When a child whose social conditions are favorable comes to us for treatment in the very first stages, then we agree with Calot, who advises a long continued rest cure without any fixation bandages. But this method is adapted only to the strata in society uppermost in means as well as in education. It requires the best of nursing, a rest cure in the open air, and considerable firmness and tact to keep a child for many months from walking and even from sitting. Slight anomalies of posi tion are corrected by the application of extension bandages and weights and by counter traction.
In most cases, however, we will find ambulatory treatment prefer able with fixation apparatus which at the same time takes off the weight. This treatment permits the children to walk around, makes their care much easier, and is more beneficial for their mental as well as their bodily health.
Nothing is equal to a well-fitting plaster cast.
Now how should this be applied and what shall we do for the mal positions which are present? Notwithstanding the differences of opinion which crop out all the time, we think that we will find the right method when we consider the pathologic anatomy, the condition of the disease, and the social condi tions. We are not treating eases but patients and our object is to obtain the best possible joint. We must therefore make our treatment as short as possible, and in order to do this we must treat the disease and the malposition together.
With the first plaster cast we correct the malposition by very slight pressure either wit bout or with narcosis, and then put in a well-fitting and carefully moulded plaster cast with the least possible padding. This is done if possible in abduction, because nature teaches us that in this Position the leg has to bear the least possible weight.
The bandage readies from the lower ribs to the ankles to prevent motion in the hip when moving the knee. [The late Abel M. Phelps taught that the east should reach above to the mills, because any shorter one will permit motion in the hip-joint.—THE TRANSLATOR.] In some cases with a very painful exudate it will be advisable to let the cast reach down even to the knee on the healthy side, to prevent any motion in the pelvis during the painful stage.
The patient has to remain in bed as long as there is much pain. When this ceases we fasten a walking stirrup to the east (see Walking-splints in fractures of the femur); on this the patient walks around; it keeps the heel from the ground and the cast transfers the weight to the tuber osities of the isehium, to which the cast must be moulded especially care fully if we want it to fulfil its purpose. When the cast is entirely finished
we inspect this part of it once more, and insert here pieces of felt to keep back the soft parts and to bring the tuber ischii in close contact with the pad. In this way we take off the weight entirely and avoid constant slipping inside the east. We must further see that the cast is not nar rowed in below the tuberosity of the tibia, because otherwise the knee would have to bear the weight and not the tuberosity of the isehium. We place an extra sole under the sound foot so as to make, them of the same length (see of the femur).
When pain is no longer felt on walking, then the stirrup is no longer needed and the abduction (Fig. 12:id) will suffice; we must not try to anticipate Nature, as keeping the weight off the limb altogether has its disadvantages in increased atrophy of the bone.
Thus, treatment should be instituted and continued according to the symptoms. After the patient has been walking with the stirrup for some months, we begin to leave this off; if we can do this then we can cut off the east at the knee after a few more months. We renew the casts at intervals of a few months.
Among the wealthy the plaster cast may be supplanted, in the after treatment, by a brace (Dossing, Lorenz, Haifa, Dollinger). But we must not omit to mention that even the best of braces does not work as well as a carefully moulded plaster cast, not to mention the frequent defects in the material and the repairs. The brace should take up the weight at the tuber ischii the same as a cast awl transfer it to a solid sole through metal braces; this sole should he several centimetres from the heel. The leg bangs in the apparatus and is held by to extension sling. We may also add to the braces vances to correct the sition by means of pressure from springy or elastic tion.
We, as well as other authors, give preference to the plaster cast, because it works better and we order braces only d tiring the period of after-treatment Should we find severer anomalies of position, such as contractions in flexion or adduction, then these should be gradually corrected in the beginning of the treatment by extension; by slowly increasing the weights we can do this in a very few clays, or we can do it in several stages.