CoUegc of ^fjpsiiciansi anti burgeons;
IN-KNEE: ITS RELATION TO RICKETS,
PRINTED BY WEST, NEWMAN AND CO.
HATTON GARDEN, E.C.
MEDICAL AND SURGICAL ASPECTS
ITS RELATION TO
PREVENTION AND ITS TREATMENT WITH AND WITHOUT
W. J. LITTLE, M. p., F.R.G.P.,
LATE SENIOR PHYSICIAN TO AND LECTUKER ON MEDICINE AT THE LONDON HOSPITAL ;
VISITING PHYSICIAN TO THE INFANT OKPHAN ASYLUM AT -VVANSTEAD,
THE EAELSWOOD ASYLUM FOE IDIOTS ;
FOUNDEK OF THE KOYAL OETHOPaiDIC HOSPITAL ; ETC.
E. MUIEHEAD LITTLE, M.E.C.S.
Illustrated by upwards of Fifty Figures and Diagrams.
D. APPLETON & CO., NEW YOEK,
PROFESSOE GROSS, M.D., D.C.L.,
FATHER OF SURGEEY
AN ENLIGHTENED AND HONOURABLE EXAMPLE OF ALL THAT
IS NOBLE IN OUR PROFESSION,
AND TO HIS
MEDICAL AND SURGICAL BRETHREN,
GRATEFUL ACKNOWLEDGMENT OF THEIR CORDIAL RECEPTION
OF HIM WHEN ON A VISIT TO THE UNITED STATES
THIS BOOK IS INSCRIBED
BY THE AUTHOR.
Digitized by the Internet Arciiive
in 2010 with funding from
Open Knowledge Commons
Aberration of form, no, without alteration of structure
Accident may cause the distortion . . .
Accommodative changes ....•••
Activity, intellectual, of parent, in excess, a cause .
,, cerebro-spinal, ,, ,, 5? • •
Adolescents, tall, often become affected with atonic in-knee
Adults, curable in, without operation . . . .
Aitken, Dr., on undue hairiness in rickets
Animal food, aversion to, often observed in atonic distortions
Annandale, osteotomy by
Antiseptic system, Lister's, available in osteotomy .
Arms, the, disproportionately long in rickets . . . .
Arthritis deformans and rheumatic in-knee . . . .
Asphyxia neonatorum, in-knee from
Atalectasis and in-knee . . ...
Atonic disorders, increase of, through civilisation
„ in-knee may co- exist with atonic in-ankle and atonic
,, in-ankle may precede in-knee and scoliosis .
,, in-knee, diagnosis from rickets . .
,, ,, may return on re -application of exciting causes
,, „ occurs mainly at the two most rapid periods of
,, ,, occurs more readily in tall infants .
Atony of fibrous tissues a stage of rickets ? _ .
,, ,, structures, cause of other disorders
Atrophy of external condyle, see deficiency of .
Baker, H. F
Beaded ribs in rickets . . . . •
Belly very protuberant, in rickety cases
Billroth on redressement force . . . •
,, ,, statistics of osteotomy
,, ,, supra-condylar osteotomy
Bloodless method, Esmarch's, useful in osteotomy
Bone, simple division recommended .
,, removal of portion undesirable _
,, ,, „ length impaired
„ bent, lengthened by simple division
Bones, Macewen on cutting the comparatively soft, of adole-
., once ebiii-uateil after rickets do not again soften from
may they soften from scorbutus ?
most rapid growth in lower limbs during the earliest
months of life
primitive malformation of, eiToneous . . . .
curvature of, may take place after subsidence of rickety
„ from gravity
,, ,, scorbutus ?
,, ,, phthisis'?
,, ,, atony and paralysis .
wasting of, Mikulicz on .
,, in paralytic in-knee
density of, increased in rickets
Bouvier on iu-knee, as the first stage of rickets
Bow-legged knee curvature ....
Brain, excess of stimulating amusements and pursuits favours
Breast-milk, absence of ....... .
Broca, views on rickets ........
Brown, Dr. Buckminster, on mechanical treatment
Cartilages thickened by undue pressure
,, thinned by diminished pressure
,, C. Reyher on .
CerelDro-spinal system, influence on in-knee
Changes, the mechanical, similar in all forms
Chest flattened and narrowed in rickets
Clavicles arched upwards and forwards in rickets
Compression of limbs, undue, evils of
Condyle, internal enlarged, not a primary cause
,, ,, ,, pathognomonic
,, the normal length of
,, prominent ....
external, deficiency of primary cause . . 19,
,, ,, )) a more common marked con-
„ ,, slight deficiency occasions appreciable dis-
Confinement, long, hurtful
Congenital in-knee ....
Constitutional conditions in distortion
Creases in rickety thighs .
,, j)osition aids cure .
Curvature of bones from paralysis
Curvature of bones from statical inilueuce
,, ,, ,, innutrition, atrophy
,, of knee outwards
Curves, successive, in scoliosis .
,, ,, rickety limbs .
,, explanation of production
Cyanosis, and in-knee
,, Mikulicz on, as a cause of in-knee
Debility, cause of in-knee ......
Deficiency of external condyle . .. . ...
Density of bones increased in rickets
Diet, a too watery, a cause of atonic in-knee
Digestion, weak, often a co-existent atonic ati'ection
Disease, any of knee, may cause the distortion
Distortions, rare amongst oriental and tropical races
Disuse, persistent, influence of .
Eburnation of bones froixi rickets
,, density of bones increased in
,, none in " mollities ossium"
Elasticity of structure
Enamel on teeth, want of in rickets .
Epiphysis of tibia and fibula in rickets
Esmarch, bloodless method in osteotomy
Exercise during treatment
Extremities, the lower, most visibly affected in rickets
„ ,, development of them in rickets more or
Fascia lata, its action in bracing the knee .... 53
Fatigue as an exciting cause ....... 53
Femoral diaphysis, changes of, in in-knee .... 53
,, ,, Linhart on ....... 41
„ „ Mikulicz on ...... 55
,, ,, Macewen on 41
,, ,, increased growth ..... 136
,, epiphysis, changes of, Mikulicz on .... 56
Femur, natural adduction of, not a primary cause ... 4
,, and tibia, form of, may aid other causes ... 49
Fevers during convalescence cause of in-knee . . . . 2, 9
Flat-foot, co-existence with in-knee ...... 7
Food, animal, aversion to, often shown by atonic subjects . 75
Foods, unsuitable articles for infants . . . . .67
Foot, inversion or eversion of, in in-knee .... 99, 116
Gap, between external condyle and tibia .... 27. 131
,, modes of filling up ...... 29, 13o, 155
,, nature can fill up even in the adult ..... 30
Gait in iu-kiiee .......... 7
Gentle means, explanation of action 132
Genu-varuna .......... 13
Genu- valgum (see in-knee).
„ not confined to rickets 2, 143
Genu-valgns talipes, spui'ious, with in-knee .... 7
Genu-varus talipes, ,, ,, ,,.... 7
Genu, extrorsuni cui'vatum ....... 12
Gravity, influence of . . . . 2, 8, 15, 36, 49, 65, 78, 188
Gross, Professor ......... 147
Gx'owth, two fast periods of ..... . 16, 19
,, explanation of rapidity at particular periods . 16, 87
,, inordinate rapidity of, cause of distortion . . 10, 75
,, rapid after severe illness, need of rest and good feeding 75
,, does osteotomy impair it ? ...... 158
Guerin, Jules, experiments on large subcutaneous division in
animals useful to men 19, 31, 33, 90
Hand-feeding of infants a cause of atonic in-knee
Hairiness, undue in rickets .....
Hamstring division .......
Head disposed to be relatively enlarged in rickets
,, may be one-fourth the length of the body in rickets
Height, inordinate cause of distortions
Hips and knees sometimes contracted at birth .
Holden, exaggerated opinion as to normal length of external
„ pathology ....
,, treatment of in-knee by flexion
Hutchinson, on rachitis ....
Hygiene, neglect of, favours production of in-knee
Infancy, earliest period of, growth most rapid
,, rate of growth during .
In-ankle, with in-knee
In-knee, adiilt, cured without operation
,, definition of .
,, varieties of .
,, from fatigue
,, spasm ....
,, atonic ....
2, 7, 10
2, 5, 8
2, 10, 95
8, 15, 19
,, from inordinate stoutness
„ „ „ growth
,, disappearance on bending
,, fevers from debiHty, after
,, never a normal condition
,, influenced by normal anatomic conditions
,, frequency of
,, from partial luxation of epiphysis
,, with scoliosis, miscalled "lateral curvature
„ outward rotation of leg in
,, with flat-foot
,, ,, ankylosis
,, from carrying heavy weights
,, in cyanosis and atelectasis
,, from excessive use . .
,, morbid anatomy .
,, prevention of
,, from curvature of tibia
,, non-i'achitic, Dr. Shaffer on
,, hereditary influence in
,, cure of, by deposit of bone and cartilage
Intellectual activity of parent in excess a cause
2, 9, 15
Jenner, Sir W., on the rickety skull .
Johnson, Dr. .......
Joints, less well-knit in some families and races
,, constant fixation to be avoided
Knee, mechanically altered relations in
,, hyper-extension of .
Knee joint, opening of, for in-knee
Knock-knee, symptoms of .
Legs, disproportionately short in rickets .
Leg bones, curvature of, augments apparent in-knee
Ligament, internal lateral of knee, elongation of
,, external ,, ,, shortening of
,, ,, Linhart on .
Limb, the soundest, provided only with a maximum
Linhart, morbid anatomy .....
,, on instrumental treatment .
Lister, his antiseptic method available in osteotomy
Little, Louis Stromeyer .....
Locomotion, excess of, a cause ....
Lordosis, not always from rickets
Luxation of patella, partial or complete
. 19, 3
Miilfonnatiou, primitive, of bones theory erroneous
Manipulations, mode of doin^^ ....
Mechanical appliances .....
,, ,, unsuitable ones
,, treatment, relapses after
,, on wasting of bones ....
,, ,, cliaufjes in ligaments
,, ,, increased growth of femoral diaphysis
Microscopical conditions .....
Milk, fresh or unfresh, important difference between
" Mollifies ossium," nut rickets ....
,, ,, is incurable
^forbid anatomj', obliqiiity of articular surfacos
,, ,, Sandifort ....
„ „ Mayer
,, ,, Mikulicz ....
,, ,, Linhart .....
Muscles, structural shortening of . . .
Muscular contraction of secondary importance .
Natural cure by deposit of new bone and cartilage ... 29
Nervous system, disorder of, in in-knee ..... 66
Nodes at the extremities of the long bones in rickets . . 89
Nutrition of tissues, insufficient in atonic in-knee ... 65
,, full, necessary during convalescence from acute
c fcn-mations in in-knee ....
., Mikulicz on ...
,, Sandifort on ...
Macewen on ..... .
relapses after ......
Macewen, successes in .
necessity after puberty in severest cases .
chisel, introduction of, in ...
the complement to instruments
W. Adams on .
Barker on ......
Barton Rhea on .... .
Grosse, Professor on ....
Langenbeck on .....
L. Stromcyer Little on .
Osteotomy, Reeves on . . .
Rupra-condylar, Bilrotli on
,, ,, Macewen's mode of perfovmin
effect of Macewen'fi method
subcutaneous, first performed
unnecessary, often been done
simultaneously in both le.sfs
unnecessary and undesirable in young children
Out-ankle, with in-knee
,, accommodative .
Over-work and over-use
Pancoast, Dr. ........
Paralysis, infantile, a cause of in-knee
Patella, luxation of, partial or complete
,, ossification of ..... .
,, wearing away from undue pressure
,, Mikulicz on .
Periods, the two fast growing, of life a cause of distortions
Phthisis, bones wasted in .
Position, extended .
Pressure, undue, thickening of cartilages from .
,, absence of, thinning of cartilages from
Prevention of in-knee ......
Progress, rate of, with mechanical treatment
Puberty, rapid growth about .....
Races, oriental, joints less well-knit than in robust Europeans
Rachitic disease exclusively limited to early childhood 18, 34
Redressement force ........
Rest, a means of preventing distortions in chilhood after severe
Reyher, C, on the changes in unused cartilage
Rheumatic in-knee and arthritis deformans
,, extreme in-knee ....
Rickets, a more or less general and specific disease
,, restricted growth during
,, period of its occurrence
,, discussion at the Pathological Society .
,, not a recurrent disease
., Guerin on ..... .
,, intra-uterine .....
,, increased thickness of bones in
,, eburnation ......
,, shortening ......
,, artificial production of .
,, occurs only at the first fast growing period of life
,, nodes at the ends of the long bones, in
,, curving in of lower third of femur
Rickets, many foi-ms, formerly described ..... 101
,, ■ dependence should be placed on more than one sign in 105
,, creases in limbs, how produced ..... lOG
,, undue hairiness in ....... 107
,, coustitutioual treatment ...... Ill
,, mechanical and operative treatment .... 113
Rickety subjects more or less stunted .... 19, 81
,, in-knee, diagnosis from atonic .... 20, 71, 88
,, head 81
Rotation outwards of tibia as a cause ..... 52
Sandifort, morbid anatomy
Scarlet-fever, weakness and convalescence as a cause
" Schlottern," or " wobbling" of knee
Scissor-leg distortion .......
Scoliosis, analogy of, with atonic in-knee and in-ankle
,, often co-exists at puberty with atonic in-knee
Spasm, infantile, cause of in-knee
Standing, excess of, as a cause .
Statical influence, C. Hueter on
Stoutness, undue, cause of in-knee
Shaffer, Dr. N. M., on rachitic form .
,, ,, ,, value of gentle means of cure
,, Louis .....
Synovitis, in-knee from ....
Subluxation of tibia with in-knee
Tailor's occupation favourable to cm-e
Teeth, condition of, in rickets
Thomas, Dr., observations on fresh and unfresh milk
Tibia often most affected in so-called in-knee
Toes, the, turning in or out in in-knee
Tone, deficiency of, a pathological state
Town, life of, compared with country, as cause
Trunk, the, relatively long in rickets
Vegetables, green, and animal food, aversion to of atonic subjects 75
A^ertebrte comparatively little affected in congenital rickets . 83
Violent method of cure 129
Volkmauu . . . . . . . . . ■ . 7, 18
Von Aramon on congenital in-knee ...... 35
Wasting of bones in phthisis
Watery diet, cause of atonic distortions
Weber, the brothers ....
Weights, undue carrying of
Will, influence of
" Wobbling " of knee .
27, 42, 132
LIST OF ILLUSTRATIONS.
1. Peculiar crossed-leg deformity ...... 1
2. Moderate knock- or in-knee (non-rachitic) .... 4
3. Severe neglected knock- or in-knee (non-rachitic) . . 5
4. Rachitic in-kuees ......... 6
5. Atonic in-knee ......... 9
6. Double outward curvature of lower extremities ... 13
7. Rachitic in-knee and curvature of one leg .... 20
8. Drawing of average femur, with a femur probably rickety . 23
9. Drawing to show the amount required to rectify the greater
length of internal condyle ...... 23
10. Views of the corresponding leg bones ..... 24
11. Moderate atonic in-knee, to show the prominence of internal
condyle .......... 25
12. Natural contour of limbs in atonic in-knee .... 26
13. Morbid anatomy, view of in-knee, from Sandifort . . 44
14. The same, placed by us in the proper relation to exhibit the
same gap, shown in diagram a ..... 44
15. Extreme atonic in-knee, from Mayer ..... 45
16. View of a case called genu- valgum, from Mayer, in which
the principal disorder consisted of abduction and curvature
of the tibia ......... 46
17. The left limb from the same patient after osteotomy, which
had been doubtless more severely affected with iu-knee,
as shown by the obhquity of the articular surfaces . . 46
18. View of out-knee curvature (genu- varum), from Mikulicz . 50
19. ,, the normal relation of femur and tibia ... 50
20. ,, considerable in-knee distortion (genu-valgum) . 50
21. ,, the bones of a considerable in-knee when placed in
their normal relation, to show the manner in which
nature then fills up the gap before alluded to . . . 51
22. Anatomical representation of the relation of the thigh and
leg during over-fatigue and the carrying of heavy weights,
for which we are indebted to Mr. Alexander Shaw . . 53
23. Contains three views from Mikulicz, showing the progressive
increase of the diaphysial portion of the internal and
lower part of the femur, and slightly of the epiphysis . 55
24. Genu-valgoid distortion of knee disease .... 62
25. Complete ankylosis of knee with genu-valgoid deformity . 63
26. Genu-valgoid distortion, taken from the living strumous
patient .......... 63
27. Extreme destruction of the external condyle, &c., from
chronic rheumatism •••.... 64
28. Front view of slight atonic in-knee ..... 71
29. In-knee with hyper-extension on one side, out-knee of the
other, from Macewen ....... 74
30. Extreme in-knee, with local and general rachitis . . 81
31. Extreiue rachitic arrested ilevelnpmrnt, wilh in-kuees and
curvatures, from Bouvier ...... 82
3'2, 33. Tyjncal distortion of the epiphysis of tibia and til)ula . 84
34. Lt)rd()sis, from atonic rehixation ? ..... 85
35. Shght paralytic f<enii-valf(nm ...... 92
36. Severe paralj'sis, with in-kuee ...... 93
37. Most severe paralysis, with in-knce and paralytic talipes-
varus .......... 94
38. ISpasmodic knock-knees, combined with flexion of knees and
tahpes-cqninus ........ 95
39. Ordinary leg and foot curvatures of rickets .... 102
40. llickety out-knee curvatures (bow-legs) .... 103
41. Accommodation curves in lower limbs and spine from
I)aral3-sis . . . . . . . . . .104
42. Ordinary' rachitic curve in shaft of long bone . . . 105
43,44. Manner of manipulating in-knees ..... 115
45. Adjustable splint for back of knee ..... 117
46. Side splint for meelianical treatment . . . . .118
47. Shows four figures of in-knee at different periods of treatment 124
48. Shows the thigh and leg bones of a genu-valgum anatomical
specimen, from Mikulicz ....... 137
40. The same, placed by us in a nearly natural position to
indicate by dotted lines the amount of new bone and
cartilage required to be deposited for cure by mechanical
means, without such obliquity of articular surfaces as
may leave a liability to relapse. Compare with fig. 17,
p. 46, from Mayer ........ 137
50. Front view of the condylar end of femur, from Macewen,
before supra-condylar osteotomy had been performed,
but which we represent luith the inoper degree of
inclination common to tolerably severe in-knee. Com-
pare fig. 36, p. 146, Macewen, ' On Osteotomy,' 1880 . 155
51. Front view of the same femur after the osteotomy had been
performed, and the operator had with gentle force
brought tlie ankle and foot into a straight line with the
thigh. Compare this with fig. 38 of Macewen (op. cit.),
p. 147, and with the remarks, p. 15(), in this work . . 155
52. Diagrammatic representation of a curved tibia . . . 160
LIST OF DIAGRAMS.
A. To show the gap between the external condyle and tibia in
atonic in-knee when the prominence of the internal con-
dyle is temporarily reinoved ...... 27
B. Schematic arrangement of curved limbs .... 100
C. „ ,, apparatus for in-knee . . 119
D. ,, ,, adjustable side splints . . 122
CoiiUiGENJjUM. — On page 20, line 12 from above, /o/' tig. 'A read lig. 4.
" PBINCIPIIS obsta:'
We have placed at the head of our remarks an
oft-quoted maxim, because we hope we shall have
convincingly shown in the succeeding pages 'that the
distortion of Avhich we have treated, though one of
the most serious, when looked at either as a mere
unsightly deformity or as an affection which, in its
advanced stage, renders the act of independent walk-
ing impossible, is one which is completely preventible
by the commonest care of the medical man and
The occurrence of in-knee and out-knee has been
long known, but its etiology, pathology and morbid
anatomy had not been described until the publica-
tion of our lectures on deformities in the 'Lancet,'
Nevertheless the records of general hospitals show
that during the last few years many hundreds of cases
of in-knee had attained to so great deformity and in-
utility that surgeons have thought themselves obliged
to have recourse to violent methods of cure, or to a
serious "operation," for its relief, although others,
as well as ourselves, had never met with a case that
did not recover by the help of instrumental means
alone. We dare not say that in all the cases in which
osteotomy has been performed the operation was un-
necessary. We (\o, however, affirm that, from the
descriptions of many cases which we have read, the
operation was in a large number of cases unneces-
sary, and that in all the distortion should have been
arrested in the earlier stage.
We have therefore considered it needful in the
following pages to sift the writings, within our reach,
of subsequent writers, in search of facts illustrative
of the symptoms, pathology, morbid anatomy and
treatment of the distortion, with which we have
interwoven our experience of the last four decades.
From these sources we believe that the result of our
labours will shed fresh light upon the knowledge of
the distortion, its nature, its prevention, and remedy.
The work has been a labour of love, for it has sup-
plied us with clearer views of several problems in
regard to this and other deformities, and has raised
our esteem and regard for several of those whose
names we have quoted, who have been simultaneously
working in the same direction. Nor have we spurned
recourse to some writers of the last century, who have
treated of some of the subjects we have touched upon,
for as Huxley says:* — "The growth of Science is
now so prodigiously rapid that those who are actively
engaged in keeping up with the present have much