In previous chapters have been considered the various morbid conditions of bones, joints, muscles, and tissues which help to form the locomotor apparatus of the body. It would seem then quite proper in this place to insert the chapter usually relegated to the end of text-books on surgery where it stands by itself, i. e., the chapter on Orthopedics. As a subject orthopedics deals with the causation and the treatment of deformity, whether inherited or caused by disease. The term is used in a more or less elastic sense, and is made by some to cover a larger field than others would accord it. The subject divides itself into two parts:
1. The consideration of deformities produced by tuberculous or other infectious disease, and
2. Non-carious, congenital, and acquired deformities.
Tuberculous lesions do not differ in pathology or other respects from the tuberculous diseases of bones and joints described in earlier chapters of this work. Inasmuch, however, as some of them form distinct and clinical types of deformity they assume an importance which justifies reasonable consideration by themselves. Of these we shall consider spinal caries, sacro-iliac disease, hip disease, and tumor albus.
These various terms have reference to deformities of the spine of similar type, but with considerable variations, produced by caries (tuberculosis) of the vertebral column. Where osseous structures are separated by cartilaginous or more or less complete joint cavities the primary focus may form within the spongy structures of the vertebral bodies or in the softer tissues of the intervertebral joints. In other words, it is caries of the ordinary type which assumes special significance only because of the accident of its location. The entire vertebral column should be regarded as the main support of the body, while to it is due the maintenance of the erect position which raises man above the animal. When diseased and softened it yields to pressure, the result being exaggeration or distortion of its natural curves. As the instinctive tendency of the human being is to maintain the head in the line of the centre of gravity above the pelvis, any marked degree of curvature in one direction brings about, by natural causes, a compensatory curve in its opposite direction. A well-marked case of kyphosis, then, is characterized by more than one exaggerated curvature or protuberance, one being due to disease, the other to compensation.
While there may be several foci of active tuberculous disease, even in one vertebra, there may be found pronounced forms of angular curvature as the result of destruction occurring in but one or two of them. The carious process once begun may be checked at any point in its course, or it may proceed to complete softening and destruction, with formation of cold abscess. The tuberculous process once begun spares no tissue, and thus bone and intervertebral cartilage melt and disappear in the same manner. There may be a possible danger from spreading of tuberculous disease to the spinal meninges or to the cord, or of its being generalized. In the former case there is pachymeningitis and myelitis with paralysis; in the latter case it causes more or less rapid, acute general tuberculosis. Paralysis is more often induced, however, by actual compression than by mere tuberculous involvement, although the disease products which cause this pressure are likely to come from a caseous pachymeningitis.
The disease is most common in childhood, about 80 per cent. of cases occurring before puberty. Of the three regions of the spine the thoracic is the one most often involved, next the lumbar, and lastly the cervical. The most common site of all is in the lower dorsal region. Deformity once established as the result of this disease cannot be expected to spontaneously disappear.
—Slight injuries occurring in those of tuberculous diathesis, by which there is produced a focus of least resistance, or secondary infections following upon such conditions as scarlatina and typhoid, constitute the most frequent recognizable causes. There can usually be obtained a history of some injury in about half of the cases. The disease once established may assume either an acute or chronic type.
—As indicated when discussing caries in joints the principal signs and symptoms are pain, muscle spasm, muscle atrophy, tenderness, deformity, and impairment of function. These are all present in Pott’s disease, to which they give that distinct clinical picture which Pott so graphically described about a century ago.
—Pain is rarely absent. It may be misleading, but is usually referred to the terminal distribution of the intercostal nerves, and thus may be complained of in the chest, the abdomen, or the legs. Many a “stomach-ache” in children is of this character and origin, and a complaint of frequent “growing pains” should be carefully investigated. Even in sleep these pains are characteristic, and have been previously described as “starting pains.” Children cry out with them in the night. They tire easily and tend to seek rest instinctively. Pain is always aggravated by excessive pressure upon the upper spine or by jars, such as may be received in jumping. It is not necessarily constant. Vertebral tenderness may sometimes be detected by pressing upon the ribs. This will especially aggravate symptoms when respiration is of a groaning character or when there is any expression of dyspnea. There may be vomiting or dysuria. A sudden increase of these painful features means a fresh focus of infection, impending abscess, or a danger of paralysis.
—It is by muscle spasm that we account for the attitudes and postures of Pott’s disease. It is a constant feature, but will vary in its expressions with the location of the disease. In caries of the cervical spine the chin is raised, the head is balanced somewhat backward, while the lower spine is straightened and given a backward curve. In the stooping posture the head is supported by the patient’s hands in the instinctive effort to protect it. In caries of the mid-dorsal region there is elevation of the shoulder, with marked tendency to support the weight of the upper part of the body by placing the hands upon the knees or thighs. Lumbar caries often produces perceptible backward curve in the lower portion of the spine.
In all cases there are stiffness and rigidity of the spine, and patients resort to all sorts of instinctive expedients to avoid motion in the affected area. When that part of the spine which is in relation with the psoas muscle is involved there is more or less psoas contraction, with characteristic flexor deformity at the hip, which is usually bilateral. This will give a peculiarity to the gait and cause it to be not only stiff in appearance, but it will be seen that the patient walks more upon the toes and with slightly bent knees, which are thus made to act as springs. An attitude assumed in stooping or in the effort to lean over as if to pick up an object from the floor is characteristic; the spine will not be curved forward and the patient will not stoop as usual for the purpose, but the spine will be more or less erect and stiff and lowered to the floor by flexing both knees and hips until the squatting position is assumed. In rising the same effort will be made to protect the spine from any motion between its component parts. (See Figs. 253 and 254.)
During sleep this muscle stiffness becomes even more pronounced, so that in the morning patients are “stiffer” than later in the day. The existence of muscle spasm can often be detected by palpation of the spinal lesion. Some lateral deviation or asymmetry of signs may often be noted, according as the muscles of one side are more pronouncedly influenced by the location of the disease focus, and it is the more common in proportion to the greater severity of the case.
The confinement caused by the disease will naturally be followed by more or less atrophy of the body muscles, but, in addition to that, those immediately involved about the centre of the disease undergo an atrophy due to it and often apparent on inspection.
—In numerous distinctive ways the patient constantly evinces tenderness and makes invariable efforts to protect against movement or even jar. Tenderness can also be evoked by pressure upon the head or shoulders, which will cause severe pain, or by causing the patient to jump down a step or to rise upon the toes and then come down abruptly upon the heel. Pressure upon the spines of the affected vertebræ or upon the ribs which connect with them will also cause complaint of pain.
—This is the most striking objective feature of well-marked Pott’s disease. It is practically a backward projection known as kyphosis, the vertebra first affected being usually the first to yield, the others following or changing in shape as the disease spreads or as the growth of the individual permits accommodation and necessitates rearrangement. The more acute the disease the sharper the projection. Old and mild cases cause an abrupt curvature rather than a protuberance.
Fig. 253
Fig. 254
Typical postures of the spinal muscle spasm of spondylitis. (Bryant.)
It is well to keep a record of the deformity in cases under treatment. This may be graphically preserved by putting the patient flat upon the abdomen upon a straight surface and bending a strip of lead so that it shall fit the contour of the spinous processes. After it has been made to fit it may be removed and a tracing of the curve made upon a sheet of paper. Comparison of tracings thus made at intervals will afford a graphic record of the progress of the disease or of the improvement made. Kyphotic deformities lead to a shortening of the spine, so that growth is stunted and patients become dwarfed in appearance. Secondary curvatures are produced above and below the primary projection. Gradually as the shape of the vertebral bodies and of the entire spinal column changes the ribs are pressed more or less together, often being made to overlap, the shape of the chest undergoes alterations, the sternum sometimes being depressed and sometimes protruded, giving the chest, in the latter case, the so-called “pigeon-breast” appearance.
—There are but few disorders which produce more pronounced and widespread accompaniments than spinal caries. As change in the shape of the spine occurs and assumes a marked type we see changes occurring through the body, not only in the direction of anemia with general impairment of function, mental irritability, and cachexia, but there occur trophic alterations as well. The shape of the face changes, the expression assumed is one of anxiety, and the features become less mobile.
—Tuberculous meningitis, cerebral or spinal, is the most dangerous and acute condition, while other tuberculous complications may occur in various regions of the body. In fatal cases meningitis, in consequence of acute or mixed septic and terminal infection, furnishes the explanation for the great majority. Paralysis is not infrequent as a sequel, assuming the type of paraplegia and developing slowly. Motion is first impaired and a considerable interval may elapse before sensation is affected. Motor impairment varies from mere mild paresis to complete paralysis, beginning as fatigue, loss of strength, and inability to stand. Unless the disease be located in the lumbar region the reflexes are exaggerated and muscle spasm is easily provoked or occurs without perceptible cause. As above noted the muscles become atrophied, and when the cord is seriously compromised are rigid in chronic spasm. The rectum and the bladder suffer finally, especially in disease of the lower segments. Occasionally in cases of high dorsal disease the arms will suffer more or less motor impairment. Sensory paralysis begins usually as paresthesia. In merely bedridden but not actually paralyzed individuals the reflexes should be normal. Of the muscle contractures, those of the psoas are the most common and distinctive. Paralysis follows rather than precedes deformity, and is noted in perhaps 20 per cent. of advanced cases. It should rarely occur if effectual treatment has been begun.
—Abscess is usually of the “cold” type. Its general character has been previously described. It may be of the purely tuberculous type, but is not infrequently the result of a secondary pyogenic infection. It is a consequence of neglect, but cannot always be prevented. Signs, both local and general, of the presence of pus or of pyoid are noted here, as under other circumstances. There is exaggeration of local tenderness, with development of tumor, which fluctuates as it approaches the surface. General septic features, proportional to the activity of the process and its location, accompany the local indications. Sometimes it occurs insidiously and with but few evidences.
Pus travels here in the direction of least resistance. The fascial planes of the body are mostly so placed as to protect important body cavities, consequently pus will travel usually around them and toward the surface, burrowing long distances, for instance, from the lower dorsal region to the groin along the psoas muscle. Cervical abscesses usually spread anteriorly toward the pharynx (postpharyngeal) and deeply into the thorax (mediastinal); they may open into the trachea or esophagus or externally through an intercostal space; or they may burrow laterally, opening behind the sternomastoid muscle. Dorsal abscesses usually travel posteriorly, opening not far from the spine, or they burrow downward and forward along the psoas so as to appear beneath Poupart’s ligament. Lumbar abscesses escape through the psoas sheath as psoas abscesses, so called, or between the fasciæ of the spinal muscles and those of the abdomen to appear upon the side; they may extend downward beneath the iliacus, escaping over the brim and into the pelvis and then out through the sacrosciatic notch. Of all these the psoas abscess, opening in the groin, is the most common. This will in time destroy the muscle fibers of the psoas, but it leaves the vessels and nerves intact, whose sheaths are much more resistant, and which can be found passing through such a cavity like cords through a chamber. This form of cold abscess, with its consequent bulging and final escape in the groin, has been mistaken for hernia as well as for abscess due to perinephritis and appendicitis. The most serious mistake would be to take it for a femoral hernia. The customary routes of all these collections of pyoid have been thus indicated. Nevertheless abscesses may burrow and appear almost anywhere. They will give rise to varying and to superadded symptoms, according to their location. For example, retropharyngeal abscess may seriously threaten respiration by pressure upon the upper air passages, while a collection of pus in the mediastinum might cause serious respiratory difficulty of another character.
Cold abscesses of spinal origin may remain stationary, the fluid portion of the pyoid material may even absorb, while the balance undergoes more or less degeneration and conversion into inert material, or they may slowly or rapidly increase in size. The best that can be hoped in such cases is absorption, with encapsulation of the solid residue. Even this may be a source of danger, as it is a focus of lessened resistance, in or about which subsequent trouble may result. Those abscesses which seem to remain stationary would best be let alone, hoping for subsidence under good treatment. Those which open spontaneously leave tuberculous fistulas behind them, which may possibly close in time, but which lead often to subsequent acute infection, and which are the bête noir of surgeons, for it is often impossible to heal them. The best that can be done in such instances is to wash them out, keep them clean, and guard them from infection from without. It is often possible to pass a tube along the sinus and through this to irrigate with a solution of iodine, of formalin, or of any other antiseptic which may be preferred. If anything be done with them in the operative way it should be as radical as possible, seeking the original lesion, thoroughly curetting its site and the whole interior of the cavity, and making ample opening so as to provide for effective drainage.
Retropharyngeal abscesses usually necessitate evacuation because of the obstruction which they cause within the pharynx. Lumbar and psoas abscesses may be let alone. When this is not practicable, then choice should be made between simple aspiration, aspiration with washing or injection of some antiseptic fluid, and free opening with radical treatment. In these cases we are to be guided by the peculiar features and surroundings of each, and by our own facilities for such work and for subsequent care of the case. An abscess which will soon rupture should be opened and counterdrained; but in one where this is not impending, and where home features are such that the patient can receive no adequate or prolonged care, it would be wiser to abstain. Under the best of circumstances in these cases it is always a difficult problem to decide. Even aspiration leaves at least a needle track to be subsequently infected, while the contents may be too thick to flow through a small trocar. Aspiration with thorough washing out and then with injection of emulsions of iodoform or of other irritating antiseptics have found favor with only a part of the profession. If any radical measure is to be adopted the greatest care should be given to carry out the principles expressed in the general consideration of cold abscesses. (See p. 114.)
—Intelligent comprehension of signs and symptoms should enable one to make a diagnosis in most cases. Nevertheless the surgeon is occasionally in doubt and has to distinguish, for example, as between Pott’s disease and sprain, lateral curvature, hysterical spine, cancer, cord tumors, rheumatic arthritis, rickets, syphilis, actinomycosis, hydatid disease, acute osteomyelitis, i. e., non-tuberculous diseases, and certain abdominal affections followed by suppuration, such, for example, as peri-appendicular abscess. Moreover, spondylitis may be simulated in the course or as a complication of typhoid, scarlatina, gonorrhea, and other acute infections. Psoas abscess should be distinguished from perinephritic abscess as well as from acute appendicitis, which often causes psoas contraction, especially when the appendix is posteriorly placed and left in contact with that muscle. We may also have to distinguish this condition from sacro-iliac disease and from ordinary hip disease.
—In some degree prognosis depends on what is meant by a cure. Absolute cure, with restoration to the original condition, is exceedingly rare. Arrest of disease, with improvement of deformity, is possible in cases seen early. Even considerable motion may be restored under suitable treatment. In late cases hectic, amyloid degeneration, and dissemination of the disease make the outlook very discouraging. At best its relief is slow and in time it is always chronic, no matter how rapid the onset, except in those instances where dissemination occurs early and rapidly, in which case there is little or no hope. In ordinary cases there is a certain tendency to spontaneous recovery, but not without deformity and impairment of function, while obviously the occurrence of abscess prolongs a case to a considerable degree.
—Those general measures so necessary for the treatment of any tuberculous lesion, namely, hypernutrition, fresh air, and general constitutional measures, are needed here as in any other such disease. Physiological rest, i. e., absolute rest in a bed without springs, the patient lying flat on the back or on the face, and not on the side, and lying quietly, constitutes the best part of local treatment. In the case of children it is best to have a gaspipe frame, across which cloth may be stretched, on which a fretful child can be secured by straps across the shoulders, pelvis, and knees. This frame may be laid upon the bed and lifted from it while a cross-piece is removed for toilet purposes, or a suitable opening may be left if a single piece of cloth be stretched across it. If the patient can be made to submit to this repose, then a pad may be placed under the projection. After a sufficient length of time, with the desired improvement, a plaster shield may be molded to the back, with the patient lying upon his face; and then, after removing and suitably trimming and lining this mold, the patient can be returned in it to the previous position in bed, from which he may gradually be raised. This is the best method to follow in acute or severe cases, or when the disease is higher up in the spine. It will also best serve the purpose when the case is complicated by abscess. To it may be added, if necessary, traction upon the head (Fig. 255).
Fig. 255
Child in bed-frame, with head traction. (Lovett.)
Fig. 256
Jury-mast for high dorsal and cervical caries. (Lovett.)
—The simplest of all apparatus is the plaster jacket, or corset, which was brought into favor in this country by Sayre, although not invented by him. It is usually applied in suspension, i. e., with the patient in the erect position beneath the frame, from which hangs a support by which firm traction can be made, both upon the head and the arms or the shoulders. The intent of such a jacket is to apply it with the patient so stretched out that a certain degree of the projection will at least be eliminated and the back made more nearly straight than it otherwise would be. In cases where this is impossible it at least affords better expansion of the thorax and supports the ribs in better relation to the spine, affording more chest room. The plaster is not applied next to the skin, but a thin undershirt or its equivalent of woven materials should be applied, care being taken to see that it fits snugly and is not allowed to fold in ridges. After the patient is completely suspended to a degree where discomfort begins, then a small “stomach pad” is slipped beneath the under-jacket, in front, in order that more room may be given for enlargement of the abdomen after a full meal. Finally with the first turns of the plaster a strip of tin or a couple of strips of moistened pasteboard should be applied directly over the middle line in front and incorporated in the successive turns of bandage, in order that there may be material there which may be cut down in removing the jacket. Small pads should be placed over the iliac crests and over the protrusion if it be at all marked or tender. Now by the use of a series of bandages of gauze, in which reliable plaster of Paris has been incorporated, the entire trunk is enclosed within a corset, which will quickly harden as the plaster becomes firm. It should extend well down over the pelvis and nearly to the trochanters, since from this portion it takes its fixed support. It should then be extended as high as can be permitted under the arms and higher yet over the chest and back. Enough material should be used along with the plaster-of-Paris cream, as the former is applied, to ensure sufficient firmness and strength. If the plaster be reliable it will not be necessary to keep the patient suspended more than a few moments after the completion of the jacket. The finishing touches may be given it after he has been taken from the frame and placed again upon a soft surface.
Another method of application is to have the patient recumbent and properly supported, and this is particularly necessary in acute cases, where suspension is likely to cause faintness or unpleasant symptoms. In this attitude the spine is really put in better position. The method is not at all available in those few cases of lateral curvature which demand jackets (Fig. 256).
Substitutes for these jackets are made of various materials, such as leather, rawhide, aluminum, thin strips of veneering, celluloid, paper, glue, etc. These have to be constructed over a mold which is taken from a plaster jacket. When the disease extends above the level of the fifth dorsal vertebra there should be incorporated within the jacket a support for the head, known since Sayre’s time as a “jury-mast.” This consists of a metal upright, with cross-pieces, which are incorporated with the jacket and which is curved up behind and over the head and made to carry the frame from which the leather straps and supports pass beneath the occiput and the chin, and thus give to the head a certain amount of fixation. The support is so arranged as to permit of sliding and of sufficient expansion so that traction upon the head can be made effective.
Fig. 257
Frame for application of plaster jackets in recumbent position. (Lovett.)
Fig. 255 shows the application of traction to the head, while Fig. 256 illustrates one form of apparatus by which the jury-mast is made effective in producing traction on the head in the upright position. Figs. 257 and 258 show a convenient frame and method for making plaster-of-Paris corsets with the patient in the recumbent position. Figs. 259 and 260 show another form of apparatus intended for the same purpose.
Fig. 258
Application of a plaster jacket in the recumbent position. (Lovett.)
The variety of apparatus which has been devised for the maintenance of rigidity and correction of deformity, and, in suitable cases, traction upon the head, is to be measured almost by the number of orthopedic specialists, nearly every surgeon inclining to some device or at least modification of his own. Judson probably has formulated the best rule covering the entire matter when he says: “The apparatus may be considered as having reached the limit of its efficiency if it makes the greatest possible pressure upon the projection compatible with the comfort and integrity of the skin. It is essential that the brace is efficient; second, that it is one that can be constantly worn, if necessary, or can be easily detached from the body if not to be worn at night.” Certain ambulant cases can be treated by an effective brace through the day, and rest at night upon a reasonably hard mattress, with traction upon the head. Concerning the multitude of these special aids to treatment it hardly seems worth while to go into any elaborate description in this place, inasmuch as one who is incompetent to judge as to what is best should not retain the management of such a case, while one who is really competent will probably desire to make his own selection, and the writer’s recommendation would count for but little. Every case must be a law to itself, and every special brace must be constructed especially for the individual for whom it is meant; otherwise it loses all its serviceability.
—The feasibility and propriety of forcibly reducing the deformities due to spinal caries was first suggested by Chipault, of Paris, who suggested wiring the spinous processes of the affected vertebra, and then, by Calot, who, in 1896, described a method of forcible reduction under an anesthetic. The first to actually wire the spine under these circumstances was Hadra, of Texas, who had actually done the operation four years before Chipault. The method has probably less to commend it in actual practice than in theory, and, attractive as it may be in respect to time and completeness of reduction, it is often followed by serious accidents, such as hemorrhage, rupture of abscess, fracture of the spine, etc. Bradford, in 1899, collected 610 cases performed by 29 different operators, with a record of 21 immediate deaths from local trauma and 15 cases in which there were at least alarming immediate symptoms. Of 229 of these cases complete correction was effected in 119, incomplete in 94, while no gain whatever was made in 16. Of results reported later, 66 showed some gain, there was no relapse in 17, while 49 showed more or less return of deformity. The claim has been made that the more or less wide gaps or bony defects which may result from forcible manipulation are filled in by new bone, but there do not seem to be any observations to confirm this statement. The amount of force which must be employed is a matter for the finest discrimination. The method includes complete anesthesia, traction upon the spine in each direction from the location of the deformity, and direct pressure force applied to the protection itself, as by a sling passed around the body and just beneath the projection, which can be used as a fulcrum upon which the rest of the spine can be applied as a double lever, with the application, at first, of gentle force, and, finally, sufficient to either satisfy the operator that he should go no farther or that the desired effect has been obtained. Immediately after completion of the maneuver a snugly fitting plaster jacket should be applied and the patient kept absolutely at rest in bed.
Fig. 259
Anteroposterior support: back view. (Lovett.)
Fig. 260
Anteroposterior support with head-ring for high dorsal caries: side view. (Lovett.)
The method seems most applicable in the presence of paralysis, even of long standing, and this feature has often been relieved.
Psoas contraction is best treated by traction, with the patient in bed, and with the maximum of weight and power applied which can be tolerated by the individual. If this seem impracticable, then the patient should be anesthetized and force applied until it is evident that more harm than good results. Should this harm appear, then open division of the tissues may be practised. Finally, as a last resort, in intractable cases, a subtrochanteric osteotomy may be made.
Pressure paralysis necessitates operative relief. This may be practised late and should consist of a laminectomy and exposure of the area compromised by bone pressure or that produced by pachymeningitis. The operation is done in the same way as for fracture, and will be described in the chapter on Surgery of the Spine.
Finally of all cases of Pott’s disease it may be said that each should be studied by itself, and for each a suitable method or apparatus devised, rather than to endeavor to apply indiscriminately unchangeable methods or forms of apparatus. Every apparatus has its disadvantages as well as its benefits. The more acute the case the more is absolute rest in bed, with traction, demanded. This is particularly true of disease in the upper spine. On the other hand, the more chronic and the lower the disease the easier it is to handle, and with such simple expedients as plaster corsets. When the sacral region is rigid, however, recumbency is usually necessary, because of the difficulty in securing adequate fixation within any apparatus that can be worn. The necessity for general constitutional, dietetic, and climatic treatment should never be forgotten, and the danger of possible acute dissemination kept ever in mind. This is particularly imminent when too much freedom is allowed. Time, patience, and discernment are the dominating factors beyond the general principles already inculcated.
Under this name is included a tuberculous condition of the bony tissues on either side of the sacro-iliac synchondrosis, or of the cartilage itself, similar to that which produces the special caries described above. It is an uncommon expression of tuberculous disease occurring often in the young, identical in pathology with other tuberculous bone lesions, and giving rise to peculiar symptoms, mainly because of its location. Early in the course of the disease these may consist of mild discomfort in the lower abdomen, irritability of the bladder and bowels, disinclination for exercise, while, as the disease becomes more pronounced, there will be actual pain, intensified by standing, relieved by lying down, often severe at night, usually referred along the course of the sciatics. A most significant symptom is the tenderness and complaint produced by firm pressure made upon both sides of the pelvis, thus forcing tender surfaces against each other. In the later stages of the disease abscess may develop and present either externally in the lumbar region or internally, breaking into the pelvis and appearing perhaps in the groin or close to the perineum. The disease is usually unilateral, and will cause characteristic limping and aggravated pain upon standing on the limb of the affected side. Naturally this limb will be spared in every possible way. It is likely to be mistaken for sciatica or lumbago, in neither of which diseases is there any tenderness at the sacro-iliac joint such as can be evoked by pressure from the sides of the pelvis. It also has to be distinguished from hip disease by the fact that motions at the nip are not interfered with, and from Pott’s disease of the lower spine, which usually causes prominence of the spinal processes and local tenderness in a different region.
The surfaces and tissues involved are extensive and the disease is always serious. It is one of the most chronic of all such affections, and too often tends to suppuration, with its slow but inevitable consequences, or to dissemination. Thus of 38 cases with abscess reported by Van Hook only 3 recovered.
—Treatment should consist of absolute rest, with traction, so long as the symptoms are active, and avoidance of all irritation when patients rise from bed. Abscess due to sacro-iliac disease should be radically attacked, especially if this can be done early. Intrapelvic pus collections may require trephining of the pelvic walls or resection of some portion of the ilium, by which complete evacuation may be made and drainage be amply provided. When the joint itself is thoroughly broken down the case will have a hopeless aspect.
Hip-joint disease, or, as it is often called, coxitis or morbus coxæ, is worthy of special consideration on account of its frequency, its importance, and the deformities which result from its existence. The most frequent site of the disease, which is of the usual type of tuberculous ostitis or osteomyelitis, is on the femoral side of the joint, usually in or near the head of the bone. In a small proportion of cases the first lesions appear upon the acetabular aspect of the joint, while in some cases the primary tuberculous lesion is of the type of a tuberculous synovitis. (See chapters on Bones and Joints.) In addition to those changes already described in previous chapters there occur certain distinctive alterations about the hip-joint which are worthy of note. On the pelvic side the margins of the acetabulum occasionally become softened, and naturally yielding in the direction of pressure as the result of muscle pull upon the thigh toward the pelvis, cause, first, an elongation of the originally merely circular cavity, and, finally, considerable shifting of position, often referred to as migration of the acetabulum. Thus the head of the bone may be found in a socket thus formed on a level one inch higher than on the well side. So also perforation of the acetabulum may occur, with perhaps final escape of the head of the bone into the pelvic cavity. On the other hand, similar changes produce decapitation or marked alterations of shape in the head and neck of the femur.
—When the symptoms and signs of tuberculous disease in this location are studied in accordance with what has already been stated in general about caries of the joint ends of the long bones, we have among the most significant features:
—This is referred most commonly to the knee because of the relations of the obturator nerve to the hip-joint and to the region of the knee. Pain may also be radiated in other directions, but the complaints made of pain in the knee are classical. Pain is not, however, a pathognomonic feature and may be almost wanting, but the evidences of tenderness, if not of pain, are invariably seen in the unconscious protection of the joint afforded by muscle spasm. It is perhaps in hip-joint disease that night pains and cries are most frequently heard.
—Fixation of the affected joint is always noted. It begins as a limitation of motion, naturally first noticed in the extremes of rotation, flexion, and extension, and is perhaps the most important early sign of the disease. It furnishes the explanation for the subsequent postural features, as well as an index regarding the gravity and extent of the morbid process. It may be seen even in the lower spinal muscles, where it is detected by laying the patient upon the face, lifting first one leg and then the other, noting the freedom of hyperextension; in fact, this spinal muscular involvement is sometimes so marked as to give rise to the suspicion of low Pott’s disease, from which it is to be distinguished by the fact that the spasm affects one side rather than both.
—This involves in time all the muscles concerned about the hip. It begins early, but may not be very pronounced until quite late. It can usually be determined by measurement if not apparent upon inspection and palpation. There will also be noted more or less obliteration of the gluteal crease or fold.
The three cardinal features—pain, spasm, and atrophy—having been thus considered, we can better appreciate the characteristic gait and postures peculiar to this disease. Limping is an early feature, sometimes insidious at first, sometimes abrupt. Patients will avoid coming down quickly upon the heel, while they walk with the knee slightly flexed, in order to give more spring. Stiffness is most apparent on rising from bed in the morning, while the limp is more pronounced at night, and it is at this stage especially that night cries are most frequent. To mere limping succeeds actual lameness with more constant pain. Muscle spasm now leads to malpositions, no one of which is necessarily first to appear, and any of which may occur with others in various combinations, although flexion and adduction are usually the first to be seen, the patient unconsciously assuming that position which happens to give him most relief.
It is important to realize that a marked degree of adduction will cause apparent shortening, and of abduction apparent lengthening, and it is very important to demonstrate that these variations in length are apparent and not actual. This is to be done by placing the patient upon a hard surface with the pelvis at right angles to the spine and the limbs in absolutely symmetrical position. If there be adduction it may mean that the limbs should be crossed; while if there is abduction the healthy limb should be abducted to the same degree as the one affected. Careful measurement will show that the differences are apparent rather than real. The same care is needed in regard to rotation, and particularly in regard to psoas contraction which leads to flexion. One of the most characteristic evidences of hip-joint disease is flexion of the thigh, which, when the thigh is brought down to the proper level, will cause an arching upward of the lumbosacral region. By this time also will be found well-marked limitations of motion in every direction. All of these features should be ascertained without an anesthetic, as they depend upon muscle spasm, which anesthesia would subdue. It is somewhat difficult with intractable young children to make a thorough examination of this kind, but a second or third effort will usually succeed when the first has failed.
Peri-articular symptoms affording corroboration are found in thickening of the tissues about the joint, especially enlargement of the upper end of the femur, or increase in thickness of the pelvis, which may perhaps be felt from the outside or be detected by rectal examination. There is usually involvement of the inguinal lymph nodes, and there is frequently prominence of the superficial veins, due to infiltration of the deeper tissues and obstruction to the return circulation. A good skiagram will also render much aid.
As the disease progresses there will appear evidences of deep suppuration, as abscess is frequent in the advanced stages. This may be peri-articular or may connect with the joint. It may cause separation of the epiphyses of the femoral neck and complete loosening of the head of the femur, which will then become a foreign body in a joint cavity probably filled with pus. Perforation of the acetabulum may also occur. Much of this abscess formation goes on insidiously and without marked increase of symptoms. There is no fixed date when pus may begin to form. It may occur relatively early or late. It is possible for small amounts of pus to absorb in whole or in part, or to leave a residue more or less encapsulated, which will frequently lead later to a secondary abscess, the latter tending to burrow along between the fascial planes or muscle sheaths and appear at some distance from its origin. Pelvic abscesses result from perforation of the acetabulum and may break internally or externally. Nearly all of these collections are of the cold type, and after a long time, if they have opened, may cease to discharge characteristic pus or even pyoid, and simply give vent to a watery seropus. Pus left to itself usually escapes anteriorly to the tensor vaginæ femoris, but it may travel in any direction.
The deformities and possibilities which may result from the advanced stage of hip disease are striking. Persistent muscle spasm leads to more and more flexure of the thigh, with abduction or adduction, as the case may be, while later the leg is drawn up so that the knee may almost touch the abdomen. As the bony portions of the joint change their shape there occur actual shortening and final dislocation, while all the adjoining parts show the effect of muscle atrophy and perverted nutrition. In addition to this the region of the hip may be riddled with abscesses or with sinuses, and the condition in every respect made extremely distressing.
While the disease is generally confined to one side, it may occur in both hip-joints, in which it, however, very rarely begins simultaneously. Existence of double joint disease of this character makes the case more than usually troublesome and complicates it seriously in every respect. The writer has been compelled to make double simultaneous resection of both hips.
—This has usually to be made from congenital dislocation, hysterical joint, infantile paralysis, non-tuberculous disease—such as synovitis, bursitis, etc.—acute osteomyelitis of the upper end of the femur, Pott’s disease in the lumbar region, and sacro-iliac disease, as well as from perinephritic abscess and appendicitis.
—Hip-joint disease usually tends toward recovery, but generally with more or less deformity. When the circumstances are not favorable, ankylosis, with or without deformity, is inevitable, while abscesses, with persistent fistulæ, are not uncommon, and one may in extreme cases witness death from general tuberculous dissemination or from the consequences of hectic, with amyloid degeneration, or from acute septic infection.
One may naturally ask what may be considered as constituting recovery. In cases of this kind an absolute cessation of all symptoms and indications of the disease, with a minimum of deformity and of limitation of motion, are the nearest approach to ideal recovery that can be expected to secure. In favorable cases, seen early and properly treated for a sufficient time, there may be achieved almost a restitution ad integram, but such an ideal is seldom attained; otherwise there is nearly always more or less limitation of motion, with very frequent pseudo-ankylosis or actual ankylosis. Even this is favorable and most anything may be considered so which falls short of actual suppuration.
—The essential in the early treatment of hip disease is traction, so applied and regulated as to be effective. It should not be thought that by such traction as can be tolerated joint surfaces are actually pulled apart. What it really accomplishes is to tire out muscles which are in a condition of clonic spasm, overcoming thereby the deformity which they produce and thus permitting a reduction of their activity and of the harm which they have done. To do even this requires a considerable degree of traction, especially when muscle spasm is very prominent. Therefore it is best in pronounced cases of deformity to place patients in bed, and to apply traction by weight and pulley to a degree which actually overcomes the defects which we are combating. This will often require more weight than many men are in the habit of using. It should now be a question, not of amount of weight, but of effect, and of the easiest and best way of bringing this about. Physicians are very likely to use too small an amount of weight, and to neglect the use of counterextension and the benefit of more or less lateral traction, as well as that in direct line of the limb. Moreover, they often use inadequate means of applying traction, resorting to it only in such manner that traction is made at the knee and not at the hip. Even in young children it is often necessary to use twenty pounds, with a suitable traction apparatus, and four or five pounds for effective lateral traction.
Traction should be maintained until deformity has been overcome or the effort shown to be impracticable. After its complete benefit has been obtained it should be followed by fixation, the ideal method being that which accomplishes both fixation and traction at the same time; as, for instance, by the so-called Thomas splint, which permits the patient to be up and about with the use of crutches and a high shoe beneath the well limb, in order that the diseased limb may not be permitted to touch the floor, but rather to hang, and by its own weight afford a certain degree of traction. The Thomas splint is the simplest and cheapest for hospital work, while modifications in more elegant and expensive form are illustrated in works on orthopedic surgery. In cases which seem to demand it fixation can be effected by a plaster-of-Paris spica put on while the patient is standing upon the well limb and upon an elevation. The character of this work affords space neither for more elaborate description nor illustration than the hints embraced in the foregoing paragraphs.
The surgeon as such is perhaps the more concerned in the treatment of abscesses which frequently complicate these cases. Much that has been already said about psoas abscess will apply here. It is a question requiring considerable discrimination as to just how to treat a small, cold abscess about a diseased hip. Much will depend upon the environment of the patient, i. e., upon the attention and expert care which he may receive. Such abscess should be treated kindly, i. e., by nothing more severe than aspiration, until ready for more radical treatment. By the latter term is meant readiness for following it down to the joint cavity and exsecting the head of the bone, if need be, following this with extirpation of the capsule, etc. When there is actual pyarthrosis the condition of the patient is sufficiently serious to warrant radical measures. Extra-articular abscesses are apparently quite common, yet most of these, if carefully traced, will be found to lead through the periosteum at some point into the osseous structure beneath. Such abscesses are, moreover, multilocular, and have ramifications in even unsuspected directions which should be followed with the sharp spoon and the caustic, in order that absorbents may be seared and that no infectious material remain. Old and persistent fistulas should also be treated kindly until one is ready to be radical. Some long-standing cases will heal after absolute physiological rest of the joint, i. e., by fixation in plaster-of-Paris splint, with openings opposite the fistulas for dressing purposes. The general constitutional condition of patients with these lesions is a predominating factor in their improvement—a fact which should never be forgotten.
The deformity which has resulted from old, long-standing, and quiescent hip disease affords opportunity for the best of surgical judgment. It is possible to effect great improvement in position by subcutaneous osteotomy after ankylosis, but this should not be attempted during the active stages of the disease.
The question of excision of the hip-joint is one of importance. In few other instances do social surroundings or factors enter so largely into the question of surgical judgment. The wealthy can afford long-continued treatment, which to the poor is prohibited, and one may be tempted in one case to exsect early when, under other conditions, he would treat the case tentatively. Nevertheless certain indications make the operation expedient in all cases, as, for instance, when the destructive process is steadily progressing or so acute as to shorten not only the limb but life itself. It is necessary also when there is necrosis, and in most instances of suppuration extending into the joint cavity. In those cases where skiagrams confirm other indications to the effect that the disease is localized in the neck or head of the femur, Huntington’s suggestion may be adopted, after exposing the upper end of the femur, to drill or tunnel in the direction of the neck until its diseased focus is reached and thoroughly clean it out. In cases treated otherwise conservatively, yet accompanied by a great deal of pain, especially those of the femoral side of the joint, one may frequently get relief by exposing the upper end of the femur and making ignipuncture in the same direction as above.
In general it is impossible to lay down succinct rules for the treatment of hip disease. Cases differ so greatly in location, in severity, as well as in environment and their personal surroundings, that what is advisable in one case is not to be thought of in another. Of the mechanical features of treatment one may say that that is the best splint or apparatus which best meets the indication in each particular case, and that none will be effective in which the element of traction is neglected, nor that of physiological rest. No patient should be released from treatment whose hip is still sensitive or in whom there remains any muscle spasm. Rest and protection should be maintained for months and even years after apparent recovery, while the same attention should be given to diet and climatic surroundings as in any other case of well-marked tuberculous disease.
This subject deserves special consideration, mainly because of the peculiar deformity produced by the disease rather than any of distinctive peculiarity in its nature. Years ago it received the name of tumor albus, and is frequently called white swelling by the laity, because of the pallor of the surface and the increased dimensions of the limb due to thickening, always of soft parts, and usually of the bone itself. The disease may begin in either epiphysis, in the patella, or in the synovial membrane, oftener in the bone in the young and in the synovia in adult cases. Its most distinctive feature is the deformity produced by excess of muscle spasm, the hamstring muscles especially producing a backward subluxation which frequently fixes the knee, not only at a right angle, but with very much disturbed joint relations, so that the head of the tibia is in contact with the posterior surface of the condyle rather than with their proper terminal areas. The soft tissues outside of the bone are frequently very much thickened and infiltrated, often edematous, while the joint cavity may be more or less distended with seropus or with old pyoid material. The exterior surface is so anemic from deficient blood supply as to make it appear comparatively white, while the superficial veins are made much more prominent by their engorgement owing to obstruction of the deep circulation. The picture, then, of an advanced case of tumor albus is quite typical.
Here the joint cavity is so large that there is early effusion of fluid, in most cases, which is in this location easily recognizable; hence the distinctive symptoms consist of pain, tenderness, swelling, limp muscle spasm, with, finally, limitation of motion, deformity, and atrophy. In addition to these features there may be added those due to the formation and the escape of pus, i. e., one may have the signs of acute or old suppuration, while the parts about the joint may be riddled with old sinuses. The deformity of these cases is usually characterized by a certain amount of external rotation of the leg, while a species of knock-knee is not uncommon. Actual lengthening of the limb due to overactivity at the epiphyseal junctions may also be noted.
—The treatment of white swelling is based upon the principles already laid down for the treatment of spinal and hip caries, the underlying feature being traction to a degree sufficient to overcome muscle spasm, unless it be too late to permit a subsidence of active changes. When seen early a few weeks of confinement in bed, with effective traction, followed by fixation with plaster-of-Paris bandage, combined with the Thomas splint (see above) or with some other form of more elaborate apparatus, by which rest and traction can be continually maintained, will be needed. The presence of tuberculous disease about the knee permits of the application of the elastic bandage above the knee, by which the congestion treatment of Bier can be more or less effectually carried out. It would, however, be a mistake to rely entirely upon this to the neglect of traction and rest, nor should too much be expected of it in severe cases. It is a method to be used early rather than late.
The final resort is excision, which is practically adapted to cases of moderate type in young adults, where the bones have attained their full growth and where it will afford a prospect of cure in a minimum of time. It is undesirable in children because it is so often necessary to remove the epiphyses, and because of the arrest of development that follows such removal and the consequent shortening of the limb. Nevertheless even in children it may be demanded and may be considered as a resort superior to amputation, the latter being reserved usually for a life-saving measure or for desperate cases where destruction has been practically complete and the limb is hopelessly useless.
Of the other large joints, all of which may be involved in tuberculous processes similar to those just discussed, it may be said that they come under the general rules of treatment already laid down.
This term includes a peculiar postural deformity by which the head is rotated and inclined abnormally to one side in a more or less fixed position. As to the causes of the deformity two will be considered:
Congenital causes include:
1. Injury to the sternomastoid muscle at birth, which is perhaps the commonest.
2. Abnormal intra-uterine position and pressure.
3. Arrest of muscular development.
4. Intra-uterine myositis, the muscles being sometimes found actually altered in structure.
5. Defective development of the upper vertebrae or such distorted growth as is often met along with other deformities, e. g., club-foot.
The acquired causes include:
1. Traumatisms, either direct, as by injury to the muscles, such as may happen from gunshot wounds, etc., or follow operations by which the spinal accessory has been injured, or by burns, and other lesions which cause much cicatricial contraction.
2. Reflex activity in connection with disease of the lymph nodes, deep cervical abscesses, parotid phlegmons or tumors, etc. Whitman states that tuberculous disease of the cervical nodes caused the condition in 50 per cent. of over 100 cases analyzed by him.
3. Reflexes from the eyes, as Bradford and Lovett have described from the orthopedist’s standpoint, and Gould from that of the oculist, refractive errors causing the head to be held in unnatural positions in order to improve vision.
4. Compensation in high degrees of rotary lateral curvature, the effort being to keep the head facing to the front.
5. Myositis, usually rheumatic, but sometimes a sequel of the infectious fevers, or even of gonorrhea.
6. Habitual deformity, the result of occupation or sheer bad habit.
7. Tonic or intermittent spasm leading to spastic contractures whose causes are difficult to seek, but appear to inhere in the central nervous system.
8. Paralyses of certain muscles, permitting lack of opposition and consequent deformity.
—According to circumstances significant pathological changes may be found in the affected muscles. These are usually the sternomastoid and the trapezius, although in long-standing or complicated cases the deeper muscles of the neck may also participate. A long contracted muscle may change almost into mere fibrous tissue.
The secondary effects of contraction of the sternomastoid and the trapezius are really far-reaching and noteworthy. The jaw may be drawn down and to one side, so that teeth do not appose each other as they should, or perhaps even do not meet. Compensatory curvatures occur also in the spine and there is well-marked change in gait and in most of the body habits. In the young and rapidly growing cranial and facial asymmetry also become pronounced. The later results and deformities of torticollis are not to be mistaken for congenital elevation of the scapula, sometimes known as “Sprengel’s deformity,” which consists not merely in elevation, but in rotation of the shoulder-blade so that its lower angle is too near the spine. There may be some limitation of motion of the scapula and of the arm. Sprengel accounted for this abnormality by maintenance of the intra-uterine position of the arm behind the back. The acute forms of torticollis occur nearly always in acute phlegmons of one side of the neck, and should subside with the other and causative lesions. Nevertheless from such spasm may develop a chronic form which may persist.
The position of the head varies with the muscles particularly involved and the associated spasm. The sternomastoid muscle alone will draw the mastoid down toward the sternum, with rotation of the face to the other side. When the trapezius is involved the head is drawn backward and the chin raised. The more the platysma, scaleni, splenii, and deep rotators are involved the more complex becomes the condition, to such an extent even that in serious cases it is almost impossible to decide which muscles really are at fault. When the superficial muscles are involved they can usually be distinctly felt to be firm and contracted, while the sternomastoid will stand out like a cord. Pain is a rare complaint, but a feeling of tenderness or soreness is not unusual.
The spasmodic or intermittent form is less common, but more difficult to account for and even to treat. It seems to be due to choreiform spasm of those muscles which produce it, and here the condition is reflex, the causes lying deeply in the nervous system. In some instances, however, they are of ocular origin and can be relieved by correcting refractive errors. Intermittent spasm is usually absent during sleep and quiescent in the recumbent position; it is usually confined to one side.
—In the matter of diagnosis it is necessary mainly to eliminate only spinal caries, while as between involvement of the anterior and posterior groups of muscles the determination is made by palpation and inspection.
—There are few morbid conditions whose cause it is more necessary to discover. Could this be done operative treatment would be less often demanded. Treatment should depend, therefore, on the exciting cause and the possibility of its removal. The spasmodic or intermittent form may spontaneously subside. Cases of essentially ocular origin need the services of the oculist, and other acute cases usually subside with the successful treatment or the subsidence of their causes. On the other hand, chronic cases usually need either mechanical or operative treatment.
The most common operation for relief of torticollis is simple tenotomy of the sternomastoid, taking care to divide the sheath and everything which resists, and, at the same time, to avoid the external jugular vein as well as the deeper structures. Mere tenotomy of one or both of its lower tendons is an exceedingly simple measure, but in serious cases an open division will permit of more thorough work. Here an incision made one inch above the clavicle and parallel to it will permit division of everything which resists and also any recognition of that which should be spared. In any event the position of the head should be immediately rectified, and kept so either by plaster or starch bandage, or by a traction apparatus applied to the head, the body being in the recumbent position, while later some efficient and well-fitting brace should be worn for some time. The posterior cases, i. e., those where the posterior muscles are involved, afford greater operative difficulty, muscles involved lying too deeply and being in too close relation with important vessels and nerves to justify the ordinary wide-open division. Nevertheless in extreme cases there need be no hesitation in extirpating completely those muscles which are primarily and mainly at fault. The writer has removed the sternomastoid and the trapezius, with sections of the still deeper muscles, and has seen nothing but benefit follow the procedure. It should be resorted to when repeated anesthesia with forcible stretching and a suitable brace fail to give relief. These forms of wryneck which are due to contraction of muscles infiltrated from the presence of neighboring phlegmons, etc., will usually subside with massage and semiforcible stretching under an anesthetic. They need conservative rather than operative treatment. Attack upon the spinal accessory and the deep cervical nerves will be described in the chapter on Surgery of the Nerves. It, however, will rarely be justified, since the primary causes inhere not so much in those nerve trunks as in the nerve centres. Such operations are usually of questionable benefit, and cases should be carefully watched before being submitted to them.
Under these terms are included certain deviations from normal relationships of the vertebræ, both in their superposition in the median line and in their rotation on each other, by which are produced lateral curvatures, with more or less rotary displacement. Of these deformities there is a rare congenital form which is due to fetal, or rather intra-uterine, rickets, but practically all rotary lateral curvatures are acquired. One-half of such cases begin before the twelfth year of life. It may also come on during adult life, as the result of bad postural habits, exclusive use of the right hand, etc. Altogether it occurs in about 1 per cent. of females and in a smaller percentage of males. Scoliosis being not a disease but rather a process of irregular growth, cannot be said to have a symptomatology. It is known rather by signs. Only in the advanced stage can it produce symptoms. It is rarely seen in its incipiency by either the surgeon or the physician. Not until parents have noticed distortions of the spine are these children usually taken to their medical advisers. Exception, however, should be made to this in respect to certain gymnasia and athletic training schools, where trainers are quick to notice irregularities of this kind. The abnormal curves thus produced are at first flexible, but later become fixed. In rapidly growing girls who take but little exercise there may be some muscle weakness, which may cause fatigue or even actual soreness. Pain is rarely present. The rate and extent of deformity are not subject to any rule. Spontaneous cessation ensues in practically every case, i. e., a stage of convalescence and arrest, at a time when the deformity may be but slight, or perhaps hideous.
The nervous phenomena attending lateral curvature, like the discomforts attaching to it, are mainly due to the increasing strains and stresses that are imposed on certain structures as the deformity occurs and increases. Of these, muscles and ligaments suffer most, especially those uniting the thorax and spine. Pressure effects on nerves and tissues may be produced by distorted ribs and vertebræ or by final displacement of viscera. The conditions which lead up to spinal curvature are attended often by neurasthenic and neurotic features, both mental and physical. As deformity increases impairment of function of thoracic as well as of the upper abdominal viscera will occur, and such patients are usually thin and anemic, rather than fat.
To mere lateral distortion is added, in every pronounced case, more or less rotation of the entire trunk. The curvature consists of one primary curve, with one or two secondary curvatures, according to the location of the first. If the primary curve be located in the mid-dorsal region there will occur compensatory curvature above and below in order that the head may still be kept in the line of the centre of gravity above the pelvis. Such secondary alterations are of much less import than the primary. The most common of the mid-dorsal curvatures, which occurs in nearly four-fifths of the cases, has its convexity to the right. While the right shoulder seems higher its scapula will be more pronounced and carried backward, the back and the chest below it will be more rounded, and in front the breast on the opposite side more prominent. The whole trunk in marked cases becomes so warped that the arm on one side will hang free while the other touches the pelvis; thus the back loses its symmetry either in the erect or stooping position. In the lumbar region there is compensatory curvature to the opposite side, which makes one hip and flank more prominent. By virtue of the rotation of such a warped spinal column there result certain anterolateral curvatures that may later become pronounced. While such changes are going on in the upper part of the trunk there is sufficient rotation of the lumbar segment to lead to tilting of the pelvis, with consequent limp, or a peculiarity of gait.
The degree of torsion of the spinal column is the best index of the real severity of a given case, and to it are due the most disfiguring features of the deformity. Torsion may even precede curvature, causing a prominence of one shoulder or hip as the first visible evidence of its existence.
Those forms of lateral curvature due to rickets occur most often in the dorsal region, and as frequently in boys as in girls. In most of these cases the constitutional condition will be indicated by other significant features. Another form much less frequent, yet well known, is the result of inequality of the length in the limbs, so that patients stand ordinarily with tilted pelves; hence, the limbs should be carefully measured in every instance. A truly paralytic form of scoliosis is also known, which is of the infantile type and due to some form of infantile palsy. Again, scoliosis is produced by shrinkage of tissues and contraction of old exudates occurring within the thorax and following chronic disease, as when the ribs on one side are drawn down after an old pleurisy or empyema. Extrinsic causes of lateral curvature are met with among several occupations when one side of the body is used more than the other, or when the individual habitually stands in an unsymmetrical position. In addition to this, the habitual right-hand habit, which seems instinctive, and which the majority of people exhibit, leads to excessive use of the right side of the body, with overdevelopment and consequent warping of the upper part of the skeleton. The young should be taught the use of the left hand as well as the right, i. e., to become ambidextrous.
The foreign surgeons have given the term ischias scoliotica to a form of lateral curvature involving rather the lower part of the spine and occurring usually in adults or elderly people, which is accompanied by more or less acute pain, usually assuming the type of sciatica. Its etiology is obscure, as is implied by the synonym scoliosis neuropathica. It is not a frequent malady, but usually chronic and refractory. It is best dealt with by fixation or immobilization.
—Predisposing causes of scoliosis may be both constitutional and inherited. They include general debility, rickets—with its accompanying osseous instability and liability to abnormal curvature—the consequences of various diseases of childhood, and anything which greatly lowers vitality. The actual causes include congenital or acquired defects, such as differences in the lengths of the limbs or other skeletal asymmetries; acquired abnormal position of the head due to defective vision, with its natural sequences; results of intrathoracic disease, such as empyema; faulty attitudes and bad developmental habits, such as those assumed often in school and elsewhere in sitting at a desk or standing in bad position, or at work in various ways. To these should be added the right-hand habit already mentioned. These may all be summed up as among the causes of asymmetrical growth and deformity, occurring as the result of ignorance or inattention, and allowed to go on indefinitely or until it is too late to correct the malposition. Theories of paralysis of individual muscles or certain muscle groups have been advanced, as well as of contractures, but usually these are effects which have been mistaken for causes. The bones have been blamed, but their changes are secondary results of pressure, save perhaps in some cases of rickets. The structures of the thorax have relatively considerable superimposed weight to carry, and both lateral halves of the thorax should be developed symmetrically in order to distribute this weight evenly. Nothing so influences skeletal development as exercise; thus even to assume and maintain the normal erect attitude requires a certain amount of muscular effort, and if each side be not given an equal task one will develop at the expense of the other, and thus lateral curvature is sure to result.