Chapter XXXIII (2)

_The final resort is excision_, which is practically adapted to cases of moderate type in young adults, where the bones have attained their full growth and where it will afford a prospect of cure in a minimum of time. It is undesirable in children because it is so often necessary to remove the epiphyses, and because of the arrest of development that follows such removal and the consequent shortening of the limb. Nevertheless even in children it may be demanded and may be considered as a resort superior to amputation, the latter being reserved usually for a life-saving measure or for desperate cases where destruction has been practically complete and the limb is hopelessly useless.

Of the other large joints, all of which may be involved in tuberculous processes similar to those just discussed, it may be said that they come under the general rules of treatment already laid down.

NON-CARIOUS DEFORMITIES.

TORTICOLLIS; WRYNECK.

This term includes a peculiar postural deformity by which the head is rotated and inclined abnormally to one side in a more or less fixed position. As to the causes of the deformity two will be considered:

Congenital causes include:

1. Injury to the sternomastoid muscle at birth, which is perhaps the commonest.

2. Abnormal intra-uterine position and pressure.

3. Arrest of muscular development.

4. Intra-uterine myositis, the muscles being sometimes found actually altered in structure.

5. Defective development of the upper vertebrae or such distorted growth as is often met along with other deformities, _e. g._, club-foot.

The acquired causes include:

1. Traumatisms, either direct, as by injury to the muscles, such as may happen from gunshot wounds, etc., or follow operations by which the spinal accessory has been injured, or by burns, and other lesions which cause much cicatricial contraction.

2. Reflex activity in connection with disease of the lymph nodes, deep cervical abscesses, parotid phlegmons or tumors, etc. Whitman states that tuberculous disease of the cervical nodes caused the condition in 50 per cent. of over 100 cases analyzed by him.

3. Reflexes from the eyes, as Bradford and Lovett have described from the orthopedist’s standpoint, and Gould from that of the oculist, refractive errors causing the head to be held in unnatural positions in order to improve vision.

4. Compensation in high degrees of rotary lateral curvature, the effort being to keep the head facing to the front.

5. Myositis, usually rheumatic, but sometimes a sequel of the infectious fevers, or even of gonorrhea.

6. Habitual deformity, the result of occupation or sheer bad habit.

7. Tonic or intermittent spasm leading to spastic contractures whose causes are difficult to seek, but appear to inhere in the central nervous system.

8. Paralyses of certain muscles, permitting lack of opposition and consequent deformity.

=Pathology.=--According to circumstances significant pathological changes may be found in the affected muscles. These are usually the sternomastoid and the trapezius, although in long-standing or complicated cases the deeper muscles of the neck may also participate. A long contracted muscle may change almost into mere fibrous tissue.

The secondary effects of contraction of the sternomastoid and the trapezius are really far-reaching and noteworthy. The jaw may be drawn down and to one side, so that teeth do not appose each other as they should, or perhaps even do not meet. Compensatory curvatures occur also in the spine and there is well-marked change in gait and in most of the body habits. In the young and rapidly growing cranial and facial asymmetry also become pronounced. The later results and deformities of torticollis are not to be mistaken for congenital elevation of the scapula, sometimes known as “_Sprengel’s deformity_,” which consists not merely in elevation, but in rotation of the shoulder-blade so that its lower angle is too near the spine. There may be some limitation of motion of the scapula and of the arm. Sprengel accounted for this abnormality by maintenance of the intra-uterine position of the arm behind the back. The acute forms of torticollis occur nearly always in acute phlegmons of one side of the neck, and should subside with the other and causative lesions. Nevertheless from such spasm may develop a chronic form which may persist.

The position of the head varies with the muscles particularly involved and the associated spasm. The sternomastoid muscle alone will draw the mastoid down toward the sternum, with rotation of the face to the other side. When the trapezius is involved the head is drawn backward and the chin raised. The more the platysma, scaleni, splenii, and deep rotators are involved the more complex becomes the condition, to such an extent even that in serious cases it is almost impossible to decide which muscles really are at fault. When the superficial muscles are involved they can usually be distinctly felt to be firm and contracted, while the sternomastoid will stand out like a cord. Pain is a rare complaint, but a feeling of tenderness or soreness is not unusual.

The spasmodic or intermittent form is less common, but more difficult to account for and even to treat. It seems to be due to choreiform spasm of those muscles which produce it, and here the condition is reflex, the causes lying deeply in the nervous system. In some instances, however, they are of ocular origin and can be relieved by correcting refractive errors. Intermittent spasm is usually absent during sleep and quiescent in the recumbent position; it is usually confined to one side.

=Diagnosis.=--In the matter of diagnosis it is necessary mainly to eliminate only spinal caries, while as between involvement of the anterior and posterior groups of muscles the determination is made by palpation and inspection.

=Treatment.=--There are few morbid conditions whose cause it is more necessary to discover. Could this be done operative treatment would be less often demanded. Treatment should depend, therefore, on the exciting cause and the possibility of its removal. The spasmodic or intermittent form may spontaneously subside. Cases of essentially ocular origin need the services of the oculist, and other acute cases usually subside with the successful treatment or the subsidence of their causes. On the other hand, chronic cases usually need either mechanical or operative treatment.

The most common operation for relief of torticollis is simple _tenotomy of the sternomastoid_, taking care to divide the sheath and everything which resists, and, at the same time, to avoid the external jugular vein as well as the deeper structures. Mere tenotomy of one or both of its lower tendons is an exceedingly simple measure, but in serious cases an open division will permit of more thorough work. Here an incision made one inch above the clavicle and parallel to it will permit division of everything which resists and also any recognition of that which should be spared. In any event the position of the head should be immediately rectified, and kept so either by plaster or starch bandage, or by a traction apparatus applied to the head, the body being in the recumbent position, while later some efficient and well-fitting brace should be worn for some time. The posterior cases, _i. e._, those where the posterior muscles are involved, afford greater operative difficulty, muscles involved lying too deeply and being in too close relation with important vessels and nerves to justify the ordinary wide-open division. Nevertheless in extreme cases there need be no hesitation in extirpating completely those muscles which are primarily and mainly at fault. The writer has removed the sternomastoid and the trapezius, with sections of the still deeper muscles, and has seen nothing but benefit follow the procedure. It should be resorted to when repeated anesthesia with forcible stretching and a suitable brace fail to give relief. These forms of wryneck which are due to contraction of muscles infiltrated from the presence of neighboring phlegmons, etc., will usually subside with massage and semiforcible stretching under an anesthetic. They need conservative rather than operative treatment. Attack upon the spinal accessory and the deep cervical nerves will be described in the chapter on Surgery of the Nerves. It, however, will rarely be justified, since the primary causes inhere not so much in those nerve trunks as in the nerve centres. Such operations are usually of questionable benefit, and cases should be carefully watched before being submitted to them.

ROTARY LATERAL SPINAL CURVATURE; SCOLIOSIS.

Under these terms are included certain deviations from normal relationships of the vertebræ, both in their superposition in the median line and in their rotation on each other, by which are produced lateral curvatures, with more or less rotary displacement. Of these deformities there is a rare congenital form which is due to fetal, or rather intra-uterine, rickets, but practically all rotary lateral curvatures are acquired. One-half of such cases begin before the twelfth year of life. It may also come on during adult life, as the result of bad postural habits, exclusive use of the right hand, etc. Altogether it occurs in about 1 per cent. of females and in a smaller percentage of males. Scoliosis being not a disease but rather a process of irregular growth, cannot be said to have a symptomatology. It is known rather by signs. Only in the advanced stage can it produce symptoms. It is rarely seen in its incipiency by either the surgeon or the physician. Not until parents have noticed distortions of the spine are these children usually taken to their medical advisers. Exception, however, should be made to this in respect to certain gymnasia and athletic training schools, where trainers are quick to notice irregularities of this kind. The abnormal curves thus produced are at first flexible, but later become fixed. In rapidly growing girls who take but little exercise there may be some muscle weakness, which may cause fatigue or even actual soreness. Pain is rarely present. The rate and extent of deformity are not subject to any rule. Spontaneous cessation ensues in practically every case, _i. e._, a stage of convalescence and arrest, at a time when the deformity may be but slight, or perhaps hideous.

The nervous phenomena attending lateral curvature, like the discomforts attaching to it, are mainly due to the increasing strains and stresses that are imposed on certain structures as the deformity occurs and increases. Of these, muscles and ligaments suffer most, especially those uniting the thorax and spine. Pressure effects on nerves and tissues may be produced by distorted ribs and vertebræ or by final displacement of viscera. The conditions which lead up to spinal curvature are attended often by neurasthenic and neurotic features, both mental and physical. As deformity increases impairment of function of thoracic as well as of the upper abdominal viscera will occur, and such patients are usually thin and anemic, rather than fat.

_To mere lateral distortion is added, in every pronounced case, more or less rotation of the entire trunk._ The curvature consists of one primary curve, with one or two secondary curvatures, according to the location of the first. If the primary curve be located in the mid-dorsal region there will occur compensatory curvature above and below in order that the head may still be kept in the line of the centre of gravity above the pelvis. Such secondary alterations are of much less import than the primary. The most common of the mid-dorsal curvatures, which occurs in nearly four-fifths of the cases, has its convexity to the right. While the right shoulder seems higher its scapula will be more pronounced and carried backward, the back and the chest below it will be more rounded, and in front the breast on the opposite side more prominent. The whole trunk in marked cases becomes so warped that the arm on one side will hang free while the other touches the pelvis; thus the back loses its symmetry either in the erect or stooping position. In the lumbar region there is compensatory curvature to the opposite side, which makes one hip and flank more prominent. By virtue of the rotation of such a warped spinal column there result certain anterolateral curvatures that may later become pronounced. While such changes are going on in the upper part of the trunk there is sufficient rotation of the lumbar segment to lead to tilting of the pelvis, with consequent limp, or a peculiarity of gait.

The degree of torsion of the spinal column is the best index of the real severity of a given case, and to it are due the most disfiguring features of the deformity. Torsion may even precede curvature, causing a prominence of one shoulder or hip as the first visible evidence of its existence.

Those forms of lateral curvature due to _rickets_ occur most often in the dorsal region, and as frequently in boys as in girls. In most of these cases the constitutional condition will be indicated by other significant features. Another form much less frequent, yet well known, is the result of inequality of the length in the limbs, so that patients stand ordinarily with tilted pelves; hence, the limbs should be carefully measured in every instance. A truly _paralytic form of scoliosis_ is also known, which is of the infantile type and due to some form of infantile palsy. Again, scoliosis is produced by _shrinkage of tissues_ and contraction of old exudates occurring within the thorax and following chronic disease, as when the ribs on one side are drawn down after an old pleurisy or empyema. _Extrinsic causes_ of lateral curvature are met with among several occupations when one side of the body is used more than the other, or when the individual habitually stands in an unsymmetrical position. In addition to this, the habitual right-hand habit, which seems instinctive, and which the majority of people exhibit, leads to excessive use of the right side of the body, with overdevelopment and consequent warping of the upper part of the skeleton. The young should be taught the use of the left hand as well as the right, _i. e._, to become ambidextrous.

The foreign surgeons have given the term _ischias scoliotica_ to a form of lateral curvature involving rather the lower part of the spine and occurring usually in adults or elderly people, which is accompanied by more or less acute pain, usually assuming the type of sciatica. Its etiology is obscure, as is implied by the synonym scoliosis neuropathica. It is not a frequent malady, but usually chronic and refractory. It is best dealt with by fixation or immobilization.

=Etiology.=--Predisposing causes of scoliosis may be both constitutional and inherited. They include general debility, rickets--with its accompanying osseous instability and liability to abnormal curvature--the consequences of various diseases of childhood, and anything which greatly lowers vitality. The actual causes include congenital or acquired defects, such as differences in the lengths of the limbs or other skeletal asymmetries; acquired abnormal position of the head due to defective vision, with its natural sequences; results of intrathoracic disease, such as empyema; faulty attitudes and bad developmental habits, such as those assumed often in school and elsewhere in sitting at a desk or standing in bad position, or at work in various ways. To these should be added the right-hand habit already mentioned. These may all be summed up as among the causes of asymmetrical growth and deformity, occurring as the result of ignorance or inattention, and allowed to go on indefinitely or until it is too late to correct the malposition. Theories of paralysis of individual muscles or certain muscle groups have been advanced, as well as of contractures, but usually these are effects which have been mistaken for causes. The bones have been blamed, but their changes are secondary results of pressure, save perhaps in some cases of rickets. The structures of the thorax have relatively considerable superimposed weight to carry, and both lateral halves of the thorax should be developed symmetrically in order to distribute this weight evenly. Nothing so influences skeletal development as exercise; thus even to assume and maintain the normal erect attitude requires a certain amount of muscular effort, and if each side be not given an equal task one will develop at the expense of the other, and thus lateral curvature is sure to result.

It is important to impress this on parents, teachers, nurses, dressmakers, and all who have a part in the care of the young, in order that they may realize the importance of ensuring symmetrical growth and of preventing the right-hand habit. It is to be expected that after deformity has occurred there may result a series of perversions of function in nerves, as well as in viscera; thus, respiration and circulation may be interfered with, the liver may be compressed, while, of course, autopsy will show all sorts of distortion of bone, among other pathological changes.

=Prognosis.=--Too often the condition is regarded as so trivial that it is likely to be outgrown, or else is quite disregarded, or, on the other hand, occasionally it is regarded as one of gravely serious import and maltreated or overtreated on this account. In the majority of instances scoliosis is a self-limited condition, whose limit may be reached at variable stages of deformity in different individuals. In slight cases any serious illness may cause such muscular weakness as to permit of serious increase of distortion. Therefore, the patient’s general condition is to be taken into account just as much as the shape of the back.

=Treatment.=--If one may be permitted a Hibernicism, the proper treatment for scoliosis is _prevention_. This may be made to include the earliest possible recognition of trifling deviations from the normal. It should be made to include, in general, supervision of school desks and the way in which children work at them, as well as of children’s games and exercises, in which it should be made a point that they be taught to make as much use of one hand as of the other. It should include also supervision of children’s methods of seating themselves at the piano or at the sewing table, as well as the posture which they assume during sleep, while they should be taught to stand and walk properly and to avoid a too early use of corsets. _Active treatment should consist, first, of correction of bad postural and other habits by methods as vigorous as are military drill and discipline._ Patients tire easily after such exercise, and sufficient rest should be taken, the patient lying symmetrically upon the back. There is usually opportunity with young children for great ingenuity in devising suitable exercises without making them too irksome. They should be taught to play games at least as much with the left hand as with the right. Gymnastic exercises, especially those with dumb-bells, will be found effective, and it is advisable to have a heavier dumb-bell in the left hand than in the right. The more severe cases should be handled with great care in order not to overdo that which should be done. Each case should be studied by itself, which means that such cases should not be taught in classes. Roth calls that “the key-note position” which is closest to the normal that the individual can voluntarily and comfortably assume. From this as a basis the surgeon should work up. Perhaps as much can be done without apparatus as with it, particularly if will power is concentrated on the effort. This is harder with the young, but pride may sometimes be appealed to as a substitute for volition. As strength is gained more strenuous gymnastics may be prescribed, including suspension from rings or the simple horizontal bar, while much heavier dumb-bells may be used, as taught by Teschner.

_Mechanical corrective treatment_ is directed mainly to stretching shortened ligaments and contracted muscles. For this purpose many forms of apparatus have been devised. Their principal benefit lies in increasing backward flexibility at the point where curvature is most pronounced. As a substitute for such apparatus, and in private houses, padded stretchers or lounges may be supplied on which patients may lie either quietly or during massage. Finally the matter of corrective corsets and braces remains to be considered. External support takes away from the muscles and ligaments their functions and work. Nevertheless in some cases this is necessary. No appliance of this kind that may be supplied should be continuously worn. It should be removed for work and exercise, as well as for toilet purposes. Recumbency in bed is much better than too vigorous bracing. Only in old, neglected, or peculiar cases should it be considered necessary to resort to much external aid.

CURVATURES FROM OTHER SOURCES.

The relaxation and debility of old age permit of such deformities as rounded and stooped shoulders, certain degrees of kyphosis, and sometimes even pronounced stooping and deformity, whose merely senile causes are more or less combined with rheumatoid arthritis of the vertebral and costovertebral joints. These features are accompanied by more or less pain or difficulty in locomotion. Many instances of ischias scoliotica, referred to in the preceding section, would find a place among these clinical pictures. Postmortem there are found exostoses, synostoses, or ankyloses sufficient to account for the deformity. Rickets also causes skeletal deformities, in which nearly all the bones may participate, the spine rarely totally escaping. In such cases various typical and atypical deformities may be met.

Paralytics may show various curvatures, as do also subjects of pseudomuscular hypertrophy and syringomyelia. Lordosis is seen in pregnancy and in congenital hip dislocation, where it is purely compensatory in each instance and does not outlast its real cause. In fact it may be encountered as a compensatory feature of any other kind of spinal curvature.

A still more marked condition of chronic ostitic changes is seen in _spondylitis deformans_, which differs little from arthritis deformans of other joints, save that in these cases it usually spares the joints of the extremities. It has been known as a rare sequel of gonorrhea, even in the young. Osteophytic outgrowths occur frequently and fuse together, causing ankyloses and sometimes great deformity, even to the extent of making the spine assume a right angle with the extended limbs. Considerable pain is frequently experienced during the course of these very slow changes. The entire spine becomes more or less rigid, consequently there is little or no angular prominence, while the ribs become immobilized as well. For this condition there is little or no treatment of any avail. Sometimes paralysis supervenes and the condition is not infrequently fatal.

_Acute osteomyelitis_ of the vertebræ is occasionally noted. It occurs nearly always in young and growing children, and is most common in the lumbar spine. It is essentially the same here as occurring in the long bones or their joint ends, and has been described in the previous chapter. Its symptoms may be severe, and it is not infrequently followed by abscess. When such abscesses point posteriorly they may be recognized and incised. When, however, pus takes the anterior path it will probably escape detection, at least until too late. The prognosis is often unfavorable.

TYPHOID SPINE.

This name was proposed by Gibney for what seems to be an infectious periostitis involving the vertebral column, of a character similar to that which has been described in a previous chapter. It is characterized by excessive pain, tenderness, and later stiffness. It may occur during or after mild as well as severe cases of typhoid.

TRAUMATIC SPONDYLITIS.

Kümmel has shown that a traumatic and non-tuberculous ostitis of the vertebræ occurs, with succeeding kyphosis resembling that of Pott’s disease, but not so angular, usually without associated abscesses, but with occasional paralyses. This may occur without necessary reference to that curvature which may follow a healed or healing spinal curvature. Inasmuch as the condition occurs only after the lapse of considerable time after injury, it is questionable whether it represents any distinct form of disease.

CANCER OF THE SPINE.

Malignant disease of the spine may assume a type either of sarcoma when primary or carcinoma when secondary. The latter type is much the more common, and is not so infrequent as an expression of metastasis from cancer in various other parts of the body, even the more distant. It is most common in the lower spinal region. Pain occurs early and is usually severe. It is as often referred as localized. It may lead to curvature of the spine with some of the grosser signs of spinal caries, but the prominence, if any occurs, will be rounded rather than angular. When paralyses occur they usually assume that type described by Charcot as paraplegia dolorosa. (See Plate XXXVIII.)

When symptoms of a general type like those produced by spinal caries occur in adults who are known to have had previous or present malignant disease the inference will be that they are to be interpreted as local expressions of the same character. Under these circumstances treatment can only be palliative. There is no hope of cure.

SPONDYLOLISTHESIS.

The term spondylolisthesis implies a partial displacement forward of the body of the last lower or next to the last lower lumbar vertebra, usually the former, which slips forward on top of the sacrum with very little perceptible displacement of arches. The condition may be slight or well marked, and may or may not be followed by secondary changes. There appears to be a real fragmentation or separation of the body from the arch, which may be traumatic, congenital, pathological, or the sole result of pressure from above; later exostoses or osteophytes appear about the separation, thus forming a new fixation and preventing further displacement.

The condition is more common in females and in the young, and most cases give a traumatic history. In those which do, deformity may follow accident or it may be long postponed, perhaps until pregnancy.

=Symptoms.=--The lesion is recognized by certain alterations of gait, with a sharp lumbar lordosis and unduly prominent buttocks and iliac crests, so that these patients much resemble those having congenital hip dislocation, the pubes being higher and the sacrum lower than the normal, this diminution of pelvic obliquity being practically always pathognomonic. On vaginal or rectal examination undue prominence may be felt above the sacrum. Some of these cases complain of much pain, either local or referred, down the limb, the same being made worse by exercise.

Sarcoma of the Spine and Cord. (Goldthwait.)]

=Diagnosis.=--Diagnosis should be made as between this condition, Pott’s disease, double congenital dislocation of the hip, and rickets.

=Treatment.=--The condition does not admit of extended treatment, save that a certain proportion of cases are benefited by such fixation as is afforded by a plaster jacket, which firmly encloses the pelvis and supports the lower part of the trunk upon it.

KNOCK-KNEE AND BOW-LEG.

The plane of the terminal articular surface of the lower end of the femur is not at right angles with the axis of its shaft; in other words, the inner condyle is placed a little lower or beyond the location of the outer. In this way sufficient angular arrangement of the leg upon the thigh is permitted so that, with the upper ends of the femora separated by the width of the pelvis, the knees and the ankles may, under normal circumstances, be made to touch when the limbs are fully extended. Thus a slight degree of angular deflection at the knee is normal. When this is exaggerated to a degree not permitting the ankles to touch when the knees are in contact the condition is known as _genu valgum_, or _knock-knee_. When, on the other hand, the angle is lessened or reversed so that the knees are more or less separated when the ankles are in contact the condition is then known as _genu varum_, or _bow-leg_. These two conditions constitute the typical and classical types of knock-knee and bow-leg. Other conditions, however, which lead to the same result occur through various and irregular curvatures or irregularities of the femur or the tibia, or both, and there thus may be produced atypical yet most pronounced instances of these same deformities. These deformities may be apparent almost from birth, may appear during early childhood, or not until adolescence. As a rule they are not manifested until young children are learning to walk. Whenever they appear before this time they are expressions of infantile rickets, which should be recognized as such and corrected by mere manipulation while the bones are still flexible, the correction being maintained, and by suitably feeding and medicating the patient. (See the general subject of Rickets.)

Rachitic changes in limbs. (Lexer.)]

In fact rickets supplies the explanation for the great majority of these deformities; incomplete ossification and calcification of the bones accounting for the comparative ease with which they yield to pressure or other deforming influences. Rickety children always manifest a tendency to defective ossification at epiphyseal lines, and it is here that the change usually takes place. Nevertheless marked instances of curvature are seen in all the bones of the lower extremity. As deformity in any given direction becomes more pronounced the tendency to its exaggeration becomes greater. Finally these changes involve not only the bones proper but the ligaments and the other joint structures, which yield where pressure is abnormal and greatest, thus completely changing their shape and internal relations. Along with other changes in knock-knee there is a tendency to external rotation, perhaps even to spiral curvature of the tibia; the patella lies outside of its normal position, the tendons are more or less displaced, while, at the same time, there may be inflection of the feet as an effort at compensation (Fig. 261).

With the exception of spinal curvatures and torticollis there is perhaps no more conspicuous deformity than that produced by these abnormalities at the knee-joint. While at first gait is not seriously affected, it is in time, especially in cases of double knock-knee. When these knees are bent to a right angle the angular deformity disappears and all that remains is the rotation of the tibia. Hence it follows that all correction of these deformities, either slow or operative, should be applied to the fully extended leg. In advanced cases there is frequently a complication with flat-foot, which may or may not be painful. The condition is rarely produced by paralytic affections, and should be differentiated from mere atrophy of wasted and contracted legs. A form of knock-knee is occasionally seen in the adult, which is of traumatic origin and is due to improper care or neglect in the treatment of the injury.

=Treatment.=--_The treatment of this condition is either mechanical or operative._ Mechanical treatment varies between the gentlest expedients and the use of more or less extensive and cumbersome apparatus. When a young and growing child begins to show evidence of either of these deformities it is usually sufficient to supply shoes which are reasonably stiff, and raise one or other border of the sole and heel, according as we wish to influence the growth of the limb, _i. e._, in knock-knee the inner border of the foot is to be raised, in bow-leg the outer. The consequence of even slight influence thus constantly maintained when the child is upon its feet is usually sufficient to rectify slight degrees of these deformities. When, however, the case is pronounced more radical measures should be applied. Massage has been recommended along with manipulation, but should be gently performed. The different forms of apparatus in use afford various methods of making pressure against that condyle which is too prominent. It is possible to make them efficient, but only when they are both well planned and well made in the first place and intelligently applied and watched. The special forms of apparatus sold in the instrument stores are of little value. Too often it happens that when efficient they cannot be tolerated, and that when tolerated they are inefficient. Much speedier and more satisfactory results are achieved by operative methods, so that, in general, they may be regarded as the more desirable.

_Operative treatment_ consists in some modification either of osteoclasis or osteotomy.

_Osteoclasis_ has to do with the forcible stretching, bending, or even breaking of those parts which show the greatest effects of the deformity or are known to be its primary seat. In young children with tender and still somewhat flexible bones this may be accomplished by the hands alone, the patient being under an anesthetic. Manual power failing a simple instrument known as the _osteoclast_, which affords a means of applying powerful pressure by the agency of a screw at just the desired point, is used. Pressure is then applied and carried to the necessary degree, even with partial or complete fracture of the bone at fault. In this way is inflicted a simple fracture which permits of the immediate redressing of the limb, with such overcorrection of the deformity as seems desirable. The limb thus treated is completely encased in a suitable plaster-of-Paris splint, and should be held in the desired position until the plaster is completely hardened and not likely to yield. Osteoclasis, though it often appears an exceedingly barbarous procedure, is one of the most beneficent when properly managed, and is rarely followed by an undesirable result.

_Osteotomy_ is performed by the use of the chisel and mallet, the former being introduced through a small incision made in the skin, passed down to the bone with its cutting edge parallel to the bone axis until the bone itself is reached, after which it is turned at right angles to it and the mallet used until the chisel has been driven partly or completely through the shaft of the bone or the portion which it is intended to attack. The chisel should be partly withdrawn and its position changed if it is necessary to continue its use. Thus by a partial division of the bones of the young it is possible usually to so weaken them that, without undue force, and by manual power, they are fractured at the desired point. The operation should be done with the most complete aseptic protection. The procedure recommended by Macewen is now universally accepted. The incision is made at the inner side of the thigh just above the tubercle for the adductor magnus, and the osteotome (as the chisel especially made for this purpose is called) is passed through it, down to the bone, turned at right angles, and made to cut nearly through the shaft. Lest it become too firmly wedged it may be moved a little laterally after each blow of the hammer. The operation, if properly done, is practically bloodless; the small opening made for the chisel is sealed at the moment of its withdrawal, the deformity corrected with the least amount of handling or disturbance, and the plaster-of-Paris bandage immediately applied, with the leg in exactly the position which it is desired should be maintained. Such a dressing may be left for three or four weeks before being changed. One change is usually sufficient, and in from six to seven weeks the patient is allowed to slowly regain use of the member.

A special set of osteotomes, after Macewen’s pattern, is furnished by the instrument dealers for those who practise osteotomy. It consists of a set of three straight chisels, consecutively numbered, the first being a little thicker and the third the thinnest of the three, and thus made with the intent to use the thickest first in order that in the notch made by it the thinner instruments can be subsequently more easily manipulated.

BOW-LEGS.

_Bow-legs_ are nearly always of rachitic origin, occurring with less angular deformity, and as the result of the warping or bending of bones which are not sufficiently rigid to sustain the weight they are made to carry. Most cases of bow-legs have their origin within the very early years of childhood. Other cases are seen in infancy and before children have ever borne much weight upon their feet. The deformity must be accounted for by muscle tonus, mere muscle activity serving to place enough stress upon the bones to swerve them from their normal axes. The bones probably bend outward because the muscles on the inner side are the stronger. Children thus affected walk not so much with a limp as with a waddle, with the feet rather apart, and some inversion of the toes. Double and complicated curves occur in many of these cases, both femurs and tibias participating, and having an anterior as well as a lateral bowing. Such complications materially increase the difficulty of any treatment.

=Treatment.=--The _treatment_ of bow-leg is generally considered simpler than that of knock-knee. Occurring in _young_ and growing children it can be overcome, if taken early, by the expedient already mentioned, elevating the outer border of the sole of each shoe. The more mechanical and the purely operative methods of treatment are essentially the same as those just described for knock-knee, based on similar but reversed principles. In the very young manual force will often serve the purpose of a more formal osteoclasis, but the osteoclast may be used whenever it seems indicated. In those cases where the bowing is due to abrupt and almost angular deformity, _osteotomy is indicated_. This is made on exactly the same principles as mentioned above. In all instances spiral curvatures should be overcome so far as possible during the process of forcible correction and dressing in the plaster-of-Paris bandages ordinarily used. Here, as previously, all treatment should be addressed to the limbs in their fully extended position. If the rings of the ordinary osteoclast be sufficiently padded and protection afforded in this way, the skin rarely sloughs, and the damage, which is, at least, theoretically done to the tissues, is quickly repaired. Failure in union after any of these operations is exceedingly rare.

CLUB-FOOT; TALIPES.

In general the term talipes is applied to any malformations of the foot by which it is more or less misshaped and its function impaired. The commonest of these is that known and described below as talipes equinovarus. Of these various deformities there are four principal types, according as the foot is inverted, everted, hyperflexed, or hyperextended. More particularly they are:

1. Talipes equinovarus, the commonest type, the ordinary club-foot;

2. Talipes valgus, or flat-foot;

3. Talipes equinus;

4. Talipes calcaneus.

These forms may be variously blended, as well as seen in varying degrees from the slightest possible deviation to the most pronounced form. Statistics show that about one child in every five hundred is born with some form of club-foot.

Club-foot may be either of acquired or congenital origin. Acquired club-foot is essentially always of paralytic nature, following usually infantile paralysis or those injuries by which nerves have been divided or caught in callus or in tumors. As the result of such loss of nerve or muscle power, in certain muscle groups, malpositions of the feet are caused which simulate those of congenital origin.

1. =Congenital Club-foot; Talipes Equinovarus.=--This consists anatomically in an inward dislocation at the metatarsal joint of the anterior part of the foot, in consequence of which the relations of all of the other component parts of the foot are deranged; the scaphoid is swerved on to the inner and lower side of the astragalus to such an extent as to touch the internal malleolus; the cuneiforms follow the scaphoid and the metatarsals follow the cuneiforms; the cuboid is shifted to the inner side and does not articulate squarely with the calcis. In infants these bones are cartilaginous, but as the individuals grow and these miniature bones develop and ossify they take similar and abnormal shapes and positions. The calcis is drawn into a more vertical position than normal by drawing up the heel, and is even somewhat rotated on its own vertical axis; thus its anterior articulating surface is made to look obliquely inward. This displacement of bones causes dislocation of tendons, the anterior group being drawn mostly to the inner side. The patient walks more and more on the outside of the foot, and as he does this adventitious bursæ develop on the outer border, which become very thick and form in time large callosities. In the most pronounced cases there occurs, in connection with all this, curvature or spiral inward rotation of the tibia, and even of the femur of the affected limb, while the contracted muscles become overdeveloped and those which are disused underdeveloped (Fig. 262).

Talipes equinovarus.]

Among the causes of club-foot heredity seems to play a considerable part, as it often happens that two or three club-footed children are born of one mother. The deformity has been ascribed to abnormal or exaggerated posture _in utero_, with compression. This theory is at least attractive and has the force of argument from antiquity, for Hippocrates thus believed. Unquestionably the normal intra-uterine position of the fetus includes a certain degree of equinovarus. Yet if this were the real cause the condition would occur apparently much more frequently. It has been ascribed also to disparity in strength between opposing groups of muscles, that group which causes the deformity being naturally the stronger, it being at the same time unimportant whether one group is relatively too strong or the other relatively too weak. Most monstrosities or seriously defective infants have also club-foot, from which some argue that the central nervous system has something to do with it; yet it has been shown in over 1200 cases of club-foot that only twice did such defect of the central nervous system as spina bifida occur. The embryologists and comparative anatomists regard it as an expression of arrested development, while evolutionists consider it an atavistic reversion to an earlier anthropoid arrangement. None of these theories really satisfactorily explains the deformity. Therefore we should hold that either there are different and variable causes or that we have not yet found the true one.

=Treatment of Congenital Club-foot.=--There being in these cases no tendency to spontaneous improvement, mechanical or operative treatment, or both, are required. If these be afforded early the prospects of restoration, practically to the normal, are good, but treatment should be begun early and conducted with great care and patience. It is not so difficult to correct the deformity, but correctional supports should be worn for a relatively long time, while the older the case the more difficult become all the features, both mechanical and durational. Parents are often eager at first, but later become inattentive or careless. The main objects are to be attained by correction of position by force or by division of contracted or shortened tissues, or retention in position, with the addition of any other features which may influence growth and development according to normal standards. Of these we will speak first of rectification: (_a_) bloodless, as by purely mechanical force, or by means of certain apparatus, and (_b_) operative, as by subcutaneous tenotomy, aponeurotomy, etc., or by open incision, through which are performed osteotomy, excision, astragalectomy, tarsectomy, etc., as the operator may see fit.

In all of these the anterior part of the foot is to be forced outward as well as raised, two distinct features, which should be combined but not confused.

In the young infant gentle force applied many times a day, with the persuasion of a strip of adhesive plaster, applied beneath the foot and over its outer border, and spirally upward to the inside of the leg, can be made effective in mild cases; but overstretching of the tendo Achillis is a necessary part of this maneuver every time it is practised. The more positive method consists of fixation of the foot in overcorrected position within a plaster or starch bandage, the same extending above the knee, which should be slightly flexed, the dressing to be renewed every two or three weeks, and correction increased until it has become overcorrection.

In well-marked and in resistive cases an anesthetic should be given, while by the use of sufficient force, which may be relatively great, but which should be gently applied, the resisting tissues are so stretched, if necessary to the point of something yielding, that but slight pressure is required to hold the foot in an overcorrected position. When the knife is required the tendo Achillis should always, and the plantar tendons and fasciæ usually, be subcutaneously divided, under aseptic precautions. The foot is then enveloped in suitable dressings and put up in overcorrected position for two or three days, in a rigid dressing at first of starch, but after this in plaster of Paris; this is the writer’s plan of procedure. The insertion of the point of the tenotome sufficiently deep to divide all resistive ligaments and tissues (_e. g._, the astragaloscaphoid or the calcaneocuboid) nowise complicates this method, but makes it more efficient.

Cases which are resistant are best submitted at once to _open operation_ (that is, after vigorous stretching of the contracted tissues), always under strict asepsis. After decades of milder ineffectual methods it remained for A. M. Phelps, of New York, to show the benefits of this method by which all contracted tissues on the concave aspect of the foot are exposed and divided. Incision is made here from the top of the inner malleolus to the inside of the first tarsometatarsal joint. With a little care the artery can be avoided, but I have never seen any harm come from its division. Everything which proves resistant is divided, even the inner osseous ligaments. Sometimes the incisions can be made in wedge-shape, or obliquely, so that the wound does not remain so widely open. No attempt is made to close this wound. The operation may be done bloodlessly, under the Martin rubber bandage, but whether this be used or not any vessel which can be recognized as such should be tied; otherwise the wound is snugly packed with gauze (upon which I like to use Peru balsam). An ample surgical dressing is applied over it. This is covered with gutta-percha tissue, to prevent too free access of air to the blood which will ooze into the dressing, and the whole is then covered with a starch bandage, in overcorrected position; this is left, according to circumstances, for from three days to a week--the longer the better. Then everything is removed, fresh gauze placed in the wound, which will be found already largely filled up; fresh dressings are applied, and the foot put up in plaster of Paris, with or without a fenestrum or any provision by which the region of the wound may be easily uncovered for necessary renewal of dressing.

It is in the most pronounced types of cases only, with marked bone deformity, or those in which previous operations have failed, that the still more radical division or removal of some part of the tarsus is necessary. As to this no universal rule can be applied save this: take out sufficient to correct deformity. In some cases it will be sufficient to excise the astragalus (_astragalectomy_). In other cases it is better to remove a wedge-shaped piece of the tarsus, without reference to the name of the bones attacked (_tarsectomy_). I have never found it necessary to touch the external malleolus, though this has been suggested, nor to do osteotomy of the calcis or of the leg bones above the ankle, as a few have done.

Park’s club foot brace.]

These operations are usually practised, _after a preliminary stretching_, through a curved incision on the outer aspect of the foot, through which, at the same time, the thickened bursæ may be removed, or the callosities included in the incision. The chief convexity of the incision should be over the os calcis at its anterior portion. As the dissection is made the tendons are drawn aside and spared. If it be necessary to divide one or more of them it should be re-united later. According to the density of the structures a strong knife may be used, and strong scissors, or an osteotome manipulated either by hand or with the hammer. After sufficient V-shaped or wedge-shaped bone has been removed the defect should be held together, if practicable, by buried tendon sutures or wire; it is rarely necessary to use drainage. The external wound may be loosely closed with buried sutures, a suitable dressing applied, and the foot put up in a rigid splint; this should permit of removal, or at least inspection of the wound after a few days, for renewal of those dressings which are saturated with blood and for application of new dressings. After this the foot and leg should be put up in overcorrected position in plaster of Paris.

In aggravated cases of club-foot Wilson believes combined operation to give better functional results than can be obtained by any other method. The astragaloscaphoid joint is exposed by an incision over the prominence of the scaphoid, and, being cleared, is opened with chisel or bone forceps, while sufficient of the articular surfaces is removed to destroy them as such and to take out a sufficiently large wedge-shaped piece from either bone so that the desired arch of the foot is restored, or even exaggerated. Then the tendon of the extensor proprius hallucis is exposed and divided just above the great toe, the upper end of the tendon being drawn out through the first incision. To this end is attached a strong silk ligature. The scaphoid is then perforated with a bone drill at some distance from its superficial aspect and at such an angle, with the foot in correct position, that the canal thus made shall be in line with the action of the tendon. The drill is then withdrawn and the tendon passed through the opening by means of its attached silk. One inch beyond the bony canal the tendon is cut off and split in halves, each half being turned in opposite direction and fastened to the periosteum of the scaphoid with fine silk, while the foot is held in overcorrected position, so that the tendon is sewed in its new place under moderate tension. The foot is then dressed in this overcorrected position in plaster of Paris, the splint extending nearly to the knee, and the wound area being exposed by a fenestrum cut in the splint before it is hard.

The location of the incision over the dorsum or outer aspect of the foot may be varied to suit the needs of the case and the method of the attack. In a general way a flap of soft tissues is raised and tendons, so far as possible, are held outward. This is usually practicable, and it is rarely necessary to divide the latter. After operation of any type and recovery from the same it will be necessary for a long time to have the patient wear a corrective appliance. This should be applied as early as possible, and should be worn continuously, _i. e._, night and day; inasmuch as growth is continuous there should also be continued correctional influences. Many types of apparatus have been devised. That which the writer has found effective and has adopted for a number of years is illustrated in Fig. 263. It may be made single or double, as occasion requires. A part of the appliance is a spiral spring and a provision for a constant outward pressure is made upon the foot, by which inversion is more easily overcome, as well as any inward spiral twist of the bones of the leg. No such apparatus can be made effective unless connected suitably with a waist-band. This is, therefore, included in the shoe shown in Fig. 263. Furthermore the appliance should be so made as to permit adjustment commensurate with the rapid growth of the patient, and in order that it need not be too often renewed. Some degree of mechanical ability is required for its application and management. The principles are, however, easily mastered and most parents can soon learn to manage it.

2. =Talipes Valgus.=--This condition is known also as _talipes planus_, or, more briefly, _pes planus_, the common names being _flat-foot_, _splay-foot_, or _pronated foot_. A particularly painful variety has been often spoken of as _pes planus dolorosus_.

This type of deformity is rarely of congenital origin. It is characterized by abduction and pronation of the foot, on whose inner border there often appear two prominences, one the head of the astragalus the other the head of the scaphoid. The bones show much less alteration in actual shape than in club-foot. The scaphoid is deflected somewhat to the outer side and the astragalus turned a little outward and downward. A prominent feature is that the arch of the foot is more or less obliterated, while its inner border becomes convex instead of remaining concave. This is due in large measure to relaxation of the ligaments binding the foot to the calcis, especially that extending from the astragalus (Fig. 264).

=Etiology.=--The common cause of the condition is lack of sufficient strength of the parts to carry the weight of the superimposed body. It is produced often by ill-fitting shoes, accompanied by excessive strain or rapid growth and gain in weight. It is sometimes complicated by a certain shortening of the gastrocnemius (Shaffer), which prevents flexion to its complete degree and compels some degree of eversion of the foot in completing a step. In some instances it is induced by previous morbid conditions, such as rickets, paralysis, diseases of the spinal cord, and postgonorrheal arthritis. Ill-fitting footwear is the most common cause, as it compresses the front part of the foot and prevents adaptation of the foot to the position it should assume when the weight of the body is thrown upon it. The effect of this weight is to necessitate a greater divergence of the toes than such shoes permit and gradually causes the patient to walk on the inside of the foot. _Flat-foot is seldom seen in those who habitually go barefooted._