Hind limb

“ Compound tincture of iodin, 2 ounces; tannic acid, one-half dram; water, 10 ounces. It does not last more than a day or two after parturition.
CRAMPS OF THE HIND LIMBS.
The pressure of the distended womb on the nerves and blood vessels of the pelvis, besides conducing to dropsy, occasionally causes cramps of the hind limbs. The limb is raised without flexing the joints, the front of the hoof being directed toward the ground, or, the spasms occurring intermittently, the foot is kicked violently against the ground several times in rapid succession. The muscles are felt to be firm and rigid. ”

“ Every Monkey and Lemur exhibits the characteristic arrangement of tarsal bones, possesses a short flexor and short extensor muscle, and a 'peronaeus longus'. Varied as the proportions and appearance of the organ may be, the terminal division of the hind limb remains, in plan and principle of construction, a foot, and never, in those respects, can be confounded with a hand. ”

“ Whilst the hind limbs are being lifted, the entire burden of the body weight is transmitted to the knees and the tissues covering them; so that, if the ground is rough, the skin may be sufficiently displaced to produce laceration of the subcutaneous connective tissue, serous effusion in the layers of connective tissue, and the immediate production of an hygroma beneath the skin and in front of the synovial sheaths of the extensor tendons. ”

“ In unilateral cases, when the child has learned to walk at the late age of two, three, or it may even be four years, it is noticed that the back is hollow and the buttocks unduly prominent, and that there is a peculiar and characteristic limp; each time the weight of the body is put upon the affected limb, the trunk makes a sudden dip towards that side. There is no pain on walking. The affected limb is shortened, as is shown by the projection of the great trochanter above Nélaton's line; the shortening gradually increases, and in time may amount to several inches. ”

“ Tenderness is elicited on making pressure over the joint, on pressing together the iliac bones, or on attempting to abduct the limb while the pelvis is fixed. The muscles of the buttock and thigh are wasted. As any attempt to bear weight on the affected limb causes pain, the patient walks with a limp, and to save the joint he assumes an attitude which is characteristic: he throws his weight on the sound limb, leans forward, using a stick for support, tilts the affected side of the pelvis downwards, and flexes the hip and knee-joints of the diseased limb. ”

“ If an examination is made when the patient is thus halting, and even though he complains of no pain, the limb is found shrunk, wasted, and lengthened. The elongation of the limb occurs mainly in consequence of the inclination of the pelvis towards that side. When the disease has made progress, it has been supposed that swelling of the apparatus of the joint, and effusion into its cavity, might separate the head of the bone from the acetabulum, when pressure from the trunk was not applied. ”

“ After a time, flexion can be made to a right angle; and the limb becomes tolerably useful. By unsuccessful attempts to restore the natural position, inflammation is excited; and thus the salutary processes, commenced by nature for reparation of the displacement, are interrupted and delayed; in young persons such disease of the joint may be produced as might lead to loss of the extremity.
Luxation of the Radius alone, backwards on the outer condyle, is sometimes met with; but this bone is seldom singly displaced far from its original site. ”

“ When the displaced head lies against a bone, the continuous pressure produces a new osseous socket, from the margins of which osteophytic outgrowths may spring, and as the surrounding fibrous tissue becomes condensed and forms a strong capsule, a new joint results. The occurrence of these changes in the direction of a new ball-and-socket joint is largely dependent on the behaviour of the patient: a vigorous man, anxious to recover the use of the limb, will employ it with a degree of determination and indifference to pain that could not be expected in a sensitive elderly female. ”

“ The limb is pained, deformed, and unable to support the body, and swelling to a considerable extent soon follows. Reduction is extremely easy; and the parts are retained in site by the application of a wooden splint, to either the outer or the posterior side of the joint, the leg and foot being previously bandaged. The joint remains long weak, and never recovers entirely; a sustaining apparatus, fitted on the outside, retained by straps, and with a joint opposite to the articulation, is required to be constantly worn when the patient wishes to use the limb. ”

“ Hence if children are set in stocks with their heels touching each other as they sit, and are then made to rise up, till they stand erect, the socket or head of the thigh-bone becomes injured, especially in those children, whose bones are soft; and a shortness of that limb succeeds either by the bending of the neck of the thigh-bone, or by its getting out of the acetabulum; and a consequent rising of one shoulder, and a curvature of the spine is produced from so distant a cause. ”

“ The limb usually becomes flexed and adducted, and a swelling forms in front of the joint at the upper part of Scarpa's triangle; the upper femoral epiphysis may be separated and furnish a sequestrum.
The flexion and adduction of the limb favour the occurrence of dislocation. A child who has recovered with dislocation on to the dorsum ilii is usually able to walk and run about, but with a limp or waddle which becomes more pronounced as he grows up. ”

“ Those who experience a dislocation backwards can neither extend the ham nor the knee, nor can they bend the limb before bending the groin also. The leg appears shorter, the groin looser, and the head of the thigh is to be felt at the buttock. When, then, from infancy, or simply, when for a length of time the limb has been neglected after being dislocated, and allowed to remain so, the cure is impracticable, callus having been already formed. But when the luxation is recent, it may be managed in the way recommended by Hippocrates. ”

“ The other bones of the human body sometimes undergo subluxation, and sometimes complete luxation, but the articulations at the hip and the shoulder are subject only to complete luxation, more especially the hip-joint, because it has a deep and round cavity which is further strengthened by a strong brim. The limb, then, being subject to displacement from its cavity by some great violence, many differences arise according to the greater or less degree of the dislocation. ”

“ Also a wet compress worn over the disjointed limb will, with the fomentation, make it much easier for him, when he comes, properly to set the bones.
When two bones in any part of the body are disjointed, the cords and muscles which tend to keep them firm in their ordinary position usually draw the ends past each other so that they overlap. To get the joint right, the bones must be drawn until the ends can pass each other, and then they must be brought into their proper position. ”

“ If this had been so we should look upon the limb ab a modified external gill; the limb girdle, with Gegenbaur, as a modified branchial arch.
"This theory of the vertebrate paired limb seems to me, I confess, to be a more plausible one on the face of it than either of the two which at present hold the field. If untrue it is so dangerously plausible as to surely deserve more consideration than it appears to have had. One of the main differences between it and the other two hypotheses is that, instead of deriving the swimming fin from the walking and supporting limb, it goes the other way about. ”

“ To illustrate, we will take the lower limb, whether there is lameness, soreness, gouty, rheumatic, neuralgic, swollen, shrunken, feverish, cold, smooth and glassy, sores, ulcers, erysipelas, milkleg, varicose veins, or any defect that the patient may complain of, who is the only reliable book or being of symptomatology. For convenience we will divide that lower limb into five parts, the foot, leg, thigh, pelvis and lumbar region. The patient (symptomatologist) tells us he has a pain in front, center and under part of foot. ”

“ The bones also are altered in their shape and mutual relations, the talus being rotated forwards so that a large portion of its trochlear surface protrudes from the tibio-fibular socket. The skin is cold and livid, and readily suffers from pressure sores. The whole limb is ill-developed, and may be shorter than its fellow, and the paralysed muscles are wasted and exhibit for a time the reaction of degeneration.
A similar deformity may result from section of the peroneal (external popliteal) nerve, from the peroneal form of progressive muscular atrophy, and from peripheral neuritis. ”

“ Those at the knee, for example, contribute more to the length of limb than do those at the hip or ankle, and they are also the last to unite. In the upper limb the more active epiphyses are at the shoulder and wrist, and these also are the last to unite.
The activity of the epiphysial cartilage may be modified as a result of disease. In rickets, for example, the formation of new bone may take place unequally, and may go on more rapidly in one half of the disc than in the other, with the result that the axis of the shaft comes to deviate from the normal, giving rise to knock-knee or bow-knee. ”

“ If no means are taken to replace the bone, and painful feelings subside along with the swelling, the limb remains long useless, and is the seat of occasional lancinating pains, but at last motion and utility are to a certain extent restored by the formation of a new joint—the head of the bone, and the parts on which it rests, mutually accommodating themselves to each other, by degrees, and permitting a limited extent of motion. ”

“ The circumstances attending the first stage of the disease in childhood, in which the limb is lengthened, and there is no decrease, but rather an enlargement of the parts composing the joint, have been already described and illustrated. When, however, absorption occurs, and the articulation begins to be destroyed, the second stage of the disease commences, and the limb becomes then sensibly shortened; the toes are turned inwards or outwards; in many cases there is every appearance of dislocation of the thigh upward and backward ”

“ The cartilages enjoy a limited range of movement within the joint, passing backwards during flexion, and forwards again when the limb is extended; under normal conditions the lateral moves more freely than the medial. While the limb is partly flexed, a slight degree of rotation of the leg at the knee is possible, and during this movement the cartilages glide from side to side, and the tibia rotates below them. ”

“ For if the accident be recent and the patient young, we may sometimes succeed in reducing the limb by grasping and rotating the thigh this way and that. When the dislocation is inwards we may sometimes accomplish our purpose by bending the limb at the groin inwards frequently and strongly. If the dislocation does not yield to these means we must have recourse to extension, first with the hands, certain assistants grasping the thigh and leg and pulling the limb downwards, while others grasp the body at the armpits and pull upwards. ”

“ The limb is often enormously swollen and indurated. The gelatinous effusion beneath the periosteum speedily becomes organised, nodules of osseous matter project into it, and adhere to the surface of the bone frequently by a narrow neck; these increase in number, gradually assume a solid appearance: the bone is thus thickened, often to a very great extent. ”

“ It belongs to the surgeon to examine and ascertain, when the natural connexions of the joint are sufficiently confirmed. Then motions, at first gentle, are to be impressed on the limb; being afterwards gradually increased, they remove by degrees that stiffness, which usually follows a dislocation, particularly an old one. But if it has existed too long, to give the limb motion, is then the only resource: the new attachments or adhesions, contracted by the articulating surfaces in their displaced state, render reduction impracticable. ”

“ Prognosis.—After having once been dislocated, a joint is seldom as strong as it was formerly, although for all practical purposes the limb may be as useful as ever. Some degree of stiffness, of limited movement, or of muscular weakness, and occasional arthritic changes and a liability to re-dislocation, are the commonest sequelæ. Prolonged immobilisation is liable to lead to stiffness by permitting of the formation of adhesions; while too early movement tends to produce a laxity of the ligaments which favours re-displacement from slight causes. ”

“ Care should be taken not to allow the patient to rest too soon on the fractured limb; for though quite straight, symmetrical, and of the proper length, when the retentive apparatus is discontinued, it may become short and deformed in a few days from even slight weight being put upon it.
The period at which firm union takes place varies; the process is more rapid in young people than in those advanced in life, and will depend more on the extent of the injury, and its vicinity to the centre of the circulation than on the size of the broken bone. ”

“ As we restore the skeleton of the limb, several features are remarkable: The humerus, ulna, and ulnare align themselves as the major axis of the limb, each carrying on its posterior edge a process or flange comparable to those in the axial series of a rhipidistian fin. The remaining elements take positions comparable to the diagonally placed preaxial radials in such a fin. The digits appear to have been short, perhaps with no more than two phalanges. ”