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. 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. 






3 2.7 


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, 



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 


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. 

28EI FiiTH Atekck, JtMuary 1, 1B16. 


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 

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. 


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. 


January I, 1883. 




History of Orthopcdy. — General Confllderfttions which should Induce the Student 
to make it a Subject of Special Stud;. — General Plan of InstrucUon . 1 



CUMifloation. — Definition,— Etiology. — Pn^o^s. — Diagnosis , . . 10 



Treatment. — General Principles. — Jlnnipulation or Massa^. — Oymnastics. — 
Therapeutic Agents. — Dry Deal. — Batlis. — Inunction. ^-Strychnia. — Elec- 
tridiy 17 



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 



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 



Etiology {continood). — Congenital Phimosis and Adherent Prepuce.— PrognosiB. 

— Diagnosis. — Clitoritis. — Vascular Tumors. — Monatrositica ... OS 




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 



Talipes Varus. — Causes of. — Case. — Complicaliona. — Case. — Talipes Valeus. — 

Csusee of.— Paralytic Tarietj, vith Cases. — Treatment of the same . 77 



Talipes Plantaris. — Causes of Talipes. — Treatment. — Indicalions tor. — When to 

begin. — Uow to effect a Cure without Tenotomy 9S 



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 



Treatment (continued), — Tenotomy. — Indications for same, — Dressing applied 
after the OpevaIion.—After-Treatment.— Club-Oand 110 



Anatomy of the Ankle-Joint. — Pathology of Disease of. — Symptoma. — Treatment, 1(3 



Treatment (continued), — Description of Instrument, — Uode of Application. — 

Cases.— Disease of the Tarso-Uctatarsal Articulation,— Case . , .178 


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 




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 


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 



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 



Anatomy of the Uip-JoinL — Pathology of Hip-Disease. — Etiology. — Symptoms of 

Rrat Stage 234 



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 



Treatmeot. — Uechanical Apparatus, and how applied 297 



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 





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 



Digeaee of the Wrist-Joint.— SynorltiB of the ElboT-Jcdnt.— Diacase of the 

SboulderJoint (cause, guiiBbot-wouad) 848 



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 



raraljsis of the Lower Eitremitics. — Diastasis. — Fractures. — Dislocatlooo. — Bur- 

eitis and Necrosia S80 



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 


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 




Defluition. — Anatomy of the Spinal Column. — Etiology. — Pathology. — Sjfroptoms. 
— Method of eiamining the Case. — Treatment. — Mechanical Appliances, — 
Fiaster4>f-ParU Jkcket 446 


DiromiiiTiia or thi HPim. — botaet-latckai. ccbvatiibi. 


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 



Causes. — Treatment. — General ParaljGia. — Paralysis of the Elitremitles. — Fadal 

ParalTBlB. — Lead-ParalfSia 514 


DUOBicrnEs (continced). 

Torticollis. — Deformitiefi from Buma. — Genn-Talgum. — Genn-Varum . 035 



Ctn-ns. — Bunions. — Ingrowing Toe-Naals. — Ilallui Valgus.— Diflplowment of Ten- 
dons 549 



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 

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. 




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 

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 toapiC M ioQ 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 

114, ■IS.IIIkllT. Cam: Supponlkm andwlatof both •bkia-jointe, with tallpM. 


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. 



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 


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' 


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- 

163. Dres^Dg in the flrst stage for the application of Sayre's short hip-splint. 




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 

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{!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 

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 


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. 



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- 


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 

iSS, 3B0, 291. Case : Botary-laterol curvature ; section of latisaimiia dorsL 



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. 





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 

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- 



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* 

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 



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 

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. 


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. 


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 

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» 

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. 


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 

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 

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 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 

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 

He says : *' It was my bappy lot, even at my advancing time 


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 

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 


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- 

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 

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- 



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. 


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 : 




■a 2 -e j3 

■a cj £__ 



o aj ' 

"S 3 -*" S ^ P 


° g II S 



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 

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 

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 



■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- 

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 

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 


■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 



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- 

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- 


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. 



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 

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- 



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'. 



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 


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 



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 



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- 

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 



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. 



/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 

£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 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- 



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 : 



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 

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- 



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- 



Tbo followiiif; cxtm«U from lett«n show llio progrMs of tlie 

>■ 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. 



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 



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- 


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 

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. 



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 



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 


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 



^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 

Vet, in the progreM of time, we have learned still more ; aiid 
in my own exporionco I Imro been enabled to tent the correctneea 


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." 



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 

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- 




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- 



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.) 


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 


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 



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 



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- 

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- 



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- 

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- 



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, 


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 

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 

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 



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 



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 

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 



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- 


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- 



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 

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 

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, 


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. 


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 



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- 

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 


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. 



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 

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 

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 



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- 

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 



Therefore, Mdxag no otlier cause to whidi I oooM attrit 
this derangement of her nervous syBtem, I was compelled to be* 

m. M. 


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 f MMitly 
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. 



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 


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. 



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 

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- 

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. 




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. 



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 



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 

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 



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- 

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>'^ 

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 



■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 


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> 

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 



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. 



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. 


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" 


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 

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 

'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- 


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; 



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 



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. 





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. 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 

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 



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. 


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 

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 


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 



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 




■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 ; 


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 

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 




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 



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. 



" 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- 

"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 


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. 




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 

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 



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 


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 


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. 


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, 



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 


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, 




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, 


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 

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 

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. 




. 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 



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 





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 


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 



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 


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 



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 



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- 


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.) 





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, /}.) 





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- 

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 




titiis] muscles, and, in vnIgtiB, tlie iwronenlii And the extensor 
lufiguit digitoram, have liecn coneidurvd to bo tliv eoat oi die- 

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- 

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 



involved tlie wliote of tlie lower extremitiee, tmd frequently the 

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. 



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- 



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 


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, 



«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 



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*»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 


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> 

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 ■ 





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 


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 

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 



shclU found in coinprebdcd sponge sometimes cause the same 

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 



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 



[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- 



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 

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" 

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 




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 

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 



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 

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 

The practical working of the shoe is so well described by tli 
editor of tlie Medieal OastUe, in the number of December 2S, ' 



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, 



«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 


(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 



muscl<i8in sndi position a» shall best Bnpplytlie place of thoM 

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- 

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. 


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- 

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. 


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 

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 

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- 

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 



— 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 


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. 




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 


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.) 



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 



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. 



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- 

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- 


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 



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 

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 



down, while T demonstrate them upon the caaes brought before 

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. 



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,>!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 


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 


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 


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 




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 



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 


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 

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. 



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 

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 

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 


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. 



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 

2f)M. — ITas much improved. Only suffering complained of 
u tlie prcwuro of tho plaster on the c*1lu« produt-cd by the ithoea 


formcriy worn. Iicfttljiut«(l piasters, «o a« to relieve (he diffi- 

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 




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 


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- 



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 



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- 


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 



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. «. 



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 

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 


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 



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 



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> 

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 


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 


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- 







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 


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.) 


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 


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 


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). 


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 : 



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- 

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 

Sgiitmber 80, 1870.— The position of ber feet ia as seen 



in Fig. 76, from drnnvinj^ by Dr. L. M. Yale, made at tlic 

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. 


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 

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 



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 



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 

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 




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. ». 


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- 


■ '^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 


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 



•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- 


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. 



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. 



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 



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 

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 



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 



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. 


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- 



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 



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 


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 


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 

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 



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 




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 

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 



H^ oiit 


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. 


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- 

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- 



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 



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' 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 

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, 


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 

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 




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 

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 




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 



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 



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. 



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. 




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 



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. 


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 





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 bono will not bv anvbtii.1, and llie operation will llierefore 

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 



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, 

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. 



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 

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 



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 




* 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 


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 

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 



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. 



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- 



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 : 


"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 

^'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." 



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 

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. 



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- 



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. 




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. 



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 



eetoiiB, »lww condiiaively thnt Utey did pa.t9 tlirongli the anlcle- 
joinl. {Sm Figx. 120 snil 121.) 


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 



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 



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- 





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^) 



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- 



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 

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^ 


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 

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 



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 



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 



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- 


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 





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 



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. 


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. 



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 

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 



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 



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 


*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 



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 





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 



eliall be no poseibility of secretions being pocketed or othcrwUe 

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- 

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 



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- 

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 




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 






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 


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 



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 



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 

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 






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 




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).. 


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 



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. 



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*- 
h wttW 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 

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 ' 





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 





QQt poaaeflB the same power, sncl afford the gome bettofit to li!« 
patieaU ut nn^ of tlio most sncceeAful of tliene traveling manipa- 

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 )) 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 

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 



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 


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- 

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- 



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 



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 


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 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 

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 



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 


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*. 




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. 


IttiHT.iti t1 If 
LEFT. 13 « t*fi 'Mcttt. 

fa. tm. 

HiAQSom. — Chronic inflammation of the knee-joint, with 

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. 



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- 

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 

If tills progress is favorable, both locally and conAtitntioiiaUy, 




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 



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. 



^ 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 

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^ 

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. 



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. 



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^ 



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 

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. 





Anaiiimy of the Hip-Juinl. — l^tlioloKX of l[it>-DbMML — Etiology. ' ■ ' S7 »p Uiin* 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- 

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 



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. 


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 


wliidi liftve their cotiitnenccDiciit in a t;ynoviti£ I Am fully con- 

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. 



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 



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 



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 



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 

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> 



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' 

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 



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»- 

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 


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 


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). 



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 


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 



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^- 





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. 



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. 



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 


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 □' 



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 



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 



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' 

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- 

"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 



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- 

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 



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 

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 


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 


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 



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 



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 


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 


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). 

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 
Toot touehve iritli 1»II ooljr. 
Tow iarert^d a» In poetvrior mperior 

P«Kte raised. 

" prcfjcctcd backward. 
" angle of nuJinatidO nlniMt 
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- 



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 

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 

lUron Dupuytrcn, in the *'Injtir[ee and Diseases of the 



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 



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 



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 

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 

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 


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. 


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 


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 

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 



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. 


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. 


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* 

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- 



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 

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 



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- 



[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 


|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. 



<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 


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. 



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 



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.) 



Kext, pbice the inetrumont ujKin the tlitgh with iu jaws nbout 
tiircc JDches above the oomlyles, and with the thumb mid dinger 

Fia. 111. 


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. 



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 



tho fitutft, tliat id, iiuikc cxtciiuon, hffore the bfd-taUruion ta n- 

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 



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 



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. 


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- 

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 




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 


^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. 



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- 



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 

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, 



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 

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 


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 



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 

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 

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 



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 



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 



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 

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 



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- 

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 



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- 



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- 



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 



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 



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 

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— &■ 


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. 



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 

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. 



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- 



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— l orrb^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 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 



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 


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 

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 



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 

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 

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 



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 

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 



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- 

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 



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 




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 



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 

" 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. 



"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 

" 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, 



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 

" 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" 



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 

*■'.-, 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 


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 


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 


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 



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 



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. 



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 



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. 



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 


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. 


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. 



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 





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 



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 

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- 


Borbcd, and the remains of the licod of the bone were If ing lo<we 
in the acetabulutti, which was carious but not perfomted. 


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 



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- 

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 


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 



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 



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- 

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. 



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 

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 


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 



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. 

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. 


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 

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 


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 


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.) 


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 



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 : 














Bis? j 





' B E S • • 5 

I nil! 










rifl 15 





n 'lb 



























I lli IjE 1i 

i ii^ rf i^ 



ij|ii« 'ii;t. 

^15 Ei 

:fi ill 
h 111 



g^3 \i\ 



H r 


i w 






m i 











1 3 




mm . 



■a 5 B^ 


I ill 
































1* ^^^ 





11 1 I a'i 


















Boo ■ -«" J 







Or A , ^^ t - 

f. y ^ «. d-Ei 



J 3 



_i^ s • £ a -= ? 5 5 

|bK|»| = 



-1 aS 






* Eg " 

tt it 

-11 H^- I 


S 9 ^ = 






3i \i 















I d 















lU g 




□ — 





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. 



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. 



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- 


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, 



and to Bncb un extent tluit we find ttie cicatrices tliat reflultcd »tJI) 

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 




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> 
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. 



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 



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 



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 



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 



(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;^ 



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. 



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 



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 



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 

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 

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 



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. 


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 


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 


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<, 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. 



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 


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 



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 

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- 


OARreS OF TTIE ii.ftnr. 




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 

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 



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 . 





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 



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 

Oakies or TUB IscuiL-M is more dcecptivc tliati Oic betiiamod 



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- 

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 

" 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 



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. 

EncDtlon and ubdaction Inipoiled. 
Jmat painluM. 

IVJrIa oblique and ajitne ciirrod. 
Coatrnction of flwor* and addaoton. 


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. 

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, 



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 



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 

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 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> 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- 



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 

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. 



rant mssasx aicd psoas *imc^m. 
J'r«oeillllg paio in tli« ^ine. 
iPotbrlor wd caterior dofurni!!; (not 


Blmple flexion nD<l alKiniioiHg of limb. 
Limb nin^ bo iM!t«n(IeiI umJer eb]uro- 

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. 


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 

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» 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) 


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 



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 


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- 



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 



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 


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- 


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. 





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 

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& 



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, 


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 


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. 


SultliMitf p4'odncei). 

Eilmnil; iiiiii-li «vcrtcd. 


U< alii rale i>h(>nuDin(t- 


1l««d oMi bo r«U in tl>c grodo. 

wpoxD BtAOS or KOBsrs ooxAcin. 
CoDCfl on smduollj. 
Less eTtneil, 
Apfinrcnt eloogotlon. 

Uewi cniinol he hk at tM or rcrj 
ln<Ufrt.lDCt].v, and ibon at tho ac»- 


rosnnoii scpkriob Dt6i.oo*TioK. 

PdmIui-^xI audil 1-1)1 r. 

I.initi iJi(irtvDiMl aod loi'iirted. 

THiKD eTAOB or Noatca coxAxin. 
(irow)DK gnduallj. 
The iaiii«. 



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- 


Apex of troufamitttr ttbovo X^lutoii'* 
No ponnnnoDt contr»cti>,iiu od* dibb- 


Pi^iIb ftqnara. 

WalkN with boaltJijr leg b«nl. 

TounUw groiuul wlib nlinixil enUrc 

Spine atraiitlil. 
Angle of Inulinitiion of ]>ehis on- 


TKtBD moB \>r Mosncs coxAsira. 


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 

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* 

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 

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. 



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 



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^ 

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 



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 



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. 



%-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 



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 


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. 



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, 



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 



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 

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 


ap|iI,Y xn intitrainent which is a moditication of TavIoi^B Itmg 

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 



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 



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* 

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 

An important point with regard to operations for the removal 



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. 



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 



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- 




or Blips, bringing bis weigbt Budttonty to bear npon the limb bent 
at thiii Angle, it may yield eullieiently to give him rery Derioos 

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 

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. 



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 



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. 


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- 




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« 



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- 

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 



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 



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, 



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. 



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, 



onoo which time the present distortion has existed. Tliere is 
fibrous anchvlo^e of the kncv. The tibia i» luxated barlcward. 

y- i-;l 


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 



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. 



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. 



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 

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 



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 

** 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- 



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 



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. 



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). 




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 



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- 



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 



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, 



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. 


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« 



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. 



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- 

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 



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 



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 



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 


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 

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, 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 

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 

" 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* 




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 

" 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- 

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 


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- 



^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. 


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 



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. 


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 

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 

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. 



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- 

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. 



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 



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. 



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 «uc d 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. 



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 

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 

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. 



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. 



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 >i ll «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 



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 



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 

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 


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 


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, 


" 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 


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." 


'* 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." 


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 

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 



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 



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 

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- 



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 

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 


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. 


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 



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 



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- 



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- 

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 



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- 

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 



[.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 


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 



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 

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 



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(] I>o cured without any deformity oo-- 

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 


Cervical region 11 

Dorso- cervical 11 

Dorsal 163 

Borao-Iumbar 28 

Lambar 14 

Unrecorded _8 

Total 225 


Tramnatic 153 

Unknown Y3 

Total 23B 


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. 



¥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 


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- 



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 



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 



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 

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 



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) 




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 



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 



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 


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^ 



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 

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 



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 8egi