RIGID SPINE; SPONDYLITIS DEFORMANS

579

trunk upward (or up from the couch). This is repeated from ten to twenty-five times.

The more severe cases, especially in adults, are often accompanied by pain. It is then necessary to provide a brace or plaster of Paris corset. The principle of the treatment is to mobilize the spinal column first, then to reduce deformity as much as possible by strengthening the muscles and training the patient to hold the body in this corrected position.

RIGID SPINE; SPONDYLITIS DE-
FORMANS (SPONDYLOSE RHI-
ZOMÉLIQUE)

This is a chronic ankylosing inflammation of the spine characterized by local pain, stiffness, and deformity. The pathological features are atrophy of the intervertebral discs and periosteal proliferations and thickenings with ossification, particularly on the anterior and lateral aspects of the spine. On account of these bony proliferations firm bony unionssynostoses-form between the vertebræ and they extend gradually to the whole spine. Together with these bony changes we observe atrophy of the muscles and a gradual forward bending of the spine. As ætiological factors may be considered trauma, the continued carrying of heavy burdens, and infectious joint inflammations, such as gonorrhoeal arthritis and polyarticular rheumatism.

FIG. 188.-EXERCISE FOR SCOLIOSIS.

Schlesinger has described a form of ossifying spondylitis which he considers to be due to a local disease of the intervertebral ligaments, the development of which is most probably favored by a congenital disposition to excesses in bony growth.

Symptoms. The symptoms are pain of a rheumatic character, pain in the loins and radiating forward, a diminishing mobility of the spine ending in absolute stiffness, and a marked forward bending of the entire spine.

Neuralgias occur, probably from bony encroachments on the nerve roots. Treatment. The application of a brace or plaster of Paris corset, massage to the back, and the cautery at regular intervals. In the early stages,

rubber heels and self-suspension add greatly to the comfort. Regulate the diet (antirheumatic) and order general outdoor exercise and tonics.

HIP DISEASE

This is a tuberculous disease of the joint structures of the hip, usually beginning at the femoral head, less frequently in the acetabulum and synovial membrane. The causes are predisposing and exciting. Among

the first are reduced vitality, as after infectious diseases, injury, and a family history of tuberculosis. The exciting cause is the presence of the tubercle bacillus. It is most common in early life and more frequent among boys than girls.

Diagnosis. As in tuberculous disease in other joints, an early diagnosis is very important. The early symptoms are fatigue in the affected leg on slight exertion and a limp. Pain is rarely complained of in the early stage, and when it is present it is usually referred to the knee. If the disease is progressing rapidly, there are night cries; the child screams suddenly during profound sleep, wakes for a few minutes, and then falls asleep again. The night cries are due to a sudden movement of the hip, causing an involuntary contraction of the hip muscles and thus producing pressure on the inflamed parts. Lameness in the beginning of the disease is not a constant symptom, being present for some days. and absent again. The patient walks by stepping on the ball of the foot rather than on the heel; the knee and hip are held slightly flexed and the thigh slightly adducted. There is usually some stiffness in the morning, which, together with the limp, passes away toward evening. A physical sign observed on examination is stiffness due to reflex spasm of the muscles which contract and hold the hip joint when motion is attempted beyond a certain point.

Malpositions of the Limb.-Adduction and flexion are caused by muscular spasm and become permanent by the changes in the joint and contractures of the surrounding soft parts. Outward rotation also occurs in the early stage. As the disease progresses, the flexion becomes greater and the limb becomes adducted and rotated inward. Atrophy becomes manifest early in the history of the disease. It is caused partly by disease and reflexly through the nervous irritation of the joint disease.

Shortening is of two kinds, real and apparent. The real shortening is the result of destruction of the bony parts entering into the joint structure, with consequent upward displacement, and secondly to the atrophy. Apparent shortening is due to the malposition of the limb.

Abscess is present in a large proportion of cases, particularly in those cases which have had inefficient treatment or none at all. Its usual site is upon the upper and outer aspect of the thigh.

Differential Diagnosis.-Pott's disease, low lumbar disease with psoas contraction, simulates hip disease, but may be excluded when the range of motion is limited in all directions. In Pott's disease motion is restricted only in the line of extension by the contracted ilio-psoas muscle. In coxa vara the trochanter is above Nélaton's line; motion is not painful and is restricted only in abduction. Sprains and acute synovitis are excluded by their sudden onset and the history of injury. In congenital dislocation

of hip the patient has a limp, characteristic of dislocation. There is no pain, and motion is free in all directions.

Treatment. The cardinal point in the management is, as in other tuberculous joint affections, that of rest and fixation. Constitutional treatment is an important adjunct to the mechanical. It is important to reduce any deformity that may exist before applying fixation treatment. This may be accomplished by traction applied by the weight and pulley (see illustration) while the patient is in bed. Or the reduction may be gradually attained by successive plaster of Paris dressings, the leg being put in the best possible position at each sitting. Or forcible reduction may be done under narcosis and a plaster of Paris spica applied to maintain the corrected position.

The leg being in good position, some form of retentive apparatus is now applied. The best brace is the one designed by Hessing. It insures absolute fixation of and protection to the hip joint, besides permitting free motion of the knee and ankle joints, thus obviating to a certain extent the evil after effects of total fixation, namely, muscular atrophy from disease and shortening from interference with the circulation of the limb. It is worn under the clothes and is hardly noticeable. It consists of a pelvic portion, which is carefully moulded upon the pelvis, holding it perfectly

rigid; to this is attached the leg portion, or so called shell splint. The leather shells are jointed on the inner and outer sides by two light steel splints, and are laced about the thigh, leg, and foot. The steels have free joints at the knee and ankle. At the upper and inner part of the thigh the shell has a broad padded surface upon which the ischium rests, and a lacing passes around the ankle to produce extension. It is not necessary to wear a high shoe on the foot of the sound side.

A very efficient brace is the so called traction hip splint. It consists of a pelvic band made of a short steel about an inch and a quarter wide and an eighth of an inch thick and bent to a U shape. This is made long enough to go three quarters of the way around the pelvis. To this is attached a long steel bar which extends down the leg and about two inches and a half below the foot.

The pelvic band is strapped around the body and serves as a support for two perineal straps and also for an upright bar, about five inches long, to which is attached a similar band which encircles the thorax. This latter insures better fixation and lessened danger from flexion deformity at the hip. The leg stem is provided with a strap at the knee joint for holding the leg firmly to the brace. The patient wears on each side of the leg adhesive plasters (best made of mole skin). They extend to an inch above the malleoli and are provided at the lower ends with buckles. Two straps attached to the foot piece of the brace and inserted into the buckles produce traction on the leg.

A high shoe (cork sole) is worn on the healthy side. For adult cases and for mild types of cases in children, the Lorenz spica is a convenient and simple retentive apparatus. The spica is modelled very accurately around the pelvic bones, thus getting a firm and steady hold. Extending only to the knee, it allows of freedom of motion of all the joints except the diseased hip. Often it is found useful to combine a light plaster spica with the long traction splint, if the joint is very sensitive and the patient does not seem to progress favorably.

The duration of the treatment is in the most favorable case two years and may be from three to seven years. The child should remain under the observation of the physician for a considerable period after an apparent

cure.

When the active symptoms, pain and muscular spasm, subside, and the disease is apparently cured, we apply a convalescent hip brace. This is the ordinary traction splint with the thoracic band removed and about two inches of its lower end cut off and fastened to the heel of the shoe. When the brace is applied, the patient's heel should not quite touch the bottom of the shoe, thus protecting the hip joint.

As the patient progresses the brace is removed at night and then for short periods during the day, gradually weaning the patient from its use.

TREATMENT OF COMPLICATIONS.-Abscesses are treated expectantly. Even large abscesses may be absorbed. If they are very large and painful and show a tendency to rupture spontaneously, it is best to empty the abscess by aspiration, or one may incise under the strictest aseptic precautions, making a free incision, curetting out the abscess wall, and sewing up the wound completely. Primary union frequently follows this procedure. In cases

CONGENITAL DISLOCATION OF THE HIP

583

with long continued suppuration a more radical treatment may be indicated. and then we do an excision of the hip joint.

CONGENITAL DISLOCATION OF THE HIP

This is more frequent than congenital dislocation of any other joint. Etiology. It is most common in females, occurring in them in about 85 per cent of the cases. One side is affected more frequently than both

Defective

(about 70 per cent of the former and 30 per cent of the latter). development of the acetabulum and abnormal laxity of the capsule are predisposing causes. The dislocation is usually dorsal, but in rare cases it is anterior, the head being under the anterior superior spine of the ilium.