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THE PREVENTION AND CORRECTION OF DEFORMITY FOLLOWING ARTHRITIS OF THE HIP-JOINT.
307 formation. The mother had a mild saprasmic temperature for the first two days, but subsequently she made an
require subcutaneous division. If the femur be divided it can be appreciably lengthened by sufficient and extension. The ordinary extension stirrup is well-directed recovery. uninterrupted I have thought the case important as illustrating that applied 24 hours before the operation. Throngh a small between embryotomy on the one hand and Cassarean section incision below the right trochanter the femur is divided. The followed by hysterectomy on the other there may be an section runs obliquely downwards and outwards from just intermediate group of cases such as this one, where special below the neck of the femur, and thus well away from the prophylaxis adopted against an infected liquor amnii might old disease. The adductors are divided subcutaneously to have
a
distinct
Wimpole-street,
place
obliquely,
the extent that is necessary for the over-correction of the deformity. The extension is then applied in the following way. When the right hip is the diseased one, the pulley for
in treatment.
W.
THE PREVENTION AND CORRECTION OF DEFORMITY FOLLOWING ARTHRITIS OF THE HIP-JOINT. BY R. P.
Fie;. 1.
ROWLANDS, M.S. LOND., F.R.C.S. ENG ,
ASSISTANT SURGEON AND SURGEON IN CHARGE OF THE ORTHOPÆDIC DEPARTMENT, GUY’S HOSPITAL, LONDON.
IN the treatment of tuberculous and
septic
arthritis of the
hip-joint too little care is usually taken to get the femur into a good position during the active stages of the disease, so that when the disease is cured or quiescent the limb is often in a very bad position. Frequently there are flexion and adduction of the thigh on the pelvis to very considerable degrees, so that the limb is several inches shorter than the other one. This is a very great disadvantage to the patient, and gives rise to the characteristic limping gait of late hip disease. This is all the more deplorable because it is preventable by the application of a proper apparatus during the active and contracting stages of the disease. The thigh can be secured in a position of slight abduction and extension, so that no shortening need result, even in tuberculous cases with some want of development of the neck of the femur. Incidentally it may be remarked that there need never be any suppuration or pathological dislocation of the hip-joint in tuberculous disease if it is treated early enough with complete rest and suitable instruments. I need hardly say that excision of the hip in children for tuberculosis is a very bad operation, leading to excessive shortening before adult life, and very often to persistence of the disease with sinuses and secondary sepsis. For early cases conservative treatment is immeasurably better. The causes of shortening in maltreated cases of tuberculous hip disease may be classified into two kinds. 1. Palse shortening caused by flexion and adduction of the thighs on the pelvis. 2. Real shortening due to the following causes : (a) Cessation of growth of the whole limb from want of use. This is only marked when there is much shortening or chronic suppuration preventing the use of the limb for some years. The readiest indication of it is obtained by measuring the two tibiæ with the knees flexed, so that the upper ends can be easily identified. (b) The want of development of the neck I of the femur. (c) Absorption and changes in the shape of the head and neck of the femur due to tuberculous disease. These are, to a great extent, avoidable by early treatment and the entire prevention of standing upon the diseased limb. (d) The pathological dislocation of the head of the femur on to the dorsum ilii. This is entirely preventable by early and continuous treatment by rest in a proper apparatus. Shortening, however, should be very slight in all cases of tuberculous disease of the hip-joint if treated properly from the first. The same is true for septic arthritis. Unfortunately the ideal treatment is not carried out, for one reason or another, in a great many cases ; so that deformity and shortening are common, and are evident to everyone who looks about him in the streets. The worst of these cases are those which were unfortunately submitted to excision of the joint in childhood, when that operation was popular from 10 to 20 years ago. I have seen a great many patients with from 2 to 11 inches of shortening by the time they have grown up. By this shortening I mean the difference of the level of the heels, and the amount of compensation that is required by means of the high boot, or some other instrument. This, of course, includes all the shortenings mentioned above, both the true and the false. A good deal can be done to improve the condition of those patients who are the unfortunate victims of deformity and shortening, in the absence of active disease of the hip, by subtrochanteric osteotomy and division of some of the tight adductors. This allows the correction of the flexion and adduction. Occasionally the fascia in front of the hip may
operation. Old neglected tuberculous disease of the right hip with considerable flexion and adduction, and 2s inches of shortening. Note acute angle between the thigh-bone and pubic ramus, and the absorption of the neck.
Before
FIG. 2.
After the operation of subtrochanteric osteotomy. Note the correction of the adduction. The shortening is now only half an inch- Note the wide angle between the thigh-bone and the pubic ramus. The photographs de nor, show the correction of the flexion, which was severe.
the weight extension is fixed at the right lower corner of the bed, while the pelvis ia kept near the right border by means of broad straps. A well-padded perineal band extends from the left side of the perineum to the left upper corner of the bed. In this manner the adduction is over-corrected. To diminish the pressure of the perineal band and to make use of the body-weight, the foot of the bed is elevated. To correct the flexion the pullev at the foot of the bed is placed as low as possible and the right lower quarter of the bed has no mattress, so that gravity tends t) straighten the limb.
308 This treatment is continued for about three weeks, when a plaster spica is substituted. About 12 weeks after the operation the patient is allowed to put some weight on the foot; but care must be taken to delay this as long as possible on account of the risk of bending at the union. Figs. 1 and 2 show the X ray appearances before and after treatment in this way. A girl, aged 11 years, had 22 inches of shortness of the right leg. She now only has a quarter of an inch and needs no high boot. In worse cases the method has been equally successful in reducing the shortening. For instance, in a girl aged 15 years a shortening of 3 inches was reduced to three-quarters of an inch. This made a great deal of difference to her comfort and appearance. This is so far satisfactory even in cases of ankylosis, but it is far more successful when there is some mobility of the hip-joint. One of my patients with considerable deformity improved her condition very much by falling down stairs and breaking her thigh-bone in the upper third. She fell in a sitting position, the right heel coming against the right femur below the great trochanter. This patient was a middle-aged woman, who from want of exercise was excessively stout. She had been sent to me by Dr. O. T. Brookhouse of Bromley, and I had ordered an apparatus, designed to conduct most of the weight from the tuber ischii and the root of the thigh to the heel of the boot. This had afforded considerable relief to the pain at the hip- and knee-joints, which was due to mechanical strain upon these joints in a flexed position. The apparatus was, fortunately, not on when the fall occurred. The fracture was treated by weight extension. The result of the accidental correction of the deformity is very satisfactory. The limb is longer, stronger, and straighter than before the accident, and the pain has almost ceased. The pati 3nt can now walk several miles in comfort. Queen Anne-street, W.
«
stigmata of puerile tuberculosis. :I I (a) palpation for glandular enlargement of the anterior cervical and supraclavicular areas (only cases showing at least a dozen such enlarged glands to be included as positive); (b) percussion of the apices ;and (c) auscultation of the apices." Dr. Allan also writes :evidence of
It is much less easy to diagnose pulmonary tuberculosis in the child than in the adult owing to the greater difficulty of interpreting the physical signs met with. There is no single sign or symptom pathognomonic of this disease in the child, and I am not convinced that the association of dulness on percussion, bronchial breathing, and crepitations which may or may not be intermittent, in an emaciated ansemie child is absolutely diagnostic of pulmonary tuberculosis. To cite only one example, I have seen the above picture in children who suffered from enlarged tonsils and adenoids, but in whom after operation the physical signs disappeared within a few days and the symptoms rapidly improved. Under such circumstances I hardly think a diagnosis of tuberculosis is justified.
ON PRE-TUBERCULOSIS AND PREPULMONARY TUBERCULOSIS, AND THEIR DIAGNOSIS IN RELATION TO SCHOOL INSPECTION. BY WILLIAM
EWART,
M.D.
CANTAB., F.R.C.P. LOND.,
CONSULTING PHYSICIAN TO ST. GEORGE’S HOSPITAL AND THE BELGRAVE HOSPITAL FOR CHILDREN ; JOINT HONORARY SECRETARY TO THE QUEEN ALEXANDRA SANATORIUM, DAVOS; ETC.
Dr. Squire agrees "entirely with Dr. Philip that the standard of clinical training in the physical examination of the chest needs raising ; but we must, on the other hand, avoid such refinement that every chest is pronounced diseased which presents any sign differing from what belongs to the ideal healthy chest-often termed ’normal’ in error ;for few children, and practically no adults, satisfy this ideal of healthy lungs entirely and always." 2. The exclusion or the non-exclusion from school is a medical administrative question, and therefore a question of medical opinion. But an exhaustive and so far as possible correct diagnosis and report of the actual condition are a question as to facts. They are a great responsibility upon the inspector, to whom exclusively the examination of the child is entrusted. They must therefore bring into his purview the possibility of a pre-pulmonary tuberculosis, and particularly of the most common form of it, which is the glandular form. That duty weighs heavily upon the minds of Dr. Philip and of Dr. Allan when they dwell upon the necessity of a searching examination for enlarged glands. Dr. Allan had also previously II I endeavoured to show how important it is to recognise early tuberculous mediastinal glands, and referred to some of the aids that might be employed to substantiate or reject the provisional diagnosis. Some of these additional diagnostic weapons, which include the X rays, &c., cannot readily be used by the medical inspector, in particular, for instance, the tuberculin tests. These can best be applied by the family doctor or, if necessary, by a specialist." He addsChildren who are physiologically delicate, "pre-tuberculous "-call them what you will-are prone to, and may under adverse circumstances, develop pulmonary tuberculosis. They are physically defective and are not able to compete on equal terms with their more fortunate companions who are in good health. They do not, as a rule, require to be kept from school, but they should be under medical supervision, and this supervision can best be carried out at the hands of the family doctor or, in necessary cases, by the medical staff of the local
IT is essential to realise the practical distinction between (a) the identification of tuberculosis and (b) that of pulmonary tuberculosis. 1,n ahÛdren, much more than in hospital. the adult, the prevailing method begins at the wrong end. These views are an important recognition of the inevitable Their initial tuberculosis is almost invariably pre-pulmonary which should belong to the inspection when thoroughness in clinical date. As I pointed out in a paper read before the understood. To bring this into clearer light it is properly Ilford division of the British Medical Association in April, not inopportune to call attention to the subject of the traebeo1909, our ideal should be the recognition of the p7’c-
In
I demonstrated that paper on dorsal pereq6ssion the fifth dorsal spine is relatively dull on per. cussion, with a slight extension of dulness to the right of the tip of the spinous process. Fernet’s second sign in reality consists in an intensification of that normal dulness, which I believe may be correctly attributed to the presence of the infra-tracheal glands below the resonance of the bifurcating trachea. This points to the necessity for a careful routine of all anaemic children for any abnormal degree a
normally
examination
1
2 3
5
4 Cf. THE LANCET, vol. ii., 1909, p. 1209. Bulletin de l’Académie de Médecine. Oct. 11th, 1898 6 Brit. Med. Jour., vol. ii., 1899, p. 1168.
require subcutaneous division. If the femur be divided it can be appreciably lengthened by sufficient and extension. The ordinary extension stirrup is well-directed recovery. uninterrupted I have thought the case important as illustrating that applied 24 hours before the operation. Throngh a small between embryotomy on the one hand and Cassarean section incision below the right trochanter the femur is divided. The followed by hysterectomy on the other there may be an section runs obliquely downwards and outwards from just intermediate group of cases such as this one, where special below the neck of the femur, and thus well away from the prophylaxis adopted against an infected liquor amnii might old disease. The adductors are divided subcutaneously to have
a
distinct
Wimpole-street,
place
obliquely,
the extent that is necessary for the over-correction of the deformity. The extension is then applied in the following way. When the right hip is the diseased one, the pulley for
in treatment.
W.
THE PREVENTION AND CORRECTION OF DEFORMITY FOLLOWING ARTHRITIS OF THE HIP-JOINT. BY R. P.
Fie;. 1.
ROWLANDS, M.S. LOND., F.R.C.S. ENG ,
ASSISTANT SURGEON AND SURGEON IN CHARGE OF THE ORTHOPÆDIC DEPARTMENT, GUY’S HOSPITAL, LONDON.
IN the treatment of tuberculous and
septic
arthritis of the
hip-joint too little care is usually taken to get the femur into a good position during the active stages of the disease, so that when the disease is cured or quiescent the limb is often in a very bad position. Frequently there are flexion and adduction of the thigh on the pelvis to very considerable degrees, so that the limb is several inches shorter than the other one. This is a very great disadvantage to the patient, and gives rise to the characteristic limping gait of late hip disease. This is all the more deplorable because it is preventable by the application of a proper apparatus during the active and contracting stages of the disease. The thigh can be secured in a position of slight abduction and extension, so that no shortening need result, even in tuberculous cases with some want of development of the neck of the femur. Incidentally it may be remarked that there need never be any suppuration or pathological dislocation of the hip-joint in tuberculous disease if it is treated early enough with complete rest and suitable instruments. I need hardly say that excision of the hip in children for tuberculosis is a very bad operation, leading to excessive shortening before adult life, and very often to persistence of the disease with sinuses and secondary sepsis. For early cases conservative treatment is immeasurably better. The causes of shortening in maltreated cases of tuberculous hip disease may be classified into two kinds. 1. Palse shortening caused by flexion and adduction of the thighs on the pelvis. 2. Real shortening due to the following causes : (a) Cessation of growth of the whole limb from want of use. This is only marked when there is much shortening or chronic suppuration preventing the use of the limb for some years. The readiest indication of it is obtained by measuring the two tibiæ with the knees flexed, so that the upper ends can be easily identified. (b) The want of development of the neck I of the femur. (c) Absorption and changes in the shape of the head and neck of the femur due to tuberculous disease. These are, to a great extent, avoidable by early treatment and the entire prevention of standing upon the diseased limb. (d) The pathological dislocation of the head of the femur on to the dorsum ilii. This is entirely preventable by early and continuous treatment by rest in a proper apparatus. Shortening, however, should be very slight in all cases of tuberculous disease of the hip-joint if treated properly from the first. The same is true for septic arthritis. Unfortunately the ideal treatment is not carried out, for one reason or another, in a great many cases ; so that deformity and shortening are common, and are evident to everyone who looks about him in the streets. The worst of these cases are those which were unfortunately submitted to excision of the joint in childhood, when that operation was popular from 10 to 20 years ago. I have seen a great many patients with from 2 to 11 inches of shortening by the time they have grown up. By this shortening I mean the difference of the level of the heels, and the amount of compensation that is required by means of the high boot, or some other instrument. This, of course, includes all the shortenings mentioned above, both the true and the false. A good deal can be done to improve the condition of those patients who are the unfortunate victims of deformity and shortening, in the absence of active disease of the hip, by subtrochanteric osteotomy and division of some of the tight adductors. This allows the correction of the flexion and adduction. Occasionally the fascia in front of the hip may
operation. Old neglected tuberculous disease of the right hip with considerable flexion and adduction, and 2s inches of shortening. Note acute angle between the thigh-bone and pubic ramus, and the absorption of the neck.
Before
FIG. 2.
After the operation of subtrochanteric osteotomy. Note the correction of the adduction. The shortening is now only half an inch- Note the wide angle between the thigh-bone and the pubic ramus. The photographs de nor, show the correction of the flexion, which was severe.
the weight extension is fixed at the right lower corner of the bed, while the pelvis ia kept near the right border by means of broad straps. A well-padded perineal band extends from the left side of the perineum to the left upper corner of the bed. In this manner the adduction is over-corrected. To diminish the pressure of the perineal band and to make use of the body-weight, the foot of the bed is elevated. To correct the flexion the pullev at the foot of the bed is placed as low as possible and the right lower quarter of the bed has no mattress, so that gravity tends t) straighten the limb.
308 This treatment is continued for about three weeks, when a plaster spica is substituted. About 12 weeks after the operation the patient is allowed to put some weight on the foot; but care must be taken to delay this as long as possible on account of the risk of bending at the union. Figs. 1 and 2 show the X ray appearances before and after treatment in this way. A girl, aged 11 years, had 22 inches of shortness of the right leg. She now only has a quarter of an inch and needs no high boot. In worse cases the method has been equally successful in reducing the shortening. For instance, in a girl aged 15 years a shortening of 3 inches was reduced to three-quarters of an inch. This made a great deal of difference to her comfort and appearance. This is so far satisfactory even in cases of ankylosis, but it is far more successful when there is some mobility of the hip-joint. One of my patients with considerable deformity improved her condition very much by falling down stairs and breaking her thigh-bone in the upper third. She fell in a sitting position, the right heel coming against the right femur below the great trochanter. This patient was a middle-aged woman, who from want of exercise was excessively stout. She had been sent to me by Dr. O. T. Brookhouse of Bromley, and I had ordered an apparatus, designed to conduct most of the weight from the tuber ischii and the root of the thigh to the heel of the boot. This had afforded considerable relief to the pain at the hip- and knee-joints, which was due to mechanical strain upon these joints in a flexed position. The apparatus was, fortunately, not on when the fall occurred. The fracture was treated by weight extension. The result of the accidental correction of the deformity is very satisfactory. The limb is longer, stronger, and straighter than before the accident, and the pain has almost ceased. The pati 3nt can now walk several miles in comfort. Queen Anne-street, W.
«
stigmata of puerile tuberculosis. :I I (a) palpation for glandular enlargement of the anterior cervical and supraclavicular areas (only cases showing at least a dozen such enlarged glands to be included as positive); (b) percussion of the apices ;and (c) auscultation of the apices." Dr. Allan also writes :evidence of
It is much less easy to diagnose pulmonary tuberculosis in the child than in the adult owing to the greater difficulty of interpreting the physical signs met with. There is no single sign or symptom pathognomonic of this disease in the child, and I am not convinced that the association of dulness on percussion, bronchial breathing, and crepitations which may or may not be intermittent, in an emaciated ansemie child is absolutely diagnostic of pulmonary tuberculosis. To cite only one example, I have seen the above picture in children who suffered from enlarged tonsils and adenoids, but in whom after operation the physical signs disappeared within a few days and the symptoms rapidly improved. Under such circumstances I hardly think a diagnosis of tuberculosis is justified.
ON PRE-TUBERCULOSIS AND PREPULMONARY TUBERCULOSIS, AND THEIR DIAGNOSIS IN RELATION TO SCHOOL INSPECTION. BY WILLIAM
EWART,
M.D.
CANTAB., F.R.C.P. LOND.,
CONSULTING PHYSICIAN TO ST. GEORGE’S HOSPITAL AND THE BELGRAVE HOSPITAL FOR CHILDREN ; JOINT HONORARY SECRETARY TO THE QUEEN ALEXANDRA SANATORIUM, DAVOS; ETC.
Dr. Squire agrees "entirely with Dr. Philip that the standard of clinical training in the physical examination of the chest needs raising ; but we must, on the other hand, avoid such refinement that every chest is pronounced diseased which presents any sign differing from what belongs to the ideal healthy chest-often termed ’normal’ in error ;for few children, and practically no adults, satisfy this ideal of healthy lungs entirely and always." 2. The exclusion or the non-exclusion from school is a medical administrative question, and therefore a question of medical opinion. But an exhaustive and so far as possible correct diagnosis and report of the actual condition are a question as to facts. They are a great responsibility upon the inspector, to whom exclusively the examination of the child is entrusted. They must therefore bring into his purview the possibility of a pre-pulmonary tuberculosis, and particularly of the most common form of it, which is the glandular form. That duty weighs heavily upon the minds of Dr. Philip and of Dr. Allan when they dwell upon the necessity of a searching examination for enlarged glands. Dr. Allan had also previously II I endeavoured to show how important it is to recognise early tuberculous mediastinal glands, and referred to some of the aids that might be employed to substantiate or reject the provisional diagnosis. Some of these additional diagnostic weapons, which include the X rays, &c., cannot readily be used by the medical inspector, in particular, for instance, the tuberculin tests. These can best be applied by the family doctor or, if necessary, by a specialist." He addsChildren who are physiologically delicate, "pre-tuberculous "-call them what you will-are prone to, and may under adverse circumstances, develop pulmonary tuberculosis. They are physically defective and are not able to compete on equal terms with their more fortunate companions who are in good health. They do not, as a rule, require to be kept from school, but they should be under medical supervision, and this supervision can best be carried out at the hands of the family doctor or, in necessary cases, by the medical staff of the local
IT is essential to realise the practical distinction between (a) the identification of tuberculosis and (b) that of pulmonary tuberculosis. 1,n ahÛdren, much more than in hospital. the adult, the prevailing method begins at the wrong end. These views are an important recognition of the inevitable Their initial tuberculosis is almost invariably pre-pulmonary which should belong to the inspection when thoroughness in clinical date. As I pointed out in a paper read before the understood. To bring this into clearer light it is properly Ilford division of the British Medical Association in April, not inopportune to call attention to the subject of the traebeo1909, our ideal should be the recognition of the p7’c-
In
I demonstrated that paper on dorsal pereq6ssion the fifth dorsal spine is relatively dull on per. cussion, with a slight extension of dulness to the right of the tip of the spinous process. Fernet’s second sign in reality consists in an intensification of that normal dulness, which I believe may be correctly attributed to the presence of the infra-tracheal glands below the resonance of the bifurcating trachea. This points to the necessity for a careful routine of all anaemic children for any abnormal degree a
normally
examination
1
2 3
5
4 Cf. THE LANCET, vol. ii., 1909, p. 1209. Bulletin de l’Académie de Médecine. Oct. 11th, 1898 6 Brit. Med. Jour., vol. ii., 1899, p. 1168.