Xi ^/)^/?A />7^ Columbia 2Bnit)er^ft|) CoUegc of ^fjpsiiciansi anti burgeons; Hiiirarp IN-KNEE: ITS RELATION TO RICKETS, LONDON : PRINTED BY WEST, NEWMAN AND CO. HATTON GARDEN, E.C. MEDICAL AND SURGICAL ASPECTS IN-KNEE (GENU-VALGUM): ITS RELATION TO RICKETS, ITS PREVENTION AND ITS TREATMENT WITH AND WITHOUT SUEGIGAL OPEEATION. BY W. J. LITTLE, M. p., F.R.G.P., LATE SENIOR PHYSICIAN TO AND LECTUKER ON MEDICINE AT THE LONDON HOSPITAL ; VISITING PHYSICIAN TO THE INFANT OKPHAN ASYLUM AT -VVANSTEAD, THE EAELSWOOD ASYLUM FOE IDIOTS ; FOUNDEK OF THE KOYAL OETHOPaiDIC HOSPITAL ; ETC. ASSISTED BY E. MUIEHEAD LITTLE, M.E.C.S. Illustrated by upwards of Fifty Figures and Diagrams. D. APPLETON & CO., NEW YOEK, 1882. 3i r «*'■■'; >4^\ :S.'^ .■v\' V^^ ID Ui s \i TO PROFESSOE GROSS, M.D., D.C.L., ETC., ETC., FATHER OF SURGEEY IN AMEEICA, AN ENLIGHTENED AND HONOURABLE EXAMPLE OF ALL THAT IS NOBLE IN OUR PROFESSION, AND TO HIS MEDICAL AND SURGICAL BRETHREN, IN GRATEFUL ACKNOWLEDGMENT OF THEIR CORDIAL RECEPTION OF HIM WHEN ON A VISIT TO THE UNITED STATES IN 1878, THIS BOOK IS INSCRIBED BY THE AUTHOR. Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/medicalsurgicalaOOIitt CONTENTS. Aberration of form, no, without alteration of structure Accident may cause the distortion . . . Accommodative changes ....••• Activity, intellectual, of parent, in excess, a cause . ,, cerebro-spinal, ,, ,, 5? • • Adolescents, tall, often become affected with atonic in-knee Adults, curable in, without operation . . . . Aitken, Dr., on undue hairiness in rickets Animal food, aversion to, often observed in atonic distortions Annandale, osteotomy by Antiseptic system, Lister's, available in osteotomy . Arms, the, disproportionately long in rickets . . . . Arthritis deformans and rheumatic in-knee . . . . Asphyxia neonatorum, in-knee from Atalectasis and in-knee . . ... Atonic disorders, increase of, through civilisation „ in-knee may co- exist with atonic in-ankle and atonic spinal curvature ,, in-ankle may precede in-knee and scoliosis . ,, in-knee, diagnosis from rickets . . ,, ,, may return on re -application of exciting causes ,, „ occurs mainly at the two most rapid periods of growth ,, ,, occurs more readily in tall infants . Atony of fibrous tissues a stage of rickets ? _ . ,, ,, structures, cause of other disorders Atrophy of external condyle, see deficiency of . B. PAGE 88 8 11 69 69 19 30 . 107 75 148, 152 . 152 81 59 95 10 69 70 70 26, 70 78 75, 88 88 41 15 19 Baker, H. F Beaded ribs in rickets . . . . • Belly very protuberant, in rickety cases Billroth on redressement force . . . • ,, ,, statistics of osteotomy ,, ,, supra-condylar osteotomy Bloodless method, Esmarch's, useful in osteotomy Bone, simple division recommended . ,, removal of portion undesirable _ ,, ,, „ length impaired „ bent, lengthened by simple division 33 80, 85 81 130 142 149 154 160 160 160 160 Vlll CONTENTS. Bones, Macewen on cutting the comparatively soft, of adole- scents ., once ebiii-uateil after rickets do not again soften from that disease may they soften from scorbutus ? most rapid growth in lower limbs during the earliest months of life primitive malformation of, eiToneous . . . . curvature of, may take place after subsidence of rickety disease „ from gravity ,, ,, scorbutus ? ,, ,, phthisis'? ,, ,, atony and paralysis . wasting of, Mikulicz on . ,, in paralytic in-knee density of, increased in rickets Bouvier on iu-knee, as the first stage of rickets Bow-legged knee curvature .... Brain, excess of stimulating amusements and pursuits favours distortion Breast-milk, absence of ....... . Broca, views on rickets ........ Brown, Dr. Buckminster, on mechanical treatment Burdach 143 79 16,83 150 18 79 93 57 57 57 31 18 68 37 89 133 16 Cartilages thickened by undue pressure ,, thinned by diminished pressure ,, C. Reyher on . CerelDro-spinal system, influence on in-knee Changes, the mechanical, similar in all forms Chest flattened and narrowed in rickets Clavicles arched upwards and forwards in rickets Compression of limbs, undue, evils of Condyle, internal enlarged, not a primary cause ,, ,, ,, pathognomonic ,, the normal length of ,, prominent .... external, deficiency of primary cause . . 19, ,, ,, )) a more common marked con- dition „ ,, slight deficiency occasions appreciable dis- distortion Confinement, long, hurtful Congenital in-knee .... Constitutional conditions in distortion Creases in rickety thighs . Crossed-legs distortion ,, j)osition aids cure . CruveiUiier, J Curvature of bones from paralysis muscular contraction rickets 58 58 59 65 61 81 81 114 4 66 22, 25 25 58, 65 19 153 151 2 21 106 1 133 43 95 66 96 CONTENTS. IX Curvature of bones from statical inilueuce ,, ,, ,, innutrition, atrophy ,, of knee outwards Curves, successive, in scoliosis . ,, ,, rickety limbs . ,, explanation of production Cyanosis, and in-knee ,, Mikulicz on, as a cause of in-knee 101 12 99 100 lO'J 10, 61 61 D. Debility, cause of in-knee ...... Deficiency of external condyle . .. . ... Density of bones increased in rickets Diet, a too watery, a cause of atonic in-knee Digestion, weak, often a co-existent atonic ati'ection Disease, any of knee, may cause the distortion Distortions, rare amongst oriental and tropical races Disuse, persistent, influence of . E. Eburnation of bones froixi rickets ,, density of bones increased in ,, none in " mollities ossium" Elasticity of structure Enamel on teeth, want of in rickets . Epiphysis of tibia and fibula in rickets Esmarch, bloodless method in osteotomy Exercise during treatment Extremities, the lower, most visibly affected in rickets „ ,, development of them in rickets more or less arrested 2, 9 19 57 66 75 2 73 20 57 57 89 145 85 84 140 123 81 82 F. Fascia lata, its action in bracing the knee .... 53 Fatigue as an exciting cause ....... 53 Femoral diaphysis, changes of, in in-knee .... 53 ,, ,, Linhart on ....... 41 „ „ Mikulicz on ...... 55 ,, ,, Macewen on 41 ,, ,, increased growth ..... 136 ,, epiphysis, changes of, Mikulicz on .... 56 Femur, natural adduction of, not a primary cause ... 4 ,, and tibia, form of, may aid other causes ... 49 Fevers during convalescence cause of in-knee . . . . 2, 9 Flat-foot, co-existence with in-knee ...... 7 Food, animal, aversion to, often shown by atonic subjects . 75 Foods, unsuitable articles for infants . . . . .67 Foot, inversion or eversion of, in in-knee .... 99, 116 G. Gap, between external condyle and tibia .... 27. 131 ,, modes of filling up ...... 29, 13o, 155 ,, nature can fill up even in the adult ..... 30 h X C0NTKNT8. PAGE Gait in iu-kiiee .......... 7 Gentle means, explanation of action 132 Genu-varuna .......... 13 Genu- valgum (see in-knee). „ not confined to rickets 2, 143 Genu-valgns talipes, spui'ious, with in-knee .... 7 Genu-varus talipes, ,, ,, ,,.... 7 Genu, extrorsuni cui'vatum ....... 12 Gravity, influence of . . . . 2, 8, 15, 36, 49, 65, 78, 188 Gross, Professor ......... 147 Gx'owth, two fast periods of ..... . 16, 19 ,, explanation of rapidity at particular periods . 16, 87 ,, inordinate rapidity of, cause of distortion . . 10, 75 ,, rapid after severe illness, need of rest and good feeding 75 ,, does osteotomy impair it ? ...... 158 Guerin, Jules, experiments on large subcutaneous division in animals useful to men 19, 31, 33, 90 H. Hand-feeding of infants a cause of atonic in-knee Hairiness, undue in rickets ..... Hamstring division ....... Harrison ......... Head disposed to be relatively enlarged in rickets ,, may be one-fourth the length of the body in rickets Height, inordinate cause of distortions Hips and knees sometimes contracted at birth . Holden, exaggerated opinion as to normal length of external condyle Horse exercise Hueter, C. „ pathology .... ,, treatment of in-knee by flexion Hutchinson, on rachitis .... Hygiene, neglect of, favours production of in-knee 66 107 127 9 81 81 3 35 22 133 7, 29 40 113 131 68 I. Infancy, earliest period of, growth most rapid ,, rate of growth during . In-ankle, with in-knee In-knee, adiilt, cured without operation ,, definition of . ,, varieties of . ,, from fatigue ,, infantile ,, idiopathic ,, adolescent ,, rachitic ,, statical ,, congenital ,, accommodative ,, paralytic ,, spasm .... ,, atonic .... 16 16 7 30 1 2 18 8, 12 25 8 2, 7, 10 2 2, 5, 8 10 2, 92 2, 10, 95 8, 15, 19 CONTENTS. XI In-knee, strumous ,, rheumatic ,, from inordinate stoutness „ „ „ growth ,, disappearance on bending ,, fevers from debiHty, after ,, never a normal condition ,, influenced by normal anatomic conditions ,, frequency of ,, traumatic ,, from partial luxation of epiphysis ,, with scoliosis, miscalled "lateral curvature „ outward rotation of leg in ,, with flat-foot ,, ,, ankylosis ,, from carrying heavy weights ,, in cyanosis and atelectasis ,, from excessive use . . ,, morbid anatomy . ,, pathology ,, prevention of ,, from curvature of tibia ,, non-i'achitic, Dr. Shaffer on ,, hereditary influence in ,, cure of, by deposit of bone and cartilage Intellectual activity of parent in excess a cause of spine PAGE 3, 101 3 3 2, 9, 15 5, 56 2,9 3 3, 19 7 8, 62 8 9 6 9 101 10 10 10 14, 44 14 109, 139 20 32 70 51 69 Jenner, Sir W., on the rickety skull . Johnson, Dr. ....... Joints, less well-knit in some families and races ,, constant fixation to be avoided 104 69 72 135 K. Knee, mechanically altered relations in ,, hyper-extension of . Knee joint, opening of, for in-knee Knock-knee, symptoms of . 21 56 149 77 Langenbeek Legs, disproportionately short in rickets . Leg bones, curvature of, augments apparent in-knee Ligament, internal lateral of knee, elongation of ,, external ,, ,, shortening of ,, ,, Linhart on . Limb, the soundest, provided only with a maximum Linhart, morbid anatomy ..... ,, on instrumental treatment . Lister, his antiseptic method available in osteotomy Little, Louis Stromeyer ..... Locomotion, excess of, a cause .... Lordosis, not always from rickets Luxation of patella, partial or complete . 19,3 . 19, 3 of strength 147 81 90 i, 136 i, 136 39 37 39 123 140 141 69 84 60 XII rONTKNTS. M. Macewen ........ Miilfonnatiou, primitive, of bones theory erroneous Manipulations, mode of doin^^ .... Mayer, H Mechanical appliances ..... ,, ,, unsuitable ones ,, treatment, relapses after ^ilikulicz ........ ,, on wasting of bones .... ,, ,, cliaufjes in ligaments ,, ,, increased growth of femoral diaphysis Microscopical conditions ..... Mikromele ....... Milk, fresh or unfresh, important difference between " Mollifies ossium," nut rickets .... ,, ,, is incurable ^forbid anatomj', obliqiiity of articular surfacos ,, ,, Sandifort .... „ „ Mayer ,, ,, Mikulicz .... ,, ,, Linhart ..... Muscles, structural shortening of . . . Muscular contraction of secondary importance . 7, 20 effects PAGE 20 wo 115 3B, 45 IIG 122 139 35 57 59 13G 21 82 C7 89 89 35 43 46 89 11 95 60 N. Natural cure by deposit of new bone and cartilage ... 29 Nervous system, disorder of, in in-knee ..... 66 Nodes at the extremities of the long bones in rickets . . 89 Nutrition of tissues, insufficient in atonic in-knee ... 65 ,, full, necessary during convalescence from acute diseases 75 O. Osteo-pliyt c fcn-mations in in-knee .... 4 i, 59 ., Mikulicz on ... . 59 ,, ,, Sandifort on ... 44 Osteotome Macewen's ...... . 153 Osteotomy Annandale ...... 148 152 Barwell ....... 152 Macewen on ..... . 45, 141 154 relapses after ...... 142 Macewen, successes in . 143 necessity after puberty in severest cases . 143 chisel, introduction of, in ... 143 the complement to instruments 145 W. Adams on . 147 Barker on ...... 148 Barton Rhea on .... . 147 Grosse, Professor on .... 147 Langenbeck on ..... 147 L. Stromcyer Little on . 147 Ogston on . 152 CONTENTS. Xlll Osteotomy, Reeves on . . . Rupra-condylar, Bilrotli on ,, ,, Macewen's mode of perfovmin effect of Macewen'fi method subcutaneous, first performed unnecessary, often been done simultaneously in both le.sfs unnecessary and undesirable in young children Out-ankle, with in-knee Out-knee (genu-varum) ,, accommodative . Over-rapid growth Over-work and over-use U<) 149, 155 155 . 149 . 151 . 151 . 144 7 12, 74 74 15 37 P. Pancoast, Dr. ........ Paralysis, infantile, a cause of in-knee Patella, luxation of, partial or complete ,, ossification of ..... . ,, wearing away from undue pressure ,, Mikulicz on . Periods, the two fast growing, of life a cause of distortions Phokomelie ........ Phthisis, bones wasted in . Position, extended . Pressure, undue, thickening of cartilages from . ,, absence of, thinning of cartilages from Prevention of in-knee ...... Progress, rate of, with mechanical treatment Puberty, rapid growth about ..... R. 60, 15 147 10 97, 145 101 59 59 19, 75 82 58 133 58 59 109 124, 135 16 Races, oriental, joints less well-knit than in robust Europeans Rachitic disease exclusively limited to early childhood 18, 34 Redressement force ........ Rest, a means of preventing distortions in chilhood after severe illness Reyher, C, on the changes in unused cartilage Rheumatic in-knee and arthritis deformans ,, extreme in-knee .... Rickets, a more or less general and specific disease ,, restricted growth during ,, period of its occurrence ,, discussion at the Pathological Society . ,, not a recurrent disease ., Guerin on ..... . ,, intra-uterine ..... ,, increased thickness of bones in ,, eburnation ...... ,, shortening ...... ,, artificial production of . ,, occurs only at the first fast growing period of life ,, nodes at the ends of the long bones, in ,, curving in of lower third of femur 72 78, 89 129 75 59 59, 97 64 80 19 18 18 78 34 35, 82 57 57 80 83 88 89 55 XIV CONTENTS. PAGE Rickets, many foi-ms, formerly described ..... 101 ,, ■ dependence should be placed on more than one sign in 105 ,, creases in limbs, how produced ..... lOG ,, undue hairiness in ....... 107 ,, coustitutioual treatment ...... Ill ,, mechanical and operative treatment .... 113 Rickety subjects more or less stunted .... 19, 81 ,, in-knee, diagnosis from atonic .... 20, 71, 88 ,, head 81 Rokitausky 43 Rotation outwards of tibia as a cause ..... 52 S. Sandifort, morbid anatomy Scarlet-fever, weakness and convalescence as a cause " Schlottern," or " wobbling" of knee Schwartz ......... Scissor-leg distortion ....... Scoliosis, analogy of, with atonic in-knee and in-ankle ,, often co-exists at puberty with atonic in-knee Spasm, infantile, cause of in-knee Standing, excess of, as a cause . Statical influence, C. Hueter on Stoutness, undue, cause of in-knee Shaffer, Dr. N. M., on rachitic form . ,, ,, ,, value of gentle means of cure Stromeyer, Ernst ,, Louis ..... Synovitis, in-knee from .... Subluxation of tibia with in-knee T. Tailor's occupation favourable to cm-e Teeth, condition of, in rickets Thomas, Dr., observations on fresh and unfresh milk Tibia often most affected in so-called in-knee Toes, the, turning in or out in in-knee Tone, deficiency of, a pathological state Town, life of, compared with country, as cause Treatment ....... Trunk, the, relatively long in rickets 31,43 9, 75 27, 42 16 1 99 70 2, 10 69, 74 51 3 32 131 15 15 11,63 101 . 13S 85, 106 67 20 99 40 68 108 86 Vegetables, green, and animal food, aversion to of atonic subjects 75 A^ertebrte comparatively little affected in congenital rickets . 83 Violent method of cure 129 Volkmauu . . . . . . . . . ■ . 7, 18 Von Aramon on congenital in-knee ...... 35 W. Wasting of bones in phthisis Watery diet, cause of atonic distortions Weber, the brothers .... 58 66, 110 38 CONTENTS. XV Weights, undue carrying of Will, influence of " Wobbling " of knee . X-knee .... PAGE 79 20 27, 42, 132 1 LIST OF ILLUSTRATIONS. FIG. 1. Peculiar crossed-leg deformity ...... 1 2. Moderate knock- or in-knee (non-rachitic) .... 4 3. Severe neglected knock- or in-knee (non-rachitic) . . 5 4. Rachitic in-kuees ......... 6 5. Atonic in-knee ......... 9 6. Double outward curvature of lower extremities ... 13 7. Rachitic in-knee and curvature of one leg .... 20 8. Drawing of average femur, with a femur probably rickety . 23 9. Drawing to show the amount required to rectify the greater length of internal condyle ...... 23 10. Views of the corresponding leg bones ..... 24 11. Moderate atonic in-knee, to show the prominence of internal condyle .......... 25 12. Natural contour of limbs in atonic in-knee .... 26 13. Morbid anatomy, view of in-knee, from Sandifort . . 44 14. The same, placed by us in the proper relation to exhibit the same gap, shown in diagram a ..... 44 15. Extreme atonic in-knee, from Mayer ..... 45 16. View of a case called genu- valgum, from Mayer, in which the principal disorder consisted of abduction and curvature of the tibia ......... 46 17. The left limb from the same patient after osteotomy, which had been doubtless more severely affected with iu-knee, as shown by the obhquity of the articular surfaces . . 46 18. View of out-knee curvature (genu- varum), from Mikulicz . 50 19. ,, the normal relation of femur and tibia ... 50 20. ,, considerable in-knee distortion (genu-valgum) . 50 21. ,, the bones of a considerable in-knee when placed in their normal relation, to show the manner in which nature then fills up the gap before alluded to . . . 51 22. Anatomical representation of the relation of the thigh and leg during over-fatigue and the carrying of heavy weights, for which we are indebted to Mr. Alexander Shaw . . 53 23. Contains three views from Mikulicz, showing the progressive increase of the diaphysial portion of the internal and lower part of the femur, and slightly of the epiphysis . 55 24. Genu-valgoid distortion of knee disease .... 62 25. Complete ankylosis of knee with genu-valgoid deformity . 63 26. Genu-valgoid distortion, taken from the living strumous patient .......... 63 27. Extreme destruction of the external condyle, &c., from chronic rheumatism •••.... 64 28. Front view of slight atonic in-knee ..... 71 29. In-knee with hyper-extension on one side, out-knee of the other, from Macewen ....... 74 30. Extreme in-knee, with local and general rachitis . . 81 XVI CONTENTS. Flli. FAliK 31. Extreiue rachitic arrested ilevelnpmrnt, wilh in-kuees and curvatures, from Bouvier ...... 82 3'2, 33. Tyjncal distortion of the epiphysis of tibia and til)ula . 84 34. Lt)rd()sis, from atonic rehixation ? ..... 85 35. Shght paralytic f«;• excellence. It is desired in this section to draw fully the attention of surgeons to the fact that genu-valgum is an alteration in the form and relation of parts of the knee joint which is apt to accompany several, indeed the majority, of disordered states to which the knee joint is liable, either in their early or in their later stages. We lay it down as an axiom that in any disorder or disease of the knee structures, active or passive, through which either the relations of parts or the equilibrating forces are disturbed, the condition or distortion termed genu-valgum to a greater or less extent will arise unless interfered with by art. Hence it may be said that there are almost as many clinical varieties of genu-valgum as there are knee affections, and further that the distortion may arise even in a perfectly healthy knee, when owing to disorder in one limb the sound one is over-laden and over-worked. In-knee may exist at birth ; it may originate in the one- year-old fast-growing infant from the want of mother's milk, from improper and from too watery a diet, without rachitis ; it may depend upon unequivocal rachitis, upon infantile paralysis and spasm. It arises (without rachitis) less frequently in the later years of childhood, when the child has been debilitated by measles, hooping-cough, or VARIETIES. 3 scarlet fever, and has been permitted during convalescence to resort too soon to standing or prolonged exertion. On the approach of puberty in both sexes during another fast- growing period, say from the twelfth to the sixteenth year, or later, liability to the distortion again sets in. At any period before adult age the occurrence of white swelling (strumous synovitis) is apt to present, besides contraction of the joint in the flexed position, manifest inward inclina- tion of the knee with corresponding eversion of the leg (genu contractum et valgoideum) . With advancing years the rheumatic knee, especially in subjects who were regarded as strumous in their youth, besides becoming contracted in the flexed position, is apt to assume a distinctly valgoid direction, with marked pain in the neighbourhood of the internal lateral ligament and internal condyle, especially when attempts to use the limb are made, and the tendency to distortion is not checked by art. The author has seen several cases of considerable genu- valgum in tall, robust adolescents, and adults affected with undue stoutness (polysarcia), inordinate height and weight having apparently contributed to the distortion. This frequent liability to the complaint under so many conditions does not spring, as often asserted, from the natural form and relation of the component parts of the limb, and especially of the articulating surfaces of the knee joint, for in the normal state, a well-knit knee, the active and passive structures, the moving and resisting powers, are so well balanced that the most perfect symmetry and a large reserve of capability for use beyond the average use exists. It can no more be admitted of genu-valgum than of congenital club-foot, as has been stated by some surgeons, that every child born into the world has a certain degree of, or a certain tendency to, both those affections. All that can be admitted is that when disorder or disease of the IN-KNEE DISTORTION. knee or foot takes place and distortion ensues, the form of the distortion will 1)e determined in a certain direction, rather than in other directions, by the natural anatomical relations and functions. In the causation of genu-valgum the natural greater size of the internal condyle, the naturally adducted position of the femur in relation to the trunk and to the tibia, the asserted naturally less developed condition of the external articular suface of the til)ia, the known greater physiological range of the abduction of the tibia over adduction in some positions of the knee, cannot be regarded as primary causes. We equally deny the primary influence of contraction of any muscle, e. g. the biceps femoris, in producing the distortion, except where its origin has been spasm. The annexed woodcut figures of tolerably severe adole- FiG. 2. Moderate knock-kiiee, non-rachitic. DEGBEES. O scent genu-valgum will convey to the uninformed reader a better idea of the distortion than words. It consists of undue inversion of the thighs to the extent that the knees may touch (fig. 2) or overlap one another (fig. 3); the Fig. 3. Severe atonic neglected Jnwcli-'knee, arrived at the adolescent stage. legs are more or less widely abducted as regards the thighs, and consequently are separated. In extreme cases the particular change of relation of the thigh and legs is so considerable that the limb may entirely cross, sometimes to the extent that the right foot presents where the left should do, and rice versa. As the distortion augments, the individual when attempting locomotion sinks from the upright posture, so that considerable bending of knees IN-KNEE DISTORTION. becomes apparent. This bending of the knees diminishes the deformity. The disappearance of the deformity on full bending the knee is a characteristic symptom even of genu- valgum in the severest forms. In the earUer stages excessive extension of the knee (hyper-extension to 10 or 15 degrees) may also be present. It will be observed further, in fig. 4, that not only marked abduction of the legs has taken place, but that the Fig. 4. Efichitic in-lniee durinfl childhood. In this drawing one foot inclines to I'anis, the other to valr/us. tibias are rotated outwards on their perpendicular axes. The distortion, consisting of knee inversion, leg abduction, and outward rotation, is greater in the left than in the right limb. The internal condyles may be felt and seen to be unduly prominent ; that of the left leg, which has been passed in front of the right, is strongly marked in the drawing. The external condyle is concealed in the charac- teristic hollow or angle, which obtains in genu-valgum on IN- OB OUT-ANKLE CO-EXISTING. 7 the external aspect of the knee. Observers differ as to the state of the ankle in knock-knee, some stating it to be affected with valgus, others that it has a tendency to varus. It would be more exact to say that sometimes the foot ' exhibits more or less valgoid tendency, at other times a varoid tendency. As a rule, in young children, the inner ankle will be found to have more or less sunk, and the point of the foot to be proportionately turned out ; in older patients the foot, owing to the efforts of the patient to ease the ankle when walking, may assume the reverse position. Even young children, who are brought for consultation by parents because "they turn their toes in," when seated, are found on examination to have incipient knock-knee and flat-foot (spurious valgus). The gait is in all stages unsteady and unsightly; in advanced cases the upright attitude is impossible, and walking is effected with bent knees ; some- times attempts at locomotion are quite given up. The individual is then obliged to confine himself to sedentary pursuits ; the resulting want of exercise leaves the limbs to the further disturbing influence of the unused thigh muscles, which results in aggravation of the original deformity. In-knee is not only a very frequent distortion, but, as already stated, one which is induced by primary causes of very dissimilar characters. H. Mayer,* Volkmann,! C. Hueter,t and Mikulicz, § describe two forms of the complaint : that from softening of bones — the rachitic ; and that which arises from undue * H. Mayer : ' Die Osteotomie ; lUustrii-te Medicinisclie Zeitung.' July, 1852. f Yolkmann : ' Hanclbucli tier AUgemeineu und speciellen Chinirgie,' von Pitlia und Bilrotli, Erlangen, 1872. I C. Hueter : ' Klinik der Gelenkki-ankheiten mit Einscliluss der Ortliopiidie,' 1876. § Mikulicz : ' Arcliiv fiir Klinisclie Clnrui'gie,' von Dr. B. von Langenbeck, vol. xxi., 1879. 8 IN-KNEE DISTORTION. augmentation of the work which the knee joint has to perform when bearing the weight of the trunk, and especially when carrying heavy loads — the idiopathic, or statical form. They mostly regard the rachitic form as originating in childhood, and the statical that which originates in adolescence. Volkmaun coincides with our views, that idiopathic or statical in-knee occurs in infants beginning to walk; and in adolescents, Volkmann says between the ages of two and four years, and between fourteen and seventeen. It will be seen further on, that we have frequently met with the idiopathic or atonic form during the first year of infant life. Many observers have described congenital knock-knee ; and C. Hueter, oj;. cit., p. 263, refers to " a kind of traumatic form," caused by accidental dislocation of the epiphysis of the tibia in early childhood. Our experience enables us to affirm with confidence that the distortion may originate under several other very different predisposing conditions, all operating to add valgoid knee, though not an equal degree of it, to the pre- existing or co-existing disorder or contraction. Congenital genu-valgum is rare and slight in amount, and is commonly rachitic ; sometimes it is due to the same cause which produces co-existent congenital varus, viz., convulsive muscular contraction (retraction musculaire of Guerin). Gravity, in its ordinary sense, cannot affect the foetus in the same manner that it influences the fast-growing infant trying to stand and walk. The rachitic foetal limbs, however, if not modifiable in utero by gravity, are probably sometimes susceptible of external influences, e.g., pressure through the uterine walls of the neighbouring maternal organs, and the action of their own muscles. The following is the arrangement of the non-congenital clinical varieties of genu-valgum we have adopted : — a. Atonic, idiopathic, statical or uncomplicated genu- ATONIC IN-KNEE. valgum, not rachitic, in infants hand-fed upon improper and too watery diet before or when beginning to walk. h. As in older, strong-limbed children who had for one or more years walked perfectly well until they became affected with general debility followed by genu-valgum, as a sequela of scarlet, gastric, and other fevers ; too early return to the use of the limbs in such persons having engendered weak or in-knees, sometimes accompanied with other distortions caused by premature use of trunk and limbs, such as scoliosis and flat-foot. See fig. 5. Fig. 5. Atonic or idiopathic in-knee,from debility on resuming exercise too soon after acute illness, not racldtic. From Harrison, on ' Sinnal Diseases,' London, 1827. c. As in adolescents, not rachitic, suffering from general debility caused by too rapid growth, late hours, too much 10 IN-KNEE DISTORTION. standing, and too much carrying of heavy weights, as in pursuing particular mechanical occupations, often aggra- vated amongst the very poor by insufficient feeding. d. As in children congenitally weak, with congenital heart, vascular and capillary disease (cyanosis), or lung disease (atalectasis) ; rarely from non-congenital heart disease. e. From over-use of a sound knee, or from a previously sound knee having accommodated itself to a short opposite, or to a weak, wasted neighbour. /. As in over-fed, over- stout, fat, heavy infants ; over- stout and over-tall adolescents. In addition to these varieties of genu-valgum, as deduced from difference of origin, all, however, being alike in the circumstance that the genu-valgum — the morbid inward inclination of the knee — is the only knee joint affection, there is a series of knee distortions in which inward inclination — a genu-valgoid direction — of the joint is an important and striking element, though not the more important part of the disorder. They might be termed sub-forms of genu-valgum, and those forms a to /, already defined, in which the inward inclination of the knee con- stitutes the whole of the deformity, might be termed true or genuine in-knee ; and those in which the genu-valgum is the minor part of the affection might be termed false or si)urious in-knee. This denomination of cases would cor- respond Avith the manner in which we speak of true or complete (meaning bony) ankylosis, and false or spurious (meaning fibrous) ankylosis ; or as we speak of true talipes valgus (meaning congenital or complete) and spurious talipes valgus (meaning rachitic talipes valgus, or flat-foot). g. For convenience sake here we will drop the expression sub-form, and speak of the next variety as the paralytic or spastic one, arising from partial paralysis or spasm of the muscles moving the knee joint. These cases, except as to VARIETIES. 11 the disordered innervation, are closely allied to the former varieties a to/. h. From rachitis. It will be hereafter shown that in this form cm^vature of the thigh and leg bones plays as important a part in the deformity as the articular knee structures, if not a more important part. i. From rheumatic, strumous and traumatic knee affections. In synovitis, whether rheumatic, strumous, or the effect of accident, the often long-continued distention of the joint and the impairment of joint structures immediately due to the congestion or inflammation, are the causes of weakness, and relaxation of the connection of the bones with each other, upon which is apt to follow contraction in the bent position, sub-luxation,* and a genu-valgoid form of the joint with abduction of the tibia. It will now be seen that each of these primary causes of in-knee, except e, which results from "accommodation," which is an example of the complaint having been produced by a cause acting outside of the affected limb, operate by lessening the tone or strength of some or all of the active and passive structures of the joint itself, — the muscles, the ligaments, and the bones. The secondary or determining causes are, as will be seen, the form and bearing of the articular surfaces of the femur and tibia upon each other, and the action of gravity, &c., of the weight of the head, upper extremities and trunk upon the enfeebled and loosened joint, modified in the case of rickets by the peculiar form acquired by the thigh and leg bones in severe rachitic instances of this deformity. From this enumeration of the clinical and pathological varieties of in-knee it will be understood why neither con- ■•' The important and miscliievous part performed bj'^ sub-luxation of the tibia in knee joint diseases was, it is beheved, first pointed out by the author. See lectures on " Contractions and Deformities " in the ' Lancet,' 1842 — 3 ; and also in ' Treatise on Ankylosis,' London, 1843. 12 IN- KNEE DISTORTION. currence with the views of those recent authors who divide the cases into two forms (the rachitic and statical), or with C. Hueter, who adds a third form (the traumatic), nor still less with those who see in the distortion of in-knee a single form (that of rachitic origin), can be arrived at. When in-knee is looked at from an etiological and con- stitutional point of view, it will be evident that all cases, including the rachitic ones, might equally be called statical ; that in all, the weight of the body being attempted to be inefficiently borne by the limb causes the passive structures to yield beneath its influence. The principal conclusions at which we have arrived in this section are that there are several clinically and patho- logically well-marked varieties of in-knee, and that of these varieties the rachitic is not the most frequent. OUTWARD CURVATUEE OF KNEE. Cases of an opposite form of distortion of the knee, see fig. 6, termed outward yielding or curvature of it (genu- extrorsum*), are occasionally met with, mainly in rachitic subjects. It is much less frequent than genu-valgum, or inward inclination. The greater frequency of the latter is apparently due to the natural inward direction of the shaft of the femur and condyles. The immediate or mechanical cause of outward knee inclination has not been satisfactorily explained. It is com- monly of rickety origin, and is combined with curvature of the femur and tibia. When one knee is inclined inwards and the other outwards, the latter appears as if it were the result of accommodation. It may also occur independently of rickets, as when one limb is shortened from paralysis, =^ We were the first to name and describe geuu-extrorsum curvatum at the Royal Ortboptedic Hospital in 1839. OUTWAED KNEE DISTOETION. 13 knee disease, or accident, the other limb yielding outwards for accommodation purposes. The annexed figure exhibits a case Fig. 6. of considerable outward curvature of doubtful origin. There exists obvious curvature of all the long bones of both lower extremities, but they are dispro- portionately long, the reverse of the shortened limbs of a rickety subject. The individual had not the head and face of rachitis, nor were other signs of former rickets present. He had a puny chest and lanky legs, common to the ill-fed fast-growing atonic cases of distortion (such as genu- valgum atonicum), and may have followed an avocation which had predisposed to distortion. It is well known, for example, that jockeys are apt to become bow-legged. As the lower extremities are comparatively long com- pared with the trunk, it is probable that the over-growth and the curvature took place during the most active period of growth, from about the age of twelve or thirteen to sixteen or seventeen. The disproportion is so unusually great as to suggest the idea that it was due to excess in growth (deformity from excess), with proportionate weakness and liability to yield to gravity, and to any undue retention of the limbs in a particular position. Double outward curva- ture of loicer extre- mities. PATHOLOGY AND MOEBID ANATOMY OF IN- KNEE, AND ITS VAEIETIES. We have already stated (pp. 2, 11) that every disordered condition of the structures composing and surrounding the knee joint, the integrity of which is necessary for the due performance of its functions, may give rise more or less completely to knock-knee. The essential first evil consequence of disordered action is a weakening of the naturally strong connection which exists between the femur and tibia. If the weakening affect the ligaments the joint is at the mercy of the muscles, the stronger ones asserting their supremacy ; and if the indi- vidual is able to attempt to stand or walk the influence of gravity becomes irresistible, the joint yields to it, constituting displacement or distortion. If the primary evil be in the muscles it will consist of either augmented power (spasm) or diminished power (paralysis), or a modification of that less considered and less completely defined property known as tone. We have shown that from disordered, or probably rather from insufficient nutrition of tissues, both ligaments and muscles suffer from diminished tone and strength, and that genu -valgum arises more often from loss of tone than from any other single cause. Nevertheless pathologists, when treating of this distortion and of distortions in general, ex- cept as regards scoliosis, miscalled lateral curvature, have seldom taken atony of fibrous and muscular structures into account. The popular term weakness has taken its place. RELATION TO OTHER DISEASES. 15 Atonic genu-valgum is related to several other disorders in which weakness of fibrous structure (including muscular weakness, short of paralysis) exists, e.g., prolapsus ani, prolapsus uteri, ectropium senile, hernia, fiat-foot, &c. Those complaints which depend upon muscular weakness (atony) have more attracted the notice of pathologists than those in which weakness of ligaments plays the more im- portant part.* This oversight as to the important part played by atony of fibrous structures and muscles is partly due to the positive material tendency of pathology during the last four or five decades. That which is apt to be reco- vered from does not afi"ord material for the scalpel or micro- scope (without resort to the emporte-inece, a proceeding little to be commended and rarely employed). We do not despair that, attention being drawn to the subject of atony of fibrous and muscular structures, more will hereafter be known re- specting its essential nature. Gravity usually tells unfavourably against atonic struc- tures; consequently in the case of atonic distortions the ankle joint suffers most from this cause (flat-foot), next the knee (genu-valgum), next the hip (certain waddling gait,! when not caused by rickety change in the neck of femur), lastly, the spinal column (scoliosis). As an instance of imperfect gait from want of tone of parts, we may cite the hobbledehoy movement of a fast- growing adolescent boy, one who has "outgrown his strength," the power of co-ordinating his muscles (apart from a possible touch of chorea) has been outdone by the over-rapid elongation of the bones of the lower extremities proper to this period of life. We have occasionally been consulted as to adolescent girls in whom, as in the above class of boys, we could discover no distinct disease, yet the * Consult Louis F. Stromeyer : Platt-fuss ' Beitrage zur Operativen Orthopaedik,' Hanover, 1838. Ernst Stromeyer : ' Ueber Atonie fibroser Gewebe,' Wurzburg, 1840. 16 IN-KNEB DISTORTION. gait was extremelywanting in steadiness and firmness, some- times amounting in the minds of the attendants to lame- ness of hip. It is a question in some such cases of want of tone in the hgaments and muscles attached to the rapidly enlarging pelvis, analogous to the hobbledehoy gait caused by rapid elongation of the bones of the boy's lower extremities. We have elsewhere stated that we have known even a girl grow six inches in a year, just before pubert3^ The case was one of incipient scoliosis. We had periodically measured her during the year, as an aid in determining the pro- bability of cure. Hitherto it has not been sufficiently noted that there are two periods in the age of man at which growth is extra- ordinarily rapid. The first period is from birth until the age of nine months ; the second period is at the approach of, or during, puberty or adolescence, say from the tenth or twelfth to the fourteenth or sixteenth year, more or less. We are indebted to Burdach * and Schwartz for precise details on this interesting head. Schwartz watched a child which grew in the First week H in. ,, month 2 3 lines.! Second ,, 1 1 line. Third „ 7 lines. Fourth „ 11 „ Fifth „ 6 „ Sixth „ 7 „ Seventh ,, 1 Eighth and n mth month H ■■' Carl F. Burdacli : 1880, ' Die Physiologie als Erfaliruugswissen- schaft,' 3 Band, p. 236. •j- We were led to enquire into this subject through having repeat- edly observed how very often in the treatment of congenital varus in infants during "the month" it became necessary to exchange the splints used for longer ones. GBOWTH DURING INFANCY AND ADOLESCENCE. 17 . 3 in. . 2 „ . 2 „ . 2 „ . 1 „ . 1 „ If in the first seven 22 inches, it will in- so that its length increased in nine months about one- third, say 8^ German inches.* The average rate of growth in the infant is estimated to be 6 to 8 German inches during the first nine months, or from 18 or 20 inches to 24 or 26 inches. Burdach says that growth is during the Second year Third Fourth Fifth Sixth Seventh at which period there is often a stop, years the length has increased 20 or crease in the second seven years only 10 or 12 inches, and attains in the male 5|- feet. The weight which at seven years is 37 lbs. German, increases at the age of fourteen 22 or 25 lbs. Adolescence extends from puberty to completion of growth, i.e., until sixteenth to twenty-third year in the male,; and fourteenth to twentieth in the female. Growth at the beginning of this period proceeds rapidly, and, especially ini cases where it had not greatly advanced, makes a fresh start. During adolescence the growth is from 10 to 12 inches. W^ believe that in the male growth may not stop until the age of twenty-five. It is known that ossification is not com- pleted before thirty. It was stated at the meeting, in 1881, of the British Association for the Advancement of Science, that growth continues until the age of forty ; probably in width only. These two periods of most rapid growth are, we venture to say, predetermined physiologically : the first to hasten * n . , 128 * German inch = vtt? loo 1-098 English. •9519 EngUsh. German pound 56 51 18 IN-KNEE DISTORTION. the infant's fitness for independent locomotion and self-help to food, when the mother's poAver of lactation may in the normal com'se he expected to cease, and the infant's ahso- lutc dependence on the mother for hoth locomotion and food shall terminate ; the second period is, we consider, allied to sexual development, and the [ipparent necessity of then more rapidly completing the frame of the individual of either sex to fit it for propagation of the race, for a life of lahour, and its defence against dangers. Volkmann (oj). cit.) applies the term idiopathic to denote what we have termed the atonic form of genu-valgum, and remarks that it occurs almost without exception only be- tween the second and fourth and between the fourteenth and seventeenth years. He appears to attribute it to abso- lute overloading, whilst we attribute it in infancy and early childhood, as a rule, to relative overloading of the joint which is relaxed from atonic causes. In adolescents it is probable that the carrying of heavy weights, fatigue, and long hours of work, have the principal share in its pro- duction, favoured in fast-growing lads by insufficient diet, and consequent weakness of tissue. Volkmann is the only observer who, besides ourselves, as far as we have ascer- tained, recognises the fact of atonic genu-valgum taking place mainly at two epochs of life. We have never seen a rachitic in-knee produced after the age of five years. Pre- vious observers and statistical* enumerators speak of cases of rickets originating during adolescence, and even adult age. They have often, doubtless, included under the head of rickets, as originating during adolescence, cases which had commenced in early childhood, and cases of the simjAe loeak in-knee of early infancy and adolescence, all of which are liable to become aggravated through statical influences during rapid growth. Simple in-knee without unequivocal ■■' See the "Discussion ou Eickets" at the Pathological Societj', December, 1880, in the medical journals of the period. INFLUENCE OF GROWTH. 19 signs of rickets may originate at any period between birth and the completion of growth, but occm-s by far the most frequently in early infancy and during the progress of puberty and adolescence, corresponding, in fact, with the two rapid periods of growth to which we have alluded. Simple or weak in-knee occurs independently of the pre- sence of signs of rickets. Eickety in-knee is accompanied with constitutional and local signs of rickets elsewhere ; rachitic bone curvatures, for example, rickety teeth, rickety face and skull, restricted growth. (See rickety in-knee.) Simple in-knee from weakness attacks tall children, and does not lead to shortening of their stature. Rickety genu-! valgum is met with only in individuals stunted from rickets, i. e., shortened more or less according to the intensity of that disease.* As regards the proximate causes of genu-valgum and their anatomical results, the opinions which have had more or less temporary currency during the last forty years may be summarised by saying that some observers, through not having taken a comprehensive view of knock-knee, or from not having had sufficient opportunities of studying the dis- tortion in all its forms and stages, have singled out one fact, often not a constant one, in the history of the complaint, to which alone they have attributed its origin. Thus one writer has attributed it to elongation of the internal lateral liga- ment of the knee joint ; another to shortening of the external lateral ligament ; another to contraction of the outer ham- string, muscle and tendon ("retraction musculaire"), — a great number of writers have put down enlargement of the internal condyle of the femur as the immediate cause. Gradually deficiency of the external condyle has obtained a share of the etiologist's attention. Finally, it is acknow- ledged that when the distortion has long existed, deficiency * See also paper by the author in tlie ' Transactions of tlie Inter- national Medical Congress,' London, 1881. 20 IN-KNEE DISTORTION. of the external condj^le and. enlargement of the internal condyle co-exist. In our opinion these several conditions grow up jxiri j^assu, or successively, and appear as factors of the deformity. The time has arrived when it may be said that the majority of the above conditions are but conse- quences of a common cause, — a weakening of the j&brous structures and bones affecting the knee joint, which becomes statically disturbed by gravity, by passive muscular action, and may even be influenced by the will of the patient in his efforts to eflect locomotion in the least uneasy manner when the distortion has reached the highest stage ; and through inability of the patient to take any exercise the members may become surrendered to the passive adaptive shortening of muscles, and get more or less rigidly fixed in the deformed state. One of our ablest surgeons, author of a ' Monograph on Genu- valgum,' Macewen, attributes it exclusively to rickets, and in particular to curvature of the lower end of the femur and hyper- trophy of the internal condyle and adjacent part of the shaft. It may here be remarked that curvature of the tibia is sometimes a more promi- nent fact in rickety genu-valgum (see fig. 7) than femoral curvature, or inward inclination of the knee joint itself. We refer knock-knee in all its forms primarily to relative or abso- lute weakness and relaxation of the structures composing and surround- ing the knee joint, the ordinary state of perpendicularity of the whole limb being disturbed through the weight of the head, upper extremities and trunk being too great to be properly borne by the enfeebled Fig. 7. Racliitic (lemi-vahjuiit and curvature confined to one le