CHAPTER XXXIII

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DEFORMITIES DUE TO CONGENITAL DEFECTS OR ACQUIRED DISEASES OF THE LOCOMOTOR APPARATUS; ORTHOPEDICS.

In previous chapters have been considered the various morbid conditions of bones, joints, muscles, and tissues which help to form the locomotor apparatus of the body. It would seem then quite proper in this place to insert the chapter usually relegated to the end of text-books on surgery where it stands by itself, _i. e._, the chapter on Orthopedics. As a subject orthopedics deals with the causation and the treatment of deformity, whether inherited or caused by disease. The term is used in a more or less elastic sense, and is made by some to cover a larger field than others would accord it. The subject divides itself into two parts:

1. The consideration of deformities produced by tuberculous or other infectious disease, and

2. Non-carious, congenital, and acquired deformities.

Tuberculous lesions do not differ in pathology or other respects from the tuberculous diseases of bones and joints described in earlier chapters of this work. Inasmuch, however, as some of them form distinct and clinical types of deformity they assume an importance which justifies reasonable consideration by themselves. Of these we shall consider spinal caries, sacro-iliac disease, hip disease, and tumor albus.

SPINAL CARIES, SPONDYLITIS, KYPHOSIS, POTT’S DISEASE.

These various terms have reference to deformities of the spine of similar type, but with considerable variations, produced by caries (tuberculosis) of the vertebral column. Where osseous structures are separated by cartilaginous or more or less complete joint cavities the primary focus may form within the spongy structures of the vertebral bodies or in the softer tissues of the intervertebral joints. In other words, it is caries of the ordinary type which assumes special significance only because of the accident of its location. The entire vertebral column should be regarded as the main support of the body, while to it is due the maintenance of the erect position which raises man above the animal. When diseased and softened it yields to pressure, the result being exaggeration or distortion of its natural curves. As the instinctive tendency of the human being is to maintain the head in the line of the centre of gravity above the pelvis, any marked degree of curvature in one direction brings about, by natural causes, a compensatory curve in its opposite direction. A well-marked case of kyphosis, then, is characterized by more than one exaggerated curvature or protuberance, one being due to disease, the other to compensation.

While there may be several foci of active tuberculous disease, even in one vertebra, there may be found pronounced forms of angular curvature as the result of destruction occurring in but one or two of them. The carious process once begun may be checked at any point in its course, or it may proceed to complete softening and destruction, with formation of cold abscess. The tuberculous process once begun spares no tissue, and thus bone and intervertebral cartilage melt and disappear in the same manner. There may be a possible danger from spreading of tuberculous disease to the spinal meninges or to the cord, or of its being generalized. In the former case there is pachymeningitis and myelitis with paralysis; in the latter case it causes more or less rapid, acute general tuberculosis. Paralysis is more often induced, however, by actual compression than by mere tuberculous involvement, although the disease products which cause this pressure are likely to come from a caseous pachymeningitis.

The disease is most common in childhood, about 80 per cent. of cases occurring before puberty. Of the three regions of the spine the thoracic is the one most often involved, next the lumbar, and lastly the cervical. The most common site of all is in the lower dorsal region. Deformity once established as the result of this disease cannot be expected to spontaneously disappear.

=Causes.=--Slight injuries occurring in those of tuberculous diathesis, by which there is produced a focus of least resistance, or secondary infections following upon such conditions as scarlatina and typhoid, constitute the most frequent recognizable causes. There can usually be obtained a history of some injury in about half of the cases. The disease once established may assume either an acute or chronic type.

=Symptoms.=--As indicated when discussing caries in joints the principal signs and symptoms are pain, muscle spasm, muscle atrophy, tenderness, deformity, and impairment of function. These are all present in Pott’s disease, to which they give that distinct clinical picture which Pott so graphically described about a century ago.

=Pain.=--Pain is rarely absent. It may be misleading, but is usually referred to the terminal distribution of the intercostal nerves, and thus may be complained of in the chest, the abdomen, or the legs. Many a “stomach-ache” in children is of this character and origin, and a complaint of frequent “growing pains” should be carefully investigated. Even in sleep these pains are characteristic, and have been previously described as “starting pains.” Children cry out with them in the night. They tire easily and tend to seek rest instinctively. Pain is always aggravated by excessive pressure upon the upper spine or by jars, such as may be received in jumping. It is not necessarily constant. Vertebral tenderness may sometimes be detected by pressing upon the ribs. This will especially aggravate symptoms when respiration is of a groaning character or when there is any expression of dyspnea. There may be vomiting or dysuria. A sudden increase of these painful features means a fresh focus of infection, impending abscess, or a danger of paralysis.

=Muscle Spasm.=--It is by muscle spasm that we account for the attitudes and postures of Pott’s disease. It is a constant feature, but will vary in its expressions with the location of the disease. In caries of the cervical spine the chin is raised, the head is balanced somewhat backward, while the lower spine is straightened and given a backward curve. In the stooping posture the head is supported by the patient’s hands in the instinctive effort to protect it. In caries of the mid-dorsal region there is elevation of the shoulder, with marked tendency to support the weight of the upper part of the body by placing the hands upon the knees or thighs. Lumbar caries often produces perceptible backward curve in the lower portion of the spine.

In all cases there are stiffness and rigidity of the spine, and patients resort to all sorts of instinctive expedients to avoid motion in the affected area. When that part of the spine which is in relation with the psoas muscle is involved there is more or less psoas contraction, with characteristic flexor deformity at the hip, which is usually bilateral. This will give a peculiarity to the gait and cause it to be not only stiff in appearance, but it will be seen that the patient walks more upon the toes and with slightly bent knees, which are thus made to act as springs. An attitude assumed in stooping or in the effort to lean over as if to pick up an object from the floor is characteristic; the spine will not be curved forward and the patient will not stoop as usual for the purpose, but the spine will be more or less erect and stiff and lowered to the floor by flexing both knees and hips until the squatting position is assumed. In rising the same effort will be made to protect the spine from any motion between its component parts. (See Figs. 253 and 254.)

During sleep this muscle stiffness becomes even more pronounced, so that in the morning patients are “stiffer” than later in the day. The existence of muscle spasm can often be detected by palpation of the spinal lesion. Some lateral deviation or asymmetry of signs may often be noted, according as the muscles of one side are more pronouncedly influenced by the location of the disease focus, and it is the more common in proportion to the greater severity of the case.

The confinement caused by the disease will naturally be followed by more or less atrophy of the body muscles, but, in addition to that, those immediately involved about the centre of the disease undergo an atrophy due to it and often apparent on inspection.

=Tenderness.=--In numerous distinctive ways the patient constantly evinces tenderness and makes invariable efforts to protect against movement or even jar. Tenderness can also be evoked by pressure upon the head or shoulders, which will cause severe pain, or by causing the patient to jump down a step or to rise upon the toes and then come down abruptly upon the heel. Pressure upon the spines of the affected vertebræ or upon the ribs which connect with them will also cause complaint of pain.

=Deformity.=--This is the most striking objective feature of well-marked Pott’s disease. It is practically a backward projection known as kyphosis, the vertebra first affected being usually the first to yield, the others following or changing in shape as the disease spreads or as the growth of the individual permits accommodation and necessitates rearrangement. The more acute the disease the sharper the projection. Old and mild cases cause an abrupt curvature rather than a protuberance.

[Illustration: FIG. 253

FIG. 254

Typical postures of the spinal muscle spasm of spondylitis. (Bryant.)]

It is well to keep a record of the deformity in cases under treatment. This may be graphically preserved by putting the patient flat upon the abdomen upon a straight surface and bending a strip of lead so that it shall fit the contour of the spinous processes. After it has been made to fit it may be removed and a tracing of the curve made upon a sheet of paper. Comparison of tracings thus made at intervals will afford a graphic record of the progress of the disease or of the improvement made. Kyphotic deformities lead to a shortening of the spine, so that growth is stunted and patients become dwarfed in appearance. Secondary curvatures are produced above and below the primary projection. Gradually as the shape of the vertebral bodies and of the entire spinal column changes the ribs are pressed more or less together, often being made to overlap, the shape of the chest undergoes alterations, the sternum sometimes being depressed and sometimes protruded, giving the chest, in the latter case, the so-called “pigeon-breast” appearance.

=Loss of Function.=--There are but few disorders which produce more pronounced and widespread accompaniments than spinal caries. As change in the shape of the spine occurs and assumes a marked type we see changes occurring through the body, not only in the direction of anemia with general impairment of function, mental irritability, and cachexia, but there occur trophic alterations as well. The shape of the face changes, the expression assumed is one of anxiety, and the features become less mobile.

=Complications and Sequels.=--Tuberculous meningitis, cerebral or spinal, is the most dangerous and acute condition, while other tuberculous complications may occur in various regions of the body. In fatal cases meningitis, in consequence of acute or mixed septic and terminal infection, furnishes the explanation for the great majority. Paralysis is not infrequent as a sequel, assuming the type of paraplegia and developing slowly. Motion is first impaired and a considerable interval may elapse before sensation is affected. Motor impairment varies from mere mild paresis to complete paralysis, beginning as fatigue, loss of strength, and inability to stand. Unless the disease be located in the lumbar region the reflexes are exaggerated and muscle spasm is easily provoked or occurs without perceptible cause. As above noted the muscles become atrophied, and when the cord is seriously compromised are rigid in chronic spasm. The rectum and the bladder suffer finally, especially in disease of the lower segments. Occasionally in cases of high dorsal disease the arms will suffer more or less motor impairment. Sensory paralysis begins usually as paresthesia. In merely bedridden but not actually paralyzed individuals the reflexes should be normal. Of the muscle contractures, those of the psoas are the most common and distinctive. Paralysis follows rather than precedes deformity, and is noted in perhaps 20 per cent. of advanced cases. It should rarely occur if effectual treatment has been begun.

=Abscess.=--Abscess is usually of the “cold” type. Its general character has been previously described. It may be of the purely tuberculous type, but is not infrequently the result of a secondary pyogenic infection. It is a consequence of neglect, but cannot always be prevented. Signs, both local and general, of the presence of pus or of pyoid are noted here, as under other circumstances. There is exaggeration of local tenderness, with development of tumor, which fluctuates as it approaches the surface. General septic features, proportional to the activity of the process and its location, accompany the local indications. Sometimes it occurs insidiously and with but few evidences.

Pus travels here in the direction of least resistance. The fascial planes of the body are mostly so placed as to protect important body cavities, consequently pus will travel usually around them and toward the surface, burrowing long distances, for instance, from the lower dorsal region to the groin along the psoas muscle. Cervical abscesses usually spread anteriorly toward the pharynx (postpharyngeal) and deeply into the thorax (mediastinal); they may open into the trachea or esophagus or externally through an intercostal space; or they may burrow laterally, opening behind the sternomastoid muscle. Dorsal abscesses usually travel posteriorly, opening not far from the spine, or they burrow downward and forward along the psoas so as to appear beneath Poupart’s ligament. Lumbar abscesses escape through the psoas sheath as psoas abscesses, so called, or between the fasciæ of the spinal muscles and those of the abdomen to appear upon the side; they may extend downward beneath the iliacus, escaping over the brim and into the pelvis and then out through the sacrosciatic notch. Of all these the psoas abscess, opening in the groin, is the most common. This will in time destroy the muscle fibers of the psoas, but it leaves the vessels and nerves intact, whose sheaths are much more resistant, and which can be found passing through such a cavity like cords through a chamber. This form of cold abscess, with its consequent bulging and final escape in the groin, has been mistaken for hernia as well as for abscess due to perinephritis and appendicitis. The most serious mistake would be to take it for a femoral hernia. The customary routes of all these collections of pyoid have been thus indicated. Nevertheless abscesses may burrow and appear almost anywhere. They will give rise to varying and to superadded symptoms, according to their location. For example, retropharyngeal abscess may seriously threaten respiration by pressure upon the upper air passages, while a collection of pus in the mediastinum might cause serious respiratory difficulty of another character.

_Cold abscesses_ of spinal origin may remain stationary, the fluid portion of the pyoid material may even absorb, while the balance undergoes more or less degeneration and conversion into inert material, or they may slowly or rapidly increase in size. The best that can be hoped in such cases is absorption, with encapsulation of the solid residue. Even this may be a source of danger, as it is a focus of lessened resistance, in or about which subsequent trouble may result. Those abscesses which seem to remain stationary would best be let alone, hoping for subsidence under good treatment. Those which open spontaneously leave tuberculous fistulas behind them, which may possibly close in time, but which lead often to subsequent acute infection, and which are the _bête noir_ of surgeons, for it is often impossible to heal them. The best that can be done in such instances is to wash them out, keep them clean, and guard them from infection from without. It is often possible to pass a tube along the sinus and through this to irrigate with a solution of iodine, of formalin, or of any other antiseptic which may be preferred. If anything be done with them in the operative way it should be as radical as possible, seeking the original lesion, thoroughly curetting its site and the whole interior of the cavity, and making ample opening so as to provide for effective drainage.

_Retropharyngeal abscesses_ usually necessitate evacuation because of the obstruction which they cause within the pharynx. _Lumbar_ and _psoas abscesses_ may be let alone. When this is not practicable, then choice should be made between simple aspiration, aspiration with washing or injection of some antiseptic fluid, and free opening with radical treatment. In these cases we are to be guided by the peculiar features and surroundings of each, and by our own facilities for such work and for subsequent care of the case. An abscess which will soon rupture should be opened and counterdrained; but in one where this is not impending, and where home features are such that the patient can receive no adequate or prolonged care, it would be wiser to abstain. Under the best of circumstances in these cases it is always a difficult problem to decide. Even aspiration leaves at least a needle track to be subsequently infected, while the contents may be too thick to flow through a small trocar. Aspiration with thorough washing out and then with injection of emulsions of iodoform or of other irritating antiseptics have found favor with only a part of the profession. If any radical measure is to be adopted the greatest care should be given to carry out the principles expressed in the general consideration of cold abscesses. (See p. 114.)

=Diagnosis.=--Intelligent comprehension of signs and symptoms should enable one to make a diagnosis in most cases. Nevertheless the surgeon is occasionally in doubt and has to distinguish, for example, as between Pott’s disease and sprain, lateral curvature, hysterical spine, cancer, cord tumors, rheumatic arthritis, rickets, syphilis,

## actinomycosis, hydatid disease, acute osteomyelitis, _i. e._,

non-tuberculous diseases, and certain abdominal affections followed by suppuration, such, for example, as peri-appendicular abscess. Moreover, spondylitis may be simulated in the course or as a complication of typhoid, scarlatina, gonorrhea, and other acute infections. Psoas abscess should be distinguished from perinephritic abscess as well as from acute appendicitis, which often causes psoas contraction, especially when the appendix is posteriorly placed and left in contact with that muscle. We may also have to distinguish this condition from sacro-iliac disease and from ordinary hip disease.

=Prognosis.=--In some degree prognosis depends on what is meant by a cure. Absolute cure, with restoration to the original condition, is exceedingly rare. Arrest of disease, with improvement of deformity, is possible in cases seen early. Even considerable motion may be restored under suitable treatment. In late cases hectic, amyloid degeneration, and dissemination of the disease make the outlook very discouraging. At best its relief is slow and in time it is always chronic, no matter how rapid the onset, except in those instances where dissemination occurs early and rapidly, in which case there is little or no hope. In ordinary cases there is a certain tendency to spontaneous recovery, but not without deformity and impairment of function, while obviously the occurrence of abscess prolongs a case to a considerable degree.

=Treatment.=--Those general measures so necessary for the treatment of any tuberculous lesion, namely, hypernutrition, fresh air, and general constitutional measures, are needed here as in any other such disease. Physiological rest, _i. e._, absolute rest in a bed without springs, the patient lying flat on the back or on the face, and not on the side, and lying quietly, constitutes the best part of local treatment. In the case of children it is best to have a gaspipe frame, across which cloth may be stretched, on which a fretful child can be secured by straps across the shoulders, pelvis, and knees. This frame may be laid upon the bed and lifted from it while a cross-piece is removed for toilet purposes, or a suitable opening may be left if a single piece of cloth be stretched across it. If the patient can be made to submit to this repose, then a pad may be placed under the projection. After a sufficient length of time, with the desired improvement, a plaster shield may be molded to the back, with the patient lying upon his face; and then, after removing and suitably trimming and lining this mold, the patient can be returned in it to the previous position in bed, from which he may gradually be raised. This is the best method to follow in acute or severe cases, or when the disease is higher up in the spine. It will also best serve the purpose when the case is complicated by abscess. To it may be added, if necessary, traction upon the head (Fig. 255).

[Illustration: FIG. 255

Child in bed-frame, with head traction. (Lovett.)]

[Illustration: FIG. 256

Jury-mast for high dorsal and cervical caries. (Lovett.)]

=Treatment by Apparatus.=--The simplest of all apparatus is the plaster jacket, or corset, which was brought into favor in this country by Sayre, although not invented by him. It is usually applied in suspension, _i. e._, with the patient in the erect position beneath the frame, from which hangs a support by which firm traction can be made, both upon the head and the arms or the shoulders. The intent of such a jacket is to apply it with the patient so stretched out that a certain degree of the projection will at least be eliminated and the back made more nearly straight than it otherwise would be. In cases where this is impossible it at least affords better expansion of the thorax and supports the ribs in better relation to the spine, affording more chest room. The plaster is not applied next to the skin, but a thin undershirt or its equivalent of woven materials should be applied, care being taken to see that it fits snugly and is not allowed to fold in ridges. After the patient is completely suspended to a degree where discomfort begins, then a small “stomach pad” is slipped beneath the under-jacket, in front, in order that more room may be given for enlargement of the abdomen after a full meal. Finally with the first turns of the plaster a strip of tin or a couple of strips of moistened pasteboard should be applied directly over the middle line in front and incorporated in the successive turns of bandage, in order that there may be material there which may be cut down in removing the jacket. Small pads should be placed over the iliac crests and over the protrusion if it be at all marked or tender. Now by the use of a series of bandages of gauze, in which reliable plaster of Paris has been incorporated, the entire trunk is enclosed within a corset, which will quickly harden as the plaster becomes firm. It should extend well down over the pelvis and nearly to the trochanters, since from this portion it takes its fixed support. It should then be extended as high as can be permitted under the arms and higher yet over the chest and back. Enough material should be used along with the plaster-of-Paris cream, as the former is applied, to ensure sufficient firmness and strength. If the plaster be reliable it will not be necessary to keep the patient suspended more than a few moments after the completion of the jacket. The finishing touches may be given it after he has been taken from the frame and placed again upon a soft surface.

Another method of application is to have the patient recumbent and properly supported, and this is particularly necessary in acute cases, where suspension is likely to cause faintness or unpleasant symptoms. In this attitude the spine is really put in better position. The method is not at all available in those few cases of lateral curvature which demand jackets (Fig. 256).

Substitutes for these jackets are made of various materials, such as leather, rawhide, aluminum, thin strips of veneering, celluloid, paper, glue, etc. These have to be constructed over a mold which is taken from a plaster jacket. When the disease extends above the level of the fifth dorsal vertebra there should be incorporated within the jacket a support for the head, known since Sayre’s time as a “jury-mast.” This consists of a metal upright, with cross-pieces, which are incorporated with the jacket and which is curved up behind and over the head and made to carry the frame from which the leather straps and supports pass beneath the occiput and the chin, and thus give to the head a certain amount of fixation. The support is so arranged as to permit of sliding and of sufficient expansion so that traction upon the head can be made effective.

[Illustration: FIG. 257

Frame for application of plaster jackets in recumbent position. (Lovett.)]

Fig. 255 shows the application of traction to the head, while Fig. 256 illustrates one form of apparatus by which the jury-mast is made effective in producing traction on the head in the upright position. Figs. 257 and 258 show a convenient frame and method for making plaster-of-Paris corsets with the patient in the recumbent position. Figs. 259 and 260 show another form of apparatus intended for the same purpose.

[Illustration: FIG. 258

Application of a plaster jacket in the recumbent position. (Lovett.)]

The variety of apparatus which has been devised for the maintenance of rigidity and correction of deformity, and, in suitable cases, traction upon the head, is to be measured almost by the number of orthopedic specialists, nearly every surgeon inclining to some device or at least modification of his own. Judson probably has formulated the best rule covering the entire matter when he says: “The apparatus may be considered as having reached the limit of its efficiency if it makes the greatest possible pressure upon the projection compatible with the comfort and integrity of the skin. It is essential that the brace is efficient; second, that it is one that can be constantly worn, if necessary, or can be easily detached from the body if not to be worn at night.” Certain ambulant cases can be treated by an effective brace through the day, and rest at night upon a reasonably hard mattress, with traction upon the head. Concerning the multitude of these special aids to treatment it hardly seems worth while to go into any elaborate description in this place, inasmuch as one who is incompetent to judge as to what is best should not retain the management of such a case, while one who is really competent will probably desire to make his own selection, and the writer’s recommendation would count for but little. Every case must be a law to itself, and every special brace must be constructed especially for the individual for whom it is meant; otherwise it loses all its serviceability.

=Forcible Reduction.=--The feasibility and propriety of forcibly reducing the deformities due to spinal caries was first suggested by Chipault, of Paris, who suggested wiring the spinous processes of the affected vertebra, and then, by Calot, who, in 1896, described a method of forcible reduction under an anesthetic. The first to actually wire the spine under these circumstances was Hadra, of Texas, who had actually done the operation four years before Chipault. The method has probably less to commend it in actual practice than in theory, and, attractive as it may be in respect to time and completeness of reduction, it is often followed by serious accidents, such as hemorrhage, rupture of abscess, fracture of the spine, etc. Bradford, in 1899, collected 610 cases performed by 29 different operators, with a record of 21 immediate deaths from local trauma and 15 cases in which there were at least alarming immediate symptoms. Of 229 of these cases complete correction was effected in 119, incomplete in 94, while no gain whatever was made in 16. Of results reported later, 66 showed some gain, there was no relapse in 17, while 49 showed more or less return of deformity. The claim has been made that the more or less wide gaps or bony defects which may result from forcible manipulation are filled in by new bone, but there do not seem to be any observations to confirm this statement. The amount of force which must be employed is a matter for the finest discrimination. The method includes complete anesthesia, traction upon the spine in each direction from the location of the deformity, and direct pressure force applied to the protection itself, as by a sling passed around the body and just beneath the projection, which can be used as a fulcrum upon which the rest of the spine can be applied as a double lever, with the application, at first, of gentle force, and, finally, sufficient to either satisfy the operator that he should go no farther or that the desired effect has been obtained. Immediately after completion of the maneuver a snugly fitting plaster jacket should be applied and the patient kept absolutely at rest in bed.

[Illustration: FIG. 259

Anteroposterior support: back view. (Lovett.)]

[Illustration: FIG. 260

Anteroposterior support with head-ring for high dorsal caries: side view. (Lovett.)]

The method seems most applicable in the presence of paralysis, even of long standing, and this feature has often been relieved.

_Psoas contraction_ is best treated by traction, with the patient in bed, and with the maximum of weight and power applied which can be tolerated by the individual. If this seem impracticable, then the patient should be anesthetized and force applied until it is evident that more harm than good results. Should this harm appear, then open division of the tissues may be practised. Finally, as a last resort, in intractable cases, a subtrochanteric osteotomy may be made.

_Pressure paralysis_ necessitates _operative relief_. This may be practised late and should consist of a laminectomy and exposure of the area compromised by bone pressure or that produced by pachymeningitis. The operation is done in the same way as for fracture, and will be described in the chapter on Surgery of the Spine.

Finally of all cases of Pott’s disease it may be said that each should be studied by itself, and for each a suitable method or apparatus devised, rather than to endeavor to apply indiscriminately unchangeable methods or forms of apparatus. Every apparatus has its disadvantages as well as its benefits. The more acute the case the more is absolute rest in bed, with traction, demanded. This is particularly true of disease in the upper spine. On the other hand, the more chronic and the lower the disease the easier it is to handle, and with such simple expedients as plaster corsets. When the sacral region is rigid, however, recumbency is usually necessary, because of the difficulty in securing adequate fixation within any apparatus that can be worn. The necessity for general constitutional, dietetic, and climatic treatment should never be forgotten, and the danger of possible acute dissemination kept ever in mind. This is particularly imminent when too much freedom is allowed. Time, patience, and discernment are the dominating factors beyond the general principles already inculcated.

SACRO-ILIAC DISEASE.

Under this name is included a tuberculous condition of the bony tissues on either side of the sacro-iliac synchondrosis, or of the cartilage itself, similar to that which produces the special caries described above. It is an uncommon expression of tuberculous disease occurring often in the young, identical in pathology with other tuberculous bone lesions, and giving rise to peculiar symptoms, mainly because of its location. Early in the course of the disease these may consist of mild discomfort in the lower abdomen, irritability of the bladder and bowels, disinclination for exercise, while, as the disease becomes more pronounced, there will be actual pain, intensified by standing, relieved by lying down, often severe at night, usually referred along the course of the sciatics. A most significant symptom is the tenderness and complaint produced by firm pressure made upon both sides of the pelvis, thus forcing tender surfaces against each other. In the later stages of the disease abscess may develop and present either externally in the lumbar region or internally, breaking into the pelvis and appearing perhaps in the groin or close to the perineum. The disease is usually unilateral, and will cause characteristic limping and aggravated pain upon standing on the limb of the affected side. Naturally this limb will be spared in every possible way. It is likely to be mistaken for sciatica or lumbago, in neither of which diseases is there any tenderness at the sacro-iliac joint such as can be evoked by pressure from the sides of the pelvis. It also has to be distinguished from hip disease by the fact that motions at the nip are not interfered with, and from Pott’s disease of the lower spine, which usually causes prominence of the spinal processes and local tenderness in a different region.

The surfaces and tissues involved are extensive and the disease is always serious. It is one of the most chronic of all such affections, and too often tends to suppuration, with its slow but inevitable consequences, or to dissemination. Thus of 38 cases with abscess reported by Van Hook only 3 recovered.

=Treatment.=--Treatment should consist of absolute rest, with traction, so long as the symptoms are active, and avoidance of all irritation when patients rise from bed. Abscess due to sacro-iliac disease should be radically attacked, especially if this can be done early. Intrapelvic pus collections may require trephining of the pelvic walls or resection of some portion of the ilium, by which complete evacuation may be made and drainage be amply provided. When the joint itself is thoroughly broken down the case will have a hopeless aspect.

CARIES OF THE HIP.

_Hip-joint disease_, or, as it is often called, _coxitis_ or _morbus coxæ_, is worthy of special consideration on account of its frequency, its importance, and the deformities which result from its existence. The most frequent site of the disease, which is of the usual type of tuberculous ostitis or osteomyelitis, is on the femoral side of the joint, usually in or near the head of the bone. In a small proportion of cases the first lesions appear upon the acetabular aspect of the joint, while in some cases the primary tuberculous lesion is of the type of a tuberculous synovitis. (See chapters on Bones and Joints.) In addition to those changes already described in previous chapters there occur certain distinctive alterations about the hip-joint which are worthy of note. On the pelvic side the margins of the acetabulum occasionally become softened, and naturally yielding in the direction of pressure as the result of muscle pull upon the thigh toward the pelvis, cause, first, an elongation of the originally merely circular cavity, and, finally, considerable shifting of position, often referred to as _migration of the acetabulum_. Thus the head of the bone may be found in a socket thus formed on a level one inch higher than on the well side. So also perforation of the acetabulum may occur, with perhaps final escape of the head of the bone into the pelvic cavity. On the other hand, similar changes produce decapitation or marked alterations of shape in the head and neck of the femur.

=Symptoms.=--When the symptoms and signs of tuberculous disease in this location are studied in accordance with what has already been stated in general about caries of the joint ends of the long bones, we have among the most significant features:

1. =Pain.=--This is referred most commonly to the knee because of the relations of the obturator nerve to the hip-joint and to the region of the knee. Pain may also be radiated in other directions, but the complaints made of pain in the knee are classical. Pain is not, however, a pathognomonic feature and may be almost wanting, but the evidences of tenderness, if not of pain, are invariably seen in the unconscious protection of the joint afforded by muscle spasm. It is perhaps in hip-joint disease that night pains and cries are most frequently heard.

2. =Muscle Spasm.=--Fixation of the affected joint is always noted. It begins as a limitation of motion, naturally first noticed in the extremes of rotation, flexion, and extension, and is perhaps the most important early sign of the disease. It furnishes the explanation for the subsequent postural features, as well as an index regarding the gravity and extent of the morbid process. It may be seen even in the lower spinal muscles, where it is detected by laying the patient upon the face, lifting first one leg and then the other, noting the freedom of hyperextension; in fact, this spinal muscular involvement is sometimes so marked as to give rise to the suspicion of low Pott’s disease, from which it is to be distinguished by the fact that the spasm affects one side rather than both.

3. =Muscle Atrophy.=--This involves in time all the muscles concerned about the hip. It begins early, but may not be very pronounced until quite late. It can usually be determined by measurement if not apparent upon inspection and palpation. There will also be noted more or less obliteration of the gluteal crease or fold.

The three cardinal features--pain, spasm, and atrophy--having been thus considered, we can better appreciate the characteristic gait and postures peculiar to this disease. Limping is an early feature, sometimes insidious at first, sometimes abrupt. Patients will avoid coming down quickly upon the heel, while they walk with the knee slightly flexed, in order to give more spring. Stiffness is most apparent on rising from bed in the morning, while the limp is more pronounced at night, and it is at this stage especially that night cries are most frequent. To mere limping succeeds actual lameness with more constant pain. Muscle spasm now leads to malpositions, no one of which is necessarily first to appear, and any of which may occur with others in various combinations, although flexion and adduction are usually the first to be seen, the patient unconsciously assuming that position which happens to give him most relief.

It is important to realize that a marked degree of adduction will cause apparent shortening, and of abduction apparent lengthening, and it is very important to demonstrate that these variations in length are apparent and not actual. This is to be done by placing the patient upon a hard surface with the pelvis at right angles to the spine and the limbs in absolutely symmetrical position. If there be adduction it may mean that the limbs should be crossed; while if there is abduction the healthy limb should be abducted to the same degree as the one affected. Careful measurement will show that the differences are apparent rather than real. The same care is needed in regard to rotation, and

## particularly in regard to psoas contraction which leads to flexion.

One of the most characteristic evidences of hip-joint disease is flexion of the thigh, which, when the thigh is brought down to the proper level, will cause an arching upward of the lumbosacral region. By this time also will be found well-marked limitations of motion in every direction. All of these features should be ascertained without an anesthetic, as they depend upon muscle spasm, which anesthesia would subdue. It is somewhat difficult with intractable young children to make a thorough examination of this kind, but a second or third effort will usually succeed when the first has failed.

Peri-articular symptoms affording corroboration are found in thickening of the tissues about the joint, especially enlargement of the upper end of the femur, or increase in thickness of the pelvis, which may perhaps be felt from the outside or be detected by rectal examination. There is usually involvement of the inguinal lymph nodes, and there is frequently prominence of the superficial veins, due to infiltration of the deeper tissues and obstruction to the return circulation. A good skiagram will also render much aid.

As the disease progresses there will appear evidences of deep suppuration, as abscess is frequent in the advanced stages. This may be peri-articular or may connect with the joint. It may cause separation of the epiphyses of the femoral neck and complete loosening of the head of the femur, which will then become a foreign body in a joint cavity probably filled with pus. Perforation of the acetabulum may also occur. Much of this abscess formation goes on insidiously and without marked increase of symptoms. There is no fixed date when pus may begin to form. It may occur relatively early or late. It is possible for small amounts of pus to absorb in whole or in part, or to leave a residue more or less encapsulated, which will frequently lead later to a secondary abscess, the latter tending to burrow along between the fascial planes or muscle sheaths and appear at some distance from its origin. Pelvic abscesses result from perforation of the acetabulum and may break internally or externally. Nearly all of these collections are of the cold type, and after a long time, if they have opened, may cease to discharge characteristic pus or even pyoid, and simply give vent to a watery seropus. Pus left to itself usually escapes anteriorly to the tensor vaginæ femoris, but it may travel in any direction.

The _deformities_ and possibilities which may result from the advanced stage of hip disease are striking. Persistent muscle spasm leads to more and more flexure of the thigh, with abduction or adduction, as the case may be, while later the leg is drawn up so that the knee may almost touch the abdomen. As the bony portions of the joint change their shape there occur actual shortening and final dislocation, while all the adjoining parts show the effect of muscle atrophy and perverted nutrition. In addition to this the region of the hip may be riddled with abscesses or with sinuses, and the condition in every respect made extremely distressing.

While the disease is generally confined to one side, it may occur in both hip-joints, in which it, however, very rarely begins simultaneously. Existence of double joint disease of this character makes the case more than usually troublesome and complicates it seriously in every respect. The writer has been compelled to make double simultaneous resection of both hips.

=Diagnosis.=--This has usually to be made from congenital dislocation, hysterical joint, infantile paralysis, non-tuberculous disease--such as synovitis, bursitis, etc.--acute osteomyelitis of the upper end of the femur, Pott’s disease in the lumbar region, and sacro-iliac disease, as well as from perinephritic abscess and appendicitis.

=Prognosis.=--Hip-joint disease usually tends toward recovery, but generally with more or less deformity. When the circumstances are not favorable, ankylosis, with or without deformity, is inevitable, while abscesses, with persistent fistulæ, are not uncommon, and one may in extreme cases witness death from general tuberculous dissemination or from the consequences of hectic, with amyloid degeneration, or from acute septic infection.

One may naturally ask what may be considered as constituting recovery. In cases of this kind an absolute cessation of all symptoms and indications of the disease, with a minimum of deformity and of limitation of motion, are the nearest approach to ideal recovery that can be expected to secure. In favorable cases, seen early and properly treated for a sufficient time, there may be achieved almost a restitution _ad integram_, but such an ideal is seldom attained; otherwise there is nearly always more or less limitation of motion, with very frequent pseudo-ankylosis or actual ankylosis. Even this is favorable and most anything may be considered so which falls short of actual suppuration.

=Treatment.=--The essential in the early treatment of hip disease is _traction_, so applied and regulated as to be effective. It should not be thought that by such traction as can be tolerated joint surfaces are actually pulled apart. What it really accomplishes is to tire out muscles which are in a condition of clonic spasm, overcoming thereby the deformity which they produce and thus permitting a reduction of their activity and of the harm which they have done. To do even this requires a considerable degree of traction, especially when muscle spasm is very prominent. Therefore it is best in pronounced cases of deformity to place patients in bed, and to apply traction by weight and pulley to a degree which actually overcomes the defects which we are combating. This will often require more weight than many men are in the habit of using. It should now be a question, not of amount of weight, but of effect, and of the easiest and best way of bringing this about. Physicians are very likely to use too small an amount of weight, and to neglect the use of counterextension and the benefit of more or less lateral traction, as well as that in direct line of the limb. Moreover, they often use inadequate means of applying traction, resorting to it only in such manner that traction is made at the knee and not at the hip. Even in young children it is often necessary to use twenty pounds, with a suitable traction apparatus, and four or five pounds for effective lateral traction.

_Traction should be maintained_ until deformity has been overcome or the effort shown to be impracticable. After its complete benefit has been obtained it should be followed by fixation, the ideal method being that which accomplishes both fixation and traction at the same time; as, for instance, by the so-called Thomas splint, which permits the patient to be up and about with the use of crutches and a high shoe beneath the well limb, in order that the diseased limb may not be permitted to touch the floor, but rather to hang, and by its own weight afford a certain degree of traction. The Thomas splint is the simplest and cheapest for hospital work, while modifications in more elegant and expensive form are illustrated in works on orthopedic surgery. In cases which seem to demand it fixation can be effected by a plaster-of-Paris spica put on while the patient is standing upon the well limb and upon an elevation. The character of this work affords space neither for more elaborate description nor illustration than the hints embraced in the foregoing paragraphs.

The surgeon as such is perhaps the more concerned in the _treatment of abscesses_ which frequently complicate these cases. Much that has been already said about psoas abscess will apply here. It is a question requiring considerable discrimination as to just how to treat a small, cold abscess about a diseased hip. Much will depend upon the environment of the patient, _i. e._, upon the attention and expert care which he may receive. Such abscess should be treated kindly, _i. e._, by nothing more severe than aspiration, until ready for more radical treatment. By the latter term is meant readiness for following it down to the joint cavity and exsecting the head of the bone, if need be, following this with extirpation of the capsule, etc. When there is actual pyarthrosis the condition of the patient is sufficiently serious to warrant radical measures. Extra-articular abscesses are apparently quite common, yet most of these, if carefully traced, will be found to lead through the periosteum at some point into the osseous structure beneath. Such abscesses are, moreover, multilocular, and have ramifications in even unsuspected directions which should be followed with the sharp spoon and the caustic, in order that absorbents may be seared and that no infectious material remain. Old and persistent fistulas should also be treated kindly until one is ready to be radical. Some long-standing cases will heal after absolute physiological rest of the joint, _i. e._, by fixation in plaster-of-Paris splint, with openings opposite the fistulas for dressing purposes. The general constitutional condition of patients with these lesions is a predominating factor in their improvement--a fact which should never be forgotten.

The deformity which has resulted from old, long-standing, and quiescent hip disease affords opportunity for the best of surgical judgment. It is possible to effect great improvement in position by subcutaneous osteotomy after ankylosis, but this should not be attempted during the

## active stages of the disease.

_The question of excision of the hip-joint is one of importance._ In few other instances do social surroundings or factors enter so largely into the question of surgical judgment. The wealthy can afford long-continued treatment, which to the poor is prohibited, and one may be tempted in one case to exsect early when, under other conditions, he would treat the case tentatively. Nevertheless certain indications make the operation expedient in all cases, as, for instance, when the destructive process is steadily progressing or so acute as to shorten not only the limb but life itself. It is necessary also when there is necrosis, and in most instances of suppuration extending into the joint cavity. In those cases where skiagrams confirm other indications to the effect that the disease is localized in the neck or head of the femur, Huntington’s suggestion may be adopted, after exposing the upper end of the femur, to drill or tunnel in the direction of the neck until its diseased focus is reached and thoroughly clean it out. In cases treated otherwise conservatively, yet accompanied by a great deal of pain, especially those of the femoral side of the joint, one may frequently get relief by exposing the upper end of the femur and making ignipuncture in the same direction as above.

_In general it is impossible to lay down succinct rules for the treatment of hip disease._ Cases differ so greatly in location, in severity, as well as in environment and their personal surroundings, that what is advisable in one case is not to be thought of in another. Of the mechanical features of treatment one may say that that is the best splint or apparatus which best meets the indication in each

## particular case, and that none will be effective in which the element

of traction is neglected, nor that of physiological rest. No patient should be released from treatment whose hip is still sensitive or in whom there remains any muscle spasm. Rest and protection should be maintained for months and even years after apparent recovery, while the same attention should be given to diet and climatic surroundings as in any other case of well-marked tuberculous disease.

TUBERCULOUS DISEASE OF THE KNEE-JOINT; TUMOR ALBUS.

This subject deserves special consideration, mainly because of the peculiar deformity produced by the disease rather than any of distinctive peculiarity in its nature. Years ago it received the name of _tumor albus_, and is frequently called _white swelling_ by the laity, because of the pallor of the surface and the increased dimensions of the limb due to thickening, always of soft parts, and usually of the bone itself. The disease may begin in either epiphysis, in the patella, or in the synovial membrane, oftener in the bone in the young and in the synovia in adult cases. Its most distinctive feature is the deformity produced by excess of muscle spasm, the hamstring muscles especially producing a backward subluxation which frequently fixes the knee, not only at a right angle, but with very much disturbed joint relations, so that the head of the tibia is in contact with the posterior surface of the condyle rather than with their proper terminal areas. The soft tissues outside of the bone are frequently very much thickened and infiltrated, often edematous, while the joint cavity may be more or less distended with seropus or with old pyoid material. The exterior surface is so anemic from deficient blood supply as to make it appear comparatively white, while the superficial veins are made much more prominent by their engorgement owing to obstruction of the deep circulation. The picture, then, of an advanced case of tumor albus is quite typical.

Here the joint cavity is so large that there is early effusion of fluid, in most cases, which is in this location easily recognizable; hence the distinctive symptoms consist of pain, tenderness, swelling, limp muscle spasm, with, finally, limitation of motion, deformity, and atrophy. In addition to these features there may be added those due to the formation and the escape of pus, _i. e._, one may have the signs of acute or old suppuration, while the parts about the joint may be riddled with old sinuses. The deformity of these cases is usually characterized by a certain amount of external rotation of the leg, while a species of knock-knee is not uncommon. Actual lengthening of the limb due to overactivity at the epiphyseal junctions may also be noted.

=Treatment.=--_The treatment of white swelling_ is based upon the principles already laid down for the treatment of spinal and hip caries, the underlying feature being traction to a degree sufficient to overcome muscle spasm, unless it be too late to permit a subsidence of

## active changes. When seen early a few weeks of confinement in bed, with

effective traction, followed by fixation with plaster-of-Paris bandage, combined with the Thomas splint (see above) or with some other form of more elaborate apparatus, by which rest and traction can be continually maintained, will be needed. The presence of tuberculous disease about the knee permits of the application of the elastic bandage above the knee, by which the congestion treatment of Bier can be more or less effectually carried out. It would, however, be a mistake to rely entirely upon this to the neglect of traction and rest, nor should too much be expected of it in severe cases. It is a method to be used early rather than late.

_The final resort is excision_, which is practically adapted to cases of moderate type in young adults, where the bones have attained their full growth and where it will afford a prospect of cure in a minimum of time. It is undesirable in children because it is so often necessary to remove the epiphyses, and because of the arrest of development that follows such removal and the consequent shortening of the limb. Nevertheless even in children it may be demanded and may be considered as a resort superior to amputation, the latter being reserved usually for a life-saving measure or for desperate cases where destruction has been practically complete and the limb is hopelessly useless.

Of the other large joints, all of which may be involved in tuberculous processes similar to those just discussed, it may be said that they come under the general rules of treatment already laid down.

NON-CARIOUS DEFORMITIES.

TORTICOLLIS; WRYNECK.

This term includes a peculiar postural deformity by which the head is rotated and inclined abnormally to one side in a more or less fixed position. As to the causes of the deformity two will be considered:

Congenital causes include:

1. Injury to the sternomastoid muscle at birth, which is perhaps the commonest.

2. Abnormal intra-uterine position and pressure.

3. Arrest of muscular development.

4. Intra-uterine myositis, the muscles being sometimes found actually altered in structure.

5. Defective development of the upper vertebrae or such distorted growth as is often met along with other deformities, _e. g._, club-foot.

The acquired causes include:

1. Traumatisms, either direct, as by injury to the muscles, such as may happen from gunshot wounds, etc., or follow operations by which the spinal accessory has been injured, or by burns, and other lesions which cause much cicatricial contraction.

2. Reflex activity in connection with disease of the lymph nodes, deep cervical abscesses, parotid phlegmons or tumors, etc. Whitman states that tuberculous disease of the cervical nodes caused the condition in 50 per cent. of over 100 cases analyzed by him.

3. Reflexes from the eyes, as Bradford and Lovett have described from the orthopedist’s standpoint, and Gould from that of the oculist, refractive errors causing the head to be held in unnatural positions in order to improve vision.

4. Compensation in high degrees of rotary lateral curvature, the effort being to keep the head facing to the front.

5. Myositis, usually rheumatic, but sometimes a sequel of the infectious fevers, or even of gonorrhea.

6. Habitual deformity, the result of occupation or sheer bad habit.

7. Tonic or intermittent spasm leading to spastic contractures whose causes are difficult to seek, but appear to inhere in the central nervous system.

8. Paralyses of certain muscles, permitting lack of opposition and consequent deformity.

=Pathology.=--According to circumstances significant pathological changes may be found in the affected muscles. These are usually the sternomastoid and the trapezius, although in long-standing or complicated cases the deeper muscles of the neck may also participate. A long contracted muscle may change almost into mere fibrous tissue.

The secondary effects of contraction of the sternomastoid and the trapezius are really far-reaching and noteworthy. The jaw may be drawn down and to one side, so that teeth do not appose each other as they should, or perhaps even do not meet. Compensatory curvatures occur also in the spine and there is well-marked change in gait and in most of the body habits. In the young and rapidly growing cranial and facial asymmetry also become pronounced. The later results and deformities of torticollis are not to be mistaken for congenital elevation of the scapula, sometimes known as “_Sprengel’s deformity_,” which consists not merely in elevation, but in rotation of the shoulder-blade so that its lower angle is too near the spine. There may be some limitation of motion of the scapula and of the arm. Sprengel accounted for this abnormality by maintenance of the intra-uterine position of the arm behind the back. The acute forms of torticollis occur nearly always in acute phlegmons of one side of the neck, and should subside with the other and causative lesions. Nevertheless from such spasm may develop a chronic form which may persist.

The position of the head varies with the muscles particularly involved and the associated spasm. The sternomastoid muscle alone will draw the mastoid down toward the sternum, with rotation of the face to the other side. When the trapezius is involved the head is drawn backward and the chin raised. The more the platysma, scaleni, splenii, and deep rotators are involved the more complex becomes the condition, to such an extent even that in serious cases it is almost impossible to decide which muscles really are at fault. When the superficial muscles are involved they can usually be distinctly felt to be firm and contracted, while the sternomastoid will stand out like a cord. Pain is a rare complaint, but a feeling of tenderness or soreness is not unusual.

The spasmodic or intermittent form is less common, but more difficult to account for and even to treat. It seems to be due to choreiform spasm of those muscles which produce it, and here the condition is reflex, the causes lying deeply in the nervous system. In some instances, however, they are of ocular origin and can be relieved by correcting refractive errors. Intermittent spasm is usually absent during sleep and quiescent in the recumbent position; it is usually confined to one side.

=Diagnosis.=--In the matter of diagnosis it is necessary mainly to eliminate only spinal caries, while as between involvement of the anterior and posterior groups of muscles the determination is made by palpation and inspection.

=Treatment.=--There are few morbid conditions whose cause it is more necessary to discover. Could this be done operative treatment would be less often demanded. Treatment should depend, therefore, on the exciting cause and the possibility of its removal. The spasmodic or intermittent form may spontaneously subside. Cases of essentially ocular origin need the services of the oculist, and other acute cases usually subside with the successful treatment or the subsidence of their causes. On the other hand, chronic cases usually need either mechanical or operative treatment.

The most common operation for relief of torticollis is simple _tenotomy of the sternomastoid_, taking care to divide the sheath and everything which resists, and, at the same time, to avoid the external jugular vein as well as the deeper structures. Mere tenotomy of one or both of its lower tendons is an exceedingly simple measure, but in serious cases an open division will permit of more thorough work. Here an incision made one inch above the clavicle and parallel to it will permit division of everything which resists and also any recognition of that which should be spared. In any event the position of the head should be immediately rectified, and kept so either by plaster or starch bandage, or by a traction apparatus applied to the head, the body being in the recumbent position, while later some efficient and well-fitting brace should be worn for some time. The posterior cases, _i. e._, those where the posterior muscles are involved, afford greater operative difficulty, muscles involved lying too deeply and being in too close relation with important vessels and nerves to justify the ordinary wide-open division. Nevertheless in extreme cases there need be no hesitation in extirpating completely those muscles which are primarily and mainly at fault. The writer has removed the sternomastoid and the trapezius, with sections of the still deeper muscles, and has seen nothing but benefit follow the procedure. It should be resorted to when repeated anesthesia with forcible stretching and a suitable brace fail to give relief. These forms of wryneck which are due to contraction of muscles infiltrated from the presence of neighboring phlegmons, etc., will usually subside with massage and semiforcible stretching under an anesthetic. They need conservative rather than operative treatment. Attack upon the spinal accessory and the deep cervical nerves will be described in the chapter on Surgery of the Nerves. It, however, will rarely be justified, since the primary causes inhere not so much in those nerve trunks as in the nerve centres. Such operations are usually of questionable benefit, and cases should be carefully watched before being submitted to them.

ROTARY LATERAL SPINAL CURVATURE; SCOLIOSIS.

Under these terms are included certain deviations from normal relationships of the vertebræ, both in their superposition in the median line and in their rotation on each other, by which are produced lateral curvatures, with more or less rotary displacement. Of these deformities there is a rare congenital form which is due to fetal, or rather intra-uterine, rickets, but practically all rotary lateral curvatures are acquired. One-half of such cases begin before the twelfth year of life. It may also come on during adult life, as the result of bad postural habits, exclusive use of the right hand, etc. Altogether it occurs in about 1 per cent. of females and in a smaller percentage of males. Scoliosis being not a disease but rather a process of irregular growth, cannot be said to have a symptomatology. It is known rather by signs. Only in the advanced stage can it produce symptoms. It is rarely seen in its incipiency by either the surgeon or the physician. Not until parents have noticed distortions of the spine are these children usually taken to their medical advisers. Exception, however, should be made to this in respect to certain gymnasia and athletic training schools, where trainers are quick to notice irregularities of this kind. The abnormal curves thus produced are at first flexible, but later become fixed. In rapidly growing girls who take but little exercise there may be some muscle weakness, which may cause fatigue or even actual soreness. Pain is rarely present. The rate and extent of deformity are not subject to any rule. Spontaneous cessation ensues in practically every case, _i. e._, a stage of convalescence and arrest, at a time when the deformity may be but slight, or perhaps hideous.

The nervous phenomena attending lateral curvature, like the discomforts attaching to it, are mainly due to the increasing strains and stresses that are imposed on certain structures as the deformity occurs and increases. Of these, muscles and ligaments suffer most, especially those uniting the thorax and spine. Pressure effects on nerves and tissues may be produced by distorted ribs and vertebræ or by final displacement of viscera. The conditions which lead up to spinal curvature are attended often by neurasthenic and neurotic features, both mental and physical. As deformity increases impairment of function of thoracic as well as of the upper abdominal viscera will occur, and such patients are usually thin and anemic, rather than fat.

_To mere lateral distortion is added, in every pronounced case, more or less rotation of the entire trunk._ The curvature consists of one primary curve, with one or two secondary curvatures, according to the location of the first. If the primary curve be located in the mid-dorsal region there will occur compensatory curvature above and below in order that the head may still be kept in the line of the centre of gravity above the pelvis. Such secondary alterations are of much less import than the primary. The most common of the mid-dorsal curvatures, which occurs in nearly four-fifths of the cases, has its convexity to the right. While the right shoulder seems higher its scapula will be more pronounced and carried backward, the back and the chest below it will be more rounded, and in front the breast on the opposite side more prominent. The whole trunk in marked cases becomes so warped that the arm on one side will hang free while the other touches the pelvis; thus the back loses its symmetry either in the erect or stooping position. In the lumbar region there is compensatory curvature to the opposite side, which makes one hip and flank more prominent. By virtue of the rotation of such a warped spinal column there result certain anterolateral curvatures that may later become pronounced. While such changes are going on in the upper part of the trunk there is sufficient rotation of the lumbar segment to lead to tilting of the pelvis, with consequent limp, or a peculiarity of gait.

The degree of torsion of the spinal column is the best index of the real severity of a given case, and to it are due the most disfiguring features of the deformity. Torsion may even precede curvature, causing a prominence of one shoulder or hip as the first visible evidence of its existence.

Those forms of lateral curvature due to _rickets_ occur most often in the dorsal region, and as frequently in boys as in girls. In most of these cases the constitutional condition will be indicated by other significant features. Another form much less frequent, yet well known, is the result of inequality of the length in the limbs, so that patients stand ordinarily with tilted pelves; hence, the limbs should be carefully measured in every instance. A truly _paralytic form of scoliosis_ is also known, which is of the infantile type and due to some form of infantile palsy. Again, scoliosis is produced by _shrinkage of tissues_ and contraction of old exudates occurring within the thorax and following chronic disease, as when the ribs on one side are drawn down after an old pleurisy or empyema. _Extrinsic causes_ of lateral curvature are met with among several occupations when one side of the body is used more than the other, or when the individual habitually stands in an unsymmetrical position. In addition to this, the habitual right-hand habit, which seems instinctive, and which the majority of people exhibit, leads to excessive use of the right side of the body, with overdevelopment and consequent warping of the upper part of the skeleton. The young should be taught the use of the left hand as well as the right, _i. e._, to become ambidextrous.

The foreign surgeons have given the term _ischias scoliotica_ to a form of lateral curvature involving rather the lower part of the spine and occurring usually in adults or elderly people, which is accompanied by more or less acute pain, usually assuming the type of sciatica. Its etiology is obscure, as is implied by the synonym scoliosis neuropathica. It is not a frequent malady, but usually chronic and refractory. It is best dealt with by fixation or immobilization.

=Etiology.=--Predisposing causes of scoliosis may be both constitutional and inherited. They include general debility, rickets--with its accompanying osseous instability and liability to abnormal curvature--the consequences of various diseases of childhood, and anything which greatly lowers vitality. The actual causes include congenital or acquired defects, such as differences in the lengths of the limbs or other skeletal asymmetries; acquired abnormal position of the head due to defective vision, with its natural sequences; results of intrathoracic disease, such as empyema; faulty attitudes and bad developmental habits, such as those assumed often in school and elsewhere in sitting at a desk or standing in bad position, or at work in various ways. To these should be added the right-hand habit already mentioned. These may all be summed up as among the causes of asymmetrical growth and deformity, occurring as the result of ignorance or inattention, and allowed to go on indefinitely or until it is too late to correct the malposition. Theories of paralysis of individual muscles or certain muscle groups have been advanced, as well as of contractures, but usually these are effects which have been mistaken for causes. The bones have been blamed, but their changes are secondary results of pressure, save perhaps in some cases of rickets. The structures of the thorax have relatively considerable superimposed weight to carry, and both lateral halves of the thorax should be developed symmetrically in order to distribute this weight evenly. Nothing so influences skeletal development as exercise; thus even to assume and maintain the normal erect attitude requires a certain amount of muscular effort, and if each side be not given an equal task one will develop at the expense of the other, and thus lateral curvature is sure to result.

It is important to impress this on parents, teachers, nurses, dressmakers, and all who have a part in the care of the young, in order that they may realize the importance of ensuring symmetrical growth and of preventing the right-hand habit. It is to be expected that after deformity has occurred there may result a series of perversions of function in nerves, as well as in viscera; thus, respiration and circulation may be interfered with, the liver may be compressed, while, of course, autopsy will show all sorts of distortion of bone, among other pathological changes.

=Prognosis.=--Too often the condition is regarded as so trivial that it is likely to be outgrown, or else is quite disregarded, or, on the other hand, occasionally it is regarded as one of gravely serious import and maltreated or overtreated on this account. In the majority of instances scoliosis is a self-limited condition, whose limit may be reached at variable stages of deformity in different individuals. In slight cases any serious illness may cause such muscular weakness as to permit of serious increase of distortion. Therefore, the patient’s general condition is to be taken into account just as much as the shape of the back.

=Treatment.=--If one may be permitted a Hibernicism, the proper treatment for scoliosis is _prevention_. This may be made to include the earliest possible recognition of trifling deviations from the normal. It should be made to include, in general, supervision of school desks and the way in which children work at them, as well as of children’s games and exercises, in which it should be made a point that they be taught to make as much use of one hand as of the other. It should include also supervision of children’s methods of seating themselves at the piano or at the sewing table, as well as the posture which they assume during sleep, while they should be taught to stand and walk properly and to avoid a too early use of corsets. _Active treatment should consist, first, of correction of bad postural and other habits by methods as vigorous as are military drill and discipline._ Patients tire easily after such exercise, and sufficient rest should be taken, the patient lying symmetrically upon the back. There is usually opportunity with young children for great ingenuity in devising suitable exercises without making them too irksome. They should be taught to play games at least as much with the left hand as with the right. Gymnastic exercises, especially those with dumb-bells, will be found effective, and it is advisable to have a heavier dumb-bell in the left hand than in the right. The more severe cases should be handled with great care in order not to overdo that which should be done. Each case should be studied by itself, which means that such cases should not be taught in classes. Roth calls that “the key-note position” which is closest to the normal that the individual can voluntarily and comfortably assume. From this as a basis the surgeon should work up. Perhaps as much can be done without apparatus as with it, particularly if will power is concentrated on the effort. This is harder with the young, but pride may sometimes be appealed to as a substitute for volition. As strength is gained more strenuous gymnastics may be prescribed, including suspension from rings or the simple horizontal bar, while much heavier dumb-bells may be used, as taught by Teschner.

_Mechanical corrective treatment_ is directed mainly to stretching shortened ligaments and contracted muscles. For this purpose many forms of apparatus have been devised. Their principal benefit lies in increasing backward flexibility at the point where curvature is most pronounced. As a substitute for such apparatus, and in private houses, padded stretchers or lounges may be supplied on which patients may lie either quietly or during massage. Finally the matter of corrective corsets and braces remains to be considered. External support takes away from the muscles and ligaments their functions and work. Nevertheless in some cases this is necessary. No appliance of this kind that may be supplied should be continuously worn. It should be removed for work and exercise, as well as for toilet purposes. Recumbency in bed is much better than too vigorous bracing. Only in old, neglected, or peculiar cases should it be considered necessary to resort to much external aid.

CURVATURES FROM OTHER SOURCES.

The relaxation and debility of old age permit of such deformities as rounded and stooped shoulders, certain degrees of kyphosis, and sometimes even pronounced stooping and deformity, whose merely senile causes are more or less combined with rheumatoid arthritis of the vertebral and costovertebral joints. These features are accompanied by more or less pain or difficulty in locomotion. Many instances of ischias scoliotica, referred to in the preceding section, would find a place among these clinical pictures. Postmortem there are found exostoses, synostoses, or ankyloses sufficient to account for the deformity. Rickets also causes skeletal deformities, in which nearly all the bones may participate, the spine rarely totally escaping. In such cases various typical and atypical deformities may be met.

Paralytics may show various curvatures, as do also subjects of pseudomuscular hypertrophy and syringomyelia. Lordosis is seen in pregnancy and in congenital hip dislocation, where it is purely compensatory in each instance and does not outlast its real cause. In fact it may be encountered as a compensatory feature of any other kind of spinal curvature.

A still more marked condition of chronic ostitic changes is seen in _spondylitis deformans_, which differs little from arthritis deformans of other joints, save that in these cases it usually spares the joints of the extremities. It has been known as a rare sequel of gonorrhea, even in the young. Osteophytic outgrowths occur frequently and fuse together, causing ankyloses and sometimes great deformity, even to the extent of making the spine assume a right angle with the extended limbs. Considerable pain is frequently experienced during the course of these very slow changes. The entire spine becomes more or less rigid, consequently there is little or no angular prominence, while the ribs become immobilized as well. For this condition there is little or no treatment of any avail. Sometimes paralysis supervenes and the condition is not infrequently fatal.

_Acute osteomyelitis_ of the vertebræ is occasionally noted. It occurs nearly always in young and growing children, and is most common in the lumbar spine. It is essentially the same here as occurring in the long bones or their joint ends, and has been described in the previous chapter. Its symptoms may be severe, and it is not infrequently followed by abscess. When such abscesses point posteriorly they may be recognized and incised. When, however, pus takes the anterior path it will probably escape detection, at least until too late. The prognosis is often unfavorable.

TYPHOID SPINE.

This name was proposed by Gibney for what seems to be an infectious periostitis involving the vertebral column, of a character similar to that which has been described in a previous chapter. It is characterized by excessive pain, tenderness, and later stiffness. It may occur during or after mild as well as severe cases of typhoid.

TRAUMATIC SPONDYLITIS.

Kümmel has shown that a traumatic and non-tuberculous ostitis of the vertebræ occurs, with succeeding kyphosis resembling that of Pott’s disease, but not so angular, usually without associated abscesses, but with occasional paralyses. This may occur without necessary reference to that curvature which may follow a healed or healing spinal curvature. Inasmuch as the condition occurs only after the lapse of considerable time after injury, it is questionable whether it represents any distinct form of disease.

CANCER OF THE SPINE.

Malignant disease of the spine may assume a type either of sarcoma when primary or carcinoma when secondary. The latter type is much the more common, and is not so infrequent as an expression of metastasis from cancer in various other parts of the body, even the more distant. It is most common in the lower spinal region. Pain occurs early and is usually severe. It is as often referred as localized. It may lead to curvature of the spine with some of the grosser signs of spinal caries, but the prominence, if any occurs, will be rounded rather than angular. When paralyses occur they usually assume that type described by Charcot as paraplegia dolorosa. (See Plate XXXVIII.)

When symptoms of a general type like those produced by spinal caries occur in adults who are known to have had previous or present malignant disease the inference will be that they are to be interpreted as local expressions of the same character. Under these circumstances treatment can only be palliative. There is no hope of cure.

SPONDYLOLISTHESIS.

The term spondylolisthesis implies a partial displacement forward of the body of the last lower or next to the last lower lumbar vertebra, usually the former, which slips forward on top of the sacrum with very little perceptible displacement of arches. The condition may be slight or well marked, and may or may not be followed by secondary changes. There appears to be a real fragmentation or separation of the body from the arch, which may be traumatic, congenital, pathological, or the sole result of pressure from above; later exostoses or osteophytes appear about the separation, thus forming a new fixation and preventing further displacement.

The condition is more common in females and in the young, and most cases give a traumatic history. In those which do, deformity may follow accident or it may be long postponed, perhaps until pregnancy.

=Symptoms.=--The lesion is recognized by certain alterations of gait, with a sharp lumbar lordosis and unduly prominent buttocks and iliac crests, so that these patients much resemble those having congenital hip dislocation, the pubes being higher and the sacrum lower than the normal, this diminution of pelvic obliquity being practically always pathognomonic. On vaginal or rectal examination undue prominence may be felt above the sacrum. Some of these cases complain of much pain, either local or referred, down the limb, the same being made worse by exercise.

[Illustration: PLATE XXXVIII

Sarcoma of the Spine and Cord. (Goldthwait.)]

=Diagnosis.=--Diagnosis should be made as between this condition, Pott’s disease, double congenital dislocation of the hip, and rickets.

=Treatment.=--The condition does not admit of extended treatment, save that a certain proportion of cases are benefited by such fixation as is afforded by a plaster jacket, which firmly encloses the pelvis and supports the lower part of the trunk upon it.

KNOCK-KNEE AND BOW-LEG.

The plane of the terminal articular surface of the lower end of the femur is not at right angles with the axis of its shaft; in other words, the inner condyle is placed a little lower or beyond the location of the outer. In this way sufficient angular arrangement of the leg upon the thigh is permitted so that, with the upper ends of the femora separated by the width of the pelvis, the knees and the ankles may, under normal circumstances, be made to touch when the limbs are fully extended. Thus a slight degree of angular deflection at the knee is normal. When this is exaggerated to a degree not permitting the ankles to touch when the knees are in contact the condition is known as _genu valgum_, or _knock-knee_. When, on the other hand, the angle is lessened or reversed so that the knees are more or less separated when the ankles are in contact the condition is then known as _genu varum_, or _bow-leg_. These two conditions constitute the typical and classical types of knock-knee and bow-leg. Other conditions, however, which lead to the same result occur through various and irregular curvatures or irregularities of the femur or the tibia, or both, and there thus may be produced atypical yet most pronounced instances of these same deformities. These deformities may be apparent almost from birth, may appear during early childhood, or not until adolescence. As a rule they are not manifested until young children are learning to walk. Whenever they appear before this time they are expressions of infantile rickets, which should be recognized as such and corrected by mere manipulation while the bones are still flexible, the correction being maintained, and by suitably feeding and medicating the patient. (See the general subject of Rickets.)

[Illustration: FIG. 261

Rachitic changes in limbs. (Lexer.)]

In fact rickets supplies the explanation for the great majority of these deformities; incomplete ossification and calcification of the bones accounting for the comparative ease with which they yield to pressure or other deforming influences. Rickety children always manifest a tendency to defective ossification at epiphyseal lines, and it is here that the change usually takes place. Nevertheless marked instances of curvature are seen in all the bones of the lower extremity. As deformity in any given direction becomes more pronounced the tendency to its exaggeration becomes greater. Finally these changes involve not only the bones proper but the ligaments and the other joint structures, which yield where pressure is abnormal and greatest, thus completely changing their shape and internal relations. Along with other changes in knock-knee there is a tendency to external rotation, perhaps even to spiral curvature of the tibia; the patella lies outside of its normal position, the tendons are more or less displaced, while, at the same time, there may be inflection of the feet as an effort at compensation (Fig. 261).

With the exception of spinal curvatures and torticollis there is perhaps no more conspicuous deformity than that produced by these abnormalities at the knee-joint. While at first gait is not seriously affected, it is in time, especially in cases of double knock-knee. When these knees are bent to a right angle the angular deformity disappears and all that remains is the rotation of the tibia. Hence it follows that all correction of these deformities, either slow or operative, should be applied to the fully extended leg. In advanced cases there is frequently a complication with flat-foot, which may or may not be painful. The condition is rarely produced by paralytic affections, and should be differentiated from mere atrophy of wasted and contracted legs. A form of knock-knee is occasionally seen in the adult, which is of traumatic origin and is due to improper care or neglect in the treatment of the injury.

=Treatment.=--_The treatment of this condition is either mechanical or operative._ Mechanical treatment varies between the gentlest expedients and the use of more or less extensive and cumbersome apparatus. When a young and growing child begins to show evidence of either of these deformities it is usually sufficient to supply shoes which are reasonably stiff, and raise one or other border of the sole and heel, according as we wish to influence the growth of the limb, _i. e._, in knock-knee the inner border of the foot is to be raised, in bow-leg the outer. The consequence of even slight influence thus constantly maintained when the child is upon its feet is usually sufficient to rectify slight degrees of these deformities. When, however, the case is pronounced more radical measures should be applied. Massage has been recommended along with manipulation, but should be gently performed. The different forms of apparatus in use afford various methods of making pressure against that condyle which is too prominent. It is possible to make them efficient, but only when they are both well planned and well made in the first place and intelligently applied and watched. The special forms of apparatus sold in the instrument stores are of little value. Too often it happens that when efficient they cannot be tolerated, and that when tolerated they are inefficient. Much speedier and more satisfactory results are achieved by operative methods, so that, in general, they may be regarded as the more desirable.

_Operative treatment_ consists in some modification either of osteoclasis or osteotomy.

_Osteoclasis_ has to do with the forcible stretching, bending, or even breaking of those parts which show the greatest effects of the deformity or are known to be its primary seat. In young children with tender and still somewhat flexible bones this may be accomplished by the hands alone, the patient being under an anesthetic. Manual power failing a simple instrument known as the _osteoclast_, which affords a means of applying powerful pressure by the agency of a screw at just the desired point, is used. Pressure is then applied and carried to the necessary degree, even with partial or complete fracture of the bone at fault. In this way is inflicted a simple fracture which permits of the immediate redressing of the limb, with such overcorrection of the deformity as seems desirable. The limb thus treated is completely encased in a suitable plaster-of-Paris splint, and should be held in the desired position until the plaster is completely hardened and not likely to yield. Osteoclasis, though it often appears an exceedingly barbarous procedure, is one of the most beneficent when properly managed, and is rarely followed by an undesirable result.

_Osteotomy_ is performed by the use of the chisel and mallet, the former being introduced through a small incision made in the skin, passed down to the bone with its cutting edge parallel to the bone axis until the bone itself is reached, after which it is turned at right angles to it and the mallet used until the chisel has been driven

## partly or completely through the shaft of the bone or the portion which

it is intended to attack. The chisel should be partly withdrawn and its position changed if it is necessary to continue its use. Thus by a

## partial division of the bones of the young it is possible usually to

so weaken them that, without undue force, and by manual power, they are fractured at the desired point. The operation should be done with the most complete aseptic protection. The procedure recommended by Macewen is now universally accepted. The incision is made at the inner side of the thigh just above the tubercle for the adductor magnus, and the osteotome (as the chisel especially made for this purpose is called) is passed through it, down to the bone, turned at right angles, and made to cut nearly through the shaft. Lest it become too firmly wedged it may be moved a little laterally after each blow of the hammer. The operation, if properly done, is practically bloodless; the small opening made for the chisel is sealed at the moment of its withdrawal, the deformity corrected with the least amount of handling or disturbance, and the plaster-of-Paris bandage immediately applied, with the leg in exactly the position which it is desired should be maintained. Such a dressing may be left for three or four weeks before being changed. One change is usually sufficient, and in from six to seven weeks the patient is allowed to slowly regain use of the member.

A special set of osteotomes, after Macewen’s pattern, is furnished by the instrument dealers for those who practise osteotomy. It consists of a set of three straight chisels, consecutively numbered, the first being a little thicker and the third the thinnest of the three, and thus made with the intent to use the thickest first in order that in the notch made by it the thinner instruments can be subsequently more easily manipulated.

BOW-LEGS.

_Bow-legs_ are nearly always of rachitic origin, occurring with less angular deformity, and as the result of the warping or bending of bones which are not sufficiently rigid to sustain the weight they are made to carry. Most cases of bow-legs have their origin within the very early years of childhood. Other cases are seen in infancy and before children have ever borne much weight upon their feet. The deformity must be accounted for by muscle tonus, mere muscle activity serving to place enough stress upon the bones to swerve them from their normal axes. The bones probably bend outward because the muscles on the inner side are the stronger. Children thus affected walk not so much with a limp as with a waddle, with the feet rather apart, and some inversion of the toes. Double and complicated curves occur in many of these cases, both femurs and tibias participating, and having an anterior as well as a lateral bowing. Such complications materially increase the difficulty of any treatment.

=Treatment.=--The _treatment_ of bow-leg is generally considered simpler than that of knock-knee. Occurring in _young_ and growing children it can be overcome, if taken early, by the expedient already mentioned, elevating the outer border of the sole of each shoe. The more mechanical and the purely operative methods of treatment are essentially the same as those just described for knock-knee, based on similar but reversed principles. In the very young manual force will often serve the purpose of a more formal osteoclasis, but the osteoclast may be used whenever it seems indicated. In those cases where the bowing is due to abrupt and almost angular deformity, _osteotomy is indicated_. This is made on exactly the same principles as mentioned above. In all instances spiral curvatures should be overcome so far as possible during the process of forcible correction and dressing in the plaster-of-Paris bandages ordinarily used. Here, as previously, all treatment should be addressed to the limbs in their fully extended position. If the rings of the ordinary osteoclast be sufficiently padded and protection afforded in this way, the skin rarely sloughs, and the damage, which is, at least, theoretically done to the tissues, is quickly repaired. Failure in union after any of these operations is exceedingly rare.

CLUB-FOOT; TALIPES.

In general the term talipes is applied to any malformations of the foot by which it is more or less misshaped and its function impaired. The commonest of these is that known and described below as talipes equinovarus. Of these various deformities there are four principal types, according as the foot is inverted, everted, hyperflexed, or hyperextended. More particularly they are:

1. Talipes equinovarus, the commonest type, the ordinary club-foot;

2. Talipes valgus, or flat-foot;

3. Talipes equinus;

4. Talipes calcaneus.

These forms may be variously blended, as well as seen in varying degrees from the slightest possible deviation to the most pronounced form. Statistics show that about one child in every five hundred is born with some form of club-foot.

Club-foot may be either of acquired or congenital origin. Acquired club-foot is essentially always of paralytic nature, following usually infantile paralysis or those injuries by which nerves have been divided or caught in callus or in tumors. As the result of such loss of nerve or muscle power, in certain muscle groups, malpositions of the feet are caused which simulate those of congenital origin.

1. =Congenital Club-foot; Talipes Equinovarus.=--This consists anatomically in an inward dislocation at the metatarsal joint of the anterior part of the foot, in consequence of which the relations of all of the other component parts of the foot are deranged; the scaphoid is swerved on to the inner and lower side of the astragalus to such an extent as to touch the internal malleolus; the cuneiforms follow the scaphoid and the metatarsals follow the cuneiforms; the cuboid is shifted to the inner side and does not articulate squarely with the calcis. In infants these bones are cartilaginous, but as the individuals grow and these miniature bones develop and ossify they take similar and abnormal shapes and positions. The calcis is drawn into a more vertical position than normal by drawing up the heel, and is even somewhat rotated on its own vertical axis; thus its anterior articulating surface is made to look obliquely inward. This displacement of bones causes dislocation of tendons, the anterior group being drawn mostly to the inner side. The patient walks more and more on the outside of the foot, and as he does this adventitious bursæ develop on the outer border, which become very thick and form in time large callosities. In the most pronounced cases there occurs, in connection with all this, curvature or spiral inward rotation of the tibia, and even of the femur of the affected limb, while the contracted muscles become overdeveloped and those which are disused underdeveloped (Fig. 262).

[Illustration: FIG. 262

Talipes equinovarus.]

Among the causes of club-foot heredity seems to play a considerable part, as it often happens that two or three club-footed children are born of one mother. The deformity has been ascribed to abnormal or exaggerated posture _in utero_, with compression. This theory is at least attractive and has the force of argument from antiquity, for Hippocrates thus believed. Unquestionably the normal intra-uterine position of the fetus includes a certain degree of equinovarus. Yet if this were the real cause the condition would occur apparently much more frequently. It has been ascribed also to disparity in strength between opposing groups of muscles, that group which causes the deformity being naturally the stronger, it being at the same time unimportant whether one group is relatively too strong or the other relatively too weak. Most monstrosities or seriously defective infants have also club-foot, from which some argue that the central nervous system has something to do with it; yet it has been shown in over 1200 cases of club-foot that only twice did such defect of the central nervous system as spina bifida occur. The embryologists and comparative anatomists regard it as an expression of arrested development, while evolutionists consider it an atavistic reversion to an earlier anthropoid arrangement. None of these theories really satisfactorily explains the deformity. Therefore we should hold that either there are different and variable causes or that we have not yet found the true one.

=Treatment of Congenital Club-foot.=--There being in these cases no tendency to spontaneous improvement, mechanical or operative treatment, or both, are required. If these be afforded early the prospects of restoration, practically to the normal, are good, but treatment should be begun early and conducted with great care and patience. It is not so difficult to correct the deformity, but correctional supports should be worn for a relatively long time, while the older the case the more difficult become all the features, both mechanical and durational. Parents are often eager at first, but later become inattentive or careless. The main objects are to be attained by correction of position by force or by division of contracted or shortened tissues, or retention in position, with the addition of any other features which may influence growth and development according to normal standards. Of these we will speak first of rectification: (_a_) bloodless, as by purely mechanical force, or by means of certain apparatus, and (_b_) operative, as by subcutaneous tenotomy, aponeurotomy, etc., or by open incision, through which are performed osteotomy, excision, astragalectomy, tarsectomy, etc., as the operator may see fit.

In all of these the anterior part of the foot is to be forced outward as well as raised, two distinct features, which should be combined but not confused.

In the young infant gentle force applied many times a day, with the persuasion of a strip of adhesive plaster, applied beneath the foot and over its outer border, and spirally upward to the inside of the leg, can be made effective in mild cases; but overstretching of the tendo Achillis is a necessary part of this maneuver every time it is practised. The more positive method consists of fixation of the foot in overcorrected position within a plaster or starch bandage, the same extending above the knee, which should be slightly flexed, the dressing to be renewed every two or three weeks, and correction increased until it has become overcorrection.

In well-marked and in resistive cases an anesthetic should be given, while by the use of sufficient force, which may be relatively great, but which should be gently applied, the resisting tissues are so stretched, if necessary to the point of something yielding, that but slight pressure is required to hold the foot in an overcorrected position. When the knife is required the tendo Achillis should always, and the plantar tendons and fasciæ usually, be subcutaneously divided, under aseptic precautions. The foot is then enveloped in suitable dressings and put up in overcorrected position for two or three days, in a rigid dressing at first of starch, but after this in plaster of Paris; this is the writer’s plan of procedure. The insertion of the point of the tenotome sufficiently deep to divide all resistive ligaments and tissues (_e. g._, the astragaloscaphoid or the calcaneocuboid) nowise complicates this method, but makes it more efficient.

Cases which are resistant are best submitted at once to _open operation_ (that is, after vigorous stretching of the contracted tissues), always under strict asepsis. After decades of milder ineffectual methods it remained for A. M. Phelps, of New York, to show the benefits of this method by which all contracted tissues on the concave aspect of the foot are exposed and divided. Incision is made here from the top of the inner malleolus to the inside of the first tarsometatarsal joint. With a little care the artery can be avoided, but I have never seen any harm come from its division. Everything which proves resistant is divided, even the inner osseous ligaments. Sometimes the incisions can be made in wedge-shape, or obliquely, so that the wound does not remain so widely open. No attempt is made to close this wound. The operation may be done bloodlessly, under the Martin rubber bandage, but whether this be used or not any vessel which can be recognized as such should be tied; otherwise the wound is snugly packed with gauze (upon which I like to use Peru balsam). An ample surgical dressing is applied over it. This is covered with gutta-percha tissue, to prevent too free access of air to the blood which will ooze into the dressing, and the whole is then covered with a starch bandage, in overcorrected position; this is left, according to circumstances, for from three days to a week--the longer the better. Then everything is removed, fresh gauze placed in the wound, which will be found already largely filled up; fresh dressings are applied, and the foot put up in plaster of Paris, with or without a fenestrum or any provision by which the region of the wound may be easily uncovered for necessary renewal of dressing.

It is in the most pronounced types of cases only, with marked bone deformity, or those in which previous operations have failed, that the still more radical division or removal of some part of the tarsus is necessary. As to this no universal rule can be applied save this: take out sufficient to correct deformity. In some cases it will be sufficient to excise the astragalus (_astragalectomy_). In other cases it is better to remove a wedge-shaped piece of the tarsus, without reference to the name of the bones attacked (_tarsectomy_). I have never found it necessary to touch the external malleolus, though this has been suggested, nor to do osteotomy of the calcis or of the leg bones above the ankle, as a few have done.

[Illustration: FIG. 263

Park’s club foot brace.]

These operations are usually practised, _after a preliminary stretching_, through a curved incision on the outer aspect of the foot, through which, at the same time, the thickened bursæ may be removed, or the callosities included in the incision. The chief convexity of the incision should be over the os calcis at its anterior portion. As the dissection is made the tendons are drawn aside and spared. If it be necessary to divide one or more of them it should be re-united later. According to the density of the structures a strong knife may be used, and strong scissors, or an osteotome manipulated either by hand or with the hammer. After sufficient V-shaped or wedge-shaped bone has been removed the defect should be held together, if practicable, by buried tendon sutures or wire; it is rarely necessary to use drainage. The external wound may be loosely closed with buried sutures, a suitable dressing applied, and the foot put up in a rigid splint; this should permit of removal, or at least inspection of the wound after a few days, for renewal of those dressings which are saturated with blood and for application of new dressings. After this the foot and leg should be put up in overcorrected position in plaster of Paris.

In aggravated cases of club-foot Wilson believes combined operation to give better functional results than can be obtained by any other method. The astragaloscaphoid joint is exposed by an incision over the prominence of the scaphoid, and, being cleared, is opened with chisel or bone forceps, while sufficient of the articular surfaces is removed to destroy them as such and to take out a sufficiently large wedge-shaped piece from either bone so that the desired arch of the foot is restored, or even exaggerated. Then the tendon of the extensor proprius hallucis is exposed and divided just above the great toe, the upper end of the tendon being drawn out through the first incision. To this end is attached a strong silk ligature. The scaphoid is then perforated with a bone drill at some distance from its superficial aspect and at such an angle, with the foot in correct position, that the canal thus made shall be in line with the action of the tendon. The drill is then withdrawn and the tendon passed through the opening by means of its attached silk. One inch beyond the bony canal the tendon is cut off and split in halves, each half being turned in opposite direction and fastened to the periosteum of the scaphoid with fine silk, while the foot is held in overcorrected position, so that the tendon is sewed in its new place under moderate tension. The foot is then dressed in this overcorrected position in plaster of Paris, the splint extending nearly to the knee, and the wound area being exposed by a fenestrum cut in the splint before it is hard.

The location of the incision over the dorsum or outer aspect of the foot may be varied to suit the needs of the case and the method of the attack. In a general way a flap of soft tissues is raised and tendons, so far as possible, are held outward. This is usually practicable, and it is rarely necessary to divide the latter. After operation of any type and recovery from the same it will be necessary for a long time to have the patient wear a corrective appliance. This should be applied as early as possible, and should be worn continuously, _i. e._, night and day; inasmuch as growth is continuous there should also be continued correctional influences. Many types of apparatus have been devised. That which the writer has found effective and has adopted for a number of years is illustrated in Fig. 263. It may be made single or double, as occasion requires. A part of the appliance is a spiral spring and a provision for a constant outward pressure is made upon the foot, by which inversion is more easily overcome, as well as any inward spiral twist of the bones of the leg. No such apparatus can be made effective unless connected suitably with a waist-band. This is, therefore, included in the shoe shown in Fig. 263. Furthermore the appliance should be so made as to permit adjustment commensurate with the rapid growth of the patient, and in order that it need not be too often renewed. Some degree of mechanical ability is required for its application and management. The principles are, however, easily mastered and most parents can soon learn to manage it.

2. =Talipes Valgus.=--This condition is known also as _talipes planus_, or, more briefly, _pes planus_, the common names being _flat-foot_, _splay-foot_, or _pronated foot_. A particularly painful variety has been often spoken of as _pes planus dolorosus_.

This type of deformity is rarely of congenital origin. It is characterized by abduction and pronation of the foot, on whose inner border there often appear two prominences, one the head of the astragalus the other the head of the scaphoid. The bones show much less alteration in actual shape than in club-foot. The scaphoid is deflected somewhat to the outer side and the astragalus turned a little outward and downward. A prominent feature is that the arch of the foot is more or less obliterated, while its inner border becomes convex instead of remaining concave. This is due in large measure to relaxation of the ligaments binding the foot to the calcis, especially that extending from the astragalus (Fig. 264).

=Etiology.=--The common cause of the condition is lack of sufficient strength of the parts to carry the weight of the superimposed body. It is produced often by ill-fitting shoes, accompanied by excessive strain or rapid growth and gain in weight. It is sometimes complicated by a certain shortening of the gastrocnemius (Shaffer), which prevents flexion to its complete degree and compels some degree of eversion of the foot in completing a step. In some instances it is induced by previous morbid conditions, such as rickets, paralysis, diseases of the spinal cord, and postgonorrheal arthritis. Ill-fitting footwear is the most common cause, as it compresses the front part of the foot and prevents adaptation of the foot to the position it should assume when the weight of the body is thrown upon it. The effect of this weight is to necessitate a greater divergence of the toes than such shoes permit and gradually causes the patient to walk on the inside of the foot. _Flat-foot is seldom seen in those who habitually go barefooted._

The condition is best relieved by making a graphic record of each case. This is done by making the barefooted patient step first on smoked glass or on wet dusted paper, and then upon a piece of plain paper. If such a print be compared with the print similarly obtained from the normal foot it will be seen how different are the points of contact and how differently distributed is the body weight. A non-graphic but sufficient inspection may be afforded by having the patient stand upon a stool whose top is made of glass and by using a mirror beneath the feet. In any event it will be shown that the inner border of the foot is at least nearly straight or even convex, whereas it should be neither.

[Illustration: FIG. 264

Talipes valgus.]

There are tender points over the astragaloscaphoid joints, at the base of the first and fifth metatarsals, in front of the internal malleolus, as well as often beneath the heel. Patients who thus suffer find that the feet perspire very easily. In walking the feet are everted, and when tenderness is very great it is because too much weight is borne on the inner borders of such everted feet. Inspection of the shoes will also show wearing of the inner border and over the inner malleolus.

Spontaneous cure of such cases does not occur, except perhaps after long confinement in bed from other causes, but patients occasionally become tolerant after a time, though many of them grow steadily worse and avoid using the feet more than is absolutely necessary.

=Treatment.=--Mild cases will be benefited, often practically cured, by simply raising the inner border of the sole and heel of the shoe. This causes more weight to be borne on the outer border than in the natural attitude of the foot. It will be sufficient usually to make from ³⁄₈ inch to ⁵⁄₈ inch difference in the level between the inner and the outer borders of the sole and heel. Shoes may be so constructed that this difference is made invisible, or suitably bevelled narrow strips of leather may be sewed beneath the sole along the inner side, or laid in between its upper and lower layers.

While this suffices for the milder cases it is not sufficient for the more severe cases, which require forcible correction, and often under an anesthetic. The best way to accomplish this, after having patients thoroughly relaxed with chloroform, is to make a thorough manipulation of the foot, trying especially to so loosen its outer ligaments that it may be more easily put in proper position and finally overcorrected. The foot is then put up in plaster of Paris in this much overcorrected position. Such splints are worn for five or six weeks, after which suitable shoes should be provided, either with their inner borders elevated or with metal flat-foot plates inserted, or both. These plates are now in general use, and may be procured from instrument dealers and in shoe stores. In particular cases it is advisable to make a mold of the lower aspect of each foot, to have this cast in iron, and then over the iron model to have a suitable metal plate hammered so that it shall exactly fit the individual for whom it is intended.

Only in extreme cases, rebellious to other treatment, has it been shown necessary to resort to such treatment as division, by osteotomy, of the neck of the calcis or of the astragalus.

Most of these cases may be benefited subsequently by gymnastics and massage, _i. e._, by stretching the contracted gastrocnemius, if necessary, with some mechanical device, and improving the general condition of the leg muscles by suitable massage.

=Metatarsalgia; Morton’s Disease.=--Under this name has been described a peculiar painful affection of the third and fourth or the fourth and fifth toes, which gives rise to constant sensitiveness and sometimes attacks of acute pain, especially when the foot is shod, and which is often only relieved by immediately removing the boot or shoe. These affection’s are more common in the upper walks of society, especially among women who are disposed to cramp their feet in shoes which are too small for them. Aside from the location of the pain there will often be found a tender spot at the point of greatest complaint. As these cases become worse pain radiates farther and farther up the leg, and may even assume the type of a sciatica.

[Illustration: FIG. 265

Talipes equinus.]

Careful inspection usually reveals either a mild degree of flat-foot, or of distortion by which the anterior part of the foot is broadened and held in a depressed position--or else the dorsal part of the foot is depressed behind the anterior part; there is also usually limitation of dorsal flexion of the foot and plantar flexion of the toes.

Morton, who first described the affection as having a peculiar type of its own, thought it due to entanglement of the external plantar nerve between the heads of the fourth and fifth metatarsal bones, and recommended for its relief excision of the head of the fourth of these. The etiology of the affection is not always apparent, but it is sometimes due to what has been described as a non-deforming type of club-foot, while in practically all other instances it is in some way connected with the use of badly fitting footwear.

=Treatment.=--Without proper treatment it does not subside. A really weak and pronated foot should be supported with a proper plate and elevation of its inner border, while a short gastrocnemius should be stretched. Only in extreme cases or when these milder measures have failed need resort be had to Morton’s suggestion and excise the head of the fourth metatarsal.

3. =Talipes Equinus.=--In this condition the _equinus_ position is simulated, and the patient walks upon the anterior part of the foot only, perhaps even upon the ends of the metatarsal bones. While the congenital form is extremely uncommon the acquired form is that which commonly occurs. Appearing thus in all possible degrees it may in mild cases cause merely a slight limp, while the extreme cases cause a pronounced deformity and alteration in gait. The actual condition is one of shortening of the tendo Achillis through contraction of its component muscles, with corresponding change in shape of the bones of the foot. There is also more or less shortening of the plantar aponeurosis, and depression of the astragalus, which is drawn down upon the calcis (Fig. 265).

=Causes.=--Perhaps the most common cause is paralysis, either of infantile or cerebral and spastic type, of the anterior muscles of the leg, the condition being simulated sometimes in hysteria. The spasm which follows disease of the ankle-joint may also produce it. It may be the result of muscle contraction after fractures or even after certain fevers, the foot dropping naturally into this position and remaining there altogether too long. Hence may be seen the necessity for putting the foot in the right-angle position whenever the lower limb is dressed in plaster or other rigid dressings after fracture. Talipes equinus may also be due to injury to and loss of power in the anterior muscles of the leg, or it may be compensatory, as when one leg is longer than the other. In any of these events the body weight is borne on the ball of the foot, and some degree of arching of the foot, which may be excessive, is sure to occur.

=Treatment.=--In the milder cases, when seen early, it may be sufficient to thoroughly and repeatedly stretch the sural muscles, but, in the more severe forms, tenotomy of the tendo Achillis, with subcutaneous or perhaps open division of the plantar structures, will be needed. In paralytic cases tendon grafting (_q. v._) will be required, probably with one or more of the measures mentioned above. In some instances nerve grafting might be profitably employed. After recovery from operation, braces adapted to each particular case will in all probability be required, at least for a time.

4. =Talipes Calcaneus.=--In this deformity the anterior part of the foot is drawn upward by its anterior flexors and a little to the outer side, while the sural muscles are relaxed; thus the patient walks upon the heel. The condition is often more or less combined with talipes valgus. It is rarely of congenital origin, but is generally due to paralysis of the distal muscles following injury or poliomyelitis. It is sometimes of hysterical origin, and it may occur as the result of muscle spasm following bone or joint disease (Fig. 266).

[Illustration: FIG. 266

Talipes calcaneus.]

[Illustration: FIG. 267

Pes cavus, hollow clawfoot.]

Those forms due to infantile paralysis are to be treated mainly by tendon grafting or some similar expedient, and this to be followed by a suitable shoe containing a sole plate with an upright attachment and a joint opposite the ankle. Other forms must be treated, each on its own merits, but according to general principles already enunciated.

=Pes Cavus.=--Here the anterior part of the foot is drawn backward and the plantar arch made much more prominent. It may even be converted into a Gothic arch. Extremes of this type are seen in the feet of Chinese women. One form is due to contraction of the peroneus longus, owing to paralysis of the sural muscles, by which the long flexors are permitted to work to extra advantage; and yet another form is often of congenital origin, having its explanation in paralysis of the interossei and other small intrinsic muscles of the foot (Fig. 267).

When an ordinary metal sole plate fails to give relief a subcutaneous or open division of the contracted structures may be practised.

CONGENITAL MISPLACEMENT (DISLOCATION) OF THE HIP.

Perhaps a more proper name for this congenital deformity would be “misplacement” rather than dislocation. It is seen much oftener in females than in males. It may be either unilateral or bilateral. The displacement is usually upward and backward upon the dorsum of the ilium. In rarer instances it is anterior and sometimes the head of the femur lies not far away from the anterior superior spine of the ilium.

Regarding its cause absolutely nothing is known. It represents defective development rather than arrest, and is a condition of intra-uterine life. The acetabulum is usually found incomplete, but whether this is the cause of the misplacement or whether it fails to develop because of the absence of the head of the femur from this cavity it is not easy to decide. The influence of heredity in these cases is undeniable, for it is known to have prevailed in certain families. Thirty years ago but little was known in regard to the affection, and nothing could be done to atone for it. Of late years it has been the subject of special study by numerous investigators (Figs. 268 and 269).

[Illustration: FIG. 268

Double congenital displacement of the hip. Buffalo Clinic. (Skiagram by Dr. Plummer.)]

[Illustration: FIG. 269

Skiagram of coxa vara; deformity most marked at the epiphyseal junction. This illustrates the mechanical limitation of abduction caused by the deformity, and the compensatory tilting of the pelvis. (Whitman.)]

[Illustration: FIG. 270

Congenital misplacement, with consequent atrophy and shortening. (Calot.)]

Pathological changes are noted in the capsule itself, as well as in the bony components of the joint. Thus the capsule is usually elongated and stretched out of shape, while its lower portion may be adherent to the margin of the acetabulum or may be shut off into a small cavity by itself, this cavity having but a small connection with the balance of the capsule and affording irresistible obstacles to reduction. With changed joint relations the muscular arrangements are also changed, some being lengthened, others shortened, as would naturally follow from the approximation or separation of their points of origin and insertion. Conspicuous change is seen in the upper end of the femur, which is often atrophied, while the neck is shorter than normal, its angle lessened, and the head of the bone often altered in shape. A secondary acetabulum is in time formed and is usually found upon the side of the ilium. This is shallow and insufficient to ensure firm support for the head of the femur, even were this well developed. Aside from these changes the pelvis is usually poorly developed on the affected side, its inclination increased, the sacrum forced forward and downward, the pelvic outlet widened, while a considerable degree of lumbar lordosis is present (Fig. 270).

The condition is rarely noted until a growing infant begins to learn to walk. The condition is one which has _no symptoms, only signs_, and these do not at first attract attention. Sometimes it will have been noted that there is an abnormality about the hip, with too free play, or a snapping sound about the joint. When the condition is unilateral there is a marked limp which increases with the age of the child. With each step the femoral head is pushed upward on the side of the ilium, and, in consequence, the pelvis is tilted toward the outside, as well as twisted downward and forward. The limb being thus actually shortened, the limp or waddling gait is easily accounted for. Along with it there is usually flattening of the tibia, while the trochanter may be felt and often seen on a level considerably above that where it properly belongs. Motility in the joint is abnormally free, and with a child on its back, by alternately pulling and pushing, the abnormally free play of the upper end of the femur may be easily demonstrated, either with the limb in its extended or the flexed position.

When the misplacement is _bilateral_ the individual is more symmetrically deformed. The lordosis is increased, the abdomen protrudes, the thighs are separated more widely than is normal, leaving perhaps a considerable space in the perineum; the gait is of a peculiar waddling character, which makes locomotion apparently difficult, although it is free from pain. In these cases abnormal mobility of the hip may be demonstrated on each side.

As these patients grow through adolescence into maturity they sometimes improve, but usually suffer more and more difficulty in locomotion, while the abdominal protrusion and the lordosis become more and more pronounced.

Three varieties of congenital misplacement are described as _backward_, _upward_, and _forward_. It is in those instances where the head of the bone rests well back or well forward upon the ilium that the gait is most pronounced, but in all instances the great trochanter will be found above Nélaton’s line.

=Diagnosis.=--The diagnosis offers few difficulties. The peculiar waddling gait may be seen in extreme cases of bow-legs, but then the hip-joints will be normal. Extreme lordosis may be seen in cases of lumbar spinal caries, but here again the hip-joints will be normal, while the spinal muscles will be rigid and the patient disinclined to walk. Traumatic dislocations and the results of hip-joint disease will be indicated by a history to correspond, as will also early acute joint affections following the exanthems. The diagnosis is to be made principally from _coxa vara_, considered below, and the various defects following infantile palsy. In coxa vara there is no corresponding abnormality of motion, while in the paralytic cases there will often be failure in muscle power, which is not present in cases of congenital misplacement. Finally in instances which offer difficulties the Röntgen rays now afford a method of diagnosis.

=Treatment.=--For a long time after this condition was recognized its treatment was unsatisfactory, and it was not until Hoffa, about fifteen years ago, advanced his operative method of relief that surgeons felt at all like advising operation in well-marked cases. Then came Paci and Lorenz, first with improvements on the Hoffa operation, and then with a method of so-called “bloodless” reposition, which has been under severe test and testimony. Last of all come Bradford and Sherman with their improved methods of operation, which seem to me the most promising of all as well as the most scientific.

[Illustration: FIG. 271

A plaster bandage applied by Lorenz, illustrating the extreme thickness of the pelvic portion and discoloration of the adductor region. (Whitman.)]

Lorenz was doubtless correct when he stated that the principal obstruction to reduction is the narrowed part of the capsule, just at the upper part of the acetabulum, and that if this could be torn here sufficiently to permit the passage of the head, reduction could be accomplished by manipulation alone, and maintained if the acetabulum were sufficiently deep. An almost insuperable difficulty in most cases is, however, this narrowed capsule, and the number of accidents, including not only fractures of the femur and the pelvis, but various other injuries which have resulted from too great violence, is altogether too large and too disturbing to justify the use of such force as has often been used. Of more than one hundred children upon whom Lorenz operated when making a tour through the United States, but little over 10 per cent. have given anything like ideal results; while the danger from fracture and laceration of muscles and nerves, as well as of bloodvessels, is fully as great as that pertaining to any open operation. It may therefore be maintained that the percentage of success from the use of manual force without incision does not justify the risks of the method. Sherman argues that if we may open a knee-joint without hesitation to take out a small piece of cartilage, we need not fear to open a hip-joint in order to clear away a small obstacle. The patient is thereby saved from many dangers and exposed to so few that it seems more humane and desirable in every respect.

Sherman’s method is to make traction upon the limb, drawing the femoral head down to a point just below the anterior superior crest, where it can easily be felt, and to here make an incision over it in the direction of muscular fibers so that they are not divided. After division of the capsule the head of the bone is exposed and retractors substituted by long loops of suture, put in on either side of the opening in the capsules. In many cases a tenotomy of the adductor tendons close to the pubis will also be of advantage. The leg is next released from traction and the head of the bone allowed to glide upward, while the finger is slipped into the capsule and down toward the acetabulum. Upon this finger as a guide a long, straight, probe-pointed bistoury is passed, and with it the narrower portion of the capsule is cut through, down to the bone, taking care to not cut off the ileopsoas tendon. The incision must be large enough to give free access to the acetabulum. Traction is then again made with sufficient manipulation so that the femoral head may be forced into its proper cavity. When the head is in the acetabulum the retracting sutures are tied together so as to close the upper part of the capsule, and other sutures are introduced, as needed, to close the wound, leaving space for a cigarette drain. The limb is then put into a position of abduction of from 50 to 90 degrees, rotated in or not, as needed, and a comprehensive plaster-of-Paris spica applied. In this both limbs or only one may be included. The drain should be removed in two days and the dressing left otherwise undisturbed for three months.

Bradford has added somewhat to our methods by showing not only the arrangement of the capsule, but the fact that the acetabulum is often filled with dense fibrous tissue which sometimes obliterates it, and that this tissue can be curetted out, but that if it could be utilized to aid in retaining the reduced head of the femur it would be a great benefit. He operates as follows: The hip is subjected to preliminary forcible stretching of all soft parts which can be stretched by manual or mechanical force. A posterior incision is then made, which, without dividing muscles, permits free opening into the capsule and affords a channel to the deepest portion of the acetabulum. The posterior wall of the capsule is then split, after which all constricting and other obstacles at any point are carefully divided. These may be detected by the finger, and can also be seen by a small electric light passed down inside of a sterilized glass test tube. The capsular wound is then retracted by deep retaining silk sutures, placed at the lower rim of the acetabulum, thus affording a pathway for the reduction of the head. After this has been accomplished as described above, the sutures are tied closely around the femoral neck, and these retain it in position. The other portions of the split capsule are then sewed around the head and neck, to the trochanter and fascia, in such a way as to retain the bone where it has been placed.[37]

[37] American Journal of Orthopedic Surgery, October, 1905.

The earlier the operation is done the better. It is necessary to always maintain the limb in a position of well-marked abduction, and for a long time, nor can patients be released from this at the expiration of the first dressing period, usually twelve to fifteen weeks, although the abduction can usually be reduced with each dressing until at last the limbs are permitted to come together after the expiration of nine to eighteen months. Even after the lapse of this length of time it may be necessary to provide some form of apparatus by which too much rotation in either direction may be prevented, or by which pressure may still be made over the trochanter, in order that it may be kept constantly pushed into the acetabulum (Figs. 271 and 272).

[Illustration: FIG. 272

Unilateral congenital dislocation, showing the fixation bandage. A shoe with a cork sole about two inches in height should be worn on the operated side, while the attitude of exaggerated abduction is maintained. (Whitman.)]

[Illustration: FIG. 273

Coxa valga, with defective development of the right femur. (Albert.)]

COXA VARA AND VALGA.

This term is applied to an _abnormality in the shape of the neck of the femur_, consisting of a downward curvature or bending of the femoral neck, which is thus displaced until it stands almost at a right angle with the shaft instead of at the normal obtuse angle. At the same time there is often posterior curvature, or sometimes an anterior curve, of the neck, which causes a corresponding rotation of the axis of the whole limb. The pelvic side of the hip-joint is unaffected, the change occurring usually solely in the upper end of the femur, the joint not being involved. It may appear in congenital form and then may be attributed either to intra-uterine pressure or to antenatal rickets or osteomalacia. The acquired form is usually due to a non-inflammatory softening, or to structural changes which permit of yielding, as above described. Doubtless different cases have different causes, and they are not to be included in one brief sentence. The condition corresponds to those abnormalities at the knee which produce knock-knee and bow-leg. Were the bone as easily examined at the upper end of the femur as at the knee the condition would be more easily recognized. Therefore the term has reference not so much to the results of active disease as to deformities of congenital or acquired character. Fully three-fourths of the cases are met with in male subjects, and the majority of these occur only on one side. Thus of 190 quoted by Whitman, 85 were unilateral, while only 26 occurred in females.

The more nearly the angle of fixation of the neck of the femur approaches a right angle the further above Nélaton’s line will the trochanter appear, and the more conspicuous this change the greater the difficulty in abduction. Moreover, to shortening may be added internal or external rotation, with consequent tilting of the pelvis and compensatory alteration of the spinal curves.

The disease is by no means often of traumatic origin, although traumatisms may produce an arthritis deformans, even in juvenile cases, and that this may simulate a non-symptomatic coxa valga is now well established (Fig. 273).

=Symptoms.=--Coxa vara produces certain symptoms, among them pain in the joint, radiating down the front and inside of the thigh. If the deformity be very marked, joint function is impaired. Tenderness is rarely present. When pain or tenderness occur they may lead to the mistaken diagnosis of rheumatism or neuralgia. The condition may arise as the result of an acute ostitis, in which case patients will be confined to bed for some time. Actual shortening may vary from one to one and a half inches, while the limb will be found adducted, the gluteal region flattened, with a deep curve between the trochanter and the gluteal muscles.

=Diagnosis.=--The diagnosis is to be made mainly between this condition and hip-joint disease or misplacement. When abnormalities in the shape or position of the limbs in the young occur in a comparatively short time, coxa vara may be suspected, especially in the absence of that disability which coxitis usually produces. The patient should be examined in both the upright and horizontal position. Coxa vara may have an abrupt onset, but it never produces abscess. It is practically self-limited and will be followed, sooner or later, by spontaneous cessation of all acute features, while coxitis is progressive, with a destructive tendency. In coxa vara we do not have the starting pains nor muscle spasms of coxitis, while the actual shortening is much more marked. In doubtful cases the cathode rays may be employed and will often greatly facilitate diagnosis. The condition may be bilateral, but will still fail to show the muscle atrophy so significant of tuberculous disease.

As between coxa vara and that senile form of coxitis already described in the chapter on Joints as arthritis deformans, it should be remembered that the latter is a disease of advanced life, while the former occurs rather in its earlier periods. Moreover, in the former there is no tendency to change in the femorocervical angle, no matter what changes may occur in other respects about the joint. When in the senile disease shortening really occurs it results from actual absorption of bone.

Coxa vara tends usually to _spontaneous cessation_, which may be considered recovery. Acute symptoms after a time subside, and function is regained to the full extent permitted by whatever changes have occurred in the shape of the bone. If symptoms are at all severe they demand physiological rest in bed, with traction, and the limb should not be used until pain has entirely subsided. Conspicuous deformity may call for correction by subcutaneous osteotomy made just below the trochanter. Only in exceedingly serious cases is exsection of the joint necessary.

DEFORMITIES CAUSED BY INFANTILE PALSIES.

Deformities induced by more or less acute affections of the cord and brain, or by hemorrhages, have assumed an ever-increasing importance in orthopedic work. Most of them resolve themselves into those due to acute anterior poliomyelitis and those due to cerebral hemorrhages.

[Illustration: FIG. 274

Anterior poliomyelitis. Extreme flexion deformity at the hips, inducing quadrupedal locomotion. (Gibney.)]

=Anterior Poliomyelitis.=--Anterior poliomyelitis is an acute inflammation manifested especially in the gray matter of the anterior cornua of the spinal cord, involving both the neuroglia and the cells, producing atrophy of the same and consequent paralysis of muscles supplied by the motor nerves. It may assume an acute febrile type, with rapid onset of paralysis, or it may be of slower development. Usually conceded to be of infectious origin, it still lacks the minute explanation for many of its attendant phenomena. It may appear with acute symptoms, febrile and convulsive, paralysis appearing more or less promptly. With the subsidence of other serious symptoms this paralysis remains. There may then be a period of partial improvement in the muscular condition, with disappearance of some of the most pronounced phenomena. Finally with the growth and development of the child more expressions of damage remain, and produce various distortions and deformities, varying with the muscle groups affected. Not only do deformities result, but there is more or less arrest of development, with disproportion in size between the limbs involved and those which have been spared. It is the early paralytic features which may permit diagnosis to be made in the early days of the acute febrile attack.

=Cerebral Palsies.=--The cerebral palsies, so called, are the result of hemorrhages or acute disorganization of the brain. The former are usually unilateral and give rise to a corresponding hemiplegia, with either paralysis or spastic rigidity, and usually with atrophy. The paralysis may not be complete, but is rather of the paretic type, involving the entire limb, the reflexes being increased and the muscles stiffened rather than flaccid, with loss of electrical reactions.

_A paraplegia points rather to lesion in the spinal cord and hemorrhage than to cerebral lesion._ Transverse myelitis is rare in children. Multiple neuritis may produce somewhat similar effects, as may also the toxic paralyses due either to drugs (especially lead or arsenic) or that following diphtheria, in which case it is the muscles of the throat and neck which are likely to be involved. Figs. 274 and 275 portray extreme types which are rare, but instances of minor degree of affection are frequent.

[Illustration: FIG. 275

Anterior poliomyelitis. Duration seven years. Showing atrophy and slight lateral curvature of the spine; two and a quarter inches of shortening. (Whitman.)]

=Treatment.=--As two cases of this kind are seldom alike, treatment should be planned to meet the indications. Massage, electricity, hot-air baths, and similar non-operative measures find here a large field of usefulness, but, save in the milder cases, are insufficient. In no class of cases do tendon grafting and nerve grafting find a wider range of applicability, while tenotomy, myotomy, aponeurotomy, and occasionally osteotomy will permit of atonement for deformity which has not been treated. These operative measures have been considered.

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