NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE LIBRARY. Section,-------------------- M. /UP}, NLM051115942 ><•■ '■■<•,■ -.»■;;'. General Orthopedics INCLUDING SURGICAL OPERATIONS AUGUST SCHREIBER, M.D., Surgeon-in-Chief to the Surgical Division of the Augsburg Hospital REPRINTED FROM WOOD'S MEDICAL AND SURGICAL MONOGRAPHS I LI BR Ail Y ! | SURGfON SI NERAi.'S OFFICII I ! APR. I—t?)-:^ i- :.....JMVJl NEW YORK WILLIAM WOOD & COMPANY 1891 WE I83\ CONTENTS. GENERAL ORTHOPEDICS. PAGE Introduction,...........1 CHAPTER I. General Orthopedics,.......... 3 General Treatment,.........17 Gymnastics,........... 18 Electricity............20 Mechanical Appliances, ....... 20 Surgical Orthopedic Operations, ........ 37 CHAPTER n. Rachitis,............55 CHAPTER III. Torticollis,............60 CHAPTER IV. Deformities of the Spinal Column,.......71 Lordosis,...........72 Kyphosis,.......... 73 Skoliosis,...........113 Deformities of the Thorax,........167 CHAPTER V. Orthopedic Affections of the Extremities,......172 I. Contractures and Ankyloses,.......172 Contractures and Ankyloses of the Hip, .... 179 Contractures and Ankyloses of the Knee, .... 186 Contractures and Ankyloses of the Shoulder, ... 196 Contractures and Ankyloses of the Elbow, .... 197 Contractures and Ankyloses of the Wrist, .... 199 Contractures and Ankyloses of the Hand, .... 199 Finger Contractures,........202 Dupuytren's Contracture,.......204 iv Contents. PAGE II. Genu Valgum and Varum, ...„. = • 207 Genu Valgum, ........ 207 Genu Varum,..........224 III. Rachitic Curvatures of the Diaphyses, . . „ „ . 221 CHAPTER VI. Contractures of the Foot,.........232 Talipes Equinus,.......... 244 Pes Calcaneus,.......... 252 Pes Cavus, . ..........255 Pes Planus,...........257 Pes Varus, ........... 258 Pes Valgus,...........289 CHAPTER VII. Deformities of the Toes,.........309 Hallux Valgus,..........309 Hammer Toe,...... 314 CHAPTER VIII. Paralytic Deformities,..........315 Infantile Paralysis, . . .......315 Cerebral Paralysis of Children,.......319 Congenital Spastic Rigidity of the Limbs (Little's Disease), . 324 Paralyses of Special Nervous and Muscular Areas, . . . 325 Lead Palsy,...........327 CHAPTER IX. Orthopedic Affections Following Fractures and Luxations, . . 329 CHAPTER X. Congenital Luxations,........ . 333 Luxation of the Hip, ....... . 333 Luxations of the Patella,...... . 341 Luxation of the Knee, ....... . 341 Luxation of the Foot,.........341 Luxation of the Upper Extremity,......341 GENERAL ORTHOPEDICS. INTRODUCTION. A work devoted to modern orthopedic surgery will un- questionably be of great practical value to the physician and will fill a void. Marked progress has of late years been made in orthopedics, a branch of the surgical art, and on account of the frequency of deformities, it is a subject which should at- tract the attention of every thoughtful physician. The physician who, during his student days, has not ac- quired the knowledge of and the readiness in applying band- ages and apparatus will have cause for regret, for he will be frequently called upon to resort to these measures in his practice and it will not always be possible to send his patient to an orthopedic dispensary or surgeon. Although many de- formities can only receive the requisite treatment at special clinics, or at the hands of the specialist who has acquired the essential technical skill, it still holds true that the subject, in general, should be the property of every physician. As v. Ziemssen says, "orthopedic methods belong to those which every physician should master; the technique should be thor- oughly acquired and expertly understood." Further still, modern orthopedic methods are of greater importance to the physician than those of the past, when the more active opera- tive measures were not countenanced to the same degree as obtained in other branches of surgery. Owing to the fact that deformities are met with chiefly among the poorer classes, our aim should always be to resort to the simplest and cheapest therapeutic apparatus. Cou- lomb's words " il faut el re democrate du moins en orthopedie " are most apt ones, since the simpler the contrivance, the more accessible it will be to the majority of patients. 1 2 Orthopedics and Orthopedic Surgery. With truth did Bauer complain that many inventors take out patents for orthopedic apparatus, since "no liberal-think- ing- physician should place his inventions within the reach of the rich and deny them to the unfortunate poor." There is, however, scarcely any method of treatment with which fault might not be found; simplicity has rarel}' prevailed in ortho- pedics ; ordinarily there is call for knowledg-e as to the tech- nique of bandages and apparatus, for anatomico-physiolog-ical insight, for pathologico-anatomical research into the causal factors of deformities, in order to obtain a correct estimate of the obstacles in the way of treatment. The chief require- ments, indeed, of our subject lie in a pathologico-anatomical and in a diagnostic direction, I have borne in mind, in the preparation of a work on or- thopedic surgery, the difficulties I would have to meet: the vast orthopedic literature contains much that is uneven and obscure, so that it is often difficult to pick out what is correct. Still it is not possible to neglect entirely the description of older methods and apparatus, since, in individual cases, these may be of value; but modern orthopedics has progressed to such a degree, that I have felt obliged to consult many different and not easily accessible contributions, all the more since many of them did not originate in Germany and are therefore not within the reach of most practitioners. Through a careful statement of the etiology and the pathological anatomj- of the subjects with which we are con- cerned, I have endeavored to expose clearly the methods of treatment, and to simplify early diagnosis. In the choice of illustrations (and it seemed to me essential to select a large number) I have aimed at picturing the slighter as well as the more uncommon grades of deformities, and at representing apparatus of the most varied nature, which the physician must order even as he does the drugs in his recipe, that is to say he must give the mechanic explicit directions, and herein the illustrations will be of much service. I trust that the following exposition of orthopedic practice and methods may excite the interest of phj'sicians in this branch of medicine, for orthopedics may be looked upon as a step-child of the other medical branches, and I hope it may obtain for orthopedic methods more general recognition. CHAPTER I. GENERAL ORTHOPEDICS. Under the term orthopedics (from op$o$, straight, and naidsia, knowledge) we understand the subject of the deformi- ties of the human body and the methods of prevention and of cure, and we see at once, therefore, that it is not separable from surgery, but must be considered an integral portion. As in every other branch of medicine, so in orthopedics was the growth gradual up to the present stand-points; and in addition to marked advances (such as tenotomy, oste- otomy, etc.) there have occurred many serious errors (such as the forcible straightening of the spinal column, the cutting of the muscles in the treatment of skoliosis, etc.). The opin- ions which have obtained have been in many respects opposed, and in regard to many points there has arisen great and pro- tracted discussion. Bias and egotism have stood in the way of the recognition of some methods, or else a method has been open to the charge of charlatanism. At times, indeed, our chief aim, that of helping our patient, has been lost sight of amid these disputes. In these respects, our subject is darker and more forbidding than other branches of the medical science. To sketch briefly the chief points in the history of ortho- pedics, we must, at the outset, state that its inception may be traced as far back as can human deformities; Hippocrates, Galen, Arabic physicians, Ambroise Pare, Severinus Arceeus, —these all have yielded us considerable information on this subject. Fabricius Hildatus reports, among other things, a case of severe contracture of the hand which he cured by suit- able apparatus. In the year 1500, Glisson first resorted to suspension in or- thopedics; in 1G85, J. Minius first performed tenotomy in case of caput obstipum, and certain physicians of Holland (Tulpius, 4 Orthopedics and Orthopedic Surgery. Mekren, Roonhuysen), described orthopedic results in their writings. Andry (1741) first collected the observations of his prede- cessors, and gave the science the name it holds to-day. In 1780, A. Venel opened, in Switzerland, the first hospital for the treatment of deformities; in 1782, Lorenz, on the advice of Thilenius, first performed tenotomy of the tendo Achillis in a case of club-foot, but this fact was forgotten, and Delpech must be considered the man who first established orthopedics on a sound basis. In 1803 Scarpa devised the since much-modified Scarpa club-foot shoe. Jorg (1806), Rudolphi (1832), Palletta, Soem- mering, and others added much to orthopedics by their labors; but the science only made essential strides after L. Stromeyer substituted subcutaneous tenotomy for the early method practiced by Michaelis, Delpech, Dupuytren and others. With Stronger, Heine, Dieffenbach, Langenbeck, must be men- tioned as men who furthered the advance of orthopedics. Little, who himself suffered from club-foot and was operated upon by Stromeyer, spread the new methods in England, and sowed the seed for the founding of the Royal Orthopedic Hos- pital, in which, during its first ten years, not less than 12,000 patients were treated. The first fruits of this enormous series of observations was the work of Tamplin, and his colleagues, Lonsdale, Brodhurst, and Adams, made further advances in our subject in England. In France, the names of Bouvier, Margolin, Pravaz, Guerin and others must be mentioned, and Bonnet and Malgaigne added as much to the knowledge of the diseases of the joints as they advanced orthopedics. In America, orthopedic surgery was especially advanced by L. Rogers, Detmold, Mott, and the latter had schemed the foundation of the American Orthopedic Hospital, although his desire was not fulfilled till after his death. With the increase in the number of orthopedic hospitals (and almost every large city to-day has one) the interest of physicians in the subject increases, and it is highly to be de- sired that the schools should give special instruction in this, the youngest of all the specialties, for thus the knowledge of matters which relate to orthopedics would be increased gener- ally among the profession. Orthopedics and Orthopedic Surgery. 5 As in every branch of medicine, however, we cannot attain our aim without effort, for many individual methods endeavor to secure pre-eminence, as for instance the Swedish gymnastic cure, which originated with Ling (1776 to 1839) and has been extended by his pupils. Others, on the contrary, seek to work solely through me- chanical apparatus, and in some respects Langgaard was right when he said, " I believe that the claims advanced for gym- nastics alone should not be deemed progress in orthopedics." For a long while there was great discussion over the dy- namic and the mechanical methods (Schreger, Heine, Werner), until each had been assigned its proper sphere. Finally, the essential foundations of orthopedics were laid by the anatomo- physiological mechanical studies of Weber, v. Meyer, Hencke, and especially after the appearance of the works of Hueter, Volkmann and others. The endeavor to accomplish what is essential by means of simple bandages, etc., has especially led to important ad- vances and to betterment in methods. Of greater importance than the improvement of mechanical apparatus, of more utility than the introduction of subcutaneous tenotomy (although since this time dates, in truth, a new era for orthopedics), has been the introduction of the antiseptic treatment of wounds, the great discovery of Lister. This has widened greatly the bounds of orthopedics, and since we have learned that we can, for instance, break a deformed bone without danger and cause it to heal straight, we have obtained the most brilliant results and cures in the shortest possible time. Through these operative measures we are in a position to cure cases which, at an earlier date, no one thought of attempt- ing to treat, in the presence of which, indeed, the physician was formerly powerless. We must here refer to a number of methods of great importance in orthopedics; namely, the ex- tension method of treatment devised by Volkmann, which has quickly obtained acceptance, the use of elastic traction (Bruns, Barwell, Blanc, etc.), and, above all, the jacket method of treatment of disease of the vertebral column, for which we have chiefly to thank Sayre; all these methods are very valu- able therapeutically, in the great majority of cases, and they must be looked upon as essential advances in the subject of which we are treating. 6 Orthopedics and Orthopedic Surgery. These advances have led to the rejection of many ancient objectionable orthopedic methods of treatment; and have caused orthopedics to be considered to-day an essential part of surgery, and even of an importance from a strictly medical standpoint, and we have only to glance over the records of the first, as well as of the smaller clinics, in order to see what a great role orthopedics play. Special courses in orthopedics are offered the young physicians in order that they may ac- quire the information which will afterward be so useful to them, and it is in this connection highly to be desired that each hospital (like the New York Orthopedic and others) should have a special work-shop, for the preparation of ap- paratus, in direct connection with it.1 In the past few years, particularly, there have appeared a number of noteworthy works on orthopedics. I need recall only those of v. Meyer, Lorenz, Vogt, Margary, Noble Smith, Kocher, Liicke, Mikulicz, Roser, Romanit, and others, which are mostly founded on pathological and anatomical researches as applied to new methods of treatment. We may define the term deformity, in general, as being a morbid change of form of some part of the bony skeleton, or as a deviation from the recognized configuration of the sj^m- metry of the human body (Tamplin); many orthopedic affec- tions, however, as for instance anchylosis, depend on an abnor- mal alteration of function in a portion of the body (stiffness, limited mobility). In the majority of orthopedic affections we deal with a curvature, that is, the form of the affected part is so changed that it deviates from the straight line, and it is chiefly in the joints rather than in the bones that the changes are found (the so-called loxarthroses). In general, in orthopedics, we have to deal with diseases of the organs of locomotion, disturbances and diseases of the bony system, of the joints and ligaments, or of the muscles, and we may thence divide orthopedic affections according to the system chiefly involved, and we may further subdivide the subject according to the nature of the change in form, according to the causal factors. Above all, according to the time of occurrence, we may subdivide our subject into the two great classes of congenital and acquired deformities, as in the following scheme: Orthopedics and Orthopedic Surgery. y ( 1. Malformations, primary errors in development: a, Primary error in the germ, defect in forma- tion, b, Disturbances in development of the normally formed foetus through loops in the umbilical cord, etc. 2. Intra-uterine deformities resulting from: a, Ab- Congenital J normal position of the foetus in the uterus Deformities. (congenital luxation, etc.). b, Abnormal in- tra-uterine pressure. 3. Deformities resulting from disease during in- tra-uterine life (rachitis, etc.), or injuries (foetal fractures). 4. Deformities following on traumatism during labor. f 1. Such as result from essential disease factors or traumatic influences: a, Unsuitable clothing (ill-fitting shoes), etc. b, Abnormal posture and what may be termed deformities result- ing from occupation. 2. Such as result from disease: a, Of the bones (rachitis, tubercular osteitis, etc.). 6, Of the joints, the cause of which is arthrogenous. Acquired . 3. Such as result from disturbances in localities Deformities. I removed from the affected region: a, In the muscular system (myogenous cause), b, In the central or peripheral nervous system (neurogenous cause) . Such as result from traumatic influences: a, From changes in the soft parts (cicatricial contractions, etc.). 6, From changes in the bones and joints (deformity from fractures or dislocations, etc.) The question of the origin of foetal deformities is still in many cases very obscure; often we must suppose an error in the germ, a vitiumprinice fornuit touts. An hereditary influence will explain certain congenital de- formities (such as congenital luxations, club-foot, etc.). Tam- plin, for example, tells of a family where there were eight children suffering from similar bilateral club-foot. In other instances we are dealing with a primary disturbance in devel- opment resulting from a foetal disease, where, for example, a part remains rudimentary, or may even be entirely lacking, and so in the course of the development of the other parts we witness deformity. A good example of this character is of- fered bv curvature of the fore-arm or of the leg, which results 8 Orthopedics and Orthopedic Surgery. from lack of development of a bone and which leads to distor- tion of the hand or foot. Such cases have been described by Mosengeil,2 Billroth,3 and others. Those cases are very obscure (although in some the data are authentic) where a sudden maternal impression during preg- nancy (fright at the sight of a cripple, etc.) has caused the de- formity of the foetus. Instances of deformity are bet- ter explainable which may be traced to loops in the umbilical Fig l.-Curvature of the Radius; Lux- cor(J? or to abnormal posture ill ation of the Head of the Radius with . Defective Development of the Ulna. Utei'O, which IS offered as an ex- (Humphry.) plana tion of talipes, and where, at times, a deficiency in liquor amnii is determined, leading to abnormal pressure on the misplaced part. The etiology of deformities which result from intra-uterine disease or from traumatism suffered during pregnancy, is readily understood, although we cannot give absolute credence to all the recorded cases. A fair percentage of deformities are caused by unfavorable, purely external causes; we will see how the carrying of infants on one side predisposes to skoliosis. Camper, Soemmering Fig. 2.—Congenital Infraction and Curvature of the Fore-arm. (Munich Path. Institute.) and others claim that the tight chest bandages ha\-e an un- favorable influence on the muscles of the chest. The modern, faulty method of shoeing children (pointed tips with high heels to the shoes) leads to characteristic deformities, such as hallux valgus, etc., and may cause serious trouble. In the great group of deformities due to abnormal and constant pressure (genu valgum, flat-foot, etc.) a weakness of the muscular system is an efficient cause. The most impor- Orthopedics and Orthopedic Surgery. 9 tant factor here is the abnormal, constant malposition, under the influence of which there occurs unequal growth of the affected limb, in that at the points of pressure growth is interfered with, while at other parts growth is increased, and genu valgum offers a typical example of this. In this con- nection H. v. Meyer 4 differentiates a relative excessive strain (as in rachitis), and an absolute effect of external factors act- ing on the body. Habitual methods of holding the body may lead to asym- metrical growth, to curvature approaching skoliosis, as wit- ness the deformities in certain artisans, in watchmakers, in stone breakers, etc., and this is the more likely to occur when the cause acts early in life, before the bony structure has at- tained its growth. More important still are the deformities resulting from disease of such a nature as causes softness and bending of the bones (rachitis, osteomalacia), or such as leads to disturb- ances of the bone tissue (tuberculosis, osteomyelitis,5 and again, syphilitic osteitis, rheumatism). The arthrogenous deformi- ties, those which follow on inflammation of the joints, are more infrequent the better such inflammation is treated. We deal here, generally, with the affection characteristic of each special joint, as we will note when speaking of contractures. Bone disease following on causes which check or interfere with growth, such as necrosis, may also lead to deformities. Of no less importance in the etiology of deformities is the effect of diseases and their sequeke. Thus, disease of a muscle may lead to diminished function, and as a result of excess of strength in the antagonistic muscles there may result deform- ity, or the same may follow on a lasting spasm or cicatricial contraction (the so-called myogenous deformities). More frequently the cause of paralyses and spasms lies in disease of the central nervous system, and the great group of infantile paralyses is due to meningitis, etc., that is to say, to disease of the cord, of the brain and its membranes. Deformities less frequently result from affections of the peripheral nervous system or from reflex effects from disease of the genital organs. Sayre reports a number of severe in- stances of muscular contractures due to phimosis, etc. The cause of these myo- and neuro-genous deformities is very variable according to the extent of the process. IO Orthopedics and Orthopedic Surgery. In regard to muscle-antagonism, it was the belief that in all cases where the antagonistic group obtained the ascendency a nutritive shortening or deformity resulted from the contrac- tion of the muscles and from the approximation of the inser- tion points. Hueter and Volkmann, however, have shown that we are rather dealing with mechanical influences, that is, with the wreight of the affected section of joint, the habit in walking and in standing; that such influences favor the occur- rence of paralytic deformities, and that much depends on the manner after which the affected joint is used. A further influence (and Seligmuller, among others, has laid stress upon this) is the fact that the paralyzed muscles are not able to redress the position enforced upon a joint by the non-parahyzed muscles, and consequently each movement in the direction of the latter is effective, and the resulting pro- visional contracture merges, in the majority of cases, into a definitive. Where all the muscles of a joint are paralyzed, the condi- tion becomes that of a movable joint; when such a joint is used, the check influence of the muscles is lacking. The movements occur to such a degree as the approximation of the bone sur- faces to one or another side, and as the tension of the liga- ments allow, and since this tension will ultimately relax, the ligaments become stretched, and the bone surfaces suffer change in their configuration, and the deformity is magnified. We will not consider further paralytic deformities, but will only note the fact that frequently a number of conjoined causes lead to deformity, that is to say, combined etiological factors are at work. In the small group of congenital deformities which result from trauma, there belong those caused b}' injury suffered during labor (for example, torticollis, the rupture of muscles during rapid delivery, on which Stromeyer has laid stress). Of the injuries to the soft parts which come under our ob- servation, it is particularly the cicatrices following on burns and scalds, that is the contractures, which concern us, and these most frequently affect the hands and fingers. Deformi- ties also result from injuries to the skin of the most different kinds, such as abscesses, etc., and these are of great importance when they cause separation of tendons or of muscles ; or when a motor nerve is involved and there ensues loss of its function. Orthopedics and Orthopedic Surgery. 11 We must mention further the deformities following on in- juries to the bones. The most frequent are those which are the result of improperly treated fractures, also instances of fracture near the joints or inter-articular fractures, where proper manipulation or passive motion (massage) was not re sorted to in time, or where a splint was worn too long. The imperfectly reduced dislocations are infrequent sources of deformity, as is faulty union of fractures of the epiphyses. The occurrence of deformity varies greatly, according to age and sex. The large proportion arise chiefly in childhood, and those due to external influences, as for instance, skoliosis, are met with chiefly in girls, while, on the other hand, those resulting from strain, such as genu valgum and pes valgus, occur with greater frequency in boys. The symptoms of the deformity must naturally be specially treated, according to the demands of the individual contract- ure. As to the frequency of deformities, we need only recall the fact that Schrauth, in 1860, estimated the number in Bavaria as being 25,000. Werner claimed that there were 56,000 cases of skoliosis in Prussia, and he states that a cen- sus for England and Wales mentions no less than 409,207 deformed individuals, of which number one quarter, or 90,277, belonged to London alone. We see at once what a burden these deformed individuals are to the state, for it is not possible, as Dieffenbach6 suggested, to utilize the club-footed as cavalry men. Many orthopedic diseases, further, render the sufferers partially or totally incapable of work, and un- fortunately, the majority belong to the poorer classes. The deformity, again, reacts markedly on the individual himself. The state of the general health often suffers from direct implication of internal organs (as in aggravated skoliosis and kyphosis), and in instances of exaggerated talipes, etc., from lack of exercise in the open air. Further still, we must note the depressing effect of the deformity on the mind, a circumstance to which Tamplin7 has well given expression. Indeed, in how many cripples is not the pyschical pain apparent in the physiognomy ? Poor and rich, high and low, stand on an equality in this respect. How much pain did not Lord Byron's club-foot cause him! That master in depicting hu- man feelings (Shakespeare) expresses this, among other places, in the opening monologue of Gloster's in Richard III.: 12 Orthopedics and Orthopedic Surgery. " But I,—that am not shaped for sportive tricks, Nor made to court an amorous looking-glass; I, that am rudely stamp'd, and want love's majesty, To strut before a wanton ambling nymph ; I, that am curtaiFd of this fair proportion, Cheated of feature by dissembling nature, Deform'd, unfinish'd, sent before my time Into this breathing world, scarce half made up, And that so lamely and unfashionable That dogs bark at me as I halt by them." On the other hand, it is well known that the intellectual faculties are apt to be highly developed, and many a distin- guished man has been more or less deformed (Socrates, yEsop, Alexander the Great, whose head is said to have been turned toward the left, Burleigh, Pope, Talleyrand, Flaxman, Byron, Mendelssohn, etc.). Little was operated on by Stromeyer for club-foot. In regard to the diagnosis in general, of deformity, in the vast majority of cases simple inspection proves its exis- tence. Still it must not be taken for granted that the variety of deformity always suggests itself; at the very beginning, when correct treatment is of the greatest importance, this is not the case, and we often must recognize a slight deviation from the normal, a minor projection, etc., and often the posi- tion assumed by the patient suggests this, as for instance, the forward curve when the arms are raised, in case of skoliosis. Occasionally, orthopedic affections only cause functional disturbances, and in these instances examination under anes- thesia often first teaches us the degree of the diminished mo- bility, etc., as, for instance, in case of contractures. It is highly important in many cases, for comparative purposes, to carefully measure the deformity and to make a schematic drawing of it. The ordinary tape-measure answers the first indication, and the second is fulfilled by the1 plaster cast, by photography, by the direct tracing of the contours. In case of many deformities it suffices to measure the angle which the joint abnormally forms, and for this purpose, in ad- dition to the ordinary square, the goniometers are useful. I may mention the goniometer of Morisani,8 Krohne, Paci,9 Gutsch.10 I will only figure the Roberts' instrument. In many cases it is essential to take the measurements at Orthopedics and Orthopedic Surgery. 13 different levels (the sagittal, vertical, and frontal), and for this purpose complicated instruments are necessary. Among others Roberts n has made use of geometry for the description of deformities, terming the method diasiropliometry. A number of useful instruments have been devised for the pur- pose of measurement. In Roberts' Goniometer (Fig. 3) both arms may be used and made so short that the angle of a kyphosis may be deter- mined. Pelvic obliquity, abduction or adduction, flexion or ex- Fig. 3. -Roberts' Goniometer. tension, in short any deformity at any level may be measured by this instrument. For the determination of deformities at different levels Robert's epipedometer (Fig. 4), which may be placed at any angle, is useful. The two arms of the instrument, at right angles to one an- other, may be fitted to any surface of the body, and the devia- tions of the arms are carefully registered in degrees; one arm may readily be shortened, so that the instrument is also of utility in the measurement of club-foot. 14 Orthopedics and Orthopedic Surgery. Instruments of this nature are especially applicable to sko- liosis, and many are nowadays constructed. To obtain the configuration at any level an ordinary strip of lead will suffice. The lead-cur v e thus obtained may be transferred to paper. To measure the thorax the kyr- tometer is useful, as also analogous instruments con- structed like hat machines. To reg- ister simple cross- sections, the ap- paratus of Stark 12 (a double-circle with pencils at each extremity), that of Schenk and others may be re- sorted to. In many instances of de- formity of the foot it is advisable to obtain an outline of the plantar sur- face a pelmato- gram (-,-///«, sole). \ \ The patient is \\ made to tread % \ \ with blackened \ \ \ foot on a sheet of \ \ \ paper and thus a \ \ \ picture of the sole \ \ \ is obtained: the \ '"'. \ \ patien t can be \....'^"" caused to walk on the paper and thus Fig. 4.—Roberts' Epipedometer. Orthopedics and Orthopedic Surgery. 15 his manner of placing his foot down when walking is obtained (an ichnogram or stibogram). The value of this method has been particularly emphasized by F. L. Neugebauer,13 Vierordt and others. The prognosis of deformities, in general, may be considered good when no severe general disease is at the bottom, and when we are not dealing with a defect in formation of the bony parts, as in skoliosis. By means of bandages and ap- paratus, and particularly by the modern operations, the sur- geon is able to obtain complete cure, or essential betterment, in a relatively large number of cases. Even in case of curva- tures not specialty accessible to therapeutic methods, such as skoliosis, the prognosis has become much more favorable when the cases come early under treatment, for then we frequently obtain betterment, or at least check the progress of the affec- tion. We would note specially here that only in case of a few deformities does spontaneous cure occur, as in the slighter de- gree of rachitic curvatures; in by far the larger majority of instances, the deformities are progressive, and it is a mistake to tell the relatives that in the course of growth the deformity will alter for the better, for thus the most profitable time for treatment is allowed to pass. In connection with therapeusis we must lay stress on pro- phylaxis, the entire aim being to cause the body and brain to develop simultaneously, to further by all means the mens sana in corpore sano. Under this head are included not alone the proper food and clothing in childhood, in brief, attention to every detail of hygiene, but also suitable hardening of the bony and of the muscular system. Gymnastics, swimming, riding, out-door exercise and work, etc., these may do much to prevent the development of many deformities. In how far this bodily exercise may favorably affect the race, ancient Greece with her Olympic games is a witness, and I recom- mend, in particular, gymnastics after Busch's14 description. In this connection it is a cause of congratulation that the chief sports in England (ball playing, rowing, etc.) are obtain- ing a greater foothold with us. Another important factor for the prevention of deformities lies in the spreading of the knowledge of how to treat diseases of the joints properly. It is essential that the inflamed joint should be placed in such a 16 Orthopedics and Orthopedic Surgery. position that, if anchylosis ensue, it may be most useful (that is, hio and knee well straightened out, foot and elbow bent at right, angles); further, it is important to resort in time to passive motion, manipulations and massage, as soon as the essential inflammatory symptoms have disappeared. Most frequently it is the congenital deformities which reach a high grade, since the parents of the sufferer, from stupidity or ignorance, do not seek the requisite treatment early, and herein lies the great value of state institutions such as Stromeyer and Dieffenbach aigued for and Lorenz has lat- terly recommended. "What good end would not a state in- stitution fulfill where all the crippled children of the land could resort, and if possible be cured,—" thus speaks Lorenz, and indeed such institutions wrould be of far greater value than the offering for sale of faulty orthopedic apparatus. As regards the appropriate treatment of deformities, we may in general range ourselves on Seneca's side when he says: "Sanabilimus segrotomas malis ipsaque nos in rectum geni- tos natura si emendari velimus, juvat," the majority of ortho- pedic troubles being curable or subject to betterment, and in many cases by means of the simplest appliances. No single scheme of treatment, however, is applicable here, no single method but a combination of many methods usually fulfills our aim; we must not alone depend on mechanical means but also resort to dynamic, and among the former must be classed gymnastics, "orthopedic-gymnastics," as Delpech termed them. In orthopedics we must, in particular, individualize, for each case has its own special indications which must be attended to; a method which in one case seems suitable, in another will not be appropriate. In any event, the general state of the patient must be considered. To mention now the most essential orthopedic methods of treatment, we have: 1. The constitutional, general treatment, which includes: a. Attention to hygiene; b. Medicinal agents; c. Physical agents (gymnastics, massage, heat, etc.); d. Elec- tricity. 2. Mechanical agents (bandages, orthopedic apparatus); and finally, 3. Orthopedic operations (either requiring the knife or not). The error was formerly made of considering the constitu- Orthopedics and Orthopedic Surgery. \y tional treatment the chief one, and to-day actually this princi- ple obtains to far too great a degree. There can be no ques- tion that attention to the general rules of health, the obtaining of fresh air, care of the skin by baths, etc., strengthening food (breast milk for young infants), will effect much, and that in orthopedic hospitals the good results obtained are in part to be laid to the application of lrygienic principles; still these health-rules will not alone suffice, except in very rare cases where they are associated with the strengthening action of sea air, as at the sanitariums at Norderney, Sylt, Margate, Ramsgate, Eastbourne, Bec-sur-mer, Trouville, etc. Of medi- cinal agents of value the chief are iron, preparations of qui- nine, cod-liver oil. In rachitis the phosphates and sulphates are especially useful at an early stage to replace the lack of bone salts. To-day, owing to the researches of Kassowitz and of Wegner,15 we must grant considerable value to phosphorus in the treatment of rachitis. In case of 500 rachitic children Kassowitz witnessed the most marked results from the administration of phosphorus, and Unruh, Th. Toeplitz 16 and others have confirmed these results. Kassowitz recommends a daily dose of TV of a grain in mucilage or in cod-liver oil. B 01. Morrhuas, . . . . I iij 3 ijss. Phosphor.,.....gr. fg. Or in an emulsion as follows: 5 Phosphor.,.....gr. ^. Solve in 01. Amygd. dulc. 3 ijss et adde Pulv. acaceae, Syr. simpl., . . . . aa 3 j gr. xv. Aq. destil., . . . . 3 ij 3 v. M. S.—One to four teaspoonfuls daily. Latterly, Lesser has recommended the following as an anti- rachitic mixture: TJ Tr. rhei vinos., .... 20 parts. Potass, acet. sol., .... 10 Vini stibiat.,.....5 M. S.—According to the age of the child administer from five to ten drops three times daily. Increase the dose every third day by one drop until the child receives from twenty-five to thirty drops three times daily. 2 18 Orthopedics and Orthopedic Surgery. In addition to the above remedies, in cases of paralysis, strychnia may be ordered in the dose of ¥V of a grain three times each day, or else it may be administered subcutaneously in the dose of ^ of a grain once a week, this dose being in- creased according to circumstances. Of the general physical therapeutic agents, we note: heat in the form of the sun-baths, warm baths and douches, the use of the vapor bath to equalize the circulation. In paralytic cases and in chronic joint affections, the peat and salt baths, dry heat as recommended by Beard, of New York, may be used and the latter may be applied by means of Leiter's coil. Hot poultices, protected by gutta-percha paper, will often be found useful. A method which has been enthusiastically claimed as the only true and efficient one in orthopedics and again has been rejected as simple humbug, is gymnastics, that is to say the methodical exercise, active and passive, of the muscles. There is no question that this method, carefully and continuously Fig. 5. used, aside from its general strengthening effect, is valuable in the treatment of many orthopedic affections, especially where we aim at exciting and restoring function in certain groups of muscles. Of special value is the method devised by the Swede, P. H. Ling (died in 1839), and amplified by a number of others (Bronting, Rottstein, Norman Roth,17 etc.), the method of so- called " Swedish gymnastics," whereby not only active and passive movements are utilized but also a general effect on the muscle functions is exerted. This method has many ad- herents, and it is applied in a number of institutions, such as those at London, Stockholm, Baden-Baden, etc. The most essential point about the Swedish gymnastics is the methodical movements to which the individual is subjected. Either the operator endeavors to overcome opposition on the part of the patient, or the latter on the part of the former. Apparatus for these passive movements may also be used.18 Especially useful are the so-called thoracic joint-st rongtheners (Largiader19), the restorator (Goodyear), which is seen in Figure 5. Orthopedics and Orthopedic Surgery. 19 The restorator20 is especially useful for the methodical ex- ercise of muscles, for owing to the necessity of stretching the rubber band, the patient may himself take account of his mus- cular power (Vogt, Weil21). The same is true of other appara- tus, such as those devised by Sachs, by Seeger, and others. Massage (from ixaeesiv, to rub) was used by the ancients, the Indians and other races,22 for therapeutic purposes; its utility has lately been exposed by Metzger (Amsterdam), Mosengeil, and others, and the results obtained have led to its wide dissemination. Massage consists in rubbing, pressing, striking, etc., a por- tion of the body. It increases the force of the circulation, it causes a more rapid absorption of the products of inflamma- tion; under the influence of massage partial stiffness of joints disappears, atrophic muscles become richer in blood and stronger, in short the nutrition is improved, and the retrogres- sive phenomena occur to better advantage in the parts sub- jected to the manipulation. In particular has Mosengeil23 util- ized the various manipulations (effleurac/e or centripetal strok- ing by flat hands, frictions, ellipsoid rubbings with the finger tips,petrissage or kneading of the affected part, tapottement). These various manipulations have become popular, and latterly, works on massage have appeared in which the technique is carefully described,24 and instruments have been devised to take the place of the masseur's hands (such as the elastic muscle-beater of Klemm, or that devised by Flasher25 which is constructed of wood). The effect of these methods is due rather to the rubbing than to the materials which are rubbed in, such as vaseline, borax ointment, olive oil. In this connection we must refer also to passive move- ments, the so-called manipulations, the rotatory motions in the direction opposed to the deformity, which are applicable especially to club-foot, being repeated frequently during the day, the foot being redressed and held in such position for awhile in a suitable apparatus. In this way the ligaments and bones are prevented from developing abnormally, for the deformity increases with growth, and thus the obstacles to redressement are lessened without the motion of the affected part suffering. Generally, other methods, such as holding the affected part for a long 20 Orthopedics and Orthopedic Surgery. time in as good a position as is possible, will effectually assist. As regards the applications of electricity in orthopedics, the faradic, and more frequently the constant, current may be used over single muscle groups, but the current must not be too strong, or of too protracted duration (five to fifteen min- utes once or. twice daily). Sayre lays stress on the point that, when a paralyzed muscle is galvanized, it must be placed in such a position as to be subject to no strain of any kind what- soever. The action of the current is all the stronger when it is ap- plied to the spot where the most effective motor branch enters the muscle. Duchenne, of Boulogne, and v. Ziemssen26 have considered at length the preferable points of application, and for such information I must refer to their valuable works. In exceptional cases galvano-puncture of the muscles will prove effective, that is to say, the passage of the current through the muscle, by means of a needle connected with an electrode and inserted into the muscle while the other elec- trode is placed on the surface of th3 skin. We now pass to the description of the simplest mechanical appliances, the position and fixation apparatus. The former plays an important role, especially in the treatment of disease of the spinal column, and it may answer the purpose of afford- ing rest to the entire body, or else of only a portion of the body (as for instance Eulenburg's27 scoliosis apparatus, and the devices of Bonnet, Mayer, Rauchfuss, and others). For the sitting posture, the Volkmann-Barwell's oblique seat is to be commended (for skoliosis). AVe may mention here, also, the numerous orthopedic beds, as those of Valerius Venel, Guerin, Bouvier, Pravaz, Boynton, Harrison, Heine, etc. The majority of these beds are supplied with extension and counter- extension mechanism. Such apparatus will be spoken of under the heading of mechanism for reduction. As an example, we will describe here the Beely extension bed for skoliosis, which is seen in profile in Figures 6 and 7. Jig answers the purpose of elevation to the desired extent; bf is for the attach- ment of the girdle; / is a roller over which the weight is sus- pended; cd is the linen covering of the surface ad. In Fig. 8 the girdles are seen which pass under the chin, back of the neck and under the axillae. Orthopedics and Orthopedic Surgery. 21 Other beds are provided with mechanism for lateral inclina- tion, such as Delpech's, H. Bigg's, and girdles may also be fitted to them. In the Biirings28 apparatus for skoliosis, pads worked by screws assist in reduction. The same holds true of Hiiter's modification of this apparatus, and of Loring's, which is used in hip contractures, etc. I can all the more readily pass over these apparatuses since most of them are only of historical interest and have latterly been described by E. Fischer,29 and I may dismiss from consideration the orthopedic chairs, etc., for they are no longer in use. I will mention the so-called mechani- cal beds and the beds fitted with appa- ratus for lifting the patient. The first allow of defecation and of change of the bed-clothing without specially disturb- ing the patient, and this is accomplished either by sliding a board with an open- fig. s.-oirdie of Beeiys Bed. ing in it under the patient, as in the R. Volkmann bed,30 or by an extension mechanism,31 as in the Liicke bed; or further still by mechanism by means of which the mattress sinks down and may be removed, as in the Crosby bed. Of the 22 Orthopedics and Orthopedic' Surgery. apparatus for lifting the patient, the best is Beck's, since it is contrived so that the whole body of the patient or an indi- vidual portion, may be lifted. We pass now to the consideration of the various orthopedic bandages which are intended, usually, to maintain a de- formed portion of the body in position and thereby lead to better appearance, Fig. 9.—Hook for insertion in or possibly, only to betterment in func- blaster of Paris Bandage. ^^ The* importance of these bandageS is all the greater, seeing that by means of them we can, in the cheapest and quickest manner, apply suitable treatment, and Fig. 10 a.—Roberts' Elastic Tension Corset with Jury-mast. Fig. 10 b.—Roberts' Plaster Bandage with Ex- tension and Elastic Traction Apparatus. in that the physician may combine with them a number of other adjuvant therapeutic means (such as extension, elastic traction, pressure, etc.). They are generally useful, in par- Orthopedics and Orthopedic Surgery. 23 ticular in dispensary practice, where they most frequently answer the indications. The plaster bandage with justice leads the others, and it is best prepared from large-meshed gauze rubbed in finely pul- verized modeller's plaster. The plaster, when it has hardened, answers the purpose of holding the bandage in place. To strengthen it in various places it is advisable to fit in here and there pieces of wire or corset-steels, etc., or pieces of linen dipped in plaster may be inserted in the bandage as it is being applied. It is often essential in laying the bandage to insert splints to maintain redressement, and these keep the parts in position during the setting of the band- age. In children it is advisable to varnish the bandage after it has hardened to prevent its becoming wet through by urine, etc. By sinking hooks or brackets into the plaster we obtain points for attachment of extension or traction apparatus, as is seen in Heine's32 extension-splint. In Fig. 11 a simple apparatus of this nature, made bj7 Rejmders, is seen. The arm D is moved by the long screw C by means of the key G and is fastened at E. The ends are inserted into zinc plates which are fitted r}p~~^J into the plaster bandage. The splints of this fig. n.-Extension nature devised by Beely,33 of the Konigsberg spimt. Clinic, are especially useful in orthopedics, particularly where the lower extremities are concerned. We may note here the Robert's plaster corset with exten- sion blades sunk in, the length and force of which are regu- lated by the screws. The bandage made from plaster with the addition of coal dust has the advantage of being lighter, of setting more quickly, and of resisting moisture better, and was recom- mended by the workers in Langenbeck's clinic. The parafflne bandage has been warmly indorsed by many, Whitson for example, owing to the lesser danger of decubitus resulting. The silicate of soda bandage has, in general, the advantage of lasting longer and being less heavy, but its disadvantage is the fact that it requires more time for hardening; in ortho- 24 OrtJiopedics and Orthopedic Surgery. pedics, still, it is advantageously used for making corsets,34 etc., but the precaution must be taken not to moisten the first turns of the bandage too thoroughly, else the lower surface will become impregnated and be rough. In order to overcome the objection to the silicate bandage that it requires too long an interval for hardening, an oiled- paper may be laid over it, and next a few plaster layers which may be removed in a few days after the silicate has hardened. (Wolff, Fowler, etc.) The sili- cate bandage is as appropriate for the lower extremities as for spinal corsets. Konig uses, with good result, a mixture of mag- nesite and silicate of soda; such bandages are readily worn and are not likely to be broken or wet through. Paste-board bandages are also used, and are recommended especial!}' on account of their slight weight, and they may be made very solid and lasting by the insertion of splints, etc. Plastic felt impregnated with hair (presented hy Cocking in 1870, and first used by Ernest Adams) has quickly obtained a foothold in orthopedic surgery. It may be readily shaped by Fig. Id- -Or. .hopedic Plastic Felt Apparatus, dipping ill hot Water; Beely 35 has used it after impregnation with an alcoholic solution of shellac. It may be modelled over a plaster cast of the part where it is to be applied, and it may be loosened or tightened, according to desire, when in place (Schwartz36). We will now speak of the methods of preparing casts from plaster of Paris over which the plastic felt may be modelled. Over the oiled surface Beely place's a plain, lightly applied, plaster bandage, and this is cut and removed as soon as it has hardened. The interior of this cast may then be filled with plaster and the desired model is obtained. That the model Orthopedics and Orthopedic Surgery. 25 may not be too heavy a tube may be inserted through the centre. For the preparation of casts of the back certain modifica- tions have been introduced. Braatz37 makes a light cast by covering the inner surface of a linen model with an inch or so of plaster; after the removal of the covering the plaster cast is smoothed down and the felt is fitted over it. Karewski38 quickly lays a plaster bandage around the sus- Fig. 13 a.—Patient before Fig. 13 b.—The Corset with Fig. 13 c—Patient Suspended with Adaptation of Corset. Suspension Bands. Corset in Place, prepared for Covering with Plaster. pended patient, inserts the hooks while the plaster is soft, cuts the corset when the plaster has hardened, smooths the edges, and then oils the model and rubs plaster over it. In Figs. 13, a, b, and c is represented Heidenrick's39 method of obtaining a cast. He suspends the patient and places around him a sack made of coarse linen, brought together above with a running string, packed with cotton below and made fast above the trochanters. On each side of the oiled 26 Orthopedics and Orthopedic Surgery. body extending over the shoulders is a string which serves the purpose of cutting the plaster cast, before it has hardened too much, into two pieces exactly adapted to one another. In Fig. 12 Beely's40 method of using felt is shown. Leather has also been utilized for corsets, etc., and owing to its durability and elegance its application is a wide one, Beely used stout leather hardened in glue, and by painting it over with double potassio-chromic acid he makes it very re- sistant to moisture. Karewski41 and I. Smith recommended fine wire gauze for orthopedic bandages, and this has the ad- vantage of being light and permeable to the air. In excep- tional cases hard rubber, softened in hot water, will prove useful; when heated it may be readily bent to any desired shape and retains it'when hard. Another material often used in orthopedic surgery is di- achylon plaster, and this leads us to speak of the traction bandages which are resorted to to prevent contractures, to assist growth in a desired direction, etc. This plaster is most frequently used for the redressement of slight deformities of the feet, etc., generally in connection with splints, etc., and for orthopedic purposes it must, of course, be not too yielding, and be possessed of good adhesive proper- ties. Maw's moleskin plaster is a good article. Before the application of the plaster the surface must be washed off with soap and thoroughly dried. If necessary it must be shaved. In case of extension bandages, which are chiefly used for the lower extremities, the Volkmann method of plaster and foot- piece has obtained wide acceptance. In addition to the quality of the plaster, care must be taken to pad the tibia and the pro- jecting bones of the ankle, lest decubitus ensue. In the majority of cases, extension may be obtained by stones or sand-bags slung over a roller, while the counter- extension is yielded by the weight of the body. Rarely are inclined planes requisite for counter-extension. When extension is made from the head, it is obtained by leather bands (a and b) encircling the chin and occiput, which are united each side under the ears by buckles (c), and are suspended from above by slings attached to rings (vide Figs. 14 and 15). A simpler method is, after shaving the head, to use strips of plaster under the chin and occiput, extending them over the Orthopedics and Orthopedic Surgery. 27 ears to the level of a tangent across the sinciput and here to attach them to a hook by means of a third sling of plaster. To obtain horizontal extension there are a number of ap- pliances applicable to skoliosis, torticollis, etc., which will be spoken of under the subject of curvature of the spine. We find the principle of vertical extension in ancient or- thopedic apparatus, such as the Bloemer chairs, the Shaw sling, and these are not only useful in case of disease of the spinal column, torticollis, etc., but also in cases of curvature of the limbs.42 Thus, the vertical appara- tus recommended by Schede and others, for fracture of the thigh in children, may be utilized in case of aggravated rachi- tic curvature of the femur. In simple suspension, that is to say in the lifting of the body from the sitting or standing posture (as may be accom- plished by Glisson's slings, axilla slings, Beely's self-suspension apparatus, Fig. 16,) Sayre's tripod, which may readily be Fig. 14.—Head-Sling. (Beely.) Fig. 15.—Head-Girdle in two parts. improvised, is useful. The body-weight acts as counter- extension : occasionally we may, in addition, obtain a species of lever effect by causing the patient to bend over a line (Vogt43). Orthopedic apparatus should not only be cheap, lasting, and readily applied, but in the majority of cases it should be carefully supervised. As Noble Smith says, " No instrument will be of much use unless the surgeon devote his attention to its adjustment and re-adjustment" ; and as Hennequin44 says, "Un appareil quelqu'il soit ne vaut que par celui qui l'ap- plique." It is not so much the apparatus as the manner of 28 Orthopedics and Orthopedic Surgery. its application which makes it efficient, and badly applied it will work harm. As to orthopedic apparatus in general the simplest is the* best.45 In many cases, where formerly apparatus was neces- sary, we can to-day dispense with it in favor of operative pro- cedures, etc. Much always depends on the exact application of apparatus, and this is the reason why the aid of an expert orthopedist must, in special cases, be invoked. Fig. 16.— Beely's Apparatus for Self-suspension. Fig. 17.—Suspension Apparatus. We may divide the apparatus into: 1. Retention means; 2. Reduction means, by which curved or deformed parts are re- stored to the normal position by traction or pressure; 3. Am- bulant apparatus. In general, orthopedic apparatus may be divided into am- bulant, that is, that which may be worn by the patient while about, and into apparatus which can only be used with the patient in bed. Orthopedics and Orthopedic Surgery. 29 The materials out of which the apparatus may be con- structed are steel, iron, wood, leather, hard rubber combined with elastic straps, etc. The most durable and elegant splints are those constructed of leather fashioned over wood or plas- ter models, connected together by steel blades and straps, and with movable joints. These are light, and therefore particu larly advantageous when, as in case of paralyses, etc., they must be worn for a long time. In regard to the nature of the joints, the hinge, as we find it in any pocket-knife, is the most frequently resorted to. Less frequently the joint is constructed similarly to the hinge of "a door, the motion being at the level of the surface of the splint (as in Bonnet's apparatus for the prevention of inward rotation of the foot, where the pelvic gir- Fig 18.—Extension Projection of Iron Fastened to a Door. The suspension portion moves on rollers. die and the splint for the upper leg are so connected. This is shown in Fig. 20). Where it is essential to obtain motion in a number of direc- tions, a variety of joints are combined. By the combination of three, Stillman, for instance, has devised a universal joint, thus obtaining all the advantages of the ball and socket joint (free motion in all directions), without the disadvantage of being obliged to entirely fix the joint or else to allow of motion in any direction. The enarthrosis, or ball and socket joint, is less frequently used, as it is found in certain apparatus devised for torticollis (Bruns), in a number of club-footed appliances (Busch), in ap- paratus for congenital luxation of the hips (Nyrop), etc. The joints are rarely entirely uncontrolled, for they are in- 3° Orthopedics and Orthopedic Surgery. tended to guide, as it were, the movements of the part of the body concerned, to control the motion of the limb in a certain direction; in the knee, for instance, to prevent lateral move- ments; usually the object is to allow motion only to a certain degree, or to prevent motion in a special direction. With this end in view counter-checks are inserted in the joints to prevent undue movement in the direction opposite to that which is desired. On the other hand, it is often essential to prevent motion only to a certain degree for a special purpose, that is to say, to be able to limit motion, and for this purpose screwrs answer best. By means of screws the two sections of the apparatus may be joined together at any desired angle. A very practical application of this point we find in the Stillman sector splint among others, where one splint maybe placed at any angle to the other and is held in position by a screw. Where the aim is to secure position in a special direction, as in extension, then a simple bracket or bolt-like mechanism is the readiest, as is exemplified in the apparatus for keeping the knee extended, where a small steel arm, projecting from one splint, fits into a circular piece on the other splint. Fastening may be accomplished in a very simple manner by means of clasps, fitting- the no. i\i.—rtyropsma- •*• ° chine for Paralysis of one into the other, attached to the sections the Lower Extremity. 0f the splint—as in the Nyrop apparatus for paralysis of the extremities, a contrivance which is all the more valuable practically in that by slight pressure on a circle (D in Fig. 19) the apparatus may be quickly set out of function. Where fixation in very different directions is essential, we may insert a small spring which fits into a toothed wheel, as in the Baedenheuer shoe for club-foot, etc. In the ambulant apparatus for the lower extremities, the mechanism is ordinarily fitted into the shoe, the two blades of the splint being united between the inner and outer sole of the shoe, or, in order to be able to separate the blades, they are OrtJwpcdics and Orthopedic Surgery. 31 inserted into projections at right angles to the shoe or firmly bound to them by a clasp spring. Where we are not obliged to take the question of cost into consideration, it is preferable, from the stand-point of dura- bility of the apparatus, to fit a well-padded metal sole on the shoe, so that the apparatus may be worn independently of the shoe, that is even with slippers. The orthopedic shoe is of special importance. Often, by making the sole of one shoe higher than that of the other, or by the addition of an extra section of leather to the sole, we may counteract an abnormal position of the foot, or by build- ing up one side of the shoe we may oppose a curvature. These points are exemplified in the Kolbe club-foot shoe, and in others. By a very simple contrivance the patient can be com- pelled to place his foot down in a special manner, as is exem- plified in the mechanism in the Roser stirrup shoe, where a metal stirrup projects laterally from the surface of the shoe. Occasionally a rubber sole is to be commended, owing to its durability and pliability, the latter quality allowing any de- sired shape. In order to make locomotion easy and in order to secure certainty of adaptability of the foot to the shoe, it is advisable to have it laced all the way up in front above the ankle joint. Thus the foot is thoroughly secured. A large majority of the ambulant apparatuses are attached at the pelvis and for this purpose a well-padded girdle is neces- saiy. This may be made of sheet iron and in front of leather. In many instruments steel bands, padded, pass over the crests (Langgaard) and are attached to the pelvic band. Where it is particularly desired to fix the apparatus to the pelvis we may use corsets, as is the case in various French appliances. These may surround the hips, sacrum, or the en- tire lower abdomen and back, and the special apparatus may be attached to the corset b}^ steel clasps or by leather straps. Again, as in the Nyrop corset for inferior lumbar kyphosis, a pad may be placed over the nates behind the trochanters and be attached to the corset. Further, dorsal splints, with head supports, etc., may be adapted to the pelvic bands and these may be fitted into an orthopedic corset. Other important orthopedic apparatus is seen in the reduc- 32 Orthopedics and Orthopedic Surgery. tion machines, which we may divide into ambulant and non- ambulant, and in the construction of which we find the most varied mechanism. In case of the non-ambulant apparatus, we deal with extension mechanism by weight, bands, etc., either in one direction—as in Stromeyer's equinus apparatus (Fig. 20), the Lorinser-Bonnet knee contracture apparatus— or in two opposed directions, as in various extension beds (Heather Bigg's, Fig. 23, Heine's, and others) which will be spoken of in detail under the subject of diseases of the spinal column. The ambulant apparatus is to-day used with far greater frequency, and here the principle of the lever (one-armed or two-armed) may be utilized, as in the apparatus adapted to Fig. 20.—Stromeyer's Equinus Apparatus. genu valgum, contractures, club-foot, etc., in the shape of dif- ferent lever splints. A very efficient means of reduction is offered by elastic traction, whereby we may obtain a continuous, slight, gradu- ated force, or, if desired, a very great force (Barwell, Bruns), and we may use for this purpose either material with rubber set in (as in the Barwell skoliosis bandage, the Fischer band- age for skoliosis), or else rubber bands (as in the various con- tracture apparatus), or rubber rings which are placed between two straps, and the force exerted by which we may graduate by means of the straps. Elastic traction is exerted in many of the recently devised orthopedic appliances, such as the in- genious apparatus of Blanc, the club-foot apparatus of Sayre, Stillman, and others, and this traction is all the more to be recommended-since it may readily be combined with plaster- bandages, or any material which it is desired to use. Thus, elastic traction is resorted to in rotation of the foot, by con- necting the lateral bars of the splint with elastic bands (Beely). Orthopedics and Orthopedic Surgery. 33 Among these appliances with elastic traction are included those where groups of muscles are re-enforced by the tension in order to antagonize other groups. Delacroix, Duchenne and others have commended such appliances, of which number we will only refer here to Delacroix's apparatus for paralysis of the extensors of the fingers, and to the apparatus for use in paralytic pes equinus and pes calcaneus, where the paralyzed muscles are re-enforced by elastic bands or rings. Spiral metallic springs may also be used for traction pur- poses, as is exemplified in Heather Bigg's extension bed (Fig. Fig. 21.—Lucke's Apparatus for Club-foot. Fig. i'i—Bigg's Extension Bed. 23), and the spring may also be utilized for obtaining rotation, as in Doyle's apparatus for the after treatment of club-foot. In case of paralysis, these spiral springs are also resorted to, as in Mathieu's apparatus for paralysis of the quadriceps femoris, where the thigh and the leg splints are connected to- gether in front by a spiral spring. Springs are also adapted to many appliances for pes equinus, pes calcaneus, and to Duchenne's apparatus for paralysis of the muscles of the foot, where small springs, corresponding to the paralyzed muscles, are inserted into the leather. These springs are also useful to keep two portions of a bandage apart and to obtain extension, as in the Roberts corset (Figs. 10, 25.). 3 34 Orthopedics and Orthopedic Surgery. In spring steel splints we also have a valuable means of reduction, and they may be used either to exert traction or pressure, In the first instance, they may be parabolic in shape or S-shaped. These springs are used in the numerous club-foot shoes (as in Scarpa's shoe and its many modifications), the band fast- ened to the leg keeping the foot pro- nated and abducted. The S-shaped band exerts not only extension but also sub-luxation backward, as is ex- emplified in many pes equinus, and in many contracture appliances (Heather Bigg's knee apparatus, for instance). Resort to metal bands for the pur- pose of exerting pressure we see in connection with pressure cushions, and Nyrop's skoliosis apparatus may be taken as the tj'pe. In this apparatus the vertical dorsal blades are held backward by elastic steel bands, and at the point where these are brought forward to be fastened they exert pressure on the cushion, that is, di- rectly against the angles of the ribs, while the remaining blades exert no Fig. 24.—Doyle's Apparatus. ^ n 4.1-11 w pressure at all on the body. The toothed-wheel and toothed-bar are utilized in many orthopedic appliances for effecting reduction where we aim at considerable gradual extension by the apparatus. The toothed bar is also used with a surrounding metal spring, and this en- Fig. 25.—Roberts' Elastic Extension Bar. ables us to obtain fixation in a better position, and prevents return to a faulty one. This is exemplified in the Roeser- Baedenheuer club-foot shoe. Formerly the screw mechanism played a great role in or- Orthopedics and Orthopedic Surgery. 35 thopedics, and this is not surprising, for, before the introduc- tion of elastic traction, by means of the screw gradual and Fig. 26 a.—Nyrop's Spring Splint. Fig. 26 b.—Beely's Corset. great power could be obtained according to the desire of the surgeon. Fig. 27.-Reynder's Apparatus for Torticollis. Fig. 28.-Kolbe's Club-toot Apparatus. The most popular Was the endless or Archimedes' screw, and this was utilized in many contrivances for contracture of the extremities. 9999261 36 Orthopedics and Orthopedic Surgery. While the simple endless screw is seen in many contracture appliances, such as the Ulrich and Mittler's hip-extension ap- paratus, the Langgaard knee-extension apparatus, the H. Bigg and the Goldschmidt's finger-extension apparatus, we also find the manifold endless screw utilized for the purpose of effecting reduction, as in club-foot appliances (Charriere, etc.), skoliosis contrivances .(Langgaard, Eulenburg), torti- collis apparatus (Fig. 27), Stillman's and H. Bigg's machines, for antero-posterior curvature of the spine, contrivances which naturally act the more effectively, the longer the lever arms which are adapted to them. The screw mechanism is also utilized at the angle between two articulated splints, so that the distance between them can be lengthened at will by the screw. This is the case in Kolbe's elbow machine and in a number of club-foot appliances, etc. i.-Screw in Bonnet's Fig. 30.-Bonnet's Machine for the Exercise of Apparatus. the Tai0-tarsal Joint. The vis a pression, which Guerin formerly used to a great extent, has to-day much less recognition. A simple screw passes through a stationary nut and presses on the movable arm of a lever, forcing down this end or preventing its eleva- tion, so that excess of movement is impossible. This form of screw is seen in many club-foot apparatuses (Lutter's and Langenbeck's), the aim being to prevent the equinus position, and also in Bonnet's machine for the prevention of inward rotation (Fig. 29). A further group of appliances are the self-movable ma- chines, many of them ingenious and devised by Bonnet, by means of which the patient may himself exercise'the functions of a joint by exerting passive motion, usually through a cord passing over a roller, on which the patient makes traction. These machines allow of motion only in one level (the best known is Bonnet's appliance for knee-contracture), and in Orthopedics and Orthopedic Surgery. 37 order to apply passive motion to the foot, for instance, three machines are necessary and therefore apparatus of this nature Fig. 31.—Apparatus for Movement of the Talo-crural Joint. has yielded in general to movements applied through the hands. In this place belong the appliances in which, by changing an elastic band from one to the other side, the movability of Fig. 32.—Changeable Elastic Traction for Fig. 33.—Changeable Elastic Traction for Correction of Knee Contractures. Correction of Knee Contractures. (Collin.) (Collin.) a joint is increased (as in the Collin, and the Reibmayer con- tracture apparatuses). SURGICAL ORTHOPEDIC OPERATIONS. Surgical operations also play a most important role in or- thopedics and in this respect has progress in modern times been most marked. The operations are: 1. Special manual, without injury to the skin, and, 2. Cutting procedures, and these may be either subcutaneous or percutaneous. It is evi- dent why, at a time when, by a 113- cutting method, there ex- isted danger of abscess, suppuration, septicemia and pyemia, the subcutaneous method, owing to the slighter risk of wound complication, should have been preferred; to-day, however, owing to the aseptic methods of treating wounds, the open operations are growing more in favor. We need mention only the open myotomy of the sterno-cleido-mastoid, the Phelps operation for club-foot, etc. 38 Orthopedics and Orthopedic Surgery. We may further divide operations into those which are limited to the soft parts and into those which concern the bones; in both, however, it is essential that the after-treat- ment should be the correct one. As regards the special manual operations without injury to the skin, they are intimately related to massage manipula- tions, extension by bandages, etc., of which we have already spoken. When the insertion points of muscles become so approxi- mated as to lead to deformity, the manual stretching of the muscles, with or without anesthesia, may be resorted to in order to overcome this deformity. Manual manipulations are oftener called for on account of inflammatoiy adhesions, etc., in or near a joint, and we will speak further of the method of brisement force under the subject of contractures; in general, the force used should not be too great lest rupture ensue. If, by such methods, the malformation be corrected, then it becomes necessary to hold the part in good position by means of bandages, or else, through passive motion, to recover the normal movability and thereby to restore function to the limb. In connection with the osseous system also, methods un- associated wTith injury to the skin are called for, and owing to the greater accuracy of the modern apparatus for osteoclasis, that is, the breaking of deformed bones by weight without the making of a wound, this method excels osteotomy. Usually osteoclasis is performed b}7 lever action, either by the hand of the operator alone, or else with the assistance of special ap- paratus (osteoclasts), as a rule, under anesthesia. The hand is suitable especially in case of long, non-sclerosed bones. Many curvatures of the bones in infants, due to rachitis, pro- vided sclerosis has not set in, may be bent straight with almost no force; the same holds true for badly united fract- ures before the callus has hardened. We work in these in- stances with both hands on each side of the eminence of the curvature, the thumbs being placed at the site of greatest curvature, and we may thus readily straighten the bone; we usually feel crepitus resulting from slight fracture, but this heals quickly under a fixation bandage. The English writers compare this fracture to the variety known as "green-stick." Where rachitis with sclerosis has occurred, and this may Orthopedics and Orthopedic Surgery. 39 happen as early as two to four years, then the strongest man is not able to break the bone of a child, and here osteotomy finds its indication. In case of adults, only exceptionally is it possible to break a deformed bone manually (especially, for example, in case of badly united fractures of the fore-arm). Ordinarily, a large hollow hone may be broken by bending it over the knee or the edge of a table, etc., these points acting as resistances to the lever action, and when the bone is too short it may be lengthened by plastering on a splint.46 Usu- ally large arc-like cur- vatures, where sclero- sis has not set in, yield best to such methods. In the majority of instances in adults the requisite force must be obtained through special instruments, and here the chief dif- ficulty is to obtain the fracture at the de- sired place. While, formerly, forcible ex- tension by the Schnei- der-Menne I apparatus, etc., was the practice, to-da3r the ostecolasts are substituted, espe- cially the improved ones of modern times. With the majority of osteoclasts the portion to be operated upon rests on a hard surface, and at the site of greatest curva- ture force is exerted through a pad, etc., and thus the bone is fractured. The simplest instrument of this nature is that of Bosch,47 which acts on the principle of the book-binder's press. Of the numerous osteoclasts (or dysniorphosteopalinclasts) those of Blasius, Oesterlen, V. v. Bruns, Taylor,48—we will only represent Rizzoli's (Fig. 34), which has been especially used for the fracture of rachitic curvatures, and which consists of two iron rings, the one applied above and the other below the site of greatest curvature; these rings hold the bone and are Fig. 34.—Rizzoli's Osteoclast. 40 Orthopedics and Orthopedic Surgery. connected by a bar through the middle of which works a screw. To the end of this screw is attached a plate, through which pressure is conducted at the eminence of the curvature which is covered by a pad. This pressure is increased till the bone is fractured. In order to measure the applied force a dynamometer may be attached to Rizzoli's osteoclast. The apparatus is a very simple one. The padded rings surround the bone; they are connected by the iron bar and fixed by screws; the large screw is worked down until the pad over the eminence of the curvature is thoroughly adapted, and then a Fig. 35.—Robin's Osteoclast. few quick turns of the screw will break the bone, often audibly. A fixation bandage or extension is applied. The new apparatus of Robin and Collin has the advantage of breaking the bone at the exact spot desired; the fracture is usually transverse, and this apparatus is also suitable for breaking the bone quite near joints. These inventions have greatly stimulated resort to the osteoclast, especially in France.49 The Robin osteoclast consists of a strong wooden base which is screwed at S to a firm table. The wooden base is perforated for the insertion of iron bars EE, and these are fixed by the lever D. The arcs BB are movable on the bars EE, and these compress the plate 67, by means of the screw- key C. The lever force is regulated by the spring R. The Orthopedics and Orthopedic Surgery. 41 force is applied to the periphery of the bone through the three- fold leather girdle L. The new Collin osteoclast, which was devised for the cor- rection of genu valgum, consists of a firm base, to the centre of which is attached a strong quadrilateral iron plate which may oscillate forward and backward; through this plate works a compression screw, which is movable so as to be ap- plied, where desired, on the bone. Of the two lever arms onty one is movable, and when it is approximated to the other, the requisite force for fracture is exerted. (See Fig. 36.) In many cases the very simple Volkmann apparatus, which consists of a ring and a long lever arm, may be used. The ring is pushed over the site where it is desired to cause fract- ure, and the requisite force is quickly applied through the lever. According to Bockel,50 of 120 patients with contracture of the extremities the above method succeeded in three-fourths of the cases, and for more than half the use of a simple appara- tus sufficed. Thirty times osteoclasis was requisite, and with the exception of one case, it succeeded twenty-seven times in children ranging from eighteen months to eight years, and only failed three times. Recent reports have strengthened the position acquired by osteoclasis and it is not surprising that statistical data should speak in favor of it over osteotomy., Pousson,51 in ninety-eight 42 Orthopedics and Orthopedic Surgery. cases, has never seen much after-disturbances except in one case where there was a slight bruise. In regard to the cutting methods, we must consider those involving the soft parts (skin, fascia, muscles, tendons), and those involving the bones (section of bones, removal of a por- tion). The further subdivision is made into the so-called sub- cutaneous operations, which are performed through a small incised wound in the skin, and into the percutaneous opera- tions, Avhere the skin is severed in order to expose the part to be operated upon. While, in the days when man was power- less against wound complications the subcutaneous opera- tions were naturally resorted to, since thus certain of the risks were avoided, in these days of antisepsis the percutaneous operations have had a wide prospect opened before them, since, by the free exposure of the parts, we may better recog- nize shortened tissue or the bands which prevent reduction of a deformity, and we may further the better separate them, and since we may, by Esmarch's bandage, avoid the haemor- rhage which would otherwise obscure the field of vision. Of the operations on the soft parts, we must first consider those which consist in cutting the cicatrices which cause de- formity. Where such cicatricial contraction exists we may reach our aim by simple incision of the bands, by transverse incision followed by vertical union, by flap operations, es- pecially the A—, V—, and |—l-shaped incisions (Busch, Burns, etc.), by extirpation of the cicatricial tissue, and by transplan- tation of large flaps from the neighborhood. The cutting of fascia and of aponeuroses is not frequently resorted to in orthopedics; usually this involves the palmar and plantar fascia, and the fascia lata in case of contractures, etc. These operations majT be also performed subcutaneously and percutaneously, and in regard to the palmar fascia we will speak later in connection with Dupuytren's palmar fascia contracture. The cutting of single ligaments is also, in general, not often resorted to in orthopedics, although formerly the section of the external lateral ligament of the knee played a role in the treatment of genu valgum. More frequently, it is a question of cutting different tissues Orthopedics and OrtJwpedic Surgery. 43 as in Phelps' method of treating club-foot, where all the tis- sues which hinder redressement,—the skin, fascia, tendons, ligaments,—are cut, and the wound is then allowed to heal antiseptically. In the orthopedic practice of earlier times, in particular, the cutting of muscles and of tendons for the correction of de- formities played a very important role, and tenotomy is of far greater value than myotomy, and should be selected in- stead, seeing that the necessary wound is a slighter one, its cross-section a smaller one, and, owing to the speedier union, the subcutaneous operation will to-day, in the majority of cases, be given the preference. Especially is this the case for those tendons, such as the tendo Achillis and the tendon of the sterno-cleido-mastoid, which are not surrounded by any special sheath and therefore where the risk of permanent non-union need scarcely be taken into account. The section of muscles and of tendons was even resorted to in the middle ages for the correction of deformities, but sup- puration, etc., frequently resulted and this nullified the result. Tulpius, Solingen, Roonhuysen performed tenotomy; Lorenz, on the advice of Thilenius, in 1782, for the first time cut the tendo Achillis for the relief of club-foot, and Sartorius and others imitated him. In 1822, Dupuytren and others tenoto- mized for caput obstipum. Tenotomy, however, first gained acceptance as a valuable operation after L. Stromeyer (1831 to 1833) had learned how to avoid its risks, and we may, with justice, say that orthopedic practice was thus revolutionized as much as was ophthalmology by the discovery of the ophthal- moscope (Bauer). The enthusiasm which this operation evoked was all the greater, seeing that, in comparison with the great results it yielded, it could be termed a minor operation. Dief- fenbach, especially, cultivated the method in his large prac- tice, so that in his work on the section of tendons and of muscles, which appeared in 1841, he could report 120 cases of torticollis and 350 of club-foot where he had tenotomized, and in one year he performed no less than 250 operations of this nature. As in the case of many new methods, tenotomy was re- sorted to far too frequently, and we may rightly speak of " excess in tenotomy " when we read of cases where twenty and more tendons were divided in a single individual. In a 44 Orthopedics and Orthopedic Surgery. large proportion of instances which were formerly 1 enotomized, we may to-day attain our aim through the use of orthopedic contrivances (elastic traction, etc.); there still, however, re- main a large percentage of orthopedic affections (especially contractui-es of the foot, torticollis, etc.) where a tenotomy will considerably shorten the time requisite for treatment, and for this reason it should be resorted to. In any event section of a tendon will only be of utility when the necessary after- treatment is instituted, and herein there was formerly, and there is to-day, much still to be desired. Union after tenotomy consists in the following steps: The small space between the severed tendon generally fills up with a little blood, the coagulum becomes organized; the paraten- dinous tissue is involved in the plastic infiltration, and since the original plastic material spreads into the connective tissue, the ends of the tendon become united by connective tissue fibres which possess all the characteristics of tense connective tissue. Paget,52 Lebert, Amnion, Brodhurst, have carefully studied the steps of this process. In regard to the technique of subcutaneous tenotomy, we need small, curved or straight, pointed or rounded, convex or concave knives, the so-called tenotomes, which should only make a short cut in the transverse diameter of the tendon. The pointed tenotomes, of which the slightly sickle-shaped tenotome of Dieffenbach may be taken as the type, have the advantage that no other instrument is required for the opera- tion, and further, in that careful use does not carry with it the risk of unnecessary wounding of the tissues. The blunt, rounded tenotomes possess various shapes. In their use the tissues are incised at the desired spot by a small bistouri; the tenotome is inserted into this incision and the tendon is cut. Two instruments, therefore, are requisite for this small operation, and this is always a disadvantage. The little instrument of V. v. Bruns combines the advan- tage of both, in that the point is cutting and is curved for- ward to such a degree that, after, by a quick stroke, the tis- sues have been cut, the tenotome may readily be pushed down to the tendon and then the tenotomy may be performed without risk of injuring the neighboring parts. Owing to the short time requisite for the performance of this operation anesthesia is not absolutely essential; still, many Orthopedics and Orthopedic Surgery. 45 authorities recommend it, seeing that the movements of the patient may interfere with the operation. With good assist- ants, however, especially in children, the limb may usually be held so that there is no indication for anesthesia on this score. It is always essential that the patient should occupy a posi- tion in which the part to he operated upon may be steadied to the best advantage, and that the limb be so held that the shortened tendon may spring well forward. Tenotomy is then performed, as a rule, at the spot where there is least danger of injury to the neighboring parts and where the tendon has the least transverse diameter. The incision on the border of the affected tendon should, as far as possible, be made in the direction of the fibres of the ten- don; it should be small (to avoid entrance of air), and should Fig. 37.—Tenotomes, a, Guerin's Lancet- Fig. 38.—Tenotomes, a, Straight-cutting shaped Knife and Blunt-pointed Tenotome; Tenotome; 6, Dieffenbach's Tenotome; c, b, Stromeyer's Tenotome. v. Bruns' Tenotome. further be made on that side which is the most convenient for the operator in the use of his instruments. The position of the tenotome during tenotomy is somewhat like that of a knife while peeling fruit; the tendon is rather held against the tenotome; the motion of the instrument should be rocking not sawing. The tenotomy may be per- formed either from within outward or from without inward. In case of tenotomy from within outward the left hand of the operator, or of an assistant, holds the affected limb so that the tendon which is to be cut springs sharply forward; the operator, holding the tenotome in his right hand, inserts it into the small incision near the border of the tendon, carries the instrument flat under the tendon nearly to the skin on the opposite side, turns the instrument to an angle of 90°, so that the cutting surface lies against the tendon and this is severed by a number of slight t factions, while the thumb of the oper- ating hand controls the action of the instrument. 46 Orthopedics and Orthopedic Surgery. When the tendon has been severed, and this is generally evidenced by an audible crackling, the tenotome is again turned on the flat and pulled out through the same incision, the wound being at once compressed by the finger and then dressed antiseptically. In case of tenotomy from without inward, the limb is held so that the tendon is not put on the stretch, and the tenotome (blunt like Guerin's or Bruns') is inserted flat through the wound above the tendon, between it and the skin, until it has passed the tendon; the tendon is then made tense, the opera- tor then presses the back of the knife outward, the tendon is cut through in part by the tension, and an audible crackling, with an immediate yielding, tells us that this has happened: the extension is relaxed, the little knife is turned and slowly drawn out of the wound horizontally; a compressive antiseptic bandage is at once applied. It is important that the operator, or his assistant, should at once relax the tension of the tendon as soon as it has been cut, and that immediately on the withdrawal of the tenotome from the wound, the blood should be pressed out of it and an anti- septic dressing applied. The correction of position should, as a rule, not be resorted to immediately after the tenotomy; it is preferable to wait until the trifling wound has healed, usually about three days at the earliest; the correction, further, should not be sudden but gradual. The complications following tenotomy may be stated as the following: 1. Profuse haemorrhage from wounding of a large vessel, which calls for a compressing bandage, rarely for the ligature. 2. More frequently it happens that, owing to movement on the part of the patient, the wound in the tissues is greater than is essential, or that the tissues on the opposite side are pierced. Such occurrences are of no importance if the after- treatment be in accordance with antiseptic principles. 3. Incomplete section of the tendon may lead to difficulties, seeing that the operator must forcibly rupture the remaining fibres, or else insert the tenotome again in order to completely sever the tendon. Suppuration after tenotomy is-to-day a rare occurrence; it may happen, however, in uncleanly children, and then care Orthopedics and Orthopedic Surgery. 47 must be taken to secure free drainage, lest gangrene, etc., of the tendon ensue. Myotomy is less frequently indicated than tenotomy. At times free section through a large wound may be advisable, since we can thus better loosen cicatricial bands, etc. A large incision is especially indicated in Phelp's operation, or in the percutaneous section of the sterno-cleido-mastoid, in order to avoid, with greater certainty, injury to vessels and the result- ing sequelae. The modern operations on the osseous system mark still greater progress in orthopedics than the introduc- tion of tenotomy. Such are the operations of osteotomy, os- teoectomy, resection, arthrodesis, etc., and they have been made possible by the modern methods of treating wounds antisep- tically. These operations constitute a most valuable advance in surgery and are applicable generally whenever osteoklasis and other mild procedures cannot promise sufficient result or are out of the question, or where treatment by apparatus, owing to cost and length of requisite time, cannot from the circumstances of the patient be instituted. Although section of bone was performed in remote times (Avicenna) and lapsed into forgetfulness, and although in the pre-antiseptic era it was again practiced as subcutaneous os- teotomy by A. Mayer and Langenbeck, yet severe after-dis- turbances, death from pyemia, etc., not infrequently occur- red, and only on the advent of the antiseptic era did these operations on the bones become established, and they are, to-day, frequently practiced to circumvent deformity, to over- come anchylosis, old dislocations, and badly united fractures. In regard to the instruments which are requisite for these operations, in addition to the ordinary scalpels, etc., bone knives or resection knives (Langenbeck, Billroth, Nelaton, Bruns, etc.), and rasps must be mentioned. To-day the chisel plays a great role in these operations (Billroth, Volkmann). The carpenter's chisel, which is sharpened on one side (Fig. 39, b) and answers for the removal of pieces of bone, is not only used but also the sculptor's chisel (sharpened on both sides, Fig. 39, a), which has the form of a slender wedge. The latter is resorted to for simple perforation of bone. The chisel must be constructed of well-tempered steel; it must be sharp and in various sizes. The handle should end in a metal knob or else be of hard wood so that it will present a broad, firm surface 48 Orthopedics and Orthopedic Surgery. for the hammer to act upon. The hammer may be con- structed either of lead or else of hard w^ood (lignum sanctum, etc.). Before the general introduction of the chisel operations, the saw, in particular the panel saw (Langenbeck, Adams), was widely used, and the latter, in particular, is for many in- stances a very useful instrument, since it is only dented at the upper end, and the soft parts, hence, may be the better pro- tected. This form of saw is especially useful when it is a ques- tion of cutting through a superficial, readily accessible bone, or when the bone is sclerotic, or when only the cortex of the bone is firm. In the cutting of large bone surfaces, as in the a ft n Fig. 39.—Chisels. Fig. 40.—Billroth's Osteotome. ordinary orthopedic resection, the saw is preferable, since it yields smoother sections, and then the resection saws of Szy- manowski, Bruns, Farabceuf, Mathieu, and others, are valua- ble, especially those with large arcs; for many purposes the rotatory saws (Charriere's) and Other's " scie a volant" with elastic transmission are valuable. The use of the chain saw is generally to be discountenanced, owing to the difficulty of obtaining proper antisepsis. The bone perforator is used less for the purpose which its name implies than for the introduction of a ligature, and the instruments of Collin, Langenbeck, and others may be resorted to; the ordinary gimlet will usually answer. The bone scis- sors are rarely called for in orthopedics, and are only useful for the severing of thin bones with small narrow canals, or flat Orthopedics and Orthopedic Surgery. bones, or fragile readily depressed bones (as in the tubular bones of children with thin cortical layer); the bone forceps, on the other hand, is frequently required for the purpose of leveling a surface, or, of removing sharp projecting portions of bone. Liston, Luer, and others have devised bone forceps. Osteotomy, that is to say, the section of a bone without the removal of bone substance, may be performed in a variety of ways: as a simple linear osteotomy (generally transverse section), as more or less oblique or as bow-like osteotomy. While formerly osteotomy was performed through as small a wound in the tissues as possible—the so-called subcutaneous linear osteotom3T—in order to avoid the danger from entrance of air, since the introduction of antiseptics less weight is laid on the wound in the tissues, and under these circumstances the bone is freely exposed. Under careful antisepsis osteotomy is a safe and certain operation. To cite a few examples: R. Volkmann,53 in fifty-seven os- teotomies, observed neither suppuration nor fever; in only one case was subsequent amputation called for, all the others yielding good results; in forty-two osteotomies Hofmokl re- ports thirty-one instances of healing perpriinam, suppuration in ten cases, one death; in 361 osteotomies Margar3r had three deaths (onh' one of which could be laid to the operation), and MacEvven,54 in 835 osteotomies (557 of which number were per- formed on the legs) had no death. These good results, how- ever, should not lead to excessive performance of the opera- tion, for Owen says, " I have seen p3'emia and death follow the operation when performed by a careful surgeon with all Listerian precautions, etc.;" where osteoklasis will lead to the same result it is to be preferred, since Pousson, for exam- ple, in 276 osteotomies noted severe disturbances ninety-five times (four times haemorrhage, fifty-four times suppuration, etc.), and in only fifty-eight did union \>y first intention occur. In the performance of osteotomy, formerhy, the bone was bored through with the perforator a number of times, or after a single perforation the bone was sawed until it was possible to break it; to-day the chisel is the chief instrument used in the majority of cases (MacEwen's osteotome) and in order to note its progress in the depths of the wound the instrument is graduated (Reeves). In the choice of site for the performance of osteotomry we 4 50 Orthopedics and Orthopedic Surgery. must take into consideration the necessity of not injuring the neighboring parts; as a rule, a vertical incision is made down to the bone; when necessaiy, muscles are cut through length- wise, and tendons, etc., are pushed aside. After the chisel has been applied where desired it is driven try blows from the ham- mer, either the right hand of the operator holding the latter, or else, where great care is requisite, an assistant using the hammer and the operator guiding the chisel with both hands. A simple "linear osteotomy" is performed as follows: The patient is deeply anesthetised; as a rule Esmarch's bandage is applied;55 the limb is shaved, washed with soap and disinfected according to antiseptic requirements, and is laid on a sand-bag or cushion covered with rubber-sheeting. A short vertical incision down to the bone is made at a point where the bone is as superficial as possible and where the vessels and nerves will be injured the least. A chisel of the breadth of the wound is inserted along the knife, so that when the latter is removed the former will rest transverse'^ on the bone. B3r a number of sharp blows with the hammer the chisel is driven in until the bone has been nearly severed and the remaining cortical la\'er can be readily broken. The wound is again washed out antiseptically, is brought together Iry sutures and bandaged, and the limb is then placed in a re- tention bandage or splint, and slung up for awhile, a procedure which is of special utility^ in children, since the dressing is thus less likely to be soiled. If fever or other disturbance do not call for a change of dressing, it may remain in place for one to two weeks, and the retention bandage is to be worn until thorough consolidation has taken place. Ordinarily an ap- paratus must be worn for a number of months or even for a year. A special variety of osteotomy is the semicircular (Me3^er, Rosmanit, and others), where the bone is cut through in a semicircular line, eversion of the edges being thus prevented. Greater contact of the surfaces and better adaptability are obtained by this method. Under this heading belongs the trochlea-shaped osteotomy which Defontaine56 has recently performed in case of ancltylosis of the elbow. We must further mention vertical osteotomy. This pro- cedure was devised by Oilier57 for the correction of rachitic curvatures and at the same time to lengthen the shortened Orthopedics and Orthopedic Surgery. 51 bones through longitudinal extension applied to the cut sur- faces. This procedure calls for great permanent extension in order to overcome the resistance of the muscles, and it may also require tenotomy\ Oilier has thus secured an increase in length of from .7 of an inch to 1 inch and a fraction. In case of vein- considerable, and in particular right-angled curvatures, where shortening is lacking or even increase in length is present, the wedge-shaped osteotomy (osteotomia cuneiform is) is to be preferred. A wedge of bone is removed from the convexity of the curvature and the cortex of the bone is broken toward the concavity. In general, this wedge- shaped excision is performed in order to obtain good position in case of angular anchylosis. A wedge of bone is removed sufficient in size and in form to allow of restitution of the bone to a good position. The apex of the wedge lies in the bone, that is to say, the latter is not entirely- cut through. The posterior wall is fractured with due regard to the safety of the neigh- boring parts. The limb, rendered bloodless, is firmly held, and a sharp carpenter's chisel is placed obliquely on it. With a few blows of the hammer the chisel is driven in to the requisite distance, injury to the periosteum being avoided as much as possible; the opposite side of the wedge is similarhr cut, and, after the remaining bridge of bone has been broken, the bone surfaces are adapted the one to the other, the wound is sutured, dressed antiseptically, and the bone is held in position by a suitable retention apparatus. In certain instances, where, for instance, the bone is very compact, as in the knee, the saw may be substituted for the chisel, even though resort to it requires greater exposure of the bone; in this case the periosteum must first be loosened and pushed out of the way. Rarely is it requisite after the wedge-shaped excision to bring the bone surfaces together by suture or by nails. A number of new orthopedic operations, allied to oste- oton^, have been devised, chiefly by Oilier,58 with the aim, in the young, of checking or of entirely preventing local growth of a bone, and exceptionally of increasing this growth. These operations are, in particular, indicated where the growth of two connected bones is unequal, especially in a longitudinal direction, as, for example, in the bones of the fore-arm, thus 52 Orthopedics and Orthopedic Surgery. leading to deformity. Where the object is purely to check growth, simple chondrectomy may be resorted to. In case of beginning deformity (as in genu valgum, etc.) a simple in cision may be made into the epiphysis; often, however, this will not suffice, although the attempt risks nothing (Oilier.) Where the aim is to stop growth, particularly in older children, chondrectomy is indicated. This operation consists in removing a portion of the epiplrysis, occasionally its entire thickness. For example, where the radius from one or another cause is shortened and where the growth of the ulna ma3^ lead to hideous deformity (subluxation of the hand), here only re- section of the epiplrj^sis can permanently check the deformity. As 3Tet we have had too little experience with these opera- tions, which are based on theoretical views in regard to the growth and the regeneration of bone; the same remark holds true of the proposals to artificially cause increase in the growth of bone \>\ scarification of the periosteum, by the in- sertion of irritants (such as the driving of a nail) in the neighborhood of the epiplrysis. Oilier, for example, was able to increases the length of the tibia b3T about half an inch through repeated cauterization of the diaphysis, or through subperiosteal laceration. The resection of a portion of bone, or of a portion from two bones in contact, is often resorted to since the advent of the antiseptic method of wound treatment. The so-called re- section en bloc (Gurdon Buck) is utilized in case of bom- an- chylosis of joints (anclrylosis of the knee at a sharp angle), either for the purpose of obtaining a movable joint (as at the elbow, the shoulder, the jaw) or else onl3T in order to obtain better position from the stand-point of function. Further still, resection of a joint is undertaken in order to obtain better function in irreducible or in old dislocations, and also in instances of congenital joint deformity. In case of curvatures, resection of the joint is also resorted to, as for example, in case of aggravated pes equinus, and we must also refer here to the procedure, frequently performed to-day, of removal of wedges of bone from the foot in instances of club-foot. Less frequently is resection from the diaphysis indicated, as, for example, in badty united fractures where union has oc- curred at an angle, in pseudarthrosis, etc. Gtiterbock 59 has Orthopedics and Orthopedic Surgery. excised a piece from a large radius, in order to correct angular ulnar-ward bending of the fore-arm. Resection, performed for orthopedic purposes, often differs somewhat from the ordinary operation. Instead of the usual longitudinal incision, flaps are often raised in order to secure good exposure of the bone. Only sufficient bone is in general removed as will suffice to obtain correct position, etc. In case of resection en bloc we must carefully estimate the size of the wedge which it is necessary to remove, and, where, in addition to flexion, there exists a lateral deviation of the bone, the section, if removed, must be higher on the one side than on the other. Usually, the requisite size of the wedge may be estimated by the eye; sometimes it is necessary to make a plaster model of the limb, and with this to experimentally secure a wedge of the necessary size. We must refer, under this heading, to the many methods, recommended in particular by Albert, of operating on the joints, such as removal of the excess of bone from some part of the joint surface, whereby an entirely useless limb has its function restored, partially at least, or whereby firm supports may be attached to such a limb. (See, in this connection, the subject of parah^tic deformities.) Plastic operations may also be resorted to for orthopedic purposes. Nussbaum, Oilier, and others, have been successful with bone transplantation in case of pseud arthroses, etc.; and Albert has undertaken a plastic method in case of a congeni- tal defect in order to afford good support to the affected limb. In a female child, nine months old, with congenital defect of the tibia, he opened the knee-joint and implanted the fibula between the two condyles. The child convalesced without fever, and bon}^ union was obtained with the limb at but a slight angle. BIBLIOGRAPHY. 1. Shaffer, X. Y. Med. Journ. xxxiv., No. 4.-2. Langen., Arch. f. klin. Chir., 12, Bd. 1.—3. Langen., Arch. f. klin. Chir. 12, Bd. 1.—4. Missbildung des Beckens unterdem Einflussabnormer Belastungsrich tung, Jena, 1886.—5. Diesterweg, fiber die Yerbiegungen der Diaphy- sen nach Osteomyelitis acuta. Diss. Halle, 1882.—6. L. c. p. 7(>.—7. L. c, p. 4.-8. Monatsschrft. f. arztl. Polytechnik, 1880, p. 172.—9. Lo speri- rnentale, Nov., 1883.—10. Yrh. d. xii. Congr. d. dtsch. Ges. f. Chir.— 54 OrtJiopedics and Orthopedic Surgery. 11. N. Y. Med. Record, Feb. 21, 1885.—12. Monatsschrf. f. arztl. Poly- technik, April, 1885.—13. Entwickelungsgeschirhte des spondylolisthet. Beckens, p. 278.—14. v. Zieinssen's Handb. d. allg. Therap., ii. 2, p. 5. —15. L. c, p. 77.—16. Ueber Rhachitis und ihre Behandlung mit Phos- phor. Breslau, arztl. Zeitschr. 1886, No. 23.—17. The Handbook of the Movement Cure, London.—18. A. Helmke, Reform der Orthopadie. Lehrbuch der gymnastischen Orthopadie. Helmstadt, 1871.—19. Kata- log von Walter-Biondetti in Basel, p. 55.—20. L. c, p. 152.—21. Weil, der Restaurator, elast. Kraft- und Muskelstarker fur Zimmergymnastiker, Berlin, 1881.—22. Bunch, p. 40.—23. 4. Congr. d. dtsch. f. Chir., Berlin, 1876.—24. A. Reibmayr, Die Technik der Massage. Wien, 1886.—25. Centralbl. f. Chir. 1886. No. 43, p. 745.-26. v. Ziemssen, H. d. Eleetri- citat in der Medicin., Berlin.—27. Goldschmit, 1. c, p. 31.—28. Pitha und Billroth, Handbuch der Chirurgie. Lorinser, Krankheiten der Wirbelsaule, Bd. hi., 2. Abth., p. 50.—29. Geschichte und Behand- lung der seitlichen Ruckgratsverkriimmung, etc., S trass burg, 1885.— 30. Pitha und Billroth, Hand. d. Chir. Bd. ii. Abth. 2., p. 798.—31. Die permanent extension mittelst Gypsverbandes nach Zipp. (Illustr. Monatsschrft. f. artztl. Polytechnik, 1882).—32. Fischer's Hand. d. allg. Verbandlehre.—33. Berlin, klin. Wochen., 1875, No. 14. Dissert. Aron R. Unterberger, Konigsberg, 1878.—34. A. Kapeller, dtsch. Zeitschr. f. Chir., vii.—35. Wiener Med. Woch., 1886, No. 37.-36. Wiener Med. Woch., 1886, No. 37. Beitrag zur Yerwendung des plastischen Filzes in der Chirurgie.—37. Orth. Centralbl., Jan. 1, 1884.—38. Centralbl. f. Chir., 1886, No. 14, p. 242.-39. Centralbl. f. Chir., No. 21. 1886, p. 361, zur Technik der Gewinnung von Gypsmodellen fiir die Anfert. orthop. Corsets.—40. Centralbl. f. Chir. u. orth. Mech. No. 6, 1885.—41. Orth. Centralbl. xxx., p. 455.-42. Ueber ein einfaches Yerfahren, etc. Ber- lin klin. Woch., July, 1883.—43. Yogt, moderne Orthopadik, Fig. 20, second edition.—44. Revue de chir.—45. Holmes1 Syst. of Surg., iii. 577.-—46. Bardeleben, Chirurgie, ii., p. 382.-47. Richter.—48. Pousson. —49. Bull, de Med. di Bologna der N. Coll. xii. Pousson.—50. Osteo- tomie et osteoclasia Bull, et meinoires de la soc. de Paris, vol. x.—51. L. c, p. 147.—52. Lect. on Surg. Pathology, London, 1853, p. 176.—53. Heise, tlber osteotomie bei rarhitischen Curvaturen des Usch. Diss. Halle, 1881.—54. Mac Ewen, die Osteotomie, etc.—55. Arch. f. klin. Chir. Bd. xxi., p. 145, 1887.—56. Progres Med., No. 15, 1887.—57. L. c. p. 55, Lullongement des os rachitiques de'double's par rost^otomie verticale. —58. L. c, p. 558, De Fexcision des cartilages de conjugaison ou chron- drectomie orthop<3d, etc.—59. Yerhandl der Ges. f. Chir. vii. Congress. CHAPTER II. RACHITIS. The most frequent cause of deformity, in particular of the lower extremities, is rachitis. Under this term we understand a constitutional disease, a special anomaly in nutrition, which is due to an excessive increase in, together with a deficient calcification of the elements from which bone is formed. This disease is most prone to occur in childhood. The synoiyms for rachitis are: German: Englische Krankheit, Zwiewuchs; French: rachitisme; Italian: rachitismo. This disease is found the world over,1 especially in cold and moist climates (Holland, England), and it affects, in par- ticular, the poorer classes who live amid bad lygienic sur- roundings, their houses being dark and ill-ventilated, their nourishment insufficient and of poor quality. Rachitis, indeed, constitutes a very high percentage of the diseases which affect dispensaiy patients. Owen places this percentage as high as 30 per cent. It is questionable if heredity pla3Ts a role in the establish- ment of rachitis. Many authorities claim that it is an heredi- taiy form of SA'philis,2 but this view is not tenable for the majorit\' of cases. In general, bad hygienic surroundings, exclusive nourish- ment on bread, pap, and poor milk, insufficiency of light and of air, these factors are very influential in the etiology of rachitis. The disease is only exceptionally met with in infants reared at the breast, and more frequently in those which are bottle fed. Baginsky and Roliff have been able to produce rachitis, experimentally, by removing the lime salts from the nourish- ment; others by the administration of lactic acid. Heiss, however, has not been able to confirm the latter statement. Rachitis 11133- begin even in intra-uferine life; Chance, in- 56 Orthopedics and Orthopedic Surgery. deed, claims that in all cases such is the origin. The most frequent form of the disease is infantile rachitis, which appeai-s during the first two yrears of infanc3r, that is to sa3r, during the period of dentition (from the fourth to the thirtieth month). While, further, rachitis often enough develops in childhood, it is an infrequent affection in adults and in old age. The dis- ease generally appears extensively throughout the body, rareh- being purely localized. After vague general S3Tmptoms, such as fever, diarrhoea, disturbances of digestion, tendenc3T to catarrhal affections, profuse perspirations, the nutrition of the body diminishes and the alterations in the bones appear. These alterations affect ver3T differently the various bones, and they are the chief cause of curvatures, the abnormity softened bones yielding to the traction of the muscles. In nearly 1,000 cases Treeves found almost constant^ swelling of the lower end of the radius and of the ulna; in 250 cases the clavicle was bent, in 115 the humerus, in 210 the spinal column was affected, usually in the form of skoliosis. Most frequently the changes were noticed in the lower ex- tremities; in 300 cases the femur was bent to a greater or less degree; in 415 genu valgum, or bow-legs, were present; in 394 the joints were enlarged; in 294 genu valgum predominated. Chance, also, found that thickening of the lower end of the radius wras a constant phenomenon. In 600 cases he deter- mined thickening of the malleoli 300 times, bow-legs 368 times, genu valgum 396 times, curvature of the femur 142 times. The changes in the skull are of general interest. The most essential consist in an enlargement of the occiput out of pro- portion to the face. Shaw states this relation to be 7:1 instead of 6:1. The parietal protuberances project markedly, the fontanelles remain open. Elsasser first called attention to the craniotabes (the thinning out of the bones of the posterior portion of the skull). This thinning results from pressure on the bones when the child is recumbent, and it may lead to severe disturbances, such as spasm of the glottis. In the thorax the changes first appear as a swelling at the point of junction of the ribs and the cartilages, forming the so-called rachitic rosary. Gradually the ribs yield to the in- spiratory traction, and the lateral walls of the thorax, where the ribs have the least resisting power, sink in, the sternum Orthopedics and Orthopedic Surgery. projects like the prow of a vessel and presents the appearance of a hen's breast (pectus carinatus). This is a frequent rachitic deformit3% and a further etiological cause is the press- ure of the arms against the sides. In the spinal column, in addition to the softening of the bones and the swelling of the cartilages, the weakening of the muscles is effective in leading to deformfiy. Owing to the lack of power in the muscles the spinal column bends and, in course of time, permanent deformity ensues, usually a sko- liosis or lateral curvature. Under the influence of the rachitic softening of the bones the pelvis undergoes the characteristic changes leading to the flat, the elliptical, the kidne3*-shaped, etc., pelvis. The changes here are met with in varying degree and extent. The changes in the extremities are of chief interest to us. At the outset, the thickening and broadening of the epiplyses are characteristic. These alterations lead to the joints ap- pearing as if double, whence the expressions double-jointed, Ztuiewuchs, etc. In addition to the deformfiy resulting from enlargement of the epipli3'seal cartilages, a similar effect may follow on un- equal extension of this process, and when we add to this un- equal traction of the muscles the highest grade of deformity may ensue. According as to whether the child walks or not, the deformity varies in characteristics. Usually, we find an increase in the normal curvature of the limbs, that is to sa3r, in curvature outward. In aggravated instances an angle is formed. especially in the lower third of the lower extremities, and the deformity ma3T extend to such a degree that the feet are crossed. Curvatures with the convexity inward (Figs. 41 and 42) are less frequently met with, and in these instances, unequal pressure on the knees in creeping probabl3r plays a role. The most complicated curvatures may result from repeated partial, or total fractures, and these are indeed frequently sympto- matic of rachitis. The rachitic changes of the upper extremities are of less importance. The most characteristic is the projection of the lower epiphysis of the radius (Fig. 42). The curvatures of the humerus, usually with the convexity inward, form a zigzag line with the fore-arm, where the convexity is outward. Ra- 58 Orthopedics and Orthopedic Surgery. chitic changes in the clavicle are often found. The rachitic flat foot is a characteristic affection. The pathological findings consist in an increase of osteoid matter, with diminished and unequal calcification. The epiph- yses of the hollow bones are thickened, the periosteum and medulla^ substance are hyperasmic; on section the epiphyseal line is irregular; here and there in the bones are zones of thickening; the medullary spaces spread irregular^ into the thickened sections; the periosteum may be readily detached and is very succulent. These stages of rarefication and of effusion may be differ- Fig. 41.—Rachitic Curvature of the Lower Fig. 42.—Rachitic Genu Valgum in a Four- Limbs, year-old Child entiated from the stages of beginning deformity, of consolida- tion and of eburnation. The epi- and diaphyseal thickenings disappear only slowly, and not infrequently they are permanent. In case the rachitis is cured there results a rachitic sclerosis, that is to say, an increase of the bone, as calcification and ossification of the osteoid layers, whereby the bones increase greatly in weight, and they become so hard and so compact that it is often very difficult to crush them. Usually a greater or less disturbance in the growth of the body follows on rachitis. According to v. Rittershain, for Orthopedics and Orthopedic Surgery. 59 example, the mean height of the bod3T, at a given age, is never attained. Not uncommonly rachitis results in the individual being dwarfed. BIBLIOGRAPHY. 1. Vide for further information: Hirsch, Histor. geogra. Pathol.— Rehn, Gebhard's Handb. d. Kinderkrankheiten, 11., p. 47.—Senator, Ziemssen's Handb. d. spec. Path. u. Ther., xiii.—2. Parrot and others, Internat. Med. Congress, London, 1881. CHAPTEE III. TORTICOLLIS. Under the term torticollis or wry-neck is understood that pathological position of the head when it is bent toward the shoulder, and the chin is directed toward the opposite side. The condition may occur before birth, during delivery, or it may be acquired later in life. The acquired form is divided into the nryogenous, the arthrogenous and the cicatricial, and in addition there is a variety called the compensatory which is seen as an accompaniment of aggravated skoliosis. In regard to congenital wrv-neck heredity possibly pla3^s a role; at least Petersen reports an instance wdiere a number of children in the same family were thus affected. In the ma- jorffy of congenital instances, however, the wry-neck depends on a congenital deformity of the vertebrae of the neck, or else on lack of space for the foetus during intra-uterine life (the result, for instance, of deficiency in the amount of liquor amnii). That contracted space or abnormal position in the uterus is a factor is rendered probable by the frequency of other deformi- ties as accompaniments of wiw-neck. According to Stromeyer, in a large proportion of cases torticollis is due to rupture of muscular fibres intra-partum, and the subsequent cicatricial contraction. This view is shared by Fischer, Busch and others. Volkmann does not entirely reject it. Petersen,1 however, was not able to determine a direct connection between the subcutaneous ruptures, the hematomata of the muscles, and wrv-neck; neither did the ex- periments of Fabry and Witzel prove such a relation. Ac- cording to Petersen hematoma is rather found in an already existing torticollis, and Fasbender has seen the hematoma on the side opposed to the wiy-neck. A variety of etiological factors must be taken into account. We must grant that in certain of the cases traumatism during Orthopedics and Orthopedic Surgery. 61 delivery2 (breech presentations, the application of forceps) was the causal factor. For instance, Fabry,3 in fourteen cases, found that in eight the presentation was of the breech and in four that the forceps was applied. A larger proportion of cases are myogenous in nature, being dependent on rheumatic and other influences which lead to a shortening of the sterno- cleido-mastoid. The posterior muscles of the neck may like- wise become shortened on one side, and Delore calls this con- dition torticollis posterior. In rarer instances shortening of the platysma myoides may result in wiy-neck. Paralytic torticollis may be met with, seeing that paralysis of one sterno-cleido-mastoid may be accompanied by shorten- ing of the other. Disturbances of the nerves, such as paraly- sis of an accessoiy nerve, may lead to torticollis. We are particularly likely to meet with torticollis as an accompani- ment of listeria, and it has been observed in the course of this affection as a clonic spasm of the muscles of the neck. Torticollis of an arthrogenous nature is dependent on dis- eases of the cervical vertebra? and of their ligaments. It usu- ally" follows on unilateral cicatricial contraction. The fungous and tubercular diseases in this localit3r may be cured with angular anchylosis, and we will refer to this under the subject of k3rphosis. Cicatricial torticollis results from burns, abscesses, lupus of the soft parts of the neck. The cicatrices following on de- generation of the glands of the neck are also causal factors. Torticollis has also been noted as an accompaniment of tumors of the sterno-cleido-mastoid. Graser has lately re- ported a striking example. Since the time of Tulpius, Robert, Bouvier, and others, ana- tomical descriptions of torticollis have been rare. The condi- tions observed on operative interference have been, on the other hand, frequent^- described and are important. In cer- tain severe cases nothing abnormal has been found either in the muscle or its surroundings which would point to an ante- cedent trauma. In many cases, however, there have existed cicatrices in the muscle, and occasionally very marked changes which could only be due to a severe and extensive inflamma- tory process (Volkmann). Hensinger,4 for example, found the sterno-cleido-mastoid of one side one-half an inch shorter than that of the other. The 62 Orthopedics and Orthopedic Surgery. shortened muscle, however, was increased in breadth, and at the broadened and thickened portion there remained no mus- cular substance but there existed a soft, sinewy cicatrix. Witzel,5 at the autopsy on a woman of forty-four, affected with wry-neck of the myogenous variety, found the cervical vertebras curved with convexity forward; the left sterno-cleido- mastoid was altered into a round, sinewy band, its border be- ing only four inches long and .39 of an inch wide, while the right sterno-cleido-mastoid was seven inches long, and .56 of an inch wide. There existed asymmetry of the face and head Fig. 43.—Congenital Torticollis. (Asymmetry of the Face.) and a compensatory curvature of the lower spinal column (convex to the left). Whether the cause of the wrv-neck be congenital or not, there is rarely lacking a certain asjmimetry of the face. Nelaton, Eulenberg, and others, claim that this asymmetry is dependent on a lesser development of the vessels and the nerves on the side of the concavity; Dieffenbach considers it due to traction of the shortened muscles; Witzel believes that it results from stretching of the soft parts, in particular of the muscles of the healthy side of the face, whence the shape is imparted to the growing skull. In Fig. 43, a man of twenty-four is represented with con- genital right-sided torticollis and quite marked asymmetry of the face. The symptoms of torticollis consist in the abduction of the head toward the affected side, associated with a traction (ro- tation) toward the healtly side. There exists an abnormal Orthopedics and Orthopedic Surgery. position of the head and neck which results from tlie approxi- mation of the insertion points of the affected sterno-cleido- mastoid. The chin is drawn upward, the head pulled some- what backward. The ear is nearer the shoulder of the affected side; the projection of the muscle is veiy striking, and the in- sertion points of the sterno-cleido-mastoid are usually very well marked (Fig. 41). The neck appears not to exist on the affected side; the entire half of the face on the same side is shorter and thence the appearance of asymmetry. We may readily detect limitation of the active and passive movements. It is not sufficient for diagnostic purposes to establish the Fig. 44.—Torticollis, Lat. Sin. Fig. 45.—The Same, after Tenotomy. mere fact of the existence of wiy-neck. The cause of the deformity must be sought for. The rational history must be carefully weighed; the cervical vertebras must be examined to see if pain can be evoked on pressure or if there exists -Any swelling. Diseases of the vertebras (in which event pain, fever, etc., are present) and dislocation of a vertebra must be differentiated. In case of myogenous wry-neck the contracted muscle ma3r be felt on the side of the concavity, while in dislocation of a vertebra such is not the case. Boyer's statement that in paralytic wr3T-neck the abnormal position may be readily overcome is not an absolute one. The prognosis of wry-neck, particularly the common myo- 64 Orthopedics and Orthopedic Surgery. genous form, is in the large proportion of cases good. B3^ means of suitable apparatus, and in aggravated cases by means of tenotomy and the proper after-treatment, the de- formity may be overcome, and even the great asymmetr3T of the face will then disappear after a few months. In congenital wry-neck, the result of muscular rupture, if it be seen before cicatricial contraction of the sterno-cleido- mastoid has become established, the wearing of a suitable neck-bandage for a few months will prevent permanent con- tracture. Usually, however, the affection in an early stage is Fig. 46.— Sayre's Wry-neck Apparatus. Fig. 47.—Bruns's Wry-neck Apparatus. overlooked, and is only determined after it has reached a con- siderable grade. While, then, in infants, daily repeated rotatiou, manipula^ tion with subsequent fixation, and in older cases, daily exten- sion by means of Glisson's swings (Berend, Petersen) will suffice to effect cure, in adults, as a rule, special apparatus or tenotomy is requisite. The simplest apparatus consists in the use of elastic trac- tion. Sayre, for example, draws the head to the side opposed to the deformity by means of a rubber band which is attached to a strip of plaster around the forehead and to an axilla strap around the shoulder opposed to the deformed side. By varying the tension of the rubber band the head may be main- tained in good position (Fig. 46). Orthopedics and Orthopedic Surgery. 65 For the rectification of wry-neck a number of appliances have been devised, such as those of Delacroix, Bonnet, Bouvier,6 Mathieu, Collin, Bigg, and others. These take their point of resistance on the trunk and by means of screws and joints the faulty position is rectified. A number of these appliances are attached onlv to the upper part of the trunk; the majority, however, are provided with pelvic bands, dorsal splints, etc. Bruns's apparatus consists of four padded sheet-iron splints, which may be curved to correspond to the shape of the parts to which tiny are to be adapted. These splints are united into a quadrilateral frame which may be slipped over the head. Union of the splints is effected so that the shoulder parts are movable. At the centre of the convexity of the shoulder and thoracic portion there is a screw-joint b3^ which the component portions of each splint may be approximated, and into which the steel tubular rods, which are attached to the head, are inserted. These rods may be screwed up or down to suit the individual case, and their extremities are cushioned. The a pparatus is attached to the body by straps which fit on to hooks in the splints. (See Fig. 47.) Weinberg7 has devised a combination of a chin-plate with shoulder straps, united together by springs and screws, the action of which is to approximate both portions of the appara- tus. Liicke8 has devised a similar apparatus for lifting the head in case of contraction of the sterno-cleido-mastoid as well as for use in case of caries of the cervical vertebrae. Richard's apparatus (Mathieu) consists of a leather pelvic girdle, into the back of which is adapted an iron splint which extends vertically upward. At the upper third of this splint there is a longitudinal bar to which axilla straps are adapted. These straps pass under the axillae, over the shoulders, and are attached posteriorly to the leather waist band. The upper extremity of the vertical bar is connected by means of a mov- able ball and socket-joint with a leather cap which fits the head. By means of this apparatus the head may be fixed in any desired position. (See Fig. 48.) In Langgaard's9 apparatus the head, which is drawn down toward the shoulder, may be lifted up and the pathological twisting may at the same time be rectified. Reynders's 10 ap- paratus (Fig. 49) consists of a pelvic band, a, steel dorsal splints, b, transverse bar, c, axilla-straps, k, and movable 66 Orthopedics and Orthopedic Surgery. lateral splints, m. A malleable iron head-piece is attached by straps, extending over the forehead and under the chin. This head-piece is provided with openings for the ears. It is connected with the spinal splint ly an iron bar, d, which is divided into three joints, efg. These joints may be fixed at am- desired angle. At h this iron bar fits into the spinal splint, and it may be held at the requisite height by the thumb-screw, n. The Eulenburg-Langenbeck n apparatus (Fig. 50) may also Fig. 48.—Mathieu's Torticollis Apparatus be used after tenotomy, and by means of it the head may be maintained in any desired position. A large number of ap- paratuses aim at overcoming the contracture of the sterno- cleido-mastoid by means of extension of the head. An inter- esting apparatus on account of its marked simplicity is that of Petrali12 (Fig. 51). It consists of three pieces of wood, one horizontal (C) and two vertical (AB). The vertical pieces are cut out to fit over the shoulders. This apparatus is attached to the body; two bands hold the chin upward; one band op- poses rotation of the chin; a cravat-like band straightens the Fig. 49.—Reynders's Torticollis Apparatus. Orthopedics and Orthopedic Surgery. 67 curvature of the spine; another band pulls the head over to the side opposed to the contraction. Popoff's13 extension apparatus is also useful in this connection, and it will be re- ferred to under the subject of caries of the cervical vertebrae. Davis' apparatus consists of an arc-like frame fitting over the head and taking purchase on the shoulder toward which the head is bent. Of non-ambulant apparatuses we would refer especialh- to the Esmarch extension bed. It is a slanting plane on which the patient is fastened by means of Glisson's slings. The Fig. 50.—Eulenburg-Langenbeck's Apparatus. Fig. 51.—Petrali's Apparatus. patient may rest with relative comfort on this bed, being able to read, do hand-work, etc. He need not undress. Delore and others recommend forcible reposition under anesthesia. The rotation of the head is accomplished by slowty increasing manipulations. When the aim has been secured the head is held in position by means of a silicate of soda bandage encircling the chest, neck and head. This band- age may be strengthened by the insertion of steel blades. In the majority of severe cases of myogenous wry-neck tenotomy or myotomy of the shortened muscle is the first step toward speedy cure. In 1670 this operation was often resorted to by Roonlny- sen. In 1822 it was first performed subcutaneously by Du- 68 Orthopedics and Orthopedic Surgery. puytren, and since his time it has been frequently done. In 1841 Dieffenbach recorded sixty-two cases. By moving the head toward the sound side the operator determines which portions of the muscles are chiefly shortened. Occasionally, division of the sternal portion alone will suffice; again, both insertions or even other muscles must be cut in order to obtain correction of the deformity. The operation may be performed with the patient in the sitting posture, or lying down. Anesthesia is occasionally advisable. An assist- ant pulls the head over toward the opposite side until the in- sertion of the muscle becomes prominent. A second assistant may make downward traction by grasping the arm at the elbow. Usually both insertions of the muscle must be divided. The two incisions for this purpose are made about .7 of an inch above the border of the clavicle. When the division is made from within outward (Dieffenbach, Hiiter, Sa^-re) a sickle-shaped tenotome is inserted on the flat under the tendon of the muscle until its point lies under the skin of the opposite side. In drawing the knife out the tendon or the muscle is divided by the point, the thumb of the operator making counter-pressure. The sudden yielding of the severed portion is evidenced by a snap. When the section is resorted to from without inward a con- vex tenotome (Little's) is used. A fold of the skin is raised, the tenotome is thrust through this in front of the muscle, and the latter is divided by pressure on the back of the instru- ment. Many operators are opposed to this method on account of the risk of wounding a blood-vessel. Other operators rec- ommend making a small incision by the bistouri, inserting a blunt-pointed knife through this incision, and dividing both the insertions of the muscle. After the completion of the operation the wound is dressed antiseptically. For four to five days the patient must remain in bed, the head being maintained horizontally. Then the requisite orthopedic after-treatment must be resorted to. Klopsch, as early as the third day, applied permanent extension to the muscles of the neck by means of traction through an apparatus attached to the head. In this respect he imitated Stromeyer. Other operators deem it advisable to wait until the fifth day before resorting to orthopedic treatment. Fixa- tion by means of cravat-like apparatus is, according to Klopsch, Orthopedics and Orthopedic Surgery. 69 Langgaard and others, insufficient. Such apparatus con- sists in a tight paste-board cravat which, being higher on the affected side, prevents the head from returning to the abnor- mal position. These retention cravats are more lasting if constructed of felt, metal (Mathieu), leather (Charriere14), or silicate of soda (Falkson15). Petersen begins treatment by ac- customing the patient to the apparatus which he will be obliged to wear. When he can wear it for at least one hour three times dai^y, he performs nyotenotomy. Two to three da3rs afterward, the patient is subjected to treatment on the extension bed for two hours, thrice daily, and in the intervals he wears a Sayre cravat. In order to increase the traction force the ring of Glisson's sling ma3* be at- tached more laterally over the iron brace, and thus the head is draAvn over to a greater degree toward the healtly^ side. Port16 resorts to elastic traction after tenotomy after the manner shown in Fig. 52. The thorax is encircled by a plaster jacket. Special ambulant apparatuses are more frequently used. For in- stance those consisting of a jacket to which a jury mast and Glisson's slings are attached. H. Bigg, and others, have devised appara- tus of this nature. The apparatuses which fix the head toward the healthy side, which over-correct the deformity, so to speak, are still more preferable: such as the appara- tus devised by Richard, by Eulenburg, by Re3Tnders, by Ko- nig, etc. Occasionally, tenotomy of the sterno-cleido-mas- toid does not suffice, and it becomes necessar3r to sever the anterior fibres of the cucullaris, or even of the levator scapulae, when these fibres, after division of the sterno-cleido-mastoid, oppose reposition of the head. Dissatisfied with the result from subcutaneous myotony in a number of aggravated in- stances, since new cicatricial bands formed in the deeper parts, which prevented reposition, Volkmann resorted to the follow- ing procedure: He laid the muscle bare by a large vertical jo Orthopedics and Orthopedic Surgery. incision along its inner border, and severed it, as also the tense bands below it and in its neighborhood. In certain cases he even extirpated the fascia, etc. The result in all the instances was good, union occurring by first intention. The after-treatment was relatively short and ended in permanent cure of the deformity. One of the most aggravated cases was an officer in active service. A number of surgeons, for instance Heinecke, resort to this method. It has the advantage of allowing the operator to control the steps of the operation, and the risk from haemorrhage is far less. Heinecke sutures the wound with catgut. He exaggerates the correct position of the head and maintains it by a paste- board bandage covered with silicate of soda, extending up to the ears and down to and around the shoulders. After four- teen days union is usually obtained and further treatment is unnecessary. In spastic contraction of the sterno-cleido-mastoid, particu- lar^-, certain operators—de Morgan,17 Wood,18 Annandale— have excised a portion of the accessory nerve with good result. In paralytic wry-neck, on account of the liability of the occurrence of secondary- contraction of the antagonistic mus- cles, energetic electrical treatment and massage are indicated. In case of cicatricial wry-neck, subcutaneous section of the cicatrices, or excision followed by precautionary measures against shortening, are called for. In instances of osseous wry-neck special apparatus must be resorted to, and of this we will speak under the subject of kyphosis of the cervical vertebrae. BIBLIOGRAPHY. 1. Langenbeck's Archiv. f. klin. Chirurgie, xxx., 4, p. 781.—2. S. Roge, tieber Verletzungen der Kinder bei ursprunglich oder durch der Wendung herbeigefuhrten Beckenendlagen. Zeitschr. f. Geburtsh. u. Kinderheilk. i., p. 68.-3. Dissert. Inaug., Bonn.—4. L. c—5. Deutsche Zeitschrft. f. Chir. xviii., p. 542.-6. Bulletin de l'Acad. de MeU de Paris, iv., 1840.—7. Hueter, Klinik der Gelenkkrankh., p. 259.-8. Monatsshrft. f. arztl. Polytechnik, 1886, p. 91.—9. L. c—10. Vide Reyn- ders1 Catalogue.—11. Goldtschmidt, Chir. Mechanik, p. 36.—12. L. c, p. 796.—13. Wratsch, No. 45, 1887, or Centralbl. f. Orth. Chir., 1887, Na 5.—14. Gaujot, Arsenal de la Chirurgie Contemp., Paris, 1867.—15. L. c, p. 456.—16. Trans. Am. Med. Ass., vol. xxxi.—17. Brit, and Foreign Med. Chir. Rev., July, 1886.—18. Ogle, Clin. Soc. Trans., vol. vi CHAPTER IV. DEFORMITIES OF THE SPINAL COLUMN. Deformities of the spinal column are of the greatest pos- sible interest, owing to the frequency with which they occur and their great influence on the health and capacity for work of those affected. For anatomical and physiological details I must refer to our text-books on pli3Tsiolog3r, in particular to the works of the brothers Weber, of Henke and Meyer, etc. I onl3T desire to note here that the so-called pl\ysiological antero-posterior curvature of the spine present in adults does not exist in the new born. In the infant the spinal column is straight, and onty gradual^, after the child has begun to sit up, does the column uniformly curve backward. Later, under the influ- ence of walking and standing, the pelvis becomes inclined, the lumbar spine curves forward, and gradually the two compen- sator curves are formed, that is to sa3T, convex curvature backward in the thoracic region, and convex curvature for- ward in the cervical and dorsal regions. This ptysiological curvature is of great importance, since the body thus acquires elasticity. According to the direction of the curvature the following subdivisions are made: Forward curvature is called Lordosis, Backward " " " Kyphosis, Lateral " " " Skoliosis. These varieties of curvature are not always regular in one plane but are often very complicated. It is useful, further, to differentiate the curvatures from the flexions of the spinal column. According to the causal factors the division is made into congenital curvatures, which are rare, and into acquired curvatures, which are ordinarily met with. The latter are designated as curvatures due to habit, as static, traumatic, 72 Orthopedics and Orthopedic Surgery. pathological, etc., curvatures. According to the behavior of the curvature on suspension we speak of mobile and fixed or stationary curvatures. Lordosis. Lordosis is the rarest variet3^ of antero-posterior curvature of the spinal column. The column is curved with the convex- ity forward, and the deformity is almost exclusively limited to that portion of the spinal column which normally projects forward, that is the neck and the lumbar region, in particular the latter. Lordosis of the cervical region is rare; it is very exceptionally congenital, and is usually due to muscular action. Lordosis is frequently the result of the occupation of the individual. It is met with in people who cany weights in front of them; also in tailors, who, from the constant posture on their benches, acquire contraction of the ileo-psoas muscles, and this results, when the individual is erect, in lordosis. All processes which lead to great obliquity of the pelvis may result in lordosis. Among such causes ma3r he mentioned contracture of the hip-joints, large abdominal tumors, mus- cular paralysis eventuating in pathological increase of the ply-siological curvature. Busch1 gives a marked illustration. In the large group of compensatory lordoses we must men- tion those which are associated with congenital luxation of the hip, with pathological luxation of the hip, with contract- ures, etc. Here, owing to the great pelvic obliquffy in stand- ing and in walking, the upper surface of the sacrum approaches the horizontal plane, and the patient is thence compelled to bend his lumbar region forward and at the same time to hold the upper portion of his body backwrard. Lordosis rareh" attains the degree of fixation, m the para- lytic form certainly not. In case of lordosis following on coxitis, etc., however, as a result of permanent unequal press- ure, the vertebrae may gradually attain unequal height in front and behind, and then from anatomical alterations the lordosis may become fixed. In lumbar lordosis of high de- gree, ordinarily the retraction of the loins, the projection of the abdomen and of the gluteal region, are at once apparent. Examination in the dorso-recumbent position with flexion of the limbs, etc., will enable us readih' to determine as to whether the condition is movable or fixed. Orthopedics and Orthopedic Surgery. 73 The treatment must be mainly prophylactic. In the man- agement of the coxitis care must be taken to prevent perma- nent pelvic obliquity and angular contracture of the hip-joint. Among the special therapeutic points we may mention suitable g3Tmnastic exercises, the lying on the abdomen for a considerable time daily, frequent climbing of a steep ascent, etc. The apparatuses recommended for lordosis consist gener- ally of an abdominal band, two lateral axilla bands, and an elastic band which prevents the projection of the abdomen and of the lower part of the thorax. Heather Bigg, b3r the insertion of an endless screw in the Fig. 53. Fig. 54.—Nyrop's Lordosis Apparatus. centre of the lateral splint, has enabled us to tighten at will the bandage which encircles the abdomen. Nyrop's lordosis apparatus is readily understood by con- sulting Fig. 54. In Fig. 53 the purchase-point of the pelvic band is seen. The apparatus consists of a steel spinal splint, a, with a cross-piece above to which the axilla straps are fastened. The pelvic band takes purchase through two pads, one of which is shown at e. To a cross-piece, b, is attached an elas- tic abdominal band, d, by means of which projection of the abdomen is prevented. Kyphosis. In the second variet3^ of antero-posterior curvature, in- creased flexion in a segment of the spinal column leads to 74 Orthopedics and Orthopedic Surgery. backward curvature, to which, in general, the term kyphosis is applied. It is useful to differentiate here the so-called round backs, from the pure kyphosis (flexion) which generally results from spondylitis. The so-called round shoulders are met with in young people with relaxed ligaments and muscles, and the condition results from the habitual assumption of faulty position. Anxious mothers often deem this condition the first symptom of begin- ning deformity. In certain instances the entire spinal column above the sacrum presents a flattened arc with convexity backward. The scapulae sink in forward and their apices stand out like wings from the thorax. In other instances the Fig. 55.—Faulty and Correct Position in Reading. (Roth.) position is not assumed bjT the individual but the vertebrae are abnormally movable and the normal curve of the spinal column thus readily becomes exaggerated. The lateral con- tour is not as3^mmetrical and the scapulae do not alter their position to the one side or the other. As a rule, the greatest degree of curvature exists in the median portion of the dorsal region, which is tense, owing to the stretching of the muscles. Round shoulders are also found among adults whose occupation requires constant bending forward, and also in those who carry weights on their backs. Lane2 has lately recorded a marked instance in an individual who in his 3^outh was obliged to split wood. Here the antero-posterior curvature was so excessive as to give the appearance of a wedge. Orthopedics and Orthopedic Surgery. yt Certain of the kyphoses met with in old people may be traced to their occupation. As a rule, however, kyphosis here results from senile muscular weakness and tissue atro- phy. A further variety of round shoulders is found in children from two to three years old who present evidences of rachitis. This variety is, in general, rare. It is not fixed, but disappears on the assumption of the horizontal position. It is due to great relaxation of the muscles and ligaments and to the softness of the bones. The habitual carrying of the shoulders forward is a predis- posing cause of lateral curvature. We must also refer to the kyphosis associated with osteomalacia; this form, however, is rarely seen purely in the sagittal plane and is ordinarily preceded by great pain. The rachitic variety of round shoulders calls for anti-rachi- tic measures. The child should not be allowed to assume the upright position, but should be made to recline, as far as pos- sible, on a good mattress. Nourishing food should be admin- istered, the muscles of the thorax and of the limbs should be exercised. Cold bathing and rubbing are of value. For small children a gutta-percha splint shaped to the back and fitted with axilla straps, and a broad abdominal bandage is the most appropriate apparatus. Older children require one or another of the maiy varie- ties of supporters. A suitable supporter must be provided with a pelvic band, and it should be constructed with two 76 Orthopedics and Orthopedic Surgery. vertical steel blades to extend up and down the back, as also with shoulder straps. Thus the required position is secured and the weakened muscles are suitably re-enforced. Staffel's apparatus is an excellent one. Heather Bigg and others have devised supporters which only control the shoulders and the pelvis, leaving the thorax and abdomen free. Banning's apparatus (Figs. 57 and 60) takes purchase at the lower abdominal region through a pad, A. Two steel springs (O) pass over the iliac crests and obtain purchase at the gluteal region through two pads, B. Fig. 57.—Banning's Truss. Fig. 58. All supporters which are not fitted with a pelvic band and those which, like the well-known Bouvier, simply extend be- tween the shoulders, are worthless. Corsets, lightty constructed and fitted with steel blades, are also suitable for the treatment of round shoulders, espe- cially when straps for holding back the shoulders and neck are adapted to them. Nyrop's spring supporter consists of a pelvic band to which a posterior steel blade is attached. Above, this blade is connected with a cross-blade which carries the shoul- der straps (Figs. 59 and 61). This supporter corrects the habitual anteflexion of the spinal column, and it is especially Orthopedics and Orthopedic Surgery. yy valuable in that it does not compress the thorax, is light in weight and may be worn under the clothing without attract- Fig. 59.—Nyrop"s Supporter. Fig. GO.—Banning s Supporter. ing attention. The Stillman apparatus also fulfills well the indications, and it takes purchase on the sacrum. The pathological variety of kyphosis is the result of caries of the vertebrae, as a rule, dependent on tubercular osteitis. The deformity is characterized by an angle in the spinal column, the concav- ity of which is forward. One or more of the spinous processes of the vertebrae project backward forming a hump. The bones are softened by the granular os- teomyelitis, and the anterior portion of the bodies of the vertebrae sink down- ward under the weight of the body. This disease was first described in 1783 by P. Pott, and it therefore bears his name, although the affection was known FlG" ei-^r^s Supporter. to Hippocrates, Galen, and others, and although Delpech and especially Nelaton had recognized its tubercular nature. Although American writers (Bauer, Sayre, Owen, and 78 Orthopedics and Orthopedic Surgery. others) are inclined to consider trauma an etiological factor, even though the history 3Tields no clue in regard to such an occurrence, there can be no doubt but that the affection occurs spontaneously without anv determinable cause, and that weak children and those predisposed to tuberculosis are apt to be- come affected. The disease unquestionably develops in a tu- bercular soil, and can only exceptionally be traced to other diseases. The disease may develop at an3r time of life, but it chiefly affects children from two to six years old. The infant is not apt to be affected and the disease is rare during the first 37ear. After fifteen years it is very exceptionally met with. Nebel found only twenty-eight instances above fifteen j^ears out of 225 cases. It may, however, develop in adults and even old age is not absolutely exempt. Bo3's are, in general, much more likely to become affected than girls. Nebel3 out of fifty-four cases found thirty*-one male and twenty-three female. In regard to the frequenc3T of caries of the vertebral col- umn we can offer the following statistical data: In 52,250 records of autopsies Menzel4 found 702 cases of caries of the vertebrae and 238 cases of caries of the knee-joint; Nebel found 82 instances in 1,957 autopsies; Billroth states the percentage of vertebral caries as 35; Konig claims that this percentage is far too low. As to the frequenc3T of the disease in one or another part of the spinal column statements are very different. Accord- ing to Billroth, the vertebrae are most frequently affected in the following order: the sixth dorsal vertebra, the1 second cer- vical, the fifth, seventh and eighth dorsal, the third cervical, the third, fourth, ninth and tenth dorsal, and next the fourth lumbar vertebra. According to Hiiter5 the eleventh and twelfth dorsal are most frequently diseased, and next the first lumbar vertebra. Nebel also states that the lumbar portion of the spine is most frequently diseased. In 183 cases Parker6 found the cervical vertebrae diseased nine times, the dorsal eighty-two times, the dorso-lumbar twenty-one times, the lumbo-sacral thirty-seven times. Kyphosis, then, in the vast majority of cases, is the result of a tubercular affection of the bones which either begins as a granular myelitis (granulation tuberculosis) ' at one or more OrtJiopedics and Orthopedic Surgery. 79 places, thence spreads and leads to sinking of the affected por- tions under the weight of the bod3, or else it begins as a tubercular infiltration of the bone substance leading to a pur- ulent osteitis. This latter form was described by Delpech and Nelaton under the name of tuberculosis of the bones. On sec- tion of the affected portion of bone it is found to be infiltrated with a yellow material. The surrounding bone tissue is ly- peraemic and the two portions are separated on^y by a thm layer of tubercular granulations. (Fig. 62.) Fig. 63.—Spinal Column of a 4J^-year old Child. Caries of the Tenth Dorsal and of the Second Lumbar Vertebra, ab, Carious rem- nant of the vertebra; cd, Kyphosis; e, Last rib. (After Paul.) The affected bone ma3^ speedihr break down, or else the tubercular sequestrum may remain latent for years, being sur- rounded b3' granulations. The inter-articular cartilage ma3' become involved through extension of the granulation proc- ess, or else suppuration and necrosis ma3' start in the carti- lage and the process ma3' thence extend to the adjacent ver- tebra. Primary fungous inflammation of the vertebral joints is very exceptionally met with, and then ordinarily in the verte- Fig. 62.—Osteitis Caseosa (Tuberculosa) of a Vertebra. (Cross-section.) 8o Orthopedics and Orthopedic Surgery. brae of the neck leading to displacement in this region. When the upper cervical vertebrae are affected dislocation of the diseased joint, in particular the first, may lead to sudden death from pressure on the medulla. The suppurative process is rarely widely disseminated su- perficially. In such instances the periosteum is undermined and many of the vertebrae are eroded, as it were, on the sur- face. Such is the case in actinoinykosis. Usually the sup- puration is more central. In an unexplained manner the proc- ess invades one or another neighboring vertebra. A cavity filled with granulations or with detritus is formed at the diseased locality, and when the bone substance surrounding this cavity is no longer able to withstand the pressure, the vertebra sinks in, its spinous process projecting backward. This is the beginning of the hump, which is of course the more marked the more extensive the caries of the body of the ver- tebra. Occasionally the epiphysis is destro3Ted and the proc- ess involves the apophyses and vertebral arches. Such an extension, however, is rare. If the affected vertebra be macerated, then, after the gran- ulations have been removed, we may readily inspect the cavity in the bone. The vertebra looks as though it were worm- eaten. Frequently only remnants of one or more vertebrae are left (Figs. 64 and 65), so that the number affected can only be estimated by counting the spinous processes. It is readily apparent why the softened body of the vertebra cannot with- stand the pressure to which it is exposed. The point of union of the spinous processes remaining intact, the anterior portion of the affected vertebra sinks forward. Without question there occur cases of spontaneous cure of caries of the vertebral column, especially where the process is superficial rather than deep. The pathological granulations are replaced by healthy; these latter ossify and lead to a species of bony union. In other cases the formation of a marked gibbus is counterbalanced as follows: The inflamma- tory process leads to the formation of osteophytes in the neighborhood. These coalesce and bridge over the diseased portion of the spinal column, thus yielding an efficient support and preventing additional deformity. In the vast majority of cases, however, an abscess results from the extension of the destructive process. The pus infil- Orthopedics and Orthopedic Surgery. 81 trates the neighboring parts, and eventually a large abscess cavity is formed. Since the anterior vertebral ligaments con- stitute a barrier in front, the pus sinks downward through the loose cellular tissue until it appears at certain determined spots as the so-called cold abscess. This abscess gradually increases in size; it may remain latent for long, or it may quickly spread toward the skin, and, if the knife is not resorted to, it breaks externally, the air enters the large cavity which is covered with the fibrinous, so-called p3~ogenic membrane, and the patient ma3~ speedty die of sepsis. Ac- cording to Ta3'lor a bsces- ses develop in 14 per cent. of cases of kyphosis. Konig and Henke,8 Soltmann and others, have pointed out how in the dissemination of the pus to form an abscess the loose cellular tissue offers no obstacle while Fig. 64.—An Instance of Cure of Ca of Cervical Vertebrae. Three Vertebra? merged into one. Slight amount of In stitial Tissue remaining. the fascia and the aponeuroses do. The abscess rarehT breaks through the latter. The pus sinks by gravity in the direc- tion of the least resistance and it points at certain character- istic places. Pus from caries of the upper cervical vertebra1 gravitates along the phar3Tnx. It pushes the mucous mem- brane forward and it forms what is known as the retrophaiyn- geal abscess. Such an abscess is of special importance, since it may readily lead to dyspnoea and dj-sphagia. Its sudden rupture mny cause death. Pus from the dorsal vertebrae, as a rule, gravitates through b Fig. 65.—Macerated Specimen. Entire De- struction of a Dorsal Vertebra. Ultimate Anchylosis of the Apophyses. 82 Orthopedics and Orthopedic Surgery. the aortic hiatus into the abdominal cavity. It then follows the course of the psoas muscle, occasionally leading to sup- puration of the muscle. It passes under Poupart's ligament through the inguinal ring and points in the upper part of the thigh, as the so-called ileo femoral abscess. Exceptionally the pus travels along the psoas muscle into the abdominal wall and points in the inguinal region (Fig. 70 a), or else it sinks into the scrotum and there simulates a hydrocele or an ingui- nal hernia. In other instances the pus passes along the iliac fossa into the cavity of the pelvis and travels outwardly along the ischi- Fig. 66.—Purulent Remnants in the Fig. 67.—Complete Bony Union in a case of Middle Dorsal Vertebrae. Notwith- Vertebral Caries. Three dorsal vertebrae fused standing the mirked kyphosis the together. (Reduced J^.) spinal cord was not compressed. atic muscle through the major ischiatic foramen. The gluteal fold becomes effaced, a tumor forms in this region and an ischio-femoral abscess exists. Seeing that flexion of the hip may be associated with this abscess coxitis is simulated. Exceptionally pus from the cervical and upper dorsal ver- tebrae travels down and points in the axilla, or else it travels along the ribs outside of the pleura pointing in the thoracic walls. Or, further, it penetrates between the muscles of the back and presents there as a fluctuating tumor. Rarely does the pus penetrate the pleura and form an enqryema. These abscesses may also rupture into the intestine—into the duodenum, the colon, the rectum, or into the bladder. Orthopedics and OrtJiopcdic Surgery. 83 Owen has directed attention to the fact that fistula in auo may follow from rupture of an abscess resulting from vertebral caries. In kyphotic patients there are also present disturbances from the side of the muscular system. So-called counter- curvatures are developed, especially a lordotic curve of the cervical vertebrae. Gradually this curve becomes a perma- nent one and the position of the head characteristic of severe instances of kyphosis results. When the seat of the affection is in the dorsal region the framework of the thorax collapses, as it were, through the sinking together of the vertebrae. Occasionally the ribs approximate one another so closely as to come into contact. In disease of the lumbar region the lower ribs sometimes project over the pelvis or sink down into the iliac fossa. In general the ribs are lifted upward, the sternum projects like a keel (chicken-breast), the vertical diameter of the thorax is marked^ lessened and congestive and pressure S3'inptoms are in consequence present. The concurrent sjmiptoms from the side of the spinal S3*s- tem are above all of importance. Frequently the nerve bun- dles, which pass through the intervertebral foramen, seeing that the^* lie imbedded in infiltrated or lyperaemic or suppu- rating tissue, take part in the disease process. It is often as- tonishing how the spinal cord escapes alteration notwithstand- ing k3*phosis of high degree. As a rule the membranes of the cord near the diseased region are thickened and callous. Peri- pacb3*meningitis results. The pus ma3* perforate into the spinal canal, or the disease may extend to the substance of the cord itself through implication of the membranes. In a certain proportion of cases, especialy when the hump forms quickh-, the spinal cord suffers directly from compres- sion. A so-called compression myelitis develops, and the de- generation may extend above and below (Turk), giving rise to the so-called secondaiy degeneration. This degeneration is characterized by disease of the posterior fibres above the spot of softening, and of the lateral fibres, in particular, below. Macroscopically this disease is evidenced in the fresh specimen by a grayish, transparent, pale 3*ellow appearance, and micro- scopically, after staining, we uuy find fatt3r degeneration of the nerve bundles and interstitial increase of the cellular tis- sue. 84 Orthopedics and Orthopedic Surgery. Exceptionally the spinal cord is compressed b3* the projec- tion of an abscess inward. The S3*mptoms of implication of the spinal cord may be varied, such as slight contractures, paraesthesiae, pareses, even complete paral\*sis. The paraplegia will be extensive accord- ing to the seat of the1 disease, and C3*stitis, decubitus and other affections may be the sequelae. The reflex symptoms are usually greatty exaggerated. The triceps-reflex is often ob- tainable. A further important sequela of k3*phosis, when the seat of the disease is in the lumbar region, is alteration in the shape of the pelvis. For information in regard to the kypho- tic pelvis w*e must refer the reader to text-books on obstetrics.9 More infrequently still than the tuberculosis of the bones (spondylitis) of which Ave have spoken, may tumors (sarcoma, carcinoma) of the spinal col- umn, gummous osteitis accompanying general syphilis, and possibly actino- lmxotic changes lead to kyphosis, or else the disease mux develop more grad- ually as the result of trauma (Fig. 68). Fracture, associated with comminution of the boc^v of the vertebra, the proc- esses remaining intact, nuy eventuate in k3rphosis. As regards the S3Tmptomatolog3* of 8a the disease, the premonitor3^ signs are characterized try the individual becoming readily tired, by intercostal and lumbar neuralgias, by stiffness of the verte- bral column in walking or other motions, etc.; often the child simply shows a disinclination to play, has an anxious look, and is careful not to move the vertebral column in ascending stairs, in jumping, etc. The most marked symptoms are the deformity-, the formation of the hump, the accessory phenom- ena from the side of the spinal system and the gravity ab- scesses. Often the sudden crying out of the child during the night, or grinding of the teeth, or a deep-lying pain in the epigas- Fig. Bri.—Traumatic Dorso- lumbar Kyphosis in a Man aged Orthopedics and OrtJwpedic Surgery. 85 trium, are the first symptoms leading us to suspect disease of the vertebral column. Then the rubbing of the column with a hot sponge (Copeland) ma3* reveal sensitiveness of the af- fected vertebra, or else pressure on the spinous processes ma3' result in causing marked pain. Occasionally the formation of the gibbus is evidenced ly projection of the spinous process of the diseased vertebra when the patient bends forward. The deformity is especially* apparent in the dorsal region as a pro- jecting knob which gradually becomes evident and attracts the attention of the parents. Very rarely the deformity ap- pears suddenty without premonition, and in these acute cases the spinal S3*mptoms in particular pre- dominate. Such S3*mptoms are often not marked to a surprising extent in instances of long forming, although aggravated l^yphosis. The motor ner- vous S3*stem is naturally less severe by implicated, and, according- to the seat and the extension of the disease, we may determine onty slight paresis of certain muscle groups, a certain diffi- cult3* in motion, or entire paraplegia or total paratysis of the parts tying below the disease centre. Weakness of the sphincters up to complete pa- ratysis of the rectum and bladder fre- quently form the sad accompaniments Of aggravated kyphosis. FlG- 69.-Fixation of the Verte- -,.„, , , . . . . „ bral Column in Bending. A\ hen there exists a suspicion of caries of the spine the child should be entirety unclothed and then examined. It is of the greatest possible importance to make an earty diagnosis, for thus the extension of the disease ma3* be prevented. Parasthesias of slight degree, sensation of constriction, an- aesthetic zones, weakness, etc., such symptoms should direct the attention of the physician to the spinal column, especially if, in addition, the subject becomes readity tired and is averse to movements. We ma3* often obtain an absolute diagnostic S3*mptom of disease of the vertebrae by making the child bend forward and noting how the act is performed with the spinal column held rigid (Fig. 69), and, next, how the erect 86 Orthopedics and Orthopedic Surgery. position is reassumed purely ly extension of the lower extrem- ities. Often these patients rest their arms on the thighs in order to lessen pressure on the diseased surface, or else they avoid standing or walking as much as possible. In children, as a rule, the disease progresses rapidly to the formation of the gibbus, while in adults the affection fre- quently exists for a long time without angular kyphosis, and the disease of the vertebrae may be readity mistaken for other affections. In aggravated instances with marked gibbus, or where abscesses or S3*mptoms from the side of the cord are present, the diagnosis offers no difficulties, while in the begin- ning the disease may be mistaken for coxitis, or for lrysterical Figs. 70 and 70 a.—Lumbar Kyphosis. Front and Profile View. Beginning Abcess above the Crest of the Ilium. manifestations, or for disease of the cord, etc. This holds true in particular for adults, where the affection is apt to pro- gress slowty before the characteristic deformity appears. In case of coxitis it should be noted that the contracture is not a simple one, as in that accompanying spondylitis, but it is com- bined either with abduction and outward rotation of the limb or else with adduction and inward rotation. As regards disease of the vertebrae of the neck the deform- ity, as a rule, appears somewhat differently. Often we can only determine a thickening on one side of the neck, a bending or drawing of the head. Eventually the abscess appears laterally in front of the cucullaris muscle and it ordinarily breaks through the supra-clavicular fossa. Orthopedics and Orthopedic Surgery. 87 Kyphosis in the neighborhood of the last vertebra of the neck may readily be confounded with the normal projection of the vertebra pvomiuens. Frequently torsion of the neck toward the healthy side results. (Torticollis oss.) In order to determine beginning abscess formation it is requisite to look for the following symptoms: Deep-lying neu- ralgic pains, pain on pressure, swelling, distention of the'veins, oedema, etc., in the affected region, and, in particular, we must Fig. 72.—Kyphosis in the Lower Cervical Ver- tebral Region. Wing-like Backward Projection of the Scapulas. Fig. 71.—Kyphosis of the Upper Dorsal Fig. 73.—Tracings of Varieties of Kyphosis. Vertebrae. (N. Smith.) examine the iliac fossa' when the patient is in the dorso- recumbent position with flexed limbs. It is often essentia] to obtain a tracing of the kyphotic projection, in order to follow the successive changes. For this purpose a strip of lead molded over the vertebral column will answer, or we nrmy use one or another of the apparatuses which will be described under the subject of skoliosis. The progress of the disease leading to k3*phosis is usualty chronic and rarely acute or sub-acute. Where the affection runs an acute course it is associated with febrile phenomena 88 Orthopedics and Orthopedic Surgery. and may end in death before the deformity appears. In chil- dren, as we have stated, the progress is ordinarily more acute and in a few weeks a very marked gibbus may form. In adults 3*ears ma3r elapse and numerous abscesses may form before the appearance of the characteristic deformit3*. We ma3* frequently differentiate a number of stages in the prog- ress of the affection: 1. The stage of onset where the symp- toms are not specially marked; 2. The stage of characteristic gibbus; 3. The stage of suppuration and of paraty*sis. The disease does not always progress to the latter stage. In mam* instances, after two to three 3*ears' course, we rather find the vertebra again solid through a species of ossification, and a cure results. This may happen at an3* time, even after abscesses have formed. Even spontaneous resorption of ab- scesses has been noted. This, however, is infrequentty the case. The prognosis of the disease is, in general, unfavorable. The old saying of Hippocrates "qui gibbosi ex asthmate et tussi fiunt, ante pubertate moriunter," refers to the high mortality rate from tuberculosis of kyphotic children (Busch), and it is certainty true that a large proportion of those affected succumb to miliary tuberculosis, amyloid degeneration, etc., and that even where the local process becomes arrested there remains a tendency to emplysenni and above all to lung and to heart diseases, and therefore the affected individuals rarely reach middle age. Formerly the abscesses often endangered life and true enough the modern treatment of these accumula- tions of pus has bettered the prognosis a trifle; the S3*mptoms, however, from the side of the spinal cord, alwa3*s modify the prognosis, for, after an interval of man3* 3*ears, we often wit- ness the development of paralysis, and when once sy*mptoms of compression and of paralyses have appeared (particularly from the side of the bladder and of the rectum) the clinical picture becomes a ver3T sad one, decubitus, hypostases, etc., soon form and end the scene. The higher the seat of the dis- ease, the more extensive the process, the more unfavorable the prognosis, which, of course, also depends on the general constitutional strength, on the concurrence of affections of the lungs, etc. As regards the subject of treatment we must dif- ferentiate the general from the special mechanical. It should be tin? endeavor to re-enforce the general health Orthopedics and Orthopedic Surgery. as far as possible by means of suitable food, preparations of iron, cod-liver oil, sea-baths, fresh air and sunlight. In an early period of the affection cold applications to the spine by means of ice-bags (Chapman), are very valuable, as proved by Esmarch's and Eulenburg's experience. ' Hueter recommends the injection of carbolic acid in the neighborhood of the diseased vertebra or deep injections of a solution of cor- rosive sublimate. It was formerly the custom to depend to a great extent on derivatives (Pott, Rust). To-day these agents have been rejected, although latterly fly-blisters have been extolled b3* a number of gentlemen, for example hy Busch. The chief indication in the treatment of caries of the ver- tebrae is the fixation of the spinal column and the removal of pressure from the anterior portion of the vertebra, that is to say we must seek b3T means of rest to prevent irritation of the affected part, and our aim must also be as far as possible to remove pressure from it. It is in these directions that modern practice has chiefly excelled, and especially in that attempts at forcibty straightening the spinal column have been con- demned. Formerty, the chief indications were deemed to be the keeping of the patient in the horizontal position and the for- bidding of the assumption under am* pretext of the erect pos- ture (Eulenburg, Baum, Noble Smith, and others). Bauer, for instance, recommended the horizontal position on a water bed; others have commended keeping the patient lying on the abdomen on a suitable bed—the prone S3*stem of the English (Harrison, Bampfield, Knorr). Others have extolled the lateral position. Noble Smith10 claims that the advantage of the abdomino-recumbent position is that pressure is thus taken from the diseased part and the unfavorable traction of the muscles on the anterior portion of the column is prevented. He does not believe that there is thus risk of the pus gravita- ting forward. Such methods, however, cannot be carried out without injur3* to the general health, and in am* event harm may result from uncontrollable movements of the patient. In a proportion of the cases, especially in infants, the dorso- recumbent position on a good hair mattress must be consid- ered the best procedure. Apparatus (Volkman, Kappeler) for preventing involuntaiy movements on the part of the patients, a matter of the greatest possible importance where the dis- cjo Orthopedics and Orthopedic Surgery. ease affects the vertebra* of the neck, can certainty only be used in childrien who are old enough to be taught the necessffy of restraint. Such apparatus may act either through counter- extension ly weights or through elastic traction. The patient is placed horizontally on a hard mattress. Extension is ob- tained by the following mechanism: To a collar around the patient's neck a stout string is attached which passes over a roller on the top of the bed and carries a w*eight of from four to six pounds. The weight of the body yields the counter- extension. In case of caries in the dorsal or lumbar region traction may also be made from the axillae. Where the disease is located in the middle portion of the spinal column Rauchfuss' suspension girdle11 may* be used. B3* means of it pressure is removed from the diseased portion, and the requisite degree of traction is readity obtained b3* lowering or raising the girdle. This girdle is drawn tightly transversety over the bed under the affected portion of the spine and direct pressure on the gibbus is avoided. For the median portions of the spinal column it is possible to utilize the weight of the body for purposes of distraction through Rauchfuss' suspensory* belt. This is a broad belt stretched across the bed, which can be applied with special facility to the ordinary* children's slat beds, and on which the a fleeted portion rests; the amount of stretching can be easily regulated by higher or lower suspension of the belt. Pressure on the gibbus can be readily avoided by* cutting out a corre- sponding segment from the belt. The difficulty of fastening the child sufficientty to the belt, which seems to reduce the value of the apparatus in the eyes of some (Nebel, Koenig), has been overcome by Schildbach's modification.12 This belt (1| to 3 inches broad according to the age) is fastened to the sides of the bed and hangs in a curve. Schild- bach attached to its two ascending portions two cross strips, the ends of which are fastened over the body of the child, thus fixing it, while two lateral cushions relieve the pressure on the gibbus. Koenig employed for fixation a close-fitting jacket with sleeves and thigh-pieces which are fastened to the dorsal belt. Reyher recommended a broader belt (7 inches), together with shoulder and perineal belts for fixation. Mass13 devised a simple and convenient way of relieving Orthopedics and Orthopedic Surgery. 91 weight and exerting extension by placing the patient on roll- pillows. B3* causing the patient to recline over suspensory belts or rolls, we may* usual ty attain rapid relief from pain and we Fig.74.—Phelps' Upright Bed (schematic); Fig. 75.—Upright Bed with Fig. 76.—Upright Bed a, Lateral; b, Front View. Movable Leg-rests. containing patient. may exert a favorable influence on the deformity*. These pro- cedures are simple and, in tractable patients, are very* effective. One application of the principle of extension which can alwayTs be easily and cheaply- resorted to, is the upright bed devised by Phelps (Figs. 74 to 77), and it is an apparatus of great value in infants, particularly for paralytic cases, and for those where there exists marked curvature. By measuring or by making an outline drawing of the child with legs spread apart, we may have constructed a wooden case with openings for the arms (Fig. 75) and for defecation; 92 Orthopedics and Orthopedic Surgery. the foot-board must be about 5$ inches high, and places for the heels are cut out, while the top of the bed is only closed at the posterior half by means of a slat. The case is then padded on both sides and especially across the middle with jute cushions; the padding (Fig. 74) is covered with water- proof material, the child is laid into the case and fastened with flannel roller bandages; the head is covered by an or- dinary cap or rests in Glisson's slings, the straps of which are hung to nails on the lateral wall of the case. When the case is lifted and placed nearly or quite upright, the child is, as it were, suspended partially by the head. As a rule, children with spinal caries are bedded afresh about once a week; the legs should be bandaged anew every- day and be subjected to passive motion. Portable kyphosis machines, in their simplest form, con- sisted of fixation by dorsal splints (the old cross of Heister) or of firm dorsal shields to which the pelvis and thorax were fastened, as in the wire cuirass of Bauer, the Volkmann half- cuirass of rubber, etc. At an early period apparatus was devised which supported the spinal column through axilla crutches or braces; soon, in order to obtain vertical extension, Le Vacher 14 added a sus- pender for the head to the supporting apparatus (an appliance which, after having long been condemned as dangerous, has now again found general application in the shape of Sayre's juiy-mast). These extension bandag-es with dorsal splints and Le Vacher's suspender for the head for a long time represented the chief means of treatment. Then Taylor pointed out that a bent stick, which may be taken to represent the kyphotic spine, can be straightened not by extension, but more appropriately In* being bent over a fulcrum placed at the point of flexion; and he applied this principle by means of a bilateral padded splint, acting as a lever, and casing dorsal flexion of the anteriorty curved spine. It soon became evident, however, that Tay*lor's machine, which will be more fulty described below, acted mainly* as an immobilizing dorsal splint (Hueter, Vogt15), that the correc- tion was onty apparent, and P. Vogt noted in numerous chil- dren that the apparent over-correction of the anterior inclina- tion was due solely to a lordotic flexion of the neighboring spinal segments, while the kyphosis persisted unaltered. He Orthopedics and Orthopedic Surgery. 93 therefore modified Taylor's apparatus by the addition of means for the removal of pressure from the spinal column. He ef- fected this by adding lateral arms with axilla crutches to the splint at the level of the shoulders (occasionally also adapting lateral braces to the pelvic belt), and for the support of the head he added a steel collar covered with leather and united to an extension from the dorsal splint. All these appliances must be carefully* watched; they* can onty be made by a mechanic, their construction takes time, and they* are expensive. It is apparent, therefore, that a Fig. 78.—Suspension for the Application of a Corset. (After Beely.) method applicable to the routine needs of every* physician was bound to find rapid and general recognition, and for this reason Sayre's method of treatment by* the corset and suspension spread quickly* and proved valuable everywhere. Reports from numerous clinics (Esmarch, Madelung, Nebel, etc.,) cer- tify* that the plaster-jacket method of treatment is one of the handiest, most certain, and cheapest means of fixation. By* an early application of the plaster jacket it is usually* possible to forestall the occurrence of permanent deformity, and fre- quently to prevent the formation of gravitation abscesses (Nebel16). By means of this method we undoubtedly* give the 94 Orthopedics and Ortliopedic Surgery. patient great relief, mitigate his pains, and frequently effect a cure. Sayre's method can be employed for caries at almost any point of the spine, and neither gravitation abscesses nor bed- sores are contra-indications. It is hardly possible to lay* too much stress upon the fact that thereby we do not aim at brisement force, or obliteration of the kyphosis, but that we try to circumvent the injurious influence of weight and mus- Fig. 79.—Suspension for the Application of a Plaster Bandage. cular traction by* careful, gentle suspension, simply* sufficient to lessen the pressure on the affected parts, the toes never leaving the ground. Sayre lays stress on the point that the suspension must be gradual, and that we must never go be- yond the point at which the patient feels entirely* free from pain. The plaster jacket is applied as follows: Everything necessary for the plaster dressing having been prepared (good modelling plaster, starched gauze bandages into the meshes of which plaster has been rubbed, dishes with warm and cold water, cotton, etc.) and the patient having Orthopedics and Orthopedic Surgery. 95 been dressed in a seamless stockinet jacket, the head is fas- tened in Glisson's suspender, due care being taken that the chin strap does not slip, the body being at the same time sup ported by* axillary* rings (Fig. 78) in Say re's tripod (or by* a hook in the ceiling) by means of pulley*s, so that the patient still touches the floor with the tips of the toes. Then we insert under the stockinet jacket, which is tied over the shoulders, a pad of wadding (".dinner pad") over the region of the stom- ach; the mammary* glands and the crests of the ilium are pro- tected by* pads, and small felt bolsters are placed on both sides of the gibbus (Madelung). Then, commencing at the pelvis and winding upward until we reach the axillae, the trunk is surrounded with plaster bandages, avoiding folds. A fresh bandage is placed into the water to soak only* after removal of the preceding one. While bandaging, the physician stands preferably behind the patient, while one assistant kneels in front, holding the leg's to prevent rotation, and another at the side holds the cord and hands the moistened bandages. Usually* it is sufficient for the corset to extend upward a little higher than the nipples, covering half the shoulder- blades. In case of dorsal or cervical kyphoses, the jury-mast must be included in the plaster dressing. (In children, as a rule, five to six plaster bandages about 13 feet in length and 3f inches in width will suffice; occasionally, the back of the bandage may* be strengthened by chips of veneer, etc.) The patient must not be taken out of the suspensory* ap- paratus and laid horizontally on a mattress until the plaster has set, and then the dinner pad is removed and the dressing is cut out somewhat at the axilke, etc., if necessary*. The application of the plaster jacket with the patient in the horizontal position, as recommended by* Walter, Willet, and others, has been tried more especially by* Petersen-17 the head and pelvis of the reclining- patient are supported, sus- pension being obtained by a bandage carried around the gib- bus, and in this position the plaster dressing is applied. When no special indication arises for its removal, the jacket may be worn for from three to six months. If the jacket is constructed so that it may be removed at will, its effective- ness is partially nullified, and this is allowable only* for dight cases near recovery. The removal of the jacket is greatly facilitated by including in the front of the diessing a strip of 96 Orthopedics and Ortliopedic Surgery. leather, which is divided after the plaster has set, and if per- forated with holes on both sides can be made to lace. Roberts added anterior metal clamps for the pur- pose of removal (Fig. 80). A number of modifications aim at making the plaster jacket in sev- eral layers and to include extension apparatus (Stillman, Wyeth, etc.). Wyeth18 recommended that the jacket be made in two pieces, with extension screws passing through nuts fastened in the dressing, thus allowing separation, the interven- ing part (gibbus) being bound mod- erately* tight with a roller bandage. During the night the posterior rod can be removed, the two lateral sufficing* when the patient is in the horizontal position (Fig. 81). Similarly*, Roberts19 has devised a means of extension in connection Fig. 80.-Roberts'corset with central with a double plaster jacket, in- ciamps. eluding four supporting clasps of perforated sheet copper (Fig. 9); a corresponding number of iron rods with screws and spiral springs allow of gradua- Fig. 81.—Wyeth's Double Corset with Extension Rods. Orthopedics and Orthopedic Surgery. 97 tion of the spring pressure. This modification can also be used for the correction of a co-existing lateral deviation, by connecting two of the iron rods by a rubber cord or adding another clamp on the side opposite the deviation, the rub- ber cord passing along the outer side of the corresponding extremity and being fastened to the shoe (Fig. 82). For cervical kyphosis, in particular, the ambulant appara- tus requires a number of additions, in order to relieve pressure Fig. 82. Fig. 83.—Jury-mast. Fig. 84.—Jury-mast. (After Nebel). and to provide extension; this has been effected by* a number of appliances included in the plaster jacket, etc., thus, for in- stance, in Berger's method, reported from Thiersch's clinic, ■•the bridge plaster dressing" consists in a plaster jacket in- closing the shoulders, from which extend two lateral iron bands with proper curve, which are fastened in a plaster dressing applied around the occiput and forehead. The juryr- mast (Fig. 83) consists of a two-tined fork, E, of soft iron, which carries above (corresponding to the handle) a movable, solid, more unyielding rod, C, which projects over the head 98 Orthopedics and Orthopedic Surgery. and in front to about a line uniting both ears; to this is fast- ened a cross-piece which can be rotated around a rivet, B, and which carries at its two ends small hooks for the suspension of the head-piece, A. The iron blades constituting the prongs of the fork are curved to fit the back, and are provided at the sides with two or three narrow brass hoops, F, which almost completety encircle the thorax, and are perforated like a grater, so as to give hold to the plaster bandage. In using the juryvmast, the patient is first wrapped in the usual manner with a few turns of plaster bandage, care being taken that the bandage surrounds the thorax smoothly; the juiy-mast, properly surmounting the head and in the sagittal plane, is next placed in position, and the apparatus is fastened by* additional turns of plaster bandage, the assistant carefully moulding the bandage into all the depressions caused by the apparatus. Morris (New York) has devised a very* cheap substitute for the jury-mast. It is made of iron wire the thickness of a lead pencil. This is bent to the proper shape, and the parallel wires are fastened at equal distances by* brass bands soldered on and reinforced at the points of greatest curvature (thus securing elasticity*), small square hooks soldered on serving for the sus- pension of the head-piece (Fig. 84). In regard to other apparatus resembling the jury*-mast we may mention Roberts' elastic traction head-rest, which does away with the annoyance of the jury-mast extending over the head, which is objectionable to many*. It consists of an upper cervico-mental collar, with metal clamp under the chin, so that it can be applied and removed with ease. To this the body*- piece is fastened by* means of lateral coiled springs and a hinge- joint. This trunk-piece can be moved longitudinally* and placed at any desired point in the sagittal plane by an endless screw. The lower forked part of the apparatus is inclosed in the usual manner in the plaster dressing. W. Pye,20 in many* cases of kyphosis of the upper dorsal vertebrae, incloses in the plaster dressing a dorsal splint in- stead of the jury-mast; this splint is forked below, so as to avoid pressure on the diseased parts. Above, it reaches only to the occiput, and at its free upper extremity* it bears two transverse rods (one at the upper end, one at the height of the first dorsal vertebra). To the former arm-slings are at- Orthopedics and Orthopedic Surgery. 99 tached, to the latter slings of stout material for the thorax and abdomen, which are included in the plaster dressing and thus counteract the tendency to bend forward. Although there is no doubt that the plaster dressing is one of our most important therapeutic agents, on account of its cheapness, facility- of construction, slight weight, and non- interference with taking exercise, we must remember the dis- advantages of the method, pointed out, for example, by Smith Fig. 85.—W. Pye's Modified Jury-mast for Upper Dorsal Kyphosis. Fig. 85 a.—The Same Apparatus after Fasten- ing the Slings. —viz., the impossibility* of watching the morbid process and of determining when it is necessary to remove the jacket; further, the facts that perspiration is interfered with, that vermin may lodge in the bandage, and especially* the fact that it in- terferes with the development of the thorax when it is worn several months. For these reasons the exclusive use of the method has been largely abandoned. The material from which the jacket may be constructed has been modified. In order to secure greater durability, the ioo Orthopedics and OrtJiopcdic Surgery. jacket has been made of silicate of soda—a method recom- mended among others, especially by Wolff, Fowler,21 Kolliker,22 and Witzel. The silicate of soda is preferable to any other material on account of its lightness, its durability and cheap ness, and particularly because the jackets can easily be made in a removable form. According to Kolliker, the silicate of soda should be applied with the patient suspended, the heels slightly raised from the ground, the traction acting mainly on the head; flannel bandages are first applied, then four to six lay*ers of silicate bandages, which must not be too moist, lest the flannel become saturated. Strips of veneer are in- cluded in the dressing at the upper and lower edges, in each axillary line, and laterally* at the spinous processes to reinforce the bandage. A temporary* plaster dressing consisting of three to four bandages should be applied over all, to keep the silicate bandage in position until it has hardened (two to three days). The patient must remain suspended until the plaster has set (Wolff). For cervical spondylitis, silicate of soda bandages surround- ing head, neck, and trunk, and fashioned over a plaster cast, have been much employed in Schonborn's clinic (Falkson23). They are made to lace by covering the edges with strips of linen having- hooks sewed on, and are lined throughout with flannel. Besides plaster of Paris and silicate of soda bandages for spinal deformities, use may* be made also of simple starch-paste bandages with pasteboard shaped to fit the back, and satu- rated with shellac, and strengthened by pieces of linen.24 The old and now almost obsolete glue dressings for making soft corsets with firm dorsal shields can be used to advantage, es- pecially for poor patients, being cheap and durable, and the necessary material being everywhere obtainable. Smith,25 Braat, and Karewski26 employ jackets made of woven wire shaped over the patient's body* or a plaster model; they* are tinned, to preserve them against rusting, and the jury- mast can easily* be added to them. They* possess greater dura- bility and cheapness than the other appliances, and they can be used for cases of inferior lumbar kyphosis, where the pa- tients are confined to the bed, by* adapting splints reaching to the knees and by leaving openings for urination and defeca- tion (Karewski). Touvers27 and others recommend a leather jacket shaped Orthopedics and Orthopedic Surgery. IOI over a cast, to which a jury-mast can be readily applied and which may be made removable. Mathieu also employed leather (strengthened by flexible steel springs) for corsets shaped over casts, but they* were too dear to find general ap- plication. H. Bigg's leather corset, however, with elastic material over the chest and abdomen and lined with soft leather, is a very* durable apparatus, which gives suitable sup- port and which does not interfere with respiration. Fig. 86.—Owen's Stiff Leather Cuirass for Caries of Fig. 87.— Cooking's Poroplastic the Cervical Vertebras. A, Anterior; B, Posterior P'elt Jacket. Plate; A', Chin Piece; B', Occipital Portion. Owen, among others, employ's in cervical spondylitis a stiff leather cuirass firmly* encircling thorax, occiput, and chin, lined with soft leather, and fastened by straps and buckles (Fig. 86). The value of plastic felt (according to Coking-Adams) for kyphosis was demonstrated mainly* by Beety, Madelung, and P. Vogt; it is easy of application, and it can be formed into a cuirass which yields equally* good fixation. The plastic felt can be applied after having been cut from a paper model. The heating necessary for moulding formerly made the appli- cation of a felt jacket somewhat difficult; but this is no longer 102 Orthopedics and Orthopedic Surgery. the case, since Bruns has taught us to saturate the felt on the body of the patient or to shape it from a model. The corset is cut from soft felt and then saturated or painted with an alcoholic shellac solution (nineteen ounces to one quart of al- cohol). Two to three days are required for drying, in winter four to five, but it forms a very* durable (three to six months) corset that can be easily* removed and arranged for lacing. Beely28 has devised a very practical application of the felt jacket, which, if the necessary splints, rivets, etc., are at hand, can be readily* constructed by* any* physician. (See Figs. 88 to 92.) The patient is either suspended after Sayre's method, so Fig. 88. Fig. 89. Fig. 90. that the toes still touch the ground, or else he is seated and suspended by* the head, with extended arms, and fastened by a belt transversely across the thighs (Fig. 78). Without pad- ding, the circular plaster bandage is applied and is made just strong enough to keep its shape after it is removed. This bandage is'cut open in front, removed, again closed by a plaster bandage and strengthened at the weak places. Then we may* either use it as a model, or we may* make a plaster cast by* filling its interior. Over this plaster model we mould strong but soft felt (\ to -J of an inch thick). The margins must over- lap somewhat, and where the felt does not adapt itself closely to the model elliptical pieces must be removed and the edges sewed together. The felt is next coated as far as the upper dorsal vertebra' or the mammae with the alcoholic shellac Orthopedics and Orthopedic Surgery. 103 solution (:>:7) until it is hard. In front, on each side of the mid-line, a space of from one to two inches, and above and below a space of from one-half to one inch must not be coat- ed. Spaces for the arms and for the mammae must be cut out, and the edges must not be coated with the shellac. After repeat- ed coating and drying for several days, the jacket is removed from the model and is fitted to the patient in the dorsal decubitus over the ordinary* under- shirt. On the front edges of the jacket are sewed two Fig. 91 b.—Felt Corset with Double Mast. Fig. 91 a.—Felt Jacket. (After Beely.) strips of leather, with but- ton-holes or else two rows of strong hooks to serve for lacing, while one or two buckles with a belt (Fig. 88) are fitted below. To the posterior sur- face of the dressing (Fig. 89) two somewhat elastic steel longitudinal splints are adjusted and two transverse splints firmly united by* screws or rivets; the height to which they reach depends on the seat of the disease. In case of spondylitis of the cervical and upper dorsal vertebrae the two longitudinal splints are lengthened 104 Orthopedics and Orthopedic Surgery. above, brought somewhat to the side, and bent so that their upper ends project two to four inches above the vertex, slightly beyond the plane of the mastoid process, and more than the width of the head apart; these serve as jury-masts, to which are fastened by four straps a belt provided with an excavated chin- piece (Fig. 91). In this way it is possible to attain almost com- plete fixation of the head; and when the head is not fixed the apparatus can also be worn in the dorsal position. Carefully padded shoulder-pieces pass over the shoulders; in jackets of greater size we may further strengthen the sides by* longi- tudinal splints, and the latter may* be made to turn above the upper end of the felt jacket around a vertical axis and be rendered adjustable in any posi tion by* an apparatus similar to that in Tay*lor's machine. The spinal col- umn is protected by* being covered Fig. 92.—Felt Jacket (after Beely), with Double Jury-mast. Fig. 93 — Walsham's Felt Cuirass for Cervical Kyphosis. with a soft piece of felt (with a special incision for the gibbus) broad enough to cover the rivets. At first the jacket should always be applied in the dorsal position and be laced below as tight as the patient can bear; above it should be loose enough to permit respiratory move- ments. V. Horoch29 states that there is a factory near Prague which makes a felt exactly* like the English article at about half the price, thus rendering this mode of treatment accessi- ble even to the poorest patients. The felt cuirass recommended by* Walsham,30 w*hich only Orthopedics and Orthopedic Surgery. 105 leaves the lace free will always be open to objection on the score that it is too warm, even if provided with a number of openings. Although all these jackets have the great advantage that they can be made by the physician himself and generally are not too dear, in some cases special advantages may be secured by more complicated contrivances which can only* be made by a mechanic. The majority* of these consist of splints ascending along the back on both sides from a pelvic belt, or else of a firm dorsal shield (Fig. 94); many besides possess extensible axillary Fig. 94.—Torticollis Apparatus. (After Lan- Fig. 95.—Spinal Supporting Corset. (After genbeck-Eulenburg.) Nyrop.) crutches, by* means of which the collapsed trunk may be gradually* raised. Especially in cases where a marked gibbus has not as y*et formed may these corset-like appliances be of value, and they may* be readily* combined with a jury*-mast for purposes of extension in high-seated spinal caries (Fig. 96). They* resemble certain of the appliances recommended for tor- ticollis. A very useful apparatus, among others, is Nyrop's spring corset, represented in Fig. 95, in which the juiy-mast, c e, with the head suspender,/ (Fig. 96), may readity be inserted into the slides, b c, on the dorsal splints, a, while lateral springs, d, contribute to the firmness of the corset. 106 Orthopedics and Orthopedic Surgery. With reference to extension apparatus, Taydor, as has been stated, pointed out the necessity for dorsal flexion, and recom- mended retroflexion of the anteflexed spine against a pad placed under the site of curvature. Taylor's apparatus31 is one of the best known; it consists of a broad pelvic belt, from which arise two parallel steel double splints which do not touch the spinous processes and are broken by a joint at the point of the kyphosis, where they are well padded and should exert pressure. Their upper ends are fastened to the neck by* two clasps and carry two axilla- Fig. 96.—Jury-mast for Nyrop's Corset. Fig. 97. straps, which draw the shoulders backward. In case of cervi- cal kyphosis a frame is added for the support of the head. In order to avoid the unyielding pressure of Taylor's appar- atus, Schildbach (Fig. 97) employs elastic steel dorsal splints, united above by a cross-piece. These splints are fastened to a stout pelvic belt, and carry buttons for the attachment of the axilla-straps and a broad abdominal leather belt. In England, Chance's adaptable metal splint for caries of the dorsal and lumbar vertobne has many adherents. It con- sists of two light metal splints ascending from a pelvic belt and bent according to the angle of the kyphosis. They reach to the height of the shoulders, where they are united to a plate from which the shoulder straps extend. At the an«ie Orthopedics and Orthopedic Surgery. 107 of the deformity, on each side of the hump, two pads are placed under the splints and exert leverage, relieving the pressure on the vertebrae, and drawing the trunk backward, while an ab- dominal belt prevents lordosis of the lower portion of the spine and fixes both the upper and the lower parts of the back in as straight a line as possible. This apparatus may be easily* adapted to cervical caries by* adding a dorsal rod and head band. In all these apparatus for backward traction, the fatal ob- jection lies in the fact that the deformity* is increased when the patient bends forward, for which reason the material em- ployed must be very* strong. Stillman endeavored to utilize for these cases a species of lever power, by* joining the short arm reaching to the kyphosis to a longer frame, the two being adjustable at any desired angle. This apparatus for ordinary* dorsal kyphosis is described as follows (Figs. 98, 99): On both sides, along the line of the spinous processes, two padded splints ascend from a belt to the seat of the ky*phosis (forming the short arm of the lever). The portion of the ap- paratus which exerts backward traction consists of a dorsal frame (representing the long arm of the lever) fastened to the pelvic belt and adjustable at any desired angle. When both arms of the lever are set at an angle and the dorsal frame (Fig. 98fr) is drawn close, the short arm of the lever will exert pressure on the transverse processes by* means of the pads io8 Orthopedics and Orthopedic Surgery. fastened above, and then, even when the upper part of the trunk is bent forward, there is no increase of the ky*phosis, Fig. 100, f*g- l'»2- Fig. 103. Stillman's Lever Apparatus with Jury-mast. since the short arm of the lever will hinder flexion by* forward pressure upon the gibbus. If well fastened, the apparatus Orthopedics and Orthopedic Surgery. log secures a higher grade of fixation than any* other; it is light, and does not inconvenience the patient. In apparatus for superior dorsal kyphosis the anterior straps are omitted, the long arm of the lever is fastened by* axilla-straps with infra-clavicular pads (Fig. 100). In the apparatus for kyphosis of the cervical or the first and second dorsal vertebra1 a jury-mast must be added (Fig. 100), or else some other form of head-piece, by* means of which the head can be fixed in any* desired position (Fig. 102). In the apparatus for caries of the lumbar (Fig. 103) or kyphosis of the lowest dorsal vertebra, the short arm of the lever would not be long enough to exert sufficient forward pressure on the gibbus, k; Stillman, therefore, altered the apparatus to meet this objection. The base, A, rests at the upper thoracic region, and is fastened there by straps; from this the splints (short arm of the lever) descend to the seat of the disease, where they* are supplied with appropriate pads (Fig. 103 a); while the long arm of the lever reaches to the sacrum, where it is united to the pelvic belt (Fig. 103 b). When (as in Fig. 103 c) the contrivance is fastened to the body, it represents a lever apparatus which stretches the vertebral column and fixes the spine, that is to say, it fulfils the indica- tions. At R a belt is applied, which serves for the correction of any co-existing lateral deviation. In many* instances it is advisable, in order to permit a cer- tain amount of muscular activity while the extension action is 110 Orthopedics and Orthopedic Surgery. at work, to employ* special apparatus for locomotion in which the patient is partially suspended, and in this connection the various wheel crutches, etc., should be enumerated (Fig. 104). The patient may* also exercise when suspended from an iron spring arm similar to that represented in Fig. 18. For the later stages of kyphosis, w*hen there is no further tendency to collapse of the affected portions of the spine, sim- ple retention apparatus will suffice; for instance, corsets with accurately* fitting pelvic belt and taking purchase on the iliac crests, lateral splints with axillary* crutches, and slightly* elastic posterior splints, with soft pads, if necessary*, on both sides of the spinous processes. In still other apparatus32 a posterior splint divides at the gibbus like a fork, and extends on each side of it. This splint is connected with the pelvic belt, and an elastic pad is placed over the prominent spin- ous processes, protecting them from injurious pressure and, in a measure, fixing them. Lateral splints are connected with the pos- terior. In the acute stages of the dis- ease1, absolute rest, extension by various means (suspensory* belt, etc.), and for affections of the cer- vical vertebrae Volkmann's exten- sion by* weights in particular are absolute indications. In the later stages, portable apparatus of varied construction, espe- cially corsets of felt, plaster, etc., and the more complicated machines (Taylors, Stillman's, etc.) must be resorted to, be- cause otherwise the patients would be debarred from the im- portant factor of exercise in the open air. Even when all symptoms seem to indicate complete recovery from the morbid process, it is advisable to have the patient wear for some time appropriate supporting apparatus, which takes pressure from the spine. The gravitation abscesses, which are so frequently* sequelae of caries of the vertebrae, call for special consideration. When we remember that Stromeyer declared, and with Fig. 104.—Meigs' Spinal Aparatus (re- sembling Darrach's Wheel-crutch.) Orthopedics and Orthopedic Surgery. 111 truth for his day, that the opening of cold abscesses was not allowable because it was an operation which was nearly always followed by* death or prolonged invalidism; and that nowa- days, under antiseptic precautions, we not only open grave congestive abscesses, but make a wide incision, drain, etc., the change in opinion effected by* the introduction of the antiseptic system is most striking. In all cases where we can guarantee efficient antiseptic after-treatment, early incision of these ab- scesses (as soon as they* become accessible to the knife) should be the stringent rule of practice. Such is the view held by Leser,33 of Volkmann's clinic, and by Koenig, Bardenheuer, Dollinger, and others. Incision is followed by* irrigation with warm aseptic fluid (borated salicylic-acid solution, weak sublimate solution). The pyogenic membrane is removed with the sharp curette as far as it can be detected. Usually* the membrane can be easily* wiped out with a wad of gauze or sponge held on a dressing- forceps. Where possible, counter-incision and drainage near the diseased portion of the vertebra, suture of the wound, and antiseptic dressing should, in addition, be carefully resorted to. At the first change of dressing, the drainage tube must be cleansed, so that permanent dressings, as a rule, are out of the question. Even where only* minute fistula? remain, strict antisepsis must be maintained. In Volkmann's clinic, between 1873 and 1884, 58 cases of congestive abscesses were operated upon (among these 53 fol- lowed on spondylitis and the formation of a gibbus). There were no deaths from the operation; 23 permanently healed by first intention; 20 died subsequently* of tuberculosis. Psoas abscesses, which are frequently met with and can be opened even when still high in the iliac fossa, must be opened early* and the purulent contents must be removed, thus guard- ing the patients against gravitation and spreading. This is in accordance with Dollinger's view. The incision is made behind the anterior superior spine, and above and parallel to the crest of the ilium, and is then carried backward 2| to 3i inches, the muscles being divided. The fingers are then inserted into the wound, the abscess is opened by a long incision, and the tubercular membrane is wiped out with a one to two per cent, chloride of zinc solution. After being cleansed, the counter-opening is made at the quad- 112 Orthopedics and Orthopedic Surgery. ratus lumborum and a drainage tube is inserted. Tincture of iodine diluted with water until it has merely a yellow color is also recommended for irrigation (Owen). Retropharyngeal abscesses, in particular, must be opened early, since they* may cause suffocation when they* extend or rupture spontaneously*. According to Hilton, deep cervical abscesses should be opened at once by* incising the sterno- cleido-mastoid and making an exploratory* opening through the deep fascia1. If pus be obtained, the incision is extended. Still, even at the present time, many* authorities pronounce against early operative interference (Noble Smith), and for those cases in which the necessary* antisepsis cannot be as- sured, it should be remembered that we are also in possession of other less energetic measures, which may be carried out in dispensary practice, such as tapping the abscess with a trocar, followed by* sublimate irrigation and iodoform injection. This method is performed by* Schede and others. The treatment by* iodoform injections, according to the statements made by* Frankel,34 Andrassy,35 Verneuil,36 and others, is a very simple, harmless, and effective procedure which is of the greatest value, especially* in cases where the abscesses are very deep, if not almost or quite inaccessible. P. Bruns, for instance, had twenty* permanent recoveries among twenty-two cases. The aspirator needle, attached to the sy*ringe, is thrust into the abscess, and the contents are withdrawn as completely as possible; then, through the same canula, we inject the iodo- form solution (10 : 90 of glycerin, or 10 : 50 of water and 50 of glvcei-ine) or a five per cent solution of iodoform in ether (Verneuil). As a rule, the amount of fluid injected should be from one to two fluid ounces, at most three fluid ounces, ac- cording to the size of the abscess. According to Andrassy, the abscess usually- rapidly* refills to its former volume, and the aspiration and injection must be repeated, if necessary*, at intervals of two weeks; in general, two to four injections are required. In the sixteen cases ob- served in the clinic until recovery was complete, the time oc- cupied varied between two weeks and two and a half months —an average of four to five weeks (Andrassy), according to Frankel six to eight weeks. Orthopedics and Orthopedic Surgery. 113 Skoliosis. Under the terms skoliosis (from «/.i>}.:<>w, to bend, to curve), lateral curvature of the spine (French, deviation laterale de lataille; German, seitliche Riickgratsverkrummung; Italian, Scoliosi) we understand any* permanent lateral deviation of the spinal column or a part of it from the normal physiologi- cal direction. In a more restricted sense, the term skoliosis is applied only to the abnormal lateral curvatures caused by* mechanical influences, exclusive of true morbid processes (Drachmann). The curvature seldom implicates the entire spine, total skolio- sis; usually one portion of the spinal column is chiefly* affected, partial skoliosis; and hence we speak of right dorsal skoliosis, left lumbar skoliosis, etc., according to the direction of the convexity* of the curvature. The curvature of a certain segment, however, never per- sists alone; owing to efforts at maintaining the equilibrium the original primary* curvature soon becomes associated with secondary*counter-curvatures (compensating curvatures); the simple skoliosis becomes compound. Although statements such as those made by* Werner (who estimated that there were 65,000 skoliotic persons in Prussia) have but a relative value, there is no doubt that skoliosis is the most frequent of all orthopedic affections. Berend found, among 3,000 orthopedic patients, 900 with skoliosis; Lang- gaard, among 1,000, 700; and Schilling, among 1,000, 600 with skoliosis. Drachmann, on examining 28,125 pupils, found 1.3 per cent skoliotic, 0.8 per cent boys, 0.2 per cent girls. Most observers agree that the majority* of cases (9.335 per cent, Drachmann) occur in girls (10 : 1, Eulenburg; 577 : 144, Kolli- ker). The skoliosis of later growth (A7ogt), which occurs almost exclusively* among girls, is certainty traceable to defi- nite causes, though it is possible that the proportion is rather apparent than real, and is due to the fact that the develop- ment of girls is watched with greater care and that they* are, therefore, brought earlier to the physician. Even if the abso- lute frequency* in girls is perhaps no more than double that in boys, still the physician is consulted about a much larger pro- portion in girls. Roth found, among 200 cases, 183 females; Wildberger, ! Iz|. Orthopedics and Orthopedic Surgery. among 120 cases, 101; Lonsdale, among 170 cases, 149; Ketsch,37 among 229, 189; Berend, among 896, 773, etc. It is further of interest to note that counting the aggra- vated forms of skoliosis alone the number of males is in excess. As to age, skoliosis occurs even during the first years of life, and then is usually* of a rachitic nature. The great ma- jority of cases (56.4 per cent, Eulenburg) develop between the seventh and tenth or fourteenth year, that is to say, at the time when the patients begin to go to school and are sub- jected to the associated injurious effects. In the female, the early establishment of puberty would seem to have an influ- ence on the greater frequency of skoliosis. Ketsch reports, from an anatysis of the material of the New York Orthopedic Dispensary, that the number of cases of skoliosis between the first and twelfth y*ear formed 52 percent; from the twelfth to the eighteenth year, 14 per cent; of later development, only* 3| per cent. In general, it cannot be asserted that, aside from rachitis, an essential part is played by* the diathesis in the production of skoliosis. Delicate, tall, and weakly* children are most frequently* attacked. In these -re- spects, the better classes furnish the greater FiG.ios.-RachiticSko- number of cases, while in the children of liosis in a Boy of Four the poor bad hygienic conditions are to be blamed. Skoliosis seems to be a consequence of civilization, and, ac- cording to several authorities, hardly* ever occurs in savage races. Children with flat backs, it is claimed, furnish the greatest proportion of the graver forms of skoliosis. As regards the tendency to skoliosis of the several portions of the spine, there is no doubt that dorsal skoliosis with the convexity* of the curvature to the right (the ordinary habitual skoliosis) is the most frequent (Kolliker3S). Drachmann states the proportion 42.3 per cent, Eulenburg 92.7 per cent, Adams 84 per cent, Heine 81 per cent. Still more recent investiga- tons (Drachmann, Lorenz) show that primary* left-sided lum- bar skoliosis is much more frequent than had been supposed; thus, Lorenz found among 163 cases. (52 left lumbar skolioses, 64 right convex dorsal skolioses; Klopsch39 noted the same Orthopedics and Orthopedic Surgery. "5 fact, determining left convex lumbar skolioses in 71 cases out of 121 instances of skoliosis (all girls). Meyer, Schmidt, and others have made similar observations. As will appear hereafter,however, left convex skoliosis is rare in later childhood (21 per cent, Drachmann) and more frequent only* in nurslings and infants. It usually* appears as a lei't- sided deviation (skoliosis simpler totalis) of a rachitic nature. Very rarely does skoliosis consist in a simple lateral bend- ing; as a rule the condition is associated with a rotation, a tortion (rotatory* lateral curvature) rendering the deformity Fig. 106.—Slight Habitual Skoliosis in a Fig. 106a.—Fixed Skoliosis in a Girl of Girl of Thirteen Years. Eighteen Years. of the spine serpentine (see Figs. Ill, 113). This compound deviation is necessarily* conjoined with a displacement of the ribs and hence there results deformity* of the thorax (see be- low) when the dorsal vertebrae are affected. We must, then, define skoliosis as a distortion of the trunk in which an ab- duction and rotation of the spinal column is associated with deformity of the thorax (Vogt). According to the mode of origin we distinguish congenital, habitual, static, professional, pathological (inflammatory*, cicatricial, empyematic), traumatic skolioses. According to Eulenburg, an hereditary factor may be de- 116 Orthopedics and Orthopedic Surgery. monstrated in 25 per cent of 1000 cases of skoliosis, and P. Vogt also finds that heredity can be shown to be a cause in more than one-half of all the higher grades; in such cases there is a transmission of a peculiar form of development of the spinal column which manifests itself only* at a certain period of evolution. Congenita] skolioses are, however, extremely rare, and they are due either to a vititim primce formation!s or they* are the consequence of other deformity*. Busch, among others, has de- scribed an interesting' instance.40 Rachitis and other processes associated with abnormal softness of the bones (osteomalacia) rarely of themselves give rise to skoliosis; as a rule to the ab- normal quality* of the bones is superadded, as a predisposing factor, the effect of weight. The most frequent form of skolio- sis, the so-called habit-skoliosis, must be considered as a de- formity due to the effects of weight, and here we are dealing with a lessened sustaining capacity* of the spinal column occur- ring at the time of the second dentition and associated with the increase in growth of the skeleton which occurs at this time. These are the predisposing causes, and unequal weight on the growing parts of the skeleton is the exciting cause. So-called static skoliosis arises from unequal length or functionating power of the lower extremities, which leads to obliquity* of the pelvis and to primary* deviation of the lumbar vertebrae. Staffel, for instance, found the static cause present in 76 out of 230 cases. The pathological skolioses, on the other hand, are excep- tional. Skoliosis is here due to osseous or articular disease of the vertebrae, i.e., primary osteogenetic and arthrogenetic skoliosis, or to disease of the surrounding soft parts (myogenic, dermatogenic, etc.). The inflammatory* skolioses are usually combined with kyphotic curvature and occur particularly* in the cervical region of the spine as the so-called caput obstipum osseum, and also largely* as arthritis deformans of the lumbar region of the spine, etc. Cicatricial skolioses may arise from extensive burns, phlegmons, defects of the ribs due to caries, necrosis, etc. Empyematic skoliosis is more frequent, and it occurs in consequence of contraction and the formation of false membranes with defective expansibility of the diseased side following on empyema; usually the concavity is turned to the affected side. Orthopedics and Orthopedic Surgery. uy It is doubtful whether a purely* muscular disease may cause skoliosis, as, for example, a rheumatic skoliosis due to inflam- mation of muscles (as is claimed by Eulenburg and others); cases have been recorded, however, where skoliosis has fol- lowed on a neuritic process, such as sciatica (Albert, Nico- ladoni41). The explanation offered is that in sciatica the patient instinctively endeavors to obtain more space for the swollen nerve fibres which are inclosed in the lumbar segment of the spine, and therefore bends to the opposite side. Only after eliminating all other possible causes may we assume that a simple disturbance of innervation is at the base of a skoliosis. Trauma rarely- results in skoliosis, since fractures of the vertebrae are more likely to cause curvature in the sagittal plane. Non-reduced luxations of the cervical vertebrae might possibly, however, lead to permanent lateral curvature of the spine. By far the great majority* of skolioses are to oe considered as deformities due to weight, and since the patients perma- nently assume an oblique position, the vertebrae under the un- equal weight acquire an asymmetrical form and thus habitual skoliosis arises. Besides the faulty position maintained during writing, which is a chief source of the deformity*, a number of occupations which require an oblique position (violin playing, one-sided bearing of burdens) may cause skoliosis, and indeed we not infrequently* see in some occupations what may* be termed professional skolioses. If the first tendency* to skoliosis has resulted from the habitual assumption of an oblique position, then its increase toward a curvature will naturally* ensue from the unequal pressure; for increase in growth of the portion of the y*oung bone least exposed to pressure, and retarded growth of the portion most exposed, while this bone is still plastic, leads both to the wedge-shaped malformation of the vertebrae and the torsion of the skoliotic segment. If now we consider first the anatomical alterations of the skoliotic spine, by inspecting-, say, a pronounced (habitual) skoliosis with right-convex dorsal, left convex lumbar curvature, and left-con vex counter-curva- ture in the cervical segment, it is readily apparent that the curvatures are situated, not in the sagittal plane, but in diag- onal planes (Fig. 113), and even on viewing them from above 118 Orthopedics and OrtJiopedic Surgery. they* are not seated in a frontal plane. The curvature is rather serpentine, spiral, and there is, aside from the lateral curvatures, a twisting of the median sagittal plane of the ver- tebra1 around a vertical axis which is termed rotation or tor- sion and which strikes the eye on inspecting any* skoliotic spine from in front, by* noting the most anterior points of the several vertebrae (see Fig. 113). A perfectly* accurate conception of the anatomical altera- tions will be possible only* when all the stages of the skoliotic process have been studied. The alterations of the initial stages would certainly be of the greatest interest. In this stage we must surmise that there has existed unequal ossifi- cation, for cases are on record where ossification had advanced Fig. 107.—Skoliotic Dorsal Vertebra, Fig. 108.—Frontal Section through Front View. two Skoliotic Vertebrae. much farther on the convex side of the skoliotic curve (Nico- ladoni). The anatomical changes do not mainly affect the ligaments as was formerly believed, but the bony* framework; and the several vertebrae not only undergo change in form by* the lat- eral curvature, which may be briefly designated as atrophy* of the concave half of the bone with resulting wedge shape of the skoliotic vertebra, but also in torsion (torsional changes) which causes the chief deformity*, the costal projection. If we compare one of the skoliotic dorsal vertebra? with a normal one, we notice, on inspection from in front (Fig. 107), that the former is wedge-shaped with the base toward the convexity (and this wedge shape is most pronounced on the eminences of the curvature and may be so great that several vertebrae are actually joined in one curve, and may become Orthopedics and Orthopedic Surgery. 119 fused into one by* an osseous proliferation due to periosteal irritation). (Fig. 110.) This wedge-shaped deformity affects not only the bodies of the vertebrae, but also the roots of the arches, the articular surfaces, etc. (Fig. 107) (Lorenz). The root of the arch on the concave is shorter than that on the convex side; at times the former appears as if retracted into the upper surface of th<> body of the vertebra, often it is reduced to a very* thin translucent piece of bone. The articu- Fig. 109.—Skoliotic Dorsal Vertebra seen Fig. 110.—Part of the Dorsal Portion of a from in Front. Skoliotic Spine. lar surface of the arch on the concave side is also much re- duced in height; the upper one in particular is often changed into a low translucent flake of bone. The articular surface, by including the neighboring portion of bone, whose perios- teum is transformed into a kind of fibro-cartilage, is irregu- larly widened; while on the side of the convexity*, where the articular surfaces are partly lifted from each other, they be- come gradually smaller by* the disappearance of the cartilage. The vertebral canal is ovoid, the larger end being directed to the convexity, the smaller to the concavity; this results 120 Orthopedics and Orthopedic Surgery from the altered position of the roots of the arches which do not diverge uniformly*, but have an asy*mmetrical direction. Fig. 111.—Lumbar Skoliosis (rotation), Front View. Fig. 112.—Lumbar Skoliosis (rotation), Rear View. The root of the arch on the convex side approaches the sagit- tal, that on the concave side the frontal direction, and the ideal union of the roots of the arches is not sagittal in front of £% &%%&&*> Fig. 113. the vertebrae as in the normal condition, but on the side of the convexity. The vertebral body itself is even asymmetrical, the concave half presenting a more frontal, the convex half a Orthopedics and Orthopedic Surgery. 121 more sagittal direction. On viewing a macerated skoliotic spine from in front, we observe a peculiar oblique direction of the bony fibres instead of a vertical one; this is especially* noticeable in the single vertebra (Dittel, Fischer, and others), and becomes more conspicuous the higher the grade of the deformity. The internal vertebral structure is also similarly altered, the oblique course of the bony trabeculae producing a shortening of the vertebra; hence the torsional changes should be looked upon mainly* as a torsion of the bones (A'olkmann, Lorenz) and not as a rotation in the articulations. Similarly, the transverse process of the convex side has Fig. 115.—Portion of a Skoliotic Spine Fig. 116.—Skoliotic Spine and Protruding Seen from Behind. Ribs, Rear View (Specimen in the Munich Pathological Institute). usually a more sagittal position and is directed more back- ward; that of the concave side is more frontal and the angle formed by* the transverse and spinous processes becomes more acute on the convex side, the sulcus paraspinosus being nar- rower, etc. (Fig. 117). The spinous processes are displaced to the concave side with reference to their insertion, whilst the direction of the points of the dorsal spinous processes form, so to speak, an excrescence toward the convexity. The row of the extremi- ties of the spinous processes does not correspond with the in- tensity of the curvature, being sometimes in a straight line (Fig. 112) notwithstanding aggravated skoliosis. 122 Orthopedics and Orthopedic Surgery. As regards the explanation of the appearances of torsion, it is no longer possible to accept the view of Nicoladoni (who looked upon them as an optical effect) or that of Hencko, viz., rotation in the articulations. The same may be said of the different attempts at explanation by Roser, Meyer, Maigaigne, Dick, Eulenburg, Drachmann, Schenck, etc., which will be found in Lorenz's work. Lorenz finds in the presence of the epiphyses of the roots of the arches the tendency to torsion of the growing vertebra, in the same way* as the epiphy*ses of the bodies of the vertebra? favor the Avedgo-shaped deformity, and he lays stress on the sudden bend of the basal epiptryseal joint of the roots of the arches toward the middle line or the con- cave side; for here, as the point of least resistance, the root of Fig. 117.—Skoliotic Thoracic Hoop. (After Lorenz.) the arch with the adjoining thoracic hoop, as it were, remains behind the body* of the vertebra which is crowded out of the middle line as the result of pressure. Of the greatest importance with reference to the deformity are the anatomical alterations of the ribs which are closely united with the vertebrae and which cause the marked change in the shape of the thorax. These alterations may also be divided into alterations in position and into alterations of tor- sion (changes in shape), the latter being much more impor- tant. Since the rib, as far as its angle, is to a certain extent dependent on the arch of the vertebra, there results a more or less sagittal direction of the root of the rib on the side of the convexity; hence the greatly flexed costal angles cause a seri- ous deformity, (the so-called posterior costal eminences), while the ribs of the concave side, being directed more to the front, Orthopedics and Orthopedic Surgery. 123 sIioav a diminished curvature and this explains the flattened condition of the skoliotic thorax. These costal curvatures at the posterior part must corre- spond to diametrically* opposite curvatures at the anterior part of the ribs, and the places Avhere the more strongly curved portions of the ribs join the more extended portions are termed, in turn, the anterior costal eminences (at k, Fig. 117). As to the changes in position of the ribs in skoliotics, in case of dor- sal skoliosis all the ribs are depressed on the side of the convexity (Fig. 116)—a fact to be explained probably by the resistance of the muscles of the trunk to their elevation (Lorenz). At the concave side, the ribs of the lower border of the curvature are moderately depressed; superiorly* this de- pression becomes less, the ribs grow horizontal and finally are slightly* elevated. The ribs of the convexity are divergent, while those on the concave side are approximated, usually atrophic, and where the skoliosis is great they* may* articulate with each other or be united by synostoses. In skoliotics, therefore, the thorax is oblique, and in right- convex curvature the thorax extends in the right, in left- convex curvature in the left diagonal diameter; the convex half of the thorax is diminished in all dimensions, the capacity of the concave side is lessened only in height, but is increased in all the other diameters. In a horizontal section the skolio- tic thorax represents an ellipsoid whose greater axis is formed, in right-convex curvature, by the right, the lesser by the left diagonal diameter (Fig. 117). Aside from the rachitic form, the pelvis in case of habitual skoliosis is not in general much deformed. Adams says in this connection: "Obliquity* of the pelvis is supposed to exist much more frequently* in cases of lateral cur\*ature than it really* does." In the severer degrees of skoliosis, especially that of the lumbar segment, the pelvis is somewhat oblique. The deformity* of the sacrum is above all the cause of asym- metry* of the pelvis. In left-convex lumbar and in right- convex dorsal skoliosis the left diagonal diameter of the pelvic inlet appears elongated, and the right shortened; hence the obliquity* of the pelvis is opposed to that of the thorax. The changes in the ligaments are only the consequences of the alteration in the shape of the affected parts of the skele- ton, and those of the muscles (especially* of the long dorsal 124 Orthopedics and Orthopedic Surgery. muscles) are not very marked. In the early* stages of the skoliosis there are no changes in the muscles; in more chronic cases, the muscles on the side of the convexity are relaxed, pale, and fatty degenerated, while those on the concave side are altered to a less degree. The relations of the long dorsal muscles to the spinous processes are altered, the distance be- tween them being increased on the concave side, and lessened on the opposite side; in the higher grades of skoliosis the longitudinal muscles may* become subluxated over the spinous processes on the concave side. The broad dorsal muscles also adapt themselves to the deformity of the thorax; thus the rhomboids, passing over a costal eminence on the convex side, are usually* thinned and atrophic; on the concave side they are shortened and thickened. The numerous theories in regard to skoliosis can scarcely* be harmonized with these anatomical findings, and we shall here consider only very briefly the various attempts at ex- planation. As Copeland aptly* says these \*iews furnish ma- terial for a keen satire on the medical art. Up to the beginning of the present century*, skoliosis Avas looked upon as an arthrogenous affection, and the ligaments in particular Avere thought to be at fault. Delpech, Guerin, Eulenburg, and others sought the causal factor in disturbed muscular antagonism (the nxyogenous view). Some assumed a paratysis of the dorsal muscles on the convex side, others a contraction on the concave side of the cuiwature, and the lat- ter vieAv led to the performance of myomotomies in skoliosis, which operation Avas shown by* Malgaigne to be based on false premises. A weak constitution was considered to be the pre- disposing cause of the habitual oblique position. This led to passive dilatation and weakening of the dorsal extensors on the convex side, the exciting cause of skoliosis. Although this myogenous theory has been sufficiently* refuted by Werner, it is still held by* some. Neither the anatomical nor the clinical facts are supported by* Stromey*er's respiratory* theory* Avhich explains the skoliosis by* a unilateral relatively* stronger action of the right serratus—a view maintained by* Sayre, for in- stance, for primary* dorsal skoliosis. The views maintained by Malgaigne and Adams of a primary* relaxation of the ligament- ary apparatus, or Werner's gratuitous vieAv of the primary- disturbance of the will, also offer insufficient explanation. A Orthopedics and Orthopedic Surgery. 1215 mere historical interest attaches to Hurler's theory of pressure by* growth of the ribs, the fallacy* of Avhich Avas clearly shoAvn by Dornbliih and Lorenz, and is proved, in addition, by* the occurrence of primary* deviations in other segments of the spine. Lorinser defended mainly the osteogenous explanation, i.e., he found the tendency* to a skoliosis in an insidious inflamma- tion of the bone, an inflammatory* softening process, the pa- tient instinctively* assuming the position in which he escaped as much as possible the effect of pressure on the softened part. Lorinser sees in skoliosis a morbid process in nowise differing from kyphosis, but considers both expressions of the same disease, only* varying in degree. The cases, however, are rare in Avhich we find anatomical alterations corresponding to this theory* (as in a case recently* observed by* me). Von Lesser42 produced skoliotic curvature experimentally in animals by unilateral di\*ision of the phrenic ner\*e and be- lieved that unequal functional de\'elopment of the two halves of the diaphragm also play*ed a part in human skoliosis. Another theory sees in skoliosis only* a pathological in- crease of the lateral curvature Avhich, according to Sabbatier, BouA*ier, and others, is physiological. It is not certain, how- ever (Adams, Lorenz), that skoliosis is physiological as is claimed, about the seA*enth year, and which is thought to be due to the pulsations of the aorta (Sabbatier), to the greater weight of the organs on the right side (Desruelles, Struthers), to habitual right-handedness (Busch), and generally to an in- creased growth of the right side of the body*. Schildbach and others defended the view of a primary* anomaly* of growth. The theory of pressure, which is applicable to the majority* of skolioses (Roser, Volkmann, etc.), i.e., the conception of skoli- osis as a gradual transformation of the previously* well-formed spine under mechanical influences has at present the greatest number of adherents. It is evident that in most occupations and even in ordinary relaxed attitudes, unequal pressure is present, and that, if this be continous, especially* about the seventh year at the time of the second dentition, which is associated with increased growth of bone, development Avill be uneven and the deformity* will become greater. Attendance at school at this critical time, and especially faulty position during writing, which is largely 126 Orthopedics and Orthopedic Surgery. due to badly constructed seats, are chiefly to blame for begin- ning skoliosis. In the position which the fatigued child usually* assumes in writing, the right shoulder is higher and projects forward, the right forearm rests on the table, while only* the left hand or a feA\* fingers, touch the oblique book or the table,43 especially* when the desk top is too far from the seat; this causes a right coiiA*ex dorsal curvature of the spine. According to others, the left curvature of the spine (Fig. 118), especially* that in the lumbar region, is more frequent, but its frequency is under- estimated OAving to the symptoms being less conspicuous. Schenck has determined with a special apparatus the position in AA*riting of 200 children, and found that in 160 the trunk Avas displaced to the left on the pelvis, the aveight of the body* rest- ing on the left elbow and arm, thus producing a left-convex total skolio- sis; 34 pupils displaced the trunk to the right, but turned to the left so as to relieve the pressure on the right forearm which was used in Avrit- ing, and they* exhibited an habitual dorsal sko- Fig. 118.— a, Faulty; b. Correct position. (Alter Roth.) liosis AV i t ll A* e T V prO- nounced right dorsal flexion; only* 6 showed no lateral dis- placement of the trunk during writing: in all, excepting 38, the pelvis was not parallel but oblique to the edge of the desk. In addition to faulty* position in writing, skoliosis is favored by all acts and occupations causing obliquity of the pelvis and sinistro-flexion of the trunk. Here unequal pressure and the resulting dissimilarity in growth cause skoliosis. As for the symptoms of skoliosis. the onset cannot be determined clinically. The affection must reach a certain degree of development before it gives any external indications. Rarely- it is the curvature in the line of the spinous processes which is first observed, more frequently- the greater height of one shoulder or hip; often, in beginning skoliosis, it is possible to recognize only a slight displacement of the trunk on the pelvis, which is always in the direction of the primary curva- Orthopedics and Orthopedic Surgery. 127 ture (in the right primary dorsal curvature to the right). As a result of this displacement, the lateral borders of the body- become asy*mmetrical; in right displacement the right Avaist line and the right crest of the hip disappear, while the left outline has a concave SAveep, the left hip being prominent, the left Avaist line somewhat deepened, and vice versa. The arm, on the side of the displacement, hangs down; on the opposite side it is opposed to the crest of the ilium, where it forms a triangle with the Avaist line (Lorenz) which becomes unequal in bilateral skoliosis (see Fig. 120). According as there exists a primary* lateral curvature in the lumbar or dorsal spine, we find the position of the hip or shoulder altered as the expres- sion of the deA'iation of the vertebral column, and according Fig. 119.—Beginning Skoliosis (right side), Fig. 13i>.—Primary Lett convex Lumbar Girl aged Four. Skoliosis. (After Lorenz.) to the appearances Ave may distinguish betw*een a primary* lumbar and a primary dorsal skoliosis. In primary* left-convex lumbar skoliosis, the relatively fre- quent occurrence of which, as a primary* deviation, has been repeatedly referred to, the left angle of the waist appears flat- tened or completely obliterated in the higher degrees, so that the left arm is in contact Avith the lateral surface of the trunk nearly* throughout. The right angle of the Avaist, on the con- trary*, is more acute, and, in Avell-nourishod persons, a trans- verse fold extends toward the middle line, while the distance of the arm from the waist line is increased. There results, hence, a diminution or disappearance of the left, an increase in the right triangular outline of the waist, that is to say, a deepening of the right waist line. The left waist line, and the 128 Orthopedics and Orthopedic Surgery. crest of the left hip disappear; on the side of the concavity* they* become more prominent, and, owing to the rotation of the lumbar spine, the left lumbar region becomes fuller. A prominence is visible in the left lumbar region along the mid- dle line Avhich is also noticeable on palpation and especially when the patient bends forward. The longitudinal SAvelling of the erector trunci appears much flatter than on the right, because the transverse processes deviate forAvard. As the affection increases, changes of position (counter-curvatures) also occur in the dorsal vertebrae. Primary* right-convex lumbar skoliosis, a very exceptional condition, causes similar changes, although, of course, on the opposite side. Primary right-com*ex dorsal skoliosis (next to the left- convex lumbar skoliosis the most frequent and important A*ariety*), in its first stages, while the spinous processes may* still be entirely* in the middle line, presents a slightly* in- creased curvature of the right costal angle which becomes more conspicu- ous on inspection from aboA*e. Soon the changes in the position of the scapulae become marked, i.e., the right scapula projects backward, is somewhat higher, and its outlines are sharper (resting as it does on a higher base, that is, on the more strongly backAvard-curved ribs); \A*hile the less prominent left scapula, slightly tAvisted, approaches with its angle the sagittal axis (the left upper extremity* sinking down on the flat ribs), and a fold of the skin extends from the left scap- ular angle down and outward to the waist line. Essential alteration of the lateral contours is not perceptible. Shortly, the secondary lumbar curvature is superadded and at the same time the lateral outlines become more and more asym- metrical, the right waist line becomes deepened, the right hip more prominent, while the crest of the left hip is obliterated, the left triangle of the waist is elongated and nearly semi- lunar. This latter circumstance presents an essential differ- ential point from primary left convex lumbar curvature (Lorenz). The concavity of outline on the left side becomes Fig. 121.—Primary Right-convex Dorsal Skoliosis. (After Lorenz.) Orthopedics and Orthopedic Surgery. 129 still more pronounced Avhen the entire trunk is displaced on the pelvis to the right. Then the angle on the right at the waist opens outward, the right arm hangs down straight and the projection of the right hip is absent (Fig. 122). As soon as Ave can recognize a deviation of the spinous processes, the diameter of the half of the body* on the side of the com*exity appears shorter, and this is also the case in lumbar skoliosis, while in dorsal curvature the conditions are obscured because the greater distance of the right scapula from the spinous processes simulates a Avidening of the right half of the trunk. In case a compensatory* left-convex cerA'ical curvature is superadded, then we notice a characteristic alteration in the shoulder line across the neck. This normally* forms a gentle double curvature. It becomes flattened on the left, the left side of the neck is shorter, and the rounding of the left shoul- der is less prominent laterally: Avhile on the right side the neck is longer, the rounding of the shoulder more prominent, and the line across the shoulders is more curved. In comparison with this form of curvature of the fully* de- A*eloped habitual skoliosis (skoliosis duplex adolescentium), the remaining forms are of but little practical interest on ac- count of their rarity*, and their symptoms Avill be discussed in connection with rachitic and static skoliosis. The onset of skoliosis differs in so far as in certain instances left-convex lumbar skoliosis appears first, in others right- comex dorsal skoliosis. Only exceptionally does the deform- ity begin at the outset Avith several curvatures. Ordinary habitual skoliosis, as a rule, has an insidious course, it deA*elops slowly and increases gradually*; but at times, especially in girls of rapid growth, the development and increase of the affection are exceedingly* short, so that in the course of a few months high grades of deformity may be produced; usually the affection progresses the more quickly the y*ounger the patient. In general, three stages may* be distinguished: In skoliosis of the first degree we deal, as it were, with an habitual skoliotic attitude; marked costal projection is not yet present; by* vertical suspension, horizontal decubitus, or slight manual pressure the curvature of the spine can be readilv made to disappear. 9 130 Orthopedics and Orthopedic Surgery. In skoliosis of the second degree the deformity can no longer be entirety removed by* active motions, suspension, etc.; the torsional changes are marked, and the differences in level of the posterior surface of the thorax disappear only in part even on suspension, although the curvature of the spine may still become quite or nearly obliterated. As a rule, compensa- tory counter-curvatures have already* developed. In skoliosis of the third degree, there is complete or almost total unalterability of the cur- vature, whether on man- ual efforts or on vertical suspension. The spine has become rigid by uni- lateral atrophy* and an- kylosis. Skoliosis may* oecome stationary in any* stage and does not always reach the highest grades. Early* diagnosis of commencing skoliosis is of the greatest impor- tance, since the first stages chiefly* offer hope of cure from treatment. The indifference Avith which the anxious moth- er is quieted by* the phy- sician consulted for the Fig, 122.—Pronounced Grave Habitual Skoliosis " hi°"h Shoulder " Or the " oblique attitude " of a child, Avith the statement that this will be "outgrown" and spontaneously disappear, without even making a careful examination, cannot be too strongly con- demned and must be taken to indicate a lack of conscientious- ness Avhen Ave bear in mind how frequently- skoliosis and its consequences destroy the happiness of tin1 afflicted individual. Eulenburg justly* criticises the indifference of many family* physicians toward beginning skoliosis, "'for Avhile in other diseases not pertaining to their special sphere, as of the ey*e, Orthopedics and Ortliopcdic Surgery. 131 ear, etc., they* usually refer their patients to a specialist, in cases of spinal curvature they unnecessarily assume a respons- ibility Avhich the daily* sight of numerous unfortunate A*ictims should have rendered distasteful to them." The factors to be taken into consideration, therefore, in the examination of a beginning skoliosis must here be discussed more in detail. By inspection we must first notice the atti- tude of the patient (Avhether there is displacement of the trunk on the pelvis, whether one shoulder is higher than the other, Avhether the Avaist is oblique, etc.); in addition, Ave must observe the excursions of the thorax during respiration. The fact must be emphasized that the patient must be stripped cloAvn to the trochanters. The clothing should, be tied around the trochanters, otherwise the patient, in order to prevent their fall, moves constantly* and does not remain quiet and erect.. The hair should be tied over the head, the arms should hang free at the sides, the toes should be equally* directed outward. After the patient has been inspected in his ordinary* position he is told to assume a firm military attitude. Under good illu- mination, the light by preference falling from behind on the patient so that no disturbing shadows are thrown, the back is inspected from behind and from varying distances, the rela- tions betAveen pelvis and trunk, the position of the shoulders, the lateral outlines, the waist lines, the relations of the pend- ent arms to the trunk, the condition of the triangle of the Avaist, etc., being noted. On inspection from in front, the rela- tions of the neck, naA*el and sy-mphysis should be noted, as to whether they* are in one plane, Avhether one region of the cos- tal cartilages projects more strongly* or one mamma is more prominent, Avhether the sternum is in the middle line, etc. The spinous processes are next stroked by the finger tips, a red line being produced marking the course of these processes and making a curvature or deviation from the normal evident; the condition of the paraspinal sulcus is noted, as to whether it is filled up on one or the other side, etc., and in high grades of torsion care must be had not to mistake the lateral verte- bral processes, which are well marked on the convex side, for the spinous processes. In beginning dorsal skoliosis it is adA*isable to cause the patient to lay his hands on the opposite shoulders, crossing the arms, or else the patient with extended knee joints and I 32 Orthopedics and Orthopedic Surgery. raised arms should be directed to bend forward/whereby the region of the costal angles can be better inspected and the fact of torsion becomes more evident. The possibility* of overcoming any* alteration of form is next tested by* attempting to restore to its normal position the projecting costal eminence by* means of gradual pressure. Next it is noticed whether static alterations (e.g., the placing of a book under a shortened leg, etc.) Avill cause disappearance of an existing curvature. The condition of the patient having been tested both under active changes of position and by pas- siA*e measures (diagonal manual pressure), if the curved seg- ment is found to be even slightly* moA*able, the behavior during \*ertical suspension is tested to determine whether compensa- tion can be effected or not, and at the same time Ave may en- deavor by* means of manual pressure to ascertain if the thorax can be sprung back into the normal position, as is usually the case in children with slender bony* framework. Sometimes it is essential to examine also in the horizontal abdominal position. The length of the legs must ahvays be carefully* compared. The prognosis of skoliosis in general is unfavorable, and only* Avhen the case conies early* under treatment may* a good result be attained and the progress of the disease be arrested. The prognosis in primary lumbar skoliosis is. in particular, more favorable. Correction of the deformity* here presents less difficulties. By* means of Lorenz's belt dressing (see below) Avith elevation of the corresponding half of the pelvis by the interposition of extra soles on the shoe, cure may be effected in a relatively* short time, that is to say, in a feAv months. The prognosis of primary dorsal skoliosis is worse, but in general more favorable when the changes in shape of the ribs are not pronounced. Where the disease begins with- out notable lateral displacement of the thorax, it is usually- first noticed through the projection of one shoulder, and in most cases avc must rest content with preventing the further advance of the curvature. We must beware of assuming too early* that the skoliosis has become stationary*, and avc must rather consider it the rule that a beginning deviation pro- gresses into the higher grades. The third stage is absolutely- incurable. Skoliosis is a permanent misfortune, not alone on account Orthopedics and Orthopedic Surgery. 133 of the deformity, but also because of the associated embar- rassment of the respiratory- and circulatory* organs. For al- though the general health, even if the patient is skoliotic in a high degree, is often very little affected and the thoracic organs adapt themselves nicely to the altered space, still, in the graver cases, there is a certain insufficiency of respiration, there is dyspnoea on moderately* active movements, which becomes quite marked on prolonged muscular exertion during walking, singing, etc. There is also a tendency* to chronic catarrhs, etc. Digestive disturbances, congestions, cy*anosis in consequence of defective emptying of the cardiac caA-ities, a cer- tain tendency to hemorrhages, etc., these should be considered as direct sequela? of grave skoliosis. According to BouA*ier, heart lesions and apoplexy* are the most frequent causes of death in skoliotics. Se\*ere skoliosis may* further be accompanied by* \*ery pain- ful symptoms. Aggravated neuralgia may be caused by* pres- sure through the depressed ribs on the intercostal neiwes. Positive proofs are Avanting in regard to the truth of the belief that skoliotics are short liA*ed. The risks from skoliotic pelvic anomalies in women have also been greatly* overesti- mated; only* when the disease is of high grade, especially* if of rachitic origin, does it interfere with gestation. This is cer- tainly not the case in the slighter grades of the deformity*. In order to enable us to observe the course of the affection and the influence of treatment, Ave must resort to scientific methods of measurement in skoliosis. Since the taking of plaster casts at intervals for obtaining a picture of the de- formity* (Heine) is rather cumbersome, and the outlining of the trunk by* means of the camera, obscura (Schildbach) repro- duces only* a small portion of the alterations, it Avas but nat- ural that the photographic reproduction of the patients, as practised by Berend and Wildberger, should find many imita- tors, particularly since stereoscopic vjcavs yield such excellent reproductions of the curvature that they were specially rec- ommended by* Lorenz. In order to obtain actual measurements of the skoliotic curvature, it Avas formerly the custom to notice mainly the lateral deviation from the vertical; to take the diameter with the callipers or the outlines Avith a lead band or kyrtometer so as to gain by this means, at definite intervals, a picture of the progress of the affection, etc. 134 Orthopedics and Orthopedic Surgery. Only* in recent times, however, have we had at our disposal exact scientific apparatus which will soon displace the methods of earlier date. Biihring's44 apparatus consists essentially of a glass plate 16 inches broad and 20 inches high, divided into half-inch squares, Avhich is movable by* means of a frame on a vertical scaffold on the sides of Avhich is a device for fastening the arms. In the centre of the upper border of the frame is a plumb line, while beloAv is a horizontal projection to which is fastened a diopter movable on a vertical rod. The apparatus with the diopter is placed toAvard the light with the patient behind it; his arms are fastened to the scaffold, and the out- lines are draAvn on the glass Avith a brush and paint; the plumb line is fastened at the level of the spinous process of the seventh cervical vertebra, and by means of the diopter the curvature of the spine and its deviation can be accurately- marked. The apparatus, therefore, permits only the measure- ment or pictorial representation of the line of the spinous processes and of the lateral contours; it gives no picture of the torsion and no real image of the deviation of the A*ertebrae, and is hence of little practical interest for the measurement of skoliosis. The same may* be said of Gramko's method.45 The apparatus Avhich permits measurement in two or more planes is more suitable, for instance, that of Heather Bigg. Schildbach's camera gives only the outlines and cannot reproduce the differences in leA*el of the back. For obtaining horizontal contours, a good apparatus is the thoracograph made on the system of the hatter's form by* Walter Biondetti at the suggestion of Socin. About four to six thoracic outlines are drawn and designated by the corre- sponding spinous processes; these are cut out of strong paper for comparison with those taken later. The apparatus of Murray*46 (Stockholm) is similar to Burk- art's modification of the above. The thoracograph of Schenk47 permits the drawing of the horizontal outlines and of measurement at any desired point; the patient is placed in the centre of a massive ring, the pelvis and shoulders being fixed and the head resting against a pad. Around the ring is the plane for drawing; AA*here this plane joins the ring is a vertical column divided into centimetres which bears the movable bent index pointing inAvard and Orthopedics and Orthopedic Surgery. 135 connected with the writing lever lying on the movable plate. While the drawing-plane is carried around the ring, the index, depressed by a rubber band, follows the outlines of the body horizontally and the writing lever marks on the slowly rotat- ing Avriting plane the exact tracing of the motions of the index. It is possible by means of this apparatus to project any' point of the body on the horizontal plane. Schenk usu- ally* makes one outline at the height of the spines, another at that of the acromia, measures the line of the spinous processes eA*ery* five centimetres and projects the position of the seA*eral points on the drawing-plane, so that at the termination of the measurement the line of the spinous processes may* be con- structed in a sagittal and in a frontal direction. For simple measurement of the lateral deviation Heineke's pendulum rod48 is appropriate. After marking the spinous processes with a blue pencil, the belt with the triangular plate is laced around the pel\*is, so that the point of the metal plate is exactly* OA*er the anus. Opposite to this, on the metal plate, a rubber cord is fastened and is stretched to the spinous proc- ess of the seAenth cervical Aertebra and thus the points where the sagittal plane and the line of spinous processes cross can be easily marked, and the deviations from the sagittal plane may* be measured in centimetres. For measuring any* lateral inclination of the spine as a whole, the pendulum rod is used, being hung to a stud projecting at a right angle from the belt plate. As the rod is divided into centimetres and reaches to the head, any deviation from the median line, for instance of the vertebra prominens, can be readily measured. The skoliosometer of Mikulicz49 permits the measurement of the height of the spinal column, its lateral deviation, tor- sion, the height and position of the shoulders. It consists essentially of a vertical and a horizontal narroAV steel band, flexible so as to folloAv the lines of the body, and divided into millimetres. These bands are so joined by a brass piece that the horizontal rod can be moved both laterally and vertically. The longitudinal rod is fastened to a metal plate (Avhich is joined to a pelvic belt by* a corresponding pad) and it carries a horizontal goniometer from Avhich may be read the position of the thin pointer which forms the end of the longitudinal band, the motion of which is around a vertical axis (indicating the torsion). 136 Orthopedics and Orthopedic Surgery. Since the apparatus is movable around a horizontal axis at the pad, the longitudinal rod can always be given the direc- tion of the inclined spine. Height, lateral deviation, and posi- tion of the shoulder blades are measured by corresponding position of the transverse on the longitudinal rod. According to Mikulicz, measurements with this simple apparatus can be completed in from five to ten minutes. Probably the most complete apparatus for measuring sko- „ liosis, the only* objection to which is its high price, and the application of Avhich is simple and rapid (fifteen to twenty minutes for complete measurement) is that of Schulthess.50 It permits measurement in three planes and gives a complete plastic representation of the trunk, and all the important bony* points can be fixed in their mutual relations. It con- sists of a heavy* cast-iron frame, the sides of Avhich are joined at the back and bot- tom by* iron rods, and Avhich carries the devices for fixing the patient and making measurements or draAvings. For fixation there are four adjustable pads: two to rest Schulthess' Apparatus for Measuring against the anterior supe- rior spines (2 and 3), two broader ones for the hip or pelvis (4 and 5), which can be set parallel to the measuring plane. A board, 1, which can be set higher or loAver on the four toothed rods of the side- pieces, permits the use of the apparatus for persons of different heights. The base of the measuring and drawing appliance is formed by two exactly parallel lateral slides, 12, 13, and their trans- verse connection, 14; between the former is a brass frame, 15, about twenty inches broad, Avhich can be moved up and doAvn' Fig. 123 and Delineatin Orthopedics and OrtJwpcdic Surgery. 137 I* 50 JB being held in equilibrium by a counter-Aveight running OA*er pulley*s, so that a slight pressure of the hand suffices to raise or to lower it. On this frame, 1 ">, is a small rider which travels to and fro, and in order to permit motion also in the third dimension (depth), the rider is perforated at a right angle to the direction of its motion, the perforation carrying a blunted steel pointer, 17, which can be greatly lengthened by* the ad- dition of a second point- er. Hence this pointer can folloAA* the course of a ny line accessible to the measuring frame. The motions of the pointer are transmitted to the paper-covered glass plates,Avhich are at right angles to each other, in the following manner: 1. From the rider, 16, a horizontal leA*er twenty* inches long is extended laterally, 18, and it carries at its outer end a pencil Avhich marks on the vertical plate, 19. This plate has the same direction as the measuring frame and forms the projec- tion of the object to be measured on the meas- uring plane (Fig. 124). 2. The posterior end of the pointer, 17, is so joined to a steel rod, 20, placed parallel to the brass frame by means of a forked eye, that it may* be easily* shifted from one end of the rod to the other. The steel rod with its tAvo ends lies, by means of two rollers, 21 and 22, on the rail-like carriers which project backAvard from the brass frame, 23, 24, and it thus follows the slightest motions of the pointer connected Avith it, while it remains at rest during lateral movements of the rider, 16, or pointer, 17. To assure these movements, especially with ref- Fig. 124.—The Same Apparatus in Use; on the Right Plate is the Projected Frontal Picture; on the Left, the Posterior Sagittal Contour. 138 Orthopedics and Orthopedic Surgery. erence to the parallelism of rod and measuring plane, its outer ends are united at the rollers by means of two levers to a right-angled lattice, 26, which in turn is made movable in the rails, 23, 24, by* doAvels at its two loAver corners. At one end of the steel rod, 20, is a pencil which writes on the smaller ver- tical plate, 25, and furnishes the tracings of the ky*photic or lordotic deviation, and these tracings may be taken at any point of the back. 3. For delineating horizontal contours, there is applied to the posterior end of the pointer at a right angle to it, a writ- ing leA-er, and Avhen this is to be used, the brass frame is fast- ened Avith a screw, a paper-covered glass plate is inserted horizontally between the rails, 23, 24, and the pointer is made to folioav the contours from right to left, or vice versa, Avhere- by half-outlines can be obtained at any* level. This measuring device is completed by* an index, 27, marked in centimetres, Avhich is movable, with the sheath in Avhich it rests and the graduated curve, on a vertical rod smooth on the back and marked in front in centimetres, 9; the index can be both rotated and drawn in and out of its sheath (in order to determine the position of certain points on the anterior sur- face of the body*). (See Fig. 123.) By* reading off the dimensions: 1, the length to Avhich the rod has been drawn out; 2, the height at which it stands; 3, the angle around which it has been turned, Ave can aiAvays re- produce the position after the patient has left the stand and transfer the various points to the Avriting planes by* means of the pointer, 17. Thus any* line within reach of the pointer can not only be folloAved, but may be reproduced on the three plates, and all the drawings thus obtained are projections. For taking the measurements, the patient, after the line of spinous processes and the scapula1 have been marked, is placed on the board, 1 (Avhich may be covered Avith paper in order to draAv the outlines of the feet), then the toothed rod is inserted, the pads, 2 and 3, are placed against the spines, the pelvis-hold- ers are pressed close, the iron rod is laid against the upper end of the sternum, and the pointer is carried along the line of the spinous processes, when the two writing levers mark on the vertical plates, 19 and 25, giving the skoliotic and kypho-lor- dotic curvature. Then the outlines of the scapulae are drawn Orthopedics and Orthopedic Surgery. 139 and two A*ertical profiles over the two scapulae, also the out- lines of the figure against the light, and at last some of the horizontal contours, and their extent arc measured by* one or both levers on the vertical plate. Then the patient steps out of the apparatus and the points measured on the anterior surface of the trunk (projection of the sternum) are drawn. After drawing a vertical line on the sagittal and frontal out- lines, and a line parallel to the measuring frame on the hori- zontal outline, the measurement is finished. In addition to the ordinary* habitual skoliosis, we must take into account the rachitic and static forms. Rachitic skoliosis (which according to Guerin occurs in about 9.7$ of children affected with rachitic curvatures) originates from overburdening (unequal effect of pressure) of the rickety (pliable) bone; it usually* occurs in the form of an arched (dorso-lumbar) curvature. The oblique posture Avhen carried on the arm of the nurse, etc., has been mainly* considered as the cause of this deformity, and the greater frequency of left-sided skoliosis has been ex- plained on the same theory. The fact is that in rachitic skoliosis left-sided curvature is much more frequent (9 : 5 Eulenburg, 3 : 2 Heine), the deform- ity* being arch shaped, Avith the greatest de\*iation about the middle of the spine. According to most obseiwers, the two sexes are about equally affected, although some have found boys in the major- ity7. With reference to age, the second y*ear yields the great- est number of cases, that is to say*, rachitic curvature begins almost constantly in the first years of life, at the latest up to the fifth y-ear, and the frequency* toward the sixth y*ear de- creases rapidly (Eulenburg). As regards the sy*mptoms of rachitic skoliosis, aside from other rachitic manifestations, the predominance on the left side and the arched shape of the curvature should be noted. The vertex of the arch is nearly in the centre of the entire spinal column. The counter-curvatures are high up in the dorso-cervical and beloAV in the lumbo-sacral portion of the spine; the greatest projection of the primary costal eminence lies below the shoulder blade, and hence the differences in level of the scapulae are less obvious, Avhile a marked prominence of the shoulder in the region of the dorso-cervical counter-curva- 140 Orthopedics and Orthopedic Surgery. ture is more frequent (Fig. 125). As a rule, in pronounced rachitic skoliosis the costal eminence lies below the left shoulder-blade; in (left-convex) curvature of the median por- tion of the spine there is moderate (left) displacement of the trunk upon the pel\*is, the (left) arm on the com*ex side hang- ing free. In rachitic skoliosis, changes in the pelvis are dispropor- tionately* more frequent than in the habitual form; the thorax, too, may exhibit considerable asymmetry, which, hoAv*eA*er, need not be connected with the skoliosis as such. The prognosis depends, in the first place, on the fact as to Fig. 125.-Rachitic (left-sided) Fig. 126.—Slight Static Sko- Fig. 126 a.-The Curv- Skohosis in a Boy aged Four liosis by Shortened Growth of ature Compensated by Years- the Right Leg through Infan- the Addition of a Sole. tile Paralysis. Avhether the rachitic process is still active or has run its course. In general the prognosis is very unfavorable, owing to the age of the infant; in older children of from four to eight years the prospects from treatment are good. The term static skoliosis is applied to a primary lateral lumbar curvature which occurs in consequence of depression of the pelvis (e. g., by shortening of one lower extremity), one, therefore, which is a sequel of a disturbance of equilibrium or of effort at compensation. This variety includes Bouvier's hemiplegic total skoliosis. the ischiadic total skoliosis with the convexity of the flat curve to the healthy* side described bv Orthopedics and Orthopedic Surgery. 141 Albert, skolioses in consequence of large tumors of the upper extremity*, etc. A great many7 diseases—arrest of growth, paralysis, osteo- myelitic, etc., affections, genu \7algum, talipes, etc.—may cause a shortening of the extremity* Avith resulting obliquity* of the pelvis, and, through the efforts at preserving the equilibrium, bending of the lumbar spine Avith the convexity* to the de- pressed side of the pelvis occurs. The observations of Hunt, Cox, Wight, Garson, Roberts, etc., show that unequal length of the extremities is very frequent, the measurements haA*ing been made both on the living and on skeletons (Garson). Garson, in measuring the skeletons in the Museum of the College of Surgeons, found the extremities equal in only* ten per cent. The variation ranged from one to thirteen milli- metres. It Avas formerly7 believed that static skolioses never became fixed, that the night's rest, etc., ahvay*s effected compensation, and that the graver affections of the extremity* limited the function of the leg altogether too much to give play* to the static factors; but this is not true for all cases. It depends upon the duration of the disturbance and the age of the patient Avhether the curvature will become fixed, i.e., Avhether permanent anatomical alterations Avill ensue. The signs of static skoliosis are easily7 recognized on in- specting the patient from behind. The physician should sit behind the erect patient and placing his hands on the iliac crests he should determine Avhether there is any real depres- sion of the peh*is. Another Avay is to place the patient by* a table and to com- pare the height of the tAvo anterior superior spines over its edge, when it will be easy to recognize any obliquity of the pelvis and to ascertain the degree of shortening of the one leg- by placing a board underneath the foot. The shortening of the extremity may* also be ascertained with a tape measure in the horizontal dorsal decubitus, or by a plumb line dropped in the erect position from the anterior superior spine. Busch51 measures with a horizontal board having a semi- circular segment cut out and provided with a spirit level; the board is accurately applied to two corresponding points of the pelvis, when the deviation of the air-bubble will indicate the obliquity. 142 Orthopedics and OrtJwpcdic Surgery. The importance of treatment, especially* in beginning lat- eral spinal curvatures, should not be underestimated. Owing to the great frequency7 of habitual skoliosis, prophy7- lactic measures are urgently* demanded, which implies, of course, some radical changes in our present sy*stem of educa- tion, especially in girls of the so-called higher classes. While boys, Avith all the exorbitant demands made on them, still ex- ercise their muscles in their leisure time by* tussles on their way* to and from school, as well as by walking, SAvimming, skating, etc., it is different Avith girls. The latter, even before they attend school, are accustomed to a sedentary* mode of life, and with the advent of the school age their training be- comes of the faultiest possible nature. The hours of instruc- tion follow in long succession and in the intervals the girl is taught knitting, embroidery, crocheting, etc. The children have barely sufficient time for lunch Avhich must be consumed hastily, for they must hurry7 back to school, carrying a heavy- bag packed Avith a great many* unnecessary* books, sit in an over-crowded room, and, Avhen e\*ening arrives, they7 reach home tired, but must at once prepare their home studies or the mother urges them to practise at the piano. "Modern"' children have no more time for playing, jumping, and running in the open air, etc.; the older they* grow the greater becomes the number of subjects of instruction, and the less " proper"' is it that pupils should be seen romping in the street. If sent to an institution or boarding school, then even the hours of recreation and class Avalks acquire an almost cloister-like character, AA7hich gives them a greater resemblance to a task than to a real recreation. Although in boys Ave must grant that all the studies, ex- aminations, etc., open a way to definite professions, and aim at preparing them efficiently7 for the struggle for existence, in girls, however, avc must admit that the examinations, etc., in female colleges are more for the purpose of making an im- pression, of satisfying maternal vanity, and Lorenz and others justly declare that physicians should never cease to protest against a mode of education which is productive of such a frightful percentage of bodily deformity, even to the extent of crippling growing- young womanhood. We must aim for a reduction in home tasks; at least three or four times a week instruction should be given in gymnastics which should consist Orthopedics and Orthopedic Surgery. 143 Fig. 127V -School Desk and Seat after Lickroth. Slides Back on Pising. The Seat less in certain exercises of force or skill than in drill without apparatus; lessons in swimming, common games in the open air, instruction in natural history, geography, etc., Avith asso- ciated excursions, these should be included in the education of our girls. Both par- ents and teachers must Avatch over the correct attitude of the children; occupa- tions tending to oblique position (em- broidery at the frame, ironing', A*iolin playing, etc.) should be avoided, and chil- dren should not be alloAved tocarry their younger sisters or brothers.52 When at study*, special stress should be laid on a correct position during writ- ing, etc., and noAV that well-constructed school seats can be obtained (Fahrner, Kunze, Erismann, etc.), a step has been taken in the right direction to guard against habitual oblique position. A correct school seat should ansAver the following demands: the distance between desk and seat should correspond to the size of the child, and this should amount, in girls, to \, in boy*s to \ of the height of the body7, so that the edge of the desk do not reach abo\*e the pit of the stomach; the seat should haA*e the proper height (f the height of the body*, according to Fahrner); the top of the desk should have a slight inclination; the back of the seat should be suitable, preferably7 one inclined back- ward with corresponding projection in the lumbar region, or a curved back, or a lumbar rest. Fig. 128.-Normal School Seat. 144 Orthopedics and Orthopedic Surgery. The number of desks constructed on these principles is already very large and nearly* every exhibition shoAvs altera- tions and improvements. We must alway7s remember that these changes remove only* a part of the objections, and Ave must emphasize the necessity of sufficient intermissions in in- struction, change from sitting to standing, etc. At home, too, attention should be paid to the correct posi- tion of the children, and since modern chairs, eA*en if made higher by* a hard cushion, are hardly* suitable for children at Avork, it is preferable to gi\*e them chairs specially* made for them, such as those devised by Staffel,53 Lorenz,54 and others, and which are constructed Avith arm-rests (Pansch55). Staffel's chair takes the place of a domestic school seat, as it is only necessary* to place on a table an ordinary* desk top to make the apparatus complete. With some slight alterations it is suitable to children of all ages, and its distinguishing feat- ure is a back-rest, com*ex in front, corresponding to the nor- mal lumbar cuiwature, four to five inches high, intended to reach in general from the upper edge of the sacrum to the loAver dorsal vertebrae. The height of the chair is calculated for the average height of our tables, and as the child grows the legs of the chair and the foot-rest are correspondingly7 shortened and the depth of the back-rest is regulated every two y*ears. Lorenz's work-chair has a back-rest reaching to the upper end of the dorsal vertebra1, inclined backAvard at an angle of 100°, and curved to correspond Avith the normal spine: it is covered with cloth or plush. A-movable foot-rest is adapted to the front legs. The height of the chair is determined by- measuring the distance of the olecranon, the elbow being bent to the surface of the seat and deducting this figure from the knoAvn height of the table; by* pushing the chair under the table this distance can be easily made negative. Lorenz has also made his chair adjustable, both as regards the height and the back-rest; the several slats of which it is composed can be taken off and regulated, as also the foot-rest. Others combine the back-rest with a holder carrying axil- lary crutches for keeping the sitter straight (Kuhn,56 Vogt,57 Fiirst). Children disposed to skoliosis should also during the day be made to rest for a time in the horizontal position on a well-upholstered hair mattress; for the first indication is un- Orthopedics and Orthopedic Surgery 145 burdening of the spine whose resisting poAver is weakened, and special care should be taken that the child have a suitable bed. It is best to advise the use of a hard mattress Avith a low Avedge-shaped bolster for the head, since feather beds and particularly high bolsters easily lead to a skoliotic cur- vature. Further, it is certainly* advisable that phy*sicians skilled in the recognition of commencing skoliosis should be attached to schools and should examine the children several times during the year (Lorenz) in order to inform the parents as to the ex- istence of the affection. As to the actual treatment of skoliosis, Avhich, of course, should be instituted as early: as possible, the object is to shift the unilateral weight-pressure, to unburden the spine, and Ave may* distinguish dynamic and mechanical methods. Each of these has its advocates, but usually7 both methods should be combined, and neither should be employed exclusively. Unquestionably, appropriate gymnastics are Aery- effective in commencing skoliosis and are not only- invigorating to the entire system but act especially- on the curvature. In chil- dren particularly-, by means of certain movements and exer- cises, we can work against the curvature, and counteract any* fixation. In the main those positions and movements should be practised which tend to a compensation of the curvature, and the children should often exercise '-self-righting." We should particularly recommend exercises Avith rings hanging from the ceiling Avhich, under certain conditions, may* be at un- equal height, also on the horizontal pole, trapeze, ladder, etc., especially hanging by the arms Avith backAvard curvature, then forward and backAvard flexion from two rings hanging from long ropes the feet being fixed, circling with the rings, forAvard flexion betAveen two vertical poles, upward climbing ivith the hands on the back of the oblique ladder (Busch)—-all these are appropriate exercises; so are the lateral (left) rais- ing of the Aveighted arm, the unilateral deep breathing (the left arm being raised over the head, the right resting on the hip) recommended by Schildbach. In view of the fact that skoliosis does not occur in persons who, like the English milkmaids, washerwomen, etc., are ac- customed to carry loads upon the head, Say re recommends bringing the patients into a straight position by making them 10 146 OrtJwpedics and Orthopedic Surgery. walk about for some time, at intervals during the day, Avith a book on the head, thus forcing them to balance the head. In this connection, mention should be made of the self-sus- pension recommended by* Lee, Avhich is performed for fifteen to twenty* minutes several times daily on an occipito-mental strap, with or without the aid of the arms; or, better still, lateral suspension, the so-called self-redressement by* lateral suspension (Lorenz58). Busch,59 Eulenburg,60 Roth,61 Saetherberg, and others have also ascribed great importance to Swedish gy*mnastics with as- sociated opposed movements. These include, Avith the assist- ance of a specially* trained per- son, different simple or compli- cated manoeuvres—rising from a suspended horizontal position, Figs. 129 a and b.—Prophylactic Gymnastics. Fig. 130.—Replacement of Skoliotic Dorsal (After Roth.) Spine by Lateral Suspension and AA7eighted Feet (After Lorenz.) dextro- and dorso-flexion Avith raised weighted-rod, etc.— the details of which can be found m the Avorks cited. Figs. 129 a and b show, for instance, the passive torsions of the trunk in the straddle seat. These exercises are to be prac- tised with military accuracy and have a terminology* of their own (of which I give only a feAv, e.g., left-right-stretch-seat, right-stretch-Avalk, left support-Avalk, dorsal-right-lateral-flex- ion, etc.), and are intended to indicate the exact movements which set some special muscular areas into isolated action. Great importance attaches also to passive corrective move- Orthopedics and OrtJiopedic Surgery. H7 ments, such as diagonal pressure in stretched suspension, high chest suspension, straddle seat, etc., and particularly lateral suspension over a peculiar apparatus according to the method recommended by- Lorenz and represented in Fig. 130. (Any carpenter can easily construct the requisite simple apparatus.) Between two vertical posts, a, b, about four feet high and forty inches apart, resting on the frame, c, d, e,f, is a cross piece, h, Avhich can be set at any height by- wooden pins, g. The centre of the cross piece is giA*en the form of a half-cy*lin- der by* superimposed slats and is upholstered Avith horse hair or coA*ered Avith velvet or plush. The half-cylinder, i, is about thirty inches long and fiA*e inches broad. One cross rod of the frame carries a leather strap, /, Avith a handle, A-, which may- be buckled at any7 desired height. (A cheap substitute for the apparatus may be formed by fastening a cross piece, uphol- stered, between tAvo door posts, together with a long rope tied to a screw hook in the floor.) The patient grasps the handle Avith the left hand, places the right foot on the step, in, and then lies on the padded cen- tre piece so that the prominent crest of the ribs, R, bears Avith its greatest convexity A-erticalty on the pad. Thus the skolio- tic trunk is suspended, as it were, upon the costal eminence, and when the patient allows the foot to glide off the step, the body represents a two-armed lever, so that the recurvation is effected Avith a force corresponding to the weight of the body7, and this AAreight may* be increased by* suspending bags of shot from the ankles, o o, after the patient has become accustomed to the lateral suspension. Lorenz points out that lateral sus- pension should not be entrusted to the child before it has be- come accustomed to the correct placing of the trunk, and that the position is correct only* when the right diagonal diameter of the thorax is vertical to the pad. The hand of the physi- cian may7 increase or modify7 the force. Lorenz also states that the first attempts are painful, that disturbed respiration is sometimes present, and that Aveeks elapse before the patient becomes sufficiently* accustomed to the procedure to bear it with comparative ease. Beely*62 has devised a very* simple apparatus, essentially in the shape of a long, right-angled frame. Resting on two stout posts, it may be revolved around a central axis, has superior cross rods to be grasped at different heights by the 148 Orthopedics and Orthopedic Surgery. patient, and has two movable pads which can be so applied to the body as to effect diagonal recurvation. By depressing the upper part of the longitudinal frame, the force exerted by the weight of the body can be graduated, and the length and fre- quency of the exercises are regulated by the endurance of the patient. Shaw devotes a chapter to the consideration of the propo- sition to cure curvatures of the spine by friction, kneading, and shampooing, together Avith a picture of a special frictional roller. The advocates of the myogenous theory* of course claimed that massage Avith electricity* and gy*mnastics were deserving of the first consideration and these means have also been employed in suspension (P. Vogt). Of late, this plan has been again Avarmly* recommended, especially7 in the form of pounding and rubbing of the dorsal muscles on the tAvo sides— massage of the thorax. Landerer63 thinks it important that the phy-sician should perform the massage himself and reports striking results after seA*eral weeks' treatment; so do Kolliker and others. It is advisable to cause the patient to Avear a corset in the intervals. In order to strengthen the weak dorsal muscles Avhich alloAV the habitual lax attitude, the faradic current has been recom- mended (L. Vogt and others), not only7 for the production of vigorous contractions of the dorsal and thoracic muscles with' the associated increased contractility7 and nutrition, but also for obtaining appropriate positions and movements in isolated portions of the spine. Important as these methods are from the standpoint of prophydaxis, and in the treatment of commencing skoliosis and in mobilization of advanced, little effect can be expected of them in fully* developed cases. In the latter, mechanical auxiliaries must be resorted to which are based either on traction and counter-traction or pressure and counter-pres- sure. They may be divided into couches and portable appara- tus (corsets, etc.). It is of the utmost importance to utilize the night's rest in the treatment (all the more because one disturbing element, weighting, is eliminated), and the first care should be to pro- vide a hard mattress. A simple device for overcoming the curvature is the Lons- dale-Barwell suspensory sling (the suspensory belt) (Little, Orthopedics and Orthopedic Surgery. 149 Schildbach, Busch64). This is a sling hanging by a rope from the ceiling at the proper height over the bed, into which the patient places himself on the com*ex side, whereby pressure is exerted in a correcting diagonal direction or a lever effect is produced. Busch and Wolff have modified the method of lat- eral pressure by a suspensory belt, by applying the belt, hand Avide, to a special support (a base board with two pair of obliquely* ascending' iron rods), thus making a suspensory- frame. Its only drawback is that its effect is at once nullified if the patient turns in it. Rest for se\-eral hours daily* in a hammock can also be used; for instance, in right-sided deviation the patient should Fig. 131.—Beely's Couch for Skoliosis. Fig. 132.—Beely's Couch. (Representing the Position of the Patient.) lie with the left side down, thus changing the concave side into the convex, that is, reversing the condition. Next in order are the couches for skoliotics, of which the one devised by Beely,65 represented in Fig. 131, may be adapted to any7 individual and may easily* be made by any mechanic. In a right-angled bed, upon Avhich the patient rests, are tAvo excavations for the head and pelvis over Avhich straps are stretched; four smaller boards are fastened vertically with angle-irons; two of these reach from the axillae to near the iliac crests, tAvo extend to the middle of the thighs, their height being equal to the sagittal diameter of the thorax. 150 Orthopedics and Orthopedic Surgery. The boards are padded on the inside and those for the thorax rest on but three points, so that straps can easily be carried under them. Near the upper outer edge each has five or six equidistant buttons for attaching the straps. Tavo buttons are applied to the head end for attaching a neck-strap. For a patient Avith right dorsal left lumbar skoliosis five straps are applied; only one of these (t) is of leather throughout, the others have a piece of stout rubber interposed. The upper straps run from right above to left below, the fourth forms a simple suspensory7 belt, the fifth runs from left above to right below, and Avhen the patient places himself in the apparatus the pelvis is fixed by two transverse straps, the neck is pre- A-ented from bending to the left by* a well-padded strap, and straps exert an elastic corrective pressure on the most promi- nent parts of the back. A low pillow may* be placed under the head. A couch which is largely used is that of Biihring—an iron plate carrying pads adjustable by screws to bear against the convexities of the curvature. Hitter's modification66 of this apparatus still has its adA*ocates. Schildbach used, instead of the Avedge-pads, traction pads, and Staff el67 has devised a combination of Biihring and Schildbach's apparatus. He used the Avedge-pad for the lower curvature and for a dorsal pad a broad oblique belt connected Avith a strongly cmwed steel spring; all these parts are adjustable, as is a third padded brass plate. When the straps are buckled, the spring acts, the pad is pressed in front against the ribs and a rota- tory effect is produced by the combination. A variety of apparatus acting by* traction and counter- traction has been constructed since the time of Hippocrates, in the shape of the extension beds of Venel, Heine, Valerius, Moncour, Guerin, Bouvier, Pravaz, Major, Coles, and others. On these the poor patients were formerly tortured for years without effect, so that Wildberger justly condemned them. From the large number we select only that devised by Heather Bigg, which will be readily understood from Fig. 133 and which permits at least some movements, while the elastic appliances exert constant traction, correcting the curvature; and we also show the simple extension frame of Beely-68 Avhich may be used in connection with other methods (in the inter- vals of rest). (See Fig. 6.) Orthopedics and Orthopedic Surgery. 151 The numerous orthopedic chairs devised since the time of Levacher de la Feutry have merely an historical interest. Of importance, especially- for static skoliosis, is the anti- static treatment which aims at a correction of the lumbar or Fig. 133.—Heather Bigg's Extension Bed. other curvature by causing an oblique position of the pelvis. By the interposition of a cork sole, not over one and one quarter inches thick, on the side of the convexity (e.g., on the left in left- convex lumbar curvature) the pelvis is made to incline to the right and the curvature is compensated; but care must be taken lest bending of the knee counteract the effect of the measure. This method of course is applicable only to mobile skoliosis. Lorenz69 has attained very effectively the simultaneous correction of the dorsal and lumbar curvature in the erect Fig. 134.—Beely's Extension Frame for Skoliosis. position of the patient as follows: A well-padded pelvic fork, fastened at the proper height in a vertical post, grasps the pelvis of the patient at the level of the spines and is (dosed by a padded strap. 152 Orthopedics and Orthopedic Surgery. By placing the left foot on a rest one to one and one-half inches high, the pelvis is depressed on the right, the left-com'ex lumbar skoliosis is bent back, and the thorax being surrounded by7 a padded belt and fastened to the vertical pole, is pressed to the right and the head is inclined to the same side. It is thus possible to attain correction, and after frequent repetition and intensification of the belt action, the dorsal skoliosis may- be even slightly over-corrected. By7 weighting the shoulders by a collar filled with shot (60 to 65 lbs.), a marked OA7er-correc- tion can be effected (the line of spinous processes being closely- watched). In the sitting position, particularly7, it is possible to attain the desired end by* elevating one half of the peh'is. Volkmann and Barwell have deAised for this purpose the well-knoAvn oblique seat (Fig. 135) to which Vogt has added a suspender. This seat may7 be improvised by7 a wedge-shaped oblique cushion. According to Staff el, this apparatus can be easily* made portable by* being attached to the corset in the shape of a small wedge-shaped bolster. Konig and others recommend testing the effect of the oblique seat on the back of the patient before advising its continued use. A lady's saddle also represents a similar oblique plane and under certain conditions riding is considered appropriate in the treatment of skoliotic female patients. The large group of portable apparatus, the corsets and girdles, AA*hich merely* keep the spine extended or are intended to act by measures (pressure and counter-pressure) specially directed toward correction, must be conjoined to the above in the more highly developed forms; but avc must not restrict ourselves to their use and neglect gymnastics, etc. The num- ber of skoliosis apparatus is enormous and their close descrip- tion would fill volumes; I therefore must restrict myself to some in present use, especially since Fischer10 has only re- cently published a careful synopsis in historical order, to which the reader is referred. The apparatus which acts by* elastic traction devised by* Barwell71 has the advantage of great simplicity; but it can Fig. 135. —Volkman's Oblique Seat. Orthopedics and Orthopedic Surgery. 15^ only exert elastic lateral pressure, and has no torsional power. In the elastic traction apparatus (the oblique bandage) constructed for habitual skoliosis, the line of traction, rendered elastic by rubber bands, is from the left trochanter to the pro- jecting portion of the ribs and from there to the left shoulder. The latter, as Busch points out, may have an injurious effect by* draAving the left shoulder with the entire trunk to the right side—an evil which Heather Bigg tried to OA*ercome by adding an axillary crutch ascending' on the left side. In Barwell's elastic spiral bandage, which starts from the region of the right trochanter Avhere a soft leather pad is fastened by a perineal belt, passes obliquely* o\*er the abdomen to the prominent ribs and thence to the left shoulder, encircling the body* spirally, there is not a sufficiently fixed point for the force to act. Say re's 72 modification of Barwell's oblique bandage—of which the author himself says that it is rather a monitor to the patient—and which con- sists of the addition of other elastic lines of traction, two perineal straps, etc., will hardly make the apparatus more useful, exerting as it does a correcting elastic lateral pressure, but no rotatory poAver. By his elastic spiral bandage (which has not y7et been sufficiently* tested in practice) E. Fischer applied elastic torsional traction imme- diately* to the body*. The apparatus draws the shoulder cor- responding to the convex outward curvature (hence usually* the right) downward and forward, and by increasing the pressure on the convex side, restricts its growth. The contrivance has the advantage of being cheap, easily constructed, permitting gymnastics, massage, etc., while caus- ing hardly any pain from pressure, etc. It consists of a leather (right) shoulder-holder, narrow in front, becoming rounded, and deeply cut out, which is intended to reach the mid-line and to cover below the outward curved portion of the spine; it is fastened by an elastic bandage around the shoulder of the con- cave side (left)—Fig. 137— whereby this (left) shoulder is Fig. 136.—Barwell's Spiral Bandage for Skoliosis. 154 Orthopedics and Orthopedic Surgery. steadily draAvn backAvard but not dowmvard. From the shoulder belt two elastic bandages pass which lea\*e the (right) breast free, extend over the abdomen to the (left) thigh where Fig. 137.—Fischer's Spiral Bandage, Applied with good Fig. 138.—Beely's Supporting effect to the Girl Represented in Fig. 119. Apparatus, Lateral View they are fastened so that Avhen the left hip is loAver the pelvis is constantly kept straight. The great majority of the numerous skoliosis appliances consist in a,n upholstered pelvic belt which forms the point of Fig. m-Beely's Corset. Fig. 140.—The Same, Rear View. support; it rests above the anal fold between the iliac crest and trochanter (occasionally with special auxiliary supports above the crests), and is buckled in front over the symphysis pubis. Orthopedics and Orthopedic Surgery. 15c From this ascend, either behind or also laterally7, one or tAvo steel splints, to the former of which are fastened belts or pads for the correction of the costal eminence, and to the latter axillary crutches (props) for stretching the spine. Hossard, TaA-ernier, and others have been mainly instrumental in the introduction of the corset treatment. Particularly for slight cases is it adA-isable to use, in ad- dition to appropriate gymnastics, massage, etc., simple supporting apparatus for the spine —c orscts made of strong material, fitting Avell at the waist, and supplied with Avhale- bone or steel plates and arm props. Fig. 130 represents a suitable corset of the kind de- A-ised by7 Beely,73 Fig. 140, the same seen from behind; while Fig. 138 represents the mechanism for the gradual elongation of the lateral splint. Ac- cording to Beely, it is sufficient in most case:-; to model only one late ral splint (for the con- \*ex side of the thorax) and have the other made exactly symmet- rical; in grave skolioses a special model must be made for each side, and the length of the arm props be exactly- regulated. Beety's axillary props are rarely* lengthened behind above the lateral splints, and in fact consist merely of the anterior half of the ordinary7 form of axillary7 crutch, and end in axil- lary straps; they are made either of quarter-inch iron Avire padded Avith soft felt so as to be still slightly flexible, or of square steel rods, in which case they must be given their per- Kig. 141. —He. ly's Supporting Corset in a Case of ('rave Skoliosis (Comp. Fig. 182). 156 Orthopedics and Orthopedic Surgery. manent form before being hardened. The lateral splints, about one-half inch wide, one-eighth to three-sixteenths inch thick, carry* only the extensible arm prop; they are but slightly elastic, pass vertically doAvn from the centre of the axilla, and above the crests of the ilia are bent forAvard. The back of the corset is provided with vertical elastic steel splints of varying length and thickness, so shaped as to exert a correcting effect on the most prominent parts. At the upper end of each lateral splint are three, at the lower ends tAvo buttons, and at the level of the waist one on each side, which serve for fastening the back straps, breast straps (below the mammae), and two abdominal straps (uniting the Figs. 142 a and b.—The Latest Form of Beely's Corset for Skoliosis. ends of the lateral splints). In front and behind the corset is made to lace; the anterior splints on each side of the lacing openings consist of three parallel steel Avires one-sixteenth of an inch in diameter, inserted aboA*e and beloAv in a small metal sheath; they bend in any direction and hence are ahvays closely applied to the body*. Where necessary7, elastic traction may easily be added over the greatest convexity7. The latest modification of Beety's corset, Figs. W'l a, b, has two lateral splints which are joined only* on the left side by the crutch; the dorsal splints are almost inelastic in the mid- dle, very7 flexible above; at their lower end they* are flat; the lateral splints are strongest at the Avaist. The upper, median, OrtJiopcdics and OrtJwpedic Surgery. 157 and lower parts can be laced unequally* tight (the median por- tion to the greatest extent). The belt originally* devised by Hossard aimed only at re- dressing the deformity7, offered no support to the spine, and could be of slight use only* in simple skoliosis, but would be rather injurious in more complicated forms (Bouvier, Volk- mann). Hossard's belt in its simplest form consisted of a broad, well- padded pehic belt; from its posterior portion ascended a stout median iron rod as far as the shoulder; it Avas movable by7 a toothed Avheel, could be fixed to the right or left, and carried small buttons on its posterior surface. The buttons served for attaching padded leather straps Avhich passed in a semi- spiral from behind o\*er the prominent shoulder blade and the costal eminence to the front, where they* were buckled. The steel rod Avasto be so adjusted as to bring its upper end to the side of the dorsal convexity alongside the spine, crossing the latter obliquely*; the straps in the ordinary* habitual skoliosis Avere to be so draAvn as to shift the entire thorax to the left. Tamplin74 modified the apparatus by adding an axillary prop on the concaA*e side of the cuiwature. Guerin75 put a hinge into the posterior rod and added a corresponding anterior splint, so that the strap between the upper portions should act on the dorsal cuiwature, that be- tween the loAver portions on the lumbar curve. Mathieu's apparatus, similar to that of Duchenne,76 devised especially for skolioses succeeding muscular paratysis, repre- sents a belt acting by elastic cords; the lower shoulder is raised by an axillary prop, and the deA*iation is counter- acted by7 elastic straps Avhich may at Avill increase the inclina- tion of the posterior steel rod and thus press the broad belt against the dorsal convexity7. Additional more complicated modifications haA*e been de- vised by Charriere (ceinture a pression continue), Wales, and others. In Brodhurst's apparatus the movable dorsal rod is united with the axillary props in the region of the shoulder blades, from it extends a lever Avith large pad to the side of the con- vexity* where it exerts inward pressure, Avhile the lower shoul- der is surrounded by a well-fitting cap of rubber which is fast- ened behind to the upper end of the dorsal rod. 158 Orthopedics and Orthopedic Surgery. Volkmann77 recommended, especially7 for slight unilateral skoliosis of static origin, a simple apparatus Avhich consists, in ordinary right-sided skoliosis, of a pelvic belt with left thigh splint, left axillary prop, and a median rod with slight spring action to the left. From the upper end of the latter an elastic belt, broad enough behind to inclose the entire promi- nent part of the back and the shoulder blade and then becom- ing narrower, passes over the abdomen and the left crest of the ilium to the pel\7ic belt, where it is fastened behind the tro- * chanter, so that the apparatus exerts a slight rotatory effect. Fig. 143.—Mathieu's Modification of Hossard's Fig. 144.—Staffers Belt. Belt (for Left-sided Skoliosis). Finally7, a very simple and practical modification of Hos- sard's belt has been devised by Staffel.78 He employs a spiral rubber bandage, the broad end of which springs at a right angle from the upper end of the vertical mast which follow*s the outlines of the body. The bandage curves around the prominent (right) dorsal side, passes in front obliquely over the abdomen to the opposite (left) side, which it surrounds, and is fastened behind by two straps. The mast may be applied either at the posterior centre of the pelvic belt or to one side, as it can be shifted along a slit and fastened by a thumb screw so as not to interfere with bending of the body. A spring piece, a, is placed in the mast at about the level of the lumbar curve, while the upper end rests against the back with slight elastic pressure. A thigh strap prevents upward dis- Orthopedics and Ortlwpedic Surgery. 159 placement of the pelvic belt on the left side, and where the height of the shoulders remains uneven, an axillary prop is added on the concave side. In place of the median rod, Eulenburg, Heather Bigg, Chance, and others recommended two masts adjustable by7 an endless screAv to Avhich the correcting straps or pads are fastened. One of the most extensively used appliances is that of Goldschmidt-Eulenburg (Fig. 145) Avith spring axillary props, Fig. 146.—Sehildbach's Lateral Traction Machine. 0; behind it carries a stout steel splint, c, reaching exactly* to the centre of the back and fitting closely* to the body*, at the middle and end of Avhich is a toothed-Avheel. From these as- cend to the right and left round steel rods Avhich can be given a lateral motion by turning the screAvs with a key- and which cany the tAvo pads, d, for surrounding the convexities. The pads are movable forAvard, backward, up and doAvn. The apparatus may7 be stitched into an ordinary corset, does not annoy the patient, extends the spine by the spring axillary props, and is intended to redress the curvatures by the elastic pressure of the pads. One modification substitutes elastic straps for the pads. Another group of apparatus, like Schildbach's portable Fig. 14.") —Apparatus for Skoliosis. (After Gold- schmidt-Eulenburg. ) i6o Orthopedics and Ortltopcdic Surgery. lateral traction machine, applies the traction or pressure more in an oblique direction. In ordinary7 right-sided skoliosis the left shoulder is raised by an extensible axillary prop Avhich forms with the peh*ic belt an angle open to the inside, so that, before the chest straps are laced, the upper end points away7 from the thorax; after being laced an elastic lateral traction is exerted from right to left. A strap carried over the left shoulder is to prevent deviation of the pelvic belt. Lorinser's79 apparatus is also intended to crowd the con- vexity* of the dorsal vertebral curvature toward the middle line by* elastic traction. To the pelvic belt is adapted a splint, movable on a hinge, along the opposite thigh (the left in right- sided dorsal skoliosis), which reaches to the axilla and Avhen fastened to the thigh by7 straps it tends to deviate to the left above. If fastened above by a broad leather belt Avhich sur- rounds the prominent (right) side and beloAv over the abdomen to an iron tongue connected with the splint, a correcting effect is exerted. Displacement of the splint is preA*ented by a crutch-like attachment above, and an axillary* prop is also applied to the opposite side. Another apparatus having mainly a lateral effect (hence unsuitable AA*here torsion is pronounced) is that of Goid- schmidt,80 in which endless screAvs exert pressure on tAvo pads on racks, applied against the main curvatures, thus aiming at reduction. Of more importance are the numerous apparatus acting also upon the torsion. Langgaard's81 apparatus consists of a well-padded pelvic belt composed of two parts and closed in front by a hinge; it rests by two steel arches on the crests of the ilium. On the concave side is an adjustable steel rod with axillary crutch and from it extends a jointed spring arm. At the end of the latter is a pad adjustable by a ball-joint to any portion,82 in- tended both to redress the torsion and to exert direct pressure on the projecting parts; it is moved by an endless screw. For producing counter-pressure, a steel rod is on the convex side Avith interposed spiral spring for adapting it to the move- ments of the arm; at its extremity is a rounded pad for the anterior region of the shoulder. Straps passing over the shoulders help to fix the apparatus. Orthopedics and OrtJiopcdic Surgery. 161 The apparatus devised by Heather Bigg83 also has pres- sure pads. From a light pelvic belt, somewhat oblique in front, corresponding to the inclination of the pelvis, ascend one or two posterior, well-padded steel splints Avhich carry, at the leA7el of the shoulder-blade, a cross rod Avith two curved portions which surround the axilla\ At the proper height of the dorsal splint, pads are fastened which exert a redressing- effect, through spring or screw pressure, on the deviations. Chance has devised a simple apparatus, largely used in Lon- don, which for slight cases consists of a pelvic and lumbar belt, Fig. 147.—Apparatus for Skoliosis. (After Fig. 148.—Apparatus for Skoliosis. Langgaard.) (After H. Bigg.) median dorsal splint and pad against which the shoulders are pressed; for graver cases tAvo pads are added for the dorsal costal eminence. Another apparatus, de\*ised by Heather Bigg for graAe cases, acts mainly on the torsion and aims at tAvisting the thorax on the pelvis by means of a spring ascending on the left from the broad pelvic belt across the mid-line to the right aboA-e, Avhich presses by- a broad pad upon the right costal convexity. Aufrecht Avith his apparatus endeavors to press by7 one pad the posteriorly projecting right shoulder forAvard, and the forward protruding left shoulder backward by7 an- other pad (Fig. 149). 11 162 Orthopedics and Orthopedic Surgery. Of the numerous pad corsets, Nyrop's spring pressure ma- chine84 is justly one of the most popular and is preferable to others also on account of its slight AA*eight. The apparatus consists of a pelvic belt from which ascends in the mid-line of the back an iron rod which carries above, on an adjustable cross-piece, two axillary crutches ending in straps for fixation. To the dorsal rod are fastened an equal number of steel springs tending outward, i.e., convex in front (they should preferably7 be compound springs), each of Avhich carries a movable pressure pad and these are fastened in front by7 straps so that the pad exerts a correcting action on the convexity. For the lower (left) shoulder the machine is supplemented by a lateral splint which, according to Jessen's proposal, should be forked below and be arched over the iliac Fig. 149.—Apparatus after Aufrecht. Fig. 150.—Corset after Trelat. crests, being fastened at the pelvic belt. The lumber pad may also be replaced by an elastic strap Avith corresponding obliquity*. Vogt and others prefer IStyrop's corset to any other. As for the good results attained with this apparatus, the reader is referred to ISyrop's paper.85 Collin's apparatus (with pelvic belt, lateral axillary props united by a metal frame) is also provided Avith devices for ex- erting elastic pressure on the projecting parts of the body, similar to the apparatus of Trelat and Le Fort, the loAver parts of which consist of pliable sheet copper closely* fitting the body, or of shaped leather. Some of these apparatus may also lie looked upon as mod- ifications of Hossard's belt, like Mathieu's apparatus after Trelat, represented in Fig. 150. Orthopedics and Orthopedic Surgery. 163 Staffel,86 too, has recently- devised a pad corset which, for the common (right-sided) skoliosis, consists of a pelvic belt of sheet steel, an axillary prop for the lower (left) shoulder, and a splint extending from the (right) posterior circumfer- ence of the pelvic belt, adjustable by an endless screw, and provided above Avith a hollow pad; in other respects it is a strong whalebone corset to be laced in front. By* means of it we can exert any* desired pressure on the posteriorly project- ing ribs, and thus produce a forAvard twisting effect; Avhile the right shoulder band being draAvn tauter, the higher shoulder is depressed. In the latest corset of Nyrop, Avhich he much prefers to the plaster jacket, the apparatus is provided with appropriate (jointed) steel springs capable of exerting pressure on the body from Avithout imvard. The apparatus is remoA*able, but may be Avorn day and night; it may7 also be easily combined with LeA*acher's SAving, as may7 be seen from Fig. 95. The appara- tus fits the body as closely as a plaster jacket, and thus in many* respects resembles the above-described corset of Beely. We may* gather from the large number of apparatus for skoliosis that their corrective effect is by no means prompt, and some authors (Sayre, Daily7) reject them all. Say re at all eA-ents goes too far in rejecting all such apparatus as useless and as merely forcing the patient to bear horrible torments. At any7 rate, their disadA*antages—that they are expensive, cannot be used long, and need frequent repairs—-are apparent in most of them, and hence it is easy* to understand the delight Avhich greeted Sayre's announcement that he had found in the plaster corset applied in suspension a method of treating skoliosis which was accessible to any- phy*sician. But soon the original enthusiasm gaA*e place to sober after- thought, and noAvadays all that can be said is that the plaster jacket, applied in specialty redressed position and made re- movable, is of importance in skoliosis only* Avhen used in con- nection with other treatment. Plaster jackets worn too long may act injuriously7 by7 causing atrophy* of the muscles, etc., and, important though they are for kyphosis, they* are un- suitable to slight skoliosis, and Dollinger87 has demon- strated by measurement an increase of slight skolioses in the plaster jacket. Constructed as removable retention dressings, however, they* are of importance in severe cases, seeing that 164 Orthopedics and Orthopedic Surgery. they* liberate the thoracic and abdominal organs from the weight of the trunk, and facilitate the equalization of the cir- culation. The plaster of Paris, however, should act here only as an adhesive material for the bandages and merely7 be rubbed into the gauze rollers (about three and one-half inches broad). The plaster mass cannot be employed; and the dress- ing, which is applied over a tight-fitting stockinet shirt, has decided ad\*antages over others in that it sets rapidly*. Silicate of soda corsets have the adA*antage of being more durable; but the first bandages applied over the stockinet shirt must be well Avrung out, otherAvise the silicate penetrates into the shirt, making it hard and rough, and possibly7 giving rise to excoriations, etc. The application of the corset in suspension is not as handy as in the hammock method or in reduced lateral position (Dornbliih, Petersen,88 Frankel). Petersen places the patient as folloAvs: The legs are sup- ported on a table as far as the trochanters, the head rests on a pilloAV on another table, the trunk is supported only* at the greatest convexity7 by* a Barwell's sling, i.e., a triangularly7 folded cloth the ends of which are fastened to a cross rod which is drawn up or let doAvn by pulleys. After the position has been corrected or over-corrected and the spines padded, the sling is included in the plaster dressing and the ends are cut off. Lorenz has devised definite methods of applying removable plaster dressings for the several forms of skoliosis; they- are intended to supplement the result attained by methodical cor- rection and to maintain position; thus, for primary dorsal curvature there is the lateral traction dressing and pressure dressing (the former, of course, acts only against the lateral curvature of the spine, leaving the costal curvature out of consideration, while the latter is specially directed against the ribs). The lateral traction dressing (Fig. 151), i.e., a plaster dress- ing fixing the trunk in left displacement to the pelvis, with the addition of traction at the thigh, is suitable to somewhat advanced primary dorsal skoliosis with considerable lateral displacement of the trunk on the pelvis toward the right. Owing- to the disfigurement caused by wearing' it, it is applied several hours daily at home, in such a way that the lateral Orthopedics and Orthopedic Surgery. 165 displacement is quite considerable, forcing the child to active opposite bending of the spine, while for use outside it is advis- able to apply* a less conspicuous dressing which causes only slight lateral displacement. The lateral traction dressing is applied in the erect posi- tion, the pelvis of the patient betAveen trochanter and iliac crest being grasped by a padded pelvic fork; the trunk is first brought into the desired position or fixed by a belt attached to a lateral A*ertical post and surrounding the thorax. The right arm being abducted, the plaster dressing is applied. It reaches above only to the point of the right shoulder-blade; on the left side it may be still shorter. The pelvic folds of the bandage in- close a two-armed tin plate hav- ing grater-like openings and bear- ing beloAv a stout ring; to the latter is fastened, after comple- tion of the dressing, a strap arising at the left from a legging laced to the thigh Avhich serves to prevent displacement of the left lower edge of the dressing. The pressure dressing, which is directed especially7 against the torsional changes of dorsal skoliosis, is applied by7 Lorenz like an ordinary7 Sayre's jacket; the patient being suspended in Beety's sling, and the pelvis being fixed by a fork, a (Fig. 152), so as to prevent rotation of the body*. The dressing reaches to the angle of the shoulder-blades, the flat parts of the thorax having previously been padded Avith felt placed under the 166 Orthopedics and Orthopedic Surgery. stockinet shirt. Over the most prominent points thick felt pads are fastened to the inner surface of the dressing, which, Avhen completed, is laced in suspension. Thus pressure is ex- erted in the right diagonal diameter, while dilatation of the thorax is permitted in the shortened left diagonal diameter. It is easier to effect correction (or fixation of the affected segment in a position opposed to the curvature) in case of lumbar skoliosis, by using a still lower and hence less trouble- some removable plaster dressing. This dressing Lorenz rec- ommends, as the " belt dressing," for primary* lumbar skolio- sis, and at the same time it has a correcting effect on the commencing secondary curvature of the dorsal segment. This dressing is also applied in the erect position. In left Fig. 153. Fig. 154. lumbar skoliosis the left side of the pelvis is raised by elevat- ing the foot three-fourths to one and a half inches high, is fixed by the pelvic fork, the trunk is inclined to the left and sup- ported by a padded axillary crutch. This position the patient can readily maintain for fifteen to twenty minutes; then the plaster dressing is applied in the usual maimer and thus the lumbar spine is maintained in a right-convex position; in left- inclination of the trunk the dressing is applied or laced from the right side. KareAvski,89 at Israel's instigation, recommended corsets made of close-meshed galvanized wire netting, or plates for the anterior and posterior surface of the trunk, with proper openings for the arms and moulded to fit the mammae; they are accurately fitted to the patient in suspension or other- Orthopedics and Orthopedic Surgery. i6y wise. These wire plates, the borders of which are lined with strong adhesive plaster, are united into a corset by means of a silicate of soda bandage which is applied in suspension. After twenty-four hours the corset is opened at the side and removed, when the edges are bordered Avith soft leather, one lateral edge is pro\-ided with hooks for lacing (with rubber cord), the other is made flexible by a stout strip of leather, and on each shoulder, front and rear, hooks are affixed for elastic shoulder straps (a piece of rubber tAvo inches wide, with perforated leather straps at each extremity). These wire corsets are said to be preferable to the plaster jacket on account of their better fit, light weight, porosity7, and durability7; only a close-fitting stockinet shirt should be worn underneath; they should be remoA7ecl at night and ap- plied in the morning in suspension. Of still simpler material are Bernhardi's pasteboard corsets which may be reinforced Avith splints, and A7ance's90 paper jacket which is formed of strips of brown paper glued to- gether. Corsets of plastic felt have also been used. They are shaped directly* on the body or on a model; but they are much inferior to steel spring corsets and are valuable only in case of skoliosis of the third degree, in which some supporting ap- paratus must be Avorn for preventing neuralgic pains; they are applied in suspension. Deformities of the Thorax. Pigeon breast,pectus carinatum s. gaUinatum, is the term applied to a characteristic deformity- of the thorax (with or without implication of the spine), in which the anterior ends of the ribs are bent inAvard, the sternum and costal cartilages project in the shape of a keel, the thorax being enlarged in the sagittal diameter, and narrowed in the frontal diameter. The costal cartilages being bent inward with concavity- directed forward, a sulcus is formed on both sides in front of the thorax. The deformity usually depends upon rachitic softening of the bones, but other processes may be concerned in the etiol- ogy, though more rarely, and Eulenburg, e.g., distinguishes: Pectus carinatum rachiticum, " " ex gibbositate, " " paraly-ticum. 168 Orthopedics and Orthopedic Surgery. That pigeon breast is among- the most frequent of rachitic deformities is shown by observations such as those of Chance, who obserA7ed 156 cases among 600. Besides primary local softening of the bones, there are a number of other causal conditions to be considered, such as those which prevent the free entrance of air into the thorax, especially attacks of spasm of the glottis associated with soft occiput (Elsiisser); for in these cases the glottis does not open far enough to per- mit the ingress of air with sufficient rapidity to meet the sudden en- largement of the thorax by the action of the dia- phragm. The air pres- sure then acts on the sides of the thorax and c r o av d s the wea kest portions inward (Jen- ner, etc.). Besides spasm of the glottis, there are other condi- tions in which the ex- pansion of the thorax is not accompanied with sufficient dilatation of the lungs; paralytic states (after Avhooping cough, etc.) are also mentioned as etiolog- ical factors, as well as enlarged tonsils (Shaw). Further still the lateral pressure of the arms upon the chest may play a part in the formation of pigeon breast. With reference to the sy*mptoms, avc observe here, too, widely differing grades of the deformity, and in the higher of these the lateral flattening of the thorax Avith the keel-like projecting sternum and flattened costal cartilages which form a real hunch-breast constitutes one of the most terrible disfig- urements (Fig. 155). The thorax at the same time is consid- erably shortened in its transverse and lengthened in its sa-rit- Fig. 155. —Severe Pigeon Breast with Paralytic Lor- dosis and Kyphosis; Bilateral Spontaneous Luxation of the Hip. Orthopedics and Orthopedic Surgery. 169 tal diameter, its capacity* is absolutely* diminished, and hence in the graver cases seme dyspmea is rarely absent, especially if spinal curvatures coexist. The prognosis is favorable only in the slighter grades in early- infancy, since in the course of growth, after the rachitis has run its course, a spontaneous compensation of the de- formity is here also possible; in the higher grades, of course, the prospects of improving the deformity* Avill become Averse. The treatment (in addition to being anti-rachitic) must counteract the narrowing of the thorax by appropriate active exercises and gymnastics (some exercises, such as rowing, are here specially recommended) and by stimulation of the inspi- ratory* muscles (baths, cold affusions, etc.). Of course, circular bandaging of the thorax cannot be re- sorted to, but the application of Aveights (shot bag, etc.) to the anterior surface of the chest in the dorsal position may be tried. Passive exercises may be performed methodically seA*- eral times daily and be productive of good results; only7 rarely* will resort be necessary* to more complicated apparatus Avhich approximate the sternum to the spine by* elastic pressure Avithout touching the lateral wall of the thorax. In comparison with pigeon breast, other deformities of the thorax are of minor importance. A characteristic deformity, also usually7 due to rachitis, is the pectus excat-atum Avith de- pressed sternum or in-draAvn prascordium (similar to that oc- curring as the result of some occupations, as in shoemakers, etc.). These varieties are entirely bey*ond the reach of treat- ment. BIBLIOGRAPHY. 1. Busch, 1. c, p. 11!). —2. Trans. Path. So., 188.-).—8. Reports of Hamburg hospital.—4. Arch. f. klin. Chir., Bd. 12, 1871.— 5. Klinik der Gelenkkrank., III., p. (54.—(i. Brit, Med. Journ., 1884. 1., p. 59.-7. Annal. de dermatologie et de syph., 1881.—8. Beitrag zur Auat. des Menschen, etc., Leipzig, 1872.—9. Ischroder, Lehrbuch der Greburt.—10. L. c, p. 218. —11. Vogt, plate II., Fig. 9. —12. Piidiatr. Section der Magdeburger Naturf'orseherversammlung.—13. Scriba, Berlin, klin. Wochenschr., 1878, Xo. 28 and Vogt, 1. c, plate IV., Fig. 25.—14. Mem. de TAcad. de Chir. de Paris, 1768, Vol. IV.—15. L. c, 2. Aufl., p. 14.—16. L. c, p. 309. —17. Langenbeck's Arehiv f. klin. Chir., 1885, p. 23.—18. See Ref. arztl. Polytechnik, 1881. p. 8(5.-19. The Lancet, January 27, 1888.—20. Brit. Med. Journ., 1885. 31st Oct. Ref. Centralbl. fur orth. Chir., 1886, p. 64. —21. Annals of Anatomy and Surgery, 1882, December.—22. Centralbl. 170 Orthopedics and Orthopedic Surgery. f. orth. Chir., 1, III., 1886.—23. Berlin, klin. Wochenschr., 1883, p. 453. —24. Home-made Apparatus for Pott's Disease. Xew York Med. Journ., Sept., 1886.—25. Danger of Plaster of Paris Jackets, with a Descrip- tion of the woven wire Jacket. Med. Record, Oct. 18th, 1884.—26. Langenbeck's Archiv f. klin. Chir., XXX., p. 445.—27. Chicago Med. Journ. and Exam., III., 80.—28. Sammlung klinischer Vortrage, No. 199, Zur Behandlung der Pott'schen Kyphose mittelst tragbarer Appa- rate.—29. Wiener med. Presse, Xo. 14, p. 437, 1885.—30. Barth. Hosp. Rep., XX.—31. Mechanical Treatment of Angular Curvature.—32. See for instance the figure in Heather Bigg's Spinal Curvatures, 1882, p. 87. —33. Wiener med. Wochenschrift, 1885, Xo. 52.—34. Behandlung kalter Absces.se mit Jodoformemulsion. Wiener Med. Wochenschrift, 1884, No. 27.—35. Andrassy, Behandlung der kalten Abscesse mit Jodoforminjec- tionen. Beitrage zur klin. Chir. von P. Bruns. Tubingen, 1886.—36. Inj. d'6ther iodoformee dans les absces froids. ReA-ue de chir., Xo. 5. 1885.—37. XeAv York Med. Record, April, 1886.—38. Zur Statistik der Skoliose. Centralblatt fur Chirurgie, Xo. 21, 1886.—39. Klopsch, Or- thopadische Studien und Erfahrungen. Breslau, 1871.—40. L. c, p. 135.—41. Wiener med. Presse, 1886, Xos. 26 and 27.-42. Berlin, klin. Wochenschrift, 1884, Xo. 38.—43. See the illustration in Vogt, 2. Aufl.. Tafel IX. and X.—44. See the illustration in Vogt, 1. c, tab. XL, Fig. 72.—45. Neue Messungsmethode, etc. Berlin, klin. Wochenschrift, 1881. No. 43.—46. Instr. for matning och afbildning of brSstkorgens bugtiye ytor fOrceA-isade, etc. Hygiea, 1882.—47. Zur Aetiologie der Skoliose, etc. Chir. Sect, d. 58. NaturforscherA-ersammlung zu Strassburg. Abb. Mo- natsschr. f. arztl. Polytechnik, 1886, p. 99.—48. See Vogt, 1. c, tab. XL, Fig. 71.—49. Centralblatt f. Chir., 1883, p. 305. Illust. p. 309 (to be ob- tained through C. AValowski, Vienna, I.).—50. Centralblatt fur orth. Chir., 1887, Xo. 4.—51. L. c, p. 151.—52. For faulty positions see, among others, the investigations of Schenk, Orth. Centralblatt, 1886, p. 2.—58. Centralbl. ftir orth. Chir., 1885, No. 5. Centralbl. fur allg. Gesundheits- pflege, III. Jahrg.— 54. L. c, p. 147.—55. Anatomische Vorlesungen fur Aerzte, etc. Berlin.—56. Centralblatt ftir orth. Chir., 1886, Xo. 1.—57. L. c, plate XII., Fig. 76.-58. L. c, p. 175.—59. Allg. Orthopadie, Leipsic! 1882.—60. L. c, p. 205.-61. The Prevention and Treatment of lat. Spinal Curvature. London, 1885.—62. Centralblatt fur orthopadische Chirurgie, October, 1886; see the illustration.—63. Vorschriften fur die Behandlung von Riickgratsverkrummungen mit Massage. Leipsic, 1887. —64. Handbuch der allgemeinen Therapie von Ziemssen, allgemeine Orthopadie, p. 184.-65. S. Strassburger, Erfindungsausstellung. Illus- trate Monatsschrift ftir arztliche Polytechnik, 1886, p. 86.-66. Illustr. see^among others in Konig's Lehrb. d. spec. Chirurgie, 4 Aufl., II. Bd., p. 727.-67. Centralblatt ftir orthopadische Chirurgie, 1885. p. 74.— 68^ Illustrirte Monatsschrift ftir arztliche Polytechnik, 1880, p. 150.—69. L. c, p. 187.—70. Geschichte und Behandlung der seitlichen Riickgrats- verkrummungen (Scot), Strassburg, 1885, 1. c, Fig. 77.-71. Causes and Treatment of Lat. Curvature of the Spine, 1888.—72. L. c, p. 340 —73 See Centralblatt fur orthopadische Chirurgie, 1885. p. 1.—74. L c p Orthopedics and Orthopedic Surgery. \y\ 184.—75. See Gaujot and Spillmann, 1. c, Fischer, 1. c, p. 115.—-76. Comp. Fischer, 1. c, p. 106.—77. L. c, p. 189.—78. Centralbatt ftir or- thopadische Chirurgie, 1886, p. 73. Deutsche medicinische Wochen- schrift, No. 35, 1886.—79. Pitha and Billroth, Handbuch der Chirurgie; Lorinser, die Verkrummungen der Wirbelsaule, p. 53.—80. L. c, p. 28. —81. Langgaard, O., Zur Orthopadie, Berlin, 1868, p. 75.—82. Comp. Fischer, 1. c, p. 119.—83. L. c, Manual of Orthopraxy, 3d edition, pp. 279 and 285.—84. Illustrirte Monatsschrift ftir arztliche Polytechnik, 1879, p. 145.—85. Bandager og intrumenter etc. ved Cam. Nyrop, Kjo- benhavn, 1877, p. 25.—86. Berliner klinische Wochenschrift, 15. Juni, 1885.—87. See Dollinger, Wiener medicinische Wochenschrift, Septem- ber, 1886. p. 1305.—88. Langenb. Archiv f. klin. Chir., 1885, p. 23, orth. Centralbl. 1885, p. 91.—89. Arch. f. klin. Chir., XXX., p. 445—90. New York Med. Record, June 21, 1879. CHAPTER V. ORTHOPEDIC AFFECTIONS OF THE EXTREMITIES. I. Contractures and Ankyloses. The term ankydosis (from ayxuko?, crooked l) (French, roi- deur articulaive, anchylose; German, Gelenksteifigkeit, Ge- lenkverwachsung; Italian, auchilosi) designates that condi- tion in which, through adhesions or other alterations Avithin or Avithout a joint, its mobility is partly* or entirely- arrested. It is customary to distinguish complete, true, bony7 anky*- losis, Avhei-e the articulations are united by7 bony adhesions (synostosis) and Avhere mobility* is therefore completely* ar- rested, and false, partial, fibrous ankylosis, in which the ad- hesion is effected by connectiA*e tissue and a partial mobility7 is retained. Some distinguish, in addition, cartilaginous anky- losis which arises mainly from inflammatory* processes in the neighborhood of joints, resulting in gradual obliteration of the sy*noA*ial membrane, and in Avhich the cartilaginous layers at first remain intact, but become subsequently* adherent and atrophic. Bridge-like ankylosis is the term applied to the condition in Avhich the ends of the articulations are united only7 by* some flakes of bone, which usually correspond to the ossified fibrous ligaments or muscles, as for instance, the anterior longitudinal ligament of the spine, the brachialis internus at the elboAv, etc. Furthermore, we may distinguish straight or angular, sim- ple or complicated (e.g., associated Avith luxation) ankylosis. In general, the term ankylosis is understood to mean the condition of absolute immobility7 (immobilitas compacta) of a joint, while diminished mobility, pathologically restricted ex- cursion of motion (mobilitas incoinpleta) is designated as contracture (pseud-ankydosis, rigid itas avticuli). The latter is divided into the arthrogenous, i.e., that due to changes in the articular apparatus, into the neuro-myogenous, i.e., that due Orthopedics and Orthopedic Surgery. 173 to alterations in the muscles or their innervation, and into the cicatricial Avhich are caused by cicatricial processes, the con- traction of cicatrices. We will speak of the neuro-myogenous contractures mainly under the head of deformities produced by* paralytic conditions, etc., and Ave are at present chiefly con- cerned Avith the arthrogenous contractures, and Avith those due to pathological processes around the joint (peri-articular) AA*hich include also the cicatricial contractures. Congenital contractures and ankydoses as the result of ar- rested development, or in consequence of inflammatory7 pro- cesses in utevo rarely- come under obserA-ation. We find, how- ever, for instance, in the Histoive de VAcademie des Sciences, 1716, the description of a child aged tAventy-three months with complete ankylosis of the entire skeleton. Ankydosis is obserA*ed much more frequently in ginglymoid joints than in others; usually it is found in a single joint, rarely* in several. Cases like that reported by* Conner (de stupendo ossium coalitu), in which there Avas an almost uni- A-ersal ankydosis, are very exceptional. As to the causes of contractures and ankydoses, they may arise gradually from simple non-use, especially in elderly per- sons, as has been demonstrated by Menzel,2 Paget, Reyher,3 and others. An interesting example is furnished, among others, by the Indian fakirs Avho, for the sake of penance, often remain for y-ears in one position, and Avhose joints are said to become frequently7 ankydosed in such an attitude. In such cases, there occurs not only7 muscular contracture, the inser- tion points remaining permanently7 approximated, but also proliferation of the A-ascular sy-novial processes, and charac- teristic changes of the cartilage, especially at the points Avhere the articular surfaces no longer touch; and here some part is also play7ed by7 the first motions made after prolonged rest, Avhich then act as an inflammatory irritation (Volkmann4). The great majority* of cases originate in articular affec- tions. Indeed most of the deeper articular processes lead to contractures or ankylosis of the joint. The process is usually7 this—after destruction or perforation of the articular carti- lage, the granulations on the surface of the tAvo extremities become adherent, and during recovery- firm fibrous adhesions are gradually- formed, Avhich later may- become ossified. Or else, as the result of inflammatory irritation, spicula of bone, l74 Orthopedics and Orthopedic Surgery. stalactite-like osseous proliferations de\*elop and interfere with motion, or lead to complete adhesion (Fig. 156). The most various articular affections, especially of tuberculous, rheuma- tic, but also of gouty7, gonorrheal, sy-philitic, puerperal, neuro- tic, etc., nature, may thus lead to ankylosis; and many7 of these articular affections have a particularly7 marked tendency to cause multiple ankyloses, especially the gonorrheal and rheumatic. Inflammatory processes, traumata, etc., in the neighborhood of the joint, may7 also giA*e rise to ankylosis. Phlegmons, phlegmonous erysipelas which causes extensive Fig. 156.—Ankylosis of the Fig. 157.—Fibrous Ankylosis of the Knee with Knee with Subluxation (Seen Tuberculous Remnant in the Condyle of the Femur. from Behind). (Onix.) necrosis of cellular tissue, burns, etc., followed by consider- able cicatricial contraction, cicatricial contractures, fractures, etc., near the joint are of particular importance as causal fac- tors. Morbid processes in the muscles, e.g., so-called myosi- tis ossificans, may7 cause extensive ankyloses. In the majority of cases these etiological factors are com- bined, e.g., in the finger contracture occurring frequently in consequence of gangrenous forms of panaritium, the loss of the flexor tendon and cicatricial contractions and adhesions around the joint playing a part in the abnormal position. The pathological anatomy- of ankyloses allows the differ- entiation into ankylosis spuria (fibrosa, cartilaginea, ossea), OrtJiopedics and Orthopedic Surgery. 175 also into synostosis and ankylosis extracapsularis (bony-bridge ankydosis). Usually* the real osseous adhesion is preceded by a stage of fibrous or cartilaginous ankylosis, and the patho- logical conditions found vary according to the stage or dura- tion of the affection. Chronic ankyloses may* lead to adhesions so uniformly firm that it is hardly possible to recognize any7 demarcation of the bones, either on the external surface or in the internal struc- ture ; frequently, Avhere the inflammatory process is still pres- ent, the synostotic bones are co\*ered Avith numerous stalacti- tic fine bony- needles, etc., Avhich are inclosed in a more or less firm cicatricial mass (Fig. 156). An important fact is, that in ankylosed joints morbid de- posits are often included, e.g., tuberculous foci, AA-hich in case of * trauma, etc., may- cause a relapse or a fresh eruption of the disease. As a rule, the form of the joint is much altered, and cases are rare in Avhich the affected bones appear only- as if connected by7 bony7 substance, and otherAvise unchanged. The muscles which are thrown out of action by the anky- losis are usually more or less atrophic, in chronic total anky*- loses they* are often fatty7 degenerated throughout; the groAvth of the affected limb is more or less markedly7 stunted, accord- ing as the morbid process has occurred early in life, and has implicated the epiphyses or not. The symptoms of ankylosis consist in the greater or less loss of mobility, occasional major or minor deformity, and further in secondary7 or compensatory disturbances. A positiA-e diagnosis of the condition can only be made in narcosis, since involuntary contractions of the muscles, etc., may simulate contracture or ankydosis. Amesthesia Avill also permit the recognition of the kind of ankylosis; for instance, if in case of bony7 ankylosis one hand is placed above, another beneath the affected part, a peculiar sensation of rigidity* is imparted Avhen passive movements are attempted. Immobil- ity alone is by no means a sign of bony7 ankylosis. In exam- ining without anaesthesia, it is to be noted that gentle manip- ulations (the patient's attention being diverted) facilitate the diagnosis, since forcible movements readily* cause reflex con- tractures. Sanson5 relates a case in Avhich a hospital physician had diagnosticated ankylosis of the hip of a child; but another 176 Orthopedics and Orthopedic Surgery. physician present, by directing the child's attention to some other subject, easily demonstrated the mobility of the joint. At the present time, the prognosis of ankyloses and con- tractures is generally* favorable, for it is possible in most cases to cure the condition by apparatus, massage, manipulations, etc., and if necessary- by operative methods (Avhich have be- come justified only7 since the advent of antisepsis), or at least to give the limb a position most useful to its function. In the way of treatment, mention should first be made of prophydaxis, which consists in the correct treatment of the rather frequent joint affections, fractures, etc., that is to say, the diseased joint should ahvay-s be fixed in its most useful position (e.g., elboAv flexed, knee and hip extended). In gen- eral, the fixation should not be continued too long, but be sup- plemented at the proper time by* massage, manipulations, frictions, passive and active moA*ements, etc. Where cicatri- cial contraction is anticipated, this should be counteracted by appropriate position. The treatment aims at stretching the contracted parts, at making the ankydosed joints movable, or at least as useful as possible functionally7. The milder measures, gradual (elastic) traction, massage, etc., can be successfully* employed only* Avhen the adhesions are not too firm. The great number of ingenious appliances deA*ised for the treatment of contractures and ankyloses con- sists usually* of tAvo excavated splints for receiving the re- spective parts of the limb, made adjustable at the desired angle by* screAvs, etc. Where it is necessary* to change an angular position into a straight one, the commonest methods are simple extension by* Aveights, according to Volkmann, or elastic traction appliances. Where mobility is aimed at, the splints are made movable on each other by a cord running- over a pulley*, on a higher level, as in Bonnet's automobile ap- paratus. Elastic traction may* also be used for this purpose by being made to act alternately* in the direction of flexion and extension. Reibmayr and others have devised such appara- tus. Figs. 158 and 159 sIioav a simple apparatus for restoring mobility to the elboAv joint (a hinge joint is inserted at A). Since, however, these methods are slow in action and without effect on the firmer adhesions, it was but natural that efforts were early made to break up the ankylosis forcibly, or to Orthopedics and Orthopedic Surgery. 177 o\*ercome an abnormal angular position. It is mainly* since the time of Louvier, avIio performed forcible redressement Avith a machine of his OA\*n inA*ention, that Ave can speak of a sepa- rate method of "redressement brusque" or "brisement force" (arthroclasm), i.e., a rapid, forced correction of the position —a procedure perfected chiefly by Dieffenbach, Langenbeck, Palasciano, and others. Brisement force, howeA-er (Avith Avhich, by7 the way7, Louvier did a good deal of mischief, as shown by some autopsies), only found general acceptance after the introduction of anaesthesia. As a rule, the manual poAver of the surgeon suffices, but the osteoclasts Avhich we have al- ready- described (Collin, Robin, Beely, et c.) may likeAvise be used. The aim is to start the movement in accordance with the nor- mal axis of the joint, so as to avoid infractions or fractures. It is particularly important that the force should not act too far Figs. 158 and 159.—Apparatus for Correcting Contracture of the Elbow by Alternate Elastic Traction. (After Collin.) along the long lever arm of the peripheral portion of the limb, and it is advisable in some cases whore great force is to be exercised to cover the limb Avith a plaster dressing up to the point where mobility is to be established, and by including a long splint in the dressing, to use the latter as the prolonga- tion of the lever arm. The first attempts at forced movement should always be made in the sense of flexion, only the later ones being toward extension, afterward flexion and extension may be combined. It Avas formerly7 believed that the tense sinews and fascia? should almost invariably be first divided (Brodhurst, etc.), but this preliminary tenotomy can lie avoided as a rule, and where it becomes necessary it is, of course, to be done under antiseptic precautions. If the bone is connected with adhe- rent cicatrices, their subcutaneous detachment may be indi- cated, so as to avoid rupture of the skin in the redressing; in 12 178 Orthopedics and Orthopedic Surgery. the case of cicatricial contractures, dtvision or excision of cica- trices must occasionally be performed. Brisement force is performed in profound narcosis; the limb is properly fixed by* the hands of the assistant, the sur- geon grasps the peripheral portion with both hands, forcibly flexes and then extends the limb, continuing the alternate at- tempts at flexion and extension until good mobility* in both directions is attained. After this a suitable dressing is of great importance. Say-re recommends bandaging the limb, commencing at the peripheral end, and exerting compression OA-er the joint by7 sponge (a cotton pad, etc.). The limb is kept elevated and the bandage is changed only* after six or seA7en days. When the adhesions are extensiA-e, a distinct crackling can generally be heard during brisement force, and all of a sudden the joint gives Avay; with proper precautions the method is free from any- great risk. The method is, of course, out of the question, Avhile inflammation or sup- puration is still present. We must remember, above all, the possibility of setting up acute suppuration (Oberst6) or the occurrence of general tuberculosis from brisement force (Szumann7), and latterly7, indeed, the method has been em- ployed less frequently7 than it Avas by* Langenbeck. Even complete bony ankydoses in unfavorable position are of faA-orable prognosis to-day-, for the antiseptic treatment of wounds justifies us in performing various operations on the bones—operative correction. A combined method is that where ankydosed bones, like the patella or the olecranon, are detached Avith the chisel (Maunder8) before performing brise- ment force or Avhere the soft parts are first divided (avoiding vessels and nerves). For true ankyloses in unfavorable posi- tion the operations to be mainly* considered are osteotomy (simple linear, arciform, etc.), osteectomy, more rarely resec- tion en bloc, i.e., removal of the adherent articular surfaces. In case of angular ankylosis of the knee, Bauer used to resort to amputation; but, to-day, such radical means Avill be called for rarely, except in case of ankydosis of the fingers which interferes with working or where the fingers are no longer functionally useful owing to considerable degeneration, stunted growth, etc. To pass, now, to the consideration of the contractures and of ankylosis of the special joints, the larger articulations of Orthopedics and Orthopedic Surgery. 179 the trunk and those of the hand are practically7 of the greatest interest. Contractures or ankydoses of the hip-joint are probably A7ery rarely* of a cicatricial nature, and are more frequently due to peri-articular inflammations, such as that following on psoas abscesses, etc. The great majority7 of cases of true an- kyloses are arthrogenous, i.e., arise in connection Avith coxitis, and result in flexion, adduction, and inward rotation of the limb. The characteristic position of the leg, Avhich is usually asso- Figs. 160 and 161.—Deformity after Coxitis. The Affected Extremity is Stunted in Growth and Nutrition. ciated Avith muscular atrophy7 and shortening, causes essential disturbances in walking, such as limping, and the greater the flexion the more pronounced will be the secondary lumbar lordosis and the depression of the pelvis, the result of efforts to use the leg in walking. Secondary kyphotic compensatory curvatures and static skoliosis may7 be ultimate sequelae; the disturbances are of course greater in bilateral ankylosis.9 The disturbances are the greatest in the rarer forms of ankydosis of the hip in flexion and abduction, where even crutches cannot be used. The most aggravated of all is bi- lateral ankylosis in abduction, of which I have seen several 180 Orthopedics and Orthopedic Surgery. examples (Fig. 162), where the patients are forced to move on all fours or to jump like frogs.10 Such deplorable deformities occur especially after severe articular rheumatism, and they* may* not be recognized for a long while, owing to the fact that the patient is bedridden. Prophylaxis of contractures of the hips, etc., consists in the correct treatment of hip-joint disease by extension and fixa- tion (Thomas, Taylor, Bryant, Say*re's splints, etc.), and in ap- propriate resort to passive movements after acute rheuma- tism, etc. In examining for contracture of the hip, care must be taken that the pelvis is straight, and that the lumbar spine rests on the couch, for even in flexion-contracture of the hip the thigh Fio. 162.—Bilateral Contracture in Ab- Fig. 163.—Flexion Con- Fig. 164- Apparent Equal- duction following on Rheuma- tracture of the Left Nation by Lordosis of tism. etc. Hip-joint. the Lumbar Spine. can be pressed down on the bed (Fig 164), since the lumbar spine assumes a compensatory- curvature, and the hand may be passed under the sacrum of the patient. If the lordosis is straightened so that the entire spine rests on the couch, the thigh in flexion-contracture points upward. In order to test the degree of mobility, an assistant must firmly fix the pelvis of the anaesthetized patient, while the surgeon manipulates the leg. In contractures permitting some motion, the ordinary- extension dressings may7 suffice, provided the pelvis is properly fixed. Lorinser n deems it better to fasten the thigh and to make the two tuberosities of the ischium points of fixation, grad- ually raising them by a screw, while the weight of the trunk effects a slow depression of the lumbar spine. (See Fig. 165, in which b represents the pelvic bolster which is raised by the Orthopedics and Orthopedic Surgery. 181 screw S, betAveen the two segments of the mattress; while Fig. 166 shows conjoined extension of the leg by7 the screw S.) Fig. 165.—Lorinser's Apparatus for Contracture of the Hip. The various forms of extension beds (Heine, H. Bigg, etc.), may- also prove useful in the graver cases. A number of special apparatus have also been devised for contracture of the hip. One of the simplest methods, which Fig. 167.—Stillman's Sector Splint. may be conjoined with extension, is that by Stillman's sector splint (Fig. 167), Avhich is applied in a plaster dressing, sur- 182 Orthopedics and Orthopedic Surgery. rounding the pehis and thigh, and it permits changes of posi- tion only in the sagittal plane. Another apparatus of Still- man's aims at mobility in all the three planes through a uniA*ersal joint. Of other apparatus for ambulatory7 treatment in redressi- ble contractures of the hip, mention may* be made of that of H. Bigg, the mechanism of which is based on an S-shaped spring, or of another devised by the same gentleman, in which elastic traction is applied from behind to the thigh splint by a leA-er arm, the endeavor being to extend the thigh, while the pelvis and spine are supported by7 a belt and an axillary crutch, respectiA-ely-. Berthet has devised an apparatus in which tAvo angular leA-er arms (one springing from the pelvic belt, another from the thigh splint) are approximated by elas- tic traction. Other apparatus (H. Bigg, Mathieu, etc.) utilize an endless screAv at the hip-joint for OAercoming the contracture. In the extension apparatus devised by Ulrich and Mittler12 motion is also effected by* means of an endless screAv, Avhile fix- ation is secured by7 an iron band surrounding the peh'is, and by pads bearing on the symphysis and on the iliac spine. Peri- neal belts preA*ent displacement. Where the object is not merely correction of the position, but mobilization of the hip-joint, use may7 be made of an ap- paratus recommended by Brodhurst13 after H. Bigg, in Avhich the pelvis is properly* fixed, and a cord is attached to the lower extremity and carried over a pulley in the ceiling, so that the patient may practise passive flexion of the hip by* traction on the cord, Avhile the weight of the limb brings it back into ex- tension. Other ingenious appliances have been devised by Bonnet for passive movements, especially7 for rotation of the hip. For the rare cases of adduction-contracture, successful use may be made of H. Bigg's instrument, which consists of tAvo splints, connected by a hinge, passing along the inner surface of the thigh, with leather caps for the region of the knee. The splints may be set at any desired angle by means of screAvs and extension rods, while the point of the instrument rests below the perineum. A similar apparatus has been devised by Busch. The simplest instrument for keeping the knees apart is the spiral spring set between pads. Orthopedics and Orthopedic Surgery. 183 In cases where bony adhesion has not yet occurred, more rapid results may be reached with the method introduced chiefly by Berend, Dieffenbach, and Langenbeck, viz., forced redressement, a method Avhich, of course, is contra-indicated when the disease has not yet run its course, or fistulas, etc., are present. Usually we hereby only* secure improved posi- tion, and even this by* several repeated attempts, rather than at a single sitting. Ordinarily* manual force will suffice, but we must beware of causing a fracture of the diaphysis of the femur—an accident Avhich has occasionally occurred. Fracture of the neck of the femur (as has been observed by Rossander, Tillaux, and Volk- Fig. 168.—Terrillon's Apparatus for Fixation of the Pelvis. mann14) is no great disadvantage, since the thigh may after- Avard be extended. Special fixation apparatus has been recommended for brise- ment force of the hip. Bauer's apparatus consists of a Avooden block, padded Avith leather, Avhich is closely fitted and strapped to the posterior surface of the pelvis. The apparatus of Col- lin-Terrillon is easily understood from Fig. 168. For instru- mental brisement force the apparatus of Robin, Collin, and others, previously described, may be used. When the limb has been straightened, much depends, of course, on the correct maintenance of the improved position, and to this end traction dressings, Bonnet's wire hose, etc., must be used for several Aveeks at least. 184 Orthopedics and Orthopedic Surgery. In a large number of cases, especially of osseous adhesion, operative methods must be considered. Many7 operators favor tenotomy7 followed by7 brisement force (Say-re). For bony ankydosis of the hip in angular position, opera- tion under antiseptic precautions is certainty a safer method than forcible manual or instrumental osteoclasis. Rhea Barton, in 1826, Avas the first to divide the femur be- tween the trochanters Avith the fret-saw, in bony ankylosis of the hip, and since then oteotomy had been further developed. Langenbeck first perforated with an auger, and then divided the bone from this point as far as the cortical layer, when the fracture Avas completed. Adams (1869) performed subcutane- ous osteotomy of the neck of the femur Avith the saw, but Avith careful antisepsis it is certainly prefer- able (MacEAven) to make the wound large enough for the introduction of the finger, and then to diA'ide the neck of the femur with the chisel, Avhen the thigh can be easily straightened and healing ensues un- der the first dressing. Brodhurst pointed out that it Avas of great importance to fig. i69.-a, Osteotomy effect the division as near as possible to of the Neck of the Femur; .,, , f ,■ b, Intertrochanteric Oste- ^he Centre Of motion. otomy; c, Subtrochanteric In many cases it is better, OAving to de- struction of the head of the femur, or to osteophytic proliferation around the neck, etc., to make the division below the trochanter according to Gant15 and to Maunder. Subtrochanteric osteotomy has been chiefly* de- veloped by* Volkmann,16 so that at present it represents the most frequently employed procedure, and is especially* adapted to serious adduction-contractures in which the head of the femur is outside the acetabulum and brisement force is there- fore inapplicable. The division is effected with the chisel about opposite the small trochanter (Volkmann), after detachment of the perios- teum; a wedge-shaped piece is excised, wdiose base, correspond- ing to the conjoined position of flexion and adduction, is directed backAvard and outAvard; the bone is not cut through entirely, but the wall at the minor trochanter is fractured, as the last step. Holmer and others carry the osteotomy somewhat deeper Orthopedics and Orthopedic Surgery. 185 than Volkmann. What serious deformities may* be rectified by these operations is shown among others by G. Ledder- hose's n case of bilateral subtrochanteric osteotomy for anky7- losis of both hips, in extremely adducted and inward rotated position, in a man aged twenty, represented in Figs. 170 a and b before and after operation respectively. Next in order are the wedge-shaped osteotomies for ankylosis of the hip, which were also largely practised by Volkmann, K. Rodgers, and Sayre. Although after various osteotomies of the neck of the femur, mobility has been attained (Brodhurst, Adams), the Fig. 170 a.—Ankylosis of both Hip-joints Fig. 170 b.—The Same after Operation in Curved Position. (Ledderhose). majority of operations aimed only at improvement of position; and in order to secure mobility after osteotomy, Sayre18 has only excised a semilunar piece from the neck of the femur, the concavity being directed downward, and in such cases he has attained his object of imitating the natural joint and of mak- ing it movable. Where we have reason to believe that morbid residues are present in the hip-joint, i.e., where the inflammatory process has not run its course, it would appear preferable to remove the remains of the head and neck of the femur, by making Langenbeck's usual posterior longitudinal incision and sepa- rating the great trochanter with a chisel. After that the acetabulum should always be exposed and inspected (Kol- liker 19). In rare cases, e.g., in strongly abducted position, an 186 Orthopedics and Orthopedic Surgery. anterior longitudinal incision is more suitable (as performed by Billroth and others). The after-treatment of orthopedic resection of the hip is the usual one, extension by weights for from three to six weeks, after which the patients practise walking with Volkmann's stool (Gehbdnkchen), while exten- sion is continued during the night for a longer time (Kolliker), and then follow active and passive gymnastics by methodical movements, etc. The cure of angular ankyloses, together with retention of mobility of the thigh, has thus been secured after resection Avith the chisel (Gritti). Rosmanitw has calculated the following mortality: after 35 osteotomies at the neck of the femur, 11.43$; after 34 sub- trochanteric osteotomies, 8.82$; and after 28 Avedge-shaped excisions below the trochanter, 7.14$. Hence there is no ma- terial difference.in the statistics and the same may be said of the functional results; resection, being a more formidable operation, has a greater mortality*, 30$ (Rosmanit), Avhich Avill, however, be reduced by antisepsis. Resection is absolutely7 indicated only in bilateral ankylosis, since tAvo stiff legs cannot be used for walking, especially since not even crutches can be employed in the abducted position. On one side simple osteotomy with correction of the false posi- tion may7 be done; on the other side, resection must be per- formed. Such double operations haA-e been done by v. Bruns, Volkmann,21 Billroth, Mordhorst, and others. Studensky22 performed double resection and he obtained mobility* on both sides in the new-formed joints, although, of course, the length of the legs became unequal, owing to the upper end of the femur on the right side gradually gliding up on the venter of the ilium. The most frequent and important contractures are those of the knee-joint, which too often result from the faulty treat- ment of articular inflammation; according to their severity they represent a permanent grave injury Avhich can be avoided by appropriate prophydactic treatment. While in Germany retentive dressings in extended position stand foremost in the treatment of the usual fungous (tuber- cular) form of inflammation of the knee-joint, the only mis- take being that these dressings are removed too early7 and contractures develop subsequently, in England and America special apparatus is in favor, which permits extension and Orthopedics and Orthopedic Surgery. 187 fixation in the desired position and can be Avorn through all the stages of the articular inflammation. Of these, mention will be made onty of the apparatus shown in Figs. 171 and 172, after Stillman. In addition to the sector joint, it carries a pad which crowds the head of the tibia forward, thus counter- acting the characteristic subluxation of the tibia. Ankyloses of the knee-joint in extended position will seldom come under treatment. Angular contracture or ankylosis of the knee, being a very frequent deformity, probably usually requires' Figs. 171 and 172.—Apparatus for Inflammation of the Knee-joint. (After Chas. Stillman.) surgical treatment, although, under the methods of treatment now generally employed in chronic inflammations of the knee- joint, it is exceptional that we see cripples who ride, so to speak, with the thigh on a wooden leg, the angular stiff knee projecting in front. For straightening angular contractures of the knee and fibrous ankyloses, use is made in mild cases of gradual exten- sion (with oblique foot-board, extension by weights downward at the knee, elastic traction, etc.); in most cases we must rest content with stretching the leg and thus enabling the patient to walk. 188 Orthopedics and Orthopedic Surgery. Wiskemann23 effects the stretching by fastening to the ex- tensor side of the thigh a long splint which is nailed to an upright board at the lower end of the bed, whereby7 he attains a sort of suspension of the leg, and (with appropriate fixation of the pelvis) the leg is gradually approxi- I I mated to the splmt, or stretched by elastic % I bandages. If the pain is great, the elastic If | traction may be intermittent. K ,.| Elastic traction may also be applied by ^i if fastening to two articulating splints elastic ~^^ Sl'€z cords, running over pulley*s affixed higher fS***^i,Tp-^f up, as, for instance, in the apparatus devised If i. 1 -^ Schepeiern« ™ I I Another very* suitable apparatus is that I I of Lorinser24 (Fig. 174), which consists essen- jjji tially of three small boards adjustable to Hf^^, each other (2, 3, 5); of these the leg board, fig. 178—Anguiar An- which is joined to the thigh board by a hinge, kyiosisoftheKnee. (Af carries at its lower end a movable nut (6), through which passes the horizontal scccav of the base board, which is turned Avith a key* (Fig. 174). The apparatus of Tamplin and Duval belong in the same category. Bonnet's well-known apparatus is very7 similar. It consists of two hollow splints joined by a hinge in the region of the knee, and a base board. The foot is surrounded by* a sort of leather gaiter, to which is fastened an extension cord, to be tightened by a spindle. Two small pulleys at the foot end of Fig. 174.—Knee Extension Apparatus. (After Lorinser.) the leg splint prevent friction as much as possible. Volkmann recommends the apparatus in the form of two well-fitting- tin splints joined by hinges and fastened to a base board, using weights as the extending force. For the gradual ambulatorv extension of contracted knee-joints a large number of appa- ratus has been devised. Among the simplest are the retentive Orthopedics and Orthopedic Surgery. 189 dressings Avhich are applied after the best feasible correction of the position (under anaesthesia) has been attained and are reneAved at suitable intervals after further correetion. Since it is desirable to keep the joint under observation during this time, frequent use has been made particularly7 of interrupted re- tentive dressings, Avith articulated splints adjustable at the side. A very suitable form is the sector splint, such as that recommended by Braatz,25 in AA*hich the leg splint can be set at any* desired angle in a sector grooA*e of the thigh splint, so that the position can be improA*ed manually eAeiy few days, and be retained by* a thumb screAv; or the form advocated Fig.i75.-sectorsplint. by Stillman26 under the name of "sector joint brackets and splints" which can be set at any* angle without being re- moA7ed, permits extension and occasionally motion, and is usu- ally fastened by7 means of a plaster-of-Paris or adhesive plaster dressing. These sector splints are made of steel with a flexible, per- ,--t forateel copper plate for encasing the limb, fZ^'lSl a sector (Fig. 175) being interposed at the joint. A slit in the sector permits motion to any* desired angle, where the thumb screAv Avill retain it. A large number of the apparatuses de- vised for angular contracture of the knee, are based on the application to the side of the angle of an extensible screAv-Avorm, by7 which the angular position can be gradually di- minished (Kolbe, Pancoast, Roberts,27 Salt, BuroAv, Ny7rop). One of the best knoAvn of these is Eulen- burg's extension apparatus, consisting of tAvo fig. ne.-stiiiman's articulating capsules, in which the leg and sector splint. thigh are fastened by7 straps; by means of endless screAvs, a spindle and a winch, they may be moved on each other as described. The apparatus permits the patient himself to make exten- 190 Orthopedics and Orthopedic Surgery. sion and flexion movements, and is distinguished by facility of application, uniformity7 and, as desired, either slowness or ra- pidity of effect. According to Bidder,28 the apparatus has the advantage that (since buckles and straps are not used) any circular con- striction is avoided. Two semicircular grooves for the calf and anterior surface of the thigh form the main points of support, to Avhich are applied the curved steel splints which articulate in a joint with endless screw tying anterior to the axis of rotation of the knee. The " saddle-groove " fitted to the posterior surface of the thigh, Avhich adapts itself to the movements and is to be fastened with straps, prevents sepa- ration of the upper portion of the thigh splint Avhen the screw is tightened. Ridlon29 in his apparatus employs a hinge-joint adjustable Fig. 177.— Dieffenbach's Apparatus for Extension of the Knee. by7 an endless screAv. Thigh and leg are bandaged to the dor- sal padded steel hollow splints. Dieffenbach's contriA*ance, Avhich is Avarmty recommended by V. a*. Bruns, consists of grooved thigh and leg splints with tA\*o lateral splints (connected by cross pieces) articulating at the knee. The outer thigh splint ends in a semicircular plate toothed at its convex margin, the cogs being geared into the grooves of an endless sci-oav at the upper end of the leg splint, so that the leg piece (which, like the thigh piece, is fastened with several straps) can be set by means of a key* at any7 de- sired angle to the other. A square knee cap, applied in front over the patella and the condydes of the femur and buttoned to the splints, serves for further fixation, and prevents for- ward deviation of the knee. The apparatus devised by Langgaard 80 (likewise provided with bilateral splints, laced thigh and leg pieces, and anterior Orthopedics and Orthopedic Surgery. 191 knee cap) is moved by* an endless screw on each side of the upper end of the leg splint, where it engages in a toothed wheel at the lower end of the thigh splint. In the form de- w > HI * iijl lI \ Fig. 178.—Stromeyer's Apparatus for Extension Fig. 179.—Erichsen's Apparatus. of the Knee vised by Stromeyer (Fig. 178), the toothed wheel is at the upper end of the leg splint, and the endless screw at the lower end of the thigh splint. Of great value for slighter cases is the ingenious apparatus of Erichsen, or that of Heather Bigg, which is based on the action of two S-springs acting in opposite directions and, by Fig. 180.—Oehler's Knee Apparatus with Spring Action. means of two leather casings, it draws the leg forward, the femur backward, thus counteract ing flexion and subluxation. Other apparatus similarly employ spring power, as that constructed by Oehler31 (Fig. 180), in which the laced leather 192 Orthopedics and Orthopedic Surgery. pieces are attached to tAvo lateral articulated splints, each of which carries three small forks (one median, open in front, close to the joint; one above and one beloAv, open behind). Into these forks springs are in- serted (from one to six on each side, according to requirements) which give the leg a gentle, steady impulse toward extension. Uniform, poAverful traction can also be effected by the employ- ment of rubber, Avhich acts even more vigorously. Blanc,32 of Lyons, has devised several appli- ances, all on the same principle, fig i8i.-Apparatus for slight Angular viz., jointed splints for thigh and contracture of the Knee. (After Nyrop.) ieg (fastened by retention dress- ings or straps) are pro Added Avith anterior iron leA-er arms, Avhich are approximated by7 rubber rings, thus aiming at the obliteration of the angle. H. Bigg applies to the thigh- and leg-pieces anterior iron hooks united by* elastic traction; so does Nyrop (Fig. 181); tAvo leg splints, hinged at the knee, united above by7 a pelvic strap, e, carry beloAv a joint for the ankle, and a strap, /, for fixing the foot; above and beloAv the knee are projecting lever arms for applying elastic traction, b; a knee cap, c, presses against the prominent knee. Such apparatus can be easily improvised Avith strong Avire and an interrupted plaster-of-Paris dressing. Reibmayr applies the elastic traction for extension of the knee-joint, by making the rubber cord act on the lower end of tAvo iron rods fastened at their upper extremities to a band surrounding the femur. Quaas' mode of application is shown in Fig. 182; the leg being draAvn by elastic traction toAvard a prolongation of the thigh splints. In many cases, after re- moval of the contracture, it is necessary* to wear for some time an appropriate protector, e.g., like that of Lorinser shown in Fig. 183, in Avhich 1 represents the lateral steel splint; 2, the clasp for the thigh; 3, that for the leg; 4, the thigh band; 5, the knee band; 6, the leg band. In many cases of contracture and fibrous ankydosis, in which the presence of residuary morbid foci maybe excluded, brisement force suc- ceeded by fixation in improved position, may be expected to OrtJiopedics and Orthopedic Surgery. 193 yield the most rapid results; but it is important to avoid the danger of infraction of the tibia, in other w*ords, the long lever arm (the leg) must not be made to bear too great a strain. Redressement force at the knee is performed in the fol- lowing manner: The patient lies on the abdomen, the anterior surface of the thigh resting on the table so that the lower end of the femur occupies the edge of the table, and the flexed leg projects free into the air; the latter is grasped by the right hand of the surgeon immediately beloAv the popliteal space, and pressed Fig. 182.—Quaas' Apparatus for Extension of Fig. 183.—Apparatus for Fixation of the Contracture of the Knee. Knee. (After Lorinser.) forward, AA*hile the left hand bears down on the thigh. In this Avay we dispense Avith the long leverage of the leg, but can easily* augment the force by* throAving the weight of the trunk on the hand, until the leg yields to the pressure and the exten- sion can be completed, when it is fixed in a plaster-of-Paris dressing or secured by an appropriate protective apparatus (Fig. 183). In angular osseous ankyloses or those in which the morbid process has not quite run its course, operative measures may be indicated. Where the patella alone is adherent, it may* be sufficient to free it, either according to Hitter Avith a simple wedge of wood 13 194 Orthopedics and Orthopedic Surgery. without injuring the skin, subcutaneously as it Avere; or else, according to Maunder,33 with a tenotome inserted at the edge of the patella. In bony angular anykloses, osteoclasis of the lower portion of the femur has been repeatedly performed (Oilier, Perrusset). Pousson collected fourteen cases. Surgical methods will, how- e\*er, still be required for a portion of the cases. The first to be considered is linear or arciform (Rosmanit) osteotomy of the tibia or femur or both for acute-angled ankyloses, where mor- Fig. 184.—Wedge-shaped Excision in Right-an- Fig. 185.—Schematic RepreseL.ta- gled Ankylosis in the Knee; a, before; b, after tion of Excisions in Angular Anky- Operation. losis of the Knee. bid foci are no longer present, and the process has terminated in bony ankydosis. Volkmann performed the first antiseptic osteotomy of the femur for ankylosis of the knee in 1874, then folloAved Billroth, MacEwen, etc. The first rank is to be accorded to Avedge-shaped osteot- omy7, as performed originally7 by* Rhea Barton, that is to say, it is necessary to remove a wedge of bone from the lower end of the femur, which usually projects forAvard, so as to effect straightening; the shaded part a in Fig. 1S5 represents this method schematically7. Next to be considered is resection en bloc (Gurdon-Buck), i.e., the resection of the bony7 adherent joint (b, Fig. 185) for cases in Avhich prolongation of the affected bone is associated Orthopedics and Orthopedic Surgery. 195 with angular fixation. The size of the bony wedges which must here be occasionally removed appears from Figs. 184 a and b, which represent the extremity7 of a young man of tAventy, before and after resection en bloc.u The gait of the patient in this case was all the more ob- jectionable because, besides the right-angled complete bony ankylosis, the affected femur had elongated in consequence of the long-standing articular disease; the function of the straightened leg has become quite satisfactory-. Much more frequent are the orthopedic resections of the knee-joint in angular ankylosis Avith incomplete bony ad- hesion which has not quite run its course; resections Avhich, in children, should be per- formed as conservatiA-ely* as possible. The operation is best begun with a curved in- cision below the patella; the condydes of the femur are first removed with the curved saAv, after a flap containing the patella has been turned upAvard. Frequently it becomes necessary7, in order to avoid a sharp edge, to remove an additional piece of bone obliquely upAvard from the posterior portion of the sawn surface (Kolliker); if the leg can then be easily straightened, the tibia must be freshened as superficially as possible, in order to attain bony7 ankylosis. If the pa- tella lies well upon this, it is freshened and may contribute to the subsequent firmness of the joint; but if it is diseased or fits ill to the tibia and femur, it should be removed. The bone and the ligamentum patellar may also be sutured, as Avell as the capsule; then folloAv drainage, closure, and asep- tic permanent dressing. Owing to the good results from such operations and their safety, it Avill be exceptional that Ave will be compelled to order apparatus for patients with angular ankylosis and de- fective gait, such as the various appliances from the simple wooden leg with saddle to the more complicated apparatus, which answers no other purpose than to permit the ^atient to walk at least tolerably (Fig. 186). The contractures of the ankle-joint Avi.l be discussed in the Fig. 186.—Supporting Apparatus for Angular Contracture of the Knee. 196 Orthopedics and Orthopedic Surgery. following chapter on talipes. Complete ankylosis at the ankle- joint will furnish ground for operative interference onty when it has occurred in a direction which disturbs the function, e.g., pronounced equinus or calcaneus position. Osteotomy and wedge-shaped excisions are here also in place. For bony* an- kylosis at the tibio-tarsal joint with pes equinus, Berend35 and Billroth performed Avedge shaped excision from the tibia—a procedure which had been recommended by Velpeau. Fig. 187.—Reibmayr,s Apparatus for Contractures of the Shoulder-joint. The important ankydoses of the maxillary* joint do not be- long in orthopedics; concerning them, the reader is referred to the recent contributions of Komg, Ranke,36 and Zipfel.37 Contractures and ankyloses at the shoulder-joint may7 re- main as sequehe of various forms of articular inflammation, disease of neighboring structures, etc. Here it is advisable to employ prophydactic fixation in different positions, and early manipulation and massage. Appropriate treatment is of es- pecial importance in children, to avoid the occurrence of dis- turbances of groAvth in the affected region. Reibmayr has devised an apparatus for the clastic stretch- Orthopedics and Orthopedic Surgery. igy Fig. 188.— Flexion of the Elbow joint. ing of ankyloses and contractures of the shoulder-joint which is shown in Fig. 187. The rod b is adjustable in three direc- tions corresponding to the free excursions of the joint; g is the elastic strap Avhich effects move- ment at the peripheral end, Avhile eounter-pressure is represented by the pad Avhich is also adjustable at the main rod a. In severe cases, brisement un- der anaesthesia and, where the muscles are in good condition, eA*en resection may be requisite. Cicatricial contractures (espe- cially after scalds) at the elboAv require appropriate extension dressings, and occasionally7 operative interference (division of the cicatrix, plastic operations) Avhich cannot be discussed in this place; even myogenous contractures, though rare, haA*e been observed. At the elbow-joint, however, the arthrogen- ous contractures and ankyloses are by far the most important, and most frequently require special orthopedic treatment. The degree of contracture or ankylosis is easily recognized under anesthesia. The possibility of increasing the flexion differentiates contractures from ankyloses even without narcosis. In all cases of trauma, or dis- eases of the elboAv-joint, passive moA*ements should not be too long delayed. Where the latter alone are insufficient, Bonnet's apparatus for the mobilization of the elbow is a very* suitable instrument for gym- nastic manipulations and exercises. Liicke's38 apparatus with elastic traction (originally intended for use after resection of the elbow) is also of value, as are those of Reibmay*r (Fig. 188) and Collin (Fig. 158), by* means of Avhich, according to requirement, flexed or extended position may be aimed at or interchanged; similar apparatus are those of Blanc and others. Fig. 189.—Extension of the Elbow joint (Reibmayr). 198 Orthopedics and Orthopedic Surgery. Suitable apparatus may be constructed very readily by applying to the elbow an interrupted silicate of soda bandage with suitable hooks included, to which rubber cords may be fastened for flexion or extension. Splint and clasp dressings, like Bidder's elbow splint, can easily be combined with elastic traction, and Vogt39 justly calls attention to the fact that the hinge should always be applied above the elbow curve of the fore-arm splint. Berthet effects flexion of the elboAA*-joint contractured in extension by7 affixing to fore-arm and upper arm, respectively, tAvo lateral splints by means of circular clasps; they* extend behind more than a hand's breadth beyond the elbow, hinges being applied at the joint and the ends being approximated by a rubber ring. In order to counteract flexion-contracture of the elbow and to enable the patient himself to make passive motions in ex- tension, v. Bruns40 among others has devised a simple appa- ratus which consist essentially of hollow tin splints for the hand, fore-arm, and for the upper arm, respectively, joined by* a hinge at the elbow and fastened to the extremity by band- ages or clasps. At the lower side of the upper-arm grooA*e extends an iron rod with a pulley at its anterior end, which projects beyond the groove for the fore-arm and which can be easily attached to a table by an angular hook with thumb screw. A cord passing from the lower end of the fore-arm splint over the pulley of the iron rod, manipulated by the hand of the sound side, effects extension, while flexion is per- formed by the flexor muscles or the elastic retraction. A similar contrivance has been devised by J. Hoppe. In a number of apparatuses for contracture of the elbow (Kolbe,41 Stromeyer) the position can be altered by a screw thread applied on the flexor side, betAveen the upper-arm and fore-arm splints; in others, like the apparatus of Parone42 and Manget, the screw, by means of which the gutters joined by- two articulating splints can be given any desired position, is applied laterally. More complicated are the appliances of Goldschmid, H. Bigg, and others, in which the two lateral splints, articulating at the elbow-joint, can be given any desired position by a screw hinge, and the upper and fore-arm, fixed in padded con- cave metal sheaths, can thus be held at the necessary inclina- Orthopedics and Orthopedic Surgery. 199 tion to each other. Where the adhesions are very* extensive, brisement force, followed by passive movements, will also yield the most rapid results at the elboAv; where the contracture shoAvs a tendency to recur, this can be counteracted by suita- ble splints with elastic traction. Elbow-joints ankylosed in good position, i.e., at about a right angle, will rarely call for operative interference; but in firm ankydosis in extended position resection is the best pro- cedure for obtaining a movable joint; in bony ankylosis a wedge-shaped excision from the synostotic adherent joint sur- faces will be requisite. Defontaine43 obtained good results in one case by a trochleiform osteotomy. Sayre performs the resection by making a simple straight incision over the joint, exposing the bone by drawing the soft parts aside, and, in order to reach the point of attachment of the triceps, separating first the end of the olecranon, then saw- ing through humerus, radius and ulna; then the extremity is placed in a fixation apparatus and passive movements are soon begun. At the Avrist-joint, as at the foot, various kinds of contrac- tures occur which are termed club-hand (main bot, Klump- hand); but while the lateral abduction and adduction contrac- ture and the rotatory* pronation and supination contractures are of but little practical importance, Ave are most interested in contractures of flexion and extension (dorsal and palmar club-hand). Contractures at the hand are rarely congenital; in such an event they are usually combined with other abnormities (de- fective development of the bones of the fore-arm, webbed fin- gers, etc.). Congenital club-hand is ordinarily7 a contracture in the palmar direction, i.e., an approximation of the volar surface to the flexor side of the fore-arm, at times with more or less pronounced lateral deA7iation. The acquired contractures of the hand are much more fre- quent. They may result from injuries, especially burns, as cicatricial contractures Avhich often give rise to the greatest deformities of the hand, e.g., with fingers completely7 adherent to the dorsal surface of the fore-arm and fixed by* cicatrices; or else, phlegmons, injuries to tendons may cause such deform- ities ; or again they may occur as arthrogenous contractures in consequence of disease of the wrist-joint. The most fre- 200 Orthopedics and Orthopedic Surgery. quent of all the acquired contractures of the hand are proba- bly the paralytic forms, i.e., those occurring as sequelae of Fig. I90.-Congenital Club-hand. Fig. 191.—Traumatic Club- Fig. 192.-Pathological hand, Cicatrix at N. (Neurotic) Claw-hand. infantile paralysis and other diseases of the central nervous system (Fig. 192). Appropriate prophylactic treatment, fixation in a position opposed to the direction of the contracture, passive move- ments, and especially the application of elastic traction may here prove of considerable value. Reibmayr44 among others has devised an ingenious apparatus for effecting alternate ex- Fig. 193. tension and flexion of the wrist-joint and the fingers The apparatus (Fig. 193) consists of a well-padded leather bracelet, a longitudinal rod, a, with detachable frame, b, a rod, d, verti- OrtJiopedics and Orthopedic Surgery. 201 cal to a, and the Iavo racks for affixing the rubber tubes (the latter the thickness of medium-sized drainage tubes, and tied at the ends into a loop). For the protection of the fingers, Fig. 194.—Reibmayr's Apparatus for Flexing the Wrist-joint. i.e., to prevent the rubber tubes from cutting in, Reibmayr uses small tubes of sheet lead. Figs. 194 and 195 show Iioav the wrist-joint may be alter- nately extended and flexed. Similar apparatus can be easily improvised Avith interrupted retentive dressings, articulated splints, and included hooks or rods for the application of the elastic traction. For flexion contracture of the hand, particularly, a number of appliances have been devised. Fig. WS-Reibmayr's Apparatus for Flexing the Fingers. Blanc, for example, utilized the elasticity of a rubber ring for approximating the ends of lever splints, and bringing the hand into a straight position. 202 Orthopedics and Orthopedic Surgery. Gross' apparatus has a dorsal splint fastened to a sheath for the fore-arm which carries at its lower end, over the met- acarpal joints, a transverse rod toward which the hand is drawn by an elastic cord, while a dorsal pad exerts pressure on the region of the wrist. Bruns' apparatus consists of two gutter-like tin splints, joined by a hinge, for fixing the hand and fore-arm, together with an iron rod attached to the dorsal fore-arm splint, Avhich projects bey7ond the wrist, toward which the hand is drawn by elastic cords. In other apparatus, like that of Eulenburg and others, end- less screws and toothed Avheels constitute the adjustable mechanism of the parts Avhich are held together by7 tAvo lateral articulated splints and straps. Similar apparatus, arranged inversely, has been constructed for dorsal contracture of the hand; for instance, by a7. Bruns (who secured perfect cure by its means in a patient the dorsal surface of whose hand lay on the fore-arm, after he had first tenotomized the extensor tendons); it consists of gutters for the fore-arm, upper arm, and hand, united by hinges. From the volar surface of the hand-splint extends a steel arch which is fastened with a screw to a steel rod, provided with an an- terior fissure and extending along the convex side of the fore- aim splint; this renders it possible to maintain the result obtained by manual reposition. In congenital contractures of the hand, manipulations with fixation in the best possible position will quickly* succeed. In the more extensive cicatricial contractures, the division of cicatricial bands, occasionally their extirpation, and transplan- tation of cutaneous flaps, may be necessary; tenotomy* will rarely be required. A wrist-joint ankylosed in good position does not call for operative interference; on the other hand, ankylosis in aggra- vated volar flexion may occasionally require resection and straightening, in order to improve the usefulness of the hand. Finger contractures may also be the result of the most various traumatic or morbid disturbances. Prophylactic treatment will depend on proper management of the causal factors, on passive motion, etc. Apparatus for finger contracture may be improvised very simply by adding suitable prolongations, such as iron rods Orthopedics and Orthopedic Surgery. 203 Fig. 196.- -Collin's Apparatus for Finger Contrac- ture. with notches, to a dorsal forearm splint. Against these rods the contracted finger is draAvn by elastic cords. A further method consists in placing the hand on a board with processes for the seA*eral fingers, pad- ding the contracted finger Avhere it rests on the board, and gradually stretching it by- an elastic cord (rubber band) passing oA*er the ver- tex of the curA'ature. Appliances suitable for the treatment of flexion contrac- ture of the fingers have been devised by Bigg, Goldschmidt and others, in which dorsal splints adapted to the several fin- gers are movable by* endless screAvs at the le\*el of the articu- lations; the phalanges are fastened by elastic silk bands to the splints, Avhich are in turn adjustable on a padded plate surrounding the metacarpus; or they7 may7 be made movable on the dorsal side of a padded tin splint for the fore-arm and hand (Goldschmidt). Schonborn's apparatus for extending contracted fingers consists of a deerskin glove, made to button at the ulnar bor- der, Avhich extends aboA*e the Avrist; into its dorsal part is inserted a steel splint (ten inches long) Avhich, broad at first, narroAvs at the wrist, again Avidens at the metacarpus, and at the contracted finger again narrows into a gutter shape, and surrounds two-thirds of the first phalanx. To this gutter a second covered with leather is joined by a hinge, and it re- ceives the volar surface of the second and third phalanges. It carries two Avire frames, the peripheral one being one and one half inches high, the central one three-quarters of an inch. To the peripheral frame is fastened an elastic band Avhich runs over a friction roller on the hori- zontal portion of the central frame, and is but- toned to a knob on the dorsal splint. Thus the traction acting on the finger depends on the thickness of the band and degree of its tension. Nyrop employs elastic traction in the following manner (Fig. 197): To German silver thimbles, d, provided with a slightly curved dorsal process, / (to prevent slipping of the Fig. 197.—Nyrop's Apparatus for Flex- ion-coiitractur e of the Fingers. 204 Orthopedics and Orthopedic Surgery. elastic cords), are affixed round elastic cords which are fast- ened to hooks on a German silver metarcarpal bracelet, b, Avhile the elastic extension cord from the thumb, e, is fastened to a bracelet, a, situated higher, but connected with the other by elastic material, c, and padded inside with soft leather. Ap- paratus for paralysis of the extensors of the hand and fingers (Collin, etc.) may7 also be found of use (Fig. 198). For finger contractures, Mathieu45 has devised an appa- ratus with volar splint and a pad fastened to a long lever arm intended to bear on the vertex of the curvature, the pressure being graduated by a screw. In fully7 developed cicatricial contracture of the fingers it is adA-isable, as a rule, to operate: to perform subcutaneous discission, detach the cutaneous cicatrix, divide it transA*ersety and unite it longitudinally, making a curved or flap incision, especially a V-shaped incision Avhich is continued in a Y form Fig. 198.—Collin's Apparatus for Extensor Paralysis. (Busch, etc.). In serious cases of cicatricial contracture in the palm, good result may be secured from the transplantation of a pediculated skin flap from the Avail of the thorax, as recently7 recommended by Salzer;46 to take pediculated flaps from parts adjoining the hand can hardly7 be commended, since other parts would be thus endangered. Partial resection may7 also have to be considered in cases of severe contracture. Where the finger contracture is complicated with defect of the tendon, etc., and the affected stiff finger interferes with Avork, etc., exarticulation of the finger will be the most radical procedure, and if conjoined with resection of the correspond- ing head of the metacarpal bone, even the cosmetic effect Avill be entirely satisfactory7. In this connection, Dupuytren's finger contracture, so-called retraction of the palmar fascia (previously* described by Boyer, Bonnet, and others as crispatura tendinum) should be Orthopedics and Orthopedic Surgery. 205 mentioned. It is a flexion contracture affecting preferably the ring and little finger of older persons, which has a ten- dency to increase sloAvly until the affected finger is completely- bent into the palm (Fig. 199). The cause of the affection has been ascribed to repeated traumata, especially in professional Avorkmen (gardeners, car- penters, glaziers, coachmen), and this assumption has some- thing in its favor, particularly- in unilateral cases. Thus a SAvitch-tender ascribed the affection to the A-ibration imparted to the hand on the switch by passing trains; a glazier, to the jarring of the hand from beating the putty7 into the windoAv- frame; others, to the pressure of the head of the cane. Un- doubtedly*, acute and chronic traumata, especially* in thin Fig. 199. Fig. 200.—Dupuytren's Contracture, the Little Finger mainly Affected. hands, have some influence, although I have obseiwed the affection several times in very- fat hands, and it may* occur eA*en in people A\ho only handle the pen (Goy*rand). Heredity* is blamed by* some authors (Menjaud,47 Konig), others assume a certain connection Avith rheumatic and gouty* affections (Adams, etc.). The anatomical alterations48 present in this affection haA-e been studied mainly by Goyrand, Adams, Blum, Kochor, and others; they consist chiefly* in a retraction of the palmar fas- cia Avith connective-tissue proliferation; trabecular springing from the fascia fix the finger in the peculiar position and leave only7 the third phalanx invariably* free; at times there are curved extensions toward the neighboring fingers. The flexor tendon has nothing to do Avith this retraction, though it is easy to mistake the prominence in the vol a formed by* the contracted fascia for one due to the tendon. 206 Orthopedics and Orthopedic Surgery. The symptoms of the affection at first consist merely7 of slight restriction of extension, especially of the ring or little finger, some tension on the A*olar side interfering with com- plete extension; at times rheumatic pains are present in the beginning, or nodal thickenings are noticed in the palm which cause adhesion of the previously* freely7 moA7able skin. Grad- ually* the finger assumes a contracted position, the flexion affecting- the phalango-metacarpal and the first interphalan- geal joint, while the second interphalangeal joint is neA*er attacked. By* degrees we may notice in the palm a projection, appar- ently formed by the tendon, over Avhich the skin extends in an arched fold which is adherent below (Fig. 199). The condition occasionally remains stationary in degree, but usually7 it is progressive, and leads to the firm flexion of the affected (ulnar) fingers into the palm, thus interfering more or less with func- tion. The diagnosis is simple: the predominant affection of the ulnar fingers (in very- rare cases only is the index finger or thumb mentioned as implicated), the exemption of the second interphalangeal joint, the characteristic alterations in the skin of the palm, these points permit the ready differentiation of the affection from others. Mechanical treatment, as a rule, cannot accomplish much, except, perhaps, in mild cases at the outset. Pronounced cases require operatiA*e measures. Tenotomy* here, of course, Avould be a faulty- procedure; division of the tense prolonga- tions of the palmar fascia will remove the deformity7 in the majority* of cases. Subcutaneous discission, especially* multi- ple (Adams), of the trabeculae has given quite satisfactory re- sults in several cases. Where the retraction is very great and the skin greatly adherent, it would be good practice, in order to avoid laceration of the skin during extension, to select a more thorough procedure which will be free from danger if performed antiseptically (best by Esmarch's bloodless method), viz., either transverse division of the trabeculae, through a longitudinal incision (Goyrand, Hardie49) or the formation of a square flap (Richet). Busch's method may be most warmly recommended: a triangular flap, its base directed toAvard the fingers, is dis- sected off at the point of retraction, and Avhile the finger is Orthopedics and Orthopedic Surgery. being stretched the tense bands are divided until extension can be completed, when the Avound is united longitudinally*. Gersuny7 and Kocher50 have operated successfully7 in sev- eral cases by making simple longitudinal incisions and dis- secting off the skin from the thick, firm, projecting bands, and then excising the palmar fascia with its processes so far as it is diseased. They* therefore recommend the thorough extirpa- tion of the thickened and contracted palmar aponeurosis with its processes, after simple longitudinal incision of the skin, as the correct method for the radical cure of Dupuytren's con- tracture. II. Genu Valgum and Varum. Under the term genu A*algum (knock-knee) is understood that deformity* Avhere the bones of the legs form with that of the thigh an angle opening outAvard, or, in other Avords, where the knee projects inward from a line draAvn from the head of the femur to a point midAvay* betAveen the malleoli. Genu valgum is an abduction contracture, as is well shown in Fig. 204. This deformity is rarely congenital (Dittel, etc.), but, as- a rule, forms Avhen the child begins to Avalk. Formerly genu \7algum rachiticum Avas distinguished from genu valgum staticum or adolescentium (Fig. 202) AAdiich first appears in infancy. Mikulicz first suggested that the latter form Avas also usu- ally7 of rachitic origin, and therefore it is preferable to speak of genu valgum rachiticum infantum (Fig's. 42, 201), and of genu A*algum adolescentium. The deformity appears with greatest frequency* betAveen the ages of tAvo to four, or later between the ages of twelve to eighteen in the male. Bakers, carpenters, Avaiters, etc., or men avIio are obliged to stand most of the time, are peculiarly7 lia- ble to be affected. Rarer A*arieties of genu valgum are those which folloAv on congenital luxation of the patella (Maas, Middeldorpf), that which is of paralytic or traumatic origin (Seydel, Mikulicz) and that which results from disease of the joint, the so-called genu valgum inflammatorium (Volkmann, Maas, and others). Various degrees of knock-knee have been distinguished. As a rule, the degree may7 be accurately enough measured by 208 OrtJiopedics and Orthopedic Surgery. the ey-e. For more careful estimation Tillaux, Roberts, Mi- kulicz and others, have devised special instruments. Ordi- narily the tape measure will enable us to note the amount of deviation from the correct line. We thus may7 obtain the dis- tance b in (Fig. 204), from the line A c (Fig. 203) AA*hich extends from the head of the femur to a point midAvay* between the malleoli. The angle which the leg makes with an ideal line extended from the femur will also serve for measurement. However obtained, the leg must be extended, the patient Fig. 201.—Genu Valgum Rachiticum Sin. Fig. 202.—(ienu Valgum Adolescentium. standing or reclining, and the measurement must be made in the anterior plane of the leg. Formerly the cause of the deformity* Avas sought in the ligaments and in the knee joint. More recent investigations haA*e proA*ed that it resides in the bones themseh'es. The ligamentous theory, Avhich Avas advocated by* Stro- meyer, Guerin, and Blasius, maintained that first the internal lateral ligament became relaxed, and that next the internal condyde hypertrophied; the muscular theory* sought the cause in a retraction of the biceps muscle, in a paralysis of the pop- hteus muscle, etc. This view was held by Jorg and by* Duchenne. Orthopedics and Orthopedic Surgery. 209 The articular theory* of Hiiter stated that the cause of genu valgum staticum resided in the form of the condyles, that is to say*, it was claimed that the articular facet of the external condyde of the femur Avas abnormally7 deepened by7 pressure of the semilunar cartilage, and that the condyles of the femur and of the tibia remained relatively too Ioav from lack of de- A*elopment. It is to-day established that the cause of knock-knee resides in changes in the bones. While formerly the partially erron- eous view prevailed that the chief alteration Avas hypertrophy, leading to abnormal height of the internal condyle of the femur or else levelling of the external condyle (usually sec- ondary in nature), the anatomical researches of Mikulicz, Weil and others, have proved that the first changes are to be sought to a less degree in the epi- physeal ends than in the diaphyseal, especially the loAver diaphysis of the femur, and further that genu valgum in children depends on the fact that the epiphyses of the femur or of the tibia are set obliquely on the diaphyses as the result of rachitic change in the diaphysis (un- equal impregnation Avith lime). Neudorfer claims that the most frequent cause of genu valgum is diminished obliquity of the neck of the femur in relation to the shaft. This mav occur Avithout rachitic changes and is , -, Figs. 203 and 204. rarely congenital but almost always acquired. The post-mortem findings have certainly at times revealed lengthening of the internal condyle of the femur, but this was secondary in nature (Chiari, Gueniot, Lannelongue, and others). An essential alteration in the profile curve has, how- ever, not been determined. Usually more or less marked rachitic changes have been found. The affected bones have been abnormally soft; in half-grown children the epiphyseal ends have been considerably broadened, especially at the ex- pense of the germinative zone. Occasionally the process of growth near the epiphyses has been unequal in degree, and there has existed an abnormal curvature of the entire diaphy- seal end. The cartilage of the joint is occasionally found in a state of atrophy on the outside, while internally it is hyper- trophied. 14 210 Orthopedics and Orthopedic Surgery. The changes are, as a rule, most marked at the end of the femur, rarely- at the upper extremity of the tibia. In aggra- vated instances the patella is 'occasionally found pushed out- ward. In old age arthritis deformans may be an accompani- ment. A predisposing cause of genu valgum is abduction and outAvard rotation folloAving on extension. Abnormally con- tinuous extension position, particularly7 Avhere the bones are rachitic, leads to unequal pressure and to disturbances in groAvth. There can be no question but that in tired individ- uals Avith Aveak muscles, prolonged extension of the limbs results in changes in the bones, and the prolonged unequal pressure is folloAved by unequal groAvth. Therefore genu val- gum adolescentium is also static in source, even though rachi- tic changes ordinarily are the prime cause. Mechanical causes may also apparently* be influential in the production of knock-knee. Liicke51 has claimed that the elastic stocking supporters worn by children may*, in case the general nutrition is poor, lead to genu valgum. The symptoms of knock-knee are a greater or less imvard position of the knee, an outward projection of the lower limb, and a varying degree of separation of the feet. These phe- nomena may be uni- or bi lateral. When the limb is extended the angle formed betAveen the tibia and the femur becomes especially marked. A characteristic point is the fact that on flexion of the limb the deformity* disappears. Various ex- planations of this fact haac been offered. Hueter and Girard claim that the reason is the shape of the condydes of the femur; others belke/ve the fact due to compensation by out- ward rotation of the hips; Mikulicz and Albert52 are probably* right in their assumption that the disappearance results from the obliteration of the anterior plane of the tibia and the femur Avhen the knee joint is flexed. In marked instances of knock-knee the walk of the indiA*id- ual is more or less altered. In case of unilateral genu A'algum the shortening is compensated by7 sinking of the pelvis. In aggravated bi-lateral instances the X-shaped limbs contin- ually interfere. In consequence the individual keeps the knee flexed and the hips are rotated outAvard, in order that the knees may7 as far as possible not strike one another. The subjecttve symptoms are diminished power of resistance to Orthopedics and Orthopedic Surgery. 211 labor and fatigue. Where the muscular system is weakened the symptoms are more pronounced, especially if the genu valgum is complicated, as it not infrequently is, by pes valgus. In case of unilateral genu A-algum a skoliotic curvature of the spinal column often deAelops, beginning as a lumbar skoliosis in the direction of the shortened limb. The symptoms noticeable from the side of the knee, espe- cially* in children, before any7 marked deformity exists, are pain on its inner side, inability* to stand for a long time, etc. These symptoms will frequently suggest irritability of the joint due to an inflammatory process. In individuals in whom the musculature is not Aveak, there frequently* deA7elops a compen- satory supination, that is to say, the muscles opposed to those which keep the foot abducted and pronated resist and abduct the foot, so that, notwithstanding the oblique direction of the loAver limb, the foot is planted firmly on the ground. Only* in case of infantile genu A*algum is the deformitA* likeh* to become rectified. As a rule, Fig.20o.—Locomo- genu valgum, especially in y*outh, has a pro- tion in case of Genu gresstve tendency* up to the tAventieth year,- Valgum. Avhen the groAvth of the bone being completed the deformity remains permanent. Occasionally7, hoAvever, a similar result occurs earlier, and this is to be explained on the assumption that the yielding bone has consolidated. In general, treat- ment is most effectiA*e the earlier in the disease it is instituted. Knock-knee of long duration calls for most radical methods of treatment. The prognosis is A*ery unfa\*orable in chronic cases Avhere arthritis deformans has developed, and in such an event the limb may become entirely7 useless. The treatment of genu valgum varies greatly* according to the degree and the age of the patient. It is sy7mptomatic of progress in our art that an affection Avhich no longer than fifty years ago Avas considered incurable, aside from its occur- rence in young children, to-day7 may be looked upon as almost uniformly7 curable by7 one or another of the methods at our dis- posal. Infantile genu valgum must be considered separately, seeing that it rarely* requires operative measures, but may be cured through resort to orthopedic devices and apparatus. 212 Orthopedics and Orthopedic Surgery. The treatment of genu \*algum must subserve tAvo pur- poses: It must restore normal function to the affected extrem- ity, and it must fulfil the esthetic indications, that is to say, give the limb the natural appearance. The simple section of the external lateral ligament, of the tendon of the biceps and correction of the curA*ature in the middle of the lower extremity Avill not alone suffice (Mikulicz). There are tAvo methods at our disposal: the one is the gradual and the other is the forcible correction of the deformity. The first is especially applicable to the deformity in children, and the aim is secured by appa- ratus and orthopedic appliances. The second method is pref- erable in case of adults and particularly in case of dispensary patients, avIio can neither spare t he time required by mechani- cal treatment, nor afford the expense of apparatus. For this class of patients the operative measures, of which more than a dozen have in modern times been suggested, are suitable. In case of bilateral genu A*al- gum of slight degree, one of the simplest methods is the use of a cushion (Fig. 206), AA*hich is fast- fig. 206.-Heine^conicai Cushion. encd betAveen the knees and then, by7 elastic traction over the ankle joints, the feet are draAvn together. This method may* be readily* resorted to at night. A further simple method is Langenbeck's, Avhich consists in making traction on the knees outAvard. This method, hoAv- ever, is open to objection on the score that it Aveakens the ligaments and it is therefore not used much noAvaday-s. We may* di\*ide the appropriate apparatus into those Avhich the patient may* Avear and attend to his occupation, and into that Avhich necessitates rest in bed. Of the latter variety* the simplest of all is an elastic traction splint (Tuppert, etc.), placed on the outside of the extremity, to which the knee is strapped. In children this method is open to the objection that the splint is apt to slip from outAvard rotation and flexion of the knee, and therefore quickty becomes useless. It is pref- erable, hence, to immobilize the pefvis and the foot at the same time, and Avith this end in view the Say*re-Wolf coxitis splint may, among others, be resorted to. This is the method advocated by7 Neudorfer. Orthopedics and Orthopedic Surgery. 21 $ J. v. Heine53 has described a number of useful orthopedic apparatuses for the correction of genu valgum. Among others Ave note the f olloAving: He applies a plaster bandage to the limb extending from the toes to the perineum. He im- beds in this on the outside of the limb, above and below, iron stirrups, the lower one carrying a small wheel. An elliptical piece is cut from the bandage on the inner side at the knee, and a splint is adjusted on the outer side of the limb. There is a, groove in this splint in which the Avheel fits, Avhen the knee is drawn against the splint. Rotation of the lower ex- tremity is impossible when this apparatus has been adjusted, Fig. 207.—Heine's Plaster Band- Fig. 208.—Heine's Apparatus for the Treatment of age, with Splint. Genu Valgum. and gradual redressement of the deformity* is attained. The apparatus in position is shoAvn in Fig 207. A second method of treatment requires rest in bed. The patient is placed on the side, one leg is bent out of the way, and the other is straightened against a conical cushion which rests behind the knee. Pressure is exerted over the malleolus by a screAV-mechanism Avhich is attached to the foot of the bed. The pelvis is firmly strapped doAvn. The pressure ex- erted by the screAv is at the outset gradual, and is increased as the patient becomes accustomed to the position. Fig. 208 amply explains the procedure. The special apparatus which, for eA-ident reasons, is only applicable to older children and adults, consists, ordinarily, of tA\*o longitudinal steel bars, Avhich articulate at the knee and are provided with mechanism by means of which abduction 214 Orthopedics and Orthopedic Surgery. is possible. The upper and the loAver extremities are immo- bilized by straps and a suitable knee-cap controls the knee. The entire apparatus is attached to the pelvis by a pelvic band, and it articulates below with a special shoe. Apparatus of this nature may be worn in walking, and the deformity is gradually overcome by screAv pressure. Heine, Lonsdale, Beely and others have perfected such apparatus. A further variety of apparatus utilizes the inner projecting side of the knee as a fulcrum, the loAver portion of the extrem- ity being draAvn against a horizontal splint, placed along the inner side of the limb. Hester, of Oxford, has devised appara- Fig. 209.—Apparatus for Bi-lateral Fig. 210.—Hester's Genu- Fig. 211.—Tuppert's Genu- Genu Valgum. A7algum Apparatus. A7algum Apparatus. tus of this nature, and it has been modified by Heather Bigg. It consists of tAvo arms of a lever united at the level of the internal condyle of the femur by a ring, the whole having the shape of the normal ext remity. The upper portion is strapped to the thigh, while the inferior portion of the extremity- is drawn to the loAver part of the apparatus by* Avell-padded straps as firmly as the patient can bear. Apparatus Avith articulated joints may* quickly* get out of order, and the non-articulated is therefore not alone simpler but also more effective. Tuppert's54 apparatus (Fig. 211) may7 be recommended as very simple for the treatment of knock-knee in adults. It Orthopedics and Orthopedic Surgery. 215 consists of a flexible rod, one and one half inches broad, and about an inch thick, and the ends of Avhich are inserted into brass plates. The plate for the femur is larger than that for the lower extremity, and they are strapped to the limb as shoAvn in the figure. By means of a knee cap, the knee is drawn to the rod, the elasticity of Avhich tends to restore the normal position to the limb. During the first fortnight the patient must sit or recline; thereafter he may Avalk around, and, as a rule, the deformity* is overcome in from four to six Aveeks. At the end of tAvo to three months the apparatus may be remoA*ed. For the treatment of genu A*algum infantilis every appara- tus is open to objection. Landerer's method of elastic trac- tion may* be considered the simplest. It exerts a continuous pressure on the internal condyle, thus checking the tendency7 to excessfve growth, and it removes pressure from the exter- nal condyde. The extremity has thus an opportunity* to re- turn to the normal curvature. The method consists in the use of tAvo fan-shaped pieces of plaster, connected together by an elastic band. One piece is applied to the inner side of the thigh, and the other to the inner side of the loAver extremity, the elastic band betAveen the two being stretched, and the limb is then bandaged. Children may play around Avhile Avearing this apparatus and the pain caused by* the exerted tension soon abates. In cases where the deformity is slight, the bandage need not be changed often; in cases of a higher grade, Avhere the angle formed is 145° to 155°, four applica- tions are requisite, or tAvo to three months' treatment is needed. Only in the most aggraA*ated instances do six to nine months elapse before the deformity is overcome. In Fig. 212 is repre- sented a case of genu A*algum in a female infant of free years, AA*ho was first treated by Tuppert's splint, and on account of rotation this had to be removed. Landerer's method Avas then resorted to, and in four months the case Avas cured (Fig. 213). For dispensary* treatment of children, the plaster bandage is useful. The child should be anesthetized and the deformity- is corrected manually as far as possible. A plaster bandage is then applied, the knee being pressed outward. After the lapse of a few weeks the bandage is removed, the deformity further corrected, and a second bandage applied. A point on which stress must be laid is the necessity of placing a com- 216 Orthopedics and Orthopedic Surgery. press on the thigh above, and below on the lower extremity7, under the plaster bandage. In older children and in adults, the plaster bandage asso- ciated with elastic traction, is a useful method for gradual correction of the deformity. Mikulicz55 applies a plaster bandage to the limb in its pathological position. An articular anterior and posterior iron splint is imbedded in this bandage, as also t\vo stout hooks on the inner side of the thigh and of the lower extrem- ity. After the bandage has hardened a wedge-shaped piece is cut out from the inner side at the level of the knee, and on the outer side at the same level the bandage is cut transversely. Fig. 213. The two portions of the bandage are then simply held together by* the points of the splints. An elastic band or a spring is next attached to the hooks, and the deformity is gradually* overcome by the tension. In moderate instances of genu A*al- gum Mikulicz, as a rule, succeeds in a few weeks. (Vide Fig. 214.) Vogt56 has essentially modified Mikulicz's method. He uses either the silicate of soda or the leather bandage, and I am in the habit of following his procedure in my7 clinic. The differences between Mikulicz's and Vogt's procedures are apparent from a comparison of Figs. 214 and 215. Hiiter advocates applying the plaster bandage Avith the limb flexed, since thus he obtains diminution of the unequal pressure. He has in this Avay reached excellent results in Orthopedics and Orthopedic Surgery. 21 y cases of rachitic genu valgum, especially when the knee was drawn out Avar d during the application of the bandage. Other observers (Konig, Waltz), however, have not had the same results from the method. If noAv Ave consider these various mechanical methods of treatment of rachitic genu valgum we find that, aside from many objections to which they7 are open, they7 often require a protracted application and the final result is frequently unsatisfactory7. For these reasons the aim has been to deA*ise methods more rapid in action. Tenotomy* of the biceps, and section of the external lateral ligament have been in vogue for a long time, and after these methods the Fig. 214.—Mikulicz's Plaster Bandage. Fig. 215.—Vogt's Plaster Bandage with Elastic Traction. deformity has been overcome to a greater or less degree. Delore5T as the result of 200 observations has ekwated rapid correction (redressement brusque) into a recognized method of treatment. It has frequently been resorted to successfully in Billroth's clinic, and Mikulicz5S recommends it in cases of genu A*algum infantilis where the desire is to avoid protracted treatment. By this method the epiphysis is fractured and the external ligament is torn from the loAver end of the femur. FolioAving Delore's method, the patient lies on the deformed limb and is anesthetized. The trochanter is utilized as the fulcrum, and the loAver limb is held by an assistant. The pro- jecting internal condyle is struck sharply7 until the deformity is overcome. Mikulicz claims that repeated attempts at re- 2i8 OrtJiopedics and Orthopedic Surgery. dressement will giA*e more certain results, seeing that [thus there occurs gradual separation of the epiphysis. Tillaux59 places the internal condyle on the edge of a table as the fulcrum and uses the Ioavci- extremity as the lever, straightening out the limb at once. From three to six weeks thereafter a fixed dressing must be worn. Vogt's60 researches have proved that the fear of disturb- ances in growth, etc., after the above separation of the epiphy- sis is unfounded. While Schede, Maas, and others recommend such measures only in case of small children, Gussenbauer ap- plies them as Avell in the treatment of genu A*algum in adults. Next to manual reduction of the deformity7 we must con- sider instrumental measures, or osteoclasis by* means of spe- cial apparatus as practised even by Hilppocrates, P. v. Aegina, and others. For this purpose Ave may use the osteoclasts Fig. 216.—Rizzoli's Osteoclast for the Treatment of Genu Valgum. devised by Rizzoli, Bruns, Volkmann, Beely*. Especially7 brill- iant results ha\*e been obtained from Robin's instrument.61 Collin's instrument (Fig. 36) received the prize of the Paris Academy*. Pousson claims that osteoclasis is an effective and a safe method of curing genu \*algum. In all cases of considerable genu valgum in old children or in those in whom the bones have already* hardened and where gradual treatment Avould require too much time, or cannot be instituted owing to the social condition of the pa- tient, the surgical methods of treatment must be considered. Especially is this the case about the twentieth year when the epiphyses haA7e become ossified and wdiere in consequence re- sults can only be obtained through resort to operation. In these days of careful antisepsis the surgical methods are safe and in a few weeks cure is complete. Anesthesia and Es- march's bandage materially lessen the difficulty of the opera- tion. Orthopedics and Orthopedic Surgery. 219 Ogston's operation62 (1876) of osteoarthrotomy7 or condyl- otomy7 with the saAv, although, Avhen performed antiseptically-, it appeared rational, has to-day* been replaced by better methods OAving to the fact that it is based on the false premise of greater length of the internal condyde. Ogston operated as folloAvs: After careful disinfection of the field of operation and with careful antisepsis, the knee Avas sharply* flexed and a slender knife about tAvo and one half inches long- Avas inserted obliquely7 above the internal epicon- dyle doAvn to the bone. On withdraAval of the knife the tis- sues down to the knee Avere cut. An Adams' saAv was next introduced into the opening and the internal condyle Avas saAvn obliquely7 from in front backward. The deformity was then if// iff a. 6 Fig. 217.—Ogston's Operation for Genu- Valgum. a, Schematic Representation of the Deformity; x, Point of Entrance of Saw; b, Limb after Correction. forcibly corrected, and the limb Avas encased in a firm dress- ing. Although in about 300 operations, performed, among others, by Nussbaum, Thiersch, Kolaczek, Sprengler, Partsch, Barde- leben, Graeff, and others, a straight limb with movable joint was obtained, there occurred still instances Avhere the opera- tion was accompanied by much hemorrhage or was followed by* suppuration (Sonnenburg, Schonborn), paralysis of the peroneus muscle or partial ankylosis. The operation has also been followed by7 death (Graeff, and others), and therefore not only have Konig, Volkmann, Mikulicz, and others characterized the method as a faulty* one, but Ogston himself has rejected it for MacEwen's osteotomy.63 In 1879 Reeves endeavored to avoid certain of the accidents likely to follow Ogston's operation (such as the breaking off Fig. 218.—a, Genu Valgum in an Adult Before Ogston's Operation; 6, After this operation. 22G Orthopedics and Orthopedic Surgery. of pieces of the saw in the joint) by performing condydotomy7 Avith the chisel. After making a small incision through the skin and the periosteum above the most projecting portion of the internal condyle, he applied the chisel obliquely to the bone and struck it in an outAvard direction. He next chiselled backAvard a trifle and then straightened the limb. After the lapse of two wreeks he applied a permanent bandage which was Avorn from six to eight weeks. The more the cartilage is aA*oided in the operation the more certain the result. From Mikulicz's observations osteotomy of the bones im- plicated in the formation of genu valgum is to be preferred to an operation on the joint. The supracondylar osteotomy7 of MacEwen,64 is a simple operation and more certain in result. This operation avoids the epiphysis, the joint and the liga- ments; the wound under antiseptic precautions unites by* first intention; the method is not dangerous and it ansAvers in its aim most correctly to our vieAv of the pathology7 of genu A*al- gum; it is further applicable to the majority of instances of the deformity. MacEwen operates as folloAvs: The patient is anesthetized and Esmarch's bandage is applied. The limb is thoroughly- disinfected, laid on a sandbag and held firmly7 under the spray, and with a sharp-pointed knife a longitudinal incision is made a finger's breadth over the upper border of the internal con- dyle, and one and one half inches in front of the tendon of the adductor magnus. This incision is continued doAvn to the bone and is made large enough for the introduction of the osteo- tome or even, at times, of the finger. The bistouri acts as a guide for the osteotome; the former is Avithdrawn and the latter is placed transversely to the bone, and is carefully* driven in until it reaches the posterior border of the bone. The osteotome is next directed from before backAvard against the external and posterior edge of the femur. In case of soft bones it suffices to divide the bone for tAvo- thirds of its thickness. Where the bone is hard and brittle the section must extend just under the superficial compact layrer and the remaining bridge of bone must be sloAvly* frac- tured while a carbolized sponge is pressed against the Avound. The limb is dressed antiseptically on a long lateral splint, and this dressing is not disturbed for a few days, unless the tem- perature rises above 38° C. OrtJwpcdics and OrtJiopcdic Surgery. 221 This method has been resorted to by Schede,65 Maas, Tren- delenburg, Schonborn, Brims,66 Willet, and they have almost uniformly7 obtained good results. A number of deaths have still been reported by MacEAven, Hofmokl, Schede; neverthe- less this operation is t o be commended in ninety* cases out of one hundred and Middeldorpf67 justly calls it the operation of future. In performing MacEAven's operation Poore68 bends the knee at a right angle, since thus he is better able to determine the mid-line, the extremity- can be held to better advantage, and Avhen the limb is straightened after the operation, the skin co\*ers the wound in the muscles. Reeves, Gussenbauer, Czerny* and others haA-e recommended Fig. 219.—Genu Valgum Be- Fig. 220. rection of Deformity (MacEwen); d. Correction fore and After Operation. after Incision in the Outer side. and performed supracondylar osteotomy on the outside of the limb. MacEwen's operation has, hoAveA7er, been most fre- quently performed. MacEAven has done it 820 times; it has been resorted to about 1,384 times in England, and of this number ten died, although only three succumbed to the oper- ation. In Germany also the operation has found great favor. MacEAven claims for his method that the defect in the bone made by the osteotome is filled in when the limb is straightened, and that only in the Avorst cases is the bone slightly fractured on the outside and this is covered by the periosteum. Where the section is made externally, however (Fig. 221), a greater cleft results, and this is filled in more slowly. Further, he thinks that the latter method entails greater injury to the soft parts, in which the femoral artery may be involved. 222 OrtJiopedics and Orthopedic Surgery. Osteotomy through the diaphy7sis is certainly the simplest operation, ydelds very good results, and avoids a number of untoward sequelae common to other methods. It is recom- mended by* Billroth, Neudorfer, Reeves.69 It is performed by repeated boring through of the bone through an external incision midway between the middle and lower third of the femur. Reeves resorts to it without anti- sepsis or Esmarch's bandage; Billroth selects the site one and three-quarter inches above the condydes; Neudorfer uses the chisel Avithout previous incision. The limb is bandaged and Fig. 222.—Genu Valgum. MacEwen's Opera- Fig. 222 a.—Condition of the Limbs Six tion on the Left, Orthopedic Treatment on the Weeks After Beginning of Treatment. Right Side. Left Leg Straight. this is ordinarily only changed after consolidation of the bone, that is, in from four to five Aveeks. If after correction the extremity is not as long as the other, then extension must be applied. We are dealing indeed Avith a simple fracture of the femur, which frequently unites with slight dislocation, the upper fragment projecting outward an- teriorly. Osteectomy on the femur is somewhat more complicated. In general, the wedge-shaped excision at the inner condyle has found but feAv adherents. Orthopedics and Orthopedic Surgery. 223 This operation, as described by* Chiene,70 is performed as folloAvs: An incision from tAvo to three inches long is made parallel to the long axis of the bone, beginning one-half an inch below* the tubercle of the internal condyle and extending aboA*e it. On incising the fascia, the tendon of the adductor magnus is laid bare. The wound is extended between this tendon and the fibres of the \7astus internus, the arteries are ligated and se\*ered. A cruciform incision is made into the periosteum and this is pushed up till the bone is exposed. A Avedge-shaped piece is next removed Avith the chisel and ham- mer from the base of the condyle, just above the tubercle Avhere the tendon of the adductor is inserted. The breadth of , the Avedge varies according to the degree of / / deformity, its long axis extending doAvmvard Xr.\............I , and outAvard toAvard the intercondydoid ( \\ \ groove. The Avedge thus lies on a higher V_^X_/ level than the epiphyseal line and its apex (^mT ^~X may reach this. ..\r^-^=/ ) MacEAven,71 Mazzoni, and others chisel the \ h J Avedge outside of Ogston's line (Fig. 223, a), '' ' its apex lying in the cartilage of the joint. fig. 223.—Genu Vai- rrjie :om£ js no^ opened, and on correction the gum Operations. a. ° MacEuens; b, Annan- inner condyde is not fractured, but only* dale's; c, Schede. pushed up. MacEwen, however, rejects this procedure on the ground that it is difficult of performance and uncertain in its results, compared Avith his linear oste- otomy-. From his experience with genu A-algum Neudorfer has per- formed and recommended osteotomy7 across and beloAv the trochanter, and this is less risky than osteotomy of the dia- pfysis of the femur, Avhere the canal of the bone is opened. Operations on the tibia were performed at an earlier date (Mayer and others) than those on the femur, and where the chief deformity involves the tibia (as in rachitic instances) such operations are the most rational (Mikulicz). Linear (subcutaneous) osteotomy- is performed after Billroth as folloAvs: Under antiseptic precautions a transverse incision one-half an inch long is made with the chisel, three-quarters of an inch beloAv the spine of the tibia, extending through the skin and the periosteum. The compact portion of the outer surface of the tibia is then cut transversely, and the rest of the bone is 224 Orthopedics and Orthopedic Surgery. fractured. The limb is dressed antiseptically and a plaster bandage is either at once applied and left for three to five weeks, or else this bandage may be put on at the first change of dressing. Mikulicz,72 Gussenbauer, Volkmann, Middeldorpf, and others have reported numerous cases treated after this fashion. Schede performs wedge-shaped osteotomy of the tibia and linear section of the fibula, an operation which Volkmann, Maas, and others also favor and which, in rachitic cases, Avhere the deformity* involves chiefly7 the bones of the loAver extremity, is to be preferred to others. In the case represented in Fig. 42 a straight limb was hereby obtained. Konig makes a longitudinal median incision, about three and one-half inches long, through the skin and the periosteum, beginning one-half an inch below the spine of the tibia. A second incision is then made transversely and at right angles to the first, overlapping to a degree the lateral border of the tibia. The triangular skin and periosteal flaps are retracted and the periosteum from the inner and the outer ends of the incision is loosened. A sufficient Avedge is then removed with the chisel to overcome the deformity, and it is essential to cut entirely through the lateral Avail of the tibia. The wound is sutured, dressed antiseptically, and as soon as consolidation has occurred Konig allows his patients to walk. From six to eight Aveeks are required for union and six months before com- plete restoration of function. For the great majority* of cases the varieties of osteotomy suggested and resection as performed by* Bauer, Annandale73 and others are only of historical interest. Under the term genu varum (genu extrorsum, Sabel-Bein, genou en dehors, boAv leg) is understood the opposite condi- tion to genu valgum. It is an adduction contracture of the knee-joint. The knee deviates outward from the normal line of the leg (ac, Fig. 224). The essential seat of this deformity is almost never in the knee itself. The lower end of the femur may* be alone affected Orthopedics and Orthopedic Surgery. 225 or the curvature may invoh*e a greater extent of the limb, in particular the upper portion of the tibia, Avhich is often also curved anteriorly. Rachitis is here also the etiological cause, and genu varum cannot be sharply differentiated from rachitic deformities of the loAver extremity, for both are usually asso- ciated, and genu varum is caused by* a rachitic bending of the bone near the knee-joint. Genu varum is chiefly7 met Avith in children. It may be unilateral or bilateral, and in the latter eA*ent the legs form an arc. Very ex- ceptionally genu valgum of one side is associated with genu varum of the other (Fig. 225). The anatomical changes are those which are characteristic of rachitis. The lower end of the femur may be de- veloped at the expense of the external condyle, the line of the knee-joint ex- tending obliquely from within outAvard. The external ligament is stretched; the internal lateral ligament is tense; the essential seat of the process is in the bones, the tibia being curved to an angle opening inward (Fig. 225)—a cur- A7ature Avhich can rarely* be considered as due to infraction, but rather to dis- turbances in groAvth at the diseased epiphyseal line. In addition the diaphysis of the bones of the lower extremity is characteristically flattened out. The symiptoms of genu varum are, in addition to the dimin- ished height of the individual, the hideous method of walking with the outAvard curA7ature of the region of the knee. Secur- ity in progression is not so much affected as it is in case of genu valgum. The treatment in the initial stage in children consists in forbidding walking in order to spare the soft bones the effects of pressure. As soon as the deformity7 becomes evident, manual correc- tion and fixation by7 a suitable apparatus are indicated. These aims are best fulfilled by* applying an internal lateral splint thoroughly* padded near the internal malleolus, and by making elastic traction on the knee against the splint. 15 Fig. 225.—Slight Genu Varum of the Left Extremity and Genu Valgum of the Right in a 17-year- old Rachitic Subject. 226 Orthopedics and Orthopedic Surgery. For older children a variety of apparatuses is at our dis- posal. The essential of the majority is a splint against which the extremity rests, the knee being drawn toAvard the splint. In other apparatus the point of greatest curvature is used as the fulcrum, and the lower end of the leg is draAvn against an external splint. In bilateral genu varum of slight degree, a stout cushion may be placed between the feet and the curA*ed extremities may* be drawn together by elastic traction. The apparatus for ambulant treatment consists of tAvo iron blades fitted to the shoes, Avith a joint at the knee. Against these blades the knees are held by elastic traction; or else the loAver extremity may- be gradually straightened by the action of a spring splint fastened to the leg. Complicated apparatus, such as that of Heather Bigg, is open to objection, and the tendency7 in case of much deformity is to resort to operation. At the age of about two y*ears and under, as a rule, the leg may- be straightened manually7, under anesthesia, and if a suitable fixation apparatus be then applied, and anti-rachitic remedies administered, the result will ordi- narily- be a permanently- good one. In older children forcible! straightening (Delore) or else osteoclasis (the fracture of the bones, usually7 at the upper third of the lower extremity-) are measures to which we may resort. Where the deformity- affects chiefly- a single bone, such as the tibia, and this bone has sclerosed, that is to say, the rachi- tic process has become cured through sclerosis, then manual straightening is no longer to be thought of, and the instru- mental means at our disposal find their application. A simple linear osteotomy* (Langenbeck), performed pre- ferably- Avith the chisel, as a rule w*ill suffice to straighten the limb, and only in case of great deformity is it requisite to re- sort to a Avedge-shaped osteotomy7. In Fig. 226 is represented a case of Middeldorpf s where lie performed linear osteotomy7 on the tibia of a patient aged nineteen, and removed a wedge from the fibula. The result is shown in Fig. 226 b, the cure being complete. In exceptional instances, the deformity7 is so great that repeated osteotomies are called for. MacEAven74 records a case where osteotomy Avas performed ten times before the limb was straightened. Theoretically7, where the tibia is curved, its outer side should Orthopedics and Orthopedic Surgery. 227 be incised and chiselled and the inner side should be fractured, but it is simpler to cut the inner superficial portions together with the external wall of the tibia, and the fibula must also be chiselled in case it cannot be bent or fractured. Resection, in case of genu varum, as performed by How*se,75 is scarcely7 indicated. The rarest form of deformity of the knee is the genu re- curvatum. The condition here is one of hyperextension, the thigh forming with the loAver extremity an angle opening for- Avard. This deformity7 may* be congenital (Kleeberg, Chata- lain, Maas, and others), or acquired from inflammatory (tabetic affections of the joint,Westphal and others) or due to traumatic Fig. 226 a.—Genu Varum. Fig. 226 b.—The Same After Fig. 227.—Genu Re- Osteotomy, curvatum. cause. Usually this deformity is of paralytic origin (Hitter), the movements of the joint not being limited by the normal muscles, and the ligaments being relaxed (Fig. 227). This deformity may be so marked that, as in a case re- ported by Bauer, on the assumption of the dorso-recumbent position the limb projects vertically upward. As a result of this deformity, the gait becomes uncertain, the pelvis sinks on the affected side and occasionally a static skoliosis develops. The treatment depends on suitable apparatus. III. Rachitic Curvatures of the Diaphyses. We have seen that a large proportion of the curvatures affecting the knee are rachitic in origin; similarly the curva- tures of the diaphy7ses are caused by the same disease. 228 Orthopedics and Orthopedic Surgery. Rachitic curvatures of the femur are of little interest, seeing that we cannot do much in the way of treatment. Schede's vertical suspension in case of small children, osteo- clasis, osteotomy7 in the worst instances, these measures are at our disposal. Of far greater importance, owing to their frequency7, are the rachitic curvatures of the lower extremity* (crus varum). These curvatures affect in particular the loAver third of the extremity7. The curvature is ordinarily7 met Avith in the ante- rior plane, although curvatures in various planes occur, giving rise to the characteristic badger-legged deformity. Excep- tionally the curvature is regular, and usually there is a sharp Fig. 228. Fig. 229. Fig. 230.—Rachitic Curvatures of the Lower Extremities. bend a few fingers' breadths above the ankle-joint, Avhere an angle exists (Fig. 2:5:5), the feet gradually assuming a position similar to that of flat-foot. In exaggerated instances the de- formity* is not only* a. hideous one, but the function of the limb is materially interfered Avith. This almost ahvay*s yields to the pressure of walking or standing, and after the cure of the rachitis there remain changes in the bones. The bones which were formerly abnormally soft become sclerotic, and have been bent and flattened by7 muscular action in a characteristic manner (Fig. 2:51). In connection Avith this deformity Ave often speak of equali- zation of the deformity by* growth, and unquestionably, even in instances of great deformity, the formation of neAv bone, in course of time, gradually7 fills in the concavity of the curva- ture, and the limb may- become entirely straight. Orthopedics and Orthopedic Surgery. 229 These curvatures, howeA*er, in the majority of instances become permanent and call for special treatment. As soon as the deformity is noted, the child should, as far as possible, be preAented from AvaIking and standing, and the ordinary7 anti- rachitic remedies may- arrest the changes in the bones. The ap- plication of splints and of extension appa ratus may also prove serviceable. The simplest apparatus is a long internal Avooden splint, Avell padded at each extremity, to Avhich the limb is draAvn by- one broad or by a number of slender elastic straps. The majority- of orthopedic apparatus suitable for these cases (Heather Bigg,75 Salt,76 Ford77) consist in one or tAvo lateral splints fastened to the leg at the knee and foot, and Avith elastic straps for traction on the limb above the com*exity- of the curvature. When the curA*ature is purely- anterior, the best apparatus con- sists in tAvo lateral ba rs Avith ankle- joint attachment, splints for the carves, and a leather cap for appli- ^-=-^_ s^ e^\ cation in front over the curvature FlGS. 231 and 232.-Marked curva- and gradually tightened to Correct ture of the Lower Extremity with . -, -, » .,' Anterior Angle. the deformity. Where, howeA*er, the deformity7 is very* marked and the patient is an infant, then an orthopedic apparatus cannot be Avell applied. A forcible straightening of the limb, even if this results in fracture, is the method which will yield the speediest result. Forcible straightening of the limb is accomplished readily by grasping the loAver extremity above and beloAv the de- formity-, placing the thumbs on the most projecting portion of the curvature, and then the exertion of a gradually increas- ing force Avill accomplish the aim, ordinarily without any crepitant sound. Where simple manual osteoclasis will not suffice, then the osteoclast of either Robin, Collin, or Beely may be resorted to. If this instrument be not at hand, and the bones are sclerosed and therefore cannot be broken manually, then osteotomy is indicated. Figs. 233 and 234 prove how even marked deformity may be relieved by* osteotomy. The patient Avas thus cured by me 23° Orthopedics and Orthopedic Surgery. the present year. A short incision down to the bone is made over the most superficial portion and the tibia is then nearly chiselled through and the remnant broken, or else a wedge- shaped piece is removed. The periosteum, of course, is pushed to either side. The fibula, which is ordinarily flattened, must usually also be cut. The so-called vertical osteotomy of Oilier possesses certain advantages in that shortening of the limb is less likely7 to result. It is rarely essential to perform tenotomy of the tendo Achillis in order to maintain the limb in the correct position. Figs. 233 and 234.—Rachitic Curvature of the Lower Ex- Fig. 235. tremity Before and After Osteotomy. N, Cicatrix. Ordinarily it is sufficient to apply an antiseptic dressing, and then a firm bandage is to be worn a few weeks. In Fig. 235 is represented the result after wedge-shaped osteotomy of the tibia and linear osteotomy of the fibula, per- formed on the limb shown in Fig. 232. Albert78 has performed six wedge-shaped excisions on the tibia in succession and obtained union by first intention and good consolidation without the slightest suppuration or rise of temperature. I have obtained a similar result in five severe instances operated upon during the past few months. In only one case did a small fistulous opening remain for a few months after normal consolidation. This fistula closed after the sepa- ration of a small sequestrum. BIBLIOGRAPHY. 1. Celsus calls "contractos articulos quas ay/avlac " Grseci nominant. lib. v.—2. Langenbeck, Archiv f. klin. Chir., XII., p. 990.—3. Deutsche Orthopedics and Orthopedic Surgery. 231 Zeitschr. f. Chir., III. Bd., p. 18!).— 4. Berlin, klin. Wochenschr., 1870, Nos. 30 and 31.—5. Diet, de med. et de chir. prat., 1829, Appendix.—6. Vier Falle von acuten Eiterungen nach Brisement force. Centralbl. f. Chir., 1885, No. 21.—7. Bris. force eines scroph. entz. Kniegelenks mit consec. allg. Miliartub. Centralbl. f. Chir., 1885, p. 517.—8. Brit. Med. Journ., 1873, II., p. 586.—9. Lucas, R., On Cross-legged Progression the Result of double Hip Ankylosis. Clin. Soc. Transact., 1881.—10. S. P. Bruns.—11. L. c, p. 51.—12. See Volkmann, 1. c, p. 766.—13. On Anky- losis, London, 1881, p. 45.—14. Beitrage, etc.—15. The Lancet, 1872.—16. Centralbl. f. Chir., 1880, No. 4.—17. Deutsche Zeitschr. f. Chir., 19. Bd., p. 463.—18. L. c, Dumont, p. 277.—19. Deutsche Zeitschr. f. Chir., 24. Bd., 506, p. 594.—20. Langenbeck, Archiv f. klin. Chir., 28. Bd., p. 61. —21. Centralbl. f. Chir., 1885.—22. Centralbl. f. Chir., No. 15, 1885.—23. Berlin, klin. Wochenschr., No. 24,1882.—24. L. c, p. 763.-25. Centralbl. f. orth. Chir., 1883, p. 9.-26. Boston Med. and Surg. Journal, No.24, 1885. —27. Abstr. and lllust., extension knee splint, etc., Centralbl. f. orth. Chir., Aug. 1st, 1884.—28. Vierteljahrschr. f. arztl. Polytechnik, 1881, p. 55.-29. Centralbl. f. orth. Chir., 1884, p. 87. Med. Record, Jan. 5th, 1881.—30. L. c, p. 167.—31. Centralbl. f. orth. Chir., March, 1886.—32. Comp. Volkmann, 1. c, p. 775.-33. Med. Times, 1875.—34. See Mtinche- ner med. Wochenschrift, 1886.-—35. Allg. med. Centralzeitung, June 15th, 1861 ; Ehrendorfer, Wiener med. Wochenschrift, 1881, p. 414.—36. L. Archiv fur klin. Chir., XXXII., p. 525.-37. These de Paris, 1886.— 38. See illustration in Fischer, Handb. der allg. Verbandlehre, 1884, p. 102.—39. L. c, p. 215, Deutsche Chir., Lief. 64.—40. Handb. der chir. Praxis, p. 1227.—41. Comp. Volkmann, 1. c, p. 770.—42. Monatsschr. f. arztl. Polytechnik, 1879, p. 148.—43. Progressed., 1887, p. 297.-44. L. c, p. 104.—45. Comp. Vogt, Krankheiten der oberen Extremitaten, p. 25. —46. Wiener med. Wochenschrift, No. 3,1887.—47. These de Paris.—48. Histol. findings, comp. Kocher, Centralbl. f. Chir., 1887, No. 27.-49. The Med. Chronicle, October, 1884.—50. Centralblatt fur Chir., Nos. 26, 27,1887.—51. Centralbl. f. Chir., 1884,10.—52. Lehrbuchf. Chir., IV— 53. C. Weil, Beitrag z. Kennt. des Genu valg.—54. Aerztl. Intelligenzblt., 1885, 4 Deutsch. Med. Zeit. 1885, 48.-55. Arch. f. klin. Chirg., XXIIL, p. 561.—56. Diss, von E. Hoffmann, Greifswald, 1882.—57. Gaz. des hop., 1874, p. 251.—58. L.c, p. 713.—59. Bull, de la Soc. de Chir., 1876, 7 and 8.— 60. Langenbeck's Arch. f. klin. Chir., XXIL, p. 343.—61. Lyon Medicale, 1882.—62. Langenbeck's Arch., XXL, p. 537.—63. Trans. Path. 1885.—64. MacEwen, Osteotomy.—65. Verhand. der Deutschen. Gesell. f. Chir., 1882.—66. Kleimann, Reports from Tubingen clinic, 1884.—67. Deutsch. Ztschrift. f. Chir., XXIV., 1 and 2.-68. Osteotomy and Osteoclasis, New York, 1884.—69. Diaphyseal Osteotomy, Brit. Med. Journ., 1SS1.— 70. On the Treatment of Knock Knee, Edinb. Med. Journ., 1879, p. 881.—71. L. c, p. 83.-72. L.c, p. 749.-73. Edinb. Med. Journ., XXI., p. 18.—74. L. c, p. 116.—75. Guy's Hosp. Reports, 1873 ; Centralbl. f. Chir., 1875.— 76. L. c—77. New York Med. Journal, III., 1884.—78 Operat. Beitrage, I., p. 53. CHAPTEK VI. CONTRACTURES OP THE FOOT. Under the term Talipes (club-foot, pied hot, pes contortus) are grouped together those deformities which consist in an abnormal position of the foot, or of its divisions, in relation to the leg or to each other. Since Ave usually find alterations in the fascias and ligaments, and retraction of certain muscles, these deformities are also termed contractures of the foot (Fusscontracturen). A diA*ision is commonly* made into con- tractures of the ankle (talo-crural) joint and contractures of Fig. 236.-Talipes Equinus. Fig. 237.—Talipes Calcaneus. Fig. 238.—Talipes Varus. the tarsa. joints. Under the first head we have: 1. Talipes equinus (flexus) (Fig. 236), in which there is abnormal exten- sion (plantar flexion) of the foot; 2. Talipes calcaneus (exten- sus), in which the foot is flexed dorsalty, and the heel seems to be lower than normal (Fig. 237). The contractures of the tarsal joints, whore, in addition to a vertical displacement, there is also a deviation in other directions (adduction or abduction, pronation or supination), are divided into: 3. Talipes varus (flexus adductus inflexus), in which there is supination or adduction (Fig. 238); 4. Talipes valgus (extensus abductus) or flat-foot, in which the contrac- Ortliopcdics and Orthopedic Surgery. 233 tion is in a direction of pronation or abduction (Fig. 239). We have also, according to the condition of the plantar arch: 5. Talipes planus (reflexus) or flat-foot, in which the arch is sunken, the anterior portion of the foot, at Chopart's joint, is in a manner bent upAvard, and the entire sole rests upon the ground (Fig. 239); 6. Talipes caA*us (inflexus), in which the arch is higher, the sole seems excavated, the anterior portion of the foot, at Chopart's joint, is bent dowmvard, and this part and the heel are nearer each other (Fig. 240). In the great ma- jority of cases none of these deformities exists alone, but they are usually* combined, as, for example, in talipes equinus there is usually more or less deviation to the inner side (talipes Fig. 239.—Pes Valgus. Fig. 240.—Pes (Calcaneo) Cavus. equino-A*arus), or the heel is depressed and the foot is pronated and abducted (calcaneo-valgus). Without doubt, hereditary* influences are concerned in the production of club-foot, and deformities of this kind may* often be traced through several generations. Indeed, talipes has not infrequently* been noted in the foetus (Little, Parker). K. Roser * found among 100 malformed foetuses, 36 in which there were deformities of the feet. Of these there Avere 8 cases of double talipes Aarus, 11 of double calcaneus, 9 in Avhich both varus and calcaneus existed, and 9 in which there Avas uni- lateral deformity. Deformities of the foot may be either congenital or acquired. The former are usually* bilateral, and consist in an abnormal shape and position of the bones of the foot, more particularly* of the tarsus. Acquired club-foot is most commonly consecu- tiA*e to disease of the nervous system (neurogenous), in which the cause of the deformity* lies outside of the foot; less fre- quently* it folloAvs disease of the bones or joints (arthrogenous), or occurs as a result of fracture or subluxation (traumatic). 234 Orthopedics and Orthopedic Surgery. The relative frequency* of these different forms varies greatly, but club-foot in general is of rather common occur- rence. Stromeyer2 calls it one of the great sources of human misery, especially* among the lower classes, and says that in almost every* large hamlet one or more individuals may be found Avhose existence is embittered by this eA*il, and who are hindered thereby* from earning their living. Many different theories exist as to the origin of congenital talipes, but Ave may* here distinguish between the mechanical, and the dymamic (muscular) theories, and that of arrested deA*elopment. Hippocrates, Galen, Ambroise Pare, and others sought for a mechanical explanation of congenital club-foot, but Scarpa may* be regarded as the scientific founder of this theory*, for he looked upon it as a result of abnormal pres- sure of the uterine Avails upon the affected parts. Although much has been Avritten against the mechanical theory*, and cases have been cited in Avhich children Avere born with club-foot, notAvithstanding the presence of a large amount of amniotic fluid, Cru\*eil- hier Avas an upholder of it, and he has been followed by Volkmann, Liicke, Kocher, Vogt, FiG.24i.-cicatriciaicon- Banga, Parker,3 Conrad, and others. These traction. (After Parker.) j.i-^-i • -i • i * i ■, authorities have instanced, in support of the mechanical theory, the presence of marks (Fig. 241) indicat- ing pressure upon the prominent parts, although one could scarcely form a conclusion from the presence of these marks of the time at Avhich the pressure Avas exerted. According to Parker and Shattuck's investigations3 we may* suppose that the feet assume different positions at different periods of intra- uterine life, and that any influences which hinder the feet from assuming the position that they* ought to take at any* partic- ular period, or which keep them too long in any* one position, may* act as efficient factors in the production of talipes. Kiistner4 is, among others, one of the most active supporters of the mechanical theory, epecially as regards the production of varus and valgus, and he looks upon a certain degree of ex- tension of the leg as specially favoring the production of flat- foot, since the pressure of the uterine Avail thereby acts at greater advantage upon the sole of the foot, pushing it up- ward and outward. Orthopedics and Orthopedic Surgery. 235 K. Roser and others look upon typical congenital varus and calcaneus as instances of a true deformity* due to pressure. The foetus lies usually .with legs crossed in such a Avay- that the outer sides of the knees and feet lie close to, if not in actual contact Avith, the Avails of the uterus. Any movement that the foetus may* make brings these parts against the in- clined plane of the uterine Avail in such a way* as to increase the tendency to A*arus, Avhich already* exists in consequence of the flexion of the loAver extremities against the abdomen. The production of calcaneo-Aalgus is explained on the assumption that the foot is in a position of dorsal flexion at the time that it comes in contact Avith the Avail of the uterus. When the tAvo legs are parallel, but disposed in such a Avay that the outer side of one only* touches the uterine Avail, the effect of pressure upon the feet is to produce A'arus in one, and valgus in the other. The mechanical effect is similar to that seen Avhen one walks along the side of a slope, one foot being then forced into abduction and the other into adduction (K. Roser). In rare cases one foot may be compressed against the other in such a Avay as to cause marked valgus in one, and equally* marked A*arus in the other. The Avell-knoAvn case of Volkmann5 is an instance in point, and Vogt6 has also de- scribed similar cases. Wolff7 regards inAvard rotation as the primary* position, and any*thing that hinders outAvard rotation of the extremities may* cause talipes varus. Velpeau believes that, in addition to the position of the foetus, its weight may- also be of some moment in these cases. Although congenital deformities of the feet may* be ex- plained from the standpoint of mechanical causes (Hencke, Hiiter),that is to say*, they* are the result of pressure (Roser), a proportion of the cases must be considered as due to defectiA*e development, to a primary* disturbance in growth of the af- fected bones and joints. This view is peculiarly applicable to those instances where congenital defect in certain bones has led to talipes, and to the additional cases Avhere there coexists deformity of another nature, such as spina bifida. The dynamic theory* as to cause, in particular the view* that the deformity* is the result of unequal muscular traction (Du- verney, Guerin, Stromeyer will certainty not apply* to con- genital talipes, since careful im*estigation has never revealed abnormity* in the muscles. 23" Orthopedics and Orthopedic Surgery. The my-o-neurogenous explanation of acquired talipes has also been rejected, even in instances of paralytic deformities, that is, those Avliich were assumed to depend on disease of the central nervous sy-stem (myelitis, meningitis, encephalitis), such disease causing an entire or partial paralysis of special muscle groups. Hiiter and Volkmann have shoAvn that here as well mechanical causes are far more influential, and that the weight of the foot, in particular its anterior portion, plays an essential role. The soft parts, fascia and ligaments, and even the bones gradually adapt themselA-es to the altered position and the consequent effect is a retraction and shorten- ing of the antagonistic muscles. In addition to simple Aveight Avhich, even where the patient is confined for a long while to bed, may lead to the formation of pes equino-varus, the pres- sure resulting from walking increases the deformity, the foot assuming more and more an abnormal position. Where the bones are exposed to the greatest pressure growth is dimin- ished, and where, on the other hand, there exists scarcely* any pressure, the bones increase in size. Again, where the bones are but little in contact the cartilages disappear, while a new cartilaginous surface forms where the bones constantly move the one on the other. Spasmodic deformities, such as are met with as an accom- paniment of hysteria, etc., infrequently complicate instances of my-o-neurogenous talipes, and the same remark holds for the congenital and acquired spastic contractures. Talipes may also depend on traumatic causes. Cicatrices following burns, local injury* to a tendon or nerve, may* lead to the deformity. Very frequently badly united fractures or subluxation result in talipes. Witness talipes valgus depend- ent on union at an angle of the fractured external malleolus. In general we may* differentiate three degrees of talipes: 1. Where the deformity is not marked and we are able readily to bring the foot into the normal position; 2. Where it is just possible to correct the deformity; 3. Where correction is an impossibility, the deformity being permanent. Although the anatomy and symptomatology of talipes must be specially referred to under the individual varieties, we would lay stress here on the fact that the seat of the deform- ity is not alone, as was formerly the belief, in the affected joint as an entirety*, but far more in changes in the form of the Orthopedics and Orthopedic Surgery. 237 bones the result of groAvth in an abnormal direction. In very- rare instances, for example in paratytic pes equinus, essential alterations in the bones and joints may- be absent. As a re- sult of abnormal pressure, etc., the direction in which groAvth takes place alters, as also the shape of the bones and of the ligaments. Callosities form on the part the least subjected to pressure and these may* be the source of great suffering. The sequela^ of talipes extend generally bey*ond the region of the foot. There occurs an atrophy of the muscles of the loAver extremity or of the entire limb Avhich, in comparison Avith the normal limb, is often most striking, and this atrophy* leads to marked shortening. In the paralytic forms partic- ularly*, the temperature of the limb may be greatly* loAvered and it may* haA*e a bluish appearance. The sy-mptoms resulting from talipes, aside from the pecu- liar method of progression and the lessened ability of endur- ance, are chiefly painful affections, Avhich render the affected indiA-idual entirely unable to perform certain duties. Where ulceration and inflammatory symptoms are superadded, the patient's condition may become so aggravated as to lead him to demand amputation, as the sole measure offering relief. The prognosis of talipes naturally* A*aries much according to its degree, A*ariety*, and time after formation when the pa- tient comes under treatment. The earlier treatment can be instituted the more favorable, of course, the prognosis as re- gards cure of the deformity. Modern treatment is so superior to the methods formerly* in A*ogue that the prognosis is by* no means as bad as for- merly, Avhen the patient had to content himself Avith the vari- ety of apparatus mentioned by* Dieffenbach.8 The introduction of tenotomy* into orthopedic practice marks the boundary* be- tAveen the methods of to-day* and of the past. The aim of treatment in case of talipes is to restore the foot to its normal position Avith respect to the lower extrem- ity*, to maintain it in normal position, and to correct the shape of the foot as far as possible. Further still, particularly in case of the paralytic forms, Ave are called on to increase the nutrition and the function of the part by massage, passive movements, electricity, etc. Since treatment should be instituted as early* as possi- ble after deliA*ery, we nalurally cannot speak at such an early 238 Orthopedics and Orthopedic Surgery. period of apparatus, etc. The following measures are chiefly of importance: movements aiming at reduction of the deform- ity*; holding the foot for a feA\- minutes in correct position; the application at night of bandages Avhich will maintain the foot in position. These means are applicable to the congenital A-arieties until the skin becomes hardened, when plaster and permanent fixation dressings are to be resorted to, and Ave may* thus obtain gradual correction of the faulty position. The apparatus useful in the treatment of contractures of the foot may be divided into tAvo classes: 1. Apparatus AA*hich aims at draAving the foot from the faulty* into the correct posi- tion; 2. Apparatus Avhich will maintain the foot in the position which can be secured. A further subdiA*ision may be made into: 1. Apparatus which acts through elastic traction and pressure; 2. Apparatus which acts through constant traction and pressure, such as the plaster bandage. Although certain apparatus may be adapted to any* vari- ety* of talipes, owing to the possibility* of altering the mechan- ism for apptying the requisite traction, the majority of the contriA*ances under consideration Avere deA*ised for special forms of the deformity7, and must be separately studied. For the congenital varieties of talipes, in addition to man- ipulations and manual correction, plaster and splint bandages may be resorted to for maintaining the foot in the position ob- tained by* manipulation. Small splints made of rubber or felt or zinc (Smith, Vogt, and others) Avill in this connection be found very useful. Reeves has devised a good splint. The portions for the loAver extremity* and for the foot are connected by a ball-and-socket joint, so that Avhen the splint is adapted the foot may be turned in any* desired direction. The feet are placed in this variety* of splint in the intervals between the manipulations, and thus gradual correction of the deform- ity* is secured. In the construction of foot-splints, leverage has also been aimed at. St. Germain's9 appaveil en plaquette consists of a foot-piece ABPT (Fig. 242) and a more or less vertical (accord- ing to the A-ariety of deformity) portion AS. In the foot- pieces are two linear openings FF. The angles SAP and SAT may be modified in the construction to suit the variety of tali- pes to which the apparatus is to be adapted. Strips of plas- ter are applied to each side of the loAver extremity- (D in Fig. Orthopedics and Orthopedic Surgery. 239 243); these strips are passed through the openings in the foot- piece and are then brought over the foot, to maintain it in position. A circular strip of plaster (C) surrounds the calf of the leg to retain the A-ertical strips, and then by means of a bandage (B) the vertical splint is drawn against the legs and the deformity is corrected. In case of older children the chief method of treatment has for long consisted in a retention bandage, changed from time to time, the foot being secured in as good a position as possi- FlG. 242. ble. We Avill speak of this method particularly under the subject of club-foot. Barwell's method of treatment by elastic traction through plaster is one of the simplest procedures, and it has been Avarmly indorsed by* Sayre. It has the advantage of not in- terfering with the movements of the muscles and joints. A triangular, fan-shaped piece of plaster cut into a number of strips and carrying a wire loop (Fig. 244) serves as one point of attachment for the elastic traction, while a zinc splint (Fig. 245) on 1 he front of the leg, and fastened to it by* plaster, offers the second point of attachment. An elastic ligature ex- tends betAveen these two points and makes the desired amount of traction, the degree being regulated at will by a chain at- tached to the ligature (Fig. 246). Fig. 243.—St. Germain's Splint. 240 Orthopedics and Orthopedic Surgery. Blanc, Andrews, and others have devised similar appliances for the use of elastic traction. Andrews, for example, com- bines the plaster Avith an elastic band and utilizes a soft cush- ion as the fulcrum. Reibmayr has applied similar traction to talipes as to other joints. Stillman has adapted Barwell's principle to an apparatus which is easily removed and applied to any shoe. It consists of an external splint for the lower extremity to which a num- ber of elastic bands extend from the foot. This external lat- eral splint is bent backAvard from a point corresponding to the level of the ankle joint to the heel, Avhere it is connected by a hinge joint with a short horizontal steel blade, to the anterior extremity of Avhich the elastic bands are attached. At the Fig. 244, 245 and 246.—Barwell's Apparatus for Treatment of Contractures of the Foot. centre of the horizontal blade a shorter blade is attached, and this extends under the foot, and fits into a plate Avhich is riveted into the sole of the shoe. Thus motions in the verti- cal axis onty are possible. Apparatus of this nature is especially* useful in the paraty- tic \*ariety* of talipes. Beely's club-foot shoe may* be taken as a type (Fig. 248). Say-re's shoe (Fig. 22) has a movable ball- and-socket jointed sole. The sole is metal covered with leather. Two lateral straight bars (B) extend from the sole, and in them, at the level of the ankle, there is a hinge joint (A). The bars are strapped to the leg at C. At the heel at J and on the sides of the sole at G there exist points of attach- ment for the traction chains which extend upward to the leg and backward to the heel. The chains or rubber bands (E) Orthopedics and Orthopedic Surgery. 241 act as artificial muscles. Apparatus of a similar nature to this has been frequently* deAised. The Luck and Wolfermann shoe, devised for pes varus, valgus and equinus, is a further instance of a universal club- foot shoe which acts through elastic traction (vide Fig. 21). Non-ambulant apparatus is also resorted to in the treat- Fig. 247.—Stillman's Talipes Apparatus with Fig. 248.—Beely's Talipes Shoe. Elastic Traction. ment of talipes. Hansmann has devised an extension appara- tus (Fig. 249) Avhich he has tested chiefly* in the Hamburg hospital. This apparatus enables us to maintain the foot in any* desired physiological position and it is therefore useful, not alone in the treatment of fracture of this region, but also in case of talipes. This apparatus consists of a flat Avooden splint, thirty*-one inches long and seA*en inches wide, Avith an excavation for the reception of the heel. At its lower extrein- 16 242 Orthopedics and Orthopedic Surgery. ity it is united to a vertical wooden foot-piece, eleven inches high; at its centre and upper extremity*, on each side, there are two vertical wooden bars from Avhich counter-extension is made. A number of holes are bored into the foot-piece, into Avhich hooked screAVS are inserted. The lateral upright bars carry leaden grooves in which similar screAvs fit. The care- fully bandaged leg and foot are strapped to the longitudinal splint as is represented in Fig. 249. By* varying the traction direction of the chains which are attached to the screws, the foot may be held*in the desired position. In the majority* of instances, after the normal form of the foot has been approximately obtained, retention apparatus must be Avorn to prevent recurrence of the deformity. We will refer later to suitable apparatus of this nature. In many cases tenotomy, especially- of the tendo Achillis, Fig. 249.—Hansmann's Extension Apparatus for Talipes. materially* shortens the time required for treatment, and when- ever the contraction of this tendon is an obstacle to redresse- ment it should be severed. This operation may be performed with the patient tying either on the abdomen or on the back. In the first instance, tenotomy is performed from Avithout inAvard, in the second from within outward. In any event the foot must be sharply- flexed so as to cause projection of the tendon. A small inci- sion is made at the edge of the tendon, a tenotome is inserted on the flat into the loose cellular tissue around the tendon, the edge of the instrument is turned toward it, and then rather by* pressure (under the control of the thumb) the tendon is severed, as is evidenced by* a loud snap. It is not ordinarily- advisable to attempt correction immediately* after tenotomy*. It is preferable to Avait until the slight Avound has healed. It is not often necessary* to resort, in addition, to the section of other tendons, such as that of the tibialis posticus. In case Orthopedics and Orthopedic Surgery. 243 of great contraction of the plantar fascia, hoAvever, the subcu- taneous section of the plantar aponeurosis may be called for. The transverse depression (Fig. 250) between the heel and the anterior portion of the sole of the foot is the site for incision. On dorsal flexion of the foot the aponeurosis projects at this spot, the tenotome is inserted either above or under it, and the shortened fascia is seA*ered. Of the apparatus formerly- in use we will refer to Schuh's10 club-foot appliance, since it is cheap and readily constructed by any locksmith. It consists of two separate portions: A foot- Fig. 250.—Contraction of Fig. 251.—Bruns1 Club-foot Fig. 252.—Kolbe's Club-foot the Plantar Fascia. Shoe. Shoe. piece of the size and shape of the sole of the foot of the patient, and a padded tin gutter w*hich fits the lower half of the leg. From the edges of the gutter a stout ring projects An iron blade, which may* be fixed at any angle, is attached to the gutter, and the bandage Avhich holds the footpiece to the sole of the foot is drawn over this bar and the foot may* thus be maintained in any desired position. Bardeleben n has substi- tuted for the ring Iavo lateral A*ertical projections Avhich are connected by a rectangular piece. In v. Bruns'12 apparatus for Aarus, \-algus, and equinus, the correction force is applied bv the hand of the physician instead 244 OrtJwpcdics and OrtJiopedic Surgery. of by* screAv mechanism. The foot is maintained in the posi- tion in Avhich it is placed by the surgeon, and by* repeated manipulation and adjustment of the apparatus the normal position and function are gradually attained. The apparatus consists of three portions united by bolts and iron rods, and it is represented in position in Fig. 251. Kolbe's shoe (Fig. 252) is also intended for the correction of A*arus, A*algus, and equinus. Under the apparatus Avith screAv mechanism Langgaard's13 must be referred to. It is useful both in varus and in valgus. The foot fits into an ordinary* tight shoe Avhich is supplied with an endless screAv mechanism, by* means of which the lat- eral position may* be altered. Extending up the posterior por- tion of the shoe to the kwel of the ankle-joint, where it is connected lii;, |l \ with an endless scccav, is a curved % 1 bar the revolution of which straight- ens the foot. Although this appa- ratus -will correct equinus deform- ity*, Adams rejects it on account of the ease with which it breaks. Talipes equinus (sp i t zfu s s, pferdefuss, pied bot equine) is a deformity due to contracture of the foot in the position of plantar flex- ion. The heel is draAvn upAvard, the apex of the foot doAvnward without FlG' 254^SSUtaU8 comcident lateral deformity of the foot. The foot lies in a more or less straight line with the lower extremity. The patient walks on the metatarsal emi- nences. The foot is broad beloAv, slender above, its longitudi- nal axis is shortened, Avhence its resemblance to the foot of a horse. In aggravated instances the patient walks on the dor- sal surface of the curved toes, or even on the back of the foot (equinus dorsalis). Ordinarily there then coexists a certain degree of adduction and supination and there results the most frequent deformity: the equino-varus. We must differentiate a pes equinus congenitus, although Tamplin rejects this variety and Adams and Little consider it very infrequent. As a rule, in the neAv-born, the motion of the foot in the sense of dorsal flexion is greater, and in the Orthopedics and Orthopedic Surgery. 245 sense of plantar flexion is less than in the adult. Pes equinus is more frequently acquired. The chief causes are: The effect of weight during protracted sickness (typhus, etc.), although this usually results in the pes equino-varus; inflammation of the joint, abscesses, etc., of the calf of the leg, traumatism in the same region such as burns (traumatic pes equinus); certain nervous diseases, hysteria, etc. (spasmodic pes equinus). Fre- quently pes equinus is of paratytic nature, the result of paral- y*sis of the extensors, or a sequela of infantile paralysis or other central affection. We also meet with pes equinus as compensatory- to shortening of the extremity due to one or another cause. The angle formed betAveen the lower extremity and the Fig. 255, a, b, c—Atfyxavated Instances of Pes Equinus. foot in mild instances is a trifle over 90,° in ag,irra\*ated cases it may exceed 180°. According to the degree of deformity* we may differentiate: 1. Instances where the heel is lifted upward, the toes are extended, the patient Avalks on the metatarsal eminences, the foot can still be placed at a right angle Avith the lower ex- tremity (Fig. 253); 2. Instances Avhere the retraction is greater, so that the axes of the foot and of the Ioavci- extremity are coincident; 3. Instances where the anterior portion of the foot is bent backAvard and the patient walks on the tarsal bones (Fig. 255, c). In view of these varieties, the external appearances of pes 246 Orthopedics and Orthopedic Surgery. equinus differ very* greatly*. The foot appears to be shortened, its arch is deepened, the plantar fascia is, as a rule, contracted. The muscles of the calf, particularly* in the paratytic variety*, are markedly shrunken, and the entire lower extremity- is atrophied. The leg, in consequence, resembles still more that of a horse. Ordinarily the head of the astragalus projects to a greater or less degree on the dorsum of the foot. In instances where the dorsal surface of the foot is utilized in walking, the skin and the underlying tissues are thickened, bursse are formed Avhich become inflamed and are the source of pain. The deformity* is thus greatly aggravated. In gen- eral, the degree of deformity* depends on the state of the mus- cles. So long as the extensors functionate, the toes remain extended; while, when the anterior muscles of the lower ex- tremity are paralyzed, the toes sink toAvard the plantar sur- face of the foot, and in aggravated cases the entire foot is retroverted (Fig. 255, c). The walk of patients with unilateral pes equinus of slight degree is but little disturbed. Through flexion of the knee the increased length of the affected extremity is offset. In paralytic pes equinus, the individual drags the limb and swings it forward by circular movements. Frequently uni- lateral pes equinus of mean degree affects the individual more than a more aggravated type, the foot and the lower extrem- ity functionating in a straight line like a stilt. Instances Avhere the patient walks on the dorsum of the foot are always aggravated, especially when bursitis and ulceration compli- cate, and then the individual is practically helpless. The walk of an individual Avith bilateral pes equinus is uncertain and lacking in normal elasticity. The pathological anatomy-14 of pes equinus reveals rather an alteration in position than in the form of the parts which enter into the composition of the foot, except in the later stages of the deformity. In a case observed by Adams the bones of the foot Avere in eA-ery respect normal. The astragalus is only in contact posteriorly Avith the tibia and the fibula, and projects on the dorsum of the foot (Fig. 256). The scaphoid is not infrequently* subluxated, approaches the calcaneus and, in marked instances, articulates with it. In severe chronic cases, only the posterior portion of the trochlea of the talus is covered with cartilage. In Dittel's Orthopedics and Orthopedic Surgery. case, the caput tali projected above the upper surface of the scaphoid, so that the anterior articular surface of the astrag- alus was nearly- tAvo-thirds free (Fig. 256, d c). The posterior portion of the calcaneus is lifted upward and in severe cases it may be in contact Avith the bones of the loAver extremity; as a rule, hoAvever, its position is altered less than that of the other tarsal bones. Its anterior portion may be subluxated from the cuboid and be bare of cartilage. The metatarsi may* eA*en be in contact with the calcaneus. In Dittel's 15 case and in Chance's, new joint sur- faces Ave re formed betAveen the tibia and the calcaneus and between the extremity of the fibula and the external surface of the calcaneus (Fig. 256, a). The tarsal bones, on the dorsal surface where the pressure is the least, increase more in size than on the plantar surface. The arch of the foot becomes unusually* deep. If the toes remain in normal position (the individual being recumbent), then the metatarsi are sub- luxated when the individual is erect. The ligaments and aponeuroses take part in the abnormal changes. The ligaments (especially the talo-naA*icular) are stretched on the dorsal and shortened on the plantar surface of the foot. As a sec- ondary* change Ave must note the irregular course of the pos- terior tendons of the lower extremity. They form an acute angle forward as they pass OA*er the heads of the metatarsal bones, Avhile the extensor tendons may* span the metatarso- phalangeal joints like a bridge. Atrophy of the muscles of the calf is more or less striking. Pancoast's assertion that the soleus is almost or entirely re- tracted lacks anatomical confirmation. In making the diagnosis of pes equinus the knee must be extended, since, when the knee is flexed, a slight degree of equinus may entirety disappear, that is to say, it is possible to dorsoflex the foot to a greater extent. The prognosis of pes equinus is, in general, good. The rare congenital form may ordinarily be readily* corrected, as also the acquired form when of recent formation. When the deformity has existed for a number of y*ears, the nutrition of Fig. 256.—Pes Equi- nus. (Af ter Dittel.) 248 Orthopedics and Orthopedic Surgery. the joint has been deepty affected, and the component portions of the foot have adapted themselves to the abnormal position, then many* obstacles are in the way* of treatment. The para- lytic variety, especially*, calls for the protracted Avearing of apparatus to prevent the development of a higher grade. In connection with the treatment of pes equinus we must state that all forms do not call for it. The compensatory equinus, for instance, in case of shortening of the extremity*, is a favorable occurrence, and then a thicker sole to the shoe Avill amply* fulfil the indication. The prophylactic treatment of pes equinus may* be said to consist in applying suitable support to the foot during the course of all affections which necessitate protracted assump- ~>>^ tion of the dorso-recumbent position. The ^ modern custom of using the Volkmann and other splints under such conditions will con- 0 f I siderably diminish the frequency of pes 11 ^Jl equinus which is dependent on this cause. Figs. 257 and 258.—Stillman's Apparatus for Pes Equinus. In infants, manipulation, redressement, and fixation by- splints will suffice to effect a cure. In older children, forcible repeated correction with the application of a plaster or a silicate of soda bandage will accomplish the aim. In seAere cases of pes equinus, gradual correction after Stillman's method is possible. The splint shown in Fig. 258 is applied to the foot and the lower extremity. A plaster bandage sur- rounds the two portions of the splint, and these are gradually approximated by the screAv mechanism in the bar connecting them (vide Fig. 257). In the slighter grades of deformity the treatment is of the simplest possible kind. A piece of cloth may* be looped around the patella, another piece around the foot and the tAvo are connected by a third or byr a strap whereby reduction may* be gradually accomplished. Or, better still, a Avooden foot-piece Orthopedics and Orthopedic Surgery. 249 may be attached to the foot and a cord may* be extended from its anterior end upAvard to the patella, where it is fastened to a strap. By shortening this cord, gradual correction is ob- tained. Braatz's apparatus (Fig. 259) consists of felt splints for the foot and loAver extremity, and of an iron articular frame-w*ork fit- ting under the foot and along the front of the leg through which, by means of straps, the foot is drawn upward. Another method is to carry* a broad strip of stout plas- ter under the foot and attach it to the anterior portion of the lower extremity*. Elastic traction has in a num- ber of Avays been applied to the treatment of pes equinus. One of the best knoAvn and still frequent- ly used appliances is the Stro- meyer apparatus (Fig. 260). Its component parts are: A posterior splint, a, Avith strap, d, a foot-piece, b, movable on an axis, c, attached to the foot by* the strap, e, and cords passing laterally from the footpiece over rollers in the posterior splint and reAolving on the cylin- der, /. By means of this apparatus the foot may be dorso- flexed to the desired extent. Since the individual may Avalk while wearing them, the 1' Fig. 259.—Braatz's Equinus Apparatus. c '■ Fig. 260.—Stromeyer's Equinus Apparatus. different apparatuses with elastic traction are more useful. Such appliances may* be readily devised. Davis, Bigg, and others recommend plaster spirals around the upper extremity*, similar ones around the foot, the two 250 Orthopedics and Orthopedic Surgery. being connected by* straps and rubber cords. Heidenhain 18 (Fig. 261) obtains elastic traction through a rubber ring com- bined with the spirals of plaster. A more efficient means is a firm bandage around the upper part of the leg carrying a hook or a ring, a similar one over the foot and an elastic band extending between the hooks along the anterior surface of the leg. Many of the appliances with elastic traction are to a greater or less degree modifications of Bauer's (St. Louis) shoe (Fig. 262). This shoe has an iron sole articulating with which are two lateral bars strapped to the leg beloAv the knee and at the ankle. A ring in the toe of the shoe serves for the attach- Fig. 261.—Heidenhain's Fig. 262. —Kolbe's Shoe. Fig. 263.—Sayre's Equinus Appa- Equinus Apparatus. ratus with Elastic Traction. ment of the rubber band which dorso-flexes the foot. Sayre's apparatus (Fig. 263) answers the same purpose and may be fitted to the ordinary shoe. The lever instruments of Liston, Bigg19 and others, Scarpa's shoe, apparatus with endless screw mechanisms (Parona, Langgaard) may7 also be utilized for the treatment of pes equinus. When, by one or another of these appliances, the correct position has been restored to the foot, the individual must wear an equinus shoe which will not in- terfere Avith walking, but which will prevent the recurrence of the deformity. These shoes have a hinge-joint adapted in them at the level of the ankle or they prevent plantar flexion through the action of elastic bands (see Figs. 264 and 265). Tenotomy of the tendo Achillis unquestionably in the most �7984235�8 Orthopedics and Orthopedic Surgery. 251 aggravated cases shortens the duration of treatment, and since this operation, performed subcutaneously, is entirely without danger, it should be resorted to. In case of paralytic pes equinus tenotomy* will certainty rarely be called for. In Figs. 264 and 265.—Stillman's Equinus Shoes. Figure 266 (a and b) is represented an instance of pes equinus in a boy of twelve, before and after the performance of tenot- omy. As soon as the tenotomy wound has healed, a suitable ap- paratus must naturally be resorted to. Occasionally, Avhere pes cavus complicates pes equinus, subcutaneous section of the plantar fascia is requisite. Even Figs 266 a and b.—Pes Equinus Before ' and After Tenotomy. Fig. 267. Fig. 268.—Pes Calcaneus. resection of the talus may be necessary in very severe cases (Lund). In case of complete ankylosis of the joint, osteotomy may be called for, in addition to tenotomy (Billroth) or resec- tion of the ankylosed joint after Velpeau's method. For 252 OrtJiopedics and Orthopedic Surgery. this purpose Reid20 used the saw, but the operation is simpler when performed with the chisel and hammer. Pes Calcaneus.—The reverse of pes equinus is the deformity knoAvn as pes calcaneus (hakenfuss, pied bot calcanien). The essence of this deformity is a contraction of the foot in a posi- tion of dorso-flexion. The patient walks on the heel and the sole of the foot is lifted upward (Fig. 267). The deformity is of common occurrence. Nicoladoni21 has critically* analyzed this deformity*. With him Ave may differentiate the following varieties: 1. The pes calcaneum sursum flexus, which is due to the flexion of the foot against the lower extremity* and where the sole of the foot looks forward; 2. Pes calcaneus in a narroAved sense, Avhere Ave deal mainly- with a pure oblique posi- tion of the heel. The latter A*a- riety rarely* depends on trauma- tism, but is usually* paralytic. In paratysis of the muscles of the calf, the plantar muscles gain the ascendancy* and pull the calca- neus forward and doAvmvard, the arch of the foot being thereby- deepened. The first variety may either be congenital or acquired. The congenital form depends on intra-uterine disturbances, the feet, for instance, being maintained in a position of dorso- flexion. [Breech cases Avith extended limbs (Adams).] Parker and Shattuck beliea*c that the deformity first ap- pears in the later months of gestation Avhen the normal pos- ture is one of flexion. Dorso-flexion may extend to such a degree that the entire dorsum of the foot may lie apposed to the lower extremity. According to the angle formed betAveen the foot and leg, we may* differentiate varying degrees of pes calcaneus. The congenital form is rarely pure, but usually- complicated by* valgus, forming the variety knoAvn as pes calcaneo-valgus. The calcaneus sursum flexus may further be due to paraty- sis. Exceptionally the cause is pathological, as in a case re- ported by Kundrat, where there occurred displacement of the v^ Fig. 269.—Pes Calcaneus. Nicoladoni.) (After Orthopedics and OrtJiopcdic Surgery. 253 epiphy*ses consecutive to osteomyelitis with central necrosis, or as in Mensel's case,22 where a similar separation occurred spontaneously. Pes calcaneus, further, follows on traumatic causes, such as burns and subsequent cicatricial contraction or rupture of the tendo Achillis. ReeA*es divides congenital pes calcaneus into three grades: 1. Where the angle between the foot and the lower extrem- ity is normal, y*et plantar-flexion is not possible; 2. Where the angle is an acute one; 3. Where the dorsum of the foot nearly or entirely* rests against the anterior surface of the loAver extremity*. Acquired pes calcaneus generally depends on paralysis of the muscles of the calf. Partially as the result of weight and Fig. 270. —Schematic Sections of Calcaneus in Pes Calcaneus and in the Normal Condi- tion. (Nicoladoni.) The line b c, the inser- tion of the Tendo Achillis, is bent at an an- gle in Pes Calcaneus. partially owing' to the action of the plantar muscles, the heel is drawn downward, it becomes more conical in shape, its position more vertical—pointing directly downward like the stump after Pirogoff's operation. The tendo Achillis can scarcely be felt, the anterior portion of the foot sinks down, and in the adult the arch of the foot is more or less deepened. As regards the pathological anatomy of pes calcaneus,23 only* in adults do we find essential changes in form. Ordi- narily the position alone is altered. In Nicoladoni's case (Fig. 270) the posterior portion of the calcaneus, near the talo-cal- caneus joint, was bent downward, a' b'. The tubercle of the calcaneus, which normally points downward and backward, may* be lifted slightly forward, c' d' (Fig. 270). The gastroc- Fig. 271.—Pes Calcaneus Apparatus with Elastic Traction. 254 Orthopedics and Orthopedic Surgery. nemius, plantaris and soleus are usually atrophied, while the deeper muscles of the calf and of the sole are healthy. The treatment of pes calcaneus aims at lifting the heel and depressing the apex of the foot. In the congenital variety in y*oung children these indications are readily satisfied by fast- ening a cotton pad between the dorsum of the foot and the anterior surface of the lower extremity*, or by correcting the malposition as much as possible and maintaining the foot in good position by a splint bandage. In many cases of burns of the dorsum of the foot and of the anterior surface of the leg, we must counteract the tendency to the formation of pes cal- caneus by resorting to transplantations. Pes calcaneus may* be corrected after a very* simple fashion by bandaging the foot to a splint which has a projection back- ward like a spur. This projection is connected by an elastic cord with a band or a strap above the knee. As soon as the individual is able to walk, the question arises of a suitable calcaneus shoe. These shoes have a metal sole Avith a hooked projection backAvard. Tavo lateral bars extend to the knee and an elastic band is connected along the dorsum of the leg with the knee-strap and the hook of the projection from the sole (Fig. 271). In Kolbe's shoe an articular splint surrounds the leg a hand's breadth above the ankle, and an elastic band extends from it to a species of stirrup in the shoe, and this band counteracts the tension of the tendo Achillis. Judson24 has de\*ised an apparatus for paratytic pes calca- neus, the essential part of which is a hinge in each lateral splint, at the level of the ankle joint, which alloAvs of plantar flexion, but prevents the foot from dorso-flexing beyond a right angle. In walking and standing, then, the foot is main- tained at a right angle to the lower extremity. In simple cases of deformity-, H. Bigg's apparatus25 Avill suffice to restore the normal form to the foot. A splint, artic- ulating at the ankle joint, is attached to the outside of a shoe and carries an S-shaped spring extending a trifle above the ankle down to an ivory roller. The heel is thereby lifted up- Avard and the anterior muscles are stretched. Langgaard, in his apparatus, draws the shoe, and Avith it the foot, doAvnward and backward by* means of a circular spring attached to the leg splint and through the arm of a lever to a vertical pro- tection from the shoe. OrtJiopcdics and OrtJiopedic Surgery. 255 In severe instances of paratytic pes calcaneus, operati\*e measures have been recommended. Albert, for instance, aims at obtaining artificial ankydosis of the ankle joint; Nicola- doni26 adA-ocates the section of the peronei behind the external malleolus and the union of their tendons Avith the severed tendo Achillis. Hacker27 successfully* accomplished this in a young girl of ten. Resection of the tendo Achillis and subsequent suture haA*e a number of times been resorted to. Killet per- formed this operation through a V-shaped incision; Wal- sham,28 in four patients Avith paralytic pes calcaneus, excised a piece from the tendo Achillis one half to three-fourths of an inch long through an oblique incision. He sutured the tendon with catgut, and in all the cases the deformity was bettered, in tAvo complete cure resulting. Naturally, in case of fatty- degeneration of the muscles of the calf, such measures are useless. The electrical reaction of the muscles must be tested beforehand. Tn many instances, where the tension of the tendons on the dorsal surface is Aery great, tenotomy* may be requisite. Where cicatrices are at the bottom of the deformity*, these must be excised and the customary* after-treatment be adopted. In A-ery* severe cases osteotomy of the inferior pro- cess of the calcaneus has been adA*ocated. In combination Avith pes calcaneus and pes equinus we fre- quently* meet Avith pes cavus (pied bot talus, hohlfuss) which rarely* occurs alone. This deformity consists in an excaA*ation of the sole of the foot Avith an eleAation of the arch. Usually* the com*exity* of the dorsal surface is increased and this sur- face is shortened. Pes cavus is rarely* congenital and is then generally due to contracture of the plantar fascia. It is usually* acquired (Fig. 272), being dependent upon muscular paralysis, especially* of the gastrocnemii and the solei, whereby the heel sinks doAvn- « Avard. In the Chinese woman this deformity* is artificially* produced by methodical compressive bandaging and by- the peculiar shoes worn. The ligaments and muscles are not specialty altered in this case, and the ultimate result is a hoof rather than a foot. In Figs. 273, 274, ty*pical instances of paralytic pes calcaneo- cavus are represented. The foot is shortened, abnormally bent, with dorsal surface sharply* curved, and in profile the 256 Orthopedics and Orthopedic Surgery. sole appears nicked (Fig. 273). In the upright posture there is considerable space between the sole and the ground, and in Fig. 272.—Paralytic Pes Cavus in a Girl of 14. Fig. 273.—Paralytic Pes Cavus in a 20- year-old Student. aggravated cases the individual walks only on the heel and the ends of the metatarsal bones. Callosities and ulcers often form and give rise to great pain and inability to walk. In talipes plantaris, a number of the universal club-foot apparatuses to which we have referred may be used. One of the most useful appli- ances is that of Bigg (Fig. 275). It consists of a steel sole strapped to the )\ Fig. 274.—Foot of a Chinese from a Prepara- tion in the Hunterian Museum. Fig. 275. foot and which may* be straightened out by* means of a screw. By* means of tenotomy, especially by section of the plantar Orthopedics and Orthopedic Surgery. 257 fascia and of the muscles of the sole of the foot, the treatment of pes cavus may be materially altered. Where the fascia may* be felt as a tense band it must be incised subcutaneously. Where we are not dealing with single tense bands, the muscles and fascia must be severed until the deformity can be corrected, as has been done in cases recorded by* Schede and others, and the Avound should then be treated antiseptically. We may thus assure a good result. After tenotomy* Bauer applies a boot with an iron heel and makes vertical pressure on the dorsum of the foot through the double screw Avhich he has devised. He was thus enabled to cure a case of eighteen y*ears' standing. Pes planus (splay foot, pied plat, spurious valgus, platte fuss) must be sharply differentiated from flat foot (plattfuss) since in case of this de- formity* the relation betAveen the navicular bone and the caput tali is not altered, Avhile in pes valgus the head of the astragalus pro- jects inward over the navicularis. In splay* foot the most essential feature is the lack of arch to the sole and of the external curva- ture of the foot. Pronation is not present. The foot of the new-born is ahvays flat and Ave may- consider pes planus the outcome of absence of that phase in groAvth Avhich leads to the arching of the foot. Pes planus is further characteristic of many African tribes. The JeAvs also have a splay- foot. Re- laxation of the ligaments, etc., is said to be a cause of pes planus. The foot is markedly* broadened and flat, Avithout the pro- jection of the head of the talus Avhich is characteristic of A-al- gus. The arching of the sole is lacking and the bones of the tarsus, as in case of valgus, rest on the ground. The prona- tion phenomena are Avanting. Whether splay foot tends to become valgus, as some writers have claimed, or not is ques- tionable. Treatment is usually* not requisite. Occasionally elastic adjuA-ants are called for. Some writers, Emmert29 for example, differentiate the broad foot (breitfuss) (Fig. 276), where the anterior portion of the bones of the middle foot are broadened out from abnormal 17 258 Orthopedics and Orthopedic Surgery. length of the transverse ligaments. The function of the foot is not affected. This condition may coexist with splay* foot. Pes Varus.—Under the term pes varus (Khtmpfuss, pied Fig. 277.—Pes Varus in a Man of 23. bot varus, supination contracture, adduction contracture) is understood that deformity* A\*here the foot deviates imvard from its longitudinal axis, is supinated and usually- adducted. The apex of the foot is directed inAvard, the sole is curved in- Avard, the internal border of the foot %:■ I is lifted from the ground and the exter- !•: ~/M9$ nal border is depressed (Fig. 277). As a rule, the talo-tarsal joint is not alone implicated, but the talo-crural joint as well. The foot is plantar-flexed, that is to say*, its apex is sunken, form- ing a pes equino-varus, not a pure pes varus. To this deformity* Henke gave the name of pes flexus adductus-inflexus. In all small children there exists a tendency to the varus position of the foot, and avc may* say* that this is the normal position in the fetus and that later, as a result of the at- Fig. 278.—Infantile Pes Varus. Orthopedics and OrtJiopedic Surgery. 259 tempts at Avalking, etc., the varus changes into the normal position. Pes varus is the most frequent of all the congenital deform- ities. Adams, in 764 cases of contracture of the foot, found the varus type 668 times; in 999 cases of non-congenital de- formity*, equino-A*arus occurred 162 times and pes varus 60 times. Out of 800 to 1000 men AA*e may* expect to find one in- stance of pes varus. The deformity affects most frequently males, it is ordinarily* bilateral and when unilateral the right foot is implicated by preference (Roberts30), although Dieffen- bach 31 claims the reAerse. We may- differentiate a number of degrees of this deform- ity*. It Avas formerly* customary* to make five divisions, but to-day* the folloAving three forms are dif- ferentiated : 1. Where the foot can still be brought into the normal position and the angle betAveen the foot and the loAver extremity is greater than 90°; 2. Where correction is not possible to such a degree, the foot being draAvn more internally*. There then exists contracture of the tendons and fascia; 3. Where it is impossible to correct the deformity* manually*, the foot being at an | acute angle Avith the inner surface of the fig. *279.-Paraiytic Pes lOAA'er extremity*, all the tiSSUeS OI1 the Varus in an Early Stage. . , , . ' -, -■ Young Girl of 9. inner side being shortened. A division, according to etiology, into congenital and into acquired pes varus is preferable. In the congenital variety, the deformity* is due to a primary change in the bones, in the acquired form the causal factor, in general, lies outside of the bones, the majority* of cases being dependent on paralysis, either peripheral or central, and this, secondarily, leads to deformity of the bones. The cause is rarely* to be sought in spastic or inflammatory* conditions or in trauma which has left lasting changes in the bones or the joints of the foot and lower extremity (the traumatic pes varus). Congenital pes varus depends on abnormal shape and posi- tion of the separate bones of the foot and of the joints, and various explanations haA-e been offered as to the cause of the 260 Orthopedics and Orthopedic Surgery. deformity-. Esricht32 considered the deformity* the result of a persistence of the curvature of the foot which normalty exists at a certain stage of fetal development; others belieA-e it due to abnormal position of the foetus in utero, claiming that the bones and joints of the foot, being subjected to pressure, are forced to maintain the varus position, and that this in the course of fetal development becomes exaggerated (Kocher33). This pressure is not ahvays due to the fact alone that the liquor amnii is deficient in amount, for in a case recorded by* Kocher the deformity* existed in a \*ery early period of fetal life. Indeed, the observations of Liicke, Volkmann, Kocher, Parker,34 and Roser render it doubtful if Martin's vieAv in re- gard to the effect of uterine pressure be correct. In many Fig. 280.—Infantile Pes Varus, the Talus being Fig. 281.—Talus of the Normal Exposed. Adult. instances it seems that pes varus may develop in the later stages of pregnancy. Parker and Shattuck have found the caput tali divided into tAvo apposed facets, the one of which had degenerated from the fact that it had not been used, and this would seem to point to extensive capacity* for motion of the feet in early fetal life. As regards the anatomical changes35 in congenital pes varus, Adams and Hiiter36 haa*c shoAvn that there exists es- sential abnormity in the configuration of the bones, an exag- geration in the foetus, as it were, of the form of the bones and joints met with in the adult.37 Kocher, in particular, has shown that not only are the talus and the calcaneus impli- cated, but that all the bones of the tarsal joint take part in the changes Avhich are characteristic of congenital pes varus. Orthopedics and Orthopedic Surgery. 261 Fig. 282. — Talus from an 18-months- old Child with Pes Varus. (Parker.) On considering these congenital alterations, we find not only7 the bones and joint surface altered, but also, not infrequently, ab- normal changes in the loAver and o\*en in the upper extremity. In the talus there is a constant characteristic deformity, its neck being lengthened in an oblique direction inward (vide Fig. 280). While in the noAv-born the normal obliquity of the talus is 38°, that is to say, the sagittal axis of the talus forms an angle of 38° with a line drawn parallel Avith its external border (Fig. 282), and Avhile in the adult this angle only amounts to 10.65°, in case of congenital pes Aarus the angle is 49.6°, the maximum being 64°, and, in conse- quence, as Parker has shoAvn, the talus bears a strong resemblance to that of the ape, in whom the foot possesses great range of motion in the sense of inversion and of supination. The Avhole body* of the talus is flattened. It is sharply cut off backward like a Avedge and, as a rule, it is flexed on the plantar surface of the foot. The talo-crural joint has lost the character of a hinge-joint and approximates that of an amphiarthrosis. The trochlear sur- face projects backward nearly or entirely to the posterior bor- der of the lower joint surface; ante- riorly this surface is worn down, the internal articular facet is scarcely recognizable, and that Avhich articu- lates Avith the external malleolus is pushed forAvard. The head of the talus is directed a trifle doA\*nAvard, forming an angle of 65° Avith the axis of the talus, instead of one of 45° as in the new-born. The articular surface of the head of the talus points imvard and occa- sionally it is divided into two apposed facets, of Avhich the internal alone is in contact Avith the navicular bone, the other being only covered Avith a thin layer of cartilage and by* the (dongated ligaments. The calcaneus (Fig. 283) is sharply rotated internally under the talus, its tuberosity is directed toAvard the flbula, Fig. 283.— a, The Calcaneus, Pes Varus at One Year; b, the Calca- neus, Normal, in the New-born; c, the Calcaneus, Pes A*arus in the New-born. 262 Orthopedics and Orthopedic Surgery. and the abnormal height of its anterior process is especially* striking, as also the oblique slanting of the upper joint-sur- face. The sustentaculum tali—the apparatus AA*hich checks supination (Hiiter) and Avhich in the new-born is much deeper than in the adult—is lacking. The articular surface for the cuboid is situated on the median side and the longitudinal axis of the calcaneus is curved so as to be concave internally and the anterior process and tubercle of the bone point inward. The cuboid, seen from above, is quadrilateral rather than triangular in shape, and this is due to the increased lateral growth Avhere the effects of pressure are wanting. The navic- ular bone lies to the inner side of the caput tali and the longi- tudinal axes of these bones are + rather parallel than at a angle. The lower extremity is 1 2 Fig. 284.—The Cuboid. 1, Normal at Two Years; 2, Pes Varus (One Year). quently tAvisted inward at its lower portion, and the end of the fibula projects forAvard. The ligaments are altered in accordance with the change in position and in form of the bones. The internal lateral, the plantar, calcaneo-fibular and talo-navicular ligaments are shortened, and the external ligaments are stretched. The muscles retain their normal relations. Even after section of the muscles and ligaments, entire reposition is not possible. The tendons are altered in their relation to the bones. The tendon of the peroneus longus, for instance, forms a groove on the external and under surface of the cal- caneus. In a single instance Roser found a sesamoid bone in the tendon of the tibialis posticus, in its course between the internal malleolus and the first cuneiform bone. Similar changes, in the main, are found in all cases of pes varus in infants, and the feet are in a position of supination. We refer, in this connection, to Kocher's description of pes varus in Orthopedics and Orthopedic Surgery. 263 infants of one year and of three. The soles of the feet may be approximated like cyrmbals. The anatomical changes in congenital pes varus of adults are of a still higher degree than in children, and they are marked especially by the forma- tion of new and abnormal facets. The internal malleolus is less prominent, shorter and rounder, Fig. 286.—Talus of an Adult. Fig 287.—Talus of an Adult with Pes Varus. and a joint is often found between it and the navicular or even the cuneiform bones. The groo\*e for the tendon of the tibialis posticus is Aery- shallow. The bones are not of nor- mal size and thickness, but they are rather osteoporotic and fatty, and the two posterior bones of the foot are most mark- edly altered. The talus is more slender and longer, the trochlea is, pos- teriorly, only partially covered with cartilage and, anteriorly, it is divided by a transverse line (Fig. 288). The lateral joint surfaces are unequal. That for the fibula is sharply pushed for- ward against the neck of the talus, it is larger and, at the posterior border of the trochlear articular surface, it is divided into a triangular surface. The articular surface for the tibia is gen- erally very small. The caput tali is ill-developed, misshapen, and frequently carries two facets, of which the external is not covered by cartilage and the inter- nal articulates wdth the navicular bone (Fig. 288). Fig. 288.—Pes Varus Sinistr. The Talus and Scaphoid. (Adams.) 264 Orthopedics and Orthopedic Surgery. The calcaneus is altered in shape and position; its longitu- dinal axis is curved Avith median concavity; its upper articu- lar surface is flattened in the centre and so sharply pushed iinvard that it does not reach the eminence of the bone (supination position). The anterior portion is longer and higher and springs forward a trifle. The tuberosity projects upAvard and lies just behind the fibula. The upper surface of the calcaneus lies in contact with the posterior border of the articular surface of the tibia, so that in severe cases the os calcis seems to belong to the joint of the foot. The articu- lar surface for the cuboid maybe displaced entirety toAvard the centre. The navicularis is also altered in form and in position. It is shaped like a double Avedge, the central portion having a lesser sagittal diameter and being flattened like a Avedge dowmvard. The bone is frequently displaced under the in- ternal malleolus and, as a rule, articulates Avith it by a facet, as though it had been drawn into the assumed position by* the action of the tibialis posticus. The cuboid is displaced to the same extent iiiAvard; it OA-erlaps two-thirds of the articular surface of the calcaneus and is connected with it by* the stretched ligaments. Its transA-erse diameter is ordinarily increased, is more quadrilat- eral in shape, its external surface is more conA*ex. In a case obseiwed by Noble Smith, the enlargement of the cuboid seemed to be the chief cause of the deformity. The cuneiform bones are directed from above backward. They* are not A*ertical and are more behind than near one an- other. The ligaments and the tendons are adjusted to the changes in the bones. Roser38 found a sesamoid bone in the tendon of the tibialis posticus Avhere it extends betAveen the internal malleolus and the first cuneiform bone. In regard to the external appearances of congenital infan- tile pes varus (Figs. 289-291), the tarsal joint is bent inward and shortened, the anterior portion of the foot is directed more to the front and the sole more backAvard; the internal border of the foot looks upward and the external doAAmward; the heel appears very* small and frequently assumes an almost vertical position. The internal malleolus is not as prominent, the external projects markedly-. In very aggravated cases, the angle formed betAveen the OrtJwpcdics and Orthopedic Surgery. 265 foot and the loAver extremity- is an acute one; the longitudinal axis of the foot lies more to the front; occasionally* the foot is shortened and there exists a deep transA*erse depression in the sole, due to rigid contracture of the plantar fascia. Figs. 289, 290 and 291.—Various Grades of Infantile Pes A'arus. As we have stated, as the result of the action of weight the form of the foot is essentially changed. Since this action is not on the arch of the foot but on its external border, and the foot, in consequence, becomes greatly supinated, the indi- vidual soon Avalks on the dorsum of the foot. When we meet in the adult with pes varus Avhich has not been subjected to suitable treatment, the foot, in aggravated Fig. 292.—Congenital Pes Varus in a Man Fig. 293.—The Same, Seen Posteriorly. of 26 (Adams.) instances, looks like a club; the sole points upward and back- Avard, the dorsum forward and downward; the decrease in length is the outcome of atrophy; the heel, which is draAvn upAvard, is small, the skin tense; on the dorsum of the foot a 266 . Orthopedics and Orthopedic Surgery. thick club-like callosity has developed, the subcutaneous cellu- lar tissue being infiltrated and containing a bursa (Figs. 277, 294). The anterior and posterior portions of the sole of the foot are separated by* a deep transverse groove; a second longitu- dinal groove divides the sole into two halves (Fig. 293), and these grooves are characteristic of congenital pes varus, for they are not marked or are entirely absent in the acquired form (Adams). As a result of the great atrophy* of the muscles, the calf of the leg is effaced, the limb looking like a cylindrical stilt. The length of the extremity is occasionally diminished, and the appearance suggests the leg of an animal, wdience the popular names " coAv-foot " " devil's foot," etc. In severe instances, not only is the foot, but the loAver extremity, the knee, and upper extremity are also turned iiiAvard, and in order to make measurements it is necessary to remember that the patient masks in part the inward rotation of the loAver extremity* by an outAvard ro- tation of the femur. "The real inAvard rotation is, as a rule, much greater than the apparent" (J. Wolff) and, in order to determine it, the legs must be placed Avith the patella exactly* in front, or, when the individual is recumbent, looking directly* upAvard. Thus this rotation is eliminated. Acquired pes varus may* be the outcome of a number of causes: 1. Disturbances of the neiwes, unequal muscular traction; 2. Traumatism. The majority of instances of acquired Ararus are certainly- paralytic, the sequela of infantile paralysis of central origin, and, ordinarily-, pressure, etc., leads to the formation of an equino-varus. In its inception we are not dealing, as in con- genital A*arus, with a primarily* deformed foot, but only with a certain degree of deviation from the normal shape. As the result of use of the foot, the acquired pes A*arus assumes simi- Pes Varus in a Man of 30. Orthopedics and Orthopedic Surgery. 267 lar appearances to the congenital. Less frequently the ac- quired variety* may be traced to spasmodic affections, such as contraction of the supinators. An instance of this is the ac- quired pes varus hystericus. Traumatism may lead to pes varus through unequal mus- cular traction. Thus, an injury to the peroneal nerve may- cause paralysis of the pronator muscles, and, in consequence, the supinators obtain control over the foot. In the majority of instances of traumatic varus, the cause is to be found in direct changes in the affected bones, as, for example, disloca- tions of the tarsal joints, fractures of the tibia, of the internal malleolus, of the talus, etc. Diseases of the bones, in particu- lar partial necrosis, may result in varus. Bartels has re- ported an instance following on osteo- myelitis and sequestrotomy-. Cicatricial contraction from burns on the inner side of the ankle-joint is a rare cause. The anatomical changes differ greatly according to the degree of the A*arus. As a rule, Ave find arrested groAvth and an atrophy affecting all the tissues. Essen- tial deformity of special bones is less marked than in the congenital form. The talus, especially, retains to a greater or less degree its normal shape, the calca- neus its sagittal direction. The alterations are chiefly in the joints, leading to the so-called subluxations. The atrophy of the muscles and of the tendons is quite marked. The external appearances of acquired pes varus are less characteristic than those of the congenital form. The general atrophy, especially in the paralytic forms, is striking (Fig. 279). The lower extremity* resembles a thin stick. The bony projections on the dorsum of the foot and the depressions on the plantar surface are lacking. As a rule, the deformity is not a rigid one. In paralytic cases the livid color and the coolness of the entire extremity are striking. As for the influence of pes varus on the indiAidual, Dieffen- bach has said, Avith truth, that the deformity* is a greater affliction than the loss of a limb. From early* childhood to the grave it is a lasting source of bitter complaint. The indiA*id- ual considers it a disgrace to have been thus brought into the Fig. 295.—Aggravated Pes Varus. 268 Orthopedics and OrtJiopcdic Surgery. world. According to the degree of the deformity, locomotion is more or less interfered Avith; in bilateral instances, where in Avalking the toes are in contact, the individual progresses as though he were on stilts. The deformity cannot be concealed by the most expertty constructed shoe, and these, usually*, resemble a hoof (Fig. 296). The difficulty* in locomotion often causes these individuals to resort to work Avhich may be accomplished in the sitting posture (tailors, etc.). Dieffenbach has pointed out that many patients on being cured seek more active occupations. The special diagnosis of the individual form depends on the appearance of the posterior segment of the tarsus, on the re- lation of the heel to the malleoli, on the distance of the apex of the external malleolus from the plantar surface of the calcaneus. The clinical course of congenital pes varus is the following: With the first attempts at Avalking the external border of the foot alone touches the ground. The doAvn- Avard weight does not, as is normal, cause increased pronation, but su- pination of the foot. Gradually* the dorsal surface ser\-es the pur- pose of locomotion, and as development increases, this per- verse tendency is exaggerated, the ligaments and the muscles adjusting themselves to the abnormal relation of the bones. On the dorsal surface of the foot callosities and subcutane- ous bursas form, particularly OA-er the projecting anterior pro- cess of the calcaneus. Not infrequently* these bursa1 become inflamed and suppurate, thus adding to the suffering of the unfortunate individual. The muscles of the foot and of the lower extremity*, which are not used by the club-footed in Avalking, gradually atrophy, eA*en though at birth they Avere normal, and thus, at the out- set, unequal muscular traction is at Avork—a factor which in case of unilateral pes varus is especially marked in the calf (Fig. 339); at times a marked shortening of the affected limb may be determined. The therapeutic indication in case of pes varus is to con- vert the supination position into that of pronation. Formerly Fig. 296.—Congenital Pes Varus. Orthopedics and Orthopedic Surgery. 26g it was the custom to defer treatment of congenital A-arus until the child Avas a year or more old. Unquestionably it is Aviser to resort to treatment as early as possible, eA*en in the first Aveek of the child's life, particularly since J. Wolff has shoAvn that the child's foot groAvs A*ery* rapidly during the first months of its existence, and that therefore the elements which interfere with correction concomitantly increase. This vieAv is in accord with that of Albert, Kocher, Konig, Margary, Mensel, Sayre, Vogt, and others. In the neAv-born, of course, it cannot be a question of com- plicated apparatus and bandages. We may attain our aim by* means of suitable manipulations, traction into the normal position, that is of pronation and dorsal flexion, especially Fig. 297.—Manual Correction of Pes Varus. Fig. 298.—Correction by Bandage. when, in addition, avc maintain the obtained result by* small splints. Thus, in a few Aveeks, an aggravated club-foot may be almost entirely* cured. The manipulations should be resorted to frequently and the mother may readily- be taught to perform them. The lower extremity should be steadied by one hand and the other should grasp the foot and endeavor to carry- it into a position of pronation and of dorso-flexion and to maintain it in such position for a few minutes (Fig. 297). During the night, and occasionally during the day*, the foot should be held by a small splint and bandage in a position as much opposed to the faulty- one as possible. Splints of various material, sticking plaster, and the ordinary bandages are at our disposal for this purpose (Fig. 298). 270 Orthopedics and Orthopedic Surgery. In Mellet's " Manual" there are tabulated 150 cases of pes varus cured by manipulation and bandages. Formerly it was customary to treat congenital club-foot in two stages: First to convert the varus into an equinus by Fig. 299. Fig. 300. Fig. 301. Fig. 302. Treatment of Pes Varus in Two Stages. (After Adams.) means of an external wooden-splint to which the foot was bandaged (Fig. 300), and next to restore the foot to the nor- mal by tenotomy (Fig. 302). In Fig. 300 is shown the application of the splint to the foot and in Fig. 302 the result. Adams39 recommends a sim- ple, infantile varus splint which consists of a splint for the upper extremity, of one for the lower with a joint at the knee, of a foot-piece provided with an endless-screw mechanism. Fig. 303. Fig. 304. Fig. 305. Fig. 306. VogCs Club-foot Felt Splint. Splints constructed of the following materials may be used : metal, pasteboard, leather (Paraeus, MacEwen), silicate of soda and pasteboard (Vogt), rubber (Lorinser). Felt splints Orthopedics and Orthopedic Surgery. 271 are, after pasteboard, the best, and the relatiA*es of the little patient should be instructed Iioav to apply- them. In the in- fant, splints and manipulations are the chief means of treat- ment, for permanent bandages cannot be utilized OAving to the fact that they* become so quickly* soiled. When the foot has been placed in the desired position, the parents may* be taught to apply* the felt splint, and the case, therefore, does not re- quire the constant supervision of the physician. Vogt shapes the felt as is represented in Fig. 303, forming a posterior splint and two overlapping portions which make the foot-piece. Konig prefers an internal lateral splint modelled as is represented in Fig. 307 and applied as in Fig. 308. The foot is maintained in correct posi- ,. . tion by* means of a roller flannel bandage. When the skin of the foot has become less tender, that is to say*, in older child- ren, then the methods which aim at elastic traction by* sticking plaster and the per- manent bandages are applicable. Strong plaster (MaAvs' mole- skin is the best) should be cut into strips about one and one- half inches wide and bound around the foot and leg, draAving the former into a position of pronation. Fischer, Sayre, Mensel, and others, have recommended this method. Say-re carries the plaster strip as high as the head of the fibula, places a roller bandage over it, and, when he desires greater traction, he surrounds the bandage by a second strip. Mensel40 envelops the foot in three lay*ers of moist gauze, and, after this has dried sufficiently, he applies strips of plaster in such a way* as to keep the foot pronated. Bamvell has effi- ciently* combined elastic traction with the application of mole- skin plaster (vide Figs. 244-246). Forest Willard carries strips of cambric, one and three-fourths to three inches wide, around the leg and foot (Figs. 309, a, b) and connects them by* an elastic band. Sticking plaster may-, obviously*, be also used Figs. 307 and 308—Felt Splint (After Konig.) Fig. 309.—Elastic Trac- tion. (After Willard.) 272 Ortlwpcdics and OrtJiopedic Surgery. in combination Avith silicate of soda, plaster-of-Paris, etc., bandages. When the child has reached the age of Avalking, retention apparatus is, as a rule, resorted to. The aim of apparatus of this nature is to prevent recurrence of supination of the foot. Felt splints have the advantage that they* may* be worn under the clothing. Club-foot shoes, of which Ave will speak in detail later, answer the purpose of keeping the foot pronated. In its simplest form such a shoe consists of a laced boot carrying a flexible bar, with slightly outward spring, articulating at the level of the ankle-joint. We must emphasize the fact, how- ever, that club-foot shoes should not be used too early*, lest recurrence of the deformity* set in. In case of still older children, apparatus which acts by* elas- tic pressure and traction may* be used. In this way* gradual correction of the deformity* may* be attained (redressement continue), or else correction may be reached at one sitting (redressement force). Formerly the plaster-of-Paris bandage was used almost exclusively* in the treatment of pes varus. The foot was placed in as correct a position as possible in a plaster bandage; at the end of from one to two weeks this bandage was removed, the deformity still further corrected and a second bandage was applied, and so on until the normal position was acquired. The case was considered cured when the foot remained in normal position without being held there and w*hen, in ascending the stairs and in Avalking, the sole of the foot rested entirely on the ground. Halm uses a simple means for holding the foot in position Avhilst the plaster bandage is being applied, and yet not interfering Avith the operator. This is a T-shaped Avooden splint (Fig. 310) which is set in the bandage. UpAvard traction at a and at d overcome the equinus and inversion position. In small children, to prevent the bandage becoming soiled by* the urine, it is advis- able to varnish it and to bind its upper edge Avith sticking- plaster. Inward rotation must, as far as is possible, be guarded against, and such a tendency* may* be overcome by* tying the feet together and, at night, by fastening a Avedge shaped cushion between them. The objection to the plaster bandage, that it interferes with active and passive movements, does not hold, for the bandage is changed every* eight to fourteen days, Avhen an Orthopedics and Orthopedic Surgery. 273 opportunity* is given for bettering the position of the foot by- means of passive manipulations. For many reasons it is important that the patient should soon be enabled to Avalk around, and the ambulant appara- tuses are, therefore, of great utility. In order to prevent in- Avard tilting of the feet in walking, Roser has recommended a stirrup-shoe, that is to say a shoe provided with an n-shaped stirrup projecting about one inch beyond the sole. In older children and in adults, the indications for the treat- ment of club-foot differ somewhat. J. Wolff, in particular, has resorted to redressement in stages by* means of ambulant apparatus. He first applies three to four strips of adhesive Fig. 310—Hahn's T-Shaped Splint. plaster, after Sayre's method, over this a moist bandage, next a silicate-of-soda bandage, and, OAer all, a provisional plaster bandage, the foot being held in as correct position as possible while this bandage is setting. After the lapse of a few day*s, the plaster bandage is removed, a second silicate of soda band- age is applied, and over this an ordinary stocking and shoe are worn. According to Wolff, it is peculiarly important that the pa- tient should walk on the sole of the foot, that is, that the foot should functionate in normal position, for thus the normal architectural structure of the foot Avill be regained. Such should be the aim of every* method of treatment of club-foot. After very forcible reduction (at times after tenotomy, etc.) 18 274 Orthopedics and Orthopedic Surgery. the silicate-of-socla bandage should be applied and should be Avorn for seA*en to nine months. In severe instances of con- genital club-foot, betterment of position is attained at the A*ery outset by cutting a Avedge-shaped piece out of the bandage, cor- recting the position still further, and strengthening the bandage by* a second application of the silicate. It may* require, there- fore, eight to twelve days for the completion of the bandage. We Avill noAv consider forcible redressement of pes varus under anesthesia (Konig, Wolff) with after-treatment by* a retention bandage. With the exception of A*ery young chil- dren and of adults with Aery compact bones, this method is suitable for the majority of cases of club-foot, congenital as well as paralytic, especially* in the deA-elopmental stage. Konig operates as folloAvs: The projecting external side of the foot, at the point of articulation of the calcaneus with the cuboid and the lateral border of the talus, is placed against a hard surface. An assistant or one hand of the operator presses the heel firmly against the surface, and the operator, taking purchase1 on the inner side of the portion of the foot which projects over the fulcrum, corrects the deformity- by the weight of his body. This, as a rule, requires tAvo to three seances. The foot is then surrounded by- a plaster bandage in order to secure the result, and, Avhere the force resorted to has been great, the foot is suspended vertically*. This forcible redressement results in rupture of ligaments, in fracture of fragments of the bone from the concavity, and in splintering of the bone in the convexity. Konig prefers this method to operations with the knife, seeing that, in his experience, it has been folloAved by better shape and function of the foot. Instrumental forcible reduction has also been resorted to and has been recommended particularly for instances of rigid club foot in older children and in adults. Velpeau, Morton, and others have devised apparatus in which screw- pressure is utilized to redress the foot. In Fig. 311 is represented the ap- paratus devised by Kolbe, of Philadelphia. The apparatus consists of a block of wood carrying a padded horse-shoe for the fixation of the heel. The foot is strapped to this block as is represented in Fig. 311. The adduction is overcome by the outward traction exerted through the screws on the eminence of the tarsus and of the great toe, while movements of the block will effect flexion and eversion. Orthopedics and Orthopedic Surgery. 275 Fig. 311.—Kolbe's Traction Apparatus. Bradford41 uses an apparatus provided Avith padded cush- ions for the purpose of forcible reduction. Two cushions are applied on the inner side of the foot over the calca- neus and the metatarso- phalangeal joint, and a third on the outer side a little in front of the exter- nal malleolus. These cush- ions are held in position by means of screAvs, and by means of a fixed rod in the foot-piece forcible prona- tion, supination, plantar and dorsal flexion are pos- sible. Bradford, as a rule, resorts to this apparatus after he has tenotomized the tendo Achillis and the plantar fascia. More gradual forcible redressement may be affected through Stillman's42 club-foot tAvister, Avhich is represented in and readily understood from Fig. 312. Before I proceed to speak of the operative measures, I , must refer to the various j club-foot machines, which, as a rule, are provided with lever- and screAv-mechan- ism, elastic traction means, etc. These machines are only suitable for patients AA-ho come under treatment in late childhood. They cannot be used during the early years of life, for then they are ill-adapted to the little feet, readily become inefficient, and may exco- riate the foot or induce gangrene from pressure. In general, apparatus of this nature is only suitable for the second stage of treatment. In the application, great care must be exercised that the foot Fig. 312.—Stillman's Appa- ratus. Fig. 313.—Venel's Sabot. 276 Orthopedics and Orthopedic Surgery. rest thoroughly on the sole and that the splint for the loAver extremity is exactly adapted. Ordinarily, apparatus of this nature is provided with means for dorsal flexion, pronation, and abduction of the foot, and also Avith a device for lifting the ex- ternal border of the foot, similar to that in Venel's --sabot" which consists of a wooden foot-piece and a lever bar extending along the external surface of the lower extremity* (Fig. 313). V. Bruns43 has modified this simple apparatus by* fastening the foot by a number of straps passing through holes in the foot- Fig. 315.—Stromeyer's Club-foot Shoe. Fig. 316.—The Came, Applied. piece, and by making elastic traction on the foot by* means of rubber tubing extending from the foot-piece along the outside of the extremity* to the knee. In this manner the foot is pronated. The well-known Scarpa's shoe is the type of the sandal- formed club-foot shoes which have been devised by* Scoutet- ten, Delpech, Guerin, Blasius, Gunther, Schuh, Martin, and others. These shoes differ, hoAvever, in many* respects from the original Scarpa model. One of the best known of the many modifications of the Scarpa shoe is Little's. The mech- anism in this shoe effectually overcomes the equinus position Orthopedics and Orthopedic Surgery. 277 and prevents plantar flexion, Avhile offering no obstacle to dorso-flexion (Fig. 314). Stromey*er modified the Scarpa shoe by* making the anterior portion of the sole moA*able, and by- attaching the screAv, c, Avhich alloAvs of the external splint, a, being placed in the desired position. The spring, b, on the out- side of the shoe effects inversion of the foot (Figs. 315 and 316). Tamplin's modification, as used at the London Orthopedic Hospital, consists of an iron sole, a, co\*ered with leather; of a heel-piece, b; of an external lateral splint, c, attached to the lower extremity* by* the strap, d. The external spring, h, everts the foot; the straps, e and /, maintain the heel in correct Apparatus. position; the strap, g, serA'es the purpose of fixing the appa- ratus firmly* abo\*e the ankle. Flexion and extension are reg- ulated by the screw, k, and inversion (eversion) by the screAv, I (Fig. 317). In Adam's44 modification the strap, e, draAvs the foot outwards; flexion and extension are obtained by the screAv, c (Fig. 318). In a later model, in Avhich there is more direct action on the anterior part of the foot Avithout the exer- cise of lateral pressure, Adams inserted three joints controlled by screAvs, one at the ankle-joint, a second at the transA-erse tarsal joint, a third at the tarso-metatarsal joint. Leather straps encircle the upper and Ioavci- extremities, and the splint is jointed at the level of the knee. In Ebner's and in Langgaard's (Fig. 319) apparatus, the sole, c, is also movable on the heel-piece, b. In Ebner's appa- 27& Orthopedics and Orthopedic Surgery. ratus there is a pad which exerts pressure on the convexity of the foot; in Langgaard's, an endless-sere av, d, controls inver- sion and eversion. In the Sutter-Langenbeck sandal-shaped club-foot shoe, the equinus posi- tion is overcome through a screw, and the foot may be pronated and supinated at will by Fig. 320.—Kolbe's Club-foot Shoe, for the Left Side. Figs. 321 and 322.-Kolbe's Club-foot Shoes. means of an endless screw in the lower extremity splint. In Kolbe's apparatus, lateral splints, jointed at the knee and carrying rings, are used for fixation; correction is accomplished Fig. ^--Bardenbeuer's Club- Fig. 324.-Sayre's Shoe. Fig. 325.-Klopsch's Shoe. by means of turn-screws, and abduction of the anterior portion saltomt ^ PreVent°d ^ a ^"^ Carried °Ver the metatar~ In Nelaton's apparatus, the foot may be brought into any 4999 Orthopedics and Orthopedic Surgery. 279 desired position and it may be gradually redressed. In the Robert-Collins apparatus and in the Heather-Bigg, the mech- anism for correction of the deformity is posterior. In Busch's apparatus, the loAver extremity is incased in leather; two lat- eral-splints are united behind the ankle-joint by a nut-joint (enarthrosis) which secures dorso-flexion and pronation, Avhile a second joint of a similar nature in the sole permits abduction of the apex of the foot. Bardenheuer's45 club-foot shoe (Fig. Fig. 326.—Willard's Shoe. Fig. 327.—Blanc's Apparatus. ism are to-day less in favor, for the reason that the advantage which they possess of enabling us to maintain the foot in the desired position is counterbalanced by the disadvantage that the great pressure exerted may lead to gangrene. These shoes should be used with great caution and be« carefully supervised. In many cases, especially in the paralytic variety-, apparatus provided with means for elastic traction is to be preferred. In addition to Sayre's apparatus (Fig. 324), we would refer, in this connection, to Blanc's (Fig. 327), Avhere rub- ber rings supply a continuous correcting force, the foot being effectively pronated and the tendency to plantar flexion being opposed. The mechanism is apparent from the figure. 280 Orthopedics and Orthopedic Surgery. The majority of club-foot appliances are intended for use after the chief deformity has been overcome by* the plaster bandage, etc. They enable the patient to Avalk correctly and thus further act as correcting agents. In Willard's apparatus the heel and metatarsal portions of the sole are united by soft leather, and the elastic band, b (Fig. 326), passing through the opening, a, and attached at c, overcomes adduction of the foot. Stillman adapted Barwell's method of elastic traction to an apparatus which may be used Fig. 328—Stillman's Club-foot Shoe. with any form of shoe (Fig. 247). The hinge-joint behind the ankle-joint increases the action of the elastic traction. In Stillman's apparatus abduction is acquired and the equinus position is corrected by* means of elastic bands (Fig. 328, a, b). To prevent rotation of the apparatus on the foot, it may be necessary* to attach it to the lower and upper extremities by strips of adhesive plaster. Beely, Kolbe, and others have devised shoes Avhich act on a similar principle to Stillman's apparatus (vide Fig. 331). Stillman also endeavored, by means of springs articulated at the ankle-joint, to counteract the tendency- of the foot to Orthopedics and Orthopedic Surgery. 281 rotate inward. In Fig. 329 the spring blade Avhen fastened to the loAA*er extremity* tends to pronate the foot. In older chil- dren and in adults, in order to complete the cure, it is essen- tial to accustom the joint to maintain the pronated position. With this end in aIcav, manipulations which suggest them- selves are useful. Fig. 329.—Stillman's Fig. 330.—Shoe for the After Treat- Fig. 331.— Beely's Shoe. Pulling Spring. ment of Club-foot. vie strap on the opposite side of the pelvis. The cord must, of course, be tightened as the traction force relaxes. Bonnet's apparatus (Fig. 333) consists of two splints for the upper and lower extremity*, respoctiA*ely*, articulated at the knee and ankle. The internal splint terminates in a thigh strap; the external splint extends up to the trochanter and is provided with the ordinary joints for flexion and extension and is also jointed to a steel pefvic band at a right angle. The mechanism of the external splint maintains outward rota- tion of the leg (vide Fig. 29). Meusel's apparatus (Fig. 334)46 consists of a pelvic strap Avith upper extremity* splint articulating at the hip-joint and fastened at the condydes. The loAver portion of the apparatus plays in the groove a. 282 Orthopedics and Orthopedic Surgery. This portion is made up of tAvo splints for the lower extrem- ity, articulating at the knee and ankle and attached to a shoe. The apparatus may be combined Avith any club-foot machine, and occasionally it is advisable to make the external lower extremity* splint someAvhat shorter than the internal in order to render the axis of the tibio-tarsal joint a trifle oblique. Doyle47 has accomplished the same object by means of the spiral rotatory springs represented in Fig. 24. Sayre,48 to obtain outward rotation, has inserted an endless screw across Fig. 332.-Bruns' Appa- Fig. 333.-Bonnet's Fig. 334.-Meusel's Apparatus for ratus to Overcome Inward Apparatus. Overcoming Inward Rotation. Rotation of the Leg. the thigh splint. When this screw is turned, rotation may* be accomplished to the extent of three-quarters of a circle. For the purpose of preventing inversion of the anterior portion of the foot and inward rotation of the extremity, ap- paratus has been devised with mechanism common to' both feet and aiming at keeping the apices of the feet apart. An- nandale49has adapted to his club-foot apparatus mechanism for everting the anterior portion of the sole as much as may be desired. Although, for the vast majority of cases, tenotomy- is not absolutely requisite, yet this operation will materially shorten Orthopedics and Orthopedic Surgery. 283 the time necessary for treatment. In addition to the tendo Achillis, the tibialis posticus may call for tenotomy, particu- larly- if it be a*cry tense. While this tendon retains its normal course along the tibia in case of club-foot, beloAv the internal malleolus it becomes stretched. Tenotomy- of this tendon should be resorted to from above the internal malleolus (Stro- mey-er, Vogt) and the operation had better not be performed subcutaneously. A longitudinal incision, about one and one- half inches long, should be made doAvn to the tendon aboA-e the internal malleolus; the tendon should be hooked up and cut Avith a blunt bistoury*. Section of the plantar fascia is also often a A*ery essential step. This operation, originally* recommended by Guerin, is to-day* chiefly* performed after the method deA*ised by* Parker50 and Phelps, that is to say* the section of the contracted soft parts on the inner border of the foot. Phelps'51 method, as performed by* Ph. Schede,52 Nonchen, Cordua, Lauenstein and others, consists in the section of the tendo Achillis, of the plantar fascia, of the tendon of the tibialis posticus, and of the internal lateral or deltoid ligament. The incision is a circular one at the internal malleolus. FolloAving the operation, the foot is straightened and suitably band- aged. Where all the tissues are tense (the third degree of Phelps), Phelps first performs subcuta- neous tenotomy* of the tendo-Achillis, and next, through an open incision extending betAveen the loAver and anterior bor- der of the internal malleolus and Chopart's joint, he cuts all the tendons and the fascia, to the degree requisite for oA-ercoming the deformity. The Avound is bandaged anti- septically* and, after the lapse of four weeks, a removable plaster shoe is applied, carrying a suitable —1 -shaped iron pro- jection, and the muscles of the calf are subjected to massage and to electricity. In Fig. 335 is represented the case shoAvn in Fig. 295 and treated after this method, and this is a striking instance of the good results attainable. We may* noAV pass to the operations on the bones suitable in case of club-foot, over a dozen of which have been proposed Fig. 335. — The Case of Club-Foot, Represented in Fig. 295, after Tenotomy and Orthopedic Treatment. 284 Orthopedics and Orthopedic Surgery. and in regard to the value of which there is still room for skepticism. Extirpation of the cuboid bone Avas proposed by* Little in 1854 and first performed by Sully. According to Lorenz,53 w'ho resorted to this operation in eleA-en instances with gener- ally* bad results, it is only of A*alue from an historical stand- point, seeing that it does not correct the plantar flexion and the internal border of the foot soon re-assumes a faulty* position. Extirpation of the talus has much more in its favor and has been warmly* indorsed by Lund, Rupprecht, Reid, A"ogt, Bockel, Bessel-Hagen, Margary*54 and many others on the grounds that the arch of the foot is retained, that there are no consecutive disturbances in groAvth and that there results greater mobility betAveen the calcaneus and the bones of the loAver extremity. Lorenz, hoAvever, deems the latter point objectionable on the score of likelihood of recurrence of the deformity*, and he claims that the operation in the adult Avill frequently not correct the plantar flexion and that torsion of the foot often remains. According to Lund's tabulated re- sults, the mean time required for union is six to seA*en Aveeks, and in this respect, therefore, the operation has nothing in its favor over others. Indeed, extirpation of the talus is adA*an- tageous only* in so far as it has but little influence on the after- development of the foot. As regards the technique of the operation, the procedures are various: Reid preferred a lateral, circular incision begin- ning behind the internal malleolus and extending oA*er the heel to the antero-external side of the extensor tendons. The flap Avas rolled upAvard, the foot joint opened and the talus re- moved. Maas also made a circular incision aboA*e the talus. Lorenz found an anterior longitudinal incision sufficient. Konig55 carried his incision from the external malleolus above the eminence of the lateral borders of the talus to the side of the extensor tendons below Chopart's joint. Rupprecht56 resects a piece from the apex of the external malleolus in the belief that thus extirpation of the talus and subsequent re- dressement is rendered easier. Bessel-Hagen advocates chis- elling off obliquely* the outer side of the external malleolus. In children the cartilage of the loAver end of the fibula must be avoided during any* of these methods, lest the bones of the lower extremity* develop unequally. Orthopedics and Orthopedic Surgery. 285 In a number of a-cry- aggravated cases it has been neces- sary, especially- in adults, to remove pieces from the os calcis, the naA-icularis and the cuboid, and eA*en to extirpate one or more of the cuneiform bones before it Avas possible to OA*er- come the deformity. Halm also remoA*es a segment from the anterior process of the calcaneus. Albert has enucleated the talus and cuboid, Halm the talus, cuboid and navicular, and West and Bennet the navicular and the cuboid. Of the various resections, that of the head of the talus (Liicke, Albert) is performed by- preference by Kocher57 in cases which are not specially* aggravated. Lorenz has re- ported two cases of paralytic pes A-arus successfully treated after this method and I can add a third case. In severe con- genital club-foot the method does not seem appropriate, for it does not of itself remove the obstacle to correction, it being often essential to cut, in addition, the shrunken ligaments and the tendon of the tibialis posticus. Lorenz claims that the method is irrational, being followed by* shortening of the inner border of the foot. Hitter's method of the removal of a Avedge, with outer base, from the external portion of the neck of the talus has not found favor. The procedure generally* in vogue is wedge-shaped excision from the tarsus (O. Weber, Davies-Colley*, Davy*, Hirschberg). Lorenz58 has collected ninety-one instances, the mean duration of treatment being six to seA*en Aveeks. This operation best fulfils the indications. It corrects the torsion and curvature and it compensates the plantar flexion. The function of the foot, OAving to the subsequent stiffness, certainly- cannot be compared with that of the normal foot; still, Mensell, Reid, Schede, and Roser59 have recorded very* favorable results as regards function, especially in connection Avith the talo-crural joint. The methods of performing Avedge-shaped tarsotomy* are varied. O. Weber first removed a wedge from the cuboid and calcaneus. Davy and DaA-ies-Colley removed the cuboid and then portions from the talus, calcaneus, navicular and cunei- form, exceptionally even the cartilage of the two last meta- tarsal bones. Nicoladoni removed only* the caput tali and a piece from the proc. ant. calcanei. The Avedge of bone to be remoA*ed should haA*e its apex, as a rule, in the navicular bone and its base in the anterior por- 286 Orthopedics and Orthopedic Surgery. tion of the neck of the calcaneus and in the cuboid. The tarso- metatarsal joint should be avoided. The base of the \*ertieal wedge naturally lies backAvard, and the bones must then be resected to a greater extent. Many operators advise the de- termination of the requisite size of the Avedge to be remoA*ed by experiment on a plaster cast. After the removal of the wedge with a sharp chisel—the base of the Avedge implicating the cuboid, calcaneus and talus, and the apex the naA-icularis—the tense ligaments of the sole of the foot must be cut and then, ordinarily, correction is possi- ble. The wound must be dressed antiseptically- and the posi- tion must be maintained by* suitable orthopedic apparatus. Exceptionally* the bone suture may* be employed, and for this purpose Duret and others recommend crin de Florence. The methods of incision for tarsotomy are also varied. Bryant makes a transA-erse incision over the dorsum of the foot, extending from the tuberosity of the navicularis to the outer border of the cuboid; a second incision is made along the outer border of the foot in order to cut the extensors. As a rule, however, owing to the displacement of the extensors (vide Fig. 279), this latter incision is not requisite. Bush's flap method is objectionable on the score that in case of para- lytic club-foot the flaps readily* become gangrenous. Albert makes an incision doAvn to the bone along the outer, and a smaller incision along the inner border of the foot. The soft parts of the dorsal and plantar surfaces are next pushed off the bones, and then the Avedge is sawed out. In the A*ast majority* of cases, especially* when the foot is not large, a longitudinal incision, parallel to the course of the extensor ten- dons, 0A*er the centre of the convexity*, Avill suffice for the operation. Although noAv, even under antiseptic precautions, the ope- rations for club-foot are not without risk (Lorenz places the mortality at 1.25$ and he estimates the risk to life at nearly 10 per cent), still, without question in chronic cases these ope- rations are justifiable. In infants any operation on the bones must be considered erroneous, and although, OAving to the social condition of the parents, extirpation of the talus, etc., is performed in many* an infant, still such methods should here be rejected, being, as Lister and Guerin express it, unneces- sary* mutilation. For by means of suitable orthopedic treat- Orthopedics and Orthopedic Surgery. 287 ment, associated exceptionally- with tenotomy- or Avith Phelps' operation, the foot will continue to deA*elop, eA*en though the appearance of the foot is not essentially* bettered (vide Fig. 336, b). In the exceptional instances where in children an operation appears essential, enucleation of the talus is the most rational procedure (Lorenz, Rupprecht, and others) since it does not interfere as much with the development of the foot as, for in- stance, the Avedge-shaped excision. In adults, the conditions are very different and in cases of accidental pes varus resection is the only way of restoring function. In case of paralytic and congenital (chronic) pes Fig. 336.—a, Bilateral Club-foot Before, and b, After Tarsectomy (Margary.) varus at about the twentieth year, mechanical treatment has to overcome such obstacles that Avedge-shaped excision here, as well, appears justifiable (Hirschberg,60 Rydy*gier). According to Lorenz, the interests of the patients demand that Ave should endeavor, by* means of tenotomy* and section of ligaments and of fascia, to limit the extent of the resection as much as possible. In regard to the choice between Avedge- shaped excision and enucleation of the talus, opinion varies. Some favor the former, while the latter has Avarm advocates, and both methods have yielded good results. We reproduce tAA*o of Margary's61 cases. In Fig. 337 a is shown a case of bilateral varus and in Fig. 337 b the result after extirpation of the talus, navicularis, and cuboid on the left side. In Fig. 288 Orthopedics and Orthopedic Surgery. 338 a is seen a case of left club-foot and in Fig. 338 b, the same after wedge-shaped tarsectomy. According to Bessel-Hagen, the statistics speak in favor of extirpation of the talus. In 122 Avedge-shaped osteotomies there were 5 deaths, 45 distinctly bad results, in over 30 recur- rence; in 61 talus enucleations, in 11 of which wedge-shaped Fig. 337 a.—Bi-lateral Club-foot. Fig. 337 b. After Operation on Left. excision Avas also performed, there was 1 death, and 57 good results. In regard to paralytic club-foot, operations which aim at artificial ankydosis may be resorted to. These operations have been chiefly* deA*ised by- Albert, and they are particularly adapted to poor patients A\*ho live in the country where treat- ment by orthopedic apparatus is not possible. Lesser and Itydygier62 have lately* described their methods. A longitu- dinal incision is made oA*er the ankle joint along the fibula to the extent of tAvo inches. A slender Avedge, with base out- Avard, is removed from the upper surface of the talus; the Orthopedics and Orthopedic Surgery. 289 cartilage is remoA*ed from the lateral articular surfaces of the talus and from the fibula and tibia; the deformity* is corrected and the foot is dressed antiseptically* in a fixation bandage. In order to insure the result, the patient should be made to wear a shoe fitted with immoA*able lateral splints. Pes Valgus.—Pes A*algus (flat, splay* foot, pes abductus pronatns reflexus [Hencke]) constitutes that deformity where Fig. 338 a. Fig. 338 b. the foot is pronated and abducted. The outer border of the foot is lifted upAvard, the inner looks dowmvard, and the curv- ature of the sole is obliterated. Pes valgus may- be congenital or acquired. The latter is by-far the most frequent and essential form, the reA-erse of AA*hat holds in case of pes varus, Avhere the congenital form is usually- met Avith. Talipes valgus congenitus is ordinarily* a calcaneo-valgus, and in the majority- of instances the deformity- is due to ab- 19 igO Orthopedics and Orthopedic Surgery. normal intra-uterine pressure (Tamplin, Lonsdale) or position (Liicke, Volkmann, Vogt). Exceptionally it is the result of defect in growth, such as a rudimentary development or defect of the fibula,63 instances of which have been reported by* Wag- Fig. 339.—Acquired Pes A*algus. Fig. 340.—Congenital Pes Valgus. staffe64 and Meusel. According to Kiistner, 8.6 per cent of the cases are congenital. In 764 cases of congenital talipes, Adams found 42 cases of talipes valgus, 15 of talipes A*algus on the one side and talipes varus on the other. Of the 42 instances, 15 Avere on the right side, 10 on the left, and 17 bilateral. As characteristic points in congenital valgus, Kiistner lays stress on the sharply* pronated, abducted, and dorso-flexed position. The com*exity* of the sole is very marked. The dorsum is bent in, and, ordinarily, on the inner border of the foot, the caput tali and the navicularis project strikingly*. The anatomical alterations in congenital splay* foot do not im- plicate the shape of the bones i o any* great extent, eA*en in aggra- vated instances. As a rule, the heel is only slightly elevated, although, even as in pes varus, it may* be sharply* draAvn upAvard (Fig. 341). This will vary, of course, according to the contrac- ture of the muscles of the calf of the leg. The talus is sharply directed forAvard and downward and is not essentially altered in shape. The navicularis suffers rota- tion around its antero-posterior axis, its internal portion sink- ing markedly downward. Its external portion, in slighter degrees of deformity, projects upward. In aggravated cases Orthopedics and Orthopedic Surgery. 291 there results convexity* of the sole of the foot. The cuboid is rotated transA-ersety. The relations of the bones of the tar- sus at Chopart's and Lisfranc's articulation are somewhat altered. The ligaments between the talus and the navicularis are generally stretched on the inner side; the muscles are not Fig. 342.—Pes Valgus Paralytic. Fig. 343.—Pes Valgus in an Adult. specialty altered. In a number of instances Holl65 found con- genital coalition between the os calcis and scaphoid, and he thence concluded that when such a coalition is determined, it points to the congenital origin of the deformity*. Acquired splay* foot is far more common than congenital. The differentiation is made between rachitic valgus (occurring Fig. 344.—Spastic Pes Valgus in a Girl of 14. Fig. 345.—Traumatic Pes Valgus Following a Railroad Accident. in infancy and up to the fifth year) and ty*pical or static valgus (developing at puberty). The paralytic variety (Fig. 342), the spastic variety (Fig. 344), and the variety due to trauma or to disease of the bone (Fig. 345) are very infrequent. 292 Orthopedics and Orthopedic Surgery. In 999 cases of acquired contracture of the foot, Adams found 181 instances of pes valgus, 80 of equino-valgus, 110 calcaneus and calcaneus-Aalgus. Rachitic pes valgus results from abnormal softness of the bones and it is usually* associ- ated with genu valgum or rachitic curvature of the thigh (vide Fig. 42). Pes A*algus adolescentium unquestionably* is the result of abnormal lasting pressure, such as protracted standing. This is proved by the infrequent occurrence of the deformity* in girls in the higher walks of life, and its frequency, on the other hand, in individuals Avith relaxed muscles and in those avIio are obliged to Avork hard in the standing posture, Avhence insufficiency- of the muscles and relaxation of the ligaments result. It Avas formerly* the belief that atony* of the plantar aponeurosis (Stromeyer) and Aveakness of the muscles, partic- ularly* the tibialis posticus and those of the sole of the foot, Avere the first etiological factors in the production of splay- foot ; but the fact is, that protracted and increasing pronation of the foot, the result of pressure, constitutes the most essen- tial factor. There can be no doubt that the etiological cause of pes A*algus adolescentium is abnormally frequent and long-con- tinued pressure, and especially- constant standing. It is there- fore exceptionally* rare among girls of the wealthier classes and is most often seen in persons of lax musculature Avhose groAvth has been rapid. Flat-foot is frequent in certain occu- pations for the same reason, letter-carriers, domestic servants, porters, etc., being often affected; their Avork being arduous and carried on standing, and their hours of recreation and sleep being too short, so that muscular insufficiency- and liga- mentous relaxation set in. Atony of the plantar aponeurosis has been regarded as the cause of the valgus by* Stromeyer and others; weakness of the muscles, especially of the tibialis posticus and the plantar muscles, has been blamed for flat- foot; but there can be no doubt that the above-mentioned per- manent position of the articulation, caused by pressure upon the foot, gradually* leads to a sinking in and flattening of the arch of the foot: or, in other words, that the permanent and excessiA-e pronation is the immediate cause of pes valgus. Henke regards the condition a change of position of the component parts of the joint, from the widening- of some and Orthopedics and OrtJwpedic Surgery. 293 the destruction of others of the articulations, and calls flat- foot pes flexus pronatus reflexus; in which vieAv Konig and others agree with him. Hiiter, on the other hand, regards it as a developmental deformity-, an unequal distribution of the pressure upon the points of contact of the bones causing un- equal groAvth of these structures. Lorenz has shown the un- tenability* of Hitter's A-iews. V. Meyer inclines to Henke's opinion, but he regards the change of position of the articular parts not as a direct sink- ing,, but rather as an overturning of the bones; claiming that the internal border of the foot and the lig. calcaneo-scaphoid Avould necessarily be lengthened if the former occurred. Lucke66 says: A complete flat-foot, and a complete abduc- tion-foot (P. plano-valgus) can only occur Avhen there have been changes Avithin the joints, the articular surfaces having separated from one another, and having thereby caused a change in the shape of the bones. Reismann6T regards flat-foot as an actual contracture, first of the extensors, and then of the pronators, consequent upon insufficiency of the plantar flexors from oA*er-exertion. But although muscular contracture is the most prominent symp- tom in some cases, Ave are not therefore entitled to base the entire theory of flat-foot upon a single phase of the condition. Lorenz68 has subjected the various theories of flat-foot to an exhaust!A*e criticism, and I must refer the reader to his Avork for information. He has shoAvn that an exaggerated position of pronation alone is not enough to cause articular changes similar to those found in flat-foot; for in addition to the motion betAveen the astragalus on the one hand and the os calcis and the scaphoid bone upon the other, Avhich is not rotation upon the axis of the joint, but is rather a motion from postero-externally to antero-internally, there is an actual sliding of the bones upon one another. Lorenz's exact patho- logico-anatomical inA*esttgations lead him to this result: that "valgus acquisitus is caused by pressure, and consists of a sinking of the external portion of the arch of the foot, to- gether with a partial sliding off of the internal from the ex- ternal arch of the foot " During the development of the deformity, there may* occur irritative conditions of the periosteum in those places; they being either involved in the displacement (external surface of 294 Orthopedics and Orthopedic Surgery. the neck of the astragalus, parts of the upper surface of the neck of the os calcis) or they* are implicated later in the for- mation of independent nearthroses (nearthor. calc. fib.; calc. nav.; talo-nav.; Fig. 347) (Lorenz). The results of such irritation are the osteophytes and bony* walls which are almost ahvays found in such situation (Figs. 346, 347); these bony walls forming a kind of " self-limitation " to further development, and accounting for the fact that, under certain circumstances, flat-feet which are contractured Fig. 347.—Reflexed External Arch of Foot, a b, Nearthrosis Calc. Fibul. (After Lorenz.) Fig. 348.—Internal Aspect of Flat-foot, a, Tub. Nav., which forms a Fulcrum, and which is the deepest portion of the Internal Border of the Foot; c, Lig. calc.-nav.-plant., forming an arch between its two points of insertion a and 6. On account of Fig. 346.—The Astragalus in Flat-foot, the adduction contraction of the middle portion of x, Bony Wall. the foot, the metatarsus hal. appears shortened. and with repeated active symptoms are of a more faA*orable prognosis than those which run a more torpid cause, and in which such a limiting bony Avail is not formed in any* such de- gree. Changes in the bones and articulations, especially in the talo-tarsal articulation, occur in pes valgus acq. These can- not, however, be regarded as resulting from an actual osteitis, but rather as due essentially to the valgus condition of the calcaneus. For the calcaneus is noAv no longer situated under the middle of the loAverlimb; the astragalus, A\*hich usualh* rests upon the calcaneus like a lady* on horseback (Starke) Orthopedics and Orthopedic Surgery. 295 has slidden off Avhen the latter bone assumed a position of pronation, and pressed upon and stretched the lig. calc. nav*. The tibia and fibula show nothing abnormal in mild de- grees of flat-foot. In the seA-erer grades the point of the malleolus externus is someAvhat flattened and rounded off; in the worst cases it is entirely- flattened out (Fig. 347). The head of the astragalus is usually* very* prominent, the scaphoid bone being displaced upon it laterally, and being, at the same time, rotated upon its sagittal axis, so that its tuberosity is entirely* beneath the border of the foot. The astragalus is not essentially* changed, the line of inser- tion of the capsule, eA*en in high degrees of A*algus, being on the Avhole analogous to that of the normal foot. But the relation of the cartilaginous border of the articular surfaces is altered, and the curA*ature of the astragalus is markedly- flattened (Fig. 346). The articular facets for the malleoli are changed in shape and direction, being displaced anteriorly* without being covered with cartilage. While the cartilaginous coat upon the pos- terior surface of the astragalus is entirely* normal, it is defi- cient Avholly* or in part upon the middle upper surface. Upon the anterior surface up to the insertion of the capsule it is absent (Fig. 348), the border between the anterior and middle parts being fairly* straight and similar to the cartilaginous border in the normal bone. Hence the lengthening of the intra-capsular strip of bone is only* apparent, and the internal and external surfaces are of equal breadth. The head of the astragalus is considerably* changed in shape; it is diA'ided by an obtuse angle into two surfaces, the greater part of its oval being taken up by the facets for the scaphoid bone. At the inner lower portion of the circumference of the head is the facet corresponding to the lig. tibio-calc.-naA*.; and a small flat facet is frequently found in connection Avith it, for articulation Avith the median edge of the upper part of the neck of the calcis. The more pronounced the flat-foot, the more does the apex of the navicular facet recede from the lower inner tuberosity* of the oval head of the astragalus. It slips outward, upward, and backward, and the ligamental facet takes possession of the entire inner lower portion of the surface of the head of the astragalus (Lorenz). In marked valgus the entire surface of the head of the 296 Orthopedics and Orthopedic Surgery. astragalus is taken up by- the ligamental facet, Avith the ex- ception of a small part of its upper external surface. In a number of cases the naAicular facet has been found displaced bey*ond the normal external upper border of the OA*al head on to the external border of the neck; and its continua- tion is found on the anterior surface of the body of the astrag- alus in the form of a rounded tubercle Avith raised edges and covered with coarse fibro-cartilage. In veiw bad cases the hollow of the scaphoid bone extends over the distance from the upper end of the oval head to the anterior surface of the body* of the astragalus, and lies like a bridge OA*er the external con- striction of the neck, forming a canalis talo-naviculare. In 1 •-? Fig. 349.—Talus of a Marked Case of Flat-foot, A'iewed from Above and Within. (After Lorenz.) c, Upper curved surface covered with cartilage as in the noimal; n, inner curved surface covered with normal cartilage; d, upper curved surface with defective cartilaginous covering; m, inner curved surface with defective cartilaginous covering; e, (shaded) former extent of the intracapsular ridge of bone; 6, intra-articular surface, narrowest at a; g, (shaded) remains of the intracapsular ridge of bone in the talo-nav. articulation. fact, the na\*icular bone has suffered an almost complete luxa- tion. In other cases, the displacement between scaphoid and as- tragalus causes, by means of periosteal irritation, the forma- tion of an absolute bony Avail (Fig. 350), which forms to a certain extent a lengthening of the external upper oval head; it is sometimes irregularly flag-shaped, but is oftenest remark- ably regular in its outlines. Its anterior upper surface is rough and irregularly covered Avith cartilage. In these cases the oval head of the astragalus can be distinctly- divided into three surfaces. In the astragalo-scaphoid joint avc find no special alteration in the intra-capsular ridge of bone. At all events, there is no widening at the inner border, as Hiiter's theory* would demand- it is rather lessened.69 In the calcaneus also, the changes incident to flat-foot are Orthopedics and Orthopedic Surgery. 297 chiefly* surface changes; the height of the neck of the bone being not specially affected. Along the external posterior sur- face of the articulation the astragalus is not in contact Avith the calcaneus at all, the surfaces being imperfectly covered with cartilage (Fig. 352). In bad cases of flat-foot, this free border becomes Avorn doAvn; and the fac. artic. lat. Anally is composed of tAvo sur- faces meeting at an obtuse angle, the larger anterior and inner Fig. 350.—Flat-foot Talus from Without. (After Lorenz.) b, Ridge of bone on the external upper border of the oval head of the astragalus with nearthrotic surface; a, boundary line between the cartilage-covered posterior part of the lateral curved surface, d, and the anterior portion, im- perfectly covered with cartilage, c: e, nearthrotic surface on the anterior margin of the lateral edge of the crest of the talus. one representing the remains of the joint-surface. The short- ening of the calcaneus joint-surface caused in this Avay* may be as much as two-fifths of an inch in aggravated A*algus. The joint surface of the sustentaculum tali begins to lose its cartilage at the anterior external and loAver border in mild cases of flat-foot, in the worst cases of A*algus acq. it may dis- appear entirely, and the sustentaculum tali may become a rough uncoAered tubercle. With comparative frequency there is found on the median upper border of the edge of the os calcis a cup-shaped facet, Avhich, Avith the nearthrodic hollow on the anterior surface of Fig. 351 .—External Arch of a Normal Foot Seen from Outside, ge, Lig. Calc. Cuboid; co, Profile of theFacies Artic. Lat., the surface of pressure in the ex- ternal arch of the foot. Fig. 352.—Sunken External Arch of a Flat-foot (after Lorenz), with the Formation of a Ridge of Bone, the Cuboid being displaced upward on the Fac. Cub. Calcan.; at b, the plantar edge of the Fac. Cuboid, rests upon the Lig. Calc. Cub., whose position is shown by / g. 298 OrtJiopedics and Orthopedic Surgery. the body of the astragalus, forms a complete bony bed for the scaphoid bone. Lorenz has also demonstrated the interesting fact that there occurs a movement of the lateral edge of the astragalus on the neck of the os calcis—from behind outward to in front inward. Like the head of the astragalus, the anterior joint-surface of the calcaneus may* consist of two or of three facets. The under portion of the lower joint surface shows not in- Fig. 353.—Astragalus and Calcaneus of a Flat-foot in their Natural Position, and seen from Within. (After Lorenz.) a, Boundary between intact, c, and defective, b, cartilaginous covering of the median side of the curved surface; the sustentaculum tali, /, corresponds to the sulcus tali instead of the facet, d, of the talus. frequently an atrophic covering- of cartilage where it is unco\*- ered from the cuboid. The os cuboideum shows special changes only* in the higher grades of valgus, so that its anterior and posterior surfaces lose their normally parallel relationship, the anterior surface becoming inclined forAvard and perhaps irregular and ridgy*. The shape of the navicular bone is often greatly* altered, It becomes Avedge-shaped, and its external sagittal diameter may* sink to about tAvo-flfths of an inch. Its upper and outer cartilaginous covering may* be lost, according as its contact Avith the astragalus is changed. As regards the ligaments, flat-foot shows a general loosen- ing (Lorenz). Thus it may* be demonstrated anatomically* that the ligaments betAveen the astragalus and the calcis permit Orthopedics and Orthopedic Surgery. 299 movements betAveen the bones in A-arious directions, but es- pecially from behind externally* to Avitbin anteriorly, just as in a loose amphi-arthrodial joint. This shows that the ligamenta calc. interossea must have been stretched and become loosened enough to permit of motion betAveen astragalus and calcis. The lig. talo-calc. is lengthened and changed in direction; in A*ery* Avell developed A-algus it may disappear entirely*. The lig. calc. fibulare in aggravated cases forms an acute angle Avith the fibula; and in case of a nearthrosis betAveen the point of the fibula and the calcis, it may* be entirety destroyed. The lig. tibio-calc.-nav. and the lig. calc.-cuboideum are always stretched and lengthened; while the lig. calc. naA*. interosseum, when not de- stroyed, is always shortened. As regards the positions of the joints in flat-foot, in bad cases the talo-tarsal joint is not only in a position of pronation, but the astragalus appears to have slipped off the calcis entirety. With respect to the articulatio calc.-cuboidea reflexion of the joint occurs Avhen the external arch of the foot is flattened. FlG. 354 _ outlines of The talo-crural joint is in a state of an Adducted Fiat-foot -, n , r, ■ r, j p , seen from Above. (After greater or less plantar flexion in flat-foot. Lorenz.) Note the zig- This may be considered a compensatory* zag course of the Axes movement, for it is a direct consequence of ° te ones' the sinking of the external arch of the foot. In aggravated cases, the motion of the joint is almost entirely lost, only* a slight amount of dorsal flexion being obtainable. The normal arc of motion of 70° to 80° sinks to 45° or even 32° (Lorenz). Finalty, in well-marked cases of flat-foot we must not for- get the contracture in adduction of the metatarsi, which gives the inner border of the foot a peculiar zigzag course, as shoAvn in Fig. 354. The head of the astragalus forms the most inter- nal point, and the notching of Lisfranc's articular line can be plainly seen. If we draw a straight line (d h) from the median curved surface, the distance from it to the tarso-metatarsal articula- tion, in high degrees of flat-foot, is, according to Lorenz, about one and one-half inches instead of about one inch in the nor- 300 Orthopedics and Orthopedic Surgery. mal pronated foot. The distance, k h, of the cap. metatarsi from the line Avill be about one inch, as against one and one- quarter inches ordinarily*. The angle, in ns, formed by* tarsus and metatarsus is about 170° normally*; it is here diminished to about 135°. As to the sy*mptoms of acquired flat-foot—as the name im- plies, they consist mainly of a flattening of the arch of the foot, and a depression of the proc. ant. calc. and of the head of the astragalus (Fig. 355). In rachitic flat-foot, sy*mptoms of rickets in other places Avill rarely* be Avanting; rachitic curvature of the limbs being present with especial frequency. A fixed contractured position does not, howeA'er, appear to result from the rachitic valgus of childhood. In pes valgus adolescentium, evidences of early* rickets are rarely demonstrable. When the patient stands, more especially, the foot appears broad- er than normal, clumsy, and turned outward; the arch of the foot and the inner border of the foot are sunken; the heel is more promi- nent posteriorly, and the tendo Achillis seems tenser than natural. The point of the foot is abducted, the toes are extended, the AA*hole ante- rior foot is pronated. Under the prominent internal malleolus, c, is seen a rounded prominence (flat-foot hump) (Fig. 355). It consists of, first, b, the caput tali, beloAv and anterior to this is a, the tub. o, navicularis. The foot is usually* livid and prone to be covered with sweat. Not infrequently- the mus- cles are imperfectly developed, and the veins are dilated. The consequences of pes valgus are a heavy1- inelastic, drag- ging gait; the patient is easily fatigued and is incapable of much exertion. Hence flat-footed persons cannot serve in the army7. In accordance Avith the grade of functional disturbance Ave distinguish a torpid and an inflammatory pes valgus. In any* severe case of valgus the functions of the foot are more or less interfered Avith, the mobility of the astragaloid joint in respect Fig. 355.—Pes Valgus Ad. a, Tub Navicularis; 6, caput tali; c, malleolus int. Orthopedics and Orthopedic Surgery. 301 to dorsal flexion, and that of the talo-tarsal joint in respect to supination, being diminished. Not infrequently the faulty- position becomes a fixed one, and the pes valgus becomes a contractured Aalgus. In these latter cases, the symptoms become very* typical, and the subjective troubles of the patient reach a high grade. Characteristic and violent pains (tarsalgia) appear, located in those joints that are most affected. The French authors call this condition tarsalgie des ado- lescents (Guerin, Gosselin) or pied plat v. douloureux (Teril- lon), AA*hile Avith us the designation of inflammatory or acute flat-foot (Volkmann) prevails. Neither term is very appro- priate. There is no real inflammation of the joint, but rather localized traumatic irritation of the periosteum, causing the appearance of the ridges of bone above mentioned. The term contractured static flat-foot (Konig, Lorenz) is perhaps the most appropriate one. The condition usually appears after excessive exertion, a long march, or prolonged dancing. Violent pains, Avith pro- nation, abduction, flattening, and especially* fixation of the foot in the above-mentioned position mark its advent. In very- pronounced cases the tension of the tendons (tib. antic, pero- nei, Achillis) can be plainly seen; and the muscular contrac- ture becomes more marked when avc attempt to OA-ercome it by passiA*e motions. The mobility of the ankle joint is dimin- ished; pronation and supination cannot be effected, since motion betAA*een the talus and calcaneus is suspended. There are almost constantly present certain characteristic painful points (Hiiter), corresponding to the tuberos. oss. miA*., the head of the astragalus, and the processus ant. calc; for the lig. calcaneo-nav-. is tense and stretched and the entire foot is compressed by the extreme pronation. Other painful points in the sole and OA*er the metatarso-phalangeal joints (Liicke 70) and at the loAver tibio-fibular junction sometimes appear. Local oedema occasionally' occurs, which has led some observ- ers to predicate the existence of actual inflammatory action (Gosselin, Lanneloque). The contracture that occurs is prob- ably an instinctive fixation by- muscular action similar to that which appears in joint inflammations (Roser). The diagnosis in the early painful or intermittent stages sometimes presents difficulties. Not infrequently* a commenc- 3°2 Orthopedics and Orthopedic Surgery. ing osteitis, a neuralgia, or rheumatism is diagnosticated (Liicke). When young persons complain of being easily tired when they Avalk and stand, they should be thoroughly ques- tioned as to occupation and habits. The foot should be exam- ined and compared with its fellow. If necessary an imprint of the foot should be taken upon paper; for in pes valgus, besides the normal track (Fig. 357) consisting of the external edge of the sole, the ball of the foot and the toes, a greater or less part of the internal border will be imprinted (Fig. 356), in accordance with the amount of the arch that is lost. As regards the course of pes valgus, there are occasionally three stages: one of development, a painful stage, and a con- Fig. 356 a. and 356 b.-Print of Sole in Severe Fig. 357—Print of Sole of Pes Valgus. Normal Foot. fractured stage. But the affection may remain stationary at any stage of its development if the conditions which caused it alter. There is usually permanent though not very marked disability (inelastic gait, etc). If there is marked ab- duction pain will seldom be wanting. In the higher grades contracture is usually present, and the patient is completely incapable of any protracted exertion. In the less severe cases the contracture soon disappears if the foot is not used for a day, and cold is applied to it. Even if untreated not all contractured flat-feet become stiff; and especially in individuals over twenty years of age there occurs an accommodation of the muscles to the changed joint relations. Only in a small proportion of cases is there Orthopedics and Orthopedic Surgery. 303 nutritive shortening of the muscles; but in these cases a luxa- tion of the peroneal tendons over the malleolus ext. may even occur. The consecutive irritation may* interfere greatly with motion, and may* even cause complete ankylosis of the tarsus. Flat-footedness is therefore an affection that deserves at- tention even in its first stages. By appropriate measures its progress may be checked. The prognosis is best for valgus dependent upon muscular weakness, and is not bad for the rachitic form in its early* stages. It is fairly unfavorable, however, as regards restoration of function in marked cases of inflammatory* A*algus. Prophylaxis also is possible. Good general nutrition, baths, massage, and the avoidance of over-exertion of the feet, and Fig. 360.—Spring Fig. 361.—The Same with Fig. 358 and 359.—Correct Contour for Sole Apparatus Lateral Piece. (After Shoes. (After Meyer.) for Flat-foot. Beely.) especially of standing much in beginning cases of tarsalgia— these measures Avill tend to preA*ent the deAelopment of the affection. Gy*mnastic exercises, active and passive motions of the feet, and attempts to Avalk upon the external surface of the naked feet, haA*e been recommended especially by B. Roth.71 The use of electricity*, both induced and constant current, is to be recommended. The mechanical treatment of pes valg. cong. consists of mechanical replacement in as correct a posi- tion as possible, and fixation there by firm bandages, or Volk- mann72 recommends gutta-percha splints for that purpose, at- tached to the extremity Avith bandage or plaster. Tenotomy* is rarely necessary* in flat-foot, though Tamplin 73 and others have recommended cutting the ext. communis, the peronei, the tib. antic, and even the tendo achillis. ffi 304 Orthopedics and Orthopedic Surgery. The rachitic flat-foot must be prevented from getting worse by* some supporting apparatus. A flat-foot shoe, which is a Scarpa's shoe with tension in the opposite direction, and with an articulated piece to be applied to the inner side of the leg, may be employed. Suitable anti-rachitic treatment must not be neglected. In congenital pes valgus, also, when pains appear, a suita- ble apparatus is indicated. The important point is that the apparatus correct and redress the deformity as much as pos- sible, keeping the foot somewhat supinated, and counteracting the tendency to further flattening of the arch. The shoes should be laced, and should extend above the ankle. The inner edge of the sole should be thicker than its external margin. The heel should be of medium height (about one and one-half inches), broad, and placed well forward, so that it reaches the region between the calcaneus and the cuboid, so as to keep the neck of the astragalus in its place. The sole should be gradually bevelled off outward, and should have a suitable adduction-curve (Myer, Roser). It is well to give a pattern of a proper sole to the shoemaker. Soft elastic compresses placed under the arch of the foot were formerly employed. Lorenz has demonstrated their complete uselessness. A properly shaped steel spring, how- ever, suitably* padded, such as Reynders has recommended, may* be used instead of the crooked thick sole. It should sup- port almost the entire breadth of the foot, and should be split into separate springs lengthways and transversely*. (Beely*,74 Wolfram, etc.) Such a sole may be made to fit the plaster model of the foot, and it may* be supplied Avith an internal lateral splint which is fixed by a band above the ankle (Fig. 361). It should not be immovably fixed to the sole. Formerly there Avas always an internal piece articulated at the ankle attached to the flat-foot shoe. Some recommend bilateral splints fixed to a garter beloAv the knee, or an elastic band at- tached in the same Avay to sustain the arch of the foot. Lorenz recommends an external splint, sustaining the inner surface of the foot with a leather band. His flat-foot shoe has a thick external wall and a cap for the os calcis; it slopes gradually to the external border and backward to the heel, which is broad, placed well forward, and one and one-half inches high. Orthopedics and Orthopedic Surgery. 3°5 But patients Avith flat-foot frequently apply to us only* when they* suffer pain—Avhen contracture has set in; and eA*en if rest soon eases the pain the patient's ability to work is never theless much diminished. No one can reconstruct an arched out of a sunken foot; deAeloped flat-foot is not an object for our therapeutic efforts (Lorenz). If any operation is to be recomended it is that of forcible reduction under anesthesia into a somewhat supinated posi- tion (Roser), Avith subsequent retention for a month or six Aveeks by a plaster bandage. The plaster may- be replaced in a feAv days by- a starch bandage (Konig), or it may- be covered Avith leather so that it may- be used in the street. It is conceiA-able that under the altered pressure-conditions, the anatomical changes may retrogress to a certain degree. But atrophy- of the muscles is liable to occur under the perma- nent bandage. Tenotomy* of the peronei (Bai-Avell) can only be necessary in the rarest cases. Hausmann mobilizes flat-foot by* means of the apparatus AA'hich has already* been shown in Fig. 249, which pulls the in- ternal border of the foot upAvard, and the external border doAvnward. In the short time of tAvo or three weeks the most aggravated fixed flat-foot may* be brought into extreme su- pination, and this, if the foot is massaged once daily*, Avithout injuring the skin. A remoA*able plaster boot for flat-foot is then employed to maintain the position. A patient can Avear such a boot at least three months, even in bad Aveather. After placing a pledget of cotton in front of the toes, an ordi- nary* woollen sock is put on. A closely folded piece of flannel is then seAved under the site of the arch. A stout piece of paper-mache forms the sole. With the aid of three long plas- ter bandages a shoe is made which may be strengthened on each side Avith pieces of sole leather. While the bandage is setting the foot is to be kept pressed into normal position. The dorsum is then cut up, the whole is covered Avith leather and provided Avith a sole and a broad low heel. It is for the paratytic pes valgus that an artificial substi- tute for the lost muscular tone may be provided by means of elastic traction (Duchenne). The tibialis ant. and post, espe- cially may* be thus supplemented. The simplest Avay is to sup- port the arch of the foot by an (dastic bandage running inside 20 306 Orthopedics and Orthopedic Surgery. the shoe and attached above to the circular piece connecting the two lateral splints (Fig. 362). None of the older valgus appliances are much used to-day*. I figure here Adams', with an internal lateral spring, an end- less screAv corresponding to the joint, and a valgus pad on the inner surface of the sole. It is onty in the severest cases of irreducible contracted valgus that bone operations are to be thought of. Our experi- ence concerning them is yet insufficient. Bennet proposed to excise a Avedge-shaped piece from the side of the astragalus, without opening the joint. Ogston75 attempted to produce a sy-nostosis between the Fig. 362.—Reynders' Apparatus for Paralytic Fig. 363.—Valgus Apparatus. (After Adams.) Pes Valgus. For Cases of Medium Grade astragalus and scaphoid bone in the redressed position. By a longitudinal incision on the inner side he exposed the joint and the caput tali without injuring periosteum or ligaments. He then chiselled so much off the articular surface of the head of the talus and the scaphoid bone that redressing could be effected. Then boring two holes obliquely* through the navic- ular bone into the talus, he inserted two iron pegs to nail them together. He then applied an antiseptic dressing and a plaster bandage. After three months he allow s the patient to use his feet. Up to 1884 he had done the operation seventeen times, in ten patients. Kendal, Franks, Livan, etc., recommend it. Stokes76 regards the essential change in flat-foot as skele- tal, and believes that that of the ligaments is only secondary. He therefore recommends osteotomy* of the astragalus. Based Orthopedics and Orthopedic Surgery. 307 upon one successful case, he directs an incision to be made along the inner border of the foot OA*er the head of the astrag- alus one and onedialf inches long. Another incision meets this at right angles somewhat behind the line of Chopart's amputation incision. After turning back the flap, a wedge- shaped piece of bone, Avith its base dowmvard, is remoA*ed by- means of the osteotome from the enlarged neck and head of the astragalus. By adduction and supination the arch of the foot can be re-established. An antiseptic dressing is put on, and Dupuytren's fibular splints maintain the Avhole in place. EA-en extirpation of the talus has been recommended for pes A-algus (Vogt).77 BIBLIOGRAPHY. 1. Beitrage zur Lehre vom Klumpfusse und vom Plattfusse, Leipzig, 1885.—2. L.c, p. 69.-3. Allg. Wiener Med. Zeit., 1879, 43, Langen. Arch., XXIV., 2.-4. Pitha u. Billroth, II., p. 692.-5. Mitth. aus der Chir. Klinik Greifswald, I.—6. Berlin Klin. Woch., 1885, 11.—7. Klinik der Gelenke., 1876, p. 288.-8. L. c, p. 75.-9. S. Pascand, Diss Paris, 1882.— 10. Prager Vierteljahrschr., 1851.—11. L. c, p. 880.—12. Hand, der Chir. Heilmittellehre, p. 1206.—13. L. c, p. 191.—14. Dittel, Zeitschr. d. Ge- sell. der Aerzte in Wien, VII., 6,1851.—15. St. George's Hospital reports, Nagler.^16. 111. Monatsschr. f. arztl. Polytech., 1881, p. 85.—17. Monats- schr. f. arztl. Polytech., 1886, p. 88.—18. Arch. f. Klin. Chir., 1878.—19. Bigg, 1. c, p. 449.—20. Voigt, Inaug. Diss.—21. Langen. Arch., 26, p. 4(;7._22. L. c, p. 603.—23. Progres Med., 1884, p. 775.-24. New York Med. Rec, 1885, p. 538.-25. L. c, p. 509.—26. L. c—27. Wiener Med. Presse, 1886, No. 27.-28. Brit. Med. Journ., 1884, p. 1147.—29. L. c, p. 437.—30. Wood's Ref. Handb., II., p. 196.—31. L. c, p. 81.—32. Deutsche Klinik, 1851, No. 44.-33. Deutsch. Zeit. f. Chir., 9, p. 353.-34. Trans. Path. So., London, 1884.—35. Vide theAvorks of Htiter, Adamo, Hocker, Bessel, Parker, etc.—36. Klinik der Gelenkkrankheiten.—37. Clark's diss., also Centralbl. f. Chir., 1885, p. 291.—38. L. c, p. 26.-39. L. c , p. 242.—40. Gerhardfs Handb. f. Kinderkrankh., VI., 2.—41. New York Med.Rec, March 2d,p. 216.— 42. Med. andSurg.Rep., 19,1881.—43. Hand- buch der Chir. Praxis.—44. L. c, p. 106.—45. Centralbl. f. orth. Chir., IV., 1886.—46. L. c, p. 585.-47. Phila. Med. Times, 1880.—48. Idem.—49. Edinb. Med. Journ., 1872.—50. Brit. Med. Journ., 1886.—51. Deutsch. Zeit. f. Chir., 25, 3, p. 287.-52. Deutsche Med. Woch., 1886.—53. Wiener Klinik, 1884.—54. Arch. f. Orthopedia, I.—55. Lehrbuch d- Chir., II., p. 634.-56. Centralbl. f. Chir., 1882.—57. Deutsch. Zeit. f. Chir., XVII., p. 82.-58. Deutsch. Zeit. f. Chir., 23, p. 530.—59. Beitr. zur Lehre vom Klumpfuss, Leipzig, 1886.—60. Verhandl. d. Deutsch. Gesell. f. Chir., 1885, p. 91.—61. Arch, di orthopedia, I.—62. Versammlung der Natur- forscher u. Aerzte zu Berlin, 1886, p. 341—63. L. c, p. 600, Mensel.—64. 308 Orthopedics and Orthopedic Surgery. Journ. of Anat. and Physiol., 1872.—65. Langen. Arch. f. Klin. Chir., XXV.—66. L. c, p. 204.—67. Langen. Arch., II., 3, p. 722, 1869.—68. Lo- renz, Die Lehre v. erworbenen Plattfusse, Stuttgart, 1883.—69. Lorenz, 1. c, p. 91.—70. Ueber den sog. Entziindlichen Plattfuss. Volkmann's Vortrage, 35, 1872.—71. Brit. Medical Journal, 1883.—72. Beitrage zur Chirurgie, Leipzig, 1875.—73. L. c, p. 71.—74. Exhibition of the Strass- burger Naturforscherversammlung.—75. Lancet, Jan., 1884.—76. Trans. of the Acad, of Med. of Ireland, Vol. III., p. 141.—77. Mitth. aus der Chir. Klinik, Greifswald. CHAPTEE VII. DEFORMITIES OF THE TOES. Deformities of the toes are frequently regarded by* physi- cians as hardly Avorthy of notice; and, though they often give the patient much trouble, he rarely obtains relief. Onty a small proportion of deformities of the toes are congenital; most of them are acquired from improper shoeing of the feet; for this latter is the chief factor in the etiology of affections of the toes. The accompanying figure will show the extent to which the deformity may extend. It is from the Munich Patholog- ical Institute. The small toe is curled over the others, the great toe is reflected dorsally, and the nails have degenerated into long claws. The toes may be displaced trans\*ersely or vertically. The former is peculiarly* apt to affect the great toe, and is therefore of es- pecial importance. Most important of all probably is the ex- fig. 364Zneform- ternal deviation, the abducted contracture, of ities of the Toes from the great toe, hallux valgus. Instead of be- mproper ing a continuation of the first metatarsal bone, the great toe lies across the other toes, either above or below them. Hence the metatarsus and the great toe form a more or less acute angle with one another, and the head of the first metatarsal bone is more or less abnormally prominent. Not infrequently* the bursa over the head inflames, and it may lead to the estab- lishment of a fistulous opening. This extremely* painful and disabling condition is a "bunion," in French "oignon." If the inflammation does not go so far as this, callosities and corns may appear. Hallux valgus is more frequently, though not exclusively, seen in elderly* persons. It sometimes seems as if the process 310 Orthopedics and Orthopedic Surgery. had some connection Avith chronic rheumatic or arthritic affec- tions. Very marked cases are rare in youthful individuals, although I have recently seen one in a boy* of sixteen y*ears. Position in life does not seem to affect its frequency* of occur- rence. Malgaigne supposed there Avas Aveakness of the inter- nal lateral ligament, and he and Dubreuil regarded muscular retraction as the cause of the affection. Nelaton held that there was a retraction of the extensor hallucis. Nevertheless, in most cases the cause is to be found in the wearing of im- proper shoes, in Avhich the internal border does not form a straight line, and the great toe is therefore pressed against the others (Fig. 365). It occurs the more readily when high Fig 365.—Position of the great Toe Figs. 386 and 367.—Proper Shape of in Consequence of Faulty Sole. (After v. Meyer.) Pointed Shoes. heels are worn, since then the phalango-metatarsal joint is abnormally pressed upon. The sharp toe of the modern shoe is not hurtful to the foot if only the inner edge of the shoe is straight and the apex cor- responds to the great toe (Fig. 367). The older broad shoe is only partly filled by* the toes, which of course have more room for their deAelopment. The anatomical changes in hallux valgus, which Broca first studied, vary a good deal. Not only* is there a large callosity, but there appears a bursa, often multilocular, over the promi- nent head of the metatarsal bone. The base of the phalanx is often displaced entirely from the head of the metatarsal bone, and a new articular surface is formed for it on the side of the latter bone. The head of the metatarsal bone is then covered only with the elongated capsule and the stretched internal lateral ligament; the cartilaginous covering also becomes im- OrtJiopedics and Orthopedic Surgery. 311 perfect (Fig. 369). The furrow in which the tAvo sesamoid bones glide is frequently- crooked instead of straight. Not uncommonly ossified cartilaginous outgroAvths or peculiar Fig. 368.—Position of Hall. A*alg. in Comparison Fig. 369.—Hallux Valg. (Transverse with the Bones of the Normal foot. Section), x, Exostosis. ridges of bone appear behind the articular surfaces, Avhich (like the similar ones we saAv occurring in pes A*algus) are to be regarded as the products of periosteal irritation. Sometimes, again, there is an actual exostosis from the head of the meta- tarsal bone that is thus relieved from pressure—as is Avell seen in a section of such a preparation (Fig. 369)—only that por- tion of the head articulating with the base of the phalanx Fig. 370.—Hallux Valgus. Only the Surface, 'Sk") / d, is in Contact with the Phalanx and Covered -—^ with Cartilage. Fig. 371.—Hall.Valg. in an Elderly Woman. showing a cartilaginous covering (d, Fig. 370). In articular surfaces Avhich are no longer in apposition we find smooth sur- faces, fibrillation of the cartilage, etc.; in short, a fairly marked 312 Orthopedics and Orthopedic Surgery. picture of arthritis deformans. Even the little bones may participate in this process; in seAeral specimens I found their cartilaginous covering Avholty or partly* gone. The flexor and extensor tendons glide off externally, the soft parts on the ex- ternal side are shortened, Avhile the inner ones are more or less stretched. The symptoms of hallux valgus consist chiefly* in the ab- normal position of the great toe. It is usually* situated be- neath its neighbors, not above them. We also note the abnor- mal prominence of the head of the first metatarsal bone. The callosities and bursas forming upon it may inflame and sup- purate. EA*en caries of the joint may* occur. Very much pain and suffering may be caused in this Avay. Pitha tells of a seventy-five y*ears old surgeon Avho, driven to desperation, cut off both great toes with a chisel. The treatment in the first place consists in proper shoes, so avoiding an aggravation of the condition. The boot should be large enough, and its inner edge should be straight. If a painful nodule has already- formed over the joint, a slight prominence may be made for it, and a large bunion-plaster can be worn to protect it. In slighter cases orthopedic treat- ment can consist of a roll of adhesiA*e plaster of appropriate Avidth being wound around the great toe and then passed along the inner border of the foot to the heel, and then back again to the base of the metatarsal bone. Strips of plaster or a roller bandage may- be employed for fixation. An elastic bandage may* be applied in the same Avay*. According to Lothrop 1 the finger of a gloA*e may* be passed oA*er the great toe, and adduction effected by* an elastic band or by* plaster. Konig recommends forced reduction folloAved by a plaster bandage; a method, hoAvever, Avhich is useless when once the affection has become marked. Pitha2 recommended the Avearing during the night of a kind of sandal Avith a spring attached to its internal border, toward which the toe Avas to be drawn. Similar to this is the apparatus of H. Bigg,3 Avhich can be Avorn Avithin the shoe, and consists of a lateral spring with an oval ring for the artic- ular region (Fig. 372). The tenotomies and divisions of the lateral ligament for- merly recommended are not A*ery promising; and the same Orthopedics and Orthopedic Surgery. 313 may be said of the subperiosteal resection of the head of the metatarsal bone, which Hiiter proposed, and Hamilton, Rose, and others recommended. Sayre performed the operation successfully-; but it only* seems to be indicated in cases of sup- puration of the joint. In all other cases, Avhere there is much disability, or bursal inflammation, a Avedge-shaped osteotomy* of the metatarsus, such as Barker4 describes, or the removal of the internal ex- ostosis, as done by ReA*erdin and by* Riedel, is our best resource. With appropriate antisepsis the chisel is the best instrument for the purpose. Riedel's experience Avarns us to be careful in these resections; since, after an apparently entirely* successful opera- tion of the kind, he Avas compelled to remove the heads of the other meta- tarsal bones also, on account of the vio- lent plantar pains caused by the extra pressure on the tarsal bones which made them bore into the sole. Riedel's experience has taught him that resection is permissible only Avhen flat-foot is present. Of much rarer occurrence than hal- fig.372.—h. Bigg's Hallux vaig. lux v-algus is the contrary* deformity* Apparatus. of the great toe, in which it is draAvn toward the middle line of the body*—the pigeon toe, or adduction contracture. The affection may occur alone, or with equino-varus or genu valgum. It may cause much spasmodic pain. A sandal with an appropriate contrivance for retaining the toe in the correct position, massage, and manipulation, will as a rule be sufficient to cure the condition. A tenotomy of the abductor hallucis Avill rarely be necessary*. Lateral deviations of the middle toes, crossed or riding toes, are rarer. They frequently* lead to ingrowing toe nail. A suitable footgear is the most important point in their treat- ment. Of vertical displacements we have those caused by* flexion of the toes, those caused by* extension of the toes, and those in which the first phalanx is extended and the others are flexed. The latter affection is the commonest. Flexion and contrac- 314 Orthopedics and Orthopedic Surgery. ture of the toe, hammer toe, orteil en mavteau, en Z, en griffe, is most frequently* seen affecting the second toe (Figs. 373, 374). According to Starke, too short shoes form an important etiological factor of the condition. As a remnant of an essen- tial paralysis passed through in childhood it is prone to affect the great toe. The metatarsi are mostly strongly- plantar- flexed, and the toes are dorso-flexed as regards the first phalanx. Here also cramp-like pains occur, especially after exertion. Callosities are very liable to develop over the metatarsal Fig. 373.—Hammer Toes heads that project in the sole of the foot; and bursitis, sup- puration, and fistula may occur. Sandals provided with elastic loops for the toes should be used (Fig. 374). Molliere recommends elastic insoles, to press the caput metatarsi upAvard. If there is much disability*, ten- otomy of the extensor tendons or of the plantar fascia is in- dicated. Appropriate after-treatment, howeA*er, must not be neglected. The foot must be fixed to a Avooden sandal or a shoe with low heel and an inclined plane for the ball of the foot. Tenotomy of the flexors, practised by* Goyrand, is hardly* in- dicated; the division of prominent fascia? is more likely neces- sary^ (N. Smith). With the smaller toes, if there is much disability and con- siderable anatomical change, exarticulation is the best method of quickly and radically* curing the trouble. BIBLIOGRAPHY. 1. Boston Med. and Surg. Journ., June, 1873.—2. Handb. von Pitha u. Billroth.—3. New York Med. Record, 1874.—4. Lancet, 1884. Fig. 374.—Apparatus for Hammer Toes. CHAPTER Till. PARALYTIC DEFORMITIES. The paralytic deformities form a series of characteristic orthopedic affections, and may be caused by various central and peripheral diseases. Infantile paralysis, idiopathic poliomyelitis anterior, has been Avell described by Heine. Rilliet and Barthez rather im- properly- designate1 itparalysie essentielle. It usually occurs in perfectly* healthy children of from one to four years of age; but analogous cases have been seen, though rarely, in adults (M. Meyer). After a short initial stage, fever, ex- haustion, convulsions, and even sopor occur, folloAved suddenly by more or less extensive paralysis, usually affecting the loAver extremities. The pathologico-anatomical changes have been especially studied by Charcot, Joffroy, Roger, Money,1 Kussmaul. The brain is almost ahvay*s normal; the spinal cord, howev*er, shoAvs acute inflammation of the anterior grey columns (hence called poliomy*elitis ant. ac. by Kussmaul). Localized espe- cially at the lumbar and cervical enlargements,the inflamma- tion causes destruction of the ganglion cells and a consecutive atrophy of the anterior roots. Muscular atrophy is usually* readily recognizable, wherefore Duchenne called the affection paralysie atrophique grais- seuse de Venfance. But simple atrophy Avithout any fatty degeneration may occur (Laborde). As regards the frequency of the affection, the statement of Holmes Coote shoAvs that out of 1000 sick children in the Royal Orthopedic hospital, 80, or 8$, suffered from infantile paralysis. The sudden advent of the muscular disability is character- istic; for without any previous symptoms it may occur in a realty apoplectic manner. 316 Orthopedics and Orthopedic Surgery. Characteristic also is the fact that the paralysis immedi- ately* reaches its maximum in extent and intensity*, and begins to retrogress in a few days or Aveeks; so that partial recovery, at all events, is A*ery rapid. In a general way we may say that the paraly-sis which does not disappear in six months will be permanent. In more than two-thirds of the cases the lower extremities are affected, and especially the feet (81$, Seeligmuller). Mon- oplegias are most frequent, and next paraplegias, hemiplegias and crossed paralyses being rare. In almost all cases the paratysis is partial, some muscle-groups being affected, and others being normal. Thus even when there is marked paralysis of the extremi- ties the ileo psoas and glutad usually* escape, the extensors and the quadriceps femoris being most affected. In the upper extremities it is the muscles of the shoulder and arm that suffer, the move- ments of the fingers and hands being usually* nor- mal. Atrophy* of the affected muscles can usually* be de- fig. 375.-paraiysis infantilis. (After monstrated earl v, Vven in Rockwitz.) two to three weeks (Seelig- miiller); the affected part is cool, relaxed, and livid. Disturbances of sensibility* and affections of the sphincters are absent; mild contractions of the muscles may occur from time to time long after the paralysis has set in. Mental or sensory* disturbances do not occur. The reaction of these paralyses to the electric current is important. The nerves no longer reply to the faradic or gal- vanic current. The muscles act similarly to the faradic cur- rent, but are affected by even a weak galvanic current (there occurring a stronger anodal closure contraction and a weaker cathodal closure contraction). Even after years the galvanic current causes a long-drawn contraction in the affected mus- cles. The reflexes are usually much diminished, that of the pa- OrtJiopcdics and OrtJwpedic Surgery. 317 tellar tendon being absent. After a time (Seeligmiiller2 has obser\*ed pes equinus four weeks after the appearance of the lesion) the altered pressure relations, Aveight, etc., cause con- tractures and deformities, especially- of the loAver extremities. Thus we see contractures of the knee and hip, talipes, and par- alytic spinal curvatures. In accordance with the amount of sliding on the floor and bending of the limbs, we have peculiar and often A*ery* ugly* deformities of the limbs (Heine). The affected limbs undergo further and further trophic changes; they* atrophy-, and remain livid and cool. Their growth, also, is interfered Avith; and hence arise pelvic de- formities, static scolioses (Fig. 126), especially when the par- alysis is unilateral. In rare cases all the muscles of a limb may* be paralyzed; the patient then has a perfectly* lax "swinging leg." By far the most frequent are the paratytic contractures of the feet, causing equinus most frequently* (equino-varus), and more rarely* calcaneus, calcaneowalgus, or pure A-algus. If the foot, from the superincumbent Aveight and the sink- ing of the fore-foot, becomes fixed in a position of plantar flex- ion, one of the most frequent of these deformities, the pointed foot, occurs (Figs. 254, 255), which mostly- appears as an equino- varus. This is especially the case in y*oung children that do not Avalk, there being no counter pressure upon the supinated foot; and also in those Avho move on crutches after the setting in of the paralysis. Pes calcaneus and calcaneo-valgus (contracture in dorsal flexion and pronation) are rarer; for the dorsal flexors retain- ing their poAver and the plantar flexors being paralyzed, graA*ity opposes the formation of such a contracture. Only in cases when the foot is permanently used for walking, and is forced into dorsal flexion Avith abduction and pronation, the muscles opposing the pressure being paralysed, does the dis- ability increase until the meeting bones and tense ligaments stop it. This barrier also, hoAvever, ultimately gives Avay*. In the knee-joint, also, we sometimes find contractures, usually in flexion on account of the preponderating frequency of paralysis of the quadriceps femoris. This is especially* the ce.se Avith children that only creep on the floor or who use crutches; since the knee and hip-joint are then kept flexed to keep the point of the foot from the ground. -13 Orthopedics and Orthopedic Surgery. As a usual thing the patient's night's rest suffices to counter- act the tendency to contracture, and in high grades of paraly- sis the condition at the knee is rather the opposite one. The joint is abnormally loose and shaky, forming the "schloter- gelenk." The children walk by* employing the non-paratyzed exten- sors of the thigh to bring the knee forAvard by* a kind of jerk- ing motion, and then letting the body* weight act so upon the knee that it remains hyperextended. The centre of gravity* then falls behind the base of the foot; the pressure of the femoral and tibial joint surfaces upon one another prevents the limb bending anteriorly, and the tense capsule and ligaments hold it in place behind. These latter structures, however, eventually* give way, and we then have the hyper-extended knee (Fig. 227). In the hip-joint contractures from infantile paratysis are rare. If they do occur it is in neglected children, Avho lie for months curled up in bed, or only creep around upon the floor, "or who have used crutches for a long time. Such flexion-con- tractures of the hip lead to a compensatory* lordosis (Fig. 375), since the pelvis must incline itself to correspond to the contracture, and the spinal column must bend to keep the centre of gravity correct. The function of the glutasi in Avalking and standing is so to fix the pelvis that the long muscles of the back have a firm point of insertion. When the glutaei are paratyzed, the ante- rior part of the pelvis sinks downward from the contraction of the psoas and iliacus. A condition corresponding to genu recurvatum may occur in the hip. There the tension of the lig. Bertini fixes the pel- vis posteriorly, and a lordotic curvature anteriorly* of the spinal column naturally occurs. If the lordosis is very* marked and the ligaments of the hip are relaxed, the similarity- of the ap- pearance of the condition to congenital dislocation of the hip (Fig. 386) may be very marked. In fact, cases of paralytic dis- location of the hip in infantile paralysis have been described (Reclus).3 The contraction of the intact adductors Avhen there is paratysis of the glutaei and pelvi-trochanteric muscles favors the occurrence of such luxations. In very extensive paralysis the extremity hangs entirely* lax, as in a doll; hence the designation, jam be de polichinelle. Orthopedics and Orthopedic Surgery. 319 Paratyses of the dorsal and abdominal muscles always cause anterior curA'ature of the spinal column. Besides the lordosis there occurs compensatory* kyphosis in the upper por- tions of the column and eA*en skoliotic curvature, in conse- quence of infantile paralysis. This latter may be entirely static in its nature and be due to shortening of a limb; or it may* be due to unilateral paratysis of the muscles of the back and consequent unequal pressure. Deformities of the upper extremities in consequence of in- fantile paratysis are much more rare; and the mechanical conditions leading to contractures and deformities are almost entirely* absent. The shoulder joint rarely becomes fixed by the simultane- ous contraction of the pectorales and the lat. dorsi. More fre- quently Ave find a paralytic subluxation present, in w*hich the weight of the arm has caused the capsule and ligaments to elongate, and the hu- merus has sunk so far that there is a distinct hollow betAveen it and the acromion. The total atrophy* of the deltoid renders the condition still more marked (see Fig. 376). The fingers are flexed into the palms; the hand is slightly flexed. If the hand be more strongly flexed, the fingers may be passively extended. If the fingers be sided Paralysis of flexed, the hand may* be extended to at least theShoulderJoint 180° (Volkmann). This variety* of contracture depends upon the amount of use made of the hand, and also upon whether the flexors or the extensors or both are paralyzed. Another ty*pical affection, Avhich causes paralyses as fre- quently* as infantile paralysis, but much less commonly leads to contractures, causing mostly* pes equin. spast., is the cere- bral paratysis of children (hemiplegia cerebr. spast.) (Heine, polioencephalitis acuta). Strumpell has especially studied it, and has located the disease in the cortex. Pathological anatomy has also shown the presence of atro- phic processes, parencephalitic defects in the motor territory of the cortex (cicatricial remains of inflammatory* action), frequent embolisms, thromboses, and hemorrhages; but all Avithout any special localization in the gray* matter of the cortex (Wallenberg4). The children are apparently healthy* and, after a short 320 Orthopedics and Orthopedic Surgery. initial stage of fever, vomiting and convulsions, are suddenly attacked with the paralysis. Hemiplegias are commonest, monoplegias more rare. Though the arm is usually affected more than the leg, the paralysis is generally not so complete as in cases of infantile. Most of these children learn to walk again, though the gait may* be a halting one. Ataxia, and a permanent clumsiness for certain motions may be left behind. The intelligence may be disordered; and in right-sided paralyses there may be speech disturbances. Attempts at passive motion soon show that we have not to deal, as in infantile paratysis, with a relaxed paretic condi- tion; tension of the muscles is plainly present; but the spastic condition rarely leads to absolute contracture. The muscles and nerves preserve their faradic irritability*, and—an important point for differential diagnosis—there is no trace of a degeneration reaction. The tendon reflexes are not only* preserved, but they* are frequently exaggerated on the healthy and ahvay*s exaggerated on the affected side. But the cerebral paratysis of children is especially distin- guished from the spinal by* the motor irritation symptoms in the paralyzed limbs. Finger, hand, and arm are not infre- quently spasmodically retracted, peculiarly* stiff, and occasion- ally turned. The paralyzed limb sIioavs the same spasmodic tendency*; and the hands and fingers especially* sIioav the pecul- iar spasmodic motions, which are generally* confined to single peripheral muscle-group. They* often consist of comparatively sIoav motions of extension and flexion, and haA*e been called athetosis by* Hammond. The in\*oluntary muscular action is especially* liable to occur on intended motion; the fingers and toes are stretched out like claAvs, and separated; it may* occur on one side only — hemi-athetosis. Occasionally these mo- tor-irritation symptoms are so considerable as to become epileptic. The sensibility* of the affected part is usually not much disturbed, nor is the tempei'ature or color of the skin. Crying or fright at passing Avater, or involuntary* micturition may occur. Bladder and rectum are never affected in spinal infan- tile paratysis. Paralytic contractures rarely* occur. As a rule there is no Orthopedics and Orthopedic Surgery. 321 other deformity- than pes equin. spast. and contracture of the knee, with occasional adduction of the thigh in addition. According to Heine, curvatures of the spinal cord do not occur in cerebral inflammatory* paralysis. The treatment of these paralyses falls within the domain of internal medicine, and consists of central galvanization, strychnine injections (beginning Avith one-sixty-fifth of a grain,) baths, hydrotherapeutic cures, etc. Gymnastics, massage, and the peripheral application of the electric current must be lauded; patiently* applied avc will see the vitality of the affected limb gradually- increase. Above all it is necessary- to preA-ent the appear- ance of contractures and deformities. Thus Avhere the foot tends to sink it should be retained by a bandage in a rectangular position. Ready shaped gutta-percha splints are useful; the foot can be retained in one by a flannel roller bandage or by- plaster and elastic bands. Frequently it Avill be sufficient to heighten the shoe at the side to Avhich the foot sinks, and gen- erally to see that the patient wears laced shoes, Avhich hold the foot in proper posi- tion. These children should not be left to themselves. They- should be provided with mechanical arrangements and put on their feet (Fig. 378). The use of crutches must be entirely FlG 377_ Nyropis SlIS_ forbidden; they* predispose to the develop- taining Apparatus for Par sJvsis ment of deformities. If contractures are already present, gradually increasing manipulation, plaster bandages (sometimes after tenotomy), must be employed to correct them. Various splints and supporting apparatus can then be employed; so that these unfortunate cripples need not drag themselves around like quadrupeds. Such apparatuses are necessarily of varying height, in accordance with the ex- tent of the paralysis. They should be made light and grace- ful, and fitting well to the limb, without any constrictions, which would further the atrophy. Such machines (Fig. 377) usually consist of side splints with hinges at the joints which can be fixed immovably; they are covered A\*ith leather, sili- 21 322 Orthopedics and Orthopedic Surgery. cate of soda, etc.5 Where onty a few muscles are involved, artificial muscles, to a certain extent replacing the paralyzed organs, may be employed. Duchenne and others have con- structed such Avith elastic bands of rubber. More will be said about them under the head of paralyses of the hands. Or again, elastic springs, or lateral spiral springs, may be applied to the joint on the par- alyzed side, so as to fix the joint Avhen in use. Charriere, Mathieu and others have con- structed rather compli- cated apparatus of this kind, Avhich have arti- ficial pronators, supina- tors, flexors, and exten- sors. In sublux, paralytica of the arm, to preA*ent a further relaxation of the capsule, a Avell-pad- ded leather breast-ring encircling the base of the neck, Avith a leather capsule for the fore-arm attached to it with straps, may* be used. This apparatus is A*ery* useful for other purpo- ses also. In the sewerest par- alyses of the entire lower extremity and the buttock, the splints must reach up to the hips; there must be a good pad over the tuberosity of the ischium, and steel bands must ascend the back or a suitable corset arrangement must be added. A practical apparatus for the purpose has been described by* Heusner,6 in which the girdle is replaced by complete trouser legs of strong but soft material, to be buttoned in front. They are very secure. The pelvic girdle and the upper part of the lateral pieces is a broad piece of cloth, which is fastened on Fig. 378.—Walking Apparatus, for Spinal Paralysis; Papier Mache Apparatus with Movable Hip and Foot, and Fixed Knee Joint. Orthopedics and Orthopedic Surgery. 323 with buttons in such a Avay* that the child can loosen it when it wants to go to stool (Fig. 379). RockAvitz7 describes an apparatus which he has used in the worst cases of almost complete paralysis of the legs and lower dorsal muscles, after the most troublesome contractures had been remoA*ed by tenotomies and extension. It consists of a strong padded corset to extend up the back, reaching almost to the axilla, and sustained by shoulder bands. On each side, someAvhat above the hip, are attached pieces to sustain the legs; they- reach to the feet, and bear on their inner side the shoe for the reception of the paralytic foot. At the hip-joint there is a flexion hinge, and above that an abduction hinge. The knee can be bent, but is secured by- a spring that fixes itself firmly* in extension. The splints run inside the limbs, and broad, Avell-padded rings fix the legs. Operative procedures (te- notomies, division of fasciae, etc.) are frequently* necessarv before the deformity can be OA-ercome and before Ave can proceed to the second part of the treatment, the artificial „ j, „ . . Fig. 379.—Heusner's Supporting Apparatus. replacement of the function of the limb. Recently other operations have been deA*ised to artificially fix the useless limb and to make it a serviceable support for the body. Albert8 has designated as arthrokleisis (artificial production of ankylosis, arthrodesis) a series of very successful resections for the fixation of the affected limb, both in the upper and the loAver extremity. Quite recently J. Wolff9 has described an interesting case of arthrodesis operation in a boy five years old suffering with complete paralytic'relaxation of the limb after traumatism. Winiwarter10 reports the case of a ten-year-old boy with completely paralyzed lower extremities (infantile spinal paral- ysis). He formed an artificial ankylosis of the knee first on the right, and a few weeks later on the left side. He then did the same with the tarso-crural joint. As the child died later 324 Orthopedics and Orthopedic Surgery. of diphtheria he had an opportunity* to satisfy himself of the existence of complete bony* ankydosis. V. Lesser, Nicoladoni, Rydygier haA*e practised the opera- tion for paralytic foot contractures (see above). By- congenital spastic rigidity of the limbs, congenital spas- modic muscular contracture, or Little's11 disease, we mean a group of symptoms characterized chiefly* by* a tonic spasm of certain groups of muscles occurring with every- active or pas- sive motion, Avith increased tendon reflexes, but Avith no lessen- ing of the faradic contractility7. The preponderant implication of the adductors and flexors of the leg causes a characteristic gait, and a deformity* of the foot due to spasm, not to paraty- sis. Delpech observed the disease; but Little saw two hundred cases, and first recognized it as a distinct affection. Stro- meyer, Busch, Benedict, and Rupprecht12 haA*e studied it. Seeligmuller, Seguin,13 Bradford 14 and others haA*e described special cases. The pathological processes Avhich cause the affection are probably* A*ery various. Little believed it to be due to hemor- rhages into the brain and cord occurring intra partum, leading to sclerotic processes; Benedict saw the cause in a cerebritis leading to atrophy*; disseminated sclerosis, sclerosis of the lat- eral columns, cortical defects, etc., haA*e been blamed. There is some bulbo-spinal or cerebro-spinal lesion. Premature or complicated births are usually- associated Avith the disease. It is frequently* first noticed when the child experiences dif- ficulty* in learning to Avalk. It may be the fourth year before the child can move at all. There is no paralysis, but a mus- cular spasm on attempted motion. Brusque passive motion also evokes it. The tendon reflexes are increased; the sensi- bility is normal, though psychic abnormities, spastic face-play and articulation, laryngismus and spastic strabismus, may be present. There are, however, no trophic disturbances. The gait is the opposite of that of paralyzed patients. The knees are bent and flexed and the heels elevated. There is a short, tripping Avalk, for the spasmodic muscular contraction stiffens the legs. The toes are turned in and pointed, so that the patient treads upon their tips. Rupprecht15 thus characterizes such a case. If led, the patient can painfully* walk a Icav steps; let alone, he inimedi- Orthopedics and Orthopedic Surgery. 325 ately falls stiffly- to one or the other side. If he attempts to grasp anything, there occurs sloAvly alternating hyperflexion and flexion and finally* clinching of the hand. If we attempt to passiA-ely* move elboAv, hip, or knee-joint, it can only* be done by* overcoming the elastic resistance or the clonic con- tractions. To a certain extent the symptoms are similar to those of a compression-myelitis, from spinal caries; but this latter may be distinguished by the deformity of the spinal column and the posture of the trunk. Infantile paratysis is distinguished by the diminished or abolished faradic contractility, the galvanic degeneration reaction, the absent reflexes. A mistake for the acquired form of spastic spinal paratysis is more liable to occur. The prognosis is unfavorable. Nevertheless, there occurs in many* cases a spontaneous diminution of the sy*mptoms. Treatment does much to improA*e these cases. The constant current and the cold Avater cure haA-e been recommended by Erb. Little recommended passiA-e motions and a redressing splint-bandage. Adams and Busch employ*ed a plaster bandage with adA-antage. Rupprecht used during the night lateral extension, a splint-bandage with dorsal flex- ion of the foot piece, and a Scarpa's shoe Avith elastic traction. Tenotomy- is of great A'alue here, improving the Avalk markedly*. The heightened irritability of the tendons when stretched disappears, and movement of the astragaloid joint returns permanently* (Rupprecht). Paralyses of special nervous and muscular areas, patholog- ical or traumatic in origin, may- cause certain characteristic deformities. Especially* is that the case Avith the upper ex- tremity. The ulnar nerve supplies the flexor ulnaris, gives branches to the flexor dig. prof., the muscles of the ball of the little fin- ger, the small flexor, all the interossei, the tAvo innermost lum- bricales, and partially the adductor pollicis. Hence in paratysis of ulnar origin Ave get ulnar flexion and abduction of the hand, the bending of the three last flngers is hindered partly7 or wholly, and movement is so interfered with that AA-riting, drawing, etc. is difficult if not impossible. If the paralysis has lasted long, Ave get besides the --clawed** position of the hand, the main en grijfe (caused by 326 Orthopedics and Orthopedic Surgery. the extensor dig. comm.), a characteristic surface change. The ball of the little finger disappears, and a depression takes its place; the region of the adductor pollicis is flattened; and betAveen both hollows the flexor tendons and the intact muscle bundles of the lumbricales, innervated by7 the median nerve, form a prominent cord traversing the palm of the hand. The two last phalanges are flexed; the first is dorso-flected (ex- tended). Even dorsal subluxations of the first phalanx may- occur; while on the back of the hand the atrophy of the inter- ossei causes deep furrows to appear between the metacarpal bones. The median nerve supplies the flexor dig. subl., the lateral part of the flexor dig. comm. prof., the flexor carpi rad., the abd. flexor brev., the opponens pollicis, and the muscles of the ball of the thumb with the exception of the add. poll. Paralysis of median origin seldom occurs alone, being gen- erally part only of a cerebral paratysis. It is characterized by* inability to bend the second and third phalanges of the second and third fingers, and inability to bend and oppose the thumb; while flexion of the first phalanx of all four fingers can be effected by means of the interossei. Hence the thumb is extended, adducted, and ape-like, the index finger is extended, while the three other fingers are slightly* flexed in the normal position. The hand has a "com- mand" posture. Further, deepening of the hollow of the hand, prominence of the first metacarpal bone in consequence of the atrophy of the ball of the thumb, flattening of the flexor surface of the fore-arm, are the later consequences of the lesion. Most important of all, orthopedically, is paralysis of radial origin. The radial nerve supplies the anterior muscles of the arm, the anconeus, supin. longus, ext. radiales, supin. brevis, ext. dig. comm., dig. Ar., ext. ulnar., ext. long, poll., ext. dig. ind., abd. poll, long., and ext. poll, brevis. Hence, in complete radial paralysis of traumatic or other origin, the hand is flexed, the thumb is bent under it in adduction, the fingers are median flexed, extension and abduction of thumb and index finger are impossible, and supination of the extended arm (Avithout the help of the biceps) cannot be accomplished. The extensor paralysis causes the approach to each other of the points of Orthopedics and Orthopedic Surgery. 327 insertion of the flexors; and from the added interference with. their function and the paralysis of the thumb, the hand be- comes almost useless. The atrophy7 of affected muscles in old paralyses of this kind causes flattening of the fore-arm upon the extensor and supinator side, and wrist-drop. Fig. 380 shows a case of partial radial paralysis from chronic lead-poisoning. Lead-poisoning occurs in painters and also from the use of Fig. 380.—Position of the Hand in Lead-paralysis. lead-containing face preparations (bloom of youth, Sayre). There is extensor paralysis of the hands, which hang down relaxed when the elbow is flexed. The complete impossibility of extension, usually bilateral, gives us a typical picture of an affection which is not likely7 to be confounded Avith any other. Besides the use of electricity, iodide of potassium (one to two drachms daily7), orthopedic apparatuses are of use. Elastic ex- tension may replace the extensors, and hence prevent nutritive shortening of the healthy flexors. The old Delacroix16 appa- ratus is very useful. 328 Orthopedics and Orthopedic Surgery. Hudson has invented a light and elegant apparatus, which Sayre recommends.17 Collin's apparatus is excellent, and is constructed in accord- ance with a plaster model of the hand and fore-arm (Fig. 198). BIBLIOGRAPHY. 1. Trans. Path. So., 1881.-2. Seeligmiiller, Gerhardt's Handbuch der Kinderkrankheiten.—3. Revue Mensuelle de Med. et de Chir 1878 —4 Jahrb. f. Kinderheilk., 1886.-5. Kappeler, 1. c, p. 138.-6. Langenb. Arch., XXXI— 7. Deutsch. Zeitschrift f. Chir., 19, p. 300.—8 Lehrb d Chir, 3, 4, p. 524.-9. Berlin. Klin. Woch., XXIII., 1886.-10. Verhandl. des XIV. Chir. Congr, p. 141.-11. Holmes' Syst. of Surg. Ill p 580 12. Volkmann's Sanimlung, 198, 1881.—13. Arch, of Med 1879—14 Boston Med. and Surg. Journ., 1885.-15. L. c, p. 1647.-16. Volkmann 1. c—17. L. c, p. 366. CHAPTER IX. ORTHOPEDIC AFFECTIONS FOLLOWING FRACTURES AND LUXATIONS. Unreduced luxations and improperly treated fractures fall within the domain of orthopedics. Improperly set fractures consist of union in false position, either from not properly remedying the original displacement, or from secondary displacement during the period of healing. Hence there remains angular union, axis rotation, or overriding of the fragments. The importance of the condition A-aries with the grade of the deform- ity*. It is more serious when it affects the lower extremity, when it more frequently requires our care. Gurlt collected 149 cases affecting the loAver extremity*, 71 being of the thigh and 59 of the leg, against 12 of the hu- merus and 7 of the fore-arm. Bruns1 collected 330 cases, 275 of them affect- ing the lower, and 55 the upper ex- tremity. Etiologically the fracture may not have been noticed, or no attempt at replacement may haA-e been made, or the retention may7 have been insuf- ficient from looseness of the dressing or restlessness or delirium of the patient. The muscular pecul- iarities of the part influence the form of fracture markedly*. Thus Bruns found that almost all the faulty7 fractures of the thigh were situated in the upper half of the bone and were angular outward Avith shortening. In children, in particular, Fig. 381.—Deformity Following Epi- physeal Fracture ofthe Humerus. 330 Orthopedics and Orthopedic Surgery. fractures are not infrequently* OA*erlooked, especially- at the epiphyses; for the displacement frequently appears onty after the absorption of the large amount of extravasated blood (Fig. 380). The disturbance caused consists first in the alteration in the direction, length, and shape of the part, but more espe- cially* in the consequent diminution or abrogation of its func- tion. And this is not alone the case in the larger bones of the extremities; in exceptional cases Ave may- ha\*e to interfere to remedy the results of lesser injuries because the projecting end of the bone caused interference with motion, or eA*en inflam- mation and ulceration of the skin. Treatment consists first in seeing that repair goes on in the most adA*antageous position possible, and occasionally* in breaking up the faulty* union. Where the union is not y7et very* Arm and the callus still elastic, the deformity* may be remedied by- bending or infraction of the callus. This is especially the case in the fractures of children, when, on taking off the bandages, Ave find that they have not healed correctly, as not infrequently* happens, espe- cially7 with the fore-arm. Duplay* say*s sixty* days is the extreme limit of the time after the injury in which this procedure is practicable. In older cases we have the choice of 1, manual or instru- mental osteoclasis, and 2, osteotomy or resection. The earlier -- Dy-smorphosteo-palinklasts" (Oesterlen, Riz- zoli, etc.) allowed of but a very approximate localization of their action, the neAver osteoclasts (Robin, Colin, Beely) are so precise in their action that it is not to be wondered at that instrumental osteoclasis of badly healed fractures is again coming into the foreground. Thus Pousson reports 124 cases. Manual osteoclasis is then reserved for cases of fresh callus in children with the lesion in the middle of the diaphysis of the bone. Where osteoclasis is impossible, as from adherent scars, etc., osteotomy is in place; and especially* longitudinal linear osteotomy. This consists of the separation of the callus uniting the fragments, longitudinally* if possible, so that, if necessary, a bone-suture may be applied to insure correct union. Thus Fig. 382 shows a badly-healed supracondyloid fracture of the femur causing genu varum, which Avas readily cured by* Orthopedics and Orthopedic Surgery. 331 osteotomy. Other operative procedures, such as tenotomy, are sometimes necessary7. In very extensive deformities the excision of Avedge-shaped pieces2 or partial resection may be indicated. When the ends of fragments project toward the skin, it is not infrequently necessary to lay- the part open and remove the projection. In the case shown in Fig. 381 there was ulceration of the soft parts over the sharp edges of the bone. I therefore re- moved the projecting edge of the diaphysis Avith the chisel. Bruns, in seA*enty* cases of antiseptic osteotomy (thirty* - Fig. 382. — Supracon- Fig. 383.—Pseudarthrosis Fig. 384.—Protective Apparatus dyloid Fracture of the of the Tibia. (After Fer- in Recurrent Dislocation of the Femur with Consequent gusson.) Shoulder. Genu-Varum. eight linear, thirty-tAvo wedge-shaped), records sixty-six cures without notable disturbance. Pseudarthroses also may need orthopedic treatment; y7et they hardly belong here. Probably Avhere there is marked de- formity connected with the condition, removal of projecting ends of bones, resection of both fragments with bone suture or screwing, will be proper; while retention apparatuses will only be employed for the mild cases. As regards dislocations, the rare cases of so-called habitual luxation may* need special orthopedic treatment. Thus Fig. 384 shows Le Fort's apparatus for habitual dislocation at the shoulder joint. Old luxations also occasionally fall under the charge of the 332 Orthopedics and Orthopedic Surgery. orthopedist. Although few dislocations are uoAvadays to be regarded as irreducible, and though even for them arthrotomy and resection may be employed, there are yet cases in which a luxation has either not been recognized, or the patient has not sought medical aid at all. Here there may* be considera- ble disturbance of function, either from faulty* position (as in dislocations of the hip and the astragalus) or by pressure upon the neiwes (as in axillary dislocation of the humerus). If the possibility of reduction can be excluded, to be determined rather by the condition of the limb than by7 the length of time that has elapsed, massage and manipulation may do much, especially in youthful individuals, to form a favorable near- throsis, and prevent ankylosis. In many* cases, especially* in the lower extremities, there will be no (juestion of anything more than bettering the position of the limb. The accidental fracture of the neck of the femur in the attempt to reduce an old dislocation of the hip (Volkmann and others) has shown us how the abnormal position of the limb may be remedied by osteoclasis or osteotomy where, as in the upper limb, motility is of greater importance (at the head of the humerus, or radius). Resections of the head of the irreducible bone, divi- sion of adhesions, will giA*e a fair amount of function. In this way entire resection of the joint Avill be less often neces- sary. These measures, to be done under the strictest antisep- sis, are, however, no longer in the domain of orthopedics. BIBLIOGRAPHY. 1. Die Lehre von Knochenbruchen ; Deutsch. Chir., p. 518.—2. Al- bert, Operative Beitrage, I., p. 15. CHAPTER X. CONGENITAL LUXATIONS. Congenital luxations are conditions in which the nor- mal relations of the bones composing a joint are disturbed. Though rare, they may occur at various joints: hips, knee, hand, shoulder, elbow, jaw, etc. The most important are those of the hips, which Ave shall consider someAvhat at length. Most of these cases are due to defective development of the articular head of the bone; rarely do intra-uterine joint affec- tions, paralyses, or abnormal muscular contractions cause them. Since the idea of dislocation presupposes the former existence of normal joint relations, the designations of dysar- throsis cong. (Amnion), congenital malposition (ReeA-es)1 Avould be more appropriate, especially* as some of the most important elements of a dislocation, for example the rupture of the capsule, are absent. Our scientific knoAvledge of congenital luxations begins Avith Dupuy*tren in 182G, though Hippocrates, Avicenna, Pare, Morgagni, Heister, and Paletta undoubtedly* observed them. Dupuy-tren's pictures have been copied in most of the text- books. Recent im-estigations show that the condition is by7 no means a A-ery* uncommon one. By7 far the most important, as aboA*e stated, is the hip dis- placement (lux. coxas congenita). It may*, however, appear in earliest childhood. The femur is displaced upAvard and back- Avard on one or both sides. As regards the absolute frequency* of the affection, Pa rise found it four time in 332 autopsies of neAV-born children, PraA7az saAv 125 cases in sixteen y-ears' practice, and Dopp, at the St. Petersburg foundling asylum, reckons one congenital hip dislocation to tAventy-three children with club-foot. According to some observers, its frequency A-aries in different countries; Albert saAv it exceptionally often in the Tyrol. 334 Orthopedics and Orthopedic Surgery. Hereditary7 influences are certainly poAverful, as Paletta, Schreger, and Stromeyer found. Observations Avhere it oc- curred in several generations are by no means rare.2 Never- theless Adams found this to be the case but once in forty-five times. Undoubtedly the affection is much more frequent among females. Kronlein found 87.6$ of the cases in females; Adams forty-seven females in sixty cases, Albert flfty7-eight females in sixty cases. Roser explains this by the adducted position of the legs, which is much more likely to persist in the female during fcetal life. There is some difference of opinion as to its unilateral or bilateral occurrence. Dupuytren, Langgaard, and others believed the latter to be most frequent; but Kron- lein's combined statistics give only 40$ of bilateral cases, and Adams, in his sixty*, cases, had forty*-one that were unilateral. As regards the etiology, there is much truth in Dupuy-tren's idea that it is a developmental anomaly*, the acetabulum remain- ing undeveloped as a shalloAv furrow. Dollinger believes it to be due to a premature ossification of the Y-shaped cartilage, in consequence of neighboring inflammatory processes; and Gravitz, though he found no calcification of this cartilage in seven cases, yet supposes the occurrence of its tardy develop- ment. While Adams and others think this is the case in the ma- jority of instances—from the frequently simultaneous occur- rence of other malformations, if nothing else—yet they believe that there are other explanations for certain cases. Thus they claim as etiological factors a peculiar position of the foetus when there is pathological laxity of the tissues, or the absence of liquor amnii (Roser, Liicke). The older authors looked upon fcetal joint inflammations, hydrarthroses (Parise, Verneuil), or destruction of the capsule and the bone (Moreh Lavallee) or intra-uterine convulsions (Chaussier) as causes. The idea also that traumatisms of the mother's abdomen, or injuries during confinement2 (Capuron, etc.), might cause congenital dislocation of the hip, has found its defenders. Brodhurst,3 especially, believed that it usually occurred in breech cases. Sedillot regarded pathological relaxation of the ligaments as the cause. Recently some cases have been ex- plained as due to paralysis of the tensor of the capsule in consequence of infantile paralysis, especially since Liicke and Orthopedics and Orthopedic Surgery. 33*; Roser4 have attempted to explain some instances as due to paratysis of the pelvi-trochanteric muscles. Verneuil5 had previously- stated that isolated paralyses and atrophies of the gluteal muscles, causing relaxation of the joint, were at the root of the trouble. The pathological findings are quite various. The Musee Dupuytren contains forty-nine specimens of dislocation of the hip, twenty* of which are congenital. The variety depends upon whether the specimens belonged to Fig. 385.—Preparation of a Lux. Coxae Cong. (Mus. Dup.). children who had not learned to walk, or to adults. Most cases were originally incomplete luxations. In the new-born, or in children Avho had not yet learned to walk, the acetabulum was mostly in the normal place, but shallower and smaller than usual, and with its posterior bor- der flattened. The head of the femur also was flattened and atrophied, and rested on the posterior upper edge of the ace- tabulum. The lig. teres was absent or elongated and thin; the capsule was intact, perhaps a little relaxed; but there was no rupture of it, nor was there any other essential alteration of the pelvis. Fig. 385 shows a preparation taken from a small child with 336 Orthopedics and Orthopedic Surgery. right congenital dislocation of the hip. The non-ruptured, lengthened, and hypertrophied capsule; the elongated lig. teres; the small triangular shallow acetabulum, filled with fat; the small conical head of the femur resting against the resistant upper border of the capsule—are all well shown. Absence of the lig. teres, or of the head and neck of the femur Avas only- present in rare cases (Carnochan, Harrison). In older children Ave see plainly that the acetabulum has not kept pace Avith the other parts in its growth; both it and the head of the femur are small and misshapen; the shaft is imperfectly developed or absent; and the older the child the more the neck is placed rectangularly to the axis of the bone. The capsule is toughened and stretched, but normally in- serted; it permits great freedom of play-to the head of the femur, and is especially thickened where the bone plays against it. Now, since the rump sinks when the patient Avalks or stands, the thickened capsule and the ligamentum teres may- be eventually* worn through. Hence, in grown-up persons, Ave either And great thickening of the capsule, or perforation and the formation of a nearthrosis. Yet such nearthroses never attain the completeness of the nearthroses that occur after traumatic dislocations. The pelvis undergoes characteristic changes from the altered pressure relations. In unilateral congenital luxation, the affected side of the pelvis is atrophic, and is dragged upon from before backward and from above and within inward. Thus the illium is forced inward, and more vertically, and the ischium is displaced outAvard. With bilateral dislocation, on the other hand, the peh*is is distorted symmetrically. Both ilia are forced imvard, the pelvic entrance is someAvhat dimin- ished in both diameters, and the transA*erse diameter of the pelvic entrance is someAA*hat increased. Hence avc understand why congenital dislocations do not interfere with delivery* (Bouvier, Lassman6). The symptoms of congenital dislocation of the hip consist in the disturbed gait, the uncertain motion, and the deformity. In bilateral hip-dislocation the child learns to Avalk very- late, and has a peculiar vacillating .noose-like gait, Avith pro- trusion of the abdomen, marked flexion of the pelvis, and lor- dosis. There is also elevation of the hips; that is to say*, a Orthopedics and Orthopedic Surgery. 337 fulness abo\-e and behind the region of the normal hip-joint (Fig. 386) caused by7 the displaced head of the bone; in older cases Ave notice the relatiA-e shortness of the lower extremities and the excessive breadth of the hips. Fig. 386.—Bilateral Congenital Dislocation of the Hip. In unilateral congenital dislocation of the hip the gait is oscillating and limping; the affected leg is shortened; there is inclination of the pelvis, and scoliosis of the spinal column. 338 Orthopedics and Orthopedic Surgery. The limb is weaker than its fellow, and is adducted and rotated inward. The diagnosis of the condition is frequently not made. It is based on the excessive mobility- of the joint, while in coxitis and traumatic dislocations the joint is fixed. The limb can be easily pulled back into the normal position, overcoming the lordosis and shortening. From the slight amount of change that occurs at first it is conceivable why the affection is seldom recognized in very* young children. Nevertheless Kronlein7 made it in tAvo cases at two days and at four months respectively7. Besides the absence of pain, SAvelling, fistula, etc., avc find Nelaton-Roser's line above the side of the head of the femur; and the pres- ence of other malformations, and the anamnesis, should help us. The prognosis of congenital hip dislocations is certainly7 unfavorable in older cases. In very y*oung cases Brodhurst, and Buckminster-BroAvn have reported favorable results from treatment; but these are certainly* exceptional. In most cases we must be satisfied to prevent further increase of the de- formity. If the condition Avere more frequently* recognized immedi- ately* after birth, it would be more often possible to effect re- position, as can be clone in most cases of dislocation during delivery*. At all events it would be possible, by* fixing the thigh in the most favorable position, by* passive motion, etc., to obtain a favorable nearthrosis. Unfortunately- a large pro- portion of cases are seen only- so late that reposition is out of the question. For a long time our therapeutic attempts con- sisted only in protracted extension. Humbert, Jacquier, Guerin, Pravaz, Heine, Behrend, and others claim to have obtained favorable results, even complete cures, by this means; while Dupuytren and others lay* most stress on a roborant treatment. Pravaz constructed three apparatuses, the first to bring the head of the bone back into the acetabulum by extension, the second to prevent its get- ting out again, and the third to increase the depth of the ace- tabulum. Very recently a case of cure has been reported by Buck- minster-Brown.8 The treatment consisted of eighteeen months' rest in bed, with extension, passive motion in appropriate directions, and then the use of a AA*heeled walking apparatus. Orthopedics and Orthopedic Surgery. 339 Nevertheless, such cases are the exceptions; and in most cases tonic treatment, strengthening of the muscles, reten- tion for long periods of time in the abducted position (Roser), give us most hope of preventing the affection from becoming worse. For unilateral cases Taylor's coxitis machine, or other ap- paratuses resting upon the ischial tuberosities, and tending to preA*ent a further upward displacement of the head of the bone, are most appropriate. For double congenital luxation a variety* of apparatus have been proposed by7 Dupuydren, Bou- vier, Stromey*er, Heine, Froriep, Langgaard, Hiiter, SchAvabe, etc. They* are all more or less on the style of the cinc- ture a godet and consist es- sentially of a pelvic girdle Avith a hollow lateral pad, whose object is to prevent further upward displacement of the trochanter, and of a cir- cular arrangement for fixing the thigh. The pads, as in Langgaard's apparatus, are fixed by7 a ball-and-socket joint to a firm rod attached to the pelvic girdle (Fig. 388). In Kraussold's9 apparatus the trochanters are fixed from above by* movable concave pads which are attached to the pelvic girdle, and are supposed to fit in the region betAveen the anterior superior spine and the trochanter. The apparatus made by* Schwabe10 consists of a steel strengthened leather pelvic girdle accurately* fitted after a plaster cast of the part, Avith arm pieces and a broad band over the stomach above connecting them, to correct the lordo- sis. A smooth polished pad, of ivory, hard-rubber, or ebony, is attached to the pelvic girdle. It can be turned in any direc- tion, and with it any* amount of pressure may be made down- Avard and inward upon the trochanter. After putting on the apparatus, the patient is placed upon his back, the extremity is extended and the luxated head replaced, and the pad is fixed in the proper position. Fig. 387.— I Coxae Cong, ii 14-year-old Boy. Lang- gaard's Apparatus for Lux. Coxae Cong. 34o OrtJiopcdics and Orthopedic Surgery. All these apparatuses are dear and complicated, and mostly- useless. " I have frequently seen children encased in steel," says Adams, "but have failed to observe any7 advantages de- riA*ed therefrom/' It is therefore readily* conceiA*able that corsets of silicate of soda and other plastic material haA-e been tried. Thus Landerer recommends the application in exten- sion of a silicate corset reaching from the axilla to the tro- chanter; the trochanteric part is to be carefully- pressed in be- fore it dries, so as to make a kind of depression. The corset is then to be slit in front and behind. Landerer found the working of these corsets very satisfac- tory7, the patients immediately7 appearing one and one-half incites taller, the lumbar lordosis being straightened out. and the bearing becoming normal. One patient, for instance, avIio had before not been able to go at all, Avalked for half an hour immediately7 after its application. For the case shown in Fig. 386 I had a leather corset made after such a one of Landerer, Avith the result that his gait improved remarkably*. In those cases AA'here paralysis of a certain group of mus- cles has caused the deformity, it is proper to attempt to strengthen them by electricity, massage, gymnastics; and these are the cases in Avhich hydrotherapy7 and the Swedish movement cure accomplish remarkable results. G-uerin, Brodhurst, and others haA-e recommended tenotomy of the pelvi-trochanteric muscles, to remove the opposition to reposition Avhich they* occasion; but this can only be necessary in A-ery- few cases. Buhring proposed to bore a hole in the bone, and others thought by* subcutaneous scarification of the periosteum of the ilium to excite the bone to osteoplastic activity*. Mayer seriously* proposed to shorten the healthy- femur by* resection; and Hiiter recommended exposing the atrophic head of the bone and removing it, loosening the peri- osteum from the neck of the femur and the ilium, and bv stitching them together to obtain a synostosis or immovable joint connection between pelvis and femur. Konig believes that in any rational operation Ave must attempt to fix the head of the femur in a new cavity, perhaps by means of ivory- pegs; since even if in a unilateral dislocation ankylosis was the final result, this would be better than the abnormal mobil- ity* of congenital luxation. As regards resection of the hip for this deformity we possess a series of observations. Thus Orthopedics and Orthopedic Surgery. 341 Heusner u in a female se\*enteen years old, after vainly* tiying Taylor's and other machines, did a resection, removing the elongated head of the femur and chiselling off the edges and enlarging the acetabulum, and obtained a good result. Margary*12 also tried chiselling out the acetabulum, and has done seven resections for congenital hip dislocation (three unilateral, four bilateral). Rose and Reyher also were com- pelled to resort to it. For old cases, Avhere the motion of the head upon the peh'ic bones causes great pain and disturbance of function, the operation of resection is fully7 indicated, and has giA-en good results, especially when combined with deepen- ing of the acetabular cavity. Congenital dislocations of the patella have been obserA*ed. They* are mostly unilateral or bilateral, incomplete or complete external luxations. When complete, it is only when the knee is flexed that the dislocation becomes prominent or apparent (intermitting form); when incomplete, the patella lies upon the external condyle of the femur, and Avhen the knee is flexed, the patella returns to its normal place. In a few cases the secondary* genu valgum Avas so great, that operatiA*e treat- ment Avas necessary7 (Middeldorpf).13 Cases in point have been described by Paletta, Wutzer, CasAvell, Boy7er, Ravoth, and Bessel-Hagen.14 The amount of disturbance Avas usually marked, especially on going doAvn- hill, or doAvn-stairs. Suitable knee-caps were in most cases sufficient to relieA-e the trouble. Our main endeavor in treat- ment should be to gradually7 correct the position by passive flexion, fixation in the correct position, etc. In congenital dislocation of the knee the tibia is usually7 displaced forward with abnormal hyper-extension of the joint; and this may be so great that Avhen the child lies upon its back it may* be possible to extend the leg vertically* or even to make the anterior surfaces of leg and thigh meet. Congenital luxation of the foot has also been noticed ( v. Volkmann). Rarer and much less important are the congenital luxa- tions of the upper extremity. Probably most of the cases of congenital luxation of the humerus described by R. Smith,15 Mayer, and others were of a paralytic nature (Little, J. Wolff). At the elbow there were chiefly noticed isolated congenital luxations of the head of the radius, which, like those of the 342 Orthopedics and Orthopedic Surgery. hand, mostly* depend upon defects in and disturbances of de- A*elopment in the region of the fore-arm. BIBLIOGRAPHY. 1. L. c, p. 202.—2. Kronlein.—3. Brodhurst, Lect. on Orthop. Surg.. 1876, p. 160.—4. Tageblatt der Strassburger Naturforscherversamralung. —5. Gaz. des hop., 1866, p. 60.—6. Arch. f. Gyn., V., 1873.—7. L. c, p. 99. —8. Boston Med. and Surg. Journ., 1885.—9. Centr. f. Chir., 1881.—10. 111. Monatschr. f. arztl. Polytechnik, 1883, p. 971.—11. Langenb. Arch., XXX., p. 666.—12. Archivio di Ortopedia.—13. Deutsch. Zeitschrift f. Chir., 24, p. 151.—14. Deutsch. Med. Woch., 3, 1886.—15. A Treatise on Fractures in the Vicinity of Joints, etc., Dublin, 1850. INDEX. Abscesses, cold, 8t. gravitation, 81, 110. leading to kyphosis, 86. psoas, 111. retro-pharyngeal, 112. Acquired deformities, 7. deformities of the foot, 233. flat-foot, 291. pes varus, causes of, 266. Anatomical changes in acquired pes varus, 267. changes in congenital pes varus, 260. changes in hallux valgus, 310. Anatomy, pathological, of cerebral paralysis, 319. pathological, of pes calcaneus, 253. pathological, of talipes equinus, 246. Angular union, 329. Ankylosis, 172. and contractures, general treat- 176. causes of, 173. symptoms and diagnosis of, 175. Anti-rachitic mixture, 17. Apparatus, 28. for congenital flat-foot, 304. for measuring skoliotic curva- ture, 134. for skoliosis, 152. lever, 107. for simple extension, 27. used in treatment of contract- ures of the foot, 238. Arthrogenous club-foot, 233. Atrophy of the muscles of the calf, 247. Axis rotation, 329. Backward curvature, see Kypho- sis. Bandage, elastic spiral, 153. oblique, 153. Bandages, 22. in orthopedics, 22. silicate of soda, 164. Bauer on inventors, 2. Beely's corset, 35, 156. extension bed, 20. Bed, upright, 91. Billroth's osteotome, 48. Bones, operations on, in club-foot, 283. Bonnet's apparatus, 281. Bow-leg, 224. Brisement force, 177, 193, 217. Bruns' apparatus for treatment of wry-neck, 65. Calcaneus shoe, 254. Caries of the vertebra?, 77. Casts, preparing, 24. Cerebral paralysis in children, 319. paralysis, pathological anatomy of, 319, paralysis, treatment of, 321. Cervical spondylitis, treatment of, 100. Cicatrices and talipes, 234. Claw-hand, 200. pathological, 200. Club-foot, 232. see Talipes. shoes, 279. Club-hand, 199. congenital, 200. traumatic, 200. Cold in kyphosis, 89. Congenital deformities, 7. deformities of the foot, 233. hip dislocation, prognosis of, 338. infraction and curvature of the forearm, 8. luxations, 333. pes valgus, 289. pes varus, 259. skolioses, 116. spastic rigidity of the limbs (Little's disease), 324. torticollis, 61. torticollis, treatment of, 64. Contracture, congenital spasmodic muscular, 324. 344 Index. Contractures, 172. and ankyloses of the elbow, 199. and ankyloses of the hand, 199. and ankyloses of the hip-joint, 179. and ankyloses of the knee, 186. and ankyloses of the shoulder, 196. and ankyloses of the wrist, 199. of the tarsal joints, 232. Corset, Beely's, 156. spinal supporting, 105, 156. Corsets, materials used for, 26 Couches for skoliosis, 149. Counter-curvatures, 83. Cow-foot, 266. Crus varum, 228. treatment of, 229. Crutches in paralysis, 321. Cur\*ature of the radius, 8. varieties of, 71. Curvatures, rachitic, of the diaphy- ses, 227. Deformities, causes of, 8. of the foot, 232. of the spinal column, 71. of the thorax, 167. of the toes, 309. paralytic, 315. Deformity, definition of, 6. Desks and work-chairs for children, 144. Devil's foot, 266. Diachylon plaster, 26. Diagnosis in general, 12. of pes equinus, 247. of pes valgus, 301. Diaphyses, rachitic curvatures of the, 227. Diastrophometry, 13. Disease a cause of deformity, 9. Dorsal splints, 106. Dupuytren's contraction, 204. contracture, 205. Elastic traction, 5. traction in pes equinus, 249. traction in wry-neck, 64. Elbow-joint, contractures and an- kyloses of, 197. extension of the, 197. flexion of the, 197. Electricity, application of, in ortho- pedics, 20. in pes valgus, 303. Equinus apparatus of Stromeyer, 32. Extension apparatus, 96. in orthopedics, 20. from the head, horizontal, verti- cal, and simple, 27. Extension cravats, 69. treatment, 5. Extremities, orthopedic affections of the, 172. Faulty shoes and their conse- quences, 310. Felt dressings, 101, 167. jacket in lumbar kyphosis, 101. Femur, rachitic curvatures of the, 228. Finger contractures, 202. contractures, Busch's method, 206. contractures, diagnosis of, 206. contractures, treatment of, 206. Flat-foot, 257, 289. congenital, apparatus for, 304. theories of, 293. Foetal deformities, 7. Foot, contractures of the, 232. luxatiou of the, 341. splints, 238. Forcible redressement of pes varus, 274. Forward curvature, see Lordosis. Fractures and luxations, orthopedic affections following, 329. Genu recurvatum, 227. varum, 207, 227. appearance of, 207. Genu valgum, 207 appearance of, 207. appliances for treatment of, 214. cause of, 209. Heine's conical cushion, 212. infantile, 211. mechanical causes of, 210. osteotomy in, 222. soft bones, 220. symptoms of, 210. treatment of, 211. varieties of, 207. walk of patients, 210. Genu varum, 224. ambulant treatment, 226. anatomical changes in, 225. recurvatum, 227. symptoms of, 225. treatment of. 225. Glue dressings, 100, 167. Glula-i, paralyzed, effect of, on Avalk- ing, 318. Goniometer, of Roberts, 13. Gymnastics in orthopedics, 18. in skoliosis, 145. Habitual methods of holding the body, 9. in skoliosis, 129. Index. 345 Haemorrhage following tenotomy, 46. Hallux valgus, 309. anatomical changes in, 310. treatment of, 312. Hammer-toe, 314. Hand, contractures of the, 199. Heat, sun baths, douches, vapor baths, etc., 18. Hereditary influences in club-foot, 233. Heredity in rachitis, 51. in wry-neck, 60. Hip, congenital luxation of the, 333. luxation of the, 333. Hip-joint, contractures and anky- loses of, 179. paralytic contractures of the, 318" Infantile paralysis, 315. rachitis, 56. Instruments required in orthopedic surgery, 47. Introduction, 1. Jacket method, 5. Jury-mast, 97. Knee, ankyloses of the, 186. congenital dislocation of the, 341. luxation of the, 341. Knee-joint, contractures and anky- loses of the, 186. paralvtic contractures of the, 317" Knock-knee, 207. see Genu valgum. Kyphosis, 73. abscess in, 80. acute stages of, treatment in, 110. and occupation, 74. and tuberculosis. 78. apparatus for treatment of, 76. Banning's truss, 70. causes of, 75. changes in the pelvis, 84. cod-liver oil in, 89. corsets in, 76. counter-curvatures, 83. disease of the vertebrae of the neck in, 86. dorsal splint in, 98. felt jacket in, 103. general treatment, 88. ice-bags in, 89. in the spinal column, 78. jui v-mast, use of, in, 98. later stages of, 110. Kyphosis machines, 92. muscular affection in, 83. paralysis after, 88. pathological variety of, 77. Phelps' upright bed in, 91. prognosis of. 88. psoas abscesses in, 111. retro-pharyngeal abscesses in, 112. round shoulders in, 74. Sayre's method, 94. sea baths for, 89. Stillman's lever apparatus in, 108. supporter, 75. suspensory belt in, 90. suspension girdle in, 90. symptomatology of, 84. Taylor's machine in, 93. time of development of, 78. tumors, a cause of, 84. value of plastic felt in, 101. with rachitis, 75. Wyeth's double corset in, 96. Kyrometer, 14. Lateral curvature, see Skoliosis. Lead palsy, 327. Leather dressings, 101. Lever apparatus, 106. Linear osteotomy, 50. Lister, value of treatment of, 5. Little's disease, 224, 324. Lordosis, 72. apparatus, Nyrop's, 73. Lueke's apparatus for club-foot, 33. Luxation of the foot, 341. of the hip, 333. of the knee, 341. of the patella, 341. of the upper extremity, 341. Luxations, congenital, 333. Machines, club-foot, 275. Malposition in utero a cause of de- formity, 9. Massage'in orthopedics, 29. definition and methods, 19. in skoliosis, 148. passive movements, 19. Maternal impressions, 8. Mechanical agents, 16. appliances in orthopedics. 20. beds. 21. Medicinal agents, 17. Methods of treatment, 5. "Modern" children, 142. Movable joints, 10. Muscle-antagonism, 10. Muscles, paralysis of the, 319. 346 Index. Muscular atrophy in infantile paral- vsis, 315. Myelitis, 83. Myo-neurogenous talipes, 236. Myotomy, 47. Nervous system, deformities aris- ing from diseases of, 9. Neurogenous club-foot, 233. Non-ambulant apparatus, 241. Nyrop's spring corset, 105. Oblique seat for skoliosis, 152. Orthopedic affections following frac- tures and luxations, 329. bandages, 22. operations, surgical, 37. shoe, 31. Orthopedics and orthopedic surgery, 1. definition of, 3. general, 1. general treatment, 17. gymnastics in, 18. history of, 3. massage in, 19. mechanical appliances in, 20. Orthopedists, eminent historical, 4. Osteitis, tubercular, 77. Osteoclasis, 38. Osteoclasts, 39, 40. Osteotome, Billroth's, 48. Osteotomy, 49, 194, 220, 226. in genu valgum, 222. Paralysis, infantile, 315. of the abdominal muscles, 319. of the dorsal muscles, 319. of the quadriceps femoris, springs for, 33. of special nervous and muscular areas, 325. in the foot, 317. of radial origin; 326. radial, 325. ulnar, 325. Paralytic club-foot, operations on, 288. contractures in the knee-joint, 317. contractures of hip-joint, 318. deformities, 315. pes calcaneus, 255. Paraesthesia, a symptom of kypho- sis, 85. Passive corrective movements, 146. movements in massage, 19. Pasteboard dressings, 100, 167. Patella, congenital dislocation of the, 241. luxation of the, 341. Pathological skolioses, 116. Peat and salt baths for paralytic cases, 18. Pes calcaneus, 252. cavus, 255. contortus, see Talipes. planus, 257. valgus, 289. varus, 258. Pied-bot, see Talipes. Pigeon-breast, 167. symptoms, 168. treatment of, 169. Plaster bandage, 22. bandage in genu valgum, 216. bandage in pes varus, 272. casts, 25. Plaster jacket, 93, 163. application of. 94. Plastic felt bandages, 24. felt, value of, 101. Poliomyelitis anterior, idiopathic, 315. Pott's disease, see Kyphosis. Prognosis of deformities, 15. of pes equinus, 247. Prophylactic treatment of pes equi nus, 248. Prophylaxis, 15. Psoas abscess, 111. Rachitic curvatures of the diaphy- ses, 227. curvatures of the femur, 228. curvatures of the lower extremi- ties, 228. curvature of the lower limbs, 58. deformity, pigeon-breast, 168. flat-foot, 304. skoliosis, 139. Rachitis, 55. changes in the extremities in, 57. changes in the pelvis, 57. deformities in the skull in, 56. deformities of spinal column in, 57. deformities of thorax, 56, etiology of, 55. general treatment, 17. symptoms of, 56. Radial paralysis, 326. Redressement force\ 177, 217. Resection of bone, 193. of a joint incurvatures, 52. Rest, influence of, on contracture, 318. Retro-pharyngeal abscesses, 112. Rigidity of the limbs, congenital spastic, 324. Rickets, see Rachitis. Index. 347 Roberts' elastic tension corset, 22. epipedometer, 13. goniometer, 13. Robin's osteoclast, 41. Round shoulders, 73, 74. Sandals for the toes, 314. Scarpa's theory of club-foot, 234. School desks and seats, 143. Schreiber, August, on orthopedics and orthopedic surgery, 1. Screw mechanism in orthopedics, 34. Semicircular osteotomy, 50. Shoe, calcaneus, 254. orthopedic* 31. Shoes, faulty, 310. for club-foot, 279. for congenital flat-foot, 304. Shoulder-joint, contractures and an- kyloses of the, 196. Shoulders, round, 74. Silicate-of-soda dressing, 100, 164. Skolioses, causes of, 117. cicatrical, 116. congenital, 116. considered as deformities due to weight, 117. empyematic, 116. inflammatory, 116. pathological, 116. theories in regard to, 124. Skoliosis, 113, 683. anatomical changes in, 118. apparatus for, 152. apparatus for measuring, 134. appliances for the correction of, 134. Beely's extension frame for, 151. Biihring's apparatus, 134. changes in the ligaments in, 123. changes in the muscles in, 123. changes in the ribs in, 122. deformities due to, 122. diagnosis of, 130. early diagnosis of, 131. effect of, on health, 133. faulty attitudes, 125. faulty position at school desks, 126. habitual, 129. habitual, instruction of youth, 142. gymnastics in, 145. lumbar, diessing for, 166 measuring- and drawing appli- ances, 136. occurrence of, 114. ordinary habitual, 129. pelvis in, 123. pressure dressing in, 165. Skoliosis, primary right-convex dor- sal, 128. prognosis of, 132. prophylactic measures, 142. prophylaxis in, 148. rachitic, 139. rachitic, changes in, 140. rachitic, symptoms of, 139. static, 140. static, signs of, 141. symptoms of, 126. theory of treatment of, 145. time of occurrence, 114. Skoliosometer of Mikulicz, 135. Skoliotic dorsal vertebrae, 118. Spinal column, deformities of, 71. Splay-foot, 257, 289. see Pes planus. Splay or flat foot, see Pes valgus. Splint for caries of the dorsal and lumbar vertebra?, 106. Splints, dorsal, 106. for congenital club-foot, 270. for the foot, 238. Static skoliosis, 140. Stromeyer's equinus apparatus, 32. Surgical orthopedic operations, 37. Suppuration after tenotomy, 46. Suspension in skoliosis, 146. Suspensory belt, 90. Swedish gymnastics, 18. " Swinging leg," 317. Talipes, 232. calcaneus, 252. calcaneus, acquired, 253. calcaneus, congenital, three grades of, 253. calcaneus, differentation of, 252. calcaneus, pathological anat- omy of, 253. calcaneus, treatment of, 254. equinus, 244. equinus, differentation of, 245. plantaris, 256. symptoms, prognosis, and treat- ment of, 237. theories as to origin of congeni- tal, 234. three degrees of, 234. valgus, 289. valgus, consequences of, 300. valgus, diagnosis of, 301. valgus, treatment of, 302. varus, 258. varus, differentation of, 259. Taylor's extension apparatus, 106. machine, 93. Tenotomy, 43, 44. in club-foot, 282. in flat-foot, 303. 348 Index. Tenotomy in wry-neck, 67. of the tendo Achillis, 242, 250. Theories as to origin of congenital club-foot, 234. Thoracic joint-strengtheners, 18. Thoracograph of Schenk, 134. Thorax, deformities of the, 167. Toes, deformities of the, 309. Torticollis, 60. appliances for rectification of,65. apparatus, 64. cicatricial, 61. congenital, 60. etiology of, 60. Mathieu's apparatus, 66. paralytic, 61. prognosis of, 63. Reynder's apparatus, 66. symptoms of, 62. treatment of, 64. Traction by elastic bands, 32. by springs, 33. in club-foot, 32. in paralysis, 33. in reduction, 32. in skoliosis, 150. Traumatic club-foot, 233. Treatment of cerebral paralysis, 321. of hallux valgus, 312. Treatment of pes calcaneus, 254. of pes valgus, 302. of unreduced luxations, 330. Tubercular osteitis, 77. Tuberculosis in kyphotic patients, 88. Ulnar region, paralysis in the, 325. Vertebrae, caries of, 77. Vertical osteotomy, 50. Von Ziemssen on.orthopedics, 1. Walk of acquired pes varus patients, 268. of children with paralytic con- tractures, 318. of congenital pes varus patients, 265. of genu valgum patients, 210. of pes equinus patients, 246. Wedge-shaped tarsotomy, 285. Wheel crutch, 110. Wire dressings, 167. Wrist-drop, 327. Wrist-joint, contractures of the, 199. Wry-neck, 60. see Torticollis. NLM051115942