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INDISPENSABLE ORTHOPAEDICS
A HANDBOOK FOR PRACTITIONERS
BY
F. C A LOT
CHIEF SURGEON TO THE HOPITAL ROTHSCHILD, HOPITAL CAZIN,
HOPITAL DU DEPARTEMENT DE b'OISE, INSTITUT
ORTHOPEDIQUE DE BERCK, ETC.
TRANSLATED FROM THE SIXTH FRENCH EDITION
BY
A. H. ROBINSON, M. D., M.R.C.S.
AND
LOUIS NICOLE
ILLUSTRATED
VOL. II
ST. LOUIS
C. V. MOSBY COMPANY
1916
\X)L. 11
AlillllXJKI) I \r>LK or (ON I KN IS
2nd Part : — Acquired non=tuberculous affections.
Chap. VIII. Scoliosis of adolescents ^^"i
— IX. KouiKl back and lordosis 60:i
— X. Rickets. Rickety deviations 608
— XI. Genu valgum or varum of the adolescent. Coxa
vara 640
— XII. Tarsalgia or painful flat-foot 645
— XIII. Infantile paralysis and its deviations .... 660
3rd Part : — Congenital orthopaedic affections.
Ch.jlI'. XIV. Congenital luxation of the hip-joint .... 711
— XV. Congenital club-foot 820
— XVI. Torticollis 846
XVII. Little's disease 863
4th Part : — or Appendix.
CuAP. XVIII. Cervical adenitis 881
. — XIX. Other external tuberculoses ( cold abcess, osteitis, synovitis, spina ventosa, tuberculosis of the testis and epi- didymis, tuberculosis of the skin) 908
— XX. Multiple tuberculosis 934
— XXI. Syphilis of the bones and articulations . . . 941 -^ XXII. Treatment of acute and chronic osteomyelitis . 952
— XXIII. Practical diagnosis of osteitis or of chronic ar-
thritis 969
— XXTV. Some malformations of the hand and fingers . 974
— XXV. Some malformations of the foot and toes . . 981
— XXVI. Additional notes on tuberculosis, fistulae, frac-
tures of the neck of the femur, coxa vara, etc. 992
SECOM) ivvirr
ACdlJlUEU DKVIATIONS, M)^ TlJIiEIUllJiLS
CHAPTER Mil
SCOLIOSIS
Amongst tlic oilliopoedic alVeclions, scoliosis is, I believe, that which most embarrasses the praclitionor.
In the presence of the multiple and diverse Ibeories held by authors as to the nature of this malady, he docs not know what to believe : among the diflcrent treatments proposed, he does not know which he must choose, and if he choose one. he does not know exactly in what wav to appl\ it, in order to reap some benefit, in the end he does nothing.
I call it doing nothing, and avoiding doing anything, ^\hen he confines himself to prescribing strengthening wines, and furnishmg the address of a manufacturer who will make some kind of corset, and thus free himself from all responsibilitv.
How disastrous to the patient is this inertia of the practitioner who sees tlie scoliosis from the onset, from the moment when it is yet
so slight!
And how annoying it must be to the practitioner himself, who will be held in poor esteem by the parents, when they see their child become more and more deformed without anything being done to prevent it.
I would like to react against this tendency and to persuade prac- titioners that they are able, and ought henceforth, to assume a diffe- rent position with regard to the " essential scoliosis of adoles- cence ". Thev must look the malady in the face, frankly, bravely, and deal with it with the same confidence they deal with the other orthopaedic affections. They will triumph over this malady as well, if thev know how to track it from its earliest hour, and apply to it without delay the treatment we are going to describe.
568 THE ESSENTIAL SCOLIOSIS OF ADOLESCENTS
In this description I have endeavoured to he explicit, practical and useful. Havingmadcuse of all the treatments, I Avill describe, without any hiassed opinion, that which appears to me the best. But, before- hand, I ought to point out the means of tracing scoliosis from the beginning.
Diagnosis. — I shall deal, in this chapter, only with the essential scoliosis of adolescents, or common scoliosis ^ It is easy to recog- nise the existence of the condition from its onset. There is brought to you an adolescent, nearly always a young girl, whose parents tell you she has held herself badly for some time, in spite of their re- marking upon it, or the mother has noticed in undressing her — more often it is the dress maker or the stay maker who has made the remark — that the child has one shoulder a little larger than the other, or one hip projecting. This has been a revelation to the parents, who had had no suspicion of any deformity up to that time. It must be growth, the parents hasten to add, for the child has shot up very quickly, too quickly : that has fatigued her.
In fact, you see a young girl of from 12 to i4 years of age, rather emaciated, a little anaemic, somewhat flabby and easily tired, cata- menia not yet appeared, or if so, irregular.
When a child is placed before you Avith these appearances, you think at once of the existence of scoliosis. You must ascertain this at once by proceeding to an examination of the vertebral column, the entire back being uncovered. Whilst the mother is undres- sing her (which always takes some time) you interrogate her as to the hereditary or personal antecedents of the child.
I. 36 varieties of Scoliosis have been described; the essential or " habi- tual ", the rachitic, the constitutional, the static, the neuro-patliic, etc. One can reduce all these varieties to the three following :
i". The scoliosis of adolescence, of which we are now speaking.
a'"^. Rachitic scoliosis — that Avhich begins at, or rather is recognised at 3 years, 5 years, 8 years. — It is distinguished by important characteris- tics, and by its very grave prognosis : it will be studied in the chapter : Rachitic deformities, Chap. x.
3''^. Symptomatic scoliosis, which includes :
a). Static scoliosis, that is symptomatic of an inequality of the lower limbs (coxitis, congenital luxation of the hip, infantile paralysis, etc.) in which cases one must treat the maladies, or compensate the inequality of the limbs with a boot;
b). Symptomatic scoliosis, symptomatic of some other affection altogether (and these casual affections are very numerous) ; empyema, thoracic affections, hemiplegia, the contractions of torti-coUis, etc.
I)1\(.\(ISIS Ol' SCOI.IIIMS Vr IIS COMMl.MJ.MI.M
,j(i(j
Soiiu'tiiiu's llic iMollicr doclaies llicir was an auiil. or a j^iaiul- iiiolliiT. ^\ll() had a didonnilv of licr spinal coliiiiin. Soinclimcs llio inollicr Iclls \ou nolliiiiu; bul linown li-iu-c, lier rallKM- round hack, h(M' uno([nal slionldcrs. speak lor lui'-
As lo personal .uilcccdrnis, never oniil lo enquire how llio cliild has hoeii hrought up. \ou will -enerallv learn that she Jias hecn hollle-l'ed, or hv a series of indiU'erenl or nianifcslly bad nurses. Eiupiire if she has had dijrestive trouble, because in these children repealed enteritis is nearl> always the rule, also constipation w ilh a large abdo- men and offensive stools. Make a note of previous debilitalini^- diseases, such as wliooping coui;b, broncho-[)nennionia, ern|)live fevers, etc.
lleinendiering that scoliosis is the " school disease " (the bad [)osition of- ten brought aliout at scbool, or discove- red there), iulbrm yourself of the num- ber of the child's class hours and of her attitude in writing.
But now she is undressed, the back in full view , in front of you, the arms close to the body. You tell her to fix her eyes straight before her, on some point you indicate.
Fig. Gob. — Scoliosis. convex curve on tlie ri
Single it side.
On looking at her back, vou are struck by the difference in height of (he two shoulders, bv the absence of symmetry of the two scapulae (one is much near- er the middle line than the other), bv the projection of one of the hips, and by the difference of the two triangles ^vhich the arms form Avitli the corresponding side of the trunk and the pelvis. These signs seem lo gro^v — if you leave the girl for a lime upright.
This strikes one often more than a deviation in the line of the spinous processes; a deviation which is, in fact, ^^h '^ I'l^le or not at all apparent. To reveal it, vou trace the line of the spinous processes with a crayon, or more simplv, by pressing Avitli your index finger over all the processes from above doAvnwards. A rather vigorous pressure in this wav and repealed two or three times, leaves a red line which gives vou the line of the spine, and you easily recognise that
570
SCOLIOSIS.
UIFFEREXTIAL DIAGNOSIS
/
\
the line is no longer rectilinear, but that it describes a curve
towards the right or tOAvards the left, sometimes opposite the lumbar, more often opposite the dorsal region (fig. 6o5).
Make the child bend forAvards, the arms hanging: in this posi- tion you Avill see the deviation of the processes become obliterated, but then there will appear a slight arching of the ribs on the convex side of the dorsal spine (fig. 606).
Your diagnosis of Scoliosis is made.
Nevertheless, you examine the chest, which may be already a little (very little) asymmetrical; percuss and palpate the abdomen to judge of the general condition of nutrition : do not forget to ascertain there are no ocular troubles^ or adenoids, or inequality of the legs (mea- sure very carefully, see fig. 892).
Differential Diagnosis of Scoliosis. a. Normal back : the positive charac- ters of scoliosis indicated above are wanting here (line of shoulders, projection of hips, brachial triangle, deviated line of spinous processes) .
6. Pott's Disease (see Chap. v). The curve of Pott's disease is median (and not lateral) ; it is not a long curve (as in scoliosis) but an acute projection, a spinous process fallen out of the rank. More than that, in Pott's disease there is pain on pressure ning itself, the asymmetry over One or several spines ; there is a rigi- produced by the arching of ^. ^ marked stiffness of the back : the
the ribs on the convex side.
two shoulders, the two hips, the two la- teral triangles are symmetrical, at least when the disease is not in an advanced stage, in which case the lateral inclinations may be superadded to the original inflexion : but at this period of Pott's disease no comparison is possible.
Such is the almost constant rule. Nevertheless, there exists, in children in indifferent general condition, scolioses with very slight lateral deviation and even slight pain on pressure over a spinous pro- cess : where there is a meeting point of two lateral curves, superim- posed; sometimes such process makes a slight projection (v. Chap. v).
Ascertain the existence of these lateral deviations, more or less dis- tinct above and below the sensitive point : make sure that the move-
Fig. 606. — Make the patient bend forwards, the arms hansfing : one sees, out'.i-
I'lUXiNOSIS or SCOLIOSIS.
I Mill iii;r;f\i;ns OF scoliosis 5- i
monis nl lli(> spine are IVcc, and llial llic nidlian projcclion isalmosl nolliinn and llic pflin scarcely apprcciahlc, and thai will cnahJc nou, in these difficult, but fortunately rare cases, t<i make a diagnosis. In donliUnl cases, make mi positive slalcinenl, ask to sec llie child aijain : (he diagnosis will rapidly heconie certain, hy the development of the disease.
Il is necessary to yuard youayainst Iwo prejudices.
Projjnosis. — .i .^ ..v^vco... , ^.^. ^ opposcci and contradictory to one ano- ther, e(piall\ unreasonable, sinister and of old slandiny. The first is that scolio- sis always cures itself. The other, con- trary one, is that scoliosis is never cured.
Scoliosis does not become cured spontaneously; or rather, spontaneous cure is so exceptional tliat it would be foolish to depend upon il and to abstain from undertaking treatment. If, in children of very good general nutrition, j)articularlv boys, one may have seen scoliosis in an early stage, once in a hun- dred times, arrested of Itself, that may not do a\yav with the necessity of actiyc therapeutics. On the contrary, if there arc found at the other end of the scale and in opposite conditions, children who are pale, breathless, rachitic, languid, with grave hereditary defects, in whom the scoliosis is of a malignant form and with a tendency, almost inAincible, to become aiigravated Avhatever one may
CO
do, the case is just as rare and exceptional, in essential scoliosis at least, and we ought not to take it into account. It is not upon yery rare exceptions that a line of conduct can be based.
One may say, and vou ought to remember it. that the future of your scoliosis will depend upon the period at which you have commenced the treatment, and upon the way in which vou have carried il out.
Three degrees. — One has distinguished three periods in scoliosis when left to itself :
i/'' degree. — Scoliosis with a single curve, to ihc right or lefl, dorsal or lumbar, of recent date (tig. Go5 and Go6).
Fig. O07. — Scoliosis with a double dorsal curve on the right and a lumbar one on the left.
572 SCOLIOSIS OF ADOLESCENTS. ITS TREATMENT
2"*^ degree. — Two curves in opposite directions : generally a convex dorsal one on the right and a lumhar convex on the left (fig. 607).
3"^ degree. — Three curves exist : a principle and primitive one in the dorsal region, and two secondary, cervical and lumhar, called compensatory, in the opposite direction to the first (fig. 608).
The serious scoliosis of the third degree In the last stage presents veritable " lateral gibbosities ", or the back is bent, with a projection of the ribs forming the side of the classical melon and a contrary deformity of the front of the thorax. The back in these cases is nearly completely welded together and " incorrigible ".
The course to follow. — You can and ought to treat scoliosis of the first and second degree. In fact, you have chiefly to treat sco- liosis of the first degree. In your oi'dinarv practice you will see the children at this stage : if the parents do not shew the children unasked, you should make it a rule to see, every six months, for instance, the backs of all the young girls of the families of which you are the regu- lar attendant, and if you treat the scoliosis at once, it will never reach the third degree.
If a neglected child is brought to you with a scoliosis of the third degree (fig. 608), do not attack it, it would be useless and you would reap only disappointment. The specialist alone can deal with it.
I. — TREATMENT OF SCOLIOSIS OF THE FIRST DEGREE
Amongst all the treatments proposed, which is good, and is there really a good one.»^ That is the cjuestion. Where is the truth among the different opinions held.*^
We will hasten to tell you ; truth is certainly not in extreme opinions, in opinions exclusive and absolute. In this subject, we are eclectic, in therapeutics as in pathology.
Thus, it cannot always be said, as some would have it, that the essential scoliosis of adolescence is always, not even generally, really rachitic. What we will admit is that there very often exists, in scoliosis, troubles of nutrition presenting some analogy with those engendered by ordinary rickets. In children debilitated by enteritis, or by improper feeding, or by a faulty hygiene, or by a too rapid growth, or by previous illnesses, in the same way as in true rickets, the smallest
rm; \ I Mi'.NT or scoi.rosis a i' iiii: onskt
'n:^
innu(Mii't\ llic ovciloading '. llic had silling'- liahil in scIkm.I, ro|)oalt'il v\r\\ (la\ aiul several hours a da), are able lo bring
aboiil scoliosis.
'riif IrCaliiKMil liicirlMiT will never be delermiried bv an
MmJ
Z=7'
Fig. 608. — Scoliosis of the third degree (or rather at the lime of changing from the second to the third degree).
absolute theory, exclusive, and, until thoroughly investigated, arbitrary. The treatment, general, anli-rachitic, reconstituant, would not be sufficient any more than the local or gymnastic treatment. — Our treatment should be at once general and local.
I. Tliere are scolioses among tlie quadrupeds. Tiicrefore tlie overloa- ding, as tlie Germans understand it, is not necessarv to produce scoliosis, and the predisposition distinctly exists in certain subjects.
074 SCOLIOSIS. GENERAL TREATMENT
THE GENERAL TREATMENT
Tliis includes : A. The feeding of the child and supervision of its digestive functions; B. General hygienic measures.
A. In the matter of feeding ', prescribe as for an ordinary rachitic, taking the age into account. AIIoav only foods Avhich leave the minimum of residue, and counteract the intestinal fer- mentations by the local antiseptics you are in the habit of using.
AA ith the same idea, deal Avith constipation. Order mas- sage of the abdomen and support it Avith a girth made of several turns of broad Yelpeau bandage.
B. From the point of view of Hygienic principles, you Avill advise the girl afflicted with scoliosis to live as much as possible in the open air. A stay at the sea-side Avould evidently be most beneficial, but it can be adopted only bv a A'ery small number of families.
Do not forget the usual medicines ; cod liver oil, phosphates
of lime, syrup of iodine and tannin, etc. But I need not insist on
general treatment ; that is a chapter Avhich you knoAv as Avell as
I do.
A Word upon School and upon the Bed.
School. — Ought the child to go to school P You knoAv the unfortunate effect of bad sitting in class.
Yes, if he is alloAved long and frequent recreation, during Avhich he has fall liberty to enjoy the amusements suitable to his age, and if, during school hours, the school furniture at his disposal completely satisfies your orthopoedic requirements.
Therefore no small straight tables, uniform for cA-erybody, too high for the little, too Ioav for the tall.
In the first case the child is obliged to hang on by his arms AA'hile he writes, pushing up the shoulder; and in the second, he bends himself, lying over his copy-book, his shoulders depressed.
This mischieAous attitude, kept up for scAcral hours a day, Avithout being counterbalanced by anything, ends by persis-
I. ScrjUosis is a malady of the stomach qniie as much as it is a " school complaint ".
I III". WlllllM. lil>K liiU Siiil.lo I KMJKS
liii"^ in all tlir siiltjccis who arc ever so lilllc predisposed. It is l(ii' lliis rcMSoii llial scoliosis (iid\ iiirrits llic name of *' school ('oniplaiiil ". It is \n\- llic v.iine reason, if the CDridi tioiisol" the school where our MdllDlifpie ^^oes are ohvionslv had, thai il is necessary Id withdraw liiiii at l(>asl for some Mionths.
Fiir. Coy — Our cIosk and cLair for scoliotiqiies.
^^'hal tlic writing desk oiujiil to be liLe. — You should order a seat with a very higli back, where the head and the back will be constantly supported over as large an extent as possible, and a desk placed at a distance of from 20 to 20 centimetres away with an inclination of from 20" to 00", so that the eyes can easily follow the characters drawn by the arm, suppor- ted by an elbow rest (the head and back remaining in contact with the back of the chair). The feet will be supported on a foot-stool, at a height which allows the thia-hs, in the horizontal
576 SCOLIOSIS. LOCAL TREATMENT
position, to be at the same height as the seat.- This is (fig, 609) the school desk AA-e shoukl use. (Your carpenter can make it).
We Avill acid that the child ought to become gradually accustomed to upright handwriting, Avhich has not the numerous disadvantages of the slanting one (v. fig. 645, p. 601).
The Bed. — The child will lie on a flat hard bed (a plank under the mattress), without pilloAA" or bolster.
The different hygienic principles, good for all children, are indis- pensable to predisposed children, that is, for candidates for scoliosis, either bv heredity, or by the bad condilion of their alimentary canal.
AVhen scoliosis already exists, it is necessary to do all this as a matter of course ; but it is till more necessary to follow the special treatment for the deformity — Avliich is summed up in two words; gymnastics and corset.
THE LOCAL TREATMENT
Medical Gymnastics. — Exercises for Redressment.
Oh! do not be afraid, it is very simple, lou need not have been born at Stockholm, nor assume an inspired look, to knoAV that a curved arc is redressed by traction on its two extre- mities and by pressure made on its convexity.
True, in scolioses which have been left unattented, secondary curvatures are produced, and the really " corrective " manoeuvres, whether they have much or little effect, have become very difficult to determine. But these scolioses concern the specialist. Do not undertake their treatment. It is only at the beginning that you will interfere. At the beginning, the curvature of the spine is single, and at this time the problem is reduced to redres- sing the arc. Not only will you redress it, but you may attempt to inflect it in the direction opposite to the deviation.
All manoeuvres Avhich lead to this result are good, lou will easily find them by simple reasoning or by the modifica- tions which the back of the child undergoes in the course of different movements Avhich you tell him to perform, or Avhich you yourself perform upon him.
MKiiicM. (.^\i\\sri(:
So iinifli Icii- llic (/Yiiiinislics spcnnl In cmcIi (msc,
^(Hl will use l)csi(lt's. ijcnrrnl iiytiinnslics, llic .s;mic I'oi ;ill,
liaviii- I'm- \ntii- nl)ic(li\r : n. llic development of tlie thoracic
cajvi-*- l»^ riii'ci'ij iiis|)ii;ilii>iis, rMJIowci! I)\ coiniilclc cxiiiiiili' ni'- ;
/*. the exercising of the muscles
of the back and limbs, by >-\in-
iiiclriral lunNciiH'iils ol' llic aims.
llio It'fi^s. wliicli all scliDol (-hiMrcii
know how li ' make ( mic. I w o I . . . ) ;
llic tlcxiii^r of the biniy lorwanls,
backwards, niarcliiiifif to the word
of commainl. (Iiiuibs bells, elc.
Bill vou may be scarcclyconteiit willi these sumiiiar\ iiKlicalii ins. To be really useful lo you we must be precise and codify, so to speak, all the exercises. Here is a pro- gramme, easy to I'olldw, wliicli we have drawn out i'n^ you with our able assistant and friend Roederer. It has this advantage that you can make use of it without special outfit and w ithout rigging, in the most modest families.
It is inspired by two principles Avhich ought to be the two directing ideas of the whole treatment of scoliosis :
i". To strengthen the organism.
2"'. To correct the deformity.
It requires two sittings a dav, at nine in the morning and at five o'clock in the afternoon, for instance. Each seance should last from three quarters of an hour to one hour.
You will yourself preside at the first exercises; then, after the third or fourth sitting, w-hen you have educated the mother as w cU as the child, she will be able to replace you satisfactorily.
Calot. — liulispeiisable orlliopedli.s. Sj
SCOLIOSIS AT THE ONSET.
TREATMENT BT GYMNASTICS
You will only have to see the child again once a week or even less often. We remind you that this refers to scoliosis of the first degree. The example chosen (fig. 6io and following) is that of a boy' of twelve years of age, of feeble constitution, who goes to school ; slight right scoliosis, right shoulder higher than the other.
'^^t::^
The gymnastic and redressing exercises comprise four parts. The first and fourth are general gymnastics, useful and applicable to all children ; the exercises of the second and third parts are the special treatment for the deformity.
I'* PART. — Respiratory Gymnastics. — Duration : 7 to 10 minutes.
Upright, — I**. Make a deep inspiration through the nose,
I. Although less frequent than in girls, essential scoliosis is far from being rare in boys.
IU>I'IU A IMHV (;\ \l\ \N| ics
•>79
followcil by an cx|)iriili()ii as cdiiiplclc as possible li\ llic iiioiilli.
!>■"'. Slailiiii,^ posilioii. — - lllhows hciil .iiid liori/.otihil, hands \c\r\ w illi >li'>ii|(|(is ( lii^'. (lin).
|-]\lcn(l llir iiiiiiN m ihr loriii (if m (•|nv> dnrliiL.' in--|»iraliiiri
(fig. 6ii). Return to the starting position during expiration.
3'''. Starting position, — The arms lianging by the sides. — Raise the arms laterally, llrst cross-wise, then above the head (during inspiration), remaining so for three or four seconds (fig. 612).
Let the arms fall, as far behind as possible, during expira- tion (fig. 6 1 3).
58o SCOLIOSIS AT THE ONSET.
GYMNASTIC TREATMENT
Recommence the series (i^*., 2""^, 3^^^) for three or four mimites. Afterwards, rest a minute.
Seated. — i". The same exercise as that performed just
Fig. 6i5.
now upright (N° i), the hands heing clasped at the level of the pelvis, behind the chair (fig. 6x4).
2"''. An assistant passes his hands under the child's axillae and raises the thorax at the end of the inspiration, which is thus " forced " (fig. 6i5).
Ill ^I'lii \ 1 1 iu\ (.\ \iN \^ 1 1(> 58i
lu'Ct Miimi'iici' I lie, I '. ,111(1 •.>'"', lur lliicciu loin niiniilcs. As a l;i iM Till iiilc, cliildren do not know liow to distend the thoracic cajie \\ ithout special instruction.
Till- !('S|iii;itni\ CO (•('liciciil , 1 1 1.1 1 |s, I lie ilin'crriicc (if I he j)crl- mcler in iii'^|iii ,il k ui and ex |iiraliMii, is haivK one en I w o ccnli-
lUclrcsal llir lirij lilllllli.;' ol llir I real llMMl I.
Alter two iimiitlis (if I hcse Irssons and cxcrcis'is, ihc co-crfi cienl rises In \, ,'> or i) ccnllmolres.
Draw llii' allciirmii ol llic jiaiciils (o this; llialis, make llieiii measure llic |)erliuelcr ol'llie thorax al ils maximum ampliludc, in forced inspiration, first al llic beginning of llie Ircalmenl, antl llicn at the end of the first or second month ; the comparison will sur- prise and ~~!liiiu laic lliciii. It is certain thai a lar,i;cr \ en I Hal ion of thcluni;s, determining a more complete oxxgenalioii ol the hlood is, for the child, a condition which improves ils general health.
Indeed, after a few weeks of these lessons, all children not only hold themselves better but are better. It is manifest to everybody, and is to the parents a great encourage- ment. This is not immaterial, because it necessitates much perseverance on the part of every one, for many months, to arrive at a definite result.
For the rest, the practice of these respiratory exercises is becoming generalised. They Avill soon be, if ihey are not al- ready, part of the daily programme of all the schools, ranking with, and of more utility than, the lessons in astronomy, ana- tomy, chemistry or physics.
But besides these eight or ten minutes devoted speciallv to respiratory movements, it is necessary that the child profit bv the lesson in a continuous way. For all the remainder of the gymnastic exercises he ought to breathe deeply, taking care that for each exercise, the end of respiration coincides Avith the maximum of effort, and that, during (he whole day he should remember to make several forced respirations everv hour, which will insensibly lead to a better respiration at ordinary times, even when he is nol thinkin"- of it.
582 SCOLIOSIS AT THE COMMENCEMENT. — • AUTO-REDRESSMENT
After the 8 to lo minutes devoted to the respiratory move- ments a rest of Jive minutes, in the recumbent position, on the floor; then one passes to the second part of the lesson.
Fig. 616.
a"*^ Part. — Active exercises, made by the child alone under your direction.
A. AuTO-REDRESSMENT.— i^*^ Excvcise . — The child, his arms hanging downwards, his back supported at the angle of a door, tries to make himself taller, Avithout raising himself on
SCOLIOSIS.
Ai:ii\i: I \i:u isi;s oi" <;ouui;<:iio\
583
his loos, r.iisiiij^- liis sliouldcis, or lllliiii; up his cliin ((i;^. (JiO) as one insliiictiv('l\ slrolclics oncNrll iiiidcr llie slandard lo
pusli llii' ^lidr will) llir head. lie is able III tlii> NVay lO
increase ids lieiylil by i, :>, 3 ceiilimclrt's. IViini lln' Ix'i.'-inniiig of ihe eveicise.
:>'"'. To olilaiii s| ill iimic |)\ I his OKcl'cisc, lie |)la ces liis liaiuls upon his liips (lliund)s behind) using them as a support and raises himself on his arms, always without raising the shoulders (fig. Oiy).
Fig. Oi7-
^^^^2:^^-
Fig. (3i8.
Fig. 6in
After having repeated these exercises for six minutes, he rests for two minutes, and passes on to the folloAving.
B. Correction. — This exercise lasts from four to five minutes. 1^'. The child, arms down, Inclines himself to the right,
584
SCOLIOSIS AT THE ONSET. PASSIVE EXERCISES
on the side of the convexity, the shoulders remaining in the same plane transverse vertical, or frontal (fig. 6x8).
By this movement, the right curvature will be placed in a state of hyper-correction, and you Avill even see a curvature
produced on the left side. — There Avill be, as it Avere, a sco- liosis in the opposite direction.
2"^^. The child holds his left arm (of the concave side) straightened vertically, he stretches himself as far as he can
Fi.o-. 62 1.
(fig. 619) Avhilst Avith his right arm semi flexed, he pushes forcibh' the right convex side from behind forwards and from AV'ithout inAvards. He repeats N°' i and 2 for four minutes.
After that, five minutes pause as above. Then, Ave pass on to the third part of the exercise.
3"^. Part. — Passive Exercises. Here, it is Ave (and later
r.EM:n\i i.\ m\ \si us
585
llif nmllicr) wlio slrai;jlil(ii the ck\ialion. Tlic cliiKI Mihinils passively to correction.
I-'. The fliild !■< laid on llie ri^dil side lli;il is. on the convex side : a piljitw is cluiil)leil np and placed l)(l\\e( n (lie floor and the cliild (duralion, two minnlcs : lig. G20J.
Fig. G22. — Scoliosis with convexity to the right (single curvature' . The child being suspended on the horizontal bar, one carries the pelvis lo the right.
Fii.'. G23.
2'"'. "iou join your hands under the convexity and raise tlie child from ten to fifteen centimetres above the folded pillow. Repeat this from six to eight times a minute (fig. 621).
3"^. The child is hung up by the hands to a bar fixed in a doorway : the feet off the ground, you take him by the pelvis which you displace towards the right (convex side) from 3o to 00 centimetres. The right curvature will be corrected. Repeat this five limes, taking, after each movement, a few seconds rest (fig. 622). Afterwards, Jive rninules pause as above.
586 SCOLIOSIS AT THE ONSET. TREATMENT. GYMNASTICS
4^''. Part, You will complete the practice by some gene- ral Exercises, symmetrical, regular and slow.
% |9
Fig. 628
Standing Upright. — i'*. Elevation of the arms in all directions, in two or four stages (fig. 62 3).
Fig. 629.
Remember that the movements of forced inspiration ought to coincide with the elevation of the arms, and the movements of expiration with their depression.
2°*^. Movements of lateral inclination, of flexion forwards, of rotation of the head in two stages.
MASS.Vr.K OK llli; ItACK IN >(:OI,H)SIS
587
3"'. Flexion of llic llii;^'lis (lig. ij.i-j and G2<Sj. Kepcat n"' I, •-» and 3 lor Iwo or llirco niiiuiU'S.
I-viii'/ Down. — r'. The arms arc cairied oiiluards. ihen above the head, wilhoiil leaviii,:,'^ the lloor. then reluming' lo ihtir
first position (lij,'. Ga;)
Fi-. G3o.
a"**. The lower limbsare widely separated, then approximated. 3"'. The legs are flexed on the thighs, the thighs on the pelvis, the pelvis on the thorax (fig. 63o).
Fia:- 03 1.
Then repeat n"' i, 2 and 3 for one or two minutes.
Laid on the face. — Raise the trunk, make swimming mo- vements. Some one supports the feet, at the beginning (one minute) (fig. 63 1).
588 SCOLIOSIS. ELECTRISATION OF THE BACR MLSCLES
Massage of the Back. Before leaving the child, you per- form a massage of the back ; first, skimming over from the head doAvnwards ; then firm frictions with the palm of the hand, from below upAvards; afterwards vibrations with the index and second fingers together, on both sides of the spinous pro- cesses, one hand on the right, the other on the left.
Scoliosis is an arc of a circle. On the concave side, all the tissues, muscles, tendons, ligaments, aponeuroses, are contracted. Therefore, on the concave side fatigue, knead, extend, elongate the muscles as you would do for the contracted adductor in coxitis.
On the other side, on the contrary, the muscles are feeble, ill nourished : one must strengthen, treat them gently, improve their nutrition. Reserve for these muscles a slieht massase, slow and rather prolonged ( 10 minutes), causing the lymph and the blood to circulate, hastening, by an incessant return of new blood and a vigorous circulation, the nutritive and respiratory exchanges.
The application of electricity in the form of constant and faradic currents, will render you very great service in hastening the regeneration of the muscles and increasing their forced
This is Avhat you can do and know how to do wherever you
I. Electrisation of the muscles of tlie bacli, in scoliosis, is performed at a seance composed of two parts : the first devoted to the galvanisa- tion of the muscles of the convex side whose increase of vitality is neces- sary; two large electrodes are placed one at the nape of the neck, the other at the loins ; the positive pole is at the nape of the neck. The current is turned on and gradually increased up to 1 5 milliamperes : it is applied for lo minutes.
The second part is devoted to the rhythmic faradisation (Bergonie) of the different muscles of the hack. It is of advantage to electrise the muscles of both sides. Faradisation is made hy means of induced currents obtained from a coil with a large thread. The necessary interruptions to excite the successive contractions of the muscles are determined by the opera- tor with his finger, or better by a metronome interruptor introduced into the circuit (the apparatus is regulated so as to obtain medium contractions with an interval-of a second's rest). The second part of the seance should las! about a quarter of an hour (D"" Bergugnat, d'Argeles-Gazost). — The elec- trical seances should be repeated three times a week for two months, after which one discontinues them for six or eight weeks. — For installation of the apparatus, seepage 66 1.
Ilir. (HISIKlN (II A COUSI I IN SCOLIOSIS
')H(j
aiv : soiiu'lliirifj; w liicli a ilcsolcd .iiid inlrllif^Tiil inotlicr will do wlioii >Ih' li.f^ niice seen it donr.
Ill llic aik'innnii a secnnd seance of ^'\ iniiaslics and redre.ss- nicnl, ill c\or\ \\a\ (lie same as llial of llie iiioriiiii^'. *
In llie interval, llireeor lour liniesa day, aquarlcr of an hour's wallv. No violcnl -aiiies, no cycling, no fencing-, no swimming.
Belween limes, al meals, lor iiislaiicc. and lo learn his
FiiT. C)3a. — Special form ; lo the left of the reader) the scoliotic child is badly seated : on the right, the seat is oblique, raised on the convex side : the child, to keep his equilibrium, straightens himself instinctively.
lessons, the child should be seated on an inclined seat as sheAvn here (fig. Qo-2).
As to school, as I said before, if the child is to attend it, the special desk is necessary (fig. 609), two hours class in the morning, with a quarter of an hour for recreation, and two hours class in the evening, are permitted.
Finally, it is well to ensure for the child an hour or an hour and ahalfofrest. now on the back, quite flat, then laid on his side, with a folded pillow interposed betw een the floor and the convexity.
^A e have already mentioned his sleeping at night on a flat bed.
THE CORSET IN SCOLIOSIS
Is it necessary to wear an ortliopLudic corset?
I uarn vou that cverv fanillv, or ncarlv cvcrv fainilv, cavil with
5qo scoliosis. THE CORSET IN SCOLIOSIS
you as to the utility of a corset in this first stage of scoliosis, where, say the parents, there " is absolutely nothing ".
It is true that the corset may not be indispensable at this moment, for a child >vho is almost ahvays reclining.
We cannot reasonably insist on this at the beginning; it would be too harsh a proceding to remove the child from the ordinary life of children of his ow n age. The family would not be agreeable to it and it would not be agreeable to ourselves were we dealing with our own children. We will therefore allow the child to continue his studies and at the same lime give him liberty to come and go to the seances of exercises and massage. But to allow this liberty to walk and remain upright for several hours a day is not without inconvenience; it is well to suppoi-t the vertebral column Avith a corset. I do not say that the disease will never be cured without a corset, in scoliosis in its earliest atage : nevertheless, even in mild cases, there will be a much better chance of a good and rapid cure with a corset than without it. To judge of the expediency of a supporting corset, think of club- foot. If, after having redressed it by manipulations two or three times a day, the patient is made to walk without a support, what Avill become of him? Not only will there be no correction, but, as a ge- neral rule, the condition will become aggravated, and one is obliged to support the foot in the intervals of the exercises. Well, the situa- tion is just the same here.
Therefore, bear in mind that the manoeuvres and exercises of redressment in scoliosis are not carried out in many families more than once every two or three days. If, from one seance to the next, the spine is not well supported, the scoliosis will easily become aggravated. But it is not sufficient " to put " on a corset, it is necessary that it serve its purpose well. In practice, nearly all the corsets are defective; they do not support and they prevent nothing or next to nothino-; and the back, instead of being eased, is made to carry increa- sed weights; it is a burden which, added to the already too great pressure of the head and shoulders, only accentuates the deviation instead of attenuating it.
Look at the corsets generally used : whether intended for a sco- liosis situated high or low, the corset invariably stops at the axilla, often manifestly leaving the deviation outside the upper edge of the corset. On the other hand, the corset does not descend low enouoh, it terminates at the iliac crests. So that, if one could see throuo-h the corsets in common use (you could try to do so : make a dorsal opening, to convince yourself of what I say) one would see the deviation as it is under the corset, sometimes even accen-
i'Hi:m:h couskis in celi.li.oid
.)(,!
Imilcil l)N llii' w t'ii:lil t)| llic ;i|)|i,ii;ilii-^. Ilow is tills .liHiciillv I.) lie sdImmI .'
Tlic lic^l mclliiiil (il >ii|i|H irliii^;- llic spine wDiilil he. you aiiliiipalc it. a inovrahlc piaster corsel, similar to llial iisiij ill Poll's disease, sec Chap, v, a iiRHliuiii piaster or a |)lastei' accordiiif,^ lo llie situation of llie scoliosis. It should he constructed in a position of correcliDU of the scoliolic s[)ine. willi an opening in the hack in order lobe able to exercise direct and precise pressure on the convexity.
And this is the kind of apparatus \vc advise you lo make for hospital children, Avhere arrangements do not permit of the seances of gymnastics and rcdressmenl.
But there is something better lor private cases Avhich you (or the parents) can shape, exercise and redress once or twice a day.
For them, in order to meet every requirement, namely the support of the back and the possibihty of making the daily exercises, it is necessary to apply a moveable corset in leather or celluloid, Avhichis at once lighter and firmer (fig. 633 and 63 'i).
\ou take a mould in very slight extension of the spine (the feet resting on the ground by the whole of the sole) and on this mould you construct, or. cause to be constructed by the ortho- poedist, a celluloid apparatus.
Fig. G33. — Corset wilh an ope- ning to compress the convei side.
Fig. 03-'i. — The same, front view.
592
SCOLIOSIS OF THE SECOND DEGREE
A, KIM, I
We have described, on p. 97, the method of making a mould of the trunk and an apparatus in celluloid, as well as the technique of dorsal compression.
Ought the corset to be worn always?
In theory, it would be excellent lo keep it on constantly, omitting it, of course, at the seances for redressment.
As a matter of fact, it would be belter, in order to spare the muscles, for the parents to remove it at night and also, if practicable, during the hours of rest (in the recumbent position) taken during the day time.
II. - SCOLIOSIS OF THE SECOND DEGREE
If a more advanced scoliosis is brought to you, Avith already two curvatures (for instance, a dorsal convexity lo the right and a lumbar convexity to the left, that is, a scoliosis of the second degree, v. hg. 607), you can and you ought to treat it. With a treatment longer and more severe, you will not only stop the actual deviation, buteven obliterate it almost completely.
Nevertheless, do not be positive in such a case, for a perfect result is not certain, in a patient who has come to you rather late.
GENERAL TREATMENT
You will prescribe the same dietary, the same hygiene, the same respiratory exercises and general gymnastics as for a case in the first degree, but the manner of life of the child Avill not be exactly that described above.
Several things which Avere permitted in early scoliosis should be proscribed in this stage.
In order to carry out a consistent treatment, it is necessary to withdraAV children from school for at least a year. Piano playing must be discontinued and, it goes Avithout saying, horse riding, cycling, as Avell as violent games and long Avalks are forbidden.
The girl, AvithdraAvn from school, Avould ho av ever be able to continue her studies, either sitting on a special form or, still better, lying on the face or the back.
HIE TUK.VIMKM OK SCOLIOSIS Ol I Hi: -l<oM.
.Ji,.
Slic musl rcsl. al ;m\ rale, lor .^i or .'i hours tvcrx day, in ihc iccumbcnl posilioii.
One caiinol, genorallv, condemn Ikt to conliiiual k.cuim- bciicy, as soiiu' would have- it. Il would he loo great an upsd in the niotlc ol WW' o\ the child, as well as thai ol iicr friends. Her ge- neral liiallh wiiidd -nll'iT. iiidess shc lived by ibe sea, Nvhicli is uol possible for all. or at least for ihe majority ol' children.
Therefore you will permit smnc amount of walking; o or 4 limes a day. for a quarter ol'an hour or twenty minutes al a lime. These moderate walks will have the effect of preser- ving the general health of the muscular system.
Fi?. 035. — Corset witli two open- ings, one over the dorsal con- vexitv, the other over the lumbar convexity, allowinir of compression being made as with the corset shown in fig. Oia, p. 597.
LOCAL TREATMENT
A. — The Corset.
There is no possible hesitation about vising a corset here; it is always necessary. It should be a celluloid corset, with two openings opposite the summits of the I wo curvatures, to effect the two compressions in opposite directions (fig. 635).
During the day it is only removed for redressing exercises and for the hours of rest 011 the back. It remains, moreover, in place at night (at least one night out of three, to effect part of the correction without fatiguing the muscles too much).
B. — We come now to the redressing exercises to be made in scoliosis of the second degree.
I*'. Alto-redressment.
a. Begin with the redressing exercise advised for the first
degree (v. fig. 616).
Calot. — Indispensable orlhoped.cs.
3S
594
SCOLIOSIS OF THE SECOND DEGREE
b. The same, the hands on the hips (fig. 617).
c. Advise also the altitude of fig. 687.
The child, upright on a stool, stands on the left leg, the
-rf-^TT
Fig. 037. outside. The lumbar curvature is redres-
rightleg hanging over sed(ng. 636).
He raises his left arm on the side of the dorsal concavity
i>\u I HI I \iis (II 1 1
I HI \ I \1I.N I
5 (J 5
Kig. (-.38.
Tljc dorsal ciirvaliirc is corrcclcd (fig. 637).
He pushes \vi ill llic riiilil hand over the riirhl concavil y. The dor- sal curvature is hyper- corrected.
2'"'. Active exercises of cor- rection. — a. The same exercise of lateral flexion as in fig. 6i8, the left foot resting on the foot stool.
b. The legs in the same posi- tion, the child draws up his left arm, as in fig. Gig.
3"^ Passive exercises. — a. The child is laid on his right side. — The dorsal convexity is raised up and corrected by a folded pillow, just as in fig. 620.
6. The child is lifted up by that part of the body opposite the dorsal convexity as before (fig. 621). But, besides that, you pull on the right leg. on the side of the lumbar concavity, and that redresses the concavity.
c. The child is laid on his left side, and the left arm (on the side
Fig C3y.
596
SCOLIOSIS
FORCED REDRESSME>'T IN SCOLIOSIS
of the dorsal concavity) stretched as much as possible; you pull on the right leg, on the side of tlie lumbar concavity, and this manoeuvre (fig. 622) redresses both the curvat .ires.
d. The child holds by his hands upon a bar fixed between two door-posts, hut the bar is inclined in such a way that the right
Fig. 6/|0. — Redressment of a scoliosis : the child is laid on his side, a pillow placed under the convexity : the surgeon presses upon the pelvis and upon the shoulder to redresf the vertebral column.
hand (on the side of the dorsal convexity) is lower than the left (fig. 639).
Then the legs are carried to the left and the pelvis is brought down a little to the right.
e. The child will often place himself, during the day. in the recumbent position, on the left side, and will perform flexions of the right leg.
Forced redressment and treatment by the plaster.
Can anything more be done for these scolioses of the second degt'ee? For instance, can we seek for a more accentuated pas- sive redressment, and maintain the result obtained with an irre- movable plaster P
iiii:\r\ii.M n\ i'i.\-ii:u iiouskts
•>07
Vcs, willioiil (l(Uil)l, hill foiavcrN liiiiilcd lime .iiul onl v iiflcr h.-nini; w('llin(>l)ilis(Ml llic vcrlcltial arlicuhil ions and slrciigllieiicd
Fig. 64i. Fig. 6^2.
Fig. 64i. — Scoliosis with convexity to the riglil. Dessiccation of the plaster. One
pushes the right shoulder forward and the left backwards. One pushes backwards
and upwards the right hip. One pushes forwards and downwards the left hij).
Fig. 6^2. — The apparatus completed and furnished with two openings opposite the
two convexities (right dorsal and left lumbar).
the muscles of the back by the treatment we have just described, continued for six months, for example.
Then you may make a more accentuated passive redressment
598
SCOLIOSIS OF THE SECO^^D DEGREE
of five or ten minutes, the patient laid on his side — by manceu- vres analogous to those which one would make for redressing
Fig. 6/|3. — A case of forced redressnient. Scoliosis of ibe third degree, of eigtt years standing. Albert G., of Paris, 19 years and a half. Condition on arrival at Berck in igo3. Height 1.57 metre. The following figure shows the result.
any deviation whatever, a club fool, for example, and going as far as hyper-correction (fig. 6/io).
Immediately this is reached, one applies, in the upright posi- tion a very accurate medium plaster (fig. 64 1 and 642), with
A CASK 01-- SCOI.IOMS oi I 111; llllKli Ip|i.I;|:i.
•".I'.»
dorsal ami lateral oppiiiii^'s (scr, ('..i llic coiislruction oi" the cor- set, j). nSi)). The plaster will hr k(|)| on for s<-voial months
Fig. C^i. — The same six \ears later. Height 1.66 metres. The treatment had lasted two and a half years and consisted in the apnlication of a new large plaster every 3 or i months; he had seven plaster apparatus, of which the two tirst were applied under chloroform.
about three or four, after which one removes it to repeat the ordinary treatment Avith gymnastics and a removable corset in celhiloid made on a new mould. This method economises the
Goo SCOLIOSIS OF THE THIRD DEGREE
muscles of the back much more than that which consists in car- rying out the whole of the treatment with a plaster.
Nevertheless, this last treatment is the one you would be obli- ged to apply to hospital children and to those of the working class, to w^hom the daily treatment by gymnastics is not possible.
True ! the complete treatment of scoliosis by plaster Avill generally give the best immediate results; but the muscles having been enfeebled by the pressure of the plaster and the want of exer- cise and massage, the result is often lost, in part, after the remo- val of the plaster apparatus.
So that, in private cases, it is necessary to try to make the redressment of the osteo-articular trunk at the same time that you preserve the muscles. That is what you Avill succeed in doing by the mixed system, gymnastics and celluloid corsets, as we have described it.
SCOLIOSIS OF THE THIRD DEGREE
We have defined this at the beginning of the chapter. There can be no question of classes or studies to be kept up by the children ; they are patients Avhose treatment should be as con- tinuous and strict as that of Pott's disease.
They should live by the sea if possible.
Mter having mobilised the more or less ankylosed vertebral articulation by gymnastic treatment kept ut for several months, one will submit them every three months to seances of forced redressment, i5 or 20 minutes at a time, under chloroform, fol- lowed by the application of a large plaster with dorsal openings for the compression of the projecting parts'. Rest for one or two years in the recumbent position (fig. 643-644)- Our am- bition is limited, here, to fixing the back in a better position, Avithout immediately concerning ourselves with the muscles.
This treatment is very difficult and very thankless, o?i account of the excessive torsion of the vertehrse in such cases, a tor- sion against which we are very badly armed, in spite of, all the
I. Vide Calot, De la correction des Scolioses graves (Masson).
HI SI Ml'; 111 I hi: iur\iMr\r oi- sc.di lo-i^
(irn
• • {Icldi'^ii 111 .i|i|';ir;ilii^ wliicli li.i\c hiTii IiimiiIciI ii|i (o mow . litil. as I lia\('sai(l. llie Ircalmeiil is c\(liisi\r|\ icsorved lor spoi'ialisls. and I do nol iiisisl.
RESUME OF THE TREATMENT OF SCOLIOSIS
Tliis is whal \oii will |iiescril)C for llic young scoliolic girl who has conic lo nou '// llic l>r(/iniiin'j a f lite disease.
Fig. 6ii5. — A. The liandwiiting straight (characters straight) leaves the spine straight.
B.. C, D. All the other handwritings carry with them the vicious attitudes of the spine lateral inclination and torsion).
(Copied from Ritzmann and IF. Schullhess, of Zurich).
Should there be adenoids, troubles of vision, deformity of the lower limbs, they must be attended to.
I"*'. General Treatment.
a. Dietary sound and simple, supervision of the digestive functions, massage of the abdomen.
b. General Hygiene : life in the open air of the country and of the sea-side, salt baths, good conditions of climate and of dwelling, as a matter of course.
602 SCOLIOSIS. DURATION OF TREATMENT
2 "^. Local Treatment.
a. Ensure a good attitude in class (v. fig. 645).
b. General and special gymnastics : 3/4 of an hour mor- ning and evening (active redressment, passive redressment). Instruct the mother how to carry out the exercises.
e. Massage and electrisation of the muscles of the back.
d. A fenestrated corset and compression, except in scoliosis almost imperceptible at the beginning.
It is sufficient, after having " started the treatment ", to see the child once or twice a month, in order to control it, and to take a mould once a year in order to replace the corset.
If you treat commencing scoliosis in this way, in your clien- tele, I do not say that there will be no more severe cases \ but I affirm that they will be a hundred times less frequent as is the case in Sweden, where they are practically never to be seen.
The Duration of Treatment of a Recent Scoliosis.
You will carry out the treatment w"e have described, as long as the scoliosis continues, that is, for a year or two, as a general rule, for scoliosis of the first degree — those you are called upon to attend.
After that, your active part W'ill practically come to an end : ' you will be able either to discontinue the treatment, or reduce it by half, leaving the parents or the children to continue it themselves to the extent you judge to be necessary. They will do so without difficulty. Nevertheless, you will have to look after these young girls for several years and even up to the end of their development, stopping the active treatment and returning to it, according to the needs and indications of each particular case.
I. Because tliere may exist, as we liave said, some very rare malignant scolioses, wicli may become aggravated in spite of everything, in the same way as certain malignant external tuberculoses. But it is the greatest exception for the one as for the other; it does not happen more than once in a hundred times. I am speaking always of the essential scoliosis of adolescence, and not of scolioses distinctly and frankly rachitic, existing from the earliest in- fancy, the prognosis of which is much more serioiis (v. p. 689).
CM \i>Ti:i; i\
ROUND BACK.
LORDOSIS
Beside.-- llic laU'ial ilcvialioiis we inusl mention llic median devia- tions (non-lubcrculous) which form :
KiUier ihc round back, kypltoxis, thai is, a posterior convexity (lig. (j/i6) :
Or, on llic contrary, a saddle shaped hollow, a lordosis, tliat is, a deviation with a posterior concavitv (fig. 647);
^ erv often the round back and lordosis exist together. Tlie patient presents a dorsal kyphosis at tlic level of the shoulder blades and a lumbar lordosis which is simply an exaggeration of the physiological curvature of the loins.
Kyphosis (round back) and lordosis may exist without anv other deviation : but thev mav also be added to a lateral scoliotic deviation.
One may even sav that, generally, scoliosis accompanies a deviation slightly or strongly mar- ked in the anterio-posterior direction (kyphosis or lordosis), or even a ilat back.
Therefore alwavs remember to carefully examine the spine and look for a scoliosis, Avhen vou are consulted as to a round back, just as a suspicious lumbar hollow invites you naturally to examine the gait and condition of the hip and to think of a congenital luxation or a coxitis.
The same treatment and the same exercises are suitable lor kyphosis and lordosis, whether they exist alone or are associated with a scoliosis.
6o4
ROUND BACK
Kyphosis or Round Back.
A. Respiratory Exercises.
Starting position. — The child's arms are extended and brought together m front, the hands being in contact.
Fig. 647.
The child then takes a deep inspiration, opening the arms at the same time. An assistant makes resistance to the move- ment of separation of the arms — a gentle, equal and sustained resistance.
■iui:\i\ii;m ui' uol.mj iiAi;k
Oo."
Tills exorcise ile\elo|)s llic muscles wliidi iip|troxiinule llic ^c.l|)^llae I" lln' vcilel)ial cnltiinii.
Fi- G.'iS.
h.^' Active Exercises. — r'. The child extends the head backwards, at the same lime that he curves the loins.
2'"'. Standing- upright, against the edge of a door, he carries his elbows as far backward as he is able (fig. 648)-
6o6
ROUND BACK.
C. Passive Exercises. — The cliild is placed against a ladder, suspended by the arms. A cushion is placed behind the shoulders, opposite the deviation (fig. 6/19) •
In school, the child, as often as possible, keeps his arms crossed behind the back of his chair.
... / f
Fig. 6/19. Fig- 65o.
Fig. 6/|r). — RouQcl Back. The child hangs upon an upright ladder >Yith a cushion
beneath her shoulders. Fig. 65o. — The child is seated at the foot of a straight ladder, the arms are raised, the thighs in forced flexion, the knees flexed on the thighs and kept so hy a strap.
Sometimes the wearing of braces, which draw the shoul- ders backwards may be recommended on the condition that they do not impede the respiratory movements.
The other points of treatment of essential kyphosis, diet, hygiene, school hours, walking and promenading, recum-
i.(iuii'i>^i^ (io'j
|)t>iic\. oil-.. ;ii«' IIm' same .1- \nv •^n ilid^^i- ol' tlw lii-t degree
(\. p. :^-;->).
I'lir coi'scl. — III |ii'i III ciici' 1(1 llir liiaci'v iiHiil iMricil aliove, IIk' cliiM will wiMr. c\cc|)l diirinij IIm' iiil'IiI. and. mI coui'se, at the liiiic I'l llii' i.;\ uiiia.slic o\crcisc.<, a colliilMiil cnr.scl willi a median dor.>^al opening lo allow of compression by cotton wool \\liiili will Im'I|) llic correclidii n\' \\\r k\ pilosis.
We lia\c niiii|)lcii'l\ cui-cnI. I)\ |ila-^U.'r oi celluloid corsets alone, anil witlidul ollur tivaliueiil, a i;ieal niiinher of round backs ami lordoses (willi. il is line, the |)rciii>u> adjuvanl ol sojourn l)\ the sea). I)ut the best is lo combine the two lliora- peiilii" factors ; t;vmnastics and the corset.
Lordosis.
Active Exercises (v. fig. 648).
Passive Exercises.
Correction (jf the lumbar hollow b\ the leciindjcnl position face downwards, witli weights on the buttocks and the back.
Note also the good eiTecls of extension of the spine by sus- pension, or rather simple tension (v. fig. 243 and 244); repeat such tension of the spine three times a day. five minutes each time.
The corset is the same as that for kyphosis : by pressing on the dorsal region througb an opening there, one lessens much the ** hollow " of the lumbar lordosis.
CHAPTER X RICKETS
AYe concern ourselves Avitli Rickets from the ortliopcEclic point of vieAv only.
Rickets deform particularly the lower limbs and the back.
I. — DEFORMITIES OF THE LOWER LIMBS
Thev are, in order of frequency :
a. Deformities of the knee and, in particular, genu A^al- sum; much more rarelv. genu varum;
b. Curvature of the tibix:
c. Curvature of the femur and coxa vara.
A. — GENU VALGUM
A little child of from 2 to \ years of age is brought to you with a knee, or more often both knees turned inwards, what are you going to do?
You will adopt a general treatment and a local treatment.
The general treatment of Rickets as you know quite well is :
Medical : Cod liver oil, phosphorus, etc., with the discreet use of intestinal antiseptics;
Dietetic : milk and eggs constitute the basis of the feeding.
Hygienic and Climatic ; living in a house and in a cUmate Avhich is dry and sunny and, if possible, at the sea-side, which works marvels in such cases, and cures the cliildren with a minimum of local treatment.
i.(ji;al lUL.viMiM iti ii\ciiiii(; uiiiouNimiis i'u,
y
Local Treatment.
I lie lirsL lliiii^ is Ui [)i(;\enl walking, it ym can iiitliicc llic paiciils to sec to this; rest in the silling posilion, the legs hori- zontal (I'm- sdiuc iiKMilhs, I'nini (i In hj months, or ihereahouls).
At the soa-side, rest siiriices to hring ah(jnl the rodrcssnicnt of near!} all the rachitic (lerorniilles nol far advanced.
,\t Berck. for example, il has been so, in iiunv, than three quarters of the cases which have come to us. After a stay of from G to 10 months, ihc knees have become straight and strong spontaneously. One can then let the children get about ; they are cured and remain cured, without ever having worn an apparatus.
But matters do not go so simply with children who live under conditions less favourable, lor example, in a large town, nor even in those who live at the sea-side, when the genu valgum is very marked, as in the case, figured here, of three brothers, attacked at the same time with serious rickets (fig. 607 and 658).
Therefore, in a poor neighbourhood and in severe forms, you would be Avrong in discounting the cure by rest only; begin active treatment, without loss of time.
On the other hand, if the parents do not agree to allow the child to rest, the use of an apparatus after correction is neces- sary, even in mild cases.
There are two ways of effecting correction, or rather two methods to remember, although the classical books point out several dozens.
The first, the ordinary and most simple w^ay, is to redress by dealing with the joint : a bloodless procedure.
The second is that of operating upon the lower part of the femur by means of the osteotomy of Mac Ewen.
Both methods are good, how are you to make your choice.'^
It is first of all an affair of temperament on the part of the surgeon.
If, instinctively, you prefer not to use the bistoury, or still more, if the friends recoil at the idea of an osteotomy, remember that you can alwavs arrive at a cure by orthopoedic
Calot. — Indispensable orthopedics. Sg
.6io
GENU VALGUM 1>" CHILDREN
manoeuvres, by accomodating yourself to circumstances in the most difficult cases, to the making of two or three seances and
as many apparatus, and devoting three or four months to the treat- ment, Avhich puts you after all to very slight inconvenience.
On the contrary, if you are a surgeon, and consequently osteotomy is an operation fami- liar to you, you will willingly perform it, which is quite easy and will give you the desired result with a single apparatus and two months of treatment. On principle, in spite of the good results of osteotomy, I ad- vise you always to prefer an or- thopoedic redressment, because the treatment is more simple and more practicable for you. Need I add that, for other reasons, the purely orlhopoedic treatment appears to me more rational than the surgical, here as in other deformities, club- foot, congenital luxation, etc. Remain faithful to these principles. So far as I am concerned. I used often very wil- lingly to perform the classical supra-condylar osteotomy, or even manual osteo-clasis ; I adhere now-a-days to a simple articular redressment. I proceed in the following manner :
Fis. 6c
- Schema of tbe redressment of genu valgum.
I". Method. — SIMPLE REDRESSMENT
a. The case of slightly marked genu valgum.
Be the joint relaxed or not, you Avill accomplish, by gentle
riir. rur\r\ii:Nr nv '-imi-ii: ui:i>ur:ssME.\r Gii
])rogrcssi\c inaiKruNrcs, i>l lluoc. (miv or live iiiimilcs, n redress-
Fig. 052. — The fool is pushed inwards, and the knee is dra«n oulwards '^see preceding figure).
mcnl more than sufficient for the knee. \A lien llie result hat
-z?' J ^
Fig. 653. — Redressment of genu valgnm the patient is laid on the sound side) : the internal surface of the knee is placed on a block ; one Uses the femur and presses on the foot and lower part of the leg, by small rythmical thrusts.
been obtained, yon fix the hmb with a plaster reaching from
6l2
GENU VALGUM IN CHILDREN
the trochanter to the malleolus (v. fig. 656). With the plaster apparatus the child is able to walk if the parents Avish it.
The mean duration of the treatment is 5 or 6 months.
Is it necessary for me to describe in detail the manoeuvres to be made in order to arrive at the correction.^
It is evident that, since the femur and the tibia make an angle with it's concavity outwards our manipulations, our tractions, our pressure will tend to open that angle, in acting on the two extre-
Fic
654. — Genu valgum. Redressment. One rests the internal condyle on a « hard tampon » made of three bandages of muslin tied together.
mi ties (trochanter and malleoli) in order to push them from without inwards, whilst another hand will push in the opposite direction, from within outwards, the apex of the angle which corresponds to the internal condyle of the knee (fig. 65i and 652). During the redressment, the patient may remain laid on his back, but it is better to place him on the sound side (of the trunk), then to draw back the sound limb, in such a way that the internal surface of the affected limb, or rather of the internal condyle, rests upon an edge of the table covered with a serviette folded in eight. The thigh and the leg being kept in this posi-
TECiiMQiiE oi" siMi'i.i; iii.i>ni;sNMi:\r
Gt.-?
lion l)\ ;iii ;l•^si•^l.llll. \ on vnuiscll liikc llic foot and niovi; it upwards and dow n\\ ards, lildr \)\ little, until v<>n have hroug^lit it down to lli(> level of lli(> tahic and even hclow thai level, in order tool)laiii a li vper-correclion ollioni i 5" to ■io'*(rig. 653 and 65/i).
Fig. 055. — Double plaster apparafus- ruraished with openings, to permit of compression -nith cotton wool over the internal condyle.
Fig. 050. — Plaster appara- tus permitting of walking, after the redressment.
It is necessary to take care, in these manipulations, to keep tlie leg in forced extension upon the thigh (hg. 65 1 and following).
6) The case of a genu valgum very marked.
It is here necessary to prolong the manipulations up to- lo or 1 5 minutes.
They will be made with or without chloroform, according
6l4 GEM' VALGUM IX CIIlLDRE^i
to the pleasure of the surgeon ; one may dispense ^a itli chloroform , because, if the manipulations are made gently, progressively, methodically and sloAvly, they are not, or very rarely, painful. Allien the child is fatigued, one desists, to renew them one or
Fig. 65-. — Three brothers affected \\'ith double and severe genu valgum.
two minutes afterwards, or even better, one is content, for the first sitting, with a partial correction.
However, I advise you, in a general way, to have recourse to chloroform, because it facilitates the proceedings and enables you to obtain a complete result at once.
Kill' Ml \ ^IMI'li: HI niUXMIM-
(JiT)
GENU VARUM
ll ■:nos willmiii -,i\iii-- lliii in tli-' '•.i-'' "!' ijcnu varum 'mm
Fig. C5S.
The same, five months after simple orlhopoedic correction by us in three sittinss, a larse plaster aflerwards.
performs similar manipulations, but in the opposite direction, to arrive at a correction (fig. 609).
The correction or hyper-correction obtained, it is necessary to kno^v how to maintain it entirely; but. in order to maintain a correction of the knee, one ought to include the two adjacent
6l6 GENU VARUM IN CHILDREN
articulations, that is, the ankle and the hip [with the pelvis] (seefig. 655, p. 6i3). When the last bandage has heen applied and before the plaster sets, one makes certain that the degree of correction previously obtained hy the manipulations is maintained exactly, but no more ; because in one's desire to add something by pressure forcibly made through the plaster, one runs the risk of causing a sore, particularly over the internal condyle.
If one has any reason to suspect a sore, or if the patient com- plains much at a point near the internal condyle, on the evening of, or the day after, the application of the plaster, it is well to make an opening opposite the spot, and replace the square of plas- ter by several squares of cotton wool which may be retained in position by a bandage, just as in compression of a gibbosity in Pott's disease (v. Chap. v). This precaution allows of one preser- ving exactly the correction, without running any risk (fig. 655).
When there is a " double genu valgum ", one corrects both at the same time, and a large plaster will immobilise both the lower limbs, Avith an abduction of the thighs of from 3o° to lio" (Jig. 655).
If the correction has not been completely made at the first sitting, one removes the plaster in a Aveek or two, to complete the correction.
One makes a new redressment, gentle and progressive, repeating the manipulations described above, folloAved by the application of a new^ plaster for a duration equal to the first, and so on, until one has obtained a correction not only suffi- cient, but more than sufficient, until one has transformed the genu valgum into a genu varum of from i5° to 20".
For, here as everywhere, it is necessary to obtain too much in order to preserve enough.
When the hyper-correction has been obtained (in one or several sittings), one secures it with a plaster Avhich is left on for two or three months.
After being thus fixed for about two months and a half, in hyper-correction, one may set the child free from all apparatus, but yet at repose in the sitting position for four or five Aveeks.
GENU V.VRIM IN <jim.i)ai:>
•■•>7
Dinintr tliis lime llie euro IjoiOiiics coiifinnerl, llie kticc reco- vers ils nitnoiiiculs. and iIkmiui'xIcs hccniiio slroiifrer. Toas>ist it. one massaf.'-os and hatlies the cliild. and one niohiliscs the knee carefully (two sliort sittings of one or two minutes every da>).
After that, the child is made to get ahout with a knee- piece supporting the slilTened knee, a moveable knee-piece in plaster or cdhiloid. roachini: IVoui the ischium In the malleoli,
Fig. Gbg. — Genu varum. Redressment. The knee reposes by its external condyle upon a bandage of firm canvas, against which it is held by an assistant : the sur- geon presses on the fool by jerks to correct the deviation.
which one takes ofT outside tiie hours of walking, but which must be worn for walking during two or three months.
In about six months from the commencement of the treat- ment, the cure is accomplished and the child has no longer any need for an apparatus.
You surmise that one would, if the friends requested it, after the removal of the large plaster, place the child at once on its feet with the knee-piece, removing the latter at night. in order not to allow the knee to become stiff.
On the other hand, as long as the large plaster is worn, the
6i8
TREATMEiNT PERMITTING WALKING
child remains at rest. Nevertheless, it may, strictly speaking,
walk with the aid of crutches.
If I mention this question of walking during active treatment, it is because it is nearly ahvays raised by paren ts . You Avill find a good num- ber who will refuse to agree to a treat- ment Avhich creates an impossibility of walking, even when it is a question of a marked degree of genu varum.
If the parents will not listen to you either as to rest or to crutches, this is how you would treat the case :
Treatment with a plaster permitting walking
You will redress, at several sittings (without ana3sthesia), bearing in mind what we have told you (p. 6x3). After each new slight correction, in place of a large apparatus taking in the pelvis, you will apply a plaster reaching from
the groin to the malleoli,
and leaving
Fig. 60o. — A movable appa- ratus with a screw which is turned slightly every 2 days, to restore the straight position.
at liberty the adjacent articulations (see fig. 656) ; the child walks with this apparatus.
You may tbus arrive at a cure ; only it will take two or three times longer than the other method, each correction being maintained less perfectly.
For the same reason you Avill be asked to carry out :
The Treatment with Orthopoedic Apparatus for Walking.
These apparatus for walking attract parents a priori. For my part, I do not advise you to use them, because thay are very delicate to manage, too likely to get out of order, and because, after all, and in spite of appearances, they constitute
riii:\ I \ii:n I ithmiiiim. \\ aikim
G19
a less simple form of treatment llian llu' coircclion willioiil chloroform mailc every eij^lil tla^s, r..||.i\\cil |)\ the apphcalifjti of a plaslor knoc piece. IIo\vever. il ihc parents ai'o ohslinale
and prefer an (ullitipdMlic .ipparaliis, lake a iiidiiM oI lhe delor- metl linih and scntl it to lhe inslnmuMil maker; he will send you a rack-work ap[)araliis. wliieli lhe parents will alter as directed cvers two ila\s, and wliiili will end, d' il is wrll constructed and well loidved aflei-. in hiinging ahcjul a satis- factory rcdressmcni. (tig. G60). Ihil this method of procedure is certainly much longer and niore unrehahlc than the use of
Fi^. 00 1. — One malies an incision in the skin (above the swellintc of tlie internal condyle) over a line cr/ni-ilislant from the anterior median line and the supero- internal margin of the popliteal space. (The black spot marks lhe adductor tubercle).
Fig. OO2. — Schema sliowing the manner in uliicli lhe osteotome reaches the femur (F.). 1. The osleolomeis pushed into the sofi tissues, parallel to the axis of the wound, up to the bone. 2. It is afterwards turned round perpendicularly to the wound and lhe handle is carried backwards to attack the bone from behind forwards and within outwards.
620
GENU VALGUM.
OSTEOTOMY
successive plasters. It ought only to be an exceptional treat- ment, or one of necessity.
Fig. 663. — Place of election marked on the bone for the incision; two centimetres above and one centimetre in front of the adductor tubercle.
2^<^ Method. — SUPRACONDYLAR OSTEOTOMY
I do not make to osteotomy any other objection than that it is a cutting operation which one ought to avoid; one does not cure with it much more quickly than Avith simple redressment.
Fig. 66i.
Second stage. Then one turns the osteotome cross-wise, one ought to perform Mac Ewen's osteotomv.
Point where
It is true that it demands of the surgeon himself a little less time.
I reserve the operation, myself, for certain very resistent cases of genu valgum in the adult, and even here one can obtain the correction by a simple redressment; we will return to this in the special chapter devoted to genu valgum in adolescents.
In any case, it is an operation which you should know how to perform.
I ICIIMol i; Id -I I'llA I ii\l>\ I AH (ISIKOIOMY
♦Jai
Technique of Siipra-condylar Osteotomy
(li^^ ('»('•:> Im (i(iS)
Instruments : bistoury, chisel and mallet.
In small cliildicii. nf wIkhii we arc s[)oakiiifj^ oxclusi\cly
i^. (iOo. — The section made.
lierc, (he mallei is mil always necessar>, ui order lo divide the bone; it is sufficient to push the osteotome with the two hands.
Fiff. Gf)<'). — Introduction of llie osteotome, its edge parallel to tlie axis of ttie limb.
HoAvever. as the bone may be very resistant and even eburna- ted, you should always have a solid mallet in reserve.
Have in addition a cushion of moist sand upon which the knee will rest on its external surface.
Position of the Knee : flexion, abduction and external rotation of 3o° (figr. 666).
622
GE>U VALGUM. OSTEOTOMY
i" The Incision: at 2 centimetres above the superior border of the internal condyle, and in front of the tubercle of the adductor magnus (the tendon is quite easily felt), you com- mence an incision of 2 cm. ascending parallel to the axis of the thigh. The bistoury goes with one cut down to the bone and divides the periosteum.
2"'^ One introduces the osteotome parallel to the incision, down to the bone, then one turns it transversely in a direction inwards and backwards, and (from 10° to i5") from behind
Fig. 6G7. — Arrived at llie bone, ihe osteotome is turned round, tlie edge perpendicular to the axis of the femur.
forwards; in this way, there is nothing to fear for the popliteal vessels and nerves, from Avhich the osteotome gets further and further away, in proportion as it penetrates. All that is possible to happen, at the worst, is to go through the skin over the external side of the knee ; but that is not a serious incon- venience, with good asepsis.
If pushing with the hand is not sufficient to make the osteotome penetrate the osseous tissue, one can make it do so with some sharp and precise taps with the mallet, held firmly. One osteotome will be sufficient.
It is often necessary to give from i5 to 20 small taps to effect the breaking of the two-thirds or three quarters of the thickness of the bone. One feels instinctively when one is
Ill i.\i'>i:s
Ga3
there; one oii|,^lil also lo have a giaihialcd oslcolomc which records ihc ilcfiice o[' pencl ration.
3'''' Ono nnlshes with an Osteoclasis. Il is heller nol to cIInIcU' the hone coniplelclv. \N hen the hono is cut lo .'v 'i ol its thickness, one wilhdiawslho osteotome, a tampon is |)la(ed overlhe small \\()und,and one endeavours lo hrcak the bone by manual force.
It is sufficient lo press from Avithin outwards on the lower fraj^menl. b\ taking, in order to elongate the arms of ihe lever of the small fragment, the entire limb held in complete extension, or better, in hyper- extension. One presses firmly in this way (two or three times) until ihe bone gives way.
4''' One corrects the devia tion, one makes even a hyper- correction of from 1 5° to 20°. The genu valgum is thus chan- ged into a slight genu varum.
^Oi
a large
Fi^. 668. — The osteotome oujjlit to enter the femur from within out and rather from behind forwards : the osteotome is pushed by the hands (or, if the hands are not enough, by slight blows with the mallet) until the bone is divided to three quarters its thickness. The instrument is then withdrawn and the resisting Hbres of the bone broken by pressure exercised from within outwards upon the limb placed in hyper-extension.
o'" One applie plaster (see fig. 663
This is removed at the fif- tieth day. Then, the same proceeding as above after simple redressment : the patient walks for two months with a movable knee piece; massage and slight mobilisation of the knee.
Relapses. You will not have any, neither after redress- ment nor after osteotomy, unless : i"'. you have been satisfied with an insufficient correction, or. 2"'. you have left the child
624
ILICHITIC DEFORMITIES OF THE TIBIA
Avithout an apparatus before the complete cure of the rachitic vice. It goes without saying, that whilst Rachitis is in pro- gress, A"ou ought not to allow the child to walk and especially to walk Avithout a very good support.
B. — RACHITIC DEFORMITIES OF THE TIBIA
The deformities of the legs aflect generally the loAA'er third, of the hone, and assume two principal forms : a curvature Avith an external convexity, and a curvature with an anterior convexity.
A good general treatment, a stay at the sea-side, and
Fig. 669. — A vertical incision opposite the external border of the tibia, the osteotome is placed parallel to the wound i" step;.
rest, are sufficient to make slightly marked deviations of the tibiffi disappear.
How many children come to the sea-side, whose distorted legs appear to justify an osteotomy, and who, without anything having been done, return six months later, with legs straight or fairly straight! That is the case of nearly all.
If you are not able to send the child to the sea-side, or if a stav at the sea-side is not sufficient in some exceptional case, you will have to interfere actively; but it is understood that you will only do this if it is Avorth the trouble, Avhen the devia- tion is sufficient (an angle of more than 3o" or 4o" for instance) to render Avalking defective and produce a noticeable reduction in height, or Avhere a line draAAn from the middle of the patella to the anterior spine of the tibia and prolonged doAvnAAards, leaves the foot completely Avithout or Avitliin it.
SIMIM.I: »i:t)KESSMENT AM) OMIOIONn
Gui>
It is neressarv llieii [>> make a correction. How will you do it?
1*' \ou \villeiidca\oui' to redress iIk- l<'g with your hands, bending it, like a soft iron r..d. >>v a piece of green wood. This is possible for a certain leiiglli of lime, from a year and a balf to nearly llirco years; somelinie'^ up to four or five years.
,^■7
Fiif. 670. — Osteotomy of the tibia (sequel) ; the edge of the osteotome is turned per — pendicularlv to the wound and comes in contact with the tibia from without inwards
However, there is no fixed rule as to this, it Aaries much with the children, the development of rickets being prolonged in some instances. You will attempt it then, in all cases.
You will proceed at first with gentleness : but, if in exer- cising a force of some kilogrammes, you do not succeed in making the bone bend, still continue; use a force of from 3o to \o kilogrammes (this varies, but I prefer to give you an idea of the effort to be employed), and then the bone will bend,
Calot. — Indispensable orthopedics. io
626 RACHITIC DEFORMITIES OF THE TIBIA. OSTEOCLASIS
Fig. (5-1. — A radiograph after osteoclasis made by the hands for rachitic deformity of the legs (in a child six years of age .
or you break it, Avhich is again a favourable solution (fig. 671), or the bone refuses to yield.
If the bone is resistant, perform an osteotomy, not on the
uvciimc i)i:i'()nMirii:s oi- riir- m-ki am> oi- im: kkmi u C}jn
same ilay, Ixit a lilllc laler, when llic conliision of llic tissues lias passed ulV.
Tliis ostcoloniN will he linear, .uid iml ciitN ilinoar or
Fig. O73. — A case of severe multiple rachitic deformities of the lower limbs treated by multiple osteotomies. Here, one has cut the femur from ■without inwards. (The upper section .
cuneiform, because the first is much more simple for you, and certainly as effective as the two others (fig. 671 and 672). So as to be certain of avoiding all the important vessels and nerves, you Avill enter from without inwards, from the exter- nal surface towards the internal surface of the tibia, contrary to what is said in books. You will support the limb afterwards with an ordinary plaster apparatus (v. p. 61 3, lig. G55).
628 COXA VARA OF YOUNG CHILDREN
C. — DEFORMITIES OF THE FEET
OF RACHITIC ORIGIN (RACHITIC FLAT FEET, ETC.)
The general treatment is the same as given above, and for local treatment, that of ordinary club-foot (v. Chap, xv) or of the flat foot of adolescents (v. p. 645).
The redressment is made at one, two or three sittings, then one proceeds to a veritable fashioning of the feet, which one supports with permanent plaster for two, three or four months, and afterAvards with a small celluloid apparatus^ which one can introduce into ordinary boots.
D. — DEVIATIONS OF THE FEMUR
In a general way, I recommend here merely the general treatment and rest. It will probably never happen that you find yourself in the presence of deviations of the femur so marked that a linear osteotomy may be necessary to secure a certain benefit to the patient.
If it should, you will make a longitudinal incision 3 or /4 cm. in length on the antero-interual surface of the thigh, but at two fingers breadth outside the artery, ahvays easy to locate ; :then you will go by means of a button-hole, between the muscle fasciae, down to the bone. You will then introduce your osteo- tome on to the internal surface of the bone ; you will turn it round transversely in order to push from Avithin outwards (or from above downwards), towards the external aspect of the thigh which has become the inferior, this external surface rest- ing on a very firm cushion of damp sand (fig. 672).
E. — COXA VARA
Coxa vara. — Look at, in fig. 670, the normal direction ot the neck in relation to the diaphysis. The neck forms Avith it an obtuse angle of 100°, that is almost a right angle and a half. There is a coxa vara when the neck has become weakened until it has become perpendicular to the diaphysis (fig. 674) and much more so Avhen it makes an acute angle Avith it (fig. 676).
[On the contrary, if the neck is raised making an angle
ni AfiNOSis M I rn concfmim iivxiihn m im iiir hmvi (Jacj
iiiiifli iiidif lliMii I 'i<i" (liij. (iyfi), N\(' liiiNc a coxa valga \vliicli is lallicr rare. J
I iiKMilion coxa \ara here because il is nearl\ always of" racliilic orif,Mti. in llic same \\a\ llial pemi val{^Mini is'.
As in thai, coxa vara is (ihservcd either in chihhen ol two or llirce years of age, or in adolescents of Iron i twelve to eigh- teen years. The two deformities are produced uiidor analogous iiinucnces.
Fig. 673. Fig. G74. Fig. G75. Fig. 67G.
Fig. 678. — iVornui/ femur. The axis of the neck makes with the axis of the diaphysis
an angle (at the base) of about i3o degrees. Fig. 67^. — Coxa vara (medium degree). The angle of the neck and the diaphysis
is a right angle. Fig. G75. — Coxa vara of very severe type. The angle of the neck and the dia- physis is only i5 degrees. Fig. G76. — Coxa valija. The angle of the neck and the diaphysis is of 100 degrees, instead of 1 3o degrees, the normal angle.
AAe are speaking here only ofcoxa vara in very young children.
It is because tliese children walk badly, because they are lame, that they come to consult you. And it is neces- sary to know that this lameness may be mistaken for that of congenital luxation of the hip joint.
I . Coxa vara may he a congenital deformity, like luxation of the hip, for example, and it very often co-exists with it. But it is generally due to some defect of nutrition of the bone; rickets, osteomalacia, etc.
A secondary coxa vara may be produced in coxitis (see fig. 67^ and 675) or even as a sequel of fracture of the neck badly united.
63o COXA VARA OF YOUNG CHILDREN
The diagnosis of coxa vara and congenital luxation of the hip. The child swings from side to side and pitches heavily in both cases. If one goes by the characteristics of the gait in children with their clothing on (without any other examination) one may often be deceived.
It is not only the characteristics of the gait, there are other signs common to the two diseases.
Unilateral shortening of the leg may exist in coxa vara, as in luxation.
In both cases, walking has been late, the trochanter is above Nelaton's line ; there is a hollow in the lumbar region and a large abdomen; there is limitation of the movement of abduc- tion of the thigh, consequently of contraction of the adductors.
How do you distinguish the two affections? One may already say, a priori, that luxation being lOO times more frequent than coxa vara, there are 99 chances in 100 that one is dealing with congenital luxation rather than with coxa vara.
Further, in the case of coxa vara, there are antecedents and other manifestations of rachitis, but that is not sufficient to establish the diagnosis.
It is indispensable to establish the diagnosis thoroughly, because of the absolute difference in the treatment. Luxation can only be cured by reduction. Coxa vara Avill be cured by the treatment for rachitis, or sometimes spontaneously. This is how certain lamenesses from birth, mistaken for luxations, and which were coxa vara, have been cured without treatment.
Most fortunately, we have two certain means of making a diagnosis :
i'^ The X rays;
gild Without the X rays, ascertaining, by palpation if the head of the femur is in the natural position.
If you do not find the head of the femur beneath the femoral artery, it is a case of luxation. If you do find it there, it is one of coxa vara.
In short, you are never able to affirm the presence of one or
iivciiiin: i)i;i iiiiMi iii;s oi nii: rmmw (J'ii
llio (tllicr (>r (li(' h\(i maladies uiilil now have made a careful palpalioii of \\w lii|) joml '.
HciiKMidxr llial lliclwii conditions mas co-exist, tliat coxa vara tn'ciirs rrc(jucnll\ with con^^'cnilal luxatioti.
Diagnosis of coxa vara (unilateral) with Coxitis.
(j>niniiin sif/ns. — Lameness, limitalion of movement of abduction, sli^rlit cxtiTiial idlalion of lln' knee.
Different iai si(jiis. — In coxa vara, liic leg shortens (and does not eloiif^^itc as it does in coxitis at the hegiiming). — In coxa vara, the Irocliantcr is above Nelaton's line. There is no pain on pressure over the head of the femur, as in coxitis.
No nocturnal [)ains. There are other signs of Rachi- tis, etc. The child SAvays from side to side in coxa vara, whilst in coxitis he drags the leg. Further, coxitis is rare at one or two years of age, whilst coxa vara is chiefly seen at that age : Finally, unilateral coxa, vara is exceptional.
The Treatment of Coxa vara.
One is scarcely ever called upon to treat coxa vara until lameness has set in. The treatment is that of rickets, general treatment, sojourn by the sea, phosphates, milk diet, etc., and local treatment, rest and continuous extension.
This treatment nearly always suffices to cure coxa vara in young children, and to bring about, after a year or two, the disappearance of the swaying motion and the duck-like waddle'.
II. — THE RACHITIC DEFORMITIES OF THE TRUNK
A. Thoracic Deformities (without scoliosis or kyphosis).
B. Vertebral deviations : Kyphosis and scoliosis.
1. In coxa vara, the trochanter neither ascends nor descends at each step as in bixation (v. 712).
2. In adolescents, there are some very rare and severe cases wliere these means are not sufficient and where one is obliged to have recourse locomplexed surgical operations iv. p. CiSV
63:
RACHITIS. THORACIC DEFORMITIES
A. THORACIC DEFORMITIES
These generally assume one of the two followinffs forms :
Fig. 677. — Thorax boat-shaped or en brechel.
Fig. 678. — Corset in celluloid with
anterior opening for compression
in the case of boat-shaped thorax.
Fig. 679. — Funnel-shaped thorax : St. sternum : Ca. costal cartilage.
i^'. The boat-shaped breast (fig. 677) : a""*. The funnel- .:shaped thorax (fig. 680).
UACHIIK kM'IIOSIS AM) SCOLIOSIS
033
p' |.'o,- ilic liisl. I ailvisc ail irionutvahle corset in [jlaslcr, or hc[[v\\ a inoval.lc corset in celluloid, with on anterior opriiifK/ o|>|»osile the llimacic projeclKui (ll^^ h7S).
One will ( \eit over this point a coin[)rcssion with squares of cotton w(.ol, as if one were Ircalin-a frihhosity in Poll's disease (v.(-hap. v). One will arrive thus alexcellent results, iairlx rapi(ll\ . / in the space of 8 or i:> months. on an average.
2'"'. It is not so easy to cor- rect the funnel-shaped thorax (fig. Oyg and (J8(>).
We have employed here, with some success, the prolonged use oi" celluloid corsets w ith an ope- ning, always patent, opposite the depression.
One removes the corset several times a day, to perform respira- tory exercises (p. 5 78).
Whilst the child makes the movements for enlarging the tho- rax by forced inspiration, one compresses the two lateral surfaces of the thorax w ith the hands placed upon it flat . One may also direct
these children to blow the horn vigorously ; in a word one makes use of any exercises which Avill efface, little or much, the thoracic depression.
The child should lie quite flat. Sometimes when the child is lying down one may see the deformity slightly lessened on placing a pilloAv under the back. If that is so in the case of vour particular patient, use this simple device during the long night's rest.
Fii{. GSo. — Funnel-shaped ihorai.
634 RACHITIC KYPHOSIS AND SCOLIOSIS. DIAGNOSIS
B. VERTEBRAL DEVIATIONS. KYPHOSIS AND SCOLIOSIS
Rickets sometimes brings about a kyphosis, rarely a lordosis very often (in i5 cases in a lOO cases of rickets) a scoliosis.
The vertebral deviation may even be, in certain cases, the only (visible) osseous manifestation of Rickets.
i" Kyphosis and Scoliosis in children from 1 to 6 years of age.
DIAGNOSIS
a. Kyphosis (fig. 68 1). — Rachitic Kyphosis differs from that of a Pott's disease (v. Chap, v) :
i". By the shape of the vertebral gibbosity, which is not angular, as in Pott's disease (v. p. 2^1), but rounded.
2°''. By the absence of vertebral stiffness. The patient being laid on his abdomen, if he raise his legs backwards (v. fig. 2i4 and 21 5), the deviation here is effaced, whilst in Pott's disease it persits.
S"^**. By the absence of pain on pressure and the absence of contractures of groups of neighbouring muscles, Avhilst pain and contracture exist in Pott's disease.
4*''. By the antecedents, and the frequent co-existence of rachitic lesions in other parts of the skeleton.
b. Scoliosis.
The diagnosis of the nature of the Scoliosis is easy to make in children of from i to 6 years, for at that age it is always rachitic.
TREATMENT
If the deformities are only a little marked, place the children at rest and make them live at the sea-side for eight months or a year.
If the children cannot go to the sea-side, or if the stay there is insufficient to redress very marked deviations, do more, redress the spine and support it afterwards with a plaster.
One redresses the spine as one would a club-foot, in one or several sittings, Avith or without chloroform, by manipulations.
TIIEIK TUKATMENT
G3;
malaxalions in the direclioiis, or cliircrent direclions, wished. ^ou ho^'in A'f^a'm with a mohiUsation of the spine, already more or less fixed in its defective position. Once this mohilisation is accomplished, you place (with the pressure of :> or 4 hands)
Fi". 68 1. — Rachitic Kyphosis: the delormity is not angular as in Pott's disease,
but rounded.
the vertebral column in a corrected position, or partially cor- rected position if you proceed by stages. You support the spine in that position with a plaster corset, either a large corset (v. p. 270) which would be the best, or a medium apparatus with a •• col d'officier " when the large apparatus is objected to by the parents. You apply the apparatus in a very moderated extension of the spine : the greatest extension which one can make without
636
RACHITIC KYPHOSIS AND SCOLIOSIS
the heels leaving the ground (v. p. 277). In order that your apparatus may be exact and accurate, before the plaster sets, re-make with your hands, by pressure made through the still pliable plaster, the correction you have obtained, and maintain it exactly until the plaster is quite set. .,=:r::^ ^ ^
Next day, Avhen the apparatus is ^^t^?^^'|>]
quite solid, you will take care to fry ^\^K^J
make an opening at all the points V ^ ^^-v?/
HI ///
I
Fig. G82. — Most often the rachitic scoliosis has its convexity to the left, as in this case.
Fig. G83. — Rachitic scoliosis of the right side is rarer than on the left side.
where you brought pressure to bear with your hands. That is necessary ; if we do not make such openings , we shall have sores at those points, and more than that, we shall lose something of the correction. If we make them, not only shall we have no sores and lose nothing of the correction, but
I III III I HI \ INirNT (J.S7
wi' shall 1)0 al)lc lo add l<. tlii^ willi squares of collon-wool placed in increasing' niiiiilxrs diiiinj,' llic Ibllowinf,' weeks.
liut you have already learnt to correct the giblxtsilies ol Pott's disease in (his way (v. ("ha|i. \).
The child will be kept at rest in the rccuud)ent position, il the parenls force your hand, you may, as a last resource, allow him !.• walk a little, tnr instance, half an hour or an hour every da\ .
The plaster will he left in position for ei{j:ht weeks; then YOU will remove it to make a new correction followed by a new plaster; and so on, until ihe correction is sufficient, which requires from eight lo twelve months, and even longer.
When it is com[)lete, one may. instead of a plaster, apply a corset in celluloid or leather, witli openings and sbutters for com- pression, and the child will be able to walk with the apparatus.
Celluloid has tliis advantage, that one can take it off every day, and even several times a day, in order to carry out redres- sing exercises and massage (v. Scoliosis, Chap. \ui).
In the hospital, and in private cases not well looked after, I advise you to keep on an immovable plaster during the period of convalescence.
AM lb very good general treatment, and local treatment car- ried out in this way, one arrives at surprising results in dorsal deformities of rachitic origin.
I may cite, among others, a child of four years, Pierre B., of Chaumont, who was sent to me by my master Jalaguier; he had a scoliosis so complex and serious, that after examina- tion I scarcely dared to hope that I should arrive at any kind of result. For a year, the deviation was hardly improved, the general condition remained bad and hampered the continued use of the plasters; but, in the second year, the sea air had fortunately modified the general nutrition, the apparatus were tolerated, so that, after two and a half years' treatment at Berck, this horrible deviation was completely obliterated. I have seen results nearly as striking in the generality of cases.
638 RACHITIC SCOLIOSIS AND ITS TREATMENT
One may however have to deal with a scoliosis of particu- larly malignant character, but this is the greatest exception, — and I am able to promise you that, if you carry out the treat- ment exactly, you will arrive at very satisfactory cures in the rachitic scoliosis of young children.
2°*^. Rachitic Scoliosis of older subjects [from eight to twenty]. (See note to page 568).
What I have just said as to the generally favourable prog- nosis of rachitic scoliosis is applied exclusively to very young children; for if these rachitic scolioses havenot been treated from their first appearance, if they have been allowed to develop up to ID, 12 or i5 years^ their correction becomes very difficult and almost impossible; it is these rachitic scolioses which will form, later on, the quota of the severe scoliosis Avith lateral bosses; but it is necessary for us to describe how, in a child of from lo to 1 5 years, who comes to you with a scoliosis, you Avill recognise wdiether it is a question of rachitic scoliosis or the essential scoliosis of adolescence, that studied on p. 667; they are differentiated by a great number of characteristics :
i^*. By the date of appearance. The rachitic scoliosis commences in the first eight years of life, that is. before the age for going to school, whilst essential scoliosis, " the school com- plaint", is especially frequent between eleven and sixteen years.
2"'^ By the clinical and anatomical condition. The ra- chitic scoliosis has a single curvature, or rather it appears single, the secondary curvatures, cervical and lumbar, being situated very high up, or very low doAvn ; the apex of the great curvature in rachitic scoliosis corresponds closely lo the middle of the spine, whilst, in essential scoliosis, the curvature, when it is single, has a larger radius, and it's apex corresponds either to the back, or to the loins, and, later, Avhen two curva- tures exist, one is distinctly dorsal, the other distinctly lumbar, and they often have an obviously equal importance.
S'*^. As Ave have already said, by their very different prog- nosis.
Tur.ATMr.N r ni' oi.n siwniNr; iwciinic .s(;<>liosi:s
(i.iQ
llacliiUo scoliosis is cssciilially, aiul l»\ ils lon;^ standing, much inoi(^ niali'rnaiil and more serious lliari " essential scoliosis.
'I'lic j^rcal (Icroruiilic^. llie lalcial t^i l)l)()>ilics iikf llir sides of a mi'lnn. tlic Iw isliiiLis and dc|ti('ssioris ot the li-unk, wliicli make, in a word, the malignant scolioses, belong almost exclusively to true Rachitis. Here, llic bones are eburnatcd, the articulations already more or less ankyloscd, wliicli adds still more to thediniculty of treatment.
riie liealmenl is like lliat of scoliosis of the third degree (v. p. (3oo) : it is here, in Tact, a ques- tion of scoliosis of the third degree. x\t first a treatment by gymnastics is necessary to mobilise the spine, then quarterly forced redressmenls, followed by the application of a large plaster apparatus.
One keeps to these severe appa- ratus until tlie fixation of the spine in a satisfactory position. These treatments require from two to three years, with a stay at the sea-side. It is, then, comparable to that of Pott's disease.
Once more, take care how you undertake the treatment of these malignant scolioses against which we are still so poorly armed, and of which one ' has been able to say with so much truth : " Since congenital luxation has ceased to be the opprobrium of surgery, the title has gone by right to the old rachitic scolioses ".
In the presence of these bad cases (v. fig. 684), which are not worth the disappointment, practitioners may learn to remember a propos, that there exists some part of the specia- lists' work which they may let pass.
O84. — Very old rachitic scoliosis ; 3"* degree).
CHAPTER XI
GENU VALGUM OR VARUM OF ADOLESCENTS COXA VARA OF ADOLESCENTS
It is designedly that ^ve are studying these deformities im- mediately after Rachitis to Avhich they are connected by more than one tie, so much so that they may be confounded Avith it.
There should be much to say on this point but we wish here to avoid all pathological discussion, and Ave Avill simply maintain, as to this relationship, that in the presence of genu valgum and coxa vara of adolescents, we shall have to carry out, as for rachitic deviations, outside of the local treatment of the deformity, a general treatment : a. dietetic (milk, eggs, etc.); b. climatic (life by the sea, if possible); c. medical (cod liver oil. iodine, phosphates and phosphorus in all its forms).
The general treatment you know; the local treatment is equally well known to you, after what we have said of genu valgum and coxa vara in young children.
l"" GEXU VALGUM (OR VARUm)
The deformity exists on one or both sides. Refer to p. 608, where we have indicated the course to be folloAved. As in young children, the correction may be obtained by simple redressment of the knee, or by supra-condylar osteotomy.
Of these two treatments, which will you choose!'
If you are something of a surgeon, perform osteotomy, a
(;1:M \ MCI \l IN NDnl.lXMN I <
(J'll
l)ciiii;ii .111(1 ^Iiii[)lc .111(1 iiinrc f. rpcdiliniis (t^if\:i\'ii>[\, llir- n.iilicil- lars I il \\ liiili ;iic -rl out on |). (i i <).
lull il \Mii. or ihc |iai(iils, \\is|i III ;i\((i(| *• ,1 hnli' in ihe skill .iml llir clliisioii III ;i (li()|i III' lijiiiiil. \iiii cm (Im so; one ran clVccI redressmciit li\ siiii|)l(! 01- lliO|»ir(lic niaiii|iiil.ilion^ a! IIiIn .iuc. as in \oiin;r iliildicn : oiil \ il will rpiiuii'i' .1 lilllc more lime.
Ami. Ill till' saiiK^wax as in voun^r cliililiin. il llic [larcnls tli'iiiaiiil ol \oii a lic.ilnirnl ii<>l iiivoKiiii; (lie iiii|»ossi- bililN (if walking, Nmi will be ahlc lo salisfv them, because the cure can he obtained in spite of walking, nn llie coiitUtiori tbal you are given the addi- lional time you desire.
In that case, to allow of walking, you terminate your plaster above at (he upper border of the great trochanter, and below, opposite the malleoli (see fig. 656).
In the case of genu varum, one carries out a similar treatment in the opposite direction.
:>'"' CoV-V \All\ OF ADOLESCENTS.
Fig. IJ.S.). — Altituile in coxa vara, atlducliun ami external rofalion.
We have spoken of coxa vara in yoimg children on p. Q2S.
According to German authors this deformity is generally observed in young persons who are employed in the fields; hence the name Baiierhein in opposi- tion to that of Bacherbein (baker's leg) given by them to the genu valgum of adolescents; however, I ought to say that, for my own part, I have seen it only in private cases, still attending school. I may add that this deformity is very rare in France,
C\ior. — Indispensalile orlLo[)e(Iics. ', i
642 COXA VARA OF ADOLESCENTS
if I can trust my own observation. I have not seen more
Fig.'686. — A severe case of coxa vara (after a radiogram of one of our patients, aged
li rears).
Fig. 687. Fig. 688. Fig. 689.
Fis. 687. — 1" step of operation : separation of the neck from the diaphysis.
Fig. 688. — 2°'' step : refreshment of internal face of great trochanter.
Fi^. 689. — 3''' step : traction on the diaphysis and placing in contact the neck and
the refreshed face of the great trochanter ; then a plaster apparatus.
than 10 cases in 16 years, whilst the Germans say they encoun- ter it very often.
1 hi; \ iNir.N I III covv \aiiv in adui.ksckms
r.'i3
The position ol tlic liiwn liiiili'^ in (loxa vara is chararlcr- iseil hv a lonclciuN Id addiiclioii ><\ llic tliiglis and to n)lalion outwards (li^'. (itS")).
Tlic first sign ina\ he the appearance of a [)ain caused l)\ some insi^Miilicaiit injurv, or a feeling of lassitude in the legs; but most usually lln' first sign is here, as in \oung children, a defect in walking:, ;^ defect Avhich progresses insensibly until it becomes a real lameness. In advanced cases, one sees the patients stagger,. y/^'av and in<i<l- dle, so that one thinks it is either a coxitis beginning, or a conge- nital dislocation of the hip unre- cognised until now, or even an acquired luxation, in the case where the patient attributes the origin of the lameness to a fall or a wound.
The diagnosis will be made between tlie two maladies, as in young children, either by clinical signs alone (v. p. 629) or bv the X ravs.
The Treatment.
A.
General anti-rachitic t'g. 6<jo. — Operation performed on one treatment ' of our cases. The funclional result has
been
sood.
B. Local Treatment :
a. For mild cases, rest and extension in abduction for 5 or 6 months.
h. For cases rather more pronounced, one adds kneading or even tenotomy of the adductors of the thigh, which are always a little contracted. And one succeeds thus, in a few months, in effacing entirely the defect in walking.
644 COXA VARA OF ADOLESCE>TS
c. But, in very advanced cases (fig. 686), one can scarcely hope for a complete functional cure, — and the treatment is a little uncertain.
One has proposed sub-condylar osteotomy and various resections, and even resection of the hip-joint! This is what we have done in a very grave case :
I"'. Division of the bone at the root of the neck (fig. 687) ;
2'"'. Refreshment of the internal surface of the great tro- chanter (fig. 688) ; and 3"'. Traction on the femur until adap- tation of the refreshed surface and of the external surface of the neck was effected (fig. 689). Suture of the skin with cat-gut (with drainage), and immobilisation for three months in a large plaster reaching from the umbilicus to the toes.
The drain was removed on the sixth day, by a small ope- ning made in the apparatus.
It is necessary to say that the plaster should be, here, par- ticularly well fitting, without which the two fragments will glide over one another and the leg ascend.
The last bandage being applied (whilst the assistants keep up the traction), before the plaster sets, one scratches with the fingers a deep trench above the trochanter, in order to wedge it up. To the same end, the femur will be placed in the greatest abduction compatible with the coaptation of the fragments.
One might also fix the fragments with an ivory peg or even with a metal screw.
See additional notes on Coxa Vara, end of Chapter xxvi.
cii \v'y\:\\ \\\
TARSALGIA OF ADOLESCENTS OR PAINFUL FLAT FOOT
A. - Diaj,>:nosis.
Bd'ore solliiifi- onl tlir Ircalinciil. \V(' mi^lil lo sa) a word tipnii diagnosis; it is necessary, seeing; thai, in se\rn cases of tarsalgia wliicli have come under observation in six mf)nths, we have seen three errors of diagnosis committed by well informed practitioner.
The lirsl had been mistaken for rheumatism, ihesecond for a tuberculous arthritis, and the third for a dislocation of the foot (tntwards, which is difficnlt to understand at lirst, but which is explained in a certain measure by the exceptional contracture in this case (such as we had never seen before) of the peronei and the extensor communis digitorum, which had drawn the foot ontw'ards in valgus, to a point which closely simulated a real dislocation.
In the other two cases, it Avas the weakness and aching of the foot which had led to the belief that they were cases of rheumatism and while swelling respectively.
Three mistakes in seven cases, it is too much! Neverthe- less, exact diagnosis was important here in the highest degree; for, if it were a question of tuberculous arthritis (a blunder commonly made) one ought to put the patient to rest for at least a year; if it is a question of tarsalgia, the patient, on the contrary, ought to walk about as soon as the foot is redres- sed, almost at once, and the cure Avill be complete in two months. You see the unpleasantness to which one is exposed in mistaking the true nature of the malady.
By what signs can one recognise tarsalgia :'
646
TARSALGIA OR PAIKFUL FLAT FOOT.
DIAGNOSIS
i^'. By the age of the patients — they are adolescents ^ . Thus then, in the presence of a painful foot in a patient of from ten
Fig. 691. — Valgus flat feet : one sees in this figure the abduction en masse of the foot and the sinking of the plantar arch. Prominence of the scaphoid on the inner border.
to twenty years, one ought always to think of a possible tarsalgia and verify the value of this presumption.
Fig. 692. — I. Imprint of the normal foot. 2 and 3, Valgus flat foot in two different stages.
2°*^. By the character of the pain — which has come on generally after a rather long walk, and which has disappeared completely after a night's rest; then, it reappeared on certain
I. Nearly always.
i»i\(;\(isis Willi 1 1 111 III. I I. Ill s Miiiiiiiris ur rm; I'oor {\\-j
(la\s. when llir |);iliriil was iMtiLMioil , .iiiil iliil iml shew ilsfjll ollici w 1--I'. Till' |i;iiii w.i--. ;il llir hrLiliiiiiii;^;, a sciisalion of (•iaiii|i ill ihi' rail ami llir IdoI; lalri mi. this became such an af^'OMisiiiL!' |);»i II I if slirlcliiiiu uf till' fm il I ha I is w as irnpn^'sihle to take a sle|).
;V''. /)_v the sli<ii>c <if Ihc fniil. ll
is MOCOSSarN In cxainini' llic Innl
naked (fif,^ <'•)!) willi the patient stanthii";' u|)rii;lil.
(I. The foot is flat, il has im vail 1 1 : il si a 111 1 5 i>ii I In ^n mi id w illi llir entin> sole (lij^'. *><J'0 "- die internal border i.s convex inwards, the apex of the convexitN . thai is. (he niDSl pio- ininriil [lart, is formed by llie head of the astragalus and the scaphoid which sometimes touch the ground.
The external border, on llie con- trary, is almost concave.
b. The foot is thrown en masse outwards, in valgus; this is especially marked when the foot is inspected from behind; the axis of the leg falls well inside the middle of the heel. | ^
c. Under the influence of the I upright position, the foot is of a vio- let hue, it presents varicosities and is sometimes covered with perspiration.
4"'. By palpation of the foot, wdiich is negative at the outset, one finds neither fungosities, nor pain on pressure over the bone. At an advanced stage, the foot may be swollen, it is true, but it is an uniform oedema, there is no coUerette nor any fungous points over the course of the articular synovia^, as in tubercu- lous arthritis ; there may be however, at this time, pain on pressure over the bone, always localised at the internal part
Fig. 6i)3. — Flat fool seen from the ImcL : Ihe axis of the leg falls inside ihe heel.
6/,8
TARSALGIA OR PAINFUL FLAT FOOT. TREATMENT
of the astragalo-scaphoid articulation (fig. 694)- The diagnosis will be easy even in this case, thanks to the history, to the shape of the foot and to the absence of fungosities.
5''\ By the two feet being very often affected, although in unequal degrees (v. fig. 691). The patient complains of only one of the feet, that which causes him the most suffering. It is for you to remember always to examine the other; oblige the patient to recall if he has not suffered a little in the other foot also.
6*''. By what one often finds, that the same conformation
Fig. 69/1, — The painful spot is situated nearly always at the internal part of the medio-tarsal joint. Here, it is a little in front of that.
of the foot exists in other members of the family without pain being present in every case.
We ought to remark, hoAvever, that a child with a flat foot is in a condition, just like anyone else, to produce a tubercu- lous arthritis ; one Avill then find the signs of the two maladies super-imposed.
Upon the whole, and in ordinary cases, the elements of the diagnosis are included in the synonymous denomination of tarsalgia, namely, painful valgus flat foot of adolescents ; they are all there.
a. Foot flat,
h. And valgus,
c. With pain.
d. In patients from 10 to 20 years.
I'l Ui:i.\ UUl lliiliH.DIC TIlKA I \11:M Is SLFI'MJIKNT
GV)
l'> — Treatment.
I lie (li.i^iKisis hciii^'- iiimlc, whii will hr llic Irealiiicnl ;' riial tlcj)L'tuls upon ihc Viiiiil\, m- imIIhi'. U|iiiii ihe rliriical loiin of I he tarsal jria.
OiuMMii (lislillglli■^ll two forms, line mild, llir oilier severe
Fij;. (jgO. — Flat loot, front view : depression of the inner border.
Hg. '197. — The inner border is raised, the external depressed in the direction of the arrows.
Fig. 0(j5. — (Correction of abduction. The foot is carried bodily inwards, in the direction of the arrow : the dotted line shews the normal atti- tude of the foot.
which correspond in a general way with the two periods of the disease.
In the first, it is a question of a conrimencing subsidence of the foot under the weight of the body; pain is present onlv on waikini;'. and then onlv on taking rather lons" walks.
In the second, there is a secondary inflammatory arthritis; a contraction of the peronei and extensor communis muscles; the foot is painful at rest and on pressure; it is fixed in valgus,
65o
TARSALGIA OR PAINFUL FLAT FOOT.
TREATMEiNT
and resists " like wood " if one attempts to place it in varus; and such attempt is very painful.
Fig. 6g8. — The thumbs are placed over the tubercle of the scaphoid ; the other fin- gers of the right hand clasp the internal surface of the os calcis, leaving those of the left hand at the anterior part of the external border of the foot. The thumbs serving as a fulcrum, the two hands work so as to curve the internal border of the foot.
Loss of power is complete or almost so.
"Whatever may be the variety of the tarsalgia, the rational
Fig. 699. — Flat foot seen on the plantar surface.
Fig. 700. — Scheme of the manipulation described in fig. 698.
treatment is to change the statics of the foot, to return it to its normal position and to keep it there.
Tiir rnrvrMTM' ok Mir.n iohm^
>i I \ii- \r.(,i \
ti.ii
iui:\iMi.\i <>i iiii; I lusi \ Auii r> (\iii.i> \ \hii:tv).
a. riic lortt is iii;issaji<'d once or twice a (la\, is carried into correction, or ratlior. Iiypcr-corrccliori, in one silling of len mi- nules, willi inanipulalions in llio opposite dircclioii lo ihosc made in iirdinar\ ilnb-lool in varns (fig. Oc).'), 69G, 697, G98, 699, 700, 701, 702). \on exjilain to the parents how llie nianipnlalions are to he perloiined.
6. I he patient is made to wear a hoot with the inner hordcr raised two centi- metres, witli a shght curve to re-t"orm the arch of the foot (fig. 708) .
This is sufficient in vcrv mild cases,
-j^
I
■ Raising the inner border of the foot.
Fig. 702. — Foot corrected : com- pare this with fig. GgS. The axis is over the outer border of the heel.
and the patient is able to continue his ordinary mode of hfe. If it is not sufficient, one adapts to the boot our lever-sole, in the way represented (fig. 704, 705, 706, 707). Thanks to this boot the patient becomes able to walk immediately like a normal person; it is indeed necessary for him to walk, because, in Avalking, the
652
TARSALGIA OR PAINFUL FLAT FOOT.
TREATMENT
foot becomes shaped more quickly than Avhen remaining at rest. After from six months to a year, one can return to ordinary boots, simply providing them Avith an inner border a centimetre higher than tlie outer.
Fig. 7o3. — Boot sole for valgus flat feet. It is very much curved at its inner border : the sole and the heel are much thicker on the inner than the outer side ; at the arch of the foot, it is furnished with a soft pad intended to raise the inner border of the foot.
TREATMENT OF THE SECOND, OR SEVERE, TARIETY OF TARSALGIA
The foot is poAverless and painful, and is fixed in valgus. If one wishes to manipulate it, the patient cries loudly, and nevertheless, it must be manipulated. — This is hoAv it is done.
A. With chloroform. — There is an easy and expeditious wav to succeed in this; it is to put the patient to sleep for five or ten minutes, to place the foot in varus, in adduction, in such a way that the inner or concave border is raised, and then to fix it immediately in a plaster (fig. 708, 709), with Avhich the patient is able to walk the next day.
B. Without chloroform. — In the case where the parents dislike either chloroform or plaster, you can still arrive at a cure.
i^'. You are able to redress the foot, proceeding as you
nil': iiu;vi\ii.vi oi >i;\i:ai: ioumn i>\ i \ii>.vi,(.ia Cj7}'i
Fig. ■yoi. — Our lever-soIc adapteil to a l)Oot view of plantar surface).
FiiC- 700. — Our lever-sole, viewed on inner aspect.
654
TARSALGIA. SEVERE FORMS
would in the presence of a very painful sprain ; you proceed to massage the foot, at first very gently, scarcely touching it, for several minutes, in order to deaden and benumb the sensibility and overcome the spasms; then you proceed a little less gently, then more vigorously, and after fifteen minutes you are able,
706.
Our apparatus applied.
707.
The trowser hides the lever.
w^ithout causing pain (or with the least pain imaginable, and quite supportable by the patient), to knead it, work it and place it in varus at one stroke, or at least in a nearly correct position, postponing until the next day, or the day afterwards, at a third or a fourth sitting, the effort to obtain hyper-correction in varus.
You can make two sittings for massage each day.
2""^. To support the foot. — You proceed, at the end of each
(IK I imiMH Die iui;\i\ii\i IS Mwvvs >iiii(.ii;\T
(Ijj
sillinir. !<• Ii\ il will) "ui lexer, wliieli iv rcprosonlcd licrc ((i^^ -III 111 y I 7 ). ;iii(l. rmiii llie-cemiil (h lliii d da y, llic piilieiit
Kiit 708. — Al'ler the manipuhi- lions. one puis on a plaster appa- ratus supporting (lie fool in hyper- correction : tliis apparatus ought to leave onlv the toes free.
Fig. 709. — Plaster seen from the back ; one strengthens with a plaster buttress the inner border of the sole, in onler tliat the plantar surface may be perpendicular to the axis of the leg and bo placed quite Hat on the
ground (in order to facilitate walking).
\vill be able lo walk willi tlie apparalas, placed iti a snilablc boot, as he would with a plaster apparatus. Plastei- has this advantage, that one has no need lo touch il lor six weeks.
656 TARSALGIA OR PAINFUL FLAT FOOT. TREATMENT
— On the other hand, the lever sole is often more favourably
^-•-j
Fie. 710. — Construction of our lever sole : one places the foot on a sheet of paper and one traces the contour with a pencil.
received by the friends of the patient ; it may be changed at AA^U; one performs a nev\^ massage every two or three days; in
Fig. 711. — Tracing of the foot in outline. The clotted lines shew the form of the sole which will be cut out of sheet iron for the lever-boot.
the interval of the sittings the patient continues to Avear the sole (that is, day and night) in order to shape the foot.
i>m; (.iiu- Willi I in 1 IK ijM hdk; \ii:\ns m.om-:
Altci' si\ \\ ccks. ( MIC i('iiin\('s llic pLislrr or llic Icvcr-hoi i| , and rcphircN il willi .in iinliii,ii\ slntc willi llic inner horder raised and Nli;jlill\ \aiillcd; hi llii'- slioo is adapted a lever of llic l\ind i('|)irM'iilc(l licic Willi an *' eleplianl'^ lool Irowser. m- siiii|>l\ a lallior wide orn'. and hcllci' slill willi gailei'S. <iM(' liidi's lli(> lower part nf llir lc\cr \i'i\ wrll.
The paliciil wears lliis Ixinl. in severe cases, lur a \ear or
Fig. 712. — Seen on the inner surface. Fig. 718. — By the posterior 3/4 face.
lAvo, to shape his foot (but ^vith this very convenient support, he comes and goes like an ordinary individual). As time goes on, the patient will wear, if need be, a slioe raised a little on the inner side.
And that is all. See how simple and accurate the Ireamentis. , There may be brought to you, an individual who has been completely helpless, for several months. Almost instantl}, on the first day, or at least the next day, you have rid him ol" all his pain, and he becomes able to walk as much as he likes.
And this small miracle you will elTect always, because all tlie cases are suitable for this treatment.
C.\LOT. — Indispensable orlliopetlics. /ia
658
TARSALGIA.
VALUE OF SURGICAL OPERATIONS
Value of Surgical Operations.
Then, as to surgical operations for the severe cases, the
operations of Ogston, of Vogt, of Trendelenburg that is,
cuneiform resections of the bones, ablation of the astraga- lus, etc. PP.. . I never perform them now.
Fig. 714. — Application. One fixes first the fore part of tlie foot whit several turns of Velpeau bandage. The heel overhangs the extremity of the instru- ment behind .
T V :?■'
Fig. 715. — A cast of the bandage for- ces the heel inwards, on to the appa- ratus ; the inner border of the foot is then found to be arched.
Formerly, I treated old standing tarsalgias with the saAV or the chisel, like all other surgeons. Today, I treat the same severe cases by vigorous shaping of the foot, with or without chloroform , followed by the application of a plaster or of a lever-sole, and I cure them, not only as Avell, but certainly better than by my surgical operations of earlier days. I have not seen, for six or seven years, a single tarsalgia which bas resisted this treatment.
Yhe treatment, besides its admirable efficacy, presents this
mm; aui II it.Ai. xii.i; slmicks roll ai.i. \i;in mii.d cases ()5o
Fij;. 71(3. — Tlie Toot is intiruatelv fixed to tlie artificial sole.
!■ ig- 717- — The lever drawn asaia^t the calf raises the inner bor(!er of the fool aad replaces it in adduction.
.--'?'
Fig. 71S and 719 — Simple steel sole (in the boot) which suffices for mild flat fool at the beginning : i. inner surface : 1, plantar surface : 3, cut of the hool furnished «itli liie artificial sole (according to .\ B in fig. 2).
precious advantage, that it is very simple and may be carried out everywhere, hv each of vou.
CHAPTER XIII
INFANTILE PARALYSIS
Before touchina- upon the treatment of Infantile Paralysis, -we Avisli to mention Avliat it is necessarv to knoic about electricity : I'^Mn order to make the diagnosis of the condition of the affected muscles: 2°'', in order to combat muscular atrophy, seeing that this information does not appear to us to have heen anvwhere set out Avith the preci- sion and clearness which is desirable^.
One utilises for this purpose the galvanic or continuous currents and the faradic or induced currents.
Apparatus employed. — Galvanic currents are furnished hv a batterv of cells of 00 elements (fig. 721 Avhich can be bought Avith tbe necessarv accessories, sucb as : a switch or rheostat to 2:raduate the current, a milliamperemeter to measure it. an interruptor and reverser to establi-h it. to interrupt it. to modify it"s direction; tin plates and tampons covered with felt or chamois leather, serving to applv it to the patient, and -ome pliable \\ ires for establishing the connexions.
The faradic currents are furnished bv an induction coil (tig. 728) supplied with an interruptor which can be regulated and fed from a batterv. The current of induction mav be au<rmentedor diminished at will : tlie induction coil ought to be of thick wire.
Method of employment. — The plates are moistened with warm water. One, verv large, of from 100 to 100 square centimetres called the indifferent electrode, because it only serves to close the electric current, is applied against the middle of the patient's back, if it is a case of paralvsis of the lower extremities : at the nape of the neck if it is a question of the upper limbs. It remains fixed during the Avhole of the sitting : the other, the smaller, of olive or spherical shape, called the active electrode, is applied over the muscles to be electrised, and
I. These few pages liave been drawn up by my old assistant, Doctor Ber- angnat, of Argeles-Gazost, A^bo is a particularly competent electrician.
iNM-'i KN^Mti i: luniMi'M^ ')!• MRDicM, 111 i.f rui<;i ! V
(iOi
iiiONcd aljont according as iiiaN l)c loquirccl. Oii('i->lal»lislirs tlic con- iirxions with llio exticinilics of llic iiuliKlion coil, or willi llie pole> of iho l)atl(MY, lakiiii,' caro to oslablisli llio ciirrciit ijrnilnally , and. in iho case of the conlinvions ciirii'iil, dclcrniining cxartly the direction of the current, tlio active elcclrodc Ix'int:. accordini: fo llie case, positive or nei;ati\e, ami nut lia\iri- tlic ^anic cIVocI-. Tlie second cleclrode
I •! '1 '1 I [• ii |i
<f
mr- n
MmWV
uuuuuy Uj
Fig. 720. — Schema of an apparatus for the continuous current and the necessary connexions for its application to the patient. The rheostat enables one to gra- duate the current. P. Batterv of 3o cells : R. Rheostat : 1. Interruptor-reverser : G. Galvanomeler.
is sometimes represented, for electrisation of the limb, by a trougli of water into which the hand or the foot is plunged (lig. 724)-
Exploration of Muscular Contractility. — For this, the strength o[ tiie currents employed should be precise, and it is necessary to localise the active electrode well over the motor points of the muscles.
In the normal state, the faradic current produces muscular con- tractions during the passage of the current, more or less strong according to its intensity: a series of isolated and repeated contrac- tions if the interruptions are suiticientlv slow, a sustained contraction
66;
INFANTILE PARALYSIS
if the vibrations of the inteiTuptor are rapid. The galvanic current, which has profound effects upon the nutrition of the muscles and favours their development, provokes pricking sensations, burns of the skin at the points of contact of the electrodes; but if the current has been established gradually, ivithout jerking, and diminished in the same way, there will be no contraction of the muscles during the passage of the current. On the contrary, if one violently interrupts the current and
Fig. 72 1, — Model of a portable case with switch. C, Collector;?. Cells.
G, Galvanometer ;
if one re-establishes it as violently, the muscle receives at the break and at the make of the current a galvanic shock to which it responds by a lively contraction, brusque and immediate. This contraction varies with the intensity of the current, its direction, the nature of the galvanic shock received (opening or closing of the circuit). A normal relationship exists in the order of appearance of the contractions when the current is changed successively from i,2,3, up to 20 milliamperes and in their force for the same intensity of the current. At one or two milliamperes, the closure contraction occurs if the active electrode is negative ; at three milliamperes, there is a closure contraction with the positive electrode ; at 3 or 4 milliamperes one can notice the break contraction
INDISPENSAIU.E HUDIMICNTS Ol MI.DICAI, KI.F.C I lll<:iTY (KJ.)
Willi llie posilivo clccl nxlc ; willi the iiogalivc ficclrodc, the break c-oiiliiulioii oiih shows ilscll il' Ihi' curiciil rises to if) inilli.iiiiperes.
"h^iI
2 2-
Tl
fi„. -22. — Scliciua I'oi- an apiiaraliis I'.ir llie larailic nnicnl au I connexions. 1'. Cells : H. Hulmikorirs Coil.
^^ ilh a current of Ironi i5 to 20 milliampcres, one obtains with the t^^o poles, indilToreiitly at the make and break of the current, a
TZ
Fig. 728. — t^orlable Induction Apparatus. — AVhen the luhe is drawn in the direc- tion of the arrow, the current is augmented. — B. RuhmkorlT Coil : T Inter- ruptor : V. Screw of the inlerruptor ; T I, Secondary Tube.
contraction, but at the make the contraction due to the negative pole predominates, at the break it is the contraction due to the positive
664
I>"FA^TILE PARALTTSIS. ELECTRICAL TREATMENT
pole which is the stronger. On the other side, the contractions pro- duced by the abrupt make of the current are always stronger than those following the break.
As to the pathological condition : when a muscle is attacked by infantile paralysis, it does not react normally to electrical excitation. At first, it becomes less and less exci-
Fig. 724- — Posilion of the patient for application of the continuous current in the case of infantile paralysis, left leg. The electrode on the hack, held by meeuis of a bandage, is positive ; the trough of water represents the negative electrode
table to the faradic current. When the case is serious, there is no contraction with the current, whatever its intensity may be.
Galvanic excitability may then be increased or diminished, the relations between the contractions obtained remaining the same as in the normal condition.
But if this relation be modified, the muscle being found to be inexcitable by the faradic current, then there appears Avhat is called, by Erb, the reaction of degeneration. The contraction due to positive excitation Avill be stronger at the closure of the circuit, than the contraction due to negative excitation. It is
I\|i|><l'l \S\lll.i; lUIMMIMS (11 Ml hICM. CI.Kr: I MICI T Y ()(;.')
llie reverse of dial wliiiMi occuis jn ihc iMinnal rondilioii ; ihc saiiir i(>\t'rsal luav Ix- iirodiited a( (lie hrcak (if llio curir'nl. ll is lliis tlisliirhaiiLC caused in llio iKiinial Ibrinnla of muscular responses to ilie «ralvanic current whit h characterises the itMclind of de<i;enerati(tii.
< >ii the other hanil, the contraction produced, no lon'rer shows il> chaiactcr of iiistantancoiisness; it is slow, slu^';.'isli. retarded. In olher g-raver cases, the muscle remains inert in the presence of ihe apitlicatinn o|' the I'aiadic and galvanic currents.
Value of Electricity in Establishing the Prognosis. From the muscular reactions one may draw interesting conclusions as to the prognosis of the disease.
I. When the muscles present only a diminution of their contractility hy galvanism and faradism. one may hope for a rather rapid return (8 to lo months) of their motility.
II. If they have become inexcitable to faradism. hut react still to galvanism without the reaction of degeneration, tiie case is still curable, but a year or a year and a half of treatment is necessary.
III. If llie muscles present the reaction of degeneration. one may still hope for an amelioration if (he treatment is applied with perseverance.
l^ . Finally, when the muscles have lost all electrical excitability, in spite of methodical treatment continued for a year, their function is irremediably lost.
Electrical treatment of paralysed muscles.
The electrical treatment of infantile paralysis may be summed up thus :
I*". Early intervention : two or three days after disap- pearance of fever.
2'"'. The employment of galvanic currents of Irom lo to I.") milliamperes applied two or three times a week by means of two very ^vide electrodes, a positive plate placed over the back the other being represented by a cup full of tepid water into
666 INFANTILE PARALYSIS. ELECTRICAL TREATMENT
which the extremity of the hmb is placed. Duration of the passage of the current : lo minutes. Take care to reach this strength of current slowly, commencing at zero at each sitting.
3'''^. Produce at the end of the sitting some contractions by brusque interruptions and reversals of ihe current.
4*"". After this treatment, which is directed to the limb, electrise, by means of the tampon electrode, muscle by muscle, those which are found most sluggish. Use for this the same form of current as in the preceding.
5*''. No faradic current : one may employ it in order to ascertain from time to time the muscular reactions, that is for the purpose of diagnosis, but it should not be applied in treatment.
6*'\ Much perseverance is necessary on the part of the physician and the patient, for the treatment may be of long duration; when it lasts for more than a year, it is useful to allow a rest every three months.
7'"'. Before considering a muscle as definitely lost and giving it up, one must see that, in spite of the treatment employed, there is no re-appearance, for at least a year, of electrical reaction. (See IV, preceding page.)
THE TREATMENT OF INFANTILE PARALYSIS
I only occupy myself here with Infantile Paralysis from the ortho- poedic point of view. It brings about deviations and loss of power more or less serious. What is to be done?
There is no general rule to be adopted for all the patients. The course to be followed depends on each case, and the cases differ much from each other.
We will pass in review the different clinical forms wbich one may encounter, and point out the treatinent in each of them.
The treatment may be orthopoedic or surgical.
I. — PURELY ORTHOPCEDIC TREATMENT
(that which all practitioners can apply.)
A. — The Infantile Paralysis is localised in the foot.
You know that it is the loot especially which is attacked. One can differentiate three varieties :
IM'AM ll.i: I'AllAI.^ >IS.
ourii()i'(H;i)M; iUKxiMrM
(i(i7
I"'. \ AHiioT-v : .1// IIm! musclos of llu' Ic^r are ;iir»'((cil, — dijIiUy IhiI uniformly nlVcrlcd. — Tlirn' is no ilcforiiiilv.
:<"''. VAlilFTV : I// llic lllllS(•|(•■^ arc allrclcd .n\i\ niiiijilrlflv h,sl. The fool is limp.
3"\ v\nii:i\ : ( hie miisclr only or I w o oi' llircc inii-^cle^ onh
aro afTcrlcd. and oiio lias a jKwalylic <lnli fool ijjroduccd l)\ llic |iipdo- minaliiiy aclioii of (ho anlagonislic sound musclosj.
Fig. 720. — Infanlile Paralysis of the right leg. All the muscles have been alTecled (slightly affected). There is no deforraifv.
-/ J*
Fig. 72(1. — All the muscles of the leg have been attacked and are completely lost: the foot is limp. The thigh is normal.
I*'. Variety. — The child drags the foot a little and is slightly unsteady on that side in walking; when one examines it, one finds a Utile weakness, but no deformity (fig- 723). On comparing the limb with that of the opposite side, one finds
668 INFANTILE PARALYSIS. PARALYTIC CLUB FOOT
that it's development is rather behind-hand ; all the muscles are a little more flabby, a little less strong; but this diminution is very little marhed and moreover it is spread over all the muscles Avhich ensure the equilibrium of the foot and the preservation of its proper attitude.
The treatment is very simple.
Here, apparatus or operation is out of the question. The only thing to do is to strengthen all the muscles of the foot, by massage, by electricity, warm sea baths, or warm sea sand baths, or even by the baths of Bourbonne, of Aix, of Argeles- Gazost, of Salies, etc.
If there should be at the same time a shortening, one may correct it by a special heel to the boot.
2°''. Variety (fig. 726). — All the muscles of the foot are affected very seriously, entirely, or almost, lost; the skin is cyanosed, the foot is limp and cold. It is placed in equinism by the sole influence of weight.
Here, there is no need for hesitation.
You will redress the foot, divide the tendo Achillis if it is necessary, in order to obtain the correction. \\ hen the foot is straight, you take a mould, upon which you will make a rigid boot with strong buttresses fixing the foot in this position.
The mould taken off, you place on the foot a plaster which you leave on for four or six weeks — the time required for making the boot. This should be Avell padded to prevent sores on the badly nourished foot. The boot is worn during the day, and even during the night, at the beginning, until adhesions have occurred which fix the foot at a right angle.
3"^. Yariett : The Paralytic Club Foot.
There exists a deformity of the foot which is produced little by little; it is nothino^ at the beginning, but it ends in becoming a veri- table club foot.
It may be an equino-valgas, or an equinoclub foot, or a hollow foot, or an equino-varus.
Diagnosis. — One distinguishes it from congenital club foot :
OKI IK M'Ol.lill . IIUVIMINI III l-MtM.^in: (I.I It I ( H I I ()(i(^
r' l)N lis sli.iix': J"' li\ il'- liisldiv; 'V' hv oxamiiiiilioii of llic liinh; V'' l>v IIh- relative ra(iril\ willi wIikIi vou ;iro able to rotlress il.
A. Till' slitijir. \\ liil-l (oii^ciiilal cIiiIj fool is nearly alwajs
e(|iiino-vartis, llie |iaial\lic rliili I'ool is ver\ (il'leii e(|iiiiif)-val;,'us or 0(|iiiiiiis, or lain- \almi>. linllow ioul, clc.
1). rite liislorv. — lii |)aial\lic clnl) tool, the iof)l was iioiiiial al l)ii ill and y;piiorall\ the child walked well at the usual j)ei lod ol \ j. to 1 'l luontlis. At a Near and a hall'oi' two years, a fever' siiperveiied, with or without convulsions; the liiid)S were almost cr)in|)letcly iiaraKsed l'oive\eial weeks, iheii the | i;i la I \ -is d i-a | i|iea red I'khii every nail. e\ee|il ihe lool, which look, lillle h\ lillle. ihe deleciise diapi- \oii now sei'.
\\ hen you have a history so elear as this, the diagnosis isohyious. \\ lieu the history is not so clear, the diagnosis is nalnrally less ccr- |;iiii. It will he wise to look lor other symptoms.
c. li.raininiilinn of Ihe jxdienl. — If it is a question of a paralytic club foot, \ou may lind signs ofinlantile paralysis in the foot or leg, namely : loot less warm or even cold, skin more or less rosy or even vioh'l on that side, which is evidence of a defective nutrition: the musculature of the leg is more flahbv, owing lo lack of contraction of certain muscles; in a word, vou are in the presence of a paralysis, or of a pai'csis, of one or se\(>ral muscles, of a manifest atrophy either of the leg, or even of the whole lower liml).
1 know , however, that in congenital club loot, there is a slight amount of atrophv hut to an incomparably less degree: the muscles are alwavs much stronger and more resistant.
d. Easiness of Redressinent. — This is again a very valuable dia- gnostic point, so much so that one is able to establish, as a general rule, that a club foot of six, eight, ten years standing, which one is able lo redress in eight or ten minutes, is not a congenital club foot. Thai, at this age, will require for its correction, three quarters of an hour of vigorous manipulations.
The Treatment of Paralytic Club Foot
I'" degree. Simply a tendency to a bad position. — There exists, so far, only a tendency lo deformity ; but, if nothing is done, this slight tendency may run one day into the very marked deviations which are represented in the figures from 769 lo 772. — The only harm done so far is the wasting-
I. Most tfenerallv al niirlit time.
670 I>.FA>"TILE PARALYSIS
ORTHOPCEDIC TREATME>'T
N
of a single muscle which the paralysis has slightly affected. It seems that, if ^Ye were able to assist this slightly wea- kened muscle, we would re-establish the equilibrium and make sure of tlie future. And. really, we can do this by supplying ihe child with an 07'////r/a//r/a.'^c/e. Thisexpres- B / sion must not alarm you 1 There is nothing more
easy to do, as you can see by looking at the mo- del represented here of an artificial muscle which I have had made by the mother of one of my little patients (fig. 727 and 728).
If the foot has a tendency to be carried slightly outwards and in extension (slight equino-valgus). it is nearly alwavs due to a paresis of the anterior muscle of the leg. One can ascertain this by comparative electrisation with the opposite side ; or, more simply, by inducing the child to make the movement pecu- liar to the muscle, namelv. to place the foot inwards and to bend it on the leg, whilst one palpates the muscle and compares it in every wav Avith the anterior muscle of the other leg. It is manifestly weaker than that. It is then desirable that we should help it with an (( artificial muscle •> . This is a canvas gaiter. to which one attaches the two extremities of the artificial tibialis anlicus, giving to it the attach- ments and direction of the real muscle. It is composed of an elastic body (simply 2 or 3 folds of elastic webbing fastened by a few stitches: the body is not fixed to the gaiter and is able to move over it) and of twri rigid extremities (cords or tapes, representing the tendons and stitched to the gaiter opposite the natural points of insertinn of the muscle (below, opposite the inner side of tlie internal cuneiform bone, and above, opposite the external tubercle of the tibia), and there we have our artificial muscle made.
Fis 727. — Artifi- cial tibialis anticus.
i>\u \i.\ I k; cm II I ooi
AHI II KIM. Ml SCI.KS
'•Tl
'I'Ik'IO aro cprlaiii pcculiaiilics to |)(»iiil oiil in ils conslriic lion. Hclow. till' i^ailcr ('ii(li)scs llio o\lrciiiil\ dI (Ik; lonl like a sock, and aliiiNc it liscs up In a |ioinl altdvc llic knee Dr is lixcd In llic waislcoal l)\ a ^Miler. I his doiililc ai raiif.^'-oiiiciil
Fig. 728. — Artificial peroneus lonsriis.
prevents any sliding, it prevents the twisting ol the two ends of the gaiter (which would be brought about, ^vitllout that, by the traction ol" the elastic part). Strictly speaking, one can do without the real gaiter by simply placing, opposite the fleshy body of the muscle, a portion of elastic webbing carrying at its
672
I>FA>TILE PARALYSIS.
ORTHOPOEDIC TREATMENT
extremities two canvas thongs passing- upwards and downwards the length of the hmb and attached opposite the articulations by bands of the same canvas, real annular ligaments and flexion pullies : the upper attachment will be the garter, the lower
attachments, two small cords passed between the toes.
There are some children who do not tolerate the two cords over the toes. In that case, be content with tightening behind, but very near to the toes, the annular band of canvas, so that it may not be turned over by the traction of the artificial muscle, or, still better, use the entire lower end of an ordinary sock.
This (fig. 727) is the artificial muscle w'hich helps the paralysed tibialis anticus; the case of a foot in which the point goes a little outwards and downwards (slight equino- valgus).
To help the peronei (the case of a foot going inw^ards), the muscle will have the arrangement represen- ted (fig. 728).
To assist the extensor communis digitorum (the case of a foot in slight equinism and slight adduction; see hg. 729) the artificial muscle is to be worn almost constantly, during Avalking and even when resting at night. It is no more uncomfortable than an ordinary stocking. Here is the degree of tension to give an artificial muscle : it is necessary that, Avhen the foot is at rest, the muscle, taking the place, for instance, of the tibialis anticus, should place the foot in slioht varus with flexion on the leg, that is to saY, in
"3.- J-?:
Fig. 729. — Artificial extensor communis digitorum and pero- neus tertius.
ui;i>m>s\ii:M oi a i'\» \i.\si;ij ci.i u mor (',-;<
a position lallicr llie icNcrsc of that \n liicli tlic fool lias a t('n<iciicv lo asstimc. And llms. \\licii llic loot is moved, llie tibialis aiilicu^. Ixini: parti \ paialvscd. hut assisted l)\ it^ artilicial supplement, is ijoinf,' its ulmnsl.
//'. hnii'crcr. you arc unable to rely on the enloaraye of the c/iil'l, or if von hare not succeeded in ohtaininrj a sadsfactorv resitll in Ihisiray, because the muscle is already too mm li ailVcted. mhi will treat this first degree of deformity in the same way as the next one, that is t<^ say. \ou will have made for the child a rigid articu- lated boot, the joints of w liicli will |)revent the lateral movements and limit its extension be\<iiid a right angle (v. fig. yo.j).
a"' degree of Paralytic Club Foot. The i)aralylie cluh foot is clearly and distinctly estal/lished.
On ought : i~' to redress it ; 2'"* keep it redressed.
Redressment of a Paralytic Club Foot.
One manipulates in identically the same w ay as for a redress- ment of congenital cluh foot (v. Chap. \v).
In (I disentangling » and successively correcting the dilTerent factors of the deformity, one arrives generally, after 8 or 10 mi- nutes, at a very satisfactory result; but one does not stop until one has obtained a hyper-correctiou of at least from i5" to 20".
I said that you would be astonished at the facility with which the foot allows of redressing. One mav even redress it without ana?sthesia, at two or three sittings, made at intervals of 8 days.
Nevertheless, a tenotomy is sometimes indicated in order to achieve the correction. Thus, in the case of equine club foot : if, at the end of the sitting, the correction of the equinism be still incomplete, you feel the tendo Achillis strongly resisting ; instead of tearing it it away by a very considerable effort, — which might be possible, strictly speaking, although you would probably tear aw ay some pieces of the os calcis in doing so — you may divide or elongate tlie tendon.
Indications for dividing or elongating (fig. 780).
One ought to divide, when it is merely a question of obtain-
Calot. — Indispensable orthopedics. 63
674
INFANTILE PARALYSIS.
PARALYTIC CLLB FOOT
ing a lengthening of i cm. and a quarter in a child, or of tAA^o and a half in an adult, because nature may fill up this
amount of separation. But, if you ought to obtain more than that. YOU AYill perform elongation of the tendon.
Fig. ySo. — The necessary lengthening of the tendon is equal to a third of the dis- tance separating the heel from the ground. Here this distance is 6 cm. The tendon must then he lowered by 2 cm. Bui as, in. the child, a growth of only 1 cm. lakes place after tenotomy, it is necessary in this actual case to perform the lengthening of the tendon and not a simple tenotomy.
CI) Sub-cutaneous section of the tendo Achillis
Instrument : a tenotome or a narroAY bistoury.
Ordinary precautions and minute asepsis.
Make the patient lie on his abdomen, so that the tendon may be easily seen and felt. Direct the assistant to flex the foot slightly, in order to thro\Y the cord of the tendon a little into prominence.
Ilou divide the tendon (fig. 781 and 782) U\o centimetres above its insertion into the os calcis, entering from within out- wards so as to be quite certain of avoiding the bundle of ves- sels and nerves. Finally, divide the tendon from its deep to its superficial surface.
nnisiu.N oi' TiiK nc.NDo .V(:llll.l.l^
G75
r'. \\\[\\ \(iiii' index linger III- \ our lell llmnil), invii;-Miiale llie skin liom williin (uilwartls mider llie tlcc[) surl'aco ol' llio tciulon. wliiili is. Im llie morneni, relaxed.
i>"''. (liiiidiulinf,' over \(iiir (Intier-iiail \oiir line bistoury,
$$i?^iSi
Fig. ~3i. — Division of the tendo Achillis. The left thumb depresses llie skin under the tendon to protect the deep organs and lo serve as a guide for the lenotome.
flat, you punclure the skin in this told, and thus you penetrate directly up to the level of the external border of the tendon.
Fig. 782. — Tenotomy (continued). The blunt tenotome, passing under the tendon, makes a prominence beneath the skin on the outer side. The left hand fixes it in this position; an assistant makes gradual flexion of the fool, following the direction of the arrow, and the tendon cuts itself against the sharp edge.
3"', \ou then remove your left index finger, and the inva- ginated skin returns upon itself.
4"'. After that, you turn the edge of the bistoury round to attack the deep surface of the tendon.
5"'. At this moment, you direct the assistant to flex tiie
676 I>'FA>TILE PARALYSIS. PARALYTIC CLUB FOOT
foot, more and more forcibly. The tendon in this AAay cuts itself against the sharp edge, gently, sloAAdy, millimetre by mil- limetre, until you have attacked the superficial fibres (subcuta- neous). The tenotome should always be held in such a AAay as not to pierce the skin. For greater security, you may also raise the skin with the left index finger and thumb, whilst the section is made.
In a moment, even before you have withdrawn the bistoury, a sharp separation of the tAvo fragments of the tendon is suddenly produced (generally) or else the separation is eflected by degrees.
If this does not occur Avhen your tenotome has arrived under the skin, you will nevertheless withdraw it, and press on the small wound with a tampon, to arrest any hoemor- rhage. Whilst you are pressing thus, you direct your assis- tant to flex the foot further Avith his two hands and Avith a smart and vigorous stroke (« le coup du malin »).
This manceuvre ruptures the fibres Avhich have escaped the knife, and you Avill feel that the tendon is loose. The redress- ment of the foot is then obtained as completely as you Avish.
You place a slightly compressive aseptic dressing OA^er the small Avound ; and over all you apply a plaster Avhich fixes the foot in a hyper-correction of from 10° to 20°; it is thus flexed on the leg to 70° or 80°.
61 Elongation of the tendo Achillis
You perform this elongation by the open method, or by the sub-cutaneous route, in the Aery simple manner you see here (fig. 783 and 734)-
i". lou push in a fine bistoury OAer the median line of the tendon and at about 6 or 7 cm. aboAe its inferior attach- ment. And you diA'ide its external half from Avithin eutAvards.
2°''. Then you remove the bistoury and carry it much further doAvuAvards to a centimetre and a half only above the attachment of the tendon ; you enter in the median line and divide, this
Ki,o\(;.vrn)N tJi nil. iim>i> \< iiii.i.i-
time, llie internal half of ihc leiidon, rnmi willioiil inwards. 3"'. This (lone. Null gently raise llu- point of llic foul nn<l M)U feel, iis il is straif^'litcning. the two halves of tlic k-ndon ;;lide ^fently "mc over IIh' oIIhi iinlil \nu acquire llic elonga- tion dcsirrd.
!:!
-JD-' 1- '
Fio-. 733-73^. — Method of performing elongalioa of tlie lendo Achillis (see theleit)
If vou have never performed elongation, try, for the first time, the open method. In the operation by the open method, one rejoins by one longitudinal median incision the two trans- verse incisions. One sutures afterwards the two extremities of the two small tendinous tongues with catgut, then the skin with catgut in the same way.
One fixes the correction in a plaster (as after tenotomy).
678 INFANTILE PARALYSIS. PARALYTIC CLUB FOOT
The plaster is left in position for three or four months. But, with the plaster, the child will be able to walk when the foot is no longer sensitive, that is, 6 or 8 days after the redressment. At the end of the four months, the plaster is removed and the foot set free.
Preservation of the Redressment.
The foot is corrected and even over-corrected for the mo- ment. What remains to be done? — That depends on what is going to happen.
a) It happens, in some favourable cases of club foot, that the foot remains straight' after leaving off the plaster (wi- thout any assistance).
As long as the deformity existed, the stretched muscles were unable to do anything, for their action was wasted in wrestling (ineffectively it is true) against the deformity. When this is corrected, or even slightly over-corrected, and when, besides, the points of attachment of the muscles are approximated, the action of the muscles may return sufficiently to balance their antagonists which are on the contrary rather the weaker, having been elongated by over-correction.
To improve them, you massage the muscles, formerly stretched, now contracted, you electrise them, you make them perform active movements.
Improve them still more if need be with an artificial muscle, which, insufhcient before the redressment, may not be so now.
b) But, most often, you will see that this treatment is not sufficient; it will not prevent the foot returning to its bad position^, because, after as before the operation, the groups of muscular antagonists will remain very unequal". After a few
1. In the case where the antagonistic muscles are almost equally strong, and where the deformity is only produced because the posterior muscular group has returned more quickly to life than the anterior, after the attack of infantile paralysis.
2. It was on account of these inconveniences, produced by the inequality of the different 'groups of muscles, that Duchenne (of Boulogne) said : " It
■iiii:\ iMiN I' oi' i'\u\i.\ii(: cr.i II Koor
''79
(lavs or a \c\\ weeks liaNc elapsod since llie piaster was Icll oil'. if you see iImI. in spite nf massa^'c ol llie arlilicial muscle, the roriTCti<»ii ohhiiiieil i> imt preserved, if the Inol resumes ils old tlireclion, inaisc haste and re capliire it. Kedi'C'^s il iniriie diateU. wliieli this time is (piileeasx. and take a mindd in llie ^-^ood position, inorder to lia\e a jointed boot made, wliicli hoot will prexenl sitle movement and extension beyond a right angle (fig. 735). The mould removed, you fix the loot in the right posi- tion h\ a small plaster, which \ on leave on lor the lim(> necessary lor the making of the boot.
With this boot, I dare not say that the lameness ^\ill entirely disappear, but it will at least be greatly diminished.
Take note tliat this boot may be easily made anj^x^here, at a price w liich will certainly not ex- ceed the resources of the most humble, seeing that it is sufficient to take two metallic shanks Avith an articulation with limited play, and to make an ordinary boot on this armature. In other words, you have only to place in the interior of an ordinary boot the appropriate armature; to clothe with leather this kind of metallic stirrup.
If there is shortening, one orders a heel-piece (see p. ^79. the boots for coxitis).
would he better to lose all the muscles of the fool than one only of the most imporlaiit of those muscles "'.
But we shall see further on that, for those who wish and iinow how to perform tendon transplantations, it is no longer true, and that the result of operation will be the more beautiful according as the foot has lost fewer muscles.
Fig. -3
Articulated boot permit- ting flexioa only within or beyond a riiclit angle (according to the case).
68o INFAIXTILE PARALYSIS. ORTHOPOEDIG TREATME:>JT
It is necessary to say that boots articulated or rigid are not alAvays well borne ' and that by the always predominating action of the sound muscles, it is possible for abnormal pressure to be produ- ced on certain points, setting up callosities or even excoriations.
B. — Paralysis occurring about the Knee or about the Hip.
If one is dealing with another segment of the limb than the foot, namely, with the knee or the hip, one can distinguish three va- rieties on all fours with the preceding cases, and the course to fol- low is evident, after what we have said with reference to the foot.
i^'. VARIETY. — If there is almost no paresis, and no defor- mity ivhatever, one endeavours simply to strengthen the affected part : massage, electrisation, baths, etc.
2°''. VARIETY. — The articulation is loose. — If it is the knee, you will prepare a rigid knee support in celluloid reaching from the trochanter to the malleoli; if it is the hip, the small apparatus for coxitis (v. p. 421).
It is most advantageous, in these two cases, to cause the patient to wear a large apparatus (from the umbilicus to the toes); rigid at the knee and articulated at the hip and the foot, if the knee only is affected; articulated at the knee and rigid at the hip, if it is the latter which is affected.
The apparatus should be as light as possible, in celluloid.
3'''^. VARIETY. — a) If the deformity is scarcely visible, and if one muscle only is affected, one has recourse to an artificial muscle, although it's use here is lessconvenient than at the foot. It is more difficult to attach it to a pair of drawers than to a gaiter.
b) If the deformity is evident, one performs a correction, or, rather, a hyper-correction, in the way described for the defor- mities in coxitis or in Avhite swelling of the knee (Chap, vi and vii).
At the knee, section of the contracted tendons of the ham will be sometimes (very rarely) indicated,
I. See Note 2 at the bottom of tlie preceding page.
TiN()rf)MY OF Tiir UK I I's (ir rirr. riiif;ii in mm ham (ISi
Section of the Tendons in the Popliteal Space.
In roalilv, in order lo ri'(lie>s;i (li-ldrniilv ol lln- kmc wliidi is allccloil Willi inlanlilo paialvsis or lulieiculusis. orthoptedic mani- pulations alone will nearly always be sufficient.
l'(Msonallv. it lias not liappoiied In luc to divide llie liamslring toiuloiis, on ail averaije, once a vear.
Von know, in anv case, that it is easv, siinjjle. and liarmless, to cut llieiii either hv the open nielhod. or h\ the snh-culancoas route.
For the iiiiiscles on llie inner niaiLiiii of the popliteal space this
TETE Ou pea
Fig. ySf). — (S>ee tlie te\t.) — The external popliteal nerve is in intimate relation with the flesliv barbs which unite with the tendinous cord, but not with the latter, from which it is separated bv more than a cenliinelre 'tml a Italf.
is evident, but it is equallv true for the biceps, in spile of its being so near the external popliteal nerve.
One does not find these relations clearlv set forth In books on aiia- tomv. Here thev are (fig. ~S6) from our own dissections.
At its low er part the biceps is composed of two parts : one exter- nal, rounded into a tendinous curd, hard and slippery under the Jin- (jer : the other, internal, fleshv, spread flat and uniting with the preceding cord like the barbs of a bird's feather lo the quill of the feather.
The nerve is found in contact w ith the internal fleshv part and is always separated from the tendon itself by a distance of nearly 2 cm. So much so that, bv carrying the tenotome against the internal bor- der of the tendon, parallel to it. in the space between the tendon and the fleshv part, one is sure to avoid the nerve.
Technique of this Tenotomy.
1. Place the left index iimrer flat upon the tendinous cord.
2. You piess over the internal part of the tendon in order to allow
682
INFANTILE PARALTSIS.
ORTHOPCEDIC TREATMENT
it to glide gently outwards (fig. ~5-) like a ball : owing to this glid- ing, the nail of the index finger corresponds to the inner border of the tendon with which it keeps in contact.
3. Over the back of the finger nail (fig. ySS) you conduct the teno- tome, the blunt edo;e inwards, the cuttina; edq-e outwards.
4. Incliningthe handle slightly backwards and inwards (at an angle of about 15"), you pierce and penetrate for 2 or 3 centimetres.
5. Cut the tendinous cord slowlv, from within outwards, and from
Fig. 707. — One presses on the tendon of the biceps, then, moving the fin- ger slightly inwards, the tendon glides out'wards, loithoul losin-j conlact ivilh it.
Fig. 788. — Then one conducts the fine bistoury on the finger nail, nearly level with the internal border of the tendinous cord ; one is always sure of avoiding the nerve. Then one cuts from within outwards and from the depth to the surface.
the depth to the surface. U'ith the index finger and the thumb of the left hand, you raise the skin in order that it may not be wounded by the tenotome.
The division of the tendon being made, one is not concerned at all with the internal fleshy portion. One Avithdraws the tenotome and places a tampon over the opening. One compresses, and directs the assistant to extend gradually and slowly the leg which has been bent back. By this movement of extension, the fleshy fibres stretch themselves out, then they are broken fas in torticollis [see Chap, xvi], the fibres which escape the bistoury give way).
One cuts the tendon 3 centimetres above the interline of the knee.
i'AiiAi.\>i> 111- nil'; whom; (ti iiii. i.owiu i ism fi83
( rill- l(Mi(l()ii IS fell \ci\ (lisliM(ll\ and casilv iil llic cxicrii.il n.-iit ol llif [)()|)lil(Ml sn;i((\ (lir()iii;li llic clolliiii^' ; |ii;iclicc iiiiikiii'' lliisi);il- patioii on Miui^cir, the leg; semi-flexed. <)iic Iccls it especially oasih when llic Imcps i-; con traded, llic Lncc ncscdi.
^ on M'c how I lii> lc(lini(|nc is cirri cd on I .md w 1 1 Imiil d.inLjcr to llic nerve; llial is \\li\ I recomiiK'iid .sul)-ciilaiieons lenoluim Icj vou rallier than open leiioloiiiN wliicii neccssilales a lonir incision; and llie wound wliicli gapes (hiriiiL; the iiiani |inl,il ions ol llic rc'drcssinent ma\ . pel lia[)s, become inrecleil, so ihal lliis lcnoloin\, tjie open one, is on llic whole less simple and liannlcss Ihan tlic oilier.
On the inner side oC the popliteal space, the suh-ciilancous section of the Icndoiis is eas\ .
It also is done 3 cm. above the interline. The technicjuc is copied I'rom the privinling one. The lenolome. resting on the nail, is car- rieil close to the external side of the first tendon, the semi-mcmbra- nosus. i)ivid(> it, then the semi-tendinosus and the tendon of the gracilis and lastlv, if need he, divide also the sarlorins tendon.
riic (■itrrcclidii is niaiiilaiiicd l)\ a piaster worn for Ix or 5 months. Sonielimcs it is spontaneously preserved after the removal of the plaster. Should it not be so. you would make a still' knee-piece.
C. — The whole of the lower limb is affected, or even both sides are wholly affected.
Only the large celluloid apparatus can be of any use here; the apparatus takes its support from the ischium and the patient ivalks like a man luhose thigh has been amputated.
lour part consists in redressing the legs in one or several sittings, Avith or without tenotomy, Avith or without anaesthesia, according to the case; then, Avhen the legs are straight, quickly take a mould of them and fix at once the correction in a plaster for 4 or 5 weeks, the time required by the orthopoedist to construct the celluloid apparatus.
D. — Paralysis of the upper limb.
lou uill act in the same way as for infantile paralysis of the lower limb.
684
INFAIVTILE PARALYSIS
It is possible to make an artificial muscle to do duty for the extensor of the fingers, etc.
II. — SURGICAL TREATMENT OF INFANTILE PARALYSIS.
In the preceding pages I have endeavoured to give you a prac- tical method easy for you to follow, without having recourse to a surgical operation, for I do not call the sub-caianeous section or lengthening of the Achillis tendon a surgical operation.
Fig. ■ySg. — Total transplantalion.
Fig. 7/10. — Partial transplantation.
But you are a surgeon and you object that it is not practi- cable for poor children, and even for rich ones, to wear the appa- ratus all their lives, and you ask me if modern surgery has not found the means of avoiding those articulated or rigid safeguards for ever. I reply to you : les, we have to day a relatively simple means of re-establishing, even in the Avorst case, the shape of the limb and of fixing it in its correct position, that is, of escaping the obligation to wear an apparatus ahvays.
Even better, we have the means of recovering not only the shape, but also the functions, I dare not say normal, but nearly normal functions of the affected joint, in a certain number of cases, in the cases Avhere one muscle alone is lost, but in a lesser measure
>l U(.n:\r. nUCATMKNT
()85
■\\1hmi l\\i> III' lliicc imiv(|('> ,iic in ;i slate of parosis oi- paralysis '\\\r siiii;i(;i|, opriiili\c 1 1 call 11(11 1 ol" in la utile paralysis is lion
ill ;i lew w I iicU.
il. 1 1 is. ill tlic sccoikI case sludicd ,iIm.\c. iIciI i>\' ti liiiijt nrlifu
Idlion, llic slillciiiiii^ of the joint
oilluM- l)y llir >(pi(l('riii^'- of llic aili-
iMilar suilaccs {ni'llirodcsis) or 1)\
llir lixalinii (if llii' UmkIoiis of llio
paralysed and deyeiieralo nmsclos
to tlie peri(^slenm, or lo the hones.
or III the aponeuroses, in urder to
thus transroiiu these tendons into
yerilahle ligaments (tenodesis or
fasciodesis), or h\ Ihe l\\o proce-
dings in conjunction, arthrode- sis and fasciodesis.
h. It is. in the third case, of
a paralvdc deformily, ^vhere there
arc onl y \\\n or three muscles para-
hsed. the making of a muscular
graft, a tendinous anastomo- sis, by transplantiiKj the Avhole
of a neighbouring sound muscle
(fig. 739), or better, of part of it
(fig. 740), upon the tendon of the
paralysed muscle ; or even by
transplanting upon the tendon of
the lost muscle a healthy muscle
far removed, should it be an
antagonist of the muscle paraly- sed (fig. 74i); ill Avliich case, at
the same stroke, one strengthens muscles too weak, and one Avea-
kens muscles too poAverful. In a Avord. one calculates the plan ol
operation in such a Avay as to re-establish the shape of the limb and
the eijnilibriiim and harmony hehoeen the different groups of muscles.
Fig. 7^1. — Tendo Acliillis elongated and from which one has detached two lateral strips in order to transplant them upon the anterior tendons on each side.
686
INFAlNTILE PARALYSIS
I have performed a good number of these operations, but there is
F.g. 7^^
Fig. 7i/|.
Fig. 7/|5. Fig. 7/12, 743, 7/1/1, 7/16. — The method of shorteniDg a tendon which is too
i;;/;i//j;;/'i)i;i/iiijinii)i;ii!ii;iMi'in!iMinii/j/;;)IOl777/jp)iji)iM))//ii;i|i)ui)i!iii;TPi~^
Fig. 7^6.
Fig. 747_. Fig. 7/16, 7/17. — Method of producing shortening by wrinkling.
a surgeon who has performed more than anyone else in the world. That is Professor Vulpius of Heidelberg. I have asked him to write
11 s St lu.ic \i, riu;ArMi;\ r
()S7
lor your information IIh- ilia|>lt'r oh llic suii,m(;iI IkmIhu'iiI uC Inlari- tilc Tiiiiilvsis.
He lias coiisiMilcil with a good grace and with a uiiliii^iicss lor \\ liicli 1 desire lo lliaiik liiiii.
||er(\ jusl as lie wrote tlieiii, willioul iii\ altering: a single word, are several sul)stanlial |>ai;cs, clear aiul praclical, in w liiili lie |»oinls out llie rule of eoiidml lo Ije I'ol lowed in order lo cany out these delicate operations.
Surgical Treatment of Infantile Paralysis.
In examining a liinh [iieviously at- tacked bv inl'anlile spinal paralysis you may ascertain </(ree different conditions o( the muscles which offer you an opportu- nity of operating on the muscles themsel- ves, on the tendons, on the articulations: shortening , eloiKjation. and loss of fanrtion.
r' Treatment of Shortening. The unilateral traction ola group ol' surviving muscles in a case of partial paralysis of the musculature of an articulation, or the continued vicious position of an articula- tion totally paralysed, have their origin, as \ou know, in a nutritive shrinking of the muscles of w Inch the points of inser- tion are firmlv approximated. Under such conditions you see developed the paralytic deformity of the soft parts at first, later on of the bones. How can you, in such a case, obtain lengthening of the tendon? The most simple means is sub-cutaneous or open tenotomy, of which a technical description is not in my province. You perform this small ope- ration bv reiving upon the reparative force of nature which will interpose a
portion of tendon between the two retracted ends of the divided ten- don. That comes about certainly in a small separation, that is. in one of I cm. in children or 2 cm. in adults. If it should exceed this amount, I advise you to have recourse to plastic elongation. Allow me
Fia; 7^8. — At llie points wliere thev are sutured to the super- ficial aponeurosis, one sees tliat the three tendons have been pre- viously shortened by folding, a. tibialis anticus. b. extensor proprius. c. extensor com- munis.
688
INFANTILE PARALISIS.
SURGICAL TREATMENT
to explain, by the example of the retraction of the tendo Achillis, how you ought to practice this plastic method.
The tendon, laid bare, is divided bv alonaritudinal and sagittal inci-
Fig. 749. — Incision for arthrodesis of the ankle.
sion corresponding to the elongation desired (see above, fig. 783 and 734). You accomplish the division by adding two lateral incisions in
Fig. 760. — Arthrodesis of the ankle. Luxation of the foot inwards and opening of
the articulation.
a contrary direction, at the two ends of the first incision. In correc- ting the vicious position, the two parts of the tendon slide over each other and are placed end to end: they are fixed in this position by two sutures of silk.
\u I iiiuii>i;sis. — IIS m;(.iim()I i;
(iH(
^ oil 111,1 \ \ ,ii'\ I lie 1 1| in .1 1 hill !i\ (111 I 111 l; I lie triiilnii m I'lonl.
^^lll in:i\ alxi iii.ikc ii^c dl llic >,iiiii' iiiclliod I Mil)-cut;iiiCOu;s) in iiKikiiiuoiilv IwoMiiall lalcial i iicisioiis aiuljiiiisliing the lon;,'iludiniil si'paialioii 1)\ loitc'il icdrc'ssiiKMil. Ur, iiioio siiii|)lv still, \<ni ciilllio lemloii across, as lii:,di as possihlc. wIkmo il is slill laii,M'l\ in coiilacl with llir l)cll\ ol till' iiiiiscic, and ^noii inalvi' il ^lidr a- iiiiicli as is ncii'ssarv, uillioul cnliioK inl('iiii[jling ils iclatiun with lln' niusclt;. Supposing \()n have made a sini[)le lonolomv I)V mistake, or lliat llie
Fij?. •;5i. — Artliioilesis of llie knee. One refreshes the articular surfaces of tlie patella, of the femur, aad of the tibia, and one cuts the patellar ligament in order to brino; about shortening-.
Fig. •j52. — The refreshed surfaces placed in contact. Shortening of the patellar ligament.
plastic strips are very short, and \ou find vourself vis a vis a separa- tion, Avhat do you do then? \ou insert an artificial tendon of silk bv passing some threads, not too delicate, Ironi one evtreniity to the other, to ensure the continuity of the tendon.
By any of these methods you can be sure of obtaining an absolu- tely satisfactory and duiable result.
2"'^ Treatment of Elongation. — You find elongation, that is, hyper-extension of a muscle, as a sequel of a paresis, or of a complete paralysis.
You see, for instance, the three anterior muscles of the leg in this state of hyper-extension Ayhen they are so seriously enfeebled that the weiii:hl of the foot overcomes their conti'action. you then sec the equine foot. You see perhaps, slight contraction, voluntary or eli-
C.4LOT. — Indispensable orthopedics. W
690
I?fFA?*TILE PARALYSIS.
SURGICAL TREATMEiXT
cited by the electric current, but quite insufficient for their function.
Later, even these slight remains of muscular activity disappear through continuous hyper-extension.
Then, what is to be done to obtain sufficient shortening of the muscle and of the tendon necessary for the normal function ?
You may employ'the method of overlapping or that of wrbikling.
Fig. 753. — Arthrodesis of the knee. Opening of the articulation.
Fig. 75/1. — The tibia is ah'eady deprived of its articular cartilage. The curette engaging the cartilage of the condyles of the femur.
You will understand more easily, by examining the figures on p. 686, than by a long explanation, how the margins of the tendinous folds are re-united by sutures, or how one fixes the extremity of the fold on to the tendon (fig. 742, 743, 744 and 745).
In order to wrinkle the tendon, you pass a thread of silk in the length of the tendon, you pull on both ends like the strings of a purse, and by that you wrinkle the tendon atAvill (fig. 746 and 747)-
If you apply one of these methods in the case of equinus, referred to above, you will at once arrive, by shortening the three muscles, at a correction of the deformity, and in cases as favourable, at a return
Alt I iim»i)i>is oi' iiii: kM:i;. — us ikcmmque
691
ol llic riiriclioii^ III llic iiMi'^i Ic-, lil)i;ili- .iiili(ii'«, cxlrnsitr projiriii-; uollicis ;in(l t'vlciisor cormiuiiii'^ (li^iloniiii .
In (iIIkm" casos von will liiid snriu' of llu- riiiisclcs mciilioii cd, l<i- Uillv jxiidlvst'd. Tlicie, llic ()|)(Mali(in i(ir sli(irlcniiiL!: is useless. Tlie llesliv |)ails of llie niiiscles hciiiif (Icgciieraled, are eloiiga led again, under llie inniience nlllie weiglil nl llie fool, and produce a ro- lurn of llie delorinilN. In llial ease, voii iieilDiin an operation, wliicli oiu- ealls tenodesis ( iii,'. 7-V'^l- Ignoiiiii,^ llie dci!;encrat(>d innseles, vou lix llie lliice lendons (willi llie lension nei'CSsarv lor llie ((tireclKin ol llie posi- tion ol llie Inol I to tlie lelieslied perios- leuiii ol llie Iwo hones ol llie log. and, as I have ollen done, lo llie fascia of the leg (fasciodcsis).
\\\ this means, \ou transform the tendons inlo accessory ligaments.
AN e are going lo speak direct I v of llie comhinalion of this tendinons operation with arthrodesis.
3''' Treatment of the Loss of Func- tion, fl. — A complete paralysis of all the muscles of an articulation produces, as you know, the loose joint, which mav render the entire limb useless. In such cases, you can produce artificial ankylosis bv the operation of Arthrodesis. To ankylose the ankle Joint, vou proceed in this way :
Opening o[' the articulation bv an incision passing round the external malleolus (fig. 7A9). luxation of the loot inwards with or without incision of the peroneal tendons (fig. ~')o). free and irregular refreshment of all the articular surfaces so as to produce ridges penetrating the cartilages and denuding the bone here and there. Add, if you like, a metallic suture between the tibia and the os calcis. Complete the suture yyith Florence horse-hair.
A light dressing and a plaster. Exact apposition for three months at least.
You will find after removing the plaster complete ankylosis, most ollen fibrous, of the joint, a result which you mav complete bv teno- desis of llie llirec anterior lentloiis described above.
To cause ankylosis of the knee, you open it by an anterior llap,
Fi
753. — Suture of the tendon.
692
I?JFA]VT1LE PARALYSIS.
SLRGJCAL TREATMENT
you make a very sparing resection, refreshing also the patella (fig. 75] 752,753,754and755). You join bone to bone, make the suture of the extensor appara- tus very exactly, so that it '.'■ ought never to become loose. >;'/ You add a tenotomy of the ; U
Fig. 706. — Arthrodesis of the shoulder. Incision.
5 ■ >
Fig. 76;. — Arlhrodesis of the shouhler (continued).
Fig. 768. — Arthrodesis of the shoulder (continued). Metallic suture of the two bones.
II I II Mix r or uniiuiiDKsis
093
nt'\oi<. 1(1 aviiid. I.ilcr mi. coiil imcI iiir nl llir knee jii llcxion. Mli-r lliicr (ti- loll! iiiiuilli>' li\,ili()ii ill ,1 |il,i>lci- ilicssiu^, llicrc
Fig. '/b(j. — Active elevation of tlie arm renileied possil)lc Ijv aitlirodesis of the shoulder.
will result, in nio.^t of (lie cases, an osseous ank\losis v\liic!i it is
Fig. -ho. — Passage of llie lendon llirougli tiie imltoii-liole.
necessar\ lo snjiporl for sonie moiilli? al least, w itii a Icallicr case. Do not entertain the idea of arthrodesis of the hip joint, a very
69/
OFA>"TILE PARALYSIS .
SURGICAL TREATMENT
grave operation, of which the technique and the results are not very clear.
_Lp.l
cp-1
Fig. 'J62. — Exposing the peroneus longus.
Fig. 'j6i. — Position of the Esmarch's bandage : below, the track of the two internal and external incisions.
You niav, however, be certain of remarkable success in arthrodesis of theflail-likeshoulder,
if the muscles of the arms and fore arms are intact.
A longitudinal incision opening the articulation, luxation of the
703. — Relations of the tendons in internal region of the ankle.
I i;<;ii.M(ji !■; ui \hi iihhdisis
<!()5
head of llii' Ihiiikmus, which it is ncccs^aiN lo rtlrcsh owv Ihc wlioln ot ilsVinuiiircrtMicc as well as the f,'h'noi{l cavitN (li^'. iiiC), ~-}~, ~-)i^). Fixalion ol' the luimcnis lo iho scapiihi by two iiu'tallic wires ^wvio- raliiiu the aeromion and I he coiacoid process, f^iviii"; lo the arm a
Fig. 7G.'|. — The peroneus longus is seized by the forceps and divided at i; or 3 cm. above.
Fig. ~6b. — A long forceps is introduced into the internal VYOund obliquely, passing close
■ to the bone, to seize the end of the peroneus longus.
considerable elevation from the side and forwards. Fixalion lor three or four months.
The time having passed, you verif\ the union of the humerus and scapula. The elevator muscles of the scapula now^ move at the same time the humerus. The arm carried before like a useless weight may regain its usefulness, the hand may be raised to the face (fig. 759).
696
INFAiSTlLE PARALYSIS. SURGICAL TREATME>T
Post operative gymnastic treatment is of great value and is abso- lutely necessary to complete the edifying success.
b. In the presence of a partial paralysis of the muscles of an articulation you will very often have two pathological conditions to contend with; contracture' and loss of function.
You commence the treatment by the modelling redressment of the deformity. Then you make vip for the loss of function by prac- tising the transplantation of tendon. The idea, in this opera- tion, is to profit by the healthy muscles in the neighbourhood, so as to transmit their function in pla- ce of that of the paralysed muscle. Before proceeding with the operation, you make an exact plan, studying care fully the sound muscles and those paralysed.
It is necessary for you to take into consideration that one may not sacrifice a muscle altogether for a graft unless its function is of little importance (v. fig. 789), and that, on the other hand, it is necessary to divide the sound ten- don in such a way that one pai t may be employed for the graft whilst the remainder preserves its primitive function (v. fig. 740). Partial transplantation or divi- sion of functions.
As to the technique, take no- tice of the following advice :
Fig. 766. — A forceps draws upwards the tibialis posticus, a second draws the peroneus through thebutton-hole.
Minute asepsis of the field of operation, Esmarch's bandage. Longitudinal incision so extended as to lay bare the sound and paralysed tendons up to the peripheral extremity of their muscles, which allows you to ascertain the state of the latter. Protect the tendinous sheaths as much as possible, cut or divide the tendons, distributors of poAver, lead the sound tendons towards
The Germans call contracture what we call deviation.
irciiMoi I. <»!• iiii: I n.VNsi'i AN TviioN ni' ii:.\i«»v
vi:
llic p;iralvsi'(l ones. (UiccIIn , il IIicn arc near, of, il llic\ are iiol loo CarawaN, Iin ImiMcIliii^' tlic soil pails with a blnnl iiislniiiioiil.
To ohiain inliiiialc miioii ol llie two tendons, draw llic sound tendon |Iu(>iil;Ii one or Iwo hiillon-liolcs ( lii,'. 7<)o^ made in tlic paia- hsed li-ndoii. Snlnrc llic two tendons with a lew stitches ol silk
"X
Fig. 767. — Suture of tlie two tendons.
boiled in sublimate solution. Take care that the suture is not made with a tension too strong lor the two tendons, bv drawing them in the opposite direction with the forceps in such a Avay that. A\hen the operation is finished, the articulation is found to be fixed in a cor- rected position. Complete suture of the skin. Aseptic dressing, then plaster. Immobilisation in bed for five or six weeks. Post operative treatment prolonged by massage, electric current and gym-
698
I_\FAJ\TILE PARALYSIS, SURGICAL TREATMENT
nasties, to accustom the muscles, and especially the nervous system, to their new function.
Here are several other examples of the application of the method in cases of pes equinus, or talus, or varus, or valgus.
c- 768. — The end of the operation represented on the foot opposite. Suture of the tibialis posticus.
But technical indications so summarv Avould not enable vou to understand; and, to be really useful, we ought to enter into all the details of one of these operations from the first to the last.
A typical transplantation.
Here is, for instance, the minute description of the transplanta- tion of a tendon, supposing that we Avish to graft the peroneus longus on to the tibialis posticus.
A IMMCAI, ritANSI'I.AMA I ION oi \ ||.\|i(i\
I>!)
AllcM- li;i\ iiii; larcfuIlN slciili/fd llic Inol and llic li'^. and allt'r liaviii-^ placed llic Ksiiiarths handa-e on tlic lliigli. wo will makoour first incision.
This coinniciiccs hcliind, at a centiniolrc ahovc the inlcrnal nial- leolus. and diiccled from bolow upwards, lor a lon^lli oC Iroin n to lo cm., accordiiii: to llir liciuhl ol'tlic palienl.
Fig. 7G9.
After having divided the skin and sub-cutaneous tissue, one rea- ches the deep fascia Avhich we open in the same direction and for the same extent as the skin : In this way we expose the flexor tendons of the toes and of the tibialis posticus. We isolate this without injuring the sheath up to its muscular bellv, which presents to the eve a pale rose or yellow colour.
Then, the second lateral incision ffig. 7O1, 762, 7G3). commen- cing behind and 2 or 3 centimetres above the external malleolus and reaching as far upwards as the median incision, but made 2 or 3 cm.
700
INFANTILE PARALYSIS.
SURGICAL TREATMENT
higher. We open the sheath of the peronei, and we isolate the tendon of the peroneus longus of which the muscular fibres satisfy one of its normal condition by presenting a deep red colour. The tendon is then fixed below by a forceps, in order to prevent the peripheral end from escaping after it has been divided now to 3-3 cm., above the forceps (fig. 764).
We introduce the point of the forceps into the inferior extremity of the incision and bore a tunnel which is directed very obliquely tOAvards the upper end of the lateral incision.
The canal produced then finds its way
Fig. 770. — Talus foot.
771. — Club-foot, equino varus.
behind the fibula and between the flexors of the toes on the one side, and, on the other, the vessels, nerves and areolar tissue surrounding the tendo Achillis, to the peroneus longus.
One dilates the canal a little by opening slightly the forceps, which seizes the central end of the cut tendon and conducts it through the tunnel (fig. 765).
The foot placed in slight hyper-corrcction, we catch hold of the tibialis posticus with a second pair of forceps. With a fine bistoury
TIIK TECIIMIU r, ()|- TI;M)ii\ IK WSI'I.ANTATION -oi
we m;iki> a l.iit loii-licili- in llic li-ridoii coricspoiHliML,' lo llic opeiiiii;^ ol llic ImiiH'l.
I>\ means (>r a pair oC line rnicc|)<. uc pass llic Icndon ol llic pcro- lunis lliroii-li llic hiillon-liolc. W C draw on tlic Iciuloii siiriiticiitl y slroii'dv ill llic cciiliiruijal dircclion, and coinniciicc lo sulurc wllli
Fig. 77a. — ^'algus flat foot.
silk soaked in solution of sublimale. The first suture fixes the ten- don of the peroneus in the button-hole, those aflenvards join together the parallel tendons.
A last suture holds the two tendons above the button-hole (fig. 767, 768). _ ...
Finally, two or three sutures shorten the tibialis posticus in the central part, if it be necessary.
We close the incision in the skin without troubling about the fascia.
702
INFANTILE PARALYSIS.
SURGICAL TREATMENT
It remains to fix the peripheral end of the pereneus longus to the peroneus hrevis, without tension, by two or three sutures, and to close the lateral incision .
A very exact antiseptic dressing to prevent movement of the foot, and a plaster bandage from the toes up to the knee, which is kept on for five or six Aveeks.
Fig. 77'
I**' Poot|in equinus (fig. 73o). — a. I'ou find the tibialis anticus completely paralysed, the other muscles intact. After having leng- thened the tendo Acliillis, if it is shortened, it is necessary for you to transplant the extensor of the great toe entirely on to the tibialis. The peripheral end of the cut tendon is fixed to the extensor of the toes, to prevent the great toe becoming flexed. The operation com-
I III I II w-i'i. AN I A I ION (u ii:m>()\s i> I Hi; roor ~o'i
pli'lod. llu* loot ought to lia\c ;i posilidii ol ;il least a ri;^lit angle, (lig. 7'>i))- - ^- Viu\\\ss\s ol llic liliiulis tiiiliciis aiul ol the rxleiiaur comiiiititis diiiitonmt. The same ()|UMatioii as in \' i , and again Iraiis- planlalioii ol llie peroiKMis loiigiis on to llic (>xl(Misor cnininiinis (liiri- loriiin ; the pcriplicial end ol' the peronens longus is lixed lo the short poronens.
c. PaiaKsis ol llie Ihrec aiiiirior innsclcs. Oporalion ; transplaii- talion ol the pcroncus longus and ol' the llexors ol" the Iocs lo the lihialis anlicus and lo llie extensors ol llie toes throngh llic liilcr- oxseiis inemhraiie.
2'"'. Talipes calcaneus dig. 770). — Paralysis of I he Iricepsune. Operation : Kedrcssnienl ol the dclormily and elongation of llic ante- rior tendons, if it be necessary. Transplantation of the pcroncus longus, of the llexors of ihc toes and of the grcal toe on to the lendo Achillis or dircctlv on to the periosteum of the calcancuni. Fixation of the peripiieralend of the peroneus longus on to the peroneus brevis. As a consequence of the operation, the foot ought to have a position of slight talipes equinus.
3""' Talipes varus (fig. 770). — a. Paralvsis of the exlenaor of the toes. Operation : plastic elongation of the lendo Achillis, if it is necessary. Transplantation of the extensor of the great toe on to the extensor ol the toes. If this muscle seems lo be insufficient, take part of the peroneus longus to reinforce the extensor of the toes (fig. 771). Fixation of the peripheral end of the extensor of the arcat toe to the extensor of the toes. At the end of the operation the foot should be found at a ri^ht ano;le and slii^htlv in valsfus.
b. Paralysis of the extensor of the toes and of the peronei. Trans- plantation of the extensor of the great toe, and, if it appears neces- sary, of part of the tibialis anticus, on to the extensor of the toes. Transplantation of the tendo Achillis on to the peronei. Fixation of the peripheral end of the extensor of the great foe on to the tibialis anticus. Position of the foot produced immediatelv bv the opera- tion : at a right angle and slightly in valgus. The same procedure for the tendo Achillis as in the preceding number.
Talipes valgus (fig. 772). — a. Paralvsis of the tibialis anticus and tibialis posticus. Operation : Transplantation of the extensor of the great toe and of part of the extensor of the toes on to the tibialis anticus. Transplantation of the peroneus longus on to the tibialis posticus, by moving it inwards, between the bone and the tendo Achillis. Fixation of the peripheral end of the peroneus longus to the peroneus brevis.
b. Paralysis of the tibialis anticus and tibialis posticus and of the
7o4
INFAJNTILE PARALYSIS.
SURGICAL TREATME>T
peroneus longus. The same operation as above (a) on the anterior group. Replacement of the tibialis posticus bv the flexors of the digits or by part of the tendo Achillis.
c. Paralysis of the tibialis aniicus and tibialis posticus and of the lendo Achillis. Operation : The same transplantation as above (a) in the anterior group. The flexor of the toes on to the tibialis posticus.
Fig. 775. — Extension of the leg rendered possible by transplantation to Ihe quadriceps.
the flexor of the great toe and the peroneus longus on to the tendo Achillis or directly on to the periosteum of the internal border of the calcaneum . The peripheral end of the extensor of the great toe is fixed to the extensor of the toes, the peripheral end of the peroneus longus to the peroneus brevis, etc.
The Transplantations of Tendons at the Knee.
As to the knee, what is required of transplantation seems more difficult of accomplishment, because the muscle to be replaced, the quadriceps, is very large and of great functional importance. Howe- ver, experience has shewn that it is possible to respond to the exigences of the situation.
II MilNdl S I » VN>I'I.AN I A riON>
IIIK kNKE
ll is necossiiiy lor nou lo know lliat j);ir;il\sis (A llie (|M;i(liicops iilone is nol a siiHicioiit iiulicatioii lor opcMation, hut that il is indi- calod oiilv in llio case ol" riinclional Iroiiblfs wliicli arc not i[i llic Icasl \ho regular sequence of llie [)aral\sis.
ir the llexor nuiscles ol" llic knee have escaped ihc [)aralNsis, one niav notice that, in walkinir, tlieir exclusive action provokes a flexion of Ihc joint, and. Iiv ihal, the danger ol" falling, and later, one linds
Fig. 'j-jC,. — The >aine case clemonblrating the possibility of llesion.
even a contracture ol' the knee in flexion, a\ hich sulTices lo make ^valk- ing unsafe.
That is Avhv one sees such patients supporting themselves in walk- ing by placing the hand on the thigh.
It is not rational, in such a case, to transplant the flexors whollv or in part on lo the tendon of the cjuadriceps or directly on lo the patella (fig. 7-3 and 774).
Apart from these muscles, il is the sartorius which, by its analo- mical situation, is the especiallv appropriate substitute for the qua- driceps, and \\hich escapes paralvsis astonishingly often.
^ou will excuse me from giving vou the details of this operation which, although nol serious or diflicult, demands, however, very
Calot. — rndispensajjle orlliopedics. io
7o6
I.NFAXXILE PARALYSIS. SURGICAL TREATMENT
extensive manipulations of the soft parts, and, accordingly, an abso lute asepsis, and a large amount of practice.
Permit me onlv to tell vou that, by this method, one can obtain very satisfactory and, at the same time, interesting results as to the physiology of movements ffig. 77.3 and 766).
Transplantations in the Upper Limb.
The same Avarnings hold good for the practitioner Avith regard to similar operations in the arm, and especially the fore-arm. The
Fit;. --- . — Patient \Yalking c on all fours ».
musculature is more complicated than in the leg, and requires a more extensive practical experience.
After having explained the different methods of surgical treat- ment of the paralysed child, it remains for me to tell vou that one ought very often to combine these methods in order to obtain the best possible results.
It is precisely this appropriate combination Avhich allows of such remarkable successes in serious and extensive paralyses which render
UliSLLlS Ml lULAI.ML.M
/"/
w a I ki II u; possible In iiulividiials who woiv helorc ohligcd to walk '• on all lours " {li'j,. 777 ami 77'^).
Wo will roiiclmlr l)\ supphinL; llio results in a more (Iclailcd
Fiy. 77S. — The buuie patieal after trealment.
way. And you Avill permit me to relv upon aiv own experience, the Iruit of thirteen years' special Avork.
^^ hat ought we to hope, what can we promise to a patient, who is confided to our care by the family, as to the sequelae of a special paralysis ?
You are convinced that the degree of amelioration or the perfec-
7o8 OFANTILE PARALISIS. SURGICAL TREATMENT
tion of the cure varies according to the extent of the paralysis and according to its localisation.
On the whole, you Avill perhaps see less complete results in the arm than in the leg.
However, vou, as well as your clientele, will rejoice at each ame- lioration obtained in the upper extremity, because such cases were considered incurable up to our day. We will first examine the results obtained in the arm.
Il is not too much to say that the effect of arthrodesis of the flail- like shoulder is a real miracle :
For the function returns, increasing year by year, to a limb until then absolutely useless.
I have been able to convince myself that by transplanting a por- tion of the triceps to a paralysed biceps of the arm, one is able to obtain the return of its function independently of the triceps ; and it is the best proof of this fact that you are able to divide a muscle into two individual muscles endowed Avith their own proper and even antagonist function.
As to the fore-arm, you have the right to say that paralysis of the radial nerve does not any longer remain incurable. In shortening the extensors of the wrist, you give to the hand those positions of hyper-extension necessary to close the fist firmly. You add trans- plantation of a flexor of the w rist to the extensor of the fingers, and you will have recovered enough strength and dexterity for any number of manual occupations.
These results as to function, however agreeable, do not attain complete restoration, and consequently remain inferior to the results obtained in the leg.
You can cure all the paralytic deformities of the foot, not only in a temporai'y manner, by means of redressment, but radically, by adding arthrodesis or a plastic operation on the tendons.
Arthrodesis of the foot, completed by a fascio- tenodesis, changes the flail-foot into a precious support and restores entirely to the limb its locomotor function.
And your success will be no less brilliant in arthrodising the knee when it is totally paralysed.
Without doubt, the results of a tendinous transplantation will cause you much satisfaction, it is an operation which preserves not only against a relapse, by enfeebling the antagonist muscles, but gives you a quasi-perfect cure.
You will attain the ideal object in the case where there is only one muscle paralysed and surrounded by sound muscles — a success
IIICSII.TS <)|- rm.ATMIOM ■JOfJ
\\liuli li;\s a j)roy;iosslvo cliaijiclor 1)} llic rxncisc ol llio muscles and of llic lUMvc iciilrc, |irvsiiiirmj; thai your plati of opcraliou and noiw tccliiii([iio have Ix-oii i;oo(l.
Allow mo lo lolalc some cxampli's :
III llic caso oi' a talipes equinus you find yourself confronted willi the sdle thitv of traiis|>Iantin},' llie extensor of the f,M'eal toe on lo llie tibialis aniicus uhieli is cxclusiveh [laralysed : perfect success is assured
NOU.
ill the second case, il is nccessarN for \ou lo add i^Malliii- ol (lie peroneus longus to the extensor of the toes : son will see (he move- ment of the extensor muscles reappear.
In the third case, vou cause lo arise oul of the complete helpless- ness of the three anterior muscles a limlled dorsal IL'xion, but suffi- cient, bv introducing the peroneus and the flexor of the toes.
You will see reappear, in ihecase of talipes calcaneus, firm plantar flexion surmounting llie weiylit of the fool, you will see your patient walk plantigrade. Letters of gratitude will come to you, perhaps from the top of a mountain, or from a ball, such as 1 have received.
The frequent relapse of talipes varus will never again be brought before your eyes with the discouraging " non possumus "; you make rather the redressed foot to raise itself into a mean normal position, you will procure for il even an active abduction,
Vou will find, it is true, more difficulty in the treatment of para- lytic talipes valyus, because the weight of the body always has a ten- dency to destroy the effects of your operation. But by calculating well the muscular forces to be transplanted, you should be able how- ever to obtain a good result, that is, the normal position of the foot, and even active supination.
You will re-establish the function of the paralysed quadriceps femoris by transplantation, and you will see your patient w alk without the help of a support, and without fear of the roughness of the road.
I have been able to show such patients climbing easily the stairs and even ladders.
In summing up. I can onl\ say lo you. from experience and con- viction : " Practice plastic operations on the tendons, and you will have a harvest of satisfaction for yourself and of happiness for your patients " (Vulpius).
Tllini) PART CONGENITAL ORTHOPCEDIC AFFECTIONS
(111 \PTi:il \IV CONGENITAL LUXATION OF THE HIP JOINT
A. — Diagnosis.
Kiisl of all, a ^vol•d on diagnosis and prognosis.
r' Pbesvmptive signs. — They bring to you a child — generally a lilllo girl — Nvho is lame on one or both sides, waddling and balan- cing herself on her hips, like a duck.
She walks willingly, however, like a child who is in no pain. There already are two signs : the characteristic walk and the absence of pain, which ought to make you think of a congenital luxation of the hip. even before the parents have said anvthin?.
If the swinging, if the lolling movement exists on both sides, the thing is almost ceii;iia. 11 ihc swinging is on one side onlv, it i< a simple presumption.
2""' siGxs SHEWING PUOBABiLiTY. — Bul liic parents sav to vou : Our child has always walked in this way, from the verv first attempts, which, however, were late, lor she did not commence lo walk until sixteen, eighteen, or twenty months. She has never suilercd. This waddling were been nothing, but it now seems tliat it is still increasing lor some time, and that the leg is becoming shorter.
\A ilh this history, the existence of a congenital luxation of the hip becomes probable, even more than probable. However, vou will not be able lo affnm that it is so until after bavins; examined the child cowplelely naked, first in the upright position and whilst walking, then laid on a table or on the floor.
712 CO:VGENITAL LUXATION OF THE HIP
Character of the walk. — When the child walks, you will see the great trochanter more prominently on the lanie side (v. fig. ^'yg to ■^84), rising into the buttock and descending with each step. It
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Fig. 779. — Congenital luxation of the right hip.
rises up with each tread, as if the sole of the foot had been placed on a spring.
Examination in the recumbent position. — ■ On placing the two iliac
1)1 MiNOSIS
7l3
spines ;il llic saino Icsi'l.imd in l)riiiL:irii,' logcllicr, .illi'rw.nds, llie Iwo IVct. YOU Si'f llitil one limb is sli<irler lli'in lln- ollter, il llic cliilil is lame
ig. 780, • — Right congenital luxation of ten years' standing. — One sees the wasting of the luxated limb. The shortening is enormous. The sound leg is obliged to bend on itself at the knee when both the heels are on the STOund.
Fig. 781. — The same. The sound limb is no longer bent at the knee, the heel of the luxated side no longer touches the ground (the iliac spine remaining at the same level). The trochanter, more prominent and more raised on the side of the luxation. — The labium majo- rum is also drawn up on this side.
on only one side. The great trochanter is projecting on this side ; it is raised above Nelaton's line (^fig. 782), which you determine by car-
7^4
CO\GE^'ITAL LUXATION OF THE HIP
rying a tape from the iliac spine to the ischium ^ -whilst the thigh is flexed at an angle of A5°; more than that, the trochanter is moved ayx&y from the median line : the lahium majorum is drawn upwards. On looking at the profile, you Avill find a lumhar concavity. But that does not give you the certain sign.
Fig. 782. — The same, seen from the side. — Lumbar hollowing. — One sees how the great trochanter is raised above Ne- laton's line. — If there were no luxation, the trochanter ^YOuld be level with Xelaton's line. — Shortening of the limb (heel off the ground, the two iliac spines being at the same level.
Fig. 783. — The same, seen from behind. — Lateral deviation of the back with convexity on the sound side. — It is so in most of the cases (but not always).
3"* THE cERTAix SIGN. — You Avill obtain it by palpation of the hip made when the child is lying down, the thighs well extended.
Palpation of the Hip (fig. 786 to 791 ). — This Avill give you two indications which, taken together, are pathognomonic.
I"' If, clasping the upper part of the thigh with the hand halt opened, the four last fingers behind the trochanter, the thumb in
I. For Nekton's line see fig. 892 and 785.
niAr.NDSis
front, Nou tMi(l<';iM>iir lo |>;il|i;ili' the head of the femur in ils normal situation, llml i^, in I lie luld dI I lie urum, IicimmIIi I lir li'moral artery,
Fiji. -8.'i. — Exaniinalion of tlie eliild In llic reciinilieiit position. — V'ery distinct sliortening of the limb. Tlio Irocliantcr is raised above Nclaton's line (to an extent practically equal to the vhortening).
^\ll^cll crosses llic head at llio juuclion of llio inner lliird and
Fig. 785. — Luxated hip. — Relations of Nelaton's line and of the trochanter in the skeleton (the thigh flexed at an angle of ^5 degrees).
external Iavo thirds — you Avill feel no osseous resistance; you will find an empty space belo-\v the anterior border of the iliac bone.
7x6
COXGEMTAL LUXATION OF THE HIP
To render this impression more precise, compare it -with the other, normal, hip. You will perceive there, on the contrary, very distinctly, the hony resistance of the head (which is out of the acetabulum for a centimetre or a centimetre and a half) and even of the anterior surface of the neck (v, fig. 332 and 333, p. 354).
Fig. 786. — Diagnosis. Method ol palpating the head of the left femur. The posi- tion of the right hand ; the four fingers behind: the right thumb in front in touch with the artery. The left hand grasps the limb at the knee , imparting to it the different movements of internal and external rotation, flexion and hyper-extension, abduction and adduction. The right thumb is against the outer side of the femoral artery -nich is felt with the extremity of the pulp.
2"' If you grasp the knee of the suspected side and impart to it extensive movements in all directions, you will generally see, and you always feel, above and within the empty space mentioned above, a rounded, mobile body, very mobile, raising the skin in front (fig. 790) during the movements of hyper-extension, of external rotation and of abduction of the knee, raising it, on the contrary, behind (fig. 791), towards the buttock, in the opposite movements of
I I S I'Ki KilVESS
lloxion. 111 iiilcnial lolalloii anil adilialioii ; [jalpalc lliLs liartl, kimimI.iI body — it can oiil) be the bead of the rcimir.
Here is the certain sign cil" liixaliiui. Morenvei-, the history ena- bles \ou to sav tlial it is congenital.
Dia^^nosis of double luxation (lig. 792). — Double luxation is recognised b\ the waildling gait existing on both sides, by the pro- jection of both trochanters and their position above Nclaton's line.
Fig. 787. — Melhod of palpating a normal tiip joint. — Exploration of the head. The trochanter is embraced by the first interdigital space, tlie thumb in front; the others Gngers behind are able to feel only very feebly the movements imparted to the head.
by the shortness of the two thighs in comparison with the length of the legs, and finally, by the perception on both sides of vacant spaces, Avhere the heads of the femurs ou^hl to be found, and tlie recognition of those heads above and without their normal situations.
B. — Prognosis.
The lameness from birth wliicli, hardly h\elvo years ago, was considered to be incurable, can generally be cured today : it is no longer possible to doubt it ( witiiout the exhibition of inexcusable ignorance), after the number of proofs clinical, radiographic and anatomical, which we possess. Some hundred of children have
7/8 CO>GE>ITAL LUXATION OF THE HIP. PROGNOSIS
already been cured, that is, they are no longer lame at all, and several autopsies of children treated, dying of intercurrent diseases, have sheirvn that the head of the femur had been replaced in the nor- mal position and kept there.
Fig. 788. -- Normal hip on the left, luxated hip on the right. On the left, one finds a bony resistance very high up. On the right, a sensation of an empty space : helow the iliac bone and on the anterior -wall of the acetabulum, represented by hatching, one sees the empty space represented in white (there, where the head and neek of the femur ought to be).
This " preliminary question " of the curability of