as to the site of fracture, and osteotomy is now to be regarded as preferable. Osteotomy. — Osteotomy is by far the most preferable of the ope- rative procedures for the correction of deformities of the hip due to bony ankylosis. Rhea Barton' performed osteotomy in 1826, for the correction of bony ankylosis of the hip at a right angle and ^ North American Med. and Surg. Journ., 1827, iii., 279. ////' n/S/CASE. 331 obtained a movable joint. He was followed by Rodger, Clemot, Maisonneuve and a succession of other surgeons, including Dr. Sayre. A very decided advance was made when Adams performed the operation through a very small external wound, using a keyhole saw for section of the bone. The methods of operating have varied very much with the devel- opment of the operation. The earliest operators divided the bone above the great trochanter or at least between the trochanter major and minor. Adams' operation is devised for section of. the neck of the femur, and can only be performed where the neck is present. Barton, Bar- well, Maisonneuve, and Sayre, however, have performed the operation lower down, but all above the trochanter minor, until Gant ' devised the operation of subtrochan- teric osteotomy, by which the femur is divided be- low the trochanter minor. The anatomical reasons which he gave for this step were that the resist- ance of the psoas and iliacus muscles was set free and that a return of the flexion was not there- fore to be expected, as when the bone was divid- ed 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 diminishing the liability of rekindling the old joint inflam- mation. Stephen Smith has performed a modification of this oper- ation in sawing one half through the femur at different levels, one- half an inch apart and then breaking the bone by manual force. In doing this he made a half tenon and mortise, the object of which was to prevent any further displacement of the lower fragment which might endanger firm union at the point of section. - Fig. 317. Figs. 315 and 316. — Former Apparatus for Fixation after Forcible Straightening. ' Lancet, Dec, 1872, p. S81. Med. Rec, June 2d, 1SS3, p. 589. 332 ORTHOPEDIC SURGERY. Volkmann ' has removed a wedge-shaped piece of bone from the trochanter major in order to correct adduction of the Hmb, and later, in place of performing simple osteotomy, he substituted an excision of the joint by a chisel and gouge, first performing a regu- lar linear osteotomy and then removing the head and neck of the bone in small pieces. He reported six patients operated upon in this way who recovered, with the establishment of a new articula- tion." To-day Gant's operation takes precedence of all others in the correction of bony ankylosis with deformity after hip disease and after arthritis deformans. The reasons why the operation is to be preferred in these cases is thus stated by Mr. Gant:^ ^' When in consequence of continued disease of the hip-joint the head of the femur has disappeared, leav- ing only a stunted nodule of bone representing the neck above the trochanter, in such a case the opera tion of section in the femoral neck cannot be per- jgl}'/ formed, there being no neck to divide. Even when supra-trochanteric section is practicable, the state of the neck may Fig. 318. — Diagram of Lines for Osteotomy of the Hip. /S/C/lS/C. 335 the sound skin about an incli or an incli and a half below the f:jreat trochanter, accor(h"nir to whetlier one is ojjerating upon an adoles- cent or an adult. The chisel sliould at first be held with the blade in the long axis of the limb and turned when it reaches the bone, Fig. 323. — Result of Gant's Operation in a Case of Right Angled Flexion of the Hip. (Vance.) until its edge is at right angles to the axis of the limb. The osteo- tome 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 becomes wedged it should be loosened by lateral motions and a 336 ORTHOPEDIC SURGERY. thinner one substituted if possible. Any attempt at prying with the osteotome would probably result in breaking the blade. When the spongy tissue has been traversed by the blade of the chisel it will come in contact with the opposite wail of solid outside bone and will at oncebe felt to be driven with greater resistance. Then, as Macewen remarks, the osteotome 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 further — always loosening it after each blow of the mallet, and directing the blade in a new direction. The bone breaks with a loud snap, and in most cases the flexed leg can be extended and the adducted one brought straight and no unnecessary manipulation of the bone should be made. Very little force is needed to correct the deformity, and if the leg does not yield to gentle force then the best obtainable position should be taken and at some subsequent time rectification should be com- pleted, There is little bleeding and scarcely any 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 be placed on a bed frame and a light extension applied to steady the leg. This mode of after-treatment is simpler and more comfortable than a plaster of Paris spica bandage, which is particu- larly objectionable and dirty, and which does not allow inspection of the leg and that accurate adjustment which is possible when the hip is exposed to view. Confinement to bed should last between five and six weeks. If adduction or abduction is present it should be corrected at the time of operation and the leg retained in the corrected position; and if it is desired to compensate for slight bone shortening it can be done by putting up the shortened leg in an abducted position. There is no need of a cuneiform osteotomy in these cases, as the simple linear cut makes rectification of the lateral deformity as easy as the correction of the flexion. The risks attending the ope- ration are very slight. Hemorrhage is very rare — although acci- dents have been reported from pressure on the femoral vessels by sharp edges of bone.' Poore,^ in his admirable book on osteotomy and osteoclasis, has summarized the results in 167 cases of osteotomy about the upper end of the femur as follows : ^ Post : Ann. Anat. and Surg., Jan., 1883, and Rev. de Chir., Dec, 1881. = C. T. Poore ; " Osteotomy and Osteoclasis," New York, 1884. ////' DISEASE. 337 68 sections throuL;li tlic neck, 64 linear sections below the trochanters, 35 cuneiform sections, f iired. Died. l-'ailures. 5^> 6 6 54 6 4 28 5 2 138 17 12 giving a mortality of 10.18 per cent. This is misleading, because, as he points out, many of the opera- tions belong to a period before the advent of antiseptic surgery ; of the 17 fatal cases, 12 occurred before 1877, and only 5 after that date, although the number of operations performed in each of the two periods was nearly the same. Moreover, many of the cases were operated upon altogether too soon after the cessation of active symptoms. To-day with the increased experience in the operation and the better understanding of the indications for its performance, the operation is one of the most satisfactory in surgery, and the risks of suppuration, fever, or untoward results are hardly greater, if due aseptic precautions are used than those encoun- tered in an ordinary fracture of the upper part of the thigh. The ultimate functional results following the operation are excellent. Although there is no motion at the hip-joint, the lumbar vertebrae are usually more movable than is normally found. The operation is indicated in all cases of severe deformity where the distortion interferes seriously with locomotion. Shortening of tJie Limb. — Shortening of the limbs after hip-joint disease and after excision occurs in a certain number of cases; the shortening is not limited to the femur, but occurs also in the tibia and fibula and the foot.' Nothing can be done to prevent this arrest of growth. Prevention of the development of the disease and such use of the limb as is compatible with safety of the joint (inducing proper circulation in the limb) may be regarded as the only means at our command. In cases with subluxation and absorption of the head of the femur and enlargement of the acetabulum the deformity entailed is necessarily permanent, as far as the alteration of the bone is con- cerned, but the accompanying flexion and abduction can be cor- rected. Patients with much shortening of the diseased leg vary a great deal in the relief afforded by a high shoe ; sometimes they find it of the greatest possible benefit, while at other times it is a constant annoyance and bother. The shoe can be raised by a cork sole, or more cheaply by an iron patten. Double Hip Disease. — A combination of hip disease with tubercu- ' Wolff: Berlin, klin. Wochenschr., 1SS3, No. 28. 22 338 OR THOPEDIC S UR GER V. and-pulley method. lar disease of another joint, is occasionally seen. These cases can be treated by a combination of the appliances needed for each joint affection. Double hip disease is not so rare as might be supposed. Dr. Ridlon, of New York, has recently reported a collection of fourteen cases, and cases of this sort are not infrequently met in hospital clinics. In treating double hip-joint disease, the first indication is to pre- vent or check pain. This is readily done by the ordinary weight- But with this method it is impossible to carry the patient about, an indication which is particularly important. This can be accom- plished readily by means of a double Thomas splint, a wire cuirass, or more conveniently by the use of the oblong bed frame. To the latter should be attached arrangements for traction fastened to the frame, and in this the patient can be carried about readily with thorough fixation at both joints. This will be found to be much more comfort- able than the wire cuirass or the Thomas hip splint, and it is also more readily ad- justed. The chief difficulty in treating dou- ble hip disease is in the prevention of de-. formity, not during the active stage of the disease, but after convalescence has been established. Deformity will not occur if patients are kept recumbent for a sufficiently long time to establish a perfect cure. If, however, patients are allowed to walk or move too soon, before the joints are thoroughly strong, weight must necessarily fall upon the affected limbs in walking. If these are not strong enough to sustain the weight, deformity will ensue and occasion great annoyance. This danger can be avoided by keeping the patient recumbent a suffi- ciently long time. Ultimate recovery with a certain amount of motion at one or both hips may take place, but locomotion is often possible, although the gait is necessarily awkward and limping. Fig. 324. — Patten for Use in Shortened Limbs. The Operative Treatment of Hip Disease. The subject of excision of the joint in hip disease is one on a question of great practical importance and has excited much dis- cussion, especially of late years. The early history of the opera- tion is of significance in defining its place, as Mr. Marsh has recently pointed out. " The operation of excision was introduced, about forty ////' Disi'.yisr:. 339 years ago, by Sir Win. Fcrgusson and liis school. At this date com- paratively little attention had been j)aid to diseases of the joints, which frequently grew worse and worse until amputation was all that remained. Under these conditions it was, as it was hekJ at the time, a great advance in conservative surgery, when Fergusson anfl his contemporaries resorted to excision as a substitute for amputa- tion ; but although excision has had the important effect of largely diminishing the number of amputations for joint disease, it rests upon a principle which many confidently anticipate is only a link in the chain of progress." ' With the improvement in the conservative method of treating the disease, it is to be expected that excision would find itself in a changed position. So that although resection of the hip has been praised as a measure of great value and con- demned as an unjustifiable proceeding, no general agreement among surgeons can be said to have yet been reached as to its exact value as a therapeutic measure. The operation itself is not a difificult one. A straight external incision (Fig. 325) is the one most commonly used, and the most ser- viceable. The original T-shaped incision is useful where one intends an extensive oper- ation upon the pelvic bones as well as the removal of the head of the femur. It is easy to add the transverse incision at the top or middle of the longitudinal cut if it seems necessary at any stage of the opera- tion. A V-shaped incision employed by Cheever has the merit of allowing a careful inspection of the part. There are various varieties of the straight incision Avhich are advo- cated by different surgeons. The incision as described by Sayre (Fig. 326) 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 trochanter and then downward and forward, the length of the incision being from four to eight inches. Ollier's incision (Fig. 327) is less curved and begins four fingers' breadth below the crest of the ilium and the same distance behind the anterior superior spine of the ilium. It is then carried down to the top of the trochanter and then follows down over the shaft of the femur. Wright, whose experience has been very extensive, finds the best incision to be the simple longitudinal one known as Langenbeck's, over the middle of the trochanter, about three inches long and Fig. 325. ' Brit. Med. Journal, July 20th, 1889, p. 119. 340 OR THOPEDIC S URGER V. slightly curved backward. The tissues should be incised down to the bone, and above the trochanter the soft parts should be divided and the capsule opened. It is best to incise the periosteum of the trochanter, and if possible with a periosteum elevator to free it with its muscular "attachments from the bone. Sometimes the whole trochanter can be uncovered in this way. Oilier advises an addi- tional detail, which consists in separating the great trochanter, with its muscles undisturbed, and then turning it up to resect the head and neck of the femur ; he then replaces the trochanter, hoping thus to obtain better power in the limb. In using any of these incisions, after having then made the cut Fig. 326. Fig. 327. down to the outer aspect of the trochanter and separated the peri- osteum 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 practica- ble 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 pos- sible. Then passing the finger around the femur and adducting the leg slightly, will raise the head of, the femur out of the aceta- bulum, 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 before dislocating the bone if the finger is ////' DISIiASI':. 341 kept inside of the neck of llu- femur as a guard. If section is made in the latter way, the saw should pass just below the trochanteric margin. 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 tissue. 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 periosteum may be stripped up from the inner aspect of the shaft and cause necrosis. If it can be done, on the other hand, the condition of the head and neck of the femur can be much more accurately deter- mined. When once excision is undertaken, the diseased bone should be removed, even if it is necessary to remove several inches of the shaft. Where the head is adherent, it should be curetted or chiselled from its place, as has been done by Volkmann. 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 ofY until the point is reached where the periosteum lining the pelvis is attached to the bone. It is a difificult matter to re- move all of the tubercular 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 incom- plete measure for the eradication of the disease in those cases where the tuberculous material has infiltrated all the tissues in the neighborhood of the joint — tissues which cannot possibly be thor- oughly removed. In many cases of extensive disease it is not easy to do a sub- periosteal operation, and but little satisfaction can be gained by any extensive attempt to separate the periosteum with its muscular attachments from the bone. 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 contact with the acetabulum and dislocation is easily accomplished. The bleeding from the operation is generally trivial. Before speaking of the after-treatment of the excision wound, it is necessary to speak of several other incisions recommended for excision of the hip. Heyfelder's posterior incision is advocated by Ashhurst. This begins a little above and behind the great trochanter, toward which it passes in the line of the fibres of the gluteus maximus, and then curving around and behind the great trochanter, passes down- ward and backward, ending on the linea aspera. By this means no muscular fibres are divided transversely. Roser would preserve the trochanter by making an anterior in- 342 OR THOPEDIC S UR GER V. cision in the line of the neck of the femur, beginning just outside of the crural nerve and cutting transversely through the iliacus, the rectus, sartorius, and tensor vaginae femoris muscles. The cap- sule is divided in the same line, and the head of the femur thrown out of the wound by rotating the leg outward. The same end can be accomplished by the longitudinal anterior incision identified with the names of Hueter in Germany, and R. W. Parker in Eng- land, which has lately come into much notice. A simple straight incision is made from just below the anterior superior spine of the ilium and carried downward and slightly inward for three or four inches. The upper two-thirds of this cut should reach the femur, the lower one-third should be more super- ficial. The capsule in this way will have been divided and the opening into it can be enlarged. Then with a narrow-bladed saw the neck of the femur is divided and the head removed, but the Y- ligament should be left, as far as possible, intact. It is said that the anterior incision heals as well as any 'and that there is no trouble about drainage. The writers have had no personal experience with the method. McNamara has excised through an incision on the inner side of the thigh near the in- sertion of the adductors. 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 inflammation. A heavy antiseptic dressing should then be applied and the child may be fixed in the gouttiere cuirass, or a posterior wire splint de- FiG. 328 -Bed Frame scribcd abovc, or a Thomas hip splint, or a bed for Use in Excision of frame, which sliould be widened at the hips as '^' shown in the figure to allow the change of the dressings without altering the child's position or disturbing the joint. Plaster of Paris, here as in osteotomy of the hip, is a dirty, uncomfortable, and generally unsatisfactory method of dressing. A light bed extension may be applied to steady the leg, and kept on until the child gets up. As soon as it can be done without causing pain, the child should get up and go about, using a long traction splint at first, folloAved by the use of a protection splint of some kind for months. If the leg be used too soon, the condition of the joint must necessarily prove unsatisfactory, for shortening ' Barker: Brit. Med. Journ., June 23d, 1888. ////' niShlASl'l. 343 and displacement are almost sure tf) follow any misuse of the limb. Where splints are not readily at hand, crutches can be used as a substitute, but they cannot be relied upon to prevent ultimate deformity. Rinne," after excision at the hip-joint, attempts to avoid the re- sult of a cure with a sinus by leavinjT the wound open, using no sutures and leavint^ an antiseptic tampon (t[ carbolic gauze in the wound, putting on iodoform. On the first dressings, the tampon should not be removed, but left to be pushed out by granulation. In ten cases treated in this way, seven healed without a sinus, and none had formed in the earliest case three years later, and in the latest, one and one-fourth years. In all of the cases the disease at the time of the operation was well advanced, and in the three not healed complications existed. Rinne claims, as the advantages of the method, prompt arrest of hemorrhage, good drainage, complete juxtaposition of the antiseptic with the wound, diminution of the pain caused by pressure of the upper end of femur against the pel- vis, and a solid a-nd firm cicatrix. Schede, after excision, places the limb in an abducted position to anticipate the subsequent tendency to adduction. If it is desired and expected to secure healing of the wound without the formation of sinuses, it is best to remove the drainage tube at the end of 24 to 'I16 hours and insert a small gauze tampon at the outlet of the wound, and in comparatively early excisions first intention should be aimed at. It would seem as if the mortality of the operation, when com- pared with the death rate after conservative treatment, would defi- nitely settle the place of the operation, but on both sides of the question the various groups of figures lack uniformity and the results of a statistical inquiry are even less satisfactory than usual. The sam.e is in a measure true of a comparison of the ultimate results obtained by the two methods. The mortality of the opera- tion cannot fairly be judged by generalizing from the results of operation before the introduction of antiseptic surgery. Leisrink's - tables of operations done without antiseptic precautions set the death rate at 63.6 per cent. Culbertson tabulated 418 cases with 41.6 per cent mortality. Sayre's 75 cases gave 34.7 per cent. These were all without antisepsis. Caumont^ divided his cases into two groups, and he found that before antisepsis the death rate was 66 per cent., while with anti- septic precautions it was only 41 per cent. ' Deutsche Medicinische Wochenschrift, 1SS4, No. 20. ^Arch. f. Kl. Chir. , xii., 177. 3 Deutsch. Z. f. Chir., xx. , 1SS4, 344. 344 OR THOPEDIC S URGER V. Grosch ' has collected one hundred and sixty-six cases of this operation, done under strict antiseptic precautions. In presenting the cases he has grouped them under heads corresponding to the condition of the joint at the time of the operation. The first stage he classifies as that where the pathological change is slight, and where the suppuration, slight in amount, has not worked to the outside. In the second stage fall those cases with extensive sup- puration and established fistulae. The third class comprises those patients who have become much reduced by prolonged and exten- sive disease. Out of one hundred and twenty cases watched to the end, forty-four died, a mortality of 36.7 per cent, a percentage which corresponds with that of Guy's Hospital, Volkmann's clinic, or the Copenhagen clinique, and is lower than Culbertson's tables taken from cases not all treated antiseptically, and is much lower than Leisrink's mortality before the introduction of the antiseptic method, 64 per cent. Furthermore, dividing the cases into two groups, those occurring between 1870 and 1875, during the appren- ticeship of the antiseptic technique, the percentage of mortality was 9 per cent higher than since that time. The mortality in the first stage of the disease among children was o per cent, in the second stage 24.1 per cent, and in the third 67.5 per cent. Anti- septic dressings do not seem to have effected any change as to the usefulness of the cured limb as compared to that before the method was introduced. This is a matter which is not yet definitely set- tled, but a number of cases were established where an almost nor- mal usefulness of the limb had remained unimpaired many years after the operation. Where, during the operation, perforation of the acetabulum oc- curred, the percentage of mortality increased twenty per cent. Grosch further found that the duration needed for recovery was not influenced by the antiseptic method of dressing, but it gave a greater immunity against wound complications. Results in Excision of the Hip-Joint. — Elben - reports the analysis of results in three hundred and eighty-eight cases of excision of hip-joint for coxitis. One hundred and eighty-four died ; seventy- five did not remain under observation. Of the living, in sixty-one only were the ultimate results as to the usefulness of the limb as- certained. Of these, forty-one were able to walk without an ap- paratus, fifteen needed an apparatus, and five had no use of the limb. The following groups of cases are reported when the operations were entirely aseptic. ^ Cent. f. Chir., 18S2, 14, p. 229. ^ Centralblatt f. Chin, 2, 77. jiir Disi-.ASi-:. 345 Cases I'cr cent. 48 25-30 33 48.5 166 Z^>-7 3^^ 30.5 Volkmann/ . .... Korff;-' ...... Grosch,3 ,...,. Alexander, . Wright has tabulated 2,461 cases, new and old all together, and finds 1,566 recoveries and 841 deaths, or 34 per cent mortality. None of these statistics are of very great value because they are from different writers, who estimate the results by different standards, and some observe the cases for many years, while others estimate only the proximate mortality. Most of them, moreover, are from a partisan standpoint, either attacking or defending the operation. The Clinical Society committee, analyzing a smaller number of cases (45), found that the deaths were as follows: Per Cent. Resulting from operation, ..... 15.6 Tubercular disease, " meningitis, Albuminoid disease, . Intercurrent disease, . 9.0 4.4 6.6 4.4 40.0 In these cases, as in fatal cases where excision is not performed, the deaths are due chiefly to tubercular infection of the lungs or cerebral meninges, to progressive caries, or to amyloid changes in the viscera. The claim that excision of the hip is a preventive of systemic in- fection, is one of such importance that it demands investigation; for if this is the case, the operation has a value apart from its purely surgical aspect. That general tuberculosis and tubercular meningitis supervene in a certain proportion of cases of hip disease is a fact well known. In the Alexandra Hospital from 1867 to 1879, there were 23 deaths from tubercular meningitis in 384 cases of hip disease, there were in these, 260 suppurating cases with 16 deaths (6.15 per cent), and 124 cases with 7 deaths (5.6 per cent). In these cases the treatment was conservative throughout. The risk, therefore, is a small one even in serious suppurative cases treated conservatively. Considering groups of cases treated b}- ex- cision, Mr. Croft reported 45 cases with a mortality of 4.4 per cent from tubercular meningitis, while Mr. Wright in 100 cases had only I death from general infection. But these operative cases were ' Verhdl. d. Deutsch. Ges. f. Chir., 1S77, 59. = Deutsch. Z. f. Chir, xxii., 149. 3 Cent. f. Chir., 1SS2, p. 22S. 346 ORTHOPEDIC SURGERY. probably under observation for a shorter time than the conservative cases above noted. On the other side, Konig/ speaking from a very large experience in excisions, stated that the hope of immunity from tubercular in- fection had not been gained by resection, even by antiseptic resec- tion. Of 21 hip excisions, 47.6 per cent had died of tuberculosis in 4 years, and his experience was the same in the resection of other joints. Caumont found no preventive effect in his cases of resection. Of 26 cases treated conservatively, one-fifth died of tubercular disease; while of 12 cases resected, one-third died of tubercular in- fection. Mr. Barker, a warm advocate of excision, in his lecture at the Royal College of Surgeons in 1888 on the treatment of tubercu- lous joint disease, said that in no less than 10 per cent of all deaths following excision " rapid miliary tuberculosis supervened in such a way as to suggest strongly, if not to prove, that the surgical in- terference was the cause of the generalization of the disease." In any operation upon a tubercular joint, it must be borne in mind that the risk of what is called " operative tubercular infec- tion " is added to the risk of the disease. The statistics of Wart- mann, based upon 837 resections, show that at least 10^ 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 exci- sions the work should be done cleanly, with as little tearing of tissue and,, opening of lymphatics as may be, with the most careful and constant irrigation. It may be stated then, in brief, that resection of the hip-joint as an operation is attended by an immediate fatality of about 7 per cent. The mortality of the disease after the operation cannot be estimated as less than 35 to 45 per cent, and where cases are followed up for several years it is higher still, as in the cases of Caumont, where it was 62 per cent. The operation does not, so far as one can judge from statistics, lessen the likeli- hood of tubercular disease elsewhere. Besides the cases which are fatal and those to be classed as re- coveries, there is this long series of cases in Avhich the wounds do not heal nor does the leg become useful. Leisrink classed 12.5 per cent of his cases as " unhealed " and Holmes speaks of 26.5 per cent as " failures." In the matter of relapses, Yale would set the per- centage at not less than 20 from his personal experience, and he quotes Neuber as saying that about half of his cases have relapsed. ' Archiv f. Klin. Chir. , xxvi., 822. ////' niSF.ASl'.. 347 Nearly all of these limbs are, of course, useless as regards their function. An analysis of lOO cases of excision of tlie lii^j by Mr. Wright gives the following results, up to the time at which the patients were last seen: ly soundly healed, 57 unhealed, 13 dead, 5 dying or going down-hill, 2 in a bad condition, 1 might need amputation, 4 had undergone amputation, i recent case doing well. As this table includes just 100 cases, the percentage results are apparent at a glance. Now as all these cases occurred within the last ten years, that is, since the management of wounds has been so much improved, and as they were in the hands of a surgeon of well-known ability and ample experience, it does not seem as if they can be regarded as affording strong evidence in favor of excision ; for, of the whole number, ly only were satisfactory, that is, had healed; and against Fig. 329.— Unfavorable Result in a case of Excision of the Left Hip some Years after Excision. these successes must be placed 17 in which the operation had com- pletely failed, that is, there were 13 deaths and 4 amputations; and 8 in which there seemed no hope that failure could be averted, for 5 were reported to be dying, or going down-hill, 2 were in a bad condition, and i was reported as a case in which amputation might be required. In other words, while 17 per cent were successful in regard to sound healing of the wound, 25 per cent ended in failure, and the remaining 57 (one case being excluded as too recent to be classified) were still unhealed. In many of these the patients were in good health, and the wound appeared to be merely superficial, and discharge was slight; but, on the other hand, in several dis- charge was free, and the general health defective. In short, any one who studies these cases will be driven to the conclusion that about 20 per cent were successful and that about 80 per cent were unsatisfactory. Even in early excision where one would expect highl}- favorable 348 ORTHOPEDIC SURGERY. results if anywhere, the ultimate results seem disappointing, for in these 100 cases of Mr. Wright's there are 30 in which the disease had been in progress either nine months or less than nine months when excision was performed, the average period being six months, so that they afford us some information as to the ultimate results of early excision, a point upon which evidence is at present very meagre. Of these 30 cases, i died of pyaemia, i died of measles and tuberculosis, i died of exhaustion, i was dying of lardaceous disease, and 2 underwent amputation ; that is to say, 6 (20 per cent) entirely failed; 6 (20 per cent) healed soundly; 7 (20 per cent) were unhealed at the end of one year; 6(20 per cent) were un- healed at the end of two years; 5 (20 per cent about) were too recent to be classified; that is, omitting the 5 recent cases, about 20 per cent were successful, and 20 per cent ended either in death or amputation of the limb, and another 40 per cent were unsatis- factory.' Mr. Marsh has arranged the earlier of his cases treated conserva- tively so that they may be compared with similar cases which were excised by Mr. G. A. Wright, whose figures have already been re- ferred to. Considering the earlier of ^6 cases discharged from the Alexandra Hospital more than a year previously, Mr. Marsh says : ^ " If we now take out the 33 cases which were admitted within nine months of the onset of the disease — the average duration being six months — we find that 16, that is about half, suppurated, and 17 did not suppurate. Of the 16 cases that suppurated (two were double cases) the general result was: 2 excellent, 5 good — not quite 50 per cent ; 9 moderate, a little more than 50 per cent. ''As to Shortening of the Limb. — 7 had under i inch, 4 between i and 2 inches, i was 2'%, inches, i was 3;^ inches, i was 4 inches; 2 were double cases. Average shortening, i^^ inch. ''As to Movement. — 5 had free movement, 4 had slight movement, 7 Avere fixed, i not noted ; i was a double case. "As to Power of Walking. — 11 walked well, 5 walked indifferently. "Of the 17 non-suppurating cases among the early admissions, the general result showed that 7 were perfect recoveries, 4 were excel- lent, 4 were good — 88 per cent; 2 were moderate — 12 per cent. "As to Shortening. — 4 had no shortening; 7 under i inch, 5 be- tween I and 2 inches, i was a double case. Average shortening, half an inch. "As to Movement. — 5 had perfect movement, 5 had free movement, 2 had slight movement, 4 were fixed, 2 were not noted, i was a double case. ' Clin. Soc. Trans., vol. xiv. ^ Brit. Med. Journal, Aug. 3d, 1889. jur I)Isi-:ase. 349 ^^As to Power of Walking. — 7 were ])crf(;ct, 9 walked well, i walked indifferently. "If we compared the results obtained in the 16 cases of suppura- tion in which the patients had been admitted within nine months of the commencement of the disease, with the cases in which Mr. Wright excised the joint within nine months after the disease set in, we see that whereas, of the excision cases, 20 per cent entirely failed, 20 per cent were unhealed a year afterward, and 20 per cent two years afterward (the remaining 20 per cent being too recent for classification); in the cases of non-excision, all the sinuses had healed soundly, and the general result was satisfactory, the patients being able to walk well, on a limb shortened, on the average, by only i^ inch. " The average duration of the 37 cases of suppuration up to the time at which all symptoms of disease disappeared and the chil- dren were walking freely on the limb and without crutches — that is, until they were apparently finally cured — was a little under 5 years. In the non-suppurating cases it was just over 3 years. " I think it important and, also, only right, to make a distinct statement as to the time occupied in recovery in these two sets of cases; those, namely, in which the disease had progressed to sup- puration, and in many of which it had advanced, almost without treatment, for upward of a year; and in those in which the disease had been adequately treated before suppuration occurred. I think it important, first, in order that all possible care may be taken with the early treatment ; and, secondly, because it is desirable to have clear data upon which to found prognosis, and to regulate the period during which treatment must be carried out ; for undoubt- edly many cases relapse and end badly because sufficient time is not allowed." Usefulness of the Limb after Resection. — 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 acetabulum, perhaps somewhere else, and out of this very un- certain 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 successful cases, as has been shown by Kuster, Sayre, Israel, \\'ood- ward, and others. 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. Such a case is figured in the frontispiece of Sayre's " Orthopedic Surgery " (Second Edition\ where there has 350 ORTHOPEDIC SURGERY. been a formation of new cartilage and new fibrous tissue. In cer- tain cases the functional result is excellent, both as to motion and stability; but such cases are not readily obtained under such un- favorable mechanical conditions for the establishment of a stable joint as exist after the removal of the head of the femur. It should be borne in mind that motion at the hip-joint is of very little importance when compared to stability. The extreme mobil- ity of the lumbar spine in cases where the hip is ankylosed quite compensates for loss of motion at the hip, when the limb is fixed in good position. 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 the writers {New York Med. Jo7ir?ial, April, 1879) in a patient seen five years after excision. In Culbertson's tables (Transactions Am. Med. Asso., 1876, p. 142) the case is reported as fol- lows : '' (No. 464.) — Recovered 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 con- dition of cure was in a favorable condition, live years later the boy could only touch the floor with the toes of his affected limb, and was unable to walk without crutch or . ,, ^ ,, x^ , . V, cane and could bear little or no Fig. 330. — A Very liavorable Result of Ex- cision of the Right Hip, showing the amount of weight on the affected limb. ^°''°"- It is difficult to determine defi- nitely how large a proportion of useful limbs ultimately result in cases where recovery has taken place after excision of the hip. Elben ' traced out 61 cases and found that 41 could walk without any apparatus, 15 could walk only by the aid of apparatus, and 5 could not walk at all. The Clinical Society's committee investi- gated very carefully 12 cases which were cured. Two could stand and hop on the excised limb, four could stand firmly, four were able to stand but not firmly, 2 could not stand. The functional re- sults under antisepsis are no better than they were before (Grosch). Mr. Holmes concludes:" "The limb is hardly ever so firm or powerful in walking (after excision) as we constantly see that it is after the natural cure by ankylosis, nor is the patient so active or ' Cent. f. Chir., 1879, No. 2. = Med. Times and Gaz., Nov. 3d, 1877. 7TI1> n/SJCASK, 351 enduring." The committee of the Clinical Society reported in regard to excision of the hip joint, "that movement is more fre- quently present, and is also more extensive in the former class (of excision); but that patients often walk insecurely and with consid- erable limp; while the limb after treatment by rest and extension, though frequently more or less fixed, is more firm and useful for purposes of progression.' Shortening necessarily results after resection. In all probability ' the shortening of the limb after conservative treatment is less than after resection, but this is a matter which cannot be readily deter- mined. Mr. Croft estimates that the shortening of the limb is only a trifle more than it is in the most favorable cases of ankylosis after destructive disease of the joint. In the 13 of Mr. Croft's 45 cases in which measurements are given, the average shortening was two inches and three-quarters; while, in the Alexandra Hospital cases, in 24 good cures (after suppuration) the shortening was one inch and a quarter; in 2 (also after suppuration) there was no short- ening, and in 7 moderate cures the average was three inches and a quarter. Here the balance is in favor of non-excision ; for though in 7 cases the average shortening exceeded that in Mr. Croft's 13 cases by half an inch, yet in 26 cases of non-excision the shortening was less than half the average amount in Mr. Croft's excision cases. In Mr. Wright's 100 cases of excision, the shortening is given in only 30. In them the average amount was only one inch and a half, and this must be accounted as a very favorable showing. It has been claimed that time is saved by excision, and in many instances this is undoubtedly true; but in severe cases after excision of the hip, as after other excisions, the operation itself, so far from arresting a carious process, seems to prolong it. This is particularly true after excision of the hip, where a complete removal of all tubercular tissue is difificult. The after-treatment of excision is moreover a matter requiring much time and care. Union at the hip-joint is a result v\diich comes only after the lapse of months, and protection to the joint and a certain amount of fix- ation are necessary meantime. To allow too early a use of the leg renders a good result very unlikely. The use of some fixation splint or of a fixation and traction splint is advisable for several months, and confinement to bed after the operation should be as brief as possible. In comparing the results of conservatism with those after excision, the difficulty is such that the results of conservative treatment have not been thoroughly investigated. From those which have been collected, it would appear that the mortality following conserv- ' Clin. Soc. Trans., xiv. , p. 234. 352 ORTHOPEDIC SURGERY. ation is less than that after operation, and even in severe cases, the difference in favor of resection is not as great as has been sup- posed. Cazin, Howard Marsh, C. F. Taylor, Yale, Dhourdin, Hue- ter, Judson, and Shaffer and Lovett have all investigated the matter, as has been already shown under the heading of prognosis. Exaggerated statements of the value of hip excision are often made by general surgeons who have not gained an extended ex- perience in the value of thorough conservative treatment, some going so far as to say that the presence of suppuration indicates a complication which demands radical measures. In the 39 cured cases, investigated by Shaffer and Lovett, where only conservative treatment was followed, 27 had one or more abscesses in the course of the disease, and 12 had none; and the following table will show that the presence of abscess not only did not prevent a cure, but in two cases a cure took place with perfect motion at the joint. Table Showing the Influence of the Presence or Absence of Abscess UPON Joint-Motion. Condition of Joint as Regards Rlotion. No motion in joint . . Slight motion 10° to 45° of motion. 90° of motion Perfectly free motion One or More Abscesses. No Abscess. Total. Cases. Cases. Cases. 12 4 16 4 2 6 5 2 7 3 3 2 I 3 Indications for Resection. — The report of the committee of the Clinical Society of London appointed to investigate the subject in 1880, gives certain indications for excision which are of interest. "As to the indications for resorting to the operation of excision, there are certain conditions which when developed in the course of hip disease, either preclude recovery or make recovery improb- able unless some operative interference is adopted." These, in the opinion of the committee, are: " I. Necrosis, and separation of the entire head of the femur and its conversion into a loose sequestrum. " II. The presence of firm sequestra, either in the head or neck of the femur, or in the acetabulum. " III. Extensive caries of the femur, or of the pelvis, leading to prolonged suppuration and the formation of sinuses. " IV, Intra-pelvic abscesses following disease of the acetabulum. " V. Extensive and old-standing synovial disease and ulceration of the articular cartilages, with persistent suppuration. "IV. Displacement of the head of the femur on the dorsum ilii, with chronic sinuses and deformity. ////' JilSICASE. 353 " With respect to the general question of operative interference, the committee are of opinion that the effect of complete rest and weight or other modes of extension, and the withdrawal of matter, should always be patiently tried in the first instance, and that ope- rative interference should be resorted to only when these means have failed to secure the favorable progress of the case." In contrast to this opinion that of Mr. G. A. Wright, of Man- chester, in his admirable book " On Hip Disease in Childhood " may be quoted. The writer says that the indication for excision is sup- puration. "Treatment short of excision, when once suppuration occurs, is useful only as a palliative or a means of temporizing." The statements made by Sayre and Yale, though favorable to the usefulness of resection of the hip, are much more conservative than this, and claim only that the procedure should be used as a last resort. In attempting to reconcile these contradictory opinions, it must be borne in mind that the ultimate results after early excisions (before extensive destruction in the bone has taken place) are much more favorable than after late excision, as has been shown in the figures of Grosch. Where a late excision is done, the surgeon will always regret that the operation had not been done before. 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 where conservative treatment is practicable it should be pre- ferred. 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 justi- fiable, and the "results gained are more satisfactory than when the operation is deferred. It must be evident, in comparing the mortality and the results of excision of the hip with the mortality and the results of conserva- tive treatment, that excision has no place in the routine treatment of the disease, because its mortality is higher and its functional results 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 Avhere no home treatment or adequate hospital treatment for a long time is practic- able. Although the writers have been able to gain thoroughly satisfac- tory results after excision of the hip, and in a few instances have had reason to regret not having resorted earlier to excision in cases where conservative treatment proved unsatisfactory, yet after several years' careful experience in the treatment of hip disease by both conservative and operativ^e methods they would unhesitatingly 23 354 OK THOPEDIC S UR GER V record their opinion that the conservative method of treatment is preferable to the operative and that resection is needed only in exceptional cases. They further believe that resection will be still more rarely needed if cases can be thoroughly treated by proper conservative treatment. Other operative procedures can be spoken of very briefly. Trephining into the head of the bone was proposed by Fitzpat- rick in 1867, who trephined for a short distance into the great tro- chanter arid then attempted the destruction of the diseased focus in the head of the femur, by treating the bottom of the cavity thus made by inserting a stick of potassa cum calce. Stoker more re- ently has revived the method, except that he trephines well into the head of the femur and then uses a curette freely. MacNamara and Greig Smith accomplish the same end by tunnelling info the head of the femur with a drill or gouge and evacuating any tuber- cular material there. The operation is a most serviceable one and often affords much relief. It is especially indicated in acutely painful conditions of the joint, as it relieves tension and affords drainage. In a case recently under the care of the writers, pain and night cries were relieved by it, and the condition of the patient improved for some months, but the ultimate result was unfavora- ble. The operation, as described by Stoker, is performed most simply by exposing the outer surface of the trochanter and with a small trephine boring inward and slightly upward, in the direc- tion of the neck of the femur. It must be estimated in each case how far it is desirable to go with the trephine without doing too much damage to the joint. Then, with a curette, the operator evac- uates any carious bone found at the bottom of the trephine hole, and leaves a drainage tube running to the bottom of the wound. Incision of the Joint. — Incision into the hip-joint is of use some- times in checking uncontrollable night cries, and in cases of ex- quisite sensitiveness of the joint where tension of the capsule may be supposed to exist. A straight incision is made behind the tro- chanter major, and after the division of the muscles the finger can be thrust down to the joint, and on it as a director the capsule can be opened. In two cases reported recently,' improvement fol- lowed the incision. In the event of incising the hip-joint, it is de- sirable to remove by a curette any diseased and softened bone which may be within easy reach. The benefit from simple incision will not be found to be great in severer cases. Ignipunctiire or cauterization of the diseased tissue is advocated by Kolomnin,'' especially in " femoral coxalgia " (a distinction which ^ E. H. Bradford, Boston Med. and Surg. Journal, Aug. i6th, 1888. = Best. Med. and Surg. Journal, April 26th, 1S85, 392. ////' nisi'iASE. 355 in most cases is impracticable before operation). The operation may be superficial or deep, and should be performed with every possible antiseptic precaution. Superficial punctures may be made, or the cauterization may be carried to the hone, i)X the compact tissue of the epiphysis may be trephined and the spongy tissue thoroughly cauterized with the Paquelin point. The reporter claims remarkable success from the treatment, but the method has not been received with much favor. Amputation. — The question of am[)utation of the diseased limb alone remains for consideration. Neglected cases of hip-joint disease occasionally present them- selves, in which, owing to extensive caries of the pelvis or in the length of the femur, excision offers no chance for a cure; in other instances excision has failed to arrest the destructive process in the bone, and the surgeon is left to choose between surrendering the patient to a lingering and wretched death, or the very radical measure. of amputation at the hip-joint. In making this choice he needs information as to the chances of recovery offered by amputa- tion, and if the operation is decided on, as to the best method of procedure. The former cannot be found in the ordinary tables of mortality after amputation, as it would appear that the risk of death is greater when this operation is performed after injury, or for the removal of tumors, than when the patient is freed by the amputa- tion from an extensively carious and useless limb, which has itself served as an impediment to recovery. Ashhurst ' has collected thirty-four cases of primary amputation at the hip-joint for hip disease, and thirty-one consecutive (that is, after excision), and found nineteen deaths. This, rejecting five cases where the result was undetermined, would give a mortality of thirty-two per cent.- The death-rate of amputation at the hip-joint after injury is 70.9 per cent, and for disease in general, 42.6 per cent. It is to be expected that this percentage of mortality may be reduced by greater attention to detail, as is the case with other large operations. In fact, an examination of the accompanying table of cases of hip amputation (after hip disease) done since Ashhurst's table was made, would substantiate this idea. This is the more noticeable as important improvements in controlling hemorrhage have lately come into vogue in the operation. ' " International Encyclopedia of Surgery," vol. iv. , page 501. ^ One of these nineteen fatal cases (that of Buffos) should strictly be considered an operative success, as death did not take place till three months after the operation. 356 OR THOPEDIC S UR GER V. List of Amputations at the Hip-Joint for Hip Disease, not included IN Ashhurst's Tables. No. Surgeon. Result. Reference. I 2 3 Beddard ' Bradford F. Jordan Recovered Died British Medical Journal, June 7th, 1884, p. 1,080. Boston Med. and Surg. Journal, Dec. nth, 1884, p. 564. British Medical Journal, loc. cit. ^11 1 . 11 a 4 5 6 7 8 9 lO Lediard Littlewood Lloyd Lutz Maclaren Recovered St. Louis Med. and Surg. Journ., 1879, xxxvii., p. 560. British Medical Journal, loc. cit. 12 13 14 15 i6 17 i8 19 20 21 22 Marshall « British Medical Journal, 1885, xliv., p. 220. May Pilcher Roddick Shuter Spofforth 1 ( Died Recovered British Medical Journal, June 7th, 1884, p. 1,080. Philadelphia Medical News, 1885, xlvi., p. 220. Clinical Society Transactions, 1882-83, xvi. , p. 86. British Medical Journal, 1884, p. 1,080. According to Ashhurst, in 60 cases there were 19 deaths; in the table of later cases, 22 cases, with 3 deaths; 'making a total of 82 cases, with 22 deaths; giving a mortality of 27 per cent, and in the 22 cases done since 1880, a mortality of only 14 per cent. This table does not include other successful cases reported by Denons, Buchanan and Wheaton, as it was not certain from the report that the hip-joint was involved in the caries or necrosis. The mutilation which results is the chief objection to the operation, and is but partially met by an artificial limb. An undoubted refor- mation of bone has taken place in the case operated upon by the writer three years ago. As yet no artificial limb has been fitted, as the patient is still young — ten years of age. Absoluie 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. For controlling hemorrhage neither digital compression nor ab- dominal tourniquets are to be trusted, although the former can be used in children with less risk than in adults, and is still employed by Marshall. Davy's lever in the rectum has caused death by perforation 'of the gut, and has little but novelty in its favor.' Trendelenburg's method of compressing the flaps by means of a rubber tube which is placed over the thigh and is wound round both ends of a steel rod passed through the thigh, the vessels being 1 Brit. Med. and Surg. Journal, September 13th, 1885. ////' DfSI'.ASE. 357 compressed between the rod and tlic i-ubl)cr tube, presents no ad- vantages over an elastic cf)nii)ression [properly a[)plied. The best way is that described by Mr. Jordan Lloyd." The limb should be elevated and strip))e(l of blood, and an elas- tic 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 i)art of the band passes across the compress, the back part runs across the great sciatic notch and prevents 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. Mr. Lloyd suggests that a short piece of wooden rod can be slipped under the elastic, and is a convenience in hold- ing this rubber band; the elastic bandage, however, should not be allowed to slip down below the iliac crest or over the tuber ischii. This can be done by the hand of an assistant or by passing a band- age under the elastic and tying it to the patient's shoulder. The method of disarticulating, so popular in the operating classes, and known as Lisfranc's method, is not readily done if an elastic tourniquet is used. To check all bleeding, it will be found most convenient to amputate as if at the upper part of the thigh, and tie all bleeding points, removing the remaining fragment by a lateral incision. This is practically the method recommended by INL Furnaux Jordan. A lateral incision is made as in excision of the head of the femur, the head of the femur is excised in order that it may be out of the way, the lateral incision is prolonged and the shaft of the femur separated for two or three inches in its length from the surrounding muscles, takhig care that the periosteum remain with the muscles. A circular amputation of the thigh is then done, the bone sawn through, or if entirely freed from the surrounding tissues by the lateral incision, pulled out from the flaps. The ves- sels are tied and the tourniquet removed. The operation in this way can be performed without the loss of any appreciable amount of blood, and there is time for due delib- eration, as there is no danger of a death upon the table by a sud- den gush of hemorrhage. ^ Lancet, May 26th, 1SS3. ^ The writer has used large rubber tubing in preference to the rubber band described by Mr. Lloyd. If pulled tight the pad is not necessary. It has also proved convenient to use the tubing long enough that the ends ma}- be brought (after the tubing is fastened on the affected side) to the well side and then fastened. 358 ORTHOPEDIC SURGERY. The following conclusions would appear to be justified : amputa- tion at the hip-joint, in hip disease, should be regarded as the very last resort, contra-indicated 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 mutila- tion) would appear to be greater than after excision at the hip- joint. The amputation should be done sub-periosteally whenever it is possible. An elastic tourniquet gives the best means of pre- venting hemorrhage. Preliminary excision of the head of the femur, in fi^eeing the upper part of the shaft, will be found to facilitate the amputation. Summary. — It is difficult to summarize the treatment of hip dis- ease, for the reason that cases differ greatly in severity ; some need- ing complete fixation with recumbency for a very long period, owing to an amount 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 exclu- sive use of any splint or method {i.e., of rest or extension), but the use of such means as may meet the indications as they are present. During the acute stages, the hip-joint should be fixed efficiently either in bed or in some fixative appliance. This implies rest with fixation, and the use of thorough traction. Continued confinement to bed is not beneficial for 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 effi- ciently applied. At first, until patients become used to a splint (the Davis-Taylor splint), crutches will be found an aid in locomotion. If the acute symptoms return under this method, thorough fixation and rest in bed are again indicated. If the subacute symptoms diminish and there is less muscular rigidity at the hip-joint, greater freedom can be allowed, and eventually traction discontinued, and the joint merely protected from jar. This should be continued as long as there is any danger of recurrence of active symptoms, or tendency to contraction. In brief, the hip should be fixed as long as it is sensitive, should be protected and traction used as long as there is muscular spasm, and protected as long as it is weak. The best results are only at- tained by great care for a year or two at least, and careful super- vision and protection for two or three subsequent years. Distor- ////' JJ/SKASJC. 359 tions of the limb should always be prevented as they occur and in many cases some motion can be saved at the hip-joint, if protec- tion is not discontinued too soon. Abscesses can be treated on general surgical principles. Radical operative mea.sures are needed only in exceptional cases if thorough conservative treatment can be secured. CHAPTER VII. OTHER DISEASES OF THE HIP-JOINT. Chronic Synovitis. — Symptoms. — Diagnosis. — Treatment. — Arthritis Defor- mans. — Pathology and Etiology. — Symptoms.— Diagnosis. — Treatment. — Charcot's Diseases of the Hip-Joint. — The Acute Arthritis of Infants. — Syphilitic Disease of the Hip. — Periostitis of the Hip. — Malignant Disease of the Hip. — Loose Cartilages in the Hip-Joint. — Interstitial Absorption of the Neck of the Femur. Chronic Synovitis. Symptoms. — Serous synovitis of the hip-joint is rarely seen. The existence of chronic tubercular synovitis of the hip-joint has been questioned, but there seems to be no reason why such an affection may not well exist and escape detection, for the reason that post-mortem examinations are made after the disease has ex- tended and involved the whole joint. Chronic synovitis of the hip-joint not extending to the bone is an uncommon affection. In a majority of cases, its existence must be an inference rather than a positive diagnosis. But this inference may be made with good reason in a certain class of cases where the symptoms of hip disease (limp, pain, and stiffness) disappear in a few months and do not re- appear. The present state of our knowledge with regard to these affec- tions does not make it possible to differentiate in children between a synovitis and a real coxitis in the early acute stage. Only when the symptoms have subsided with a rapidity Avhich is impossible in a serious bone lesion, is the surgeon justified in making the diag- nosis of synovitis. That such synovitis exists at times has been proven in the case quoted above. The course of acute, subacute, or chronic synovitis ' of the hip- joint (if limited to the synovial membrane and not extending to the cartilage or bone) is not as protracted as that of epiphyseal ostitis. Synovitis of the hip-joint from traumatism may occur in sprains and contusions, the extent and course of such synovitis depend ^ " Coxitis hsemorrhagica " : AUgem. Med. Central-Zeitung, December 13th, 1871. orni'iR DISEASES ()/•' Jill': iiir joint. 361 upon the nature and amount of the injury. In patients with tuber- cular predisposition, such injuries may produce tubercular disease. In certain cases, a synovitis of this sort passes away without perma- nent injury; in other cases, permanent disease or ankylosis results. Diagnosis. — In the adult, chronic synovitis might be diagnostic- ated after a severe sprain of the joint where the symptoms of an acute synovitis had clearly been present, and had passed on to the chronic stage. When there is much distention of the capsule, swelling may be found in the groin above Poupart's ligament and behind the great trochanter. Flexion of the thigh is generally present, and muscular fixation may also be noted holding the thigh in that position. The affection is not common even in adults. In children the diagnosis of synovitis of the hip-joint should only be made when recovery has occurred in a few weeks and has proved permanent. Treatment. — The treatment can be summed up in a very few words. Cases of chronic synovitis of the hip-joint are to be treated in the same way as cases of tubercular ostitis, if from the severity or duration it may be supposed that there is danger of extension of the disease to the cartilage and bone. Cases in adults which are clearly to be recognized as synovitis should be treated by rest and counter-irritation, application of hot packing or of ice bags, blisters, etc., back of the trochanter. And every care should be taken to guard against using the unpro- tected limb too soon. Arthritis Deformans. Arthritis deformans of the hip-joint is an affection which is not uncommon in patients above the age of forty-five. It may occur as a monarticular affection or in connection with a simultaneous affection of some of the other joints. Pathology and Etiology. — When affecting the hip it is knoAvn as senile coxitis, malum coxae senile, chronic rheumatoid arthritis of the hip, etc. It begins in many cases. insidiously, while in others, and especially monarticular cases, it follows after a fall upon the trochanter. From the shortening of the head and neck in these cases it has been supposed by some writers to be an impacted frac- ture of the neck of the femur, but the shortening results from the absorption of the head and is in every way like the pathological changes found in the insidious cases. Mr. Adams divides the case into two classes, basing the distinc- tion on the pathological appearance of a large number of specimens 362 ORTHOPEDIC SURGERY. examined. Class I. comprises those cases in which the hypertro- phic changes predominate. This consists in an enlargement, thick- ening, and increase in density of the head of the femur. In Class II., the atrophic changes predominate. The bone is lighter and is usually light and porous, or spongy, and the head and neck of the bone are diminished in size. There are other cases which seem to hold an intermediate posi- tion, and in which both the hypertrophic and atrophic changes are combined. Symptoms. — The affection begins with pain in and about the joint and shooting down the course of the sciatic nerve at the back of the leg instead of down the front as in epiphyseal ostitis. At this stage the affection very closely simulates sciatic neuralgia. Movements of the joint beyond a certain arc are painful, and a noticeable limp is present. Flexion and eversion are particularly painful movements to the patient, and if the leg is manipulated a distinct creaking is sometimes felt which is most noticeable when the movements are most painful. Muscular atrophy of the limb comes on and the nates of the affected side are flaccid and flattened, and apparent shortening from flexion and adduction is present in the diseased limb, as well as true bone shortening in exceptional cases, reaching even two inches or more. Muscular fixation is at first not a prominent symptom, except in very sensitive conditions of the joint, but the arc of motion gradually diminishes until finally the joint becomes entirely stiff in perhaps a normal position, or perhaps adducted or flexed. In the earlier stages abduction and apparent lengthening of the limb may be present as in hip disease.. The position which the limb assumes in the more advanced cases of the disease is one which is calculated to be most mislead- ing, especially when the affection has followed a fall upon the trochanter. The limb is rotated outward and, with the apparent shortening, presents almost a complete picture of an impacted frac- ture of the neck of the femur. In other instances the thigh may be flexed and adducted as in hip disease proper. Arthritis deformans of the hip-joint does not show any tendency to go on to suppuration. Diagnosis. — The affection is likely to be confused with sciatica and impacted fracture of the neck of the femur. In sciatica the limitation of motion is governed by the amount of pain produced by the movement of the sensitive parts and by the tension on the nerve, and therefore differs from that resulting from true hip-joint disease. Flexion is usually free to a certain limit, but impossible beyond this and if the leg is held extended OTIIKR DISl'lASI'S 01' Till': II II' JOINT. 363 on the thigh this is particuhirly noticeable. In sciatica, hypcrex- tension is not interfered with nor rotation nf)r lateral motion. The diagnosis from true hip disease is based chiefly 011 the patient's age; tubercular epiphyseal ostitis being (juitc rare in adults excej^t in connection with weJI-marked tubercular disease. Treatment. — Morbus coxae senih's or arthritis deformans demands treatment, first to relieve the pain and secondly to correct the de- formity. The symptom of pain is rarely so great as to cause disability, unless other joints are affected. In such cases hot baths, m.assage, galvanism, hot packs, and the administration of salicin, colchicum, lithia, and potash are to be recommended in the treatment of chronic rheumatism of the hip as of other forms of chronic rheu- matism. The use of crutches and canes will often be needed. The deformities which follow this affection are usually those seen in hip disease, but they are more gradual in development. They are per- sistent and obstinate, but are amenable to proper mechanical treat- ment, such as is used in the deformities of hip disease. H. L. Taylor, in a recent article,' has related several cases wdiere rest to the joint was afforded by recumbency and traction and afterward the joint was protected for a long time by a simple pro- tection apparatus like that advocated for use in convalescent hip disease. The results were favorable in the extreme. More is to be gained ordinarily by gradual correction by me- chanical means than by forcible straightening in this class of affec- tions of the hip. The medicinal and dietetic treatment of the affection will be considered in speaking of arthritis deformans of the knee in Chap- ter IX. Charcot's Disease of the Hip-Joint. In frequency of attack the hip comes next to the knee, which among the large joints is the one most frequently attacked. As in most other instances, Charcot's disease of the hip simulates ver}' closely arthritis deformans of the ordinary type. The changes in the joint are, however, much more acute and extensive than those with which we are familiar in arthritis 'deformans. Synovial effusion is a more prominent symptom, sometimes reaching the stage of large fluctuating tumor which presents itself at the front and the back of the joint, with a wearing away of the head of the bone. The trochan- ter ascends and a state of affairs similar to the condition found in late hip disease is presented. In the matter of diagnosis, of course ' " Senile Coxitis," N. Y. Med. Journal, Dec. 15th, 1888. 364 ORTHOPEDIC SURGERY. one depends upon the co-existence of symptoms of spinal cord disease. As to treatment, nothing can be accomplished ; in cases where swelling is excessive, aspiration of the joint sac may give temporary relief. In cases where syphilitic history is present, mercury or iodide of potash should be given, and in certain cases they have a marked influence in checking the disease. Rest is indicated for the joint. The acute artJiritis of infants'" may at times affect the hip-joint. It consists of an acute epiphysitis which attacks children less than a year old. The disease was originally described b}/ Mr. T. Smith, in St. Bartholomew's Hospital Reports (Vol. X.). Its etiological rela- tions are very obscure, its character is acute, and its course is rapid. It may result from injury. The swelling is very great and it may appear in one of the large joints, only to disappear there and man- ifest itself elsewhere. The treatment should consist of free incision and stimulation of the patient, for the outlook is very grave on ac- count of a tendency to pyaemia and also because of the severe character of the affection. Syphilitic disease of the hip may occur at times. It occurs most often as a subacute synovitis as in the other joints during the secondary stage. Rarely it is present as a gummatous infiltration of the head and neck of the femur. Hip disease of the ordinary type, as pointed out by Mr. Wright, may occur in the subjects of tertiary syphilis, and run a typical course apparently unaffected by the syphilitic element present. Periostitis of the Hip. — Gibney calls attention to the little notice which has been accorded to this affection, which is at times well marked. It occurs mostly about the trochanter, as the result of traumatism, and it follows soon after the injury. It tends to run a chronic course, and localized tenderness without implication of joint motion may be present for months. In short it may be said that simple periostitis about the hip-joint may result from injury, but periostitis is so common an accompa- niment of tuberculous ostitis that the diagnosis should be made with very great care. The treatment consists in the avoidance of motions which cause pain, and the application of blisters. The occurrence of deep sensftiveness and pain about the hip after an injury may be due to periostitis, a muscular or ligamentous strain, simple synovitis, or chronic articular ostitis, and in the pre- ceding pages an effort has been made to show the difficulty of the accurate differentiation of these conditions. ' The subject is treated at length in a recent article by Dr. W. R. Townsend, Am. Journ. Med. Sci., Jan., 1890. OTHER DISEASES OF THE I///' JOINT. 365 Malignant disease of the hip is a rare affection which has not received much attention. In speaking of it Gibney says with much truth: "Its beginning is obscure, its termination is fatal, and its early recognition next to impossible." The variety of tumor which most often affects the head of the femur in young children is a round-cell sarcoma of the periosteum. But the epiphysis is rarely the seat of the tumor. In seventy cases of sarcoma of the femur, analyzed by Gross, there were only two cases where the upper epiphysis was affected.' The early symptoms in cases where the head of the femur is not primarily involved are very slight and consist chiefly of a swelling which is painless and not fluctuating ; limp, and slight restriction of motion, may be present. Soon, however, it becomes evident that the enlargement is predominating over all the other symptoms and the swelling progressively increases, suggesting perhaps hip abscess. Fluctuation, however, is absent and the swelling embraces the whole circumference of the limb. There is an enlargement of the superficial vessels and the swelling later becomes enormous. The child becomes emaciated and wastes away. The affection may be very painful or again it may be attended with very little suffering. Treatment is of course hopeless. Loose cartilages in the hip- joint are so exceptional as to be sim- ply anatomical curiosities. The symptoms are similar to those described under the head of loose bodies in the knee-joint. Their removal by operation is not feasible. HemorrJiagic synovitis of the hip-joint has been reported as one of the curiosities of surgery. Wright describes a condition which he classes as interstitial absorption of the neck of the feninr. Bell, Liston, and Gulliver and Monks- have described it as a pathological condition which is occasionally found in the hips of young people after a fall on the trochanter. The patient becomes lame and complains of a slight amount of pain. Motion is free at the joint and a certain amount of pain is present. A flattening of the head of the femur is found in these cases, which accounts for the shortening of the limb. Oc- casionally it disappears after a time, while again it infects the joint secondarily. It is of course questionable whether it should find a place as a separate affection, for what is said of it suggests to one's mind the occurrence of a focus of disease away from the joint sur- face which may either disappear or break into the joint — a condi- tion which has been fully treated in the Pathology. ' Am. Journ. Med. Sci., Jul}' and Oct., 1879. = Boston Med. and Surg. Journal, Nov. iSth, 18S6. CHAPTER VIII. TUMOR ALBUS OF THE KNEE-JOINT. Definition.— Pathology. — Clinical History. — Diagnosis. — Differential Diag- nosis. — Prognosis. — Treatment, {a) Conservative, (J?) Operative (Excision. — ■ Arthrectomy. — Amputation). Twnor Albiis. — The old term tumor albus is here applied to the most common of all knee-joint affections, otherwise known as fun- gous disease of the knee-joint, etc. The term tumor albus was chosen for use in this connection, because it involves no etiological or pathological theory and because its application to this condition is sanctioned by general usage. The affection is also known as white swelling, strumous arthritis, scrofulous disease of the knee, chronic purulent or fungous synovitis of the knee, and by all the other terms applicable to the last-named affection, as noted in Chapter IV. In speaking of diseases of the knee, it should be noted that this joint is the largest and most exposed joint in the body, and the one most fequently attacked, if we may consider Schiiller's figures (referred to above) as representative. Anatomically, it should be noted that the joint surfaces forming it are nearly flat, and the facets in the tibia shallow. Owing to this fact, the tibia is easily drawn backward and flexed by the ham- string muscles, the flexors of the leg being much stronger than the extensors,' at the same time it is rotated outward, the combination constituting the common and troublesome deformity which is the characteristic one after tumor albus. Pathology. Tumor albus, as it is seen in children, begins oftenest as an epi- physeal ostitis of the tuberculous type. It may be either a diffuse ostitis or limited to certain portions of the epiphysis, and the femoral or tibial epiphyses are attacked with equal frequency. In rare instances the patella has been primarily attacked. But it be- ' Liiche : Deutsch. Z. f. Chir. , March gth, 1885; Sonnenburg : Deutsch. Z. f.. Chir. , vii., p. 485 ; Fischer: Deutsch. Z. f. Chir., viii., 1-37. TC/MOh' ylLnUS OF Till': h-NFF.-jo/NT. 367 crins as a synovitis oftcncr than hip disease does, and in children it Ts not uncommon to sec an effusion gradually absorb, Icavmg an infiltrated and thickened synovial sac, and a condition of fungous degeneration of the synovial membrane ensues which ends by at- tacking the bone. In the greater number of cases, however, the bone symptoms clearly precede the effusion. . - \ V ^ \ Fig. 33i.-Appearance of the Bones of the Knee-joint in Tumor Albus. The origin of tumor albus is in the bone, in the majority of cases in childreh; in adults the greater proportion of cases begin in the synovial membrane, with, however, even there a certain proportion of primary osseous disease. In 71 cases of tuberculous jomt dis- ease, Konig found 47 of bony origin. They were distributed as follows : 368 ORTHOPEDIC SURGERY. Osseous Synovial. Hip, . Knee, . Foot, . Shoulder, Elbow, 8 17 II 3 The pathological appearances of tuberculous joints have been so fully described in speaking of the pathology of chronic purulent synovitis and epiphyseal ostitis that it is not worth while to enter upon them here to any extent. Owing to the large size of the articular ends of the bones which enter into the formation of this joint, it is not uncommon to find sequestra of considerable size in the bony ends, which are ordina- rily in the form of a wedge with the base toward the joint. They are not, however, the accompaniment of early tumor albus. Whether the disease begins in the bone or the synovial mem- brane, the ultimate result in the joint is likely to be the same. In either event a destructive, fungous, purulent synovitis generally develops, which becomes the characteristic feature of the process. This may end in a complete destruction of the joint or in arrest and cicatricial recovery. Clinical History. It is not in general necessary or expedient to distinguish clinic- ally between tumor albus of bony or synovial origin, although this can occasionally be done in practice. The outcome of the two varieties is practically the same and the treatment of the two is similar. It may be said that, in general, the affection is an epiphy- seal ostitis. The affection begins, as a rule, insidiously, with stiff- ness and limp in gait. The disease may be limited for a long time, and be manifested by an enlargement of the condyles or head of the tibia, or it may extend and involve the whole joint; occasioning severe pain, swelling of the periarticular tissues, effusion in the joint, periarticular abscess, and distortion of the limb, i.e., flexion and subluxation ; and ending in a natural cure with fibrous or bony ankylosis and a distorted limb, which may be more or less service- able, according to the distortion ; or the affection may result in so extensive suppuration as to endanger life from septic or amyloid changes. Sometimes an attack of severe pains supervenes, and an acute stage is reached, when the limb is flexed at the knee, hot and tender to the touch, and sensitive to any jar. This stage gradually subsides, and there is left impairment of motion, if not complete TUMOR ALinis ()/'' TJii-: k'N /■:/■:- /o/jVT. 369 stiffness. Enlnrgcmcnt of the bone is cliaracteristic of chrf;nic epiphysitis of the knee, if it persists for any length of time. The swelHng at the knee, unless suppurative synovitis is present to a marked degree, difTers from that of synovitis with effusion, in that the swelling is of the bone and soft peri-articular tissues, and is not altogether within the joint. If tlie 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 feature, it is most prominent on both sides of the patella, and is limited by the tendon of the quadriceps ex- tensor muscle and by the ligamentum patellae. In these cases where the affection begins as synovitis, thickening of the joint capsule and long-continued synovial fulness are the first signs, with an increasing tenderness over the joint and gradual limitation of its motion. Bone enlargement comes on and the con- dition is soon the same as when the affection began in the more usual way, in the bone. In tumor albus the chief symptoms are heat, swelling, tender- ness, and joint distention ; while in hip disease, a different class of symptoms, restriction of motion, limp, and distortions of the limb are more to be depended upon. In tumor albus of bony origin the knee will be seen to have lost its definite contour, the depressions on the sides of the patella have become filled out so that there is an indistinctness of outline w^hich is as perceptible to the touch as to the sight. There is no floating of the patella, unless effusion has filled the joint, but the patella seems to be raised from its position by a semi-solid mass, the whole knee 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. In some instances, one of the condyles — usually the internal con- dyle — is enlarged more than the other, causing knock-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 disease progresses to cure with a stiffened limb, or the destruc- tive process may become so extensive that excision or amputation is required. Like all these diseases the course of the affection is favorably affected by proper treatment. Atrophy of the muscles, both of the thigh and calf, is present, and reaches a serious degree in acute cases. It is quite equally distributed between the muscles of the thigh and those of the leg. 24 6/' ORTHOPEDIC SURGERY. SJwrtening is a much less important factor than in hip disease, and until la-te 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 outcome of bone destruction. During the course of the disease, lengtJiening of the affected leg may occur. The hyperaemia occasioned by the inflammation induces the over- growth 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 dis- ease, the trophic disturbance 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 exacerbations, 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 joint, jars and twists are very common, and the suffering is 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 manipu- lation fails to occasion any pain. Heat of the affected joint is present and is a most valuable index of the progress of a case. Fig. 332.— Flexion of the j^ ^^^ \^q easily felt with the hand as long as Knee-joint in Acute Tumor . . , . , Albus. the disease is active, but when it becomes quiescent, it disappears, to return at once if anything goes wrong. It can be felt to diminish, if treatment is successful in quieting the condition of the joint, and is a most urgent indication for pro- tective treatment so long as it exists in any degree. Lameness is a constant symptom. It varies with the sensitive- ness of the joint and is much influenced by the amount of flicxion present in the diseased knee. Muscular fixation is a symptom of this as of all chronic tubercu- lar ostitis. The joint may be held perfectly rigid in full extension or in partial flexion, or a certain arc of motion may be permitted and then the muscles quickly catch the joint and prevent it from going further. Persistent muscular spasm results in the character- istic malpositions of the affection, flexion, and subluxation of the TUMOR A Lin J S ()/'■ Tin-: KNFJ'l-JO/NT. 37^ tibia. Fixation of the joint by niiisciil.ir spasm is an early syinjj- tom, perhaps the earliest of all, in tumor albus of osseous f>ri^in. When the disease orig-inates in the synovial membrane, on the other hand, it may be absent until a comparatively late sta^^e of the dis- ease. Alalpositions of the limb result from the greater power which the flexor muscles of the thigh possess than the extensors. The limb becomes gradually flexed ahnost from the first, and if the afi"ectif;n goes on without treatment, flex- ion may reach a right angle, and this is the almost uncontrollable tendency of the disease and the chief obstacle to its successful treatment. Fig. 333. — Subluxation in Knee-joint Diseasa (Schreiber.) Fig. 334.— Subluxation of Knee. Cross Section. (Schreiber.) Even when the affection is nearly cured, the slightest impru- dence on the part of the patient is likely to bring back the flexion, 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 oc- curs; this is due to the shape of the joint surfaces, and the persist- ent contraction of the hamstring muscles alwa\'S pulling the tibia backward. If the leg has assumed this distortion and is straight- ened, the tibia will lie in a plane back of that of the femur, and the 372 ORTHOPEDIC SURGERY. part of the knee formed by the femur and patella will be unduly prominent. 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 accomplished. In the same way a certain amount of knock- FiG. 335. — Subluxation of the Tibia in Tumor Albus, with Tendency to Knock-knee. Fig. 336. — Flexion of the Knee and External Rotation of the Tibia. knee is apt to be present in the corrected limb after severe grades of tumor albus. Abscess appears either as a purulent distention of the capsule, which may point at any part of the surface and discharge by sinuses for an indefinite time, or abscesses form in the peri- articular tissues as in hip disease. As a rule abscess formation is accompanied by a very acute degree of the affection. Diagnosis. The diagnostic symptoms and signs in tumor albus are an inter- mittent lameness; a general enlargement of the knee-joint, with a feeling of stiffness and pain on using the limb; he:.t over the joint; and the presence of local tenderness and muscular stiffness in man- ipulation of the joint. The character of the enlargement of the knee-joint is of great rUMOR ALB us UJ' TJIJi h'N I'J'l-Jt)! NT. 373 importance. If it is in the form of a synovial distention, the affection is perhaps of primary synovial orij^in, and must be classed as synovitis. If, however, there is no fluctuatif^n in the joint, it is clear that the lesion is in the bone, and enlargement of the ends of the bones in either event shows the same condition to be present. Bone tenderness over the head of the tibia increases this probability, and the limitation of motion is pathognomonic of serious disease, when joined to the group of sympto.ns above mentioned. • Differential Diagnosis. Synovitis. — Gross errors in diagnosis in affections 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. A diagnosis between a subacute synovitis without effusion and an epiphyseal ostitis, at an early stage, is difficult or impossible. Practically it is very often extremely hard to differentiate simple synovitis from a beginning tumor albus, indeed it is in many cases impossible to do. Sluggish cases of synovitis, especially in young or feeble persons should be regarded with very great suspicion, inasmuch as they are likely to eventuate in tumor albus at any time, and perhaps the condition is already that of chronic fungous synovitis. Peri-artiailar Disease. — Peri-articular disease (inflammation of bursae, and periarticular abscesses) is to be distinguished from true articular disease in that there is little or no joint stiffness, and that the swelling, if present, does not bear the relation to the patella that occurs when there is fluid beneath the patella ; the distention being 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 of subjective symptoms. Heat is absent, limitation of motion and tenderness may be excessive, and swelling and alter- ation of the joint contour are absent. ArtJiritis defoi'vians of the knee occurs as a spindle-shaped en- largement of the bones, with but little tenderness and a perceptible thickening of the synovial sac with infiltration of the periarticular tissues. Motion is more or less lost by structural changes, but there is no muscular spasm. A very characteristic sign is a pecu- liar creaking which is felt with the hand on the joint while it is beine moved. 374 ORTHOPEDIC SURGERY. Prognosis. The prognosis of tumor albus is similar to that of the same affec- tions of the other large joints. Arrest and cure may be anticipated in the early and lighter cases, even if not thoroughly treated, but in well-advanced cases some disability necessarily follows, and in neglected cases, deformity of the limb, flexion at the knee, sublux- ation of the tibia, and the formation and discharge of abscesses are likely to occur, ending either in a complete destruction of the joint or in a cure with ankylosis. A liability of the dissemination of the tubercular disease to the brain or lungs exists in this as in other similar affections. The functional results after conservative treatment are often ex- cellent ; sometimes perfect motion is restored, but in general only an incomplete arc remains with occasionally complete rigidity. The earlier that treatment is begun, and the more faithfully it is carried out, the better is the outlook as to functional results. 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. As in all cases of epiphyseal ostitis of the larger joint, the prog- nosis as to the time of requisite treatment depends not only on the time needed to check the inflammation, but also for the re-estab- lishment of sound bone tissue capable of bearing weight without danger of relapse. This in growing children demands a long time. Protection is generally necessary from one to two years, and per- haps even longer. Treatment. The treatment requires the greatest care to preserve the func- tion of the joint as far as is possible, to arrest the progress of the disease, and to prevent and correct deformities. Aspiration of the joint, incision, injection into the joint, and counter-irritation, may be all indicated, and in the severe cases excision or arthrotomy. Conservative Treatment of Twnor Albus. — What was said in regard to the treatment of hip disease may be 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 nor- mal, which is a matter of judgment in every case. Protection TUMOR AIJU/S ()/•• 7 7/ A" KN ICI-l-JOI NT. 375 should be discontinued gradually and tentatively; if discontinued too soon, recurrence will take place, or the deformity of the limb will increase. Fixation should be usetl so lon<( as there is any activity of the inflammation; this is indicated by pain, muscular spasm, or tenderness. Efficient fixation of the knee does not re- quire confinement to bed. 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 sufficiently long. It should also be borne in mind that owing to the fact that the thigh is well covered by soft tissues a certain amount of motion is possible owing to the yielding of the soft parts. Fixation by stifT bandages is an efTficient method of treatment when the bandages are properly applied. They should reach from the groin to the ankle, and as firmly as possible grasp the muscles of the limb. Plaster of Paris splints are made by the application of crinoline-gauze bandages impregnated with finely divided plaster. The limb is first wound in sheet wadding, and then the plaster rollers are applied. The method does not give in all cases certain, definite support. Dr. 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 (337) shows the inefficiency of a loosely applied plaster bandage as far as fixation is concerned. Other stiff bandages are of silicate of potash, which may be cut down the front and laced so as to be removed at any time. Leather moulded to the limb, and stiffened with steel, poroplastic felt, etc., are all convenient fixation splints. Fixation without protection is inadequate treat- ment when locomotion is desired. For this reason it is insufficient to apply a plaster splint or a bone 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 only been considered as applicable to the limb in its straight position. Much more often a 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 alloAvs 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 under the foot so as to take the jar of locomo- tion. The best of these splints is one similar to that already de- 1>7^ ORTHOPEDIC SURGERY. scribed as a protective splint in hip disease. It will be described more fully in speaking of the treatment of flexion in tumor albus. A simpler appliance is the Thomas knee splint, which consists of a padded iron ring fitted so as to surround the thigh at the peri- neum, and fastened to two rods on each side of the limb, longer than the limb and secured at the bottom to a metal plate below the foot (Fig. 338). The thigh ring is placed at an angle of \\ ""^^^-^Rl'lb^ 55° to the uprights, which angle is reduced by the pad'ding of the ring to 45°. The 'inside upright extends from the peri- neum to three inches below the sole Fig. 337. — Imperfect Fixation of the Knee, by Plaster Bandage. Fig. 338.— Thomas Knee Splint for Right Leg, pro- vided with Leather Lacings (D), Perineal Ring (.A), Strap to go over Shoulder (E), Foot Piece (C). of the foot. The outside upright extends from half-way between the crest of the ilium and the top of the great trochanter to three inches below the sole of the foot. In measuring for the splint the circumference of the thigh at the groin should be measured and allowance made for padding the ring. The length of the uprights and the places on the ring where the uprights should be attached should be measured. These uprights should be so placed as to be in the same plane as the shaft of the femur. TUMOR A/JU/S U/' 'I'lllC KNJ'JJC-JiJ/NT. 177 The bar at the bottom of the splint can be utih/-ed as a means for usin<^ traction if adhesive plaster is ajjplied to the leg and web- bing sewn to the lower end ; the webbing straps are buckled tightly around the bar, and a certain amount of traction can be exerted. This mode of extension is not shown in the figure, which was taken from the photograph of a case where traction was not required. The idea of using traction is not in accordance with the views of the inventor of the splint. The leg can be fixed by means of band- ages which pass around Fig. 339. Fig. 340. Fig. 339. — Thomas Knee Splint Applied. Fig. 340.— Appliance for Adjusting the Length of the Thomas Knee Splint. Fig. 341. — Fi.xation Appliance for the Thomas Knee Splint. Fig. 341. the leg and spl-int or by means of leather bands attached to the splint and lacing around the leg. With this splint applied, the patient sits in a ring supporting the perineum while uprights run below the foot and bear the body weight. The protected limb can then be fixed by means of the bandages or leather lacings just spoken of. 378 ORTHOPEDIC SURGERY. For convenience it is often desirable to change the length of the splint, and this can be done by the addition of a simple arrange- ment devised by Dr. H. L. Burrell. The uprights are made of two parts, the upper one passes in the lower, which is a hollow rod; a thread is cut in the upper rod and a nut screwed on it ; by setting the nut at a higher or lower point, the upright is practically length- ened or shortened, while the inner rod is prevented from dropping out of the outer hollow rod, by means of a screw which passing through the outer rod catches the inner rod and holds it firmly. The diagram shows the construction of the appliance (Fig. 340). The Thomas splint is slung from the shoulder by means of a strap indicated in Fig. 339, and the well limb is raised by means of a cork, wooden, or steel patten. The simple posterior addition shown in the figure (341) has re- cently been devised by Dr. J. E. Goldthwaite, formerly House Sur- geon at the Children's Hospital, which contributes much to the eflficiency of the splint in fixing the limb in very sensitive cases. It consists simply of two light steel strips attached to the uprights of the splint and covered with sole leather where they are in contact with the leg. When the condition of the limb has improved so much that pain and sensitiveness are absent, the Thomas splint 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 w^alks about suspended largely by the perineal ring and bearing but little weight on the diseased joint. Then grad- ually after some months the use of the splint may be discon- tinued. Counter-irritation of the Knee. — Blisters, iodine, and the actual cautery have all been advised in the treatment of tumor albus of the knee. Recently trephining of the bone and the introduction of a galvano-cautery into the cancellous structure of the bone has been advised by some French writers. Slight cauterization, blis- ters, and iodine may be of assistance in the slighter cases; but in severer forms of epiphyseal ostitis, more radical measures are needed. The introduction of the actual cautery into the bone tissues softened by ostitis has seemed to the writers to have a bene- ficial effect in stimulating the development of a cicatricial granu- lating tissue, but only in connection with mechanical treatment. Treatment of Complications. — Flexion of the knee is the most com- mon and the most troublesome complication of tumor albus. It is commonly associated, when it occurs, in the early part of the dis- ease with an acutely sensitive condition of the joint, but later in the history it may come on insidiously and without pain. TUMOR ALT! US O]' -mi': K N I'lE-JOTNT. 379 The means of strai^htcninci- a knee-joint flexed ljy aeute disease, may be classified as follows: 1. By traction in the line of the defornn'ly a]jj)lied (a) in bed; {b) while the patient goes about. 2. By means of apparatus forcibly straightening the leg; such as the Billroth splint, the Thomas knee splint, the Stillman sector splint, etc. 3. By simple fixation by means of a succession of plaster-of-Paris bandages. 4. By straightening under ether. 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 trac- tion comes in the line of the deformity. After a subsidence of the spasm, which follows very soon upon the application of traction, the limb can be made straight gradually and fixed in a straight- ened position, and ambulatory treatment can be begun. Traction in the line of the deformity 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. It is furnished with a perineal band which takes the body weight off of the l&g, 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 de- formity of the affected knee, and traction is made upward 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 doAvn 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 exten- sion is tightened. The same end is accomplished by Dr. Shaffer's knee splint, which at the same time makes forward pressure against the head of the tibia. It is shown in the figure. The thigh bands. A, A, join the leg bands, B, B, at a point about opposite the centre of motion at the knee, i.e., opposite the condyles of the femur. Adhesive strips being applied to the thigh, they are secured at the buckles, D, D, by webbing bands which pass over the pulleys at E, E. At the leg the buckles, F, F, answer the same purpose, as applied to the leg. At G there is a screw by which the relation of the leg to the thigh bands may be changed at will, and at H there is a trac- 38o ORTHOPEDIC SURGERY. tion rod which acts upon the post-tibial band, which rests against the upper end of the tibia. This post-tibial band moves upon a remote centre at K, and the pressure being applied by the traction rod H, B and I, moves downward and forward^ carrying the head of the tibia with it — a severe counter-traction existing at the adhesive-plaster resistance and at the webbing straps L, which pass over the lower end of the femur.. In applying this instrument, the screws at G are loosened, and the leg part of the apparatus falls back, so that there is no pressure made upon the tibia at all. The adhesive plaster being secured by its webbing ends at the buckles D, D, and the femur being further secured by tightening the web- bing band L, the initial force is applied by forcibly extending the Fi5. 342. — Shaffer's Knee Splint. rod H, until the head of the tibia is pushed forward and downward to the desired extent. Then the leg traction rods, B, B, are brought up against the tibia, and the screws at G being turned by a key, are secured in the position of contact with the leg, the leg adhe- sive strips being secured at buckles, E, F. Linear traction is now made by the double traction rods of the two leg pieces (M, M), the linear traction being made after the head of the tibia is pushed fortvard and downward by the rod H. The centre of motion of extending the leg is not directly at the knee but above the joint, and several appliances have been devised to straighten the limb at the same time distracting the tibia from the femur. A powerful one of this sort has been used by Dr. Taylor, consisting of two strong wooden elbows; one portion is attached to the thigh, another to the leg by means of adhesive plaster, and both are jointed together near the knee, but a little anterior to it. TUMOR AL/WS OF TH l<: KNI'll'l-JOfNT. 381 The two unattached arms which project from these act as levers^ and if made to approach each other, extend the leg at the knee. A simple appliance of this sort has been devised by Dr. J, F. Ridlon, of New York. A screw joint above the knee is attached to two metal arms, and one is attached to the leg and another to the thigh by adhesive plaster extension. By means of the screw force the arms are straightened, and the joint being above the knee, motion tends to pull the tibia from the femur when the angle is straightened. Correction by Means of Apparatus Forcibly Straightening the Leg. — The Billroth splint is an efilicicnt means of overcoming the de- FiG. — 343. — Billroth Splint for Straightening' the Knee. Fig. 344. — Apparatus for Gradual Forcible Straightening of Knee Flexion. formity in cases where the patients can be kept under observation. A plaster bandage is applied to the limb in which are incorporated two hinged iron strips attached to broad plates. The bandage is allowed to harden and then the front over the knee is cut out and at the back where it has been purposely made quite solid, a trans- verse division of the plaster is made. Into this slit are inserted wedges of increasing size until the leg is straight. The splint has to be watched or it will cause sloughs, as it exerts considerable pressure. The Thomas knee splint can be used to correct deformity : the bandage being applied in front of the thigh and the knee and behind the calf. By tightening them, the limb can be forced into a corrected position. This is the method advocated by ]\Ir. Thomas, but in the hands of the writers it has in manv cases at 382 ORTHOPEDIC SURGERY. once started an acutely sensitive condition of the joint. For this reason, the appliance should, however, be used with great care, as, if injudicious force is used, an acute stage of arthritis can be read- ily brought about. With proper and skilful adjustment of the bandage, proper pressure on the back of the tibia can be exercised; but if too great pressure is exerted on the lower part of the leg, and too little on the tibia, the head of the tibia may be crowded against the end of the femur and the epiphyseal ostitis increased. The appliance shown in the accompanying figure furnishes an Fig. 345.— Wire Splint for the Gradual Correction of Knee Flexion. efficient mode of straightening the limb in cases where the sensi- tiveness is slight and close observation is possible. The figure (345) shows a simple wire splint, which is useful in correction of this deformity in the class of cases where the sensi- tiveness is not great. It consists of a wire splint to which the thigh is attached ; the leg is pulled upon especially behind the head of the tibia, thereby avoiding the uncomfortable results of exerting the straightening force wholly from the lower part of the leg. Stillman has devised what is termed by him a sector splint, which can be incorporated in a plaster bandage or secured by adhesive plaster to the leg and thigh, and used for fixation and the correc- tion of deformity. The construction of the apparatus is evident from the figure (346). TUMOR A/JWS OI< 77//': /