Chapter XXXVIII: Introduction (23)

=4. Deformities Due to Diseases of the Chest.=—In =empyema= or =pleurisy= one side of the chest is retracted and it will be noticed that the curvature occurs toward the healthy side. Chronic pulmonary tuberculosis producing fibrosis of the lung gives the same result as empyema and pleurisy.

=5. Deformity due to obliquity of the pelvis.=—This type may be due to any inequality of the limbs, such as equinus of the foot. Congenital dislocation of the hip may play a part while one naturally lays stress on pelvic and lower lumbar lesions.

=6. Deformity due to Distortion of Other Parts.=—Unequal visions, unequal hearing, and torticollis by causing malposition are etiological factors especially in school children. The loss of an arm will tend to cause an asymmetrical position of the trunk.

=7. Congenital Deformity.=—Congenital scoliosis occurs, but is usually associated with other congenital deformities of the spine, such as the reduction or increase of the vertebræ, cervical rib, elevation of the scapula, etc. The deformity is usually not apparent until later years, though it may occur at birth.

=8. Spinal Lesions.=—Any osteopathic lesion predisposes to curvature because it interferes with the nerve supply and tonicity of the spinal muscles and could readily cause the faulty position.

Functional or Postural Lateral Curvature

This is a condition where there is a gradual curve to one side unaccompanied by any marked rotation. The maximum deviation may be no more than one inch and a half from the middle line, which point is generally found about the tenth dorsal vertebra. In the vast majority of cases deviation is to the left and in such the following alterations will be noticed: a general convex curve to the left; elevation, and anterior displacement of the left shoulder; posterior displacement of the right shoulder; in extension, the right side of the back will be higher than the left and in addition some torsion to the concave side, which is easily understood if one recalls the exact changes that take place during side movement of the normal spine. It is important to remember that functional scoliosis disappears when the patient is suspended or assumes the recumbent position.

Organic or Structural Scoliosis

This term is applied to cases where definite change has taken place in the vertebræ. Organic curves may be simple when the deviation is unaccompanied by any compensatory curve, or compound when a compensatory curve is present. We shall consider the deformities as they present themselves in the various regions of the spine.

=Cervico-Dorsal Curvature.=—This condition is comparatively rare and according to Lovett occurs in only three and six tenths per cent of cases. The head is slightly deviated towards the concave side, the shoulder on the concave side is lowered, while on the opposite side or the side of the convexity it is naturally at a higher level. The angles of the upper ribs are prominent due to the co-existing rotation.

=The Dorsal Curvature.=—The shoulder is raised on the convex side, and the rotation of the vertebræ is very marked, causing a very definite projection of the angles of the ribs on the convexity. This rotation also projects the scapula backwards on the convex side. On the concave side the scapula is flat and sunken, and the inferior angle rotated inwards and at a higher level than the opposite side. Viewed from the front the thorax may not be displaced at all, or it may be displaced toward the convex side, and if the latter is the case it is, of course more prominent on the concave side. In severe cases the lower end of the sternum is deviated towards the convexity and you will find that usually the arm hangs further from the convex side than from the opposite one.

=The Lumbar Curvature.=—Here we find the trunk displaced toward the side of the convexity, and the waist retracted on the opposite side. The difference in the level of the hips is the most prominent deformity in this region, and it will be found that the hips are raised on the concave side. Rotation in this region is much less evident than in the dorsal region, but can be demonstrated by a fullness on the convex side of the curve, due to the projection of the transverse processes.

=Dorso-Lumbar Curvatures.=—This condition is similar to a certain extent, to a severe functional scoliosis. The findings observed in the last two regions above described will naturally be present in this type of curvature. It is not so frequently associated with compensatory curves as in the other types described.

=Compound Structural Curves.=—The appearance in this type of scoliosis will, of course, be a combination of those described above according to the types of curvature in combination, that is to say right dorsal and left lumbar, etc. If one type predominates the appearance will be chiefly that found in that particular type of curvature. The relative frequency of the common type, as given by Schaltless, in eleven hundred and thirty seven cases is as follows; functional scoliosis, 15.39%; lumbar, 11.7%; dorsal, 19%; dorso-lumbar, 20%; cervico-dorsal, 3.6%; compound, 30%.

=Diagnosis.=—To the osteopathic physician the diagnosis of scoliosis is not difficult. Let me caution you that true scoliosis must be distinguished from the lateral curvatures caused by Pott’s disease. Vertebral rotation, the absence of pain, the extreme rigidity, the characteristic appearance of the ribs and thorax should, however, make the diagnosis of scoliosis easy.

=Treatment.=—In general the treatment of scoliosis is difficult to present, because every case is considerably different, and the amount of correcting force used in any form is almost entirely a matter of judgment, as is also the time when corrective pressure should be discontinued. Continual practice in the treatment of these conditions is most essential to your success with them. I have had most gratifying results in a comparatively short time simply because I used osteopathic treatment and exercises along with a modified Abbott method.

Functional or False Scoliosis

The functional or false scoliosis might be regarded as a habitual inability to stand correctly, simply a postural malposition and lack of muscle tone without marked structural change, which is maintained for a considerable length of time or where the position is repeated several times daily. The treatment of selected types of this deformity is most successful and may well be divided into three procedures: first, the substitution of a correct attitude for the faulty one, that is careful investigation should be made to ascertain the condition which might be the cause of the incorrect position such as poor school desks which might cause the child to reach either up or down to write, poorly fitting clothing which causes a pulling on the shoulder, eye strain which would cause tilting or twisting of the neck, congenital shortening of one limb or too rapid growth, should all be looked for and removed; second, regular osteopathic manipulation, at least three times per week to increase the tonicity of the already weakened spinal muscles and aid correction, are highly essential and shortens the time required for a complete cure; third, supervised gymnastic exercises of various kinds are very beneficial to develop and bring the musculature back to normal. Such simple exercises as crawling on the hands and knees in a small circle towards the side of the convexity, and the hanging from a horizontal bar by the arm on the side of the concavity will prove to be helpful. Some authors recommend the regular army setting up exercises for some cases or a frame by means of which the hips are fixed, and rotating and side bending exercises of the head and trunk given. These last two exercises are indeed very reasonable procedures but I have found them unnecessary mainly because I used osteopathic manipulations instead.

In advising and supervising exercises it is best to have the patient’s back bared so that the effect of each movement can be noticed and the exercises directed accordingly. Care and judgment should be used as to the number and severity of the exercises and would depend of course on the vigor of the child. Treatment should continue until the condition has been overcome, and the patient should be under observation for a couple of months afterwards so that any recurrence of the deformity would be noticed and attended.

Organic or Structural Scoliosis

The treatment of organic or structural scoliosis is more complicated for it must be remembered there are two elements of the deformity demanding correction; one, the lateral curve to be corrected by a side force, and the other, the rotation of the vertebræ to be corrected by a twisting force. I find both osteopathic manipulation and gymnastic exercises are of great value in the correction of this deformity as they help to loosen the curve and develop the musculature but used alone good results can rarely be obtained especially in obstinate curvatures. I believe that I have improved nutrition and probably prevented further deformity by treatments and exercises, but I am quite positive that it is not possible to correct an organic scoliosis without the forcible correction used in the Abbott method.

As the details of treatment are tedious to follow, we will take for example a case of right dorsal curvature presenting a marked hump deformity, with a compensatory curve to the left in the lumbar region, as this is the most common type. I might say here that whether or not a compensatory curve is present, makes no difference, as treatment is directed entirely to the primary curve on the assumption that overcorrection of it will cause a secondary curve to disappear by compensation.

The patient is prepared by putting on a snug fitting undershirt and sewing pads of saddler’s felt over all bony prominences, especially the crest of the ileum and anterior superior spine. Sometimes I take a piece of felt of four or five inches wide and long enough to go around the entire pelvis, just high enough to cover the brim, and fasten it in front with adhesive. Next I make a bunch of pads two or three inches in thickness and large enough to fill up the concavity of the left side, and first sew them together, and then with a few stitches fasten them to the undershirt thereby filling up the space on the concave side. The edges of the pads should, of course, be trimmed down to conform with the general contour of the body, the main thickness being in the middle. I then sew a single pad on the right side of the thorax in front and a little to the right side.

The patient is now ready for the Abbott frame and is placed on a canvas hammock about twelve inches wide, which is cut on the bias so the right side is three inches shorter than the left. The hammock can be adjusted to the desired degree of flexion by a ratchet at the foot of the regular Abbott frame. The limbs of the patient should be elevated to increase the flexion as this has a tendency to unlock the articulation and thereby help in overcoming the rotation. Next a canvas bandage four inches wide is passed around the patient under the axilla of the concave side and fastened to the frame on the opposite side, and another one is placed around the pelvis and fastened to the same side of the frame, both on a level with the body plane. A third bandage is next placed around the point of greatest convexity and fastened to the opposite side of the frame in such a way that it can be tightened and a direct pull be made on the curve. Before tightening the last bandage the left arm and shoulder should be brought up high beside the face and pulled backward toward the floor as it is this twisting force that produces some rotation of the thorax. The correcting bandage is now tightened being careful not to cause the patient too much discomfort.

I always use ordinary absorbent cotton for padding, which is held in place by the regular gauze bandage. The plaster of Paris bandages should be applied high up under the left shoulder and well down over the sacrum and innominate bones and should be of a uniform thickness of half an inch. Sometimes I carry the plaster over the right shoulder to hold it down and back, though not always. I always let the cast set pretty well before removing the patient from the frame and if it has been applied in the morning I find it best to wait until afternoon before trimming and cutting the windows because there is less danger of breaking it. In trimming I always smooth up the edges, lower the right shoulder, but keep the left well up, trim off enough at the bottom in front to allow the thighs to be readily flexed without obstruction, and leave it low behind so as to maintain the flexion. Next, two holes or windows are cut in the cast, one over each area where the pads were inserted, and remove them. The hole in the back on the left or concave side permits expansion of the chest to the back, while the hole on the right side in front allows the ribs, which are posterior, to move forward under pressure or the pads to be inserted at the posterior angle or backward prominence of the ribs of the convexity. The canvas bandages or straps around both the axilla and pelvis are removed, but the one about the convexity of the curve is left in place so as to assist in the after treatment. The patient usually suffers some discomfort such as difficulty in breathing and the inability to move the body freely, and should remain in bed a day or two after the cast has been applied. Usually they sleep very poorly the first few nights, but the spine soon gives under the pressure and they become comfortable. When the cast has become quite comfortable an assistant pulls on the canvas bandage which was left around the convexity, while pads are inserted so that the greatest pressure is exerted on the angle of the ribs to further overcome the rotation and decrease the lateral deformity. Also heavy felt pad may be inserted over the bulging ribs in front of the left side to push them back. Care should be taken that too much pressure is not brought to bear on the side of the convexity because if more pressure is exerted here than on the angles of the ribs, it will tend to increase rather than decrease.

Casts should be worn for different periods, some being changed in a month while others can be worn for three months. It is entirely a matter of judgment. My best results have been secured by only slightly correcting the curvature at the time the cast was applied, and relying more on the proper insertion of the pads. Often at the end of a month or six weeks, in selected cases, I have split the cast down the front and removed it by springing it apart, and administered osteopathic manipulations to the spine freely in all directions, thoroughly loosening up the muscles. Then I replace the cast and hold it together in front with moleskin adhesive and insert the pads as before. I repeat this procedure three times per week for another month, together with daily exercises each morning and evening of drawing the left shoulder up and forward while in the cast to develop the muscles of the left shoulder girdle. The treatments and exercises certainly do build up the spinal muscles for it must be realized that they have suffered in nutrition to a great extent as a result of wearing the cast. Next the cast can be worn during the day and removed at night, and gradually it can be left off several hours at a time. If no bad results occur it can be left off for longer periods until finally its use can be discontinued. However, the patient should still be under observation once a week for a couple of months to determine any recurrence of the deformity. The resumption of active corrective treatment, or increasing relaxation in gymnastic work, will, of course, depend upon the progress of the case.

In the more obstinate cases, casts should be applied as long as further correction can be obtained. The procedure is entirely the same, only the time required for correction is longer, sometimes a year or year and a half, and when overcorrection has been maintained, it is better to use a removable jacket made of celluloid or light stiffened leather, with large windows cut over the region where pressure is to be avoided, than the removable cast described above.

In closing let me say that this method of correcting lateral curvature is best adapted to patients during their growing period and though it may be employed in older cases you will usually be disappointed in the final result. The only reason I can see for treating older cases is purely mercenary.

Congenital Dislocation of the Hip

Unilateral

Undoubtedly as far back as 1829, the actual recognition of this condition was due to the pathological research of a French surgeon Dupuytren, who described this deformity with great accuracy and insisted that there was no possible chance of correction. From then on until 1886 nothing was done by medical science to overcome the deformity, though it is claimed some were made. It was in this year that the famous Bavarian surgeon, Hoffa, gave to the medical profession the results of his successful attempts at reduction by opening the hip joint from behind and enlarging the acetabulum to a size sufficient to hold the head of the femur.

Orthopedic surgery has to thank the irritating effects on the skin, of antiseptics necessary in preparing his hands for ordinary surgery, as it was due to this triviality that Lorenz, a promising surgeon of Vienna, transferred his energies to the field of bloodless surgery and gave to us the most valuable early work and present day technique in the bloodless reduction of congenital dislocation of the hip.

The name, of course, is applied to a congenital deformity which involves one or both hip joints, resulting in lameness, due to a misplacement of the head of the femur from the acetabulum. Of all congenital dislocations the hip joint is by far the most common and most important. The misplacement is far more often unilateral than bilateral and far more frequent in females than in males, the cause for the latter probably being the difference which exists in aspect and position of the acetabulum as well as the disproportionate laxity of the capsule in the two sexes. It must be remembered that normally at birth, the acetabulum covers only about one-third of the head of the femur, and our most accepted theory as to the cause of this deformity, is a defective development of the acetabulum or its posterior margin, which may be primary or secondary to an abnormally prolonged fixation of the limb in a position of flexion or adduction while in utero. At birth it is quite probable that the dislocation is a subluxation only, which becomes complete by muscular action and the use of the limb in standing and walking.

The pathology of this disease is clearly established, and varies, of course, with the age of the patient in strain and friction to which the misplaced parts have been subjected. In children over two and one-half years of age the acetabulum is usually shallow and small, and filled with a deposit of fat and fibrous tissue. It is covered with normal hyaline cartilage and nearly always the ligamentum teres is present, but is so badly stretched and ribbon-like that ultimately the artery accompanying it fails to function, resulting in a malformation of the head of the femur. The capsular ligament is elongated and thickened to accommodate the upper displacement of the femur, and the anterior wall of it is stretched tight across the acetabulum like an hour glass. The interior of the capsule is always partly lined with synovial membrane. Usually a secondary acetabulum is found upon the ileum, formed by the direct pressure of the head of the femur through the capsule and the result of irritation of the periosteum of the ileum, but it is as a rule, not deep enough to form a secure support for the head of the bone. The neck of the femur is usually shorter than normal and the upper extremity of the bone is somewhat atrophied. The pelvis is usually slightly atrophied on the affected side, and a lateral inclination of the spine may be present. The long muscles of the thigh are shortened; while those attached to the pelvis and trochanter are changed in direction and are usually lengthened.

=Symptoms.=—As a rule congenital dislocation of the hip is not accompanied by the defective development or deformity elsewhere, and the symptoms are so diagnostic that there is little difficulty in recognizing this condition even without the X-ray which is, of course, a positive diagnosis.

Rarely does the displacement attract attention until the child begins to walk. Often the child does not walk as early as it should. Sometimes it may be delayed until the eighteenth month or second year and then it walks with a limp which becomes more pronounced as the child grows older until at the fourth or fifth year it is very decided. The limp is peculiar and its character is explained by its cause; for the shortened limb, owing to the elasticity of the capsule, becomes still shorter when the weight is borne upon it, thus causing a peculiar lunge of the body towards the short side like the normal motion of walking downstairs. In compensation, of course, the pelvis is tilted towards the short limb and its inclination is thereby increased, so that the anterior superior spine lies at a lower level and in advance of the opposite side. Usually the affected limb is about an inch shorter than the sound one, and in adult life it is considerably more. The range of abduction is much diminished, but flexion, extension and adduction are quite normal, and the trochanter will be found elevated about an inch above Nelaton’s line. If the thigh be flexed and adducted to its extreme limit, the neck and head of the femur can be easily distinguished moving under the gluteal muscles when the limb is rotated, or the head can usually be readily palpated in front when the limb is extended. Then, too, by fixing the pelvis and using traction and upward pressure on the limb, the abnormal mobility or telescopic motion is easily demonstrated and this, I might add, is a very important test.

Rarely do we find a unilateral anterior dislocation, in which the head of the bone lies beneath the anterior superior spine, but when this position is present, the symptoms are much less marked than in the ordinary form because the relation of the pelvis to the femur is more nearly normal. The limp and the shortening of the limb are less noticeable because the tissues attached to the anterior superior spine form a relatively secure support.

The X-ray, of course, makes the diagnosis complete. Even though the clinical diagnosis is certain, a radiograph is indispensable in every case, particularly for the purpose of ascertaining the exact position of the head and condition of the acetabulum and femur. The acetabulum is usually shallow and poorly developed, more particularly the iliac portion of its rim. After the reduction of the dislocation, an X-ray picture should always be taken within the first few weeks, and before the plaster of paris cast has been removed, to ascertain whether the head of the femur is still in place.

As to bilateral dislocation of the hip, the pathology, of course, is the same as in the unilateral type. The shortening of the limbs is as a rule equal or nearly so, and when both femurs are displaced backward, the pelvis is tilted forward thus presenting a marked lumbar lordosis and protruding abdomen. The pelvis seems to be abnormally wide, both buttocks are flattened and the thighs are separated by a considerable space. The characteristic limp in this condition is an exaggerated waddle, often spoken of as “sailor gait.” Again in this condition rarely do we find an anterior dislocation, but when such is the case, the entire body is swayed entirely backward, though the lumbar lordosis is not increased, in fact usually presents a peculiarly flattened appearance. Other symptoms differ only in a slight degree from those of the ordinary posterior displacement. The physical signs are the same as the unilateral displacement and are even more readily recognized by the peculiar appearance and distinctive gait of the patient. The swaggering gait of lumbar Pott’s Disease is somewhat similar, but this is an acquired clinical condition of the spine in which the hip joints are normal in appearance and nearly so in function.

Before taking up the usual procedure for the correction of congenital dislocation of the hip, it might be interesting to touch on several cases of this deformity in young children that I have reduced without an anesthetic. If future experience proves as successful as these cases it will entirely revolutionize the treatment of this condition especially in children under twenty months of age. To begin with, these children had just started to walk and it must be remembered that at this stage the acetabula are nearly normal and there has been no muscular or ligamentous contraction because very little weight has been borne on the limb.

First the pelvis is held fixed by the assistant, and the thighs completely flexed on the abdomen. Next firm pressure is made on the knee to force the head of the femur beneath the acetabulum and as the limb is abducted in the flexed position, the head is raised into the acetabulum with the thumb of the operator’s other hand. The whole procedure takes but a moment’s time and the child should be placed at once upon the floor and allowed to walk. Time will tell if the reduction has been successful, and if failure of retention develops, the Lorenz method followed by plaster of Paris fixation can still be used. I should always recommend the trial of this method in children who have walked not longer than six months, before resorting to the following Lorenz treatment.

=Treatment by the Lorenz Operation.=—This treatment is based on the fact that there is normally present an acetabulum of sufficient size and capacity to retain the head of the femur, providing the limb can be fixed in a favorable attitude, and as soon as possible weight borne upon it to deepen the rudimentary acetabulum. The typical operation of today is best divided into four distinct steps; first, to overcome the resistance of the tissues surrounding the joint; second, to reduce the dislocation, or rather to force the head of the femur over the posterior border of the acetabulum; third, to increase the security of the articulation by stretching the anterior border of the capsule; fourth, to fix the parts in a plaster of Paris bandage.

The child is completely anesthetized, and an assistant firmly fixes the pelvis on the table with his hand. The operator first flexes the thigh to a right angle with the body and forcibly abducts, at the same time kneading and stretching the tense adductor muscles and if necessary rupturing the adductor tendons in order to bring the limb down to the plane with the body. Next to overcome the contraction of the posterior tissues, the limb fully extended is flexed upon the trunk and gradually forced downward until the toes touch the patient’s face. To overcome the resistance of the tissues on the front of the joint, it is best to move the patient to the edge of the table and forcibly extend the thigh downward behind the plane of the body. It is also well to apply direct traction in the line of the body. This preliminary stretching is absolutely necessary, because all the tissues about the joint are so shortened, and it will now be noted that with slight traction the trochanter can be drawn down to Nelaton’s line.

Next reduction is attempted by grasping the limb with one hand at the knee and strongly abducting it while the palm of the other hand is placed on the anterior spine of the ilium with the thumb placed beneath the great trochanter to act as fulcrum. As the limb is gradually forced downward to and behind the body plane, the head of the femur is forced upward until it finally slips over the posterior and inferior border of the acetabulum. In the more resistant cases a padded wedge-shaped block placed behind the trochanter will be an aid in pushing the head forward and upward while the patient’s knee is forced downward. A successful reduction is usually accompanied by a distinct jar and audible thud, and it would be observed that the tension upon the ham string muscles causes fixed flexion of the leg. After reduction has been made, the limb should be brought down carefully into a straight position to test the security of the re-position. If dislocation appears during this manipulation, the tissues must be still further stretched and the displacement further reduced. If displacement occurs readily due to a shallowness of the acetabulum the prognosis is not so good as where the stability remains when the limb is brought down into a straight position, and one must be more particular in the fixation of it. I have also observed that the more difficult the reduction the more stable the end results. The easy replacements are usually just as easily displaced. Sometimes the head slips into the socket quietly without the distinct jar or thud but the results in these cases are just as good provided they are properly cast.

The application of the plaster spica is by far the most important part of the treatment, as the reduction is usually quite easily accomplished in children under six years of age. If the cast is improperly applied, the hip will slip out of the socket and the case is a failure. A pair of soft knitted cotton drawers are put on and the patient is placed upon a pelvic rest with the limb held in the position of greatest stability at a right angle with the trunk, or even slightly more and about eighty degrees abduction. In a case where the socket is very shallow, the position to be cast should be about one hundred degrees flexion, and in abduction the limb should lie slightly behind the plane of the body to secure the best results.

The limb and pelvis are covered with ordinary absorbent cotton which is held in place with a roller gauze bandage. A snug fitting plaster of Paris cast is now applied around the pelvis and well down over the knee. I leave this over the knee for five or six days or until the child ceases to be fretful, then I cut it away just back of the knee joint to permit motion there. The ends of the drawers are drawn back smoothly over the cast and are sewed to each other. For about a week following the operation the adductor region is swollen and discolored and more or less painful due to rupturing and stretching of those tendons. After this discomfort has passed away, walking is encouraged on the theory that the weight bearing and the stimulation of functional activity will increase the stability of the joint by deepening the acetabulum.

The first cast should remain from three to six months according to the stability of the joint at the time of reduction. If in young children the cast becomes offensive, it must be changed as often as is necessary. When the first cast is removed, the limb is pulled down to about thirty degrees abduction and the same amount of flexion, without an anesthetic, and a second cast is applied, which extends only to the knee, to be worn from three to six months longer. After removal of second cast, the child is permitted to get about carefully. The limb will be everted and slightly flexed, which position invariably causes much concern among the relatives of the patient, but this abnormal condition disappears after a few months’ time. Sometimes for even a year following removal of the second cast there will also be a noticeable hitch in the walk of the child; but this, too, disappears and in the course of two years’ time one could never tell that such an operation had been performed. Massage of the posterior and lateral muscles of the hip always helps considerably towards the relief of any stiffness or lameness.

Reduction by Open Incision

In the more resistant older cases, where manipulative reduction has failed, reduction by incision can be employed with success, but this procedure requires the exercise of care in order to do as little injury to the muscles as possible. A crucial incision of the capsule is made and the capsular constriction and ilio-psoas tendon divided. With a little traction, the head of the femur slips easily into its socket. The capsule is stretched firmly around the neck and the incision into the capsule is then closed by suture, and the limb fixed in a plaster of Paris spica in the fully abducted position. The operation should of course be done under the strictest asepsis.

Talipes or Club Foot

The word talipes signifies some deformity of the foot and is quite common in orthopedic practice, being found in nearly ten per cent of the cases coming under this branch of the science. Club foot may be classified into two types—the congenital and the acquired. The congenital type is the most common and is due probably to abnormal intrauterine pressure or to a perversion of normal intrauterine development. The acquired type is due usually to injury or infantile paralysis, but either joint disease or cerebral paralysis may be the cause. The deformity presents six different forms with most characteristic clinical pictures which, with the exception of talipes planus I have taken up in the order of frequency.

=Talipes Equinovarus= is usually congenital and is the most common type. It is characterized by inversion and torsion of the foot with elevation of the heel. The weight is borne on the outer side of the foot and in extreme cases upon the dorsum as well. Calluses are always present which are red and painful upon the point where the greatest weight is borne. The most common method of treating this condition is to divide the tendo Achilles at a level with the malleoli. The operation should be done aseptically and under complete anesthesia. As an assistant raises the end of the foot so as to stretch the tendo Achilles the surgeon enters the knife parallel to the border of the tendon through the skin and tendon sheath into the tendon itself. Next with a tenotome inserted into the incision and turned at right angles to the tendon, the tendon is divided first on one-half then on the other. Care should be taken to disturb the tendon sheath as little as possible for it serves an important purpose in repair. When the division is complete as indicated by the separation of the divided ends, the tenotome is withdrawn and the minute opening in the skin, from which there is only slight bleeding, is covered with aseptic gauze. The foot is forced into dorsal flexion and if in severe cases the deformity is not then corrected, the tendons on the outer side of the foot may be shortened, while those on the inner side may be lengthened in the same manner as the tendo Achilles. A plaster of Paris cast is then applied well up to the knee with the foot in the over corrected position, care being taken that no undue pressure is brought upon the seat of operation, as this might interfere with the effusion of plastic material. Personally I believe that functional use of the limb and foot stimulate repair, and I always encourage the patient to stand and walk after the discomfort of the operation has passed. At the end of four weeks the space between the two cut ends will be filled with new material and the cast can be removed, and in another month the splice, which is somewhat larger and thicker than normal, should be strong enough for use. In the course of a year the lengthened tendon is perfectly normal.

=Talipes Equinus.=—In this type the patient walks on his toes with the heel highly elevated, in the same position as the horse, and it will be noticed that the foot has no dorsal flexion whatsoever. Infantile paralysis affecting the anterior muscles of the leg is usually the cause of this condition, though sometimes shortening of the leg following knee joint disease, or fracture may lead to an adaptive equinus which serves to make the limb of equal length for walking. This type is by far the easiest to remedy, and the results following operations are perfect. A simple division of the tendo Achilles is made under anesthesia and a cast applied as above, in a position of exaggerated dorsal flexion. Functional use of the limb after the cast has been removed overcomes any stiffness that might occur and perfect results are obtained in a short time, compared with the other types.

=Talipes Calcaneous.=—This is a condition in which the foot is held in a position of dorsal flexion. The patient walks on the heel with an inelastic gait because the spring of the foot is absent and the whole weight is borne upon the os calcis. The best procedure in this type is manipulative treatment into a position of plantar flexion to overcome the contraction of the anterior muscles of the foot and leg, and bring about contraction and shortening of the posterior muscles. A tenotomy of the anterior tendons or an anesthetic is rarely indicated, though in severe cases, a series of casts holding the foot in position of plantar flexion may be necessary to secure good results. I have found it a help to have a shoe with a heel prolongated backward, or a steel splint laced to the leg to prevent the foot from upward motion.

=Talipes Valgus.=—This is a very uncommon type of deformity, characterized by eversion of the foot. The patient walks on the inside of the foot and, as a rule, experiences very little trouble. I find a manipulative treatment is best for this condition, aided by braces.

=Talipes Cavus.=—This form is sometimes called “=hollow foot=” and is very uncommon in this country. It is characterized by a markedly high arch sometimes as in Chinese women to the extent that the anterior part of the foot is approximated to the heel. The plantar fascia is badly contracted and one can distinctly palpate the bands beneath the skin. This condition is practically the same as the ordinary so-called “=contracted foot=” except that it is much more exaggerated. The ordinary high arch of today is usually the result of wearing too short a shoe, and if painful, long last shoes, aided by manipulations, will usually correct the trouble. In severe cases of contracted foot the plantar fascia may be divided, under anesthesia and the arch brought down and put in a cast, though this procedure is not very successful. In case it is done the patient should be made to walk in two or three weeks, as this helps materially to overcome the deformity and hasten repair of the fascia.

=Talipes Planus.=—This condition is commonly known as “=flat foot=” and is taken up in another part of this text. However, it is one of the classifications of “club foot” and is far the most common type.

=Prognosis.=—These conditions never correct themselves and if uncorrected usually get worse and the more severe types certainly become obstinate malformations. In general the tendency to relapse is strong, though if properly treated the results are excellent. In infantile cases the time required for correction is relatively short, but retentive appliances are needed for a longer time. The older the cases and larger the foot the more difficult, of course, the correction, but usually there is less danger of relapse. A perfect correction, that is when the gait and attitude are normal, will never relapse. I find it better to leave the fixation appliance on too long than not long enough. Never remove a cast under four weeks except in the cavus type, then apply a brace such as can be obtained from any supply house for any type of case, for from one to three months longer. The tendons involved in these conditions are so apparent that it is almost impossible to make a mistake in the division of them. About the only precaution necessary is to be assured that the tendon itself is completely divided, but that the tendon sheath is only slightly disturbed.

Tuberculous Disease of the Bones and Joints

Perhaps no bony lesion has caused so much difference of opinion in this profession as tubercular conditions of the spine, bones and joints and I wish it understood that in the following discussion, it is not my desire to reopen the argument. My observations have been of cases treated both osteopathically and by fixation, in private practice and institutional work. And I have come to the conclusion that the fixation method of treatment is absolutely always indicated. In general the pathology and etiology of all tubercular bone conditions is the same. It begins as a tubercular infection of the spongy tissue of the epiphysis, the first change being a local hyperemia of the portion involved, followed by one of three courses: the diseased focus being absorbed and a spontaneous cure resulting; it may extend to the periphery of the bone and break through the periositum and empty itself there by abscess formation; or most commonly it may extend to the joint, which becomes involved through attendant injury. Repair is brought about by the formation of fibrous tissue probably arising from the layer of non-tuberculous granulation tissue which grows in and replaces the tuberculous tissue. Also the replacing material may become calcified and encapsulated. A fibrous or bony ankylosis may result from this process of repair.

The vulnerability of growing bone accounts for the frequency of tubercular bone disease in children as compared with adult life. Injury not only causes a local predisposition to the disease, but it favors its progress when it is once established. About seven-eighths of the cases of this trouble occur under fourteen years of age, more especially when the vertebræ or hip-joint are involved. The knee and ankle joints as well as the elbow and shoulder joints are more often diseased in later life. While the inherited predisposition is very direct and positive in twenty-five percent of the cases, the acquired predisposition is of most importance since it includes lessened vitality due to poor food and imperfect hygienic surroundings. As to the distribution of the disease the vertebræ are most commonly affected, followed closely by the hip and knee joints, and then in the order of frequency the ankle, elbow, shoulder and wrist joints.

Tubercular Disease of the Spine

This condition is commonly called =Pott’s Disease= or =Caries=. It is a chronic destructive process of the bodies of the vertebræ. The spine bends at the weakest point and the compression and collapse of the affected parts cause the characteristic posterior angular projection at the seat of the disease. If one vertebral body is destroyed, the projection will be sharp; if several are involved it will be less angular and if one side breaks down before the other, there may be a lateral as well as posterior distortion. The size of the deformity and its effect upon the patient depend upon its situation; that is, if either end of the spine is involved the angular projection is slight because the area of the spine directly involved in the deformity is small compared with that which is free from the disease. If the middle of the spine is affected, the deformity is great, because the entire spinal column may enter into the angular projection. In the latter area the internal organs are compressed and, of course, the effect upon the vital organisms of the body is disastrous.

=Pathology.=—The first indication of tubercular disease of the spine is usually found in the anterior part of a vertebral body just beneath the fibro-periosteal layer of the anterior longitudinal ligament. From this point the foci may advance along the front of the spine following the course of the blood vessels and invading the adjacent vertebral bodies. The destruction may begin in the interior of the body itself, more often in several minute foci near the upper or lower epiphysis, which coalesce, gradually enlarge and form a cavity surrounded, for a time, by unbroken cortical substances which finally collapse under the pressure of the weight above. The intervertebral discs seem to offer some resistance to the extension of the disease from one vertebra to another but once the bone is destroyed on either side, they too quickly disintegrate and disappear. Pedicles and articulations which come into direct contact with the disease may become involved. Originally the disease is confined to one or two adjacent vertebræ and may extend in either direction, and the final area of deformity and rigidity shows that from three to six bodies may be involved before a cure is established. The infected granulations advance rapidly with the usual retrograde change of shape and structure to a cheesy degeneration and frequently liquefaction and abscess formation may follow.

=Symptoms of Pott’s Disease.=—There are three main symptoms of Pott’s disease, namely the peculiarity of attitude and gait, limitation of motion or muscular stiffness and the pain and referred pains. In the cervical region, the chin is held somewhat raised and the patient may have somewhat the same appearance as in wry-neck. In the mid-dorsal region one will always find an elevation of the shoulder besides the deformity. In the lumbar region, the patient nearly always leans backward and has a sort of sidling gait or waddle due to the contraction of the psoas and iliacus muscles. The patient in walking, stooping, or lying down most carefully guards the spine against any jar or motion, and always assumes attitudes which will relieve the strain on the involved vertebræ. There is always present an unnatural mode of standing or walking, especially when the dorsal and lumbar regions are involved, as the patient walks more on his toes and with the knees slightly bent, because in this posture all possible strain of the step may be brought into play to diminish jarring of the spine. The child becomes tired very easily and lies down or rests on the arms of a chair or seat. The pain rarely occurs in the back, but is usually referred to the peripheral end of the nerves and is thus felt in the chest, abdomen or limbs. The abdominal pain passes sometimes as a stomach ache and often times in the limbs, as rheumatism or “growing pains”. I have noticed also a peculiar grunting respiration and sometimes cough especially when the mid-dorsal region is involved. Muscular stiffness is always present, all mobility being lost. The temperature is not at all diagnostic, though sometimes in the afternoon it will be one or two degrees higher than normal and does occur independently of abscesses. About the only complication that occurs is paralysis or abscess formations. Paralysis is given as a frequent complication, though I have never seen it. It is usually flaccid and bilateral and may exist from a mere muscular weakness to a complete loss of power. It is certainly uncommon under proper treatment, and the prognosis is favorable. Abscesses, though a very distressing complication, are very uncommon in my experience and are certainly an evidence of improper or incomplete treatment. They may subside in any region and be absorbed without detriment to the patient, though if they increase in size there is no tendency towards absorption. It is best to incise them and secure complete drainage. It is hard, of course, to do this on account of the depth. Abscesses occur always in close proximity to the disease.

=Treatment.=—Some authors recommend a brace for the treatment of this condition, while others recommend a frame to which the patient is strapped, and rest in bed. I have found nothing that gets results like a plaster of Paris jacket applied with the patient suspended by the neck and shoulders. I make no attempt at correction of the deformity present other than the traction of the weight of the body at the time the cast is applied. The spine is, of course, fully extended by this and any undue pressure on the cord relieved. The cast should extend over the shoulders and well down over the pelvis and sacrum. If the disease is in the neck the cast should include the head as well. A large window is cut in front and one must be cut over the involved area of the spine behind. Ordinary absorbent cotton is used for padding with, of course, extra padding over all bony prominences. From two to five years’ time is required for a complete recovery. The X-ray is invaluable in diagnosing this trouble, and each time a cast is removed to see how much progress has been made. The casts should be changed as often as they become soiled.

Tuberculosis of the Hip

This is a chronic tubercular condition of the head of the femur or of the acetabulum commonly known as =hip-joint disease=.

=Pathology.=—Primarily the head of the femur is the seat of the disease, the epiphysis being attacked in seventy-five per cent of the cases and the acetabulum in twenty-five per cent. The irritated pelvic femoral muscles which are in a state of chronic contraction crowd the head of the femur against the upper and back border of the acetabulum. Under this continual pressure, absorption of that portion of the rim takes place with actual enlargement of the acetabulum from below upwards. This is spoken of “migration of the acetabulum” and is one cause for the shortening of the limb. Changes in the head of the femur are the result of inflammation and pressure. Partial destruction of the head also helps shortening of the limb and elevation of the trochanter above its proper level the same as the wearing away of the acetabulum. The synovial membrane is found to be reddened and thickened and granulation tissue is present, and usually the cartilage is gone from the head of the femur. Rarely does perforation of the floor of the acetabulum take place, but if such is the case a dense wall of fibrous tissue and thickened periosteum shuts off the head of the femur from the pelvic cavity. A natural cure results in two ways,—by absorption or calcification of the tubercular tissue, or by the evacuation and discharge by an external opening. This latter suppuration seems to be nature’s effort to eliminate the disease, and when a cure is established this way it is usually characterized by malpositions and shortening of the limb, and, of course, an ankylosed joint.

=Early Symptoms.=—The most characteristic symptoms of the disease are the ‘night cries’, stiffness and limping, shortening of the leg, atrophy of the muscles of the hip, leg, and thigh, and the unconscious protection of the joint. A referred pain is usually present to the inside and front of the thigh near the knee or directly at the knee joint itself, due to the intimate relations and anastamosis of sciatic, obturator, and anterior crural nerves.

=Diagnosis.=—The chief diagnostic sign is muscular spasms or the presence of stiffness of the joints and limitations of its proper arc of motion, due to the tonic contraction of the muscles controlling the joint. If there is no limitation of motion it is almost safe to say there is no hip-joint disease. The lameness may be intermittent. The attitudes or abnormal positions of the diseased limb are caused by the action of muscles holding the limb stiffly in a distorted position. The pelvis is usually tilted and always one will find the patient assuming attitudes which will favor the diseased limb. Atrophy is very significant and a comparison of the two limbs should be made by measuring at the middle of the thigh and the middle of the calf. Nearly always one will find a deep thickening over the front of the hip joint and behind the trochanter.

=Physical Examination.=—1. Observe the general condition of the patient.

2. Note the attitude in standing.

3. Note character of the limp.

4. Note shortening of the limb.

5. Remove the clothing and lay patient on the back.