therefore, leave this subject to the individual judgment and
experience of every physician. We will permit ourselves one
comprehensive remark only, that as soon as infantile debi-
lity, which is apt to precede deformity, shows itself, the
child manifesting less firmness of Hesh, weakness of loins,
consequent inability to sit up, delayed appearance of teeth,
or when actual knee weakness and morbid tendency to in-
version of knee appears, the diet of the hand-fed fast-growing
infant should be changed ; water should be discarded for
milk, or the nursing mother's probable insufficiency of
supply and quality be exchanged for a more robust diet, —
farinaceous and vegetable food should be introduced ; meat
in small quantities, suitably prepared, be allowed; a dry
food, as it were, be substituted for a too watery one. In
mere atonic laxity and distortion we have little faith in
special chemical foods or in drugs to meet the child's
requirements, except when other symptoms of disordered
health are present. The same remark applies to the ex-
ternal use of imported or artificial sea icater, and other
external applications. Such expedients tend to divert atten-
tion from the more immediately necessary mechanical means
to avert or remedy incipient distortion.
The constitutional treatment of the rachitic infant, also,
should be considered on the same principles as the case
CONSTITUTIONAL TREATMENT. Ill
arising simply from unsuitable diet. If the mother be of
rachitic family, a wet-nurse of a sounder constitution should
be preferred for the child. This is not the place to enter on
the full consideration of the nature and treatment of the
extensive disease of the system at large understood by
rachitis. We have remarked (p. 83) that in our opinion
this disease is as special a disease as cancer or tubercle,
and other diseases which are believed to arise from special
sources. It appears, for the most part, in our opinion,
hereditary, if not always so. If it does not destroy life by
urgent rachitic complications, hydrocephalus, bronchitis,'
convulsions, disorders of the chylopoietic viscera, it follows
as regards its manifestations in the osseous structures two
distinct stages, those of softening and of subsequent undue
hardening of them ; and as regards the teeth two stages of
growth, the first in which there is little or no ordinary dentine
or enamel deposited, and a later stage, as in the second set,
in which increase of bone tissue and enamel takes place.
One thing appears to be as certain of rachitis as of the
special diseases mentioned, that medicine can neither arrest
nor prolong the time which, as regards the bones and teeth,
is occupied in the above-mentioned stages. We continually
see children affected with rachitic distortions who have
traversed the disorder of rickets untended by physicians,
and to whom no remedies have been applied, who have
reached the stage of eburnation and cessation of the rachitis
in the system at the same age as those who had been
subjected to medical treatment. Except as to the dis-
tortions and intercurrent rachitic internal complications, it
may be said that the disease runs its course and subsides
at a fixed period inherent to it.*
* Wunclerlicli, C. A. : ' Handbuch der Pathologie imd Tlierapie,'
vol. ii., p. 939. Jenner : ' Med. Times and Gazette,' vol. i., 1860.
Holmes : ' System of Surgery,' vol. iv., p. 843. Atliol. A. Jolmson :
ditto, vol. iii., p. 750.
112 IN-KNEE DISTORTION.
Moreover, as stated (p. 78), rachitis never occurs after
infantile age, and never recurs during pubert_y, adolescent
or adult age in those who were seized with it in infancy.
Elsewhere we have shown that those writers on this dis-
tortion, who have asserted that rickets originates during
adolescence or adult age, have so stated because of their
propossessions that this distortion only occurs in rachitic
subjects. Notwithstanding the views here expressed as to
the nature and course of rachitis, and the dependence of one
form of knee inversion upon it, we do not advise relinquish-
ment of the use of alkaline earths when, in rachitis, the
condition of the gastric secretion denotes undue acidity, or
of steel wine — cod liver oil, sometimes with small doses of
orange wine, when mal- assimilation indicates inpending
marasmus.
Until statistics shall have enabled others to confirm the
views here announced it would be wrong to throw away a
possible chance of benefit to rachitic subjects, and not to
employ articles of at least a neutral, if not a sustaining,
quality. We have had children brought to us who have
taken, with the decidedly mischievous effect of burdening
the alimentary canal, cretaceous, phosphatic and alkaline
compounds, and advertised chemical foods, continuously for
three years, owing to the belief that such things are really
nutritious, just as we have had a patient suffering from a
neurosis bring with her a prescription containing strychnine,
which she had taken continuously for twelve years.*
When treating rachitic cases, in which we have reason
to believe that either of the parents is of rachitic descent,
and that the child is old enough to be, or must be, hand-
fed, we should remember, before prescribing drugs, that milk,
oat-meal, wheat-flour, mutton and beef contain a large
* See Bouvier on the incorrectly asserted sovereign virtues of ol.
inorrliuie in rickets, and on what he calls the " dephosphiation of the
blood," ojj. cit.
TEEATMENT BY MECHANICAL APPARATUS. 113
quantity of earthy phosphates in an easily assimilable form
to supply the place of any possible hereditary cleficiency of
such ingredients in the blood.
The surgical treatment may be divided into two parts :
that which consists in manipulations by a competent
attendant, or in the suitable application of splints and
other mechanical contrivances for the purpose of bringing
the knee structures by gentle means into a proper relation
to each other, and effacing the in-knee temporarily and
permanently (see p. 51) ; and that which consists of more
abrupt means, such as have been used in severe cases, —
tenotomy, forcibly straightening under anassthesia, and
osteotomy.
In every mode of treatment the surgeon has to bear in
mind that the principle involved in successful treatment is
to place and retain the knee in such a position that the
articular surfaces of the external side of the joint be re-
lieved from undue pressure, in order that they, when thus
relieved, may gradually return to the normal state of growth,
shape, and size, a tendency to which, under favourable cir-
cumstances, is always apparent in the economy.
C. Hueter proposes to effect this object by bending the
knee to a right angle, and fixing it in that position by
means of bandages, thus effectually preventing the patient
from using the limb. He speaks contentedly of this method.
He omits to state how long he was obliged to continue it.
It is obvious that it is not applicable when both limbs are
affected, unless the patient is to be confined to the couch or
perambulator. If applicable to a single limb, and the
patient be allowed to move about, with the help of a crutch
or stick, it is objectionable, because of the tendency which
then would arise to undue use of the other limb, which pro-
bably will already have some tendency to the same disease.
The plan is novel and interesting by its showing a distinct
recognition of the correct principle of treatment, the relief
Q
114 IN-KNEE DISTORTION.
of certain Imee structures from undue pressure, and the
encouragement of them to renewed growth. We have re-
sorted to the plaster of Paris, starch, or gum-handage. This
plan is applicahle in very slight cases, where the surgeon
contemplates employing it for only two or three weeks. All
familiar with the treatment of distortions are aware of the
evil of retaining any joint many days at a time in an extended
position, compressed throughout in a close-fitting circular
direction, especially during infancy, when growth is very
rapid. We have seen a knee permanently lessened in size
compared with its fellow after tight bandaging. It is true
that the previously deficient external portions of the femur
and tibia may be released from pressure, and thus be en-
couraged to grow; but during a long-continued fixed ex-
tended position of the knee joint, the normal shape of the
articular eminences is likely to be more or less changed,
owing to the prolonged entire repose in one position ; and
we know that partial ankylosis is thus easily produced.
Another great objection is that a return to movement of the
joint, after the plaster of Paris treatment, is a painful pro-
ceeding. .
The first step to be taken in the treatment of infantile
cases is to teach the parent, " rubber" or nurse the proper
manner in which the part can be manipulated with prompt
unmistakable benefit. It has been stated (p. 27) that in the
young an abnormal lateral mobility of the knee (wobbling)
is a marked symptom of in-knee. If the recumbent child's
legs appear to be abducted, each to about 50° or 60°, each
knee can successively be brought by the attendant from
the position, a, h, nearly to a — d (see diagram a, p.
27), by the most gentle painless pressure. The degree
of temporary restoration thus effected, is the measure
of the degree of improper movement of the knee. It is
not necessary that the parent or rubber should at the first
attempt entirely overcome the inward bulge of the knee ;
TREATMENT BY MANIPULATION.
115
after every clay's attempts this will become easier. It has
been mentioned (p. 56) that if the knee be bent the ^enu-
valgum disappears ; for the same reason during manipula-
tions it is necessary that the manipulator should keep the
limb extended, but not hyper-extended. The nurse or rubber
should not be too hasty or forward with her measures ; she
should be gentle, capable of simultaneously amusing the
child or withdrawing its attention from her doings. If the
child should resist, which may follow too tight grasping of
the limb, or be impatient and withdraw the limb, he bends
the knee or rotates the thigh, so as to defeat the rubber's
intention to straighten it : tact on the part of the nurse or
rubber soon overcomes any difficulty.
In figs. 43 and 44 are represented the manner in which
we have taught parents and rubbers to economise time and
Fig. 43.
Fig. 44.
trouble by straightening the two limbs at the same time. In
both figures a disc of cork, ^ or | inch thick, according to
the age of the patient, is represented, which is covered with
116 IN-KNEE DISTORTION.
a layer of cotton-wool and sewn up in silk. The disc serves
as a .fulcrum between both internal condyles, whilst each
leg being grasped by one hand of the rubber serves as a
lever. By the rubl)er gradually bringing her two hands
gently together both in -knees are temporarily converted
into straight knees, and by repetition of the process after a
few days, in the young child, each limb could he carried
beyond the straight line, even to the opposite condition of
genu-extrorsum. The "knack" of doing this valuable
movement of temporary restoration is soon acquired. It
should be pursued with gentleness, as we have said, the
nurse watchfully noting the temper and disposition of the
child, so as to pause when the child appears disquieted.
The process may be repeated several times daily, each
"sitting" being at three or four hours interval. If the
child is old enough to follow directions, say over three years,
it may be instructed to stand erect against a wall, with the
padded disc between the condyles, and the inner margins of
the feet touching, the limbs temporarily verging to genu-
extrorsum. Many slight degrees of in-knee, brought for
consultation in the earliest stage by parents on account of
the child being accustomed to turn the toes in, or because
the child has "double-ankles," "flat-foot," or spurious
talipes-valgus, are entirelj^ cured by the parents who have
been taught this mode of manipulation, without the em-
ployment of splints, moderate exercise of limbs being
permitted.
f A most simple mechanical aid, from which we have de-
rived benefit in the earliest stage of atonic, strumous, or
rheumatic in-knee, consists in placing a soft cushion | inch
thick, large enough to cover the whole of the inside of the
internal condyle, or condyles, and teaching the parent or
nurse to secure it, in its proper position, by a roller
bandage. The standing exercise, mentioned above, should
be practised as there described.
TREATMENT BY SPLINTS.
117
When the in-knee is somewhat more advanced, support
from one or tAvo splints during a considerable portion of
each twentj^-four hours may he needed. It should be
emphatically borne in mind that in treatment by instru-
mental appliances it is necessary to prevent voluntary
bending of the knee during their use. The value of this
advice admits of no question. Like Hueter's plan it effects
one important object, that of freeing the external side of
the joint from pressure.
The simplest, least expensive and least burdensome of
appliances are light ordinary wooden splints, properly
padded, secured in position by ordinary soft, somewhat
yielding, roller bandages. The first of these splints, six to
eight inches long, padded along its whole length, for a child
under two years, requires to be lightly secured behind the
knee to prevent bending by means of a roller bandage.
If the distortion be so considerable that it can-
not be sufficiently diminished by such gentle
pressure of the surgeon's hand as will enable
him to apply satisfactorily an ordinary straight
splint, as above described, he will find ad-
vantage in the substitution of a light metal
padded splint, jointed in the horizontal direc-
tion, represented in fig. 45. Such a splint,
lightly secured by a roller bandage, will re-
main evenly applied to the back of the knee,
however great may be the degree of genu-
valgum. Afterwards a second splint, reaching
from below the trochanter to the outer ankle, padded
only for a distance of two to three inches at the two extre-
mities, should be bandaged along the outside of the limb.
See fig. 46. This second splint when properly applied, so
that the outer hollow side of the knee is brought almost
into contact with it, at once removes the in-knee distortion.
Under these favouring circumstances, if the child be under
Fig. 45.
118
IN- KNEE DISTORTION.
Fig. 46.
the age of two years, suitable manipulations and mechanical
appliances will effect entire recovery within from two to
four months. If between two and four years
old the time required may extend from three
to six months, the child not needing after-
wards any retentive apparatus. The hand-
ages should be lightly sewn in all directions
to prevent ingenious and curious little fingers
undoing and loosening them. They never
require to be tightly applied. They should
be removed night and morning for the pur-
poses of cleanliness and ablution, for the
practice of the manipulations, described p.
114, and for a sinr/le hendiiig of the joint
night and morning, whilst the nurse sedulously supports with
one hand the internal parts of the joint. They should be re-
applied with as little delay as possible. The parent or nurse,
after being once or twice shown the manner of applying
the splints, should have no difficulty with them. If circum-
stances permit, the services of a trained rubber and mani-
pulator of distortions may be obtained for this part of the
treatment ; the child being allowed to spend nearly all its
time on the floor. It should not be allowed to stand un-
supported by splints until the deformity is seen to have
disappeared, even after the splints have been removed from
the limbs for some hours.
If treatment has been neglected it will be found that in
children between the ages of five and ten years the elastic
nature of the resistance to replacement, above mentioned,
has gradually given place to a more rigid condition of the
structures on'the outside of the knee joint. Irons should
in this case be substituted for the wooden splints. It is indis-
pensable to prompt success that these should at first permit
no movement at the knee joint. In the use of irons, as of
splints, the surgeon should remember that the gentle con-
TREATMENT BY IRONS.
119
DlACEAM C.
tinuous force employed in knock-knee should operate simul-
taneously in two directions, viz., from before, backwards, in
order to prevent bending of the knee ; and from within,
outwards, to prevent inward yielding of it. To fulfil these
objects the " irons " should be furnished for each knee with
a double firm buck-skin knee strap, so attached and secured
that one part shall prevent flexion, the other shall prevent
inward yielding. The gradual straightening of the knee
should be accomplished by the gradual tightening of this
double strap. During the first few days and nights the in-
struments should be uninterruptedly worn. They should be
so made as to permit a soft, light,
loose, proper shoe to be substituted
at night for the day-walking boot,
without removal of the knee part
of the apparatus. In these cases
no confinement to the house is re-
quired, walking in moderation may
be permitted. At the present day
such irons, either single or double
to each leg, are obtainable at most
instrument makers. The annexed
instrument (diagram c) may be
relied upon for the straightening
of even the worst adolescent cases.
The patients soon become accus-
tomed to the inconvenient method
of ascending stairs and sitting
with stiff knees, and end by ac-
quiring a dexterity in performing
DiAGEAM c. — Schematic representation of ^calking and night imtrument for
rectification of severe adolescent knock-knee.. It consists of an upright stem,
with free movement joints at hip and ankle, attached heloiv to an ordinanj foot-
piece, and transferable to an ordinary day boot, to which it may be secured by
a spring below the heel : (ci a) on the upright stem are pads on the fulcra to
120 IN-KNEE DISTORTION.
protect the skin over the trochanter <ui(J the e.rtermil maUeolus from j/re^fxre ;
(d) 0)1 the hixide of the laiee /x to iiidicnti' u pml to protect this part from pres-
xitre. Leodiii;! from tltis pitil In tlie upriijlit stem is a iiietnl boek-pieee, eonsist-
in<i of two ports, the h'ft-linnd lidlf iH'inii the feiiuile screw, and the ri(jht half a
vuile screw. Ihj tarninij ronnd the piece of metal (d a d), to which the male screiv
is atliiriieil, tliis is iiimie In enter tlie female srreir,sii Ihal iinidiialh/ the pad {a)
opposite tlie inside of tlie knee is approsinuited to the itpriijlit stem, and the
inrerted knee joint (iradnalli/ directed towards tlie perpendienlar. If the knee
he more inverted than tlie above dotted ontline represents, tlie treatment sjnmld
be commenced witli tlie use of a proportionate! ij lonrier male screw. In the ease
of both lindis beinii so severeh/ affected, it will he nnirc convenient to treat the
patient reeundjent, by mean-s of an. apparatus on the principle of the diagram d,
(//;//â– / //(' attain-: a sufficiently improved state to sit up or move about. To avoid
encuniberiiifi tlie drawiny several adjuvant essential contrivances hare been
omitted. These are a padded metal band and a thiyh strap, wliich should
be attached to the upriyht stem, opposite the middle of the thlyh, to draw
the thiyh towards the perpendicidar ; a similar band, and strap should he
opposite tlie middle of the ley. Besides these a stout buck-skin strap should
pass from the upriyht at {b b) successively over the front, the inside, and
around the back of the knee, and be hackled on the upriyht at {b h), so
as to draw the knee outwards ,• and another huck-skin strap pass from
the buckles (c c) to the buckles at (d d), so as to keep the knee completely
extended. If all these contrivances are yradually hrouyht duriny the first few
days to a state of sufficient tension and pressure, the patient will e.iperietwe no
pain, excoriation, or undue pressure; the knee even in stout adolescents ivill he
completely straiyldened. It is desirable that once a day the knee in the still-
growiny individual be bent, so as to avoid stiffening of the joint in the extended
position. It is well to order the apparatus to have a riny-catch knee movement.
If the knee of the worst class, ichether or no section of biceps femoris has been
done, he, as it should be, straiyhtened within eiyht or ten weeks, the patient
may he allowed, by means of the riny-catch, to walk with free movement of the
joint apart of, or after a time the loliole of, the day.
what at first were difficult and inconvenient feats of
activity.
We venture here to insist that the surgeon should no
more entrust a surgical instrument maker, "l)one-setter,"
or nurse, to direct the patient or the friends in what manner,
at what time or rate, gentle force is to be applied to a dis-
torted knee, than he would entrust such persons to set a
broken bone, or to restore to the proper form a badly united
PEINCIPLES OF MECHANICAL TREATMENT. 1^1
one ; as much knowledge of anatomy and pathology as is
possessed by the qualified medical practitioner is as neces-
sary in one case as in the other. Some of our surgical
brethren who have justified resort to unnecessary ablation of
tarsal bones in congenital varus in young children, or, the
performance of osteotomy in juvenile cases of knock-knee,
on the ground of "ordinary orthopaedic treatment," having
failed, have confounded the previous handing over of cases
to the mechanic ignorant of anatomy and pathology with
the treatment which should have been carried out by the
orthopaedic surgeon, if they themselves felt unable or
ashamed to accomplish it. The shades of Leonardo da
Vinci, Camper, Scarpa, and Stromeyer — who have all given
their attention to distortions, and the mechanical means of
relieving them — might rise up against this disregard of the
saying of the noble Koman : " Homo sum, nihil humani a
me alienum puto."
Irons often have failed, because owing to their mode of
construction they have acted as helps to locomotion, rather
than as curative agents. We see other splints constructed
for cure of severe in-knee exhibiting just pretensions of
superior fitness, having regard to the necessity of drawing
the knee outwards, but without any effective contrivance for
maintaining a completely extended state of the joint whilst
the morbid inversion is being counteracted, or for prevent-
ing the rotation forwards and outwards of the whole mem-
ber, and, as is especially noticed by C. Hueter {op. cit.), of
the internal condyle.
Many years ago we introduced into use here a metal
splint, adapted to the outer side of the in-knee, furnished
with a rack and pinion, or endless screw, for gradually
drawing the knee outwards, similar to that which has been
figured by Volkmann {op. cit.). We found, however, that
by its not being attached to the foot and hip it became dis-
placed, through the internal condyle and the limb generally
1±1
IN-KNEE DISTORTION.
DlA(iKA.M 11
â– working round in an outward direction. Moreover, this
apparatus does not advantageously permit locomotion, for
the Nveight of the trunk destroys the regulating machinery,
necessitates repairs, causes arrest of progress, consequent
relapse, and loss of progress already made.
It is remarkable how little regard to the simplest
mechanical principles is frequently shown by instrument
makers, and apparently acquiesced in
by surgeons. Not unfrequently we see
a side splint for in-knee of the rela-
tive length, shown by the dark line
A to A (diagram d), furnished with a
proper adjusting screw at the angle of
the inclined knee, c, and secured to
the knee by suitable straps. Whatever
beneficial influence can be effected by
so short a splint as that indicated by
the dark line, and the benefit, as the
result has shown, has been very small,
because of the shortness of the lever-
age, and the absence of any means of
completely preventing bending of the
joint, becomes many times augmented
by increasing the leverage, as from
B to B. The efficacy of the apparatus
is still further increased by extending it to the hip above
and to the foot below.
It is not to be wondered at tluit Linhart, for example
(oj). cit., p. 92), should write : — " I will not state that
orthopaedic instruments are useless, but I do maintain that
when anything is gained it has only been after years' use