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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 Fig. 260

Anteroposterior support: back view. Anteroposterior support with head-ring

(Lovett.) for high dorsal caries: side view. (Lovett.)

The method seems most applicable in the presence of paralysis,

even of long standing, and this feature has often been relieved.
Psoas contraction is best treated by traction, with the patient in
bed, and with the maximum of weight and power applied which can
be tolerated by the individual. If this seem impracticable, then the
patient should be anesthetized and force applied until it is evident
that more harm than good results. Should this harm appear, then
open division of the tissues may be practised. Finally, as a last
resort, in intractable cases, a subtrochanteric osteotomy may be
made.
Pressure paralysis necessitates operative relief. This may be
practised late and should consist of a laminectomy and exposure of
the area compromised by bone pressure or that produced by
pachymeningitis. The operation is done in the same way as for
fracture, and will be described in the chapter on Surgery of the
Spine.
Finally of all cases of Pott’s disease it may be said that each
should be studied by itself, and for each a suitable method or
apparatus devised, rather than to endeavor to apply indiscriminately
unchangeable methods or forms of apparatus. Every apparatus has
its disadvantages as well as its benefits. The more acute the case
the more is absolute rest in bed, with traction, demanded. This is
particularly true of disease in the upper spine. On the other hand, the
more chronic and the lower the disease the easier it is to handle, and
with such simple expedients as plaster corsets. When the sacral
region is rigid, however, recumbency is usually necessary, because
of the difficulty in securing adequate fixation within any apparatus
that can be worn. The necessity for general constitutional, dietetic,
and climatic treatment should never be forgotten, and the danger of
possible acute dissemination kept ever in mind. This is particularly
imminent when too much freedom is allowed. Time, patience, and
discernment are the dominating factors beyond the general
principles already inculcated.

SACRO-ILIAC DISEASE.
Under this name is included a tuberculous condition of the bony
tissues on either side of the sacro-iliac synchondrosis, or of the
cartilage itself, similar to that which produces the special caries
described above. It is an uncommon expression of tuberculous
disease occurring often in the young, identical in pathology with
other tuberculous bone lesions, and giving rise to peculiar
symptoms, mainly because of its location. Early in the course of the
disease these may consist of mild discomfort in the lower abdomen,
irritability of the bladder and bowels, disinclination for exercise, while,
as the disease becomes more pronounced, there will be actual pain,
intensified by standing, relieved by lying down, often severe at night,
usually referred along the course of the sciatics. A most significant
symptom is the tenderness and complaint produced by firm pressure
made upon both sides of the pelvis, thus forcing tender surfaces
against each other. In the later stages of the disease abscess may
develop and present either externally in the lumbar region or
internally, breaking into the pelvis and appearing perhaps in the groin
or close to the perineum. The disease is usually unilateral, and will
cause characteristic limping and aggravated pain upon standing on
the limb of the affected side. Naturally this limb will be spared in
every possible way. It is likely to be mistaken for sciatica or lumbago,
in neither of which diseases is there any tenderness at the sacro-iliac
joint such as can be evoked by pressure from the sides of the pelvis.
It also has to be distinguished from hip disease by the fact that
motions at the nip are not interfered with, and from Pott’s disease of
the lower spine, which usually causes prominence of the spinal
processes and local tenderness in a different region.
The surfaces and tissues involved are extensive and the disease
is always serious. It is one of the most chronic of all such affections,
and too often tends to suppuration, with its slow but inevitable
consequences, or to dissemination. Thus of 38 cases with abscess
reported by Van Hook only 3 recovered.
Treatment.—Treatment should consist of absolute rest, with
traction, so long as the symptoms are active, and
avoidance of all irritation when patients rise from bed. Abscess due
to sacro-iliac disease should be radically attacked, especially if this
can be done early. Intrapelvic pus collections may require trephining
of the pelvic walls or resection of some portion of the ilium, by which
complete evacuation may be made and drainage be amply provided.
When the joint itself is thoroughly broken down the case will have a
hopeless aspect.

CARIES OF THE HIP.

 Hip-joint disease, or, as it is often called, coxitis or morbus coxæ,
is worthy of special consideration on account of its frequency, its
importance, and the deformities which result from its existence. The
most frequent site of the disease, which is of the usual type of
tuberculous ostitis or osteomyelitis, is on the femoral side of the joint,
usually in or near the head of the bone. In a small proportion of
cases the first lesions appear upon the acetabular aspect of the joint,
while in some cases the primary tuberculous lesion is of the type of a
tuberculous synovitis. (See chapters on Bones and Joints.) In
addition to those changes already described in previous chapters
there occur certain distinctive alterations about the hip-joint which
are worthy of note. On the pelvic side the margins of the acetabulum
occasionally become softened, and naturally yielding in the direction
of pressure as the result of muscle pull upon the thigh toward the
pelvis, cause, first, an elongation of the originally merely circular
cavity, and, finally, considerable shifting of position, often referred to
as migration of the acetabulum. Thus the head of the bone may be
found in a socket thus formed on a level one inch higher than on the
well side. So also perforation of the acetabulum may occur, with
perhaps final escape of the head of the bone into the pelvic cavity.
On the other hand, similar changes produce decapitation or marked
alterations of shape in the head and neck of the femur.
Symptoms.—When the symptoms and signs of tuberculous
disease in this location are studied in accordance with
what has already been stated in general about caries of the joint
ends of the long bones, we have among the most significant
features:
1. Pain.—This is referred most commonly to the knee because of
the relations of the obturator nerve to the hip-joint and to the region
of the knee. Pain may also be radiated in other directions, but the
complaints made of pain in the knee are classical. Pain is not,
however, a pathognomonic feature and may be almost wanting, but
the evidences of tenderness, if not of pain, are invariably seen in the
unconscious protection of the joint afforded by muscle spasm. It is
perhaps in hip-joint disease that night pains and cries are most
frequently heard.
2. Muscle Spasm.
—Fixation of the affected joint is always noted. It begins as a
limitation of motion, naturally first noticed in the extremes of rotation,
flexion, and extension, and is perhaps the most important early sign
of the disease. It furnishes the explanation for the subsequent
postural features, as well as an index regarding the gravity and
extent of the morbid process. It may be seen even in the lower spinal
muscles, where it is detected by laying the patient upon the face,
lifting first one leg and then the other, noting the freedom of
hyperextension; in fact, this spinal muscular involvement is
sometimes so marked as to give rise to the suspicion of low Pott’s
disease, from which it is to be distinguished by the fact that the
spasm affects one side rather than both.
3. Muscle Atrophy.—This involves in time all the muscles concerned
about the hip. It begins early, but may not be very pronounced until
quite late. It can usually be determined by measurement if not
apparent upon inspection and palpation. There will also be noted
more or less obliteration of the gluteal crease or fold.
The three cardinal features—pain, spasm, and atrophy—having
been thus considered, we can better appreciate the characteristic
gait and postures peculiar to this disease. Limping is an early
feature, sometimes insidious at first, sometimes abrupt. Patients will
avoid coming down quickly upon the heel, while they walk with the
knee slightly flexed, in order to give more spring. Stiffness is most
apparent on rising from bed in the morning, while the limp is more
pronounced at night, and it is at this stage especially that night cries
are most frequent. To mere limping succeeds actual lameness with
more constant pain. Muscle spasm now leads to malpositions, no
one of which is necessarily first to appear, and any of which may
occur with others in various combinations, although flexion and
adduction are usually the first to be seen, the patient unconsciously
assuming that position which happens to give him most relief.
It is important to realize that a marked degree of adduction will
cause apparent shortening, and of abduction apparent lengthening,
and it is very important to demonstrate that these variations in length
are apparent and not actual. This is to be done by placing the patient
upon a hard surface with the pelvis at right angles to the spine and
the limbs in absolutely symmetrical position. If there be adduction it
may mean that the limbs should be crossed; while if there is
abduction the healthy limb should be abducted to the same degree
as the one affected. Careful measurement will show that the
differences are apparent rather than real. The same care is needed
in regard to rotation, and particularly in regard to psoas contraction
which leads to flexion. One of the most characteristic evidences of
hip-joint disease is flexion of the thigh, which, when the thigh is
brought down to the proper level, will cause an arching upward of the
lumbosacral region. By this time also will be found well-marked
limitations of motion in every direction. All of these features should
be ascertained without an anesthetic, as they depend upon muscle
spasm, which anesthesia would subdue. It is somewhat difficult with
intractable young children to make a thorough examination of this
kind, but a second or third effort will usually succeed when the first
has failed.
Peri-articular symptoms affording corroboration are found in
thickening of the tissues about the joint, especially enlargement of
the upper end of the femur, or increase in thickness of the pelvis,
which may perhaps be felt from the outside or be detected by rectal
examination. There is usually involvement of the inguinal lymph
nodes, and there is frequently prominence of the superficial veins,
due to infiltration of the deeper tissues and obstruction to the return
circulation. A good skiagram will also render much aid.
As the disease progresses there will appear evidences of deep
suppuration, as abscess is frequent in the advanced stages. This
may be peri-articular or may connect with the joint. It may cause
separation of the epiphyses of the femoral neck and complete
loosening of the head of the femur, which will then become a foreign
body in a joint cavity probably filled with pus. Perforation of the
acetabulum may also occur. Much of this abscess formation goes on
insidiously and without marked increase of symptoms. There is no
fixed date when pus may begin to form. It may occur relatively early
or late. It is possible for small amounts of pus to absorb in whole or
in part, or to leave a residue more or less encapsulated, which will
frequently lead later to a secondary abscess, the latter tending to
burrow along between the fascial planes or muscle sheaths and
appear at some distance from its origin. Pelvic abscesses result from
perforation of the acetabulum and may break internally or externally.
Nearly all of these collections are of the cold type, and after a long
time, if they have opened, may cease to discharge characteristic pus
or even pyoid, and simply give vent to a watery seropus. Pus left to
itself usually escapes anteriorly to the tensor vaginæ femoris, but it
may travel in any direction.
The deformities and possibilities which may result from the
advanced stage of hip disease are striking. Persistent muscle spasm
leads to more and more flexure of the thigh, with abduction or
adduction, as the case may be, while later the leg is drawn up so
that the knee may almost touch the abdomen. As the bony portions
of the joint change their shape there occur actual shortening and
final dislocation, while all the adjoining parts show the effect of
muscle atrophy and perverted nutrition. In addition to this the region
of the hip may be riddled with abscesses or with sinuses, and the
condition in every respect made extremely distressing.
While the disease is generally confined to one side, it may occur in
both hip-joints, in which it, however, very rarely begins
simultaneously. Existence of double joint disease of this character
makes the case more than usually troublesome and complicates it
seriously in every respect. The writer has been compelled to make
double simultaneous resection of both hips.
Diagnosis.—This has usually to be made from congenital
dislocation, hysterical joint, infantile paralysis, non-
tuberculous disease—such as synovitis, bursitis, etc.—acute
osteomyelitis of the upper end of the femur, Pott’s disease in the
lumbar region, and sacro-iliac disease, as well as from perinephritic
abscess and appendicitis.
Prognosis.—Hip-joint disease usually tends toward recovery, but
generally with more or less deformity. When the
circumstances are not favorable, ankylosis, with or without deformity,
is inevitable, while abscesses, with persistent fistulæ, are not
uncommon, and one may in extreme cases witness death from
general tuberculous dissemination or from the consequences of
hectic, with amyloid degeneration, or from acute septic infection.
One may naturally ask what may be considered as constituting
recovery. In cases of this kind an absolute cessation of all symptoms
and indications of the disease, with a minimum of deformity and of
limitation of motion, are the nearest approach to ideal recovery that
can be expected to secure. In favorable cases, seen early and
properly treated for a sufficient time, there may be achieved almost a
restitution ad integram, but such an ideal is seldom attained;
otherwise there is nearly always more or less limitation of motion,
with very frequent pseudo-ankylosis or actual ankylosis. Even this is
favorable and most anything may be considered so which falls short
of actual suppuration.
Treatment.—The essential in the early treatment of hip disease is
traction, so applied and regulated as to be effective. It
should not be thought that by such traction as can be tolerated joint
surfaces are actually pulled apart. What it really accomplishes is to
tire out muscles which are in a condition of clonic spasm,
overcoming thereby the deformity which they produce and thus
permitting a reduction of their activity and of the harm which they
have done. To do even this requires a considerable degree of
traction, especially when muscle spasm is very prominent. Therefore
it is best in pronounced cases of deformity to place patients in bed,
and to apply traction by weight and pulley to a degree which actually
overcomes the defects which we are combating. This will often
require more weight than many men are in the habit of using. It
should now be a question, not of amount of weight, but of effect, and
of the easiest and best way of bringing this about. Physicians are
very likely to use too small an amount of weight, and to neglect the
use of counterextension and the benefit of more or less lateral
traction, as well as that in direct line of the limb. Moreover, they often
use inadequate means of applying traction, resorting to it only in
such manner that traction is made at the knee and not at the hip.
Even in young children it is often necessary to use twenty pounds,
with a suitable traction apparatus, and four or five pounds for
effective lateral traction.
Traction should be maintained until deformity has been overcome
or the effort shown to be impracticable. After its complete benefit has
been obtained it should be followed by fixation, the ideal method
being that which accomplishes both fixation and traction at the same
time; as, for instance, by the so-called Thomas splint, which permits
the patient to be up and about with the use of crutches and a high
shoe beneath the well limb, in order that the diseased limb may not
be permitted to touch the floor, but rather to hang, and by its own
weight afford a certain degree of traction. The Thomas splint is the
simplest and cheapest for hospital work, while modifications in more
elegant and expensive form are illustrated in works on orthopedic
surgery. In cases which seem to demand it fixation can be effected
by a plaster-of-Paris spica put on while the patient is standing upon
the well limb and upon an elevation. The character of this work
affords space neither for more elaborate description nor illustration
than the hints embraced in the foregoing paragraphs.
The surgeon as such is perhaps the more concerned in the
treatment of abscesses which frequently complicate these cases.
Much that has been already said about psoas abscess will apply
here. It is a question requiring considerable discrimination as to just
how to treat a small, cold abscess about a diseased hip. Much will
depend upon the environment of the patient, i. e., upon the attention
and expert care which he may receive. Such abscess should be
treated kindly, i. e., by nothing more severe than aspiration, until
ready for more radical treatment. By the latter term is meant
readiness for following it down to the joint cavity and exsecting the
head of the bone, if need be, following this with extirpation of the
capsule, etc. When there is actual pyarthrosis the condition of the
patient is sufficiently serious to warrant radical measures. Extra-
articular abscesses are apparently quite common, yet most of these,
if carefully traced, will be found to lead through the periosteum at
some point into the osseous structure beneath. Such abscesses are,
moreover, multilocular, and have ramifications in even unsuspected
directions which should be followed with the sharp spoon and the
caustic, in order that absorbents may be seared and that no
infectious material remain. Old and persistent fistulas should also be
treated kindly until one is ready to be radical. Some long-standing
cases will heal after absolute physiological rest of the joint, i. e., by
fixation in plaster-of-Paris splint, with openings opposite the fistulas
for dressing purposes. The general constitutional condition of
patients with these lesions is a predominating factor in their
improvement—a fact which should never be forgotten.
 The deformity which has resulted from old, long-standing, and
quiescent hip disease affords opportunity for the best of surgical
judgment. It is possible to effect great improvement in position by
subcutaneous osteotomy after ankylosis, but this should not be
attempted during the active stages of the disease.
The question of excision of the hip-joint is one of importance. In
few other instances do social surroundings or factors enter so largely
into the question of surgical judgment. The wealthy can afford long-
continued treatment, which to the poor is prohibited, and one may be
tempted in one case to exsect early when, under other conditions, he
would treat the case tentatively. Nevertheless certain indications
make the operation expedient in all cases, as, for instance, when the
destructive process is steadily progressing or so acute as to shorten
not only the limb but life itself. It is necessary also when there is
necrosis, and in most instances of suppuration extending into the
joint cavity. In those cases where skiagrams confirm other
indications to the effect that the disease is localized in the neck or
head of the femur, Huntington’s suggestion may be adopted, after
exposing the upper end of the femur, to drill or tunnel in the direction
of the neck until its diseased focus is reached and thoroughly clean it
out. In cases treated otherwise conservatively, yet accompanied by a
great deal of pain, especially those of the femoral side of the joint,
one may frequently get relief by exposing the upper end of the femur
and making ignipuncture in the same direction as above.
In general it is impossible to lay down succinct rules for the
treatment of hip disease. Cases differ so greatly in location, in
severity, as well as in environment and their personal surroundings,
that what is advisable in one case is not to be thought of in another.
Of the mechanical features of treatment one may say that that is the
best splint or apparatus which best meets the indication in each
particular case, and that none will be effective in which the element
of traction is neglected, nor that of physiological rest. No patient
should be released from treatment whose hip is still sensitive or in
whom there remains any muscle spasm. Rest and protection should
be maintained for months and even years after apparent recovery,
while the same attention should be given to diet and climatic
surroundings as in any other case of well-marked tuberculous
disease.

TUBERCULOUS DISEASE OF THE KNEE-JOINT; TUMOR

ALBUS.
This subject deserves special consideration, mainly because of
the peculiar deformity produced by the disease rather than any of
distinctive peculiarity in its nature. Years ago it received the name of
tumor albus, and is frequently called white swelling by the laity,
because of the pallor of the surface and the increased dimensions of
the limb due to thickening, always of soft parts, and usually of the
bone itself. The disease may begin in either epiphysis, in the patella,
or in the synovial membrane, oftener in the bone in the young and in
the synovia in adult cases. Its most distinctive feature is the
deformity produced by excess of muscle spasm, the hamstring
muscles especially producing a backward subluxation which
frequently fixes the knee, not only at a right angle, but with very
much disturbed joint relations, so that the head of the tibia is in
contact with the posterior surface of the condyle rather than with
their proper terminal areas. The soft tissues outside of the bone are
frequently very much thickened and infiltrated, often edematous,
while the joint cavity may be more or less distended with seropus or
with old pyoid material. The exterior surface is so anemic from
deficient blood supply as to make it appear comparatively white,
while the superficial veins are made much more prominent by their
engorgement owing to obstruction of the deep circulation. The
picture, then, of an advanced case of tumor albus is quite typical.
Here the joint cavity is so large that there is early effusion of fluid,
in most cases, which is in this location easily recognizable; hence
the distinctive symptoms consist of pain, tenderness, swelling, limp
muscle spasm, with, finally, limitation of motion, deformity, and
atrophy. In addition to these features there may be added those due
to the formation and the escape of pus, i. e., one may have the signs
of acute or old suppuration, while the parts about the joint may be
riddled with old sinuses. The deformity of these cases is usually
characterized by a certain amount of external rotation of the leg,
while a species of knock-knee is not uncommon. Actual lengthening
of the limb due to overactivity at the epiphyseal junctions may also
be noted.
Treatment.—The treatment of white swelling is based upon the
principles already laid down for the treatment of spinal
and hip caries, the underlying feature being traction to a degree
sufficient to overcome muscle spasm, unless it be too late to permit
a subsidence of active changes. When seen early a few weeks of
confinement in bed, with effective traction, followed by fixation with
plaster-of-Paris bandage, combined with the Thomas splint (see
above) or with some other form of more elaborate apparatus, by
which rest and traction can be continually maintained, will be
needed. The presence of tuberculous disease about the knee
permits of the application of the elastic bandage above the knee, by
which the congestion treatment of Bier can be more or less
effectually carried out. It would, however, be a mistake to rely entirely
upon this to the neglect of traction and rest, nor should too much be
expected of it in severe cases. It is a method to be used early rather
than late.
The final resort is excision, which is practically adapted to cases of
moderate type in young adults, where the bones have attained their
full growth and where it will afford a prospect of cure in a minimum of
time. It is undesirable in children because it is so often necessary to
remove the epiphyses, and because of the arrest of development
that follows such removal and the consequent shortening of the limb.
Nevertheless even in children it may be demanded and may be
considered as a resort superior to amputation, the latter being
reserved usually for a life-saving measure or for desperate cases
where destruction has been practically complete and the limb is
hopelessly useless.
Of the other large joints, all of which may be involved in
tuberculous processes similar to those just discussed, it may be said
that they come under the general rules of treatment already laid
down.

NON-CARIOUS DEFORMITIES.
 TORTICOLLIS; WRYNECK.
This term includes a peculiar postural deformity by which the head
is rotated and inclined abnormally to one side in a more or less fixed
position. As to the causes of the deformity two will be considered:
Congenital causes include:
1. Injury to the sternomastoid muscle at birth, which is perhaps the
commonest.
2. Abnormal intra-uterine position and pressure.
3. Arrest of muscular development.
4. Intra-uterine myositis, the muscles being sometimes found
actually altered in structure.
5. Defective development of the upper vertebrae or such distorted
growth as is often met along with other deformities, e. g., club-foot.
The acquired causes include:
1. Traumatisms, either direct, as by injury to the muscles, such as
may happen from gunshot wounds, etc., or follow operations by
which the spinal accessory has been injured, or by burns, and other
lesions which cause much cicatricial contraction.
2. Reflex activity in connection with disease of the lymph nodes,
deep cervical abscesses, parotid phlegmons or tumors, etc.
Whitman states that tuberculous disease of the cervical nodes
caused the condition in 50 per cent. of over 100 cases analyzed by
him.
3. Reflexes from the eyes, as Bradford and Lovett have described
from the orthopedist’s standpoint, and Gould from that of the oculist,
refractive errors causing the head to be held in unnatural positions in
order to improve vision.
4. Compensation in high degrees of rotary lateral curvature, the
effort being to keep the head facing to the front.
5. Myositis, usually rheumatic, but sometimes a sequel of the
infectious fevers, or even of gonorrhea.
6. Habitual deformity, the result of occupation or sheer bad habit.
7. Tonic or intermittent spasm leading to spastic contractures
whose causes are difficult to seek, but appear to inhere in the central
nervous system.
 8. Paralyses of certain muscles, permitting lack of opposition and
consequent deformity.
Pathology.—According to circumstances significant pathological
changes may be found in the affected muscles. These
are usually the sternomastoid and the trapezius, although in long-
standing or complicated cases the deeper muscles of the neck may
also participate. A long contracted muscle may change almost into
mere fibrous tissue.
The secondary effects of contraction of the sternomastoid and the
trapezius are really far-reaching and noteworthy. The jaw may be
drawn down and to one side, so that teeth do not appose each other
as they should, or perhaps even do not meet. Compensatory
curvatures occur also in the spine and there is well-marked change
in gait and in most of the body habits. In the young and rapidly
growing cranial and facial asymmetry also become pronounced. The
later results and deformities of torticollis are not to be mistaken for
congenital elevation of the scapula, sometimes known as
“Sprengel’s deformity,” which consists not merely in elevation, but in
rotation of the shoulder-blade so that its lower angle is too near the
spine. There may be some limitation of motion of the scapula and of
the arm. Sprengel accounted for this abnormality by maintenance of
the intra-uterine position of the arm behind the back. The acute
forms of torticollis occur nearly always in acute phlegmons of one
side of the neck, and should subside with the other and causative
lesions. Nevertheless from such spasm may develop a chronic form
which may persist.
The position of the head varies with the muscles particularly
involved and the associated spasm. The sternomastoid muscle
alone will draw the mastoid down toward the sternum, with rotation
of the face to the other side. When the trapezius is involved the head
is drawn backward and the chin raised. The more the platysma,
scaleni, splenii, and deep rotators are involved the more complex
becomes the condition, to such an extent even that in serious cases
it is almost impossible to decide which muscles really are at fault.
When the superficial muscles are involved they can usually be
distinctly felt to be firm and contracted, while the sternomastoid will
stand out like a cord. Pain is a rare complaint, but a feeling of
tenderness or soreness is not unusual.
The spasmodic or intermittent form is less common, but more
difficult to account for and even to treat. It seems to be due to
choreiform spasm of those muscles which produce it, and here the
condition is reflex, the causes lying deeply in the nervous system. In
some instances, however, they are of ocular origin and can be
relieved by correcting refractive errors. Intermittent spasm is usually
absent during sleep and quiescent in the recumbent position; it is
usually confined to one side.
Diagnosis.—In the matter of diagnosis it is necessary mainly to
eliminate only spinal caries, while as between
involvement of the anterior and posterior groups of muscles the
determination is made by palpation and inspection.
Treatment.—There are few morbid conditions whose cause it is
more necessary to discover. Could this be done
operative treatment would be less often demanded. Treatment
should depend, therefore, on the exciting cause and the possibility of
its removal. The spasmodic or intermittent form may spontaneously
subside. Cases of essentially ocular origin need the services of the
oculist, and other acute cases usually subside with the successful
treatment or the subsidence of their causes. On the other hand,
chronic cases usually need either mechanical or operative treatment.
The most common operation for relief of torticollis is simple
tenotomy of the sternomastoid, taking care to divide the sheath and
everything which resists, and, at the same time, to avoid the external
jugular vein as well as the deeper structures. Mere tenotomy of one
or both of its lower tendons is an exceedingly simple measure, but in
serious cases an open division will permit of more thorough work.
Here an incision made one inch above the clavicle and parallel to it
will permit division of everything which resists and also any
recognition of that which should be spared. In any event the position
of the head should be immediately rectified, and kept so either by
plaster or starch bandage, or by a traction apparatus applied to the
head, the body being in the recumbent position, while later some
efficient and well-fitting brace should be worn for some time. The
posterior cases, i. e., those where the posterior muscles are
involved, afford greater operative difficulty, muscles involved lying
too deeply and being in too close relation with important vessels and
nerves to justify the ordinary wide-open division. Nevertheless in
extreme cases there need be no hesitation in extirpating completely
those muscles which are primarily and mainly at fault. The writer has
removed the sternomastoid and the trapezius, with sections of the
still deeper muscles, and has seen nothing but benefit follow the
procedure. It should be resorted to when repeated anesthesia with
forcible stretching and a suitable brace fail to give relief. These forms
of wryneck which are due to contraction of muscles infiltrated from
the presence of neighboring phlegmons, etc., will usually subside
with massage and semiforcible stretching under an anesthetic. They
need conservative rather than operative treatment. Attack upon the
spinal accessory and the deep cervical nerves will be described in
the chapter on Surgery of the Nerves. It, however, will rarely be
justified, since the primary causes inhere not so much in those nerve
trunks as in the nerve centres. Such operations are usually of
questionable benefit, and cases should be carefully watched before
being submitted to them.

ROTARY LATERAL SPINAL CURVATURE; SCOLIOSIS.

Under these terms are included certain deviations from normal
relationships of the vertebræ, both in their superposition in the
median line and in their rotation on each other, by which are
produced lateral curvatures, with more or less rotary displacement.
Of these deformities there is a rare congenital form which is due to
fetal, or rather intra-uterine, rickets, but practically all rotary lateral
curvatures are acquired. One-half of such cases begin before the
twelfth year of life. It may also come on during adult life, as the result
of bad postural habits, exclusive use of the right hand, etc.
Altogether it occurs in about 1 per cent. of females and in a smaller
percentage of males. Scoliosis being not a disease but rather a
process of irregular growth, cannot be said to have a
symptomatology. It is known rather by signs. Only in the advanced
stage can it produce symptoms. It is rarely seen in its incipiency by
either the surgeon or the physician. Not until parents have noticed
distortions of the spine are these children usually taken to their
medical advisers. Exception, however, should be made to this in
respect to certain gymnasia and athletic training schools, where
trainers are quick to notice irregularities of this kind. The abnormal
curves thus produced are at first flexible, but later become fixed. In
rapidly growing girls who take but little exercise there may be some
muscle weakness, which may cause fatigue or even actual
soreness. Pain is rarely present. The rate and extent of deformity are
not subject to any rule. Spontaneous cessation ensues in practically
every case, i. e., a stage of convalescence and arrest, at a time
when the deformity may be but slight, or perhaps hideous.
The nervous phenomena attending lateral curvature, like the
discomforts attaching to it, are mainly due to the increasing strains
and stresses that are imposed on certain structures as the deformity
occurs and increases. Of these, muscles and ligaments suffer most,
especially those uniting the thorax and spine. Pressure effects on
nerves and tissues may be produced by distorted ribs and vertebræ
or by final displacement of viscera. The conditions which lead up to
spinal curvature are attended often by neurasthenic and neurotic
features, both mental and physical. As deformity increases
impairment of function of thoracic as well as of the upper abdominal
viscera will occur, and such patients are usually thin and anemic,
rather than fat.
To mere lateral distortion is added, in every pronounced case,
more or less rotation of the entire trunk. The curvature consists of
one primary curve, with one or two secondary curvatures, according
to the location of the first. If the primary curve be located in the mid-
dorsal region there will occur compensatory curvature above and
below in order that the head may still be kept in the line of the centre
of gravity above the pelvis. Such secondary alterations are of much
less import than the primary. The most common of the mid-dorsal
curvatures, which occurs in nearly four-fifths of the cases, has its
convexity to the right. While the right shoulder seems higher its
scapula will be more pronounced and carried backward, the back
and the chest below it will be more rounded, and in front the breast
on the opposite side more prominent. The whole trunk in marked
cases becomes so warped that the arm on one side will hang free
while the other touches the pelvis; thus the back loses its symmetry
either in the erect or stooping position. In the lumbar region there is
compensatory curvature to the opposite side, which makes one hip
and flank more prominent. By virtue of the rotation of such a warped
spinal column there result certain anterolateral curvatures that may
later become pronounced. While such changes are going on in the
upper part of the trunk there is sufficient rotation of the lumbar
segment to lead to tilting of the pelvis, with consequent limp, or a
peculiarity of gait.
The degree of torsion of the spinal column is the best index of the
real severity of a given case, and to it are due the most disfiguring
features of the deformity. Torsion may even precede curvature,
causing a prominence of one shoulder or hip as the first visible
evidence of its existence.
Those forms of lateral curvature due to rickets occur most often in
the dorsal region, and as frequently in boys as in girls. In most of
these cases the constitutional condition will be indicated by other
significant features. Another form much less frequent, yet well
known, is the result of inequality of the length in the limbs, so that
patients stand ordinarily with tilted pelves; hence, the limbs should
be carefully measured in every instance. A truly paralytic form of
scoliosis is also known, which is of the infantile type and due to
some form of infantile palsy. Again, scoliosis is produced by
shrinkage of tissues and contraction of old exudates occurring within
the thorax and following chronic disease, as when the ribs on one
side are drawn down after an old pleurisy or empyema. Extrinsic
causes of lateral curvature are met with among several occupations
when one side of the body is used more than the other, or when the
individual habitually stands in an unsymmetrical position. In addition
to this, the habitual right-hand habit, which seems instinctive, and
which the majority of people exhibit, leads to excessive use of the
right side of the body, with overdevelopment and consequent
warping of the upper part of the skeleton. The young should be
taught the use of the left hand as well as the right, i. e., to become
ambidextrous.
The foreign surgeons have given the term ischias scoliotica to a
form of lateral curvature involving rather the lower part of the spine
and occurring usually in adults or elderly people, which is
accompanied by more or less acute pain, usually assuming the type
of sciatica. Its etiology is obscure, as is implied by the synonym
scoliosis neuropathica. It is not a frequent malady, but usually
chronic and refractory. It is best dealt with by fixation or
immobilization.
Etiology.—Predisposing causes of scoliosis may be both
constitutional and inherited. They include general debility,
rickets—with its accompanying osseous instability and liability to
abnormal curvature—the consequences of various diseases of
childhood, and anything which greatly lowers vitality. The actual
causes include congenital or acquired defects, such as differences in
the lengths of the limbs or other skeletal asymmetries; acquired
abnormal position of the head due to defective vision, with its natural
sequences; results of intrathoracic disease, such as empyema; faulty
attitudes and bad developmental habits, such as those assumed
often in school and elsewhere in sitting at a desk or standing in bad
position, or at work in various ways. To these should be added the
right-hand habit already mentioned. These may all be summed up as
among the causes of asymmetrical growth and deformity, occurring
as the result of ignorance or inattention, and allowed to go on
indefinitely or until it is too late to correct the malposition. Theories of
paralysis of individual muscles or certain muscle groups have been
advanced, as well as of contractures, but usually these are effects
which have been mistaken for causes. The bones have been
blamed, but their changes are secondary results of pressure, save
perhaps in some cases of rickets. The structures of the thorax have
relatively considerable superimposed weight to carry, and both
lateral halves of the thorax should be developed symmetrically in
order to distribute this weight evenly. Nothing so influences skeletal
development as exercise; thus even to assume and maintain the
normal erect attitude requires a certain amount of muscular effort,
and if each side be not given an equal task one will develop at the
expense of the other, and thus lateral curvature is sure to result.
It is important to impress this on parents, teachers, nurses,
dressmakers, and all who have a part in the care of the young, in
order that they may realize the importance of ensuring symmetrical