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LECTURES
OR
ORTHOPEDIC SURGERY
AND
DISEASES OF THE JOINTS,
DELIVERED AT BELLEVCE HOSPITAL MEDICAL COLLEGE, DURING THE WINTER SESSION OF 1874-1675.
. LEWIS A. lATRE, M. D.,
Pml^MDT of QrihftyeAic, Bnr^vry Anil Clinical Snr^ry Id BellGTtie Hoapltil Mddl«] Coll^re; Coa-
■uklDir BiimoQ ia Bi'lliivufl IToAplUl : V-iaffiiil\iig Surgeon to Charltf IlasnltDJ ; c^onKullinK Bur-
f»n loBt. Eliz>b«Ih's }Io«pltaJ: CViDfiDlTIng Hur^von to North WFAlem DlfptUABry; Merntwr
o(Ui» A merlon Medlc«lA»»oc(iil(nD ; Pemnnfol Member of Ibo New York BBto Medlril
Society; FfiUov of the Sew York Academr of Modlclite; Member i>riheNew York
County MedliHl Society, of ttif New York Pmliolot-inil Society, of the Medlco-
Lefcal Sodely: TloDoriry Member nf tho UrillBh Medical AHueia Moo ; ITOD'
onry Member of tbo Medloo - ChlruT^nl Society of E^dlabur^b;
UoDonry Member of the New Brunawlck Medici Society ; ITon-
Qrtry Member of the Medical Society of Norway; Knlghl of
theOnler of Wau. by HI) Majesti the Xing of Sweden i
u-PtealileM of the Amerioui Medical Auoduloii, eu.
SECOlfD EDITION.
BETI3SD AKD GKEATLT £NLASQ£D, WITH 3S1 ILLUSTBATIOBa
NEW YORK: D. APPLETON AND COMPANY,
1. S; AMD ft BOND BTItEET. 1882.
D. APPLKTON AND COMPANT,
3 2.7
DEDICATION.
To the Physicians and Students who have so attentively lis- teDed to my IcctareB, and who have sustained and encouraged me ID the enUDciation of now truths by their devotion and friend- ship, this work, which I hope may enable them to remember ami practically apply the principles therein tanglit, is humbly in- scribed by their sincere friend,
THE AUTHOR.
PREFACE.
Fob Bome years past I have been in tbe frequent receipt of letters from medical gentlemen of the highest standing, in dif- ferent sections of our country, as well as from many abroad, urging me to prepare a work on Orthopedic Surgery and Dis- eases of tbe Joints setting forth my peculiar views of their pathology and method of treatment.
Ab many of my views were so directly at variance with the standard autboritie?, I hesitated to write until a latter experi- ence should either confirm my observations or prove them to be erroneous. In tbo latter case, of course, I should have no occasion for publishing.
A more extended experience has confirmed my original views ; but constant professional occupation has prevented me from complying with the request of my friend?, as I have been unable to find tbe time to perform the manual labor of writing such a work as I should desire to produce.
I therefore employed Dr. Wesley M. Carpenter, so well known to the profession in this city for his accuracy as a steno- graphic reporter, to follow me during the course of last win- ter's lectures, at the Bellevue Hospital Medical College, and the present work is the result. Upon its perusal in the proof, I find many expressions which I would like to change, but, as
1 n 1 iiHH
vl PREFACE.
tliese lectnrea were delivered extemporaneously and without preparation (many of them being clinical, and upon cases just presented to me for the firat time in the lecture-room), I find it difficult to alter the text without destroying its originality.
I therefore leave the work in its original form, making no claims for literary elegance, but simply desiring to tell what I think to be true, in such a manner as not to be misunderstood.
In addition to the cases brought before the class at this term, I have added others from my note-book and from the hospital recorde, to illustrate the principles taught. I have also added a few cases that I have before presented to the profession in medical journals, or at the different Medical Soci- eties, but, as they are typical illustrations of the principles I wished to teach, I have deemed them worthy of more perma- nent record.
The long delay in getting the work through the press is on account of the number of illustrations, which have all been en- graved by Mr. R. S. Broas, of Nos. 14 and 16 Ann Street, from original drawings by Dr. L. M. Yale and from photographs; and I wish here to express my thanks for the very able man- ner in which he has performed the work.
The illustrations of the instruments were all kindly fur- nished by Mr. John Heynders, of 309 Fourth Avenue.
I wish particularly to return my warmest thanks to Drs. Tale and Carpenter, and to Dr. Wm. A. George, for most valu- able services in correcting proof, and oth3r assistance while the work was going through the press.
LEWIS A. SATRE. 28EI FiiTH Atekck, JtMuary 1, 1B16.
PREFACE TO THE SECOND EDITION.
In preparing this second edition for the press, I have carefully revised and rearranged the entire work in a more B^'Btematic and claseified order; and some of- the chapters, where new and improved methods of treatment have been developed, viz., those on spondjlitis and lateral curvature, have been entirely rewritten.
As stated in the preface to the first edition, the book was originally prepared from extempore lectures, meat of them BOgge&ted at the moment by the particular case then present in the amphitheatre, and couBequently was not systematic in order, or always accurate in dates. Tliese errors have been carefully corrected, and its present arrangement will make it more useful as a text-book for the student.
The views expressed in the first edition have been fully verified by a more extensive experience, and are therefore here reenforced with additional evidence of their value and correctness.
For the very flattering notices of the medical press, and the kind reception of my work by the profession at large, I feel deeply grateful. To the critics who have called attention to my errors I feel a still deeper sense of gratitude, as they have enabled me to correct my mistakes, and I hope in this edition they will discover that I have profited by their suggestions.
viii PKEFAOE TO THE SECOND EDITION.
I am iuily aware of its imperfections, and would most gladlj make it better bad I the time ; but incesBant occupation pre- vents me from doing so, and I therefore give it to the pro- fession as a slight coutribntion, which I hope maj enable the student to unravel and comprehend the principles involved in the treatment of defonnities and chronic diseases of the joints ; and also enable the busy practitioner to give relief to his patients in the class of cases herein described.
Fifty-two new illustrations have been added to the work, which have been executed by the Plioto-Electrotype Engraving Company, and .are beautiful examples of this new art. To my student, Mr. E. Develin, I am indebted for valuable assistance in arranging the work for the press, correcting proof, and pre- paring the index.
LEWIS A. SAYEE.
January I, 1883.
CONTENTS.
LECTURE L
INTBODUOTORT.
not History of Orthopcdy. — General Confllderfttions which should Induce the Student to make it a Subject of Special Stud;. — General Plan of InstrucUon . 1
LECTCRE ir.
DETOBHITIES. '
CUMifloation. — Definition,— Etiology. — Pn^o^s. — Diagnosis , . . 10
LECTURE III.
DETOaHITIES.
Treatment. — General Principles. — Jlnnipulation or Massa^. — Oymnastics. — Therapeutic Agents. — Dry Deal. — Batlis. — Inunction. ^-Strychnia. — Elec- tridiy 17
LECTURE IV.
DEFOBUITIES.
TreatnieDt (continued). — Uechnnical Appliances. — General Principles governing their Uae. — Elastic Tension. — Adhesive Plaster, — Operative Trealnieut. — Tenotomy. — Myotomy.— ^Tenotomes. — Breaking up of Dony or Fibrous An- chylosis.—Amesthetica 29
LECTURE V.
M A LrOH MOTION B.
Hare-lip.— Cleft Palate.— Bifid Uvula.-^pina Bifida.— Fissured Acetabulum.— Hypospadias. — Epispadias. — Extrophy of Bladder. — Fueion of Fingers, Toes, etc. — Supernumerary fingers and Toes. — Ucclusion of Anus ... 39
LECTURE Vr.
DEFOBHinES.
Etiology {continood). — Congenital Phimosis and Adherent Prepuce.— PrognosiB.
— Diagnosis. — Clitoritis. — Vascular Tumors. — Monatrositica ... OS
X CONTENTS.
LECTURE Vir.
PAflk
Definition. — Varieties and ComfainMions. — Mechanical Constraetion o( the Nor- mal Human Foot,— Talipes EquiniiB.— Talipes CalcaneuB. — Case of DiTii^Jon of Tendo-Acbillia by atr Accident. — Uochonical Treatment of Talipes Cat- caneoB 67
LECTUEtE V.:i.
ULIPES.
Talipes Varus. — Causes of. — Case. — Complicaliona. — Case. — Talipes Valeus. —
Csusee of.— Paralytic Tarietj, vith Cases. — Treatment of the same . 77
LECTDRE IX.
TALITES.
Talipes Plantaris. — Causes of Talipes. — Treatment. — Indicalions tor. — When to
begin. — Uow to effect a Cure without Tenotomy 9S
LECTURE X.
Tuiraa.
Treatment (eonilnucd). — Methods of Dressing. — Splints, — Adhedre Plaster. — Barwell's Apiiaratiis, — The Author's Club-FooC Shoe. — Crosby's Substitute for the Shoe. — Neil's Apparatus. — Case. — Talipes Varo-Equinua . . 101
LECTURE XL
tXUfSB.
Treatment (continued), — Tenotomy. — Indications for same, — Dressing applied after the OpevaIion.—After-Treatment.— Club-Oand 110
LECTURE XIL
DISEASES OF THE ]OI!JTS. — ASELE-JOINT.
Anatomy of the Ankle-Joint. — Pathology of Disease of. — Symptoma. — Treatment, 1(3
LECTURE XIIL
DISEASES OF TnE JOINTS, — ANKLE-JOINT (cONTINUEn).
Treatment (continued), — Description of Instrument, — Uode of Application. —
Cases.— Disease of the Tarso-Uctatarsal Articulation,— Case . , .178
LECTURE XIV.
DiaeASES or the joints. — kseeodi.vt.
Anatomy of, — Structures affected by Disease. — Synovitis. — Disease of Ligaments. — Eitrarasation of Blood into the Canccllalcd LamellEe of the Bone. — Causes. — Early Symptoms, and those developed as the Disease progresses. — Fain over the Attachment of the Coronary Ligaments 104
CONTENTS. si
LECTUBE XV.
DIBSIBU or THI lOINTS. — KMn-TOINT (oOMtUTm)),
Ttaa TrcaHlWDt of Disease of. — E&tIj Treatment — Treatmeat In the Adranoed Stages ot the S(>«alled " White-Swellmg." — Apparatus for maldng Eitenston. — Uode of Application 208
LECTURE XVI.
DiaiASEa or the Joiicn. — xms-imxr (comiHCio).
Treatment of Chronic Disease (continued). — Remoial sod BeappUcation of the Instmrncnt. — Passive Uotioo. — Protection of the Joint after the Sptlnt has been removed. — Shall the Joint be permitted to ancbj-lose ? — Cases. — Oper- atiTe Interference in Extreme Csses SIT
LECTCRE. XVII.
DISIASI3 or tHB JOINTS, — ENEtC-JOIKT (cOtJCLCDH)). — XXBKCTION.
Mode ot performing the Operation of Eiaertion. — Splints and Dressings used atlcr the Opcrsljon. — Partial Eiseclioti. — " Bryant on the Least Sacrifice of
Parts as a Prindpte in Operative Surgery." — Differential Diagnosis Bur-
sitia. — Necrosia of the Lower Extremity of the Femur .... 229
LECTURE XVin.
DiatABB or tUI JOIMTS. HORBCS COXARICB.
Anatomy of the Uip-JoinL — Pathology of Hip-Disease. — Etiology. — Symptoms of
Rrat Stage 234
LECTURE XIX
DISLI8ES or THE JOINTS. — MORBUS COXAMITB (cDNTINCKd).
Symptoms (continued). — Symptoms of (he Second Stage and their Explabation. — Case. — Syiaploms of the third Stage. — Discussion of the Question of Dislo- catkiu in thia Stage 24B
LECTLTIE XX.
DimSSS or TBE JOINTS. — M0BBU3 COIARIl-S (CONTINVED).
Treatmeot. — Uechanical Apparatus, and how applied 297
LECTURE XXL
DtKKlBIS or THE lOrNTS. — KORBCS OOSARIOS (cONTUICED).
Treatment (continned). — Treatment for the First Sta^e. — Treatment for the Sec- ond Stage.— Treatment for (he Third Stage.— Case illustrating Treatment of Advanced Hip-Dlaeaae without Complete EisectloD. — Indications for £x- aection 2S3
Xii CONTENTS.
LECTURE SXII.
DIBEUIS or TBI JOISn.->-UOBB[)H COUAIDS (CONCIDDD).
nam
Treatment (conlJnued). — Exacction. — QUkn? of the Opemtion. — The Operation deBcribed.— Ifode of dreadng tbe Limb tifter the Opemtion bae been per- formed.— After-TrMtment. — Tables of Eieectloua appended . 296
LECTURE XXIIi
DIBUSKS or THE JOINTS (cOKTINCED).
Digeaee of the Wrist-Joint.— SynorltiB of the ElboT-Jcdnt.— Diacase of the
SboulderJoint (cause, guiiBbot-wouad) 848
LECTURE XXIV.
DIBEASIS n'QICU SIUrLATE DISUSES OP THE JOINTS.
Sacro-itiac Disease, — DiacBEe of the Knee. — Caries of the nium. — Caiics of tbo iBohium. — FerioBlitls of Adjacent Parts. — Psoas Abscess, with Poll's Dis- ease.— Inguin&l AbsccBl. — InSammalion of (he Psoas Magnus and Iliacus Inlcrnua Muscles. — Congenital Malforoiation of the PelTia, commoni; known as " Conj^nital Dislocation " 357
LECTUnE XXV.
DISEiaEB WHICH SIUULATE DISEASES Or THE JOINTS (cOKTI.'iCEDJ.
raraljsis of the Lower Eitremitics. — Diastasis. — Fractures. — Dislocatlooo. — Bur-
eitis and Necrosia S80
LECTURE XXVL
IKCUTLOSia.
Derivation and Use of the Word. — True and Fstse Anchjlosie. — Position of Limb when Anehjlosis becomes a Necessity. — Mode of dclermining which Form of Anchylosis Is preacDt. — Brviaaeat forei. — Mode of dressing the Umb atler the Operation. — Case* 3B8
LECTURE XXTU.
AMCHTLoais (contihced).
Bony or True Anchylosis.— Operation when present at the Rip-Joint. — Coses. —
Bony Anchjtofia at the Kncc^oint.— At the Elbow-JoiuL— Case . . IIS
LECTURE XXVni.
DISEASES AMI DETOKUITIEB Or THE SPINE. — ETONDTLniS, OR AMTEBOPOSTEBIOR
CCBTATCRE.
Defluition. — Anatomy of the Spinal Column. — Etiology. — Pathology. — Sjfroptoms. — Method of eiamining the Case. — Treatment. — Mechanical Appliances, — Fiaster4>f-ParU Jkcket 446
CONTENTS. 3dii
LECTURE XXIS, DiromiiiTiia or thi HPim. — botaet-latckai. ccbvatiibi.
FlOB
The Term RotaT7-Ls(eraI Currsture eiplained. — Psthotc^ of the Defonsttj. — Clu3 of FenooB in frhom it occurs, uid how it is dereloped. — Additiooal Caaees. — Special Cause when the Deformity is developed in the Dorsal Re- ^00. — SymplomB. — Treatnient 491
LECTCRE XXX.
DET0BUITIE8 BEaULTIMQ imOM FARALTSIS.
Causes. — Treatment. — General ParaljGia. — Paralysis of the Elitremitles. — Fadal
ParalTBlB. — Lead-ParalfSia 514
LECTDKE XXXI.
DUOBicrnEs (continced).
Torticollis. — Deformitiefi from Buma. — Genn-Talgum. — Genn-Varum . 035
LECTURE XXXII.
msCKLLANEODS.
Ctn-ns. — Bunions. — Ingrowing Toe-Naals. — Ilallui Valgus.— Diflplowment of Ten- dons 549
INDEX OF ILLUSTRATIONS.
Fio.
1. Dachesne's mstniment for the remoTsl of lousculsr tissue. 3. Case -. Paralysis under iastnuoental treatinent with electridty.
8, 4. Case : Fanljsis treated with electridt;.
6. Tenotomes.
S. Section of tendo-Acliillis, Introduction of tenotome.
7, B. Case: Qare-lip.
9. Case : Webbed fingers. 10,11. Case: Supernumerary toes.
VI, 13. Case: Supernumerary toes remored. 11, IS. Ca«e: Supcniumerary fingers.
16. Case: rtiimosis.
17. Case: Phimosis.
18. Ca^: After circumci^on. 1». Case: Clitoritis.
SO. Wire breeches foiTnerly used by Dr. Sajrc In orthopediCH.
St. Analomitad chart of the tarsus.
8S. Showing impression of the aolc of the foot when nomial.
53. Talipes equinus.
54. Talipes calcaneus. se. Club-foot shoe. 26. Talipes Tanu.
37. Talipes Tsro-cquiuae.
S8, 29. Case ; Talipes Tsro-equlnas paralytica.
30,81. Case: Talipes Taro-equinus.
83. Case : Talipes Taro-equinoa, showing the result of treatment
33. Talipes rtAgua.
M. Clob-foot shoe.
ZS. Showing lateral dlrergcnce of the foot, which tnnj take place at the Tncdio-tarsal
articnlation. 86 to 40. Illustrating Tarious portions of dres^og requisite for the treatment of
talipes, as devised by Mr. Harwell. 41, 43. Barwell's dressing for talipes applied.
45. Club-foot shoe, Sayre's original. 44. Club-foot shoe, Bayre'g improved. 4B, Dr. Neil's dressing for club-foot.
46, 47. Case : Talipes varo^qninas paralytica, showing the application of Dr. Sayre's
ahoe for club-foot.
XVI
INDEX OF nXOSTRATIOSS.
riu.
4B. Dmdng (or dub-foot afur tctmUintj. tt, Sa C«M 1 Doalik Utipaa-Tirai ; ilrcadiip of «olc-1ei,11i(ir with adherir* pkiUr
(I, CL One: TaBpc* cakwwo-Tilpii ■ cufcil b; •laMk Uwliw.
M, M. Oms: DMble tal^wt vara*, «h»iriiig cafUUj of impronoMBt afur the ^
pBntIm of «ilMtIo tciuica. SO^SC Owe: Tdipe* nnn ud laroolcuicni. t7,IX. Cue: T.ilipMi; UBOUm; perfoniwd. 6a:«\SI. Clue: TdipMeqainua; rendu intbib cmc ahow dia ^MdnblHty of d*-
(tfring ICDolcni; mUU all oUiur rvan»able hmmuim Iht« bem rihaiulcd, S3, 83,94. 0^: l^lipot pknUris or cmTua; tr(wbM«,dlTfciMio( Ibc pluitu [m-
cia. Ucion, und fiiul1)r the intti^nenl. M, M. Quit: T«lip«< pUsUri*, or csnu, villi ditloAlionflf taml ba«m of dgtiUcn
jean^ alaDiBii^ a7, S8, at, lOi Clue : Talipes Taim paraljiica of five fe«n^ Mandlaf. 71, T2. OaK: Double latip«nMh«i|uiiiiu; fMimcnl, tcnoloinr «)lh fordbk roduc-
lioo of dUocatcd bom «( taraw. Tl, It. Oa*c : Tallpca nna ; Inatod with XeU'* ilMsdng, aAetannl «iih UaravlTa
drMdng. 70, 76, 77, 74. OaM: TaBpct etpdao-rani*; tnatniciit, tenotomy, wUb wapUca-
Oima taOowktg. It, 80, 81. Oaae i Aged aer** monllu ; lallpei ram*, abowios reaalti of a dwpta
dwilng oorapoMd of the i«lkT-ba»dage witb adhethc plaalcr. 8!, 83, SI. Gave: Double UHpe* Tamt; Itarwcira dreadng applied. as, M. Cue: Doulik ullp» cquino-tinia ; D*r>eU> dieaaiag appUod.
87. Sajre'ii club-foot iboe, «lUi pclii<.- btll and oatsanl rowing aerew.
88, n, m. Oaie: TUIpca Tafo^idnM with TanMakaaew; IreaiBt^ UnAomj. VI. Cbdhfoot ahoc emMlraotcd fnm Ibe otiUnai; Aoe of iht paticni.
VS, W, 84. Ca*« : Dootdv talipca wv^q^nu; trualBoM, tenotam;, «S, PB. C**e : TtiBpca eqalaqi paiBtflks ; trMlMeM, icnotoinr. 91,98,90. Ouc: Onuble talipMf^aiao-vaiwaf foar r«aLr*' *t*iiiCiig:<aaple(ccuie aVcTted ia lis »wlo.
100, \<\l. Clutbhaad, utilh amest of dcvclopant cd ll»e ndluiL
103. Di*M*»or IhB anklp-joliiL
103. TlMMam'a rablwr b^ for toapiCMioQ In dbOUM of llie JoIbU.
104. Etlan^n tplisl for dkraae at l>w anklo-Jolal. los. Flmt «iag« of dcMdng b dinaH of Uw •alilt-)elni. I0«. Stoood atage of draaifag \m db«Mo of ikc toklo-leinl.
107. Applkathm of mmmIod apUnl ia diaaaaa of llie wil^ia-iaint.
108, Dnaaiag complui*. with aiteadM appliad In dbeaae of tht anblctolBL lOV. FMiMWm (kralor.
110, III. Oaaa: Anltlo>)etBldiataati raiM*al of earloua bniu. IIS, lis. Oiaa: Anl(lo-l«lDl diaaaae, rtnua pMrfDg through lanoa i removal of cariciua bOM.
114, ■IS.IIIkllT. Cam: Supponlkm andwlatof both •bkia-jointe, with tallpM.
t^ulaua,
115, lis, Caac: Akkle-JobM dbaaae, arllh cUtBaliie caHea and oppsralSoii.
ItO, 191. CMa: AaklNjolat diaaaar ; aupiotalka prarlonilr advlatdi cured wltbovt aiDpolatka, and a aouod IM taoored.
INDEX OF ILLUSTRATIONa. xWi
Fia.
122. Disease of the medio-tarul Brticulatlon, ahawing the application of ezleoaioD
aad coiuit«r-ext«tiiBioti. 133, 124. Case : Disease o! the tnrso-metatanial articulation. IS5, 126. Disease of the knee-joint, white-swelling, so called.
127. Disea:«e of the knee-joint, showing luxation resulting.
128. Tiomann's rubber bag for compression in disease of the knee-)<^&L lis. Sajre's eitension splint for disease of the knee-joint.
130. Splint applied In disease of the knee-joint.
lul. Sbowiog the necessit? of crutches in knee-joint disease, without extension splint be appliod,
13!. Showing motiiod of making double extension Id knee-joint disease when the pa- tient is oonGned to his bed.
133. First Btsge of dressing in knee-joint disease.
134. Second stage of dressing in koee-jolnt disease.
136. Application of extension splint in knee-joint disease.
136. Application of splint, with drestiag complete lod extension apptied-
137. Showing the ability of the patient to secure the adrDntage of free out-door exer-
dsc while wearing Stjre's eitensioii splint for knee-joint disease,
138. Darrach'H splint for knee-joint disease.
139. Case : Chronic knee-joint disease with luxation.
140. 141. Packard's, Dr. John H., splint after eisectioQ of the knee-joint.
142, 143. Anatomy of the hip-joint.
144. Showing position the patient assumes when suCFering from mort)us coxarius In the first stage.
143, 143, I4T. Showing mclhod of forming a diagnosis In the Erst stage of morbus
coxarius.
148. Showin;; the position the patient assumes when suffering from morbus coxarius
in the second stage.
149, ISO. Case : Uorbus coxarius, second stage ; division of the gracilis and adductor
longus required. 160a. Case : Morbus coxarius, second stage.
IBOb. Xorbos coxarius, second stage, with Dr. Ilutchison's treatment applied. ISOc Morbus coxarius, second stage, with Ssttc's long extension hip-splint applied. I60D. Morbus coxarius, after treatment by Sayre's long extension splint. Ifil. Showing position which the patient assumes when suffering from morbus coxarius
in the third stage. 1.52. Showing partial absorption of the head of femur with acetabulum in the third
stage of morbus coxarius. 1S3, 154. Case: Uorbus coxarius, third stage ; excessive suppuration of three years'
standing.
155. Davis's splint for morbus coxarius.
156. Sayre's short hip-splint.
157. First stage of dressing for nigbt extension in morbus coxarius.
135. Second stage of dressing for night extension in morbus coxarius.
159. Drcsung complete for night extension in morbus coxarius.
160. Showing patient with night extension as applied in morbus coxarius,
161. 162. Diagram of adhesive plasters used In the nppticaUon of Sayre's short bip-
splint. 163. Dres^Dg in the flrst stage for the application of Sayre's short hip-splint.
XTlll
INDEX OF atUSTEATIONa
rn.
IM. DraMing in the wceod ttage Ua the ■pplication of Stpe'* (faorl liip4|i)iML IIIB. DmNBg cantplFi« for dtbrr oj^lit ciWiuion or (be >pplicail«m (i( 8*;i«'* tLori
hil^apttnt. IBS. Sape'a uri^nkl Rlmrt hi]hiplint, dltea 4iM>nlod. IflT. 6apv'< long ciunsioo hip-*plinL
108, 16V, IIOl Uu« ; Uorbui raiKriun or olinta vnn' •UndkiK- ITI. tiu«: Ikrbiu counui^ (UrI )t>ge : eiMictiou ol bip-JuUit pertonet, ITS. Win- cuiriM uicd ia tb« In-Mmciu of morbus eoxarfu*. ITS. HIioaiDg «fia brMche* •pplM. ITSx. ^avia^ ftpplicwloii of Strr*'* long Up.«i>liiit. ITI. Itorhu eoiMiiu, Ibir4 atagr; iiM fuocaHtuI •imcUoii (■[ thv liifi-Jolnt |i(«-
fonned In Anwrka. ITS. OiilaiQ* bone rvmovod in a mv of nsrrtkia o( th« lilp-}oInl. 174, 117, 178, CkW: Entcilon of the hiji'joinl, nhoBing rcuhof tbeoporatlnn. ITV, ISO, l»I. Cue; Eiivclkni of die hlji Joint, iboirlBj; tmuK of tbo operiiloiL 183. Carton* booe ronoTcd In clicMko of iIh> bip-jotnt. IBS, IM. t^M : KixvUon of Ibe lii{t.jo!iit, dioviiig rtiull of optralion. IM. SliiMrin); four incbiM of «baft of foinur mnOTod ia axMOlim ol biji-jiuBl. IMt m. Before and aflor «iMction of Ibe hip-Ji^l. t8& Hortu* (»»riu« ; lUnl ulage, n*M(ioti of JoiM. 15^ 190. CarioiM bono r«niOT«iil in pi«n-tioD of llio hip-JniitL 19). BiMVtinn of liip-joint, stirr Uic 0[M'ruii<iii. 193, 193. Eiavdion at hip-}oint, foiloKixJ b; foraiatloai of ncwjolal villi cwlllagti.
JSh Pronlii.plrMV IM, IM, IBS. Euoctlon of lilp-Jnint. aftrr tlw apff«lk«. 197, IM, 19B. rboltlon nf patiiDl iiJTcriiij; from wao-Ulac dJtMM. 31)0. PuaiabMoML
301, 303. Viae abMw ibowln|| lioa) at pcrlnmuin. 3un. DUcaliKHi alter IraUmrnt. 3i>l. rciiauItU of trrcliBatcr anU Upper portion of femur. tfA, 3uG. Coneenllal niiapUmnmt. 3U>, VA. SbonltiK apfillcalian of Sajre'n douUo loojE cileitilOB tfilfait in eon^nlul
■nb^ilaoHBCM. MIL DhgnniDUle Ulmtntloa of iho pclib In oonsonltal BBlttiUcement, ianri line*
IniMcillig flfnuv tSvef oilonikni la nppUrd. t\0, ill. Oim: Infantile parmljrMi uwl ita mulu. SIS. IHait»>i> of the brad of ri^t Utuar. SIS, JM. llluAlnilne Tetnaikable poiiikia (li* lloab ma* UHnw l» dbwtaib «f the
head of tbo fonur. SIS, SIS. DiallMia of IkwI of trmm Irratf I iri^ tW lin cAnm. SIT. PtaHui*, «ht> fomalioa of ono aMtalnlain upon ItiP ilomuB OIL SIS. Sajrre'a nrtebralml Brifble probe fcr eiplarlng dnuva. SIS. Aeck'n Bciiblo probe for nploeiiig rinwiw.
550. FhariTo BMlka »pliiH for ■pplioatioa afwr briwmenC toKi \a anehjkd* of ibe
km*.
551, !3S. Com: nbrouaMohjtlMiiof hnccioint itluamtliigNnlt ofbrWmetvt forv^ SSS, SSI. Caae : nbrsa* aatfciioib of knee.)oint.
SSS, SSS, SIT. StS. Car* : Fibrout aachjIoaLi of bip-Juini, UMtmml ; lenotom j with brfMONBI forot.
INDEX OF ILLUSTRATIONS. six
FN.
S2V, !S0, 2S1. Cue: AnchjIoaU of Up-joint of Beven yean* sUmding; treatment; tenokKD; with biuement forcA, perfect result.
332, 238, 234. Cmse : AncbytoeiB of hip- joint due to muscular contraction ; treatment ; tenottHn; with brisemeal forc£.
236, 236. Case: Anchylosis of botb Up-joiats.
231. lUuMrating section made in femur for artifldal bip-joint in ani^jlogis.
£38. Re«ult of fonnaiion of artifidal hip-joiol.
239, 2*0. Severe CMe of anchylosis of loft hip-jnint.
241, 242. Section of bone removed in fommtion of artificial bip-joinl in ancbjlosia.
243, 244. Dr. Nelson's fractore-bed.
84E. Case : Formation of artificial hip-joint in anchjloBis.
no, 247. Artifidal joint produced with formation of new cartilage and round liga- ments, simulating the tignmcntum teres.
248. Uagnificd micnwcopical diagram of new cartilage in formaiion of artiScial bip-
jOIDt
249, 2S0, 251. Case: Anchylosis of the elbow. joint.
262, 2ii3. Tbe spinal column in spondylitis sbowiug the pressure upon the various
portions of tho leriebrte.
254. Sling with head-piece for suspension ia spondylitis during the application of the plaster jacket.
2E5. The jurymast as used in spondyliilfl by Dr. Sayre.
256. Danach's wheel-crutch.
iGT. Practical application of the ptostcr.jncket (from phott^rsph).
838. Tbe plaster jacket aa applied in spondylitis complicated with abscess.
'Ib9, SSI. Dia^nunatic sketch of the spinal column as showing the effects of suspen- sion alone.
260. Case: Spondylitis.
288. Caw : Spondylitis, plaster jacket applied.
263, 264, 265, 266, 269, 270. Cases: Spoodylills, illustraiing the application of the
jurymast with the plotter jacket, and its results.
267. Spondylitis cured without deformity.
268. the plaster jacket worn as a corset.
271, 272. Case : Spondylitis bcforcand after tho application of the plaster jacket. 278. Elastic apparatus for rotary-lateral curvature.
274. Rotary-latenil curvature.
275. The trapeie in rotary-lateral curvature.
876. Method of self-siiapenBion in rotary-lateral curvature.
277, 278. Uodels of the spine. Illustrating a mechanical impossibility as applicable In totary-Uteral curvature under the treatment of lirace, lever, and screw.
879. Plaater-of-Paris jadict converted Into an ordinary corset.
880. Itotary-lateral curvature.
881. Uetbod and effects of self-suspension in rotary^lateral curvature. 282, 283. The plaster jacket vom as a corset in rolAry-laterol curvature. 294. Case; Rotary-lateral curvature.
286. Self-suspension in rotary-lateral curvature.
986. Case: Tbe plaster jacket in rotarj-latcrat curvature.
2B7. Besult of treatment of rotary-lateral curvature by gymnnstica and the plaster
Jacket iSS, 3B0, 291. Case : Botary-laterol curvature ; section of latisaimiia dorsL
Xj INDEX OF ILLUSTRATIONS.
Fni.
389. Pbotograph of spinal CDluinii of roUry4ateral cuiratura. (Specimen in possch
BioD of (he RUtbor.) S92, 293, 2U4. C&se: Pkralysis resulting Id rotBi7-Iat«ral cnrrtitare, treated wilh the
plaster jacket. 20S. Paralyeis of loirer cxtremitLea.
S96. Sptiat Ttth petris-belt for application in paraljds of the lower citrcmitiefl. 2U7. Splint as applied tor paraljsis. 298. Case: IncoordinatioD. 29tt. Darrach'a vheel-cnitdi in inco5rdiuation or paralyus.
500. Case; Wriat^drop.
501. Lead-paraljsis.
H02, 303. Uudson'a apparatus for wrist-drop.
S04. Torticollia, or rrr.Deck.
805. Meclianical applications in torticollis.
800. Scjnders' brace and head-pu; tor the treatment of torUcolUs.
807. lustnimcnial device for the treatment of gcnu-Talgum, or knoA-knce.
308. Case: Oenu.VBlguin.
309, 310. Sayrc'a Instrumental treatment of f^cnu-valgum.
311. Inatrumental device for the treatment of genu-varum, or bow-legs.
312. BuDlODB.
813. Dressing tor bunions.
314. loatrumcnt for treatment of bunions.
Sin, 316. Illustntiog the deformity of the foot in hallux valgiu.
317. Section of metatarsal bone removed in hallux valgus.
81S, 819. Illustrating result of treatment of liatlux valgus, u advised by Prof. Hueter,
of Greifswald. 320. Illustrating displacement of the tendons of the foot. 3SI. Side vien of dressing tor dieplacenicnt of tendons of the foot
822. Front view of drcsBing for displacement of tendons of the foot
823. Case : Result of treatment of displaced tendons of the foot. 324. High-heeled shoes, obvious objediona lo their use.
OETHOPEDIC SURGERY
DISEASES OF THE JOINTS.
LECTURE 1.
I NTRODUCTOR Y.
HiBlor; or Ortbopedj. — OvDersJ Considenitioiia irMch should induce tbe Student to make it « Subject of tipeciil Study. — General Plan of Instruclioii.
Gentlemes ; The Faculty of tliis college have intrusted me with the very important duty of instructing you upon the subject of deformities of the liuman frame, their cause, methods of cor- rection, and means of prevention.
I propose to do this in a series of theoretical and clinical lect- ures. In the former I shall endeavor to render jou familiar with the nature, causes, diagnosis, and general treatment of de- formities; and in the latter I shall place before you abundant clinical material, and offer you ample opportunities to realize and test the practical hearing and application of the abstract princi- ples which I shall endeavor to teach.
In this combination you cannot fail to master the subject thoroughly, and to prepare yourselves efiieiently for the per- formance of your future duty in this particular branch of your profession.
Heretofore, our subject has not received that attention at the hands of medical teachers it fo eminently deserved. Students met with few opportunities to study it, either in theory or prac- tice, and the profession at large was hardly prepared to take charge of deformities and treat them snccessfulty. For this rea- 1
3
nrrRODUCTORT.
Bon tliey were left to more niechanica or professional ppctcndor*, who, if tlii-y tMuld conMnicl any Mirt uf luacliinv, profeBsetl to cure all kimU of deforuiitice.
Any onu at nil uc<juaiiit«(l witb ihc iniportiiiu^} nnj iu«gtiitu<le of tliia branch of Kuipjry will not for a moment (jiKvtion tlio propriety of treating it under a ii|iceial lirail, uiid c-uustitutiiig it tlio sole o^JL-rt of a professorial cbair.
Tliia euliool, I l)ulieve, wagi tlie tir»t to CHtabttch a spociiil pro- fi-HMirBhip for orlliopctfic eiirgt-ry; and I am liappy to see tJiat our pood cxanii)le In being followtid by otlior iustitntioiw, u« such Icauhing innst nvovssarily i.!nhunc'u the value of tlio ioi'tniction Htu<lontti will receive from tlieir Alma Matfr,
The ncc*s(fily of studying tlic trvatmcnt of doformitii^a vriisi admitied by tbc anoiontfl, for we liave from llippooratcvi himwlf, who hiis been styled tLc "Fiilber of M«<diciiie," a trealiso "On ArlicuUtions," in whic^b ho tan^ht tiie proper method of band- aging, in csMCS of tile infantito deformity of ulub-foot, whtcli even in this day might l>e employed witb advantage ; for any theory of trcjitnii-nt fmindeil npim eorn-ct idi-as remains true forever. CcUuB deacribi'd tbe radical cnre of bare-lip, and of various otlier congenital dcformitici*, in a manner similar to that of tb« present day. As time went on, various persons attemptwt to ascertain the corrert niethoil of remedying deformities of tbe hnmaii frame. Empirics, and pretenders of all sorts, appeared from time to time, who professed to bave diaeovered " tbe trae secret," and as there lias alwayi* e\ii*ted, and Mtill extHtii, in tbe buman mind, a dis])osi- tion to admire tlio marvidous, and to be governed by decided J onertion, without proper and oan-fid invei>1igation into facts, eo- men then became, i^ ihey now t>ccoinc, the dupes of the deeigo* ' ing <|uack, who flourUbed and grvw important through their weakness and eredulity.
Tbiit Tciidoney of human nature has sliown its«1f, bowcror, quite as much in other branches of tlie medical art as In that of ortbopedy. Nutbing ran check thiii but the pro|>cr edncn- tion of the mind, whereby it is accustomed to examine and study into tlio trtiU* of every proposition ]>resciit«^l for it« con* Bideration.
Pret^mdera and q»ack>i invariably puhlis}! aceounts of tliclr wonderful oures, and tlio miracles they liave performed, in the ^ aecniar pre^i, or in other tlian ecioutilic and profu«dional jouiv
HISTORY OF ORTnOPEDY.
Z
l>'terer laying down any laws or rules to aid tnotW in jht foniiin^ tho fame pnru in viriiiliir cuKce. And lliui, gontlotiicn, coiistitutcfl ono of tbo 4.'«&eiitiiil dilferen<%s lietwcen ui lionoralilo physician and tlic quack. The one Utlton* to diML'iiiiinttv aud lEfFuitc liiit linoivk-dgc for tlit* lieiictit of hi'ii vrholo profession, *in order that lie luay relievo aji niucli of hiitiiAtk Miffering M U within hi« power; Iho other endeavors to concetti the little knowledge he may pocsess for hia on-n )»rticii!ar profit orgiin.
Tlio importance of the enbjeet no one can deny, who pays tlio jliteHl attention to (hit ntiinvroiis nece of malformation and formity which we ohsen-o in every-day life. Yon ean searciely walk a block in lliia ci-owded city, or visit any of tlie gmaller 3wn» and villages of our wide-t-preud eouiitry, without M-eing Iformed or cripplt^] hiilTi'rc-r», whicte cmiiitenance iK^ars tlio iuiprvMi of mortitied pride nt tlioir unfortunate condition, fra- qncntly connccteil with expressions of interu* pain, prodiiecd by their abiiiinual pbyi-icnl [xMlinn; henco, the niyresHity of giving . speeia] ponrm of ledoreB on tlib particular duparlment of sur*
The etymology of the term has been in ooiiiiiderable duabi ; Andry, of Piurii>, who lia« been generally regarded M tlio founder Lof rliia braiirh of Buigery, derived it, to use bis own words, " from Ws, wbieh (tigiiifies lUriiiijhi, fff/nwi tlt-jorinitij ; aixl TratSiov, a dtiUL Ont of these two words I coniponiid that of ort/iopwt/ra, to cxprww in ono term the dt-^if^" f pM*l«o#e, whieh i« lo teach tlic ditTorwiit methudi) of preventing and cometiiig the defonnitie^ of diildrvn." '
Other anthers, however, derive tho second part of tho word,
uin« fnun iratv, it diitd, and others from jpw, a/oot; bnt both of
thetfC derivBtiotM Htieni iuadeqiiatc to expnii^ the full Kcnsc of or-
rtliopedio surgery in the prerant day, limiting ittt extent a» tbey
fdo in ono case to deforitiitii-^ of ebildrcn, and i» the otlivr to
tlioAo of the feet ; wlierea-i at the pre^itt time it extends not only
. to adtdte as well an children, but to defunnities of all t<art« of the
\y. I would prefer, therefore, to derive the word from ^&h<t,
sfraii/M. and irtu^'w, I «tueat«; this is more eotnpntliensiTe,
and embraces all deformities of tho human frame, and aleo ddfiig^
* Sa " L'onlioptdlc. on V\n de pMrcair el de oorrigtr tiaoii 1m Ku(biu 1m D4 foradtte d<i Cm|«," i PatU, 1141.
4 IXTBODrCTORT.
nate» the princip]<» of treatment. Kiit ax tliU would neocMutate the coining: of a new word to take the plitee of the one whk-h hits hocn reoc^iized hy geDenJ astga, I prefer to rcUin the term ortAapeflia, with the uxpUiiation above given.
The history of Ortlinpedic Sargerr carrier ua IkipIc to an ancient date, and Uollaud xeenu to have bcuu tliu hirthplaoa of thi« branch of surgery. Tlie first case of tenotomy for the removal of deformity is ixrcordi-d by TnlpiuN, who mentions /mciu« Jfiriiujiy a Diiteh Mirgeon, aA having performed it in the year 1685, in the case of a boy, twelve year* old, for tiie rclii^f of irry^iwjt.'
8o)ingeD also performed tlio same operation in the flc%'cn- t<enth century,' and Meeckren, Roonhuyscn, and other Dutch eurgeona, Iwvo luft nworded cases; atill the great value of the opentioii had not been diHcovvred or nridersiood j for the great surgeon Bocrhaave, and all medical writen of tlto for- mer half of the eighteenth) <^enlury, niaititaiued the great sen- eibility of tendons and Ihe grave danger in their scttion, so that we find jO» ia Sowrdierc writes in 1742, as the closing words of a ntemoir, "The section of tendons ought, then, to be avoide<i."
Tenotomy consequently fell into disuse for nearly a century. In ITSO Andrew) Venel, of Switzerland, catabli.<hed an inf^tiiution iu which he treated dcfonidlii-s of the human frame, club-foot, spinal cur%-ature, etc. The nwt operation for the relief of club- foot by division uf the tendo-AchiltiB was performed by Lorena, of Frankfort, at the reqncst of Tliileni»«, on the Sfitli of March, 1782, in the case of a yon ng woman, seventeen years old, by making a complete division of the twft partf, enibracitig the tendon from its anterior limiu poRteriorly. Tliis allowed of an immediate descent of the oa caleia to the extent of two inches, and in six weeks the wound was healed.'
In 1803 Soarjia invented and made n«c of a shoe adapted to the boue« of the dUtorto^l foot.
On Xovemlter IC, ISO!), Miohaelia effected an imperfect sec- tion of the lcndo-Aehilli».
8artorins performed tenotomy on the »on of Martin Oust, in
' Aa TnlpUu, " mMmUonei Ufdka," Umt It.. «i|Mt U, ^ %',% 1«85.
* 8m " TMw <k Jiunor," 1 HST.
• m> cut b ncordcd U -Ctdrwgbcb* BcMtku^n," ITSI.
mSTOBY OF OnTnOPEPT. B
May, 1813, with good reenlt, bat did Di>t etinceed in mtrodDciiif; thu opi'ntt'iii inco lieniiuiy.
Tciiutoiiiv wu» not pvrfonncd again till Delpecli operated by dividinfc tho cendo-AchUlis in a ehild, six yv*n of ago, on tliu 9th of Muy. ISIti,' l>y lniii§Hxin|r thu leg in fntnt of iho ti>nd(>ii will) B ftharp-iMiiiited bistoury, iiictMiig Ihv skiii to tkc extent of an incb on each e'lde, and th«n dividing tlie tcndi'ti witli a convex knife. Tho wonnd luwl not henlt-d at tliu end of threw nionlhit, ami tlio niiiult wm only n jxtrtinl auocees.'
In 1822 nml 1823, Pnpnyircn ofK'ntwl twioo for wry-nock, ami iinprvivod that openttion iin previnufly practiced.
Thu groat dittoovury of sulouta/imiu t^MAomy was, liovrever, fttwrved for iJie geniim nf Loiii.1 Strnmeyer, of Kimover, wJio firbt pcrforiiiiHJ lliitt opunitioii in I'Vltruary, 1H3I,* nml pul>- lUti«d hia first eis cawe in 183k FosHesaed of i^at tnlcnt, ardor, and eiicr^-, hv ouii«l>«] \i\* now principle lo ho gc-ncrnlly known, uud umny gn>nt cures have diiK^e Iteen efft^eled hy ic» application.
The naniCH of nnifkncr, ('«mper, WonKel, Palletta, .Tnekwn, Bdmnn'ririiTt llciiiu, and oliici-<s niiint nut he forgoMua, as vach ODD asdieted to develop Ecicntifie koowle^lge and orthojiedie dur- gery. A\to. I>icili>nhach, Lanizt'iihtMrk, and many olherM in Ger- many, aeeonipliiihe^) innc-h; while in France we find those of Uonvicr, Iionn(<t, Gni^-tin, Marjolin, Major, [)el[)ech, and Mat- gaigne, cotispicuoits.
In Kfijriand, Dr. Litllo utamU pre&iiincnt, having introduced orihopedy into that conntry. Having i-uilercd himself from ciin> f^itnl clnb-fool, he knew hotv lo cHtiniato tho relief atT'ird- ed; and lo liiis oxertiom; and energj' London owes the eKtahlish- munt of the Royal Orthopedic llntipiiiil. ^Vithhi the Hmt ten yeans miccuedin^ its establiihment. ttcclvf Utoutand patients woro there treated, which alone \» a proof of its neco««ty. Dr. Lit- tle's oolluagucs, Taniplin, Lonnlnle, Hroadhiirst, and Adaiite, have also done good BCrvico in tlie caUf^e of orthopedic aurgery ■nd seEencu.
" 8n " Mott"« V(.I|)»«q," toL I, p. 4W.
* .W " S'niim aiij I'rfftUiurKt at ih* IMormlllni «f tlie Kuiiiaa Prune," hj V. J. lilUr. U. r>. IjiiuImi, tHS.I.
' S»t " OnM'« SjMam o( Su*s*»t," w.1. I, p. BOl, «tli ad.
IKTRODUCTORT.
Ill our own coimtrv ortliopedy met u-iib very serious o1»ta- dies, till: profft^tou K'irig )ieriiju<<^I^' opposed to uu^' iiitiovstioii, and piirtiviiliirly to aii^ eiilidi^'Uion of medical science iiito spe- eialtius. And many mcdicnl men of even grvut prortsBeioiinl attiuritnt^nts, unwilling or nnable U> take the tedious trouble of uttuiidirig to scriiiu^ ca»c« of deformity, would recommend »ncli oases to various instrumont-makurs, in order to got rid of thom ; and tlicsc, mora inccbanicK, eti^iUined by ^iicli iveomnicndation, soon b^an to assume tbe name and res|Hiiieibilitiefi of " do(.>tur," aiul woul<l undertake tlie treatment of deformities, instead ot adhering to tJieir U-gitimate busiiie«t, wbicli whb tlic manufacl- nre of Auclt iniitrumenud aidn a^ an intelligent enrgeon might dcviMi.
Tlie injury tbnii inflicted on medical science and profo^ional honor can only bo properly appreciut4-d by tbo«<> who, like my- self, have bad frequent opportunities to witooe its disastrous result.
Dr. David L. Kogcrs, of this city, was the fint to perform tenotomy in thi» country ; he divided the toiidn-AcIiillis in 1834, aesifitcd by my colleague. Prof. James R, Wood.
Dr. Kiclinrdwn, of Kentucky, wrote nn elaborate iind itistnic- tivc essay on the eubject in IS3S.
Dr. Detmohl, wlio is now n F*rofe»or of Orthopedic Sur- gery in the C-ollege of Physicians and Surgeons in this city, a German him^rlf, ami who h.id enjnyed the iidvnutagcft of Prof. Stiomcyer's iniitructiun iii (jeriiiaiiy, introduced among U£ sab- OQtaneouA vttjctomtf in 1837, three years subaeqneot to the iiilro- diiction of tenotomy by Dr. Rogvns and mudo £caK>tis efforts to render us convei-sant with its tccbnie»lili«0 and theraj>cutic efficacy.
Dr. Valentine Mott, in his " Travels in the Eittt and io Europe," publiithed in (H-t^, expressed hiuii^clf in tlio liigboet terms of admintion of orthopedic art, as he had iiecn it in Pari:!. It 18 but ji)»t to Ihii* distinguished eurgeon that I should quotv from bis nurntlivc, above referred to, in order to sliow how immeasurably he was in idvnneo of tlio profcnloii at that time. In fact, in his declining years, wo here see almnr dant evidence that ho was still entitled to (he iip)>c]littion of a piotuer.
He says : *' It was my bappy lot, even at my advancing time
UlSTORY or ORTIIOPEDY.
of life, to liare rwidcd iu xim capital (Paria), and to have wi^ noAM.-'), al-^, tlie dawiiir)^, aM ut-ll iii' the uu-riilinii »|)k-ii(Iur of another ovvr atid ilhmriuus l^^a in the healing art ; I rtift.'r to tttal bmutifut nnd exact eciciioe, Umiitdly douomiiiiitvd orlhopeilus
"This^rcnt itnprowmcnt, hulh in inochaiiiiuil and oiK'nitivo eiirgorj, is dvetitittj to he to the Iiiinian frame uhat vaccination ta awd has Iioeii to th« httnian fi^atiirw*. An ihn dinoovcry of Jcn- Utr bu( rid the mirld of a loathsoni*; jwatik'nce, and hanii<li«) from onr sight thooe dbtiguntionit whidi made the nto(<.t lovvljr linuimcnu and coniplvxions htdcons to hohold, »> will orlhnpetlic snrjferjr, hy its n\»^\<- toiieh, unbind th« fottt'ivd limb*, rwtoro eyniiitutnr to tbo distortwl form, give mobility to the imprisoned tongue, and direcineHs to the orb of vittion.
" Like many olliur of th« glorions acluevomeuts of unruly, it is based npon jtuch aimple and self-evident {iriiiriple^ that it ctm- not hilt bo ntlruftive, and cairry home conviction to the plainent cajioritit'i*. IlH adiiption mnf«t thert-foro he uiiiverMd ; and the tnoro 6o, hecauiio liberally and extensively ae the linife may be nned. nntwroting. aa it literally does, the moAt niii«diapen and vc- voltinff and convohitcd n)a»^e« of defonnity, by dividing deep, yet safely, under tlio nkin, tlimiif^h the thickefit and broadcHt niiUM'leti : yet are thuec operatioiw, in many intttaiioc*, liUwM/ive /fom pain, an«I u'itliout a drop of blood !
'*And another remarkable f'eiittire, and one wliieh givce the nliami of magic to this truly brilliant triumph of our art, in the almmt Inttantanoons re^ioralion of every diMortcd ]»irt as »oon as cut, and the righting of the lindte, the trunk and head, to their wonted beautiful symmetry and proportions as the proud i>hip that hne been bent down to the rude ttonn, racovers her position, and nwumca tier tttately courw, when the idirou<]ii have been cut away."
And further on lie says: " Haviug myself pnrsiied this new braneli, aa a student with my friend Ouerin, for the Ini^ three yean, and personally traced it (lirongh every step of its rapid progrcsH from Its birthday. I may My to it« prL>eent perfeet con- dition, T have thought that I could in no manner so well esprees my gratitude to him, to my country, and to my friendi', for the kind feelingH with which they have Iwen pleased to clierink my name, as by attempting to found i» this city of New York an
IKTRODrCTOKY.
Amerioui Orthopvilic Inttitntion, by whicli tlio principlus and prartico of tUut iiitcrcfiting ficioDco may Iw dUIueeil far and wide tliroitgli lliut my nativo liutd."
It was a gruut aud rooUnclioly misfortane, for otir a^ Bn<l profo««ion, tliut liin caroer wati m> ^luldenly Icniiiiiiktvd ; tiiiil Uiiiti tin: great di-birv uf IiU lifu vim iiitt carried into practical execu- tion.
Oentlemon, tlic ardent zeul with wliieli thia diBtin^ruifllied sn1^ poou — thu acknovi-ludj<«d Iiead of Lis proft.y«on — dvvuteil liimttelf to the stady of this now branch of tht- healing art, is well worthy of yonr admiration and iniitatiim. Wo hen! mc one who«« luimo wafl already recorded in the undying history of surgery on it« very hriglitest ]ui£es, and who had ulivady won m moiit hrillinnt and unfading Uurclis applying himself for thiiiu long yeai% m a Atndciit nnder the dietinguidied French aurgcon, JuUi) (lu^rln, in urdiT that he might bcc'onio a jwrft-ct master of tltL; now art. Strang^ to say, we find at ttio present day hqiho young geniJc- mon complaining that three years k ahno«t too long to obtain a perfect knowledge of all the lUff^retU dtpnHvtcnU of onr [>rufeti«iun. Vet a man wlio had devutod ht« life to tliix gruut work, who tiwl more knowle^lge and repatation than shnottt »y man our country han iiroduecd, and who had perfunned >me of the most wonderful operations in the world, \rait thue willing to devote three atparate years to (hi« oii« hrancli of our profession.
You liavc in thin fact exliihiutl one of the princijml caiiev« of thin great man's most brilliant eocoem. It was hia constant and nndcvinliiig dovutitin to thi* flindy of hilt choir-r ; \\\*. fsitliful tip- plication, and his unwi-»rivd toil, his detcniiiniilion to master all that gcniuH Imd conceived, or indnMry dcvt-lopi^), which was nevs in the profi-#»iou of hie adoption, which might add to its utility or give tiw- power of relieving himian lietn)^'^ in sufFering and misery. It is au example wortlty yonr imitation, and will lead any young man. who will make it his model, to nldmato anoows and honorablu diBliuclion.
Dr. Ilenri- J. Itigolow, of IWton, [MihliHh«d a work in ISfS — it being a diHH^Ttatton upon orthopedic surgory — which uhtuiiied the Boylfton Pri«! for I(y44, and was written on the following f|uestJon ; " In what CaM-« and to what Extont is thu Division of Masclce, Teudone, or other I'arts, proper for the Relief of De-
GES:KRAI, COKRIDERATIOSa
Q
fcHTDiily «tr Lanicneset " It waa written after otndjiiig tlic works of (iu^TJn. IJniiiict, \''«1|)oau, Phillij^i. Diiviil, ami Littlo.
SiiKi) tliat titiiu many gi^ntleiucn in different parts of tho world have (leroted H]ieciitl uitviition to thiHiMirticularilvpartuiont of eupjit-Tj- ; ami iimiiy iiiiprovt'iiicnts liavc Iwen niaile in the mir- ' gicil Ireatiiient and nierliatiiriil (luvicctt for tlio puqio«o of lulL-v- ingdcfumittkisof various piirt» of tho body; stiU ul present ortho- piHlifl eorgery is I'Ut imi>erfectiy iinderatood among iw, iind iiut fvw fivl i-oiitiK-u-iit to pt'iK-tUu it. It shall ha my endeavor m> to develop til JH department of enrgery Cliat no nurgvon hori-Af Icr aball feci liimwlf tliorotiKlily i-iliicnri'd in his prafeoeiou until lie )iaa also fnlly mnAli>re<l ilii<< piirtii-iilnr branch.
My tlieoretioal iwinrcH. however, will form hot n very Rubor> dinnte |uirt of the plan of itiBtmction. I am n^strii-ted in tlio time allottvil fur the pnrix^M', and thii» fnet niiiHt uuceauirily du- lennine tJic rharacter of my lecturrs. I tihail have no tinw to indiil^* in unpro<lnctivc Mjweiilation and ]typollie«tt;. i idiall. liierefore, stmty to make iny leetures brief and concise, and Hliall cmlmvor to innke thetn preuuiineiitly jirHettnl. I *]iixl\ illtiHtrate tbem by eases Ik^ii^ upon the nilee wliieb 1 bIwII lay down, and fmm my private aa well an from my hoi>pit»l pnu-lice. I find! brin^ Itefore you etuuM that will dcniuntttruto pi^urtieally wliat I cliall ntrive to inciitrate tboon-tically.
I can hardly lay etreeB enough upon tlio neeCBsity of your attenlton lo tbi?«« praelieal, clinic:!! illtiMrationii of the theories ineiilnited. What I hiy down to you in theory, if yon Blionld rlianoo to low it, yon may, if Qod spares your Hvc», eomc time find an opportnriity to study out for yourselves, or hear from an- otliur, pr()bably very niufli Iwtter exi)res*eti than hy myself; but, if you nO{(toct the praetioal wvtLW wbieh coine up before us, tlio can never bo rep-iirc'l. Therefore, yon ninst j^ive yonr clo»e ' attention, and wxteh cjiivfully the cjim>s which I bring before- you, Iwt you never find anotlier opportunity to we tbem. They are the prcat, nnfailing te*t«, wliieti yon have plac<.'d before yon ; the pmctieal testi* iiy which yon may know whether I am corret-t in tliA princlptn which I endeavor to tenoh.
I wish, thonfiire, to nrge npnn you again to neglect nooppop- tnnity of iinprttviiig rhe lime by strict attention to the clinical iOHtruclion wlueh I may l)e enabtixl to give you.
As I have said before, if yoii lose a lecture, you may make it
up, but if yon lo^ a clinical case, ;roH can never mnko that op; ior, wlifii Ilio Uiiiw comes wliun yoo woald repair tlie damage, the living illiLitratiotin of tli?ease Iinve departod. iind llio pwullar iiiaiiifo'tulion^ of the vyiiiptoiuH limy have developed have Ixien loet tuyoH forevuc
If, therefore, [ lOiall iit any time lay down any doctrine Uie trntb of vrtiich I cannot pnicttoally denioiiMiatc and c«tat>lieli by bringing before yon goniiinc castot to illuKtnit« it, you are at per- foct liberty to discard such leaching.
Never be govcrnod by the ip»e dixit of any man unlca the dcmonsti-atioD acc-onipunying it, or your own careful investigation, shall convince you that the pritici[je8 enunciated are true. If, by mcanA of clinical casea, I ahall succeed in clearly Hii)>t<tai)tiating ihu doctrines I ithall tcacii, please eiidmvor to kimi the precise method of management a«lople<l in each cnse, eo that whatever t>uccci« I may secure by treniinent y«« may nlno obtaiti.
Such, gcntlomcn, ie a brief outline of the history of ouraab* ject ; the genera) conuderatioita wbidi should induce you (o make it a Hubject of epccial study ; and the genonil plan which I fliall follow in my course of ini^tnietion.
At my next lecture I Bball take up the subject of dcformitieti in gcnerul, their clasaitication, causation, and general treatment.
LECTirUE II.
DerouHmes. OuriOeUlon.— DcfiDtOon,— Btlologr.— PrognoiU.— Dhgac^
Ok!»ti.kmkx : To-day we begin tlic etudy of defonnitiee, their divisions and eubdivisiona, caneation, and general treatment.
Defomuty has bi«n dctincd to be a morbid alterution iu tlie (onn of some part of tho body. (Dnnglison.)
Deformities are divided into congenital and acquired.
The following cla#«ilication will be elaborated in tho stibee- queut lectures :
CLASBIFrOATIOK.
11
"Mil
■a 2 -e j3
■a cj £__
13
sjl^"-^
o aj '
"S 3 -*" S ^ P
fe^"
° g II S
O lb M
PEFORMtTIES.
A congenital (/rformi'tt/ in that wliioli w prcMitt at birth.
An artptirtd d^'owutjf is one wliicli tiss l>eea developed »a\^ seqaent to l>irth.
Ctiiigeiiitiil dcfonnitie^ arc a^in divided into congenital mal- fomutionsaiid cun^'iiitAl dii^tortiuiui.
A eongtinital malformatioH is one in which, at liirtli, there is a duficioiK-y or alwcncc or incren** in tlie imiiihcr of imrts bt*- loDf^inf; normally to the body, or in vrliicb then; are abuormal juirtK or tii^iiiin-^. !Moi»trusitic« «re ako to be cUt^cd under tliift head.
A coitffmital dUtortion w one in which, at blrtli, tbero '» sim- ply a distortion of soniu of the nurniul jiartH of the body, euch as moiit ciiM'it of cbib-foot, etc.
Antuirud dffoniiitit.-^ aru divided into three f^upe:
1. Thone arising from caiisce which diree(ltf affect the articii- Intton of thf boily. stifh iw coiiiplcti* and iiiC'iiiii]iii'U' iiiichyloeis, eitlicr of traiiiiialic origin or (b>ii«e duo to coiiHtitiilitmul cauBee,; «acli a« ecrofulii, rbciimntiKin, etc.
2. Those arii^n;; from caiisi-ti imUi-eeUy aflocting th« articula- tion of iho body. Kxaniple!* of this e\yag, are tlioso <iffoniiitio« dependent upon paralysis, biinm, diiwaMs of tho palmar and plantar fawin, spnMic contraction of n)iiKc1n>, «tc.
3. Thoee arisitig from causos hoUi directhj and indinHlt/ af- fecting the arlicntation of the iKMly, sneli a» deforniittefl due to curvatare of boiioB and intcretitial softening of intra-articnlar csr- tilagca, etn.
A paralytic d^orrnittf ts one that bno bcoo dcvolopt'd in con- fieqnence of s deficiency of miUHnilar power to retain any jiortion of thf body in ir^norntul position. I bt^'livvt- that nearly alla*e%\ of congenital talipee are of thifl nature. A paraly/ed condition of ono DCt of niik^cs pcnnit« the opposing tet, cnutrucling per* haps with only their normal force, to produce the deformity. Thiit, however, will b« more fully considered under tho head of tuliiK«.
A *pa#/»V diformitij is one timt haa been devcUipcd as the rCfiult of undue nuisculur eoutraction ; c. g., a musolo that oon- tncta spoemoclically under the reflex influence of some irritating canso, such i» tho reflex contractions accompanying discus- of the joints, may produce a spastic deformity.
In certain caeiis eputic dcformitict) are developed upon par- j
ETIOLOGT.
18
■Ijftio ones alre«(}.T existing. Siieh cases are not of infrequent occtirrencc, und it ih ihia fact, without doubt, tliat \it» ginii riHU to, fuiil eiiHtained the belief in, tlie epafitic nature nf a great iiiHJorilv of tlivm.
Dvfornutics affecting x-arions purta of the body have received
i»\ naiiicv: for c-xmiiple, deformities of tli<^ tvH arc chiefly embntced uuder the genersl tunu (attjjtjt. Uf tnlipee. however, I vro have the dintinct variutio* known ii« varus, valj^us, vqitiiiiifl,
MieuB, snit plantaris.
IVfoniiitiwi of till! Hpiiic are nmitily etirvaiurrt, mid of ihcM iru have two— tltu aiileru-pustcrior and the lateral, or rotary lat- vral.
Certain deformities are embraced in the general tenn h!p^i». «aac, (tiid, when this funeral term i« umihI, tliv mind iit once pict- ures to it^f the clia meter iHtic deforinitr attending that diwaM}.
In the Hainr iniuincr have defonniticM of nil purr* of tlio body received technical names, whicJi will be cept-cially conflidcrud hcrvnfter.
ETtor.fMiv. — The i-auBes of congenital deformititw an? as yet
wrappi-d ill Ktich dwp inyMcrj' ii« to pretrltido tlie poet<iliiUty of
aa accurate doecription. Thvy cnu. ttiorcforo, only bo treated
bMoording to tlic coiuUtiiHi of tlte patiente at the time yon find
iaia.
■The cnns('8 of acqnired deformities, on the other hand, are in a majority of in<t!Ui(.-u« quite easily a«cerlaiiu-il. It not iittfro- qnenlly happna that the canw can be bo readily re^iclK'd as to pniTent the occnrrvncc uf prions dcfonnity by early attention to tlie patient ; but, if neglected^ they are snsceptiblf, more or Iobs, to the correctiri;; int)ii(.'nciM of nrlitii-!*) ap]>liiiiivc» and iiu-nns whirh science has devieetl.
AnumK thr eauM.-)) of mijuin-d <U?forniity wo will first men- tion acute and chronic aiticular inflainraation. This clii«i of af- fections moy proiltioe redox nuucular oontractionis which fre- gnoBtly will tcntiiiinto in ppniiauent deformitiL-s after the difivaeo baa iiab«it<li-d tlmt ^\<- Hmo to tJicni. This Ia beanlifully itl»»> tnUed in thv dufonnity that nccompanioii hip-joint difvasc. In Uibt instamv, the defnnnity is gradnally pro<hiced by reflex mus- ctilar contraction excited by thu diM.-a«(.-d joint : and the defonii- ily iMwnniee pemianent in eont^eqncnce of seeondary changes whicli take place in the uit»cle« tUemselvce. The fibres undergo
u
lEFOnMITIES.
certuin cIiuDgce wliicli render tli«m in«ii)al>Ie of voluntary reUx^j tion vlian the oame of llieir contraction in removed, and boiik times it is iiiipotwible to extend tlicin \>y force. We then bavea^ coniradttivd niusclc, to wliicb Dr. Little hm api^lied the niiino "etructunil rfiorteiiiag," but wbteb I have de»gnated by tba^^ tenn contrsctiired. Wben, therefore, I «*o the word "coi Iraetnred" with wferencc to a muscle, I mean one tliat has Iie- oome changed in ita aiiutonucal structure, and rendered incapable of elotigatiun, vitlu-r l>y the will of the patient or tbv application] of any amount of force short of rupturing its fibres. In the lat- ter cn8e,««ction of the coniractnred UaBUee becom<.« necessary bl^ fore a permanent cure eaii bo cflViirtcd.
The effetrta of stniftiiml shortening are more marked in chil- dren than in adult«. Jn both eases wasting of the miDwIei) occurs in oonscqiienoe of defective nutrition. Stracturul shortouing of one or mun> of the principal muscle* of » limb is accompanied by an imperfect performance of its functions; hence, a grenter or less lowering of tcrnpcniturc of tlie part U alwoi^t always to be obscrvcil. In a great majority of instuiict-s tho loniperattire {»| voiitiidi'mbly lower than normal.
A second canso of acquired doformitiee is perfect and long- eontlnned re^t of joints. Such re*t, even of a healthy joint, will produce deformity by terminating lu nnchyhisis. llcrc is anotlier evidence of the existence of laws regulating the animal economy ; namely, that action ts necosHiry for the healthy preservation o£ living tis.iiie. The sj'novial fluid for e7csmpk>, wliieh ia scnretet! to lubricate a joint, is poured out only when tlic joint i« in mo- tion. There is no waste resulting from the operation of any of; Nature's laws ; hence, there iif lui Rvrclion of (Synovial fluid whet the joint is not in motion, Ati tlie eye requires light to preserve its healthy function, «o docs tlio joint require motion to n)aintaiu iu noniinl condition ; and, as tlie delicate orb of vision becomcB blind when deprived of light, so docs tho joint fail to seerete healthy synovial fluid wben deprived of its normal stimulus,' which is motion. Thi" coneequcnce is, if the rest is maintained for too great a length of time, the joint becomes permanently im- paired.
In tJic tliird ])lace, acquired deformities may l»o developed in consequence of various forma of paralysis, but especially those forma whicli are the sequelte of diseases dependent upon a blood-
ETIOI/KJT.
u, SDoh as EonrtatJoa, diplillteria, etc. Talipes not infre- quently do])cn(]it u(K)i) Htidi a va\i*e.
Paralysis gives riee Ut Oi;formitic6 in llie (oUowing manner: The juinle Ium) llieir Htipport and bcml outward or JDwanl, &o- oirding to tins inclination of the joint snr5K.-BS in cases of general ]Uir»l_y»i8 of the nni»cle3<; or iK-nd 1«w»rd the ooutrneting' inuu-lM in vaem of partial jwnilyeie. When [MraljBie of motion ami son- ration is complete, or very exteniiively developed, it greatly intvr- fures with the nutrition of the ]>art.
Again, acquired <leformity may depend upon some diAea^c or injury to tliu spinal cord.
Another cause of acquired deformity is the slow poisoning of the Nyctoin by ourtain motidlic ]>oiik>i)#. Chief among thi-so arc the salts of lead, and one of the nioet characteristic deformitioa produced in consi-ipionct' of puiooning by ihciw folti i« wliat is <f>nmir>idy known as " wri«t-drr>p." caiiwj by the use of Ijiinl's "Uioom of Voutli." and olht-r villainoui* ci'flmeticrs.
1Saeliiti«, again, is another caiiso of ac<]uin><] deformities; these, however, art* of con»litutiona1 origin, d('pi'rKlijig npon llio liwl-nntrition of the HvMctn ami want of the proper iiii>r<^»iiic or earthy deposits in tlie tK>ne«; thns rendering tlieni unable to hear the weight of tho IxmIv, and allowing llicni nnder this Kupvrio- ciitnlH-Mt weight, and tlie e^mCraclion of the alronger muscles, to aMiiiiio raiious diGtortionH.
Bums, al*o, are a frefpient Bource of deformity, owing to tlie ponlinued euntraotiou of the eiwilrix after llie wound huf htiiletl. Another exceedingly important cause of acijuired deformity, ea- pocjally in chitdn-n, arW-^ from the retk-x inn«cu1ar eontniction« caused by congonilal pliimoisiB and adherent prepuct-. Tliia le a caUM] which had biren ovorlookexl by ilie profciuion until luy pa[>er on thU important snbjfct, which was read befoix- tho Anierioan Medical Aii«i(K-iation in IS"(>.
In continuation of the subject of causation, we oltsorvo that deformities of the apine occur most fre<incmly during the ])eriod of growth and dovelojtmont. Voung girls are more disposed to have the so-calh-il lateral curvature of the xpine than boys, for tho changes which their systenis undergo during this period of growth and development are more marked than tiinii« which take place in boys, and occur just at tho time when the bony etmc- turea are more or less pliable and not fully developed.
Id
DKFORUITIES.
Certiin dcran^mcnU iti tltu !ii'«]lh »n> u1i<o to be DOtked !n lliiit eonnection aft caiifles for deformities. DiBcaaes caased by evdeutury luibito, Hucli lu dyepopiua, bypocbondrijwis, m«lBiicboliit, ete.. frcjuetillj seem to give rise to rotary and latt-ral cunr&tnre. It is ill tbis cbuM of vn»v:» lltaC your efTorts towiird vtlucliug s cure will be mml unsalisfactorjr' ; for you liave to deal witli a loss of powiT, and nit fxlreui<; Huni^irivcuc«« to all iiiflu«uoi.>ii., cvpocijilly h<?nl ami cold, which, combiuud witb other dcrsngenicnta of the uurvouH xyetvin, render tbc«e eiucs very itttrnctable.
Tlic laat cause of acquired deformity wliicb I sball mention boru !« trauiiiatisin ; uiidur wbicli head iiuiy bu uiiibnicvd bluu'», brulies, wounrls, etc.
Moiit of tliMO eanBcs wh>«li have been iudicattxl, a* well ua tbo«)« whidi have not received Hpecial nienttun, will Iw oioru fully cotistdured a« wc proceed witb our t<K>turti), fur»nl)R04]iieiitIy I sliall dwell mora fully upon the Bpecial caui=eB of eaeb do- funiiity, which liavu thu8 fur bi-vu rufurred to only tii « general way.
PKoasoKi*. — lit f^Hi'nil, your prognoaU rftould be cxtrcnwly ffuiinled. There are very niauy esccplions, it is true, to tbis froneral rule, but to tbo«c cxecpttous yottr attention will be di- rected further on in the course. In the treatment of deformities, jMirticulnrly Iho^o of lonj; Mandiu^, you will lind ibat the pmcti- ejil ttpplication of tbo principles which are to giiido you, however diuiple lbo»Mi principliw may be, will in many caw-j* Iw exceedingly difficult. You may be led, on account of the eeeming tumplicity of many principle which are (o Ikj laid down, to anticipate Bpeedy relief and rapid recovery : but in a inajonty of cases you will really bo very mucli disappointed. Vour faith in being able to pixxluco rapid improvement by the treatmeut of deformities of lonf» standing will be very much weakened], when you come to have a few Hucb caAM under your own peiyonal obscniition and earc. Neverthclefw, it may truthfully bo said that, with patience and pcrscvenmco in the riyltt Jitrcti/m — tlic*o nre w*uriU full of moaning— yoa will bo able, in a majority of caaee, to accomplifib such results n» will lie extrt^'nioly Hiti^factory to tlie friend*, and more than compon«ate you for your extra latxir. In some cases, the improvement will be *o tapid tliat it will bccotue a soureo of great aHlonisbnicnt to you. In general, however, such reaalts arc not to be obtained. There is one exceedingly iniportaut ele-
TREATMEyT.
It
Rient In th« management of nil caaefl of deformity, and U is ouo wliitfli will iniitvriall^ ufTcct yutir progniMie, nftmfly, the «>• operation of tlio patient. If the hedo^ ccHiperatiun of tiw \tatient can l>u obtainod, a long etup lias been taken toward effecting a p<?rmiment ami eomplete cure.
DtAOKti^i^. — Tlic nilfH for making s diaj^ioeis will be con- sidered in connection with the etudy of eacb deformitj'.
LECTURE in.
DKrouumEA,
TMtmmt.— Ornnal PrindpliM.— UanlpuUtleii or MuMgi.— OjomMtloi.— TtMt*- pMiJo Agtou. — t>tj HmI. — Iia(h#. — tiiunL-lion. — Strjchnk.— Elcelrioltji.
GKSTi.nwK.v : T<Mlajr we begin thu study of trtatment of de- formitieH, «id I will tlr«t invite your utt«:utioM to the coneidere- lioQ of eortjun geucmt principles.
Thkatmkxt. — The treatment of congenital dcformitiwelioald ^commence axi-ly. This rule is especially to bu olwerved in all «I8C8 in which the doformily depends npnn dinordcrs of Tnuwular power that are of a (laralytic nature. "VVliun we ooine to aponk of tlio tniitnient of eonj^nital club-foot, wo shall iuMHt very strongly upon the rucugiiitiun of this principle.
The great re.-u«on why treatment of this clai« of deformilipfl eboidd bt< coinmvnced curly id, thu hope of preventing irritatJun or infliiiunuition of the pnrta abnormally prci«ed upon, a^ well aa the tnD'><'h-« and fasrite involveid, which may add a ejHis tic deform- ity to the already-existing paralytic uno.
Again, early treatment iii imporlAnt for tlio eakc of prevent- ing til© developn)ent of Bcrions nen'ous di^-asee liecauso of tlie Empree^ion made upon the nervons r<y<^tcm by the prc«cncc of the dofitnnity, and tbet«fore funitsbw strong proof of the neoeseity of alletiiliitg enrly to tho rom^tion of any mich niHlforniatioiiA,
Acfiuired deformities <-an very fre<iuoiitly Iw prevented by early attention to Iho nnderlying diseafic wliich produce* them ; and, as the knowlvdgu of bow to prevent deformities is equally as
mvs.
important as how to treat tiiom when tlic.v arc fiiltv developed, tli<! diHeaACA U])<>n which Aiicti acfjitired dcfonnitics ma^- (iepeiid wili lie vcTv fiill^' foiiBidcrwl in our fliitiHofiuuiit Itc-tun-*.
We now ronie to the eonM<]eration of tlic ital>ject proper. Tlie Iretttuioiit of dcfonuiUeo Di*y be divided under the follow- ing liead» :
i. Muuijuihition or mniwagc, and g,V[iina«tic«.
S. Therapeutic agent:?,
3. Mechsnieal a))pii:niee«.
4. Operative treatment.
I will tlret invite your attention to iiianipidation. Jf'iiilj)u//it!oH may lie regarded as tlie natural remedial agent
for Ilio eittv of it dcfonnit;. In very iimiiy eiiee«, i^o far as tbo ouni 13 concerned, the surgical operation is the ino«t ineignificaDt jmrt of the treutnteiit.
Without this manipulation and the varions positions in which the limb is pUced while performing tJieee movement:* but n few months would elapse before the parts would be in the same condi- tion UH previous to the operation, in coUfivpieiice of the adhoitoni* that have taken place. The im[K)rtauce of this principle we fihull be nhlc to demonstrate over and ox-cr agnin \>y axi^w; which will be brought liefore you where its obwrvanee h^ been negleoti-d.
There im n rm; in my mind at the present time, which n'ss one of tlie most uiehineliuly I havu ever t!oon. The case is worthjp of reeital. It va^ one in wliich (here was fiillydevclopeil disease of the hip-joint. The lad lived at a long diiit»iii^e from the city, and the gentleman who performed the operation of tenotomy did it iu a skillful nianiier. The limbs wcr^- droei^fd in the ordinary "wtre-breeehes," and the physician who had the caf« in charge VM inetructed with the greatest care coiiceming the ncwiwity of fretjDcntly removing the di-c^iing, performing slight munipuU- tiona, and then replaoiug it. The vtuc liad been, for three or four yeare, one in which the i>3tieot had snffen;d the most intense agony, and liiul Klept only under the influence of larjj^ doseo of anodynes. As soon, however, as the patient was placed in the immovable appamlun, and pro|)eriy extended, he wa« m> perfectly comfortable and easy, and 6lo[)t so well at night, that the doctor who had him in charge thought it uunccwftiry to nr»iorc it, fc«i^ ing ho might not be able to replace it, and make him as comfort- able aa he then was and had been since the apparatus waa applied
UASSAQE.
19
no was, tlicrefore, permitted to remain iu the "wire-breectieA" for nine inoiitlui, »inii)I,v W-ciuiku he vrtm so fri-o from \»\'m. Tliu reeiilt was tliat tbc liii^eH-Ho was ciinx); bnt Nature )tail, iinfortii- nnloly, cured it Ly ancbyloMsg not only tlic )ii|)-jo!nt which lud i>eeii Ibo seat of diaeue, hnt the hip-joint iipnn the opposite ^ide, iM well u both knoc-joint« nnd both aukk--j(iiiiti^ In five juiiile, iu whioh tliero was not a tmce of di»>asc provinus to the open- lion, iiiichyloHi)« hxd taken phioi' within nine month*^, wilhuut <iny inflaiunuttory iiction at all, and i^imply becaiiee the iloctor had ne^1cct«d reinoring the fixed a|i])amtu8 ooeauonully, and eubjcct- )n(f the garlfi to niaiiiptilHtiou and tnuvemeut. In making ))>« frfipient changi-s, ilnTufuro. in yonr a])panitnis do not forpi-t tho inanipalatione, and alito make the several movements of all the joints which may be natunil to them.'
Thorc can bo no enhctituto for manlpahition by the human band. There ia an intelligent touch that adnioniiihe«' yoit of tJio •immut of ifsistanco present, tho amount of force rcfinired to overcome it, and when you should Kto]i ita exercise. Voii are able I>y thiit ■m.'ans to detvraiine whuthur you are producing fipitHmiMlie cNintractioniA and con-tctjuem in-itation, and can arrent your force at any di.«Jred point.
1'hifl in what in fronerally underctood hy the terra w^immj/^, frtim the woi-d itdaam, to kjieatl ; tho pvat value of which ha« not been understood or used by the profession as much as it de- WrvcH. All i<ucli ntovctnont* are oxccodinply bonefidiU. and very ranch increase nutrition by stimulating an increased blood-supply to the part« ; the frietioti nnd kneading stinud^tu tlte ftb»urbcnt0 in the removal ■of atmormal deposits. All &nch manipulatinns, Iwwevcr.of whatever name or nature, should not bo oonttnncd no long, or uiicd with eo much force, as to excate inflatuntation, re- ilex contractiun, or over- fat Jjrue. Notwithstanding thoir great service nnd importance, an expcHs of ilium may produce irrepara- ble injury.
Ju ft]] aiKH* of feeble circulation, in relaxed condition of mii«- esllir ttssuc, and in cartes of partial anchylueii; a^ well as those
I Si( BonjinJi) II1o>li<^, **0n ilirSiMMctof ihp J(iint»,*'4ili«iSlioa,L«mdoa.lBSSt fMgC STfl, m}b: "I knD« SB mhtaoni uf • lad; wlin )im [>n«erv«d ibo horluntal pwliion fof (uiirtecn j*on, ukI in •hoa nM>l; all tbe Jolnu fl( tlw loinir aitraniltlM ta vUcfc no ■ftiinl tUwue exialnl, ha*« from nc-ro vant ol eiortlw bcooms ttaif
w
DEFORMmFS.
cases of depOBitfi in the fibrona tissne arotind the joinfai, the ad- Tantoge to be durivi-d b; a good manipulation caiinut bu ovit- estimated. lu cases of paraljrzed riudcIcb, iiiaoago is frequently coiiibtncd with wlitppiii); or beating of the iiium-)<w by the India- rubber inu»;li>-boutvr ut Klciuia, or eoinotimes by an India-rubber haiitinor til the form nf a thiniblo which if) fastened to an elaAtic liaudlc, with which rapid pcrcuseiouB can be given to the dec-p- nealcd niiiKcK'H, thus Inrreatiing the drciilntion in thef^i parts, and tending to uti in(;n.-iu<; of di^vclopment.
OymHtutiiv. — Theite are of great serviee in the treatment of deformitiuti, but tht-y must be uM-'d with much Cftuti«iu and mtdcr wise ^uperviftion. 'I'lic nmscles »liould be made to ]»erform an icxcuedingly eiuull amount of labor at liret, htt over-futiguc be produeed. It mue<t be caii»(tant!y kept in mind tliat, in all these deformed mcmbvns there arc feeblonetw of circulation and iin|>ov- erished muwHlar fibre, espeeially in the paralytic A'arietiee, Con- s&iuently, a very MrniiU amuutit of uiuvomout may KumWimce be rery severe work for such mnHcles,
TImhc excrcii^i.« idiould be rtr^iilar, systematic, and prognit^ver if yoa would derive the greatest possible advantage Ironi their nse.
TfterapetUic AffMth. — The judieiuiis um of tbcrapimtic a;^nt«, Iiowever, must not lie tindcr-eetimatcd in thia bnncli of surgery, cotwtitutioiial treatment being absolutely necwMiry, and h of tho, greatest importance in many coses of disease which we shall havQl to consider; but I feel wjirrsiited in warning yoti at the very outset that constitutional treatment, in tho oitlinary acceptation of that term, does not justly, in the vast majority of caj»tit, occupy that prominent pouitiun whidi lias hitherto been aesignetl to it. It will be seen hcrtuifl^r, that ninny of those ca8C« which have heretoforu been rt^rded us tb« locul manifestations of a conKl- tuttonal cachexia are of purely local origin; and, inntoad of iv- quiring a prolonged counw of genorul treatment to remove a constitutional cause, they recjiiire a local treatment to remove a localixed i»oiirce •>{ irritation, and thmugh this the constitutional disturbunce. Siich trealinent, wlicn iostilutetl, will [x-nnit the nat^irat powers of the system in a great inensutx! to restore lb«m- eelves.
The constitutional treatment which ie iiMudly mo«t bi-nuticial is tliat embraceil in a general oti^rvance of the laws of health ; Ruch ao giving the patient aji abundatioc of fresh air, a uourislilng
TIlERAPEUnC AGKXT8.
SI
tod vasily-cligmted diet, and onljr Bach medicinal rcmedieB ae may be necessary to maintain » nonuiil )>«rfonnancc of the wcretorj- and I'xcrvtory fuuctioiia. With regard to ept-cial remedies Ui b* adminicle red in !!j>e<^iiil cases, these will be fully considered when we (Hiino to MjMiuk of the treatment uf f>e{>Rnitu ditKtOEce.
The most valuable tfierapeutic affenit employed in the eonsti* totionftl treatiuent are dry htat, batJte^ iHunetwriy ttryehnia, and
Mui;ti bvnetit mur be derived from the ttec of i/ry heat. It is vejiGcially adapted to the treatment of paralytic deforinitiec, and 18 Ix.-ni'ficial fruin tbo fiiet that it »olictt» morn blood to the mrt to which it is applied. It may l>o applied by means of any jjKimlnit whicJi the ing<Min!ty of the patient or rtnr^eon may do- 'vifee. A vltv oonveiiienl method is by iiieanB of ordinary day lulling. This mean? biw iiiUily been sne}{V^sU>d by Dr. (J, M, Ifcard, of this city. CT«y tubus may bo cast of any shapi- desired, healed to any degree bearable, and tlien the limbs may be )>hiccd within them.
Tile hath i» another item of general troatment, the value of which can hardly be over-cut i mated. The tt^mperatiiro in to be varitxl aoeording lo the con>-titntion of the patiint and llie char- acter of the deformily. In the treatineni of paralytic defonui- ties the Iwith is one of the raodt nscful adjuvants to other treat- ment that can Im: employed. In such atTectiims it idiotild always be warm, and sboald Imb continued for a lonj; lime. Instead of beinc applied tn ihe whole body, it slionld be applied tJi the purl atfectetl. hi bhcIi cases the object of the Iwith is to increase the einmlation of blood through the paralyzed jxirts for the puq)o«>c of iiiereaHiiig their nutrition.
Yon all know very well that, if you place your lin^r in a vwsel of hot water, it will increase in size by increasing iho qauility of blwxl, euftk-ient to prevent ibc removal of your ring from it. If. now, you pUmge the same tinger thus swollen into a vcHWil eoiitaininff ice-water. c«>ntraction will follow and iliminish the qnantity of bloorl In the finger, and it may lie snlScieiit to puniiit the ring to fall off. In tlie same manner the <)iiantlty of blood cimilating in a paralyzeil limb can be materially inercasetl by meatu> of the loeaIi/.ed warm bath, the other )>art« of the bwly l)eing cold, and in this way constitntos an important adjunct in the treatment of jnralytie deforraiticA.
S3
DEFOSMTTrES.
/nunetum. — ^To« also bave inunction as a nieanit of general ttvatmcnt. I'pon i)m [Ktini I have but very litlle to wy. Oil —particularly petroleum — may be of beoctit ; ss a jrencral rule, liow«vcr,an greasy eut»taiic«8 are of rery litlle value in lliie con- nectiun. The laity all liavi.- grcut fiiith in uintmentiN lininientB, nnd vari<>ui* kind* of oil, for tiie cure of jiiiralyKeii liiiiUs con- tracted tendons, etc My bt-liuf ie tlint tlic eliiof, and I may say the sole, bfucfit arising from tbeir employment is dno lo ibe fric- tion and luanipiiliition wbicli iiccuiwiirily uivompaiiy tlicir n»c, and not to any virtue poiiseaeed by tlio greaite employed, nnleaa it be that the liinall <]uuntity of pliu-'p!ioni« eouivtiuies found in tho conibinalion may be a i^tiirce of l>enetit.
VtUftiite or eo$moiine, however, can now l>c obtained which po«i>cwi moiit remarkable Inbricattng properties. These articles are serviceable fruni the fai-t lliat in very Mnnll qtiantiliiw thvy lubricate tlie parts to such an extent that friction may bo kept np for a lorn; time vrithont prudueiog abnuioii.
Stri/fhttia ia a remedy so constantly employed in the treat- nicnl of paralyzed niii>'cle», Ihat a brief reference »houId here be made to its use. It should be administered in d'lecs sufficient only to produce dight twitdiinjis of the niuwlc. The adminis- tration of jig-gTain doses three tiinca a day, and the Bubcntaneons inje«tion of one-fiixticlb of a f^n into tlie muiwle, oikw in eight or ten days, will ordinarily be sufficient to produce the desired re^ulu, and will aUo, as a rule, be of mncli Hcr\'ice. Over-fiitiguc of muscles can b« brouglit about by exciting undue contractions with (his remedy, as well an by the application of electricity, or by excessive manipulation. Such fatigno is to be carefully avoided.
£l«ctricity. — Of the theories respecting the modta operandi of this agent I do not propo>»c to «p«-ak. Ito apparent value as a means for restoring vitality to paralyzed muscles is indisputa- ble. There are a few rules which Hhould regoUte itA apjilication, and it is to thiwti alone that I purpose calling your attention. I regard tbem of tlie utnioat importance, and liiorefore a.sk your can-ful attention to their observance :
I. When applying electricity for the restoration of paralyzed muscles, do not apply it too long. Three or five minnleB every day, or every other day, i« enffleient in a majority of vaecH.
S. Do not ap])ly it too ttrong. A strong current is very like-
APPLICATIOS OP ELECTRICmr.
38
ty to give r'lstt to overfatigue of the mnsdef, wliich will l>e a» poMtively iiijimoDM lu tliAl iiidiicuil bv ui.v otlior mcitiiM, and over-exenioa luuflt tlierefore be rarefully avoided!.
S. Alwnyft rcetoru thu niiuclc a« utotrly a« poMiblc to tin nor- iDa) pririilion, by titcmiii of m>m(> unificiiil Kiipjinri, ami n-tain it tJiin.-, .-i[)proNiiiialmg itD origin and itisiertion bi-foru tlio battery is ap]4ied. The princijtle it*, tbe parnlyxctt muocle eliould be placed biktIi » potiitiuii tlittt, when BtinitiUttid to coutract in rpsponiie to he electric (rnrrcnt, it xran do m tcithoitl mrrifiiiff any vy-ight. I f a {MintlyKvd niUE<cle ie compelled to a«t without this afieietanoe, pennanent daiimge ratlier cbao permanent benelit will be likely to result.
V<m will always reeollect, therefore, to approximate ttie origin Slid iti««rtioii of all pamlyised uineck-s before ap})tyiti^ llie electric current. Mna<ple^ lliat liave entirely loat tlieir excitability upon ap))liciition of tliu electric current, are incapable of contraction. The production of even a few <'niitractioiis will indicate to you tliat treatment per^intenllyaitjilie^l will finally greatly inerexce the power of the nui^-lcH. But if the contnietionH are forwd, as U exrvc<lingly apt to be the ca«e unlew) great care i» cxereined, it will l« found that, perhaps, the next day no contractions can bo obtained. Tlic ^1i^bt power of contraction which »oiiie mitsclea may have is, doubtless, inany tiniee entirely destroyed by the ex- ceiaive use of the electric current, the tnusclee being over-fatigued by thin Elimuliie the same us they would bo by o^-er-worli.
I'or the purpose of delerniiuing whether a niuftcle has nn- dor^nc fatty dogeuoration, it is only neocMary to rontovo a email portion by ineviniments speeially devised for that purpose, ■ad then submit it to nitcroeoopical oxaatiuution. (•SVt- Fig. 1,
t'Hl. t.
TliichesDe's instrument for removing mnscular tissae.) One pre- caution, bowovL-r, u to be taken, iinincly, to csamEne the mtwcle »uii|>eetecl at dilferent points from one end to tbe other. When thiit liaM been done, your i>ri)gn(«ii( cin be established relative to tliB restoration i)f lost muscular power by meaits of the electric current. Thu principlea here referred to are well illnstrated by following cases :
24
hiEFORUI
Case. Jfay 32,1961. — Mury C, Aged e1«Tcn years; father died wren months before her birth, of eofteningof iho brain ; mother vrus hcnltbvt uDil child n>biiiit and httalthy nntil nine months old. She was put to bed uno night in pi'rfcet health, and wiu fonnd in the morninfr paralvKed in both arms and lege. In a few weeks the arms and right leg partially rceovered — the arniM are well ftt the preacnt time. The right leg again became paralysed a year ago.
Then- was («lii>C8 c<]nino-7nroe of the right foot, and valgus of the left. Both limbs were very much atrupiiii-d. but the left much more than the right. The right limb re^onded to the gal> ranic current ; the left Umb gave no reifjKinHe in any of it« mus- clw, and, testing the nni»clc4 by Ducheiine's method, they were foand to be fatty. This test was applied by a single puncture to the gaetrocnemiuft and aim one to t)>e t|nadri<«iHi femoria, and, they proving in both inRtanrce to l>c fatty, I gavu an unfavondjle progiiottis reit[K!Cting that limb, and Mated to the family that treatment of it would bo aselese, as it never could recover.
The tcn<Io-.\chiI1i« of the rii;bt U-f; uml the l>ii<epii and onler hamstring of the same hmb were contracted, but, yielding under elaittic tension and giving no reflex tipum on point-prcwurc, were n<it divided. After continued application of electricity to the |iar.ilyj:(il musolen of this limb, barbing with hot-water and tlie application of elastic tubing to assist the jaralyxed musclee, her general health wa« much improved and the right leg increased in size.
After some weeks of treatment I accidentally applied the bot- tery to the left limb, and was surprised to find muscular contrac- tion. I called the attention of my aitiiiitant to thiii fact, and again applied the battery to show him that the muscle responded, when no response was given. Ue replied lltat he wa.4 certain there was no conlmetion, as he had examined tluil nm^-le under the mlcro- fwopc and found fatty degeneration, and, as we could not make it contract tinder the current, I concluded that he was correct, and that posubly I might have been mistaken in my first oUwrvation. Three dayA afterwanl, in making the same cxporimeut, the mu«- elcA gave an evident response ; and, not wishing to be mistaken a second time, I rc|M-«lod the experiment <juitc a number of timet) and satistieil myself that the muscle responded to the battery, and again callingthe attention of my as«iftant to thi« mnectilar con-
OF ELECTRTCnr.
95
tiaction, itnd applying tlio battery, obtained — no rcealt. Two ^dnys afu-rwani, iiprni making tlio witiic experiment, tlic mii»- bIm C(ititnu4L'<l. wlioii thu auvnlioii oi my aeeistuiit wiis again draw-ii to the fant, and we boiU oljflervcd tJie co)itniclion8 very distinoth-. Tla-ec contractions were repeated nuite a number of tinted during tin' hjucu of a niinnte, and then oeatted nlu^-tlicr, and no forcu tliat vo couM apply with tliu batlurv would oblain way response.
Two days aft«rward tlio uimc ex|K.Tiniont vra» performed, will) pn-elwly the same resitlt, s)ton-ing that the paRilvxe<l niu»- dea um m:ikc but few rcKjMtnsiif to the giilviinic current with- out becoming 6o mueh exhaui<te<l a& to re<iuire repose, and that we hIiuuM, tliereforv, never eoutinuo our application too long id tlicee a\eie6.
Another faet was proved by lliitt oaeo, tliat ultliouglt tlio points of ttie muBcIeH that were examined proved to be fatty, there intut have been t^me other porliuu of the muiic[i.« that bad not ^"et undergone tfaia ehange: and, conciequenlty, liefore we can pnmoiinoe the aim alMuhttcly liopoli'^^ we mu»t exj)Iure the mue- vhe (heir entire length in dilTt<rcnt plaees.
I had alR-ady applied an intttniinont to the other limb, bnt li.vl done nnihing for the left one, having considered it iiM>leH) to do Ku, J now, however, applied an iiiHtninient to tliE« Iv^ nlw, vbieh pennitled all the natural jnovement« (aw Fig. S), tlie power of the left thi-ih beiiip »n|>pliiii inwlly bv (■prinps work- («g over the knee-joint of the iustrrimenl. The right foot is Icvpt in ]KH(ition by an elaxtic 8tmp niniiin;; from toe of dioo to a belt around tlie leg above the calf; two horizontal steel pivew. with jointa at the ankle, extend from the eole of ihe i>hoe to lhi« bolL ifien Fig. 2.)
This girl had been for neven reant under treatment in an ortho{>(.-die iii>-titution, m> enlU'<d, where i^he had worn a long iron itplint on the left linit>, having neither a joint at the ankle nor knre. and nolliing bud been done for the right leg.
Jti/^/ 11, 1S^'>7. — She cin now, by the aid of the instruments, Kland abinu and take one or two «tepH. "With cmtchcfl wn]k» well, pnttiiig one foot Iwforo the other. Sb« has improved greatly, genendly a» well n» Iwally. and reliinit) home to eon- tiuuc treatment. The contmetion of the right leg io greatly im- proved.
96
SBFORMJTIES.
Tbo followiiif; cxtm«U from lett«n show llio progrMs of tlie etae:
>■ Och'btr U, IMT.— Sh« fans galnod eleven pounds la welgbt. Tbe tcfl leg (the wont o&o) neosurM ona Incli laoro In »l(o, both aboro and bdon- tbo koee, and »be in able to move it a little in varinun yrajrg in wliicfa ulic oootd not move it foraierly. The rl^it W U mncli straifhler at the knee."
•' J«ly ao, IMSu— Mflrj-'ii foot U iiiiw iiuiie wdl, and nbc improro* coiuUnt- \y in (ulng It, ud tfac nalka w Uli L-i»iif<>n.
*■ Very reffMCtfulIf, E. C."
Fu. 1:
Hemarit. — The facte olMerred in thix caflo retipeclinfc the action of ilio j;r>Ivnni(! onrmnt on th« nitwii^ of tlio K-ft \fff brought to mv mind nnutlior c-aee iti wliic-h I hxil aliaDdonod the treatiiK'iit two yeare previoni>, on account of no miiwtiiar oon- tractiou Will); pcrvvivod undor th« itiflninicv of tho hiitturr. and had told ttib parental that their child wonld be o)ni{ivlli'd to retort to nieohanio) m«uiH dnrinf; tJie rcet of her life. I fcU jUBtifiod in inuking UiL* 8tatomt'nt at Uic time, m \ could obtain no response of the muscle iii\-t«1f, and as she had already been - nndur the Ireaimont of one uf onr best electricians for many mootha without tiay bunufit.
APPUCATION OF ELECTRICriT.
87
Taking ttieRc facts into cotiAideration, ns before mAA, I >cnt for t]iu uiM>. till) htiitorv uf wliiflt is oi; followi;:
t'ASK. D«€iiifiifr 'Z\y lht>S. — I'auliuc K., a^J Ave, ream ind fiiot) inontliM, pi-rfcctly well until Hflouii muntbs old, M-Iion left fo«jt was liiwijvored to l)c juirnlyzoi. Was treated iit tlial tiinc }>y Dr. IMir Vaii Itiircn. A few iiiutith# Uti-r Dr. Ik-inrclivl diivclod a Hlioe to he applit^d, whicli she liae worn ever since, l^rof. GntMi. iiWut tiirw yftxn ii^, pro|Kt0cd to cut tlie tondoiiif, lint it waii not done. Atxnit two yean utioe, Dr. Unleke applied electricity fur ncjirly nine inunth^ vritliout uty apptirfnt Itcnotlt. 8tie waii llien l>niu);lit to me for Ireiitment, and tiiuling no re- tjMiiM; U} iliti Ixttu-ry when applied to tlie gastriH-nctiiiuM mtutele, «von when nw-dk-s had lieen iusurted iu it, iind mtislied tliat Dr. <iuleke liiiil ffiven her nil the liencfit that electricity afforded, I stated ti. tlie jjarcnts that further treatment would Iw oeeless, Olid »iniply direetvd a shoe to be worn, with «ii nrtilicial gaftlro- ciMiiuiue, ae seen in Fig. 3. This wiib in tliu latter part of 1!J66.
TtB ».
"Wlicn hIio returned to mo in Deconibcr, J868, her foot had inoreased somewhat in lonf;th and »ize, bnt the muscles of her kf; were no better developed than whon I saw her two years
S8
DEFORMtTIES.
before, and ss hero roprcscntod in Fig. 4 (as dmvn hy T)r. Talo), nriiiiij)|>orte<l by tlie elioo.
When f\iw attempts <o walk without t]ic inittnimenti the woi^lit of her body is supported un the i-!ctruini< {>ueterior part of thu OS calcis. The fiiot «x>iild very readily be broiiglit to ite nam-
rw.1.
m! position, in wlilch phwo It was held durinff the nppHwUion llio gulvsiiic curri'iit, wliich wns coiitinuud for hnlf a. minute or a minute. Afwr the action of tlie battery onc-eij^Iitieth of a grain of Etrychiitnt- was injuetion into the gaelrocneiiiiuH, uiid Uiuishou with the elastic force applied ao before.
Tlic biiUery wait applied in thi« n-ny from half il niiimtu to a minute at a time each day, for six wt-eki, before any perceptible eontniclioni* of the luiucK-^ could be ubM;rvi-(l. The injeetione of strychnine were repeated every ei^it or ten days for some tlireo nioritliH.
The improvement for the first six months was very slight in- deed, but »till noticeable, and the time oceiipit^l in the application of the battery was increased to three or five minutes as the inns- cW beramie stronger ; but, even then. It wa* nbscrved that after a few vigorous contractions the miwclcs would refuse to pesi>ond to the Aame power of the battery.
May, ISTO, — Very much improved; l»cginfi to have volun- tary power over the muBcles.
A'oven^ffr, 1870. — Caii make a forciWo» voluntary contraction.
MECnAKIOAL APPUAXCES.
39
Slay, ISTfi. — Cm extotid tlm foot nlniottt to tliu normal posi- jon wtivn HitUng down, but incapable of walking withont nrtiti- eial support.
Tlie muKclcs of tbc c«lf of (be leg bave increnficd very iiincli in sixe, bill esaot measurements wore negk»<!te<i tn \w taken. Siii> Ktill ooiilinuus to uw tbe ehou with vbelic giifctroc-nL-miu«, aa tieen in Fig. 'A.
June, lSTr>. — Patient came to the ofBce walking quite wt-11 wiibont anv arliticial aid, baring c]iiicontinii»] tbc iiac of Ibu cltiitir^ fur H>me months.
Wm 6cen again in 1$78 and the limb bad continued to Im- prove in liize and fttrcngtb, and walkvd witliout uny noticeable limp,
LECTrUE IV.
DKToKMrnKS.
TnMWml (cDMiniwd). — UocliMiickl Api>IUn<c'. — (icnttnl rrlnclpl''* Kovoiiing tbttr LW — BI»Miv Tcniilcm. — Adfavulro Pliwitor. — Of »niiT« TnMnrat. — Tonoloinj. — iljVUnuj. — Tmoloinn. — llnflklii); up vt Itnaj oi Fllironi .Vnolirloflo. — Atuto-
GssTi-Buis! : We will continue tbi' etudy of om- subjwt ibis ninniing, by liml din.-oliiijr '"ir atlentlon u> ibe fmplcij'iiifnt of niw.-bani<!al iippliancw in tbe treatment of drformitice. Sucb ap- pliannofl are of gn-jit wrrice, and, in fact, are very cttsentinl.
MfhaniMt Ap}>liani'<«. — These are ncccRani' for tlio pnr- pot« of retaining defonned purtu in (Mrtuin {Mii^itionn after titey Iiave bcon plaw-d in sneb poeitions l»y manual force; but tl»o more frei|ii<-titly tbe^ i:ii.-ebanieiil U])]>lianeeH wnt removed, and tb« i«irt eubjct'tud to manipulation, tb« greater will be tbe sue- cvN) that will attend yonr treatment of this claas of defomiitieft. While m^inf; any iii<-eli^nicid appmiitutt if nianipnlnlinn be neg- lect«Hl, your i»ti(riit will U? deprived of that t^tiuiulus, motion, wldeli is M> eMuntial for tbc (xirfeut prcm^rvation of llic n«efnl- mw« of the di>fi)nne<l parts.
I'litil %'ery reeenrly (be twc of mecbanical eontrirancefi bus bei^n tbo most valuable meanti of rectifying deformities po6Be«iiKl by the orthopedic ani^con, but, with ^e improvementa we now
DEKORSnriES.
luve at our coiomand, wo aro ctmlileil to do inoro tou-anl tlio n'tttonition of a deformed part id a m\g\o clay than cnuli! for- iiivrly l>o doito in uvulut or luoiiih.*. !ii.-j(li>rntioii in fact ii^ in ttuiiiy inslancefl, only po«&ihle wlica the operation is followed by n ]iroperly-»p]ilioil ap]mnitiie.
Great ingunuily baa Kt-n displnjed in the manufai-tnrc of diffcKiit iimttrmiiontfi, ami many coiiipli(rat<rd ci>utrivAtie«<« liave beea (ie^Tsed for tlit- apjilioation of niechantuil foree. litcoasion- »\\y, deiniinil upuii tliu iiip;iiuity and skill uf tlio mechanic h re<]uired', Imt, ue a gciiurul rule, clat>orat(! and roiiipliealed in- HtnimenU oliould he avoided. Tlie prinripal reqiiUitee of an ortliupcdic appainttw nn\ eitnplicitr, fucilitj of applioation, and ligbtnees ob far an compatiMe with tlie object to be aceompliehed by ilit iiM>. It ^boidil never eiieirclu a limb or trunk iti gucb man- ner as to interfere with tlie circulation, iierve^urrcnta, or natural iiKiveincnU of tbc pnrt. [ wuiild euiitiun you n^iiiHt Hiiob inter- ference. You can all cusily nnduKtand tbat, if the muscles and tho ^'wwU i>up|>lyin<r tbom— the ncrvci*, veins, and arteries — fi!ioit1d bo girdled with elrups or beavy iuBtnimonts, binding them down u[>on tlie bone, the itlTect wiiuld bo to obittnict the supply of blood to the limb, with He attendant dtsastor, gangrene. Tlitw, A badiy-ctintrivod iuHtniment will rather add to tbc gravity of a case than relievo it. For an apparatus to be truly mefal, it aboiilil l>e a.1 wniple in its constniction as cirounistanet.9 will per- mit, and should oumprcaa the limb in Its circumference as little ae po^ible. It should act in its trartile fun^c gradually and uou- Manlly, and, as the iino of dcfunntty iti slowly changing its direc- tion, it becomeH very neeesaary that the ajiparatim be freijiiently removed and reapplied, or adapted to the new line of dii^iortion. Tho persons in ebargo of, and n^ing tho npiwirattis, tibould thor- oughly uiKlei'olatiil tliuir iii.'Uinerof action, be perfectly acquainted with thoir mechanism, and the object to be gained by tht-ir appli* cation. At tlie ontKot tho practitioner ebould adapt tho instru- ment to the deformity, and not the deformity to tho instrument, as is too fre<jiienllyatietnpt*-d. Proceeil in a gentle nnmiier until tho first difficulty is ovcrcoino. Tho pain experienced in tlie part soon weare off aa the mind becomes more tranrjuil, and then you can, day by day, bring to bear upoa It euch forco as will tend to secure the dedred object.
In tlie uso of any apparatus, if you put on tbc ficrairs and
THE ESSENTtALS OP AN APPABATfa
81
^M stmps bj which it is adjasled, and dght«ii or lixiMMi and struoj^thuii m tbciii OM opporhiuity offitm wllliuiit any onier or <It.-(iigii, you urc » linblo to iiicrL-asp llio o-xieting difficulty and lo retard recovery. H Tlierefoiv, yon muHt uiake it your tiiaxim iit tlicM case* to " Diako ^ haetv slowly." Thu pnuciplu wltjc-b sliould coutn>l yotir action ill Uie Iroatnieiil elioutd be, nuvcr lulvitticu loo rapidly, kst it itr- tvet tiiti procvM of corv ; by elondy and appropriate pro^ea your ubjwt if really etrlicr accotiiplicbed, and usually wiiboiit mk.
In tliu clioiw of a mocbaiiical appuratuoyou tiliotild bognidwd not only by iti* adiiptability to the member to which it is to bo applidl, but aleo by your a<x)itaintaiico with it« tnecbaiiifitn and UBu; iitid you i^liould be pijiritive that you underxtand the pnn- riplv* upon u'liit.<b it i« coiii-tructed before you pureLai=c or at- tempt lo use it. Get true prineiplen of Ircatineut into your beadi), and tlieu <le>^igii ^iiie foriit of mechanical a]>i>anitu«, if De«ciifiary, to put them into praoticsil ajiplicalion.
There in anotlier iiuportnnt rule which should intluenee your nuiiui{fement of all pamtytic deformities and also many other caMv, efjHreially thoKi iii which it l^-coutcc necwiary to overcome nitUMnilar contraction, or to retain inuHoleo in a fltnto of rent for a ninnidvrablu leii^h of time; it ih iWn: permit om far aa poa«ibl* thf naturnl motion in ifu^ parln inr^ilred in the ileformiiy.
The joints and mneek-H of the human body were designed by the Creator of all tilings for active motion, atwl as far ae i« prac- ticabto tbo natural tnovemcnt)* of the body ehould be retained, ■timnlatod, and Htreuf^henud. It is for thie reuaou that all treat- ment of jmniljlie di-forniitte« by meaiiR of fixed apparatUH ia to be condemni-d. T)iu total, abeohile rvxX. which miiKt iicci'MUirily oeciir in a inui<ele when Mcure<] in mtme tixp<l apjuiratus, if too lotig continuud, will certainly induce euch structural cluinges u will prechnle all possihility of ever overcoming the deformity by reatoriiig to llie iiiuiH.'le it» noniial power.
£fatttiti Ten/don. — As ha« already been stated, Hubentancoiis tonotoim* wa* flrM applied to the relief of defonniiy in the year 1831 hyStromeyer. That operation marked a new cm in oilbo- pcdic siiriRery, and for inany years the oiwmtion of tenotomy wn» ox<'lutiiveIy relied upon for affording relief of tile oontractcd ten4lon».
Vet, in the progreM of time, we have learned still more ; aiid in my own exporionco I Imro been enabled to tent the correctneea
DEFORMrrrea.
of tlio now e8UWislii?<l principle of extendinga contraoUd musetOf} bv the constant appltvutioii uf an ulaitlic force, motleniU'ly hat ' pi'rsii^tiititly a])plied. Tliia will, in the intijority of intitanccA, a<.-ooniplidi the object fully as cfficiiruUy n« t«ii«toiny, vhvrv the luuMcIu ha« not already undergoDc structaral changes, or, in other words, beootne cunlrachiretl ; and it i* intinit«ly better for tliu future UMfiilne^v of tlie limb involved, although eoroetiuioe much more tedious in producing the result.
I h*ve made n»e of elii»tic extension, by means of India-nib- ber, ever aince my pupilage, having btvu taught itm value by my prevoptor, tlie late Dr. David (ircien. The ditHcuIly in its appU- cittion, in many inHtauc«.'», without exiKsnsive and ctimbcnome mat'hinery to wcnre its attaoliiiicnt, in order to obtain its force, wae the only obstacle to \U uiuvcnt:d cm j >I uy men t.
This difficulty baa been happily overcome witliin a few years by ibc simple yvt bcnntifnl contrivanco fiivt miggtwlitl by Mr. Barwell, of London, whereby we can secure the atucliments, for the origin and insertion of the ela»tic power to a)iy part of the body, by the use of suiall stripe of tin made permanent at the plitco du^ir^d, by mttanii of adhc«iv« planter and a rolU-r. In tiiis way we can imitate the action of aUnoet all the un&clee of the bijiiy. We get rid of the weight of cmiibcmouie macliinery, which is so M-riuuii an iueonrcnieiioe iu all paralytic deformities, and tJie pereistent action of tlie elastic during tlie lionn of filcup — which is ^'uturc's ana-«thesia — renders it an agent of most ivonderfid power, cajtable of overcoming an immense nnm- bur of ttcriouK deformil)c«.
Tbifl snggofilion of Itarweirs will make almo«t u grciat an ad- vance iu ortlio[>edic pnu'licv an did the suggestion of Stromeyerj of subcutaneous tenotomy. The rules for itf application, andj the diagnoi'lic ditTerence^ of the caK-» where it is applicable from tliaw where the knife iKcomes a necefttdty, I idiall lay down more fully in my future lectures.
AdJi^airv J'latiiv. — In all casea where it i^i desirable to main- tain long-continut-d tnu-tion by in«aiu of adhctiivo planter, the most ruttable article that I have used is that mannfactnred hy ilr. Maw. Xo. 1 1 Aldemgnte Htrcet, Loudon, and known by the name of *' Maw*s Moleskin Plaster." Planter spread a pon Can- ton flannel may be u»ed, but it i» not nearly as good u the « MoleskJu Plartor."
ELASTIC TENSIOJT.
88
I rocdvc coinpUiintA Almwt Onil}* from il<K.ora in tlio coantiy llmt lIiL<y raiiiiut niiifcc the jilafitor slay on more tluin s day or Wo. Ill llie tinsi plaoe, tlicy put it on too liot ; tlio ln^al 4luHlruy« the ritulity of the opMcrmis, aiid it peals oS tlit> aimiu lu from a |ilUt4>re<l ^urfa<!e. ami, of conr»e, carri&i with it the jioiiit of nt- tm:)iiiiL'iit. In tLv tioxt placo, they do uot tliorou^hly knead the strips of pliiiitor and mould ttieni unifornily to the limit beforu Mit>jfciing tliL-tn to the etruin of tnictioi). If a ruiiiililv iirtick- in UBOd, and those precaations taken, there need be no tronhle with raganl to making tlio pla«t«r adlivro flrmly to tJiofiurfaoo. Attan additional precaution, however, it is important that the surface ti) v,-|ii(>h llie phu>tor i" to )w applied fhotild Ik- cIl^ii mid dry. Thtfre is another exoradingly important point relating to its ra- applimtion, m in a Mwond dressing : whvn the pla^t«r has bccti on A limb fur a long time, and then removed, there will lie found more or leM dead emrf-flkin on the Knrfaco; tht« miiat be com- jtletoly removed befom making unother application of plaster; we mnit have a cleAii, aolid Mtrfiice in or^ler to get a tirui foot- hold, to to E[>eak. If the pliutcr is applioil over the dead skin which is found remaining on the Mirface, it would lie like freeoo- ingaJi old wall without cleaning it; your labor would be in vain, and your money lost; «> horo, if you ajijily the planter bef<irc ihc dead epidennis is rvmoved, you will nm the risk that it will blister the surface in boine plitet-s, while it fiiils to adhere in others; and the whole object of the drciu<ing will Ih> defeated in cutuoqueiiM of nvghx'tSng to btke this MX'Uiingly trivial pr<v rautJon.
Tlio iiurfa<'e of the limb ran be very en«ily ek-aiwed by lir»t applying u small quantity of sweet-oil, and afterward removing tbi» will) sonp and warm water. If the aurfaco Iweonief broken in removing the old plasty, the new should not hu applied until all abraisionis or tiseiurca are thoroughly healed. In some casea it may Iw tiLX't-ssary to placo the )i»tient in btid for a few day#, or reeort to some modifipation of the apparatuii which is employed, in onler Id wcun? a hwdthy, cli-an Kurface, to wliieh the planter can bi> reapplied.
Thin matter of wleeting a propirr kind of plaetvr, together
with direeliiins regarding its application, and the precautions to
l>e taken, may appear to yon like insignitlMnl ilein#; but tliej
are really vory imjiortant. For, nuless you have a reliable adhe-
»
84
DEFORSimES.
Bive plaster (Uie ordinary: kiiiils in common ose helag woKhlflMl for this piir[>0M>), nil your effort^ at lon^oontinued tmntion wilt prove eutirely uscU'^fS i>ti() your pUii of tivatmcnt will utterly fail. Tike value of tlii» agent, and the necewity of tiding a reli- able article, will be doiriouetrateJ repeatedly during the cunne.
Operative Trvatmfnt. — Under the headof ojicrative treatment, we have tenotomy, niyoComy, and breaking u]) of bony and fibrous fomiationft.
By tliv tenti Unotomff we mean Hection of a tendon. The instrament oommonly employed for thifi purpose i» ealled a teno- tome. Myotomy mean« Hection of a mu«clo.
Mlien it is necetwary to divide faseia or iibrona Itandft, they are tu bo cut in aeeordance with the general rule* wliich j^vem the division of niiiMtlef) or tendonn, Tlie history of tenotomy and myotomy luu already Inxmi referred to in our introductory lecture.
For the purpose i>f performing these operations, yon will r^ quire knives or tenotomes having a peculiar conetruetion. The liandle of the inatniment hIiou141 he so constructed that you may always know in which direction the edge of the blade is turned : Uii» may be indicated by a t>pot upon the handle. If this pre- caution is not taken, when the blade in buried deep beneath the tiivuos, you will be ignorant of tlie exact direction of the cutting edge, a thing always to be tmme in mind. The ahank should be strong, and flrndy iuiterted into the liandle. Its length shonld be {ntm one incli to one and three^uartere inch, with a blade tliree-<]uarter3 of an inch to an iuch in length, according to the size of the tendon to be divided. The blade alioutd he made very thick at the '' heel," very nnrrow in the cutting portion, and aiways
no. B.
ronndcd at the end, and aharpeticd from eide to aide like a wedge or chisel, so tliat when inlmduc«d it splits rather than punctures the tiMue tlirough which it pasw«. (Sm Fig. 5.) The instru- ment should he made of the fincAt-tempered ateel, otherwise bo email a blade as thia, in catting tlirougli a permanently oontnet-
TENOTOMY.
8tr
nred tendon or fascia, or any portion of tiswie thJit has undergone Mrnctnral cliiiiigi.-, in vi-ry liutilv to I>c brokun. Tlittto bliules are made of Tarioiis shapes; rorio fttr.iight, and Dmue ctirvit), with tlio ctitting cdj^ either on thevouvox orconEUvo border. Tbo iirj>-pointt'<l tenotoinps umially found in the shojjs ttlnnild never
aubfl, ^ thvy urv liitblu ^^^ puncture ttt^tiM whieli nhould Iw □ntiwlestc-d : and Uieir ufne in tlio neigliborliood of importnnt Tt«iicU and nervee in very liaxiirdonK.
The ui-xt important i|ne»ti<)n is, IIow are we to determine whether, in any given ease, wo shall be coni]>o11ed to rewrt to leiiotouiy ?
The law, whicli in of uiitvcrani ap])licntion in deciding tliiit qnottion, is tlio following : Pjaev (liu part contracted as nearly as poMible in itA normal p(«ition, by lueaiiR of nianiiiil tension grnd- nally nppliv<1, and tLen (.-arffully rotuin it in that position ; while tlie parts are thuH placed n]>on the stretch, make additional |>oint- prctuure with tlio end of the finger or thumb ujK>n the parts thus rendered ten»c, and, if diich additional preiumre producva niffex contractittiui, that tendon, faecia, ur mufiete. muet be divided, and the jMrint at which the reflex Hpnsin is excited h the {mint where the o|)erilion ehonld be performed.
If, on the contrary, while tlie parts are brought into their nor-' mal position by mcani! of manual tvnifiun gntdually applied, the additional point-presBwre does not produce reflex contractions, the dcfonnity can Iw ponnanentlyovereonic by mennji of conatant ela»> tic tension, and the more yon cut the greater will t>o the amount of damage done. Thi« is an imporiant law, which you will do well to remember ; for its appli<»ition, as already reinarked, is universal in deciding the ()tie»tion of cutting contracted tiH«ue». Even when tJie parte can be completely restored to their normal poaition, by means of ni:uiunl force gmdually applied, if tins ad- ditional point- preeenre produces pain or spasm, the oontractured titwne niiut be cut before a complete cnre can be effected.
The next ()nestion tliat arises is, How in tlio operation to be pvrfonued t
1. By your own hand, or by that of an oatistant, put the jwirta to be cut fully upon the stn-toh.
S. Make the cut &ntM:utaneoUEly, and thrust the tenotome through the integument at stidi an angle as will tnake a valvular inciaioti. {See Fig. 6.)
AG
DEFORM rriEs,
3. Introduce th« tenotome flittn-iM; («iyt Vtg. 6). Carry the end of the knifv through the ttsoties elowlv until the tviidon m retivhed ; tlicn carry the btado flatwise bcneatli the tendon to lU
rn.«.
opposite side, and tnm itii cutting edge toward the tendon (\\ere yoo tee the lin|>urtauco of having the baudli: of the tenotoino marked in Bitcli a war aa will indimte the diredion in which t!ieeiiMiii|; edgo is turned), and Ihi-ii prvvi the tendon down nyton th« fd^ of thu blade, at the saue time giving the inHtrament a alightlj sawing motion until the tendon ^w» way, which can be recognized by the finger, and nni iufre^nontly by an audible «nap. It is vjicocdingty important that your ecetion uf the ten- don ehonid lie cotnpl^f, otlierwiAe the deformity will remain un- less you forcibly rupture tliat portion which you have failis) to cut. The inxtant the tendon is severed, the imtrument ih turned tlntwi«v and withdrawn. Aa it ie withdniwn, elide your linger or thumb over tlte wound, thnci forcing out any blood that is in lite track uf (he knife, and preventing the entrance of air. The wound iihoidd then imme<liately be bermetinlly sealed with ad- hesive plajttur, being careful under no eireumetanee to carry tlie plaster completely around tlte limb, and the plaster he semred in it* position by a rolk-r-bandage. Thu application of Ihive princi- ples will be fully illiietrated when we come to the treatment of spodal eases.
Ttie next important question is, Shall the parta after soetioa of tlte eontniclured liMues be mtured ait nearly an poMible to tbcir oonnal position at once ; or shall a delay be made uf a few
AN, ESTHETICS.
87
hours, or « few days, until tlie external wound lias pertnsnvntl_T fUwud. nnd tin' iiiflimiiijiiturv action whioli ni\v follow tlie opera- tion lisb iiul>«idi-d t For niunv jeara my usiclung was to geciire tlie limb in itii deformed {mtiition until tlie extcnial wound tiad eliwHxl, and llie iiitlummaCurv action had suleided. and then make gradual exicnMon. Tliia is the pl»n Mill gfngraily atloptt-d. Bat Ht jirosvnt I t«acli that tbu deformed part» ehoiild bv restored AT oKrK Oi: nearly lU possible to tlioir normal pnAitton ; and for Uiut rt-iu'oii. that thv i-xudud iiiatvna!, heini; hirgi-r in amount, will when oi^nized make a stronger and more useful bond of union for future ii«e, than U'licn atnitchod ont into a fine cord, as in the former nielliod of previoiii* writCTA. At tin? same time thJH pliui ii entirely devoid of any puin, th<> parts hi-ing brought into ti>etr normal position while the j>ationt in still under the ame»- thi-tie, and thru ki-pl in a <juiet jio^iltun for ten or twelve dayii; the exuded material becomee organised, leaving the tendon at tlie tneroatied length at whieh it wu» phiced at the time of llie o[M-m- tion — wbereaa the former plan ia attended witli an intense de- grcie of suffering, requiring the daily attendance of the gnrgeon in iM^ler to secure the graduitl extension of ihe part, and fre- quently, owing to tlie intenm; sulTering cniucd by tbiit process of oxtension, the treatment ia iMmpelled to be alianduned. In tlic huudnxla of «a*>e:« iti whicli I have applied my principle, I have never euvn the firet caae of eupptiration at llio point of opcni- tioD. This i:i the gi'nenl nilo which I fet-l willing to lay down a« tlio ono which eliould govern you in tlic majority of caecti, but to this rule lliero arc notable exceptions. In all deforinitieB de- pendent up<)n ahuomial muecolar action alone, whetlier iKinilyfi*' or sptialic, restore the part^ as nearly w poi«ible to their normal potulion immtdiaUltf after section of the coutracturcd tiMuw has been made. In all <-ii.'*es however, of ac(|nired deformity wbit-h dt'iviidi^ upon pR-vtou)^ di««iwc of a joint, terminating in tibroun anchylosis, and in which section of the contractnred partii Im*- eoiiii'K necwfan,', (lie diviiiton should be iimde, and the external wound I>e periiiilt<-d to heal iicfore resorting to force for the purpose of brtnkiiig up the anchylosis. If motion and force are applicil in this ela^s of oa.veA immrftiatfty tSier Miniiow liaH been uiaib', air may enter the wound, iidhiiiimation follow, and euppn- ntion be established.
The breaking up of bony or flbroua anchyloets, aocb as U
88
DEFORMITIES.
liiible to occur In connection urith jotnt-diseaae, may be aocom- plisbed by muKiilur ur HtwhiitiicKl force In inaiiy paw^ the bruuking-iip proocAfl and the catling operation are both neoi<«»ary before tbe dietortion cun bo eorrcctud. Tbe epecial treatment tu be adopted in tliin claf» of caees will be mentiont-d wlien wu come to the coiutdvrntion of complete and ini:oinplete uncliy- losts.
An<jf*(hei4C$.~'6hiil we ti*e aniHthotieB la orthopedic opcnt- tiona I
A majority of o]>cnitionH for the relief of dcforiiiitics of tlio foot I prefer to perforin without rciioi'ting to their usv. The pain connected witli the operation i« very tJight, hence the ad- miitifitration of an aua;«thetic in not nocx'iwiiry tt« an act of homaii- ity. The child cries throngh fear of the knife principnily ; and there are Kutne ■n^tunccH in which the nervous i>y«tL-iu of the patient ia such, that great fright may bring on conrnlsona. Of L-onree under eueh cirouniAtancva the administration of an auffiH- thetic i» proper. The contractnred tendons tdionid he brought into as hold rehef as poeGiblc, and the irritation produced hy the crying of the child will c»n»e an additional contraction, that will bri'ig them mure distinctly into view. In all the more iskwto operationii, ansetbetics should alwavH be used.
When the administration of euch i6 ueoo»taiy. my preference is for chloroform, in the nso of which I ditfer fn>m all authori- ties, who insist that the chlorofonn shonid be largely diluted with air ; my nile is to exclude all air except siieh at) is impreg- nated with chluroforni ; from live to twenty drop* of chloroform administered in this way, according to the age of the patient, aa~ oouiplirhoi) the object de«ired nio«t cflieicntly and promptly, with- ont causing any violent stmgglea on the part of the patient, which often follows the admiTii>lration of air with the aiiiettthel ic ; oxy- gon being the naturul antidote tothcaiiffisthctic,iti« impoetiibto to prodnee anfe«theflia aii lung a» the antidote is in excels of the antes* ihetif. Th<; reason why thu adminiatnttion of chloroform has been attended with danger is because the dose hiw not been carefully measured, but is poured upon a handkerchief; the quantity not l>eing limited, the patient is allowed to inhale this in Home caees large qnautity ; wherea)*, hy exact moaanrement, you can ineuru the amount administered in all oases.
If by any pottijbte contingency this amall tiuantity should pro-
HARE-UP.
89
dnco darififcrous or unplensant symptoms, i few artificial ro&pira- tions effected by comprceeing the vlieet will exhale the Miiall <jniuitity of iK>i#on, and tliiiB avoid any fitlal rotult; wliurcas, if clilurufitru U given in the iisaal wav, anieetheeta is not prodiioed until a Urp.^ i|tiftiitit,v lias heea inhalod, in aonio msob many onnoee ; and if, under these cJrciinistaaces, fajlare of the heart or reHpiratory organs takes place, tlie MV8teni la 90 Batantvd witJi cldiirofurm tliat resuscitation by artifidal means is almost im- [)Otit«ili]e.
Tltns, gentlemen, I have given you a general oatUne of onr tubject. I have endeavored to lay before you the r(!u«r>ni> why you ebould inake it a special stady ; I have directed your atten- tion to tlie different varieties of deformities you will meet witb, and have mentioned tiie general principle* which are in govern yoa in their treatment. And I have also, in a general way.di- rvctvd yutir attention to lliu operative treiitnieiit, and (be me- cliaiiical appliimeee, etc., which are to lie used sulxHNjnent to the o[K>nilii>n. i{v;>ct!tion8 of what hoo already been Miid will con- stantly be made througliout the entire couree, and for bo doing I have no apology to make, but ua the contrary ithall hope thert'by to indelibly impress the principles which I teach upon your mintlii. TiVc are now ready to coiumenre tlie »tiidy of #i>ectal de- furiuitJi's, and at niv next lecture we will begin the study of Aaiv- lip.
LECTURE V.
HALFOBllATIOXe.
IlMcJIp.— Cleft hlue.— BIfld tJtuId.— SploA IBfldtL— Ftonurod Acol&biilum.— n.TjM)- ppadfau.— EpbjwdiUL— KxtKiplif of Bladder. — Fiulon o( Ftagcn, Toe, etc— SiipcraDiiwntx Plnecr* aad Tom. — OocIiuIod oI Anus.
GEKTLiaicx : To-day we oomnienoe the study of congenital dcfonnitiea, and the tlret to which I mil your attention i» hiire- Up. This malformation of the npper lip is the result of an ar- Teat of development, and ia very rarely central, but usually upon DDo or both oidoe, as the upper lip is formed from three [Kunts,
MALF0B1CATI0N8.
and, whenever the nnioD of tlit«v eeveral portiom i» not eom- plcUKl, a figure ruinsins.
There are two principal varieties of hare-lip, oiiijtle or double, according om it i» foiiiiil In vnisl upon oiio or botli eidcit. Siii};lt!. Diioomplieated Itare-lip may exteiul completely or i)artially up into llic iioetril, or it may be complicated with tituurv of tlw alveolae or wiih tif«iire of both the alveohio and the palate- boi)<w. Double iiure-lip is generally aamciatod with tUooro of bone.
My pmcticc in the treatment of ibtB deformity is to openiti' itniDediatBly after birth, althougli at the time in which I tirst
rm. I.
ftdrocBtod an early oi>cration — 18r>T — it was most strenuously Of^WBcd by some of oar moet eminent phy&inianii ; I have, boweror, suoccedcd in wearing exoi-lk-nl n»ult« by my plan of treatment, and t.;y sncceas jnstifiefi me in sustaining my viena regarding tlw wtmc. In maintaining the«« views 1 can do no bettor than to briefly mention the facts ooneeming my first operation.
On August 1, 1^57, lire, 0.. of Twenty-fir6t Street, was con- fined ivilh her timt child. I arrival a fww minutes after llie birth of the child, which I found lying in tJie bed upon its face, appar- ently dead, nttpintlion not having taken place ; upon turning the child over, a hideous malformation of the fiice presented itself. {Seti Fig. 7.) I immediately divided the eord, and, wmpping the diild in a blanket, banded it to the nnrso, and tbvu proceeded to
ABSESOE OF PARTS.
41
deiif er tlie pUoenta and l»u<]ajce the inutlicr. Respiration having now l>ccii fully cnlublwliod in tlni diilil, 1 at oiiou turned tuf at- tention to tlie advisability of \ieTtnrming an ojtenition for tlio reuioviil (if double- Iiat\--li|>, tliU being the niituru of tlio malfoi^ niutiou ; 1 tben oxpbinod to tite fatlier my plan of operation, and tito ncctMiily fur varly ircaUnvnt, to wbicli lie at oncv aoLx-dcd. I at one© proreetJed to Prof. Dwlaficld, wlio referred ine to Prof. Mu-kov; bntliuf llii^-gfiitli-muii, liouvwr. duclinvdtoafeunicanjr raeponeibility for an operotion upon bo young a child ; 1 then ap- plied to ])rti. .Io9;<-p!i M. Stiiitli ind Ai-Mla, almi Prof. Willanl Pvker; tbuio ^titk-mcn declining on tbe like groniid, I tben ap- plied to Prof. Van Unren, with whom and Dr. J. S. Thebau I nl OUci' returned to thv hous(\
llie operaiion wah tlien jierfornied. T)r. T. hoMing th« child's hwd in his Inp and ciumpr»>«tiig the Ubial artcrii.'*!, wv at oiicv dia^eeletl np the integument from (he iiithniiiH, and removed tliia portion, with the two rudiinentiiry inoiitoiv and ri-luttve portion of tbe alveolar procean ; then carefully paring and delaehing the lip Hp on cither ("idf, the |»art>» went lm.iij;ht together so as to fnnn bat one cicatrix in tbu median line; (bu tugunieutaiy septaiu,
VM. &
which liad been dissOL-tcd up from the iethnme, was now bron^ht down and inserted in a V-(iha]>e at the npper portion of the lip; tbruD neudlus wont then pawtcd throtigh from tidv to Kide, and
13
IMATION&
eccnrod by tlio fij^re-of-S ligature ; tlie cheelis of tlie ehiM were tlien drawn well forward, aod slriiie of adbceivo plustvr pnH-ed over the lip to llio iiular hoiieti on either nido, leaving the ne«dlee and ligaturt-e c\po««d. A vumpre^ wu plAOi^ ou vtther «ide of tli« superior maxilla, in order to bring tlicee Iwties id ftp- poeilion, and cloeo the cleft of (lie {laUtc. Tho noodles were withdrawn forty-eight lionrs after the operation, the wound heal> ing by tiret intention ; lliu oomprciaion upon the side of the fsce wan kept up for nonie monllkt. At tlie time of the operation the tiiwurp in the poJate wufl wide aiongh to admit the finger; the Htrncturcs l>oing compressible, allowed the opposing onrfacee to bu druwn gniduuUjr toward each other, imd thi«, with tlie oontraciion of the cicatrix, bad at the Umc of puberty brought tbvM surfaces eo eIo«e in apposition tliat fnriher trcatineni wag noedleea («« Fig. S). The bifid uvula yet remains ; Iiia speech, however, i* ahm^mt perfect.
In this ca§e the operation was performed fonr hours after the birth of the chihl, but slight hieinorrhagc rcculting from the effects of tho same.
])eliiuu performed thiit same operation two hours after birth. Prof. Gross, in his latest edition of his " System of Surgery " (l^i^S), al«o advocates an early operation for the removal of this deformity.
Clkft Palatr. — This deformity may or may not occur with that of the previous one, the figure extending in some cases from the itoft palate to the alveolar process of the Hupvrior max- illa ; the dillictilty of articaUtion being proportionate to the size of the deft,
This defonntty, however, cannot be operated npon in early life, as En tho case of hare-lip, the coopention of the patient being needed for the sooceee of tho operation, and again the difficulty of acccMt to the deop^Mtod parts of a small child is an in»iir- mountable obstacle ; this operation must therefore be deferred until the child ha^ matured. In many in«.tam-es the arti6cial jialate maile of hard rubber by Dr. Norman W. Kingsley, den- tist, of tliis city, is snch a snccewful substitute for the abscnco of the parts that an operation is nnnewssary.
I will, however, illnHtrale the method of operation by briefly staring ■ cue which e«me under my treatment.
In April, ISSO, D. J.,of Milford, Pa.,aged sixteen years, came
ABSENCE or PARTS.
48
to lire anffering from fiimire of the tM>lnt« ; hie ipeech being nlnioet iinittti-Ilif^iblo, h« wiw vcrj dt-i^irouii for au oj'i-nition. Upon I'x- atniniiig him, I concluded to opente aa eoon as ibe part^ could IxKotne Mwiutomcd to ihv touch, diroctiog Itim to inanipuluta the fiasaru dailv with a piece of ivory. In due time ho affnJn presented hintM'lf at my uflioe, the pnrts hnving lioc-onie almost insensible to tlie loucli, and I then dedded to perform the opera- tion at once. The tiMuro extended from the stv(M)1a througli to ihit M>ft paUte, preaenting also a hifid uvula. Tiy holding the divisions of the urtila viiJi the tenaeulfi, they could be etretxihed aerOBs the cha^m and made to meet without producing aiiv reflex spaani. I then prejmred two m>le of lead c1hiii|ih nfler the plan of Dr. Sime'ti for vBgioal liotuht ; one Eot being three-fonrtliei of an inch and the other flet half an inch in length : a knife curved upon the Hat i-nrface was then nu-d to divide the euft parte, cutting from atmve downward on either aide without removing m\y of tlic tissue, ihtM leaving two flaps attached to the infon'or border of the palate ; the divinionH of the u^nila were then pared. The clampD hcin^ drilled to admit of throe silver wires, the nnres being f>ecure<l on one Hide of the elamp by a split shot closed upon tliem. the snturee wcrv then paswd through both divisjotu of tile u^'ula. and held in a tiimilar manner by llie oppoviite clamp. Tlio larger of the clAnip« being nisu prcpan-d in preeisuly the nine way, the sutures were pnei^ed through the dependent Haps fmm t)H> palate; lhv»c being drawn carefully ti>gethcr over llie cl«ft, the saturee were fastened aa before by the means of the ii[Jit shot closed upon them.
Previous to the operation the patient had been cautioned not to attempt to bwsUow. ii« the prc«ure of the tongue upon the roof of tlte roontli dnring this act would in all probability tear tlie w)fl jmrt* and thu* expose the cavity.
Alimentation was supplied per rectntn ; four days after the operntion the sutuni* were romovod, anion being found to bo complete, with the exception of a small hole at the posterior por- tion of the cicatrix; this was, howi'rcr, closed by the applii-nlion of creosote as ad^need 1>y Dr. Stone, who, together with Dr. J. Marion Sims, had awiiiitted nt the oppnition.
The snceos in thia case was very remarkable, and i« in fact the only ca«c of thi# kind in which I ttave bad such perfect re- auIlH. I saw tliis patient three years ago, at whiel) time Uis artic-
ItALPORUATIOKS.
iil»tioD wM reiiiarkubly good, he being quite a oddirated Meth- od i»t exltorter.
Tiivrv src, liowvvcr, n nunilicr of diffcreDt tiioiU-s of opcrft- tion, among wliich I might mention those of Warren, Stevens, (iihson, 8iiii:)i, Whitehead, I'anixHU't, antl others; but in my opinion tho obtur<Uor, as ap|>li<.-d by Ui". Kingsley, ia far more «fl<x'tivc an<l wtiitfaftory than any furgical ojwration yet devised for the relief of tbio nialfurniation.
Tliere \i no danger whatever in the apphention of thfi obtu- rator, wbcn-aH by an operatiuii the trt^itmi^nt ih fxwsHivcly pain- ful, ti^lioiii^ and irritating to the patient, while the rcvultd can not bo awuiwd.
Spina ntFin-v. — The next diseaw to which I would draw your att«Dliou is mpinn b^dOy or hyiirorachiti", which is a congcmtat defect of the vertebral column, accompanied by a protrusion of tlie Kurrunnding mcitibrance of ihu ounl, due to an »rrr«t of ota- fioiitiou of the verti^briR of the ftetiLt at tbU point. This le«ian ig similar in nalurv to liarv-lip and cleft [n}aU% and w ui^iiiilly tutn- ated in the lumbar or dorsal region, but may occur in any part of the spinal cohimn. The liquid in hvdniru<^'bitis le Kimply a portion of the cerehro-^ipinal fluid which normally exiiX» in tJie eubariK-btioid space in the brain anil spinal cord.
The treatment of tbiti Air-Mia^ \» very untialiiifactory. Com* preaeiou, aspiration, and eiibcutauoous puncture with a trocar, and injection of the iodoglvcerine Holution, have tieen pmcli^ with more or h^s succcs*. In the esse of a tumor with a small pL>diclc. I have ligated the base of tbo Rac with fucoeiM. Thitt latter method may well be illu»tmtcd by the case of 8. F.. Avenue 1), aged two yeartt, wJm waa brought to me on June 1, 1844, with a fluctuating )R*n<luluus tumor about the size of a hen's egg attached by a small jiedicle ami situated over tlie sixth cervical vertebra. The mother stated that the tumor wax of its prevent «iec when the child was bom, but that the base was then about as large aa the tnnior, and had since then contracted. Tlicre were several small blue a|H>tii the si;:e of a di.vpenco on its surface, where the integu- uient appiwrvd thin, and there was danger of it« biirvting. There waa no pain or tendeme^ on handling. The child was well de- veloped and pcrfi^x-lly healthy, hod always been so, had never had (its or eonvolHions; sensation and motion were perfect, and no defect in itio bonv arobes oould be detected. From thti«e circum-
ABSESCE OF PARTS.
m
RlancP!) T advised tlie renioral of t)ie tumor, niid. Dr. Pnrkcr con- piirriiifi in tli« opiiiiuii, I procwudod lo wllix-t it M tJiu College of Phv&iciana and Snr^o?!*, on the 6th of Jmie, asflime^l Uy 1>«. Parker and Wiitt«, by puMinf; a iiuudle Hrmed with a duiiblu lign- tnru tbn>u^b thw centre nf the peiHcle, and after tying mie lij^ tufu on vnf-U nide, [mwwimI two lurele^ entirely aruiiiid llie {HMliele, dniwiiig tlietn so tight as to Btrangulate the mast entirely, and tlien exoisiMl it with one sti-oke of the knife. The wound was then eoverwl with adhesive phi^ttT, and the Itgiiturox left to elougb away. About a teaAjxiinifiil of blood v,-»» hut. The ehiid cried Buverely during the operation, although previously it had given no evidence of pain, even tinder nevere iHeaonre of the liiinor.
rpon examining; the tumor it wa.i fonnd to condiflt of a firm cytttof oonden«ed L-ollular tiMue. and tilled with about two ounces of pale fluid. To onr 8urpriM» it contained two large nen'cis one of tltetii H» hirgf i/i the nicdian of an adult, which came from the spine, and terminated by numerous branches in the eireuntfer* ence of the tumor, giving \is internal appearance a nscmbUnce to the cells of a honey-comb.
Not expecting to find lhe«c nerves, »« there watt no »cn«ihility to the tnmor, I was rather alarmed, and anticipated HwnouB eon- )HM)tionn.y>, and watched the eniv very closely. No unpleiuiant oocarrenoee, however, took place. Tho ciiild ate, drank, and slept well : in fact ilJd nul, afier the lintt few hiiurs, iiePDi to he in the loast alluded by the operation, and on the twenty-third day the Itgattim eamc away, leaving the wound entirely heeled, and the war r\-Bendding that from vaceiiiation. The lant time tliat I Bnw the [Mlicnt was in January, ISSii, when she came to Itelleviio IliMpitnl, bringing with her one of tier children to he treated for frw-ture of the nuliu^ She was at that time n strong, robust woman.
The tnmor is now in t)io musoum of tlio College of Ph^-«iciane and Surgeotu.
In eomo cabcb of spina bilida nature efTucts a more or le«« pet^ feet cure by closing in tlie defective portion of the spinal canal, as in the following case :
Mre. H., 41* Anthony Street, waa delivered in December. 1*45, of a male child, with npinn bifida of the four lower cervical and tbtt first dorsal vertebne. There was a large, transparent tumor,
HAIJt>RUATI0N9.
th« Hixe of a man's iiflt, with the integnmcnt distendod alniotit to bureliii;;, Hnd tbv »|iiiiiil cohiitiii t^cjiHratud nvarly two iiivhtw. Deeming Uie case hopeletui, notltiiig was dooe except directing thv mother to hv careful not to let the oiiiid lie uj>on its tiaek, nor allow any preseare upon it.. XotwithHtanding the tinfavor- aljte pnitfpuct, the child continuud to grow and improve nipidly, aud at the end of a Tear the twnj' archcH had been completely tlirown acroes thv tumor, and the spinoiu pruci.4«e» coidd bo dis- tinctly traced, the tumor shriveled down like a scrotum, and pre- sented a Very i>imilur apiK^imiiev to the csmo ju«t rolnted above. I proposed in a few montlis operating upon it in the Nimo way at) in the former case, but unfortunately the child had »cvero enteritis and died in February, 1847. I removed the whole cer- vical and dorsal portion of tJie i^pine with the nvrvo», and found at the BoV^nth cervical vertebra a small hole, through which |Mift<(!d three or fonr trntall ner^'tw, which terminalet) in the tumor ontHide, and were jireoiKvly «imihir to thu one 1 n.-moved from Mrs. F.'s chUd.
This Hpooinit'ii 'u ttlio in tl>e museum of the College of Phyai- i^ans and Surgeons.
In cues where tliere is a large separatioD iu the spinal column, in order to protei't the tumor from pressure, an<l also to prevent it from being ruptun>d, it in well to guard it by a shiulc! of plaster of I'ans, which is easily applied over a tightly-titting woolen «J)irt; the shield can be renewed from time to time us occasion rc<|uires.
The child should !>o fed upon the most nutrition* diet, with the admiuistratton of the phospliates, lime, etc^ for the purpose of increasing the earthy depoiiitd of the o«eeous stnicturu ; and thus in time the tisiiure may be closed.
Fl^CRKD AcCTABrl.ru, OR OoXriK,\nAI, Ikf ALfOHM-lTtoN OK THE
Pklvib. — This ariacs from an armtt of development of the ilinm, tschinm, and pobes, at tliat point at wliicli tlicy form the acetabu- lum. This malformation will, however, he elaborated in my leo- tun:« n|ton those diMwes aimulatiug disease of the hip-joint, this deformity having been frecjnently mintakcn for that disease.
Under the further consideration of malformations from the abaence of parts, I might mention those of the genital organs, theao being at lime« partially or entirely wanting: under this we have hypoajtadiaa, this being a malformation in which the
rUSION OF PARTS.
47
otnul of ttif> tiretlin, iti»tivi(] of opctilng nt the apox of thi> gliiDi;, teraiituitus ut ite Ikuc, or beneath the |ieniB, at a variablu tlistance ima the glaiu penii). Wliun tht- utittcb of die iirctlira ia very ■war the hiuw of the puaie, the Bcrotiim muy ho ilivided, as it wcn>, mid rrpreAent two \ti\m; lliix malforniatioii majr bu Biiid to be incurable
EpisPADiArt, — Tiiifl is the reverse of hvpospndias, the prereiv lutura) tipcning of tlie uretbrH boliig at lh« nppor portioi] yf thu penis ; in thUi iNindilion the ecrotuiti retjiini> itc iinnnnl iippear- anco. ] might bcro uientioii extrophtf of tho bladder, atid, in like manner, e-all jrour attention to the ahwnoe of 6ng(>m or earn; euch malformstiuiiH being ahnoiit or quite bejoud Kurgtcal tri'St- luent.
Weubed Finokjis axd Toks. — This condition, as n riilL-. is con- fienital, bnt it may ariiie from hiiniit or inftammattOHA ; the fitigen in thiA difticiiltjir aru litrld firmly to^^'ther by strong tegtinientary idbeeiona paatting between them. In the treatment of welibed fiiigent («M I-'ig. 9) thu ojicration had better be deferrod until tbv
fm.«.
cliitd i« HuOteiently matured to bear the ehoel:, at wliieh time ft puncture is to be made between the fingere at tlie proximal end of the fiiiuon ; a ptocc of heavy eilver wire ix then to bo inserted and allnwed to remain nntil the wound has cicatrized, npon the same pritieiple aa that of piercing the can for a lady'fl ear-ring.
43
MAT.FORMATrOK8.
After tlic cioatrization is complete, tben the in<-ision <!an be car- ried ]>ctwccn ttiu fiiijL^-Ty to tlii* (Hital cud ; the wound boing dressed with oiled cotton nnd allowed to ctcatriEe, care being taken that thu cut surfaces do not coiiio together nnd tbuu form adIicitiniiR. A iiplint should be Applied to the haiid to prevent motion of the tin^-n>.
Thi» Hame deformity occurs with the toes, hut, as it ts not conepicuoas <"id c»u»c« no i^iilTcrJii^ to the plionl, treiitment is unnecessarj.
Strp)3cxtmKiUKY ToKg A.\n KiN'tiKK^.— I cnil vour attention to this claw of deformities aliuoet solely for the purpose of impress- ing upon yon the im|>or1anco of their early conxK-lion.
All such deformities should bo attended to before the child arrives at au age when they wili produce any mental inipremiou. If permitted to remain until the child is old enough to recognize them, tbt-y are ever afterward a fonrce of nmrtiticatinn. and, in some case^ produce such mental agitation as to be the cause of ahirining nervou« symptoms.
The very fact of Iwing conscious that the feet or hands are not like t\n»K of other children may ho nnllicient to niin the child, unless the deformity is removed, thereby relieving him of the ft.-lf-accuMition of hiit defonnity. and the coniftant ohtfcn'ation and taunting of those with whom he may l>e associated. These defonnitiv« can be mndi more easily vorreetod while tlic child U yoong; growth oblilenites very many of their efTects, and the mental iinprcNtion which they are liable to produce will in th^t way be avoided.
The lame, the crooked, and defunncd, are nil influen^-e;! men- tally by their miefortanus. In many instances, I have seen the stMn}E«Ht evidence of thii* influence upon the mind; one in par* ticular I will mention, which is that of a young girl who wasi brought lo me, lo be treated for chorea in a very aggravated form.
Ab this case ia a beautiful illndmtion of the principle we are now speaking of, I cannot do l>elti-r tliuu refer to it here, altbongli I liavo already published it iu the A'ew York Journal of Mtdi' cina for I K49.
Case. Chorda indutvd hy Anxuty, on Afmunf of a Ih/orm- iiy ; and rvrfd by Htmaval ff (Ai- tame. — Mary Pheeny, Pear! Stroct, aged sixteen, was brought lo me in Ikfarch, 184(11, for
KEDryDANOY OF PABT8.
4»
cbiirea, willi which she had been nfflictod for two yekrg previous ; •lie hnd also IhhI jtflvoriil ritilfjitic fon\-nl»ione.
8he WU8 a larfre, robust, heah)ij-lookiiig girl, but exneedtngly deBiwtiding and gloomy, nhnosl an idiot in a]i])Curunco, witthiiig to ho hy livnrolf, utii] )H.'Idorii ^jxrakinf; to any one.
She wan iitraiigfly dcfonnt-d in tier fvc-t and onu band ; hiivinf; ten tow on Ikt loft foot and eight on the right, with their proper namber of phs1ai)g«8, nud cadi itrlii-uhrt^rd ivith a wfKinitu nmtu- ttnal hoitv, except the eecond ami thinl on the left foot, which were joined together, bo as to rcectiible one toe with two DailB, which gave th»t foot tlie appearance of liut nine toes; bnt after tlieir remoyal 1 found s duuiile row of phuUiig«ul bonot, itiolotkHl in ft common tog^miontAry onvolopo.
On the ri^ht hand ehe had live fingera, beoideA an extra joint D|wn tlio thumb.
Upon talcing hold of lier Jiand, my attention wsii drawn to Iter extra finger, and when I alluded to it tfhu gave an liyistiirieal ho1>, followed immediately by a severe convulsive 6t, caused, ae her mother informed mo, by my alliuion to her dufonnily, at) tito wiw exceedingly sonsitivo upon that ]ioin1.
After talking to her mother a few momenta, lOie wiitlied me to look at Iiwr fuct, as they were also deformed; and, upon my examining tliem, anotlu-r vonviilitive lit watt induced, which led tue to believe that the catise cf dislurbanco iii her nervous syetein, npon which th(-«i> tiu and tlio chorea depended, was anxiety of mind about hor dofurmity : and ehu had jfoudered un it bo coii- atantly, and let it obtain i^itcli complete control of her nervoua syuuiri. that any ulliit<ion to livr misfortune woiihl bu iiuitiedi- ately followe<l by a til.
After vximiining the envo enrcfully, I found every orjtian healthy, and all their fiunrtinns properly jK-rfunned. She luu) been under treatment for eome time jiiut, for guppn-j»ed men- Btrtutton, which had been 6iicce(wfnl ; and for the la»t two DionlliH Itur menstruation had been perfuctly r^ular,'
* Or. PonliCT, now of Ctisrioton. *lio ircatvil licr tnr nomo Ilrni>, h::* published tiiv utc in tho dmrliMn J/nlit»t Jvuntil and HrrUw for Uarch, IStH. uil aiatcfl llui )li« wat (Mrltclljr tuni in four •tvVt, by Uiv ui>v of nrboiutu at Iron uut iba- liwb.
If hr hwl nfvivtit* to tiw nHmMmnilon (linplr, Iio wonld hsie bcoD «rr*ct. But, In iNchwIluit 111 lliu iraRl c<u« ilie <tiona utit o|iUep>f umJor vbldi she Uborvd (w 1 4
KO
MAXFORMATIO!
Therefore, Mdxag no otlier cause to whidi I oooM attrit this derangement of her nervous syBtem, I was compelled to be*
m. M.
rw-a
lieve it caosed by anxiety on account of her deformity, and ad- vised tho removal of her extra toes and finger, to which ehe readily ac&ented.
From that moment her conntenancc awnmcd a cheerful, smil-
pftMim* ho doe*, lor hr hu htuuled hU anick "St Vltiu'* Dmm«"), b« b fMMitly mbukan i for bar gmH w4b cicmUnglj' aaattmdj «hoD (he came M mj •Cm, uiil th« fmcl of bcr liaTinf; two coarulilTC fiu upoD tn; allvdlag to b«r 4ctfanDllr prorca that bar rpllcpaj uid chom Mill mntinuiMl ; uid ll b tOMimct tUi MaleiDeiit tint I ban bj (he (drloe of MTcnl madi>^ friends made tlia caM pwbttci
She ITU 0D< rclivTod of het chona uid (^iltptr ONlil ihc wu BMarvi) (bat her dofonidtf oonld be ranoTcd ; from that HMmail btr ooanteiMBCv aMnnmd > ['btwrtul Mp«cl, aad bcr diorva aod cptl«p«y Wt her Mtlnlj, irUbeal mi; tMdkal titatBMOl wiMMrer, Mid ban iMTvr rvlunMd.
REDTrSDASCT OF PARTS.
tl
iag ispecC, the Imi^^hod wxl t»tk«M] lidf liy«tvri<:»ny, and walked about with aliiiniit s frenzied delight, and exhiltit^d not the slighti-et iividt-itLi: of chorea. Shv wan cxciwdiugly atisiom to have the ojieratton performed at onn;, but it wafl deferred in order to tiikc the cute, froni whtvh the accompanying drunHiigs wore made. (&vr PigB. 10 and 11.)
Un Uic &tl) of Harcli, aieisted by Dn. Trudeau and Van Cnrcn, I ivinoved her superiiumerar; toes, having first pnt the }*atiftit uiulur tlie intluutioe of ether, whicii Imd tliv du^irvd ctleel of bonambing all wnBatiitn, aad, wlieu restored to vonecioasoeaa, she exprt!«M!d great surprise at tlieir reinornl.
The parts were linnight in close apjKwition bv sutnrcB, atnpa, and lirm bqindaf;v«, and drG!>siKl with cold \fnti.>r. I'tiioii of tlic whole womiii, in each foot, took place hy first intention without tli« fonnatiun of any puH, and in twi'iity-chree days after the op- eration she walked to my oSiee (nearly one mile), and the eei-ond cute were taken from Iter fuel, from wbieh t)iu improved draw- ings were made, y&y Figs. 12 and 13.)
The m«st singular feature in thiii caae i«, tliat, from the mo mimt she bceftrne couvinct'd that bcr feet ooold be improved, her chorea left her, and haa not retamed ; neillier iiafl she had a ain- gle ejiilfptic coiivnliiion.
I removed the extra linger nnder the influence of chloroform, at tlte carj>o-meta<.-uq)al articulation, by a Himiglit inci&ion o» the
Kw.
hu. iji.
bock of the band. Tho wound united by first intention, and tbo Itand looka quite naturul, as tit Been by contraitrjiig Figs, 14 and 15.
IIyi-kbtroprt op Parts. — This may occur in various part* of the Imdy, a» ujion the fiiigora or tut-K, and involving one or more of the tissues.
53
MALFORMATrOSS.
Tbie difficaltj roquiros B.r»tcmutic comprcesiou with ific Indla- nibbtir bandage ; sliould ttiU fail, and tlie dofortaity (M^CDiiie. >u> great, ant pututioD itiuy l>e uuceeiuin'. Tliis dc-furmity is gununWy hereditary.
luPEUFOKATX Anus. — This i* sot sn iinfi-oqiicnt m&lfoniift-| tiuii; the anna externally may preAeiit a perfectly noniinl a[ pOAranee, th« occlusion being caused by n slight but tougli mem- brane.
In IS'IO I was calM in consiiltntiun vith tliv lutv Dr. Beale to see a child of Mrs. L., in Greene Street ; at that time the child •vna but twenty-four hours old, and, being born with an impetv- forete nnns, wa.t at the time of our arrival «ulfering itevcrely, nn<l^ making great efforts at stool, the abdomeu being greatly dis- tended. There waa a flight indentatiun indicatinjf the po«tition of tho anus; after a caiTvful examination it wa« decided to mate a puncture at that point, and endeavor to discover the rectnm. The child was then laid upon its back, with the thighs Hoxed u()OM the abdomen ; a flattened trocar wax then introduced into the ti^tues in a line where the indentation indicated the normal portion of the anus, passing the blade in the direction of the promontory of the sacnini.
The trocar was liien inserted t<i the depth of half an inch, and upou the withdrawal of the Htilctte thu canula was prvHsed in a little farther; this wan immediately followed with an escape] of gas and meconium ; a large rubber catheter was now insiirtvd to the depth of two inches ; this was tlicn cut off and secured by cords {>ii#ing around the thighs.
Cicatrization occurred within a few days; rectal bonnes being afterward resortoil to for the jmrjioite of enlarging the anus, tbeee lieing increased in size as the child developed, until, at the time of pnhcrty, the anu» had assaincd the normal ttixe o1>9crvabl4j at that period of Ufe.
PUIUOSIS.
6S
LECTl'RE VI.
BlUa(7 (ooniiaued). — Cong«Dii*l Hilaimia kiid Adiwrcni Pnipuoc.— IVogiiiMLi.— IKi^DiMiii. — CUtorilii. — VttcuUr Tunjiirh — UuiutrMiliM.
GmnxotRM: I shall continue the stud^ of the caimtioii ot dofunnitics t<Mlay hy iinft dii'CC'tiiig ^uiir attuntiou to Hnotber cx- ceediiiglv important caiLie of acfjaired deformitv, especiiiLly in cliiliJrcn — mmioly, the reflex niUHciiIiir contrtctioiis, cuu£V<l b^- CMff^iiial j>/iimo»i« and adherent prfj>u(v.
Tills ii A ciiusc wliit^h hiw hi-cn uluiust untircljr ovorloukod bj Uie profeeaion in general.
The lint Bt«p in the proeoee is an almo^it perjK'tiiiil i-xcitation of the genital orgatia. Thui excitation i» followetl hy [»rtial pit- nljrsia, and tliU jiiinilvsiA is looompaiiied by (Ifforinity.
It haniig been my fortniie to see Beveral of these cases, I oan ilo no butter than to give you the dotuilcd hii^tory of the fltst which fell under my observation.
On the Dth of (Vbruary, 1870, I received the following noto:
"DbabSatbe: P!«mw l«t me know «t wliat Iiour roa tan romt' to mv
bonM to ■«« tliv iioii (if Ur. M , of MUwimki-i-. Tlio Iiill« leiUKr hiu> a
[lalr ot Irgn that you vruold walk m\\» to wv.
■'Ywiin*, truly, J. Makiom Siitt.
-Ka ia bOTaeolT-OlMti Rlmt.~
I tinme4liut«.'1y went to the dootorV offlne, an<i found a moflt beaotifnt little boy of five yeant of iige, but oxoeudJii/ily wliitu and dulimti* in ht" upixmnnoe, unable to walk without awiiHtance or stand erect, hie knooe being flexed at about an angle of 45% and the doctor had sent for nie to perform tenotomy upon )ii» hamstring t«ndons.
After a very careful examination I diflcovered tliat. when I amneed the child and diHtractcd bis attention from liini»elf, I n>uld with very little force caitily extend both of hifl limbe to their nornml length, but as lioon lus I releofietl iny hold of them they Would instantly b«eoiitc flcxei) ag»in, and no irritation that 1 oould produce upou the quadriDL-p« iimM-Iuit wu£ uufficicut to ex- tend the legs except in the very slig)ite«t degree.
u
PHIMOSIS.
I soon iattKfied itiyecif, M well ae Dr. Sims, that Uie dcfonn- ity WM <lne to jxiraii/fis and not (ymtraetion, And it was therefor necesaary to rfstom vitality to the partiaUy paralyMd nitwofM, rather than to cut the apjHtrently contrad^ fiexart.
I tlicnifon: had him seiil to my ofiioe for ihe pnrpoee of np-' plying tli(! constant current <>f the gah-aoic battery. In lUt appli- cation, wliilv pacing the epong« over tlie npi)er part of the little fellow's thigliA, the nurse cried out, "O, dot-tori be very cans- ful — don't touch hi« pec-pee— il'« very t>ope ;" and upon examin- ing his peuis I found it in a state of uxtroine croction.
The body of the peniH wiw well <!eveloped, but the gtans va very small and pointed, tightly imprieonud in the contracted for ekin, and, in itfl efforta to eAca]>e, the meatus urinarios had b^ come as puffod out and red as in a caee of severe granular nro- thritia ; npon touching the orifine of the urethra he was tilightly oonrulsed, and had a rvgular orgasm. This was repeated a uuiu- bor of time^ and always with the latno result.
The nurse stated tliut this niut his condition most of the time, and that lie fnc-fjuenlly awoke in the night crj-ing bocauitc '• hi» pee-pee hurt him," and the same thing had often occurred when riding in the stage or car; the friction of his clothes exciting hi« penis would cause erections.
Ajb excesoive venery is a fruitful source of physical proetni- tion and ner%-ous exhaustion, sometimes producing jiaralysis, I WBB disposed to i<xik upon tliis case in tlie mine light, and rccon mended circnmcivion as a means of rolieving the irritated and imprisoned penU.
Tilts I [wrfonncd on the following day, assisted by Dr. Tale, who administered the chtoroforin, and Dr. Pbilli))«, and in the ■ presence of a number of »iy privato students The prepuce wa pulled well forward and cut otf with a pair of acisM)r», wlicn the ttgumtniary portion readily glided back over the gtans, leaving tlie uiuoons portion quite Jirmly adherent to tlie glanii nearly to the orifice of the urethra. t>ei2ing the thickened mucous mem- brane on either side of the glaiis with the thumb and Soger naila of each band, it wiw suddenly torn off from the glans penis, to which it waa quite tinnly a<llierent nearly to the corona. IVUind the corona there was impActed a hardened mam of sebaceous ma- terial, almoet completely surtx>unding tlte glana. This waa re- moved ; the muoone membrane wliich had been torn off from the
CASE.
55
gluw ms split in it« ocntrc nearly down to ite rcflcctioa, au<], be- ing turned backwani, was attached to the outer portion of t)io prepneo hy a number of HtilcLvH witli an onlinnry cambric seedle sod very Gne thread. The penia wm t]ien covered with a well- oiled linen rag, and kept wet witJi cold wiiUsr.
Xo untoward symptomH occurred, aiid in leee tlwn two weeks the vonnd bad entirety healed, and the pcuiH woo itnmeuevljr in- crcucd in «!»■. Thi; prcpucu was liufflcicutlv long to cover the gbna, and cuiild be readily glided over it without any irritation wlinl«vcr.
From tbo verv day of the oi>enition, the child began to im- prove in bis gvucnil b<.-alth ; slept quietly at night, improved in hU xppetit«, and, altlmugh contined to tli« hou»e all tbo time, yet at tliv end uf three wockx ho Iiiul re>covfn-d quite u roey color in hifi checks, an<l waa able to exteu<l hici limbfl perfectly stnught vhite lying upon bis buck.
From Uiis time he improved niofit rapidly, and in IcMt tlian a fortnight v-tts able to walk alone with hi« limbH quito etraigbt.
ITe left for his home in the West about the Ist of April, en- tirely recovered ; having UKpd no rcmctly, either iron, elwrtricity, or other menus to restore bia want of power, but simply quieting lits nen>'otiM oytttem by relieving bi« imprieuued gbns penis m above described.'
Tbu cnM« that jurt now preM:»t« itself before us is one of this doeeription :
Cask. Dot/hlr^ TaHjtfg Equina 'Varus, Paralytica^ cifp^ndtni upon Ctnitfenilal Phimoaia arul Adherftit Prvjtutv. — This boy, C. n. W., ngttl three yt^nt, has been under treatment in a public institution in this city for two or three years, with the hope of overcoming his deformity; and that treatment has )>ecn solely by the application of instruments to bold the feet in their proper position. The mother Rtatctt that the deformity was pn.>Hent nt birtJi ; in other words, it is congvuital. As soon as he began to
' D. CuDpbell Blark. U. P., io W •mV on " Funrtloul DiwUM of (be Hna.\ ITriBkr;, 4n>l Reptclucliis Or^ot," »t\er rvpnnliiiir mm* at ay cue* In fiiU, Mjt*. fugB Hi I " I (lifer no ipolo^ lor (hua Kliiag cwulilonble prominnm to lh« tan- piag oMW. I kllach to thcin Immi^nM bnporUnu*. u di«atoalDg,pOMlb1]r,a fr»<|U«nt WOTM el iafantiW paralrrU, viJ tbo mimcroiu IndiaaUon* of atrrtn* trrlMballtf lit dAUboM), vhlU), to lu t kuowQ tu mi', Or. Stjn't cmm sra unique to uicdJcol ■Urmun;'*
56
toeis.
walk, liiH ffiut Ix^n to got more crooked, unt] Iiato at la«t ^t into the eba])e you see here. When I take the foot in my hand, yoa etse tlinl it can be immuiliiLt«;1y rt^tored to it« noniin] poeitiun with the greatest powiible eaae ; and wlicn I let go it swings around the unltle like the loooc end of ii finil. Tlii« 8liovrr> tltut ibe de- formity is paralytic in its nature.
In order to remove tliis piimlytie doforniily. lie hiu worn all manner of inacbinerr until both his tibia) bones have been Iwnt out of »iiti\K\ and still be is as bud %» he was at tir»<t. l\\» general health is good, and he baa never bad any sickness w1u<;li can ac- count for tluH condition of things.
In looking about for a cause of this paralyzed condition of the niHsclei* of the lower extretriitiea, I find that the bead of bin penis Iia» neror been nncovcred ; in other words, be lias amgfni- tal phimtmn and adherent prepnce, oa proved by the introdno lion of a probe. The external opening of the prupucc is searcu'ly large enough to admit tbe smallest probe, and aii the pi'ol>e i» mode to sweep around the gluns the prepuce is fnurid every- where adherent, except for a few lines back from the orifice of the uTvtbra.
Tbe penis is in an almost constant state of erection, and the ooacluMon I l)iivv arrived at w, that this boy has been tbe enbjcct of undue ncrvmi.* irritation from genital excitement, which has resulted in partial paralysis of the lower extremities, and in con- sequence of tbia partial paralysis the defnriiiity bas been devel- oped.
This subject of nervous irriLition and consequent exhaustion from undue gt^'uitjd excitement is one of a vast deal of im]Hir- tance, and \u\a not received tbe attention at tlie haudii of the pro- Am^oii tliftt it juKtIy deiK*rvu». The prvMure continually exerted upon the glaus penis by the contraction of the adherent prepuce • keeps the organ in an almost constant state of irritation and erco>'^ tton.
Such A constant genital cxcitcnient, no matter wliat its canM may be, wbetber occurring in a child or in an adult, iscertainlj detrimental to tbe best condition of the nervous system. In tho class of cases before its, this undue genital excitement ends in pantlysia, and tbe consequent deformity varies according to the manner in which the weight of the body is placed upon tho foot. A ainiple mechanical support will restore the foot to ita normal
CASE.
57
■ition, hut tlie diilil can only l>o relieved pcimanently of the ' dctfonnit)* by nMnovin;; t\w raiixv whicli has pvon nw to tlio paralysis. The tirst f«tcj>, then, to lie taken tnw-aisJ cui-ing tlii« case i» to perforin iIki oitcrntfon of circittnci»ion, ntid libenUv th« gUna penis from the a<iberent prepnce; for I am firmly of ttie opinion thiit ttiu |KiRilyi<i)> in tliii* caMv i» tlic rcsiiilt of non-oiis irri- tation from genital excitement which ie eiiused liy tliis adherent prcpwco. [Th« operation wiw performed.] Tlie child will b« n'tnnje<l at tie end of two weeks, an<i wo Bhall then see whether any benefit has boon duriv«d from tlic openttiim. Mennwhilc,
no drG«nrig whatever will be applied to the distorted feet, in order that we may itee what effect tU'n ncrvoiiH affection hnd tli producing the dufonnity.'
' 7W nMlhpr rpliirwd U llw cd>I of llie tao wwiii. ttotlng thKt the chiM h»A bMM pcrfrrtljr ixalm uTcry nigtil siuo« iht: upcratlcm, dtwplng vlihaut any dliiiitbftnoe. ■nd pvttag Uji mtWT niilioul dilUciiUj, which liwl nov«r ocrurreil bvfure. he Ut ««U, *M nc7 uinch SnipK>(«iI iu hi* general uppcurancc, and <iiuld Hianil Ou on hit fort ulthout »rij utfitiUncp. Vptxii Mtipinajf tht I'liild's feci Ihe n)Oih«r'« siaunvmt ■ra* fully eotrotNiwUd, m will bt »na by lb* anauei] figur* (Mg. 16). wh!oh van
pmuosB.
We will add another case of r*jt«x paralyai*, which bcanti- fultjr illustrates tlie rapidity with whicli the uiiuchM rcfijuiii their power o{ contraction, stid also how nadilj they will reepond to the directions of the will when the Moroe of irritation is n> niored.
Casr. — T. B^ a^d three yeara and eiifht monllis, wa» brought to me by Dr. P. Brjrnbei^g Porter, of 65 West Forty-eighth Street,
rra. IT.
on the l8t of Jnne, I8T5, to be treated for piiralj-nis of the lower extremities and prolapsiu of the rcctam.
The doctor had detected the phitnoKiH and constant priapiBm, and, 8U«{>cctin^ thut it might pwLsthly W the cauiM' of hi& tronblv, brought him to me for examination.
Ukon immi-'diiiicl ;t uttrr by Mr. Haann, pliotognphn lo BvltcTuc no»r'il"l, j'i*l twD vcckit fnim llic o|HTr*lion. An *<t1 be Bnii. the pliilrj itanila piTftvll; flal upon lb« (Mt, wtlh «impic iuiunlun of (lie icivuMor ut \bv Icfl foot. Thi> Snctv*M<l muMnlKr pomir without lli« Ufv of nty «ln-lrirUy Iim tipim klmu-l nuincloa«, tnd on* bf tbt ippliMtlon o( llin ]C>tvanlc currt'Cit lo 1I10 prranrnl Diii'cKf w* Iibto ■ prMpoci of ttM perfect rwoTcrj of tbc cblld wtthoui uij furiliur muobanlcil fuppon.
CASE. 50
The cbild was very peevish und fretf al, very eoBtive, and the ber Btateo that " in straining at »totA and in making water tiin iwd vronld frviiuunlly coiiii; duwn, and give Uw great trwuble in pueitiog it up."
He begiU) to tuniMe down wry fnviuuiitly about iiyvara^, and v,-aB growing more aiid more cluiiit>y in walking, lie coold not otnnd alon« without support, and cvon wbon f>npp(trt<Hl liis legs would bt-nd in different dirt'ctions, au seen in Fig. 17, from a photograph by O'Neii, June 1, 1875.
He wa» circumcised on tlie 2d of June. The lining mem-
10 of tbo prepuce was firmly adherent to tlio glniii>, requiring ^seetion by the knife Ijefnre it could bo torn off. Behind tlii< co- rona wa» the usual hanluiicd Hmegmn, which had produced ero- sion of the mucous membrane.
Tlip jiarta were drc(«ed with an oiled rag and eold water.
(/m;ut itA, — The boy cuuld stand M-itliout support, and had slept quietly the past two nights.
At the «nd of twelro dayt ho was entirely well ; could walk
60
PHIMOSIS.
and rnn without tripping, and his bowels had beeome perfectly rt^lar, without miy prolAjt^iis.
Till' aTiiiesed photograph by O'^cil, taken July let, sbowa the improvement in hi* lttiib«.
lu tho picture tAkcit June Ht, his shoce had to be laced tight* 1y around tlie ankle to enable biiii to stand even with support; but iu tliat tiikcn July tat (Fig. IS), it will be wt-u that he stands erect without any assiHtance.
One uf his limbe is slightly abduoled in the photograph, but tint was on apoonnt of his restlefiHiiess — it is not h> coniitantly.'
The following om) i» a very rvmarkablc insUtnce of genital irritation, in conjunction with general nervous disturbance. The patic-iit coining to my ofHcu tiimdod me the following letter:
■ X(« You, rUritarp 10. ISRk "ill DKAn nooTon: PIcm* ffivo bonrnr jaar attrtitioa. Il« litw putlal ntnipNy of both uptiu nerved anrl |>blD)oiiU Uralcfutly remeroberlnt; the
MTviow ;ou rwdarod to , I hope 7011 will bonolil boNr«r 9* raiicb.
"Youw, trulv, H. KsAM-.
*• Dr. L. A. Satsb."
CwE. Phimog'is and Partial Atrophy qf Optic A^ervea. — Februai'y 2H, lH7r>. — L. II., aged thirty-four (Oeriiuin), has beet married four months, very stoat and active, but very nervous, very easily tired ; eight years ago he began to have trunble with his eyos, tindiug he could ouly re*d tt little while at a time, and then getting so nervoua he would throw his book away, and could not again read for (Ktiiie time ; can now only read large print and tlien hut for a few minutes together.
Hh« eotuinltud various Mirgoons in Europe as well aa in the United States, without deriving any benefit.
Patient ha* never lioen Ihe gliiiiM penin; prepuce being very lightly contracted and twisted to the right.
Ft^ruai-ij 22</.— l^ivided the prepuce and uneoven-d the glans ; murouti membrane very tough and thick, almost Gbro-car- tilaginouD ; waa divided witli bistoury down to corona, and then stitched to togdmentary prepucf.
At the end of a mouth the jmiienl liad entirely recovered his
■ For * taon full rapon of Injur; to tho ncrroai iTvlfm tiT IrrllaUoD ot Ihe (tfilttl OfgMi* of both wiWv trt auibor't paper lii " TranMciioiu of tlio AmctlnB Hadltal Auodatlon," fnr U7S.
CASE.
61
natunil Im-aIiIi, all iicrvoiut iymptoiiis having disiiftpcoKd, find, elmti^ to ^y, cmild read a |Mgo of email print wilh faoilit^ and without tiiiy iiii{)li-»A4iit i-tisull following.
On Korember 14, iSSl, I received the following letter from Dr. Kdajip, ill rep]y tonn tnqiiir}* in rctution to tliv putiont.'
"Mt DtAR DiXTom; I rocolkirl ihe p.itU>nl well, IHit fiRlit Bft«f Uw PApentiun li»(l mntoriaU; ini]iriii'i.-il, lioih ni lo aculvnvia uul proloDged OM. lU lioa (.■oni>ii|[«d iii« >0T«ral tim** Kaw. tin hoe »tLI] iDcoiQ|>]e(« atrophj' of tli« uplio DcrvM, nnil modcriiM ainblj'oiiiii ; jot I cnniiilcr it a grMt rMult tliM Ui* Bin>pbf bM not pd'ogrMM-ii, snd tlie polivnt alwa^ra ex}ir«e8«<l bis MtbEictioci and gidtituilu to Jon. Witb kindcait rcitnriU,
•' Yuure, very iroly, H. Kxarr.
•Xtrtmtir It, Mt.-
Bcfore leaving this »n^ject in ndation to tlic mule w^x I dwirf to call attention to the grent change thin condition can bring about in a »liort time even in a etrun;;, hvallhy child.
I therefore, perliapn, can do no iK'tter tlian to cull a few line* from a letter recvivi-d b^' uiv from tb« motbvr of a child »o af- flictwl, it coming under my treatment:
ti.lHf ftUltib «U nssoBmoDljr stronx tod vigorona, utxA iDcrooMd in I'KHOfth UbIEI at abt montlia bo Hit alone. I wa« <Mnieenied at IIbim ant an ocriwionnl inflsnimatloD of ih» \n-a\K nod noticed that wbu h« ^vouiil trj to crvup ho would bu in a slalo of vcolaxj and Ireinur, and tliat wh«n in this condtlloD tbe penis was aIwbj-b aroot.
" A* mj bo7 poMMl hi* lint birtlidd^ ho gr«w di.-Iicnt«. lli« \tg* M«tning ■Ic, and abuut tblit tini« h<> liod a tall from (lie carrtaire; I was not, bow- ■*'^f■ Krontlj alarmed, a* lb«re w«re no brui»v«, nod the eliiUI vim H|>|)urvnllj III loured, ..■MliatMd of ilecpUiit ijiilctiT iw h« imed li> do. ho wnnld now •cream lontlljr ■r time* during tlie ni|;bt ; li« now givvi inorv iltliuute, DulTurvd Mvefvljr from imlig<«lon ; irns not nUa to irnlk until ninvt^^n month* old, and lltfin WW Kiuffantlj fflllinft dovB. At the age of tnu jcnrii he wad bright but Terr iMrvouB; at Hbuut tliLi lim<i he fell off ■ step and watt lame for a weeli. Hi* flM cnrapliiinl w:m uf Ilia knoo. At that lime n« brougbt him to ^du, BBd rnu |iruii')uii<vd it h>[f-<llHM>e; nt tliu same tini« you adviited and iierformed an optratioB for |>him'in<i. Iiiiiiicllatc benellt win rM<«4r«d fhom tliitk nnd nl the pre*«4it lime jot can Karedy Knd a l«aa uervoiie and more eT«u-tvm- pervd ohUd tbon my own.
"Kiwtrrd; yo«n, Uas. E. L. V."
■ See AVtf Yorlt JMint A'nortf. Norember IS. ISSl.
CUTORITIS.
The ilUoaso of tlie liip in ilile caiw aseuiiied a nioet serious napect, developing even to the thin) &tage, with excej>»ire t<iip- pnration; but the result obtained finally wae complete recovery, Willi a niuvablo joint.
The same gcDt-ml dieturhsnce takes place io tlte female from initution of the clitom; to illustrute which, and the rveultfteo cured from clitoridoctoiny, t quote the following ca«u« :
J/ay 8, 1677. — A. B., aged nine yvars. This child was sent to mo by Dr. Elder, of Uobobun.
IIiffriiBV, — There was nothing parti<ru!ar noticed in relation to t\m child until tlie full of lS7(i, when she began to walk in a ourions maimer, very much like a horee with epring-balt, and ueied to fall frcfjiienlly without any apparent cause ; Rhe la, at tbo present time, a stout, well-nouri*licd girl ; both gaBlrocncmii are Contracted, the flexora of the great toes aUo being ahortened ; cannot stoop down without being thrown forward. Has great mnfcnlar rigidity of tlii^li^ so that the hipe cannot be Hexed or the thightt opened. Prciuture on the clitoris causee ti]Mu;niodic contraction of the muiwies of the lower extremity. I clipped off the cud of the clitoriH in the preHCiioe of Dt*. Klder, Ei, A. Didama, Syracuse; Whitemore, Xew Ilaven ; Uutherfon) and Kearney, Now York. The clitoris was then CttUteri^tcd and (Ireeted with eold water, feet to be kept apart by a lath between tlie ahottB.
ifay I2th. — Can flex the thighs on the trunk ; Iiaa ntept per- fectly ; Home swelling and aorcniiM of clitoris.
Maff I9M. — Ilelnnied perfectly well ; can flex thigW and move all joinU nuniially. Has not fallen down once during hkSt five days, and walks freely and naturally.
I afterward received tli« following letter from Dr. Elder Id relation to the ease :
■llOUIKKN, JmM 9, UTT.
" Dkar Bih : 1 lisvp miwlo a (horonKh cxamlDatlon into the oon^ltlnn nt Uiu It., whoM- clittiria yon exo\n-d n short time iiiiii>w. Tu me llii* cnwe pru- mdU notisiul lDt«Tc«i : 1 illd not, at ilie tjiiii- of tli« opwutlou, believe the wo«ld roceivo muoh bonrlit. iin<l thi* opinion wiu rDncnrr^d in bf tiro pruini- n«ni *ur]s«iMi8 »f N«w York. I now tliink timl nil ilie imllcntiuns deartj Iioint to B porfKt noavurj. I Hliall «liU wBirh tlip cmo witti mnclt intcrwt, aa<l coRftilly nol« itic rMulL Youra truly,
"L. W. Euwt"
68
Cahe. May 9, 1876.— C. J. U., a^<l eight yoare. This diild at birtli WM Mn»ll, aiul nickly tiiiiil liirvo yann of hj^, wliuii sliQ began to iraprovo in getieml huulllt, but up to the present time haa never been nble to walk ; dnring tlitite yeitra Ibo patient boH been nixn hy a number of phv^ioiiins, bouiu of vhmii slAted that U was i^ptniil Oif^cafle. others tltat it nua & iicrv- uui kffoclioo, aod for wliich the child wiut truiu-d witli vl«ctri- city, etc., but without securing n.>lief. The child, nt tlio present tittio, iti bright mid cheerful, both ulccping luid ciitiug well, and is aiidoobtedly a healihj child, bat is unable to extend her limbs ■t all.
On examination, found tlie clitoria verr much congested, and tlto sligbtcot touch produced ApAttin of the whole body.
Mitif \b(h, — Advised section of the clitoris ; the operation was
jrdingly porfomied.
Jxiiy \Alh. — Child has improved greatly, and can extend her limbs witli froedoiu, uid hu walked acroM three roomit witliout kseieUnoe.
AwjHti 18M.— Continues to improve.
Sfplirmbi'r ]«^.— Applied a ]>air of sbom with artificial elastic nmsclefi for the purposic of elevating the front of tlie foot ; wtlti ilicKO eliucs ebu ran stand alone and with the use of crutelie« can walk a long difltance.
Cahe. .September 20. 1873.— Female, aged five \imn. The I following rase was sent to me for idiocy, and on aoconnl of tlio Inaljilily of the child to ittuud. Vifi- 10 givvu a good Kpresentft- tioaof her appcarunco. In tlie pictnro she is hold tip by ttie operator, which prevents the deformity from r>bowing tt» con- spicuously as if she bad altomptc-d to bear her weight upon her feet.
'Wlien bho attempti»d to stand, the limbo onMwiwI go fur tliat tlie nates nearly touched the l1<>or, and the child Imiked idiotic; the chin resting upon the stonmrn, tlto mouth being open, and . aUira flowing from it; the eyea were watidering, the bead and liaads living in constant movement; an cxprouiioii of complete atnpidily pervading tlie whole face.
I' pen placing the child in tho horizontal jKWtnre. after a few moment:* her countenance changed to that uf intelligence. After a time she began to talk, and talked sensibly. Slio wOrt after- ward phiced in the erect posture again, and soon asuinod (he ap-
CLtTORITIS.
j>eaninee of iduicy and lost tho power of speech entirely, tite IiuilH> lit once 1>ccuuiiiig strungly addtictcd.
When again laid upon tier back elie improved in her inlelH-
Fi.-. V--
gence: tlio 1iiiih» conld tlien he eR«ily abducted, uid in this \to9A- tion she iijid tlie power of voluntary contnictioa of nearly all tho miiM^ioA of her limbs.
The clitoris vtaa vcvy red and much enlttrjjod. the slifrhtmt friction upon it throwing liur into » peeiiliiir iipasin. I therefore diugno»tie»ted the case as one of spastic coiitntetiou^ of evrtain mnMlcfl, and parlinl panlyKui of ot.her»~from anieniia of the Hpinal coni iind urreat of development, prubahly from peripltcml or genital irritation.
T«icATM>;xT, — Tho patient w«* eveiircd in tlio wire breeches, ae seen in Fig. 20. Tiie clitoria waa clipped and cauterized, fol- lowed by the application of iec. I then advi»ed that the child be kept in the horizontal poetnre, and to lie taken into the open air;
TASCCLAR TUMORS.
«tf
muntaiuing u nutritious diet, with tbu adminttratiuu of cod-liver oil, iron, ami plioAphoms.
TliiXf inuiitliH lator 1 ruc-oivcd u Ic-ttt-r froiu thu attending plijaicuin, stating that ibe obild vas intnieDse)^ improved, nnd iu Jiinv liiKt wiut iible to walk witlioul aetHHtulco, iind hiid u<.-(]uiix'd coonliiiating power,
Vascclab TvMoKfl. — I would next call your attention to tlie pecnliar vasrnlar liimors Uuown un ntPtit, or mt*tJier'« marl-*, ocmr- ring ill iliHiiivnt n-giunii of tin' I'Otly, c-«pec-iiil!y on tlit^ la-ad and face, and wliicli coni^titnte an important and intereftltng form of morbid grovtliA. They aro cbnipo«tid uitlier of tortuon« capillary vtiiiu) or arterieR, or of both, and the color rariee from a dark par* plv to a tvddi«h huu. Thuw Tascular grawtlLS almoftt always he^u
in tho RiibslaiMw of the Hkin, and extend to the coiincctirc tituno tM-'Ut-ath. Among tho uioet protxibio caniics may be nivntjoned violence inflicted ditrinfj piiitalion, irritation of the nervous cen- troH, I'tc. Of tiiu uicthudi^ of trcutnieiit by ligation, incifiion, cs- di&rolict), electrolvflia, and deetrnction by hot needles^ tho choice of vxpi.-diont« dc'|>ui]de upon the cin^'iitnMannw of the caiic.
As a rule, the actnal cautery ie to lie preferred, using it in tho following maimer; tho needle, or » sliooniaker's nw), which t» an excellent eub^titate, ehuuld be heated to a white heal, and then
ft6
MONSTROSITIES.
plunged into the groiirth to a stiffident depth to reach ita hue ; a clif^ht revolvinfjr iitoveinent is then to be m»de, and tltc in»tru- meiit trithdrawD ; it is tlien bested again and plunged in as !)e- forc ; ttii« i« repeated a sufficient number of timiit and plaooa ao as to completely drastroy the abnormal development.
If tlie nt^vdlu !.< used at a while Iii-at, the uperalton i» nttcnded with no pain whatever, and without the Iors of any blood. With- in a short time the tisniee, thus burned, plough off, Imring a whit- ened cicatrix, which gradually diminishes as the child develops, often leaving no truce of tliu di«ligurement.
MoNSTRoami'S, — Of the extraordinary and preternatural con- fomiution of imrU included under monstroaitieis tlu-rc is, little to bo 6aid of practical interest. They are curious and interesting ua crratie freaks of future, whieh nir«Iy nditdt of surgical relief, and are almost imposaihle to describe in anything like a clnssified arrangement. We eometimeo see these deformities as represent- ing two bodies and one head ; again, others with two beads and one body; otlters, again, representing two distinct l>odies, both being wt^'ll fonncd, and joined by a mere Hgamonloiis union, as in llie Siamese twins, and the two negro sislcrit from Georgia, twlcbratvd vocalists. We uiuy, again, meet with these deformities as representing hut a single body with mulliplu lower or upjwr cstromities. A very elabonite and most (.-omprehcnsive work on tliis subject has recently been written by Dr. Fisher, of Sing Sing, New York, to which I would refer you for any further infoniiation in relation to tliea© jioouliar malfonnations.
At our next Ivetdrv wo will take up the subject of talipes, and to this branch of orthopedir* »>i>r^-n' I would M|n-<'iidly eall your attention, as caaca of thi« defonuity will be met with almost daily in your practice — tlieee cases readily admitting of prompt relief if tho proper trt-atment be efficiently followed ont in early ohildhood ; whereas, if the appropriate treatment itt neglected, the ranlta arc most diastrous. as will be fully verified in the oasee which will be brought before yon during tLe term.
DEFismos.
87
LECTURE VII.
TALtr&S.
DoUtbML^TvietiM &nd Cdntblutlont. — lt«1iaiilc^ C<>Diiniclicin oT lUo Kamal Hwnu FooL— Tali^ Et|Utnu*.—Tn!ip« Cokuicoa. — Cue of DItuIod of Ttndo- InMHiM by an A«d(luiit> — Hochaoical Trcotmcsl of T*£pfl* CalcMiDUt.
Gbntlkmkn: To-day wo contmunco tlio study of 8()«ml do- foniiitiea ; and that nbioh will tirxt f^ngage our atlcntion ia com- monly known by the name of dtA-j'tnil. Tbe Ut'linicul iiitiiic for this claaa of deformities (for there arc ttcveml vsrietie«) i» talipt*.
Under tli« tcrnj Tjli.ipks are inelnded all defonnitii-s in wliich there Li a permaDCiit dcviution from thu nt^innul relnlioni> of the fool to the leg, or of tJie parta composing tbe arch of the foot to each other, witetber this deviution coni-ide in flexion, exli'nr'itin, inrerftioii, or cver*ion. Tftiii>ei« ii iHually descrilied under four dintiiivt besds, namely, ialipea eqainut, iaiipet caleanfua, taliptt vortu, HnJ Utlij/f's rtalgui.
Typir.il exniiiples of any of tfaoee varieties are rare, for, nearly always Uto dcfoniiity is a eombiDition of two varieties. For ex- ample, e<tiiiiiiiA may lie combined with ^'B^ua or valgus, and tbe aaiue is tmu of cuk-aiiuiis.
When we wiiih to designate sncli a deformity, the names of the two ei>nip<inL'nt diHtortions are combined, the more important always bein^ jiln^ed tiret. Tims when we bare a combination of eijuinoa and vame, it is styled etpiiiKwanis or varo^.><[ti{n»>t, according n» the e<|uinui4 or varus is the more prominent, and the Bame principle of uomeuclature in used for CJilc»neo-v»rua nud valgua.
In addition to the above-mentioned viirielio*, tberw is one known us tulipoe cavtu or ptantarii. Tbia in a very frequent complicalion of other varieties of tali{>e«. ^^^len it is present as a eomplicntion, it does not, as a rule, enter llie name of tbe Oeformily. When, however, as oocaeiomdly buppcne, the case pcescDlB no other deformity than that eaujted by the oontrac* tion of the plantar fascia, tlie ii»mv talipes cavns or plantaria is naod. The deformity knomi as jlot-foM, I tltiiik, »bnuld be COO* sidervd a« a variety of valgus, as the peculiar breaking down of
«8
TALIPES.
tbc iircb i« tiie same iti Lotli, and tlic two nfToL-tionit are rer}- pcn- emlly aRSOciatct). In order to liave & correct iitidt-rtitikiitlirip nf onr Mibjcct, it ii nt^cuuutry, before {>rocct>()iiig to tlie <l(rtiiiiliu» and description of tlie different varielies of cluVfont, to turn our iitk-Titioii to tlio fttudj^ of tbo mecbanic*] construction ot ttiu nor* timl tnniiait foot.
Tho human foot, in itt) natural state, ii ono of tlte ino«l beau- tiful examples of a complicated machine, combining great »tronf;th with gracefnl nmbilitj*, that uin Iki found in auv juirt of tin* liii- man frame: consiiiting aa it doea of twelve bones (in addition to tbo«o of the tocb). joined to each other by rcgularly-coni-truct- ed articalalionti, admitting of motion to a greater or lc»ft degree of cacli iiidividunl bone — so tliat no restraint can be put upon these slight movementji between the varioiw bones without de- etixiying tlic hanuony of their combined action in the foot as a whole — and at the eamc time being to firmly bound together by ligamentts and sustained in position by tendons attached to strong muscles, as to give it un abundant security to brar ibe euperincnmbent welji^it of tlie body, while it allows of sntHcient I'xpanMiui) and e.\tt.-iiHiou fur ease and elasticity in locomotion. It is connected with the leg at tlie astrngalo-tihinl articulation, and prevented from any (afenU movement by the projecting raal- iooli on either side, which tit i^o closely to the aides of the a(<trn;:A- lue as to permit of no motion at' this joint, except that of llexion and extension, or that of pointing the to(« up or down. Tuniing the toes out or in is produced hy rotation of the thigh and leg at the hip-joint, or by the revolving motion of tho fibula, produt-iid by the contraction of the biceps and tenaor vaginie femoris, wlieu the knee is licxod,'
' Prnf, Et, I). Onim, ttivt tlianking mc Tiir k copy of n; «or1t OH cIiib-roM. *likh lie KtnlPii in ~ of f7f«i pnctiuil tkIuc It Uie profeMton," •diln, lu liU Inttnr : " I ilutf ■(111 L'ciiiiliiui- Ii> mtltfi latrrai molion it idt mnklr-Jidiil wtlliout roUlliin mv tilp at n- vnlitiiK tlio licul nt mx flbulk." So gnai ■ dlllL'ninof of ojiinlon from i^cii a UtO IpiliiliiHl kutlioril; made me, ot counic. cuvMnlJiigtir uniMitjr U> ihlnk thnt I liad bctwl Mch ■ owel«M obMrrer, anil I Ihnrrntv dliuivted d nonilier of r<riT|, bntli of vhililmi ■nd adalU, makinft moal rardUl ligamcDtcniii pcFpantioiu of mcli, anil, iftiti 1)11- iiion uritto*) MMiiinalJou uf all Uine ■ipcriniFii*, 1 itai unolilc to )>toi1ii« tliv tli|rliu«i Ulir- at moTcmenl in toy ot ibtta. I ibcrrrorc fori pcrfMilr jiintiAcd in aMn-rling idmi poiilivvW Ihe cunvrlnca* of mf fint lUiantni — thai thcrv ii no htrrvl moliun at iho RMr*|pilo.1tblal articolalion. Up laletnl mntcmcnl of tlic foot, which apfXHn hi laka j pkMU thb joint, atluallit oocunat ihojustdoa of the □« «aldi «>Ui Iho wlnfalui lh« klUr Imuc being bo firmlir cmbncnl by the ctumul and ioWRiol roallcolua U pirrmit of no laicrat Diovrmcnt whatever.
ASATOMT OF THE FOOT. 60
Hsving Btdtod tbat no nioUiin can oct-ar at the tiliio-tnrBol or wikle joitit, except jJexiun ami exfetishn, and tlint the pointing «( the tow out or in is iloiut liy tliu muwlea of tlie hip, as above dviKTibcd, it follows, OA a matter of vourw.-, tliut all tlic other nio- tioiiH of the foot, sm-h tt» twUtin^ the sole inwanl or outwanl, rniBing or d(!pre**ing the an-b, etc., niuBt ot-tur birtwfon tile joints of the other eleven buuce of tlic foot. Tlie toee, being merely uilarlimeiits, aru not considered aa having any inflticuco iu tJieee uiotion».
If we carefully exjuniiic t]ie foot, aa seen in Tig. 21, wo ehall obMTve that, between the oe cnhU and atttmgiilus behind, and the caboid and suiplioid in front, is tlie mwiithtaratU joint, a, h.
rn. tif-a. K Um n«dlu-MMl vUnklUn ; <■. lbs uUwnliii; H. VM vt nOdii K tb» MaptMUt
gding complotcly across tbe foot, ditHdiug it into an anterior Mid posterior portion, admitting in a liniitvd degree of i-vcry variety of motion — flexion, extension, abdntrtion. and adduction, aa woU Alt mtfltion inward and outward upon tbe long axis of tbe foot. I deeire to call ]iartinilar attention to Ibtr* ii>m|>onnd artip- iibitiuii in the tarsn^ beMusi^, by a nio«t remarkable oversight of auiguons tho very important part wltieb it plays in deformities of Uui fuel \ia» until very rueenlly )>een cuttrcly unnoticed.
The foot, as a means of support, rests upon three buttrcMes: tbe liei-I behind, which iti stationary ; and the first and fifth meta^ tar^o-pliabiiigeal articulations in front, which are sliirblly mor- ablu, i-apable )>otb of ex|Mnr|ingand extending, tburcby increatiiug the luiM of I'lipport, wbioli a<lda to the Bectirity of the body, and l»y this verj- expansion and extennton of the anterior pillars, or buttresHo^, gives clafttieity iu locomotion.
Between these tliree pillam, or points of baae, spring two
70
ArcliM : ODfi from the heel, reaching to the anterior two piQftre, narrow behind, and wider in front, calle<l the antero-po«t«rior arvb ; and chio from the two anterior pilliirs arching across the foot, tailed the transvente arch. The niitero-posterior arch U higtier on the inner than on the otiter eidc, and cannot be brought to the grotiml in the nonnnl condition of the foot, whereas the ' outer line of this arch is always brought to the ground whenever tlie weight of the iwdy i» borne upon it.
Let any one dip hifi naked foot in a pail of water, and then, while wet, eUind with it upon a dry board or piece of brown pa- lmer, and he will get an exact iniprewion of the part* of the foot which come in contact with the earth in supporting the weight of the body. {See Fig. 22.) It will be seen that the outer Ihtc
PM.B.
rw.K.
of the arch touches it« entire length, which ihun girefl it a firm ' and extensive base of support, whereas the inner line only touches the ground at it« two extniuiitiM, the eentTal part of the arch on the inner side being retaine<I in pouilion by the tibial itHintieus inuM.-le, which i« inserted into l)ie inner and under surface of the internal cuneiform and base of the P.nt luctatana] bouc«. It will, therefore, bo Kon that the rtrcngth and perfection of this an-h are greatly dependent u\>on tlie condition of the anterior tibial niUHcle. The importance of understanding the constmc- tioa and retention of tliis ardi will be more fully seen when wo come to 6tu4)y the defomiltieii of the foot, more particularly tali- pes valgus, or flat-foot.
We are now prepared to go on witli the titudy of tlie morUd
TALIPES EQUINCa
n
»
■Iterations in the fonn of the foot, which are more nnmerooft than thuf-L- affcctiiif; any other jidPt uf iLl- IkmIv. Thf finst van- vty to which I will direct jonr xltentiou i» that knowu hy tlie nume of talipes eqaiouii.
Talipm eijuiHus receiver its nainu fWim the position of the foot, fliuiulatiiig the hoof of u horeu.
The Ovformit^- eonuBts io t]ie nituii^ of the licv) and drop- ping of the anterior portion of the foot^ eo that the weight of tbc bwly ie borni'r upon ilie met«tarM-pha]angeal articulation alone, in»te!id of upon tlie three points above spoken of. (Sm Fig. 28.) The wmvoxity of tlie nrvh of tlie foot i« generally very uiucb inemnud ; and tlic concavity of tlie arch becomes more and more angnlar in proportion to the dc^jirec of the deformity. The tuea arc extended upon the foot, and tlie foot ia extended upon the leg. Sometimes the foot ii; »o much extended oa to mnke almo«t a stmight line with the tibia. Thid peculiarity in the defonnity in tuually oMtuctatefl with a ])aralyzcd condition of the extenHor miucles of the toea. Ordinarily, however, if theoe nttiAclM poAH-Mt t!ie power of contrn«.>tion, they voluntarily con- tract and elevate the toes eufBriently to enable the patient to walk npoo tlie base of the metatarsal bone of the great-toe, M ■cen in t^g. 23. When tho pamlyEed condition referred to is present, tliere is absence of power for lifting the toee, which necessitatee the nse of erutches when the patient walke.
Talipes oquinua nuty be either c-ongonital or acquired. The deformity much more frequently occurs tmdei' the form of eqni- uo-vani)t, or varo<H}uinu&. Tht-sv are also by far the most com- mon forma of dofomiitiea of the foot. The origin of these roriottes is usually congenital. Again, talipes eqninas may be paralytic or itpnetic; or tbc «pit»tic condition may t>e developed upon tlie paralytioi The latter condition niny be developed by long-continuud walking ujion the deformed parte, thcTei>y ex- citing inflammatory action, and when present will rc<inire t«> nototiiy before a cure can be i-ffeclLtl, If the deformity Is purely paralytic, it can l>e overcome by the application of me- clianical means and chi«lic force, which i^hall take the place of the parnlyxed muscles, until by tlie nse of electricity, friction, itryohiiia, etc, they luive been restored to tlic ]>owcr of proper contraction. The paralytic variety is easily recognized, from the fact tliat the foot can bo easily restored to its normal position ;
TALIPES.
but, wlien tlie force which has restored it is removed, the deform- ity iminediately returna. Tlie muscles diiefly affected in the (Wrtlytie variety are those upon the anterior aspect of llic leg. On the contrarj-, wheu the oquinos is Hpastic, it i« due to abnoi^ nial coDtntctjuu of the muscles upon the poeteriiH' aspect of the leg.
The next variety of deformity wlilch wre shall study ia called ■ talipes ralcanciiiu
'J'cUipet oalcaneut i« that variety of deformity where the
IM. N.
8utcrior poTiioii of the foot i« elevated, and the be«l 1> depw— d.1
{tk€ FiK- 24.)
This variety may also be <«iigcnital or ac<|uired. It is fre- tjuetitly ftecit a« a congenital defanuity, and all the cases which have falle)] under my observation have beeu of a panlytic nature. Tbivt deformity i* much more liable to occur compli- cated with varus or valpis, than to present itself unc(tmi»iicated. When ]MtraIytii-. tlie mu»clc« cbielly afTccte<i are the jnutrocnemius and solens ; and in the treatment to be adopted the application of artificial iiiuHt^H to take llie place of tlie paralvKcd j^astro- cuemins and soleus fonns an esential element.
Talipes ealfanfua is very often acquired. It may reeult from jumping, wreMlinp, or the application of any force sufficient to
RgyOVAL or CICATRICES.
78
I
niptiirc or cut llto tondo-Acliilliit. ft wcuk u^in m tlio result uf injtm'es received upon the anterior iH>rtii>n of the foot. A vtry common atunv iti thiti vuiiDi-clioii i» lliv ciiiitriciiil cuii- tnctton following bums. The gradual oontmcdon of the cica- tricial tisiiio overcomes the iictluii of the ■{itt^trocn ennui- ami iwleuti ninaclci*, tkud, aa a i-on^^tjuonce, the anterior [H>rti>in of the fiK>t bocomus elevated und the heel dopri'4M;d. Jii ull cnvit caccs, tli«refon>, it h an ext^-vdiii^ly im]>onimt |>oiiit in their nmitag^ nient to prevent \\m contraction during cinatrizatiou, and thue prtivtont the dofonnity. It i» irn{M>rU»t to kocp (lie foot as forcihiy extcmied iw po«Aili)v. Ry this measure, as a matter of course, you uiatttrialiy delay the cicAtrization, but you promote llie ultimate u»cfulne#» nf the limb v«ry eeaentially.
£xtend the ulwrated eurfacx! as far ns you can, anil let it hoal u slowly lu jiuHMJble. Tlii^ iK one methotl of management, and the one onlinarily employed, imtil another stop had hueu taken. By tlic old uictliod cicatrisation wiw allowed to go on from clr^ mmference to centre until the whole granulaling surface luul Uwn clo«e<l in, which n-as usually an exceedingly tediouM proccae. Xow the surgeon trauKplantit a number of little islands of skin to the granulallug surface, aud from t^^ch of thc^e little islands new skin grows and sprv-n^ls, and you litwl tlic wound by cicatri- zation as before : but it is from the new blood-vesseU foniied. giving as a far different cicatrix from that obtaincKl by the process tif granulatiou. The cicatrix is much more yielding, is i-ofter, and low liable to contrai'l. The aanie principle in applicable in th« tnntinent u( extensive bums about any of tlte joints, or Jii- rolving the palmar fawia.
vV case, however, may come to you for ti'eatinetit in which very great coutruetion lunt already taken [>lacv. Hie <(UC«tion arisMS Shall wo undertake to correct such a defonniiy I In many cn«4>« the deformity will he m great, and the deidruction uf llasnes so extensive, that nothing can Iw done. If, however, you nIiouIiI judge that an o|ienition would bo jiistitiable, never Miiiply cut across the adhesive bands, for no pennanent heneiit will fol- low your ojwration. Vou muet disMct away the entire cicatrix, ami then bring the foot intn \\t normal ])i>sitii>ii, and i-etain it there. leaving the wouiid open. As soon as gnmulations havo nuulo tlicir np|>carauce, and the wound has taken on a healthy condition, trimeplanting may be rewrted to for the purpose of
7+
TALIPES.
hastening and improving cicatrization. If yon mccecd in rcstop ing the defunncil ]>art« to tlicir iionmil position, soine artiticiat apparatus must be applied, and the application inuflt Ito kept up until tlie pati«i)t can voluntarily Hex and cxteiid the foot in the nonnal manner.
PtmtniioK of dcforaiitj- is therefore an essential part in the managenient of all injuries alTeding the nnt«rior portion of tho foot, but wiKH:iall>' bums. When the tendo-A<-hilliB becomes mp- tared from any cause, or is accidentally cut, the foot Hhonld be dreiwed in the poflilion of talipca cquinus, and the leg flexed upon the thigh. This position is to he ninititained until the tendon id fnlty ln-ttled, when pa**ivc movemenU should l>e retiorted to for the purpose of bringing the foot into it« normal position.
The following case, treated hy Dr. Yale, is a henutiful illnfr- tration of the «ucce8M tliat may bo obtained by proper treatment :
Cjt»f- Wound of Ankle, dividing the Tendo-AvJiil/ia ; lie- cowry, with J'erfni Use (if i'ooi. — *' Air. IJ., aged about t«'cnty- cigtit, 6epteml>er 1, 1873, stood on a chair, and jdaeed his right foot in a stationary wnsh-hiieio to buthe it. His weight being great, about two huudred jKiunds, the bottom of the luuin, already crncked, gave way, and the foot and part of the leg paaeed through tlic hole thus made. This occiirreii alwiit S a. m. lie was eoen soon after the accident by one or two medical men, who did not, however, permanently dress the wonnd. At 1 1 a. u., three boon after the accident, I saw the patient. The iueinorrhage had been quite profuse but apparently venoufl, and had then eeaM^l. The line of the inciKton was transverse directly above the os calcia, ita direction waa forward and upward, and was nn incli and a half deep. The tendo-.'VchittiA was eut off near its insertion, and ita short stump was plainly visible. The posterior tibial artery could be eeen beating umler a thin rovering of ennnective tissae. The joint apparently was not opened. Tlie cut rcju-Iied on the outer Hide to the posterior margin of the external malleolus, on the inner side to the anterior surface of the intcnutl inalleoliu. The anterior, one and a half or two inches, waa probably torn ratber than cat, Krom the anterior extremity of the lino a V-shaped piece of integument, with its a[>ex at the malleolus, was torn up, the anterior line Iieing about live incliMlong; the posterior line curving around, behind the calf,««ven or eight inches. Tho Hap bcliind was alao everted.
DIVISION OF TESDO-ACiraXIS.
T5
" From the wound I clcttiied out a number of Bmall chip« of tile tirokcii poivt-lain Imunii, aud also eomo cloto. TIib V was mn;fullv »>ti^l'lle«i into jiWe. The upper p«rt of the tendo-Ai-hil- lis vraa retmvted out of sight, tauX ooulil not bo rMchiHl. 'Vim Korfiu-ctt uf the w^iurul wcri> approximntecl an aroiirately as pOMdihIe, and Bti(ched,a vent far di-aiimgio being li>ft uu the uut«ide of the •tunip of ttuj toDdo-Ai'hillU. Adhesive pliuter, comprcsset*, and bftnitagcfi, were appUetL To keep the foot in a proper position, a Itiin buurd wa<t fiwtenod to tlio sole of the fool, tlie knee was flexed, the foot extended on tlie leg, the limb laid upon ito outer N^pcct, and this posterior extremity of the solo-bonnl drawn up- ward bv a corti tuwntd iiimie turnct of bandage encircling tlie lower part of the thigh. This rulaiued the limb lu the poution he«t odculsted to approximate the aeparatcd enda of the tendo- Achilliii.
"At night it u-ait nei'easary to nick the bandage around tlio wound, to accommodate it to the swelling, and to give an opiate.
"The after- history contains no poinlit of ti»]>ccial intureet. There were no bad symptoms. The patient eufiered from sleep* Icesnew for a few nighlH. Tin- wound healed ipiickly, except jn^t near the tendo-Achiilie. where, after the firvt clotiiiig, pua to the amount of a half drachm or thcrcaboutx collected Hcvcral times and required a small incision to evacuate it. The timh was kept in the {KMution above described mot»t of the tune for flro or six wcekit, until the wound neemed securely honied.
*' At llic end of two montlis thu patient tiegan to go to his bnsi- noM. At first he wore a shoe witli an npriglit support jointed opiM>6ite the ankle, and an elastic band behind to supplement the action of the gadtroenemiuci and relieve that uiuHclufrom too great i^rain. This was discontinued as soon as the disappearance of ico front the street* n*n<Ierii.| walking safe.
*^ April 3, 1873. — lias had pvi-fect control of the arlicuUUon (or some time, anrl wears no arttficiRl support wliatever."
The mechanical appamtUK iiwd in the treiitinent of twIipM oal- ■nen« differs soniewtiat in its construction from that commonly employed in llMi treatment of the other varieties of talipes, and can be better described here than under the head of general treat- tnimt. Tlic objects to Ik* gained are elevation of the hool, and a comeponding depret»inn of the anterior portion of the foot; con- w<|uently. yonr apparatus must be eonslnictod in a manner to
TALIPES.
meot tliv»c iiuticatioiis. With t]ic8e object* in view vou may construct an apparatne in tlie following manner :
Take ft tliin ymiv of board, n pivci- of cif;»r-l>ox or thin eliiii- gle, a little longer than tlio cliild's foot, cover it witJi ndhl^Kivlt jtlafilvr, iiud ffli^Ivn it to tlie .^olc of the foot, allowing tho hoard to project somewhat lnJtind the heel. When fastened lo ihi; aii- leriur portion of llic foot, brin^ tho foot lulo position, and thi-n carry the long piece of adhesive plaster attaolii^d to the pwleiior extremity of tliw board up along tb« posterior aspect of the Icp, and thcro set-nre it by means of a mller-bnnda^-. Sucli nit nppa- mtni* riliouhl be constantly worn until the cliihl is old enough to walk, when « elioe will l)e required. For tliiH purjjcwe an ordl- iiarj' rfioe may be used, having a steel sole. From the heel, pro- jecting A trifle behind like a spur, is sn eyiet. Two upright Ittrs are attached to the &ole of the shoe, one upon either nide, Imving a joint opposite tho nnkte-joint. Tlietc han tvnniuiite in a hand which gm-s around the upper portion of the leg. At the poetu- rior portion of this band an artificial muscle is attached and ex- tends to tho cylct befoit mentioned. (Sen Fig. 25.)
tu. ax
One or more artlfieial mnscle* arc to be used, according to the auioimt of tniclioti rc<iuiri'd, anil are to take tin- place of the paralyr^d muBclcs until they are able to perfonn their functions without artificial aid.
The af RT-iri'«tnicnt of laiii»es calcaneus is to Ik* condncteil upon the same jilan as the other forms of talipes. Tins will Iw fully considered when we come to the subject of general treatment.
TALIPES VARUS. 77
LECTURE Vm.
TALIPES.
TaUpes Vwtib. — Csumi of. — Cmte. — ComplicaUoiiB. — Case. — T«lipe« Valgus. — Cbuki oE, — Pml;tic Variety, with Cues. — Trealmeiit of the lame.
Gentlemen ; At the close of ray last lectnre I was Bpeaking to yon apon the mechanical treatment of talipes calcaneus ; to- day I invite yoar attention to another variety of talipes which has received the name of talipes vams.
Talipes varus is that variety in which the foot is inverted, and more or less rotated, in such a manner as to bring its inner snrface upward, and the onter edge to a greater or less degree npon the ground. {See Fig. 26.)
Fio. so.
The mnscles chiefly affected in the paralytic variety are the peroneals.
This variety of talipes may be congenital, and, when combined with equinua, usually is of such origin. Complicated with equinua, it is one of the most common forms of deformity of the foot. Indeed, uncomplicated talipes varus is exceeding rare.
When congenital it is usually of a paralytic nature, but it may be spastic, as the result of some influence exerted upon the ftetus. When the deformity is acquired, it is also moat frequent- ly of a paralytic nature. The most common cause, probably, is that form of paralysis known as " infantile." The child may go
78
TALIPES.
to bed npparentlj in perfect li«altli, and awal:e in the morning vritb tlif lower o\t remit iw panihvud ; or tliv cLilJ niav have coii\iiliiion» in onnsecjuence of flume peripheral irritation, Siu-li OA teetliii)^, the prvsenw of some Irritflting Bubetunce in the in- ttM<l)iio», ef«., etc., aiwi tlieae nwy be foll*iwe<l by jmraljus whicli perliaps may aflcc-t nil four extiviuitiw!. Gmduul restoration may go on until perfect motion is restored to sonic of tlio parts [d- vulvttcl, bnt tliere htill remains a paralyfliti of certain nni«cleti or gruuiHi uf uiii;cli<6, and ouuKci^ueutlj:, motion ii; lost and defor- mity developed.
Cask. TuHpea Yaro-Equinux Paralytiai, nltevdd hf ISa^O ' TetmoH. — Catbarin« K., ii^^-d four yvar*. No. IB WseLington Street. Tbc mother states timt the child, when two years of age,^ wetit to bed in perfect ticalth. In tbc ntonitng bi>tb lower cx- treniiticH were <'oni]>IeIely pBraJyMd. The probable faii«e wsb ad apoplK'tic effusion into the lower portion of tlie spinal eord.
After a fuw weeks felic bcpin to move the right limb a little whou it was tiekled or pindied ; these movements gradnally in- emectl until she liad recovered jHTfeot motion of that ^ide. The left leg remained iximlvKetl on tbo outer «de, causing a severe form of varo-cnuiniis, as seen in Fig. 27. "Wbeu her weight was
riB.ii.
put tipon it the rnrii* wa« very mitcli increased, tlio foot malting nlnioet a complete rotation at the nicdio-tarwil articulation.
The limb wan very much wastcil, blue iirid C()ld. T!ic pcronci mu»clc« would not contract under a strong Kidder's battery.
f>n the Irtth of Angnst. 1S(17, I applied tbo India-nibbcr ' musclcH over tJ»e tibialis anticnB and pcronci uuim.'W in order to elevate and evert tbc foot. The muwle was applied with only a moderate degree of tendon, bnt in lees tliiin half an hour tt Itad produced a marked ctiauge in the form and position of tho foot
CASE OF TALIPES VARCg.
Tlie chain -vctia sliorlene<l a few liiike, aud in throe \yo\tn she conld rtand ti[>oii htT foot, touching the grooud both with ttie Iteel and greaMue, aa in Fig, 28.
rui-M.
Kio, CT.
Electricity vm applied iu this caw to the outer and aiit«rIor portioiis of the leg from live to t«n minutee every other da,r, and the child ciieoum^ed to run nrouiid tut much um powible. The pliu)ter» and tin had to be readjui>led oocafiionallv ; but at the end of eJKht morith» i^he had so fur rccorered m, to n>(|uir« only the Blightvet oluetic, hooked into tlio oyek't of an ordinary shoe, and attndted above to her garter, With thiti filight fnroe ehe could vluvntv the toes and walk jwrfoctly natumlly, as seen in Fig. 29.
Again, talipes varus may be developed by blowe or otliiT in. jiiricK to tho niusclra, by which thvir nerrons supply is iinpAired, anil la*> of power cauae<l.
In thi« coBiiwtion I present a case which is worthy of yonr «pecJal attention. It u one of varo-ecjuinus. Tlie foot, m yon eee, is slrongly inverted, lhc heel elevated and x-cry mucli dimin- iilicd it) itiw, and upon the outer eide of the foot are large callosi- ties whit-li have redHltwl from walking npon it in this abnormal poftilion. Afiain yon will notitc- that the little toe of tlie affected fixit ia Very much larger than that ujion iho sound one. It lias been inritjili-d and tornient<!<l by tho almost conslant prewnre made upon it, thereby kwping up an excaaive amount of circulation, and g«n- oiiwliypertrophyhajt resulted. (.Sm Pigs. 30 and SI.) ITcre.tlien. vo have a pructical tlln.itration of the eamo law I Bliatt ho often lyr down to you, that constant manipulation, friction, shampooing,
80
TALtPEB.
deeCridty, etc., sre nf tlie utmost .wrvioo iii an attempt lo restore muscular power, fur tlie rcnAMi tlut llicy mtvo Io iiK-rcasc tb« uuiouut of circulation tliruugh the parU to wliich they are applied.
Fiu. M,
This foot is not At jircBunt in a condition to be cut, for the reason that these callooitiee are lofUiiied. This ib a poiut to bo
rn.ai.
rm-m.
taken into con«i<)emtion in the treatment of nil nuitftios of do- ffirmity. This foot elionW not be walked upon for sc^-eral dnyi,
TALH'ES VALOCS.
81
I
aDil thcae callofiities eliould havo coUl-wntor (Ircseiiigs applied to tbeiii uutil nil inflamnutory action liati 6<ulwid«<!,
[Tlio oftse was subsequentlv opuruU'^l upon, and wirtioD made of tlie U:n(lo-.VcIiilli» and plaiitur faiU'iH. Tbe first dn£«iug np])]ted wait tlic ordinarjr tward and mlliciii vu |>IiiHtor appimitiui illustrated in Fij:. 48. The Barwwil ai-i-ai-iUiis, Fig. 42, was subeeqiiently uwd, tttui the appearance of tliu fuot wlicn mmd ia Htiutniled in Fi(f. 32.]
Taiipu valffu* pn»«iit8 tlic converee of talipes varus, tho t»»- ntr bonier of the foot being downwurd. (Sm ¥ig. 38.)
This deformitj' ta mnch more likely to arUo from traumfttic .« tbuii any utb«r duturniity of tUu foot. It fro<incDtly n>- sultd from intlamniatioii of tbe nnkle-joint. It may retiult from a pull or wruiiL-li of the foot, rausiiig itiflniiiiiiiition of tho pcro- ttei mufclea and subsequent apatilic contraction.
Talipes valgua may bo conibiaod with uiininus or cnlcancUN nuking vftlgo-ofiuinus, or valgo-mlcAncui!.
Li aomo cuDca this deformity ia of a purely p,iralytii; origin. ThiacuUM boiiig unapprociatod, tha projV-titig Ixinus which make llieir appe-jniiicu at tho front (lortion of tho foot are vciy linblo to bo iiiiitlaki'n for "diR>ai>od lionvo," " pcnoHtcal tntiammation dependent upon scrofiila," etc., and are treated awording'ly, Tl»iiw CHUM I roj^nl as worthy of spoi iul con!-idcralif>n, and elial! dwell u]>on them suflidenlly. 1 truxl, to make them pc-rftvlly clear, lu the severer casoe the dufonnity is ao conepicuous as to be readily rcoif^nize*), but the lesa marked caaca arc very liable to bo ovcrlookwi.
lu tbe majority of case^ Ihif kind of tronblc occmm in iiersoiu who are ob1ig*il to sUnd or widk for many lioiu's in sticcesaion, 0
TAUPES,
tlicrel)j giving ooDstant exerci)^ sntl Mrain to tlie tibUlle-anticiM muscle, which Riipports the an-li of tlio foot, Fiiinllv, from over- work this iiiiiwIl- tifcomL-s jMirtiallv paralyzod, th« urcli of the foot settles, and ralgviA l>e<;tiiit to lie ilcveloptMl ; nn<I, as it iu- cnasos in eon^iifiicu of Uiu \osa of tliv arcJi of iho foot, tJio head of the scaplioid bone Itog'iiis to project, iinihic pix-8faiiiv is produced on n part of tlio foot not intended hy Xatnre to receive it, and iufliiiuToaturt' action in exHtcfl, whicii uiTcvts the staplioid on tlic inner border, and also tlie articulations between the two nineiform, cuboid, and ilic fourth and fifth mi-latarajil bones, and gives the patient thu laoet exquitiite and torturing pain.
When the arch of the foot is ])ropcrI_Y supported by a hcalihy tibialii^aiitiL'Ufi muscle, the articulating facets of the l>ones com- pi»ing it pre»» upon racli other, hO »t to i<u»tHiti the weight of tbo body without producing pain. These articnUr cartilages having no blood-vessels or nerves of their own, ai-e insensible topi-essore; but, when the arch of the fo<>t 1o«ct« it« proper support in eonao- quenec of a complete or jiartial paralysis affecting thu tibialis- nnticui* luueclc, thcso articulating Ijnects no longer pi«M^ upon each other ecjttally, bnt are made to tilt a little, and the pixissnre ia brought to ]>var upon the edges of the articular surfaces, where the supply of blood ■veRM'ls and nerves is niosit abundant, whidi gives rise to indescribable pain aud suffering with every step that 16 taken.
Tlie pntholog;}- of these cases is. first, paralysis of the anterior tibial muM-k' ; SL-eoiid, settling of the nrcU of the foot ; third, ahnonnal prcHDurc npoii tlie edges of the cuneiform aiid coaphotd bones.
Tlie prc««uro in tJiU abnoniial position produces periostea], it may 1>o osteal, or synovial inflaniination. niul then it is that tlie caw is «o often regarded as one dependent upon eonstitutioual disease.
Now, having arrivod at the tnic [>atholog%', let »b study their symptoms. The pamlysia of the lil)ialis-aucirns uiu»rlu can be detected by it^ wasted and flabby condition when cfunparcd with tJie same niuttcle upon the Bound leg, or with a normal mitscle wh«n both tile nnticus mustrk-s are afTo.-liil. The spine of the tibia will t>e much moiv pmniincnt than normal, the fool will be fthghlly abdnctoil, and any iacrcaso of the alMluction, either by traction or hy bringing tlie weight of the body to bear upon it.
PARALVTIC TALIPES VALGUS.
88
I
. uitn,
eausee pniit at the poinu licretofore mcmtioitod. Pn»(iare with iIh) tbniiib over tJiv bunlccs uf tli^ nrticulHtinj; FHirfaoeA of the ouiieiform unci acaplioid Iwuee, wlteii in tW iilniuniitil poeition, produces vxlrvmu jmiu ; but wlivii tlie ]in;«#iiru npon tbese bor- 16 removed, wliit-U may W <l<mc by rututiu^ th« foot iiiw'ard ntUiiig Ibc- aix-'b, Iho ft^ut will hu iiblu to bonr the weigbt of UkIj- witlioiit producing \}tdn. VixaWy, thvTe io hut twy ^tijht <!i-f</riiiit'j in tbt;iio cum.'js bonou tlioy ivqiiiru tlie niiiiiipnln- lion iii(lii.-Mo4l ill onlcr to «l«tocl tlie itreci?* nature of tbe (litRcuity.
The foUuwing case, wliick I «aw iu coiuultntioa with Uio kite Itr. Kra^-kowixor, ie n very ^lod tllustration of tlie disease or deformity of wbicli we are now Kpeiiking :
C'A»e. — On the Stitb of Doconiber, IST'i, I nm nxiuctited by Dr. Krai-kowizer U> see in consnliiitiim with bim Mr. II,, of Tbirty- niiitb StrL'vt,>'vw Vork,u(^ lio b.'K) Uvii lumc mom or k>»» for tlie liaat three yeni^ ^Vs the patient liad been t^iignUrly alTected, Miul lu nil tbe treatment wlitoli he bud ndo])C«d luid not relieved him, the doftor waii anxioufl to liave me examine the caee.
I foiinil Mr. II., It yonng man of about tM'ciity-tive, in iip-
i<nlly perfect henltli, ratlier miiacular in clevelopnicut, »nd lo niilk tiromiil tbe room nt tbut time with very Uttle di»- cofflfort. The doctor elated that tbia tiad be<.-i) bis eondition for the last three years whenever be remained quiet in hU house for * niimtM;r of diiy^ toother, but very moderate oxerei&e for ntie or tuo dayet wi>uld rause him to comphiin of jfrcAt |)ftin over tlie inner border of tlio muiphoic!, and itt n nurruw line ou the top and outer side of the foot, whieh correflpondod prwi*ely with the jiuictioii of tbe »oi.*on<l, third, mid fourth luctatarsil, with the middle and external cuneiform and cuboid bonce. Any attempt to liear tbe wei^it of liiK body upon this t<ingle font very greatly af{gnvated tbe (miu in ihc-w ^itnalioiiit. He liad bocu fi-e()iient)y blifllurotl over tlicw poinle, but at tbe time of our vicut they were painte*! with imliuc. The doctor etated tluit ut tir^t, looking Mpou it fi« ii rbvumulic ulfection, be had lreatc<i it »i.-conliii^ly, and tliu [Mlient biul n.-eoveit.-d ; but, llnding that exeivim] al- ways eaufied it to return, be bad »u»pieioii& of hi» dtajtrnoois be- in^ cornx-t, and wa« unable to satinfactorily (.'X]iliiin the ciiiso. There waa oo evidence of apecific taint or be woub) liave hus- poeted that an itK on^n ; but tbe nmn had uuver been allected witli Rv-pbilia, and the doctor, to iitnke as«»mnce doubly 6ure, bad
u
TALIPES.
seremt times trealod liitn witb iodide of potaiiMuin, umI eocli time liv would rei-orer from tlie puin, but ho witK dispowd to altrit)ute liie frL'cdom from pain to tlie reel he secured daring the time ho wa« c<»iifi»ed to hie room aiid not to tlic mvdidne.
The hi&tor;rof tbecaae was aafollowii: Tlireo ycnr« |treviou8, wlicn cromng the fvrry to Aetorin, oitc of the horses Hiiddc-rily ttecanie ahirmed when going on the hoat, and h« jumpod from tite wiigon, tiMid coiii^idcntblo exorlion to get his hoi-itee on the boat, and tinally was coiiipelWd to jump or opritig very forcibly togvton th« bout liiiiiiielf. Itoforu be bad croB«iod the river ho b^ui to feel « ali^tt pain on the oittxidc of hix sliiu-hone, and wlien he arrived at Astoria fonn<l himsolf i^uito lame, but not anffici«ntly so to call in a phyiiioian. In a few weekn this all pifised off, find b» never cumplaiiied of pain along hia Hhin-lmiic or leg from ttut time, but aftiir 8O1110 tiiuiitlu^ began to cmmi'lMtn of pain at the inner border of the scaplioid, and at the junction of the two cuneiform and eiihuid boms with the melalarsns, ae before described. I'pon a verj' eareful exaniination of bin two logs, the foot upon the right ^idc wim found to be A diotinet Valff»9, and upon the outer side of the flpinc of the tibia there was a deep 8uleii8 in which the finger cx>uld he readily placi.'d. Indicating tliat the tibialib-anticus muBclo had probably been partially ruptured at tlic time of the accident. The diamelcre of the two legs at thiit point showed itn inch and an eightli diiftiivnce. The peroneals on the right tudo were very rigidly oontraotcd, and coiilrl not be extended eo as to allow the foot to be brought around to its normal position.
The diagiio»i8 «'a«, tlici-efore, rupture or ]>aralysi» of the tibialis-anticua muscle, evontiuii, abduelion, and tlatteiiing of tlio £ooL 111 eonHfqiieiioo of this loss of llie flnp|)ort: to the arr^h, proeaore u]>on tliese abnormal parts occasioned the inteUH) pain at tlic points previoui^ly describtHl, and the retlrx onnlrRctinn from this pain produced the spasmodic contniclioii of the peroneale.
Dr. KntL-kowiKer was w> charmed wirh rho dingiioi^it! that ho requested nio to bike diarge of the case, allowhig him iho privi- h;ge of seeing it from time to lime.
I dressed him witli the Barwell dressing, as seen in Fig. 42, placing a tin on the outer side of the leg, and connecting il« to]) ivith an t^j'clet secured to adhesive pla&ler on tlie inner border of the foot by ludia-rubbcr vlaetlc^ so that by their oontntction
PORJT.PBESSCRE.
85
I I
I
t3ioy took Uto place of tbc tibialis-Anticus miisele. Tlie relief to tlic pain WHS instaiitiineous upon the sppHuitiun of tliU clastic ttteix, and thv pntivnt wm ubl« to walk about with great coiiiforU TIm cure, liuwever, was not perfect until N!dion liad Itwn tnndfl of the cx>ntra<-tur<M] peroneal niutK-1c«, wliicli whh done by Dr. lin».*kowi«.'r at uxy suggestion in the following Marcb.
Wlien 1 first saw tbie jintient I wm not »\v»Te of the prind- pie wbieh I Ii.ivl' since iiataMisliud, viz., llmt point-presure u]Kin iicontncture<l tendon, producing rvlk-x i^piLMn, ie an iiidicAtion of thfi noceasitj' of section, or we tthoitld luive divided tlicse niiiwclcw Imfore any otbt-r troUment was adopted. Finding tliJit I bad bimply gained relief from psin without making any iinjirovc-nient in tbc position of lilti fuut wben the elastic force was rvniovctl, I then examined bini, and diseovcrcd that pnwsnrc upon ibe coii- truclfd pcroni-jilii pr<.>ducud a reflex ciiMia. Dr. Krackuwizer tnib- eutuneonsly divided them, as before inentionM), when the foot wiia inUDtidiiiluly )>ruii;;bt with uii&u into iU normal pfvilton and rc- tuttLed there by a<lhesi\'e pla.'iter an<l a rtilter. The ^^'olmd hesled iu H rory few day», And at the end of a munlh, with a slight ebis- (tc tu biko tbe place of tbi^ tiliialiN, In; was eiiabliul to walk and ex- ervHijo OS well ns be uvcr tlid, and h able to do &o to this day, ^m- ply u«ing u etecl Holu wit]i an l-IovaIlkI arch to support bis foot.
1 buveiieenninnycases, of which the one ju!<ti'0pi>rted iitaiipoci- men, hut will only narrate; one or two, for ^Itll further illu&triition.
Cask. — Some years wnce a gentleman called on mo with bia little boy, who, be etated. bad been suffering for several yiwrs with eurofulous disease of tbe Uines of bis foot, IIc> bad applie<l to various phy«ictana and bad uH>d all tlic cotiMitiitional i'unicdic«, as well as local means, for Its n-lit-f without benelit, and wished Uiv to examine it. I found an open sore about an inch in dr- canifereji(« over the junction of tbe cul)oid and two cuneiform bonu with the mutalarsi) bime-s wbicb \t'ii^ kept diccbarging by BORie ointment which wa-* daily applied. The peroneal intiselea wore very rigidly eontivrled ; tJio foot was n splendid specimen ntvtilgtta; the Kuknis nt tbc i^de of the tibia was very distinct, in conlnul with the plimip condition of tbe other leg; tlicre wa« BO enlargement and projection of the sciipbojd bone, the skin over which w,» covere<l with the tinctnpc of iodine. As I waa going to my lecturu at that monieiU, and as I was lecturing upon dnb-foot at tlie time, I asked the gentleman if he would be kind
TALIPES.
onottgli in get into tlie earriiigo an<l let me Inkc tlie boy l)cfoi« the e\Mt». Ifc AtatM) that, a^i my «x])lnn»tiun was the first ch-ar one he had evei- Inul in rogsrd Ut the lioy's rondilion. if it wovJd be of any bciiffil to Bciettoe, he would go with mo iiioflt chwr- fiilly. I toiik liiii) to Itflk'viio Hospital Mt^liml Collcgi; anil euhculantfoaely divided the jwroiuiil iimi-cic*. The fwit wiw then mtorcd to itft natural poeition, nnd Mx-im\l thi-re by a «trip of lidhisivt- piaster parsed anmiul fho ftmt, and i-arripd np th* int^ido of lliv leg. the plaster ln'ing Reriired hy a wvll-iidjiisU-d rtdlgr, cure having k-cn tnlc«n to put n cotton pnd on either utile of thv inflwuod wiiphoid where the adhwivo plartor piiswul over thi» bono. I then onloivd him a tHum to bo made with nn ck-vatud inside steel sole, so as to support Iho arch of t]iu foot ; an iron rod, nmniiig under fho sole, eame np on the inner wde of the ankle, where it had « joint ; from thit^ |>u)nt a «teel spring long onongti to reiK-h aliovo the eidf, terminating in a bnnd to go ni'ound the leg. WIioii thi<i «tii>1 was bent outward, aad Becun'd to the c«If of the leg, it necessarily bent the foot hiward, and the stwl solo in the Iwttoin of ttio shoe susiainccl the ]>one8 of the foot in »iich manner an to allow them to reoeivc ]irc8Bure in iLeir noniial position, und g^ive {>erfcct relief from pain.
One wi-vic fivin tlic tUy of tlic opcmtion, tins gentleman again hn>ne;ht his boy with tlie slioe to my lecture at the collegw. The adhesive plaster was roniuve<d ; tlie wound ocrasioned by llio tunotoiny had firmly united. The sore upon the top of the foot not having vuttrcly hmlud, a greased rug was pnt upon it ; his etocking and «hoe having l>een put on, and the «ipniig nmund the ealf prii]M>rly adjusted, the boy iumiedi^itely walked around tbv room witli i^cifin-l c«w.
Case. DonhU Talij>e» VaJgu», or J^it-^ooi, from fTeaiimed AnUrivr TibiaU, mUttik-en ttnd trtititd fnr lihemniUic Gout; cured iy A lilftnal Forces to take the Pt/tee of the Weah^ntd JTmoIm. — Mr. M., aged thirty-two ; » veni' large nnd heavy man, weigliing two hundred and forty i>ouniIs ; proprietor of a publie tsaloou. Uu had been for ^nie year« afflietc<l vriih great [win in bin feet, ujmn taking the slightest e!cen;ise, more particularly when «t.tiiding behind bii>; Ixir. Ik-iuf; a free-liver, it liad been snj)- posed that he had rheumatic gout, and had bcca treated according* ly. Findingno pcnnanent relief, except in the horizontal posture, be changed hit> medieal adviser, and his new attendant, snq>eic-ting
DOnBLE TALirES VALGrS.
8T
tliero miglit bo a ^-pliilitk- laiut in the dlBoise, plnc«(l biin upon a liUiral iiw of jxitnpxiiini ntit) iron, in niUlitiuii to the i-uU-hieuiii, tine ti.*e <jf wliich lie was directed to i-oiitiniie. By a few weeks' coutliiiMiicut to hia bitt), liu would [itvariitbly y^t rcliuf front tJie pain in hU foct, Imt his fltotiuiob and other dige>4ive orgjim; hwl beooniL- M> iiiipjiti-i-d by tliv oonrtAnt liM of coldiicuin mid poltw- siuui, titnt after some yvun uf trcutna-nt ho slnudoned uU mi-<li- cai advtcv, and eiinply rt'Dcrted ti> hi^ Ix^ vehvn \ux puinftil attnok came ou, mid dLsi-uiercHl that hu r<.-ci)vured abont aa quickly by ruel aluiio »& hu h:td bufuru througli medical trvatnioiit, and, at tlio aunic tiitie, hu digestive organs weixi much impnivod ; hut ono or two days* et&uding beliind bis Uir would iitviiriably comiK*! hiui to keep to his bod tiie three or four dticcceding diiyii.
In thii; nmdittun, and with this history, he came umlor my TWV. irpDii hift Dukud fei>t he walked iti the most awkwarti mniincr. hie fc«t bwiiy very much everted, and Uie arch com- pletely broken down. PreiiJiure over the junction of the culwtd, oxtumal, mid iniddlu cuucifunn bones with tliu three mudijui iiictatiin'al*, nod over the lower and inner bonier of the ^capboid, gnvo intense pain. The libiid musclvi- on cither side wore very (lefldciit in development, and ho had no power of inverting or elevating Uie inner border of lus foot.
It! lhi« ea^c, I injected vlniTlmia ^oue iixtieth of a grain) into the tibial muscles, ntiil repealed it every twelve day«, and applied tlie liaru'ell dn-Min'; to botlt iwA, in #ncb a manner ue to take the phiee of the delicient tibial mn»:Ics, and the following day he nv iinmc<l his avocution of waiting upon eufttoiner)) at liia bar. Elec- tricily was applied to tlio tibial muHclen, every other <lay, for about three montlis, during which time he constantly woi-o the Burwell dressing. After tbi« ]>eriuil, »teel wilet, iiuide to lit the nrcfa of the foot, so oa to sustain tliem in the natural position, yretv worn in either eboo, and from that time to the present, over 6ve years, he has reinaiucil in jicrfect heallh and attcndit to III** buNincw^ never having an attack of rheumatism, gout, or any of his former Auiipoctcd mxiUulie«.
On reviewing my note-book, I find more than a Korc of ca^es slniDSl. identical with the thri-c just dcecribod, but I will only quote one more.
Cask. — " Mr. M. D. F., aged about fifty years, a very hirge and heavy man, ci^-il engineer by profc^ion, was brouglit lo me
TALIPES.
in tlie fall of 1857, from TTnlifnx, to ftee if it were poMoble to hare an operatiou performed upon lu» foot tliut might relieve him from 1)18 intense agony, and rcndur him <-n{)al)le of following his profit- sion, or else to have hte feet amputated at the ankle-joint, as etand* ing for any length of time, oi- locomotion, had be<.ioine almoet im- [xjsfiible. During the luet three vean he bad been confined either to his tcntii on the ishmd of Newfoundland, and vanoiis placMJ vhere he liad btien engaged in placing the telt^ragih-wirc from Port AubaM|ue to St. John's, or dec in St. Juhn'a, or Halifax, to which p1aoe» he had been carried xcvcral times for trealnicnt.
" In all his confiucmente ho tiad been Ripposed to have had rheamatisin, gont, or a complication of the two, and had been treated for tlietw diseases aceordiug to the best lights of science. He then reiiorted to all the various spctrifics that are adver* tiscd for the core of gout, euch ss Dlair's pillis White's pills, La- ville'it g^iccitic, Ilcynold«'e specific, and nil the other remedies that promise to cure the gout, but all without any re»ult except to greatly injure his digestive ui^us. His attju.-ks recently liad bo- come so much more freijaent and £>evere, that he was compelled at last to abandon the wurk, another engineer taking his place. He tiad formerly been an exceedingly active man — a great alh* Ictc — scorning the idea of fatigue or over-e-xertion, and during the lirat two yeara of his woi^ on the ishind of Xewfoiindlnnd had walked several times from Port Auhasque to St. John's, leaping cnH-l>», climbing crag«, and det<«ending olilTfi, tmtil at last his mus<;le8 had become over-fatigued. The tibials having be- come wasted in tone, flat-feet resulted, and, when the weight of the body was pliteed upon them, pressure was bronght to bear ■ upon the upper border of the edge of the junction of tlie cuboid < external and middle cuucifonn with the upper edge of the artie- \ ulating facets of the corresponding melntarsa) bones of each foot, Tlie under and itmer surface of either scaplioid was nlao exquisitely scnititivc, like an attack of acnte periostitis, a perfect counterpart of the other ease already describerl.
" I asked lum to walk Into tny inner otlice. This he started to do upon his crutches, ami, as he reached the doom-ay, 1 stopped i' him and asked him to place each of lii:« feet over the i<ill of the iloor (wliich liappened to be about the proper height to sustain the arches of his foet), and, after some peniiiasion, indueed him to lajr aatde his crutches and see if he could bear his weiglit upon
DOVBLS TALIPES VALCFS.
69
bis feet iit tbat pMitiuii. He nt timt lieHitatcd to malic the at- li<iit])t, bill, I>piii^iu«utv(l tltiit I would nut Wt linii fall, lio handed mc liis (.TUtcln:!', ami wtood erect upon liie fwt iiiid iniitittitlv burst into tears, telling bU brother who waa with him, tliat from this tbuv mi;;Iit thiiil< hi* iliwase ami the agimy he tuflVn'il wiw all lin,-l«'ii»o, but it w:u uut mi, and be I'uulil nut niulfrntaiKl how it was pciesiblo tluit niUiiig only three clays on the ship tbu liuiv luni (riircd bill) j>erfpcUy, for be was just as bad when be left Unlifax ii» he buil ever been in iiiir of hh nuiiierotu attacks, mid BOW he fvlt no (xiiii whatever, lie was not iiwaro tluit tlio Mip- urt lo the anbes of liis feet bad aiiytbiiiir to dn willi liU relief, md wan very urgent in trying lo |>ersn»<Ie bis brother tliiit he hud nut been playing this game in onler to he relieved from labor in that distant eouiilry, but that his disfasu was rtiil. I gave hirn hh cnitelies, and lukcd hiia to slop off tnnu the "ill of the door and stand upon the ovcu utrfacc of the flrwr without any sujiport lo the arebes of )iU feet, when ho sereuined out, iu the most in* tctuu ugoiiy. " ThoM? is that old pain liaek again 1 "
" I took two pieces of »ote-k>atber, and, marking tliom to fit his feet, ont out a pair of soli,* These were dtpj>ed in cold water until they were pcrfucily soft, and (hen carefully iiu>uli!e<l to the bottom of biti fcut and secured by a nieely-ad justed roller. Tlie (cet were tlicn pressed into Ibeir luitural Bhape, the leather finiily pressed up imder the nreb of each, and the feet held in this posj- lion for some time, until the leather had arcnnitely assumed the aliape of the bottom of his feet, lie wa* then permitlcil to go bouio. Fmni thevo leather models Mcsatb. Otto A Reyuderis of Chatham Street, constnided Mecl soles exactly nmilar and in- M;rte<l them into well-fitting boots, securing them at the heel by a rivet or screw.
"Some days after Mr, TEeynders informed me ihat the boolH were done, and had been «;nt to the brother's house in this city. 1 railed there, on my way to the hospital, to eiee him, and to my amazenu'iit found that ho had put tlicm on and was cnniing down-etuirs with Ida carpel-liAg iu band, and going to the depot, rotirlh Avenue and Twenty-seventh Street, to leave for his home in Ma^-)i-liuselts. Hy the uw of this artificial support be has \wfn entirely relieved from his gout, rheumatism, an<l rheumatic gont, without tlie employment of any internal pcinedy."
The muscle chiefly concerned in this {naralytic %'aricty h lliQ
00
TALIPES.
tibialU anticus, vrhieli failfi to snAtain the amh of Iha foot. There lire various metluHls of relieving this ])«rtitular fla«« of c»svi, but tliB following are aiiioitj; the iiKxst servicealde : In the liral jtlDoe, » et<%l H{>riiij{ tiiay bo (.'oii^lnK-tcd of thi> exact *\ia]K of tbe ardt of the foot in ita normal position. Such a AJ'rin^ imty be placvd in n xhob and fasleiit-d »t thv lievi, U-aving thv iiiilcrior portion freo to move a.i the n'eiglit of tbe l>ody is (brown it|K>n it. A psttvni for tbtf ^pnng L'Au be obtaiin-d by making a pbeter caet of the foot with its aivh elevnted to the normal jx^Mtion, and aftcnraitl the i^tucl caa bu easily fitted to mirb a model. A eboe Mid ttpriiig arnmged in tliia way will give support to (be ux'h of the foot, but before jx-rmaiiciit relief can l>e obtained vitality niiMt Imj rcBtored to tbe i«iralyj:wl nnterior tibinl muscle. Mr. RcNiulcrs, tbe inst m men t maker, has made an ingenious eonlriv* ancc which iif vcrii- ui>cful in Ilitf clui» of dcfonnitic^, which con- sists of un u))right bar on eitlier side of the leg, with joints nt the ankle, and eet-iim] to the koIc of the i>hoc. Tbvsu up- rights extend nearly to the head of the tibia, secured by a band behind and buckle in front. From the top of tliewi bat» a web-
FU1.M.
bing passes dovn inside the t)oot under llie arch of tlie foot, tite inner webbing having a few inchvii of ebrtic insertion. This webbiug ran l>e made taut or loose at tbe top of tbe Xntn by n buckle, m> that tlio sreh of the foot is Hustaincd when stepping by tbe extra support g^ren it by this piece of webbing. {See Fig. 34.)
APPUOATIOS OF DRESSnrU.
91
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Another nietliwl of trcabiiont h to nltncli to tlie inner eUle of tile Boll- of tkv ^liiii! nn iijiriglil strip of t4>riiig-«tCH.'l, linving s jiiiiif iijiiHHite the niiklu-joint iiiirf rlivergirij; from lh« side of liie log with a CTinsidonilili! angle. Wlicn tlio fuot U BCCiirod in micli A fthiKi, tUi' iipriii^ IK bnni^lii In rontact with the tihinl aUU' uf tho leg, Jinii tlii-n etviirwl. The action of tin.- spring id to adduct the foot nnd i^ivo ndditionnl liupixirt to the nrcli.
The most cHuenient mctliml of tit-titmeiil, Iiowcvt-r, nnd one equiillv wrvicciMt!, i* that hy nifsiiii of llie elanlic toiision wliioh u nflordi'd \ty RnnvulL's appunitue. ThiB ftppaiatiifi vrill bv fully dMcribi-*! when we wmie to the snhject of treatment of tiilipeii, and it is, tliuruf>iro, only nt'cc^'^ry (o kav hvrv that you »itnj>ly IiHr« to reverse thiK apiinrntni) bs applied for varas, to nmke Et «])• plicihle III the treatiiimit of valfi;iia. (Sse Fig. 42.)
Thi' n])]>:irntUK ltlll^t he m!i<k< pro{iorlionately atrong, Recording to the weight of the patient.
Tht-re nrc » few puhiw with regnnl to tlio appliralloi) of the dri7jising which deserve upocial mention, fhie of tlie pointji of tcndi^rnv^sA muy ho over tlie :«rtic-ulatiim of the t>cap1ioid wtili tlio intcninl otmeifono hone, which in evnctly in the line of tntction nudo hy the duiin to M'hich tliv nrtificiid niuBi-le is attacliud. Tlio precantion nhould, therefore, lie taken to p<h1 anntnd this inflnined point, by moans of adliesive plu^ti^r and cotton, applied one Htrip iipim another, ntittl it ttnttiiicnt thiirknf^ i« oblaim-d to prevent the chain from doing any harm by pressure. Tlie origin and in- Hrtion of the artifieial mniiele arc to he applied ni;j>wtively over tlic origin and inwrtion of the tihinli^i-uTitit-tiM mtiiX'le, and one or murt' iniis;-loa ni-iy bo attachL-d as the rase may reijuint. Yttu nbmild always ent n hole in the i^trx-king for the rhidn to {Kuts throagb, bo that the artificial nni^ole ran act freely ujion tho oiit- fiidi*. If hiw fA\ns* are woni they will oaufC no olmtriietion to a frw! action of the mu»c1e, hut if a hijrh slioe is woni it will lie n©- cewiry to cut a hole in tho upper leather through which llieelmln i* to [tas*, as through the atocking. When arranged in this way the arliticial miiiK'lc ran act without n.%truint. (.S^f Fig. (H.)
In mtHlerate casen, all that may be neci'saaty is a broad Rtrip ofa-lheiiive phiiitcr applied in (inch a manner as to give itu]iporl to the we.tkouod tihialix-anticim mtisele, and tirmlv' M-ctired in po»i- tJnri by mvsna of n rollcMuindagc. (&v Fig. 4S, /}.)
93
TAUPE8.
LECTUKE IX.
TALIPtS.
lUpMFU»Uri*.—CuuMorTalip«>.—Tytatm«iil.— Indication* for.— Wbc« lo bq^. — U«w to «ft«t » Cnn: viUioul Tcnotouy.
Grntlrxri : There is Hlitl nnother vnricty of th« deformity wlik-b wo have been rfiidjiiig, wliicli mtiet he briefly peferred to before pamug to (he ^tiuly of the cjiiim?^ au<I trcatinont of tftlipcx. It 18 the form which bns hwn aillcJ talipes cavtis, hut I prefer to spenk of it as talijyea ^antaris. I Ix-iicvc tlinl this varii-ty of club-foot is, aa a rule, acquired ; and that it Eometimcs resalts froin eom« other vnriety nlrendy exi:i|ing, while, at other time^ it is the result of direct injury to the sole of the foot.
It i» n very frc<juent eonipliention of other fomisof talipes, and coufiists in a sboi-teniug of the pliuitar fascia, by which the heel and ball of the foot are approvininted and the nreh exag- gerated.
Thii* variety i« often mistaken for talipes cqiiiDu«, and ecetioD of the tendo-Aehillis scconlingly performed. The resnlt is by no mvnnM beneficial ; the heel lis dimply di-opi>ed (o corre»|H>nd with the anterior part of the foot, and the arch becomes like an in- verted U.
OAtfiBR or Tampn. — I do not desire to discuBS at length the numerouis rem^e vAwtt:* which luivc been ae«igned for the cxi«t- ence of clnlvfool, and shall only refer to the immediate patlio- lo^cal condition thut produce* the defonuily.
The congenital forma are all due to some interference, general or locni. with the nuntial innervation of the part. So nnich has bwn generally accej>ted, but the real nature of this ncri'ous dis- turlinnce baa been for the most part mii^imderxtood. The prevail- ing treatment of l^ilipes is based upon the tlietiri' tliat the palho- logicnl condition {« a ?ipaetie mnwrular contrnctiim. The muHrlee At faidt in any given case have been considered to b« thoec that by contnidion would draw the foot into the jinsitiim which it ooct*- pi(«. Talipes eqainos is attributed to a spafilic coutraclion of tbo gulrocnemius and loleiiii muK-le«; talijtea ralcaneus to the i«me condition of the aiiterior muwles of the leg. So iu vani«, the
6A.VSBS OF TALIPES.
08
I
titiis] muscles, and, in vnIgtiB, tlie iwronenlii And the extensor lufiguit digitoram, have liecn coneidurvd to bo tliv eoat oi die- Buae.
The natural therapeiitiiTal inference from eiich a pAtbolugienI iheory wu tenotomyf aud it ncvordingly lini* beronie a jnW qua rum of treatment.
Now, experiment and ohscn-ar km have fully demonstmtc<) that in tlie immentie majority of rases the pathological chan^ is prociselr contrary to that which Iia« Icon believed to exiht. BpaMie eontraclion is the exception, paralvsis th© nde. Tlie muBclcs Bupp(K«d to lie in a etuto of Bpaiiiii are ri-elly cnntracting with only their nnniiat degree of force, which ppodures an escos- «ivo effect, simply hecause paralysLi) of the oppos^in;; miiMrlcA hm d(»troved the natnral hamionv of action which exists between
* m
tlie tnctile forces which govern the motioiiA of the foot. I have nid ptndyRta la the lesioii, as a nile ; I believe, rather, that iioarl; •11 cases of congenital talipes, (/" acamtrud unmeilicUdif oflfr birth, would be found to he paralytic in their nature, and that the ^|i;ism, or eontrrtilurc, found tA> exist in i^>mcoaK(» aftera ttintr, LH really a<''piii'ed, and due to irritation or inHanmiation of the muscles and fascin; involved, which inflammation ■« the rcsalt of their abnonnal position, and conseqneiitly secomlary to their pifiilylic cause, ^ot that I would deny the iio^ihility of such a spinal discAfe as shouhl caune a tonic Hpaam of the muscles exittt*
g in uUro; but, if sui'h aav* do uxi»t, they must be verj- rare,
d, for niyself, I Iiave never seen them. If any one doubts the panilytie nature of tltcao congenital do- fonnitics, let him examine the tirst cnse be may meet within a few days iifu.'r tli«! birth of the child, and lie c-annot fail to mark the gi^al ea-«e with which the defonnity can he reduced and the foot HBStorod nearly or <itiite to its normid povitiou, if he does not excite reflex contraction by too rapid and violent attempt!) at re- duction.
Wh»t baa b<icn «>id ahove, of the legion in congenital talipes, is to a great extent true of tin; aopiirod fonn. Ai^jinml tidipe» very gent^rally is due to the various kinds of " infantile par-ilyeia,"
bid) are the frequent seqaeliB of Kcarlatiiia, diphtheria, dent!-
ion, and many other dii!en«e8 in which a hloud-^wisoning exists, Ar whidi are attende<] with ^reat exltaut^tion. Very many of U» cMca of tbi« isort give a hiMory of iiaralysjs that ongiiiully
9i
TAUPE9.
involved tlie wliote of tlie lower extremitiee, tmd frequently the upper.
Some CAMS of aoquircd tAlii>e», hovevrr, are not j)amlj-tte in their cliaructer: these are occu»ioiial cnees do|xrndcnl upon <!!»- Quae* of the itpinnl cord, in wLicli treAttneDt cau be of little niso while the orifpttating disease ie nnciired ; caeoe following direct injury, wliioli I1H8 ('atiii«<l inHummntion and eub#ec|U«»t itliurti-n- ing and rigidity of miist-les and faticite; and certain c-a^es in wliich acquired ftpa^tic deformities are added to tlte pnraljrtic ones previoiirily exit^ing. This last is a verj- common condition of tilings, and doiilj()e«e has been the chief ranee in prulonging the belief in the spastic origin of most of these deformities.
To apply tlie»o principles to Bpeetal varidieeof tal)i>e«, wc must look for the seat of the di»eflse, not in tlie iiiuacIcii on that Bide of tlic leg tatcaitl n-hich, but on tliat from which, the foot is diverted. In e()uiniiH, iTl^tend of the gnMrocneiiiiiit'and soleua bdng epartically contracted, the anterior ninstlesof the leg are paralyzed. The paralysis ie of>eii to extensive, tint the only muscle retaining contractility is the cxteneor propritie jwliicis, whidi, acting alone, at length produces a miblnviition of the great- toe. {See Fig. 23.) In calcaneus, the gaetrocnemiua and eolens are paralyzetl ; in vaniri, the j^ieroncals chiefly; in valgue, the libiaK anil {KThu^i^ the long flesor.
The teat of talij>«8 has always till recently been supposed to be at the ankle-joint. If the ideas expi'e^se<l in our fomier lect- ure, when describing the anatomy of the iinklc- joint, conwming tlie motion poeiiible at the aetragalo-tihial articulation, are cor pect, then the only forms of tali)>c« that could conci-ni the ankle- jmnl arc those where the heel i<< raised or droppwl, eipiiiiuH aiid calcaneus. Examination of ca«eK of so-csltcd ei{tiinu« will m\Mtj tny one that in them (with the exception of tlie few acquired cases having their oriKin in a tnumatic contraction of the soleus and gaslrocnemios) the heel is little if nt all removed from, and can es'iily l)C re^ored to, its normal relation to the axis of the luiib, there being rndly n dropping of tlie anterior portion of the foot ; and tliat, as in vams and valgus, the defonnity takc6 place at the medio-tarsal junction. The defonnity of eatciineu«, which in dependent upon paralysis of tlie above-named muscles, does occur at the ankle-joint, and this I believe ii tlie only vari- ety of which this \» tnie.
SEAT OF TAUPES.
w
A farther Anatomipnl ronmn for ihe truth of tlm gtMem«nt rescartliug tim H»t of dufoniiity i^ tim : Of the twvlve muwles of tlie log whicli move the foot, nine, nutnely, Ihe tiliialii' aiittcue, vxteiitior prupriui; polliri^, vMi-iiJ<or luiigiii^ difiptorum, pvroneua tvrtiuA, lloxor longtii< polliciB, Hexor langn^ (Irptontm, tihinlii) po9- UciiB, poroneus IungTi>^ nnd pcrouuiitt bn-vtif. have tLiHr iiii-crtiun anterior to the nnKiii>tarHal junction, and bot three — the gnstro- crifmius, Bolen^and pluntaris — posteriorto this urtlfulatioii, these three niuK<'li^ Iinvlng a common inwrtion, hy meaitHnf the t«iid<}- Acbillis into thw ot caleis. It followtt, im ii matter of coun*, lltnt atiy defoniiity dependent njxjn an ahiionnal condition of theee three uiusfle«, iniust hjive \U Bcat at t]ic nrticulation niored bv them, namely, the Knkic ntid llic (-nlrdiii-o-ii«trHgnloid urtieula- tiMi ; »nd that, if uny of the oilier nine miwles be atfectcd, the re«uUii)^ dI»tortiuii will be anterior to the mcdio-taniial junc-
Tliin infereno!, drawn from tli* anatomy of the foot, wiU bo pmirlicnlly confinned by the olweni-ation of the rasea whicIi I •ball luive frc([tiLUit opportunity to pn-i^unt to you. It is a mnttor wortliy of remark how tint a denial U given to the otaienienti) of many standard works upon orthopetlic wirgery by the cuts with whii'b tiittKi} very works are illnsti"ated — the descnj>tii>n being oiado to accord willi a falae theory, and the tllustratiuDS being eojiled from Uie really -existinj^ deformity.
Tlie wrtiail diifphiet'mmit taking place at the medio-tarant junction is fhown in Fif^. r>9, which h n reduction from a tracing made by laying the foot upon a pioce of pai>vr and carefully cur- ryinp » b*itdi>eiiefl nmmid its cnntonr.
The hi<:ral divcT^p'tico Is rpa<lily pJiown by tracing npon a fiiace of paper the outline of Ihe sole of the first ca*c of vnnni that pruM-nt« iteelf, and com]i»riti^ thu tnicing with that of the nppcwite fiiot, if it Iw flound, or with tlmt of any noriniil f'x>t of similar sise. You will And tliat the deformity doce not c<otuitBt in n tW)>>t at Ihe ankle-joint, by which the loci* arc thrown inwanl and the hud oiitwanl, but t)iat tbo tlcxiou occurs at tho areh of the foot. The ImwI and posterior {tart, alK>ut one-tliird of the de- formed font, will coincide with tbiit of the nnnnfti one, while the atiteriiir [win tiinw suddenly Inwnrd at the middle of Iho tnrstta. (&e Fig. 35.)
Tho rcsHltaut compllentions of talipes nrv: the effects of in-
96
TALIPES.
flammation or irritfltion ; defeotive nutrition nf the foot and leg; and lite cSqcU of prcMurc iu clianginj; th« bon^' structure.
Inflainmnton* fti4ion is sometimes set up in the muscle* a* the result of (Ure<^ injury; tliin i* very frequently the ease with tlic faxekB and inte^umonte in the eole of the foot. Tlie re«n1t in either case is a permanent ahorteuin^ of these tinaueA, which be- eonio then one of the firgt o))«tH('le« to be overcome iu the treat- menl. Hat wntractu re ig produi-ed in another way. Tlie mu»- clcs that h»v« rcmainitl eoiind, if unirritated, rontraet only with A normal de^rree of force ; hut a conMant <>ourfc of irritation i» found in the malposition of tlie foot. Pressure Itcing made in abnonnal direction?, and upon )inrfAec« not prepared for ita re- ception, especially if inflammation has heightened the seneibility, cAuscB frequent reflex contractions of the mnBelei>. Cmti-adui-i is the physiological resnlt of tliis jnvtonffed eontraetion.
The effect of talipc*. in preventinff proper nutrition, i« wen in the atrophy of the teg, or entire tinih, the smaller mzc of the foot t* eomiuin.'d with \U fcTlow, m well a« its lowered tempera- ture and lirid color. The atrophy of the leg is due to the pa- Tslysisof one sot of muscles, and the gnulual wn»tinj;of the sound ones, (Vom want of the exercise necessary to keep them in projiev condition. The same want of exercise will partly account for the arrest of pjrowth in the foot, hut mainly it depends upon the dimiantion of the supply of arterial blood tent to the part, and
TBEATMEHT.
Ujp olwtmction of the ivtam of Uie vonimii Moo^l, cnumrd by ttie malpositiuii of the vesscU of the foot, A lioso will carry water ■ given distaneo vrith a certain forw applied, when tltc tube i« tmight and uDobetriicted; but the Bamu husc, with the eame amount of foixw, will carry the water a much sliorter dietaiico if the tnl)e lie Iwat ut aii acute anglf, and particularly if these an- CIm bo ii)crca«od iu number. So an artery, mipplying any pai-t, rill do it better when iu lU natuml pottitiou than it can do when it iroHiul u bono, or bent upon ileetf, which partially cloflca it« Jibrc, aud by uhnormsl preseura diminii>licH the amount of blood lowing thmugti it, within a giron apace of time. The veina also, by thi« distorted position, are prevoftted from returning the hhwd as freely a» natural, tliui caueing all deformed feet to prewnt the blae and cold appearance spoken of aboi-e as eo diaracteristic of tboni, which ia the result of i-cuoue congestion.
Moreover, when the disease is allowed lo continue till adult life, Hu octwil deformity of tlio hones of the tarsua occurs. Kot only is the normal relative poiiJtion of the bones changed, but ttio ang^ontinued prctitiure in the new poeilion briugs about cvent- lly a change in their artii-utar fleets. The weight of the body ti|>on thcw) deformed feet aggnivnt«« the dcfonnity, till the foot comes a misshapen mass, covered with callosities, and is wino- imos qiiito inadequate to sustain thu body without urtiticial as- sistance. Locomotion becomes laborious, painful, or oven itnpoe- ■ible. Wo sometimes mod adult« with deformity of so grave a ler as to make amputiUion and the u»e of artificial iixt a (>eticfl(-i.Hl change.
mnienpver the defimnity luis procw'dcil to the degree of alter- ing the lihape of the Ixmcs, we can Iiardly hope for a perfect cure; for, however carefully and frequently the deformity bo corrected, the bone« cannot fail to retTini to the new articulations which have taken the place of Uic norinid ones, if thu artiflelal means of retention be removed.
TRKAnrKxT. — Wo are now reftdy, gtiitlemGn, to study the treatment uf talipes.
From tJie charactoristHM of talipes above given, namely, tin ^malposition and defective nutritinn of tlie foot, it follows that the rime indications for treatment will be — 1. To restore the foot to its normal position. St. To assist the nutrition by all the moans within our raadi,
93
TALIPES.
«iich AB heat, friction, motion, galvaniHrn, injection of etrycb-
nine, etc..
Prupor treatment «liouliI fulfiU botli tlicsc indiMtiong ; many plans have been proposed that met only the former, and cork- qucntly the HucceAo ftttcndiii^ tiivm has b«cn inoomplcte. The second can hardly be aceompliBhed at all if tlie first be neglected.
First, then, of the means to be employed for ro*lorii-.g tho f(K>t to its normal position. AVliatever method of treatment you dc«tdo to adopt, there is an important ])rineiplc which should govern Its application, and this millet be taken into eonaideration at the very outMit. The pHneipk- !>>, tn»tnicut of congenital club-foot should b(^n at birth. TbiH principle baa already been laid down in my book upon fhib-foot ; but, as proof that it has not l>een an- nouDoed with fon.'e sufficient to attract the attention it jurtly deserros, I may mention that I have this day received a letter from a very disalin^iiiihod pliywian of thia city, onntainingan inquiiy with regard to the proper lime to commence trestmcnt in this ch»S8 of c»«*. Tr«atmfint oftfute com* sAohM he commtrnced Hie ituUmt the chSd is horn. The butty practitioner niiiy, [M.Tliaps, l>e exciwcd if he slinll tirxt Rce that the third titage of labor >« com- pleted, and the neceasary duties of the lying-in chamber dis- ebirgeil. but, as tioon m thew dutiM are clinchar^, the feet of the chihi rIiouM receive nttention, and the proper trejitment Iw in- etitated before the medical attendant Ivtivcs the boose. In cases of tK^ired talipes, tlie rule is equally important, and trejitinent should be commenced immediatfty «j>on (he }ftvipt of the injur;/. Every day, week, or month, tliat trcttmcnt i" nej^lected, dimin- ishes the chances of its success when finally resorted to.
In congenitAl talipo^i, if treatment i« befnin ftt birth, wo may reasonably expert that, by the time the child is old enongh to stand, the feet will be ^ nearly in the normal position that the attempt at walking will complete the cure, rather than aggravate the ease, as it will do when treatment lias been neglected. In u large majority of caaes, if proper attention is paid to the correc- tion of the deformity, from the birth of tho child onward, the font can 1)c made to maintain the normal position without the aid of tenotomy. The importance of this rule and it« observance can T>e seen at once, if for a moment we refer to the most serious obstacles which stand in tho way of NKOeaefuI treatment of talipes. T)»c most serious difRculliee are those which arise from
TUEATMEST WrrnoCT TENOTOMY.
99
the following conditions: 1. Advanccil Atsge of fiitt; di^Deni- tion in paralyxt^l luusclce, dno to proluii^d iie^lvct of lliu i>er- ,luntuu)ccol their nornisl function; nnd, 2. ElTecIs of intUiiuiiiatioD ^rodnoed in tlio miuc-lee Hud tatciai hy the irrittilion from walk- ing witli the feet in an almonnal position.
tlotb of these difficulties wiUd I>c avoided, or greatly diiniii- ■lied, bv early attention to the case. Thia principle of early trtiatmvnt appcirs to have houii nx-ii^ia.-d hy Hippocnttoj, who ■pplied proi)er bnndages immediately after hiilh, in cases of coo- genital talipes. Why this Bound practito Hhould ever have fallen ^nto disuw, it ii* impi.it)»iMe to eity ; bat certain it is tliat it was it^lected to fiuch an extent that, in the rargical text-booktt of fifty yoan n^ tlie -snhject t» hardly referred to (a ali^^bt mention in ell's " SnTgery " is the only rcferfntrii tliiil I tan find in any of the ake of that date at my command); and, in practice, so little
I done for the coi-o of club-foot, that wittiin a quarter of a ccn- ury it WAi> cxlrcmi-ly common t4> meet per^ns who had all their lives endured this deforniity, without ever having undergone any treatment for Its rclivf.
now can the deformity be cured witliout the aid of tenotomy t
Tho best means of euro would l>o c>>n8tant manipulation, and the retention of the foot in a proper position by the hand of an Ittendaiit. Tlii^ however, i» unfortunately an iinjMt««ible plan of
ktnient, allhonglk I have known cases in which a faithful nurse bos very eoasiderahly diminished the dcfurniily hy constant han- dling. No inntnimcnt oan ov<.t liave the delicute adJuMtnent^ tlie nice applii.-»tii)]i of power, without doing injury, which the hnmaa itand poiiflesse^ ; and the degree to whidi any apparatus approxt- nifttis the hand in these respects is the raeasuro of its cxcelluuoc
Still, much can be done by the tiand before lite drcwing, or iuslrunient which may ho selected, is applied, or during the inter- ^vaU when it is removed for readjustment. Tlie manipulation iiould lie made in the following manner :
Take the foot in the liandst and rub it gently with a shampoo lug motion. Hold it lirmly in the hands, and gradually press it as nearly BA )>o^blc into it« iiomiul po^ilion. While thiit i» being done, tlie foot beeomes tpiite white. When the limit of the pa- tient's endiimncc is reached, tlie foot should be allowed to fall bock as it was befoiv, an<] to reet for a few miniites. The opera- tion sliould ttien be repeated, and after several repetitions it will
100
be foand that, tpith verj:* little discomfort to the [Mitient, the foot can bu bronght nearly, or quite, to its normal poKilion. The ittanipulationH should not he continncd so long, or luwci with to much force, t» to excite iiiUniiinintion or rvflex contnirtion.
Again, tliD foot should never bo retained, by any drewing, any nearer to a nomml ]Mi«ilion than i-an be done Kith&ui eml8n<{i'riitg free drcuUtion. AVhen, therefore, you apply the Griit dressing, yon may not be able to reRtore the foot to it» noniial position, but must be content with a partial restoration, one which will [icnnit a free and unobstructed circulation in tlie parts.
At the second dressing, tlie foot can he restored olitl nearer to its normal pocqtion, and yet permit free etrciilation ; end thns yon will go on, iitep by step, until complete restoration has been ob> Uined.
If the foot is restored at once to its normal position and held there by some appamtns, rcgnrdlcse of a free circnlalion (iiidieatcd by the color of the toee), ^longhing will probably supervene, and your treatment will be delayed for ft considerable time. Tlio shampooing frirtion of the niuM^lee should be very thoroughly applied, and, in ndditiuii, they ^liuuld be lightly whij)(>cd with the fin^rs tntniiversely to their fibres. If a muscle be struck so that tlie blow fidls in the dirti-tiuii uf the fibre*, the contraction pro- duood if far less than if the blow I)e received transverEely ; the object being to awaken the paralyzed mnscles to action, tlie latter method is far preferable. These manipnlatioup, by drawing a large supply of hlood to the [wrt, very nuich iiioreni?e iti» nutrition. They shonid he repeated daily if possible, and I consider them of so much imi>nrtaiicc thfit I greatly prefer thufo fiimis of dret^ ■ ing which do not iuterfere with these ami other kinds of acoeaeoty ■ treatment.
METHODS OF DntSSIHO.
lOl
LECTURE X.
TAUrCS.
Titti««tn(eMHJiiotiJ).— MtthodiofDmrtng.— Spllnw.— AdhwlrcPUitiar.— Btfw«a'« Apptntnt.— The Avihor'* L'lob-Foot Shoo.— CN*b/H SubMHuU Tor iIm Shoe.— Kc>r« ApfWrmlUh — CtMt. — TaDpc* Viro-EquiMM,
GK.<m,EMB»: To-day we will continue our study of the treat- DMot of taWpw hy d*!ferihmg eoinu of Uie tuc-tliods of drcwiiiig lliat may be emjiloyctt for correcting (he defontiity without hav- ing recourse to tuiiutotuy.
To de«ci-ibe in detail tl>e various plans whidi have been sug- gested wou]d occupy loo umcli time. I eliidl niciitiou only (lie principal onets which are really valuable, and, sh briefly and dearly aa possible, point out tlm ttidiiiition« for, and objt)ction« to, well plati.
Tlie Biniplest of all is the ordiiiarj- roUti'4>andage. If the patient bctiUcvn while tli« csm! is yet recent, by hrm^af^ the foot lU near ila proiK-r [Hisitioii as poaeible, and carcfidly bandaging it to Ktuinit tliere,andby conntantobsorvalion and readjuBtnieiit of the dressing, a cui-e may eonii'timce be effected. Thoro are very coiiKidcrablt! obj«ciionit to this plan of treatment, viz. : it is appli- cable Ic) u very litnited number of ca^cs; it is very liable to get unt of order, and therefore demaudttcont^tant care; it has, more- over, an objection, in common with all which permanently cover the limbti by l>an<In^-s or bplintis tlmt it intcrfen.-« with Ihu nec- teaaary application of fridione and gaK'anism.
Tho gyptum handaijf ]>08»«^eii« the advantage over tliu last plan tliat it does not eliango its fonn ; the limb i^ aa Heciirely locked a* in a vice. In tlie detaiU of it« application, quite a con- siderable variety exists — some preferring to firtvt bandage the limb, and tlien to cover tlie bandage with the g}'pKiim mixed with water ; others, to fill the mcBlies of a loosely-woven cotton roller- bandage witli ttie dry powder, and to nioietvu it after it has bovu applied ; and others, again, to make from woolen or cotton cloth 8 rovering to fit the leg, and to apply to Ihiif tho pln^ter. These varieties are, however, immaterial; the property which gypsum posMMos, of " setting " when wettctl, 'u tho essential ono to bring into openition. The objections to this plan are, tlie weight of
TALIPES.
tho divesing, the iiii|i<>^iliility of inspecting (be limh, and of applying to it friction, electricity, et*-., aa before ineiitionc<].
A^tii, apltnU of sote4ealhfr and ijutla-jx-irfui liavc Lccn reo- oinmcndcd as a plan of treatment, A pattern is titled to the linil> held in tlie jKi^ition dceinxl. Tlic leutber or gtittft-percba ia eoftened by immcreion in water (if tlie former in xxsvA, raid valcr ta necesMiry, n« hot wotcr shrivels it ; if the latter, buib'ng water ifi neceseary to warm the material) ; it it. then moulded fir»t to tlie foot, after which tlic foot is gnidnally and slowly forced aronnd into iu nntural position, and finnly held there while tho i^-port of tliu splint is moulded to tbo limb above and secured by tiie continuation oS ihe roller, and csrefully held in tho re- quired position until the splint in hurdcniKl. Leather is to bo preferred to gutta-percha, owing to ite greater cleanlim«s and aocesaibUity. Both leather and gutta-percha are aiiperior to gypsum, in that they can be daily removed for i>ersoiial inspectiM), manipnlMliou, friction, thumpooiug, and electricity.
Another article wliicli I \m\e employed of Into witli f^^nnA satisfaction is, AliFs fell-eplint. This material is light, hait no offeueivc odor, can tw easily moulded to fit any irregiibiritivs of Btirface when softened by being dipped in boiling water, and hardens quickly by being dipped in cold water, and is com- paratively inexpensive. For the mke of convenience in its a))plication, I have tiad made for my own use a wooden model of the foot and leg of a child of nicdiiin) oize. Over this model tlie felt can be moulded with the greatest ease, and it Is suffi- ciently accurate for any foot within it:; Iiuiit>>; for the«e feet arc always smaller than normal, and can bo easily padded to fit the model.
Before applying any of tlie bandages or dressings above de- Kribed, the limb should be cnvcIojM'd in cotton, or, what is bet- ter, wool {the advantage of tlic wool- is it« elasticity, whii-h prc- ventH its becoming rampreosed or irritating to the skin, while it seems to l)c rendered foul by the [x-Tsjiiralion nn more quickly than the cotton) ; this prevents the ])ermancnt flrcssing from ex- coriating or unduly constricting the limb at any |>oint. Great cue slioutd lie taken that no fiHcign matter \re entangled in the fibrea of the cotton or baodagoe, as very severe excoriations and nkerations may be produced by them. I have been obliged to eus- pood treatment owing to a grain of sand in the cotton. Tlic small
ADHESIVE PLAflTET
lOS
shclU found in coinprebdcd sponge sometimes cause the same troulile.
A targe mftjority of congenital dcformitiee, if taken iminedi- at«iy after birth, oiin be i^\y rciitored t», and retained in, tlivir iiomul [Mijition \>y adhesive plaster. This (^n be applied in tlte follo^ving miiuner:
Cut n picue of otrong adheiiive plnHter (TiLiwV moleiiktii \» the beat) from tiro to four iuc-ltos in width, and of suBieivut k-ngth to go nciirly iiruund the foot and to ■.•xtend M»ne inches upon the tbigli. Commence on the dorsum uf the fuot with unecxtreiiiitj of the pltetcr nt ii tilightly obliijiic nn^Ie, and wind it around the tX'le Hmoothly in lite direction in which the foot is to be drawn ; thvn with the baud draw tlic foot a* neaHy sa possible into the natnml position, and cany the plaster np the leg and secure it by a wrIl-:idjuAlcd roller an far as the heiid of the fibula ; m the pliui- t«r was cut longer than the leg, the cii(! can then be i-eversed with th« plaster uut«idu, over which the ruller is uguin carried don-n the limb, and tlie plaster will thus prevent it from clipping. C^ire niitt^t be taken not to tuive thv plaster completely encircle the foot> and n few nicka cut in the edge ntart*t the ankle may be DOotMary to jtrevent stningulation of the cireiilatiun, when the foot hecotnes flexed. A xccond etrip of adtiesivc plu^ter may be npplied ill ihti uime manner mvr the first bandage if the foot refjnirea still greater traction than tlrnt afforded by tJte one applied flr^. I'hc same care, however, must be exercli^ with respect to completely encitvling the foot when applying tlie pliutor over tlio bandage as wheu apph'ing it to the naked skin.
Snch small points, gentlemen, may apix-ar to ynu a» nnworthy of mention, but tt is the neglect of the«e little things which has been the canse of many fnilnrm in the treatment of deformities;
Land I think, therefore, that nothing can be eo insignificant as
Jto be unworthy of ymir attention which haa proved in practice to
l^ba of real value to nic.
Allhongh this plan is frequently smvpssfnl, eases do occur in which the nitisnilar rigidity is too gi'cat to yield to manipulation, nnlcaa oonlinued for n longer time than cnn be gcncmlly given. A constant tnidile force then become necesflary, and the plan miggestetl by Mr. Richard IJiirweil, of I>ondun, is by tar the bcet- Thie consists in cutting from stout adhesive plaster spread on
'Canton flannel, or the "mole«k!n plaster," a fan-«hapcd piouc. In
104
TALIPES,
this »re cut several ftlipa, convei^mg townH the apox of tlio pi< for ita better adaptation to the part. (.^ Fig. 87.) The apox" of the triangle in paaaed through a v'tn loop witli it ring in the top («M Kige. 3& and ST), brought back upon it«olf, and i!«curod
no*. St. at.
by sewing. The plaster k finiily eecnred to the foot in Mich a manner that the wire eye ehall bo at a point where wc vrish to imitalu the insertion of t)i(> niuacrip, and that it ahall draw evenly on all parts of the foot when the traction i» applied. Soi'ure thia by other adhcaivo 8trap9 and a wiioothly-adjnsted roller.
The artificial origin of the mnaclu in mado sta fuDows: Cut a atrip of tin or 7.lnc plate, in length about two-thiixb that of the tibia, and in width one quarter the ciri'uitifcrcucc of thti limb, {See Fig. 40.) This {g i(|ia])ed to fit the limb ea well sa can l>e done (vnvoniontly. AlH>ut an inch from thu upper end farton nn eye of wire. Care should 1)6 taken not to hare tbia too large, M it would not cunfino the rubber to a fixed \K>int. The tin ie ko- cured Dpoii the limb in the followinf^ manner : From the Htout plaster abovo mentioned cut two etripe long enough to encircle the limb, and in the middle of each malte two slito jnat lar;^ enough to admit the tin, which will prevent tiny hitenl motion ; then cut a Atrip of planter, rather more than twice as long as the till, and a little wider ; apply this smoothly to the side of the le^ on which the traction is lo be made, beginning as high np as the tulH^rofiity of the tibia. Lay n]>on it the tiu. placing the npper end level with ttiat of the piaster. (&« Fig. 41.) Secure this by
BABffELr;8 DRESSING.
105
[parsing the two strips above tnentianed around tlie limb («m Fig. 4'2), tlien tnrn the vcrtiwil strip of p!nst«r upward upon the tin. A slit shuulO he iimde in the plaslwr whero it passes over tlie eye, in order that the latter tazy protrude. Tlic roller eliould then ho continued «niootlilr up tlio linth to thu tup uf the tin. The p1»itter in again reversed, and broughl down over the bandn^, unothur slit biiini; made for the eve, »tid the whole ^-curcd bv a few tnniA of tlie roller. A small fhiiin, a few iitdies in length, omtaiuing a dozen or twenty links for gradualing thu adju»t- ni«nt, ill then secured to the eye in the tin.
Into either end of a piece of ordinary Indiii-rubber tubing, about one-(|iuirter of nn ineli in diameter and two to six inchen In length, hooks of the jMltem hero exhibited [»e6 Fig. 3S) are fastened by a wire or other ^tjxing ligature. One hook (see Fig. 3d) is fxiitenud to the wire loop on the plsMti-r on the foot, and tlie other to the chain above mentioned, tJie varioiut linkn making the neceaeury changed in the ndjustiuunt.
The dreesing, when complete, ia shown in Fig. 42.
ru. U.— Pr«a B4rwtU.
Fm. 41.— noin BtnilL
The constant traction of this robber tubing is sufficient to overcome the •troogwt muscles, if they have nut already under-
too
TALIPED
gone structural changes,' i. e., if tlie,v liave not become contrno- (uped (ppmwneiifly riiortonod), or if fa«.'iiB have not become coutractud us thu iiitiuU of inflHiiimatiitn.
The adv»Rt«ge of this plan uf trcutnieiit o\-er an;r of the otben proposed, where the Itmh ie forced into its poiiition, and tliere pecnrelj- fi^o^l hy the retniiiing apparatus (whether it be plneCuruf I'arie, or complicatod machinery with Rcrewit and eogSij and wlildt caa only bo altered by the key of the attendant), ie, that it cauHoe iiKiveuiente in imitation of the natural iiiovenicnt^ of the parts; j>cnnitting and promoting the constant movement of the musoltt and jointi^ tliereby incrca^ng the eiivillation in the BBm<^ and necwswirily impruvlng their development and power.
ITlo joints and muscles of the hnman body wore designed for active motion, and w far m in ito^i^ihle tliese nntnml movenienta ehuiil<l be retained, stimulated, and strengthened. It is for this reason that I aln-nyii condemn any appftmtnis dcvi»ed for the euro i of this clasA of defonnities, that places tlie foot in a rigidly-fixedl |io«ition. Tiic deformity is ei«i-i>tially paralytic in itei iialnre, and treatment of jiaralytic deformities by retention in a fiscal ap- parntus, is all wi-ong. Rneh apparatus, tliercfore, as plsster of Paris, gntta-perciui, or shoes made witli a certain «!t of iron fa^t-j eniiigs and ttcrewe, by nicanfl of which the foot is Iwld in a certain fixed position, are erroneous in principle.
Tlic permanent fixing of any limb or joint in a stationary a| paratus, tliiiti preventing even the healthy mnscTes from contnio-1 tion mid relaxation, will eooner or later cause even these musclei I t« become atrophied, and undergo fatly degeneration ; and l-cp- tainly tliia pbui of Ircatinciit eould never have a tendency to develop the L-itent jmwer of a partially-paralyzed mUEcle; hnt, on the eoiitrnry, woiilil have a teiideney to place it in a condition bo- • yond all hope of ever again being able to perform its normal fuoo" tione.
I ntnnot, theref<'re, too frequently m^ the ncoe*«ty of mo- tion a* u means of piirmaucnt ctire, or too stmngly deprecate tlie ose, for any length of time, of any fonn of appliance whieh dtall prevent or materially limit the pri>]tcr movements of the foot. Witliout motion, the mosclee cannot bo restored to their nonnal
■ ir Uio rnbbire tabInK I* not ttrclchod hoTond rix CIukui iU leu^llt, U iriU OOBlinot * 14 oonuael to lu orl^ad IragUi for ao indcStille pvriixl of timb
lUPROVED SHOE.
107
i
degree of development, and consequently tbe talipes will be cured <jiily in fonii, nml iuft in rt-ality, and relBpse will lie tlio OAtoral »t><)iieiice of eucli iuojiiiplctv truatmcnt. Motion U tliu cwootiiil vIooKiit of euro ; au<l I tliink tlic eluef value of gil- vuni^ni and far.ulii%in, aa ]>n>niolvn< of muiicular growtb, lies in the inuH.'ukr cuutnii-tiuiis whu'li tliey proijure. Thu gniwtli 'n the teetiU of action. By tlie application of ttiu clastic nibbur, or ooii- ttiK-ting force, in jiist eiioli » degree of strength Ba shall overcoino tive (listLirt iiig iniui-W only, uftvr u tvuidon on tbom for A eliort time, iu oider to prudiicu futigiic, an<l ai^ slmll not prevent ttioiii from contracting by iin effort of tliu will, und tlins rvdi&lorliug the piirt, It coustsnt luotioa is prodneixl In llie deformed and partially p:iralyzed Ittnb^ similar to ttmt wliidi occtirs in the act of walking, wliicU will materially atset tliu circulation, mi»e the t4;nipcrfttiire of the part, and ui:tiiifett]y \ui» a t«n<leiu!y to improve its nutri- tiuo and iiicrcoeo its power. Tbo exact amount of force applied can bo re<^latvil .it will by moans of tlic ctuiin attached to tho tubing. The cliange of the hook from one link to another in- cre«e« or dcci-caM.'H tbu power Hccurdioj; as the length of the chain and tubing is diniini»lied or increased. A very little practical ex- pcrieoDO will Koon indiL-atu the amount of force rc<:|tun.-d in cai-h case. The only objection that can be urged againat tlitit plan of tntatmcnt ie, tlmt the adliveivti plaster will Eometimcs Hlide and chaitge its position ; will soon become worn out, and require fre- ([iiont rvuvljiixtmenlB ; and, whitt U the moiit annoying, will often, particularly in rery young cliildren, and in hot weather, so irritate and excoriate the skin lut to comjicl, for a while, the abandonment of ite appliuitiou.
This can be rc*nedicd to considerable extent by tint carrying a fbnnel roller over the foot and leg before applying tlie planter. Of eounw, this will r^iuire a more frequent appiicMion of the tlriiflsing. inaHmneh ae the roller will get loose and slip do«-n the
log- To permanently overctime or remedy this defect, I con8tructe<l a club-foot sIkk', on tlic general plati of thu '* Sc»rpa'a shoe," with a lateral KtiifCfi in the sole, for casc8 of valgus and varus ; the only dillL-reriee being that the motive jtower was tlie rubber tubing in plaiie of the ordinary different kinda of Rpriiigs witicli had former ly be«n naed for this purpose.
Jtist here it may be remarked that the shoe should not be
108
rALiPGa.
reeuricd to until the child in old cnougli to walk. It ib exc«ed> ingl^ difficult to properly adjust a slioe to tlie foot of a littlo child, and much more no iit a eaue of cliib-fooU It ii^ fnr better to u»e Bamell'fi apparatus or the sunple strip of adhe^ve plas- ter, or nltcrnato tlieiii, until the Uinc Hrrivcs when the child can valk.
As all distortions of tlio valgus and irsrus varieties iii> Tolve the incdio-tanuil articulation, no shoo is applicable for their treatment that has not a joint in tlie sole opposite tliii articulation, and any elioe for th« troilnioiit of theso varieties of club-foot that ban a solid or immovable sole is not con-j Btructed upon pbysiulogical principles, and is, therefore, wor tlian ndeat.
This dioe which you see here was constmcted in December, 1867, for a little child four ycare of age, that liad been subjected to tenotomy several times, and had worn, almoflt since birth, heavy ioBtrunientA of various kinds, ouly omitting them when the ulcere and excoriations were so great tliat danger was appre- hended from continued pressure. None of the dux* that lUie ha<l worn had been constmeted ui>on correct principtcA, viz., that of imitatifig natural movementa ; and the pair that site had on at the lime I tirj-t saw her had neither motion in tlie tolcs nor at tin ankles — in faet, were simple straight bars of Eteel, bolted at right^ aoglee to steel solv« ; and into tliote prisons the doctor had en- deavored to force and secure! the feet by straps and bandnges in different directions, but the pain was eo great as to requir^l clian^-i4 every few hour#, and frequently he had been compelled to omit the treatment for several days together, in order that the skin might la-al. And yet these shoes liad Iwen contrived and applied by a gentleman of very great reputation in orthopedic suigcr;-. Even when the baiidagos were jkIjuwIc^I most carefully, tlie child could only walk in an awkward manner, on the outer edge of the soles, being unable to balance liersclf unless held by an aasutant, no motion whatever taking place at the ankles or any of the JMUU of the feet. The fiither of the child, a very intelli- gent physician, kindly permitted me to exhibit the cose to my dasa in this room, as I was lecturing on tliat subject at the time.
The practical working of the shoe is so well described by tli editor of tlie Medieal OastUe, in the number of December 2S, '
AtrTHOK'S SHOE.
109
1807, that I will take tlie liberty of transcribing bl« report in tliat jounwl :
" Ah Impiiot-xd Olcb-Koot Shoe.— I>r. Sajro exhilltod and &pfi)l«d at bis
Uot l«ctur« a |iiur of cluti-fuot titot^ to tiie liltlo vbiltl uf Ur. , of Stw
Jvnttj, wliicli, In tli«lr necbuiiciil OMUtrontMn, dmo of BiipllMlluD, sod eflleiMcj pf action, »iiry*uei anylltlag of tbe klud we bare over »e«a, and trbkJt «rill doabtfau soon r«]>1ace &II tba eumbcrtorao niacbinor; liltbortu bi OM fat tbia nafortnuU oIum ordefonnilloa.
"Dr.SajrrorcKAnliabniMt all tli« mw* of club-foot u being otuparatftU origia, itad Lh«mforu tlw ncoMaity ariMa ot mxppU'mg locae artiUdnl, «oa* Mantljr ooolractiBg foroo, to tolui Uie placM) of Ui« psralyivd moaolaSi as the aaljr mMM, in addition to galnuun) o&d friction, tli&t la mooMarj to roitora tbein to tbelr oonns) [mmUIod: and bjr tbe proper adjualiaanl of ibis furoo
alnioUallof th««odcf(>rniitie«caii be rcctifi«d, witbooiraaortlng lotcDolom^T- Thla b oMlainlr « nsf penX lBi{>rovaDi«nl in tli«ir trontmoDL Tbe timpit jalufflciaat plaa aiigK«u«d bj Mr. Uarwell, of epplyiitg olaatic tabiog,
'/■
rte.a.
«MV»d at Iho (vitnts ioArtii bj the iiMinns of adboriro pl8at4r, haa tli* very ■Iritnu objection of irritAtiiiK U14 Hkin. vhleb, la youDK cbildrcn, la rerj aniiajrlng, coniuiltneH ntypAiit^itiiig oisiaiion nf its ofiplioatlon for fievcral davi, ■ad ol tbe anmc titnc inlrrf^nnit wttfa tbe maatpubitiDna and frictioiu wiiiefa ora ao eea«ntLal In tli«lr tri'utiiient. The aimplo but Ingenloua alioe OOBtrirad \ij Dr. Sajro i* »o conftracl«d that it can bo applied nad aoouritd aodtraUtf to the dafunned fool Iwfvro the cliulic foroo la attaobed, intlead ^ adjutltnf
fAUPES.
(At/wf to tit tSM, wMl* tha power Is scting, u ia the com in aD oUicr ia- Mmineiil*, acd tlii* i» 111* MMntiul difference iMtveon It and tlie ordiaarj sbuo with a Jointed sole now In dm<, after wbicli it ia modeled.
"Tlie McompMnj-ing drawing (fig. 48) ^t«s « verj ourrvoi idea of iu coBilraetloB and node of actiuo.
>-Tbo riiuc* wore B|>|ili«d in iliU iaitaiu^e with Uw mcwt tatisbctor; reaultts ibo tliitd in a idicirt time iift«r tbcir a4)u«tinefit rwDmng alMut iLo leoliir«-n>oni with bor fMt oo th« floor In u ualurnl )>oaitloii, wlilcb bad nm-cr \»ta aoooiniiliabed bj anj of the numeruas inttniracDla (he bad forwerl; worn."
In Jantiary of 1868 I improved this titioe by putting in the Die, opposite the imxIiu-laTval urti dilution, u haU-aml-aocket^ or liver&al joint, insteatl of the hiiigr-jniiil, which pennitte<l onlv lateral movements. Tliix sole and part eiul)nu.-iiig the hiwl con- siiits of strong shoet^teel, covered with leather on t>oth eudeii. Two Utural upright bar*, B, joiuted at tho ankle, are fiuteiu-d near the heel and to the co]lar-band ; O, ff, and /, are points for the attachment of arti6c^iiil niniiclee, made of nihhc-r tuhiiif;, with hooks and chaiiiA at their cmi*. To tlie inside wallft of the nhou near J, two flapii of chamois-leather are attached to laou together, whidi, pasoin;; over the frunt of llie ankle-joint, keep the heel firmi)' in the hack part of the &hoe. The atvi>ni]uni,ving figure shows the result of the last effort to make this ftlioe reeemble an ordinary one as much a^ i>oiMb)e.
1. Trace the outlines of the affected foot on a piece of paper. 9. Ciretimfvrc-nce aX I,K-^>-^^^
3. Len^h of foot.
4. Length from sole to hclow knee. &. Circumference of leg helow knoe.
In addition, the nhoc ha« hoen made more oomfortahlc and convenient l>y a plight heel, and by making the uoterior part of the sole like that of an ordinary slioc, and not w clumsy as that of inoft cluI)-fiKit shiics. Tlic upper leather luces neatly over the foot, adapting itself more pcrfc:;!!^' than if arranged with straps and buckles. (See Fig. 44.) The shoe as applied is seen in Fig. 47.
The sitoo pictured aborc is arranged for valgns or varus. There ta really no essential difference between the different forms of talipes, and the single principle is to apply the artificial
TOR'S IHPROVEr
111
muscl<i8in sndi position a» shall best Bnpplytlie place of thoM paralyzed.
My friciul siirl coIlMgno Prof. A. B. Crosby informn ni« tlml he has made n wry cheap and evrviccablv eub«tttutv for my h)ioo, in tlin following mnnncr : Ilnving procaral a pnir of fltout eliOM vrlikh fitted the p:itieiit well, he i!Ut the m\a of the one for the
defomtod foot quilo ncroe^, opposite the mcdio-tartuti jnnction. The two parta ho oonti(>ct«d by two linlpi of chaiti, and mnde the ncccft^ary evcr^ioti or iiivvrvion by olasttf*. If to thix an upright of tia or sheet-iron were added, for the applirdtion of nitiivlc^ for the elevating of tlie toe, I doubt not it woiild tcrve orery purpose in mty*X <ii«c«.
Sndi a rlevieo will bo of great acrrice to gentlemen who prac- tixti at a dii>l»nMi frutii citic*, and who, Ihvrcforo, find great diffi- culty in obtaining instriimenta. Many other siiccf(hnfii will doubtlca^ BUg!!Ci)t thoiii»4^IvcK for " necuwity it the uiother of iii- Tention."
Corlaiii t1iiii}*i« slioiilil be bonu' in inmd (to which attention haa alroady lieen called, but which will hc-nr repetition) in mak- ing any drri«ing : the aim of the drilling or itietrumont ia simply to imitate the action of the fiiirgeon's hand ; and that la bo«t whJL-h neareat aocompIiithcH this, or whidi moi-t readily permits the hand actually to be used ; accordingly, an appnnitiis combin- ing ulastlc force is far superior to any flxcd appliance ; and.
TALIPES.
moreorer, of the (Ircaeings cone<tr»rted on tIttH prioclple, that to bv {ircfurrL-il which is th<! irioet readMjr removable. Shoe therefore, are better than handsgos or splints. A proper die tniii^t linvc a joint opposite the iniiiti joints of thv f<)Ot — tlio snl and metlio-tarsBl junction ; it must be arranged for the mdj applicMtion and udjustnH'nt of (>liuiti(.> power, nnd it must nc girdle the limb at any point eo na to interfere with the circula- tion.
The plan of treatment devised and pniirlii<cd by Pr. Henry Noil, of Phikdelpliia, in 1825, und which was so well <iegfril>ed by Dr. John L. Attee, of L.nncfl*1er, PeiiiiMvlvanin, when dieeu«&-j ing luy report iit th« mectiug of tlie Amerieim Mediml Ab tion in AVaaiiington, May, l&GS, ii* tto correct in theory — viz., oomjK-lliiig a(.-liun in the partially-parulyzod muscles in order to. remove the deformity — tliat I give the «iibfttanre of Dr. Alloc*! roniark^ in order to claim for American siirgerj- tlio credit of Laring first i)ro]i08ed the correct or phyeiulugical plan of treat- ment. Dr. Neil, althong^i a gentleman of high professional etJUldiog and of great pmcticul ingenuity, waH not much of an author, sn<l I can lind no account of Iiia treatment, alllioiigli it may have been publiahcd in some of the uiedieul joumuk of that date. None of the medical gentlemen pre^^nt nt the meeting had over heiird of the plan before; and it i» dne to the memoiy of Dr. Neil tliat it Hhould be permanently recorded to hie credit. Tlic plan of treatment is einiply to fasten the child's feet to a board made to fit the solet* of the feet, and joined together op- posite th« ankte-jointe. The restraint is, of course, irksome to the child, nnd, in his efforts to kick liiniHelf out of the bandaf^s, he brings into action all the nrnsclea of the legs — nccoitiji'iitJiing the very object desired — and, iu llio graphic language of Dr. At* lee, " kicks himself straight."
To make an apparatus of this kind to fit tlie child, yon place his foot on a piece of folded pa])er, alwnt one inch and a half or two inches from its folded edge ; murk with a pencil the Rize of the child'ii foot, commencing at hip inner ankle, and going round the heel, the outside of the foot and toc«, and back to within on half inch of the starting-point. From these two points draw' lines at right angles to the folded edge of the paper, and then with edssors cut the double paper, and when unfolded yon have the pattern from which any carpenter can make, in n few mln-
NB[I.'8 PLAN.
118
at«R, tlio nci«MU-; board ou( of liglit but ctn>ng vood. {Su Fig. 45.)
A Btrip uf ]«atlicr is folded Into A loop iind naS1«ii at uitlier boul, ihrougli whicli a Etrlp of adhi'sivfi pliisior is pii^aeO, and car
rtod in a " fignro at 8 " over the instep and around the foot- tinont. BiicJi otlter Imndages afi are needed to M>c»re tlie foot in ]KHUti<>n arc of cotirsL- u{)[>lit^id in tlie proper tiisniiur.
I tinve tried thiit pbn in several ca.4es, and bave been well plraa-d with tbc result, but do not And it i\» saliKfactorj as tlic ^idliivtire plaster and Indiu-rtibbcr aprin^, n^ it giree tbe cbild contddurublo uuea«inn», and few motherH will mibmit to Itie oon- liniuinco of a plan of trentment which causes such distress to " the baby."
Cahb. Paralytic TalipesVaro-Equinus, — 11ie«iae now before yon, j^ittetnen, is a very good illustnktioii of tbe paralytic variety of ta)i[x.'H, niid also showti yon bow cftxily it can be ovi-rcome by an oLutic for^^e to lake the place of tbe pamly^ied ntitKcloa.
Tills boy, now eight yeara old, was paralyzed when twenty-ono RinntliN of ajre. Ho recovered frmn his ]iftmh*ittt; — with the ex- wplioii (if thw nitiMcIca of bis right leg — more particiihirly the IKjmiicatit.
lie ba« worn »lilT braces almost conntantly «incc be was Xtir^ enough to walk ; only laying tbeui by wlien the pressure had bttconio nnbcaittblc, to lie retoimcd again as aoon ns Uie points of Influniination would ponuit the application of the torturing la- BtrumontA.
He was sent to our clinic last week, you will remember, to have tcnotmny performed. Of course, I did not do it, as tho op- eration would only have increased his difficulty.
Mr. lieyndera has made for him one of my club-foot shoes, and Mr. Mason has this morning taken a photograph of hia foot
IH
TAUPESl
— wiiliout the shoe — aud ftnotherwitti it on. Both of these pit ures were taken n-illiin a few minutes of each other, mid huuuti-j full}- iltuHtnkt« tlio advantA^w of this i>tan of treatment; as youj now see, this boy walks perfectly well, with his fool in luitiiniL
FK.4&
position when the nihbcr oketica are properly adjuated. Figs. 46 wid 47.)
So much, gentlemen, for tlio miknngcnicnt of that class of eatai of club-foot tJint can be' rationally and eacoeesfully treated with- out resorting to any operation.
TENOTOMT.
Its
LECTUKE XI.
TkeaBamU (ceallnB«d>— Tmotomr.— Inllmtiana for umi^.— Draiaiag applieil aher lbs {ipi!niiloii.—A[iGr-Tr«»laii!iit.—Club. Iliad.
GEsn-BUKS : TIius far w« liav« been etudying tlic treatment >f talijwK in Uiyse ca-sea which may be cureil without r«iioi1iiig to llie knife. Unfortwnjiteljr, liowtver, the gi-cat nmjority of casee rtbat full under our «»ru require Unotoiny ; mid almost witliont Bxeoption require encli oxierutive ititcrfi'rcnce, )-iiii]>Iy Iwcause a mtioiiat Hicthud of tre»tiiK-nt 1iai« not been put In g^mctico early ill their hinlor^*. Thlii hringc> lie to tliu study of touolomy as ctin- net-tud with thu truatmeitt of dub-ftKit. From the puhlimtlon of Slmnioycr's work, in ISIll, dates a nuw vta m orthopedic Burgery. The openition of totiotomy, advocated by him, found many fnendti ; and, from the 8urpniLing nature of tit) nwullE, became Rpidly popular. Il w^ta brought into general iiho in thiii country by Dr. William Dutmotd, of this city, who luid himi^flf boeo a pnpil of Dieffcniiach and Stromcycr. The iinnien»c ad^aiitagee whivh thi(> plan of treatmcut puMCBRsl over the let-alone method fur eotno time rendered ihe profeHsion blind to the disadvantagos altviidiiig it. After a time, howovvr, surgeons notiood that all cases of club-foot were not cured by tenotomy, and tiiaoy that had app<!ared to bu cured afterward rohi{)6ed.
Tbti failure waa due in ewme cases to the neglect of proper after-treatment, but gviierally to the fact that the o^ieration of tcuoloiiiy was baaed in many cn«e« upon a faUo pathological the- ory, namely, tliat the deformity was dn« to a Rpastio oontractioD or abnormal shortening of the muKlo, tlie tendon of which was to be ent.
If what I have told you regardinjf tlie paralytic origin of most CAiMof club-f.iot b true, then the severing of the tendons of mu&- d«B still remaining wnnd is entirely irrational. The very beet reiiult that pould be expected frotn the operation wotdd be, that the nniscidar support of the foot U'ltig removed on all tiidea, gravity would throw it into a uonnal portion. The disoMO which underliee the distortion, namely, the pnralyaa, bu been untouched. And, if tlie tendon becoinw finnly reunited, tlicro
116
16 likely to be a compJot« rcIapBc of the tlefonnity ; if the union 19 incomplete, tlie foot hanga ae lielplcea at the ^d of tlie leg as tbe flail of the tlirexher.
But, wliile I believe tliat in cases of congeiiitjil or anjutrcd paralytic talipes, if tiikeu in Inind ojirly, tenotomy ia very rarely, if oTer, needed, caseR frequently present tbcmselves where, from neglect, it is absolutely etiseiitial, ob a preliminary measure to nil other trv«tnteut. Tiii^ie cases are tliotic in M-btch tbe faeciie or muscles have becouiv coutracturcd. liy contractrnvd, I mcMi A tinuo that baa undergone structural change, and cannot bo stretched or luugtbunod without severing its fibrea eitlier by the knife or force.
Xow, how is Ibis contracture to be diagnosticatod ! By tnsea* tbetixing the patient, and then attempting to redaco tlio de- formity. If the (-onlrai-tion nelds nntbout the rupture of any of tbe tissues, the condition i« one of simple contraction, and c«n be relieved wilhont section. If, however, the defonnity persista, contracture has taken place, and tenotomy or rupture of the shortened tisAiies in demande<).
I tuiro boen obligvid to cut tlio plitntar fasria in s dtild of only fourteen months of age, that bad walked Icsa tlian two monllu, and wti<»e history sliowed that the contracture had taken place during the laKt-named period.
The law by which yon arts to be governed in determining whether a mnscle, tendon, or fai^cia, must be cut, has already been fnlly laid down in a previous lecture, but its importance ia Bucb that I shall offer no apolog_v for repealing it. It is this: Put the parts to I'C examine.! upon the sti-etch to their fnllest extent, and, while thus stretched, press with the finger or thumb upon the tendon or fascia thus made tense; and if this additional point-pressure produces j^fftv contractions, tluit muscle, fascia, or tendon, nmrt be divided, and the point of pain is the point for tbe operation. If, on tbe contrary, the additional point-prcwure iJiufl ai)plied doe* not produce reflex contractions, the contraction can be overcome without cutting, and by the application of cou- Btant elastic tractile force.
A full description of the maimer in which tbe opemtion should he p<>rfomie<l, and the instruments to be uwsd, ha» ■Iso been given ; hence it will not now be neceaeaiy to go orer thtao subjects again. (Sm Figs. 5 and G.)
DBESSINO AFTER TESOTOMY.
IIT
We will therefore put at onee to the «oii»i(icrat)i>n of the drcfttiiijfil to \x applied after the opuriitiui] lua hwu porfunnml.
Af Ivr ilivi»io» of «iy of tlie tt;ii<]oiH or faw-ia for t!iu retit-f of the different diatortiuns of t\w foot, and hennetically cloning the wuiiii'1 in tlic iiiaiinor nlrc-adjr d««crihed, bring the foot immedi- itti'hj into its natimil |K>tiitiuii, orna nearly ao ait uin bu duui'^ and retain it there by tlie following dressing:
Cut A Ililn hoani (the top of & cignr-box answorfi very welt) into the tthiipc! of tliL' ^lu of tlic foot wbirli is to he drenncd, only a little longer, and aijnare at tlw toa
Thou take a piLvo of strong *'inolcskEti " adticairc plaster, aa wide ae the board, and long enough to cover Iwtb sides of the same, and to reach from tlio toe to fOine inclius above tlie knoc.
Apply tho adheeivo side of the pbster to the board, com- meocing at the anterior cxltx-mity of tho under surface, passing backward over the posterior extremitjr of tho hoard, and under tlic same Vi it» nntorior cMreniity ; the remainder of the strip ia autMe<|ucntly lo lie a])plicd to the nnlerior earfaco of the leg.
The foot in then pUccd uii the bu»rd, A^ and wciired at the htsol by a strip of the same adhoiiiivo plaster^ B, paseed over the laokle, and um-.ind the heel-part of the board, and a<]ditionally secured hy a well-adjusted roller, wliicli also extends above the ankle. The foot is now bix>ught into il8 natural position, and the adhesive plaster, C, is finiily drawn up aiui Bccurt-d lo the leg bf a continuation of tho roller; tho Kupcrfluous extremity is to be reversed, bringing its adhesive surface outward, -ind the roller, ouried back ovor it, will ho mure firmly retained in poititiou.
If ttie fool has a tendency to valguu, another atrip of plaster, D, \» made to nearly encircle it, and iit drawn upon the inner side of the leg tt> cunvL-t the deviation, and secured by a roller- hiiiidage. (Se« Fig. +S.> If tlu; dcfornuty is a varue, of couree this last Strip of plaster \b applied in the opposite direction, and securetl in thn aamo manner. I have found that tliiii &!mplu dressing answers much butter than " StromeyerV toot-hoard," or any other compU. cite«l form of appttrntus that I formerly uinployed. It is simple, tuexpensiv4t, an<I eife«tive. It is a plan of treatment tlial can be adopted in the country, without being obliged to send to the city for somu kind of machinery, and in far better fur the reason itiat, in a majority of cases, if you send to the inbtniment-tnukers, they will aoud you an apparatus that will ret^uire the Bcn'ioes of
118
TAUPEa
a special engineer to adapt it to the case, and then operate it. In a few instances where contraction of the sole exiBted (gee pages 129, 134), I have fonnd that section of tlie plantar fascia was not Bnfficient to reduce the deformity. Tlie integuments themselves had become so shortened that they would not yield, and their section was indiEpensable, and followed by a ready cure. I have
no. 48.
seen the same condition exist in long-standing deformities of other parts of the \x>dy.
Dr. Benjamin Lee, of Philadelphia, reported to the American Medical Association a case of severe talipes, of ten years' standing, in which he substituted hHsement force, or forcible rupture of the contractnred tissues, for tenotomy, the child being under chloro- form. Tie says, in his report of the case : "These manipulations were made with all the force I was capable of exerting, and were occasionally accompanied by the audible rupture of ligamentous or fascial fibres. They were repeated every third day for three weeks." It remains for further experience to determine whether, in cases demanding operative interference, rupture or section is preferaljle, I am unable to offer any opinion, as liitherto I have used only the knife, or at least have never used rupture alone.
AFTER-TREATMENT.
119
I Iiftvo, IiowDTor, eoveral tirnvs been obliged to force into place ligties, wliicb have become i1iiJ<x-jitu(l, or ratlivf eubluxKted, t>jr UiQ long ooiitiaiulDce of the defoi-mity. The comiilicatton do- mn most frequently, I tJiiiik, iu varus, the projecting poiiita being lie head of the atitragaliis and fttitvrtor portion of Ike calconetim, [ Bometimes the cnboid bone. This condition exiHted in canes re- corded on pnj^ 185, 187, 1^. The latter cnao, in particular, do- aanded so gi-cat an imiounl of force to accomplish the reduction, list I aiitici[iatbd ploughing of tlie integiimeitta. l-orliinalely this did not occur, tlte indurations and caJloeitiee almut the part being /doabtlue a »oun-c of protection in tliis instance. It is well, if mnch oroe ban been xia&i in the i-etluction of the luxation of thu bones, to institute Komo aftor-treatuu-nt, with a view to diminishing the liability to inllaniniation ; elevation of the limb, to\<\ applications, and slight compre;isiun uf the arlcricis will be found most service- able.
A^Hkii the tenotomy and bandaging have tlins na nearly n« Bible restored the deformity' to the condition which existed before inflammatory' action hiid taken place, the treatment proper can lie continued ju^ as if tlte ca^ were one of nncomptioated ctingcnital talipc)<, and the patient bo mndo to wear such drcsoiiigB Barwell's apparatus or the nhoea which have already been nSescrilted. (&e Figs, 41, 42, and 4t.) There Ls one prncticnl point, howevi-r, which may be mentioned relative to obtaining a shoe 9t a defoniied foot, and that is, do not measure tlio foot until it been unjblded and lengthetitd by tho operation. If thia precaution is neglected, it will almoAt invariably tiappcn that the will U' nis<it too small and too sliort, as seen in the last two . brongtit before you. Thu nest ini]>ortant part of the management of a caac of club- foot iH the treatment after the o])i'ratiou luia been performed. Wlien you Iiave done the cutting which may be necemary, yon have simply put your patient in a favorable condition for the com- vmcnt of the treatment whirh is to curt the defnmiily. The Brnlion may be nccessiiry, hut the case must receive a proper aftt•^t^e^llraent, if you expect to have any benefit follow it. Tlic Mmplc application of an instrument also, however perfect it may lie iu its construction, is but a small part of the Irt-ntniont of elab-fooL A< Boon as the external wonn<Is are healed, whicli is lUBally withui a week or ten daya, the foot is ready for the com-
TALIPES.
mencement of those paaeire moveraenta, manipnlatioiu, etc., tbkt contribute itio«t to tliu cure of tliv dufonnUy, JUndliDg the foot, gentlemen, is tJie great secret of curing it. Fri<:tion, eluni- pooing, wliipiiinj,' of the |>anl)-zQd mu»ck«, and the inanipula- tiouH so f ull^ referred to in onr ecoond lecture, slionld be repctitod daily. Ctux* arc constiintt^ cioiuiiig to an iu whicli tenotomy han been performed aa many as fire or six times, and y«t tlic dcfomi* ity remains uti bad as wlicn lir«t operated upon, perhaps worse, and whyt Simply because the treatment ndojitud (tfier tjio operation bait l>w;n that by means of ,/Ewrf appamfus, wliich wa» rcfprded as aufficient. What has occurred in bui-h catcsT The P«rta being permitted to remain in a quiescent state, adheaiona have taken place which render the case as bod as it waa before the operation.
'• The more frequently the foot of the patient is manipulated, the greater will be the benefit derived from the operation, pro- viding the manipulation tit performed thoro\ighly,hut gently, and nevtr carried to owrfattgue. Electricity is a very powerful ad- juvant for restoring lost musnilar power, and eJionld be used in accordance with ibc rules ali'cady laid down, namely, always ap- proximato the origin and insertion of mnseleH to such an extent tlmt they will not be compelled to carry any weight whatever, and maintain them in tlint position by some artificial support, while the battery is being u»ed. Again, never continue the cnr- reot Bufficiently long to produce exhauaHctu Strychnia ia an- other valuable agent in many of these c«««s, and ii<> (o be admin- istered according to the directions already given nnder the head of general treatment of deformities. Tlie nurve should bo in- strncted to watch for the occnrrence of excoriations, aa they, if allowed to take place, aeriotuly retard the treatment. To prevent diis, the appUrtitJon of astringents bIjouM t-e f rpijuently repeated. If the trcfilment adopted is snch as to rcKjuire liandagoa, extreme care sliould be taken in applying and rtapiilying (hem. It may appear to you like an indgnificant matter, but a ungle thread of ravclings from a bandage may npect the most seemingly c<jin- plcto surgical dressing; and it may do this by girdling the limb. If at any time the dressing ^rea the patient vcrii' much discom- fort, remove it at once, and endeavor to find out why it does so ; for such timely precaution may save yon weeks, perhaps rnontlif, of oeedlees anxiety and care. You diould always bear in mind
APTEE-TREATMEST.
131
thv fact that these feet and liiiilxi arc niiich more uneitivc to beat Dtl (x>l<), niid all forms of irritation, than ia nutnral, and at the
111) lime, liiiviiig much K'hh vitiilitv, will nlougli niu«h mom A very common place for sloughing to on-ur is over ilus, whepo prceeure often hwonii-i* nepi'ssiry in order to restore the parts to their normal jKifiition, Care, therefore, should be vsvrciMKt in applving HUtrh pressure. Pn>ft<»rc about the ball of the toe is frequently complained of, heiioe that part shoald Iw especially prolLVted.
Tbe treatmont nhouM lie perwrered in for a long time. Tn the most favoralilo rases s few months mar euflice fur a cure, but, M a nilc, the tn-ntiiioiit xhoiild not be rcla:(od when the de- formity is apparently atrcd, but slioiild be continued with the hope of devclu])ing tlio paralyzed nmsclee to the ^inc or nearly flte same degree us those of tl>e sound limb. If this be aecom- pli»hed, relai^M can hardly take plaoc.
It is trao that in some i-ases the disease of tbe nervous system h so great lliat wc may nut restore the muiwlcs to their normal contraotion eo soon as we would wisli; but even in these, the niou unfavoniblc of eascA, by the n«e of an in«trumcnt for retain- ing tlie foot in plare, w« sliall nt Iwwt have prcMrved the natiiml poxition of the feet, mid thus have prevented the hideous dcfonn- ity that would otherwise have ivsiilted; and, by the apgdication of nrtifii'ial ttitisL-lce, to take tlio place of the paralyze*! once, Lave eaibled the patients lo walk without limping. The exercise they am thus enabled to take, while the blond-vessels arc held in their natural relation to other part«, Ih the very best method of devel- oping thii gr.>wtli und nutrition of the liml>a. Whereas, if they are permitted to walk without the feet being retained in their imtunJ position, the weight of the body has a tendency to jnereaso the doformity, and the abnoniud pneilion of the blood-vessels, bifth iirtei-ies and veins, interferes with the natural ciivubtion of the parts, prevents development, and in fact tends to atrophy. Tbo faradaie and galvanic currents will aliw have a mneh more benefimi effect upon the limb when retained m its natural posi- tioa, tlian they hare when applied willi equal power whito it a distorted.
Tliis, gentlemen, conctude» what I have to my upon the sub- ject of club-foot in the theoretical coui-se ; bnt in my clinical lect- ures I »hall t«kc occi^oD to reiterate the prineiplcti now laid
122
TALIPES.
down, while T demonstrate them upon the caaes brought before you,
Tlie followiug CMM, tnoet of which were treated beforo tho daes, will terve to illuBtrate the principles I Itave endeavored to iaealcate. Some of llicm liave been already pubiiahitcl in my "Mannal of Club-Foot."
Oa«b. Double Talipts VaritSy eonyeniUU; treated by Softi- Leatherand Adhesive J'latUr; liecowry perfect. — On the Srtth of March, ISflS, I was requested by Dr. C, of New J«ft<.'y, to eee hiB little child, five daye old, wtio bad been bom with talipes vnnis or var(M»|uiniu of both fevt.
I saw the child on tho rame day, and found him very vigor* 0U8 aad robiiet mid exceedingly well dcvelojx'd, with tlie excep- tion of his feet, which oxhibitetl a very severe form of varus, with slight e<|uinu», and wlucb arc well roprc«eiiled in tig. 40.
Tlie feet were much colder tlian any other part of hit body, and quite blue or purplieh in color.
By grasping the foot in one hand, and the teg in the otlicr, I could with ftoine oonitideralile effort, continued for a few minatea, evert the fool, and slightly flex it. The capilhiry circulation eeemed to he nrrc^ted entirely when I did this, and the foot became as white as Know. After holding it in this {Ki^itiou a few minutce, I would relax my hold, when tlie f<xit would iuime<liate}y resume ■tsabuormal position, and in a short time circulation would retuni to it aa at first.
I then perfonned the same operation on ttio other foot. After repeating tht.'Miiiaiio'uvreH a number of timex on each fiwt, allow- ing Bome miuules to vlapso between each effort at elniiglitcning Iheui, I fotmd tliat I could bring them into almost a natnrat pou- tioD, and retain them there by a very eligtit force.
CASE.
133
I then wrapped the fact anil legs in cotton, and npplied a piece of sole-leathor pre\ ioiiHly softened in cold wntcr, and cut into the lluipu of A half-boot.
After the roller had been carefully adjusted, and the leatlier ■Kumtcljr iiio^IeWl uijoa his foot, tlio fool wa* fon'iljly held tin nearly ae poi^iiiblu in itct natural position, while Uie rollui* ecctircd the reft of the lusther to h'lB hg.
It was then held iu llii» position with the two hands for a short time, until tho tcatlier had recoivod ite forni, and, when perfectly dry, it held the liuilis very ecfurely in place.
Thf!* IvaiidiiKt'S wore removed on the third day, and the feet and legs well nibbed and moved in all dirL-tlJons. The leather WAS then again aoftcned by eoaking in cold water, and rwppUod M at first, with the only diffci-eiice that al thiB time the feet wore forocd eoinpletely ni-uniid into a nntuml jtot^ilion, and held there, nntil tho leather became dry and retained tbcui there. Tho (Mndages and Icatlicr wore n-niu%'ed every day, and the feet and legH fireely rubbed and all the joints moved by the uuiim.-, after which the bandages and leather were reapplied.
Thi« plitn Wiu par»ued for five wcek«, when it wait fonnd that the fei-'t could t>e retained in their natural potation by a very ■light force. 6trip« of adhesive planter wore then applied, com- mencing on the dorsum of each foot, pa.ir>!ng around the inner margin, aixl then, the foot being held wdl outward and flexed an much aa possible, passing upon the outer side of tho I^ where they were secured by a roller.
This anewered tlie pnrpoee of holding tlio feet in a natural podtion, and at tlic Mine time admitted of slight motion at the Icle- joints.
Thin plan wag continued for some weehu, until tlie feet ro- iled in their nonnal position without artificial aid, when it
idiaoontinucd.
Tho child began to walk when iiixiccn monllu of ago, with tlie feet perfe^-t in form and development.
The photograph, Fig. 50, taken April, ISrtS, five yeant after alt troatmetil wa« tiuepundcd, kIiows how well the feet are devel- oped, and the perfeclness of the recover^'.
Cask. Congenitni- 7'aUpf^ Ju/uino-Vai'y*; Tmotomif per-
formed Three TtmeavSthmtt J?--!i>f f/tfu) D^orm'dij ; Pfrma-
'it/ retiexxd I'j Indla-ruhler Muadei and Elevincity. — ^Walter
TALIPES.
C, aged three, New York Cihr, was hrouglit to ine, May 17, 1863, for wi.-1l>fiiarkcd talipes varus, wliicL m-sb c^tngt'iiital. The mother Btat«(l that " at birth the left ftkot was much tiuialler tliau thf right, au(] voB almost without ni>v hvel ; the vholis leg was a
FM-H.
little smaller than the right ; and tliat the seneation of the Umh was very imperfect, hut never entirely ab«eRt." The note of treatment at tliat rime in my record-book is; "I divided con- tracted muiicle* (tcndo-Achillis and tibialiH antini»), and brought the foot into position by adhesive etrajis. Progrefis rupid and result eatisfuctovj."
I had divided the muscles, liaving full faith in the necessity of tliis trejitment. The defonnity was reduced readily, but, as will be seen, the tme disease was not removed, and consequently tbe deformity rutumod.
Mai/ S3, 1807. — The boy returned, being tlien seven year* old. Tenotomy bad been perforn>od three times in all, but with no satiiifactory n?Mull, although ho hiid worn a variety of club-fuot liboes. The foot was much smaller than the other, as was also the tcfr. When standing, the foot heetime almort com])IctcIy in- vertetl, and the hwl drawn up, the wciglit coming upon tlie dor- sum of thv foot, jui^t behind the Uttlo toe, and the one adjoining, near tho mclatanwi-phalangeal articulation, at which place was a liirpe rallosity. which was very tender. Tho ni-tragalus wn« snb- lnxatc«] forward, and cauld he diMinctly felt in front nf tbe tibia, making a tcrious deformity.
Ibe foot could be (jnite readily brongbt into an almost natural
CASK.
]S5
I
position, with only a modoratc ftmoant of force, ihowing conctn- fliv«ly tliftt tliu (U'fMmiitj- wjw ono from paralysis, nnd not depend- out apoij nay almomial ooiitriiction.
I Applit.'d tJic Indift-riiUhur tubing on the onter side of tlio leg — aoeopJing to the plan of Mr. Harwell— ami tlio foot was almost imine<luili^)y liwught iuto its untumt iHiwtion. By :> very iJIglit addition to the tliicknosa of the hL-c-I nnd Kok- of hi« ehoe, to e<:|uiilu!c ihu Unigtii of tltc liiubs, be walked almost naturally in a very few days.
Tie was dirtx-ted to nin aronnd as much as poeeihle, nnd to have olpctrieity Applied over tJie |)eroQed must^Iee five to ten toinntM daily.
«Af/y let. — Tlio motJier statce that after three or fonr weeks the k^and foot had m mm-h incr^isod in mxc (tint ithc had to get a larger slioe. I{i.'.tdjuKli.-d the hiindugee, and iipplivd new plaster. Continue troalment as Iwfore.
He^tetnber \»t. — ilas iiiipro\-ed bo iiiucli thiit, when all the bandageaand ludia-ntbber are remove<l, he i-nn slightly evert nnd flex tbe foot by making a strong effort to do so. I ordeivd a well-fltting slioe, with n Bicel spring on tlic outer tiide to run up the leg, with a hiugo at tlio uuklc-joint, and ft rubber spring (■ewed faAt oppo.4tte the little toe, and sotnired to a chain at tlie lop of the steel spring, nour the head of the fibula,
January 1, l$iig. — He haH improved so much that he can tread fUt u[>on his foot without utiy SHsit^tanco. I tlicrefore took off the frteel snp|)ort and rubber spring.
Hid foot and l«g arc well nourished, nnd very innch inrreasod in aixe. The solo nnd heel require Hl)out onf^fourth of nn inch more tluin Ute other ehov, to e<iuAlize tJiu length — otherwise tliere ts no deformity.
Odaher 81, l^S, — Huy has not lieen seen since hist entry till DOW, 09 Ite has l)cen away from the city. Has given uji rlie imc ot tiio elnfttic sIkii*, nnd luk; been wearing an apparatus consisting umply of a fimi iron i«4.)ie, with no joint, which Is tixi n.^rr')w for the foot, and a stiff upright bar, jointed at the ankle, which is fastened about the calf. Thix ehaiigc tn treatment has hln- dvred tlio ppogrfus of the cure. The skin is warm and of a good color, bnt the ninnies nre weak. In walking, he \& unable to evert Ibo little toe, and allows the weight of the body to fall upon tlu outer mlge of the foot, thua endangering a relapse. The core
190
TALIPES.
is, however, eo well ndranood, Ihnt I tliink nn ordinary neatly* fitting, broad-«ole<l ittioe, wjtti an upright bar, aod a rubber for everting thu fuot, sEniitar to tlint xtiuwn in Fig. 64, will be eufB- cient for its completion.
Sitioc tbc above <laie Walter C. ha» agaia mllvd at my oBve. The 001*0 is now perfect, tbci sole of the foot coming Hat upon the floor without any arlificial aid. TIte ]«g baa grown to very near- ly the same eizo as the soond one.
Cajie. I'atijifs Caicanto-Valfffis Parvlytima f Cvre b>/ £hatie\ EHennon.—Mii'j 4, 1867.— G. B. M., aged three, New York City. During dentition the child Buddenly lu»t the uiiv of ids lowvr Umbs. lie wa« enable to eland, llts (loreal mnacles were M wt-nk that be had tn be propi^e*! up in a sitting po*1ure. After tlic expiration of tbrro weeks be begun to creep, drugging hia body. A weiglit was then attached to each foot. After two montliH bu was able to ^tnnd, when it wait noticed that his right foot had Ie»i power than the left The toeti were elevated and tuniod outward, and the heel deprcMed. In March, 1866, anj a[mght sDpport was made for lib 1<^, and elastic extension ap-
Fu. u.
plied in the popliteal ep3<xsto taketbv place of thcgaMrocncniiita. He has worn this above a year. He is able to n-alk well witli a boot on; but wbcn it is rbmovcd there is no improvciuont npon the condition exi^iting liefore tjvatiiicnt. There is no teudo- Achilli« visible; the anterior muwUx arc very prominent; Xh heel is atMpbied,snd the internal malleolus displaced. (Se€ FigJ
CASE.
51.) Artificial nrnsclw were applit-d. nftor tlio manner of Mr. Bara'cll, over the gftstrocDemins and tiltialiii-nnticits niuM'leK.
Pig. !>2 s]ion-« tlm ooodition afti'r the uee of tlie rubber tiiUHcliv, galvanism, and strychnia bTpodermically, from M«y to Septuuibcr.
Fio. M.
Ca&k. This cofic shows vory well the eftevi of only a few lioiirs* tciuion on tliP distorted feet, particularly Ihu left oae. Fig. H'S, from photogra))h, elxows Iiiis cuudltiuii at time of
rM. M
rin. M.
application of dre^ng. Fig. 54, ali«o from photogmpli, hIiows the result after only three hours' application.
The lndift-nibl>er pjiritigs were woni with the tin splint and adhesive plutttvr, a« eccu in Fig. 54, for tvro months.
1S8
TAUCES.
After this rime he wore the imjimvetl shoe with halt-nn^-socket joint, which nn^wcred iiiUL-h betlvr, as the epring from the \Mck of the heel to the Ultle toe materiall}- aided in everting the fuvt, iitid wtieu this wm properly sdjin^cd he could walk remarkablj well.
This boy went to the eountrj-, and I I(*st flij;ht of hun ; and I am therefore imnble to tell the ultiniate rtanlt of the trc-atment in his cose ; but I hear th»t ho recovered perfc-etly in less thaa tvoyem.
Case. Congtnittd Varus of Hight Foot., and Vaiv-Calea- ruat qf Lffl Foot, curtd h>j Eliuitc Tubing. — John F. C, 432 Second Avenue, aged eix months (Fig. 5^), was brought to the
rM.u.
out-door department of Bellevuo Hospital, Kovembcr 7, 1867, under care of Dr. W. II. Young. Parents healthy ; no other ehildrcn. Tnutuicnt by elastic tubing (mo Fig. M). The right foot was drvs^ November 11th, the foot being quite ea^y brought round and retained in the ^traiglil position. Xovember K'lth, dressings have given no pain or uiieufijne«( to the child. Reapplied by Dr. Sayrc.
20M. — Deformity of riglit foot about onc-Italf ; drcsdngs ap- plied to left foot lo^lsy, which i* retaiued in jiosilioD by a very ttmall amount of elastic force.
The dressing* were n-appIieJ about onoe ft week, nntil Janti* fti-y 2d, when tJiey were removed, the feet being nearly in the normal ponition, and oanly retained in a straight position by a common pair of laeed boota. Tlie Indi»-rubber will be rc«ppltod ue eoon as the child commence* to walk, if niressary.
Tlic photogntpb, Fig. !>8, showing the improvement, waa taken April 8, 1S6S.
O^flE.
199
Cams, Double I'alipea Hjutno - Varus treated It/ Sedum df Platitar Fatolm and Elaitic Extantion ; Section qf InteQu- vukI uUimaUltf rtquired. — JiUif 'i'i, 1867. — Aiinio L. W., aged Itirefi and a half years. New JerBey. Tbo dvfortuity is congeni- tal, ftnd is sttribiitect )>y tbc fatliur, u jitiyeivian, to ** a fright of ibo mother at a dcfonnwl cri|ijiit: while tlic habe yim m tUero." Wlien tliree montlis old the child whs broufjtit to tiu'. I then
flocoeeded in brin^n^ the feet nearly into tJtoir proper {toiiition by handling, and thvii appliod a leather i^pliiit, an described in Lcctare X. The father continued the treatment for thi-eo months, with bdiictit. I{« then cuterL'd the army, and the treatment wm changed for another plan. During the last eight loonthit the child haa bean treated by a lixod modification of ScarpaV ehue, which cftosed ulcers upon the dorsum of both feet, and the condition )ta» bwonje wonte rather iIihji better for the treatment. The feel are now strongly inverted, and tho plantar fasciie fmnty cxintract- cd. She walks by eejiarating her feet a.i far ait poiieiWe, and tak- ing (JiorL. awkward, waddling steps. On tlio Kideji of the f«et arc Bcart of fonucr tenotomy. On each dorsum is a (-icatrix of a larige ulcer, caused by freatment, which, I fear, seriously compli- catM the treatment of the ea«o.
Juli/ 22, 1 S67.— Cut both plantar fiweiup, Tlic fi-<?t wore then bound down to thin bonrd-«])]ints.
Auifuai (WA.— Applied two rubber mtisclca to right foot, one to the left. In lesa than an hour site b^n to nm about the office.
2f)M. — ITas much improved. Only suffering complained of u tlie prcwuro of tho plaster on the c*1lu« produt-cd by the ithoea
TALIPEa
formcriy worn. Iicfttljiut«(l piasters, «o a« to relieve (he diffi- calty.
J?ecen^er n, ISGS, — Tlic futlicr agairi bronglit tlivcliild to my office. lie complains tliat for some reaaon the evenion of the fift i« etill i>iiiiifu1 : the child haa deft^ted tlie trt-atment l>y turning lier feet in »ucb a manner ba filtall bring the outer i-dgcft. npon the grotind, by th»t means relaxing tltc strain U]>on ihf plflntAr fucisc; when tliie niancenvro fail^, kIiu foreihly inverlA the feet with her hands. Exaiuinadon diowed tlie faaciie to be tense and oonlraeted, reunion )>aving taken place. Aocoixlingly, the child bcin^ under cblorofonn, I cot the plantar fasciip, but the deformity did not yictil, the integuments liaving become con- tracted and rigid. I accordingly made an inctjiton tlirough tlie integument aixtul an inch long, and brouglit the fuot into \misi- tion. Tho straigliteniog of the foot caui»ed the cdgce of the vroand to aeparate about tbree-fourths of aa incli.
Since this last operatitm the fatlier reports the progrow as perfectly eatisfactory.
Case. — S. S., Brooklyn, aged neren, was bom nith double clul>-foi>t, apcnrding to tlic mothfr'n i^latcmcnt ; was o]icrated npon when Ihpce months old by a anrgeon in this city, who cut the t«tldo>Ackilli« of both eidc« ; a few months afterward the tendons of both anterior tibials were cut, and abont two yean aincc tho tendo-Achillis was ^-ut again. 8hoc« of dilTurvnt kinds had been vorn all tlic time, and at last the suigcon had abandoned the cnae to Mr. Foni, the instniment-makcr. who bmiight the child to me.
The feet at the time were «icnred in ahoee with a firm *iieel sole, and, althongh they liad, oppo«t« the ankle«, joints in the nuts running up tho legs, which were acted npon by screwii, and. intendM to elevate the feet, utill, as tlicy were only moved when' tho attendant applied force to tlio screw, and then fixed in the position ohtnined, the mueeles of the leg, even the normal onee, from being so long in a passive condition, Itad become atrnphicd ; and liis legs, from the nnklo to the knee, weie more like two Btrai^)t litickH. or nearly eqiuil in ftize at top and bottotn, than like an ordinary leg with wolUii-velopfd muitclcti.
When the shoes were well adjured, he conid walk by the aid of c«n««, on the outer comer of tlw little toea, for a little distance, the feet croaung over each other; bat the pnin was to great ttiat in a few minutes lie would gi%'u up hi« exercise, and could not
CASE.
Idl
I
tgaiit 1m indoced to walk until the shoes had been removed, and ihe feet allowwi to resit.
Wbuu lieRltviufitcd tuwulk witlioitt the ebocs his feet dn^ped nnd were inverted, t<o that lie walked ajioii t]ie outer part of tbo foot, wbere tliurv wius iin ext<M)iiive callus. {Soe Fig. 57.)
On tbe 2Tth iiay, 1868, Dr. L. M. Yale pnt the child under chlorofonn, wbco I found t)ut by moderato furtxi I could bring tbe left foot iiiln nearly a natural position.
On the right nidc, tiic heel could be brought down to a natoral pomtiont but it waa impw»ible to elevate tbe foot, or rotate U ontwaisi ; in fact, the whole anterior part of tlie foot seemed like a solid plastercast, with uo motion at any of tlie joints, except the toes.
I therefore nitide a free ^nlHnitnneonB section of all tbe re^jot- ing structnriMi In tliu hollow of tho foot, closed the wounds with adbeeive phurter and a roller, and immediately brought the foot alnioflt HtraighL It wa« fiec-uri-d in tliis posiliou by a hoard under the foot, and a roller with ndbe^vo plaster in my uBu:d manner.
I diructud Mr. Ford to make a pair of shoes, with orbtcotar
PW.BT.
FM. H.
joiDtA in the soUm, and rubber elastics to cIo\-ate the foot and rotate tt outward, aa I liave already described, uid to return with the child when tbo fibocs were con)|>le1u<l.
lie returned on tbe lOlIi of June, thirteen days after tlie op-
139
rALIPES.
eration. The wounds had partly healed without snjipnratlon, and the cliild had suffered very little pain from the operation. Tho baoda^ had been removed onee or twice hy my snlataRt, and tlie foot well wa^hod and nibbod.
Mr. Ford had constructed the shoes remarkably well, fi-ora tJic U]o<lel 1 bad given liim. Tboy went put upon the child, and fulfilled all tlie indicationo desired nioHt admirably. The rubber waa hooked on with only » very moderate tcitition St first, but thin was gradually increast^d a link at a time for an hour or more. At the end of about three lioitrs hia feet were in a )>erfoctly natural po«itiou, and he could walk wtthuut a cauc, with his heels upon the ground, and his feet parallel with each other. He walked to the photograph-gallery without oaiii^tanou, and bad his picture taken {aee Fig. 58), thirteen daya from the operation.
ElK'tricity was applied to the anterior portion of tho leg and foot every other day, and very free handling and motion made to all tlio jointa of both feet.
Jum 3U, ISOS.— He can fie:t liU feet dighlly without tlic aid of the rubber ; hia feet are much warmer, more natural in color, and the legs have incr<»8ed aromid tlie calf nearly Ihrce^itartcrs of an inch in circumference.
January 1, 1869, — Tlie improvement has continiied up to the preiicnt time. The motlier haa applied faradism, frictions, and has manipulated the feet daily with great care, and the result liaa been a perfcet cure.
Case. — II. F., Hudson, Now York. A girl four yearn of age waa aeitt to mo to divide the tendo-Achillis for clubfoot of the right side. The history of the case as given by the mother waa, that the child presented aa a " croea-birth," and was delivered by tho doctor by turning, and tho deformed foot vai the one seized by the doctor in the delivery ; and, in the opinion of the physician who delivered her, tlio foot was injured at the birth.
When the child was old cnongh to walk, this foot was found to drop in front, the ankle was stifT. " and the heel wetned to be pinned to tho bat-k of the leg." " Pr. T.iylor'i* Swedish move- tnentcure" waa tried for two yeare, hut with no rc^t beyond making the ankle more Rcxible.
When the foot in permitted to hang in its natural position, there ia a remarkable protulMiranco of the astra^lns. as seen in Fig. 59, which was traced from her leg. By taking hold of the
CASK.
133
foot, bowcver, with a very sliglit force Uic tcndo-Acbillie couW be stTCtdiwi, iiiid the liwl csiitly liron}!;lit down to its natural poatioD, at a right angle witli the 1^, as seen in tJic dottird linc«.
iBut the foot, in front uf the medio-tarBst articnJation, Btil] jdroopcd, as lecn in Fig. 59, xnd muld not he elevated. I lu my luite-lxMik I find the fullowing entry, made at the time of in,v firiil (.-XHitiiniition, hy my ii#«ietiiiit, Dr. Yale: "It ih ijuito possible that the plantar faivia and fihort flexors of the font will n.-(|uiro divicion, but shall at firet attempt to atroinpliith the rce- i^Utratioa of lliv foot hy itianipnlation, ntid shoo with claEtit.' esten- ^WOB.** The rcHtilt of iJie treatment proved the wukIoih of this
I put her undt-r chlorofomi, and hy rcry firm prvMsurc and
txteneion, continued for Honie time, I foniid that 1 could make a
k'i!ry dwided diminution of the arch in the hollow of the foot,
liid ver^' materially increase itA length ; and, rh I never nit iw-
BiicA tlial will Btreteh iindor a moderate degree of force, I resolved
use tbe shoe, without renortin^ to tenotomy.
Tlw foot wag handk-ij with gi-eat fi-eedom every day while the
ice waa being made, and ttretched aa much aa the child ooiiM
bear without Huffcring much p&in ; aiid elcclricity wae applied to
liti aiiterior miiiiclefl of the leg every other day.
On the ii4th of June, the photograph (Fig. 00) wa« taken,
id cheii an ordinari' ithoe with etci-l supports on either side,
Iditiled opposite the ankle, and huckled around the leg above the
If, to give attachment to a nibhcr elastic which ran from a
limip over the hall of the toes, for the purpose of elevating the
t, waa applied, and the photograph (Fig. CI) woh taken about
ne hour afterward. With this cihoe on, and the rahher proper-
rALIPES.
1y adjusted, she rans with perfect freedom, and without (he d)glit«)it limp,
October 31, 1868. — A slight invenlon of tlie toe remaitu.
no. m.
pm. *i.
Ordered a bBll-and-^tockot shoe in order thnt the prenuon niuselo ma; be applied. Thiit convct^ the invcreioit perfectly.
Cask. Talipes Plantarity Section of Plantar Fascia, Flex- ortfOnd sfthtftpienUij the Integttmenft ; £3a»tie Ertatmon ; Cvre. — ^MisB N., of Georgia, nged twelve, gives tlie following hls- toiy: Wheu ttixtoua months old iihchad an attack of oonvuleiom, and another four niontlio later. Soon after, the left foot wua no- ticed to he fontraeted ; or, as the mother expresses it, "ebe wan pigetm-toed when her weight came upon tho foot." For a short time she wore some sort of a clnb-foot shoe, hut mon abandoned it Ko tri'Stment hvyund liniments was employed, until Oetohcr, 1865, when, in aecordanee with the adnce of several surgeons, the temlo-Achilli!' w:iscut, and tho treatment continued br apply- ing a very (ititT club-foot slioc. No material lienefit followed the operation. The deformity increased, till, in the winter of 1S67- ViS, it wiw »o far advanced tiiat, in walkinj-. (he toe alone touched the ground. In Hay, 186S, the tendon of the extensor pmprius pollicis was rut, with the cApcetation of relieWng the deformity. This hope was not realized, the difficnity in walking Xivmsr gn-atcr than ever. The parents luvordingly bronght the child to thiat city, to Prof. W. IT. Van Buren, who sent the case to mo.
Jvly 20, 1S68, — The poHilion of the foot, when no weight ia
3ASE.
135
llpoi) It, IK :i8 !ii Fig. 62; nlien, however, tlie cliild attenipta to wjdk, the pottiliuu liwomtis ii« in Fig. 63. TIio prwit-too U scmi- luxnUHl bv lite pr<s*nre falling din-clly upon the Iwll of it.
Under clilorofonn I mit the plAritnr fuscix and t^hort fluxora of Uio foot, aud (lutcned the foot U> a board. The patient went out
Fn. «.
IWtt.
I I
dt town for a few <Ia_vK, and the foot was not properly attended to. The wonnd did tiut unite Uy tir»t inteiitioii, but a nlight amount of nappnnition followed.
Aufuft nt/t. — Tlie foot i>rtill rei«iMod att«tiiptH at fltraightcn- iag. I acoordingly divided Uie integuments in the wh of the loot, forcibly prcHHod the tanutl boiie» into proper pMitioii with tlie hand, and broke n]) the adlie^ions in the sole of the foot. The ftfot wa« then tiniily handagud to a board with a hirgo vom- pnau of wool orer the inotep. The operation waft foHowed by MHiio febrilo reaction, which had disappeared on the following dajr.
SepUmhfr 1, 1868. — Tlie progress has been uniutcn-uptod ■fnoo the last oi>eration ; though (he wound in the sole is not en- tirely healed, she irt able to have the shoe with tlin jointed eole tpplicd, and to walk in it without pain, the hool being down and the foot in n natural position. Since the operation the foot is ■tiout one and a half imrh longer than before.
Vith. — liecovery porfort. She everts and flexes the foot roIuMtarily. In walking, nhe wears an ordiiwry laced IkhjI, with
TALTPE8.
It single niblrer muscle from opposite the little toe to oive of the tipper eyelet-holea. {Sat Fig. 64, from » pbotogmph).
Fn. M.
Cask. Talipe* Plantant, or Cavm, Traumatica, with Di4- location of Tarsal Honff, of FlyMtmi Year^ Standing ; Oj}er' alion; Treatment fuj Elastic Krtfimon; Cure. — Sgptamber I. 1808.— Mia* F., agi-J twoiity-livt'. New York City. Wbea about seven years old she injured her right foot bj jui»]nng from the Mat of a high vogon to the groimtl. The injury %raa sufficient to catue severe pain for a time. Aftt!!' the disftppesiraiK-o of lint pdin the foot was neglected for two or tbrec years, bnt, after the lapse of this time, surfrical care was demanded. The pliyi^imn in attendftnc-o cut Iho ten do- A chill is. lie proposed section of the plantar fiiscia, btlt, f(»r some i-oasoti, it wn« not made. From that time the was able to walk toler.'iblv well until between three and four ywin* ayo, when, she Laving adoptod n seik'iilarj- oi%ii|iintion, the foot became painful in walking, and the nnlcte, which had alwa,>'s been weak, frequently tHnied under her weight. She attributOA this change to a failure of i(trength from eontinement in-doors, rather than to a prograsave contractioa of the foot.
The sound foot h eight iueliea in length, the diseased one is BO flhortt-ned («¥ Fig. 65), by tlie contraction of the 6olc and ele- vation of the toee, that but five tndieB rest upon the ground. The calf of the sound side is twelve and a quarter inchea in cir- cumfer^nce, tliat on the injured side ten and a half inches. Tlic limbs are of the same length.
After aniBBthetiang the patient, the deformity was reduced
CASE.
187
by cutting the plantar fascia and then forcing the projecting bone as a wedge down between the adjoining bones. To accomplish this, very considerable force waa required. The wound of the jkin in the sole was tightly closed, as described above when
Ro. a.
speaking of tenotomy. The foot was secured in proper position by bandaging it strongly to a board padded with cotton. The foot was now seven inches on the ground, instead of five. Dr. J. C Nott assisted me in this operation.
Septemher 12/A. — Applied ball-and-socket shoe, lacing in front, tnd with a slight heel.
20iA. — The patient having returned to her work, the foot has
Fia. «.
tronbled her considerably, owing to tenderness over the tarsiw. The force required to reduce the bones to proper position ap- pears to have caused a slight periostitis, which is reexcited by
ISB
TALIPES.
ittiy ftttt-mpt nt wnlkin^. Eo«t for a week, with eoid sad eodn^ tive lotions, wore accordingly directed. The result was perfectly Mtiefiictory. Ordered to nmnipulate tbe foot witb the bud.
January 1, 1889. — Tlie foot has improved &o much tliat tlie clnb-fuot «lioe ia no longer ncec«eary, an ordinary*, ncat-titttng, laoed t)oot Bufficiiig to kct'p tlu- foot in ito normal poeiUoa. Fig. 66 show? tlie condition of tite foot.
Cash Talij/eji Varus Parali/tica^ aaptired., of Five Tearit Standing; Unsticcet^tU 7'n>atm«rU by I'enolomy ; Sulf$equent Treatmtnt by Llattie £cetension aucoet^vl. — SepUmbei-9, 1808. — ^Harry M., aged Boven, New York City. Until two ynurti of age wax perfectly well. At that time he suffered from a severe dinrrh'i'fl, nnd during the ootir»e of tho diMaeo wu eud- deuly HEfizod with jmralveiB of both upper and lower extremities. After about two niontlis he recovered the uec of Lis arms and of his left leg. The peroneal muwlce of the right leg remained paralyzed, and are i^tiil eo, a markttd talipes vurus biiiig (he re> salt.
In 1865 the family phyriciaii cut thctcndo-Ao!iiIlis.thc tendon of the tibiatitt-nnticn^ and the plantar fascia, and applied a fixed oluWfuot ehue, >vlii<.'h allowed no motion to the foot. 1'lic result
b\'
na.sr.
rn. K.
was negative. The condition of the foot at tbo present time is tfliowu in Fig. 67.
I applied the ball-and-mcket club-foot shoo, with nibhcr miuolcs, for floxion on the fibular sido of the leg, and for cvcKioii of the foot. Figii. (}7, Cd, and CD, are from photographs taken
OASE.
kt tlie tAme visit to tlie plioU^raptierV. Fig. €>"» ox1iil>it« tli« dofonnil)-. Fig. CS lOmwti Htc «.lioc a(lii)it«4l lo tlie foot (not tlio foot to the 6lioc), and Fig. C9 tbe R-etoratioii of llie foot lo iu normal condition, after tlie rubber inu3clc« were attached.
In addilioQ to wrarin^ tlto elioo, frictions and electricitir have been applied to the leg.
January If, 1869.— The ])rogre«8 toward cure has been steady. The calf of tbe jwi-alyzed leg has increastxl about an inch in cir-
IK
i\^---
•^
A.
JM.M.
rn.m
oinaferenoe since the conimcnoeinent of treatment. The power ' over ihfi nuis^lL'S has increased, so that ho can voluntarily flex the foot, although he i» still un:ible to evert it.
January 22(/. — Tbe condition of the ca«o ie shovrn in Fig. 70, from photograph by O'Neil.
CiSK. Vori^nUal Doiih!e Tedipfi Varo ■ Kquinua ; T«no(o- my; Htducthn qf Dhkh-nt'ui Tarsal Bones by Force. — ITerljert F, C., aged ten, Mwifi:ichuK6tt&. The mother tliinks the deform- ity duo to the fact thiit, about tlio second month of pregiianey, the eat in a cramped position for some hours, and, from tliat time till the hirtb of the child, whk inipi-osBcd with the idea t}iat the child would have deformed feet. When eighteen nionlLsold be was placed nndvr treatment. Sinoe lliat timo he ha^ worn Constantly orthopedic dioes of one sort or another. They fiavc, bowuvt-r, always been still and fi.ted. At present the deform- ity ifl to great that be can with difficulty tttand alone without .VtiOcial support. Cnlvce, nine inchoH and seven and a quarler
TAUPE8.
inches, llis gait is very labored and clamsy. Tlie planUr fnsciffi and tUv short Svxure of llio fcvt nrc tc-iider whcu put on the Ktrctoli, as a]»n arc tlio tendons of the aolei niuBclce. Ttic lioud of tlio a«tra<^dufi flud anlorior txtremity of tlio calcaneiira are pro- truded to a reuinrknble extent (see Fig. 71, from pliotogmph.)
FBI. II.
Novemfier 16, li>68. — Before the cIsm at Iktkvuc IloepiUl, ana?Btliftizod tho patient, cut the tcndonee-Achillift, plantar fagcise, and tho fthovt tiexore. By exerting great force upon tlic taml bones with the handa, they wei'e forced down into their proper
.s?=
Pin- 11
pl&cce. The soles of tlie feet were fixed to boards and tlie feet properly padded and very firndy bandaged.
Dooember 9, t8«8.— There has been no disagreeable result from
CASE.
tlie force employed, Tlic bov walks very well with tbe bttll-nnd- 80cket shoe. The feet are very nearly in nonnul position.
Fig. 79 fthowB the chaiigc which had tAkun place, Jwinary 20, 1869, from photograpli hy Mascm.
Oa*k. DoubU Taiipet Vanu, congtniUd; ireaUd by AViT* J'Uin, latfr hi/ Adhetive PlatUr, arid hy BarwdPa Method. — Jfovftnher 5, 1868. — A. J. K., aged three weeks. Now York City. IIm doiiWo TOnf^-nitrtl tnlijKS vartu. The jwBJtion uf the feet in as in Fig. 73. Appliwl the drewinf; of Dr. Uenry Neil (Fig. 45).
rM.m
vm. n.
Notfemher X(\th. — The treatment haa stmightened the feet con- aidembly, but tlte chilli ha" criL-d m iiitivh tlmt the iniftlier removed the dreuing. Accordingly, NDvcmber 14th, the adhe&ive-plaeter drening (Fig. 48) wait applied. This wa« worn for two or three weeks, when it became loosened. Th« mother neglected to come ' the ofBca ngtlii, aad the child wont without treatment for '''•everml weeks.
January 9, ISflft.—AppIied Barwell's dreeaing.
IIWA, — lieaiilt wu very wititsfactor}*. Position as tn Fig. 74. The inner etlgoa of the two feet can be placetl in appoi^lion from heel to too.
The following caae of acquired talipen, the renult of spinal meningitis, is of H>nic interest, as illustrating itie existence in the nine ]uitiunt of the most inlon»c hypenestlicsia of the cutaneoua ■tufaeo and perfect or complete motor paralyHifl at the eame tiute :
143
TAUPES.
Cask.— "Miss ITattie B., ngod twenty-two, Wfts always ro- biwt and very active until Dec«njlter, ISfiS, when, Id Stuttgart, Germany, she contra<rted tyi)liyid fevurtiiiriiig im epidemic. Can get btit little acn>ant of tiiis UlnetB, save that it loGtvd many weeks, during much of which time the patient wa^ in a state uf low ddiriimi, and lator she wae too weak to tnkv ruucli notice of occurring eventa. When »he finit recollected herself after the fcwr, all power over her limbs was gone. She could not even move a eingle toe on either foot, and conld not lift a fork or apoon from the tjthlv. She bad extcnttivo bnl-eores on the heels, over the sacrum and trocbautcre.
At thio time the cntancouH surface of tlio whole body was io exceedingly MUMlive ae to cause her great agony when touched or ruhhwl, even in tlie lighti^I manner.
In .\ug«i;t, 1809, her moiher went to her, and found her «if- fering chietiT from the trouWe which still in part remains, vit, conlractioiis of tbo lower linif* with liyiwra-slbcHia. llcr kneoe at that time wei% ver^' rigidly extended ; the lower Iiii>lu>, c«pe> cially the feel, were excessively sensitive, the weight of a sheet l>cinp too mucli for her to bear.
The feet after waiting could not bedtied with a towel, raw cotton being used instead, and even this would cause an involun- tary ifhuddor as it touched tlio tikin. Under tlie treatment at Stuttgart, tlie knees partly regained thctr mobility, the hyper««- thesia dimiui«Jicd, and the position of the feet was eoinewhat im- proved.
After her relnrn to tliia country, Dr. Barber, of Leroy, New York, practised manipulations of the feet with the hope of di- miniiiliing tlie distortion, which iii that of talipes equino-vams, with a strong curve on the edge of the plantar fascia.
Dr. Barber Improved the pot>ition of her feet somewhat, but, not being satisfled with the prc^fren of (be eiise, sent her to me in July, 1870.
The mnnipulaltutis were continued for some weeks, hut the sensibility wa* too great to allow of tJie exertion of much force; in fact, you could scarcely touch the feet, or rub the skin in the lightest manner poMtible, without cau.*ing her to scream with agouy. The deformity could not be reetificd, even under fall anipsthefiia.
Sgiitmber 80, 1870.— The position of ber feet ia as seen
CASE.
143
in Fig. 76, from drnnvinj^ by Dr. L. M. Yale, made at tlic time.
She vrBA placed fully under clitoniform, »nd I divided the teodo-Aoliillis and plsiitar fnacia of the left foot, luid was tlion
Tn. n.
compollod to divide the ^kin nlt>o before I could restore it to po- sition. Tl]c foot was tlii.'ii drc:«cd witli sdhi'dvc plaetor nnd a board (tee Fig. 48). When die eflecta of tlie chloroform lutd panod off, tOiu euinplninoil of grent agony, uUhou<;h n full dose <if Magendie'B eolution liad l>oen given at 4 e, u. At 13 t>. u. ropeatcd the niorptiinc. This being the firxt and only case where mndnaed pain lias followed llie operation, I have reported the daily notes of thu cum; as taken at the time by Dr. Vale, under whuee treatment slie was placed during an attack of eickneas which oceumxl to me fit that lime:
Oefaber \si. — Oontiniiea to romplain greatly; has not slept; pivc bromide of potawiuni without effect. Sd. — Some relief, due probably to the foot having slipped in the dressing. Fifteen- prnin doMii of hydnito of chloral seemed to produce better effect tlion morphine, to which latter elie had become accustomed dur- iflfT her iHct itlnesfi. After her rotiim to this country, she had great difliculty in breaking up the habit, 4?/i.— Dri'*8L'd foot. At baxe of little toe an ecchymosed spot looking likely to slough, txssencd the strain of the adhesive plaster. dtA. — DrctMiiug very inconvenient; a Himplc nide-iitrap Riilwtituted. Begins to have louo appetite, but hu8 constant chilly sen^ation^^. iOth. — Has been sitting up for pa^t few iHys. Could bear presure on foot much better. Allowud wound in sole to close. The tendo AchilliB wound has aho united.
TALIPES.
nth. — Had laiit evening, at 10 p. u., a severe cliill, laetiti^ An hour and a linlf, followed \>y fevvr and delirium; aUciuptod to get oat of bed. Delirium continned tlirough the day; palae 130, respinklion -13. No signs of pneumonia, or any internal inflammation. Gave epiritus Kindereri and spirits of nitre; liquor pota^ijtc ar^eiiitis. Foot looks all ri^tit ; no eignof trouble- except tbe bntiaed Bpot nnder little toe, from preesure of the board.
12/A, y A. M. — Pnlae 120, reopiration 2^. Krj'fiipelatoue bluah runniug up left leg, and tlic buck and iniude of left thigh. Opened wound ; found no confined pus ; l)p» had granulated un- der the «»b. Poultice to foot.
p. it. — Met Dr. Clviner in consultation. Ful«u 118, rc*pini- tion S9. Temperature under right thigh, 103^ tg"* under left (er^HipelatouK), 104°. To take hourly one grain of tulpkatc of qnininv; one-lmlf drop Fowler's rolution ; nitras argenti locally. Food, every two liouni, milk and broth.
The fever continued unit! October &8th. The highest temper •tnre (under sound thigh) was lOS'.S, Remisaona below 100° occnrred 12th p. m., I6th a. «., 19tli a. h., 23d a. «., 24th p. u., 281h p. M. On the ITth the eryeipelaa became migratory in chai^ actor, and diminished in ooverity. On the 15th I wn« eiinblt-d to see tli« patient, and finding an occhymoeed spot nnder the
n».n.
rM.n.
little toe, I opened the same, aod from which a small quantity of pas was immediately discharged. From that time she b^an to reeover. On the 38d then was ao eruption of sudiunina ; oa the
CASE.
14fi
34th, over bftcV and nntfis an oniption, viyrj much resomliHng acarUtiiia, ab«L>nt fruiu tlio anteriur surface of tlie hcuh. TliU lasted unltl the 2Dth. From lliiii time (iliu cuiivnk'M^ alowlj, tod, iift«r HOiiio timo, lliv inaiiipulatiuns of tlie foot were again rcemmcd, and rejDlted, in about nix niontIi«, in prodncing a vury ncvful luid nuarljr normal foot, iw eeiiu in FJg. 76.
The operatiou had been attonde<l with m> iniieb danger, that refovcd to operate npon the other font until her general health >ald be improved. She, tlit-rL-fon-, left the cit_v for Leroy, New York, where riie reinaiited for two years, getting around on her orutdtea, and bearing hor entire weight on the " Sarrc " foot (aa die G«11od it) without any pain ; but the other foot was entirely DwleM^ and very painful on the sliglite&t pressure.
She rvtnmed in May, 1873, niuoh improved in general hvAltli, witli her left foot as seen in Fig. 76, and the right one as ge«u in Fig. 77.
May li*. 1873, »he was put under chlorofonn by Dr. Tale, and I divided the tendo-Achillis, and cut the plantar fascia, and dn-«wed the foot with the board and adhetiive pliuitur («■« Fig. 46), with an additional plattter around the foot, and drawn lirndy upon the outside of the leg. An injection of niorphiito wai; ad- mioistered hypodermieally. In the evening the patient was very comfortable, and det-liiietl taking any more morphine, on aeeount of the difficulty she had formerly experienced in breaking up tlie habit.
JuM 18M. — ^Dressing was removed ; had been on twelve
Pni. n.
dan; all the wounds entirely healed, witlid'nt pas. The itutcp WM a little bmieed, but no dough. Tito foot very much improved
iu
146
TALIPES.
in po«ition ; licci oomce dowii to the floor williout pain. She is able to flex the foot voluntarily. There U Home itiveruoQ of the fool, which i« retaiited in po«ilion hy adlivsivi; #trft[i«(.
24M. — Much improved ; ehe ie able to walk a little by tlie aid of a chair.
From this time she improved rapidly ; waA able to have her feet Hhampoocd and rubbed freely without pain, and ou July 1, 1873, wafl able to walk i» an ordiiwry shoe. The feet are both eliortor than natuml, and thicker at the ball, on account of the contraction of the toeA ; but die i» able to walk without asust* &nce, witli both feet naturally upon the floor, as Been in Fig. 78.
Tlie following Cfluw show* what can be done lo rectify the defonnitiea of tlie part by very simple means, if applied at an early ago:
Case. — A n>n of J. H. It., aged aeven months, 16 Eaet Third Strt^-t, was sent to mo by Dr. J. P. Lynch, February 1, 1870, with congenital talipca vartis of the left foot. {See Fig. 79.)
Fu. ».
rH.«L
After manipnlating the foot for about one hour, as already described, the foot wa« dressed with adhesive plaster and a roller, and retained in its natural pot^ilion without any difliculty. (&M| Fig. 80.) Both from drawings by Dr. L. 31. Yale, and both drswings made within two honn of each other.
The#e dreeeings were cliangc^l from time to time as occasion rcjnirod, and, when the child ws« old enougli to walk, a slight rubber elastic from the outer toe of the shoo to the garter was all that was required to guide the foot to its normal position. Gal-
CASE.
■ '^Modam, friction, and shampooing, were continued nntil the child waa two jcan old, when the cure was complete, aud remains eo. (&# Fig. 81.)
na. 81.
The following owe diows wliat can WHnctiraeK !« done, eten In tli« Worst form of tnliiR-*. by iiitolHt^eiit and porMrverinjr effort, .Irilbont tenotomy, although tbe twatmunl wio. carried out entire- ly by the falber (a non-])rofew'ioiiftl man) after only two prwtical t as to the principles inrolvcd in Uie treotnient of paralytic
V'A»r.. — Ilarry fi., aged one year, was sent to mo on Decem- Iwr 3«, ISfiO, hy iJr. <.r. W. Hod^wn. of White Plain*. Xew York, with tlie statement that be had been under treatment in on orthopedic institution in this citj, by his advice, »ince h« was eleven weelvii old ; but, 6n(ling no improvement, he had ad- viftcii Uiem to briti|; the child to me. lit.- litid bwii wearing club- foot eboes with stiiS soles and an iron brace up the legs alt tlio time, with no other rctuilt than producing a number of c«llo»tiefl on the feet, wliich were quite iiore and infUnieil. In consequence of tlie puin inflicted hy the sJioea, they could only l»o worn a very short time, and had to l)e removLM) eeveral times n day.
As ttoon US tliu alioes were removed, and the child made to stand, the feet aeaumed the iwwition as seen In Figs. 83 and S^, from photogT<iphs by O'Neit. Decemlwr 2fl, 1869.
Aftor inanipnkting the feet a short time, 1 found that tltoy could be brought very nearly into llieir nonnn) position without umotoiny, and, finding them to be of paridytic origin, I therefore dressed them after " ]!itkr\^-eirH method.'' an previously described.
In referring to my case-hook, 1 find tho following, and the
148 TAUPES.
ouljr entry in conoectiou vith this ca»c: "FAmary 1, 1870. — Redrewed ; progressing favorably." From this time 1 \mx itlglit of tli« case ciitirulv, and never tew liim until Juiiv 21, 1^7^, M-hen hia feet were almost perfect, as will be seen in Fig. 84, from a
photograph sent to me by the father with the following Idler in AnewLT to uiK' from Dr. lIoclg»on inquiring as to the result of treatment in the case.
At the eecoiiil visit, Februnty 1, 1870, the father Btat«d that
PM.SL
be had llrMdy spent so mooh money on the child that he eonld not afford to go on with the treatment, and 1 therefore took gn-at pftins to inatroct him as to the application of the platter anil " robber niUBclcft,"' and also the proper inanipniatioiiA to l>e given to tho foct, and trusted to his ubttity to carry on the treatment.
The result is seen in Fig. $4, from a photograph Bent by the father, with tho following letter, dated
CASE.
149
•Autiat, Vmrnam Oman. An* I(^ IM. '•Tb. L. A. Satbi—
** Dkau Sir : I •cn^l ^oa n pliotoKrnpli of Ilnnj'tf foM, nnd ain «o proud lo think foil Imto askml fur one I
" Uttlo dill I think tticv would ever bo mndc *ci ]>i>rfvctt 1 Iiav« <Ioo« I Jost IB jon lold luc to do from tL« flr»t, and have worked Di|>ht and ds? to Ho it. You luTo •ctcd like a faclivr t<> th« lilll« f«U<iH-. ami. hj yonr skill ' «im1 good lrMtni«ul, the/ arc abuut perfiMrt, M«e|)t n liltk- eruok in the to«.
" Gratefolly j »ur*, «tc.,
" a T. B."
llad Uie hthcT a])plte>d the plaster nenror llie toe, ilic bhiaII iiiity Mill ruiiiftiiuiiji; cuiild have been eaeilj- correcled ; l)wt fae Bimplj^ applied it ae he had awn n>o do it uii the firet visit, and iitnilu iin ehiitigc iii hin ]>uint8 uf fillachineiit for the artltlnal tiiuficled as the curu projfrfesed, as lie should have done. As the bjcOM i)luMrAi<.i4 a very iin[>ortniit pmeiicnl point, [ tiave tJioii)^hl it worth reiTording. to impreBs upon the i^tudeut and phyei<'ian wtwt cuii he acieoniplUhed by i-onKtant c-jirv and attention, and the [ftpplieation of a continnous elastic force properly applied.
The fulluwiii^ <:n«c, tJtoiigh not m ^m a defunuity, illus- tnitea the snine principle of treatment, and the Bneoees that can be obtained by the L-utii^t»nl uiiv of uon-prufcHeioual attundantK, if tliey are only properly instructed :
Cask. — Catherine M., Susquehanna, Ponnsylvauia, aged seven-
FM-M.
teen ilaye, was hrought to my clinic at IJellevue Hospital in Sop- ttjniher. lfi"0, witli conjjenital talipes (.'<iuiuo-%T»niH of botli feet, of jtnnilrtic origin, a» teaa in Fig. 85, from photojrraph tskoo ai the lime by Miwn, photo^^pher to Eellevno Hospital.
150
TATJPEa
After manipiilatitig tlie feet a ^liort time, and bcin^ eatU- tied tliat tliu dt^'fi^tniiity was of jHinlytit.' origin, I dreeeed tlieni with Noil's foot-board, in order to eliow the c\aa» \U mode of up- plinttion. {See Fig. 45.)
Thia wu« used soinc three weeks, withnnt nny [ii«rkod im- provemen^ and " Bnnii'eira" dressing, with ladia-ruhber mnsde*, woe euletituted in its ])Iiice, and llie mother relnnied with the diild to lior home in PviiiD^vlvftnia.
The mother look entire charge of the csi^ from this time, dianj^ng the pluters as occaaion rc(|iiired, an<I morinf; their po> sidon aoctHxIing to infitrnetjons ae tlie childV fM'I bccamo more straight. The piaster and rubber mu£cle« were worn until the diild was able to walk, when she ajtplicd my improved diib-foot shoe, which she wore unlil the tpring of lS"a, when nhe waj» per- foctly cured, a» seen in Fig. 80, from pliotogrspL bv O'Ncil, taken March 21, 1878.
In looking over my note-book, I find a number of caeca very similar to the last two here described, and that hare terminated with the same fortunate result, b_v following the tn-ntmcnt abors lecomniended ; and I can, tlierefore, e{>eak of it with confidenoeL
It freqnentlv hapiH.-ii^ in bad vmv* of varus and varoK^qmnns, that after we have restored the foot to its normal shape, either by the constant u»e of elariie tension, or by tenotomy of the tcndo- Aeliillis and plantar fascia combined with elastic tension, as the rase may l>e, that tlie foot, although perfect in shape, cannot be held in the proper position, but will remain inverted on account of the paralysis of the rotator inusdw of the thigh ; and, to ovci^ eome this deformity, it Itecomee neressary to evert or rotate out- ward the entire limb.
To accomplish tliii* object, Mr. Reyndcrs, 303 Fourth Avenue, Xew York, lias recently oonetmcted for mo a shoo with the additional attachment of a rotating screw, which fullills the indi* cmtions most completely. It is the application of the same priu- dplu which 1 luive for so long » lime used in the outward rotation of the femur in the Ihinl stage of hip^lisease.
In applying this force for the milward rotation of ihc foot, in ca«c« of elub-fet^t, a liglit metallic rod, or shaft, is secured to the bottom of the shoe, in front of tlie heel, puses up od tlic outer side of the limb, and connects with a well-padded jwlviB-belt, A, having jointa, of course, opposite tlie anide, il, knee, My and hip, s.
SHOE WITH EVERTING 9CBEW.
151
Jnst below the joint, opjxtsito the hip, the shaft u diridod into two Mections, and nt tliii* jMiiiit lit lu eiidlcits screw, o, placed trui»- veraeljr to tJie shaft. The wrew is worke<} hy a key, c, and i» capable of producing rotatiuit through lwu-thii-d« of the arc of a drdv. F, is a vreli-paddetl brlt, just alxtve the auklc, and D, •author bolt ubovu Him kiivu. i&x l-'ig. S7.)
Fio «.
Tlie following case, fur which the instrument was cnniilrneted, illuatntes not only this point, hnt aim another, u'hich it scorns iitiportiitkt to tiring more prominently forward, namely, tlje impor- tanco of comnienciTig the troitiiiviit of thi& ela«8 of deformities Emmeiliately after hirlh, as it will he seen tliat the jKisition of one of the feet wai» perfetrtly n-cliticd in a very short time, hy ifiinply plodng it in tlte natural poflilion, and luing proper dresHing«. Tho other foot, whicli had nndeif^ono stnietiinil uhortening, lOqoired eei'tioa of the eontraotured tendons and fascife before iwrfoct restoration could bo effected.
Case. Om^enitat Varo-Eguimu, L^t Fool; Vara-Caltxmeu*, Right Foot {aa seen in annex^l Drnwing^ by Dr. Yai-k. Fig. 88). — Janmiri,- 2, 1S74, 1 wax oalled. at the rc<i\i(.*t of Prof, ilarker, to tee the infant child of Mr. B., Eighteenth Street, aged fonr days.
By miinipulating his feet for ludf nn hour or more, I wu
US
TAUPE8.
enabled to bring tlwriglit into Ua nAtiml pofiition, And the left uuc nearly so, viHumt much trouble, aiid to retain th«in in lliU position, with llie cmmlnlioii rei«tonKl.
Buring the tii'iit <.-tTurt)« at resturation of the feet to their natural poeition, iljey would become luhy wbilv, but the ivlor
-\^
;\,
Pra. SO.
vonbl tniitantly return on letting llicin go back to tlicir original dJMortion.
The i^t foot vrs» retained ns riearlj in its normal position ■» it coul<] be brought by a «itgle piece of iidhesit'e pbutier around the foot, tb-ftwu up on tbe outside of the leg nnd secured by a tUiiiicl roller.
Tbe right foot Iiad a piece of adhefrive plaster placed on the plantar surface — drftwtn^ the liM-l up, and secured on the hack of tJie leg; and another Htrip of pla&ter. to correct the varus, eame as the left, and both eecured by a flannel roller. No ansMtboUc; no crying; nu eutting.
Janvary 4iA. — Child very comfortable. Renewed drcwtiiige, with friction.
C/A. — Child perfectly e«8y, and feet improved in poitition. Readjusted druMJnpt.
Fehrtiary Sd. — Dressings reapplied (eamn pitutcr being need) every two dayK until FL'bniary 1st, when the dressings were entirely removeil from the right foot, whicli wiw iwrfcctly cured, the cliild volwitarily retaining it in tia natural position ; but the left foot gave reflex Kjjiiem on poiiit-prciwrure upon the tcndo- AchiliiH and plantar fascia. However, on account of tlic removal of the child to tbe countrj-, these tiwues were not divided, but elastic tension was advised to be continued, in hope of benefiting
8H0B8 FOR DOUBLE INVERSION.
153
tlie child, And vitb the int«ntiou of cutting iu the future, if fonnd to be necesBBTy ; and on —
December 11, 1874, tinding thnt poiuf-prcMure npon the ten- do-Acbillia and plantar faacia, when stretdied, produewl retli*x ronEmctionfi, thi* budk- im wliun I b:iw the i-hild nine luunths pi-e- TitniH, mid tliHt na impniv«iiient had taken place durinfc this time, ■Ithough under the conHtant iuHiiciici'' of an eliu-lic tractile force, 1 decider! tliat theAe tJEetiefi niui-t he divided, as 1 Iiad intimated irmild hav« to he done nine nionths bt-forv. I (.-onseiiuently nit the tciidu-ArhilUs and phintar faflcia of the left fm>I, am) dretieed rith adheitive piaster and hoard, as seen in Fig. 48.
27M, — Heeult perfwl, us far a» form of foot Ja conoerned ; (tandei flat on the fioor, hut tlie foot ia inverted, the whole limh being rotated iiivrnrd. The child hw-ks tlie powvr of evert- ing the foot or rotating the limb oatwanl. It in easily rotated outward \>y the hand, and frf^juvntlv. in etvppiog, the child will do it himself, hut nioet of tlie time it reiiiaiiiii inverted (aa »eeD ixi Fig. S9); and, as he is too j'ouug to reottoii with, it ie neees-
rto. ««.
Vk. W.
«ary tocnntrive some plan to make the outward rotation constant; nnd for (hi« pur[K)«t: the shoe above described waB applied, which answers tire object perfectly, the child walking quite well. (&a Fig. 90, from photogriipli by O'ls'eii.)
Where there 18 only one foot involved in this deformity, the ■pjilieation of this rotary force to the ordinary t^hoc will ho found
IM
TAUPE&
of tltc greatest advtnUige ; but, where both foct arc impUcsted in the same ileformity, a Hiniilar reittiU to tlie above ran he pro dueed bv n inucl] ftiuipler anA tiiore cconoiiiicAl up]Kinitue, al- tliongh it 16 nut quite m perfect in allowin/ free movements of nil the ]>ftrt«, or io elcgwit in appcftnuicc. h will be found very useful fcr Che poorer clasps of patieots.
rw. «.
It consists itiinply in securing llie lieelft of a pair of common sboce together bv an iron rod, with joiutH on cai'Ii nhoe, and the •olea secured in tlie Mime way, with a rod a' little lungur tlum lh« one at the heel, in order to evert the foct. (Stv Fig. 01.) On cither side of the *\»}V». iron imrc, jdinted at the ankles, paw np to near the top of the tibia, connectiiig in the rear with a i>adde<l iron belt, which buckles in front. The practical uee of this ap- panttoe is well illuBtratcd in the following ca«c :
rni. fl
Cask. Cony^tb'l DouUe Yaro-£quiniu (aa seen in draw- ing by Dr. Yale, Fig. 92).
Jamiarif 8, 1S72, I saw the iDfant [liild of J. W. P., of Brooklyn. Plaster (lrc««iig8 were iipplittl.
Ocfe^r hth. — Cnt left lemlo-AcbilliA at Bell«vne College.
loth. — ntwl cunivK down vory well. Tbvre ]* « tvii«v cundi- tion of tbo liullow of the foot, which appears to be contracted integument and coiidt-nsc-d poimcctivc liiwti<; only ; at Icuet Uio cdgu of tiie ]>lanur faKia cunnot bo rccogni£e<l.
llttA.— Out right tendo-Achilli* at Ik-IIuvin; Coll«go.
i\.9t. — DreeMKl with itdlieHive etiips alone, ledving off the fiwt- boait). The wound liaa tiitiivly hc«led.
December SO, l!*74, — Both feet were perfectly restored in
fonn and position, tlie child stepping flat on tiic grutind, but both
Itlie feet and tb« limbs were \cr\ t^trongly rotated inwaixl (ae
■seen in Fig. 93); and, aa th« pnrcntK wore too poor to purchaiK-
th« instrument with the rotating an'cw, I advised the fatlter,
Pn. w.
no. 41.
who was a lockNiiitb, to ootutruct n jmlr of ehoe« *» above do- Bcribi-d, wliicb, being put on the child, retainetl his feet in their normal poution {«» MSi-n in Fig. 94).
AVith these nlioes on, the- <'lii1il nin>' about with great adivityi hl«etfptt merely being limited in length by the Iwrs Inilween his shoes, wliieb cnnipei eflcb step to he made with an ever^ion of the tocfl in the nHtnral direction. In all <.>asea of donble varus, with this tendency to inversion and inward rotntion, in the poorer ctoasK of jintientH, this eimpiv contrivance will bo found of the greatest practirail utility.
TALIPES.
The following ciwe of cxtromc cquinns — of a paralvtic ori^n — ie a l>ciiutifiil illiietratton of how rapidly lliey sometiuie* recover, afUT heing restored to pro]>er puc^itiuo.
C;a*k. Paral'jtic Mijuinyi, te^ith HetuUtng Contracture (jf Tendo-AchiliU and PUtntar Faacia. — Emuia II., 14 Cottage Place, aged twclvo, wn* a perfct-tljf heallhv child, till 8>i« wh» upward of three veare of age. She was tlien enddenly atlapked with paral}'«d« of tb« right npper extremity and left lowur CJC-
trciiiity. In the coureie of three or four months, tlie upper ex- tremity recovered its power. The lower eslromity {lol\) lias par- tially recovLTCil, It is ntlll Blmrter and pmaller than it« fellow. The lueaeuronientB art? : Lfiigth, right, ait iitcliw; left, ^8 itiches. Ciri'iimfereneo of tliigh, right, 14 inches; left, 12 inchts. Cir* cuiiiference of calf, riftlit, 1 1 inches ; left, II incbes. The motiotiH of ibc thi^h are perfect, niul uTulcr I'oniplcte eoiitrol. The left foot presents an extreme case of talipes e(|uinUH (w^ Fig. 95, from photc^aph by O'Neil). The plantar fuiwia and teudo-AcliillJe arc tvti^e, and %'err tender ; ]>oint-pre86iire in eoeli causes fi[>a«in. Owing to the distorted put'itiun of llie foot, tlie astragalus pro- jects markedly, as seen in the cut.
O^o^i" 12. 1S7-1. — ('lit plantar fascia and tendo-AcbiIHA, aud dfceeed with foot-board and adhe«To ]>la«ter. {See Fig. 48.)
PrcMiire over the a^tni;;rt'l"N in order to roduoo It, waa Tory great, and may eiidanj^r sloughing.
Slouching <li<l oet-ctir, lu fearol, and aleo on tlie sole, bBimth the heel and ball of ttie foot. These aocidenta neceeeitated pro-
0A8EL
IBT
longed dreasings. The eorea finally cic^al^iz«d oompleUly. Tbo preMiit ]>(KUtion »ik1 cioixlitioii nre aIiowii iu tliu uooompiinying figure (yO), from photo^rrsph by O'Neil, which was takvii just lliree muDtUs Bft«r tlie operatii^n.
Tbfi foot is restored to lUmoet porfoct form ; and the recovery
of mneciiljur power to flex the foot ttaa been more rapid tlian in ■ny cam of the Bamc tusvcrity that I 1iav» cvor tavn : kikI it is for tliis reason that I have lhong:ht it worthy of being recorded.
With one ntoro tliickiit-Ks of leathiir on the heel m»i1 sole of tlie left tthoe, to oqtinliM) the lenfrth of the limbs, §1te walks witli- ODt any liiup, and has no deformity that can be diHcovurc-d.
The following ease U of extreme interest, showing tbo rapid- ity with which the patient Bomotimcs rwovcra fruni tho most ferrioiu deformity, and al»o beautifully iUuHlrateA the mode in vhich Mj*. Uudeon adjusts elastic tension by a ucalvr method than liBS heretofore been applied :
O^K. I><nti^e JUiiuinthVayus; Ii(*uU <^ Tretttment, Ptrfect Rtatoration ^ Form ami Motion in Six Wteia. — Miss M. de O., iged fonrteon aad a half yean, of Colombia, South America, was
158
TALIPES.
brought to mo by Dr. Forcro, of Bogotn, on tlic SOth of Maj, 1S82, snffering from double cl»1)-foot, eqaino-Tama in ita most exaggcratod form (Fig. 91). Her i^ireiits were porfcctlj htitltliy, nnd the luid alwaj's been healtliy until ten j«ani of age, when, after oxposaru to cold while in a state of perspiration, she wa« wlzed ivith an attack of acute rheumatic fever, involving the knece, aiikkv, wrisia, and c1Ih>w8 of both Hidue, the orbicular joints not being attacked. Slie van confined to her bed for sev- end moutha. As she rucoverod from the acute pain, the heels
ym.n.
b^gan to draw up, and tli« foot beonmc invun<.<d and extended. She waa nnabte to etand nnthout i>u|)]Mr1, and had lie>>n com[>clIed to walk with crutches for the past four joara. Her body was annsnally large, but the lower cxtrcmittt^ were badly dcreloped, and from the kncue down the liJnbs were atroplued, very eold, and quite purple.
The feet could not be flexed, nor the heels brought down by the strongest manipulation, and when prciwiire was made upon ttie tendo-Achillifl or plantar fa£cia, while thus etrotcliod, it waa followed instantly by a severe reflex spaara, showing that these
CASE.
fiamea had become etrnctnrally shortened, and therefore required sectioD Wforu thu f<.>ct coiilj hu nMtorud to tboir proper poeition. Tbis ia one of tlie nianj casef) which prove the principle Uiat I hare so often laid down in relntiou to tlio ncociwity of division of these contractnred tia!<ue^ whenever they are followed by Rpaem induced by point-prciwiirb u)>on thctii while placed in a Ktatc of (euBJon.
She had for three years applied every device invented for the relief of cinb-foot without tlie sli^fbteet improvement in the direction of her feet ; indeed, sn inorea»o of the deformity, by tho callodititfl pruducccl by pn.<««uix; over the bony promiuouccB, Wl taken place. Thcee finally became so painful tliat all treat- ment bad bbon abandoned for the poet year, and kIio d(;pciidi-d iltogetlter on her cratches for locomotion. The eallo»itieB had all SDb«idod. and her fuct were therefore in good condition for operation. I operated on the !23d of May, 1SS2, aseteted by
Dr. Forcro, of Colombia, South America, my eon, Dr. Lcvria Hall Sayre, and Dr. Kobert Taylor. After the patient was fully andor the inflnenco of chloroform, I divided subcutancotuly the
160
TAUPES.
tondo- A chillis and plantar fatuiia nt rw\\i font, with tlie 1o«8 of only a drop or two of blood, closed tliti woundB with adltwtive pliuKir, oorerecl the foot and anklo with a thick layer of cotton- wool, wliich waa tecured by fi rollpr-lMnnliigv, and thvii, by the ap- plication of eoRie comiderable niannal force, I hrouj^it the feet immediately into their normal po«ution, and rcttained thmn there by tlio application of my footboard, adheeire plaster, and a roller- Inndage (am Fig. 48).
The entire drcHiinf^ wan perfectly completed while the patient was Btiil under tho iuflncnoo of the uuaullietic. No eonetttutional
trouble followed, and at the end of eleven day» the drcMtnf^ were removed for the firrt time ; aU the wound* were perfectly united, witliont the formation of a drop of piu.
Tho new tiKsuu butu'ven the eeverod ends uf the Achillea ten- donn (more tlian an inch in length) liad already become so firmly otgaitized that very elight movcmeuta uf the hcela were quite perceptible when tlie patient made volnntary oontroctiona of her gMtroctiMnii mu«clc«, ahowing that union of the Bovertd ends bad alretdy taken place
Tbe feet vrere again droieed, iu after the nperution, for another WL-ck, wltvi) nil divings wvrv rvinovud, und i\io foot und linibo IrL-at&d every day by niaseage and ptueive uioveinenis for half an Iiuur, and llic Apjilicntiou of thu furadic currcut for five iiiiiiutog.
Foot weVa from the date of the operation ftho began to walk, witli the aid of a " Iliidxon m]io(! " (eVKf Tig. 93).
Daily manipulations and the application of clfx-tricity won) coDtiiiQcd until July Sth, wlien »hc could walk wititout any su\y purt, and the miiaclea of the log liad booome quite proiuinently developed {»« Fif». 9ft).
Tliiti yonng lady oallvd on uio August 14th, ulovoii wooks kfter the oiwmtton ; had walked over two uiilett tliat morning, and the inen*ik^- in the site ot tho niusoloH of the k-gti vam aifloiiLihtng. tihefitill conliiiuud llto mai«ago and electricity.
Clum-IUxd. — The uoxt deformity to which I would call your ■ttvntiun h elnh-haml ; thb is always oongenltul, and in illustra- li<jn of rho lunne X cite the following, which U a typio»1 eii»e :
On the morning of October 21, ISSS, Mrs. S., of Cincinnati, brought to my oflieoher little girl,ii^>d 6h tnontht;.with auarrc«t of devolopiiient of the left arm and hand — tlie hand l)cing des- titote of tlio tltunib. and the lower two-thirdit of tho nidttL-> having Siiffertrd complete arrest uf dovolopinoiit,
Tho elbow wa« normal, with perfect motion; the foreima Ixiiiig fleJccd upon itsalf, with tho fiugcrs lying just above the
Fto. ua.
rro. to I.
«Hk>w (m> Fig. 100). I lit first thought it to bo a fractiirc, bat ti[M)ti careful examination found it to Iki an arrest of development
uf a most romplieated nature.
[ found, upon taking tlie hand and extending the arm in a
line towani the nonnal position, that a» T reached a certain point
II
10'i
CLCB-HAND.
in my cxtoofiion, the liaiiJ and lower portion of tlie arm became &nowjr n'bit«, allowing that 1 had completely amsted ru'culatiim, and that my cxtetii^ioii must bv made to u It'iut dt^p^^: for (be present
I tbcii secured tlio arm in the hixt pcKU-ililu pu«ition by tbo use of the plaAter-of-Pari» iundage, and uitliout oI>6trncting the oiroolation ; th!« vriu left on for ten day^, uo constitutional di«- tnriiance occurring from the treatment. At tbc end of that time tliu dnvsiuj; uiw remorcd, and it was found that tbc tis«ui<s were leaf) eontracted, and that Htil! further cxteiiuon could be made without obetructiug the circulation ; tbiis wa« accordingly done, and the plaster drewiing aji^iin applied.
Thi« treatment was faithfully followed out, until at the end of (en weeks the arm bad iteen brought into perfect line and a»- »uuH>d the normal po«ilion (see V'lg. lOt), the arm and Imnd in- creasiDg in development and &tren}!:tb, ho that the child could gT«8p a fun in iho liand and play with it when the arm wa« en- cased in .1 bandage. At this time the mother left for her home, taking niili her iii»tnictioii» U> remove the plaster-of-Faris slicU from the arm daily, and treat the arm with massage for a short time, then to reapply tlic i*liell, or to have a piece of moderately 6rm leather moulded to the arm to eerve as a support, and see if posBtbly there migtit not be Bonio development of oseeous ma- terial in the ptfkce of the abeeoce of the miesiog portion of the radiQfl. In thifi atac the ulna wxi nmuiually large and well de- veloped, and this, in connection with the arm in its normal posi- tion, will at Iea8t afford a most useful limb; whereas in its pre- Tious condition it was {terfectly useless, and presented « most nn- sigblly deformity.
In this instance the result was more satisfactory titan could at first hai-e been nnticipated, inasmuch as there was so grcdt an arrest of development of the radius. In many of the cases, however, where there ii* «iniply a deformity from ntuAcnlar con- traction, nncomplicatcd with any deJiricncy of jiarts, by tlie application of the name principK-it which are laid down in the treatment for club-foot, a encceesful issne may bo generally an- tici|)atcd, by tJie commcncomcnt of treatment immediately after birth: gently extending the parts toward their normal position, never oarrying tlie traction to the point of obstructing the circubi* tion; then retaining tbo hand in the improved position by felt
TREATMENT.
108
oUta H^ oiit
I
fpHnta or plnster-of-PnriH bnndngcs moaldvd to tbom ; nmevmg tliu draniiig avery fow duys, act-ording to the improved |x«Etion oUtalned. B^ tJiix nieiins a ciirc otn gcnerully Itu i-fTL-ctvd with- out auy operative procodoro.
In Home ctkSCB, however, where, on mnkiiig tmction upon tlio B without boiDg ftblu to bring tho liand to ite noniinl position, asd point-prceeure being mode npo» the etrvbrhud tiiwtii'S, ft re- flex Bpasm be produced, soctiun of the contmctured dseaee be- fiome* oeccsBary, In iiU suclt cases the luiinc prindplca are to govern jour practice aa in the treatment for club-foot, where tenotomy is, necessary for llie relief of iho deformity.
The trvatinent above iudioated is applicable in all cases where the deformity in tho result of Hpuetic contnetion ; if, on the con- Imry, it is of paralytic origin, then the hand must be retained in it) nonnal position by artiticial mcona; elastic traction being supplied to take the place of the partially paralyzed mufiolcs. Tbix can be easily accompli&lied by the proper adjuetinont of a eplint, Bflch as ia seen in Fig. 302, togvttber with the application (rf cl«ctrieity, friction, mas6agc, etc., for the jiurposo of develop- ing the partially paralyzed mnaclea.
LECTURE XII.
DISBA6ES or TlIK JOII)-I«.— AHKLE-JODIT. ttaUndaj ol ibe Anklc-Jotail.— Pklliologj ol IJiwuc of, — Sjmiptoni*.— TnAtmcnL
GiuTLiafEN : We will next etndy disease* afToeting tlie ankle- joint. Tliia snbject is a proper one for consideration by the or- tliopcdic enrgeon, for the diM;aM« of this joint frequently ttTini- aate in deformity, and, sa " an ounce of prevention is wortli a pound of cure," the method of preventing deformity during the oominiunce of the dineaee makes it a proper subject for oonwd- encion in our department- It in to the pathology, ayniptoma, and Iroatmcnt of the disease, then, that I shall specially direct your attention. Before proceeding, however, to the study of the dia-
niR AKI
eases affecting tlie ankl»-joint, wc inuet turn onr attontion to ttie oonatmctton of tliie joint, and to aotne of its anatonikat peculiari- ties
Anatomy. — The (kiiim which enter into the fornintion of tlic ankle-joint are the lower extremity of the tibia with iu mallco- lu«, the lower extrotnity of the fibula, or the external mnllcohiM, and the oppor eonvex surface of the aMragalus. These articu surfaces, covered with oartiUge, are held in plaee hj the internal^ and external ligamentfl and the anterior li^iiicnt of tlie ankle- joint, which are liavd b^ fijiiovial membrane.
The important thinjj to be reniembertil with reference to tliisj joint is, tlut it is simply a hin^-joint, has a to-and-fro movi ment and no otAer. The articulation between the astragalus, the lower eitromitj of the tibia, and the two malleoli, in ao complete, eloee, and perfect, tluiC it will admit of ito lateral movement whatever, lliia in one of the Btatementa whirh I make with positjveneiw. The apparent lateral motion which takes ]>lacc is not at the astragalo-tibial articulation, but below, at the articula- tion of the a»tra^alii» with the oh cali^in. AVhcn the toce turned tmt or in, it ia in obedience to rotation of the leg and tliigh^ at tbo hip. joint ; or, if the leg U flexed uiMin the thigh hy the action of the biceps and tensor vaginie fcmoris, giving a revolv- ing motion to tlie head of the tibula.
pATUOLoov. — All lateral movemento made at the ankle-joint are done at the expense of an injun- to the rtrurtHrcs of that, joint ; for no lateral movenient, external or internal, alxluctioa' or ad<luclion, can take place witliont producing undue prefisnre againbt the synovial membrane and articular cartilages, or bnwmeiit membrane beneath them. These articular cartilage*,' like those in other jointa, are elastic, non-vii«ciilar, and receive their nulrimmit by imbibition fmm the synovial membrane and from tlie vessels of the articular hmiclla. Necrosis of these c«r- tilaget takes plaee with the greatei>t rapidity on account of the low degree of vitality they possess, heiiw they arc the source of great danger when, in any manner, the tiiwaes beneath them be- come so diatnrbcd as to interfere in the least with tlieir nutrition. I do not believe, however, that disease ever couimenoes in the car- tihigc it^f. The malleoli, which stand as guards on tlie side of the joint, arc not so well protected, because in the nonnal move- ments of the foot they are not subject to mndi pressure, sod eon-
PATHOLOGY.
IW
leqnfntly tlic cnrtiliige ooverinfi tliom is not 60 thic!: as that covering tlie top of the afltragntuii or bottom of tlic tibia. You bivc |>robixb)y all at wmc timu twisted your atiklo in walking, Old jrou cannot hare fniled to notice how instantly tlte mal-jiost- lion of tlio joint U followed by a ^ii«ni of tbo niuM^lcs uf the [og.
Wo may have disesoes of the ankle-joint whicli eonimeiKe either in the lignuicnts or in Uio syDorial mcmbmn« ; or, vrhtdi [ U-liovo to bo far the most fnKi«ent, in tlie articular lamella ini* mudiatvly buinsath the articular oiirtiliigv.
In a great majority of instances what we have to deal with itt au extravasation of blood benoath the synovial membrane, or between tlte cartilage and bono, iniitc analogous to the "blood- blister" wliich it foniii-d u|Kin the external eurfaeu whcno^'cr the (Icin 18 severly pinchi*d but not broken. This may owiir either Bpon the a^trag-Alud, or at the lower extremity of the tibia, or, still mure commonly, m llic n-Milt of ]in^^nro produced by tlic astng- ■)os agiiinetthe inner eurfaL-es of the malleoli, which are not siiffl- ineiitly protectml to niuvt severe pressure, t' rider mieh cimim- iUncc5, no swelling occiini that can he seen; there \fi pain, proba- bly, but the L-*scti are very liable to be nugloctinl, their imporlaniN) i>ver1oob»), and thus a slij^ht injuria', pro^lucing only trifling dam- age kt tin^t, may be purmitU'd to go on and develop the most lerions <-onilition, ending in inflammation, which gnes on to Hoften- ing of the bono, noero<iiB of the cartilages, and destrnotion of all the tisHiieA involved in the joint. The intlsinmalion may extend to other t>oue«, and you may linve as a nwiilt luftcning and carien of ail the bones of the tamia, aa in the ease yoo now see before you.
fio. im.
(I)g. IDS.) Tbew arc the t»M>H that are ealled " scrofulous 'dianse of tlie ankle-joinL" Tliere is no a'l-ofnlft about it In tlic
1C6
DISEASES OF THE ANKLE-JOIKT.
vftft mnjoritjr of caw^. It is ^ilnflIJ iiiJltimiiuitorj softening, ending in caries and iiocro»is of the bones, and ulcerative dc^Irucv tion of other tiiutueji entering into tlie foniuition of tlie joint ; and inetcad of hving cunstitutioniil in itw origin, dependent upoQi a constitutional cachexia, it iit .liniply intkninuition of tlie joint d^>endent upon injury, eonDoqucntly traumatic in its origin.
When children who have a scrof ulouii diftthcMB rocfive, ae of j couTve thej'niay.an injury nuQiciont to lead to serious re«ult«, such' Kenlta arc usually more rapidly developed and leae atncnalfle to treatment than when the injury ocoirs to previously healthy obildrcn, or childrtMi buna of healthy parents.
STMrroMB. — With this view of the subject, gentlemen, yoti can at ODCC «eo the very great iuiportancc of earli/ recognition of the exMt nature of these trifling injuries to the structures of the joint, whii;li may lead, if neglected, to sach ecrions rceulta. To this end, therefore, I shall endeavor to point out to yon in the plaincstJ manner possible the sj-mptouiB l»y whit-h you will ho able to recog- niJte them in their very earliest stages, «» that you may he able to adopt a plan of treatment which will prevent such unfavorable resnlta.
First, then, if tlie twist, wrench, sprain, or bmise, winch the patient has reoeiTod luw produced an injury that involves the synovial membrane chiefly, it will be followed very speedily by inoreased eEFusion within tlie joint, giving to the joint a peculiar foIlDcasin front of either malleolus, within which swclUngan indis- j tinct flnctnation can he recognized. This in a few hours is followed' by groat heat and intense pain ; a eenee of tension, aecompaniod by throbbing, and great tenderness and pain will !«• present when ' the artttrulating surfaces are crowded together and idigtitly twtttted upon each other. If, on the otlier hand, the ligaments are involved more than the ^-novtal membrane, the injury will not bo attended irilh ao inucli swelling aa when the lt^■no^•ial membrane alone is invol ved ; and the tendcme&» and pai n are not produced by preaa- j lug the articular surface* together, but, on Uiccontraiy, are relioTodjj and it is by making extension and rotation, together with prewurai upon tlio ligaments over tlieir points of attachment, that pain ia pnxluced and tendemeaa delected. If, however, the injur)- is the result of a blow or coucuasion, with or without much twisting, but received in such a manner a« to produce rupture of blood- ve».j ecla nodenuiath the articular cartilage, in the articular lamdla,
PATHOLOGY.
eitlior at the top of tlio sistni^Iu*, bet«e vt tliu tibia, or iaoer iuf- iiux* of the mnlluoli, then tht^n; will \>e but dli^lit pain at tint, but aftcrwanl llio autTc-nng will bu altoj^lher out of proporlioii to Um! iippvnruDriM presented. At firat tUe c.\tniva8.iti»n of blood into the boiiQ is vur}' eliglitt and, being in a Uhsuc vrtiicb umnot 8wu)I, no apgwrent enlargement takes place ; nor is ili^coloration oI>served, betrause tlii< uxtnivaiwtioii is bO doep-seatod. Tbc Ugu- mvntti not being npoi'inlljr involved, making them tenae does not produce pain. All these fjct« add to tliv dtt-virtioii, and tuukv at, verv liable to ptwa over the case aa one of trilling importance.
When this accident lute occurred, the only iiianuur in whicli it unn bo reuo^uxed is hy mcikn» of diroL-t preeHure upon the pnrt afleL-tcd bv the e.xtra^'asatioa. The seat of the injury may be ut my point on tlic surfaces of the joint, and it therefore becotnw necesearj to make pressure upon iill part^ of the joint, by moving the bones in every dirix-tion, nnd aluo nutking Utend pressure to aa to bring it to tK\ar upon the sided of t]ic malleoli.
We are not lufe in giving a diagnosis in tluiW casM until in thie manner we have thuronglily explored every portion of tlto joint
Tou muetnot, however, entertain the id.*a lliat you will see Tory many cniWA in which thu KvuiptoniK uf either one of the«o tliree conditions jiut dc3rril>ed will be prctietit, clearly defined and alone, nnauoeiatod with eyniptums indicating the preiwncc of one and jierhaiu Ixtth of the other conditions. A wrench, or sprain, or bnii«!, may be rccvivod, which wiU givo rise to eymp- toios iudic-ating injury to aU the strueturcs of tlie joint — iignment«, eynovbl membntne, and arlicular lamella ; but your examination iniut bo conducted upon tlie »anic plan in sneh ca«^, for in that manner only will you be able to detennine positively what Btnict- nres liaru becrHiie involved.
The important thing for yon to recollect and always keep in mind when yoii arc called to examine and treat this claea of cases U, thiit eerioufi injm'iee of juinls comjiel attention, and flight ones ore tti^lec'ted, and, gcncnUly bpi-jiktng, the Eligbtcrthe ikci-idcnt the more apt to l>e neglected ; but tho^ are tlie ver}' onea which arc excL*c<ling!y (hkngeroUH.
If an injury be sevcm — for example, a fracture involving n joint, a diitlocalion, or orcn a Buvero sprain — it cannot bo oveHooked or tteglected ; surgical aid i» indtsjiensable, and ia itnmedialely
168
9EASE3 OE
JOINT.
Called for, nnt] generally n care remits after a rcfl8onab1c time, ^STien, however, a jtereou receivcB what is termed a " sUj^t sprain of the ankle," the nmouiil of iiiiM>hicf from » neglect in rvoognijiiiig what structures nrc involve*], aiid inetitutin^ a proper method of trcatiMcnt, is often extreme, and ninv terminate in a Kueritlcc of the limb as the only remcJy for a chronic intlammstion of the joint involved.
I^t ns, then, next consider how each difafitroun reftuUs niay bo brought about. We will tnke, for example, n simple i^pniin of the ankle, which is very common, and from which all of you, it may be, luive mffero). As I Iinve already told you,* "hlood- bli^ter," or extravasation, is firttt produced. Soch a "blood- blister'' ii couMiilercd as insignificant imder ordinary drcuin- fitancet), if it be allowed immediately to heal. If, however, the "blood-blister" i» conMantly irritated by friction, an ulcer ts fonned which rapidly increases in size, and involves the deeper tissues.
Thi«, I believe, is exactly the morbid proccw going o» In one of these neglected sprained ankles. The small quantity of blood effufled behind tlio li^-novial membrane, or between the cartilage and bono, would be sjieedily abeorbed, if aufUcIent rct4 were allowed to the part ; but there is no swelling, and little pain, it may \x, to give warning of the mix-hief dune, and the patient docs not stop hid usual walks and exorcise. The " blood-blister " biicomc* irritated and inorcnsc» in mA.; and finally, on aeronni of the diHturhance produced, he is obliged to lay by for a sliort time. The trouble apparently disappears, and he rMunics his nvoratiotu ; a slight over-exertion, however, brings liatk the same train of syuiptoniK, namely, exhaustion, HtifTiiL^ie, pain, tendemew, and perhapt) swelling. This is repeated agsin and again, as often u rest allays and exertion awakes the morbid process, the attacks becoming more and more Revere and prolonged, till at laiil the condition of chronic inflammation is reached. TIio liquid now contained in the joint in nbnormAlly abundant, and in changed in conaistency; instead of the clear synovia, there is an opaque, riiwid eubetance. To thi», in part at IcMSt, in due ttiat i>cculiar distention and "boggj-" foel which the joint now pn'scntA. Ordinarily, suppuration very rapidly 8ui)er\-enea upon Ibis con- dition of the articulation. The cartilages become necrotic, and caries of the adjacent surfaces of the bones ts set np. The paiu
PATHOLOOT.
1G9
I I
now is often excmciatirijr, as is gcnvrnllv ttic case when cartilage ii lUKlL-rmiing ilitdritf^^rotion. As » result of tliin prixrciw, tlio cunslitutiontil disturbance is uiiiiiilly quitu suvcro, uiitl tbe pain |>roduoes sIcepIcRsness and loiS of appetite, llie iiiuftrlefl aff«ct- ing tliv artiadatioii arv coxulAntXy '' on guaril " to fix tiiu joiul, ■lid prevent any nibbiag togetlier of its Burfacefi.
Su(.'li constJ>iit t«nMuti CAtiM« an ntropliy of the limb both ubove tnd Wlow tbe joint; thoujfh in the tatter eituation it maybe obscitTed by tlio HtvelliDg. At night, wliL-n t)iu iik-ep line bccomo to Boiiiid tluit the tau»('Ied relitx their tonic contraction, mo- tion will take plnoe in tliu joint, and the p«ticnt Hwake^t with n sadden, piercing shriek. 80 quickly do the masdeH resume tbejr eoiiscrvittivc contnu-tion. that, by tbv time the nunc hau readied the bedside, the patient is again asleep or is unconfMrions of the nam of bis awiikeiiing. Tliii^ pn-veni-c of Ihu joinl-Kiirfucu^, llthoagh painfnl, is less 60 tlian the motion which would o<vfHr if tlto muHultM were not tlms cuulnu-tetl, but it very much incrun«e» the destruction of the cartihigc and bone, and you will Itud, in jMwf • mortoji cxiiminittion of the p.irt«. erosion of the tiKsaos fsrtheet advanced at those points wlicre the presBiire fn>m mns- culsr contmotion had been grontottl.
Wlien the joint is thus lllled with a liquid, which is causing dl«turb«noo nit n fon-ign body, one of two temiinAtiontt is neoee- sary, tbe alisorptiou or evacuation of the liquid.
If there is ft probtiliility tliat idi»i>r|ilion of the fluid can take plftcv, it in l>c«t proiiiolwJ by Hxiiig the joint in sneh u manner as will relieve tbe pain and defend it from attrition of the ailicuhtr Kurfacos, ibiifi allowing our ftit*.-nipt^ to renovate and invigorate the syatem re:illy to take elfect.
If in wldltion we apply smno apparatuN which will permit ttie pttioat to take out-of^Ioor exorciBO wittiout disturbing tbe wrf M eiwontial to [be articulation, we uliall Iiavo done the ImmI thing possible, and, fortunately, our efforts will often hs crowned with ^iicl-csh. If, however, such precautions are not em- ployed, and often, indtKid, in Hpite of them, the diswwc pruL'coda to nleentinn of tbe bone,' and, now if we do not make an exit for (he pus, it will eventually nmko one for itself. In tbe mean time, however, long and Inrtuous s!nuAes will tmve formed, tbe pua tiurn)wiog thifl way and that among the muswrle* and between faiiciir, DO tliat these tissues arc involved, white by long-continued
no
DISEASES OF THE ANKLE-JOINT.
sctioii of llic pHs the disease of tbc bones becomes greatly ex- tended. Much of tliin tTx>uble is avoided bv opening the joint wlicn wc arc (.'ouvinocd tbat any eoiwidewible amount of pnfl is eontained within iu cavity. The old-estabtish«l doctrine of the great danger of ujK-ning u joint »till continues, for the luoeL part, to be fnlly accepted toKlaj. I must, however, expra.<H my diotent from t1i!» general iK'Uef. Of euUTM-, no one would dream of opening a joint i»o long as tliere was a prot>ability of the intt^ity of the urticidatioD ; but when the articular surfaces are wholly or in part dutroyed, then, I say, the eharaeteri»1ic« of n joint are aJeo destroyed ; tlierc remains nothing but an abiiC'ess of a joint, which in to be treated in the same manner n« an abnees el«e> i when-, or, more exactly, as un ub^e^s eonnected witli bone.
When the disease has advanced to this stage, the case is lool:eil upon by Die mass of tlio profcfisioo m an nnniiitakablo illuEtmtion of " scrofulous disease of the joint," but I believe it to bo tlte result of inHammalor^- proce««c-s de]>endenl uj>on a trauninlic cause.
Tkeatm[3ct. — We are now re*dy to study the treatment to be adopted for the vcriou« conditions which have been described. In all sprains or bniiaes afle'.-ting tho Miklejoint, invotring the ligament.'! or producing effusion of blood, tiie very boitt treatment that can be adopted is to immediately immerse the limb in water of as high tcmjK-niturc as can pOKsibly be borne, gniduaHy in- rrcasing this lempenttiire, until the beat is csrried up to the highest |)oint the patient can tolerate, and then maintain this for a ran-ing length of time, perhaps Ee%'eral hours, until all pain upon pressure and slight movement has entirely subsided.
Many have rccommendod that various articles be added to the water, such as wonnwood, sniartweed, wood-aelies, Pond's extract, tincture of arnica, etc., etc., but it is ([uestiunalilo if any of them arc of much service ; the principal agent is the heat, and that can always !« obtained, whereas the srticles recommended may not l>o at band, or cannot be procured. When the pain is relieved by tl>e foot-bath, the patient sJiould be placed in an hori- zontal po«sition, with tho limb elevated and firmly bandaged with a flannel roller fjiun the toc« to the knee, and then kept wet, or dry, ss may be more agreeable to tlic feelings of tho patient.
Perfeet rest of the limb in tho elevated position, with this even compression, is to be maintained until all tenderness opon finn pressure has completely subsided, and until the limb can be
EL&STIO COUPRESRION.
m
Iield in Uie dependent pneiiion without producing nny unp1c:ifsnt Bjmptom& If the tynovial membraM \\m b«cn involvud iii llic iiijurr, and effusion and ovcr-dixtOD^ion of the joint tiare ensaecl, «!asiic cotnpivsviwt in the e«ji«nliRl element in tiie Ireatineut. Thift cu) be ol>taitiod I>y eurrouiiding the joint with a largo epon^Q. llic epongc tthonld first be thoroughly- euturatcd with wjiriii wiiter, then nmdo as dry as poiu-ihie by wiuet-zin^ with the luind, Bud liiiiilly made to ooniplctely surround the joint, being portii-uUr to have it quite thick over the instep and both malleoli. After it baa lieen prnporly applied around llie joint, hind it firmly in place with a b«ndaf^ that will permit water to ptuw tht-ough i(« mealies. Thiit banda}^ tihould include the foot, ankle, and leg, and, after the sponge ha« thus Wen eoinpri-secd hy the bandagu, both RpoHf^ and bandage should l>e thoroughly eoaked with water ; the ^{wngu, absorbing the water, will iucnHMC ineizc,aiid,Ke the bond- age prevents it from expanding outwai-d, tlie prfs,iiiie inducwd by itj enlargement i« done nt the e.\ii«n»c of additional presHure of the parts enveloped hy the sponge. This tiietliod of making elutic pretwiirc ir» within the rviwh of every gnrgeon.
A more convenient method of making even prewurc over ibo
Fu. 101.
joint is by means of llic double Tudia-nibbor bag, manufactured by "netnuin & i'kt. of this rity. It is simpiy an indta-ruhber sac with doable walls, which inclowH the ankle and foot ; a tube connects with tlii« hollow bng, wliiuh can ha%'0 warm water ponred into it, and then the l>ag is to be blon'n np either hy the moutii or a pair of bellows, and a stoi»coL'k tnrned which retains tlie air. (Sw Fig.
ITS
)rSEA8E8 OF TIIE ASKIX-JOINT.
108.) In thin manner pressure can he made wlitch will be cxccul- inglj powerful, and vvt 6U «uft nnd vlaetic ns to bo easily borne. Such pressure, omietaiitly applied, on account of its elastic cbnrac- ter, will cAiiec »n Hbriorptioii of the fluids witliin thv joint ; nod also, hy thiH very pressure, we have n tendency to eeparate tlie articulating Hurfaces; therefore, lo a very L-ousidcmblo cxt4.>nt, we secure the double advantage of preisure and extension and conn- ter-cxlemtion, by forcing llic Jiuid into the joint, thus preventing the articulating surfaces from being fon-ed upon each other by muevnliir contraction. After a few dtiye hiivc eUpt^cd, friction with the hand is of the grentcst possible advantage; but to ikfTord the f)fBt result it should be much moi-c briskly applied, and con- tinued for a much longer time, tluin has generally been done by the gnat majority of t-urgcons.
In fiiet, many casai of quite severe injuHr' nfTectin^ the ankle- joint, or any other juint, such as a wrench or a sprain, will yield, in a comparniively short time, to manipulations and friction por* sistently applied for some few hours evorj- day.
You may call thin " ma«flffjf<' " if you have a fancy for n new iiitme, but I ha%*e employed tliis plan of ti-estment for many years, and long bef.)rc the tenn " matMffe" was rt]>plied to it. It it, however, sometimes necosairy that a method ortrcnlmt-nt i^hould go across the water niid bo baptized witli a new name before it becomes popular.
So much. gi-ntli>nien, for the treatment to be adopted when the injury is tirst received. This is the importimt time fur tho application of measun» which are to prevent the further develop- ment of the dieoftse, nnd, could such treatment be faitlifully car- ried out in every case from its carUest conunencoiticnt, there would mroiy bo need of the mcehanicAl appliances and enrgical interference to be described at onr next lecture.
INSTRUMENT. J 73
LECTURE XIIL
ni3EABES OF THE JOINTS. ASKLE-JOINT (cOMTINtlED).
TmtiDent (ccntiniied). — Description of Instrument. — Uode of Appliotion. — CoaeB. — Disease of the Tarso-MetatunMil Articulation.— Case.
Gentlemen ; At the close of my last lecture I was speaking of the importance of early treatment of injuries of the ankle- joint, hoping thereby to prevent destructive discfiee. Unfortu- nately, however, very many eases pass unrecognized, or, being recognized, are neglected, and gradually arrive at a etage in which surreal aid is sought, and then they probably are in a condition which will demand some more formidable method of treatment than that which has already been given ; and it is to this part of our eubject that I invite your attention to-day. "When there is still hope of preserving the joint intact, which is to be detei^ mined by the length of time the condition lias existed, the amount and character of the fluid in the joint, the degree of constitutional disturbance, and the general condition of the joint, I employ an instrument which I have devised for this purpose.
This instrument consists of a Una steel plate, made to fit the sole of the foot; at the heel is a hinge-joint, and attached to ita rod.
slightly curved at the bottom, and extending up the back of the leg to near the knee. Over the instep is an arch, like the top of a stirrup, with a hinge-joint at its summit from which springs an- other rod, which runs in front of the leg, of equal length with the
!74
DISEASES OF THE ANKL&JOIFr.
ono bcbind. Theec rocU arc mude with a iiiale and female torcir, or ratclipt and cog, Ibr cxteiif>ioii, and eonnccted ut tlii' top by a firm band uf feliwt-iruii, oD ono eidti of wbicli i» a lungc, ami a loc-k on the other, like a dog-(«llar. (5m Fig. 104.) In front of the an-h that guL« over tliu inelcp is a joint in the foot-plale u-liidi peniiitii flc.vion of tlie tue*.
The inetrument is applied with firm adhesive plaet«r, cnt in Mripfl about one inch in widtb, and long enough to reach from
m. 110.
the ankle to a »hort distance above the kneo, and placed all around the limb, as eevn in Fijs;. 105.
The plaMcr i« itccnred in its position to vritbin a few inches of itfi upper extremity by a wfll-adjusled roller, aa aeon in Fi^, 106.
The in«trument is tixod, and tiro foot firmly WK'urwJ, by a number of ttripe of adhesive plaster, as seen in Fig. 107.
r».i<H.
A roller aboald be carefully applied ovor this plaelcr to pre- vent its slipping, and the ends of the plaoter at the top of tLe
CASE.
175
I
I
It tnmed over tlic collar, which lias been previously Ioc1:d(], jtuit tijrlit enouj^ u» bo<.'i>mrortiil>lLsand t>ec'urod by« turn ur two uf till! bandage, as euou in I'lg. 108.'
Willi the iti«truiiicDt accuntely adjusloi], the oxtciutun ciiti bn ru^lated bv the key, fo »tj U> iiiiiko llic imtieiil <'(iirif*irtiililc
If, howdvcr, tbc nymjitwtiia eliow the Hvi«tem lu bv MitlLTttig from tltc [Ktison of tbe pno retained iu tlio joint, or if, tlic joint beiti^ oIH!!!, tbv putii'nt inoinking under tbe dmiti of pixihuigi'd flUppunitioii, tbe diiieaiietl Itoaa sliuuld ut once hv miuuvi'd, mid a porfixt dntinngo establisbod, tto that no pwrkels ur Binofice can bo fomiui). if tbJA latter at-i-idpiit lie alluwod to owiir, thu disease uf t.be bono will not bv anvbtii.1, and llie operation will llierefore boOHlOH.
Now, \o\x cannot in lb« anklo cxMct lliu bone, aa, yon can at ttw> shoulder or hip, by a strai)jht incision. In tbv^ orbicular jointe ibv uporatiun i» hiiiiplu ; yuti ttavo but to cut down to tbe bone, open the capnule, throw out the head of tbu bone through tlio " butloii-bolu " eltt, runiovo it with tlic i-bain-Mw, and finieli witb tlie rongenr or forceps, if nec«»aary. _
But in tho hinj^joini«, au a rule, and c«peHa1tT Bncli ooni> plieatvd ones as the ankle, you cannot Ntfely operate in thia way. To make t]io neociwary incUion«, th« niiuclcs and vckcIs must ho tlivided triuiiver^ly, and Bo mncb daniaf^e i» thus done as to seri- ously inti-rfi-ic witli thu hui.-cl-«s of thu opcmtion. The oUkiw- joint is tlw exception to this rule, the ordinary operation for orbicular joints, i. o., a #in^Ie inci^'on parallel with the muscular fibres and Teeeels, being applicable to it. In view of thiis 1 have fur many y«ra refused to ojiurati' by exsection upon tlie anklo and wrist joints. Ttio method whicli I HubMitutc I shall now proceed to <lomoii<)trate to you, m by ho doing I can much more dearly explain and more iinnly ini))n.v» the cwM^ntialx of the op- eration tlum by any nniount of lengthy description. The history of thu caae U^foro you is, in brief, as follows:
Lowlii It., a(reil nino; latt wnter, in Deocmber or Januari*, sprained his ankle while tJiatin^;. For Heme tiniu he experienced no trouble in Iho joint, but cvciitiially it be^n to swell, and the dtseoso ran the usual course, till he was admitted to IVllvvuo Hospital ill July witb an opon joint. On tlie 22d of that month I removed wliat dead tionc could be found, and poeecd a wton of
' Tb* Bpna rtfirtxttl llw inanniciit w applied to ■ Joint which bmt been Hltin«<l
176
DISEASE OF TBE AKKLE-JOIKT.
oakDm through the joint from 6i<le to ^ide below the mnlleoli. The joint WHS fixed hy & ]jIaHtcr-of-Pari6 splint, which wa& changi-d in & few days for one of leather. The case remained nnder my care Tmt n short time. The Mirgi-on to whoce mre lit- DL-st pu«^, holditLg different viowb rt^snliiig tlie treatment of theae ca8c«, removed the setoa a month after it luid been iiuerled, Bttd after that the treatment waa simply applying pnalticeit and stimulating iirc«»ing!i. The ^urj^eoii now having charge of thu esse bae kindly consented to Burrender it to me for one year, a1 tiic end of which time it ii to he n-tuniix] to bim for an ampu- tation. You see, he hai> no faith in my j'lan of treatment.
You will notk-v the foot and ankle present the ni^uul appear- aDce found in chronic inflammation and Ruppiir.ition of thiii artic- ulation comj)Ii(.'aIvd with caries of the tnriuJ ItuncB. {See Fig, 102.)
The usual contours of the joint are ohiitcmted, and it presents an irrc^krly rounded tumefaction, nearly twict; the size of the opposite ankle, of a purplish color from venous congestion, which hu been aggravated by long^eonlinm^ poulticing of the part, and a bog^, doughy feel, with Kvenil o|ien sinuftMt, through which the probu readily passes to dead hone. I would remark, in th)« connection, tliat the long-continncd use of hot poulliccH to a joint El) the condition of this one is always injurious. The heat soli*' cila more blood to the part, and tlic relaxing effect of the fomen- tatJou favore the passive congestion of the capillary vefuels, andj Ihns adds to tl>c OKlematouA and " hogg>' " condition of the part.]
While the patient is under the chloroform, 1 sliall remove till carion« bone »ub-periostealbj. If I destroyed the pcrioetouro, f diould defeat the chief object of my oi>cration, nsmely, the regenetation of bone and ibe formation of a tnovahU Joint.
Into the sinuses already existing I pass this inBtrunieot (Fig.
109), wbich I have formerly called an "oyster-knife," as its form most resembles that of the im])leinent UKed to open oystere, but it h more properly called s pi-riostcal knife, or periostea] elevator.
OASE.
177
Tlie blades are strong nud wctljice-Hhaped, Uie edgoa not boing infiirittntljr tihkrp to cut tliu xuft ijarts, Witli it I can eoiioleate tlio diwtttted bone withuiit fear of lacenilin^ tliu vceaelB, perioB- leuiu, or oUicr important piirt(«. Hake yonr excavation tbor^ ougliljr, seeking to remove not only all thv dead bone, but espe- eialJ^ the gelatinous matter m abundant in ihcae diseased joints. In this case ;oq see I have removed, betudvw a inas« uf dvtritu^ a piece of carious bone about tlio size of a hickor^-nat, which ia bwn tlie lower end of llic tibin, including a part of the articular tarface. If I can, I generally, before ^nisliing tlie operatioii, place my finger within the joint, to inoiv perfectly awurc mywlf tbat I have reached all the cliauased etruL-tiiri-s.
Now. I draw coni[)l«tely through the joint, and sleo through the other sinuiics, a large evton of oakum, saturated with Peru- rtan balsam, letting tlic cnd« extend bvyond the ulccn for eevcral fnoheB. The advantage of the oakum 1 will mention in a moment.
The operation proper ia now complete. We now place the foot ill a comfortable posilion, and at a proper aiiglu with the axis of tlie limb, and fix it tliere by an anterior spUnt of plaster of PariK, from which amis extend around tbe foot and leg below and aiiove tlie wound, so as to leave the latter entirely free for tlaily dremlng. (jSeo Fig. 113, witli plaHtvr-of-Pari» ttplint.)
When the plaster has "set," envelop the joint witli a thick pud of oakum, filling with it tlic fenestra^ in the platftcr dressing, and bondage tlic foot and ankle aa finnly aa possible.
The reason why 1 in«\ti upon the am of oakum is this: it to ' ehutic and makes an e<iunblc prc»mi<e, bnt at the same time it is I always pon'ioiu to tbe utcape of putf. Vou know liow dense , compreaied cotton is, how it cannot he n-ctted tlioroughly for u liiQg time: lint hns muoli Ihc twnio qualitiiit. I sincerely believe tluil the life of many a soldier wu<i lost (hiring the late war, sim- ply from the lint witli which his wounds were dresMnd, or rather plngged, Deyond this ndvantagei CMikum iapjirlicularly service- able rut a ectoii by reason of its etrongtii, and the ttir with ^vhich It is so thoroughly impn^oated prevents it» 1>eci>ming readily foul. Therefore, gentlemen, I use lint only to urri-«t or prevent hxmiorrbngc, ami never after suppuration in fully e^tabliabed.
Id this case, then, I have accomplished what! By my ex-
avation I have njtuoved tbe essentia) morbid cause; by the IS
3^
DISEASES OF THE ASKLE-JOrifT.
sptint I pre%'enl motion, which would be a cuiiKe of a relapse ; and l>y the finn i>re«*ure I liiivc givt-n tho enfeebled and «tJi(,nisiit circulation of tlie parte the best posailile support. Tli« eclou will be moved daily, and tlic soiled part cut off ; yon can eaaily twiitt on more oakuin, and thus continue it &» long ag ncetegarii-, and what (/SiH9 of carion* bono luw b<)On k-ft behind will be drawn out entangled in the fibrett of the oakum. Ity-nnd-hy, when tho reparative process shall liavo been fully e^tablieliod, lliu extension instrument, which I have already doKribed to yon, will 1>e applied, and the boy allowed to go about. Even before that, if your patient is of Bufficivnt ago to take proper precaution against injury, he may bo allowed to go Jibout a little on cratelieB. In this event, bowcvor, yon will be oapecially careful tlint Ibo band age^ be applied with Kuthcient neciinicy and firmness to couni act the congelation from graritation of blood to the part.
I hope, gentlemen, before thi« winter eM«ion closet, to be able to present yon the retiult of the atse I have jnat o^terated upon, but a longer time may be ncoeeeary for a perfoct euro.' I have, however, here several jienioii-i u|>on whoni I have already operated, and wlK^ living in the oily, have coneenlod to como liefore you in order that yon may see wlut degree of succesB you may antidpato. And fintt, let mc present one which should fol- low the eatte ju&t operate<i upon, because tliey botlk exemplify tho danger of the too i>pocdy removal of tlio wtong. This one, tnore- over, will Kaliiify any doubt which may have arisen in your minds, I rc^rdiug the propriety of repeating the gouging and sotoi process, if necessary.
Case. —John R., Davtmport, Iowa, aged twenty-seven ; borer. In ^November, 1806, while ploughing, hv cjirained left ankle. He did not, liowover, experience sufficient tncon- ! venience from the i'ljnry to prevent him fn^in working until four montlis had elapsed, although during this iulvrval he wa« aware tliat tlic joint WM not quite sound. From the time he wai obliged to give np work, until lie came to Xcw York, in April, 184(^, lie bad buen uu<ler surgical treatment. His attendant luIvUed him, last spring, to come to Kew York to oonealt mo.
The foot preaented the general appearances already descrif
diq
lOWbl
1
* Thtodiihl wu prMcatod loth* cluw Fchnui; sn, I8TS. Tim wound* til hrtiM I OMifttid trail It lliur««MT«rjiiIlKhidi*chiii)(c. IdoUoii of Jolal i^ocid, dii<1 i\x cliild'a gviuinl bMltb iicrfvctl; nutond. January, ISSa, In pcrftcl bMltb and good mo
tD retfttiBg tlio other case*. Beluw Loth Dtallcoli n-crc o[K;uing», ||»<J tlirrinKh each dead bone could be i-ecognized hy the prolM>. Still attuthur liiitiitii opened on the iHlt«r gide of the tihia, about five iuohea above the ai'ti<nilati^>n. The general health of the patient vrae oomidcrahly inipatrtHl,and ho was (|iiitti thin.
At that time, April, IStiS, X n-movod a large qtianlity of can- OQB hone, con&Lstingof the ecnphoid bone, a ptrt of the aslnigiilus, Olid piovcs which appeared to 1)e pariti of the jimaller tarBal honeft. The calcaneum was thuo iiiiitu MUiid. The dressing, with the tvlon and plaster-ttpliiil, wa^ applied as yon have alresd}* seen duUL'. Throe win^tku after thv uperution, I gent him to nclleruc Hospital, as liU lodgiiigs were not united to hie wantif. The sur- geon to whose ear« lie fell, removed the plaster-ftjilint at once. and fonr weeks later removed tlie eetone. Tliitt diangu of (ruat- niciit wan due to tlio fact ttiat the surgeon hold» the opinion that vtiXion U neoeffiary to tlie cure of the Joint, in order to exi-ile n bcaltlty action. Kow, I have already insiet^d upon the aheuluto iNoeaiity of ivxt in certain stages of tlie diftea»ed joint, hnt there is A [leriod when motion bocomce necoaeary, and t ehould do woll, 1 tliiiilc, to explain to you when motion its injurious, and when it is demanded.
So long &A there is active inflaniniatiui) in a joint, motion i» ity'uriouK, and re^t abe§olutcIy necessary. In ihu first elagce of inflsuunation of any joint, rest is also imperative, and, lu fact, is tho esiRintifll eluniriit of the treatment; and, ae lung as acute ]iaiii is produced by pre^ug the 6)iiovial surfaces and articu- lar dtrtilagee together, rest must be enjoined : or. tf motion of the joint is requisite, in order to prevent anchylosix, Uien this motion must be always accompanied with oxtouaon, in order to rdievu llits pressure. Bui, when pressare can be home without INUti, and the difDcnIty in ni(»li' ndi; upon tho contraction
of tiaraoB around tho joint froiu <i ui«e or from deposit?, as
Uio result of an anteci-dcnt inflammation, then motion — paauro motion — applied with diM'tetion, is juAt as much a part of the traatnicQt as rest was in the cati'licr 6t»ge uf tlie disease.
So, too, when a joint has been opened for ttuppiuration and atrioa, as long as there is dead bone remaioing and vxces^ve ■appnmtion, rv6l is imperative and motion injuriout* ; but when the dund liono has all been exfoliated uud removed, the pus diminished and of a healthy character, then the setons can be discnnleil, tlie
DISEASES or 'fflB ANKL&JOIK
anoeee allovcd to olotse up. nn<l passive motions mmmeiKcd, wliich cut be incrcaitei] with judgnicnt and dLwretion, in otxier to miike a new or artificial joint in tbe new bono funned from ikc origiiittl perio^t^iim, which, lu* I stated to yon before, moBt always be left for tliie puqxiBG when making yoar rt-M-ctiouk WLfH i canie on duty, tiie following July, I found the p»-
Fiu. m.
tient's foot presenting nearly the same appearance M at fir*t. The premature removal of the sotons had allowed tlie aoenmulatioa of pu8 within the joint, and the caries htd been reCstablii^cd. Examination with the probe i-howcd the cslcancuin to he now in- Ivcd. The operation of excavation was repeated, and a largo
FM.ni.
portion of the on calcis removed, a wrton passed througli the joint, another from each of the openings on tliv udc to an arti6cia] oponing at the point of (he licvl, «> that, in any posilion the pa- tient might aesume, the drainage would bo perfe^-t. Ry refer- ence to Figs. 110 and 111, yon see tlie condition of the patient at the time the photographs were taken. The aotoius bod ftl) been
CASS,
181
lOved, and Ute n-oim<l« luul c1o«ed. Tlicrc was no pnin tit UtQ itrit. Tbe patient walked without limping, filmwing tlmt tliere tas no tondernoes. Tbv fi^tuls on lliu leg itiid tliut on Uie poiitt of tlie heel were bo jierfectlj bt;a1e<l that tlie cicstriceB coo](t be found onlr with difficulty. Ilie ouiitntir of tho foot was «> pvrfout thJtt one wuiild naturally douht that bc> much bone bad been re- raovod. Tbid vroc, I tbink, evidence that the boon of Uio tanras bad in nnme Bort been reproduced by tbe periostcutn. I bare DCTcr had the opportunity of examining poet mvrU-iit, any of these reproduced ankle-jointa.
Tlitd man at that lime appc«r«<l to bo perfectly cured («w FigA. 110 and Hi), and you might think tbat treatineiit sliould be euApcndcd. On the contrary, after thi« point hae been reached, the limb miiat be carefully bandaged for tnontlis to come, until all tJie diai'oloratiun from cuitfrcstion shall bare diBAjipffli-ed. If you neglect tbia precaution, there ie. great (knger of a relapse. Vim will notica in titMO c*»e«, when you let the fuut lumg down, that the skin becomes discolored frnni capillary* congestion, and Oiu roller sliould be reapplied with cuuHidumblu tirmuc«K,in order to support tlie circulation in theeie new tiwiiifA, and this accurately- adjusted L-omprLi;«iou must he continued for nioiitba after the cure has been apparently complete.'
Cask, — Annie L., aged four, came to ray clinic January 13, 1875, with the following history : She wa» injured, a# the father atatcs, by jumping down two steps, on December 2i!, IS73. She went to tlie Oeniian DLipensaiy from Jftnnary 4 to March 1 1, 1874, whi-n eho went to the Forty-«ceo!id Street llospital. Continued under trootjuent there until four dtiys since. The only tiyniptoin for whiohiihe wu« sent tu tbt; German Dispensary was the Inability to walk. She is now much emaciated and snffering inteiiw [Ktin ; tho motltcr says slie screams out at night every time she getii imlccp, and cannot be moved without linrting her — cannot have the sligliteat motion at tho ankle-joint without extension. Appctitu bud ; posi- tion ati seen in Fig. 112; ankle mnc)t swollen, with openings on tuner and outer side. ISefoi-elhecliu&eat [tclIevucColk^, I dilated tho sinuses, and gouged out a large quantity of dead bone ; pa.iscd nn eoknm setun fi-oni «ide to udo through the onklu-joint (I-'ig. 113, 1, 1), and another from front to bcel (Fig. 113, H, H), and,
' JaauMj 10k 181S>' — Bt«uni»d perfectly well, with good motion i» lli« tukUs.
1S3
DISEASES OF THE ANKLE-JOIST.
piittitig tbe fnot into its natural po.4ition, f»eoiire<] it there witli plastor-of-Pam tuLndikgo, loading feuortnu lu htcii iii Fig. 118.
Januart/ 20, 1875. — Child wm At cliniis much itDproved. Tier appetite has returned, itlie is free from pain, and tihe b1cc|>« well ; the wound pnwcnti) » healthy aspect. Coo b«ar weight of
FN. nt.
th«. II&
body on foot when planter drcfifing ie applied. Only compUins when oakum eetons are drawn throngh. One or two small pieces of bane have come out on the oakum.
2"M, — Very much improvwi; nirw aronnd without p«in ; ankle simply stiff frofu the plaster. Dischar^ much diniinieticd and more liealthy.
FiAruanj^, — At clinie, roCT-chcekcd and playful; discharge very tJiglit. Mother ties dressed the aukle daily.
Matxh 31*/. — Was at the clinic, looking the picture nf health. Seton tiir<.>ugh heel had lieeii out some days; no diecliargt.- from ant ero- posterior opening, and very little from lateral einu«e8. Child runj< on plaster fiplint without any pain. Removed plaster casing, and site could \m,r her entire weight upon her foot. Aa there was still a olight diiM-harge, left scton in as Ken in Pig. 114, from skeU-h takun March 21, 1S;5.
August 1, 1 875.— Recovery perfect, with motion [see Fig. IIT)). JiUi/, 1883.— ftumainft in (ivrfect health.
Cask. Snj^ntratiim and Caries of both AnHthJoinU from Injurif; DoubU Tait/v^ £^uinus; Operation; Rteovery, -mUh Motion. — Elizabeth B., aged &ixteou. Admitted to Bollevne Hos*
pital, Jat3U3i7 29, ISU. Uer fstltur div(] of phtliifiie. In 1602 die Bprtinud licr riglit ankle. Ttio injiirj' produ<ted n rbronic fonii of itiflainniation, and in two inonthit it luid iiiercsHod to much that «liu eouM bear no weight at all upon it. She now moved about b^' hopping on the well (left) foot, and in about six woeke
Pm. iw.
Pw. lU.
she b&d excit«d thu samo fonii of inflantinntion in that one M in the otlior. Two years after the first injnry, when admitted to tlio hospital, her appuaranco wiut ciiclioi-tic and iiiiaerable. The iliseaAe in her anklet) had gone on to the formation of abwcflBtand nveral sinntu^ Ivd into the joint, through n-luch diaintegrated bone had escaped.
Thu gastrocnuinius of both sidM wcro so contracted a^ to ex- ivnd the feet nearly to a slnti^ht line with the tibia*. She could Dot bear thu t^igbtc-ait preiMurc- on either foot, and could not use cratcbea, as abe could not poise lierself on the end» of her toce, vhich vrerci the only points that could touch the floor when in tlie
rio. lu.
erect posture. She vob, therefore, compelled to moveabont upon her kDoes, m bocii in Fig. 116, which also eliowa the sinuses con- necting witli either joint.
All actiru diiioase about the joints bad anbsided ; but the dla-
IM
DISEASES OF THE AKKLE-JOINT.
cliftrgo fmm the \-arioiis sinuses waa conei^eralile, and, bj proljiug them, iieveral sniali piece* of bone c»cs|)cd.
Oil tlio 17th of Fvhruary, 1864, in the presence of the clflM i Bellevue IToapital, I divided fltibcutaiieoiisl^- the tcndo-AcliilUs on both mlc*, nod rt'ttorcd tho foot to thoir naturs) angle witJi tJio. le^ I.«ather splinte were then applied, to retain them in this noi position until I oould hnre a pair of instruments manofacturedJ which I am in tlie habit of using to extend the ankle-joint. {Set' Fig. 104.)
On the 24th of Fcbniary, jnst seven days after the £!«ction of tiie tendon eii-Achi 11 iit, theite instninients were applivd in the presence of the class ot Bellevue Uoepital, in the manner alwve described. (Sm jmg^lU.)
The sinuses were enlarged, and a aeton of oakum drawn tlirongli the ankle-joint, &b indinUod in Figs. 105, 106, 107. A wad of oakum thoroughly wet in cold water was placed over emh ankle, and secured by a linn roller. The wrewewere extt-ndwl, and the ditferenee in the appearance of the ankle before and after is wdl represented by compering Fige. 107 and tOS.
Theao drawings were taken from life by Dr. Henry 0. Eno, Bouee-Surgeon of Dellevue Hospital, and aru as accurate aa any pbotograph could be.
As soon aa the inelniments were properly adjusted, she stood Dpon her feet without the aid of crutch or cane, for the first time in two ycan>. and withont any pain wliatcver ; but, the instant the screwii were shortened, the pain was most intense.
She was directed to hare the oakum around tlio joints kept constantly wot with cold water, and Umily supported by a bandag and cliangod aa often as necessary. Tliu sctoii was to Ite puUe through, and the soiled part cut off daily, and to be continoed long as any bone was exfoliating, until tlii^ matter sliould chan^ from itfl Ranioiia condition to a consistent pus, when it was to removed, the wounds allowed to heal, nnd, if poi^ible, j^aedi motion made. If motion could not l>c> attained, then the feet were~^ to l>o anchyloRod in their natunil position, dvcming that a stiff ankle wan better than an ninpntation.
The following notes of the case, copied from the hoepital records, which were taken by Dr. Irving W. Lyon, Uonse-Surgeon, now of Hartford, Connecticut, will show tlie progrcfs and the nsult of the treatment :
OABE.
"F^rtiary 28rt. — She is rwjr comfortalile, and there ia no psin about the snklvo.
" March 1 5^. — Hm been out of bed most of tho time sinc« the op«nitioii ; but remained eiltiug: »t tho bedeide until to-dny, when, with the aid of crutches to balance the bo<ly, xhe walkod about, I bearing her entire vxight upon th« feet, thv cxtoosion nudo by thu iiiJ^rrutneut being k> perfect as to prevent preMure upon the joint-aorfaceB.
^'Api-U filA. — Apparatus removed from both feet, and motion made at the ankle-joints, which an; i>crfectl_v frew and movable, but preasure is yet reri/ painj'iil. The upparatas in reapplied. It ehould be utatod that tho purioiit was put upon the l>i»t diet the ho«pitat could afTiird, together with <;od-Uver oil and iron.
<* ItA. — ThciKliieHivo phistcr having become diKamingHl, neces-
aitated it« rtiodjuBtment. It was now discovered ttiat the &inu»e8
hadall uioeed coTiipk-ti-lv ; but prcwuro while extension was ofi
rtiU gave her some poiii. Iler geoenil health verj* materially i»i-
I prored.
' " i/u/y 20/A, — All extension being removed, she i« able to
sd erect without |<aiu in either iinklv ; but iitt^mptf^at walking
ocouioQ a considerable amonot of pain and uneasuieas. The
rn. lu.
motions of the ankles are all nnimpaired. Tier health ia thor- oughly restored, and she has not only grown taller sint^'C her ad- mtasion, hut hn» atfto grown much more flodiy, and wilt weigh at laut thirty pounde more now than in Febniary, The splints are reapplied, and will re<iuire to be worn n Utile while longer to complete tlio cure."
186
DISEASES OF TlIE AKKLE-JOINT.
In a foot-note I find the following Kcwrd : " It dmnld bo mentionerl that »nce the 15th of March (the date of her com- mencement to walk upon the t^oes) ehe has continutd to walk upon her fe«t, bearing the entire weight of her hody upon them, and only needed crutches to supply the ■place of tlie muarleR of the leg, which, on account of being ooutincd by the apparatus, were unable to bttlanoe the body.*'
Dr. Lyon left the ho^^pital about this time, and I can find no ftiTtht-r not«a of tbe c»«j on the n-oords of the institution. She wore the instruments, however, until about the middle of Jan- uary, 1865, when they were pennanenlly rerooTed. The motions are almost perfect, and she can walk without p«in. Fig. IIT i» an illui^tration of her lega and fret after recovery.
Case. Suj^ratton and Cat-ies <(f th^ Anl-fe-Jomt ; Opera- tion ; Seton ; £a:tennon ; Hfwtery with Motion. — In Jao- nary, 185.1, I was sent for by Dr. L. C. Ferri* to amputate the leg of Ella S., iigcd five years — for disease of the right ankle-joint. In Ihlareh, 1954, ten mouths previous #hc had fallen from a chair, striking her right anklo against the sharp comer of a he<lHtefld. Tlie injury- wa.i imme<Jialely followed by eonsid- orahlu swelling and vori' great pain. The pain eoon subsided, but the swelling continued.
For two or tliree weoks eke ei<emcd tolerably well, but at the end of that time she began to limp badly. She was then put upon crntchee, sad various lotions applied to the foot and ankle.
Tlie disease, however, continued to progrcM, her general health became much affected, with loss of appetite and sleep, and die waa greatly emaciate^l. The limb waa much siiinllor than the ' other, hut the foot and ankle were swollen into a rhapelesa maM. In November el« Inrgan to liavo repeated chills and liectic fever, and in the early part of DeccmluT the ankle ojiem-d in H-veral places, giving exit to a large amount of ill-conditioned or stro- moaa pus. Her general health I>ecame much iinpairvd, and in JaoDary, 1S65, 1 was sent for to amputate the limb. Her suffer- ing WM most inteniv!; she woidd not permit the limb to be handled, and, until she was under the influence of chloroform, crppilus oould not lie detected ; sercral sinuses around the joint difwharged quite freely a cunly pus mixed with a material very much resembling quince-jelly.
0A8E.
187
A probe paiwed into one of these sinoees, jufit poeterior to the inUirnal tiialluoIuK, went into Mid tlirniigti tlie joint, making iu exit at a point in front of tlio oxtornul malleolus. A strip of lioen (in dufaiiU of nn^'tlting lietler) wns torn from the eblld'a drvis, pnwd tlirough the eyo of the probe, and diswa through the joint.
A piece of firm so}e-teathor, cnt to fit the front of tlio leg and (lorsam of the foot, having been thoroughly eonkvA in cold wutt-T, wa» thfU Hjipliod over the top of the foot and eecuretl by a nicely-adjnsted roller ; the foot was finnlj eztvudud lio lu to ficpftmte the tibia and a^tmgfllu^, and tlie roller then carried up the leg, over the leather, which, wlien dry, served to extend the joint And at the Haiiio t!mo prevent nil motion. Thin gave Iier great relief, and her limb could be moved with comparative cont- fort. The child was put upon tlie most nutritious diet, with (jill- ttino, ood-Hver oil, and iron.
Tho drvttfiings were removed and changed as often as they bcoame soiled with pus, and, in tho progress of tho cn&e, com- pmaJOQ with epongos and cold water was reeorled to. Hur im- provement waa most marked and rapid. At the end of a few WQ^s the iniilnuncnt was applied, as in the other cAsee, and with the eam« happy results, enabling the patient to walk with cnitdl- wand obtain tho bonetit of ont-door exerciAe, which added ma- torially to the impnivcntent of her general health.
The setons were retained nearly t«n luontliK, being gradually redaced in size ae the bone ceased to exfoliate and the pus tw <ame more healthy, until fur a number of weeks they were hard- ly larger than a single thread. When tliey were finally removed, tho sinoaex hetilMl in a few days, and pa»nve motion was oom- mencod as in the other eases. The i)aticnt continued to wear the inHtnuiient for nearly a year after she was perfectly well, as a muanH of pruvention against accident, and then left it off entirely.
tt is now twenty-one years uuce this case was operated on, Rnd sho is as well in the one leg m the other, and the motioiiH are almost a» perfect. The foot is one size smaller ihau the oUier, and tho leg a little sliorter ; but the limb is perfectly developed, unipre«entcd in Fig«. 118 and 119, which were taken fmm a plaotor ca6t of her limb, atHl which also represent the cicatrices whore tho seton pasMKl through tho joinL Since recover)- her liitib lias continued to increaae in aizc tmtll it is now as well de-
188
DISEASES OF TBE AKKIX^OINT.
veloped »B the other, and llio motloiifl are eqnallj perfect; In fact, she b the prize female skater of tlie city.
m. iul
rM. lis.
Cub. CBtrienff the AnJde^oint i SOon; Recovery.— K'W., agiHl Kren, of healtby parentis x"^ whose brollieni nn<] Netere wcrv all healthv, had hiiiiHelf alwaj's enjoyed jcood health, until in tlie euiiimer of 1854, whim he injured hi« left ankle by a fall.
The joint awelletl immediately, and wa§ quite painful ; bnt Gtill did not c-ontiuc him to Ids bod until after four or live days. It tlton beeamo fo painful att to prevent motion, and for a number of days hi* wiw treated by perfect rest, and altonuUc npplicntions uf hot and cold water. As he made no improvcmi-nt, uftvr a few weeks \u» anklu was bliiitpred, and thi;« was repented every ui^lit or (en dayn fi>r a f^rcat number of times, but without any improvement iu hie ankle.
fiia general health became much affected, with losa of a^^w- tite and of aloep ; he bccatne greMly omadatcd, and fuflfered in- tense pain constantly, which was greatly ajtgmvatcd at night by frequent ^lums, or " jerkings of 1U» loot " m he described it
The development of the leg and thi^b on the affected side became nrrcxted, the ankle and foot vcr>' muoli swollen and sliape- leae, a number of Binuse& funned, lewling into the joint, and the bones crcpilated wbou the joint wsa moved.
CASE.
180
^
Dr. Valentine Mott saw Urn in July, 1S36, and advieed am- putatiwi lu thu only means of saving his life. The iiiotlicr, how- erur, wuiild nut consent to the operation, and I nas caUud to see him in coiieultutioit with Dr. David Oi-o<>n in October. 1855. Sovorat sinuttes thi>n existed, leading into the joint, t3irougli which the probe whb |>»gKed without dilHciiIty, but coming in con* tact with carious bono in almost owry diruction.
On the 2Ut of October, Ig.'ill, I opened the joint frocly on oittior liidv by connecting 6onic of the Biniii^cis and removed a large amonnt of carioos bone, leaving the pcriostcnnu
Two eetone of oakum wore parsed through the joint, the one Intcmlly, and tho other antcro-poRteriorly, and tlie foot extended by the in£tramcnt doecribod in \i\v cilsd of Elizabeth B. Aa the BCtou wn» ptill»I tlirougli, a rinniher of email picoe» of bono were dniwn out, entangled in its meehee.
When ho rocovcrcd from the cffectK of tiio chloroform ho could liear prcssnre on the foot witliout pain, niid wouhl permit it to be handl€<l in any direction without cumplaint, although be- fore ita application he would not pennit it tu Iw touched, and it was inipo8siblu to move it in any dirCL'tion, even in the most caro- fal manner, without giving him tlie m%t intonae agony.
Uc Hlcpt quietly the night lifter tlio operation, without any anodynot although he had been eom^ielled to uae anodynes freely for many montlif, but never resorted to thdm again during the time he was under treulmcnt.
Ilis general health began to improve almost immediately from the time of the operation and tlie application of the inMrumcut, Lis appetite rctunicd, and he wttK able to ride out in the niien air witli oom[)arative comforl. The si-tous were pulled through daily and the soiU-d pftrls cut off ; and the whole aukle constantly stUToimded with oakum saturated in cold water, and ^uDtaJncd by a tjgiit bandage.
For two or three montJis snuiU pieces of bono were frequently fonnd entangled in the fibi-es of tJie fleton, when puUitig it throttgh ; but the diMi.-irgo griiduuHy dimiui^cd in quantity, be- conw more consistent in cliaracter, and, as H did so, tho setong were grwlually n^duted in eize, until tinally they were a mere thread or fibre. At the end of eleven montlis from their first insertion they were removed eutiruly, and tlio sbusoe closed up in a short time after, never to he reopened.
190
DIS£AS£3 OF TUE ANKLE-JOIKT.
The extension was continued for nearly two jwirs before it was n;lIlo^'oll permaucntly, altliougK be had walked about for maaj monttw b«fore tlie instrument was removed. As soon as tbv siniuK'H bad buoonici cloci-d and bv i-ould )>ear moderate prcs»- ore upon tlio font, wbeD die e\teni?ion was off, williout iiafforing pttui, I commenced ]>naeive motions dHily, hy acting on the ante- rior and posterior screws alternately, thereby imiuttin^ tbc natn- inl molions of the joint. In about two years from the first op eisUon, the iDiitnuue&t was removed permanently, when h« could walk without difficulty, hikving considcrablo motion in ihctdfcctcd joint. This motion baa very materially incrcseett, and is now (twenty years af^ the operation) almoet aa perfect as tho other. Ttm foot if Miialler than the other, and about half an inch shorter, but bo ttupplieis the deficiency by a thick aole inside bia boot, and can run and akatc without the deformity t>cing detected,
Dre. Mott, Stephen Smith, and other sur^oonsof tliis city, fiftw tills case when under trcuituicui, aud therefore know that the
Fm. m lot III.
Mtona paiwpd through tim ankle-joinl ; but, as tliere has been aomo question nltout it by otlicra who luvc not seen ihc cme, I have had his fool dagucrreotypcd on botli sides by Mr. Gnmoy, ami tlie cicatrices on either aide, giving the entrance and exit of the
DISEASE OF THE UXDI0-TAR9AL JDNOTION.
101
eetoiiB, »lww condiiaively thnt Utey did pa.t9 tlirongli the anlcle- joinl. {Sm Figx. 120 snil 121.)
Dt»>RA(IK OF THE TAttS(i-M CTATARSAL AltTIOPLAlinjl. — DlMUO
affootitig the font at thi« nrticiiliitiuii is eoiuetimoB mietakeii for dliCAso of tlio ftnkle-joiiit, and niiitit receive n pA»Hmg notice.
This articulation, like the ankle-joint, Ims its articuliir earti- ligc, Kvtinviitl iiicnibrane, nnd ligiuiienta, and tlio name cause* that prodiii.'C difieofic in one umy produce it in the other. You may h.tvc then, a fall, blow, or 9[>raii>, producing an cxtmvfttO' tinn of Woixl into the bono-eellB beneath the articular csrtilagea, in tlu] name manner as ot^curii in ronneetion n-itli injuries of tlio ■nldo-joint. The cxtra^-neation instead of being shsorbed tnay go on to Rupptirntion, and osteitis ami chronic softening of the bone result. The sj-niplonis by wliich lliis condition is to be recog- atzcd are essentially the same as those which aid us in dtajpio^tfof ankle-joint disease. The only method of arriving at a safe diagoo- ala in ttiudo ca»ca i» to malcea tiioi-ough examination (l>y means of preaanre and compression, extension and twisting) of each and e%'- en- sriiciilfttion nnterior to the ankle-joint. First make the anklo- joint imniiivaMu liy firmly grasping the astnigalns and os caleia, and then tlic foot is at your command to make motion at Oftcli articuhktion uf the tarsus and also at the tarso-iuotatarsal junction. Preaeuro may lie made directly over eai-h articulation, but, when yon wish to bring the articulating eurfaces in contact, pressure ia to be mafle, not by holding the \eg and preasing tlic foot upward, hat by holding the posterior part of Uie foot tirraly, and erowd- ng the anterior part backward. If pain and tendomcaa can I developed at all by ppceauro, tticy can bo developed in this man- ner, l^en, by pressing each metatarsal bone Imckward in this nunner, you will b« able more accurately to deturmine the point of disease. When it is determined wbicli joint i» involved in tJic disease, the patient ehonld at once bu placLsl upon his baek in bt'd, and extension made from the toeii by slip])ing an '*Indian- ile " over each toe and attaching them to a cord fastened in lie ceiling («M Fig. 122). The weight of the foot form* the i>unter-extcnding force. This treatment is applicable to dia- of all the articulations, anterior to that of tlio astragalus vith the OS calcis, where extension and counter-extension are re- quired. If the di«oase has gone on to auppuration, «uch extvusion will probably do no good, and, if absorption of tlio material poured
19S
DISEASE OF THE MEDI0-TAR8AL JUSCTIOH.
out into the .ntmotnres within and abont the joint cannot be oh- tJkinvd by ineniis of com[>rc««ion iind iuitine, no ■ij>eniiig niD6t be made, and the- bony strurtitres gouged and drilled until nil no- eroficd ur cnriuus bone i« tliorougblj- removed. When thjtt U
done, fill the wotmd with Peruvian baUam, coTcr with oAlcm and give firm etipiiort an<l compression to all the parts by of a rolle^bnlldsgi^ In all theeo cawcs of earicA of the bono, poulticiiii;, the continiipil application of hot fomi-ntatioriK, and sucJi like trcntment, arv iiijiiriuiir*. TIi«y ni-e injurious from tht- fn<< tliat tlicy relax the tissues, give rise to engnrfji-mcnt of the Wood- reseets, not only by inviting more bloml to the partu, but by weakening the conts of (he veins, and dimtnisbing ttioir power of eoQtractility. Such Irtviltiicnl, therefore, tcndit to a more rapid and more extensive destrnntion of tissues.
The parts are nuuli more rendily restored to their normal con- dition by giving propersupporttn the circutation,Bucb as con be secured by a well-adjusted rollerbanda^. T\m ba« a tendency to remove from the tissues infiltrated matcriid, which, if permit- ted to remain, contributes largely to the eubttequent deHtntctivo changes that may occur. When a free outlet has been made for
CASE.
ins
the discharge of retainvd fUB,^rm et/mjnvstion is one of tlie beet BMlativea tbat can l)C viiijilo^yocl. ]f the disease is within the joint, extensiuu must be made before romprt-Bfiiou le ix-sortvd to. If tbo diKcsM! doe« not involve tliu urticulnting MirfucoM, thi'ti the est«n^on will not (w required, and this is a rule tliat h applicable to thf iiinniigeiiiciil of all joi[it-«ffectioii&
lie following caae illuBtrsles the method of nunaginj; this
Cask. — Catliertne D., aj^d three years and three months, in May 1S73, began to be laiiie in the left foot. Tlic fout began to swell on the oater side, and over the tarso-metatarral junction, which VCM purjilu in color, and " boj^gj- " in fui-ling; not very painful to the touch. Several me<lieal men have treoted her for tlie piiMt ymr by inteninl rcmodivs. Condition on April 0, 1873, WHS aa seen in Fig. 1^3. Tnmor semi-flnotiiatiuf;, puq)Ie,und hot.
Aprii 1th. — I covered the whole f*»ot and le;i with « thick fluinel blanket, fitting it very nicely, and over it iippliod a plaxtor- of-P«ria roller, with a sufficient number of thickuciweB to make a
Fw. Itt
rw, iM.
firm support. After tlie plnetor was jiartially set, I ont a fenestra orer the tumor, which immediately bulged up through tho opoa-
18
101
DISEASE OF THE MEDIO-TARSXL
JcrnoK.
Ing, and was Almotit btue-bbck. A vrad of oakiitn was placed over it for a coniprt;*, and a very firm roller carrii-d over tli« whole, Prof. AV. II. Pancoast, of Philadelphia, t>eing prc^eiil.
StA. — Komoved roller and eomprce^ in pn«ciico of Dn. Pan- ooaat and Cln^, and we were bo miieh eurprieed at tlio improve- mi'^nt in eolor, and diminutiou iu she of tlic tumor, tliat I de- ci<led not to open it, but to tr^ to absorb it by pressure. Cliild hud elvpt wvll, and wae <.-onifMrtabIe.
0/A. — Still further improvement, bnt^an indistinct fluctnatiun being obt^inod, t made a number of «midl ptinetureii, at the re- quest of Prof. Panooaflt, ditielinrfiing eonsideral>le blood. One < of tbe puncturoH Hhou-itig j>us, I made a tn-a inetfinii and evi oated ft largo quantity of bri>ken-down eellular tiesiio, tougii aloughe, and piis. The tingcr detected cxpo««d bone at the outer portion of the i^eaplioid, onlj ; this was scraped, and tbc wound iillcd with Peruvian balsam and oakuro, and a firui roller applied oa before.
WiA. — Appearance much improved.
June 2I)/A,— Wound haa eieatrijtcd. Proi»urc continued. Plaster dressing removed. Toe elevated by adbostve ploelvr.
Atiffwt 12/A. — TTaa continued to improve. Una not cod- fcssod to any tondomc»« for nearly or i}uit« two niontbtt. C^anJ walk on foot. Has a ^lif^t tendency to ralgua. Adliesive pli ter continued to retain foot in po«ilion.
November I, 1S73. — Perfectly well, without defonnity, and is robust lieallb. {See Fig. 13^)
LECTURE XIV.
DISRjUES or TUK JUlNTtt. — XX CE-JOINT.
Aiiiilain)> of.— SlnicturM affccMl by Dtoaiwo.— Bmoxilb.— Di»«»»e of LIkkimM*. — KiCnruatiun of Eftuod inio tho CUMlUuri I.>in«llie <tf (hi! Bone— CaiiMH. — Earif 8/tnptimu>, «nil (hoiif ilrTclapcil u tliv DiiMase progtMMtk— Pmd mtr Uia AttarbmuUof iba Coraonry LignriicnlH.
GKNTt,iMRs: This morning we begin tllc alndy of diet-ascs of tlio knee- joint.
Tliia joint is more t^^bjoct to accidenta than any other arttca-
ANATOMY OF THK KNEK-JOINT.
195
blion in lite l)0()jr» on atwount of its luorv vxpuBod position. I think it is evuii mow ViMu lo injury Limn Ibe aiikle-joiui, jtitlg- ing from itic i-vliUive Dumber of casee pruwtutiiig tliuiiiHiivcii duily in Diy practice.
A-VATOHY. — I will first briefly stalu llw prim-ipal atuitonii<:ul wmiKHiciit* of liiB kntv-jwiiit, « kiiowleilge of whioli in essential ta a full understjinding of wbat 1 ali&ll iiftvrvi'urd c-xpltiin wlicQ I cwno lo speak of my viewB in ru«i>o(rt lu liie origiit, iiutlioI<^, Aud treatment of diseawe aflix^riug ita structun^e.
Tlio oond^loM of tlio fuinur abovi*, tliu liund of tbe tibin bclow» and the patellii in fnint, are tlie boiiCfl tbat tsaler into tb« fonufr- tlon of t}ii» Joint.
Theae booea are tield io paction by ligaments, aoniu of which an oxterior to, while otliem are within, tin* joint. Tha'« which are exterior are tliu anterior or li^nmntuni patella, thu puitterior or ligumi'utum puottcum WinalowJi, the internal latemi, the two external lateral, and tlie cajMulAr.
Tbu tigiinieiit« found witliiii the joint nru the anterior or ex- ternal cradul, tlie {Msterior or internal crucial, ttie tran^venie, and tlte ooronary.
The two eoinilunitr fibnxnrtilagea of this joint are al^ placed aiuoug tlic internal ]igauient« by Home writere.
In addition there are the ligamentum nmcoiinm and tlie lif{A- nii-nt;i aluria, whiirb are merely prulongiittonB frum the evnurial membrooe.
Tfaore are alM) two buna-; one &itnated l)etween the patella and the eitin, covering; its anterior surface; the other urnallcr in eize, AJtiiated Ii6twvt;n the ligauientmn pntellffi and the upper part of the talterofiity of the (ihia. The piititcnor mirface of the li^ mciit i« i«ei»rated above fmni tho knec-juint by u large maso of adi]>06e tissue.
f nflsiuinjition of tlicee bnrste Mmetimce givea rise to appear- ances very much resemblini; those prceentcti by the «o-<-allod " whiln swelling" of the knee-joint. The synovial membrane of this joint ia the lar}(e»t and most extensive in the Ijody, and forms %-arioua euU^a-aac in the procese of enveloping the internal Bur- laces of the joint. The articular gurfaceH of the bones are covered with mrtihi^i! which aubeen'o the purpose of " buffers," or cueh- ions (the same as buffers npon railway-cans), to mitigate jars and cODCOaaons which otherwise might do serious injury to Uie iiito^
DISEASKS OF THE EKEC-JOIKT.
lul etructnrcA. As the situation of titv ninsclea wliicb flex titul extend the leg upon the tliigli \s inijwrtiint to be umJentood io iti)|)lviii^ vxtuui^un, in the cate ot diiruiiMnl knuc-joinl, more spe- <;ial reference to them will be reserved until we come to the tiub- jed of treatment,
rA-moLoov. — All the etnictures wliioli cuter into Die fonuation of Iho joint pro|»er iniiy bt-coiiio t!ie msut of disease. We have, tliereforc, diiwrftM!^ affecting tlie liganibnts, the svnoviul inutiibrano, or, which jwi'haps motit coinmotilv Ii-iids tu M'riutiit dvi>4ru('tive diangea involving the joint, iiijiiry of the deeper liBsiiufl, chiefly extrav«Ratioii)) of hlood into tltv bone, wtiidi gives rti>e to OAteitia, Id a singlo oasv two or more Htructuree nmy be involved ; or, what i& much Icf» fi-equeni, the itymptoms will indicate tite prca- oucu of (liiteusu aflfoctiug one structure principally.
We slial), liowcver, he obliged, in order to gain a clear idea of theei) different afl'e(^i<in&, to Htii<Iy lliein rfpamlely ; white at the same time yuu must underi^tuud they aie liki-ly to be aiuociatod.
In this latter eMC llie ityiiiploni^ of each affection iiliontd, »» far as poeeihlv, be separatt-d from those of the othcn).
Etiology. — The eaunee of diM.'a6e affecting Ibis joint are the flame aa those which prodaco dboaKi in other joints, such aa blows, epnun^ contiiition», over-exertion, strains and eudden olieck of perspiration, etc., etc.
I now invite your attention to the dlneaecA which aSect the structures of this joint.
tlrKt, tiicn, respecting the ttynovlal membrane,
SYXovrna. — This disease may be caused by wrenches, blowsy punduree, exposure or sudden change's of teiupernture afli-r vio- leut exercise, or may be dependent upon couHtitutioual affectioc such as r)icun)ati«in, gonorrhu'A, ete.
Tlie disease is usually considered under two heads, acute Aol Tronic.
If, then, a wrench, blow, or other cansc. producer results chief- ly afl^ec-tiiig the rtnoviid meinbrune, un effusion of fluid i^on takefl place, which may be readily detected by the change pro- duced in tlio oxteniul a])peanincc of the joint. The effusion dis- tenthi the synovial sac to a greater or less e\tent, and causes it to bulgv out upon either side of the lignnienttini patella).
If there is acuU inflammation, it will be attended with great beat, ewolling, and rednut^M, wtuc of tetuion ajid throbbing, unO
STNOvma.
19T
aooner or later intense pain. Thete ejniptonig will also be nc- companie'l '»v ft general febrile raovemenl. If the effusion into the joint ii moderately abiindunt, distinct fliu'liinlion niiiv l>o oV taiiie<l. When the effoaion is oonaiderablv, the pateiU is lifted, M that wlifii tlio leg is exU'iidctl and ek-^-ntfcd it i» verj- eft.^J■ to peicuBB this Ixme aj^inst the condvlcrs of the femur, and produce an audible click. Under thc«c circnniHtances it i« almost impoti* eible to mistake t)ie nature of tho di^^aee. Tlic ehxrp an^lar contour of the joint ix oblltoRttt^l, and there are presenl a general enlargement, rotundity, softnetw, and pnfflncte about the joint, whii?ti ludiL-atu tlio cxiHt«uoc of an abnonua] amount of fluid within the svnovial sat?.
In the more chronic form of the di«ea»e we hare effuHion of fluid into the joint as before, hut it is usually not so mailed ; tliere is leas tendenuss u|x^n ])ne««ure, nud tlio pain is not ao •CDto. If tlic dificsso has gone on to erodon of the structures within the joint, the erosion can be very easily detected by crowd- ing (he artiinilar surfaces together and sligtitly twiding them up- on e«ch other, when the most intemic pain will he produr«d. On the other band, extension euflident to scgmmte the articular sur- faces, thereby removing all pressure from the inflamed membrane <Hr the eroded tissue, relieves the pain ut unee.
LiaAHBjns. — If, npon the other han<l, the ligaments are the parts chiefly involved, the amount of swelling which follows tlio injury wilt not be nearly as great as that which follows an injury of the synovial membrane.
If the ligaments Iiave been put npon snrh a stretch as to pro- dure niptnre, even of a smsll number of their fibres, the point of niptoro can frequently be detected by making careful and thorough prc««ure «-ith the finger along the course of the liga- ments injured.
Extension by stretching the ligamentsat once gives tlio patient pain, and if the ligaments are the |>artfi alone involved, romprea- aion, en>wding tlje articular stirface* together, by taking tension from the ligament^ affonU instant relief. Extension and com- preeaion, therefore, in the manner indinite<d, are the chief tneane of reoogninog the seat of the disease with reference to the ayno- rial membrane and ligamenta.
ExTKAVASATios or B1.00D. — If the injnry to the joint be the result of concussion, causing damage to the osseous structures and
I
DISEASES OF TIIE KNEE-JOINT.
extra vnMt ion of blood into the tne«li«t) of titc Imne, yon will find great difficulty lit timcB in making your dia^node in the earlier »taff.'». It in under these dn-uin-tt&iioeii ttiat we may have tlie beginning of a meet sortouB dtscnse, and yet no ewolling what- ever nt>out the joint be present; there may, nisto, he sb«enoe of dafoniiity iind nil appcaniicc* of iiijnri,-, and fur eome time no abnormal heat ean be detected by the hand, and it is in these CH«e« that Dr. Sequin's thuniiottcope is invaluable.
Your dingnofli^ now can only be made by compree«iioti, exten- »ion, flexion, coDctusion, and the unual routine which a earcfut examination of a joint implies, and, ax before intimated, you may be a«fli8led hy the tiiermoficoi>e.
Lt-t 08 trace the hitttory of encli a case a little more in detail :
In the great majority of caaea a hititory of ttome injury, r» a blow upon tlie knee, a fall upon the knee, a etrain, or a enddon concuHHton, or anything of tliif nature, will he the firet tiling elicited when <iiic8tioiiing the jiaticut. The child may pay but little attention to his injury at tirAt, and is soon at play again. After a while ho may, and probably will, complain of Bomc l>ain ; feelx a little etitf when he firet startB off, bnt goes 1>etter when he getH wnrmi<d up a little, like a Rinvined horw. Thia may eoi»> mence within a few hours alter the receipt of the injury, or it may Iw dulayed «;vvral tlayg. A tier resting for a short time he fculfi better, and is up and out at play ; within a few days ho h down again ; he goes to bed, remains quiet for a few days it* probably obliged to remain quiet a little longer the second time than Uie first; tlien he w up again and around as unual, and ao lie goL« on. now down, now up, bnt finally gel« so liinio and stiff, or suffera so much pain, that the attention of the patient ami or friends ts c«pceia]ly attracted, and now off Uiey go to
doctor for advice.
The doctor, if unfamiliar with tlieeo caacs, probably faila to determine the real condition, and, diwovering no abnormal ap- pearance of the kneo, tell» the patient there w nothiiif; the ni.ilt<T with it, and that he is " humbugging." Yet tJie patient is nnablc
■ to walk without suffering a feeling of uneaeinesa, and more or
■ lesR pain. In certain poditiomi, perhapa, lie can etand apon hia B leg, hut the instant he bends it the pun will be very much in- I creased.
m Tbe psUont thus dismissed, atill disabled and becoming daily
3AUS£tJ.
189
ineredQlom, consulu another doctor, who, taldng fur gnuit- 'W what tiiB predeceieor said, cotUimifi his dectaiuti, aud so the patient ie laid up, purUapts fuur ur live muntlia, got* oo rulicf, iDd tliu damage becomes irreparable. So, you will observe, the svinptoms aru etmictiniM vxix-viliitgly ubitcuro, aud let iiiu adviM; ^uu, when yi>ii Imve a chho of tliis kind, to explore the joint in erery poasible direction, for the very tiK.'t of hie having luul a Kvere cotwussion oJFccting the j^art should be sufficient to make yon tlioronghly awake to thv danger of th« «uc.
In tho tirst »tAge of tliia condition, the injury' to the bone mnr be exceedingly slight, jiut a li^t blow tluit hiu cauetKl the extravai«tio]> of but one drop of blood — but the injured ear- face being coustantly irritiitwd, iin^tcad of tlio blood bc*iiig «b- ■otImhI, intLaiiiuiatiun supervenes, and at last suppuration takee p)aoe with diBorgauization of the whole joint.
When thu diitea^e hiw progreued thus far it becomes very easy to make a diagnoais. The thing wluch you must fmt clear- ly iMi-crtuiD ift the tociu in qito, as upon thin depends the charac- ter of the disease a« well as the nature of your trvutiiieiit. You will, tlivrvforv, cxcum: rciti-ratioii, gunllcmen, in my efforts to impreda u|>or you the importance of determining whether the diHutux* ori^Iniite^ in the nyiioviid invinbraite, iu the ligsmonte, or in the cartilage proper. ThLTo ii> so little circulation in cartilage, however, that I doubt if diiieaeo of any kind cvor comtneiu)e» hen uiiloss it be dirix-tly cut or torn; although necrosis readily OCCIUH ill tliia tiK^iiie, an itit vitality U no flight.
Id orditwry caM» of 6o>callod disoaeo of tlic cartilage, the dUeaae commenoen in the network of bloud-resAelii immediately nndomcath the cartjlagv. The cartilage:! are nniply atta<:hcd to the bonc^i, have no circulation thruugh tlieir structure, except enough toviialixc them, and are not liable to Hsriou^ Injury. On the contrary, the blood-vesacU which underlie these caililages are very cajsily injuivd by blows or concuarions, and are the fruit- ful source of chronic tr'>uble. Iu the oornial state the cartihkges have Very Utile ficnsibility, but when intlaniud they are exceed- ingly senaltive.
When the diBease has gone to dcitnictiou of the cartUagee and other Htructun'« within the joint, kHous constitutional dls- tarbsBcv will be dereloped, a» Ioh of appetite, slecplcuncM, great emaciation, and perhaps hectic. The joint is usually enor-
DI8KA8ES OF TUK KSEE^OIKT.
niousl; enlarge*], nnd presents a titriking contiust to tlic cmici- Ated limb both above ftiiJ below. Tliu timuut) aho\it the joint arc OKunllj' iikflttnted with oeriim, and, conse^^aenllY, havu a bv^^ feel. Thej^ "^t^y't too, eontnin eullectious of pas, and tJtie, by its burrowing, fomiit long, tortnoiis ainuaea in varioua diroctioiu. The muficlw will b« "on guard," as already mentioned wlien speaking of diseafiea of the ankle-joint. The mymptonu, when Uie cartilages become involved, are entirely different from any that have preceded them. The jiatient will suffer from gpasoki of tlie limb, and every now and then, particularly when asleep, cry out with a eliarii, shrill scre«in. This it due, probably, to tlie fact that, while the patient is awake, the contraction of the mu»- cle« i» more nniforni, and the prcMiirc i* «> constant aa to be- namb the »;ntiihility of the porta; hut, when sleep comes, moinoi- tary relaxation of the muscles take* place, some involuntaiy movement abruptly canace a sudden resumption of the contractiHl
ru. nk
Fm. ISfc
oondition, and tlie diseascil snrfaces are annpped together violent- ly, causing intcnee pain.
At thia «tago of Uie disease the tibia is utwally snbluxated
CAUSES.
SOI
>
»
Ittclcwaftt An<] rolAted ontwAnt. This ha* been canted hy the powerful contraction of tliu bicepft-rniris muscle, and, ^hen prcDcnt, gives to Uie joint that peculiar overlmriginj^ prominence •0 dianctcmtic of the advuncetl »tsge of the disease, as seen in KigR. 125 and 12fl.
'Wlien the difCiiMC has become developed sufficient to give ri*© to the symptoms juBt CMumt!r(it«d, tbo t'Ji*« will ]>rc«cnt an onmietakablc example of what li knoH^l as "white-swelling" or " (Krrofuliinfl di^aw: of tbo knec-joinl." Yoii may n.-meitibvr tliat the authuHtiii; in our pi-ofes.sion from time immemorial have regarded dentrnctivo dii^easc of the kucc-joint, a>minouly called "whito-Bweiling." aa being e«aentially of eonstitntional origin. lu other words, that it is fitTofulous dia-asu developing itself in ft joint, tbo siinu 06 K'jrofulA may develop itself elitew-lierc.
Now, with nil due deference to the opinions of tbe profee- sion, I nndorstsiid this subject of nrofula, or " whit^^!tw^■!ling" of joints in a very dilTerenl light ; and while I do not deny that the disenao in question may and doce occur in pereons having a BcrofulouHdiatbi>»iis, I j'bnl! prove to you that the Hi-i-of iiloui* diatlic- ds U fiJniply an accidental accompaniment, and has no more to do with tlic dovolopmeiit of tbe local dise-iso within tbo joint than baa the biemnrrbagic dialbe^is, nor, in fact, as much, since a ])eail- iar fonuuf hmmorrbagc into the uincelluus tissue of the epiphyses from violence in some fonn is almost invariably the m-igin of this KH»lled ecrofuloufl disease, or " white^welUng."
Ituttiad of accepting the ii£ual designation of this diseaae, " wbite^welling or sorofulouH disease of th« joint," I eoufiidcr it to ho an inllumniatorv softcnlnj; of the epiphyses, ami the retmlt of the extrnviiKalion of bioi^l, fn>m rupture uf bloud-vessuls situated imnicdiutviy lieneatb their protecting cartilages. If this extrova- ion of blond into the mosbn« of the injui'ed bonc«, for it gen-
lly restiltK from violwit c<iiiciiB«inn, is not absorbed, it will de- relop A condition which will terminate in iuflannnutory softca- iag, that will lead directly to erosion and ulcerative deflimctioo of tbelionesnnd their intervoiiing CHrttlagcif. TbcEyiiovial meiD- braiio, if not injured by the ori^nnal concussion, or other caueo which haii (jiven rise to the disease, will sooner or later take on inHamiiiatory action from lying in contact with the part« uf tlie joint involved. The disinlegrution and ulc«rativc destmo- tioD of the injured portion of bone and cartilage are veiy luvxh
309
DISEASES OP TIIE KNEEJOISTT.
inonased bvllio unremitting pn-esare vxurcisvd upon the disesscd surfaoee hy rca»on of tlic'contniction of the mu«dus surrounding tlie joints. This muscular L-ontnu'tiun i» reflex iii cliuracter, and is excited l)y the presence of tlie diseaw witliin the joint. If thi» grinding of tbe injured surfncox together U not counteracted b; extenNon and counter^xtenjiion, great destniction of the kon;^' Btmctares may take place, attended with nnuvoidnhlc defonnity.
The outer condvie of tliu femur in tJie part which, almost ex- olusiveljr, Euffore from the unintermitting presoare, caused bj iniut- colar contriu-tion. The coniftant triR-tiuii of the single musdo attached to the outer side of tlie liitib keepa up preasare at ono jiarticuhir spot, thcrefoic ouiiNM intoralitial ubsurptiou more nt)i- idly than tlio contraction of tlie four niusclca on the iimer nirlc, iKvauKe of their varying points of pressure; coiiectiuently thi^^ outer edge of th« articulating surface becouiis more rapidly di^^H integrstud, and gives rise to abduction, cvcreion, and rotxition, after Uie manner il)u»tmted by Fig. !27, taken from a plmiter osst. In addition to my own observations, I tiare found this stnteinont amply confirmed hy examina- tion of many morbid H[>eeiinenB of this <li!«iisp in the anatomical intuwums of Eurojie aa well as thove of this country.
The apparent scrofulous condition of these pa- tionts is simply in consequence of the exhaustion induced by the prewuce of a chronic joint-disease. If the dWa«o is purely conMitutional, it sliould be cared by internal rcmediets but the use of intcmni roincdie« alune does not cure, and tlic ca»e gradu- ally growit woriie, nnletts fiomething is done to reme- dy tlie local difficulty, and the trouble nnll finally kill the patient by the irritation And exhaustive euiipuration produced.
This is the usual termination of these cases when loft to themselves, or when hinijily treated by the use of in- ternal remedies. Cure may, however, and does eoinetiwes take place with the limb dti>Iorted and the joint onchylosod, anil in many instances the distortion is ntui^t surpriaing, as eeen by ttiese models. (So: Vi^ IStJand 127.)
Before leaving the study of the symptoms of this dlacasc I wish to make frpeuial reference topain.
r». in.
FATN OVER OOROHART LI0AUEHT8.
Id many caeee dUcase of a joint ta&y be rec<^iizeJ hy the loca- tion of tlio pK>n which ai.-eoiiip!iiiice it, m, for uxuiiiplCt llie pain in lii|>-ilti«aai> is frequently eiilirety referred to the knee. In a caae of clironic disuaeu of the kuco-joint, you vrill ulwayo lind the [miq toost acute and mo6t ejisily developed b^ preii^uro at the outer por- tion of Uio head of tliu tibiii, ju«t over the Uiscrtiuiitt of the coro- nary ligaments. It is quite common to I« able ti> make pres-iure over (ho wliolu 8urfa«i of tho joint without causing pain, if you trill avoid thiii partiouUr point ; but, the moment pressure is ma«]e over cither tliu internal or vxternnl coronary ligninentii, morec^jx}- oiatly the external, intense pain will be produced.
TbL« paiu is distinct from thnt caiiM-d by suddonlyHtrikingtho head of the tibia againM the condyles of the femur, and also, dis- tinct from that vauHid by the pnteeuro upon the discard Articular Burfaeee produced by reflex muscular oontntction.
i^ain jirodnced by pressure over the situation of tho corooAi^' ligBuientit liaH n special value a» a symptom, for, by ita presence or ubscneCt w« are able to Gafely judge with regard to the oon- tiniiatinn or cessation of extension in the treatment, a« pain mil be developed at tlioeo points by a rensonablc amount of pnesuro }mig after all other Rynipli,)ins of joint-<]iM!a«« luvo pasttcd sway ; consequently, treatment should be continue<1 until k re«Bonable amount of preMure over the atlaclimeuto of ttieec ligaments can be home without pradueini; pain. We will next tarn our attention to the subject of trenttnuut.
LECTURE Xr.
D1BU8K8 OF THE JOlVTH. — KNEE-JOINT (oOtlTIXDSD).
TnWmmM at DuwM «r.— Karty TmlniML— Tmlmml in tbc Adnncod Sta^ of Ihc Ho-cUM " WMl^Uvvtliiig."— A|)fMmliii Cor in«king Kili-Diion.— Hodv of ApjiltnUiin.
Grxti-eukm: At our lant lecture wo etudictl ilie anatomy of tho knee-juint, the diMiascs whieb may affect this articulation, tiieir causes and early symptoms, and also the eyniptoma which
904
DISEASES OP THE EKEE-JOINT.
are prenent when chronic knee-joint cUiiea»c becomes UWly devdl. oped. To-dsy wc will eoniinvD(.-c the- ^tudy of —
Theitmest. — This part of our Aobjcet may be coavcnicntiv oonsidcrttl uutlor two Iwaih :
1. Treatment for the earlier siagim of tlw disease.
3. Treatment when the dtseaec has become so developed that the ease nyinirt-e oxtcneion and conntcr-extenuon, operative in* terference, etc.
Wd hIiuII ttpcftk Brst, then, of the treatment to be adopted when a eaise !» ^en early.
The most import^int element in the ti-eatment of mjnr^es of tlte knee in the earlier etagcfl i» absolute rest ; no matter whether the ligaments or the feytio\'ial membrane ia the pari chiefly in- volred, or whether there is extnvneatiou of blood beneath the jtrticiUar cartilages or (r^novial membrane. Yoa may secure bdcIi rei^t for the joint in any munner yuii »-u fit. In many instances it ie, doubtless, the safer plan to carefully adjust a po6teiior »plint made of «>lv-loalher, felt, or other material, according to the con- venience of the wirjjeon, which shall extend along the npper por- tion of the leg and lower portion of the thigh, and hold the articu- lation and its surroundingH perfectly fixed. Plaoe the patient in bed at once and keep him there until nx-uvery i« well advanced.
If the tigamenti) ai'e the parts cliictly affected, yon will not ordinarily ha^o nuich difficulty with the caiie. SomotJmce simply ai^lying a bandage around the knee will give sufficient supiiort uid sceure sufficient immobility to mi^t nil the indieatiuns. The |x«terior ftplint and bandage will certainly fulfill every indication. The joint inny !)« kept wet willi hot or cold water, according to which affnnlfl the greater relief to the patient. After a few days have elapsed, when probably mo«t of the acute symptoms will have Etibi'ided, yon may write for a liniment, if the patient can- not 1m! induced in any other way to give the joint n liberal amount of hand-rubbing and pacsive motion. Tiic»c caeca are UHually slow in recovering, and it may be well to communicate this fact to the (tatient at the beginning. Treatment lihould con- tinue until pain and tendcniess liave entirely «ub«idcd. The prinnplcs of treatment arc, perfect rest, hot or cold applications, HiCt-ording to the fi-elingvt of the jiatienl, and firm ooniprc»sion. In a majority of vaaes, hot applications will l)e more agreeable. Cumpreasion can bo secured by means of n roller-bandage, sponge
ELASTIC 0OMPRER8IOS.
SOR
and batulaj^,or bv mcana of tlio doiitilo Inilia-ru1)tM>r Ihij; fllrtwly rofvm^l to. Th« Intlt-r is tin* be«t iiiodtt, c«|K-cially fnr tlip Vne«- jwnt. (See Fig. 128.) Tbis liag oin be ptLrtiiilljr tilltid with
rw-ui
*itbcr hot or cold wntcr, m niav be indicated, and, tlieti being dia- teniled willi nir, ;ron bave oven romprcseiun^ witb tbv advantage of R hi>t or cold puultitie as ntay be desired.
When, however, tl>e svnoviul membrane Iwcomiss involved in tlic injury, cither alone or iii«ocintcd witli injury to the ligament^ ft inncli more serioufi condition of affairs is prcwiit, and will in a majority of ciuww rciini«i a more active plan of trcatnicnt.
When the injury lias \tci>n followed by cffusiou into the joint, next to nbiioliite rest, dastli'. mmj/rfmon i« the most vt^iiuntial olo ment in the treatment. Place tJiu patient in bed at onee. It may Iw, aud ^nilc pmbably will be, necessary, in a niitjortty of csMfl, to make some loinl depletion by moans of Icerboi) or vret rapH licfore reft«irting to any nmn^nreii for the iiuri>ofo of pro- moting absorption of the flnid. Tlie necessity of local depletion, and it4 amunnt, will be decided by the vigor, general hcalUi of the patient, and the d^reo of inflammatory a^.'tion pi'e:>ent, as mnnifoNtLvl by in'TCOecd beat about the joint, inci-ejised fretineney of ptilrie, pHin, and general constitutional diiilnrbancc. After loeal depletion, hot fomentations and elastic compreesion. eeeiired either by mean<i nf n fine Imlia-mbber bandage, or, Htill bett<'r, by the doul>ln Iiidi[i-nibt>er Iwg before referred to (jM Fig. 12S), will bo of the greatest poedible Hcrvice.
If idiHirption of the lluid docs not take place rapidly under
206
DISEASES OF TTIE KSEE-JOINT.
tilts treatment, uiunter-irritntion nay be reaoHeJ to by appl.ving blisters above and billow tlio joint. Xevcr HppI; your bliHlon direct]}- over tbc kiK-c-joint, but upply tliem above ttic capenlar ligament, and below tlio ligatnentiim patclliv. In addition, iudine- oiutnieut may be applied uvcr the joint, and covered witb otied-sitk. Never use iodine locally in tlie foiin of tincture, for Ilii; reaKUt that it iH painful, the aleubol is soon evi^nted, thereby leaving tlie iodine an a costing upon the ^i» which pumiit« only a vory eniall qoaiitlty tn be absorbed. After tlte tint application, Miraeediug appliL-atiuiLd are of no wrviw a« f ar a« aheorptioD goes ; for they simply facilitate the de&tnielion of the eiiticte, and until this la^'cr is reniovi-d further abeorplion uf the iudinv cannot take place. Tlie objection to iodine, therefore, in tlie form of tiiKrture, ia that it renders bnt little aorviiv except when its effect m an eschai-otic is deeired ; but, used in the form of nu ointmrnt, H.-arcely any pain \f produced, no exfoliation of the cuticle follows, and iIhto- fore aI)Sorptiou can go on, and in this manner the remedy renders continuous t»er\'ioc
When the ueute BjTnptoms have subwded, great benefit may he derived by freely aliampootug the partii, slightly lubricated with co»- moline, \'flSoline, or any Mibstaiioc which will pennit the hand to glide over the surface freely n-ithout producing too nuu-h irritation to t]ie skin. Frictioa diould be applied in this manner with very great freedom for from twenty minntea to half an hour at oacli sitting; and, while one hand is made to do nibbing amxW the joint, Uic other hand ohould rnb up and down upon the limb above (he joint, thereby greatly facilitating the absoqrtion of the cffuAod fluid. If the fOBe does not yield to this trt-atmcnl, and tlie effijsion int-reaaea ao aa to make tension sufficient to paralyze the aUorbont veseols, it may be necessary to a»pinito tJic joint and remove all the fluid possible. In many instances, if only a email quantity of the fluid is removed, the tension iijion the abaorltent vcseels will he relieved to such an extent thai tlio rctitnindor may be absorbdl by the means already mentioned. This is an application of the same principli! that governs iis in tiie ttuuiagement of certain caww of uM-iles ; namely, liret. removing a portion of Ihe fluid from the alidnniinal cavity in eases when) great distention is present, and then rc*<irting to diuretics, hydmgo^e catliartica, etc., for the removal of the remainder.
Before the aspirator came Into use, it was the cu$t<Mn to make
PTjyOTrRE OF TnE JOTST.
m
I
k
I'alvuliir inciHiixt tlirougti the intt^giimciit tuiH Btnidaren be- neatli it, lotting the bbdo glide uIon<^ until tlio juintwiis rciR-hod, »xtd tbea plunging it in, and glTing vont to the imjd-isonfHl fluid.
'Wltvn tliu tliiid is eeruuii^ or of sucli (.'hiinR-tcr that it enn flow tlirmif;)i die uinuta, aai>iratton ran be i>niplo^\<od vritli murti grcster advantage than incision witli tli« knif«. hornet irnc-M, however, it hupjions that the fluid contains so much floceulent material that it cannot lie removed by the aspirator. I'ndcr 8uch cireumslftii«« no htMitntioD need be made with rcgiird to opening the joint, and giTitifi; free dlecharge to tlie fluid. Ax a nuittor of ooonw, pnnclnrin^ this joint, as puni-turini; any other joint, Is a very seri'iiiR and, if not properly managed, a very ditn^Toue thinf^ Ut do.
If yoa punduro thin joint fur the purpowof withdrawing the exceaaive amount of synovial fluid, and pundnre it in such a way as to admit air, the consojufneo will he very aerious indeed, bsoiuiwdcvnmpDiiitionof thecontenta of the synovial me will (nice pbce and yon will have csceeeive fever, and euppnration will be Mt up. I am not nfmid of air : but 1 fear hnprimH(<l air. There- fore, if compelled to make an opening which will permit the en- tnincc of air, nt oneo make it large enough and in each n position tliat tlie air can get ont again. I wish to he distinctly under»to(Kl about this inatliir, and I wimt to Imprcfis it clearly on your minds, tliat the guccotM of the operation depends alntost ontircly on Iraeping out the air when you punctnre s joint. With this pre- caution there is no danger whatever connedeil with it. ^Vllen yim have punctured the joint nnd are altont to withdrnw the cannin, no movement whatever of the joint must ixs allowed to ocvnr until it ia, Ao tospeak, hermetically sealed and locked. Yon mnxt have for thin purpose eomc pla«ter-of-Pariii, leather, or starched I>and- age — anything on earth, in fact, which will, wJien applicil on the posterior aapeet of the limb, promptly enlidify and prevent the loaat movement. I*t me, al*o, impreiw upon you not to allow the joint to move until the external opening is perfectly unitetl. If yoo do, the air will be siicko"! into the jtynovial wwr in spile of your valvidar Bubcutancous opening. Tliis precaution is very ahupltf, but is most important for the safety of the patient.
If, on puncturing the joint, you find the fluid wliicli it contains has already begun to cliange, has 1)ecome converted into pus, then, inateod of leaving it with n simple ptmeturc, make a frev incision, tlwaye cutting at the most dependent part of the eac, ao that there
906
DISEASES OF TnE KyE&JOIKT.
eliall be no poseibility of secretions being pocketed or othcrwUe reUined.
Ab eoon a» it ii dtwovered tliat reflex contnictioii« are taking j>Uoe, which if not overcome will terminate in the production t>f serioiu defonuity, niechnnical appliances which afford cxteuHun and ooDnter-extensioQ must tw rc&ortcd to, and are alwayn re<{uin>i).
Such rofleit cuntmctiiims will not only produce deformity, but will greatly Oj^mvate the pain by bringing the difleaacd articulat- ing surfacctt iulu cuiitacL ExteiiMon and countcT-esteneion may tlicrtfore be nece*ary for the relief of [nflin incident to such mvs- cidar contractions. When cxtravufialion of tlie blood has taken place at any point beneath llie articular cartilages, which can be dijii'overcd only by firm coiupresgion of the articulating surfaces of the tibia and femur in nil [ioi>«ibIe dircctiumi, and also ujwn the patelU, and especially mailing preesuro immediately over the ineertiou of Iho coronur*' ligamcnli', yon libould imnicdiutely re- Bort to the treatment already indi<-ate<l, perfect rest, and tinn comprceeion with the »pongc and rolter-bandago or double India- rubber bag, tffier exfennoH. and confUer^ixteruion have been ap- plied.
By the use of this bag which I now show you (aw Fig. 128X the itressuro on the joint is maintained evenly, and there is no danger of pressing the ec<rhymo*«d surface* of bone against eadi other. Prceeure by tlits means ja to be continued until abeorption of the effiued blood takes jdiK-e, and nntil the patient can bckr oofr ruK8i(in of the bonce, the tibia and fomnr, again^ each other.
When the dieeaao of the joint, no matter in what particular tiaaue it originated, lia» ad\-anced to a condition of suppurative disorganization of the stnicturc*, it is often attcndinl with grave con&titutional symptoms, such as sleeplessness, loss of appetite, great pain, and irritative fever. This (.vmdition is then generally apoken of oa " white-aweiling of the knee-joinl."
Sueh a condition will require a much more ajstaooatic and prolonged course of mechanical and snrgical treatment than has been indidttcd for llie prcwatum of tliis advanced stage of the diaease. One great indication in the case now is, to place llie patient in a condition such aa will permit him to have all tlic advantage* of frceb air and snnlight, and at the same time be relieved of all irritation attending the constant attrition of tlie diacMud articnlar anrfaoce. It is in ibie partictiW form of the
KTES9I0N Aia> OOl'NTEB-EXTEXSION.
I I
disemtc, therefore — inflnnimntinn of tlie artii^lu* tia^iics — ^that. exteowon W of t\K utni<Mt iiiiporiaiice. I regnnl tliu i)riTinpIe a» one of sucti iiioiitent that, wurt! itM pnu-titrHl njiplinitiun iiilvr- fered with ttj partifi)Miti<m of tim tii%tit« iu tlie infUmmntory action, 1 fltoiiM hitvo no IiMitAlion in cutting tbcni, for tiiu tendons will lietl liv the time the articular surfaces have nsuinod A h(!9ilth,r condition.
Kxtvnsioii is vspiTiall^- imporiAnt here, for the rosMit tliat, even when the tendonii nre not inthiniedt tlie irritation produced by the infljiniinatioii nntliiu Hic joint inviiriably excites reflex action. The niniirl<« contrart, an<I theivliv incrraee the nonipres- tion tipon the idrciidy iiufFc-riiig lissiiOH witliiii the joint, nnd if (Tontiniied pniduoe serioiiii deformities, according to the dinx;- tion iu which tbu predominating itet of initsi-les uru drawing.
In h>(>kin^ over Sir ncnjoiniii lirwdie's works, 1 find be rvoommends positive rtst, and tluit is nil, IJut you may do thia — you tnny n.-*i tho joint in »pliiit4 — but you do nut do nil Mint is re<|nir(:d. You may keep tho limb pi-rfcctly still, and locked up In m-orj- conctivahlc way, and yet you do not ovi-rt-onio tho tendency of tlie nuisclee to contract — you do not prevent the rvHex action until extenHion Im ajiplted.
The resnit if) the diseased surfaces are brought in contact ; the )>ain is continuous, nnd tho parte prvsted upon undergo interstitial alMorption. But when yon give exifnmon to the»e Iim1)«, thua looker) up by diHcOjee, you will f^irc the patient instant relief.
1 liave liecn very auccCAiifnl in the treatment of this elnsa of eases, and I attribute tny tiucceiw. in a great measure, to the faet that extension lias been wade a leading feature of my treat- luent.
Sonie people imagine that tJiia extension inean$ hitching on a p«ir of horse*, and siibjci-ling the pntiunt to a itaniplu of what Mine of the old-time martyr* eiiduri-d. Ilut you have seen in our clinical practice tliat all we want is simply enough extension to ovtirpome tho reflex contraction of the inuwlew. and to sepnmto the <li<eaBed surfaces of the joint so far as to remove the pre«eure o«!twioiH<<d by their contntction. Ity doini^ thiti you relievo the pain. Of course, if you extend to<» much you injoi-e ituitead of binielltlit]; the patient ; for, anything that has power to do good, has power to do harm, if indiwi-reetty used.
Kometnber, then, in the fir»t place, that i-at — permanent rest
14
SIO
DISEASES OF THE KNEE-JOUfT.
of the lissncs involved — ^ia an awentidi yart of tJie tnatment. In addition to nxt, exteneion, ooiLslautly mid piTHielciitly ciiipioytxl nntil tlie patient is cured. De^dea reel an<l exteusion, vou wit wmprcMion; but this iiinrt Ixi vm|>ioycd *i\vT tlie two foniitT. for cotupreeeion of tlie joint, without first obtaining rest and extt.'rDdon, would aggravate the difii«tilty.
Tliese indications are met hy an iniitrniiient that I dorised eevoral ycare ago, which you here we. (&» Fig. 129.)
ru. It*.
Tbio instrument should bo applied the moment there is any evidence that the dij»ea«e has affected the ftrticular Htnicturcft, or ivllcx muscular contrartioiis have been excited, which, if per- mitted to continne, will produce deformity.
When tho knee-joint is filled with fluid, and the articular snrfaceii are f^nnitive to pre^ure, we i«hould te»t it at) wo did the anlclv-juint in a Eirnilar condition ; viz., fix it in an apparatna which not only keeps it in a i4ate of absolute rest, but is capable of M> extending the yarX* a» lo n^niove all pn-^iiro from the articular surfaces, and thas relieve the pain ; while it enables the patient to exerciKV in the open »Sr. and tliiu iiivifrontcs tho gei>> eral gyfltem, ren<lering absorption of tlie effused fluid pofldbte without rc»or1ing to aspiration or incision.
As long as there is any hope of preserving the joint intact, this apparatufl Hliontd be applied. The inittnuiient consisis ea- aentially, as you see, of two slieet-iron bands or collars, connected by two bars so eoustnicted that they c»n be made longer or nhorter as required. The bands are almut an inch in width, bar*' a joint behind, and flots and a pin for fnittening in front.
The hinge-joint at the postvrior portion of the band that is to
KITKE-ESTENSION
IATP8.
su
I
I
surroim<l the Ug ie dimIc hy cutting ^miglit bctom the band, and tJien fastening tlie pieces in tbe pro[>er manner for foriiiiiifr a joint Tlic Iitn^joint At the poMUiriur [lurtion of tliv luiiid that is (•> BUtTonnd the thigh iti maile hy cutting ont a V-^mited pievu, and tliun fii^itouiiig tliu piucvn in the proper mannur fur forming a joint. Tliis V-siiaped piece is removed for the purpose of 80- 4.-ariug a siiiallur drcle at the low«r edge of the hand tlian at the nppcr, which will be(t>.>r adapt it to the nnturnl titpcritig hIi«|>u of the thigh. The hand which eurronnde the leg ehonld he inimov- ahl,v attached to the Kidc-ljor^. The hand whidi surrounds the tJiigh ohould he attached to tbe ude-bam in euch a manner (hy a single rivot or hinge) tliat it can be tUtod about at ph'smire, which pcrmitji the iBe of the inatniment when the leg \* flexed npon the thigh at a slight angle. The hare which connect theeo hands or collant are divideti into two pieces*, one of whidi carriefl the cog and tbe other the ratchet, by nicAus of which extension
no. in.
I'lu. ;ti.
w to ho made. Tito ratchet i^ moved by means of a key, and in tlitH manner any amount of extension dcaircd can be readily ob- tained. {See Fig. lao.)
So mucli for the description of the instrnincnt, and now we
DISEASES OF THE KNEE-JOIST.
como to tlio mctliod of its a]i])lic-Atioi). lu the linrt plar^. if tlie limb is much rlUtorted,tlte leg dexed iip^n tint ihtgh. aiid i^vrhuiM tlio tibia (lartiall^ luxated backward, an illustrated iii Fig, l.'ll,ex- t«iiMon inuft heniado, n-liilc the fnAliotit i»iii bi-d, until lIil- liuib in hruught to OMrlf a ittraiglit position, before tlie inHtniiuGiit la ajv plivd. Such extcuMoii pi-cvioui* to tliv appliculiuu of thv instru- ment (as alrefldy in<ii(ated in cases of lon^; standing when sublux- ation is present) niii«it bu uindu in twu diiivitiunH: 1. From the foot and lower portion of the tibia by nienns of weight and pul- loj, witit the linib pbvcd in i^ueli a putiitiuu thiit t)ii- i<atic>nt cau endnre the extension iciMoM^Hnfforingpain ; and, 2. From beliind tlio libiii ujiunrd nnd forward. {&e Fig. 132.) It is all-inipor- t«nt that snob dou/jle extension be applitNl, for more than tikeljr tho direct extension from thu foot will givo ptiin until iho tttconJ line of extension U bronglit to bear, This dotMe extension fan bo applied to H limb, and conthi'iffl v!\w\i the limb U placi'd in the pro])er po&ition, so that the extending force is brought to bear ut ft proper angle without giving pain. This proper imglu mu«t be fonnd, which can be easily done by moving the limb about; and thu extension should not bu nuido until auoh poitition \\at been obtained. When this lias been done, and the extension is
Tin. IM
properly applied, tho pain is immediately roliercd. Tlio iqipoiKtiu for making the direct extension is the ordinary extending ap[«- ratos, eonsietisg of adfausire plaster, rollcr-biindagu, con), and pul- ley and weiglit. (&« Fig. laS.)
The eDcond line of extension can l>e nude by meaua of « cord fastened to the ceiling, or other apparatus such as the ingenuity
APPLIOATtOS OF THE INSTBrMENT.
S13
of the Kiirgeon may devise. When the double extension, the two linM hiMii^ iiutdti ti> ;^iliin1Iv npproiich t-ucii othvr, lias brouglit the liiiib itilo nearl; the i^traight pmition, it iii leiidy for the in- strument, whidi \» to be nppUed in tlie following innniior:
Surroimi] tbo leg witli Btriptt of luUa-^ive pla(^ter abont one inch in wiiilli pliu-eil lenglLwipe, and reaeliing from the lop of tlie tibia down to t)w anklo-joiut, and Kxrure tUein with a roUor- bsodage from Ihu top of the tibiitduwn to tliv point at wliioh the lower band of the instrunmnt is to be applied, leaving fuiir or &V0 iDcliofi of the lower cxtrcinitira of tlio pluter looso, fastening the bandage ivilh Mitcbes. ^ext, anrroand the thigh with etrips of adlieMve pliwter of about tlic Mine width iippliiril in the aame manner and extending lenglhwise upon the thigh from the lower extremity of the femur iR-Arly its catiro lenjjflh. Secure tlieoo pla>klera with a ni(-elv-at]j listed roller bandage from the knee up- ward to tlic point where the upper band ef the iu»trumeiit in to be applied, leaving the remaining portion of tlie plaster loose. (^See Figs. 133 and 134.)
The limb lA now ready for the api>lieation of the instrument.
f» in.
Pm. im.
Fib. isa.
Pboe the )i»trunient on the limb in mich a manner aa to bring the side-ban upon the same ptnno with tbo eondyk-« of the femur, and ])lace it in the handfl of an aiwAtant, to t>o held mead- jly in that position. The collar ouibracing the le^ should be cloaod w M to closely engage the leg, but not aufficiently tight to
314
DISEASES OF THE KKKE-JOINT.
interfere in the lea^t with a free retnm-rirculation. Now n>- ver^^ tliv loose extremities of thv piee»i of ndliuviw )ila$t«r, briog them enugly over the <n>Uar and npon the leg, whei-e they are to bo secured by a few tnms of the rol]er-ban<lii^ which bait just corered the foot an<] tiecurecl the upper portion of the pliixter. Next press the lowi-r coUur down into the plasters wtiidi now engage it, and then »ecnre the upper band about tbe thi|i^>. This band yon muet nx-olloct is attaclKHl to the Htle-liare in flach a manner, like a nwivH, that it can be tilted ftuttiriently to comi; in contact witb the thigh and produce eerioue rcsutte, by pressure, onleM it is properly secured. ThiH can be done by taking one piece of plaster behind and another in front, at points exactly <^p08ite upon the circumference of the limb, and reversing them in BDch a manner as to bring otjual traction upon the collar poa- teriorly. and anteriorly, which will balance it to that its e^es will not coioe in contact with tlio thigh at any (wmt. The band is fir*t closed around the thigli only sufficiently tight to be com- fortable. Wlien this in done the remaining strips of plaster can be rovcrscd without cnuaing tlic edgraof the collar to make press- ure at any point, and all are then i^ecurcd with a roller-bandage. {See Hg. 13i>.) Now we have the injitrument fastened at ila lower and upper extremity in a manner which will enable na to mJike extension anil counter-extenMi>n to any degree rci|uircd.
This iii done by means of the key and ratchet on the bam of tbe instrument. The amount of extension and oountcr-extcnsion required is that which is sufficient to produce perfect relief from all pain, or the po&sibility of producing {Mtin by making conciu- aion or prcKsiire. This can be obtained by extending the hara first on one side and then on the other, until the dcsin-d amount of extension is reached, when the instrument is kicked by the tJide and retained there.
An important point to be remembered la, that yon can do a good deal of tiann by making too mnch tension ujwn the lateral ligamenlA. The point to be aimr<l at is, to make juM imfKcient extension and pounter-extcnBion (o give ]K'rfect relief from all pain by prt'wure upon the articular surfaces of the joint, and no more.
If too grcAt tension is applied, tlie patient will complain of a aenw of discomfort. In eitlier c*se, therefore, the countenance and fcvlings of the patient are to b« yonr guide with referenoe
APPLIOATIOS OF THE nreTRDMEKT.
315
I
^
^ »
to tlie amount of «xt«iisio» to be ft]iplii;(l. When the dre^ng u first upplied, the pki<t<>rii am] tioiulagee may bo yield tliiit tlic- ps- tient, soon after tbi-ir iipplioiilJon, itgaio eaffen paiii. When tlitn hftppeng, extension is to be immediatelj uicre&eud, until tjio po- Itent givm no rcsponsu in liis fnoe ii|<<>n the ftpplii-ntlon of c>»i- ciu^on or pmeure. Xow we have an appai'stue upplic-d to the limb, ao jon will tee, which U oompetciil to remove all pressare from ihc artitriilating surfaces of the joint.
If thi-re arp preeent any ovidonci's of inflaiuinaloty action about tlic joint, such as may demand active treatment by leedieo, cold or hot applications, connler-irritiition, etc., your command of tb« joint ii* iMirfcct, and such applintiions can lie made as may be deemed neceesarr. IE yon wish to apply hot or cold, tt can be dono by incunK uf a fiHinge and rt)IIcr-bandu{;ro- Jn^t here there M iD easential dement in practice which must never be lo«t sight of; for, if we should kwe the limb as you liiN^ it with th« in- atmniont ap[»1ied, »> il* to make extcntiion, and do no more for it, it would \k mined. Tho lioggj', infiltratMl connective tie«uo wliicli ever^'whcrc nirrounds the joint, if left without proper aopport, would l)eroiDe more and more engor|red by the bandagra wliioii have been applied utilil Htmnj^lation would take place, gangrene ensue, and the knee-joint and patient go togetlter.
Compression, then, is an e)«ential element in the imiiingcrucnt tla-AO cases and must nex'or be neglected, hut is nt-ver to be lied until after the extcmioii iii pro[K!rly iidjuKled. Then you itut tinnly strap tJie joint, lirst filling the popliteal space with cotton, old THgR, or sponge, and, commencing below w itii the adhe- sive )4ripH, go npwurd. diiugling tlie joint, as it were, in endi way ■a to leave no pt^int uncovered. TheM^ adhesive straps niti«t also liu applied in such a manner as will make uniform pressnre over the joint. You will not, howcrer, strap the joint after this fa«h- ioQ nntil yonr iruitrnmcnt has been applied, and ext«UNon and cotinlcr'extcnsion have been made ; for, il' applied before this luut been done, the skin will bo folded into pleats, and etrangtilation and gangrene may result
Again, we wifih to cootiimo the tloahU extension which has boon applied to bring the limb into the present position, and this can bo accomplished by carrying tho bandagv (after covering tlio kneu just strapped) l>etween the ham of the instrument and tlio leg, then over tlie bars, nod under or behind the tibia in such
/
816
DISEASES OF TIIK KNEE-JOINT.
a wsy ns lo orowd lUt liciid of t!it« tibiii./<>i-imrf/; and in the eumc aiitiiiior abovu the knee, ajipl^'iDg tliv buudKgc tit froDt of the femur and nnder the bare so «a to crowd tlie luwer extremity of tbv femur hackwitrd {«te Pig. 130), In tlii» tiiftiinor you will »t ouee BLt! tJmt we aru putting into practical iipplicatiou, upon the in«lniment, tbe fame principle wc were ajiplyiof; wlion tbe duuble exluiifeioii nas used while llie patient wiu in bod.
Now, if the patient be an ndult, he will probably require tho aid of crutcbvit in walking, othcm'ii^u too great « straiu will be brought to bear upnn tlit; ]ilMtcrg which hold the instrument in placu ; but, if a child liki; the one before yon, ho may go atM>nt without their a8*i»tancc. As you «ce, he walkn witboni any limp. >ng, by koi'ping hie well knee stiff to tuntch the dUcaecd one, and has no pain whatever vtlien tho instrument i« properly adjn&ted. Oumpan^) hiK pretiunt condition with what it wae an hour sinoo {fiee Fig. 131), and no argnmcni in neeeiuuiry la prove the vati uf the ireatmunt («m Fig. 137, from photograph by Mr. Muon)..
r)a.lM.
Artifieial iinpporl for tlicea diM-'aned V-*- properly -ipptied, romovee all prt-t»iirv froir faeci<s and gives t)w patient [M.TfM-1 comfurti ^ for months, and, if need bo, without
.l.i..1. \t
REAPPLICATION OF ISSTRCMEST.
BIT
licnl: to l*e out-of-door^, where he (tan olitam freoli sir, the iiiflu- vDOe of eiiiili^lit, aiul, in <)hort, to avuil liiiiiM;lf uf all the hygienic DteuunM wliich si'e (<j contribute m largely t^ his timil reuuvurv.
LECTURE XVr.
MSMSX3 or Tllli JOINTR. — KKKE-JOIXT (coXHXVED).
TnUMkoit of Chnmip Dilate (ciintinu^lV — Romnrkl mil Rcappllcnilon oT (bo fn- Uniiwnl. — Pa»iTc Uulirin.— f ludirtlun uf th« Jolul afUrr the Splint hu been mMVBl— SliatI lb? Joint be [loiiiiitud Ui onRhjlMc !— Cuo.— OJicnUre Inu*- hwttW in EMtwup Ciae»,
OB:m.RUE!i: In our liuit lecture we studied tlte method of trc«iirii(!nt in the ivirliur Htaj?is of the di^'tiee and tlie mode of applying the intitrutnent Ui^ed for making extent^Iun in chronic ilietuiHO of tliD knee-joint, and to-d«v we will first anewcr the questionii, How often in the instrument to lie removed and reap- plied, and bow long must it he worn i
It may he ne«^*!*nry to reapply it very often, if it has hcca careletmly or un^killf ully upplied, or if poor plaster hm been used. I-'or it niii8t l>c rba|<pIio<l just as Houn hh it fails to meet the tiidi- oitions, no matter if it is every hour in the day.
Rut, when tlic iui'^tninienl is carefully adjusted, good plaster is used (Maw*e moleskin), the tikin dfan and dnj, and the planter |Aot warmed too intieli hefurc it is appliotl, tt may remain purhapo ir lliivo numths, or even longer.
At hin^ m tliu iit»1rnnient maintains the pro)H.'r amount of i«i.<nu;,.T. ir r..««l n..( hephangeil. When it di>e6 he>"ome noce»- I- ' li niurj remember never to attempt to ap-
'he Inyi>r of dejid epidermis which wilt t>e • t.<i'n worn for a long time, for you might mil.
tm until t]ie juint is well ; imtil
thft lihin and femur together,
•siirt) ovor the eoroniiry llga-
done, you may remove the
[llV IIL'.V I
IiiMiiil if r '
■j:
■-iii>'
318
DISEASES OF THE KNEE^OIST.
in^tnimciit and eoiiimenee tlie ))a«si\-c mov-dmcnbi and manipulft- tions tliitt are to restore motion to the joint, and roinplete Uic cure. Thi« part of Uic trciitiiiviit R-quirM tiinv. When the pa- tient has reached this point he is upon the highway- which leadi to complete recuvcrv, and perfect succcm may bo obtainod if we are not too haiity in onr endeavors to restore the limb to its nor- mal condition. Il i» just hero, not infrctjiiciitlv, tluit a very great miGtakc ia made. The cn<l of the diseai« liaa been reached, hut the n^pair of damage donu hiw to be ao(<oin|>li»ht.-d, and iiuw the flargDon should recollect thiit perfect restoration can onlv be ob- tained b^ ciitiliouB and gradual advances. The old eayiiig thst " tlie limgest way ruitnd is the surent way home" if particularly applicablu to the nianHgeinent of theee ca^-s from this point on- ward. Wlien paonive mnvenienli) are cotiimenced ihcy should not at any time be airriwl beyond tin? point of producing pain. Von will hold one hand beneath the knee-joint, an yon i>ow we me doing, whilo with the other the leg may be mrefully flexed upon the thigh, until yoit have i-eached tlte )>oint at which jiain is produced, but never carry it farther. If this trcatnicnt te pnclincd regularly and systematically everj- day. yon will find that flexion can lie slightly increased each time, and ihns you •ro to go on nntil complete flexion in obtained. Von will aleo find that such paasive movements will be much more sucoesa- fid if ai-oonipaniod by a grc«it deal of hand-rubbing. I do Dot believe we have given the conxideration lo gentle but thorongli friction with the hand which its importunce dcnuinds. Tliere is no more offlcient meanei for reducing capillary congetttton and removing infiltrated material from the tissues than gentle, free, but careful rubbing with tlie hand. There are those who prt>tend to poxseas remarkable heating power in their hands, and claim to be able lo perform wonderful curea by rubbing, etc., bnt no <inu of any sense believes one individual i>o«h.'wk-« any K{>ecial power over another in thi» direction ; it is all humbug; and yet many joints, in which partial anchylosis may be present ns the i-usult of ditieasc or frotn siniple rest of the joint, arc abandoned by surgeons and fall into the hands of tlie«c pretenders, who ofFvct marvelous nires. The#e preti>nders may 1>e stientific by scvident, perhaps, and one cure will bo sutlicient to give them a life-long reputation and to do the profession and society bd immen»e amount of injury ; b»t there is no nawon wlty any surgoon should
AFTEB-TREATlfENT.
S19
I
»
QQt poaaeflB the same power, sncl afford the gome bettofit to li!« patieaU ut nn^ of tlio most sncceeAful of tliene traveling manipa- latom.
Tlie oeciwionni (implication of electricity may also be of eerviee. Hut, ill resciftiog to anv or all of ihvsv niottHuiv^. tLc ffival poiut to bo bikua into cotiitidomtion is, to carefully- gaani agaiiitit i-arrjing tliem to ancli an extent as to rvdovclop inHumtiintioD. If tt toy time yon liave been a trifle indiscreet, and have carried your pas- sive movements too far, or bitvo made your mariipiilatiuiiit tuu freely so as to anw. pnii) which ahall Uat for more tlian twenty- four hour* after the manipulations have C(.<a8cil, or to give rise to the tJighti*«t i.-Icvhliuii of tctuptTJiluru about the joint, place tlio patient in bed immediately, elevate the limb, apply cold, and secure abaolulc rt,-3^t until all inflamniutory action lia» sulMidcd; after which your passive movements can be renewed. Passive movcmentM Hhort of exciting inflammatiou may be made fts freely and as often as desired, without danger,
IduII tlietic ca^«, no matter in bow favorable condition tlie joint may be when tlic instniment is removed, it is ueocsenry for a time to apply »>uio kind of sppamtus to protect the joint against flicd<leata, ftuoh a^ falls, tripping, et*.-., and h1>u> to prevent tootyee motion of the joint. Yvtr this pnq>oBe a piece of ordinary sole- Inatbi'-r answers very well. Take a ))ioi.ie of itolc-leathcr about tlie same Icn^h a« the instrument which hai> been employed, and sulBcieulJy wide to ombmce one-half or two-lhinls of the limb, dip it in cold water, and, when it baa become tboronglily flexible, mould it to the posterior surface of the limb, and «ccnre it witli « bandage. The leatliur when wet can lie moulded to the limb so as to fit it perfectly, and, when dry, it gives firm, tinyielding Bup- |»ort, and at the saine time can be easily removed and reajiplicd at flucli time* as you may desire to pr.icti«c puHsivc muv«tncnt« and band-friction.
Again, €rm snpport may be given to the limb, and at the same time motion of the joint allowed within the limit** of safety, by the use of the ini>trtmu-nt which I now show you, made by Hr, Darraeti, of Orange, New Jersey. (Fig. 188.) It consisU of Icttther rawhide moulds, fitting the back juirt of the thigh and I*^, and buckled in front.
ThcM are connected by lateral steel liars, jointed at the knee; tbo Uexion and extension are made by means of a ratcbct-snd-eog
MO
DISEASES OF THK KJfEK-JODJT.
wtieel ; at tho t)ack, tliere is aIdo b npirnl e[>ring on tho exten<liiig rod n'litcb ])itmiil« liitiitvd motion when wulkiiig.
A knee-citp retains the lim^ in its projter position Iti tlie epUtil wLuti iiiolioiiii arc niudu.
There are Boine caaes uf chronic diseawi of the kDCti-jutut^
lis. IHH.
howcTor, in n-hioti anchyloBis ift the best poetuUo roBolt tluit can be oblaiiidl. Of course tlie qncBtion, whether you permit anchj- losiH to t^ko pliiceor not, miitit bo fully dc('i<k-d, if po««bl(.-. before you reiirirt to pa»«ivc movements. In mme rases it may be im- poBHiblc to decide thie question until pii«eiv(; muveinont« luive fir«t been tried.
If, after the application of tlio iiiBtrnrnent, which sbdl main- tain a constant extending and connter-extending force, t)ie joint- ditoaM f^tii* on fnvonibly uihI Htettdtly toward a ctire. and ^lowa no dispoeition to n^airr^nt sltarka, you may rea^-onaldy expect that, when tho inflammation haa entirely eiib«idcd, poMivo movtv ments and otlter neccsistry manipnlations will rentore the use of ttio joint completely.
On tlie other hand, if there is a hirking tendency to the dc- Tclopmeot of inflammatory action, iit consequence of nearly every
iNOHYLOSia OK THE
effort made for establieliing a cnre, vrhelhcr it be in tlie way of ptMtvc inrn-eriiei»ls or tlie oniirmry menn^ for affording «xt«itition and oouuter-pxteiiiion ; or, in «irne cases, apparently itKli'pcnilent of «ny exciting caiL*e ; in nhurt, tlie dii^anad joint is fre4|uciitly tiking on a now iiiilummstury nvtion, and l>t'liiivcH hndlv, tou may liarc ^^vc appn^lientiionii rei>pc<rting tlio fntnre mobility of the joint, and may rvaiMiiiiiiily rufpii-d ancbylo«ie as a vory favurable nstilt. TbcrH ore some cai^s in wbtcli ibe disease pix^^reswt) refiAonably well imtil pasalvu mownientii are resortod to, and then thoro 16 at onco nn almost constant ttniik-ney to now iiillaniniiitory action, in cofteoquent'e of micb movciuents, however oarufiilly ihey may bcmatle. Such eases require to be managed with thc^i'Hito«t caution, and are ver^' nnpronuetng witli regard to timil reHultD, as far a*t niution U co»iN>rned.
If cnrefnlly watching the pmp«i», the behavior, and tito tendencifB of tlio case, bring you to tbo condusicm tJiat tbp heftt nwull that can be obtained is that of anchylofiin, let the anchylosis take place with the limb in a gtraight position. The old rule liati been to w-rnru aiichyli)i»i*, Ui owes in which it wne uimvuiiUblc, with the leg flexed upon the thigb at a slight imglis but 1 am opposed to thi« nilo, for the rouon that, when nncbyloi^'d at this nngle, the eoliditicalinii w very in^^-urc, and li liable at some future date ttf give the patient trouble. Thin qmt>lii>n, however, will be more fully conBi<lered when we come to speak on the sub* ject of ancbyluHiM.
We have now completed the study of the e-ieentinl fcntiiros of treatment, both wheu the ciuo ie eceii eoon after tlie receipt of the injury, and aLw when clironic disease of the joint \t, fully estab- lished.
The foUowlDgcaw tlluKtmtot tltc disease sod tlio treatment we have just l<cen rtu<!ying :
Cask. Chrotiic ^'jhoiuHk of JCnef^/oint, with Angntar Contrae- iionandjnvbabfer'lf^ratianofCttftiiaffes; TenotoMij; E^Um- g!on hi/ Splint ; Rfcovenj. — Aim IT., .Tersey fity, aged fourteen; fatherhoalthy, but mother di<;(l of phthisis; fell, when nine year* of age, on the sidewalk, striking lier right knee on the cnrbstone, proibming a severe inflnninrntion of tbc knee-joint, which confined Ler to ber bed for some weeks. Leeches, cups, poultices, and the usual anliphlogir^tic tit-.itmcnt, were adopted for ^onic time, and finally resulted in recovery. For nearly a y&a she conaid-
229
DISEASES OF THE KNEE-JOIKT.
ercKJ heriielf well, alUiough fHw. atwavH had more or leM |Htiii in thu kutt'-joint, after any very ecvvro fxiToiBC ; but it was mrt tbonglit uf Hiitticiciit imporUiiKic to call fur profoMionnl w]Ti«% SB it gooenOly eubdded by a few ilays' re^t, althougli \wt father hwl applinl a bliKter to it occaitiumilly. Wlii:n about twolvc year* of age slie again sprained tlie joint by slipping on an orange-peel, which produced the moist int«ni<u paiit, iniiiiLtliatuly xftc-r the am- dient, and which continued until the time 1 (iow her, two yt.>ai^ after. t$ho had been cupped and IciH-hc>d repeatedly; bli&ters and iaencs had been applied for some monthit, but nil without any benefit, and finally the agouy beesmu to intense and the patient ao iniich prostrated, tliat the diseaae wag decided to bo incumbk-, ani]mtiiliun adviited, and I was sent for to perform it. Pr. M'm. K. CleveUnd went with me to ftBaist in the opera- tion, Vi'v found the girl «ttin;; on a chair, wilti her knee flexed at an acnte angle, the fiiot renting on a utool a little tower llutn tlie chair on which she tat, her body Hirongly bent forward, and botli iiands firmly clasped around the limb just below the knee to prevent, as fur as possible, any movement at the j()int; the same time fllie appeared to piwh with oonwdi-nddo for and stated that that was the only way in whidi elie could get any oasc. Uer father stated that 8he hadwt in tliat ]>o»ition nioi<t of the time — day and night — for the past three months ; slie would not let go her log crcti to feed hcrMilf, and tlicy had therefore to feed her. AVhenevcr her position was changed, either to be put in lied or to attend to the ncL-c«s»ry calls of nature, it produced a paroKy»m of tjie nto^t intense pain, which frequently lasted some hours, and could not be relieveil by nny anodyne, although she look morphine in very largo doses cunatanlly. Her knee was very much enlarged, almost tnuishicent, and the irregular eon- tours quite defaced by the general rounding out of all the parta. The limb below and above the knee was very much smaller than the opposite one. Her pulse was IGO; face %-ery pale and emaci- ated, and her countenance bore the most marked cxpre*8ion of intense suffering that I liave ever witnessed. It was impossible to wnlk about the room, or in any way jar the Uoor, without caas- ing her to scream in agony.
When Dr. Cleveland took hold of her foot to move her in lion for the operation, alie seized him by the arm with her teeth, and held on with the grip of a tigrets«s until I gras[>ed her limb
CASE.
S2S
b1»vc atid bolow the knee, and bj firm extension am\ connter- cxUjtision, to sopftnte tliu buiiois fruin cncli othvr, fp^vn lier tiucli fcltuf tliat itlie let go lior hoUl upon bis arm. As long as I oon- tinaed tbv v\lvni^iun »1ic eocitivd oomparotivvly qiitut, und Miid it guvi; lu'j* great relief; Imt tbe iuatunt I relaxed it at all slie Bcreamwl in agony. Tliu fM.-t decided nie not tu amputate, until sill) liiid lind llio lierK'fit of extensioii fairly tried. It was ini[>09a- lilo to do tilts vtUdc-iitly witLout tirt<t dividiiigtholiaini»tring mus- cle*, as tlie leg had been so long rnntrac-tvc). I therefore held tho limb still wliilo Dr. Cleveland put her undvr tlie full influence of fhlorofiirni, wlieii I dividi-d the outer and inner hantxtriiig tendons satKmtaneuasly, covering the wounds immediately with adhusive |»laster and a mlW. By a very e^lighl force the litnb wati at oooe Diade nbiinst slraigbt. A long strip of adbceive plaster, about four inoIiM in widtli, wa» ^ecuri'<l to butb 6ide« of the leg by & roller, for ihepnrpowof making extension; and in the loop below tlto foot a liuHrd was ]>l:icud, M'idv enough to remove preee- nre from either malleolus. To tliia board a cord was attached, uid run through a hulu in^de tu tbo foot-board and over a pulley, And t4i its extremity 1 attached a smoolliing-tmn weighing about five pounds. Two brickit were ])la<.-«d under eac-b poi^t at tJic foot of the lied, to nii-« it higher than the other end. »n that the body, constantly sliding in thu opposite direction, would make a proper conntur«xtending force, without the necessity of a perineal band. Tlii« was all aocoinpllslicd bofon^ the effects of the chloroform luui psaaed olT, and when t^he recovered her senses she said she felt jicrfectly ca«r. As hIid Imd already taken a Urge do«c of morpliine just before we arrjve<l, nnthing more was given her, but iii.'itruclious left to uilminiiitcr to her twenty drops of iLigen- die's eululion in the night if necessary.
She passed a more comfortable night than she had done for months, and from tliat time took nu opiate or other anodyne. llor appetite improved, and her bowels became regular, without ti»e use of any caihartic medicine. I ron and (piinine, together with the most nutritious food that she could digest, were the only reme- dies given. A large coartte Mpongo, placed around the entire knee- joint, and secuitKl by a veiy tirmly-appliod roller, was thoroughly wet in cold water, and constantly kept so by frcqnent irrigationa day and night. The extension of the joint by the weight and pulley and the compression by the wet sponge were continued
DISEASES OF TlIE KN'E&^nilfT.
about two montliB, after wliieli I made extvtiKioii by nieaiie of the Rppantiu ali¥:iilv «)*.t>c-nlM''), and whivti allou-ii ttiu |iiitiviit to exercise in tbe open air at tliv same tiuv tliut the exteiiBion i» OOnUnued, whidi i« fO I'tniiorCaiit in tlio trxintiiieiit of nil cliruaio inilatnroationii of thu joltiti^
Tlio iri*truiiiciit wafl applii-d, and when the cxtctitiiou was ad- justed she could bear almost her eutiro weigtit upon tlie limb ; but, w)icu the bars wore ^hortcntxl io ag t*) remove the oxtemion, the 6lightVI^t preHsnre upon tbe foot gave her the iinuit intemie agony. Witli tlie inHtniaieiit properly iidjusted, slie could exercise in tbe open air U|x>n her erntohee, witli tlie gresteat freedom, and in i>crfeft comfort. From this time lior general bealtb b«^«j to improve rapidly. After tlie lifiit npplieatian she came to my offieo from Jersey City, a distance of several miles, eveiy few weeks tu have it readjiutci), and eaeli time allowed ovldenecft of most marked improvement. It was nlmoid a year before she could be.tr much prcjuure without pain, when the extension Mtat^ removed ; hut, as this pain subuded, I became more free in my use of passive muliun and in about twenty montlm from ihr time of the operation I bad the eatisfactioo of seeing ber wulk without p»in, and with tolerable motion of tbe joint. It la now nearly fifteen yenrs ulnee the care was nnder trejitmenl, during which time she bus oiijoyod uninterrupted good hudth, and aki the presient time the motions of licr knee-joint are ao perfeet tliuc nu one but » critical oWrvcr would eiiiqMHrt tliat there lind been any dij«ai*e there.
Case. Thomas It. C, J'oitrtA Strtfet f Chronic SynofUis of JCne^ffilnt : S'ippHrafion : SuMtijrntiim ; Aneh'jtoKt* ; Opei-O' Hon; Rtctn-enj, — This patient bad t^-ai'Inlina when two ytiirs old, following wliicli he b»d ehmnic inHanmiation of Uie left Icuoe-jolnt. commonly culled white swelling. After about eiglh teen monthit, contraction of the nmsi'le^ took place to ancb Acgree as to cause subluxation of the tibia liackwaR) into tbe posterior inter-condyloid notch. Eijjht or nine fistulous open- ings around the outer part of llie knee led tit eariotw boue and into t!io joint. \it%. ^. K. TinSinan and It. S. Kiseam had ex- amined him, and pronouuced amputation tbe only nicanja of core.
I was called to see liim in the spring of 18.'i3, in eonsultatinn vitb Dr. n«tcbe)der, who adviatx] compreeuon by mentis of
CASE.
395
ongo, ami gntdtuil extension; tlii« was fftitlifully persisted in iTor Miii« months, but witb nu approciublo iinpruvetiicnt in ikn jMsition of lliv limb. The Hiiiuwe on the outer »t<)e of the knee were then Uid freely op«;n — connecting with the joint — giving i-xit to a largt' amoimi ui jnis, itiid ^inc variotiti bone which Kocnicd to ooiuo from the 4fxtermU comlyle of the femur and tlie patelU only. Tlie joint was freely injet-ted with warm water, and the Wound ki^pt open by tvniH of ouhuin Mturattnl with Peruvian iKllfiam. Snuill piecea of hone continue*] to exfoliate for Boine months, whun the woumU gradually cimtrizc^l, and the pnrta became perfectly healthy, but with no iniprovciucnt in the poM- tiuu of ihu limb. All the eoni^titutioiuil »^'1nptome improved from the titiip the joint was freely opened ; hia appetite inrreaaed, luid liU (Jeep wa« tranquil without uarcotica.
In January, ISS'l, ta his general heahh had become restored, I docidt-d to attcmiit to improve the deformity by tt-notomy of the tijuiihtntig uiu^cles and bnsemeftt /orci of the knee-joint. The boy waa perfectly anteathetized witji chloroform, the ten- dona divided HubL-utancoUftly, the woimd» ciirefully cIo;>«d with iidhe^ive planter and a roller, and tlien the knee-joint forcibly brukon — l»y fivxiou imd uxtoueion, and internal rotation — ^until tlie limb wn.-i brought parallel with the other, and alnimt [wr- fcctly Htniight. A tight i-oller was applied from the toes up to near the km^o; n Ini'ge eiwngc placed in tlie popliteal aparc, and Htripa of adhesive jdaHter went applied ovur the upongp. and drawn t'tgi»iiy around the joint from tlie bandage below the knee, tn soma aix ineliee at>ove it. The imIW whb then eontinueil over the ]di.4ter, Miiigly applii-'l to the whole thigh. A piisw of Kponge alxtitt two inoliL'ii in length, and al)out the size of the fore- finj^er. tianiig boen placed over the tmck of the femoral artery — as iif my usual ciifltom in this o{>eratioR — the roller was rarefully appbed to oau^; partial occhii'ton of the calibre of the artery, and thtte diminieli the supply of blood to the joint. Milhont l>eing bo tight ft:* to induce it^i completo islrangnlntion. Two piwc of firm ROle-leatbcr, cut to tit the foot and limb iti its entire length, hav- ing been »oft(inc<d by winking llicm n few niinutesin cwhl water, wuro ipplioti on either side of the foot and limb, and senircd by a bandage. Cineat cnro was taken to model the leather to all the invc)ualltic« of the |>art, while it was still soft and pliable, and the limb wntf forcibly held tn its improved position ntitil tho leather
DISEASES OF THE KNEE-JOINT.
bccAinc dry siul Imnlencd, wlieri it retainwi it as perfectly na anj planter mould could do.'
I wifib to oall «8[MX'iul uttentiua to the priuciple involved in the dreesing in this case, a» 1 tliink it of cardinitl impoit*oov, Uaviiig wihiusu-d itN practical b«ui^tit in at»uy atrious operntinnB. / nuatt the pivwture on th« main trunk <>f an art^ri/ leading (o any j>aH in ttanffer of in_fiamniation, in nuch manner <u to di- minUh th« gvppfy of btood., to prevtnl injiammation b>/ partial l^arwAion, Great c&utiou to, of c-ouivo. iivrftmary not to prxKluce gangrene ; but a little practice, and ctoso observation, will toon give tl»> necessary tact of knowing how to twd pressure, without ahwuiny it.
In this cii«) of young C, although tlie operation was very Kvcru, «nd tlic fon^ rcijuircd to bruak up the adhesioiu wry gKAt, and continued for 8<>nie time with rather rough manipula- tion in ordvr lo gi't the liiiib in good podtion, yet it was not followed by any constitutional excitement or irritative fever.
The boy took an anodyne tlie lin^t night only, and front that tiiue bad no pain or troulilu wiialcver. The limb was krpt im- mo^'able in the leather splint, and was not disturbed in any manner for thirtovu days. At the expiration of ttuit time it was dreMod and foinid perfectly satisfactory, the wounds all hcaliMl, with no in flam mat ion flWut tlie joint. Our objoct Vicing to obtain anchy- losis, the limb was again redressed, but withont tJto ^iHingo over tbo femond iirtcrv. At the end of two wtin-ks, on again examining it, it looked po favorably lliat I determined to produce a movable joint, i»et««d of anchylosis. Fawive motion waa tried, with great care at first, but afterward ponliniicd with nmoh moit- frci'dttni, and finally rcstiUed in & vi>ry ii«efid joint, having about Iwo-tbirds the motion of a natural one.
The patella is very email — not mon; than onc-tliird tbv sixe of the opposite one, the t^xtoiiiiil condyle of the femnr is very much reduced, Uiorc is {xiralysis of the peroneal muHcIt*, from plough- ing of the periiiieal ner^'p, the foot is smaller, and the log one inch ehortcr than the other. Yet, witli a high heel, an oWlic spring on the outside of tbe shoe, and an India.mbl>er substitute for the
■ SubH«|unit (xppHmce bw tau^t me that H is twtter lo oIon ilw wounih Md rHlin Ihelimb >l pinfMt rnt in iu ■liDurmul pojiition until iIih »lnn«l wound* Imtb titdod (whicli iiill ftPiiFFtlly be done in flic or >ii ila:ri>), btfurv iirccMdlog to farwk up ibe ban; MJhuion*.
CASE.
23T
*
perooeal miuclve — nmninf^from tbe tci{)of tlie fibula to tbc finklc, where it tcrniinatee in a ciitgtit tiorj, which plava »roiiii<) u piiltoy, Atid i» irisvrtvil at tlie onk-r mnrgiii of the »olu of tlit.- bout tivw the toe — the boy wollu, duncvH, nius, aiid ekstcs with tiis play- iiutCH without crutch or cane,
Cabk. Chronic Infiainmatiim t^f the Knce-Jotnt tcitA Sub- luxation.— Matvh i, 1873. — James J[., of WilltRinsburgh, oai^ pentcr, a^d fifty-two, vt-py ttroiiy and robust; four jcare sinoo, while lifting a heavy wciglit, he Htepped on a stone and idtpped, '' something cracked in his right kuc« liko a piHtol." The kn<w Rwelled very much ; did not lay him up ; continued work all the time for two youru, although tlic kuce wmt kwoIIcu to nearly twice tbe eixe of the otlier. He vm then thrown from a wagon, strik- ing upon tlic oulisidc of thu lanio knee, and van hiid up wilfa an acute inllaniniation of tlie joint. Six months after this a gather- ing took phK-c, and o[»cned un tiw iunor «do of ttiti pojilitcul space, dii»cliarging very fi-eely for two or three montlis. The opening Ktilt ditiohargM a Mitalt amount of ghiiry fluid. TLo prol>e piLsSM five and a half iiichea around the joint, but I do not touch bone.
i*resent condition seen tu Fig. 139, witli comparative nieaMire- mente of Ihv two limbs.
fweort.
IttiHT.iti t1 If LEFT. 13 « t*fi 'Mcttt.
fa. tm.
HiAQSom. — Chronic inflammation of the knee-joint, with Kublnxation.
Tkbatuk-vt. — Kxtendou in two directions, as »oe» in Fig, 197, after which the knoo is to be compreeoed with wet sponge and roller. May poBsibly require cxsection.
223
DISEASES OF ITIE KNEE-JOINT.
Api-ii Vith. — Meaaarenients decrcftsod from 17 to IftJ alioiit Uic knee; below itte kofo ITijl to 14^; above knee not chniigiML Foeition Btraighteued to doited line in Fig. 139; kime-cxtviieifia fi[>liiit npplitid.
May Itl/A. — Rcadjiuted rollers. 'I'lie |i}Mton<, wKicli IiMve tKHiii on one iiioiitli, arc in good i-oiidittoii, and tlie itxstniment was properly e.xtondcd ; could ttear almosE hU entjre Woiglit on limb witliont pnin. Limb porfvctly fttniiglil ; diechargo fruDi it very eliglit ; iiiiprovod in cvt-ry wiiy.
Jane 16M, — IteadjuHted pUjilor* for the first time; iiiucli im- proved.
J/iry 7, 1S74. — Plnrtcrs removed for the fourth lime, and llic joint U perfectly cured. The limb h straight, and can eitfitain entire weight of body, lias moderate motion. Komovod all dressings, and applied hiller-bandagc ; advisn frictions and eloe- tricity, with pastiivv motions.
Juty 1, 1S74. — Patient walked to the office from 'WilliantB- hnrgh, a dintance of two miW; itt in j>erfvot heallli; no |»[n wliiituvcr about the knee-joint ; can extend leg perfectly stntighl, and flex it to nearly a right angle.
\'ory many of the cai*c», however, which yon will bo called upon to treat, will Iw lho.-« which have been noglw'tcd, and in itniH->lti(.>n»- the diseiuc hntt bi-conie fnr advanced.
Ynii may, then, see a joint in which lher« is exteneivc deetruc- Uou of t]ie Hoft parte, ext«i»ivc dlMuiiHC of tlto bony i4ra(.-ti)n«, accompanied by exhausting discharges, and very gnkvu cooBtitii- tionul disttirbaiicc.
In snch caBce, if there is reasonable hope of being aide to rvlicvo the patient of tlitu source of coni«tiliitiiinal exImiiiUion and dietturlianee, by removing the dead bone, and i.«tiitili thing fret- drainage from the bottom of all isinuou« tracts an operation may be made for tliat purpose. If deemed jti^tiliable, nuiko a Uirge opening in the soft parttt «o «» to cetablinh perfect draiiuige and prevent any collections of pns; then drill, gouge, and cbiM-l, nniil all dcsd bono ii» removed; draw wtonit of oaknm or perforated India-rubl)er tubing through the joint to avoid the {)0««ibility of the retention of pus place the limb upon an extending and I'onn- terextendiug apparatus, and carefully watch the progress of tlm eaec.
If tills progress is favorable, both locally and conAtitntioiiaUy,
4 4
EXSECriOS.
22fl
It trill be gooct eviiJencc tlint youroperAtive intcrfercncv hiw liocn ill the rifitit liircctioti. If, liowttwr, llic (;lukng«i are iinfavoinUle, you may next reeort to exsection of the juint.
In tlio»e ca»e6 wliicli tuivo bc-comu eo far advanced ai< in admit of no tieiay, exsecttmi or nnipiitation may lie Pt'sortvi! to at iinc«.
Tlw!r« are cwott also in wliic-h tli« di«.>a8i3 titeiulity prograe«eH tovranl aii unfavorable terminntion, even whcu tliv very bent plan of treutnii-iit is aduptod aiid carrivd out in the mofit faithful manner. Such chika will proliably ro<|uire exKCtion or aniputa- ttun ; therefore we will fetudy the subjeet of exeeetloa at oar next lecture.
LECTURE XVII.
OIBEAJIR OF TUB JCIIXTS. — KNEK-JUIXT (uuKCL.l'Ut'J)). — EXSBOnoK.
MtMe of p«KatB>n|; tfa« Opfniion iiF Kutction. — .Splinia and Drruin^ twcd after thr 0|HniiMi.— I'arliat Et^ifiion, — " llrrHnl mi llir (.cut Siu'riflce i4 Patia u ■ frinriplr in Op«T«tifr Siirjiwy." — Diffwtntiul I>l»(pni»iii. — Buraitbi. — XpCKwii of lliv tj(>>cr btrtntily of lJii> Kuiiiur.
Gmtlkmks: Yon will recollect I stated at my Inst lecture tliat there are certain easvs of chronic disease of the knce-juiut ill which tJic opcnttiuu of ex»ection will be dcnuindod, and it i« tu tlic ciinaideralion of this subject that I shali first direct your «t- tuiiti'in this mornini;.
Exaction of the knee joint shimld be performed in the follow- ing manner :
Hake a single U-sha|)cd incision, bepinninp at tlie jKisterior porfioD of tlic inner otmdyie of the femur, passing downward and ncrojti) a little below the lower border of the patella, and thence ttack lo ihc poslerior portion of the external condyle of the femur. I prefer the incitiion made in this manner to tlie H-incisinn, for the nwson that it is equally serviceable, and exposes a nmeb less extensive enrfnce of bone. Turn the fiap back and remove the patella whether it is disea^'d or not. By m>mo it is recoinniendc<l to peel the patella out from the periosteum, but reroonng a Itcttltby patvlhi in tlial manner is inipowible.
wo
DISEASES OF TTIE KITEEJOIST.
^ Having removed the patella, you will next loosen the attach- ments of the ligamentA as little at« pnHsible, jut^t snffinent to per- mit section of (hu bones with the saw.
The next Btep in the operation iit to remove a t«eginent of bono from the lower portion of the feiTiur and upper portion of the tibia, in euch a manner an will pennit rcatOTatinn of the limb to till! Dtraiglit pusilion iu which voa wiiib the anehyloais to take place.
To perform thii) part of the operation properly, requires con- eidcnibltt itkill, and you may not i^uecwed at tlie first trial in mak- ing your sections at Hncb nnjrles «s will allow yon to plaoo limb in the propter position after the pieces of hone hare removed. To ttiit end, you have eimplr to recollci^ that your saw must pace throogh the femur and tibia, parallel nntb the artien- Ur surface of each bone, and not at right angles to the ehafts of tlie boneft. The bonee Bhonld not be laid Inre to an extent great than l» absolutely neoc«Mry to fairly oxpoeo tho portion to be^ removed.
Section of the bouc ntuBt bo Miftk-icntly extensive to remove alt necrosed and eariouB portions; consequently you will continue removing bone, if your tintt section is not suflicient, until you arrive at a point where a fresh bleeding snrface is obtained, in- dicating healthy bone.
The nest step in the operation h to bring the fresh iinrfa of the bone into perfect coaptation, and then retain them in position with salver-wire mituren.
After the l>onee have i)een properly secured, you will fix the limb in some apparatiw which will give alutolute J-i*t. For this purpofw the splint of Dr. John II. Packard, of Philadelphia, is one of tho best that cau be employed, and which in described by him as follows:
" In order to get a perfectly accnrate mea«urentent. I Irioo aa^ outline of the limb upon a alieet of coarse strong paper pla beneath it. Should the knee lie very much flexe<l, the outline of the thigli may be made f)r«>t and then that of tlte leg, mark- ing the limb and paper eo that the two proportions may cxActly wrresjiond. Tliis pattern sliould extend on the outer eiilc np to tlie greater trochanter, on the inner, up to tho perina'um, and about four inches beyond tho heel. A cur^-ed line should bo drawn corresponding to that of the buttock for rij^t or left aide.
PACKARD'S KXEE-SPLIST.
331
Tbe fi^ire m> described iiia)- be cut out and mad« Uie pntteni for this epliiit, whidi sbould Ik- iimdtf of inoli-boaix) (nltbough thinner atulF will do for smaller limlK)). Above, At tbe bittt(H*lc cud, tbiit bourtl is beveled off fo thiit no vdp> sbaW irrlum iho akin, and a hollow is iiuide near the lower end to receive the heel ; tbe whole id Bligbtly hollowed from Btdo to side tra ni; to ninko » ivri/ abultow
" A filit is ntortitHHi lengthwiiK! iit the middle line, eloMi to thv lower eiK) uf the ttplint, to reoeivo the tenon of the foot>pieee. Tbia btter eboiild be slightly inclined and long enough to extend np above the toes so aa to ]ivv\> the weight of the bedelothes off tbe foot. It tuny 1>e fastened weurely nt any dei<ir(?d point by meaiw of n wooden pin or wedge. (-Sr^ Fig. 140.)
A piece corresjKtmling to the knee is now Rnwed ont, the saw lino* being made to cun\'ergt: liligbtly from without inward to that the piece sliail lie a little wider on tlio outer side, making it slide out an<i in more c«»ily. Tlic luiw may be earried eo a« to cut the edge^ nf the knco-pie«>, as oeen in the diagram ; or, if n carjwuter 1w employed, a regular groove may l>e cot in the thigh und leg pici-eH. with a eorrcKponding ledge on the knec-ptcoe.
Two throng metal brackettt of giiicable size are screwed ou to the thigb-piooe above and the k^-piccu below eo as to eonnvct
FM. 1tl)L~F(lllt TD« tJVt (KUBC UMICU^
Pin. UI.— fViM t»<t*.
thvm firmly. TlicHo brackets ahonld be from six to nine inches high, niid shonld be Hared somewhat out ward ; jitst at their point of attachment they should curve sharply outward, as seen in Fig.
S3S
DISEASES OF THE KKEEJOIST.
141, so as to provvDt any pre^saro against the limb in cue the Utter rIiouKI swell.
" 8i<k<-pivue8 of Hoft leather arc next tAcked on t)»o upper sur- face near the eilgc of codi portion of tb« spUiit ; tliev niaj be made to fi«(>tc>n by laces, or, if preferred, by strapti ami buckles.
" Tbe liiiil) beiiit; laid on this splint, previously padded, if. per- fectly aeciire. Soiiietiraes it is well to add a small vtrip of pasto- lio«rd on tlie upper tturfnoc of the thigh aud another for the le^;.
"To eliati^ tbe drefiRitigs it U only necciiWiary to undo the hathfru, and to draw out tbe middle shelf, holding the dressings at the inner side lest they shoidd have bi?<^me adherent. Tlio kneo is thus left cxpo«i-d, and, when the dret«ingK have been changed, the shelf is slipped in again and ffc<tene<l a» before. I hav«eouc times had a small catch put on at the outer edge, but do not think it neceasarj. lieforc using the splint it is well to huvc the linei--piere, and tbe adjoining portions of tlie thigh and leg pieces, thoroughly oiled eo thnt they may be k«8 apt to absorb any discharges which may flow down over them."
You will doubtless get into trouble in attempting to u^ Fuch complirnted ap^mniliiii, unlei« you are tboronghly familiar with its mode of ap]ilication; but, if you will keep tbe principle in mind, namely, absolute rc«t with the limb in tbe proper position, it will soon he seen tliat a great variety of mechanical appliances can Ih; devieed to pnt it into [)ractical operation.
The plaster-of-Paria dressing is one that can be easily applied. and is both cheap and etlicicnt. It consists in the application of stripA of flannel, isaturated vrith plaster of Paris, along the poft>J teriur surfitee of the thigb and leg, and along the luile of the foot, and of suflicicnt width to half encircle tbe limb. In this way a Btn»ng and immovable splint can be easily made. The plaster hardens very qnickly. and when hartlened the limb am bo addi- tionally secured to the splint by mean* of a roller Imndage. Tbe entire secret of succea in exsection of the knee-joint is, first to make yonr incision through the soft |wirts in niich a manner that the outer angle will be as low as tlie lowest i>ortioa of the inci- sion throngli tlie bone ; and, second, to secure absolute rest for the ports after the operation has bccu performed. It is )in[K)rlant tO| extend the incision tlirough the soft parts as far back toward posterior aspect of tbe limb as the incision through tlie bone extend*, in order to gire perfect drainage. AU that is oeoeEHuy^
iLttTlAL EXSECrrON.
sm
when iheix i»<lic*tions are fall/ met, ii; to retain the limb in the ooiKlitioii uf alm^uia rcet until jierfect coiuolidatioo baa taketi place.
Exseclion at tlie knee-jnint 'ia nttc^nded with congiderable diuigcr. av.A in tiiany iiwtaucftt you may justly hesitate iHifore reeoiting to the operation.
If tlie (liiieaae uf tliu joint iii uut euflit-ii'nlly i-xti-ngive to war- rant 0(HiipIut<' cxiiwtioii, you may remove all the dead hoiic, by drilling ami gouging: |mim nctons of ogkum or perforated nililwr tiihiri-; tUmu^h the joint for tlie purpose of seciirinj; coiiiplvto dmiiuge. and ronduct the tronlniunt upon thi- general plan i«c< ounnvudeil u-hi-n speaking of the mann^miiut of Iliu ankti.>-juint.
KxEie<!tion pan !«> performed nmch more <juickly than tlie op- eration juiit indioatud ; but, wliou tliv <lisc&MC dou« not invulvc the entire joint, n-ben the r'xaV k considerable, or when the Riir- rounding oondiliunri are undivoruhlv, 0XM!Ction should bo avoidvd. lu such (^aesi' I rely chietly upon the operation for partial removal of the joint and tlie rtwult in many cases i« very tmliiffactory, as yon have already aeon nt our clinica.'
This pl:in of trciitmvnl, which I bavo practised fur mom than tvenCy years, I am happy to nay in now lieing adopt^l in t^ng- land. Hr. ISryant. tbt* diT-tini^itiiiliu*! fiurgi-on of GuyV H'M<pita1,ia UI3 recent pajtent puhlitilied in the lAtndon Laneet, '*On the I.eaitt ' Bacrifico of Parts as a Prinnplt; iu Operative Surgery," hii£ this remnrkahle statement :
" 1 tni>t Uinl tliii ac^i^w of cueo i« enougb to SnaORttnite with (mfficlmt clearnew lllt^ vuiisv uf (li« |>ni«4ic« I nii) oavr iaoalckting, and to abuw tluit in ■ Iatro Burabcr of cmm of iliMiiM nf tlie Joints a c-niv may tfo ecoured t>.v a Minjilv iMiUiiiD iaiu Ibc afftxrlciJ joint am) the rminvnl of nccriiM»iI hauo. Tli« •oriM Jao]nd«a Mainplaa of di'eaoe of tliu Bhonlder ami «ll)ow, hip, kni>v. onklo, ntiil grcat-tou j<iint«, ami I ilo out tliink I Khoiilil bo fnr itroag if I wen to oxpreM mj heWvt tliat in uianj of tin.' ttuua*, if aol in all. many »ur- lto»a*— mora purtii-uhirly Hmm who ore adrocat<« for Mcifnon— would Iiave cxitiiHsl tbo juinK ami until* tvw u'<iul<l bnvu ara|iuiflt«il. I nia sot hero, howerrr, to oonileinti ch*'ir praciii-o, for lliclr r<-uilta niiplil hare bean good ; liui, whntvvtc tli«]r minlit linT« been, tlivj <ri>iild haie been aocnrad by Mrcre »]>^nitive nettwrw. and coD*«<|uenlly by (laim^ron* litk*, whercaa in tli« tfuatiDpnt I am ooir adcocalia^ llio aurpical prooccdln^ are almplo and oro nUrixlol with a minimum of diiiiK«r. The riipcom of Uio practiou I liar« racordod waa also grtal."
' Si ete Thoniu B- C, Lertart XVI.
834
HSEA8C3 OF THE lUP-JOIST.
LECTURK XVm.
DttUSEB or TUK JOIKTB.— MOKUL-g COXARIUS.
Anaiiimy of the Hip-Juinl. — l^tlioloKX of l[it>-DbMML — Etiology. ' ■ ' S7»pUiin* of
Fint Sugn.
Oknti-rmrx: We nliall noxt consider that malady which occtt- pies the chk-f pliunt among affcctioUK of thv juiuli^, nanioly, Mur- bns Coxnriii^ or liip-dieease. But, befuro eiilering upon the oonsidenttlon of tlic j(yi>i[>tom8 and moriiul chant's of structure in tlii» di«nse, it will he neoeeeary for ine to give a brief <li>»cri|>< lion of the most irii]>ortjtiit aafttomical otruviurc^ unluriug into the composition of the hip-joint, in ordur tliat yoii may fully comprehend tltu {irini'iploi which I Khali endeavor to oatabliali as the ]>n>pcr ba-tlH for entrect treatment.
A:cATt>MT or the Hii*.Joixt. — The oneoita etracturc of tho hip-joint \i mnde up of the oi innominatum »nd head of the oti femonSf the lattor being received into a deep cavity of th*' former, the a/xtabulttm, by a kind of articulation cslled mttr- (hroitiai, or ball-and-socket joint.
The head of the femur and the acetabulum are eaiioultoua In Btrueture ; quite vascular, and eubjoct to inflanmiation.
The acetabuliini i^ lined with cartilage nt all part«, except nt a circular pit (fundim seetulmli), which cecnpieit the lower part of the cavity near tlie notch, and iu cuehionod with fat. The head of the femur, which iits into and artiirulatett with the ace- tabulum, i« nearly two-thirds of ihe eegmeut of a sphere, and \» entirely covered with cartilage, except at the deep pit, which is for the insertion of tliv lignmentinn teres, at its upper and inner face looking; toward the cavity of the pelvis.
The proper ligameiite of the tit|><juint are the vajmtlar, the iUo^tawral, tlie U^mentum feret, the cottjloul, and the tiHinm- verse.
The Capeular Ligament {A, Fig. Hi) is the largest and strongest capsule in tlie body. It is attaclK^l above to the outer border of tho acetabulum and outer fii™ of the cotyloid ligament ; and below, to the anterior inter-trocluuiteric line, and nerk of the femur, which latter it oompktely surrounds. It h thicker and
AS ATOMY.
38S
longer in front tliHn licbind, nnd it i» more extenuvcly attacLeO at its npper part, wlipro flli-eiif^h diul ftfcurity nro rctjuirt'd. Tlie ttroii<^li of tiiB i-apHular ll^tiipnt ia further greatly iiicre^ed liy the iieo-femoral liyament {U, t'ifr. 142) which ia accessory to it, uml exteiiiiif from the anterior inferior epinous procctw of tlm ilium to the anterior inter-tro<'liant(<ric line. Thio ligament Iwa been called tho Y-ligament by Dr. Bigelow, of Boston.
FM ua
no. u*.
Tho Cotyl<nd Ziffamertt {C, Fig. 143) is a thiek prismalio I'ing of fibro-<!art!Ii)ge, iiiounting and attached to the brim of the occtabulmii by which the cavity is docpi-ucd.
The IJjfotMntvm Tfves {A, It, Fig. 143) is attache<l by a round apex to a pit juet K-Ion- the middlo of tho bead of tho femur; it dividc« into two fascicnli, which are in»>rtcd into the comers of tlie notch of tlie ncutabidiiiti A , Jl, imd the cotyloid ligament, and i« covered by synovial nieiiihrane,
Tho Tratimerae Ligament is contiiiuoiiB with tho cotyloid, extending from one point of the notch to the other, and com- pMing the clrclo of the cotyloid ligamont, tbui> converting the notch of tlie acetabulum into a foramen, through which the blood- vcwcU enter to supply the interior of the joint.
The synovial meinbrane is t]nitc extensive, lining the CApfliiUr ligament, tho free surface of the cotyloid and transvenw ligft- meabi and the ligamentum tereo, as far as the head of tlio bone.
DISEASES OF THE OIPWOINT.
TTe arc now reftdy to pAM to ttic etudy of the pathology of thi» tli«eas«.
Patboloov. — UaOcr thU hcsd wo ehall dc«oribu the changes that take jilnce in tlie tWiiee of the joint at the very beginning of the diaease, leaTing those which are prei»ent in tlui more ud- \-auoed cunditionfi to be coiuidered in connection with the symp- toms to which they give rise.
1. The dii^ciuu iiuiy begin as a synovitis,
3. It niay begin in a rupture, partisJ or complete, of the liga- montum tvrc« ; tJivtrvby interfering with the nulriliun of the head of the femur.
3. It may begin from rupture of eoine of the minute blood* vetwelii whi<'h are situated in the bone just beneath the cartilage of iDcmstatiou. Thi^i may occur dther upon the lii'ud of thv femur or at aome point in the acetabulum, and results from blows, jumping, or imytbing which may produce a euddon coneuM^ou of tbe.»e articular on rf uces. The«e three conditions retjuire special GonsidCTation :
1. Ofsynovitin. Inflammation of the synovial toembratie of the hip-joint may be priHluL-t-d in the ^mu manner a» it \» pi\>- duc«d in any other joint of the body, but it is almost always the result of exjMsunj to suddiMi ohangM of tcmjieralun; affr violent cxerci^, »iicb a» skating, racing, jumping, playing at foot-ball and other movements that orer-cxcreiw the joint.
When the synovial membrane becomes inflamed, efTusion of fluid into the cavity of the joint always lakes place. The ^yno- vilis may be subacute in cluiracter, and attended by tlie effusion of only a small quantity of fluid, l>ut not followed by diKinicgra- tion of the ti)<«UM of the joint; or the same dt^ree of iii6amnuir tion, in some caties, may be followed by coniplete disintegration of the joint stniclitre^.
Again, the avnovitia may be very violent, accompanied by intense pain and the cfl'usion of a largo qiuntity of flnid, and make rapid progress toward destructive chnnfres within the joint. WHien the joint becomes distended with tlnid there will be pres- ent A pecidiar deformity, which we kIihII fully dveuribo when we come to stu<ly the s,\-niptt>nis of the disease in its second stage. Of courtte the aynoiial membrane «»oner or hitvr bivotucs in- volved, as do the carlilagiv, ligaments, and bones, no matter how the diiwuso begins; but tlint there arc cases of hip-joint diseaae
PATnOLOGT.
wliidi liftve their cotiitnenccDiciit in a t;ynoviti£ I Am fully con- vitK'wI.
iJ. Anv vitilent piminiiig uf the ligiimtiittini lores, eiieh ae nia_T he anscd Ijv fonnlily Btrelching tlie lejp Afiart, or bv wliw violent exercise ivlitch {jivvs inotiun to tlio joint to tlie extreme l!n>itii, uiuy {uirtially or completely «-]narate it from any of it* ntlacli- Dienb* to tlie Ifonc^ It it luottt likely, however, to l)e fle|iiirated fruin itii attaclmientB to (he head of the feinitr. 'When such an iie- eident oociirs the ve*8el(( which supply the hearl of the femur arc dvHtmyed, ftnil necrosiei followfl a» the «wn1t of interfi-reiifu with itn nulrilion. Secondary chim^cs soon occur in the eartlla^'s and the Bynoviiil memhrane, and the caie go« on, if not relieved, to thr «iovelin>mi'iit of tliu dlM'aiio In it» worst fomi.
3. When the dieea.^ l>egin» in the Iilootl-veiwele in iho artic- ular lamella, it lintr a[i[)can) iib au extravasation or "hlood-hliKter" Bt Home point. This h the nidnx, or t<tjirlin^-|Miint, nnd. if the dauuige done i» detecteii at the lime of the intlielion of the in- jnry, resi, alone, if continued for a siiflioient lonplh of time, will proliahly hring ahoiit a favorublo termination in a grrat majonty of infltimoeiii. Itnt tlie damage done not heinf; detected, and in many instanevH not even nuspected, the rest nec-cissary is not tntlifttd upon at the pmper time; conseqnently thf- (li«'ji«ic i» slowly devt-l- oped, and frequently ut not distinctly pronounced nntil lon^ afti^r tlie aoHdont t)uit has caiuod tlio trifling damage to the blood-ro6- 8el». and given ri^e to to miirh trouble, haw been entirely forgoltpn.
A pinch of the skin prodiiting u " blood bliBter," or slight extravasation of blood witliin the cellular tisane, ta of ctmimon : ocRiirrence, and is of uo gi-eat iin]Kirlauce. If let aloito, it will won be ahwiirliHl ; or at niiwt, if yon let the flnid out and do not irritate the wound, it will tmon get wx'll. But eiij>pofie, «r»a in thiH i\n*A trilling ''vi"fy, tiiat. ii»-'te»d of giving it rest and tiirie (o Ileal, yon eoni^tiintly wralch it with a rualy nail ; you will pivducc a fioro thai will hist n« long a^ the irritation in continued. This ih A iKtrallel case with a joint that is oxcrnVetl after concuiwion, or a blow or wrvnch tikal hue produced an i-xlravasation of blood from tlie tuflit of hlood-vet)Act.-i already referred to.
Xow, whilu I lielicvo that thit) disease begins in one of the lhre« wavi* mi'ntioncd, 1 would tuive you understand that the di»- eDfie doea not progress very far, without involving all the stniet- tucs entering into the com])osition of the joint.
238
DISEASES OP THE UIP-JOINT.
For instance. wli«n tlio diseaso begins as s synovitis, the carii- \ttgeSy boneA, and li^iiicntii K>oiit.>r or later l>cconic involved. So, whvii the d'lecam begins in destruction of t)w ligamentam teres, partial or ci^iiipletc, tlic Kiine confteqDenocs ennuo, and the name ia Irut; when thi- diiKrusi; begins as AD extravasation of blood in the manner d(»cribed, the osteitis soon involving the joint
1 do not believe, however, that thu dtiH:«i<« eror bi-j^'nM in the cattiiagcs of tlio joint, for the rea»on that thei>e Htnirture« contain neither blood-reseols nor nerves. Kecrosis occurs teeondarUy in the csrtihigea on account of the losa of nervous and vascular sup- ply to the tissues upon wbieb they dopMid for nutrition.
This, according to mj view, constitutes the pathology of this disease at its very beginning. Tbcro aro other and very impor- tant pathological changes lltat oiTur as the diitease pr»greew«; but, inasmuch ax certain symptoms, suc-h as ocrlaiii positions which tlie limb a«^umc», are directly dependent upon stieh pathological changes, I shall consider them in cotmcctiou with llio symptoms to which tltoy give jim. We now paM to tho subject of ctiolog}*.
Etioloov. — Almost all Hnrf^cnl autlioritias agree tliat morbns ooxarins is invariably the result of a contaminated vonHtitution ; in other words, that it is essentially strumous in its origin. This has been tlie universal opinion, and the doctrine has descended from teacher to student, and la still extant among the majority of Burgioal practitioners. It has been so often taught and enforced by froiiicnt repetitions, that nobody considered it worth while to question iu truth ; hut nearly all have taken it for granted tliat an ai^Mrtion so poHilively made and universally accepted must be based ujKin mature investigation. AVhen I first entered the pro- fession I accepted this doctrine taught by our fathers, but must confess that I never was fully 8atii>tled with regard to its oorroct* nbsa. Now, while I revere the labors of thoae great men in the advancement of scientific investigation, I must be permitted lo question what is questionable, and to doubt vkliat is doubtful.
Kxamiiialion of the ca«es which have presented themselves to xaj notice since tluit lime has convinced me that ttie cachectic condition ho often seen is the resuli and not tho cauge oi the dis- ease ; for verr many of the patients in the earlier stages of the diMOBo have (MsscKwd all t]>c appearances of robust health, and, in all those cases in which the diseat^ has been cunxl by Xature's method, the patient, subsequent to the cure, has boon hale and
ETIOWGY,
S88
bearty. I do not Bappo«« tlicrv U ii person in this room who cannot call lo mind some old fellow with a eliortiinud hip, per- fectly- uiicbjrloMod, who yi!t hits a niddj^ face, a good health;^ Ri>nipl«xion, and is a vigorona, rohuEt old man. If hu had had Kcrufulu in liiit »,VMtuin, it uould liiive nmiiutic'd tlicre, and when his hip had recovered the ntan would have been a tDiBemblv ulil fidlow after all. The very fad of hi» be<'oiiung a vigorous, roburt mail after going through all the vxliaufiting cfTcct« of hip-joint disvftMu provL«, in my judgtncut, tliat Ukc diBen«o 1m not neccMsrily of const ituti on nl origin.
The aihlilioDul fact that, in sto many ciiece, tho joint has been
exfioctvd when tho patients liave been, apparently, at tho point
ro( death, and after th« removal of tlie dead bone have bi-como
rigorous, Btnong jwreouH. is good evidence that tho difienso is not
joatitatioiial. Then thora is the ntill xtronger fact tlint, hy
itEng the dim.-iiHo locally without reference to voniititiitional
lint, we obtain ]>erfect reeults, ho inncli lio tlint tlie iKiticnUt rc-
jTcr with perftft motion and withont the slightest deformity,
rhioh ifl the heiit proof in the world that the disease is eH.4entiaUy
in eharactvr.
Another fact worthy of eonaidcmlton i« that a very large pro- portion of caMv of the diseiue occur in children, while- the Bcrufu- loQH conditinli i» by no means so restricted.
I have unfortunately n^^-orded only a ^nnll part of the cases which have fallen under my oliservation, bat three hundred and oinoty-nino ciik-s have been fully cntcn^ upon my record, uud, of tbeee, two hundred and fifty-three wero under the age of fifteen ymn, and one hundred and thirly-fotir wero under tho a^ of five years. Similar results have been obtained by other gvntlenien who har« collected Ktatixtics n[Kin thi« point.
Now, it is ni>t npcesaary for me to prove that adults are nearly M liable to iw nlTectcd u-tth K^mfiiloum discoues as arc children, tboleea nuinlior of cases seen being due mainly to the fiict that these lickly rliildren aiv. v<'ry liable In die before Kuchin^ adult life. If, therefore, wc still adhere to tho scrofulous theory, we are foreed tn conclude that the diathesis, which in childhood developH itiKiIf tn joint-di)te:i«c, manifects it«ulf in lioniu other way after pnberty. This I cannot believe. Childhood is the age of nitlbw activity, and, out of the himdrcda of caitos in which I bare taken the trouble to trace their history, I have found that the
&¥>
DISEASES OF Tf!F. UIP-JOiNT.
immense majority, T niaj* safely say seventy-five per cent,, Itave oc- enrrod in the mo»t vigoruii^, rubiisl, wild. luirtim-eearuiit diiMrcu — those who take their diancefi uf (lunger, who run races, cliiiih over foiirce, jump ont of applu-trfu^ kii'k Ihuir playmates down-iitairs, ridu down l>alust«n^ and ary generally oarelesa and reokletui.
On the other liand, the sdult does not place himAeli in the position in wlik-h he can nwuivu su lumiy Mows or falls as ihc active child iloei*, and furlherniore lie immediatt;ly notices the cllecU of his injnrv.aiid takes prccAutioii n^iiiKt its dcrolopincDt iiit't nerioii--' ti-oiible. Tlie child, however, knows nothinj^of re- t^ults, and, uide») the pain from the injury in gi«at, will pmliahly fail to complain of it, and hoou forget it ultogvthvr. This, I believe, in the true reason why .no many more atsea of joii)t-di« iiro siMm in children than in ndulto.
I do not wi»h to be undentood as Ntying that iwiv>fuU \» a j>wiw/i6*iv of diflejurcof thcliip-joint, ax Ium Um'ii ueeurtL-d concern- ing my Tenchiiig. Ail tilings coii^ideivd, a smaller ainoimt of injury will prodtice the disea.<ie in one of thceo nueemhlt.', sickly diildri^'ii, than in a hiiiltliy, rohust child, [fut tlie itickly, M-nifii- lous chil<), who clings to hiH mother's apron, does not run thu risk of getting; iiiirt Ai do lhc«e active, resllviw children ; ooiuH>4)ucntJy, the iiiaJDrity of ca»ce. occur nmon^ the active and robust.
I'Vom what lias been said, yon have protably already drawn tlw inference that I reganl the diiteasc ns one almost iiivarinbly due to a (ninmaile cauec, and fmt dependent n)>on {i»me ron- 8titulioii:il taint. To wlint Itaa already been said upon this )H>int, we may add the positive evidence of etstiftics.
Of (ho thn>u hundred and ninety-nine caset; alliidc^l to nbovo. traumatic cause was assigned by the (Kilifiir <ir the jMniit in two hundred and eigbly-tiiroo, while in one himdrL-d and sixteen caam the eatiec wiw recorded as unknown.
In tlirce hundred and sfven cMk4», the previous general con- dition of the patient was good ; in forty-seven vasten it wu bed ; and in forty-five eases It w:iii unknown. The«o tignrc^ art^ taken from the notes of my own fully- recorded ea.4c«. Cmha iiol fullv recorded have been rejected in nmkiiig these Matisties.
Now, (he crisi* in wliicli the previous condition whs biu], to- gether with those in which it waw unrecorded, make up k-ss than twenty-four per cent, of the wliole; and it is potuihio that very many of ttioee lutd a traumatic origin that had been overlooked
SYMPTOMS IX FUtST STAGE.
^1
or forgotten, owing to the itisiilioOE manner in which the elianges liad come on.
My own clinical olwiTvations with reference to this point stand br no meana isolsted. The winie obflervntions liare l>ecn niadc l>y oMkt mir^-uiiH, buth in this country and Kiirupe.
It generally nKjuires n very close exaniiimlluii to tind out tli« cuiiec, Nuoo Uio disease doee not Uftually iuiuiediately follow the injury, but often first mnnif€i*t8 it»clf wcclc^, and cvvn inoutlt«, nfter the accident that lias given rise to it has occnrrwl; »o that tbo pAtient and bis friends natunlly enough forget the amdent and ite connecstJon with the diaease, until especially reminded of it in the invMtigution.
&o moch, gentlemen, for the pat}iuIog%' and causation of hip- joint dboaM, and now we are ready to 1)egin the etndy of its a^mptoou.
Stkitous. — These will vary acconling to the stage in whidi tlie disease pretienta it«c]f.
Ordinarily three etagea aredeeoHbed :
1. The Riagc of irritatjon or of limited motion, before the occnrrence of effusion.
i. The stage of " iippitrcnt lengthcniug," or of cSumou, the capsule of tlio joint remaining entire.
3. The Btage of " shortening," or of raptured oapfiule.
For the M-cund and (bird a(ago», I prefer to use the terms ^f^tmon and rujdure, rather than " apparent lengthening " and "shortening," as the Utter dettcribe only a single feature of the di^fonnily pn?Aent in ew^ stage, while the former designate nn essential pathological change which underlies a griiKp of Eyin|>- tonia. What, then, are the symptoms of the first ttage T
The eymptoms of this stage oro soniotimee exceedingly ob- Bcure, particularly if the iuflamnmtion l>e of a low grade, or of the rhroniu character generally found in those of a etruinou» diathesiB. The tintt thing that attmot« the attention of the jiattent or bis friends is generally a stiffness about the joint and a limping gait, for which, pcrbap«. they will be unable to af«ign a cause. The real canse (commonly traumatic) has been forgotten in conae- quenec of the alow and ineidioiia approach of the discJise. Tlits attffnoM of tlic joint is commonly noticed tirst in the nioniing ■when the patient gets np. After he luia been about fur n wliilo he bocomca limbered up, and can travel without stiffness or ap>
S43
DISEASES OF TOE HlP-JOrST.
pndable limp. But, even then, when be stops walking or ran- ning he will, n-itliin a niiimlu or lwi>, iiiviimlil^' eUixl upon thori sound ivg, a))|iiirfiitly for the purpose of relieving the affected' one.
Now, even at thin e»rlv etn^ of tlie diAeiute, if the patient he tsken to tl>e aurg<eon, a careful cxaiuituition will reveal tlie fol< lowing cooditioii of thiti;^:
It Ib to be noticed, however, that no dt-formity of which yoo-' are certain ran bo dutecU-d at thte »tA^ onle«« the patient ie com- pletely etripjied of clothing from the waiHt down, and then placed^ in a proper position.
When the patient has lieen stripped, place bira liret in the Btanding poHitioo, and directly in front of you with his back tow- ard You.
The light flbould fall directly npon his back, in order that yon may not be dwMJivcd with re^rd to details of contour hyanyi shadowH. Vour examination eliould not Iw harried, for yon wi«b to detect the disease in its very tncipieiicy, in it» nio«t i^budowy fonn. After watching the patient a sliort lime you will notic^e that he makes a sobd coluniu of the sound \ejf for the purpose of receiving concussion and bearing the weight of the body on that limb, and also carefully avoids all concussion of the suspected! limb. You will further uoiico that the snspcctcd limb has a Tendency to flight a1>duclion and slight flexion at the knee and bip, but the feet stand parallel with each other. The nutls upon ll>c side of tlie lameness drojis a tritte, is Romewliut Ihutetied, and the gInteo-femonJ crease is tower and shallower than upon the healthy side. {■Se'' Fig. 144.)
This droppitigof the natisis due to relaxation and gravitation of the gluteal muscles while the weight of the body is thrown npou the oonnd leg ; for the xame thing oecnra if the kiie«-jo!iit be affix-led, or a perfectly sound poncMi throws his weight upon one leg.
This symptom, then, has a dUgnoetie valne only so far as thtBi — it {ndieat«« to tis lliat from some cauw tlie )iiitient rests the weight of the body chiefly or entirely npon one limb. But from tliit* peculiar favoring of the affected side we can often del^i^l tlie incipient disease, even before a limp has been noticed. Xext yon will determine whether tliere is present any rigidity of tlie psoni-J niagnuB, iliaeus intcmus, or adductor muscles of the thigh ; for
EXAMINATION IN FIUST STAGE.
M3
rigidity of tbese mosctes appears f ery early in tlie di^eatw, and, if iiono of lliem give rcjii^iincc to tliv full pcrfuniiikQce of their normal fauctiom, it ie fair to aseuiue thtit the joint is not (li»- eased.
To inat;e an vximiination for tbia pDrpose it is ne<-e«Mnr to lay the patieut upou liitt back upon a linn, flat surface like a table
Fto. lU.
nr 6<)or. Tbis exaitiiimtioii mvtit he inftde upon a WiW. flat siir- f»f e. A bed. op »ofa, or lounge, tliL'refore, will nrd answer ; for the IntKjiuditim of cttbir will iKli)]it tlieiiiH.^lveH to tliv eurviitiires of t]tes]iinef therehv preventing yon from detecting the deformity of tliiti early period of the diseaiic.
Ilefore proreeding further it ia neoeseary to pliiee the patient in such n poeitioii n« will furnish a pnjper 8tnrting- point from which vow may condiirl vonr examination. Such a position in onu in which tlio p4.-lviKand tninli arc at right angles with eaoli otber, and in obtHine<t in the following manner: Lay the patient on hie b(H-k n[M>Q a titble, or Boine iwlid surfticc, covered only witli a blanket, in .lurh a manner that bis entire ainnc will be bn>ught upon the plitne. This can bu done by ]ilaring your ann under
SI4 PrSEASES OF THE HIP-JOIKT.
tbe knees and lifting tim tliigtis, or by lifting th«in in »ny otiior wny, until tlic ii)>inoiiti proceAcKiti of the vertehnB hitre toaflitnt the Holid plsno upon n'litch thu child i« lying^Mct Fig. 145;. Th«n draw a line from the centre of tlie stemam over the umbili- eufi to tlio c«nlre uf the pubis, iind orxMt it nt a right miglo liy » liae drawD from one anterior superior spinoiiB procees of the ilium
rM.ui.
to the other. Wlien this i.t done, and the two lines nbovo men- tioned are at right unglo), the spinal column is slightly Btn»ight4'r than Donnal, hut it and the pelvic are at riglit angles witli each otlier; and, if no dii^cave exisu within the hip-joint, the limb can he brought down, so tliat the popliteal ftpaco can be made to touch the plane, without disturbing the relation of the lintM above dcHcribc-d, or lifting the Hpinoun proces^e* from tlic plane. If you, therefore, hold the suspected limb in your hand in bucIi a
rie ue.
manner ne to keep the spinous prnce-»efl on tlie table, while the other lines arc at a right angle, you will obeervo that the well limb can be prei'««l down to the table mj that the popliteal rimoo will touch (»ee Fig. 146), The diseased one can be preasod down to nearly thii« jiotfition, but, before the popliteal space touche.4 tlio piano, you will notice tbat the peUne bucoinvs tilted, making a curve in tlie lumbar vertebne so that the hand can be passed be- tween the child's liat-k and the table (•« Fig. 147).
EXAlIfNATION IN FIEST STAGE.
2-15
Tbis arching of tlio epiiie iu manir cases at tliis early ]>eHo<l in t3io (liHL>»i<4r is BO ^ight tliat it would be entirely ovi-rluukud were tlie cxnminalion niiute ujKiii oUiur tliAn a 9olid flat xurtace.
Oumplfilo fli-xion at this period of th« di«Cft»o ik hIh> impos-
Laible. The well limb eau b« flexed 8o as to bring the kiie« in ooit-
tnct witb the cheet ; but the diwaaed limb utu pmbubly Iw flexed
only at a right angle or a little mure than b right angle with the
fm. h;-
bodj, before the pelvis will l»e raised. The moment the pelvis begins to riae, that moment you have reached the limit of flexion.
Addiii-tiuu 16 very limited iiKl(M.-d. The diM-jiMnl limb cunnnt be crosaed over the opposite limb, and even by the time it has
ehed the median line the polvi!^ begins to move, sliowing that have rcnehoil the cxtmme limit of adduction.
Abdnction, partieiilarly if the limb is slightly flexed and at
rtbe sante time rotated outward, can be carried to an extent »otno-
rhat greater than a<ldur1ion, but not to full abduction, before
the pelvis will begin to move, ^bowing that muncular rigidity is
present.
Now, in wluitet-er po»ition the ntlceted limb mniit l>e held in order to bring the pelvit^ and tnink into a normal relation with each other, that is, so tlmt the two linue mcntioneil shall cro0» e«eh other al right angleii and the spine be upon tiie table or floor — snch po&itiun indicates the deformtti/ present at the time of mnk- ing the examinalinn, and the utage at which the diK.-asu has arrived.
In the first etage, tliereforc, n« can be »een in these caws before you, the tliifjh is flexed very slightly upon the [wlvie, and very slightly ahditcted ; and, the pelvis being hM jMr>-feetly afili, very limited motion ean be made at the joint, when i^Iight exten- fiuii is nude npon the limb. vVltempts to cJit^d the limb beyond a certain point, aa you now ol>«er\'e, tilt the pelvis ; flexion lieyond a certain point — in tliis case not quite to a right angle willi tlie body, in other coMe it may be to more than a right angle — tilts
M6
DISEASES OF TTIE ntT-xtOlKT.
tbo pchis ; wlioreofl npon the welt limb extension can bo made coiii{ilete, ftiiil Hexioa complete, ao w to bring tbc knee against the trunk, as rou Me.
Abduction, a<l(li)dion, and rotation, arc a]«> limited, an yon oh- serve, and wlic-n carried beyond a certain [>i>int the pelviti at once inorea with the liiiiU giving llie patient an appeamnff an if t-oni- pletc Aiichyloeie bad taken plae^' at the hip-joint. Bnt (here is no real anchylosis present in tbie sta^ of tbu di«ea»o. There is MiehyloaiK, perfect and complete to nil appearance, but il is due simply to niasciibir rigidity. For, by placing the band upon the polriit^ and making gentle exteitsion n]ioii the limb for a few gee- OTids in the line of the deformity, motion can Im made at tbu jiiint witliout canning pain ; but tlie moment extension in removed limited motion causes pain, the muscles suddenly become rigid, and the child can be rolled around Uke a solid marble statue.
If the disease, however, ban pa«Acd beyond the first fitage, and effusion has taken place, then abdui-tion in nmeh more niarkisj. and flexion tM much stronger than in tbc tir^t elage, but the i>ri'.u!iar feature of the deformity then is evemon or rotaiioH of tAe J'oot- OHUeanl. Thotic Hymptoms will be more fully considered when ve come to speak of the Hyinptotnii of tlie second rtage.
Another eyiiiptom of the tint etagc that is too often over- looked is atrophy of the thigh or entire limb. Therefore, always compare the limbs by actual measurument, for the rapidity with which atrophy takes place in »ome caaea i» really surprifiing, and is due to tlio direct influence of immobility <if the joint. The symptnmjs as we have «ihidte<l them thus far, all jwint to one thing, namely, fixation of the joint, restraining motion aa miidi ha possible. This will occur without the slightest recognition of puiu on the part of the patient, ami is due to wliat Mr. Barwell terms "joint-sense."
The symptoms of which the patient will complain are ten- derness and pain. TendoniMs is usually well marked, although sometimes it is ucccsBary to make a thorough examination of the joint before its pre«etice can be detected. The diM.-asu imiy bo situated at any part of the joint-surface, and we ought, before denying tlie existence of tcndenieee, to make prcBsure upou every part of tlie head of the femur or acetabnlmn that could have been iarolred tn the original injuni-.
This can be done by placing the thigh in all poanble po^-
4
4
SYMPTOMS !S FIRST STAG!
241
tioos, and at tJie same time niiikiii" prc«Eurc npnn tlie head of the bone and tlic acctabtiluni hy orot^ding tti« ortk-ular eurfaoce togoUier, in all pomiblo directions.
In addition, pKt«nre shoald be iiinde njxiii tlic great Iro- < chanter in order tu bring tlio timdof the femur and aoelabolani riu contact fmm that direction.
Again, holding tbo knoe nHth one hand and fixing tlie pelvia ^with the other, press the tliigh-lHtne upward. Tliis mauuiuvrc snvndly catucw pnin, which can bt> dctettfd in the patient's face, even when he denies he feels tt. If the nmnn^uvrc doaamse '"poiD, tbi-ii ob»er%'e whvtlior or not vxtcnaion rulievee it. To niake yonr examination doubly xure, if tendertiew liax not already bceli dflfctwl, ewce]t with the thigh its largest jioBeilile rirde, by which tneiinii the bend of the bone cannot ixM^ibly eM'tt]>c being brought in contact with every part of the iieetabiiliim.
Pain may or may not bo experienced during the ^rst stage, independent of motion or prei^iinre upon the joint inirfncei*.
In thoij« (.'AM'v: where the diBcaf^e nianifdite iti;elf immediately after the injury — whi<'h caws are jimViably either synovitis or perio«.titiit of the great trocbiintcr — tbepain i» also immediate and constant, and freijuentty excnieiating.
In other i?i(r(?s, when probably the teat of the disoaxe is in tlie articular buiiellii — either beneath the articular cartilage of the head of tlie bone or the acetabulum — pain is developed lute tn the firat, or even not until the second stage.
This pain may be referred more or lees definitely to the hijv
joint and its surrounding ti««uee, or it may bo so entirely located
in the knee a» i^onietinies to completely mislead the feuriici.n in
-his diagnosis. 7 have many times seen the knee bliricred and
itod for moiitba, when there was no diaease whatever at that
"joint, it lioing merely affei'te«l by the discnee i« the hip.
Jtr, IJarwel! explains the knoe-pain as follows : It is produced ft) by direct irritation of the nerves paeaing in clow oontigitity to the joint. Tliewj are the obturator nerves, the sciatic, the gluteal, and perhaps the anterior crural. It is produced (^a) in coiiseqiietice of an obscure sympathy between the two ends of the bone, or even direct projiagation of the intlnnnnstion from one to Um other ; and (8) by spasm o( certain niiiicle^.
Soch, gentlemen, are the symptoma by wliich you arc to rec- lEze hip- joint discaao in the^fvf stage.
SMS
DISEASES OP THE HIP-JOIHT.
No one of th«n) alono is entircljr (liaj^ncetir. The oertamtj of the diagiioeu depends upon » careful coimtdoration of all the Byniptomii described.
W© have thus dwult upon them at »c>nie lenjrth, because many of them differ from thoee of more advant-ed stages only in degrw, conjieqiiently require only one description ; but more especially because it is in tliis ftage that the diagnosis is uio«t difBcult and important. In the later i^tages, it i« ahiKist impoiisible not to rec- ognize tlie diseaw, but the patient has then endured grwil kuSct- ing, and perhaps irreparable mi«?hit;f niav Iinve resulted, which might have been oasly prettenUd Iiad the true natun; of tlic dis- ease been early recognized and properly treated.
LECTCRE XIX.
DtSEASK or TUK JOmiS. — MOBBl'S COXAKIITB (oOSTDTCED).
Symptonu (rootlttued).— fiTraptoois of tho Second Aa^ «nd thdr EiptniMiiM.— Cmo.— KjTnptoDM of ilic Third SUgc.-.-DiK«ulon or thvQanilian of DwbcalkiB in d)i* Stag*.
Gkntlekex : To-day ve will continne the history of hip-di»- tam by first stiuiying Uii' symptoms uf the second sia^
The iiymptoma described at our U«t lectnro ae belonging to the first stago — namely, pain, teitdemeea, swelling, atrophy, and limite<l motion — continue into the Kcond stage of tliu disease, but are generally increased in severity.
Tb« [)«culLnr position of tbe limb Ji^vM to the second stage of the disease the name " apparent lengthening,^ but I prefer to dudg^ iia(« it a8 the tt$go of effusion.
If you examine tlie patient while in the standing position, u ill our previous examination (»e^ Fig. Hi), it will be mitiovd thlit the foot is now eoerifd, and the leg is n liltie more dexed upon the thigh, tlio thigli is a little more flexed upon t]ie trunk, tho obliteration of the gluteo-fenioml creaeea little more nmrke<l, and the entire Umb more markedly aliduvted.
Tbe foot upon the affected side i« «om«wltat in advance of the
SECOSD STAGE.
one apoD the xound side, and the weight uf the hody of connte 1 thrown npon Ihp Utter, as wen iii k"ig. 148. It is this tilling o^ liiw [n'Uiif thBt prudticva the uppureiit lengtheiiiiiff of the Urn Bt careful nieasarenient, howcvLT, it ha* hocn shown tlmt lutiglhctiiiig whMtcTiT it) pniscnt, hut on the coiitmrj-, hy reason
Tn. I4«.
of the ohange of the relation of the anterior snperior apine of ilinrn to the fciitur, tlie distance from the former point to the ml leulud is slightly cliiiiini.slied.
Whr, tlicri, docs the timh lesamo thi« peculiar positionl does sn for the pnrpow of ficcoininodating the eflfii&ion which hits' tnken pliwu within the capsule of the joint, and the deformil protlnoed in exjikined in the following manner :
If j'ou will refer to the anatomy of the liifvjoint (Fip. 139), will be notioed thnt the ilio-femoral lignrneni, extending from the anterior inferior spinous process of the ilinin to the trochanter minor, lies in front of and \» lirmly united to the capsule, from hImjvu downward, forward, and inward, in Kuch a manner na to cause it to remain in close contact with the bone. There is □'
h
DISEASES OF THE HfP-JOINT.
mally a very t>mfiU qtutntity of fluid witliin the cap«iile, and joii euinot increafle tltal amount without also intTCaiiiiig the capacit,v of the capBuIo, whit-h id done by unfoleiing it, an<i that can only bonoeomplUhed by nhductiiig aiid Hexing thv ihjgh, and rotating it ontwanl. That is fxiit-tly wlint occurs when tJie joint is in- thinic-d and etfiLiion takeit pt:u?e ; the rapHulc is unfolded and it« capacity' is thus incrvneed, i<ini]>ly to accoinraodatc the fluid effused witliin it, and that necefiftarily gives rise to distortion of the limh. This is the rea«0D why the limb is alwavK slightly flexed, abducted, and rotated outward. If the effn&ion becomes very great, the limb is more flexed, more abducted, and more rotated outward, and at the Htnie time more fixed. The limb may 1>e so rigid as to be apjtarontly anphyloeed, hut it is only an ajuuircut anchylosis, and simply de])eudit upon a distention of the cap.-mle and rigid muacu- Ur eon tract ion.
lliut the mere prosvnoc of Itipiid in the perftytly closed joint \» capable of producing snch immobility and distortion is clearly demonstrated — 1. By tUeexpsrimcnlsoif Prof. E. W. Weber, who injected the litp-joint through an opening in the pubie bone. Ity this procedure he invariably produced everaioit, jhxton, an<) ah- dttttion of the thigh, and immohitUy of tlte joint. The latter was eo complete and nnallerablc that an attempt to overcome it either bun^t the capKular ligament or drove tlie stopper out from the artificial opening like a pellet from a pO[^nn ; 3. By ptmc^ uro of jointti greatly distended with fluid, in which immobility and tliift peculiar diiitortion are both present, mobility and the proper position of the limh are at once restored. It slionld, how- ever, l>e borne in mind that these symploms. c%'erG!oii, abduction, and immobility, may Rometimes be continued after the ia]i8Hle has been ruptured. Then they depend npon the altered condition of tin oapsnle and Hurmnnding part«i, fi»r the«^' have boeome Ihick- enod aud adherent to each other, consequently more or less un- yielding, and necewmrily retain the part« in their malposition.
The clianwtcristic sxinploms, then, being due directly to the presence of liquid, synovia, pus, or lymph, within the rapsnlo of the joint, the «ec<Hid stage is properly called the Mage qfe^uglon. The pain in thin »tage in mnch greater than in the first, and is aggravated by the inability of the cap»ule to perfectly occotonio* date itaelf to the increMed amount of effusion.
If yoa will seize the knee of one of the«e patients in t3ie i
ASCnYLOSlS FROM EFFUSION.
S51
und 8tngc of liip-iluoaBO, who itt suHvring iiidosrribable pain, and m&ke slij^hl estenfiion m iKg Un* of ifu/ drformity, and, ut the Muno tiiiio, sli^htl^ evyrt tbe limb, vou will givo almost io^tutit rcliuf, eiiiiply becaiira yoti atwint iii accommodating tlie cnpaoitj of Uko cii[<«ulv tu tliv amount of tliu elTnsiun. If tbv liiiil) is abdnc-ted ur oxieiidod lit tlio line of the deformity u>HAoul the evonion, the ttliglito^t di^^^rce of udduction vrill eauM pain at oncu ; but, when everted, it may W abdnct«d to a trifling extent without caufling pain, aa you see in tliiit <!a«e.
But why doe8 nut the joiut fully ac-commoilate itself to the increased elTiiaion vrithiti it, and bow do we acounnt for ibc pivat p«in in tliit 8l«^i It is bocanite there is a c-on8^tnnt titnigg]!.^ gtnng on between the addiidor iiiusclw of the limb nnd the ovcr- distendfd oai^ule. The addiirtoi^ are excited to cnnstflnt I'cn- tractioni) by tb« iiritntiun rL>uitinmii«li.-d tu tbvm by tlic nrlicular bmneh of the obturator nervi% which iiiimcdiatcly KUpplies the joint. The iiction of these nntscles, however, is resjfited by the aliduclion and evcrfion of the linib, «u»«cd by ovcr-di^ti-nlion of the cii[)6ulu. Tlic limb csunot yield to the traction of the addiio tor«; neither ntn the joint peKLtotly accoinmodiite it«elf to the increased effiLiion, and tbitt <!onfitant struggle rauseo tlie intenw pitiu which U rufurnid to the point of diMribntion of thi" norvvti involvc-d. It otinirs nearly always at night. The child boconies completely tired out. droiw off to sleep for a minute or two, tlie mUM-li-8 \mii their huld upon thu limb, the limb ftille, causing niovementi4 at the diseased joint, and inManter there is a epaa- modie coutritctiun of the mu6ck-« which bringfi the diwased Rur- faces together with a anap, and the child immediately awakea with a shriek. Thu mother or nunc lia»1enK to tliu bcdudv ; hut, perhapA, bvforv it cin l)c rcaclied, the child has dropped off to aleep again, an<i this is repeated over and over.
You i-ji« lianlly appreciate Ihiit fact, iinlewt you live in the bocipital, or stay for eeveral nights in a house where there is a child Huffering from difleaHC of tJie bii>-joint in ihia atage.
Thia pain, moreover, ti> self-perpetuating, for the irritatioa of tbo di^easod joint CRiteoi the muscular rontractioUiS and theee, in tuni, aggravate the inflammation and dei;lructive cbangm within the joint, by coitHtant prea^nre.
The continued contraction of tlio adductors voiy frequently render* them bArd, thin, wiry, under the linger, and able to
s$a
TSEASES OF THE IIIP-JOIKT.
resi&t Any nttvin])t to move the limb from ita poation. Sonte- titii«i) positive amtrticture takes i>bi(.i>, imd tlicn »ubciitAiicoii8 sec* tiou must procc'le niiy Attempt at extenisioii, as the following caaa' illui>tratc«:
Cask. — 8al>ina D., nged six, was bronglit to Bellevno Uoe- pital in .Tsnaary, 1^^. She wiu » wi-ll-runiiwl diild, an<] liad nI»-i»j-8 been perfwtly healthy until Auguiit, llSftl. Hvr mother erutes that die fell from thu t»b^>, irtriking upon her right liip, wbiuh catwod her cDngiidorable pain at the time; in b few iliiyB ' she resumed her pky as if nothing had M-ctirred. This vttn- United nntil early in October, over two months from the roceipt of the injury, wlien Khe wan atta4>ked with a severe pain in her knee, witb a noticeal>le limp in her walk. Tbu mother thinks tiw limited fur sinnc day* before hIio <^>mplaine<l of the pain. The pain was mnch more violent at night, the thiid frc<juently awakening bor parents by her sliarp tcrcunA. She waa taken to St. Luke's Ilagpital, where she remained more than two months, extenMon Ix-ing kept np during tlio wholo timu by weight and pulley without any 1>enefit ; on the eontrary, all her aymploms were ngfTT'ivated.
She was admitted to Belleviie Hospital, January, 1868, M bcfora nionttoiied, whc-n the following notes, as recorded by the honse-^urfiicon, Dr. W. F. Peck, were taken : " Right foot, when she Etauds ere<-t, is four and a half incbca from the floor, and very miicli addncled; the leg h Hexed upon the thigh eligbtly, and Uio thigh upon tliu jtolris. {See Fig. 141t.) When the slightest motion of the fcmnr is attempted, the pehns moves with it, as thongb bony nnchyloEis exli^ted ; conMant [Min at the hip-joint, which is increased by precsuro ; leg atrophie<]. Exten «on WA8 a))])lied for a few days, but tbe pain waa m great, and no improvnment in poaition following it, that Dr. Savre aabcota- neonsly divided the gracilis and a<lductor tongue muecles. Tbo wounds were immediately covered, and moderate extension ap- plied to the limb. "When comparing the length of the two leg*. tJie diseased one was found nearly an inch shorter than ita fel- low.
"Januar;/ .ItVJS. — Tli© extension now give* her perfect rdief i from pain. Before the operation, it was torture when tbe extoD- ' sion was eontinuoniOy applied. She eats and sleeps well.
"F^ruar'j id. — Woimd made by the tenotomy perfectly
OASE OP OOSTRACTPRE.
9BS
liealod. As long u extension is kept ap, she fvels no pain. Appetite aiid cUgeetiou perfect.
"l(i/A. — Siivrt''» Hhurt liip-«plint wu» applied tJii» aflemoofl, when elie wnlkod withont difKoult^.
^' April 4M, — Piiticnt was bnioglit to hospital to-day, to bave lier dre««iiigH reappllod, as tlic)' bad uut been moved rinoe slie
m. !•.
Cw iw.
left t)io liospital. Imprnvenient most itiarlu-d ; iii^teud of tlie peevish, iirilalile dis)>oHition she manifested wben first admitted, tihc iit now ob<><Tful and linppy, and tlie {{low of heultb i« upon her oheeliB. Iler motber Htatea that tibe ban not complained of pain fcinco tiic Mi llie boflpital. Her pritsent condition can be seen in Tig. 150, taken from a pbotoj^ph."
Tlie immobility wbicli in present in the Mcond »tage, rnult* in^ from orer-diiiientii)n of tlie capenle and mnscular rigidity, Is oBually well marked. Tlie muscular contr*clion, however, is reflex in character, and is Jor the purpose of keeping the joint parftetly trtiU. Tlicrc is apparent anchylosis, but it is only ap- parent.
Motion is mnch more painful thuii rest, even vheo rcet !s ac- companied by prensure proclaced by muxcnlar contraction. Ilenoe the patient, naturally choosing the least of two evils, obtains
2S4
DISEASES OF THE HIP-JOIITT.
itutt uf the part bj- mesiiit of tlii« initMular rigiditj, nlthoa<;Ii !t w done at the expense of abeorhiug the tis&uoa by prc&aure, and at Uie same dme giv«« rise to Itectic and exhauAtion.
The flexor musclce of the (high, the puctineits, the tensor va^itH! fttinoris, and the roctns femoris, are so timilv contractixl that the whole pelvia moves u^mu the opposite acetabulum ; in ehort, the ilium of the opposite aide mnj- b« di>liiK-tly »een to move when any attempt is made to rotate, adduet, or alxluct the difwnsed limb. Even under chloroform, tliiK motion takeA place tttUfiM J&m erteriMon is made bufon; the trial is be^n, tm I have seen in ecrernl infttances, and even then the motion h onlv very limited.
Ca*b. Hip-Jotut /JwAzft.',* Second 8ta^. — Tlie following case is n very good illustration of tlie inefficivmT' of thu phin of treatment raggeated by I>r. Joseph 0. Hutchiaon, of Brooklyn.
Jnlia Swensou,agcd eight years, 772 Faltou Stnx-t, Brooklyn, was brought to mc on April 4, \'6%'i, suffering from Iiijvjoint dio- eaM! in the second stage. Parents both Iicalthy ; live other chil- dren, all healthy. The patient wtK aU-ays licnlthy nntil fonr yean of age, when she had K^rlet fever, since which lime she has been delieate.
In Aiignat, ISSI, tlie child had a fall which cao^od her to cry a grejit deal at the time, and soon after slie began to limp ; the mother took the cliihl to Br. Ostrander, who sent lier to Br. Joseph C Uutchieun.
Br. Uatchison saw lier in September, 1HS1, and Jie mother statei' that lie diagnosticated it us hipjoint disease, and orden^l the Uatehison elioe and a pair of crutcbcB, and direeted that the child be made to walk thrve or four hours daily and swing the diseased limb.
The mollier utates that Dr. Hutchison saw the child fre- qnently at his office during the ensuing winter, and that ithe fol- lowed hi« directions as closely as possible; but also s>tuies that the child desired to sit Mill most of the time, and was diMnclined to walk with the leg enspendod, aulves comjwllcd to do so.
As the timb was becoming more distorted, and »he wae Buf- fering more pain, fnM]ueiitly screaming at night, the mother brought the <Juld to me. As I had tried Br. Hutchison's plan of treatment in a nnmber of ca»cs, in each of whivh the result was precisely the same as this case presented, I refused to treat
S55
Uwltlioiit tlicconWDt of Dr. UutcliiHon, and gnvo tiio moUiora nute to Dr. Uutdiison, n)(ia»ting luni to make aii examination i>f clio oliild, tliat lie iniffbt bco hor tltvu preM.-ut condition. Dr. lIutoliiHuti very kindly* returned tlie patient to me, re(|ucHtinj^ tliiU I would take cliur^^ of tliu «iut), stutiug tlutt tbu mutliiT luu) negjeoted to follow out bis principles of treatment ofBcientlj'.
April 12, 18S2, — Patient returned to iiic witb limb fluxed nt botli bip und knii-, tbe foot being everted as seen in Fig. 150 a, from pliotograpli ; the limb wait appuruiitl^ iuioby]o«od uiid tbe pittiviit Htiffering itiKsiiHO pain upon t]ie sliglitest nioroment at tbe
n»iMj.
no. IWa.
joint. Wbon placed Dpon Wr criit^ltcH with the cleviitvd dtoc, there was n very Might improvement in tbo position of tbv Umb, IM M-on In Fig. 150 b, from phottigrapli ; but the least movement at the joint canned intcufie pain, unlcs)i cston^iiiin was made bjr tbu luuid prcvioaa to tbo motion being given ; «>liowing that tbe weight of the limb alone was not mfficieat to overcome the reflex tniUKiilur cuntnu'tions.
Tbe patient retnmod home tbe eamo dar, att4.-ndcd by my eon, wbo appliod cxtviiition by tJie weight and pulley ; tnaking tbe
26«
OF THE BIP-JOIST.
traction in the line nt tlie (Jcformity, (jiving diroctioits for the line' of traction to 1» lowered d&y by cky until tJio limb lilioald lieoonie perfectly Htraiglit, without proiliicing a curve in the ftpino — * blis- ter, two iucheti by tlireo inclicK, being placed over tliu joint.
May lid. — Limb perfectly titinight, child liaving bucn frw from pain tifiicc vxtonKlon wu nuido ; long hip-splint now applied.
June 1£M. — Patient at ofiioe, walking <]iiit« well, increai)«d In tlcdi, motion ut joint quite free, and without pain wbcn the inetm- meut was properly adjntited.
During the siiitiiiier the child caniu to my office «vvcnil tiniM, out no change was made iu llio treatment, as there was marked improvement at each visit.
DeeVMher Qf/i, — The patient was pri«cntcd heforu tlie eluse at Bellevae tlospital with aplint applied, as seen iu l-'ig. ISO c, from
no. una,
fi*. itoo.
photograph, being (o perfect health ; and, upon csroful cxatmiw- tlon with the inAtniiiicnt removed, the motions of the joint were fotmd to be alnioet perfect and tlic cure coniplelo, with but half an iticli shortening of the limb; with that exception, there was no duforuiity, as seen in Fig. 160 ij, from photogmpli ; tld« being
THIRD STAGE.
257
Uie only time the drcseings !utd been removed Binco tUcir upiilicn* tion on April 12lli.
The plnn of treatment suggested by my friend Dr, Ilutebl- 80II WW 80 attrnctive, oii iic(>ouiit of ilft Hitiiplicity aiid economy, thtit I at once adopted it, having eon^dotiix- in liis ubet^rvutiofw; but after re|>eatiMl IriaUj finding in <-vfiry insianop results pre- cisely ettnilar as in the case here recordud, I vra» conipcllod to alMindoii it. T}r. Steplion Smitli, who was nt that time on duty witli mc in Itellevuc Ilopita!, also applied it iti n nuniiier of cases ; and he reports to me tliat tlie results in all instances were oxaclly Mimilur to niy own. I am thurcforo rt-IiK'tanlly cumpelled to abandon lIiU plan of treatnu-nt, altlimigh, when timt proposed, I gavv it a nio«t cordial I'udoreemt'tit bcforu I had had any prac- tical expcrienee with it.
Li^t IMS next study the symptoms of the tMrd stage
If tlie disease is not arrested, the acctabulmn becomes per- fonite<l, or ulcieratioii aiid rupture of the cnpe<iile talto place, and tbu itnpriiwned fluid escapee into the surrounding tissues. Wb«n this )ia8 occnrred, the diwMO la in the third »ta{!^,«nd tlic patient is comparatively froo from pain. In the majority of insumctw tlie effiif>ion soon biirrowii in varioiu directions, and finally pro- duces Olio or more opc-niiigs upon somi- portion of the tliigli, and in some instances at M>nie distance from the afFecIcd joint.
It \» often thought that a great dual lias Iwen gained hccaufiO the patient is so much more pomfortable, after rupture or perfo- nitii^n has taken phtcu, wheniao the diHoaeo luu only gone on to tlw third stage, in which effnsion takes place into tlie surround- ing etaxiic tiwneH iuHtcad of being retained in a closed BTid inelas- tic aac around the joint.
Almost immediat^ily, however, there ii> a nmrlcod change in tlio chaniclcr of the doformily. The limb is now addueted, inverted, and flexcl, very often at the hip only. The pelvis \% niteed upon the afti-etcd side, which brings the corresponding natis above that of the s<.)Rnd side, iMtmin); it lo pntject Imckwani, and now the gluteofemoral fold !>; higher than upon the (-oitnd i-idv, or ubliter- Bte*l altt^ther. The pmition of the limb, as yon ««e, h in wo«t nvpccts the reverse of that seen in tlio second stage (m<* Fig. 151),
The change in position U due to t]ie fact tliat the fluid con- taiuLxi iu the cavity of tlw joint has been evacuated. The dis- tention of the capsule, vhich was the mechanical cause of the
DISEASES OP THE HIP-JOINT.
everdon and abduction of Uie Unili, tiaving been relieved, nothing now obstructs the full action of the adductoni, and ibe iimb ia therefore adducted aiid incfrt^d. Ttio eqailibrium of the bodv is presen-cd by raiding the jH-lvis »o as to brin); tlic centre of gravity over tb« eound foot. The loaa of etilMtancc in the head of the femur and the scetabuUim acconnt« for the actual sliortcu- ing that occurs, and the tilting of the polvb makes it appear even
Pn. IftL
CKfttor than it is. Sinec the foot of th« affected side no toui'hoe the giomid. the flexion of the knee ia unn«oe6rtn-, therefore often disapi>cai*.
This change from the second to the tlurd stage is mdde. when there are iio ndhesionn in the snrrriunding tiaoca (•« ready indicated), and when the opening in the capsole te ll and allows of the rapid and total e<Mnpe of iu contents into (■ummniliiitr tisttiit-^. Hut if the nipture is verv small, perl tiswurelike, the thml oozes out by slow depw*, conMfiuenlly change in the defonnily will take plaec slowly.
I liflvo seen tlie change talte place io a single nigJit, while in
OOUPAKISOS OF 8EC0SD ASD THIRD STAGES. Jfifl
oUior eases it irui>' require wo«kB for its contplctloii. There are extreme casee in wbich this i-Imngc does not taku plan.' iit all, ftltbongh tho offiLfiioii luui t;ik>ajK.-<l fruiu the juilit. Thiiiie are lliv cam in wbicli tlie liead of the bone has brokun tbruu^b tlic- iut- tabulum, and is bvid linnly in Ibe »i>«iting, ^r tliotw in wbicti in- dauiiuiitiirj wlboBiotiH, uitteopliytcA, etc, bave taken pUoe between tlie bones compriiiiiig tbe joint, holding it in its TbIm poBition even uftvr ibc raptuilu ie niptiired.
Fitr eonvenioace of reference the ej-mptoins of tlte MMfuf and iAir^i Ktiigc« uf hip4li«!»M) arc placed »ide bj side below (Buner).
SM^iulSlafe. Umb (oppArwitly) lon^r.
* flaiad in both Joints.
foot toiieliM tbe ground with mJo. tow everted m in fracture ofovci:.
IVItI* lowcved on dtictuod ildv. " pn^«etMl forw&rd. " angh) uf inctiuklitio ncule.
Natis liiv anil Ant. [liiM* IbUc nat«e liMlliwd toirinl of.
teettii Ma, 'Pain moat brteiiM.
Third .H<v«. liinb iiborter. " addDct«d. " inrurlvd.
** ll«x«d 111 ht|i-JuiDt oal7 ; raaj be flexed ftt kn«c-juiiii «Iik>, bat not neoewATiljr. Toot touehve iritli 1»II ooljr. Tow iarert^d a» In poetvrior mperior
laxatioD. P«Kte raised.
" prcfjcctcd backward. " angle of nuJinatidO nlniMt rlfbt. Kalb high and round. Line* Inter natce devlatM from affect-
l^d Mdu. Pain pttttljr dim I II Idled.
It wiH loii^ bolii-vc-d ttiat this clian^ of i<,rinptoiiiH was due to a n-al dislocatinn of tlie lioad of tbe femur upon the dorsum of ■be ilium, brought about by the gradual dwiniction of lliu upper ritit of tbe aoetatmluni 1)^- carit«, thus allowing tho head of tho bone to encaiH; fruiti tbu ewket.
The first to cImllcnBe this thoorj- waa tho late Dr. Alden Murdi, of Alluiiiv. New York.
In his pnjM-r u(K)n this suliject read Itefore the American Mitlical As6n<-intion. nnd publi«>lie<l in their " Tranaactions '* for tlie yenr 1K53, he cttubliebed the fact that di^ocalion doe» not rrnlly take place.
Vt. Mnn-li iaid : " It has been my privile^ to examine tho ipoeimens of iliU disease in the London Univetstty Uoepital Mn-
S60
DISEASES OF THE HtP-JODTT.
Beum, where Itfr. liellV morbid epcdiiictis arc dvpositcd, and yet I pould discover no preparation of "hipKJisease" where it ap- p«Hr»J in the lea^t degree as llioiigh thu Luad of thv fviiiur wis luxntMl during tlie life of the patient."
In fact, the profession in iliix coiiiitrv nrc indt'btt-d to I)r. Much for tli« iiret clear, (.■omprehenftive, and correi-t iilateinent of tJM pathology of tliis dUeaw; and the l)iwi« wiu laid down hy hEni for the- proinT phm of tnwtnient, from which all improve* ments in tlie treatment have flince been <)vvelo}>cd.
Wc need only refer to the following well-knnwn test-liooks upon wirgery to show that onr best tiutliorii ii.-« h«vo alwajn oon- aidcrcd tliu ix^-ouliar del'unnity, which occurs in what has been deeoribed as the third Htage of t)ie diMui««, to bo dependent tipoti A tru* liirnt/'fm of thu hend of the femur upon the JorBum of the ilionif and not upon murtoulnr contraHion, twisting of the {N>)vis onLuged H4!Ctnbulum, and diminished head of the femur from pmgreesive absorjition of buni'!, which I believe to b« tlie tnic expLuution.
It. Dnilit, in hie "Prindpl*.'* and Practieo of Modem Sur- gerj," eaya in bis chapter npon lii[Mli»easo : " But, if the dUease proceed, it i« sut'eceilLHl bv another kiud of tdiurtening, caui^-d either hv the destraction of the neck of the femur hy cariea, or (ae is more eomnionly the case) by tlic dcBtructiuit of tlio iicetAbll- luni and capiiular ligament and di«localion of the l<m« uptcard by the mnscles^''
Janieu Miller, in bin "Practice of Surgery," under the head of morbus coxariiis, save : " As disorgaoizatioii advance* within, the joint become« more and more loose, and dittoouiion may occur by mvncfdar aH'xm alone, without the intervention of a fall or other injury. Tlic didocatiuii is nsnalty upward OD the dorsum of tlie ilium."
Sir Charic* Kell, in his "Inetitutw, of Surgerj-," remarks: ** Another peculiarity, in the position of the patient with di»cn«cd hip, is tliat of tlirowing the thigh of the affected side over the other, that Uie head of the thigh-hone becomes as n lever loaded At the lower end, by which tlio upper end is raised and the pre9»- «w tahfn off the itifiamed glmotd oai^Ii^. It is a iwitilifin of ifrMt reli^'; but Uio coneoquvnco Is actual dislocation in extreme caeee."
lUron Dupuytrcn, in the *'Injtir[ee and Diseases of the
SCPPaSED DISLOCATION.
961
BoDM," Biibjcct, " Congenital Dislocfttion," says : " WTiatevcr itnporUuine may l>e uttacbfid to this diMlocwtioD in tlic ftbtttravt. it kdeeerviitg of ^lil) more sttciition oa account of itfl |>rt«eiitiiig «II the KigiM of tuxation eonaequent on diteate of the hi/tyot'nt, with wliicli it hna aheaya baen iMt\founded" Iti wnotiibr pliiec li« iviuiirkH : " It " (congenital dislocation) " does not include that painful and cn)i>l dij<eB«e of tlie liip-joint wtiich usually reBult« in gjamtantoiit dislooaiioH qftAe/emur."
Clii'tiii». Pciri^, Li*ton. Samuel Cooper, and Gibson, all agree witli the autliore above quoted in regard to the KitontAtiiwus luxa- tion of tlio femur ill tliv hitlur mU^-h of htj>^iiteaiie.
And eren Sir Antley Cooper, iu his livaliHc on " Dislooationfl and Fnicturcft of tlic Julnt«," m\6 : " l)i»looation8 iiiay ariite from nl<-ention, as vo freqaently find thiH otatc of the parte in the ]ii|>-Joiii[ : the ligament* ulcerated, thv edgu of the aovtuljiiliim aheorlied, the head of the thigh-bone changed both in its magni- tmif and tigni-c, e»eaplng fmin th« acetabulum upon the ilium, and thuA forming for itself a nt'W wdtet."
Yiit, none of the above authors, although so positively stating that luxation oocur>i in tlie discuc, have Bustainod their SMHertiotu by tliQ evtdeoce of a tingle jpottmorUm examination.
These refereDC«« could bo iiicrawcd, but quotation bait been mode from a sufficient num1)er to estnbliiih the fact that the idea of Insation in hip-diAoaite lian been one of ahnt^l univerMl adop- tJwi. Yet, whenever any one of them lias made a pogt mortem, or baa cut into the joint for exmiction, ho has invariably fmind that no luxation had t«ken ]iUco, but thi:t thu "lioad of the femur was still within the iMpHuhir ligament," much abi*orljwl, probobly, and frtijuently aeparatfid from tJie ahaii of tlie femur entirely, thua jiermilliug the trochanter major to dlip iijton the dorsum of the ilium; and this no doubt has been mistaken for true luxation. I have i^-eu this condition uf the parts very many tiines, and seen the mistake made by most excellent sui^;;eon». At other time* the an'tabnlum has been found " muub enlarged by abtorptioKy and extending upvnird and bochtpard, an if Natunt •haA itiadcBit attempt to form a neie joint in this direeiion"
As the npper portion of the aeetabulum 'w<A»orhed by the con- tkuU pre«#urc, tiio periosteal inflammation, which h prevent at (lie same time outside of the joint, \» eonstanttr throwing out new material, and wc even liud finn otttouphytos of cousiderablu
2$2
DISEASES OF TllE HIP-JOI>T.
tiiAgiiitadc, Tbus, as the proffremw ahmrption goes on witbiti tlio joint, thcro U a conMmit <iejM>»it>on taking jtlnoe uuUidc uf tbti joint, bv wbicb tneaiis tbe acetahUutn with the aqteular liga- meiU tind contents in ■» it wi-ru, tilippvd upwaixi ujk>ii ibc dorsum of tlie ilium ; so tliat, in»U.'<id of a lu-zaiivn of tho hip, we have in fact a diiipUtoemfnl i^ the acftabulum iitelf. (See Fig. 132.)
Pm. 1U.
As long as tbe acotabulum rt-tikins the remnants of tbe head of the femur M-itliin Its cavity, it aliotdd not be cttUed tuxatiMn of the fvninr. Now, if the disease is of long Bt«n<lin];, Uic ace- tal>ulam is frequently perforated, tlie oynovial membrane and eartilageH more or less destroyed hy uU-eratiun, tlie bonce become carious or necrosed, tbe lignmentiim teras is invariably destroyed, and ibe joint is li!l«l with pus; or tin , l[i.i.1 a- li^iuiieiit itiHV Iw perforated by nk'eiiitiunut one or inoit- jl.-i i - ,liiini|;h wbitb the pus liHs escaped, and thia generally occurs at tlie inner and lower border of tlie HfCtnlmiinn. Tliix. mvnrdinji to my obttervation, lias bw-'U the real patljolo^iral couilition of this i*t«gc of nil the i-aMM that I have esnminej, and it aeconiits very Baiisfactorily for tiui shortening and other appearances of luxation. If, for example, the head oi tbe femur in dimini^hed by alwwrption three-fourths of an inch in length, as is often the casi.-. and the acetabulntu i» extended upward and backward to the same amount, the gluteal
POST MORTEM.
SOS
and other n)ii«clcs holding tliu bones in clovv louUict, there will I pnxliiced an inch and a half itf ^lortontn}^ of the limb j and twiiitiui; of the [x^lvis upon Uiu trunk will inorcase thin sliortenin^, and produce the other ejmptoma which hare been DiiHtaken for e\'idt'nn.-i> of luxiilion.
To illoBtrate my position, I will qnotc a post-mortem exami- nation from Sir Benjaiuiu Brodie's work on " Diacflfiod Juinle," pab]i»hed in 1 "^lU :
** A niiddle-agod man wii* admitted to St. Gooi^gc'a HoEpilal, in tlie autumn of 1805, on account of a dtM!a»e of his left hip. He also labored tindt.T other (.'omplaintH, and diud (n the February following. Oil iuflpecting the body, the Hnft [Mirtii in the neigli- borbood of the joint were found slightly tuflamcd,and coaguhited lyinpb had been effu»ed into the celbilar membrane round the ragMular ligament. TIiltc were no remains of the round ligiimc-nt. The cjirtilageA had been deMroyed by nleeration, except in a few Bpota. The bones, on their exposed fiurface«, were carious ; but tJwy rctainctl their natunil form and fixe. The acetabulum wm almost completely tillod with pus and coagulated lympli ; the latt«r adhering to the carious bone, and having become highly vascular. T/te fuad of tMJemur waa Unlfffd on the dor»um of tiu ilium.
Tliu capsular ligament and synovial membrane were mucli dilated, and at the )iu[>erior part their aU<ichmmt to the hon« wot thrust upiearti, so tluit, although th« hf<id of the femvr Kot no longta' in the aeetabiUum, U unx* s(iU vithin the cavity qf the Joint."
H(-re we have llic testimony of Sir licnjainin Brodie tluit " Mf head of the femur xcaa lodijed on the dorsum of the ilium'* and in almost the next eonteuoe lie saya "Tit tm* stiU zeithin the cavity of the joint." f'omraent seems to me unneoeesary, for this can- not bti called luxation aix-onling to the ordiaarj' delinitiou of that tenn.
In BrnithwuilcV " Retro*i»cct," No. 22, Jann.iry ", 1855, p. 196, is tlie report of a caite of exsection of the head of the femur for " hip-diiica«e," by Mr. 6. Key. After giving the Mf^, bcx, and pre- viona condiHon of the patient, he describes her condition on ad* niifieiiin t6 llic hospital, and tayn: "The l^femw teas di*looaied on the donum tVu, the limb shortened and the leg ami thit/U flexod." After con^ultalion, *' it waa eomidered that removing the
DISEASES OF TUE HIP-JOniT.
head of the I>odo would ^vu tlio patii'ut llic bc«t chniicfi of re- ooverr." lie then dewiibeii the operation and tlie morbid appear- ancea he ol)«>n'e() about the joint. Ilv Htntce that " thv acetabv- turn watt found to have enlarged by ulaorptiiM* and was extmdfd in a direction vpieard an<l ba^^aeard, ae if an attempt bad I»cen mad(^ bj Nature to fonii n now joint in (b>8 direction. Tfit heitd efthe Jemur had be^n entirely ahgorbed ; a portion of the neck remained, which with the grout trxx-hanter was the part removud." I wonld dimply ask how it could l>e poBsible that there vaea "(/i^- foM/Von on thu doreuni iiii,'^ if ''th« head of the femur wa« en- tircly abAorbed i" Can a bone be luxated when it haa no exist- ence \ The answer it Keoma to mc \i perfevtlr plain, imd it is that tbc luxation never took place, the apparent luxation being due to tbe ahflorption of the bone.
I do uot deny tliat luxation ean take place in morbus coxarins aa well as in a bealtliT joint ; but, on the contrarr, a much le&a amount of force ought to be able to produce it. If, however, tlie nnnte, while lifting the patient out of bod, or bv twigting tbe teg acroa the opixraite limb, niptur(4 the capmile and pro(hice« a luxa- tion (ail I have feen <lone), it ig as much a traumatic luxation as if it bad been prod uced by a fall from a home or by any other aocideot. And if a careful in(|niTy tamadeinall cases of ^o^^lled '• spotttatif' otu luxation" we ^liallfind tliat tliey have oocurreil after the appli- cation of violence more or lees severe, and not as the result of un- aided "muttcnlar coutrnction" according to Miller and the other authors whom I have ([uoted.
I have now performed exeeotion of the hip-joint seventy-two time!-, and Itave found luxation in oidy one cju^, tluit of M. D. I-'iuld, and it was cniisc^l a few days previous to the operation by the nurtiG twtHting hia leg while getting out of bed.
pRooN<Jsm. — This will be raried very much liy the conetitn- tion of tbe patient pruviuur' to the otvurrence of the disease, or more juirticulnrly by tlie treatment adopted, and the stage of the di«eai«e at whifli it is conniienoud.
In the earlier Mages, before organic changes have taken place, in coii8e<iuene«of inflamtnatoty processes or disintqrration by caries, if a proper conr^ of treatment i.-i adopted a ino«l favorable result may be pnilictcd ; for recovcrv usually lakiis place with a naeful joint. If the second stage luut continued for soinc time before tnwtment is begnn, the effusion into the joint may have beoomt.
rROGNOSTR.
organized, or adlicsioii tnkon place, which will rcniiiin after tho dUeoM Uasentirelr aulwdwl. I'liilvr ihvue i>ir<'tiini)lsim« recoveiy will take pluco n-ith tome deformity-, bikI aiichTlwis riivru ur len ramplclc. This will demand KuUwqiierit trealmeni at-cordiug to ttw poiiditiim of tlw- patii'iit, ntul ti> decide what is the b<*t troat- niQDl that can hemloptvd requireH thv givfttii^t skill nnd jiulginutit on tltti purl of thu Biirf^n.
If the tiisea^? has pro^-iwwl iinlil it lias michwl the third etugv. hcfort! triMliiK-iit t» «immoiiwd, yoii fhuiild not promise recovery without deformity ami impaired motion. Thisso etusm Boiiiolimi's n-covi-r, after applying the proin-r meohaiiii'al appara- tus, hut ahiio't always with niorw or Iom cumplctv anchylo-ie aud deformity. But. if, after proj^er treatment, the dbieaHV Htill pro- grcese**, there (8 nothing left fur the surgeon to do hut exeect tiie joint, thoruhy removing tho onrious iKtiie hotli of the femur and aeetahulum. If thin n|>enitinn is properly pcrfonm^l, it nin be done without danger; and, with judinou» after-treatment, will, in a lar^ m^tjurily of caAai, reenit in a ueeful joint.
When, however, the eaeo is nocn during tho jfrvl, or tarijf part of tite «tvv,nii utiure of the 4li>«(ti>c, and put nnder proper treatment, an n nde, far different results may he expn-ted. a^ wo will \iuvo ahunchint ocrasion to kIiow you that they fn.-<iuently recover without deforniitv, and with perfect molinTi.
If the dieeittre i'i altowetl to priign->« without proper treatment, it wdinarUif runti through the three atn^ctt.
Occasiomilly a (laliunt is ee*'n who has l>een c^iTvd hy am-hy- lewis in the »p>.'-ond i>tage, and he 18 UniK ooui^hiIImI to carry this deformity througli life.
These inolances, liowe^er, are very rare. If. as 'u gvnemMv lliu eaw, when pr<)i>er mensnres have heen ne^fleeted, abxcexscs liHve fimncd after ru[>lure of the cn(MiiIe. one of two lenninatione is to }tv expeetcl — cure liy anehylons with defnnnity — or death. The former mtinetinieti mvurs, hut only a minority will he found with a niHh'iently strong coniititnlion to stuttain the cxt'tMtivu dminof the loug-^'onlinned Kuppuration.
If, however, tho parient hai* the Itcnefit Hri»ing from recent inipnivementf in the appltam-cK u&e<i in the treatment of this dis- eisp, a far dilTert>nl result iimy he hoped for and expected, if tlio treatment Afffii>/f/<</rty«/ itnt!/ (oo/atf. If the patient haa already advaneetl to the third utajp*, and w nmch redunnl, death may
DISEASES OF THE HIPJOIST.
ensue, or tho beat reBiilt inny he nncliyUifU ; but, even hetVt hy prupcr truiktiiiuiit, n tiinjurUy iiiay Ixj tuvoil, and we may expect ti> secure a ca^e nilb partial, often complete, motion in tlio juini, lu titu following ante iUnstniU'ft:
Case. — Katie K., nine years old, was broiif;bt to Rcllrvao Iloepilal Medical College, January, 1875, in mbnut h«*Uli, but wilb h«r rif{tit hip ancliyloced in tbc position 6fvn in Fig. 153, from a pbotognipb taken by Mr. Maaon at tlie time. Slie liad
fm. u&
fallen down-titaiw wh«t wbe was five y«ir» of age, hntiaing h«r rigbt bip, wbifb was aliiujst immediately followed by all tlio iiKiinl symptotiia of liitKliHjenac. She waa trented by re])eKted blietere and intcntal renicdii-6, but no extension or conntdH^xt^n- won wiwi employed to prevent deformity. After three years of exwesivu siippiirattnn, she eventually recovLTL-d villi the limb ancbylueed, in which condition ebe lias been for the past twelve ruonthe.
A<t lOie wat) in perfect health, no -luppnration exigting at tbe time, I put her niider cblomform, divided tho adductor longtu and tensor vaginiu fcmoria mii«cle8, with oome bands of oon- tnct«d fascia, broke up the adbesiotis, and placed her in the wire
TREATMEITT.
M7
cutraffl beforo the HaHfl, January 13, I8T5. Xo nntowauxl ftj-mp- ttnuK foUoui-O, and, Fvbrtiiirv id. t^lio ww reitiovf<l frtrni tlto wire coirase, uid a long liip^plint applieil (*« Fig. 1^4), by the aid of wliicb Hhe could walk purfit-tly vol! withoal a ennc. Thv motions «t tlie jitint wore i|ait« free, hut the psoaa tnagnus and iliaouii internua iiiii»pU>^ nrv iiut fiilJj extonded, wliicli ]m<(liii.'«« the gligbt curvu which is itoticvahle at tJie Gacro-lnmbnr junction ; she cnn abdiirt the ]iiiib to nearly the normal extent, and is able to flex the thi^h to an uculo angle. In the tipring of 18Tti the epUut wu disooDtiaaed, « complete cure having been effected.
LECTURE XX.
DUE-lSta OP TtIB JOIXre. — IIOBHI'ij COXABIITS (OOKTl^fUBD). Ttnaimcnt,— MKhu^nl Apptniiu, mnil how ■]ipl!«<i
GENTt-ioiKN : We have arrived at the aubject of Tbeatmrnt in oar atudy of hip^iecHAC, and tbut will engage otir attention thiit morning.
The treatment of morbus coxariiie may he divided into^
1. Ijucal;
2. General.
Many of the guceral remedies employed have b©cn pven to connteract the acrufnlouii diathe-'us which was )).n])poiied to nnder- llti these joint-di(*«w8. Of coufr-, if the diBcaeo occurs in tt patient wlio Imppenii to be ocmfulouii, it will he neoesnary to bear in mind tla* diatheHis which rompliuiteH the trouble, and employ the prio))er remedies. Bnt, an baa alrea^lv been iihiiwn. ihoM) " white HwelUngB*' of joints havo no ni-coHturt' connection wltli wrofula, and occur indifferently in the weak and the robust, ftctimlinp iifi ihf exi-itiiiK <-a»ises, gi-nerally traumatic, are bronj^fit into actiiiii. It Would, (ben, be highly illogical to eubjcc-t cvet^ case of joiiit-diaeaae to a course of anti-scrofulous medication. You will, liowover, generally find that thcso ptttteata arc benefited by thi^ee remedies, sut-h as tonics, cod-liver oil, and stimulants, which are of vuhie in the treatineut of any disease of long dura- tioo and debilitating teoduncy.
OF THE H1P-J<
Ko more exact nile, I ttiiiik, should be laid down than this: vary your mediration according to tlie actual deiiumdM of 1.111-I1 CiUie, aud do not baeu it upon a tiivon-tical morbific muse wlitcli yoa desire to combat. I aliall, therefore, Bimplj recall the lueana whidi are usually of meet benelit in the vhv of general treat* mvnt.
First, see that the patient haa sufiicient food, and that it i« properly assimilated. A very oonunon dilBc-ulty in the^ cases is tliat, even before the appetite fails, tlie food taken into the ittom- acb is not properly digested.
It may be mentioned here, tliat the local mennn employed for qnitsting tjio pain and allaying the destructive processes within the joint are generally the best remedies for reotoring the appe- tite and assisting digestion. But you must ece to it that your patient tuu food lliat i* highly nutritive and eaiiily aMiniilated. Endeavor to n^late the condition of the bowels, by varying the food aecording as eomtipation or a tendency to diarrhcc* cxista, God-liver oil, so commonly oaed in these Sections, I am confi- dent, owes it« cfflcncy simply to its nutritive rather than to any pArtiouJar medical property.
Again, uhscn-c the hygienic surroundings of the luticnt. If you find Uim under the influence of Iwl ventihidon, noisome exhalations, or, above all, deprived of sunlight, endeavor to cor- rect and improve hia condition in these respects. Look to all tho-io thing)' ; for, while I uni a etrong advocate of the efficiency of local treatment, you cannot expect to succeed in tlie face of advcrwo hygienic surroundings and iiisuffident and improper food. As regards niedication proper, 1 know of nothing demanded lie- yond the usual tonics and stomiu.-hi<« found (o be of service in other disenseH. I would mention particularly the use of baths ; sea-bathing in warm weatlier, when it can be liad, or its subsli- tote, wilino baths with friction, lo stimulate the skin, when the open-air bath is beyond reach, or wlR>n the weather U too cold for its use. With Iliis brief outline of general treatment, I shall pass to the oonsideratiun of local treatment.
Tlic only local tnsatmcnt in nso till within a few ye«rs was the application of counter-irritants, blisters, isenes, setonM, etc., over tlie affec-tetl joint. It was customary to leave the joint it- self to the via mfdieatrix naturte, a force that n'as sometimes found so eonsenative as to save the life of ttie patient, bat pre-
TREATITEST,
369
aerving lor him a withered, nialfortni-c], anchytoflcd limb, epoci- IIIUII9 of whicli yon now xee l>efore ^v<m. It wsh aii opininii eiiter- tniocd by «>me Burgvons of n.ttptK.'tiibility that, if tliv buiii'H of tlto joint become involved in caries, there )g little or no hope for tht; |>atiL<nt. Even au bigli an autliority n» Mr. Syiim atiiwrtcd t}iul, "if tlie heail of the femur becarionii" (which implied, in hie eetiinution, n carioUH condition tieovMiirily of Uiu aevtabutum), ■'the patient iit'u^t <lii' ."^ But, it affords me great pleasure, gt-n- tlemt-n, to lie able to^lay to <lii*provc, in thu iiioet unanBWcnthle niAnner, Ui« broad aMMertion of Mr. Syme; and this pleaitiiro doe« not arise from a considemtiuit of being able to point out the crrorn and rcftite tlio KtiiU-mi-nt)t of m dcevrvc-dly great a man, hut ratlier from the fact that I am able to give yoa micli tangible, such ehi'ering vvidenee of the progrutu of coniiervati^'e sur
The local treatment which has grown into favor during the past few j'uans but wliioh I have advocftted earnestly sinec l'S4A, is such OA to give abaoliite rest and freedom from prcceure of tho pnrto involved in the diMw^c, without materially interfer- ing witli the mobility of the joint or ordiuiiry cxcrcisis of the patient.
Bonnet's method — lixation without extension — for local treats inent )uu been the plan ubmiul. In tliis countn*, however, tixa* tion with extension hn^ been chiefly emp)oye<l, and, to nBbrd an BpparatuK tliat would me^-t tbe#c indienlioiin, leathern KpHiits, gyjktDm and Htarch ban<lageg^ and strong wire gauze, moulded to fit the limb, have all hwn employed with more or Iv^ beuetit, but all thene plans prevented mobility.
Fixation with oxtoni^ioii, I iblnk, wa* first employed in 1825 by Pr. Harriti, of Philadelphia. Ilifl apparatus, however, iieces- altatod eonllnoment to the bfd for » loiig time, and, u a eonso- qoence, the patientA became <'achectie, and the diseafle pro^n>«ik-d to an unfavomhle or fatal (urniiuation in many ausw, despite tlto relief from pain given by the extension and fixation.
The IreatuiL-nt by fjrftiiuU/n wh» an unavoiibiblu infi.<reiico from the demonstmliona made in the paper of Dr. Alden March, already referred to, upon the mum; of tbv aj^'imit digloeation in Ute third stage of coxalgia. But, if the patients are kept niton the straight splint, as rerammended by Dr. Ilarrix, of Philadvl- phtn, or Dr. Tilarc-h, of Alluuiy, and eaimuricn i» maintained in
970
DISEASES OP THE niP-JOINT.
addician to tL« Ration, we will relieve our patients inyta sll MiiiTc-rii>g, it ie true, anti f^neralh* nmiiit the disease ; but, onleM tlie greut«st care be ob»(7rvv(l, iiii<I in tliu latter etagve t]i« pMient be frvqucQtly removal from tlic tt|)pnmliii) iitid pMsivo motion empIoyiKl, it will alino«t invariably b«j>pr» thai aucliyKisis, more or lees complete, will be le(t, and, so far m pm^.Tcssioii is con- «en)ed, tlie patient is in a mnch worse condition than wlien left to Nature. To obtain, tben, jHirmaiicnt exien»ion of tbo joint witbout a damaging anioniit of eontinement, or, in other n-ordis extension in euch a manner ae to permit mottoo, becomes tlie problem to be aolvctl by surgical ingenuity.
Tliere are many i-asefl in which the inlUmmation is eo viglent, and the pain upon the sliglitoBt movement so inlcndc, tliatnAiOL luia rtM is requiiiitc for a time, and in such cases the lixcd dresa- iiig alUidL-d to anii«-vr» a most exoi'llont pur|io««. Under lhn>o drcnmatancea I emjttnr most commonly the cuirass with exten- sion. i^Set Fig. 172.) But motiun is as essential in retaining a hceilthy condition of the rtnicture about a joint as light is e«eeii- tial in retaining a healthy cunditiou of the eye ; fur the liga- lueuts around a joint will becomu fibro-twrtilaginoue, or oven oaseous, if motion is denied them, partinilarly if a chronic inflam- mation is going on within tho jwint with which they are e«nnoct- od. It wa« in conKe<)uencc of Htieb acc-idente oocurring in wveral instances that I was led to contrive some plan by which exten- eiou could be maintained that WfHild remove prcwnre from the acetabuhtm am) the head »f the femur, and at the same time per mit motion of the joint, thereby retaining tlic caitnulnr ligaments in a healthy condition.
I never sticccoded to my wtisfRction in my efforts to attain this desideratum until Dr. II. G^. Davis of tliis dly, ajiplied to one of my mm-* an iniftnmient which he had devised that an- swered the purpoiie a4lmirably, and in '\U< construction embraced the very principkic which I had to long «ought to apply.
As Br. Davis in, I lielieve, tho 6ret. person wIki conMnn-ted ail instrument embrndng thc«c important adnmtages — extension with motion — I have j^ven him fidl credit for lite same with a phitc of his in(!trument, and hit own remarks in rc«|K-ct to the method of its application, in my report to the American Medical Association in 1860,
I have since made, as I think, some very important improve-
ORIGINAL SPLIST.
?n
[xneute nnd nvxlifionUtine of this iDstramciit, which I will tloeeribe more fully heresfter.
A« I>r. Dav'tH ainco timt time tiM taken out n putcat on bi« instrument, and as others hsve since lieen derised by various per- 'BOHB that are so much moru iitHficut witltoiil Iliv ol>JM-timiiiblu Efealures of Davie's original infitnimenl. it h not nei^iMary to inalte fany further rufvrenoo to it. Tbo ini<truniei)t of Dr. Davis wtis applied in the case referred to, with the happiest reKull^ for a fi>w duytt, but it sooii bGfj;an to cxcori-tti; the ^roiii ; and u1k> t)iu method of extension was not entisfadory, and cx>uld not be con- trolled at will. It would l>e cither too feeble or too Movere, and I therefore ha<l an iniitrunient constiactcd embracing all the
pm. isi
principles of the infitniment devised by Dr. Davis, but which could lie worn with much more comfort to ttie jintiviit, wai* much more effcetuiil, and was entirely under tbe control of Uto surgiKtn.
The in^tniment I tlien devltod conxisted of a narrow Ateel .«|>lint, extending from jimt above tbe crci^t of the iUiitn to witbiu two or three inches of tbe exteninl malleolus, ami wan divided into two [Kirta at the knee. «o that one ran into or by (he Hide of tbo other, and n-as capable of being extended At will by a ratchet and
>wlteel near the knee, that was worlcMl by a key. The upper
OF THE HIP-JOINT.
|K>rtion of tlio instrument w«8 pumigntt'd tu incresK lU titrcnfrth, and in a groove at its npper extremity wan a baU-and-socItet-joint U} n-liich WM attached <i pulley' or wliuel for tlio couiiterH^xti-nd- ing cR^t oord to play tlirougb. TUie catgut was attaeben) at viliicr cud of the ]icrmcn1 band, or counter-oxl ending; belt, whirb was made of ibick Indui-nibber tubing, aud, being lirmly secured at citber end, made an clastic and comfortable air-cushion for the pcrintpnm. and could bo vroni without excoriating or cliafing the juirt^ At the lower end of tlie itutnmient wa« a small roller, ex- tending nearly its entire width, and juat alxive it a bncklo fortlw purpoM] of securing the firm webbing or strap whii'h plaje ov«r tlie roller at the lower end, and was sewed la^t to the alrong ad-
boaive plaster for the pnrpoAe of mak- ing extension. {Sm Fig. 155.)
Such is a brief deacripiion of the in- etrument I tirHt dcviitefl for the treat- , mcnt of hii>-ju)iit d)iieiu«. Since that time I have improved it in many re- epochs and till) instrument I now most coiumoniy employ iaashort tbigh-flpliut, as seen in Fig. 156.
The following tii a tlescription of this iiiHtninient, togotlicr with the method of application :
It conBil^te of a jielvii; band, pdMing jiarlly around the bo<ly under the erest uF the ilium, well padded on it4 inner Kurfnce, to wliicli iiHutdly two perineal fetrape are fastened for counter-extension ; iu outer larfacv holds a ball-and-socket joint, from which mns a steel rod or bar down the ouifir wde of ihe thigh to within about two Jncheeof \hc lower end of the femur. Thi» outer bur i« divided into two H-ctions, one running within the other, and gauged or controlled by a ratchet and key, which can make It longer or Hhortcr. At the tower extremity of tliis outer hu la A projecting branch going over to the inner surface of the tliiglt to receive the attacbmeut« of the plaster, hereafter to be dcAcrilwd.
APPUOATIOS OF EXTENSIOK.
873
<rf tlie lower extreiuitiwi tenninaU', hb yon ob&BTre, in a <iy1imlri<.'3t roltfr, over wliiclt ttiv tugK uf tUc plneterH nre attached to tlt^ lw<j hiii^klcc* pln(-<'<l »t the lower endii of tin- iiiftriiment.
Wliun the Kliort epHat in iiiwd, sornu iiieuns mti&t be employed fur ttinking extcniiiiin Hiirinjr the iiijfht, and alwi st olht-r tiiiicn when it ie vxped'wut for the pAtiunt tu liu in bed. This ie beat effcetod by meaits of weig^lit and pulley.
To apply it, cot two Ktriptt of strung adhesive plaater, two or thrco iticlK^ wide, a^.'oordiiig to the me of tht- jiutiunt'a leg, and long enon^h to reach from the mollooU to ax or serren inches •buvo tlie coudyles of the feinnr. To the lower end of eadi strip
n^ist.
Fn. vs.
no. iMk
Btv a piece of strong webbing three or fonr ineheH long. {See rig. i:.7.)
After Hmootlily linndaging the foot and ankle, apply the enda to which tlie labo are nttiiched, one jniit above eitlier nialleoltu, and cnrry Die stripe uf phutvr up tho inner and outer sides of tlie lug and thigh, and ticoure them with a roller, nicking tlio edgM vf the plafttore to make them fit entoothly, and prevent any fold- ing or creasing. IS
RE8EASK8 OF
JOINT.
Th» proper icLttliod of fa«t«mng the plaaters to the liinb is lo allow them to hnoff Ioo«e along the »klei, and bring them in con- tiUTt wit}i it by the eucL-cssive turns of tJie roller, for in tliis way you will be much lesa h'able to wrinkle tiiein, and that i-s an iiu- portAiit item. Tlii« may appear to you like nn inHiguitieautnu ter, and banily worthy of ej^ecial mention ; hut it i» not, for single wrinkk- in the adhesive planter may, by the iiritatioii it will prodnee, defeat the whole plan of treatment.
The tahii should rceuive a few extra tume of tbe roller, over one and under the other, weaving litem in, for the purpose of making them additionally KKmru.
When the knee ii> reached by the roller, a/wr/y* oovcr it in with the figure-uf-S turn, for the edge of a reverse in the band at M{« plueo nifly give rtsu to BeriouA uicouvvnieacv, and DC tate it:a entire removal.
When the bandage baii l)oen carried two or three inches abovo the condyle!!, the remaining portions of the plaHtcra are to be re- verwd («« Fig. 15S), and then a few more tunis of the roller will, by the bandage adhering to the plaater, fix t)ie drewiing no Ibat it will not oa«ily slip, iSee Fig. 15fl.)
The phuiter should be applied cold, bnt when the bandago tu been applied the plaster should be moulded to the Umh by finnlj squeezing it with tlie hand. It U also vei^' important to secur tlie plaster above the condyles of the femnr, in order that exten- aioti may be made npoti the thigli and not rtpon tJte Uiteral liga- menU (^ftfie knee-joint.
Tile bandage should then be faatcned, and witli atitehee, for it b to remain a long time.
\i the limb iH held in the proper position, natncly, in the liiu tffth* d^ormit'jy and ffeatie trtmmOH maintained by an a£eistAnt, it can be prepared fur the bed-extension anri the spMnl without giving the child the slightest pain whatever.
Next take a piece of thin board about three incites long and two or three inches wiile, nnd iirninj;e across it a piece of tape or webbing so that it fihull project three or four incbeit n|>on either ^de. To the en<U of tliese tnbe fasten bucliles or bnttona, tluit they may be attached to the ends of the tabB upon either aide of the limb.
A simpler and more efficient method, for tlie board i» ItaUe to turn out of poHition, is to take a round piece of wood three or
NIGirr F.XTEX8I0K.
SW
four incites long, and li»ving a groove in the centre for the atl»ch- ntint of tlic ivnl, ntx! sW <mo on eiu^h extremity to liuld it in rtlnce, where it is biittuncd into button-holvH ntudu in tliu luwur part of the tibe attwlieil to the strip of adhisive plaster already fit&tuniHl to tlic sidvH uf tbc- limb. To thv middlu uf this fout- iKMird, or round Uivk, iu iittached a Btout cord. The object of the ird nr stick ib simply to pruvent the ttiuid« from making un- '<!Oitifort«blc prcBSiinj »])on tiie imdlcoli. At the foot of tJie bed a policy is to be arranged in eufli inimiK-r us the iiigvuuity of the Bui;gcon dictAt«8, tlio oord from Uie foot-iionnl placed upon it and a weight attached, just suflicient to make eucb ext^slon as will render tlie patient coinfortablo.
Fora weight, a bag of shot or sand is meet convenient, because tllc Amount can then b« very esuily rt'gutftted.
To prevent the patient fmni slipping down in the bed, it should be ralMKl t«ti or twelve inches by iiicMiBof bricks or blocks. {Set Fig. 160.)
Tho foregoing U for night extension ; to apply the lOiort lii[^ splint for extenitiou while the patient \» ^xi'ttrimng, tho limb ^onld be prepared in the following iiumncr:
First cut two irtangulur or faii-ithapcd picow of adhesive plaa-
ter, the broad extremities of which diould be wide ciioiigli to (.■over about half the xurfaoe of the apper part of the thigh, and are to be alit into fttrips an inch or more in width, for tlie pur- POM of permitting a more |>erfcet iidjualment, and, also, to be nnrted ui detail over the liandage. They sJionld bo of sufficient length to reach from tlie knee to the groin. To the narrow ends of these fun-«bRpod piccc« you will i^cw a piece of Htouttape or webbing, something non-ela«tic, three or four inches in length and aa wide as tlie cylinder iit thu lower extremity of the in- stmuicnt. {See Figs. i(il and 162.)
S76
DISEASES OF THE niP-JOINT.
Kext, pbice the inetrumont ujKin the tlitgh with iu jaws nbout tiircc JDches above the oomlyles, and with the thumb mid dinger
Fia. 111.
r>«.iM.
grasp the limb at tlio point upon either iride where the instra- ment eomw in contact with it. Theee two points indicate exactlj where the tabbed end« of the fan-otiapod pieces of adbetivo plaeter •re to be applied. {Ses Fig. 103.)
How, having placed the tnbbcd extrcmitiea over tlieeo points, iecurc them in i^KM^ition with the roller-bandage by first niaktni a few extra ttiniii near thu tub«, and then carry the bandsfi stnigljr and anioothlj over the plaster upon the thigh, until the perinieiini io renirhed, when the strips of plafter wliirh arc DOl lloailng looBe arc cvciy other one to be reversed as t!ie Imndaj goes around the thigh (AitvFig. liI4), continuing the bandage at t)u> pcriiitenm until all of the strips of plauti^rs are revereed, and then the bandage is carried down the tliigti uniil tlic pLirtcn an; eu- tiroly covered. {See Fig. 165.)
The effect of all thlii Is to hold the drcsMng fimily in place.
The thigh is now ready for the splint, and, after the eltaft been Hhortenod as nmeh as it ean he, wo will place it in poeition with the pelvic erosa-bar, at the upper end, juat onder the creet of the ilium.
Now, fasten the lower extremity of the splint first, and tlits iadone by paB»in<: r)ie titb« aruiind the little (ylindvrit in tlie jaw upon either side, hurkling them as high ii« pusetble, and tliea hackling the Rtrap tlmt \imif* behind the thigli. Next buckle the perineal bandti, drawing them snugly, but uol too lighlty, and gee thiit the tmiooth Mdu i» next to the fkln. It i.-* wull, also, to lay a piece of old linen in the groin niuk-r thu buode to protect the piirt« from pre«i^urt.-, and also to absorb the moisturo com* monly present in '-his region.
ISG PLASTER FOR EXTEK8I0K.
m
Tlie ut^lect of these little poiiita often gives the pAttent aiu) Ute enrg^on a good deal of nniiovaiicO'.
The iiiKlruiiicnt now being in poeiitton, tlie alec adjustinotit, wliich is to regulate tlio luiiount of cxteiiHion, is miujv b^- mctmii of tlie key. In tiii« way the exact amount of extension necessary
Fw. 1«L
Km. IM.
Fto. in
coo b« nppliud, and is to be re^nilatcd by the following rulo: Apply sufficient exteneioa lio that when a ebarp, euddvti coucus- Hioti is iiuulo from tbo knee, or the 1kh>I when tlie limb is straight, it will vause no pain ^vliatover ; tliat is all the CKteusion n.^jiiired, and your patietit'it ftu-c )a to l<e your guide in deciding when a BnlBi-ient nmonnt has been ohtaiued. Horu oxtcofiion than this tuny givo riw; to an obetruction to tJte circulation^ and do an infi- nite fiinount of harm.
At ni^it, and at suoh other times as deemed necefl»nrr, the patient i» placed in bed, and the bed-extension adjusted l^on the tptint u rtmovtd or Aorientd. So. bIko, whenever tJie p*tient wlsliea to get np you are to apply tlie inatrument and lengthen
278
DISEASES OF THE niP-JOIKT.
tho fitutft, tliat id, iiuikc cxtciiuon, hffore the bfd-taUruion ta n- nwred.
If Uic pntictit 10 n small diild, liku tlii« uitc bitfuru yott, he may t>e permitted to wear the eplint without miag ixutchce. (See Fig. 166.) If ibti patient be of muvii uzc, crutdies will be n«
Fm. Ut.1
aarr, fur thu plaster ik otilj- inteiiclcd to rcuin tlie iiistramont in poi^ilioii and maintain sufficient extension to relieve tlie joint from all pruM-Mix', but not to (*iippwrl ilit* weiglit of tlie bodj if the child is hearj. If, after the application of (he splint, tlie patient ifulTcrs paEii, it is evidence that the f!]>lint has not been , properly adjusted, and it should bo carefully examined, for it majr ' be tliat the plasters have yictded Bomewhat eo as to i>ermit pres»- nre upon the joint. If eo, it can bu easily remedied by ^ving a httle more uxten<<ion with tliu key. Now the putio4)t in in a condition to recei%-e the couHtitutiomtl treatment bo ncceseary in hiM cage, which oouKists of buL-f, nitik, bread-and-butter, etc., but, above all, plenty of Bimlight and pure air. The ajipart-nlly trivial points which I wish yon especially to remeutber (for tliey
'Tbr lii|>-«pliDt 1icr« thocn In Fig. ISA I fatT« condemBod ia»ajytan iLmv; it •hould BOW b« lued, ibo thon U[h«|>Uii<, Flj. IBS, iNdug Ut anparior la mmj ■nj.
LOSG SPLINT.
279
arc mJly important, and neglect to obecrvc tlicm hat man^ lima brought llie instnimnut into disrepnte) are the following:
I. Alwaj'tf i<li»rtiTi the sbaft l^cfort- upplj-iiig or rmnoving tlic in«trumont. 2. See that the jawB are tij(htly buckled, eo that tJiey will not lie <Tx>w(loii down, and pr^wt upon lii-- i riovK- S. \)ij not, w) I have eoeii dime, tiick the tstpe bctwi. n ily. M^ilif :iiid the buckle, i. Do not backle tlie perineal bands too tightly, for in tliat manner joii may oliatrut-t the femoral reasels, but mako the cxUiieion with the key, whicli tightens the band by crowding It upward mlhor than by girdling the Umb. There U a point witli n^fereiteo to the eoutid 1im)> that must bo mentioned ; when Uio \orig splint is worn, liave tho sole of tlie boot or hUoc worn
Fid. in.
fu. iar>
upon tliat Kido made extra tldcV, tor the purpose of eqnalizing the length of the two llinbe.
Finally, it will b»* noticed that the fence i« left to move fw freely as it may. I ean me no propriety whatever in ^e)^truini^g the movomctita of this joint In caeee of hipjoint diwose in JU
9B0
DISEASES OF THE niP^OIKT.
earlier eta^^ when itio tliigh U long enough to pormit tlie appli- cation of tlie short splint. Tliere may l)e other cirvuiufltADC wbcu it bcdOinCH noot^sitry to give thu knee liHpporl, (.-tc. wberfi-^ t]ie long splint ahould be employed and the movements of the Icneojoint rcHtrainod, But, all Hiidi ouneidt'ratioiiit liuing ect Afiide, tiiere in no reason why iinreHtrtcled motion at tlie kiive may not be pfrmitt«d.
It was <iesij;iied tliat tlio motions of tlie joints sliontd be free, and no bami will attend this fn-udom of mutiim, unless the joint it*elf beeomea the seat of di»ea»e ; but, on the contiwy. rt*tniiiit will give riae to more or lefw an<'hyln9iB and defonnity.
I rL>«ort to the n»c of thi)> «li«rt upliiit as (.-urty as pofftildv, in order that the patient may have the Wuefit of exercise in the upen air. It Bomctimce 1ia])]>cum that it oannut Iw applied by rca- Hon of abfloeases, or some other cause. In such casea tlie bed' with extciii^un may be arrangiti upon tome liglit wagon or wheel-chair, so that the patient can be carried ont-of-doora, and placed as bur ae potwiblu under the influence of good hygivnie' conditions. In *ucli caKiie. however, I more commonly employ the long t-plint, which is a modilicalion of that devised by I>r. V. F. Taylor, of this city. Thiii splint differs from the abort one dvMrribed tbove, in the following purticulara :
In the lirBt place it extend.^ the entire lengtli of the limb, receives the weight of the body at a crow-bar under Uic fool, and has two perineal straps with an iron girdle nearly encircling llie pelvLi." The long Imr, reacliing from tJio pelvis to the bottom of tlio foot, is hollow, and has another running inside of it fnmislied witli a ratf^ict and key {tea Fig. lt>7), by wIiiHi we make cxten- i^ion, and k lucked in the same way as apon the short splint. Tlie croes-bar at the bottom of the instrnment Is covered with leather, and a strong leathern etmp, c/, pacscit beneath two iron, rods just above the erutvi-bar, lo winch tire attached the tabs from the adhesirc plaster npon tbe teg. Tlds completes the attacli- incntH at the lower [lortion of the inHtrnmcnt for making exten- fiion. There is aUo a knec-]>ad, O, which is iittachcd to the bar nmning along the onter side of the limb in cnich a manner tlwt it can be moved np and down to any jioint desired.
' I hBTO wwd tlw MnM long pchut ginllo ftail dou1>l« perineal ilracw In lb* (htft ■pUnl for wHDo jrran fan.
LOSG 6PLIXT.
An Ad<lttiunal uuwtu for appljiii^ vliutic force U atlacliod to tbo po^ttfriur [Murt of Uic infltriiiiietit whidi is to b« used in caees when the thigh ie strongly dexed. It coiuiitU of an olaAtlc band whii^h in nttadted above the knee, I'uns along thu txtck of tbe thigh, iind is secured to llio puHtvriur )>nrtion of the pelviit-belt. Tliis band can be made tighter m occneiou auty roquira, for (ho pnrpose of extending tlio liitits Ami flhoidd t>o elafiti<-, for the pnr- poM! of keeping np a constant trartilu forc-0, and ut iho saniv time allowing fluxion wlivn tliv jNitivni Willie!) to Hit down. A non- elutio or leatlior E>trap, xs need by Tuj'lor, prttvenl« any motion whatuwr at the liip, and dimply aiichyloe«s the joint.
Tliiii inittniment has been esfiuiitialljr improved b}' Hr. Revn- dere, by iho fullowliig ndditioiw:
The improved parts arc whore tbc long rod Is attached to the pdvic lMn<l. llic long rod is attached at vl to a round revolving plate. Ji, which is faHtomid to iho pelvic biuid. AVhen tlie plate Jt is revolved (partJy) thu long rod mnvui forward and bovkwnrd. From tile point A, tlie long rod movce from and lowani the other leg, as shown by lli« doltod liiivi! towai-d Z. V is a screw tormiaating at /> in a email )«ijtuirv xtem of ittwl, fitting to a kef. This ncrow turns in and out of the revolving plate H. and luu at tbu end uf its tlireiid n little kimb. which in a little larger than tlie perforation at the npper end of tlie long ml, so lluil, when the Icoy is applied at D and tunii'd, the screw C will force the long rod in the direction towaitl L. In tlii« manner abduo- tioii \e made. At J"' the long rod in divided into two partt^; the tower part holds an endless screw transversely, wbivh is worked bj a key, and mlatinn ihu» pn>diiei-<l. {S^ii Fig. 167.)
As a matter of comfort to puitientis tbe«: long splints are also lued with joints at tlie knee, in slight casenof disease, or when poovaleseence has ddinitely set in. These joints arc sometimes loado with citilcl springs at the knee, by which, wlten the 1^ is Iwnt backward and the ]iowor relaxed, it will spring forward in- voluntarily.
The limb is prepared for the long splint in the following miiiiicr :
(Jwt two Mrips of i>trong moleskin adliesive planter from two to four itiches wide, a4;i-onling to the wzo of the limb, an<l long enongli to reach its entire Ivngtli. and divide the npper extremity of tho plartor into narrower atripH for a distance of (wo or three
I
383
DISEASES OP THE niP-JOINT.
inrfi««. Pieces of atroiig webbing, on© or two indice in length, with bncVle.4 attached, ai-e eewed to tlie lower <>3ctreiuitt«fl o( ihc pliuMvnt. Thvic [iliutcrs nrv then plaocd on »itlicr (<!(](.■ of the log in such a inunQer as to leove the buckles a little above the ankle- joint, mul tliun no eeatnd bv n ttniiglv-adjuMtcd roller n« to leave the talxs with tlie hticklea sttochod lian^ing loose. The roller is then carried up over the knee, and ne far n]) the thigh a» ean be done with eonvonivncc, when the upper split ends of the strips of pWter are reversed and braided in with the rolk'r a« it re* turns down thu tliigli, eecuriug it enioothly. The stocking is tlien pulled tip on the foot, htileti having hiN^n cut mi eittier side for the hutrklcs to jtass through, and the shoe applied witii holes cut through it in the same wav.
The limb now beiug prepared, the instrument is placet] on it^ outer tide, and the en]«»-bar at the bottom brought in front of the heel of the shoe, and secnrely buckleil to the tal» above described. The pelvis-bett is next brought around the hijis, and secured by tlic b\u-kle upon the oppoi^ile side, and tJic pcrini'M) band^ are next attached a* tirndy m may be. The knee-pad lian<l is then dipped up or down until it !» made to rest opposite the kni-«, when it is pASsed around the teg and buckled. Extension is now made with the kev u|Mtn the ratchet until free compresttion in bonie without pain, and the patient can walk without cane or eratdi. (See Fig. 154.)
If the limb is addnt-ted. the alwlucting screw can be use<l, daily inci<easing the teneiuii for the piirpo^eof abducting the limb.
If the limb be AtTx>ngly Inverted, the eversion-screw enn t>e nsed, the force being gradntilly applied for the purpose of rotating the foot outwani ; and, if the thigh is strongly flexed, the force exert- ed by the elastic band upon the posterior part of the f>i)lint cru 1)6 applied for the purpo«o of pn>diicing extension.
In <Mi»c you are not able to obtain either a *hort or lonff splint, it is jmssible to treat the ease euecci^sfully by means of Ibe bcd- cxteusion alone. Another method is, in addition to the lied-ex- tension, to make exteuHon by increasing the weight of thu iJioe worn upon the foot of the afiectvd limb, and pcrniitting the patient to go about on crutches. This ran Iw done by ninning lead into tJie sole of the shoe. In such a eiuse you will be obliged to increase the length of the around leg by making the sole of the slioe considerably thicker. In this manner tlie patient can be op
TREATMENT OF FtRST 8TA0E.
^JtoA'trOaiid » pnrtinn of thv time, eufficient, iit leii«t,to rclic^-o liira fntm tlio Wd iiifiutnce of conHnned pnnfineineiit in bed. \iy lining t!ie whoei-trnjlpli, iiinii)ifactiir«d by Ihirracli & Co., iind the weight in rliv bottom of lite eIiov, ib mlditiou to the bed-cx- lentiinn, the patient run lie made very comfortable indeed.
Thviuj arc- mi-tbotUi wl>ii>li iiiav bu nM>ort4.\i to until {nvper splints can bo obtained.
LECTL'RE XXI.
D!6EASEe OF TBK JOINTS. — UOBBC8 COXARIDS (oOXTIN'UEd).
TKWnwiil (oonllnaoil). — TrMlmmt (or ili« ftr*! StiRC. — Tmlmcnt for tlu Sowod 8(l||f.— Tmtnicnt tat tlip Tliird KUfpi. — ('•*« lllntliBtlnK TiFalincnt nt Ad- mio«d Ulp-DUooxc miltiout ConiplcW Kui«tl<m. — IndlcMknit for Kuwctlon.
Gbntleurn: At iitv lout Icdurc wu Ktndivd tlio print^iples wbich lilioiild jruide us in tiie IocaI trentinetit of bip-diseiue, slid 1 nUi) pirv you n dcM^riptioii of the diflvrciit kindit of apimrntiLi and tlie mannor of their appHealion, by menne of wittch you ani to oarr>- tbein into pmctioil operutinn.
Now, for the sake of cleurness, let us return, and to-day OHi- aiJvr separatvly the treatment to be adopted in web stage.
What, then, in the ti-eatinent for the^nrf tta{^ t
Local dupk'tioD by inuniis of Ieir<.-lic« or cupA is often noceft- •aiy. Tlie ImweU e^hould be kept free.
8»ch coustitntioiud rcmodiM arc to be employed as may bo rcx^Hiwte in earh parlicular case.
Such gviienil eupjwrt Kbould bo girea as the eystom seems to demand. Iwnie^ in tJiin stage of tlie diftooeo aro wono tlian nso- leas, and do barm inKtcnd of good. The only good tbey ever have offeeted t-Hn be explained by tlie fact that they nmdu the parts so painful the patient vrae compelled to keep more (jniet tluiit he otluTwitie n-onid have done. TIio wcnitionalapi^calion of iodine or a blister may bo of some servioe ; but in a majority of CAM* I liAve found the applicatJon of leocbes and ice to bo nineh more beneBcial. The most important of all the means to be eiu-
SSI
DISEASES OF TUE HIP-JOINT.
ploired, and tb« one upon wliich fkll prwpoct of sncoea depends, is fvst t^ the joint and petfact freedom yromprvtmtrv (^ the I'n- fiamtd articular ttufaciv. II left U> Ueolf, tbe n»t whicL in to eseenlial to llie joint i» prucui'ed l>^' the tinti muscular coiitntction wlik'li jiivvoiittt niotiuii, and this U so pcrft-ct, iu many iiietimces, sa to ai«unie the appearance of genuine bony nueliylosta. But such cotvttant riiuKiuW contrut-tion exlmusts tbo nen'ons syAeta, preases tbe bead of the funiur a^inst the acetabulum, and pro- duces ab«oqitiun of botb.
I therefore at once resort to artiUcial nieaua for oreroomlog (he mugcular ooiitrAi-tton, Uieroby removing; pressure from the partfl involved in the disease. For this purituae I most oommotdy employ tbe extcn«on by means of weight and pulley, while in bed, and the &hort itpliiit, unlc»8, for ocrtnin rooAons, the long splint is prt-femble, while the patient is taking exennse. This a])p»nituii has been alrmdy described, with the mode of applica- tion, in uur lact lecture.
If there ts « gmtt deal of tondcruese around the joint, and , tlier ovidenpw of inflammatory action are present, it is alto- Fgetlier belter to tir»t pbit-e the patii-nt in bed, and apply the simple ext^ision by weight and pulley, and let bim reuiAin in thiH position until the inftammatory fl<;lion has to a coneidcrtlblo extent sulwided. Tliia may be facilitated by the application of leeches or ice, or botb, ae already indicated, and the admtuistru- tion of MUcli remedieii m the case may demand.
When tbe intliiitunatory action bus been ^ihducd, tbe tdiort or long eplint may be applied, and the patient permitted to go about.
If tbe patient is nncaey, re»tle«», irritable, and does not bear the extension apparatun well, he may witli proprtely bo placed in the wire cuirass {^ee Fig. 172), or other (iw-d apparatus. ]Jut I moat again warn yon of the danger of permitliiid; tbo [katicnt to wear such fixed dregdngx too long. If employed at all, they must he fref|itftitiy removed, and pasiiire motion employed, else aucby* lusis, more or less complete, will take pbce, and the lust state of tlie patient m.ty be worse tlian the 6rst.
Again, the deformity, even in this stage., may be eo great as not to pennit of the immediate application of tbe Bplint. In puch cases yon must plaoe the patient in IkhI, and apply extension first in tite line qf d^ormitj/t an<i then gradually, day by day,
TREATMENT OF SECOND STAGE.
S85
bring the limb toward tlic nornml position, and, when tliis bas been nearly or quit(^ reached, the splint may be adjiiRted and the patient fiermitted to get np. SoiiictinivH tt happoim tljtit the niuKtcs hare lieoome ho firmly contracted tliat they will rcijiiirc twI>ciitancouE Eoctiuii befure the limb van bo brought into itA proper position.
It should be yi^nr aim to bring the limb as soon as posEible into a proper position, so that the ttplint can l>e Used, for, wli«n it is applied, prossuro can Iw removed frum tlit- articular eurfat.'ee, motion pennitled, and the iiatient is in it condition to obtain all the Iveneiits of suidight and fivsh air. Even if the splint {-annot be worn ijiore than two, lliroo, or four hours each day, the change of poeition, the moderate exercise, the eunlight and fresli air which tho patient is able Uy obtain without ondan<rcring the dtwu.^ joint, will be of more benulit to him than all thL> medicine in the world.
In very many eases the bed-estenaion and the eplint can t>i> applied at once ; one to be used at night and ttlorniy dn\>, and the other to be worn when the weather is pleaaant, bo aa to permit lUo pntlent to l>e out-of-doors.
Change of air, from the sea to the interior, and vie« vena, and from low valleys to the niount^ns, and from the mountains to the sea, is very eii^vntia).
Next, wliat is the treatment for the second staffef
The treatment of this xtagc necessarily differa affording to the condition of thu joint uud the character and quantity of its con- tentA. If tlie dlMMO is simply stibncuto in character, the joint not disintegrated, the cffoaion small in quantity (recognized by tho auiall degree of malposition and limited motion), slight but per- manent extension comes first. Tliis c«« be accompliftliod by the extension apparatus already described. Extension is employed for the purpose of counlcntcting the morbid contraction of the niuselcH, and to relievo the pressure upon the articular surfaces of the joint, and is to be pei^irted in until the more jiromincnt in- ftamuiatur^- s.^'mptoms have subsided. Here, again, tlie extension mast always t« made in tht Un« t^f the d^&rmity, and gradually chnn^^-fl until the limb is brought as nearly as possible into tJie normal j» IS it ion.
The cODtinuoRs extension in bed, preparatory to the applica- tion of tho spHut, will be more frequently required in tliis than in
DISEASES or THE HIP-JOINT.
the firtit Mnge, and, when the nnniial paiition of tlic limb has been reached as nearly as possible, the instrument may be applied, and the pntieiit allowed to take outKloor oxcrcJso. If the in^atnmatoty uction is eoiiiewhat active, repeated hut moderate depiction by lueaiiH of leech^ or cuf)«, pres<<ure by meanM of adhc^ivo Ktrape, and a mild mvrcarial treatmvnt both internally and externally, will »statX in 4tibdiiiitg it, and promote tlio nb^orption of the fluid. This treatment will he Applicable in a majority of oa^e^ but there are those in which tbe intlamnuition is co violent, and the pain upon the iJighteHt motion wi inton^e, that al»oivte rest will t>c re- <]ujri-d fur a time. For giicli case*, the wire iiiiratw \* almost in- dispensable, CBpectally in email children. If the inflammation is very acute, inilii-:)tfd l>v l«x-al pain, best, and genorul eoiiGtitu- tional dislurliflnoe, and the patient has a viji^nroufl conRtitution, the cntLM being clearly traumatic, and suppuration sot yet beteun, I deem »n enet'getie antiphlogistic treatment to be the safest method of subduing tbe iuflammatioii.
In such cases, the eSusion may aet as a new excitant for the porpetualioii of llie inflammation; conM.-'juciitly, if the joint lie- eomes diitlended beyond endurance, oauMng great Im-hI trouble^ and reflectB detrimentally upon the genera! system, tbe prompt removal of the fluid becomes abBohitety necessary. This opera- tion never fails to give hnmediate relief from all the m<ire prominent symptoms, and restore rest and comfort to the pa- tient. In fact, it is tbe only aiiodyno that will perfectly relieve the pain under these eirciiinjitances. Ity removing this intolerable pnaanro we dimply imitate Natiu%, who accomplishes the same thing by itpontnneous rupture of the capmile.
The accunmlated fluid in ^uch ca^ee can be safely removed by me«ii8 of the aspirator. In case you have not an aspirator at hand, a small trocar may be used with a eanula. to which is attached an air-tight syringe, tliat acts upon the same principle as the stomaeh- pump. A small trocar and canida mat/ be employed, but mucji greater care is nec4>s««ry in its use, Ie«t air should enter tlie cavity and become imprisoned. The operation by means of the trocar and canula is to bo perfonneti in the following manner: The patient should be placed upon the healthy side, and an aateetbetic administered to ohvijite the ]<ain caused by moving tlie limb in the manner nccceeary to expel the fluid.
The most favorable place fur puncture is immediately behind
PDSCTCRING OF UH'-JOIST.
28T
the mktille line of the femnr, an<l <Aooe tbe large tr(M.-)iimtor, clotie to tliu 8ii|)4irior iriar^n uf tlic tendon of tlio gluu>»8 iiiaxitiiun niiia- de. At llib point wo ciui enter the hip-joint just above anil in front of ibu di^tul tuss4. TIk- ontiuU Hhrniltl not i-nler tltc joint, psrhapA more tttan one-eijfhth or tine Bi.\tcentJi of an inch. This in [wrtic-ulurl^ to be l>unifi in mind, wlivii it bucunieti nvo««eurv to iLie an onlinary trocar and eannia, for the moment the rapsule lui8 been punctured the ttttatr in to be witlidruu ii, and the affuctud limb ste.'Mlily inverted, adducted, and rotated over and acro-'e the op|io«fiU- limb fur the piiqxxMi of i-oinpletely removing the fluid from the joint. This ]Kifiition should be retained until the csnulit is withdrawn, the wound curefull^' doted bvadhi-sivc plaster, and the joint cnrcfiiltv snrrniinded by oompreas and hing adhesive Mraps, which will escR-ise prc««tire and prevent idr from untui-ing the racmint that will l>e created when tlte limb is returned to the -fltraight potution. The {mtiunt ithould tJien ho wcured in winie iipp«r«tiiit — ^tlio wire cuirass (Fig. 172) is most convenient — which will prevent the possibility of inottoii. Besides the rest, a low diet and a muderat*- ]inti)>hlo;;i''tii.- la-atment may be neeefparj- for b few ibiya. When the Huid has been removed by tlie aspirator, as in the manner jiii^t dcM-nbi-d, rciuMnimulAtion very mrely t«ke« place; bnt, if it does, the nperalion may tie r<-pealixl with safety.
If the tluld removed from the joint \6 jtiiritlcHt (which might have heen ascertained previous to tlie operation, by a careful aniily^'is of the const it ulionttl symptoms), the question orieee vliether the pus is simply the product of synovitic, or whetlier It is BMocidtod with ulceration of the outilage and caries of the iKnie.
With very few oxooptions, when there is ulceration of cartilage and bono, we find more or leee crepitus, which can be canly rco- wnii^ed hy rotating the affected limb after the fluid has been withdrawn. In the ahscsce of orepitnv, e^pedslly if this disease in of bnt short duration, we are jnstifiei) in presnming that the case is simply one of cnppurativc synovitis; hcnoe wo may give the patient a chance of recovery without any further ojierative procedure.
If, however, we can satisfy ourselves that the articular surfaces have become olcemlcd, the carlilagi^tt di»intt^'titi'd,and the bones oroclcd, which is indicated by the presence of a crepitus peculiar to {tself and altogether different from tlie crepitus of healthy
388
DISEASES OF TRE HIP-JOINT.
bone, we consider eamection of thv joint not onlj' justifiable, bat 11) most instances alieolutely ee&cntial.
When other juintH have bt^cii found in « duiilar condition, more especially wlioro the difiintp^rration hu gone on onlv to a limited extent, I have fruely ojn-iiL'd Uiem, removed all carious bone, {MiKricd setons thron^h thetn, injected tlicm with iodine, and thereby obtained ratisfactoiy reoiili*.
In many iriHtJince^ 1 h»%'e )iHtl porfcti nc-coveir, with free mo- tion. But tlie principle of incinioii seems not to be applicable to the hip-joint, ifiiioi! ilo ounfunnation, it« doeply-fieated eitnatjon, ind iuvestment with soft parts, olt^truct the f n% exit <>i tlie diAcbarfne.
In fact, the hip-joint can hardly bo said to bo frvcly opened withont removing the head of the- fcmnr, which fill» it completely.
Finnlly, wliat ih the trmttnent for the thii'd Magt f
In this etagc there is iuvariably ni|>turv of the capside or per- foration of the acetabulum. Rupture of the capsule may take piloe from over-<]iMciitiou with the pruclucts of inflaiuuiatiun, ancli aa serum and lynijih ; or it may follow ulceration of the car- tilage* and bones, in which case the contents will be purulent. TbeM two conditions differ Im.m each oilier veiy widely, for in the former the contents of the capsule escape into the cellu- lar tissue, thereby relieving the prcwure wiliiin the joint, consc- qnently the most pmmincnt ttymptoms, and are finally reiiiovod by t)>e abiwrbeiits or disebftrgc<l. Indanimntory adtieaJons v.'ill fre- quently fomi about the joint, and the limb will be left in mal- poMlion, but a sponlaneoun cure may be effected. Such casiei are by no means rare, and it ib this fact, prottably, that lias led many surgeons to rely u[»on the Miiiple effort* of Nature, more than npon sii[jt>cal art, to effect a cure. Nor do I proiWBe any active interference ; but, ou Ihe eontrnn', 1 only euggest tlint Nature should be awiiiited by mechanical appliances in her efforts to bring alMut this spontaneous cure. The object of such appliances is inen-ly to relieve the joint from pressure, by ponnanently ex- tending the niurbidly-ettutraetcd muscles, and at the same tiuic ■ecurinjc ila perfect mobility, toother with a normal position of the exlremily. When the cure Itas been effected by the unaided efforts of Nature^ it ia invariably accompanied by deformity, and that deformity, in a hrgc number of cascft, is de|>endent upon false or fibrous anchylosis. This result vra formerly con»idere<l the most satisfactory termination tltat could be ex]>ected, but even
mrANCHYLOS
'889
tb'u lias t>ecn limught within the rvnoli of vitrgU-»l art, anil is Btiftcfplibli; oi' |H.'rf«!t n?lief ; for dirision of ihc contracted raus- vlvr. iiii]iiicate<l in the dofomiity, ai«i IjR-ukin^ ujt the udhmuns bjr forvc, while tli« patient Is under the influence of an itniei^ tbetic, followeil I>r proper orthopedic treiittncnt, hctvv in niiiiiur- nnB iuatflncoK rvtnoved the dcronnity, nnd re^itored motion and ns«.'fuln«6S to the limh. {See Cote, ytngc iiOtt.)
When, howi't'cr, nWretion of the curtiiagee and bone is pres- ent ainl is aiiconn>anied by purulent effusion, we have n verj- dif- ferent poudition of atfAii-it to dwil with, coniicqnenlly our Hur^icul prxcitbirc nnint vary accordingly. In thtB c<(>tiditioii £puntatiooui> cores are extrciuoly rare, and, if we deduct from them the ea»L'« of porioi>titi!t that have been mistaken for caries affec-ttng the hip- joint, the number will be Htill further nnluced. ludeud, n cafu- ful cxaniinnlion of many esses, in my own practice and in the practice of otherv, Uae led mo alutost lo doubt whether it ever oocnrN. We can hardly be Miqirimnl at this when we coUMiler the many natural oh^icIeH to a free di^'harge of the delritUH, thereby slraotit invarialily creating; new di>cai«e in xuch tiKtme^aji it may eome in contact with. It is in this manner that the diBea«e is ])«rpi>tunIi-<}, hcc:uiso of the inability of Nature to c-stubliiih a Buf- ticiently free opening for ibe removal of the iwrti* ftlrvftdy de-' ittroycd. Nntiire, ntuiidod, ha« only one cfBt-iont method for cur- ing caries, and that ia by gradual exfoliation and removal of the (lend bone, eHtablixhii];; hwilthy granulations in the sound ]M)r- lion, tlu'it'liy ikiibtititutin^ fur the yavt roniovcd tibmns and often- times oaiilying rtmcture. 'I'hU process is extremely slow, and may pwjuire even years for tlie ix-moval of n comparatively Bniall fragment of bone. In t\m morbid s)Kwimen yon see here, kindly funii«lie<l mc by Dr. Jancway, the disMw; biid been in existence eigliteen yeaw. and yet. «» you see. the removal of the dead bone had not been (jiuto completed. Hut. if these patients do spon. laneoaaly recover, after udvancinpr thus far in the di^we. deform- ity iit alwayn present, unless ihe very gi-eatest care is exeivised in rctainitig the limb in ii pro|K:r poejlion while recovery is tak- ing plaoo.
It is fnitri Naturn-'a method, however, that we are to deduce the principles that are to govern na in the treatment of those wwes. These principles have long been reeogniited and practically ftdnpied by the profeaaion, for exsection of other joinU for tlie
soo
DISEASES OF TOE HIPJOIST.
pure of c«riee and necrcmi* i« an o))crAtioii of daily oociirrence:. itut, etrangt.- to Bay, caries uffet^ting tbe liipjoiut has, until within A few jeam, been excluded from tlic lUt of taww to be benefited by Has ofvTRtUm, and by many eargeons tbe operation of tiOD udi«<-iiinitt!iuinoed at tbe |>rt?«ent time.
Tbe queelioD now arisex, Ilow are we to dotcrmine whether in A given ciue the operation uf fXMX'tioii i4ioiiId bi- [n-rfunncd I
If you tind that tbe dittcharge is diminishing, the general besltb of tJio patient iinproviug, and that the limb can be IwoogbtJ into a poftition in wbiob it will nventiuklly be of iwnioc, it i» liett^-r to permit the case to go on, an<l allow tbe cure to be completed by tlie gradual exfoliation and dieehnrge uf dctid bone, according to Nature's method, than to report to the o|>cnilioti.
In tb<.-eo c««ce, however, you can do a great de-al to a^»t' Katnre by dihiling tlie sinuses leading to tiii: dead bono with spongcvtent^ and, if nccvsear^-, malting free openings in Tariou« direelioni^, and inserting dniinn^o-tiibi> uf Iiidiii-rubber or oakimi ntons, thereby facilitating tbe ready and complete exit of the discharge.
Thio was done in t]ic case you now see before ynii, and, bj ihoK) who Kaw tbo i»»e previous to treatment, tbo rveult can be readily appreciated.
O-uiK. JJip-Joint J)i»f«ae of £Zevetn Yeari Standing ; EeeeB- aire Sitppnration ; ErftduUion of S'umtrmu Pitett tf Bone ; Orgaf Ditiortion and J^tbrowM Adhaion* ; Nttmerous &*n«aef j ttUldincharying ; Tcnof(tmy; Fordbif- J m}'roc«tnent<f Position f Sinusfs diMfd and I)fad Bone remoefd; India-rubier Ttihes drawn through the Limb from Side to Side ; Extension, Abduo- tion, and BtkationSplint ; Befoveri/ teith Moderate Amount of Motion, — Xellie A., aged thirteen, wa« broiif;ht to m« at IMIis Tne Tloepital, Dofcmber, li^tS, in the condition seen in Fig. ICS. Tlic right limb wa.4 firndy adducted across the left thigh, andJ fixed by fibrous adtiesioiis ; eleven sinueo« in different parts of the thigh \icA to necroiied hone, which was detected by the Dexiblv probe (the sinuses being tortuous, an ordinary probe waft nscleas in tbo examination); a deep oicatri:^ extended from the rre»t of the ilium down throu^i tbe groin and ba^rk upon the outer por>j tion of the thigit, very nearly encireling tbe timb ; another hard- ened cicatrix passed from the anterior #u|>crior sjnnoiui process of tbe ilium down below the trochanter major, and then curved in a
CASE.
aei
V-sIispe back to the on(cr portion of the thtgli, meeting tVie first cicatrix dtffcrilKxl; in tliese cicatricea there were varioim itiiiuBws throogb whidi the probe could bo passed in dillerent directions
rn. U9.
Tlie mother stated that, when tlip oliild wns two yeftrs of agfi, etho full dowi)-8tair», »ilrikiii^iiiK)it ht-r right hijt, whieli n.'KultiHtin a few tnonlhs in a severe inUiiiiiitiiition of tJiat joint, ondtiig in |AM^i.«Mts wliich have been diicttarging with exfoliations of bone >re or less for the hist ten yesra.
During the first ,vc»r of her siifferitig, thu limb wiut ap|inrpiit],r ^^n;^)^, and tiimod tmtwanl ; but, after the large «h«oess formed on the outer part of her hip, the leg tiinied inward and wai) «lMrtvr. Shu wiia ninth more free from pain after this than she was daring lhec>oinm<-n(Ttticiit nf the ditM-M-c. but she Ixvamcverv much ciiifloiiiicd aiide.\hsuHt«.>d fnjni thuu.\ii-«»ivoditK-h»rge. AL) kinds of internal medication hud been rcflortod to, but no efforts hod been mode to piwcnt the di^torlion and deformity.
As she was unable to walk hi Hiinb a c4>ndilion, she was sent to nie for the purpo«rC of having uxMction of the hip-joint per- formed.
l'[>on cttrufully examining tlic cabc, I found tlint Nature had, during Ibew eleven jcara, nearly eucceeded in removing all tbu dttid bone, and, as there was so much deposit around the jwrts as
293
DISEASES OF THE UIP-JOINT.
to rcn<i«r cxsection diffic^ult, if not dangeroiiii, I dotcmiinod dilate the sinusvis ftud tliu» aid Mature in tli« romuvul of tbe re-' tiwiningdead hone, and, by tenotomy and Bection of tlie contracted fascia, endeavor, Ijv forci-, to iinin-ovo her paeition, ratlier lliati take the risk of performing ex.seetion. Tliiit o)>eration vag, per- formed at the timu before tbi; class, th« limb forcibly abducted and extended, and Kcure<l in tbe nomial po«.ition by nutkiiij; long Eplinl, extending from the axilla to the foot, witli a croM-^ |H€ce, Boine three feet long, at t)ie bottoDi. ThU splint vnn eecurcKl to licr widl side, by buiidagus, lliv foot being tinnly placedJ against the croes-piece. A pulley was plai^ at lite t'lid of ttidl eroee-piix'C, orer wliieti tlie cord from the adhesive plnsters npon her dipeaaed leg wad run, and a hix or eight jnnnul HcS^jlit wat . attached. Tliiit weight wa« increased or diiniuifljvd according to' bor ftelinge, thus keeping up constant extending and abdncting forces. Hie hi]) wax cnvclo]R>id in cloths wet with mid water; bat, finding tliat thvse gaie great pain, large hot poitltico^ were substituted for thvni, which affofdcd much rcUof. The sini were dilated with Kpunge-teats.
In a few <lAys several of the sinnses had become »o mnch en> larged that einall piocc« of bone were readily picked out with the forceps, and three weeks after the lir^t o)>eration a lai^ llexiblu probe was paiuKd from the outer portion of tlic thigh, nhout an inch above the trochanter major, dt>wn through tlie limb, making its exit (hnmgti one of the einojscs near the perina-um. A perforate Iiidia-rubl)er tube was Uireaded thnnigti tlie eye of the prol>c, tmi dniwn through tliis canal, and is still woni l,as seen in Fig. 1C9), altboogh there is no occasion /or it, the diifcliarge having long tattm ceased ; but the girl hnving derived so much benefit from it* nae, insists upon still wearing it — like an ear-ring, more for ornament than use. ^Vi(hin a few months after tliis tube waaj passici through the limh, alt the oilier Mnn-** gnidunlly eloeed,^ and have remained so.
Four niontlLi from the time of the tenotomy ami hrisetnent- faroe, I applied to her one of my long uplints, with sliducting and rotating screws, modified in such a mauncr as to be slip): into the sole of her shoe, like a spur iu a gcntlcmnn's boot (soe^ Fig, 167 a), by which means the necessity of applying adhesive plaster to the limb waa avoided. It also had a joint, ut tlie knee, capable of permitting flexion in the silting posture, but becom-
CASE.
ssa
iag stiff in the erect position, nnd with it applied, and tlu> solo and hivl of the ehoo elongated to maloh llio oppo«Jto leg, she is enabled to vaik witliout caiio or crutcli, as swa iii Fi^. 109, und i» perfectly healthy.
Thifi piitieiit vfoa last .teen December I, 1875, vhen (he photo- graph from which Fig. 170 »•«« cut, wa» t«keii.
There it no discharge from ant/ of the anuses, and no neceo- 8ity for wearing the drainagv-tuhu lias grown veiy much and
riB. in.
m. no.
i» in perfect h&ilth ; has mmc motion nt hip-JMnt; can 6vx, nhduct, and extend lier Ivg to a considerahle degree.
If, notwilliKtaiiding thii' treutrncnt, tliu diR-lmr^^ doeit not di- minish, hut rather intreases; if sympti^inii of ]>rogre*iive caries de- velop in tine part ; if the dt»e»»c, imtteod of improving, progreseeK in ^ite of all your efforts to RutKliie it ; the };eneral health of tlie p»- titMit ill daily boL-uiuIiig uiidi'miiui-d, and tlicri; aro no symptonu indicating repair, the only juBtifiahle treiitnient left for the snrgeon is exeection of the joint. ^lAturo curt's these cases by exsection, but the patient very frequently dieii before the operation is com- pleted, in consequence of exhaustion produced by the long-contin-
in
DISEASES OF TIIE HIP-.IOrST.
avd diecluu'ge. It is for tbis rcamii that UA operation U jnstifiaMe. More can be done in hnlf an hour witb t)ic knife aid nvr, in the way of removing (lend boup, than can l)e done by Katiire in many years; licnce I iirjpi that it is the dnty of ihe eurgcoii to oxisert the joint, thtfri-by removing the i>atient from the dangent attending long-continued finppnnttinn. It would ««cm, to an un- bia»-d mind, that Ibc same tbciupontiral indications miglit be applicjilile to the hipjoint, so far 88 exwction goes, as to any other joint. In fact, it is my firm conviction that cariea of the hip-joint, by reason of tlie impending danger of [K-rforatiun of the acetabulum, roiiuirm more prompt and decided surgical inter- ference than when it manifeMs itself in any othtr joint of the body. The operation ii; not only justifiable, but imperatively demanded. Xo lem an authority than Prof. Symtt bus made the assertion that, "if the acretabulum he canou*, the patient must die." We can tlierefore lo«e nothing by the operation if this be true, bnt will, on the contrary, invariably procure comfort for the patient. i3ut the a»M!rlion is not true, for in the majority of cases, as shown by my own statiHtical table, the patients have had their lives saved. Nor h that all : wc not only save Ihe life of tiic [Mktient by the operation, but we aiaa restore form and motion to the limb. Of course yon mnst not expert tliat every case of exsection will prove Kiicecvsful. Jn one case, the disease may I>e so AMocialed with constitutional vitiation that a mere local opera- tion will not eradicate it. In another enae desirwetive proo«*c« may have gone on to snch an extent as to preclude tlio possibility of removing all the diseased tii^fiues.
In all such cases the disease will prnljahly proceed to a fatal termination. Itut when tlie diwase is chiefiy local, the c«in- rtitution not yet undermined, and its extent so limited as to admit of ita entire removal by the knife, saw, and gouge, and when we can have the advnnlage of proper air and diet, I am cvrtain that this operation, if performed at the proper lime, offers the best po^ble chance for recoverj-.
It U now twenty -nine ycflrs since I performed the first boo- eos^ful exAcction of the hij>-joint in this coiintry, and at that time the operation wa« very aeverely eeiisored by nearly the en- tire profession ; but the nnmerons cjiwh in whieb perfert succM* )ias l>e«n obtained have proved its feasibility, and it is now quite generally considered as justifiable. Therefore, I now feel Uko
HISTORY OF EXSECTIOK.
995
making Uic prediction tliat hy the time the oiUirc profession Iiik accepted it a# a jngtitJnble o|)cratioii, surgeons will know BUtBcienI (■onccniiug hi[t-joitit disuasu sad its trcJittiioiit to rcii'lvr tliu oporation entirely iiniieceitMrk' ; for a thorough knon-ledge of ild puthologj, etiology, and vcrj* i?nrlifst symptome, will Iiaui th«iu to sudi an early re<>>giii(ioi) of the diM>ai«! iia will eiiahle thorn to trwut it in a manner that will ohvistc tho ncct-ssily of i-xtHxrtioii. At present, however, we are ulfligol to perfonn tho ojioration in those cases where proper treatment in tho ciirlitr Htuf^it has been imji^lcctvd, and niii^t therefore ^tmly the method in whteh it shouhl b« done. To this subject we sliall turn our attention ut the next lecture.
LECTiniE XXII.
DMKA0E8 or THE JOINTS. — MOKBCft OOXABIt? (onKCI-CDBD).
Trv«linpnt (oonilaiind).— F>t]>(V(tun, — IIlMlaTy (if the Opetation.^The Oppralioa ile- ■cribol.— Mode of drviaiiie ilm I.inili ttter ihn Opemlion bu bewn pnforiniKL — After-Tmtmcnl,— Tallin of Etwctloni appcDdcd,
Gkntlemkx: Tiie liistory of Exssenox, for the relief of kip- joint dtseaj«, lies wit)iin the present century.
Tho po»abiIity of removal of the upper extremity of the fo- Hinr was tiist suggested by Mr. Charles White, in ITGH ; hut the Unt surgeon to attempt tlie operation in morbus roxnrius wiw Schmalz, ill ISlft. In hiifciiwetho head of the bono was found lonoc, and simply re([uired removal. Tlie ca^e of Sclilehing." Hoffmann, Batelivldor, and Kiinger, were wmilar to that of Sehmiilz,
In 1SSI Antliony Wliite performed his eek-bnitod o])cnitio4i, which has generally been referred to ae tliu tirst successful exseo- tion of tJio bead of the femnr in morbus coxjirlus.
From 1S21 until Ij;45. it i;p|)enrB that the opralion km per- fonned by only two surgeons, namely : Ilcwson, of Dablin, in
* SrfiMhiag'i cue >u oat of exioti<an •nd not euMtion, uid U Ihc ftnt eM« of tfcii dcMrijiUon cTcr reporlnl, n* fur ai 1 coa disovrer. Il occarrcd in IISIX— &■ •'riilloMFptiiailTntiMcUaM"forlT4i.
DISEASES OF THE inP-JOIST.
1828, and Textor, Sr., wljo operaU-d three times prior to 18+5 — owe in IS'^, once iii lS8tt, nml agsiii in I8.^9; all tcniiiiixting unsuoccaifully. Tuntor upoRitud ngato in 1845, and the ciuie ter- minated ftticcetKifnUy, the man Hubaequ«ntl;r obtaining lii« Iiviii|; IS ft pL<dd1ur.
lllr. Fvr]gu»on has o^Htrnted five times, nml wttli uiuform euc- nesG. One uf bis puttcntHdiwl tn-o jettns after tho operation, " of onlArgero«it of the liver, »ft«r ttaving exiwricna'd great rvlivf from the proot-eding,"
Mr, I''i«rg«w>n stiUft* ("Mt'dia>-<.'hiriirp<«l Tranatctionfl," vol. xxviit.) that he bus Wnied tlmt Mr. lirodie performed tbiti operM t.ioit, and "tliv piilit-iit diitl within u few days afti-r, thi! dir effect of that prix-eetling;" l)iit Mr. llvnry Smith, writinji; in 1848 (l^iiduii Lancff}, remarks that be bat not been able toj "obtain any accurate inforniutiuii n;*ip<^t'ling the cKrn-clnt^g this assertion." There is no doubt, however, that this siirgeoc did esstirt the head of the fi-innr nt St. George'd Ho^tita), aboulj the year 1H30, but, under what drciiniBlances, and with wh&lj result, I tuive l>een unable In aec-orlain.
CAmiiclmcl, of Dublin, it has lieen Bupposed, [XTfornieii ibid ' operation in \'^-^) ; but it is more than probable that the case ba« been eonfotmded with an exarticulation for medulUry san-omi which be nimle at tbat time.
In this cnunlry lliv ojiorHlioii attiiu'tcd but little atJcntion, nntil I published my first case in the .AVw York Journal ttf Medicine for Janunry, 1h55. That was the fin»t time the oj*n»- tion bad bwti uncotiisful in lhi» i-ountry. l>r. IJif^clow, of h<wt<>n, had perfonned the o|M!rBtion, and publiidiod an at'connt of tlie simie in tb© Aintvic'tn Journal of Mi-dinine and Si'^ncn, •Itdy, 18112. His caae torniinatod fatally the twelfth diiy after the o|H'ration.
A ease is rei»(irtcil in the AVw Yori Medivo-Surgicttl Jtejwrier, January 10. I8H(. in wliicb Dr. S. P. Batebelder, of Ibifl city, removof] the heud of the femnr in IS^.^ under the fnllowing cir- eumstancos; A ymmEr uuin had boon kinked npou his hip by a hor«e four or live years before. Severe symploniit followed ; fistnlons openings formed, and pun was freely diwharged. l*'i- nalty, dead Iwne was detected by the pntbe. The fi^lnla was dilaU'd wUh tj^ong^fents, and the deiid bono removed by the forecpB, wliicli proved to he the liead of the fcnnir. After tho operation the patient improved rapidly, and eventually recovered.
OPERATION" OF EXSECTION.
SS^^
Thw ooald not I>e called a cow; of c^cMtction, nnd tticreforo iat not liticii itiftiided. I liitve heard that Dr. P&rkman, of Boston, es&ei^tud tluH boiiv in 1S5S, but lixvu been uuablo to obtain any particulars of tliu oatte. This Icavi-s my rtperation id March, 18M, as the tirst in Ibis eonntrr that tc-nniiiutcd i>UM-(;tu< fully. I hiivo now pcrfonneil the operation in seventy-two caws, und tho ri«u1u may be seen in tJie tsblus appended to thia chapter.
So niuob, fTviitk-iiien. for lb© history of the operation, and I will now show yoii pnn-ticfilly bow to portorm it, and explain the varions tiepi in t.bc ofHimtion, nnd tlie mode of dreeung the pa- tk«it after it i8 peiforniwl, as we proceed.
This little patient you eue before you was brought to the lioejiiud tome monlliit uncc in a dyin^ condition, having lieon found in a ip'iT^'t i" Buxtt'r Street. Her fatbi;r bad beon dead for eunw time, niul her iiiuthi-r wim in a lunatie nsyluRi. She had no friends or relations tliat L'ould give any utfonnation of her prOTJouB condition, tlic eau^ of licr diiieaae, or how long it lia<l existed.
At tlte time of Iter ndniiMion tJio wm ho nearly dead fi-oui ex- hatulion tbnt an operation was not deemed ju^litiubic.
Hut heallli line gruilly iiiipruvixl niiiet; pbe baa been in tlie
n». III.
hofipital, hnt *\w i» Rtill in a most nTCtcbcd condition, ii» Been In J'1^. 171, friHii a pliotit^nipli by Mr. Mii«>n. This photograph li»d to be taken in the ward, «« it waa iin[iotwiblo to move bur to tlu! gnllorj', and therefore the pictare is very indistinct.
29S
DISEASES OF THE mP-JOlKT.
Slie but laid in Itie pcwition yoa now Bee her nearl;r all tlw time i»iDoe she hu liecit iii t\w litntpiuil, nnd it i« iiiiposEible to more her in any manner without giving bvr lira inwt iiitenM! pAtD. Tlie thigh, as yon see, is dexed, and Btruiigl^- adducted acroBB tho uppoi^ilo litnb, and there are wverat einus«R throng which the priil>e readily passes to necrosed bone.
AVe will DOW proceed to the operation, which is performed id the following manner: Administer an ana>«lhetii?, and then place the pallciit uiwii tliL- I'ound tide. Next eeleet a sti-ong knife, and drive it home to the hone at a ]>oint midway helwewi the anterior Enporior Hpinoui* proL-css of the iliimi and tire top of the great tro- chanter ; then drawing it in a ciirveil line over Iho ilium, kwping it linnly in contaet with the hone, make an incision aerosa lo tlte top of the great tmoiianler, extending it not directly over tlie centre of the trochanter, but midwav between the ceiitrv and its posterior border, and eomplct« it by carrying the knife forward and inward, making the whole length of the ineisicHi from fonr to six or eight inches, according to the size of the thigh. In this manner a cnrved inciiiion is uknde through all the tuift parts down to the iKine and through ti^e j>erio«fruni. If you do not fool cer- tain tliat the periosteum has been divided over the femnr by the first inci^on, carry the point of the knife iilong the same line a second, and, if need be, a third time.
The lint inehtion having been made, an assistant, by means of his Kngersor retractors, draws the t^of I purls aside, and you come at once upon the grc«t trochanter. Then, with a narrow, thick knife, make a second incision through tlic penoti^vm only, at right anglc-s witli the fin4, at a pi^int an inch or an inch and a half below the top of the great trochanter, as iho c»*e may be. just opposite the leaser trochanter, or a littJe above it, and extend it as far as pottsibie around the bone. Here, again, make sure that the periosteum isy-jWy divided. Veryoften a thick involucnim will be present, and great care will be necessary in order lo make tlic incision through the porioslcum complete. Now, we have first a curved incision tliniugii the soft parts; and, second, a T-^haped itK-i«ion through the periosteum at the point indicated on the out- side of the femur, jud above the lesser trochanter. At tlte junc- tion of the two incisions through the perioNteum introdoee the blade of the periosteal elevator (ma Fig. 109), and gradnally ped up the periosteum from either aide, together with its meoibn-
OPERATION OF EX8KCT10S;
290
nous stCiu^hments, until the digital foeea has been i-eacbed. At tliis puint tho rotntont of tlic Ihi^i nru ini'crti'K!, nmi tlic attach- tnenta are h> tiriii that vou uill not be uble to peel them o% but will be obli^Hl to iltvidu tlwm with Ibo bnife.
When dividing theee iniserliuus you filiotild W very cantioiig ftnd kcv)i the knife dose to tlie bono, iimkiiig only a very Hiinll indsion, na a branch of the internal rircimiflex artery lies very clo«(! to tlicm. and, of Ciinnk', inni*t be ciirt-fuUy iivoidcl.'
Aftur tho tendon:* have Ix-en divided, (.onliniio lo elevate tlio periosteum u^hhi uitltor i^ide ii.^ far na can bo Mifcly dono without Imiakinf; it. Vou fthould aitn to peel off the perioMeiiiii intiict, and leave it as a perfo<rt ^lieuth after ibc botie has 1>wmi ivnioved, for the jinrpMiie of preventing any infiltration into tlie nurround-
' Tlw following ni>tc ahivli I h*T« rMfthvd ttom Dr, J. A. Wxvlh, ilnturllilng tlia arttv rUI (KMribulion, I Iutv ilivrnvdof mich iinporunr* tli«t 1 liavo&HtluJ it lum ri>ot-tiol«: "nie oomjikrvlJvi-Iy irtlliu;; •iixxint of IiIikhI lott In nii «i>priiijuii uf nnh nngniUiile M 111* exdiioa of tli« hiji-j^t, •li(*« Uier* b no nir«nii or nioiiiihtii ilio miiplj at lihiod la lb« flirt. Iiaa dnubthM added ver/ much to tli« rvmnrhiitili' *iii.-««hi wUtch liM •llffiibd Uili ii|wr«linii h) Ihti liand* cf lu tiilhor. Tlir (uUdniiii; iijrnuFnii iif twenir dl*NWllon« nf ili-> lil|i.j(ilnl.inaiii> with rnctnl loih#>rii'rin1<1i>iHtiiiiii)ii tii lhi« Nglnli, i««jr wrvp to *ti'iw \he riiwinp nli-rtj- of oxiviition nviulnitr in <i»Jcf to ■viiiil h— lorrb^ff Uiat vuuUI alaars lir nuiKi.'ini;. an-I in *iiinr in»Uiii:i]> iliinjcproiii'. Tliv Mi«riiti rMiiicI •UtitUiuliiitc brunoliiH ii> llil* r^K^on •vrv thv ^hrml, ■ciniir, obninitiir, flitomat, ami LiiM>niNl cirviiinlii-i. miil iIih *ii[i(iriiir fvrfomiing bjr uiulomiuu; nunc of Ibntr aiiproii'Iml tlw line of Endtion itlvrn lii' Prof, Saiir aear ciuiu;ili tn he ■Stlilcl borvio ilicy broke u|i liilo btandiM of di>>lriliution too nniill to give nm tn ■ay aotkulilc liH-iTiEirrlnxv, I'lnrpt ntic at tb* ttrtnliul branehe* of th< InUrnal rir- vumIIci, innictinivi' ni<.iill<"it<^ aa tlw iroi^hantnle hrMi(>h, btil otvrr dworibtd In con- Bt^nn wilh Ihc ^iirKtrat ■nninmy of tliii npvnilioti, lo the >ril«r'« knowlcdttv. In tvtcMj ilL.ti>ai"nit i1ii> artutjr wm (imtnit to •■iinr ruo. In cifitiln.'n of ihcM il came tmm Oiv inlrriial rlrriinilliti. puM*>l iH'loopn Ihr iiiiadmiiiK fvinuri* behind, tad the oUvralciT numnii \u Iront, and, lirrnliiK tii<ranJ tlia ili^ptal tutta, biok« up into ill la*nil»*l liraoi^liB* wlltiln from onr-cl|{liili to onf^ciiiarttr «r an tucli uf the inipnioD of tli« oliluralor cilcruui liiui llmt t<if*m, ananloiucwliii: ailh tin- acialic, f^Iutoit, wvl oiUtml rtrcomflri nrtorici. In two ca»<« lii wliii'U II failwl la coii-c fntnt tb« laMtsa) vircuniflcx, it wm dcriTcd fWim Ihn iirSiitii'. an<l ran in Ili4> dcprrMiun MwfSli llio quadraliu Craiflrli and obliirnUir nitvrtiui' lo it* ii-uiil ilHirtbulinli. TbU *«■*] nrind In >bu IWon a crovV-ijulll down, ollonor Miiall llian larvv. but )n all CTUM* of ■ufBclcni iJie at tlic diitanin frnni lhi< fuMta iitvMi atiovu to itilTrfrrc Willi the (Ucrfu oT Ihi' opirallon il tirrlrwlj diviili.il. A* tl 1* Milj at ibif pollil llial tin knife il a»nl in tin.- divficr ilnirturvs (in milling; ih' tmidona uf the obluniKir cl- tcniua oivl of iu forua) ii brliooii'i ibc yoitug lurgtvn lo gnanl aijalaat ibit danpr hj kmplas (be point uf hi* knife 'well n^niioit the bone' aaadciufil iu lli« a|iontlan, Mid ■rrer lo attempt lo di'idc iliii ti-ndon out of Din f»uiL Tlii> nbiunlor otwrtiua nuwIr WW acoKlanall; obarrrcd to be inttTlcd IdIo the givat tt«cbaiil«r, and sol (n tedlgtl^llMM.*-
300
DISEASES OF ITIE TTIP-JOIST.
ing tissite«) ; and, also, tr> retain die mtistnilar attachments for Uio future ntobilitv ui tin; ji^int.
Wlieii tbe jieriofeteiiiu has liecn removed as far a« can be Bafely dOMO, tlje \cy- itt to be slightly adductcd, and the head of ttio ffmur Ufte<) out from the iicetiibulntn.
In ihiii tiiiiitncr th:(1 p'jrtioii of thu perio^tuun) tlwt «ould not be reiuilied with the elevator is removed fmni the twno.
Horu, nj^in, yon i^Iiotild excrviM' ;;mnt v»n> And turn the bono it only juHt enough to {leniiit the linger to go behind it for tbe purpose of guiding tlio bhw in it« removal ; for, if too frco hixa- Hon IB made, yon will (li§pUu;e tlie perioetoiim ttw extensively, and tlie coiuwiiuuni-e will Iw a »»b«e<]uuiit exfoliiition of tlic lioiio thus nn«overcd. You will, therefore, uncover only no muvli of the bone as you wish to remove by tlie saw. This leadit mo to speak of another precaution : never remove the bunv witli auy> thing except a saw, a citain or a linger eaw being most convenient. If yon attempt to remove the bono with tlio bone-forropR, it« ex- tremity win almost invariably be slivered and eiibsequent exfo- liation will (like place.
After the periosteum, then, has been removed as far as ncocii- mry, ad<luct the limb a Intle, depa-ieK the lower end of the femur to a slight extent, and lift the heed of tlic Imne out only juKt fl8 far m i» reipiisite to permit it^i n-niovul with the xaw, and then saw through the bone just above the tmcliunter minor.
JTeverMwlhrtjiigh the ncek of tlie bone and leave the trochan- ter major, for the reason that, if tliie hirgu portion of the bono is not removed, it will prevent n free discharge from the wound, and in tliat manner cauito retention of pu8.
Ily i-cmoving the perioMteum from tlie greater troclmutcr, you have carried all the muscnlar attachments witli it, so that lliceu are prewined ; hence there is no necosity for leaving the Imne, and by removing it you have made a free opening fur the di«- eharge to flow Ihrongb.
It sometimes biippenn tluif the invoUirnim is to finn that llw head of tiie bono cinmot be lifte<) tn»i> ita bed ; and in two case<< I have aeen fraetare of the femur produced bv tlie efforts at luxa- tion, preparatory to sawing off the hone.
In snch enacts or in any case where luxation cunnot eotiily bo effected, eo as to iwrinil the linger to puea aroiiad the bone, saw the bone off without attempting luxation, and then it cat) bo
OPEEATIOS OF EXSECTIOS,
tiftt>(l out by inMtns of ttic forccpH or tlie elevator. In aucb cases tlie iijterBtJon is aoDBimlly Utdiouii.
If, «fti>r thill jinrlion of tlie bone Iiiia be4>ii n'liinved, it ia di^- covere*! tliat liviii;; burn! liii* not bi-c;! ri-aclif.*']. llie jicrioiiliiiim iiiiiMt \>ii ftirtlier reiiiiivt.'<l, iiUK-tt can be doiw hy luxating the feumr a liule mum, elippiiig the boitu through it, liki.- a turkvy'^ iici^lc nUvr hiA Uf^A \ma lieeii cut off, until hving hone haH l>ecii reached, no mutter wbeilicr it r<Mjuircs ouc, two, three, or live inc;h«« of th« bone to be removed.
I have seen oue oase in wbiL-b iiciirly the entire shaft of tlie foniiir vriw r»;inovcd and perfect recovery look |»liiee. In tJiat caw) the operation was performod by Dr. Spcut-er, of M'atcrtuwn, New Vork.
One great eecret of aucceee is to leave tbe pcriofttoiun entire. If tlie iDroliicniin which UMially eiiirouniU the bono iKtsewece HufBi-ienI vitality, it may bo permitted to remain ; but if it is at all dftit^icut in thiif refIH'<c■^ »» indicalod by ite apjti-aring like iiarioiu bone, it must lie removed.
Next the aootabulum h to bo eximiinetT, and, if found diseased, all tbe dead bone must l»e raivfully removed ; if the ai^elahuttnn be perfomted, tbie part of the operation must be performed with the grcateHt rare, le^t injniy be done to the internal hi\er of pe- rJostenm. The intenml periuBtvnni will be found |ieoIed off, or lifted awBy, ao aa to make a kind of oavily beliind the aoctabu* Intn ; and an BxcL-edin^ly iinpurtant point is to cliip olT all the vdgus iirrmnd tlic ]HTt'iir;itio«, down to ihc point wbcru the intcr- ital pcrioBtenm is reSecteil from the annnd bone. Thi-i id one of thfl niotfit dcliejlti' Htiipn in the n)>i'iiitiiiii, to he able to remove nil <lead bone from tho wall furmed by the internal perii>!it<-nm with out iujiiriiigorwoHtidin;; it. In some cmok, when tbe operation is f'>mplete<i, titer© will lie nothinjf inter\'eninfj bi-tween the flng^-r iif tbe ii])cnttor and the roL-tuui uf The patieiil, exivpt tlii« iuteriiHl layer of pcriotiteuin.
AiHittier im]>orlnnt i>oint ie to thoroaifhly elt'an tbe original flinases, carefully removing all portinnit of dc»d bmiv whii'li may have lodgvil in tbeir courM: durin;;; the prt^^fn-iK of tbe diecase, as well aa the false mcmbi-ane which lineH tliem.
If thin precaution is neglected, rnucb Bubeeipient trouble in tho way of continued diflcbarge, and perbapfi aliHcestt, may arise.
When all the du«d bone luie been removed, wash otit the wound
3oa
DISEASES OF THE IlIP-JOIKT.
tlionxiglilj, fill it full of PeriiTian balsam and Muff it witli uakum. The extremitiat of tlic wuiiiitl iiitiy hv dusud with Etiti'ii<^s hut the central portion, which Icuda direotly to the ni-vtuhiiluin.niu&t be kept open in itiich ft mniinvr a* to prvvoiit tliv poteibllity of Uiu diBL-littrgo Ldxiiiting i-etained. Fur lhi» jiui-jx^e h«! b plug of oatmin. Never plug tlio wound vritti cotton or lint, for tlwy will not permit a fi«e diticluirgv from the hoitt'in.
I Lav« tM-'U one <»Be tluit terminated fntally, t^iniply hwuiiH> tlu' nttvndiiit; Bur- geon iised cotton, lherel>_v giving riiw; to re- tention of the dii^clmr^, and lihres of cot- ton were foimd among the grannlalions nrid deep-«bfttod Ussitca, monthit iiftcr opei«tion.
Now tho piititMit IB rvudy to he plar in an apparaltin uliioh will MK-tirc ahMdutu rest, and a projicr piisitioQ for a cortain length of time. For this piirjMuie, the mont eoiivunieiit instrument ttoit can bu cm- ployed is what is known as the wire cni- rasM. (&v! Fig. 172.)
This in.itrumcnt is a moditicalion of BonnctV tfrand appttrfU, and (.-oniuetii of a Rtmof; wire netting, well padded iu&ide.
The cuinwK hcing prupcriy prepared and well {ladded, the patient is laid in ft 60 that thu anu« x« oppuNto the opLiiing, and free froni any poesihility of olMtntt" tion, when the well leg is the first to lie dre«#od, Tliix is done hy malting Ihu leg perfeetly slraiglit and scremng np the foot- tn~ in. rest until it id brought lintilr against tlie
heel of tlie patient, plneing a pad between the foot and the rest to al>sorb tlio perapiration ; the InMep is lhi>n well puddi'd »'ith ootlon or a bUinicct, and a roller is carried firmly round it and the foot-rest, niuniug up over Uio limb; but U-foro going over the Itnoe a piece of pasteboard, or IcatlHir, nr scvoral piecea of folded paper, are placed over (he 1^, knee, and thigli, and tho roller carried firmly over thi« cxtunijiurized e)>lint for tlie
OPERATION OF EXSECTION.
903
pnrpoee of proi-cnting ttiu «li^lit(Mit bonding of the knee, wlien tlio roller iit I'sniett uj> the entire length of the thigh, aruuud tliu periniEiim an<l ov«r the uutvr urni of the iiiNtrtiinetit, hikI scvernl timet buck through tlie ))erinffium, iinc] tlifin cicroai tlic pulvK Uy which meaiiB thu wt.>II limb in mntlu a linn counter - extending foroe.
Two strips of Ji<iiii'*ivi' {i!iut«>r, two to four inches in wirllh, ac cording to the size of the patient, are then placed upon either side of the operated liiub,And Mtcurud with a nicely -iu]jii8tcd roller over the foot and up the !<■/ nnd iJiigh, as fur as the aliece^tuts on it or the wounds will puniiit, being careful (o leave a i^utHcierit length of the phLiiterti at tiie lower cxtrenitty free, for tho purpose of lipplying them to the fout-ri-itt where extension i» made. 'I'he foot-re«t in then screwed up to meet tho heel of the shortened limb, and tlic«o «tri[M of adhesive plaster are brought down around the tbot-reet and securely fastened. The foot-re*t iif now extended by the wrew, *lowly and gradually, at tiiue.-* waiting ■ few moments for tlie muselee to yield, which have been so
.long oontrnelcd. nnlil the limb ii* brought down to it* full ex-
rtent. It Hometiines happens tJiat, from long contraction of tlio addactore and the tensiir vagina; feiiioris, Kubciitiuieous 6o<-tion
lof those ten<louii and faa-ia will be reipiiAite liefore the lintb ean be brought to itf j)ri>pi.'r ]><>?itiuii, evi-n tifler the head of the ^iniir has been retnoved. After the limb ia brought into this sition a roller in carried fmm the foot, over its entire snrfuce;
Fb large wud of oakum is placed around the wound to aK^orb the dtecliarge. and tho roller i» carried tiniily over the wound, inner Barface of tlie thigh, and around the pelvix. [ place great inipor MOO upon thit Utter part of thudrc»«iiig,!Ui we thereby compress tho tisduea, ami prevent the burrowing of pU8, the oakum, which liiui alriwly been plnred In the wound, allowing of free dmiitago, no matter how tightly the roller may Iiave l)ecn ap|>lie<I.
Inimciliatcly after (he {uitiont h dressed in this way, and baa recovered fiTim the amesthctic, he is capable of being stood up ognini^t tJie wall, or riding out in a carriage or liont, and can take hiii daily exorcise in this way. I have, in several instanees, had pa- tients removed a long distance, some miles, in fact, within an hour uf tlie operation, and without the slightest inconvenience or pain, ThisdroenQg will probably nut require to he changed for from forty-eight to sixty hotirii. or nnlil »ecretion lia^ been formed to
801
DISEASES OF THE Ilir-JOINT.
muiKten tlie cU-essingiB, wlieii the oaknm plug can be ronioved without Iia'morrbugv. If this dro:i)iiufr (i<)C« not cuiuc awnj euiiilv, warm-water injections vdll readily float it out. The wonnd, iniiOo L-leaii. h itpiiii tilliil wilh IVnix-imi baliwtu anil drvsitcd as before. After tliia it ma)- reijuire drcaidiig onto or twice a da_v, ■ ftixording to the amount of dUcharge, and the child should be removal from tlie entire iustniment a« often as i% reijuisite, The well leg ehonUl be removed from the wire bivtsrhce at least onra a week, every da,v i» belter, and free niovvnient«i given to all the joinis, anlcle, knee, and hip, otherwise we may anHiylope tbcni, altiioitgli tliey are nut diHuievd, Thu wire ciiiraiw Uiould be used for from a month to two montliB, acronling to necntsity, after wbidi ttie patient ciin be put upon the hmg or short uplint uml allowed to exepcise, tiiereby increawng bis prospects of per- fort motion in th« new joint.
The rrafliin for »liitiin]|; the pc'rioHteum with oaknm h becstis WL> wiith it to retain tte projier Hbiipc, to mould tiie mntorill* thrown ont for the fonnntion of tbe new lone that U subsequent' ly to l)eur tliu entire weight of the juttienl. If tlii« prLi-antiun le taken, we mny have a femur nearly um well formed an the origiiud hone, and equally as sen'iceahle.
It is irnpoiuiible to pat-k tlir wound wJtli oaknm so that piia ' cannot escniw througli it* niCKlies, hence it is the he«l eulxitanee that can Ik; cnipioyerl, for it permit* free discharge from Ihe bot- tom of the M-ound, and at the same time pennitt^ firm support to the surrounding tWueK witliout endaugering llie life of the patient from absorption of pus or ichor.
Having completed the driwng. I will Htand the patient against the wall {«>•« Fig. 17Z\ nnd 1 ask you to eom|>ai-o her present condition with what it waii half an hour since (Hg, ITI). It seem.') to ine that every one who sees it niiut be con- vinced of the pii)priety of the operation I Imve juut now per- formed.
The long and sliort splint*, find the modes of ibeirflpplication. have already been dc*cribed. nii<), when the patient has recovered fmm the operation sufficiently to wear one of tlicm, the after- trenlmctit of the case ix to be continued upon the same gt-neml plan us tliat which guides us in the treatment of cases where no operation has In-en perfomied. Frc^h air, eunlighl, and g<]0(l< food, nre the great e^entiab. Tonics and otlier renivdios may be
TRZATMEKT AFTER EX9ECTI0N',
SOS
Mnplojed lui «bcIi cuse may Beera to (ktnand. The wound eliould Y)0 kvpt tliorou^lily cli'ttiitrcd, ftud every prt.-oniitioa Uikvn to eocura s free diHchnrge, so aa to prevtmt the formation of abeceeSM in tbo itiinx>unding tiiMUi«.
When tlie dtseharg« b^ns to oe«se, you may commence past! to
Fib. IIS.
nv. ia>.'
Riotioos, and tlM>D« fdionld he rogiilArly and iiy»temati«t]ly resorted to; alifjlit at first, but pnuhuiWy inoriMWud n» rtH'ovvrjr grxa on.
If tkU treatment is fiiitlilully pereiHlvd in, you will lio able, in a majority of cn>i*s to obtain a uinch more Ui»eful limb tlian Xatiire oui ever pnxliico wliun iilio itt puiiiuttvd to effect n euro acconiinj; to her o«ni metliod.
1 will ber« inikrrt the tir^t eiioceMful case of oiwetion of tbo I of tbe femiir performed in tliia ooantry, republiiJied in full from tlic lYfW Vork Journal ^ Medicine for Jiinuari,-, 1855, in order to sbow tbe improvements thttt have been made in 0]>cra- lioii and after-tn-utritvnt eincu tbat time ;
"On March ao, 1S.'4, I wn« called, in con«iltaliou willi Dr. Thrwekmorton, to mw Ellen G., 21*7 FiftJi Street, aged nine yeus, who bad lieen eullering for eiglitoeu months n-itb morbus
' Flit lis i U fran ■ pbMognph of ttio Mma pAticnt, mtcd wccki titer Qm ofMntloa,
SO
80«
DISEASES OF THE HlP-JOnn".
caxariuB of the left liip, wbidi wsa suppoeed to liave rejiaUed from a fnIL Sb« had been treated wiUi inmee, blUten, etc., to- fCether witb tbe geoenl Ionic and anti-worhutic reniedi«e adapted to encli cnMR; bat the disease continued to pn)gTee«, iiDtU an abM.-efis wafi disoorvrcHl, involving tlio whole u])per front and inner jiorlion of tlie tliigb, sccoinjuaniod v:UU rcpioited cliill», prufiue sweats, and f;reat prostraticni.
" When I first i>aw Iter, tliin alweciM Itnd pointed in two plaoea^] and KBB apparently jiiet rvady to open ; tbe point nearest tlie sa^■' face snd moat fluotuattug wiu ni-ar the anterior superior Bpi- nouR progress of the ilium, immediately in contact with tlio attocfa- niont of tbu temtor va^niu fvniorie muscle, and Poupart's liga- ment. The other place of pointing waa about live inches below the ligament, just over tbe fvniural artvr)' ; preiu-nre on anr part of the upper portion of the limb distended both of thcH* fxiint- ing abe('L<«».«, &huwinj); cuitiniunication between them.
" Tbe leg was shortened two end a quarter inches, and turned inward, but not permanentli/ ^red in its pmition (as is nxual), bat allowing of contiiderable motion, which gave a di^tini-t hony\ erepitua iMStwecn the femur and ilium. The pelvis was twiMed and drawn upward. Her general health had become much affect- ed ; she had lost her appetite, and was suffering from IieeticT with constant chill)> and profuse »>wc«tii, and wai« rendered comfortable only by the rouatant use of anodynes.
" I advised a f rco opening of the obetew, and, if necee«arj-, the removal of the bead of tbe femnr. At tirrt tbiu wb« object^ to ; bnt, as the child's health rapidly failed and dcalli seemed inevi- table, the father, in a fi'w davit, consented to the operation. Ac- cordingly, on Man-h 29, 1^''4, ajwstcd by Drs. Throckmorton, Drake, lliebtnid, leaner, and Hertholf, I ]>roc«eded to pcrfonn it
"I first l.-»id o[)en tbe al)«;e»* by a free incision of altout six inches over tbe trochanter major, on tlic outer ai*]>ocl of the (high, and ia a line with the femur, and then cut into the floor 1 of Ibe abwww (which principally oeeujiied the inner and front portion of (be tbiffh), and discbarpwl about a pint of thin eerona and flaky pii*. Tlw finger wiw then readily passed aronnd tbo neck of tbe femnr, and detected an opening in tbe capmilar liga- ment on tbe inner «urf«™ of the neck. The upper border of the acetabulum bad been absorbed, and the head of tbe femur waf 1 npon the dorsum of the ilium, near the anterior superior spinous j
TREATMENT AFTER EXSECTIOS.
WT
proccsfi, tun-ounded by ita <iaj>«ul^ (witicli eeciiicd to liare been alipjiud up), and a largo deposit of bone, apparently being an at- tempt of Natui-u to iiiakv a new ac-etabnlnm. itiit the cavitjr tliiiH formed li:td no lining membrane, as the femur grated rough- ly upon it. I then opened tlio cafMular lignmvul ou a line witb tlio fxtei-nal ineiaion, and diwrticulateii by bringing the leg Htrongly across the opposite dugh, nud then, with u lar^ pair of Liier'A fort'upB, n-jidily cut off tliij hoad of the femur.' Tlic bone at this point appeared [>erfectly healthy.
**The upper rim of the aeelabuluni had been absorbed (*o- cfinting to tiie theory of Or. March, of Albany), and the new deposit of bone, which was intended to Mipply it« placf, was <ie- niidcd and carioue. I guugi-d it off with a eharp, firm chisel, made for that purpose, and, in this wiiy, took off » number of flakeB of bone, until I nimu to a healthy, bleeiling surface.
'*Tbe anterior snitcrior spinous proecM on its outer surface, and the external lip of the crest of the ilium, wan blat-ft and cari- oiu fur some dislam.'e, and witli the forcejM I easily clipped it off until I came to healtliy bone. Very little blood wao loflt iu the o[)vr.itii>n, and, after cleaning away all tlie tUbria, I brought itie ic^ in thffltraight po«ition,fll!e<l tlic wound with tovr, unddrcMU.-d with a roller and cold-water compreea. She was then put to bed, and a cup of strong coffee administered, after which die soon fell aaleiep.
" Tlio child was under the influenoo of chlorofonn during the opemtion, which occupied nearly twenty minutes, and was per- fectly iueeiiKthle the whole liiue.
" The following extractfl from my note-book, taken at each daily visit, exhibit the progretw of the caae:
"11 H. M. — Has iJept occasionally and is quite comfortable j pnUe 128 ; skin good ; voniitetl freely about 4 p. m.
*' Mari'A 3(WA, 10 a. m. — Passed a good niglit, without any tuin'oUo, and tslept about four hours; had had im chill; taken brcak^t with a relish, and in surprisingly comfortable, consider- ing the mii^ltude of the operation ; pulse 12o; no haimorrluigc ; passed orine twice.
" 31^.' — Took half a gnin of opium last night ; slept well ; pnlse 1S>0 ; skin good ; removed external layer of tow ; found small amount of pus. * 1U( b llto onl<r ow« in «hicl) ( bate made Mcdoa ot Iho bono wlifa the fbroepa.
80«
DISEASES OF TUE niP-JOINT.
"April \at. — Slight fever; heat of akin and tbirat ; palselSO. Admiiiifltereci live grains Dover's powder, with addition of half a j^raiii ijNxiAC'., cvi-ry four houra.
" 'id. — iiss pU£He«i a j^ood night, ^lept nix hours, ate * good brcskfavt, and fuuiit every way bvtu-r, but is much more fee)>le. DrcHtied the wounii ; on removing the tow, fonod henlthy pii£ in abunduiiL-e.
" The abscess, wliieh pointed at the anterior i^u]icrior epinona procesB, buing Again full and tlu(.-tualiiig, I opened it, and gav6 exit to about a tablespoonful of tolerably healthy ]>u£; pulse 140, and more feeble ; directed to admininter brandy and beef-tea more liberally; I do not think the family give mithcleDt etimulant or nonrifihinent. as they are very rtningly oppo«e<l to brau<ly, and are afraid of meat on aeeouiu of fever.
" id. — Slept well all night n-itliout opiate ; pnloe ISO ; boweU nioverl twice nahirully; appetite good; finding great improve- ment follow a more nutritious diet I advii^ed its continuance.
*^hih. — Child xery comfortable, amusing herwlf by entting paper dolU; applied the etniiglit splint for cuiinter-extemion to the well »ide. and made exten*ion by means of the foot-lmard, bringing the limb down to tlie same length of the opposite odo.
" 7M. — Slept well, bnl mn<>li weaker, haAnng had tliree loose diftchargee in the night, and Bonie lia.'niorrhage from the noec, whidi wa»arrt's»le<l by mttringenti* and compreee. Ordered brandy and laudanum, witli more liberal use of iron.
" 8/A. — Diarrho-'ft not yet ehet-kod ; the brandy and opium was not given, and yet the chihl is somewhat stronger than yusterday ; pw more oonsistent.
" 9fA. — DiarrlifRa (-becked ; slept well ; eata freely ; diechujge lesscopiona and more comuKteiit ; pulM 120.
'' |i"M. — Very comfortable ; looks a« if it will rc'|niro a coun- teropening on the front of tlie thigh, at the old phice of )H>inting.
" 14/A. — I applied a oompre»» and adhesive etrapA on the in- side of the thi^i.
"J»ly \itt. — Dr. I'll rock morton lum *een tlie child daily bines ' my last visit, and reapplied the bandage and comproM, which has bad a most ealutary effect, and the abftceas has the appeanuti-e of heftling rapidly.
" lOrt. — ^I was again called to meet Dr. T. to^ay, and found tlie cbQd much prostrated from a severe attack of dysentviy,
TREATITEKT AFTER EXSECTION.
309
wliidi ImmI lusted foar or five d»_vB ; eliu w very iiiurb reduced, and, I fuir, will uot rally. The graimlntiontt are fliibby, and pus Uiia ami copioiu.
"Auffu*t lat. — Tlie dysctitcry ting been clicckt-d for emno cUyB ; but the woiiiid, wliiob vrua tiesriy cla^efl, baH ojieiied, and R emnll piece of ragged bon« vtams uwur, wliicli wutt probably soiiio jiiirtion of tbc eh«vingti or diipa reaioved from tlie iliuui, at th^t timu of the opcnttion, aiid wbiclt [ hud not been Hutticiently cim'f ul to remove.'
" sort.— Tbc cbild very mucli improved, but tlie listnloiw opening, from wMob the pieee of bono bad fscnpcd, roiiiniiiitiij:, niid having nitia-r u white und Ihtbby tippearanee, I iiijecteil it wfth tincture of iodine.
"2tilA.— Tbc injection has K-en fullowi-d bv a smart attai-V <pf erj'sipeliLA, whidt bus exictided down mime dittlnm-e In-low tlie knit', and there U considerablo con]^tituttonal diHtnrbaui'e,
^Sfpiemh^r Irf. — The erysipelas /^nbmlly^iiibsiilcil, but seems to liavo bcL'u of great Bcrt'it'C, ax it )m8 cruii^d niiixn of tbe walU of the abi>ce»» all around tbe tbigh, and tlie small o|>ening in the cicatrix Ih nearly clo«.'d, diiichurging a very few ilrojw of Ik-nlthy pus. The limb is stitl in the exteniliiig :>|>linl ; bill, on removing it, tliorc swuicd no tcndoncy to rctrartion of the limb. Tbe splint vaa renpjilied; but the body was left fr<,-o from the bambige, lio as to allow of tloxion, in order to prevent ancliybwiii.
" I might here mention that, for »otiic weeks psi^t, ^ince about the Ist of Augufit, at each droeeing her Ijody lias lieen brought ot a right angle with the Ibiglis. having tbiK objn-t in view; and I have now pennitted her to do it ns often as ebe like*.
" jVotw/iA^r Ut. — I had nut s-een tbc «iso for two mouthy un- til to-day, when, to my aHlonisbment, I found ber wtilking on her cnjtchiw, which sJie ha.* been able to do for some two weeks. Ilor limb Mp]>L-«r« tbe tiamo length Bfi the other, and ebe can flex and mlate it fi-eely. ! dirr-cted la-r to bear no weight upon it yet.
" 20/A. — To-day I pl«oe<i her iti the lioriKnntal position, and
' "Siare niakiiif; tlib doUv n; Impmnioiu Iuit« been mon (^ifirnierl, ■slvrntlml- Im pitcu uf buiiL- hrtvo tM-ra rcmoTCd from di0to«(il pirt* of llip cicalrix. uiJ Uir« lliM ualniBllT nUrdvil Hm ]>nj)n««e of Uie eMC ; I tdioutd iticrcrore adtite gmU »Kh %tUx lb* pvrforniani-v of thia opcivtlon, thai all ilitrit Miil furo'ign Itotlita b« canAiDf •uh^ from Ihe woiinii g aod. in lo Iwge tnil m^^nl an aluona M tbSt oo* VM, it aSI itifuitt uiore euro tlwn rbj one Nonld imagine. uuIom ibejr luwl mcd El"
810
DISEASES OF THE HIP-JOINT.
mesAured li«r <.'arcfutlv, and find there is about une-eiglith or iii-arlv oiie-qtuirtcr of an inch ^ortvninji^. Uy utkin;:; hold of tbo fudt, the whole hody can bo dnvrii down in hed without pain in the joint, and a pressure mav )h> iiuide ^uflicieiitly ittroiig to move tho pt;lvi» and body upward without prodiit^^iiig any Bhortening of the limb. When she lies upon tlie lnu-k, witli thu log extended upon the thigh, fih« can vivvate the heel MXt«en inches from tbe bed. and flox the knee so M to bring thu thigti fit a right angle with tlie polvie ; eke can rotate it inteniatly, no a^ to tonch the other foot, and oxtentally eo M to touch tbe bed, Uor gunvnd hoaltb is perfect, and thu case baa terminated quite eucres^fnlly. Tho hone was examined nitcru«copiciUty, but no tiiwo of tubercle was frtund."
Uer present condition is ae sc«n in Fig. 174, from a pti graph.
*■'.-, ill
Aa the caaee of Itoiudell, Storch, and Sehletttng, arc among the must pi-rfcot of my rocoverioe, find Field alti:^tber the m< diEtortt-d and Bhorti>ned, I append them with photographs, u i tbe other caeea of recovery present various gi-odes of iniprovenient between tbeee extromoe. I have also added tho case of Matilda
811
HJIlury, because it presents eome poinU of interest, parliciilarly tlie fmctore of tlie fi-mur ut thu time of tlii; upurAliou.
Thu«e, [ lliiiik, uro nuflicienl to prove tlie value and pmpriety of tlie operation witboat adding to the expense of the work by «u^vini; any of tbu otbcnc, nlthuii};]] many of Uion are nearly m pi^rfeirt an 8lorcli and Sflilctting.
CiSK. Ju«(Hion of Ilip-JoitU ; Jiemoval <{f 7'hrM Inthtt ^ Bone, and a Porfltm nf tK* AivtalnJum ; Jiejmxi'iction of Jtoiu to ntariif tAe Normal Length ; Jiccorxnj wtVA Petfeci Motii/tu {See Tahle, "Sa. ti2.) — Adolph N. ItuuMkill, Hgcd nine yennt and MX moiitliD, bad bip-di^waw for four months, the retinh of a slight injury, nt-civod whilu rccoveriuft from a i^-vcrc attiii'k of fever. Suppuration 60on set in, and, wlii<n 1 tuiw him, (k-tx^bur 1% t'S64, he presented the usnat appearances of the tliird etago of hip-dis- CMe, the leg and Ihigli I>uiiiL; well drawn np, and adduoted aeroM the other thigh. Several siniLies alno e\!»ted, thruugli which the probiTvadily paeecd todi'ad bunuin the iivigbbor1ioo<l of the joint.
A free iticiuon was made orer the trochanter major, connect- ing three or four of tbe einusee, and giving exit to a largu amount of pnii. After the escape of tbe pn*, titc btniea gave dUtinct crepitus on being rubbed together, and an opening waa found in tbe rftpeule, on its inner and posterior Wundarv.
Die cap«u1e was laid freely open, and the ineiciion carried donn over the trocliaiiler uv\yyr,fair{if Oimugfi th« periosteum (which wae much thickened) to a {mint opposite the trochanter minor; the m(t ]mvU being well held npart by spatulas in tbe hands of Dr. James S. Steele (who was my only a&iiiFitant in the operation, exr«pt my son, a tarl twelve years of agv), I made an- other incision Ihmugb the periosteum at rigtit angles to the tiret : this division through the periosteum was carried on either side of tbe first, as far around the bone as 1 i-ould go, making tlie ])crio«^ teal cut in tlie form of an inverted T ( X ).
Into the angles tlius ma<le, I pressed my periosteal elevator (Vig. 100), which is a large and ilrm instniiin-nt. very much like tbe ordinary " oyster-knife." With this instrument the perios- teum was readily )>c«lcd off, necessarily carrying with it all the muscles attached to it, which, in my judgment, is tlie most im- portant fcuilure of the operation, for upon this particukr iact depends the future usefulneea of the limb.
Tbe cutting edge of the knife was only required to separate
DISEASES OF TUE BIP-JOIST.
tliv Attaclunonts of the rotittor musclos in the (tig'ital fosBA, Iwhind the great trochanter. All the reet vrtm pc%lcd oS witli groat facil> ity oQ tlto QXtemal portion. snJ, the tliigli Itcttig then tinnl v mI- ^ diioted acmes the other, the bone war eiisily hixated fmni tlie acetabulum, 1111(1 peeled it»elf oil trum the internal layer of periu*- teum, whirh was left in gUtt, and thim laiuiv a continuoQii wall or layer of deneo tihroiw tiit«Uf, whifh prevented tlie burrowiug of puft on the inner portion of the thigh.
The femur wan then sawed off just ahore tlie trochanter miaor, but, \mng otill further dim^HLil, it wim eneiiy pushed up through the pcriostouin. and again eawed off iid inch and u quai^ tor below litis point ; the limb then bciiifr reduced to lU normal I poeitiuii, thia eufl of peritwtfuni was innsed on its onter eide, la prevent any pocketing uf mnttur. 8uveml j>iei'ce of bone were
^i>'
Fid. ITIl
enaiij removed with tho forceps from tlie acetabulum, and tlifl
vholc of the dennded sni-face thoroughly scraped. &v Fig. ITS.
After injecting the wound with wann water, to wash awmy i
CASE.
818
dtbriA^ Uie pRtivDl was pljicod in tiie " wiro-broedieB," the wound tllltKl with PcruvUi) bali4»in and stuffed witb oaknm,Bml tlio limb extended to nmrlj its normal Ivngtli.
Xo r(!e«el» were tied in tlic o|H^nit>o». A few stripe of adlio- tire plaster at either end of the iticieioii, with u tinu n>ller aronml tbo liui)) and jwlvis, cuiiii'tittileil llie dn^iij;.
From tlieday of the oponition lie began to improre in his general hcAltb- A very g«nfroiii« and nutritious rliet, with ii full allowtoce of ale, tc^;other with daily u-ashtng uf the wound, fill* iug it with octkuiu ami Pertivinu liulsnin, and always Iteopiu-; the parts sustained by a wcll-adjuetod roller to prevent tbe burrowing of pitH, wa« the Mftvr-lrc»tiiioiit.
After a few <Iayfl he was able to bo carried out to ride, wear- JRfr tlio wirc-bret-ehcH. At the end of mx monlb? I applied my frliort hii>-«])linl in the dajk'tiine, when he eonld escreiHi fruely
with hi» cmtchett, and at night I kept up uxtunsion by a weight and pulley at tlie foot nf tlie bed.
The siuuiHS atl hnled in about eight months, and at tlie end
914
OF THE lUP-JOIST.
of a year ho walked qwito well witli cratclic*, and bad only a baif- ineli shortening by the moet careful ineaHurvtiicnt,
lit} used his enitchva for about cightoun niontliB, and, after- ward, a RUie for eight wcekn, hut for the pairt ten yuan baa oot used anything, walking without any limp.
lie can run and daui-e aa well aa any hoy of Itia age ; in fact, he won a pair of ftkates in a itkating-inatvh on the Central Park pond, in Deceinlwr, ISfilt.
The mo*t ivniarkahlit feature of the caw is, that the limb con- tinues to grow in length as fa^t aK the other, and there ia now scarcely a Imlf-ineh dilTvrcnou in tliu longlh of the two by the moat carefnl men^urement.
Figiirtw ITA, I'd, 177, and 178, from photographe, showing the n»aH of t]ie operslion a» well aa the bone removed, represent the length very accurately, a<> well an the ability to flex the iiuib,
fh. m
and also to bear tlie entire weight of the body upon tl. I think it can fairly bo called the nio»t succeeafnl coau of reproduction of the hip-joint tliat haa aa yet boon rveordod.
CASE.
SIS
CACE.~Bemard Storch, aged niae. (Sm Table, Xo. Si.) Fonr years sgo tmil a fall, eiiiee vlucli time lie baa been troubled with his Mil. 1Iji« bifii wtmied and blt6tt>n-<), witliout bmii'fit. Con- dition, Feltmary 25, It^Tl : Greatly emaciated, limb eiliort«ned two iiictKo, mldiictod, and nearlr etrfti;;ht. A lnr^> opeoio);, over tro- chanter major, bao Uiuu discharging trvcly for the past tive weeka.
ii-. 11^
i'm I Ml
I'm. lul.
Finger ptuseft readily into a deep dnus running around tbc under sarface of the neck of the iHine into the joint. The operation wsi pcrfonnoil by slightly enlarging the external opeitiiig at it« upper border, and carrying the incision down tbrotigh the ]>erio«. t«um, over the centre of the troclmnter major, for about an inch and a half; the periosteum vug t}tun divided at right anglea to the tint iiici»iou, and peeled off with it6 attactmieuts, the joint freely opened, and the head luxated from the aeetal>Dlam by Mrong adduction, and peeled off from the internal layer of perio»- tenm, and aawed off just aliove the trochanter minor ; the upper rim of tilt* a<.'i.-tJibulum was ubrorbed, and the hojul of the bone rested upon the dorsum ilii, but surrnunded by ita capralar liga- ment. Fonr pivova of necrosed bone, us bocu in Fig. 1S2, were
wi
DISEASES OF TQE niP-JOnTT.
removiid from Uic acctabnluin, n-liioli was perforated. Woonil (Ireeeud in usual way, and boy pliicud in wire ciuni««.
The hiittiiry presenta no points of eepecial intercut.
lie can bonr bis i>nlin: wui^ht upon tide limb, m seen In Fi;;. 170, can Hex it to a right angle, ab M-cn in Fig. ISH, iind rain etaiid with tL« linibtt parallel, Fig. ISl. There 1« n »liorto»iiig of a quarter of an inch. Fig. l>-2 is from a photograph of tliw bones removed. A cure in Uiis eaao wan effected in nine niontlia.
't:'
V
Fte. m.
Cask. — M. D. Field, aged fonrteen vean and oix montliH. (Sue Table, No. S$.> Sixteen weclu provioiu to tho tinto I mw dim lie was titniek upon right trochanter, producing great pain; tlie next day took violent exercise, and waa ex]KM>cd to eold. Thi« waa followed by a ehill and great pain in hi|>-joint ; be has iioi been out of bed flinoe.
A large abMieKn foniiud in front of trochanter major, which mu openod. Condition, December 23, IStlT : Emaciated almost to a ekeleton, very greatly distorted, utiio fietoloafl opettingB
CASE.
ftround tlio lii{s nnd the upper part of the tliigli dlntendcd wiUi pufi. 7'iiMAat*(«r ujfon the dorsatn, ef the ilium. This is tb« onlv ante of dialonttinn that I hare aeen in nil m^' M)>i>rationA, AD<1 tliiii took plucu II few d»v8 bcfuro the o]>omtiiiii, whilu tr^'iiif; to ttirti him in hia hed.
Thu huul, DLvk, ntid four iticlit^ of tho ^iiait of the femur, vim rctiioTorl ill the ii^iial way.
Tlie beiul of thv fi-iiiur was viitin-Iy out of the acDtahuluin, wbicli TiM not di^eaiud except at il* upper and outer border. The entire feDinr was surruutKlt'd by an iiivolucrum of now bone uearly Diioeighth of An inch thick. The wound was stuffed with eaknm, and extension applied.
The boy inipruve<i rapidly, but, llie exIenHion havinji; been removed, be retinvered with nosrly fi>ur inches sbortooing, whU-li is supplied by x liighbuuled boot, and with which be walks re- nfurtwbly well.
,;l'il
pie, IW
Ful. IM-
Hv WAB not scon by me from tlie Hmfl of the operation antil November 25, 18<i9, when the photographs (Fig». ISd and 1S4) were taken. Fig. 1&5 is a representation of tho bone as removed.
ips
DISEASES OP THE HIP-JOnTT.
without havinj; been clcnned or vraslicd, diuwiug that tlie peri- osUiim was Ivfl uiitire.
I Haw Mr. Field in Aiigunt, 1^75, iind found tlto motions of hie joint very materialljr increased Biace the photograph waa
!fv
^■<^^v
V
/
ru. iul
taken, from whicli Fl^. 183 was engrurod. The leg reniainfl four inches shorter than the other. Tlii« iii the groateel auioinit of shortenini^ which hmt occurred in any of my maei>of uxHirtion, And I attribute it to the fact that vxtcnnon vus not contitiD«d during the profiroMs of Lrcatinent.
The two following ca^s are added to eltow that fnvomhtv resiiltti may M>nivtinieii occur, even uiid«r the most »)>[>«rciitty unprnmiiing circninstnneeH :
Cam;. Kcstdion t^f JUpr/oint ; fltad and JVVtft e^torhtd; Aeelahvlum- cariowt; Seeiion of the Femur Ona Inch hdovo Tro- chanter Minor ; liivotfrij, irM aimost Perfect Form and Motion. — [u May, IStil, I was retjueeted, by Dr. Wni, H. Church, to aoe in oonsnltation a case of h)p-di»c«»e, in Fifty-fourth Street, near Eighth Avenae. We found a girl (Annetta SchlettingX
Q&BB.
319
to be iibont ten jcara of o^e; her Aitttor anil motlior nvrv dfiad, bnt tlie cause of Jeatli wo were oiuble tu uecurtuin. Slio wiw living with jioiiic jmor reUtivea, wlio gkve us the follow- ing history ; Eigbtveu tuontlm bufon: she hud fallt-n frutn a wiigou, striking on u curb^tonv, bniisiiij^ iicr rijchl hip ami knee very badly. She was contined to hc-r bi5<l Miine diiyir, tlion got about to her pU^- as uxual, but was nlwAj'a a httle lame in tlint limb, and wotM earl; in the morning, or when ooutmencing to move, liter eome honr^ of rvot.
About three months aft«r the acc-idvnt she bemmo much wonoi berlvg hcpian lo "draw up, »iid tnni out," and tlic {)«)n WRA ao intense that tliev were compelled to give licr lat^ doses of opinio to keep her quiet. Her 8crDuini> at night, every time she fell aaleep, were so violent na " lo frighten eveiybody in the boiuc."
lliiH lAflt«<) for nearly A y«ar, when suddenly one niglit the le^ twtHted in a<'r()6s the other foot, and s large en-clUng came on the outaide of tlie hip.
Since that time she han been much more free from pain, but her lu^ lias beini tixi^l in that position, and i^till remains w. ^^'llc^ lying on her Irack, nhe retpitreH two or tliree plllouii under her well limb, whicli it placed behiod the discaaod one, and the outer portion of the diseased foot in tinnly held between the great-toe and ita adjoining one of the well foot. In thi<i poaiUon, and at perfect rest, she is compai-aHvoly comfortable. The leaet attempt nt mnvvment of tliu dieeaaed limb pn>dui'«i^ tlie mu«t intvn«e torture.
About tlin'c months after the limb aiwnmed th)i» jioKition the largo Bwclliiig on her thigh broke in thrw sepanitc plucefl, from eetcli of which a eopiona discliar]ge of pus ha» continuwl up to the praaent time.
A photograph of the girl waa taken previous to the operation, and it will l>e observe*! how she bears almo.Tt her entire weight by her handa ujton the t.ible, and how firndy filiu praepa the die- oaaed limb with the well one, for the purpose of preventing mo- tion in it. (Ssf Fig. 18fi).
On the Sth of May. l!4(51. ajweled by Dr. W. H. Cbuivti. 1 per formed exsoction of die hip in the usual way by a cnrvwl inci«ioo over tile troclianter major and through tlte periortcum, whicli was verj- niiwli tliickened. The neck of the femur was entirely ab-
BEA9E9 OP tllE HIP-JOIST.
Borbcd, and the remains of the licod of the bone were If ing lo<we in the acetabulutti, which was carious but not perfomted.
nait*.
fm. ir.
Very little 1)1o<m1 wae lust during the operation, and no vesaelA weru tied. She wm dnwtcd in the wire broeuhm in tlio asnal wuj, as previouBly described.
'Die idiantj in nhioli itho rt^idwl, wiUi all the iurronndings of extreme poverty and foul iiir, gave very little proapect of a favorable rcBiiIt. I thcn*forc ntovwl lior out in tlie v«rd in the o|>oii air, under a temporary tent, where she waa kept most of the time, day and ni^ht, i^xeept when a ec^'ere etonn oraurrod.
From the day of the operation she improved meet rapidly, and in Ict« tlinn three months the wounds had healiid etitlreljr, wiUi lees tlian n half-inch f^horlening of the femur, la &x months from ttio operation she walked well without any «up)Kirt, rootiotw of the joint alniopt as free a.i normal, and her tipure nearly (wr- feet, as seen in Fi;;. 157, from photo^iph by O'Ncil.
Case. KxACCtion of Ifip-Jo'tnt ; Perforatum ef Aeetabutum ; JSdfruirx Intntjitlvle Ahsceaa ; J-'ra/^mv of Femur at Time <(f Optration ; liecett^eri/, with Oood Motion and Two /nc/K» SAorten- ing. — Hntilda Ililluiy, agvd fourtoon, Burlington, low*, July 8, 1649. Two years previous pushed over by another girl, etriking
CASE.
SSI
upon lier hip ; for three weeks aft«r gnvc her great pain when ehe walkvKl. I'niii ffrndiiuily iiicTMfiet], Confined to Iier heel for one year. Six montlii) after conimenceiiieut of trouble, pum bo- CAioe much \roi«« at uight, with frequent epSBms. The limb was elongated, abducted, and otmnfrlT rotated outward, aixl could not bebroogfat to it* normal position. HubBecjucntly tbe hip began tt> swell, and, e\x montlis sincv, the altewem broke, and at prcNDt tlic-ro arc four sinuHi-M diK^'har-ring prufuficty. Since the breaking of the aVjseeaa, the patient tuwt been much niurv fri'c from pain^ and the limb is t^hurtor, Wrongly adductcd, and fixed against the opposite limb, as »een in Fig. 18S. One of tbe i>iuu6L-«, close by ttiv rectum and batween it and the tuber isobii, dis- cliarged profusely whenever elie aammed the erect position ; in fart, die piw mn down her leg and collected on the tloor white she vra£ standing fur her photo- graph.
Jtdjf 8, 1S62.— A*»iKfed by Dn. Ma- son and Shaw, I exaected the hip^joinl, by making an incision over tlie posterior border of the tri>i-lianter major, the tn- daion >Oiglitly curving tiaekwani and go- ing through the perioj-tcum directly down to the bone ; the joint was freely and eaiily opened, but it waa foand imposai- ble to diearticulate the fomur. In using force the femur was broken about two iDcbes alcove it» lower extremity.
~ The finger could be easily passed aroond the canons bone and into tbe joint, which vra^ filled with epicula) of bono. The neck of the fciiuir had been entirely a1>sor)>ed and yet the shaft seemed permanently fixed in the acetabulum, and the limb eonld not be flexed or bronght across the opposite one. t there- fore paased a chain-eaw around the femur and sawed it off, jaU above the trochanter minor. The npper fragment was then readily picked out with the drewdng-forcepa. The difficulty of diNLrticttlation waft then fonnd to be dne to the fact that upon tbe upper end of the femur was a projection threu-<{HaRcr« of an
inch in length and over lialf an inch in diameter at its base, whidi 21
n«.itt.
disejV8ES op the nip-jorjrr.
protrndn] titrough m opening in tlio upper wall of the Acetabu- lum. {Sea Fig. 1 SO). The only reniiiaiit of tlie pa]>«t fcmoru was a (Jiell of bone which wiis picked out with the forceps. (Sm Fig. 190.)
At tli« ituertiou of the ligutni-iitum torn was a fiattened eiti^ fflce about the nize of a ten-ct-nt piece, whi(^h was enxlctl U)d carious; aod in tlio scvtabulum a tuiiiilur ptiic<c at the point of contact of the two aurfaceti. lliis latter I mmped ; nn opening was tound in llio Acetabulum which would readily admit tlie fore- fiuj^T. The iiitertml periiuiteum had not been jHTforHtcd, but was separated ixoin the bone, and produced tlio pouting in the
Fn. tm. Tu. i»*.
pelvis which had been detected by rectal examination previous t(» theo[>eration. This jwrtion of the ftci-tiibuliini wati carefully chipped off down to the atr«cbinent of the intertuil periosteum. The wotmd was thoroughly waslicd with WArm water, dreeeed witli Peruvian Imlaam and onkum, and the patient placvd in the wire ciiinuM, which aiiHwervd the douhle purpiw* of miataining tlie hip, and at the HAme time providing one of the IxMt nppLianceti for the treatment of a frart\ire<l femur.
It iit ]inn.lly worlh while to ^Kve the daily details of trcittraent, as notliing unitaoal occurred, althongh the case had been compli- cated hy the fracture. The wounds entirely healed by the Ist of October, except the ftiniis near the anus, which c<n»tinued to dis- charge a sniall amount of healthy pns. She could bear almoet her entire weigiit upon the limb, and liad remarkahly free volun- tary motion of the joint. The Iinib wa* two inches shorter than the other.
She left for her home in the West, Novemlicr 20. ISfiS. wear ingalong exteusiun-eplint, in almost robust health, having gained nearly twenty pounds in weight since the operation.
Id 1866 sh« eent me her photograph, from which Fig. 101 is
CASE.
838
ou^tsTed, Mid ia tlifl letternccoiiiiMDringthoMimesheRajB: '*M^
bnlUi Im perfei-t, tiiv limb it m good »6 the other, and has been
for tn-o yvais past, bikI, witli Iwa than ati indi o» tho hod and
Hole of iiiv shoe, I can rim and dance as well as any girl in Iowa." ^riit-n thin jMitient was
ltr<iti];lil to inu, I gave a vury
unfavorahte prognoeis of the
case; her extrcinu vniaointion,
iho extcDBive inlrapelvio ab-
HMM, which waH dvtocted hy
the rectal oxaminatinn, ren-
di-red it, in my judgment, al-
moA certain t]iat no operation
would be snccGaflfnl, and liad
she bcM«n a reiiidcut of this citv
I would not have pcrfoniicd it.
Her timlis were in so awkwant
• position, and ht-r »itlTfnrip«
bai] been bo great while she was
being bronght frmii her homo,
that I coniH.'ntod to pL-rform
tlie operation rncreljr for the
purpose of iinpK>ving her po- aition andoitablin^ mc to plttcu
her in the "wire enirass" so that »hc eunld be taken home with loM suffering than elie had endured during her journey here. Thta was distinctly slated to the pArcntit and the ph^'sidans pre»- VDt, before the oporatiun waa perfomiod. Tlie nnfortunatc frac- ture of her femur, which occurred at the time of the operation, compelled me to keep her under treatment, and thu result pi-ovcd that mj progno«ii( waa not correct
The following case is an instance of the reparative powers of natnre, even un<lrr thv nic^l unfuvoruble circumtitaiices :
Cabp- Keaection of lHjhJoirU ; Perforation (fAcet^AulwR / Jieproiluciinn of lioM, vrtth C<trtit^^ itnd Formation qf New JoitU (*v Krontis piece). — Rosa Mullins, 246 West Forty-soTenth Street, iigci.1 two reare and nine months, but very tiinalt for her age, Iteing alwat the size of a child eighteen mouths old, wn« brought to the Bcllevuc Ho«pil]d July 92, l$7ri, fiuffering from diMase of the hip-joint in the third stage; tho loft leg being
ru, ivL
.124
EXSBCTION OF THE HIP-JOIST.
flexed and croaeed npon the right, na ahown in Fig. 103, drawn by I'rof. J. Wj-dtli ; the liietorv of the t-atic being u follows:
J*arents bolli liealtliy, )iaving two oilier cliildren, botii liealtliy ; previous history of cliild diovm tio known eaate. Wag v«ry «i<-k during the pi-evions Biiiiimer ; lamene*s comnienced almiit Novcui- bor, 1S74, ail uImc(.-6(! u|ifuiug at liip about tlic Ut of June, 1ST5, and which diitcbar^ed profusely.
Patient wiifi gri>»tly oiiuic-iuted, und the nbJoirien wnn im- mensely diHtcndcd. A pi-obe being pae9c<) into the dnusoe al that time proscnt, dtiad bont.- was di8i»vered; cx»cction was tlirn advised as soon as tlie weather l>ecame cooler.
Sfjptiitnlt'r i9tA. — Thu patient wn« placed tinder the iufluoucc of an aniMthetto, and the uenal incision for exAeelion was ttion made. I found thu head of thu femur, with tlio n«ck aiid part of
Tie. IM.
tlie great trochanter, entirely absorbed, and tJie aeetabiiluni perfo- mtcd ; the upjier end of the »buft of the femur wa« thou «awed off, three snuiU pieoue of deiu) bone being also pried off the aee- tabulum.
The wound was then washed with a mlntion of rarlxiltc acid and nil dead bone removed, and the lower portion approximated by a onturc ; the cavity being tilled with balsam of Pent and packed with oiiknm, the cbJhl was then placed in the wire cuinue (*M Fig. 172).
The following is the official record taken from the books nf tlie lioapital, and as furnished by S. K. Morrow, M. D., junior aK)-ii(tant:
Octoier Itt. — Child has done well ; wound cireseed t<MlaT.
Oetob«r Sd. — Wound discharging freely, child is lees irritable^ appetite improved.
CASE.
8S6
OdtAer ftM, — Child bas improved elowly ; temporatnre at tluB 'time iweto l(>2i".
CMtjher lUflA. — At night cliild seemed to have Konte laryngeal trouble ; examination nhowed some broncliitis and coDflidemble Riuciw in liiroAt. Ordcrud wunn futiiontntiuits, oti;. The fol- lowing niominj^ the child was iiiach better, t>ut it wm tlioilgbt bcM to omit dreuting tim bip.
Octc^ter Zath. — Diwbnrf^ from tlie wonnd i^ diminii'liiti^ ; the Opening over tlio troetuintor ih cluHud, the oiiiiis pofitvriorly iit etill open ; appetite baa been good mo«t of the time ; temperature bo* ing gononJljr below 100°, onou only mounting to 103".
Deetmber \Ztli. — Dr. Sayre'n Hide extenAtun fplint vrm to-day applied beforo the daw. The posterior t^inuH ntmainH open ; bat little pna la dtacbarged when dreeaed. In every way there haa been Emprorcment.
December 18M. — Patient ia able to ait np in a chair.
March 10, 18T0. — Fo«tonor sinutt yot o|Wii and diadiarging freely; general condition has improved. No splint haa been worn for tlie paitt t«n days. The di«ciiacd limb is at \vwbX an inch longer than the other; paeHivo motiona are made every day.
Ma^ 1!>M. — An abeceae deep down, about midway on the outer aido of the thigti, woa to-day opeuixl by Dr. Sayre, and Notne four ouncee of ill-smetling pni> evacuatetl ; poulttcu applied. (This u-aa probably due to thu wound closing too enon, the tent not having been anffieiently pressed in. — Sa>/re.) Since tliis date the child Iioa boon in the bo!(])ital, and no tipc-«iul attention paid to it beyond dresHing the wound. No epiiut la now worn. (At this date my scrt'icfs in tliu hoifpital terminated, and I did not again wc the child until Noremher, 1877, when I was reappointed, and ttic oaae transferred to me in an apparently dying condition, with on coonnoas waxy liver and hopelessly incurable. — Sityre.)
Nmemher J, 1877. — Patient to-day trancferred to First Surgi- cal Diviriou, Ward 2. She remains in bod all the time ; limbs sli^itly flexed and adducted ; one sinus over left hi]> out of whieh aomo pus escapes ; complaius of no p«!n. Pbaws uHuo and fa.'cca in bed involuntarily.
March 1, 1878. — Child's condition about the same nntJl the last few days. Abaoeeses have formed ocea«ionally and some have opened. It ia noticed that there are two promiuenoce of the
896
EXSEcnos or the Htpjonrx.
fipiiious proceemw ; oue in the itp]>cr donul r^oti, vcr}* diarp^ nnd one in (tie latnbur region,
Cliild t«kefl htpi qitantitioH of milk; for Uio Imi few dftji^ breatliin^r baa been rapid und luborcd.
March it/i. — Child liaa been steadtlj gettinj; weaker, luid at 7^ A. M. she died.
[After duuth It pliotogmph waa taken b^ Mr. Manet), of Belle-l vne HoHpital, the body beiuf^ euflpended by the bead-raet («w Fig. 193). it will bu obBurvcd that tbo UmlM are nearly normal^ ,
asitnminjr this position by tlieir own gravity, witlifmt any cxten- eiuii or traction being applied to tlivni ; tLu limb u]>unitud upon i», in fact', tlio etiai^tor of the two. A sharp, angular projection it di»tinnt over tbu tliird dorsal, and unotlivr, nut m> pruiiiiiH-nt, over tbo first Inmbar vortebne; tbo eiionnous abdomen being markedly conspicnooa. — Sayre.'\
Avieptjf.—Six boars atWr death, by Dr. E. G, Janeway, in tlio preeeoce of Drs. Sayre, Wood, and Stephen Siuitli.
Length of body, thirty inobee ; length of left lower extremity, thirteen Indiea, from anterior superior apinoua pn>c«68 of ilitun
CAS%
327
to exbirnal mollooltu ; Icngtii of right lower extremity, thirteen and a quarter inchee, from same points on corresponding tiidc. Circiunfcreni-« uf body over urnbilic-ius forty ini'lios; over false ribe, twenty inchea. (These meafiurementa were taken by I>r. S. Smith.)
A abarp, »ng<ilar projection observed over tbe third dorul vertcbm--, and another not quilv io promini-ut over tbo first lam- bur. Ovor tbe left hip exists the line of an inci^i'm two inch«» in lengtli, it being ooinplotely clo«ud, with thu t- xucplion of a mi- nute opening at its nppor part. A second cicatrix, one and » b*]f iodi lonf;. i» M)en on the outer Burface of the thigh, and behind is a thini itiHsion not yet closed.
Tbe body being now placed upon the back, tbe left limb be- eonMBfltraight, and slight motion at the bip-jnintig detected: body is emaciiited, facu u.-duiiiiitou8, und belly uuirkudly protnberant.
On opening tbe abdomen no ascites ia found ; mu»c1c» of the abdominal wall much n>laxi'<d.
The liver projected fonr inches below tbe free border of tJio rib«, being slightly rounded at its right extremity, the border l)e- ing sharp in tlie reat of its extent ; upper border extendi^ to the fourth rib. Liver in waxy and wuigtut two tind ii quarter pounds (a v.).
The spleen projocta downward and toward the median line for two inchea ; ita upper extremity is curved on itself at right angles to the body of the uplcvn ; it i» flrtn, waxy, and weighs tliree ounces (av.).
On opening tliu tJiomx the pcricnnliiim \» found to contain a small quantity of serum. The right heurt is loaded with clotted blood, the left heart ia contracted and nearly empty ; the clots are Boft and fibrooa, most elastic in tlie right ventricle, und tltere art) a few in tlio right auriHc; fommen ovale is closed, valves normal; weight of heart, throe ounces (uv.).
The left pleura \» coated with recent fibrinous exudation* ; the plcunl canty contaim a emull amount of R-rum, colearcoua matter being found in the pleura, and more escapes from the pee- torior border of the lung on section. There is hepatization of tlie upper and back part of the left lung.
In the right lung, apex is adhcrout; in it is found a creta- ceous inaaa one inch in diameter, with eoine cheesy matter; reat of Itmg healthy.
SUECTION OF THE mPJOHTr.
Left kidney marktMllv wiijtj. cspocia]!; In tbe pjmnnids : in- temtitial ohnngofl be^nniDg. Right kidnoy aleo wax}*; right supra-rcnul capeulu vuiit»iiiu(l ■ clut of bluod. Weight of twth kidneyn, five oanccH (av.).
H(.i>outoric glandK culargcd fttid ctioewy, a crot*ceoat deposit in iiiot't of them. Slight vraxj changes in the intestinos.
Spinal oolanui, jh-Ivls, and upper tialf of both femuis, ns moved en ma«iM ; Itift hip covered hy a thick mafia of fat ; a tnini;vurHo et-ctiuu of Ivfl. hip now made tlirougli the joint; Ute upper end of the femnr is found to net in the old occtabulam, and to bv iitiiti.-d to it by A mow of vascular and app«reat]y lihroufl tiseiie which admits of quite free moToment. A probu can be pa«>«d from tlie jXMterior «inu» down to thl» mase — tliU i« the only sinus left, and do canons bone whatever can bo fonnd.
The fipccinicn wa* immediately sent to Dr. Heilnmimn for examination, who made a Tery accurate drawing of both hip« («w frontispiece), and nl»o a minnte mieniAoopic examination of the newly-formed hip, by which it will bo swn that not only waa the bone reprodnced very nearly in form and bizc, as well aa length, of the ojipoeite one, but also that true articular cartilage had been newly formed, and the motiontt of tlie joint were rjuite free.
The IcBfton to lie learned from thin csM is that, if Nature can produce such good results under such aufavorable ctrcum- Rtanctts and In itnch a depraved constitution, we certainly are ju«ti. Hod iji perfonniiig the operation under more favorable condttious.
Case. Exmiion of flij}- Joint ; Pfjfect Jietvtmy, mth Good Motion ; Youngrret Case upon my fftvoiy/s. — Robert Ijimbi'rt- «m, aged twenty-one monthH, No. 646 West Forty-tliird Street, patient of Drs. Uut>twl imi] Btii!#, of Forty-wcontl Street.
Oetder 25, 1874. — Patient was a very healthy child until four months since, when iiu had a Kcvoro attack of pneumonia in the right Inng ; recovered fairly, but waA very weak ; and while climb- ing up by the side of a chair, his lege itnddlcd apart and he fell to the floor with the leg>> widely sepanted, tlms putting the liga- mentum tores sereroly apoD the Htrvteh.
In a few d»v» a Hwclling appeared in the groin, and altout two weeks sinco Dr. Hur^tcd oponed an abeovss upon tlio outer part of tlic tliigli juHt below the top of tbe trochanter major, dl»- charging about four ouQCM of thin pus. The dischai^go has be«o
820
very profuse, and tlic cliild i» uow oxtremcly anjcmic, uot buving ^takcii an; uouriahmttnt l>iit from the niotlier'fl brvast, and, she eing deitotc auil overtaxed, tbu child u gruallj vmucuUcd.
I Baw (Jiia patient t(Klay for the first time in eonmiltation with
Dr. Hiii^ttHl : and ilivn dilated tliu o]>tiiiing over tlie (ruc-huut«r,
pUBing my finger direotly in, discovered dea<l ))one, tlie foot and
li'p bfinp cxtn^iui'Iy a-deinnloiitt. Not Imvinfj my ini-tnmioiite
witli me, I deferred operatirijf, and temporarily applied a roller
to tlie foot And k-g wicti iili^lit extcnMloii, witli tliu limb in &n
ftleratMl position ; adnsitij; tlio adminial ration of niitritioiis diet,
jVoiw^^i- I, 1S74. — The cliild W-'uifi; jiltiix-d under ati mm*-
tliotio t>y Dr. Yale, Dre. llneted and Dliss being present, 1 tbeu
. dilated the opening iipwani, and, finding ibc up|H'r end of llio
tfhaft denuded of its pcTiueteum, I removed tbi& portion witb a
, Bmall finger-Raw jnst below tlie trochanter minor ; (lie head of
the fcmar was lying loom in the acetabulum, and was removed
with the dre^ing-fomeps. The acetabulum vstn nut perfonite<l,
but was somowbat rougiicnwl, and vm therefore carefully scraped.
On fortlier eiaminaiiou of tlie femur, I discovered that the inner
BXSECnON OF THE HIP-JOINT.
portion of tlie bone tnui denuded of periiMteDm for Home lin«i ; T tIi«Q removed a wedgo-tdiapcd piiKo of hone, extending to tlio verge of the healthy perioiirtenm.
The wound being so nmcli in front — and in a dilTi-rcnt ]>oei- tton from my usnal incifiion — I mnde a counter-opening directly posterior to the joint, nnd put in u tunt; 1 thun sowed ap tbo anterior wound with tliroe ^titciieo, hopinfc thus to eeonre union, and cftrrv the drainage througli tlio roiintvropcning [ bad just nrnde. (This ie the firet caso'iu which 1 hare done thut.)
rM.M
The child wu then plaeod upon a board a little longer tlian tlie body, and the portion undvr, and correiiponding to the di*- eased limb, was aawvd oat ; the 8ouud limb was tlten Mtctirvd to the board, as is my neual custom in the ciiiraeo; the foot being socnred to a croeit-piece at the Ixtttom, which extended out u> tlio oppoflite side, and to which the diseased limb was also Beoiinsd, and extended by mcanit of adhceire piaster and lite roUor band- age ; oounter-oxtonsion being applied by a jwrineal band npon the »ouDd aide. VcTy little blood was lost, and the child waa perfectly comfortable in half an hour from the oomtneneement
CASE.
331
of tlic operation. Tlic ti-Mtmont vm tbon foltowod out by Di«. Hneted trnd Bli^a.
April l.j, l^7&. — Dr. Hiutcd cnlk-d at luy ofHec ond in. fonntKl mo that the boj barl recovered perfectly, witli warcely any perceptible fdiorteniti^, with mutioim iippareiitly a* fn-c m in thu oth«r limb, TLo doctor had given him but very little treatment bejond keeping bim porfoctly clcai). A» thu i>arent8 were too poor to piircibawt a miv ru!ra«a, ho had kept him upon t3ie ex- temporized splint wliiflli I hitd applittd.
No bono (Motped iftor the oporation ; the wouude hoidcd op
aboot the let of Fi-bniary, and for tho poet month thu hoy could not be controlled, but would mn up and down ataini, lieing nesrlj' as adivo m any of tbo cbildron of hi« a^ iu the houtw.
June 2S, 1S61. — The patient was brought to my offloe (or in- ^joction ; tbc limb wn^ found to be half an inch i<.l)ortcr than tho other; the motions being almost normal, as shown in Figs. 19i, 1»5, 196.
The following tahle of all my caws of exsection of thu hip- joint, as well n« the synopis of the same, hoH been compiled from my note and rase books, by my son, Dr. Lewis Hall Sayro :
T.VBLZ OF EXSECTIOKa.
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DISEASES OF TilE IltP-JOINT.
TAlltE OF EXSECTIONS.
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TABLE OF EXSE0TI0N8.
837
DISEASES OF THE HIP-JOINT.
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TABUE OF EXSECrftONS.
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DISEASES OF TUE HIP-JOIST.
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TABLE OF EXSECTIONa
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HP-JOIST.
TABLE OP EXSEOTIONS.
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DISEASES OF THE HIP-JOINT.
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STSOPSrS OF EX8ECTI0KS OF THE HIP-JOINT.
847
flTKoraiB O^ BKTKKTT-TWO CA8IS OF KXSKCTIOII OF THK HIP-JOLVT FtJB MOKBrS CUXAUtUS.
Of tliCM, Teeovwy followed the opcnition in cixlv-tlirec<!a»e«; Dtiio onl>' dying from the exhansting effects of hi|)-clisi>]i£e.
Forty-«even of them casM arc now alivo. Of these, one n- oorercd without shortening of the linilj; twoiitj--iiiHc recovorcd wiUi 1c88 tliati one inolt »hort«Riiig; tiflceo recovered with one incJi or more ehorteoing ; of twenty-five there was no rtjcord of the itbortouiuf; talct^n, tis iti eonie iutitHncM thv juitients left for their homes Itefore the wounds wci-e entirely cloeod; oiid olliors, ngiiiu, dii-d, Hit EtMted in appended list, death in sonte aa$en being entirely foreign to (he ojierHllon, and following many yeans after a complete cure hud been efTeetwl. Aiu-hylnflis rei^iiltci) in hut two caeea, and two are under treatment at ttH< present tiiuc
CiM S died from whanHtlon on tli« vUblb Aaj.*
Out 8 died ttam exhauXton in two inontb*.
CaM 10 illed fr»m totoaos od the flneenlli day,
CiM 14 divd from cxtinaittion in two week*.
OiM IS (lioii from double [ini-uinonla on tbo fourtoentb day,
Cmo 16 di«d frticn djwcDtcrjr lurcnlccn mouth* atUir tint opcrntiou, tbo voooib baTJag been atmuH closed for ftu[ii« luontbs.
Cmc- 19 died from tn*numiiii tvo yr*T» anJ two tnoatlis after the op«r^ tiMi. Tbe wound liiul bccu closcil for nix moDttis.
Cue SO died from iIjHOtery in two weok^
Omc S3 died from d.vumtcrjr eight tuontli* uftc'r llio Operation.
Otao S7 died from pliiliioli two j-eara after Itie operntlon. Woaud li«aled for mora tfavi • j*ar.
Cm* 39 died from mioslrobe from expotmro on tlie fortieth daj.
OaM 80 died from esbonstion in threo weekn.
Cm» 83 di«d from fult; d^^^'netrulion of tbo liror nod ktdnojrii IwODtT-- tbre« moBtba afttr the operatioa. Wound Doerl; beolod ; tltroe lacboe of new boDc liirmed.
OMe 84 died tVom exbaiiatloa in eighteen moatlis, froui jirogreMlre dis- MH of the iliam.
CA^e 87 died of tnbcrculodts, October 11, IBTP ; the wouDila having healed more tbaa fire jeant prcviouvl.r.
Cue 89 died from amyloid degeueralioa or kidneja in tliree w<.-<>kii.
Cue 4S died from snddvn tiupgianitiTe D«pbritl». two ,vcars and lliroe nwalh* after tbe opuratjuo. For ncnrlj' a j^car hod been able to walk with* out lupport.
Oa«c 43 died from dyiwotcrjr thirteon montb* after tba operation. Tbe wooad bad been eotlrdf dosed for four months.
' Tlie figure* fder lo the nunber of tbe ca*e in tbe lablo.
848
SBASES OF TEiE WRIST-JOINT.
Caw 44 dlod IVom DoiihritU froin cold, ninotvM tnonths ahor tba ofi«r^ tiun. tioil bvi^D w<.'ll fur iiMrij- ft jroar.
Cam 47 di«d from oxbassdoQ two and a balf hkidUis atUir Um opentUoii.
CaM 4U di«tl from oxli«u«tiiHi in one month.
Can ftS AM Anitii»t iH, lUTi, frout n^plirilift following an attack of *aar- lot fever. Tlio wound* wcrv rnlircl]^ clowd nix nioRt)i» |>r«vlon«.
Caae S7 died tevax pcritonilU, Jane 3, 1670; tlie wound* at that tinw beiiiR «lill opm.
Cow BS tlioit Marcb 4. 1S7S, two jtun and hx nontli* nftcr l]i« operation. (&» hittory of cum, and froniUptooo.)
Com GI died from tubttrciiUr ni«aiia|pti<i, Vay SI, I8TC, lottjAi daja tHei tii9 operation, tli« woonili at tbat tiui« l>«iag still opeo.
LECTURE XXUI.
DIAEJIEIB OF TItK JOIXTtl (cOXTmiTRn).
IKMaM of Ihe Wrini-Juiat.— STBoriti* of Iho Elboir .Joint .—Dimbw of tbo SbovMai^^ Joint (tauce. gunlboUirounil^
Qksti-K«es : At my last lectnre we pompleted the stady of hip^Hiofic, xitd tliu> iiioming I invite your altviitiun to di^coM of the wrist-joint, and to a few points suggested by the case which is now btforo m*.
This joint is liable to be altacl;ed with the raine diseases as other joints, and should be ircAted in accordance with the same prinriplcs that govern the troatmont of other diseased joints.
The folluwin/j oim; it offered iwan illiiiitmtiun not only of dis- ease bat of the manner in which extcneion and counter-extension nmy be npplied lo the wrUt-joint.
Some time since this man rtt-olved a fracturo of the forearm. Pkle^totioue cry^ipeta^ wa« developed in the limb, and thirteen openinj^ were made to permit tlio free discharge of pas and «oram.
The hami ami forcnnii were a>demntoUA, and pus wna burrow- ing about in suveral places. Th« wrist-joint became involved in the inttammntion, and the qncMion of ainpnlation was serionnly consiiiered. Constitutional disturbance had become well marked.
It waa, however, de<nided to make an effort to tave the limb, and the treatment coDNstod in keeping the opening five for dis-
TREATMENT.
of sacli matoriiil as might bu formec], tlio admin istration of BQcli constitutional romcdicei as his case noemed to demand) eucU ut iron, tonic^s <itc., and tlio uj>]>li<.':ttion of extvneion un<I CDtintcr^xtension in t)io folloiring nmiiuer U> relieve the conRtant pain in tliu joint. In the &nt pinoc, vach Ihigvr vras bandugvd separately. 1 then took a piece of common sole-leallier long unuugh to rvach from lite np{K.T portion nf tho furoamt to the end of the lingers, and about aa wide as half the circumferetKt.- of the limb, dipped it in void water until it wiis«oft and fluxiblv, and then mouIdc<l one end of it to the palm of the hand, and eo cunxl it with a roUer-bandago ; then, m an aMJstant made vxtun- eion from the hand and another from tlie elbow, nntil the snrfacee of tho di^rai^cd joint were separated ami tlic piiiii ri'lievcd, I brought the remaining portion of the ](3atlii!r splint agsinat tlio forearm and there secun-d it by continuing the roller-bandage np over the forearm. Tho splint was now k-ft in position nntil it became dry. wliun it \viu removed and lined with a »tri]) of adhi^- eire plaster, planter side out, of tlie same width aa the Bplint an<] »ng enough to go eitmplctely around it lengthwise, and lap a >nplc of int'lies or more. It was then ready to be reapplied to tho limb, and, after the openings had been covered with liltlu pieoee of oakiim to absorb whatever discharge might take ]>laee, ft wan ndjtutcd in lt>« manner ali-oady doMribed, tint accuring it to the lund, then making extension of the wrist and Iniuging iho plaster againnt the forearm, and retained Ihero by continning the bandage over it. Sincu the application of this splint, only one woek ago, the o^lematous condition tlien present Iiaa nearly dlft- appunn^l : the discharge liaii diiiiinisliod to a very great extent, tlie constitutional ditilurlmnce hsA ])eMed away, and the 4jtiei'tion of amputation i« ito longer to be considered.
In tho M!Ooiid case which I here present to yoa the patient is a man thirry-«ix years of ag(>, a carjKmtvr by occupation. Two and a half years ago, while engaged in his usnat avocationa, he wuh struck with a hammer on the vxtermil ntdial itiirfacc of tlw wrist-joint. lie continned to work for two months after the acci- dent, which occurred in June, 1877; but «9lhe injured wrist kept growing worse all tho time, he wu* finally obliged to atuindou liia occupation altt^tlier. To relieve the exLittng inflamniation ponl* ticLit were applied, and at length an abscess opened on tho inter- nal oapect of the wrist. The part was then blistered with iodine,
880
OF THE WRIST-JOINT.
and to Bncb un extent tluit we find ttie cicatrices tliat reflultcd »tJI) romoijiiiig.
Nov what we liave liore ttwlay ia eimplj tbe refitiU of iiiHnm- matJou of tLv wrist-joint, which wfts Hct up by an ordin&rj blow, and which wan not properly attended to at tbe time n-bun it commenotHl. In consequence of the ucglvet at first, and tlie sub- seqoenc mifinianagernent to whioh it wiis snlijccted, tbe JnHatn- imitorv pn>(X-»t huA gone on until, u» you eev, it tias prodaead flnblnxation of the joint, with the hand flexed pcrmsnently at an angle of iibont a hundred and eighty degrecK, and the nlna, wliicb ia completely dislocated l>ackwar<l, projecting fnlly half an incli. And not only do wo find ttiiu well-inftrked deformity, but also great xiiffering, and the pain boromee most agonixiiig if by any. meiuie the enrfaceit entering into Ibo composition of the joint are crowded together. Ilorc, then. Is an excellent apecimen of chronic diseiwe of the wrisNjoint, resulting in diKint^'gration from abnorp- tion of the articnlating surfacos and con9e(]uent deformity; all of which iiiigbt have been avoided if the origJiial trontilc had] been treated by continued extension. Tliis, I U-am, has never;; been applied in the cajie. Now dteease of any joint which cod* limies fur a few months will inevitably produce rcfiex lunscolar eiinli-aclioiiH, whi<h not only aj^;ra%'ate the affection by ajwiating. ab^orjitjoi) of the artiL-uUtiitg surfaces in coneeqacnco of tbepreea' ure which they uuintermptediy keep up, but al»o Anally romlt to tpHcb deformity as you see hero, which is regulated iu extent bjr4 the miisi'lea concerned. The flexor ransclefl are of conr»c much i more powerful than tbe cxtonmr onw, and hence tlio rceistance of tbe latter ia gradually overcome by the force of the former. If these two eetn of miii>cles were ctjual in powur, in such a caso as tbia, instead of the kind nf deformity which exiat^ here, wu should bavo the hand simply drawn upwnnl toward the vHkiw, mtlt disintegration of tbe bones and cartilages of tbe joint under the continoed prctwuro. The specUl charactcp of the deformity that is hero present, therefore, is due to the superior power of tlie flexor niuKo.ltjA of the forearm. In order that the eifcct of trcat- Rivut may bo fviUy apprcvliitcd in such a case, a plaster cast of tbe joint should always be taken before commencing it, ti» tbit* exhib- it* the real condition of the jMirts in a much more perfect manner than any phott^^ph or drawing can ]mesibly do.
Now let mc show you what tJio effect of extension, made in
CASE.
I
I
the propor direction, will be even at tliU Into utiigc of tlio disease. My assJHtant now making firm reiiiiitAncc »t tlie bcud of tltu elbow, I Uko tliv innn'it tiiigcnt nnd tbuml> in my bands and niako exten* sion at tlio eanio limo that I [triiftieo supiiiatiun. By tlii^ hiirjiIo procedure yon observe tbat 1 at once diininiflb Ibe deformity to a confidernblo extent, and not only docs t)ii« cauec- tio |Hiin, but it niakiie tbe intlanied partD abe^olutely comfortable, afl you can readily see by tbo relieved expression of hie countODnuee. Jn tbe course of • few honrtt I have no doubt that I could in this way ooid> plctoly Htntigbton out tbiA deformed condition; whicli, indeed, tbould never have been allowed to occur.
From tbe above facts I think non« of you can fail to appreci- ate the important leAson that is to be gathered from a case like tliis. AViUi all the camev^lncM that 1 can possibly ouumiand, I beg of yon never to forget tltat, naleae some interference ia made, chronic disciiio of the joints inevitably produci'H reflex nnii>cul.ir contractions, and tbat these eontractioRs just as eurely aggravate tlio dittuue and result in defonntty, such ns is men in tlic case be- fore you. This ia half the leiwon. The other half is, that all the had efft-cts of thwe mnaciilar contractiond can be sDCocMfalty over- come by keeping up proper extension during tbe acuto stages of Uio diienso.
For instance, if in the present case I could eit here indefi- nitely, holding the patient'.^ hand in tlie manner tliat I do now, it would he the bosit method of trciitinent that could possibly Iw resorted to, becJinso there is no instrument or appnmtUH tlial can Mali equal the human hand In delicacy and applicability; bat,u tliis is manifestly out of the qne^tlon, we «liall have to adopt in- stead the best means at our coniitiand for the purpose, ^ow let me oonrinoe you that the plan of treatment by extensiion, of which I have Bpokcn to you. is the only corrvrt one in these c^eos. "While 1 hold the patient's hand in the manner described ho is, as I have «aid, perfectly at en-te ; but the moment I let go, an instantaneous sjjosui is proilueud by the impact of the diseased surfarcR, in con- Mqiienoe of the nntuciilar eontmetion, and tJie man jumps to bis foet with the pain as you see. If, now, any prwsiire, Iiowever slight, should bu u«od to crowd the surfaces still more closely to- gether, it would increiLsc the patn a hundred-fold, while if motion shooid be made in the joint, with t3ie ports in this condition, be would snffor the most iuexpressiblti agony.
858
DISEASES OF THE WRIfiT-JOIST.
Is it «i»y wonder, tlion, that a patient with one of bis joints in thU condition, wltidt cau^s hiu) tmintcrrupted and inteofm buf- foriug, and keops up a constant etrniu ujkiii the wliulu ej'stKtD, aIiorM evcntuallv i<nfFor marked ixmt'litiitional di8tarl)aiioo in con- eoqilcnoi-f Whciii thcsu c-ouHtitittioual retfulls octrur, he is sap- poaod to be 8uffcrin{^ from ecri^'ulmat diecsse of the joint, although tUvrc may not be, and in tb« va&t nujority of instauceft tbvrv in not, the siighteAt scroftdooa element previons to the receipt of the injury wliich h:is produced tbt8 di^'UMt. Thu trouble is, that tho original injury is usually of such a trifliiij^ nature that it is nl- litwt-d to pn£H almost iinheodod, und tlio patii-iit govs about his onlinary business without thinking it worth while to do anything for it. If ihm inuii hud had lii« hand nlnio«t cut oH, he would have been all right long sgo^becauije he would have gone at once to a surgeon and hud it properly attended to; but the accmlDg *'Uiberniani«n," that "the less yon nre hurt the worse it is for you," often conies true in point of fuel, on account of the time tliat is lost and tho sulTering that is endured before one (intilly re- covers from the effects of an injury trivtul in itself, Tho princi- ples hero laid don'n are appliiMble to aU diaeases of the joints. Only get a correct comprehenflion of tho jMtbology in any ca»e tiut may come under your care, aud then, aiid then only, will yoa t>e able to treat it to advantage
But now OS to the treatment to be adopted here. The mosclcBiJ and tendons may hare remained so long contracted in this ease that they have become coniraetured, or, in other words, structur- ally shortened. Sucli a marked deformity cannot bo reduced in a moment, and in treating it tho important quet-tion firat nrises, (^n the contraction of the innscles and tcndona be overcome I by gradual traction, or will it be necessary to cut any of tbem 1 On making point-prcfeure here while the mtL^rics are on tlie stretch, I find that no reflex contractions arc produced by it, and this at once convinces mc that with tho aid of gradual traction, maintained for a suJtk-ieut length of time, they can bo fully ro- stored to their original position; whereas, if reflex contractions hiid thus been caused, sueh gradual traction would have been of no senice whatever, and we should have been obliged to use llie knife. What we have to do, then, is to maintain extonsioo and counter-extension, and at the same time keep the parts |>erfectly at re^t. This eau be meat cwily done by iue«u» of a piooo of
CASE.
SAS
ir about tlic widtli of iialf tlic cireumf«reiioe of tliu limb, ftnd sufficiently long to reach from tde up|»r part of the foraimii to the cxtn-mittut) of tlie Unj^nt, mouldcil to tli« nnrfaoc luid jirnperly secured to th« limb as in thu pruvious i-ase, while the build it vxlendt'd in ibc lunltion that overcomes the defonnity to the greatest extent, after which wo fitwiini it by means of « roller. Wlien tlie latter hiia been put on we shouhi look carefully at the ein^ulation of the firir^-r-(;iidi<, which HtiMtdd he left exposed, tuid if thii! \» At all interfered wilh, the bandage eihonld immedi- ately be taken off and reapplied. Tlii« dressing havin<|; now been properly ailjunted, we find that tlie patient is entirely free from pain. To-niurrow, when the leather »]>Iiiit liiia become pei-fectly haixl, it will lie taken off, lineal with adliesive planter, which tlionid Lap a couple of ineliv« or more, and then bound n^iin to tlie limb ^extended as ttefore), with tlie plaster against Die fore* arm. SoIc-k-Ather appli«d in this manner is etiff and nnyicldin;; when it hopomes dry, and, if afterward it is covered with adhe- live plitKtor, it will keep up jwrfect extension and counter-exten- eion, thereby relieving the surfocw of the joint from all pressure. Inflammation of the wrist-joint i» not very infretjiient, and it is liardly possible to deviso a more simple and eAeetive method
[ for phicing tlie joint perfectly at rerit than that whiHi you have jueteecn in opcmtion in this ease. In this way permanent ex- tension and countei^e.vtenstion will bo mainlaiiied. and the dii^ esMsd surfaces of the joint consetpienlly kept from coming in contact witli each other. In a few d:iy« later, when the deformity has bceomu to a certain extent reduced, tint splint can l»e taken
I off and remoulded to the part ; and ihli* can be rci)cated m often as neceeuu-y, nntil a cure hns been effected.
If the diaesAe is sn far advanced that some of the bonce have become necruoed, the tii^luloiis openings leading to the necnwed bone can Iw enlarged, and the dead bono rvinoved cither by the forceps or gonjje; the limb then beinf; retained in place, and the Jndia-ruhber drainage-tulies inserted for the pur|ioee of prevert- iug the burrowing of puK. In this caku, instead of unng the sole- leather lis a splint to extend tlie arm, it ta neceesai^ to use AIiI'b felt splint ; il can be moulded to the arm the iuimc as the leiitlicr, and Jiaa the advantage over the leather of not living utfcetcd by the Bcoretions, and tJiiis it retains its fonn ; wberca», if there m a»v diBchargt^' from the wound, the loatlier woulil become soft
8M
DISEASES OF THE ELBOW-JOIlfT.
And ]i]iable, and hence the limb could not be rcUiiicd in tbc proper potiitiuti. JLiving, tlioi-cfore, appHctI tLe Alil'fl felt splint cov- ered wiih adhesive planter, tb« aaiiie as we did tho Wllior, and tilled tlic wuuiid witb feruvian bnLsani, and i[i«i<rt«d tliv dniina^o- tubee, then well covering tlie wonnd witli oakum for the purpose of ■Iworption. wo bind tlic wliolu flmily with > roller in order to prevent infiltratidii into the connective tisHUe. This plan is pnr- Huw) daily, (li[iiiTiii«hing the sUc of Uic dniinn^tubut nti rotjuirvd nntil all nei'i'oeed bone ia exfoliated and tJie wounds entirely heal«d, wW-n piiMnivc motion fhimld be carefully comnieni'c^] and gradually increuBetl, witb friction and massage, until, in mnny in- stnnceA, an filmot iH!i-f<-('t joint iit th« rc«ull.
This partial exscttiou of tlio joint, simply removing tlie bone involved in the dineaii^, ij> » more ^luptc inetbud of trvalment in tito wrist, the same as it is iu tbc ankle, tlian complete oxsectioD of the joint, and i* attended with much Icsa risk, and it ibu wimo time yield* far better results.
iJisEASE OP THE Ei.Bow-JoisT.— I wouM Dfixt clircct your »t- toutiun to diseoeo of tb« elbow-joint, aud in illuHtration of the same I <]H0te the fidlowin^ ciLse as taken froni my booka, imd at tho eame time present to you tbe patient himsulf, who, you will obecrre, has perfect motion at the joint :
Oakk. Suppitrtitiee Spiorifia o/ thv liiijht EOxyw^oint, — John Woram, aged forty years, 1(>3 Gt«ene Street. One year ap) the pntii-nt'n ri^ht 4-lbiiw wii^ caught between two ftta^^ utd greatly injured, icsiilting in a eevcro synovitis. This abated un- der treatment and rc»t, and two months from tbc date of the injury the patient returned to his w(irk (upbolstering) until the following Mari'h, ntite months after the n-ccipt of the injury, lie then eommcnecd to have pain in the elbow at night, and uIho when finit i-oiinnemriiig work in the morning; ibi*, bowevur, would diminiflb after working for an hour or two. The patient attributed thin pain to rbeumtiiiBim, and nought no advice until he presented hirowlf to me, just one year from tlio date of the in- jury. I found the joint greatly distende*!, the forearm being flexed and stmngly pronated ; the Bligbtest motion at the joint caused intense pain, eiipecially if any attempt at rotation was made. Un the inner surface of the joint fluotuation was dotc«tod, the con Hti tilt ion a I Kymptomfi rendering tlie diagnosis of pus proth able. An incision was then made juitt anterior to tbo latomal
TKEATMENT.
S5S
eondylo, which rcenltod in the immediate diticlisrge of almnt one und u Imlf ounce of fibrinoiii' matter mixed with ))u», the matter being of a pulpy consistent-y, resfmbUiig jvlly of a dark-brown color. The amonnt of motion was at onco increa»ed, and tJie pain dimiiiishi'd. A small piece of bono donudi'id of airtilago waa tlteii exposed at the internal condyle, the bone being carious to about the extent of half an inch iu diameter; this was then Hcrapvd and the wonnd tilled with Peruvian halBam and packed with oaknm.
An AlilV felt splint was (.-arcfully moulded and applied to thu arm, leaving the internal condyle expased, the wonnd being filled with Peruvian b(i])r;un and oakum to admit of froc draimigo.
Jio con^tituiiiinal dintiirbance followed the operation, and ttie patient slept bt-'tter that night than h« had dono for the past two inontliii; no Q]>iate wax given. 1'lireo days after tlie operation tliere was markvl improvement in the general health of the patient, the pus as&uniing a healthier condition. Tliiii improvement con- tinued until the wound wAt entirely closed ; tho patient nx-orer- ing with perfectly normal motion of the joint, a^i you observe.
In Boin« oascK it may be ttuit the disease lias extended so far tliat the necrosed bone or carious eon<lition may involve the whole joint ; then it become iiecossary to make a eomplet« cx> section of the joint instea*) of the incision and gouging, as in the ca.4C jmit preiiented. In «uch e»»et it is ncec«iiury to ann?«thetiiie the patient ; flex the arm and make your incision over the ole- cranon process down rhrougb the periosteum, earefully hugf^ing the bone, care being taken to avoid injury to the nlnsr nerve ; making your incision according to tJie wise of tlic patient; then, with a lingcr-eaw, remove tho upper end of the olecranon procc« which carrier with it the tendon of the triceps muw-lc, and thus gives you immediate entrance to the joint ; then with a periosteil elevator carefully remove the periosteum and ligamentous attach- ments from the boue, and with a chain or tinger-saw remove the lower extremity of the hnraems ; by this meians yon secure a free opening; for acce** to the upiKT extremity of the ulna ; then with the periosteal elevator carefully remove the periosteum and liga- mentouB attachments around that bone, and saw off the »pi>or extremity of the ulna on a line with the bead of the radius. If the radius is. however, involvi'rd in the disease, remove the head of that bone also. The wound is then thoroughly cleansed and filled with Peruvian bal»am. The arm i« then made straiglil and
356
DISEASES OF THE SIIOI^LDEIWOnrr.
(MX'urcd with an AlilV folt splint, the wound being covered with oakuiu ; a flnug bandage is now applied, and the patient placed in bed, witb the arm pcrfecUj^ at n*\.
In a few weelcfl, an the wound heals, passive moTemonts are oumnieiiced nnd incrt-ufied day by duy. In tlic vn^ mnjority of casea the reeult k almost pei-fect, the arm being as aseful as tliougli no cxKCction hud tAkeii place.
DtsKAfiP. or TUK SiiotiLDER-.lotxT. — Wc Will now dlnx't oar ftUentioii to (Ii.««a«M of the slioiildvr-juint, and in reUlion to the BMiie I will bring to your notice an extreinvly inturtHitinf; caee irhich came nndur my trcaliimnt, and fn^iu wbioh a valuable leeson may bo leamct) as to the extent of the ropiinitive powvn of nalnre, in what might nt tirRt weni an almost hopeless case^ and only to be remedied by anipntJitiun.
Tliia man, Mr. .1. Mel'jko, unw before yon, wan shot in the right filiouldur August 'SO, 1862; thu ball ent«red three inchuB below tiie clavicle, {KtHAtng through the pcctoralli major and eli^htly upn-ard; then, pacing tliruii^Ii the Ktir;;ivuil noi'k of the right humema, completely Ahnttcred this bone at that point. In Lhe field he was tn^-at^d Miiipty with tlic ordinary dn-ssing, but was afterwanl tranoferreil from one hospital to another in the South; in the following Fobniary a targe abHoe«H o|>ened in the flhoulder; this ahscess continued to diectmrgu until 1»6^, wben tJie patient came North and placed himself under my treatment. At tliat time ho was greatly emaciated from oxeesBive suppura- tion, loas of apjtetite, and want of sleep; there were two large ainueee, one In front of tlio axilla, nnd the otlicr behind tho oJe- cranon, giving exit to a large union nt of pus; through each of these tho probe readily detected neeroeud buiie. ThcM HJnusce were enhtrged hy a probe-pointed bistoury ; the perioetonm, being vcT)- greatly thiekonod, was preesed off with the |)erioo^teal eleva- tor, and with a pair of strong forceps the head of tlie bone — which I now ahow you split in two piecMt — was removed with several other small ])ipoes of hone. Tlie wonnd was then thor- oughly cleaiitted and tilled with Peruvian iMili^m, and drevecd with oskiim to admit of free drainage. An Ahl splint was tlieo carefully moulded over the Bboulder and under the fon-nnn, keeping t!io limb in the desired position, Ko constitutional dis- torinnce followed the operation, hut on the eontrary llic genenl health of the patient improved from that moment; the dischai;^
TREATMENT.
8B7
cvMcd, liiii nppctito rctitnicrl, aitd in two monllis hU recovery waa pcrfi.'ct und cotiipk-to. It ie now more tlian tlircu years fiiouu the cIhIo of ihe operation, during wlii<;h time jiasaive movement of tbe joint biivu Imkiii gnKluiilly incrciiecd ; until, us you now sec. It iii almost j>ei-fect in its moiinn, with the exception tliat the deltoid miiM-to 'u noniuwluit lucking in power.
In chronic inflammatioQ of tliis joint, which sometitnea oociira, the ann can ho placed in r fUng, ttiid, by uttuchiiig u weight to the foniarra at the elbow, the extension reqniflito to ^ve caee from pressure upon the nrticulor surfnce* can beiweured. Thb is the most simple tnelliod of separating tJie articniating Hurfacus of ttiv Hlionlder joint ; hy this means attrition U prevcatcd, and the in- flammation epcc-dily &u1>dued.
LECTtlHE SXIV.
OISBASKS WIIIC-U StMULATK UHBASBS OF THE JOISTO.
BumJliMi DiMMo — DiiiMf* uf th# Kne^.— (krtni ot lli« Ilhim.— Otriox at iho Iicblum. — hrioMitlti u( Aili*ivnl I'art*. — fiKrju AtMcmn. with PoK's DlMtM^ — Inf^lnol AtocMH. — Inflkimiiatlun of (lie ri-oiui !ilD^a> and llloiii* Intcrnu* Uuwloi.— CdD' grallal ItaUonniillauof ttu:rclib,c(imiDonljlEiuwii M"Oaageniul DUloratioiL"
GKNTL>:Mi!N: Tliie tiioniing wc will take up thooc discuses which aimnlute ditieikfio of ihe jointi*. I will firet call your atton- tiott to thoM) di«cn««s which «initilatc di««ase of the hi|>- joint.
Hip-joint diseaso is liable to Ijo oonfoundcd with sacro-iiiac diBciiM! ; disease of the knco ; caries of the iliiim or i-ichiuin ; peri- eetitis of the parts adjacent to the hip-joint, particularly of Uio grunt trochanter. It is more nirely eonfoimdeil with psoas nbseesa asso- ciated with Pott's disease: inguinal absce^; inflammation of the paoH mngnusand iliactts internusmuscIcK; congenital nialfomna- tion of the ]>elvi8, comnionly knowni as "congonitiil dislocation ;" paralysis of iIil- lower uxtn>inities, anrl injuries to the hip.
6ACR(>-n.iAC DtHKAfiB. — The anatomy of the sacro-iliiu! junction 18 tliiM given by Gray :
"The sacro-iliac articulation is an amphiarthrodial joint, formed between the lateral aurfncc« of the sacrum and ilium. Tbi5 anterior or auricular portion of each articuhir surface is
858
DISEASE OP THE JOIKTS.
covered with a tliin pUte of cartilage, thicker on tLe ncrnm than on the ilium.
'* The etirfiK-cs of Uieso eartib^ in the nduU nro rough and irrcgnkr, and sepantted from one another \>y u soft, jrellovr, pulpjr ijiibstaiicc. At »D vsrlv period of life, occaeionall^- in the ndiilt, nnd in the female during pregnancy, they are smooth and lined by ft delicate aynovial mcmbrano. Tiw ligamcnta cnunuctttig these anrfacefl arc the anterior and posterior »cn>-iltac.
" Thu anterior eai-ro-iliac ligiuneiit eon0i«48 of nnmerona ihln liganiaitoiijt hn»d« which connect the anterior surfaces of tbe Bocnim and ilium.
'^The po«t«rior iwcro-ilinc ie n strong Intennswoua ligament^ t»ititate<l in the deep <Iepreii!iion between tbe sacrum and iliom buliiud, and forming tlie chief bond of connoetioit Iwtn-euu tlicM booeg. It const»t^ of ntmierouit strong faiwiculi, which pass be- tween the hones in various directions. Tlinse of tliete are of large uze. The ttco 9tij>erior, nearly horizontal in direction, arise from tlic (irst and M^coud tran«vcr>io tiiberelcv on the i>o»tvrior Bur- face of the sat-runi, and are inw>rted into the rou^li, nnevcn e^ur- facv at the posterior [wrt of the inner eorfaeo of the ihun), Tlie third fasciculus, oblique in dire<'tion, U attached by one extremity to tlie tliird or fnurth tmiisveri^ tubercle on llie posterior Hur- faoc of the i>acmtn, and by the otlit-r to the ])o«tcrior eujierior apine of the ilium; it in Bometimeo called the ol>!iqne eacro-UUc lignmcut. There i« only very alight movement between tiio bones themselves."
Disease of thia joint ia quite common, an<l ia invariably of trnumalic origin. I havu ecou a numlM.-r of ckmi^ in which the disease originated in injuries received by (he Ultle patient.i as ihry slipped over behind a trunk and got caught Itctween it and tlio wall, where they weredonblod up vtrry tig)illy. In tlicir effort* to get out wliile jammed down lietwet-n the tnink and the wall, the junction of tlie sacrum and ilium i» brought In contact with the edge of tbe base-boar<), and gets bruised snftictently to set up an inllai nutation of tlie [Kirtti injured.
While the inflammatory process is going on, tlie patient will <wniplain of difticully in nmkiug walcr, difRcully in luiving a moveiturut from the Imwels, and more or less pain in the tmwola; in sliorl, the aame class of symptoms referable to llie front part of tlie body of which the patient con.plains who Iiaa Pott'a dioflo
eACRO-IUAO DIBEASE.
859
of tho spine. Aftvr it wliilv nn at)«cc«» niKy tJtow llwlf, which Ditty be poeterior at the upper (lart of the Bacrain.or up alotij^the side of tho Fpiiic, or t-xtvmliug in vnrioue din-etionti, «»(! iimy poMihly work it^ way through IjoIwcch thf^sacinni and iJiuin^and apptar ajmn the nnturtur pnrtiiin of thv lliigh.
Of counic, wlicn it hiui rearheil thio jKiiot, it is almos^t a hope- Ices caee fur truutiiicnt. Tliu ii_viiiptomM wliich iirv prcwiit in tli« eiiHy stage* of tlic disuse are very much lilco those of hip-joint tlisenw.
That i«, thu child eitunot walk without lim]iinf;, aiul walking; alfKi giveti him i)!iin. CoucufiEion o£ tho hond of tlie femur agaitiMt tho aectahuhim also catLsos \mn. Crowding upon tlie ffreat trnclisntcr cauw^.4 pain, becanso tire pi-ei^urv ih tniniiinittvd through iho ilium to tho part involved hy Iht- di^iMWi-.
But, wh<tn the wEngs of the ilia are held linn, and then an examination of thu hip-joint niiidc in the manner dcMTlbed to you when speaking of )iiiHliiM»sc, no pain will be prodaeed, and free motion can lie made. In liip-dieeaso, aMuotion or rota- tion outward, or adduction or rotation inward, depending ii]>on the stage of the diiieaf<e pretient, aggravstoi) to a greater or lean tfictent, often almottt inlolerably, tho HulTvrings of the patient. In tliis manner you can exclude the probability of diseaae of the joint.
Now make direct eompreswion npon th« wingv of the ilia, crowding tho bones against the »K-riiT!i, and you will produce pain at onoe^ and at the scat of tttu disease. If extension !» made, the pab will l>e relieved, and tliat i» alw true of hip- diiease; but, when the pelvjg i« firmly held, and eoni])re<^Hiun made of the hip-joint mily, it will not develop paih if the difleaKo is at the sacroiliac joint, but it will develop pain if tlic diiscaec is at the higvjoint.
Now turn the iinlient upon tho laoe, and m»ke proeniru along tlio lino of the sacro-ilise junction, and you wilt find that tlie greatest degree of pjiin ii^ pi'odncL-d in that region. Then* may l)C more or lees tendernesa all over the ^hitcnl region and about the hip-joint, but the grea1e«t amount of pain will be produced hy prctwing iinmeiliatclj over the articulation.
In iuu<n>-iliac diMOse there is no abduction or evcrsion of tho limb a» there ia in the first and i»econd stages of hip-dii^eaae, hut simply eloDgatioii. On the contrary, the distortion present in
3A0
DISEASE OF TIIK JOINTS.
Moro-iliac dlt)eR«c is a dislortiuii of the Ix)!!}*. (See Fig. 107.) Tliv patient t>emU the ImxI^ over to the opposite sidf, to thftt tL« weight of the linili mav uiuku extension enffieient to give relief
Fti^ u:.
to the diseaeod articulation. {See Kg. 198.) This bonding over to one iiifte, for tlie purpose of rcmnvinjr presanru fixnn the dis- <MWud Htructuree I>_t l>rin^itig the woi^lit of \\io limb In hear upon tlie ilium, pro<Ii«Hi» « deformity th«l h pwiiliitr and chantcleristie of fiuvro-iliac disease. (See Fip:*, lUS and VM.)
In Kavro-iliac dist-aao tLc lenjirthcning of the limb is absolatev while ill hip-joint disease it is only appcircnt. In hipKliwoM tbu elongnlton itt diM-ovfre-d by nit-ai-uriiif» from the anterior siiperior BpinoiiH procc'Mt of the iliiun to tlie interna) nialU-olui>. nnd ia umiix^'d by Hie effusion into the hij)-joint. The elon^tloo is apjHtrvnUy greaUT than it rwilly i«, and is due to the twisting of the pelvis. In sacro-iliar disease the diiilanco between ilie iiial- leoltignnd anterior superior apinons proceas of tho ilium ia Uie eatiiti upon botli sides. Wlien the diseafio has projrr€s»ed eo far llut abse««ecsare pr«<«nt and uprninp* formed, it alioidd bo recog- nized at onoe ; for, by ineana of Ihe flexible or vcrtcbrated probe, dead bone can often be detected.
TBEATSreST.
Trbatuhht. — The principle of treatment arc ttie wiine wliivh guide lu ill tlic iroiitment of ull juiut-(ii»cu«cc, oaniely : nst, ex- teDsioti, and countdNCXlviision. This is aocoiiiplistiiM], wlicii iho patient is confined to lii» bed, hy mcnng of the weiglit and pulley, w in hip-dieeoee ; and, doriag the dny, by tlio doU; of ihc »huc worn Dpon tlie well foot being of suflicJent tJiickiioas to permit the •ffecled linil) ta ewinjj; fn^o, &o that it* own weight may becomo lU extending force. If the weight of tlio limb is not sufficient to make the amount of oxtentiion reqiiiiXHl, tend can ho run into the Kulc of the tthoc, and tlius Uio weight can be increased
FM.tNl
u oirCDtnBtancos may re<;Hiro. "Sovr ^ivc the patient a pair of erntobeA, so that the weight of the body fihsl) he receis'ed by the axillu) and not by the [lelvix, and all tJie indications in treat- ment liave been met. Darrach'B whwl-tTUteh is a very ad- niimblu support in llicee tanea. If the ciiae tH one of long stand- ing, and ttiere t» more or less depoett in and about tlie juint, or if llio inflammation doL« not readily aubaide, iippHcation of the aettial cautery direi^tly orer the sacro-ilJac artii-utation will bo of tho greate^ H^rvioc The actual cautery in prcfernblc to any other means of counterirritation. There is nothing like the
DtSEASE OF TUE JOINTS.
action of intoruo hMt in the ti%atmciit of man; of thoM Thcrw is a relaxed condition of tlio ligamenI^ niid an engori state of tJic Wood-voesels, wliicb on bo morv liffet-tually relieved by tho use of the nctiwl tautury tliaii by any oilier meiinit tbat can b« cniployod. The contractility of tho blood-vewelfl is ex- fitod, by whidi nieaim they are emptied, iitid in this manner V0IIOM8 engot]gomcnt is relieved, and, as the wound Itoala up, the cicatrisation tiint followa contracts and condennei* tlie lignnientoua Btnirturcs in euch a manner lu to firmly hold tlie joint in p4>silion when recovery has taken plac*. If ilie diwaae lins pro(rrw*«od, and euppiiratioQ becomes estaWiiJied, then, instead of canteriia- tion, lay the parts open freely, paasing down until you havii laid tho joint bare, nnd. if the probe det«(tft dead bone unywhere, fol- low it up by freely layiiij^ tho siniu«a open, or make wiunler- openiiigB, and gougw it out, for it umet bo removed before the patient can get well.
C'AHE. — Paoag Ah«cf«»from Saero-Hiac Ditease mis/aX-tm/or f/i/hl>UM»6. — Cornelius M., aged four yeani and nine months, came to me at Uellovue Ilwpital, December 15. IH~% to be trwit- wl fur disease of tho right hip-joint. He )uid been roniphiining for some months and had been Univ for several weeks ; had com- plaine<I all sunnncr of i<tonia<:h.ai-he, and bml been tri'iiUiI tor worms, but for the past two moiittu had been treated for lilp- disease:, and wna sent to mc to be treated for titat di«c«so, Upon ft rarcfid exaioination before tlie class, I could tind no diwiow of either hip-joint, but a manifest tcndcmeiw over tncro-iliw; junc- tioD of both sidea, but more particnhirly on the left eJdo. No swelling of the in(;uinal glnnds on either sido. The motlier states that lie was a very active child, and his father useil to make him jnuip over boxes, and from greiit hciglii«, and in one of liiesr jumps he hurt hi« buck, but they had fni^ntten ihtH fact, unltl ! (lueKtiuiicd her upon tho subject. I loet sifjlit of thii! chihl until January, 1874, when lie via* apain brought tu the ho»{>it«], ptv- •onliug tho appearance as seen in Fig. 800. An {mnicoGu ab- Bccsei on tho left groin nearly ready to bunt. No diseaao in either hip, but well-marked disease in both Bacro-ilioc janctioafi. Boy died June 11, 1874, from oxliim.*tion ; wa.t awn twenty-four houni before death, and wa« found to be dying from the exoue- «ive discharge from a «nuH exislinf; in the inguinal region, and a stnns on upper and outer portion of thigh.
8ACR0-IUAC DISEASE.
SftS
Pod mortem, twenty-four hours after dcalli. rcveaU'd ext«ii- eive oarioft of bol]i ncro-itiac jiiiictionH, nnd extensive nl)ficC£S ox- tending <loini psuaa mascl(.>s <>q c-UIiit eidv, on llie left oniiiing out abovo Potiptrt'« ligament, and im tlie right puseiiug uudur xho
k
t an<t cxtvttdtng dorni the thigh. Both hSp-jninta were 'Xy healthy.
Kkcf^ihnt J>ni:A8B is wmetimeH nri.<<taken for mnrhiie coxs- riu<t. The^fV* of liip-joint disease is vcrj- oftcti referred to the knee, thereby cauun^ th« di«e»8C tu be nii>itaken for i>yn(>vitifl <if the knee-joint. So a\m when the knee-joint U reullv diKeoceil the defonnity preoent inuy Mmiil»t« tlint which in neen in the »teunfl afarfe of hip-joint digeaae.
The p(;«ition of the limb in dieea^c of the knee 'i» one eim]>lj of flexion lit the knee atid hip, sccoiiipunied with di-opping of the corrcipoiiding natis. Thti droppiiif; of tlie iiatt>i i-i cniiftod by throwing the weight of the body upon the Eoutid limb and ftllow- ing the diseased limb to be (lendent. At « Inter perio<l in the diMOM it nuy depend upon the luuscolar contnietioa which ftttonds chronic diieatte of. the knee-joint
The position of the limb in tlie second stage of morbus coxtudus
361
DISEASE or THE J0IKT8.
arises from effuBion within ttiu capaulu and contraction of tito pecHU) and iliacus miteclce. Mid i« an aiiatominil necesAily.
So far as position is concernit), tben, tlic dilTcrcucu id origin iB iinportaut in tliu difTcivnliution of the two diMues. Agata, the pusittnn of tlie limb in liip-<tisease is constant as long as th« effusion romaiiis within tbu c»]isulc ; whilu the ])o#itioii in kuee- disen^ innv be varied nt will.
lu hip-diso.'M), souund stiigo, tlie limb is aiteai/a in ath'ance of tlie sound one, the toe tooching tlie floor ; wEiilo in knuMlieeaso it is somethnet in frunt for the sake of comfort, but the patient is able to bring tbe he-el behind the sound one, and often duea to place it, or even bring it to the (rround, and is able to evert or invert, adduct or nb<hict the limb nt plcaiturc. Wlii-n tho p«ti««t can perform these movements you may be certain that llie second stage of niorbos ooxarius in abttenL
When kneo-diwase has advanced to a conHidemble degree, there is strong adduction of tbe limb for the sake of dalimm ; the popIitc>al space closely hugs the patella of the sound kneo, and the heel U t^'iicntlly behind tliu sound one, hut sometimes it may be curried forwani for the sake of renting.
In the third etngv of hip^iseitsc, for which advanced knco-dis- eaae is ])erhap6 more likely to be roiHtaken, there i» ndduction, roinng <if (hj- jyeloif and whole Itrnb, iuviTHion of the foot m that the toe of tlie di»eafied side rests upon the instep of tho sound foot.
Cawks of the Iijtm. — This affection hasbeen frequently mift- taken for hip-disease. A dcfonnity may be present, and it injiy beacconip'inicil by an oxoesaive diKcbni^c of ymt,, and mimy other ayinptorax of hip-disease; but Uie ]>efuliar deformity which i* pn.-«viit when the liii>-joint i« involved i^ not seen in caHe« of caries of the ilium. Aliduction and eversion at a certain stage are not necft-^rily pre^nt, lu in the fioeond tHa^'. of hipKliwww; nor are adduction and inversion neoe«sari]y present as in tlie third stage of bip-diiteaw.
A diagnosis in these cases is to he made to a certain extent by exelusion. If we place tlte patient in (lie position so frequently referred to, with the pelvis and trunk in pn^wr relation to etcli other, and ^>M«;7('/iri'A,fJigfit motion can be made at the hip-juLnt without causing pain, so long as the ilium is held firmly in posi- tion.
4
OARreS OF TTIE ii.ftnr.
306
I
I
Tour (lirDct examiiiutiun is to bo made with the prol>e, wtiidi will enable von U> riotoniiine whether there ia aity dead bone or not. For thU purjxii^ tin- th'xitilv prohe in the only one that should he employed, for it will follow a lead Imt will not make an opening.
If you will remember the points in dtagnosiit of hip-diwaec ftnd keep them accurately in your mind, it seems utmost impos- siUe to confound it with rariea nf the ilium.
Aslsliall not lecture upon varies of the ilium separately, I will mention ttie treatment in thia connection.
Trgatukn-t. — ThiH i^ ttimpte. and con^i-'iU in makiu)i| a free in- cision down to thi^ ilciui bone and rBniifviug it. If the diiicase in- volTea parts of the ilium where it would be dangerous toi-ut,t]io tJnWGS may be dilated hy means of laminaria or epoiigu-tcntB, until they are of suHioient ttize tn permit the inti-oduction of the elevator for the purpose of dipping off what dend bono can be etw^ity reached, and then removing it with the forcepi). If it is not poi;fiible to remove all the dead bone at once you uuiy drill through, ptuLi in nakum Ktriuga or India-rubber drainagt; tube^, and wait until Nfituro reniovM the remainder by exfoliation. The danger in theiie ea«>e8 is not from dead 1>one. but from impritmned pus, making tortuous tiniiiieit in difTerent dir^vtiunt' nnd ultituutely pro- ducing deatli from exhauiition. Therefore, if ynu are not nhle to rvniove all the dead bone at once, if you can eHtubliHli a free drain- age in the pmpcr direction, you have done the Iwwt possible thing for your patient in the way of local treatment.
Cabe. — Thomas K. C, aged fourteen. Jcrecy City, N. J. In infani'V puny an<l feeble, inaettve, walked when three yenra old ; wju> llefihy but mibealtliy, lui« improved since he was iive or mx yean old. In sumtner of 1S64 bad nates repeatedly bruised by kiirka, and by riding s rough-irotting home, The bniifles were treat* m1 with the u»ual dumeittic rctuedia'i. In tlm fall he w-a£ again injured by being thrown down the stone steps at «rhool. and tratn- ple<l on. and was «l*o wverely beaten by s man with a hesvy cane. Soon after thia the Iwy begun to BUtTer from cramping patnti in tlic left tow, tlic paiiiN gradually extending u|i to the hip. The surgeon who siiw Iiim thought an abscess was fonning which would rc«nll in lii)MlieeaM!. There wim an cxleiit^ivo swelling over the lower part of his back, but no pointing to indicate ila exact hical* ily. In the euuimcr of 1S65 an ab«co» wag opene<l in the left
B60
DISEASE OF THE JOINTS.
glutwl region, and dieciiargi^d from it » very larjie quantity*^ pus. For a wliile he seemed tu impi-ove, but in lite fall of ISfifi he had geiivral Hiiasari-a from niituiniii, and it v,-»b thought hi« caw i would tennhukte fatally. All tJic plivHiirianx who had Wvn cod- ta\tvi\ looked upon it a« a eiuv of advaneed hiiMliaeaM'. lie wb« ' sent to tJie country in the fall of lii65, nod lucd iron and ciHl-liver oil freely. lie improved for some time, but in tli« spring of 18ti(l .
/
u-
--^
FK.IOI.
another alisccss formed lower down on tlio buttocks, whoii ho seen by a etirffuon in Ohio, who called it I)i|Mlif*e.sfie, During the summer of ]S<l4t another alv&eess formed, making four in nil. Dr. C. Orahn, of the Ohio Medical College, then saw him, and vma Ibe first who Sfiid it was not n^iiKaae of thf /ilji-Joint. Varioii^Mdvcii and ointmentf were np)ilied to the sores, which continued to dis- charge more or less nntil August 16, l?^<tB,w)l«^ hu wati hrouj^il to me in the ciiiidiiion seen in Figs, 201 and 2"2, with eeventi sinuiicii on the nates near the wternm, as Huen in Ftg. ^)1, and two in the peHna-um, as seen in Fig. 302, all loading to dead bone on the back of the ilium, and the Itiherosity of the titehium, but the hijhjoint VM perfefili/ h^nlifty, and had never I>ecn involre<l in the disease. By dilating the various llHtnlotw openings with sponge- tonta, I wa0 able in a few days to pass a flexible silver probe from
CASK.
MT
tlie posterior opouin^ throuf;)i to Uic pcrinfcum, w Men in Fjg6. 3'U and 202(1, 1, and 2, 2. repi-ceient oakum Hotons drawn tlirougb Uiti fislnluns tr«ot« by tli« «iik> nf the dead bones). One piece of botie nbnut the aize of tlie tbuml>-uiul was knoeked off, and came out entun^k-d witb the oakum on tlie limt *\ny. This oakum waa utumlvd u'ltb Pernvian balsam, and tbu concealed port dniwn througb diiilv, nnd the soiled oakum cut olT. Small pieecs of boDe oontiaaed to come awAy for tJiroo or four inontba, but the
t'I'i, HIT.
boy's health bc»an to improve from tlio dny free drninn^ vag tsUbliAliud, and be be^^n to have more nito of liiti linilMt. fijr pasiivo motions friction, and frcijuont luindling, bo gradually riN fOTcrwl Win jifrfivi form, as seen in Fig. 303, and wn« dJM'Iiar^d cured, nnd Vfiih peiyiet viofion, in June, 18tS9. I received u letter from his father, Hev. T. K. V., dated April 27th, 1871, saying: "Our Tom i* a frMw»/>, that you know is the oliort iov tntimj>h. IIu can run thmngb a troop and leap a wall, be can ably wrestle agwmt flesh and hluod ; be enn travel on bi« mnsclc. Without a duuht tbt' wry best reiis()n is, the fact nf your frei|iient manipula- lioris of tlie boy. ... He and we nil feel ven* i^Ueful to l>r. Say re."
MantK T, 1873. — Father calle<l to eay Tom khs in exoelloat condition.
Oakies or TUB IscuiL-M is more dcecptivc tliati Oic betiiamod dboase.
368
DISEASE OF THE JOINTS.
The foUowingoaM, which was under thocnre of Mr. Oil)cnd4*r, bM been Ukcn from the report made in tJie BritUh Medical
Journal for July 23, 1S71, and was mistaken for hip-joiut dU- eose:
Cabe. — ^^Al)ont sis years ^o, A. R, aged forty-five, by orou- pHtion an fininibiiH-d river, first iioticoti «>ni(.' tendemesw alioiit tho loft gluteal n>gion, whicli WI18 followed liyHWelling,«n<l utUiniit^ly by tlic fumiutiou of an nbeccss in tbe iEchio-nx-tal fo«M and middle of the bnck of llio lbif;h. wliicb broke abmit twenty niontbs ago, and bos been ditctisrgitig over EiDoe, despite Iriiittniciil nt vnriouM inatitutioiiif,
" Sevprnl sinnstes, with pouting, praniilar orifices, oconpicd tho loft ifiohiu-ructal region, and ouo bSuuh bad its opening rm tlio middle of the back of t)ie left thiglt. Into any of theBe a probe oould be pii»wd in tile direction of the tiil>crut<ity uf tlie iM-hiiim ; but, owing to tlio tortuosity of tho ]»i««ngc, failed to rencli any (lend bone. Dr. Sayre, who eaw the case at a eonsiiltntion on tlie 13lh io»t., remarked on tbc ooiDcidenee that it was m a precisely
CASE.
361)
eiroilar caw tliat h« first used his flexible prolo in Americ&> and tJiis iiiiitniniont travereod with grcnt vtutt- tlie winding; cotinw of the sinuB imlil iu |H.>iiit wa? distintily arreeted by bure botie.
" O0 the foUovring SatunUj, Dr. Saj-re being pre»ent «t the operation, a fn-u incisiou was made over the left ttilier-ifchii, aiicl ■ wiuiderable pttrtion of doid hone wiis n-niowd fraiim cavity in the tubvroeily, iu widch it vm contained. The eimis wtiidi trftverKd tiie ttiiKh had followed the coiirM: of the muwtee arising trotn the ttiheixjdty." This patient made a rapid ivKO\cry.
FsiuosnTU OF THE Trocuaxtkk Ium nU«o hceu oonfonnded with inurhus coxnriiw.
For convenience in etudy, tltu t;yinptom« of tliese two diwuiNS have been ubuluted below :
miiwnT» or ruiiii. At a rate oooimeueM •a(Id«nl7.
i'emuT mm* or lew enlarged. PcnDr palofti oa presMM. JoiDlfiwo.
EncDtlon and ubdaction Inipoiled. Jmat painluM.
IVJrIa oblique and ajitne ciirrod. Coatrnction of flwor* and addaoton.
TBIKD DBOSSK or MOXIiri COXABir*.
OtovB paduaJljr oDt of preceding
Not at nil enlarged.
Femur out {alnful ia tbo I«mI.
Almont fixed, nnd, vIicd morvd.ofUa
linve crepllua, Tli« Min«.
Joint piunRil uo preararo. Tlie uuue. Tbeaame.
The following; CMfig will furtlier illustrate the distinctive fcnt- »rcti of the two diHenws:
Cask. PerimtUU of Trochanter and Upper Exfremiiij (ff Fe- mwr mutakenfiir IlijhDiteaM. — Hamilton L. a^ted nine, Clinton,- Worcester County, Miu»achu»etta, wa* bruni^lit to me Oetober 8, 1SG7, to be treatod for di6ea8e<l hip-joint. lie bad on at the time <Hie of my short liip-ri(>lintjt, which ho had been wearing for some months, but n.foiWn^ nn t>enelit his phyeidan <>cnt him to me to to aee if anything further could he done. Inquiring intu the history of the t'ii»e, I found that he had l»ccn ittniek by a brick on the outer and j>o«(eHor part of th« right tro(;liant«r major, thrown by a hoy. Tlie pain was intense for a little while, but the next day he pl.trcd nn uMunl without pain, tinlee« iwnie one toudicd the outer part of the thigh at the place where he wna 8tni<;k. Some time aft«r,tie foil and Klniek the Fame place on a &re-dogor and- iroiL About two months after he fell again in a heap of ooal,
870
DISEASE OF THE JOINTS.
and Btrnck the Mune place with hik^ violence a» to caase in- tense paiiii and from tliis time tlio iiiflHtniiiuttvn utid swelling oomtnenced, which in three nionthn refiiilt«<t in aliAceAa, whicli vm cqwned by Dr. Ue Witt, U. S. A., jiiet behind and below the trochanter tn»jor. Thi« was about live munth« aftvr the flritt fall. Dr. T>e Witt, as the fatlier Btat«6, told htm that the joint was all right, and tliat he conid And no naked bone. This opening hM continued to diacharge npto the present time. Three montha after the tin-t opening another ab«ce«» funned uid opened itevlf directly at the iwrt where the first blow was received. Another a few months after opened on the front of tlio thigh about four inehca below Poujmrt's li^nient.
Preaent Condition. — .Very much emaciated, weighing forty- two pounds; right thigli flexed and flightly abducted, but toea not everi^ as in flecon<l stage of hip-dlseaso (as seen in Fig. 201,. from photograph taken at the time).
Via. tH.
The father states that the toe« never were everted, but ntlier tended to turn in. At the prc«ent time they are not inverted or everted ; the limb is of the eame lengtli as the other, the big-t
CASE.
871
tooching tti« floor; a hard, iiifluminatory swclliDg just above the taboriiK-liii, which may proliahly t«nniiiftte in nnrillier ahflCMM, The knee is flexed at nearly a right angle {ua flguru), and fixed by fibrous anchylosis. The father says th^t previous to the fir^t accident the boy vne in perfect health, and very robust and active^
DuoKoats. — Our diagnosiB is perioBtitis of tho trochanter major, with cellulitis anil abitccM around tM joint, hut not involv- iiuf thi ariiciUation. At tliia moment Dr. Gross, of l'ltilad(^l- phia, happening to ciMno into my ofi)c«, I a^ked hint to examine tJic boy, who wan Mtill naked iipnii the table. He Etati^d that it wasacaeeof hip-tliecaee "eo well pronounced as to r«quiru no examination," but, aCt«r drnwing his attention to eome of it« peculiarities, he immediately aiknowledgwl liis mistake.
TitKATiiKXT.— LeAve iili the splints and exten^on; as the diseaae waa not within the joint, no extension it requires). Apply flaxHsced poultice and open tho slwceHx when necei**ary. Keep him outnlours and improve his gener.il heriltli by a nutri- tioiu diet ; make pa»uve mutiona at the knee, and increase these movementii as he can bear them. Directed to bring him back at the end of the month.
I saw no more of this boy until September 32, 186i?, when Mr. Lewie, his father, called to inform me that he was in per- fect health, and that my dingnoaiii Iiad been correct, althongh upon his retnrn to MasaachiiBette the year before. Dr. AVarren, I)r. We*"!, Dr. l!ifp;liiw. of Hotiton, and others, liad still in- formed him tliHt the diseai* was in the hip ; he. however, liad followed tny advice, applied motion to the knee, which was now straight, and all of its motion^^ perfect. Motions in the hip were very grvMlly inipi-o%'cd, but not qnite so perfect as on the oppo- site »i<le. One abscess had oj>or.cd near the tubemaity of the isetunm, but was now healed ; no hone had eAt'a]>ed. He nov weighs fifty-eight poiindi> and is in perfect health.
Case. Ptrio9titi« of Trachanier Jifajor, nmtattn for Hip- Ditetue. — Kate B., aged eight, of Bridgeport, ronneoficiit. Her health has never Iwen very good. Sixteen months since fell from a ladder; o»c month later the disc«iie began by pwns in and around the knee, very similar to hiixliseape. Condition. Septem- ber 10, 1807: Limb slightly atrophicil; same length as the other ; no pain on pressure in the joint, bnt acnte pain on press-
rs
DISEASE OF TUE JOINTS.
uru just below trochanter major. Motions of tlic Joint not quite 60 free as iJie odicr. t'ltrxion limilcd, vi-n- eimilar to hi]Mliscase, but can adilud &rn\ nrtate the iimh imcarxl, wliicli ainnot be done if thediiiejiAo is wit/iin thf joint. Tboni is bligtit tendcraoMi of nearly eiiHiv longtli of tliigli on the outer side.
Tkf.atmi:.nt,— Kert, It-efhce, and then actuai cautery over and bi'Liud trochantor major.
Juttt 1.1, 1871.— Thin patient presented herself with a jvr- /ect hip, but has n large hunai Mtiud the trochanter, which Homuwhat interferes with the mottcnia uf tlie joint. Tb« tnotlicr thinks it iit the rvHilt of a full from a f^v'm^ ln«t autumn. She Lad been perfectly well for thn^i' yoare previous to the fall. Thin bonod Mu: wai« opened freely and soon healed, leaving tier Id yw- feet bcalth.
With tlii« case I receive<l a note from tho attending eiirgoon, in which be eaid that the limb wne fcxed and adduced in the early Ktagc of tbu case. Xok-, tlii» did not indicate hi|>j»tnt dis- ease, for tho reamin that flfxion and addiictiuii do not gu to^-ther in the early Btago. If the limb was ^/iravrf and adducttd,\i diould he in the third etup! of hi])-diHeaKe, after niptnro of the capsnle linK taken place. It wa^ also stated that the toes were inrvrttti. If efluidon had t.-iken pluru within the capfiule, the toceiniuit have been fvcrU-d, unloM rn]i1nre of the c-ajwule had owiirred. If rnptnrc of the capsule bad ocmrn-d, the limb ehouK) tiave l>een iidduet&I, Jtcrfd, and the toe* iHtwrtA/ ," therefore, the vorj" fact that the limb was addveitd and^fwr/, and the tot-s inverted dur- ing the early Hla^eo of the dii^cajte, was evidence that tlie diffictdly wttanot in the liip-joint, but was the rMult of reflex nitiiM-nhir contmetion. The periostitis li»d produced muK-ular contraetionn which had developed distortions, and exliaueting ifuppnration was alao ph-Bcnl ; bwt tlint peculiar distortion which would hare been present had the disease been within the hip-joint, was not eeen, and the result of the case proved my <liagno«is to have l>eoti correet-
Pott'b 1>bka»k am> PeoAe Abstmb may possibly be mistaken for bi]>-joint dii^ease in tho third stage The distinctive symptoms of the two diioeww arc hero arranged eide by ^de to aid in the ditTereiitial diagnoMs in the following table (from Bauer). Tlie arrangement of the symptonu in this manner makes tLem more eosv to remember.
INCnSAL ABSCESS,
378
rant mssasx aicd psoas *imc^m. J'r«oeillllg paio in tli« ^ine. iPotbrlor wd caterior dofurni!!; (not
tiwnyay.
Blmple flexion nD<l alKiniioiHg of limb. Limb nin^ bo iM!t«n(IeiI umJer eb]uro-
(bnn. F<kk sqiiaro. Hates «v«n. ^Oaniwt walk cxMpt by scipportlnR tlio aplae bj mtiug liniiik un tlia knuv*. AbawM noilcr Totipan's lif^meuL lYip BrliealAlian fn-c. Sllj^lit reUoeiioii of flexors.
Hay have »tt!iiit of pnraplfgin.
TUIKD STAOB or KOB>n C<lZAlltt«.
rroirriiiiR p«in in hip-Joint. LnliToI utiJ uuk-riur dufoniritjr,
FlL'xio«i, uililuclion, luul utvernoa.
CftDtiuL
F«lvit oblique.
One lil^Uer.
Cnu wAili on well leg, &d(1 ititbout tlicdo prccuiition*.
iiaj li«VD tbu Mine.
AliQiMt fixed.
Fixed euntrHctioosof both &iixon lUul adductor*.
Hu noii«. Order vf dav*1opmeDt, vrr; diSorvui. If tli«re ia ]>ort(>> ralioTi ot ili<> HiH'Mbuluin, it miir be lucerliiiiio'l bf an cxamionticu Uirwig)i tlio rectum.
IxoaKAi. Ab»ci»8 may \>e tiiiRtnlcpii for ttio iinit stnge of lii|»- Joint diM.'asi>, In inguinal aW-L*E» oxtcui;ii)n nnd ultdiu-tioii will in<rr(UL4o tlie jiain l)v hrinfjing tiie iiitliuiio'l pirt* under ]>r«'A«- uru ; wh«reatt, iu the tirst stage of niorhua coxariiia, these move- ments will diminUh tlie [uiii by reliovin;; tlio irillHmod iwrt-t from proamire. Pressure on llio shaft of the femur, or on the trodinnter, will ini^reiHO the ]iain in tho ttret stage of morbus coxjuios, but will not ner«^««irily do an in inguinal ab^<eB8. In tingninal ftbi<ee«a ^reat pain will be e»ua.il by lUreiit prcMure npon the abecesa itwif.
IkPLAIGUATIOX ok tub PflO-VB SrAOXCB AKD Iliaui'b Ml-(irLt«
' may produce flexion of the limb, and there ni.iy bcHlight evereiun,
Bimulaling the kiIvhik^l-cI finit or commencing; Becond etngc of
, morbus t-oxariuB. Rut im-ojiing tho head of the femur into the
|8ootabulum, either from the knee or fmrn the troohanler major,
[doee not inerenBe the pain, chowin^ that the trouble is not in tlie
joint. <Jn the other band, the pain is afi^rravaled by extension,
whereas in hip-diAenoe extension affordi^ relief.
CcvonNtrAL M.MjORMATiox OF THE pKi-viB, commonlv known as " dnnble congenital dislowtion," may be confounded with hip- joint dietjase, as in the oase now before you, whieli wm* wnt to me to be treated for hip^iscaoo. I object to the term congenita)
JISEASE OF TOE J0IKT9.
diiilocatioti, for t!ie reasoi] tliat we uaiiiiot with prujiricty ep«ak of ft dulatxUion UDlil ihvrv bius tirot buCD n location. Again, a real dialocation of the bip-joiiit in the nortiiAl pdviii, I Iwliuve, catiiiot he iiroducud by tliu nio^-unicnu of the fcetus m utero. It might be cauBeil hy the nianipuUlionH of the aoeouchear, but in tlut cattc it could not he propcrlv cftUul sponlaneoni).
The real difficulty in this condition, which Ilm been ti'ruivd ooDg(!»ital dltlocatioti, but which I prefer to call congenital mis- placement, cunsists in the walfot-nuition of the iicciubnlum, namely, a Don-fiiMon of the three honw which eiitur into il« con- Btriii-ti^tn. Ttie cnvity of the ncetahuUim being incomplete, the _ id of the femur rides thrDU^h the o))bnin^ left, and \» found opoii the dorsum of the ilium. Inasmuch, tliorefore, as the Hcutabuluni liax ncvL-r really eu^ted, iit romtequenra of an arrest of development, there can, of coiirw, be no di^catimi from it. You uiii^Iit a.* well BpBak of the roo/oi a childV mouth with cleft pahitc. For the eame reason ivJuctivn with retention is inipoa- ifiWe, 80 long a»i t3ie imperfection rematui). The dcfonnity, bow- ever, is frequently mistaken fi>r Iiiit-dipwisc, coiiwdering the rarity of the nialfiirtiiation. It is not dilKcult, ustudly, to arrive at a correct di(i>^io^is in theae casce, if the following poinU are euxs- fully considered ;
Congenital niisplncctnent (dependent upon congenita] malfor- mation) generally occurs in liuth bipa; morbus coxaiiutt alnioot invariably occiirnonly in one.
Congenital inisplacement is not attended with pain ; while morbuH coxartus is attended with extreme pain. In congenital miK- pkcemeut the deformity is peculiar, and differe e«eontiully from that pruuent in hip^liwtuse. The bnsdih of tlie hipe is very much iuftreased, the pelns is tilted forward and downward, the buttoeka rounded out and flevated, making a very prominent hump when the patient is standing; but, when la- is phured in an horixoutitl position, and extenahm is made upon both limbs, the bump will disappear, and he will lie elongated; and I lien, by pressing up- ward upon the limbs, the hump can \» made to reappear. If, while an a»i>istant makes sncli extension and proasure upwani, the fingern are pinceii over the trochanters, they will lie foumi to glide up and down, like the len^hening or sliortentng of a telescope. If tiie linger is introduced into the rectum in yoting children, a distinct tissure in the plane of the i»chium cmn be
CONGENITAL yiSPLACEUEST.
875
eoructim«« felt. In the lulutt pelvis the plnnc of tb« ischium will often be mnrh wider ttuin norma). The dUtanoe from the cnsit of lh« ilium to Ilio trochanter major, whon the limba are preesetl limily upward, or when the pnticnt ia Htandiiig, will bo shorter, a» Mien in Fige. 904 and 305, than whvu thu HmbB are firmljr extended, as seen in Figs. SOT and ^S.
Ijtying thitt (.'hild upon thu table, w« will first applj- N^'laton's taitf whicli consists in dmwiiig a lino from the tulwroaitj of the iwhium over the hip to tiiu antvHor superior spincxu process of the ilium. Thin line jiaaws directly over the top of the trodian- tor major if the Iii-sd of the- fi-miir be in its socket and there is 110 fractiiro of tlie nticrk. In tliis case, even in ,io small a subject, we find the trochanter one inch aud a half above the line. We
r»M.
F*t. Na
will next slip this piece of paper beneath the chikl. and pencil on it her fonri us sJie lies on the table, and now, pulling her ont, aee how wo inercaBC her lenpth until her trtx-hanter reaches my fing«r on Xelaton'n line ; releasing our extension, and pushing against her feet, ishc goes togi^tlier ajfain— teleeccqieft— like pusli- ingft pencil in its ca«f, aud the trochanter ia nearly two incites above the line. Here, gentlemen, is the paper witli the pencil-
S7fl
DISEASE OF THE JOINTS.
iag open it — « drawing from life — and yon can eee tbo great dif- ference in licr fonii in the cxluntU-d iind Ebut-u[> conditions. {See Fig. lil'i*, from II skelcli taktn at tin- time.)
In congenita] iniiiplat.'cnicnt, motion ia ufun {icrfectly freu and painle<«, ami onlinarily somewhat more extensive ttuin normul ; while in murinu cuxariuB it ii* alicaija limited, and alwayh Attend- ed nitli pain.
Tit):AmK.vT. — In tliie cbild 1 pro[>oee to nrntnf^e soniclliing tliat will keep the limba extended, and prevent tbeir gliding ujt- ward, and aluo to put amuud tbe pelvic bon<w a comprcM which will »mfX in holding tbe heade of tbf feniura steady and approxi- mato tliti edgi.^ of tbe tiiwiired acetabulum.
I have ?een a fi«urcd pidato in an infant, which involved tlio
rra. MI.
r». Ml
whole roof of the month, closed by meana of c»mpra«Ion. It ia tl>i8 simple prinoi]ilo, gontlemcn, that I pro|Ki«« to put in use in tliis child. It Hhuuld have been done at birth; bat tbe rhild ia yet young, and much bcnetit to it may Mlill be anticipated.
I havo had made for thi« patient, by John Reynders & Co., of 808 Fourth Avenue, a double long hip-eplint, capable of extend- ing tbe limb« and at Ibu Kamu time permitting motioo of the
TTTEATMENT.
877
j(^iite. It comiiiU of a pelvic bolt, witb u liin^ in thu po«tvrior iwrt, and fa^t^ned in front liy a »<lut and Imckle ; tliio in flcwured in [Meitiuik hy two pcrint^l baiidi>. On eitbt-r Hide uppbeito tbv hipB ia a socket into which i» ini«rted the rounded end of the shaft wbidi runs down the k-g, thoro bving a joint at thu kiiix.', and the abufta on eitJier side tennioAting at the bottom in a BnmW Bslu whidi nini) at riglit an^Ii»i with th« (ituift> and is fittvd into a Ateel \m)x, vhiuh iei fastened to lite aboe jiut in front of the heel under tliu instep, tJiu uxlu being Kvcunxl In tlic box b; nieaus of
rMi.«M.
a Dninll <>atch. The upllnt from the hip to the knee consistA of a double idiaft, ouo running into tho othpr, capable of being ex- tended or Hlirirtened bv mennn of a mtcltet and key, and ht^ld in its pi'upt.T position by a gliding catch. A broad buckttkin l)and posses around the knee, to add to the aecnrit^- of the patient when walking; the- hinge Iti tho iiUaft opjiosite tho kiieo enables it to Ik) Hexed when the patient OAiQmcs the sitting po^nre.
liy tJiis inetrnnicnt wo can elongate the child, us yuu perceive by comparing Fige. 205 and 20C wltli Figs. 207 and 303, and, slip-
rHE JOISTS.
ping tlown tbc «atcli, wc hold Ii«r lege extended ; ahe cannot oliut iiereelf up nntil some one touches the key.
Do yuii «ee, goniloiuoi), how beautifiillj we can extend thcM limbs and hold them in their natural places ! Witli Uiis inetni- mcut to keop the limbs extended, the <K>mpress to approxiniaU) the edgee of the fissure, and a I>arra<.'li'6 wliocl-trulch to give h«r out-door exercise, it i» poeeibic we nmy obtain a good reault. In the courec of a month or two tlie child will bo returned lo lut, and we can then Ace what progress will have been made.
This child wore thiii instrument for two years, when »l)0 wan BO far recovered ai to walk in quite a graeefal manner, as com- juired to her former movouiuuls; atill, however, using a broad pelvic Mt in the platw of the extension epHnl.
In December, 18H^, she presi'hted herself at ii).r office, at tlut time wearing no mechanical appliances whatever, having Imt en- tirely the ]>eciiliBr waddling gait so oonspiciiotu in this defono- tty. I had the pleasure of showing this patient to Dr. Uroea, who IiapiK-ned at that time to be calling ii))on me.
Cask. ('oiigpnUni }Mformationof Ptlvit.ieilhSpcndj^Uisof tAeSiuiA, SctVfitA. t'iijhlh, and Ninth /?<>r«a/ FWC^A/vp.— Uislory : 8. V. Fouuier, aged five years, 1 14 Bank Street, New York. From tlie time of the birth of the child, the parents have noticed an un- usual breadth of the pelvis; at the age of tiftwn moulhM ho be- gan to walk, with a {leculiar swaggering, waddling gait, the body being thrown backward and the feet everted; he continued to walk nntil November £R, 18iS, since which time he has been un- able to take a step alone. The parents were infonncd by tlie at- tending pliy^ii'iitn tliat his peculiar gait was dne to general de- bility; the child, however, bad never suffered from any indiges- tion, and apparently its food was well assimilated. Electricity was then uppHud for two months without deriving much beneflt, and at tlie i,'n<l of that time the mother noticed a projuction upon the spine, and called the attention of the physician to tlua de- formity. Tliis was in Angnst, I87S. The esse was then pro- nounced one of cnrvataro of the apinc, and on November 29tli tlie (;hild waa taken to the Forty-seoond Street Hospital, having lost tliu use of his legs three days previous.
The mother informed nie tliat, upon the examination at tlie hospilid, the whole of the child's difficulty was pronounced to be due to disease of the spine.
CASE.
879
I
I
The following week tlie rf^uJatton erSi was applioi], aod wu worn lip tn Febnarv 2(1, I ST!), when tlie child wan then uken to thti Brllcvuc lloiipital. I'pon ruuiovul of the brnct; thun.- wiu extcnalre ewhjmosi* for about four in«)iea upon cacli siile of tlte t>rojecliup vertebra.-, owing to prcsHiiru of the puds of thu brace, tlie aliotililer-t^trap of the inctniment having priMluced a like re- sult upoD the ehoulilvra; the child iit thjit tiiiio 1>cing cntinily unable to stand.
J-'ebrnarij 29/A. — To-d<ij I wiw the cliJId for tlio first time, and upon careful examination found thiit tho trochanter major of cither liip voa ahovo the aoetabulum and riding tthovc N«lato»'t Hm, the dcfonnity being more marked on the right side: the
vis being held porfectlv still, the Icga could be drawn down
tho extent of threo-quurtt'iy of au inch.
DiAoxooi^. — Congenital malformation of the ])eIvU, wttli e]>on- dylitid of the tiixlh, ncvviith. eighth, and ninth dorail rertebrte. A plafiter-Qf-I*»rie jacket wan then applied, with the double long i)Xtension splint.
Jf<ty ll/A. — Tho patient returned, complaining of great pain at the hi)k«, due to ahst^-nsos over thu tuber iKchii, and in tho groins. The perineal bands of the splint were then removed, and the pelvie belt eecnred by a ridge of plaster being placed around thu jacket at thu lower portion agninst which the belt could preeti; the child being then quite comfortable.
Jfai/ sort, — New jacket was applii-d, the patient improving.
Se^embrr aiWA. — New jacket applied, with hoad-rc»i; can lift tlic feet bettor when walking backward than forM-ard.
Man-h, IRSO.— New jacket applied ; abscees ha* formed on the Anterior portion of right thigh, and another jiut l>elow the tro- ohauter niajor on the left thigh ; both discharging freely.
tfun*! 27M.— Al>«cc*8<» Htill discharging; the patient can l)ear quite firm prossure on hia head ; head rt^t waA now permanently removed.
Jttnuanj 27, 18SI. — AbMeases closed; the child can now stand for a fhorl time without cither jacket or splint.
May lOM.— Oim walk a short distanne without jacket or Kplint; general health perfect; new jacket was applied and worn as a poitot.
September, 18S2. — Boy is now in jwrfcct health, walking with- oTit bmee or jacket, with good luotiou at hip-joint&
«80
DISEASE OF TBE JOF
LFXTITRE XXV. oisEASEs wiiicu eixuu'rs uubase op tub JOL<n« (cosTivctn).
PinljoUot the iovcr B»r«iiiUt«*.— OiMtwti.— I''nctum.— DIAMaikB*.~BantUt
uid Metswik.
Grxtlrurn : To-daj we will continue the subject nf diooMiM that simuliitii diMsaw of tlie j(>nit«, and tlio flrat to wlik-h 1 would direct yoMT attention in :
Piiriil}-Ki« of itio lowvr vxtr^iuitioe as causing Arnwt of dcTo1o[^ ment. and which has frotiuwuly been mUtakon for liip-diswiBC.
This cane, wliicli I now pre*ent to yon, was sent to uio by a dbtinguiBhed surgical friviid, for iromo hip-trouble.
('AiiB. Arn'Jit of I>'-vt!opiH/'nt from fnfantilr Par<Uf/*t«. — Julia li. E., R^d nine, of Wtuchtwtvr, Tcdd., of hcidlhy punmts,
^1
Fill. ilo.
illwap in good liudlh until i>hc wits twenty inoniiifi old, when she loet the use of her riglit leg suddenly, waking np in the inoraing with totnl low of uiotion and eoD»ibility. Itcgan to move her toos in about six months, and in a year dragged her foot after her, bat would fall down about every third Htep. Condition ati Heen in Fig. 310, from a photograph taken August 37, 18^7. Lar]go
WJCBIE« OF THE IIIP.
And wcll-flereloped child, except riglit limb, wbicti ie four and a batf invhett »li<>rlor tban tlic Ivft, nml liinall in pmjiortion. Spinnl colnnm very much carved lalemlly at tlio juiH.'li.)ii of the dursal •nd lumbar vertelirtP, the pvtvis of the right wde IwinK inuoli tower thnu the oth<->r. TIiu oasu vm soiit to iiicnb n ciuv uf luxa- tion of tlie ft'iiitir, hilt I found it morely a vase of arrest of devel- opment and atix)p!iy. from infantile pomlysis, I applied to ln*r filioe a Dolo niid heel »tifK«i«iit to canalize tlie lengtli of tliv litnlie, wlton L(.T epinu bi-cainc jwrfoctlj titmi^lit. a» Hoeti in Fig. 311, and e^hc wa» enabled to walk without a cratch or cane, by eimply applying India-niblicr innHclcK. to take the place of the partiiilly patHl,V2etl ones of tlie leg. AdviHed cleclrit-ity, Blijimpooiug, and ]ia««iive iiiovciii«nt«.
The treatment in thia eaae vriia ho outircly Hatiefuctori- that ehe left f>>r home on Septomlier lAth, able to walk reinarlkahly well with the aid of the ruhber niU8L-lef« and the iucreaeMl length of heel to her 4ioe. The extreme cnrve that can take place in the t^iiine to accommodate the difference in the length of tlio limbs ii> well shown in Kig. 210,nnd thiitcaticis »l»oan iti>«lructiveunc in having been miitaken by en maiiy eniinent men for a case of hiivdiseniic.
iKjrKiK-t or T1IK llir may l)e mistaken for hip-joint di«e.Ai«. These im-hide fnictures, dislocyitioni-. diawtasia, etc.
Injuria of the bip can generally be oxcltidvd by t}ie hintory of the accident which caiified the trouble. The following diffoi^ enliul BigiiB (from Umicr) will enable you to deternune the ijuee- tioa in case of doubt :
DUheatian ■>/ Femur.
AXTBBIftRLT AXn Bi;KBIOU.T.
SultliMitf p4'odncei).
Eilmnil; iiiiii-li «vcrtcd.
InmoUlli.v.
U< alii rale i>h(>nuDin(t-
AlitJuctioQ.
1l««d oMi bo r«U in tl>c grodo.
wpoxD BtAOS or KOBsrs ooxAcin. CoDCfl on smduollj. Less eTtneil, Imrooliiltty. Apfinrcnt eloogotlon. Abila«tian.
Uewi cniinol he hk at tM or rcrj ln<Ufrt.lDCt].v, and ibon at tho ac»-
tllbulllED.
rosnnoii scpkriob Dt6i.oo*TioK.
PdmIui-^xI audil 1-1)1 r.
I.initi iJi(irtvDiMl aod loi'iirted. AilduetML
THiKD eTAOB or Noatca coxAxin. (irow)DK gnduallj. The iaiii«. ThvMune.
889
»[SEA8B OF THE JOlNTa
Dutotvtion tf Femtir.—{0>t>tiav*d.)
Munttioi AvruHOH mtitjocATiox.
Imtnobilitf of ftrtloalalion.
l-'Ii^xion of tli« liip.
M<")crat« ihortcfiiiBir.
ll«Ail uNuuJI.v fvtt undor gluten* muci-
BIDB.
Apex of troufamitttr ttbovo X^lutoii'* No ponnnnoDt contr»cti>,iiu od* dibb-
olMk
Pi^iIb ftqnara.
WalkN with boaltJijr leg b«nl.
TounUw groiuul wlib nlinixil enUrc
Mift. Spine atraiitlil. Angle of Inulinitiion of ]>ehis on-
clunipid.
TKtBD moB \>r Mosncs coxAsira.
Th«Mm«.
The MiDu.
AiipHFoat sliorUfiin^ oonthknUe.
tlcu'1 itttt Ii'lt at nIL
Below or OTen wllh Xf-laloo'a line.
PcnnAoent eoninicllon of fl«xon laA
luldnatora. IVIvU raised nnd obliqiMi. Itoolthj' h>g alralghl. Ouly wit)] tlic lictll of Iho foot.
Spino llcnc*! Intcrnllj- nnd anteriorly. Atiple wl' incliiiBlif'Q of iiulTb in* cr«n»0(l.
ritAcnias axd i>ia»ta*im or bcadl MroNn rtKax or iKicaco coxAKrt*.
I*roclii(«d «u<M«n]j. Kveniioii of limb. 8)j<>nt>ntD)f of llnil). StrniRiit limb. Locioci nrlkuktion. Btmiglil iwli'is, Creplliis to onrlf irtBKO- Spine vertifiil. Bboiildcrs oi^uare.
KflHton'B te*t (apex of large trouboD- ler nboru tbe line).'
GrowinK CJjtnjiiifBttwiIj rfowlj-. Eveniuii uid nbctoctioD of limb. AppurMit elongation of tJtnb. dexvil ill liip uDil knee, Fixi-rl lilp-Joiiit Oljliqiio pt^liU. No <Ti.-)iilU«. Spine CDneil. One •iHiuliler liitibar. NfUiun'B u«t (trodiaater Mow tlw line).
TliB impacted fi^tctur^s are of course excluded in this eolleo- Uon of difEorenlial symptoms.
DuBTMia OP •mv. Head ok tur Femihi is FREQrEirn,T MifTAiCRX fOK Hii*-r)iBRAHK, as iij the case now licifwre yoti.
This littlu (;irl van lirou^^ltt to me aohie time since, to lie XrvtA- «d for liip^lifteaae, but I betninc eiitiefitHl, tipon citrefiil vx»iniiiB- tion, that elic was not fliifTcriii^ from liip-dise&fie, iilt)iou{;b ^le liad buen under treutniunt for tliat diliiviilty for a long tinio.
' XAJBton'i iMt (er Koter'* (eat) b mxlo b; dntwing a cord rr««D (be tubvfMtil to tbe •nu-rior dupfrior ipinoii* procM* of llm Ilium, whicli will i^niicnllT' paM U Ibe WTf apt! of Ihr troclianin- ini\)or ; now, in fruciurp of thi tuxk o* to lt«e loiatkn, lb* apex of the Irurhanter vlll be founil above tlii* lino.
fASIS.
888
I was positive thitt there w«« no hip^iiwiioe in tlie com, and whj t Tliorc n'&9 a largt^ altsretiB upon the litp, and there vos evidently eoine trouble in tlmt n^giun, upon wliicli Iliiii abscora depended ; coniiequeutly my exaniinatii^n waa rerv niuoli obscured by tlioiie attending <.<ouditiuuif. But, upuu cIomo fxamiuution witli rcfi-ronvc to tlie l>^iniiing of llie diDic^ulty, I foun<l lliat ll>e accident which hiu) oreurrud to tbi« Itttle girl lutd been fol- lowed immediatd'j by »liort«ning of the liiub witliout going tlirough till! gti^rcs of al)dnction, everaion, and effusion of the sec- ond stage of hijMliseaHe, and then th« adduction and »hortuning of tlic thin] Htagi>, whicli tiocessHrily must have taken place had the case t>een one of hip-joint disenee.
Id diosUwU there may bo adduction but not invention, but tliese are in\'ariably present in the third etago of hip-di»eaee, ex- cept in extraordinary ea«es already mentioned. {S-e nymptuma of third Ma}^ hip-diiteaw.)
Again, when I applied X^laton's test, wbicli eouisiHta in draw- ing a line front the tuberosity of tJie ischium to the anterior su- perior s|tinnn>i process of the ilium, the troclianter major waa foand ab<>\x that line, which proved conelusively that there was either a separation of the head from Uie ».hftft of tlic bone, or a luxation. But the onliniirj- symptoms of luxation, inversion of the foot, etc., when the head of the femur i« upon the dorsum of tho ilium, were absent, and there was nothing left to account for the svnnplomi) except fracture, or what U its eipiivalent in the young subject, dinstasis.
Again, in diit^tasis, after it has existed some time, concn^^Bioa of the joint produces no p«in, nor doe* crowding the hoad of the bono into the acetabulum by making pressure upon the gi-eat troclianter. The deformity which was prcwnt in the case wa8 the result of an amdent that bad occurred two years before, and tltc nbtK.'ii)i<« WAti caused by inthimmalion of the bursa over tho great trochanter, and it was this abscess whicli had caused tliem to diagnoeticntc the oii«e a« one of discuscd hip-joint. Diaetaeia had not been saspccted, and, as the child move^l about, the IrritA- tJoti set up cnuwd the ptwas magnus and iliacns internns mnsclee to contract in such manneras to Hex the tlugh upon tlio tnmtc, and on this account the cjk* was mistaken for one of hip-joint disease. • But the flexion that takes place where diaetaaia occurs differs from tluit which results from disease in the joint. For, if the
361
DISEASE OF THE JOINTS.
joint contains more than ibi normal fjunntity of fluid, the flexioal u alwaifs owoinpanifid by Abdiictiuit a,m\ cvcreion, ftnd, wliun th»' capsule becomes nipture<l and the fluid escapes, the floxion is alicitys ttcwoniiiaaicd by adduc-tiou and invoreioii, uuton tbore ara^ adliesions.
in diaatosu dietortioa is present, but it docs not bare that peculiariEy which necewuirily acvompanios cfliif^ion.
Tills little fellow you liere see is a very good illustnttion of
Fru. til.
the d«'foriiiiEy in cases i»f diastasis before any contraction of lli« ' miuck'A hae producvd tlexion of the thigh upon thu trunk.
Case. — James 11., three yeara of age; pareiils h«aUhy ; re- etdinff at ^3 Wcet Forty-«eventh Street, Kew York. Child rubiut and strong.
WlioD thrcu nioitth« old the child was rolled out of a ct«dle, and the mother, catching it by the l«g vliilo falling, folt aomc
DIASTASIS.
S8S
tiling snap. Xothing partionlar was noticed until nbout a week ■ftcr. wlicii the mother stntc!* the liip Kioked »oniewhst awolleu. lie was taken to a ph<rsician, who eai'i it was a riniple eprain, and ordered sonp-liniuient, whieh was applied for eig:lileen months, vith a bandage. He waa then taken 1u St. LukcV Hospital, where it was prononm-cd hi)>-di«enti<e, hikI a we)j!;ht and pnlley wan apptietl for fsix months, tlte obild buin;; ruiietantir contined to tUe bed. No iinpruvc'tnent oomirring in his hip, and his gen- eral health becoming injiu^d hy i-oiitineiiient ^liie mother states that he i« not io Atont a« when he went X» the hospital), lie was removed from St. Luke's and brought to Bellv^nn!.
Uifi pra»eut condition is, as you see, toleiuM y good, althongli, as the motiier sayft, he im not so Aeohy as six months ago. The limb, as ym observe, k s1iorlc>ncil, a<lducM, and the fiN)t very strongly fivrU'i. {Se^ Kig. 212, fn>ui a photograph by Mnxon.) In fact, yon boo it cam bo rotated completely around, so as to liring (he toes hebiiid. There ia no pain on pretuttire in the axis of the liiul), or over t)io trochanter ; oonsetiiioiitly there o»nnot lie inHammatiim witAin the hip-joint. Tliere is very slight pain upon extreme rotation of the limb. In drawing a string from thu tu)>ero^t V of the iitchiiiin to the anterior au])erior spinous process of the ilitnn {N^laton's test), you observe that the top of the trochanter i* above that line.
Om" diiigno^)^ in this esse ts, therefore, dia^atia, and not hip- diteasc, and that the sepeinition, or fructnre, if you chooM to call it such, occurred at the time the mother seized it by the leg to prevent it« falh'n<r whun it was throe niutitbs old.
TKKATMK.vr. — We etiall put the extenttion-«pImt upon him, the same ax if he had h!p-disca»o, and thns prevent further cuiitrac- tion and deformity, and to take the weiglit of the body on tlto perinipnm. allow free motion to the parts, and thus aid in tho formation of a nuw joint on the dorsum of the ilium.
Oa«k. Diastasis of M< I/ettd of the Femvr.—E. M. J., female, ngcd four years, was hrouglit to me on Jauuarj- 5, 1ST3, with the following birtor)- :
On Christmas, 187^^, being then twenty months old, and a very active, robu»t child, and ba^'ing walked for six months, was left by her mother for about two hours in cluirge of the nurse. On her rotuni the child was fomid lame in the left leg, which was tbortened and slightly tnmed out, and has not been able to walk
386
DISEASE OF TIIE JOIXTS.
npon it or tonch the floor nince. Tlie iiur«o ineUtwl with great posid^oncM tlittt dtc lifttl ivcvivvd no fnll or other nvcidoiit ilurltig the motlier's absence, and that eho had not bevti out uf her sight a single munierit. Thv child buiiig tuo young to coiitnulict thi« titaleraeiit, it haa to be received for what it is wurth.
Ah the parontit were tlien living iu Loinion, titc child parried to tlio different hoepitala, acourdiiig to the motherV statc- uiont, and <;^anlitlcd bv vnriouH surgeons, who {>ronounct-d it a caae of hip-disea&ts and ad^nacd leeching, blietcring, and reet. Th« liitib gndtiaily contrikded, ndducttt), and rotated, until in the couj-se of a vear it assumed its prcsunt condition (aii seen in Fig8. 213 and 214, from photograplu hy 0'N«ii), wliicli it Iin>' retained until the pi-esenl time.
_fvi^'
:iiis^^^^^
%-VA^^^V'^ -
rm. ttK
no. rii.
The parents came to America in 1S72. Tli« Hiiid wns taken to two of the public institution* of this city, wlnriv ihe trou'ilo vat) pronounced to l>o hip-dteen'»e far ad^'aueod In the third stage. Slie was then sent to me to Imvp esMfotion performed.
Upon examination I found her to be a very nihtut and ro- niarkably healthy child, and bum of lieallhy parents. Upon «trip> ping the child and laying bor upon the floor u|>on her bock w
DUdQWB.— CASE.
asT
tltat the spinous proceaee* would toiioh tlie sarfn«c, while nt the tiBRic time a line drawn from the coiitiv of the bk-niiitn over the romlHlicuB to the centre of the i^Yniphyaifl \niWn. wa^ cn)ti«ed at a riglit »ngle by a tine drawn from thv auterior eiipurior BpiDotis , of one ilium to thnt of the other. In thiii jKitiition, the slvifl and trunk being held in their uoniiiil relatiuiit^, the right Uiigli could ho exten<li'd Ktmi^ht with th« body until the ]>o|))ileal louehed the floor, while the left wau fitandin;; at a right agle with the body, slightly n^Idurtcd and rotated ontward uenrly onc-luUf upon ita axift, no lliat the heel wa« poiutlng in a line over the right Bboulder, aud the foot in the opposite direction, s» wen iu Kig. 2U.
In thie position the limb was fixed and apparently iuichyIo«ed. Tliere mw no puin or tendcrnosa aronu<i tlio joint upon the moat severe pnciisuri', and the molhtr »tid that lliure had not Ifoeii for ift year paM. The child would bump heriielf alon^ the tioor upon her bottom and the foot of tho well limb, as ftist as most fhildren would creep, her anna l>eing uaed aa cnitehc«>, and tlii^ w.ib her rmode of loeomution. WLen standing up the thigh was at a right anglo witJi the pelvig, addueted across the upper third of the o]i- pDtUte thigh. The buck was strongly curved at the Bscro-luiubor jimctinu, but not uifficiently to etuible the foot to touch the floor. (&wFig. 213.)
Tliere has been no suppuration nbont tliu joint, ab«eoe«ci>, or Btlier evidences of carious diisease of this articulation. The promi- 1)00 in the gluteal region whieh Imd been miMakon for an aheooae was caused by the troclumter nuijor, which upon exaininii- tton wAfl found an inch above the line of X^lnlon's te«t, indicat* ing that there was either n fratrture or luxation. The outward Lvotation of tJie foot contraindicated luxation on the doremn of the ilium, and there was therefore nothing left in the diagnosis hut fracture through tho neck, or ilo e<ftiivideiit in a young sub- ject, diastcuis, or separation of the head fruiu tho neok at its epi- pbySM) junction.
The iniddi^nneia of the occurrence, Uie entire history of the
ItflM, and ita present condition, confirmed tliis opinion. The child
w«8 phwed under clilorofonii, and with aomo force limited movo-
mentABOuld be obtniued, showing ttiat anohyloeis had not occurred.
A pntrof wire bre«chea were onlerod for her ; and on Janoaiy
?9, 1873, at Bellovue Uoepital, in tho presence of tlie class, I put
DISEASE OF Tins JOlSTa.
her under ebloroforrn, unci subc-uluuvoiuly diyidod the BddDCtnr lr>ugiiK, graoiliFi, Knil tenM>r vnginR fenioria miuwlen, cloacil tlu.> wounds with lulliL'eh'C plaster, ftad with mmtj littlv fom; brukc np tlie ndliesioiui, and brought the limb parallel with the otltvr niul nvarly of the bjuiiu k-nf;(h. She wiu then pla«d in the "wirt; cutnae," whidi had been well podded, the veil litubetiaifrliteuvt) 80 as to bring the foot firmly ugaiuet th« foot-piew, while the nnuA had been secured in it« prtiper pUoe for dvfeciition. Thitt limb wan then secured by s roller from the foot up, with a pieee nf pasteboard over the leg and thigli, tokeepthe knee from bend- ing, so as to make tltat liinb a solid column against the foot-board for counter-extension.
The defoniied limb was dreewed by placing strips of adhesive plaster on eaeh side from jii^l nbove the ankle lo the middle of the thigii, and secured by a well-adjuBtcd roller from the foot np, leaving n few inelico of the plaster o» eitJier aide of the lower ex- tremity, to he pinned around the foot-board, whidi latter had been
fto. IIS.
Flo. nt.
wrewcd np to meet the shortened limb. A few turns of tire screw readily brought the limb down to the desired length, and it WM seeured to the other leg of tlie wire cniraes by a roller, and tlie dressing was complete, as seen in Fig. 3L5.
D!A8TAaiS.-CA8E.
ssd
She wns sent home to her boarding-liousc in a Iittio liaad-car- e, And went out riding every day, notwithiitsnding the hi- iiuut wcJtthur, without the elightc-Ht iia-onveiitcnoc. Shu n.-- larned to the hnqtitid on JnniiMry "i'Mi. The wonndE< hitd entirely huUed without Kiippu ration, only h very slight tcchyinoiuD vxiiiting aronnd the puneTiire over the teiiAor va^nni^ feniorLfl. She wan redreeeed compli-toly, wit]i the exception of the pbelers upon tlie extended linili, the lintliti washed, pawive moveraentn given to lUI the joints, und repliuteil iu the wire cuir»6H for another week.
F^runr>/ 4/A. — Ap]ilied long extenAion>ti]>lint with alidtietioii- K-rew, when Dho w»ft able to w»lk with the aMJctaitco of a cane. The liitib eoiild lie exteiKled to very nearly the normal lengtli. She wore the e.xteniuon-i>])Iint (or nearly fourteen months, wlieij had entirely recovered with scarcely a half-inch tthorteiiirij^nf )!ml>, which wae Cdsily roctitied hy increasing the heel of her ahoe. and the motions of her hip-joint iw neai'ly perfect as not tu attnu't stt(.-<ntion.
t'ig. *21<t, fnim a photograph taken clghtt^cn monthit after the ojwnition, allows her present condition. TliU photograph was taken at Poi>;flil<ce{)ftic, her present retiidenec, and the operator had made the Ukvb ench as to represent her as much smaller than in tlie other picture*! taken eighteen montlis before, but Mr. Braea ba^ preferred to copy it exactly, rather tlian to enlarge it to eorrespond with the others.
Ilere is a specimen (Pig. 217) which illustrnles mo»t heauti- fully what lakbs place in the dii<«^'aM; or accident we are now con- si<lering, both in the change in the original acetabulimi, whicJi is I noarly obliterated, and also in the formation of a new joint upon th« dorsum of the ilium, which is almost ti» perfect in form a* the original acetabulum.
The little feUow from whom i\\U ilium wan removed was hrnoght to mo in 186l> by his phyaimn, for the purpose of having his hip-joint e.x«ecteil, as lie was xiipiHwcd to be suffering from dieoaac of that articulation in its advanced thinl stage. lie was then six yeant of age, and prcseiitetl n mot>4 singular deformity, different from any I had ever seen at that time.
He waa quite a robust and healthy-looking hoy, without the
lui^ECgard and cachectic look of moat cases of advanced liip-ilisease,
iuid t was therefore led to scnittnize him with more than ordinary
Cftro. Uis thigh was flexed at nearly a right angle witfe the pelvis,
390
DISEASE OF THE JOISTS.
and addnctcd Acroafl the median l!n«, nnd Hx«d in ttii« posiiion ; but tlic foot woe nioet elniiifrely everted and rotated niilvard, ect tliat lluOiccl prcecntt'd in front. Iliif ]>uHltun nn» vcty similar to that in Figs. 21:) and 314. There vrae no pain or lendemeM upnii ]irie»uure, ntid to niv mind there were nuno of the indica- tious uf hip-joint disease jtresent,
Tlie phyiiioian who brought him to tn« had only 8<Kii) him a short time before, and knew nothing of his previous hiBtoiy, but
nc ti*.
enppoBed it to be a ease nf advanced 1ii]H)isea9e on ae(wunl nf the deformity and his inability to move tho limb, although be bud never earefiilly examined him.
Upon milking rareful int{uir%' of hiit piarents and the phyMrian who had first seen biiii, I lennied that he bad fallen down tbu celhir-etairs two years before (when ho was four yeans old), and that when the doctor daw him, on tJie following day. his foot wn« already turned outward and his leg Amiened ami adduett'd, very similar to Rg. 312, and he considered it u caeo of fracture or 'iiiit^tiiifiB of the bead of tin- femur.
Tlie child Hnlfered so little tliat the parents were Indined to doubt tho comx-tneae of the doctor's diagnntiis, and dismisEed him. Anotherpbysicianwaaealleil in, who pronounced it to be a aimplo apruin, and that it was of no iuiiwrtanoe.
Tho child bi^n to hop around in a few wecka, but could never bear ftny weight upon tho foot. In a few months tbetltigb
FORMATION' OF SEW ACETABFLCK.
891
JbfigH) U> draw np, and tinall^- became fixed in itii d«forni«d pod- ilpD, abuut ono year befuro ho was l>roug}it to mo.
Uiiving obtained tbis infonnalion of it^ early Iiistoiy, Ibe ease was cluar, and tlii< diagnoKis oasj, namely, dutfitaufi, wicb rosaltant innHt^uUr contractions and tibmiiK nni!byIfR<ii>.
Till! trcatmoiit was, to dividL* tliv contracted tendons and brin^ the limb into tlw i^trai^lit poiiition by fore*. When llio woiindg eauEed by the tenotomy bad heialed, a long nplint was applied, wbteh he wore for about two yestn, and finally rocorerod with almoet as complete motion a^ in tbe normal joint, witli only abonC ono and a balf ineb dliorU-ning. Tbo boy died of double pncn- niuitia ill 1868, and tbe attending pliyaician was kind ennngb to allow me to make a jioM^nortem examinatioit, wlien tlie Hpoeiincn (Fig. 317) was obtained.
We bare liere a natural ilium, and tii>on It an irregular acts tabuhiin, li, triangular Jn shape, in wbich what is left of tbe old head of tbe fenmr remains. Just below thifl jwint, \\\ion tbo plane of tbe Ucbium, there is a little round fai-et, A, i-unii-thin^ like tbe faeet upoii tbe vertebne for artienlation with the bead of the riba, whieh is the point where the end of tlio femur reeled before I tav liitn, and wben the leg was flexed at nearly a right angle with the body. By cutting the tendoiii* and allowing ibo liuib to eome down, and by tbe use of the instrument, eventually » new aoet«buInm, C, was nude, which is upon tbe dorsum of the ilium, and haci a crCAOentic edge so as to make a more perfect aliouldur for tbe femur to rest against.
Thia new acetabulum, when mbbed with another piece of
!»e, gives the Mnie feeling as when lliia i« done with two pieres
r«f ivory nibbed together. It is exactly such a sensation ae is felt
when the femur is more<l in the acetabtiliiin of ttte little patient
who has juat gone out.
Tbi« acetabulum was surrounded by a new capsular ligament, and the new formation performed all the fundioiis of a normal joint, althougb there were no nrlieiilar cartilagea, synovial metn* brane or lignmentani teres. So far as usefnlneM was concerned It was just as good as a normal joint, being a perfect fpceinicn of 'eburnation.
Tbo treatment which I adopted in all tbeso oasca was, ttrst to divide such lendoiu and fa»ci«c as were necG«)siry to per- mit tlte limb to be brought into the frtnigbt position, and then
BURSITIS BlMtXAnSG DISEASE OF KXEE-JOrKT.
ap|iI,Y xn intitrainent which is a moditication of TavIoi^B Itmg splint.
In the ease of the tittle girt who has just gone out, the ab- ducting and inverting ecrcwit were also noccsMrj. (iSv Fig. 147.)
Tlicfie instrumeiite and their mode of application huro «ln.'ady ' bcou diiecrilMHi. iSff Ivvtun: on lJi[>-diiti!aj««.)
In tliose casus of diastasie, however, in wUicli tticro is no con- traction of the tendon^ and the iiiiib can be n^^tored lo its iionnal po6itioti, the long splint sliould be iuiuiodiately np|iUed, and worn until recover)* has tnlccn place. If you arc called to attend the case imraediatetj after tlio occnrronco of tliu accident, trvuit it preci»ctr n» you would a case of fracture of the thigh, and place tile patient at onoo in the wire cuirae^, pluetcr-oI-Puri* drewing. or other apparatus), which will hold the parts perfectly <^uiet. I prefer the wire cuinu^, cepeciaUy for Email children.
Jt'tr»tti*as nmuiatitty Dtseaite of the ICiu^'-'/oint. — Tlte buraie ahuut thiii joint Koiiietiiuoit become the eeut of intlaniinaiion, wliich goea on to aupparation and tlie formation of large absocesee.
"NVhcn tftich a cu«e ]irL-i-cnt» iteclf. if of lung kl»mUng, tliore will pn>l>at)ly W numerous openings above and below the joint, and many of them will oonnwt with each oihor through long, torluoiia sinuses, that lead off into pockets here and thuru fill«<l with pus. These niniises and poukets are always lined with a thii:k nietubraue, winch kee|>« up a constant secretion. The long- continued and exlmusling dischai^ givc0 riae to more or Ick) eon- etitutionul dielurban(.-u, and the swollen and iuGltnitod condition of all the liiHues about the joint imparts to it an appeamtioe and fii-l vary much tike that seen in true disease of ttie joint ittolf.
nu. tiK
When, however, thccc «inui%H arc explored with my verto- brated flexible probe («m Fig. 31S), or llie elastic flexible pn>l>e of Mr. Charlw Steele, F. !{. C.S., of Meridan Place. Clifton, Bristol, England (m« Fig. 21'^), you will find titat they have l>een
TREATjreST.
&9S
made by piia bnrrowiiig in the cellular tissue benoatli tlie ekin nn<) umoixg tlie tiiii>«I«e, and are all extra-cai>suliir. The ctuu«e- U-riiilic upiwiirutK-c of the oxternitl opculugH wbvii dcatU bonit ia [trenent iA not seen in theee ca^es. This probe of Itlr. Steelo'0, altliougb apparentlv xiidi aii iiuignificaut iiittti'iiineul, is yvt one of the greatest vahit>, and I think an impntvetiiDnt upon my own.
Thv ino»t c-crliiiii nivlhod of rwogiiizing the dillicnlty. bow- ever, is to luuke a thorough examination bv crowding the bones together, by oxtcn^ion, and hy ]nv«*iiru over tbo Im^urtion of Iho curonanr ligaments, for in this way you will be able to determine wbetlier the joint 13 involved or not. When thin is done it will bo found that epart-ely any symptoms are present indicative of true diftease within the joint. It is very diffienlt in oertniit mscb to dutiTiniuu whether the Ituetuation tliat may be present is within the bnn<a over the joint, or ifl due to the prectence of Hutd in tbc joint \t*icli. 1( the hui>a ulonv is involved, the patella will bo crowded tinnlyagainM the eondylea of the fenmr; whereati, if thu effusion is within the joint, the [Nitella will he lifted from ttie eonilyles, and can he preivic-d again-it them in many inntanccil KO as to produce an uudiblu cliek.
The TREATUENT for caHee of burxitis of long standing » to open all the einii«vs frxrely, removi^ the lining membrane, and fill the cavities with oakum isatiiruted with I'eruvian KiUam. In this mjmncr yon will bo able to establish the healing process at the bottom of the caviticA lined with pYogenif membrane, and thu case will prububiy give you no further trouble; in n.-eent cases of bnrsitia aapiratiou nuiy be resorted to> often with the luoet satisfnictory ri'milTs.
Ncerogts <sf th* Lowtr Extmmiiif of (he Femur, — Xecroeis of the femur at !te lower extremity u quite commonly mistaken for chronie disease of the knee-joint. {See Case, page 40.'i.)
In oconKional earM.-« it i» very ditlicult to make a correct dia;^ noeis. The most common seat of the necrosis is along the coane of the bram-he* of the linea iifiKTa, indudinff ihe popliteal space of the femur. These bifureations have edges more or h-wt rough and cutting, which will break Ihrongh the perioi>leam when it is firmly pressed against them. For inslanoe, a person may fall from M}nie hi-iglit, and in the descent bis leg may become caught in such a manner as to make severe pressure just over the jH-ri- osteiim coreriag these ridgc«, }>erlni{)6 sufficient to wound tbo
394
JTECROSIS OF FEVCR.
pcrioAteuna without tnakiiig any externa) woatit). Suoh aa injary may gtvv ri«L- to pcrioftilis and »iib«e(]ucnt nucriMis of the botii'. Whftn iiticli reeultfi follonr an injnrr of tliU ehanoter, it takeft a loDg time for till) (Iftticnlty to niako it»clf manifest upon thu t]ii^li, on account of the depth of the difleai^e tienealh the Aurhce. . But thu dumngti dotie. and hL-crutfi^ following, jmtt is ruuined nndf biirrowa among the tisHnee, and the disease is eo near the knee- joint that it is very liable to he mistaken for true joinl-diM.w««.
All that is neccBsary to do in these cases, to arrive at a correct diagnotif, is to make n thorough cxaminnlion of the joint in tho manner already described. If your exainiuarion is thorough, and diaciifw of the joint is prei<ent, yoii will lie able to detent it. Yon will alBo observe that there is no abduction or twisting of tho Icfc outward, art ^liown to re«uU wlicn Ibe joint has been long in- volved ; but, on th« contrary, the leg will bo fonnd flexed in a straight line with the fennir, and has no outward rotation. The o.xtoraul openings of siiinsos oomuiu nitrating with dead bono havt) flucli a characteristic appearance, d8Acril>ed by the late Dr. Alex* nndor Stevens -m rescnililing thu anus of the hen, ae to bo nbecwi lutely amuistakable. When this is preMint, therefore, you will nt once iise a flexible probe (we Figi*. tilS and 21&), whSob will follow the lead of any opening under the fascia or elctewhere, and] tinaily conduct you to the dead bone, and then your diagnuatt is* positive.
In fumie caflOfi, however, which hHvc fallen nndcr my obwen'o- tion, thfrn wore no openings until I had made one for the pur- pose of exploration. Sndi an incision can be made through the vtiaiuit exteniti« ^niasclo. when the hone is very readily reached without incurring any risk from hpemorrbnge.
The incision will probably give free discliarge to pna; and then, with your finger or probe, the exploration can l)e coiitinuwl UTilII the diiLgnoi^ix is coinplotod. In some cases, perltaps, the parts can 1>o saved by making a free inciition through the ]>ori- o«leuni before death of the bone takus place. When dUeas Itono is found, proper mcasurea can be resorted to for it* n-inoraL^ If you arc not able to remove all tli« dead bone at tho time of tbe firet operation, draw a seton of oaknm or an India-rubtter lnl>e through ihe wound, and leave Nature to remove the remaining portion,
An important point with regard to operations for the removal
TREATMEKT.
895
of dead bone in tliH rc^on, m well as ebewhere, (9 to preserve Uie p«ri(«.toiim iie mucli -m pcnmh\v,
Tbe permanent defomuty which commonly follown ditonic dieeaee of Uic knG«-joiiit ia ancliyluele witb distortion. Thu sub- ject of ancliylodis will be fully considered in onr next lecture.
LECTURE XSTI.
AXCIIYLOBia.
Dtriratioa inil Tw oT llie Wonl. — Tfuo&ml Falac Anrlijln*!*.— PmkiuBorUmb •liMi AbcIijIimIh becotDM ■ Xvcmuli; — Ucxlc i>f il«t«niiliitn|t wliloh Korm of Aneliylo- tit i* prt»ent.~Briitnml/oriti. — Umtt ot drewlbg tJic Limb after lh« Op«nIlo&.
Gfatt-kmen : To^Iay we begin tlie study of ancbytoRiB.
Ancbylu«ig in a wunl dcTivuil fmni Iliv Oruck (A/^kvKik, erooitd or hool-ed), and has been ii^ed to designate immobility of a joints beeauik; mwt of tbc juinta wli«n itilTcticd are deformed in this crooked manner.
Alllioiigh tlio tniu pathology is t'tiffnoes, ininiubility, or eon«oli- dftUon, no miitler wbetlier in a etmlgbt or crooked poi^ition, yet tbe term ani-bylotiiB. or erookedneiw, \m& been so long used by tbe profoMiioii to designnti! thu putbologii-ul condition of wlu'cb wo are now Rpeakin^, tliat I ttball continne to employ it.
Aitcbyli<«ifi ii^ either Inii*. (>tr«euuti, or complete ; ur faUe, fibruiie, or incomplete. True or complete ancbylo«ii) iiigntfieit the fixed and nb««>liitoly motionloss l^tnu■ of n joint. Katiic, tibroua, or in- com|))ete an['hyl<K<i.i denotes a limited motion in tbe joint, no mat- ter bow fdif^ht tJiat motion niity bo.
Ancbylosii; ia uiore oommon in tbe j^n^liinoid articalations than in olber:^ but mnv ooeur in every dcM-ripttun of joint. In general, only ono joint is aucbyloEed in the anme individual ; but I have seen one case, in a f^entleman under thirty year» of nge, from Prfividenw, Rliodo lolund, in which both hips, one knee, and l>olh aiikteft, were apparently completely uiidiyloMsd, as the rciult of rbeimiatic iuflanunation. I bare eccn one other caae, in a young
1^898
Ascnvtosis.
laj of 6ft«en, from Kentuckr, wlio had difiease of hin right bip- joint, and, fur tiie piipjiosc of procuring ntt of tlim juiiit, was put hy hiB uttetiOiti^ stir^on into a lixcd apparatu>s eiiilirariii){ tlie trunk, pelvifl, aiul both lower cxtrutiiitics, and so retained for Bcvenil montliH. At the end of this time, the duea^ed hip wa^ cumt] ))V aiio)iyl<>nii<, and thv knee and ankle of thu diH-'asL-d liuili, AB well as the hip, kiiue, and ankle of the opponile one, were com- pletely nn(.-hyloi>ed, and titill ri'main in the nuue condition.
In Uiifi euee there luid huen no intlammatorjr acliiin in any of the jointa, except the riglit hip, and he liad never coiuphiiuod of or suffered pain in any of them. This oaee is of great iinporLsnce, ghowiii|f as it d<^eti that anchvluHiii can take pUiv even in h young person, in n perfectly healthy joint, by long-continued rest.
In old age, anchylo»i«, in certain ]iart« of the i<keh'ton, Is A natural ohani^'; itnd in this peiiod of life it is mnimon li> tind the heads of the rilis anehyloccd to tlie bodies iif the vertehnp, or the tuherck-K to tlio traiisveree proeeeeec, the vertebnc to onu an- other, the ensiforra cartilape to the rtemtun, etc.
AnchyluHts is not n diwasc of itself, hut may Iw the re^nlt of any disease, affection, or injury, which interfere* with the uunual functions and motions of a joint.
Anchylo^s may he the most favornhlo tcnnination that can occur in many diseases and Accidents of the joints. In t>uch caM« it is of the most vital iiii]>orliince that the surgeon tJiould Helct-t tlie nioftt favonihle position for the fntnre usefnhiese of the limb thns involved. As. for instance, the cll'ow id more useful when anohyloiicd nt m right nnglc than if made stniight, where^ the kncv would )>e entirely useless if anchy1oS4.*d in the muic manner; its future Unefulnoss .ind seeurity heing better obtained by hmv- xug it ancliylosed perfectly straight, or as nearly «t ac n>ay !«.
It han l>een ctn^tomsry nniong aurgeons, when »ii('hylu«is WM the best result that could be obtained in any given case, to eecure it with the \cg flexed ujwn the tliigh at an angle of 3*)' to 46'. ¥tt>m this I disjient. and recommend that you shmild secure anchy- lofliaat the knee-joint with tlie limb in a nearly A/mry^f p(i«ition.
My reason for preferring this i)06ition i* thia: it gives a more lecare position and one tlint is not liable to give the patient trouble «t some future date.
If left to anrhylosc at an angle, the anchyloais t$ wry inM>- cure, and somotimea, as tlio man steps down an iinexpecteil di&taiHt-
I
nOX FOR AXCIIYLOSlI
897
or Blips, bringing bis weigbt Budttonty to bear npon the limb bent at thiii Angle, it may yield eullieiently to give him rery Derioos trouble.
It -KM only ycftterday, aa I was riding do«Ti Rniiuln'sy, tlint I oiw a gentlcinan about fifty yean; of a^ wbo, in guttiog ont of an omnibuis jn»l <>ppoi<it« the Metropolitan Hotel, clipped, and fractnred Iiis anchyloiiiHl knee tluit bad buen in a cfmditiun, ss he »up{>D»ud, of lino bony aiicliyloAU for eleven year», and bad never given him any tmuMo wbatuvor.
He had bc«n able to walk and »tnn<l upon it witli perfect cam and apparent aecurity, but, by this aovidental slip, an additional weight wm thrown upon tlie joint snchyloftod at a slight angle, and the attachments were fractured, and the man rendui-ed holp- lois. I Iinve known of quite a number of itintilar in»tanc«t>.
If, on the voiitrar)', the bono* are plncvd in tlie Etraight posi- tion iw ne«rly lut may hv, the Inige, arlicnUling »iirf8ce« of the tibia and eondyles of the femur give nnch an immense expanse for atttu'hmenlii to l>c formed nx to render that porti«in of tbe limb <n-eii uioi-e necnre agninitt fraotnre tlian any other [Kirt vf it.
When the amdent bappenod to Uio mail in ilroadwiiy, it be- came neo^^ary to carry him Home distance before he reached hitt home, wliurt' horonld rel■ei^■c siiririfnl attention, tberebyi'ndiiHgor- ing an attack of inllammatinn in a ti^«ie which had formerly been Iho euit of diM&M. lu otber wordm h« had bad hie ancbytoela broken up, but was in a situation that prcventefl tliat imniedinte iTWtinont which I rvf^ard aa m iinpurtnut ; whereas, when the fnicttiro ia made intentionally, treatment ia immediiitely iH-giin, by eemirinp rest, position, proiwure, art^nin'on, control of circulatiim, all of which are eMential to prevent intlammatiuti after forcible mplnre.
The inun awity from bom*?, who accidentnlly broak« hie anoliy- tosed joint, cannot liavo these advantages, and hence the danger of leaving tlic knee toancliyloHe in micb a {WKition as will render tbe patient liable to fiu<'h accidents.
The straight po«itiun has been objectctl to, upon tbe ground that it phicos the patient in a very awkward and inconvenient atiilu<le when Mtting, That may be true, but I ri^ard a ».-cure ]MMilion which will, perlwpe, prevent any accident^ aa being pi-ef- erablc to inMcnrity, although it be aecompanied with a greater dugree of comelineea.
T988
ANcinxosis.
It U owing to Uie ncj^lect of observing this principle of plxe ixig * liuib in iu moet fiivomble poeition for fiilurv UM-fiilucfiS,'' wliile confioUdation ia taking plac<.>, tbat eubec^tient aurgica] inter- ftirtiiw is iieoeesftry.
In chronic or long-continued inflammation of «i>y joint, reflex irritittion, prodncitii; niii^c-ulnr contnictionii, invariabl^v tiikvtt pluoo.
This contrnriion not only aggrsvutca tlio disease by cansing undue pn.v«iii« on tb» }>nrte inftamcd, but altHi dielorls tlic limb in accordance with the action of tbv most powerful muscles in> volvL-d, and the diifiurlion can only be prc\entcd by tb« proper application of an extending and counter-extending force duiiiig the trcotmcnt of the- ditvasc. When thi^ principle ban bei.-n neg- lected, the patients frefjuently recover with such wriously distorted Nud UMilEvGt limbic iiK to render surgical interference iiccvHfiury.
In such msee it ie of tbe utmost import«»ce to ascertain n-liet]ier the nni'Iivlosifi I«» coniplcteor incimpletc, a« the ])Ian of trwitttic-nt in uach particular case depends cntii'vly upon tbe accuracy of this diagnosis. If fibrous, or incomplete, it can be broken up by manual or mechanical foi-ce, aide<l by suhciitsneoug tenolotiiy, myotomy, inid llic M^Mion of 8uch fascia.*, tibruus bands, and other adhesions, aa have prevented it« mobility; wherpaK, if tbe anrfay- lonis betr»w),orbo»y, the deformity csu only hv rclicvM by K-ction of the l>one itself with the saw or other instrument. In many Cflse« of simply fibrous or incompletu HnchyloHitt, the adliveions am «o firm and so short att to allow of no ]>erce]>til>lc motion, even under a very careful inspection. In Biiih cai^s, if any motion whatever hsa been made, although so slight as not to Iw ob«orv«d at tJto titne, the parts which have been subjccti-d to tb^ violtmin neoeesary for the examination will on the following day give evidence, by pain, tendornbfis, and inflnminatiun, that eomc motion muBt have bwn given to the part* involved. In one rtiiC of aochylotiis of both hipA, witli very gn-at distortion, by conipleit) flexion and adduction, in n young girl of uinctcvn, f rom long-oon- tinuod suppuration of both bip-joints, the andiylosis waa eo com- plete tbat, in consul rat ion with all ibe suigeona jU IJelleuie llo«- pitjil, wo all decided that it was a case of osseous fiuiion, and conid only be relic\-ed by ecdion of the bone.
On the following day, when I went to perform the oporation, there was so much tcndorai«8 about the pnrta, that I was satisfied tome modon had been given to the articulation, although so slight
FOROmiJ! EXTESSIOS.
3!>9
ttiat none of ita had been able to detect it at the tinio of the ex- nininnlton. I tbvreforu dctcrniiiie<I (o break up tbe adhceions, instead of sawing out a portion of tb« bone, llic midtictors tvuKor ^-sgimv feinori^, and Icecia lota, of both Bidre were Habcti- taneonaly diviidvd, the wounds carefully cIuHcd and t-overwd by long »iri[ii* tif adliesive plast^T and conipre«»e& A fignre-of-H roller was then carefully applied around eaob hip. after whith tlio adhnionit were forcibly liul very freely hrcAen up, and the lind)i» brought as nearly as possible to tbvir natural position, and rvrjiiui-d thvrOt by cxtenwim and nbduftion, by neiglil'* and pnllevfl, whioJi were Aecured to the limb^ in thu u^ual u-ay, by adhciiive phi«tor atvl roUvr. The patient was kept perfectly quiet, the parts kepi oool with ire-ba;rs and at tlie proper tinio pasfiivc motion n^u Duulo. The n-Hiik in thtH eate wha perfectly «atid'acloni-, the |«tient reeovering, with gnnd motion of both jo!nt«. 8he has married wnee, and wiw <ielivored. by the late Dr. Cieoi^^e T. Elliot, of a living child, who is now a robui^ Uoy, of live years of age. Prenous to tile operation, thiii wixnan could only walk u[x>ii her liattdtt and feet, the limbs hcii)^cl<>s«'ly flexed and odduded, and the auchyWix w complete, as before ittJited, that all who examined tier tlionght it to be outeouH. She ia now in perfect health, and pcrfoniiif all hor liuuM'hold duticH without the aid of a i^'rvant.
]Iaring made mir diagniiHiK that the anohylntiiii iit librouH, and not o»«h;oU(I, how shall it be broken api In former timesgradnal extension, with steaming and friction, was considered all that watt nctxiuary, but the lengllt uf time demanded and the givm pain induced by this nieltuxl of treatment, fre^pieiitly prevented tlib patient and i^ui^i-on fnim carrying it to the cunipletinn of eoc'uriiig ]>erfect motion. The i^low and gradual ntretcliing of ttgeucH, long contacted, producer reflex contractions in many instjmoefl to such a degree as to compel the treatment to be aban> doned, and iHttionU prefer to remain with their liitib& In the dis- lorte<] condition tether than undergo llie eontitsnt pain of con- tinned exteiiMon.
In all such ca^s it is infinitely lietler to proceed to the im- mediate restoration of the joint to its normal position, with entire freedom and mobility, by manual force under t]ie inlliience of an aiuesthelie eumbiucd with teimtomy or myotomy of eul>cutanenHs WMtton of the fascia, if necessary, Uian to resort to the «.low pro- ecu of gradual exteiuion.
AXOHYLOSIS.
In all euoli m»c«, tiowovor, it is of the ntmost importance that manual force t^hould not be rceorTed to for brealcin^; u]) liltniiitt nncliyloHii^ uutil all tnii-ic* of juiiit-diM'ai^e bavo EtiWded. Then we iiiaj resort (o britement/ciVi', and not imtil tlion.
Uow are wo to docido wlmther tenotomy, myotomy, or tlie ecction of fatuna is reqniaitei I'tit t)ie jiartM ii]ion vxtreme ten- sion, and, while tlins strotohcd, if puiiit pi-ess-ure hy the finder' or tliiimh, made on the faacia or tendon tliU8 slrctchi-d, prodncoa reflux contract ions, then that fascia, tendon, or tit<sue, murt be Bub- ciitaneoiisly divided ov else foivihly niptured before the limb enn be restored to it"« tioniial position. If the tiiwueE thus eontroeted can be reached with tlie knife withonl the danger of involving large blood- vossel it or nerves, section by tlic knife ie lietter than forcible rupture. If it ia noceHsary to make tbii» nubciilaneous section, it in better to do it three or four days previona to the breaking up of the joint, so that tlie external wound made hy the teuotouie may hii\o healed before the latter operation is per- formed. This tenotomy may he performed under the influence of aiiana'sthetic, ornot,as thesiirgeonchooseei but when the ii'iw- tm'nt proper is performed an nnfesthetio la absolutely er^ential. In fact, it is due to ana^tliceia that hr!sement ford hae (c&ined its reputation, and to it it chiefly owes its Biici'eKs.
The p:ilient lieing- thoroughly anipsthctixvd, the limb is mzed by tbw handit of amistanl^, holdinf; it with timmeea, between tbo joint involved and the trunk, while the sui^i^n tokea tbc further extremity of the limb and fort-iMy flexes it upon itself, whidi U frt^iiucntty attended with slinrp snagw and cracks that are some- times <juitt' audible and that are very dii^tiuilly .^W/ by tbo sni-- d^-onV bfiud while making the rupture. Having tlexe<] it eafK- ciently to begin to allow of moderate niovcnienta, he tlien revorava the movement, and forcibly extcndrt it ; and in this way, by furc-lMe flexion and cxtt-nsion, continues until he bits gikincd perfect and free motion of the joint involved in all ita normal movements. If the knee is the joint inv.ilved, care \nvt& be first taken to fract- nre off the patella from its Attachnieiila to the femur, wbii-h is sometimes the most difficult part of the operation to In) per- formed. In many inrtancee the anrjieon can aid bimaelf by cover ing the handle of the key with buckskin, and by its use give him- aelf a tinner levemjre af^iniit the edge of the patella llian ho can get with his naked thumb. Having thus obtained perfect exteo-
l
BRISEHEST FORCE.
401
Bion, And flexion, in fact, tiie complete moTementa of whatever joint iuvttlved, these movements are repeated with great freedom and with gn."Jt fnxjuciioy uutil ail tlic adliCHiuiiH ure ttiorou^tlj and «niiplet«Ij broken up.
One of tlie comnioiR-Ht ouii«it( of failiin- in the tn-ntmcnt of jJJnxMi anchyUnis by liri*emen( ford is, that the surgeon, succeed- ing in getting a moderate motion, and becotning nlaniii-d at the audible fntctnres tlutt occur, contents liiioiielf with that sliglil mo- tion for the present operation, intending to complete the cure t»y aubK^nent operations, and thuH, b,v making frequent attempts to inoreaae these slight movements, seta up » new infliuiimittion in Uie parta invulvLHi, preventing any further interfuruiiee, and fre- qnentljr resulting in a more firm consolidation of the joint than before; whereas, by breaking up tlio adliesiuns thoroiiglily and completely at the time of o]»eration, and then by proper dresjiingi* «f ttie imrtH and the prevention of inflamniation, bo may ooutl- dently exi>ept that he will liave a mneh more satisfactory reriult.
How are tiie^n; drettisingM to be a])pliod ? and how it this inflam- mation to be prevented i This I look upon aa the most inijior- tnnt part in the treatment of an anehylowd joint. For many years past I have alwavii ailopted the following plan : If, for ini^tanee, it be tlic knee which I have broken up for angutar jibrom ane^fflo- n», I 6rst strap the toea with strips of adhesive plaster if it be A amatl ttubjeet. or, if an adult with long toc«, pad the toes with cot- ton and bind with bandage, carrying the roller over the foot strongly and firmly, pudding the itialleoli and tendo-Arhillie with cotton ; the roller is carried snugly over them ; two strips of «<!• heaive plaster having been phiced on eitlicr ddo of tJie leg for ex- tension, the roller is passed over them, leaving the lower extrcnd- tioti of llie adhesive pliuter expt^eed for the future attachment of weight and pulley, and is carried lip as far as the top of the tibia. The pojiliteid space id then padded and tirmly etrappecl with strips of adhesive pla^^ter. each one shingling over the other until the entire kneo ia covered. The roller is then continued ovur the knee amoothly and very firmly until you eome to the junction of the middle and lower third of the femur, when a piece of sponge an inch or tvo in length, or about the size of your thumb, first being wet in cold water, iit plaee<l over the truck of the femoral artery, and the roller carried on over this Rponge for the pnrpose of making partial oompreBsion of this artery, so aa to diminish it« •m
403
ANOIITtOSIS.
calibre and thus prevent the full Mpply of blood to llio pnrU be- low. Grc»t iMutiuii IB Dcoc^«)tni', iti tlie applicsdon of this preuiira J upon the arterj*, not to obdtnict the circiilstfon bo a« lo proJacsl gangn-Qc; wo iiiu«t h<TC mm prL-iuture without abusirtg it.
Tliie picc^e of spon^ should )>e Iti'pt n^ft and cUstic h^ wet- ting it uouiifiomilly with vAA wuUt thrutigh the l>itnibigeK If pennitte<I to get dry, it will bo Uko a hard foreign body, and IlivJ prc»6un^ inmJe upuu it will bu much more liable to cause elongli- ing.
Hie limb \f- then occtircil in an absolutely inimovublo position, eitlior by a wuudcn opUut well padded plaoed behind the ley,,i giitta-peix-lia, sole-leather^ jilaster of Pnrii^ iron bai« on either side^^ of it, or in any way tliat tbo surgeon may deem best for the pur- pose of preventing tlie fliglilei'l pot«ibte inoveinont. TliciMtient U then placwl in beil, the lower extremity of whieh is raised ten or twelve inches higher than the head of the bed, no that tlie body may act a^ a counter-cstending force, and the weight and pulley applied over the foot of tlie bed to the etripft of adhesive pluvter at the ankle-joint before described. Ice-bags are then placed around the knee, and »ucb constitutional treatment in the univ of narcotics, cathartics, etc., as may be re<juired is judiciously used. At the end of six or seven tlayi* Ihc drcssingB are removed, tlie sponge taken from over the femoral arterj-, the adbfsivc etmps cut tVoin over the knee, and the jmuIs carefully examined, and a very slight movement given to the joint for the parpo^e of prevent- ing i^oliditicstion, when the dressings are reapplied with the sponge left off from over the femoral artery. At lliiti drewing the burguon will often l>e eur^iHwd to liud ccchymocis to t<om&| extent, both above and below the joint, from extravasated blood' cauiod by the rupture of vessels at the time of tlie operation ; but, by following the plan that I have here laid down, I have never seen a ea«o that went on to suppuration since I liavo ad»pt«d this melboil of treatment, now numbering nearly one hundred easea. The extension is still continued and the elevated position of the limb is preserved for some days, until all diinger uf intlDmma- tion ia past, the surgeon exerviiting bis judgment whether the application of ice ia Btill to be kept up or not. At the end of a few dnys the dressings are again rentoved, an<l more tree motion i-i given to the part. It may be necessary at lliti time of niiiking tliis movement, and the three or four aubaequont nwveinenta, to
PASSIVE MOTIOS.
403
adntinister &d anfl»tbetiv; tbcso niuvomenu should lie niitde qnite free wheii an anipsthetic is used, tlie aurpeon being wirefnl nnttocirry tlieni tutliepoiutuf fxeiliiiffiiuwiiitlaiiiiiiAtion. Aftci- StKne dayii tlie pasaire movements can he made daily, accompanied with fnirtioii, luid itliiimpooiD^ eliuiild Ik; very libi-rnlly dune. Tli«>M> movements may be increa!»ed in freijuoncy aa the case ad- vances, tiiitil tinally sn ioBtrumi'iit c«n be HoadjustiMl to Ilic limb tliat tlie patient can cause t)ie moveineuta many times in the <lay without diu att4.'uduucv uf liie [)liyMciiiti. {See Fig. 320.) t$o eooti
no. no.
ae the parts can be pressed tngethvr by bcarinft the weight of the body mwn the foot without 1enderner«, the extension can l>c omitted, and the muv-omunttt daily increased.
Tiicsc are the t^'nci^l principU-ti whicli sbouli] guide you in the management of all caM» of libroiijt anc)iyiotiiM, whvtiier wciir- riiig at the hip, knee, elliow, or other joints.
When the hip-joint is opcrnlod n]>on by britt'inent farci. I lUilftlly SGCuru the patient at once in ibe wire ciiirasfl. The wire cuimaa is also an uxcecdinf^ly cimvvnivnt iitHtritmcnc to be uhchI when the knee-joint has been broken np. es])pcially in children.
The circulation of the hip «iu be conlrolk-d by placing* bag of ehot over the external iliao artery.
WHien the elbow and wrist joiulsarcoporated upon, the Bponpe ii placed over the brachial artery for partial compreRdion and control of the ciividation, the «aine aii ali-i-ndy duK-ribcd when
404
AKCUTLOaS.
speaking of tlio feiiiora) nrtory in refiTCiii^c to tlie prvvcntion of in- 11a ni motion of the knc<p. Aft«i' the rolltfr-baiidn^ niid artorinl <»n)- pixiutiun Iiitvt; bti-D properly apiiHvd, lli<! joinlH are to lie :§«('iirc<l H^aiii8ttliepos«iliility (if tite »li(fAt*«t t/uiUvh furnfowdkyH. Alter iill danger of priKlucing inflammation Iiaii pasaecl, llit-n tlie name ^i-nt^riil princijilL^ luitl <!own to you in the tr^atmctit of nncbyluBis of tlie knee-joint are to govern yon, sucb om friction, stuunpooiDft, paueivu mutiuii, vtv., bi-tng c-Hrc-ful nowr to carry your treMtlucut to the extent of rec-xdtin}^ inflammation.
By tiw pLin of trc-atincnt lieni given I bare never bad a single CMC of foUBtitutional fover or Hii]>|iiimtion followiiif* brin^nent forei of any of ibe joints; and, as before alnted, 1 liave per- fomied tlie oiieration, including the different joints, more tlian on« buiulred tiiuoe. I tbcrefoiv feci tliat I cnntiot urjie upon you too fttrongly the necessity of cyirrying out all tbo dt'IuilH of the aller-treatjiiont I tiave laid down, for I have Been a number of ciwes in which hrimmeni forw \i«* been perfonneil by eonipett-nt eurgeone, but they neglected to apply extenMon, and the result wan that reflex inuwular cmilniction followed, which pnjventcd a successful termination of the operation ; or, ihey allowed a little lime to olnpee aftt-r the operation btrfore the drcM^irign wert' ap- plied, hihI a reaction came on which prevented their application, and disastrous intlamniatioii followml. 1 regard «twy detail of lliu plan of ti-eatment aa essential, and cannot urge you too^trongly to observe tbein alL'
Ca»e. Aneh)fUm« of Knee; Britement Ford; IteuiU ^ler- ftet; from Bt^Uniue Ilonpltid Jiewrd*.—'^ Ji. I). S., June 211, 1809, aged twenty-two; Kentucky. On the lltbof Dccvutburla^t, patient accidentally »liot hinitiolf witli a Colt'a revolver, the Imll entering the right thigh, ou its anterior aspect, midway bi'twoen the groin and the knee. It lodged in the tisanes on the outer flidu of the patella. The next day the Inll vtbs reiniivcd. Patient mya titat hia knee then began to inflani:-, getting swollen, red, and painfnl. There waa much dii^:harge thrnngh the ci]wning made by removing the ball, aud patient wiw cuntincd to Wia bed for two inontliR. During tliis time hie kneo became aucbylosod, almost in a straight line. On admiiwion to hoi<pita], the right tlijgli
* IS8S.~A «UII moTt eiicndcd (qieritaw bu confimittl ili« valve ot ilia jicHitoa ben Uuglii,
CASE.
405
and leg were smaller ttian K-ft, ttio following mcusnremciits being taken: Kijflit thifili, fifteen and tlirt<?-eighth3 inches in cirenm- ferenoc; left tliigh, seventeen and omveif;liili inebue in c-trctiin- feronco; right leg niul calf, ten and stialf incheHincircumferenDo; left leg and ealf, twelve and a ijuarter inelios In ciremtiforeiico.
" There is larelj any motion of tlie joint The iwtcUa ih eligbtlv mo^'able.
*' Patient".-* general eomliitnn good. He gives no hUtor^ of hflreditST)' di«s»Bo; tlic limb givKs him no imiu.
"^imaSOM. — To-day the patient van etlierized, and Dr.Sayrc brok^ tip the ndhesionni with liltl« tmtiblc, 6o that the leg conlH be ei'Uiplcti'ly extended, ami Hexed at an acute angle npwn the tliigb. Tho toofi were etrappeO, tho foot and 1^ baadagod, a laiyo npimguBtrippod into the popliteal sp3(«, and another placed over the femoral arttTv, bo as to coinprefia it moderately. A long apHiil of lc:kther was then adapted to the back of the thigh and leg, niul bandaged firmly. 7 r. u. — Patient doing welt ; haasome pain ; onlorod liq. niorpliim aulph. (0. S, P.), 3 "j-
"(AiJy 1st. — Slept well last night, and bas no pain tn knoe. I p. Ji. — Foot rebandftged.
" CM. — Since laat not« patient has been doing well. Tfwlay Dr. Sayre look off the splint and bandage, and niade passive mo- tion, wbieb waa very painful, Patient wa* then anosthetized, free passive motion made, and drei^ng reapplied.
" 7M.— Joint was movetl again.
"fl<!A. — Splint removed today. Patient nnt of bed.
** I4M, — Joint moved to-day nuder chloroform. From this time the motions were made more frei^nently, and an instrument ad- jii3te<l, so that tlie patient could flex and extend tlic limb at his pteuurc. lie *ras adviiied to do this frequently every lUiy. The rvsult was, that be recovered with perfect motion in less than three luoiitha." *
Cabb. NeerotU of Latter En^ ^ Femvr^ CAmpiicat/d wi'M Fibrout Anck^loti* of Kne^oint f Britement Forw- ; Recovery viih Motion. — G. W, O., of Bloomtngdale, agvd twcnty-fotir yean ; fell, when lie waK ten years old, from n height of t4!R feet, striking upon his right limb, followed by a pcriofititU of the lower end of the femur, ending in neera^iis of femur and anehy- lo«ia of the knee-joint. "NVbcn he wa* tiftotTi yeans of age (after
■ I MH Mr, S. b Jonudry Imi, tnd hb limb vu m pcifcct u the ollior.
406
ANCnYLOSIS.
a lap» of five years), one of the slnoMs on tbe outer portion of tlic tliigb wile dilated, ftiid a piece of hone two and a half iwhc§ in length, and about twi>tldrdfl of the drcumfereiice of ttio femur, WA« rciuuved. A sinus cxitttod at Uiu Bamo time on the inner afipeet of the tliigh connecting with the external one. A perfo- rnt«d Indiik'rnlihur tube wae patsi-d tliruu^h itn track and worn for some time, until all dead bone bad come away, liia leg at thst time wnB flexed at an acut« an^le with titu knoc.
The wounds of the thigh healed aft«r a few mmitbs, when, undtir the influence of olilorofonn, hy brtSifmeut forw, bis limb wafi made perfectly straight, dreesed in my usual way with a partial comprv^s ovrr the femoral artm-, binding the knee, retain- ing splint, extension by weight and pulley, ice-bags to the knee- joint. No conetitutional or other irrilation followed the operation. At the end of seven days tlie dre>«.sing»i wen- ttmoved. Consider- able eccbyntous a])pcAned around the neighborhood of the knee fWim the rupture of hlood-vcesels at the time of the opemtion, but no excessire heat or other evidence of inflammatory action. The limb was very vtiglitly moved and again n.-dri-«HKl «» Ix-fore. with the exception of the sponge compress ujwn the femoral urtcry. lu two dayit it was again redressed and mure free nloT(^ mentA given it.
From this time on, the drcssinga and inotiuus were made daily for about a fortnight, when the pa^ive movements were advised to I» made eereral times within the t«'euty-four houn. These movements were constantly increased, imtil, at the cud of three mont]ii), the cure was perfect and complete, with the entire mobility of the Joint, eom]>lete extension and perfect tiex- ion, as is nuw seen in the case before you. (•Ssv I'igs, 221 Mid 2S2, sliowing flexion and extension ; tlie deprcMUtu on citltor aide of tlie limb are the cicatrices whence the bone was removed.)
C^c I-'ibrotta AnehylotiU t(f Knt« ; Sriaement Ford ; He- TOwry with Motion. — Joseph S,, aged seven y«u«, was bronght to «ic fk-tobcr .to, 1873. The following scanty history of tlie case was all that ouulil lie elicited :
WIivu two years old he luid rheumatism. The joint chlctiy affected was the left knee. The father says, " Uis physician called it ' bony aftchyloai* * and ' whtU awetliui/.' " It was treated with iodine externally; no extension. The limb was always crooked, but he coidd walk upon it until tlie summer of ISTS,
0AJ9E.
407
onoo which time the present distortion has existed. Tliere is fibrous anchvlo^e of the kncv. The tibia i» luxated barlcward.
y- i-;l
rw-tn
There is vcrv sli^rht motion nf the joint ; the patella >fl probably niorablc. {S/e Fig. 2i3, from photograph.)
Veoetiiher C, 1873. — At the collcjjo clinic 1 divided the ham- Btiing tendoDH of the left iinil> siihcutjineously without lotiti of blood. Tlio piktv]la n'fls then forcibly Mtparnted from the end of the femar, and tha limb drown down to the position of com- plete cxtcQ«iun, and retained by a wuight^anil-pullcy drc»»in^. The tiDib was di-eescd in my usnal manner, viz. : t}ie inBtep and auklu were well pa<ldod with cotton, the roller noatly njipliod over this and up thu !f^. The popliteal space is protected by a lar^ soft sponge. The inequalities of the knee bcinj; (-arcfully padded, ^ripti of strong adhesive pUister aru enngly drawn over the Hponge and [>ad, and the whole covered by carrj'ing the roller up over the knee and lower part of the tliigli. A small pieL-e of Rponge is then placed over the course of the femoral artery, abovo the juni'tion of the middle and upper third of the tliigli, and the roller earned farther up and completed by a apica. The
408
ASCnYLOSIS.
bo; vM taken directly to luJgitigs, put to b«d, and n dose of morphia giv«n bint.
llth. — Drc^Ming rctiiovi-d mid icnpplied. lklo«t cxcellviit con- dition in every way.
SOM. — Oiiio to clinic with cxtunsion-braoe, wliioh v,-ni4 npplicd yesterday. Motion good ; paesire motion ordered. Retuntvd to hio bouiv iu YorkvlUe.
January 12, 1S"4. — ]{ji8 for a week past complained of pain, particularly for the past thi-c« days. Coniprewion in axis of liijib gives pain. Extension gives relief. Knee^xteneion instra* ment ordt^n.'d.
April tti. — Boy walked into my ofQce witliont crntchcfl. In- Btmmciit readju&U'd. SiilTere none from knee, but bae dymptoma of "cliills and fever." Live« near the " Vmulerbilt improve- ment,'' ' Kinetietli St]«et. (Ordered i|iunine and iron.
Tut. m.
fm. »t.
JuM l«f.— General condition good ; Rlill tender over lower
insertions of lateral lig:ament!i. Inetramont readjusted.
' Tba " VMiUrtilU ImproTiiDeDt " haa nfrrnee to ib« tlnkiog of tbc Fwrtb Atcdiw Railroad.
CASE.
409
23^. — Bof doing well. loAtruiucnt not removed, but band- Bge reapplied.
AutftiH 1«/.— Inetnimoiit removed; vmlk* well, with good motion, nboiit oiie-tliird normal freedom. {See ¥\g. 224.)
Cabe. ^'ibrufis Ancltylmh; Knee tuMtatttted ; UruutMnt; R«eovtrij With M<Aion ; Death from Typhoid Fev«r Thre« Month* after tlte Operation, — 'Willtitiii M., w^iA niitt.- ycnn^ tVom Auburn, .New York, cnni« to me November ft, 1S(!S, and gave thu following iiiHtury : About J un«, 18434, the fAlber noticed ib^it tlte lad began to drnf; \\\» left foot. He complained of no pain, and spiM.qiR'd lo liuvc nfarly perfocl power ovi-r tbv timb. Five or MX iiii»iitti8 Intel' ilie knee began to hwbU, and appeareil to be "^/W iTfVA wtter^ This condition coutlnued for about two yean. Gradually the owelling di»appenred. lie was treated at interval)! during the contiiiuancu of tin- trouble by variout) pbysi- oian». About two ycfirs since, tlie child was ordered lo go upon crutcbeti, no alti^ution bc-ing paid to the ooutractiun. Thu limb was tben nc:irty Mraigbt, but piuce that time the contrnetiou luu gnidu:ill.v iuoi-pfisod. For the last cightoen months the limb ban been nearly sa " tough and eound '* aa the healthy one, saving llio Cunt ruction.
The jMiiiitioa of ttie limb i^ ae follows : Tlie leg 'v- tinb-liixalcd backward and outward eligbtly. There is slight motion at this new joint. Tbe pntelta is appareiilly ndberent by bone.
CM. — Brs. Ilaiiiilton and KruckowuM-T saw the patient with me. While examining the patella, Dr. Hamilton thought he de- tected motion. Tbi« wax ren<lcred evrtain by the following ma- nu'uvrc: Dr. Hamilton placed his finger npon llie groove between tlte patella and exlernal coudylc, ivo tliat the itharp edgei; of the two bonus could Ite at the same time felt. I then made tirni preasare upon the inner edge of the patolhi, and the two od^ ol bone before mentioned were felt tti approximate, the patella slightly overriding tbe condyle. The opinion of the coufioltation was, that an attempt ithouhi be made to rettoro the nonuol posi- tion of the limb; that, under ana^ethesia, as mnch afi ponsible abould be done, and tbe limb retained in the poaition gained, by a eplint, or by estoiiBioa, according ae might be beet in practice.
9M. — Tlio boy was chloroformed, and tbe limb forcibly etraightened as ^r as poioible. While the limb wiu fimtly held in proi>er position, a weightHknd-piiUcy extension wna applied.
410
ASCnTLOSIS.
Tbo veeecU were prot«ct«<l by a sponge in tliu po]>Iiteal npiice. The supply of l)lnod to the joint was diniiiiiRhed )iy tlio pri>eeare of a hiuhII i^jHJiigv placed over the feaiorul arterjr atid conliiied liy the baiulaj^H.
3TM.— Made a teeonA opemtion. At this sillinp t\w limb was bnjiiglit nearlr fltmtjfbt, the hainfltrinf^s wtro |>n>bablj? broken. Tbo Huib was tixvd bj a po^turior leatlier splint. No reaction of itiipurtanoe followed.
JJcccmbtnr VJth. — The limb is nearly in perfect line. J'asaivo (t)ov«ineiit«« liavu boeii omplojed for two or three weeks. Pot on an instrument for angular motion of the knee. The buy left for home : treiitmeut to be coutinued under direetiuQ of his fnmity physician.
J'effruar}/, 1809.— The father writes: "TJa- knee had im- proved very inneh, when tlie boy waa eeized with tyi)hoid fever and died."
Case. Fif/rou* AnrAi/tosia of Zeft Kntt. — Calharine B, was admitted to Bollevne Hospital June 8, 1808, when die gitvu the following history (copic<d from hospital register) : '• She was eontined April 1, ISfiR, and remained in bed but two davft after. On the 13lh of April i^lie ^rst noticed p»in in the left leg and knee. Very soon the jwirt* became niuoh swollen, red, and very tender; at the eame time she had chilltt, fever, and sweat. She wa« coinpelIe<l to keep the bc<I for fonr weeks. Since her udniis- sion to the hospital, the knee has l>cen blietered, eonipr&secd with «pongce, and extundi'd. All thcee plana seemed to be of Eomu beneiSt. Pasuve motion, showering with alternate hot and rold water. Iiiive bucii employed with little effect upon the anchylosis. For Hever.ll months the joint has Uten atioh\lotic<l, the angle being about thus /~ —136"." There is at present but little pain in the knee, thongli she rays "it is wor«! in djtnip wi-nther."'
At clinic. January 6, 1 809, I made the following eouiincnt on the case, previous to operating : The hectic sweats, etc., lead to tliv belief that this was a »i»c of pyartlirntti^, but the litjutd luis since l>een nearly alt a1ji»ort)e<1, and it was prr>bnl)ly all synovia. The aiichylosia is at too gn-at an angle, and I sliall tlierefore try by britemmt to place it in a lietter position. The patella wfm* to be movable. There ix some danger of reC*xcitation of inflamma- tion by the hrtnerMnt', since hitherto all attempts at ettablithing motion have been attended with conaiderable reaction. There is
CASE.
411
one point, below and outiide of tlio patclln, whivli is etill tender. " I (to not tiopo in thui case to get motion," I nppliod tliv pre- {xtnitory (In.-s«ing8 us uguul. Ttio pat«IU wns iitarled off by bend- in;; tbc limb backward, slid then Rtraigbtening it. Frtie uiotion vfMs given to tbo joint. The kntsc bad l>e».x»iiK! ftb^iitly inveried ; tbi» w«0 lit rai|;)i toned by prceeure. Tbo usual drci^ingsof bpougcd And plaster and roller, with n poeterinr splint, were applied. Di- rect*^ absolute rest for ten or twulvo day*.
" 13M. — No reaction took place. I^verylhing proceeding i»ei^ fectly well. Patient liaa had no p«iia sftor the lin^t tbii'ty^ix hours (tucceeding tlia opcriition.
" iOth. — Extension no longer giving relief, naa removed as anneoesBBry.
** F^rnary Wh. — TlaiJ continned to do well.
**Ma'j \9t. — Has eontinued to improve; is walking witb the aid of astiek.
" l-WA. — Having left the hospital on n pa**, and ovcretaid licr tinio, elic w«» dii»charf!;ed to-day." (1882. — Ilcniains well.)
Case. AnehylonU — JUp; Recovery with Good Motion. —
Mii» , of lfudM>n, N. v., was brought to me by Dr. P.,
of Claverack, N. Y., November 27, 18U7, giving the following history :
AVIien tliree yoHro old, ebe caught; her foot in a hole and fell. She wiM able to wnlk home, bnt complained of ec-vere jwin, and wain confined to the bed for two ycani from that time. Dnring thtA time the right lower limb became strongly flcYcl on the pel- vis, and adducted acroea the upper portion of the opposite Uiigh. Previona to the injury she had been perfectly hctaltby.
Since t)he waA live years old i^ho has been able to go round ■>n crutchufi, and for the last sis or seven years has been able to ,tffx the thigh n)M>n the pelvis and extend it slightly, but cannot abduct it at nil.
General health perfect, and tolembty robiuit. Ktght lindj live inchcji shorter than the other ; that is. llic foot winiiot l)e brought within five inches of the floor (when tlie «outid limb ia straight), and it is very strongly adducted,
A line drawn fnnii the right ttdjcrosity of the i«']iiiim nrouiid the hip, to the anterior Kiijierior dpinous proecsaof tlie ilium of the same side, pafMMxl nearly three inch«a Uiaw the top of tlio tro- chanter major, which could l>e distinctly felt on flexion and exten-
419
ANCI1TL09IS.
sion of Uie Ujigh upon Uie pelvis, sliowing that a mu> joint bad been made iipim llie ilortiiiiii of liii- ilium, but, on (wcoiiiit of the fulductioi) of tlie limb, ^hc could bear an weigiit vpoii it without falliiif; on tlic right aide,
I put her uiwler clilorofonti, and, by modvrnte forco with my iiands, vL-r^- sluwly kii<1 griulually ubductixl the limb, Dr. Pliil- lip8 hohlin^ tlw [icKHei c|ni«t, when, Aiiddenly, t)iv tcnduii of the udiiuetur loiigus miuppucl oil with quite a loud noiKe. After r few niinutet) I wns able to ahtluet ihv tiiifjh to iK-arly a right angle with tbo bucly, tho pelvifi l>eing hebt still an<l tlie other limb hettig fltraijfbt, tJinwinj^ thfit tliv motion wii« in thv now Iiip- jiijnt and not in ibc lumbar region. The recovery from chloro- fonn wflji »low, but at tJic end of two hourx Aw could rite and walk with the limb Btiaight under her. She t^mild tyiiunfuriii/ ■bdiH>t the limb six incIUM from llio i-viitnil line of tlit' Uidy. It was now only two inches Hhorter than ila fellow, and conid nearly Mipport the weight of the body.
The patient returned to IIudiMin on the same day in a slcep- ing-<?ar, without v\]>cricnoing any trouble, having bven nirvfully bandiiged on ii well-paddt*d board, and, on reai-liing home, wa« put to bwl and fomented.
Dfcftnler 1*/. — I wiw her in Hudson; fonnd her j»erfwtly comfortable, and fhe had suffon-d no pain anee the operation. Tbero wa« a slight di»columtion niton the inside of the Ibigh. She h Hble to fex, mienil, and ahduet the limb, and to bear her eiitiro weight upon it without pain, if kIio \\a» gentle ^up)K)rl to prevent her falling, the muaclea not I>eing strong enough to sus- tain or eteady her body.
I dii-eeled that the limb ultonld be nibl>ed, slmmpooeil, and tluit faradisjn should be applied to it.
12M. — Dr. P. report*, "(.'aae Btilt improving."
Soptettiber, IS1J8. — Miss CAlIed upon ine. The limlM
are parallel. The limb formerly anohyli>se<l can now lie moved voluntarily in every dirix'tion, and over qiitle » large arc The knee of the diseased side if- c<^>nf>idcmbly above that of tliv Mund ^de. The right luril>, measuring fi-um the top of the troehanter major to tlie external vtaiteofu^y is one inch shorter than the left. This shortening is increased by the pcvitton of the head of the femur, so that, mcaenring from the anterior siipcriur Sfiinoun pro- cess to the Internal mallvuluv, the shortening ia two and a liatf
case;
413
jncbee. The discrepancy is made up by a thick cork-««le, an<1 nlie wiilks H-vIl with llic HHsiriancc of a cmic.
Case, FibitntM Anehijlotia of Hip ; Tenotom>f ; Brieem^tt; liewceri/, with Motion. — (i. W. S., nged fuiirtocn yean, ood- HiiltcU mo for IliQ tirst time, So[>U>iuber 17, lt!T:fi and garu tlio history of liis ea*e ha follows:
Nearly ten yeare beforu, lie was attacLcvd with hipnlisease on the left eidc, ax llio result of a full. The troiihle contiiiticd for live years, during which time thi- diiiease progressed to tlie third Bluge, ab8ceHM» formvt), were opened and disclmrged, ftinall pioces of bone coming iin-ay from time to time. No lai-ge pieces have over been diufhard^-d.
Al)nul five yean from the beginning of his trouble, while fanning, he caught and twi«,U^ hiit fool in a ro|)e. For ecvend n-eeka afterward he was unable to move wiihuut the greiiteiit suffvi-iii;*. }[c milNtetpiently improved, and became qnite sound and strong.
Ilcflltb guoil. Wcivw, in wfllking,y<«*r and a half incite* Ufi upon the left shoe. lie is nut easily fatigued in walking, nn<) doeti not comphiin of pain. When his trunk and the sound limb are in normal portion, the affected limb is flexe<l and addttdcd, the left foot fiillin){ upon the outside of the right knee. (Stc Fig. Si25, from drawing by Dr. Vale.) It is brought down to
a podtion permitting walking by strong tilting of the pelvis. It is poirible ttiat the second aocident, above nicDtioocd, niay have increased the motions of the joint.
Sfptemher 3SM. — Under chlorf)form, I divided Kuhcutnneously the tendons of the adductors (pectiueus, adductnr-Iongus, grueilis) and the tensor vagime femoris ; dre^ed the usual way, and placed in the wire-b reecho;.
Octobft Xat/i. — No inconvenienee hft« been experienced by the patient, lie n-as removed to-day from the wire-breechee.
19M. — Was allowed to ride out.
iU
ASCHTLOera.
DMembfr ath. — Now weara in walking bnt two and i liatf inc1it.« lift ti)>uii lliu k-ftehoo. Wtlks very wt-ll witli U; tbo limbs are parallel when walking, as flcen in Fig. 3:2ri, and lie is able tii flex the tbigh upon tlic polrio to a right angle (as iwcn in Fig. :i27), and also abdttct it (as seen in Fig. 228, from photograplis).
rio.m
t\o.:
Wn.tli.
Case. Anchyiofiv of fHp^oint fi-om liheumatio Inp$mma- tion qf Sewn Y^ari Staiulhig aiucfssfuUij frftt'-d. h;/ Trtiotomjf and Brieement Force. — II. II. R., aged twent^-ciglU, was brot^t to nie for trcntmcut in Jiiiio, 1861,
In April, 18,14, when twentj-one years of age, he ranglit cold by aleeping on dump gruiind in Califuniiu nbilv viigajfotl in niin> iog. lie was confined to bed alioiit a year with scute rltenio^itasm, which involved iK^rly all the jointtt in tbo body, bnt ut liutt Kittled in hii; hip, which became cootmcted and finally anchylosed (as seen in FigH. 221) and 230, from photf^rajilte). Fig. 220 ttliows liifi inuilo of nitlktii;;. with a wry high he«l on hii> hoot, and even with this Hiisiittanw )iu hat) to bend hi» epinv and other knt-e to ifnch nn t^>xtent as to compel hint to use a cnttdi in order to smcain liinieelf. Fig. 2S0 allows bis position when attempting to ittand erect. It will
CASE.
41R
be seen by tlie ciin'e in tJio lumbiir n^ou tlutt the foinur is nt riglit nii^W to tlto ]>elvii», nml liU foot ia elevatot) just tliirteen incites from tbe ground liy Hctuul tnuiiKureiui'iil. A mimlH.'r of cientrices mv on tlie ontside of the thigh, and the tissues Iwni-ath
fw. tw.
Flo. tM.
Pio. m.
lljem are attJichiM] to tbe hone. The limb U very fimilj- Jincbj- Inaod in position, ae seen in tbe tigurve, and luia been so for die \»»t Mivcn _vi'!ii>.
The man is roniarhahly miiscoilftr and rohaet, but fonii>laiiis bittorly of tlic strain ujioit liim in walking in hir. t>oiit jioiitiux;, luid ie anxions to have relief, even if his hmb has to be amputated. If bi» joint (.-antiot be broken up, be thinU« rutting olf fiix limb bij;h up would remove tbe stniin npon his back and enable hitu to walk much belter on one h'p than he can now du on two, and \a therefore very an.\i<tns to huve me perfomi aniputution in esse 1 cannot give motion.
June 10, 1861, 1 divided the tensor va|rinii! foinoris and fat<-ift, rectus femorifl, and addudor lon^iis, and with considerable diffi- culty nt luHt broke tip tlic adbciuutis around tliv joint aud got i)ie Umb in a very good position.
The a(lhe«ton£ iiiuHt have been moetlj by ostoopbytce, 3mA cx-
410
ANCHYLOSIS.
terior (0 tlie joint, as there wore n number of fnu:tiirc« with a Ktiuppiiig eonnd. When the mteoiilivtes were broken, the ox- tremity could be nt once exletnk^ iiikI rutiitt-d without i-ffttiaint
The limb was extended by weight and pulley, and tlie hip covered with » hirgc bag of ])oiuidcd ici- ; difrercni thicknc-«iie6 of llniuiel nere placed between the iee and hit* »kin aivordinj^ lu hia comfort. Very ^ight rcnetion followed the o|K-niiiun. The ex- teiii^ion wa£ kept up by weight ami pulley in bed fur fonr weeks; after tliat the lli]l-^pIint \vm worn, wliii-h enEtbU-d him to exetrise in the u])cu air with only the aB&ietance of a eane. Four tnonlhg after the o|)enition lie ooiild M-alk well without any iMietADec. The motiouii of hii> joint were quite fn>e and aluiovtt natuml, and the tinib wni of iti^ iionu&l lun^h, m eeen in Fig. 2S1, from pbo- to^nph, showing that there could not have l>een any deetnictivc inflammation or loss of i>u1>etaiico in the boucB.
C.t«K. Rffitip Cotiti-adiimji of Flexor and Addvd&r 2fv»d*t Iff L*ifi I'highy pivdftcitty JJtfoitftitt/t nmvtatiny Zitratim in Itchiatie ^'atch, and mmplicati^ with Ftht'oua Anchyionity *w<v ctvfviltf tr«ti«d bij Suheuttim'ous I'cnotomy and Jir!*tnient Ford. — C. R. aged twenty -four, iiingle, native of New York ; teaiuster for bardware^toru ; admitted to Belluvue Hospital, January 4, 1872, with the following hiMory :
About the middle of Jauuiir^-, 1S71, while attempting to lift A barrel of naiU into hit* wagon, he felt gometliing give way low down liis back, and at the Mime time a neverc pnin intiide iMith hip-joIniM and groins, hut mo«l severe on the left eide, Thia wan foUoweil in a few weeks by a bubo or swelling in each groin, and, Ai> he had a flight urethral diRchnrgc at tliie time, it wua suit- pected they were eympathetic with thin dillieulty, aA no mendoti WM made to his then attending physteian of the previous niuccii- lar strain,
He was sent to the Strangers' IIoBpital, March 10, 1871, and I am indebted to my friend Dr. F. N. Otis, one of the phyaiciaoB of the above hospital, for the following notes copied from their eaae-lwok: "On admission, the patient wanaatrong.healtliy man. In both groini! a decided induration exiete, slight Huetnatien on left side with tension. Mart-h 13th. ab^ew in tt-ft gnnn opened ; very Utile pus and some blixtd dim'liarged. Manh i;!lh. oi>ening was enlarged to prevent burrowing, and bul)o atufled wiUi coUon [my italic^]. March 15th, tcnderncw in serotnm on left side, with
CASE.
417
hard ewuUing oxtca<3ing front external nliiloiniiiul ring to the outer Bi<le of the t''i« tli!fe}vn8, and just over th« left cnu of lliu peois; wrv [minful to the touch, but giving no iinpuUe when oonj;bing, an<l iiiightly movable. Mareh 'MiX, explorative openi- tioo [wrfoniicd by Ilr. Otii^ Dru. BtiniKteiu], Sandis ami Subine, present. A »Erni^lit incifdon was made through the ei-rutmii on tho left eide, and the uiAtufl fairly cspustd. It was found to be closely (roiitieHed with n hernia above, from which it wng dvlachod by the (Scalpel ; the maw was bard, and at the lumu time very fri- able ; the linger penetrated it without much rceiirtance, and on eo doing H little puA escaped, A piece of the nia£8 an tn<'h long was reeerved for cxnminutioa and found to be non-uuligimnt. The wound WW BtulTod with lint." The daily record of the case is very interesting, Imt loo tedious to bo inttcrted here. I run otdy »um it ap by saying Iliat he had exeesoivu tiuppurntion, hectic fever, an<I great proHlrntion, followed in a few weeks by acvcre mu«cular eontrtctiona, and on the 25th of April the notes Mate that "the thigh ta drawn nji at right angles to the binly ; he m nimble to relieve it; motion in knee perfect." Kxtcnaiou n-a>i appUud at various tinicni wilh difTerent wcighta, hut could not be borne on account of pain produced, Juno lot, the notoi« statt; "sinun has healed; hia eonttition iii> pitiful, being unable to extend the h-ft tliigli and leg. which is still lient nt an angle of 100' with the body, and aW addnctcd no ihnt the knee pulntii out to the right tide." An extensire slough formed over the left trochanter major owing iii the extreme prwwnrc of it agaiiiHt the soft parts from tlie rtroTtg adiltictton of the thigh. October ITth, "Diuti^ hiu tinally healed; patient n« ati-oug ac ever. There is great deformity of tho left lower extivmily ; wholu pelvis x* obliiitie, left side being the highest ; the thigh still Hexed, bat not so nmoh as previously, sad I» drawn over to the opposite side. There it tonic oontrao- tion of Uie adductors, flexor and hamstring mnecli», much more marked in the foriner. 1 )im^hargod."
When be presented himself at Hellevne Ilospital, he was care- fully sketched by llr. Leroy M. Yale, from which the engraving was made. {Sf« Fig, ii33.) His limb could be <lrawn nearly paral- lel with the other, but it was done by rotating tho entire pelvis on the opposite acetabnlnm, and raising the crest of the left ilinm nearly four inches higher than the o]>posite fide.
Januart/ 10, 1872. — I operated in the amphitheatre of Rellevue, S7
418
ASOnYLOSIS.
in the preaence of a )&rge clasn, and a numtier of phv&iciaru of tlio city, aiiiuii^ tliL'iii I>rti. J. C. Nutt, MvIlvaiiiL-, Uunn', und others.. AIj- hwiise-surgeon, Dr. Cusliiti^, liad previoiwly fitted to tiio ri^ht^ side of hie Iwdy » plnetcr-of-Fariii model, extending from his uIIU to the foot for the pnrpose of coiinter-exteni>ion, when the ttbdnction should Iki ap|ilit'd Eiflvr thv upvniliuii.
Ether \rm administered by Dr. Yale, when I divided the gra- cilis and the adductore subcutaneously, cli»e<I the wound n-ilh adhesive- pls^tor, and applied a flg;ure-of-$ nUlisr. Then, laying bini on \m )>ark and placing my kneeo on either ilium to hold bit pelvis, I forcihly hrokt> tip the rt-muining sdhceioiiii ami sue in bringing the l!iii1> into poditton. AdlieKivu plaster for exten- fflon was secured to the whole limb by roller, an<l the pIa«ter-of- P»ri8 mould fiwtened to tlie right side of the body nnd ky by an- other roller. The patient was then secured in IkmI, and exteosion
ru. m.
no-i
Flu. ISL
and abduction kept up by weight and pulley. Ice-bags were ap- plied aromid the hip.
The wotmd healed without any iuppuration, and no nnpkasantj 8ymptum« followed the operation. V
Fehruary 23, 1872.— Patient walked from my office to tli«
ANCHYLOSIS.
419
photf^nptior'e, siid bad Figf. S-ltt uid 250 Mlccn, irliicb show bis present portion, as well aa bis power of motion, piarticulurly lits Ability tojlEsr aud abdu<4.
LECTURE XXVU.
AHCRTLOBtS (OOKTISrKD).
hottj or Tnie AnclijIoRi*.— OixrUtoa trhM pMHtit «i llir ni|i-JoinL— Cm**.— Bony Aiiuhyloai* U ttra KiMtnloIiit. — At the Elliow-JoltiL— Cue.
GKyrLRUKs: At mj last lecture I gave you tlie Bymi>tum8 and treatment of inlni:, or til>rou», iiDc-hvloaiK. I will thie mum- ing invite vour Attention to the HyraptoiiiR and treatraent of btnty, or trae anchylo^e.
In eh6e» of complete, or bony anchyloHis, the deformity is ometime^ so grt-at au to ruquiru com^ction. To accomplish tlus, etioti with the saw is alMwIutely necessary.
W« will tiKt study bony ancbyloniK lu it occurs nt (he hip- Joint,
It is well known thnt Dr. Rhcn Parton, of Fhiliidelphia, first operated fnr the relief of a deformity of thia kind in lS2fi, nnd lis operation wiis followed hy a perfect result. Ho operated !>y nakiRg a V-^ection in the shuft of tlie bnne, and Iha^ bring- ing the luf! from tliat i>oiiit down parallel with the other, nnd ob- taining an iinprfivcd putiilion. The late Dr. .T. Kwaniev Boi^era, of tliis oity, ri'pcnted this (iperntioii in aiiotlier arnv, only higher up on the shaft of the Iwnc, with equnlly good retiults. I modified riartan'a openHion in 18(J2, liy tiinkin;; i> curvi'd Bft-lion of the fetnnrahove the trocltiuiterininar, and a sti-aiglit Hection a Tew lines below tlio first curved cut, thus removing a block of hone.
My objeft was to go above the trodianter minor, so as to
retain the insertion of the psoas RUignuM and iliacus intcrnuti
moBcles attached to the lower fragment for tlie purpose of fiexion :
ctnd hy cutting out a s«mi(rireufar pit-oc thus, o, witli its t-oii-
f«8Tity downward, and then rounding off the upper end of the
lower Boction, I would more nearly imitato the natural joint, and
420
ANCHYLOSIS.
give the patient a fair civance for motion at that point, with ' danger of th« jwirU slipping hv «icli oilier when lie walked tlmii th«r6 would he if I eul out a panilU'logrum or a V-*li,i]ied piece.
TliiH opi^rittioii I have niadv in two ciiees, and Ixitli resulted in jierfc(-t suwBBs. Tlio fii-st raso is titill living. The otlitr case died of anollivT di^i-JiKu eoiiiu iiiunths aflvr the operation, luit live<l long enough for Xatnre to make an entirel,v new joint with cajieiilar li^aiiiL-nt, svnuvinl nioiiibi-Hiie. und a d»ul>le ligiiiitentum t«re!t, which is neen in the c<pecinien liefore yu\t. (fier i'l^. HH.)
Dfr. Ad&ni«, of London, haa very much Himplitie^l thi» o]>cm> tion iiv making a simple Huhrutmieoui' i^ingk- »ucti<>n through the neck oi the fuuiur in theKr angulur defonnitieit of the hi[>, with very iiatigfactorj' results. Dr. Hands, of this city, \iMi rcpcaliKd Br. Adiuno'fi o[>i-ratioii, willi the rewult of a movable joint. Reatuinin;; aj>riori, I wuidd »u]ipoi^ thHt by the »inj;Ie M.-ction through the hone, s1Uion>;h you might by it remove the deformity, you would bo in danger of effecting a cnrt* by ani-liy]o«i#. lite caoc of Ur. Sandit, and nome of lho»e rep<irted by Dr. AiLmi^ ««em to dis- prove this position, but sufficient time has hardly i-Iapsed to judge whether they may nut after a while become anchyIo*e<i, allliougli in an improved position.
Tlie plan of my o|>cration iH fully given and iUustrated tn connwlion with the two cases here appended :
Cask. vXnch'jitaUof both IIip-Jf>in(ii f Tenotomy and Brise- tneni J'wve in one, and in the oth^r fCxKCtion of Semleitvular Seff'ii'nt (if liinte aiovti Trocfiatitfi' Minor ; Hecovery irith Arti- ^fial y»*V(A— Robert Anderson, native of Lexington, Kentucky, Age twenty-«ix, war admitted into Uolle^-ue Hospital in May, 18418, and gave the following history of himself: During the summer of IS+D, when fourteen years of ngc, he watt an-Uftomed 1" go in the river every evening to ewim, and on one occasion remained in the water some hours, hax-ing prcviomdy taken very ecvero exercisu in rimning and jumping.
About tlie middle of September he waa taken with a <]h11 pain in the right hip. which continued about one week, so gradually and iinperceplibly deveIo[HHi that the exact date of conunenee- ment ia not knon'n. During this lime he continued in attend- aitco at achool. and enjoyed the nsnal sporta and game* of kiit aehoolmates. One day, after having exercJM-d more freely than UMinl, he waa attacked with fever, and tlie following day etupor
CASE.
431
set in, whicli )iut«<l nrjirly three w«ek«, witli tlie exception uf Enterviila; when aron»Ml liy (iio family, wi« totiilly indilTi<n>iit to nnytliini; that trniiepircil ai-oiiml hitii, except when thus diverted hy hiA f riemls. All thta time he eiifiercd lUtvitM) piiiit in thv right hip, which was ))liur]> niid litnt-in-itin^. The hip was rett, Iwt, aad greatly swollen, which extendiHl liaif-way to the knee.
Attlio end of ft munlh the Hwclliug had much subsided, and the pain very greatly diiiiini^ioil, though when moved it vriia etUI very inteiiMs — of the uiiiic ehariKter felt in the hip, and never at the knee.
About this time begun to hnro pain in hip-joint of left icicle, and also in the knee, which was dull, and never of tliat Kliarp, hticinatinfr nature whii-h ho itutFeretl in the other joint. Thi» continued two months.
Ten day« after Iheeoiumcnccmcnt of tlie disease, pillows wem pla<-ed imiler his knees to relieve the pain. These were iacreuwd in thickness ami eontinuetl all tlio time he remained in bed, whidi was »\x months; al!<o during the next six months, whenever he was in l>ejl ; hut during thi«i latter jteriod ho t&t up occasionally in a chair. From the position assumed <hiring this prolonge<l confineincnt, tlie leg:< were flexed upon the thighs and the thigliH upon the pelvis, and have been immovably tixod in tliut position ever since. Had occiuioual pains all tliis time in both hips, Imt most severe in the right.
At the end of two years from date of attacU, an abscei«3 formed in left groin, whieli remained and di»oharged ptis for two vwiiy. AbscOBMS al»o fonned about the right hip ; one beneath the gluteal muscle, and another near the anus. These diwliarged very froely, mid eontuiuod ojwn for nearly a year and a half.
At the end of the Hrat ycJir, began to use crutches — compelled < two them wer ^imv. I-'or the laM six or eight years, goncnl
1th has been perfectly good.
On admission he had ancbylo<sis of both hijie in the position seen in the (igiirea 235 and 2311. from pliotographe.
The left thigh was immovably 6sed at nearly a right angle with the pelvis, by bony cementation, or trite anchylosis. The right was very firmly attached at an angle not ipiite »o acute, and by a very careful examination I thought some sliglit motion could be detected, which indicated tliat tlio atlaetiments wer« fibrous in ohamctcr, or at most wore oeteopliytee only, and external to the
422
AXCHYWSrS.
joint, and that tliere was no a^latinatinn between tlie fmonl liMid and tlie accUtbnlmn, whereait ctie opposite stdv lux-nied per- fectly cemented togetlitT. Ilo could not walk, except by whirling liiniwlf iit ^eiiiic'in'K'v', tiriit on one leg ne n pivot, »nd tlicn the other — or else by swinging himiielf on bie crutches from the axilla. In order to get Iwth feet u|K>n the ground at the tJiino time, hb bftclc wiifl carved innard very luiicli at the sacro-luintjar junction, tlie left knee' dexci) nl an angle about furty-1!vc di^^t'S with tliu
FM.«aiL
PM.ni,
thigli, and Uie right side of the pelvis was Home inetice liigher than tho left. Ho could only nit by awuming a most awkwarrl poBture, half-rerlining on hie siUo npon a couch or sofa ; and, in lying down, was curled up either on one «idc or the olber, or, if upon bis back, he had to be supported by piUuws nndiT his knecK and under Uiv hinibiirvurlcbnc. In fact,hewii8 thcaioeit piliable object I ever saw, and one that would excite the e%*niputby of any Burgeon.
Oil the 4tb of Ifay, I divided subctitaneouely tbo adductor DiU8cle>s the rccttit), tcnaor vaginffl fomori«, and femoral fascia of tlio right liip, and, breaking up tlie adhesions by some coneidcr- able fon?e, obtained very good motion of the joint Extension waa made to tlie limb by a weight and pulley, and the hip cnvel oped in clutb* wet iu cold water ; uo seriouH trouble followed tbe
OPERATION FOB ARTIPIOIAL niP-JOINT.
Operation, and in six weeks lie could flex and extend, abduct and adduct hiH ri;;ht limb n'itli i-oueidcnible freedom.
On the lltli of June, lUtii, I removed a ^emii;! rcniar flt^iuent
of bono above tlio trocluintcr minor of the left fcuiur, for th«
ppppow of Gfllabliftbing a new joint. Drs, I. P. Batchelder,
Woodhull, 811(1 Ortbonie, of tbiseilv, I>rs, Hooker, of Jt'ew llavcu,
LCttimectJcut, Iliclilx>nie, of Mn^at-tiiiHettti, and Dr. James 8.
' Orcen, of Elisabeth, N. J., were pmitent at the operation.
The plan of thi.s operation will be seen in the Annexed figure (237).
Tlie dcMcriptiun of Uio opcmtion niid notes of the ca«e are taken from the boepi- tal record», which were kept bv Dr. Shaw, faotis&«ur^>n ut that lime, and at preseut in tbe Unite<i Stutei* Navy :
"An incision of about iix inches was inado over the troehanter major, in the Iftxift of tbu limb. Tiio cut was slightly lu- nate, with Ihe cnnravity looking downward. The tips were then sepamted, and tlie deeper structorvs, including tbe periostenro, were detaclied fnun the l>ono.
" A curved instrument, amiod with the cimin-«nw, wai* packed around the bone be- tween the trochuiters, and the femur first ■awn tranAverBely acroM. A roof-iibspal piece was then sawu out of tbe upper frag- ment.' The limb WAA then put ui>oti modernto traction, loogt- tadinal and liitcral ; thu margins of tbe wound approximated hy adhesive strapn, an<i cohl dresaingit ap]itic<I.
"JuM lUfi. — Wound begins to suppurate, and looks very well; nocutislittitinnal citcitemcnt.
** l6tA. — lie tuu ronsiderable pain in tJie limb, and baa been Iliui1)le to sleep. Kelieved by increit.'te of oxtcnnion,
"SCWA. — Futient finds tlint puin is relieved sometimes by lesft Mtcnsion.
" July HA. — He has toss pain ; purulent dischaige free.
" Se//tetribt<r Ut. — Since IftHt rejiorl patient hu experteDced no
' In mj MCmid nporatlon, I tiaacd Iho ourvnd NCttoa flrat, utd nhnuld (dTltC (lu opanUoB 10 b« ptHormcd Sa tlul waf, for rmodi >hkh arc Ibcn ^rtu.
Pitt. m.
I. Iliad af ftnour: t. wodiai- Mtiiu>h; 1L iRichvilariBlDDr; 4. Hm at liuwnlan nr eapm)u UnnwDl (Tuublfl; D. tMiliMi
of pAnO* mM' *ll^ U1VU« LDlrf'
iiu» imiirld: Oh Uua uTi^iifv^
•kOod; «.t^ iteCM IUi« tiid>- tttlog nnotbig off of Inw tnjrnioM iltM mooTol of tt*
WCnvnl.
434
AMcnTtcms,
tintowaril symptoms ; discharge from vrotuwl is now very alight. All extension i* rottioved, ami he begins U> ext ny. Ocuvriil con- dition verjr good, and has improved very niucli iu Heeh since iuIiiii»eIon.
" Ocfober lat/t. — Sini?e liut report patient liaa lipeu n-nlklng oronnd tho hoftjntnJ on erutdu-it, wlii<.-li had to bu Icngtlietietl hovi'd inches, as he is that much tutler than he wa.i before tho opemlion, an<l IB now cjiiite straight, u.vcept thv lateral curvature of thu lower Imnlrar vertehrii>, which I'sinee one itide of his pi^lvie mure thnn the other, tiinl itiakiv the right leg apparently ijiorler than the one from whiih tho Augment of bone wii« removed ; but tlii^ is uAeily rcctiticd by « higher heel on that side. He can tit down in a chair, and get up without ii«de.t»iicc, except Hiieh ae he ob- tains from big crult^'hee^ To-^Iay ho walked into the amphithentro by tho aid of his crntche^, and exhibilt'd himself to the class, and left the inttituliun well, and witli very good motion at both hip- joints."
About three veeiks after he left llie hospital, he vras attacked with ncutc pain in the region of tliu wound, which be(«in« in- flamed, and floon ftiippurated. In a few dayn a small wmicitx-n- lar piece of bono came away, and four days after another similar piece; the two tiigether making ahiiont a ring, and seemed to he exfoliations from tlio lower fragment. All the pctin immediately left bin], and the wound healed in a veiy short time.
Mr. Anderson remainetl in the city until late in December, when lie left vei-y unexpectedly for Kentucky,
The night t)efore lie left he walketl to my otHee, and eonld go up and down the etv\m without any dillii-nlly; couhl stand on eitlter leg withont crutch or cane: could take a itep wilb either fool twcnty-scvon inches, and, when he supported hia body on his erulches, could abdnct his legs so that his hwl» were thirty-six inches apart. Jle could cross either leg over the oilier below the knee, without aMiislance, but could not eroes them npon the thigh.
The following extract is from a letter of hia, dated the SOtli of Januani-, 1S0:J:
"My le^ is getting on famonaly, since I eame to Kentucky. The first day after leaving New York I grvw very tin-d. but con- tinued night and day until we arrived at <'inoimati. I believe that when I got to Cincinnati I was frcslior than when 1 started. Wo were in the city about half a day, and then came on to Lexington,
-Bbdd ftll night, ftiid a^min rt«uriiv<l our joiiraey. So far from being exhausted at the end of tho trip, 1 eturti.-d next luoniiitg in A bogg}' and drovuMOinu twenty uiilvo. I think, if I had been
I eompelled to tnvel a tlioiisaiid milvs Wfurv Ht^jppiii^, 1 could almost have ()»nc-vd u jiff At llie teniiiiialiou uf the trip. Itnt to »]>t!ak serioiuly, I think I am doing \GTy well iudced, and my leg gaiiu ttruDgth contiiuialtr."
V\g. 338 U cngra^-ed from a cart4de-}n«ite, which wae i-cevived in a letter dated Sprinfr Station, Woodfoni (\>»nt.T, Kemncky, April It, 186:J, in which lutter ho et^tu^: <'I c&n now 'rouf^h it' a little witliont apprehension of hflving to Riiflvr for it aftenrard. . 1 ean be;ir in}- whole weight on mr left leg wtthont inconven- 'Imce, and can walk vt-rj- well without otlier assi^tniiM- limn n wa]ki»g«tick, and llw improvement is as great in a month now, as at any previon* time."
Ca«e. Anchyloau of Ltfl Hip, Section of EUiptic^ Se(f- meni of J^emur afxitv TroelMnUrr Minor ; Roeovtry, with FaiM Joint and (lood Motion. — MiM Sunan M. Loeee, of Buffalo, New York, age<i twenty-four, of healthy parents and of a rohinit and vigorotiA euni^titution. wm attiieked with pneumonia in March, 1$S6 ; attended by Dr. F. II. Ilamiltoo. After three weekj» went
ANOHTL08I9.
dovm-Htairs, conlrarv to tlie nd^nce of her pli,T»icisn. Mict tbe fol- towiug liny wiw nlliK-kod witb mt«UMC pniii in tliu li^ft iiip iiiid thigli, which vas ooiiMant, pereUtenl, anil most severe for Hereral niontliB. Shu diil nut full ur rtx-civv anv injury tluit nhc wne aware of, but it vna mppmeii that aUe must hare nrennhed her hip in eome waj going (]own-t>tair«, an «h« vttui very weak and wi-nt down witli- ont any ajsiatanoe. During the tirst few weeks her leg was Blmight and could not be flexed, abducted or adduetcd u-itliuut inteii.'te tuiffering. Bed-aores )>y this time had become eo exten- sivD Mi to make it imponittvc to chaiigv her {)osilion, and in doing this her limb voa forcibly Hexed at the knee and hip, but frith the mo«t iut«nt)(t pain ; and wlit-n flexed in this poiiitiuii it rould not be extended ajj:ain without the greatest suffering, and waa therefore permitted to remain in tlwi flexed pooturc.
New aloughs appearing over the right trixihanter, Htie wba placed in a largo chair and was not removed for two months, when Bloughing oceiirrud ovor tJiv tuber i^chii, and at the extremity of tbe coccyx, and she was again compelled to afdumo tli« hori;:ontat poiution, and, being forcetl to lie upon the right side, tbe left thigb WAS tlirown over the right, in a flexed position, and thus l>ecanie pennanently ami perfectly andiylotwd, at the vx])ir«tioii of about Hcven months from the coiiimenceinent of the disease.
Xo local iipplicatiou wait made to the hip, Imt the pain and oonHtitutional diflieulty were combated princijially by niorpbine, and no extension was applied to prevent the muscular contraction ami deformity. When »he recovered, her left thigh wan |>ern)B- nently flexed, at about forty degrees with the pelvis, and strongly Ad<hic1ed ncniss the lower Ihinl of tlte right lliigh, an seen in the accompanying drawings, which were taken fruin life. Fig, 330 rcprcMintfi her standing ; F'ig. 240 in the act of walking.
In the erect poetun;, the heel of the left foot was ten and a lialf inches from the &onr, and on the right side of the right leg. In attempting to walk, it was brought to the floor, still on the right side of the opjn>»ite limb, or cross-l<^rgeii ; and was matUj to reach tJie floor by a remarkable cur^-ature forward of the lumlisr portion of tlie apinal column; but walking was attended witli great fatigue, and a peculiar dull pain in the lumlnr region. Uri- nation produced constant excoriation of the liinbe, roiniring great care and trouble in drawing a handkerehief or soft rag between the clo«ely-compre88cd thighs, to keep tlicm clean and comfort-
CASE.
497
^l^lfRk Several efforts were made to insert ft catheter, in order tliat t6e urine iiii^t 1»e te<l oS witlioat irritating her UmiM ; but it wim iiitpo«.'iit>lo to intfort tliu finger eo iw tu reacli the orilice of ttie
rm. w.
ru-Mo.
nrctlirft, c-itlivr from ttiu anterior or [wsterior position, ftlthough every effort was made, and witli grvat perseverance.
Sim rL-ni:iined in tlm condidoit until tli« dUi of November, lHt>2, seven j-ears. She came to New York and placeii lieraelf under Uie care of Dr. C. P. Taylor, in tlij fall of 1801, who tlii^'tt^lit tlie am^iyloBis was simply fibrous and cnpfthle of lieing n'lii;vi.-il by p.issiw niovvintiita. Dr. Van liuren hiw hvr at thia titne, an<t di^j^ioitticated the caea as one of truv bonr anchylosis. I saw her in April, 1802, in lunsiiltiition with Dra. Taylor, Pefliilea, and K. Iax Jones, and eonfiniied tlie diagnosis of Dr. Vaii Itunin ; but it was tlioii^iit by all present that I might powihiy break up tlie adhesions if 1 preceded the attempt by section of the tendons ot the contracted uiiistleft.
Accordingly, on the lOlh of April, tsuatcd by Drs. Penalee^ Taylor, and Jones, I divided, aabcutaneoualy, the adductors longus ■ud magiiu«, the grnc-ilis and pcctinou^ thu rectus, sartorius and tensor vagina: femone, and immediately closed tlie womids with adhesive plaatcr, and applied a firm roller. Ku hntmoiTliage ful- lowud the operation. The pelvis va« them firmly secured, and every effort was njado to give motion to the joint, that was con- Btstont with safety or prudence, but without the alightert benefit
whatever, and wo were all sntii^tM] th«t sn cnliro Hcdioti ot tlte bone by the saw was the only way that tlio Umb enukl be iiiov«il irmn iu &exe<i and tixod position. The patient was under the fall influence uf ehlurofonn, administvred by Dr. Jones, and was entirely intieiitiiblc during the wliute o)>erKtioii. 11ic wounds healed kindly in a few days, witliout euppuration, and she waa then in exactly tjie mmc i^mlitiun a« bIic wii« previuiiH tu the opera- tion. Afl the weather was getting warm, I determlnet) to leave her until fat), and then iniike n MM.-liou of the bone abuvv the trochanter minor, and give her s eliance to fonn an nrtiticial joint, eimilar to AnderouuV cam>.
On the 4Sth Kovenilier, IHiiS, a^Med by ProfsL Pcaiilee and Rapliucl, and in the preM^ncc of Dr. J. F. Bat^holder »nd Mr. Doane, medical ijtudent, 1 performed the folltiwing operation : The patient Iiitving been put under the full influence of chtorofonn, a longitudinal in<-iflion nix inchet^ in length vm miide over tliu tri>* chanter major, commencing jutit above ite cre&t, and Os near afl possible to itit centre, and eitrried directly down to tlio bone. About the centre of the ineUion I made another at right nnglee to it, in the }irMtenor t1a[^ but only carried it through the tegument* ary and aiii\to«e tis»ne and the femoral fawia. The Made of tlie knife wiis then laid A^dc, niid, with it« handle and an elevnt<>r immo- thing like an ordinary oyster-knife, I carefully peeled off the nttachmenl8 from the bone, on ita anterior Kurfaec, itntil my fore- finger poiild reach the trochanter minor in front. The same thing wati tlien <lone on the jiutitcrior surface uf the bone, Hud the two fingerscoidd then«irround the l)one, with (he exception of a tliin, firm fascia, between thiin on the front. Thie wasremiily [wrcwl by a steel sound, curved to fit the fcinnr, at this part, and a cluiin- Mv was then dntwn through above the tn>ct>ant«r minor, which eouhl be dialinctly felt and wa^ my guide.
About hiilf nn inch above it I eotnmenccd to eiw, and carrying it first u/>itKtr<i anil outward, then outwanl, and tlien down*e*trd and outward, 1 made a curved Bcetion «nlh its concavity down- ward, thus X — N .' Tlie eaw v:^ again paiweil around tlia bone,
I II win !■• (ri'n (liat in (hi« kmq I nTT«rM<d iLe <wdw «f the >«clkm of Iht bois fi«m what I illrl ia A iiiWnKiii'ii oaIX^ and mada Ihctvri'nf MClion firtl,»xu\\tkmi\A'\ ■dvbo Llio <>|ipriiiliiii lo l>« (lorfgnncil In thi* whj. » it i« mucb tmUtt, and jrou arc 1 innn> cciulii In make jour *■• Piili-r at tlir pari dislrcd whoi the ahan \» (ompMo,^ bcaldta hariiiy the linili la koep thv part* ntcodr while ibc Kftion it inadK XnA. tad
CASE.
4S9
DA at Am, and itiM>rtc«l about hh ci>^itli of an iitfili boluw titu first section ami tUe lioiie sawed Bqiiare off, at right anjifleii with liii; long (iiuiiiettT of the hnnv. The Bi-f^riiviit iJiuii rL-iiinvvd vios oi)o-4>tght1i »i an inch in front or internal nmr^n, tlire^toiirtha at itA nii'lille. mid nearly half an indi at iu external margin, m 6WH >u V'lg. 2-H.
Tlie bone was very Uvntsc in tvxturc, alnitwl obunmtoO, oB econ in Fig. 242, which ro)>n;genU the lower aoction,
Fn. Ml.
m
rm. aa—rifo a Lam snrim.
There was not more than two onnces of blood lost in tlie op- eration, and no ligature whs Qc-ccssiry.
The w(ntnd wiut lironght together bj two i>utiireii amt mlhesive plostvre, ex<-cpt the posterior ini-iiUoii, which was kcjit open by a lent of otiknta. Adhtwivu ptn-ntor was ajiplied hi'luw tlio knee, for the puq)o*e of making extension, and s rtiller applied toler- nbly finn, from the tuvti up, over lliv •.■ntirv limb, and around tho ]jelvi-i.
She was then put in bixl, tim foot of which wan mi^-d Bomo twelve inc-hi-A higher l]ian tlic head, and a pitllcy applied, over which & weight wiw attached by a conl to the adlieeive plaHtur, for extension, llio juidk^ a» in a cnsc of fmctiire of the thigh. Lateral exten^ou was ideo applied to the upper portion of the thigfi, to kwp tho iipjier end of tli« foniiir from civ>"ding »gninKt the femoral veswls hy means of a broad hand pa^ed around the thigh and aourd attached to itK outer aitpect, which played through a pulloy fixed in an upright by the nide of the bed, JH§t below the pclvii4, and a weight attftchcd. l^y this means the limb was broug)it in its natural position, parallel with the otliet' and ap-
II rfqiiIrM rtmn titllr dvlincj of niaiiipulallon to rttrj a oliain ttw in lli!« piMtllon
III tlio fUTxv rtigtiirod. It i» woll not lu ftdd to th« uumfJinlfoB \iy luvloft ■ raov&bia Iranp.
ti miv lioMli«d, wliT nol intka hflih HMnions cnncd t BMitwcll UixidlOcultto <lo 1) <rlili Mcuncj, wli«n <iiio mil of Ihe bone t* roovabk, aiid, m tha roiuuUng olTof thr \owtt sertlon It taotv tiiaph and tqualljt iMittuVtrj, 1 |a«fer it.
uo
AKCEITLOSIS.
parentlj of Uic mriu length. Tiii drops of morphine were given, with inBtnit'lioiifl Ut rejieat if nccewacj.
Till! f^'lluwing ri.i.-un] of the case u aa abstract from my note- book:
iVcrtwnicr 17M. — IIii« }iiid a very pomfortahle tiight; urinntcd without BL-aldin^ her linihs, for the lim liiiio ill seven years. No lia>iiii)iT)iagc, or much hont of limb ; pulse 94 ; com])!ftinH uf paiu . in the hut-k, otherwii*e perfectly wtOI.
11 i: M. — Pwiii iu tbe back very severe, just at the lower lumbar vertebne, which i» earned very mnch forward, and can only ho r*^>li«ved by ^Msmg well holwtenii up, and by mising tbe head ami phoubtenialmoHt to the sitting posture.
19tA. — Slept well all niglit, with only *ixty drops of Magendie'a Mintlon; pul«j i*-l, m\d only cdinphiins of her Iwcl:, which requires to be pres^eii freiiunntly and (juite firmly to niiikc her comfortable ; as it was ditllcult to use a bed-jian, and withont it the urine soiled tbe bed and i-xcorintud lier person, I drew it by the eatlictcr, wliieb can now be inBertwl withont the least diHieuIty.
IdM.— Wound conimenciag to supjinrate, at the tent, the rest of the wound nnited by Jirat intention ; removed the Biiture« with- out disturbiii;^ tbe »dheMve plaster: pulM; (M; bowuitt moved naturally, and, with tlte exception of pain in tbe lower part of tbe back, iviAs well.
DiTemf)'^ lit. — No particular change since last report; top- puratioR healthy snd not profuBC. The only complaint «lieDiakos is from her back, and tbe difficulty she has in nsing the bed-pan. I put her to-day upon Dr. Nelnon'e fracture-bi-d, which is a triple inclined plane, witti an ojiening for defecation, and it lua tnado her verj' comfortable indeed ; and the exteusion wiu ncctunpliebet] by Kintply flexing tbe legs at the knee, over the inclined plane, aa seen in Figs. 243 and 244.
This fracture-bed wna first coufttructed by Ur. Robert Kelaon, of tliia city, formerly of Canada, and for convenience and com- fort, n« well a" fultilling all tlie indicationa nK|uired, is the most perfect contrivance I have ever used, and I cannot speak too highly in its favor.'
' tn HuMclbuh** "Handbuch iw Chinii^HliDn," printed In Jnna, IMS, •111 bt rounil an tliDMl cnot doplSctte of K»tiran'« b«d cm pl«t« uili^ wUh ■ dMcrfptlon <n p«icv lOSA, M having b««ii cotwtructed by Werkfrn ; but, u Dr. KoImb iumIo lib br4 in 19X0^ we tDuoi glr* lilm th« prcArmce of jiricrlty.
CASE.
431
From tbe time tlie patient was pWed upon it until slie e»- rirely recowne)!, n period of neiiriv four iuoiitb». she was perfwtljr coiiifortublc ; coiiI<] be raiiied or depressed to an^ desired angle. SB often as required, witbout laconveuii-ncie, which greatly addcil
Fd». Ml.
to her oomfort, l>j- tla- change of poeition. Tlie wound healed entirely within four weeki*, except ft very emnll opening in tlio pueterior cut, whieb was at the moet dependent position, aud from which n Kinull dim^-harf^ of piu <>8enped ; tluH di:i<ib«rge gradually diminished and finally reaeed about tlie 1st of March, four months t]*ftor the oitoriLtion. Two i<^niAl1 pieocs of bone ««c»pod daring 'this tune the si;:e of a piiiVhead. For Bomo weekB before its stoppage the d!ecbarp> eonststed of oitly a few drope in n day, of a very peculiarly wbiriftli-vellow semi-fluid, of tlie consistency of tliick Marcli-wftU-r, and upon exauiiuftlion proved to bo nearly pure albumen.
\Si
lyCHYLOSI
After the lir^t ten iUy» fri^m tlionpenilion I iiimIc i<liglit movo- mente of tlie limb very frequently, in onler to prevent anrhyloftis, Hnd tWis wiM also juxoinjilislied by tti« cxtciiitiun, wlik-li kvpt the severed bones from coming In oiittact witb enelt utber, and tlitui prcvoiitod iHtgcotM iidhiMion.
I gntdnHlly inci-ea»ed the extent of theee motions, initil, nbout the l»t of lebritury, I ewiid tlux nnd uxtviid, rotates addut't and ahdncrt the limb with almost the freedom of a natural joint, aiid could alw) [)iv«« the boucx together with eonsider^blv force with- out pain.
On Iho 8tb of February. ISfiS, »hc gut out of bed for tlio first time — the limha are perfertly nyinmetrical and parallel — the loft nearly thruiMiuurtcrs uf iin inch shorter tliaii the right, when hor weight is jiut upon it ; but. when she titande erect upon the other limb, it falls down, and U nearly if not (itillv ae long as its fellow. I(y pressing it up you can shorten it n full Imlf-inch, and by con- cussion it gives a suiootli, cnsihioned feel to the hands, without any crepitus or pain to the patient.
F^ruarif 'iiith. — She begins to have some control over tluj
Fm. hd.
movements of hor limb by voluntary muscular contraotion, and can l>o«r nearly her whole weight upon it, A« soon in Fig. £45. The motions arc nearly as perfect as those of the natural limb.
CABS.
4S8
From tlio perfect Buccctw atUindiiig tbo oporntion in tliceo two cDMe of trtie unph^losis, and the. freedom fi-om all danger, aa well as eoee uf its pcrfumiaiicc-, I feci jui^liHvd in recommending it to the profvasiDii as A»fe, and am »itie<tied that it will become eetab- lifilifd as one of (tie propor opcratione in mir^rv.'
SiKii'KL. — The ]>atient progr«ucd rapidly* am) favorably dar> ing several weeks, Iwiiig able to bear Iivr entire weight on tlic affvct«d limb, with perfe<!t f reetlom in passive motion, and gradual increase of contml nver ibe voluutftrr movements.
Sho wai acquiring euflleient command over tbe Iiinb to enable her, as the ivsnlt of praetioe, to wmlk amund her room, the ex«r- ei«c conducing to the improvement of lier general health, ss well as to the education and development of mii«cleii whieli had long remaimt^l dormant; when, slwiit tlie Irt uf March, in opposition to my advice, she removed her tlannel^ Sho n.-maiiie"! with them off for Kcvcral dayx, and, on the 4th and 5th of March, being ex* pcmed for some hours to the intense coM then prevailing, she bad a severe chill, followed bv great difficulty in breathing, pain in the che«t, congb, etc, arising from eongtrKtion of the lungs.
Sh« neglectwl to sonil for me at once, and, when slie did, I wa» out of town, and Am refu*e«l other medical attendance. She grew worse rapidly, and, when I aaw her upon my return, I at once recognized Iter condition ait one of extreme danger, and requested tbe presence of Dr. Flint in coniitiitntioii.
'We found tbe left lung had become almost hc)>atizod, and for some (Uyi> no respiration oonld be detected on that flide. Under truiitmeiit resolution gradnally took place, with tbe exception of an abst-oM jn the upper lobe of the left lung, which Dr. Flint thought was the result of an apoplectic cffunion. Dr. Flint did not ot thi« time diagnostiL'ste tMbercles, but did at a later period.
To tbe pneumonia waa HU]>emddcd, in a short time, pleurisy of the left side. The uigont symptoms of the pneumonia were Mibduc-il, but the cough, which wa« very dirtrc-ssing, continui-d. There waa no expectoration at any lime.
Under a sustaining plan of Ireiitinent, witb xpiritt of turpen- tine locally over the hepatizud lung, slie improved, and I was en- oouraged in the hope that tbe atx^ceKA might become mieculated, and remain eireumM-rilied.
The weather up to about the middle of April bad been too ' 8i* Xr. Aitaaii'* improv«nmt on 017 operation, in Lecture 00 AndijrlMU, p. 410.
4M
ASCHTL0SI8.
inclement to Mow her tlic advnntagct of poeaivo out-door excr- I'ioe, wliiH), together vith nourishment, wna now coneiOeret] the [>rin(-iiiiil trcutiiioiit retjiiired.
During all tliis time the cough had remained of tlie same rark- ing, distrc««itig chariK-t^r, and uitliout exjiectonitiun.
On the !i!Ol]i of Aj)ril, ^he (.-oniplained of Bome pain in the vicinity of llic eicatrix of the wound left by the operation, luid the lower part of tho wound became inDamed and puSe<l out, altliotigh it had been ckised Beveral week».
On tho 22d, au abwfiut having formed, the wound opene<l, and ft 1011131 curve*! pieee of hone escj»|>ed, about oni^oiglith of an iiieli lOB^ ind of tho lliickuc-iw of an onlinarv prol>e, quite rough and ja^.
The wound discharged a little Woody pus for a few days, after which it gradually merged into the i«me kind of oily Quid as had exuded during eome months atibeequent to tlie operation.
ThU, in a (ow more d»y*«, began to diniiniiih, and gradually tlio wound again cloitpd, Icaring no tendenicai upon prctifciire, or mo- tion of tlie new joint.
She could again bear her whole weight upon the limb without inconvenience, and her connnand of ii« movements nialeriidly improvetl,
About the Ut of May bIio clmngixl her residence, and for* number of diiya iiuproveil rapidly in .strength and AeA), the prin- eipul annoyance being the cough.
On tlic 10th of May, having buitinc«» out of town, I left the ease in cliai^ of Dr. Flint, w ho preecribed, for the cough, codcia, fourgraim^ to eimpto xiynip, four ounces, with diredionH to tho nurac to give the patient a teaspoonful once in three hours while the patient remaint-d awake, but to discontinue it while ahe »lept.
During the night, as the result of larger and more frwjuently repeated doset; of this mixture than had been oiflereil — which ap- peared from the admiKflion of the nuree, and the small (juantity left in tlio bottle — tlie patient had bci-omc thoroughly narcotized, and subsequently eulTcred, for more than forty-eight huura, witii moHt alarming s)-mptoms of narcotic poiconing.
The utmost exertions on the part of Drs. Flint, Pea»lee, and Wcll*i, were required to Buslain life, in consequenceof the slomadi rejecting stimulants, coffee, etc.
Tho cough had now entirely ceased, and never returned.
CASE.
435
Orett distreM in tlie lun^ wa« cotn{)Uiiiied of, und [>arttiilly relieved by counUT-irritanU The Btomiit-h continued so weak as oot to retain even n teaspoonful i>f j<«d water.
On ttie VitU situ had rvouwrvd from tliv severe ejrtnptoms, when a rclaptu: utvurrtMl fnini tlie admin Est ml ioti of aimllier doso of the oodcia, in direct viuUtiuii of urdc-ra tliHt no more should be given, which it eeems were misunderetood \>y the nnrse. louring die Diglit the patient was viulcnti v delirioiLs, bur ecrtMnif^ aroudng And disturbing the hou«.'hoId until morning, when Ur. WdU AdminiHlerod, by inhalation. B &nia)l ()uautity of cUorofimn, which Ml onw wdnied the luiticnt, nnd slit- i-lq>t for wvimil liourew
I returned on the l-'Jth, and found her siill In a wild aiid dis- tracted state of mind, and cxce««vi>ly proijtratcd, the Blomach not having retained anylliinf; for itoine days.
The proocse of nntritiun was nvci!(««riiy xuspctidcd, and the patient wan dying in eon»o()uence.
The Htoinach liad Io«t all lone lut the result of protracted nar^ cotisni, induced earelecely, hut with humane intent, and slio wa«; now Bustainod by euoma.
On the Hth i*hc had rallied, and hecomfi quite cheerful, but had no rofullcctiiin of the terrible ordeal through which slie hiid p(ui»od. Liater in tlie day, while I wag fitting by her bed, ahe suddenly had two severe convnlsiMiia, during which her lower limbs were flexed at a right an^le, and i^trongly addnote<l, the left one requiring almost as much force to alraiglitcn as the right.
Hie nunte stated that llie patient bad had a similar fit during tlie preceding night, the limbs being fixed in the wnne mauuer for ft long time, and that when the spuem passed off she volun- tarily straightened] her litnhs.
On the lOib she sat up alviut an lionr, and, after getting back in bed, discovered that the wound had again opened and dia- thargwd a few drops of bW^ly itenim.
She pattsiol a reiuarkably goo<) night. »nd on the following day felt eo much better that fho begged me to allow her to take a ride the next day,
I tried to persuade her that she waa too weak, but ^e was quite importunate, and after I had left, iu order to tiwt her strength in view of tJio anticipated ride, abe got out of bed, and sat up in a eliair for two hours.
Tlie oxcrlion was too mucli, and elie faiatcd.
480
AXCnYI/)SIS.
I -wAt hurriedly summont-tl, and found her cold »nd pulseleo^^ csoept at tlie carotidii. Pupils miicti diluted ; jaws relaxe<l ; rettpi- ration vvr)' fix'blc »nd viovr; unable lo swallow. Brsiidy waB given in enema, but not retained.
Slivgrodualty rM-ovvrcd cunseionsiiefie and ubility totalk,whicb ftlie did rationalW. bul grew weaker and weak<>r until about nlx p. M., on Ihi; 1 till, wlion alio died from exhaimtioii.
Po«t^MorUm. — An examination of llic body whb mtde tboot thirty-eix hours afUT death, in the preeenee of Profs. Buah, of Lexiu^oti, Kentucky; Parker and Raphael, of Xew York; and
Pu. 3W.— a. II. a. a. rmpnSit Ut*nrat opiBtll and nnaetnl: h (i.ri>and tlRunHil ta >ill«Ui» «( UKuBibliiiu um; e, am^luioi tiMd Af U-mr tmlon. ivrmd «Kb aiillt^; A 4 >*« loeUboliun. fsnrcd irllb canll*(»i boUi Itiud with *}b«UI imnlma*.
Drs. Spt-ncer, of Wnteitnwn ; Batchelder, DewecB, Stone, Be^ nadii, Elsbnrg, Wells, Swift, Doyle, and Peck, of New York.
Thu body WHS extremely emaciated; the left leg being parallel witb the right, the foot lying in t]ie natural position, and wm
CASE.
437
found to 1)0 half an inch ^liortcr, aiitl admitted of fr»e^ paiuiive motion ill all directions wilhotit rrcpilation. Upuri opening tlie ihorss, ailiiosions were noticed of vurious portions of the pleura And lunpt, and a tnrge nlwccs^ in llie anterior portion of the up[K>r lobe of the Ifft Inni;. Two quite ^mall iilisceiifies were found in th« lower lobe of llie right Inng, Imt ncithtr of lliwni cunitnuni- oated vitti tbe hroncbi.
Then; w«« intillmtion rtf de|io«^it tlinnifrluiut the Mibetance of the npper lolie of the left tnn^, which, under tbe raicroeoope, voa dutonniited hy Dr. Dewees to be tuberculous.
Upon exAinination of the artificuil joint, it v,-m found to btt provided with a coinpl«t« capillar ligauiunl. and the articulating Hirfaeo8 were tipped with cartilage, and fumished vrith Avnovial memhranc. {Sm Fig. 240.)
TUiin: waH n very tunall eplculn of bone, which had cxfoliatctl from the lower section in thu orifice of the external wound, and wUch would have e^cnped in a few days. Four other email fihrillie of )>one, altout one-hslf inch in lengtii, and tlm thickncM of the lead of HI) ordinary pencil, wvre found attuchod at one of their extremities, by pcritisteum, to the margin of tlte new head of the femur; tlivir free CNtrciuttte« wero thrust into the tisene around the joint. They were easily pulled off, Iwving nearly
Fn. hi.
exfoliated, and <lDubtlci« would have come away aa tlio other pi«^-B lia«) done, had the jialient lived.
All th« other partH of the head and tbe new acetabulum wora Bmootb, an<l covered with cartilage.
Tlie fonjunctioii of tlie articulating surfaces was perfected by
"IM
AKCHYLOSB.
thu formation of tn-o round lignmi-iits epringing from the surface of the new acetabulum, and, hy their convergence at the eamaj point of atlAchiiivnt to the row caput fctoorie, fonned a new ligt"' mentum teres. (Stt Fijr. 24C.)
These convergin^f portions of the ligament were fau-etiaped, and nnited at the sulcus of the new li«id of the futuur.
A portion of the ilium, together with the cotyloid CMvicy, con- tainin;^ the utichyiowd head of the femur was removed, and, upon section through the original acetal>ultim and caput fentoris, only a dight line of domarkation wait diiicoverahle, the whole joint being fn»ed into one iwlid bony mtus. (&v Fig. S-17.)
Dr. Austin Flint, Jr., examined the specimen hy the tnicm> scope, and reports that the lining is true cartiUgc, and it is then^ fore as perfect in all its pliysiologtcal charactera a^ any natural joint.
The annexed diagrnm (Fig. 24S] shows the cartilage, cnritiee and celli), hd taken hy Dr. Flint under the microscope, from Uie artificial joint of Miss Lo^ee.
Wit}i respect to the case of Mini) ].c»oe, Itauer, in his work upon " Orthopedic Surgery," published by Wtlliaui Wood & Ca, ISCS, mi^tated the facta concerning tlie appcai-ancee found at
>.miii-
Fn. MK-CAmuoK, CiTRu* ucdCbu: ^. «miiwr. »tiilt« wittMOl oiUtL M,
die post mortem. On pages S.^ and 235 of hia work may be found tlic following statement :
"True bony anchylo^s of th« bip-joint linds ita relief in
CASE.
Rkea Barton's operation. I hftvc never had o.-oft«)uii to porfonn it, mid ran therefore offer no euggeations drawn from perMinal oxpericiioe, 1>ut it would iwm to inti that tliv uttcinpt at vsiah- linhing an artiticiAl joint at the line of dinoion U unattainable for twor(ia«on6: 1. An artitii>i«l joint could nuvcr givu a Hullick'nt sapport to the auperstruclure of the bod}'; S. It ineritahlj pro- tracts the euppuration, with itM irnpc-ndiug danger of pyutoiijt. Baj-re a few yeani ago pcrfornu-d thiti operation, as he alleged, with Huc-vess, but hie paltuut uuvorlhulues died a few monthu aftur of p>femi«.
" The appciinen derived from the caao did not euet^it the ae- aertion of that gentleman ; no cartilaginoua covering, a^novial lining, or a new (capsular ligament, luiving bi-t-n formtd."
I have taken imiiia to secure letters from every gentleman wlio was present at the />ogi-moi-ten exainination, with the exception of two who aro dead, and they all concur in the statement that there woa mobility, and that a false joint waa formed at the point whore Ecclion of tlio bone waa nmde.
The following letters, however, fi-om Dr. Doyle, Dr. Anstin Flint, Jr., Prof. Parker, and Dr. lliwli, Profeswir of Surgery in Transylvania Univonity, I regard as all that are neceasary to ptihli«)i in this place Id corrCL-t. any iniMippttiheueion ttuit may have l>een cntertaineil with reference to the actual re^nlt^ of tliat operation. The letters of all the other geutlomen have already been published in tlio A'eto Tork Medical Journal for January,
vm.
" BiitaBAinuK, New Yoas, AfrU M, ItSA. "Pwir. Satke—
"Dbab 8ia; In penulog tli« work of Dr. Ii«u«r on orlhojieiliR surgery I wMtomoirbat «nrprWd lu rend tli«r« (pa|[0 335) agroUowt: '8«jr«afeir jcon i^o p«rfonnccl ibia opemtion ' (Aitifioinl hip-Joint), * t* bo iill«|tod witli SUMM^ allhon^k his patlt^nt ili«d sbortly afti-r with pvmnin. Tbe BpMltnm derived bom Iho cimm did not proro ibo Htiertinn of ibat iKnll«aiiii : no c*r- Ulogtnous oov«i4ug. synovial lining, or oagwaliir ligMnenl, iMving betn forai«d.' Tb« qnnUtion refrrs to thfl oom of HIm Lowe.
" A* I fri-'iiientlf niw the pA^ent Bud took a pcraonnl iiit*Kat in licr ohm, I feet It ray duty ludbabiwo tlt»pul>llc»f Uietftlae hnprcnion wlilcbkU itai«- nuoitji are likuly t4> prodnce. Younm, tbi>re((>n>,lf yon dMm it propor, ptib- Ush tli« fuIlowUig fiict«i, to wliioh I can cl«arly levtify : Tklisn Suun >f . I.chmi, on whom yon [>orrorm«i) tli« oporHtion for anlflFld lilpjolnt. irns seen by me Mvi-rnl lim«c during the inonlli provionn to licr AeceMe, A* far on the operation wu conoerQed, It M«ined in every way a oooiplcu' aacceu, bat it
ASOUTLOSIS.
was v«rr svident to mo Uiat «lii> wu In tho last ttagt of phlliUa pulmoull^ ' \a coDMqaence or wliicli tier death took |i1bm od the ITth day of Hay, 1873. '
" Id conipnn? irilli suvoral oth^r medlnU men, I was praeot at the omoixir, which Kvcolcd imporlnnt factn, wtiii^b i;n Kroiwlj to aiintain not ooljr th* fMUiliitit;, but alH» tin- jiiilic* of tho opvrattDn. On opening tlio thoMS, llisi hings were found to ooniain a large anoual of tul>«mlou« depoKit, macb of) whielilkad brakoodonn, li-iiving aoreral cavitia*. Our altcotloD wna nait> turned to tlie limb on wbi«b tho ciperation bad bevo performed. It wm found to poBion llie property of \Mag moved witb uiiai' lii any directluo with- out cr^]iiCati(in. The nrtificiul joint waa tlirn dliiwrttxl down lo, and wat found to be f>rovid«d wiili a capsule, rery inueli riiwiiibUii)]; tbu capoular lign' iDcnt of tli« ftormal hip-joint, boinit cmnplotf and lined with a synuvia] sur- face. On ojiun'tng tho cnpnute to trFt an interior view 'if tito joint, we found (tie articular surfacea covered wltb nrlilage ami proi-ldud willi a doultlo tiguneDt, wliicb aeenHd to anawer all tb» porpooe* of n ToritaUe titcamentan terM^ Id order to leave no doubt an tu the lubatanc-.' on tbu artificial aurfaoei ' b«iog Irao cartilage, a portion of it was examined under tb« inlrroKopo by an emiuDDl pliysiologi-it of Kew York, and found to contain Mrliliwe-cclU.
"Tbo llgamcDt waa found to hn Mfiircaleil, having a ainglo origin in th« be*d of tho bono, and th«n Mp>araliiij and finding an iiucrtioo at two dlflcr- out pointa in the new occtabnluin.
" Tli« apcelinon waa takes from the body and I prepared It for prewrra- tioD. I alM> miido drawinga of It wlain fmb, and look it 1<> tho pbotog. raphar'a and bad a picture token from it, iu order, aa you rcntorked at tli« titno, that th«ru uiighl be no room for any one to think that the drawing* were Incorrect,
" Engratlniia made from tho pbotograptu v«re fborlly after pnblislMjd In the " Trnniuctiona of Ilie Muillcnl Society of th* Slut* of Sow York,"
"Now, the ooDct(ii>ioti nliich I draw froiu tlio caM in quMtloa is tliia : if Um operation tuftMdiit no well in a tuborculona laltjeet, how much better and more praplicublu would li have \>eva in n pcrfcctiy healthy penon !
'' Dr. Bauer iiiakii* ffrrat uiiKlnkcii in his H^^t-rliond a» to there being ntti cartil.-ifK'. "jnovifll liiiinR. etc. Hi^ Iuiowk oa dverr mritcon ought to know, that very oflen ctues are met with when arlilidnl Joiota are occidentaJly formed aa a con«ec|tience of non-nnion of frscturea, the diatal ends and prozl- nal c«lr«niilic« being wn-ered with true oartllago. Now. if Nature, under all tlie diudvantA^a of acoldental contingcnpicit, can form a new and nearly porfeol joint, how much raorc effective would be her reprodnctive powera if JudiGiansly aa^aled by the skillful rceonrcxw of art !
" In conclomcn, then. I feel juMilieil in ouvinK thai ibo caao of Miaa 1 w«* n tDConw a* for bk the opernii«n for arilflelal hip-joint waa «oaoenMd ) and It cl<arlr illiiBlrales tlie practicability of tho operation, and alf<-irdf a precedent for sltnilar operation, wbioli will yet be perromie>l f»r the relief of auSering haoianity.
" I rtnuiin, a* ever, yonn Imly, (Signed) "GwooBT DoTU."
CASE.
'* L«xnioT<», Ekxtvoxt, April ts, ISM.
"Mr VKAK Dootoh: Votin of the Utii of April juxt nicetT«d. I wu present wllb wvcrnl prufowlooal |[«Dtl«mco, Prof. P&rkor Bmonic the nnmtior, kt Iba pt»l mvrUm of four arliliaiiil bi|>Mut«, wliicli pntvuii MliBCKitoriljr tlial tli« pnti«nl (li«0 of tuberutiUr ooQmuu|)tioD.
" Tb« specimen d«nv«d from the amo otTorvd abcnatiful illunlrationof uti> fleUI jiunt witli eArtilugc, o*|wuliir, t^nuvial, euit lifsunivTituiu Hlnicturu pro- diieed bv tbe oporatioDsof Xalurc otioT onrffic^ "kill had pr^orcd the parts. Yuit mny romombtir, I poinUKi out Uio mtumrticuliir !i|!iiiii«iit4, one of wliiob hwl been MporatcU trt on* of lU alUwfaioenta, )>j the too lV«e maaiputationa of tlN limb bjr on« of th« sontlvmcD prMvnt. Th«M intorurticulur liKiuivnu were the nioat remarkable f««ture in the iterelopnient of ibu Joint ; kii<1 70U nay not bave furf oltvn nif remark to jroa npon the oxaniination of tlio rpcci- moB fohtei^aenll V at yoor olficv : ' IIow wundftrful and buiiutifnl vait Nstare la this reproduction of even tb« li^uuientTiai teres, in oonalruotlBg tbe new hip-Joint for your patient, imitating «o well thu aRHtomy of the Domikl orticn- lation! >
'* Uost truljr jonr O-luod, (Sign«(1> "J. SI. BcOT."
"BiLLinra RotHTAL Uedicai. Collxoi, j^IX 19, IMS. "P«or. I.BWW A. Saym—
"DKAttSiii: In May, 1803, 1 reoeired from yon a speoinien of a portion of the ilium, iritti the appcrextrcimilyof thefemur, tftkenffoin apntinot apon wliom yon liAiI operated jualbvlov tiiegrvat trof^linoter, for ibv pnrpiwe of malting ui artificial hip-Joint, bolnj: completely and irremedlalily anchyloacd. "The pationt'n nninn urua Suwb \L. Im%m, and nbc died, ax 1 li«ard, of ta- tierculoaii lomo time ofUT tlie operation. Tlie tjiccimvu vtiicli I examined woa the cat end at the femur, viih a portion of the pelvic boneo, fonni&i; a neir Joint. I found tliU end of the fomar incniitted witli Inie articular c»rt3- la;re. and »ent yoit at ibe llm<? a report of the microiicopical exnminntion, witb a drawinit ihourinic tlio carlllaffa, cavitl6^ and eells.
" Toon vOTjf truly, (fflgned) "A. PiJsrr, J«."
" Nrir Voai!. Siplimttr W. tWS. " DiAn Doim>i! : In reply to your inquiry. [ beg to nutm I iras pruMit at tbe eiotninntjon of tbe body ot Him L. In the spring of 1813,
" I made a full «xaininatioo of the limb opcmled np»n, and tlie motion yitiafrtt at tbe sow joint. Tbe paria were ibi-n laid open ; Uie new Joint oooalaled of a firm stractnre mrroonilinK the point of ofM-mlion, and rnode a cnpmlar Itgamoot. Ob opMiiug ilii* enpialur li^iimeul the easily waa foand to bo lined by a ^noviol metnbra&e iraooth and tubiioalcd. ilotwooD tlie •swod anrfaceaof tbe bone an Interartieular rarlihiKu and li),-ainent were foond. The «aM waa of great interaat, loaamuoh aa it TeriSed views whkh we bad under diaouaioii.
" Toon, ete., (Stjmcil) " WaijiKD Passib.
"To Paor. Laww A. Satub."
ANCHYLOSIS.
KxEE-JoncT. — In liouy am^iylo^is of the fcnce-joint, utiles the deformity is such as deinnnds interfcrenou, it is better to let it remain m)iliHturt)(.-<i,
If the deformity is sufficient todenuuid opcnttivc interference, A wtd}^ :Om{io<l |>iL-ce of bone inuy ins reiitoved of Muflirient eize to permit the limb to be brouj^lit into the iitrai{i;1it poeitiuu.
Dr. Giiriloii Uuoli, of tJiis city, pcrfonued tliia operation in Uie New York nog|)ttal in IS4I or 1S43. Tlie ojwmtion ia per- foriiicMl in tbe fulluwiiig mHaiivr; Two iiimions ure ninde, one li]>on each nide of the knee-joint, at tlie lower bonier of tlio eon- dylL<« of the femur, and tbesc are cionneeted in tbe middle by an ineision over the patella, ihuii making what i» known tui the \i-\t\- eifiiou. Tilts Q»\t» Qi-e then diutected np, and a narrow, leaden «]uitula worked ihrouj^b behind the joint from cide to side to pro- tect the blood-veKselB from injury while the bone is twing m- muved with the mvt. Any »mnll «nw may be xi6cd, as Butcher's or the metacarpal eaw, and a V-shaped portion of bone removed, of such dimensions us will permit the limb to \k bronglit into the fltrai^t poHilion.
Coueidemblu ciirc is necessary in removing this portion of bone, ill order thai it shall be of the exnci ntn required to allow the cut surfaces of bone to come Kjuarely in contact with each other, and at tbe same time have the limb straight. If too largv a tie(>tiun h made, the limb will curve backward, and you K-ill produce another deformity by the oi>eralto».
If the adju»1nient is not sufficiently acenrate when the «iiv faces are brought togetlier. another eeotion of bone must be removed.
In order that tlie surgeon may remove a portion of bone of the exact »im> requisite to pennit restoration of the limb to the straight ]>osition, it is a good plan to liiy a piece of pastobotrd or paper by the »ide of the limb, and i<^etcli an outline with » peoeil while it remains at tlie angle at which it le to l>e ojwriitwl upon. Then, by cuttin-; a V-»^h»l>ed section out of this pattern, which will permit of restoring it to tbe straight position, you can aecertaiu the exact sixc of tliu piece of bone to tw removed to enable you to restore the dofonned limb to the desirwl position. When the Ijono hiis been removed, three holes are to be drilled tlirough tlie lower extremity of the femur and upper extivniity of tlie tibia, exactly opposite each other, one upon cuch side and one in the
CASE.
443
middle, for the insertioD of silver-wire flutares. When the bones hare been brought tnp-'ther and K-ciiri-ni by nioftDE of ibo BUtai'O^ the whulv limb is to be pUoed in ^orne apimratun, and retained there until anchyloHis lias taken place. In other words, tlie caee is to bo treated hku unc of coiiiponnd fracture.
Tlie inait (complete apparatus that can be employed is Butch- er's Bpliiit. or Dr. Packaixl'it, of Philaddphia, wUich lia* boon fully deaprilwd when S]>eaking of exsection of the knee-joint. {Sm Figs, 140 and 141. J vV very efHcii'nt and (.-heap dressing is a firm p]a»ter-oM'ariH fplint, appliet) alonf^ the posterior aspect of the limb. Any lixed apparatus, howeTcr, may be employed that ehall suit the convenience of tlic Kurgi-on. Dr. Flulirur, of thi« city, lias recently constructed an lurtrumont for retaining the limb in a fixed pOi^ition after i*erti"u of the knee-joint, whi<-h i^ more ainplu In its application, and at the tamo time mure eftitn- cioos, than any other tliat 1 have seen applied. Prof. James I(. Wood has recently ompluyed it with the most satisfactory r»iult.
Ei.Bfiw-Joi.vT.^If tlie elbow-joint has become permtincnlly anchyloscd at a right angle, an operation for correcting the do- fnnuity is not jti^tifiablc. If, however, anchylosis has taken place with the liiitl) straight, a section of hone of the ellww-joinl may be removed. For, in such cases, we may reasonably expect to obtain mobility at the point of section.
I perform this opemtion by making a single straight incision over the joint, and, drawing the soft parts aude, export the bone. I then fii-st remove the tip of tlic olecranon for th« purjMjsc of retaining the attachment of Uie triceps muscle, and then saw thron^h the humerus, and nultii«. and ulna. When the sections of bones have been removed, the forearm is to be at once re- stored to a right angle with the arm, and tlio entire limb secured in some fixed appnratus until all inflammatory action has aiib- «idcd, when pasMve motions should be commenced.
In ifuiny i-rtKcs where llie cIImjw has been anchyloseil in the straight position by impro|»erIy-dres»ed frncturcs, imd the dreeft- ings retained so long as to lose the mobility of the joint, you may, potwibly, succeed in restitring motion to the joint by re-fract- uring it, if done within a rcasonalde period after couM>lidation, without rcaorting to any other o]>cration.
The following case illustrates this fact very well :
Cask. — George W. O., aged thirteen years, fell from a tree
444
ASCHTLOSIS.
in A[»ri), 1S74, frnctnring !iis ano. Tlic gentlctnao wlio saw liim Bt the time placed hia ami in the etraiylit position, and tccui-e<l it ill tlutt tnaiiiii>r by a boiml iii {rvtiit of Im ann, to which it wao secured \>y a roller, and retained in thin position for tKVvn veeki, nt the end of which time firm uiiiun had ooctirred, the arm being perfectly Hti-aight, but tlie hand tttrotigly pronuted. ^Vlicii the dre«eiiigs were remored, tliere was very great disap- pointment in lindittg tlic eli>ow otuiipletely nn«hylo»od. One week from tliut time, eight weeks fmm the time of (be accident, ho vas brought to nic willi th« ami firmly ancliyloiw) iu t]i« posi- tion seen in Fig. 249 (from a photograjih).
I put hi»i fully under thu iiitluunco of chlorufunn, and, with
rm.tm.
some force, euccee<ied in gradnally hrealcing up the adheeiona and rcfitoriiig the urm to an acute angle. Tlio fingers were well padded wit]) cotton, An<l aecure<l with a timily-ad justed roller. Tlio blindage was then carried up tJic foruiinn and over the elbow, whicli had been pn*viously pBdde<l, and up the arm, b [nece of sponge huviug been placed over the brachial artviy for pftrtiid comprossion. One of Aid's fi!lt-«jdint« w«« mouliied to tiie anil in tbi« angular position, and retnined there. Ico-bapB were placed around tlio elbow for several daya, and fortunately no conrtitiit ioiial di»tiirlianr>p followed.
At the end of tfnd«y* tliccpliiit was removed, and the spongO' comprew taken off. Gentle friction was applied to the limb, which was very mucU oechymosed, and verj- slight passive mo-
CASE.
445
Hon given to the joint utidor the inflnencc of on nnipiitlietir, nftcr wtiicJi die arm was renlreaseil m before, with Ike exception of the eiiongCH-oitiprewt ovvr tbu bradiitil arterj'.
Two tlays after, the same nianipulutiona were repeated, with a little tiiure t'rvcdoin of niovcinent.
Each BuoceeJing daj tbexe manipulationa were continued, to- ercaaing tlic tnoveuiciit a trifle e&rli time, for ahcpiit two weeks. An anicsthetic n'as required each time motion was given to the joint.
From tilts time onwanl the dremings were removed daily, and manipitlntioiiA iiinde witliout the aiia^^lliutii-, mid, nt tlio end of a moutb,an instrument was adjusted to Ids ami witli a liingc at the elbow, and, by means of a ratchet and key, I could obtain flexion to an acute angle and i>erfect extcnsinn. The boy was instnicled hoff to uitc the instrument, and vrm tuld to apply the key acvcrul tirneft a day for the puipose of making complete Itexion and extension, but never carry the movements to the pnlnt of pro- ducing pain wliicli would laut more ttian twenty-four boiirs. Onoc or twice during the treatment, slight febrile exeitcmeril I produced, accompanied with great tendemcsB and beat over joint, and tliv motions luid In bu omitted for two or three days, ice and cold water baring in the mean time been applied.
rio. Mc
With the exception of ihia febrile phenomenon, nothing OOmrrcd ill Uic raee worthy of mention, and, at the end of four , montba, he waa capable of making perfect extension (as »een in
MC SPOSOTtlTTS.
Fig. 260), and comploto flexion, to an ncuto angle (nsecon in Fig. S51), botli motions being the reenlt of the volanuty contracUotw
fm. «n.
of Itit own mneclea withotit meclianicat aid. (Figs. S50 and ^\ »re from [iliotogruplia l>^' O'Nvil.)
LECTURE xxvirr.
niBKABBS ASD I)KPOBMmK» OF TIIK HPISK. — >i POSDYXITtg, OR AN- TEKO-POffTKRIon CtrSVATrRE.
Deltiitiioii. — Anitlomj of the Spln«t Coltimn. — Eiiola^. — Pnthotocj. — SriD|>l>Hna.— llcihod of eiaffliniiig lliv Cuu. — TrtatmcoL — Ucdmnkal A|>T>IUiicM<i — FluMr> a(-F>rli Jnvkei.
Gexti.emf.x : Tfw]jy w« liave to speak of dofoniiitiee of ibe Bpine, of which there an.- twu variotim :
1. The one known by tl>c name of Pott's dtoeaaef or anbero- piNttcrior curvature, in wbidi there ia a dvetructive infUinination
ANATOMY OF TTIE SPINAL COLUira.
44.
of the bones, accompanied witli luw of Aubetanoe in the bodies of the vcrtebrn! ami iiitorvi-rtfbral diitkB.
2. The deformity known as rotary lateral cniratnre of the Hpiiie, in wbiolt tbcrc is no dtiMnee of the bones, but tlio distor- tion is dependent entirely npon in-effiilar nmscular contraction.
Tlw one is distortion the rcsnlt ot destrtictivu intkniination of tlio bonee and intervertebral AiibHUuce ; the other is distortion do- pendent iqion irropuliir, abiiuruml iiuiscukr coiilraction. Some- itmw the diBtortiun produced by lliie action of the niueclco wry closely npproacho^ in degree and appmrnncc that present wbou the bonm niu) cartilagett are diseased, and is then oocastouully mis- taken for IVtt's diseaM («« V'lg. 289).
You will recollect that the epinal cohitnn is made up of twen- ty-four bones and twenty-three intcr\'crt«l)ml earlilap'tt, indepen- dent of the HCrtini and cucvyx. The buiics or vcrtebno arc uiado up of a body, prooeescA, etc., which in early life ni'e aej>iirate, be- ing dot'clopod from etjjbt distinct points of os^idcstion ; and voin- plote fnsioii does not take place until life has become considerably adxtncod. The bodies of the vertebra) hnvo n mit, »pongy toxt- itre, while the proocsscs and aniciilating facets are more dense and 6rm. llio bodict-. bcin^ epun^y. are much li^jhter and are rnneh less freijuently fractured tlian bones of denser etriictura ; tkoyare also much better adapted to receiving concn^ion without injurii'. At the aame time the force of concussion is broken by the intervening cartilu^ts which are nbo i*pong)' and ehiHtio, and in tliia manner shocks are dissipated which would otherwise be tiHiismttted to the brain, when a por«on conio« down firmly iijwn tlie pelvis or feet. The intervening cartilages ai-o like the rublKtr bufTeni at the end uf railw»y-enn«, nud arc ko ehutic tlist when pnwsure is removed from them they will rotiim to their original dimemioiM. This i« u prnclieal fact that cau bo demoujttratcd by measuring a man in tlra momiug before he gets np and agnin at niglil after be has been u;>on his feet xll day, when it will bo fonnd that he has sliortcned from one-f<mrtIi to one-half an inch. which loe« will be restored when he luts had n certain number of honrs' rest in the horizontal position.
The anttro-po*terior airvatuiv, or Pott's disease, will first en- gage our attention. This name was applied to this diKoase be- i«uue Peroival Pott first accurately described it in l"ti3; but it shoold bo called $pondtfUtift frotn awiv&vKvif a vertebra, as this
448
BPONDTLITta
n4me gives an a«ctirate i<]ea of it& patliolog^r, ai>(I tUeo its location, viz., nn iiiflumiii&tion of tliu vcrti^'brte.
Tliis disease niflT occur at any period of life, lint is much more lilcvly to occur in diildhood, and especially in tboBe diildren who *pe reckless and earclefs, and expose tbenieelves to all sorts of ae- CtdvnM. It aUo oecura more frequent!/ among lioys titan among girls, because tbey are mure exposed to aecidvnts ; wbereae the Uteriil cur%'atiiro i* sot-n more fri?iiui;nily among pirls, Willi n^ gani to this affection, 1 have arrived at the coneliision, bae«d npon an aceunttc and eiirefully-rcoordt-d cxpericnec, tliat it is produced almost always, if not always, by some injury to the bone or carti- lage, and is lience tniumiUii^ in iw un^^'n.
By tlie profession in general, Pott's disease, above all other?, has been eoiiKidcrvd na oe»ontia)1y of «1nunouH ori^^n ; ati depend- ing upon a tuberculous diathesis, and not occurring unless ooneti- tvtional (tyscmiiift ia present ; but, in my own judgment, it macit more frofiuently depends upon some injury than upon any oonsti- tudnnal conditirtn. Ttio very fact that hundreds of people are waik'ing about difitorled, in many case« to a grrat degree, and yet remain in this condition and enjoy an average degree of health until thoy have reached a good old ago, is evidence that the di&- ea»e vhicli has produced the deformity is not necessarily tutwrou* lar in character.
The aecidonlii which produce thia disease are iwaally cot>cuft> Bions and blows. Those children who are generally full of play may in some of tlieirearcless iinink.t jiiiop from Bonie height, and como down straight without bending the knees or hips, thereby giving a liiidden and (>evcro concnwion to the bodie* of the verle* bra* and their intervertebral disks of cartilage, and in tliis manner disturbing some centre of oi«ificatinn to snch an extent that in- flammatory action follows, and the ca«o terminatM in inflamma- tory softening and dJAJntogration of the bone itaclf. Many timea direct blows are received which are sufficient to injnre the lioues and give rise to snlme<pient trouble of a aeriou* cliaraetcr. It sometimes happens that even the transverse processes of the vor tebra become fractured, and tlie injury paiwe^ nnMtiii>ccted and uDrecogniziTd, and is accidentally found atywrf mortem or in the diasec t i ng-roo m .
After «ich difiturbancc or tM^pfintion of one or more oaeifl« centres of the vertebrce, several months may elapiiie before atten-
eriTPTOMs.
440
tion u) drawn to the case, nnd perliape br that time the bonce httVtf bt'i-n [lartiiilly di-Btmycd nnd thtnlisturtioii develop*.^. Then it is said al om^ that tlie exhausted eotxlition which may Ih) present U uvideneo of constitutioitul caclioxtii, witcrcas it itt itiiiiply ''the result of long-vontitniL-d enfTermg from a hwal disease depend- ent upon MHiie dirvft injury lo tbv {nrt-i involved. Abacctwoi, commonly knon-n lis peous or lumhar abBoeee, are quite fre<|uently developed in poimeictiiin willi ihia di^eiiM), and the piw fonnod among the diseawxl vortehra> becomes imprisoned by the fihrons tUsa« wtlh which it ii> mrruunded, and does not reach tlic Mirfuce, in many cafva^ an in un urdhiary abecc«(^ but muot travel along under x\w. i>heatli of the tendonn until it reai'beft the point whore psoas abeoceees usually show th«m£«lvos. This ni»5' nxjuiro a Jong time, and give rise to scriouD oontititiitiouiil disturbance. In
ame cases these nbeex>«sos pcuelnito tho tiiwuiti and present tliem- »elvoA l>etw«en the ribft.
AVhen the diNcnsu has advanced so far tluit inflammntury soft- ening and degeneration of the bone are present, the weight of the body upon tho inflamed and dcgonoruttng parts will caiiso abiwrp- tioD to take place, whJeli will go on nioAt markedly upon the an- terior portion of the bodies of thevcrtcbno; and, as they lose their tliiekncM at this point, the bodies fait together, and this
iDsos the spinous proovesos to nssutnv a pccniiiir-sltapod pronii- noe, which ba.4 given T\ne to the name poi^tcrior angular curva- ture.
SyHnx>«s. — The mtmptomt of Ihifl disciwe vary aecording to its location in the t:]>tTial eohnnn. When it has advanced far
tiongh to produce a deformity, there is nsually no difiicuity in
liagnosis; but the di^eaw has existed long before the defurinity is obMTTed, and the important point is to diagnosticate the di»- Mso Wforc the deformity occurs. The symptoms, at the begin- ning, are ctoinetinict) very obscure : but the nerves that make tlieir exit from the spinal canal at |Xiint« opposite to the seat of the disease become more or loss involved, and will manifest such dis- turhimcc hy symptoms devetut)e<) at their di»1»l extremities. For instance, if the disease is situated in the cervical region, long be- fore any dii<t»riiiin apjiears the iwtient wilt eomplnin of diffieidty in swallowing ; many have a choking sensation as if there were a string around tho nock ; difUcuIty almut the liirynx, producing an irritable and continued cough; pain in the thorax, etc. Such
450
SPONDYLITIS.
symptoms may be the only ODca present that will attract atten- tion ; but tlicy arc snfficiont to aroiiKC your eiiiipicioiiii, an<i, if ynu cannot by means of the laryngoscope and physiral examination of tlw clicftt dvti'ct liny dt#cii«o of tlie l»rynx or linigis or any of the thoracic organs, euDicient to account for the symptoms pixtiODt, you shouli) at on<% nmko a tlioningli examination of the spine.
When tliv diecoso is in the dorsal n';{ton the patient very often compUini* of jKiin in the hiwer part of the chest and nppor jiart of tlie alxlomen ; also a contfrictinff svnsatioa as if a band were around the body ; coniplains more or lees of indigetition and flutnleiiee, and may liav« been treated for dyspepsia. He may ahin complain of pain in the chest, iwin about the heart, and pei^ haps may bare been treated for rheumatism.
Again, when the dtsca^ is lower down in tlie spinal column, ho may have a eenso of coiutridion about the abdomen, may siitfer from constipation and 6atn1cuce, and perhaps liave ttvatcd for worm«.
When the disease is still lower in the spine, the leading symp- toniH may bu those refenible to the bladder and rectum. Thu eltief symptom in the ease may be a frequent desire to pas8 the nrino. Tlien tlie [laticnt may aUo euffur from radiating pains down tlie thiglis.
When enrh symptoms arc prcxcnt, and thoy cannot bo ex- plained by th« presence of some weU-recogniiied disease, always go back to the point where tiie ne^^'0>diiitribute(l to xXivtv n'^limg make their exit from \\\v spinal cuual, and carefully oxaminc the bony stmcture^ which snrround them.
Early in the progrec« of thu disease reflex eontraclions nro excited among the muscles, whicli result in a change in the ai>- poonoce and action of thu child, tJiut \* worthy of e|iect»l atten- tion.
Er«r}' joint of tlic lower cxtremitiea Is hcDt for the pnrpow of preventing any ooncnasion from afTecting the Imdica of the rcrtebrv. The rliiii \* made to project ; tlto iihouldent become vk>\-atod ; and it is impo^ible for the child to stand U]mght and receive any concuRtiion whatever which may b« oommnnieated the bodies of tlie vcriehra-' without suffering jmin. The maBol- of the hack are held ri^id, in order to prevent any ninvcuionta < the bodies of the vertebra! upon each other. The cliild is nnnblo to Btoop down and pick np any object upon the floor ; but, if
SYMPTOMS.
451
[.sshed to do so, lio begios by bontling hie hip«, an<] then his knec^
laud finally n-nchi'^ the ohject by iti{u»ttiiig down to it. Thwo
■jMtieotfl nvvcT bend tbu l>ack forward, for bending it thus preBaea
the boilii* nf the verttbiw togolhcr, ftii<i ji\vv» rise to )inin ; t-on-
sciiiiviitly nil thu luovvitiunts of ttm child uru directed in such a
manner as to prevent any motion in the spinal eolnnin.
When walking about the rouiii, lliu cliihl will rcacli with his hands from one article of fumitni« to anotlter, making iMrtful caletilutioti that hu i>Lull not be di-prived of the euppurt furnished by one objeet tjefore he receives ihut derivc<l fruiii another. If he cannot obtain any »ui>|)ort by eatehtng hold of fiiriuuii artieles ' within reneh, he will rest his hands ujiou his thiglm in order to transmit the weijilit of the head and shouliicra thmtif^h the leg* to the ground, thereby giving them supj>ort without beanng apon the diseased vertebne. The patient instinctively makea every |>o«ition which hu takes eervo to lift the weight of thu shonlden auil head from a spinal column whieh is in a slate of dtaeoM. VThou, tltcreforc, a ease prevents itself in which tlm patient ooin- , plains of cough, indlge^^lion, disturbances atwut the bladder or rectum, or constant and |H!n^i»teiit puin in the chest or abdomen, and yon are not able to detect any disease of the lungs, stomach, liver, or other orgim* which will account for the development of such syniptoins, I liave to repeat to you agHiu, do not fail to ex- anihio the )>pine. The cjneation now aniw^ How is tliis to bo donv i In the fii%t place, put some object upon the Hoor uiid ask the child to pick it up, and then carefully note tlie position he asanmcs while pcrfonntng thu acL If thu vertebm ora diwufld, lie will srjnat down and pick up the object in the manner just de- ecribod. and rise up in the i^inv careful way that he went down, keeping the back aa nearly fltraight as possible, and allowing no movements in the spinal column which he can prtn-cnt. He never bcnd^ over like a healthy chihl, but kee{i« his spina! column a» five from movement as powiblo.
Ton will then strip the child naked and lay him across yonr tap, face down, with the nnris over one thigh and the legs over the other, and then gradually separate yonr thighs. "When that is done, tlte llmt thing you will notice, proUibly, will l)o tliat the child takes a long breath, a long-drawn sigh of relief ; and this lead* nie to ajK-ak of another symptom which I have omitted to mention. When the child is walking about, pitrticularly if the
45S
SPOSTDYI.ms.
diM'suto ia in the Aorml nr lower cervical region, lie breathes in a short, griiutiiig tiiKiiiior, bcuiuHO of the «oiiittimt effort on the purls of the musctefi to liohl the trunk etill. In utber wortls, tburo !a a coui^tnnt vffort to put a muiKular Hj^ini on the child'ti body to prevent motion in the spinal colninn, mkI thuH tliu child, by his short, grunting bii-nth and tnnitciiUir rigidity, \a trying to teach UH dootors what the in(li<;ution<i for treatment uro in hiit case. The prcMure npon the iiiti^nimtiil nerrc« \» eoiiietimes ho great ail to produce aluuwt g|)a8niodic respiration. Kuw, hy plac- ing the child ncroAH the Inp in the manner deM^rilta), and then malting gradual extonuon upon the spine by Et-pamting your tliighs, thereby relieving tlie nervw of all prewure and the ma* clee fnim all irriration, thu finit thing that will I»e iiotinrd \i thia long sigh of relief —a full inspinttion and coinjylffa exjtlration. As long as the child is held in that niaiiuvr, he will b« perfectly ooniforlable and breatlie eaflily, if you do not can-y the extension so far a£ to prudiieo reflex muscular eoiitrnetioii. Then close the thighs again, and the muscIeH are at once excited to contract, and the child again )>egins his short., entchiug nwpirntion.
There may be more or lead epasmodip miispiihir action all over the body whoti the extenition w removed ; but, if thiTO is not, it can be very easily developed by placing one Iiand npon the head and the other under the sitonim, and crowding the bodies uf the vertebne together. The instant tliis is done, you will see a sjiaom, proliably of both legs and iimis, and the child will crj- nut on ac- count of the pain ; but, the moment extension is made, he Ia per- fectly eB»y again. _
Kow, all this can ho done when the disesEe is in the antorinr ' part of the hodiea of the vertelmi', or in the inter»'ertebr.»l disk* ; Jmt it may be, in the case which you are examining, riiat the anterior portion of the body and the diiikH have not yet bcoomu involved, and yd the child is ifuflering from spondylitis. For, when tlio dorsal portion of the spinal eolnmn in affected, the dla- ease doc8 not alu'ay^ attack llio anterior )Kirtion of the bodies of the vertebne at first, but the part most extensively involved may bo upon the #<W^* of the vertobra^, where they form a junction with the rilis.
In these eases the blow or injnry h generally reoi-ivwl upon the side* of the body, and the heads of the ribs are driven against the vertebra with such force as to give riw! to a otartiiig-|ioitit
MODE OF EXAMINATION.
4&8
for ftn ill flam mation. Consetjuc-titlyyoiimiiKt not be content willi I exftiniiiiiig the spuul culomn, is far aa the bodittt of tlie venubni; ^■lotiu iiro voncorncd, but yon tntut twt tho eid«M of tlic vurtcbne by preening the heads of tho ribe agaiust their articulating facots. Very fpcmiently yoti will not be able to dcvo]w|i any Kym|itoiii6 of B[tinal disL'aso until you prtwa upon tlie ribs in this manntir. Yon may be able to preafl tlie spine down without producing .pain ; pcrcUM the; i^pinu wilhout j>roduc!ng pain, and the spinal 'eollimn may apparently be »ln)tghl, atl of wbioh might li^ad you to tlio <.'Oiiclu«iuu tluit it is not discouted ; but prossuru upon the ; ribo, which will bring their heads in contact with the srticn- plating fncot«, givos thv {uttiuut (lain, and at once yoti havu evi- dence of diseased viTtetirte. By preaeing npon the ribs sejia- raloty in thi« mnnnvr, the exact location of tlic di«ca«c can be determined.
If th« dieieaj^ be lomti-d in the anterior portion of tlio vcrlo- bne, tho child being then placed acToas llio lap, and extension iitade, a moderate downward pressure upon the spinous proceswK will maku him mure (.<onifortublo. The fact tliiit prussun'! can bo made over the spinous prooesses without cauiilng pain ia regarded by many w evidenoe tluil no disease of tliu houa h present. Itnt it ia the anterior jiortioii of the boily of the vcrtebrte that is af- fected, and, when Ihciic begin to give way, the spinous processes begm to project, and by crowding upon them we roniore tho prciwurn from the diAcasoil HurfaccA, and conspquently the itutfer- ing of the patient is diminished. There are some cnscs in which no definite i>yin]>toni8 can be obtained by examining the patient in the manner described. In such cases the application of loc or intense heat may be of ctcrrice ; for the nerves made irritable by tlie disease will receive impre«sion» much cjnickcr tliun thuy do .normally, bo that when a piece of ice, or a vial nr tliimble con< taining hot water, is passi-d along the «pino, no response id oIj- tained until tho ]H>int oppoeJte tlio di-iease Li reached, when there will be a sadden movement of the body as if to get out of tho way of the irritant. On the .'uiine principle T)r. Rosenthal has adriscd the application of a strong farudic curreut to test tliu dif- ferent points of Ment>jl)ility uloiig the spinal column. In this man- ner you will sometimes bo able to spell out cusi's which cannot be easily oxphiined in any other way, and also by the delicate snrface tlienuomctor, recently devisod by I>r. Si^iuin, of this city, yoo
454
spOKDYtma.
will b« able to dutcct nn deration of temporatttre ovor tlio in* flameil part that you c-onUI not otlicrwiso (Iibcovlt.
Partial or comiilttle |innilyi»i.s of oik- nr Viotli lower extremilieB, sometimes occurs during the progrtws of Epouclyliti«, un<] cliDical olMervitionH prove tlmt it may take place irrefl|>e<!tive of tbe lod^ don of the disease. It depends eitlicr upuii vfftisiou into tho cord, or prcsflore D]K>n it hy tlie dUtortion of tlie bones, and in tlio first instiinoc will gradually impruvK, m al>«orpti»n of tliv effu- sion taltes plane ; but, in tbe Utter inatancc, prognosis, 6u f ar as tbe riHtoratioti of power is concerned, i« very nnfarombla
Aa to the theoriee relating to tlie etiology of tbe disease, I think it liiirflly worth while to ooti]>iumc your time in dt:H;ui«itii)g thviit, for ro\i can road tbem at your leisure in all tlio text-books upon flnrgery. I simply wish to m&ke these points : that it \a, llie rusult of injury in ahnost all cm«oa ; ttiat tltie iiijnry is followed by inftanimatory airtiou ; that it can be diagnoaticated by niaking ' extension and eounturextensiou upon the spine, and by prMisure upon the aides of the vertebrvj a]e»o by syniptonis referable to the dietal extrt^uii licit nf the nuTM involved in tho di«M80, long before the deformity is produeed ; and, being delected in thia oarly i>ta^, can fre(]ueut.ly I>o cured without any deformity oo-- ourring.
It 18 a remarkable fact tli^t, of the two hundred and tweD^- fire cases that 1 have recorded during tlie last six years, beude« hospital cai>eR, etc., only three were brought tn me l)eforc deform- ity liad appeared ; and yet all of these cases bad been under treat- ment for dil!orent »npj>o»od di»ea»ect for some tnontha, and In many instances bad been seen by numerous medical gentlemen of the bigliest distinction in onr profcftftiun; tlie tnie cauae — lUimely, inAamination of the vcrlehnv. or sjwudyliti^, which had given rise to tbe symptoms of which the patient complained — had never been suspected until the mother of the cJiild aodduntally discox'ered the defonuity.
MiAtaken like tbia need not he made in diaj;no«iit ; and it ia to this point that I would specially call yotu* attention, as it is of tho
ntest importance that the disease should be detected early, be- fore ttio deformity ui>i>oars; for, once having taken place, it la never perfectly removed.
The following w n synopia of the two hundred and twcoty- fire cases of spondylitis previously mentioned :
BEOOKDED 0A8E3. 455
LOCATION OF DISEASE.
Cervical region 11
Dorso- cervical 11
Dorsal 163
Borao-Iumbar 28
Lambar 14
Unrecorded _8
Total 225
CAUSE.
Tramnatic 153
Unknown Y3
Total 23B
AQE Of PATIENT.
Under fifteen years. 1B8
Over fifteen jears 28
Unrecorded 4
Total 226
Unable to stand without support before treatment, sixty-one. Of these, fifty-five were able to stand without other support than the plaeter-of-Paris jacket, after its application.
Two cases became paralyzed during treatment.
Cases cnred 189
Cases now nnder treatment 40
Cases unrecorded 80
Cases abandoned treatment 8
Oases died 8
Total 225
Of the eight recorded as dead ;
Two died from double poemnonia.
One " " concussion of brain, resnlt of nulroad accideoL
" " rapture of aneurism of aorta.
" " brain-fever.
" " capillary broncbitis.
" '' membranous cronp.
" " phthisis.
This brings as to the subject of treatment.
Tbeatment. — In the earlier stages (and it is during this period that treatment is most important) there is nothing which can com- pare with reat and freedom from pressure, absolute and complete.
4M
sposDYLme.
¥oT prcMiirc upon Uio parl;^ didc-ji^cl <?anst>a more mpii] M>ftcn- ing, degvuonitiuii.and iib«ur])tioii. and in thiKuiiiiiiiurn pL'mianviit (Ivforiiiity may bo very rapiillv (levelopc<l» sack as you see in the epociineiis bcforo you. {Ser Figi^. ^'>i mid 2">3,)
The threat object in tlie direct treatineat of spondylitin is to mitiutain ntf atul fi-ivdant from prttture <^ tha (Rectal part«. by micli means as will not debar the patient from tlie benefits of freab ■ir, V'litiliglit, find cbnii^u of i^cene. Tbi; patiuril sbould not bo permitted to aaenrne the upright position l>efore he has been fitted with BOirie artttiriiil i^iippurt, aipiibk- of rfttioviii;* utl pri'«iire from the bodies of the diseased vurtcbrw. The idea involved in the
Vii].«t.
Fnl •■.
oon^triiction of M>me inMnmicnt«, of lifting the bodies of tlio verlebrfB apart by placing b belt about tlie liipa aud a support tttidcr the annti, is i>imp1y nbiturd, bccaoM the mobility of llie Acapulo) is so gnsat that they ran bo clerat<.>d w far as tlio en- durance of the patient will allow vithout relieving the weight of the body upon the spine. This cim bu done only by an accuratvly- fitting apparatus applied to the h'/dy ilAolf when extended.
Until tlie year 1874. 1 had for «!vvnil yeare beou in lb« Iiabit, in the treatment of spondylitis, nf '* curtle-sbelling " patients, as I ealled it, with plajct«;rKif-[*ari», thus encasing tho spine and half or two-thirds of the body in au immovable appamtus, after har-
TREATMENT.
457
ing mado Ui© proper amotiDt o( oxtvneion with tfio patiunt Wing across the tap. The edges of tlic elieU were titcn nnited b_T tueatis of vlntftic bandit paesin^ acroao (he front uf the body, Hiipport be- ing thua given, and Ute respiratory morementa pennitted to go on tinn.-»tricte(l.
In November, 1674, a lilllc boy, four years of age, wmt brought Co inc, baring a sharp pooturior curvature of the ilirt-u hist donsal and the lin<.t Ininbur vertebra.'-, togetlier with partial paralyusof the ructum and one leg.
As ho u'a.4 tttiublu to Htnnd up while Mr. TtcyndcrH ineai>ure(t his back for tlie purputto of tilting a "Taylor's brace," which 1 intended putting on liim, 1 lisd my turn lift him up by tiie armn, ao that thi': inoasurcmunts could he made.
When he was thus held up his haflk became very perceptibly atraightcr, and I (ibM>rvi'd that he had more motion of his para- ilyzod right foot, Tiiis experiment was tried several time«, with Uio Himu ivttult at each eu^pi-niiioii. As Mr. Itcynders couhl not supply htm with aii inntrnment for some days, and the parents had to ruluni to the country by tlio next Imin, and a« I had no time to apply to him my " turtle-shell " dressing, I thoreforo concluded to apply a plaster-of-I*ari» biindngi', from jkiIvih to axilln>, cota- pivtely around the body, in onler to gt't an accurately' fitting moald, and tiicn out it down through tho centre Ju front, ^luiUu' to " Darrach's celluloid jacket."
^^hile he was »iuiipend<.-d in this manner, T pulled dnvrn hit shirt and tied it between his legs, thus making it tit the body doM-ly and Kuiootldy : nnd then <.'ommencing at the pelri», my jaasistant, L)r, Vale, ii|)|)ticd ndlen^ saturated with phisterof-Paria around the entire trunk. At first I wax anxious eoncerning the cffeet that would be produced on the n.'spiration, bnt, innsmuch as the Itoy cried lustily, all of my fears in that respect wei-o quickly dispelh-d; so tho bandaging wa8 continued, bringing it back to the pelvis, again carrying it upward, etc., until the body was completely encircled by four or five rhieknenws of the roller. The child was tlien laid with his face downward on a sofu, and wa instractoil to remain there until the pla.'iler had become firmly set. On my petnm, after a short alisenco from tho room, I found, to my Kiirprise, that the little fellow had gotten up from the sofa > and walked aen>i» the room to a window. Still fearing tliat res- pimtiou might be too much interfered with, I cut through the
458
)Y LITIS.
dreseiuj; from the top of tli(> etcrnuiii to tlic piibi)!, tlius allowinf; it to frnpe confiiderably, and permit a more complete expftUKion of the clii'st. The boy, however, <Iiil notftfl a« eoii\fortable aft^ at ttffort the inemon thmugk tht front jmrt (ff' the jackH, I tlico applitrd H roller- bandii^ uroitiid tlio pelvic portion of the jacket, anil again brought its edges together, but left the upper portion to eepamto as much to. the movements of retipiration seemed lo retjiiire. In order to give eecnrity lo the upper or thomvic pop- lion, the cdgw of the jni-ket wrre tiod together by strips of elaa- tie bandage. When thin drctsiitng had been oomplett-d. 1 nxiueelod the piireiitci to briiii; back tlie child after an interval of ten days, vrhi'ii I propus<;<l to ap|ily and udjiist a Taylor's bmcu. Tlie above- described plaater jacket had been put on simply for the purpose of rundering the diild vonifortnble while being earned home. I did not Hee either the child or the parente until the following March. In the mean time, tlio little (xitient hud gniwn connidcr- ably, looked healthy, wsa able to walk without mechanical idd, and could support the upper imrtion of the trunk without pUcing hJH hands upon hie knec^ Without staying to make any fiirllior examination, I at oiioo took the lK>y in my carriage to myctiniral loeture nt the college. As tho fitruetK were bmct with holes and elevaliouH fonned by ice and snow, the joltinfi was most intoler- able. I wait nnxiouft fur my patient, but, I'Ininge to niv, he imide no complaint whatever. This fset of itself showed the efficiency of tlH! drei«ing for securing nb»>lute n.-«t to tiie diwoMd parts. At the college the dretuiug was removed in the presence of the ' class, when it was found that the curvnture had been much re- duced. The boy was then unable even to sit up, hut, as soon u the diesttiiig had been reapplied, the mother {Kiinted ont to tne tliat. he could ngnin nit up and walk.
This in brief, is the history of the first case in which I ap- plied tho dreitiiing called by me the " plaslcr-of -Paris jacket." Since that time this phm of applying a pbstcr dressing com- pletely around the body, from the pelvU to the axiihe, has oon- Htiluied Almot>t tho only treatment which I have adoptvd for spondylitis. I have tued it in many hundreds of eaaea, and Iq eacli instance with great benefit.
Tho himdages u»<ed in tlic application of this treatment roust consist of some loocwly-woven material, such ha creoi^-barred niii»- lin, mosi|[uito-uctling, or crUioliuo. Tliia ohould be torn into
TREATMEKT.
459
ftrip«, tlircc jan\« long nnd from two and a half to tlirto iuchufl widf, according to llii^ niix of tlio patient upon wliom it hi tn lie IIMhI. IU ineelii'^ miit^t hv cunipluti-ly fllk-d bv druwiiig tlio band- ago tlirougli very fine nod freiiiily-gronnd plaster-of-Paris that lias not long boon exposed U> tliu uir — this ]>]ii»lor at. tho naim; time ielrttf B^rtf tiioi'ouijhlt/ I'uhlml into t/i<- maUr'ud. Eacli strii> ifltould tlien he looitcly rolled up ito uk to form nn onJinitry roIli-r-lKtiHlii^c, Sorund of the bandages tJius prepared may bo kept ready for uee in an air-tight tin ressel. Wlien rcijnircd, ihny am net on end^ one at a limv, in a basin containing siifficiont depth uf water to eowr them ^iiiityty. A free escape of biibblett of ffis tlirougli the water will be obKer%'i'<d for a short time; when this bus leased, the bandage is ready for nse.
The «iirfaee of the sliin should bo probeeted by nn chislie but cloeoly-filtiiig shirt or vest, without aruileto, but with laU to tie over the )ihoui<)en>, and composed of ko»io toil woven or knitted material.
Fi>T the purpose of saepending the pcttient during the applieo* tion of the dreeing. I make uw of a very convenient apiurntuB contrived by Mr. Kvyiider*. of thJa city, which consUts of a car^'ed iron eroHs-beam, to whieh is attached an adjustable licad- aud-ohin tvillar with straps and al>>o two axillary banda. To a hook in the centre of the bar is fised a pulley, the other end of wliich IB secured eitlier to a Iiook in the ceiling or to the top of an iron tripod about ten feet in huiKlit. (.Vw Fig. 2i"i4.)
The head-and-chin collar, and the axillary supporte, Iiaving been carefully adjusted, the patient is gradually drawn up nntil ho feels oorufortttble. Before applying the plaster bandage, I place over the abdomen, lietwwn the shirt and the ekin, a [wid composed of a towel folded uj> so as to form u wodge-xh-iped mass, the thin edge being direeTed downwanl. This iti intended to leave room, wbcu removed, for the expansion of the abdomen after meats, and so T eall it the " dinnei^pad." It i« important to nuikc it thin where it comes under the lower edge of the jaeket, or else the jacket would tit too loosely about the lower pari of the abdomon. It ahould bo taken out just before the plaster sets. It is always a good plan to get the patient to eat a hearly meal before tlw jacket Is applied, but tlii»^ pre<!a»tiou of allowing room for incAlfi should never be neglected.
If there are any very prominent spinons prooeeses whicli, at
44W
8TONDYLITI9.
the same time, may have beooine inflamed in couaoquenoe of presfiun.' juTHhifod hy iiulrumoiite previously worn, or from lying in 1x^(1, ttiich p!ai\-i« t<liaul<l ho jeuanled hy little patU of c-otton or cloth, or little glove-tingurs lilluci with woo) plicud on cither dde
PU. BH.
of tlicm. Another detail, which I have fonnd to be of pnK-tical value in Bome caAeo, is the Application nnder the itliirt, ox'er rach anterior i)i.te spine, of Iwo or llirec tliielinefiscB of folilwl elotli, tliree or four indies in length. If these little pwla he removed 1 JDitt before the pliiAtiT h»« completely set, etic-li bony proceBseaj will be left free fnjin prcsBiire,
If the patient lie a feinnle, niiii ci4])ecia1ly if »lie be developing at the time, it will bo neotsfiary to ajiply a pa<l underthe eiiirt oror each breast liefore the planter iMnda^ i» pnt on. The»e pads should be rvnioveil jii»t Ixifore the plarter evlH, and ut the Hamo ' time eliglit i>ri?»tire should be mado over the sternnni for tho purpose of indentinjf the central jwrtion of the planter jacket, wul of tliiiA f^iving form to the body, and of reuioriog preMDmi from tJie breaats.
The ekin-titting rhirt having been tied over the slioaUlcrft, aim)
w
TBE.4TMENT.
401
Uien pullctt dowi), wtd kept 8tn;tcli«<t hy m«anE of nipos applud, one ia fnint, tie otlier helunii, near iu lower edge, and tied liplitly oror » liiindkcivliief piaciMl r>i) tin; jHirina^um, tlio luttk-nt i» to ho gently and elawl; drawn np l>y means o( tbe appamttio nntil lie (iSfU iH.Tfo<;tly «>nifortal)lo, aTi<i /i<rivr brr/rnni th»t jH>i>tt, and wJiilo he U rt'tuiiiud in this position tbe plaster bandage is to be applied {Fig. Sr>i), A pR'parwJ and Mititratvd roller, wliicli bus been gently e(itH!«zed to rcniore all surplus water, is now applied amund the amgikst part of tbe body, mid in rarrled around mid around tlio trunk downwanl to tbo en.«t of tbv ilium, and u littk' bt-yoiid it, and afterward from Itelow upwarfl in a spiral direction, until tbe entire trunk from tbe pelvic to tbe axillu- bfii^ been ciioaM-t.1. Tbe bondage slioiild bo placed miioothly around tbe body, not drawn too tight, and ei>j>ecial care taken not to Imve any single turn of tbe bandage tigbter tban tbe ntt. £acb layer of bandage sbould Iw nibbed moat tborotigbly with the band by nii iuwi«tant, that tbe plaster may be cloecly incorporated in tbo nieeliee of tbo crino- line, and bind togctiier tlie vaHous bandages) wbicli make up tlic Jacket, tbiifi making it mueli strongor tban if iittentJon ii; not paid to this particular. If you notice any spot wbicli Heems weak or likely to give way, pass the bandage over it, and then fold it bavk on itself, and do ibis iinli! you have placed several tliioknesses of bandage over this [loint, being curiful to wet all well togetbcr, and then pasa a Inrn completely around tbe tmnk to retain any end* wbieb might have a tendoney to bceumo detached.
In a very short time tbe plaster sets with sufficient timinwa, so tliat the imtieiit can be removoti from tbo nn^pending ajiiura- iDs, and laid Upon bis face or bnok on a baJr mattress, or — what is preferalilc, (5<i)ceiatly when lliore in mueh projection of the spinous prow»»« or sternum — an air-bed. Before tbo plnfltcr bas completely set, the dinner-jiad is to l>e removed, and the plaster gently pressed in with thu band in front of each iliac Kpiiioiii pro- 0MB, for the purpose of widening the jacket over tlie bony pro- joclinm. In tbe oise of a voting child with a Mnall pelvU it may happen that the eircumferenee of the body at tbe nmbiticne ts as groat art around the pelviii, but, iis tbe M>ft juirtH In tlio lumbar rc> gion allow us to monld the plaster as wo choose, yon can still ob- tiinajMint of fliipportat thepelvii*; if, a* the jacket hardens, jow will pieKS it in at the sidoe above the ilinni, and in front and rear above the pubes, the antefo-po»terior diameter alx>ve will be tlie
403
SPONDYLITISt
lungur, wli!lc below it will lie the traiurcrsc one. Tliis jaokot, which 1 show ^'ou, wait uki-n front a very email chiM, nnt] on meuureintitit yoii perceive that the vircumforcnvc \s tli« umc at the waUt and at the peU'ic portion ; when, however, I attempt to piiss thi« lead-poneil tip the jiivket, IioMiiig it in the line of tJtu traofiverHO «lianieter, it can only pa^ in « short dietance, owing to the waiiit which 1 formed by prei«irig iii the «dc6 of the jnekoC while it was drying.
If any iilm-ci'i'e^ be present, they muttt he fni-ly opened autt- septioally at the most dependent part, and their contents com- pletely ahi([rni.-teil. The ai>rgeo» will oeeni^ionully find large maHsee of sloughing connective tissac, having the appearance of wads of wet cotton, all of which should he removed. Afri.T each abeceae has been thoi-oughly evapuat*d, fill the cuvity with Peru- vian balMim ; plaee oaknm ovcV the o|iening, and cover it with ft piece of oiWilk. Then phicu on this a piece of folded pasttOioard Miniowliat larger than the absee-w, carrying a long, i^lmrp ]»n through its outur leaf. Now pull down the shirt, and the pin will project, indirating the jwint of the alwceiw, and u.ic!i him of tJie bandage can be carried over the pin without fon-ing it iiitu the ab»ce»)-cavity behiw, und the ei)igeoni« fiiniiflhcil withagiiido in making an ojieniiig which elmll lead directly lo the diseased anrfaoe. When the plaMcr Una nearly »et, thi- bandage fibonld be'' cut away around the pin until the «hirt it< reached, when the lat- ter should be Htarred, or cut in strips from the pin till an o|wning hii» been made of »ulhvient eixe to remove the pasteboanl. The oil-«ilk which ia then expowid should be starred in the kiuio nmii- ner from the centre, to that when the stripe are reversed ihey will cover the edge« in the opening of the pbuter, where they can be gluod down with gntn-§hellae. In thiit manner you will eotabliflh a fencslm for drainage that leadti dii-ectly to the abtoem (*w Fig. 25S).
There are some eascR of spondylitis in which the oprvirail or up|)or doniid vertebm-, or both together, nru involved. In thi»u casee, treatment by the plaster jacket alone can do but little if Any good. It. then becomea neccwsry to treat the diseuso by the nw of an instrument whicli I call the " jnryniasL" Thif) conniHta of two pieccit of mfilleablu iron bent to fit the curve of tliv back. To the lower portion are attachexl three or more strijMi of tin, long enough to go nekrly around the body. Theeo 8tri|)« oru
JURYMAST.
463
roDgbcDcd like a nutmeg-grater, hy having holes punched throngh them in both directions, in order to tirmlj fasten the etrips to the jacket. The tins must be rough on both sides, else the layer of the jacket on the smooth side will not hold the tin, and the jurj- mast will slip np and down.
From two cross-bars at the upper extremity of the curved iron pieces, springe a central Bteel sliaft, carried in a curve over the top of the head, and capable of being elongated at will. To this is attached at its tipper extremity a swivel cross-bar with hooks, from which depend straps supporting a licad-and-chin col-
lar. This cross-bar must be placed above the curved steel arm, or it will be liable to become detached, owing to the constant trac- tion on the screw by which it is held in place {see Fig. 255).
The apparatus is thus applied : the patient, having been en- eased in the usual manner in a few tliicknesses of plastei^roller, the jurymast is put on over tliis, care being taken that the malle- able iron strips are bent so as to conform to the surface of the plaster, on each side of the spine, and that the sliaft over the head be kept in the same line with the spinous processes. The extremity to which the swivel cross-bar is attached should be over the vertex of the head, so that, when the straps are applied, the
8POSDYLITI9,
line of traction eball be neither too fur forward nor too far back. The perforated tiiu Are carnvd partially roiin<l the I»ody. Tlie apparatus having been thus earefallv adjuKtH, frc«h taycra of plnsttT bandag<o »rc applied over it lii order to liold the irwtru- inetit 6rnily in itB place, the assiBtant being carcfii! to rub tho b:in(]:ige into all tho innjiialitiai nitiRed by tlie infitramenL'
After the jacket lias tlioruiigbly hardened. th<: rbin-pieco is to bo applied arnnnd the patient's neck, oo that it Buppnrta the cliin and oceiput comfortably, and the Mnkp« nttaclicd to !t ore hooked on to the CTos8-l)ar {»m Fig. 203), tho degree of traotion made upon tliotn boiiig regulated by tlie foL-iings of the patient.
Ilcfore narrating the caeea illnBtrative of these principlee of treatment, I wish to gire, or rather repeal, a word of caution, fearing tliat 1 may not have enforced it with sufficient distioct- nees already. It is t!ii« : do not attempt tho impotwible ! do not try to Btmighten curved spinei* the result of nari'^it that have tie- come partially or completely consolidated. If Nature has already thrown oat oasilic matter, and adhesions arc beginning to take place, do not hrtak tAtiu up by too liovero extension, but t-iinply extend tho patient very slowly, no that tho contracted mnscles alone will yield, until the patient 9a*/a he Jiiels cott^ortabU, and Tiee^r heyond thaf point.
If it is a child who cimnot t»lk, watch it« conntenanco, and aa Boon as tlte expreeaion of patH ohangcH to one of ple<umr^ ti'tn $toj> and «fcun your patient by the plaetcr-of-Paris bandagea, keeping him in that position until the plast«r haa set ; he will then retain this sense of comfort ao long as tho bandago ia prop- erly adjusted.
Tho treatment of course will be modified by the location of the disease, age, development, nnd condition nf the patient whun ho is fir«t pri«cnted to you. If it is a very small child, with an undeveloped pelvis, no matter nt wliat portion of the itpinal col- umn the dtaMM may be located, the horiitontil posture with iiight extension is tho only method of ti-catnietit by which yon can expeH reoovory without deformity. This is best acctim- pliahcd by placing tho child in the wire ouinus («« Fig. ITS);
< Ml tricnd Prof. S. D. Grou ban rDOoiiiiB«itd«d ihe applioiUiw of ihr ptrymtM, in ndJiiioa to the pUM«r.j*«k<:l. in atl cum ot «poniljlili« wiMn ibc dituftM i* tbovc iliu uOTum : u)d mj o'ra pnciiccl cxfMtlnicii liu prorwl ib« iriMton ot U« aufg^ iluo.
TBEATJtEST.
4(U
which may be fitted with a hair mattress, or an air-bed if neoM- auy ; applying ttjuryriMut at (lie upper portion of the cuinuw for the pnrpofic of inakiug the necessary extension of tlie rertehral oolnmn. In this app«mtit8 tlio diild can be taken into the opon air for the daily cxorciitu whicli is so important an element in pre- serving the health of the patient
CliildrcD wliu aro so bduU, and whom it is necessary to treat in this manner, must he removed from tlie <>iiiniii« every few daytt, tnd pftisiTO itiutiun appliud to all the joints in unlur to prevent anchylosis ; as soon, however, as tlie child is BufKciently devel* oped, the plAAter-of-Parii> jiu.-ket should ho applied.
If ihvro shonld ho a great elevation of temperature over the seat of the diseoao — this can be r«oo]|piizcd by the thermomctor — it may be advisable in some cases to ahetrnct a small quantity of blood by the application of leeches; thi» tdiould be followed, if Doooaeary, by the application of ice-bags to the parts, or, what is still better, the new plan of irrigation through Hexible Dnetallic tubing.
A most excellent and wrviceahlc adjuvant to all these eup- porta is the wheel-crutch, invented and manufuetured by Mr. IJarrach, of OnagCf^. J- (Fig. 25C.). The idea involved in the construction of the cmtt-h U to keep the patient in nu tipriglit pOftition, with support nndcr the arniR, and avoid the intermitting ttnin and swinging aotton atU-nding the use of the ordinary crutch. By Mistiuning the body of the patient in a pendent posi- tion without fatigue, the dificaeed part« are relieved of preasare, while the patient can liave all the )>enefits of exercise without Injury. Tlic erect |>o«lurc, however, is not dceirnble excc])t so &r as is ahsoltttely necessary to permit exercise and obtain fresh tir; but, when the erect jw^turc ix aeenmed, tlie tnink should be anpported by artificial means, applied in such a iitnnncr as to nv move all prcwure from the bodies of the dineased vertebne, until complete consolidation lias taken place. This croteh, therefore, answers a very good pnrpow.
Since the application of the pla»tor-of-Paris jaekct for the treatment of spondylitic, various dre^ings have been devised to (fupcrM-dc the same. For this purpose jackets liavo l>een made from leather, felt, silicate of soda, etc.; these lieing made over moulds taken from the originiJ planter jacket, which had been previonsly applied to tlie patient. All of these applications being SO
M6
8POKI>TLrn8.
iii>pcr\ioaB to tb« air, prevent Hie escape of the insensible per* spinttioii of iLc Wl^- ; aixl, morvovur, ucvcr being made to tit will) tbe iicciirary oi the original mould, cause chafing and exco- riations upon dillcrcut poru of llic trunk ; wbcreae in the plaster-
riB. wL
of-Parig jadcet the air cuii reach all ^iirfaocfl of the bodj, it being perfectly porouH. and if propurlj applied never protlu««6 exoori- Htione or pain, and withal is so easy of appli(;ation by ])liyMciana in renioto parte uf the country, that s patient euflcring fruni caries of the spine 'n not in any cai>e trampelled to tnvel long dtstaooes in order to wcure tho advi<.-e of the specialist or instra- moDt-makcr. In oarice of the Hpine an open jacket ie. never ad- ' miasible until the diseaM; ia far advanced toward recovery, wheal the lut jacket uaed can readily be converted into a corset.
Again, Tarious moditicationa of tliu mode of applying the plaster jacket have been nude by different pereoni), such as di- viding it into two 8egin«Dt« and joiniDg theac two 0egaieDt8 l^
TREATMENT.
467
instrameiita worked with a nitcliet «nd key, for tlic pnrpose of extension {Wyrtli). Otbere, ugittn, bavo joiiii'd the ei-giiienU hy an eiafltic spiral Biiring; for the iinrpoBe of ktM-jiiiig uji Ilio euiitin- ued extonsioii iKoborte). Still further moJifieations have been made l>v an iron brao« on eitlier tiidc of thi> ^pine, and a )>1iu>Ut belt {uueiitg around tlm tliunkx imd pi'lvi« (Sliatli:!-). Again, tbe e^ntents bave been joined witli a nnmlier of st<inr iiplinte, for the purpose of incn-adiug the «xten>^ion and varj'ing Uiv position of tlio bmlv b^ tliiH menna (Stillman).
All tlicM) moditications, however, I Iwvo found to bo of do practical value, afi the fixed extenaion aecnred hy tlie jurymant or Iicad-rcet, wbieh can bo tncreaeed if newjesary, aceonipliHlii-a all parposcd required by preventing pressure upon t}ie inflamed sur- facutf, and allowin]^ at tho winio tiiuo all the moromcnt« of the body and npine that are jintifiable.
Ottier«. again, liavc modified the metliiid of applying tho piaster jaeket, by suspending tbe pAti'ent in a banitnock, face downward (Mr. Uavy). Some, by placing the patient itt the hori- zontal poatnre, baxing the ])laater rollers cat into Bec-tions like the nwny-tailed bandage, and laid around tbe body : nn this latter operation reqairea some time, it is neccesary to mix Hhellac or gino witli the plaster, to prevent it* too rapid setting (Walker). Now, as the mixture of glue or ehellac rondere thu ])la«t«r iinpcr- viong to uir, it i* an influprable objection to this method of its application. The sufipcndiiig in the hammock by Mr. Davy enrres the ^pinc of the patient too innoli backward; this, there- fore, of nccr^ity places the patient in an abnormal petition whi>n lie aasaniea the erect posture.
Having tried all tlio»e varioos methods, I have fonnd the original plan of suspending the patient by the head and axillte aUo(|ffthtT i)refi'nd>lc, as you can regulate the amount of exten- siun applied with the exact preci&ion re<jtiin:d, and the po'^ition of tho p«tiutit is ao inncli more convenient for tlie accurate and comfortable application of the plaster iMiiidiigce. Objections have beOD made by fK)nie iu to ita want of cleanliness : tliir^ need not be, if the putienta are properly cleauised when tho jacket U applied ; and at a)l timea a t'>wel can be easily applied to the skin by the u»e of a piece of whalebone, passing it nndcr the sliirt from tttcmum to pnbce, and then, taking tlie two ends, by alight movoments it can be pasNd around tho trunk, pro-
sposDYi-tna.
dwnng « j^Dtle irrilatioa to the ekin, and thno removin); all eiccrctorj matter. Thi« Munc purpo«« can aIao bo aoci>iiipli»L<idj after ttie plan of Mr. Ogsden, of Liverpool, hy putting on tv shirts at the time of tho applioution of tLo jaekvt ; wlivii desiring to change the shirt tho inner one iti sewed fast to a fresh ahirtf wbioli w then drawn np in the place of the toiled one ; this be repeated as often as ni-cessary.
Othcre, again, have obji^eted to tho plan of treatment on then ground of its crueltv, and chaige it with obstmcting reepiratioE Till]* chargo w absolutely fal«e, an hundreds of inatanoea liave proved, where the patients have fallen asleep while tlte ptaeter is, beinfr appliud, and in all in»tanoc« oxprew adegrce of pleami tho infltant the proper extension is secnred. 80 far inm interfer- ing with the respiratory organs, it ia proved by pradiei] demoo* stration in every case of epondylitis tliat the inspirations and expirations arc ^-ory grcnlJy ini.'roa8ed after the jacket lias becnJ applied ; in fact, complete encircUng of the tmnk by an indexi-i ble caaing is tlie only means by which any snpport can be given to the spinal oolnmn witliont restricting the rmpirstory f unctic In those braces which are aecured lo the body by means fiexible bands or cloths fastened in front, in order to secure the bar^ of the inMniniont in proficr p(^<<iti'>n, thctw bands are conb^J pelted to be drawn so tightly as to necessarily interfere with roepiiatonr functions.
Fig. 2S7 fully iltufitrates the mode of suspenuon and the manner of applying the plastcr-of-I'aris jacket.
To illustrate the advantage of this plan of treatment, as well M to point out tome modifications in its application in certain peculiar oases, I will narrate a few of the caaee in which it lias been applied :
Cask. ;^|M>nf/^i/£*.— Michael X., aged three yeara, of healthy ptrenta. Was always healthy till I>ecember, 16T4, when his mother noticed a stiffne«a of tlie right aide. Ue was treated for hip-diseaee, in an institution in this city, without relief. Marcl 1876, the mother notioe^l a swelling on the right side of t)>6 spinel which gradually incnnscd to the size of a hen's egg. Was ex- amined in my clinic, and aspirated. I found pus, and a free in- eJMon was made; also, on examination, found PoU's disease in Inmhar vertcbne. lie was then dressed with phutor of Paris, and a fenestra left fur tlie escape of pus.
APPUCATTOS OF THE PLASTER-OF-PABIS JACKET. 469
Th« cliild woro llio dt««fiiiig six wouktf, wlion he bc^n to eom- plain of pain. The plaiiter was then removed, and it wn« found tbut all BbM-iMs Imd formed buluw uiid to the rif;Iit of the old one. A free ioeision was made, connecting these two abeceesee, wbidi ftfitorded great relief. The wound was filled with Peruvian bul-
rw. w,
eaiii and oakum, a piece of oiled eilk pnt over it, and his Khirt dnwD lirml}- over all and made Hmooth, when the plaster jacket WIS applied m before, while the child waH Hii«pcnd(Hl. A pin, paeeed through a folded bit of pasteboard or card, was placed over the wound, »o that each turn of the bandage, pai«ing over tiie
470
SPOSDYUnS.
pin, mndo a certain pu'Jc to tlio point over which we wi«he<) to cnt a fenestra. When the pliiHter had heeome nearly *tet, a fvtii* int, tlirvu inchtM) wido and iiboiit five inohi-x in k-ngtli, was cut aronnii the ptn, ontil we came donii to the oiled silk. Ttii« was thfu stumtd ill lines froiu its cvntro, and tlio fdpcs of it turned over the planter Lnndage; and the Hpace, carefully xtutTod with oakum to prcvyiii burrowing of pus mado a uico drain for tlto diflchaigos of the ahsoees (as 8«en in Fig. S5$),
The dark and dotted lint-e (Fig. S.'>!>) hIiuvt the relativo posi- tion of the epiiittl column Ijefore and aft«r snspeasion.
ll
ncmi
fM. tfi*.
The wound wm kept clean with oakum and Peruvian lialHnm dressings, and a tight roller paseed ov«r it overy day. The child wa« able to wiilk abont without any awistance on the day after the last (treesing wb« applied, since wliioli tinio ho hat been per fectly comfortable and free from pain.
Odober 20rt. — The chihl was brought to the ofitec tlio mother ftaying that he waa getting m fat that his jacket was Imt tight. The wound had etopjied di^-haiging for more than a fortniglit, and the diild had the appearance of almost robust health. (Dfr comber, I&82. — Cliild in perfect health, alight dofomiity.)
CASE.
471
Cadk. Sp&ndyliiu ; fnjury. — Hinnie O'B., Aged thne ycare, »( Imiilthy ittrents. About November, 1R74, she fell down*tairs. Shortly uftcr t\iK began to complain of ii ptiin in bur fttomncli. Th« mother found that tho abdomen was very bard and ewollen. Tbo cliild biut not boon able to stand erect tiucw. tho inotlier states tliat Blie wan alwsjm comfortable when lifted hy tbe arms. Throe months ago a email lump appcnred in the lumbar vertc- brs^ abont tlto size of a hieknry-nut. Jul; 3S, 1875, eho vm broaglii to mo, and on cxaminutioii I pnMiouncud ii Pott's dL#- eflae. Child was eiinpended in tho apparatus and I applied tbo plastei^f-Pariit dn-s-ing on the 4th day of Augiinl, in the jirw- encQ of fievi-nil pliy^icians, &ince which time tho child bat) boon perfectly eotnfnrtable and free from ]>atn.
September Irf, — Child complained of pain ; dreasing removod and found a Mnal) ubruMun from a fold in tlie idiirt.
6th. — Ke-tlre«ei'd in piaster javkef ; perfectly oonifortabltt.
Octabi'r "M. — Child has betn iu tlic country «neo Inst rt-jwrt. Betumed to-day, very much improved in general health, feeling well, running around without cane or LTiitch, and tho mother eay- iog that it is impofiflible to keep her quiet.
/^•■bnutry ^, ISTfi.— Child h«8 been without jacket for two months; reumiiis in perfect health, I>eformity very slight.
Cask. — O. E. d., five and h half years old, sent to me from West Virginia, by Dr. CampboU, Soptc-tnber 1, 1>*75, suffering from epondylitiis in the seventh, eiglith, and ninth doniat verto- bne.
She was unable to stand withont supjjort, either upo7i h«r crntehes', or banging on to chairs or tables, or sustaining herself by her bands upon her Iwnt tbigbs.
The diiiease began to develop itself after an injury, having fallen upon ht-r b;ick tvirly in tbo spring of IS74. In the nmnth of June, 1MT4, she wan taken to tho National Surgical lustitnte, 1 ndianupotiis where &he had an iron bnice applied to her, and whieb slio bad worn from that time until the preeiem, and, although a Temarkably well-litcing im^tnuncnt, it hud not prevented the curve from taking place, as seen in Fig. 260.
By having a piece of load rolled out in t}ie form of tape, T was enabled to accurately mould it to the curve in her back (as eeen in dark tine, Fig. 261), and after the child was suspended under the axilla and from tbo chin and occiput in the usual way for a
)NDYI4TI8.
fow inoineats, tliis leodoo tape-mfasnre n-ae agim applied the ei^ tiro longlJi of the spine, and tlie cbango in position i» iteoD hy the dotted line, Vifi. 2*11, tlms proving witli a positive mstbenutlcal curtainty tlui ciiange that had taken pUoe ta tlio conipciuAting
ceent
Fiu. leo.
eiirvc8oftticepino,witlKiut,hovevcr, nuking any uiatcria! change at the angle of dnformity.
The pliu(t«r jauicut wiie then applied over a niwl^-fitting ehirt, and the following daj she ran without any crutches or cane, very mncli to the father'it i<urpri»e, and returned to her homo in Wcftt Vii'ginia.
Six week8 afterward I received a letter frotn her fatlier, elating tliat hIiu had iin|iroved lioth in heaUli and spirits, and that her reiativeti an<l friends were pei-feotly a><toninhed at tlie great oliango in her form and carnage. Shu itiinply sufforvd after eating, ant) he feared that the jacket wa& growing too tight, and mggcMod tiic pruprioty of ite roitiovaL
Xorember 3d, 1 received another letter, rea^ling an follows:
" CiiAHiJvnoi, Win Vinarati, Xrttmtir 1, IBTS. "Mt db&b Doctor: TIio case .tou put on mj little girl b«caiii«BO tlglit Aud nnomtorCnIrlu tbnt I got niir fnniilr phTMrian, and we tncd oar lund* at a removal. 1 am glad to report our operation a perfect nueeeaa.
CASE.
478
" Oqr p*ti«nt it inti« Hvdy ta-dajr, and « tiiari«d SmproTotuent lu li«r bri>aUiiufC iit iilaMrrnlbl«, m the Jacket we h4V« appUad u in MourOkUCo viitli lior (Ivvviuiitnont »inoo the appKuation of tlie Ant jacket
"1 wild ■ pklurc of her preseat cooditlon. and yon can m« bow inach •traigliter ah* is than when yon first saw her. (■'^ t'\g. 2(12.)
"We fcvl confldNit tn>m the improvement thai hiu b^n inailis aiwl ihv conttort that she lias enjoyed by the use of the Jnck«l, tbut h«r ntiuvGry will be pnfoct aiid compkto.
■* OraWfully youw, Joyn W. O."
If tliere uo anjr cn«c8 in wb!ch it woiiM be jnstiliftble for thti application of the actuul caatciy, (hi» cui etteily be done
by making a fencetra over the plare where tlic cnatcry has bwii applied, the nine M in tliu ca»c ubovo nportoU whvm mo Abeceis extebid.
It ifl powible ttiat a flat Iiidi^i-rubbvr bn^ p1itc«(I over tlie abdo- men for the purpose of being inflated during tlic lime tti»t Uio plaster i» bciii^ applied, and wbioh can baro the gas let out of it after tlio plaster has set, will accommodate the digestive proccf*, eimil&r to tlie dinii(!r'])tid alrt-ndy iii(.'utiuUi.-d,
Having here recorded the reeiilta of the application of the pluterof-PariA jacket at tlw time in whieli I first drew tJio at-
BPOSDTLr
tcntJon of tlio profoseion to its rncritt>, I dov gire tbe history of several caee&, as copied from my reoonls, which folljr BubAtantiitta my early prcilirtioiiK t)utt ihi« droxeing in tlie mo«t dci(ira))lv and effevlire that can be applied in the trvatinvot of BjwndyliliH.
Cask. — LouiHe \V,, aged three years, I>ohhe Ferrv, Nuw York. Fatlicr and mother and one other cdiild very lioalthy. This child waA alwayti lioalthy tilt akotit one year ago. The father Ktatce that while pUying uiidvr a table she struck the top of her hcml very forcibly in rising, and criiHl for a long time fpi>m piiin bvlwran li«r shoulders Shortly after, she became irritable and crosa, ecrearaing at night with pain in hflr stomach.
These »vniptotna continued, and die ako bocainu paralyzed in the lower extremitieii abont three months ago, when Dr. P., of Dobhs Kcrrj", -Kan called, but failed to detect any diccaiw of tlio ^ne. ProjeclioiJ of verlebrre was first noticed about two week* ago.
June 7, 1880. — Patient brought to my otBce, crjnng violently, with a »Iiorl, hiccoughing nwpiratioii. Complains of great [lain in her stomach, in nnable to nit up or stand witlionl assistance, lower e.\treiriitie« ))arti»lly i»iralvziHl, and there is a marked prominence of the fifth and sixtli dorsal spines.
l'ni??ijro on the head causes Bcvi-rci pain, which is entirely ro- lievL'd by fiiis|>ension. When projierly siispendeil, the plaster jacket was apjilied with the juryniaitt. When the jacket had «et and the hend-roHt was adjusted, the child walked ahout the room, and said she felt no jiaiii whatever.
Juna 18/A. — The jacket failing to give proper support, it was cut off and a new one applied.
Julyi%t/i. — Child returned very much improved in everyway, and has grown much stouter. The last jacket has broken, and it was reapplied to-day with the jurymoKt.
Ociubtr 26M, — Child remme^l greatly improved ; has been in tlie country all Bummvr, exerciHing freely; ha« bcvn perfectly comfortable till foar days ago, when she complained that the jacket did not allow her to eat enough. Xuw jacket applied to- day with jur}-mast, and the child was able to run and jump witli- out pain.
J)evemJ>er lUi. — Child luis grown so that she complains that tlie jiieket is too tight. C»t throtigh centre of titc jacket to front, but not through the shirt ; padded over stomach »o oa to
OASC
475
gnp« the edges bolf nn incb : took off oiitsido thuW down to the jnrymast, and seciired the head-reflt. with fresh h^titlageii, over the uld jacket (hm culuigcd, uud the oliild n-iui luudo pvrfttctl,v coinfi>r1ul>1«.
^etruary^9, tSSI. — Very marked improvement in tlio child. N«w jackft n6«,*»arv on account of increased siie,
/lywiY 3rf. — Child returned to-day. <^fln i*timd and walk alone without any pain, and slight pain inily produced by firm pretKure on the head, ^ew jacket npgilied.
Jiiru' 4/A, — Find consolidation coiuplotv, but the jftckct vritt reappIiBi], and iiiiulc into cnntet aa a protection againftt retnpK«.
SepUiiihfr 'ii't. — 'Eliut worn corset ifiiioe a]i]ilie»tion ; cont-olida tion oonipleto ; oor^t removed ; cured.
The following \* a» extract from hor father's letter of Feb* nuiry 10, 1&82 :
** Th« truioiMt wna n purfuct huoonh, and titu \» Dow la perfect li«iiltli, and at kinkiitlil rikI unlive a olilld oa 1 have cvor ttm. Tlierc U yet a oliitbt pTu JVC tion on tlic «|nne, but aa sbe grow* older and larger I thiiil: il will nl- IDOM diwppear.*'
In this ca«e a complete cnre was effected in lese than eighteen months, and the child ruiiinin» in perfect he.-iUh, l^SI).
Cabb. Sp'^niltffitM, Vpiier DoriMl Vert^fnte. — History ; Hal- lett Xliddaugh, aged three yeaw. Del Norte, Colorado. I'ai-entB healthy.
Octohfr, 1880. — Child strong atirl niddy, when he was taken ill, and treated for woriiiB, in<Ugieiition, etc., by Dr. P. ; ajipiir- eiitly reeovere<l frum thi», but the mother »tftte» tliat since tliat time he appeared to have more or less inward fever at all times ; aliortly before thia attack of eiclcnewt the child had a »1if;ht fall while climhin;; upon a sewinff-machinc, hut wn« HCcmiii^ly not hurt to any great extent. In January-, 1881, the father took the child ti> Florida, and n w<wk nfter, while riding him on lib font, he complained of the jar hurting him ; he then eomplained of n ierore cold, and wa» taken to Dr. 8., of JackBonvjlle, Florida, who, owinf; to the cbild'e labored breathing, pronuniiced it pneumonia, and treated him fur thiit dinea^e for soitiv tiine, hnt witlniut relief ; but from the reet in bod the patient ficcmod to n.^in strength. He wao then taken to Codar Keys. The mother noticed at thia time Uiat the child would walk crooked, u she cxprcfi»cd it ; he
470
STONbTLITIS.
was then takeo to Dr. F., wbo etatvd lio Und a little pleural tron- blc, and tliat the warm weather would cnre him ; no relief, how* over, could bo obtalucd for tlit- cougb, uud Ui Fcbniarv his lower extremities became paral^'zed.
MatvA 26, 1$81.— The vhild was brought to my office for pMialjsis of the lower extremities; had boeu unable to etaiid for iK)m« weeks, or nit without being eupport^id ; he luid a votiiitant cough, and a peculiar drapbragmatic t<paAm, wliieh the motiier stated hud been ({uitu ]Hinii8t<>ut for mtuiy ilayH ; he eried Goa- etantly, and, from the peculiar poHttion ia which he <'arried hia head, I wn« led to suspect vertebral dineaKe, and, placing my hands nndor hia cliin and occiput, he immediately ceased crying, the diaphragmatic i>paHm t>nb«4dcd, and he breathed quite freely without coughing; the mother stated tliat thia was the tiret ap- pearance of comfort the child had enjoyed fur many week». The moment 1 removed my hands from his chin an<) occiput he screamed in aguiiy, and tlio eamo pcviiliar re«piratioii wag again resumed, whicli led me to suHpect disease of the vertebral column.
He was tlien stripped and a distinct prominence was observed at tho last cervical and firat doreal vertebnti, which up to that tiTDC Imd not been suspected ; the thighs were flexed n]>on the abdomen, and enuld not be extended ; the ulKlomen was enor- mously distended and tympanitic; the mother stated that the eliild wait continually complaining of colic.
The abdomen being greatly distended, and the pelvis ao smalt la to render tho application of the planter jacket imtKiMtiblo, ho WW placed in the wire cuine«, and when alight vxtcuaioa vaa made he was perfectly comfortable.
April 14tA. — The rest, with extension in ttw cuirnsa, so im- proved his digefltion that his di&tended abdomen sn fHr Hulifjded ao to admit of the application of the plaster jiiekut, which was accordingly applied.
April ir>M. — Father brought thecliild tomyoffic«. and stated tliat the ]uitieut had slept better during the last ntght than WDCe he arrived In New York. Thia morning the child can waljt and tt/ind alone ; docs not seem to be inconvenienced by the jacket.
J/</y 25/A. — Waa much improved until two weeks ago, when be was taken with dysentery caused by eating strawlwrriee, whioli oeoee^itatcd removal of tlie jacket ; during thia time tlio juatieat
CASK.
477
f^M kept in the rMumbent position; to-day the jacket waa >e> applied.
«Am« 39/A. — Hiw been at t)ic Kcn-diore for the pout tlircc iredLs; Las gn>wn tnnch stonter and itt6ln>ng<or ou his lug»; new jacket and iK-Jid-rt-Ht upplicd.
jltiyu*/ UUA. — Has grown too etuut for the jackot; new one vitb bead-rest nppliod.
fm. m.
Fhi. W4.
Septembo' lOtA. — Ua» improved in every way; leaves for Colorado in a fuw duys. Now jac^kct and bead-reet applied. Fig. SOS aliowit condition of ttiv cliild at thU time.
Noivmhfr tX^fh (extract taken from letter received from Mr. MIddaiigli). — "ilas Iteen doing well until tliree weckB npr*), when the jacket bccniuu too tijflit, and wiw, tberefon-, out down in front and secnred by a bandage ; child haii grown uiueb taller.**
FAr'iary \5, 1S82. — Piitiont again at my office; i« tttondily impm\-ing ; ean ^tand and walk withont any lUipporC or pain ; new jacket and liMid^reitt applied.
October 18/A. — Child ba« made rapid improvement Binoo but dat«.
Fig. 264, by Mr. Stead, eliow« hie present condition, a perfect onre having been effected in this case in lew tlian two yearn.
478
)SDTtrTI9.
J}<Memher 30, I8S2. — Letter from the father etiitcs tltat th« patient is iti {torfect tiealth, and no jacket ii* rvquirtHl.
Cask. S/>oiu/ylUU of Thinly Fourfk, and F{fth CWeical Ver- Ubi'a. — UwTOUY. Jowphiiic Ijirkin, aged two years and eleven montliB, Palatka, Florida. Panjati hcaltJiy ; have one other child i>erftfctly liealtliy; pAticnt, when three inontltit ohl^ hod a severe attack of portui^eis ; seemed to entirely njcovcr, and ro- niaininl in ]HTfect heiilth for one year; at that time she was no- ticed to carry the bead a HttJe £tiffiy ; throe itiuiithit prcvtoaslyt however, fllie foil liackwanl, ttlriking her head forcibly, hot in a short time appai-ently recoreroU from ihc accident.
On April 11, t&Sl, the child waa sent to me by l>r. W. IT. Buotli, the patient at that tinio being unable to fvtund or even eit erect ; alwoew had fornied on right side of neck juitt above clavi* clc; wa« opened in Kovomber, 1860; oonnidcrable enlar^mcot at back of neck, neck eborter; bodiee of third, fonrtlt, and fifth ccrvieal vortebmi «wmed to be abeorbod ; huwl draim back.
Tkkatmrnt. — Wait placed in wire euirase for a few days.
April It), 18!^!. — Small piece of bone escaped from eions on right side of neck.
April I8r/*.— Applied pliister jacket v:\X\i jurymatt. Child waa comfortable a» s'xm a» suspended, and fell a^tleep immediately after the jacket wii» applied.
May l«f. — Child cuinfortahle and much improved. {Se^ Fig. 2fi5.)
June 2i/. — For the past foar days baa complained of jacket being too tight ; cut the jacket open in front without cutting tJio fihirt, and found a large pin between the jacket and skin over tbo left nipple, wliich hod caused pain. A pad was pIiK^d un<]er the eliirt, pressing ojMjn the jacket in front for nearly au inch ; a free!) plaster roller wa^i llicn applied to weiire it in thin position ; tlie patient WOK then perfectly comfortable, and could walk by taking iiold of my hand.
ikplember 30M. — Has been perfectly comfortable rince hut date, has gained in strength and health, sleeps well and has good appetite, weight ninrkcilly increavcd, no other \i\ixc* of bono have been discharged, and the discharge from the aliecose is gradu- ally diminishing; can now bear quite firm prcMurc upon tlie bead withont pain ; new jacket and head-rest applied.
Decett^r I, 1S81. — Child rung and jumpe with perfect frso-
OASSL
479
dom ; ha« gnincd four tnd « half pounds since SOtli September, and is in pe^f^^(!t lienllh; alMcew discliarptw a. few divipfl every dny ; can now hold iLu httid erect when i>up[>ut't U Tumowd ; leaves for Florida to-morrow.
April IT, 1S82. — Ilatt been perfectly- wuH u'lice Iii^t date; a piece of bone vraa i-enioved from einiiH bv ]^r. Boolli in Decern- bor,18SI, Can now bear preK«uru oii tlio Lead ; new jacket and heod-reet applied to-day.
Flo. Mb
Fio. VA
Odder 6, 186S.~Cbild has been pcrfoctlj well during the sammerr baa taken a great deal of exercise; no distortion of >pinnl culuiiin obwrvable, consolidation of pre viouiOy •diseased Tertebne nearly complete, can stand and walk vitbout any Nip- port; new jacket and head-rest ajiplicd to be worn lut a conet for protection.
JITowmhfr 25/A. — Haw been in perfect health since last date ; has been out in all kinds of weather. Can hUud and walk witl>- out pain or Bupport. Motions nt bciad perfent ; corect to be worn as a protection for a few months longer. Fijr. 2tJ6, taken by Mr, 6teu),&bow8 condition of the child and her ability to stand alone. Leaves to-morrow for Florida.
MO
Brosi>yLm&
Dteemher 2MA. — Received a tetter from tli« fatlier, stating chiUl was pcrfvclly wvU. Abeocw luw dried iij>.
Caas. S^HdyUti« of tht Eleventh and Tteei/th Dorsal Yerttbrte. — On« of tJic f ouogcst cMM to n-hom I liavo applied the pla-'^ter jaelcet.
Matj "i'iy 18S1. — Wtlliftin H*lwy Baird, «ged two yean two months, 28 Cottage Street, Kewark, N. J. Fareuts both hoalUiy ; have one other child which is etrong and heoJUiy, and is now Mven yeara of age.
PatJont waa always well until Se])tomber, IflSO, last, when the child had a cold, aiid wau taken to Ur. S. It. Dennis ; at be had ncv«r walkixl, the doctor treated him by electricity, sall*water batliH, massage, etc.. for nine months; not improving, the child was taken to Dr. Blylie, who, finding frefitient prispiam fmm con- tracted prepncc, attributed his want of nuiscular power to reflex irritation, and circumcised him. Not improving, however, in his ability to Bland or creep, and complaining of constant etomach- ache, Dr. Illytie suapected trouble of the spine, and on examina- tion found two Email projei-tions over the two lower dorsal epintw, and advised the father to come to me.
On cxamiiintion I found that tho cluvcnth and twelfth doreal vertehrw were qnite prominent; the child ^vas unable to stand. On laying him on hiM etomach acro«a my kucvo and extending tliu Bpine, hiH breathing was more free, and he said he felt well ; on pratatng x\\v head mid Nicrtim tuwan] each other it producod a apasm of his legs, and he cned Beverely with the pain induced by the preeaure.
I>iAnsosiB, — Spondylitis of the eleventh and twelfth dorsal Tcrtcbra>. TVo cattso coutd he n«iigned for the ditHcnIty.
Treatukkt. — Horizontal position, in wire ontrasa.
Mnif Mtt. — Chihl was plucml in a wire citiraM*.
Jidy \sL — Child has improved sinpo being placed in the cni- raaa ; to-day aiispended hltn and applied plaater-of-Paris jacket.
Ath. — Child stood up tonlay for the first lime,
Au^u«t^th. — ChiUl has been perfectly comfortable since the jacket was applied.
November 8(WA.— Child hiut bc^n tn excellent liealtit since last , date ; has been walking for the past five or six weeks ; the jacket i was «it down abont two wceka ago, bceaoae it waa too tight, and secured by a roUer-bandagc ; child has grown in eretT' way.
CASE.
481
April 4, 1882. — Five weeks ufto tlio child complained of tlie jtcket being too tight ; the father Itien cut it down and Mtcnrcd it witli B n>ll«r-biindage ; line K^n perfectly well all the winter, and has been walking; all the time. AVhen tlie jaekrt wu removed, tiio child ounM fc'tsnd unci walk withont any piiiu or support. There \» no pain on compreesioo or ooncuwiion ; a new jacket was thou applied a» ii protection iigiiimtt rclap«c^
SeptgmlKr IsM. — Patient taken to the clinic at the BpIWho Uoepit*]. Child U pcrfecUjr well, aod do pcrceptihlo deformity
l^.t«i.
Fw-ftHL
of the Bpine, with the exception of a stight fnlnesa hardlv ohscrra- blc; van run and jump as well as »ay child.
Weighs thirty-one and a half pounds, and meafnires three feet and a quarter inch in heiglit. (The child was then strip)>od, and placed before tlie cla.<ts.)
Now here (pointing to the child), by carefully looking, you can eee a slight shadow and f olnees just at the lower doreal vertebrw ; it i?, however, hardly noticeable. (8«e Fig. SAT.)
Kow here is a Iwy, you observe, who has been cured almost without any deformity at all in less than eiglitecn montlis ; thu 81
183
SPOSBTLITIS.
ehitd (hero placing a penny on tlie floor) Atoo|M over and picks up a peniij' from the floor as wull ha iiny child ; you will set thoes diildix-n w)io ore tiuffering from tlua disease, wli«ii attempting to ' pick anj-thing up from the Jioor, will ecjuat down bending etdo- ] way», «iid avoid bending the fpine, whicli they would not do if free frmn dieeaeo of tho verltbriB, Whi-n vc have cured tbo child of the dbeaite, we out tlie jacket down and allow him to wear it aa' A coiwt for Home montliK longer, simply as a protection nguinet ft relapse (** Fig. 2GS).
Cai*:. Spondylitis; Ei'jhth and Jiinih Dorml Vfii^ra. — Showing the application of the plaster-of-Pam jacket and iron lirace, with the relative result* of each method of treatment.
Edward A. Hoyd, Woody Crest, riarleni River, N. Y., aged four yei:tn>. Parcnte and four other cliildien all healthy ; patient healthy until March, ISHO, when he fell from hiit crih, striking on hi* Bide; in a few weeks ho began to droop and was less play- ful, and in the early ciummer was taken to iho monntaini): the health of the child still eontinuing to fail, he was brought hack to tlie city, and Dr. O. ■]. Jaeknon wa<t called to mx htm : he din- covered a small projection over the dorsal vcrtobne, and sent the child to me August 17, 188l>.
At this time he was unable to stand without support, the body l)eing bent strongly toward the right as. in hiteral curvature, hut without rutfLtion, and a marked aiitero-posterior curvatun* at the eighth and ninth dorral vertebne ; the right thigh was flexed very much more tliiin the luft, and could not be extended; the child complained of »tomaeli-ache, and the motlier stated that for sonic wtrvk« he liad coniplainud of feeling " as though he wim bound too tightly amund his belly." The child being placed in tlic su8pL-itdi»ga]iparalu», wiw can-fully extended until he aald lie was free from all pain; by the suspension the lateral curvature en- tirely (liKappeared, and n marked <liiiiiiiiition was ob«er%'eil in the antero-postcrior curve; as the pulley was let down, the deformity immediately returned, and the child began to cry most pitoousty.
DiAoxosts. — Spondylitis of eighth and ninth dorsal verlehne.
Trkathe.vt. — Plotter jacket and juryinadL Cliild was kept in bod until jarymast could bo made.
A ugua/ 21,1 (^SO. — Plaster jacket and jurymiUtt applied ; when set, the child could etAud without astidtauce, and said he folt vvry well.
CASE.
4S8
24M. — Patient at office, looking much healthier'; motJier he ti»d hwn quite well, and had txieii able to pla; all day rithout any pain or complunt.
SuptfmhiT 21rf.— (Jhiid has not compliiincd of nny pain or ^^iscoiiifort einoL- the jiickvt n-iut appliud ; has taken a gnitit deal }f ex»rci»e, and itnproved in evory way.
Xfovemher \1fh. — Child much iniprovvd; jacket too tight; DOW one applied, with jurymaAt.
Novemh'.r 'H, 1^81. — Five jiickutfi lijive been applied Bince lant date ; patient can now sliuid without the jacket or other sup- purt for a fi^w iiiomentx ; new jacket with juryina^t nppltvd.
January 31, 1882, — I received a lettter from Mra, K., Mating that filie was tonicwhnt discouraged nt the progrcHs thu child was making, and intended to try another method of treatment,
J-'ftfuaiy 1 IM. — To my HiirpnW, I tvci^ivud a visit from Mnt. B., bringing with her the boy, and requesting me to apply a plastor^f- Pariit jatikel, »^ho having abandoned the " Taylor bmee " after wear- ing it only 6rc days; at this time he was wearing the old plaster jacket which Aiv had rca])plitd after removing the brace. A new jacket and jnrymast were then applied.
J-'thriuii-y \&th.—\ rut-eived the fallowing letter:
" WooDV Ctatt. /Wroiry ^*, IttS.
■*Dctft Da. Savhi: I ktiuw yon will be eind t« bear tUt Eddlv's Jacket
Km Mt bcMiliriill/ : lie i* jnxl n* *(rai|^bt anil comfortabhi in it n» 1i«< oiii pos-
liblj be ; *n'l now I uiu'<t li'll vou li»w glad 1 un tlial I lAok thnt liraoo off w
FfooB as [ ill<) ; I cnn imA be loo tliHnkful ; five days of tiM brace wa« miod^
tar mc ; poor UiU« KikUv iitffcred inur'u id (hut time than bo vrcr sufforcd in
all lh« time li« hm lia<l l\w diabase Ho never slept ten mlnntea at one*
dnrioK the (iiiie he wore it ; mi miiltur liuir 1 Iriod tu lix bim. it liurt : ir be
lay on IiU aide St pnUicd him, and lie couldn't He on liis back el all. for ttie
iron prcMwl io on ntch aiile of iiin npinc, u tbnl it n-oi impoudble for tiim t"
be «0aifar1ut>l«. Tli* iilr«p on the bottom of tlie nproD— I ibiiilt It in called —
hurt lilm very macli ; it bnd to lio tightlj dmvrn, or diw tlii- irona don-n the
i^bMk irould not May in Ibu rijilil plocf, but vroold get over ou tlie lump on
^bie *plni\ and inaki> iliat niytv, «a t did not know wlut to do ; bo «ro« (pittiaic
nerrouii I i-onUI do mitliiat: ^i'li bitn. I came to the coudauon, aa ho
raarer had any auub (rouble io ibe plaHier, llist the heat thinx I could do vaa
[to pot bim back in hi* old hnracK*. How glad tbo poor fulloir wna to ^
I'baok in it! He went to aliMp and slept nil ni^ht witboot moving, the firat
[good eWp bo had luxl Id fin niKhta. I am porfacttr t-ititdlrd tiav, and will
JnM want to Irj tmj more braoee, I ohd aamre 7011. Vi'iih ihia new Juokvt ou
l^s la tike a differoDt bo; ; be plaj* aad Tomps all dn^. nod fs u bright end
b^ipr a* au; cliild con be, I forgot to M7 iJiat wbilo lie wore the braoe he
434
SPOJTDTLITIS.
bad paliu in his Blomacb oMriy 4II Uie time; ho Ims had dodo at all slim I ]Kit liim bock in Uio plittUr. Tlwro U noliiing liki- iioriutiii liiii]im|[ out fur theiasvlvo'i. «o I du not tliink (rylog t)ie cLati^ at tri'utiiiEDl hw doM any liftnii, for I would Deror hsvo bMn Mitiafieil atlicnriic, a* I did aot diink EdUie wa« gctcini; wtJlfAtttnougb, andiometbing duv ulKi>t Wlwttvri iww 1 kouw for myxelf what tho olbor Is, and bavs bad ooougb i>t it.. " Witb ttiBiika, etc, b«li*Ta nut jruitru, linccKlj,
» Ub. i. Kon."
Tui. S«.
Fn. tID.
March 20, 18S2. — Child rvtumcd to-diiy for first tiiiio t^inco February 11th ; jacket became too tight n week ago and waa cut duwii ID front hy the mother, itnd Hccurod hy 11 mlkT-bimdj^. Kcw jacket and head-rest applied. Has been perfectly cuiufort- abte nince previoiiR dale.
J/o^ ad. — •Tncki-t last applied cut don'n t<Mlay and mado into a corset; can utand erect withont support when jacket Lt re- moved ; can concnM upon his heels withont pain.
OetcifT" 9tA. — Has been perferlly conifortaMo during the BUin- tner; grown very stout ; walko qnite well witliout BUppurl. New jacket applied as oorHet for protection; apparently well. {Sea Fig. 269.)
0A8E.
48fi
- ^ll^Wmdvp 24(!i. — Returned ttwliiy; jacltei pcmovcd ; perfectly '^tt, and bnt slight defarmit}', aa K«n in Fig. 270,
Theae cans ftilly illuHtrato tho value uf tliis pUti of treat*
I mwt. And its upplical>ilit,r even in enrly cJiildhood ; ullowing tho
patient in all caAca, hv lie ndiilt or infant, to secure tlio adruntage
of otit-door exercise, tUus invigorating tlte constitution, und b^
thia means incrc^ing the nipiditjr of the ounx
TLo annoxod two vases are good illuEtmtionH of the immedi- ate benetil derived from thiit plan of treatnieut, and iho ability of tiie puticnt to pursue his daily avocation.
While I was in che Orthoi>edic Uo«pitnI, in London, in July, 187T, J<j«opli HuUigan, of Cork, Ireland, came in with a letter from Mr. McXan^hton Jones to Mr. BroiKllinrHt, with a request to Iiavc him apply a braoe, Mr. Broadhuret Jtindly consenting U> let me apply the plaster jaeket to him.
Mr. BalkwcU accompnuied mo with the patient to Mr. Mayall's, and bad hia photograph taken, us seen in 1*'!^. 271, from photo- graph. The samo day he was Euependod uud tho jacket ap- plin).
I went to the hospital on the followinff day, to obtain tlie previous history of the case, for the purpose of including it in my book on FipinnI curvatures then going through the pn^^ of Metisre. Smith, Elder A: Co., and found that tlie man had left tho lioffpita) a few hours after th« jaekut was applied and tiad not retnmed.
I next met this patient at tho railway-station in Cork, in Sep- tember, just aeren weeks after the application of tiio jaelcot — do- ing his full work as porter. He attended my demonstration the following day at the Queen's Collegm Uospital, Cork, wlii-n Mr. McXaughton Jones gave a full history of hie case, and the man atatud that he left tho hoi-pitid for Dublin the same ihy Ibe jacket was a]iplied, and had Ijeeo regularly at his hu^ine^s since that time, altliough ho had boon disabled from work for nearly BIX moiitlis Iwfore Mr. Jonea sent him U> London for a bmcc.
He Went with Mr. Jones and myself to the phott^^iupher'a, and had his pieture taken (m« Fig. 372), juet seven weeks from the time the jacket was appliinl.
Mr, Jones took ehai^ of tlie case, and puhlislied the same in the " Dnbiin Medical Joomal," as perfectly cured in lees than Mghtecn monttis from the eomm::ncemvnt of treatment, and that
SPONDYLITIS.
be liad not Imt a day from Iiis work Bince bis rotnrn from LoDiloii.
Mr. .Tones applied two jackets, tasking only tlireo in all.
I Mw tlit^ iimii in AugiiMt, 1S8I, doing ftill U)>nr as porler at the Limerick junction. Ue was a very strong, robust inwi, knd lid b« liad worn tlie jacket nearly two year*, and been perfectly well all the time.
Case. — Mary , aged about fifty, native of Ireland, very
Btout, strong, aad active woman, fell from steplatldor in 1877,
Fw. III.
Pia. ffl.
striking on a «>fa on the middle of her back. In a few weeks began to compUin of pain in bending or lifting, but still con- tinued at service with Mnt. M., VVeftt Thirty>tbird Street, for futir months, when a slight knuckle appi-arvd over the middle dorsal spines
"Was Hcnt to Iioo«evclt IToepitnl, remained tome montti«, and was removed to St. Lnke'et, where flhe was retained in the hori- zontal poi«lnrc for over a ycJir. The disease and deformity pro- grcuL-d rapidly, notwithstanding she was constantly retained in Uie recumbent poeition, and ahe tiually became completely par-
CASK.
48T
iljied in both lowor cxtroinitiw, tnd l]ie earn vi« pronoiitiocd incnralilo. Mm. M. then ncoured her a bed for life in the " UoiiK- for luL'iirttbk'*," itt Fonlham.
She retiuuned here some months on a enft mattrees, vritii a
' stocking stuffed with Hand on iMtUor Hidr of tli« Itimp on her buck stitched together at their extreiiiitiott, for the j>ur|KRW of iiinking a hollow in wliich the projection of her «pi»c cuutd lie jirotectvd from preeeure.
Stio wae complotvlj^ pamlyxcd in tlie lower extremities, and conld not even &ex her feet or make any movement of her tow.
] first saw her in January, 18$1, lying in the poHition ahove
' dncribed. On roilinp: lier over, there wa« u very iiiurked angular projeiotioii of the 9tb. IWh, and Uth doi-sal vertebriP, and this de- formity tukd ocnirred.notn-itliMtanding uhe had buen in the recum- bent posture all tlic time for more than three years — showing that, even in the recumbent poHture, exlenfiion is abitoliitvly neeet^ wiry to prevent the dcfnmiity, which will be cauei-d by preestire from rellex niuaeiilar pontraotion even in the horizontal poature.
By milking alijjlit tniclion from her feet, wbile I>r. Campbell held her under the axillie, she immediately said she could feel in her low, and moved her fuet.
A few daya after I placed the tripod on her bed (she conld not ait up), and, having put on her « knitted «Jiirt. tOie was par- tially suspended until tlic said the was " free from all pain and
>tli« hot, tight Rtring around her belly wan all gone." &fy son immediately applied the plasttr jacket and jurymaat, and when it had aet and the hi-ad-Mring properly adjusted, she said ahe waa more comfortable than she bad been for yeare.
On my visit the following Snnday, I waa mirprised to find her tfitling np in a chair. An she eontd then utand up, I was able to put on a muL'h Wttcr-fitting jacket than the one ajiplied wIiQe sitting on tJic side of the bed, and I tliercfore removed her jacket, and, placing her under the tripod, i-bo wiun suspended in the
' standing pOMtion, and a new jacket with tlu! jnryinast was ap- plied. This jacket was mnch more accurately fitted to her than the former one, and, strange as it may seem, as soon aa it had "set," she widki'd around the ward <|»ite naturally and said she was entirely free from pain.
In the annual report of tliis institution for 1881, 1 find tlie
488
FRAOTCRE OF T1TE 8T
following from Dr. ('arapbell, the Visiting Physician: "Dr. Sayre has rigitot] thu liuiiie fruqucntly during tlio Inst y«ar, and has it])]>lied hU pln^tnr jacket to three inmat€«, with great relief to oil, and with owry it-uKoniihli; certainty of euro in the case of one woman with Pott'H <]i»eaAe, who, when she ent4M«d, had to be varriud to her bod, and nuw ifliu onti daily bo eocn parading the' groands in 'jacket and jary.'" Tliia report was writtOD tmly four montlis after the npplieation of tlte first jacket.
She oontiiinod to improve daily. A ucw jacket was applied in tlic fall, when 8lie waii able to exercifte all day, and Iiad grown romarkubly Htuut and Hirong. This jacket wait n-orn nbout i-ight months, when die seemed entirely eonBo1idate<] and in perfect health, could dunce iin Iriuh jig will) gnwt vigor, and wa« anxioiw to get a Bituation as cook.
This Hftme plan of trentment is equally apph'cahle to cnsM of fracturo of tlm eplnv, and I have applied it in three caHft in whicli the paralysiii had been complete for many montlw^ln one case over two yeare — and all three of these awes made perfect recoveriea ; and in .ill of the eases they were enabled to r^ume tliuir BVocationH in a few wceke after the appltealion of the jacket — which certainly ia a strong evidence of the fmperiority of the treatment over the plan by re»t iu tlio horizontal poeturo, aa it enabletithepiatientfi to attend to their hnsinesfl and earn their support, which is a very important point in ease* of the poor and [ Uboring classes.
The aiuioxcd ease of Dr. C. W. Ilaekett, of MoKaehusetta, aa reported by himself in a letter to the " Boston Medical Journal,*' of 1880, I have copied from tliat journal :
RAILMOAD IJIjrKT. CASK Ot XiK. C. W. tlAvnTT.
"October 15, 16T7, in Awllvtiiiii; frum a iiiaiD iniolc to a lirnach, the trnla gotag round a carv« at a rnpid rnt«. while I wiui otaDiIinK in tlie kw of tbo ' CAT, I was Tt<klvn<Ij ibravn iiih'O ifie cunx^r of a iituT«, and initantl;r par*' i Ijxcd bolovr tho woi«l, probnM/ by n (1-Bctnro tt on* of the lumbar ven«bnB, jtreKuiiinblf the Ititrd. Wliit« partljBi* of rootioD wai complete at tba tfni«, tber« VM M»ii« MBsatior) and pnln In lli« oulside of tli« l«n iblg fa for a fe« hoar*. Tliere wu tuM of control o( Ibc bUilikr nnd rectum, with a (Mliaf i of ooontrlctioD, as of a il^bt baoil, about tlie lower |>arl of Uie abdooicn. tba lln« of demarkntion between tho actin and poraljrxod parts bolnic dcartjr d(<fin«d. Pain at the point of iiyurr was UKiMMDt. niul aercre bejoDil d«- •cription. Th« bowcU wore evartiaUd by ««lbarll(a and djtUn, and tlio bladder hj tlie oatliet«r, wltb treatneot i;jtpeot«ai oaljr. After Un wceka
CASE.
489
\thtn waa •oiBO rvtnrn of leowition, with oliUitj' to eraeaste tlve Uedder rolnntarlly b» a g«ii«ral thing, and in a liltl« innrn (hnn flro n>i)nt)ii> from Iho SoDcaf tho injurj then) oomiiKMiccd a alight inuMulHractiuti In tlie luff*, wliicb htarwed irregakrlj, so that In n year un«rtlio burl tboUmWcnQld bi> drawn Dp and piubcd down in tlio Im-iI, und ev»a be ninde to rnova m in wiilking, 1th Ui« body wippurted un crutvliea aod b; CD attcDdaut ; bot oiilj a IriUIng EMnoDat of woiKht r^nld bo f><iainmc<d bj tbom.
" Daring nil tfiU time thi^re vtn fre<|ti«nl periods of almoA totnl pcinilriiia
of hotb motion and wntation, Rrpoilr inflaaoc«d, ovidintlf, by Iho foraiaiion
of namerom abaeeiMS, wblch hv^aa about >\x inonibD ader Ibc injur;-, dia-
diow^S throngtb lb<t ractiUD, tho outeidft of tb« rlybl Ibixh, and tti« inaido of
llliv Ivft — tbL> luit«r gtviog exit to two rragnienta of bonu buU ao Inch to ua
llDch or naore in Icntrlli. and from on« to two )in«» in Iblcknow: one piece
Ifrom two ur tb^el^ Ilnm in widtli at IIm baiw, taperitit; to a pitint, and )>nrll.v
Btoroaed: tbo other, froio one to two Hoes wide, eomewhat pointed tHid
I11I7 curred or t»i*tet) in abniio, bat [lerfcL-tly lirii;bt noil clean, and kIiow-
log lis fracinre very plnlnly. I ain eunfldent Ihat uuother frngioenl of boae
had prcTiomljr ctciipLiI per ivdtnui, vliite •lill nn<ilt)«r wnx di*lin<llj> Ml fa
the abaoew tbat formed In tbe outside o( Ibo rlglit tlii^li, bnl aftenrard die
Daring the rintrf of lS78-'7» nlmccvw formed witli ffrcat fro-
qMougri oauiliig macb low uf sircngib llirougb Uie large quaDtitiw of pop
armsd and tho Mrere pain th4<y orimtod ; llii> partinl r<«^ar<>ry of the nrtlon
tt tbe tnnadot wwt in a great meaanre lost, au ilmt lljey r<.-»pODdvd to Ui« tort
F.vf (Ivctrfdt.T no more iban wnnid iIioro of a innn rvcontlf decvaned, nnd 1 waa
rnnable lo di«lingai*h tlie diffvrence betwct-u bvnt and cold when applied to
tbe Mrfaoe of tiie extremities— lnd«<d, ao Imperfect wa« WDMlioD rliat 1 bad
bolb legs Ijadlir burned on diflercnt occauona by ton bot *oap'*ton«s without
being swara of It at the time (It t>elng neoowsry to u»e nriltlcial lient to luain-
tain proper wamiih in Iho oitremiliei).
"Tbe abacefties linallj Mopped funning under the nae of iodide of ]»ota^ am, «o that aft<tr Mn/, \ft7\<, only two apppar«d~ihe bet about thn fln>t of LagusU With tbo cvsaatiun of alniotosnt tin prove raent took place In ibe gen- I baaltb and In tbo action of the 1eir>, app«mit]y nidod by the daily dm of pAlectricity and fricliom, and ihu pvrslixunt exerelae uf the niuaele* by rolilloa ; M tbat by tbe antarnn of 1AT9 I waa able, at llniea, to get a port of my weight on my ffct by oupporting myoolf 00 crutobcci or over tlio back of a (Jialf. Bill I wa« «tlll nnable to be off my bed, exc«^t for a abort time dur- ing tbo day, anil nftoo did not even make tbo prctcnoo of rilling np for more I than a week at a time ; waa compelled u> evacuate tbe bov^s by iojeoiiooa, at tiiiiM wbao stifferiDg from poioRil diarrhtra; ami waa auflining Btenae pain In my aplae and limbe all tbe lime, whieb euoipelled me to take from one lo three trains of morphb daily to keep oven bearably eomfortablo. "On November 30, 1879, tbe aoluul cautory harbg prevlonaly been applied with but trifling beneRt, if any, I was suspended and cDcnucd in a plaater-uf-rari* jaicket by I'raf. Lewi* A. Snyre and hi* ton L. H. Snyre. of New York, ustsled by trtber members ot tbe i»rof«wlon In tbat city and ftrom rMootaehuMttta, tbe relief from pain and Uie improvement in tbe MtiaatioD and
m
ntAGTORE 0!
tnoliun of tU« llnibs prodnotd hj ezt«Brioo indlMtlag th« probability of b*ii«* fit hj tbis n>ud« of trcntmoat. Tbo Jnolcet wat apjtlM In exoetl.v tlie mantior >o deorlj' Wt forth by Prof. Sayra io liis rahiAblo work on 't^piniil bUciuHi and .Spinal Ciirralur«,' etc., tbu cUimbC AltentioD brintc given to the tnlnat«9t dctiuU of tli« i>|ivnillon (roia b<>^Dntng to cod, and tti« remit ww ■ r<qiinrk- ftblj Bccnratoly littinK pok, wliicb g&ve pcrfevt and tnea nppvrt to tlM whole tranlE, iind coni|>lut« nud absolol* re«t to tlie itijund and dI««aMd parta Thrw dsja aft«r bvioff ' tiirllo-*lielltd ' I could walk abonl lh« room witlioM iMohAnici&l fupport, and two iUts Ittt«r I went out «■ tlia atroet for iot Arst walk for mora than two y«ar*. Sfnnilion, vrbidi bod been xvtj ii)i|icrf<«l, htcamo Bcarljr Dormal ; oontrot of tbe muscl«a becaoie constaot and niacJi murv pvrfM-t; ttie frwiacnt attaokx of ipaxmodie oontroetiona of Jtnrapaof iDuadea CDtir«l]' c«a>Kid, a* did nbo tb« oruurrenota of alinuht lolnl piralrata of ibe ItgB, durbig wblob 1 wonld oA«d ba nnnblo to drnw Ibnin np in bed (or dajv nt a timo ; coniplola eoDtrol of t1i« bladder wai obtained, and tbo bowcia became much nior« nornul In llirir ai-tlon. onaliling me wholly to do away with t]i« uao <tt ii^jortioDK, which 1 hod olmo«t invoriobly boon compi'lled to TMort to bttforo to produce evooiisltous. I waa alio ablo to dbeoatiuu« tb« ii3« of Iwiat to the limlis tlifij beinji a* warm w olbcr piLD* oTthe body.
" Tboiigb *ttl] HlTorin^ BuTore pain at tlio point of ii^ary, I have sacoceded in roduolng the qnantlty of morphia to Ims UiaJi nn^-bnlf of that lak*n baforo tbp jndieC WM applied, and that in a pt-iiod ofsii weclcn' time. Tbe mavrlM , aru btitl too weah to Ruecain ibe woitcht of tlio body with ibo Icfa flased, or to nim it on tlio l)nl] of tho foot and |iropi.^l it forward, nji in nnlural lomimo< lion, thim piiiDi; ma a Deoowarily uluw Hiid Aoiui^iiliut aaknuril oiuvmik^I ; but Ibora apponm ti> bo pnmlyria of no innad* now, and I nm abia to imlk a foarlb of n nitlo witboui ottiHclol aid of any kind, except the n«ml supjiort of a ll^lit bamboo can«t.
"On removing th« jacket, January 19th, I fouml mTitrJf nnahlolAwalk Bcroa* tbe room wtihout Buinpon of Hoiue kind, white iliere woa a ni*r1i«) in«TcnM of pnin. Tbero wan aUo a pore«)itib!« chnoiro in t)i«< form of tho trunk. It being two Inobee anialler around thi- waist, prolwhly by al>Mrf4ion from laUire] pr«iunr« of the jacket abova the tlla. where It bad beta crowdud ill to get a point of Bupport to maintain exleniion. L*pi>n tlie applinatkiii of ' a Drw iilottcrnnMi there wot inm«illnto r«licf of the increwcd pnin and rctiira of iIjl' use of till' legs aa beiVire. with conndi^rable lmpr»vi-nii-iit in lltcir notion (tbe naw Jacket b«it;g a bolter fit than the fir^t. If poMible), altowlnff ' uio»t cloarly the need of and the great bcnufit derived from tho extonaioD nnd aupport of the plaHor-of- Paris Jacket.
" /e&rudrjr Ul.—l oan now raita my«If on the toc» by rotnntary coolno- tion of tbe eitenaor luusolea of the (eot.— C. W. H."
Dr. nackett railed at mj- oflaoe March II, 18S0, in perfect bcnllli; could walk without cnnc orotlior enpport nuuriir as well as before tlie accident. He wore the jncket etghtoei) montlie, when lio woe ])erfi.-ctlr<!oneolid&tt.>\l, uud Imfi tiuvcr lx.«n troubled with his back, although engaged in the active practice of his profotrion.
CAUSES OF ROTARY-LATERAL CCRVATtlRE.
491
LECTURE XXIX
DBFORMITIEg OP TUB BVKIK. — UnTART- LATER AI. OPBrATmB.
I Tttm RnUrv- lateral CHmtui« <'t|ilainKl. — Ihlliolugr or Ihp Drfonnllv.— Cka of rcnoiui ia whom k covut>i, uiil liuw it it dtTvloprHJ. — AdiiiUonal (l^uacfk— Spodkl lUiuc irbon Iho l>«ronnlty I* (t«¥«lo)>«tl Id ihc itoraai Rc^on. — Sjtaptaau. —Ttmtment.
Gentuoiks; T*Mky wb eontinuw the study of deformities of the »pine. The next in order is what u ooniiiiotily knoi^ii as kt«ntl curvature, but, for reocouB which will l>e given a tittJe ^hrllter ou, I prefer to call it the rotary-Uternl ciir^-alurc.
Tlicrc hao bei'u vH^tly iiiun.* writleu upou this dofoniiitir, aud more instrumeiita devi&wl for its relief, than for almost any other deformity tlint nuty oi^-iir t» the liunian body.
Lateral curvature of the spine is alwa^fi accompanieil by a oUtiOD or IwiMin^ of the hollies of the vi-rtelinu upon ihem- Ivee. In cliildreii. the spinal mlumu is nearly etniiglit, and tins in that condition until they begin to sKuitio the erect tnre. When, however, they l»egin to assume this jmnture, the loae mA^iiLs and iliacus internus muHclcs begin to si-t upon the lumbar Apiiie and pelvis, niirl <Irnw the pelvis forn-ard into tlio uglo it normally occupies relative to the long axi* of the body the adult, at the etame time giving to the sacrum its peculukr curve. The mui»cIeH of llie batrk, in addition, develop a back* ward comiU'nwtory curve in fhu dorsal region, in onlt-r that the centre of gravity in the body may be projwrly innintHiitcd.
llic e[HDa] column \s held in its normal portion by the oon- otions of tuUKcIcs »ititatod upon either eide of it, which i^bould KAOtly balance each other. If, for any resikin, one net of muwlea overcomes tho set upon th« oppoeite side, the spiuo yiulds, and a curve is produced with its concavity toward the side upon which the Kti'ougor set of niu>^clcfl ii eilualed.
RotJiry-Ialcnil curvature de)>ends entirely upon abnormal mus-
eiltar contmctioit. aud oseurs independently of »oft«niiig and dis-
int«{gntion of the vertebne and inCvrvertcbnl cartilages; for
l.tliese arc mrcly, if ever, aifoctcd in this diM.'aso. Tlic rotary
ennrature Is developed first, and sometimee takes place to such an
493
DEFORMITrES OF TtTE SPIKE.
ostuDt tbat the angles of the riW may be inistakcn for tlie pro- j(»;ting spinous proce«n» in Pott'tt diMiiuo, u Mwn Id this Bpeci- mull. (&*! Fig. 380.)
In all these severe eases, however, the bodies of tlie vertebrie remain iicarlv of their nonnul thickn«ii«, nnd the dofonnity in <lue to abnormal muecuhtr contraction, which prnducoa a rotation of tlie Ijodies of the vertcbno ooe upon another.
There is einiply compre&sion and HomctiinoH absorption of the posterior, and expannion of the nntorior portion of tho inl«rvcnc- hral disks, hut no Hctuat discsHc of these disks or of the vertebrw.
The tnio pfltholiigy, therefore, of rotarv-lntoral cun*aturc of the fipine i^ almornial muscular contrection. This contnu.-tion produres St Ivaet two oun-o», which occur inoel commonly in the lumbar and domal regions. The seoondarf corre, whichever it may be, is called compensatory.
Sometimes the lumbar curve is developed firat, and then the dorsal curve becomes compeiuatury ; and vt'eevana. It is im-, portant, however, to ascertain which curve made it» ap]>earanc lirat, for it is in the pathological condition ^-htch has produced tlie Jfmt evtvQ tliat the surgeon i» chiefly interej<t«d, for tho secondary ciin'e is merely compensatory, and is produced in con- sequence of the pn^scnoe of the fir«t.
It is a noticeable fact that this deformity never occurs in thoae^ penou who are coinpellod to matntajn an erect poeition. For instance, those who are accustomed to rarry weights upon their be&d«, such as bitskotd of clothes or pails of water, do not got lateral eurvatnre of the spine, simply becanse they are obliged to maintjiin the body in a ]H^rfoclIy erect posture, ami that is done by causing the muscles of the trunk to contract with etiual foreo upon both sides.
Half of these deformities are the re«ult of want of enci^, want of life enough to sit up straight; conscqneotly are most commonly 9een among that careless lifeleAs class of pentons who are in the liabit of sitting tho greater share of the time with tlieir tnclcs twi»ted and bent in a half-citrvcd position. Indul- gence in such careless habits of sitting not infn-<]»ent]y develops a curve i» the spinal column at Home point, which !« sufficient U>i eetabliih tlie dofomiity ; and then in a very short time a second' curve will be deve1op«cl, which is compensatory. Again, fracture of the femur or tibia, when followed by considerable shortening,
CAUSES OF LATERAL CrRVATTTRE.
498
causing the body to lean toward tlie side upon which the fracture toc4c place, may bv etifHcivnt to cstublUh Inteml curvature of the spine.
Shortening of one of the lower extremities may be tlie result of paralvAU foUowi^fl by arnst of dii\-clopiijcnt. The con*e- qitenco i*, an unL-<|ual support to the sides nf the pelvis; hence one eide drops down, and with this doprM»ion oomw a iatcml curve in llic- iipinc. TIiohu uro the more prominent causes that ^vo rise to this defonnity wlicn it cxiiits tit the lower portion of the Hpinal eohimn. (.SV Ftp;. 210.)
When the first (mr\-e In the epine la developed in the dorsal region, it de[iend» upon an entirely dtilerciit cBuee, nud is duo to tlie action of the inspiratory miieclea.
As you all know, the gr^-nt M.Tr»ti mnscles are the most im- portant external iiiBpirat'n'v nmwlee. in the body, and ivhen the aliouldcra arc fixed llivse act in such a mauner afi to olo^'ate the ribs and inerease the capacity of the cheat.
This ran be nisily understood, when wo refer to the relations
of t]ie»e mitades a little more in detail. The eerrntus iiiagitita
L trise«, by eight ornine iifshy digitatiuns, from a corresponding nom-
rlwrof rlb«,and paswtiiniiitl't'rentdit^clions, backward, and upward
anil bacltward, until it reaches the posterior portion of the scapula,
when it in innertt-d into the entire exletit nf it.* baw!. Now, in
, order that the scapuU sliall l>e a firm point of BUpport. from which
the sen-atns magnus may act, it is fastened to lh« »pinal column
byineanttof the rhomlioidei mnscleB; bo that, ao&raa acting upon
Fthe ribe is concerned, for the ]tnriK)«! of incrcMing the capacity
«f tlio chest, and alao upon the liodies of tlie Tcrtebne, the«e two
iKta of muscles become practically a Bingle act, with the movable
apula between thcni.
With Buch A mnecnlar arrangement wltat do we have? We have a meims of applying a force which, every lime an ini<piration is made, acts upon the vertel)r(c throngh the ribs, which play the part of lovers of greater or Icm length. When a full ins{>i ration is taken, thia action \a mncli more marked.
Now, yon will observe that the ribis bending at their angle*, against the transveree proceaae« of the doreal vcrtcbne. The bead of llic rib, an inch or inch and a half from this angle, rests ainat the Iwdiea of two of the vertebra.', eligbtly sloping upward. We thus iiave the ribti, at their angles, resting against the trans-
iu
DEFORlCmES OF THE SPINE.
Tereu procwGcs of the vertebrie, like a fulcram, tbe ekort ami running tn tho head of lite rib ngnlnst the bo(1ic« of the vcrlobnp-, und the lon^ iirtn butiig ike btidy of the rib, and tht> power wliii-h moves thifl lerer i» Uiu eerratu« rnKgnm nm»clv, wbicli is inifertod into this long iirm. Now. when the trapedus and rbomboidci| of one side wntraot and draw :hc Hcupulu backward t«wsrd thoi spine, tbt^y ttiHs make tonee tb« fioiratas ma^tu miiEcIo on tlmt eide, and give it full power to net ni>0D tite ribfl, and bjr this leverage rotatu thu Mpino upon it«i-lf.
This in tho Htarting-point of tbe so-called lateral curvature, hut, iw it begins in a rotary movement of tbe bodivit of tlic verto- brnf, I prefer to call it rotiiry-IiUvral curvature.
In the lumbar cnrve tho Iwdies of tho vertebiw lire twtiftlly twistfd to the left, wliilo in ibe dorsal curve the.v are ordinarily twiNted to tbe riglit. Why lliia is («> I am not prepiuvd to MjJ This order, however, may be rcverewl.
WbenacnrveljecoineiieAtablUhed bvtheaction of one ecrrHtus muscle, it i^ liable to bei'omu gradually (ncreAwd on m^cotinl of Uie progrwfiive relaxation of tbe opposing serratiis niUM>le. Some- tinieB this curvature beconiea eo grout ttuit one lung in almost eoiiipletety coniprcwed, and tde anglea of the rib* upon tlint ""ide may become almoHt obliterated, while those upon tbe opposite] Bide liecotne corr(W|>ondingly acute. {S<f Fif;. 289.)
This defuriiiity occurs much more frequently in girls tluiD in boyii. In its very commencement it may be due to apparently trilling affairs, tbojo which favor tbe im<]ue conti-action of rvrtain miucles ; it may Ite due to tbe flligltt relaxation given to the niuscrlea ' of one aide of die trunk, by iis«uming an improper posture wliile sitting; standing babittially in a half-leaning, careless position, ni>on one leg, or fi-equcntly throwing one anii liebind Ibe body, tlierehy making tlie sernituK iitognus U])on that dde more tcnsu'l tluin the other.
Any of tlieiie apparonlly trifling cmuhw, approximating ono itcapula nearer to the opinouH prooenses than tJie opjHiaite one, render the semicui^ niagnus on that eidc teUHi, and thus ploec it in a favoRilile position for undue action on the riba of that Bide, and tbua commence a distortion. As already slalt^xl, when the curve io once established, it is very liable to increafie ratlier than diminish.
Itotarr-lateml curvature of tlie spine may be corrected before ;
TREATMENT.
495
tlic bon(», Ii>^iiu-iit^, and ribe become iixc<l in their nbnortim) position; but wbeii that bns nwrnred, tbe deforniity will be ]«?r- manvn:. Il 16 importuiit, tiii'i'vforu, lu be iiblu tu rvcojiikizu tliu deforniitjr in its earliest <]eTelTipmeDt.
SvuiifiM?. — One of the earliest iiviii]itoni« i» an nndiic pmiii!- oeni-u of one of the ecapulfe. If, tliu'rvforw, tliie be i)re-eiit, alwn^rs e-tftiiiine the »]iiiie: but even at tliis vtngo of tliv de- formity if H I'lirw is fotmd, if jou will remove the weight of tlic head and Nlioiddoo fvnm tlie wpinal column, by iilai-ing your lisiidg in tbe uxiIIil' And lifting tlio patient up, the eurve will en- tirely diKipi>ear; or, if the patient ie laid faw dowiiwunl upon n table, the spiiitt will be found to be perfectly Mraight, or can be made eo by « tnflinj; amount of extension, itut, if ibc pntitnt etaiids withimt giipjMirt under the arin», you ran, by carefully not- ing the Bituiition of the Kpinoui; proecsi^e (which ciin bo done con- vuniently by rubhing the linger over them, thus producing a red- di»li line, or by dotting them with ink), detect a etirvatuic, very trilling it may be, in the dor)!)!! region.
Now, if the deformity is pGnnitt<-d to go uncorrected, it will gradnAlly incre«»e m tlie *pine yieldi* to tlie muscular coniractiona ReeiHteJ by the weight of the head and Klioulders, until liimlly, is tlio body tuigs ov«r, it is fully devclo))od. The deformity does not advance far in the doisal before a compensating curve ia de- veloped in the lumbar regiun.
Tke.vtwent. — Almost an innumornble variety of inHtnniients have been deviatl for the treatment of tlii>; defontdty.
The use of all fixed apparatus in the earlier stngcft, aa in the treatment of uU deformltiett where we wish tu reiitoro ioKt mumru- lar power, ja pot^llively injurious. The principle which eliould guide you is, to i>laee vjjon ihe. stretch thine mvsdtt which have been inactive and r^axerl, and approximate the origin and inter' Hon of the tnuM^es '/-nt tei«h to remain guiteeeni.
The great serrati muscleis are the ouve chiefly a0eet«d by tliiii principle.
What we wihIi to a^'complish is, lin^t, to place the eerratus insgnns, upon the i^me aide hs tlie dorsal cnrve, in Buch a position tlwt ltd fibrea will Iw at ivjit. Thi* can be don« by carrying llie arm of thst side across the chest, in &ncli a manner that the hand ineet« tlio upper portion of the lapul of the cost.
Second, we wish to place tlie fibres of the oppoeilo ftcrratns
496
DEFORMITIES OF THE SPINE.
magnus Id as Unse a oonditioii as puMtiUe. Tliin can be dono \jy carrying tlie ariii, upon tliis Hiile behind tlio budy, its ia the act of placing th« hand iu the biick <;o«^I>o^•kvt. When the arm i« ]>liu.-(.-d in this positiun, the Bcapula is drawn backward, and the nerratuB muscle ia in the moHt fiivorablo position for contracting with all iu power, thereby rotating the bodies of the vertebrae hack to their normal position. Iu this manner the p<iti«nt is unrulk'd, fl» ii were, and this must be done before uny benefit will be obtaineii by treatment.
You will llicrufore i»Ktnii-t these patients to liahitunlly cany llie anns in the pnsiliona mentioned, and at Iho same time prao- liiw tflkiny full int-pii'iUiunH. The rosult is tliat, by fastening Uns »L-.ipulii! in tliis maimer, the luii^ npan the side of the relaxed eerratiis is changed very little in size when tlio full inspiration is made ; but, the- tibruK of tlic opposite Mrralns niagnus now placed upon the ntmost stretch, the full inspiration ltu« a tendency to lift up the angles of the ribs ujiou this hIiIo, and curve them bftck to their normal position, and thus griuluatly unfold the de-^ fonnity.
There are several aldl in carrying out this principle, which are of great servicHS. One is to cause the pstieiit to sit upon an inclined plane, the lower side of which corrciiionda to the de- pressed shoulder, which is placed at such an angle as will oece«- sitste a constant muscular i^ffort to keep from falling off. Such an inclined plane can b« alta^-hed to any chair, and in each a manner as the ingenuity of the surgeon may siiggCfit.
In some cases in the early Klug»s the bcnelit derived simply from sitting upon snrli a stnul a certain number of hours, erery day, is sufficient to ovor(H>me the deformity. The patient should never Bit upon the inclined plane long enough to produce mitacQ''^ liir fatigue, and should immediately nitumu the horizontal post- ure when not thus sitting.
lint, when the inclined plane is used in connection with the powtion of the arms already described, still greater effect can bo produced by ati elastic force so applied as to assist the mu»- cles in unfolding the deformity. Tliis can l)e accomplislied by fastening elastic bands, wtiich have handles attached to their free extremities, to hooks in the wall on either side of the ))atjcnt. The bands should lie of such a length that, when tlie patient sita with the arms in the position before described, alie can juM gTMp
TREATMENT.
497
the handles. Now, while she ib sitting in this position, direct her to inflate the lungs as much aa possible, and at the same time make traction upon the elastic bands, and then let the expiration be gradual. The elastic bands should be stifE enough to give quite firm support to the arms.
These simple adjuvants to the general treatment are worth more than all the appliances I have ever Been devised for the correction of this deformity in its earlier stages, i. e., before the bones have become changed in form.
Another elastic apparatus that can be used with benefit is one devised in accordance with an idea I first obtained from Mr. Barwell, of London. It is more of a reminder to the patients what they are t» do than anything else, but at the same time furnishes considerable aid in the efiorts made to straighten them- selves by means of muscular contraction. (See Fig. 273.)
It consists of a piece of sole-leather four or five inches wide,
FM.1U.
and six or eight inches long, with its upper end hollowed out like a crutch ; th^ is placed under the axilla of the depressed shoul- der; a band going over the opposite shoulder is buckled to the 82
498
DEFOBMITIES OF THE SPISE.
lotMT end of tlii» Icntlicr crutch in front and beliiml. This on either side has a few inchos of c1:istic itisortod, so tbnt it Iws n coni>ttuit temiency to liJl the depreHded ehoulUer, which \», m fact, BUBpended fix>ni the oppueito one. Two othvr tMiU(U, one id frunt Mtid one bvhiitd, descend from the top of the onitcli to tht! opposite hi|), aiul uru there seciirixl to tt pifc« of leather, which i« rvtjiiiicd in pUce bv n perineal band ^omg around tJie thij^h.- From the rentre of the criitch. two olajitic hands, one in front end ono behind, ^ itroiiiid the body to another picc« of leatlivr placed over the projecting portions of tlie ribs upon the opposit side of the body. This Icalhur pad is relninod in position hy Mmpt* descending from tJie first -mentioned stnip over the sliouj- (ler, and also hue clastic bands cittencling to another [^eeo of leather over the oppniiit«> hip, which H secnred tike the &vA hip- piei'C by a pcriDe:iil band ;^>in^ urumid the thi>;h.
All the^ bunrU are made ixirtially of ehislic webbing, and by their constant ixintraelion huvc a tendency to tui«t the body iitniij>ht, or rather to untwist it from ittt distorted pusition; btit their practical object is to act as a reminder ti> the patient of tho necessity of h)« making voluDtai^ action of his own uiuBclee for tho purpose of keeping himself straight.
In tlic very early i^tagee of tliia deformity the diiitortion ain 1)0 rectifie<! by instructing tho patient to use liis muscles, so a£ toj cauftc their development in exiu-tly tlic opposite diivetion to thf which has prodnced the defonnity.
We never M-e thi« defonnity in that class of penons who nse no n^stnctions to the full development of the mnselw of their trunk by tight lacing or had drei#iug, aud who xre in the habit of carrying baskets, pails of water, or other artic-les, evenly Iml- anced on their licad». The Hervant-girl, walking with a haaket of desii and well-iruned linen poised upon her head, it* compelled to carry her head erect, or lotw her buJance. when down come the clothes in the mud, and with the loss of her balance she also loee0>l her place, if hhe receives no ftirllier pnniithmcnt. Take ft hint, gentlemen, from this practical fact, and teach yonr young lady patients to walk abont the room with a book upon their heads eevcral minutvs at diflerent times during the day. ThiB simple act alone will cauae an eqnipoii« of mti«cnlar power which will prevent the oecurronec of this defonnity, and even correct sli^it distortions when first commenced. Swinging from the ftnns, or
1
GYMNASTICS.
409
from the rings at in tlio gymnasium, is olso very valuable exer- cine to aocoinplieli tbis oliji-ct, uIvrajB placing Uio hand oil the tiiio of tlio concavity, one or two iitclies higher than the otlier (aw Vigi. 27+ and 275'). Tho [nticut rfiwild be nuido to IIu prono u|ion the Hoor, pinning the hand on the nlde of tlie con- cavity ort-r tlio ho/ck, of the head, atid tho oppooito hand ncroBS tlte back on the hip of the opposite side ; the patient then volun- tarily eonrniotit ht» ttpinsl mu8olo« go as to Hft tho thorax from the floor, holiling it thuin for a moment, and then allowing it to fall ;
rut. «». tte. t%
repeating thia opi^ation but threu limes at the commencement of tlw treatment, the number to tie increased ue the strength of the patient improves. It may l>e necessary at first for an auistant to liii]<l iho pelvU and Ivpi down when titey first commence this ox- erciM ; after tho muscke have acquired some tone, the ottistont
' From AiLuM on " LAIetal CarraWra," Moond odHlm,
500
DEFOBStlTIES OF TIIE SP!T
can tlien malce preesore npoa the head of the patient in order to increase Utc redatanee^ and odd to tlie power of the contiactililj of the muscles.
Every effort Rhoald be made to develop the enfeebled moselcs bj repeated bnt limited exercifi4<e, care being taken at all timee to aroid over-fntigiie, and at tbe eame time to limit the action of the OTor-dcvuloped mnsclee as much as poeeiblo.
Fu. m.
Sclf-snspcnsJon, an recommended by Dr. Benjamin L<*, of Fhilad(.-lpbiii, by climbing up a n)i>e wUich paaeee over a pulley and is attached to Htnip« paflsing under the chin and oocipnt of t)ic patient («« Fig. 276), is specially to be recommended ; great care should he taken that the handti be kept above the head, and the patient should reach one Iiand slowly oTor the otbcr until tbe beels are just raised from the floor ; when tlie patient liM e)erat«d
8ELF-SD8PENSI0K.
601
the bod^ to the higliest point desired, the nppermoet haud on the cord hIiohM b]«'8v« be the one npon the side of the connrity of the dorsal rE^on. AVliile he is in this po&ition the great thorado mtwcles — the pcctomli« inujor, Itttis^itnus dorsi, serratUB magnag, etc. — are brought into pUj, and tlte ligaments of the neck are relieved of the greater part of the strain. If the hand« be al- lowed to descend below the level of the bead whilu the patient is ■clf-si>i<i>endcd, tliere will be a risk of too much ptrain being thrown upon the lig:unients of the uock, and coiisctjucnt ecrious damage. During tlie i««lf>siiBpen3ion Bomo one sliontd always be at baud, e«pi't-iiil1y if thu piLtivut bu a child, to guard ugaiuet the twiflting of tlie roi>e, and to i»ee tliat the exercise i« properly per- formed. The imniediikto rBsuit of eelf-euspcneioo, prodneed hj the above^eecribed means, will be a diminutiou of the abnormal ftpinal curve* (prlmarilj- and secondarily), increase iu the girth of the chest, and a decrpafie in tliat of tJie waist. These exercises should be performed tvico a day nt firMt, making three full inspi- rations at each snspensioD, and repealing these suspensions thnw sepanto tintcs at each stance ; the number and length of time of exercise can he increased aa the phyiu<rian thinks requisite.
In slight cues and early etagcs uf lateral duviutiou of the spine, self-snspenelon, if regularly practised in connection with gymnaetto exercises heretofore described, wilt alone snfHco to bring about a cora It may bo neoeesaiy, howercr, iu eome cases where the ditfcaH! is more advanced, tliat some artificial support be Applied to retain the improve<] portion of the body which self- susponsion lias given it; for this piirpose there is no substitute tliat has ever yet been devised, or that is at all to be compared in case of appliattion, and certainly of producing the denired result, to the plasterKtf -Paris jacket w/ien properly applied.
Various iiirtniiiicnta have been devised for the purpose of re- storing the spine to its normal po«tion in lateral curvaturu ; «jmc of these iimtnitnentii being in the form of braces constructed in such a manner afi to endeavor to bring the spinal column ttniglit by direct force; Uidng for this purpose levers and E^rings, ratchet and keys, etc., M.-cured to the instrument and being most ingenious mcclianical contrivances; consisting of a pelvis-belt fastened securely around the body witli udc-ban attached, and passing npwanl, from which are passed straps over the shonldore, thus holding the body flnnly together, and preMure being then
DEFORMITIES OP THE SPINE.
upplied at the side hy the means above stated, in order to force the Hpiiial cutumn etniight. AU each lustrniuente nro nlisoliilel}- lisoleefl, and compel tiie patient to un<Iergo nntold misery and tor- lure. Voa might u) well tuku a piuve uf wire iu the sbiipe of tlie letter B, and nail it nt itA two extremities to a board, and then uttcuipt to straighten it by lateral prcesure and cuuntcr-proeeuro on either side ; you will not succeed without loosening one or the other of tlio cxtreniitiL-i>, and thus allowing it to extend.
It is exactly the same in the hnmnn hodr ; as yon will see, by referring to the models of the spine (Sf^e Figs. 277 and STS) by
FN. trz.
Fm. «».
Dr. Jndson, that it is absolutely tmposslblo to Ktniif^btou the Bpinal column wEthont elongating it : ho long as tlie finger is prened upon the knob at the top, thns prerenting the spine from eloDgatJug, no amount of pressure upon the sides of the colnmn can remore the lateral curvatnres; hut tho moment that the pronare is removed and the rod palled up, the apinal cotitma is immediately made straight without any eido-prc«suro tt kll (*•• Fig. 277).
ApPLtOlATION OF TUB pLASTEat-OF-FABIS JaOCKT KI LATCEAL
CcavATv&M. — The patient k to be fitted with a knitted shirt — the same ae in the application of the ehirt for spondyUtis — with the
PLASTEn JACKET IS ROTAET-LATERAL OOBVATCHfi. 603
exception tltnt it is made twice tlie length for tl.o piirpooo of being roveniL-(J on tliu ontcr side of tliu j:icket and miido into a corset ; in casee wlit-re tlie patient is a female, pad» of a jtroper sixe lire tlion pliiood over tJio miimnuc, occordiug to the development of the patient, and tlift aliirt tlien tied tigbtlf over the stiouldern. Tlie patient tliL-n Kii«pL-iiding liL-rnilf, as soen in Fig. 285, the lilurt i* to be pulled down Ptingljr hy an adsiiitant, tlie dinner-pad not being ntied in luternl oiirvnture, a full mud Wing takun before the ap- plicutiuR uf tlie jacket. The planter bandage then being im- inented in wtiter witUcicnt to cover it whoii Munding on it« end, is loft until alt gn^ lia^ ceeaped ; a second bandage ifi then placed in tbe water, and the tirnt one being n^inuvud, and the iturpluB water praSBed out of it, ia then applied snugly aronnd tbe vraiet, each turn of tbe bandage coi'eritig two-tbirda of thu one prcvtuuHly applied ; it is carried in this manner down below tbe cret^U of the ilia; then, pausing bnek, up toward tbe tbomx and over thu mum- tnte ; an tuaii^taDt nibbing each turn of Ute bandage into the one previously applied, until a eufHcicnt tliickneH boa been Becurod to givo the necessary support to the patient, wliich varies accord- ing to ttie size of the luiUent ; the adult not refjuiring more than the thickncMof the bookbinder's pasteboard.' In a few miuutea tlie plftitter iit euffieiently fct to allow of the removal of the jacket; tbiB being effected by a section made from tbe reiitru of thu ster- num to the centre of the pnl>eA, nislng a sharp carved knife for this purpose, dividing both shirt and plaster dressing; tbe jacket being taken off while the patient still retaiua the suspended posi* tion, In cii^-s of persona w]to aru very obcec, a small strip is cut out of tbe reutro of tbe jacket in order that it may be drawn in At tlic wniftt; but in tlie majority of oaH» thi« is not roqui^ilo. On the removal of tbe jacket the edges are brought cloeely to- getiier, and a rollor-batMlage paewd around it in ord<;r to retain it« shape ; it i« then placed before the fire until thoroughly luirdcned — which occupies generally about twenty-four hours. Tbe follow- ing day tbe {vitieiit suspends herself as befon-, but having on at this time a thin nnder-vest ; the jacket is then opened and sprung around her, and fitted into the exact position in which it was fir«t
■ 1 iumI formmlf loappljrtlghl RripR of Un in the mMbc«ol^« butd«|^ In order to t\'n idititkinal tirvnfctli, liut <>ip«rltnoo liu proTMl H lo be mtinl; utmremMij U the dllTtrcnt larcn arc propcrlj rubb«d tofMlifr; •nd, tliartfoio, for Um paM B*9 fCMa 1 lia<ro diHwitlaucd the uaa of tbatc aUlpa of tin.
DEFORMrriES OF TRE SPISB. ,
applied; U is then socored by passing a roller-bandage arounil tbo vaiet, makiDg aL^o a fow turii» uf ttie iMuidage above and b«- lov the waist. The patient is tlioa remored from the sospendin^ appAratti«, and tlto jacket cut out under the arms on either side until ehe is perfectly comfortahlu, 60 ttiat uo preiwuro is mule in the axilliB, and the shouldera ore not elevated by the jacket ; the p:ittoiit iethen allowed to lul down and ticx the limtxi, the lower part uf the jacket being trimmed siitiiciently to admit of free motion of the litnbe. Tim jnckut u then removed and »cnt to the inHtmmenMnaker, where the ahirt is reversed and t>titched at the top, cutting off all eupcriluoiu outcml ; Ktrips of luatlier
Via. in.
arrnngod with eyelet-hook» are then sewed down tlie front of the jacket for the purpose of lacing it ; thns forming a complete cor- set (*ee Fig. 279), this bping worn during the day, and alwavfl re- moved at niglit ; the {uktiunt taking the gymnastic exorcii^-H pro- vious to the application of the jacket in the morning, and after ite rumoval at nigbt. The patient is to 1« self-snspendcd in the morning before the application of the jacket, in order that it may be properly adjusted while in the extended position.
Many persons are Rtitl under the imprefuiion that the apptica- tioit of the ploetcr^f- Paris jacket in lateral cnrvaturc is for the pnrpoae of effecting a cnre, and to be worn as a permanent jacket, w ill epondylitia.
ROTART-LATKRAL CUBVATCBK.
SOS
I vrishf liowever, for it to be dietioctlj nnderetood tliat tlie piaster jacket, in tlie treatment of lateral ctirvatiirt-, is ttimpty lui adjuvant to the g^'iiiniL^tic oxcn.'i«!S »u ncci'esurv fur tlie cure of tliifl defonnitv, and wbich are for the purpow of developing tbo weokeiieil iiiuecleti npon the afifocted aide ; the plavter jm-kot being untplj a])plied for ilie purpose of retaining tlie bodv in ijie im- proved position -which Kilf-titupcnition, etc., give ic Again, and to tliifl I wontd specially draw your attention — that the jacket ia to be removed at night, and at all timoo when the gymDaetie oxor- cisea are taken.
Hr. Adams, in Lin work ("Lectures on Curvatures of the Spine," eecwud edition, page 3S1), is under an eiToneous iiiipree- aion reganling Uw object for which the plaster-of>Puri8 jacket is applied in Literal curvature, and also aa to ite continued use, etc., in this deformity, (See Note, page 613.)
Tlic following cases, however, will illustrate the advantages of ita D&e, and the improvement in tlie jmeitionii of the patient by its appliciition in lateral eurvatnru :
Cask. — C. A. R,, male, nged twenty years, came to Bellevno Hospital, Janusiy 2-3, 1^79, presenting a very pale and haggard appearance, «-ith a greatly exnggerated double rotary lateral curva- ture of the spine. (iSw Fig. inO, from photograph by Ma«oti.) The patient had worn iron braces of variouA kindfl, constantly, since twelve years of ago. The mother stated that when he lir«t commenced wearing these braces the deformity waa very slight. At the pri-«>nt time there are several croeionis due to tlte press- are of the brace which has jnst been removed, one upon the left acapuU, one over the top of each shoulder where tlio shouldcr- stntp passed, one under the left axilla, and several siiuiUor ones at different parts of tho trunk ; tie lind a painful exprcwion of Countenance, was unable to take nmch exercise without fatigue, aiid was entirety dij^iibled for buAliieM for more than a jear.
Self-sDepeosion dimiiiLshod tho defonnity (as seen in Fig. 2S1, from photograph by AtiMon), and greatly incn-ii*«d his capacity for respiration ; ae soon as it was discontiitiioil, the patient felt great discomfort, and the defonnity immediately returned.
TBE.iTOcrrr. — Advisinl to practiw: M.-tf-susponsion daily for one month, to improve his position, and ako to allow the sores to beal, aud tliou to retttm for application of plastcr-of-1'aris jacket.
^6
mruEa of the spiyE.
Felfruarij 20, 1879. — Patient eolf-safipended and jadiet ap- plied before the class. An JncrcHRO of two aii<] a lialf incites in Ilia heiglit was then obecn-od, o£Ecctiiig a tiiarkcd improvement, 00 Been in Fig. S83, from photograph hy Ma»on.
April lltA. — Patient ruturned ; general liealth greatly im- proved ; the poitnfnl e:cprcs6ion of face entirely diflappenred ; boa now hoaltby color in cbL-eks. States lie i« growing etroiigt-r owry day, feela mnch better tlian when the jacket wa.1 applied, and feeU as though a great weight had bei^u removed from hte left
rM.>i«L
Flo. M.
ehoulder, which was liouud down by the strap of the brace ; and tliat the cnitrli of tlic bnoo in the right axilla had alwa^-s cansod him great diBcomfort, which was now entirety relieved. Old jacket removed and a new one applied before the claw. Patietit'a form mneh improved, and no erosions npon the skin.
Sopt^nhfr iit/i. — Oroat improvement; new jacket applied.
Deofmler 20th. — Patient mnch stronger ; can now walk and work neoriy all day ; jacket eat down and converted into a cor*
CASE.
007
fct to be worn I)v patient ; to he removed at night ftiid renppliod in the monnng whvn twlf-i^uiijtunded.'
April 10, 1S80. — Pniient markedly improved; new jacket applied and mode into corset.
J)eoeniber S«A. — Oontinaea to improve; samo jaeltet being still worn u« corset, {iki Fig. 283.) As this U au incurublo do-
ria.1tK
nu. ««.
fonnity, ho will tto compc-lled to use thia earoo B&pi>ort during the remainder of hii> life, tliu jiiirkcC« being changed occ-iisionally to ocoonuDodatc hiit iucrcaeiiif; gize.
Cub. — July 14. 1880. — A. L., Chatham, Canada; aged fif- teen yeare and a half. Purcuts healthy ; child gn;w rapidly ; wlien at adiool w^ia conlined for five hoiirg daily ; for i<omc months Itiid ooiDplaincd of fueling tirtd, pain in Bide and lower jwirt of back; not inclined to play. Mother notioed riglit hip projecting aboQt eix months ago, and shortly after noticod riglit shonldcr- blade waa very prominent. At tlio present time \vai double ro- tary lateral curvature ; enperior to the right, inferior to the left
I V; prMnil plaa in laUrsl currnim \t to remore ttie jftclMt itUDodlatcl; after IH BtM ■ppUcaiiun, oud iliea Msvcri it into a ooraet.
508
TnroRinrrES of the spiite.
(«M T^g. SS4, fmin pliotognpb by Steail) ; right nipplo lialf ui inch nt^srer the navel than tho left.
TaEATM>:sT. — ISulf-ciuApfaBioit twieu diilj, with nppropriito gymnAetio exerci^B, for two monthB; with Bea-hathing.
■S?yrf'^w</tr 1t/i, — Itetiinitid improved in ^-iienil hojiUli; «i»1 eclf-BUHpendei], which romoved the deforniitir almoet enlirely, m' eocn iu Fif?. 2S5, from photognph by Stojid. l*buiterK>f-Piiria jacket applied and cut off with tbo eliirt wliile the patient VMJ yet nuBpendod.
Septeni&er 10/A. — Corset waa reapplied over akin-fitting vest
FU. lU.
Ftu. IMt
vhile lelf-WHpended, which retained her in the position as seen in Fig. 28(i, from photograph by Stcud. Ilctnmed lo C:iuada, vilh iiiBtructiona to continue geli-daniwniiion, with ^innaslic cx- eTci«<»; and always to Eiupeiid horeolf bcforo applying the jacket in the morning.
Man.'hy 18^2. — Again nt office; Improved very much ; «pli neariy sttaight ; new corset applied.
JwM S6M.— 'Bctunicd mucU improved, but conct too loow ;
Q&SK
M»
back perfertly Rtrniglit ; new cor»ct npplied, which ebg prefers to wcur to the ludk-e' ordiuiuy corot-L
Juiy 5?^— Left for home, perfectly well. (S» Fig. 237, from |>hotogmpI> by Sund.)
In Ibu majority of casee of the deformity in their eartier Bt«ge6, before Ihe bune« nut] ligMnmiU hnrc beoomo cbuiged in font), Uio trcatmcut above deecribod, toother witli vigorous out- door exerrUc, to inijiruve the tone of the ^neml nystem, will luually be found «U lliat is roquired to correct it.
There are casca, however, lilce tlie otio now before yon (Fig. 28S), in wliiclk the deformity has Ia«tod eo long, niid tbo bonus
rw-us.
rra. wi.
themselves have become so changed in form, that the deformity can never be purfi-etly rectified.
This man'B deformity commenced as a Inmlmr curve on the Itift side, ciiuitcd by liii> tliij|:h on tliitt side being otio inch shorter than tJio otlior, and the <iorHal cnrre has been prodnced u a coin- pensating curve. This defuriiiily has been greatly a^^^vated and mido permanent by his avocation, whieb was carrying large has* kets, by placing bid loft hand on bis hip, making a resting-plaea
510
DEFORMITIES OF THE SPINE.
on his left itliouldcr and arm, and holding the basket iu place hj throwing hU rin;lit hand over ha hood sod holding on to the top of the haflket. You see that he has an immense muecnhu* do- vulopincnt ; liio nbs of hi« left eido arc drawn down below tlie creat of the itinm, and hia body is rotated to the right, almutt throngh one-quarter of a circli;, an alinoi^t Miinteritart of tlie »|iot>i- men Lore seoti, iu which thu diatortioa wha eo gn<«t that hv many it was ii)iHt»lceii for Pott's diseaae, or antero-posterior cur\'iiture, iiulcud of liklunLl {tt4 Fig. 389). Iti thin Bpocimcn jrou ohcurvv a
line drawn at right anglctt with the anterior portion of the lumt vcrtcbrK-, in.«tat<] of K-liig pAnillul tu a similar lino drawn frondl the middle of tlie dorBul, ia at right angles to it, althougli parallel to a line drawn fnnii tlic cervi<-ul.
This hIiowb that the vc-rtobral column has been twice twia npon itaelf ; you aee how admirnbly thu specimen iUnstnttea tlio deformity of thiH p,-itiont now b<?foro yon.
When I place thin man within a oling pa.<«[ng nndcr bis axilln, and another band under the chin and occiput, and olovato his bodj by drawing upon the pulley («m Fig, SifO), you immediately
CASE.
611
see this broad band of the latiseimus dorsi maBcIc bronght promi- nently iuto view, and it is an impoBsibility to bring him straight
Pis,- EOT.
TiQtil this mnBclo is either cut or rnptiired. While he is thns stretched out, I make preseure upon tiiis muscle with my finger,
619
DEFOKUTTrES OF TBE SPISB.
and ho instenUy liiu a «p«S(»odic contraction of nearly nil tlie mti»clua of Ilia l>oOy, tliUB proving that tlii» nuii<<.-le is contracturtd,' und that no power, no inntter Itow long continncd, can Btretdi iti to its normal condition, nnk'sfl tbe fibres are severed, and this miMt lio done eitbcr by force or with tho knife. On the coa- traiy, I bavo proviid to yoa over and over iigaiu, in the many^ CMce of DontiBcinred tendons and muHcles which have been here, tiat, when Mm structural ehcrUiiin^ has taken place-, toAwA matl« evident by the r^^ttetpturm which is pmiiiieed in it hifj ure vjpon its^rM toAm under extreme tMtion, continued . *«j tends cnly to irritate that mu«eU and eause it to undergo* ttrojigtr and ttron^er cotitratiions, and that any attempt to stretch a musrfe thuA eJianged in ^ructvre exrittis additional irritation^ rather than produca any fiongation of its ^fibres.
If tbiti rule, vltiuh I have laid down for some years, and fol- lowed in pmotice untb the greatiMt euocen with almust all tho other muiicleB of the Iwdy, be a correct rule, it sliould be appli- cable to tbifl caKe. Ut-lieving it to be correct doctrine, I hUuII, therefore, proceed to divide tlie muscle.
You alt see that tbia strong band, houic tlirce inches in height, which, with all my toteo, I can stretch no further, gives mo a rellex spasm every time I pinch it. Tliin fact secina to me to make sc-etiun of it perfectly jiistiHable.
I take this long, strong tenotome (made ei))>ecially for the purpose), and p<i«« the blade under the anterior tylgc of the Inti*- eimus dorsi nearly oppo&itc the angle of the Bcapala, and, passing it under the ntnsele, I now turn its edge toward the surfaeo and cut with a eliurt, Niwing motion, while, with my thumb, I press upon this firm, tightly -drawn hand. Yon hear tho tinapping of the fibres ae they arc being divided, and, now tliat thoy aro all cat, see how instantaneously the spinal column ia rendered almc atnight. I instantly turn the knife upon Ete side, withdraw it and close the wound with my thumb, having pressed out a few drops of blood. I now dress tho wound witli adhc^re plaster and a finnly-adjnsted ruller.
The patient tttatce that the operation has given him but trifling pain. And that ho feels very oumfortidilo.
Yon all mnst observe the won<]erfiil cliange in his fomi. The spinal column has become almost stnipht, the only distortion ex- isting being at the angloa of the ribs Dpon tJie right side, and
CASE.
613
this lins cxlitted m loDg tluit It nil] tnoet probablj- ranmiD per- manent.
We can now take tlie niiin down from tlie uling, and, an he lies upon Uie Uble, hv cxpn»<«s himevlf ao Iwinf;; frco from puiti. IIl* will 1)0 jiiit to Ireil, witJi a liroad band ]in!i»c<l around the iipjicr portion of tli<! trunlc, Kfcurcd by an ludiu nibbcT etnp to « tixturv apon oue eide of tlio bed, and a tumitar band around tbo pelvis,
Fill. Ml.
In a Hitniliir war to tbu oppoi>!to eidi; of th« bed. Between two elastic fon-ee the body will be nrtained in the strai^rtit pOMtion, and wv will diow you tlio ix^fiilt m our nvxt clinic.
By reference to Fij^. StH, engraved from a pliotograph taken by Masitn twelve liayi ■ficr tbo o]»eration, ran be foen tbo prcs- cut (.'oiiditiun of the [latluut wbilu Bitting unsnppurtud on tbv eido of hiaoot.
KoTt.— Ai Ih* rntCTiwlioia) M«dl«I OuiKrcM. bdd •! Cop«ili««B to ISM, Mr. Williuu AJuiH" olacmsl tbol " tb* uodlAMIkni in ilie plfc-(ct.o(.P»rU jukot wLidi Pnituwor Sayra Iim rvcrntlr ininilucrd and exkiblMil to diu lnn)llu(^ hxids to bkve prrfmtil ilie J*t*e« M • Bi«l»i>i«l ■uppott- And it nm "pII bo ipplivi b thMS
I of IkUnl curvalBi^ to whicb I conabkrvd it WM not pr«rtou*ly aiitilttttble." U
Ml
DEFOBMITIES RESFLTISG FROM PARALYSIS.
LECTUKE XXX.
DKKOKUm&i RXSrLTtNO PBOM PABALYBIS.
C^DM*.— Troatmciit.— G«DfFiii Paialrniti.— Paralysin of ili« Kxremitles.— hdal J'ualyib. — L*Bil-I'mly*i8.
Obxtleukn : Thia iiiorniDgT invite your atteiitinn to fleformi- ties rciiultiiig from iiifaiitilcptiralyeu ; eomctinti-sciillcO llti; paraly- sin of dentitinn, becaiute it occurs very frequently at that period of infantile lifu; tliu paralyei^ being llio result of vonio loKiuii in tlio ttpinal cortl : frecjuenlty, Hpinal mcningitiH protinciiig effntiiun and pn-H«urt^ in tli« cord will result in punilysis. i^uinctiiues tlii^ pa- 1 ralyfliii will affect one extremity only, nn arm or a leg, bnt more gienonilly two of tlic cxtri-mitioB an nffuolud nt thu lume time; fionietimes it affects the entire body and bolli upjier and lower fxtrumitJetf, tliccliild bein^ then perfectly iiel])l(MS. A» tlio effu- sion in the eont diiiappeani, and sensation and motion begin to ri'tiini, certAin muscles will become viuilixed lyooncr than orliurK; t lie flexor muscles, being the stronger, will generally buve the pre- ponderanec, and thii« divert the position of the limbs in tlic line of their contraction. After the c]nU\ recovers sufticient power to In-gin to ereep or partially walk by supporting hiuiHuIf upon va- rions objects, the additional weight that is put upon his limb« will very materially inor«ii>c the dii^tortlon. uiid they mayusome many and almost indescribable shapes ; there is then a neoesaity for some artilicrial means of supporting tlio twdy in the proper poeition, and of artificial aids to the weakened muscles by elastic tmction, which I havocullcil Iiidia-nibbermnscIcA, tobc appliird in difliircnt positions as the case may need, in order to enable them to ai«ume their noniial po«tition, and thtiA aid ihcm in perfoniiin|{ natural niuvi-meitts. In like manner injuries to various parts of the nervons system may rvsnlt in paralyws of tliOAC jiarta to which the nerves are distributed. In such aaas tlic application of arti- ficial aid is also neoi'^istry.
The following nmn* beautifully illuvtrute the beni-tlt derived from artificial support :
CAi>e. Partial Paral>jsU and Lateral Curr^tutv. — H, 0., aged six years, 'Washington, D. C, son of Captain C, IT, S. A. Child was perfectly well until four years of age, when he was at-
CASE.
MB
tackod with epinal meningitii*, n»uUing in partial paral,v«ie of llw upper iind lower extremities, involving ohiefly the hand>> and feet. Curviiture of the epine was obsLrvixl one year uft*;r, which hue gradually increased. A Hingiilnr fnct in the hitftoi^ of this family of etx chiliiren is, that four of tliurii t-iiffiT from thv miiio purtial paralym nf li.indii and feet; all were di(?k at the eame lime at Kinggoht Uurraoks, Tosao, in thu Kumnicr of 1875, with a fever ftnppiwt^d to be spinal meningitis. They all walk »t the present lime as if they had artifi<;ial feet, and have hut little power of grasping with tito hands. A brother of the boy, tliree yeara old.
/
fl- A^^- -^y
Pn. 3K.
ha* sIbo comiiiDneing ciirvattire of the spine. Vitrtons instm- munte have been applied in this 0000, but could not be worn, owing to tlic pain wliEcli they produocd.
The above history was f iimighcd by Dr. Basil Norri*, U. S. A., who brought the child to me May 1*, IStl*. The api>earance of tlie child was as repreeuuted iu Fig. 292 from photograph by O'Neil, He ha<i paniiil control of hU tower extremities, and the hips and thighs soi-med well developed, but he had no power of controlling the body or head from the pelvis up, which would (all in different diroclions unloea supported, uud had no power in
B18
DEFOllMlTtEa RESULTIXG ntOM PARA1,T81B.
tlie bandx, and but littlu mottun ftt Uie wrUt. Suspension bj the headandaxillH'can.'iCfiihe change as Been in photograph by O'Xeil, Fig. 393; patiuiit had nut patuiod water for tltii-tecii bouns and being unable to do ao, a catheter ww mwrtcd, and tweuty'five oiincott of vriitt.T withdrawn ; from tbu maunor uf tbi> flow, it was eTJdent that the bladder had loAt its contractilitv.
Patient WAS llivn 8U0{>cndud, and the pbuter jacket and JU17- mut applied.
Miij/ lOM, — lioj- ]>crfc!Ct!y comfortable, could walk <|uit« w«U without the head being supported except by the jnr^'niast, as
ria.«k.
Fn. Ml,
Men in Fig, 21)4, from photograph bj O'Neil ; mt he had not paM«d water fiiouo tlio withdrawal of it the day previous, Prof. Gootey inserted the ralheter, withdrawing more than a pint. Patient ro- titmed to Wairhingt^n the eatiio afternoon. JCatf iHA, I recM>ir«d tlie following letter :
"Dear Dr. Satre: . . . TImi boy i« vorj well, and runs aboat tli« strMlA wltb olb^r diildrcn ; I rrgivnl the npplkAtion of i*rl;(4 nnd Jurymart t» a porAet MiooeM; It Is not at all uncomforuble, aaA a<lni(u of lils Mng itnAti along ttie broail and book ; Uitnforv I hmn tuA. had it (pUt np and laovd, a*
CA8B.
517
jaa racomtncndvd iiw to do if aewmuj. I drew lib wftter tt nlgbt u lU- reotcd ; but oil oam« rifbt on tbo Ibird daj, nnco wbiob dma li* has bnd no trouble. Verj tnilj j'oara,
- jby H i»n luu n stHdt. vthiubcub, Ik &"
(Vise. Comfit Paraly*l»; Parfiai Jltxoivry, wiVA Con- traettnv o/" GaeirocnemixiSy Tibialis Prntifw, and Plant'tr Fan' eta. — r>. S.^ aged twelve years, IlmiHton, Texae. Fatiior bcallby ; tnotlior died uf pIitliiHtM ; wlioti tlic cliild wiw three months nf age Itad rongcfltion of the brsin, with fever, reenlKng in complete I»nilyi«ui of Wtli upiier and lower extreiiiitici>, articulation al»o being affected, but rocorered the iiBe of hvr voice when one year old ; wiitf nli]<! to I'Hrtiiilly cit ii[) when eighteen moiitliK old ; the ebild gradually regained i>owcr of her upper extrcmitive; the left leg giii<lually impri>ved, but the weight of the body could not be bomo upon it ; the right log was pt-rfcelly pun-erlc«^ with the exooptioit of a fJiglit i<wi(igiiig motion of the hip.
\J^
it-- »».
October 7, 18^2. — Patient was brought to me ; tlie condition of her lower extremities is well rvprcsented in I''!g. 295 (photo- graph by Ma«oti)> alic being unable to stand at that tJuie. The
518
DEFORMITIES RESn.TISG FROM PARALYSIS.
inUintiil latrnil li^ment of each knee-joint wns very greatly rfr lazcH, allowmg of complete luxation of the riglit tibia, iind iiti HbnoniutI nioveuieut also of the left. The right foot vras a Bevere case of cquino-Tarus and contracture of plantar fascia; the foot
eould not bo replftcod by traction, and poEnt-prcKturo upon iho oontractured tiissuoa producing a rcltex Epasm, made section ■>£ them neciitwnr^'. The left fix^t wajs capable of being rcpUced by tivction, but rvquin?^ artificial iiieims to retain it there.
OciofkT Sffi. — iJirideil teiido-Aoliillift, tibialis jH^iticufl, and pluntar fu«cla of right foot, and drut«ed it in niy uvuid manner for chili-foot- (i^*' page IIS.)
October "iiiii.—liviaovvd nil dressings found woundo hcalud, ^nd the foot could easily be retained in the norma) ptwition. Ad- iscd electricity, iiuu«tige, and jiasiiirc niovenicnt* dnily.
yffivmli^r i:?M. — Marked improvement ; has some voluntary control of tlio inuHclcs of tho toca of foot 0{>vnUed ujnn, luid cut *leo flex and extend tlte foot.
December S<A.~Applied a brace with Tludwa** vpAnf^ at
CASEL
Kid
knee and ankto (mw Fig. 2!)6), vhicli enabled patioot, by tlic u<l of a crutcli, to walk qxiiU) well, as eeea in i'')g. S9T.
Deeemher 1 IM. — Electrid^ uid maseage bare been coutmued daily ; grcAt improvvmout iit (Mndition ; can now walk quite well witboat oratcli. Patient left for her home in Texas.
Fw. nr.
Ca»8. Iiicixiiv/ination, wliA Partial Paraiy»U of both JJppirt and LtncfT i^tivmitiea, eompUcalfd iclth I'fiimwiia.—l.. M. It., male, aged five ami a balf ycare, Fredonia, New Vork. I'lirunts botb lii-JillhV' No biKtorj of tnbcTL-ulosiit on eitbur eido. (^ild wae a forcejis mse ; mother had aevere convulsions at time of delivery. ■ Weight of child at birtli, tlircc and ii Imlf poundo ; groat diffioalty at restiaeitation ; marked contraetioii of all the miBc1e«of the extromitio« at tluit tiine.
Dtcttnler 3, 1882, — Patient brought to my office ; during the three ymra prorious mother »tatc« that the phiApliate^ bad been freely admiuii^tured, togotbor with ibe application of ulcctrtoity. with some btnt-tit. At llii* time the i-liild could not Miind or sit without being Lutd, and when laid upon the floor the thighs wviv croeeed upon each other, with the knees flexed, and re^^uiring the
520
DEFORMITIES KES!
greatest cHort to turn upuii lik eiile, ut he wus uuublu to ace his han<tfl or his amw ad a moaiii) of asAiHtinj; hiini>elf, Irnth beinj; eota- pliitvly i»:ir»lv»Ht ; he had uuvur {tut his ImiuN to liis hcnil ainoo birth, aod the head fell forwanl upon hb chest whvD tii« body wvag rii^e*! up; the Unglut wore Mroiifrly itddiictvd, utd miiv effort
hie part to move them pnxhiced an instantaneous spasm, caufi- Jnfj them to cross, ji^ving the characteriMic wi»«or*-lejf deformitj, acconiptiiiicd by an extreine priapiiyn. 'i'liis l«i mo to examine tlio penU, and I found a very redundant, indurale«l, and contracted prcpu(!«, with an exceedingly small orifice scarcely admitting the amalleiit probe. On attempting to relmct the prepuce, it was found iinpM«ibIc, and the slightest touch upon the cxpotted mu- cous membrane vas followed by an instantaneous con^nUsivo movement of tlic muwclee of tho entire body.
DtAtixosts. — Paralysis from injury of the spinal cord, probably receivi;<I at birtli, nnd nervous irritation, v^'itli incoordination, po«- sibly induced by the retlox irritation following tlie phimosis.
Tlw child wail uniiAually bright and intelligent, but jwrfectly lielpless, as rcprescnti-d in Fig. 5*1*8. from photograph by Stead.
Dteembcr Atfi. — t'liild was circ«mci>^ed, and a comudeniblo amount of sniogma was found under tho adherent prepuce; oi>cnition i>erfonned in the usual manner.
December riM,~5iollicr stated child Iiad slept bettor the pro- rioua night than at any time since birth, aa he u»ed to frequent- ly awaken in the night with ecroaming-tits, aceompanitid with spasms
Dettinlfr \'2(k. — Wound honied completely ; child can extend his legs while lying upon the bed, and ean adduct the thighi* n> lltat the knees are nut in contact; no n-tlex spa«ni induc^-d by toaobing the penis.
December lAth. — Marked iniprovomcnt ; can flex and extend Wtli legs slightly, and voluntarily put up his Imud to take mine. Friction, Bbampooing, and inaftsa^ ordered.
J)fcemher^KHh. — Still farther improvement; can extend both limbfl nearly straight, can abduet thighs a few inch*^ aiul cnn with some effort place the hands upon his head when in the horizontal postnre ; but is unable to keep hla body and bead erect without a8fiistanc«. I therefore advised the application of tlie plaster jacket with head-rest, and a Uarmcli^s wlieet-crutch with tr«adlc« for exercise.
PACTAL PABAI.TSI9.
631
Deeemher 21<rf, — Appliwl plaster jacket ami jniymaBt.
Jttiiuari/ n, 18H3. — M<«t marked iin|irovement ; can place eilliur luind upon hU hviid williuut dilKoultv ; \6 ablv tu feed tiim- eeXt, nnd when held under tlio amiii is able tn flex either thigh at a right angle with the hwdy ; could abduct the thigliH volunliu-ily to the extent of four inches at the knees; wnji put in Darraoh's wheel-crutch with walking treadles, in which he can move uhout with great ease and comfort. {See Fig. 29!).)
rx.. ui.
fM. tM
Facial Paraltbi!). — The deformity which acenmpanies pamly* of the fiicial I)er^'e ix due to mure or low euuipleic loss of mue-
nlar power in thone mtiK'les to which the tiervo ia diftrihuted. The cauu* of punilysiH of thiH ncr^-e have been bo fully explained in text-bookH. and the ])ernliarilieH of the deformity are so well nndcretood, that but little time n»cd be Hjwnt in their oonsidorsp tion. The moBt common eauee of tliis paralysia, perhaps, is direct
sporara to cohl, »w\\ m eowi% from a current of cold uir striking liructty npou the Hide of the faw. The deformity coneiete in a drawing rif the month toward the umkffectcd eidc ; tlie patient is Qtukble to whistle or laugh properly; tko angle of the month
522
DEFORMITIES RESCLTIXG FROM PABALTSW.
npon the affected side ts lower than Rorma), and the eye npoa tlio sanie side eau be only in(-<>iii|ik-U'1y clucifl. TIm deformity may not be T017 oonepiwicniB when tJiu pntieiit is qaie6<;t;»t ; if you akIc liim to wtiJAtle, you will immcdiiitely oliserre that the iiioiitit IB twiatc-d elrnngly to one side, thuB wnderinp the «et of wliii>ll!iig an iiiiposaibility ; or, should you »y anything odd, caofiiiig the patient to laugh, the deformity at onoe hecumus veiy coni«]iicuouD. the mn^'lefl ujioii tin- unaffected side drawing the fuuturufi completely around, cButiug the face to aeeume a most strange and grotesqne ajipearance.
This deformity not infretgncutly beeomoe permanent.
In many ca»a, liowever, ao far as the check is concerned, it can be fctieved in a very simple manner.
The principle is to approximate the origin and insertion of all the niUM-les alTected.
This can I>c dntio by bending a hook upon the end of a piece of silver wire and hooking it into the angle of the mouUi, and then fastening the other extremity by bending it amnnd the ear, na enf^itwtod by I>r. Dctmold, Tlie ear vill yield iu:>mewlial, whicli may be eufflcient to afford all t)ie relaxation desired ; hut, if it in inniitltcient, a pleci! uf ehi«tio can be used, with a piect: of yrim attacht-d at each ostrumity. "When the muscli« arc sup- ported in tltis manner, galrani«ni can be a]iplied with benefit, for the niui^etoM are then able to contract without tutving toovercomo any resisting force.
Thi» is a nile ttiat should never ho violatM, wlieu applying galvanism or electricity to paralysed muscleB.
Frecint-ntlv, however, tlie entire deformity may l>o rt-movt-d in a few da\¥, by the apjdication of a bllslor alone, at that point where the nerve passes through it* foramen : this being applied previou* to tlio use of the electric cnrrent.
The last deformity to which 1 uliall direct your attention, and which is induced by paralysis, is that commonly known by the name of
Wuiirr-iiiKir.— Thic deformity consists, as Its name implies, in a dropping of the hand, which is an nndue flexion, consequent npon |>«rah>ls of the exteniwr inuiwles of the forearm. The most eomtiion cause of paralysis of the extensors of the forearm U leait- poii»oning.
Wlien tlie "lead-pal^,** aa it is sometimee called, has oon-
WRI8T-DR0P.~" LAIRD'S BWOM OF TOUTD."
5S3
tiDUed for mme time, atropbyof the miieclvs is a rommon roeult, and in mHny com}* it i» vary marked.
The opinion U quite coiumun that the lead manifeet« its poi- aonotu efToclH alone upon these exteiiHor musL-tef, but that is not tnie.
Tho lead affects tlie entire f^fstem, and the patient has not only wriat-drop, but he lia« diimmMhi'd tnuecular power in all the raoecleg of tltc body. *
The |>oi»onoiu utTvcU are manifest in const ijiatiou coiiHetjitunt upon paralyois of the iiiuscutnr ooat of the intoMitie; and «W give ri«! to a peculiar gait in whith the jtatient tii-st rtrikefi the heel, and then brinj^i' hif^ weifjlit ii]iiin thu nntvHor portion of the foot with a whack. The preeence of the blue line along the mar- gin of the ^iims and tht- cxiittvnce of lead tn th« tirini; arc Midi* tional evidenced that the entire iiystem is afiec-ted.
The more common manifti»tatioii, however, of lead-poi«o»ing
Ha paralyai.t of the extenBor muaclw of tho hand and tingerx. The
liKin for this iis the flexor iuu»clc« arc tlie more powerful of the
two »el(>, and re^iiiit the influence of tJie lead lonj^er than the 6.x-
toni^^rA, hfUL-e continue to net and producu tho dofomiity after
the extcnsj.)!'*! have become paralyze'!.
Those muiL'lL"* u.vbihit the effect of tho poison tirst which are Ibo loost able to n^-i^i»t iu influence.
In Bonie caiiea pamlyais of the exteniwi's in complete, and tlie patient is unable in the leiuit degree to extend the hand and fin- gers.
Thid deformity, incompletely developed, can lie ceen every day upon the atreeU) of thiH city, for there ii* many a fii^iioitnblo hidy who suffers fi-om it in consequence of her own folly. Their hamU are held in a peeiili.'»r yet faMhionable position, a nort *>f kjin^Aroo style, and many of them fancy that they are imitating the fauliion admirably, while they are i>iin))1y obliged to ciury their hands tn this portion because the extensor muscles are not strong enough to hold them up. The polirfi they liavo put on tlwir faciii has manifested itjwilf in producing {lartial paralysis of the extensor muwle«iof the foreanii. and a fni^hton hau been intro- ilnced to accommodate the deformity.
The nse of " Jjiird's Ttlooin of Youth,'' ae a coemetic, i« a very fruitful source of lead-poisoning among women.
I have had three most digressing cases of this character onder
524
WKIRT-DROP.-CASK.
my ovm obeervation, vrliidj were caused by the nee of lliis single article ; ain] yet Uie nuinufacUirer haii dared \o \in- my mtniv himii his advertiiiemeiits, recuinnHmdiug it sa a safe and nOittble ccifr- meticl
Tlie cmnmim people, perlupe, are not to Matno for tlieir igno- ronoo re^rding ihoe articles, but for l]ie iiKilii-al man tlivre i» no excuse for recommending each vjlUiinoue com]K>nndi).
Oencrn? leiulpoiMining \i 8oiuoti»ie« miHtukcn for locomotor ataxy.
Tlie following cntte^ illnstrntc the defunnity prevent in wrist- drop, and tlif mode of treatment:
C.MiK.~<>n till' :!7tli of Hepteiuber, 189S, I wne oaUoO to see'
Miss , of Kanais, vi-Jio lia<l been eient to nie from (bat Btnte,
by [)r, Lognn, to be trcutci) fordiaeasoof ttiu »pinu, and paralysis nf tlio fotenrnis.
I found a very tall, benutiful woman of abont uiiieUien, of remarkably largu fmnie, very erect, with botli liands drop[)Cd at nearly a rif^Iit Mi^le ut rlio wrii^t^ iind perfect inability to ixtend them. She could not extend the fingere in tlie lea»t, or extend or abdtict either thtnnb. The mntv'lcti wero more atrophied, and the foreanne and hand;) more >vaAte«l ihnn any cane I had M that time ever seen.
The largest i-ireiimfercnce of the forearm jnft l»eIow the elbow wa8 eight inches, circumference at wriM five inches. The int«r- Dsseoaa s])aoe9 on the hack of the hand were very distinct, and the adducenii^ and extenwir^ of the thumhti, ma well as all the muscles in the t^^lms of the haiid^ were so atn>|ihicd that ibv contours of the first tnetacorpnl bone^ on either mle were alinoitt aa n>n»ptcnous as they would have been in a skeleton, with a tight glove drawn over it.
She wa8 nnablo to fucd hercielf, comb her hair, pick up n pin, hook or button her drc'^ts or in fact make any movenienl» wliat- cver with her hantk ex«>pt tlio mrif gUghUtt fiexion of her lin- gers. She had been in this condition for tome months, and waa ■ gradually getting worse. She could tle.x and extend t]ie forvanna, and could elevate tlie arms almost to a right angle with thebi>dy; but wajt perfectly unable to extend the handa or tinffcro in iho least. She could walk tolenibly well, hut was not very 8t«ady or olAAttc in her t^lep, and easily became exhausted. Going up or down stairs was done with great difficulty, and I observed that.
CASE.
fi£5
to ait down, or gut up from a veiy low iic*t, required all tlie innit- cnlar uxortion of whtdi she was c!a|>abte.
On roinoviti^ her vlothM to exaiiiiiiv tlic e{>iii«, I found ihnt fthe n-as 6u$(ain«(I in the very erect portion, wliioli bad attracted Miv atti'iilioii, b.r " Taylor's Spinal Siii>]>ort«-r," a mo-t valimblc a])|iaratua in ciibi-s where its use is indicate)), and I iiuturallv in- ferred that aba niual liave beuu EiilTeriiig f^)lIl Mine dii)oa«« of tlie apiiio. On removing lite piiiipurler, wliii'li weifclied Ihree |K>undfi, hur head Hnd trunk inunedialely Iwiit furwurU; and with lior anm crossed on the chi-«t, the liauds drop|>ed at the wriBt, ut almost an »L'iit« anfjle with the foreflrms, she presented an exact pountorparl <>f the " Orenan-liend " photognijih, which haa been so common in the shop-windowst for the past year or morCrf
I examined her spina) oohimn with t'nv groateiit poiwihie eaiQ, b^ eoncnitg^ioii, eiunprvaMoi), cxtenxifHi, bending her foi-wani, luick- ward, laterally, and by rotatinjr the spine npon the pelvis, so iis to put every iiguiucnt Hjwn cxtiviiio temiun. and culycet every cartilage and bone to firm pre^ure, without (he aliglitcst evi> donoo of pain or ineonvenienee. I therefore cojieludot) lltitt, if she had ever had PottV diMiaae of the spine, it was the iuohI per- fect cure tliut I had ever seen.
She pave the followinjt histrtry of her*elf : That in the Riui* m«r of ISiW she had hiiious iulermiltent fever for Home weeks, whicli prostrated her very mucli, and after siiglit fatigue she had a relap«w fi-oni which she recovered very slowly. Tliat in Sep- tember fthe took a ride on horsehack, a distance of ten miles, and on her return the lionw ran off, and carried her at great apecil nearly a mile. She exerted all her str<Mij;th to rtop him without effect, and was finally compollcl to put him into a fence. She ma very much e.xhau»t«d, but did not dismount until she reached home, a diataucv of »ttmc two miles or more. A few flays after this great exertion, she found " her lumds were gettiufr weak, first di«!ovcred it by luvidenially droppin)r n skillet out of her handfl at n eandy-pullinjr." Sho then noticed that a lioik wonid frequently drop out of her bands while reading, and thiit she could not strilto the piano-keya corrcclly, or with a* much force a« formerly, and Itiat her arms and bands were getting much thinner.
She came to New York to coneult nte ; but, as I was absent
TRIST-DBOP.
from the aty, die was recomtiK'iniwl to Dr. C. F. Taylor, to try tliu Swinish movcmunt-curt'. The doctor disgnoeticated her raae as Pott'H dieeajte, aiid applied a spina] ()U|i]iorlvr. Sliu vns very ill for eome day-Hat Dr. Tiiylur's vKliililielimutit io Broadway, with what thti doctor Mates in hi» letter to 1>t. l»j^ii,of Luivt-n- worth, wiiH »))iuiil oetdtis. l>r. Thoiintii, who saw Iier at thifi titiie ill consultation, informs nie tliat lie coiistdci'vd h«r caBO tut on« of hysteria.
She wait nent home after a few wueks, with Uic spina] snp- portvr lipplicd, nod wUich she baa continiiol tn wcsr until the present time, having been Aeeiirud that licr hands and anua would soon recover their use, after her hn«lc f;ot well. I mention tJtwe facte, not in tito way of ceniiiiro, but simply to bhow the difficulty of dinj^iOMiH, and the dungcr of dmwinf; wroni; ci^nclu- siona, without the mo«t careful oliflervation, for this ver;r case wati ptiblishcd in the QvarleAy Jownal f^' I'hjfaiotoglcal Medicine, April, 1S6S, pp. 282, 2S3. a» a case uf " <-iimvmat%ia."
Her back fleeiued to 1>e nnpported by tlie brace, and she conld walk with hur body more erect ; hut lu<r entire niniiculnr fiy»t4Mi> ^ew weaker, Hhe could walk only a short diBlance without ^^lait fatigue, and her forearms and hands wn»to(l m> rapidly that in a few moiitha iJie completely lost tlie power of extfitsiun, and for the pant year had been perfectly ht'lplee«, ojid had to be (Ireaaed and fed like a child.
Ah I could find no evidence of diKCiuk; >ii the njiinnl onhimn, or cord, and no organic leiuon of the nervous cfutn.'fl, my diaguo- HiM was tlmt there waa no " Pott-H disease," but a caste of " leadrj palay." Tlie usual blue martjin of the gum was not conifpicHouB,] hut between I'sch of the teeth the gum was more purple t]iai natural.
I made mo*.t careful in<iniry to aecertaiti the wmn-e of the lend, but was not succeesful. They had no lead I'lpw in llw iHHise to contaminate the water drank, but t*"ik it from a spring in wooden bucketi*. had used no lend in painting the houw, b»d drunk nothing fnnii lead pipes, or been cspoeod to il.^ influence in any way that I couhl ascertain, «von after the mo*t eari-fu) inquiry.
I'mf. William A. Hammond saw her in eonsullation on the following day, and, without my giving hira any hint or informa- tion, confirmed my diagnosis of lc«d-p«l»y, althotigli from the
PARALYSIS FROM "LAIRD'S BLOOM OK YOCTU." 527
motlicr'it <lci'cription bo cxpccfaxl to fitid n cA»e of " Pott'tt di»- ease,'' and examined her eapeoially for it.
Xot \iiimg able to aitecrtaii), after ihc most nirofitl in<{iiir)-, any wnree from wliich the lew) coidd bave lieen received into tlic sjBtein, bv etiitod tlint it iiii^lit [xiHKiblybc u niHu of iiuisLuiiir Atrophy from cxoctwive ii^>, mid, unle^ tlii> ni»»cli;8 cuiiUl be stiintdated by tlie coiitiituouB cunt'iit of i;:id«-aiiism, the prognosis Will" very unfavoniblo.
The exertion of stopping the ninawAy liorae eeeine<l to jmtify tbiti opinioii. I applied a powi-rf III biittoi^' of Kiddvr'o without producing any iiiiiiu-iilar conlrnction.
Aft there nfii; ratber profuse inonKtniHtion, attendod with great pain, and intcntH^! va^iiiimniii>, and as Dr. Tliomaa had in- foniiod iiiv that there was an tiystorieal eieiiient in the cum.* when be bad i^^'en her two yean before, I eullcd L>r. Marion SiniH in consnitation September 27, 186s*.
The ])ain of exannnation wa« m> iiiten»e that, having no chlo- roform at band, wo hati to poetpniie it.
SeptenilKtr 2Sth, Dr. Sinw and Dr. Ncftcl lUiw her witli kh>, and I bad to carry the ebloroform to profoimd Btnpor, with ster- innms reqiimlion, ticfore Dr. Siinn eould make any CKainiiiiition of the vagina. No serious diseaiie was discovered save this inttinee vftginiHnti«. Dr. Xcltvl MUtitl t bat be hiul ^ecn tlirue cn«4.-e of "lead-paUy" in which ^-aginiemufl had been a prominent symp- tom. Is it a aymptom of the dij^ca^e in feinaliyit
On again examining tier for the Ronrre of the lead, she asked me " if it wuld i>osr>ibly come from the wbiling," On Bilking her wiiat that was, 6be informed me that it waii the " Bloom of Youth," use<] for the comptexioti, and manufaetured by Liird, 74 Fulton Street, New Yorlc. She had used nearly a bottle a monlli, for iiboiit two yearH and a half, but for tlie Iaj<t eight or nine iiirmtlis luid l>een eonipelled to have the application made l>y an afiniitant, as the was unable to apply it herself.
She gave mo the remiianlB of a liottlo of the "Bloom of Vonth," which, itpoit analysis by I'rof. R. <). Doremiia, wa^ foand to be biglily impregnated with acetate and carbonate of Ilw).
I immeiliiitely pnt ber on large doeee of iodide of potassium, commoiicing with twenty grains a day, and inercfieed it np to ninety. Collecting the secretion of urino for tlie following three
WKIST-DBOP.
clnys I also eeiit it to tlic doctor for examination, and I'eceivod tliu following replj :
" S*m Yom, OrMir 8, 16(&
" Ur Dun DorroH ; TIm toiniile of urioo ;oa mm mo ;Mib a emtU qiian- Ut)' of lead, Toore oonJlitl),v,
" It. OanKK OoRUtDa.
Aftur »lio hail been iiiidi>r t]io ueo uf tlie iodide of potA&i>iun) foi' alwut one week, the ICiddcr'e butt«rr, at tbe ennie strength as lit lii>t upplivd witliout effect, now prxxluce<l quite %'igoroud cod- tractions.
It» UHU wii« now coiilinned e^'eiy other day. for about teti or twenty niiniitf-^ iit ii tirno, with moot niiirktii iiii)>rovotiioiit.
Bdicviiig tliat the iiiUural jiosiiion of the tinjrers wan impor- tant to 8U»itaiit the circuUtion, and that voluiitani' cxerciou was tuxxesury to im-reaw the iintntion and development of the inuft- Hm, I got Dr. lludMii, the nuinufacturer of artiliciiil linih«, to pon^nict for lier a very light e.\lenflion apparatUH for the hauda and fitigt-rs which attswered the ]>uii>ow nioGt adniiraltlv.
Dr. liixlMfn lia» niodc anollivr^i-lnf tlu-ite insti-iiments for mo in aiiother erne, which are so great an improreniont upon the first that I will rofer to thorn in the dc^ription of the cn^e in wlticb tliey were applied.
AS'ith tlio iiiMtr\mi(.'iitii prop«r1^ adjuttttnl eho could play u[>oii bo piano remnrkaMy well, and 1 think that tliii; n§e of her handa iterially aided in vx])oditing her nx'overr, ulii<.'h in now almost perfectly complete.
I received a Icttt-r f ix>ni her dated NovcmhcrSK, 1S*I8, written in A most beautiful liand, and in which she statoD: "My hands have improved wonderfully, and heyond all expectation. . . . My left hand, which, you will rcincniK-r. I couhl only raise for a second, and then witli great ditliculty, I can now uw better thait I could my right hand when you saw me two weeks ago. My right hand lui» impi-oved »o rapidly that I cnn extend t)a> fingers almost perfoptly straiglit. ... 1 have gained over twenty |x>MndH, and my arms measure at the wrist six und a quarter inches, and juHt helnw the elbow nine and a Iiidf. And I fe<:4 belter in every pai'ticular than I lutvc for more than two yeani."
CaaE. — Mrs. , residing on the Hudson Iliver, came to
me, Norembor, 1868, suffering from complete paralysis of the
CASE.
&20
cotenwr moseles of boUi hands, and of all tlio fingers, cAosed bjr the nae of " Latrd's Bloom ot Youtti." Tlio «niis were coKI, the interweeouii iiiiikIch were wmted, a» well a^ alt those upon tliu posterior aapect of the forearms.
The pctRiIy»-d iiitieclcs give no raponse to a enrrctit from a strong Ividder'M battery. Tlie annA ineoAured nbove the wri^tA fire inchcft, below the elbows seven and a half inches.
Three ycam ago slie I'uiiinieiiced iixing "Laird's llloum of Youth," for the complexion. After a rear she began to suffer from nausea, pain in the hack, colic-like imiiin, frequent headache*, vitb general debility. Shortly after this she began to observe vtearineaa in the extensor musclL'« of the wriittA and foreantut, both handa having a tendency to drop.
Drs. Clark nnd Thomas, of this city, saw her in ootuultatian witJi her regular attending physician, Ur. llasbronclc ; by them tho caae was considered (as the patient states) a one of " paral ii-els and nervoHB debility, witli dytt]>ep«iN.'*
She continued to iiae the cosmetic at the nito of about a bottle a month.
Tlie piu-niyitiii of tlie oxtouon {ncreiued continnonsly, nntil for die lut six months she has become perfectly helplvw as regards tlic power of e.vtension of tlie liands or fingers. She has to be fed and dressed by her maid ; in fact, ha« no more use of tlic ha»d« tiuin if tliey were deaii.
She walks with an inelastic step, etunihlcs on going op and down tttaira, and bccoine» ensilj- exhausted upon any muscular exertion. In this (^nae there was shght blueiicss on tho margin of the gnin».
I gave her 80 gr-iins of iodide of potassium every day, with dilute Bulphurii: ai-id, and ordered a '■ Tiirkiuli bath " twiee a week. At the end of one week the battery, applied with the same power, prodncod manifest contractions. Thiit was applied every other day for twenty or thirty miuntes, friction and shampooing of the maselua, with passive movements every day, and in three months she had bo far recovered as to dress herself — even to the putting on of a well-fitting glove, and altto buttoning it. At the end of five montlii) ithe bad entiruly recovered, and gained twenty-eight pounds in weight.
Cash— Mis* , of Maryland, aged twenty-one, came to ine
ID April, l$A9, with complete loss of power of all the extensor M
R80
WniBT-DROP.
tnwclee o{ both foreamu. Tbo Imnd* were wiutod to ft skeleton, and the inlcro^couft i^pnccs on the back of the forearm of eiltier aide were so coi)B]>icuoii» and dwp Uiat, wlicii Llt forvamie were pron« and ftcxcil at a right angle with the arms, water would re- main in them like a trough, (&iir Fi^ 3U0 and 301.)
She stated Uiat live yeare before, in 16134, while very thinly clad, she wa« exposed to intense cold; that both of her were neariy frozen, and looked almost tninspareiil. This expoi ure vtui followed by a rheumntic fever, euriliiiing her to txxl full thr«e nioRthfi, Duriiiji; this attack, and after her rveovcry, »l)e waa truiihled with eevere i-onstipntiun, fn^qiiciit attacke of colic, and eouKtant naiiMti. W&e eoniiKilled several I'unvs to ri'«»rt to croton-oil to eeciire an action from the bowela.
In maa »ilio went to Canada to be under the chaips of Dr. Mack, who treated her for aoine uterine Irotible (wait it vaginia- mnsi), and nliM applied the tictnal«iiitei;y to tlie lower part of the apine, hut all withont any benefit, att the eolie, cr8ti)|>e in thi etoniAch, nausea, and geuurul proHtration, remained the eame before.
In 18t>(t she firet began to notice the droppinsr of her handaj and the waetitif; of her forenmiB. Abotit this lime she made violent exertion in attempting to hold a liard-pulliiig pair of horeeit in their nitenipt to run away with her, and itii mediately after loet all power over both of lier hand». The flexor muaclee after a while reeovcred slightly, hut the esctensora of the lingers and luuid have renmined powcrlese until tlic present time
Dr. S. Weir Mitchell, of Phihtdelpliia, has treated her for the lost two winters with eWtrieity, hut m> far «» extension of tbi hands or lingei-s ia coneerned without the &ligliest apparent ben< fit.
She states that the muscles of her arma and shoiddera \m\ very materially improved under Dr. Mitchell'ii treatment, an that her general health ie somewhat better, but that her handa uxi fin^'re are the same n# nt UrAt, and that Dr. M. had givou bor ft vCTf unfavorable prognosis.
Dr. Mitcheire knowledge, skill, end experience in the use of eloctricity being equal, if not anperior, to those of ouy one in this country, I felt fiiitisfled that ehe had had all the benefit thai that agent alone could give her, and I asked her if he liad ever sua- pected that lead tuiid anything to do as an agent Id causing the
CASE.
581
paralysis. She replied that he had not ; hut that she bad recently informed bim of my first case, which was so eimilar to her own as to attract her attention, and stated to him that she had used the same material, *' Laird's Bloom of Youth," since she was six- teen years of age. He then gave her iodide of potassium, but as there was no improvement he was inclined to think that lead had nothing to do with it.
My impression is, judging from the result since, that he did not give the medicine in sufficient quantity.
I applied the electrodes from a seventy-cell Kidder's battery, and also from a powerful battery of Drescher's without producing the slightest contraction of any of the extensor mnscles except a very feeble action in the extensor minimi digit! and a barely per- ceptible action in the extensors of the ring-fingers. Sensation was not entirely abolished. The same battery with only thirty cells when applied to the shoulders or lower extremities produced
Fio. 300.
strong muscular contractions. I immediately put her on 90 grains of iodide of potassium a day, and, as soon as the specific eruption of this medicine began to appear upon the face and neck, the same battery would produce manifest contractions.
The electricity (continuous cnrrent) was applied about fifteen
533
WEIST-DEOP.
mimitefl every day, and she wore Dr. Hudeon'a extension appa- ratus moBt of the time, day and night. At the end of three weeks, without the extension apparatns, she was able to take a
Fra. sot.
plate of ice-cream in her left hand, and feed herself with a spoon in the right, a thing she had not done for two years.
Of the valae of Dr. Hudson's apparatus in cases of this kind, I cannot speak in too high terms. It is very light and beautiful.
Fio. BM.
is worn without any inconvenience, enables the patient to exer- cise the muscles of the hands and fingers constantly, and thus materially facilitates nutrition and development. Figs. 302 and
OASE.
533
303 give a very good idea of ite conBtructioo and manner of ' application.
Fig. 301 is a cut from plaater-caste of her arme, taken for Dr. H., to adjuBt the extension instruments by.
Figs. 300 and 303 show the difEerence in the position of her hands, before and after instrumenta were applied.
All of these cuts are from photographs hy Mr, Hason, pho- b^rapher to Bellevue Hospital.
TluB patient recovered entirely in about eighteen mouths from
Fm. SM.
the time the treatment was commenced, although the case at first was considered as almost hopeless.
The use of cosmetics has within a few years become so vei7 common, even among tlie better classes of society, and, as most, if not all of them, arc equally as dangerous to use as the particu- lar one described in this report, I have deemed it my duty to place these cases before the profession, that, knowing their in- jurious effects, they can guard their patients against thus volun- tarily poisoning themselves through ignorance.
This class of cases has, also, been mistaken for spinal conges- tion, and the patients have had their hacks burnt with moxas. In females there is almost always associated, with wrist.drop from lead-poisoning, a condition which has been called vaginismue. This is an irntable condition of the vagina that may very easily lead to errors in diagnosis, unless proper care is exercised in the examination of the case. This condition of the vagina has been particalarly described by Dr. J. Marion Sims, of this city.
534
WRIST-DROP.— TREATSrENT.
la all doubtful citscs n cnrcful ntml^-sie of Uie urin<! ehould be niftde, fur, if lead U {iresent in the system, it can be very cuily detected in tliis excrL-tiuii.
TnKATHKNT. — The indicatioiw in the treatment are to elimi- nate the poieon from the fiVHt^iii ; to reBtoro lost or unpoirud niiiMtibtr power, and to atwist the mii»cles iii tlic perfunnancc of their fanotion.1.
livcovi'fy ii ui^ually complete when tlieac indivatjons arc |)ri>)> erly fnm)]e<l.
For eliminating tlic poison, iodide of potacsium i« the chief remedy; and it ninHt be administered in saoh tjiLantilte» as will inoreB£e tlie elimination, which ie gradually taking place tlirou^i tlie kidneys.
In many cases success lias not been obtained in this direction, simply because tlie remedy liM not been u^-d in Midiclcnt ([luui- titles.
It may be ndministcrod, if noceBeai^, nt the rate of 120 or 150 grain!) a day, altboiigb HO or 80 is all that is naiially required.
The mcana to be ut>cd for rutttoring lost or iiupmirod mascular power, in addition to the internal treatment, are galvanism, hypo- dermic iiijoetioiiE of stryvhutuo, frit-tion, ete. Tlieeo meoanres muHt not be employed, however, in snch a manner as to produce orer-fati^e of the muscles. Galvanism should be used only when the nineclcs are properly supporied, so that tliey will not be obliged to lift any weight wlicn stimulatid to contracL
To wfford mwbanical snpport to the ninacles, a very convenient apparatus can be constructed of adhesive plaster and clastic Innds, as aujzgeeted by I>r. Van Bibber, of Baltimore. Attach two strips of adha^re plaster to the posterior surface <»f the foreann in ibe form of a letter \l, ^i-ith the apex of the letter towani the elbow. The lower extrvmitics of tl)c«c strip; will servo ae {>o!nt£ for tlie attachment of pieces of elastic bands or rubber artificial muwIcA. A piece of fine ehialic bnudago, attached to one extremity of a atrip of plaster, may be pnssed into the palm of the lumd around the middle and ring finfiens and back to the extremity of the other piece of plaster. TIur fiimii<hes a coniitant elastic force, which givea support to the piinilyzed niuscU«, and does iwt inter- rupt or impede motion, but i» not to be compared, in pnotical ntility, with the ingenious dcncc of Dr. Iludson, as seen in Figs. 302 and 303.
TORTICOLLIS. 53ft
When abroad I eaw in Paris, Berlin, and London a nnmber of devices intended to accomplish the same object as Dr. Hud- son's elastic wrist and finger extensor ; hut none of them were so simple in constmction, and so light and comfortable to the patient, or bo effective in their action, as Dr. Hudson's appliance, and I can therefore commend it to you with confidence.
And here, at this point, I wonld impress upon yon the import- ance of gnarding yonr patients against the use of these various cosmetics, which have unfortnnately become so fashionable; those using them being, of course, ignorant of their disastrous effects, it is your duty to instruct such as may come under your professional care as to their liability to produce such results as witnessed in the cases which ! have brought to your notice.
This, of course, is a somewhat delicate task, but if such instruc- tions are conveyed to your patients with proper tact and discretion, you can produce the result desired without causing offence, but, on the contrary, will receive their grateful thanks for the caution given to them.
lectuhe XXXI.
DEFOBHTnES (cONXIHUEd),
TortlcoUk. — Dcfomltieg frotu Buns. — Genu-Talgum. — Oena-Vkniii].
Genti,emen : This morning I would call your attention to the deformity known as —
ToETicoLLis, OB Wet-Nbok. — TluB deformity is of quite com- mon occurrence. It may be congenital or acquired. When ac- quired, it may depend either upon abnormal muscular contrac- tion or upou muscular paralysis. The muscle chiefly involved is the Btemo-cleido-niastoid. When either one of these muscles contracts independently of the other, the head is drawn toward the shoulder of the same side, and rotated so as to carry the faco toward the opposite side.
Again, when one of these muscles becomes paralyzed, and the other is permitted to contract without anything to counterbal- ance it, wry-neck is the usual result.
In this respect, therefore, it is similar to the deformity of
K36
tORTlCOLLie.
clnb-foot, and depends upon lack of balance in the contractions of oppoeiitg miiscleH. It iimy aUo depend ujwn pemmnent con* tractions of tisBne following iuBamniation. Scrofulous abeoesB upon the neck mar b» foIlowtM] b^' ttiickvning of all tlio HiirrunDd- ing tifiaiieH and Blotiglunfr, and Uie euhACqiient eontractionit attend- ing the pruL-c»« of Hcatrizntion may givu tIm; to wn'-ncck.
Tlie cicatricial contraction following a linm is not nn infre* qucnt cauM of wrv-ncvk. Ttiu dcfontiity, bowcver, whieli cliicflj' interefltfi ns ia that prodnced by in-cgtilarmnoi-ular contractions, due cither to jiHnily»t« of one Btvmo-clcido-iiiiUitoid muecle or a 0pa»tic contraction of the other.
The deformity ifi frequently eelabliUii.-<l during tlic prooe» of parturition by nndue traction made upon th« neck of the diild. The iitad may botomo caught at the superior strait of the pelvis and, under euch diviiniKtamic^, undue traction may injure the spinal accessory nen-e to such an extent as to give nM: to rabeo-- quent irrc^lar muscular contraction of the two seta of niasclee upon the side« of the neck.
The eongoquenccd will be, gradual development of this de- formity.
The deformity consists of a peculiar po«ition of the head, that js> a rotation of the head upon its axis caused by the approxi-
ria, IM.
matJon of tlic origin and inftertion of the etemo-clddo-mMtoid moKle.
The chin is elevated, and the mtntlon of the head Ifrinps tlie car in front of Uie shoulder upon tlie affected side, ae in the ciwa .
TOBTICOLLJS.
587
now before you. (See Ftg. 304.) Ordinarily, tlio deforniity is fiHiiily recog'niKed. Tliere are, liowever, certain conditions with wliifh it luiiy Imj coiir<jimdt.*d.
It inay be mistaken for fracture of the cervical vcrtebnc. This fnu-turc k not of common uccurreiie^, but, wbun it dime take place, it h ordinarily tatal, but not iiecetit<arily »o, If no in- jm-y bas been douo to the spinal uord, it is povftiblo lo udjust tlie fractured bones by means of extension anil cnunter-eiitt'iiHion pnipurly appUod, aud tlii-n; tlii-y may be rutainud iii po^itiuu by a fixed appariitu.'', and recovery take place.
It baa l>c«n my fortuiio to truat tlinjc «ueb rafics euoceasfnlty. Tlie AUtor</ of tbe two cunditioiiH, bowever, is so entirely difFer- cnt that, with proper care, tliuy &buuld not b« confounded.
The mofet conimon queiition yon will be called ui>on to decide is, whether yon have to deal witli a deformity dependent upon [»araU'ni», or one due to upaatic contraction of innwdes.
Tins can be easily detcnuined. If tliu deformity is of pan- lytic orifj^iu, it can be readily overcome, and the head can be Msily restored to its normal position ; but, tlie moment tbe retaining forcu is i-cmovcd, the doformity will Ktiim.
If, on the contrary, the defonnity U ttie result of e>pastic con- traction, it cannot be so easily corrected. The rigidity of the muscle will be sudi aa to render it impossible to restore the head to its proper pueition, unleae the deformity ia of very rcei-ut development.
If it is of rcecnt development the Bpsriic eontraction may por- Itaps be overcome by manipulation, and the head linnlly j-e^ored to its nomud pusttiun.
Such cases may l)e jwrmanently relieved, pcrtiaps, by mcamt of elastic force so applied as to constantly make traction upon tlie head in a direction opposite to tliat in which it is inclined by tbo eontiacting muscle.
When, however, the muscle has become confraH»red, you will not be able to restore the head to it* normal position by any manipulation, and when the parts are placed upon the vtrvtch, and tlio additional /oi'n^ pnvwure made, spasm will l>e prodnced which indit-atcts tliat the contracted tissues must be divided before tlio defonnity cao be overcome.
When tenotomy is necessary, it is better to divido tbe clavicu- lar and stomal origins of the muscles scjinrately than to make a
639
TREATMENT.
single long indsion embracing bolli of tlicm from tbe same punct- nre. Tim elsvimikr origin eua lie readied moot advantageously about tbn'u-riitirtli^ of tin in(.'}i above tlie upper edg« of tbc daviele-
Tlie sternal origin of the miisclo is more supertidal titan tbe elavioitlar, and can tie reached more readily. There i« eoiiic dif- forciKi- of opiuton among oiwratont as to bow tlie operation eJiouIiI be ptrfornifd. Some prefer to tut the tendon from witJiin out- ward, while olhcrt) prefer to cut it frrmi without inward.
Aly pnifvrctRti is to cut frum within outward, itiul I lielieve it to be » niiicbwfer method than to cut in (be opjKinile direction. The tendons are to be divided in HCcordiinco wilb the rules already laid down, and when divided tlic Iicad should at once 1« restored to its proper position and retained there. (&v page 96.)
It i» very important that every tibre of tluMniii«clel>e divided, for, am long as n ^ngle librp of tbe muscle remains undivided, the deformity cannot bo perninnentty corrected. After the Itcad bu been restored to its uorniul position, it io to be retained by soma appanttii».
Here, again, we lind that a number of instruments have been
Flaw*,
devised for overcoming the defoniiity, but the greater portion of tliem are cntirclv nnneceaearv.
Perhaps, the most ftiiiiplc and efficient apparatus i« ono tliat can lie made of adhesive plaster and eln^tie baiidil. It is made in Ibe following manner: I-'imt, place a broad piece of adLeaivv
TORTICOLLia
esd
' nercrn the farcb(w], to keep yonr bandage from slipping. To eaph estmmity of ibis piwu of plaster u Btrip of musliii in nt- UcIimI, which gi>c« iiriiiitiil the head and h faitlenvd. To this l)an<L-ige, paasitig around the head, au vlaiitM; hand iti utuicht-d upon the side oppimitv the (lefoniiitv, carried through the axilhi, and returned to the pUrv of beginning. Now, tliiit daetic liuod can be made as short an nooessary to retttin the head in iUi normal po»itinn, and it keepfl a constant traction in the proper direction to turn the huid iirinind to iu nunnnl jin^ition. (■.Vcv Fig. 305.)
In thia case it will he oljserved that tlic head b not yet entirely reetored to thv naliitiit position; but tlic om^tant ti-aetion will in time accomplish ihiii olijeeL The change in the position of the cllild*ii bead,* by the appUeation of lhi« ehiattc force, even diinng the few minut&iv it Ili-i been used, must bo apparent to you all
This iippitrnluH iti very eflicicnt for overcoming the deformity in the paralytic variety, or in any case when it am bu overcome witliont the opeiiition of tenotomy.
The prini-iple which nhould govern you in the treatment of tliis class of ciues is, to supply tiio dvHciency iu uuiHctibr power by enhstituling elaiilio force.
Kcarly all the eompUcatcd machinery, therefore, which may be aeen in the aliopa for correcting wry-nock, is of no u»e what- ever.
If, however, it ia desimble to fumieh your patient witli a beautiful instrument, you can probably do no l>etter tlian to use tlie one deviwtd by Mr. Rcynders. (See Fig, 306.)
This apparatus consiiitit of a well-padded \teW\e band, a, to which an nprij;lit Hteel bar l* attached at I, parting upward along tlie spine to the upper dorsal rcgicm. A croiw-bar, c, is attached to itii upi>cr end, pa^^ing from one axilla to the other, and fai^tened to two crutches, X\ lilting well under the ann. These arc con- nected to the pelvic band by two lateral bant, m, which by means of ft slot and screw can be raised and lowered aomewhat, at will. The iKirt of the apparatus so far described is applied firmly to the trunk by means of straps pa««ing over the shoulder and fastened to the axillary crosi^bar at o e. A finn bold of the head is ttecitred by a pad, sheel-stcvl inside, reaching almost from eye to eye back- ward around tlie skull, with apertures forthe wirs. and fastened to tlie head by stm{)« over the forehead and under the chin. To il« back part a stoel l»r is riveted, </, which conoeets the upper part
TKEATMEST.
of the apparatus with tlutt npplk-d tr» tbc trunk. Tlus lower end of tliia Hteel bar ia ratohed and adjusted in a Hlide at the ii]i)iL'r ou<l uf tliu &tcL-l rod, [Miei^ing up iilurif^ thv s|iiiiu und JtcM in a de^i«d position bv a tlmtiih-Bcrew alionii near tbe letti^r /« (on tiju ligurc). Thifi connocting Itsr is inlcrL-vpted hy throe dilFeront joitit^ e,f, and ff, by which flexion can be niailc in any direction, whuii worked with the key. At thu joint g, flexion can l>e made to Uie right or left, at^ forward and Imckward, and at e rotation.
i-m.SM.
The sdvantage of tbte appamtne over many otb«n Is, tbAt firstly a firm hold is oiTccted to the head and trunk, and tluit then tbe IicJid can Ihj bruiight in a proper jKiBilion by a tmo and irre- sistible mechaiiiiiin. The ap|MraltiEi when woni is almost unliii-ly biddun iindur the clothing, and patients cannot very CA^ly vitli- draw llieiiiftclves from its action.
Wben the deformity is associated wltli di«ea9ft of the cvrrinl Tertjel>ne, as it may be, you will require something more in the way of apparatus thaii the elastic Iiaud and tlie adhesive planter.
DEFORMITIES RESULTTSO FROM BDBN'S.
541
In eiipli aacs th« instniinont just described insvcn a niot^ cxoellent purpose,
Aiiotliur itixtmnicitt x-liich U Icm expensive, nnd [s alao rcTj nnrioeable, consiete of a sa<l(t1e wbk-li fits tlie shoulders aocu- rattflv, nnd U fcourvd by incstis of n l)0(ly-bt'lt, willi iiii nrcli over tlto head from the centre of whicli i» suspended an ekBtic band to receive the oceiput and chin. This npparuttu wa« fully dc- aeribed wht-n wo were speaking of caries of the cervical verlebne.
As ftdJHVfttitit to anj apparatns that may be useil, manipula- tion, friction, and gah'suimn will be of great service.
As foon tm the stemo^lcido-nuuttoid niusclw cut act suffi- ciently to overcome tlie deformity vritliutit aiwistance, all appara- tiw niuy be>removed, hut until that time it 10 important to aseLit tliom by iiicaitfi of elastic furL^t,
In connection with the deformities that occur in this port of the body, Iwades tboee resulting from irregular muscular con- traotinn, we have those —
DKFOKMrnr^ hkmi-ltinu piiou tub CicA-ntiKA-noK followiko ExTKxsivK ScALiw OR BrRXs. — Deformity always oecnni follow- ing ah e.\tun»ivo injury of this nature ; and wlien occurring in the neighlx'rhooil of joints or in the tlexurcs of the body, as between the chin and etcnnim, u\illary sp«tcu, front of the elbow, popliteal fipace, or front of the ankle, eicatrieation at these points may pro* dueu the ntort HcriuiM defunu!tii.«.
Tbeextensivo surface that is often destroyed in these injuries is followed by exccMlvc granulutioiui in the utToiC uf n;|Mir, which are extremely exnbemnt, the veescla and tissues of which the eicitlrix i» eoinpo«cd becoming immensely hyiH^rtropliied for the pirposo of repairing the lesion ; so that when Ilie cicatrization is fully clTectcd tlicse cnlai;gcd and numerous vcm«g1», tuiving then fnltillod their function, commence to contract, and eventually are ontirely obliterated. You will tbuit see an extensit'c burn, when first oicatrised, will )»e some inches in dreumference and exceed- ingly vaaenlar and tlorid in appearance ; after a few montlu tliCM veaeeU contracting, diminish the cicatrix, and a mere tihrous band, with but few blood-veoAcls observable eirciibiting through it, re> maitu, and is perfectly white in color. This contraction neces- sarily distorts the jKirts with which it i* conneete^I in every imagi- nable and indescribable position.
Now, as the prevention \» equally as important as tbv cure, it
549
DEFOEWrriES RESULTING FROU tiUTfSS.
is requidilo in all cnaet* of bunu to keep the parte oxtended to the utmottt degree, and insert numerous ekin-gRifts OB soon as hculUiy , granulaiion of tlie wound occurs; by ttiio means cicatrbAtiun tatos place witl) Ices vsscularitj, and conse<iuent]y there i» no ne- ceaaitj for the contnctioQ of the cicatrix after tbo wound haa^ healed.
If it be in the palm of the hand or the front of the fonMum, the fingers dioiild ho extendt^d and retained iu position by the applit^liuu of wooden splints or other fixed appamtu», even for a Umg time after the cicatrixation is complete, if neoeesary; this principle slionld be applied in treating huras in all parts of tho body.
Prof. Alfred C Post, of this pity, has mado snnie almoat tniraciilonR ciirgfl in tliis manner, and Iuls written a very vatuablo paper on tliin subject, which in publisbod in tlie " Transactions of tlie .State Society."
If, howuver, tho deformity has occurred and it becomes noooa- ' atry to remove it, yoa cannot suoooeit by simply dividing tlie contractud band, witich enuM.^6 it, at various points and extend* ing the parts to the normal position, expecting a cure by granu- lation and tliu foi'iiialion of a new vieatrix, for a cure of tliat kind will not bo jwrraanent; recontraction will take place, and the delortnity be as bad a« before your opcntlioti.
Tho only way by which this deformity can be suoccsfifuny riflieved ift, by disnecting away entirely the contracted fibrous band, when yoa <-au replace tlie parts in their nonnal potiitioR. Vou will then bo unuizcd to find tliat the removal of a band of only a half an inch in width and hut thrt-e or four inches Id length — when the jmrM are placed in their normal position — ^will leave you a gaping wunud of several inches in extent; tho defi- ciency of ti(«ue tliiis resulting murt not l>e closed by approximat-f ing the edges of the wound and stitching tbvni together «» underJ oixJinary circumstance* ; but tho wound muet be bo drosaed u toj remain in this extended position, and tho vacuum Hlled in b] gliding into it healthy tiiwue from the neighboring p-irls, if potti'1 ble ; llic wound thns made in tlio parts from which the flnjM have been removed can be bronght together by sutures and atlhetivaj plaster in the ordinary way.
If tlie location of the deformity is such that no heallliy tls can be g^dod tu to till this space, then tbo parts moat be kept hi '
TREATMENT.
M3
their nortniU poiiitinn ontil tlie vroand lias healed by the xlow procen of cicattizution ; aud iti Huch cawM it dioitld bo nidcd by ntimerotis transplontatioiu of new epidermu as previonAly men- liouod.
GEsn-ViiMiPii OR Knock Knke, — Thia defonnitj consists in a bending of thv kncu iu«-iird. It it) «omolitiii» liiiown by ttio tenn &ilf-lcnee.
It nwidt« from weakening of muscnlnr supjwrt, tha joint being unable (o properly eusuio the body, and with this there is vtjvtcbing of the int^'mal l»t«ni) lif^tnicnt. Honietinie:* the sup- port U eo feel>lp, and the relaxation of thcbe ligauentA so gront, as almost to pcTinit hixitlion.
The pain which i^ suniotimes prodnced by walking, when the {Mttioat in fully grown, will expit« reflex contnictlunA in certain inusolee, and tlie biceps may Itccome «o firmly contracted tfutt it is impoiwible to bring the limb into it» normal pOHitioa without an operation. If you see tlioee cobch boforo relics contractions have been excited, the limbB can be easily reatored to a straight puEition, but will as readily return to the abnonmd position when the retaining fnree ia removed. When, however, adult life luu been rcaehcd, and oontraehtre of th« bi<x'p9 muecle hos occurred, it will be neRcvinary to divide it before the deformity r^n be eor- ructcd. It aUo bveomcs neecsKiry in eonio cases to divide the fascia AS well a8 the muficle before proper relief cJin be obtained. When the nooowary sectioua of eontractun-d tisfiucfi hare been made, you muat make extension from the foot, and at tlie sutnc time at right angles to the iddo of the leg, at the knee.
Thifl can l>e done by placing the patient upon a bed, the foot uf which I* elevated, and making ext«)uion upon each Ivg from below tho kniMi by the adhesive plaster and weight-pulley, applied in the uwiial way. An upright Ia placed on citticr wdc of tho bed oppOHitu each knee, and a broad l)and,i«iKscd around the inside of th« knee, teniiinntt^ in a cord which nms over pulleys in the up- right, and to which is attached a weight which can be increaaed or diiiiint>'lK>d nccnriling to llic patient's comfort.
These two constant tractilo forces are continued until the wonndii made in performing tenotomy have entirely healed, by which time, iu many cases, the lega will have become c«>mpara- tively etraight. Rot, in the majority of instancefi, tlie patients will be compelled to wear an artttlcial support to keep tbom in
I-VALOUM.
tliis jio«ition for rnnnj montlis, before jwrfoct rwtoratioa will have taken place.
The instrument fur ttiU purpo«o oonsbts of a cireuUr belt of steel around the pelvis (mm Fig. 307, b)^ to either ddi) of which, opposite (he femur, ii rod pasMO down, jointed at tlic hip and alito at tlio knee, tcrmiuatin^ in a circular Xaad, which half Burronnda the l^ jnst above each ankle (./'), or in tlie onicr side of the ehoc at a. Theoe two rods are tuade of epring^teet, and hoieed out- vtard. Opposite the knee-joint an eMie band (c, d, 1, 3, 8, 4) [NtaBCS around the insido of tlic knoo, and b Becured to tlioeo
IV.. Hi)',.
flexible rods above and below the knee: *'«'' is a drcolar b«nd, around the tliigli.
The following cn«e very well illn«tratc« ttie deformity, ts well as the practical application of the infitrument :
Ck»r. — Antonio, a native Afriwin, aged seventeen years, waa brutijrlit to me from Cuba, Hay li, l$fi4, suffering from genn- valguiii, caused by injnriea received durinjr his poutsa^ from Afnca, by being too elo««ly pncked in the ship, imd atiO bj caiTving heavy loads of sugsr-cane in Cuba.
]'re«cnt condition (we V^g. SOS). The Internal lateral ligiu menlA of the knees were very much relaxed, and tlie external ones very much contracted, which caused the conMdunibIc deformity of the limbs seen in the photograph, lie had great diiBeulty ill
TREATMENT.
54S
walhing, and had become completely Tiseless to himeelf or any- body else.
Tbeatuekt. — I divided the tendons of the biceps maBclee and the fascia; then straightened the limbs and kept them so for
Fu. SOB.
Bereral days by extension and connter-extension, in the two di- rections (as before described), by which means they became quite straight.
I next applied an instrument by which the knees could be sup- ported, while at the same time they could be flexed. {See Figs- 3^9 and 310, tahen from photographs.)
By reference to the figures the resnlt can be better seen than described. The limbs are now perfectly straiglit.
For the relief of this deformity, Ogston, in May, 1876, made eection of the internal condyle by passing an Adams saw from its upper border down into the joint, and then gliding the inner con- dyle up on a level with the external condyle. This operation, under the antiseptic precautions, has been repeatedly performed with marked saccese. I saw Mr. Femaux Jourdan operate twice in the Birmingham Infirmary, resulting in a movable joint in both cases. Dr. Macewen, on May 10, 1878, modified the opera- 86
OBND-VALGCU.
tion bv removing (t we4)gt^bai>o(l piece of bone from Uie Inlcninl condyle, tbu upitx of n-bii-li did uot quite resell the encraeting cartilage of tbe joint, while lb* U-uw \ay st the ti|){>er \wi of tlie inu.*rnal 6iirfiice of the condjic. On its removal with the diieol the leg wa» forcibly brongbt into a Htraigbt line, and the two »ui^ faow of the gap brought into npproxtniatiun with itich othiT, thus raising thi* interns] condyle to a lerol witli tlio on t«r condyle, lie nUo iiiiidc itectiim of the foniiir, tniii8vi.<nKiIy, with n ctii«vl, to the uxtcnt of two thirds of its diameter, about half an incli itlMve the epiphyseal cartilage, tlieo forcibly bringing thu limb Klraight.
vm. tat.
Pia. Ml
Mr. Reeves, of the London Hospital, modified the operation by driving A chwcl into tlie internal oondyle in the line of Ogston's oporation.but not qnito down to llie cartilage of incru(it«litm,and llifn forcibly straightoning tbe limb, fraclurod off the condyle vithont opening ihe joint.
All these operations are attended with more or less danger, and should hv avoided if poBsilde; and in my own cs|>erience I have always hwn able to wcure entirely satisfactory mtulta by the varions simple methods already described.
GESr-VARUM.
M7
Gkxk-Varcii. OB Bow-I-BOs. — Tliis deformity cotiMsU in a bending of tlie Icp outwiirtl.
Ill tlivac caflCH Uie external lateral lij^meiitA ^ve way. Thed^ formity is almost ulvrujs dvpenOoQt apon softening of Uic bones; liem'C linw-JpfTfiocI children are nuiiiallj' those wIjo have Hutno con- etitutiuiinl diiM.-aHu. The defurinity then i^ i-eoJIy dependent upon mme cacheiiiD or diatbeeis ; and the disoHBe chiefly productive of tbix condition [« racbilis.
Tlie treatment, therefore, which is ncocs^ry in sucb cases is both lf)c:d tuid connti tut tonal. Locally, mine kind of mcrhauical appAralus will l>e m-cwsary to bring the k'g« into the proper poei- tinii uid hold tJiein there. Conslitiitinnally yon are to rennrl to Btich remedies as give snpport to the systoro, such as cod-liver oil, etc, but tlie lactate und pho^plmteii of lime are the nio»t impor- tant. The object of adniinisturing these remedies is to fiiniish BOme of the element« uocc«eary to give the bone liurdtu-s^ and power of reeislaiice to pressore. Internal troaliiieut should not Ite ooi»menc««i until the deformity ha» been corrected by the «]>- plicntion of some iiieebanieal npparatus.
This may eonitiat of a well-titting splint of wlc-lentlier npon the outer surface of the thi^b, well lined and tirmly weured by a roller-tianda^e. The splint should be long enongli to extend below the knee for a eoniuderable distutice. llie portion of the splint below the knee is left free, and projecting Atraiglit from the i^iirfnco of the tlii;rh. Around this {mrtion of the splint and tiio leg place a inibber band. The constant tenilency of tiiie baud will be to spring the bonc^ into a Htrnigbt position.
The bending nuist lie done gradually, but, if (be els»tic ten' tdon is steadily apjilieii, the outward curvature of tho boiios of tlie leg am be overcome and the U^ made straight.
Sueh a plan of management yon will tind much ej)i>lcr and better than any attempt to adapt tm instrument to the distorted limb. In order to make tbi^ qilint more stiff, it is well to •ectiro, on the outer tide of the leather which snn-ounds the thigh, au iron rod or piece of wood extending down as long as the liuih; the leather which nearly surrounds the thigh will ke«p this rod or wooden splint in ]ioeition, and the iron rod or strip of wood will prevent the leather from bending.
If, however, it is desirable to have the benefit of some nicely- arranged instrument, the one illtutrated in tbo uiiivx<xl diagnuo
548
GENU-VARUM.
may be employed. {See Fig. 811.) It consists of two upright lateral bars fastened to the band which encircles the thigh above h, and terminating in a shoe below. At c is a joint opposite the ankle-joint, and a pad which presses against the foot. At f2 is a pad which presses against the thigh and at a and 0 are elastic bands which pass aronnd one of the upright bars, and the leg where the limb is most cnrved, fo^ the purpose of bringing the 1^ in a straight position by this constant tractUe force.
Fis. 811.
In the application of this force you must not mahe it so strong or continue it so long as to produce an abrasion upon the surface of the limb, or jou will be compelled to desist from your treat- ment altogether and thus lose valuable time.
It is very desirable to instruct the nurse or parents of the patient to handle the limb with considerable freedom night and morning ; and also frequently during the day, if convenient, to try and spring the bone straight with the hand. A much more powerful force can thus be used for a few minutes, without pro- ducing abrasions, than can be borne if it is applied continuously.
COBNS.-BUNIONS. 649
LECTUKE XXXII.
inSCELLANEOCe. Conu. — Bunions. — Ingrooiug Toe-Nuk. — Uollui Valgus. — DiBpUcement of Tcndimfi
Gentlemen : The amount of flgony and torment suffered on account of eorae, buuions, and ingrowing toe-nHils, is all the apology I can offer for bringing these Bubjects before jou. Our bneinese, as surgeons, is to relieve human sufiering if possible, no matter whether it comes from a com or a cancer. There is a wide-spread opinion that the general surgeon knows nothing about corns, or, if he does, that he regards it beneath his dignity to undertake their treatment; therefore patients go to some chiropodist to get their corns taken care of. One of the greatest insults ever offered to my professional ability was given by a gentleman, whose family physician I had been for many years, when he remarked with a scowling face and snarling voice, " A storm is coming ; I must go to my corn-doctor and get my corns fixed." I asked him liow lie could trust his life and that of his family in my hands if he did not think I was capable of taking care of his corns 1 He replied that he was ashamed to ask me to look at his corns, as he did not think I would stoop to notice a com.
Now, gentlemen, I do not feel it beneath my dignity, and I hope you will never consider it beneath yours, to stoop to do anything that will relieve human suffering. A com is inlinitely more painful than a cancer, and is capable of inflicting torment sufficient to destroy the sweetest disposition, and upset the best^ regulated families. This is no fancy sketch of mine ; for, without exaggeration, it can be practically demonstrated tiiat entire families have had their peace and comfort destroyed for years, because one of the members had been tormented with inflamed corns. I have one family in my mind now (the gentleman's just referred to) in which domestic turmoil was the rule rather than the exception, and continued so for years, until the senior mem- ber got his corns cured. So great was the change in the dis- position of that man, that one of his family remarked, " We really believe that father is becoming religious," simply be-
550
CORNS.— KrXDS.— TREATMENT.
canso pcara mid quiet have been restored to the liotisehoUl in con- •eqaenue oi Uia being reiiuvvd uf tliu piiin pn>dui.x'd hy his corns, and be and tlie family have been happv ever §ince.
Kow, what is tliu nature of tltew lonncntiiifi; fomintiunti I A coKM is simply a localized h^vpertropbv of the skin, r-aiim'il by abnoniial prcsaurc. These hypertrophied epidcniuil and <ler- inal layers I>ccornv like dry scales or shelU, with » ccntml ]>ot»t of haixletiing. which is calM tlie '• core " of the eom. Thift lit- tle eoiKToliuii dips down and pifsscs ujwn llie nerves Iwncsth like ft sharp-pointed instnuneiit, and produces indetwribahlv tor-
tllCllt.
There are ttro varieticH of corns, tlic Iiard and soft.
The go/i com is excessively tender, and is much more liable to become inflamed than the hard ami. Tliis variety la more froqnently found between the tiwe than eli>ewhure.
The Aard com has already been described.
As In-fore remarked, the canse of conis is abnormal pressure, which imiy be euiiliiiiious or intennittciit, and, in f^^ncrul, !m pro- dticvd by bad shoeing. The shoes, instead of boinf; made sutfi- ciently wide at tliu toes and aerutw lliu ball to permit perfei't free- duiu uf motion at the metatarso-plialangcal articulation, so that the foot tnny expand to its full extent with ever^' step, are tnatlc so narrow that undue pre»»ure is hiviu{;ht upon eertain points not^ intcndtsl by Kature to receive it, therfforc not properly protect- ed, and corns are soon develo|ied. The irritation produced by pressure iijiou tliowr fonnattons may give rise to rvfk-x muscular contrHCtionii, which will draw the toes up, and it is not at all tin- eoinmoti to see a row of corns over tlie second pllalIllll:^-al arlicii- latjons, caused by the olvvations of these jnint« against the shoo from this reflex muBcnlar contnction.
How are corns to bo tpcatod ?
In the first place, you must insist npon the patient wearing properly-coniitructed shoes. Shoos must be woni which will per- mit expansion of the fo<it in all dirct-tioiis nt cverj* stop, and then corns will never he prorliiced ; but, if they have lieon fitnnwl, wo must treat them. Vou begin by paring the corn, i-an-fully re- moving iho hard shell with a sharp knife as much us can l>u done without (/rawitiff blood. When that is done, rub the surface of llic corn over with the solid stick of nitrate of silver ; this n-ill remove within a few days an additional layer of liardetied tiasae.
CORNS -BUNIOSg.
SSI
which cannot bo done with the knif« withoJt drawing blood. Now the com ia ready to "collar'' with adhesive pl«»tcr. Ttus Id (lone most conveniently hy taking narrow strips aiid plwring them oroand the com, cnrrrinf^ it up onlil etifficiont eleratioQ in obtained to complololy jirutoct the com from pressure.
l-'or the eofl corn the appliration of CYincentrated nitric ncid, or the solid rtic-k of nitrate of ulver, !» ttio nioHt eerv-iceable treat- ment that can be adopted.
First remove, by ntcaim of » knife or edeeore, the thickened ekin which covers the com ; tlien wipe tl»e ]jart« dry and apply tlie acid or nitnkte of silver, lluwe lii^t uppUcatious are some- what painful, but they are also exceedingly Iteuelirtnl. After the application hiu been innde. pliicv a pledget of cotton between thu toee BO as to permit the free entmnoe of nlr. In a few daya lite dry and hardened ekin caui^ by the raustie win he easily re- moved with the foreep and a second application made if ncoo*- eary. Thie second application is not generally painful unless done too early, and very seldom liaii to be repeated.
The reflex muscular coutractiun excited by a row of coma npon the top of tlie toes, along the •eennd jihnlangenl artioidation, ifl Eometimee bo great as to produce a subluxation of all the meta- tarw>-phalaiigeal joints. Sonietinieii such orooked and def4>rnied toe^ can be lianieased into the nonnal position, by strapping them to a level snrface with strips of adhesive plaster. Jf. fre- ([Uently !iap]M>nii, however, that this cannot be done; if it cannot, tbeu siihc;ilaneuii« Kodioii of the contracted tendons will be neeeasary.
BttNioKH. — A bnnion is an enlargement and inflainnialion uf the bursa eittiated upon the side of the great-toe, at the meta- tano-plialangctLl juuetion. Intlammatlon of this burna Ia frivjuently BO severe that the reflex contractions which follow produce a sub- luxation at thill joint. In ctmscquenra of the suViluxntion, the phalanx is made to preaa against the nerve that 6uppllc« this por- tion of the i^at'tuu to HUch an cxten:a« to produce the mo^t ex- quisite and torturing pain.
ThiH condition of atTair« can be ca»ily relieved by taking a strip of adhesive plaster and commencing lietww-n the great-toe and the one adjoining, carrying it ovur the end of the toe, adjust- ing it, and then continuing tlie plaster along tlie inner si<]e of the foot, aronnd the heel, and as far back as the base of the tiftb
5S3
BUNIONS.
itietstirsal bone, where it is firmly eeciirei] with another strip of piaster ami a rnller-bandage.
It -is uhuhII^- iicceesary, before appl}-ing tlie long Htrijie of til- licttire pUgtcr, to pUoc one or two Uii<:k»(»M» of th« pliwtcrjust behind and before the btioion, to make a little elevation Iwfun.- pacing over tho grt^at-Ioo joint. It u 0(X»«inn»Ily n^vsHiry to divide tlie tendon of the extensor propnus pollids which has been lon<; contracted, before the toe can be replaced in its uomuU position.
in sovoral iiurtsnccs under my own ol>«ei-vntion, thc«o bunions have gone on to such an extent as to produce periostitis, and end- ing in caries of the joint. L'nder Ritch circumstances, cxwction was resorted to with complete euct-ess. In some cases the gre«t-toe bi*conic:^ w everted and drawn over tlic end of the adjoining loo that it cannot tie brought imm^diat^ff into position and rettdnecl by the adhesive plaster as above described.
Fio. ■■i:.
PKt.ll*.
In »ach ewes it is neccBaary to apply a tractile force, tliat i>y its constant action will in time overeouio the deformity, after whi<:h it h easily retnined in position by the simple dressing b^ fore refurTf<i to.
To do tJiis, a buckskin or linen glove can be made to lit ttio toe, and to this attiich a few inches of elastic webbing, which is again attached to a piece of adhesive planter to go around tlie foot, and is retained in place by two other pieom, as seen In I-'igs. .
INGROWING TOE-NAIL. 553
S13 and 313, photographed from a patient of Dr. Charles II. Latbrop, of Lyons, Iowa, and which gfive a very good idea of the deformity and the mode of treatment.
Ingeow7sg Toe-Nail. — The most prolific cause of thisdifflculty is wearing narrow-soled shoes and boots, Tliat class of people who will insist npon wearing narrow-soled shoes, on the supposition that such shoes and a high instep are elements of great beanty, will sooner or later become cognizant of the fact that ingrowing toe-nails are tlieir legitimate ofispring. Such abnormal pressure causes the nail to cut its way into the tissues ; the consequence is, the tissues surrounding it become hypertrophied, and very com- monly a large mass of granulations spring out from the side of the nail.
The first thing to be done in the way of treatment is to guard these fresh granulations from tlie pressure of the sharp cutting edge of the nail, wliich can be done by placing a layer of cotton between them. The proper instrument to perform this operation with is a narrow thin blade without a cutting edge. {See Fig. 311.)
Fia. 814.
Donble a few threads of cotton over the instrument, and then carefully carry it down between the granulations and the nail until tlie edj^ of the nail is reached, when the instrument is gradually turned fiatwise and carried beneath it.
The first application of cotton in this manner is sometimes exceedingly painful ; the cotton, however, should be applied in such a way that ])ressure made on the ball of the toe causes no pain whatever. But the toe cannot be cured until all redundancy of tissue is gotten rid of.
Sometimes it becomes necessary to remove the granulations with the scissors ; nitric acid is an excellent application, and nitrate of silver is nearly as good. After the application of the cotton, therefore, tlie granulations should be brushed over with the acid or silver.
As soon as the layer of dead tissue made by the caustic appli- cations is ready to fall oflt without producing hiemotrhage, it may be removed together with the cotton fibres, and the cotton again
894
KU.VZ VALGDS.
introdut-od. The second appiicntion of Uio cotton » iiot, aa a nilo, very jwrnfii!. The {rnmiilnlions are then to he bru^liet] over with the caustic, aiid, when the Uvorof dt-od tiMiica^iti ti^jinrnt^^, the drm»ing is to be renewed. ThU treatment should he continued nuti) the nuU lias hsd time to grow out nixl protvct the ti««ueft by its own presence, and reiain tlieni in their proi>er position. The nail is there for the protection of the llesh, niid if improperly eut, in addition to the nbnoniiftl pressure made by improper ehoeing, fiuriouii trouble will be much moro readily produced. The nnEl hould alwavit bo cut si^uarcly ncrosa, so as to leave the cornera 'iltogetlicr free from the flesli, and permit ihom to lui a» u shield for its protection.
A very common motJiod of treatment is to rceoiiimeiid iJiu pntient lu gu to some specialist on corns iiud too-iiails, hut you ought certainly lo l>e able to ti-cnl them yourselves.
Anuttier jilun of treatment is lo cut a gutk-r in the ceiitre of the nail, which \iii» a tendency, tt is enid, to elevate the comura. Still another plan is to divide the nail and then strip it off, Thi» o]>erntion must he repeated within a sliort time ddUim the matrix in aim reiuovcil.
All tliesc plans of treatment have rccciveil llio approval of the profession. an<i *ome of them hiivu been extensively pnietiscd ; but I btflieve the better plan of treatment to be that which I havB iiulicHtud ; at all ev^jiite, removal of the nnil should never bo ro- Borted to nnle&s hypertrophy of the tiMueii about it has (;one to «iich an extent as to make it impossible to repair the parts with- out remoWng tlie cause of irritation. If the nail is rcmovc<l, it ia uccessary to remove the matrix in order to prevent tite rvtum of the nail.
Hallux Valocb. — Caeb. — In Janmiry, 1883, Mrs. X„ aged forty-two years, preae»te<l herself at my office sutTcring from thf! deformity known hm Juilhix vul^m, Imvinj; tfullun-d cxtroiufly from this difficulty during the past twenty to twenty-tire ycunt.
About three years ago the burea on tbt; ri;Hit foot l)(.-came very much inflamed, filled to its utmost, and opened s|H)Rtanvouiily in three or four places, from whleli pus tsstwd. Tlii« diechai;ge eontinned for four or five months, when the openings dosed and liave remained so ever since. The burjta on iIk; li-ft foot lias not bMn tlte BUbject of suppurative ioflammalion, although extremely painful and macb ioflkined at times.
OASE.
555
The burese have gradually enlarged, the walls becoming thick, red, and calloused, with coma upon them.
The patient came to me and requested to have both great-toea amputated. This I refused to do without previously trying some milder mesus ; I found the great-toe of the right foot ab- ducted to about an angle of 45°, with the next toe resting upon it {see Figs. 315 and 316). Over the head of the first metatarsal
Fie. SIS.
no. SIS.
bone was a large bursa containing considerable fluid. The cuta- neous surface over it was red, thick, hard, and very tender; the head of the uietstarsal bone was much enlarged. The phalanx articulated with a small part of the outer portion of the head of the metatarsal bone, leaving the greater and inner portion free, which formed a prominent projection. The deformity in the left foot was less marked than in tlio right.
I finally persuaded this lady to allow me to first use mechani- cal means, which was followed out faithfully for three weeks, withont any material benefit.
Thinking, perhaps, structural change and shortening had taken place in the muscles attached to the outside of the base of the first phalanx — viz., the outer portion of the flexor brevis pol- licis, adductor polhcis, and transveraus pedis — I carried the toe inward as far as possible, and then with my finger I pressed these muscles which were put upon the stretch; and immediately a spasm in the wliole limb followed, the patient shrieking aloud with pain, I then recognized the utter uselessness of trying to correct the deformity by mechanical means. The patient now insisted on having both toes removed. This I positively declined to do, and advised an exsection after the method of Prof. C.
556
HAIXDX VALGtra
Hneter, of Greifswald — viz., to remove the head of the first motatarsal bone subperioateaUy, under antiseptic precantione. She finally coneented for me to perform this operation upon one foot only. The patient was then placed under an ansesthetic ; I then took a strong scalpel and made an incision on the inner side
Fm. SIT.
of the foot, over the head of and parallel with the long axis of the head of the first metatarsal bone, dividing at once the soft tissues and the periosteum ; having done this, I detached the periosteum and ligamentous attachments from tlie head of the bone ; then, passing the chain-saw between the first and second metatarsal bones, cloBely bugging the first, I sawed off the head of the bone. (See Fig. 317. The exact size of the bone removed is here shown.)
Prof. Ilueter leaves it to the choice of the operator whether he shall use the saw or the bone-forceps. I object to the forceps
Fid. sib.
Fis. Sl».
in dividing or removing bone, as yon cannot do so without more or less crushing the bone-tissue and consequent necrosis.
A horse-liair drain was then placed in the cavity and the wound closed with sutures, bringing the toe into the normal position. The parts were then carefully dressed according to
CASE. 557
Lister's antiseptic dressing; tho foot being dressed every other day for one week, then once in three or four days, until cicatri- zation was completed.
Very little local and no systemic disturbance followed.
Two months after, the patient was enabled to walk with per- fect comfort and free motion of the toe, the foot having been restored to its previous symmetrical shape {gee Figs. 318 and 319).
I saw this lady in the early part of 1882, when she informed me that the result of the operation had been simply perfect.
Displacement of Tisndokb, — There is a disability of the foot, caused by the displacement of tendons, which must be briefly referred to.
The tendons which may he displaced are those in the groove behind either malleolus, in consequence of too great weight being thrown upon the anterior portion o£ the foot, thereby giving rise to undue strain upon the annular ligament ; rupture or stretching of the ligament takes place, and the tendons are dislocated for- ward upon the malleoli.
Where such an accident happens, the patient can no longer stand, and will shut up suddenly, like a jack-knife, and as quickly as though he had received a blow upon the medulla.
The accident may occur in descending stairs or steep declivi- ties, while wearing high-heeled shoes, which throw the weight of the body upon tlio front part of the foot, and the extra effort made for the purpose of retaining the hody within the centre of gravity, produces a direct strain upon these tendons, causing nip- ture or stretching of the annular ligament, sufficient to allow them to be displaced.
Now, if you examine the foot while the patient is sitting, the most careful inspection may not reveal anything abnormal ; the foot can he placed at right angles with the leg and the motions of the joint will ho apparently perfect ; and, to all appearance, the foot and leg may be normal, the tendons in the sitting position hav- ing slipped back into the groove. The moment, however, these patients attempt to walk, or their feet are placed in the position assumed in walking, tho tendons will slip from behind the mal- leoli, and down they go.
I cannot illustrate this peculiar accident better, than to give you a brief outline of a case which fell under my observation some years ago, and which has been fully published in the " Trans-
DISPLACEITCNT OF TENDOSSl
actions of th« New York State Mmlical Society," for the year 1870.
Cabe.— Mitw T., of Connecticut, a((ed nineteen, came to my office iipun cnitcbt's, Dtt-onibcr S, 18<ty. SUc walked in a nuist peculiar mnimvr; »he wuuld btilauoc hvmilf upoii her crutclios, ant) swing liotli feet in front of Iicr from eight to ten inebe« ; tJien lirinjj liwr cnitvlii-s forward, am] Kgaiii swing Iwr fwt for- wuri] about tbe ^ino dinUm-e, and tbU was the extent of her- ability to walk. The boot« which she wort; were stout ; ligblJy larod around the anklei*, and additionallv »ini4ainecl bv iron bans bolted under the fio]Lvi,aud exu>adiug up uu vitbi-r Hidu of the teg to the knee, atul tii«n «rcurcly faetened around the leg with Mg li'athorn (straps. The (latient bad dia-ovcrcd that she could }t Ktiind 111 nil uidese these iron bars were p<.>rfv<L-tly rigid, ooiuw^ quently no joints were allowed opposite the ankle-joints. Upoa renioviug thviw boots and imms it was found that motion at both ankie-joints was free, and Ibc ftwt and legs in every way seemed perfectly normal. The examination wait made while die
ito.iM.
was sitting. When, however, I asked her to stand up, site replii-d that it waA impossible, as she liad not walked for four monthly
TREATMENT.
659
and could not take a Bingle step. She was lifted upon her feet, but she stood very awkwardly ; and the moment she undertook to walk she suddenly fell — with her feet Sexed at an acute angle ; in fact, the dorenin of the foot was pressed almost against the tibia.
She had fallen in this way while descending the Crroton monu- ment in Connecticut, about four months before, and Iiad been unable to take a step since that time. A closer examination of this girl's feet revealed the fact that whenever they were ex- tended upon the leg, as Is necessary in stepping forward and backward, the tendons behind the malleoli were thrown forward from their grooves, {See Fig. 330.)
This condition was believed to be due to rupture or stretching of the annular ligament ; the grooves below the malleoli could retain the tendons while the foot remained at a right angle with the leg ; but, as soon as extension was made as in the act of
Fm. I»L
Fu.sta.
walking, the grooves were rendered more shallow, the ligament placed upon a stretch, and the tendons slipped at once from
500
DISPIJIOEMEST OP TEKDOSS.
tlieir ptiico», Slid were fonnd upon tlio niiitlcoli, Whtia Uils bad oonirrvd, the c-oiumHml of tho Toot, of course, was imtne- ilistcl^' loAt, aiid tlie peculiar '* eliuttiiig ii{> " of ttM> limbs rotnltod. Tliu ln.-atiiit.-iit til Uiie L-Am wm Uw ipplicatiou of ii moditii-d dii)>>foot drewing. The dreoeing consUtcd of bronil picflua of itdlii-i^vc pLa«tor, applied on c-iUior side of llio leg, laj-iiig over them i>iecat of tin, having eyelets at the toi). and securing tlivni wiUi u rullcr-tKindiigu ut'tor Uits plun of Barwell's dretelug fur cUib-fooI.
A fuldi-d piece of ploeter was pM«ed under (he foot, with eyes attaclied »t each end for the purpose of atlaehing the hooks of the artificial rnu^-lcs, and liec-ured in position by iiieaiiii of n woll- adjnxted rnller-handage. (Sm Fig. 321.) By (he attiiistance of thid droesiiig, tho patient wa« at ouco nhto to walk with comfort.
rio.fui.
iiu.wi.
and experienced but Httte mnre difficulty in loeoniotiim than any Bound person. The dressings were changed every fonr or five weekK, until September SO, ISTO. This patient at tliat time had entiroly recovered, and vos able to walk withoat artificial enp-
CEMARlfS.
681
port. Fig. 332 is a pbotograpliic front view of tlie limbg, with tlie Iii<iiii-rul>I>or muscles attaclied. Fig. 333 is » view of tlie eame after being dreseiid with Biioes atiU lituckiDgK, in whicb site could walk witti eiue ant] gra«c, and even Amnts wben the chains wesre Iiooked eiillieieiil]y lig)it to ;;ivc lier K^ctinty, Imt tbo instant the artiti(;ial iiiiiHclee were unhtntkeil rite MutiM fall Ainlilenly as thnngh 6be Iiad bei-n etnick hj Uglitning. It is poiwiblv for a [)en(i»n to walk npon a &oot or Icvf^l ground with tbo present style of bigli-lici-led bouts {ge« Fig. Sii) without iiiiy griMit dan- ger, although such persons always walk, or rathor teatldl^y in a mo<it ungmciirful maniivr. But to dosvciid a vi*ry rteep hill or flight of E-tairm with the heels tJiiu elevated, eo dimini^liei) the groovuH behind tbo tualluuli, that the muM-liM which aro put upon a acvcre strain to prevent the body from falling forwani, caneo the t«udon» to ilip out of tlu-6ii ehullow groovM^ either by stretching or mptnre of the annular ligaments. This is the rea- 6on why ladicK woaring thoee bigh-hevled ii\\OQ» are frequently compelled to go down-etaJrs backward. Ton can see them every day descending the Bto0]is of our fii»bionable residences in this manner, making a pretense of talking to some imaginary' person in tlie front-tluor a« an excuM) to hide their awkward niovemenlit. The shoe taken from one of our fashionable shops, represented in Fig. 324, i* nol in tJie least an cxnggcmlion of what i» seen every hour of the day in our streets, but is much higher in l]ic hools than the oneit that were worn at tbo time the injury here de* scribed was prodnoed.
And now, gentlemen, having come to tlic end of tho term, where our lcctun?« must close, I would aseare yon that no one regret* more than myself that n'ant of time prevented nie from making them mure thorough and complete. I have endeavored, in the short apace of time allotted to me, to explain to yon, as clearly as possible, my views in rt-gard to tho patLoIc^ of tJio dbeaMa and deformities referred to, and the general prihciplet of their treatment, giving you pradieid illustrations of the ap- plication of these principles in the different cases that have been brought before you.
Yon may find in yonr future pMctice some cases which yoo may not have had an opportunity of clinically examining during this ooarse of lectnres ; bnt tho same general principles which I hare demoiutratod to you in the cases which have been presented,
662 BEMABK8.
I think yoa will find eqnally applicable to tliem. You mnat de- pend upon your own ingenuity and observation for the practical application of them.
Many of the doctrines I have taught, you will find in direct variance with those of your test-books, and jou may meet with opposition from your professional brethren when you come to put them in practice. Having tested them so frequently myself, I feel confidence in commending them to you as being reliable. If in practice you find that they will not bear the test of experi- ence, yon are at liberty to reject them. If in the future you can discover new metlioda which are more satisfactory, it will be your duty to adopt them, as I would myself renounce any doctrino that I had ever taught whenever I was convinced of its error, and adopt other methods o£ treatment which my judgment pro- nounced superior to what I had practised before. Thanlning yon for your devoted attention during my lectures, and wishing yon a happy, useful, aud prosperous professional career, I bid you all (rod speed, and an affectionate farewell.
IlfDEX.
ABSCESS, tmOment of, in ipondflitis, Mii. iDguinal ; KB Inguioat nbscees. psoas ; ue Paou al«cc8ii. AcxtabutuDi, flseured, 44. Acquired deiormitieii, 13.
CHtklCB of, IS. A dhcpj ve planter, method of appliCBtion, AS. Adams, on endijloBis olhip, 420. OD tha pla-lor jacket m rotmy- iBleial curvulure, 60.^. Ahl's felt PpliDt, 102. Air, admitlance of. Into abnccBgea, 20T. Audry, of Purii, tne Ibuoder of ortliopedic
Burgorv, 8. Anaa, imperiorate, B2.
cane of, til, Anfeslhctics, use of, in orthopedioi, 3S. Anatom}' af the tiioi, 6S. anklo, 164. tnoe, liie. hip, 234. Anctvlosis, 89B. derivatioD of term, 39S. aa a favorable tenuiuatioa in di^eaae of
the jointa, 396. po^ifjon of iLiiib !□ enforced, 896. resultins from Dcelect of pauive motion,
14-18. bony, 418. bony, of elbow, 44S.
case, 443. bony, of knoe-ioiat, 443. bony, of hip, 4111. flbrouB, 898.
t«ni:tomy io flbrous, 400. mctiioJ of broakin;; up fibroua, 400. brisetiient for?e in fibrous, 401. importau™ of dreeaing uJtcr bresking up
fibrous, 401. of hip-joinl from effusion, 261.
ooxe, 262. of hip ; caao, 411.
of iiip, tenotomy, briscmcnt: caso, 418. of hib of Bex'CD years^ ritiindinff, reauiring from inflanimutory rheumatism; t«- notomy, brUemont ; caac, 414. of both bip-jointa, tenotomy, briBcment, recovery with artiflci&l joint; ease, 420. of hip with roflfnH>ntraction of miiaclea; tenototuy, briacment; case, 416.
Anchyloaia of left hip, aaction of elliptloal 'legment of the femur abovs the Cro-
chantur; dam, 426. of hip ; formation of new joint aflw «X-
seetion ; case, 486. of knee ; bnaement (amt ; csae, 404. ofkneewith necroaiaof tfamur; case, 406. of knee ; bri^ment forc^ ; case, 406. of bnea, with aubluxation; orisement;
caae, 409. of knee ; brisMnent foroi ; oaa*, 410. Ankle-joint, anatomy of, 164. diaea-ie of the, 163. pathology of uiiiease of the, 164. symptoms of diacfiae of the, 116. treatment of disease of the, ITO. iuatrumcnul treutnient in ^sease of the,
173. application of dresidng In (lieease of the,
ns.
removal of the lower portion of tibia In diaease of the : case, ITT.
disease of the, resulting Irom sprain ; ease, 178.
disease of the ankle ; ease, 181.
auppuratioQ and caries of both anUo- joints, rccoverT with motion; case, 182.
■ni>puration and caries of; case, 188.
caries of, amputation ndviscd by Dr. Val- entine Molt; cured without amputa- Uon ; euse, 189. AQlero-poBlerior currature, or spondylitis,
AttioulalioDS, ttiaease of the tatao-metatAr- sal, 191. pathology of, 191. method of examination, ISl. troatment. 191. case of, 198. Arterial circulation in exsection of the hip- joint, by Dr. J. A. Wyeth, 299. Atlee, Dr. J. L., dressing tbr ulipea, 112.
BARTON, Db. R., on anohyloaia of the hip-joint, 419. Bath, tberapctitia value of the, 21. Bandage, roller, in talipes, 101.
Kyp«um, ill talipes. 101. Barwell'Ei, Mr., dressing for talipes. 82, 108. Batebelder on eisection of the hip-j<nnt, 296.
604
IHDEX.
Bwier'n (abk on lyiBplaiMtolcff of tpon- iljlitbiuiJiiMualuaMnMiMiyian- (umuolnsy of morliiu «oiuriu» Id tlu thinl (U«{«, ITII.
Duwr'* ub1< oa nymptoDiiilolriiiT of tiOu- ric* of tUc lilp-Joint mwM iiu»&u (iHitritiii, lUI.
Bmur or oni'lii In-i*. UA.
BcutI, l>r, U, M., on Uie ari>1iratloD of huii.Vl.
Biitvlow, Dr. IL J., iliMHiUittoD on oflho-
on cxMClion uribr liip-i'imt. iM. BocAaaio, tipctsttoD pvrlurjucd by. 4. BounvU on tnMuuiit of lil[>-joiol <liM»e,
Bov-lupl (M Otnu'VitUriOD. BrbeinCDi furot in UliTo,-*, 114. B(i*Miwn( torvi In ululi] lu>u of tlio knot. 41KI, in Miiilivl'-iiii- (jf ll<i> tii)i-Jt-iat, V'i. Brodir, Hir Itci^ifuiin, un " UMwwd
Joint*." ant. " BraiihaaltB'a RctriMMCt," hro-dUMM br
Mr. K. Key ; our, Via. BuTTUi M s oftutu of >l>'fb'nilly, IS. dclbnnltin Ntultine fWMii, Ml. tNatmcol of dttonaitiua tvHiltW ttom, MS. Bunilu niniiilallnf (Iikkm of Uio knm*
joint, SM. Bunion*. Ul.
tnalmi'nt of, SB3. Buuk, I)t, <).. "n imcbylo*l< of Uio kucf- ji>>nl, HX.
CARIKSufllK lll<im,BM. tnalHiuntof.MS. 0*riM of the iHliium. 3GT.
CMC of. US. CamnmuiU, M4. U*lm> 00 barv-Iiii, 9. dioTo, ilcfomiilio* M • MO** of, 48. Cheli<w ou hii>-diH»M!, U]. Cltlonfeno In onhopedias M. ClurlM>fiiNn. renwrk* upoo, S. CKntinKMon m oKhopodlai, H. Cleft pnlMo, *i.
treatiDcnl of, tS.
CMC oi; 4S. aitoritiK. Ci.
««■« of. Ai, <t3. C1ItortdpMoni<,43. CiMiifiation of dribrndtlti, 11. Club-lbot; McTkllpoi. OlDh-hanil ; f UmuL Cloaiiu ramarks, BCI. CaMnoUne. ose of. M. Ocnconltal ^BtomJtjr, k. 11
dhtorllcin. K, II.
miXtartmaion, a. 11. Conlnctiired, lUdiulion of. li, Coopor, Sawusl, on lii|<-join( i^i»tM«i
OOMM^SIr AmIov, on " I>l•ll^atlall■ nod FiMlim* ofUio JotoU," 1«1.
Conjenlul BtllbmiDlion of tlw ptlvis : Mt
l-oltl". (IVwiacno, ddDgtr in utian, 531. Ctn; MS.
triMtOWDt itf. ft&O. Cnrtoli, Uarmctt'* whtal-, MS. Pulnw*. WK.
Mappiled In Inbtwy, IM. Curcuiina of Uit *plm<, divUiw of, 19.
DAViES, rif. n. 0., on diMoH or Um Llp-iolm. Kpl Uavjr, un ihv inviliod r4 niupenrion i' * thi> ni'iiUinlium o( th* plMlfT J 4(i7.
Darrncli'i «hpcl-onili-li, 4*1. ai.ivntuii Ibr diicMie of lfa« koM-jolnt,
Uofirmitini. En|>pamWBU|wnll>«citi«or,<. inl inatilulinn vMalilialiCtl fcT IliO UtM-
mcDt •<r. 1. Importuim of inaDnont </. I- dollumoii of '■ iWi-nuitj," 10. diTwinn of. I A
oluiiSeation of, 11. ttiaiOfT of. It. diaipiMik of, 14. maUoenl of, 1*. nwahanioal tnalinrnt nf, D. gunpral prufnimi* in. 10. De lo Sounlkn, incinolr br, 4.
Duil<Mll, 10(11011 of (»llll'>-.\>'tllltl> Vi B.
[>»tiiiol<I,UT.,iatmclwtiDiinrM>>ofnMyb}',a. Dduua an idvocato fur carl; opvraCloa In
biira-lif, 4S. IHmmm of die anklo-J<4nt: m Ankle.
M tlw kniM" joint ; *tt Knro.
of tli« iii(vju!nt ; sh llip^
of tliB »n«l-jninl; m WwU
of Iticcllowooinl : 14 EJbow.
of Uio ihoalJoi-Joliil ; m f^honldcr. Dixaua shl.;li >4PiuLil« difoaH: of tita
jmnto, ai. Diwiatia of haai) of l)i» fnniur, M<3.
(MB of, MS, IM.
«rli]i Ibnnatlon of dcit npctabulunt ujwa
donuni 111] ; oaw. »i». Dikplacvmenlof Mnd•^»llt (MTtBdoiia, Uijr lint in orlhopmliof^ HI. Druit, Or. &, oa diivut of th« biiHo
tea.
Dnwrinv* alUar lanHom; ; let TinoioiDj. Uuiitu:ir«n,o|<vraUc«ilbriilii>f of vinr-M«k.1
b.v,»Ki. '
on coueiniial dwIocKtion, ts^
pLIUTRlCITY, rulM for arplbMliaa «!,
appUoatina of o*«i4. !», K. ElwiVc icnaloo, SI, IK.
ill lilp.<llMaao, SHI. EUati« iBTiipnMiion m tpi>IU<l Is lUw i
the jointa, 171. Buntlir toe lot Komprngion, SM). nOor, Dr. L. W., IntM from, lo Dr. BirNkl as.
INDEX.
fi6fi
ElboiT-joint disease, 3M.
troatment of, S65. Elbow-joint, anchyloBu of ; «H AnebjiliMiB.
■jHQvitis af, S54. Eo^lieh gurgeona on orthopedioe, S. EpiSjudias, IT. Equino-varuB ; »MTBlipeB. Kiercise, imnortmice of, SO. Knsootion of tlie falpjoint, history of,
286. metliQd of openitiiiD !□, 297. dreuin^of wound after, SOI. anplication of cuirw<s io, SOS. table of aevcuCf-two casea of, treated bj
Dr. Ba^ro, 8S2. BynopBis oi aeventy-two cmes of, treated
bj Dr. Bayra, 547. rase of, aST. first successnil operation of, in America ;
case, SOi, remavai of thrse inches of the femur in ;
COM, Bll. reeult ot, shortcDing quarter of an inch ;
caso. SI 6. removal of four ioohes of tho feniur in ;
case, Sie. section of the femur one inch belov
trochanter minor in ; case, 818. with fracture of the femur at the time of
operation ; case, 890. nSultiDjj in fonnation of nov joint with
carlkkfje ; <u frontispiece ; case,
SSS. with head of femur loose in the acetabu- lum ; young^t cose hero recorded,
FATTY de^neratinn of muaelea, method of diocnosui in, S3. Facial paralyBis. BSI.
treatment of, fiM, Femur, diastanis of; case, SSt. eisection of head of; ire Exsection. necroeiuof; «< Neorosis. fracture of, with exsection ; case, S20. Ferguson on exsection of the hip-joint,
sae. Finftera, wobbed, *T. Rupernumersrv, 48. FabcT, Dr.j of Smg Bing, N. Y., on mon-
etrositii!», H6. Hied apparalusca in orthopedics, objections
to. 111*. Foot, anatomy of the, 88. vortical dinpiucem^nt of, in ta!ipes, 95. lateral diverL^encu of, io ^ipes, 9fi. club; it« Ta]i|>e8. Fornation of now liip-joint, 4S6. letter from Dr. G. Dovlo on, M9. letter from Dr. J. U. Bush on, 441. letter from Prof. A. Flint, Jr., upon mi- croBOopical eiaminaUon inacaae of, 441. letter ftom Dr. Willard Parker on, 441. Fracture of spine; «m Spine. of femur, with excision of the hip-joint; *M Femur.
GENTI-VALGDM, 51S. treaCmant of, 54S. 545.
operation for, b; Mr. Ogston, 546.
operation for, by Mr. Macewen, 645.
operation for, by Mr. Keevcs, 648.
instrument for treatment of, 1.44.
case of, cured, 644. Genu- varum, 647.
treatment, S4T.
instrument for treatment of, 548. Qcnerai considerations, 8, Qibson on disease of the hip-joint, SBl. Uymnastica, SO. Gjipsiun bandages in talipes, 101.
HARE-LIP, SB. treatment for, 40. case, 40.
opsratioo by Celsus tbr, S. Ha^ta a cause of deformity, 14. Hand, club; case, 161.
treatment, 102. Harris, Dr., on treatment of diseaae of the
hip-joint, SII9. Hammocfe, use of tho, in s[>andylitiB, 4flT. Hallux valgus ; case, 664. treatment of, as advised by Prof. Hueter, 668. Hcwsou on exsection of tho bip-Joint, 296. Hippocrates "On Articulation," S. Uip-joint, fibrous ancliyioais of the ; »/t Anchylosis, bony anehyin^ia of the ; nw Anch jtoaEa. fonnntion ot nen- ; sh Formation of new
hip-joint, anatomy of the, 284. exsectinn of the ; >ee Exsection. Hip-joint disciute, 234. pathoio)(y of, 23B. etiology of, 288. general treatment of, SST. local treatment of, SOS. night extension in, S76. applicAtlon of draasing for night extenshm
in, S77. application of dressing for long splint in,
SSI. application of dressing for short splint in,
STa. symptoms in first st^re of, S41. treatment in fln-t stage of, 283. symptoms in Accond e,taei> of, 248. treatment in second stage of, S65- symptoms of necond stage nf, a,4 artifi- cially produced bv Prof'. E. W. Wcbcr, 260. BTmptoms of third stage of, S6T. treatment of third staj^ of, 288. symptoms of thinl stof^ of, rrrtua symp- toms of second stage of (Bauer), 259. treatment by Dr. Hutchison in ; cwo, 26*. ptognosis in, 284. Dr. Aldon March on, S5B. absorption of acetabulum in, 281. in third stage; case, 2Sn. of eleven years' standing ; case, S90,
fiO«
INDEX.
Islina ; oim', SCI. ««ns> of the Uliint ihoulatliig: : (Wti SAL ouloa of Ui« Uluu iwiIiUh mat kick*,
w nimulalliig ; comi, Wt. litriiwtitUorCiniuxiiaiiiliitinir; aiM.HAV. [•rioditif (d'trmJicnlirrninjur rimulMinjt ;
<*■!. 371. *I»iid}Ilti> >linululii;;. SIS. litt^irtti hbMv** HiinulxiltPiet 374* ccoiriiiutal maltmnutiun or ixilvlii Biinii-
ptnlfnb iilmubtbp, !M.
diuunU of bcaJ uf Ktiuur kltnulatinv,
fonuKtfon of De> lii|>-jiiiiit foUotuig ;
Illtfli-hcclra ■hco, dwinr of. Ml. liumitu iiri MLMvlioQ 01 thv Ull>-J»int, SM. UudM'ii'ii inilrtUD(uu) tKaUocat Tor wrist-
llj-pcrtriipli;- ur^ani, 111, llj |>ia|iaai». in.
Il.It'JI, eirirtoftlir: wtCorlis. Iininin40ii, iK.
IwlmoMntk] OMtmcnl in <IUaM« or ifae
hl|>'JOtDt: M( lltp-IOlDl lUMdML
hutraiiiiUlUl tniMuiiiit III iI'iHivc nf ttu
knfl^u^iic; tM Kiato.ji^iiii tiii4-iiv.
tintnliiuinlBl trniluicfil tri (Imoih '>r the aakli'-j"iQC ; n Ankle-joint dlM«>o.
[n|[niwiii|t miili ; $44 Nklli.
TOIXTS, dlMOW) of Ibo htp, CIL V di*OMmortliBlEii(W,lH.
dbeua of the mktc, IM.
dlMBMa of Iho n»dI<>-lB>Ml. Itl.
dbMMM of til* alionlikr, sn.
diMMMof tiM elbow, (M.
dlawtm oftlw <mn. M4. Jufimiut, iu tppIkaUon tn apuDdfliilk,
JmIwI* Ibr t(«rtm«nt of Kponiljliti*, WT.
ITKAPP, Dr. IL, iMttv ftoni, to Dr. A. (te,rr, al.
fbnuD'H inu>vlo-b«4tor, W. linffer nn rxuvlion of thf liJp-joint, itt. Ktioi?li-kiicc: fH GcDU-tnlsiiia. Kit(.'i:-JolDi, knchylonu of; mc AncbfloBi*. ■■■■■•■mv iifiliu, IM. iivni>«iU»ortlw.ll>A. alin>Dio*}novitii of ths; caM,IlS1. ohmile i^-novlila, nitli lubluintioa ; luo- tern of «(aD|inmlnn npnn artor^ a* noTonll<ra tit laAamniiCion ; vata,
^AataSe InflunmMiaD of, sn. •woollon arUiB, 1X0. traMtDtnt limuoiioiiof (Lc, Stl. dUwM of Uio, 1*4.
KtkM-jOiMt, MiAlO)^ of, IM. jHthulo^ of, lt>(l,
^mptonu of, itu.
ImUnriil jri. »)t.
loTirunirnbil moiRrnt In, 810.
olo'tlc ooaipp— iea iA, tii,
Mdi-n^on in, MR
tK«Mttr of doDl<Io •dtnidwi fat, tl>.
nicilbixl of iipfi)^Dit lirowtiiit liii 911.
tniportanot of oin'Tul nOoulaa itt, tU.
ao)ii|ir«Ml«i to, •a\
faDpoTUni pointa In Iba rrajijiHwIliii <1
irotltigt tn, SIT. ii>v««riiy »r iiiiv in ilWf^ln^iMTii, Vti, Bi>iirosi*i>r loner (ikI of InuuTklaiiMliiiKt
LATHnAI.oiiiVBtor*, rninry: *HS|4no. ] " iMtil'K Blti'iin 'if YiPuUi," writl-tlnifi'l OUUDil liy ; OMj iit. LMd-poiKailna 1 Ml Wfj*l-4r(i]i,
TUCiniiiiniw Irnm, Afi*. Lni, Dr. B., on Miomu lbt«6 la ullpwi j
|]8w Lfrlnna. plan ef, t.
l,lBt"(l Oil nll--jr>'ml lliUBM'. W\.
I.Utli', I>t.. ir>In-liM-lH-ii "f '•nlU'fCdle MT-
p'ry iiil» Knf-Uiul lij', t. Lotciix.HntopcnilMia tornUidoliiab-Otot
by,*.
Mamli, iir. A., on iUM«e«f Ui« bip-MiO,
Vit. UuitpuUiiun, le. U»*^,-r, IV. UaU'inniiUtinis tV. HMluaioil i>i>iillaooM. M.
principlM or, SI . Maekivii, opcretira W. 4. MicliatUi. hMIod ofiiiiOri-AfMlb 17,4. UUIw, Dr. J*mM, la ilinMUC of (to Mil
joint. MV. MotirtiMiliM, «e. Uolt, I>r. Vklcnttne, ol ortliapodk wir-
fierr, d. UuwIm, voiilncluinl, 14, mvtlinil of t»tii« IW ioty digcmntloA
of, IK. pniUlnii of, for apptloiUcai «f elorttldly,
IS. sntr-rBlifU* of, H. UoKlif-tHsltr, btriuoi^, V). UtutomT, JH. flnt Iniruiiiirad Into Anwfta), ft.
NAU*. Inemwiiiff. SM. trrsinu-nt <>f. Uit. KrlitoD'i., I»r. Ifc.i-t iV„rt,tw-l»d, 4J0. NB(ra*iii"rl<r' ' .. '. :M(I.
wilhuKdol ' ii' . «u«, 4AA,
Noil-i, Ur., OrtMiug fqraUb-lbol, IIL
INDEX.
B6T
OAKUM, *dTuiU^ of, ia the drenicg of wounas, 177, »». ObtuiWor, KinifBlej'B, it. Ogston'a operatioD for genu-val^m, MG. Ojjsdoo, Mr.,an the oleanlineu of the ptu-
tcr jacket, *m. Opotstive ti^aCmeDt, Si. Optic nerre, PBitUl uCrophj with phimoais ;
Ortiiapeilic aurgeiy. hiatorj of, 1. Unt iutrodurad into America, 6. flrat iniro Juoed iota tlie achoola in Amei-
irs, 2. Dr. Valentine Untt on, 6. Dr. Uenr]' J. Bigelow on, B.
PARALYTIC defoiroity, 18. FaTslyaia, defanuiaes reaultins from,
eu.
trvatmcnt o^ S3 81, fil4. (u a cauee of deronuity, IS. infantile, 6li, facial \ tse Focui] paralyaiA. lew! ; itt Wrist-drop. tVem Bpinai meninguia, 514. aa cauaini rotaiy-lBtertil curvature, 493, case olT St- em of, 25. wise of. ■17. arrest of development fVom ; ctae, SSO. partial, with rotary - lat«iol curvature;
caee, E>U. complete, with oontrscturc of raatrocnc- miua, tibialis postious, and plantar ta.-"ii ; case, BIT. partiel, nith phimo^ and incoCrdina' tiOD ; caae, 519. Parts, abseuce of, 89. hypertrophy ol, 51. aupi/mumerary, 48. Passive motion m liip-jotDt <iiseue after ex-
BCCtioD, 31 J5.
Perioetitie of the femur, S69.
PfrioHtfum, removal of, 176. eiri£ on hip-dbteuw, Wl, I'elvis, con^Dital mBlformation of, S73. caae, 375. treat mont, 378. with apondylitia ; co«e, 378. Phimosis, 53. a cauBViif deformity^ 16. double talipes equiao-vonii paralytica
dependent up<>n ; cose, 65. with partial otTophj- of optic nerves ; ease,
60. hip-disenae reuniting from Gills caused
bv ; eii8c, BI. caaes of, 53, 58. riaeturKif- Paris jacket, preparation of iund- a^a for the uppUcatLOQ of, 46S. prepanition of the patient for the appli-
catinn of, 459. method of applying bandages in construc- tion of, 4nl. method of partial niinpcnsion during the
application of, 4.^9. ■ling used in applicution of, 460.
planter -of-Parii jacket, manner of mould- ing the, 4S1. treatment of abeceises with apondyli^
when applying the, iti, application ofjurymaat with, 461. application of bead-reKt with, 164. roodiflciUona in application of the, 46S. method of clvanmng the patient while
wearing llie, 46T, cruelty (so called) in the applioadon of
the, 468. requisite tliickneos of the, SOR. practical apptiistion of the (photograph), 4<]9. Pott'e disease j tet Spondylitis. Pott, Perwval, on aj»ndyliti«, 447. tost, Prof. A. C, on the treatment of defortDitias eiisin^ frmn sodds and bums, 54^. Prepuce adherent, 63. ■ Probes for exploring sinuses, 392. Psoas abecees from sacro-lliao disease simu- lating hip-dibcase ; case, Sm.
RACHITIS, a cause of deformities, IB. KcaloratioDa of porta to their norolal position atter tenotomy, S6.
Bcflpiration, freedom of, aller tiie applica- tion of the plaster jacket, 4BS.
Rest, limg-cootinucd, resulting in anchy- loHia; «H Anchylosis.
Beeves, Mr., operation for (lenu- valgum, (>48.
Kicbardion, Dr., essay on orthoi»dic sur- gBTj by, fl.
Eoonhuy»en, opcrotion by, 4.
Rogers, Dr. D. L., first operation of tenoto- my in America by, 6.
fiogere, Dr. J. K., on anchylosis of the hip, 419.
Roiler-bandagee in talipes, 101.
Kosenthal, Dr., on the method of examina- tion in ngondylitis, 453,
Robortd, Dr., jacket for the treatment oi spondylitis, 467.
Botary -lateral curvature of the spine; xt Bpioe.
SACRO-ILIAC disease, 3S7. causes uf, 358. method of examination for, 860. treatment of, 361. Sands, Dr., on anebyloeia of hip, 4S0. Sartonus, tenotomy performed by, 4. Sayro'a short hip splmt, 271.
long hip splint, 1279. Sayre, flist successful operation in America of exsection of tlie hiji-joinl by, ago. Bchmali on exsection of the hip-joint, SDB. Bclitching on exsection of the hip-joinl, 295. Schaffer's, Dr.,jacket for treatment of spon- dylitis, 467. Scalds, ilcformitien from, 641.
treatment of, 542. Shoe lor clulvfoot, Scarpa's, 4. Dr. Say re's. 109, Dr. Crosby's, 111.
MS
>EX.
ihot. Mr. BfjiKlrTB'. ISO.
tolrs for utuuiinuii Ua, 119. RlimilUcr-JolQl dWn-i.'' : rtiK, Ufl. Kiiiui, Dr. J. Uwiuii. iMiut n««n, lo Dr. Suf IV, ba.
'»lluirvr. IcnMomy |i*rfi»iu«<l bj', t. pliu-biAda, 44. (OMH uf, U, tA. SjnixlU! dvfonnltjr, U.
Sjilmtii. >iutU')En.'ltA, IDS.
AliV. f>.ll, l(i». 8|»ii<.Tr, I>t., of Wirtrrlijirn. K. V., cti os-
HKCion cf tllG Iuf--joiDI. JOI.
spine, IhictuTu ot, rrxnlnl bIUi ilw plwlcr JBcknt, ciimyiliiia rrMiviirv ; cbm, int. lom)' titHVl rumlun' uf. 4»l. ■catomual relation of |«rts in, IM. •a •Meaning in Uw i«>pMtli>t kiib, 4wt. eniun of. Ml. (Viii (iloma «r, (Vti. tiMUnmitor, 4U&. flxF^ aiipanduuf ta, 49S.
synmaiiijoi In, MU. SfOJic, rour; laiaraJ cun'Mnn of j niMlinii-
ImI ai^liuioni in, Ml . anitUatian nftLc i>lMUijadral io, Ntt, Mclioii cf latiiwiDiu dunu in ; otM, BIO, aiMii of. (klfi, SOI. S [mi.lv] I 111, MO. tUol'«7 at, U%. Rymptams of, MP. metbod afMnniliuitlna to, iSI. trcalimnt of. 4U, (GH. iTMUnuiit nrioCuiiU fnr, 4<H. dMMilijn nlruwd ll)r inwlmi-nt of, 44^ l»ble ofioMdon of dbMw In two hunJrod
•nd iiraiiM-flvo (■«■ oC 4SS. oTlDwarilontilaiiJ flnl lunilHir vetwbn* ,
llin finl OMA In trhiob tlio pladtr
j>i7kt< woB Hppllnl, IK. with tthsnu, tLoniU); tnsUncbt of ab-
www, «<''^. nftlnmil tfiutmi; («mh, 4*1, 4*4. cured tf llio [jIhKt jnrkM. pvviiHuly
tmlml Tor vomw. pneuniciDt*, Mill
ptnilv.ilB ; «u(i, O- of loBOf ilit^fll (orlabnn (iin-l ■lllioul
(kilarniki . jount^C imm ht<ri) r«-
«onto(l, 4(». CUD of, ilionliiii mult of DtMncnt bj
btncoand iilofh^jaduil. 4fl:. ofdonal Tvnobnr,Uiu|<a(itii(<'nitM«J U>
BlUnil CO bla liiHiiii-M w iiviii m
jwk«l WQK a|>|>tinl. 4^. of (liinal VfiTtcl'nE. 4H6. (tUitctunil tbortuiiiau ; •« Miuclu* folUniO'
lUNll.
•ft«^ of, 14. 9li7«hiii>, lum of. In ortba)wdi«, JI3. &tf«BM)rar oa aabcuMncouo WooUtm}', B. Mllffian'ajaokcl Ibi tilt iTOatnuiicol'nioil- drli&a. 4(IT. Subcutoomiua umoknur, flnt lUiMOVim'
of. 6. SuficniumoreFT Aiigen and too, 40.
KCDOV«l ol^ SI.
BntptrwIOD dnriKT tlia Bpf>Ii«tion nf the ptMtar JMckvt In apondylitiii, tM,
SuaptORtm durioc llio ap)>IUatl»ii of tb*
plaator Jadot id rotaij iatcnl ouna-
hltcBOO. Suaptnaldi aa prnddiD) by Mr. Davjr ilur-
iu|{ 111* appliailiaii of lb* plaalcr
Ja(iwi.4liT. BjBtflAkl fluid, wcniJon of, 11. iMultof iinn4«er«li<inof. 14. tJyntwfUa of tbo kacu-jolnl, IH.
Muaalion, 19B. Sjrmc na diinuo of tbe bip-jwit, MS.
T.\UPE8, or dutxfirat, n. (•liiinuB, Tl.
oaiHOi of, Tl. MloanoiM, Tl.
muaaa ef, Tt. v«riit, IT.
oiunofiTT, tO> TalSU*. HI.
CBiunof, fli. pa»tnNria.«3.
MiiaM of. OS. gnnal waaiw of, tt. nticml trvotmiDi of. 84, 07.
WL ——^11
iMultast onmplwationi* xr, 9B. Wcaiii of rfTki-lis/it a «iiTu willkonl Itoot-
om; In, 13. nla tut tiiiiiiMiatt ofdrcMliia; la, 100. Barmli'i- •Irvudiii; iii, li>3. Dr. J. L. Allrf 'r iliwine ipi. 111; tanJciu-; la inllamniatloEi la, ttO. B»t (gentian for, 4. (i)aliu>-TBrua ; MM*. S4, 110, 14*. Iroitiiimi ef, by dwinvity ; twe. 94. wtdi pualj^a naullinii fKon piilBodli,.
iar»-DiiubiiipDntl7ilM; «aM,TO>
«sR>.^miiui> '. ■«•<«, TO. tM.
douUv iMliti", (fiitfl ^T KOM ; OMO, SO. •
doublv va1j;iu. »T.
•loublv vuiu. nenuilBl: mac, IW,
vanu and vaK>.«u<.-«i»iu : cmc I Vt.
•qiiinii-vaniK, d-?ublu; «Ma, l!f, IH,
■niiinua. i<im: nun, \t1,
pfuilBriit ; atrtirm of jilantar bataa and
Hexon : caM, IM. ^ntocbi or oavn* of clebtfOD fatnf naml-
iiur: (WB cvitd, fas. raruB |«ralyli(a ; auM, IW. donbb) MvinO'Tani* wllb dialMttiM);
our, IsU. doulilv varua; Banolfadtawbttcatftlod;
ouc, 141. t<litiiu>^*nii): divitica of Hodo-AcUlUi
and plaiOar <u«la: ate, IttL Tinia: man, 140. 147. iinri>-iH|utiiiu and i anxallBlleu* ; ouc,
lAI. ntnlf ticui «itb r*>ullinE mntniMur* of
landi>>AdilUia and I'laDiu bttta i U«.
INDEX.
669
Talipes, ptnlylic vanMiqiiiiitiB ; ease, IIS. TuBO-metaUira&l uticulul^oiu, disease of
the, *n. Tenotomj', 34.
pmcticsl feuturca and operation of, BE, lift.
rule* for die necceut; of, Sd.
rentontioB of parts alter, SB.
eoily operatora and advocsMa for, 4, 6.
recorded by TulpiuB for the rolief of torticollu), 4.
pubcutaneoUB : flraC discoverer, 6.
first performed in Amorioii, fl.
objectionable in paralytic deformities, 116.
droesintn afler, IIT.
after-lreaticont In, 119. TenotorotB, M. TendoAchillifi, flcst BMrtlon of, 4.
•ection of, by Dclpcoh, 6.
accklenlul divLtion of; case, Tl. TenaioD ; aw EUielic t^niiioD. Ti'udone, diHjibcemenC of, UT.
caoac of, 5&7,
treatmeot of, S60.
dreeBing for, G59.
case, 5S8. Textor, 8r., on exse<^en of the hip-joint,
Sflfl. Tberapcutic agents in orthonediea, SO. TioDiaDD A Cd.'b India-nibMr bag for com- pression, 171. Toes, webbed, 47.
supernumeraiy, 4S. Tortivollis, or wry-neck, 63G.
CAUsea of, AA6.
treatment oi^ 5H7.
instrumeDt for titatment of. MO.
first operation for the relief of, 4. Treatment of deformitice, IT.
mechanical, 29.
Treatment of defbrmitira, operative, S4. Trapeze, use ot the, 499.
VASCtPLAB tumora, ttS. Vaseline in orthopedics, £3. Va^ismus, S3S. Van Bibber, Dr. , on the treatment oT lead-
psraljuB. 534. Vam-equlnus ; tei Talipas.
colcaneua ; tee Talip^. Venery, result of eicewivo, M. Vend, Andreas, SnitiDstitution established by, for the cure of deformities, 4.
WALKER'S jacket for the treatment of Bpondylitii, i67. Webbed flnijers ; >te Fingers. Webbed toe* ; hi Toes. While, Anthony, on exsection of the liip- joint, tnt succeaaful operation, S9&. While, Charlea, on eiseclion of the hip- joint, 865. Wire Cuirass ; lee Cuirass. Wood, Dr. James R., lenotomy by, 6. Wry-iieck; «e Torticollis.
Dupuytren'g operation fbr, 5. Wriat-joiiit disease, S48. treatment of, 848. resulting fmiD fractuni with ery^pelas,
rase, 348. remlting from a blow apon the wrist-
joinl ; case. Mi. importanoe of extensiui in, SEl. Wrist-drop, (122. symptiiins of, fiE3. treatment of, 6iT, 6M. Hudson's iDBtrumental treatmeDt for, GSS. eases of, 624, 528, bUB. Wyeth's jacket for treatment of spoiidy- lilia, 487.
TBS EKD,
THE NEW YORK MEDICAL JOURNAL,
A WeMy Review qf Medicine, Edited by FRANK P. FOSTER. M. D.,
IIm for it« prinpipiil (untiir™ t.iM-ttuK-H. Oiiroix*!. CoirMrvirjiTtovji, Ci.txirjtL Its-
PORW, (.'IIHKKKIIIXIIKNITII, IWxHi NoTlrKS, I.IAOIKII AltT|i|.K8. MlM>K VxKiOHtrUi,
Xkits Itiui», LKTTRHif TO THE >:i>iT<)ii, I'MMCGiiisas OF Socmiua, Kkpuutv un TUB PKUOima or Mbdrixb, ami Mi«Lru.;kNV.
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JnallRod to ihelr Tt«pDcllira bnnchix, «ovel Uu most Te<cnl aovuM(« in nnlinil rolrtics. urrvai aMni* at iliv dty an inutrJ uiuUr ilio lusJ "t Ktm* tttms, rrrm n mcOical iUnd> pnioC. ICnntliiiu: new ■nil UMfiil iu niutiru mtilirii i- c<liroiiicl(.>i undrr llii- brtA of itu- wllaur la "Thcmptutitvl Kato," otuoii »p|>«ar n^oontl;, and arc tltiBt »cll aiirtli Uio aubawjfdnn |>rica ef (he Juitiu (i_
Tlw actaHirdBunt of lliD msUrrin Ibc JoimsAi. aiwltln ut ■'' funiUli a erraler (rocunl irf t««dinic-inMt<<r in iu laentf-elehi double- wlBitinxl pncu* tbui i* i:'*<--n t^- ob; other journal uf itfl cIiHt iii A-ucrica. IHiuu.itlaiu ale uic^to Itvcif HiivD lliMi Id meat Joumala, aiod are. a* a Tulv. much hritrr f<JbA^itti-l.
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JOURNAL OF CUTANEOUS AND GENITO-URINARY DISEASES,
rt>mt> BT JOHN A. FORDYCE, M. D.
PUDZJSBSD MOtrraLY BY D. APPI.rrOlf d CO.
Tba Urtinjr of tfaU Jomnuii. vhbh !• now In lb atrcnth rooi of publloMJon, h«< boto MM ft pmcraMdoD, and. nndor tba pmwM cdtloflal nubniionin)!, thoto oui Lo iu> drabt Uiat it will pmnrv* ami iiioi<tiik« dm n-jiiilntliiii already atlal-llHlM^,
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KUUINSON (A. R.>.
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flTEINER I.FOnANN'ES>. Cuiii|>vii4iiim of Ct.Ltili-i-n't. I»i«<w-- " - U.-l f<)il'rwtitii>ncr«iMid.'*tinlonl8, Truti«lali"! fn.;ii lliv4Mxiii<f ' -*ii,
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pOk IK fhVKB <
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