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In the pelvis was an abscess situated in front of the sacrum, at its upper part to the left side, contained white consistent pus. On removing the walls of this abscess, it was discovered that all the left portion of its first sacral vertebra was decaded of its periosteum, that the left epiphysary eminence of this vertebra was separated from the rest of the bone by a division, the surfaces of which were rough, and of greyish colour; that the collection of pus communicated on une side with the lumbo-sseral articulation, the fibro-cartilage of which was entirely destroyed in its middle portion, and on the other with the sacro-ilise articulation, the cartilages of which were also destroyed, whence it resulted that the articular surfaces were very rough to the touch.

Of the two rami of the ischium, the posterior was separated from its cartilage, and a small quantity of pas bathed its extremity. The anterior was yet in connection with the cartilage; but a slight traction sufficed to separate it; there was no abscess below this point. The periosteum could be separated from the entire bone with extreme facility.

Some traces of inflammation in the stomach and small intestine.

The lungs were crepitant; in the whole extent of their surface, slightly projecting black spots were observed, the largest of which was of the diameter of a one-franc piece. The pulmonary substance beneath these spots was of a very deep red colour, compact, and did not contain air. This alteration extended to a depth of four or five Snes. The altered patches were separated from the healthy substance of the lung by a very decided line of demarcation; there were about twenty in number to each of these organs.

The pericardium contained a small quantity of pure and liquid blood. Black blood in all the cavities of the heart and of the sorta.

The crural and ilise veins presented at distant intervals small spots and some membraniform filaments; their internal surface, smooth and shining, was of a deep red colour.

According to M. Valleix, it is very probable that the abscesses of the limbs and pelvis depended on an alteration of the bones occasioned by syphilitic disease. This is the more likely as the child at the same time presented the chronic lobular induration of the lungs, stated by M. Depaul to be characteristic of congenital syphilis. As to the osseous productions described in this case, he considers them as so many examples of what Lobstein has termed diffuse osteophyte. formation was very rapid; and on this subject M. Valleix states, that in a case of cephalæmatoma, he has observed a bony swelling of a line and a half in height become raised in one day. But this swelling, is it really of the osseous nature? M. Valleix does not state that he - afterwards assured himself of it by dissection.

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[Malgaigne attributes the first distinct and satisfactory notice of the separation of epiphyses to Bertrandi, towards the close of the last century, and cites some authenticated instances, in which it was produced from rough and careless treatment in bringing children into the world. The bones which suffered were the femur, tibia, and humerus. These accidents may ensue from analogous causes after birth and up to the time of puberty. They are, however, of rare occurrence, and require the same treatment as fracture in the same structures—a fortunate circumstance, inasmuch as we are unacquainted with any satisfactory diagnostic by which to distinguish between the two forms of injury.—P.H.B.]

BOOK XXIII.

ON DISEASES OF THE ARTICULATIONS.

CHAPTER I.

ON VICES OF ARTICULAR CONFORMATION.

The articulations of the skeleton present a great number of congenital deformities which are comprehended under the term of vices of articular conformation. They should be divided into four groups:

1st. Vices of conformation by ankylosis.

2nd. Vices of conformation by diastasis.

3rd. Vices of conformation by the absence of a part or of the whole of a bone.

4th. Vices of conformation with deviations or luxation.

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The three first groups include anomalies against which surgery is 2s inty powerless, and which it is useless to study here; I shall simply consider the vices of conformation with deviations or luxations.

1ST. VICES OF THE CONFORMATION OF THE ARTICULATIONS
WITH DEVIATIONS OR LUXATIONS.

Before examining the characters belonging to these vices of conformation in the various articulations of the skeleton, I shall rapidly point out the etiology and the pathological physiology of congenital articular anomalies.

CAUSES.

Numerous theories have been put forward in order to account for articular deformities. If some of these theories are specious, the greater number are founded on facts sanctioned by experience; no one of them is always applicable to all the varied cases which observation reveals to us. I shall first enumerate the causes the action of which has been well authenticated, and I shall then assign to each of these causes the importance due to them according to the present state of our knowledge.

Hereditary transmission should be placed in the first rank in these etiologic considerations on articular difformities; it is exercised from one generation to that which immediately follows it, and in rare instances

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to the second. The existence of hereditary vices of conformation finds its explanation in the primordial vicious organization of the germs. A derangement sustained in the process of formation may be the cause of some congenital vices of articular conformation; embryology teaches us that in the embryonic state of the skeleton, the number and position of the primary points of ossification are determined long before the period of the formation of the bone itself; if one of these points is wanting, the portion of bone which at a later period should correspond to will also be deficient; if one of these points remains rudimentary, there will be an arrest of development.

Diseases of the fœtus appear to play a prominent part in the vices of articular conformation. There can be no doubt of the influence of articular diseases developed during foetal life on the congenital deformities of the articulations; there is nothing really unnatural in conceiving that the swelling of the adipose cotyloidean tissue of white swellings, hydrarthosis, appearing in the course of foetal existence, may lead to congenital luxations of the corresponding articulations. Other foetal diseases have been cited in order to account for the deformities of the articulations; these are-diseases of the skeleton, contraction of the ligaments or of the aponeuroses; muscular retraction; pressure exercised on the body of the foetus; the unnatural positions of the fœtus, &c.

Diseases of the skeleton are observed in the trunk and superior and inferior extremities, and may engender various deviations after the expiration of intra-uterine existence.

The aponeuroses, by their primary or consecutive shortening, may determine the vicious conformation of certain parts of the fœtus; the same may be said of the primary or consecutive shortening of the ligaments, which may produce congenital articular deviations.

The muscles are often contracted near the distorted articulations; moreover, the muscles, the length of which is lessened, are especially those whose extremities are approximated in consequence of the change in position of the levers which they should move; this result of anatomical investigation, after having given rise to various theories, appears to us to have received an excellent explanation by M. J. Guérin. This learned physician is of opinion that the principal cause of congenital vices of conformation of the articulations, is the convulsive retraction of the muscles, developed in the fœtus under the influence of a lesion of the nervous system. According to M. J. Guérin, this retraction may affect one or several muscles, it may be seated in the muscles of an entire region, and it may consequently arrest a movement or a series of movements. When retraction exists, the muscular insertions are approximated, the levers moved by the muscles are displaced; thus deviations are produced, pressure of bone against bone, or against their ligaments, luxations and sub-luxations in all their degrees.

Once produced, the muscular retraction continues; at the first stage (contraction, of M. J. Guérin) the muscle is red, firm, of tolerable size; but at length, the disease progressing, the second stage (retraction, M. J. Guérin) shows itself, characterized by the transformation of the muscular fibre into fibrous tissue.

I shall lastly mention as a cause of vicious conformation of the articulations, pressure exercised on the body of the foetus, and unnatural positions of the latter; this cause, to which M. Martin would attach an importance it does not possess, would nevertheless, in certain cases, play an important part in the production of articular anomalies.

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To resume, then although the vices of articular conformation may be produced by various causes, although these deformities sometimes appear without our being able to discover the reason why, we do not hesitate to assert that in the immense majority of cases, lesion of the nervous system, followed by muscular retraction, is the sole cause of congenital vices of the conformation of the articulations.

PATHOLOGICAL PHYSIOLOGY.

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Congenital vices in the conformation of the articulations cause remark-tale able modifications in the functions of locomotion. The articulations lose their normal mobility; but in the greater number of cases, their functions are accomplished in a more or less complete manner. If we examine an articulation attacked with deformity with reference to the paralysed muscles, we observe muscles which have acquired a consider-ma able development and entirely take the place of those which do not exist; around an immoveable joint, we see the nearest articulations acquire more varied movements, and we may easily prove that the performance of isolated movements affords the lame a great dexterity Nac in using the vicious members.

CONGENITAL VICES OF CONFORMATION

DIFFERENT ARTICULATIONS.

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STUDIED IN THE

These deformities are especially met with in the hands and in the feet, in the tibio-tarsal, and radio-carpal articulations. They are much more frequent in the feet, and to them we shall first direct attention.

CONGENITAL VICES OF THE TIBIO-TARSAL ARTICULATIONS
AND OF THE BONES OF THE FOOT (CLUB-FOOT).

Grouped under the generic name of talipes (club-foot) the deviations of the foot are termed : 1st. Talipes equinus; 2nd. Talus; 3rd. Varus; 4th. Valgus.

M. Bonnet, of Lyons, has proposed to reduce the varieties of clubfoot to two classes, internal and external popliteal club-foot, according as the deviations depend on the retraction of the muscles supplied

by the branches of the internal or external popliteal nerve. This classification, however advantageous it may appear to be, not being generally admitted, we shall retain the standard division which has just been given.

PATHOLOGICAL ANATOMY.

1st. Talipes equinus. The foot is in forced extension, and only touches the ground by the toes or by the anterior extremity of the metatarsal bones. The principal movement takes place in the tibiotarsal articulation. The anterior surface of the astragalus is nearly subcutaneous; its posterior part only touches the articular surfaces of the tibia and fibula. The posterior extremity of the os calcis is raised. If the talipes equinus exists in its most advanced degree, the foot is bent at the situation of the space which separates the two rows of the tarsus.

The form of the bones is scarcely modified.

The gastrocnemii muscles sometimes undergo fatty degeneration; they are retracted.

2nd. Talus. The foot is in forced flexion, it only touches the ground by the heel. The greatest movement takes place in the tibio-tarsal articulation. The astragalus is incompletely dislocated backwards. As in talipes equinus, the bones are scarcely deformed; the gastrocnemii, which are subject to fatty degeneration, are elongated.

3rd. Varus. The displacement takes place in the medio-tarsal articulations; it is characterized by the deviation of the foot inwards, so that it rests upon the ground on its outer edge. The scaphoid bone is drawn inwards, then backwards; its internal extremity articulates with the calcaneum, sometimes with the internal malleolus; the cuboid is drawn backwards and inwards. The astragalus and the calcaneum are displaced in such a manner that the inferior surface of the first becomes internal, and the external surface of the second inferior.

The bones become atrophied in some places, increase in size in others, subject, as in the previous varieties, to fatty degeneration; the gastrocnemii are contracted, the peronei elongated, the tibialis anticus shortened.

4th. Valgus. The displacement is seated in the medio-tarsal articulations; it is characterized by the deviation of the foot outwards, the internal edge of the foot forming the only point of support. This variety presents the displacement of the bones and the dispositions of the muscles inverse to those of varus. The bones may also become hypertrophied or atrophied.

The various deviations we have just described may be combined together, so as to produce equino-varus, varus-equinus, talus-valgus, &c.

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