_Phosphorus necrosis_, on the other hand, manifests itself almost

entirely in the lower jaw, and occurs usually among the young,

in factories where matches are made. It is due to the vapors of

phosphorus, which cause a form of nearly distinct maxillary necrosis--a

fact which has been so widely recognized as to lead to State

legislation preventing the employment of the young in such work.

Phosphorus necrosis _begins as a periostitis_ with the production of

osteophytes, and is completed as a nearly total necrosis of the entire

bone.

=Treatment of the Toxic Forms.=--The _preventive_ treatment should

consist of supervision of the teeth, the use of alkaline mouth-washes,

inhalation of terebinthinate vapors, which neutralize those of

phosphorus, and the ventilation of establishments devoted to

match-making. The curative treatment consists of buccal antisepsis,

opening of abscesses, and the removal of diseased bone, especially

of dead bone, upon the first provocation. The occurrence of fistulas

should always be regarded as pathognomonic of diseased bone. In

aggravated cases, such as are rarely if ever seen since legislation has

been brought to bear upon the subject, practically complete necrosis of

the lower jaw, either _en masse_ or in portions, was far from unknown,

and the possibility of regeneration of the bone was for a long time

discredited, until the late James R. Wood, of New York, exhibited a

specimen, both at home and abroad, which proved its possibility. Since

then we have learned that it is possible for bone thus to regenerate,

the cause of the disturbance having been removed.

[Illustration: PLATE XXXVII

Necrosis of Shaft of Femur with Sequestra. (Life size.)]

[Illustration: FIG. 232

Phosphorus necrosis of the lower jaw. (Musée Dupuytren.)]

=Sequestrum Formation.=--To the portion of bone which dies is given the

name _sequestrum_, while multiple sequestra are by no means uncommon.

The sequestrum is white and ivory-like in hardness when it consists of

original compact structure. It is rare to find a distinct sequestrum of

spongy tissue, as this yields so readily to the presence of granulation

tissue and of pyogenic infection. A sequestrum may include an entire

bone shaft, or epiphysis, or only a small fragment. A portion of

the bone having lost its vitality becomes a foreign body which the

surrounding tissues endeavor to extrude or to wall off and surround.

The extrusive effort is the one which is usually seen. This is done

by the continued presence of granulation tissue, which gradually

perforates the surrounding bone at places of least resistance, the

result being the slow formation of a sinus or several sinuses,

ultimately connecting with the surface, and in which in neglected cases

the dead fragment of bone can be seen or felt, or from which it can be

withdrawn almost without operation. While this weakening of bone is

going on in certain portions a corresponding strengthening process is

also being put into effect; and the result is a quantity of new bone,

which is often wrapped around the sequestrum and is simply the effort

to atone for its pathological weakness and to strengthen it. This new

osseous tissue which so often surrounds the sequestrum is called the

_involucrum_, and in many instances it is necessary to remove more or

less of the involucrum before the sequestrum can be lifted out of its

bed or removed. (See Plate XXXVII.)

The whole necrotic process is intelligible if read aright as an

endeavor on the part of Nature to get rid of dead and irritating

material. When this effort is properly interpreted the natural efforts

can be seconded by the interference of the surgeon at a time when

disturbance is limited to the minimum and before external sinuses have

had opportunity to form. On the other hand, ignorance and neglect may

lead to the extreme condition, and most fantastic arrangements of

sequestra and involucra are seen in all pathological museums, some of

which seem to partake almost of the perplexities of Chinese puzzles.

The explanation, however, is always as above afforded. (See Figs. 233,

234 and 235.)

=Treatment.=--The treatment should be surgical, and consist in removal

of the dead portions and restoration of the parts to a condition

favoring rapid regeneration. It should always be radical, but is

sometimes made difficult by the inaccessibility of the fragment or by

the density of the involucrum and the necessity for large external

openings in order to remove the sequestrum.

Large and powerful forceps and strong and well-tempered bone chisels

are usually necessary, while, after making the necessary opening for

removal of the sequestrum, the sharp spoon should be used thoroughly

to scrape away all the lining material of cavities in which fragments

have been lying or all fungous tissue which may fill sinus tracks. It

will be well after this to thoroughly cauterize the wall of the cavity,

after which it is to be packed.

[Illustration: FIG. 233

Central necrosis of the tibia, long central sequestrum.]

[Illustration: FIG. 234

Sequestrum inside of a core of new-bone tissue, arranged much like a

puzzle.]

[Illustration: FIG. 235

Necrosis of tibia, showing sequestra after removal. (All three

specimens from the Buffalo Museum.)]

The packing of old bone cavities is of importance, and operators should

appreciate the reason for so treating them. The packing is essentially

a foreign material which the tissues will naturally endeavor to

extrude as they did the sequestrum. The method of extrusion is by

filling up beneath and around it with granulation tissue, which later

may ossify. The packing is therefore a constant provocation to the

formation of this tissue, which is now desirable, and is used mainly

for this purpose. It is antiseptic material, and will serve to prevent

decomposition of the pyoid material which would otherwise fill such a

cavity as the result of waste--Nature’s effort at formative material

gone to waste. A number of years ago Gunn suggested the use of _wax_

for this purpose, wax being plastic and incapable of absorption. A

piece of white wax was heated in hot water, molded with the fingers

to fit the cavity, where it served the purpose of a packing, and was

reduced in size with each dressing, as was necessary to permit it still

to remain. It is not now used as much as it deserves to be. (See p.

431.)

In favorable cases it may be possible to so thoroughly cleanse the bone

cavity without the use of caustics as to justify the attempt, after

rigid asepsis, of allowing it to fill with blood, which will coagulate

and organize into connective tissue. When this effect is desired the

wound should be covered with green silk protective, over which the

other dressing may be snugly applied. This healing by the _aseptic

blood clot_ is the ideal method when possible.

The extent to which regeneration of bone is possible is often amazing,

especially in the young. Thus after removal of the entire shaft of a

tibia there may result, in time, not a complete restoration to former

integrity, but, in addition, the formation of so much new osseous

material as to restore a great degree of strength, and which shall,

with the compensatorily hypertrophied fibula, make the leg as useful

as ever. In the thigh, however, complete necrosis of the femur means

amputation, as it will also in the arm unless the necrotic portion is

but a small proportion of the length of the humerus. The treatment of

necrosis of the skull, or, in fact, of any bone in the body which is

accessible, is based practically on the principles already laid down.

BONE TRANSPLANTATION AND TRANSFERENCE.

In the effort to atone for extensive loss of bone many experiments have

been tried, first on animals and afterward on men, success with the

former having lent much prospect to the latter. It has been learned,

for instance, that portions of living bone can be removed from some of

the lower animals and transferred into a bed of more or less healthy

sterile human tissues, often with the result that a fragment thus

transplanted becomes vitalized and incorporated, and serves the purpose

for which it was intended; still these efforts do not in all instances

succeed. However, experience has led to the effort to utilize some

portion of the patient’s own osseous system. This becomes more easily

possible in the case of the forearm or leg where, especially in the

latter, a small or less important bone can be utilized to take the

place of the greater. Thus, when the entire shaft of the tibia has been

removed for necrosis resulting from acute osteomyelitis, the fibula has

been sawed across, opposite the site of the ends of the lacking tibial

shaft, and transplanted into the trough-shaped depression, thus making

it functionate for the lost tibia. Huntington has recently reported a

case in which not only was this done, but later the upper and lower

ends of the fibula attached to the tibia, with good bony union and

with an almost perfect functional result. This will illustrate what

elsewhere may be done in this direction.

FILLING OF BONE CAVITIES.

Our methods for removal of sequestra and cleaning out of infected

bone cavities are now simplified and made safe. The difficulty which

is still universal is to secure a rapid filling or closure of these

cavities. If we could be certain of cleaning out every particle of

infected tissue and the removal of every germ which might excite

putrefaction, then we might resort to Schede’s plan and allow even a

large cavity to fill with blood clot and await its organization, but

no complicated and infected cavity in such tissue as bone-marrow can

ever be so treated to a theoretical degree of perfection. Therefore

disappointment often follows this attempt. Senn endeavored to improve

upon the plan by the insertion of chips of decalcified bone, but this

method is open to the same objection. Dentists have the advantage

of surgeons because they deal with small cavities, and in tissues

which can usually be thoroughly sterilized. Other things being equal,

the methods to which they resort could, with advantage, be imitated

by surgeons. In 1903, Mosetig-Moorhof suggested a mass containing

iodoform 60 parts, spermaceti 40 parts, and oil of sesame 40 parts.

When this mixture is slowly heated to 100° C. and allowed to cool,

there remains a soft material which, when desired for use, is melted,

being constantly stirred to keep the iodoform properly suspended, while

it is poured into the cavity, where it immediately solidifies. It is

claimed that its physical properties permit of its gradual absorption

and replacement by granulation, and finally by new bone, as has been

shown by a series of skiagrams. A cavity in which this preparation is

used should be prepared as dentists prepare theirs. It is successful

in proportion to the absolute disinfection of the same. For this

purpose wide opening and ready access are necessary in order to dry and

cleanse. Should oozing be persistent strands of catgut may permit of

escape of the blood which enters the cavity. It would probably be best

to use the elastic bandage and bloodless method, and to protect for a

few moments the solidifying mass before allowing the blood to return to

the limb. The originator uses, in his own clinic, a hot-air blast. The

air is heated by an electric contrivance, and both dries and disinfects

the cavity. After the cavity is thus filled the tissues are closed

over it and a sterile dressing applied. It is serviceable in chronic

cases and after thorough work. In acute osteomyelitis it is scarcely to

be thought of because of the acute character of the infection.

OTHER PARASITIC AFFECTIONS OF BONES.

These are mainly of two varieties--_hydatid disease_ and

_actinomycosis_.

[Illustration: FIG. 236

Achondroplasic skeleton. (Porak.)]

=Hydatid Disease of Bone.=--Hydatid disease of bone consists in the

development of hydatid cysts, which may be either of primary or

secondary origin. Almost all the bones of the skeleton are liable to

cyst formation, except the short bones of the carpus, tarsus, and

digits. In the long bones they occur most frequently in the region of

the epiphyses. The particular vascularity of this region is the main

factor in their location at this point. The cysts may be unilocular

or multilocular, and around them may be a thin or a large area of

infiltration. In other words, their boundaries may be abrupt or not.

Their volume is exceedingly variable, unilocular cysts sometimes

attaining considerable size and distending the bone beyond its normal

proportions. (See Chapter XXVI for further reference to the pathology

of hydatid cysts.)

=Treatment.=--The treatment is purely operative. The contents of the

cysts should be evacuated and its walls radically destroyed by caustic,

spoon, etc. All sequestra should be removed; in the limbs _amputation_

is sometimes necessitated by the extent of the affection.

=Actinomycosis.=--The general character of this parasitic disease has

already been considered. (See Chapter VIII.)

The peculiar fungus may be found in the periosteum, in the compact

outer layers of the bone, or within its more spongy depths. When the

lesion is sufficiently large to be recognizable to the naked eye it

assumes, for all practical purposes, the appearance of caries, like

that due to tuberculous or leprous diseases, while in the pus or debris

discharged from the same or contained within the invaded bones the

characteristic yellow, cheesy, or calcareous particles will always

be recognized. In this disease there never seems to be the slightest

tendency to encapsulation nor to protect against further spreading

by any process of repair. The diseased area constantly enlarges its

dimensions, involving everything as it spreads, it being limited by no

membrane or tissue of the body. Occurring in the bones, it is usually a

secondary or metastatic infection, and may be found in any part of the

body.

The symptoms will be those of osteoperiostitis, first occurring

frequently in the jaws, as it nearly always does in cattle, and often

in man; this is accompanied by loosening of the teeth and involvement

of the submaxillary tissues. The course of the disease is slow, with

little or no tendency toward spontaneous recovery.

TROPHONEUROTIC DISEASES OF THE BONES.

Under this heading it is proposed to group a number of diseases whose

clinical manifestations are distinct or classic, but whose underlying

causes are more or less obscure.

=Achondroplasia.=--This is a lesion of intra-uterine life which

includes a softening of primary cartilaginous structures and curvature

or malformation of the bones which should be formed from them. It

belongs to that period of fetal life between the third and sixth

months. It is sometimes referred to as _intra-uterine rickets_. Under

this name it was first described by Müller, in 1860, and since then

under various names, most commonly as _fetal rickets_. It appears

that in this disease the fetal cartilage contains mucus abnormally

collected, quite generally, in minute cavities or cells just at its

borders. The chondroblasts and osteoblasts are not regularly dispersed,

and the development of the growing bone is thereby much interfered

with. The periosteum appears to have nothing to do with this condition.

In consequence the cartilage does not do its proper duty. The long

bones fail to attain their proper proportionate length, but become

thicker than normal, the periosteum being unaltered. On the other hand,

those bones into whose formation cartilage enters but slightly, such

as the clavicle and the ribs, retain their normal proportions--the

consequence is a peculiar malformation and disproportion of the whole

skeleton (Fig. 236).

These deformities are symmetrical, and pertain mostly to the bones at

the base of the skull and to the long bones of the limbs; therefore

the distinctive appearance may be recognized even at the birth of the

child. The head is disproportionately large, the spinal column short,

the lumbar curvature exaggerated, all of which is rather the reverse of

the ordinary rachitic manifestations. The disease is not common (Fig.

237).

[Illustration: FIG. 237

Achondroplasia. (Lugeol.)]

=Prognosis.=--The prognosis is unfavorable, because it seems impossible

to undo the faults of the intra-uterine condition. The disease,

however, is not incompatible with a long life.

=Rachitis.=--This also is a constitutional condition, and has been

described in Chapter XIII. So far as the manifestations in the bones

are concerned it is a constitutional dystrophy caused by improper

deposition of calcareous material in the softened and somewhat

perverted fetal cartilages. It is a condition, however, pertaining

rather to postnatal life, and while inconspicuous at birth becomes more

and more marked as the child develops. It is essentially a disease of

malnutrition, and consequently may be seen in all walks of life, as

well in the bottle-fed babies of the wealthy as in the best-nourished

children of the poor. The subject should be studied also in connection

with the facts set forth in the chapter on the Status Lymphaticus,

which bear on the relation of the ductless glands to tissue growth, and

especially to rickets. The lesions are widely distributed. The disease

is divided by some writers into three periods: (_a_) _Rarefaction of

bone tissue_; (_b_) _softening of same_; (_c_) _re-ossification_.

The first stage is the intra-uterine part; the second and third stages

are postnatal. To fetal rarefaction have been attributed intra-uterine

fractures, even by Hippocrates.

The general dyscrasia and visceral alterations of rachitis interest

us here less than deformities of the various bones. The head is

disproportionately large, the vertex flattened, the frontal and

parietal eminences pronounced; the anterior fontanelle closes very

late. To the atrophic alterations of the head have been given the name

_craniotabes_. The face is disproportionately small, the lower jaw

assuming a polygonal shape. The palatal vault is of the Gothic type,

dentition irregular and retarded. In the thorax the clavicular curves

are exaggerated, by which the bones are shortened and the shoulders

made narrow. The costochondral junctions are enlarged, the result

being the so-called _rachitic rosary_. The sternum projects and gives

the peculiar appearance known as _pigeon-breast_. The pelvis is often

deformed, and frequently distorted to such an extent as in after years

to make normal delivery impossible. The spinal column may either be

distorted early or is likely to undergo alterations of curvature,

due to the combined results of pressure and traction upon softened

vertebræ. The joint ends of the long bones are enlarged or clubbed,

this being true even of the phalanges. Joint movements are often

accompanied by crepitation. The axes of the long bones are distorted,

and more or less marked deviations and curvatures result, giving rise

to such deformities as knock-knee, bow-leg, etc. (See pp. 161 and 162.)

=Osteomalacia.=--As rickets is essentially a disease of early

childhood, osteomalacia is practically confined to adults. The name

implies a peculiar _softening of the bones_, by which their resistance

and rigidity are weakened and deformity permitted. The disease is

common to man and to animals in confinement, and is frequently noted

among wild animals dying in zoölogical gardens. It commonly occurs in

_pregnant women_, where it would appear as if the mineral elements

needed for the growing fetus were abstracted from the mother’s bones

rather than from the food ingested. It is brought about also by

_starvation_, possibly by _lactation_, especially among those who nurse

their children for unusual periods.

[Illustration: FIG. 238

Osteomalacia: celebrated case of Moraud, 1753. (Skeleton now in Musée

Dupuytren.)]

_Spontaneous fractures_, especially of the long bones, are frequent.

These may refuse to unite properly and false joints may result. The

urine will under these circumstances contain an excess of mineral

salts, carbonates, phosphates, and oxalates, and when these are

discovered in the urine of those suffering from fractures it should

always be a warning to administer calcium salts and mineral acids,

preferably phosphoric, internally, and to carefully watch the

excretions. The progress of the disease is slow, yet steady, and often

not easily checked, if at all affected, by mineral acids. Occurring in

pregnant women, it may be checked after delivery, especially if the

child be not allowed to nurse from the mother. In some instances it

occurs with each successive confinement in the same patient, and makes

distinct advance with each fresh attack.

=Prognosis.=--The prognosis is therefore unfavorable, least so in

puerperal cases.

An _infantile form_, as well as a _fetal form_, have been noted, but it

is doubtful whether these forms really come under the same category,

and whether they are not manifestations of rickets. A _senile form_

has also been described which affects most frequently the sternum and

thorax, which is characterized by excess of nervous excitability and

by bone pains, as well as by liability to multiple fracture upon the

slightest provocation. This form, however, differs but little from

the osteoporosis of advanced years, and scarcely deserves distinct

consideration. Certain writers have also mentioned a _symptomatic

form_--cancer, syphilis, scurvy, etc.--which, however, is unnecessary,

since the fractures occurring in cases of cancer or syphilis are due to

secondary lesions of the same character, while those occurring during

scurvy are simply an expression of starvation and weakening, even of

the bones. Cases of cancer, for instance, where bones have broken

without being previously weakened by secondary growths, are exceedingly

rare.

Under the name of _osteogenesis imperfecta_ has been described the

“fragilitas ossium” of certain writers. The condition has also

been known as congenital fetal rickets. These cases may usually be

recognized in infancy, in that the extremities are more or less bent

and deformed, and the bones very fragile. Sometimes intra-uterine

fractures occur, which may be recent or old, and united with more or

less callus and deformity. The spinal column will be soft and friable,

with marked divisions, and the ribs are often fractured. The clavicle

shows lesions of this kind more frequently than any other single

bone. Bones so affected will be found extremely fragile and delicate,

and sometimes so thin that they may be crushed between the fingers.

They are defective in every respect of structure. But these changes

pertain mostly to the shafts of the long bones, and do not concern

the cartilages. They are to be distinguished from chondrodystrophia

fetalis, in which the extremities are shortened, the skin thickened,

and the subcutaneous tissues extremely fatty or edematous.

The condition is to be distinguished from rickets, as there is no

enlargement of rib ends or epiphyses and no disturbances of the

alimentary or nervous systems. Osteomalacia usually occurs after

puberty. Hereditary syphilis, in very rare instances, is a factor, but

should give additional evidences in other parts of the body. At present

there is no satisfactory explanation as to the cause of the condition.

[Illustration: FIG. 239

Osteopsathyrosis. (Blanchard’s case.)]

=Treatment.=--The treatment for all these conditions should be removal

of the cause if discoverable and the administration of calcium salts

in accessible shape, as in cases of rickets, combined with thymus or

pituitary extract.

=Osteopsathyrosis, or Fragility of Bones.=--This is a condition

distinct from osteomalacia and is due to trophic nerve disturbance.

The condition seems to be hereditary, often extending through several

generations. It is characterized by fracture of long bones upon the

slightest provocation, and is common to all ages. While apparently

congenital in origin, it persists often throughout life, no impression

being made upon the condition by medication. It is not characterized by

distinctive histological changes, and all theories heretofore advanced

toward its cause are disappointing. It is seen, at least in this

country, most often in _paretics_ and _inmates of insane asylums_. The

ease with which the bones of such patients are broken has given rise

to repeated charges of violence or homicide. From one case in which

this charge was made I secured specimens of the ribs, which were so

fragile that they could be crumbled between the fingers. Such patients

might easily sustain serious fractures when undergoing necessary

restraint, even of the gentlest nature. Allegations of undue violence

are frequently made in these cases, which, especially in asylums, may

be most unjust and difficult to prove or disprove.

The _relationship of osteomalacia to exophthalmic goitre_ furnishes

another illustration of the peculiar and mysterious influences which

the thyroid exercises upon nutrition. The conditions have a similar

geographical distribution, as well as being coincidental in the same

individual. Honicke, who has recently studied the subject, believes the

bone condition to be an expression of thyroidal disorder, the more so

in that castration does not remedy the disease, thus proving that the

genital glands are not at fault.

The peculiar relationship between the bone and the thyroid in these

cases is probably one of disturbance of the elaboration of the

phosphorus compounds which are necessary for the proper development of

bone, these compounds being excreted rather than utilized.

Osteopsathyrosis of this congenital type is perhaps best illustrated

by a case reported by Blanchard,[35] of Chicago, in the case of a

woman twenty-seven years of age at the time of his report, who up to

that time had sustained over one hundred fractures. In her case it was

sufficient to merely gently slide from the sofa to the floor to break

some bone. Treatment in her case had been of no avail. (See Fig. 239.)

[35] Trans. Amer. Orthopedic Assoc.

=Senile Fragility of Bones.=--This means weakening of the bones which

is incident to advanced age in either sex, due to and comprised under

the term _osteoporosis_. Added to this, in certain places is a positive

change in shape, also characterizing the senile condition--_e. g._, the

neck of the femur. Under these circumstances bones will break with a

minimum of violence and without invoking any theory of osteomalacia,

osteopsathyrosis, or the like. As bone disappears under these

circumstances fat usually takes its place, so that while the volume of

the bone may not be particularly diminished, its weight and density are

materially altered. (See introductory remarks to this chapter.)

=Atrophic Elongation.=--This is a term first applied by Ollier, and

refers to a distinct type of alteration in long bones by which their

actual volume is relatively diminished, although they _increase in

length_. It is produced largely by lack of pressure, and is seen in

many amputated stumps, in which it has much to do with the conicity of

the same. It is seen in certain cases of typhoid fever or in forced

confinement of the young in bed, where the bones appear to grow at

a much more rapid rate than normal. It may also be due to unequal

amounts, or defects, of nutritive supply, especially that furnished by

the periosteum, and in certain other cases seems to be a purely reflex

or trophoneurotic change which is always inexplicable. Frequently

accompanying it is muscular wasting, which is to be explained rather by

reflex action through the cord, produced perhaps through the mechanism

of the terminal filaments of the articular nerves.

=Ostitis Deformans.=--Ostitis deformans is often called _Paget’s

disease of the bones_, and is a condition found alike in long and

flat bones, the osseous tissue being condensed in texture and

increased in amount, or at other times the osseous tissue becoming

quite porous and the spongy tissue rarefied without alteration in

the marrow. It is due to the unknown causes which may be summed up

in the expression trophoneurotic, a _painful_ and a _painless_ form

having been described, the former the more frequent. It produces

deformities, disfigurements, and hypertrophies of the long bones. It

is distinguished from _arthritis deformans_, described in the previous

chapter, which is a distinct malady.

In the skull it is usually the face bones which are most involved,

although the disease often commences in the cranial bones. The skull

proper may be thickened even to 3 Cm. The thorax becomes globular or

cubic in form, the arms are relatively too long, and there is usually

dorsal kyphosis; the pelvis is thickened and distorted; the ribs are

augmented in size and the femora irregularly curved; the patellæ

enlarged; the tibiæ more massive and their curves exaggerated. The

disease is essentially _symmetrical_, commonly commencing in the

cranium and radius. Fractures are rare, because the bones become

stronger rather than weaker.

In many instances these changes are accompanied by severe pains,

which may be exaggerated by pressure. The malady is usually regarded

as rheumatism, but it may be said that even were accurate diagnosis

made early it would scarcely avail in treatment, since there is none

for it. It may require to be distinguished from hereditary syphilis,

in which the tibiæ have more of the saber shape; from _acromegaly_ or

_leontiasis_, which begin in the bones of the face and involve the

cranium only secondarily.

=Osteoarthropathie Hypertrophiante Pneumique.=--Under this title, which

has no exact equivalent in English, was described, in 1890, by Marie, a

peculiar affection, often wrongly spoken of in this country as Marie’s

disease. This is in large part a pulmonary affection accompanied by

enlargement of the extremities. There is reason to believe that there

are present microörganisms, giving rise to products that are absorbed

into the general circulation, the result of whose presence is an

irritative hypertrophy of certain parts, particularly the joints and

ends of the fingers, the elbow-, shoulder-, and knee-joints, and often

the wrist. There is also ordinarily dorsolumbar kyphosis, which in

acromegaly is usually cervicodorsal. The cranium remains intact; the

borders of the jaw are sometimes involved.

=Acromegaly.=--Acromegaly is so named from its tendency to increase

the volume of the bone extremities or apices. The first case of

this disease was published by Marie in 1885. It is characterized by

progressive increase in weight, by enlargement of all the extremities,

bones and soft tissues alike; but the most characteristic involvement

is that of the lower jaw, the upper jaw being little if at all

affected. The lower jaw assumes enormous size and projects so that

its teeth are far in front of those of the upper. The supra-orbital

ridges enlarge, as do also the sternal ends of the clavicles and

costal cartilages. As the disease progresses the ribs are widened and

the scapulæ enlarged, the vertebræ and the intervertebral cartilages

thickened and fused together, causing usually cervicodorsal kyphosis.

The long bones of the limbs suffer later, especially at the lowermost

joint ends--_i. e._, hands and feet. The viscera are rarely affected,

but there is a peculiar and characteristic enlargement, usually of

the thyroid and pituitary bodies. The lower cervical ganglion of the

sympathetic is also sclerosed; the mucous membrane of the nose is

usually hypertrophied; the uvula is enlarged and the larynx often

participates in the changes. Acromegaly is essentially symmetrical, and

for each change upon one side of the body is noticed a corresponding

alteration upon the other. Particular features are observed in

individual cases, but the above are practically common to all.

[Illustration: FIG. 240

Osteoarthropathy. (Marie.)]

[Illustration: FIG. 241

Acromegaly. (Original.)]

The underlying pathological condition is as yet undetermined, though

most indications point to late alterations along the original

_craniopharyngeal tract_ of the young embryo, whose remains are best

known in the pituitary body and the thyroid. On this account there is

reason for trying the treatment by extract of the pituitary body, or

even of the thyroid. The greatest complaint usually is of headache,

which is difficult of relief. The disease is steady, progressive,

unaffected by treatment, and the prognosis bad, though its course is

slow.

=Leontiasis.=--A diffuse bilateral, symmetrical hypertrophy of the

bones of the face and later of the cranium, described first by Virchow,

the real origin appearing to be in the superior maxillæ, the result

being a peculiar leonine appearance of the face, hence the name given

to the disease. There is no distinct tumor formation in the bone, but

rather the entire structure of the bones involved is affected. As it

advances function of the parts is interfered with, mastication becomes

impossible, headache and pain are constant. The special senses are

disturbed because of involvement of their nerves, and patients die

usually from inanition, because no longer able to chew and swallow

food. It is distinguished from Paget’s disease, because it shows no

tendency to involve the rest of the skeleton; from acromegaly, in which

the general shape of the jaw is preserved, though its dimensions are

magnified; from tumors of the jaw or face, because of its symmetrical

enlargement. Its pathogeny is as obscure as that of the other bone

affections mentioned in this list, and its treatment as unsatisfactory.

[Illustration: FIG. 242

Leontiasis: skull of a Chinese woman. (U. S. A. Museum, No. 10,620.)]

TUMORS OF BONE.

As between the various hypertrophic conditions of the bones above

noted should be distinguished the true neoplasms, which answer all the

requirements of the definition given in Chapter XXVI. There are few

of the true tumors which may not be met with in bone, including the

periosteum.

[Illustration: FIG. 243

Multiple enchondromas of fingers.]

=Fibromas.=--Fibromas may spring from the periosteum, especially

about the jaws and from the base of the skull, from which latter

place they may project into the nasopharynx and interfere with the

welfare of the patient. Some of these tumors are soft and succulent,

as well as extremely vascular, and I have seen death occur upon the

table in an endeavor to remove a growth of this kind, hemorrhage being

uncontrollable.

[Illustration: FIG. 244

Multiple ecchondroses and exostoses.

Skeleton in the museum at Lyons. (Poncet.)]

[Illustration: FIG. 245

Multiple ecchondroses and exostoses. (Lexer.)]

[Illustration: FIG. 246

Cancellous osteomas springing from the diploë. (Musée Dupuytren.)]

[Illustration: FIG. 247

Sarcoma of femur. (Buffalo Clinic.)]

[Illustration: FIG. 248

Fungating osteosarcoma of cranium. (Pemberton.)]

=Cartilaginous Tumors.=--Cartilaginous tumors, as stated in Chapter

XXVI, are not often found outside of the bony skeleton. They may spring

from cartilaginous extremities of growing bones, from epiphyseal

cartilages, or from the interior of long and short bones, where their

origin is probably due to inclusion of cartilaginous elements, as

comprehended in Cohnheim’s theory. In young children they are often

multiple and involve various parts of the body. Occurring in adults

they are less often multiple, but may attain considerable size. (See

Fig. 243.) They are found usually about the ribs, sternum, pelvis, and

femora. If the entire structure of a given bone be involved in a growth

of this kind, its eradication--that is, amputation--will probably be

necessary.

[Illustration: FIG. 249

Exostosis bursata. (Orlow.)]

When otherwise, complete removal with careful cauterization of the

base of the growth or surface from which it sprang will usually be

sufficient. These cartilaginous tumors tend on one hand to mucoid

softening and cystic formation, and on the other to calcification or

ossification, by which the original cartilaginous character of the

growth may be concealed.

=Osteomas.=--Osteomas are by some writers made to include _exostoses_

and _hyperostoses_. In accordance with the system followed in this

work only those growths are considered as tumors which are of

no physiological usefulness, and it is preferable to maintain a

distinction between osteomas and the exostoses or bone hypertrophies,

which pertain either to evolutionary relics or to constitutional

affections.

There is, however, a peculiar form of exostosis which becomes covered

by an adventitious bursa, whose walls become in time quite thick,

which is called _exostosis bursata_. In the cavity of this bursa may

frequently be found rice-grain or other fibrinous concretions. This

lesion is common in the neighborhood of joints, and the new bursa

frequently communicates with the joint cavity (Fig. 249).

=Myxomas.=--Myxomas are rare in bone, and are seen usually only as

degenerated forms of cartilaginous bony or malignant growths. They

lead to cystic degeneration. A primary growth of this kind has for its

origin the bone-marrow.

=Sarcoma.=--As already described, sarcoma of bone should not be

confused with osteosarcoma. (See Sarcoma.) The former refers to sarcoma

springing from the true osseous tissue or periosteum. When central

the bony walls are expanded and form a shell. Osteosarcoma refers to

a tumor springing from the original connective tissue which holds

the bony elements together, and contains osseous tissue scattered

through it. Sarcoma occurs usually in the long bones, although none

are exempt; mostly single, it nevertheless may be multiple. It occurs

frequently in the young, is seen even at birth, and in these instances

is supposed to take its origin usually from epiphyseal structures. No

period of life is, however, exempt. Tumors attain sometimes enormous

size. Marsh has recently described such a tumor weighing thirty-three

pounds. Microscopically these tumors may assume any of the varieties,

endothelioma, angiosarcoma, etc., those of the most rapid growth being

found rather of the _round-cell_ type, while those of slow growth are

usually _myeloid_ or contain giant cells.

Sarcomas frequently arise from the _periosteum_. Commencing in the

interior of a bone, they develop for the most part very slowly, and

expand the bone more or less symmetrically, in distinction to those

growths of external origin which are in evidence on one or another

aspect of the bone involved (Figs. 247 and 248).

Sarcoma not infrequently has its origin from the callus of a delayed

bone union, and I have had repeatedly to amputate for this sequel of

fracture. (See Fig. 252.)

As the disease advances there is increase of pain, usually with

increasing cachexia, while augmentation in size of such a tumor may

make a limb not only useless, but the source of greatest annoyance and

difficulty in management of the case.

=Treatment.=--There is but one treatment in cases which will permit

it--amputation of limbs, extirpation of tumors from certain bones, or

excision of entire bones. Thus for sarcoma of the scapula we extirpate

the entire bone; for sarcoma of the skull we make extensive resections

of the same, removing the underlying dura when involved; for sarcoma

of the lower or upper jaw we remove it in whole or in part. Sarcoma

of the spine is inoperable, that of the pelvis almost equally so. In

absolutely inoperable cases treatment by the toxins of erysipelas

may be tested. In all cases where pain is severe opiates should be

administered, which under these circumstances are anodyne, stimulant,

and almost nutritive. Patients in this condition should not be allowed

to suffer, and opium in assimilable form should always be administered

to any amount necessary.

[Illustration: FIG. 250

Sarcoma of periosteum of humerus. (Pemberton.)]

[Illustration: FIG. 251

Bone cyst of tibia. (Buffalo Clinic.)]

=Myeloma (Kahler’s Disease).=--Collins[36] reports the tenth recorded

case in this country. The disease was first described by Bence

Jones in connection with a peculiar proteid found in the urine. It

is characterized by changes in the bones, with pain in the chest,

back, and loins. In the urine albumose appears, which seems to be

pathognomonic when taken in connection with such symptoms as those

above. On section numerous small tumors are seen in the bones. The

disease has hitherto been regarded as an expression of osteomalacia.

All the bones of the skeleton may be involved without any tendency to

metastasis in other tissues. On minute examination the myelomatous

tumors met with seem to be found alike in the bone substance and the

marrow, and to be cell proliferations of myeloid tissue. The matter is

still left somewhat in doubt as to what should be meant by the term

_myeloma_, this being a feature to be cleared up later. It is seen

more often in males than in females, and in the later part of life.

Aside from constant malaise, with pain in the back and side, there

occur progressive weakness, with anemia, and such final softening and

fragility of bones as to lead to spontaneous fractures, or to the

projection of tumors, which may be especially noted about the ribs,

with deformity of the vertebræ. On close inspection the urine will be

found turbid and albumose is detected. The disease is usually regarded

as hopeless; there is no information regarding its successful treatment.

[36] Medical Record, April 29, 1905.

[Illustration: FIG. 252

Sarcoma developing in callus. (Haberen.)]

CHAPTER XXXIII.

DEFORMITIES DUE TO CONGENITAL DEFECTS OR ACQUIRED DISEASES OF THE

LOCOMOTOR APPARATUS; ORTHOPEDICS.

In previous chapters have been considered the various morbid conditions

of bones, joints, muscles, and tissues which help to form the locomotor

apparatus of the body. It would seem then quite proper in this place

to insert the chapter usually relegated to the end of text-books on

surgery where it stands by itself, _i. e._, the chapter on Orthopedics.

As a subject orthopedics deals with the causation and the treatment of

deformity, whether inherited or caused by disease. The term is used in

a more or less elastic sense, and is made by some to cover a larger

field than others would accord it. The subject divides itself into two

parts:

1. The consideration of deformities produced by tuberculous or other

infectious disease, and

2. Non-carious, congenital, and acquired deformities.

Tuberculous lesions do not differ in pathology or other respects from

the tuberculous diseases of bones and joints described in earlier

chapters of this work. Inasmuch, however, as some of them form distinct

and clinical types of deformity they assume an importance which

justifies reasonable consideration by themselves. Of these we shall

consider spinal caries, sacro-iliac disease, hip disease, and tumor

albus.

SPINAL CARIES, SPONDYLITIS, KYPHOSIS, POTT’S DISEASE.

These various terms have reference to deformities of the spine of

similar type, but with considerable variations, produced by caries

(tuberculosis) of the vertebral column. Where osseous structures are

separated by cartilaginous or more or less complete joint cavities the

primary focus may form within the spongy structures of the vertebral

bodies or in the softer tissues of the intervertebral joints. In

other words, it is caries of the ordinary type which assumes special

significance only because of the accident of its location. The entire

vertebral column should be regarded as the main support of the body,

while to it is due the maintenance of the erect position which raises

man above the animal. When diseased and softened it yields to pressure,

the result being exaggeration or distortion of its natural curves. As

the instinctive tendency of the human being is to maintain the head

in the line of the centre of gravity above the pelvis, any marked

degree of curvature in one direction brings about, by natural causes,

a compensatory curve in its opposite direction. A well-marked case of

kyphosis, then, is characterized by more than one exaggerated curvature

or protuberance, one being due to disease, the other to compensation.

While there may be several foci of active tuberculous disease, even in

one vertebra, there may be found pronounced forms of angular curvature

as the result of destruction occurring in but one or two of them.

The carious process once begun may be checked at any point in its

course, or it may proceed to complete softening and destruction, with

formation of cold abscess. The tuberculous process once begun spares no

tissue, and thus bone and intervertebral cartilage melt and disappear

in the same manner. There may be a possible danger from spreading of

tuberculous disease to the spinal meninges or to the cord, or of its

being generalized. In the former case there is pachymeningitis and

myelitis with paralysis; in the latter case it causes more or less

rapid, acute general tuberculosis. Paralysis is more often induced,

however, by actual compression than by mere tuberculous involvement,

although the disease products which cause this pressure are likely to

come from a caseous pachymeningitis.

The disease is most common in childhood, about 80 per cent. of cases

occurring before puberty. Of the three regions of the spine the

thoracic is the one most often involved, next the lumbar, and lastly

the cervical. The most common site of all is in the lower dorsal

region. Deformity once established as the result of this disease cannot

be expected to spontaneously disappear.

=Causes.=--Slight injuries occurring in those of tuberculous diathesis,

by which there is produced a focus of least resistance, or secondary

infections following upon such conditions as scarlatina and typhoid,

constitute the most frequent recognizable causes. There can usually

be obtained a history of some injury in about half of the cases. The

disease once established may assume either an acute or chronic type.

=Symptoms.=--As indicated when discussing caries in joints the

principal signs and symptoms are pain, muscle spasm, muscle atrophy,

tenderness, deformity, and impairment of function. These are all

present in Pott’s disease, to which they give that distinct clinical

picture which Pott so graphically described about a century ago.

=Pain.=--Pain is rarely absent. It may be misleading, but is usually

referred to the terminal distribution of the intercostal nerves, and

thus may be complained of in the chest, the abdomen, or the legs. Many

a “stomach-ache” in children is of this character and origin, and a

complaint of frequent “growing pains” should be carefully investigated.

Even in sleep these pains are characteristic, and have been previously

described as “starting pains.” Children cry out with them in the night.

They tire easily and tend to seek rest instinctively. Pain is always

aggravated by excessive pressure upon the upper spine or by jars,

such as may be received in jumping. It is not necessarily constant.

Vertebral tenderness may sometimes be detected by pressing upon the

ribs. This will especially aggravate symptoms when respiration is of a

groaning character or when there is any expression of dyspnea. There

may be vomiting or dysuria. A sudden increase of these painful features

means a fresh focus of infection, impending abscess, or a danger of

paralysis.

=Muscle Spasm.=--It is by muscle spasm that we account for the

attitudes and postures of Pott’s disease. It is a constant feature,

but will vary in its expressions with the location of the disease. In

caries of the cervical spine the chin is raised, the head is balanced

somewhat backward, while the lower spine is straightened and given a

backward curve. In the stooping posture the head is supported by the

patient’s hands in the instinctive effort to protect it. In caries of

the mid-dorsal region there is elevation of the shoulder, with marked

tendency to support the weight of the upper part of the body by placing

the hands upon the knees or thighs. Lumbar caries often produces

perceptible backward curve in the lower portion of the spine.

In all cases there are stiffness and rigidity of the spine, and

patients resort to all sorts of instinctive expedients to avoid

motion in the affected area. When that part of the spine which is in

relation with the psoas muscle is involved there is more or less psoas

contraction, with characteristic flexor deformity at the hip, which is

usually bilateral. This will give a peculiarity to the gait and cause

it to be not only stiff in appearance, but it will be seen that the

patient walks more upon the toes and with slightly bent knees, which

are thus made to act as springs. An attitude assumed in stooping or in

the effort to lean over as if to pick up an object from the floor is

characteristic; the spine will not be curved forward and the patient

will not stoop as usual for the purpose, but the spine will be more or

less erect and stiff and lowered to the floor by flexing both knees and

hips until the squatting position is assumed. In rising the same effort

will be made to protect the spine from any motion between its component

parts. (See Figs. 253 and 254.)

During sleep this muscle stiffness becomes even more pronounced, so

that in the morning patients are “stiffer” than later in the day. The

existence of muscle spasm can often be detected by palpation of the

spinal lesion. Some lateral deviation or asymmetry of signs may often

be noted, according as the muscles of one side are more pronouncedly

influenced by the location of the disease focus, and it is the more

common in proportion to the greater severity of the case.

The confinement caused by the disease will naturally be followed by

more or less atrophy of the body muscles, but, in addition to that,

those immediately involved about the centre of the disease undergo an

atrophy due to it and often apparent on inspection.

=Tenderness.=--In numerous distinctive ways the patient constantly

evinces tenderness and makes invariable efforts to protect against

movement or even jar. Tenderness can also be evoked by pressure upon

the head or shoulders, which will cause severe pain, or by causing the

patient to jump down a step or to rise upon the toes and then come

down abruptly upon the heel. Pressure upon the spines of the affected

vertebræ or upon the ribs which connect with them will also cause

complaint of pain.

=Deformity.=--This is the most striking objective feature of

well-marked Pott’s disease. It is practically a backward projection

known as kyphosis, the vertebra first affected being usually the first

to yield, the others following or changing in shape as the disease

spreads or as the growth of the individual permits accommodation and

necessitates rearrangement. The more acute the disease the sharper the

projection. Old and mild cases cause an abrupt curvature rather than a

protuberance.

[Illustration: FIG. 253

FIG. 254

Typical postures of the spinal muscle spasm of spondylitis. (Bryant.)]

It is well to keep a record of the deformity in cases under treatment.

This may be graphically preserved by putting the patient flat upon the

abdomen upon a straight surface and bending a strip of lead so that it

shall fit the contour of the spinous processes. After it has been made

to fit it may be removed and a tracing of the curve made upon a sheet

of paper. Comparison of tracings thus made at intervals will afford a

graphic record of the progress of the disease or of the improvement

made. Kyphotic deformities lead to a shortening of the spine, so that

growth is stunted and patients become dwarfed in appearance. Secondary

curvatures are produced above and below the primary projection.

Gradually as the shape of the vertebral bodies and of the entire spinal

column changes the ribs are pressed more or less together, often being

made to overlap, the shape of the chest undergoes alterations, the

sternum sometimes being depressed and sometimes protruded, giving the

chest, in the latter case, the so-called “pigeon-breast” appearance.

=Loss of Function.=--There are but few disorders which produce more

pronounced and widespread accompaniments than spinal caries. As change

in the shape of the spine occurs and assumes a marked type we see

changes occurring through the body, not only in the direction of anemia

with general impairment of function, mental irritability, and cachexia,

but there occur trophic alterations as well. The shape of the face

changes, the expression assumed is one of anxiety, and the features

become less mobile.

=Complications and Sequels.=--Tuberculous meningitis, cerebral or

spinal, is the most dangerous and acute condition, while other

tuberculous complications may occur in various regions of the body.

In fatal cases meningitis, in consequence of acute or mixed septic

and terminal infection, furnishes the explanation for the great

majority. Paralysis is not infrequent as a sequel, assuming the type

of paraplegia and developing slowly. Motion is first impaired and a

considerable interval may elapse before sensation is affected. Motor

impairment varies from mere mild paresis to complete paralysis,

beginning as fatigue, loss of strength, and inability to stand.

Unless the disease be located in the lumbar region the reflexes are

exaggerated and muscle spasm is easily provoked or occurs without

perceptible cause. As above noted the muscles become atrophied, and

when the cord is seriously compromised are rigid in chronic spasm. The

rectum and the bladder suffer finally, especially in disease of the

lower segments. Occasionally in cases of high dorsal disease the arms

will suffer more or less motor impairment. Sensory paralysis begins

usually as paresthesia. In merely bedridden but not actually paralyzed

individuals the reflexes should be normal. Of the muscle contractures,

those of the psoas are the most common and distinctive. Paralysis

follows rather than precedes deformity, and is noted in perhaps 20 per

cent. of advanced cases. It should rarely occur if effectual treatment

has been begun.

=Abscess.=--Abscess is usually of the “cold” type. Its general

character has been previously described. It may be of the purely

tuberculous type, but is not infrequently the result of a secondary

pyogenic infection. It is a consequence of neglect, but cannot always

be prevented. Signs, both local and general, of the presence of pus

or of pyoid are noted here, as under other circumstances. There is

exaggeration of local tenderness, with development of tumor, which

fluctuates as it approaches the surface. General septic features,

proportional to the activity of the process and its location, accompany

the local indications. Sometimes it occurs insidiously and with but few

evidences.

Pus travels here in the direction of least resistance. The fascial

planes of the body are mostly so placed as to protect important body

cavities, consequently pus will travel usually around them and toward

the surface, burrowing long distances, for instance, from the lower

dorsal region to the groin along the psoas muscle. Cervical abscesses

usually spread anteriorly toward the pharynx (postpharyngeal) and

deeply into the thorax (mediastinal); they may open into the trachea

or esophagus or externally through an intercostal space; or they may

burrow laterally, opening behind the sternomastoid muscle. Dorsal

abscesses usually travel posteriorly, opening not far from the spine,

or they burrow downward and forward along the psoas so as to appear

beneath Poupart’s ligament. Lumbar abscesses escape through the psoas

sheath as psoas abscesses, so called, or between the fasciæ of the

spinal muscles and those of the abdomen to appear upon the side; they

may extend downward beneath the iliacus, escaping over the brim and

into the pelvis and then out through the sacrosciatic notch. Of all

these the psoas abscess, opening in the groin, is the most common. This

will in time destroy the muscle fibers of the psoas, but it leaves the

vessels and nerves intact, whose sheaths are much more resistant, and

which can be found passing through such a cavity like cords through a

chamber. This form of cold abscess, with its consequent bulging and

final escape in the groin, has been mistaken for hernia as well as for

abscess due to perinephritis and appendicitis. The most serious mistake

would be to take it for a femoral hernia. The customary routes of all

these collections of pyoid have been thus indicated. Nevertheless

abscesses may burrow and appear almost anywhere. They will give rise to

varying and to superadded symptoms, according to their location. For

example, retropharyngeal abscess may seriously threaten respiration

by pressure upon the upper air passages, while a collection of pus in

the mediastinum might cause serious respiratory difficulty of another

character.

_Cold abscesses_ of spinal origin may remain stationary, the fluid

portion of the pyoid material may even absorb, while the balance

undergoes more or less degeneration and conversion into inert material,

or they may slowly or rapidly increase in size. The best that can be

hoped in such cases is absorption, with encapsulation of the solid

residue. Even this may be a source of danger, as it is a focus of

lessened resistance, in or about which subsequent trouble may result.

Those abscesses which seem to remain stationary would best be let

alone, hoping for subsidence under good treatment. Those which open

spontaneously leave tuberculous fistulas behind them, which may

possibly close in time, but which lead often to subsequent acute

infection, and which are the _bête noir_ of surgeons, for it is often

impossible to heal them. The best that can be done in such instances

is to wash them out, keep them clean, and guard them from infection

from without. It is often possible to pass a tube along the sinus and

through this to irrigate with a solution of iodine, of formalin, or of

any other antiseptic which may be preferred. If anything be done with

them in the operative way it should be as radical as possible, seeking

the original lesion, thoroughly curetting its site and the whole

interior of the cavity, and making ample opening so as to provide for

effective drainage.

_Retropharyngeal abscesses_ usually necessitate evacuation because

of the obstruction which they cause within the pharynx. _Lumbar_ and

_psoas abscesses_ may be let alone. When this is not practicable,

then choice should be made between simple aspiration, aspiration with

washing or injection of some antiseptic fluid, and free opening with

radical treatment. In these cases we are to be guided by the peculiar

features and surroundings of each, and by our own facilities for such

work and for subsequent care of the case. An abscess which will soon

rupture should be opened and counterdrained; but in one where this is

not impending, and where home features are such that the patient can

receive no adequate or prolonged care, it would be wiser to abstain.

Under the best of circumstances in these cases it is always a difficult

problem to decide. Even aspiration leaves at least a needle track

to be subsequently infected, while the contents may be too thick to

flow through a small trocar. Aspiration with thorough washing out and

then with injection of emulsions of iodoform or of other irritating

antiseptics have found favor with only a part of the profession. If any

radical measure is to be adopted the greatest care should be given to

carry out the principles expressed in the general consideration of cold

abscesses. (See p. 114.)

=Diagnosis.=--Intelligent comprehension of signs and symptoms should

enable one to make a diagnosis in most cases. Nevertheless the surgeon

is occasionally in doubt and has to distinguish, for example, as

between Pott’s disease and sprain, lateral curvature, hysterical

spine, cancer, cord tumors, rheumatic arthritis, rickets, syphilis,

actinomycosis, hydatid disease, acute osteomyelitis, _i. e._,

non-tuberculous diseases, and certain abdominal affections followed by

suppuration, such, for example, as peri-appendicular abscess. Moreover,

spondylitis may be simulated in the course or as a complication of

typhoid, scarlatina, gonorrhea, and other acute infections. Psoas

abscess should be distinguished from perinephritic abscess as well

as from acute appendicitis, which often causes psoas contraction,

especially when the appendix is posteriorly placed and left in contact

with that muscle. We may also have to distinguish this condition from

sacro-iliac disease and from ordinary hip disease.

=Prognosis.=--In some degree prognosis depends on what is meant by a

cure. Absolute cure, with restoration to the original condition, is

exceedingly rare. Arrest of disease, with improvement of deformity, is

possible in cases seen early. Even considerable motion may be restored

under suitable treatment. In late cases hectic, amyloid degeneration,

and dissemination of the disease make the outlook very discouraging.

At best its relief is slow and in time it is always chronic, no matter

how rapid the onset, except in those instances where dissemination

occurs early and rapidly, in which case there is little or no hope. In

ordinary cases there is a certain tendency to spontaneous recovery, but

not without deformity and impairment of function, while obviously the

occurrence of abscess prolongs a case to a considerable degree.

=Treatment.=--Those general measures so necessary for the treatment of

any tuberculous lesion, namely, hypernutrition, fresh air, and general

constitutional measures, are needed here as in any other such disease.

Physiological rest, _i. e._, absolute rest in a bed without springs,

the patient lying flat on the back or on the face, and not on the side,

and lying quietly, constitutes the best part of local treatment. In

the case of children it is best to have a gaspipe frame, across which

cloth may be stretched, on which a fretful child can be secured by

straps across the shoulders, pelvis, and knees. This frame may be laid

upon the bed and lifted from it while a cross-piece is removed for

toilet purposes, or a suitable opening may be left if a single piece

of cloth be stretched across it. If the patient can be made to submit

to this repose, then a pad may be placed under the projection. After

a sufficient length of time, with the desired improvement, a plaster

shield may be molded to the back, with the patient lying upon his face;

and then, after removing and suitably trimming and lining this mold,

the patient can be returned in it to the previous position in bed, from

which he may gradually be raised. This is the best method to follow in

acute or severe cases, or when the disease is higher up in the spine.

It will also best serve the purpose when the case is complicated by

abscess. To it may be added, if necessary, traction upon the head (Fig.

255).

[Illustration: FIG. 255

Child in bed-frame, with head traction. (Lovett.)]

[Illustration: FIG. 256

Jury-mast for high dorsal and cervical caries. (Lovett.)]

=Treatment by Apparatus.=--The simplest of all apparatus is the plaster

jacket, or corset, which was brought into favor in this country

by Sayre, although not invented by him. It is usually applied in

suspension, _i. e._, with the patient in the erect position beneath

the frame, from which hangs a support by which firm traction can be

made, both upon the head and the arms or the shoulders. The intent of

such a jacket is to apply it with the patient so stretched out that

a certain degree of the projection will at least be eliminated and

the back made more nearly straight than it otherwise would be. In

cases where this is impossible it at least affords better expansion

of the thorax and supports the ribs in better relation to the spine,

affording more chest room. The plaster is not applied next to the skin,

but a thin undershirt or its equivalent of woven materials should be

applied, care being taken to see that it fits snugly and is not allowed

to fold in ridges. After the patient is completely suspended to a

degree where discomfort begins, then a small “stomach pad” is slipped

beneath the under-jacket, in front, in order that more room may be

given for enlargement of the abdomen after a full meal. Finally with

the first turns of the plaster a strip of tin or a couple of strips of

moistened pasteboard should be applied directly over the middle line

in front and incorporated in the successive turns of bandage, in order

that there may be material there which may be cut down in removing the

jacket. Small pads should be placed over the iliac crests and over the

protrusion if it be at all marked or tender. Now by the use of a series

of bandages of gauze, in which reliable plaster of Paris has been

incorporated, the entire trunk is enclosed within a corset, which will

quickly harden as the plaster becomes firm. It should extend well down

over the pelvis and nearly to the trochanters, since from this portion

it takes its fixed support. It should then be extended as high as can

be permitted under the arms and higher yet over the chest and back.

Enough material should be used along with the plaster-of-Paris cream,

as the former is applied, to ensure sufficient firmness and strength.

If the plaster be reliable it will not be necessary to keep the patient

suspended more than a few moments after the completion of the jacket.

The finishing touches may be given it after he has been taken from the

frame and placed again upon a soft surface.

Another method of application is to have the patient recumbent and

properly supported, and this is particularly necessary in acute cases,

where suspension is likely to cause faintness or unpleasant symptoms.

In this attitude the spine is really put in better position. The method

is not at all available in those few cases of lateral curvature which

demand jackets (Fig. 256).

Substitutes for these jackets are made of various materials, such as

leather, rawhide, aluminum, thin strips of veneering, celluloid, paper,

glue, etc. These have to be constructed over a mold which is taken

from a plaster jacket. When the disease extends above the level of the

fifth dorsal vertebra there should be incorporated within the jacket a

support for the head, known since Sayre’s time as a “jury-mast.” This

consists of a metal upright, with cross-pieces, which are incorporated

with the jacket and which is curved up behind and over the head and

made to carry the frame from which the leather straps and supports pass

beneath the occiput and the chin, and thus give to the head a certain

amount of fixation. The support is so arranged as to permit of sliding

and of sufficient expansion so that traction upon the head can be made

effective.

[Illustration: FIG. 257

Frame for application of plaster jackets in recumbent position.

(Lovett.)]

Fig. 255 shows the application of traction to the head, while Fig.

256 illustrates one form of apparatus by which the jury-mast is made

effective in producing traction on the head in the upright position.

Figs. 257 and 258 show a convenient frame and method for making

plaster-of-Paris corsets with the patient in the recumbent position.

Figs. 259 and 260 show another form of apparatus intended for the same

purpose.

[Illustration: FIG. 258

Application of a plaster jacket in the recumbent position. (Lovett.)]

The variety of apparatus which has been devised for the maintenance of

rigidity and correction of deformity, and, in suitable cases, traction

upon the head, is to be measured almost by the number of orthopedic

specialists, nearly every surgeon inclining to some device or at least

modification of his own. Judson probably has formulated the best

rule covering the entire matter when he says: “The apparatus may be

considered as having reached the limit of its efficiency if it makes

the greatest possible pressure upon the projection compatible with

the comfort and integrity of the skin. It is essential that the brace

is efficient; second, that it is one that can be constantly worn, if

necessary, or can be easily detached from the body if not to be worn

at night.” Certain ambulant cases can be treated by an effective brace

through the day, and rest at night upon a reasonably hard mattress,

with traction upon the head. Concerning the multitude of these special

aids to treatment it hardly seems worth while to go into any elaborate

description in this place, inasmuch as one who is incompetent to judge

as to what is best should not retain the management of such a case,

while one who is really competent will probably desire to make his

own selection, and the writer’s recommendation would count for but

little. Every case must be a law to itself, and every special brace

must be constructed especially for the individual for whom it is meant;

otherwise it loses all its serviceability.

=Forcible Reduction.=--The feasibility and propriety of forcibly

reducing the deformities due to spinal caries was first suggested by

Chipault, of Paris, who suggested wiring the spinous processes of

the affected vertebra, and then, by Calot, who, in 1896, described a

method of forcible reduction under an anesthetic. The first to actually

wire the spine under these circumstances was Hadra, of Texas, who had

actually done the operation four years before Chipault. The method

has probably less to commend it in actual practice than in theory,

and, attractive as it may be in respect to time and completeness

of reduction, it is often followed by serious accidents, such as

hemorrhage, rupture of abscess, fracture of the spine, etc. Bradford,

in 1899, collected 610 cases performed by 29 different operators, with

a record of 21 immediate deaths from local trauma and 15 cases in which

there were at least alarming immediate symptoms. Of 229 of these cases

complete correction was effected in 119, incomplete in 94, while no

gain whatever was made in 16. Of results reported later, 66 showed some

gain, there was no relapse in 17, while 49 showed more or less return

of deformity. The claim has been made that the more or less wide gaps

or bony defects which may result from forcible manipulation are filled

in by new bone, but there do not seem to be any observations to confirm

this statement. The amount of force which must be employed is a matter

for the finest discrimination. The method includes complete anesthesia,

traction upon the spine in each direction from the location of the

deformity, and direct pressure force applied to the protection itself,

as by a sling passed around the body and just beneath the projection,

which can be used as a fulcrum upon which the rest of the spine can be

applied as a double lever, with the application, at first, of gentle

force, and, finally, sufficient to either satisfy the operator that

he should go no farther or that the desired effect has been obtained.

Immediately after completion of the maneuver a snugly fitting plaster

jacket should be applied and the patient kept absolutely at rest in bed.

[Illustration: FIG. 259

Anteroposterior support: back view. (Lovett.)]

[Illustration: FIG. 260

Anteroposterior support with head-ring for high dorsal caries: side

view. (Lovett.)]

The method seems most applicable in the presence of paralysis, even of

long standing, and this feature has often been relieved.

_Psoas contraction_ is best treated by traction, with the patient in

bed, and with the maximum of weight and power applied which can be

tolerated by the individual. If this seem impracticable, then the

patient should be anesthetized and force applied until it is evident

that more harm than good results. Should this harm appear, then open

division of the tissues may be practised. Finally, as a last resort, in

intractable cases, a subtrochanteric osteotomy may be made.

_Pressure paralysis_ necessitates _operative relief_. This may be

practised late and should consist of a laminectomy and exposure of the

area compromised by bone pressure or that produced by pachymeningitis.

The operation is done in the same way as for fracture, and will be

described in the chapter on Surgery of the Spine.

Finally of all cases of Pott’s disease it may be said that each should

be studied by itself, and for each a suitable method or apparatus

devised, rather than to endeavor to apply indiscriminately unchangeable

methods or forms of apparatus. Every apparatus has its disadvantages as

well as its benefits. The more acute the case the more is absolute rest

in bed, with traction, demanded. This is particularly true of disease

in the upper spine. On the other hand, the more chronic and the lower

the disease the easier it is to handle, and with such simple expedients

as plaster corsets. When the sacral region is rigid, however,

recumbency is usually necessary, because of the difficulty in securing

adequate fixation within any apparatus that can be worn. The necessity

for general constitutional, dietetic, and climatic treatment should

never be forgotten, and the danger of possible acute dissemination kept

ever in mind. This is particularly imminent when too much freedom is

allowed. Time, patience, and discernment are the dominating factors

beyond the general principles already inculcated.

SACRO-ILIAC DISEASE.

Under this name is included a tuberculous condition of the bony tissues

on either side of the sacro-iliac synchondrosis, or of the cartilage

itself, similar to that which produces the special caries described

above. It is an uncommon expression of tuberculous disease occurring

often in the young, identical in pathology with other tuberculous

bone lesions, and giving rise to peculiar symptoms, mainly because of

its location. Early in the course of the disease these may consist of

mild discomfort in the lower abdomen, irritability of the bladder and

bowels, disinclination for exercise, while, as the disease becomes

more pronounced, there will be actual pain, intensified by standing,

relieved by lying down, often severe at night, usually referred

along the course of the sciatics. A most significant symptom is the

tenderness and complaint produced by firm pressure made upon both

sides of the pelvis, thus forcing tender surfaces against each other.

In the later stages of the disease abscess may develop and present

either externally in the lumbar region or internally, breaking into the

pelvis and appearing perhaps in the groin or close to the perineum. The

disease is usually unilateral, and will cause characteristic limping

and aggravated pain upon standing on the limb of the affected side.

Naturally this limb will be spared in every possible way. It is likely

to be mistaken for sciatica or lumbago, in neither of which diseases is

there any tenderness at the sacro-iliac joint such as can be evoked by

pressure from the sides of the pelvis. It also has to be distinguished

from hip disease by the fact that motions at the nip are not interfered

with, and from Pott’s disease of the lower spine, which usually causes

prominence of the spinal processes and local tenderness in a different

region.

The surfaces and tissues involved are extensive and the disease is

always serious. It is one of the most chronic of all such affections,

and too often tends to suppuration, with its slow but inevitable

consequences, or to dissemination. Thus of 38 cases with abscess

reported by Van Hook only 3 recovered.

=Treatment.=--Treatment should consist of absolute rest, with traction,

so long as the symptoms are active, and avoidance of all irritation

when patients rise from bed. Abscess due to sacro-iliac disease

should be radically attacked, especially if this can be done early.

Intrapelvic pus collections may require trephining of the pelvic walls

or resection of some portion of the ilium, by which complete evacuation

may be made and drainage be amply provided. When the joint itself is

thoroughly broken down the case will have a hopeless aspect.

CARIES OF THE HIP.

_Hip-joint disease_, or, as it is often called, _coxitis_ or _morbus

coxæ_, is worthy of special consideration on account of its frequency,

its importance, and the deformities which result from its existence.

The most frequent site of the disease, which is of the usual type of

tuberculous ostitis or osteomyelitis, is on the femoral side of the

joint, usually in or near the head of the bone. In a small proportion

of cases the first lesions appear upon the acetabular aspect of the

joint, while in some cases the primary tuberculous lesion is of the

type of a tuberculous synovitis. (See chapters on Bones and Joints.)

In addition to those changes already described in previous chapters

there occur certain distinctive alterations about the hip-joint which

are worthy of note. On the pelvic side the margins of the acetabulum

occasionally become softened, and naturally yielding in the direction

of pressure as the result of muscle pull upon the thigh toward the

pelvis, cause, first, an elongation of the originally merely circular

cavity, and, finally, considerable shifting of position, often referred

to as _migration of the acetabulum_. Thus the head of the bone may

be found in a socket thus formed on a level one inch higher than on

the well side. So also perforation of the acetabulum may occur, with

perhaps final escape of the head of the bone into the pelvic cavity.

On the other hand, similar changes produce decapitation or marked

alterations of shape in the head and neck of the femur.

=Symptoms.=--When the symptoms and signs of tuberculous disease in this

location are studied in accordance with what has already been stated in

general about caries of the joint ends of the long bones, we have among

the most significant features:

1. =Pain.=--This is referred most commonly to the knee because of

the relations of the obturator nerve to the hip-joint and to the

region of the knee. Pain may also be radiated in other directions,

but the complaints made of pain in the knee are classical. Pain is

not, however, a pathognomonic feature and may be almost wanting, but

the evidences of tenderness, if not of pain, are invariably seen in

the unconscious protection of the joint afforded by muscle spasm. It

is perhaps in hip-joint disease that night pains and cries are most

frequently heard.

2. =Muscle Spasm.=--Fixation of the affected joint is always noted.

It begins as a limitation of motion, naturally first noticed in the

extremes of rotation, flexion, and extension, and is perhaps the most

important early sign of the disease. It furnishes the explanation

for the subsequent postural features, as well as an index regarding

the gravity and extent of the morbid process. It may be seen even in

the lower spinal muscles, where it is detected by laying the patient

upon the face, lifting first one leg and then the other, noting the

freedom of hyperextension; in fact, this spinal muscular involvement

is sometimes so marked as to give rise to the suspicion of low Pott’s

disease, from which it is to be distinguished by the fact that the

spasm affects one side rather than both.

3. =Muscle Atrophy.=--This involves in time all the muscles concerned

about the hip. It begins early, but may not be very pronounced until

quite late. It can usually be determined by measurement if not apparent

upon inspection and palpation. There will also be noted more or less

obliteration of the gluteal crease or fold.

The three cardinal features--pain, spasm, and atrophy--having been

thus considered, we can better appreciate the characteristic gait

and postures peculiar to this disease. Limping is an early feature,

sometimes insidious at first, sometimes abrupt. Patients will avoid

coming down quickly upon the heel, while they walk with the knee

slightly flexed, in order to give more spring. Stiffness is most

apparent on rising from bed in the morning, while the limp is more

pronounced at night, and it is at this stage especially that night

cries are most frequent. To mere limping succeeds actual lameness with

more constant pain. Muscle spasm now leads to malpositions, no one of

which is necessarily first to appear, and any of which may occur with

others in various combinations, although flexion and adduction are

usually the first to be seen, the patient unconsciously assuming that

position which happens to give him most relief.

It is important to realize that a marked degree of adduction will cause

apparent shortening, and of abduction apparent lengthening, and it

is very important to demonstrate that these variations in length are

apparent and not actual. This is to be done by placing the patient upon

a hard surface with the pelvis at right angles to the spine and the

limbs in absolutely symmetrical position. If there be adduction it may

mean that the limbs should be crossed; while if there is abduction the

healthy limb should be abducted to the same degree as the one affected.

Careful measurement will show that the differences are apparent

rather than real. The same care is needed in regard to rotation, and

particularly in regard to psoas contraction which leads to flexion.

One of the most characteristic evidences of hip-joint disease is

flexion of the thigh, which, when the thigh is brought down to the

proper level, will cause an arching upward of the lumbosacral region.

By this time also will be found well-marked limitations of motion in

every direction. All of these features should be ascertained without an

anesthetic, as they depend upon muscle spasm, which anesthesia would

subdue. It is somewhat difficult with intractable young children to

make a thorough examination of this kind, but a second or third effort

will usually succeed when the first has failed.

Peri-articular symptoms affording corroboration are found in thickening

of the tissues about the joint, especially enlargement of the upper

end of the femur, or increase in thickness of the pelvis, which may

perhaps be felt from the outside or be detected by rectal examination.

There is usually involvement of the inguinal lymph nodes, and there is

frequently prominence of the superficial veins, due to infiltration of

the deeper tissues and obstruction to the return circulation. A good

skiagram will also render much aid.

As the disease progresses there will appear evidences of deep

suppuration, as abscess is frequent in the advanced stages. This may be

peri-articular or may connect with the joint. It may cause separation

of the epiphyses of the femoral neck and complete loosening of the

head of the femur, which will then become a foreign body in a joint

cavity probably filled with pus. Perforation of the acetabulum may also

occur. Much of this abscess formation goes on insidiously and without

marked increase of symptoms. There is no fixed date when pus may begin

to form. It may occur relatively early or late. It is possible for

small amounts of pus to absorb in whole or in part, or to leave a

residue more or less encapsulated, which will frequently lead later to

a secondary abscess, the latter tending to burrow along between the

fascial planes or muscle sheaths and appear at some distance from its

origin. Pelvic abscesses result from perforation of the acetabulum and

may break internally or externally. Nearly all of these collections are

of the cold type, and after a long time, if they have opened, may cease

to discharge characteristic pus or even pyoid, and simply give vent to

a watery seropus. Pus left to itself usually escapes anteriorly to the

tensor vaginæ femoris, but it may travel in any direction.

The _deformities_ and possibilities which may result from the advanced

stage of hip disease are striking. Persistent muscle spasm leads to

more and more flexure of the thigh, with abduction or adduction, as

the case may be, while later the leg is drawn up so that the knee may

almost touch the abdomen. As the bony portions of the joint change

their shape there occur actual shortening and final dislocation, while

all the adjoining parts show the effect of muscle atrophy and perverted

nutrition. In addition to this the region of the hip may be riddled

with abscesses or with sinuses, and the condition in every respect made

extremely distressing.

While the disease is generally confined to one side, it may occur

in both hip-joints, in which it, however, very rarely begins

simultaneously. Existence of double joint disease of this character

makes the case more than usually troublesome and complicates it

seriously in every respect. The writer has been compelled to make

double simultaneous resection of both hips.

=Diagnosis.=--This has usually to be made from congenital dislocation,

hysterical joint, infantile paralysis, non-tuberculous disease--such as

synovitis, bursitis, etc.--acute osteomyelitis of the upper end of the

femur, Pott’s disease in the lumbar region, and sacro-iliac disease, as

well as from perinephritic abscess and appendicitis.

=Prognosis.=--Hip-joint disease usually tends toward recovery, but

generally with more or less deformity. When the circumstances are not

favorable, ankylosis, with or without deformity, is inevitable, while

abscesses, with persistent fistulæ, are not uncommon, and one may in

extreme cases witness death from general tuberculous dissemination or

from the consequences of hectic, with amyloid degeneration, or from

acute septic infection.

One may naturally ask what may be considered as constituting recovery.

In cases of this kind an absolute cessation of all symptoms and

indications of the disease, with a minimum of deformity and of

limitation of motion, are the nearest approach to ideal recovery

that can be expected to secure. In favorable cases, seen early and

properly treated for a sufficient time, there may be achieved almost

a restitution _ad integram_, but such an ideal is seldom attained;

otherwise there is nearly always more or less limitation of motion,

with very frequent pseudo-ankylosis or actual ankylosis. Even this is

favorable and most anything may be considered so which falls short of

actual suppuration.

=Treatment.=--The essential in the early treatment of hip disease is

_traction_, so applied and regulated as to be effective. It should not

be thought that by such traction as can be tolerated joint surfaces

are actually pulled apart. What it really accomplishes is to tire out

muscles which are in a condition of clonic spasm, overcoming thereby

the deformity which they produce and thus permitting a reduction of

their activity and of the harm which they have done. To do even this

requires a considerable degree of traction, especially when muscle

spasm is very prominent. Therefore it is best in pronounced cases of

deformity to place patients in bed, and to apply traction by weight and

pulley to a degree which actually overcomes the defects which we are

combating. This will often require more weight than many men are in the

habit of using. It should now be a question, not of amount of weight,

but of effect, and of the easiest and best way of bringing this about.

Physicians are very likely to use too small an amount of weight, and

to neglect the use of counterextension and the benefit of more or less

lateral traction, as well as that in direct line of the limb. Moreover,

they often use inadequate means of applying traction, resorting to

it only in such manner that traction is made at the knee and not at

the hip. Even in young children it is often necessary to use twenty

pounds, with a suitable traction apparatus, and four or five pounds for

effective lateral traction.

_Traction should be maintained_ until deformity has been overcome or

the effort shown to be impracticable. After its complete benefit has

been obtained it should be followed by fixation, the ideal method

being that which accomplishes both fixation and traction at the same

time; as, for instance, by the so-called Thomas splint, which permits

the patient to be up and about with the use of crutches and a high

shoe beneath the well limb, in order that the diseased limb may not be

permitted to touch the floor, but rather to hang, and by its own weight

afford a certain degree of traction. The Thomas splint is the simplest

and cheapest for hospital work, while modifications in more elegant and

expensive form are illustrated in works on orthopedic surgery. In cases

which seem to demand it fixation can be effected by a plaster-of-Paris

spica put on while the patient is standing upon the well limb and upon

an elevation. The character of this work affords space neither for more

elaborate description nor illustration than the hints embraced in the

foregoing paragraphs.

The surgeon as such is perhaps the more concerned in the _treatment

of abscesses_ which frequently complicate these cases. Much that

has been already said about psoas abscess will apply here. It is a

question requiring considerable discrimination as to just how to

treat a small, cold abscess about a diseased hip. Much will depend

upon the environment of the patient, _i. e._, upon the attention and

expert care which he may receive. Such abscess should be treated

kindly, _i. e._, by nothing more severe than aspiration, until ready

for more radical treatment. By the latter term is meant readiness for

following it down to the joint cavity and exsecting the head of the

bone, if need be, following this with extirpation of the capsule,

etc. When there is actual pyarthrosis the condition of the patient

is sufficiently serious to warrant radical measures. Extra-articular

abscesses are apparently quite common, yet most of these, if carefully

traced, will be found to lead through the periosteum at some point

into the osseous structure beneath. Such abscesses are, moreover,

multilocular, and have ramifications in even unsuspected directions

which should be followed with the sharp spoon and the caustic, in

order that absorbents may be seared and that no infectious material

remain. Old and persistent fistulas should also be treated kindly

until one is ready to be radical. Some long-standing cases will heal

after absolute physiological rest of the joint, _i. e._, by fixation

in plaster-of-Paris splint, with openings opposite the fistulas for

dressing purposes. The general constitutional condition of patients

with these lesions is a predominating factor in their improvement--a

fact which should never be forgotten.

The deformity which has resulted from old, long-standing, and quiescent

hip disease affords opportunity for the best of surgical judgment. It

is possible to effect great improvement in position by subcutaneous

osteotomy after ankylosis, but this should not be attempted during the

active stages of the disease.

_The question of excision of the hip-joint is one of importance._

In few other instances do social surroundings or factors enter so

largely into the question of surgical judgment. The wealthy can afford

long-continued treatment, which to the poor is prohibited, and one may

be tempted in one case to exsect early when, under other conditions,

he would treat the case tentatively. Nevertheless certain indications

make the operation expedient in all cases, as, for instance, when the

destructive process is steadily progressing or so acute as to shorten

not only the limb but life itself. It is necessary also when there

is necrosis, and in most instances of suppuration extending into the

joint cavity. In those cases where skiagrams confirm other indications

to the effect that the disease is localized in the neck or head of

the femur, Huntington’s suggestion may be adopted, after exposing the

upper end of the femur, to drill or tunnel in the direction of the neck

until its diseased focus is reached and thoroughly clean it out. In

cases treated otherwise conservatively, yet accompanied by a great deal

of pain, especially those of the femoral side of the joint, one may

frequently get relief by exposing the upper end of the femur and making

ignipuncture in the same direction as above.

_In general it is impossible to lay down succinct rules for the

treatment of hip disease._ Cases differ so greatly in location, in

severity, as well as in environment and their personal surroundings,

that what is advisable in one case is not to be thought of in another.

Of the mechanical features of treatment one may say that that is the

best splint or apparatus which best meets the indication in each

particular case, and that none will be effective in which the element

of traction is neglected, nor that of physiological rest. No patient

should be released from treatment whose hip is still sensitive or in

whom there remains any muscle spasm. Rest and protection should be

maintained for months and even years after apparent recovery, while the

same attention should be given to diet and climatic surroundings as in

any other case of well-marked tuberculous disease.

TUBERCULOUS DISEASE OF THE KNEE-JOINT; TUMOR ALBUS.

This subject deserves special consideration, mainly because of

the peculiar deformity produced by the disease rather than any of

distinctive peculiarity in its nature. Years ago it received the

name of _tumor albus_, and is frequently called _white swelling_ by

the laity, because of the pallor of the surface and the increased

dimensions of the limb due to thickening, always of soft parts, and

usually of the bone itself. The disease may begin in either epiphysis,

in the patella, or in the synovial membrane, oftener in the bone in the

young and in the synovia in adult cases. Its most distinctive feature

is the deformity produced by excess of muscle spasm, the hamstring

muscles especially producing a backward subluxation which frequently

fixes the knee, not only at a right angle, but with very much disturbed

joint relations, so that the head of the tibia is in contact with the

posterior surface of the condyle rather than with their proper terminal

areas. The soft tissues outside of the bone are frequently very much

thickened and infiltrated, often edematous, while the joint cavity may

be more or less distended with seropus or with old pyoid material. The

exterior surface is so anemic from deficient blood supply as to make it

appear comparatively white, while the superficial veins are made much

more prominent by their engorgement owing to obstruction of the deep

circulation. The picture, then, of an advanced case of tumor albus is

quite typical.

Here the joint cavity is so large that there is early effusion of

fluid, in most cases, which is in this location easily recognizable;

hence the distinctive symptoms consist of pain, tenderness, swelling,

limp muscle spasm, with, finally, limitation of motion, deformity,

and atrophy. In addition to these features there may be added those

due to the formation and the escape of pus, _i. e._, one may have the

signs of acute or old suppuration, while the parts about the joint may

be riddled with old sinuses. The deformity of these cases is usually

characterized by a certain amount of external rotation of the leg,

while a species of knock-knee is not uncommon. Actual lengthening of

the limb due to overactivity at the epiphyseal junctions may also be

noted.

=Treatment.=--_The treatment of white swelling_ is based upon the

principles already laid down for the treatment of spinal and hip

caries, the underlying feature being traction to a degree sufficient to

overcome muscle spasm, unless it be too late to permit a subsidence of

active changes. When seen early a few weeks of confinement in bed, with

effective traction, followed by fixation with plaster-of-Paris bandage,

combined with the Thomas splint (see above) or with some other form of

more elaborate apparatus, by which rest and traction can be continually

maintained, will be needed. The presence of tuberculous disease about

the knee permits of the application of the elastic bandage above the

knee, by which the congestion treatment of Bier can be more or less

effectually carried out. It would, however, be a mistake to rely

entirely upon this to the neglect of traction and rest, nor should too

much be expected of it in severe cases. It is a method to be used early

rather than late.

_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.

[Illustration: PLATE XXXVIII

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.