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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 


I 
I 

I 


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&ltan  •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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DISEASES  OF  THE  HIP-JOINT. 


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HP-JOIST. 


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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. 


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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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man  in  the  pmfunioD,  «hoMjiaiM<n  ««  voliMblp  ailditioiu  tsmviUtnl  U(orKun>.  TbeBortctr 
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tMbaedre  RialUt.    7be  Kopnna  on  tha  Proarcw  oT  Uodioliio,  wilUan  hf  tuwt  ipooUlly 

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> 
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aubawjfdnn  |>rica  ef  (he  Juitiu (i_ 

Tlw  actaHirdBunt  of  lliD  msUrrin  Ibc  JoimsAi.  aiwltln  ut  ■''  funiUli  a  erraler  (rocunl  irf 
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To  ibo  pliiaitiuiti  Willi  dioSr.-a  ti>  ki'i'ji  s1>n<Mt|  -r  tlii<  timiu  iii  ini>JirIn»  aiid  natoiy.  Tut 
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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^, 

Thin  JoiKnti.  >•  tint.  D*  itn  nuuK'  niiubt  iuJioMa,  anlvlt  (or -jHoliilUtt.  tiul  il  appaali qiiilu 
at  fUiiogly  tv  lbs  KMii-nil  iirw.-lilunier,  to  whom  It  la  an  mtaluuble  aU,  id  tliul  it  enablaa  bim 
to  b«mm«  ooavtrant  wlcb  Ibe  advanoea  in,  and  the  lltoialur»  at,  dennatolc^  and  *7phU 
to^mpb?-  Itarotod  Id  ih«  dimwai  Lndleo^cd  Id  it*  tHIr,  the  Jncnxi.  vlll  be  wnlribuiRl  to 
by  the  iimmC  omlnvul  d«riu:iliil<ifitl>  niiit  >i|>hil<i^(ilier*  te  Ib'u  umiilrv.  Ui'li<iiiiv«r  lti# 
•ublni  miuirat  Ulunlnitimi,  ici>»l<!ii:>  or  tbromo-  Itthonnpkt  ■ill  t,i'  •  mpV-viil. 

Lftlen  from  Bun>|K'.  mic  t  ini>n!  of  nhich  will  apprar  in  cD<-b  i->uo  c>)'  tb«  JncaxAi, 
will  ktep  the  rrnler  InlonuoJ  of  iliv  odiunuM  In  tliU  dc[«IInicDt  of  mcdidlic  at  Ihc  j(r«a> 
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A  ruatUTV  of  ihv  .l-iiHiTAL  Will  Iw  the  publiralion  nt  aliitracia  of  tmittiitioiiH  at  iiutablo 
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of  tho  JovRXai.  Bni  dtrotad. 

BiHh  tho  iiilitnn  and  tlie  pubUHban  will  put  f:>nb  tvtrr  eflbrt  lo  mikr  tlir  Jotuial  Io- 
•tniolivp,  niirnoiiYc.  and  a  repmcntatlTC  «no  of  lli  claa>;  and  they  (eel  amirtd  ihattverj 
pnerltiiDfr.  wlioae  wt-rk  brlnv*  hliu  in  coniact  with  cutanDon*  or  gonllo- urinary  di*iw««, 
will  Sod  It  oT  sroit  luluu  wid  w-litaiicu  to  bim. 

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T.  MITCHELL  PRDDDEN,  M.D,, 

JOSEPH  LE  CONTE, 

APPLETON  MORGAN, 

FELIX  L.  OSWALD, 

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THOMAS  nn.L, 

N.  S.  SHALER, 

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AMBKOME  L.  RANNEY,  M.D., 

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Sir  WILLIAM  DAWSON, 

J.  HUGHLINGS  JACKSON,  M-D. 


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MILLS  (WEHLEY).  A  Text-Uook  of  Comparjii ive  Pii.vsir>ioi.'y.  For  Students 
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SIEMEVER  (FELIX  VON).  A  Tern-Hook  of  Pra.;ti.ul  Mfiieine.  with  parlicu- 
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NIGHTINGALE'S  (FLOIIENCEi   Notes  on  Nursiiis.      l-2iuo.      ("h.th.  Toeonta. 

ilSLKIi  (Wn,LI.\M).  Tbe  Priiic-iph"'  and  Pr»cii.>e  of  Mcdi'^ine.  Designed  for 
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6 


PELL&W  (E.  U.J.     A  JIaiiiMl  uf  PrKllcol  Uedlc«l  Ulienihlf?.     ISnio.    Willi 


t*KKKIHAfi  (l>r.)    Rl«i»e>iu  of  Malorla  Mtdlca  ami  T)i«rai>riitl(-H 
and  aikiilfi]  fur  tlie  Uw  of  Mci)ir«l  aoi]  PhunuMwulicAl 


Abrldee>l 
Pnutltlontr*  and 
Slutkiit*.  ttixl  coinprii-liii.'  alt  tlxr  Mmlk-inn*  of  iJiO  Hriliitli  rtiamiki'o|HitiK, 
wlUi  duoli  otlirm  u  nrii  frviiucotl;  urilorvd  ui  l'rv«criptiiini^  or  ri>oulT«i)  by 
t)i«  I'bjHiTJBii,  KiIIUkI  bj  Itobvrt  B«ntl«]r  bihI  Th«o]itiihia Kedwovil.  Kiival 
8vo.     Clolh.  $7.1)0;  iibc<!fi,iS.OO. 

PliYBUtAI.KXAS'JrKK).  Aa  Atlu  of  iliniuiil  UicriM-opy.  TruMlulol  aai) 
v)liir<l  b;  Alfrc<l  C  (limril.  II.  [).  First  Ani«rioan.  fri>m  tl>c  iiMDnwflM 
oi  Ibe  Rui-oiiil  Gvnuan  «lltioii,  willi  Addillunf.  Ninoty  PlaWa,  Willi  IW 
ltliiaimion\  Chroniu-l.ilba^rapbH.        Sqiiari<  6vo.    Ololli.  itt.OO. 

I'IKt'AUIi  illENKY  <;.).  A  Pnwtlcal  TrwlU  on  IMmxMMor  il>e  Skin.  Hr 
Henry  U.  PitTard.  A.  M.  .M.  U.,  M8l»t«d  I.1  liobert  M.  Fuller.  M.  D.  WiUt 
Firt,v  rii1l-|fa^4  Orie'oa'  Plittp*  Mil  Thinv-Uiieo  Illiislnttliint  lu  tli«  Text. 
4to.    (.•'Mil  ly  fobKriptiam  OHtf.) 

PUMEROY  (4;|{KS  l>.).  Tbo  I>ln|tnoH>  nnd  1'r«ati(iOBt  of  DImmm  <>r  (li«  ijtr. 
Wlib  Oii<>  lliiiidrtil  llloslrationii.  SKMd  fdlllM.  rvriMd  nad  ODUrKi^.  liro. 
Clotti,  ta.ixi. 

POUKE  {C  T.).    UMcirtittii]'  iui<l  0>t«m-liui»,  for  Ibu  UorrocUoti  of  Doforuilt 
of  tfao  I^wer  l-tailiti.    50  niuotmliont^    8ro.    CIMh,  tS.S'i. 


QUAIN   (l'.U'ilA>U>t.     A  I>;i-li<inHrj  of  Ucdinlno,  iiidudinit  (i<.'ii*f»l  I'hI 
(irucritl  Tlien>jii'iitii-s,  lli>'^l<.-Uf,  nnd   lb«  IJlac^wo  |i«iiiliar  lu   Wi^ii 

Uhildreu.    By  Vnriout  W  riurs.     Edited  bjr  lti«li«nl  tjuain.  SI.  U ^.„ 

■  ' -■■'■  ^  ^iDpl^io  Index,  and  I8»  llliiatrnlii'nii.    {S»l4*Hlg 


\u\st  Htu  vuliimo,  viib 

(jr  «iri«fHf  turn.) 


VII*f»l  l'Htllllt0|7, 

'Vi.iaoa  Awi 
III  ihm 


■-MID 


KANNCY(AMBRQ!>KU).  A|>|>)if<l  Aiuhiiay  uf  tbo  KefToc-.  Systnu.  Mug* 
Smd;  of  llii'  PoHinn  "f  tlif  lliiman  Rodj  fr»iii  n  MAiKlifiiil  uf  iu  (ivnentl 
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Ololh,  $5.1)0;  ■bfi-i..  $il.(H>. 


KUUINSON  (A.  R.>. 


A  Uuiual  of  l>enut'>lutiy-    lUvitod  ai>d  <«rrwclvd.    svu 


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e4ldoii,  nil*n:r4  and  nmrttd.     lawit.    Ololb,  tl.tS. 

SAVKK  ^Li:Wl^  A.)-  luicnaiw  on  OrUiopedio  i^urcer;  tnd  PtuMSes  of  Uie 
JoiritP,  .li-lii urtKl  ut  ItulloiiM  lIiMplUl  Mcdickl  Call«|[e.  Ilt«  fdMlH.  illu*- 
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(iiTiniuitJilioii,  liTl'iinrtci  U.  C'lirltr,  M.l>.  WlHi  3<i  I'DirrmiHjt*  <in  W<>oil, 
8m.     Ololb.  «».S0 :  nbeec,  $4.liO. 

SCIU'LTZE  (it.  S.).  The  l'«il)olo(;v  uiiil  Treiitimiii  of  l>i"|'liiri.'iii*iita«I  tli* 
rt«ira(>.  Triiri><liilvd  tmin  lli«  (.icnnfln  l>y  .lnnic«iii  J.  )liKvn.  H.  A,,  v(^. ; 
nii<1  ttViteA  l>r  Artbai'  V.  M»CM.  M.  B.,  olc.  With  Uou  lliindrdl  uid 
Twent.v  ltl<uir«lioni>.    Kro.    <1u4li,  ^.OO. 

SHIELD  (A.  HARMAI>L^KE).  AuigimI  Anauiui;  for  tiliiileiitd  19nio. 
(.'Wkdutt's  Sksikk.)    Cloth,  fl.Tfi. 

SHOKMAKEIt  (JUHN  V.).  A  Toxl-Oocrfi  of  tlisMMM  ut  Mi«  8hin.  bb 
L'brotnu-I.ilbograpli*  anil  uuiiKrou^  Ei if rai Itiir^.  So<-uti(]  villlioo,  rarlwl 
iin<)  nnlnrii«l.    8vo.    Cbtli,  <6.iiO;  ihrv\<.  pi.inx 

&[MP!*UN'  (JAMES  Y.).  S>;1m1mI  Uorlis:  AniPMlK<i>'K,  IHw«W6  of  Wuntoii. 
S  voU.,  8vo.     I'or  votuini-.     C'lotli.  $3."<>;  f>liT«|>,  Ct.OO. 

SIUS  (J.  MARIO.V).  tfa*  SlDTT  n(  bi>  Ulf.  K^ilts)  bj  >>l»  Kod,  U.  JfarioD 
SiriiH,  M,  l>.     Willi  Portrnit.     ISu>i>.     Clixb.  $t.2l>. 

SKENE  (AI.EXANDEK  J.  Cj.     A  Ti»l-!ti>ok  .<a  tli<>  Dixw*!?  •>(  V •« 

]|1ii*triiT«l  with  two  hundruil  and  liOj^'tlmr  lllimirali.-ni,  of  ' 
hiiiiilnil  mill  oiit.v-tJvo  kr«  originiil,  iinil  niur  <'tirniiiO-l)l1iiitfrn|i|i- 
edition.     8*0.     i/MJ  in  rvb4eriptiini  i/ttts/.l 

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, 

hj  UwMio  I'nit.    (tvih    Cloili,  ^.wo  ;  tliov].,  t4M. 

bTEVEN?^  iriEOItdM  T.)      rnncU.jn&l  Strvoao  l>i*t-,»».   tMr  Cmh*  Hcl 

tt'  "     ii'>ir  for  Ili«  Coticoiitnu  uf  |K4J.|H8S.  A«*Uail» lio.ial 

il<  .■■■..  iitw.      Witti  n  Siiji|.li-m<)0|.  no  llin  .loT-miilFr"  ••t  Mi- 

lt <  i  .V<^uuiui'"ltli-iD  uf  llit^  Elf.  aiiil  uf  '  ili 

b'.  '  tlfBHttV' )'-''<'  Plal^v  MK^  tw«]v«  In  ' 

iivoU  at  Uoiloni  M«diiinr.  iuHodiv  l'rt»d^  «r 
huii.'!.   II  III,  iii..t..  r.../i.i  u.«.wsndiai<  VsImM 


pOk  IK  fhVKB   < 

liw)E(..l   'filiSu 


b1 


THOMSON  (J.  ARTHUR).    Outlirie«  of  Zoology.    With  Thirtv-two  fnll-paji* 
Illustrations,     lamo.     Cldth,  $3.00. 

TRAOY  (ROGEK  8.1.  Tiie  K-seiifials  of  Anatoniv.  PliysioloKy,  and  HjgieM. 
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TRANSACTIONS  Of  THE  NEW  YORK  STATE  MEHIOAI,  ASSOCIA- 
TION, VUI,H.  I  tinii  II,  BeioK  the  ProceeiIinfp<  of  the  First  Annual  Meet- 
)Dg  of  tlie  Ni-w  York  fStaie  Medical  Association,  held  in  New  York,  Noveiti- 

ber  18,  IB,  Mud  20,  1884.     Small  Svo.     Cioth,  $-5.00. 

TYNDALL  (JOHN).  Efaaya  on  the  Floating  Matter  of  the  Air,  in  Relation  to 
Putrefaction  and  lofeption.     13ino.     Clotli.  tl.50. 

ULTZMANN  (ROBERT).  Pyuria,  or  Pus  in  the  I'rine,  and  its  Treatment. 
Translated  by  permission,  by  Dr.  Walter  B.  Piatt.     l2ino.    Cloth,  )1.00. 

VAN  BUBEN  (W.  H.).  Lectures  upon  Diseases  of  the  Beetum,  and  the  Sur- 
gery of  the  Lower  Bonel,  delivered  at  Bellevne  Hospital  Hedica)  College. 
SMMd  cdRlN,  rCTlged  ud  enlvpTMl.    8vo.    Cloth,  tS.OU:  sheep,  $4.00. 

Van  BL'REN  (W.  H.).  Lecture*  on  the  Principles  and  Prsctioe  ot  SurHery. 
Delivered  .it  Uellcvue  llospttid  Medical  Culleira.  Kdited  hv  Lewis  A.  Stim- 
aon,  M.  D.     fivo.     Cloth,  $4.00;  sheep,  $5.00. 

VOtiEL  (A.).  A  Praclicul  TrentiM  od  the  Diaeari^B  of  Children.  Translated 
and  editeil  by  11.  Buphat^I,  M.  H.  Third  Amrltai  tram  tke  r^klh  £ermaa  edl- 
11m,  refiifd  ud  calaricMl.  Illtisi  nited  t>v  six  Lithoeraplik  I'lates.  8vo. 
Cloth,  $4.50 ;  xhi-ep,  j.j.oO. 

VON  ZKISSI.  (IIERM.\N'N).  I.liilliiic^  of  lUe  Pathology  and  Ti-euWiieiit  of 
Syphilid  nud  Atlicil  Vciieri'id  niMea-cs.  SMoad  edlUon,  revised  by  Maxinnt- 
ian  Ton  Zeissl.  .\iitltorii!c<l  I'ditinn,  Traii.*l>itcd,  nitli  Notes,  hy  H.  I{«- 
phnel,  M.  I),     hvo.     Cloth,  *4.(Jii;  sheep,  i!!").ilO. 

WAGNER  (RIJ)OI.F).  Uand-liook  ol  ChomJcul  Ti-chn.ilotr;-  Translated  acid 
edited  from  the  eighth (■eriiiiin  edilinti.  uilh  extensive  Additinns.  hv  Williain 
Crookes.     With  33ti  llliistr:itii)iis.     (.m.     Cl.ith,  $fi.Oii. 

WALTON  (GEORCiE  E.|.  Miner;d  Springs  of  the  I'liiteil  States  and  Uanadaa. 
Oontainini?  the  lutect  .Analyses,  iiith  full  l>escripti"n  of  LocidilieH,  Routes. 
etc.     Srtaod  rdlllM,  rertird  a*d  tnlarged.     l^nm.     Cloth,  $2.00. 

WEBBER  (S.  (i.l.  A  Treatise  en  N'crvous  Diseases:  Their  Svinptotns  and 
Treatment.    A  Text-Hook  for  Stndcnts  anil  Practitioners,   hvo.    Cloth,  $3.00. 

WEEKS-SIIAW  (Ci.AHA  S.|.  A  Text-Bunk  of  Nurfinu,  For  the  Use  of 
Training- School,  Fiiniilies.  and  Private  Stnili-ni.'',  Second  edition,  revised 
and  enlarged.  ISiim.  With  [Ihistrntioiis,  Qnestiuiis  for  Review  and  Ex- 
am inat  ion,  and  Vocnlmlary  of  Mi-dical  Ternii.      I^mo.     Cloth,  $1.75. 

"WELIS(T.  SPEN'OER).    Uiscasi-s  of  the  Ovaries.     Kvo.     Cloth,  *4.50. 

WORCESTER  (A.).     Monthly  Niir?itijr.     Swond  tdllisn,  miiml.     Cloth,  $1.25. 

WYETII  (.JOHN  A.).  A  Text-Book  OT)  Surgery ;  Cenera!, Operative,  and  Me- 
chnnieal,     Pritfusely  illuHtrated,     ftvo.      {Sohf  hy  tiihatripthh  only.) 


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