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JACKSON CLARKE, M.B. Loxu., E.R.C.S. SUIiGEON TO OUT-PATIENT.S AT THE NORTH-WEST LONDON AND CITY ORTHOPAEDIC HOSPITALS, MEMBER OF THE COUNCIL OF THE BRITISH ORTHOP.KDIC SOCIETY, LATE SENIOR DEMONSTRATOR OF ANATOMY, CURATOR OF THE MUSEUM, AND PATHOLOGIST AT ST. MARY'S HOSPITAL WITH 30'.) ILLUSTRATIONS ib;.iT. ■ * Li--; Al,j HC-- J.,.:;a&3 ' NEW YORK WILLIAM WOOD & COMPANY 1899 ALL RIGHTS RESERVED rrvrse X VE TO MY WIFE. PREFACE. For many years past it has been my intention to write a book on the Surgery of Deformities based upon their pathology, and giving in a systematised form an outline of the various therapeutic measures applicable to their treatment. In dealing with the special deformities, it has been my aim to begin with simple and familiar conditions in order to be able to explain more complex conditions by reference to them. The rich material of the North-West London and the City of London Orthopaedic Hospitals has formed the basis of the clinical parts of the work, but I have taken information wherever I have found it, and it has been my endeavour in every case to acknowledge the sources to which I owe such gleanings. AVhere obligations are many it may seem invidious to make special mention of but a few. I cannot, however, refrain from acknowledging in this place the debt I owe to Mr. William Adams and to Professor A. Hoffa. Mr. Adams has kindly allowed me to use many of the illus- trations to be found in his classical works, and much of what knowledge this book contains can be traced to these works or to information generously given to me in conversation. To Professor Hoffa, too, I owe permission to viii OBTHCWJEDIU SURGERY. use several illustrations from his well-known " Lehrbuch der orthopadischen Chirurgie." The influence of this, the first of all systematic works on orthopaedic surgery, will be felt in many parts of my book. To the President and Council of the Royal College of Surgeons of England I owe permission to reproduce illustrations of specimens in the Hunterian Museum, and to the Councils of the Royal Academy of Medicine in Ireland and of the Clinical Society of London the use of illustrations from their published Transactions. Mr. Frederick Treves lias also kindly allowed me to repro- duce some of the illustrations from his well-known works. Some of the matter contained in this book has previously appeared in the medical journals, and I have to thank the editors of The British Medical Journal, The Lancet, The Medical Press and, Circular, The Practitioner, The Clinical Journal, and other medical journals for permission to use illustrations and letterpress. London, July 19, 1899. TABLE OF CONTENTS. Introduction.—Andry— Origin of the term "Orthopedic Surgery"— Scope of Orthopaedic .Surgery—Necessity for Orthopaedic Depart- ments at Hospitals—Proper Relations between Surgeon and Instru- ment-makers—" Orthopaedic Illusions " ............ 1 Part I.—General Pathology and Principles of Treatment of De- formities—Primary Congenital Deformities—Secondary Congenital Deformities—Acquired Deformities—Pressure Deformities—Yesti- mentary Deformities—Contractures—Anatomical Changes in Bones in Pressure Deformities—Meyer's Law—Wolfl's Law ... ... 9 Rickets : Rachitis Adolescentium—Congenital Rickets—Achondroplasia— Syphilis—Fragilitas Ossium—Osteitis Deformans ... ... ... 2.3 Rheumatoid Arthritis — Chronic Dry Ulcerative Arthritis — Chronic Traumatic Arthritis Deformans—Rheumatoid Arthritis in Children —Rheumatism—Chronic Ankylosing Arthritis—Gout ... ... 3o Contractures : Dermatogenous, Desmogenoa.s, Myogenous, Inflammatory Muscular, and Neurogenous—Causes of Paralytic Deformities— Arthrogenous Contractures—Ankylosis... ... ... .. ... 47 General Prophylaxis and Therapeutics of Deformities—Statistics — Symptomatology—Diagnosis—Prognosis ... ... ... ... 60 General Treatment of Deformities: Massage—Gymnastics—Passive Exercises—Resisted Exercises—Electricity—Hydrotherapy ... 64 The Principles of the Treatment of Deformities by Instruments : Plaster of Paris—Hessing's Apparatus—The Rigid Splint—Scarpa's Shoe— Thomas's Splints—Chance's and Taylor's Spinal Splints —Springs and Elastic Traction .......„ ............ 69 Correcting Manipulations: "Bone-Setting"—Forcible Stretching of Muscles—Orthopaedic Operations on Skin, Fasciaj. Tendons—Repair of Tendons after Subcutaneous Tenotomy—Open Tenotomy—Opera- tions on Tendons other than Simple Tenotomy—Lengthening a Tendon—Shortening a Tendon—Tendon Transplantation—Tendon Grafting—Myotomy—Syndesmotomy............... 86 Open Division of Soft Parts—Operations on Joints: Osteoclasis—Osteo- tomy—Adams's Operation— Maeewen's Operation—Oblique Osteo- tomy—Cuneiform Osteotomy—Curvilinear Osteotomy—Excision of Bones—Osteoplastic Operations—Arthrodesis ... ... ... ... 108 Part II.—Special Orthopaedic Surgery...... ........ 117 Section I.—Deformities of the Fingers and Toes: Hallux Valgus: Pathological Anatomy—Causation—Treatment—Operative Treat- ment—Hallux varus: treatment... ... ... ...... ... 127 * x ORTHOPAEDIC SURGE RY. PAGE Hallux Rigidus or Flexus : Symptoms—Pathology—Prognosis—Treat- t. ' 128 ment ... Hammer-toe : Anatomy—Pathology—Treatment—Illustrative Cases ... 130 Arthritic Deformities of the Toes : Contraction of the Digital Processes of Plantar Fascia—Ankylosis—Hallux Retractus—Paralytic Defor- mity of the Toes ........................ 134 Congenital Deformities of Fingers and Toes: Polydactyly—Bifurcated Hand—Suppression of Digits (Ectrodactyly)—Webbed Fingers and Toes (Syndactyly)—Treatment—Operations. Congenital Dis- locations of the Fingers. Congenital Contracture of the Fingers: Diagnosis—Treatment ... ... ... ••• -•• ••• ••• *"" Acquired Deformities of the Fingers : Trigger Finger—Drop Finger- Writer's Cramp. Dupuytren's Contraction of the Fingers : Symp- toms—Anatomy — Incidence—Pathology—Diagnosis—Prognosis- Adams's Operation—Illustrative Case—Other Operations ...... 143 Section II.—Deformities Affecting chiefly the Ankle and Tarsal Joints and the Corresponding Deformities of the Upper Extremities ... 153 Introduction to Club-foot and Club-hand—Varieties of Talipes—Con- genital Talipes Calcaneus: Symptoms—Anatomy—Diagnosis. Con- genital Talipes Valgus—Congenital Talipes Calcaneo-valgus : Anatomy—Treatment—Illustrative Case ... ...... ... 156 Paralytic Talipes Valgus—Paralytic Talipes Calcaneus : Treatment. Paralytic Talipes Calcaneo-valgus : Symptoms—Anatomy—Treat- ment. Nicoladoni's Operation ... ... ... ... ... ... 161 Congenital Talipes Equinus—Congenital Talipes Varus—Congenital Talipes Calcaneo-varus—Congenital Talipes Equino-valgus—Con- genital Talipes Equino-varus : Degrees — Anatomy — Treatment — Gradual Method — So-called Relapsed Cases — Operations : Buchanan's—Phelps's. Osteotomy of Astragalus—Bradford's Opera- tion—Fitzgerald's Operation ... ... ... ... ... ... 164 Acquired Talipes Equinus : Causes—Symptoms—Anatomical Changes —Treatment. Paralytic Talipes Varus—Paralytic Talipes Equino- varus—Talipes Cavus : Congenital—Acquired—Treatment. Con- genital Flat-foot—Acquired Flat-foot (Talipes Valgus)—Varieties — Spasmodic Flat-foot (Illustrative Case). Static Flat-foot: Symptoms — Anatomy — Degrees — Treatment — Operations : Ogston's (Illustrative Case)—Stokes's Operation. Transverse Flat- foot — Metatarsalgia : Causation—Diagnosis—Treatment—Illustra- tive Cases ... ... ... ... ... ... ... ... ... 181 Deformities of the Hand : Congenital Club-hand—Congenital Dislocation of the Wrist—Acquired Spontaneous Subluxation of the "Wrist— Paralytic Deformities of the Hand—Contractures and Ankylosis of the Wrist and Carpal Joints ... ... ... ... ... ... 215 Section III. —Deformities caused by Changes in the Long Bones of the Extrem- ities—Spontaneous Arrest of Growth at the Epiphyseal Cartilages —Congenital Absence of Tibia—Congenital Defects of the Fibula— Rachitic Deformities of the Long Bones of the Lower Limbs : Periods of Life—Seat of the Changes in the Bones. Definition of Genu Valgum and Genu Varum: Varieties of Abnormal Curves in the Shafts of the Long Bones. Genu Valgum: Anatomy—Measure- ment of — Degree — Mode of Examination — Complications__ TABLE OF CONTENTS. xi PAGE Symptoms—Prognosis—Treatment—Ambulant—by Recumbency— Operative—Comparison of Results of Conservative and Operative Treatment. Genu Varum: Symptoms —Anatomy — Diagnosis- Prognosis—Treatment—Operative Treatment. Rachitic Deformities of the Shaft of the Femur — Outward Curves of the Leg Bones : Treatment. Anterior Tibial Curves—Treatment—Osteotomoclasis... 220 Rachitic Incurvation of the Neck of the Femur—Coxa Vara: Symptoms —Differential Diagnosis—Age of Onset—Pathology—Treatment. Rachitic Back-knee (Genu Retrorsum) ............ 248 Deformities of the Long Bones of the Upper Limb : Treatment. Rachitic Deformities of the Bones of the Forearm—Deformity of the Forearm after Fractures ... ... .. ... ... ... ... ... 259 Section IV.—Deformities Caused by Changes in the Large Joints of the Extremities, with a Consideration of the Surgical Aspects of Spastic Paralysis, etc.—Traumatic Deformities of the Ankle-joint: De- formities due to Suppurative, Rheumatic, and Tubercular Affections of the Ankle. Deformities of the Knee-joint: Congenital Genu Recurvatum : Symptoms—Anatomy—Treatment. Congenital Con- tracture of the Knee-joint: Treatment. Congenital Affections of the Patella : Absence—Dislocation—Illustrative . Case. Acquired Contracture and Ankylosis of the Knee—Paralytic Contracture of the Knee: Treatment—Illustrative Case. Paralytic Genu Re- curvatum : Causation — Treatment. Paralytic Flail-joint at the Knee—Arthrogenous Contracture of the Knee : Treatment. Internal Derangement of the Knee (Hey's Joint). Deformities of the Hip- joint : Symptoms—Diagnosis and Method of Examination. Con- genital Dislocation of the Hip : Anatomy—Causation—Frequency— Symptoms—Differential Diagnosis—Prognosis—Treatment—Reduc- tion by Manipulation—Operative Treatment. Congenital Paralysis —Contracture of the Hip from Infantile Paralysis—Tubercular Coxitis ("Hip Disease"): Symptoms and Diagnosis—Hysterical Hip—Illustrative Case—Prognosis in Tube»cular Coxitis—Treat- ment—Ambulant Methods—Complications. Non-tubercular Affec- tions of the Hip—Deformities arising after Specific Fevers— Illustrative Case—Arthritis Deformans of the Hip : Symptoms- Diagnosis— Treatment—Illustrative Case. Sacro-iliac Disease: Pain —Abscess — Muscular Spasm — Diagnosis — Prognosis — Treat- ment ... ... ... ... ... ... ... ... ... 261 Congenital Defects of the Clavicle—Congenital Displacement of the Scapula—Deformities of the Shoulder-joint—Congenital Dislocation —Illustrative Cases—Congenital Paralysis of Shoulder - Muscles— Paralytic Deformities at the Shoulder: Diagnosis—Prognosis— Treatment. Contracture and Ankylosis at the Shoulder-joint: Symptoms and Diagnosis—Treatment. Deformities of the Elbow- joint : Congenital Dislocations—Symptoms—Causation—Treatment. Cubitus valgus and varus—Contractures and Ankylosis of the Elbow —Cicatricial Contracture—Ankylosis ... ... ... ... ... 312 'The Surgical Aspects of Spastic Paralysis: Causation—Symptoms— Diagnosis — Prognosis — Treatment — Illustrative Case. Pseudo- hypertrophic Muscular Paralysis : Causation—Pathology—Symp- toms—Diagnosis—Course—Treatment ............ 319 xii ORTHOPEDIC SURGERY. PAGE Section V.—Deformities of the Spine—Wry-neck and Deformities of the Thorax ........................... 328 Preliminary Observations—Chief Varieties of Spinal Deformity—Method of Examination of the Patient ...... ... ••• ••• ••• ""° Congenital Deformities of the Spine : Thoracic Kyphosis, or Dorsal Ex- curvation of the Spine : Causation—Diagnosis— Treatment. Lor- dosis : Rachitic — Secondary—Causes—Treatment. Lateral Curva- ture of the Spine or Scoliosis : Frequency—Pathological Anatomy- Predisposing Causes—Exciting Causes—Experimental Investigation —Types of Scoliosis—Diagnosis—Method of Examination—Scoli- osiometry—Course and Diagnosis—Prognosis—Treatment—Preven- tive Treatment — Exercises — Instrumental Treatment — Forcible Correction ... ... ... ... ... ••• •■• •■• ■•• "^ Rickets of the Spine—Rachitic Kyphosis: Symptoms--Differential Diagnosis — Prognosis — Treatment. Rachitic Lordosis—Rachitic Scoliosis—Rheumatoid Arthritis of the Spine : Types of Deformity —Age of Onset—Symptoms—Prognosis and Treatment. Other Forms of Non-tubercular Spondylitis : Syphilitic Disease—Rheu- matism — Diagnosis — Post-scarlatinal — Gonorrheal — Post-typhoi- dal and other Spinal Lesions ... ... ... ... ••• ■■• 372 Neurotic Affections of the Spine : Forms—Treatment—Illustrative Case 380 Tuberculosis of the Spine—Tubercular Spondylitis : Pathology—Ana- tomical Effects—Tuberculosis of the Vertebral Arches—Recovery— Abscess—Secondary Effects on the Skeleton and on the Spinal Cord- Symptoms—Examination of the Back—Method of Recording Angu- lar Deformity — Differential Diagnosis — Course and Prognosis. Complications of Tubercular Spondylitis: Abscess—Diagnosis of Abscess. Treatment of Tubercular Spondylitis : Recumbency— Mechanical Treatment—Forcible Correction of Deformity—Illus- trative Case—Costo-transversectomy—Treatment of the Complica- tions of Tubercular Spondylitis—Psoas Contraction—Treatment of Spinal Abscesses—Expectant Treatment—Illustrative Cases—Treat- ment of Sinuses—Paraplegia—Symptoms of Implication of the Spinal Cord—Operations in Paraplegia—Laminectomy ... ... 382 Malignant Disease of the Spine ... ... ... ... ... ... 419 Wry-neck or Torticollis : Acute or Rheumatic Torticollis : Causation— Course—Treatment. Ocular Torticollis—Chronic Torticollis. Con- genital Wry-neck : Anatomy—Illustrative Case—Treatment. Articular and Osseous Torticollis—Spasmodic Wry-neck (Chronic Nervous Torticollis): Clonic Form — Varieties — Tonic Form— Varieties — Prognosis — Treatment — Operations—Hysterical Torti- collis—Illustrative Case—Paralytic Torticollis ... ... ... 420 Deformities of the Thorax—Congenital Deformities—Acquired Deformities —" Pigeon Breast"—Retraction of the Lower Part of the Thorax from Respiratory Obstruction—Respiratory Exercises ... ... 437 Index to Subjects ... ... ... ... ,.. ... . 443 Index to Authors ... ... ... ... ... ... ... 447 LIST OF ILLUSTRATIONS. FIG. 1. Webbed fingers 2. Single monster with amniotic bands, etc. ... 3. Hand with flattened and deformed fingers... 4. Infant with congenital deformities... 5. Congenital club-foot caused by mechanical means 6. „ annular constriction 7. The " attitude of rest " 8. Diagram showing mode of growth of a long bone 9. Frontal section of the upper end of a tibia in genu valgum 10. Vertical section of a radius with a green-stick fracture... 11. Back of a patient with ankylosis of left hip L2. The same after correction of the deformity of the hip ... 13. Vertical section of a femur with rachitic deformity 14. ,, ,, normal humerus at birth ... 15. ,, „ humerus during active rickets 1G. Portions of ribs affected by rickets...... ......... 17. Infant with severe congenital deformities... ......... 18. Achondroplasia 19. The bones of the lower limbs in achondroplasia......... 20. TheTower end of a femur and the patella in rheumatoid arthritis 21. Histological appearances in osteo-arthritis combined with gout 22. Hot-air apparatus 23. „ „ ..................... 24. Rheumatoid arthritis in a child aged four years......... 25. Longitudinal section of a finger deformed by gout ...... 26. Ischaemic contracture of the hand ... 27. Attitude assumed by a patient with paralysis of the lower limbs 28. Osseous ankylosis of the hip ............... 29. The bones at the hip-joint in a case of tubercular coxitis with dislo tion 30. Bonnet's apparatus for exercising the ankle ......... 31. Apparatus for applying plaster of Paris bandages ...... 32. The same— the bandage applied ............... 33. Hessing's apparatus for the pelvis............... 34. "Wooden splints for knock-knee 35. ,, splint for outward tibial curve ... ... ...... 36. The same applied ... ... ......... 37. Metal part of walking instrument ... ............ "v ORTHOPAEDIC SURGERY. FIG. 38. Ring-catch joint 39. Detachable joint 40. A method of elongating steel supports 41. Leg and foot in equino-varus 42. External malleable splint applied to same... 43. Antero-external malleable splint applied ... 44. Rectangular splint ... 45. The same used as a " Scarpa's shoe " 46. ,, holding the foot in a corrected position 47. Early form of " Scarpa's shoe " 48. Modern type of "Scarpa's shoe " ... 49. Walking-instruments and boots for equino-varus 50. H. O. Thomas's single hip-splint ... 51. ,, double hip-splint ... 52. Chance s spinal splint 53. Taylor's „ 54. Boot and iron with toe-elevating spring ... 55. Prothero Smith's spinal support 56. H. O. Thomas's knee splint... 57. Prothetic apparatus for use after amputation at or below the ankle 58. ,, „ „ through the leg... 59. Tenotomes 60. Parker's tenotomes ... 61. Minute tissue changes in early stage of repair of tendon 62. Repair of rabbit's tendon—14th day 63. The same—histological appearances 64. Different methods of tendon suture 65. ,, „ ,, ............... 66. „ „ ,, ............... 67. Lengthening a tendon by Z-shaped incision 68. ,, ,, by turning down flap ... 69. Tendon transplantation 70. Grattan's osteoclast ... 71. Adams's saw .. 72. Lower end of femur showing points to be observed in Macew operation ... 73. Mace wen's osteotome 74. Osteotomes and chisels 75. Gighli's saw ... 76. Oblique osteotomy (Oilier) ... 78. Cuneiform osteotomy 79. Curvilinear osteotomy 80. ,, ,, .................. 81. Hallux valgus 82. „ „ .................. [[[ 83. Anatomy of hallux valgus ... 84. Meyer's plan for sole of boots 85. Sole of ordinary boot 86. Footprint of a child aged three years 87. Normal footprints, etc. LIST OF ILLUSTRATIONS. FIG. 88. Footprints of feet deformed by fashionable boots ...... 89. Bunion spring 90. „ lever........................ 91. Bandage for hallux valgus ... 92. ,, 93. Hallux varus 94. Hallux rigidus : Position of the bones ............ 95. Hammer-toe ... ... ... ... ... ... v.. 96. ,, The neighbouring toes held apart......... 97. ,, Schematic section of 98. ,, Adams's splint for 99. Outline of foot with deformities of toes and metal splint 100. Deformity of the third toe from wearing tight boots 101. Side view of a foot showing hallux retractus and flat-foot 102. The same foot after treatment 103. Casts of the foot of a boy showing clawed-toes ... 104. Bifurcated hand 105. Bones of a foot with six metatarsals and seven digits ... 106. Zeller's operation for webbed fingers 107. Didot's „ „ ............ 108. Method of adjusting flaps in same 109. Congenital contracture of fingers ... 110. Pen for writer's cramp 111. Dissection of Dupuytren's contraction 112. Dupuytren's contraction before operation 113. ,, ,, after operation 114. „ „ Splint for 115. Diagram showing the normal range of movement at ankle 116. The position of the feet in the later stages tf utero-gestation ... 117. Dissection of congenital equino-valgus 118. Congenital talipes calcaneo-valgus 119. ,, ,, ,, extreme case 120. „ „ ,, partly corrected 121. ,, „ ,, after three months' treatment 122. Paralytic talipes calcaneus 123. Chinese lady's foot, dissected ............... 124. ,, ,, ,, external aspect 125. Apparatus for the gradual correction of pes cavus 126. Congenital talipes equino-varus, from behind 127. ,, ,, ,, from before 128. ,, ,, ,, dissected ...... 129. „ ,, „ P.oncs and joints in 130. Astragalus and scaphoid in congenital equino-varus 131. Bones of the foot in congenital equino-varus ........ 132. Stages in the cure of congenital equino-varus ... ...... 133. ,, „ „ „ ......... 134. „ „ „ ,, ••■ ...... 135. Impression of the soles after cure of congenital equino-varus ... 136. Feet of a child aged two years with so-called " relapsed " equino-v 137. Diagram showing ligaments exposed by turning down the tendon the tibialis posticus XVI ORTHOPAEDIC S URGER Y. FIG. 138. Club-foot wrench (H. 0. Thomas's) ...... 139. ,, wrenches (F. F. Baker's) ...... 140. Congenital talipes equino-varus 141. Sole of the foot in the same case ... 142. Outer aspect of foot in the same case after treatment 143. Front view of the foot in the same case ... 144. Instrument applied to the foot in the same case ... 145. Fitzgerald's splint 146. Right-angled contraction of the ankle 147. Paralytic talipes equinus with total paralysis of extensors ]48. ,, ,, with partial paralysis of extensors 149. Dissection of a foot affected by paralytic equinus 150. Paralytic equinus with shortening of leg 151. Little's night-shoe ...... 152. Paralytic talipes equino-varus 153. Talipes cavus ... 154. Flat-foot .............. 155. ,, Appearance of the sole in 156. Footprint in an average case of flat-foot ... 157. ,, „ ixtreme case of flat-foot ... 158. „ of a narrow foot with a medium degree of flat-foot 159. Radiograph of fiat-foot viewed from side to side 160. „ „ ,, dorso-ventrally 161. Photograph of feet showing extreme flat-foot on one side 162. Radiograph of extreme flat-foot 163. Diagram of the bones in extreme flat-foot 164. Plan of instrument for flat-foot 165. Whitman's metal valgus plate 166, Footprints of normal feet and in metatarsalgia 167. Congenital club-hand 168. Skeleton of foetal hand in congenital club-hand 169. Congenital club-hand with absence of radius 170. Skeleton in the same condition 171. Congenital absence of the tibia 172. Diagram of genu valgum 173. ,, genu varum 174. Combination of genu valgum with external tibial curves 175. ,, „ „ femoral curves 176. The bones in genu valgum ... 177. Radiograph of unilateral genu valgum 178. Tracings of the lower limbs in genu valgum 179. Thomas's splints for genu valgum ... 180. A case of genu valgum with anterior tibial curves 181. Case of genu valgum before operation 182. The same patient after operation ... 183. Radiograph of the same case before operation 184. ,, ,, „ after operation 185. Wooden splints for genu valgum (bis) 186. The legs of a patient aged five years, genu varum 187. The same with the legs crossed ...... 188. Radiograph of genu varum ...... LIST OF ILLUSTRATIONS. xvii FIG- PAGE 189. Genu valgum on the right, genu varum on the left side in the same person ... ........................244 190. Tracing of the lower limbs in genu varum ... ... ... ... 245 191. Apparatus for genu varum ... ... ... ... ... ... ... 246 192. Instrument and boot for antero-external tibial curve .........248 193. Eversion of the limbs in coxa vara... ... ...... ... ... 250 194. Coxa vara, scissor-legged condition in, front ...... ... ... 251 195. „ „ „ „ „ back ............251 196. „ „ with marked adduction, patient lying down... ... ... 252 197. Resting position of a child with rickets and coxa vara.........253 198. Radiograph of coxa vara ... ... ... ... ... ... ... 254 199. Rachitic back-knee (genu retrorsum) ... ... ... ... ... 257 200. Radiograph of same ... ... ... ... ... ... ... ... 258 201. Congenital genu recurvatum ... ... ... ... ... ... 262 202. Walking instrument with springs at hip and knee ... ... ... 264 203. Hessing's apparatus with elastic spring at knee ... ... ... ... 264 204. Braatz's joint for knee instrument... ... ... ... ... ... 265 205. Paralytic contracture of knee-joints, etc. ... ... ... ... ... 266 206. ,, genu recurvatum... ... ... ... ... ... ... 267 207. Ankylosis of knee ........................268 208. Apparatus for palliation of contracted knee ... ... ... ... 270 209. Patella truss...........................271 210. Method of examination of the hip ... ... ... ... ... ... 274 '11 ''74 -ii. ,, ,, ,, ... ... ... ... ... ... -it 212. ,. „ „ ..................274 213. Foetus with bilateral congenital dislocation of the hip ... ... ... 276 214. Position of the bones in congenital dislocation of the hip ... ... 277 215. Head of the femur „ „ „ ,, .........277 216. Appearance of the joint ,, „ ,, ... ... ... 277 217. „ „ after reduction of the deformity ... ... 277 218. Os innominatum in congenital dislocation of the hip ... ... .. 278 219. Normal os innominatum at birth ... ... ... ... ... ... 278 220. The pelvis in congenital dislocation of the hip ... ... ... ... 278 221. Old unreduced congenital dislocation of the hip ... ... ... ... 279 222. „ „ ,, ,, „ ............279 223. Child with double congenital dislocation of the hip ... ... ... 284 224. Radiograph of a case of double congenital dislocation of the hip ... 286 225. Congenital paralysis of the lower extremities ... ... ... ... 295 226. Paralytic contracture of both hip-joints...............296 227. Hysterical contracture .................. ... 298 228. Thomas's single hip-splint......... ...... ......300 229. Apparatus for the ambulant treatment of hip disease ... ... ... 301 230. Taylor's traction splint for hip disease ... ............302 231. „ short traction splint ............ ......303 232. Dislocation from tubercular coxitis ... ... ... ... ... 304 233. Patient with ankylosis from hip disease before and after operation ... 233 234. Dislocation of the hip after scarlet fever...............308 235. Apparatus for severe arthritis deformans ... ...... ......311 236. The lower limbs in spastic paralysis ...............320 237. Frame for use in spastic paralysis ...............323 238. The position of the feet in pseudo-hypertrophic paralysis ... ... 326 xviii ORTHOPAEDIC SURGERY. FIG. PAGE 239. Congenital malformation of vertebra ... ... ... .-■ ••• 332 240. Thoracic kyphosis........................334 241 Severe scoliosis ... ... ... ... ... ... ... ••■ 336 242. Scoliosis of moderate degree ... ... ... ... ■•• •■• 336 243. Scoliotic skeleton, front view ... ... ... .. ... ••• 33/ 244. ,, ,, back view ... ... ... ... ... •■ 338 245. ,, ,, side view ... ... ... ... ... ••• 339 246. Scoliosis, flat-hacked type ... ... ... ... .. ••• ••■ 340 247. ,, ,, ,, side view ... ... ... • ■■ ••• 341 248. Scoliosis of slight degree, showing inclination of the body ... 342 249. Three dorsal vertebras from a case of scoliosis ... ... ... ... 343 250. Diagram of the thorax in scoliosis... ... ... ... ... ... 344 251. Case of severe scoliosis, back view ... ... ... ... ... ... 351 252. „ ,, ,, front view... ... ... ... ... ... 351 253. The back in total left-convex scoliosis ... ... .. .. ... 353 254. Tracings from the back and loins in scoliosis ... ... ... .. 354 255. Radiograph of a case of scoliosis ... ... ... ... ... ... 355 256. Primary left-convex cervico-dorsal scoliosis ... ... ... ... 357 257. Chair and desk for use in school-room ... ... ... ... ... 361 25s. Adams's support for scoliosis ... ... ... ... ... ... 366 259. Sheldrake's „ „ .....................367 260. Chance's ,, ,, (diagram) ... ... ... ... ... 368 261. ,, „ „ (photograph) ............368 262. Barwell's seat...........................369 263. Rachitic kyphosis (sitting) ... ... ......... ... ... 372 264. ,, ,, (lying prone) ... ... ... ... ... ... 373 265. „ „ back board for..................374 266. Dorsal vertebrae in rheumatoid arthritis ... ... ... ... ... 375 267. Side view of spinal column, rheumatoid arthritis ... ... ... 376 268. Back of patient with scoliosis due to rheumatoid arthritis ... ... 377 269. Hysterical dorsal kyphosis ... ... ... ... ... ... ... 381 270. ,, ,, ,, instrument used in ... ... ... ... 381 271. Spinal column, showing the effects of deep and superficial spondylitis 3*3 272. Side view of skeleton, showing high dorsal kyphosis .........384 273. ,, „ ,, ,, low dorsal kyphosis ... ... ... 385 274. Healed tubercular spondylitis (diagram) ... ... ... ... ... 386 275. Section of spine in tubercular spondylitis (photograph) ... ... 387 276. Sequestrum pressing on spinal cord ... ... ... ... ... 388 277. Attitudes assumed in tubercular spondylitis ... ... ... ... 392 278. Child with cervical disease of spine ... ... ... ... ... 393 279. Tracings from cases of tubercular spondylitis ... ... ......394 280. Atlo-axoid disease ... ... ... ... ... ... 396 281. Abscess beneath anterior common ligament in tubercular spondylitis... 397 282. Psoas abscess ... ... ... ... ... ... 398 283. Prone couch ... ... ... ... ... ... ... 401 284. Case of severe dorsal deformity ... ... ... ... 4O4 285. „ „ with felt jacket ... ... ... ... 404 286. ,, ,, Chance's splint ... ... ... ... 404 287. Section of spine showing effects of forcible correction of deformity ... 406 288. Wullstein's apparatus for tubercular spondylitis ... ... 409 289. Chance's splint with head-piece ... ... ... ... ... 410 FIG. 290. 291. 292. 293. 294. 295. 296. 297. 298 299. 300. 301. 302. 303. 304. 305. 306. 307. 308. 309. LIST OF ILLUSTRATIONS. Vincent's case, showing method of draining abscesses Patient after operation for lumbar abscess, wearing instrument ■' '• without instrument Method of applying extension to the head Anatomy of congenital torticollis........ Congenital torticollis before operation, front view " » >> back view »• j. after operation, front view " v ,, back view- Rack and pinion apparatus for wry-neck Chance's apparatus for wry-neck Mental torticollis i, ,, corrected Spasmodic torticollis Hysterical wry-neck Section of chest in pigeon breast >> ,, depressed sternum Boy with pigeon breast and adenoids, front view " >> ,, side view 0 r t h o p. e d i c Surg e r y. INTRODUCTION. THE word " orthopaedy" was invented by Andry, whose work, " L'Orthopedie ou l'Art de prevenir et de corriger dans les Enfants les difformites du Corps," was published in 1751. Andry explains the meaning of the word thus: " As to the term in question, I have formed it of two Greek words: to wit, opdos, which means straight, upright, or free from deformity, and iraihiov, which means a child." It seems necessary to give this simple piece of etymology because many well-informed medical men have asked me whether orthopaedic surgery takes cognisance of anything besides the "feet." One learned man suggested that the word should be " orthopodic." Andry's work dealt with a branch of preventive medi- cine rather than with surgery; his aim was to teach the different ways of preventing and correcting bodily deformi- ties in children by methods within the reach of "fathers, mothers, nurses, and others entrusted with the bringing up of children." The importance of these preventive measures is so great that they should be familiar to every practitioner of medicine, and the spirit of Andry's work must animate everyone who is more closely responsible for the treatment of deformities, and thus the retention of the term orthopaedic as qualifying a department of surgery is perhaps justified. In most works on orthopaedic surgery a variety of existing deformities, from wry-neck to hallux valgus, are described and, to some extent, the original meaning of the term orthopaedic has become obscured. Orthopaedic surgery, B 2 ORTHOPAEDIC SURGERY. properly understood, refers to the prevention of threatened deformities as much as the cure of those that already exist, and it regards the functions of the mechanical parts of the body even more than their form. Although the scope of orthopaedic surgery, as generally understood, is limited to the spine, the thorax, and the extremities, the principles of orthopaedic surgery equally concern other parts of the organism and are applicable, for instance, to the surgery of the eye, of the nasal passages, of the uterus, and of the teeth. Thus, in its widest sense, orthopaedic surgery embraces more than the limitations of practice enable one surgeon to perform with satisfaction to his patients and himself. In restricting a province of medicine, it is desirable not to carry the narrowing too far, and it is, in the writer's opinion, necessary for an ortho- paedic surgeon to be not only well versed in, but also by daily practice to be familiar with general surgery. Thus alone can he know with unfailing certainty when the time for conservative measures in any case is passed, and that for energetic and, if necessary, destructive interference is come. A general idea of the conditions that come under the designation of deformities may be gathered from Volkmann's broad subdivision of orthopaedic cases into two groups— firstly, deformities in the wider meaning of the term ; and, secondly, deformities in the narrower sense. In the former group are included badly-set fractures, unreduced dislo- cations, and other traumatic cases ; also rachitic deformities, ankyloses, contractures, and other definitely pathological conditions. In the second group are included deformities such as congenital club-foot, and cases of flat-foot, genu valgum, and scoliosis that arise in adolescence, and are attributable to the habitual assumption of certain attitudes. Whilst this rough classification gives a good idea of the scope of orthopaedic surgery, and has the attractiveness that is found in the sharp differentiation of groups of phenomena some of the distinctions it affords can easily be pushed too far. In most cases of adolescent flat-foot, genu valgum, and scoliosis, among the causes that have combined to produce the deformity, a pathological element will usually INTRODUCTION. 3 be found if carefully sought for; and the successful manage- ment of these cases demands a clear appreciation of all the factors that have a part in the production of deformity. In the present work I have attempted not only to give a scheme of classification, but also to sketch somewhat more fully than is usually done in similar works the pathological factors that enter into the various classes of deformity. My own interest in deformities dates back to the year 18!S5, when my attention was drawn to them in the dis- secting-room at St. Mary's Hospital, where, as demon- strator of anatomy, numerous opportunities of study came in my way, and still more during the five years that I held the post of pathologist and curator of the museum. After my appointment as surgeon to out-patients at the North-West London Hospital many cases of deformity came into my hands for treatment, but it was only after my appointment to the City Orthopaedic Hospital that I found real satisfaction in the work. To deal success- fully with the class of cases that are here in view requires an organisation which only many decades of continuous labour and experience can produce. The necessity for such organisations has long been recognised in Cermany, Austria, and America, In the metropolis of England, where some of the best work in this department of surgery has been done, there are well-organised orthopaedic departments at only a few of the many metropolitan schools, and, at the same time, but few students apply for the post of clinical assistant to the special hospitals. The latter circumstance is explained by the practical absence of questions on orthopaedic treatment from examinations in surgery. This condition of things is no doubt accounted for by the limitations of time and the ever-widening range of the subjects of medical education. Considering, however, the importance of a training in orthopaedic work to all classes of practitioners, and especially to those engaged in general practice, it is hoped that now the five years' curriculum has been established, better arrangements will be made. The severer cases of flat-foot, genu valgum, and scoliosis, which constitute a large proportion of those who come for 4 ORTHOPaFDIC SURGERY. treatment to orthopaedic hospitals, would not exist if the deformity were recognised early and the proper treatment adopted. The number of persons disabled by preventive deformities is very great, and entails a heavy burden upon the community as well as on the individual sufferers. The need of the periodical inspection of growing children by a medical man trained in orthoptedic work is not sufficiently recognised either by the public or the profession. How many cases of deformity are first brought to the notice of the family doctor when they have advanced to a severe degree, and have become fixed by secondary changes in the form of the bones! A training in orthopedic surgery is necessary alike for the general practitioner and for the surgeon. There is an impression that an orthopaedic case may be defined as one requiring instruments. This does not represent the facts and, indeed, the converse of this often holds good. In the various cases that still too often find their way to the bone-setter, it is the too prolonged use of splints, bandages, etc., that is usually at fault, and a period of study at a well-equipped orthoptedic department would enable the practitioner to laugh at the empiric who in country work is too often a galling reality. At the same time, the question of instruments is a crucial one. When I began my work as surgeon to out-patients I felt the lack of training in orthoptedic surgery. For help with simple rachitic deformities I sent for an instrument- maker whom I knew to be employed at a large general hospital. I found that he usually made the instruments to Jit the deformity, and so to exclude the possibility of any improvement being obtained. For cases of club-foot I sought the assistance of another instrument-maker, who had been recommended to me as being employed at a general hospital and a large special hospital for children. This man was always ready to air his views on the anatomy and pathology of the various kinds of club-foot. His pathology was grotesque, and the instruments he made were usually wrong in principle. It is not necessary to detail further the steps that led me to study for myself the principles of instrumental treatment. By testing the knowledge of a succession of house-surgeons trained in the various medical INTRODUCTION. 5 centres of the three kingdoms, I found that my own case was not at all an isolated one. Some have shown a capacity for understanding the problems at issue, but none have given evidence of any training in orthoptedic surgery. Not a few have evinced a superiority to the whole matter, and when I have asked them to measure a patient for a simple instrument, have replied: "This is merely mechanical treatment, for which the instrument-maker is responsible." Here is the fundamental error. In my opinion, the surgeon is responsible to his patient for knowing when an instrument is required, under what conditions it should be worn, and how soon it may be left off. The surgeon should be able to design any instrument and to make all the necessary measurements, to take contours, etc. The mechanician's work is to follow these directions, and if they are complete it should not be necessary for the instrument-maker to see the patient. On the other hand, the surgeon should never be pecuniarily interested in the price paid for the instrument by the patient. That some misunderstanding exists in some quarters on this point is evidenced by a recent article,* from which the following passage is quoted:— So far as regards the medical profession, its inclusion among the professions which accept commissions appears to be founded upon two statements received by the Committee. One was made by a pharmaceutical chemist, who wrote that " secret commissions are given by chemists to medical men on their prescriptions supplied to patients, in some cases amounting to from 25 to 50 per cent, on the price charged by the dispensing chemist." The other statement was from an "optician, jeweller, and silversmith," who said that he had about fifty years' business experience. He wrote that "it is an open secret that hospital doctors received commissions from makers of surgical instruments." The surgeon's duty in this matter is merely to see that the patient is charged a fair price for the instrument and that the latter is satisfactory in every way. Some instrument-makers, who have worked for a long time under orthop.-edic surgeons and for convenience have been entrusted with fitting and measuring patients, in time acquire a dangerously superficial knowledge of surgery, and * Brit. Med. Journal, "Secret Commissions," March 11, 1899, p. 612. 6 ORTHOPaEDW surgery. on that presume to prescribe for different deformities^ In the past, cases of deformity were handed by the physician to the instrument-maker, and from his love of mechanism and ignorance of physiology and pathology much unneces- sary and injurious practice arose, to the discredit of orthoptedic surgery. Many medical men, influenced by this tradition and from want of training in orthopa'dic surgery, still send patients directly to the instrument-maker, and leave the diagnosis and treatment of the case to him, and thus encourage a great deal of unqualified practice, which is against the true interest of the community, since it entails often defective or erroneous treatment, unnecessary and unnecessarily prolonged use of instruments. There is evidence that these matters are becoming more generally understood, as may be shown by a quotation from a recent review :— Even nowadays too many surgeons think that they have done all that is required of them when they send an orthopaedic case to an instrument-maker. They themselves should provide the measurements and details of the instrument which is to be made, and unless they can do so they should not attempt to treat these cases.* For the successful working of an orthopa'dic hospital department it is necessary that the surgeon should control every detail of the instrument-making. An enthusiasm for the promiscuous use of instruments is almost as dangerous as an enthusiasm for surgical opera- tions, and just as to those who are truly interested in medical education it seems a mistake to place the description of operations in the opening instead of the concluding chapters of a text-book on general surgery, so in a text- book on orthoptedic surgery the section dealing with instru- ments should be placed after milder and more natural and before less conservative measures. Nothing has done more harm to the progress of orthoptedic surgery in this and other countries than the advocacy of a certain mode of treatment as applicable to all cases of one or other deformity, to the exclusion of other means. Success in orthoptedic cases depends upon the most scrupulous attention to detail as well as a full under- ' Review of Moore's "Orthopa'dic Surgery," Lancet, Dec. 24, 1898. INTRODUCTION. standing of the pathological character of the case. Ortho- paedic work is most exacting in that it demands of the surgeon the closest personal attention to every detail of treat- ment. This necessitates the sacrifice of more time than is required in almost any other kind of clinical work. In many cases the treatment from the nature of the case must extend over a considerable period. This makes it necessary that very careful records, often aided by radiographs and photographs, must be kept in order to avoid errors of judg- ment as to the progress of a case. These errors are alluded to by De St. Germain* as follows: — I must also carefully warn you against what are ironically termed " orthopa'dic illusions." You have all seen in surgery those tumours which when measured every other day were found to diminish 2 mm. each time, and, at the year's end, were half as large again ! In ortho- paedic work one must, above all things, guard against this very human tendency to see an improvement where it does not exist, and to convert into reality the hope that is based upon any given therapeutic measure. There is another source of illusion. . . . How many times has not one been led to believe that one has been successful in curing an equino- varus when only the fore part of the foot had been raised, and the resistance of the tendo Achillis remained unchanged ! Only a thorough knowledge and a long experience of orthopaedic work will enable the surgeon to avoid such errors. Every student and practitioner of medicine is frequently confronted with orthopaedic cases and has opportunities of studying the commoner deformities. Without some guidance much of the experience thus gained is wasted. The need of text-books dealing with this department of surgery cannot be disputed. In order to render such works as helpful as possible the simpler and commoner deformities should, I think, be discussed first, so that the more complex may be explained by reference to the simpler conditions : in the present work this idea has, as far as possible, been kept in view. Readers of books devoted to orthopaedic surgery will observe that certain congenital deformities, such as hare- lip and cleft-palate, tire not, as a rule, included. Such deformities are fully considered in treatises on general * L. A. De St. Germain, "Chirurgie Orthopedique," Paris, 1883, p. 33. 8 ORTHOPAEDIC SURGERY. surgery, and rightly so; for the methods employed in their treatment are rather those of ordinary surgical than of orthoptt:dic practice : in other words they are combated by direct operative measures, the aim of which is to obtain immediately the maximum of improvement, the same end not being arrived at nor contributed to by any form of gradual correction. These and other similar conditions are not dealt with in the present volume, in order that more space may bo devoted to deformities that require a course of treatment that may occupy a much longer period than can be given by the average student to surgical clinical work. It is in the more strictly orthopaedic cases that the student is unable to follow the whole course of treatment and to witness the degree of improvement obtained: consequently it is in the same class of cases that occurs the error of deeming incurable a condition that at the time the opinion is expressed admits either of complete and permanent cure, or of distinct amelioration. 9 part I. INTRODUCTION TO THE GENERAL PATHOLOGY, PRINCIPLES OF TREATMENT, ETC., OF DEFORMITIES. Rational surgical practice depends so closely upon a know- ledge of pathological anatomy and a correct appreciation of pathological processes that the fullest possible consideration is due to this aspect of the department of surgery with which this book is concerned; limitations of space, how- ever, render it necessary to curtail into a single chapter matter which, if fully considered, would more than fill the whole book. It is customar}' to describe instances of any abnormal condition in two categories : (1) Congenital and (2) Acquired. Whilst this subdivision is convenient, it may be at the same time misleading if it be taken to mean that there is something antithetical between the two sets of conditions. On the contrary, the effects of ante-natal adversity may be of the same character as those of un- toward conditions of post-natal existence. Thus an acci- dental cramping of a limb within the uterus may produce deformity in precisely the same way as cramping of the toes by badly-fashioned boots will produce hallux valgus and other deformities after birth. In many particulars, h-owever, developmental errors that result in deformity give a peculiarity to congenital cases and necessitate their separate consideration. Primary congenital deformities are such as cannot be attributed to any simple mechanical or other recognisable 10 PRIMARY CONGENITAL DEFORMITIES. cause. They are sometimes termed "idiopathic." Some of these conditions depend upon peculiarities of the ovum or the sperm-cell. The exact character of these pecu- liarities, though doubtless of simple nature, if the structure of these cells were completely known, is at present not ascertained. To this class of cases belong peculiarities such as supernumerary digits. Some other conditions, at present included in this group, such as spina bifida, certain congenital dislocations, etc., may with further knowledge prove to be of mechanical origin.* When such a defect appears for the first time in a family it is designated a primary germ-variation, and when it has previously been observed in the same family it is termed a hereditary defect. Allied to hereditary transmission of deformity is the occurrence of congenital deformity in several offspring of the same father or mother. The explanation of primary con- genital defects involves the problems of evolution with which the name of Charles Darwin must ever be asso- ciated. It is of interest to recall the more recent work of Weismann,t who strongly opposes the view that acci- dental traumatic peculiarities may be transmitted. It is probable that in many instances of super- numerary parts the underlying cause is akin to that which gives rise to double monsters, the reduplication occurring at a later stage of ovum- segmentation, and affecting only one or more members of the embryo. Hereditary primary malform- ations are not infrequently of various character * See Dareste, "Production Artificielle de Monstruosites." Paiis, 1877. t Weismann, - Kssays on Heredity " translated by Poulton. Fig. 1.—Webbed Fingers. The clotted outlines represent supernumerary lingers that have been removed. . PRIMARY CONGENITAL DEFORMITIES. 11 in different members of the same family. As an instance of this, the history of the family in which occurred the case of webbed and supernumerary digits represented in Fig. 1 may be quoted. CASKS OF WEBBED FIXGEBK, SCPEItXlMEBARY FJXGEPS, WEBBED TOIX Ac* Fa mil ij History. Eliz. P., M. = F. 3 4 r> 6 7 8 i) I I I ! I I X X m. m. Eliz. Mary. tot. 6. aet. 4. a't. 2. aet. — 12. x Signifies congenital deformity. Xo history of deformity in the father's family. Elizabeth P., ;et. 38 (mother of two following children) :— Riijlit Hand.—Webbing half-way up between second and third fingers. Operated on when a baby; now webbing extends half-way up to the first inter-phalangeal joint. Both Feet.—Both great toes webbed, and third and fourth toes webbed. " Only three toes on each foot." Elizabeth P., a;t. 2 (daughter of above):— i. Ear.—On right side rudimentary : can hear a clock ticking. A rudimentary lobe is present in middle of the right cheek, like a red currant in size and shape. ii. Douhle Squint. iii. Left Eye.—Oataracta reducta. iv. Rv/ht Hand.—Third and fourth fingers joined whole length ; fourth and little fingers webbed ; one extra little finger. v. Left I fund.—Thumb and index webbed; third and fourth digits joined whole length ; extra little finger. vi flight Foot.—Three toes webbed together—second, third and fourth ; and one extra toe. vii. Left Foot.—Extra toe and webbing of third and fourth. Maky P., let. nine months :— One extra finger on left hand on ulnar side. Both Feet.— ^ix toes: it looks as though patient had two great toes on each foot. * For these notes I am indebted to Mr. M. Cecil Ilayward, Senior Kesideut Medical Officer at the North-West London Hospital, 1898. 12 SECONDARY CONGENITAL DEFORMITIES. Hoffa notes the frequency of heredity in 100 cases of congenital deformity in the following table:— 70 cases of Scoliosis, of which 18 in iJ7T» per cent, were hereditary. 7 „ Club-foot „ 2 „ 27o „ >, 7 „ Kyphosis „ 2 „ 27T> „ » 7 „ Congenital hip 1 , ^.^ dislocation 1 5 „ Deformity of the knee 3 „ Flat-foot „ 1 „ 14-3 1 ,, Wry-neck „ 1 „ 14'3 1 14 3 Fig, 2.—Single Monster with Amniotic Bands and Deformities attributable to want of Liquor Amnii. Secondary congenital deformities are such as can be traced to mechanical causes, or to the effects of intra- uterine disease. Among the causes of abnormal intra-uterine pressure during gestation some stand out prominently. Such are:— (1) a small amnion, or, what amounts to the same thing, a deficient amount of amniotic^fluid ; (2) multiple pregnancies; and (3) myomata in the uterus. As a marked example of many deformities associated with a total absence of liquor SECONDARY CONGENITAL DEFORMITIES. 13 amnii the specimen shown in Fig. 2 may be adduced. It is preserved in the museum of St. Mary's Hospital. The short description I gave of it in the catalogue reads: ">37. A single monster, with total encephalocele, hare-lip, and cleft palate, spina bifida occulta, etc. The lower limbs are greatly deformed. The left testis was retained within the abdomen (Xo. 1277). The right had left the external ring, and been dis- placed outwards to the ant. sup. spine of the ilium. From a woman who had previously borne five well-formed children. In this case the liquor amnii was absent. 1891. The absence of liquor amnii in this case Flg-3--LeitH;ind i i • -i i < oi tne Specimen was ciearfy ascertained by Mr. H. S. Collier, shown in rig. 2. who was at the time obstetric officer and attended the labour. The amniotic and tegumental bands are referable to pressure of the amnion upon the skin and of the skin of the occiput upon that of the back. The flattened form of the left hand, Fig. 3, and the deformities of the lower limbs are also traceable to the same cause. In my opinion the same pressure of the amnion upon the embryonic head would ac- count for the failure of the formation of the bones of the skull and for the deformed condition of the brain, and also for difficulty in the closure of the medullary groove, and thus for the occurrence of spina bifida. The re- tention of one and ectopia of the other testis would also be explained by the pressure of the thighs upon the inguinal canals. Less extreme results of abnormal intra-uterine pressure are not uncom- mon. The infant shown in Fig. 4 was brought to me for treatment of congenital club-foot. When I first saw the patient at the age of six months the thumbs were firmly adducted into the palms and the forearms were abnormally curved with a forward concavity. About the middle of the forearms and legs there were depressed Fig. 4.—Infant with C genital Deformities. 14 ACQUIRIED DEFORMITIES. scar-like marks, one over the middle of each of the bones. The mother said that the birth was " very dry." The dependence of congenital club-foot upon intra-uterine pressure* has frequently been observed. An instance in which this mechanical factor in the production of double club-foot consisted in the umbilical cord being securely tied around the feet and ankles is shown in Fig. 5. Intra-uterine amputations, constriction furrows around limbs (Fig. 6), and numerous other congenital errors are at- tributable to a similar constric- tion by the umbilical cord or an amniotic band. Other deformities may be due to the normal intra-uterine pressure acting upon softened Intra-uterine fractures resulting in deformity may occur from injuries suffered by the mother during pregnancy. Achondroplasia and other foetal diseases account for a re- latively small number of congenital deformities. Deformities of Post-Natal Origin.— The variety of deformities that may be acquired after birth is very great, and the modes of production of such deformities are correspondingly varied. Some of these deformities follow immediately upon an injury such as a fracture or a dislocation, and are termed " primary"; others are of gradual production, and are termed " secondary." The physiological functions of the skeleton, muscles, and other parts of the locomotor apparatus of the body, as well as the pathological changes to which these parts are subject, have all to be borne in mind * See Parker and kShattock, "Congenital Club-Foot," 1887. Fig. 5.—Sketch of a Baby, born dead at full term, with the Umbilical Cord encircling both Feet. bones. Fig. 6. — Congenital Annular Constriction. (From Owen's "Surgical Diseases of Children.") PRESSURE DEFORMITIES. 15 when contemplating the origin of deformities. Many writers appear to dwell too exclusively upon the mechanical sources of deformity, others too exclusively upon the patho- logical loss of resisting power produced in the skeleton by disease. In every case the mechanical and the pathological factors must be duly weighed. Pressure Deformities.—The mechanical factors come into play most prominently in what, since the views of Volkmann and Hueter were published, have been termed pressure deformities. The normal growth of the skeleton, ligaments and muscles is determined by healthy nutrition in the first place, and by a certain range of movement, and in the case of the bones by the regular daily transmission of force in certain directions for certain periods, alternating with periods of rest. A bone, even in a healthy state, will become altered in form and internal structure if its normal range of function is limited in a given direction. As examples of this the various trade deform dies may be adduced. Many of these deformities are the result of the fixidion of a habihud attitude. Thus, in a person whose days are spent in carrying heavy weights upon the shoulders with the dorsal spine curved forwards, the attitude becomes fixed from modifications of growth in bones and ligaments; in other words, a trade kyphosis results. If heavy weights are habitually carried upon one shoulder, as in millers, the spine is curved laterally, and a trade scoliosis results. When the nature of the occupation is very severe, as in coal- heavers, the effects are more akin to those of traumata, and, as Arbuthnot Lane has pointed out, ankylosis of the cervical vertebras, and, in the lumbar region, spondylolisthesis may result. Bland Sutton has described similar effects in the dorsal and lumbar vertebra; of draught horses and in the cervical vertebne of draught oxen. If in addition to modification of function disease such as rickets or osteo- arthritis is present, the resulting deformities will be more severe. If any one posture is habitually assumed for a dispro- portionately long period of time whilst the parts concerned are bearing the weight of the body, this posture tends to become fixed in the same way as and for similar reasons lb' VESTIMENTARY DEFORMITIES. to those just referred to as trade deformities. Thus the common occurrence of flat-foot in bakers, cooks, apprentices, and others is explicable. In school children flat-foot, knock- knee, etc., are frequently deter- mined in the same way. In every case evidence of bone dis- ease must be carefully excluded before the conclusion is arrived at that the deformity is due solely to mechanical apart from pathological causes. The mode of origin of many cases of flat- foot and knock-knee has been indicated by Annandale, who has attributed it to the long daily assumption of what he has designated the "attitude of rest" shown in Fig. 7. In this posture the strain is on the ligaments on the inner side of the knee, ankle, and foot, in order to protect the muscles from excessive fatigue in long standing, and thus the growth of these ligaments is adapted to this mode of standing—they become elongated, and at the same time thickened. The danger of basing theories of deformity on anatomical re- searches alone is shown by the fact that many deformities were formerly referred to changes in ligaments as a primary cause where it is merely a secondary .effect. If the cause, that is the habitual posture, be not re- moved, alterations in the form of the bones and joints occur which fix the attitude, and permanent deformity results. In a similar way muscular fatigue or weakness may lead to scoliosis from the weight of the body being borne chiefly upon one leg for long periods together. Such is the " stand- at-ease " position, in which the pelvis is tilted laterally and Fig. 7.-The "Attitude of Rest. (From Hoffa, after Annandale.) VES TIM FN Ta \RY DEFORMITIES. 17 the spine is curved. Here, again, pathological processes must be considered, for such muscular weakness as is likely to cause the posture to be assumed is, in most cases, the outcome of a general state of malnutrition which affects the bones and ligaments, and renders them unduly soft. In other words, pressure deformities cannot be entirely separated from rachitic and other pathological groups. Deformities produced by the instinctive assumption of attitudes that can be maintained without muscular action are termed kuhitual pressure de- formities. To this group are allied deformities produced by unequal growth in length in the radius and ulna or the tibia and fibula, or inequalities in the length of the lower limbs or again, deformities due to scars resulting from injuries in early life that offer one-sided resistance to the growth of a member, and result in its assuming; an abnormal curve towards the side of abnormal resistance. These are the stidic deformities, a term which is often used to include also the habitual pressure deformities. Vestimentary Deformities.—Among pressure deformities those due to badly-fashioned clothing are among the com- monest. Narrowing of the thorax produced by tightly-fitting corsets, and hallux valgus and other deformities of the foot are familiar examples. The manner in which such defor- mities are brought about, i.e. by the prolonged and daily main- tenance of parts in one position and the adaptation by growth of bones, ligaments, etc., to that position, is quite analogous to the production of congenital deformities by direct pres- sure of the uterine walls upon the fietus owing to lack of amniotic fluid. There are several important deductions to be drawn from this class of deformities, and chief among them is this: that if by continued daily maintenance of a part in an abnormal position a permanent deformity can be produced by adaptive growth, so by patient maintenance of a deformed part in a corrected position a permanent cure of deformity may be effected. This principle is of great importance in orthopedic surgery. Contractures.—Deformities due primarily to shrinking of the soft parts are termed contractures, as distinguished from pressure deformities and from ankylosis, which is due to the union of two or more articular surfaces by interposed tissue, c 18 CONTRACTURES. so that movement is prevented between the bones con- cerned. A contracture by fixing a joint may in certain conditions lead to ankylosis by favouring the growth of connective tissue between the articular surfaces. This I have observed in the case of the ankle and tarsal bones of an cedematous limb that was fixed in splints for four years on account of an un- united fracture. Contrac- tures are named from the tissues primarily at fault: thus there are (1) dermato- genous, (2) desmogenous, (3) myogenous, (4) neurogenous, and (5)artltrogenous contrac- tures. Before passing to the con- sideration of the various forms of contracture, anky- losis, etc., it will be perhaps more profitable to pass in brief review some anatomical considerations and the patho- logical states that most fre- quently contribute to the onset of the pressure de- formities. Among the latter rickets and what, for want of a better name, is known as rheumatoid arthritis or osteo-arthritis are prominent. In connection with these, for purposes of diagnosis, certain conditions that do not strictly belong to the domain of surgery will require mention, if only to show the more clearly Avhere the services of the surgeon cease to be required. Fig. 8.—Diagram 1 ('presenting on an en- larged scale a Metacarpal Bone at Birth. The small central figure shows the same bone at an early period of intra-uterine life. The ingoing arrow marks the medullary artery, and is directed towards a star which marks the centre of growth in the bone. (Modified from Kassowitz.) CHANGE IN BONES DEFORMED IlY PRESSURE. 19 The Anatomical Changes produced in Bones Deformed as the Result of Pressure, etc.—The diagram, Fig. 8, will serve to indicate the complex mode of growth of a long bone,^ and as far as longitudinal growth is concerned it is sufficiently accurate, for it recalls the fact that the chief seat of longitudinal growth is at the extremities of the diaphysis where the latter abuts upon the epiphyseal cartilages, the "juxta-epiphyscal" region. At the same time the existence of a diffuse interstitial increase in all parts of the bone is not to be forgotten. It is important to consider the conditions of normal growth in bones. In clinical work some of these conditions may be learned by their absence. Thus, in cases of infantile paralysis the shortening of bones from retarded growth is often remarkable. In part this depends on defective circulation; in a large part also it is dependent upon the absence of function. That this is the case is shown by the increased growth of the bone that follows the application of a portable apparatus to a paralysed and pre- viously long disused limb. After such a limb has been used again for walking for some time the growth-rate improves and ceases to lag so much behind that of the healthy limbs. The effect of muscular exercise on the nutrition of bones is well known. Besides increasing the bone-circulation, it calls into play the mechanical function of the bones and in so far stimulates growth. Intermittent strain and pressure within physiological limits produces increased growth in bone as in other tissues. A third factor is the altered innervation. Volkmann* and Hueter explain certain static deformities by changes produced by pressure on the articular surfaces and the immediately adjacent bone. Thus Hueterf writes : " By the term 'joint-body' [Gclenkkorper] I mean the portion of cartilage, or, later in life, of bone that bears the articular surface, and hence gives to the joint its special functional form and arrangement"; and again ".lust as by the development and growth of the bones changes are produced in their * Richard von Volkmann, "Krankheiten dor Bewegungsorgane," in V. Pitha and Billroth's " Surgery," 1865-1872. t C. Hueter, " Klinik der Gclenkkrankhciten mit Einschluss dor Ortho- pa'dic," Leipsig, 187'i, pp. 14 and 19. 20 CHANGE IN BONES DEFORMED BY PRESSURE. articular extremities, so, again, impediments to growth affect directly the articular extremities of the bones, and may alter the form of the intracapsular articular surfaces." According to this view, the deformity resulted from decrease of growth on the side of the joint on which the pressure was increased above the normal amount, and from a corresponding increase of growth in the bones on the side of the joint at which pressure is diminished below the normal amount. That this view is not universally applicable becomes clear when the joint is examined in, say, an average case of genu valgum. The joint surfaces are found to be practically normal, the deformity lying principally in the dia- physes of the bones. The mathematician Culmann* showed that the pressure upon the joint-surfaces is small or even nil, and that the greatest pressure is felt in the centre of the shafts of the long bones. And this agrees with the fact that in the chief deformities the first and principal change of form is in the diaphysis ; the joint-surfaces are only secondarily changed. If, however, the same view be applied to the juxta-epiphyseal region, it will be seen to explain, in part, the change of form. In the case, again, of joints affected by severe osteo-arthritic changes, this view gives the best explanation of the deformities encountered. Thus, for example in dissecting the parts involved in a pathological dislocation of the hip due to osteo-arthritis, it is found that the upper part of the rim of the acetabulum has been flattened out and the head of the femur has been correspondingly changed. When, by pathological changes, the substance of the bone is softened so that pressure can obliterate the blood-vessels in the articulating surfaces of bones, this explanation of the resulting deformity holds good. Hermann Meyer,t to whom science is indebted for consulting Culmann and obtaining his views, pointed out that fully formed bone in normal conditions, possesses a definite internal structure, which in every part represents the lines of greatest pressure or traction, and is so * Culmann's researches are fully referred to in Wolff's work quoted below. + H. von Meyer, " Die Architectur der Spongiosa." Reichert and Du Bois Reymond's Archiv, 1867, p. 627. CHANGE IN BONES DEFORMED BY PRESSURE. 1\ arranged as to give the greatest resistance with the smallest amount of material. The neck of the femur and the cal- caneum were the bones examined by Meyer. His view was fully confirmed and shown to apply to all bones of the body. Julius Wolff* showed that when fractures united with angular deformity the architecture of the bone became altered to cor- respond with Meyer's law. Wolff further showed that when a primary deformity occurs from pathologi- cal changes in a bone, the alteration in architecture is not limited to the bones imme- diately con- cerned, but ex- tends to all those that are affected by the altered static condition. 1- '■ ~"A%:, >*;4-' *■*:t:i^ ■ 'A -LSSsajS Fig. 16.—Portions of three ribs at the junction of shaft and costal cartilages, The "beading" is more marked on the pleural than on the superficial surface, owing to the sinking in at the junction of cartilage and bone. Section has been made through one of the ribs, and it shows zones 1, 2, 3 similar to those shown in the humerus in Fig. 15. some time. To appreciate the kind of change that exists in rickets a normal bone may be compared with one that presents marked rickety enlargement, as shown in Figs. 14 and 15 respectively. The enlargement at the ends of the lono- bones is fully accounted for by the increase in amount of tissue at the epiphyseal line, and in a severe case like that from which the humerus, Fig. 15, was taken the greater part of the enlargement is found to consist of soft tissue; fine bony spicules can, however, be felt in the layer (3) by drawing the finger over the cut surface. On pressing upon the head of this humerus, the soft tissue RICKETS. 27 of the surface of the enlargement bulged forwards. The histological changes which lead to the formation of swellings at the junction of the ribs with the rib-cartilages, Fig. 16, are precisely similar to those observed at the juxta-epiphyseal regions of the humerus and other long bones. In severe rickets marked changes occur in the bone of periosteal formation. This is more porous than the normal bone in texture. In Fig. 15 the superficial layer of periosteal bone is somewhat more porous than is normal. Sometimes the change in the periosteal bone is more marked than in the epiphyseal line. When this is the case there is a great deficiency of lime in the periosteal bone. Much of it is osteoid tissue. Occasionally in rickets islands of hyaline cartilage are formed from the periosteum. In rickety animals the formation of subperiosteal osteoid tissue is often very marked. In membrane bones, such as those of the skull, changes occur similar to those described above in periosteal bone. This is especially noticeable at the sutures of the skull, where distinct thickenings from the formation of porous bone and osteoid tissue may arise. When this formation of bone extends over a considerable area of the skull, the latter has a resemblance to the nodes of congenital syphilis. The seat of rachitic deformity in any individual is deter- mined partly by the degree of pathological change in the different parts of the skeleton. In Fig. 15 the upper end of the shaft of the humerus is more extensively affected than the lower end. In the body of an infant aged one year and eight months, that I examined by the courtesy of my colleague, Dr. Leonard Guthrie, the rachitic changes at the costo-chrondral junctions were very pronounced, in the bones of the limbs they were but slight, whilst in the spine they Avere only just beginning and were confined to the lower lumbar vertebne. This child had suffered much from bronchitis and hence the ribs had been the seat of much motion and had felt the effects of atmospheric pres- sure, whilst the limbs and spine had been at rest in bed. Thus it may be inferred that the degree of rachitic change at any part will, in some measure, be proportionate to the amount of wear and tear of the part. With regard to 2S RICKETS. the pathological changes in other parts of the body the most important that I have found is a general increase of lymphoid tissue. This is marked in the bronchial and intestinal mucous membranes, in the liver, spleen, and lymphatic glands. The constancy with which post-nasal adenoid growths occur in rickets has suggested to me the probability that they are the expression of this same rachitic change. In other words, I believe that adenoid vege- tations are often a symptom of rickets, though I do not suggest that the same hyperplasia may not sometimes arise from other causes. The association of rickets with " adenoids " is practically important, for patients relieved of nasal obstruc- tion by removal of adenoids and enlarged tonsils usually require a course of medical treatment, and not infrequently deformities of the spine, thorax or limbs are present and demand orthop.edic management. Causation of Rickets.—The importance of diet in the causation of rickets cannot be over-estimated. The disease, it is true, is often observed in breast-fed infants, but the more marked cases are nearly always in children who have been brought up on artificial foods, which are less assimilable than the natural raw diet proper to infants up to the age of nine months. After this early age also the disease can be produced by errors of diet. The usual one consists of giving excess of starch and insufficient proteid and fat. Cheadle emphasises the importance of giving suffi- cient fat, and the value of cod-liver oil proves the necessity for this. Systematic sterilisation of milk as a preventive of tuberculosis plays a part in the produc- tion of rickets. That other factors besides diet contribute to the production of rickets is well known. Good hygiene is required as well as good food for the prevention and in the treatment of rickets. Another factor, namely, heredity, is, in my opinion, undoubtedly present in a fair number of cases and, as in other pathological conditions, must be regarded as a predisposing cause. The period of life at which rickets becomes pronounced is usually the first few months after birth, and not many cases develop after the age of two years. In a few in- stances the onset of the disease has appeared to be as late RICKETS. 29 as seven or eight years. Another period of life at which skeletal deformities frequently arise is at the approach of puberty. These deformities are attributable in part to mus- cular weakness, but there is usually, in addition, a weak- ness of bone, a condition termed rickets of adolescence. Rachitis Adolescentium.—This term is used somewhat vaguely. Distinction should be made between three con- ditions : (1) Persistence of rickets from infancy into adolescence; (2) recrudescence of rickets during adoles- cence after an interval of freedom from the disease; (3) rickets appearing for the first time during adolescence. It is not uncommon to find among those who apply for treatment of deformities children of ten to twelve years who have every symptom of rickets : tumid abdomen, swollen epiphyses, disordered digestion, muscular weak- ness, etc. In some of these either a continuous history of rickets from infancy or a period of rickets during infancy followed by a period of comparative health can be obtained. In another class of cases there is no history of infantile rickets, but during adolescence osseous and muscular weak- ness, accompanied by amentia and the occurrence of various deformities. As a typical instance of the latter type of rickets of adolescence, the following case may be briefly noticed:— A girl, I.V., of plump and well-nourished appearance, aged ten years. Always strong and active as a child. No traces of infantile rickets. Brought to the City Orthopaedic Hospital for pain in the left hip and knee. She walked with a distinct limp. On examination distinct but moderate beading of the ribs and enlargement of the ends of the long bones was found. There was also fairly well-marked lateral curvature, evidently of recent date. All these symptoms appeared to have developed in two mouths. The patient was slightly anamiic, and her respiration was marked by an occasional deep inspiration followed by a sighing expiration. No sign of lung or other disease was present. The patient was growing rapidly in stature. Under treatment the anamiia, the enlargement of the ribs, and the pains in the limbs disappeared. Mr. Clement Lucas * has observed cyclical albuminuria and a sexual neurosis in this class of case. As far as the rickets is concerned, these two symptoms would appear to me to be accidental concomitants, for in a marked case of * Lancet, vol. i., 1883, p. 993 ; Brit. Med. Journ., i., 1SS1, p. S52. 30 CONGENITAL RICKETS. persistent rickets in a girl aged ten years I found the urine taken at different periods of the day to be free from albumen. Albuminuria and neuroses are more commonly observed in rheumatoid arthritis, which is not unknown in child- hood and adolescence and, by giving rise to flat-foot and other pressure deformities, may easily be mistaken for rickets. Congenital Rickets.—Belief in the occurrence of intra- uterine rickets has to a large extent been lost in Great Britain owing to the fact that at least two other conditions— cretinism and achondroplasia—quite distinct from rickets, had been mistaken for this disease. Yet Kassowitz, in one of the most recent (LSNl) and most thorough investigations of the subject, says :—" But still it is not, I believe, sufficiently known that in the great majority of cases rickets begins in a very early period of intra-uterine development. Most authors still make the error of believing congenital rickets to be a rare condition, whilst, according to my experience, Fig. lT.^Dr. Railton's Case of Congenital Deformity. COaNGENITAL RICKETS. 31 this is by no means the case." This opinion is based on the careful histological examination of new-born children. I have carefully examined the bodies of many stillborn infants, but I have never found any macroscopic rachitic changes in the bones. A striking case of congenital deformity has been published by Dr. T. C. Railton, and by his courtesy and that of the editor of the British Medical Jourmd I am permitted to reproduce (Fig. 17), a photograph of the patient. Dr. Railton* gave the following history of the case:— A. W., aged seven months, was brought to the Clinical Hospital on April 24th, 18<)3, on account of certain deformities of the limbs, which are shown in the accompanying photograph [Fig. 17J. Personal History—Rev mother stated that these deformities were in existence at the time of her birth, and that the peculiar softness of the back of the head, to be presently mentioned, was remarked about the same time. The child had always sweated a great deal, and her limbs had been noticed to be tender when they were handled, especially the left arm. These points were, of course, carefully inquired into, and, apart from the evidence of the bones themselves, which one could hardly imagine to have become so completely and universally deformed had the rickets commenced after birth, there remained no reasonable doubt that the child had come into the world with the disease fully developed. She had been brought up at the breast until she was two months old, and subsequently she had been fed upon condensed milk. She had not cut any teeth. Family History.—There was no family history pointing to syphilis ; the mother certainly had miscarried once (after the birth of her second living child), but none of her children had shown any symptoms either of snuffles or rash. She herself had suffered from rickets in childhood, and as a consequence had bow legs and a somewhat contracted pelvis. Of the four other children of the family, I had the opportunity of examining one, aged two-and-a-half years, and found beading of the ribs, enlarged epiphyses of the radii, slightly bowed tibiae, but no signs of syphilis. The mother had not been in ill health during the time she was carrying the patient. Cemdifion on Admission.—On her admission the following notes of the child's condition were taken :—She has an intelligent face, with good though very thin features, the sucking pads showing distinctly. Her height is eighteen inches instead of twenty-four, her weight six pounds instead of nineteen pounds. Her limbs and body, except the abdomen, are emaciated. There are no blood extravasations and no indications of cachexia. The forehead is rather bossy, but the vertex of the skull is not flattened. The anterior and posterior fontanelles * T. C. Railton, Brit. Med. Jowrn., June 16, 1894. 32 ACHONDROPLASIA. and the sagittal suture are widely open, and there are small lateral fontanelles at the inferior angles of the parietal bones. The mem- branous part of the occipital bone is quite unossified, so that it feels soft and yielding wherever pressure is applied. The neck is thin but not short, and there are no fatty swellings. The thyroid gland can be felt. The chest has the sternum thrown forwards, and there are well- marked beads at the junction of the ribs with their cartilages, and also smaller beads behind in the region of the angles. In front a deep transverse groove passes outwards and downwards from the ensiform cartilage. The abdomen is globular, and shows no enlargement of either liver or spleen. The patient moves both upper and lower ex- tremities perfectly well. The arms are shortened by the extreme distortion of the humeri, so that the tips of the fingers barely reach the junction of the upper and middle third of the thighs. At the upper end of each humerus there is an abrupt bend, with the convexity turned towards the axilla, and the corresponding receding angle is visible on the outer side of the arm below the acromion process. There is no thickening of the shafts of the humeri or of any other bone. In each forearm there is a curvature of the radius and ulna, with the concavity forwards, especially marked on the left side. There is little or no enlargement of any epiphysis in the upper extremities. The hands are small, and have long, delicate, tapering fingers. The lower ex- tremities are greatly shortened by their various curvatures, and are habitually folded in tailor fashion, much the same, I imagine, as they were in the womb. The lower epiphyses of the femora are enlarged. The femora themselves are much curved, with the convexity outwards. In the middle of the left femur there is a green-stick fracture, bending the lower half forwards and causing a projection behind and externally. The tibiaj are the most deformed bones in the body, the upper two- thirds in each leg being much curved, with the convexity forwards, while at the junction of the lower with the middle third, there is an abrupt bend backwards, leaving a strongly projecting angle in front. The lower third on each side has two curves, so that there is a con- vexity both forwards and outwards. On the left side this double curvature is exceedingly abrupt. The feet are small and well formed. After-history and Treatment.—After admission it was observed that the child perspired profusely during sleep, so that the sweat stood in beads upon her forehead. She showed great tenderness in the limbs when they were handled. The child improved under treatment but after leaving hospital died of broncho-pneumonia. The deformity of the lower limbs in this case recalls that seen in some instances of achondroplasia, and in all probability rickets was super-added after birth. Achondroplasia is characterised by deformity of the foetal skeleton, affecting the bones of the limbs and the ACHONDROPLASIA. base of the skull. The membrane bones of the skull and the clavicles are normal. The long bones are shortened and thickened, hard and compact. By the kind permission of the Coun- cil of the (Tinical Society of London and Dr. Arch- ibald E. Garrod, I am able to give an illustra- tion of a typical case (Fig. 18). Porak* is of opinion that achondroplasia un- dergoes its full evolution during the first half of pregnancy, whilst rickets develops during the se- cond half of pregnancy; and is in full activity at the time of birth. The accompanying sketch (Fig. 19), of the bones from a stillborn infant affected with achondroplasia is bor- rowed from Porak's me- moir. The absence of cartilage inthebones is a strikingfeature. Another condition not in- frequently mistaken for rickets is a dystrophy, not as yet definitely named. The sub- jects of it are generally of stunted growth and their joints possess remarkable mob- ility. The fingers, which tend to have a square shape, can sometimes be bent back almost Fig. 18.- - Achondroplasia in a Girl aged six years. (Dr. Archibald Garrod's Case.) Fig. 19.—Bones of Lower Limbs of a Still-born Child, the subject of Achon- droplasia. (After PoruV.) * Porak, " L'Achondroplasii Gynecologie, 1890. Nouvcllcs Archives d'Ohstetrique et de 34 SYPHILIS. to touch the dorsum of the hand. In some of these cases kyphosis or contractures of the knee- and ankle-joints, in others genu valgum may be present. Many such patients are intelligent, other are idiots of the Mongolian type. In a case now under my care there was plain evidence of con- genital syphilis. In these cases, which appear to have nothing to do with cretinism, not much can be promised in the way of improvement. Syphilis.—In early infancy slight congenital specific enlargement involving the juxta-epiphyseal regions of several bones may mislead the observer into mistaking the condition for rickets. More pronounced syphilitic inflammation in the same regions will be readily distinguishable by the accompanying " pseudo-paralysis." Parrot confused the bone lesions of congenital syphilis with those of rickets. In orthopaedic practice, as in other branches of medicine, the observer should be ever on the watch for evidences of syphilis, especially in aberrant cases. The anteriorly-bowed tibise that not infrequently occur in syphilitic children may be distinguished from those of rickets by their form and concomitant symptoms and by the thickening of the bone that occurs in the former condition. Tertiary syphilis has been recognised as the cause of some cases of spinal disease and deformity. Syphilitic affections of joints are not always of the rapidly destructive character made familiar by pathological preparations. In some cases of chronic joint disability that have resisted other treatment, I have found a thorough course of iodide completely restore the part to its normal condition. Fragilitas Ossium leads to deformity from the multiple fractures that readily occur. In a case that recently came into my charge—a boy aged ten and a half months—the symptoms of both syphilis and rickets were combined, lending some support to the suggestion made by Kassowitz, that congenital syphilis may in some cases be provocative of rickets by producing disturbance of nutrition. Osteitis Deformans, osteomalacia, and other diseases of bones are usually of a progressive character, and offer but little scope to the surgeon. RHEUMATOID ARTHRITIS. 35 Rheumatoid Arthritis.—Rheumatoid arthritis, or osteo- arthritis, is no more a joint disease than rickets is a bone disease. Indeed, in many ways these two affections resemble each other. The influence of heredity is very marked, and although the grosser symptoms of the disease do not, as a rule, show themselves before adult life, cases of typical rheumatoid arthritis are met with among infants and children. In osteo-arthritis, as in rickets, the nutrition of the whole of the bodj7 is deranged. The digestion is often seriously affected. The nervous organs are so far deranged that many observers attribute the articular changes to trophic nerve influence. Neuralgias, neurasthenia, etc., are of common occurrence. Sometimes severe peripheral neuritis is observed, and may lead to serious deformity. Thus, in a case of rheumatoid arthritis that Dr. G. A. Sutherland brought to my notice complete paralysis of the tibiales and calf-muscles leading to a typical talipes calcaneo-valgus developed in fourteen days in a woman aged seventy-two. Vasomotor disturbances, such as " dead fingers" and Raynaud's disease, are not infrequently seen. Some desmo- genic contractures, e.g. Dupuytren's contracture, are at times part of a general rheumatoid arthritis. With regard to the joints the chief changes are as follow :—The synovial membrane secretes an excess of viscid synovia. When this is in very great quantity the membrane is bulged out, and where the capsule of the joint is weakest this bulging is greatest, and may take the form of hernial protrusions. In many cases there is hyperplasia of the connective tissue of the synovial membrane resulting in the formation of numberless pear-shaped projections (see Fig. 20,1), which remind the observer of the warty condition often seen in the skin about some chronic ulcers of the leg. These hyperplastic synovial villi sometimes become sepa- rated from the membrane from which they spring, and so constitute one variety of loose bodies which occur in joints. They may become cartilaginous, and the cartilage in them may calcify. It occasionally happens that in dissecting a joint after death dozens of these calcified loose bodies fall out. Fig. 20.—The Lower End of a Femur with the Patella, showing changes due to Osteo-arthritis. 1, part of the synovial membrane with fibrous projections; 2, cartilage over the patella showing the velvety condition ; 3, part of the collar of ecchondrosis and exostosis growing beyond the margin of the articular cartilage ; 4, part of the articular surface of the femur denuded of cartilage by friction. (St. Mary's Hospital Museum, No. 460.) where the cartilage is exposed to friction the surface of the cartilage becomes fissured, and some of the cells escape into the joint-cavity. This gives the cartilage a velvety appearance (Fig. 20, 4). This velvety cartilage is readily worn away, exposing the bone, as at 2 (Fig. 20). The exposed bone, if the joint is much used, becomes grooved RHEUMATOID ARTERITIS. 37 from friction, and assumes a peculiarly increased density, which gives it an appearance like the glaze on porcelain. At its Fig. 21.—Section at the Margin of the Articular Surface of a First Metatarsal Bone from a case of Osteo-arthritis combined with Gout. 1, articular cartilage, the cells of which are pr .lifeiating, and the superficial layers of which are undergoing cleavage; 2, hyperplastic tissue of periosteal origin, consist- ing of areas of dense fibroid tissue surrounded by cells, some of which are multi- nucleated. Thesa cells are supported by connective tissue continuous with the periosteum and containing newly formed capillaries. 3, commencing focus of in. flammatory new tissue resembling tho.-,e described under 2; 4, fibrous tissue derived from the synovial membrane growing for a short distance over the cartilage; 5, stellate cluster of urate of soda crystals in the articular cartilage ; 6, cleft in the cartilage ; 7, normal fatty marrow; S, lymphoid marrow replacing the original fatty marrow; D (in the bone), focus of the newly formed fibro-cellular tissue resembling those forming ''lip" at 2; 10, periosteum. In this instance the "lip"of nuw tissue consists neither of bone nor of caitilage, but resembles the inflammatory foci seen around gouty " tophi " in the soft tissues. margin, where it is not exposed to friction, the cartilage from the inflammatory overgrowth forms a collar of ecchon- drosis. Similar changes taking place in the bone beyond the cartilage there results a growth of bone (exostosis), on which that formed of cartilage rests. The histological structure in a case of osteo-arthritis combined with gout is shown in Fig. 21. 38 CHRONIC DRY ULCERATIVE ARTHRITIS. The "lipping" of the cartilages, as the formation of ecchondro-exostoses is commonly termed, is in some cases extreme ; a large collar turned away from the articular surface, and consisting chiefly of bone, then exists. Now and again, in osteo-arthritis, the denuded bony surfaces, instead of becoming indurated (porcellanous), are rarefied and worn away progressively, so that in this way deformity arises either 'by allowing displacement ("dislocation by deformation"), or by interlocking ("ankylosis by deforma- tion "). Neither fibrous nor osseous ankylosis occurs in di- arthrodial joints in osteo-arthritis, but the bodies of contiguous vertebra may become joined together by bridges of bone. The changes in the vertebra? are known as spondylitis deformans. The histological changes of osteo-arthritis of infants include besides the changes in the joints excsesive proliferation at the epiphyseal lines (osteo-chondritis). Chronic Dry Ulcerative Arthritis is a term applied to conditions similar to osteo-arthritis, but marked anatomically rather by degenerative than proliferative processes in the articular cartilages, the matrix of which becomes fibril- lated and fissured, whilst the proliferation is wanting. It is met with chiefly in the malum coxcb senile, and is regarded as a senile disturbance of nutrition. It is not clinically separable from osteo-arthritis. Chronic Traumatic Arthritis Deformans. — Arthritis deformans may result from injury to a joint. Thus, after a slight injury to the hip-joint, deformity may gradually be produced, and in such cases medical men have been wrongly suspected of having overlooked a fracture. Arbuthnot Lane* regards such a condition as simply traumatic. The close study of many such cases has con- vinced me that this view is untenable. After a period of rest in a simple traumatic case exercise of the joint improves the condition of the part instead of producing the changes that are correctly described by Lane in the hip-joint:— If such, a joint be examined after death, the head of the femur and the acetabulum are found to be completely altered in form and character. The opposing surfaces of the innominate bone and femur are rubbed down, sclerosed, and eburnated, while around these * Arbuthnot Lane, il Clinical Lectures," 1897, p. 70. CHRONIC TRaIUMATIC ARTHRITIS DEFORMANS. 39 eburnated surfaces there is an abundant deposit of more or less dense bone, whose obvious function is to compensate for the altering direction in which force is transmitted through the joint, and to render it as secure as possible under the circumstances. The capsule has become thin and lax, and has ceased to perform most of its normal functions. The synovial membrane in the joint is bulky, and contains an ab- normal amount of synovia. The causation of the several changes here described is quite obvious. . . . The opposing surfaces of articular cartilage have been bruised sufficiently to interfere with their vitality, and there being no means of replacing the damaged tissue it is removed. The habitual transmission of force through the damaged joint results in the progressive destruction of the remainder of the articular cartilage, in the exposure, eburnation, and the progressive gradual destruction of the subjacent articular lamella of bone. These changes are followed by the others already described, the factors determining their evolution being solely mechanical. In several cases of the kind that I have carefully watched I have been able to find the general symptoms of osteo- arthritis, though there were no pronounced anatomical changes in any save the injured joint. On the other hand, in cases where, owing to traumatism of joints, fibrous ankylosis has occurred, it is familiar to all that after breaking down the adhesions movement forms the most important factor in the restoration of the joint to its normal form. It is therefore, in my opinion, probable that in all cases of deforming traumatic arthritis the trauma only serves to awaken into activity a local expression of a general pathological condition. The essential nature of osteo-arthritis is disputed. The majority of observers regard it as an auto-intoxication. Recently Bannatyne* and Wohlmann have advanced the view that the more acute forms are due to infection, the more chronic to degeneration. In the course of making over 2,000 autopsies, I have frequently studied the pathological changes in this condition, which I regard as essentially a chronic inflammatory process, associated with degeneration in varying degree. Atheroma of arteries is often associated with the joint changes. The histological lesions of osteo- arthritis present both inflammatory and degenerative changes. The former are shown by proliferation of con- nective-tissue elements. (See Fig. 21.) * Bannatyne, " Rheumatoid Arthritis," 1898. 4-o RHEUMATOID ARTHRITIS. The effect of these anatomical changes depends upon their deo-ree In the more advanced stages dislocation or inter- locking may occur. The latter condition has been termed <" ankylosis by deformation" (Volkmann). It closely resembles the effects of tabetic arthritis (Charcot's disease). Slight degrees of stiffness of joints are common in osteo-arthritis, and forcible passive movement is then sometimes advisable. This operation is sometimes spoken of as " breaking down adhesions," though it is to be remembered that true intra- articular adhesions do not form in osteo-arthritis. The resistance to movement is due to irregularities in the articu- lating surfaces and changes in the peri-articular structures. The course of rheumatoid arthritis is chronic, and tends to be progressive, with intervals of remission of symptoms. By proper diet and medical treatment a great deal can be done to alleviate the sufferings of the patient, and especially in the young and neurasthenic diet is of the first importance. The most difficult cases, as far as treatment is concerned, are those in which there is chronic effusion into the joints. As an instance, I may record the following case:— Mrs. S., a Jewess, aged fifty-nine, came to the North-West London Hospital with great fluid swellings in both elbow-joints, of three years' duration ; and pain and creaking in the knee-joints. At the age of thirty-six, in spring, about six months after a baby was born, she was seized with a " rheumatic " attack in the right knee. The attack lasted some months. Towards the end the arms became affected. The doctor took the temperature, and found that there was some fever. Three years later she was attacked in the arms, but did not feel feverish. She was ill for several weeks. An acquaintance recom- mended two ounces of mustard in half a pint of gin. Of this formidable remedy the patient took a wine glass twice a day for ten days. At the end of that time she felt well, and was free from pain for nearly twenty years. Her next attack occurred at the age of fifty-six. She had then been in London some years. The knees and arms were affected, the knees more severely than the arms. She had fourteen Turkish baths, and was relieved a little. The doctor ordered her cod- liver oil, maltine, and iron and quinine. Since this attack, which was eleven years ago, the patient has never been free from pain. During the last three and a half years the disease has progressed, chiefly in the elbows. The jaw has been stiff for three and a half years. A couple of sulphur baths were taken at ---- ■----Hospital (London) but no good was obtained. The patient then tried the hot-air bath RHE UMA TO ID A R THRITIS. 41 six times ; no relief at all. She could not say that any kind of weather makes the condition better or worse. At----Hospital (London) blistering was tried three times ; it gave no relief. Iodine painting seemed to relieve, but caused eczema. Hutton (bone-setter) gave black liniment with CHC13 in it; no relief. Rubbed by a nurse every day for fourteen days, Sundays excepted ; this made left elbow swell to double former size, and increased the pain. Went to Bath in March, 1894 ; remained four weeks ; first fourteen days had hot baths. This did her no good. Went into a Homoeopathic Hospital, where she had " white powders" and six vapour baths. This did no good. She had no Fiiis. 22, 23.—Greville Apparatus for localised Hot-air Bath to Thighs. previous illness. Has pain in chest ; (?) indigestion; no shortness of breath or swelling of legs. Neither mother nor father had rheumatism. She is the only survivor of eleven children, the rest died in infancy and childhood. She has four children ; one has asthma and bronchitis, one healthy until two or three years ago, when he had slight stiffness in right arm. At one 42 RHEUMATOID ARTHRITIS. time the patient had severe neuralgia right side of face ; for this, four teeth were taken out without relief. The pain yielded to medicine. Now she has pain about the affected joints, cramp in calves and feet. I have given the chief points in the history of this case in order to emphasise the great difficulty there is in the treatment of obstinate rheumatoid arthritis. The surgical bearings of rheumatoid arthritis are many. Spondylitis deformans, when severe and painful, may require the adaptation of a spinal support for the prevention of deformity and the arrest of pain. Arthritis of the hip and knee are also much benefited by rest, and not infrequently require supporting apparatus. When joints are stiff and contracted forcible passive movement may be called for. This proceeding is made much easier and less painful to the patient b}^ the use of the hot-air bath. The best form of this bath, where there is an available electric supply, is the " Greville," the value of which was demonstrated to me by Mr. William Armstrong, of Buxton. The heat is generated by electricity, and hence it has not the drawback of apparatus heated by gas. The temperature is regulated with great precision, and the appa- ratus for various parts of the body can be placed on the patient's bed. In Figs. 22 and 23 the apparatus is designed for application of heat to the thighs. A temperature of from 300° to 340° F. * continued for about forty minutes is the most useful, and the local effect in the way of increasing the mobility of joints is very great. This method of treatment should only be employed under close medical supervision. Sometimes the pain in the neighbourhood of joints can be relieved by drilling the bone with antiseptic precautions. This simple procedure acts by relieving intra-osseous tension, as may be readily understood on noting the new inflam- matory tissue shown in the interior of the bone in Fig. 21. When obstinate effusion is present in one or two joints, aspiration, drainage, or even excision may be re quired. * Dr. A. P. Luff (Practitioner, February, 1899, p. 173) points out that this temperature as registered by the thermometer at the side of the bath i probably higher than that of the air close to the skin. RUE UMA TOID AR THRITIS. 43 There is no affection in which there is more scope for co-operation of physician and surgeon than in this. G. F. Still, in the "Transactions of the Royal Medico- Chirurgical Society, 1896," describes, as distinct from rheu- matoid arthritis, a joint affection met with in children before the second dentition. The disease may be defined as a chronic progressive enlargement of joints, associated with general enlargement of glands and enlargement of spleen. The onset is almost always before the second dentition ; ten out of twelve cases began before the age of six years, and of these eight began within the first three years of life ; the earliest was at fifteen months. Girls are more commonly affected than boys ; seven of the twelve cases were girls, five were boys. The onset is usually insidious ; the child, if old enough, complains of stiffness in one or more joints, which slowly become enlarged, and sub- sequently other joints become affected; but occasionally the onset is acute, with pyrexia and, it may be, with rigors. I wish to lay some stress on the character of the enlargement of the joints. It feels and looks more like general thickening of the tissues round the joint than a bony enlargement, and is correspondingly smooth and fusiform, with none of the bony irregularity of the rheumatoid arthritis of adults. The absence of osteophytic growth and of anything like bony lipping even after years have elapsed since the onset, is striking. There is, I believe, never any bony grating, although creaking, probably either of tendon or of cartilage, is frequently present. There is no redness or tenderness of the joints, except in very acute cases. The absence of pain is generally striking, but it may be present in slight degree, especially on movement. Limitation of movement, chiefly of extension, is almost always present ; the child may be completely bed- ridden owing to more or less rigid flexion of joints. The joints earliest affected were usually the knees, wrists, and those of the cervical spine ; the subsequent order of affection being ankles, elbows, and fingers. The sterno-clavicular joint was affected in two out of twelve cases; the temporo-maxillary in three. The affection is symmetrical. There is no tendency to suppuration nor to bony ankylosis. The muscles which move the diseased joints show early and marked wasting, which contrasts often strongly with the good nutrition of the rest of the body. The electrical reactions both to farad ism and galvanism were brisk in three cases tested, but not otherwise altered. Perhaps the most distinctive feature in these cases is the affection of the lymphatic glands. The enlargement is general, but affects primarily and chiefly those related to the joints affected. 44 RIIIEUMATOID ARTHRITIS. A typical example of the kind of case under consideration is now under my care. B. B., a girl, aged four, was brought to my out-patient department of the City Orthopaedic Hospital suffering from the form of joint disease described by Still. There was no liquid effusion into the large joints, but enlargement of the ends of the long bones and beading of the ribs, and a painful angular curvature of the spine in the upper dorsal region. The general condition was one of severe anaemia and prostration. She was admitted as in-patient under my colleague, Mr. John Poland, under whose treatment her condition improved geatly, so that she was able to leave t lie hospital. She now attends my out- patient department again. The anaemia has entirely disappeared, but the knees and ankles remain contracted and stiff, whilst there is great improvement in the deformity of the spine and the nodal swellings of the fingers and beading of ribs (see Fig. 24). Whether the condition is dis- tinct from rheumatoid arthritis is perhaps open to some doubt. One certainly sees in adults affected with undoubted rheumatoid arth- ritis similar ovoid swellings about the joints of the fingers, and also beading of the ribs is sometimes observed in older patients suffering from this affection; for example, in the case of a lady, aged thirty- five, sent to me by Sir William Broadbent for a painful condition of the right twelfth rib, which presented a swelling near its free extremity. There were also oval swellings at other osteo-chondral junctions and a general condition of anemia. The pain arising from the twelfth rib was so severe that the patient asked to have it removed by operation. Seeing however, that the affection was only one of several indica- tions of a general condition, I advised the use of a small abdominal belt specially designed to steady the rib and Fig. 24.-Sketch of B. B., aged four years, suffering from Rheu- matoid Arthritis. (From a Photograph.) RHEUMATOID ARTHRITIS. 45 protect the swelling—a plan that proved completely suc- cessful. Commenting upon Dr. Still's account, Dr. Bannatyne observes :— The pure rheumatoid aithritis in children he considers to be characterised by bony thickening and lipping about the joints, and by the presence of bony grating and the absence of enlargement of the glands and spleen. Now, his description of the first class corresponds to my description of what we see in adults in the acute form of the disease, and also his second with the chronic form. To me he appears to be considering just the self-same forms of the disease. I do not believe that the first form he describes as peculiar to children differs in any respect from the acute form in adults except in the splenic enlarge- ment, which may have been an accidental occurrence, so common in children; but, of course, the question still remains, "Are these two diseases both in adults and in children ]" Dr. Still's idea of what is pure rheumatoid arthritis is the popular one—that there must be bony enlargement. This, I would strongly urge on my readers, is not the case ; at least, not in the forms we most frequently see it in in Bath.* Two other conditions that may give rise to contracture or ankylosis are to be distinguished from rheumatoid arthritis These are true rheumatism and the peculiar affection termed " chronic rheumatic arthritis." Rheumatism or Rheumatic Polyarthritis, when acute, is associated Avith the general constitutional symptoms, the full consideration of which does not come within the scope of this work. Several joints become affected one after the other. The synovial effusion is marked by great pain and tenderness, and is accompanied by some para-arthritis. The distribution of rheumatic joint-effusions recalls those of pyaemia. And possibly the joint affections, which are not infrequently observed after the injection of antitoxic serum, throw some light on the nature of rheumatism, which may be the result of an intoxication. The tendency of acute rheumatism to simulate other affections and to become sub- acute or chronic, renders rheumatic affections of importance to the surgeon. In doubtful cases subcutaneous rheumatic nodules on the scalp, about the elbows, wrists, patella and ankles should be looked for. Chronic Ankylosing Arthritis, or Chronic Rheumatic * G. A. Bannatyne, " Kheumatoid Arthritis," 1898, p. 91. 46 GOUT. Polyarthritis (arthritis panperum). — This affection is marked by the joints of the body becoming ankylosed one after another. The disease may follow an attack of acute polyarticular rheumatism, or it may begin insidiously. Once begun it continues for the rest of the patient's life. The changes in the joint have some resemblance to those of osteo-arthritis, but differ in that the changes in the cartilage are accompanied by less pronounced cell-proliferation. ^ The cartilages become villous and converted into fibroid tissue, which Is replaced by vascular fibrous tissue, the blood-vessels of which are derived partly from the neighbouring synovial membrane, partly from the marrow-spaces of the underlying bone. Fibrous adhesions form between the articular surfaces. The remains of the articular cartilages become converted into osseous or osteoid tissue. The fibrous ankylosis once begun k Fig. 25.—Section through a finger extensively disorganised by gout. The inter- phalangeal joints and their cartilages have been destroyed. Collections of urate of soda (tophi) are present in the ends of the bones and in the peri- articular and subcutaneous tissues. becomes more extensive, and finally the fibrous adhesions become converted into bone. In old-standing cases this remarkable disease may result in bony ankylosis of every joint in the body. But little can be done to alleviate the disabilities of the patient in this condition. Gout. —■ Of the anatomical changes in gout the most characteristic is the presence of urate of soda in the tissues. On opening a joint affected by gout, the articular surface may appear as if covered with a coat of white paint. DERMATOGENOUS CONTRACTURES. 47 Without further marked change there may be, in addition, all the changes described under osteo - arthritis. Deposits of urate of soda in the soft parts (tophi) are some- times very extensive, as in the instance shown in Fig. 25. On histological examination, such collections are found to be deposited in degenerated tissue, and to be surrounded by a zone of inflammatory tissue,* exactly resembling that seen in osteo-arthritis (see Fig. 21). Whether or not there is any relationship between gout and osteo-arthritis is disputed.t Even at the present time very different views are held—e.g. Sir Alfred Garrod (1859) described the condition as distinct from gout and rheu- matism, thus agreeing with Heberden (1804), whilst Mr. Jonathan Hutchinson holds that rheumatoid arthritis is the inherited form of gout, In the course of making over 2,000 autopsies, I have very frequently observed the typical lesions of osteo-arthritis combined with gout, so that the two conditions have become closely associated in my mind. From a practical point of view, it is important for every surgeon to be on the watch for evidences of gout and granular kidney, with which it is often associated. Myogenous and desmogenous contractures are of equally frequent occurrence both in gout and rheumatoid arthritis— e.g. Dupuytren's contraction of the palmar fascia may occur in either condition. The arthrogenous deformities due to gout are similar in kind to those met with in osteo-arthritis, but they tend to be more severe. In gouty deformed hands the "seal-fin" type familiar in rheumatoid arthritis is often recognisable. Grave disorganisation, such as has been shown in Fig. 25, may demand amputation. Rickets predisposes chiefly to pressure deformities, osteo- arthritis to both pressure deformities and contractures. The remaining conditions that more commonly cause contractures may now be briefly reviewed. Dermatogenous Contractures are such as are due to cicatricial changes in the skm—e.g. from burns, ulcers, etc. * See a paper by Berkart, Brit. Med. Journal, vol. L, 1S9.*>. t A historical account, by Archibald E. Garrod, " Twentieth Century Practice of Medicine," vol. ii., 1895, may be consulted. 48 MYOGENOUS CONTRACTURES. A large scar at the side of the neck may cause a dermato- genous wry-neck; a scar about the ankle may determine a dermatogenous club-foot. Desmogenous Contractures result from shrinking of fascia— re. Com- pcnsatory muscular contracture is seen in some persons who, to overcome the disability of a short leg, hold the corresponding foot habitually in the position of club-foot. Symptomatic muscular contractures depend upon organic changes in the muscles. In the so-called ': muscular rheu- matism " the pathological condition and the contracture are usually of a temporary character. Such a condition causes acute torticollis, lumbago, and other local painful conditions. In applying massage to such muscles, knot-like, tender points are felt. When the condition is more chronic, the knot-like swellings are larger, and permanent contracture may remain. These conditions are probably more nearly related to "cramp" and litlnemia than to articular rheumatism. Inflammatory Muscular Contractures.—Muscles involved in suppurative, tubercular, or syphilitic inflammation are partially destroyed, and undergo secondary cicatricial con- traction of the fibrous tissue which takes the place of the destroyed muscular tissue. In this way, contracture of a finger after whitlow and contracture of a psoas muscle in tuberculosis of the spine become permanent. Fibrous Myositis is a condition in which, as the result of inflammation akin to the chronic form of "rheumatic myositis," there is a new formation of interstitial fibrous tissue, either diffuse or insulated. Ossifying Myositis.—This rare condition in its earlier phases may readily lead to errors in practice. It usually ISCHaEMIC MYOSITIS. 49 commences before or about puberty, and is rather more common in males than in females. Inflammatory areas following the long axis of the fibres are succeeded by the formation of indurated bands in the substance of the muscle. The indurated areas finally become ossified. The muscles throughout the body become affected in turn. As a diagnostic feature shortening of the thumbs and great toes is to be remembered. The condition is very slowly pro- gressive. Ischsemic Myositis is the result of prolonged amemia of muscle. It is commonly produced by tight bandaging or by swelling of a limb after splints have been applied. I have seen it follow ligature of the popliteal artery and vein. The deprivation of blood leads first to degeneration of muscle fibres, and this is followed by inflammatory infiltration, and subsequent induration and shrinking of the affected muscles. As this condition is of great practical importance, a typical example may be adduced.* A boy, aged six years, was brought to me with a history that six weeks previously he had sustained a fracture at the lower end of the humerus that had been put up in splints and reset three days later. There had been much swelling of the elbow-joint, and for the first two or three weeks the boy had screamed if any of his fingers were touched, and he Fig. 26.—Ischoemic Contracture of the Hand. was incapable of moving them. The swelling about the joint subsided in about five weeks, but left the joint immobile from adhesions that were broken down under chloroform. When I first examined the patient, there was no reaction in any of the muscles of the forearm to either galvanic or faradic currents, but after about a week's treatment with weak galvanism and massage, slight reaction was noticed. This was followed by reaction in some of the fiexors of the wrist, but the * For notes in this case I am indebted to .Mr. Stroud Hosford, House-Surgeon at the North-West London Hospital, 1897- E 50 NEUROGENOUS CONTRACTURES. flex. sub. digit., the pron. rad. teres, and the pron. quadrat, never reacted at all. The supinator longus always reacted. Sensation returned coincidently with the muscle reactions. Under this treat- ment he got back considerable power in the forearm, but the thumb muscles were very obstinate. For some weeks he had fair use of the arm and hand, for he could grasp a knife or fork and even use dumb-bells. The whole arm then began to waste and stiffen, and became much more pronated, though sensation was perfect. A tendency to clawing of the hand was observed about four months after the original accident, and it increased in spite of regular massage. The evidence in this case pointed to secondary shrinking of muscle. As soon as the deformity, which is represented in Fio\ 26, had ceased to increase, I divided the flexor tendons above the wrist through a short longitudinal incision. This operation removed the whole of the deformity. The various affections regarded as progressive myopathies —(1) pseudo-hypertrophic paralysis ; (2) hereditary (or Erb's) muscular atrophy; and (3) the various forms of progressive muscular dystrophy may occasion deformities such as club- foot, and, in exceptional cases, orthopaedic surgical measures may give temporary relief; but the full consideration of these conditions belongs to works devoted to the diseases of nerves. Neurogenous Contractures. — Contractures which have their origin in abnormal conditions of the nerves fall into three different categories—(1) reflex; (2) spastic ; and (3) paralytic. Reflex Contractures.—The commonest conditions of this kind are contractures due to chronic joint-affections—e.g. rheumatoid arthritis. In tubercular and other forms of arthritis, reflex contracture also plays a large part in the production of deformity. In some cases of spasmodic flat-foot the painful contraction of the muscles is also of a reflex character. Spastic Contractures are due in most cases to central nerve-lesions. Brain-lesions, whether haemorrhage, syphilis, tumours, multiple sclerosis, or what not, are all frequently characterised by spastic conditions of the muscles, of which the innervation is disturbed. Cord-lesions, whether meningitis or myelitis, also produce the same effects. It is in spastic PARALYTIC CONTRACTURES. 51 paraplegia that the orthopaedic surgeon more often wit- nesses spastic contractures. In post-mortems made in cases of this affection the crossed pyramidal tracts have been found to be degenerated secondarily to brain-lesions, such as meningeal ha'iiiorrhage, caused by pressure of the mother's pelvis on the skull-bones of the infant during parturition; thrombosis of the superficial cerebral vessels, etc. Paralytic Contractures.—Deformities due to paralysis of muscles form the largest class of contractures. In order to understand the different ways in which deformity may occur after paralysis, in the first place, the-normal elasticity of muscles is to be remembered. Normally, within the bo:ly, the muscles are stretched to a slight extent. This enables a muscle to act immediately upon the points of its insertion when it enters into a state of contraction, and it also explains the immediate retraction of a muscle that occurs when it,, or its tendon, is completely severed. The retraction of a muscle that follows division of its tendon is gradually followed by further changes ; the muscle retains its elasticity, and, if reunion of the divided tendon occurs, it recovers its functions, but with a somewhat shortened form, and hence a diminished range of action. In other words, the difference between its length when in full voluntary contraction and its length when in a state of rest is less than it was before the tenotomy was performed. It no union takes place between the ends of the severed tendon, the shortened muscle after a long time undergoes changes described above as " fibrous myositis." At the moment of division of a tendon of a muscle, or physio- logical group of muscles, the antagonistic muscle contracts actively and remains shortened on account of its elasticity. " Antagonistic muscles (Galen) are those which, during their action, have exactly the opposite effect of other muscles, e.g. flexors and extensors, pronators and supinators."* The shortening of the antagonist is not, however, as great as that of the muscle of which the tendon has been divided, because the antagonist, being intact, is involuntarily elongated by the action of adjacent muscles. Thus, as Hoff'at observesj * Landois and Sterling, " Human Physiology," vol. ii., p. 676. ■f Hoffa, " Lehrbuch der Orthopadischen Chirurgie," 1898, p. 37. oz COMPLETE PARALYSIS OF A MUSCLE. "If the flexor tendons of a finger are severed, the finger assumes an extended position. This position will, however, be frequently modified in the direction of flexion by the patient involuntarily using the other fingers to move the damaged one." When, however, the antagonist is not thus brought into physiological employment, it undergoes atrophy from disuse. The antagonist, though atrophied, retains per- manently its power of voluntary contractility. Complete Paralysis of a Muscle, e.g. from section of a peripheral nerve, has, as far as the antagonists are concerned, Fig. 27.—Attitude assumed by a Patient suffering from Paralysis of the Lower Extremities from the Hip-joint downwards. practically analogous results—analogous to those that im- mediately follow complete division of tendon; thus, when the musculo-spiral nerve is severed, the extensors of the wrist are paralysed, and the antagonists, the flexors, contract, pro- ducing flexion of the wrist, which persists even in the supi- nated position of the limb : that is to say, the contraction of the flexors is capable of counterbalancing the weight of the hand. and hence is something more than is implied by the term "wrist-drop." In a similar manner, contracture of the knee CAUSES OF PARALYTIC DEFORMITIES. 53 in the flexed position follows paralysis of the extensors, in spite of the counteracting force of the weight of the limb when the patient is in the erect position. This contracture of the antagonist to the paralysed muscles is increased by their voluntary contractions. If only a group of muscles acting laterally on a joint is affected, the resulting deformity is in the opposite direction; thus paralytic pes valgus results from paralysis of the tibiales muscles. These purely muscu- lar contractures are modified by mechanical factors brought into play by the weight and use of the limbs. Thus, in the case of the little girl depicted in Fig. 27, I was at a loss to account for a marked flexion-contracture of both hips, for all the flexor and the extensor muscles were equally powerless from infantile paralysis. I found that the habitual posture of the patient was that shown in the figure. When thus arranged, with the thighs placed against the abdomen, the little girl, by the combined use of legs and arms, could move with remarkable celerity for very considerable distances. The contracture of the soft parts at the front of the hip-joints in this case was determined by this posture assumed as the only one that, before instruments were applied, made locomotion possible. Thus, when all the muscles acting on a joint are completely paralysed, what is termed a " flail-joint" results; but the movement of this flail-joint may become limited in one or other direction by secondary changes resulting from habitual posture, pressure, and other mechanical conditions. When paralysis affects all the muscles about a joint, but is incomplete, the primary contracture takes place towards the side of the flexors because of the greater relative power of the latter. The Causes of Paralytic Deformities are either peripheral or central. Peripheral nerve-lesions are (1) traumatic ; (2) toxic neuritis, e.g. alcoholic and post-diphtheritic, gouty, etc. Central nerve-lesions are either cerebral or spinal. Among Cerebral Lesions, some are congenital, such as some cases of hydrocephalus and porencephaly ; others are acquired; e.g. traumatic lesions, haemorrhage, tubercular and other tumours. Spinal Lesions much more commonly give rise to M. ANTERIOR POLIOMYELITIS. contractures. Spina bifida, the later stages of tabes_ dorsalis, compression-myelitis, syringomyelia, spinal meningitis, pro- gressive muscular atrophy, and, above all, anterior polio- myelitis of both children and adults, may be given as examples of spinal lesions which are known to cause contractures _ Anterior Poliomyelitis is an inflammatory affection of the anterior horns of the grey matter. The destruc- tion of the large motor cells leads to degeneration of the corresponding motor nerve-fibres and of the muscle-cells. The acute form of the affection known as infantile paralysis is marked by a sudden onset, fever, headache, pains in the loins and limbs, and, in children, convulsions. The sufferers have usually been in good health at the time of the attack. As the initial symptoms pass away, paralysis or paresis is noticed in one or more, sometimes in all the limbs; the muscles of the trunk may also be affected. The paralysis develops rapidly and reaches a maximum within a few hours of the attack. As a rule, much of the original paralysis is recovered from, especially under suitable medical treatment. Permanent paralysis may have a hemiplegic (unilateral or crossed), a paraplegic, or an irregular distribution. Extensor muscles are affected more commonly than flexors. The bladder and rectum, as well as the sensory nerves, escape. One important effect of extensive paralysis in children is a diminution in the rate of growth in the bones and all parts of the paralysed limb. Though the paralysis is purely motor subjective tingling is sometimes felt, and the affected muscles may be tender for a time. In even partial paralysis of the extensors of the knee, the knee-jerk is lost. The important question for the surgeon is what is the period of time during which the case may be dealt with by the physician, aided by simple retentive splints designed to prevent the occurrence of deformity. The answer to this question amounts to a knowledge of the average course of the affection. Usually the paralysis remains stationary for from two to six weeks, and then improves, at first markedly, and then less rapidly, for three or four months. After six months, further spontaneous im- provement is unusual. An idea of the commoner modes of distribution of ARTHROGENOUS CONTRACTURES. 55 paralysis may be gained from the following table, which is taken from Bradford and Lovett's work and is based on statistics given by Duchenne and Seeligmtiller:— One leg paralysed.......74 One arm „.......03 Both legs „.......23 Both arms „.......3 All four extremities paralysed .... 7 Hemiplegic paralysis......3 Crossed „......3 Paralysis of trunk and abdomen .... 1 137 In but a very few cases of infantile paralysis does the impairment become progressive. I have, however, observed this in one or two cases. In such cases a chronic anterior poliomyelitis is ushered in by an acute attack instead of beginning, as it more commonly does, insidiously. The chronic affection is known clinically as progressive muscular tdrophy. Infantile paralysis being, as a rale, due to purely spinal lesions, is to be distinguished from spastic paralysis, which is usually the result of cerebral lesions. The chief effects of infantile paralysis are, besides the impairment of motor function, contractures such as club-foot or dislocations ; proneness to ulcers from impairment of circulation are also to be remembered. These effects will be dealt with in detail in connection with the different regions of the body. The indications for mechanical treatment are (1) preventive; (2) corrective. In the latter case operative measures are often required in addition. It is a too common experience to find proper orthopa'dic treatment omitted altogether or too long delayed, with the result that avoidable deformities are allowed to develop, and un- avoidable ones to become exaggerated. Arthrogenous Contractures depend upon changes of a cicatricial character in the synovial membranes and peri- synovial tissues of joints. The ligaments of a joint, when attacked by gouty or tubercular inflammation, undergo cicatricial contraction. After fractures and other injuries in the neighbourhood of joints, intra-articular adhesions are of 5(! ANKYLOSIS. common occurrence, and they frequently limit the range of movement in a joint or fix it in an abnormal position. ANKYLOSIS. Ankylosis differs from contractures in that it is a fixation of a joint by the union of the articular surfaces themselves by interposed connective tissue. At the commencement the uniting tissue may be soft and yielding, when the ankylosis is termed incomplete. In opening the ankle and tarsal joints in a limb amputated on account of an ununited fracture and oedema that had persisted for four years, I found that the processes that lead to ankylosis had been in progress, and that the first step consisted in the formation of a thin layer of plastic lymph between the articular cartilages. In joints in which the process was further advanced the articular cartilages had been perforated here and there by buds of granulation tissue which sent vascular buds into the lymph within the joint, meanwhile the cartilage was thinned by the deeper part being transformed to granulation tissue and to fibrous tissue. At the stage in which most of the articular cartilage remains whilst the amount of fibrous tissue is small, the term ankylosis cartilaginea has been applied to describe the condition. When much of the cartilage remains and the uniting fibrous tissue is more abundant the term ankylosis fibrosa inter-cart ihayinea is employed. The latter is usually only a transitory state, for if the original cause of the disturb- ance continues in action the remainder of the cartilage is removed, and the condition becomes ankylosis fibrosa, inter- ossea. Osseous ankylosis is produced in two different ways: (1) by ossification of the fibrous tissue formed as above described in ankylosis fibrosa inter-ossea after metaplasia of the cartilage, or (2) it may occur as a new formation of bone after destruction of the articular cartilage by inflam- matory processes. Both these processes may occur in different parts of the joint. How complete the obliteration of a joint may be in bony ankylosis, is shown in Fig. 28. VirtuM osseous ankylosis may result from the formation of uniting bridges of bone beyond the articular surfaces, as is seen in spondylitis deformans, in osteo-arthritis of the ANKYLOSIS. temporo-maxillary joints and synarthrodial joints ; or again from great alterations in the form of two articulating sur- faces such as is often seen in osteo-arthritis and in tabetic arthropathy. To the latter condition Volkmann has applied the term "ankylosis by deformation." Congenital ankylosis from abnormal development or from intra-uterine pressure is also met with from time to time. It has been maintained that fibrous ankylosis is only a passing stage of a process that would naturally termi- nate in osseous ankylosis. Seeing that in cases of un- united fracture an interval of fibrous tissue uniting two bony surfaces often shows no tendency to ossification, it would hardly be expected that the above rule should prove to be universally true. Many instances might be quoted to prove that fibrous ankylosis may retain its char- acter unchanged for many years. Thus, in the case of a lady aged twenty-eight whom, in conjunction with my col- league, Dr. W. K. Sibley, I operated on for fibrous anky- losis of both hips, the condi- tion had been present for Fig. 28.—Osseous Ankylosis of the Hip. fourteen VearS and dated (Royal College of Surgeons' Museum.) from an inflammation of both joints that supervened after an attack of measles, and was treated for some months by extension. The flexion and abduction movements were greatly impaired, and a con- siderable degree of force was required to rupture the adhe- sions in each joint. The causes of ankylosis are varied: traumatic conditions, suppuration in joints, gonorrheeal rheumatism, tubercular, and syphilitic inflammation are among the commonest. Long 58 TRAUMATIC CASES. fixation of a limb on a splint was once thought likely to lead to permanent ankylosis. In the case referred to on p. 5b this process had only begun at the end of four years and then there was the presence of oedema to explain it. \\ hen a fracture occurs near a joint the formation of adhesions between the apposed surfaces of the folds of synovial mem- brane is likely to occur, and it must be guarded against as far as possible, and care should be taken to examine the joint carefully at the end of the treatment and to break down any adhesions that exist. The neglect of this on the part of the medical man is the golden opportunity of the " bone- setter." The clinical aspects of different cases of ankylosis are of the highest importance and often require the closest atten- tion and judgment in their management. In America, following the example of Sayre, orthopaedic surgery is taken to include the whole of the surgery of joints. This course is, I think, unnecessary, since the more acute forms of joint- disease and their management is well described in works on general surgery. The more chronic cases are those that require orthopaedic treatment, but in every case the surgeon must be prepared to relinquish conservative for active measures as soon as the indications for so doing are present. Of the various clinical groups of cases the following require special mention. Traumatic Cases (non-septic).—These furnish a class in which simple manipulative measures are often of use, and whether the adhesions are few or many a good result may be anticipated. In many cases of the kind slight weakness of the joint remains for a period and calls for light support. This is most commonly seen in the knee. Suppurative Arthritis.—In this class come most of the worst cases of joint-disability. Excluding cases that are secondary to acute osteomyelitis, there are traumatic and pyaemic suppurations, which may end in destruction of the endothelial surfaces and complete obliteration of the joint by dense scar-tissue or bony ankylosis. By means of prompt surgical treatment this result may frequently be averted, as is seen strikingly in the suppurative arthritis of children. The responsibility of the orthopaedic surgeon begins when TUBERCULAR ARTHRITIS. 59 the joint condition has reached a permanent state. The greatest caution is required in manipulating a joint that has been the seat of septic inflammation. Though every chance should be given to conservative treatment, excision is often to be preferred to forcible manipulation in such cases. Pyaemic conditions include arthritis following scarlet and other fevers, as well as gonorrheeal arthritis. Tubercular Arthritis affects joints in various modes. The infection of the synovial membrane is often secondary to that of one or other of the articulatory bones. In children the primary seat of infection is frequently the juxta-epiphyseal extremity of the diaphysis. In adults, and occasionally in children, the cancellous tissue of the epiphysis itself may be first affected. The synovial membrane is sometimes primarily affected. In a few cases a localised thickening of this membrane has been observed, and the spread of the disease to the rest of the membrane has been noted in the course of the case. A some- what rare variety of tubercular infection of the synovial mem- brane of a joint might be termed an acute tubercular synovitis. In this condition the joint swells rapidly, and, upon opening it, a large quantity of opalescent fluid escapes, and the synovial membrane is found to be thickly studded in every part by recent miliary tubercles. In the vast majority of cases the course of tuberculosis is a chronic one, and no condition offers more problems to the surgical judgment than does this. The natural course of the affection varies according to the stamina and age of the patient, the particular joint affected, and the primary seat of infection. The prognosis of joint tuberculosis is much better in children than in adults. Howard Marsh* writes: "Indeed, recovery, when either the hip or the knee is attacked, in patients between thirty and sixty-five, very rarely takes place." The majority of cases of tuberculosis of the hip- and knee- joint require a patient trial of orthopaedic treatment. Perfect immobilisation, with complete relief from abnormal intra- articular pressure, gives, in average cases, the best chance of recovery with a useful limb. In many cases of undoubted tubercular arthritis these measures have resulted, not only * " Diseases of Joints," p. 119. 60 VROPHYLaIXIS <)F VEFORMITIIES. c but in a restoration of mobility in recovery from the disease. in the joint. Deformity from tubercular arthritis is brought about by contracture, ankylosis, and dislocation. Contractures from this cause are fairly definite in direction, and are the result of muscular action, which is partly reflex spasm and partly an involuntary adap- tation with the object of protecting the joint from movement. Ankylosis, follow- incr tubercular arthri- tis, may be either fibrous or osseous. The latter was for- merly supposed to occur only after septic infection had super- vened upon tuber- culosis, but Howard Marsh has shown that bony ankylosis may occur in cases of tubercular arthritis apart from septic in- fl am mat ion. The appearance of the macerated bones in a case of dislocation from tubercular cox- itis is shown in Fig. 29. The General Prophylaxis and Therapeutics of De- formities.— Propliylaxis. — To those who see regularly a large number of cases of deformity, it is striking what a considerable ratio of them might have been prevented. Many phases of deformity are not preventible. Such are deformities that are present at birth. But even in these cases the future of a baby depends upon the early recognition and early treatment of conditions such as club- Fig. 29.—The Bones from a case of Tubercular Coxitis with Dislocation. The head of the femur, a, has lost its cartilage; the articular surface is composed of porous, rarefied, cancellous tissue ; tin: upper and posterior part of the acetabular rim has been absorbed by the joint action of the carious process and the continuous pressure of tiie head of the femur; b, buttress of bone, composed of sharp stalactitio osteophytes thrown out to support the dislocated head (Pepper). PROPHYLAXIS OF DEFORMITIES. 61 foot or congenital dislocation. Thus, even when a deformity is present at birth, there may be scope for prevention, in the direction of preventing the deformity becoming permanent or aggravated. The examination of the new-born baby requires more than a superficial investigation, which would suffice to detect obvious malformation. The hip-joints, for instance, should be carefully examined, in order to ascertain whether a congenital dislocation is present. In principle prevention is the same as early treatment. A considerable proportion of acquired deformities is due to rickets. Therefore, of this class of cases, the prevention of deformities amounts to the prevention of rickets. Rickets is, to a large extent, a preventible disease. It has been shown that the young of certain animals, e.g. lions, can be made rickety by withholding milk and bones from their diet. Among the poor, prolonged suckling and ignorant feedino- are the commonest causes. In a few cases I have observed rickets develop in the first months of life during suckling ; in such cases the origin of the disease can only be attributed to some defect in the mother's milk, and in some cases circumstances have seemed to point to this defect, oriolnatinof in indigestion in the mother. Rickets is by no means confined to the poorer classes, and in its slighter forms is common among the children of the well-to-do and wealthy. Nor is unwise and insufficient feeding confined to the poor. In too many public schools an ill-considered and often illiberal dietary accounts for many cases of deformity and prevents many a young fellow from entering the navy or the army. It is a remarkable fact that in but few families is any arrangement made for the periodical inspection of growing children by the medical attendant of the family. Until such an arrangement becomes general, and until the methods of examination of children for incipient deformities are more systematically taught in the medical schools, it will be left to the tailor and the dressmaker to discover scoliosis, often when the deformity has progressed so far that a complete cure is impossible. Statistics of Deformities.—A good and comprehensive 6-2 STATISTICS OF DEFORMITIES. statistical statement of the various classes of orthopa'dic cases based on pathology and giving the results of modern treat- ment has yet to be made, and it is to be hoped that before many years elapse such statements will be forthcoming in Great Britain. Hoffa* records that out of 67,910 surgical cases treated at the Munich general hospital 1,449 were orthopaedic cases. The ages of the patients were as follows:— 0—10 years..... ... 602 40—50 yeai 10—20 ,...... ... 481 50—60 „ 20—30 „ ..... ... 182 60—70 „ 30—40 „ ..... 70 70—80 „ 54 30 28 2 In this list the two sexes were about equally represented. The frequency of occurrence of the various kinds of deformity (where recorded) was as follows:— Scoliosis 399 Hallux valgus 27 Pes valgus 338 Dupuytren's contraction 23 Pes equino-varus 171 Pes calcaneus 9 Tubercular kyphosis 142 Torticollis ......... 7 Genu valgum......... 119 Congenital hip-dislocation ... 7 Rachitic curves of the tibia 107 Genu varum ... 3 Pes equinus......... 52 Club-hand ...... 1 Rachitic kyphosis ... 39 The deformity was noted as congenital in 150, as acquired in 1,175 cases. Symptomatology and Diagnosis. — The symptoms of deformity are not limited to alterations of external contour which "he who runs may read." In many cases most care- ful examination is required before the kind and decree of deformity can be ascertained, and an exhaustive account of the history of the case must be taken before its pathological character can be decided upon. The subjective symptoms are of most importance in the early stages of deformity. Pain and Tenderness.—In the earliest period of the habitual pressure deformities dull aching pain is frequently complained of. The pain in rickety yielding of the neck of the femur (coxa vara) may closely simulate that of early * Hofl'a, he. supra cit., p. 51. PROGNOSIS OF DEFORMFTIES. 63 tubercular disease. Tenderness and neuralgic pain is a prominent feature of early rheumatoid arthritis, and in the spine these symptoms are more marked than they are in tubercular disease. Alterations of Function are determined by several different factors: pain, muscular weakness, and alterations of structure may, separately or combined, produce alterations in function. The Objective Signs. — The attitude of the patient, peculiarities of posture and gait, should all be observed before the part specially complained of is inspected. The deviations from normal form and size are to be noted, and when necessary, measured. Contours may be recorded by moulding a strip of tin or lead to the part and transferring the strip to paper and tracing with a pencil the contour obtained. For angular deformities various sroniometers are in use. Palpation gives valuable information as to the firmness or otherwise of muscles, the form of superficial bony struc- tures and bands of fascia. The range of movements of suspected joints should be carefully ascertained by gentle manipulation, and if necessary an anaesthetic must be given to differentiate between limitation of movement due to organic changes and that due to muscular spasm. By manipulation also the degree of resistance to correction is to be observed. In the differential diagnosis of certain conditions the Rontgen-ray process is of the greatest service. Prognosis.—The first question raised in many cases is whether the deformity will disappear if left to itself. In the majority of cases in which this is predicted only disappoint- ment ensues. Since the results of treatment will be discussed later in connection with the various deformities a few examples will suffice in this place. Among congenital deformities club-foot, if properly treated from the first, is completely curable, and if the treatment is efficient, relapse is out of the question. Even congenital dislocation of the hip is curable if treatment is begun at the proper age. In some congenital affections, such as webbed fingers, the degree of perfection attainable depends upon the extent of the defect. Rachitic deformities of the bones of the 64 MASSAGE. lower limbs can all be cured without operation if orthopedic treatment is began sufficiently early. Among pressure deformities scoliosis, contrary to the opinion of some surgeons in Great Britain, is curable if efficient treatment is begun at the right time. In paralytic cases palliative measures are all that can be undertaken in most cases. General Treatment.—The predisposing condition, whether this is rachitis, rheumatoid arthritis, or tuberculosis, must be treated by suitable hygiene, diet, and medicines. In children, cod-liver oil and iron, and cod-liver oil and hypophosphites of lime and soda; sea-salt baths and frictions are the more generally useful. The dress, the bed, and every detail of the patient's daily life and surroundings should be considered. Massage.—The value of friction and manipulations in medicine have been recognised from the earliest times. Hip- pocrates (4(>0-357 b.c), in his work "De Articulis," says, "The physician, besides being accomplished in many other ways, must also understand massage." As it is now understood, massage includes the following manipulations :— (1) Centripetal stroking of the part with the finger-tips and palm of the hand (efjieiirage) empties veins and lymphatics and, by improving circulation, improves nutrition. The chief groups of muscles are followed with the flat of the hand, the thumb making firmer pressure. (2) Centripetal kneading of muscles with the fingers of the hand placed transversely to the course of the muscle-fibres (petrissage). (3) Circular friction, combined with centripetal friction and kneading (friction). This manipulation is most useful for joints. It is done by pressing the fingers of one hand upon the skin of the part, and making them execute small circular movements, whilst the fingers of the other hand inter- mittently perforin centripetal friction. Instead of the fingers, the thumb may be used to perform the circular movements, the fingers of the same hand being used as a '•' rest."* (4) Tapotement consists of a rapid series of slight blows, delivered by the backs of the two distal joints of the fingers, * A. Symons Eccles, " Practice of Massage," p. U. GYMNASTICS. 65 or by the ulnar border of the hand. The manipulation is used in muscular parts, the fingers being employed when the superficial, the inner borders of the hand when the deeper parts are to be influenced. This measure is most useful in spastic paralysis, and in other conditions, where the contractile pro- perty of the muscles is diminished. (5) Vibration is a combination of petrissage and tapote- ment, with a vibratory movement. Among the physiological effects of massage, that of relieving muscular fatigue has been proved. Hence its utility in deformities due to habitual postures, assumed on account of muscular fatigue, might be inferred. Massage is also indicated in many cases in which any instrument that prevents the movements of a limb is required to be worn. The effect of massage to improve the contractile power of muscle and its use in cases of spastic paralysis have also been proved. In helping to remove residual inflammatory effusions, as, for instance, after fractures and other traumatic conditions, massage has a well-recognised place. In muscular rheuma- tism and similar conditions, massage is used for this purpose. The place of massage in orthopaedic surgery is often mis- understood. Thus, it is a not infrequent experience to come across a case of slight contracture or a case of spastic paralysis that has been treated with massage for many months without any real improvement, whilst with simple operative measures the condition has been easily remedied, and this done, massage has been employed with distinct advantage. Gymnastics.—The value of systematically ordered move- ments of the body, or gymnastic exercises, as a factor in physical education and in the preservation of health, has been recognised in all civilised countries. In England, general exercises form a prominent feature of public-school life, and latterly the value of systematic outdoor sports is becoming recognised in the larger schools for girls. The value of systematic general exercises is illustrated by the good effect of the physical or "setting-up" drill upon young recruits. Apart from educational general exercises, the importance of remedial gymnastics has also, like massage, been recognised F 66 GYMNASTICS. from the earliest times. Galen (a.d. 130-200) distinguished clearly between active, passive, and compound movements, and his appointment as physician to the School of Gladiators at Pergamum gave him ample opportunities of studying the general effects of gymnastics. The application of gymnastics to the treatment of deformities is a very wide one, and, like massage, they are more often of service in combination with other measures than when used alone. Before exercises are prescribed in any given case, the diagnosis must be made perfectly clear or much harm may be done—e.g. if severe exercises are ordered for a rapidly-growing girl, in whom the bones are softened by "rachitis" adolescentium" and lateral curvature of the spine,' genu valgum, and flat-foot are developing, these deformities will be aggravated. In the same way, the healthy general exercises of a public school will have a most deleterious effect on a weakly boy if he is compelled to do all that his stronger class-fellows perform. Medical exercises, when carefully administered, are of the greatest service in the treatment of deformity, owing to dependence of proper postures upon healthy muscles and the influence of the muscles on the growth and form of bones. As an example of active remedial exercises directed to the correction of deformities that have arisen from faulty postures that have been assumed owing to weak muscles, Ellis's tiptoe exercise for flat-foot may be taken. In this exercise the patient stands with the toes slightly turned in, rises on tiptoe, and returns at once to the original position. This is repeated a certain number of times according to the patient's strength. The exercise brings into action chiefly the gastrocnemii, tibiales muscles, and the flexors of the toes, and tends to strengthen them, and so enable the patient to resist the tendency to eversion of the feet. Even this simple exercise may do harm if the condition of the bones and ligaments is one of greatly diminished resisting power, as is not infrequently the case. Other simple postural exercises will be mentioned in the treatment of scoliosis. Passive exercises are familiarly employed after injuries involving, or in the neighbourhood of, joints to prevent the RESISTED EXERCISES. 67 formation of adhesions, and in certain phases of rheumatoid arthritis. By passive movements the elasticity of muscles is exercised and the circulation is improved. Resisted exercises constitute the original feature of the Swedish or Ling's system of gymnastics, established at Stockholm about LSI3, and they remain as a valuable resource when divested of the extravagant and useless complexity into which Ling's methods degenerated. As applied to the limbs, they were named by their originator the " compound concentric " and the " compound eccentric " movements. An example given by Hoffa will best indicate the meaning of these terms :— Let us suppose that it is desired to strengthen the biceps biachii muscle. It may be done in two ways. First, the patient may be told to bend the elbow, whilst the gymnast, holding the patient's wrist, offers resistance to the movement. The patient's biceps is seen to contract vigorously, and the gymnast's art consists in gradually diminishing his resistance till it is overcome by the contracting muscle. In this instance the patient performs an active movement whilst the gymnast offers passive resistance, in that he allows himself to be moved by the patient. The movement is thus termed active- passive. At the same time, the two extremities of the patient's biceps have been brought nearer to the middle of the muscle in the contraction of the muscle, so that the movement is described as concentric. Thus, gymnast and patient have effected what in Ling's terminology is termed a " compound active-passive, concentric, resisted movement." If now the patient, holding the elbow in the flexed position, is requested to keep the joint flexed whilst the gymnast endeavours to extend it, the patient offers passive resistance to an active extending force, and once more the biceps enter into marked contraction. Finally, the gymnast overcomes the resistance and extends the patient's elbow. The two extremities of the muscle, in spite of a series of small contractions on its pert, have moved eccentrically from the middle point between them ; in other words, a "compound passive- active, eccentric, resisted movement" has been effected. Ling's system became extravagantly complicated; as Busch* observes: - It was an error of Ling's to ascribe to every single muscular movement a special enect upon the general health ; as, for example, when he believed tliat an arm movement while standing had quite a different effect from an arm movement while lying or sitting. From this assumption an extremely complicated system of gymnastics arose, which sharply differentiated the movements necessiry in different cases. * Busch, '' General Orthopaedics," 1885. 6S RESISTED EXERCISES. Thence arose the necessity for a considerable number of assistants for four people might be required to hold the patient in a certain position, while the fifth-the gymnast proper-conducted the required move- ment. The physiological effects of resisted movements are practi- cally the scame as active movements, and the chief indication for their employment is in conditions of muscular weakness, in which great care is required to prevent fatigue of muscles, and it is necessary at the same time to strengthen the muscles by exercises that are gradually increased as the patient's strength in- creases. In order to avoid the necessity of numerous assistants and the direct intervention of the "gymnast," Zander* more recently founded at Stockholm a medico- mechanic al institute. There the resistances, etc., are obtained by mechanical means, and are so arranged that any set of muscles may be exercised, and the work done may be graduated exactly according to the needs of each case. Before Zander, Bonnet (see Fig. 30) and others had employed mechanical measures for self-exercising in orthopaedic cases, and of late years the simple machines of Dowd and Whiteley have enabled physicians to prescribe for their patients home-exercises—the benefits of regular exercises without the expense entailed by the gymnastic institutes. Simple exercises with dumb-bells, bars, the trapeze, etc., are also of service in many cases ; and the surgeon should thoroughly understand their influence in the treatment of deformities, and know what exercises to prescribe and what to avoid in a given case. * Zander has described his methods in his hook " Die Apparate fiir Mechanised heilgymnast und deren Anwendung," Stockholm, 1890. Fig. 30.—Bonnet's Apparatus lor exercising the Ankle. DEFORMITIES TREATED BY INSTRUMENTS. 69 Krukenberg* has introduced a system which combines active and passive movements by means of pendula. The part or limb below the joint to be exercised is fixed to a metal plate or socket, to which is attached a pendulum. The slightest movement of the joint on the part of the patient starts the pendulum, the swing of which is increased by each successive impulse, however small. Thus a passive movement is produced by the atrophied muscles about the joint. Electricity.—In the diagnosis of nerve-paralysis electricity is of tried service. The value of electricity in the treatment of certain paralytic affections is estimated very highly by some, very slightly by others. The faradic current applied directly over the affected muscles is safe. Its use, according to some, consists in the local gymnastics it affords the affected muscles, enabling them to escape atrophy from disuse until the nerves have been afforded full opportunity of recovering their functions. The action of the constant current is more complex, and its application should be left to those who are well versed in its use. Hydrotherapy.—Owing to the fact that many deformities are connected with gout, rheumatoid arthritis and other diseases, the patient often obtains much benefit from a course of treatment at one of the recognised Spas, such as Bath, Buxton, or Harrogate. . THE PRINCIPLES OF THE TREATMENT OF DEFORMITIES BY INSTRUMENTS. The surgeon must have a taste for practical mechanical work. All the usual surgical dressing materials must be at his command. Bandages and adhesive plaster, used according to the indications in each particular case and not according to the examples figured in books on bandaging, will too-ether with the simplest instruments, e.g. tin splints often answer every purpose. One important group of appliances is formed by the sheathing splints; plaster of Paris, poroplastic felt, leather, and many other materials are used for this purpose. *H. Krukenberg, " Lehrbuch der Mechanischen Heilmethoden," Stuttgart, 1896. 70 PLASTER OF PARIS. Plaster of Paris may be used either in bandages or on house-flannel, as a single sheathing splint, e.g. Croft's, or again as the more convenient lateral splints. It is not necessary in this place to go into the details of the appli- Fig 31 — TJlrich Grosse's Apparatus for applying Plaster of Paris Bandages to the Pelvis and Thighs. Fig. 32.— The same. The Bandage applied.* cation of these familiar apparatus, but it is desirable to indicate what, in my opinion, is their scope in orthopaedic surgery. Plaster of Paris is suitable for the same purpose as a rigid splint, and is often the best form of splint to employ during the first week or more after an operation. Personally, I use plaster of Paris more for purposes of * Figs. 31 and 32 are taken, by permission, from the Centralblatt fur Chirurgie. PLASTER OF PARIS. 71 fixation than for reduction of deformity. Thus, after osteotomy, plaster splints, whether of Crofts pattern or as bandages! may be used either from the first or after the first splints have been left off; there is a period during which the union of the fragments of bone is weak and requires some support for the first few weeks during which the patient is allowed to walk. Although, as a corrective orthopa'dic apparatus, plaster of Paris has a more limited scope than many surgeons appear to think, its value as a temporary fixation appliance after operations cannot well be exaggerated. Thus any aid to the application of plaster of Paris bandages with precision and security against pressure sores is^ of importance. Ulrich Crosse (Centralb. fa r Ch era rg., July, 1898) recommends the simple apparatus shown in Figs. 31 and 32 for the application of plaster apparatus to the pelvis and thighs. In the bloodless reduction of congenital dislocation of the hip, and many other conditions, plaster splints are useful in the earlier part of the treatment. By an ingenious device Mikulicz has used plaster as a means of correcting genu valgum, but much simpler and less irksome means being at hand in the simple splints shown in Fig. 34. it is unnecessary to employ it in this condition. Many surgeons use plaster bandages as part of the means employed for the correction of congenital club-foot. The value of daily manipulations in these cases has made me relinquish the method in favour of malleable metal splints. The method of applying plaster bandages as a corrective measure in cases of congenital talipes equino- varus has been well described by YValsham and Hughes* The method of correcting the deformity by means of planter of Paris bandages may be employed either with or without operative treatment. When employed alone without any operative measures the aim of the surgeon is gradually to stretch any resisting tendons, ligaments, and fasciae, slowiy to replace the displaced bones, and to mould those that are misshapen into their normal shape. The foot at each application is gently forced by the hand into the best position approaching the normal that it can be made to assume without causing pain, and is thus held whilst the plaster bandage is being rolled on and until the plaster has firmly set. * " Deformities of the Foot," p. 146. 72 SHEATHING SPLINTS. The plaster keeps the foot in the corrected position into which it has been forced by the hand till the next application, when iurtner correction by the surgeon's hand is again made, and the foot retained by the plaster in the still further improved position. . . "The method of applying the plaster bandage.—A cotton- wool bandage is first evenly applied from without inwards to the lower half of the leg and foot, enclosing the ankle by figure-of-eight turns. The bandage is made by taking a sheet of cotton-wool and .cutting it into strips three feet long and from three to five inches wide, according to the age of the patient. The strip of cotton-wool is next rolled up like an ordinary bandage, and is ready for use. The cotton-wool bandage having been applied, and the foot forced by the left hand of the surgeon, or by the hand of an assistant, into the improved position, we are now ready to put on the plaster of Paris bandage. After the bandage has been soaked in water .....it should be applied to the lower part of the foot, just to clear the phalanges. Beginning at the outer side, two turns should be taken round the foot, the bandage being kept taut all the time. No injurious effects will follow if the cotton-wool bandage has been carefully applied and the plaster bandage is kept quite flat and even. The bandage should be carried from the outer side of the foot to the inner side of the leg, well above the ankle, forming the first half of a figure of eight; then for a turn and a half round the leg. To complete the figure of eight, the bandage is carried from the outer side of the leg to the inner side of the foot. A turn and a half should now be taken round the foot at a higher point than the first turn, and so on as before until the whole foot and leg are covered in." Poroplastic and other sheathing splints are open to some of the same objections as plaster of Paris. In Germany the orthoptedic instrument-maker, Hessing, has brought to great perfection the combination of sheathing- splints of leather with jointed metal splints. By confining the muscle and shutting in the perspiration, Hessing's apparatus has some of the disadvantages^of plaster, but the metal supports and joints allow the joints to be free, and enable the surgeon to readjust the instrument from time to time. As applied to a case of one-sided congenital hip- HIES SING'S APPARATUS FOR THE PELVIS. 7;? dislocation, it consists of a moulded corset for the trunk and hips, and others for the thigh, leg, and foot, all jointed together by steel bands. Hoffa records the case of a child who had worn this instrument for several years, and at the end of that time was so weak that she could scarcely stand. The appar- atus so completely replaces the func- tion of the skeleton that the bones tend to atrophy from disuse, and the muscles are weakened by compres- sion and restricted movement. Of all Hessing's ingenious apparatus, his pelvic girdle for walking instru- ments is the most useful (Fig. 33). For the great majority of cases, I prefer the ordinary apparatus to that of Hessing, the chief value of which is, perhaps, in cases where extension is needed, and where the apparatus is required to act as an artificial limb. For the construction of artificial limbs, some abdominal bands, knee supports, and other apparatus, it is sometimes necessary for the surgeon to make a plaster cast of the body. The new method of C. A. Peters gives very perfect results, but it is expensive, and for orthopaedic work the older methods are sufficient. The following account is abbreviated from Hoff'a's text-book. In order to take a rough plaster cast to show the contours of the part:— 1. Grease the skin. t 2. Apply a strip of tin-plate if on body, a thin cord if on limbs, in the middle line. 3. Lay on several layers of plaster bandage. The case is cut up before drying, taken off when dry, wrapped in an ordinary bandage, and filled with plaster. For more perfect casts, the part is carefully greased with lard, mixed with petroleum, and a cast is taken in a box of stiff cardboard in the usual way. The surface of the edges of the first half of the mould is smoothed off, several hemispherical depressions 33.—Hessing's Apparatus for the Pelvis. (After Hoffa.) 74 THE RIGID SPLINT. being made in them. For very delicate casts Krukenberg's elastic material may be used. £ Gelatine . • ^° Oxide of zinc......1/;> Glycerine.......400 Aq Uest....... . 300 Rub up the zinc oxide with equal parts of glycerine. When the negative cast is set it is removed like a glove, and used to mane a plaster cast. . Leather is treated with bichromate of potash to make it resistant to water. Calf leather is used for the foot, ox-hide for the limbs. Models of paper are first cut, then the leather cut to this pattern is soaked in warm water, spread over the model, and fixed with brass tacks. This is called "fulling" the leather. It is dried in the sun. When half dry it is smoothed with a stick. When quite dry it is removed, rubbed with shellac, and spirit varnish, and lined with flannel; lacing is added. The mechanical actions of any orthopa'dic appliance may be classed under one or more of the following three headings :— (1) Retentive ; apparatus designed to prevent threatened displacements. (2) Reducing; designed to restore crooked parts to their normal form and function. (3) Supplemental; apparatus such as springs and elastic bands that replace the action of paralysed muscles, and pro- thetic apparatus that takes the place of amputated limbs, etc. Whenever it is compatible with obtaining the best possible result, the instruments should be so constructed that they allow the patients to walk and follow the vocations proper to their age. The component parts of portable appliances are (1) the fixing, and (2) the active parts. 1. The Rigid Splint.—We may take as a familiar example of this, the simplest orthopaedic appliance, that given by Andry* in his founding work on " Orthopaedy." One of the quaint illustrations in this notable work represents a sapling with a bent stem which is bound to a strong stake at its middle and upper extremity, whilst the stake is fixed to the lower end of the tree by being thrust into the ground. In this instance the " deformity" of the trunk of the growing sapling is prevented from increasing, and if the * Andry, ;< Orthopedie," 1741. THE RIGID SPLINT. 7o middle band were tightened from day to day the stem would gradually assume an erect position, and by daily increasing in thickness and strength would soon be enabled to maintain the upright form without the assistance of the supporting stake. If instead of the curved stem of the sapling we take two common rickety deformities, such as outward bowing of the tibiae and knock-knee, we see that the same principle, that is, a rigid splint pro- perly used, can be successfully applied during the period of the patient's growth. The splints em- ployed for these conditions should have one most important feature; they are so constructed and applied that the patient can walk, about ■with perfect ease and comfort ic/iilst wearing the splints. This ambulant method of treating rickety deformities of the bones may seem to contradict the sur- gical axiom that in rickets, when the bones of the leg are yielding to pressure, the child should be kept " off its feet." There is no real contradiction, and treatment both by rest and by the ambulant Fis- 34.-Wooden Splints for ,,,.,, ,, ... Knock-knee. method is frequently required m , , . . 1 J 1 _ The upper bandage does not pass the same case. There is no diffi- in front of the body. culty in deciding when a child is fit to bear suitable " walking apparatus." He generally requires it as soon as he insists on walking. Rest is required when the rickety process is most active. i.e. when the softening of the bones is very great. But rickets is not a matter of five or six weeks, or even as many months, under the best of treatment; in many cases the bones remain for years below their proper resisting power, and it is in cases of rickets, whether of moderate degree originally or remaining so after treatment of a more severe stage, that apparatus that admits of walking must be used. THE RIGID SPLINT. Mechanical treatment, always accompanied by proper diet and hygiene and medicinal remedies, allows of the child s soing to school, and so removes a great additional disability. To consider more closely one example of the use of portable apparatus, a case of knock-knee may be taken. The simple wooden splints shown in Fig. 34 are those employed at the City of London Orthopaedic Hospital. They are readily com- bined with the splint for out- ward bowing of the tibia (Figs. 35 and 36), a frequent concomitant of knock-knee. Among the patients whom I have discharged as cured of this double deformity was a little girl aged five, who had worn the splints for two years. Not a trace of either deformity re- mained. The perfection of form resulting in this and many similar cases that have passed through my hands has con- vinced me of the undesirability of performing operations such as osteoclasia or osteotomy whilst rickets is still in progress and the patient is growing. Only when the disease has ceased and the bones have become hard should osteotomy be performed. These simple and inexpensive wooden splints answer all the indications for surgical treatment, but still they are not so perfect of portability as well-constructed steel instru- ments. The chief points in an instrument of this class adapted to a case of knock-knee may now be examined (see Fig. 37). The fixing parts of the apparatus are at the pelvis and the foot. There are joints opposite the hip and ankle. The Fig. 35.—Wooden Splint for out- ward Tibial Curve, THE RIGID SPLINT. 77 active part is opposite the knee, where the steel must be Fig. 36.—Wooden Splint for out- ward Tibial Curve, applied. ordinary " Walking Instru- -r,. ment "for Knock-Lee. Flg" ^.-Bing-catch Joint. 1, 2, 3, tenon joints ; above 2 a ring-catch is shown in section. Fig. 39.—Detachable Joint. gg=oio Fig. 40.—The Method of elongating Steel Supports. rigid when the child is standing, and the knee must be pulled outward to the splint by fastening the straps of a knee-cap. 7S THE RIGID SPLINT. In order to enable the patient to sit comfortably, there may be a joint at the knee, which can be locked and unlocked according as the patient stands or sits. This effect is obtained by the " ring-catch " joint as shown in Fig. 3 ORTHOPaEDIC operations. manipulations is the use of the superheated air-bath (sec p. 41). The pain that often follows the operation, and that felt during the operation, are frequently avoided by its use. Massage is often of use in the after-treatment. Forcible Stretching of Muscles.—This proceeding is of use as an element in the treatment of contractures, e.g. in diminishing adduction of the thighs and the adductor spasm in spastic paralysis. In slight cases of paralytic contracture of the knee it is also of service. In performing the operation the patient is anaesthetised to full relaxation of the muscles. Then the joint is forcibly moved as far as possible in the desired direction. The amount of force employed must stop short of rupturing the muscle or its tendon. When the parts have been stretched as much as is safe the joint is fixed in plaster, and if full correction has not been obtained the plaster may bo removed a few weeks after the first operation, and a further stretching effected. In stretching the adductors in spastic paralysis it is of advantage to manipulate the stretched muscle by firm trans- verse massage. Orthopaedic Operations.—(1) On the Skin.—Deforming scars that resist treatment by massage, weight-extension, etc., may require operative treatment. Since the form and extent of scars vary widely, the exact method of dealing with them differs in each case. The various procedures are: (1) Excision ; (2) plastic operations. Both these operations may be done with or without skin-grafting or flap-trans- plantation. Careful after-treatment is required to prevent re-contraction. 2. Fascia'.—Contractions of the palmar or plantar fascite may be dealt with by simple transverse section of the bands correction of the deformity, and subsequent long main- tenance of the part in the corrected position. The division of bands of fascia:, contracted in a linear manner, requires avoidance of important vessels and nerves, but is otherwise simple. A small tenotome is inserted between the skin and the band, and its edge is so turned that it is vertical to the tissue to be divided. The band is then put on the stretch, and the division is continued until all resistance is overcome. ' ORTHOPAEDIC OPERATIONS. 93 When wide areas of fascia are involved, as in contraction of the fascia lata in connection with tubercular disease of the hip or knee, simple transverse division is no longer suffi- cient, and the fascio-plastic operation introduced by Y. Wini- warter is employed. It consists in making a V-shaped section, including skin, fasciae, and, if necessary, subjacent muscles. The base of the wedge is generally to be placed towards the proximal side, but wdien this procedure is em- ployed in the treatment of Dupuytren's contraction the base of the V is placed distally. The section made and the deformity corrected, the wound is closed by sutures in such a way that the lines of sutures form a Y. In order to main- tain the improved position the part is encased in a plaster of Paris case or a moulded splint for some weeks, and after- wards a suitable apparatus is worn to prevent recurrence of the deformity. 3. Tendons. — Subcutaneous tenotomy, established by Stromeyer in LS-'U as a regular surgical procedure, remains to the present time as one of the most valuable of surgical resources. The only instruments required are tenotomes. (iuerin's small narrow-bladed knives are those in general use. The two chief forms of tenotomes are the blunt and the sharp-pointed, as shown in Fig. 59. The sharp-pointed knives should not taper too much at the point and the latter should usually be in the central axis of the blade; in the case of the small fascia knife of William Adams, however, the cutting edge should be straight right up to the point. Most tendons may be safely cut with a pointed tenotome, but in the neighbourhood of large blood-vessels, as in the divi- sion of the sterno-mastoid, it is safer to puncture the skin and fascia with a sharp-pointed knife, which is then used as a director to guide a blunt-pointed tenotome, by means of which the section of tendon or muscle is done. The slightly curved tenotome of Parker (Fig. 60) for cutting the tibialis-posticus tendon, ligaments, etc., below the internal malleolus, is also useful. Dieffenbach's sickle- shaped instrument is still used by some Continental surgeons, and some use a tenotome with a slight backward curve. Tendons may be divided either by cutting from the super- ficial to the deep aspect, or vice versa. In the former method 94 S UIU ' I "TA XEOI'S TIE NO TOM Y. in the case of the tendo Achillis a fold of skin is pinched up over the narrowest part of the tendon, whilst the foot is held by an assistant, so that the tendon is relaxed. A sharp- pointed tenotome is then introduced on the inner side of the tendon and pushed on the flat between the skin and the tendon till its point can be felt under the skin project- ing beyond the other side of the tendon. The tendon being put on the stretch by the assistant, the edge of the knife is then turned against the tendon. The assistant then increases the tension of the tendon, whilst the operator presses the blade of the tenotome against the tendon with (\ A \ r\ J Fig. 59.—Tenotomes. his left thumb, and with the right makes the blade execute a series of rocking movements, which cause a sort of grating sensation as the stiff tendon-bundles are successively cut. The completion of the division of the tendon is evidenced by a sudden yielding of the hitherto tense tendon At the moment when this is felt the surgeon turns the knife a^ain on the flat and withdraws it; the assistant at the same time relaxes the parts previously put on the stretch The second mode of dividing the tendon is to pass a sharp-pomted tenotome from the inner side beneath the tendon, and the latter being put on the stretch, the tendon is cut through by rocking and sawing movements of the REPAIR OF TENDONS. 95 knife. In Great Britain it is usual to have the patient lying on the face for this operation, and to use a sharp-pointed, straight tenotome. The best description of the operation is one given verbally to me by Mr. William Adams who recommends that the tenotome be passed through the skin near the inner border of the tendon and then under the latter at an angle of 45° : the edge of the knife is then turned against the tendon which is divided by a suc- cession of leverage movements of the knife against its under surface. If the knife is passed from the outer side, there is dan- ger of puncturing the posterior tibial vessels. Some Con- tinental surgeons have the patient lying on the back, and pass a sickle-shaped tenotome from the outer side. During the division of the tendon by this means, the surgeon holds the patient's foot with his left hand; and, in operating on the feet of little children, it is always advisable for the sur- geon to hold the foot, wdiilst the assistant steadies the leg-. Before passing to the consideration of tenotomy of other tendons, the process of regeneration of tendon may be briefly examined. The repair of tenilon after dirision may be studied in detail in the case of a tendon divided subciitaneously with antiseptic precautions. If the tendo Achillis of a rabbit is examined twenty-four hours after aseptic division, the clean-cut ends are seen to have separated about one inch, and to be coated with a thin layer of blood- clot. They are joined together, and for a short distance ensheathed by a jelly-like, straw-coloured coagulum, which is as large as the tendon, filling out the tendon-sheath. Fig. 60.—Parker's Tenotomes. 9b' REPAIR OF TENDONS. The puncture in the tendon-sheath is closed by a little blood-clot which is adherent to the tissues outside. This uniting coagulum of "plastic lymph" is formed by the coagulation of lymph which has escaped from the divided lymphatics of the tendon, and from plasma which has escaped from the small blood-vessels injured by the operation. At the end of forty-eight hours the appearance to the naked eye is just the same as at the end of the first day, but if the tendon with the sheath and the uniting material be excised, hardened, and cut in sections, it is seen that active biological processes have occurred. The whole of the uniting bond is traversed by branched young connective-tissue cells linked together (see Fig. 61, 5), and careful examination reveals the fact that these cells are multiplying by indirect division, and also that other cells are being formed by the division of (1) the endothelial cells of the divided blood- vessels of the tendon, and (2) the connective-tissue cells of the sheath and of the interfascicular spaces of the tendon. Besides the newly-formed connective-tissue and endothelial cells are seen white blood - corpuscles, both the more numerous variety, with a subdivided nucleus, and the less numerous uni-nuclear variety, or lymphocytes. In the neigh- bourhood of the clot leucocytes of each variet}^ may be found to have engulfed some of the red corpuscles. In the interior of some of the young connective-tissue cells both red and white blood-corpuscles are to be observed. This activity of growth and multiplication of cells are caused in part by the presence of an unusual amount of food in the shape of serum, fibrin, and blood-corpuscles. The cells become predatory amoebae. From their destina- tion, which is about to be described, they are termed " fibroblasts " and " vasoblasts." A divided tendon examined on the fourth day presents a new appearance. The uniting medium, though still jelly- like, is now everywhere traversed by red streaks, due to the formation of new blood-vessels. In other words, the plastic lymph has been transformed to granulation tissue. The newly-formed blood-vessels arise as buds from pre-exist- ing capillaries. Examination of sections of the divided tendon on the fourth day affords evidence of the mode of formation REPAIR OF TENDONS. of new blood-vessels and also of the formation of new connec- tive-tissue fibres from the young connective-tissue cells or fibroblasts. Some other features in the structure of the new tissue Fig. 61. —Part of a longitudinal section tlirough one end of the tendo Achillis of a rabbit, forty-eight hours after operation. 1. A capillary lying between two bundles of tendon fibres. The cut (lower) ends of tendon fibres show no change ; they are surrounded by effused red blood-corpuscles which extend upwards be- tween the tendon fibres and also on the outer side of the tendon. 2. The inner part of the tendon-sheath where it closely invests the tendon and contains many small blood-vessels. 3. The outer part of the tendon-sheath which consists of fibrous tissues with some blood-vessels. 4. The inner aspect of the sheath with proliferating cells. 5. Young connective-tissue cells. X 500 diams. at this stage are worth)' of note. The cut ends of the tendon still present no change, and the blood-clot adhering to them has been to a large extent removed. Traces of digested red blood-corpuscles reduced to hamiatoidin granules are to be H REPAIR OF TENDONS. Fig. 6'2.—Sev- ered ends of rabbit's ten- do Achillis, 1 and 2; with the sheath, 3, and unit- ing tissue, 4. Fourteenth day. seen in some of the fibroblasts. The formation of fibrous tissue by the fibroblasts appears to occasion some shrinkage of the new tissue, for it contains in its centraf part clefts of relatively consider- able size filled with serous liquid. By the eighth day the new tissue, as seen after removal from the bod}', has a greyish-pink appearance. It is now fairly firm, having lost its jelly-like character. The microscope shows it to be vas- cular throughout, and the fibrillation is still farther advanced ; the fibroblasts are now closely packed, and, for the most part, are spindle- shaped. The cut ends of the tendon still pre- sent no marked change. On the fourteenth day the uniting bond consists of well-formed scar-tissue, and although to the naked eye the o-listenins- white original tendon still contrasts sharply with the new material, as shown in Fig. 62, under the microscope, in parts where the fibres of the new scar-tissue continue the direction of the tendon-fibres, it is somewhat difficult to distinguish where ten- don ends and scar begins; but where the fibres of the scar cross the cut ends of tendon-fibres the distinction is easy. The junction of the scar with the tendon is made more intimate by the exten- sion of the former into the inter- fascicular clefts, as shown in Fig. 63. Moreover, fibroblasts find their way between the individual tendon fibres, as at 4 (Fig. 63). After the second week a scar tends to contract owing- to the progressive formation of fibres from the protoplasm of such fibroblasts as are not fully transformed. By this contraction the capillaries of the scar are narrowed and some of them are obliterated, Fig. 63.—Junction of divided end of tendon, 1, with scar, 2. At 3 a capillary of scar extends into a cleft between the bundles ; and a fibroblast, 4, is seen between the tendon fibres. REPAIR OF TENDONS. 9J hence scars on the skin which are at first of a red colour become gradually white. , Before contraction begins the formation of new fibroblasts in normal conditions comes to an end. The time occupied in the formation of scar-tissue is about the same in the rabbit as in man. To recapitulate the steps in the formation of a scar:—■ 1. During the first few hours the effused blood and lymph collect between the severed tissues and coagulate, forming plastic lymph. 2. The cells of the areolar tissue, and of structures such as a tendon-sheath formed of connective tissue, begin to proliferate, and the new cells (fibroblasts) extend into the coagulum and, at the same time, the endothelial cells of the neighbouring capillary blood-vessels also begin to subdivide. These pro- cesses are well advanced at the end of the second day. 3. The fibroblasts form bundles of fibres by the con- version of their protoplasm into fibrils (the latter yield gelatine on being boiled). The cells resulting from the subdivision of the endothelial cells of the capillaries (vasoblasts) extend into the coagulum like the fibroblasts. They remain in continuity with the parent vessel, the lumen of which extends into them, forming at first blind capillary diverticula. These become new capillary loops by coalescing with neighbouring diverticula. These processes are well advanced by the fourth day. 4. The development of fibroblasts and the formation of fibrous scar-tissue is so far advanced by the ninth day that the scar has some degree of resisting power, so that stitches may be safely removed from skin wounds at this period. 5. By the fourteenth day the growth of scar-tissue is fairly complete, and changes which tend to cause contraction commence. It is often of importance to allow scar-tissue to attain a certain degree of strength before allowing a patient use of a part that has been operated on. It may be concluded that in aseptic wounds this stage has been reached at the 100 REPAIR OF TENDONS. end of five or six weeks.* Mr. A. H. lubby found that the uniting tissue after section of the tendo Achillis in rabbits that were allowed to run about freely continued to elongate up to the end of the thirteenth month at which time°it was nearly three inches in length. Other modifications occur in the course of time induced chiefly by the physiological use of the repaired tendon. In the external part of the uniting bond, where it is attached to the sheath, from which it was largely generated, the fibres become drawn out by the alternate to and fro movement during the action of the muscle. At the same time the blood-vessels which pass from the sheath become elongated and attenuated, whilst those which pass into the uniting material from the interfascicular spaces of the tendon under- go compensatory enlargement. In some instances, where tendons have been divided and examined after death some years later, it has been found difticult to detect any difference between the old and the new material, although on closer scrutiny the parallel course of the fibres of the old tendon is seen to be interrupted where the scar-tissue joins together the two ends. In elongating by a Z-shaped section in an open wound the tendo Achillis of a man who had had an ordinary subcutaneous tenotomy performed twenty-five years previously, the new tissue was, I found, as strong as that of the original tendon, and to the naked eye was only distinguishable by adhesions which stretched from it to the sheath. The fibres of scars run in various directions, and the tissue which repairs the gap in a divided tendon is scar-tissue. These phenomena bear on surgical practice in regard to tenotomy, showing that though the ends of a tendon are separated for a considerable distance, good repair may ensue, and if the tendon-sheath is preserved intact, the lateral adhesions of the new piece of tendon will be limited to the sheath. It must be remembered that the new tissue is merely scar-tissue, and is capable of contrac- tion or of elongation unless this is prevented for a sufficient length of time by suitable apparatus. The old practice of putting up a limb after tenotomy * This account is abbreviated from the author's " Surgical Pathology and Principles." Longmans & Co., 1897. REPAIR OF TENDONS. 101 in the deformed position and subsequently gradually stretch- ing the uniting bond has been proved to be unnecessary. A gap of three or four inches between the divided ends will in most cases be solidly repaired. It is important, how- ever, to remember that the uniting material like all scar- tissue remains capable of being elongated by continuous traction for several months. Thus, in cases of club-foot, where multiple tenotomies have been performed, but the condition has been allowed to relapse for want of proper after-treatment, the deformity may often without further operation be corrected by patient stretching of the " callus " of the tendons as long as a year or more after the tenotomies have been performed. Thus in a child aged two years who had been operated on for equino-varus at the age of six months, I have found that the deformity was still uncorrected. In this case by gradual instrumental treatment I was able to correct the deformity completely in the space of four weeks. The chief facts regarding the union of tendons divided subcutaneously were established by the classical work of William Adams. The behaviour of the tendons of different muscles after subcutaneous section is a question of importance. Adams has shown that the tendons of the tibialis muscles undergo repair in a manner quite similar to that observed in the tendo Achillis. In some instances Adams noticed complete repair of the tendon of the posterior tibial muscle without any adhesions whatever. Similarly the tendons of the tibialis antieus, the flexor longus digitorum, the hamstrings and other muscles, readily undergo repair after tenotomy, whether done subcutaneously or by open incision. After division of the tendons of the fingers over the phalanges function is almost always lost by reason of adhesions that form between the divided ends of the tendons and the sheath. Dr. F. Wolter, in a very instructive article*points out that when the division has taken place over the first phalanx and tendon suture is performed, the prognosis is not so grave. Precautions to be taken in performing tenotomy are * F. Wolter, -'The Functional Prognosis after Tendon Suture," Arch, fur klin. Chir., 1888. 102 OPEN TENOTOMY. the same as in other operations. Before deciding upon the operation care should be taken to make sure that the patient is not a " bleeder." Before and during the operation every detail of antiseptic surgery should be observed with as much completeness as though the peritoneal cavity were to be opened. If these precautions are taken there are no complications to bo feared after a skilfully performed operation. The causes of failure of tenotomy are mainly three. 1. The presence of dense scar-tissue remaining from previous tenotomy. This is a frequent condition in the relapsed cases still so commonly seen. In such cases the method of gradual stretching should be patiently tried before any fresh tenotomy is decided on, and the open operation should be preferred. 2. Incomplete division of the tendons. This causes much pain to the patient, and results in imperfect correction of the deformity. 3. Ill-directed or insufficient after-treatment. Open Tenotomy.—It is sometimes said that need of subcutaneous tenotomy has disappeared with the advent of antiseptic surgery. Though there is now no danger of septic complications of wounds, in cases where the simple section of a tendon is all that is required, it is still better to leave the skin intact for several reasons: firstly, with a view to minimising the extent of the wound ; secondly, in order to prevent adhesion of the new piece of tendon to the wound in the skin, and subsequent stiffness when the patient begins to use the part. Still, if for any reason it may be desirable to operate by the open method, there need not be any hesitation in resorting to it. Thus, after division of the tibialis-posticus below the internal malleolus, in a case of talipes equino-varus, if it is necessary to divide also the flexor longus digitorum, I do so by a short incision a little above the base of the internal malleolus, and when the sheath of the muscle is exposed, I puncture the sheath with a sharp-pointed tenotome, which I then pass under the tendon to cut through the latter. The preservation of the sheath is of importance in securing, as far as possible, absence of adhesions between the new piece of tendon and TENDON SUTURE. 103 the surrounding parts. Where a tendon is in close relation to important structures it may be preferable to divide it by the open method. Again, when a tendon at the part at which it is desired to divide it sends off' processes to the deep fascia, it may be desirable to make an open incision and to divide any offshoots of the tendon that resist cor- rection of the deformity. This is the case with the biceps Figs. 64, 65, 66.—Different Methods of Tendon Suture. (After Duplay and Reclus, from Treves's " System of Surgery.") femoris, of which the lower tendon sends from its posterior border strong fibres to the fascia lata. Operations on Tendons other than Simple Tenotomy. —Tenotomy is usually performed with a view to removing deformity by elongating the tendon. In certain paralytic cases, and more still in spastic conditions, it serves another purpose, namely, diminishing the range of movement of a muscle or set of muscles the contracting force of which predominates over the antagonistic muscle or muscles. Both these ends are equally well attained by elongating the tendons by a plastic operation. Tendon sat are after rupture or 104 LENGTHENING A TENDON. traumatic section of tendons is frequently required in ordinary surgor\ TIk exact manner of passing the sutures will vary according to the character of the tendon in each case. Various plans of passing sutures are shown in Figs. 64, (>5 and 66. For suturing: tendons sterilised silk stitches are the best in my experience. Lengthening a Tendon.—This operation is usually performed by making a Z-shaped section of the tendon and suturing together the divided ends in the desired position (Fig. 67). It is most frequently practised on the tendo Achillis for talipes equinus. Some attention is required in order to judge correctly the necessary lengths of the vertical incision, which is frequently made too short. After the operation the sheath* should be carefully sutured over the elongated tendon. Another mode of tendon-lengthening is by making a transverse section of the tendon and then turning down a flap from one ex- tremity, as shown in Fig. 68. This method is commonly employed to repair a gap left after sloughing of part of a tendon. Shortening a Tendon. — Willett's operation :—t " A L Fig.07.- Diagram showing Method of Lengthening Tendon by Z- shaped Incision. a, tendon before ; b, tendon after elon- gation. Fig. 68.—Lengthening Tendon by turning down Tendon flap. (After Duplay and Redus, from Treves's "System of Surgery.") * Some writers state that the tendo Achillis has no sheath. Though there is no firm fibrous sheath, there is a definite sheath with a smooth inner°surface and the proper management of this makes all the difference to the patient's comfort after the operation. f St. Bartholomew's Hosp. Reports, vol. xvi., 1880, p. 309. SHORTEaNLNG a tendon. lor. Y-shaped incision, some two inches in length, is made over the lower end of the tendo Achillis down to the tendon. At the lower or vertical portion of the in- cision the dissection is continued until the tendon is fully exposed over its superficial and lateral surfaces for the space of one inch in length, its deep connections being left undisturbed. The tendon is now cut across at the point of junction of the oblique portions of the wound with the vertical. Next, the proximal portion of the tendon is raised, with its superficial connections to the integuments undis- turbed, to the extent of fully three-quarters of an inch, by dissecting along its deeper surface, i.e. by reversing the dissection made upon the distal segment. A wedge-shaped slice of the tendon is now cut off from both segments, that from the proximal being removed from the deep sur- face, whilst from the distal it is taken from the superficial, in both instances the bases of the wedge-shaped portions re- moved being at the point where the tendon has been divided. The heel being now pressed upwards, the proximal portion, including both skin and tendon, is drawn down and placed over the distal, thus bringing the prepared cut surfaces of the tendon into apposition. In this position they are held by an assistant, while four sutures, two on each side, are passed deeply through the integument, then through both portions of the tendon, and again out through the integu- ment, and fastened. When the operation is completed, the united edges of the wound assume a V-shaped appear- ance, owing to the angle of the proximal portion being now attached to the terminal point of the distal portion of the orio-inal incision." Gibney* has modified Willett's operation. He makes use of the same Y-shaped incision in the skin, but instead of removing a portion of tendon he makes a very oblique section and sutures the upper portion as low as possible to the lower, putting up the foot in a position of full plantar flexion. Instead of either of the foregoing operations, the Z-shaped section may be made as for tendon-lengthening, and the * Gibney, " Annals of Surgery," vol. xi., p. 241. 10(1 SHORTENING a tendon. required amount cut off from each severed end, before they are united along every part of their cut surfaces. Phocas* has practised the following operation : The tendo Achillis is laid bare by a median incision tlirough skin and sheath and transfixed from side to side at the upper end of the denuded part; the knife is made to split the tendon so that the greater thickness of the latter lies superficially. This superficial (posterior) part is freed by cutting outwards at each end, whilst the anterior part is folded upon itself and fixed with sutures. The amount of shortening so ob- tained is equal to one half the length of the incision in the tendon. Walshamt has practised transplantation of the tubercle of the os calcis with the view of producing the same effect as shortening the tendo Achillis without the risk of weakening the tendon. " A vertical incision, about four inches in length, is made over the centre of the lower portion of the tendon, and is carried downwards over the point of the heel. The sides of the wound are retracted ; the lateral margin of the tendo Achillis immediately above its insertion into the bone is defined, and a director passed beneath the tendon. A key-hole saw is next slid along the groove of the director, its cutting edge turned downwards, and a p3rtion about half an inch thick of the os calcis cut through, the saw emerging on the under surface of the bone. During this procedure the skin-flaps must be well retracted. To ob- tain enough room the first or skin incision must be carried sufficiently far forward along the under aspect of the heel. If this has not been done, it must at this stage be pro- longed. It should have been carried tlirough the fatty tissue of the heel down to the bone. The lower half inch or so of the posterior detached end of the os calcis is now cut off, and the upper end of this portion, to which the tendo Achillis remains attached, is drawn down and fixed by an ivory peg to the lower part of the section of the posterior part of the os calcis. Whilst this is being done the foot is held in the position of extreme plantar flexion. The wound should then be completely closed by sutures." * Revue d'Orthopedic, 1894. f Walsham and Hughes, " Deformities of the Foot." TENDON TRANSPLANTATION. In? The foot is dressed and put up for six weeks in plaster. In a case reported by Walsham and Hughes the trans- planted bone was found to be firmly united at the end of this period. Tendon Transplantation.—This operation (Fig. 60) was in- troduced by Xicoladoni for cases of paralytic calcaneo-valgus, the tendons of the sound peronei being divided at the ankle and attached near the insertion of the tendo Achillis. This operation may be profitably combined with shortening of the tendo Achillis by the Z-method. Mr. Frederick Eve* has applied the method of tendon transplantation to ordinary i i Fig. 69.—Tendon Transplantation. The free end of divided tendon is being fixed in a slit made in another tendon, as suggested by Goldthwait. (After Duplay and Rectus, from Treves's " System of Surgery.") paralytic equino-varus and other conditions, but it remains to be seen whether the functional result in this class of cases is as good as that obtained by the ordinary methods. Tendon Grafting.—A freshly isolated portion of tendon may sometimes be successfully grafted into the course of another tendon to fill a gap left by sloughing. Myotomy.—The division of muscles like that of tendons may be done either subcutaneously or through an open wound, and repair, as in tendons, is effected by scar- tissue. Another mode of altering the length of a muscle is by either subperiosteal detachment of its tendon of insertion or, better, by separation of the portion of bone into which its tendon is inserted (p. 106). * Frederick Fvu, Clin. Soc. Trans., 1898, p. 316. Ins OPERATIONS ON JOINTS. Syndesmotomy, or section of ligaments, was introduced as a systematic proceeding by J. Guerin in club-foot. Langenbeck applied it to the treatment of knock-knee, dividing the external ligament. This latter operation has been rightly abandoned. In congenital club-foot properly treated from the first, the operation is, in my opinion, never necessary, whilst in neglected cases it is often of service. R. W. Parker gives the following indications for its employ- ment :— Division of ligaments is indicated (1) in a certain number of originally severe cases : (2) in some which have not been treated in early life ; and (3) in some relapsed cases. In many cases it will be found that the position of the foot cannot be rectified even after section of several tendons, including the tendo Achillis. This is usually attributed to adhesions which have formed between the tendons and their sheaths, sometimes to inefficient operations, some- times to other causes. In preceding chapters I have discussed the anatomy of this condition, and shown that it largely depends on the ligaments, which, like some of the tendons, have been developed too short. The extreme shortness and the unyielding nature of the ligaments render it almost impossible to lengthen them by any amount of stretching which can be tolerated by the living foot. Open Division of all the Resistant Soft Parts.— Examples of this procedure are V. Yolkmann's open opera- tion for wry-neck and Phelps's open operation for club-foot. These unsparing methods should only be adopted when there is no chance of obtaining a cure by gentler measures. Operations on Joints.—Forcible correction of angular deformity due to fibrous ankjdosis. An instance of this procedure has already been given on p. 89. Careful selection of cases should be made, since forcible correction has been known to re-awaken suppurative or tubercular activity in a joint. The operation consists of a breaking down of adhesions, and consequently entails some haemor- rhage into the joint. The blood thus poured out will certainly be transformed into fresh adhesions unless this is prevented by suitable after-treatment. After the opera- tion the joint should be firmly bandaged in the corrected position and an opiate given, if necessary. The time at which passive movements should be begun varies in different instances. Where the adhesions are few in number the OSTEOCLASIS. 109 patient may use the joint from the operation. If the previous condition of the joint has been an inflammatory one, and the adhesions are abundant, it is best to wait two or three days before performing passive movements, and gas may be given for the first movement of the joint. If a stiff" joint in an improved position is all that can be hoped for, the joint must be fixed in the desired position for four or five weeks, and after that the patient may be allowed to get about with a support. Forcible Correction of Bony Deformity or Osteoclasis. —This operation is indicated in badly-set fractures, rickety deformity, and cases of osseous ankylosis where there is a bad position of the joint. The bone may require to be divided through the diaphysis, the epiphysis, or the epiphy- seal line. The operation may be performed in slight cases by manual force. Green-stick fractures of rachitic children Fig. 70.—Grattan s Osteoclast. are often overlooked, and receive no surgical treatment until the resulting deformity is accidentally discovered, and they furnish a large number of cases in which the deformity can be forcibly corrected without instrumental means, Thus ll'J OSTEOTOMY. a green-stick fracture of the radius may often be straightened by3 the surgeon's two hands. In this instance the hands are used as a double lever. Manual force may also be applied as a single lever, an assistant fixing the limb Just above the spot where it is desired that the bone should be broken, whilst the surgeon uses as a lever the part of the limb below the point of fixation. Mechanical osteoclasts work on the same plan as these manual methods; a simple example of the two-armed lever as osteoclast is that of Pizzoli. An ingenious form of the two-armed osteoclast was invented by the late Mr. Nicholas (Jrattan, of Cork. The instrument is made of polished steel (Fig. 70), the two curved arms can be fixed at varying distances apart, and by means of a powerful screw the fulcrum can be brought to bear with any desired degree of force upon the middle of the convexity of a curved bone. The pressure of the fulcrum of machines of this type over the projecting angle of bone is apt to produce contusions of the soft parts, and for this reason osteoclasts of the one-armed type are safer. Osteotomy.—Since 1-S26, when Rhea Barton* first per- formed intertrochanteric osteotomy of the femur for osseous ankylosis operating through an open wound, and V. Langen- beck subcutaneously through a small wound, the operation has to a large extent replaced osteoclasis. Osteotomy is now one of the commonest of surgical operations. This is to a great extent due to the freedom from danger that Listerism has given. In rickety cases there is now a tendency to abuse of the operation. In Great Britain William Adams and Maeewen have done much towards the perfection of this operation, and the * R. Barton: N. American Med. and Surg. Journal, iii., 1829, p. 279. OSTEOTOMY. Ill two chief modes of performing osteotomy may here be illustrated by Adams's oper- ation for subcutaneous osteotomy of the neck of the femur in ankylosis of the hip and Macewen's osteotomy of the lower part of the shaft of the femur for old-standing genu valgum. Adams's Operation (1869). — The patient lies supine. An incision is made through the soft parts down to the neck of the femur with a long narrow-bladed knife. The knife is then made to incise the periosteum, etc., along the anterior aspect of the neck of the bone, and before the knife is withdrawn the saw (Fig. 71) is passed along the blade. By short sawing movements the bone is almost completely divided, the division being completed by the posterior layers of bone being fractured by forcible ab- duction of the limb, which is then put position. Fig. 7'-.—Lower end of Femur, showing— a, line of incision in soft parts ; b, line at which the osteotome is driven into the bone; line of epi- physeal cartilage is indi- cated at c; d marks the internal condyle of femur. {From 1'reves's "Operative Surgery.") up in the desired Macewen's Operation.—The method of osteotomy de- scribed by Macewen (1880) may be best appreciated by describing this sur- geon's operation for genu valgum. The limb is ex- sanguined, and a flat elastic tourni- quet is applied to the middle of the thigh. The knee is bent and is laid on its outer side on a Fig. 74.—Different sizes of Osteotomes and Chisels. The two figures to the left show the difference between Chisel and' Osteotome. 11; OSTEOTOMY. Fig. 75.—Gighli's Sa firm sand-bag (18 in. by 12 in). The surgeon feels the adductor tubercle and the tendon of the adductor magnus. A longitudinal incision reaching down to the bone is made with its centre at the intersec- tion of two lines, one a finger's breadth above the level of the upper border of the external condyle, the other (in the adult) half an inch in front of the adductor tendon. The osteotome is introduced along the blade of the knife, and the latter is then withdrawn, and the edge of the osteo- tome is turned so that it rests on the bone at right angles to its long; axis. The shaft of the osteotome is directed outwards towards a point a fing-er's breadth above the ex- ternal condyle, and made to enter the bone by sharp taps of a mallet. The osteotome should be held firmly with the left hand, the inner border of the hand resting on the limb so as to prevent the in- strument being driven too far in any one direction. The deeper part of the incision in the bone may be effected with a smaller instrument than that used at the beginning. The extent to which the bone must be divided varies according to its hardness. Usually two- thirds transversely is sufficient, the remainder should be broken by forcibly adducting the leg, the surgeon placing his left hand over the wound, which is covered by a sponge, whilst the right hand exerts leverage on the leg. If the bone should prove to be insufficiently divided, a few taps with a small osteotome on the posterior layers of the bone will usually render the completion of the operation easy. Figs. 7(i, 77. — Illustrating Ollier's Method of Elongating a Limh by Oblique Osteotomy and subsequent Extension. Fig. 76 before, Fig. 77 after, operation. OR THOPaEDIC OPERA TIONS. 113 The chief points to be observed in this operation are shown in Fig. 72. Macewen's osteotome is shown in Fig. 7:3. For performing osteotomies of various kinds, the surgeon should be provided with sets of chisels and osteotomes as shown in Fig. 74. These instruments should be carefully tempered and tested on ox-bone before being used in surgery. Oblique section of bones in some instances gives a better correction of a deformity than simple transverse section. With care Adams's saw can be used for this pur- pose. Gighli's flexible wire saw (Fig. 75) renders section of the bone in any direction safe. Oilier has suggested elongation of bones deformed by rickets after oblique section by means of continuous traction ; and by this means he has obtained nearly l^oinch of length in a limb (see Figs. 76 and 77). This method has also been successfully applied for ankylosis of the hip with shortening, as will be described later. Wedge-shaped Resection of Bones.—This is sometimes practised instead of transverse osteotomy, e.g. in the neighbourhood of joints for osseous ankylosis and in bones severely deformed by rickets (Fig. 78). Curvilinear Osteotomy.—This operation was performed by Sayre (1869) for ankylosis of the hip with a view to the formation of a false joint in the intertrochanteric segment of the femur. It has also been performed at the knee and elbow for osseous ankylosis. A simple curved sawing of the bone may be done. Or a segment may be removed, as shown in Figs. 79 and 80. When it is desired to obtain a movable false joint passive movement must be begun about the tenth day. Operations for the re-formation of the hip-joint, as practised by X. Volkmann in hip ankylosis, by Hoffa and Lorenz in con- genital hip dislocation, and by Arbuthnot ^ Lane for pathological dislocation, belong to rig. 78.-Cuneiform this Categorv. Osteotomy. -.,,", . , • i (From Treves's Chondrectomy is the name given by » o^mtive surgery.") i 114 OR thopaed ic ope ra tions. Oilier to an operation consisting of the removal of an epiphyseal cartilage with a view to checking the rate of longitudinal growth of bone. It has been successfully employed at the lower end of the ulna in a case where the lower epiphyseal cartilage of the radius had been destroyed by acute osteomyelitis, and the hand had been deflected to the radial side. Ghondrectomy should not be resorted to in cases where the epiphyseal cartilages lie within a joint. Resection of joints, as a remedy for the results of de- forming arthritis, or ankylosis, is sometimes employed as an orthopaedic measure. In some cases the aim of the surgeon is to obtain a fixed, in others a free joint. If the former, the ligaments of the joint and the muscles that act upon it are to be spared as much as possible. This operation is not to be used in young growing subjects if more conservative measures hold out any pros- pect of success. Orthopaedic surgeons, perhaps more than others, so often witness the physiologically bad effects of early excision of the hip-joint that, in this articulation especially, conservative treatment is indicated during the period of growth. Excision of bones, e.g. removal of the astragalus for severe and intractable equino-varus (Lund), or for severe flat-foot (Vogt), is sometimes employed in fault of more conservative measures. Such operations are called for but seldom, and only owing to the neglect of earlier treatment. Osteoplastic Operations.—A striking example of this class of operation is the Wladimiroff-Mikulicz plastic operation, as applied to the treatment of shortness of one leg or to chronic ankle-joint disease. In this operation a talipes equinus is established artificially, in order to compensate for the short- ness of the limb. Arthrodesis, or the operation for producing artificial Figs. 7(<>, SO.—Curvilinear Osteotomy, with removal of a Segment of Bone. ORTHOPaEDIC OPERATIONS. 115 ankylosis, was introduced by Albert in 1877. It is used in cases of flail-joint resulting from paralysis. The operation consists in opening the joint, removing the articular cartilages and a thin layer of bone, and then fixing the joint in the position that it is desired it should retain. The bony surfaces may be wired together, or fixed by ivory pegs, if it be thought necessary. A bony ankylosis is aimed at, but sometimes only fibrous results. Arthrodesis has been performed (1) at the shoulder-joint, when the shoulder-muscles are completely paralysed; (2) at the elbow-joint, when all the flexors are paralysed; (3) at the knee ; and (4) at the ankle. In most cases, in my opinion, suitable mechanical appli- ances afford the patient as much relief as the fixation of joints by ankylosis. 117 part II. SPECIAL ORTHOPAEDIC SURGERY. SECTION I. DEFORMITIES OF THE TOES AND FINGERS. Hallux Valgus. — In countries where boots are worn hallux valgus is the commonest of all deformities. In the normal foot the inner surface of the great toe is in the same plane with the inner border of the foot, as may be seen when the foot is placed firmly on the ground close to a wall. In those who wear sandals, or go with naked feet, the great toe may be slightly adducted and retain a share of the pre- hensile power seen in the hallux of the quadrumana. Symptoms.— The appearance of hallux valgus is so familiar that it may be con- sidered superfluous to give illustrations of the condition. There are, however, certain points in different cases that require at- tention. Thus, in the accompanying illus- trations (Figs. 81 and 82) it will be noticed that in the right foot the displaced great toe has passed beneath, whilst in the left it has passed above the second toe. In other cases, again, the Figs. 81, 82.—Hallux Valgus. (After Hoffa.) 118 HALLUX VALGUS: PATHOLOGICAL ANATOMY, second toe is doubled back in the peculiar form known as haminer-toe (p. 130); or, again, the second toe may remain parallel with its displaced companion, being simply flattened against it. In this last instance either the outer, or more rarely the inner edge of the nail of the great toe may be forced into the soft tissues, constituting what is grievously misnamed "ingrowing toe-nail," a term implying a false accusation of active perversity on the part of the nail. This error of nomenclature is responsible for the misdirected surgical proceeding still much in vogue, namely, avulsion of part or the whole of the nail of the great toe. In the more severe grades of hallux valgus the great toe may be almost at a right angle with the metatarsal bone, and much discomfort or pain is usually complained of. Indeed, the complicating bursa and other sequels of the deformity described below often render it a very serious affliction. Pathologictd Anatoniy.— In the slighter cases the altered position of the great toe may be described as eversion ; but in the more advanced cases there is a subluxation of the meta- tarso-phalangeal joint. The inner edge of the base of the first phalanx rests against the middle of the head of the metatarsal bone. The sesamoid bones are displaced outwards with the first phalanx, and thus they no longer articulate with their proper facets on the head of the meta- tarsal bone (see Fig. 83). The tendon of the long flexor of the great toe and the attachment of the abductor pollicis and other muscles attached to the base of the first phalanx are also dis- placed, and these muscles, acting in an abnormal direction, tend to increase the displacement when Fig. 83. — Diagram showing the once it is begun. The inner part changes of the chief parts con- _ir fi -i ? £ tl r . cemed in Hallux Valgus. 0I me_ neaa oi the metatarsal 1, internal lat, ligt. which is elongated ; bone is exposed to pressure of 2, bursa; 3, inner part of the head of tbft hnnt onrl £rw*.™„ the first metatarsal; 4, inner sesa- 0t and /0rms a promi- moid bone displaeed outwards. ^ nence, to which the term HALLUX VALGUS: CAUSATION. 11!) "bunion" is applied by the laity. This part of the head of the bone, and the facets for the sesamoid bpnes, in time lose their cartilaginous covering, and a groove forms from the pressure of the inner edge of the base of the first phalanx. This groove constitutes a further obstacle to reduction of the deformity. A bursa forms beneath the skin which covers the prominence, and the latter is thus increased in size, especially when the bursa is over-filled with fluid from inflammation. The skin over the bursa may give way and suppuration ensue in the bursa, which may extend to the joint, causing its disorganisation. A painful corn may form on the skin. The internal lateral ligament, which is thickened in slight cases, is stretched and thinned in old-standing cases, and may become completely atrophied. When osteo-arthritic or other changes are present in the joint, there may be extensive ulceration of articular cartilage, and the inner border of the base of the phalanx may be found to have caused a deep groove upon the head of the metataisal bone. Sometimes there is a similar condition at the inter- phalangeal joint, the terminal phalanx being displaced out- wards. Causation.—Hallux valgus is caused by pressure. Con- genital cases are met with. At the present time I have under my care an infant of a few weeks whose right foot presents a well-marked hallux valgus, the second toe riding on the displaced hallux : the latter is, however, easily held in its place. In the same foot the little toe is displaced up- wards and inwards upon the base of the fourth toe. Acquired hallux valgus is due to the use of boots or shoes that are pointed towards the middle line of the foot instead of being straight along the inner border. In infants and weakly children tight socks are sufficient to cause the displacement of the great toe outwards. High heels also favour the development of hallux valgus, by forcing the toes into the narrow part of the boot. When the affection arises in otherwise normal feet it is, like the Ghinese lady's foot, an example of an alteration of form pro- duced gradually by simple mechanical means. Alteration of the form of a part by long-continued slight pressure \I) HALLUX VALGUS: TREATMENT. is frequently aimed at in orthopa'dic surgery. In hallux valgus this displacement is produced in an abnormal direc- tion, whilst in surgery similar forces are employed to rectify abnormal deviations from the natural direction of different parts of the body. When the ligaments of the metatarso- phalangeal joint and the bones are softened by inflammation, whether of rheumatic, osteo-arthritic, gouty, or other nature, the displacement occurs the more readily. The outward displacement of the great toe necessitates alteration in the position of the second toe, and of all the other digits. Treatment.—Preventive measures are readily to be deduced from a close study of the causation of hallux valgus. Medical men are frequently able to enforce such measures, especially in the case of young girls, and it is to be hoped that in time the absurd attempt of fashion to impose upon a, the foot a unilateral instead of the more beautiful bilateral symmetry will be relin- quished. If the print of the sole of a normal foot is studied it will be seen that the shape of the sole of the boot should be as is shown in Fig. 84. It is some- times very difficult to induce a bootmaker -to understand this, even when the order is accompanied, as it should he, by a tracing of the sole of the foot and an outline of the shape that the sole of the boot is to have. The principles of natural boot - construction have been correctly laid down by Hermann Meyer: "A sole is of the proper construction when a line [Figs. 84 and 85] drawn at half the breadth of the toe distant from, and parallel to, the inner margin of the great toe shall, when carried back- wards, pass through the centre of the heel. In the usual Fig. 85. Meyer's scheme for Plail Gf construc- the construction of a sole of a shoe or boot about a line (a b) passing through the mid- so'3, die of the heel and along the middle of the great toe when placed in its normal position. tion of an or- dinary " shoe- manufacturer's" BALL UN VA LGITS .■ THE A TMENT. 12] form of a sole this line passes out of the inner margin of the heel [Fig. So]."* A properly-shaped boot or shoe is in reality far more pleasing to the eye than a boot of the fashionable or deforming shape. In children who have not worn shoes the toes are more outspread, and the boot or shoe should be relatively broader than for adults. (See Fig. 86). Some boots said to be after the natural shape are aggressively straight right up to the tip of the great toe. There is no need for a well-fashioned boot or shoe to be anything but graceful and pleasing to the eye. The general outline of the sole and the hollowing at the " waist" are shown in Fig. 87. Other features of importance are that the "upper" should not slope rapidly either at the toe or at the sides of the boot. The "waist" of the sole should be gently arched. The under surface of the heel and of the thick part of the sole should form one horizontal surface, i.e. when the wearer is standing on a level surface every part of the heel and of the thick part of the sole should touch the supporting surface. A sole that rises upward in front has been termed the " rocker " sole. With such a sole the toes are extended at the metatarso-phalangeal joints, and thus are predisposed to the condition of hammer or claw-toe. Whilst the front part of the sole should be flat, the heel should be but very slightly higher than the soles. In persons who habitually wear very high heels a slio-ht degree of talipes equinus, or non-deforming club-foot, not uncommonly results. Royal Whitman (New York Medical News, August 14th, 1N!)7) makes some practical remarks on shoes which deserve careful study : " The object of the shoe is to cover and to protect the foot, not to deform it or to cause discomfort; * H. Meyer, translated by J. S. Craig, " Where the Shoe Pinches," 1861. §i5/ 86.—The normal footprint of a child, aged three years, who had not worn shoes. U-2 HALLUX VALGUS: TREATMENT. therefore the one should correspond to the shape of the other If the feet are placed side by side, the outline and the imprint of the soles will correspond to the accompanying diagram rFi" 87] The outline demonstrates the actual size and° shape of'the apposed feet, emphasised by enclosing them in straight lines. Thus each foot appears to be somewhat triangular, being broad at the front and narrow at the heell The imprint shows the area of bearing surface, and, owing to the fact that but a small portion of the arched part of the foot rests -upon the ground, it appears to be markedly twisted inward. The sole of the shoe, if it is to enclose and support the bearing surface, must also appear to be twisted inward in an exaggerated right or left pattern ; it will be straight along the inner border, to follow the normal line of the great toe, and a wide outward sweep will be necessary in order to include the outline, and thus to avoid compres- sion of the outer border of the foot. " I have found this statement of a self-evident fact and the demonstration of the true form of the foot to be almost an indispensable preliminary to an intelligent discussion of the relative merits of shoes, and, indeed, somewhat of a revelation to those who have thought of the foot only as it has been subordinated to the arbitrary and conventional standard of the shoemaker. This ideal, or shoemaker's foot, upon which lasts are fashioned, is much narrower than the actual foot; the great toe is not a powerful movable member, provided with active muscles, but is small and turns outward, so that the forefoot is somewhat pyramidal in form, and turns upward as if to avoid the contact with Fig. 87. Shows (1) the impressions of normal feet, the tracing (2) obtained from such feet, and (3) the proper soles for normal feet. Shows the impression, etc., of feet deformed by wearing fashionable boots. ( Mod ified from Royal Wliitman.) HALLUX VALGUS: TREATMENT 123 the ground. This imaginary foot, drawn after the shape of the ordinary last, appears in the diagram [Fig. 88.] Upon it the sole of the shoe has been indicated to contrast it with the shape of that necessary to include the outline of the normal foot. The actual foot is thus com- pressed laterally by the shoe until the stretching of the leather during the ' breaking-in' process allows it to over- hang- the sole, the great toe is forced outward, and, with its fellows, is compressed, distorted, and lifted off the ground by the rocker-shaped sole, so that normal function is reduced to the smallest limit. Thus the foot, according to the age at which the re-shaping process is begun, and the constancy of the application, gra- dually approaches the ideal, and fits the shoe." Additional points of importance in the proper shape of boots are mentioned by Parker Sims (New York Medical Jour- nal, October 2nd, 1897) in an article on " Bunion." " The cause of this deformity is the wearing of shoes which are faulty in shape or are ill-fitting. A shoe that crowds the toes together or pushes the great toe backward will tend to produce this trouble. In this class are shoes with the following characteristics: First, shoes with narrow points, with the point in the median line; second, shoes that are too short; third, shoes that are so loose at the instep as to allow the foot to ride forward, and thus bring direct backward pressure on the toes; fourth, the worst of all, are shoes which combine two or all of these defects. Some pointed lasts are so constructed that the point is on the inner side of the shoe, and the toe is not necessarily displaced." Curative Treatment.—In slight cases it is sufficient to order stockings with a separate stall for the great toe, and to see that the patient's boots are of the right shape. The toe should be drawn inwards several times twice a day. ^ When once the great toe has been brought into line with the inner border of the foot, the "tip-toe" exercise Fig. 89.—Bigg's Bunion Spring. 121 HALLUX VALGUS: TREATMENT. recommended by Ellis should be practised twice daily in order to strengthen the muscles and to render the joint firm. In more severe cases all the foregoing measures must be adopted, and in addition mechanical means must be taken to keep the toe in its place. There is a groat variety of these to choose from. Perhaps the most familiar is Bigg's bunion spring (Fig. 89). This is practically an internal splint fixed to the foot round the instep by a band to which it is connected by a movable joint. A second band passes round the heel to prevent dis- placement forwards. The instrument is only suitable for wearing at night. A more con- venient appliance, and one that can also be worn by day, is a lever (Fig. 90) having a broad, well-padded fulcrum about the middle of the first metatarsal at the inner border of the foot. Sayre's plan consists in using a leather cap fitting over the great toe and secured by a tape which passes from the inner side of the leather cap along the inner border of the foot, where it is fixed by straps which -Bunion pass round the instep and just behind the Lever. ball of the toes. A length of elastic webbing may be inserted into the tape if it is necessary. A metal or leather sole-plate, such as that shown in connection with hammer-toe (Fig. 99), may be worn both by day and at night. The idea of making a separate partition in the boot for cases of hallux valgus appears to have originated with an American surgeon, G. R. Fowler* who writes: " A stocking of rather more than the ordinary width is chosen, and a double line of stitching run at the side of the interspace of the great and adjoining toes; by cutting accurately between the lines of stitching, a separate cot or receptacle was provided for the great toe, similar to the thumb portion of a mitten. ... A last straight line along the inner edge is chosen. The partition separating the compartment for the great toe from the balance of the front of the shoe is made of two thicknesses of calf- * G. R. Fowler, New York Medical Record, Sept. 7, 1889. HALLUX VALGUS: OPERATIVE TREATMENT. 12:. skin, and is secured in place in the following manner: The last is split, and the pieces of calf-skin from which the partition is formed are placed in position in the slot, a sufficient projection being left to pass through a slit in what is to be the inside sole of the shoe, in which latter location it is secured while still on the last. The shoe and welt are then ' lasted ' in the ordinary manner, the reflected upper edges of the partition being stitched to the toe portion of the upper, and the shoe being arranged, in order to facilitate putting it on properly, to lace as low down as the site of the partition, which latter may be only just sufficiently deep to get a firm hold upon the toe—say, about one-third the depth of the interdigital space." A similar idea has been embodied in the " toe-post." Many patients find the latter too rigid for comfort. The fact that proper sandals are an efficient preventive of hallux valgus suggests the use of sandals as a curative measure. A stiff' sole-plate with slots for tapes by which the toes are retained in good position is often the best appliance. If made of stiff thin leather it can be worn inside an ordinary stocking; if made of metal it must be applied over a digitated stocking and worn inside the boot. Latterly I have recommended a method of bandaging the toe to avoid the use of rigid appliances. With slight modifications, according to individual needs I have found the plan answer in a considerable number of instances. The bandage consists of firm webbing 1£ inch in width. An idea of the method of making and applying it may be gathered from Figs. 91 and 92. Operative Treatment.—Very severe cases that have proved resistant to, or have been found to be unsuitable for, milder measures require operative treatment. Sometimes Figs. 91, 92.—Bandage for Hallux Valgus. 120 HALLUX VALGUS: OPERATIVE TREATMENT. subcutaneous division of the tendons, etc., attached to the outer side of the base of the first phalanx will enable the surgeon to correct the deformity under anesthesia, and fix the joint in a good position. As in all orthopaedic work careful after- treatment is required to secure a good result. Partial excision of the head of the metatarsal bone is the operation I have most frequently adopted and found successful. In order to avoid having a scar on the inner side of the joint it is best to make a curved incision, the middle of which lies rather on the dorsal than the internal aspect of the joint. The latter is opened between the internal ligament and the dorsal expansion, and then with a small chisel; the outer part of the head of the bone beginning at the groove shown in Fig. 83, is separated and care- fully removed with forceps. If a bursa is present it can be removed by careful dissection between the skin and the internal ligament. The deformity is now easily corrected, the wound closed, and the toe put up in the proper position. This operation has the support of Mr. Arbuthnot Lane, who rightly says that after it has been performed, " the base of the first phalanx and the outer part of the head accommodate themselves to one another." G. II. Fowler has recommended opening the joint from the inner side:— An incision was made from a point upon the dorsum of the foot somewhat below the level of the head of the first metatarsal bone, and just outside that portion of the tendon of the extensor brevis digitorum which goes to the great toe ; this was continued to the bottom of the web between the first and great toes. A similar incision was made on the plantar surface of the foot slightly to the outer side of the line of the flexor longus pollicis. Subcutaneous osteotomy of the neck of the first meta- tarsal bone, as described by Mr. A. E. Barker, allows the toe to be restored to a straight line with the inner border of the foot, but it leaves the altered relationship of the articulating surfaces unchanged, and hence it is, in my opinion, not advisable to use it in the advanced cases, which alone require operative measures. Excision of the head of the metatarsal bone with result- ing ankylosis of the joint has been recommended by William HALLUX VARUS. 1 Fig. 93.—Foot with Six Digits, the innermost in the position of Hallux Varus. (From a cast in the Museum of the City of London Orthopcedie Hospital.) Anderson* amongst others, and it has given good results. Glutton has excised the entire joint. liiedel (quoted by Hoffat) and Davies-Oolley recommend removal of the base of the first phalanx; this measure has the disadvantage of leaving the deformed head of the meta- tarsal bone. The treatment of the complications of hallux valgus, such as inflammation and suppuration of the bursa, belong to general surgery. All concomitant deformities, such as haminer-toe and flat-foot must, of course, be treated at the same time as the hallux valgus. Before deciding on any operation the general state of the patient's health, especially in relation to gout and granu- lar kidneys, must be carefully considered. Personally, I have never found it necessary to do more than chisel off the inner part of the head of the metatarsal bone. After this operation the toe is easily straightened, but, as is the case with all operations for hallux valgus, patient after-treatment is required to prevent a relapse. When, as so frequently occurs, flat-foot is combined with hallux valgus the requisite measures are more complicated, and they will be described later under the heading of " Flat-foot" (p. 200). Hallux Varus. — Hallux varus, also known as hallux malleus, is the converse of the condition last described. The great toe is bent inwards at the metatarso-phalangeal joint. In most cases of severe congenital equino-varus (see Fig. 127) this deformity is present as part of the general inward deviation of the foot, and not infrequently when the club- foot has been fairly corrected by orthopaedic treatment some of the hallux varus persists as a trouble some remainder of the original deformity. Sometimes congenital hallux varus is present without * W. Anderson, " Fingers and Toes," 1897. + Hoffa, "Orthopedic Surgery," 1890, p. 718. ■ 128 HALLUX PLEXUS. any of the other deformities which are summed up as con- genital equino-varus. Such cases arc doubtless of similar causation to congenital club-foot. Paralysis of the adductor muscles may produce the deformity. William Anderson* records a case in which the deformity was associated with macrodactyly. The patient was a boy, aged eleven years, who was unable to wear a boot on account of the deformity. The toe was straightened after subcu- taneous section of ligaments, and three years later was found to be in a good position. Treatment.—Slight cases will yield to a light splint worn for some months along the inner border of the foot and toe. More severe cases demand section of the internal lateral ligament of the metatarso-phalangeal joint, or ex- cision of the head of the metatarsal bone or the base of the first phalanx. Hallux varus is sometimes due to dichotomy of the great toe. In such cases the proper treatment consists in removal of the innermost toe. This was done by the late E. J. Chance on the two feet of the case from which big. 93 was taken, and both feet were thus rendered symmetrical and useful. Hallux Rigidus or Flexus.—This condition, though far less common than hallux valgus, is met with more frequently than many writers would appear to think. It is not men- tioned by many orthopaedic authors. Mr. Davies-Oolley first described it, in 1887, as "hallux flexus." This term has been objected to on the ground that the flexion constitutes but a minor part of the condition. Simple hallux rigidus is seen chiefly in young subjects, and the condition should be distinguished from painful stiff- ness of the great toe, as it is seen in rheumatoid arthritis and gout. Symptoms. — The great toe is slightly flexed at the metatarso-phalangeal joint, and attempts at passive exten- sion cause pain to the patient. The position of the bones of the toe is shown in Fig. 94. The normal extent to which the great toe can be bent back varies in different individuals; in hallux rigidus this range is diminished. * Anderson, he. cit., p. 121. HALLUX RIGIDUS. 129 In many cases the toe cannot be brought into a straight line. The condition interferes greatly with walking; the patient limps on the outer border of the foot. Pathology.—I have had an opportunity of examining the head of a metatarsal bone removed from a boy on account of this condition by Mayo Collier. It showed but a slight thinning of the articular cartilage where the margins of the sesamoid bones had rested upon it. In course of time this thinning of the cartilage might result in exposure of the bone and the occurrence of ankylosis. There may be also secondary shortening of the ligaments at a later stage of the dis- ease. The term hallux rigidus should be restricted to such cases, to the ex- clusion of instances of rheumatic, oste< >-arthritic, and gouty fixation of the joint. From the cases that Fig. 94.—Position of Bones in Hallux have come into my hands, Rigidus. I conclude that the con- dition is usually secondary to slight flat-foot, which by elongating the foot causes tension of the tendon of the long flexor of the toes, and so flexes the great toe. In a few cases, however, I have not been able to detect even a slight degree of flat-foot. Prognosis.—There is a tendency to a natural cure in hallux rigidus. Davies-Colley is of opinion that the affec- tion is often converted into hallux valgus. My experience is that this painful deformity, if left to itself, remains un- changed for many months. Treatment-—In the earlier stages treatment of the flat- foot (p. 203), combined with passive movements, is sufficient; in the later stages forcible correction of the deformity under anesthesia and subsequent fixation in the corrected position should be tried. Excision of the head of the metatarsal bone is required, after milder measures have had a fair trial and have failed. The results of this opera- tion are very satisfactory, but in my experience the milder treatment is nearly always sufficient. J 130 TLIMMER- TO IE .• AN ITOMY. Other Deformities of the Toes. Hammer-toe.—This deformity has already been men- tioned in connection with hallux valgus. The term hammer- toe was first applied to the condition by Sir Astley Cooper. Fig. 95.—Hammer-toe, the remain- ing toes in the position they tend to assume. Fig. 9G.—Hammer-toe, the neigh- bouring toes held apart. The deformity consists in a permanent flexion at one of or both the inter-phalangeal joints. The second toe is by far the most commonly affected. The clinical appearance when the seat of the deformity is at the proximal inter-phalangeal joint is shown in Figs. 95 and 9G. In the early stages of the affection the deformity is readily overcome by man- ipulation, whilst in the later stages it is fixed by the rigidity of the parts con- cerned. Anatomy. — Adams on clinical and Shattock on pathological grounds have shown the chief obstacle to rectification to consist in a shortening of the lateral liga- ments. This I have been able to confirm in the dissection of a hammer-toe, which I have thus described in the Catalogue of the Museum of St. Mary's Hospital: "A hammer-toe. The first inter-phalangeal joint is over-flexed; on straighten- ing it the anterior fibres of the lateral ligaments became 97.—Schematic Section of Hammer- toe. There are callosities and bursa' over the head of the metatarsal bone and first phalanx, and a callosity over the tip of the ungual phalanx. hammer- toe .• pa tholog y. 131 tense." The chief points in the anatomy of the common form of hammer-toe are shown in Fig. 97. In cases of old standing the skin on the flexor aspect of the contracted toe becomes atrophic and adds another obstacle to rectification. Pathology.—Wm. Adams* describes hammer-toe thus: " Essentially it is a hereditary affection, frequently traceable through two or three generations, and when existing in a severe degree in one member of the family it may often be found, though to a less extent, in other children." Though it sometimes appears independently of hallux valgus and cannot be ascribed to badly-shaped boots, I am of opinion that in the majority of cases a slight hallux valgus is the determining cause of the affection. The patients who most frequently come for treatment are schoolboys destined for the army or navy, whose parents are desirous of remov- ing an obstacle to their passing the medical examination. The deformity may not appear till old age. I have at the present time a lady, aged seventy-five, under my care for hammer-toe. The condition has been present only for one year, and hence had developed long after the growth of all the tissues had ceased. Anderson considers it to be analogous to the corresponding contraction sometimes observed in the fingers, and refers it to a primary want of growth on the part of the lateral ligaments of the first inter-phalangeal joint. That this may sometimes be the case I am ready to admit, but in the majority of cases the origin is in my opinion as stated above. Most of the cases that have come to my notice have been in growing boys or girls, many of whom have been slightly amende and delicate, and not a few have had definite signs of rheumatoid arthritis. Treatment. — In the earlier stages, when the /tiS^r-z? ifwWxM parts are still supple, cor- ^pplllF8^^ P"% W\Pl recti ve manipulations and the use of a simple splint at nioTit will serve to check the tendency to . , Fig. 9S.—Adams's Hammer-toe Splint. deformity, if care is taken ; Win. Adams, " Finger Contractions and Hammer-toe," p. 124. 132 HAMMER-TOE: TREATMENT. to secure the use of properly-shaped boots or sh«,,s in the day In more definite but still yielding cases, Adams s splint (Fio- 98) should be worn both day and night. It causes no inconvenience, and allows the patient to enjoy football and other athletic games. When the flexed joint has become rigid operative treat- ment must precede the patient use of retentive apparatus In cases where there is no great amount of shrinking of the skin, subcutaneous section of the lateral ligaments and of the lateral parts of the anterior ligaments, as recom- mended by Adams, is necessary before the toe can be brought straight In practised hands this method is free from danger and gives excellent results if the after-treatment is properly carried out. Adams's Operation.—"I use the smallest fascia knife, with a straight-cutting edge to the point, which is always preferable to the'ordinary tenotomy knife with a central point, when any fascia or ligament has to be divided. I introduce the knife close to the angle of flexion in the concavity of the contraction and carry it under the skin with the blade flatwise, obliquely upwards and backwards towards the dorsal aspect of the first phalanx, just behind the head of the bone. I then turn the cutting edge of the knife directly towards the bone, and using chiefly the point, cut through the lateral ligament, and by repeated strokes also any fibrous bands connected with the capsular ligament that may be detected. I make sure of dividing everything down to the bone; and then, introducing the knife at a corresponding point on the opposite side, I repeat the same operation. The knife may also be entered at the middle of the flexion crease, and the whole of the anterior ligament with the flexor tendons, as well as the lateral ligaments, may be divided through the one puncture. The flexor tendons are also divided in this operation. It is requisite to have an assistant to hold the neighbouring toes apart while the surgeon steadies the affected toe with his left hand." For cases in which the skin is shrunken Anderson's operation is preferable :—" An incision is made in the lateral aspect of the affected articulation, following the axis of the bones and exposing the lateral ligament, while leaving intact HA MM EIOTOE: THE A TMIENT. 133 the vascular and nervous trunks. The ligament is then divided by a touch of the knife, and by a forcible lateral movement the head of the proximal phalanx is made to protrude through the wound and is removed with a pair of bone-nippers..... After a fortnight's rest the patient is able to walk, the toe being extended upon a dorsal splint of flat steel..... The result is all that could be desired, and the relief immediate and permanent." Hoffa recommends Peter- sen's plan, i.e. cutting deeply through the skin, tendons and capsule of the first inter-phalangeal joint, and leaving the open wound to granulate under an anti- septic dressing, a dorsal splint being applied to keep the toe in an extended posi- tion. The result is said to be good and lasting. When several toes are affected a sole-plate with slots (Fig 99) must be worn night and day for some months deformity is overcome. A u Fig. 99. A, foot With hammer-toe, hallux .valgus and congenital deformity of the fifth toe. B, sole- plate for the same, with "toe-post," slots and tape. until the tendency to Illustrative Cases.— Cask I.—A young gentleman, aged twelve, destined for the navy. Rather tall (5 ft. -J- in.) for age, and somewhat anajmic. Slight flat- foot. Hammer-toe of usual type on both sides, and.pronounced. Toes readily straightened by the fingers. Properly-shaped boots were pro- cured, and plantar metal splints applied. Four months later the deformity was found to be corrected, and after removal of the splints the toes remained perfectly straight. The patient, though at school, had found no difficulty in applying the splints night and morning, nor in playing football with them on. When last seen, eight months after commencement of treatment, the toes remained straight. Case II.—An artillery officer, aged twenty-six. Marked deformity in both second toes. Congenital. Patient has had "rheumatism" in one knee. He had had much pain latterly in the affected toes. The latter were very rigid and the skin was contracted on both sides of the flexor aspect. In each toe I removed the head of the first phalanx, and is amputation. In 134 ARTHRITIC DEFORMITIES OF TOES. straightened the toes and applied a small metal splint. The stitches were removed on the eighth day, and on the tenth the patient was able to put on his boots, the toes being protected by small splints. A very common mode of treatment for the condition my opinion this operation is rarely justifiable. Indeed, I should not use this resource unless the toe were in a state of gan- grene. In cases where the condition is due to hallux valgus, re- moval of the second toe makes the former condition worse, and renders its successful treatment impossible. I have seen very many unfavourable results of amputation, and in only one instance have I seen the great toe remain straight after this operation. Fig. 100. —Deformity of a Third Toe from Wearii Tight Boots. Fig. 101.—Side View of the Right Foot of a Man, aged thirty years, showing Deformity of the Great Toes and Flat-foot. Fig. 10'2.—The same Foot after opera- tions for Flat-foot and Retracted Toe. (From Photographs.) In some instances one of the outer toes is deformed from the compression of boots. Fig. 100 shows a deformity of the third toe from this cause. Arthritic Deformities of the Toes are common in gouty or rheumatic subjects, and especially in those who suffer from rheumatoid arthritis. Arthritic hammer-toe is a common condition. The four outer toes are doubled back as in HALLUX RETRaWTUS. 135 ordinal-)' hammer-toe, often with the addition of* outward deviation of the toes. This condition differs from simple hammer-toe by reason -of the pathological changes in the articular ends of the bones and in the ligaments. In ad- vanced gouty conditions palliative and medical measures are, as a rule, all that can be adopted ; but in the painful de- formities of rheumatoid arthritis operations similar to those mentioned under hammer-toe may be required. In these arthritic cases the great toe is usually deformed. Hallux valgus is the com- monest deviation. Contraction of Digital Processes of Plantar Fascia. —Some cases of contracted toes are similar in origin to Dupuytren's con- traction of the fingers. Such cases have been recorded by Adams and Anderson. Their importance is not so great as in the corresponding members in the upper extremity, owing to the smaller relative importance of the parts involved. Ankylosis of the joints of the toes from traumatic in- flammation, from nerve-lesions or chronic rheumatism, is often associated with rapid wasting of muscles, and may cause a considerable amount of lameness. Such conditions are often progressive and are then not amenable to treat- ment. Hallux Retractus.—This term may be applied to a con- dition of the great toes seen in some cases of rheumatism and rheumatoid arthritis of the feet. An example is depicted in Fig. 101. In such cases the joint has been excised with success. Personally I have not found this measure necessary, Fig. 103. Gelatine casts of the feet of a boy suffering froma condition akin to Friedreich's disease. Both feet when left to them- selves assumed the position of equinus, the toes becom- ing markedly clawed. The deformity was easily over- come, e.g. by the patient placing the foot on the ground, and with the disappearance of the equinus the toes came to their normal position, as shown by the cast of the sole of the foot. (From a Photograph.) 136 NUPERNUMERAR Y DIGITS. for I have found that section of the extensor tendon and lateral ligaments, and subsequent splinting, gives, as it did in the case referred to, satisfactory results. Paralytic Deformity of the Toes.—In cases of talipes equinus, or its modifications, it is usual to find the toes " clawed," i.e. retracted at the metatarso - phalangeal and flexed at the inter-phalangeal joints. That Duchenne's theory of this being due to paralysis of the interossei does not applv to all cases is shown by a dissection made by Walsham and Hughes* in which the interossei were found to be normal. In the majority of early cases, whether the talipes is due to infantile paralysis or to some less promising con- dition, such as Friedreich's disease, the clawing of the toes disappears when the talipes is corrected, as shown in Fig. -103, taken from casts lent to me by Dr. G. A. Sutherland. Treatment.—The importance of this fact is in its practical application to treatment. In other words, the deformity of the toes is to be treated by treating the equinus in such cases. Some ( 'oxijkxital Deformities of the Finoeijs and Toes. Supernumerary Digits, or Polydactyly.—This condition is frequently hereditary. Cases may be arranged in various groups. Thus, (1) the extra digit may be rudimentary; in such cases it is usually attached to the outer or inner border of the hand, and is attached by a short pedicle ; (2) the extra digit may possess all its complement of bones, etc., and it may either (a) be coherent with a neighbouring digit, or (b) free and functional; (3) in a few cases almost a whole hand has been reduplicated in development, there being eight fingers, with a little Fig. 104.—Bifurcated Hand. (Clutton : Treves's " System of Surgery.") border, and the thumbs being absent finger on each (Fig. 104). * Walsham and Hughes, " Deformities of the Human Foot/' 1896 WEBBED FINGERS AND TOES. 137 Both hands and feet may be affected in the same case, Thus, the anatomy or only one member may be affected. varies widely in different cases. The dissected with seven digits and six metatarsals is shown in Fig. 105. Treatment. — If the extra dilidinsf of the cuboid on the os calcis. 1 f the inverted position of the foot is to any degree fixed, i.e. if the normal range of eversion is restricted, then to that degree talipes varus is present; and if the everted position is in any degree fixed, the foot is to that degree in a state of talipes v PARALYTK1, TALIPES CALCANEUS. The cavus met with in paralytic talipes calcaneus may be com- pared with the artificial talipes calcaneus exhibited in the Chinese lady's foot (Figs. 12:5 and 124). Although the mode of production of this intentional deformity is by continued pres- sure of bandages, resembling in character the intra-uterine pressure that determines congenital club-foot, the shape of the foot is more like that of the paralytic than the congenital affection. The slighter degrees of paralytic calcaneus are designated by some authors following Nicoladoni as "pes calcaneus sensu strictiori." In such cases the " pes cavus" constitutes the Figs. 123, 121.—Disssction of Foot of Chinese Lady. ( W. Adams.) chief part of the deformity. Even in these slight cases the form of the os calcis is changed. Treatment—There are two objects to be aimed at: first, drawing up the heel and maintaining it there; second, reducing the pes cavus condition. The difficulties of retaining the foot in a good position are greater than is the case with many other deformities of the foot. A metal sole-plate fixed by straps, of which one passes across the prominence of the dorsum of the foot, must be made and worn inside the boot, which in its turn is provided with an outside iron with a " front-stop " joint at the ankle. Instead of this, Judson's apparatus, in which the iron is fixed to the foot-piece and at a right angle to it, may be used. If there is any difficulty in reducing the deformity, measures should be adopted in order to overcome it before applying instruments Avhieh must be worn to prevent its return. When there is marked hollowing of the foot, it may require gradual correction by some such appliance as that shown in Fig. 125. When some sound muscular tissue remains in the calf-muscles, the PARALYTIC TALIPES CALCANEO-VALGUS. 163 operations for shortening the tendo Achillis are useful in certain cases (see p. 104). A sufficient length of the tendon is removed, so that on joining the ends of the tendon the heel is drawn up to the desired amount, Walsham observes that this operation is useless when the gastrocnemius and soleus muscles are completely paralysed. The same surgeon has successfully substituted transplantation of the tubercle of the os calcis for shortening the tendo Achillis (see p. 106). Paralytic Talipes Calcaneo-val- ,,T1 . ,„ .. Fig. 12.3.—Apparatus for gUS.— When the calf muscles are the gradual Correction paralysed and the peronei retain ofPesCavus. (Heather their power, the foot is everted in "Sw/') addition to the ankle being dorsal- flexed. In other words, the condition is one of calcaneo-valgus. Symptoms.—The tendons of the peronei stand out prom- inently on the outer side of the ankle ; viewed from the inner side, the foot has much the appearance shown above in Fig. 122 : it is, however, more markedly everted. Anatomy.—The chief alterations in the bones concern the astragalus and os calcis. In the former the tibial articular surface is extended forward upon the neck of the bone, whilst the posterior part of the surface loses its covering of cartilage. The os calcis becomes modified in form. In severe cases, when the bone has been placed almost vertically, during life the anterior process of the bone may be completely atrophied. Treatment—The treatment for this condition is similar to that already described for paralytic calcaneo-valgus, but there is a further important resource in Kicoladoni's opera- tion—transplantation of the tendons of the peronei. The latter are divided opposite the external malleolus, and the tendo Achillis is divided just above its attachment. The tendo Achillis may be shortened at the same time with advantage (see Fig. (>9 and p. 107). In Nicoladoni's operation a vertical incision four or five inches long is made along the anterior border of the peroneal tendons ending below at the external malleolus. From near 1H4 CONGENITAL TALIPES FAJUINUS. the lower end of this incision a second is carried inwards at right angles, and a flap is made, exposing the peroneal tendons and the tendo Achillis. From the outer part of the latter a portion is removed, and thus a fresh surface is obtained to which the tendons of the peronei are sutured. In a small foot I have combined this with removal of a section of the tendo Achillis above the point of attachment of the peroneal tendons. The result of this operation was very satisfactory. In another case I adopted Goldthwait's plan of fixing the upper ends of the tendons of the peronei in an opening made at the lower part of the tendo Achillis. Congenital talipes equinus is one of the rarest of con- genital deformities. Cases have been recorded by Little, Adams, Walsham, Tubby, and others. I have seen several cases in which the equinus was the predominant deviation, but in all some share of varus could be distinguished. This accords with the experience of R. W. Parker, who writes : This is so rare a form of congenital deformity that it may be dis- missed with a mere mention. I have only seen one case that could with any propriety be called equinus. It will be observed that the foot is somewhat inverted, as well as extended. The inversion was easily over- come ; and the whole deformity yielded quickly, after section of the tendo Achillis. Treatment—The method to pursue is similar to that de- scribed below for congenital equino-varus. For some months after birth regular splinting and daily manipulation should be employed. In some cases a normal condition may be restored by these means alone. When necessary, the tendo Achillis should be divided. Congenital Talipes Varus.—This term applies more pro- perly to cases in which the foot is inverted without any elevation of the heel. Some confusion has arisen from the fact that many authors adhere to the old nomenclature and apply the term " varus " to cases that are better termed equino- varus in that the heel is drawn up in addition to the foot being everted. Although varus may occasionally be found without equinus, it is so rarely the case, and is so readily corrected, that no separate, detailed account of the condition is called for. Congenital Talipes Calcaneo-varus.—The inversion of CONGENITAL TALIPES EQUINO-VARUS 165 the sole met with in some cases of congenital calcaneus has been referred to above (p. 157). Since the foot below the ankle is usually everted in such cases, the inversion probably depends on changes at or above the ankle, and the essential condition is, in my opinion, calcaneo-valgus. In other cases, however, the sole is inverted without there being any eversion of the foot below the ankle. Such cases are rare and of no great clinical importance. Congenital Equino-v : It was noticed that the peroneus tertius is well developed and active. A boot with a pad sole inside and an external iron was provided, and patient discharged November 1. There was no further tendency to recurrence of the deformity. KK! STATIC FLAT-FOOT. Static Flat-foot arises from prolonged standing, and is met with in voting subjects whose occupation obliges them to stand for long periods of time. A predisposing cause is a long, narrow foot. In school children about the age of puberty who have this condition, it is generally possible to get a history of their having been delicate in infancy, and in Fig. 154. — Flat - foot seen Fig. 155.—The Sole of | the from the front and outer Foot with Strips of Paper aspect. pasted on to show the (From a cast in the Cit/i of London Degree of Abduction of the Orthoptedic Hospital.) Fore Part of the Foot. many are found the marks of infantile rickets in the shape of slight bow-legs or knock-knee, and thus such cases merge into the rachitic group. In the many porters, bakers, cooks, etc., who suffer from flat-foot, one often finds a general anaemic condition accompanied by coldness and hyperidrotic feet, so that here again a condition of malnutrition of bones and ligaments is present in addition to the fatigue of excessive standing. To Lorenz* belongs the credit of having shown that in the production of ordinary flat-foot there is something more concerned than muscular fatigue. All such cases are included with the static group in which there is no pronounced disease such as obvious rickets or rheumatoid arthritis present. When the production of flat-foot by the weight of the body is * Lorenz, "Die Lehre vom erworbenen Plattfusse," 1883. STATIC FLAT-FOOT: SYMPTOMS. 197 examined, the first condition to consider is the usual posture of those who have to stand for long periods together. This has been termed by Annandale "the attitude of rest" (see Fig. 7, p. 16). If such an attitude is persisted in too long, it will become a fixed position from adaptive growth of the ligaments and bones themselves, and thus the first stage of flat-foot and knock-knee will ensue, and continuance of the position will, when the nutrition of the tissues is impaired, go on to the establishment of graver degrees of deformity. If a definite disease affecting bones and periosteum or liga- ments is present, the progress of the affection is more rapid and the onset of bone deformity is earlier and more marked. In some traumatic conditions, e.g., after Pott's fracture, there remains an eversion of the whole foot which aids in the production of flat-foot. In paralytic cases the counter- balancing effect of muscles is removed. Symptoms.—-The characters of an ordinary case of static fiat-foot of average degree of severity are well marked. The instep is sunken, the hollow that should be found beneath the inner border of the foot when the patient stands up is diminished or lost, and the inner border of the foot may be convex inwards, presenting prominences corresponding to (1) the displaced head of the astragalus and (2) the tuberosity of the scaphoid bone. The skin is often thickened over this projection of the inner border. In most cases the internal malleolus is seen to be unduly prominent, and it appears to be displaced inwards, and below it the foot is bent outwards, i.e.. everted (see Fig. 154j. This condition in slight cases is often designated as weak ankles. The sole of the foot loses its O hollow on the inner side, and its fore part deviates outwards so that a line drawn from the posterior border of the foot forwards through the middle of the heel (Meyer's line) would pass to the inner side of the great toe instead of along its centre (see Fig. 155). In severe cases the weight of the patient in walking is borne entirely by the inner edge of the feet, the outer edge being so far everted that it does not touch the ground. l>y the sinking of the longitudinal arches the foot is elongated. The sole of the foot has an ungraceful, flattened appearance, 1!)S STATIC FLAT-FOOT: SYMPTOMS. and gives a characteristic impression (see Figs. 15G and Fw), in which the normal hollow is lost. Hallux valgus is a frequent complication of flat-foot. In every case the degree of rigidity or resistance to manual correction of the deformity should be observed. Other points to be _ observed are the presence or absence of rickets or osteo-arthritis. Fig. 156. - Foot- print in an aver- age Case of Flat- foot. Fig. 157. — Foot- print in an ex- treme Case of FJat-foot. I %«» C^ !A ' lr&»A Tig. 1")S. — Footprint of an extremely nar- row Foot, showing a Medium Degree of Flat-foot. It is in long, narrow feet that the exact nature of the deviation from the normal can best be analysed by clinical examination or by radiographs. The impression of the sole in such a case of medium degree is also greatly changed from the normal, as is shown in Fig. 158. The bulging on the inner side of the foot is here seen to be pronounced, and to be accompanied by an inbending of the whole of the foot. This footprint is that of a patient whose case may be quoted here:— STA TIC FLA T-FOOT : S YMP TOMS. 199 A girl, aged ten years, came under my care for lameness and painful feet. For the age and size of the patient the feet were remark- ably long; they also showed an advanced condition of flat-foot, the whole of the inner border of the foot touching the ground when the patient stood up. The foot, naturally a long one, was still further Fig. 159.—Eadiograph of a Right Foot showing a Medium Degree of Flat-foot, viewed laterally. The scaphoid is sunk below ths head of the astragalus, which shows but faintly. lengthened by the sinking of the longitudinal arches. The footprint, reproduced on a reducedjscale in Fig. 108, measured 8,:,„ in. from front to back. Both feet were similarly altered in form and since they showed the condition uncomplicated by hallux valgus, &c, I thought radiographs C.-rfJ^'SSffi 160.—Eadiograph of the Left Foot in the same Case (Fig. 159), showing Abduction of the Scaphoid upon the Astragalus. would be useful in demonstrating the exact changes in the relative position of the bones. The radiographs (reproducedon a smaller scale in Figs. l.>!) and 160), were made for me by Messrs. C'oxeter, the patient sitting down with the sole of the left foot placed flat on the plate whilst that of the right rested on its outer edge. In a severer case of the same kind (Fig. 1(51), the foot- print (Fig. 157) is even more abnormal, and the radiograph (Fig. 102) shows that the astragalus is placed with its head vertically downwards, just as it is in the severest forms of talipes equinus, but the os calcis in flat-foot does not follow the displacement 2oil STATIC FLAT-FOOT: PAIN. of the astragalus, which is turned inwards as well as down- wards. 7-Wh—The amount of pain present in flat-foot varies greatly. In the case of children it is usually absent. In most ordinary cases it is a marked feature for a time, but it frequently ceases when the condition has become fully established. In rheumatoid arthritis, pain is usually severe and may continue in spite of treatment. Tenderness.—Tender points are usually present in severe Fig. 161.—Photograph of tlicpcetof^a Girl^agedfourteen years. The left foot shows an extreme degree of flat-foot. cases. Their usual situations are over the astragalo-scaphoid joint, in front of the malleoli, and at the bases of the first and fifth metatarsal bones. In rapid cases there may be redness and swelling of the foot. In rheumatoid cases there may be effusion into the sheaths of the tibial muscles and the peronei, and swelling about the ankles. The gait of one suffering from flat-foot is characteristic. The toes are directed outwards more than is normal; in walking the foot is placed on the ground in a flat, inelastic manner. In standing, the outer border of the foot may be actually raised from the ground. Anatomy.—Some of the anatomical features have already been alluded to in connection with the radiographs. The altered positions in a marked and typical case, are chiefly as follows:— 1. The ankle-joint is extended or, to use a more correct STATIC SLAT-FOOT.- AXATOMY. 201 term, i.e. one less opposed to the term used to designate the movements of the wrists—plantar-flexed. ■1. At the beginning of the displacement the foot is in the position variously termed "eversion," "pronation," or " abduction." This is thus described by Arbuthnot Lane :—* " ()bserve this foot in a position of abduction or of rest, and you see the head of the astragalus projecting inwards, and the calcaneo-scaphoid Fig. 162.—Radiograph of the Left Foot in the same Case (Fig. 161). The astragalus is placed vertically as in severe talipes equinus, and its head is below the level of the scaphoid. (Coxeter and Son.) capsule elongated to its utmost capacity ; the scaphoid articulates with the outer segment of the head of the astragalus, while its tuberosity is separated by a considerable interval from the sustentaculum tali; the long and short plantar ligaments are arranged in their longest diameters, and the articular surfaces of the os calcis and cuboid are in accurate apposition, the cuneiform and metatarsal bones all being directed forwards and outwards." Later the astragalus becomes subluxated inwards from the os calcis, and the calcaneo-cuboid joint becomes subluxated dorsal ly, and in severe cases the metatarsal bone becomes * Arbuthnot Lane, "Clinical Lectures." 202 STATIC PLAT-FOOT: DEGREES. adducted. The sum of the changes results in giving to the longitudinal direction of the foot the aspect shown in the diagram (Fig. 1C3). . , In the last stages the form of the foot is completely wrecked. The head of the astragalus reaches the lowest part of the fallen internal arch, and the inferior calcaneo-scaphoid li.-ament lies stretched out beneath it. In the worst cases, the outer arch is not only destroyed, but the lower end of the fibula forms a new joint with the os calcis, and the bones become gravely deformed. rram of the Bones in Extreme Flat-foot. (Lorenz.) Degrees of Flat-foot—It is usual and convenient to divide cases of flat-foot into several degrees. 1st degree, or "weak ankles." The deformity appears when the patient stands up, and disappears again when the weight is taken from the foot. Even in standing, the deformity dis- appears when the patient stands on tip-toe with the toes turned in (Ellis's exercise). 2nd degree. The deformity does not disappear when the patient sits down, nor when the patient attempts the tip-toe exercise, but if the surgeon takes the foot in his two hands, the fingers of one grasping the outer aspect of the heel, whilst its thumb rests on the head of the astragalus, the other hand holding the fore part of the foot and exerting steady force in the direction of inversion of the foot, the deformity is over- come. This is sometimes painful to the patient. 3rd degree. The deformity is usually reducible by manip- ulation under an amesthetic. The resistance may be due to inflammatory stiffness, or adhesions, or to spasm of the peronei. In the last-named case the deformity reappears when the amesthetic passes off". STATIC FLAT-FOOT: TREATMKXT. 2o:j 4th degree—"osseous" flat-foot. In severe cases where the patients have been allowed to grow up without proper treat- ment, and in inflammatory conditions such as osteo-arthritis, the articulating surfaces have become changed and the deformity is extreme, the sole being convex downwards and the fore part of the foot raised from the ground. Such a foot can only be corrected by osteo-plastic operation. Treatment.—The general condition of the patient must be carefully examined and suitable treatment adopted. Flat-foot is chiefly an affection of childhood and adolescence, though in some of its forms it may arise in adult life. Many of the younger patients are anoemic and require a liberal diet and iron. In rickets a sufficient supply of raw albuminous food and plenty of fat are required, with cod-liver oil and iron. It is to be remembered that the sterilisation of food required by the prophylaxis against tuberculosis favours the development of rickets. Slight cases of rachitic flat-foot will disappear in the course of a month from the beginning of a proper dietary. In this place one other practical point may be mentioned; that is, the value of iodide of potassium in moderate doses in flat-foot due to rheumatoid arthritis; in many cases the severe pain of this condition is at once relieved, Loccd Treatment (Prophylactic). — 1. Rest. — Rickety children and weakly adolescents who suffer from flat-foot should never stand and never walk when fatigued. The tone of the muscles should be improved by friction and douching, as well as by generous diet and tonics. Passive corrective movements should be practised daily. In order to secure complete rest in severe cases it is advisable to apply an internal splint similar to that used for Dupuytren's fracture, or, as some surgeons advise, to apply strapping or a plaster of Paris bandage. 2. Exercises.—When the muscular tone is sufficiently good, active exercises, namely, circumduction of the feet against resistance, walking on the outer border of the feet (Roth), rising on tip-toe with the feet slightly pointed inwards and the feet inverted (Ellis), should be gone through for three minutes twice a day. It is somewhat difficult to teach young children to perform exercises. The majority of these early cases are, however, 204 STATIC FLAT-FOOT: TREAT MEM. rachitic, and will get well without exercises if proper general treatment is adopted, together with passive exercises Ellis's tip-toe exercise is the most generally useful, the patient should stand with the toes turned slightly inwards. rise in regular rhythm to tip-toe and return at once to the original position. It is not advisable for the patient to attempt to stand or walk on tip-toe, since, in doing this, strain is put upon the plantar ligaments, which may yield still farther. In certain cases, even after careful instruction, this exercise may make matters worse ; it is, in my opinion, only to be advised when a fair amount of muscular vigour is present. In performing the resisted inward circumduction exercise, the knee should be extended and the leg crossed over the opposite knee and rotated in (Walsham). Patients can readily be taught to replace the resistance of the surgeon's hand by a rubber cord with a suitable attachment. The Outer-edge Exercise.—The patient stands as in Ellis's exercise, with the feet close together. At first it is sufficient for the patient to exercise for five minutes at a time by rhythmically rising on the outer edge of the feet and at once returning to the original position. When sufficient improve- ment has been obtained, he may be allowed to walk about on the outer edges of the feet. The exercises are best done with bare feet. Foot-clothing in. Flat-foot.—In every case of flat-foot it is of the greatest importance to see that the patient has roomy socks or stockings and properly-shaped boots, as described under the heading of " Hallux Valgus " (p. 120). Hallux valgus may play an important part in the production of flat-foot. The outward displacement of the first phalanx of the great toe entails some outward shifting of the tendon of the flexor longus hallucis and so weakens the support of the inner arch of the foot. The frequent combination of flat-foot with hallux valgus supports this view. Mechanical Treatment—The chief objects of mechanical treatment of flat-foot are to place and maintain the foot in an inverted position. A well-fashioned laced boot will itself tend to maintain the normal form of the foot and to prevent extreme eversion. In slight cases of flat-foot merely raising the inner STATIC FLAT-FOOT: TREATMENT. 205 border of the heel and sole will suffice to arrest the progress of the deformity. This result is obtained by the slight in- version of the foot effected by the raising of the inner border. In inversion the astragalus is placed more nearly vertically above the os calcis, and hence, in standing, the action of gravity has less effect in tending to cause the astragalus to move forwards and inwards over the os calcis: it causes the outer border of the foot to bear its proper share of the weight of the body. The inner border of the foot may be raised either by thickening the sole internally or by the insertion of a pad into the boot. In some cases, in or- der to prevent the " waist " of the boot giving way, it is necessary to prolong the inner part of the heel to join the sole of the boot. These measures suffice only for the mildest cases. When the condition is at all severe, some leverage is required to prevent eversion of the foot. This is best obtained by an out- side leg-iron which fits into the socket of an iron plate inserted into the heel and the back part of the sole of the boot. The hoot being put on and laced up, the foot is inverted by placing the band at the upper end of the iron in position above the calf of the leg, i.e. with its upper edge below the head of the fibula. action is further maintained by an inside T-strap which encircles the iron above the malleoli* (see Fig. 104). The iron may be jointed opposite the ankle, or, when expense is an object, its lower end may be made to work freely in a round socket at the front of the heel, vertically below the malleoli, so avoiding the necessity of having a joint opposite the ankle. The efficacy of this mechanism is greatly in- creased by the addition of a properly-shaped valgus pad of vulcanised rubber within the boot. In a great number of cases this apparatus alone suffices to correct the deformity, * In order that the T-strap may not be dragged backwards and forwards in walking, the boot-iron may he prolonged upwards beyond the ankle-joint, as suggested by AValsham. Fig. 1G4. —Dia- gram showing Construction of the Outsi.U-Iron, Valgus Pad and T-strap. This leverage 206 STATIC FLAT-FOOT: TEEATMEXT. and even in an extensive experience of severe cases of static flat-foot I have seldom known it to fail. In private practice, especially in the case of boys at public schools, there is often great objection to the wearing of any visible apparatus. For such cases Muirhead Little's "concealed spring" is of service. Where hallux valgus is combined with flat-foot, the rubber pads may be fixed to a sole-plate of white metal furnished with a projection to keep the great toe in position. It has been objected to the use of valgus pads that they only act on the inner arch without affecting the outer, which is also depressed. The absolutely good results that I have seen in many cases of severe flat-foot obtained by this method have shown me that if the inner arch is restored the outer follows suit. The appliances just described have the advantage of allowing the patients to pursue their usual vocations. In some cases laborious work has to be given up for a time in order to obtain a good result. Instead of the rubber pad, some surgeons recommend metal valgus plates. Hoffa re- commends the use of Sidney Roberts's steel sole-plates, made upon a plaster model of the normally arched foot. They are slightly convex and cover the whole of the sole and the inner border of the foot. The metal is thin enough to retain a certain amount of spring. A serious drawback to steel plates is that they perish rapidly by rust. This can be to some extent provided against by giving them two coats of paint and covering them with leather. Whitman's metal valgus plates are shown in Fig. 165. They can be made of aluminium bronze to the shape of a plaster cast of the corrected foot. In some cases this apparatus answers ad- mirably ; in others, although made with equal care, it causes intolerable pain. Elastic traction may be employed instead of solid pads. For this purpose Walsham recommends a modification of Nyrop's shoe: "In a properly-shaped boot provided with an outside leg-iron and calf-piece a rubber band is fixed so as to exercise elastic tension on the sunken arch. The band is firmly secured to the upper leather inside the boot, along the outer border of the sole, in such a position that, as STATIC FLAT-FOOT: TREATMENT. 207 it crosses under the sole of the foot, its centre corresponds to the middle of the calcaneo-scaphoid ligament. It is then carried up on the inner side of the foot to just above the top of the boot, and thence through the medium of a leather strap and buckle is se- cured to the calf-piece. A soft valgus pad can be slid over the rubber strap. and be so adjusted that it corresponds, when in posi- tion, to the situation of the yielding arch."* Gradual Correction.— In severe cases of flat-foot accompanied by marked rigidity and spasm the patient cannot be treated by ambulant methods throughout. For a time it is necessary for him to take to his bed or couch so that no weight is borne by the feet. After a period of rest, the foot should be wrenched and put up either on a suitable Scarpa's shoe or in plas- ter of Paris. Where the former can be obtained, it is preferable, since it allows of daily improvement being obtained. The best form of shoe is that designed by Adams. It has a divided sole-plate, the front part of which allows of gradual inversion of the foot and carries a valgus pad at its upper and external angle. If plaster bandages are used, they should not be put on too thickly, and no ad- ditional plaster should be rubbed in, or much time is lost in changing the bandages. . As an aid to the relaxation of the tissues of the foot, the hot-air bath (see p. 41) may be used for from one-half to three-quarters of an hour at a tempera- ture of from 250 to 300° F. By persistent and continuous * Walsham and Hughes, he. cit.. p, 9. Fig. 165.—Whitman's Metal Valgus Plate 20S STATIC FLAT-FOOT: TRLATMEST. treatment of this kind even unpromising cases are completely corrected. After correction has been obtained, the patient must be fitted with a valgus boot, as described above, or the deformed condition will return. Forcible Correction.—This should be done under full anesthesia. Manual correction is usually ' sufficient and where it fails instrumental wrenching usually fails also. When the foot is put up in plaster after wrenching, the plaster should be allowed time to set before the patient is permitted to come out of the influence of the anaesthetic. Section of the peronei tendons may be required in some cases in which spasm of these muscles persists after correc- tion, with a long period of rest in plaster of Paris or in a splint. They may be divided together behind the lower end of the fibula, or just below the external malleolus, or separately. just beyond the peroneal tubercle. Osteoplastic operations are required in the severest eases accompanied by great deformity of bones. Many different operations have been performed :— Excision of a wedge-shaped portion of the tarsus, includ- ing the astragalo-scaphoid joint and establishing an ankylosis between the astragalus and the scaphoid (Ogston). Excision of a wedge-shaped portion (base inwards) of the neck of the astragalus (Stokes). Excision of the astragalus (Vogt). Excision of the scaphoid. Linear osteotomy of the tibia and fibula above the ankle and fixing the limb with the foot inverted. The resulting position is the converse of the flat-foot which results from a badly-set Pott's fracture (Trendelenburg). Transplantation of the posterior part of the os calcis ((Heidi). Ogston's and Stokes's operations deserve more detailed notice. Ogston s Operation.—After the usual preparations, the foot is rendered bloodless by Esmarch's band placed upon its outer side and a longitudinal incision is made over the astragalo- scaphoid joint on the inner border of the foot. All the soft parts are divided down to the bones and the joint is opened. The opening is enlarged by cutting across the ligaments for STATIC FLAT-FOOT: OGSTOX'S OPERATION. 2o.—Diagram showing the Nature and Degree of Genu Varum. (JA/rwe//.) knee-joint; in knock-knee the middle of the knee-joint is thrown to the inner side of this line." In genu varum the converse of this holds good, and hence Ave arrive at the folloAving definitions:— Genu Valgum is the deformity in Avhich a line drawn *For the use of Figs. 172, 173 and 171, I have Prof. Macewen's kind peimisMnn. RACHITIC DEFORMITIES OF THE LEG BONES. 225 from the head of the femur to the middle of the ankle-joint passes external to the centre of the knee-joint (Fig. 172). Genu Varum is the converse of genu valgum, namely, the deformity in which a line drawn from the head of the femur to the middle of the ankle-joint passes internal to the centre of the knee (Fig. 173V As an illustration of the confusion caused by the lists of Fig. 174.-1 'ombination of Genu Valgum and External Tibial Curves, or Tibial " Bow-leg." (Maceircn.) synonyms already alluded to, the common combination of genu valgum with outward bowing of the leg bones may be given (see Fig. 174). In this instance, if "boAv-leg" be taken as the equivalent of "genu varum," there Avould be tAvo mutually exclusive conditions, genu varum and genu valgum, present together in the same limb. Similarly, external femoral curves may be associated with genu valgum, as shown in Fig. 175. Both genu valgum and genu varum may be produced by different anatomical changes, as will be discussed more fully later (p. 226 et seqq. ; p. 241 et scqq.). As far as instrumental treatment is concerned it does not matter Avhether the anatomical changes are situated at the upper end of the tibia or the loAver end of the femur, or in both these situations, but in view of operative treatment Avhich is required in some cases OAving to neglect of early treatment, it is advisable to distinguish betAveen tibial, femoral, and tilno-femoral genu valgum, or genu varum, as v 226 GENU VALGUM. the case may be. Among the commoner rachitic deformi- ties of the long bones of the lower extremity are anterior curves of the femur or tibia; the latter is frequently associ- ated with genu valgum. In severe cases of rickets S-shaped curves of the femur are common. It is necessary to use a some- Avhat extensive terminology in order to speak Avith precision of even the commoner rickety curves in the shafts of the bones of the loAver limbs. The more useful of the terms and their abbreviations are :— External tibial curve . . E. T. C. Anterior tibial curve ... A. T. C. Antero-external tibial curve External femoral curve Anterior femoral curve Antero - external femoral curve ... ... ... A.-E. F. C A.-E. T. C. E. F. C. A. F. C. Fig. 175.—External Femoral Curves associated with Genu Valgum. (From a cast in the Museum of the Citii of Lmnlon . 232 GENU VALGUM: SYMI'TOMS. .Etiology.—The predisposing cause of knock-knee is in most cases rickets. A feAv cases of congenital genu valgum have been observed. The two or three cases that have come to my OAvn notice have been obviously intra- uterine pressure-effects akin to congenital dislocation of the knee. Traumatism and suppurative arthritis of the knee may also cause the deformity. Numerous rickety infants Avho have never Avalked may have marked knock- knee. In such cases, either the proliferative groAvth at the inner side of the lower femoral and upper tibial epi- physeal planes has occurred to a greater extent than it has on the outer side, or this proliferation is diminished to a greater extent on the outer than on the inner side by the stronger action of the biceps muscle as compared Avith that of the inner hamstrings. In the majority of cases, however, the deformity is of less uncertain origin. It is directly pro- duced by the Aveight of the body in standing or Avalking- In the erect posture, Avith the heels together, the weight of the body is transmitted through the knee-joints midAvay betAveen the condyles.* A line let fall from the summit of the head of the femur to the middle of the loAver articular surface of the tibia passes between the condyles, and has been termed by Mikulicz the " direction-line." In genu valgum this line falls external to its normal position, and in marked cases it falls outside the joint altogether. In order to stand erect, Avith the feet close together, the muscles of the loAver limbs and trunk must be in a state of activity in order to preserve the balance of the body. When the muscles are weak, as they are in rickets, a person stands with the feet far apart, so that the supporting base is Avidened. In this position (see p. 16) vertical growth of tissue is en- couraged by diminished pressure on the inner aspect of the knee, whilst the converse holds good for the outer aspect It thus folloAvs that the groAvth of the upper ends of the diaphyses of the tibke, or the lower ends of those of the femora, or both, may be increased. Symptoms.—On looking at a person affected Avith knock- knee of marked degree the straddling carriage and gait are * Some observers consider that the line of gravity passes normally just outside the centre of the knee-joint. GENU VALUUM: THEATMEXT. 233 striking; in slight cases a closer inspection is required. In standing, the patient's knees are unduly prominent at the inner side. In cases of genu valgum the patient, in order to avoid the knees coming together, abducts the thighs alternately in Avalking, giving at each forward step of the advancing limb an outward swing which is very conspicuous. If the deformity is very severe the knees form a lozenge-shaped interval, one knee being crossed behind the other, and then Avalking is extremely difficult. In some cases, besides the alteration in the direction of the legs, there is an outward (more rarely an inward) rotation of the tibia. Prognosis.—As in other rachitic affections the question of spontaneous recovery must be considered. The greater frequency Avith Avhich knock-knee is seen in children as compared Avith adults is sometimes taken as an argument to prove that most cases of genu valgum recover spontaneously. As an answer to this proposition, Whitman counted the number of cases of knock-knee in 2,000 male adults he met consecutively in the streets of Boston. They amounted to thirtv-two. Another consideration is that in almost every severe case the surgeon will hear from the mother that she had been assured that the child Avould "grow out of it," or she would have had the child treated for the condition. No reliance is to be placed upon a natural recovery from the deformity. In children under five or six years genu valgum is easily and certainly corrected by the simplest apparatus, and if the treatment is begun whilst the disease is still in progress there will be not the least necessity for operative measures. Treatment—As in all rachitic affections the general treatment must be attended to, for the local condition is but an indication of the general disease. The great majority of cases can be treated without confining the patient to bed; only when rickets is severe, as shown by great weakness, emaciation, and great enlargement of the epiphyseal regions of the bones, the patient must be confined to bed until the general condition is sufficiently improved. In the majority of cases the children are sturdy and, if the genu valgum is their only complaint, are much better treated by the ambulant method from the first. 234 GENU VALGUM: TREATMENT. The apparatus required is simple to a degree and has been already referred to (pp. 75-78). The best method of applying splints for genu valgum is shoAvn in Fig. LSo. it will be noted that the upper band does not pass across the front of the body. The essential points are, that the knee-joints must be kept extended, and that the treat- ment must be applied night and day. Hoffa recommends Thomas's splints, shown in Fig. 179. Where the patient's cir- cumstances allow, I usually advise the use of a steel apparatus, Avith ring-catches at the knee, by day, and simple splints by night, the limbs being douched and rubbed twice daily. As a Fig. 179.—Thomas's Splints for Genu Valgum. (Hoffa.) record of the progress of a case tracings of the limbs, made as suggested by Bradford and Lovett, are very useful. The patient sits on a sheet of paper Avith the legs extended, knees close together, and feet pointing upward, and then Avith a pencil held vertically and close to the limb, the surgeon traces the outlines of the parts. Such tracings when dates are re- corded also serve to record the rate of progress (Fig. 178). The method of treatment by recumbency is thus described by Mr. H. S. Collier:—* *H. S. Collier, St. Mai if s Hospital Gazette, April, 1S9S, p. 52. GENU VALGUMi: TREATMENT. 235 I show you the splints which are in use in the out-patients' room at Great Ormond Street Children's Hospital, for most rachitic deformities of the lower limbs. Each consists of a light padded board to be applied to the outside of the pelvis and lower limb. Its upper end is on a level with the crest of the ilium, and its lower end reaches three inches below the foot. A splint is applied to each lower limb. A webbing band connects the upper ends of the two splints, both in front and behind the pelvis ; a second band passes from the splint round the middle of the thigh, a third round the middle of the leg, and a T-shaped strap connects the foot with the splint. This arrangement does not abso- lutely oblige the child to remain supine, but as it becomes irksome in the sitting- up posture, the child is not likely to sit for long at a time. The splints are removed tAvice a day so that the nutrition of the limb may be aided by friction Avith oil or with salt Avater. For hoAv long must the restraining treatment be continued . In the minor degrees of deformity, six months' splinting may suffice. In the more severe cases two or even three years may be required. The prospect of such a long process may make you hesitate to recommend such a course of treatment, but you will not err if you will bear in mind that the alternative measures are almost sure to be followed by relapse, unless the same tedious splinting be insisted upon. Children adapt themselves very easily to circumstances, soon become reconciled to the splints, and their general health does not suffer to any great extent from interference with their normal activity. Hueter at one time tried fixing the knee in the flexed position on the supposition that since the deformity disappears in the flexed position, it might be cured by fixation of the limb in that position. This plan, after patient trial, Avas found to be highly unsatisfactory. Bradford and Lovett record that they tried Rushton Parker's plan of treating knock-knee by raising the inner Fig. 180.—Photograph of the Legs of a Girl, aged nine years, who had severe Genu Valgum and Anterior Tibial Curves on both sides. From the position of the Limbs the Genu ATa lgum shows best on the right, the Anterior Tibial Curve best on the left side. 23(i GENU VALGUM: TREATMENT. border of the boot. They found that no reliance could be placed upon the plan. In conclusion, the words of these authors may be quoted: " Mechanical treatment, it has been said, is of two kinds. The old-fashioned method was to confine the child to the bed, or to some retentive apparatus,^ while modern treatment allows and encourages locomotion." Fig. 181. — Photograph of the Legs of a Girl, aged eight years, showing severe Genu Valgum, before Macewen's Operation. Fig. 182.—The Case illus- trated is Fig. 181 three months after Macewen's Operation. Among some hundreds of cases of genu valgum in young children I have only had occasion to recommend recum- bency in tAvo or three instances, and in these for a short time only, on account of some complication. Opera.tire Treatment—This is only necessary Avhen mechanical treatment has been neglected, i.e. Avhen the deformity has been alloAved to persist until the bones have become hard. In genu valgum, oftener than in any other condition, are unnecessary operations performed. It is impossible to give any age-limit for the operation, since rickets and genu valgum may not begin until a person has reached adolescence, or, on the contrary, rickets may have ceased and the bones have become hard by the age of eight or ten years. For my OAvn part I try to avoid osteotomy GENU VALGUM: TREATMENT. 237 whilst rickets is in progress, and I seldom perform it on a child under eight years of age. The only operations that need be considered are MaceAven's and the Reeves-Ogston operations, and osteotomy of the tibia. Macewen's supra-condylar osteotomy has been described already (p. 110). A feAv fatalities and accidents have been reported. MaceAven attributes most of them to faulty operating, e.g. (1) slipping of the chisel from its being loosely held; (2) directing the chisel too much in a backAvard direction Avhen dividing the posterior layers of the bone; (3) by the use of too broad an osteotome. Fat embolism also has occurred. Seeing that in most cases the chief deformity lies to a considerable extent in the tibia, MaceAven's operation cannot rectify the deformity present, but it rather compensates for it by the addition of another deformity in the femur. Schede introduced osteotomy of the tibia and fibula just below the level of the tuberosity of the tibia. When the de- formity is chiefly tibial, this operation is certainly indicated. Mr. John Ewens* of Bristol, in 1892 advocated removal of a wedge from the inner side of the upper part of the tibia in similar cases. Sometimes several osteotomies are necessary ; thus, in the patient Avhose loAver limbs are shoAvn in Fig. 180 I found, after dividing the femur by MaceAven's method, it Avas necessary to divide the tibia beloAv the tubercle in order to correct the genu valgum, and again at the meeting of the middle and loAver thirds for the anterior tibial curve. Ogston's Operation.—Ogston recommended separation of the internal condyle of the femur and subsequent correction of the deformity. The knee is flexed and a narroAv-bladed knife is entered tAvo inches above the adductor tubercle of the femur at the middle of the inner border of the thigh, and is passed doAvmvards and outwards across the front of the condyles, until the point reaches the groove betAveen them in the interior of the joint. The knife is then AvithdraAvn and a narroAv-bladed saAV is passed along its track. The bone is then sawn nearly through. The saw is then AvithdraAvn and the limb forcibly corrected. Reeves modified the operation by using a chisel instead * John Ewens, Provincial Med. Journ., Jan. 1893. 238 GENU VALGUM: TREATMENT Fig. 183.—Radiograph of Genu Valgum in case shown in Fig. 181 (posterior aspect) before Macewen's Operation. (Co.rcter and Son.) of the saw, and making a smaller incision. Mr. Willett* recommends the Reeves-Ogston operation for severe cases of knock-knee. * Willett, Biit. Med. Joarn., Dee. 11, 1897. GENU VALGUM.- TREATMENT. 2;<9 Fig. 184.—Radiograph of Genu Valgum in case shown in Fig. 181 (posterior aspect) after Macewen's Operation. (C'oxcter and Son.) Since this operation traverses the epiphyseal cartilage, it should be reserved for patients who have passed the period of growth. 240 GEN U I 'A LG J rM: TREA TMENT. Results of Conserrtdive tend of Operative Treatment Com- vared.—In a considerable number of patients ranging from five to eight years that I have discharged as cured after from two to three years' treatment by the ambulant method, the resulting form of the bones and the function of the knee- joint has appeared to me to be perfect. In the case of a girl aged eight years I performed MaceAven's operation, not because the conservative method would not have cured the patient, but because the patient suffered from excessive shyness, Avhich rendered frequent visits painful to her. The appearances of the legs before and after operation are shoAvn in Figs. 181 and 182, and radiographs in Figs. 183 and 184. It will be seen that the operation leaves an altera- tion in the plane of the articu- lating surfaces of the knee-joint Avhich is the converse of that due to the femoral part of genu valgum. I have known cases in Avhich after osteotomy this alteration in the joint-planes made it impossible for the patient to walk, although the legs were straight. Returning to the consideration of the case of my patient aged eight, I will mention that she had still a slight degree of rickets. I therefore ordered her to wear the splints shown in Fig. 185 for at least a year after operation. In this time the knee-joint Avould become moulded to its proper form and relapse would be prevented. In my opinion, no operation, save in exceptional circum- stances, should ever be done during the continuance of rickets. During the last ten years the medical journals contain illustrations of numbers of children operated on for genu valgum betAveen the ages of tAvo and six years. Nearly all Fig. 185.—"Wooden Splints for Knock-knee. The upper bandage does not pass in front of the body. GENU VARUM. 241 these have, like early operations for genu varum, coxa vara and similar conditions, been unnecessary operations. Further in adolescent cases, so long as rickets is active, conservative treatment by ambulant methods suffices to cure. Only Avhen, from neglect of early treatment, the bones have been allowed Fig. 186.—Genu Varum. The Fig. 187.—The same Patient Legs of a Patient aged five (Fig. 186) sitting with years. crossed Legs. to become hard in their deformed condition are operations required. If the deformity is chiefly of tibial origin, osteo- tomy of the tibia* and fibula is preferable to Macewen's operation. The latter is required Avhen there is a femoral element in the deformity and it may need to be supplemented by a tibial osteotomy. Genu Varum.—This deformity has already been defined {see p. 225). Symptoms.—When the patient stands erect Avith the internal malleoli close together the knees are separated by * See a paper by Morton (Bristol), Brit. Med. Journ., 1898. Q o4o GENU VARUM: ANATOMY. a greater or less interval (Fig. 180;. In extreme cases the legs describe a circle. Anatomy.—A general outward bowing of the shafts of the tibia frequently, and a general outward bowing of the shafts of the femora sometimes, accompanies genu valgum It follows that these deformities may exist separately or combined, and that the change in the bones that determines genu varum has its seat near the knee-joint in the extremity of the femur or of the tibia, or of both. In the radiograph shown in Fig. 188, the plane of the knee-joint slopes upwards and inwards or, in other words, the external condyle of the femur is at a lower level than the internal: and further, the upper surface of the tibia is not at a right angle with the line of the shaft, the latter being prolonged upwards on its outer side. Thus, in this case the condition is the con- verse of that seen in a fenioro-tibial genu valgum. In genu varum, as in genu valgum, the tibia is, as a rule, more frequently and more markedly affected than the femur; and in many cases when the legs are crossed the femora are seen to be nearly straight (Fig. 187). Causation.—Genu varum is a much less common deformity than genu valgum, and in trying to arrive at an explanation of the occurrence of this deformity as distinguished from outward or forward boAving of the middle parts of the shafts of the femur or leg-bones, tAvo considerations must be taken into account:—first, the varying degree in which rickety changes occur in the same bone ; and second, the habitual attitude of the patient in Avalking and standing. If the softening of the growing tissue at the epiphyseal line is greater on the inner than the outer aspect of the bones, then genu varum rather than genu valgum will be likely to' occur. In viewing such cases as that shoAvn in Fig. 187 Avith the legs crossed, the suggestion arises that a habit of resting Avith the upper parts of the legs crossing may be the determining factor in the origin of genu varum. Bradford and Lovett observe that in marked cases the patient stands Avith the lumbar spine arched forwards and the thighs flexed and slightly rotated out. In this position the line of gravity Avould fall internal to the knee-joint even if the U EN U VA R UM : CA US A TION- A3 Fig. 188.—Radiograph of Case of Genu Varum (posterior aspect). (Coxeter and Son.) shape of the bones Avere normal. It seems possible that this posture is rather a consequence than a cause of genu varum. 214 GENU VARUM: CAUSATION. It has already been observed that a general outward bowing of the shafts of the femur or leg-bones does not of itself cause genu varum, but when this deformity is found in marked degree such curves are usually present and they serve to give the affected limb a sinuous instead of the angular appearance presented by a simple case of genu valgum. In stating this vieAv, I know that it is at variance Avith that expressed by some of the most authoritative writers. Thus Maeewen Avrites:* " In this elec- tion of site Avhich attended rickets Avas found a probable determining point between genu valgum and varum, as the latter would, be associated Avith those cases where the shafts of the long bones Avere softened." And again, Hoffa,t writing on the same subject, observes: "Its development is easily understood. OutAvard bending of the leg-bones first occurs. Then the heads of the tibi1 SECTION IV. DEFORMITIES CAUSED BY CHANCES IN THE LARGE -10INTS OF THE EXTREMITIES. The Surgical Aspects of Spastic Paralysis, etc. The Ankle Joint.—Congenital deformities and paralytic contractures ha\~e already been dealt Avith under " Club-foot," etc. The chief remaining deformities may be briefly noticed. Traumatic deformities, e.g., those resulting from badly- set Pott's or Dupuytren's fractures.—When the eversion of the foot is great and causes disability to the patient, the condition can be greatly improved by osteotomy of the fibula on a level Avith the lower surface of the tibia and suture of the detached internal malleolus to the tibia; usually section of the tendo Achillis will be required. A good radiograph should be taken as a guide of Avhat is to be done. Suppurative conditions that have been alloAved to terminate in ankylosis in a bad position usually demand excision. Rheumatoid arthritis is to be relieved by the use of light support. Tubercular arthritis, unless A'ery rapid, should be treated for a time by conservative measures, and if, after a patient trial, these fail, free excision is required. Deformities of the Knee-joint.—All the various kinds of deformity are met with at the knee-joint: thus, congenital defects, e.g., intra-uterine pressure deformities; neurogenous, myogenous, dermatogenous, and arthrogenous. Congenital Defects of the Knee-joint and Congenital Genu Recurvatum.—Congenital dislocation of the knee-joint may be either unilateral or bilateral. No hereditary influence has been observed. The tibia in nearly every recorded case has been displaced forwards. Combined with the forward dislocation there may be an imvard or outward or a rotatory 262 CONGENITAL GENU RECURVATUM. displacement of the tibia. Like other congenital deformities, congenital dislocation of the knee, especially Avhen it is bi- lateral, may be accompanied by other errors of development. Symptoms.—In congenital dislocation of the knee forAvards, the joint is in a state of hyper-extension; there is also some accompanying flexion of the hip-joint. If the receding angle betAveen the thigh and the leg on the anterior aspect is very obtuse, the condition is termed " congen- ital genu recurvatum" (see Fig. 201) ; if it approaches a right angle, it is termed a congenital dislocation. The hyper - extension can be increased or diminished by pas- sive force, but the joint Avhen released returns to its original form. Attempts to force the knee into the flexed position cause pain. The femoral condyles are promi- nent on the posterior aspect of the limb. Anatomy.—On opening such joints, the articular surfaces have been found to be altered in form ; the trochlear surface of the femur is prolonged upon the an- terior aspect of the bone, Avhilst the condyles are small and malformed. In severe congenital dislocation of the knee the patella may be absent (Maas). Treatment.—This consists in flexing the knee as nearly to a right angle as possible and fixing the knee in this position with a plaster or other apparatus. The hip- and ankle-joints must be fixed at the same time. At intervals of a Aveek massage and passive movements should be done. In uni- lateral cases, Avhere the patella is present, a good result can be promised. In complicated cases a perfect limb is seldom obtained. Congenital Contracture of the Knee-joint.—In some instances there is present at birth a fixation of the knee in the Fig. 201.—Congenital Genu Re- curvatum. (Shattock: Treres's " System of Surgery.'''') CONGENITAL AFFECTIONS OF THE PATELLA. 263 flexed position. The defect consists in some cases in the presence of a Aveb of skin joining the buttock to the heel (see Fig. 2, p. 12), in other instances only the muscles and ligaments are at fault. This condition has been observed alone or combined Avith contracture of the hip-joint, spina bifida, etc. It is most often met Avith in monsters in its severer grades. Treatment —Instruments furnished Avith lateral steel rods and a rack-joint at the knee to produce gradual extension Avill suffice in slight cases. When the skin is contracted at the back of the knee, a plastic operation may be required. Congenital Affections of the Patella.—Absence of the patella has been observed by Maas in severe congenital dislocation of the knee. The suppression of the bone in this condition is easily explicable as the result of intra-uterine pressure-atrophy. The importance of the condition consists in its prognostic significance; in the absence of the patella a perfect knee-joint cannot be obtained. Incomplete Congenital Dislocation of the Patella.—This designation is applied to a condition in Avhich, Avhen the knee is extended, the patella lies upon the external condyle, but when the knee is flexed the patella returns to its normal position. Intermittent Congenital Dislocation of the Patella.—The condition to Avhich this term is applied is the converse of that last mentioned. The patella lies in its normal position in the extended state of the limb, but becomes displaced outAvards when the knee is flexed. Complete Congenital Dislocation of the Patella.—In this condition the patella rests on the outer surface of the outer condyle in all positions of the joint; its displacement is sometimes increased by flexion of the knee. There is often a concomitant outAvard bending of the leg on the thigh (con- genital genu valgum) or an outAvard rotation of the leg. Illustrative Caze.—A female infant brought to me for severe con- genital calcaneo-valgus (see p. 159). On examining the right leg, it was seen to be rotated out (Fig. 120). The mother had noticed the fact that a cracking sound Avas heard in the knee-joint at times. This I found to be due to movement of the patella upon the outer surface of the outer condyle. The displacement of the patella in this case was accom- panied by marked outward rotation of the leg at the knee. By daily 2fi4 ACQUIRED CONTRACTURE OF THE KNEE. manipulation the displacement of the patella Avas corrected, and after some months the tendency to displacement had disappeared. In those cases of complete outward congenital luxation of the patella in which congenital genu valgum is also present, Fig. 202.—Walking In- strument with Exten- sion Springs for Hip and Knee. (Heather Bigg.)* Fig. 203.—Hessing's Appara- tus with Elastic Springs for Extension of the Knee. (Hoffa.) both deformities may be corrected by manipulative and instrumental treatment combined, if such treatment is begun in early infancy. Acquired Contracture and Ankylosis of the Knee. Dermatogenous contractures from scars are not un- common and require as treatment gradual extension or plastic operations, according to the duration of the condition. Myogenous contractures from rheumatism or ischsemia * For the use of Figs. 202, 237, 2.'>9, and 299 I am indebted to Mr. H. R. Heather Bigg. NEUROGENOUS CONTRACTURE OF THE KNEE. 265 are occasionally seen, and may require massage and mechani- cal treatment, with or without tenotomy. Fig. 204. —Braatz's Plan of Joint in Instruments used at the Knee in Cases of Flexion-contracture. (Hoffa.) Neurogenous Contractures.—-These are chiefly due to infan- tile and spastic paralysis. The contraction of spastic paralysis is treated separately beloAV. The deformities of the knee-joint caused by infantile paralysis are : (1) contracture ; (2) paralytic genu recurvatum. 266 PARALYTIC CONTRACTURE OF THE KNEE. Paralytic contracture of the knee arises when the ex- tensors of the knee are completely paralysed and the flexors retain more or less power. In bedridden, paralysed patients the contraction may become extreme. Symptoms.__These are, an inability fully to extend the knee and the tense appearance of the hamstring tendons when an attempt is made to straighten the limb by passive force. OutAvard rotation, backward and outward displacement of the tibia, is not infrequently combined with flexion in this as in arthrogenous contracture. Fig. 20').—Paralytic Contracture of the Knee-joints with Paralytic Equino-valgus. Treatment—Section of the hamstring tendons Avith sub- sequent gradual extension is required. By means of a proper orthopaedic apparatus the treat- ment may be ambulant throughout. In adjusting the instru- ment Avhen the tibia is displaced backwards care must be taken that the action of the joint at the knee tends to carry the tibia bodily fonvards and doAvnwards as Avell as extending the knee: for this purpose the ordinary rack-joint is not suffi- cient. A free joint is needed opposite the centre of each condyle, and below it a semicircular slot in the expanded end of the upper joint receives a screw Avhich is fixed in the lower iron and Avorks in the slot (Fig. 204). To this apparatus an extending spring may be added (see Figs. 202, 20:5), or daily improvement in position may be obtained by manipulation and maintained by fixing the screw below the joint Avith the limb in an improved position. When the position of the limb has been corrected, the patient may be allowed to Avalk with the knee fixed in the extended position. PARALYTIC GENU RECURVATUM. 267 Illustrative Case—A. girl, aged fifteen, whose loAver limbs are shown in Fig. 205, had been paralysed from infancyand unable to Avalk without crutches. Several operations—which had not, however, been followed up by instrumental treatment, and hence proved failures—had been performed upon the feet, but no treat- ment had been applied to the knees. The latter were flexed to nearly 45° and extremely rigid. After I had divided the peronei tendons and the hamstrings at both knees a course of splinting and daily manipulations was adopted and the deformities were removed. In this case, though the paralysis of the extensors of the knee is complete on both sides, the patient is enabled, by Avalking instru- ments that reach to the waist, to get about without the aid of crutches. Paralytic Genu Recurvatum. —This is not a very common de- formity ; it occurs in some cases of partial paralysis of the anterior muscles of the thigh. The posi- tion of the limb Avhen it is used in progression is as shoAvn in Fig. 206. Causation. —- This deformity occurs where there is partial paralysis of the quadriceps exten- sor muscle, and it is due to the patient's using the limb so that it compensates in a measure for the Fig. 206.—Paralytic Genu muscular weakness. In taking a Recurvatum. (Hoffa.) forward step Avith the paralysed limb the leg is swung forwards so that the heel comes to the ground Avith the limb in full extension, the patient keeps the centre of gravity of the body in front of the centre of the knee, so that Avhen the limb at each alter- nate step comes to bear the Aveight of the body the latter tends to hyper-extend the joint, and in course of time the posterior and the crucial ligaments become stretched, so that the extension movement becomes more than physiological. Hoffa quotes Yolkmann's comparison :— 268 PARALYTIC FLAIL-JOINT AT THE KNEE. " If you take a pocket-knife in the hand and hold it by the haft Avith the point of the blade upon the table, Avith the back of the knife looking away from you, the blade will represent the leg, the haft the thigh, and the joint the knee, Avhilst the hand grasping the haft represents the body of the patient. By slight alterations in the direction of pressure movements can be produced at the joint. ... If the pressure falls behind the joint, that is, on the side of the edge of the knife, the blade springs back when the pressure is suffi- cient ; if the pressure falls towards the back of the knife, the blade opens, and if it is fully opened you can exert any amount of pressure on the handle." To recapitulate these points: the patient, in taking a step fonvard, swings the leg forAvard so that the foot comes to touch the ground with the knee in a hyper-extended position, in Avhich the patient is able to bear his Aveight on the Fig. 207. — Ankylosis limb Avithout the knee suddenly giving of Knee, (ciutton.^ way rp^ mo(je 0f progression causes Treren s " Si/stem oj ■■ •■,-,• /• -i v Surgery.")' a gradual yielding of the ligaments at the back of the knee, and an increase in the degree of hyper-extension alloAved at the joint. 'Treatment—In slight cases an apparatus Avith a " front- stop " joint to prevent over-extension is needed; in more severe cases an extension-spring at the knee is required. Paralytic Flail-joint at the Knee.—When both flexors and extensors are fully paralysed, the knee-joint moves passively in all directions. Treatment.— In order to render progression possible, the knee-joint must be fixed by suitable apparatus, or arthrodesis must be performed in order to produce ankylosis. Arthrogenous Contractures of the Knee.— Pyaemia, post- scarlatinal, gonorrheeal, and other infective inflammations, especially tubercle, give rise to many cases of contracture. The tubercular cases arc so much more common that they may be taken first. aIRTHRUGEXOCS COXTRACTURE OF THE KNEE. 269 Deformity of the Knee from Tubercular Arthritis. —The knee-joint is a very common site for tubercular dis- ease. The general symptoms and management are so fully described in Avorks on general surgery* that there is no need to go into details here. Most of the cases that re- quire operative measures result from the Avant of persever- ance in conservative treatment. The displacement in an ordinary case of untreated tubercular disease of the knee is threefold. The knee is flexed, the tibia is displaced back- wards and rotated outwards. This applies equally to other forms of knee-joint disease and to some forms of contracture ; thus, after traumatic infection, pyaemic or gonorrlueal suppura- tion, the knee tends to the same deformed condition. Treatment.—Prevention of deformity is of the first import- ance. Plaster bandages, though they fit Avell Avhen first ap- plied, are apt to become loose from wasting of the limb. A leather splint moulded to the limb and stiffened Avith lateral steel bands is a much better splint. A simple appliance of this kind Avorn night and day, combined Avith rest in the horizontal position, will, in the majority of cases, secure subsidence of active symptoms. When all heat and tume- faction have been absent for some Aveeks, and if the patient is old enough to use crutches, a Thomas's knee-splint (Fig. 56, p. (S7) may be Avorn. If fiexion is present, it should be corrected gradually. When any spasm or other signs of inflammation are present, an extension apparatus of adhesive plaster should be applied beloAV the knee and arranged so that the traction is at first in the line of the deformity. This is done by supporting the leg on a box co\rered by a soft pillow; the height of the box will vary according to the degree of flexion at the knee. When all active symptoms have disappeared, an apparatus allowing the patient to Avalk Avith crutches, i.e., Avithout using the displaced leg, and tending to effect gradual rectification of the bad position, is required. Thomas used his splint for this purpose by applying it so that the thigh-band comes in front and the leg-band behind the limb. Its use for this purpose is not to be recommended since it causes increased pressure between the anterior edge of the tibia and the femur, * See, for instance, Howard Marsh, " Diseases of Joints and Spine." 270 ARTIIROGEXOUS CONTRACTURE OF THE KNEE. and has frequently been observed to re-Avaken inflammatory symptoms. Any force that is applied should act on the leg in a downward as well as a forward direction or on the principle of Braatz's joint. If backAvard displacement is present, it should be corrected before the correction of the flexion is begun. In the active state of the joint there should be added a weight working over a pulley and attached by a band passing round the upper end of the tibia, Avhilst a second band passes round the loAver end of the femur and has a doAvn- ward acting Aveight attached to it. Forcible Correction under an Anasttietic. —This proceeding—Avhen certain precautions against rupture of skin, arteries or nerves at the back of the joint have been taken—which is safe in cases of fibrous ankylosis after traumatic affections, must be approached with some caution in tubercular cases. In the early stages gradual correction will usually suf- fice to remove deformity. For manual correction the patient is placed supine on a mattress on the floor; the surgeon, stand- ing over him, holds the knee in both hands, the fingers grasping the popliteal space. Ad- hesions are broken down by increasing the flexion by the Aveight of the surgeon's trunk. In cases Avhere there is backAvard displace- ment of the tibia, Bradford and Lovett use a powerful lever for correcting backward displacement of the tibia. In cases of firm ankylosis, resection of the knee may be safely done in persons under fifteen years of age, and even in healthy young adults. After excision, a Thomas's splint should be worn for six months after the patient leaves his bed. In cases of firm osseous ankylosis Avith enlargement of the condyles, a wedge of bone may be removed from the femur. Some patients prefer to retain the limb in the bent position rather than undergo any operation. In such cases progression can be aided by apparatus (Fig. 20N). Internal Derangement of the Knee.—This condition, first Fig. 208. — Ap- paratus for Pal- liation of Con- tracted Knee. DEFORMITIES OF THE 11 IP JO I NT T Fig. 209 -Patella Truss. described by Hey, sometimes yields to orthopedic treatment. When an obvious loose cartilage or other free body in the knee can be felt, or is shown by a radiograph, or when the fore part of the internal semilunar cartilage can be felt to slip forwards and backAvards, there should be no hesitation in performing arthrotomy. In other cases these indications are absent, and then a support that prevents lateral and rotator)' movements should be tried. In several cases I have found this succeed perfectly. After the larger instrument has been discarded, the smaller " patella truss" may be worn for a time Avith advantage (Fig. 209). Deformities, etc., of the Hip-joint.—The functional importance of the hip-joint, and the knoAvn predilection of tubercle for this joint, together give a gravity to affections of this above all other joints of the body. This joint should be carefully examined in every child that is observed to limp. Among the many local conditions that may occasion deformity or impaired movement at the hip-joint may noAv be enumerated— 1. De mv doge nous causes, e.g., scars from burns, inguinal abscesses, etc. 2. Desuiogcnous cu uses} e.g., contraction of the fascia lata from long maintenance of an abnormal position of the limb, or shrinking of the periarticular structures owing to previous inflammation. '■]. Myogenous Causes.—Notable among these is contrac- tion of a psoas muscle from spondylitis, perityphlitis, peri- nephritis, etc. Permanent contraction of muscles is common m cases of hip-disease and, after the original disease has disappeared, may remain as the sole cause of deformity. 4. Neurogenous Causes. —'Such, is the contracture of muscles observed in some cases of infantile paralysis, a condition eomparable to paralytic club-foot. Under this head may be included the neurosis of the hip-joint or hysterical hip. 272 DEFORMITIES OF THE HIP-JOINT. 5. Arthrogenous Causes.—Of these dislocations, tubercular coxitis, arthritis deformans coxae, and other forms of synovitis and arthritis are the commonest. 6. A number of other conditions, including the results of intra-articular fractures, coxa vara, and painful con- ditions of the bone—e.g., epiphyseal hyperemia, the hypo- thetical basis of '■' groAving pains "—may simulate affections of the hip-joint. Symptoms.—With a vieAv to arriving at an exact diagnosis, each symptom must be accurately recorded. Care- ful consideration of the history of a case Avill often serve to .establish a diagnosis. Limitation of the physiological action of the hip-joint is shown by various symptoms, the chief of Avhich are :— 1. Lameness. 2. Alterations in attitude. 3. Atrophy and, in cases of joint-disease, there may also be— 4. Pain in hip or knee. 5. Muscular spasm. 6. SAvelling. Abnormal Attitude.—The cases that come to the notice of the orthopaedic surgeon are chiefly those in Avhich there is contracture or ankylosis. In such cases the abnormal attitude, due to the altered position of the limb, Avhether in standing, walking, lying, or sitting, is often the most pro- nounced feature and, in all forms of joint-affection, requires careful study, and in none is it of greater importance than in the case of the hip. The different abnormal attitudes may be given as follows:— 1. Fixation in Extension.—The patient is able to advance the foot in walking only by wheeling the corresponding half of the pelvis forwards. In the course of time the sacro-iliac and intervertebral ligaments become stretched, and the increased mobility of the corresponding joints enables the patient to move forward Avith the aid of a stick carried in the hand of the affected side. In sitting, the pelvis rests on the front edge of the seat, and by a compensating bend of the lumbar spine (kyphosis) the patient is enabled for a time to assume a more or less upright position. DEFORMITIES OF THE HIP-JOINT. 273 2. With one hip-joint fixed in the flexed position, the patient stands Avith the sound joint flexed, Avhilst the lumbar spine is arched backwards (lordosis) in order to bring the Aveight of the body over the supporting feet. When both hip-joints are fixed in the fully-flexed position, it may be impossible for the patient to stand at all without support. 3. If one limb is fixed in abduction, the sound limb must be adducted to bring the legs parallel in standing. This necessitates a tilting of the pelvis doAvnwards on the side of the affected limb, the latter being thus virtually or apparently elongated. The tilting of the pelvis is brought about by a lateral curving of the lumbar spine, convex toAvards the affected side. Abduction affecting both sides gives rise to a frog-like attitude. 4. Abduction ivith Flexion.—This is a common condition, because it is the usual position in early tubercular coxitis. When the legs are placed together in standing, the pelvis is inclined doAvmvards and fonvards on the affected side; in other Avords, there is lateral curvature, combined Avith lordosis of the lumbar spine. There is apparent lengthening of the loAver limb on the affected side. 5. Adduction.—The sound limb is abducted and the pelvis is tilted upAvards on the affected side by a lateral curve of the lumbar spine convex to the sound side. There is apparent shortening of the affected limb (Fig. 233). Adduction affecting both hip-joints, Avhen marked, gives rise to the scissor-legged deformity, a condition in Avhich the patient is severely handicapped, and is obliged, in progression, to SAving the body fonvard on crutches. Adduction combined Avith flexion of the limb is one of the more frequently recur- ring deformities, since the limb assumes this position in the later stages of tubercular coxitis, Avhen not prevented by suit- able treatment. Diagnosis and Method of Examination.—The patient should lie upon a firm, flat couch. The degree of flexion is estimated by placing the deformed limb in such a position that all lordosis disappears; abduction and adduction are estimated by so placing the affected limb that the anterior- s 271 DEFORMITIES OF THE HIP-JOINT. superior spines of the ilia are at the same level, and that all scoliosis and tilting of the pelvis disappear. This having been done, the sound limb is placed in full extension, so that Fig. 210.—Method of Examination of the Hip. Child with some fixed flexion of the right Hip. The lower limbs are parallel in extension ; therefore the spine is lordotic. (Owen's "Surgical Diseases of Children.") the pelvis may be held at its normal inclination by the ilio-femoral ligaments (Figs. 210-212). Fig. 211.— The same as in Fig. 210, with the affected Hip flexed : the Lordosis disappears. ,'s "Surgical Diseases of Children.") The nature of the disability may, in some cases, be ascertained; for instance, if it be found that the hip-joint of Fig. 212.—H. 0. Thomas's Mode of ascertaining the Degree of Flexion. (Owen's "Surgical Diseases of Children.") the affected limb is capable of a certain degree of passive movement without any alteration in the position of the trunk, a complete ankylosis is excluded, and the condition is probably one of contracture; but in every instance the history of the case should be fully considered, and other symptoms such as Avasting, pain, SAvelling, and muscular CONGENITAL DISLOCATION OF THE HIP. 275 spasm should be looked for, and where any doubt exists a radiograph will often give valuable help. Muscular spasm is indicated by slight involuntary stag- ings of the limb in the opposite direction to that in which the surgeon's hand is endeavouring to move the joint. The slightest force will elicit this symptom. The exact estimation of angular deformity at the hip may be measured by an ankylometer such as that of Lorenz, but a practised observer will be able to record the deformity Avith sufficient accuracy for practical pur- poses. The utmost gentleness must be used throughout the examination. In the case of an infant in arms, the patient may be first examined on the mother's lap. In tubercular coxitis, abduc- tion of the limb is opposed by muscular spasm, whilst in the case of psoas- contraction abduction is usually unopposed. An anaesthetic should not be given before all possible observa- tions have been made Avithout it. The distinction betAveen organic psoas-contracture from tubercular spondylitis and contracture due to early hip disease is sometimes ambiguous. If there is organic shortening of the psoas the range of the extension movement at the hip-joint remains diminished Avhen the patient is anaesthetised. By this method of exami- nation the nature of the disability will be made clear in all but a feAv cases Avhich may require to be kept under observa- tion for some time before a decided opinion can be given. The more important morbid conditions demand separate consideration. These are: congenital dislocation of the hip, tubercular coxitis, " hysterical hip," and rheumatoid arthritis. Congenital Dislocation of the Hip.—This deformity, which may be unilateral or bilateral, is marked at birth by an instability of the hip-joint, and subsequently by upward displacement of the head of the femur Avith all its con- sequences ; shortening of the limb, lameness, and Avhen, as is usual, the head of the femur is displaced backAvards, by secondary changes in the spine, e.g. lordosis. Anatomy.—In considering the anatomy of the condition a clear distinction must be made between Avhat may be called its essential morbid anatomy, i.e. the state of the articulation 276 CONGENITAL DISLOCATION OF THE HIP. at birth, and its secondary anatomy, that is the changes produced in the course of time, which resemble those in old unreduced dislocations. At birth the displacement is easily reduced and as easily returns. Mikulicz* states that at birth (1) the head and neck of the femur are nearly normal, (2) the acetabulum is large enough to retain the head of the femur, (3) the capsule is large and roomy, (4) the ligamentum teres is either absent or is thickened and elongated. The parts are all nearly normal, and there is no obstacle in the Avay of reduction. LockAvood t has dissected two foetuses in Avhich a similar condition Avas present, and found that the car- tilaginous rim of the acetabulum Avas absent, and he concluded that: "The absence of the margin of the aceta- bulum is a prime feature, and it pre- disposes to displacement of the head of the femur either before or after birth." This conclusion is not sup- ported by a case of double congenital dislocation that I examined and in Avhich, though the acetabula Avere small, their rim of cartilage and the cotyloid ligament Avere present and of normal structure, as shoAvn by the microscope. The result of the dissection of my case may be given here since it affords an example of Avhat I believe to be the usual primary anatomy in congenital dislocation of the hip. The subject Avas a still-born foetus Avhich presented, besides congenital dislocation of both hips, slight hydrocephalus, spina bifida, and a deformity of the chest-Avail Avith double talipes equino-varus. The deformity of the-chest-wall and the position into which the lower limbs naturally fell, made it easy to place the foetus in the position it had held when in utero. (Fig. 213.) * J. Mikulicz, Arch, fin- klin. Chlrurg.. Bd. xlix., heft. 2. t Lockwood, Trans. Path. Soc, 1887. Fig. 213. —Intra-uterine attitude of a. Foetus born with double Con- genital Dislocation of the Hips. CONGENITAL DISLOCATION OF THE HIP. 277 On dissection both hip-joints had the appearance shown in Fig. 216. ^> Fig. 211.—Original position of the Bones after Removal of the Capsule. Fig. 215.—Head of Femur, seen from behind. It is slightly flattened. The liga- nientum teres is drawn out and flattened. The femora Avere rotated out and their heads rested on the ilia above the acetabula. In the flexed position, inAvard Fig. 216.—Appearance of Hip- joint after Removal of all the Soft Parts external to the Capsule. Fig. 217.—The same (Fig. 216) after reducing the Dislocation by Inward Rotation and after- wards extending the Joint. rotation through 90° caused the head of the femur to enter the shallow socket, but the slightest upward pressure re- produced the dislocation. In the extended position, inward rotation through 90°, combined Avith downward traction for 278 CONGENITAL DISLOCATION OF THE HIP. a quarter of an inch, caused the head of the bone to enter the socket, and so long as the limb was kept extended and rotated in it Avould bear some little upward pressure ; but vvhen Fig. 218. Side view of the right Os Innominatuni of the Foetus shown in Fig. 213. The Acetabulum is small, shallow, and misshapen. The Cotyloid Ligament is flattened out in the upper half of the aretabular rim. The Os Pubis is not directed as much inwards as in the normal bone. Fig. 219.—The right Os Innomina- tum of a Normal Foetus at Full Term for comparison with Fig. 218. the femur was rotated out the head of the bone at once slipped upAvards. After reduction in the extended position the anterior and posterior fibres of the capsule Avere tightened, Avhilst the lax upper part of the capsule Avas thrown into folds. On opening the joint the head of the bone Avas seen to have the position shown in Fig. 214, and the acetabulum Avas narrowed, as shoAvn in Fig. 218. The head of the femur (Fig. 215), Avas not much changed, being but slightly flattened on its posterior aspect. The pelvis (Fig. 220) Avas somewhat flattened from side to side. The round ligament was broad and elongated. The acetabulum of a normal, full-term foetus is shown in Fig. 219, for com- parison. Fig. 220.—The Pelvis considerably compressed from side to side. CONGENITAL DISLOCATION OF THE HIP. None of the muscles as seen on dissection are at all markedly affected. The flexors and external rota- tors are slightly shortened. The uterus of the mother contained several fibroid tumours. It is not to be supposed that the displace- ment of the head of the bone is primarily alike in all cases of congenital hip- dislocation. In some cases there is rotation of the limb inwards, and hence the head of the bone rests on the ischium. Until the child begins to Avalk the anatomy of congenital dislocation re- mains in all probability practically the same as at birth. After the patient has begun to walk, the second- ary changes begin : 1, the upAvard displacement of the head of the bone increases ; 2, the capsule becomes stretched into an hour- glass shape (Fig. 222) ; 3, the head of the femur becomes flattened ; 4, various sets of muscles become contracted; and 5, more or less of a neAV socket is formed on the innominate bone. Lorenz has fully de- scribed the secondary Fig. 221.—Old unreduced Congenital Dislocation of the Hip. The shallow acetabulum has a triangular shape, and there is a shallow new socket above it. (Howard Marsh.) Fig. 222.—Old unreduced Congenital Dislocation of the Hip. The capsule is elongated and of an hour-glass shape. (Howard Marsh.) 280 CONGENITAL DISLOCATION OF THE HIP. anatomical changes* The result of his observations may be briefly summarised here. Anatomy of the Older Cases of Congenital Dislocation. —A recent period of operative enterprise has added much to our knowledge of the anatomy of congenital hip-dislo- cation, and this, together Avith previous knoAvledge, has been embodied by Lorenz in an admirable monograph from Avhich the folloAving account is taken. Pathological Anatomy.—The acetabulum is rudimentary, and, in some cases, completely filled up Avith firm fibrous tissue. As a rule the anterior part of the capsule is stretched over the acetabulum like a tent, and beneath the capsule there is a space into which a finger can be introduced. Sometimes, hoAvever, the capsule is adherent to fibrous tissue Avhich fills the acetabulum, and in such cases the articular cavity is completely filled up. The Head of the Femur.—The most striking change is complete atrophy. In advanced cases in adults the head may be altogether av an ting. The commonest malformation of the head is a flattening of its postero-internal segment from pressure against the part of the dorsum ilii Avhich lies betAveen the upper border of the acetabulum and the middle of the great sacro-sciatic notch. Exceptionally the head is flattened from Avithin out and then it assumes a buffer shape. In some cases the head of the femur is almost normal in shape. Rickets sometimes plays a part in the production of the changes in the head of the femur. The neck of the femur may be bent forwards (anteversion) to an abnormal extent. It also tends to become horizontal. The Capsule.—In the normal state the capsule and the acetabulum obscure the contours of the head and neck of the bone, but in the congenital dislocation the capsule is stretched so tightly over the head of the femur that the shape of the latter is readily seen as soon as the muscles have been removed. The capsule becomes greatly thickened and may be partly ossified. The round ligament becomes elongated and flattened; it may subsequently undergo disintegration. So long as it * Lorenz, "Pathol, und Therap. der angehorenen Hiiftverrenkung," Wien, 1895. CONGENITAL DISLOCATION OF THE HIP. persists it prevents adhesions forming between the posterior border of the acetabulum and the anterior part of the capsule Avhich is stretched over it. Muscles.—The upward and backward displacement of the lesser trochanter causes the ilio-psoas to rest finally over the original acetabulum, more than half-encircling the narrow part of the hour-glass-shaped capsule. The gluteus minimus may become fibrous and partly fuse with the capsule. The muscles which tend to draw the head of the bone upwards are the biceps, semi-membranosus, semi-tenclinosus, sartorius, tensor fasciae latte, rectus, and the strong lower part of the adductor magnus. The direction of the displacement is nearly always upAvards and backAvards; the exceptions are few. The head has been found to be displaced directly upwards, upwards and forwards, upon the pubes, and in one case downwards and fonvards. The New Joint—The apposition and friction of the bones produce a new cavity, but it is never sufficiently deep to contain the head of the bone, and it is only formed relatively late in life. The cavity is completed by the thickened capsule Avhich surrounds the head of the femur—in a feAv cases in Avhich the head of the bone has caused absorption of the posterior part of the capsule, and so has come to lie directly against the bone. Modifications in the Muscles.—The pelvi-trochanteric muscles are such as pass from the pelvis to the upper part of the femur; those Avhich extend from the pelvis to the shaft of the femur are termed pelvi-femoral; the group of muscles which pass from the pelvis to the upper ends of the tibia and fibula are termed pelvi-crural. Pelci-troctat nteric Group.—The ascent of the head of the femur causes the fibres of the gluteus maximus to become more horizontal in direction ; the great trochanter may come to project above the upper border of the muscle, the loAver border of Avhich rises, and the gluteal furrow rises Avith it, the ischial tuberosity being left uncovered by the muscle. The anterior border of the gluteus medius passes horizontally backAvards. The gluteus minimus, from having a nearly vertical position, becomes nearly horizontal. The deeper 282 CONGENITAL DISLOCATION OF THE HIP. pelvi-trochanteric muscles are also changed in direction, ascending instead of descending to their insertions. The psoas may become cartilaginous Avhen it crosses the pelvis. The traction of this muscle aids in producing lordosis, Avhich is thus not entirely the result of displacement of the point of support of the ilium upon the femur. Only the anterior fibres of the glut. max. and the posterior fibres of the glut. med. and min. are parallel to the displace- ment, and only these fibres are shortened. The glut. max. under- goes a relaxation Avhen the fibres of the tensor fasciae latae are divided. By reason of the outAvard displacement of the great trochanter due to the movement of the femoral head over the ilium, the middle glut, and glut. min. become elongated, and also the middle parts of these muscles are pushed upwards so that their fibres no longer take the shortest direction betAveen origin and insertion. The deep pelvi-trochanteric muscles and the psoas also undergo elongation, Avhence the result that this group of muscles cannot constitute an obstacle to re- duction. " Hence Brodhurst's plan of subcutaneous section of the muscles inserted into the great trochanter is based upon an error, and Hofta's method, Avhich is based upon that of Brodhurst, is likeAvise erroneous." Of the pelvi-femoral muscles, the inner part of the adductor magnus is shortened. The horizontal fibres of the adductors become elongated. The pelri-crural muscles are greatly shortened and consti- tute the most important obstacle to reduction. In old subjects of congenital dislocation, the muscles, especially the glutei, tend to become degenerated, OAving to interference with their functions. The great scicdic nerve undergoes shortening, Avhich can only be safely overcome by gradual extension. Changes in the Pelris.—In double dislocation the ilia become smaller, there is lordosis, and the sacro-vertebral joint is unduly mobile. The ischia are everted, giving rise to increase in the transverse diameter of the pelvis and in the circumference of the pelvis. Causation.—Hippocrates attributed congenital dislocations to injuries received by pregnant Avomen. A great variety of opinions have been advanced, but only two deserve notice— CONGENITAL DISLOCATION OF THE HIP. 283 (1) That the condition is due to a peculiar position of the lower extremities of the fcetus in utcro ; * (2) that it is due to arrest of development, the hip-joint remaining in an early foetal condition. Hoffa observes that the hereditary tendency observed in certain cases of congenital hip-dislocation favours the latter view. It must be admitted, however, that this is not con- clusive, since the hereditary tendency may be to the intra- uterine position of the lower limbs, i.e. with the hips acutely flexed, and the dislocation may follow as a consequence of the position. It is important to remember that whatever the cause the tissues of the joint and the muscles are free from disease, and hence congenital hip-dislocation is comparable with congenital club-foot. Frequency.—The hip is the commonest site of congenital dislocation. Kronlein observed ninety cases of congenital hip-dislocation to five of the humerus, two of the radius, and one of the knee. Hoffa, in 1,444 cases of deformity, observed seven cases of congenital hip-dislocation. The same author has collected statistics of 342 cases. Out of these less than 300 were in females, 42 in males: 134 Avere bilateral; 1!).S Avere uni- lateral ; 100 on the left, 98 on the right side. Symptoms.—If every neAv-born infant Avere carefully examined for the condition, the instability of a congenitally dislocated hip-joint would be discovered, and the condition could be treated from the beginning. As a rule, however, the condition usually attracts no attention until the child begins to Avalk at the age of two or even three years. " Then it is noticed to stand ordinaril}' Avith the back unduly arched and to Avaddle most markedly Avhen Avalking is Avell begun . . . When the dislocation is only unilateral, the Avaddle becomes an exaggerated limp; in stepping on that k-^ the child suddenly lurches violently to the affected side and the leg seems to have grown suddenly shorter." f In double dislocation the Avaddling occurs to either side alternately. It is explicable by the mechanical conditions * This was the view of Dupuytren, who was the first to describe the pathology of this condition. f Bradford and Lovett, he. cit., p. 514. 281 CONGENITAL DISLOCATION OF THE HIP. present, the unstable articulation of the femoral head with the ilium causing the patient to incline to the weight- bearing side, so that the ilium may lie as nearly as possible in a plane at right angles to the head of the femur. When the head of the femur is placed near the anterior-superior spine, the lordosis and the waddling may be but little marked. As the patient groAvs the tro- chanters and the buttocks become very prominent. (See Fig. 223.) Fatigue is readily felt and the unstable joints are very liable to sprains. The displacement of the upper parts of the thighs out- Avards leaves a gap betAveen the thighs at the perineum. The head of the femur may sometimes be felt near the anterior-superior spine, more commonly it is displaced backAvards on the dorsum ilii; but Avhatever the posi- tion of the head of the bone, the foot usually points more or less forAvards, OAving to adaptive changes in the head and neck of the femur. The lumbar spine becomes abnormally mobile in order to compensate for the restricted mobility of the hips. The thighs also become adducted from their separation above. In young subjects traction in the leg causes the great trochanter to descend, but in older patients the parts have become more rigid, and this may no longer be observed to any marked extent. In unilateral congenital displacement we can compare the normal Avith the abnormal side. The latter shows a Fig. 223.—Double Congenital Dislo- cation of the Hip. [Lorenz.) CONGENITAL DISLOCATION OF THE HIP. 285 marked flattening and the gluteal fold is straighter and deeper there. The great trochanter on the affected side is found to be displaced upwards and the affected limb is markedly shortened, and to compensate for this the patient usually holds the ankle of the affected side in the position of talipes equinus, or when the shortening is very great the knee of the sound side is flexed. The pelvis is inclined forwards on the affected to a greater extent than on the sound side, or, in other words, there is some flexion of the abnormal hip. Owing to the inequality of the limbs in length slight scoliosis may supervene ; if the patient is affected Avith rickets the scoliosis may be considerable. In early childhood the range of movement of the dis- located joint is exaggerated except in regard to abduction. The limb may often be adducted to a right angle Avith the axis of the body. In older subjects the range of movement is less and, especially in the direction of extension, may be diminished. Abduction is always limited in congenital dis- location. This is due to the contraction of the adductor muscles and is removed by subcutaneous section of the adductor longus and brevis. In unilateral cases the lower limb on the affected side is less Avell nourished than the sound limb. Sometimes the patient compensates for the shortening by alloAving the limb of the sound side to assume the position of genu recurvatum. Diagnosis.—This will be made on the examination of the hip as described already (p. 273). The trochanter will be dis- placed upwards aboA'e Nekton's line from half an inch to three inches. In young subjects the trochanter can be felt to descend Avhen traction is made upon the limb, Avhilst the pelvis is fixed. The affected limb may be either everted or directed normally. On moving the thigh preternatural mobility may be observed at the hip. The perineum is abnormally broad. Differential Diagnosis. — Immediately after birth there should be little difficulty in recognising the condition. A preternatural mobility of the joint and a sensation of the head of the bone slipping over the shallow acetabular de- pression as the thigh is rotated in and out will afford certain proof of the condition. Traumatic conditions, e.g. dislocation. 286 CONGENITAL DISLOCATION OF THE HIP. and separation of the upper epiphysis, are, hoAvever, possible. Traumatic dislocation will be distinguishable by the firmness of the articulation when reduction has been successfully performed, separation of ail epiphysis by some swelling in the joint, and by the cessation of active movements and eversion of the limb, as well as by shortening. If the child Avas born by the breech and also if other deformities such as Fig. 221.—Radiograph of a case of Double Congenital Dislocation of the Hip. (Mmrhcad Little.') club-foot are present, these will support a diagnosis of con- genital dislocation. If some months or a year or two have passed before the examination is made other possibilities must be considered. The chief of these are coxa vara and infantile paralysis. Coxa vara, or incurvation of the neck of the femur, was first described in adolescents and young adults. It is noAV, however, knoAvn to occur also in young infants. The most certain means of identifying the condition is by a good radio- graph (Fig. 224.)* Infantile paralysis of the pelvi-femoral muscles often simulates congenital dislocation most closely. In fat children the wasting of muscles about the joint is sometimes difficult to recognise by inspection, but by palpation it can usually be * E. Muirhead Little, Brit. Med. Journ., 1898. CONGENITAL DISLOCATION OF THE HIP. 287 made out. Electrical investigation Avill, Avhen necessary, give further information. When the muscles about the hip-joint are paralysed a partial or intermittent dislocation of the joint is very commonly observed. The absence of tone in the muscles and the ease Avith Avhich the dislocation is reduced will serve to distinguish paralytic subluxation. Prognosis.—Congenital dislocation of the hip Avithin certain limits is curable. There is no doubt that in cases diagnosed soon after the patient has begun to walk and treated from the beginning, the unstable joint can be made to become a stable one, or, in other Avords, the condition can be cured. Thus, if efficient treatment is begun at an early period the prognosis is good. Up to the age of seven years the most recent experience has shoAvn that there is a very fair chance of cure. In older children the chance of success diminishes Avith age, but a successful result has been obtained at the age of sixteen years. After the age of eight to ten palliation is all that can be certainly promised. In a few cases the head of the femur becomes arrested by a firm nearthrosis in a favourable position near the anterior-superior spine, and then no treatment beyond the Avearing of a high boot is required. Treatment—There is absolute agreement amongst all observers that at birth congenital dislocation of the hip is easily reduced and that an acetabulum is present and is capable of receiving part of the head of the femur, though from the shalloAvness of the acetabulum the articulation is an unstable one. Schede* Mikulicz f and others have found that Avhere Avell-directed treatment has been begun before the child has been allowed to Avalk, the unstable articulation can be con- verted into a stable one. Schede's abduction treatment consists in the application of an apparatus by means of which abduction and inward pressure on the great trochanter are obtained by means of a screw. In young infants Schede finds that extension in an abducted position combined Avith slight pressure on the great trochanter is sufficient. One of Schede's patients was shown at the age of sixteen years. Treat- * Schede, Verliandlungen der deutsch. Gesellsch. fur Chirurg. Cong., 1894. t Mikulicz, Arch, fiir /din. Chirurg., 1895, Bd. xlix., Heft 2. 288 CONGENITAL DISLOCATION OF THE HIP. ment by means of extension was begun at the age of eleven months and continued for three months. After this the abduction apparatus was Avorn for twelve months. A com- plete and lasting cure Avas obtained. It Avould thus appear that congenital hip-dislocation, at once the commonest and most formidable of all congenital dislocations, can be cured by the simplest means if skilfully and patiently applied during the first two years of life. It becomes, then, a matter of the first importance to diagnose the condition at the earliest possible moment. Buckminster BroAvn obtained a cure in the case of a little girl, aged four, affected Avith double congenital disloca- tion by applying continuous traction, the patient being confined to bed for thirteen months. After this, supported on a wheel-chair, she was allowed to move the legs as in Avalking, but Avithout bearing Aveight upon them. By degrees she Avas alloAved to bear more and more weight upon the lower limbs until finally she was alloAved to Avalk without support. The treatment Avas completely successful. Post, of Boston, obtained a cure in a young child affected Avith unilateral congenital dislocation by reducing the displacement under anaesthesia and retaining the head of the bone in place by means of a plaster of Paris bandage, Avhich enclosed the trunk and thigh. It is a striking comment upon recent experience in the treatment of this formidable malformation, that whilst Lorenz, in his monograph dealing with the subject, which was published in 1895, recommended operative interference as the only hopeful measure, unless in certain exceptional cases, when the anatomical conditions allowed of the head of the bone being replaced in the acetabulum without operative interference, three years later the same surgeon'* no longer recommended the operation, but a bloodless method of reduction and subsequent treatment which com- bine some original features Avith others previously practised, e.g. by Roser, Schede, Mikulicz, and Paci. The chief points aimed at in Lorenz's method are, first, to obtain a true reduction, i.e. to make the head of the femur rest in the diminutive acetabulum; and, secondly, in * Lorenz, Wiener med. Woch., Sept. 3, 1896. CONGENITAL DISLOCATION OF THE HIP. 2S9 the after-treatment to maintain the affected limb in a position of abduction for a sufficient length of time for the original socket to enlarge and the articulation to become firm. This method has only proved successful in the case of young children ; and from personal experience I can testify to its failure in the case of a patient of twelve years of age, though iviimmell has recorded a successful case at the age of sixteen years, so that the method is deserving of a patient trial, even in unpromising cases. The steps of the operation are as follow:— Reduction by Manipulation — Stage I. To bring the head of the femur to the level of the acetabulum. In children Avho have never Avalked this is easily effected. In severe cases the adductors may be thoroughly kneaded or even cut subcutaneously, or all the resistant muscles may be forcibly stretched under anaesthesia by a screAv-extension apparatus Avhich is fixed to the end of the operating table, making traction by a fillet from above the knee; counter-extension being exerted by a perineal band. This part of the operation is rendered more easy by a preliminary course of gradual stretching by extension. Stage II. To open up the passage of the head of the femur into the acetabulum, the thigh must be fully flexed and slightly rotated in. If the fullest abduction is noAv produced in the flexed position, the head of the femur clears the posterior border of the acetabulum, and reduction is effected often, but not ahvays, with a distinct shock that can be felt and heard. Stage III. Full abduction being kept up, the thigh is rotated out, thus forcing the head of the femur more firmly into the socket. The surgeon may now endeavour to deepen the socket by manipulations, grinding the head of the femur into the acetabulum, taking care to keep up full abduction, in Avhich position the tendency to displacement ceases. The limb is put up in plaster, extending from the pelvis to the knee, the position being that of full abduction and slight external rotation and extension. Lorenz directs in cases of double dislocation that the treatment of one side shall be completed before that of the other is begun. Hoffa has found that both limbs may be operated on at the same time. T 290 CONGENITAL DISLOCATION OF THE HIP. After ten to tAvelve Aveeks the plaster is changed and the limb is put up Avith less abduction. The second plaster surrounds the bathing-draAvers area. The child is now en- couraged to Avalk Avith flexed knees, which it does readily. After the second plaster Tausch* uses Schede's abduction Apparatus combined Avith a spinal support by a Hessing's hip- piece. This arrangement has the usual advantages over plaster. A screAV enables pressure on the trochanter to be kept up at night. A joint opposite the hip permits of flexion movements. Duration of Treatment—For six months fixation must be kept up. In cases of double dislocation fixation is required for a longer time. Re-education of muscles and abduction-gymnastics call for some months of treatment, massage, etc., after the fixation has been discontinued. Hoffa advises that in bilateral cases both joints should be simultaneously operated on by Lorenz's bloodless method, the thighs being put up in plaster abducted to a right angle and so allowed to remain for tAvo or three Aveeks, at the end of which time the plaster is reneAved Avith a less degree of abduction. The results of Lorenz's method are highly satisfactory. At the International Congress held at Moscoav in 1897, Lorenz reported 160 cases Avith only five relapses. In most of the successful cases the head of the femur does not remain in the acetabulum, but forms a firm neAV joint beneath the anterior- superior iliac spine. In some cases, hoAvever, the head of the bone remains in the acetabulum. In either case a useful and freely movable limb remains. The dangers of the proceeding are not encountered in young children. In older subjects paralysis from injury to the great sciatic nerve, hematoma from laceration of the soft parts, and in some cases subsequent suppuration have been recorded. In one case Hoffa met Avith a fatality from " con- vulsions and shock-like symptoms." For older children a Chance's spinal support, to the pelvic piece of Avhich are attached one or tAvo leg-irons, according as the case is unilateral * Tauseh, Miinch.med. W'och., July 13, 18!>7. COaVGENITaIL DISLOCATION OF THE HIP. 291 or bilateral, is used at the City of London Orthopaedic Hospital, together with daily massage and gymnastics. Illustrative Cases.—At the present time I have two patients under treatment. One, a girl, aged seven years, with unilateral dislocation, the second a girl aged two and a half years, with bilateral dislocation. In both I adopted Lorenz's method, and I am able to confirm the view that by this means a veritable reduction is obtained. The time of treat- ment has as yet been too short to judge of the permanent results. Operative Treatment—Since Guerin first applied operative measures to the treatment of congenital dislocation of the hip many different plans have been employed. Of these, excision of the head of the femur and the methods of Hoffa and Lorenz alone require mention here. Resection of the head of the femur was first practised by Rose and Reyer in Germany, and has been adopted by Ogston and other surgeons in England. Hoffa observes that the results of dealing with the deformity by simple excision leave much to be desired. Complete cure had never been obtained, and in the cases of bilateral dislocation the patients have Avalked as badly as before operation. In unilateral cases, out of sixteen cases six Avere Avorse off than before operation, and only one Avas able to Avalk Avithout undue fatigue. The same surgeon, hoAvever, recommends excision for cases of congenital dislocation that are too old for other modes of treatment. The essential part of the plan consists in removing, as Avell as the head of the femur, the part of the capsule of the joint that separates the head of the femur from actual contact Avith the surface of the ilium. The joint is opened by a lateral incision and the soft parts are separated subperiosteal^ from the great trochanter and the capsule is detached from its insertion into the neck of the femur, so that the head of the bone can be luxated and made to protrude from the Avound. The head of the bone is detached by a narrow saw close to the intertrochanteric line. The funnel-shaped capsule is then put on the stretch and its hinder part is severed by a cut which passes through its middle and reaches the periosteum of the os innominatum. The attachment of the capsule to the acetabulum is now severed, adhesions between the capsule and periosteum of the os innominatum and the two parts of the capsule are removed. Thus the sawn surface of the femur can be placed against a free periosteal surface on the os innominatum. 292 CONGENITAL DISLOCATION OF THE HIP. Hoffa's original operation consisted in exposing and opening the hip-joint by Langenbeck's posterior excision, separation of all muscular attachments from the great trochanter, and then deepening the shallow acetabulum and replacing in it the head of the bone. Hoffa* candidly admits: " The final functional results Avere not so good as I had ex- pected, seeing that successful reduction had been accom- plished ; and Lorenz soon showed the reason of this, namely, that the pelvi-trochanteric muscles were not shortened, but, on the contrary, Avere elongated, and he had modified my operation by opening the joint from the front and leaving the pelvi-trochanteric muscles intact. In exchange, he re- commended section of the adductors and the attachments of the hamstrings to the tuber ischii in order to neutralise the shortening of these muscles. Later he showed that these multiple tenotomies Avere not Avholly harmless, and that retraction could be overcome by forcible stretching at the operation." Lorenz's Operation.]—The steps of this operation are— I. Drawing down the head of the femur by manual force or by a windlass. In very obstinate cases a preliminary course of weight-extension may be required. II. Anterior incision in skin and fascia lata and exposure of the capsule by separating the tensor fasciae kt;e in front and internally from the gluteus inedius behind and externally. III. T-shaped incision in the capsule by entering the bistoury close to the anterior iliac spine and cutting along the neck of the femur to its attachment to the latter. With a probe-pointed bistoury the incision in the capsule is converted into a T-shape by a cut at the outer extremity of the first. IV. The head of the bone is brought out of the incision and, if necessary, the round ligament is removed and the head of the femur trimmed so that it has a spherical shape. V. Deepening the acetabulum by sharp spoons. VI. Reposition by extension and abduction of the thigh. VII. Suture and immobilisation of the limb in the abducted position by a plaster apparatus. After-treatment.—Allowing two Aveeks for the healing of * " Orthoptedic Surgery," 1898, p. 584. t Lorenz, " Congenital Dislocation of the Hip," translated by Cottet, p. 201. CONGENITAL DISLOCATION OF THE HIP. 293 the wound, daily massage and electric stimulation of the muscles around the joint, and especially of the glutei, are required. Soon active movements must be begun and persevered in until the patient has the power and the will to make them. The abduction movements must be especially cultivated. According to Lorenz, the patients may generally be alloAved to walk unassisted five or, at latest, six weeks after operation. If stiffness remains, a period of weight- extension is indicated. Anatomical Results.—Hoffa has published the results of an autopsy on a boy aged four years, Avho died of diph- theria one year and a half after his open operation had been performed. In this case a firm nearthrosis had been established at the site of the original acetabulum. The same author has demonstrated by radiographs the condition of the joints in three eases tAvo years after operation. In two of these cases the operation had been performed on one side only and in the remaining one on both sides. All the radiographs sIioav satisfactory neAv joints Avith good acetabula and a normally-directed femoral neck. Hoffa has had but one instance of redislocation among his later cases. Physiological Results.—Lorenz considers that a very good physiological result is obtained Avhen the patient can flex the hip to ninety degrees, and even one half this degree of mo- bility is satisfactory. Not infrequently a tendency to flexion- contracture has been observed, but it has ahvays yielded to treatment. Lorenz found that in one of his cases fibrous ankylosis resulted, but in spite of this the physiological result was very good. The tendency to roll from side to side in Avalking remains for a time in some cases and is to be over- come by gradual education in Avalking. Dangers of the Open Operation.—In 200 cases Hoffa had six fatalities. Lorenz has also recorded a fatal case. These deaths were from sepsis and other preATentible causes. Hoffa states that since he has operated without division of the muscles and with faultless asepsis, he has had no further deaths. Indications for the Ope rod ion.—Cases suitable for bloodless reduction are to be treated by that method. Hoffa considers that the best period for operative treatment is betAveen the 294 CONGENITAL DISLOCATION OF THE HIP. third and the eighth year, and as a general rule he would fix the age-limit for the operation at ten years, for older patients substituting the operation described at p. 292. Lorenz ob- serves that in bilateral cases this limit should be adhered to, but in unilateral cases Avhere the femur can be brought doAvn readily, the open method may be used for older subjects. In bilateral cases it is immaterial Avhether only one or both hips are operated upon at the same time. The condition of the patient as to shock, etc., must decide in each case. Con tra-indiced ions.—Lorenz says that there is only one absolute contra-indication, namely, absence of the head of the femur. Absence or gross deformity of the head of the femur can be ascertained by palpation and it may occur at any age. Rickets is the main cause of these additional deformities. This amounts to the proposition that severe coxa vara is a contra-indication, and in radiography there now is a certain test of this point, and no case should be operated upon unless a good radiograph has been obtained and studied. Lorenz also states that " anteversion" of the femoral head is a contra-indication. Palliative Treatment—When the dislocation has been allowed to go untreated for so many years that it can no longer be treated by reposition or by open operation, the question arises as to Avhether anything remains to be done. In a feAv cases nature secures a good result by a fixation of the dislocated head of the femur near the anterior-superior spine. When the parts are in this position, the balance of the body is maintained without any lordotic arching of the spine. In the great majority of cases the head of the femur rests upon the ilium at a point posterior to and far above the acetabulum. In such a condition marked lordosis, or, if the condition be unilateral, scoliosis ensues. In many cases adductor spasm and shortening result in additional disablement of the patient's Avalking powers. Many patients are relieved by Avalking instruments that transfer some of the Aveight to the ischial tuberosities. In some cases there is much pain in the spine. This and the lordosis are best moderated by the use of a Chance's single-upright spinal splint. When instruments are worn daily, exercises are required to pre- vent loss of tone in the muscles. CONGENITAL PAliALYSIS OF THE LOWER LIMBS. 2!»o Severe adductor contracture can generally be overcome by manipulation and by the patient" wearing an abduction- apparatus at night. As soon as a firm articulation has been obtained with the head of the femur directed forwards, instruments may be gradually dispensed Avith. Operative treatment, namely, infra-trochanteric osteotomy, has been suggested by Kirmisson * for severe adduction. In my ex- perience patient manipulation and stretching, combined if neces- sary Avith subcutaneous section of the adductor longus tendons, will render such an operation unnecessary. On some Affections that Simulate Congenital Dislocations. —In connection Avith congenital dislocations certain deformities of traumatic and paralytic nature that date from birth demand men- tion. In the section dealing Avith p. „„. „ .. , „ . . ° rig. 22>.—Congenital Paralysis Congenital dislocations of the of the Lower Extremities. shoulder reference is made (p. 313) to the relation that exists betAveen congenital dislocation and " birth-palsy." The distinction between the classes of cases is made more difficult by reason of the fact that in con- genital dislocation there is an abnormal position of the arm, and hence some difficulty in parturition is to be expected. On the other hand, in tedious or in precipitate labours, injury to the brain, brachial plexus, or the epiphyses, etc., may occur, leading to paralytic and traumatic disabilities that must be distinguished from congenital dislocations. As an example of a congenital paralytic condition (see Fig. 225) that had been mistaken for a double congenital dislocation of the hip, I may mention a case brought to my notice at the North-West London Hospital by my colleague, F)r. G. A. Sutherland, to Avhom I am indebted for the following notes:— * Kirmisson, '• Revue d'Orthopedie," No. 3, 1894. 296 CONGENITAL PARALYSIS OF TEE LOWER LIMBS. Mary E. D., aged two years. Patient has bronchitis and sweats about the head. General nutrition is good. Feet always cold. Lower extremities lie absolutely flaccid in a semi-flexed position with complete eversion, the buttocks, knees, and outer borders of the feet being in contact Avith the bed in the same horizontal plane. Flexion at the knees accompanied with contraction of the hamstrings. No knee-jerk. Sensation in lower limbs very defective. Arms.—Limitation of movement in the right shoulder-joint. The right scapula farther from the spine than the left. Fight elbow shows some flexion-contracture. Right arm cannot be pressed to the side. Double internal strabismus, which was not seen until the patient began cutting teeth. Talking defective : can say " da-da." Does not ansAver questions—looks in- telligent. Mother has never seen any movement in the loAver limb; patient can only move the toes. When she does move the trunk, the muscular action does not extend beyond the pelvis. Head small. Family History:— First child lived ten weeks; prema- ture ; died of bronchitis. Second, living; aged five years; quite healthy. Third, full time ; born dead after Fig. 226.—Paralytic Contrac- instrument delivery. ture of both Hip-joints. Fourth (the patient), seven months' child ; labour induced prema- turely, because of previous difficult labour. Delivery by podolic version; difficulty in bringing down right arm. There has never been any movement in the lower limbs, and the movements of the right arm were always defective. Electrical Reactions.— The abdominal muscles react well to both currents. No reaction to either faradic or galvanic currents in either thigh or calf muscles. Contracture of the Hip from Infantile Paralysis.—This is nearly always a flexion-contracture, as shoAvn in Fig. 220. The superficial muscles, sartorius, and tensor fasciae femoris, and the fascia lata, are most frequently contracted, but in some cases the rectus and other deep muscles are at fault. Treatment.—The contracted muscles require division and TUBERCULAR COXITIS. 297 the improved position must be maintained by proper instru- ments. Tubercular Coxitis.—Symptoms and Diagnosis.—It is in the slighter degrees of hip disease alone that mistakes are likely to be made. For a full consideration of the differential diagnosis of inflammatory conditions general surgical works must be consulted* The various symptoms: (1) lameness, which may be due to tenderness, altered position, weakened or contracted muscles ; (2) pain (often referred to the knee) ; (3) impaired movement; (4) muscular wasting: (5) SAvellingl must be carefully looked for and their degree noted. The most common error is to mistake neurotic or func- tional affections of joints (so-called "hysterical hip") for examples of disease or rice versa. Experience alone will enable the surgeon to separate the clear from the doubtful cases. Incipient or convalescent hip disease in a neurotic girl may require repeated examinations before a definite opinion can be formed. As a rule, however, the absence of the classical signs of disease and the emotional state of the patient will enable the diagnosis to be made, but this should ahvays be done Avith caution. In the functional affection, as a rule, the patient complains of severe pain in the limb, especially on an attempt to move the joint. The pain is more likely to be referred to the hip than the knee. It is important to measure the girth of the thighs, for Avasting, Avhich is seldom absent in tubercular coxitis, is usually wanting in the functional affection. In cases, however, of typical neurotic contracture that have been kept up for some years there may be distinct Avasting of the affected limb. Thus, in the case of the young Avoman shoAvn in Fig. 227 :— The patient was aged twenty-four. She gave out that she was "crippled Avith rheumatism." For five years she had been in one infirmary, and for two years more in a " home of rest." The matron of the latter institution informed me that the patient would sometimes get up and walk about of her own accord, but that she was always worse when called upon to work. She was admitted under my care at the North-West London Hospital. After careful consideration of the case Avith my colleague, Dr. Leonard Guthrie, the diagnosis of hysteria Avas made. I had the patient carried to the operation theatre, * E.g. Howard Marsh, "Diseases of the Joints and Spine," p. 388. 298 TUBERCULAR COXITIS. where the photograph Avas taken. This done, she was sternly bidden to put the left leg out straight. This she did with ease. All the movements of the hip Avere normal, though the left thigh Avas one inch smaller in circumference than the right. The patient walked down to the ward, and by daily exercise in walking alone she com- pletely recovered her powers. In all doubtful cases unconscious movements of the hip in Avalking should be looked for, and the Avell-known device of pressing alternately on the trochanters, Avith counter- pressure on the side opposite to the one complained of, should Fig. 227.—Hysterical Contracture of the Left Arm, Hip and Knee, not be omitted. Having excluded the possibility of the case being one of functional disability, a diagnosis of tubercular coxitis must not be made until the conditions enumerated on p. 271, and incipient coxa vara, have also been excluded. A radiograph may be required. Prognosis.—The prognosis in hip disease depends chiefly upon the completeness Avith Avhich proper treatment can be carried out. If the surroundings of the patient are good, conservative treatment holds out an excellent prospect of recovery Avith a useful limb. Treatment.—In the earlier period of tubercular disease of the hip, deformity is due to reflex muscular spasm. This spasm, although it results in fixation of the joint, cannot be regarded as a natural protection, for it results in increased intra-articular pressure of the bony surfaces and so increases the destructive process leading to pathological dislocation, abscess formation, etc., and the concomitant symptoms of pain, fever, etc. TUBERCULAR COXITIS.- TREATMENT. 2!W In the earlier period of the affection the only point in treatment that may be termed orthopedic, as distinguished from general surgical considerations, is the effort to remove any existing deformity and to secure repair in the best possible position for the future welfare of the patient. Experience has taught the necessity of avoiding inter- osseous pressure in the treatment of joint disease/ When the symptoms are pronounced, rest on a firm, flat hair mattress Avith weight-extension is called for. The patient must be secured in the bed in such a manner that the trunk is straight, and the pelvis is square with the trunk, that is, free from tilting. This is done by applying a long splint to the sound side and, in the case of children, applyl ing shoulder-straps. Instead of shoulder-straps the bed- frame, and instead of Aveight-ex tension the extension-splint recommended by Bradford and Lovett, may be used. In beginning treatment by extension it is important at first to make the traction in the line of the deformity,* gradually improving the position of the limb, a proceeding that is ren- dered easy by the relaxation of the muscles. In suitable cases, as Phelps has observed, outward traction may be added to longitudinal traction by fixing a fillet round the uppermost part of the thigh in addition to the Aveight- extension. The passage in Avhich this recommendation Avas originally made is worth quoting:—"To apply extension to a hip-joint Ave should not only make traction in the line of deformity, but also in a line at right angles to that deformity. In other Avords, to relieve perfectly intra-articular pressure extension must be made in a line corresponding to the axis of the neck and not to the axis of the shaft, for the folioAving reasons: the adductors and abductors pass from the femur diagonally across the body of the pelvis. . . . the flexors act in a line corresponding to the axis of the shaft." Phelps's bed, according to this surgeon's original descrip- tion, is as folloAvs : " A board is cut to correspond Avith the length and Avidth of the child. This is carefully padded. The child is uoav laid on the board and enveloped Avith a plaster of Paris bandage from the feet to the axilla to a thickness of * A. M. Phelps. •' Treatment of Hip-joint Disease," The X, Y, Med'ienl Record, May 4th, ISS'J, 300 TUBERCULAR COXITIS: TREATMENT. three-eighths of an inch. AY hen the plaster is set the front is cut away. This bed can noAv be lined and a front put on it and lacings put in, or the child can be held in place by means of bandages. As the plaster bandages are rolled on they should be nailed to the edges of the board, thus making board and plaster one. This bed Avill be found to fit better and be much lighter and more convenient to make than the iron cuirass. Extension is made to the foot- piece and lateral extension by cutting away the side a little and putting in a staple, to Avhich the bandage is tied." In order to save the trouble of using plaster bandages a sim- ple box-splint* can be obtained at a reasonable charge with padded wooden sides. The double Thomas's splint (Fig. 51, p. 83) is another and very valuable means of obtaining com- plete fixation of the trunk and limbs. By giving ready access to every part of the body it has the great advantage of cleanli- ness, and if the lateral bars are made movable and of such a temper that they can be wrenched of the part of the body against which they rest there need be no fear of pressure sores. But when this splint is applied and left without proper supervision very ugly sores may form. Ambulant Trcaiment of Tubercular Coxitis.—As soon as the local condition allows, it is better for the general health of the patient, and hence for the local conditions, if some apparatus that permits of the patient getting about can be applied. For this purpose the instrument most Avidely * Mr. Tungate, 3, Portman Market, Lisson 0 rove. W., makes very satis- factory box-splints. Fig. 228. —H. O. Thomas's Single Hip-splint applied. {Mayer £ Meltzer.) to assume the contour TUBERCULAR COaXITIS: TREATMENT. 301 T- C^jll known in Great Britain is Thomas's hip-splint (Fig. 228). For convalescent cases, in Avhich deformity has been almost or quite overcome, this is a very valuable as it is a simple appli- ance. If, hoAvever, it is Avrongly made or ineffi- ciently applied it is dangerous and ineffectual. The splint is more often than not wrongly ad- justed. It should be suspended by two braces, as shown in Fig. 22N. and from time to time it should be readjusted by the surgeon (not the mechanician) so as to im- prove the position of the limb and avoid undue pressure at any point. Thomas divided the course of treatment into four stages. In the first stage the patient Avears the splint in bed (in lieu of the extension treatment already described); in the second stage the splint is Avorn continuously, but the patient is alloAved to go about Avith crutches and a patten on the sound foot by day; in the third stage the patient leaves off the splint at night; in the fourth stage the splint is left off" the crutch and patten alone being used. Among the out-patients at hospitals, un- favourable results of the plan of treatment are not uncommonly observed. Speak- ing of the single Thomas's splint Brad- ford and Lovett* remark: — " A Thomas's splint cannot be said to furnish complete fixation, nor does it prevent the occurrence of subluxation or counteract the spasmodic muscular contractions of the muscles con- necting the lower extremity Avith the pelvis. . . . . The appliance, hoAvever, prevents motion to any great amount, enables the patient to be lifted without jarring the hip, and prevents and corrects flexion of the thigh." In my oAvn experience the apparatus represented in Fig. 229 offers a more certain way of fixing the hip-joint, and one admitting of more readily effected improvement in the position of the limb. The dorsal part of the appliance shoAvn *' Loc. supra cit., p. 304. Fig. 221).—Appara- tus recommended by the Author in Hip Disease. A patten on the sou nil side and crutches are us"ed in the earlier period of treatment. 302 TUBERCULAR COXITIS: TREATMENT. in Fig. 229 is a Chance's splint. It is connected with the leg- iron by means of a stout iron bar Avhich is so tempered that it admits of alteration of form by means of Avrenches. Thus, abduction can be obtained diminishing the outAvard curve, and flexion can be diminished and abnormal rotation can be eliminated by periodical slight modifications in the form of the bar; or, as is pre- ferable in older patients, two rack- joints can be inserted in the connection betAveen the pelvic girdle and the leg-iron, as shown in Fig. 229. In cases Avhere sinuses exist a dressing can readily be applied under this splint. When the joint is sufficiently recovered, the bar may be inter- rupted by a movable joint. The instrument has the advantage of being adaptable to the groAvth of the patient, and so in the end it is cheaper than the Thomas's splint, Avhich requires constant reneAval. Many American surgeons* em- ploy traction splints, by means of Avhich the Aveight of the body to the tuber ischii by means of Fig. 230.-Taylor's Traction Apparatus for Hip Disease. in Avalking is transferred perineal bands. The essential parts of these appliances are :—" An outside steel upright reaching from the trochanter to beloAV the foot. At the upper end is a horizontal rigid pelvic girdle in Avhich the patient is secured by one or two perineal straps. To the bottom of the shaft is attached some appliance for exercising traction upon the limb, the latter being well held to the bottom of the splint by means of adhesive plaster gaiters, * The treatment of hip disease by extension is largely due to the initiative of Dr. H. G. Davis, of New York (1K,*>0). TUBERCULAR COXITIS: TREATMENT. 303 circular straps, or bandages. In the adjustment of traction to varying lengths of leg the splint is easily provided for in several ways, usually by means of a sliding rod moving withm a tube, the amount of motion being controlled by means of a key and racket, a spring securing the rod Avhen m the proper position."* The best known of these appliances are Taylor's (Figs. 230 and 231). Personally, I have not felt the need of such an instrument for tubercular coxitis on account of the ex- cellent results obtained with the use of the appliance shown in Fig. 229, which, Avhen convalescence is established, is converted into a simple hip-splint by removal of the dorsal part of the ap- pliance, and when necessary a perineal band is added. Hessing, according to Hoffa, carries an iron half-hoop across the front of his thigh-piece joining the lateral rods. From the front of this an elastic band is attached, which below joins a vertical iron that passes upwards to the in- guinal part of the pelvic band, and is joined to the thigh sheath by a leather slip. The elastic band is stretched in flexion of the hip. In carrying out the mechanical treatment of hip disease there is one consideration of especial importance. This is to decide on the best position for the affected limb in any given case. It has been urged that Avhere there is shortening of the limb or a tendency to dislocation it is better for the patient to have the limb fixed in the abducted position so that when recovery takes place the tendency to dislocation and any shorten- ing of the limb may be compensated for by the oblique position of the pelvis. The great drawback to fixation of the thigh in the abducted position is the effect it may have on the patient's spine and the awkwardness of gait. In has been my rule to aim at a slight degree of flexion and * Bradford and Lovett, he. cit., j>. 311. Fig. 231.—Taylor's Short Traction Splint. 304 TUBERCULAR CONITIS. abduction in such cases as seemed certain to lead to firm ankylosis; on the other hand, where there is prospect of obtaining some movement at the hip-joint to secure the joint in the extended position. The Complications of Tube re alar Coxitis.—Abscess and pathological dislocation are the chief local complications. The occurrence of abscess is an indication for treatment in bed. In my opinion free opening, curetting, and Avashing out Avith hot 1—40 car- bolic, Avith every detail of antiseptic surgery duly observed, give the best results in case of abscess. Healthy repair is often obtained. In such cases, treatment by Aveight-extension should be carried out Avhilst the abscess is under treatment. Dislocation occurs in two dis- tinct modes—1. Suddenly from effu- sion into the joint-cavity. In this condition the acetabulum is pre- served, and the reduction of the dis- location by manipulation Avith subse- quent fixation of the joint is indicated ; in the second form the dislocation is produced sloAvly from the gradual destruction of the upper and posterior part of the margin of the acetabulum. In such cases (Fig. 232) gradual extension by weight com- bined Avith complete fixation of the joint in a good position is called for. Ankylosis.—This may be fibrous or osseous. In fibrous ankylosis the question of the desirability of forcible correction of any flexion, adduction, or other fixed deformity arises. In London the majority of surgeons, after gradual methods have failed to restore the parts to a good position, have recourse to a sub-trochanteric osteotomy or other operation. On this matter the experience of Mr. Robert Jones * is of interest :— * liobert Jones, Lancet, Dec. 17, 1898. Fig. 232.—Dislocation from Tubercular Coxitis. FIBROUS ANKYLOSIS. 305 In the practice of the late H. O. Thomas, in that of Mr. Kiisliton Parker and in my own, it has always been the custom to rectify Avith varying degrees of force any tubercular joint in a Avrong position, so far as that phrase might be applied to the deformity known as flexion. . . . Fig. 233.—Standing Posture of a Patient before (a) and after (b) Forcible Correction of Deformity due to Tubercular Disease. Xot only have I never as a preliminary condition waited for recovery to take place from the tubercular process, but I have looked upon the active stage as that most appropriate for reduction on account of the great facility with wliich reduction may be effected. In the case of the knee particularly, 1 commonly reduce an angle of from 30° to 40c', and allow the patient to travel home the same morning, sometimes a considerable distance. U 300 NONTUBERCULAR DEFORMITIES OF THE HIP. Ill the case of a young man who had the usual flexed adducted, and internally rotated deformity from old-standing hip disease, I forcibly corrected the position, with the result shown in Fig. 233. There was no pain immediately after the operation and no evidence of re-awakened ^ disease for the six months that have elapsed since the operation. When firm osseous ankylosis with deformity has occurred, osteotomy of the femur is required. The choice of operation must be made for each separate case. If the neck of the bone is long and there is no great shortening of the limb, Adams's operation will be the best. If the neck is short and there is no great shortening of the limb, sub-trochanteric osteotomy is called for. When shortening of the limb is present, inter-trochanteric osteotomy and careful fixation of the limb in abducted position during the period of healing are indicated. After any of these operations a well-designed splint securing a certain amount of abduction is required. The discussion of the indications for excision of the hip- joint is a subject that belongs to general surgery. In this place all that need be said is that in young patients the results of thorough conservative treatment are still far better than arc those of early excision. Non-tubercular Deformities of the Hip.—The contrac- tures and deformities of the hip-joint other than those due to tubercular coxitis have been briefly referred to above. Their management must be conducted on principles that guide the surgeon in the conservati\"e surgery of other parts, e.g. as in congenital and paralytic club-foot, ankylosis of the shoulder, etc. Tavo affections, however, demand more than passing notice; they are, spontaneous dislocation of the hip as a sequel to a specific fever and osteo-arthritis of the hip. Deformities of the Hip-joint and other Joints arising after Specific Fevers, etc.—Let it be remembered that this class of affections are essentially pyiemic phenomena, and further that the manipulation of a joint that has become fixed after a suppurative process is liable to re-awaken suppuration. As an example, a ease published by Mr. John Ewens* * I am allowed to quote this case and reproduce one of the illustrations by the courtesy of Mr. Ewens and the editor of the Provincial Medical Journal. HIP-JOINT DEFORMITIES AFTER SPECIFIC FEVERS. 3o7 in the Provincial Medical Journal, -luly, Fs<)2, may be quoted. E. S----, aet. eleven years, admitted into the Bristol Hospital for Children on March 10th, 1890, with dislocation on dorsum ilii of left femur, extensive necrosis of right tibia, and consequent dislo- cation backA\rards on femoral condyles, knee being ankylosed (fibrous) at an angle of 45°. He was in a very weak state, and the skin had scarcely finished peeling after scarlatina, therefore he was placed in the scarlet fever ward, and kept there until the beginning of May, when desquamation had completed. Palliative treatment of the tibia Avas adopted ; wound kept moist with carbolic-acid lotion, and gradual extension of knee Avas attempted. He Avas then quite unable to stand Avithout support and Fig. 234 gives a fair representation of his appearance at that time. History given as follows : On October 23rd, 1889, the boy complained of pain in the right knee, and began to limp. The knee swelled and was " lanced " by the local doctor. Early in Xovember scarlet fever developed and during this illness he complained also of pain in his left lower limb, but not localised, the limb gradually getting distorted. The right knee was said not to have been painful during the illness. No other joint was affected. Two bed-sores had formed, one behind the left trochanter, and one beloAV and behind antero-superior spinous process of the ilium. Scars only remain and there is no evidence of " morbus coxae." The fever lasted a month and he had a very bad throat. In June, 1890, the tibia was freely gouged and large quantities of sequestra were removed, the case progressing most favourably, new bone readily forming. On September 2nd the notes made by Mr. Morton, surgical registrar and pathologist, are as follows : Boy seems now in fair health. Right knee Hexed at 4.V, Avith some slight lateral and backward displacement. No movement of joint possible and no pain nor tenderness. The left hip is dislocated, so that the head of the bone lies on the dorsum ilii, where it can be felt, . . . Sept. 4th.—Under chloroform an attempt was made by manipulation and extension to reduce the left hip : some adhesions were broken down and the limb was put up in a long splint in very fair position, with a tendency to rotation inwards. The right hip was very freely manipu- lated and adhesions about it were broken down, but complete freedom of internal rotation and adduction was not obtained. The adhesions in the knee-joint were to a considerable extent broken doAvn and the limb was extended, but complete extension was not obtained, nor even the patella detached from the condyles. This limb was also put up on a long splint. Sept. 5th.—The boy does not seem to have suffered much from the manipulation, but yesterday had a good deal of pain in the left limb near the knee. Temperature normal. Sept. 29th.—Examination under chloroform. Left limb in very good 30S 1I1P-JOIXT DEFORMITIES AFTER SPECIFIC FEVERS. position now; not possible to compare measurement Avith the right limb, but the trochanter is not raised Avith regard to Nekton's line. Tliere is only very slight movement possible at the false joint, the pelvis moving mainly as a whole. The right knee Avas fairly straightened with considerable difficulty, adhesions being freely broken down, and a back splint was applied. Both limbs were again put up in long splints. Fig. 234.-Dislocation of the Left Hip from Post-scarlatinal Arthritis. Abduction and rotation inwards of the right hip are still very limited. Considerable pain in knee followed this last extension. Sept. 30th.—No pain now, but knee much swollen _ Oct. 2nd.-Knee swollen, but not very tender ; temp. 102' last night; ice applied. • m1' 3rd/17Knet Ies? swol]e,1> 11Q l^in, but temperature 104° last night, now (11 a.m.) 101°. Oct. 7th.—Swelling subsiding. Oct. 13th.-Some fluctuation at sides of patella, but no pain. ARTHRITIS DEFORMANS OF THE HtP. 309 Oct, 17th.—Increased swelling and rise of temperature ; free incision into joint outside patella ; considerable quantities of pus evacuated ; drainage-tube inserted. Oct. 18th.—No pain, but the boy looks very ill and pulled down. Splints removed and limbs gradually assume old distorted position. Oct. 2oth.— Cicatrix of old necrosis on shin has broken down, dis- charging freely foetid pus. From this time up to Oct. 30th the boy's condition was one causing great anxiety, counter-openings having to be freely made around the knee-joint. Temperature rose every night, but less pain Avas experienced than might have been expected. He got very anaemic. On Oct. 30th note made as follows : Hardly any discharge from any of the openings noAV ; quieting down; dressed Avith wet carbolised lint and iodoform ; knee getting back into old position again. Nov. 12.— Sinuses healed; limbs about same position as on Sept. 2nd. Temperature rises to 100° every night; no cough ; anaemic. It Avas now obvious that any further attempt at forcible extension of the knee Avould be attended with serious danger, therefore it was decided to send him home after Christmas, and readmit him in the spring for excision of the knee and Adams's operation on the left hip-joint, apparatus quite failing to maintain permanent good position. April loth, 1891.—Readmitted.—Health much improved, but condi- tion of limbs exactly as before. Small sinus leading down to necrosed bone at upper part of old tibial scar. This was scraped on April 28th and parts gradually healed Avith exception of one small spot. July 17th.—Knee excised under carbolic spray and dressed anti- septically ; put up on metal back splint, with foot-piece and bracketed opening around knee and swung. Aug. 5th.—Wound healed. Temperature never rose above 100° for first feAv days after operation; since then normal. No pain or inflam- matory condition since operation. Firm union effected in about a month after operation. Later, Mr. EAvens performed Adams's operation on the neck of the femur close to the trochanter and in the end obtained a truly excellent result. Arthritis Deformans of the Hip.—The term arthritis deformans is used to designate a group of instances of disability of the hip-joint in order to include affections variously designated as traumatic arthritis, rheumatoid arthritis, or osteo-arthritis, and malum senile coxas. In the section on pathology (p. 38), the general relations of these affections have been discussed as far as present knowledge enables this to be done. It remains noAV to indicate their practical aspects as far as the hip-joint is concerned. Arthritis deformans of spontaneous origin is not uncommon 310 ARTHRITIS DEFORMANS OF THE HIP- in patients who have reached or passed beyond middle- aero but it may, like other osteo-arthritic aflections, occur in early life. , „. In most cases the condition is part of a widespread affec- tion of joints, but sometimes it is non-articular, especially after injury to the joint. Symptoms.—The affection begins with pain about the joint. Radiating neuralgic pains are common, especially along the course of the great sciatic nerve. The move- ments of the joint are restricted, flexion and eversion being specially painful. Atrophy of the muscles about the joint, as evidenced by flattening of the nates, ensues. In the earlier stages of the affection the limb may be flexed and abducted as In hip-joint disease. In the later stages the hip-joint tends to become fixed in a position of adduction and flexion. Eversion of the limb is sometimes marked and together with the apparent shortening due to adduction and, in some cases, real shortening from absorption of bone, a diagnosis of intra- capsular fracture is very likely to be made, especially in traumatic cases. Maydl* has drawn attention to cases in Avhich arthritis deformans may either simulate or complicate coxa vara in adolescence. Diagnosis.—In elderly patients, though tubercular coxitis is rare, it must be excluded before a diagnosis of arthritis deformans is arrived at. Coxa Arara, sciatica, and impacted fracture are also to be considered. Good radiographs will assist in doubtful cases. Treatment.—In every case of osteo-arthritis careful medical treatment must be secured. A month's stay at Bath, Buxton, or Harrogate, will often greatly improve Avhat appears to be a local condition. If pain is severe, local hot-air baths and galvanism may relieve it. In some cases drilling the bone, recommended by Noble Smith, relieves the pain. Rest and weight-extension are indicated Avhen pain is severe. When the condition has sufficiently progressed, a protective walking apparatus is of great service. Illustrative Case.—A. painter, aged fifty-eight, sent to me by Dr. Sutherland, whose notes ran : " Left leg been wasting nearly twelve months. Has not been able to walk well since rheumatism in left * Karl Maydl, Wiener Min. Rundschau, March 7 and 14, 1897. SACRO-ILIAC DISEASE. 311 knee and ankle tAvelve months ago. Right leg also affected, but has recovered. " P. has some flat-foot. Tenderness over tarsal bones on dorsum of foot. Wasting left leg. K. J. present. Some grating in left knee." A radiograph confirmed the diagnosis of osteo-arthritis, and 1 had the apparatus shown in Fig. 235 made and applied. The improvement in the power of walking and diminution of pain was marked and continued. Rheumatoid arthritis of the knee and other joints is also in many cases markedly benefited by suitable ap- paratus Avhich serves to protect the joint surfaces from undue Avear and tear. Sacro-iliac Disease. — Tuberculosis of the sacro-iliac joint usually comes on in early adult life. Lameness and pain are always present and usually from the commencement of the disease. In standing and Avalking the patient throws the Aveight of the body chiefly upon the leg of the sound side by tilting the pelvis. This causes the trunk to be inclined towards the op- posite side and there is apparent lengthening of the leg on the affected side. Local sAvelling and rise of tempera- ture may be observed. In lying doAvn the patient rests upon the sound side. Pain is usually felt along the course of the sciatic nerve and it is frequently referred to the upper part of the leg. It is sometimes referred to the bladder and rectum. Inter- mittent at first, the pain becomes constant and it is often very severe. Abscess occurs in the majority of cases. More commonly it forms on the inner aspect of the joint, sometimes it is super- ficial to the joint, and fluctuation can be obtained. Muscular spasm is absent owing to the fixed character of the joint. Diagnosis. — In the earlier Fig. 23"). — Apparatus used in a Case of severe Arthritis Deformans of the Hip. stages diagnosis between 3p2 SACRO-ILIAC DISEASE. sacro-iliac disease and disease of the lower lumbar vertebra mav be difficult. The attitude of the patient and the absence of rio-idity of the spine are points to be looked for in sacro-iliac disease. Absence of deformity in the lumbar spine and of fulness at the side of the spinous processes will also serve to exclude lumbar spinal disease. A pathognomonic symptom is the production of pain referred to the joint by forcing the two iliac bones either apart from or towards each other. The affection is readily distinguished from hip-joint disease by finding that all the movements of the hip can be executed without eliciting any pain or limitation of movement. Hip disease is most closely simulated Avhen there is an abscess forming in the iliac fossa and, in consequence, there may be flexion and eversion of the limb combined with abduction. A diagnosis of sciatica is made in most cases at first. Prognosis is ahvays grave, especially Avhen abscess is present. If the disease is recognised early and proper treat- ment is carried out, the majority of cases recover. Treat ment—The chief measures are such as secure rest to the joint and elimination of pressure—rest in the hori- zontal position on a firm mattress combined Avith a weight- extension apparatus applied to the lower limb on the affected side. Howard Marsh recommends blisters or the cautery applied over the joint if the pain is severe. Golding Bird,* Van Hook, and others recommend operative treatment in the early stages. A curved flap of skin and muscle is turned doAvn from the posterior part of the iliac crest and a trephine opening is made at the root of the posterior-inferior spine. The opening in the bone is enlarged in the axis of the joint, that is, a line drawn from the upper part of the spine to the junction of the anterior and middle thirds of the iliac crests. During convalescence the patient should walk Avith crutches, the sole of the boot being raised on the sound side and a moulded support applied to the pelvis and affected thigh. Congenital Defects of the Clavicle.f—Complete absence is rare and is generally accompanied by a peculiar con- formation of the head, the frontal and parietal eminences * Lancet, vol. i., 1895, p. 1117. t G-. Schorstein; (4. Carpenter, -Cases of Absence of the Clavicles," Lancet, Jan. 7, lS'.t'.i. CONGENITAL DISPLACEMENT OF SCAPULA. 313 being pronounced and the former separated by a groove. The fontanelles are late to close—a fact that points to a general nialdevelopment of membrane bones. The Signs.—Tliere is no marked deformity ; but the shoulders can be made to meet in front of the patient's body by the surgeon. The functional effect of absence of the clavicles is not serious. Dr. Carpenter, describing the case of a girl, aged thir- teen, Avrites : " The amount of inconvenience Avas so small that neither the patient nor her mother Avas aware of anything Avrong until it Avas pointed out to them. On examination, it Avas found that there Avas practically no ordinary move- ment that the child could not carry out at will. She can lift a heavy weight right above the head Avith ease. She can give a fairly heavy bloAv from the shoulder and can lift her body Avhen suspended by the arms." Congenital Displacement of the Scapula.—This is a rare deformity. Only one case has come to my notice. The left scapula is more commonly at fault. The displacement consists in an elevation of the bone, Avhich is usually increased in size and may present one or more exostoses arising from the upper border of the bone. Pathology.—The condition was first described by Spren- gel* in FS!)1. He regarded the deformity as the result of the arm of the affected side having been fixed behind the back in intra-uterine life. Schlange attributed the deformity to amniotic adhesions. In one case recorded by Koelliker an apparent exostosis was found to consist of an enlargement of the angle of the scapula itself. In the case that came under my own observation the exostosis had been removed, but wit lout any marked improvement being obtained. Associated deformities have sometimes been observed; e.g. cranial asym- metry and club-foot; absence of radius and nialdevelopment of the soft parts on the affected side have also been observed. Deformities of the Shoulder-joint.—Congenital Dis- locations.—In congenital dislocation of the shoulder the head of the humerus may be displaced fonvards and inivards (sub-coracoid), or backAvards and imvards (sub-spinous). In one of the cases dissected by Smith, of Dublin, the head ivas * Quoted by Pischinger, Munch, meil. JFoch., 1S Pseudo-hypertrophic Muscular Paralysis.—This is another condition that, although its general management belongs to the sphere of the physician, not infrequently comes to the notice of the surgeon. The affection is char- acterised by a loss of poAver, accompanied by an apparent increase of bulk in certain muscles. Causation,—Heredity is a marked feature. The disease tends to appear in certain families, and it affects males more commonly than females in about the proportion of five to one. Pedhology.—Pseudo-hypertrophic paralysis is regarded as a primary myopathy. The distinguishing feature is atrophy of the muscular fibres and increase of the inter- stitial cellular tissue in the form of fat. Symptoms.—The earliest symptoms are the result of muscular Aveakness ; the patients tire easily and find it difficult to get up or doAvn stairs. They learn to Avalk late, and are perpetually falling down. In standing, the legs are kept far apart, and there is often marked lordosis. In walking, the patient throAvs the centre of gravity of the body over the supporting leg, and the result is a Avaddling gait. The Aveakness sloAvly increases so that it becomes difficult for the patient to assume the upright position, and then progression is effected on the hands and knees. In this position there is a marked "saddle-back " depression of the lumbar spine. The method in Avhich such patients rise from the "all-fours" position is characteristic :— 1. The patient first extends the knee-joints, resting the clenched hands and the toes upon the ground. 2. One hand is taken from the ground and placed above the knee of the same side. 3. The second hand is similarly treated. F The patient Avorks the hands alternately a few inches up the thighs until the centre of gravity is brought over a point between the feet, Avhich are placed some distance apart. The muscles of the calf are usually hard and tense to the touch. In the upper extremity the muscles ivaste as in progressive muscular atrophy; in the later stages of the affection contractures are observed. The feet tend to 326 PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. assume the position of talipes equinus, the knees and hips are fixed in flexion, and there is sometimes lateral curvature of the spine. Diagnosis—As far as the orthopa'dic aspects of the condition are concerned, diagnosis is the most important task These cases have been mistaken tor spastic and infantile paralysis, for paraplegia due to tubercular spondy- litis, and even for rickets. Careful attention to symptoms and' study of the history of a case will enable the surgeon ;;u Fig. 238.—Position of the Feet in Pseudo-hypertrophic Muscular Paralysis. to exclude spastic paralysis and paraplegia from spinal disease, It is in the later stages of the affection, i.e. when deformities have arisen, that pseudo-hypertrophic paralysis may be mistaken for infantile paralysis. The so-called paralysis of rickets is accompanied by general malnutrition and wasting rather than increase of bulk in muscles. Course.—The disease is steadily, though slowly, pro- gressive. Recovery is practically unknown and arrest of the disease is very exceptional. The first stage, that of muscular Aveakness, lasts several months and passes into the hyper- trophic stage. This begins in the calves and extends upwards and in some cases affects the upper extremities. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 327 This stage takes about eighteen months to reach its maximum. The disease then remains stationary for a variable number of years. Lastly, the atrophic stage appears in Avhich the muscles waste, contractures appear and the patient's strength Avanes. Death usually takes place betAveen the ages of fifteen and tAventy years from pneumonia or some other pulmonary affection. Illustrative Case.—A boy, aged seven years, was brought to me with severe talipes equinus of both feet. The lower limbs were some- what Avasted (Fig. 238). In sitting the patient drooped forwards from weakness of the muscles of the spine. On examination, the ankles were found to be rigidly fixed in the deformed position, and there was some flexion-contracture of the knees. Owing to the late period of the affection, I explained to the parents that it was impossible to restore the poAver of Avalking. At their request, hoAvever, I corrected the deformities present, in order that the patient might be improved in appearance. Treatment—By gentle muscular exercises adapted to the Aveak condition of the patient the last stage may be postponed, and Avhen contractures have appeared tenotomy of the tendo Achillis, and, if need be, of the hamstrings, may for a time restore the poAver of Avalking. 32S SECTION V. DEFORMITIES OF THE SPINE. Introductory to Deformities of the Spine.—Preliminary Observations.—The normal spine is almost straight at birth and during early infancy. Only when the child begins to sit up, does the desire to look around cause it to raise the head and so the cervical spine to become convex forwards* At first, in sitting, the child's back beloAV the cervical region is curved with a general convexity backAvards. This is owing to the inability of the dorsal muscles to hold the spine upright:—Avhen the spine is bent forwards the strain is thrown upon the strong posterior ligaments. It is only Avhen the child begins to stand that the lumbar curve develops. In order to balance the body on the extended lower limbs, the pelvis is tilted forwards and doAvnwards upon the transverse axis of the hip-joints. This position of the pelvis entails a forward bend of the lumbar spine, the dorsal region of the spine retaining its original forward concavity. Not before the sixth or seventh year do these normal curves in the spine become permanent, i.e. cease to disappear when the patient lies down. When the develop- ment of the spine is completed, the line of gravity in the erect position of the body passes through the middle of the head, the front of the atlas, the promontory of the sacrum, and just behind the middle of the acetabulum, in front of the centre of the knee-joint, and betAveen the feet opposite the mid-tarsal joints. The cervical, dorsal, and lumbar curves depend chiefly upon * Some authors describe slight normal curves as being present at birth. However this may be, it does not affect the importance of posture and muscular action in the normal development of the spine. The not inconsiderable number of eases in which as an acquired deformity the normal dorsal curve is reversed tends to show that the form of this part of the spine is not so strongly pre- determined by nature as some writers suppose. DEFORMITIES OF THE SPINE. 32!) the shape of the intervertebral discs, Avhich together form one-fourth of the length of the movable part of the column. Owing to the compressibility of the discs, the length of the spine is from one-half to three-quarters of an inch longer in the recumbent than it is in the erect position. For the same reason a normal person's height is slightly greater in rising in the morning than it is at the end of the day. Adams* observes: " It would probably be correct to assume that about one-fourth, or between one-fourth and one-fifth of the length of the spinal column above the sacrum is composed of elastic intervertebral cartilage, and it is important for us to bear this in mind in reference both to the production and treatment of spinal curvature." The normal range of movement in the spine is greater in the young than in the aged. Flexion and extension are more extensive in the cervical and lumbar than in the dorsal region. The movements in other directions are determined principally by the articular processes. To quote from Quain's "Anatomy" (9th ed.), they are as follows: " In the dorsal region the articular surfaces of each vertebra lie in the arc of a circle Avhose centre is in front, betAveen the bodies of the vertebrae, and round this centre a certain degree of rotation is permitted. In the lumbar region the centre of the circle in Avhich the articular surfaces lie is placed behind so that rotation is prevented; the articular processes, hoAvever, permit of lateral flexion, and by combination of this ivith antero- posterior flexion, some degree of circumduction is produced. The articular surfaces of the cervical vertebrae, being oblique and placed in nearly the same transverse plane, alloAV neither pure rotation nor pure lateral flexion. They permit, besides forward and backAvard motion, only one other, Avhich is rotary round an oblique axis—the inferior articulating process of one side gliding upivards and forwards on the opposing surface, and that of the other side gliding doAvn wards and backAvards, by Avhich a combination of lateral flexion and rotation is obtained. The normal curves of the spine are maintained by a variety of forces, and, if any one of these forces is diminished, deformity results." * " Lectures on Curvature of the Spine," 1st ed., p. l(i. 330 SPINAL DEFORMITIES: VARIETIES. The Chief Varieties of Deformity of the Spine.—The terms used to designate the chief deformities of the spine Avere introduced by Galen about the year a.d. 170. These are—kyphosis (Gr. tcvcpos = stooping), signifying a forward bowing of the spine, e.g. that commonly knoAvn as "round shoulders"; lordosis (Gr. \op8ns = bent supinely), signifying a forward convexity of the spine ; and scoliosis, ((Jr. sous Muscles.—Patient lying on the back with the arms extended above the head. The body is raised to the sitting posture. Repeat five times. 3. Erector S/iiioc.—Patient lying on the face, arms out at right angles, hands prone. Patient supinates hands, throws the scapulae Avell back, raises the hands from the floor, and lifts the trunk. Repeat three times. (R. H. Sayre). 4. Dorsal Rotation oral Respiration.—Patient seated as in 1. The arm on the side of the dorsal convexitvis passed in front of the body, the other behind the body, the hands hold- ing elastic traction cords. Slow, deep respiration. (Barwell). 5. Suspension Exercises on the Horizontal Beer.—In right- convex dorsal cases the left hand should be higher than the right: this is effected by using a double bar, the upper round of Avhich is higher than the lower. ; w; S('GLIOSIS : TR EA TMENT. The patient should be taught to breathe deeply and regularly during all exercises, a habit that can be acquired bv counting aloud. Special Resistance Exercises for the Chest—The mother or nurse can be taught to exercise yielding resistance to in- spiration with the outspread hands, Avhilst the patient sits with the back supported in a suitable chair, or lies down on a flat couch, and breathes deeply and regularly. Instrumental Tiraiment. —Bearing in mind that a certain proportion of eases of spinal curvature are due to rickets and a still larger pro- portion to conditions which are closely akin to rickets. there is a clear indication for the use of instruments dur- ing the evolution of the de- formity. In the choice of an Fig. 208.—Adams's Support for Scoliosis, instrument the objects aimed at must be kept closely in mind. The instrument should be firmly fixed to the pelvis; the main upright should have the outline of the normal slight dorsal and lumbar curves; the splint should be so applied that the dorsal excurvation (kyphosis) and the lumbar incur- vation (lordosis) are corrected. Pads should be placed so that they tend to correct both the lateral deviation and also the rotation. Whilst giving support to the spine, and thus resting the spinal muscles, it should leave the latter free to act Avithin a limited range. The instrument should be arranged in such a manner that its form can be easily modified to follow up improvement in the shape of the body. It should be as light as is compatible with efficacy, and it should bo easily removable by the patient or mother for the performance of exercises. Another desideratum is that it should be moderate in price. It should not interfere with the patient's wearing ordinary dress and mixing in society, going to school, and taking ordinary exercise. Such an instrument acts like a simple splint in such a condition as St 'OIIOSIS : TREATMENT. 367 genu valgum, but the complexity of the deformity in scoliosis demands a corresponding complexity in structure. Among the many instruments that have been employed in the treatment of scoliosis are plaster and felt corsets. These I am convinced do nothing but harm. Another type of instrument is that shown in Fig. 25S. In this instrument the crutches for the arms do not come into action unless injurious pressure is exerted upon the axilhe. For many years sup- ports, consisting of a median upright bar with lateral pads, have been used in England, as sIioavii in Fig. 259, for the use of Avhich I am indebted to Mr. H. R. Heather Bigg. The same principle in greater per- fection is embodied in the instrument that I have found of most service in scoliosis— Chance's splint as modified I >y Noble Smith (Fig. 260). A firm pelvic band (I) rests by a projection on the chair Avhen the patient sits, and has at- tached to it a firm steel up- right Avhich, Avhen seen in profile, is slightly curved to the shape of the normal profile of the spinal column. The upright ends at the level of the shoulders in a pad, from Avhich bands (2) pass round the shoulders holding back the upper part of the thorax and undoing the " stoop," which often forms an impor- tant element in scoliosis. An abdominal band (3) is fixed to the lumbar part of the instrument and tends to correct the "lordosis" Avhich accompanies the lumbar curve. Finally, padded metal plates are adjusted when the patient is holding herself in the best position she can assume, so that she cannot Ml bark into it and allow further deviation to occur. The plates act also as guides to muscular self-correction on the part of the patient. This instrument is lighter than any support of poroplastic felt that I have seen; it is easily Fig. 259.—Sheldrake's Spinal Support for Lateral Curvature. SCOLIOSIS : Tit E. I TM EX T Fig. 260. — Diagram showing Fig. 261.—Chance's Splint as the action of Chance's Splint applied to a case of total as applied to a case of Right- Left-convex Scoliosis?. dorsal Left-lumhar Scoliosis. 1, pelvic band ; i. shoulder strap ; 3, abdominal band. the instrument employed by some Avho appear to be under the impression that they treat scoliosis by exercises alone. The action of the splint as applied in the ordinary Avay is shoAvn in Fig. 2G0. In some cases of old standing, but need- ing slight support, I have found Prothero Smith's brace of use (p. 86). Where there is severe rotation I have latterly employed Chance's splint by adding in the dorsal region on the con- cave side a semicircular arm Avhich ends in a pad by which SCOLIOSIS: TREATMENT. 369 pressure is brought to bear upon the prominence of the ribs in front. A webbing band which acts on a pad over the dorsal prominence on the convex side serves to draw the body towards the middle line Avhilst the pads correct the rotation. The lumbar curve is dealt Avith in a similar way. Fig. 262.—Harwell's Seat. Barwell, deprecating the use of any rigid instruments, recommends amongst other measures the use of posture and elastic SAvathes. Barwell's oblique seat is a well-known and valuable device. Its structure and mode of action are shoAvn in Fig. 262, for the loan of Avhich I am indebted to Mr. Banvell. The SAvathes recommended by the same author are, in my opinion, of less certain value. For a typical case one bandage acts from the lumbar convexity to the top of the opposite trochanter, and Avould doubtless either abduct the corre- sponding thigh or tend to diminish the lumbar convexity. A second surrounds the right shoulder and joins the upper part of the loin bandage, both in front and behind. This 370 SCOLIOSIS: TREATMENT. SAvathe is supposed to counteract the dorsal curve, but from its disposition the force exerted by it must have a down- Avard as Avell as a horizontal action, and so tend to increase deformity at the junction of the curves, and it also would tend to increase the dorsal rotation. This last feature has evidently struck the author, Avho arranges the bands in a different manner when dorsal rotation is a marked feature. The imperfect mechanical effects of the dorsal part of this apparatus render it, in my opinion, an uncertain means of treatment If Avrongly used, any instrument, simple as it may be, may do harm instead of good. It is most important that the splint should be removed twice a day, and the spinal exercises mentioned should also be done twice daily, Avhilst general exercises for legs and arms should be performed Avith the instrument applied. The instrument takes the place of the special couch used in following the method of treatment without instruments, and it is much more effective. In most cases the instrument should be Avorn at night. The marked and rapid improvement in the shape of the spine I have observed in young subjects treated in this manner has caused me to relinquish a credence 1 formerly lent to the Avoids of those who denounce the use of any instru- ment in scoliosis. It is the abuse of instruments that is to be deprecated, not their use. The conditions are similar to those present in a case of genu valgum. The application of the force is more difficult, but, rightly applied in a suitable case, a similar effect is produced. Arbuthnot Lane* has observed, "in rickets . . . the epiphyseal line, which is large and irregular in outline, reacts to pressure in a much more marked manner than does the epiphyseal line of the child that is merely wanting in vigour." A close watch for the onset of scoliosis should be kept in rickety children —and rickets is by no means confined to infancy, nor to the poorer classes—and as soon as the condition is observed con- tinuous mechanical support is required. If this wore done in all cases, the severer grades of scoliosis would soon cease to be knoAvn. Forcible Correction.—There is no doubt that in severe '• Clinical Lectures on Surgical Subjects." 1 Kits. SCOLIOSIS : PROGNOSIS. 371 cases in growing subjects, forcible correction combined Avith exercises and the continuous application of an effective splint in suitable cases gives a rapid improvement in the form of the spine. Lorenz effects this end by bending the patient with the convexity of the dorsal curve resting on a padded hori- zontal bar ; Bar well by strong and wide webbing bands acted on by pulleys. Noble Smith has lately recommended manual correction. I employ both the latter methods in suitable cases. The Patient.—One last observation may be allowed ; that is, Avhatever the deformity may be, in selecting the exact method of procedure the strength, age, and ' sex of the patient must be considered. Treatment suitable to a muscular boy would not be appropriate to a delicate girl, and any energetic gymnastic treatment would be out of place in the case of a patient suffering from advanced heart- disease or phthisis. There is no affection that requires more thought, more careful selection of methods, than lateral curvature of the spine. Moreover, in the course of the same case the treatment demands variation as the con- dition improves. Results of Treatment and Prognosis.—In the past feAV years a considerable number of scoliotic cases has passed through my hands. In early cases of scoliosis—that is, in cases Avith some bony deformity—in adolescents I have found a combination of instrumental treatment Avith exer- cises invariably prevent increase in and frequently cure the deformity Avhen faithfully carried out. Caution is neces- sary in giving a prognosis, because a case may be of old standing when the mother thinks it is only the matter of a few months. In severe cases in groAving children and adolescents, although a complete removal of deformity is not to be expected, the deformity can be diminished and the general health greatly improved by the same means. The chief difficulty that is encountered arises from the too long delay that so often occurs before the patient is brought to the surgeon. Old cases, in Avhich the bones have become hard and adapted to their altered form and disposition, according to Wolffs law, only require attention to the general health and muscular power, unless osteo-arthritis 372 RIG RETS OF THE SPIXE. or some other bone disease should arise, in which event slight support for varying periods is required. Rickets of the Spine.—When avo reflect that genu valgum is usually due to rickets effecting changes in groAvth at the epiphyseal ends of the femur and tibia, and that the spine contains from the third cervical to the first sacral vertebra, inclusive, no less than forty-eight epiphyseal cartilages, the capacity for the occurrence of deformity Avhen the spine is affected by rickets may be realised. The proportion of instances of spinal deformity in the total number of cases of seArere rickets is a veiy large; one. The spinal deformity in rickets may assume any form—kyphosis, lordosis, or ^ scoliosis. In some cases of rickets marked lordosis may develop without the spine being seriously affected. This happens Fig. 263.—Rachitic Kyphosis. when the pelvis becomes flat- tened by the Aveight of the body acting from the sacrum, and when at the same time it assumes a more horizontal position, necessitating a certain degree of lordosis. Hoffa suggests that the bulging abdomen in rickets also aids in drawing the lumbar spine forward into a lordotic position. Rachitic Kyphosis.—Pathology.—This form of kyphosis is usually most marked from the ninth dorsal to the third lum- bar vertebra. Bouland* recognises three anatomical types :— 1. The intervertebral discs are diminished, Avhilst the ossific nuclei of the bodies of the vertebrae and the epi- physeal cartilages are increased in vertical thickness anteriorly. 2. The ossific nuclei arc deeper in front than behind, whilst^tho converse holds good for the epiphyseal cartilages.' 3. The intervertebral discs, ossific nuclei, and the epi- physeal discs all participate, but especially the two latter. * Quoted hy Hoffa. RACHITIC KYPHOSIS. 373 Symptoms.—In rachitic kyphosis the lumbar and dorsal parts of the spine present a backAvard convexity Avhen the child sits. In severe cases the cervical spine also forms part of the same curve, the whole spine assuming a C-shaped curve (Fig. 263). In moderate cases the deformity consists in the fixa- tion of the infantile sitting position. In more severe cases a certain section of the spine may project sharply backAvards, Fig. 264. — Photograph of a Boy aged three years in an Attitude assumed naturally. The child has very severe rickets and kyphosis amongst other deformities. forming an angle which simulates the hump in tubercular disease. In such cases some of the deformity remains even Avhen the child lies down (Fig. 264). Differential Diagnosis.—It is sometimes a matter of difficulty to decide between the rachitic and tubercular kyphosis. This happens Avhen there is a sharp local excurvation, accompanied by general rickets and some rigidity. Rigidity, though usually absent in rachitic spondylitis, is present in many cases that are purely rachitic.; it is then produced by muscular spasm. If in such cases the back is examined after the patient has been at rest for some hours in the supine position, the rigidity will be found to have disappeared and the diagnosis of rickets can then be made. In some cases the patient will have to be watched for some weeks before a diagnosis can bo made. Proipiosis.—The prognosis of rachitic kyphosis is favourable. RA < 'HITIC LORDOSIS. In some cases, however, where the patient has been confined for a long period in a plaster of Paris or a poroplastic jacket, I have found that the curve has become fixed from the altered form of the bones. Treatment.—The kyphosis in young infants is the immediate result of the patient adopting the sitting posture. Therefore the little child should be placed in the supine position until the more active stage of the disease has been overcome by proper diet, which should include cod-liver oil, good air, etc. In children betAveen one and two years old a stiff back-board of padded leather (Fig. 265) should be Avorn. At the same time gentle douching, massage, and passive movement of the spine should be practised twice a day. In older children a light Chance's splint is, in my experience, the best form of support; in every case suitable exercise should be performed. Rachitic Lordosis. — In rickety children lordosis develops in the stand- ing position. This is usually due to one or tAvo causes—(a) the loAver limbs, Aveakencd by malnutrition both of muscle and bone, are not capable of balancing the body so avcII as in normal conditions, therefore what may be termed the natural lordosis is increased; (b) the pelvis, by be- coming flattened from above downwards, involves some backward displacement of the acetabula and hence a com- pensatory lordosis. The treatment of rachitic lordosis is that of rickets and of lordosis (p. 335). AVhilst the disease is active the patient must be kept in the dorsal position, afterwards a light support must be worn, and daily gentle exercises performed until the skeleton and muscles are sufficiently strong to maintain the body in its normal form. Rachitic Scoliosis.—The scoliosis of rickets in its anatomical character is not different from scoliosis due to other causes. Indeed, apart from cases of simple lateral Fig. 265. — Rachitic Kyphosis. The back-board applied. (Noble Smith.) RHEUMATOID ARTHRITIS OF THE SPINE. deviation of the spine secondary to deformity of the lower limbs, e.g. hip-joint disease, some pathologists Avould attribute the great majority of cases of scoliosis of infancy and adolescence to rickets. My experience is entirely in accord with this vieAV. For this reason I have thought it desirable to combine the description of rachitic scoliosis Avith that of scoliosis in general. In this place I would only observe that since in sco- liosis there is usually not only a lateral deA'iation, but also a rotation of the vertebrae, together Avith some dorsal kyphosis and often lumbar lordosis, ' the deformity is much more com- plex than the simple ones just described. The necessary treat- ment is thus more difficult and unless it is efficient and begun in good time the prognosis of rachitic scoliosis is far more grave than that of the simpler deviations. Rheumatoid Arthritis of the Spine.—This affect ion, also known as spondylitis deformans, is one of the most common of spinal affections in Great Britain. Owing to its painful character as Avell as to the serious deformities that it occasions, it is at the same time a serious affliction. The anatomy of osteo-arthritis of the spine is peculiar in that the vertebrae tend to become joined together by bridges of bone which develop as osteophytes springing from adjacent borders of the vertebral bodies and either fuse together or interlock over the intervertebral discs (Fig. 2(i(i). The anterior common ligament and other ligaments may ossify. The atlo-axoid joint may also become stiff from changes similar to those observed in other diarthrodial joints. The bodies are usually more extensively affected than other parts of the vertebrae, but the pedicles, lamina' and processes are all liable to Fig. 266.—Five Dorsal Ver- tehriB aiikyl >sed together from Rheumatoid Arthritis. (Treves's "System of Surgery.") 376 RHEUMATOID ARTHRITIS OF THE SPINE. suffer. Thus the spines are frequently thickened and strands of ossified aponeurosis may form in connection Avith them. The heads of the ribs become joined to the vertebra' by similar bridges of bone and thus lose their respiratory move- ment. Inflammatory SAvellings of the costal cartilages at Fig. 267.—Side View of a Spinal Column affected by Rheumatoid Arthritis. (3Iii.se/ni/ of the Royal College of Surf/eons.) their junction with the sternum or the ribs, I have also observed in several cases. Previous to the stage of ankylosis of the vertebrae there is in most cases a period of inflammatory softening Avhich leads to the production of more or less deformity of the spine. The kind of deformity that results from rheumatoid arthritis varies greatly. In many cases the well-known total kyphosis shoAvn in Fig. 267 occurs and becomes fixed when no proper instrumental treatment is applied early in the course of the case. Kyphosis, however, is by no means the only deformity RHEUMATOID ARTHRITIS OF THE SPINE. 377 produced by the disease. In my experience lateral curvature results nearly as commonly as kyphosis, as in the instance shown in Fig. 26S. The scoliosis may conform to one or other of the types previously described or it may be irregular, here and there a feAV vertebrae yielding to one side or the other. The Age of Onset—In the spine rheumatoid arthritis may set in at any age from in- fancy upwards. It has already been pointed out (p. 44) that a sharp forward bend of the upper part of the dorsal spine is characteristic of infantile rheuma- toid arthritis. In one typical case mentioned below (.sec Case 2, next page) the affection began at the age of four. In young Avomen it is a relatively common com- plaint and it is frequent in adult life and middle age. Symptoms.—Pain is usually the predominant symptom. So much is this the case that when a patient complains chiefly of pain in the spine the case is more likely to be one of rheu- matoid arthritis than of tuberculosis. In many cases the pain radiates from a region of the spine and is accompanied by piiffiness of the subcutaneous tissue, indicating a neuritis of the nerve-roots. Local tenderness accompanied by enlargement of one or more of the spinous processes is frequently complained of. I have found that several cases diagnosed as "spinal irritation" have proved to be instances of early rheumatoid arthritis. When ankylosis has occurred, there is marked rigidity of the spine. It might be anticipated that Avhen ankylosis has set in the pain Avould be diminished. Unfortunately, this does not always folloAv. Prognosis ami Treidnwut.—The prospect of complete recovery in any case is small, but very great benefit which is Fig. 268.—Back of a Patient aged twenty-seven, showing Lateral Curvature due to Rheumatoid Arthritis. 378 RHEUMATOID ARTHRITIS OF THE SPINE. often lasting can be obtained in most cases. In the general measures adopted much discrimination is necessary. Some cases require a liberal, others a restricted diet. In cases of osteo-arthritis of the spine a course of treat- ment at a suitable spa is often of great utility. I have found the English spas—Bath, Buxton, and Harrogate—most serviceable. Among drugs, the iodides, colchicum, and salicylates in the active stages, and arsenic, iron, and the hypophosphitcs in the later stages, are most helpful. Locally.—Dry heat and hot air, hot and electric baths, are useful. Manipulation Avith a vieAv to correcting or preventing stiffness is, in the experience of those Avho have tried it, harmful and useless. The application of counter- irritants in the form of blisters or strong solution of iodine is frequently of service. When lateral curvature is taking place oAving to the softening of bone entailed by the rheumatoid process, or Avhen an old lateral curvature, one that has been stationary from childhood, is increasing from the same cause, and also when pain is aggravated by movements, or is diminished by resting the arms on a chair-back or other support, mechanical help is called for. For this purpose I have found Chance's splints the lightest and most useful instruments. Illustrative Cases.—1. A married lady, aged thirty-five, who has borne two children in the last tAvo years. For the past twelve months patient has complained of pain in the lumbar region and the sacro-iliac joints and has had pain at times down the outside of the thighs and legs. There has been much wasting of the muscles of the back and lower limbs, with general weakness, indigestion, etc. On examination, I found a well- marked, localised, lateral curve to the left in the lumbar region, and I recommended a double upright Chance's splint, which I adjusted. I learn that the patient finds that the support relieves the pain and enables her to walk about with comfort, and she has resumed active work among the poor. The instrument is left off at night. After a few weeks the back had so far improved that exercises were begun. 2. A girl, aged sixteen, sent to me by Dr. M. M. Loudon, of Arundel, to whom and to Dr. A. Tenison I am indebted for some of the following notes. The patient was healthy until the age of four years when, during an attack of whooping cough, she was noticed to have lateral curvature. This became gradually more marked. At the age of six years she was offered a bed at a hospital, wliich was declined on RHEUMATISM OF THE SPINE. 37!) the advice of a medical man, who assured the patient that she would "grow out of it." Present State,—The patient is of average height for her years, decidedly anaemic and walks with the spine rigid. In the lower cervical and upper dorsal region there is a localised lateral curve to the right, the corresponding scapula is elevated and a band of ossified aponeurosis stretches from the base of the spine of the scapula to the seventh cervical spine. A second lateral curve, also to the right, is present in the lumbar region. There are swellings in several costal cartilages at their junctions with the ribs. The patient suffers much from paroxysmal pain in the cervical and lumbar regions of the spine. Creat relief is given to these spasms by leaning heavily on the right arm fully extended- The right arm beloAV the elbow becomes painful, and from the elbow to the shoulder completely numb, with complete loss of sensation. She has "jumpings" of her right leg and they are so severe that they shake all the furniture in a room. Patient always knows Avhen these "jumpings " are coming on, as she says she feels "as if the leg were going to burst" and it becomes intensely itchy. About half an hour after this it begins to jump and patient cannot control it ; but it gradually decreases and passes off in about an hour. A Chance's splint Avas adjusted, and cod-liver oil and iron ordered. The patient has been free from pain and in improved health since this treatment Avas adopted three months ago. Other Forms of Non-tubercular Spondylitis.—Syfdtilitie disease, though not common, has been observed from time to time. In a man, aged fifty-six, Founder verified the diagnosis after death. T. H. Myers (A/". Y. Acad, of Med., Feb. 17,'ISDN) records two cases in boys. In one case the disease affected the cervical region, causing wry-neck, in the other the dorsal region was affected. In both cases much relief Avas obtained by instrumental treatment. Rheinradism of the spine, as distinguished from rheu- matoid arthritis, is sometimes observed. It generallv forms part of an attack of sub-acute rheumatism, which affects other diarthrodial joints as well as those of the spine. Diagnosis.—Iiheumatism is to be distinguished from rheumatoid arthritis of the spine. The former is a rare, the latter a common condition; both are painful. Complete recovery may be obtained in the former condition, whilst it is rare in the latter. The differential diagnosis is most difficult in very chronic cases of true rheumatism. Rheumatic nodules under the scalp and about the tendons at the Avrist and ankle and 380 NEUROTIC AFEECT10NS OF THE SPINE. about the elbows are to be sought for. The assistance of a physician should be obtained in such cases, especially if endocarditis, carditis, or pericarditis be suspected. Postscarlatinal rheumatism andgoaorrlueid rheunadism may also affect the spine, though this occurrence! is rare. Post-typlioid!>). I found the patient was unable fully to extend the right elboAv and knee. The movements of the right arm and leg were generally impaired. When the patient was asked to extend the right arm as in striking, her head and the upper part of the body nodded in a peculiar manner, showing that the spastic condition involved the trunk-muscles as well as those of the limbs. Treatment.—Rest from school and books, liberal diet, massage, and firm moral treatment were ordered and carried out for a month. At the end of this period, although the patient had put on flesh, the condition of the spine and limbs was unaltered. The simple support shown in Fig. 270 was then applied. The upright stem of the instrument was so arranged that when the patient's back was arched the instrument pressed slightly against the mid-dorsal spine, and the patient was instructed that when she felt this pressure she Avas to hold herself straighter. Gentle exercises were prescribed at the same time. The good effect of these measures was at once apparent. In a fortnight the dorsal excurvation had disappeared and the condition of the limbs had improved. A little later the child was sent to the "invalid" school, and save for one relapse, which lasted only a few days, the spine has remained normal up to the present time—i.e. for a year and some months. Tuberculosis of the Spine,* or Tubercular Spondylitis.— Tubercle may affect the spine at any point from the atlas to the coccyx, and it may be mistaken for a great number of other affections. Thus atlo-axoid tuberculosis has been mistaken for occipital neuralgia, and tubercle of the coccyx for ordinary " fistula in ano." The affection may begin at any period of life, from the earliest infancy to advanced years. Tubercular disease of * Since the year IK811, when E. Koch made the meaning of the term tuberculosis definite, the affection of the vertebrae caused by tubercular infection is best named li tubercular spondylitis." The term •' Pott's disease" honours a great surgeon, but it is less convenient than a strictly descriptive term. " Spinal caries'' is a common designation, but it is indefinite, since caries or rarefaction of bone may be due to many different agents. " Angular curvature" is a self-contradictory phrase and is best avoided. TUBERCULAR SPONf)YLITIS. 383 the spine is closely simulated by other conditions, e.g. rickets, rheumatoid arthritis and malignant disease, hence the closest study is required to prevent error in diagnosis and in treatment. Pathology.—The favourite start- ing-point of tuberculosis in the long bones is in the cancellous tissue of the diaphysis close to the epiphyseal cartilage. Similarly it is in the cancellous tissue at the juxta-epiphyseal region of the bodies of the vertebrte that tubercle is probably first formed in the ver- tebrae. Moreover, it is in the an- terior far more frequently than the posterior parts of the bodies that early tubercular changes are found when opportunities for post-mortem examination occur in suitable cases. From this starting-point it extends in all directions, involving the neighbouring intervertebral discs and attacking the bodies of neigh- bouring vertebrae. - Part of a Spinal Column. The l>ody of one of the lower dorsal vertebrae has been destroyed by a deep tuberculosis and extensive destruction of the anterior surface of the spine by superficial exten- sion. (Museum of the Royal Col- lege of Surgeons.) This form of the affection is by far the more common, and it has been designated "spondylitis pro- fundei" in order to distinguish it from another form of the affec- tion in Avhich the tubercle spreads Avidely beneath the anterior common ligament constituting "spondylitis superficialis." Spondylitis profunda commonly spreads from a single focus, but not very rarely several foci, resulting from the same original discharge of bacilli, are formed and may be recognised clinically by the presence of tAvo or more projections in the line of the spinous processes. An originally deep tuberculosis may become superficial by extension to the surfaces (Fig. 271). The spread of the tubercular granuloma takes place in 384 TUBERCULAR SPONDYLITIS. all directions; vertically, as has already been described, it tends to invade neighbouring intervertebral discs and vertebral bodies ; superficially, it reaches the periosteum and the soft parts and frequently ends in the formation of abscess. If caseous material or pus accumulate in the spinal canal, pressure-paraplegia may folloAV. The course of the affection depends upon (1) the resisting poAver of the individual and (2) upon the treatment. If the individual is fairly protected, the balance of power betAveen the invading organisms and the resisting powers of the indi- vidual leads to the formation of granulation tissue around the bacilli. This " granulation- tuberculosis " is favourable to the ultimate arrest of the dis- ease ; at the same time it is ac- companied by the formation of necrotic and caseous areas and sometimes of abscess. If the progress of the disease is more rapid, there is not time for the absorption of bone pari passu Avith increase of the infected area and dead masses of bone (sequestra) are left in the midst of the tubercular area: this has been termed tubercular necrosis. The presence of sequestra is usually a token of widespread disease. Large sequestra are rare in tubercular disease of the spine. Anatomicfd Effects.—The gradual destruction of one or more of the vertebral bodies causes an alteration in the form of the spine. The latter usually becomes sharply bent forAvards opposite the vertebral body in which the disease began. This kinking, or " angular curvature" of the spine, produces a projection (gibbus) in the line of the Fig. '272. — Part of a Skeleton showing the Deformity of the Spine and Thorax in Dorsal Tu- bercular Spondylitis. (Museum of the Royal College of Surf/eons.) TUBERCULAR. SPONDYLITIS. :i$r, spines. When the tubercular granulation tissue spreads more in the lateral part of the body of a vertebra a localised lateral curvature results. The sharpness of the angle varies with the extent of the destruction. When a number of vertebral are involved the gibbus is of a rounded rather than an angular form. The rounded form of the Fig. '_'"•$.—Part of a Skeleton showing Deformity arising from low Dorsal Disease. (Museum of the Royal College of Surgeons.) gibbus is contributed to by an adaptive change in the spinous processes Avhich, owing to the traction of attached ligaments, become bent in proportion to the sharjmess of the curve in the spine. In the lumbar and cervical regions, where there is a normal backward concavity of the spine, the first effect is a straightening of the region affected. In a feAV instances, Avhilst the destructive process is taking place in the vertebral bodies, new bone is thrown out from the deep surface of the anterior common ligament which serves also as periosteum to the front of the vertebne. z 38G TUBERCULAR SPONDYLITIS. In such cases there may be no deformity in spite of ex- tensive bone destruction. Tuberculosis of the Vertebral Arches.—A primary tuber- culosis of the vertebral arches is very rare. This is owing to their more compact structure. Like the ribs, however, they are occasionally attacked by tubercle. A simple inflammatory ostitis of the vertebral arches and processes, Fig. 274.—Healed Tuberculosis of the Spine. Sketch of the right half of the thorax of a woman aged twenty-eight, who had suffered from spinal tubercle in childhood and who died of bronchitis. The vertebral bodies from the 4th to the 9th have been destroyed, and are repre- sented by hard new bone which contained caseous foci. The spines of the vertebra from the second to the ninth are ankylosed together. due to absorption of irritating toxic material, is usual in advanced tuberculosis of the bodies. Recovery.—In well-treated cases where the patient is not of the feeblest resisting poAver natural recovery occurs. In such cases, when the parts are examined long after active disease has ceased, the remains of the bones of the vertebrae are found to be sclerosed and ankylosed. There is usually not so much formation of new bone as is shoAvn in the accompanying diagram (Fig. 274). Abscess.—The pus of a tubercular abscess contains TUBEBCULAR SPONDYLITIS. 3X7 tubercle bacilli and, unless it has become secondarily infected by staphylococci or streptococci, it will separate readily into a watery and a denser layer after evacuation. Like other abscesses, those secondary to spinal tuberculosis tend to spread in the direction of least resistance; thus in each segment of the spine the probable route of an abscess is known beforehand, as will be more fully indicated on p. 395. The frequency Avith which abscess-formation is observed in spinal tuberculosis is very great. Dollinger in 700 cases found abscesses in 154. Small abscesses that have not been discovered during life have frequently been met with post- mortem. Srco ia la ry Effects on the Skeleton.—The spinal canal is usually Avidened rather than narrowed (see Fig. 275). Excep- tions to this rule arise, however, iioav and then, e.g. Avhen a traumatic fracture or dislocation occurs in a case of tuber- culosis or when a loose sequestrum (see Fig. 270) is displaced back- wards. The interver- tebral spaces suffer no narrowing because they lie behind the axis of the disease. The nerves are thus not directly pressed upon. The pain is due to extension of inflammation to the sheaths of the nerve-roots. The angular deformity entails a forward displacement of the centre of gravity of the body, and to compensate for this a lordosis of the part of the spine below the projection is brought about by muscular action. In disease of the cervical or upper dorsal spine the lordosis of the part of the spine below the projection may involve nearly the whole of the dorsal vertebra' below the projection. Fig. ).—Section of part of a Spine deformed from the Tubercular Disease. The spinal canal is enlarged opposite the seat of disease. (Museum of the Royal College of Surgeons.) 388 TUBER CIILA R SPOND YIA TIS. Thus the normal convexity backwards of the dorsal region mav be changed to a lordotic condition which may extend to the interscapular region. For the same reason the part of the spine above the projection also becomes lordotic, so that the head is projected back- wards (Fig. 273). Lumbar kyphosis is com- jiensated for by lordosis of the neck and slight diminution of the normal dorsal kyphosis : if the seat of the lumbar kyjihosis is Ioav the inclination of the pelvis is diminished and the extension of the hips is in- creased. Most important are the effects on the respiratory and circulatory organs owing to alterations in the form of the thorax. When the projection is in the mid-dorsal or loAver dorsal part of the spine the thorax becomes greatly increased in its antero-posterior, Avhilst it is diminished in its vertical and transverse measurements. The upper end of the sternum becomes elevated. In this Avay the thorax assumes a keel- shape (Figs. 273, 274). On the contrary, when the deformity is in the upper dorsal region the antero-posterior measurement is diminished, the thorax becoming approximated to the pelvis and the chest flattened (Fig. 272). When the lumbar region is the seat of the deformity the thorax may sink till the loAver ribs rest on the pelvic bones. The abdomen is thus thrust downwards and forwards. The pelvis assumes the kyphotic form: its Fig. 270.—Section of part of a Spinal Column showing the re- mains of a Necrotic Vertebral Body displaced backwards and pressing upon the Spinal Cord. The patient was a boy aged nine and a half years. Paraplegia developed suddenly in the space of a' night; priapism, bed-sores, and involuntary jerkings of the lower limbs were present. Laminectomy was performed and the patient died of broncho- pneumonia. The entire body of a vertebra was found to be necrosed and displaced backwards, pressing on the cord. (Vincent.) TUBERCULAR SPONDYLITIS. ;J8!) lateral walls are approximated, the inlet is widened and the outlet narrowed. Witzel first described the change in the skull. The mento-occipital measurement is increased and the fronto- occipital diameter is diminished. The aorta and vena cava may be kinked with narrowing of their lamina and cardiac hypertrophy may occur, or the large blood-vessels may be softened and perforated by abscesses leading to extensive haemorrhage. Spinal C'o/v/.—Save in exceptional cases there is no direct pressure, but in rare instances this takes place either from the backward displacement of a sequestrum or from rapid yielding of vertebrae. According to Kraske, this direct pressure was observed only once in fifty-two eases of paraplegia examined after death. In nearly all cases the paraplegia is due to extension of the tubercular process to the tissues of the spinal canal. The cord may then be affected in various ways : (1) by the jiressure of tubercular granulations formed in the fatty tissue outside the cord; (2) by abscesses formed outside the dura mater; (3) by simple inflammatory processes (pachymeningitis externa) in the dura mater, which is highly resistant to the specific tubercular inflammation. In cases of severe paraplegia followed by a spastic condition in the lower limbs the cord itself becomes involved in the simple peri-tubercular inflammation. This has been proved by post-mortem examination. Later, even the dura may be destroyed by the specific tubercular inflammation, but this event will follow, not precede, the j)araplegia, anaemia or oedema of the cord having been the direct cause. Thus, (edema is to be referred to pressure on lymph-channels in the subarachnoid space. W. G. Spiller* has published a series of obsen'atioiis, two of which may be briefly quoted:— (1.) Hoy, aet. twelve. Lower cervical and first dorsal vertebra: attacked ; died of dyspnoea. P.M.—Early case ; no compression of cord. Intense round-cell infiltration of meninges and cord without specific tubercular inflamma- tion internal to the dura. (2.) Child, tct. three years. Disease of first, second, and third dorsal vertebrae. Paraplegia gradually developed. * "Johns Hopkins Hospital Reports," June, IS'.is. :VM) TIOIERGULAR SPOXDYIATIS. HAL—The cord was found to be compressed by the hones, and microscopically it showed in the compressed part but few inedullated fibres and no nerve-cells. The pia mater was thickened, and there was both ascending and descending degeneration of the motor and other tracts. Symptoms; Cain,—In infants the first indication of the disease is a loss of liveliness. The child, previously active and in constant movement, becomes fretful and ceases to play. These are evidences of pain. If the patient is too young to sjieak, it may nevertheless indicate the seat of the pain; for example, by placing the hands on the back of the head, the side of the chest, the abdomen, or the lower limbs, according to the site of the disease. Older children and adults who can describe their sensations speak of the pain as a dull ache, sometimes increased at each pulse-Avave. Though the pain is usually symmetrical, varying in the dorsal and lumbar regions from a sense of constriction to a distinct girdle pain, it is sometimes one-sided owing to the inflammatory process affecting one side more than the other. Fain in the limbs, in the bladder and penis, and " gastric crises," have all been noticed. The pains are worse at night and after meals. Children often scream at night, and tliere ma}' be hyperaesthetic areas in the skin supplied by the affected nerves so that the pressure of the bed-clothes cannot be borne. In some early cases pain is not a marked feature and it may only be felt Avhen the patient sits doAvn, because ht the sitting position the lumbar part of the sjiine becomes arched forwards. The pain is also madeAvorse by movements, such as stooping, laughing, coughing; also by riding in a train or other vehicle, or by the jar of a false stejj. The apprehension of the pain caused, by such movements may give the patient an anxious expression. The degree of pain present in different cases varies greatly. In some eases it is of a lancinating character. As a rule, hoAvever, the pain in a case of tuberculosis of the spine is less than that of rheu- matoid arthritis. In some remarkable cases a pronounced angular curvature has developed without any pain having been present. In the rare eases in Avhich the tubercular process begins at the back of the bodies of the vertebra' pain may be absent for a considerable time. TUBERCULAR SPONDYLITIS. 391 Thus the absence of pain must never be taken as proof of the absence of tubercular disease. Many carefully recorded eases and specimens in museums attest the fact that pain in tubercular disease of the spine may be absent, or so slight that it is overlooked. Thus, instances of extensive cervical disease have been mistaken for wry-neck, melan- cholia, etc. The dyspiKoa dependent on pressure of a retro- pharyngeal abscess has been diagnosed as " croup." If a more complete examination had been made in such cases and rigidity had been looked for, these mistakes would probably ncA'er have occurred. A radiograph is often useful in doubtful eases, especially in the cervical region. Tenderness.— It is seldom advisable in the examination of the patient to bring out this symptom, either by jm'ssing on the head or shoulders, or locally on any prominent sjiine; in tact, tenderness is rather against than for tuberculosis. In rheumatoid arthritis, there is superficial tenderness to pressure on the spine, and the presence or absence of this symptom can be ascertained Avithout using pressure sufficient to cause pain or alarm to the patient. If the patient feels pain on coughing or other sudden movement, this is the expression of tenderness of the spine. R'ojidity.—Of all the symptoms of tuberculosis of the spine this is by far the most important. Just as in joint disease, say of the hip, there is fixation of the joint from spasm of muscles, so also in disease of the spine is tliere a loss of natural mobility from the same cause. In the examination of the patient this symptom must be carefully looked for. The patient's manner of holding himself in Avalking may betray the fact that part of the spine is kept rigid. In every case where tuberculosis of the spine is suspected, the flexibility and rotatory capacity of the spine should be systematically looked for. Thus, in the examina- tion of* the cervical part of the spinal column, the degree of flexion, extension and lateral bending that the patient is capable of must be ascertained, as well as the power of rotation effected between the atlas and axis, and finally the nodding movements between the occiput and atlas. In young infants the flexibility of the spine can be ascer- tained' by placing the palm of the hand under the patient's 392 TUBERCULAR SPONDYLITIS. back and gradually and gently lifting the child by raising the hand. If there is no rigidity of the spine, it will be felt to become extended as the weight of the child's body falls more and more upon it. This same feature may be demonstrated by laying the child on the ventral asjioet and raising the body gently by the legs.* Impairment of flexibility of the spinels Fig. 277.—Attitudes assumed Spontaneously by Patients suffering from Lumbar and Dorsal Disease. often Avell brought out by making the patient pick up some small object from the ground. If the spine is normal the patient stoops and rises without hesitation, but if tuberculosis of the spine is present, the back is held rigid Avhilst the patient gradually sinks on the knees in order to bring the hand sufficiently low to enable him to grasp the object. Difficulty in ascending or descending stairs is often an indica- tion of spinal disease. Abnoruad postures are assumed in order to remove from the seat of disease the weight of the superincumbent part of the body. Thus, a child with disease of the cervical spine may support the head on the hands whilst the elbows * Edmund Owen, Clin. Journ., Aug. 3rd, 1898. TUBERCULAR SPONDYLITIS. 393 rest on a table. In high dorsal caries the head may be retracted, so that the centre of gravity is thrown farther back, and hence a greater part of the Aveight transmitted through the sound articular processes and less tlirough the diseased bodies of the vertebra'. Again, a child suffering from dorsal caries often stands Avith the knees flexed and the hand resting on the thighs, so that some of the Aveight of the upper part of the body is transmitted through the arm, and in lumbar disease there may be lordosis (Fig. 277). The Examination of the Back. —The patient should stand Avith the back to a good light. The surgeon must be cautious in basing an opinion on the disposition of the series of spinous processes, first, because in normal backs the intervals betAveen the spines van- in different individuals; second, because in Avell - marked tuber- culosis of the spine there may be no recognisable deformity. Another point to lie remembered is this, that in some cases of tuberculosis of the spine the deviation caused in the series of spines is to one or other side (lateral) and not directly backwards (angular). Lateral deviation may be observed in still more pro- nounced degree in old cases of tubercular disease of the vertebrae. In one such case I have now under observation, four spinous processes form the angles of a small square, being placed side by side. This disposition of the spines represents a very sharp bend in a limited part of the spinal column. In the lumbar region, where the spinal column is naturally concave forwards, it frequently shoAVS itself by a diminution of the natural backward concavity. The same is true of the cervical region, with the difference that the smallness of the vertebrae in this region results in the production of de- formity with greater' rapidity than in other regions, and it is Fig. 278.—Photograph of a Boy showing a prominent Vertebra in the Neck from Tubercular Disease. 591 TUBFR C ULAR S PONDYLHIS. especially in the neck that lateral deviation from tuber- culosis is most likely to occur. In the cervical region, how- ever, a prominent vertebra is usually present (Fig 278). Thus, cervical tubercular disease is apt to be mistaken for some other form of wry-neck. Method if Recording Angular Deformity of the Spine — When the ' deformity is a simple one, it can readily recorded by placing the jiatient face downwards on or other level surface, and moulding a strip of tin or other flexible metal over the sjanes, and then trans- ferring the outline thus obtained to paper by placing the edge of the strip of metal on the paper and marking along the metal Avith the point of a jiencil. The curves A, B, C, L>, in Fig. 279, illustrate the method, which is useful as a record of progress, as tracings taken from the spine at intervals in the course of the disease serve to show Avhether the deformity is increasing or has been arrested or even diminished under treatment. Differentad Diagnosis. — Many cases of tubercular disease of the spine are attributed to injury. In the majority of these, doubtless, the injury simply finds out an existent focus of disease, in some a slight traumatic lesion determines the seat of in- fection. This association of tubercular spondylitis Avith injuries imposes on us a grave responsibility in the dis- tinction betAveen early disease and sprain of the spine. In many cases it is desirable to Avatch the course of events for a Aveek or tAvo before giving an opinion. The distinction from scoliosis has already been drawn (j>. 356). Wry-neck is sometimes but a symptom of tubercular disease. The absence of muscular spasm and the presence of rigidity, together Avith the prominence of one or more spines, will usually serve to distinguish the two conditions. In some cases of hip disease there is rigidity of the lumbar spine, Fig. 27!'.—Reduced Tracings from cases of Tubercular Spondylitis. A, high dorsal ; B, extensive mid and lower dorsal; c, showing two separate pro- jections in the dorsal region ; d, dorsal curve with marked lordosis below the gibbosity. TUBERCULAR SPONDYLITIS. 39o together Avith flexion of the hip as in psoas contracture from commencing psoas abscess. The absence of spasm of the adductors in disease of the spine will help to distinguish the conditions. Rheumatoid arthritis and spiiud Itypencsfhesio are generally associated Avith more superficial tenderness than is seen in tubercular disease and in these conditions the characteristic deformity is Avanting. Malignant disease of th<' spine may for a time be indistinguishable from tuber- cular disease, but its more rapid course will soon declare its nature. Course arid Prognosis.—The course is always a chronic one, and in cases that have long been progressing favourably, a sudden increase of deformity and the supervision of some grave complication may occur. On the Avhole, however, in well-supeiwised cases, the prognosis as far as the local con- dition is concerned, is hopeful. When a fatal issue occurs it is more commonly due to tuberculosis of the lungs, in- testines, or some other part. Death may also be due to the effects of abscess opening into the pericardium, peritoneum, pleura, lungs, or bronchus, byaaiiia and lardaceous disease, and meningitis, or myelitis, may be mentioned among other causes of a fatal issue. The period of time occupied for the achievement of a natural cure is usually more than three years and pro- tective apparatus must be worn for a much longer time. The Complications of Tuberculosis of the Spine.—The chief complications are—(1) abscess, (2) sinus and (3) para- plegia. Abscess*__When liquid exudation is formed in greater quantities than can be absorbed, it collects and tends to accumulate wherever the tissues offer least resistance. _ This is in the spaces filled by loose connective tissue, e.g. inter- muscular spaces along the course of arteries and nerves. Aponeurotic; structures form barriers against the extension of pus, thus directing the course of abscesses. Tubercular pus is sometimes white and thick, sometimes thin and whey-like, or it may be reddish-brown from admix- ture of blood.' In the upper cervical region pus usually first * The account given by Hoffa, « Orthopedic Ku.gvrv," is largely followed in this section. 39(5 TUBERCULAR SPONDYLITIS. collects behind the pharynx, forming a retro-]diaryngoal abscess (Fig. 280); by gravitation it may pass behind the Fig. 280.-Atlo-axoid Disease. The atlas is displaced f inch forwards,"and the uppermost part of the cord is compressed between the posterior arch of the atlas and the ■ dontoid pro- cess. The glass rod marks a perforation in the posterior wall of the pharynx, where a retropharyngeal abscess opened. There was pus between the vertebra; and the dura mater, and the latter is adherent to the cord from meningitis. (From a girl aged nineteen who, from the age of seven, had com- plained of pain at the top of the head, and who had been treated for neuralgia. There was marked backward projection of the spine of the axis and a retro- pharyngeal abscess. Cheyne-Stokes lespiration developed before death.) (esophagus, the connective tissue between the pharynx and oesophagus being lax. Extension to the parotid region has been observed. From the lower cervical spine pus tends to pass into the posterior mediastinum and, reaching the aorta, TUB F R C ULA R S PO XD Y LIT IS. 39^ it follows its course, and may finally pass along the iliac arteries to the thigh. Pus originating in the thoracic vertetme tends first to collect m the posterior mediastinum and to follow the course of the aorta, pushing the (esophagus before it. Perforation into one or other pleura, or, if this had become adherent into Fig. 281.—Section through part of a Spine. The body of the Sth dorsal vertebra has been destroyed. The anterior common ligament (a.c.l.) is raised up by caseous pus. L.8, 8th lamina; l.Si, Oth lamina; t.p.od., transverse process of 5th dorsal vertebra. the lung, sometimes occurs. The pericardium in some instances has been perforated. More frequently the matter follows the course of the aorta to the retro-peritoneal space, and Avhen it reaches the lower part of the abdomen it may collect in the iliac fossa, forming an iliac abscess, or continuing along the iliac and femoral vessels, it may either form an ilio- femoral abscess, or pass along the internal iliac vessels into the true pelvis Avhere it may open into the bladder or rectum, or on the surface near the anus, simulating a fistula in ano. Or again, it may leave the pelvis by folloAvhig the course of the sciatic nerve, appearing as a gluteal abscess or passing 398 TUBERCULAR SPONDYLITIS. beyond into the back of the thigh. Less commonly pus from the dorsal vertebra' follows the course of one or more inter- costal nerves, appearing in the back as a dorsal abscess by tracking along their posterior branches. From the lower dorsal and the lumbar vertebrae pus usually finds its way into the sheath of a psoas muscle, constituting a Fig. 2S2.—Dissection of a Psoas Abscess the AA'all of which was Calcified. nsoas abscess. The iliacus muscles, as avoII as the psoas, may be destroyed by the suppurative process. The usual clinical appearance is a fluctuating swelling above and beloAV Poupart s ligament. The sheath of these muscles may be perforated and the abscess may pass along the adductors and point at the inner side of the thigh, or it has been knoAvn to find its way even as far as the ankle. A double psoas abscess may result from the same area of disea.se. The pus not uncommonly finds its way into the quadratus lumborum muscle and, accumulating, forms a lumbar scess betAveen the last rib and the iliac crest; from TUBERCULAR SPONDYLITIS. 399 this pus may penetrate widely between, beneath, or superficial to the layers of the abdominal wall. The wall of a chronic abscess becomes thickened and it may undergo calcification (Fig. 282). If one pouch of a complicated abscess becomes shut off, its contents may become changed to a firm caseous mass. In some cases the anterior common ligament is widely separated from the vertebra' by collection of pus beneath it (Fig. 281). Adherent to or near the Avail of an abscess from spinal disease chains of tubercular glands may be present. Diagnosis of Abscess.—The onset of fever of the hectic type and a rapid deterioration in the general health and strength of a patient are sometimes the first sign of abscess. In the case of psoas abscess flexion of the hip may be observed long before any fluctuating swelling is formed. An increase of pain is also usually present at the commencement of abscess formation, lletro-pharyngeal abscess is evidenced by dysphagia and dyspntea. The Treidment erf Tubercular Spondylitis.—There is no one method of treatment applicable to all cases alike. Each case must be studied carefully before any plan of treatment is adopted, and with A'arvmg conditions variations in treatment must lie introduced. Moreover, the Aarying ages of the patients Avill necessitate A'ariations in treatment. The various measures of proved efficacy will here be described in turn and indications given for their application in cases of varying severity. Treatment by Recumbency.—When a person lies flat upon the back on a firm hair mattress all pressure due to the Aveight of the superincumbent parts of the body is removed from every segment of the spinal column. For this reason the length of a normal adult is greater by an inch to an inch and a half when lying on a flat horizontal surface than when standing or sitting. This is not the case when the person lies upon a soft yielding substance such as a feather bed, in wliich case the curves of the spine are not diminished to the same extent as when the surface is firm ; and the amount of pressure borne by the vertebra- of any segment of the column is in normal conditions proportionate to the curves of the column. 100 TUBFRCULAR SPONDYLITIS. When tubercular disease is present in the spine in an actively progressive form, recumbency on a firm hair mattress is indicated. The mattress should be rather longer and wider than the patient and it should rest on a shallow wooden tray (Marsh) so that it may admit of the patient being carried into the open air and from room to room. Restless patients can be secured to the mattress by suitable straps. In order to render the bed more portable a light bed- frame may be used in place of the tray. " If four stout steel bars, one half-inch Avide and one-fourth inch in thick- ness, be fastened together so as to make an oblong frame of the patient's height and Avidth, and over this stout sheeting be Avound 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, Avill secure the patient in a recumbent position, Avhile the frame and child can be carried about easily. . . . The sheeting should be cut out at the region of the buttocks so that the bed-pan can be used." * Traction can be combined Avith recumbency in suitable cases. In cases of atlo-axoid disease a small pilloAv should bo placed under the neck and a horseshoe-shaped sandbag above and at the sides of the head (Marsh). The advantages of recumbency combined Avith portability of the patient have been secured by various other contri- vances such as the " gouttiere de Bonnet" and Phelps's box (see p. 299). In it the patient's legs lie in separate compart- ments, and there is provision for defecation and micturition being performed without disturbing the patient. Phelps's box is the same in principle as Bonnet's, but is rather simpler in construction and it forms a cheap appliance for hospital cases. A modification of Thomas's double hip-splint, if care- fully made and well padded, serves the same end as other arrangements for recumbency. Instead of a dorsal decubitus the patient may usually be treated by rest on a prone couch (Fig. 28-">) combined * Bradford and Lovett, loc. supra eit.. p. .">.*;. TUBFRCULAR SPONDYLITIS. 41.1 with the use of a good antero-posterior support. By this plan the patient is enabled to be amused by toys or to learn lessons when old enough. The question arises, how long should a patient be kept recumbent'. A minimum period for the complete healing of a tubercular focus in bone is about twelve months and in some cases it is found to be six or seven years. Xow, after a certain time strict recumbency by impairing the patient's muscular power and general nutrition does more harm than A A 102 TUBERCULAR SPONDYLITIS. good. As one of many instances that I have observed of this I may mention the following case:— A girl, aged six years, Avas brought to the out-patient department of the City of London Orthopaedic Hospital on a douhle Thomas's spinal splint. The splint Avas well made and well adjusted. It had evidently been carefully watched, for although the patient had lain upon it for four years there were no pressure-sores. The disease in this case had shown itself in the upper dorsal region at the age of two years, and from that time forward she had been kept supine and motionless. The spine shoAved a sharp curve involving the upper four dorsal vertebrae, there was a sinus on the right side of the projection that had developed about a year after the commencement of treatment and had remained open ever since. The general condition of the patient was deplorable. The muscles of the limbs were Avasted, the patient was limp and extremely anaemic. I applied a light metal support with a head-piece such as the one described on p. 410, and ordered 5j of 1-40 carbolic lotion to be injected into the sinus once a day. The patient's general health improved rapidly, she liegan to walk, and the sinus closed perma- nently a few weeks after the commencement of the treatment. Mechanicid Treatment.—Except in the most rapid cases, and in cases where the muscular strength of the patient is reduced by fever or other debilitating condition, mechanical treatment is indicated. The form Avhich I have found to be most effective is that which was introduced by the late E. .1. Chance in 1852 at the City of London Orthopaedic Hospital. The principles of this apparatus have been already described (see p. 84). For very severe curves the upright rods may be adapted to suit the ease. This splint must be worn day and night, and Avhilst the patient is in bed it renders shoulder-straps, etc., unnecessary. In many eases it is an advantage to place the patient on a prone couch during the day. This contrivance, combined with the splint, secures adequate rest to the spine and at the same time allows the patients to read, play with toys, learn lessons, and to feed themselves in the ordinary way. The most comfortable angle for a prone couch varies in different cases. A certain degree of muscular tone is required for a patient to derive the full advantage of a mechanical appliance, and when extreme prostration is present, or if the deformity TUBERCULAR SPONDYLITIS. 403 should be increasing, the recumbent dorsal position described above is required. With regard to Sayre's plaster jacket I cannot do better than quote Mr. Howard Marsh*:__ " In former years ... I used Sayre's jacket in a large number of cases of Pott's disease in patients between the ages of three and ten. In those in whom the disease was active, the jacket often produced decided improvement. It relieved' pain and enabled the patients to move about with less difficulty. It steadied the spine and limited movement at the seat of disease. In other words, it secured some amount of mechanical rest. But its effect was not sufficient to exercise any very marked influence on the course of the disease. It did not prevent the further increase of deformity, or diminish the proportion of cases in which suppuration occurred ; Avhile paraplegia Avas, I believe, certainly more common than it is when patients are treated in the re- cumbent position. . . . As to the 'jury-mast,' although a contrivance of considerable mechanical ingenuity, it Avas dis- appointing in practice and Avas given up. It is iioav seldom used by English surgeons." The Felt Corset.—This appliance has most of the disad- vantages of the plaster jacket. By surrounding the chest and abdomen it impedes respiratory movement; by its impeiwious nature it retains the perspiration. It is much heavier than a Chance's splint, and when strengthened by steel ribs its weight is increased Avithout the mechanical advantages of a good steel support being obtained. The defects of the mode of action of a felt corset are readily seen Avhen compared Avith a proper antero-posterior support applied to the same case. Thus, in Figs. 284, 285 and 28ii are respectively represented the patient sitting without any appliance, Avith the felt jacket, and with Chance's splint. It will be seen that the jacket supports the upper part of the body only by pressing on the thorax and the axillae. The former pressure is distinctly harmful in that it adds another obstacle to respiration : the effect of the jacket upon the part of the spine below the projection is to prevent any improve- ment in the lordosis. In recording my opinion of plaster * Howard Marsh, " Diseases of the Joints and Spine," p. 496. 404 TUBFRCULAR SPONI) Y LIT IS. and felt jackets it should be remembered that some surgeons of experience hold a different vieAv ; thus Mr. A. H. Tubby* Avrites: " In the plaster of Paris jackets properly applied, H ,3 6 P and to a considerable extent an the poroplastic jacket all the needful requirements are fulfilled. . . . With the jackets either of plaster or felt I am content." A. H. Tuhby, " Orthopsedie Surge! y," 1896, p. 55. TUBERCULAR SPONDYLITIS. m Forcible Correction of Deformity in Tubercular Spondy- litis.—From the time of Hippocrates, about 400 b.c. up to the present time, various methods of forcible correction of spinal deformity appear in medical literature After Hippocrates, (hden (a.d. 130-200) and Ambroise Pare, 1517-1500, employed the method of removing the de- formity by extension combined with direct pressure. This method has recently been revived. This revival of an ancient mode of treatment was first advocated by Chipault of Paris in 1805, but it OAves its vogue chiefly to the work of Calot, of Berek-sur-Mer. Calot's first paper on the subject Avas read in December, 1896, before the Paris Academy of Medicine, and since that time many hundreds of cases have been submitted by various operators to this method of treatment. It is clear that the great stimulus to the adoption of this method has been the powerlessness of plaster or other corsets to restrict the deformity. Thus Calot (Rev. de Therup., Sep- tember 1st, 1807) says : " If treatment is limited to the measures hitherto employed neither troughs nor corsets can prevent the return of the deformity." He quotes Lannelongue to the like effect, " In Pott's disease the deformity appears and increases in spite of rest in the horizontal position." And again : " The deformity progresses within Sayre's apparatus, as I have Avitnessed in my own cases and in cases of the most competent surgeons." Again, Bilhaut et Levassort {Jour, de Med. de Paris, 1807, p. 303) Avrite concerning Sayre's jacket:— " When the suspension ceases the patient humps himself up Avithin the corset; the deformity, scarcely diminished by the stretching, returns not only Avhen the patient sits up, but Avhen he remains immobile in the horizontal position." Pailtology.—Aha appearance of the diseased parts after forcible correction is knoAvn from experiments on the cadaver and the results of autopsies in cases Avhere death has occurred within a few months of the operation. By permission of Mr. R. W. Murray and of the editor of the liritish Medical Jourmd I am enabled to reproduce such a specimen (Fig. 287). It will be seen that even three months after the operation there is a cavity lined Avith 106 TUBERCULAR SPONDYLITIS: FORClBLF CORRECTION. tubercular granulations separating the remains of the diseased vertebra'. Such a cavity would tend to (lose by the re-appear- ance of angular deformity. In more favourable cases a certain amount of repair occurs. It is, however, highly im- probable that in any given case the whole of the cavity will Fig. 2S7. —Section of Spine showing the Cavity left after Forcible Correction of Deformity in Tubercular Spondylitis. be replaced by firm bone, and even if this did occur in the case of a child this hypothetical new bone would be devoid of epiphyseal discs, and hence Avould lag behind the rest of the spinal column in longitudinal growth, with the result that unless some efficient splint were worn deformity would return. The operation consists in applying traction which, ac- cording to Calot, should not exceed 80 kilos, in an adult and, if necessary, in applying direct pressure to the hump. In all published cases the patient has been placed face downwards on the table and ana'sthetised in that position. The operation TUBERCULAR SPONDYLITIS: FORCIBLE CORRECTION. t07 requires three assistants besides the operator. Redard, Jones, Tubby, and others have devised mechanical arrangements to minimise the number of assistants. One drawback to the operation is the difficulty experienced by the anaesthetist. Williams (Sen. Med., July 28. LS07) has advocated doing the operation Avithout anesthesia. As regards this point I do not see why the object should not be attained just as certainly Avith the patient lying on the back. The same extension oil head and shoulders in one direction, and on legs and pelvis in the other, can be made. The surgeon could meet his hands beneath the hump and by lifting upwards exert quite as much direct force. Should I have occasion to do the operation again I shall certainly use the latter method. J. E. Goldthwait (Boston Medical ami Surgical Jourmd, July 2>S, LS08) has devised a simple apparatus consisting of an oblong frame of gas-piping carrying extension screws at both extremities, and a mo\rable, arched, double bridge, on Avhich the transverse processes in the vicinity of the deformity rest. This is a great gain, since it permits of the operation being performed Avith the patient in the supine position and in most cases without an anaesthetic. " At first this method was used simply to obtain the best possible position of the spine after the forcible straightening under ether, but it was soon found that the same apparatus could be used for the correction, and that in a surprisingly large number of cases no other force than the Aveight of the body was necessary to straighten and over-extend the spine. With the spine in this over-extended position the head was thrown so far bade, and the body-weight put so much upon the spinous and transverse processes, that it was possible to discard the helmet as a part of the support except when the disease was situated above the fourth dorsal vertebra. In nearly all of the cases since the first, the after-treatment has consisted in the application of a plaster of Paris jacket carried low enough to grip the pelvis and to limit the motions of the thighs, and also high enough to prevent the shoulders from drooping forward, and the bending forward of the bead. "In the early cases ether was used for the correction, but since then the work has been done entirely without anaes- thetics, except in the cases where the disease has been of tos TUBERCULAR SPONDYLITIS : FORCIBLE CORRECTION. several years' duration. Cases of one and two years' duration have been easily straightened without ether, and Avith practi- cally no pain or suffering to the patient. " In this way the operation has been simplified to such an extent that the word operation is hardly necessary for its desig- nation, and it is so simple that in the acute or early stages of the disease the patients arc treated in the office or the hospital out-patient department, the correction being accomplished and the jacket applied with no more disturbance than is expected Avith the application of such an apparatus in the ordinary method. In some of the cases the relief of the existing acute symptoms has been very striking with the improved position of the spine." Lange* asks hoAv far is the redressment to be carried ? Must the aim be to remove every trace of the excurvation, and thus in a severe case for an hour or more exert one's own strength ? Lange thinks not. If the prominence does not give Avay to moderate pressure one must rest content Avith the improvement obtained in the position of the sound parts of the column. Many patients can be greatly improved thereby) although the prominence remains unchanged. Wullstcint also directs his aim to a correction of the deformity of the spine on each side of the hump (" Paragib- bare Korrektion "); others proceed to correction by stages; others, again, limit the scope of the operation by formulating definite indications, only adopting Calot's operation in the slighter cases, and content themselves with a partial result Wullstein considers that the " paragibbous" correction is indicated in old cases Avith much deformity. In all other cases Wullstein thinks the complete removal of the deformity should be obtained not by the one brief act of Calot's operation, Avhich entails the risks detailed above, but by a method that com- bines immobilisation and removal of pressure Avith absence from restraint of the thorax and abdomen, and a controllable stretching of the soft parts. Should complications arise, this treatment may be interrupted for a time, the amount of improvement previously gained being maintained by the application of a proper corset. For the application of this * Lange, Miinch. med. Il'och., April 20, 1897. t Wullstein, Ccnlralbl. fiir Chinirtj., July 9, 189S. TUBERCULAR SPONDYLITIS: FORCIBLE CORRECTION. 409 idea Wullstein has devised an apparatus which serves at once as a bed and an extension apparatus (Fig. 288). The amount of extension is regulated by a screw and indicated by a dynamometer, and is used in the first place to overcome the muscular spasm and afterwards to influence the form of the spinal column. Calot, on the contrary, has advocated its extension to old healed cases, where not only is there quiescence of the Fig. 288.—AVullsteiii's Apparatus for the Gradual Correction of Deformity in Spinal Disease. (Centralblatt fiir Ghirurgie.) disease in the anterior parts of the spine, but Avhere the spines and lamina are synostosed together. In such cases he chisels the fused laminae apart before completing the operation, Avhich in such cases results in a complete fracture of the spine. Mortality.—The mortality traceable directly to the opera- tion is very small. Calot lost two out of 300 cases* and these Avere from chloroform. Paraplegia occurred during the first feAV Aveeks after operation in three out of 600 cases. In conclusion, I Avould put forward the following proposi- tions :— 1. That as yet there is no evidence that immediate reduc- tion of angular curvature will be permanent, .and further experience is required before any decision can be made as to the success of the operation. * Brit. Med. Journal, Nov. 20, 1897. 410 TUBERCULAR SPONDYLITIS . FORCIBLF CORRECTION. 2. That a mechanical method of fixing the spine in the over-extended position would be better than the plaster of Paris occipito-pelvic jacket. I should not be inclined to keep a child on it longer' than three months and then I Avould replace it by a Chance's splint. 3. That only early cases free from complications such as abscess, etc., would be suitable for the operation, even should Fig. 289.—Patient wearing Apparatus for high Dorsal Caries after Forcible Correction of Deformity, it prove to be successful in diminishing or removing the deformity. 4. That cases treated from the beginning by efficient mechanical means will give as good results as those treated by forcible extension. Illustrative Case (B. M. J., Feb. \i, 1898).—Certain considerations led me to perform immediate correction on a little girl, aged two and a half years, in August last. The case was a favourable one, of two months' duration, and uncomplicated. There Avas an angle of about 20° opposite the sixth dorsal spine. The operation was easy, and the patient was put up in plaster strengthened by an iron framework extending from the head to the pelvis. The child seemed to be in no way disturbed hy the TUBERCULAR SPONDYLITIC: FORCIBLE CORRECTION. 411 operation. At the end of six weeks the plaster cuirass had to be removed on account of the presence of vermin, which had appeared in spite of careful nursing. We then found that most of the deformity had recurred. The spine Avas again straightened, and the child put up on a metal-plaster apparatus so arranged that the spine Avas over- extended, and that extension could be applied to the arm-pits and the lower limbs. The patient was perfectly comfortable in this position for a month, Avhen the spine was again examined. The deformity Avas certainly diminished but not removed. The part was now free from tenderness, and on giving an anaesthetic it was found that there was more resistance, pointing to some form of ankylosis having taken place, so the remaining deformity was not corrected. The patient Avas replaced in the apparatus. A fortnight later a Chance's splint, Avith an occipital piece as shown in Fig. 289, was applied. At the present time—three and three-quarter months after the first operation—the child can sit up Avithout discomfort and Avithout fatigue. The results of the operation in this case are a slight improvement in the deformity and a certain amount of repair, as shoAvn by ankylosis ; but neither the improvement in shape nor the degree of repair is greater than I should have expected from careful general treatment, com- bined Avith the use of a Chance's splint. It may be that a better mode of fixation after operation would give a greater improve- ment. In this connection I would refer briefly to the double Thomas's splint recommended by Messrs. Tubby and Jones. That this instru- ment needs careful management is evidenced by the extensive scars frequently seen in patients who have used it without proper super- vision. Mr. Tubby mentioned tAvo or three years as the period during which the patient would be likely to be required to remain in this instrument. This, to my mind, would be a very serious bar to the method. I have lately had brought to me a little girl, aged five, who had lain for four years on a double Thomas's splint for high dorsal caries. Although the splint was well-constructed and carefully watched, a dorsal abscess had formed and opened, and left a sinus (see p. 4<>2j. Other Ope rat ire Measures.—Chipault, of Paris, has recom- mended suture of the spinous processes of the projecting part of the spine with a view to immobilising the parts. This pro- ceeding is unnecessary when a proper mechanical support can be obtained. Victor Horsley, in a paper read before the British Medical Association (P.M. J., Oct., 15, 1808), advocated laminectomy and erasion of the diseased parts in every instance of dorsal abscess. With all deference to the opinion of so experienced a surgeon, I am of opinion that as a routine measure, if generally practised by even the most skilled surgeons, it 412 TUBFRCULAR SPONDYLITIS -. COMPLICATIONS. Avould increase the mortality and greatly prolong the period of recumbency and in the end give results inferior to more conservative methods. Lambotte* has gone even further. On the 4th September, 180G, he performed this operation on a child aged four, with high dorsal disease, when, after raising the soft parts Avith the spines, removing four lamina' after division of the right inter- costal nerves, and drawing aside the cord, he exposed the diseased vertebral bodies and removed the diseased tissues with the curette. The patient Avas Avell and able to sit up three Aveeks after the operation. Costo-transversectomy.—This proceeding was invented by Menard t as a substitute for laminectomy in paraplegia from caries. He Avas led to it by tAvo considerations—first in a case in Avhich laminectomy Avas done, a tubercular cavity was accidentally opened and the patient began to improve immediately; second, in another case he had done laminec- tomy two and a half months previously Avithout any benefit being obtained, and he then explored the sides and front of the diseased vertebrae after removing some transverse pro- cesses ; immediate and progressive improvement followed. The operation consists in making a transverse incision over the right vertebral groove at the level of the apex of the projection. The muscles are divided in order to expose a transverse process and the posterior part of the corresponding rib. The transverse process is first cut through and removed, then the rib is divided a little external to the tip of the transverse process, and the posterior segment is removed. A second or several transverse processes and ribs may be removed in the same Avay until an opening is made that permits of a finger being passed to the front of the vertebra' for exploration, and Avith a gouge caseous material and sequestra are carefully scraped away. In one case reported by Menard, although no liquid discharge was evacuated, the paraplegia rapidly disappeared after the operation. The Treatment of the Complications of Tubercular Spondylitis.—Whatever the complicating factor may be, the condition of the spine itself is always to be remembered, and * Lambotte, Journal de Me.d. de Paris, 1897. + Menard, lie cue d'Orf/iopedie, Nov. 1, lS9i; TREATMENT OF SPINAL ABSCESSES. iV.i the treatment proper to it is not to be relaxed on account of the complicating condition. Psoas Contraction.—Flexion of one or both hips in tubercular disease of the spine is usually a sign of com- mencing psoas abscess. It is a serious complication, owing to the disability it entails should recovery occur with contracture of one or both hips. Thus this complication calls for energetic treatment. The patient should be placed in bed upon a Chance's splint and weight extension applied, the limbs being gradually brought to the extended position. It abscess should develop it should be freely drained. The Trad ment of Spinal Abscesses.—An abscess due to tubercular spondylitis should be opened, thoroughly mopped out Avith small antiseptic sponges charged with 1-20 carbolic lotion, and, save at the most dependent part, where a drain of iodoform gauze Avet Avith 1-20 carbolic should be left for twenty-four hours, the opening should be sutured in order to obtain primary closure of the Avound. Scrupulous antisepsis must be observed at every stage of the operation. If such pre- cautions can be fully carried out, there is not at the present time any cause for Avaiting for a chance of the abscess undergoing resorption. Although well-authenticated cases in Avhich this event has occurred are on record, I may say that I have watched a great number of cases that have been treated by recumbency and every care, without the desired result being obtained. When the patient is first put to bed, the tension of the abscess diminishes for a time, but as a rule it reappears, and the abscess extends along the path of least resistance. Lumbar and iliac abscesses are the most liable to undergo spontaneous rupture, and since this is generally followed by septic infection, it should be anticipated. I have seen fieeal fistula result from a neglected retro-perito- neal abscess. Cervical abscesses are often accompanied by serious symptoms due to sudden rupture and occlusion of the larynx, or laryngeal or tracheal stenosis from pressure and (edema ; and, again, they are liable to extend to the mediasti- num, or to become diffused in the deep tissuesof the neck. For all these reasons they require speedy evacuation. Aspira- tion in my opinion should be avoided, since it not infrequently leads to septic contamination. E, Vincent (Revue de 414 BETRO-PHA RYNGEAL A BSCESS. E.rpectanl Trescess.—An incision aiong the posterior border of the sterno-mastoid is the oest wav of attacking abscess arising in the upper cervical vertebra'; the integuments and fasciae are divided, and a path for drainage is made as far as possible by blunt dissection, behind the carotid vessels and jugular vein, and in front of the vertebral vessels to the seat of the abscess. The cavity is carefully wa-aped, mopped out with sponges and drained for twenty- four hours. In the dorsal region abscesses usually point at Fig. 290.—Vincent's Case of Inter- somatic Paravertebral and Lumbo- abdominal Drainage. LUMBAR ABSCESS. 415 the outer edge of the erector spina*. In order to deal with them more successfully, a portion of a rib may require removal, extreme care being observed to avoid wound of the pleura. If there is reason to suspect the presence of a sequestrum, costo-transversectoniy is indicated. Lumbar and Iliac Abscess.—A psoas abscess should be opened by an incision opposite the outer border of the erector spina'. If the cavity extends to the thigh an addi- tional opening should be made below. Illustrative Cases-.— I. Lumbar Curies with Psoas Abscess.—Jessie C, aged ten. The patient had suffered from the disease for two years, when she Avas brought to me. She Avas thin and fretful. Tliere was then a projec- tion in the lumbar region and a psoas abscess. She Avas admitted into hospital and a Chance's splint was applied. In the evenings the tempera- ture averaged 100° Fahr. As early as possible the abscess was operated on. An incision was made at the outer edge of the left erector spinae, and the parts were divided until the tip of the third lumbar vertebra was reached, from Avhich the attachments of the quadratus lumborum etc., were separated, and pus was sought for by blunt dissection in the direction of the psoas muscle. No pus being hit upon, an opening, 1^ inch long, over the fluctuating area below Poupart's ligament, was made and about ten ounces of pus were evacuated. The cavity was" well mopped out with carbolised sponges and much thick false-membrane removed. The cavity Avas then explored with the finger and a narroAv aperture leading to the upper part of the cavity was found. A stout sound was passed aloDg this to the neighbourhood of the lumbar incision, and after a little dissection the end of the sound was protruded. The upper part of the cavity was then mopped out, and one drachm of glycerine and iodoform was injected into the upper and the same amount into the lower part of the cavity, and the wounds were closed save the lower part of the thigh wound, in which a gauze drain was placed and removed next day. On the ninth day stitches were removed, and the lumbar wound was found to have healed normally, whilst the thigh wound showed some infiltration. A fortnight later this infiltration had increased, and the patient was anaesthetised, and the thigh wound was found to lead to a cavity lined with grey tubercular tissue. This was carefully scraped away and the wound healed soundly. Three months after admission the patient left the hospital wearing a Chance's splint. She had improved greatly in general health and was free from pain. When last seen, one year and five months after operation, the patient was quite well and the deformity had disappeared. Case II.- Dorsal Caries; Iliac Abscess.—A girl aged twelve. Severe dorsal curve involving from the fourth to the tenth vertebrae. A large 416 LUMBAR. ABSCESS. abscess formed rapidly in the left iliac fossa. The abscess acquired a remarkable tension, and caused constipation and oedema by pressing on the sigmoid flexure and the iliac veins. I incised the skin a little above the fore part of the iliac crest, and immediately several pints of thin pus escaped in a jet, which at first rose to the height of a foot and fell at some distance from the patient. The same steps for cleaning out the cavity Avere taken as in Case I., small sponges on the holder being passed upAvards and doAvnwards along the psoas sheath. Healing took place rapidly and Avithout any trouble. The patient was provided with a Chance's splint and left the hospital some months later. Case III.—Lumbar Disease ; Diffuse Abscess in the Think.—A young man, aged eighteen. Had had symptoms of lumbar disease for more than six months. The lumbar concavity had disappeared, and the second, third, and fourth spines were prominent. There was a girdle pain, pain and tenderness along the crural nerves, and evidence of slight contraction of the patient's left psoas. There was an ill-defined swelling above and below the left Poupart's ligament. Under anaesthesia the usual lumbar incision was made, but on careful dissection right into the psoas muscle no pus Avas obtained. The patient was turned over and it was found that the anterior swelling had disappeared. It was evident that the collection of pus previously observed had become diffused in some direction. The patient was put back to bed to await events. These marched rapidly, for at the end af thirteen days the whole of the left thigh had become SAVollen, and fluctuating areas were found over Scarpa's triangle and at the back of the thigh. These were opened and much pus escaped. On exploring with the finger the inter- muscular spaces of the thighs were found to have been widely opened up by suppuration. The cavities communicated by the openings in the adductor magnus. They Ave re Avell mopped out and syringed with 1-40 carbolic, and a little iodoform and glycerine were injected and gauze drains Avere introduced. The patient's temperature came down to normal and remained so for fourteen days, when it again became elevated, and pain, over the loAver part of Hunter's canal, radiating beyond the knee, was complained of. An abscess was found above the knee on the inner side of the thigh and opened. After this, with daily syringing, all the large cavities closed slowly, but soundly, and three months after the last operation the patient left the country in good condition. In this case the pus had probably not entered the sheath of the psoas, but had coursed behind the peritoneum along the iliac and femoral vessels. The accompanying photographs (Figs. -21H, -2i)2), kindly sent to me by Dr. D'Oher, of Arundel, represent the present condition of this patient, Avhose general health leaves nothing to be desired. Sinus.—The treatment of this condition has already been referred to on p. 402. I have not yet met with a case that has failed to heal or to be kept in check when the injection SINUSES DUE TO SPINAL ABSCESS. 417 of small measured quantities {-A to 5nj) of 1-40 carbolic has been carried out regularly. In rare instances where relatively large sequestra are present some operative measures may be required, e.g. in the dorsal region, costo-transversectomy, in the lumbar, Trevcs's operation may be called for* Fig. 291.—Young Man after Fig. 292. —Same Patient after Operation for Lumbar ()peration for Lumbar Abscess Abscess with Instrument. Avithout Instrument. The latter is a systematised plan of lumbar drainage. A vertical incision is made at the outer edge of the erector spime. The attachment of the quadrat us and psoas muscles are separated from the transverse processes and the diseased .area is explored Avith the finger. For a full description see Trevcs's " ()perative Surgery." * In one instance a patient with two small sinuses that had been treated in this manner for three years was sent to a con\alescent home where the carbolic injections Avere changed for a lotion of horacic acid ; extensive suppuration and lardaceous disease rapidly developed. B B 418 PARAPLEGIA IN TUBERCULAR SPONDYLITIS. Paraplegia. Symptoms of Implieedion of the Spinal Cord.—The commoner sensory symptoms are a girdle pain and pain at the pit of the stomach and in the limbs. Hyper- aesthesia above and patchy anaesthesia below the lesion are also sometimes observed. Early motor symptoms are Aveak- ness in the limbs, clumsiness from catching of the toes in Avalking and difficulty in standing. In atlo-axoid disease sudden compression of the medulla and death may occur. The superficial and deep reflexes are exaggerated in the early stages and are diminished or lost in the later stages. Trophic lesions, e.g. Avasting of muscles, herpes and bed-sores may arise. The limbs may become cold, congested and hyper- idrotic. In cervical disease the phrenic nerves may be paralysed and in the dorsal region intercostal paralysis may occur. With prolonged and efficient rest there are but feAV cases of paraplegia from tubercular spondylitis that Avill not recover completely. Even when the condition is pronounced and there is evidence of its being not merely due to pressure upon the spinal cord, but to myelitis, in the presence of ankle-clonos, edema of the legs and bed-sores, a patient course of efficient fixation of the spine will be roAvarded Avith the practically complete recovery of poAver, a trace of increase of knee-jerk and of ankle-clonos alone attesting to some permanent damage to the cord. If after two months' rest on a prone couch, combined with the use of a Avell-made and Avell-adjusted Chance's splint, no improvement is obtained, some further measures should be adopted. These measures are—1, forcible correction of the deformity; 2, laminectomy; 3, other operations, e.g. costo- transversectomy. Forcible correction of the deformity, as has been shoAvn on p. 406, results in the formation of a potential space in front of the spinal cord. At the moment of its formation a negative pressure exists in this space and that negative pressure will exert a suction action on fluid exudation outside the cord and, by diminishing pressure, will relieve paraplegia. In the rare cases where there is direct pressure of bone upon the cord forcible correction might reasonably be given a trial. Among the many cases of tubercular spondylitis in which this opera- tion has been done paraplegia has been present in some and MALIGNANT DISEASE OF THE SPINE. 41 and 2<)(i, and the immediate result in Figs. 2!)7 and 2l)s. In order to correct the associated fixed lateral curvature that had arisen in this case the apparatus shoAvn in Fig. 300 was adapted. Treatment.—This consists in complete section of all the contracted fibres of the sterno-mastoid, and the subsequent wearing of a support Avhich maintains the head in good position until all farther contraction has been avoided. In cases in which the sternal portion of the muscle is chiefly at fault it can be divided subcutaneously. The patient, being fully aiuesthetised, is laid on the back on the table and a firm pillow placed under the shoulders. One assistant depresses the forehead with his left and rotates the head Avith the right hand. Another draAVs down the shoulder of the affected side. The surgeon draAvs the skin over the tendon outwards Avith the thumb of the left hand, and passes a sharp-pointed tenotome under the tendon from the outer side, about three-quarters of an inch above its insertion. A blunt-pointed tenotome is then taken and the section completed, the assistants holding the head as directed by the surgeon. Some surgeons prefer" to divide the tendon from its superficial aspect. The clavicular part of the muscle may be divided in the same Avay, but most surgeons prefer to do this through an open Avound on account of the proximity of the large vessels of the neck. The open operation is best done through a transverse incision an inch or more in length, parallel to the clavicle and about one- third of an inch aboA'e it. Lorenz recommends a short transverse incision an inch long, its centre placed over the space betAveen the two heads, so that by draAving the skin first one Avay, then the other, both heads can be exposed to vieAv divided in turn. An incision along the lower part of the anterior border of the sterno-mastoid may be used instead of a transverse cut. In children with wry-neck the muscle is usually very small, and an adequate incision for the purpose leaves a very inconspicuous scar. CONGENITAL WRY-NECK. 427 The after-treatment of these cases is of as much importance as the operation. For efficient fixation of the head a Chance's back splint with a cervical piece added gives the best support in my experience. The head is held by a padded metal band to which frontal and mental straps are attached and to Avhich a branch for the chin may also be added on the side opposite the deformitA'. A similar contrivance can be used for the gradual (see Fig. 2!)!)) correction of early cases. In infants, strapping and bandages may be used. Wry-neck of Articular or Osseous Origin.—Chiefly from the point of vieAV of diagnosis it is necessary to refer again to certain affections of the cervical spine that not infre- quently cause wry-neck. 428 SPASMODIC WRY-NECK. Rheumatoid Arthritis.—In certain cases of rheumatoid arthritis marked lateral or anterior torticollis is observed. Chronic articular torticollis usually follows the acute form of rheumatoid arthritis. The attacks of pain and the deformity persist Avith more or less fever. The spine is tender and pain is felt at the root of the neck and along the arms. Grave deformity, folloAved by Avasting of muscles, is apt to be produced by changes in the joint-surfaces and capsules. The cervical spine becomes extremely rigid. Tradment.—The proper treatment is to prevent deformity by a support to the head. Tubercular disease of the cervical spine, Avhether in the atlo-axoid region or in the loAver cervical vertebrae, may give rise to lateral as Avell as antero-posterior bending and so simulate Avry-neck. In rare instances the head is bent backAvards in atlo-axoid disease. Rachitic Torticollis.—This name has been applied to lateral or posterior deviation of the cervical spine, due to yielding of the bones softened by rickets. There is no muscular spasm in these cases and the deformity is at first readily corrected. Later, more or less rigidity is present from changes in the bones. The diagnosis is arrived at by the general signs of rickets and by the ready improvement obtained by suitable diet, etc. The head requires support in a good position until all trace of rickets has disappeared. Spasmodic Wry-neck, or Chronic Nervous Torticollis.— Spasmodic or intermittent torticollis shoAvs itself in a great variety of forms. Tavo principal forms are to be distinguished, clonic and tonic. The former is the commoner and from it the name of this group is taken. The tAvo forms are often combined in the tonico-clonic torticollis (Benedikt). Clonic Form.—The spasm is usually unilateral and is seated in sets of muscles supplied by different nerves, e.g. spinal accessory, facial, cervical, hyoglossal, etc. The muscles more commonly affected are the sterno-mastoid, the trapezius, the splenitis, the levator anguli scapuhe, the supra- and infra- spinatus. Before the muscles of the neck become affected spasms may have shoAvn themselves in other regions, e.g. the arm, the face, the floor of the mouth. SPASMODIC WRY-NECK. 429 The exact character of the deformity depends upon what muscles are affected. 1. Spasm of a single sterno-mastoid is not common. It sIioavs itself by a series of sometimes painful contractions which bring the occiput toAvards the shoulder of the side on Avhich the contracting muscle is, the face being turned in the opposite direction. 2. Spasm of the Upper Part of one Trapezius.—The head is draAvn backAvards and doAvnwards towards the affected side and slightly rotated toAvards the opposite side. The scapula is draAvn toAvards the spine and the shoulder is slightly raised. 3. Sjxism of the Splenitis.—The head is inclined backAvards and slightly turned towards the contracted side. In its upper third the muscle can be felt to harden during the contractions. 4. Spasm of the Lecedor Anguli Scapula.—The head is slightly inclined to the affected side ; the shoulder is draAvn up. 5. Spasm of the Posterior Cervical Muscles of both sides gives rise to retraction of the head or retrocollis. The posterior deep muscles seldom act singly and, indeed, com- bined action of muscles is commoner than isolated action in all forms of spasmodic torticollis. 6. Spasm of one Sterno-inustoid (end of the Trapezius of the same side.—This gives rise to marked rotation of the head so that the skin of the same side of the neck is thrown into deep folds. 7. Spasm of the Sterno-mastoid and the Splenius of the same side.—This produces a marked inclination of the head towards the shoulder. It is not a frequent combination. . The patient is a distinctly neurotic subject and suffers from lichen planus. She has had slight rheumatism in wrists and ankles. The deformity first appeared nine years ago and then remained for two years. It then disappeared for about two years and returned again at the end of that time. The deformity is worse when the patient is fatigued. Her friends have noticed that it disappears Avhen the patient becomes interested in anything. The head can readily be put in its proper position, but falls back at once on removing the supporting hand. I found also that when I corrected the position of the trunk without touching the head, the latter fell naturally into its place. All the muscles on both sides of the neck reacted readily to the faradic current. After a patient trial of general and medical treatment, combined with daily exercises, had given no good result, I recommended a light support to keep the head in its proper place. Paralytic Torticollis.—The head inclines to the side opposite to the paralysed muscles. The deformity is easily corrected, but returns as soon as it is left to itself. If the DEFORMITIES OF THE THORAX. 437 deformity has been present for a long time contraction of the muscles on the side to Avhich the head inclines will occur. Diagnosis.—This form of torticollis can be distinguished from the foregoing by the electric reactions of the muscles. Treatment.—-Massage, electricity and the use of a light support are required. Deformities of the Thorax.—It has already been pointed out that deformities of the spine often entail alteration in the form of the thorax. In kyphosis, Avhether the ordinary round shoulders or that of tubercular or other disease, the alteration in the form and relations of different parts of the bony thorax, and the important deformity of the general Fig. 306.__Diagrammatic Sec- of a Rickety Chest in which the tion of the Chest in Pigeon Sternum and adjacent portions Breast. °f the Ribs are depressed. arrangement of the thorax have already been described. There remain to be mentioned some congenital and acquired deformities of the thorax. Congenital Deformities.—-The sternum is not infrequently cleft at birth. It may be altogether absent, or the failure of fusion of its two halves may take the form of membranous foramina in the bone. Congenital depression of the sternum is also occasionally met with. The condition differs from that obser\Ted in cobblers, in whom there is a pit at the loAver end of the bone; in congenital cases the upper end of the bone is the seat of depression Avhich has been attributed to pressure of the chin upon the sternum in intra-uterine life. 4:58 PIGEON BREAST. Congenital Affections of the Rihs.— The most important of these is the presence of a supernumerary cervical rib Avhich may be mistaken for a groAvth at the root of the neck. The cartilages of the ribs may also be defective by failing to unite witli the sternum. Fig. 308.—Pigeon Breast due to Rickets. Front View. Acquired Deformities of the Thorax.—These are chiefly due to rickets, and were Avell described by Glisson. The two commoner deformities are shoAvn diagrammatically in Figs. 306 and 307. Pigeon Breast.—This is perhaps the commonest of the rachitic deformities of the chest. A typical example is shoAvn in Figs. 308 and 309, taken from a patient under Dr. G. A. Sutherland. PIGEON BREAST. 439 The narroAving of the thorax in such cases is produced by a depression at the junction of the ribs and cartilages, and also by an increase of the natural bending of the ribs at their angles. When deformity of the thorax is produced by obstruction to entry of air, e.g. by adenoid bronchitis, Fig. 309.—Pigeon Breast due to Rickets. Side View. etc rather than by great softening ot the bones due to severe rickets, the shape of the thorax is altered in a different manner; the retraction chiefly showing itself at the lower part of the sternum and the lower margins of the thorax ; in such cases the upper part of the thorax appears to bulge forwards Since obstructed breathing from adenoids is often present in rachitic cases (see p. 28) the retraction of the loAver part of the thorax is not infrequently combined 440 DEFORMITIES OF THE THORAX. with pigeon breast. To recapitulate; the types of rachitic deformity of the thorax are— 1. Pigeon breast. 2. Depressed sternum. 3. Depression of the lower segment of the thorax. These types may be combined in the same individual. Acquired Thoracic Deformities from Causes other than Rickets.—Empyaina, asthma, chronic tuberculosis, emphy- sema, and other causes produce deformities of the chest familiar to physicians. Treatment.—Some of the congenital deformities call for instrumental treatment, eg. for the protection of the heart in cases of severe cleft sternum and for the prevention of secondary deformities of the spine (kyphosis and scoliosis) Avhich may arise from want of strength in the thoracic skeleton due to the congenital deficiency. Cervical ribs may require excision on account of pain or deformity. In rachitic deformities the underlying condition must be treated, and nasal or other obstruction must be removed as far as possible. The resisted respiratory exercises Avhich have already been mentioned in the treatment of scoliosis (p. 366) are of the first importance in treating the rachitic deformities of the chest. In addition to Avhat has been said above on this head, the following obseiwations, kindly supplied to the author by Dr. George C. Cathcart, Avho has closely studied the subject, may be given:—■ If the deformity be more marked on one side of the chest than on the other, it will be best to pay exclusive attention to that side tiil it be brought into conformity Avith the other. First Exercise,—Place the hand on that part of the chest where the depression is, and endeavour to exaggerate it by compressing the ribs Avhile the patient expires. He Avill thus learn to feel the part that needs attention. Noav direct him to concentrate all his attention on that part of the chest, and endeavour to push the hand away by inhaling with four short inhalations, letting the breath go between each one. He will thus be enabled after a little practice to make the more depressed side equal to the larger one. Having once grasped the idea of hoAV to obtain DEFORMITIES OF THE THORAX. 441 the result required, he can noAV apply both hands, one to each side of the chest, and Avhile exhaling as before press in the ribs on either side. Then repeat the same exercise as that given above for the one side of the chest. Though this exercise seems very simple, it is astonishing Iioav much difficulty many people have in grasping the idea of Avhat is required to be done. Of course, the time required to complete the cure will vary both Avith the mental capacity of the patient and the patience and perseverance of the teacher. It is important to bear in mind that these exercises should ahvays be practised in a dress Avhich does not restrict the fullest movements of the ribs backAvards, forwards, later- ally, and upwards. Further, in order that the ribs may not be pulled up by the muscles connecting the upper ones and the clavicles Avith the head, the neck should be bent forwards so that they cannot be brought into play. Second Exercise.—Stand sideavays to a Avail, and stretch out the arm Avith the back of the hand turned upAvards till the finger can just touch the Avail. Now take a slow inspiration through the nose, letting the chest expand and rise well up. It will be found that the fingers touch the Avail more easily. Xoav step away from the Avail one or two inches, and touch it again. Go on doing this till it becomes difficult to touch the Avail. When this position has been reached, let the breath suddenly go and the chest fall, and at the same time try to keep the fingers touching the wall. It is only after some practice that this can be done. Repeat with the other arm. Third Exercise.—Stand Avith the back against the Avail or door, and stretch the arms up above the head, keeping ("if possible) the elbows and the back of the arms against the Avail. At the same time take a sIoav inspiration through the nose. Then draw the arms slowly clown till the hands are on a level with the shoulders, and then let the breath go. At first it Avill be found somewhat difficult to keep the arms and elboAVS steadily against the wall, but this can be overcome by practice. Fourth Fxercise.—Let the patient lie down on his back on the floor, and while his feet are held down either by 442 DEFORMITIES OF THE THORAX. an assistant or by putting them under the edge of the bed or wardrobe, let him slowly raise himself into a sitting posture. When this can be done quite easily, let him try to do it without having the feet held down. Then let him practise doing it with his arms stretched out above his head, and always behind it when rising, so that their leverage acts against him and not with him. Fifth Exercise.—Let the patient lie face downwards on the floor with his toes and chin touching it. Then let him flex his elboAvs and place his hands on the floor palms downwards just external to the shoulders, and endeavour to push himself up from the floor till his arms are straight and vertical six times in succession. While doing this he must be careful to keep the body straight and stiff, and the abdomen drawn well in. It is more difficult if the chin is turned slightly up. THE END. Index to Subjects. Achondroplasia, 32 Acquired deformities, 14 Ankle-joint, Deformities of, 261 Ankylosis, 56 ----, Traumatic, 58 Artificial limhs, 86 Arthritis, Chronic traumatic, 38 ----, ---- ulcerative, 38 ---- pauperum, 46 ----, Suppurative, 58 ----, Tubercular, 59 Arthrodesis, 114 Back-knee, 226, 258 " Bone-setting," 87 Bones, Excision of, 114 Bradford's operation, 180 Buchanan's operation, 176 Children, Inspection of, 4 Chinese lady's foot, 162 Clavicle, Congenital defects of, 312 Club-foot, Introduction to, 153 Club-hand, Congenital, 21.5 ----, Introduction to, 153 Congenital deformities, Primary, 9 ---- ----, Secondary, 12 Contracture, Arthrogenous, 55 ----, Desmogenous, 48 ■----, Myogenous, 48 ----, Neurogenous, 50 ----, Paralytic, 51 ■----, Spastic, 50 Contractures, 17 ----, Dermatogenous, 47 ----, Inflammatory muscular, 48 Costo-transversectomy, 412 Coxa vara, 226, 248 _________, Diagnosis of, 252 Coxa A-ara, Pathology of, 255 ---------, Symptoms of, 249 ---------, Treatment of, 256 Coxitis, Tubercular, 297 ----, ----, Ambulant treatment, 300 ----, ----, Ankylosis in, 304 ----, ----, Complications of, 304 ----, ■----, Diagnosis, 297 ----, ----, Dislocation in, 304 ----,----, Symptoms, 297 ----, ----, Treatment, 298 Cubitus A^algus, 318 ----A-arus, 319 Deformity, Symptoms of, 62 Diagnosis, General, 62 Didot's operation, 139 Digits, Suppression of, 137 Drop finger, 145 Dupuytren's contraction, 146 ---------, Anatomy of, 147 ---- ----, Treatment of, 149 Elastic traction, 85 Elbow-joint, Ankylosis of, 319 ----, Contractures of, 318 ----, Deformities of, 317 Electricity, 69 Exercises, Passive, 66 ----, Resisted, 67 Femur, Arrest of growth of, 220 ----, Incurvation of the neck of (see Coxa vara), 248 ----, Rachitic deformities of shaft of, 247 Fibula, Congenital defects of, 221 Fingers, Congenital contraction of, 140 ----, ---- deformity of, 136 ----, ---- dislocation of, 140 44 OR THO P. E I)I<' SI rR GER Y. Fingers, Congenital hypertrophy of, 151 ----, Desmogenous contracture of (see Dupuytren's contraction), 140 Fitzgerald's operation, 181 Flat-foot, Congenital, 194 ----, Infantile, 194 ----, Rheumatic, 194 ■----, Static, 196 ----,----, Anatomy of, 200 ----,----/Treatment of, 203 ----, Transverse, 210 Fragilitas ossium, 34 Genu recurvatum, Congenital, 261 ---- ----, Paralytic, 267 ----retrorsum, 258 ---- valgum, ^Etiology of, 232 ---------, Anatomy of, 226 --------■, Comparison of conserva- tive, with operative treatment of, 240 ---- ——, Complications of, 231 ---- ----, Definition of, 221 ---- ——, Macewen's operation for, 111 ----• ----, Mode of examination for, 230 ---- ■----, Ogston's operation for, 237 ---- ----, Prognosis of, 233 --------, Reeves's operation for, 237 ---------, Treatment of, 233 ---- varum, 241 ---- ----, Anatomy of, 242 ---------, Causation of, 242 ---- ----•, Definition of, 225 ---- ■----, Prognosis of, 245 ---------, Treatment of, 245 Gighli's saw, 113 Gout, 46 Gymnastics, 65 Hallux flexus (see Hallux rigidus) ----retractus, 135 ■---- rigidus, 128 ---------, Treatment of, 129 ,---- valgus, 117 ---------, Causation of, 118 ---------, Treatment of, 120 ---- A'arus, 127 Hammer-toe, 130 ----, Anatomy of, 130 Ilannner-toc, Cases of, 133 ----, Pathology of, 131 ----, Treatment of, 131 Hand, Paralytic deformities of, 217 Hip, Arthritis deformans of, 309 ----, Congenital dislocation of, 275 ----} .---------, Anatomy, 275 ____.----.----, Bloodless reduction, 289 ____; .----. ----, Diagnosis, 285 ____,____. ----, Operations for, 291 ____( — ----, Treatment, 287 ----, Deformity of, after specific fevers, 306 ----, Hysterical, 297 ----, Non-tubercular deformities of, 30G Hip-joint, Deformities of, 271 ----disease (see Coxitis, Tubercular) ----, Method of examining, 273 ----, Symptoms, 272 Hot-ah* apparatus, 41 Hydrotherapy, 69 Instruments, 69 Joints, Resection of, 114 Knee, Ankylosis of, 264 ----■, Arthrogenous contracture.' of, 268 ----, Contracture of, 264 ----, Flail-joint at, 268 ----, Internal derangement of, 270 ----, Tubercular disease of, 269 Knee-joint, Deformities of, 261 Knee-splint (Thomas's), 86 Kyphosis, Rachitic, 372 ----, Thoracic, 333 Laminectomy for paraplegia in tuber- cular spondylitis, 419 Lateral curvature of spine (see Sco- liosis), 337 Liquor amnii, Absence of, a cause of deformity, 12 Lordosis, 335 ----, Rachitic, 374 Macrodactyly, 151 Mallet linger, 145 Manipulative treatment, 87 INDEX TO SUBJECTS. 445 Massage, 64 Metatarsalgia, 211 ----, Treatment of, 212 Myositis, Ischamiie, 49 ----, Ossifying, 48 Myotomy, 107 Nicoladoni's operation, 163 Norton's operation, 138 Ogston's operation, 208 Operations, 92 Orthopaedic surgery, Scope of, 2 Osteoclasis, 109 Osteotomy, 110 ----, Asiragaloid, 179 ----, Cuneiform., 113 ----, CurATlinear, 113 ----, Oblique, 113 Paraplegia from tubercular spondylitis, 418 Paralysis, Congenital, 295 Patella, Congenital affections of, 263 Phelps's operation, 177 Pigeon breast, 438 Plaster of Paris, Uses of, 70 Pressure deformities, 15 Prognosis, General, 63 Progressive muscular atrophy, 55 Prophylaxis of deformities, 60 Pseudohypertrophic paralysis, 324 Rachitic deformities of the long bones, 222 Rachitis adolescentium, 29 Rack-and-pinion, 81 Radius, Deformities of, 259 Retrocollis, 421 Rickets, 25 ----, Causation of, 28 ----, Congenital, 30 ____( Distribution of deformities in, 27 ____ in adolescence, 29 Rheumatic polyarthritis (chronic), 45 Rheumatism, 45 Rheumatoid arthritis, 35 ____. ---- in children, 43 Sacro-iliac disease, 311 Scapula, Congenital displacement of, 311 Scoliosiometers, 356 Scoliosis, 337 ----, Diagnosis of, 356 ----, Exciting causes of, 348 ----, Exercises for, 365 ----, Forcible correction of, 370 ----, Frequency of, 330 ----, Hereditary character of, 347 ----, Method of examination for, 353 ----, Pathological anatomy of, 339 ----, Predisposing causes of, 345 ----, Preventive treatment of, 360 ----, Prognosis of, 358 ----, Treatment of, 359 ----, Types of, 350 Shoulder-joint, Ankylosis of, 316 ----, Contracture of, 316 ----, Deformities of, 313 ----muscles, Paralysis of, 315 Spastic paralysis, 319 ---------, Diagnosis, 321 ---------, Operative treatment, 323 ---------, Prognosis, 323 --- ----, Symptoms, 320 ---------, Treatment, 322 Spinal splints, 83 Spine, Angular curA'ature of (see Spondylitis), 382 ----, Deformities of, 328 ----, Dorsal excurvation of, 333 ----, Lateral curvature of (Scoliosis), 337 ----, Malignant disease of, 419 ----, Neurotic affections of, 380 ----, Post-typhoidal lesions of, 380 ----, Rheumatism of, 379 ----, Rheumatoid arthritis of, 375 ----, Rickets of, 372 ----, Syphilitic disease of, 379 ____, Tuberculosis of (see Spondylitis), 382 Spondylitis deformans, 38, 375 ____, Tubercular. 382 ____; ----, Complications in, 395 ____'t _—, Effects of, 384 ____ .____, Examination of the back in, 393 ____ .____; Forcible correction of de- formity in, 405 446 ORTHOPEDIC SURGERY. Spondylitis, Tubercular, Mechanical treatment of, 402 ----■, ----, Method of recording de- formity in, 394 ---,----, Pathology, 383 ----,----, Postures in, 392 ----, ----, Spinal cord in, 389 ----, ----, Symptoms of, 390 ----, ----, Treatment of, 399 ----, ----, ---- complications, 413 Springs, 85 Statistics of deformities, 62 Stokes's operation, 210 Syndesmotomy, 108 Syphilis, 34 Talipes calcaneo - valgus, Congenital, 159 ---- ----,----, Treatment of, 159 ---------, Paralytic, 163 ---- calcaneo-varus, Congenital, 164 ---- calcaneus, Congenital, 156 ---------, Paralytic, 161 ---- ----, ----, Treatment of, 162 ---- cavus, 184 ---------, Treatment of, 193 ---- equino-varus, Congenital, 165 ---- ----, ----, Anatomy of, 166 —, ----, Treatment of, 168 ---- ----■, Paralytic, 190 ---- equinus, Acquired, 181 ----• ----, ----, Anatomical changes in, 184 ---------, Congenital, 164 ---------, Paralytic, 183 ---------. ----, Treatment of, 187 ---- valgus, Paralytic, 161 ----■----, Spasmodic, 195 -----, Varieties of, 155 ---- varus, Congenital, 164 ---------, Paralytic, 190 Tendon grafting, 107 ----, Methods of lengthening, 103 ----,---- of shortening, 104 ----, Repair of, 95 ----, Stages in repair of, 99 ---- transplantation, 107 Tenotomy, 93 ----, Open, 102 Tenotomy, Subcutaneous, 94 Thomas's hip-splint, 82 Thorax, Deformities of, 437 ----,----, Treatment, 440 Tibia, Arrest of growth of, 220 ----, Congenital absence of, 220 Tibial Curves, Anterior, 247 ----. ■----, External, 247 Toes, Arthritic deformity of, 134 ----, Clawing of, 184 ----, Congenital deformity of, 136 ----, Paralytic deformity of, 136 Torticollis, 420 ----, Acute, 420 ----, Chronic, 422 ----, ----, of childhood, 425 ----, Congenital, 423 ---- from rheumatoid arthritis, 428 ----, Hysterical, 435 ----, Mental, 430 ----, Ocular, 422 ---- of articular origin, 427 ---- of osseous origin, 427 ----, Rachitic, 428 ----, Rheumatic, 420 ----, Spasmodic, 428 ----, ----, Clonic form, 428 ----•, ----, Operations for, 431 ----, ----, Tonic form, 430 ----, ----, Treatment, 431 Treatment, General, 64 Trevcs's operation for lumbar spinal abscess, 417 Trigger finger, 143 Ulna, Deformities of, 259 Vestimentary deformities, 17 Webbed fingers, 10 ---------and Toes, 137 ---------, Treatment of, 138 Wolff's law, 21 Wrist, Congenital dislocation of, 216 ----, Contracture and ankylosis of, 218 Writer's cramp, 145 Wry-neck (see Torticollis), 420 Zeller's operation, 138, Index to Authors. Adams, William : Method of performing subcutaneous tenotomy Repair of tendons ... Osteotomy ... Description of hammer-toe Operation for hammer-toe Congenital finger contraction Operation for Dupuytren's contraction... Congenital talipes equino-valgus ... ... Astragalus in congenital club-foot Scarpa's shoe for flat-foot Normal structure of spine Spinal support Albert : Arthrodesis Anderson, William : Operation for hallux valgus Hallux varus with macrodactyly Operation for hammer-toe Tendon elongation by Z-shaped section Theory of Dupuytren's contraction Andry: " L'Orthopedie "................ Illustration of the principle of the rigid splint Baginsky : Plantar reflex Baker, F. F.: Club-foot wrenches Bannatyne, G. A. (and Wohlmanx) : Rheumatoid arthritis ...... ...... Rheumatoid arthritis in children ....... Barker, A. E.: Operation for hallux valgus .......... Barton, Rhea: Osteotomy ... ......... Baravell, R. : Elastic traction ... ... .......... Exercise for scoliosis ............. Seat for scoliosis................ 448 ORTHOPaEDIC SURGERY. Bekkakt, J. B. : pa«e Gout.............................. 47 Bigg, Heather: Orthopaedic apparatus ............ 163,264,323,367,427 Bilhaut (and Levassort) ; Spinal corsets......... ... ... ■•■ •■• • ■■ 105 Billroth : Osteotomy for genu A-arum ... ... ... ••• • ••• 246 Bonnet : Apparatus for exercising ank'e ... ... ... ... ... 68 Bradford, E. H.: Operation for club-foot ... .. ... ... ... .. ... 180 Bradford and Loa'ett : Statistics of paralytic deformity ... ... ... ... ... 55 Taylor's spinal support ... ... ... ... . ... ... 84 Genu valgum ... ... ... ... ... ... ... ... 230 (linn varum ... ... ... ... ... ... • •• ... 245 Thomas's hip splint ... ... ... ... ... ... ... 301 Bed-frame for casus of spinal disease ... ... .. ... ... 400 Bkissaud : Mental torticollis ... .. ... ... ... ... ... ... 431 Broadbent, Sir AA'illiam : Spasm in cerebral tumour ... ... ... ... ... ... 321 Brodhurst : Congenital hip dislocation ... ... ... ... ... ... 282 Bi'dinge : Trigger finger ... ... ... ... ... ... ... ... 144 Busuh : Ling's exercises ... ... ... ... ... .. ... ... 67 Calot: Forcible correction of deformity of spine ... ... ... ... 405 Carpenter, (i.: Congenital absence of clavicles ... ... ... ... ... ... 312 Cathcart, G. C. : Respiratory exercises ... ... ... ... ... ... ... 440 Chance, E. J. : Spinal splint ... ... ... ... ... ... ... 84 Hallux A'arus ... ... ... ... ..; ... . 128 Talipes equinus ... ... ... ... ... ... ... ... ig4 Chipault: Forcible correction of hump-hack ... .. ... ... 40,5 Clutton, H. H.: Excision of metatarso-phalangeal joint in hallux valgus ... ... 127 Bifurcated hand ... ... ... ... ... ... ... 13^; Talipes cavus ... ... ... ... . ... 193 Club-hand ... ... ... ... ... ... 215 Ankylosis of knee ... ... ... 268 Congenital absence of tibia .. ... ... 221 Collier, H. Stansfield : Congenital deformity ... ... ... „,, ... 13 INDEX TO AUTHORS. Collier, H. Stansfield (continued): Genu valgum Collier, James : Talipes cavus Collier, Mayo : Hallux rigidus Colman. W. S.: Coxa vara ... Davies, Colley : Hallux valgus Tarsectomy ...... ..... Davy : Tarsectomy De Morgan, Campbell : Spasmodic torticollis Duchenne : Paralytic deformities Duaal : Terminology in club-foot Eocles, J. Symons : Massage Ellis : Exercise for flat-foot Ewens, J.: Genu valgum Pathological dislocation of hip-joint .. Fitzgerald : Operation for club-foot ... Fowler, G. R. : Boots for hallux valgus ... Frazier, C. H. : Coxa Arara ... Galen : Gymnastics Forcible correction of spinal deformity Gardner, William : Phelps's operation Garrod, Archibald : Achondroplasia .......... Gout and rheumatoid arthritis..... Garrod, Sir Alfred : Gout and rheumatoid arthritis..... Goldthwait, J. E.: Metatarsalgia ......... ■ Forcible correction of spinal deformity Grosse, Ulhrich: Plaster of Paris........... D D 450 ORTHOPEDIC SURGERY. Guerin : Section of ligaments ..... Guthrie, Leonard : Metatarsalgia ...... Heberden: Gout and rheumatoid arthritis .. Hessing : Orthopaedic apparatus ..... Hippocrates: Forcible correction of spinal deformity Hoffa, A.: Wolff's law ........... Statistics of deformities ... ..... Paralytic genu recurvatum ..... Congenital dislocation of the hip Types of scoliosis........... Hofmeister : Coxa vara ... Holmes, Timothy : Tenotomy in paralytic talipes ... Hopkins, Barton : Osteotomoclasis ... Hueter, C.: Causation of deformities........ Hughes, Kent : (See Walsham and Hughes.) Hutchinson, Jonathan : D upuytren's contraction........ Johnson, Raymond: Ischemic contracture Jonas, A. F.: Phelps's operation Jones, Robert : Metatarsalgia Ankylosis of hip.......... Forcible correction of spinal deformity Kassoavitz : Congenital rickets Keen, W. W.: Dupuytren's contraction ... Wry-neck ... Keetley, C. B.: Coxa vara ... Kellock, T. H.: Phelps's operation ....... Kirmisson : Congenital dislocation of the hip INDEX TO AUTHORS. Kolliker : Congenital displacement of the scapula Kredel: Congenital coxa vara Krukenberg: Mechanical gymnastics..... Kustner : Congenital flat-foot ......... Lambotte: Radical treatment of tubercular spondylitis Lane, Arbuthnot : Chronic traumatic arthritis ...... Buchanan's operation Phelps's operation Lange: Forcible correction of spinal deformity Levassort : (See Bilhaut.) Leavis, P. G. : Scoliosis Little, Muirhead : Spring for flat-foot Congenital dislocation of the hip Ling, P. H. : Exercises ... Lockwood, C. B.: Dupuytren's contraction Congenital dislocation of the hip Lorenz: Flat-foot.............- Congenital dislocation of the hip Lovett: (See Bradford and Loa'ett.) Lucas, Clemf.nt : Rachitis adolescentium ... Luff, A. P.: Hot-air apparatus... Lund : Excision of astragalus Llning and Schultfss : Congenital AA'ry-neck Maceavf.n, Wm. : Osteotomy ... Rachitic deformities ...... Genu varum Marsh, Howard : Ankylosis ... Tubercular coxitis Spinal supports ........ 452 ORTHOPEDIC SCRGERY. Menard : Costo-transversectomy Meyer. H. von : Structure of bones Boot construction... Mikulicz : Genu valgum Congenital dislocation of the hip ...... Murray, R. W. : Forcible correction of spinal deformity Nicoladoni: Tendon transplantation ... Congenital talipes calcaneus Notta : Trigger finger Ollier : Oblique osteotomy Chondrectomy ...... Opknshaav : Ogston's operation Oaven, Edmund : Examination of hip ......... Examination of spine ...... Parker, R. W. : Tenotomes ... Syndesmotomy Congenital talipes valgus ......... Parry : Spasmodic wry-neck Pepper: Tubercular coxitis ...... Phocas : Tendon shortening Poland, John : Rachitic back-knee Porak : Achondroplasia Railton, T. C. : Congenital deformity Redard : Torticollis......... Reeves: Trigger finger ............... Genu valgum ............... Richer, P.: Hysterical torticollis INDEX TO AUTHORS. Riedel : Hallux valgus Roth. B.: Mode of recording rotation in scoliosis Sayre: Curvilinear osteotomy Scarpa: Method of treatment of club-foot Schede: Congenital dislocation of hip Schlange: Congenital displacement of scapula St horstein, G.: Congenital absence of clavicles ... Soudder, C. J. : Congenital deformity of shoulder Seeligmuller : Statistics of paralytic deformities Shaw, John : Exercises in scoliosis Sims, Parker: Construction of boots Smith, Noble : Spinal supports Normal movements of ankle Drilling hone for relief of pain ... Chance's splint for scoliasis Operation for spasmodic wry-neck Smith, Prothero : Spinal support Solly : Tarsectomy Spiller, W. G.: Paraplegia in tubercular spondylitis ... Sprengel: Congenital displacement of scapula Still, G. F. : Rheumatoid arthritis in children Stromever : Subcutaneous tenotomy........ Sutherland, G. A. • Peripheral neuritis ......... Attitude in coxa A-ara ... .....■ Congenital paralysis .......... Symington, Johnson: Genu valgum ............ Taylor, C. F.: Spinal support 454 ORTHOPEDIC S URGERY. PAGE Thomas, H. O.: g2 Hip-splints ... ••• ••• ••• '"' g* Knee-splint Thomas, William : ^~- Club-foot wrench... Treves, F. : 4 j. Operation for lumbar abscess............... Tubby, A. H.: 100 Repair of tendons ... ■•• ••• ••■ ' ... 404 Metatarsalgia Spinal supports Vincent, F.: .. „ Spinal abscess Volkmann, R. von: Pressure deformities Open operations ... 19 108 106 71 157 Walsham : Tendon shortening ......... Walsham And Hughes : Plaster bandages ... Congenital talipes calcaneus ...... ......... Buchanan's operation ........... ...... •■• '[ Talipes equinus...... ......... ••• •" ° Treatment of flat-foot............ ......... 206 Whitman, Royal : Construction of boots ............ ...... Willett : Tendon shortening ... ... ... ••• ••• ••■ ••• 104 Williams, Chisholm : Ischaemic contracture ..... ......... ••• ••■ 219 Winiwarter, Von : Operations on fascia ... ... ... ... ... ••• Wolff, Julius : Pressure deformities ... ... ... ... ••■ ••• ••• 20 Wullstein : Forcible correction of spinal deformity ......... •■• 408 Zander: Mechanical exercises ... .. ... ... .. ... ••• 68 Zehnder: Coxa varaj ... ... ... ... ... ... ••• ••• 253 93 Printed by Cassell & Company, Limited, La Belle Sauvage AVorks, Lvdgate Hill London, E.C iQ3w jo Aavaon ivnouvn SNOiaaw jo Aavaan ivnouvn SNioiasw jo Aavaan ivnouvn 3NOIQ3W jo Aavaan ivnouvn aNioiaaw jo Aavaa' nouvn »\v ■5:-^^p,^;< E NATIONAL LIBRARY C ... ~. <>«ARY ^i-E 3NIDI03W jo Aavaan ivnouvn 3nidio3w jo Aavaan ivnouvn 3noio3w jo Aavaa NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY O 3NIDIQ3W jo Aavaan ivnouvn snidiosw jo Aavaan ivnouvn snidiqsw jo Aavaa NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY O 3NOia3w jo Aavaan ivnouvn snidiosw jo Aavaan ivnouvn 3noio3w jo Aavaa < Q. 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