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The  Journal   of 

Bone  &  Joint  Surgery 


The      Official      Publication      of      the 

American    Orthopedic    Association 

and  of  the 
British      Orthopaedic      Association 


Volume  XX 
1922 


Under  the  Management  of  Dr.  E.  G.  Brackett,  Editor, 

and  Miss  Lissner,  Assistant  Editor, 

Boston,  Massachusetts. 


Y]>  S< 


INDEX    TO    VOLUME    XX. 


ALPHABETICAL      LIST      OF      AUTHORS      WHOSE      WORKS      ARE 
PUBLISHED     IN     THIS     VOLUME. 


Adams,  Z.  B.  Treatment  of  congeni- 
ta] dislocation  of  hip  as  practised 
by  Professor  Denuce  at  Bordeaux, 
France.     P.  523. 

Allison,  Nathaniel.  Specialist  in  sur- 
gery and  his  viewpoint.     P.  421. 

B 

Barrie,  George.  Hemorrhagic  osteo- 
myelitis.    P.  653. 

Bennett,  George  E.  Lengthening  of 
quadriceps  tendon.     P.  279. 

.      Operation    for    hypertrophied 

patella.     P.  593. 

Bernstein,  Maurice  A.  Open  reduc- 
tion of  old  congenital  hip  disloca- 
tion.    P.  481. 

Billington,  R.  Wallace.  Tendon  trans- 
plantation for  musculospiral  (radial) 
nerve  injury.     P.  538. 

Boorstein,  S.  W.    Cervical  rib.    P.  682. 

British  Orthopaedic  Association.  Dis- 
cussion on  operative  treatment  of 
osteoarthritis  of  hip-joint.     P.   137. 

Brown,  L.  T.  Beef  bone  in  stabilizing 
operations  of  the  spine.     P.  711. 


Calve,  Jacques.  Treatment  of  tuber- 
culosis of  ankle  in  adult.     P.  33. 

Campiche,  Paul,  and  Eaves,  James. 
Note  on  malformation  of  carpus. 
P.  78. 

Cofield,  Robert  B.  Hypertrophic  bone 
changes  in  tuberculous  spondylitis. 
P.  332. 

Cone,  Sydney  M.  Pathology  of  ostei- 
tis deformans,  Paget's  disease.  P. 
751. 

Cook,  Robert  J.  Report  of  orthopae- 
dic examination  of  1393  freshmen  at 
Yale  University.     P.  247. 


E 
Eaves,    James,    and    Campiche,    Paul. 

Note    on    malformation    of    carpus. 

P.   78. 
Elmer,    Walter    G.     Substituting    felt 

for  steel  arch  supports.     P.  395. 


Fitz-Simmons,  Henry  J.  Simultane- 
ous hydrops  of  knees.    P.  376. 

Forbes,  A.  Mackenzie.  Operative 
treatment  of  scoliosis.     P.  446. 


Gaenslen,  F.  J.  Pain  due  to  ilio-costal 
impingement.      P.  705. 

Gallie,  W.  E.,  and  Le  Mesurier,  A.  B. 
Clinical  and  experimental  study  of 
free  transplantation  of  fascia  and 
tendon.     P.  600. 

Gibbon,  James  W.  Bone  sarcoma. 
P.  512. 

Gibson,  Alexander.  Painful,  traumatic 
shoulder.     P.  552. 

Goldthwait,  Joel  E.  "Flat  hand" 
(manus  planus) :  its  correction  es- 
sential to  normal  function  of  hand. 
P.  469. 

H 

Haas,  S.  L«  Spontaneous  healing  in- 
herent in  transplanted  bone.     P.  209. 

Henderson,  Melvin  S.  Osteoma  of 
cervical  spine.     P.  518. 

Holland,  C.  Thurstan.  Note  on  sac- 
ralization of  fifth  lumbar  vertebra. 
P.  215. 

J 

Jones,  Ellis.  SubastragalorJ  external 
dislocation.     P.  325. 


Kleinberg,  S.     Fracture  of  spine.     P. 

80. 
Kuth,   J.    R.     Study   of   208   cases   of 

lower  back  pain.     P.  357. 


INDEX  TO  VOLUME  XX. 


Le  Mesurier,  A.  B.,  and  Gallie,  W.  E. 

Clinical   and   experimental    study   of 

free    transplantation    of    fascia    and 

tendon.     P.  600. 
Lewin,     Philip.       Osteitis     deformans 

(Paget's    disease),    with    report    of 

three   cases.     P.  45. 
Lowman,  C.   L-     Spinal  pathology  in 

relation     to     ocular     manifestations, 

with  report  of  cases.     P.  580. 

M 

Masland,  Harvey  C  Practical  thoughts 
on  bone  pegs,  bone  screws,  etc. 
P.  317. 

Mayer,  Leo.  Treatment  of  paralytic 
flat  feet.     P.  39. 

Mebane,  Tom  S.  Chronic  osteomye- 
litis secondary  to  compound  frac- 
ture.    P.  67. 

Merrill,  William  Jackson.  Davis 
method  of  reduction  of  congenital 
dislocation  of  hip-joint.     P.  805. 

Meyer,  Arthur  William.  Further  ob- 
servations upon  use-destruction  in 
joints.     P.  491. 

Miller,  Edwin  M.  Congenital  ankylo- 
sis of  joints  of  hands  and  feet.  P. 
560. 

Moore,  Beveridge  H.  Case  of  spon- 
taneous fracture  of  transverse  proc- 
ess of  lumbar  vertebra,  due  to  tuber- 
culosis.    P.  322. 

N 

Nutt,  John  Joseph.  Further  observa- 
tions on  intra-perineural  neurotomy 
in  spastic  conditions.     P.  453. 

Nutter,  J.  Appleton.  On  delayed  un- 
ion and  non-union  of  fractures.  P. 
104. 


O'Ferrall,  John  Tolson.  Low  back 
pain — Clinical  study  of  cause.  P. 
384. 

Oppenheimer,  Edgar  D.  Early  symp- 
toms of  spinal  cancer.     P.  342. 


Peabody,    C.    W.     Unusual    fractures. 
P.  459. 


Robinson,  Wilton  H.  Standard  plas- 
ter bandage.     P.  321. 

Rogers,  Mark  H.  Pathology  of  tu- 
berculosis of  joints.     P.  679. 

Rosen,  Neil  G.  Simplified  method  of 
measuring  amplitude  of  motion  in 
joints.     P.   570. 


Schulz,  O.  E.  New  method  of  oper- 
ative treatment  of  foot  deformities. 
P.  219. 

Schwartz,  R.  Plato.  Mechanism  of 
new  plaster  shell  in  treatment  of 
Pott's  disease  in  children,  with  lat- 
eral x-ray  control.     P.  789. 

Shipley,  Paul  G.  Studies  on  experi- 
mental rickets.     P.  672. 

Starr,  Clarence  L.  Army  experiences 
with  tendon  transference.     P.  3. 

Stewart,  Steele  F.  Postoperative  care 
of  flexion  contraction  of  hip.  P. 
548. 

Stone,  Charles  A.  Amyatonia  con- 
genita.    Report  of  a  case.     P.  21. 

Swaim,  Loring  T.  Chronic  arthritis. 
P.  426. 


W 

Whitman,  Armitage.  Astragalectomy 
and  backward  displacement  of  foot. 
Investigation  of  practical  results. 
P.  266. 

Wilson,  John  C.  Reconstruction  of 
internal  lateral  ligament  of  knee- 
joint.     P.  129. 

Wilson,  Philip  D.  Early  weight- 
bearing  in  treatment  of  amputa- 
tions of  the  lower  limb.    P.  224. 


ALPHABETICAL  LIST  OF  TITLES  TO  ARTICLES  PUBLISHED  IN 

THIS  VOLUME. 


American  Orthopedic  Association, 
preliminary  program.     P.  209. 

Amputations  of  lower  limbs,  Early 
weight-bearing  in  treatment  of. 
Philip  D.  Wilson.     P.  224. 

Amyatonia  congenita.  Report  of  a 
case.     Charles  A.  Stone.     P.  21. 

Ankylosis,  Congenital,  of  joints  of 
hands  and  feet.  Edwin  M.  Miller. 
P.  560. 

Arch  supports,  Substituting  felt  for 
steel.     Walter  G.  Elmer.     P.  395. 

Arthritis,  Chronic.  Loring  T.  Swaim. 
P.  426. 

Astragalectomy  and  backward  dis- 
placement of  feet.  Investigation  of 
practical  results.  Armitage  Whit- 
man.    P.  266. 

B 
Back    Pain,    Low.      Clinical    study    of 
cause.     John  Tolson   O'Ferrall.     P. 
384. 

-,  Lower,  Study  of  208  cases  of. 


J.   R.  Kuth.     P.  357. 

Beef  bone  in  stabilizing  operations  of 
the  spine.     L.  T.  Brown.     P.  711. 

Bone  pegs,  bone  screws,  etc.,  Prac- 
tical thoughts  on.  Harvey  C.  Mas- 
land.     P.  317. 

—   sarcoma.     James   W.    Gibbon. 

P.  512. 

,       transplanted,       Spontaneous 

healing  inherent  in.  S.  L.  Haas. 
P.  209. 

Book  Review.  Artificial  limbs  and 
amputation  stumps.  E.  Muirhead 
Little,  F.R.C.S.    P.  855. 


Carpus,    Note    on     malformation    of. 

James    Eaves    and    Paul    Campiche. 

P.  78. 
Cervical  rib.    S.  W.  Boorstein.   P.  682. 
Congenital    Hip    Commission,    Report 

of.    P.  821. 


Correspondence. 

Bone  sarcoma.     George   Barrie.     P. 

164. 
Tuberculosis     in      China.       G.      E. 
Brackett.     P.  823. 


Davis  method  of  reduction  of  congen- 
ital dislocation  of  hip-joint.  William 
Jackson  Merrill.     P.  805. 

Dislocation,  congenital,  of  hip,  Treat- 
ment of,  as  practised  by  Professor 
Denuce  at  Bordeaux,  France.  Z.  B. 
Adams.     P.   523. 

,  congenital,  of  hip-joint,   Davis 

method    of    reduction    of.       William 
Jackson  Merrill.     P.  805. 

-,  subastragaloid  external.     Ellis 


Jones.     P.  325. 


Flat  feet,  paralytic,  Treatment  of. 
Leo   Mayer.     P.  39. 

"Flat  hand"  (manus  planus):  its  cor- 
rection essential  to  normal  function 
of  hand.  Joel  E.  Goldthwait.  P. 
469. 

Flexion  contraction  of  hip,  Postoper- 
ative care  of.  Steele  F.  Stewart. 
P.  548. 

Foot  deformities,  New  method  of  op- 
erative treatment  of.  O.  E.  Schulz. 
P.  219. 

Fracture,  compound,  Chronic  osteo- 
myelitis secondary  to.  Tom  S. 
Mebane.     P.  67. 

of  spine.     S.  Kleinberg.     P.  80. 

,     Spontaneous,     of     transverse 

process  of  lumbar  vertebra,  due  to 
tuberculosis.  Beveridge  H.  Moore. 
P.  322. 

Fractures,  On  delayed  union  and  non- 
union of.  J.  Appleton  Nutter.  P. 
104. 

,    Unusual.      C.    W.    Peabody. 

P.  459. 

H 

Hip  dislocation,  Open  reduction  of 
old  congenital.  Maurice  A.  Bern- 
stein.    P.   481. 


INDEX  TO  VOLUME  XX. 


Hip-joint,  Discussion  on  operative 
treatment  of  osteoarthritis  of.  Brit- 
ish Orthopaedic  Association.  P. 
137. 

,    Postoperative    care    of    flexion 

contraction  of.  Steele  F.  Stewart. 
P.  548. 

Hydrops,  Simultaneous,  of  knees. 
Henry  J.  Fitz-Simmons.     P.  376. 

Hypertrophic  bone  changes  in  tuber- 
culous spondylitis.  Robert  B.  Co- 
field.     P.  332. 


Ilio-Costal  impingement,   pain   due  to. 
F.  J.   Gaenslen.     P.  705. 


Plaster  shell,  new,  Mechanics  of,  in 
treatment  of  Pott's  disease  in  chil- 
dren, with  lateral  x-ray  control.  R. 
Plato  Schwartz.     P.  789. 

Pott's  disease  in  children,  Mechanics 
of  new  plaster  shell  in  treatment  of, 
with  lateral  x-ray  control.  R.  Plato 
Schwartz.     P.  789. 


Quadriceps    tendon,    Lengthening    of. 
George  E.  Bennett.    P.  279. 


Joints,  Simplified  method  of  measur- 
ing amplitude  of  motion  in.  Neil  G. 
Rosen.     P.  570. 


Knee-joint,  Reconstruction  of  inter- 
nal lateral  ligament  of.  John  .  C. 
Wilson.     P.   129. 

N 

Neurotomy,  intra-perineural,  in  spas- 
tic conditions,  Further  observations 
on.     John  Joseph  Nutt.     P.  453. 

News  notes.     Pp.     166,  400,  613,  825. 


Report    of    Congenital    Hip    Commis 
sion.     P.  821. 

Rickets,      experimental,      Studies      on 
Paul  G.  Shipley.     P.  672. 


Sacralization  of  fifth  lumbar  vertebra, 
Note  on.     C.  Thurstan  Holland.     P. 

215. 

Scoliosis,  Operative  treatment  of.     A. 
Mackenzie  Forbes.     P.  446. 


Orthopaedic  examination  of  1393 
freshmen  at  Yale  University,  Re- 
port of.     Robert  J.  Cook.     P.  247. 

Osteitis  deformans  (Paget's  disease), 
Pathology  of.  Sydney  M.  Cone. 
P.  751. 

,    with    report    of    three    cases. 

Philip   Lewin.     P.  45. 

Osteoarthritis  of  hip-joint,  Discussion 
on  operative  treatment  of.  British 
Orthopaedic  Association.     P.   137. 

Osteoma  of  cervical  spine.  Melvin  S. 
Henderson.     P.   518. 

Osteomyelitis,  Chronic,  secondary  to 
compound  fracture.  Tom  S.  Me- 
bane.     P.  67. 

,  Hemorrhagic.     George  Barrie. 

P.  653. 


Shoulder,   Painful  traumatic.     Alexan- 
der Gibson.     P.  552. 

Shriners    hospitals    for    crippled    chil- 
dren.    P.   135. 

Specialist    in    surgery    and    his    view- 
point.    Nathaniel  Allison.     P.  421. 

Spinal    cancer,     Early    symptoms    of. 
Edgar  D.  Oppenheimer.     P.  342. 

pathology  in  relation  to  ocular 

manifestations,  with  report  of  cases, 
C.  L.  Lowman.     P.'  580. 

Spine,  Beef  bone  in  stabilizing  opera- 
tions of.     L.  T.  Brown.     P.  711. 


Paralytic  flat  feet,  Treatment  of.     Leo 

Mayer.     P.  39. 
Patella,  hypertrophied,  Operation  for. 

George   E.  Bennett.     P.  593. 
Plaster  bandage,  Standard.    Wilton  H. 

Robinson.     P.  321. 


-,     Fracture    of.      S.    Kleinberg. 


P.  80. 

Spondylitis,  tuberculous,  Hypertro- 
phic bone  changes  in.  Robert  B. 
Cofield.     P.  332. 


INDEX  TO  VOLUME  XX. 


Tendon  transference,  Army  experi- 
ences with.    Clarence  L.  Starr.    P.  3. 

transplantation  for  musculospi- 

ral  (radial)  nerve  injury.  R.  Wal- 
lace  Billington.     P.  538. 

Transplantation,  free,  of  fascia  and 
tendon,  Clinical  and  experimental 
study  of.  W.  E.  Gallie  and  A.  B. 
Le  Mesurier.     P.  600. 

Tuberculosis  of  ankle  in  adult,  Treat- 
ment of.     Jacques  Calve.     P.  33. 


Tuberculosis   of  joints,    Pathology   of. 
Mark  H.  Rogers.     P.  679. 

U 
Use-destruction  in  joints,  Further  ob- 
servations   upon.      Arthur    William 
Meyer.    P.  491. 


Yale  University,  Report  of  orthopae- 
dic examination  of  1393  freshmen  of. 
Robert  J.  Cook.     P.  247. 


INDEX    OF  ABSTRACTS   FROM    CURRENT   ORTHOPAEDIC 

LITERATURE. 


Acromegaly,  Relation  of,  to  thyroid 
disease,  with  statistical  study.  J. 
M.  Anders  and  H.  M.  Jameson.  P. 
638. 

Amebiasis  of  bones.  Charles  A.  Ko- 
foid  and  Olive  Swezey.     P.  835. 

Amputations  at  shoulder  and  at  hip. 
H.  Littlewood.     P.  631. 

Ankylosis,  bony,  of  knee-joint,  Mobi- 
lization of.  Charles  Ogilvy.  P. 
411. 

Arthritis,  Chronic.  Leonard  W.  Ely. 
P.  624. 

-,  chronic,  Amoeba  as  cause   of 


second  great  type  of.  Leonard  W. 
Ely,  Alfred  C.  Reed  and  Harry  A. 
Wyckoff.     P.  625. 

-,    chronic,    Treatment   of,    with 


special     reference     to     end-results. 
Walter  L.  Bierring.     P.  624. 

deformans    as    deficiency    dis- 


ease.    G.  C.  Belcher.     P.  623. 

deformans     juvenilis     of     hip, 


Case  of.     Yvernault.     P.  838. 

deformans,     Operative     treat- 


ment of.    A.  Wollenberg.     P.  836. 
gonorrheal,   Treatment  of,   by 


injection  of  joint  fluid.     H.  Dufour, 
J.  Thiers,  and  Alexewsky.     P.  626. 
Infectious,  of  spine.     Sigmund 


Epstein.     P.  626. 

-,   Rheumatoid.     N.   Davies.     P. 


411. 


-,  Rheumatoid,  due  to  infection 
of  nasal  accessory  sinuses.  P. 
Watson-Williams.     P.  626. 

Treatment     of.       Arthur     F. 


Chace  and  Victor  C.  Myers.    P.  201. 
Arthoplasty   of   elbow-joint.       Harold 
C.  Bean.    P.  630. 

B 

Bertolotti's  syndrome;  Contribution 
to  knowledge  of.  Armando  Alba- 
nese.     P.  641. 

Bone,  Action  of  radium  on  tumors  of. 
Isaac  Levin.     P.  407. 


Bone  development,  Biology  of,  in 
relation  to  bone  transplantation. 
Philip  William  Nathan.     P.  178. 

,  Function  in  relation  to  trans- 
plantation of.  S.  L.  Haas.  P.  174. 
graft,      Certain     fundamental 


laws    underlying    surgical    use    of. 
F.  H.  Albee.    P.  173. 

plate  for  use  in  fractures  close 


to  joints   or   to  epiphyses.     W.   H. 
Byford.     P.  619. 

repair,  Some  factors  in.     Wil- 


liam Seaman  Bainbridge.    P.  410. 

Bursa,  subacromial,  Case  of  ossifica- 
tion of.     Coulomb.     P.  854. 

Bursitis  calcarea  of  the  epicondylus 
externus  humeri;  contribution  to 
pathogenesis  of  epicondylitis.  J. 
Schmitt.     P.  204. 

,  retrocalcanean,  Diagnostic  and 

therapeutic  point  in.  A.  L.  Nielson. 
P.  203. 


Carpus,  Traumatology  of.  A.  H. 
Bizarro.     P.  838. 

Cervical  rib,  with  report  of  two  cases. 
Paul  C.  Colonna.     P.  627. 

ribs:  with  special  reference  to 

surgical  treatment.  Alfred  S.  Tay- 
lor.    P.  628. 

Chronic  patient,  Challenge  of,  to  med- 
ical profession.  Joel  E.  Goldthwait. 
P.  415. 

Cineplastic  surgery  of  upper  extremi- 
ty.    F.  M.  Cadenat.     P.  176. 

Circulatory  disturbances  of  feet.  Emil 
S.  Geist.     P.  646. 

Club-foot  operation.    Gaugele.    P.  831. 

,  Treatment  of  neglected  cases 

of.     A.  Paynter  Noall.     P.  406. 

Contractures,  arthrogenetic,  of  knee, 
Treatment  of,  with  partial  alcoholi- 
zation of  sciatic  nerve.  Dario 
Maragliano.     P.  632. 

Coraco-clavicular  articulation,  Three 
cases  of,  observed  in  living.  F. 
Frasseto.     P.   184. 

Coxa  vara.     Rene  Bloch.    P.  847. 


INDEX  TO  VOLUME  XX. 


Coxalgia,  Tuberculous,  in  adult:  dry 
caries  of  hip.  Maurice  Patel.  P. 
401. 

D 

Dislocation,  complete,  irreducible,  con- 
genital, of  patella,  Operation  for. 
Albert  Mouchet  and  Jacques  Du- 
rand.     P.  841. 

Dislocations  and  fracture-dislocations 
occurring  at  the  acromio-clavicular 
articulation.  R.  W.  McNealy.  P. 
622. 

Dupuytren's  contracture,  End-results 
of  operation  for.  A.  Bruce  Gill. 
P.  851. 


Elbow,  Observations   based  on   study 

of  injury  to.     Isidore  Cohn.     P.  191. 
Epicondylitis   of   athletes.     Tavernier. 

P.  845. 
Equino  varus  in  new-born,  Method  of 

prolonged  retention  in  treatment  of. 

Lucien   Michel.     P.  832. 


Feet,  Injuries  of.  U.  V.  Portmann 
and  F.  C.  Warnshuis.     P.  190. 

Finger  nails,  Changes  in,  after  rheu- 
matic fever  and  tuberculosis.  Wil- 
liam H.  Rosenau.     P.  852. 

Fingers,  Stiff.  F.  J.  Cotton  and  E.  J. 
Sawyer.     P.  630. 

Fracture  and  dislocation  of  cervical 
vertebrae  without  paralysis.  W.  E. 
Hartshorn.     P.  621. 

of   clavicle,    Treatment   of,   by 

continuous     traction.       Burian.       P. 
618. 

of   neck   of   femur.     S.    Klein- 


berg.     P.  403. 

of  scaphoid  of  foot.    A.  Rosen- 


berg.    P.  403. 

Fractures,  certain,  of  femur,  humerus, 
and  forearm,  Operative  treatment  of. 
E.  W.   Ryerson.     P.  842. 

,  false,  of  femoral  neck,  Diag- 
nosis of.     Bloch.     P.  618. 

-,  metatarsophalangeal,  Report  of 


twenty-seven   cases.     A.   G.   Bolduc. 
P.  839. 

-,  Mechanics  of.     Fractures  from 


shearing    forces.      C.    Ghillini.      P. 
620. 

near    joints,    Management    of. 


P.  H.  Kreuscher.     P.  621. 

of     bones,     Certain    problems 


Fractures  of  forearm,  Mechanics  and 
treatment  of.  Paul  B.  Magnuson. 
P.  841. 

of    long    bones,    Influence    of 

physical  therapy  in  reducing  time  of 
disability  in.  Jonathan  M.  Wain- 
wright.     P.  405. 

of  metacarpals  and   phalanges 


of    fingers,    Treatment    of.       R.    D 
Wheeler.     P.  623. 

-,  Old  os  calcis.     Fred  J.  Cotton 


P.  402. 

■  Pathological.     E.  A.  Codman. 

P.  839. 

Physiotherapy  in  after-care  of. 


H.  E.  Stewart.     P.  842. 

recent,   Treatment  of.      Frank 


E.  Peckham.     P.  842. 
Fragilitas  ossium.     Edgar  A.  Vander 
Veer  and  Arthur  M.  Dickinson.     P. 
408. 


Ganglion  of  wrist  region.     H.   P.    H. 

Galloway.     P.  407. 
Genu    valgum,    Origin    of,    from    pes 

valgus.      Elizabeth    E.   Schmidt.     P. 

189. 
Gout,     Humoral     syndrome     of.        A. 

Chauffard.     P.  847. 

H 
Hip,  Anatomic  evolution  of,  after  re- 
duction of  congenital  luxations. 
Broca  and  d'Intignano.  P.  413. 
dislocation,  Retention  of  diffi- 
cult cases  of,  by  intracapsular  injec- 
tions of  alcohol.  H.  Graetz.  P. 
192. 

joint,  Case  of  bilateral  disloca- 


concerning.      Charles    M.    Scudder. 
P.  404. 


tion  of.     Walter  G.  Stern.     P.  190. 
Hydrarthrosis,    Intermittent.       A.    L. 

Nielson.     P.  639. 
Hypophysis,     Congenital     deformities 

and  anomalies  of,  in  a  twin.     Nino 

Samaja.     P.  627. 


Infectious  arthritis,  Chronic:  statisti- 
cal report  with  end-results.  Frank 
Billings,  George  H.  Cole,  and  Wil- 
liam S.   Hibbs.     P.  834. 

Intermittent  claudication  due  to  car- 
diac hypoplasia.     Serko.     P.  852. 

J 

Joints,  Research  on  development  of. 
Giulio  Faldino.     P.  644. 


INDEX  TO  VOLUME  XX. 


K 

Knee,  Permanent  results  of  operation 
on  semilunar  cartilages  of.  .  Bau- 
mann.     P.   178. 

Kohler's  disease.  George  I.  Bauman. 
P.  180. 


Lengthening,   Experimental,   of   limbs. 

O.   Nuzzi.     P.  634. 
Loose    bodies    in    joints.       A.    G.    T. 

Fisher.     P.  201. 

M 
Madelung's       deformity       of       wrist. 

Brandes.     P.   830. 
Mobilization,    Methodic,    in    treatment 

of    articular    affections.      Kouindjy. 

P.  630. 
Myositis  ossificans,  traumatic,  Case  of. 

S.  L.  Bhatia.     P.  842. 
Myxoma,    Joint.      G.    Bolognesi.      P. 

635. 

N 
Nerve    injuries,    Treatment    of    irrepa- 
rable.    R.  E.  Harris.     P.  412. 


Orthopaedic  surgery,  Report  of  prog- 
ress in.  M.  N.  Smith-Petersen.  P. 
853. 

Osteitis  deformans,  Fracture  in.  J. 
Anderson    Smith.      P.   844. 

fibrosa  of  os  calcis  as  cause  of 

typical   calcaneitis.      H.  J.    Bettman. 
P.  846. 

Traumatic,  of  wrist.     Mark  H. 


Rogers.     P.  844. 
Osteo-arthropathy,       late       hereditary 

syphilitic,   Contribution  to  study  of. 

Miginiac  and  Cadenat.     P.  837. 
Osteochondritis     deformans     juvenilis 

of    hip.      Lance,    Andrieu    and    Cap- 

pelle.     P.  848. 
,    Infantile   deforming,   of   upper 

femoral    epiphysis.       Feutelais.       P. 

201. 

of     hip,     Atypical     forms     of. 


Nove-Josserand.     P.  853. 

of  hip,  or  coxa  plana.    F.  Calot 


and  H.  Colleu.     P.  416. 

of  ribs   following  typhus   fever 


and    its    treatment    by    injections    of 
iodine.      Nadine    Dobrovolskaia.      P. 
643. 
Osteochondromata,  Multiple.     Bernard 
Pierre   Widmann.     P.   205. 


Osteomata  of   brachial  triceps.     Mas- 

sart.     P.  636. 
Osteomyelitis,    Acute.     A.    Cohn.      P. 

643. 
,  Clinical  study  of  pathology  of. 

A.  Gibson.     P.  409. 

Hemorrhagic.     Ernest  H.  Ar- 


nold.    P.  409. 

of     adolescent     long     bones, 


Growth    problems    following.      Kel- 
logg Speed.    P.  850. 

-,  Sclerosing  non-suppurative,  as 


described     by-    Garre.       S.     Fosdick 
Jones.     P.  179. 
Osteotomy,  Results  of  supra-condylar, 
in     flexion     contractures     of     knee- 
joint.     L.  Aubrey.     P.   175. 


Paget's    disease.      Babonneix,    Denoy- 
elle,  and  Perisson.     P.  638. 

Paralysis,  Birth.     H.  Piatt.     P.  406. 

,     Deltoid,     and    arthrodesis     of 

shoulder-joint.      George    F.    Straub. 
P.  834.    . 

in  children  due  to  bite  of  wood- 


ticks.     P.   D.   McCormack.     P.    198. 
plexus,  of  new-born,   Etiology 


of.     Weil.     P.   199. 

-,   Postdiphtheritic.     T.  J.   Elter- 


ich.     P.  833. 

Patella  bipartita.  Hans  Blencke.  P. 
830. 

Pelvic  muscles,  shortened,  Some  ob- 
servations on  static  influence  of. 
John  Joseph  Nutt.     P.  203. 

Pelvis,  Leveling  (balancing),  in  cases 
of  inequality  of  length  of  legs,  with 
description  of  pathognomonic  sign. 
Philip  Lewin.     P.  631. 

Pes  adductus,  congenital,  Contribu- 
tion to  pathology  and  therapy  of. 
W.  Jareschy.     P.  186. 

Poliomyelitis,  Diagnosis,  prognosis, 
and  early  treatment  of.  Robert  W. 
Lovett.     P.  833. 

Postoperative  treatment  in  certain 
surgical  procedures  on  upper  ex- 
tremity.    Arthur  Steindler.     P.  635. 

Pott's  disease,  Hysterical.  Feutelais. 
P.  846. 

Pseudo-coxalgia  (osteochondritis  de- 
formans juvenilis  coxae:  quiet  hip 
disease).     Harry   Piatt.     P.  639. 

Pseudo-paraplegia  resulting  from 
double  tabetic  arthropathy  of  hips. 
Andre  L6ri  and  Lerond.     P.  647. 


INDEX   TO  YOU    ML    XX. 


Rachitic  deformities  of  thorax,  Etio- 
logical  treatment  of.  R.  Boeckh. 
P,   187, 

Radiographing  spine  and  pelvis,  The- 
sis upon  subject  of.  H.  J.  Suggars. 
P.  853. 

Radius,  Dislocation  of,  forward  at  in- 
ferior radio-ulnar  joint.  L.  Rogers. 
P.   191. 

Raynaud's  disease,  Treatment  of,  with 
thyroid  extract.  Edwin  W.  Hirsch. 
P.  408. 

Rheumatoid  arthritis,  Two  cases  of. 
A.   Mackenzie  Forbes.     P.  835. 

Rickets,  Etiology  of.  G.  Bruton 
Sweet.     P.  409. 

,     Experimental,     in     rats.        V. 

Korenchevsky.     P.  848. 

Roentgen-ray  therapy  in  chronic  dis- 
eases of  bones,  joints,  and  tendons. 
Herman  B.  Philips  and  Harry 
Finklestein.     P.   181. 


Sacro-iliac  joint,  Dislocation  of.  Alex- 
ander Gibson.     P.  190. 

Sacro-iliac  sprain-  E.  D.  Martin.  P. 
622. 

Sarcoma  of  long  bones.  H.  W.  Mey- 
erding.     P.  637. 

Scaphoid  bone  of  foot,  Isolated  dis- 
ease of.     A.  S.  Risser.     P.  641. 

Schlatter's  disease  and  frequent  symp- 
toms of  late  rickets.  Bernard  Hin- 
richs.     P.  188. 

Sciatica,  Treatment  of  so-called.  J. 
A.  Nutter.     P.  851. 

Scoliosis,  Is  operative  treatment  of, 
possible?     H.  Hoessly.     P.   183. 

; ,  Result  of  extensive  rib  resec- 
tion on  concave  side  in  severe. 
Fritz  Lange.     P.  182. 

structural,    Treatment    of.    at 


Massachusetts      General      Hospital. 
Armin    Klein.     P.  646. 

-,     Treatment     of     sharp     costal 


gibbosity  in,  by  open  operation  as 
supplement  to  orthopaedic  treat- 
ment. Gaudier  and  Swynghedauw 
P.  181. 


Semilunar  cartilage  of  knee,  Note  on 
injuries  to.  James  Eaves  and  Pau! 
Campiche.      P.   405. 

Shoulder,  congenita]  elevated,  Opera- 
tive treatment  of,  according  to  Koe- 
nig.     Grauhan.     P.  831. 

Shoulder-joint,  Diagnosis  and  treat- 
ment of  some  common  injuries  of. 
Robert  W.  Lovett.     P.  844. 

-,  Observations  on  normally  de- 


veloping.    Isidore   Cohn.     P.  415. 

Spina  bifida  occulta,  Progressive  foot 
deformities  in.     L.   Roeren.     P.   184. 

Spine  and  ribs,  Congenital  anatomic 
defects  of.  James  Warren  Sever. 
P.  832. 

Subacromial  luxation,  Bilateral,  of 
humerus  by  muscular  action  in  epi- 
lepsy.    Costantini.     P.  619. 


Tarsal  scaphoid,  Disease  of,  in  young 
children.     Abrahamsen.     P.    180. 

Tennis  elbow.     L.  Cooke.     P.  842. 

Thumb,  Plastic  substitution  of.  Per- 
thes.    P.  174. 

Tibial  tubercle,  Two  unusual  cases  of 
injury  to.  James  Warren  Sever.  P. 
622. 

Tuberculosis,  joint,  Early  diagnosis 
and  treatment  of.  J.  T.  O'Ferrall. 
P.  616. 

of  patella,   Extra-articular.     G. 

Jean.     P.  401. 

of  upper  extremity.     Giovanni 


Valtancoli.     P.  616. 

so-called    surgical,    Conserva- 


tive treatment  of.     A.  Bier.     P.  195. 

,    Statistics    of    bone   and   joint, 

in   last    five   years.     L.    Frosch.      P. 
192. 

-,    surgical,    Operative    treatment 


of.     F.  Koenig.     P.  194. 

Tuberculous  spondylitis,  Operative 
treatment  of.     Bachlaender.     P.  850. 

Whitman  abduction  splints,  Mechani- 
cal  device   to   facilitate   handling  of 

«  patients  in.  O.  F.  Schussler.  P. 
622. 

Writers'  cramp:  its  cause  and  cure 
W.  H.  Bates.    P.  414. 


Vol.  IV,  No.   1  JANUARY,   1922  ™  £*; ., 


The  Journa 
Bone  &  Joint  Sur 


ARMY   EXPERIENCES   WITH   TENDON    TRANSFERENCE. 

BY    CLARENCE   L.    STARR,   M.D.,    TORONTO,    CANADA. 

In  civilian  practice  previous  to  the  recent  Great  War,  attempts  at 
restoration  of  function  by  muscle  transference  had  been  very  largely 
limited  to  the  lower  extremity. 

This  was  probably  due  to  the  fact  that  all  movements  of  the  upper 
extremity,  particularly  in  the  forearm  and  hand,  are  so  complicated 
and  exact,  and  the  muscles  controlling  these  movements  so  numerous, 
that  it  did  not  appear  feasible  so  to  adjust  the  transferred  muscles  that 
these  finer  and  essential  movements  might  be  preserved.  The  war,  how- 
ever, brought  the  surgeon  face  to  face  with  a  problem  never  before 
encountered  in  any  such  wholesale  fashion,  and  when  the  great  group 
of  cases  presented  themselves  with  deformed  and  disabled  limbs  due 
to  irreparable  nerve  injuries,  necessity  proved  the  stimulus  required 
and  for  the  most  part  these  disabilities  have  been  overcome,  and  use- 
less members  have  been  changed  to  functioning  ones  more  or  less 
perfect. 

In  some  cases  the  end-results,  so  far  as  the  restoration  of  function 
is  concerned,  are  so  nearly  perfect  that  one  feels  that  so  good  a  sub- 
stitute has  been  provided  in  such  irreparable  peripheral  nerve  lesions 
as  to  make  it  a  matter  of  small  concern  if  a  purely  motor  nerve  were 
restored  or  not. 

The  function  of  a  limb  also  may  be  often  restored  in  eight  or  ten 
weeks  by  muscle  transference  which  could  not  be  procured,  if  nerve 
suture  were  successful,  in  less  than  twelve  to  eighteen  months. 


CLARENCE   L.   STARR 


action  depending  upon  ^  je— ^  nc^  pow  is  - 
so  successfully  met  as  J£  wher-  fa £ range^ ^  ^  ^  rf  ^ 
without  great  power.     For  this  rea*°  „,ccessM  than  the  reverse. 

forearm  to  the  extensor  group  is  much  ^ore  "™  nearly  so,  due  to 

Loss  of  function  of  the  hand  -«£££££££  comparatively 
loss  of  balance,  even  though  teP^  rf  ^  forearm 

small  group  of  muscles  and  ^P**™*  exemplified  in 

remain  active  and  capable  of  j™ctl^  -x  or        terior  inter- 


sible  to  use 

due  to  the  lack  of  balance. 


due  to  the  lack  ot  balance.  -ttfflrrot  a  redistribution 

he  secured.    That  these  principles  are  n  t  f nil '  ™"££^  several 

^  Tot;  -  PO^muXhaving  similar  action  to  the  ones  they 
ar\o  replace  should  be' used,    mile  it  is  perfectly  true  that  a  muscK 
havng  a'diametrieally  opposite  action  to  the  one  it  is  to  repln  e   may 
be  transferred  and  trained  to  functionate   automatically  in  its  new 
LpS,  yet  it  is  obvious  that  a  much  shorter  period  of  training  will  be 
necessary  and  a  better  nltimate  function  will  be  obtained,  if  one  of  sim- 
ilar action  is  transferred.  For  example,  one  of  the  extensors  of  the  wrist, 
the  extensor  carpi  radialis  longior,  may  be  transferred  to  the  long  ex- 
tensor of  the  thumb  and  learn  to  perform  the  function  of  a  thnmb 
extensor  in  a  very  few  weeks,  whereas  a  flexor  of  the  wrist  so  trans- 
ferred, will  require  a  long  period  of  patient  training. 

2  If  only  a  portion  of  a  tendon  is  to  be  transferred  «t  must  have 
the' same  action  as  the  muscle  it  is  to  replace.  Using  the  preceding 
example  it  is  perfectly  feasible  to  transfer  half  of  the  tendon  of  the 


ARMY   EXPERIENCES   WITH    TENDON    TRANSFERENCE  O 

extensor  carpi  radialis  longior  to  the  long  extensor  of  the  thumb  and 
obtain  good  results.  On  the  other  hand  it  is  hopeless  to  expect  to 
transfer  half  of  the  flexor  of  the  wrist,  say  the  flexor  carpi  radialis 
to  the  extensor  of  the  thumb  and  expect  any  results.  That  would  be 
asking  a  muscle  to  perform  two  opposing  actions  at  the  same  time, 
yet  this  very  operation  is  described  in  a  recent  paper  and  good  re- 
sults are  reported.  An  even  more  gross  impossibility  is  reported  in 
another  paper  where  a  section  of  the  tendo  Achillis  is  split  from  its 
outer  side  and  carried  forward  to  an  insertion  into  the  peroneus  longus 
and  a  second  section  taken  from  the  inner  side  similarly  carried  for- 
ward to  the  tibialis  anticus,  the  remaining  section  remaining  attached 
to  its  normal  insertion  into  the  os  calcis.  A  stabilized  or  balanced 
foot  is  reported.  This  is  obviously  incorrect  and  serves  no  other  pur- 
pose than  to  bring  a  good  operation  into  disrepute  by  asking  it  to  do  the 
impossible. 

3.  The  line  of  pull  should  be  as  straight  as  possible  for  mechan- 
ically the  muscle  will  work  more  efficiently  if  the  line  between  its 
origin  and  its  new  insertion  is  a  straight  line.  This  necessitates  long 
incisions  and  care  to  see  that  the  tendon,  which  winds  obliquely  around 
the  arm,  for  instance,  is  not  widely  deviated  by  any  hindering 
structures. 

4.  The  fixation  of  the  transferred  muscle  should  be  with  a  good 
deal  of  tension.  This  will  take  up  any  slack  due  to  straightening  out 
of  the  line  of  pull  when  such  line  has  not  been  perfectly  straight  at 
time  of  operation.  It  also  allows  for  a  little  slipping  which  often  takes 
place  at  the  point  of  fixation.  The  position  of  the  member  to  be  con- 
trolled therefrom  should  be  one  of  considerable  over-correction  when 
the  transfer  is  made. 

Our  lack  of  experience  in  earlier  cases  showed  poorer  results,  due  to 
neglect  of  this  principle,  than  the  later  cases  where  it  was  carefully 
observed. 

5.  Any  deformity  due  to  contraction  of  tissues  should  be  overcome 
before  transfer  of  muscles  is  attempted.  A  group  of  cases  has  been 
seen  by  the  writer,  in  which  the  best  results  were  not  obtained  be- 
cause of  failure  to  secure  the  necessary  correction  of  deformity  before 
operation  for  tendon  transference. 

6.  Tendons  may  be  transferred  to  a  new  position  by  utilizing  the 
sheath  of  the  muscle  to  be  replaced  and  threading  the  new  tendon 
down  the  sheath,  but  for  the  most  part  transferred  tendons  should 
run  in  the  fatty  subcutaneous  tissue. 


6  CLARENCE    L.    STARR 

7.  In  the  lower  extremity  it  is  a  common  experience  that  tendons 
transferred  should  he  inserted  into  bone  or  periosteum.  In  the  upper 
extremity  the  attachment  of  tendon  to  tendon  has  been  quite 
satisfactory. 

8.  Care  should  be  taken  to  adequately  fix  tendon  to  tendon,  as  a 
good  many  cases  have  failed  and  required  subsequent  reoperation  be- 
cause the  union  has  slipped.  In  our  experience  the  recipient  tendon 
should  be  slit,  the  transferred  tendon  denuded  of  its  sheath  by 
scraping  thoroughly,  and  macerating  somewhat,  by  Kocher  forceps. 
This  tendon  is  then  threaded  through  the  slit  in  the  recipient  tendon 
or  tendons,  sutured  in  two  places  and  either  buried  in  it  or  turned 
back  and  stitched  to  itself. 

The  suture  material  we  have  found  most  satisfactory  is  linen,  and 
in  no  case  have  we  had  any  infection  which  could  be  traced  to  this 
cause  and  in  no  case  have  the  sutures  been  extruded. 

Catgut  will  not  stand  the  strain  of  attempted  movement  at  the  end 
of  three  weeks  as  seems  essential  to  get  best  results. 

9.  The  limb  must  be  placed  in  a  splint,  preferably  of  plaster  of 
Paris,  and  all  motion,  which  would  strain  the  suture  linen,  prevented 
for  three  weeks.  Then  a  removable  splint  is  substituted  and  removed 
daily  for  training. 

The  training  should  be  in  the  hands  of  an  expert  who  has  a  thor- 
ough knowledge  of  anatomy  and  who  has  seen  the  operation  performed, 
so  as  to  be  able  to  appreciate  the  aims  of  the  surgeon.  At  the  end 
of  two  months  all  splints  may  be  discarded. 

By  far  the  greatest  number  of  cases  of  muscle  transference  in  the 
army  has  been  for  irreparable  injury  of  the  musculo-spiral  nerve.  The 
best  results  have  also  been  obtained  in  this  injury,  probably  because 
this  nerve  is  for  the  most  part  a  purely  motor  nerve  and  the  remain- 
ing disability  from  anaesthesia  is  negligible,  and  partly  because  the 
power  required  to  overcome  the  disability  is  really  only  that  necessary 
to  overcome  gravity.  The  technique  of  operation  for  this  disability 
will  serve  as  illustrative  of  all.  The  object  of  operation  is  to  restore 
the  extensor  function  of  the  thumb,  wrist,  and  fingers. 

The  arm  is  prepared  in  the  usual  way  and  painted  with  iodine 
from  above  the  elbow  to  the  finger  tips.  The  whole  forearm  is  left 
exposed  by  the  draping.  An  incision  about  five  inches  long  is  first 
made  on  the  palmar  aspect  of  the  forearm  between  the  tendons  of  the 
flexor  carpi  radialis  and  the  palmaris  longus  ending  at  the  wrist 
The  exposed  tendons  are  carefully  freed  from  their  sheaths  well  up 
to  the  middle  of  the  forearm.    To  avoid  injury  to  the  tendons  they  are 


ARMY   EXPERIENCES   WITH    TENDON    TRANSFERENCE  7 

only  handled  at  the  points  of  their  insertion.  The  tendons  are  then 
divided  at  their  insertion  and  the  skin  edges  clipped  together.  A  long 
incision,  seven  or  eight  inches  long,  is  made  on  the  dorsal  aspect  of 
the  forearm  following  a  line  from  the  external  condyle  of  the  humerus 
to  the  styloid  process  of  the  radius  with  the  hand  prone.  The  incision 
ends  in  a  slight  hook  at  its  lower  end  to  thoroughly  expose  the  ex- 
tensor tendons  of  the  thumb.  This  incision  is  made  through  the  skin 
and  deep  fascia,  exposing  the  muscles.  All  haemorrhage  should  be 
controlled  by  clipping  superficial  veins,  and  if  this  is  thoroughly  done 
no  further  bleeding  of  moment  will  be  encountered.  We  believe  bet- 
ter results  are  obtained  if  no  tourniquet  is  used,  and  of  course  one 
eliminates  the  danger  of  temporary  paralysis  from  pressure.  If  this 
incision  is  properly  placed,  it  immediately  overlies  the  septum  between 
the  radial  extensors  of  the  wrist  and  the  extensor  communis  digitorum. 
With  sponge  pressure  or  blunt  dissection  the  bellies  of  these  muscles 
ere  separated  down  to  the  radius  at  the  upper  end  of  the  incision. 
This  exposes  directly  the  oblique  insertion  of  the  pronator  radii  teres 
into  the  outer  surface  of  the  radius. 

This  insertion  is  completely  freed  with  a  periosteal  elevator  taking 
the  periosteum  with  it.  By  blunt  dissection  it  should  be  determined 
that  this  muscle  insertion  is  absolutely  free,  otherwise  it  will  not  act 
freely  in  its  new  capacity. 

The  extensors  carpi  radialis  longior  and  brevior  are  stabbed  and 
the  freed  end  of  the  pronator  teres  is  threaded  through  from  the 
deep  surface  and  its  periosteal  ending  sutured  to  the  aponeurotic  sur- 
face of  these  muscles.  The  tag  ends  should  be  buried  by  a  Lembert 
type  of  suture  so  as  to  leave  the  surface  smooth.  The  tendons  of  the 
common  extensor  to  the  fingers  are  freed  from  their  sheath  above  the 
annular  ligament  and  the  separate  sheath  of  the  extensor  minimi 
digiti  opened  so  as  to  bring  all  four  tendons  together.  The  three  ex- 
tensors of  the  thumb  are  next  exposed  as  they  pass  obliquely  around 
the  lower  end  of  the  radius.  The  long  extensor  of  the  thumb  is  lifted 
from  its  separate  tunnel  and  brought  alongside  the  extensor  ossis 
metacarpi  and  the  primary  extensor  of  the  thumb.  Next,  the  fat  of 
the  subcutaneous  tissue  is  tunnelled  obliquely  between  the  upper  end 
of  the  palmar  incision  and  the  lower  end  of  the  dorsal  incision,  and 
the  flexors  are  brought  through  this  tunnel  so  as  to  give  a  straight, 
pull.  The  three  exposed  extensors  of  the  thumb  are  slit  and  the  pal- 
maris  longus,  after  being  denuded  of  sheath  and  all  areolar  tissue,  is 
threaded  through  all  three,  and  stitched  to  each  in  order,  with  suffi- 
cient tension  to  keep  the  thumb  extended. 


8  CLARENCE  L.   STARR 

The  four  common  extensor  tendons  are  similarly  slit  and  the  pre- 
pared flexor  carpi  radialis  threaded  through,  suturing  securely  when 
it  passes  through  each  slit.  The  end  of  the  transferred  tendon  may 
be  buried  in  the  extensor  minimi  digiti  or  turned  back  on  itself  and 
stitched  to  each  tendon  in  turn  and  then  to  itself.  The  fingers  and 
wrist  must  be  kept  in  position  of  hyperextension  during  this  proced- 
ure. No  attempt  is  made  to  suture  the  fascia  on  either  surface  of  the 
arm,  but  an  attempt  is  made  to  cover  exposed  sutures  of  tendons  with 
the  subcutaneous  fat  by  bringing  skin  edges  together  with  a  subcutane- 
ous suture.  A  plaster  of  Paris  splint  is  put  on  over  a  sufficient  dress- 
ing and  left  for  three  weeks. 

In  all,  about  three  hundred  cases  have  been  operated  upon  'by  tendon 
transference,  for  various  disabilities,  in  the  Dominion  Orthopaedic  Hos- 
pital, Toronto.  The  general  impression  formed  as  to  results  is  that 
they  are  nearly  perfect  in  the  great  majority  of  cases,  and  where  the 
results  are  only  fair  it  is  usually  due  to  the  fact  that  limited  move- 
ments of  joints  have  not  been  entirely  overcome,  or  that  the  tendon 
fixation  has  slipped.  In  other  words,  the  failure  to  secure  perfect 
iesult  is,  in  nearly  all  instances,  due  to  a  fault  which  might  have  been 
overcome. 

It  has  been  difficult  to  get  a  final  report  in  a  great  many  of  these 
cases,  but  the  attached  report  shows  end-results  in  52  cases  in  which 
a  recent  examination  was  possible. 

The  results  collected  are  seen  to  be  after  periods  varying  from  three 
months  to  2%  years. 

They  are  summarized  as  follows :  Excellent,  29 ;  good,  15 ;  fair,  7 ;  fail- 
ure, 1.    Total,  52. 

In  results  classed  as  excellent  the  patients  are  able  to  perform  any 
function  which  they  could  before  the  injury,  with  the  exception  of 
having  somewhat  lessened  power. 

In  results  classed  as  good,  function  is  restored  but  movements  are 
not  quite  as  free  as  normal  and  power  somewhat  lessened. 

In  results  classed  fair,  a  great  improvement  is  obtained,  but  motion 
is  restricted  and  power  limited. 

Only  one  failure  is  noted,  case  of  Lieut.  F.,  and  the  report  shows 
that  a  number  of  other  factors  enter  into  this  result. 

The  metacarpophalangeal  joint  and  all  the  tendons  to  the  thumb 
were  injured  and  an  attempt  was  made  to  establish  both  flexion  and 
extension. 


ARMY   EXPERIENCES   WITH    TENDON   TRANSFERENCE 


Pron.   Teres  to  Ext. 
Carp.  Rad.  L.  and  B. 


Flex.    Carp.   Had.    to 
Ext.  Dig.  Com. 

Palm.  Long,   to 

Thumb  tendons. 


Fig.  1.— Diagram  of  the  operation  of  tendon  transference  for  irreparable 

culospiral  injuries. 


10  CLARENCE   L.   STARR 


"SUMMARY  OP  THE  RESULTS  OBTAINED  PROM  OPERATIONS  FOR  TENDON 
TRANSFERENCES.  DAVISVILLE  AND  D.  O.  H. AUGUST,  1918,  TO  NOVEM- 
BER,   1920. 

Note. — Under  "Type  of  Operation"  the  term  "Complete  trans- 
ference" means  a  transfer  as  follows:  Pronator  Teres  to  Ext.  Carp. 
Rad.  L.  &  B.;  Palm.  Long,  to  Abduct.  Poll.  Long.,  Ext.  Poll.  Brev.; 
Flex.  Carp.  Rad.  to  Ext.  Poll.  Long.,  Ext.  Dig.  Com. 

Number  91178:  Rank — Gunner.  Type  of  Injury — Irreparable  mus- 
culo spiral  lesion,  Rt.  Type  of  Operation — Complete  transference.  No 
Palm.  Long.,  hence  Flex.  Carp.  Rad.  split.  End-Results — 2%  years 
after  operation,  functional  result  excellent.  Has  worked  as  a  carter 
since  discharge  without  having  to  stop  work.  Anatomical  result  fair. 
Can  extend  hand  from  full  flexion  to  180°.  Can  fully  extend  fingers 
when  wrist  is  at  180°.  Can  abduct  thumb  clear  of  wrist.  Movements 
are  free  and  strong.    (See  Fig.  2) 


Fig.  2.— Case  No.  91178. 

Number  10916:  Rank — Private.  Type  of  Injury — Irreparable  mus- 
culo spiral  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results— 2y2  years  after  operation,  functional  result  excellent. 
Uses  hand  for  everything.  Drives  a  car.  States  that  function  is  per- 
fect. Anatomically, — Can  extend  wrist  from  full  flexion  to  210°.  Does 
not  extend  the  fingers  well.  These  remain  flexed  on  hand  at  an  angle 
of  about  150°.  Thumb  just  clears  the  carpus.  Wrist-drop  is  perma- 
nently cured. 


ARMY    KXl'KKIKNCKS    WITH    TKNDO.N    TRANSFERKXCH 


11 


Number  663144:  Rank — Private.  Type  of  Injury — Irreparable 
musculo  spiral  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 2%  years  after  operation.  Functional  result  excellent. 
Uses  arm  for  everything,  including  heavy  work.  Spent  some  time  as 
a  laborer  grinding  rail  joints.  Anatomically — Can  extend  wrist  from 
full  flexion  to  210°.  Can  extend  fingers  separately  from  wrist.  Thumb 
clears  hand. 


Fig.  3.— Case  No.  291383. 


Number  407716:  Rank — Sergeant.  Type  of  Injury — Irreparable 
M.  S.  lesion,  Lt.  Gas  gangrene  with  extensive  adhesions  of  tendons 
to  sheaths.  Type  of  Operation — Complete  transference.  End-Results 
— 2%  years  after  operation.  An  astonishingly  perfect  result.  Hand 
is  quite  as  useful  as  before  injury.  Strength  only  is  subnormal  and 
that  slightly.  Can  extend  wrist  from  150°  to  210°.  Can  extend  fin- 
gers fully  with  wrist  at  extreme  of  extension.  Can  abduct  thumb  well. 
It  is  hard  to  tell  the  hand  from  normal. 


12  CLARENCE  L.  STARR 

Number  745202:  Bank — Private.  Type  of  Injury— Irreparable 
muse,  spiral  lesion.  Type  of  Operation—Complete  transference.  Palm. 
Long,  absent.  Flex.  Carp.  Rad.  split.  End-Results — Three  months 
after  operation.  Fair  result.  Extends  fingers  to  straight  line.  Ab- 
duct thumb  well.     Extends  wrist  20°. 

Number  192480:  Bank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Lt.  Type  of  Operation— Complete  transference. 
End-Results — 13  months  after  operation.  Result  is  not  very  good. 
Operation  was  hampered  by  numerous  and  extensive  limitations  of 
movements  of  shoulder,  elbow  and  wrist.  Range  of  movement  of  wrist 
small.  A.  G.  F.,  155.  A.  G.  E.,  180.  Thumb  just  clears  hand.  Marked 
limitations  of  movements  of  fingers. 

Number  291383:  Rank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 3  months  after  operation.  Excellent  result.  All  move- 
ments of  left  hand  normal  in  range  but  subnormal  in  strength.  A. 
G.  P..  wrist,  145.  A.  G.  E.,  213°.  Extends  fingers  well  and  abducts 
thumb.    (See  Fig.  3) 

Number  445761 :  Rank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 2  years  after  operation.  Excellent  functional  result. 
Has  worked  continuously  since  discharge.  Hospital  orderly.  Ana- 
tomically— Can  extend  wrist  from  full  flexion  to  180°.  Cannot  get  be- 
yond this.  Fingers  can  be  maintained  in  full  extension  when  wrist 
is  at  180°.     Thumb  is  abducted  well. 

Number  709874:  Rank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Lt.  Type  of  Operation — Complete  transference. 
Palm.  Long,  absent.  Hence  Flex.  Carp.  Rad.  split.  Because  of  fail- 
ure to  develop  extension  of  wrist,  the  wound  was  reopened  in  two 
months'  time  and  the  Pron.  Teres  found  to  be  sutured  to  fascia  and 
not  to  Ext.  Carp.  Rad.  This  was  corrected  with  an  excellent  result. 
End-Results — 21/4  years  after  operation.  Excellent  functional  result, 
though  anatomically  it  is  only  fair.  Worked  for  some  time  as  a  moulder, 
but  had  to  give  this  up  because  of  weakness  of  forearm.  Can  do  any- 
thing not  demanding  strength.     Anatomically — Flexion   full.     Exten- 


sa. 4.— €ase  No.  174108. 


ARMY  EXPERIENCES  WITH  TENDON  TRANSFERENCE  13 

sion  to   170°.     Fingers  can  be  extended  fully.     Thumb   is  abducted 
clear  of  hand. 

Number  i74108  :  Rank — Private.  Type  of  Injury — Irreparable 
post,  interosseous  lesion,  Rt.  Type  of  Operation — Modified  transfer- 
ence. Carpal  extensors  fixed  to  radius  and  ulna  by  Kang.  tend.  Flex. 
Carp.  Rad.  L.  to  Ext.  Dig.  Com.  and  Ext.  Poll.  Long.  Palm.  Long,  to 
Ext.  Poll.  Brev.  Abduct.  Poll.  Long.  End-Results — 2  months  after 
operation.  Moderately  successful.  Wrist  remains  well  extended  and 
fixed.  Extends  fingers  to  180°.  Can  use  hand  for  all  light  occupa- 
tions not  demanding  strength.    (See  Fig.  4) 

Number  802878:  Rank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results — 6  weeks  after  operation.  "Can  partially  extend  fingers. 
Has  nearly  normal  range  of  movement  in  thumb.  Wrist  is  fixed  in 
slight  hyperextension  with  slight  movement  accompanied  by  radial 
deviation."    A  case  discharged  very  early  after  operation. 

Number  730023:  Rank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 2%  months  after  operation.  Board  states,  "Has  good 
dorsiflexion  of  wrist  and  extension  of  thumb  and  fingers.  Only  de- 
fect is  in  decrease  in  strength." 

Number  772243:  Rank — Private.  Type  of  Injury — Irreparable 
post,  interosseous  lesion,  Lt. ;  also  irreparable  ulnar  lesion,  Lt.  Type 
of  Operation — Complete  transference,  leaving  wrist  without  any  pri- 
mary flexors.  End-Results — 1  year  after  operation.  Excellent  result, 
one  of  the  best  obtained.  The  hand  is  changed  from  one  presenting 
complete  musculo-spiral  and  ulnar  paralysis  to  a  complete  ulnar  le- 
sion only.  Wrist  movement— A.  G.  F.,  155.  A.  G.  E.,  215°.  Can 
extend  fingers  to  almost  the  straight  line  when  wrist  is  fully  extended. 
Extends  thumb  well. 

Number  231468:  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Lt.  Ischaemia.  Type  of  Operation — Complete  trans- 
ference. End-Results — 1  year  after  operation.  Result  poor.  Has 
almost  no  power  of  extension  of  wrist,  which  is  kept  in  a  slightly 
dropped  position.  Apparently  the  poor  result  was  due  to  widespread 
ischaemia  affecting  all  muscles  of  forearm. 

Number  513003:  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 6  months  after  operation.  Board  states:  "Flexion  all 
fingers  full.  Extension  all  fingers,  180°.  Thumb  can  be  fully  ex- 
tended.' '     No  note  on  movement  of  wrist. 

Number  193188:  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results — 13  months  after  operation.  Fair  result.  Extends  wrist 
35°  (A.  G.  F.,  190.  A.  G.  E.,  225).  Extends  fingers  moderately 
well.  Abducts  thumb  clear  of  flexing  fingers.  Function  is  impaired 
because  of  complicating  fibroses  of  firigers  and  injury  to  humerus.  (See 
Fig.  5) 


24  CLARENCE  l.  STARR 


Fig.  5.— Case  No.  193188. 

Number  955125:  Rank — L./Cpl.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.,  combined  with  complete  ulnar  lesion  and  anky- 
losis of  elbow  and  wrist.  Type  of  Operation— -Modified  transfer  be- 
cause of  ankylosed  wrist.  Flex.  Carp.  Rad.  to  Ext.  Dig.  Com.  Palm. 
Long,  to  Ext.  Poll.  Long.  End-Results — 2  months  after  operation. 
Moderate  range  of  movement  of  fingers.  Perfect  functional  result  is 
greatly  hampered  by  extensive  fibrosis  and  limitation  of  movements  of 
joints. 

Number :   Rank — Major.     Type  of  Injury — Irreparable  muse. 

spiral  lesion.  Type  of  Operation — Complete  transference.  End-Re- 
sults— 2  years  after  operation.  Excellent  result.  Wrist — A.  G.  F., 
125;  A.  G.  E.,  205.  Extends  fingers  normally.  Abducts  thumbs  well. 
Can  use  well  for  all  purposes  not  demanding  strength.  If  he  grasps 
very  strongly  the  hand  goes  into  flexion  due  to  the  stronger  flexors. 
Apart  from  this  the  hand  is  perfect. 

Number  475958  :  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results — 17  months  after  operation.  Fair  result.  Range  of  move- 
ment of  wrist  about  35°.  Extends  fingers  to  180°.  Abducts  thumo. 
Function  is  greatly  impaired  because  of  non-union  of  humerus. 

Number  730649  :  Rank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Lt.  Type  of  Operation — Complete  transference. 
Palm.  Long,  absent,  hence  Flex.  Carp.  Rad.  was  split.  End-Results — 
5  months  after  operation.  Moderately  good.  A.  G.  F.,  wrist,  160°. 
A.  G.  E.,  210°.  There  is  radial  deviation  on  extension.  Fingre-s — Ex- 
tension normal,  but  flexion  is  limited,   especially  at  metacarpo-phalan- 


ARMY   EXPERIENCES   WITH    TENDON    TRANSFERENCE 


15 


geal   joints,   so   that   fingers   cannot    touch    palm.      Power   grip    50% 
normal. 

Number  901431 :  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 4  months  after  operation.  Board  states,  ''Excellent  re- 
sult. Can  extend  fingers  and  thumb  well.  Dorsiflexion  of  wrist  is 
good.  Grip  is  %  normal.  Can  use  hand  for  all  ordinary  purposes 
although  it  is  a  little  clumsy  yet  in  finer  movements." 

Number  928504:  Rank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results — 4  months  after  operation.  Board  states:  "Can  dorsi- 
flex  wrist  20°.  Extends  fingers  fairly  well.  Extends  and  abducts 
thumb  well.  Power  is  one-fifth  normal.  Cannot  write  because  of  weak- 
ness of  power  of  extensors  of  wrist. 

Number  712981:  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 2  months  after  operation.  Board  states:  "Can  now 
extend  fingers,  extend  and  abduct  thumb,  and  has  slight  power  of  dorsi- 
flexion of  wrist." 

Number  858378  :  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 8  months  after  operation.  Board  states:  "Can  now  ex- 
tend wrist,  thumb  and  fingers  well." 

Number  709762:  Rank — Private.  Type  of  Injury — Irreparable 
muse  spiral  lesion,  Lt.  Type  of  Operation — Complete  transference. 
Palm.  Long,  absent.  Flex.  Carp.  Rad.  split.  End-Results — 4  months 
after  operation.  Board  states:  "Movement  of  finsrers  good.  Consid- 
erable limitation  of  wrist  movement."     (See  Figs.  6  and  7) 


Fig.  6.— Case  No.  709762. 

Number  2075444:  Rank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 7  months  after  operation.  Board  states:  "There  is 
now  good  dorsiflexion  of  wrist,  good  extension  of  fingers  and  abduction 
of  thumb." 


16 


CLARENCE  L.  STARR 


Fig.  7.— Case  No.  709762. 

Number  2256971:  Bank — Private.  Type  of  Injury — Irreparable 
muse,  spiral  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 6  months  after  operation.  Board  states:  "Can  now 
extend  fingers,  extend  wrist  and  extend  and  abduct  thumb  very  welL" 

Number  748684:  Bank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Besults — 2  months  after  operation.  Board  states:  "Excellent 
result.  Patient  can  extend  wrist,  extend  fingers,  extend  and  abduct 
thumb  very  well.  Power  of  the  hand  is  much  reduced.  Grip  is  about 
one-fifth  normal.  Has  very  good  use  of  hand  for  all  ordinary  light 
work."     (See  Fig.  8) 


Fig.  8.— Case  No.  748684. 


ARMY  EXPERIENCES  WITH  TENDON  TRANSFERENCE  17 

Number  3106024.  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results — 3  months  after  operation.  Board  states:  "25°  move- 
ment of  wrist.  Good  extension  of  fingers  and  abduction  of  thumb. 
Function  is  impaired  because  limitation  of  flexion  of  fingers  and  re- 
duced power  of  grasping/' 

Number  448710:  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results — 3  months  after  operation.  Board  states:  "Range  of 
movement  of  wrist  45°,  distributed  equally  on  either  side  of  mid-posi- 
tion. Extension  of  fingers  normal.  Abduction  of  thumb  90%  nor- 
mal.   Hand  is  weak."    Prints,  which  are  poor,  are  attached. 

Number  3130147:  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
Four  months  later,  exploration  of  wound  because  of  inability  to  ex- 
tend wrist,  revealed  suture  of  Pron.  Teres  to  Ext.  Carp.  Rad.  L.  &  B. 
had  slipped.  This  was  resutured.  End-Results — 1  year  after  opera- 
tion. Excellent  result  as  far  as  fingers  and  thumbs  are  concerned. 
Wrist  is  not  so  good.  Has  about  35°  of  flexion. — Extension  distributed 
either  side  of  mid-position,  rather  more  on  the  flexion  side  than  on 
the  extension. 

Number  246767:  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results — 8  months  after  operation.  Excellent.  Can  extend  wrist 
to  195°  from  almost  full  flexion.  Extends  fingers  and  extends  and 
abducts  thumb  well.  Can  use  hand  for  all  ordinary  light  work.  Its 
function  approaches  normal  except  in  strength. 

Number  733289:  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Residts — 7  months  after  operation.  Very  good  result.  Extends 
hand,  extends  fingers  and  extends  and  abducts  thumb  well.  Range 
movement,  wrist,    60°.    Uses  hand  for  all  light  movements. 

Number  26174.  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results — 7  months  after  operation.  Fair  result.  Sixty  degrees 
of  movement  at  wrist.  A.  G.  E.,  however,  is  only  180°.  Power  of  ex- 
tension of  wrist  is  weak,  so  that  he  still  drops  wrist  when  grasping 
objects.     Fingers  extend  well.     Function  is  improved. 

Number  444771;  Rank — Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Rt.  Type  of  Operation — Complete  transference. 
End-Results — 7  months  after  operation.  Fair  result.  Wrist — A.  G.  F., 
155;  A.  G.  E.,  205.  Fingers  can  be  extended  to  almost  straight  line. 
Thumb  abducts  clear  of  hand. 

Number  103635:  Rank — Private.  Type  of  Injury — Complete  sec- 
tion rt.  post,  interosseous.  Type  of  Operation — Complete  transfer- 
ence. End-Results — 9  months  after  operation.  Very  good  functional 
result.  Wrist— A.  G.  F.,  110° ;  A.  G.  E.,  180°.  Extension  of  fingers 
good.  Abduction  and  extension  of  thumb  excellent.  Marked  limita- 
tion of  flexion  of  fingers  at  m.p.  joint  impair  usefulness  of  hand. 


18  CLARENCE   L.   STARR 

Number  238098:  Bank— Private.  Type  of  Injury— Irreparable 
muse.  spir.  lesion,  Lt,  Type  of  Operation — Complete  transference. 
End-Results — 5  months  after  operation.  Fair  result.  Range  of  move- 
ment at  wrist  35°.  Excellent  extension  and  abduction  of  thumb.  Fair 
extension  of  fingers.  Function  is  much  impaired  by  multiple  anky- 
losis and  limitation  of  movement,  due  to  other  complicating  G.  S.  W. 

Number  672214:  Bank— Private.  Type  of  Injury — Irreparable 
muse.  spir.  lesion,  Lt.  Type  of  Operation — Complete  transference. 
End-Results — 7  months  after  operation.  Good  result.  Can  extend 
wrist  fairly  and  can  extend  finger  and  thumb,  and  abduct  thumb  very 
well. 

Number  634192:  Rank — Private.  Type  of  Injury — Flail  elbow, 
with  injury  to  post,  interosseous  N.,  Lt.,  resulting  in  loss  of  abduction 
and  extension  of  thumb.  Type  of  Operation — Flex.  Carp.  Rad.  to 
thumb  tendons.  End-Results — Only  fair.  The  transposed  tendons 
contracted  well  but  the  looseness  of  the  flail  elbow  resulted  in  the 
force  being  expended  in  pulling  the  forearm  past  the  humerus  instead 
of  being  exerted  on  the  thumb. 

Number  454818  :  Rank — Private.  Type  of  Injury — Ankylosis  of 
elbow  and  injury  to  post,  interosseous  N.,  Lt.,  resulting  in  loss  of  ex- 
tension of  fingers  and  thumb  only.  Extension  of  wrist  retained. 
Type  of  Operation — Flex.  Carp.  Rad.  to  Ext.  Dig.  Com.  and  Ext. 
Poll.  Long.  Palm.  Long,  to  Ext.  Poll.  Brev.  and  abduct  Poll.  Long. 
End-Results — 4  months  after  operation.  Moderately  satisfactory. 
Can  maintain  full  extension  of  fingers  with  wrist  at  180°.  If  wrist  is 
extended  beyond  this,  fingers  cannot  be  maintained  in  full  extension. 
Greater  mobility  is  hindered  by  widespread  fibrosis  of  muscles,  result- 
ing from  original   injury  and  infection. 

Number  472109  :  Rank — Private.  Type  of  Injury — -Partial  sec- 
tion lt.  muse.  spir.  N.  Wrist  extensors  intact  but  paralysis  of  fingers 
and  thumb  extensors.  Type  of  Operation — Flex.  Carp.  Rad.  to  Ext. 
Dig.  Com.  Palm.  Long,  to  Ext.  Poll.  Long,  and  Brev.,  and  abduct 
Poll.  Long.  End-Results — 4  months  after  operation.  Extends  wrist 
to  normal  degree,  but  it  is  accompanied  by  radial  deviation.  Extends 
fingers  to  180°  when  hand  is  at  180°  to  forearm.  Can  abduct  thumb 
just  clear  of  hand.     (See  print.) 

Number  56028:  Rank — Private.  Type  of  Injury — Section  rt. 
muse.  spir.  Nerve  suture.  Partial  recovery.  Residual  paralysis  of 
extensors  of  thumb  and  fingers.  Type  of  Operation — Palm.  Long,  to 
abduct  Poll.  Long,  and  Ext.  Poll.  L.  &  B.  Flex.  Carp.  Rad.  to  Ext. 
Dig.  Com.  End-Results — 3  months  after  operation.  Board  states: 
"Can  now  extend  fingers  and  thumb  well." 

Number  818178.  Rank— Sig.  Type  of  Injury— Partial  section 
muse.  spir.  nerve,  Rt.  Residual  paralysis  of  fingers  and  thumb. 
Type  of  Operation— Ext.  Carp.  Had.  Long,  to  Ext.  Dig.  Com.  Flex. 
Carp.  Rad.  to  thumb  tendons.  End-Results— 3  months  after  opera- 
tion.    Board  states:    "Has  now  fair  power  of  extension  of  wrist  and 


ARMY  EXPERIENCES  WITH   TENDON  TRANSFERENCE  19 

fingers.     Extension  and  abduction  of  thumb  good.     Power  is  one-half 
normal. ' ' 

Number  916918 :  Rank — Private.  Type  of  Injury — Partial  section 
muse.  spir.  nerve,  Rt.  Residual  paralysis  of  fingers  and  thumb.  Type 
of  Operation — Flex.  Carp.  Rad.  to  thumb  tendons.  Fingers  not 
touched.  End-Results — 6  months  after  operation.  Board  states: 
"Fair  power  of  dorsiflexion  of  wrist.  Extends  fingers  by  means  of 
interossei  and  lumbricals.     Abducts  and  extends  thumb  well. 

Number  901872:  Rank — Private.  Type  of  Injury — Destruction 
of  extensor  muscles,  Lt.,  by  G.  S.  W.  Wrist-drop  due  to  muscle  dam- 
age. Radial  extensors  retained  some  power.  Type  of  Operation — 
Flex.  Carp.  Rad.  to  Ext.  Dig.  Com.  Palm.  Long,  to  Ext.  Poll.  Long. 
End-Results — 7  months  after  operation.  Function  is  fair.  Wrist — 
A:  G-.  F.,  180° ;  A.  G.  E.,  220°.  Can  maintain  fingers  in  full  extension 
with  hand  fully  extended.  Can  abduct  thumb  clear  of  the  flexing 
fingers.  Range  of  movement  is  small  but  useful.  Strength  is  about 
one-eighth  normal,  due  in  part  to  muscle  destruction.  Can  use  hand 
for  many  movements  not  demanding  strength  or  skill.    (See  Fig.  9) 


Fig.  9.--Case  No.  901872. 

Number  775700;  Rank — Private.  Type  of  Injury — Partial  section 
post,  interosseous  N.,  resulting  in  inability  to  abduct  thumb.  Type  of 
Operation — Palm.  Long,  to  thumb  tendon.  End-Result — 8  months 
after  operation.  Fair  abduction  and  extension  of  thumb.  It  just 
clears  flexing  fingers. 

Number  690865  :  Rank— Private.  Type  of  Injury— Section  of  flexor 
tendons,  lt.  index  and  middle  fingers.  Type  of  Operation — Abductor 
Poll.  Long,   into  Flex.  Dig.   Sub.     Flex.   Carp.  Uln.  into   Flex.  Dig. 


20 

Prof.  End-Results — 18  months  after  operation.  Excellent  flexion  of 
fingers.  Before  operation  these  were  hyperextended  at  the  inter- 
phalangeal  joints  by  the  unopposed  action  of  the  interossei  and  lumbri- 
cals.  At  time  of  discharge  he  could  flex  these  through  a  range  three- 
fourths  normal. 

Number  :  Rank — Lieut.  F.  Type  of  Injury — G.  S.  "W.  fore- 
arm, destroying  thumb  muscles.  Type  of  Operation — (1)  Ext.  Dig. 
Com.  to  Ext.  Poll.  Long.  Ext,  Carp.  Rad.  to  abduct  Poll.  Long.  (2) 
3  months  later.  Ext.  Carp.  Rad.  Long,  to  all  extensors  of  thumb  and 
Flex.  Carp.  Rad.  to  Flex.  Poll.  Long.  End-Results — 4  months  after 
last  operation.    Board  states:    "Patient  has  no  control  of  thumb." 

Number  877334:  Rank — Corporal.  Type  of  Injury — Low  section 
median  nerve  with  recovery  of  sensation  but  paralysis  of  opponens. 
Type  of  Operation — One-half  of  tendon  of  Flex.  Poll.  Lona:.  trans- 
planted into  drill  hole  in  head  of  thumb  metacarpal.  End-Results — 
1  year  after  operation.  Fair  result.  Is  able  to  bring  the  tip  of  the 
thumb  almost  in  contact  with  tip  of  ring  finger.  It  is  not  quite  true 
opposition  though  the  thumb  is  partly  rotated.  It  resembles  flexion 
plus  adduction. 

Number  :  Rank — Lieut  D.  Type  of  Injury — G.  S.  W.  fore- 
arm, destroying  extensors.  Type  of  Operation — Flexor  carpi  radialis 
to  common  extensor.  Palmaris  Longus  to  thumb  extensors.  End-Re- 
sults— 2  years  after  operation.     Result  perfect. 

DISCUSSION   OF   DR.    STARR'S   PAPER. 

Sir  Robert  Jones,  Liverpool :  I  am  in  agreement  with  nearly  all  that  Dr. 
Starr  has  said  and,  as  his  paper  covers  a  considerable  range  ofi  surgery,  I 
will  confine  my  remarks  to  that  portion  of  it  dealing  with  musculo-spiral 
palsy  in  its  connection  with  tendon  transplantation.  The  operation  had 
proved  of  great  value  in  war  surgery,  and  long  before  the  war  I  had  oppor'J 
tunities  of  practising  it  in  civil  surgery.  Indeed,  we  are  now  able  to  state 
definitely  that  failures  to  obtain  functional  results  were  due  to  faults  of 
technique  or  defective  after-care.  Indeed,  I  would  go  further  and  say  the 
measure  of  success  was  in  direct  relationship  with  the  knowledge  and  techni- 
cal skill  of  the  surgeon.  It  would  seem  too  obvious  to  state  that  tendon 
transplantation  should  never  be  performed  when  there  is  a  chance  of  nerve 
recovery  were  it  not  that  in  my  military  inspections  I  found  many  cases  where 
not  only  did  the  muscles  act  but  the  nerve  had  also  recovered  its  power.  We 
made  it  a  rule  in  those  cases  where  we  knew  that  the  nerve  had  been  well 
sutured  and  the  after-care  correct,  to  await  for  at  least  twelve  months  be- 
fore considering  the  question  of  muscle  transference.  In  cases  where  we 
had  no  knowledge  of  the  operator,  or  the  operation  findings.,  an  exploration^ 
was  made  without  delay.  This  decision  was  more  than  justified  bv  the  ex- 
traordinary revelations  that  occurred.  A  tendon  transplantation  is  always 
to  be  preferred  to  any  operation  of  neuroplasty  or  nerve  transplant. 

There  are  certain  fundamental  principles  to  be  adhered  to,  such  as  that 
the  transplanted  tendons  should  be  kept  in  relaxation  and  traverse  a  straight 
line  from  origin  to  new  insertion,  that  tendons  should  not  pass  through, 
cicatricial  tissue  and  should  not  be  expected  to  mobilize  a  stiff  joint.  If 
the  wrist  is  ankylosed  and  cannot  be  mobilized,  it  should  be  fixed  in 
dorsinexion.     Similarly,  the  hand  and  fingers  should  be  mobilized,  where  pos- 


AMY  ATOM  A    COX  UK  NIT  A:     REPORT    OP    A    CASE  21* 

sible,  before  the  tendon  is  transplanted.  The  transplanted  muscle  should  be 
held  in  slight  tension.  Under  excessive  tension,  muscle  atrophies,  while  if 
the  tendon  is  left  too  slack,  restoration  of  its  function  will  be  long  delayed. 
The  tendons  which  I  recommended  should  be  utilized  in  pre-war  days  are 
those  which  I  still  think  best.  If  the  nerve  is  injured  above  the  level  of  the 
origin  of  the  post  interosseus,  the  flexor  carpi  radialis;  should  be  inserted 
into  the  three  extensors  of  the  thumb  and  to  the  extensor  of  the  indefc 
finger — the  flexor  carpi  ulnaris  into  the  extensor  of  the  remaining  three 
fingers.  The  pronator  radialis  teres  is  to  be  transplanted  into  the  extensor 
carpi  radialis  longior,  et  brevior.  The  point  I  have  always  laid  stress  upon 
is  cleanliness  of  dissection,  and  once  the  flexors  have  been  brought  to  the 
back  of  the  wrist,  the  joint  should  be  kept  in  dorsiflexion  from  the  time  the 
operation  is  begun  until  recovery  of  the  muscles  has  occurred.  I  have  so 
often  described  the  after-care  that  I  will  not  take  up  your  time  further.  Re- 
covery is  usually  complete  in  from  eight  to  ten  weeks.  A  recovery  is  only 
considered  good  when  the  wrist,  thumb,  and  fingers  can  all  be  fully  extend*' I. 

Dr.  W.  G.  Turner,  Montreal:  Mr.  President,  I  should  like  to  bear  testi- 
mony to  the  work  that  Dr.  Starr  has  accomplished.  We  were  very  fortunate, 
Sir,  in  having  the  example  of  various  centers  throughout  Great  Britain. 
This  system  was  organized  early  in  the  war  and  carried  on,  not  only  in 
Great  Britain  but  also  in  Canada;  and  it  certainly  was  a  great  factor  in 
bringing  treatment  to  a  high  standard.  The  advantage  has  been  that  we 
have  had  fundamental  principles  laid  down  and  well  followed.  We  must  all 
realize  that  Sir  Robert  Jones  accomplished  this  wonderful  organization. 
As  far  as  my  country  is  concerned,  I  feel  grateful  to  the  organization  t{hat 
Colonel  Starr  brought  into  existence.  It  was  due  to  that,  that  we  avoided 
mistakes  in  this  country;  and  the  after-treatment  of  these  cases  was  con- 
ducted very  carefully. 

Dr.  Clarence  Starr,  Toronto:  I  want  to  thank  Sir  Robert  Jones  for  his 
kind  remarks,  and  to  acknowledge  my  indebtedness  to  him  and  his  confrere 
for  the  stimulus  they  gave  to  the  work.  I  have  been  wonderfully  helped  by 
their  suggestions.  We  are  not  all  quite  as  competent  as  Sir  Robert  Jones. 
My  experience,  after  doing  a  large  number  of  cases,  is  that  I  can  get  tliem 
more  room  and  more  definite  alignment  from  a  large  incision  than  from 
multiple  small  incisions.  The  fault  is  to  be  found  that  Sir  Robert  Jones 
emphasized  the  fact  that  the  men  did  not  at  first  learn  the  prin- 
ciples, and  then  did  not  stick  to  them.  It  seems  so  obvious,  yet  as  he 
has  pointed  out,  you  will  see  cases  in  which  these  principles  are  so  grossly 
violated  that  it  is  patent  at  once  that  it  was  an  impossibility  for  the  pa- 
tient to  have  recovered  function. 


AMYATONIA  CONGENITA :  REPORT  OF  A  CASE. 

BY    CHARLES    A.    STONE,    ST.    LOUIS,    MO. 

From  the  Department  of  Orthopaedic  Surgery,  Washington  University 

Medical   Department. 

It  is  not  the  intent  of  this  paper  to  go  into  a  long  and  exhaustive 
discourse  of  the  condition  on  which  Oppenheim1  published  his  obser- 


22  CHARLES  A.    STONE 

vations  in  1900.  Much  has  been  written  about  what  he  called  Myatonie, 
but  cases  are  yet  uncommon  enough  to  justify  description  and  com- 
ment upon  a  new  one. 

Ten  years  after  the  publication  of  the  notes  on  this  little  understood 
condition,  Habermann2  states  that  he  could  find  no  mention  of  it  in 
any  text-book  on  either  neurology,  pediatries,  or  internal  medicine. 
In  an  article  by  Foot3  in  May,  1913,  he  mentions  the  fact  that  75 
cases  had  been  reported,  13  accompanied  by  autopsy  findings.  Dur- 
ing March,  1920,  P.  Haushalter4  says  there  had  been  a  total  of  155 
eases  reported,  including  three  of  his  own,  showing  that  during  the 
seven  years  from  1913  to  1920  more  cases  had  been  seen  than  during 
the  preceding  thirteen  years. 

Oppenheim  in  his  first  article  thought  that  the  pathological  con- 
dition was  to  be  found  in  the  muscles  which  were  retarded  in  de- 
velopment. But  further  on  he  also  says  that  it  is  possible  there  may 
be  a  developmental  error  in  the  anterior  horn  cells.  He  adds  that, 
though  the  condition  resembles  poliomyelitis  anterior,  it  is  not  the 
same  and  has  nothing  to  do  with  it. 

As  if  to  prove  the  contention  that  the  muscles  were  in  error,  in  1905 
at  autopsy  in  a  well-marked  case  of  twenty-two  months,  Spiller5  found 
a  condition  of  decided  regression  in  the  muscles  affected,  but  no 
changes  were  present  in  the  nervous  system.  However,  there  have 
since  been  a  number  of  histological  examinations  of  both  muscle  and 
nervous  tissue  showing  the  same  condition  noted  by  Spiller,  and  in 
addition  thereto,  changes  in  the  anterior  horn  cells.  Later,  Spiller 
and  Griffith6  report  finding  these  same  cells  decreased  in  number  and 
in  size. 

DEFINITION. 

Faber7  has  given  a  very  concise  one,  namely,  a  disease  found  at 
birth  and  due  to  a  developmental  defect  of  the  lower  motor  neuron  and 
of  the  voluntary  muscles,  clinically  characterized  by  weakness,  hypo- 
tonia and  quantitatively  diminished  electrical  responses,  usually  with- 
out disturbance  in  sensation  or  mentality. 

ETIOLOGY. 

Thus  far,  no  causative  agent  has  been  found.  Syphilis,  tuberculo- 
sis, and  other  infections  play  no  role. 

The  pathological  findings  lead  to  the  conclusion  that  it  is  due  to  a 
congenital  defect.  In  only  a  few  cases  have  there  been  any  others 
of  the  family  or  relatives   affected.     Where  there  is  a  record  made 


AMYATONIA    CONGENITA:    REPORT    OF    A    CARE  23 

of  the  fact,  more  than  half  of  the  cases  show  that  foetal  movements 
were  absent,  weak  or  retarded.  Nearly  all  of  the  pregnancies  have 
gone  to  term  without  mishap  and  with  normal  deliveries,  showing 
that  accidents  of  gestation  are  not  a  factor. 

A  review  of  practically  all  reported  cases  since  1900  leaves  the 
impression  that  we  are  as  far  from  a  solution  as  at  first. 

Foot  believes  that  we  are  dealing  with  the  evidence  of  some  past 
disease  manifested  by  the  reparative  reaction  of  the  body. 

The  percentage  of  males  affected   is   slightly  higher  than   females. 

research. 

Ziegler8  and  Pearce8  have  done  the  latest  work  on  metabolism,  con- 
firming the  conclusions  of  Spriggs0,  and  of  Gittinsrs  and  Pemberton10. 
that  the  creatinin  excretion  is  greatly  diminished.  They  also  found 
excretion  of  creatin  on  a  low  protein  diet;  normal  uric  acid  excre- 
tion; increased  rest  nitrogen  accompanied  by  increased  neutral  sul- 
phur; normal  phosphorus  excretion,  therefore  no  bone  disintegra- 
tion, and  lowered  chlorid  excretion. 

age. 
In  over  80  %  of  the  cases  the  onset  has  been  noticed  at  or  soon 
after  birth.  Some  cases  are  noted  as  having  come  on  at  a  later  age, 
but  from  the  evidence  found  in  the  pathological  examination  there 
may  have  been  a  question  of  the  keenness  of  observation  as  to  the 
exact  time  at  which  paralysis  occurred. 

prognosis. 
A  certain  number  of  cases  have  shown  improvement,  but,  consid- 
ering the  lack  of  development  in  the  motor  areas  of  the  cord,  it  is 
hard  to  see  how  there  can  be  much  increase  in  muscle  power.  That 
which  does  occur  is  probably  qualitative  rather  than  quantitative.  The 
death  rate  is  high;  about  90%  from  pneumonia. 

TREATMENT. 

Medicinal  treatment  has  been  of  no  avail,  a  number  of  different 
remedies  having  been  tried.  The  most  likely  course  of  treatment  is 
teaching  the  child  to  develop  the  muscle  power  already  present. 

diagnosis. 
This  is  made  upon  finding  at  birth  a  flaccid  paralysis,  with  few  or 
no  signs  of  atrophy.     It  is  distinguished  from  the  myopathies  by  not 


24 


CHARLES  A.    STONE 


Fig.  1. — Shows  the  permanently  tilted  and  deformed  pelvis,  with  signs  of  bone 

atrophy  in  each  femur. 

being  progressive,  and  from  poliomyelitis  by  the  muscle  group  char- 
acteristic of  the  latter,  accompanied  by  marked  atrophy  of  the  muscles 
involved.  It  is  possible  that  a  general  weakness  found  in  rickets 
may  at  times  be  mistaken  for  myatonia. 

CASE    REPORT. 


R.  K.  Age  12i/2.  1917.  Admitted  to  Children's  Hospital,  February 
8,  1917. 

Chief  complaint:  curvature  of  spine;  paralysis  of  legs.  Father's 
age  at  patient's  birth,  25;  mother's  age  24;  two  younger  children,  well 
and  strong.  One  miscarriage.  No  history  of  any  other  paralysis  in  the 
family,  except  a  brother  of  the  mother,  who  had  a  paralyzed  right 
arm  following  a  disease  of  childhood — probably  poliomyelitis.  No 
history  of  tuberculosis,  cancer,  or  nervous  diseases  in  the  family. 

P.  H.  Has  had  chicken  pox,  measles  and  whooping  cough;  never 
Had  mumps,  scarlet  fever  nor  diphtheria.  No  exposure  to  any  in- 
fectious diseases.     General  health  good. 


AMYATONIA    CONGENITA:    REPORT    OF    A    CASE 


25 


Tig.  2. — Typical  bene  atrophy  of  each  femur  is  apparent.     The  contour  of  the 
thigh  muscles  can  also  be  seen. 

PRESENT   ILLNESS. 


Child  was  delivered  feet  first,  the  right  foot  presenting  first,  con- 
siderable difficulty  being  experienced  by  the  doctor  in  making  the 
-delivery. 

The  mother  states  that  during  pregnancy  foetal  movements  were 
not  as  vigorous  as  in  other  pregnancies.  She  fell  three  times  during 
this  period.  The  child's  aunt,  who  cared  for  him  until  he  was  two 
months  old,  says  he  did  not  kick  his  legs  from  the  beginning.  This 
statement  was  made  to  the  mother  when  she  began  bathing  him  at 
the  end  of  this  period  and  noticed  that  he  did  not  kick.  A  doctor 
was  called  and  pronounced  it  infantile  paralysis.  He  has  always 
had  feeling  in  his  legs.  There  was  incontinence  of  urine  and  feces 
=until  four  years  ago,  when  he  began  to  gain  control  of  his  bowels. 


26 


CHARLES   A.    STONE 


Fig.  3. — Is  a  lateral  view  of  the  sacrum  and  the  spine  above  it. 

After  several  years  he  got  so  he  could  move  his  legs  a  little  and  has 
improved  greatly  in  his  ability  to  sit  alone. 

Curvature  of  the  spine  was  not  noticed  until  the  baby  began  to  sit 
up ;  maybe  not  then,  as  he  was  two  or  three  years  old  before  the  mother 
noticed  it  at  all.  It  has  only  been  so  noticeable  within  the  past  few 
years. 

The  child  never  crawled  on  hands  and  knees,  but  pushed  himself 
backward  on  his  stomach  by  using  his  elbows.  Later  he  moved  about 
by  sitting  up  and  pushing  along  with  his  hands.  At  present  he  walks 
by  bending  over  and  grasping  a  foot  in  each  hand,  lifting  one  foot 
forward  after  the  other.  Can  climb  trees  as  well  as  any  of  the  children. 
Got  some  frost  bites  on  the  calves  of  his  legs  three  years  ago.  From 
the  knees  down  his  legs  are  always  bluish-red  and  cold.  He  is  very 
constipated. 

Mother  says  she  has  had  all  kinds  of  doctors  to  see  the  child- 
even  the  osteopaths.  An  x-ray  of  spine  when  child  was  one  year  old 
revealed  no  abnormal  nndinsrs. 


AMYATONIA    CONGENITA:    REPORT    OF    A    CASE  27 


PHYSICAL  EXAMINATION. 

Patient  is  a  white  male,  I2V2  years  old.  Lies  quietly  on  his  back 
and  does  not  seem  to  be  in  any  pain.  Is  pale  and  thin.  Skin  is 
warm,  soft,  smooth  and  elastic. 

Head — The  line  of  suture  between  frontal  and  parietal  can  be  felt. 
No   cranial  tenderness. 

Eyes — React  to  light  and  accommodation.  Ocular  movements  nor- 
mal.    No  abnormal  pigmentation  on  sclera. 

Ears — No  tophi,  tenderness,  discharge,  or  deafness. 

Nose — No  obstruction. 

Mouth — Teeth  irregular.  Tongue  protrudes  in  mid-line.  Tonsils 
slightly   enlarged   and   reddened.     Pharynx   slightly   injected. 

Neck — Thyroid  not  enlarged.  Palpable  post-cervical  glands  on  right. 
No  abnormal  pulsations. 

Chest — Very  irregular.  Pigeon  breasted.  Distinct  lagging  of  left 
side  of  chest  on  respiration.  Heart  not  enlarged.  Apex  seems  to  be 
displaced  to  right.  P.  M.  I.  just  to  right  of  mid-line.  No  thrills, 
shocks  or  murmurs. 

Lungs — P.  N.  hyper-resonant  in  right  upper.  Resonant  throughout 
B.  S.  vesicular.     No  rales  or  friction  rubs. 

Liver — Dulness  rises  up  to  nipple  line.  Lower  border  of  liver  is 
above  costal  margin. 

Back — Marked  scoliosis.  Some  lordosis  in  lumbar  region.  No 
tenderness  along  spinal  column. 

Abdomen — Irregular.  Slightly  distended.  No  spasm  or  rigidity. 
A  movable  mass  can  be  felt  near  the  right  kidney  region.  On  deeD 
palpation  spine  can  be  felt.  There  is  a  hand-length  tender  mass 
about  6x4  cm.  just  above  the  symphysis. 

Pelvis — Is  markedly  tilted  to  right. 

Genitalia — Scrotum  small.  Both  testicles  descended.  There  is  in- 
continence of  urine  with  some  resulting  irritation  of  skin  surround- 
ing parts. 

Extremities — Upper  are  normal;  reflexes  present  and  equal.  Lower 
are  in  a  state  of  flaccid  paralysis.  K.  K.  and  plantar  reflexes  can 
not  be  obtained.  Cannot  use  any  of  the  muscles  of  lower  limbs.  Toe- 
nails are  small  and  irregular.  Patient  complains  of  coldness  in  lower 
extremities,  and  left  foot  was  cold  at  time  of  examination.  Patient 
has  sensation  in  his  lower  extremities. 

2-8-17— Hemoglobin— 70%.     W.    B.    C— 9,100. 

2-15-17 — Orthopaedic    consultation — no    reflexes,    extreme   scoliosis — 
loss  of  bladder  and  rectum  control.     Good  power  in  arms.    Mentality 
above   normal.     Initiative  above   normal.     Very  little  power  in  legs. 
Sensation  normal. 
Diagnosis — Extreme   poliomyelitis. 

Flaccidity  with  preservation  of  sensation,  against  upper  neurone 
and  pyramidal  tract  lesion.    If  in  lower  neurone  must  be  purely  motor. 


28  CHARLES  A.    STONE 

Discount  history  because  of  good  mentality  with  extreme  paralysis. 

Has  dislocated  but  easily  reducible  left  hip. 

Recommend  extensive  braces  to  get  patient  upright. 

3-7-17 — Patient  has  considerable  rise  in  temperature.  Complains 
•of  very  sore  throat.  Examination  shows  tonsils  considerably  swollen. 
Some  flecks  of  membrane  on  tonsils.     Culture  taken.     Isolated. 

3-8-17— Culture  negative  for  K.  L.     W.   B.  C— 15,000. 

'3-10-17 — Condition  much  better.  Temperature  fairly  normal.  Ton- 
sils still  somewhat  swollen.  Patient  says  he  has  tonsillitis  every  winter. 
Would  seem  that  a  tonsillectomy  were  indicated. 

3-20-17 — Blood  coagulation  time  taken  yesterday — greatly  delayed. 
Contracture  tensor  fascia  femoris  each  side.     Double  Soutter  advised. 

3-22-17— Urine  St.  yellow,  cloudy,  acidity  0.20,  white  deposit,  acetone 
negative,    many  leukocytes.      Hemoglobin — 70%. 

Operation — Fasciotomy   ('Soutter 's)    3-22-17. 

.Ether  anesthesia. 

Four-inch  longitudinal  incision  between  anterior  superior  spine  and 
great  trochanter  on  left  side,  exposing  fascia  lata.  Anterior  superior 
spine  cut  free,  muscle  elevated  from  inner  and  outer  aspects  of  ilium, 
and  spine  allowed  to  slip  downward  toward  the  inferior  spine,  which 
was  permitted  after  a  transverse  section  of  the  ilio-tibial  band  and 
the  very  pale  tensor  fascia  femoris. 

Similar  operation  on  right  side.  Long  double  spica  from  nipple 
down,   with   hips   abducted   and   hyper-extended. 

POST-OPERATIVE    NOTES. 

3-23-17 — Complaining  quite  a  little  of  cast.  Temperature  and  pulse 
normal. 

3-26-17 — Temperature  103  this  morning.  Front  of  cast  removed. 
Wounds  in  very  good  condition.  Small  pressure  spot  on  right  knee 
and  chest. 

3-27-17— W.  B.  C— 14,600:  R.  B.  C— 4,736,000 :  Hemoglobin— 65%. 
3-30-17 — Sutures  removed;  wounds  have  healed  nicely.  Tempera- 
ture still  elevated. 

4-2-17 — Temperature  still   elevated;   101;   no   cause  found. 

4-4-17 — Temperature  99 — comfortable. 

4-11-17 — Braces  applied.     Up  in   chair — temperature  99.5. 

4-15-17 — Discharged. 

Diagnosis — Poliomyelitis. 

5-14-20 — Readmitted.     Age  15  years. 

Returned  for  new  braces,  having  outgrown  old  ones. 

The  physical  examination  was  the  same  as  in  1917,  except  for  the 
following  notes: 

Genitals — Fairly  well  developed.  Has  incontinence  of  urine,  wear- 
ing rubber  urinal.     Fair  growth  pubic  hair. 

Arms  and  shoulders  markedly  well  developed. 

Spine— High  right  dorsal,  lower  left  dorsal  and  lumbar  scoliosis. 


AMYATONIA    CONGENITA:    REPORT    OF    A    CASE 


2£ 


Fig.  4. — Is  a  lateral  view  showing  typical  bone  atrophy 
outlines    of    the   calf   muscles. 


In  each  leg,  and  the 


Pigeon  breasted.     Respirations  equal  and  regular. 

Lower  extremities — Almost  totally  flaccid,  the  only  power  present 
being  slight  adduction  on  each  side.  Legs  are  short,  adipose,  soft  and 
flabby,  but  without  signs  of  definite  atrophy.  The  toes  are  deformed 
and  irregularly  placed  in  extension.  The  plantar  surfaces  of  the  feet 
resemble  large  pads  full  of  wrinkles,  the  middle  is  bulging  and  more 
prominent  than  either  side,  thus  obliterating  any  evidence  of  a  nor- 
mal arch. 


30 


CHARLES   A.    STONE 


Fig.  5. — Is  a  anteroposterior  view   showing  the  same  conditions  as  Figure  4. 

Hypermotility  of  the  feet  in  both  extension  and  flexion.  The  dorsum 
of  the  foot  may  be  placed  on  the  anterior  surface  of  the  leg.  Both 
knees  may  be  greatly  hyper-extended  and  there  is  permitted  much 
lateral  motion.  Both  feet  can  be  put  behind  the  head  at  the  same 
time.  The  left  knee  can  be  placed  behind  the  left  shoulder.  The 
right  knee  not  quite  so  far.  Each  thigh  can  be  placed  alongside  the 
body.  Bending  forward  he  can  place  his  head  between  his  legs.  There 
is  a  scar  on  each  thigh,  extending  from  anterior  superior  spine  to  the 
great  trochanter.     This  from  the  operation  done  in  1917. 


AMYAToMA    CONGENITA:    USFOBT    OF    A    CASE  31 

Measurements  taken  are  as  follows: 

Umbilicus  to  bottom  of  feet — 71  cm. 

Umbilicus  to  top  of  head — 48  cm. 

Circumference  right  calf — 26  cm. ;  right  thigh — 31.5  cm. 

Circumference  left  calf — 25  cm.;  left  thigh — 30  cm. 

Circumference  of  pelvis— 53  cm. 

R.  B.  C.— 1,792,000;  W.  B.  C— 8,200. 

5-18-20 — Light  cast  of  body  as  model  for  leather  jacket.  Measured 
for  braces.  Stiff  ankle ;  drop  catch  at  knees  and  hip ;  leg  braces  to  be 
attached  to  jacket.     Crutches. 

5-19-20 — X-ray.  Lateral  stereo  lower  dorsal  and  lumbar  spine  shows 
marked  scoliosis,  the  nature  of  which  cannot  be  determined. 

5-21-20 — Neurological  consultation:  Absence  of  any  sensory  find- 
ings suggests  either  an  acquired  process  in  the  anterior  horn  cells  of 
the  sacral  or  lumbar  segments  or  of  a  developmental  defect  in  the  cell 
region. 

5-24  20 — Antero-posterior  and  lateral  views  of  both  legs  show  an 
extreme  grade  of  bone  atrophy. 

Later — A  No.  10-F  catheter  introduced.    Pin  point  meatus  stretched, 
over  300  cc.  residual  urine  obtained,  loaded  with  pus,  thick  and  creamy. 
Acid  reaction.     Retained  catheter.     Put  on  soda  bicarb. 
6-14-20 — Wassermann  neg.  to: 
Luetin  Antigen. 
Cholesterin  Antigen. 
T.  B.C.  Antigen. 

£-15-20 — Bladder  irrigated,  10  cc.  20%  argyrol  instilled.  Temper- 
ature down  since  bladder  condition  has  been  treated. 

6-25-20 — Temperature    up   -to    103.      Retention    catheter    replaced. 
150  cc.  turbid  urine.     Examination  otherwise  rather  negative. 

6-26-20— Temperature  100  this  a.m.    Feels  good. 

Braces  applied.     To  be  up  and  discharged. 

DISCHARGE    NOTE. 

Able  to  get  about  by  the  aid  of  crutches.  Given  urotropin  to  take 
at  home  for  five  days.    Diagnosis:  amyatonia  congenita. 

ELECTRICAL    EXAMINATION. 

No  nerve  muscle  or  muscle  response  up  to  110  volts  in  either  leg, 
except  the  quadriceps  and  sartorius  right,  in  which  the  chronaxie  was 
.00015  sec.  (normal)  and  vastus  externus  right,  chronaxie  .0008  sec., 
or  very  poor  nerve  supply;  abdominal  muscles  and  those  of  arm  have 
good  reaction  at  normal  chronaxie.  No  anesthesia  of  legs,  and  slight 
voluntary  movement  of  quadriceps.  Slight  flexion  of  thigh.  No 
trophic  changes  in  legs;  impression,  complete  degeneration  of  motor 
nerves  and  muscles  both  legs  except  quadriceps  sartorius  right,  which 
nerves  and  muscles  are  in  fair  condition. 


32  CHARLES  A.    STONE 

Physical — Same  as  previously,  except — 

Genitalia — Large  amount  pubic  hair.  Penis  and  testes  developed:' 
out  of  proportion  to  rest  of  body.  X-ray  3-28-21.  X-ray  each  leg 
shows  extreme  grade  bone  atrophy.  Outlines  of  rather  thin  muscles 
are  observed. 

COMMENT. 

We  have,  then,  a  boy  born  with  a  flaccid  paralysis,  which  has  shown- 
but  slight  improvement.  The  increase  in  muscular  power  is  probably 
due  to  greater  strength  in  the  muscles  already  present  at  the  time- 
of  birth.  There  is  little  sign  of  atrophy,  except  that  the  thighs  are 
small  in  comparison  with  the  legs. 

This  patient  has  blueness,  coldness,  and  tendency  to  chilblains, 
which  are  very  infrequent.  Contractures  have  been  reported  in  a 
fairly  large  percentage  of  the  cases,  but  are  found  mostly  in  the  older 
ones,   probably  due  to  posture. 

I  have  been  able  to  find  no  case  where  there  was  involvement 
of  the  sphincters,  but  feel  that  this  should  not  exclude  the  diagnosis 
in  this  instance.  The  neurological  consultation,  while  not  agreeing 
with  the  diagnosis,  nevertheless  says  "this  appears  to  be  a  congenital 
defect  in  the  anterior  horn  cells,"  thus  agreeing  with  what  is  given 
by  many  as  an  essential  pathological  finding  in  amyatonia  congenita. 

An  injury  at  birth  must  be  considered,  since  the  record  shows  the 
baby  came  as  a  breech  presentation  and  considerable  force  was  used 
in  making  the  delivery.  However,  if  there  had  been  an  injury  to  the- 
cord,  some  trophic  disturbances  must  certainly  have  followed  along 
with  the  sensory  findings.     This  has  not  been  the  case. 

A  congenital  myxoedema  is  excluded  by  a  look  at  the  patient's 
head  and  face,  which  have  none  of  the  characteristics  found  in  this-, 
disease. 

It  does  not  belong  to  the  myopathies,  since  there  has  been  no  local- 
ised wasting  and  no  spreading  from  muscle  to  muscle  and  to  regions- 
not    originally   affected. 

Consent  for  a  biopsy  was  obtained,  but  the  parents  granted  it,  say- 
ing they  were  willing  if  it  would  do  any  good.  This  assurance  could 
not  be  given  and  the  diagnosis  appearing  so  evident,  the  specimen  was 
not  obtained. 

There  has  been  only  one  older  case  recorded,  that  being  50  years 
of  age.  Two  of  12  years  are  the  next  in  order,  excepting  this  boy. 
He  is  now  in  good  health,  with  little  prospect  of  a  necropsy. 

Measurements  of  a  number  of  other  boys  were  made  to  see  how  this 
boy  compared.  While  his  total  height  is  very  much  less,  the  ratio 
of  trunk  to  lower  extremities  was  almost  exactly  the  same  as  in  nor- 
mal boys  the  same  age. 


TREATMENT  OP  TUBERCULOSIS  OP  THE  ANKLE  IN  THE  ADULT  33 

1.  Oppenheim:     Monatschr.  I.  Psy.  u.  X«  m    8,  p.  232,  1000. 

2.  J.  V.  Habermann :     Am.  Jour.  Mtd.  Sc.,  N.  S.,  139,  1910,  p.  383 . 

3.  N.  C.  Foot :  Am.  Jour.  Dis.  Child.  5,  1913,  p.  359. 

4.  P.  Haushalter:   Arch.  d.  M6d.  des  Enfants,  No.  3,  March,  1920,  p.  133. 

5.  Spiller:  Univ.  Penn.  Med.  Bull.,  1905,  xvii,  p.  342. 

6.  Griffith  and  Spiller:   Am.  Jour.  Med,  Be.,  1911,  142,  p.  165. 

7.  Faber,  H.  K. :  Am.  Jour.  Dis.  Child.,  1917,  13,  p.  305. 

8.  Mildred  R.  Ziegler  and  N.  O.  Pearce:  Jour.  Biol.  Chem.,  July,  1920,  p.  581. 

9.  Spriggs,  E.  J.:  Quart.  Jour.  Med.,  1907-1908,  T,  63. 

10.  Gittings,    J.    C,    and    Pemberton,    R.,  Am.    Joufr.    Med.    Sc.,    1912,    cxliv, 
Section  VIII,  256. 


TREATMENT  OF  TUBERCULOSIS  OF  THE  ANKLE  IN  THE 

ADULT. 

BY  JACQUES  CALVE,  BERCK-PLAGE,  FRANCE. 

In  considering  the  treatment  of  tuberculosis  of  the  ankle-joint  in 
the  adult,  several  questions  deserve  special  attention.  Among  these 
are: 

1.  What  is  the  prognosis  with  the  conservative  treatment? 

2.  What  is  the  duration  of  conservative  treatment  in  those  termi- 
nating favorably,  or  better  still,  after  what  period  may  we  expect  to 
return  the  patient  to  work? 

3.  How  long  should  conservative  treatment  be  tried  before  resort- 
ing to  operative  measures? 

4.  In  what  per  cent,  is  amputation  finally  necessary? 

In  going  over  the  literature  it  will  be  found  very  diflicult  to  get  in- 
formation on  these  particular  points.  To  state  that  a  patient  left  the 
hospital  with  wounds  healed,  or  that  the  patient  made  a  good  ultimate 
recovery,  is  not  sufficiently  to  the  point.  The  time  element  is  a  very  im- 
portant factor,  and  should  receive  special  consideration.  Strictly 
speaking,  the  title  of  this  paper  should  limit  consideration  to  the 
ankle-joint  proper,  that  is,  the  astragalo-tibial  articulation,  but  for 
practical  reasons  it  may  be  well  to  include  tarsal  disease,  since  the 
tarsal  bones  are  often  involved  secondarily. 

Tuberculosis  of  the  ankle  is  said  to  occupy  third  place  in  order  of 
frequency  of  joints  involved  in  the  lower  extremity.  The  bones  bear- 
ing most  weight  are  especially  disposed  to  invasion.     The  astragalus, 


34  JACQUES    CALVE  ,.  r. 

tibia,  and  os  calcis,  therefore,  are  more  frequently  affected  than  the 
smaller  tarsal  bones.     The  astragalus  is  the  most  frequently  involved. 

While  writers  are  not  entirely  in  accord  as  to  the  seat  of  the  pri- 
mary involvement,  the  idea  seems  to  be  gaining  ground  that  the  pri- 
mary seat  is  more  frequently  in  the  synovial  membranes  than  in  the 
bone.  In  the  synovial  type,  the  disease  spreads  more  rapidly  over 
the  surface  of  the  bone.  In  osteal  lesions  the  disease  process  extends 
along  beneath  the  cartilage,  so  that  at  operation  the  cartilage  is  fre- 
quently lifted  off  readily  in  large  pieces.  This  undermining  of  the 
cartilage  accounts  for  the  fact  that  when  healing  follows  the  conserva- 
tive treatment,  a  slight  degree  of  motion  usually  persists,  because  of 
the  remnant  of  cartilage  interposed  between  the  joint  surfaces.  The 
joint  with  a  slight  degree  of  motion  is  particularly  disposed  to  light- 
ing up  of  the  latent  infection,  so  that  in  cases  where  only  a  slight  and 
not  really  serviceable  degree  of  motion  persists,  firm  bony  ankylosis 
would  be  preferable.  In  astragalo-tibial  disease,  swelling  is  usually 
first  noticed  on  the  front  of  the  ankle  on  either  side  of  and  along  the 
extensor  tendons,  because  the  capsule  is  thinnest  at  this  point.  Fluctu- 
ation is  most  easily  elicited  during  tarsal  flexion  of  the  joint.  Later, 
effusion  appears  also  below  the  malleoli.  Extension  of  the  disease  to 
the  os  calcis  and  scaphoid  is  frequent.  In  walking,  there  is  a  tendency 
to  equino-valgus  with  rotation  outward  of  the  leg  and  foot,  the  latter 
thus  taking  a  more  passive  part  in  progression. 

This  position  avoids  motion  at  the  astragalo-tibial  and  astragalo- 
scaphoid  joints. 

In  the  later  stages,  infiltration  of  the  tissues  and  elevation  of  tem- 
perature are  the  rule.  In  subastragalar  disease,  the  swelling  is  usu- 
ally noted  lower  down.  The  characteristic  signs  and  symptoms  of  tu- 
berculosis of  the  ankle  and  tarsus  are  so  well  described  in  modern 
textbooks  that  repetition  is  unnecessary  here. 

In  going  over  the  figures  of  various  authors  writing  on  tuberculosis 
of  the  ankle-joint,  it  has  been  found  that,  with  a  few  exceptions,  cases 
of  adult  and  childhood  disease  are  grouped  together.  In  view  of  the 
fact  that  both  treatment  and  prognosis  vary  so  markedly,  it  is  deemed 
wise  always  to  distinguish  the  two  groups  in  offering  statistics. 

A  review  of  the  literature  shows  that  the  prognosis  in  children  is 
very  favorable  and  more  so  with  conservative  treatment  than  with  op- 
eration. In  childhood,  conservative  treatment  should  be  carried  out 
rigidly  and  consistently,  paying  attention  to  usual  hygienic  measures, 
including  heliotherapy,  as  well  as  to  local  fixation.  Occasionally  minor 
operations,  such  as  laying  open  of  sinuses  or  excavation  of  an  isolated 


TREATMENT  OF  TUBERCULOSIS  OP  THE  ANKLE  IN  THE  ADULT  35 

focus  in  a  single  bone,  may  be  justifiable,  but  radical  operations,  re- 
moval of  entire  tarsal  bones  or  excision  of  joints  will  rarely  be  called 
for.  Humphries  and  Durham  reported  twenty-nine  traced  cases,  av- 
erage age  of  admission,  5*/2  years;  average  duration  of  treatment, 
4  V6  years.  Of  these  29  cases,  23  were  cured.  Of  these  23,  15  had 
normal  function  and  eight  various  degrees  of  limitation  of  motion  and 
deformity.     Six  cases  died. 

Gibney  reported  three  cases  with  "good,  practically  normal  or  nor- 
mal function"  in  24,  ankylosis  in  six.  Average  duration  of  treatment, 
3V*  years.  In  both  of  these  series  practically  all  of  the  cases  were  in 
children. 

Ohse  reported  on  a  series  of  115  cases  of  tuberculosis  of-  the  ankle 
at  the  Strassburg  clinic,  between  the  years  1894  and  1906;  almost 
one-half  of  these  were  in  children  under  15  years.  In  his  series,  26 
per  cent,  came  to  secondary  amputation;  19  per  cent,  of  the  resected 
cases  died  shortly  after  operation  from  other  forms  of  tuberculosis. 
About  50  per  cent,  of  the  cases  showed  good  anatomical  results,  the 
others  showing  various  degrees  of  deformity  and  shortening  from 
nothing  to  11  cm. 

Maass  reported  167  cases  from  the  Gottinger  clinic.  Of  39  cases 
treated  conservatively,  29  came  to  operation  later.  He  concludes  that 
conservative  treatment  is  contraindicated  in  all  cases  where  x-ray 
shows  foci  in  bone.  This  view  does  not  find  acceptance  so  far  as  it 
applies  to  children.  These  figures  bring  one  point  out  strongly,  and 
that  is,  that  operations  in  children  are  contraindicated;  also  that  if 
operative  procedures  in  adults  are  carried  out  they  should  not  be  too 
long  delayed. 

Sever 's  series  of  213  cases  of  tuberculosis  of  the  ankle  and  tarsus  in- 
cludes only  children.  A  comparison  of  results  obtained  by  conserva- 
tive and  operative  means  leads  him  to  urge  avoidance  of  all  radical 
operations  on  bones  and  joints  of  children  except  when  all  else  fails. 

Most  valuable  statistics  are  those  of  M.  H.  Rogers,  though  they  cover 
a  comparatively  small  number  of  cases.  He  traced  17  cases  out  of  a 
total  of  27  of  tuberculosis  of  the  ankle  in  adults  treated  at  the  Massa- 
chusetts General  Hospital.  This  is  the  only  series  found  in  which 
adults  only  are  considered.  Fixation  gave  good  results  in  only  three 
cases,  and  duration  of  treatment  was  four  years.  Of  the  operative 
cases,  resection  was  done  in  nine,  and  amputation  in  eight.  Rogers 
advises  early  resection  or  amputation  to  save  time,  believing  that  the 
duration  of  treatment  be  cut  down  to  not  exceeding  two  years,  if 
possible.     Considering  these  statistics  as  a  whole,  they  are  far  from 


36  JACQUES    CALVE 

encouraging,  and  suggest  that  radical  measures  were  often  too  long 
delayed.  The  writers  believe  that  when  the  diagnosis  of  tuberculosis 
of  the  ankle-joint  is  certain,  and  the  roentgenogram  shows  definite 
bony  involvement  of  the  astragalus,  or  of  both  astragalus  and  tibia, 
in  a  wage-earner,  our  attitude  should  be  much  the  same  as  it  is  in 
tuberculosis  of  the  knee.  Few  surgeons  will  now  hesitate  to  recom- 
mend early  resection  of  the  knee.  The  statistics  just  quoted  show 
clearly  enough  that  conservative  treatment,  even  if  successful,  requires 
loo  long  a  healing  period.  Also,  that  amputations  are  far  too  frequent 
to  justify  delay  in  resorting  to  radical  measures  in  the  type  of  cases 
cited. 

Spengler,  following  a  series  of  cases  from  Kocher's  clinic,  found 
that  40  per  cent,  of  the  patients  suffering  from  ankle  tuberculosis  had 
died  of  some  form  of  tuberculosis  within  a  ten-year  period.  The  re- 
striction of  normal  activity  incidental  to  ankle  disease,  conservatively 
treated  over  long  periods,  must  be  admitted  as  an  important  factor 
in  predisposing  to  pulmonary  and  other  tuberculous  lesions.  In  per- 
sons other  than  laborers,  with  definite  tuberculous  involvement  of 
ankle-joint  and  component  bones,  conservative  treatment  is  fully  jus- 
tified and  may  be  indicated  for  a  period  of  perhaps  six  months.  This 
will  be  sufficient  to'  give  one  some  idea  as  to  the  virulence  of  infection 
and  resistance  of  the  individual.  If  during  this  time  there  is  no  de- 
cided improvement,  disappearance  in  whole  or  at  least  in  large  part 
of  the  swelling,  pain  and  infiltration  of  soft  parts,  much  time  will  be 
gained  by  radical  operative  measures. 

A  good  general  plan  for  conservative  treatment  modified  to  suit  the 
individual  case  would  involve,  in  acute  cases,  rest  in  bed  for  two  weeks, 
with  elevation  of  the  foot,  elastic  compression  bandage  over  lamb's 
wool,  followed  by  plaster  cast  from  just  below  the  knee  to  toes.  If 
the  oast  is  well  hollowed  about  the  knee,  it  is  not  necessary  to  go  above 
the  knee.  Beginning  deformity  can  be  corrected  easily  in  this  early 
period  by  gentle  molding  of  the  foot  and  retention  in  the  corrected 
position  by  a  succession  of  casts.  Weight-bearing  should  be  avoided 
by  use  of  crutches  and  elevation  of  opposite  shoe.  Later,  a  Thomas 
splint,  also  preventing  weight-bearing,  may  be  substituted.  If  in  six 
months  there  is  decided  improvement,  a  double-bar  splint  extending 
from  below  the  knee  into  the  shoe,  with  melted  leather  ankle  support 
and  foot  plate,  can  be  substituted  in  the  later  stages.  General  consti- 
tutional measures,  exercises  not  involving  the  joint,  and  heliotherapy, 
of  course,  are  presupposed  here  as  in  treatment  of  all  joint  tubercu- 
losis.    The  Bier  treatment  has  not  been  used  because  it  cannot  be  em- 


TREATMENT  OF  TUBERCULOSIS  OF  THE  ANKLE  IN  THE  ADULT  37 

ployed  at  the  same  time  maintaining  consistent  fixation.  Attention 
to  proper  shoeing,  especially  to  support  of  the  arch,  is  advisable. 

As  in  operative  treatment  of  tuberculosis  of  the  knee,  the  impor- 
tant point  is  to  eliminate  motion.  This  is,  perhaps,  not  as  easily  ob- 
tained in  the  ankle  as  it  is  in  the  knee  because  it  is  more  difficult  to 
obtain  firm  and  continuous  bony  contact.  In  the  knee  the  broad 
femoral  and  tibial  surfaces  are  more  readily  held  by  long  spikes  or 
other  means  of  fixation. 

Of  the  thirty  different  approaches  to  the  ankle-joint  referred  to  by 
Koenig,  the  Kocher  method  appears  to  be  the  most  generally  applic- 
able and  has  been  the  method  employed  in  the  cases  to  be  reported. 

TECHNIQUE  OF  OPERATION. 

Vertical  incision  from  a  point  just  behind  the  fibula  and  about  two 
inches  above  the  external  malleolus  downward,  curving  forward  below 
the  tip  of  the  malleolus  and  extending  forward  on  dorsum  to  lateral 
border  of  head  of  astragalus,  division  of  peroneal  tendons  low  down 
below  external  malleolus;  division  of  external  lateral  ligament  of  the 
ankle,  also  of  posterior  and  anterior  portions  of  capsule  as  far  as  neces- 
sary in  order  to  dislocate  the  foot  completely  inward  so  that  the  sole 
of  the  foot  looks  directly  upward.  This  gives  an  excellent  exposure 
of  the  interior  of  the  joint,  enabling  careful  inspection  and  removal  of 
diseased  synovial  membrane  as  well  as  of  articulating  surfaces  of 
tibia,  fibula,  and  astragalus.  This  entire  articulating  cartilage  is  re- 
moved without,  however,  sacrificing  any  more  healthy  bone  than  is 
necessary.  Care  is  taken  to  eradicate  any  diseased  tissue  between  the 
tibia  and  fibula.  The  denuded  astragalus  is  shaped  so  as  to  fit  ac- 
curately into  the  fork  of  the  tibia  and  fibula.  In  one  case  of  another 
type,  not  included  in  the  present  series,  the  fibula  had  to  be  fractured 
and  the  malleolus  displaced  inward  in  order  to  secure  proper  contact. 
A  very  slight  degree  of  equinus  to  allow  for  the  usual  height  of  the 
heel  of  the  shoe  is  advisable.  The  foot  should  be  in  mid-position  be- 
tween valgus  and  varus.  When  the  astragalus  cannot  be  saved,  a 
tibia-calcaneal  arthrodesis  is  performed  by  removal  of  cartilage  on 
superior  portion  of  os  calcis  and  lower  portion  of  tibia.  In  this  case, 
it  is  well  to  set  the  foot  backward  on  the  tibia  in  order  to  avoid  the 
unwieldiness  of  the  foot,  just  as  in  the  Whitman  astragalectomy  for  cal- 
caneo-valgus  following  infantile  paralysis.  In  one  of  the  modern  text- 
books it  is  stated  that  in  case  the  disease  is  confined  to  the  ankle-joint, 
astragalectomy  may  assure  removal  of  the  disease,   with  retention  of 


38  JACQUES    CALVE 

motion.  This  advice  runs  counter  to  the  generally  accepted  principle 
that  elimination  of  motion  is  essential  in  controlling  the  disease.  Ely 
believes  it  is  the  conversion  of  lymphoid  marrow  into  fatty  marrow 
which  is  responsible  for  the  cure.  This  belief  is  erroneous  because 
these  ankle  cases  get  well  when  motion  is  eliminated,  in  spite  of  the 
fact  that  the  marrow  does  not  change  from  lymphoid  to  fatty.  So  far  as 
T  know,  there  are  no  autopsy  records  available  showing  that  even  in 
the  ankylosed  knee-joint  the  lymphoid  marrow  gives  way  to  fatty 
marrow.  In  the  cases  reported  no  special  means  of  fixation  were  used 
outside  of  a  snugly  fitting  plaster  cast.  Stiles  uses  a  long,  square 
nail  introduced  through  the  plantar  surface  of  the  heel  through  the 
os  calcis,  astragalus,  and  tibia.  He  removes  the  nail  in  three  weeks, 
when  a  plaster  cast  is  applied.  If  the  disease  is  confined  to  the  as- 
tragalus and  if  it  cannot  be  saved  with  safety  without  extension  to 
the  joints,  it  may  be  removed  and  the  foot  displaced  backwards. 

In  Stiles '  series  of  fifteen  traced  cases,  mixed  adult  and  children, 
there  were  two  in  which  ankylosis  was  not  complete,  slight  flexion  and 
extension  being ,  permitted.  In  one  there  was  a  discharging  sinus.  In 
every  case  the  patient  walked  well  without  support. 

In  dealing  with  tuberculosis  of  the  smaller  tarsal  bones,  there  is  no 
reason  why  the  principle  of  arthrodesis  should  not  be  carried  out  in  a 
considerable  portion  of  the  cases.  Certainly  in  astragalo-tibial  and 
calcaneo-cuboid  disease  there  should  be  no  difficulty.  When  the  cunei- 
form bones  are  involved  it  is  likely  that  considerable  sacrifice  of  bone 
will  prevent  firm  bony  contact  of  the  walls  bounding  the  resulting 
cavity,  in  which  case  removal  of  the  entire  bone  may  be  necessary. 

All  curetting  operations  should  be  condemned  because  one  cannot 
see  what  is  being  done ;  healthy  bone  upon  which  we  must  depend  for 
firm  bony  ankylosis  is  likely  to  be  removed,  and  diseased  bone  and 
cartilage  are  left  behind,  also  uninvolved  synovial  sacs  may  be  en- 
tered. Primary  closure  of  the  wound  is  indicated  wherever  possible. 
In  case  of  sinuses  drainage  of  superficial  tissues  is  necessary.  After- 
treatment  should  be  conducted  just  as  in  non-operative  cases.  If  the 
disease  is  very  extensive  and  not  likely  to  be  controlled  by  methods 
above  outlined,  amputation  should  be  performed.  Statistics  quoted 
here  indicate  that  it  would  have  been  a  time-saving  and  often  a  life- 
saving  measure  in  many  of  the  cases  terminating  unfavorably. 

The  cases  forming  the  basis  of  this  report  are  arranged  in  tabular 
form  and  require  no  especial  comment.  In  conclusion,  the  following 
statements  are   offered  as  answers  to   the   questions  proposed   in  the 


THE  TREATMENT  OF  PARALYTIC  FLAT  FEET  39 

beginning  of  this  article,  attention,  however,  being  called  to  the  fact 
that  disease  in  adults  only  is  considered. 

The  prognosis  of  tuberculosis  of  the  ankle  in  the  adult  with  con- 
servative treatment  is  poor.  In  the  present  series  no  case  of  astragalo- 
tibial  disease  was  treated  conservatively,  the  only  non-operative 
case  reported  being  one  of  subastragalar  disease. 

The  duration  of  conservative  treatment  in  the  cases  terminating 
favorably,  according  to  the  only  statistics  referring  to  adults,  is  four 
years. 

A  six  months'  period  of  conservative  treatment  will  probably  be 
sufficient  to  determine  efficacy  of  this  form  of  treatment. 

Statistics  referred  to  show  that  amputation  is  far  too  frequent  be- 
cause conservative  measures  are  persisted  in  for  too  long  a  period, 
also  that  in  the  cases  followed  over  a  ten-year  period,  nearly  50  per 
cent,  died  of  other  forms  of  tuberculosis.  In  further  reports  of  cases, 
separation  of  cases  into  adult  and  childhood  groups  is  urged. 


THE  TREATMENT  OF  PARALYTIC  FLAT  FEET. 

BY  LEO  MAYER,  M.D.,  NEW  YORK  CITY. 

In  the  treatment  of  paralytic  flat  feet,  exact  recognition  of  the  grade 
of  the  deformity  is  as  important  as  the  operative  technique  employed 
in  its  correction.  It  is,  therefore,  well  to  attempt  to  classify  paratytic  flat 
feet  into  a  number  of  different  types,  depending  upon  which  muscles 
are  weakened  and  the  extent  to  which  they  are  paralyzed. 
Type  1. 

In  this,  the  tibialis  anticus  is  the  only  muscle  paralyzed.  All  the 
other  invertors  of  the  foot  function  normally.  Consequently,  with  the 
foot  below  a  right  angle,  inversion  is  possible,  but  when  the  foot  is  held 
dorsiflexed,  little  or  no  inversion  can  be  performed.  In  treating  this 
type  of  case  it  is  always  advisable  to  make  a  preliminary  test  to  de- 
cide the  degree  of  paralysis  of  the  tibialis  anticus  since  very  frequent- 
ly some  of  the  muscle  fibres  are  still  intact  and  require  only  suitable 
chance  to  regain  their  normal  length  before  their  function  can  be  made 
to  return.    This  test  consists  in  immobilizing  the  foot  in  such  a  posit  i<  n 


40  LEO    MAYER 

as  to  bring  the  origin  and  insertion  of  the  tibialis  anticus  as  near  to- 
gether as  possible — in  other  words,  in  calcaneo-varus.  If  the  Achilles 
tendon  is  shortened  and  offers  any  resistance,  it  should  be  divided  sub- 
cutaneously.  The  foot  should  be  held  in  this  position  of  calcaneo-varus 
for  five  or  six  weeks.  If  by  that  time  there  is  no  return  of  function 
in  the  tibialis  anticus,  its  paralysis  may  be  safely  assumed  to  be  complete. 
In  that  event,  the  treatment  would  be  the  same  as  that  employed  in 
certain  cases  of  the  second  type.  If,  however,  as  frequently  occurs,  the 
muscle  shows  a  spark  of  contractile  power,  the  postural  treatment 
should  be  continued  and  every  attempt  made  to  further  strengthen  the 
returning  life  of  the  muscle  by  exercises,  massage,  and  all  other  means 
cf  increasing  its  nutrition.  In  this  preliminary  test  of  the  muscle,  I 
have  found  plaster  of  Paris  most  suitable  for  the  purpose.  When  the 
muscle  is  beginning  to  function  after  the  six  weeks'  test,  I  use  a  brace, 
holding  the  foot  in  the  same  position  and  allowing  the  patient,  at  the 
same  time,  to  walk  about. 
Type  II. 

This  second  group  of  cases  includes  those  of  the  first,  in  which  the 
tibialis  anticus  has  shown  itself  to  be  conpletely  paralyzed,  and  those 
in  which,  with  a  partial  paralysis  of  the  tibialis  anticus,  there  is  as- 
sociated some  weakness  of  the  other  inverting  muscles.  In  these  in- 
stances the  postural  treatment  alone  will  not  be  sufficient  to  restore  the 
normal  muscle  balance,  and  recourse  must  be  had  to  operation. 

In  using  the  term  "muscle  balance,"  I  realize  that  I  am  using  words 
about  which  we  as  yet  know  comparatively  little.  It  is  only  in  recent 
years  that  exact  tests  have  been  made  to  determine  the  ratio  of  the 
strength  of  the  invertors  to  the  evertors  of  the  foot,  and  as  yet  no 
thorough  statistical  evidence  has  been  presented  on  this  important 
topic.  Goldthwait,  Painter,  and  Osgood,  in  "Diseases  of  the  Bones 
and  Joints,"  Chapter  XII.,  record  the  ratio  in  22  normal  feet,  as  ad- 
ductors, 10;  abductors,  8.2.  At  the  Children's  Hospital  in  Boston, 
where  the  spring  balance  test  has  been  carried  out  during  the  last 
few  years,  and  certain  tables  of  averages  for  different  ages  have  been 
tabulated,  the  results  show  in  general  a  predominance  in  the  power 
of  the  invertors  over  the  evertors;  but  the  variation  is  so  marked  from 
one  age  to  another  that  a  certain  degree  of  error  seems  probable.  Thus, 
for  the  seven-year-old  child,  the  ratio  is  22  to  22;  for  the  ten-year-old 
ehild,  35  to  30;  for  the  eleven-year-old,  39  to  32;  for  the  seventeen- 
year-old,  58  to  57.  Nor  are  we  much  helped  by  the  exact  anatomical 
studies  carried  on  by  Rudolf  Fick  and  his  pupils.  They  have  attempted 
to  compute  the  relative  strength  of  muscle  groups  by  measuring  the 
amount  of  shortening  of  each  muscle,  and  computing  the  exact  power 


THE  TREATMENT  OF  PARALYTIC  PLAT  FEET  41 

•exercised  by  the  muscle  when  contracting  this  particular  distance. 
Pick's  table,  p.  629  of  his  "Anatomy  of  the  "Joints,"  Vol.  III.,— com- 
puting the  relative  strength  of  the  invertors  and  the  evertors  when 
-moving  the  astragalo-calcaneus  joint, — gives  a  ratio  of  7.86  to  3.22. 
That  is,  the  invertors  are  supposedly  twice  as  strong  as  the  evertors, — 
a  fact  which  evidently  clashes  with  the  clinical  data  obtained  by  muscle 
tests  on  the  living.  Even  the  question  of  which  muscles  invert  and 
which  evert,  is  still  subject  to  dispute,  since,  according  to  Fick,  the 
tibialis  anticus  may  be  reckoned  to  the  evertors  as  well  as  to  the  in- 
vertors. 

My  own  studies  of  muscle  balance,  carried  out  with  Biesalski,  in  1914, 
brought  out  several  significant  facts  in  this  connection,  but  still  left 
the  subject  almost  as  unsolved  as  it  had  been  before.  Our  work  stowed 
that  the  tibialis  anticus  acts  as  a  strong  invertor  when  the  foot  is  below 
an  angle  of  90  degrees;  that  when  further  dorsiflexion  occurs,  the 
tibialis  anticus  loses  some  of  this  action  and  actually  draws  the  foot 
into  slight  abduction.  When,  however,  the  action  of  the  tibialis  anti- 
■cus  is  combined  with  that  of  the  Achilles  tendon,  marked  inversion  and 
adduction  of  the  foot  occurs,  irrespective  of  the  amount  of  dorsiflexion. 

Without  going  into  further  details  of  muscle  balance,  for  clinical 
purposes  I  have  been  accustomed  to  follow  the  simple  rule  that  the 
invertors  should  slightly  out-balance  the  evertors,  and  that  when  this 
ratio  does  not  hold,  normal  muscle  balance  does  not  exist. 

In  this  second  type  of  case,  the  disturbance  of  muscle  balance  is  suf- 
ficiently accentuated  to  justify  the  attempt  to  increase  the  strength  of 
the  inverting  muscles  by  tendon  transplantation.  For  this  purpose 
I  use  one  of  two  muscles,  depending  upon  the  grade  of  paralysis.  In 
the  lighter  cases,  the  extensor  proprius  hallucis  is  used;  in  the  more 
severe  cases,  the  peroneus  longus.  Under  no  circumstances  do  I  ap- 
prove of  using  the  peroneus  brevis,  since  this  muscle  has  such  a  low 
point  of  origin  that  it  cannot  be  transformed  into  an  inverting  muscle 
unless  practically  all  of  its  muscle  fibres  be  cut  away  from  the  bone. 
In  the  operative  technique,  I  employ  the  sheath  method  described  by 
Biesalski  and  myself.  The  insertion  of  the  paralyzed  tibialis  anticus 
is  first  exposed,  then  the  upper  end  of  the  tibialis  anticus  sheath. 
Through  a  small  opening  in  the  sheath,  an  eye  probe  carrying  a  guide 
ligature  is  passed  downward  through  the  sheath  and  made  to  emerge 
over  the  insertion  of  the  tibialis  anticus  tendon.  The  tendon  to  be 
transplanted  is  then  exposed  and  is  drawn  downward  through  the 
sheath  of  the  tibialis  anticus  by  means  of  the  guide  suture. 
In  transferring  the  peroneus  longus,  a  fascial  plastic  is  a  physiological 
necessity,  since  otherwise  adhesions  would  be  likely  to  occur  where  the 


42 


LEO    MAYER 


tendon  crosses  the  septum  inter-musculare  anterius,  separating  the 
lateral  from  the  anterior  muscular  compartments  of  the  calf.  This  plas- 
tic consists  in  cutting  a  trap -door  in  the  fascia  of  each  of  these  muscu- 
lar compartments,  everting  the  fascia  so  as  to  expose  its  deep  surface 
covered  with  gliding  tissue  (paratenon),  and  uniting  the  two  fascial 
edges  by  means  of  a  Lembert's  suture,  exactly  as  in  executing  the  serosa 
suture  of  a  gastroenterostomy.  The  transplanted  tendon,  either  the 
extensor  proprius  or  the  peroneus  longus,  is  attached  to  the  bone  at 
the  insertion  of  the  tibialis  anticus  by  a  firm  suture  which  assures 
mechanical  fixation  until  physiological  fixation  has  occurred.  Animal 
experimentation,  as  well  as  observations  at  secondary  operations,  have 
shown  that  this  physiological  fixation  of  the  tendon  occurs  within  six- 
teen days;  accordingly,  after  this  period  it  is  safe  to  begin  active  ex- 
ercise of  the  transplanted  tendon. 
Type  111. 

This  group  of  cases  includes  those  in  which  there  is  complete  paraly- 
sis of  all  the  invertors  except  the  Achilles  tendon.  The  method  of 
operative  procedure  for  cases  of  this  kind  is  still  unsettled  in  my  own 
mind.  The  transplantation  of  the  peroneus  longus  alone  does  not  suf- 
fice to  restore  the  preponderance  of  the  inverting  strength.  Something 
additional  must  be  done.  I  have,  myself,  tried  a  number  of  different 
expedients,  but  I  am  not  convinced  that  I  have  yet  found  the  satis- 
factory solution  of  the  problem.     In  one  instance,  I  transplanted  the 


peroneus-longus. 
Fig.  1.— Paralytic  flat  foot  of  type  2,  before  and  after  transplantation  of  the 
A:     Before  operation;   B :     After  operation;  O:     Showing  the  voluntary 
power  of  inversion  after  transplanting  tlie  peroneus-longus. 

extensor  longus  digitorum  to  the  inner  side  of  the  foot.  A  flap  inci- 
sion was  made,  exposing  the  four  extensor  tendons  near  the  metatarsal 
heads,  each  tendon  was  dissected  out,  and  then  the  four  tendons, 
fastened  together,  were  brought  through  a  subcutaneous  channel  to 
the  inner  side  of  the  foot.     The  result,  as  pictured  in  Figure  2,  was 


THE  TREATMENT  OP  PARALYTIC  PLAT  FEET 


43 


Fig.  2.— Paralytic  flat  foot,  type  3  (complete  paralysis  of  all  the  invertors  ex- 
cept the  Achilles  tendon).  On  the  right,  position  of  the  foot  before  opera- 
tion; on  the  left,  the  result  one  year  after  transplanting  the  peroneus- 
longus  and  the  extensor  longus  digitorum.  The  middle  illustration  shows 
the  voluntary  power  of  flexion  and  extension  and  the  ability  of  the  pa- 
tient to  extend  the  toes,  despite  the  transplantation  of  the  extensor  longus 
digitorum. 


gratifying.  In  four  cases,  I  transferred  the  extensor  proprius  hallucis 
in  addition  to  the  peroneus  longus.  The  results  in  these  cases  were 
less  satisfactory,  owing  to  the  fact  that  the  extensor  proprius  is  a  much 
less  powerful  evertor  of  the  foot  than  the  extensor  digitorum.  Stoffel 
uses  the  peroneus  tertius  in  conjunction  with  the  peroneus  longus; 
Kleinberg  supplements  the  tendon  transplantation  by  attaching  the 
tibialis  anticus  to  the  tibia  in  such  a  way  as  to  act  as  a  check  ligament. 
Whitman  has  suggested  the  "loop"  operation,  in  wThich  the  tibialis 
anticus  is  bound  around  the  extensor  tendons  in  such  a  way  as  to  con- 
vert them,  supposedly,  into  invertors.  None  of  these  solutions,  how- 
ever, seems  to  me  to  be  getting  at  the  main  difficulty,  namely,  the  marked 
weakness  which  is  bound  to  result  from  a  complete  paralysis  of  that 
most  important  inverting  muscle,  the  tibialis  posticus.  Until  some 
method  of  affording  some  substitute  for  this  paralyzed  muscle  is  found, 
our  results  are  bound  to  be  imperfect. 
Type  IV. 

In  this  last  group  there  is  complete  paralysis  of  all  the  invertors,  in- 
cluding the  Achilles  tendon.     Fortunately,  this  type  of  foot,  in  which 


44  LEO    MAYER 

only  the  peroneal  muscles  and  the  extensor  longus  digitorum  function, 
is  seen  but  seldom.  I  have  not  found  it  advisable  to  attempt  trans- 
plantation, but  prefer  a  simple  tenotomy  of  the  active  tendons,  in  ad- 
dition to;  a  bone  stabilization  at  the  ankle. 

The  after-treatment  of  all  cases  of  paralytic  flat  foot  demands  as  much 
attention  as  the  preliminary  examination  and  the  operative  procedure. 
A  suiiable  appliance  is  always  indicated  until  the  surgeon  is  convinced 
that  the  weakened  muscles  have  regained  their  maximum  strength.  In 
some  cases,  a  light  arch  support  is  sufficient ;  in  others,  an  outer  bar  calf 
splint  with  a  strap  on  the  inner  side  of  the  boot,  holding  the  foot  in 
the  inverted  position.  Occasionally,  a  double  bar  calf  splint,  with  foot- 
sandal,  is  necessary.  Each  case  should  be  studied  individually,  and 
that  type  of  support  used  which  is  lightest  and  yet  able  to  do  the  work 
required.' 

Without  post-operative  muscle  training,  no  tendon  transplantation 
will  succeed,  and  unless  this  muscle  training  be  kept  up  for  many 
months,  some  cases  which  promised  well  at  first  will  prove  utter  failures. 

To  hold  the  foot  in  the  proper  position  while  the  patient  sleeps,  a 
simple  night  splint  of  plaster  of  Paris  or  celluloid  should  always  be 
employed. 

Difficult  though  the  problem  of  the  paralytic  flat  foot  may  be,  and 
unsuccessful  though  we  still  are  in  the  treatment  of  many  of  the 
severer  cases,  the  success  attendant  upon  careful  attention  to  every 
detail  of  the  treatment  in  a  large  number  of  patients  leads  me  to  the  op- 
timistic belief  that  by  further  study,  and  by  a  frank  avowal  of  our 
failures,  we  may  soon  reach  a  degree  of  knowledge  which  will  enable 
us  to  cope  successfully  with  every  instance  of  paralytic  flat  foot. 


OSTEITIS  DEFORMANS   (PAGET's  DISEASE),  REPORT  OF  THREE  CASES        45 


OSTEITIS  DEFORMANS    ( PAGET 'S   DISEASE),   WITH   A   RE- 
PORT OP  THREE  CASES. 

BY   PHILIP  LEWIN,   M.D.,  CHICAGO. 

Attending    Orthopaedic   Surgeon,   Cook    County   Hospital;   Attending 
Orthopaedic  Surgeon,  St.  Luke's  Hospital;  Associate  in  Ortho- 
paedic Surgery,  Northwestern  University  Medical  School. 


Definition. 

Historical :  Literature. 

Incidence. 

Synonyms. 

Etiology. 


OUTLINE. 


Pathology. 
Symptoms. 

Diagnosis. 

Prognosis. 

Treatment. 
Report  of  Cases. 
Conclusions. 
Thanks. 
Bibliography. 


[Age. 
Predisposing  Causes,  -s  Sex. 

I  Heredity. 


Exciting  Causes. 

Pathogenesis. 

Subjective — Pain. 
Objective. 

Complications. 

Differential, 
f  Life. 
I  Cure. 


Syphilis. 
Bacteria. 
Neurotrophic. 
Glandular. 


(Deformities. 
^Relation  of  Fractures. 
Metabolism. 


DEFINITION. 


Osteitis  Deformans  (Paget 's  Disease)  is  a  symptom  complex  of  un- 
known origin,  characterized  by  minor  subjective  symptoms  but  impor- 
tant objective  findings  of  deformities  occurring  chiefly  in  the  skull  and 


46  PHILIP  LEWIN 

long  bones.  Cervico-dorsal  kyphosis,  prominent  clavicles,  and  diamond- 
shaped  abdomen  are  found.  It  is  a  disease  of  late  middle  life  and  is 
progressive.    As  yet  there  is  no  cure. 

SYNONYMS. 

Depending  upon  the  interpretation  of  the  pathology  as  understood 
by  various  writers,  there  have  been  applied  to  this  disease  a  great  num- 
ber of  terms.  Some  of  these  are:  senile  pseudo-rickets  (Barker), 
(Pozzi),  fibrous  osteomyelitis  (Von  Recklinghausen),  localized  osteo- 
malacia (Oilier),  hypertrophic  osteosclerosis  (Menetrier  and  Gauckler), 
hypertrophic  deforming  chronic  osteomalacia  (Schmieden),  diffuse  os- 
sifying osteitis  (Lancereaux),  fibrous  megalo-osteitis  (Gauiciero), 
osteolyose  (Lobstein),  craniosclerosis  (Huschke),  hyperostose  gener- 
alised osteite  condensante  (Volkmann),  benign  hypertrophic  osteo- 
malacia (Vincent). 

English  and  American  writers,  as  a  rule,  adhere  to  the  terms  osteitis 
deformans  or  Paget 's  disease  of  the  bones. 

HISTORICAL. 

In  1876,  Sir  James  Paget  described  a  rare  form  of  chronic  inflamma- 
tion of  the  bones,  since  called  by  his  name.  He  presented  a  report  of 
five  cases  before  the  Royal  Medical  and  Chirurgical  Society  of  London. 
Only  two  of  these  cases  were  his  own.  He  saw  his  first  case  in  1856 
but  did  not  report  it  until  twenty  years  later.  One  of  the  five  cases  had 
been  previously  described  by  Wilks  in  1869,  under  the  name  of  osteo- 
porosis, or  spongy  hypertrophy  of  the  bones,  and,  according  to  Gaenslen, 
the  autopsy  in  this  case  (by  Wilks  and  Goodhart)  is  probably  the  first 
on  record.  Preceding  both  Paget  and  Wilks,  Wrany,  in  1867,  described 
a  case  which  was  undoubtedly  a  true  case  of  this  condition.  Paget  called 
it  osteitis  deformans,  unaware  of  the  fact  that  Czerny,  in  1873,  had 
used  the  term  osteitis  deformans  in  describing  "a  rare  acute  inflamma- 
tion of  the  lower  part  of  the  tibia  and  fibula;  inducing  softening  and 
angular  bending,  and  followed  by  hardening."  In  1697,  Malpighi 
called  attention  to  the  diffuse  hypertrophy  of  the  skull,  a  condition 
which  Virchow  later  called  "leontiasis  ossea"  and  thought  by  many 
to  be  very  closely  related  to,  if  not  a  manifestation  of,  osteitis  defor- 
mans. 

The  most  important  articles  are  those  by  Paget,  Wilks,  Czerny, 
Packard,  Steele  and  Kirkbride,  DaCosta,  Funk,  Bergeim  and  Hawk, 
Lannelougue,  Gaenslen,  and  Hurwitz.  The  writer  has  quoted  freely 
from  these,  as  well  as  other  excellent  papers. 


OSTEITIS  DEFORMANS  ( PAGET 's  DISEASE),  REPORT  OF  THREE  CASES        47 


Fig.      1. — From      Paget's      original 
(Gaenslen). 


paper 


INCIDENCE. 


In  1901,  Packard,  Steele  and  Kirkbride  made  a  careful  study  of  the 
literature  and  found  sixty -six  cases  typical  of  this  disease.  They  added 
one  case.  In  1910,  Higbeeand  Ellis  estimated  there  were  one  hundred 
and  eight  cases  on  record.  DaCosta,  Funk,  Bergeim  and  Hawk  found 
fifty  more  up  to  June,  1914,  and  added  three  more.  Funk  brought 
the  number  up  to  two  hundred  and  thirty-two,  June  1,  1917,  since  which 
time  the  author  found  sixteen  cases  in  the  literature.  With  the  three 
cases  reported  in  this  paper,  the  total  number  to  date  is  about  two  hun- 
dred and  fifty-one. 


48 


PHILIP  LEWIN 


Fig.   2. — From   Hutchinson's   paper    (Gaenslen). 


Fig.   3. — Skull   from    a  case   of  osteitis 
deformans    ( Frangenheim ) . 


OSTEITIS  DEFORMANS  (  PAGET  *S  DISEASE),  REPORT  OF  THREE  CASES        49 


Fig.  4. — Cross-section  of  the  upper  end 
of  the  femur  (Frangenheim). 


In  38,000  records  of  the  New  Jefferson  Hospital,  covering  a  period 
of  seven  years,  there  were  only  three  cases  of  Paget 's  disease  (Funk), 
and  Hurwitz  found  three  cases  in  30,000  medical  admissions  to  Johns 
Hopkins  Hospital. 

ETIOLOGY. 

Predisposing  Causes. 

Age.  The  average  age  of  onset  in  fifty-one  cases  studied  by  Packard, 
Steele  and  Kirkbride  was  49%  years.  Various  writers  have  re- 
ported cases  starting  very  young,  viz.,  Sonneberg  at  sixteen  years,  Eis- 
ner at  twelve  years,  Jones  at  sixteen  years,  Thibierge  at  thirteen  years, 
Hartman  at  fifteen  years.  In  one  case  of  DaCosta  et  al.,  the  head  in- 
volvement began  at  eight  years  of  age.  The  oldest  recorded  age  of  on- 
set was  seventy -nine  years.  Stillings'  ninety-two  years  old  case  has  no 
data  concerning  onset. 

Sex.  Males  are  more  frequently  affected  in  the  proportion  of  about 
six  to  five. 

Heredity.  Heredity  is  said  to  be  of  importance  in  approximately 
7%  of  cases.  For  example,  a  father  and  two  sons  (Oettinger  and  La- 
Fout)  ;  two  brothers  (White)  (Loinn)  (Abbe)  ;  two  sisters  (DaCosta 
ct  al.)    (Parry)  ;  mother  and  son  (Higbee  and  Ellis)    (Berger)    (Hur- 


50 


PHILIP  LEWIN 


Fig.  5. — Author's  case  No.  3. 
witz)  ;  mother  and  daughter  (Chauffard)  ;  brother  and  sister  (Kilner) 
(Walter)  ;  father  and  son  (Smith)  ;  father  and  daughter  (Pick). 

Color.  Color  does  not  seem  to  be  important  although  two  of  the 
herein  reported  cases  are  negroes. 

Exciting  Causes.  As  regards  the  exciting  cause  of  osteitis  deformans, 
it  is  practically  as  obscure  today  as  it  was  at  the  time  of  Paget 's  original 
communication  forty-five  years  ago.  There  are  many  theories,  the  most 
important  of  which  are :  Syphilitic,  infectious,  endocrine,  neurotrophic, 
metabolic. 

Syphilis.  Paget  believed  it  was  not  associated  with  syphilis,  but 
was  due  to  a  chronic  inflammatory  process.  The  French,  however,  nota- 
bly Lannelongue,  Fournier,  Ettienne  and  Vergne,  believe  that  it  is  a 
late  manifestation  of  hereditary  syphilis.  The  English  and  American 
writers  do  not  believe  in  the  syphilitic  theory  and  regard  that  disease 
as  of  relative  unimportance.  It  seems  to  be  definitely  in  evidence  that 
AYassermann  tests  are  usually  negative,  and  that  antisyphilitic  treat- 
ment is  of  no  avail. 


OSTEITIS  DEFORMANS  ( PAGET 's  DISEASE),  REPORT  OP  THREE  CASES        51 

Chronic  Infectious  Theory.  There  are  those  who  believe  that  a 
chronic  low-grade  infection  from  any  source  may  produce  bony  changes 
such  as  those  found  in  Paget 's  disease.  Some  of  these  writers  are  of 
the  opinion  that  this  condition  and  arthritis  deformans  are  manifesta- 
tions of  the  same  disease.  The  concurrence  of  Paget 's  disease  with 
arthritis  deformans,  cardiovascular  disease  and  carcinoma  has  led  vari- 
ous writers,  to  assume  a  close  relationship  between  them;  but  this  evi- 
dence is  merely  speculative. 

Morpurgo,  Archangeli  and  Fiocca  found  a  diplococcus  in  the  bones 
of  animals  in  which  osteomalacia  had  been  produced  experimentally, 
and  in  the  iliac  bones  of  women  suffering  with  the  disease.  They  pre- 
pared a  vaccine  and  reported  favorable  results  in  the  treatment  of  thir- 
teen cases  of  osteomalacia  and  one  case  of  osteitis  deformans.  Arch- 
angeli believes  that  osteomalacia,  rickets,  and  Paget 's  disease  are  man- 
ifestations of  the  same  disease  and  upon  this  assumption  conducted 
further  observations.  An  organism  similar  to  the  one  previously  found 
was  isolated  from  the  tibia  of  a  woman  with  Paget 's  disease  and  a  vac- 
cine prepared.  It  was  given  four  cases  with  decided  improvement  in 
two  cases,  beginning  improvement  in  one  and  no  manifest  change  in  the 
fourth.  DaCosta,  Funk,  et  al.,  tried  to  make  a  vaccine,  but  culture  and 
animal  inoculation  experiments  were  negative. 

Neurotrophic  Theory.  In  1883,  Lancereaux  expressed  the  belief 
that  Paget 's  disease  had  as  an  underlying  cause  a  disturbance  of  the 
nervous  system.'  The  relationship  between  bone  dystrophies  and  ner- 
vous conditions  was  offered  as  an  argument.  Pitres  and  Vaillard 
thought  it  was  due  to  degeneration  of  the  nerves  entering  the  nutrient 
foramina.  Recklinghausen's  case  showed  at  autopsy  chronic  myelitis. 
Various  writers  have  described  lesions  of  the  medulla,  of  the  peripheral 
nerves,  involvement  of  basal  tracts  and  spinal  cord.  There  has  been 
no  constancy  of  autopsy  reports.  The  disease  has  been  described  in  a 
tabetic  and  in  association  with  Huntington's  chorea.  Emerson  believes 
the  cord  changes  are  due  to  arteriosclerosis.  It  is  the  writer's  belief 
that  disturbances  of  the  nervous  system  may  be  the  underlying  cause 
of  a  disturbed  metabolism  in  some  cases  and  therefore  indirectly  cause 
osteitis  deformans,  the  intermediary  being  the  ductless  glands. 

Endocrine  Theory.  Many  writers  have  tried  to  demonstrate  the  re- 
lationship between  Paget 's  disease  and  pathology  in  the  ductless  glands, 
notably  the  thyroid,  parathyroid,  pineal,  suprarenal,  and  pituitary. 
There  has  been  no  conclusive  evidence  to  warrant  such  interrelationship 
because  in  the  comparatively  few  cases  examined  pathologically  defi- 
nite chances  were  not  constant. 


52  PHILIP  LEWIN 

Metabolic  Theory.  The  most  complete  metabolic  studies  which  have 
been  made  of  this  condition  are  those  described  by  Bergeim  and  Hawk, 
whose  investigations  revealed  a  decided  retention  of  calcium,  magnesium, 
and  phosphorus,  and  a  pronounced  loss  of  sulphur.  These  findings 
were  interpreted  as  indicating  a  stimulated  osseous  or  osteoid  forma- 
tion, accompanying  the  absorption  of  a  highly  sulphurized  organic  mat- 
rix. In  advanced  osteitis  deformans  the  first  step  in  the  new  formation 
of  bone  or  osteoid  tissue  may  be  the  production  of  a  highly  sulphurized 
organic  matrix  which  is  transformed  gradually  by  a  calcification  pro- 
cess, which  is  accompanied  by  the  deposition  of  calcium  magnesium  and 
phosphorus  in  this  matrix.  In  the  course  of  this  calcification  process 
they  suppose  that  a  certain  quota  of  the  sulphur  of  the  matrix  is  re- 
placed by  the  other  elements  mentioned,  a  process  which  must  entail  the 
retention  of  calcium,  magnesium,  and  phosphorus,  and  an  accompany- 
ing increased  elimination  of  sulphur.  They  believe  that  the  metabolic 
picture  of  osteitis  deformans  is,  to  a  certain  degree,  that  seen  in  osteo- 
malacia. Arteriosclerosis  of  the  nutrient  arteries  of  the  bone  has  been 
regarded  as  the  cause  of  the  disease  by  some.  This  theory  is  not  borne 
out  by  the  fact  that  arteriosclerosis  is  a  very  common  condition,  espe- 
cially in  advanced  age,  during  which  period  Paget 's  disease  should  be 
very  common,  whereas  it  is  a  very  rare  disease  at  any  age. 

Tubby  described  marked  relief  in  one  case  in  diet,  and  therefore  be- 
lieves that  disturbed  metabolism  may  be  the  cause. 

Pathology.  As  the  three  cases  reported  in  this  paper  are  still  alive, 
it  is  necessary  to  review  the  literature  for  a  description  of  the  pathol- 
ogy. The  articles  of  Paget,  Packard,  Kirkbride  and  Steele,  DaCosta, 
et  al.,  are  freely  quoted. 

The  pathology  is  chiefly  in  the  bones  and  may  be  generalized  or  local- 
ized; the  latter  are  the  so-called  non-osteitic  types.  This  is  the  term 
applied  by  Schlesinger,  and  cases  have  been  described  by  him,  Schirmer, 
Bowlby,  and  Hurwitz.  They  described  cases  of  inflammation  of  a  single 
bone.  Paget  and  the  early  writers  believed  that  multiple  bone  involve- 
ment was  constant. 

The  gross  pathology  consists  in  the  deformities,  most  common  of 
which  is  outward  and  forward  bending  of  the  tibia.  Next  in  frequency 
is  the  femur,  and  then  the  other  long  bones.  The  tibia  shows  its  great- 
est thickening  on  its  convex  surface  and  the  outline  is  wavy  on  that  sur- 
face. The  joints  are  scarcely  ever  involved  in  the  disease,  although 
in  advanced  cases  there  may  be  limitation  of  motion  of  the  hip  (coxa 
vara),  ankle,  knee,  or  elbow,  due  to  the  thickening  deformity  of  adja- 


OSTEITIS  DEFORMANS  (  PAGET  *S  DISEASE),  REPORT  OF  THREE  CASES        53 


Fig.  G. — Author's  case  No.  3. 


cent  bones.  The  occurrence  of  fractures  is  not  increased  in  frequency. 
The  occurrence  of  the  deformity  is  most  frequently  manifested  in 
ihe  lower  extremity,  probably  because  of  the  effect  of  weight-bearing. 
Gradually  the  skull  or  clavicle  may  be  the  first  bones  involved  even  in 
advanced  stages  of  the  disease,  although  various  writers  have  described 
various  bones  as  being  involved  first,  namely,  the  external  malleolus, 
bones  of  the  feet,  metacarpals,  phalanges.  These  observations  are  rare 
and  unusual.  In  Levi's  case  neither  tibia  was  involved.  The  involve- 
ment is  usually  symmetrical,  although  there  are  cases  reported  in  which 
the  disease  was  limited  to  one-half  of  the  skeleton.  Marie  and  Leri  de- 
scribe peculiar  anomalies  in  the  skulls  of  persons  who  have  had  Paget 's 
disease  and  report  the  unexpected  discovery  of  extensive  syringomyelia 
a1  necropsy  in  one  case.  They  theorize  to  explain  this  by  mechanical 
faetors. 


54 


PHILIP  LEWIN 


Fig.   7. — Author's   No.  3. 


The  entire  thickness  of  the  cranium  is  composed  of  finely  porous  bone 
substance,  with  a  thin  inner  and  outer  plate  of  harder  bone.  The  diploe 
is  lost.  Microscopically,  the  porous  substance  consists  of  a  network  of 
thin  bony  processes.  Haversian  canals  are  confluent  as  a  result  of  ab- 
sorption forming  Howship's  lacunae  which  Butlin  believed  were  charac- 
teristic of  bone  inflammation.  The  lacunas  contain  numerous  giant  cells, 
leucocytes  and  fat  cells  in  a  vascular  connective  tissue  matrix.  There 
are  scattered  areas  of  newly  formed  bony  tissue.  The  osteoblasts  of 
this  new  bone,  while  present  in  considerable  numbers,  are  not  so  plen- 
tiful as  in  normal  growing  bone  and  are  arranged  irregularly.  The 
branching  processes  of  the  new  canals  are  shorter  than  normal  or  are 
entirely  lacking.  The  new  osteoid  substance  remains  uncalcified  or  is 
reabsorbed.  There  is  sharp  demarcation  between  the  new  and  old  bone 
indicating  their  independence.  Most  observers  believe  that  the  regen- 
erative process  originates  in  the  periosteum  or  from  the  dura,  while 
Von  Recklinghausen  claimed  its  medullary  origin.  Packard,  ei  al.,  be- 
lieved it  came  from  the  periosteum. 

The  result  of  the  coincident  absorption  and  regeneration  is  a  total 


OSTEITIS  DEFORMANS  ( PAGET *S  DISEASE),  REPORT  OF  THREE  CASES        55 

destruction  of  all  symmetry  in  the  internal  architecture  of  the  bones. 
As  a  rule,  uncalcified  new  bone  renders  the  cranium  soft,  but  in  some 
areas  there  is  sclerotic  bone  of  ivory-like  hardness.  In  the  long  bones 
the  normal  relation  of  compact  and  cancellous  structure  is  destroyed. 
The  outer  walls  of  hard  bone  are  represented  by  thin,  irregular  plates 
lying  directly  under  the  periosteum.  In  general,  the  histology  is  like 
that  of  the  skull,  except  that  the  medullary  substance  is  more  fatty, 
and  that  the  retrogressive  and  progressive  changes  (Von  Reckling- 
hausen) are  observed.  The  former  produce  cysts  filled  with  gelatinous 
material;  the  latter  produce  fibrous  tumors  or  giant-celled  sarcomata. 
An  instance  of  the  latter  occurring  in  the  skull  is  reported  by  Packard, 
et  al. 

In  the  bodies  of  the  vertebrae  the  histological  changes  are  practically 
the  same  as  in  the  skull. 

Hurwitz  states  that  however  at  variance  writers  may  be  regarding 
the  initial  step  in  the  progress,  all  who  have  studied  the  pathology  of 
the  bony  changes  describe  a  similar  microscopic  picture;  essentially 
this  consists  of  a  resorption  of  bone  associated  with  the  excessive  pro- 
duction of  a  poorly  calcified  bone  designated  as  fibro-osteoid  tissue. 

From  a  careful  pathological  study  Higbee  and  Ellis  believe  that  re- 
sorption of  bone  appears  to  be  the  initial  histologically  recognized 
change.  The  reparative  processes  alone  should  be  regarded  as  inflam- 
matory in  nature,  which  follows  the  resorption  of  bone,  and  results  in 
new  bone  formation. 

Barker  describes  this  condition  as  senile  pseudo-rickets  with  softening 
due  to  a  rarefying  osteitis  and  thickening  due  to  periosteal  medullary 
new  bone  formation. 

Morton  Prince  divides  the  Pathology  into  three  stages;  any  one  pro- 
cess predominating:  (1)  Absorption  of  bone.  (2)  New  formation  of 
bone  without  calcification.  (3)  New  formation  of  bone  with  calcifica- 
tion. 

Pathogenesis.  It  appears  to  the  writer  that  this  condition  is  a  com- 
bination of  two  definite  pathologic  conditions,  namely,  osteoporosis, 
followed  by  osteosclerosis;  that  the  condition  begins  as  an  osteomalacia 
with  softening  due  to  the  abnormal  interrelationship  between  various 
chemical  substances  in  the  bone.  During  this  stage  deformities  occur. 
Then,  for  some  unknown  reason,  the  condition  of  osteomalacia  disap- 
pears and  is  replaced  by  osteosclerosis,  during  which  stage  the  cortex 
of  the  bone  assumes  a  certain  hardness  (often  ivory-like)  which  is  typ- 
ical of  advanced  osteitis  deformans.  (This  fact  must  be  considered  in 
making  x-ray  exposures.) 


56  PHILIP  LEWIN 

After  a  careful  study  of  the  literature,  the  writer  is  impressed  with 
the  fact  that  many  authors  have  been  describing  different  stages  of  the 
same  general  condition.  One  writer  sees  a  case,  or  a  group  of  cases, 
with  pronounced  osteomalacic  signs  and  symptoms;  another  writer  does 
not  see  this  type  at  all  but  meets  those  cases  that  have  gone  past  the 
stages  of  osteoporosis  into  the  condition  of  osteosclerosis.  One  is  im- 
pressed by  the  similarity  between  osteitis  deformans  and  rickets  as 
seen  in  children;  in  the  latter  condition  one  patient  is  presented  with 
the  marked  softened  condition  of  the  bone  during  which  period  de- 
formities occur.  Subsequent  conditions  of  deformities  do  not  progress, 
and  the  bones,  instead  of  being  soft  and  easily  bent,  have  assumed  an 
advanced  degree  of  hardness,  during  which  stage  it  is  even  difficult  to 
drive  a  chisel  through  them. 

The  work  of  Goldthwait,  Painter,  and  Osgood  would  seem  to  indicate 
that  in  osteomalacia  there  is  at  first  a  decalcification  of  the  bony  tissue ; 
that  the  calcium  is  in  part  replaced  by  magnesium  but  probably  chiefly 
by  an  organic  substance  rich  in  sulphur,  poor  in  phosphorus,  similar 
to,  but  not  exactly  like,  the  normal  organic  matrix.  If  castration  is 
performed  during  this  period,  the  decalcification  process  is  checked 
and  what  has  been  lost  is  replaced.  From  Newman's  work  they  believe 
that  if  the  condition  has  lasted  until  it  is  very  severe  the  decalcification 
process  finally  comes  to  an  end,  but  that  after  this  stage  castration  does 
not  restore  the  normal  calcium  metabolism.  The  hypothesis,  that  the 
process  of  decalcification  is  a  solution  of  the  calcium  by  an  acid  similar 
to  the  solution  which  takes  place  when  dead  bone  is  placed  in  hydro- 
chloric acid,  does  not  seem  justified. 

Signs  and  Symptoms.  The  onset  of  this  condition  is  slow  and  may 
be  spread  over  many  months  or  years.  The  patient  usually  gives  a 
history  of  vague  ' '  rheumatic ' '  pains  in  the  extremities,  symptoms  which 
are  in  no  way  different  from  those  described  as  ordinary  rheumatic. 
They  are  probably  due  to  stretching  of  the  periosteum  caused  by  the 
deposition  of  inflammatory  products  and  new  bone  beneath  it.  The 
late  pains  are  probably  due  to  distortion  of  the  joints.  There  is  a  grad- 
ual weakness  of  the  lower  extremities,  tenderness  along  the  shafts  of 
the  bones,  especially  the  tibia  and  femur,  a  long  story  of  gradual  de- 
crease in  height.  Osier  describes  one  case  where  thirteen  inches  in 
height  was  lost.  The  patient  notices  that  his  friends  are  growing  taller. 
He  might  notice  that  he  is  having  increasing  difficulty  in  turning  off 
a  gas  jet  or  an  electric  light,  or  that  the  mirror  that  he  formerly  used 
very  comfortably  while  shaving,  seems  too  high  for  him.  A  woman 
might  experience  analogous  sensations.     The  first  symptom  might  be 


OSTEITIS  DEFORMANS   (PAGET's  DISEASE),  REPORT  OF  THREE  CASES        57 


Fig.  8. — Author's  case  No.  3. 


increasing  size  of  head  as  noted  by  frequent  buying  of  larger  sized 
hats.  White  reported  a  ease  in  which  the  hat  size  increased  from  6% 
to  8y2.    Because  of  the  increase  in  size  of  the  skull  the  face  seems  small. 

There  is  in  the  Dupuytren  Museum  in  Paris  a  specimen  of  a  skull, 
from  a  case  of  osteitis  deformans,  which  is  about  an  inch  and  a  quarter 
in  thickness. 

Deformities  occur  in  the  long  bones,  most  common  of  which  is  the 
cutward  and  forward  bowing  of  the  tibia ;  next  in  frequency  the  femur, 
with  a  similar  deformity.  Foote's  case  measured  30  cm.  between  the 
patellae  when  standing  erect  with  the  heels  together.  The  head  is  us- 
ually flexed  so  that  the  chin  approximates  closely  the  sternum.  This 
iV  partly  due  to  the  increased  weight  of  the  head  incident  to  the  en- 
largement of  the  skull  and  to  the  deformity  of  the  spine,  which  is  so 
very  common;  namely,  cervico-dorsal  kyphosis.    There  is  in  some  cases, 


58 


PHILIP  LEWIN 


FIg.  9. — Author's  case  No.  3. 


as  notably  in  one  case  reported  in  this  paper,  deformity  of  the  clavicle, 
which  is  chiefly  shortening  with  thickening  about  the  middle,  which 
may  impress  one  as  having  been  a  fracture  with  overgrowth  of  callus. 

The  abdomen  assumes  a  diamond-shape  with  its  four  points  at  the 
ensiform  cartilage,  the  symphysis  and  the  two  ilio-costal  angles.  Instead 
of  the  normal  space  between  the  costal  margins  and  the  crests  of  the 
ilia,  admitting  three  or  four  fingers,  there  is  often  insufficient  space  to 
permit  the  introduction  of  one  finger.  There  is  usually  a  prognathian 
chin  and,  with  the  appearance  of  unusually  long  arms,  the  patient  as- 
sumes a  marked  resemblance  to  the  anthropoid  ape  i.  e.,  the  " simian' ' 
appearance.  This  is  so  striking  that  most  of  the  cases  seem  to  bear  a 
family  resemblance  to  each  other. 

A  symptom  or  associated  condition  is  that  of  morpheo-scleroderma. 


OSTEITIS  DEFORMANS  ( PAGET 's  DISEASE),  REPORT  OF  THREE  CASES        59 

There  has  been  one  case  of  this  described  by  Pernet,  and  Case  3  of  this 
series  shows  a  somewhat  similar  condition. 

The  first  roentgenologic  examination  of  Paget 's  disease  in  France  was 
made  in  1901  by  Gallois  at  Beclere  Institute  in  Paris. 

X-ray  findings  are  typical,  showing  rarefying  osteitis  with  a  thick 
cortex  due  to  subperiosteal  and  medullary  new  bone  formation.  This 
thickening  occurs  on  the  convex  surface.  The  bone  has  the  appearance 
of  cotton-wool  or  of  the  hair  of  the  pickaninny.  This  occurs  in  both 
the  diaphysis  and  epiphysis.  There  may  be  bony  striations  extending 
out  into  the  soft  tissues,  parallel  with  the  long  axis  of  the  bone.  There 
may  be  seen  early  in  the  x-ray  areas  of  rarefaction.  The  cortical  zone 
ia  more  transparent  than  normal,  owing  to  the  thinning  of  the  sub- 
periosteal layer.  The  spaces  are  clear.  Careful  x-ray  study  by  Hay- 
hurst  and  Hartung  revealed  the  following:  Marked  bowing  and  en- 
largement of  long  bones  and  hyperostoses  on  and  thickening  of  flat 
bones.  Minute  changes  found  in  all  the  bones  affected  were  a  coinci- 
dent porosis  and  sclerosis,  one  or  the  other  process  predominating  in 
different  parts.  Fine  markings,  ordinarily  shown  in  the  cancellous  ends 
of  long  bones,  were  replaced  by  a  coarse  trabeculation  which  extended 
into  the  shaft  for  a  variable  distance,  in  some  instances  involving  the 
entire  bone.  In  places,  subperiosteal  thickening  was  clearly  discernible, 
while  in  others,  decalcification  beneath  the  periosteum  had  progressed 
irregularly,  simulating  caries.  Near  the  distal  end  of  both  radii  and 
ulnae  of  one  case  uniform  absorption  of  a  limited  area  had  occurred 
resembling  cyst  formation.  In  the  tibiae  of  two  cases  the  lumen  of  the 
medullary  canal  had  been  largely  encroached  upon  by  irregular  lamellae 
of  bone.  With  the  exception  of  the  spine,  joints  were  not  involved.  The 
process  extended  throughout  the  epiphyses  but  there  was  no  noticeable 
irregularity  of  the  joint  surface,  nor  was  there  any  undue  approxima- 
tion of  the  articular  surfaces  suggestive  of  atrophy  of  joint  cartilage. 
The  spine  of  the  man  was  partially  ankylosed,  while  that  of  the  woman 
showed  a  definite  angulation  at  about  the  3rd  dorsal  vertebra,  suggestive 
of  Pott's  disease  (past  or  present). 

Both  skulls  showed  well  marked  and  similar  changes.  Calvarium 
was  markedly  thickened,  especially  at  base.  External  hyperostoses  were 
clearly  apparent  as  well  as  abnormal  porosity  in  places.  Sella  turcica 
was  approximately  normal.  In  the  man,  advanced  arteriosclerosis  of 
upper  and  lower  extremities  as  seen  in  x-ray. 

Perkins '  case  presented  the  leonine  type  of  skull  with  thickened  inner 
and  outer  tables,  a  moth-eaten  appearance  due  to  porosity  of  the  outer 
plate.    The  sella  turcica  was  small,  10x10  mm.  (normal  12x15  mm.),  and 


60  PHILIP  DEWIN 

there  was  a  shadow  suggesting  a  calcareous  roof  over  the  pituitary 
fossa.  Frontal  and  maxillary  sinuses  simulated  acromegaly  in  that  they 
were  large,  having  a  blown-out  appearance.  The  posterior  portion  of 
the  sphenoid  was  unusually  dense.  The  chest  showed  thickened  clavi- 
cles and  ribs. 

In  1902,  Kienbock  stated  that  Paget 's  disease  and  syphilis  could  be 
differentiated  roentgenologically. 

Goldthwait,  Painter,  and  Osgood  believe  that  new  bones  may  become 
affected  without  the  knowledge  of  the  patient  and  give  rise  to  no  sub- 
jective symptoms.  This  occurred,  for  example,  in  a  noted  organist  and 
pianist  whose  hands  were  x-rayed  in  the  routine  examination  of  a  well- 
marked  case.  Several  of  the  metacarpals  and  phalanges  showed  definite 
changes  which  seemed  to  be  of  long  duration,  yet  had  not  interfered 
with  his  vocation  in  the  slightest  degree. 

Abbe  found  four  cases  of  jaw  complication  in  fourteen  cases. 

McCrudden,  working  under  the  direction  of  Goldthwait,  Painter,  and 
Osgood,  found  the  calcium  in  the  urine  high,  the  magnesium  a  little 
low.  There  was  a  slight  loss  of  phosphorus  and  a  slight  retention  of 
calcium  and  magnesium. 

Complications  or  concomitant  conditions  have  been  variously  stated 
as  neuralgia,  cardiovascular  disease,  'myocarditis,  cardiac  dilatation, 
fractures,  osteoarthritis,  insanity,  arteriosclerosis,  and  malignant  sar- 
coma. It  is  probable  that  none  of  these  (excepting  the  last)'  is  impor- 
tant. Foote  reported  an  interesting  case  of  osteitis  deformans  with 
heart  complications  and  involvement  of  the  liver  and  spleen. 

DIAGNOSIS. 

The  correct  diagnosis  is  easy  in  the  advanced  stage,  but  it  is  almost 
impossible  before  the  stage  of  deformity  has  occurred.  In  the  advanced 
stage  the  clinical  picture  is  so  typical  that  the  diagnosis  is  simple.  Be- 
fore the  deformities  have  occurred  it  may  be  speculative  only.  It  is 
reasonable  to  believe  that  with  the  perfection  of  metabolism  studies  the 
future  will  show  many  diagnoses  of  this  condition,  before  much  deform- 
ity has  occurred. 

Differential  Diagnosis. 

The  diagnosis  of  Paget 's  disease  consists  chiefly  in  its  differentiation 
from  syphilis,  osteomalacia,  rickets,  bone  tumors,  acromegaly,  and 
hyperostosis  diffusa  cranii. 


OSTEITIS  DEFORMANS  (  PAGET 's  DISEASE),  REPORT  OF  THREE  CASES        61 


.Fig.  10 — Author's  case  No.  3. 


In  syphilitic  disease  of  bone  the  x-ray  shows  little  or  no  encroach- 
ment upon  the  medullary  canal;  the  bone  is  denser.  Cortical  thicken- 
ing is  found  on  the  convex  surface  of  the  deformity.  There  is  no  lack  of 
calcification.  Other  signs  of  syphilis  are  usually  present,  and  the  Was- 
sermann  reaction  positive.  The  therapeutic  test  of  anti-syphilitic  treat- 
ment will  often  determine  the  diagnosis. 

Hyperostosis  diffusa  cranii  of  Virchow  is  probably  a  manifestation 
of  osteitis  deformans.  Cranial  nerve  involvement  is  frequent,  due  to 
encroachment  upon  the  foramina  and  fissures  at  the  base  of  the  skull. 

Differential  diagnosis  of  bone  tumors  must  be  made  upon  a  careful 
history  and  physical  examination,  taken  together  with  the  x-ray  findings. 
The  diagnosis  of  rickets  is  made  from  the  age  of  the  patient,  and  x-ray. 


62  PHILIP  LEWIN 

In  rickets  the  thickening  of  the  cortex  occurs  on  the  concave  side 
(Lovett),  in  Paget 's  disease  on  the  convex  side. 

Osteomalacia  involves  the  bones  of  the  trunk  more  frequently  than 
the  extremities  and  usually  does  not  involve  the  cranial  bones,  and  in 
the  senile  form  there  is  much  pain.  There  is  no  bone  hypertrophy  such 
as  occurs  in  Paget 's  disease.  The  predilection  for  the  bones  of  the 
pelvis  and  the  lumbar  spine  are  striking  features  in  osteomalacia. 
Again,  osteomalacia  is  very  rare  in  the  male,  whereas  Paget 's  disease 
is  more  common  in  the  male. 

Quoting  from  Elliott  and  Nadler :  Dock  found  reported  in  this  country 
up  to  1895,  only  eleven  cases  of  osteomalacia,  all  in  the  female.  Hahn, 
in  1899,  was  able  to  collect  from  the  literature  forty-two  cases  in  males, 
but  the  diagnosis  in  some  of  these  cases  was  in  doubt.  McCrudden,  in 
1910,  stated  that  among  three  hundred  and  sixty  cases  of  osteomalacia 
reported  by  five  writers,  thirty-nine  were  in  men.  Without  making  a 
special  search  he  found  reported  in  the  last  twenty-five  years  ten  cases 
in  unmarried  females  and  nine  cases  in  males.  In  four  of  the  latter  the 
diagnosis  was  confirmed  by  necropsy. 

The  case  of  Elliott  and  Nadler  was  a  man  of  thirty-four  years  on 
whom  Kanavel  had  done  a  double  castration,  the  only  recorded  male  so 
treated,  and  I  quote  their  conclusions :  Five  years  after  castration  the 
case  reported  shows  no  actual  improvement  in  bone  structure.  A  prob- 
able remission  has  occurred,  which  may  have  been  influenced  by  the 
operation.  The  result  of  castration  in  this  patient  would  seem  to  indi- 
cate that  osteomalacia  is  not  a  disease  of  the  sex  glands. 

The  writers  state  that  the  early  involvement  of  all  the  bones  is  char- 
acteristic of  male  osteomalacia. 

The  loss  of  calcium  and  the  softening  of  the  bone,  together  with  a  new 
production  of  bone,  poor  in  lime,  are  characteristic.  There  is  a  tend- 
ency to  lime  deposit  elsewhere,  as  in  the  kidneys  and  bladder.  Mc- 
Crudden believes  that  osteomalacia  is  an  exaggeration  of  a  normal  func- 
tion, that  the  balance  of  bone  metabolism  is  disturbed  by  excessive  de- 
mands for  calcium,  as  in  pregnancies,  bone  tumors,  and  fractures.  When 
bone  katabolism  exceeds  anabolism  the  result  is  osteomalacia  (For  full 
bibliography  on  osteomalacia,  see  article  by  Elliott  and  Nadler) . 

There  is  a  point  in  differential  diagnosis  between  osteomalacia  and 
Paget 's  disease,  which  has  not  been  seen  in  the  literature ;  namely,  that 
when  a  person  with  Paget 's  disease  grows  smaller,  he  is  small  all  day 
long,  but  the  osteomalacic  has  a  diurnal  cycle,  which  is  beautifully  il- 
lustrated in  Elliott  and  Nadler 's  case,  by  what  the  writer  terms  the 


OSTEITIS  DEFORMANS  ( PAGET *S  DISEASE),  REPORT  OF  THREE  CASES        63 

mirror  test,  viz. :  Their  patient  told  the  writer  that  if  he  shaved  soon 
after  a  night's  sleep,  the  mirror  was  on  a  level  with  his  eyes,  but  if  he 
shaved  at  night,  it  was  too  high  for  him.  This  is  explained  by  the  fact 
that  during  the  day  his  height  gradually  decreased  due  to  body  weight 
on  soft  bones;  during  the  night  his  height  increased  considerably.  No 
doubt  an  important  role  is  played  by  the  compression  and  relaxation  of 
the  intervertebral  discs.  He  stated  that  he  stood  several  inches  taller  in 
the  morning  than  at  night. 

PROGNOSIS. 

The  prognosis  as  to  life  is  good,  some  patients  living  to  the  8th  decade. 
One  case  in  this  series  is  a  woman  sixty-nine  years  of  age.  Stillings* 
patient  was  ninety-two  years  old. 

The  longest  duration  of  the  disease  is  recorded  by  Moizard  and 
Bourges,  in  whose  patient  the  condition  existed  fifty-two  years  before 
death. 

The  prognosis  as  to  improvement  is  not  good;  as  to  cure,  absolutely 
bad.  It  is  probable  that  once  a  patient  becomes  bedridden  from  the 
disease,  he  will  never  walk  again. 

Death  is  usually  due  to  intercurrent  infection  or  malignancy. 

TREATMENT. 

Preventive  treatment  is  impossible  because  of  the  difficulty  of  diagno- 
sis before  deformity  has  set  in.  Curvative  treatment  at  present  is  impos- 
sible. Corrective  treatment  may  be  inadvisable  because  of  the  age  of 
the  patient  and  the  probability  of  failure.  Funk  hopes  to  offer  some- 
thing of  value  in  the  treatment  from  the  standard  of  calcium  metabol- 
ism. Arsenic  has  been  given  internally  in  all  its  forms,  and  the  results 
are  questionable. 

There  have  been  recommended  by  various  authors:  prepared  bone 
marrow,  cod  liver  oil,  calcium  lactate,  thymus  gland.  One  writer  rec- 
ommended giving  proteins,  but  no  carbohydrate. 

For  the  present,  it  seems  that  the  best  hope  is  offered  by  the  admin- 
istration of  phosphorus  internally;  for  example,  in  the  phosphorus  pill 
of  a  hundredth  of  a  grain  three  times  a  day,  continued  over  a  long 
period. 

Goldthwait,  Painter,  and  Osgood  reported  a  case  which  suffered  a 
fracture  of  the  affected  thigh  from  a  severe  trauma.  The  broken  bone 
healed  with  apparently  normal  rapidity  and  firmness.    This  encourages 


64  PHILIP  LEWIN 

them  to  recommend  osteotomies  for  the  correction  of  marked  but  slowly- 
developing  deformities,  especially  of  the  lower  limbs. 

Abbe  found  excellent  operative  repair  of  bones  affected  with  osteitis 
deformans.   He  cites  two  jaw  cases  operated  upon  with  perfect  results. 

REPORT    OF    CASES. 

The  writer  desires  to  report  three  cases. 

Case  1.  W.  H.  Male,  age  47.  Born  in  Minnesota  of  French-Indian- 
Negro  and  English  parentage.  For  the  past  twelve  years  has  been  get- 
ting more  "bow-legged."  Has  "pain  going  down  his  legs."  They  al- 
ways feel  weak;  tire  very  easily.  His  condition  has  been  diagnosed 
softening  of  the  bones.  He  thinks  for  the  past  ten  years  he  has  lost 
four  or  five  inches  in  height.  Married  fourteen  years,  four  children,  all 
well.  No  deformities  in  his  family,  except  that  his  mother  was  "bow- 
legged."  He  had  marked  forward  and  outward  bowing  of  the  legs,  in- 
volving tibia,  fibula,  and  femur,  and  both  tibiae  were  markedly  flattened 
laterally. 

Case  2.  A.  E.  K.  Female.  Patient  referred  to  Dr.  J.  L.  Porter  by 
Dr.  W.  H.  McCoach  of  Houston,  Texas. 

Case  3.  E.  L.  Age  69,  negress.  Born  in  Tennessee.  Father  died  of 
pneumonia,  mother  of  carcinoma  of  the  stomach,  brother  died  of  cholera 
at  the  age  of  three  years.  Family  history  negative.  Her  husband  was 
killed  accidentally  thirty  years  ago.  He  was  in  very  good  health,  and 
the  patient  states  he  never  had  any-  venereal  disease. 

Present  Complaint.  The  patient  complains  of  marked  deformity  of 
the  bones  of  her  legs,  especially  the  right.  Trouble  began  about  four 
years  ago,  since  which  time  she  has  been  unable  to  walk  or  even  stand. 
Sharp  shooting  pains  throughout  the  body,  especially  at  night.  Sleeps 
very  little  after  midnight.  She  first  noticed  right  leg  bending,  later  the 
other  leg  and  both  arms.  Twenty  years  ago  a  window  fell  on  the  left 
forearm,  incapacitating  that  member  for  six  months. 

Past  History.  "Rheumatism"  in  1871.  She  had  twelve  pregnancies, 
four  children  living,  no  miscarriages;  four  daughters  married,  none  of 
them  had  miscarriages. 

Physical  examination  reveals  a  fairly  well-nourished  colored  woman, 
approximately  sixty-five  years  of  age.  She  is  bedridden,  but  does  not 
appear  acutely  ill.  There  is  an  anterior,  sabre-like  curvature  of  both 
femurs;  the  right  tibia  and  fibula  in  their  lower  third  are  bent  to  an 
angle  of  nearly  ninety  degrees.  There  is  a  bony  prominence  in  the  lower 
third  of  the  left  forearm.  There  is  an  outward  bowing  of  both  forearms. 
Angular  kyphosis  of  the  cervico-clorsal  region.  The  curves  of  both  clav- 
icles are  markedly  exaggerated.  There  is  a  prominence  about  the  middle 
of  each  clavicle  suggesting  the  overgrowth  of  callus  as  in  an  old  fracture. 
Both  clavicles  are  markedly  shortened.  The  skin  over  the  lower  legs 
is  very  shiny  and  tight  (scleroderma).  The  pupils  are  equal  and  react 
to  light  and  accommodation ;  reflex  normal :  knee  jerks  normal.    Abdo- 


OSTEITIS  DEFORMANS  (  PAGET 's  DISEASE),  REPORT  OP  THREE  CASES        65 

men  is  diamond-shaped.  It  is  with  difficulty  that  one  finger  is  inserted 
between  the  costal  margin  and  the  crest  of  the  ilium  on  each  side.  The 
abdomen  is  somewhat  tense,  liver  appears  to  be  enlarged  two  fingers ' 
breadth  below  the  right  costal  margin.  Heart  and  lungs  normal.  Chin 
is  markedly  prognathian,  and  the  head  is  flexed  on  the  chest. 

X-ray  report  by  Dr.  E.  L.  Jenkinson.  There  is  definite  thickening 
of  the  cranial  vault,  with  a  generalized  osteoporosis  of  the  bones  of  the 
skull,  especially  in  the  occipital  region.  The  sella  turcica  is  very  shal- 
low and  elongated  with  the  clinoid  processes  indefinite. 

The  cervico-dorsal  region  of  the  spine  does  not  give  definite  x-ray 
shadow  because  of  the  kyphosis  in  this  area  and  the  osteoporosis. 

There  are  several  infractions  of  the  ribs. 

There  are  three  fractures  of  the  bones  of  the  left  forearm :  radius  at 
junction  of  middle  and. upper  thirds  with  no  union ;  ulna  two  fractures 
in  upper  half  of  bone  with  very  little  evidence  of  union. 

Bilateral  coxa  vara;  the  angle  subtended  by  the  neck  and  shaft  is 
slightly  greater  than  a  right  angle. 

The  bones  of  the  lower  extremities  are  universally  rarefied,  with  fine 
and  coarse  trabecular  scattered  throughout.  There  are  areas  of  peri- 
osteal bone  proliferation.  There  is  a  very  marked  angular  deformity 
just  above  the  right  ankle  and  a  gradual  forward  curve  of  the  left  tibia. 
Diagnosis — Paget 's  disease. 

Urinalysis,  normal;  blood  examination,  normal;  Wassermann,  neg- 
ative. 

conclusions. 

The  justification  for  reporting  these  three  cases  lies  chiefly  in  Case 
8,  which  is  unusual  in  the  following  respects:  the  marked  deformity  of 
the  right  lower  leg,  the  skin  condition  (scleroderma),  and  the  fractures 
of  the  left  forearm,  which  show  non-union  roentgenologically  after 
twenty  years.  The  last  fact  proves  that  she  had  some  disturbance  of 
bone  metabolism  many  years  without  much  inconvenience. 

I  desire  to  express  my  thanks  to  Dr.  John  Lincoln  Porter  for  the 
privilege  of  reporting  these  cases;  to  Dr.  D.  B.  Phemister  for  confirm- 
ing the  diagnosis  of  Case  3,  and  to  Dr.  E.  L.  Jenkinson,  roentgenologist 
at  St.  Luke's  Hospital. 

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CHRONIC    OSTEOMYELITIS    SECONDARY    TO    COMPOUND   FRACTURE.         67 

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CHRONIC  OSTEOMYELITIS  SECONDARY  TO  COMPOUND 

FRACTURE. 

BY    TOM    S.    MEBANE,    MAJOR,    M.C. 

Lovell     General     Hospital     (formerly     General     Hospital     No.     26), 
Fort  Sheridan,  Illinois. 

Most  of  our  soldiers  with  chronic  osteomyelitis,  following  gunshot 
wounds  received  in  the  World  War,  are  now  out  of  service.  Nearly- 
all  these  men  have  been  discharged  with  healed  wounds.  Unfortu- 
nately, recurrences  and  sequelae  are  frequent.  These  men  are  scattered 
all  over  the  country.  In  view  of  this  fact,  and  in  view  of  the  fact 
that  the  problems  involved  in  treating  osteomyelitis  secondary  to  com- 
pound fractures  in  civil  life  are  similar  to  those  involved  in  treating 
cases  secondary  to  gunshot  fracture,  it  is  believed  that  the  results  ob- 


68  TOM    S.    MEBANE 

tained  and  the  methods  employed  in  the  treatment  of  359  such  cases 
on  the  writer's  section  of  the  surgical  service  of  this  hospital,  between 
August,  1919,  and  August,  1920,  will  be  of  general  interest. 

The  osteomyelitis  in  these  cases  followed  compound  fracture  result- 
ing from  gunshot  wounds  in  nearly  all  instances.  The  wounds  had 
been  received  from  nine  to  fourteen  months  previously.  All  cases  had 
been  operated  upon  once  or  more.  Of  the  359  cases,  188  required 
further  operative  work  as  follows: 

Bone  operations,  143;  plastic  operations,  56;  drainage  abscess,  36. 
Table  1  gives  a  complete  resume  of  the  part  involved,  operative 
management  and  results  obtained  in  the  143  bone  cases.  It  is  of  in- 
terest to  note  here  that  an  average  of  six  operations  for  osteomyelitis 
has  been  performed,  in  various  hospitals,  on  our  patients  who  have 
been  under  treatment  for  two  years. 

Of  +he  original  359  cases,  33  are  still  in  the  hospital,  unhealed.    These 
cases  are  distributed  as  follows: 
Extensive  osteomyelitis  of  shaft  of  femur  15 

Epiphyseal  cavities  5 

Complicating  soft  part  defects  4 

Extensive  osteomyelitis  of  shaft  of  humerus  2 

Extensive  osteomyelitis  of  pelvis  2 

Extensive  osteomyelitis  of  tarsus  2 

Extensive  osteomyelitis  of  bones  of  shoulder  1 

Extensive  osteomyelitis  of  pelvis  and  head  of  femur  1 

Extensive  osteomyelitis  of  tibia  1 

These  cases  will  be  considered  again  later. 

OPERATIVE    TREATMENT. 

The  operations  adapted  to  the  radical  cure  of  osteomyelitis  sec- 
ondary to  compound  fracture  are  sequestrectomy,  effacement,  resec- 
tion, and  amputation.  Sequestrectomy  alone  has  been  found  to  be  unsat- 
isfactory unless  the  sequestra  is  free  in  the  soft  tissues  and  no  tunnel 
or  bone  cavity  exists.  Where  tunnel  or  cavity  exists  in  the  shaft  of 
a  long  bone,  it  must  be  effaced  in  such  a  manner  as  to  allow  the  soft 
parts  to  collapse  into  and  fill  the  defect  (Figures  1  and  2).  The  end- 
result  of  extensive  effacements  is  excellent.  Under  the  stimulus  of 
use,  the  bone  tends  to  regain  its  strength  and  normal  contour  .(Figure 
4).  At  or  near  the  epiphysis  of  a  bone,  complete  effacement  is 
not  possible  without  entering  the  joint.  In  such  a  case  effacement 
should  be  done  distal  to  the  joint  and  an  attempt  made  to  fill  any 


CHRONIC    OSTEOMYELITIS    SECONDARY    TO    COMPOUND   FRACTURE.         69 

defect  into  which  the  soft  tissues  will  not  collapse  by  turning  in  a 
muscle  flap.  Such  operations  are  less  effective  than  where  simple  col- 
lapse of  the  tissues  fills  the  defect.  In  our  series  there  were  six  suc- 
cesses in  ten  such  operations. 

The  most  ideal  method  of  treating  chronic  osteomyelitis  is  by  re- 
section of  the  entire  diseased  area.  This  method  is  the  method  of 
choice  in  cases  of  osteomyelitis  of  the  rib,  carpus,  or  individual  tarsal 
bones.  It  is  also  applicable  to  certain  cases  of  osteomyelitis  of  tibia 
or  fibula,  or  of  radius  or  ulna  where  the  entire  thickness  of  a  portion 
of  the  shaft  is  necrotic.  In  such  cases  bone  graft  is  employed  to  fill 
the  defect  after  healing  occurs.  Resection  of  joints  for  osteomyelitis 
of  the  end  of  one  or  more  of  the  bones  entering  into  the  formation 
of  the  joint  is  practical,  in  the  upper  extremity,  where  shortening  is  of 
secondary  importance.  Usually  in  the  lower  extremity  to  obtain  re- 
sults so  much  bone  must  be  removed  that  hopeless  shortening  occurs. 
Amputation  is  therefore  preferable  (Figure  5).  In  case  of  osteomyeli- 
tis of  head  and  neck  of  the  femur,  amputation  cannot  be  followed  by  a 
satisfactory  artificial  limb.  In  such  cases  resection,  to  be  followed 
by  transplantation  of  head  and  part  of  the  shaft  of  the  fibula,  has 
been  suggested   (Figure  7). 

AMPUTATION. 

Amputation  should  be  the  last  resort  in  the  treatment  of  osteomye- 
litis. However,  experience  has  shown  that  it  is  a  mistake  to  delay 
amputation  in  certain  cases.  This  is  particularly  true  in  cases  of 
extensive  osteomyelitis  of  the  tarsus  or  of  the  epiphysis  of  the  long 
bones  of  the  lower  extremity,  where  resection  is  impractical  (Figures 
5  and  6).  Spongy  bone  lacks  the  resistance  to  infection  and  the  re- 
generative power  of  compact  bone.  For  this  reason  in  six  cases  of 
extensive  osteomyelitis  of  the  tarsus  that  the  writer  undertook  to  save, 
five  were  later  amputated  and  the  sixth  patient  would  probably  also 
have  been  better  off  with  an  artificial  leg.  It  is  the  writer's  belief 
that  if  such  cases  are  not  healed  within  six  months,  amputation  should 
be  performed.  Eight  cases  in  our  series  were  amputated  for  the  fol- 
lowing: 

Extensive  osteomyelitis  of  tarsus  5 

Osteomyelitis  lower  epiphysis  of  tibia  1 

Osteomyelitis  lower  epiphysis  of  femur  1 

Severe  streptococcus  infection  of  knee  1 
(As  last  resort  to  save  life) 


70  TOM    S.    MEBANE 

To  obtain  results  in  the  management  of  chronic  osteomyelitis  cases, 
attention  must  be  paid  to  pre-operative,  operative  and  post-operative 
treatment.  Every  effort  should  be  made  to  put  the  patient  in  the 
best  possible  physical  condition  before  operation.  If  the  patient  is 
badly  run  down,  particularly  if  he  runs  a  temperature,  it  is  best  to 
open  the  wound  widely  and  Dakinize  as  a  preliminary  to  extensive 
bone  operation.  It  is  not  good  policy  to  do  extensive  bone  operations 
when  pus  pockets  exist:  free  drainage  and  Dakinization  should  pre- 
cede. By  observing  these  precautions  we  had  no  deaths  as  a  result 
of  osteomyelitis.  Pre-operative  attention  to  the  part  should  consist 
of  putting  the  surrounding  skin  in  good  condition  by  occasional  shav- 
ing, daily  cleaning  with  neutral  soap,  and  protection  from  irritating 
discharges  by  the  use  of  vaseline  strips.  Dakinization  of  existing  sin- 
uses or  wounds  for  a  few  days  prior  to  operation  does  much  to  insure 
success  by  decreasing  the  number  of  organisms. 

OPERATIVE    TECHNIQUE. 

Operation  should  aim  at  complete  eradication  of  diseased  bone,  ex- 
cision of  existing  sinuses,  and  removal  of  scar  tissue.  To  accomplish 
this  ample  incisions  must  be  made.  In  studying  the  cause  of  opera- 
tive failures  insufficient  exposure  was  found  to  be  the  commonest  cause. 
Tn  many  cases  counter  incisions  are  required.  Incisions  should  be 
made  that  will  best  expose  the  diseased  bone.  The  so-called  incisions  of 
election  should  be  employed  only  if  they  fulfill  this  requirement. 
Knowledge  of  anatomy  will  enable  the  operator  to  recognize  and  re- 
tract from  the  field  any  blood  vessels  or  nerves  that  might  be  injured. 
Considerable  aid  can  be  obtained  by  injecting  existing  sinuses  with 
methylene  blue  before  beginning  to  operate.  A  tourniquet  is  also 
of  aid,  particularly  on  the  lower  extremity.  It  should  not  be  employed 
if  it  will  limit  necessary  exposure.  Good  exposure  of  the  diseased 
bone  having  been  obtained,  the  periosteum  should  be  stripped  back 
only  from  the  bone  area  to  be  removed.  Before  using  the  chisel,  th« 
soft  parts  should  be  protected  by  gauze  compresses,  moistened  with 
salt  solution,  to  prevent  bone  fragments  being  retained  in  the  wound, 
and  later  acting  as  sequestra.  Removal  of  the  diseased  area  en  bloc 
is  best  on  this  account.  All  projecting  edges  should  be  leveled  and 
bleeding  stopped  before  the  operation  is  concluded. 

The  use  of  chemical  sterilizing  agents  at  operation  has  been  widely 
advocated.     In  many  of  our  cases  the  effaced  area  was  swabbed  with 


CHRONIC  OSTEOMYELITIS  SECONDARY  TO  COMPOUND  FRACTURE 


71 


carbolic  acid  followed  by  alcohol.  In  other  cases  we  have  employed 
ether.  It  is  believed  that  these  procedures  are  valuable  but  that  they 
cannot  replace  careful  surgery.  The  removal  of  diseased  bone  and 
scar  tissue  back  to  sound  and  healthy  tissue  is  the  secret  of  success. 


1 

esults  of 

Different 

Methods  of 

Treatment 

Kr^  loved 

TOTAL  CASES. 

Bone  Effaoement.            3one  Effaceuent. 

Wound  granulating                 Wound 

,from  bottom                      sartially  sutured. 

Bone  Effaoement 
Zino  Chloride 
Method 

BONE    INVOLVED: 

• 

*> 

i 

■ 

i 

3 

Q> 

a) 

I 

1 

•3 

a 

m 

1 
o 

a 

GO 

a 
| 

a 

*  Average 

Time  of 
Healing 

I 

V) 

f 
o 

CO 

| 

fl 

Average 

Time  of 
Healing 

• 
• 
o 
o 

3 
■ 

• 

i 

Average 
Time  of 

Healing 

Vertebra 

i 

1 

1 

101  days 

Eib 

s 

3 

1 

65     " 

2 

Unknown 

Scapula 

1 

1 

1 

64  days 

Humerus 

16 

16 

2 

9 

1 

99     " 

4 

1 

64     ■ 

1 

32  days 

Radius  4  Ulna 

6 

6 

4 

70     * 

2 

40     " 

Carpus 

2 

1 

1 

1 

1 

63     " 

Metacarpal 

1 

1 

1 

Unknown  | 

Phalangeal 

2 

2 

2 

33     " 

Ilium 

3 

2 

I 

2 

1 

72     n 

Ischium 

2 

1 

1 

1 

1 

171  days! 

Femur 

64 

49 

16 

36 

12 

149     ■    J       8 

3 

60     " 

5 

122  days 

Tibia  tFibula 

25 

20 

6 

17 

133     "    1       2 

4 

46     " 

1 

1 

Tarsus 

8 

4 

4 

4 

4 

66     " 

Shoulder 

2 

2 

2 

Elbow 

3 

3 

3 

86 

Wrist 

1 

1 

1 

100 

Hip 

'* 

1 

1 

Rnee 

2 

1 

1 

1 

1 

87      * 

TOJAL 


23 


53 


143   110   33   80   23     99 
In  no  case  was  the  fibula  alone  involved. 
Many  of  these  cases  had  plastic  operation  before  healing  occurred, 


1  72 


The  zinc  chloride  method  was  employed  in  eight  of  our  cases.  The 
results  can  be  seen  by  reference  to  Table  1.  The  number  of  cases  in 
which  it  was  employed  are  too  few  to  draw  definite  conclusions.  It 
is  interesting  to  note  that  ultimate  healing  occurred  in  all  but  one  case. 


72 


TOM    S.    MEBANE 


pIG    l — illustrating  extensive  tunnel  in  shaft  of  the  femur, 
shown  in   the  sinus   tract. 


A  Dakin  tube  is 


Fig.  2. — Same  as  Figure  1,  two  weeks  later,  illustrating  the  result  obtained 
by  effacement.  Due  to  the  splint,  the  plane  of  the  picture  differs  from 
Figure  1. 

We  abandoned  the  method  because  our  results  were  not  superior  to 
results  obtained  by  other  methods  and  therefore  the  additional  risk 
entailed  by  use  of  this  method  did  not  seem  justified. 

POST-OPERATIVE    TREATMENT. 


At  the  conclusion  of  the  operation  the  wound  may  be  left  open  or 
it  may  be  completely  or  partially  closed.  When  it  was  left  open  we 
employed  packs  saturated  with  Dakin 's  solution  or,  introducing  Carrel 
tubes,  followed  out  Carrel-Dakin  treatment.  The  latter  caused  the  pa- 
tient much  less  discomfort  although  ultimate  time  of  healing  was  not 
materially  affected.  It  was  our  custom  in  most  cases  to  continue  active 
Carrel-Dakin  treatment  until  the  wound  was  clean  and  no  longer 
tender.  Then  daily  dressings  of  dichloramine-T  or  Dakin 's  solution 
were  substituted.     Secondary  closures  were  not  particularly  successful. 


CHRONIC    OSTEOMYELITIS    SECONDARY    TO    COMPo!  \I>    FRACTURE         73 


Fig.  3. — Same  case  as  Figures    1  and  2,  showing  fracture  occurring  six  weeks 

after    operation. 

Fig.  4. — Same  case  as  Figures  1,  2  and  3,  showing  the  result  six  months  after 
fracture.     The  wound  has  been   healed  for  two  months. 


Tt  was  our  experience  that  secondary  closures  and  cases  allowed  to 
granulate  from  the  bottom  healed,  leaving  a  sinus  tract  to  close  last. 
This  leads  us  to  do  parti-al  closures  at  the  time  of  operation.  One  or 
two  rubber  drainage  tubes  were  placed  at  the  most  dependent  part 
oi  the  wound  to  provide  free  drainage.  They  were  usually  required 
for  about  ten  days.  After  that,  if  required,  the  tract  was  Dakinized 
after  the  manner  of  treating  empyema  sinuses.  The  suture  line  was  pro- 
tected by  vaseline  strips.  The  part  was  firmly  bandaged,  using  lots  of 
cotton  to  obtain  compression  without  shutting  off  the  circulation.  By 
this  method  the  soft  parts  were  pressed  firmly  into  the  effaced  area. 
The  first  dressing  was  done  on  the  second  or,  preferably,  the  third  day. 
The  dressing  on  the  operating  table  was  so  applied  that  the  dressing 
over  the  draining  area  could  be  change'!  without  removing  the  com- 
pression dressing.  When  the  method  failed,  stitches  were  removed, 
Carrel-Dakin  treatment  started  and  the  wound  allowed  to  granulate 
from   the   bottom.     Nothing   was  lost   by   attempting   partial   suture. 


74 


TOM    S.    MEBANE 


Fig.  5. — Extensive  osteomyelitis  of  lower  part  of  femur  with  multiple  tunnels. 

Leg  was  2%  inches  short.    Amputation  was  performed. 
Fig.  7. — Extensive  destruction  of  head  and  neck  of  femur. 

As  can  be  seen  from  Table  1,  an  average  of  forty-six  days  in  time  of 
ultimate  healing  was  saved  the  sixty-five  per  cent,  of  the  cases  in  which 
the  method  succeeded.  Another  advantage  was  the  excellent  scar  that 
resulted.  Re-operation  for  adherent  scars  was  not  required  in  such 
cases,  whereas  forty-six  plastic  operations  were  required  on  cases  that 
had  been  allowed  to  granulate  from  the  bottom. 

After  operation,  in  addition  to  the  management  of  the  wound,  other 
things  require  consideration.  If  the  bone  has  been  greatly  weakened, 
a  suitable  splint  is  imperative.  It  is  the  writer's  belief  that  all  cases 
do  better  if  splinted  and  elevated  for  at  least  two  weeks  on  account 
of  the  rest  it  gives  the  part.  Gentle  massage  is  of  value  in  maintaining 
muscle  tone  and  improving  the  nutrition  of  the  part.  Physiological 
use,  however,  is  the  best  method  of  obtaining  these  results  and  in  ad- 
dition is  the  best  stimulus  to  bone  regeneration.  As  soon  as  the  dis- 
charge has  lessened  and  the  tenderness  has  disappeared,  the  patient 
should  be  encouraged  to  commence  use  of  the  part.  If  the  bone  has 
been  much  weakened,  a  properly  fitted  brace  or  caliper  should  be  made 
and  its  use  insisted  upon. 


CHRONIC  OSTEOMYELITIS  SECONDARY  TO  COMPOUND  FRACTURE  75 


Pig.  6. — Illustrates  a  hopeless  ease  of  extensive  osteomyelitis  of  the  tarsus. 


UNHEALED    CASES. 


Cases  that  are  still  unhealed  two  years  after  receipt  of  their  wounds 
were  referred  to  above.  The  commonest  causes  of  failure  to  obtain 
healing  were  active  bone  infection,  improperly  performed  operations, 
unfavorable  location,  of  the  wound,  low  resistance  of  bone  or  part  of 
bone  involved,  and  great  loss  of  substance  of  the  soft  tissues,  in  addi- 
tion to  bone  injury.  In  certain  cases,  particularly  where  there  has 
been  extensive  comminution  of  the  bone  at  the  time  of  the  original 
fracture,  the  entire  thickness  of  the  bone  is  infected.  At  operation, 
therefore,  removal  of  all  diseased  bone  is  frequently  impossible.  Such 
cases  do  best  if  laid  wide  open,  sequestra  removed,  and  any  tunnel 
or  cavity  effaced,  and  then  allowed  to  heal  from  the  bottom.  Atten- 
tion to  the  general  condition  of  the  patient  is  very  important.  When 
healing  cannot  be  obtained  by  these  measures,  resection  or  amputa- 
tion would  appear  advisable.  Unfortunately,  the  femur  is  the  bone 
most  frequently  involved.  Resection  is  impractical  and  amputation,  in 
most  cases,  would  have  to  be  done  so  high  that  the  patient  will  not 
consent.  Not  infrequently  an  area  of  bone  infection,  comparable  to 
an  ulcer,  is  found  at  the  bottom  of  a  sinus  tract  that  refuses  to  heal. 
When  sequestra  or  foreign  body  can  be  eliminated,  curettement  and 
Dakinization  are  all  that  is  required  to  heal  such  cases.  When  oper- 
ation is  not  properly  performed,  i.e.,  sequestra  or  uneffaced  cavities 
or  tunnels  allowed  to  remain,  chronic  sinuses  or  alternating  periods 
of  healing  and  draining  result  (Figure  1).  Close  to  joints,  as  has 
been  mentioned  before,  complete  effacements  are  frequently  impossible. 


76  TOM    S.    MEBANE 

In  such  cases,  large  cavities  may  result  that  heal  very  slowly.  Filling 
such  cavities  at  secondary  operation  by  muscle  or  fat  flaps  is  the 
method  of  choice.  Frequently,  however,  as  in  the  cases  referred  to 
above,  loss  of  substance  and  adherent  skin  prevents  closure  after  the 
flap  has  been  placed.  The  poor  resistance  of  the  spongy  bone  of  the 
epiphysis  and  of  the  tarsus  has  already  been  considered.  Extensive 
destruction  of  the  soft  parts  usually  requires  a  pedicle  graft  for 
closure.  The  writer  has  obtained  excellent  results  on  calf  and  heel 
defects  by  such  flaps  taken  from  the  opposite  thigh.  Unfortunately, 
certain  defects  are  so  extensive  or  so  located  that  such  procedures  are 
impossible.  In  such  cases,  when  a  good  granulating  surface  is  ob- 
tained, skin  graft  is  the  only  method  of  closure.  A  permanently  ad- 
herent scar  which  is  likely  to  break  down  and  ulcerate  is  the  end-re- 
sult in  such  cases.    Amputation  is  the  only  other  alternative. 

COMPLICATIONS    AND    SEQUELAE. 

Certain  complications  or  sequelae  of  chronic  osteomyelitis  frequently 
require  treatment.     Of  these,  refracture,  erysipelas,  abscess  formation, 
and  adherent  painful  scars  deserve  consideration.     A  consideration  of 
the  orthopaedic  deformities  is  beyond  the  scope  of  the  present  paper. 
Sixteen  cases  of  refracture  occurred  in  our  series.     The  femur  refrac- 
tured  thirteen  times  and  the  tibia  three.    In  four  cases,  refracture  oc- 
curred on  the  operating  table.    In  the  remaining  twelve  a  fall  or  other 
trauma  was  responsible.    Such  fractures  do  well  and  union  is  the  rule. 
There  were  two  non-unions  of  the  femur  and  in  two  other  cases  the 
fracture  is  too  recent  to  judge  the  outcome.    Refracture  is  particularly 
likely  to  occur  where  extensive  effacement  has  been   done  or  where 
angulation  exists  as  the  result  of  mal-union  of  the  primary  fracture. 
In  the  latter  case,  refracture  permits  correction  of  the  deformity.    Our 
cases  are  treated  by  Hodgen  splint  suspension  in  the  Balkan  frame 
until  union  occurs  and  then  patient  is  allowed  about  with  a  walking 
caliper.     Adhesive  plaster  traction  in  the  Hodgen  splint  has  been  en- 
tirely satisfactory  in  our  refractures.     The  tendency  to  deformity  is 
less  than  in  recent  fracture.    "Ice  tong"  traction  is  not  required.    The 
excellent  results  obtained  in  refracture  are  illustrated  by  Figures  2,  3, 
and  4. 

Attacks  of  erysipelas  may  occur  in  healed  or  unhealed  cases.  They 
appear  to  be  due  to  colonies  of  streptococci  in  wound  or  scar,  that  for 
some  reason  become  active.  Cases  vary  greatly  in  extent  and  severity. 
There  were  no  deaths  on  our  section,  but  in  two  cases  transfusion  was 


CHRONIC    OSTEOMYELITIS    SECONDARY    TO    COMPOUND    FRACTURE         77 

required.  No  one  particular  treatment  seemed  to  be  more  effective 
than  others.  Rest  in  bed,  stimulating  elimination,  elevation  of  the 
part  and  any  type  of  wet  dressing  were  all  that  most  cases  required. 
Abscess  formation  occurred  in  cases  with  retained  sequestra  or  for- 
eign bodies  or  where  uneffaced  cavities  or  tunnels  existed.  As  men- 
tioned before,  good  drainage,  to  be  followed  later  by  the  necessary  bone 
operation,  was  found  to  be  the  most  effective  way  to  handle  such  cases. 
Adherent  scars  are  most  frequent  in  cases  allowed  to  granulate  from 
the  bottom.  Such  scars  are  frequently  painful  and  limit  motion  of  ad- 
jacent joints.  The  treatment  is  excision  back  to  sound  tissue  and 
closure  of  muscle,  fascia,  and  skin  layers  separately.  In  some  cases 
pedicle  flaps  are  required. 

CONCLUSIONS. 

1.  Of  359  cases  of  chronic  osteomyelitis  following  compound  frac- 
ture, 33,  or  approximately  10  per  cent.,  were  unhealed  after  two  years 
of  hospital  treatment. 

2.  Chronic  osteomyelitis  of  spongy  bone,  i.e.,  of  the  epiphysis  of 
long  bones,  carpal  and  tarsal  bones,  is  more  difficult  to  cure  than  os- 
teomyelitis of  compact  bone  of  the  shafts. 

3.  Extensive  tarsal  involvement,  where  healing  has  not  occurred 
within  six  months,  requires  amputation.  The  same  applies  to  epiphy- 
seal osteomyelitis,  where  resection  is  impractical. 

4.  Of  the  long  bones,  osteomyelitis  of  the  femur  is  the  most  diffi- 
cult to  cure.  45  per  cent,  of  unhealed  cases  were  involvements  of  this 
bone. 

5.  Of  the  operative  measures,  careful  effacements  and  partial 
closure  gave  the  best  and  quickest  results.  The  end-results  of  ex- 
tensive effacements  were  excellent. 

6.  The  employment  of  chemicals  at  time  of  operation  is  of  sec- 
ondary importance.     Careful,  thorough  surgery  is  of  first  importance. 

7.  Plastic  operations  facilitate  healing  and  are  indicated  for  ad- 
herent scars  or  soft  part  defects. 

8.  Refraction  is  frequent  in  chronic  osteomyelitis.  The  femur  and 
tibia  are  most  frequently  fractured.  Union  is  the  rule.  Non-union 
occurred  only  twice  in  fourteen  such  fractures. 


78  JAMES    EAVES   AND    PAUL    CAMPICHE 


NOTE  ON  A  MALFORMATION  OF  THE  CARPUS. 

BY     JAMES     EAVES,     M.D.,     AND     PAUL     CAMPICHE,     M.D.,     SAN     FRANCISCO, 

CALIFORNIA. 

M.  S.,  a  laborer,  20  years  old,  came  under  our  care  on  October  7, 
1921,  for  an  injury  to  his  spine.  In  the  course  of  the  examination  it 
was  found  that  he  had  a  malformation  of  both  wrists  and  this  was 
thought  sufficiently  rare  to  justify  a  short  description  of  the  condition. 

This  man  tells  the  usual  story  of  his  mother  having  been  frightened 
when  she  was  pregnant.  Five  months  before  his  birth  the  mother  was 
looking  through  a  window  when  she  suddenly  saw  a  man,  whose  legs 
had  been  amputated  below  the  hips,  walking  on  his  hands.  She  was 
very  much  shocked  at  that  sight.  When  he  was  born  his  parents  no- 
ticed that  there  was  something  peculiar  about  the  shape  of  his  hands, 
but  as  he  could  move  them  very  well  in  all  directions  they  did  not 
pay  much  attention  to  it  and  did  not  seek  medical  advice. 

His  present  condition  is  as  follows: 

Left  Hand:  His  left  hand  is  rather  small  and  the  fifth  finger  is 
curved  toward  the  radius.  All  the  movements  of  the  wrist  are  very 
extensive  and  especially  the  adduction  of  the  hand,  toward  the  radial 
side,  is  much  greater  than  in  a  normal  subject.  The  x-ray  shows  that 
the  navicular  is  about  one-half  normal  size  and  the  styloid  process 
of  the  radius  is  absent. 

Right  Hand:  There  is  a  marked  prominence  of  the  base  of  the 
first  metatarsal  toward  the  vola  and  the  muscles  of  the  thenar  em- 
inence are  quite  thin.  The  right  thumb  is  small  and  markedly  curved 
with  a  concavity  toward  the  ulna;  the  right  index  finger  is  similarly 
curved,  while  the  fifth  finger  shows  a  curve  with  concavity  toward 
the  radius.  The  lateral  movement  of  the  wrist  towards  the  radial  side 
is  very  extensive.  The  x-ray  of  the  right  wrist  shows  a  total  absence 
of  the  navicular  and  a  poor  development  of  the  styloid  process  of  the 
radius. 

The  patient  himself  is  rather  pleased  with  the  extensive  motion  of 
his  wrists  and  claims  he  can  do  many  things  at  work  that  a  man  with 
normal  hands  could  not  do. 

The  radial  pulse  in  both  hands  was  found  to  be  at  the  middle  of 
the  wrist.  As  to  other  defects,  he  also  has  a  hypospadias  which  is 
not  very  bad  and  did  not  have  to  be  operated  upon.   It  was  also  noted 


NOTE    OX    A    MALFORMATION    OF    THE    CARPUS 


79 


I 


80  S.   KLEESTBERG 

that  he  has  an  abnormal  overgrowth  of  hair.  A  radiograph  of  the 
skull  showed  a  small  sella  turcica,  the  anterior  and  posterior  clinoid 
processes  being  in  contact. 

Isolated  malformations  or  absence  of  carpal  bones  seem  to  be  quite 
unusual;  the  only  similar  case  that  came  to  our  notice  is  the  one  re- 
ported by  F.  Bahr.*  All  other  cases  seem  to  be  complicated  with  severe 
malformations  of  the  hand  and  forearm  such  as  club-hand,  absence  of 
radius,  etc.,  and  were  mostly  found  in  young  children,  where  the  bones 
are  not  ossified  and  the  cartilage  does  not  always  show  the  deformity 
in  such  a  decisive  manner.  Therefore,  we  have  reported  this  case 
not  only  for  the  sake  of  academic  completeness,  but  also  with  a  view 
to  the  difficulties  of  the  differential  diagnosis  of  so'me  wrist  injuries, 
especially  in  industrial  accidents,  as  it  is  always  convenient  in  such 
instances  to  have  all  known  anomalies  collected  and  catalogued  in  the 
text-books  on  the  subject  for  reference  and  comparison. 


FRACTURE   OF   THE   SPINE. 

BY  S.   KLEINBERG,   M.D.,  F.A.C.S.,  NEW   YORK   CITY. 

In  the  average  orthopaedic  hospital,  and  in  private  practice  as  well, 
fracture  of  the  spine  is  of  comparatively  rare  occurrence,  and  the  di- 
agnosis is  usually  easy.  This  is  so  because  the  history  of  the  cose — 
generally  revealing  a  condition  of  long  standing ;  the  deformity, 
caused  by  a  compression  fracture  in  which  a  considerable  localized 
prominence  or  knuckle  of  the  spine  has  developed;  and  localized  pain 
makes  the  diagnosis  evident.  Among  industrial  injuries,  on  the  other 
hand,  fracture  of  the  spine  is  of  frequent  occurrence,  and  its  early 
recognition  is  at  times  very  difficult.  The  difficulty  arises  from  one 
or  more  of  three  very  distinct  causes:  First,  the  lack  of  appreciation 
of  the  clinical  symptom  complex  which  indicates  the  existence  of  an 
injury  to  the  spine.  Second,  the  symptoms,  both  subjective  and  ob- 
jective, may  be  so  mild  that  they  are  readily  explained  by  some  simple 
injury,  such  as  a  contusion,  or  a  sprain  of  the  back.    In  fact  they  may 

*Rahr,  Ferd.  Fortschritte  auf  dem  Gebiet  der  Rontgenstrahlen  18  (1911- 
1912),  p.  203.    Fin  Fbll  von  Missbildung  der  Handwurzel. 


rB  LCTURB  OF  Tin:  S3  im:  81 

be  so  mild  that  the  patient  himself  does  not  pay  any  attention  to 
them  until  they  have  lasted  for  many  weeks,  or  even  months.  Third, 
some  one  symptom  may  be  so  prominent  as  to  distract  attention  from 
the  spine  and  suggest  a  condition  other  than  injury  to  a  vertebra. 

It  seems  worth  while,  therefore,  to  consider  briefly  tin*  clinical  char- 
acteristics that  go  to  make  up  the  diagnostic  symptom  group.  We  as- 
sume that  there  is  in  every  case  a  distinct  history  of  an  injury  in 
which  the  back  was  subjected  to  direct  or  indirect  violence. 

CLINICAL     CHARACTERISTICS. 

(A)   Subjective  Symptoms. 

1.  The  constant  and  characteristic  symptom  of  fracture  of  the 
spine  is  definite,  persistent,  and  localized  pain  in  the  back.  This  pain 
may  vary  in  intensity  from  being  so  mild  as  to  be  overlooked  by  the 
patient  for  a  long  time,  to  being  so  severe  as  to  confine  the  individual 
to  bed,  and  to  demand  very  large  doses  of  morphine  for  its  relief. 
As  demonstrating  this  point  I  refer  to  the  first  case  of  my  series  in 
whom  the  pain  was  so  mild  that  the  patient  practically  paid  no  at- 
tention to  it;  while  in  another  case,  Fred  H.,  the  discomfort  was  so 
great  that  for  weeks  the  patient  was  in  bed,  or  at  least  confined  to  the 
house,  with  continuing  agonizing  distress,  and  required  daily  admin- 
istration of  several  grains  of  morphine  for  relief. 

2.  The  second  important  subjective  symptom  which  leads  us  to 
suspect  an  injury  to  the  vertebrae  is  persistent  weakness  of  the  back. 
Though  apparently  well,  the  patient  is  very  much  disinclined  to  any, 
even  mild  work.  For  instance,  one  sees  a  man  who  looks  strong  and 
sound,  has  a  mild  pain  in  the  back,  and  states  that  he  cannot  lift 
a  small  chair.  From  the  appearance  of  the  individual  it  is  evident 
that  this  weakness  is  not  due  to  any  constitutional  condition,  but  is 
due  to  some  painful  condition  aggravated  by,  and  therefore  inhibit- 
ing muscular  effort. 

3.  The  pain  in  the  back,  above  noted,  is  aggravated  by  any  and 
all  motions  of  the  spine. 

4.  Disability:  This  is  proportionate  to  the  pain,  and  accordingly 
varies  from  a  very  slight  to  an  extreme  degree.  The  patient  may  be 
able  to  go  about  with  support,  and  perhaps  even  engage  in  some  light 
work  that  involves  the  use  of  his  hands  only,  or  he  may  be  so  thorough- 
ly disabled  as  to  be  confined  to  bed. 

5.  Referred  Pains:  These  pains  are  complained  of  in  the  head, 
chest,   abdomen,  upper  or  lower  limbs,   and   are  referred  to  the  dis- 


82 


S.  KLEINBERG 


J»--»!;;;t.'on  of  the  spinal  nerves  issuing  from  the  spine  in  the  vicinity 
of  the  injury.  They  are  usually  mild  in  degree,  but  persistent  and 
continuous.  .Occasionally  they  are  very  distressing.  They  are  im- 
portant for  two  reasons:  First,  if  properly  interpreted,  they  indi- 
cate the  source  of  the  trouble,  and  localize  the  site  of  injury.  For 
instance,  pain  in  the  lower  abdomen  refers  to  or  sufferers  rnrrn-v  of 
the  lower  dorsal  spine.  Pain  in  the  lower  limbs  suggests  a  lesion 
m  the  lumbar  vertebrae,  etc.  Secondly,  these  pains  are  of  particular 
interest,  because,  when  they  are  marked  and  chance  to  be  definitely 
localized,  overshadowing:  other  ccmnlaints.  they  are  likely  to  be  in- 
terpreted not  as  referred  pains,  referred  from  some  injury  to  the 
spine,  but  as  indicating  some  local  lesion.  For  instance,  in  one  of 
the  patients  of  our  series  the  two  chief  complaints  were  pain  in  the 
lower  part  of  the  abdomen,  ^ud  persistent  vomiting.  Counted  with 
these  symptoms  were  advanced  age  and  marked  anaemia,  and  the  pic- 
ture was  suggestive  of  a  malignant  disease  of  the  gastro-intestinal 
tract,  rather  than  an  injury  to  the  spine.  One  must,  therefore,  be 
careful  not  to  misinterpret  referred  pains  which  may  obscure  the 
real  cause  of  the  trouble. 

6.  Symptoms  of  cord  involvement.  "Weakness  of  the  limbs,  un- 
steadiness in  walking,  paralysis  and  inabilitv  to  walk,  loss  or  disturb- 
ance of  sensation,  loss  of  control  of  the  sphincters  of  the  bladder  and 
rectum,  indicate  injury  to  or  pressure  unon  the  smnal  cord.  Accord- 
ing to  Pearce  Bailey  the  cord  is  injured  in  two-thirds  of  all  cases  of 
spinal  fractures. 
(B)     Objective  Symptoms. 

1.  Just  as  localized  pain  is  the  most  common  and  characteristic 
of  the  subjective  symptoms,  so  is  definitely  localized  tenderness  of  the 
spine  the  most  frequent  and  pathognomonic  of  the  objective  symp- 
toms. While  the  tenderness  may  vary  from  being  very  mild  to  ex- 
tremely marked,  it  is  always  present,  and  by  its  localization  indicates 
the  site  of  injury. 

2.  The  next  important  objective  find'rg  is  stiffness  of  t]io  '^ck. 
!«ome  limitation  of  motion  of  the  spine  in  every  direction  in  the  neigh- 
borhood of  the  injury.  It  is  important  to  recognize  that  the  limita- 
tion   is  present   in   everv   direction,    tnono-h    o?   f»*v:iree    "***    •*«*»« '■• 

eonal  in  all  directions.  This  limited  mobility  indicates  that  the  bodies, 
and  therefore  the  adjacent  regions  of  the  inter-vertebral  areas,  have 
"been  disturbed.  Tn  an  injury  such  as  a  sprain  of  the  bnek  tint  A*y* 
r.ot  involve  the  bodies  or  the  posterior  arches  of  the  vertebrae  there 
may  be  limitation  of  motion  of  the  spine,  but  that  is  nsunFy  not  pr*'>- 


I  K  W'TURE  OF   THE   SIMM  83 

cnt  in  every  direction.  There  may  be,  for  instance,  limitation  of  lat- 
eral bending  to  the  right,  or  limitation  of  flexion,  while  rotation  or 
extension  is  entirely  free.  It  is  the  fact  that  involvement  of  any  part 
o?  the  body  or  of  the  posterior  arch  of  a  vertebra  causes  limitation 
of  motion  in  every  direction,  that  the  finding  of  restricted  motion,  in 
combination,  of  course,  with  the  other  physical  signs,  points  very  def- 
initely to  a  lesion  of  the  vertebra  itself. 

3.  A  definite  change  in  the  contour  of  the  spine,  when  present,  is 
an  extremely  important  finding.  Usually  it  appears  either  as  a 
knuckle,  that  is.  an  increase  in  the  posterior  curvature  of  the  spine, 
or  as  an  area  of  localized  flatness,  thus  causing  a  break  in  the  normal 
physiological   antero-posterior   curvature   of   the  spine. 

4.  A  symptom  less  often  found  is  limited  and  localized  sensitive- 
ness of  the  spine  or  pain  in  the  back  on  indirect  injury  or  pressure, 
such  as  is  obtained  by  jarring  the  spine  either  through  makinsr  the 
individual  jump  down  on  his  heels,  or  by  tapping  him  on  the  head. 

5.  Disability  as  shown  by  the  stiffness  of  the  back,  inability  to 
move  freely,   awkward  or  spastic  walking,  or  paralysis  of  the  limbs. 

6.  X-ray  Examination:  While  we  can  be  fairly  certain,  from  the 
above  study  of  the  subjective  and  objective  findings,  of  the  nature 
of  the  injury,  the  most  convincing  evidence  is  found  by  radiographic 
examination.  In  a  clear  picture  of  the  spine,  the  evidences  of  a  frac- 
ture are  so  plain  that  they  leave  no  room  for  argument  or  doubt. 
I  have  used  the  term  "clear"  advisedly,  because  in  a  hazy  or  indis- 
tinct picture  the  evidence  may  be  concealed.  It  is,  therefore,  worth 
while  emphasizing  a  few  important  points  relative  to  x-ray  examina- 
tion. 

The  first  and  the  most  important  point  is  the  value  of  a  lateral  or 
oblique  view.  In  the  antero-posterior  picture  of  the  spine,  we  are 
looking  at  a  flat  impression  in  which  are  projected  the  shadows  of 
the  bodies,  lamina?,  the  transverse  processes,  spinous  processes,  and 
the  pedicles,  so  that  it  is  possible,  and  it  frequently  happens,  that  an 
area  or  streak  of  increased  penetration,  indicating  a  line  of  fracture, 
is  covered  up  by  the  shadow  of  the  accessory  parts  of  the  vertebra. 
For  this  reason  it  is  best  to  take  a  lateral  or  oblique  view  in  which 
we  get  a  separate  shadow  of  the  body  of  the  vertebra.  The  anatomical 
radiographic  appearance  of  the  body  of  a  vertebra  in  a  lateral  view 
appears  rectangular,  with  the  anterior  border  somewhat  longer  than 
the  posterior  border,  and  of  even  density  throughout.  In  such  a 
view  reduction  of  the  anterior  border  or  of  the  vertical  diameter  of 
the  body  will  indicate  a  crushing  or  compression  fracture,  while  ir- 


84  S.   KLEINBERG 

regularity  of  outline,  distortion  of  the  body,  and  lines  of  rarefaction 
or  fracture  become  very  evident  and  diagnostic.  Moreover,  the  re- 
lationship between  the  different  vertebrae,  particularly  those  above 
and  below  the  one  injured,  shows  the  position  of  the  vertebrae  as 
well  as  an  injury  to  them,  so  that  we  may  readily  recognize,  for  in- 
stance, a  fracture  dislocation. 

Secondly:  An  antero-posterior  view  is  of  value  as  it  shows  the  re- 
lationship of  the  vertebrae  to  one  another,  and  especially  the  size 
of  the  inter-vertebral  discs.  A  diminution  of  the  vertical  diameter 
of  one  or  more  vertebrae,  reduction  of  the  corresponding  inter-ver- 
tebral spaces  and  approximation  of  adjacent  vertebrae  indicate  in  a 
suspected  case  a  compression  fracture.  In  this  view  one  can  often 
recognize  very  distinctly  a  reduction  of  the  vertical  diameter  of  the 
vertebra  and  lateral  displacement.  One  can  also  recognize  injury, 
such  as  fracture  and  displacement  of  the  transverse  processes. 

In  studying  the  spine,  therefore,  it  is  necessary  to  take  x-ray  pic- 
tures in  at  least  two  planes,  the  antero-posterior,  and  either  lateral 
or  oblique.  Stereoscopic  pictures  are  helpful  as  they  afford  the  op- 
portunity of  studying  the  relative  position  of  the  different  fragments 
and  are  especially  valuable  in  fracture  dislocations.  They  are  not, 
however,  indispensable. 

Thirdly:  In  order  to  get  a  clear  x-ray  it  is  necessary  to  empty  the 
intestines  of  their  contents  as  much  as  possible  by  means  of  catharsis 
and   enemata. 

Fourthly:  To  make  sure  that  shadows  of  intestinal  contents  will 
not  obscure  the  outlines  of  the  vertebrae,  it  is  well  to  use  some  means, 
as  a  rubber  ball,  for  displacing  the  intestines  from  the  spine  during 
roentgenography.  This  is  especially  valuable  in  x-raying  the  lumbar 
vertebrae,  which  rarely  give  clear  outlines.  If  the  patient  is  turned 
on  his  side  and  a  rubber  ball  is  placed  over  the  lateral  abdominal 
region  between  the  ribs  and  iliac  crest  and  pressed  down,  the  intes- 
tines will  be  displaced  forward  and  a  clear  view  of  the  lumbar  ver- 
tebrae becomes  possible. 

SYMPTOM    COMPLEX   INDICATING   FRACTURE   OP    THE   SPINE. 

The  symptoms  which,  when  found  in  combination,  suggest  a  fracture 
of  the  spine  are : 

First:  A  history  of  an  injury  in  which  the  back  was  subjected  to 
a  direct  or  an  indirect  violence 


I  KU'TURE  OF  Tin;  SPIN1  85 

Secondly:  Definitely  localized  and  persistent  pain  in  the  spine, 
weakness  of  the  back,  referred  or  nerve  root  pains  which  indicate  pres- 
sure upon  the  spinal  nerves  in  the  region  of  the  localized  pain,  and 
cord  symptoms  such  as  sensory  disturbances,  spastic  gait  or  motor 
paralysis. 

Third:  Localized  tenderness  of  the  spine,  flatness  or  angulation  of 
the  spine,  and  limited  mobility. 

When  these  symptoms,  all  pointing  to  the  same  part  of  the  spin  p. 
are  present  in  an  individual  who  previous  to  his  accident  was  well, 
we  can  be  reasonably  sure  that  he  is  suffering  from  a  fracture  of  the 
spine.  X-ray  examination  is,  of  course,  necessary  to  show  the  exact 
location,  type  and  extent  of  the  injury,  but  we  should  be  able  to  make 
the  diagnosis  without  it.  This  is  especially  important  in  the  milder 
cases,  where  the  patient  looks  well,  and  is  able  to  walk  about,  and  if  the 
case  is  compensatable,  the  patient  is  likely  to  be  considered  a  neuras- 
thenic or  a  malingerer. 

prognosis. 

In  the  prognosis  of  a  case  of  fracture  of  the  spine  we  have  the  fol- 
lowing conditions  to  consider: 

1.  The  effect  of  the  injury  on  the  life  of  the  patient. 

2.  The  effect  of  the  injury  upon  the  spinal  cord  and  spinal  nerves. 

3.  The  healing  of  the  fracture. 

1.  Fracture  of  the  spine  per  se  does  not  threaten  the  life  of  the 
individual.  The  associated  injuries,  however,  are  often  so  serious  as 
to  cause  the  death  of  the  patient.  In  cases  of  fracture  of  the  spine 
with  transverse  lesions  of  the  cord,  cystitis  may  set  in,  bed  sores  ap- 
pear and  gradual  exhaustion  supervene  as  a  result  of  the  paralysis 
of  the  limbs,  bladder,  and  rectum.  These  deplete  the  patient's  ener- 
gies so  that  an  intercurrent  affection  rapidly  claims  the  patient's  life. 

2.  Nerve  symptoms,  such  as  sensory  disturbances,  weakness  or 
paralysis  of  one  or  more  limbs,  paralysis  of  the  bladder  and  rectum, 
result  from  injury  to  or  pressure  upon  the  spinal  cord  or  spinal 
nerves.  The  nerve  symptoms,  as  pointed  out  by  Dr.  Norman  Sharpe, 
result  from  pressure  of  displaced  fragments  of  vertebrae,  edema  of 
ihe  cord  or  hemorrhage  into  the  spinal  canal.  When  the  symptoms 
are  due  to  destruction  of  the  nerve  tissue  of  the  spinal  cord,  they  are 
permanent.  When  they  are  due  to  pressure,  they  disappear  when 
this  pressure  is  relieved,  unless  it  has  been  so  severe  or  prolonged 
as  to  cause  destruction  of  the  nerves. 


86  S.  KLEINBERG 

3.  The  healing  of  the  fracture.  In  the  average  case  of  fracture 
of  the  spine,  that  is,  a  fracture  with  no  nerve  symptoms  or  very  mild 
ones,  the  prognosis  for  ultimate  recovery  is  very  good.  In  fact,  soon 
after  the  injury  the  patient  is  able  to  walk,  even  though  that  may 
be  with  some  difficulty.  These  patients,  even  without  treatment,  may 
recover,  but  the  symptoms  usually  last  a  long  time,  and  recovery  may 
come  after  considerable  deformity  and  knuckling  of  the  back  has  taken 
place.  With  treatment  the  outlook  is  particularly  good,  for  we  arc 
enabled  by  efficient  and  prolonged  support  to  prevent  deformity,  and 
ultimately  hope  for  complete  healing  without  disturbance  of  gait, 
rind  without  serious  impairment  of  the  back.  "We  must,  however,  re- 
call that  healing  of  a  fractured  vertebra  is  a  very  slow  process,  and 
consequently  the  period  of  disability,  that  is,  the  time  elapsing  be- 
tween the  date  of  injury  and  the  time  when  the  individual  is  able 
to  return  to  work,  is  at  least  two  years. 

Regarding  the  function  of  the  spine,  it  has  been  my  experience 
that  in  most  of  the  cases  there  results  some  degree  of  impairment  and 
weakness  of  the  back.  These  patients  are  seldom  able  to  return  to  labors 
that  require  great  strain  of  the  back.  They  instinctively  avoid  lift- 
ing or   carrying  heavy  weights. 

The  callus  thrown  out  about  a  fractured  vertebra  is,  compared 
with  that  appearing  about  other  fractures,  exceedingly  small.  Con- 
sidering the  associated  structures,  as  the  nerves  in  the  vicinity  of  the 
vertebrae,  it  is  well  that  this  is  so,  otherwise  the  nerve  disturbance 
from  pressure  would  be  serious  and  disabling.  The  healing  then  by 
callus  formation  is  a  very  slow  procedure,  and  is  indicated  by  the 
disappearance  of  pain,  tenderness,  weakness,  and  ultimately  of  the 
disability. 

TREATMENT. 

The  most  important  element  in  the  treatment  of  a  fractured  spine 
is  early  and  efficient  support  of  the  back.  The  support  may  be  pro- 
\ided  through  an  external  splint  as  a  spinal  brace  or  plaster  of  Paris 
jacket,  or  through  an  internal  splint  by  the  insertion  of  a  bone  graft 
into  the  spinous  processes  of  the  injured  and  adjacent  vertebrae.  The 
plaster  of  Paris  jacket  is  the  usual  form  of  splint  employed.  It  is 
the  most  useful  of  the  external  splints  because  it  can  be  applied  at 
short  notice,  and  when  properly  made  acts  as  an  efficient  support. 
Such  a  support,  changed  every  two  or  three  months,  should  be  con- 
tinued for  about  two  years. 


FRACTURE  OF  THE  SPINE  87 

When  the  support  by  jacket  or  brace  is  not  sufficient,  or  when  short- 
ening of  the  period  of  convalescence  is  indicated,  then  the  radical 
or  operative  treatment  is  employed.  This  aims  at  two  things.  First, 
to  supply  an  internal  splint  by  means  of  a  bone  graft  inserted  into 
the  spinous  processes  of  the  injured  and  adjacent  vertebrae.  An  in- 
ternal splint  naturally  affords  the  spine  more  efficient  support  than 
a  plaster  jacket  or  a  brace.  Second,  internal  splinting  haptens  heal- 
ing of  the  fracture  through  fusion  of  the  vertebrae,  and  thus  abbre- 
viates the  period  of  convalescence  and  disability.  The  operative  treat- 
ment, through  its  evident  advantages,  would  seem  to  be  the  treatment 
of  choice.  It  is,  but  not  as  it  has  been  practised  in  the  past.  We 
have  been  accustomed  to  resort  to  the  insertion  of  a  bone  graft  only 
a?ter  long  delay  with  the  conservative  treatment.  In  this  way  a  ion*,' 
time  has  already  elapsed  before  we  advise  the  bone  graft  fixation,  and 
a  statistical  study  may  not  show  any  gain  of  time  from  such  an  op- 
eration. If,  however,  the  fractured  spines  were  operated  upon,  l»»t  m 
within  a  month  after  the  accident,  we  should,  I  believe,  find  rapid  and 
early  healing  of  the  fracture,  a  great  saving  in  time  and  reduction 
of  the  disability  period. 

Nevertheless,  we  should  not  forcret  that  healing  dees  taVe  place  under 
conservative  treatment,  and  in  instances  where  operation  is  contra- 
indicated  we  may  feel  confident  that  we  will  obtain  healing  of  the 
fractured  spine  provided  the  splinting  through  brace  or  jacket  is  con- 
tinuous, efficient,  and  prolonged. 

There  is,  however,  another  phase  to  the  consideration  of  the  con- 
servative versus  the  radical  treatment  of  a  fractured  spine,  and  that 
is  the  difference  in  the  resultant  mobility  and  usefulness  of  tho  back. 
Under  the  conservative  treatment  the  healing  involves  only  the  in- 
jured vertebra  and  those  immediately  adjacent  to  it,  so  that  the  stiff- 
ening of  the  spine  is  limited  to  the  minimum  number  of  vertebrae 
and  the  ultimate  disability  is  therefore  minimal.  In  the  radical  treat- 
ment there  is  deliberate  operative  fusion  of  at  least  six  vertebrae,  and 
the  ultimate  stiffening  is,  therefore,  considerable.  If  the  dorsal  spine 
is  affected,  internal  fixation  is  the  most  desirable  form  of  treatment, 
because  the  dorsal  spine  normally  has  very  little  motion  in  it,  and  the 
stiffening  resulting  from  the  operation  is  not  a  detriment  to  the  ul- 
trmate  function  of  the  spine.  On  the  other  hand,  if  the  lesion  aft'eets 
only  one  vertebra  in  the  cervical  or  lumbar  region,  the  operative  pro- 
cedure directed  to  its  relief  promptly  and  forever  completely  immo- 
bilizes a  part  of  the  spine  that  is  normally  very  mobile,  and  the  re- 


88  S.    KLBINBERG 

sultant  disability,  so  far  as  the  ultimate  function  of  the  spine  is  con- 
cerned, is  serious.  Furthermore,  in  view  of  the  fact  that  these  frac- 
tures, in  the  large  majority  of  instances,  affect  laborers,  to  whom  free 
mobility  of  the  spine  is  of  great  moment,  it  is  a  very  serious  problem 
to  decide  as  to  the  advisability  of  completely  stiffening  a  mobile  part 
of  the  spine,  for  the  gain  in  time  may  not  be  commensurate  with  the 
ultimate  results. 

As  for  the  duration  of  the  convalescent  period,  under  the  conserva- 
tive treatment  the  period  of  convalescence  is  about  two  years.  Fol- 
lowing an  operation  for  a  fractured  spine,  the  period  of  convalescence, 
under  the  most  favorable  condition,  would  be  between  six  and  nine 
months.  The  gain  in  time  of  about  six  months  to  a  year,  while  ap- 
parently a  great  advantage,  does  not  appear  of  such  tremendous  im- 
portance when  one  compares  the  ultimate  results;  namely,  from  con- 
servative treatment,  complete  healing  with  only  a  limited  amount  of 
stiffness  of  the  back,  and  from  operative  treatment,  earlier  union  but 
complete  immobility  of  a  large  part  of  the  spine. 

Fracture  of  the  spine  with  cord  symptoms.  When  a  fracture  is 
complicated  by  cord  symptoms,  such  as  paralysis,  the  question  of  early 
laminectomy  for  relief  of  pressure  arises.  Motor  and  sensory  nerve 
disturbances  indicate  injury  to  or  disturbance  of  the  spinal  cord. 
These  symptoms  are  the  result  of  injury  to  or  pressure  upon  the  cord 
from  displaced  fragments  of  bone,  edema  of  the  cord  or  hemorrhage 
into  or  about  the  cord.  From  the  symptoms  alone  it  is  impossible  to 
tell,  in  the  majority  of  cases,  the  nature  and  extent  of  the  injury  to 
the  cord.  In  an  occasional  case  the  x-ray  and  clinical  examinations 
make  it  reasonably  certain  that  there  is  marked  dislocation  of  a  ver- 
tebra or  fragment  of  bone  with  kinking  of  the  cord.  In  such  an  in- 
stance laminectomy  for  relief  of  pressure  is  indicated.  In  the  ma- 
jority of  the  cases,  however,  the  x-ray  appearance  is  not  an  index  of 
the  degree  of  damage  to  or  pressure  upon  the  cord.  The  author  has 
seen  a  case  of  extensively  comminuted  fracture  of  a  vertebra  with 
marked  displacement  of  fragments  in  which  the  nerve  symptoms  dis- 
appeared within  forty-eight  hours  under  the  usual  supportive  treat- 
ment. In  this  connection  it  is  well  to  remember  what  Dr.  Henrv  K. 
Pancoast  says  in  speaking  of  the  roentgen  examination  of  the  injured 
spine.  He  states  that  "In  some  of  the  most  severe  injuries  to  the 
cord  there  is  often  comparatively  little  roentgenographic  evidence  of 
traumatism  to  the  spine,  while,  on  the  other  hand,  there  may  be  a 
very  serious  fracture  with  permanent  dislocation  and  marked  displace- 
ment with  little  or  no  cord  disturbance. ' ' 


FRACTURE  OF  THE  SPINE  89 

The  matter  would  be  simplified  if  we  could  determine  in  a  given 
case  whether  the  nerve  symptoms  were  due  to  pressure  from  dis- 
placed bone  fragments,  kinking  of  the  cord,  hemorrhage,  or  edema  of 
the  cord.  For  with  the  exacl  pathology  known,  it  would  be  easier  to 
decide  upon  the  proper  course  of  treatment  to  pursue.  This,  however, 
is  not  possible.  On  the  other  hand,  experience  has  shown  that  in  many 
cases  the  nerve  symptoms  diminish  or  disappear  spontaneously  with- 
in a  period  varying  from  a  few  hours  to  a  few  days.  Sometimes  the 
nerve  symptoms  persist  for  months  and  then,  especially  if  the  spine 
is  supported,  diminish  or  disappear.  The  relief  is  presumably  due 
to  the  absorption  of  blood,  disappearance  of  edema  or  accommodation 
of  the  cord  to  its  new  position.  In  those  cases  in  which  the  nerve 
symptoms  do  not  disappear,  there  is  destruction  of  nerve  tissue  sus- 
tained at  the  time  of  injury  or  caused  by  the  ensuing  pressure.  Re- 
garding the  latter  point  Dr.  Norman  Sharpe  observes  that  severe  com- 
pression of  cord  fibres,  either  by  bone,  hemorrhage  or  edema,  for  a 
period  of  four  days  only,  will  result  not  only  in  the  destruction  of  the 
injured  fibres  but  in  the  permanent  impairment  of  sound  fibres. 
Hence  waiting  several  days  to  see  what  recovery  will  ensue,  may  cause 
more  severe  impairment  of  the  cord  than  that  caused  by  the  original 
injury. 

We  have,  however,  at  present  no  means  of  knowing  in  any  given  case 
of  fracture  of  the  spine,  with  injury  to  the  cord,  whether  the  nerve 
symptoms  are  due  to  irreparable  damage,  a  removable  obstruction,  or 
to  conditions  which  will  be  relieved  by  conservative  treatment.  Hence 
many  surgeons  believe  that  the  only  safe  procedure  is  early  laminec- 
tomy, as  soon  after  the  injury  as  the  patient  can  stand  the  operation, 
to  relieve  pressure  from  the  cord. 

To  this  advice  there  are  three  objections:  (1)  The  motor  and  sensory 
symptoms  disappear  in  many  cases  under  conservative  treatment — 
i.e.,  rest  and  immobilization.  (2)  Decompression  laminectomy  is  often 
not  followed  by  relief  of  the  motor  and  sensory  disturbances.  In 
some  cases  the  improvement  occurs  so  late  after  the  operation  as  to 
make  it  doubtful  if  the  improvement  is  due  to  the  operation.  (3)  The 
reported  mortality  from  decompression  laminectomy  for  fracture  of 
the  spine  is  very  large. 

In  view  of  these  facts,  it  is  difficult  to  advise  laminectomy  in  frac- 
tures of  the  spine,  with  nerve  symptoms,  without  waiting  a  few  days 
to  observe  the  effects  of  rest  and  efficient  support. 


90 


S.  KLEINBERG 


CASH  REPORTS. 

Case  1.  James  F.  Age  43  years.  Laborer.  He  was  injured  Septem- 
ber 27th,  1918 ;  came  under  my  care  January  7,  1919.  His  chief  com- 
plaint was  pain  in  the  lower  part  of  his  back,  weakness  of  the  ba^k 
and  pain  in  the  back  of  his  legs.  His  symptoms  were  very  mild.  He 
felt  that  he  was  just  a  bit  weak  as  a  result  of  his  injury,  he  would  soon 
be  better,  and  resented  having  been  sent  to  me  for  advice  and  treat- 
ment. 


Case  1. — James  F.     Compression   fracture  of  11th  and   12th   dorsal  vertebrae. 


His  history  revealed  that  he  fell  off  a  truck,  a  distance  of  a  few 
feet,  and  struck  his  back.  He  got  up  and  walked  to  the  dressing 
station,  a  distance  of  a  hundred  yards.  I  mention  this  fact  to  show 
how  mild  may  be  the  immediate  effects,  and  how  few  the  nerve  symp- 
toms. He  was  given  some  medication  and  went  home.  The  pain  in 
his  back  persisted  and  he  went  to  a  hospital  where  he  stayed  three 
weeks  and  then  walked  home.  The  backache  continued,  and  three 
months  after  his  accident  I  was  consulted. 


FRACTURE  OP  THE  SPINE  91 

Examination  showed  that  the  patient  was  in  excellent  general  con- 
dition. He  showed  no  signs  of  suffering.  His  back  appeared  symmet- 
rical and  normal.  There  was  mild  but  definite  tenderness  of  the  spine 
limited  to  the  dorso-lumbar  junction.  Extension,  lateral  bending,  and 
twisting  of  the  spine  were  normal.  Jarring  the  spine,  as  in  jumping, 
caused  pain  in  the  lower  part  of  the  dorsal  region.  Neurological  ex- 
amination was  negative,  except  for  slightly  overactive  knee-jerks. 
X-ray  pictures  showed  in  the  antero-posterior  view  a  reduction  in  the 
size  and  thickness  of  the  intervertebral  cartilage  between  the  11th  and 
12th  dorsal  vertebrae.  The  lateral  view  showed  a  reduction  of  the 
vertical  diameter  of  the  bodies  of  the  11th  and  12th  dorsal  vertebrae. 
This  case  was  therefore  one  of  compression  fracture  of  the  11th  and 
12th  dorsal  vertebrae. 

The  x-ray  evidence  is,  of  course,  diagnostic.  The  diagnosis  is  further 
borne  out  by  the  history  of  injury,  the  localized  pain  and  tenderness 
and  the  restricted  flexion  of  the  spine. 

The  chief  points  of  interest  in  this  case  are: 

1.  The   persistent  backache. 

2.  Localized   tenderness   of   the   dorso-lumbar  junction. 

3.  Limitation  of  flexion. 

4.  Characteristic   x-ray. 

5.  Mildness   of   subjective   symptoms. 

6.  Absence  of  sensory  and  motor   disturbances. 

At  the  present  writing  (March  1,  1920).  after  practieallv  fifteen 
months  of  continuous  splinting,  the  fracture  is  not  entirely  healed, 
and  there  is  still  pain,  tenderness,  and  weakness  of  his  hqpk.  Thp  dis- 
ability has  now  existed  for  one  year  and  a  half  and  will  probably  last 
at  least  six  months  more,  and  possibly  longer. 

Ca^e  2.  Jack  J. :  46  years  old.  He  was  injured  on  August  27. 
1918,  and  came  under  my -observation  November  2,  1918.  His  chief 
co-nplaint  was  pain  in  the  middle  of  his  back.  aggravated  hv  wslkincr 
and  jarring  of  any  kind.  He  complained  also  of  a  persistent  pain  on 
both  sides  of  the  chest  at  the  lower  costal  border  in  the  axillary  line. 
He  had  in  addition  marked  weakness  of  his  back  so  that  he  was  un- 
able to  lift  objects.     In  the  erect  position  he  had  practically  no  pain. 

The  cause  of  the  injury  and  its  history  up  to  the  time  he. consulted 
me  are  as  follows: 

A  plank  struck  him  on  the  back  of  his  neck  and  threw  him  down. 
This  was  a  fracture  from  an  indirect  injury  to  the  spine,  causing  a 
sudden  forced  flexion  of  the  spine  and  crushing  of  the  vertebrae.  He 
was  taken  to  a  hospital  where  he  stayed  two  weeks.  During  this  time 
he  suffered  a  great  deal  of  pain  in  his  back  and  abdomen,  but  had  no 
other  difficulty.  The  pain  was  severe  and  continuous,  preventing  him 
from  sleeping. 

At  the  end  of  the  two  weeks  he  was  told  at  the  hospital  that  there 
was  nothing  broken  and  was  discharged.     He  walked  home  and  has 


02 


S.    KLEINBERG 


Case   2.— Jack    J.      Compression   fracture   of   8th   dorsal   vertebra. 

walked  around  since.     The  backache  and  disability  have  persisted,  the 
backache  getting  worse. 

Examination  shows  that  the  man  is  in  good  general  condition.  He 
dresses  and  undresses  and  moves  about  with  apparently  no  discomfort. 
He  sits  down  and  gets  up  without  difficulty.  The  back  is  symmetrical. 
The  spine  appears  normal  except  for  a  moderate  increase  in  the  back- 
ward curve  of  the  dorsal  resrion.  There  is  no  angulation  of  the  spine 
in  either  the  lateral  or  antero-posterior  directions.  Palpation  reveals 
marked  tenderness  of  the  spine  opposite  the  angles  of  the  scapulae. 
Elsewhere  the  spine  is  not  tender.  Flexion  of  the  spine  is  limited  to 
about  one-half  of  its  normal  range,  and  is  accompanied  by  pain  in 
the  dorso-lumbar  junction.  The  other  motions  of  the  spine  are  also 
limited  slightly  and  are  accompanied  by  pain.  All  the  deep  and  su- 
perficial reflexes  are  present  and  normal  and  there  are  no  signs  of 
motor  or  sensory  disturbances.  X-ray  examination  shows  a  very 
marked  reduction  of  the  vertical  diameter  of  the  body  of  the  eighth 
dorsal  vertebra — a  crushing  fracture.  The  intervertebral  spaces  be- 
tween the  7th  and  8th,  and  between  the  8th  and  9th  dorsal  vertebrae 
are  markedly  reduced. 


FRACTURE  OF  THE  SPINE  93 

The  chief  features  of  this  case  are: 

1.  An  injury  in  which  there  was  forced  flexion  of  the  spine. 

2.  Immediate  localized  pain. 

3.  Persistence  of  pain  and  disability. 

4.  Localized  tenderness. 

5.  Absence  of  neurological  symptoms 

6.  Typical  and  diagnostic  x-ray  picture. 

It  is  interesting  here  to  note  that  this  patient  was  in  a  hospital  for 
several  weeks  and  the  condition  not  recognized.  This  was,  of  course, 
due  to  the  fact  that  either  x-ray  pictures  were  not  taken,  or  perhaps 
were  taken  but  were  hazy  and  did  not  show  clearly.  The  history  and 
type  of  injury,  and  the  localized  tenderness,  should  have  suggested  the 
diagnosis. 

Following  my  examination  I  made  a  tentative  diagnosis  of  frac- 
ture of  the  spine  and  sent  him  for  an  x-ray.  The  pictures  and  the 
report  came  back  as  negative.  When  I  looked  at  the  plates,  it  was 
evident  that  they  were,  for  they  were  indistinct.  I  then  sent 
the  man  back  to  the  laboratory  with  the  note  that  he  had  a  fracture 
of  the  spine  and  that  the  plate  ought  to  demonstrate  it.  The  second 
series  of  pictures  showed  the  condition  unmistakably.  I  mention  this 
detail  to  emphasize  the  point  again  that  the  pictures  must  be  clear, 
and  that  they  must  be  carefully  examined.  This  is  especially  true 
if  the  pictures  are  by  chance  not  very  clear,  or  ii;  the  crushing  of  the 
vertebrae  is  not  extensive. 

Case  3.  George  H. :  37  years  old.  He  was  injured  on  Septem- 
ber  14,    1918,    and   came   under   my   observation   December   10,    1913. 

The  chief  complaint  of  this  patient  was  pain  in  the  lower  part  of  his 
back  and  weakness  of  his  legs.  History:  He  was  injured  on  the  four- 
teenth of  September,  1918,  by  a  a  bag  of  flour  falling  on  the  back  of  his 
head  and  throwing  him  to  the  ground.  When  he  got  up  he  found  that  lie 
had  severe  pain  in  his  back  and  he  went  home.  The  following  day  he  was 
admitted  to  a  hospital  where  they  told  him  he  had  a  sprain  of  the  back 
and  ought  to  rest  in  bed  a  few  days.  While  in  bed  he  had  no  dis- 
comfort. At  the  end  of  a  week  he  got  out  of  bed  and  found  that  his 
pain  recurred.  X-ray  examination  was  then  made  and  the  first  and 
second  lumbar  vertebrae  found  fractured.  A  plaster  of  Paris  jacket 
was  applied  and  worn  for  about  six  weeks.  During  this  time  his 
discomfort  became  greatly  reduced.  The  jacket  was  then  removed 
and  he  was  allowed  to  go  about  without  support.  Since  then  the  pain 
in  his  back  returned  and  his  gait  became  progressively  more  unsteady. 

Examination  showed  that  the  man  was  in  good  general  condition. 
He  can  walk  without  support  but  his  gait  is  distinctly  spastic  and 
he  holds  his  back  rigid.  He  has  difficulty  in  turning  around  rapidly, 
and  when  his  eyes  are  closed,  sways,  is  unsteady,  and  barely  manages 
to  take  a  few  steps  without  support.  He  is  moderately  round 
shouldered,  with  slight  increase  of  the  posterior  curvature  of  the  dor- 
sal spine.  This  is  especially  marked  in  the  lower  half  of  the  dorsal 
region.     The  right  side  of  the  dorso-lumbar  region  is  more  prominent 


94 


S.    KLEINBERG 


Case  3. — George  H.     Compression  fracture  of  1st  and  2nd  lumbar  vertebrae. 


than  the  left  and  there  is  a  slight  deviation  of  the  spine  to  the  right 
in  this  location,  extending  from  the  mid-dorsal  to  the  mid-lumbar  sec- 
tions. The  entire  lumbar  spine  is  very  tender,  especially  the  first  lum- 
bar vertebra.  The  lumbar  spine  is  practically  entirely  rigid,  with  just 
a  little  lateral  bending  in  either  direction.  Twisting,  too,  is  almost 
entirely  restricted.  His  knee  jerks  are  overactive.  His  gait  is  un- 
steady and  spastic,  otherwise  neurological  examination  is  negative. 
X-ray  examination,  especially  the  lateral  view,  shows  very  marked 
reduction  of  the  perpendicular  diameter  of  the  bodies  of  the  first  and 
second  lumbar  vertebrae.  The  intervertebral  space  between  the  1st 
and  2nd  lumbar  vertebrae  is  greatly  reduced. 

The  interesting  features  of  this  case  are: 

1.  The  typical  combination  of  findings,  namely,  an  injury, 
immediate  localized  pain  in  the  back,  persisting  for  months,  localized 
tenderness,  characteristic  x-ray  findings. 


FRACTURE  OF  THE  SPINE  95 

2.  The  diagnosis  was  not  made  soon  after  the  injury  because 
the  condition  was  not  suspected,  and  x-rays  were  not  made  until  some 
time  after  the  injury  when  it  was  evident  that  some  organic  lesion 
was  present. 

3.  The  reduction  of  the  symptoms  soon  after  the  application 
of  the  first  plaster  jacket,  its  early  removal  and  the  reappearance  of 
symptoms. 

4.  Spastic  gait  indicating  pressure  on  nerve  tissue  as  a  re- 
sult of  the  fracture. 

This  patient  was  in  a  plaster  support  continually  from  December, 
1918,  to  August,  1919.  He  has  at  present  no  pain  in  his  back,  and 
his  gait  is  normal.     The  knee  jerks  now  react  normally. 

Case  4.  Leopold  B.:  47  years  old.  He  was  injured  on  February 
13,  1918,  and  came  under  my  observation  November  18,  1918.  His 
chief  complaint  was  persistent  pain  in  the  abdomen,  the  upper  and 
lower  parts  of  his  back,  and  vomiting  after  taking  solid  food.  The 
vomiting  was  very  distressing.  He  ate  very  little  and  appeared  great- 
ly emaciated.  He  mentioned  his  backache  incidentally,  laying  em- 
phasis only  on  his  abdominal  pain  and  vomiting.  This  was  a  "com- 
pensation" case  and  it  was  important  to  decide  whether  he  had  a 
condition  the  result  of  an  injury,  and  therefore  compensatable,  or 
whether  his  distress  was  due  to  some  other  lesion  in  no  way  related 
to  his  injury,  and  for  which  the  insurance  company  could  not  be  held 
responsible. 

On  first  appearance,  the  cachexia,  vomiting,  abdominal  pain,  and  his 
age,  suggested  some  malignant  disease  of  his  gastro-intestinal  tract. 
Still,  he  did  have  an  injury  and  did  have  some  backache  that  needed 
investigation.  He  had  gone  for  nine  months  without  a  diagnosis  being 
made. 

History:  The  patient  was  digging  in  a  ditch,  when  the  walls  caved 
in;  he  was  struck  on  his  back  and  was  doubled  up.  He  became  un- 
conscious, remaining  so  for  three  hours.  He  was  taken  to  a  hospital 
and  when  he  came  to  he  had  pain  in  his  back,  abdomen,  and  groins. 
He  wras  kept  in  bed  six  days,  and  two  days  later  was  able  to  walk 
about  and  was  discharged  from  the  hospital.  His  pain  persisted  and 
during  the  next  two  months  he  received  adhesive  strappings  to  his 
back  and  some  internal  medication,  and  after  that  he  was  considered 
a  neurotic,  with  some  digestive  disturbance. 

Examination:  When  I  first  saw  him  he  was  in  poor  condition.  He 
wore  an  abdominal  belt  and  adhesive  strappings  on  his  back.  He 
walked  without  support  and  undressed  without  difficulty.  His  gait  was 
somewhat  slow  and  awkward  and  he  presented  a  noticeable  degree  of 
round  shoulders.  He  held  his  back  somewhat  rigid  and  there  was  a 
transverse  crease  across  the  abdomen  about  IV2  inches  above  the  um- 
bilicus. The  crease  across  the  abdomen  was  very  significant  as  it  us- 
ually indicates  some  lesion  of  the  spine.  The  explanation  of  this  crease 
is  that  the  lesion  of  the  spine  gives  rise  to  a  protective  spasm  of  the 
muscles  on  the  front  and  back  of  the  spine,  holding  the  spine  and  trunk 


96 


S.    KLEINBERG 


somewhat  flexed.  When  this  sign  is  present  there  is  always  limita- 
tion of  extension.  In  the  aged,  who  frequently  have  a  senile  osteo- 
arthritis of  the  spine,  this  sign  means  only  that  the  spine  is  limited 
in  motion.  In  all  other  individuals  it  signifies  some,  usually  impor- 
tant, lesion,  as  inflammation,  injury  or  disease  of  the  spine.  This  sign 
is  seen  in  young  adults  with  spondylitis  deformities,  in  cases  of  Pott's 
disease,  in  fracture  of  the  spine  with  posterior  angulation — in  fact,  in 
any  condition  in  which  there  is  marked  increase  of  the  posterior  curve 
of  the  spine. 


Case  4. — Leopold   B.     Compression  fracture   of  the  5th   lumbar  vertebra  and 
fracture-dislocation  of  6th  dorsal  vertebra. 


Back:  There  is  a  well-marked  increase  of  the  backAvard  curve  of 
the  dorsal  region  of  the  spine  and  flatness  of  the  lumbar  region.  The 
spine  is  deviated  to  the  left  in  the  dorsal  region,  and  to  the  right  in 
the  lumbar  region.  This  curve  is  mild  and  not  accompanied  by  any 
appreciable  rotation  deformity.  The  spine  is  very  tender  in  two  areas: 
one,  over  the  upper  dorsal  region  from  the  third  to  the  sixth  dorsal 
vertebrae;  second,  over  the  lumbo-sacral  junction. 

The  abdomen  is  normal  in  outline.  The  lower  part  is  tender,  but 
there  is  no  rigidity  and  there  are  no  palpable  masses. 

The  deep  reflexes  are  present  and  normal — neurological  examina- 
tion is  otherwise  negative. 

X-ray  examination  of  the  gastro-intestinal  tract  suggests  adhesions 
in  the  ileo-caecal  region,  and  there  is  evidence  of  marked  gastric  and 
colonic  hypomotility. 


FRACTURE  OP  THE  SPINE  97 

X-ray  examination  of  the  spine  shows  two  lesions.  There  is  a  lesion 
involving  the  4th,  5th,  and  6th  dorsal  vertebrae.  The  intervertebral 
spaces  between  these  vertebrae  are  practically  obliterated.  The  body 
of  the  sixth  dorsal  is  smaller  than  normal  and  displaced  slightly  to 
the  right.  The  lesion  here  is,  therefore,  a  fracture-dislocation  of  the 
sixth  dorsal  vertebra.  The  second  lesion  is  at  the  fifth  lumbar.  Thig 
bone  is  compressed;  a  small  fragment  of  bone  projects  from  the  upper 
surface  of  the  body.  The  lesion  in  the  spine  is  a  fracture-dislocation 
of  the  sixth  dorsal  and  a  fracture  of  the  fifth  lumbar  vertebrae. 

Examination  of  the  blood,  urine,  and  feces  is  negative. 

On  account  of  the  evident  lesion  of  the  spine,  the  other  conditions, 
namely,  the  abdominal  pain  and  vomiting,  and  hypomotility  of  the 
stomach  and  colon,  were  disregarded.  A  plaster  of  Paris  Calot  jacket 
was  applied.  Almost  immediately  the  pain  in  the  back  and  abdomen 
disappeared.  His  vomiting  ceased  and  he  again  was  able  to  take  solid 
food.  His  improvement  has  continued  and  at  the  present  writing 
(March,  1920)  he  appears  in  good  condition,  the  pain  in  the  dorsal 
region  has  entirely  disappeared  and  h  eis  walking  about  comfortably, 
with  a  Taylor  spinal  brace. 

This  case  presents  several  interesting  points: 

1.  The  diagnosis  of  fracture  of  the  spine  was  not  made  until  nine 
months  after  the  injury. 

2.  The  abdominal  pain  and  vomiting,  radicular  or  referred  pain*, 
were  so  prominent  that  they  overshadowed  the  pain  in  his  back,  and 
suggested  some  abdominal  condition. 

3.  A  double  lesion  of  the  spine. 

4.  Relief  of  the  abdominal  symptoms  by  the  application  of  an  ap- 
propriate support  to  the  back. 

Case  5.  Harry  W. :  22  years  old.  Window  cleaner.  He  was  in- 
jured on  October  26,  1918,  and  came  under  mj'  observation  November 
18,  1918.  His  chief  complaint  was  persistent  pain  in  the  middle  of 
his  back,  and  weakness.  He  walked  with  some  difficulty  but  that  was, 
at  least  in  part,  due  to  an  injury  of  the  left  knee. 

History :  He  fell  out  of  a  third  story  window.  There  is  no  informa- 
tion obtainable  as  to  how  he  struck  the  ground.  He  was  picked  up 
unconscious  and  taken  to  a  hospital.  When  he  regained  consciousness, 
he  felt  severe  pain  in  his  back.  For  eight  days  he  was  on  a  water 
mattress.     One  week  later  he  was  able  to  walk  around. 

Examination:  Patient's  general  condition  is  good.  He  walks  awk- 
wardly, but  without  support.  He  holds  his  back  stiff.  His  back  is 
symmetrical.  The  spine  is  in  the  median  line.  There  is  an  area  of 
flatness  in  the  spine  from  the  8th  to  the  12th  dorsal  spinous  processes. 
This  part  of  the  spine  is  very  tender.  There  is  also  some  tenderness 
of  both  lateral  muscular  areas  of  the  dorso-lumbar  junction.  All  the 
motions  of  the  spine  are  markedly  restricted.  Jarring  of  the  spine, 
as  in  jumping,  causes  severe  pain  in  the  dorso-lumbar  junction.  All 
reflexes  are  present  and  normal. 


98 


S.    KLEINBERG 


Case  5. — Harry  W.  Compression  fracture  of  12th  dorsal  and  1st  lumbar  verte- 
brae. Note  reduction  in  perpendicular  diameter  of  affected  vertebral 
bodies. 


A  series  of  x-ray  pictures  taken  by  one  radiographer  was  reported 
as  negative.  The  pictures  were  hazy  and  no  diagnosis  could  have,  or 
should  have,  been  made.  The  clinical  examination  pointed  to  an  in- 
jury of  the  spine,  and  a  second  series  of  pictures  was  taken.  These 
showed  a  compression  fracture  of  the  12th  dorsal  and  1st  lumbar  ver- 
tebrae. There  was  also  a  fracture  of  the  right  transverse  process  of 
the  1st  lumbar  vertebra.  The  failure  of  the  first  radiographer  indi- 
cates the  importance  of   obtaining  clear  x-ray  pictures. 

The  principal  points  of  interest  in  this  case  are: 

1.  The  persistent  localized  pain  in  the  back. 

2.  Tenderness  limited  to  the  painful  region. 

3.  Characteristic  and  unmistakable  x-ray  pictures. 

4.  Failure  at  first  to  recognize  the  condition  because  of  poor  x-ray 
pictures. 


FRACTURE  OF  THE  SIMM:  99 

Case  6.  Frederick  H. :  42  years  old.  Boiler-maker.  Was  injured 
in  July,  1918,  and  came  under  my  observation  December,  1918.  His 
chief  complaint  is  persistent  and  severe  pain  in  the  lower  part  of  his 
back.  The  pain  is  continuous  so  that  he  has  no  rest,  night  or  day. 
The  history  obtained  was  as  follows: 

He  was  struck  on  his  back  by  a  sledge  hammer.  He  had  some  pain 
in  his  back.  After  that  he  continued  to  work  for  an  hour  or  so,  and 
went  home.  During  the  following  month  he  had  pain  in  his  back,  but 
it  was  not  so  severe  as  to  prevent  him  from  working,  which  he  did. 
The  pain,  however,  became  worse  and  he  had  to  give  up  work.  The 
pain  has  been  so  severe  and  constant  that  he  has  been  getting  increas- 
ingly more  miserable,  has  lost  a  great  deal  of  weight,  and  acquired  a 
sallow  complexion. 

Examination  showed  the  patient  was  of  good  muscular  build.  He 
is  evidently  in  pain,  shifting  about  from  one  position  to  another.  He 
walks  awkwardly,  and  at  all  times  holds  his  back  rigid  and  seeks  sup- 
port, although  he  can  walk  without  help.  The  back  appears  symmet- 
rical. There  are  no  abnormal  prominences  or  depressions  on  either 
side  of  his  spine.  The  spine  is  in  the  median  line,  with  no  lateral  devi- 
ation in  either  direction  at  any  part  of  it.  At  the  lumbo-sacral  junc- 
tion there  is  a  transverse  fold  of  skin,  immediately  above  which  there 
is  a  depression,  at  which  point  the  spine  appears  to  sink  forward.  At 
this  junction  the  spine  is  very  tender ;  elsewhere  along  the  spine  there 
is  no  tenderness.  Lateral  compression  of  the  pelvis  causes  pain  in  the 
lumbo-sacral  junction.  All  motions  of  the  spine  are  markedly,  almost 
completely  restricted,  and  attempted  motion  of  the  spine  causes  severe 
pain.     All  reflexes  are  present  and  normal. 

X-ray  examination  shows  a  comminuted  fracture  of  the  5th  lumbar 
vertebra.  There  is  a  loss  of  the  usual  rectangular  outline  of  the  body 
of  the  5th  lumbar  vertebra.  The  body  of  this  vertebra  is  divided  by 
a  line  of  fracture  into  front  and  posterior  halves.  The  posterior  half 
is  crushed,  and  there  is  a  small,  loose  fragment  next  to  the  under  sur- 
face. The  upper  surface  of  the  posterior  half  appears  united  to  the 
4th  lumbar  vertebra.  The  front  half  of  the  injured  vertebra  is  at- 
tached to  the  posterior  half  in  the  upper  portion  only,  while  there  is 
a  wide  interval  between  the  front  and  the  posterior  halves  in  the  lower 
part.  The  front  half  of  the  vertebral  body  has  slipped  somewhat  for- 
ward, overlapping  the  sacrum.  The  antero-posterior  view  of  the  spine 
shows  a  loss  of  the  normal  outline  of  the  5th  lumbar  vertebra  in  the 
region  of  the  right  articular  process.  There  is  a  transverse  black  line 
indicating  a  fracture,  and  there  are  several  dense  spots,  indicating  new 
bone  formation.  The  intervertebral  space  between  the  4th  and  5th  lum- 
bar vertebrae  is  practically  obliterated. 

On  account  of  the  heavy  build  of  this  patient  we  had  great  difficulty 
in  getting  x-ray  pictures  that  were  sufficiently  clear  to  indicate  be- 
yond a  doubt  the  existence  of  a  fracture.  The  type  of  injury,  and 
the  transverse  fold  of  skin  at  the  lumbo-sacral  junction,  plus  the  sink- 
ing in  of  the  spine  at  that  spot,  suggested  a  traumatic  spondylolisthe- 
sis. 


100 


S.    KLEINBERG 


A  L 


Case  6.— Fred  H.  Comminuted  fracture 'of  5th  lumbar  vertebra.  Fracture  of 
spinous  processes  of  4th  and  5th  lumbar.  Note  irregular  shape  of  body  of 
5th   lumbar. 


The  chief  points  of  interest  in  this  case,  therefore,  are: 

1.  A  comminuted  fracture  of  the  5th  lumbar  vertebra  as  the 
result  of  a  direct  blow. 

2.  Difficulty  in  identifying  the  fracture  because  of  the  diffi- 
culty in  getting  clear  x-ray  pictures  of  the  lumbo-sacral  junction. 

3.  Pain  and  disability  which  for  one  month  following  the  in- 
jury was  so  slight  that  the  patient  was  able  to  work,  finally  becoming 
so  severe  that  the  patient  had  to  be  given  morphine  in  large  doses  for 
many  weeks,  until  fixation,  by  means  of  an  Albee  bone  graft,  com- 
pletely relieved  the  patient. 

This  patient  was  treated  at  first,  as  the  others  of  this  series,  by  a 
plaster  jacket.  This  gave  no  relief  and  was  replaced  by  a  plaster  jacket- 
spica,  This  splint  gave  no  relief  and  finally,  after  about  six  weeks 
of  splinting  with  plaster,  he  was  operated  upon  and  a  bone  graft  in- 
serted into  the  lower  lumbar  and  upper  sacral  spinous  processes.  He 
was  kept  in  bed  for  six  weeks,  after  which  he  was  allowed  to  get  upy 


FRACTURE  OP  THE  SPINE  101 

wearing  a  Knight  spinal  brace.  His  pain  disappeared  a  few  days  after 
the  operation,  and  eight  weeks  later  he  was  able  to  walk  about  com- 
fortably without  any  other  support  than  the  brace. 

Case  7.  Mary  M. :  55  years  old.  Housewife.  Came  under  my  care, 
February  14,  1920.  She  was  injured  nine  weeks  ago.  Her  chief  com- 
plaint was  pain  in  the  middle  of  her  back.  The  history  reveals  that 
she  fell  while  walking,  striking  her  back,  but  she  does  not  know  what 
position  she  was  in  at  the  time  her  back  was  injured. 

The  injury  was  not  considered  serious  and  she  had  an  adhesive 
plaster  strapping  applied  to  her  back  and  was  permitted  to  walk  about. 
The  pain  continued  and  she  was  advised  to  have  an  x-ray  picture  taken 
of  her  sacro-iliac  joints.  This  picture  was  negative  and  she  was  finally 
referred  to  me  with  a  diagnosis  of  some  indefinite  lesion  of  her  sacro- 
iliac joints. 

Examination  showed  that  the  patient  was  in  good  general  condition, 
walked  very  awkwardly,  stooping  forward,  with  a  very  distinct  increase 
in  the  posterior  curve  of  her  spine.  The  patient  experienced  consid- 
erable discomfort  in  undressing  and  stated  that  she  had  difficulty  in 
finding  a  comfortable  position  to  lie  in.  Lying  on  her  face  was  ex- 
ceedingly uncomfortable.  She  pointed  to  the  dorso-lumbar  region  as 
the  site  of  her  severest  pain. 

Examination  of  the  back  shows  that  it  is  symmetrical  and  the  spine 
is  in  the  median  line.  There  is  a  very  distinct  knuckle  or  posterns 
angulation  of  the  spine  at  the  dorso-lumbar  junction.  Palpation  re- 
veals very  marked  tenderness  at  the  dorso-lumbar  junction  but  at  no 
other  part  of  the  spine.  There  is  a  transverse  crease  across  the  upper 
part  of  the  abdomen,  such  as  we  often  see  with  backward  angulation 
of  the  spine.  Hyperextension  is  entirely  limited,  while  flexion  and 
lateral  bending  in  either  direction  are  limited  to  about  %  of  the  nor- 
mal range.  All  the  motions  of  the  spine  are  painful.  The  rest  of  the 
back  and  both  sacro-iliac  joints  are  negative.  Both  knee  jerks  are  ex- 
aggerated.    There  are  no  sensory  disturbances. 

The  combination  of  an  injury,  and  definitely  localized  pain  and 
tenderness  at  the  dorso-lumbar  junction,  limited  mobility  and  angula- 
tion of  the  spine  made  it  evident  that  the  patient  was  suffering  from 
an  injury  to  the  spine. 

X-ray  examination  of  the  spine  shows  a  compression  fracture  of  the 
first  lumbar  vertebra.  The  body  of  this  vertebra  is  compressed  to  about 
two-thirds  of  its  normal  extent. 

The  chief  points  of  interest  in  this  case  are: 

1.  Persistent  localized  pain  in  the  dorso-lumbar  region  of  the 
spine. 

2.  Localized  tenderness  at  the  dorso-lumbar  junction. 

3.  Limitation  of  the  motions  of  the  spine. 

4.  Characteristic  x-ray. 


102 


S.    KLEINBERG 


Case  7. — Mary  M.     Compression  fracture  of  1st  lumbar  vertebra. 

5.  Absence  of  sensory  and  motor  disturbances. 

6.  The  diagnosis  was  not  made  until  nine  weeks  after  the  in- 
jury, although  during  this  entire  time  the  patient  was  under  the  care 
of  a  physician. 

Case  8.  Frank  De  P. :  52  years  old.  Laborer.  Came  under  my  care 
September  4,  1918.  He  was  injured  July  30,  1917.  The  chief  com- 
plaint of  this  patient  was  persistent  pain  of  the  lower  part  of  his  back, 
aggravated  by  all  motions.  Jarring  of  any  kind  aggravated  the  pain 
and  he  has  become  exceedingly  nervous. 

The  history  reveals  that  on  July  30,  1917,  he  fell  a  distance  of  40 
feet.  Following  the  injury  he  was  unable  to  walk.  He  was  carried 
home  and  kept  in  bed  for  about  four  months.  Subsequently,  he  grad- 
ually got  about  so  that  at  present  he  is  able  to  walk  without  assistance. 

Examination  on  September  4,  1918,  shows  that  the  patient  is  in  excel- 
lent general  condition.  Walks  about  without  external  support  and  un- 
dresses without  any  help.     He  stands  erect  and  walks  with  his  body 


FRACTURE  OF  THE  SPINE  103 

in  the  normal,  upright  position.  In  sitting  down,  he  does  so  very 
guardedly  as  if  afraid  of  pain. 

Back:  The  back  is  symmetrical.  The  spine  is  in  the  median  line 
and  there  is  no  lateral  deviation  in  either  direction,  or  change  in  the 
antero-posterior  curve  of  the  spine.  There  is  marked  tenderness  of  the 
spine,  limited  to  the  dorso-lumbar  junction.  All  motions  of  the  spine 
are  limited  and  painful. 

X-ray  examination  shows  a  diminution  of  the  vertical  diameter  of 
the  first  lumbar  vertebra,  but  no  lateral  displacement.  This  patient 
evidently  has  a  compression  fracture  of  the  first  lumbar  vertebra.  A 
Knight  spinal  brace  was  fitted  to  the  back,  with  the  spine  in  hyper- 
extension.  This  was  worn  continuously  until  February  6,  1920,  when 
I  examined  and  x-rayed  the  patient  again.  At  this  date  there  was  a 
very  distinct  knuckling  at  the  dorso-lumbar  junction,  but  complete  ab- 
sence of  tenderness  of  the  spine  at  the  site  of  injury. 

In  order  to  determine  the  condition  of  his  back,  the  patient  was  ad- 
mitted to  the  Hospital  for  Ruptured  and  Crippled,  for  observation, 
and  was  advised  to  go  about  without  his  brace  for  a  few  days.  It  was 
then  found  that  he  walked  about  without  his  brace  without  any  dis- 
comfort. 

X-ray  examination  shows  that  the  body  of  the  first  lumbar  vertebra 
is  reduced  to  about  two-thirds  of  its  normal  diameter.  The  interver- 
tebral space  between  the  first  and  second  lumbar  vertebrae  is  dimin- 
ished in  size  and  is  very  hazy  in  several  places,  indicating  what  ap- 
pears to  be  bony  fusion  of  the  first  and  second  lumbar  vertebrae.  Iu 
the  antero-posterior  view  the  union  between  the  first  and  second  lum- 
bar vertebrae  is  shown  by  lateral  bars  of  bone  joining  the  two  verte- 
brae. 

The  absence  of  tenderness  and  pain  at  the  site  of  injury  and  the 
x-ray  evidence  of  bony  fusion  of  the  first  and  second  lumbar  vertebrae, 
indicate  that  in  this  case  there  has  been  complete  healing  of  the  frac- 
ture. 

The  interesting  features  of  this  case  are: 

1.  The  typical  group  of  symptoms  of  fracture  of  the  spine, 
namely,  an  injury  to  the  back,  localized  pain,  localized  tenderness, 
limited  mobility,  and  a  characteristic  x-ray  picture. 

2.  The  diagnosis  was  not  made  until  fourteen  months  after  the 
injury. 

3.  Complete  healing  of  the  fracture  under  conservative  sup- 
portive treatment. 

Bibliography. 

Bailey,  Pearoe:     Med.   Record,   March  23,  1907. 
Blackwood,  N.  J. :  Annals  of  Surg.,  May,  1908. 
Doyle,  Gregory:  Buffalo  Med.  Jour.,  Jan.,  1S96. 
Ester,  W.  L. :  Am.  Jour.  Surg.,  Nov.,  1910. 
Fisher,  Edw.  D. :  Jour.  A.  M.  A.,  Oct.  26,  1912. 
Haines,  W.  B. :     Annals  of  Surg.,  May,  1908. 
Haynes,   Irving  S. :     Med.  Rec.,  March,  1907. 


104  J.    APPLETON   NUTTER 

Jenks,  Thos.  J.:     Boston  M.  and  S.  Jour.,  Sept.,  1899. 

Lloyd,  Samuel:     Med.  Rec.,  March  23,  1907. 

Marshal,  H.  W. :     Boston  M.  and  S.  Jour.,  Feb.  5,  1920. 

MacLean,  H.  Stuart:   New  York  Med.  Jour.,  Dec.  4,  1909. 

McGrath,  John  J.,  and  Byrne,  Joseph:  New  York  Med.  Jour.,  Aug.  31,  1918. 

Nicoll,  Alexander:       Amer.  Jour.  Med.   Sc,  June,   1907. 

Sharpe,  Norman:     Amer.  Jour.  Med.   Sc,  Dec.,  1916. 

Sharpe.  Norman:     Jour.  A.  M.  A.,  Oct.  26,  1918. 

Swan,  W.  H.,  et  al. :  Med.  Record,  April  15,  1911. 

Taylor,  A.  S. :     New  York  Med.  Jour.,  March)  30,  1918. 

Walton,  G.  L. :  Jour.  Nervous  and  Mental  Dis.,  Jan.,  1902. 

Williams,   Geo.  Herbert:     Med.  Record,   Nov.  7,  1908. 

Williams,  Howard  J.:  Med.  News,  May  23,  1903. 

Young,  James  K. :     New  York  Med.  Jour.,  Nov.  18,  1916. 


ON  DELAYED  UNION  AND  NON-UNION  OF  FRACTURES. 

BY    J.    APPLETON    NUTTER,    M.D.,    MONTREAL. 

Fractures  fortunately  have  a  marked  tendency  to  unite  even  when 
the  so-called  "setting"  has  "been  left  to  nature  alone.  In  spite  of  this 
benign  tendency,  much  study  has  of  late  been  bestowed  on  the  ques- 
tion of  difficult  union.  There  has  been  so  much  confusion,  even  up 
to  the  present  time,  in  differentiating  between  delayed  union  and  non- 
union or  failure  of  union  that  it  may  be  well  to  emphasize  the  dif- 
ference between  them.  Sir  Robert  Jones  insists  that  it  is  at  times 
difficult  to  distinguish  between  the  two  conditions. 

By  delayed  union  is  meant  a  retardation  of  the  process  of  normal 
bony  consolidation  of  a  fracture.  For  example,  we  speak  of  delayed 
union  when  a  femur  fracture  is  examined  eight  or  ten  weeks  after 
the  break  occurred  and  the  bones  are  found  not  yet  united.  The  fact 
that  union  is  not  yet  present  by  no  means  implies  that  it  can  never 
occur,  and  hence  this  delay  in  union  is  to  be  sharply  distinguished 
from  non-union.  Delayed  union  is  fairly  common,  while  non-union 
is  rather  rare.  If  after  exhausting  all  means  to  promote  union,  short 
of  operation,  faithfully  and  for  many  months,  the  bones  still  refuse  to 
unite,  one  is  justified  in  diagnosing  non-union.  By  this  is  meant 
that  the  bones  can  never  be  expected  to  unite  in  their  present  con- 
dition, and  that  but  one  resource  is  left  to  secure  consolidation,  namely, 
to  operate.     Delayed  union  means  retardation  for  one   cause  or  an- 


ON  DELAYED  UNION  AND  NON-UNION  OF  FRACTURES  105 

other  of  the  process  of  callus  formation,  while  non-union  is  a  more 
serious  condition  and  implies  that  consolidation  is  no  longer  to  be 
hoped  for,  save  by  operative  means.  If  a  time  limit  is  to  be  placed, 
one  may  consider  delayed  union  as  existing,  speaking  very  broadly, 
up  to  from  six  to  twelve  months  following  the  accident.  After  this 
lapse  of  time  one  may  consider  the  case  as  one  of  nort-union  rather 
than  delayed  union.  From  another  view-point  delayed  union  in  gen- 
eral means  non-operative  treatment  with  good  hope  of  success,  while 
non-union  implies  operation  of  necessity. 

FREQUENCY. 

Stimson,  quoting  von  Bruns,  whose  fracture  statistics  are  based  on 
an  enormous  number  of  cases,  gives  delayed  union  in  one  and  one- 
quarter  per  cent,  of  fractured  limbs,  with  non-union  occurring  in  only 
one-half  of  one  per  cent.  Stanley  Boyd,  in  Treves 's  "System  of  Sur- 
gery/ '  gives  delayed  union  in  one  and  one-fifth  per  cent,  of  cases. 
Mr.  Hey  Groves,  the  editor  of  the  British  Journal  of  Surgery,  speak- 
ing in  May,  1919,  at  Atlantic  City  before  the  American  Orthopedic 
Association,  estimated  that  from  four  to  five  per  cent,  of  his  fractures 
showed  non-union.  He  did  not  give  statistics  on  delayed  union.  Hun- 
kin  says  that  fractures  generally  unite  in  ninety-five  per  cent,  of  cases. 
Members  of  the  Canadian  Army  Medical  Corps  with  extensive  over- 
seas experience  emphasize  the  comparative  rarity  of  non-union,  and, 
without  producing  statistics,  are  inclined  to  the  view  that  Mr.  Groves ' 
figures  are  too  high.  Von  Bruns'  and  Boyd's  percentages  they  con- 
sider too  low.  In  their  opinion  the  truth  lies  between  these  two  ex- 
tremes, and  non-union  may  be  considered  to  exist  in  about  two  to  three 
per  cent,  of  all  fractures.  With  the  exception  that  in  elderly  subjects 
consolidation  is  apt  to  be  delayed,  age  seems  to  play  but  a  small  part 
in  determining  difficult  union.  Some  bones  when  fractured  appear 
to  have  a  predisposition  to  delayed  and  non-union.  Robert  Jones  em- 
phasizes the  additional  risk  of  non-union  incurred  in  fractures  of  the 
middle  third  of  the  femur,  in  the  humerus  between  the  middle  and 
upper  thirds,  and  in  fractures  of  the  lower  third  of  the  tibia  and  fibula. 
The  bones  of  the  forearm,  as  a  rule,  give  little  trouble  in  uniting,  with 
one  notable  exception.  This  exception,  which  should  also  be  consid- 
ered as  applying  to  fractures  of  the  lower  leg,  has  reference  to  cases 
where  extensive  loss  of  substance  exists  in  one  of  paired  bones.  Frac- 
tures of  the  neck  of  the  femur  fail  to  unite  with  relatively  great  fre- 
quency. 


106  J.    APPLETON    NUTTER 


CAUSES  OF   DELAYED   AND   NON-UNION. 

These  may  be  considered  under  the  heading  of  general  and  local 
causes.  By  a  general  (or  constitutional)  cause  is  meant  that  retarda- 
tion of  union  is  being  brought  about  indirectly  by  the  systemic  effect 
of  some  infection  or  dyscrasia.  Under  the  heading  of  general  causes 
may  be  found  almost  every  known  malady.  The  importance  of  them 
all,  with  the  probable  exception  of  syphilis,  is  largely  academic,  and 
it  is  to  be  emphasized  that  local  causes  play  a  vastly  greater  role. 
With  regard  to  syphilis  it  is  interesting  to  note  the  experience  of  mem- 
bers of  the  Canadian  Army  Medical  Corps.  A  substantial  proportion 
of  cases  of  delayed  and  non-union  seen  at  the  Buxton  Hospital  were 
found  to  be  syphilitic  (Tees),  and  responded  favorably  to  anti-luetic 
medication.  The  presence  of  syphilis  should  therefore  be  without 
doubt  suspected  in  treating  cases  of  delayed  and  non-union.  An  in- 
teresting question  arises  at  this  point.  Syphilis  has  been  included  in 
the  list  of  general  causes,  though  there  is  not  much  doubt  that,  in 
some  cases  at  least,  it  acted  locally  rather  than  systemically,  through 
the  production  of  gummatous  deposits  at  or  near  the  site  of  fracture. 
In  the  opinion  of  those  of  wide  experience,  however,  its  effect  is  re- 
garded as  acting  constitutionally  rather  than  locally. 

Other  general  causes  have  been  given  as  malaria,  starvation,  severe 
hemorrhage,  pregnancy  and  lactation,  acute  febrile  diseases,  diseases 
of  the  central  nervous  system  (particularly  tabes  and  general  paresis), 
cachexias  of  various  kinds,  nephritis,  and  diseases  of  the  ductless 
glands. 

In  pregnancy  calcium  salts  are  well  known  to  be  diverted  from  cer- 
tain at  least  of  their  storage  depots.  This  is  perhaps  best  shown  in  the 
softening  of  teeth  and  the  giving  way  of  varicose  veins  which  have 
been  previously  buttressed  by  calcareous  deposits.  As  calcium  is 
necessary  to  callus  formation  it  is  natural,  if  hypothetical,  to  suppose 
that  in  pregnancy  the  process  of  bony  consolidation  would  be  retarded. 
The  writer  has,  however,  not  been  able  to  find  any  well  authenticated 
cases  where  pregnancy  has  delayed  union,  and  is,  therefore,  forced  to 
consider  the  influence  of  pregnancy  on  the  repair  of  fractures  as  of 
academic  rather  than  practical  importance.  By  perversion  of  the  cal- 
cium metabolism  (disorders  of  the  thyroid,  thymus,  pituitary  etc.,)  cal- 
cium may  be  diverted  from  the  callus,  which  thus  remains  soft.  Yet 
we  have  no  evidence  that  gland  feeding  accelerates  or  retards  the  pro- 
cess of  bony  consolidation   (Hawley).     The  bones  of  tabetics  and  gen- 


ON  DELAYED  UNION  AND  NON-UNION  OF  FRACTURES  107 

eral  paralytics  seem  to  unite  with  very  fair  readiness.  The  influence 
of  systemic  conditions,  as  enumerated  above,  is  probably  much  over- 
rated, although  isolated  reports  stressing  one  factor  or  another  of  sup- 
posed importance  are  still  to  be  found.  To  sum  up  briefly,  while  con- 
stitutional disease  naturally  calls  for  treatment  when  complicating  a 
fracture,  its  importance,  compared  with  the  actual  local  condition  of 
the  fractured  bone-ends:  is  in  most  instances  insignificant,  syphilis  being 
the  exception. 

The  locally  acting  causes  which  delay  and  prevent  union  are  much 
fewer  in  number  than  the  constitutional  causes,  but  are  of  the  utmost 
importance. 

(1)  Non-apposition  of  the  fractured  bone-ends,  whether  due  to  loss 
of  substance  or  to  overriding.  Loss  of  substance  as  a  cause  of  delayed 
or  non-union  is  found  principally  in  military  surgery,  and  is  too  often 
due  to  over-zealous  debridement.  With  the  terror  of  sepsis  confront- 
ing him,  the  army  surgeon  has  only  too  frequently  removed  fragments 
of  bone  that  would  have  been  invaluable  as  furnishing  continuity  of 
the  broken  shaft.  Specimens  of  compound  comminuted  fracture  pre- 
pared for  the  Canadian  Government  show  most  clearly  how,  in  spite 
of  virulent  infection,  small  fragments  of  bone  not  only  retain  their 
viability  but  are  capable  of  throwing  out  osteoblasts  and  so  effecting 
union  with  neighboring  pieces.  When  several  inches  separate  the  bone- 
ends  non-union  is  the  rule,  though  in  many  instances  bone  regenera- 
tion has  spontaneously  filled  the  gap  in  a  surprising  manner.  The 
effect  of  extensive  loss  of  substance  on  union  may  be  minimized  in  cases 
where,  as  in  the  humerus,  the  sacrifice  of  several  inches  in  lensrth  en- 
tails little  disability.  In  the  femur  also  one  or  two  inches  of  short- 
ening may  with  little  difficulty  be  overcome,  with  the  result  that  in 
the  case  of  either  of  these  bones,  loss  of  substance,  providing  it  be  not 
too  great,  can  be  robbed  of  its  dangerous  tendency  towards  non-union 
by  the  simple  expedient  of  lessening  the  extension,  shortening  the 
limb  and  allowing  the  fractured  bone-ends  to  meet.  Tn  the  case  of  loss 
of  substance  affecting  one  of  paired  bones,  however,  the  difficulties  are 
much  greater,  as  the  intact  bone  prevents  any  shortening  on  the  part 
(;f   its  neighbor. 

Overriding  of  the  bone-ends  is  another  form  of  non-apposition. 
While  this  is  popularly  supposed  to  be  a  fruitful  source  of  non-union 
its  usual  effect  is  that  of  merely  delaying  consolidation.  A  study  of 
x-ray  plates  of  healed  fractures  will  show  that  many  of  the  firmest 
results  are  to  be  found  in  cases  where  overriding  is  present.  If,  in- 
deed, non-union  habitually  followed  overriding  we  should  have  infin- 


108  J.    APPLETON    NUTTER 

itely  more  trouble  with  our  fractures  than  is  the  case.  Where  non- 
union is  found  with  overriding  it  is  likely  that  there  will  be  also  pres- 
ent either  imperfect  immobilization  or  the  interposition  of  soft  parts. 
It  may  also  be  added  that  with  our  present  methods  of  skeletal  trac- 
tion overriding  of  the  bones,  of  the  lower  extremity  at  least,  can,  with 
few  exceptions,  be  overcome,  providing,  of  course,  that  union  does  not 
exist. 

(2)  Interposition  of  soft  parts  between  the  fragments,  a  mechani- 
cal bar  to  consolidation  thus  being  formed.  Such  a  condition  is  com- 
mon in  civil  practice,  but  in  war  surgery  is  seldom  seen.  Fractures 
in  military  practice  are,  as  a  rule,  caused  by  bullet  or  shrapnel,  and 
the  wounds  have  been  promptly  explored.  Any  fragments  of  fascia 
or  muscle  lying  between  the  fragments  would  have  been  found  and  re- 
moved. Fractures  in  civil  practice,  on  the  other  hand,  are  more  often 
simple  than  compound,  and  even  when  compounded  are  comparatively 
infrequently  the  seat  of  a  virulent  infection  so  often  seen  in  injuries 
received  in  battle.  Interposition  of  soft  parts  is  to  be  assumed  when, 
in  spite  of  good  alignment  and  end-to-end  apposition,  union  does  not 
take  place.     Operation  is  thereby  indicated. 

(3)  Faulty  immobilization.  Under  this  heading  is  to  be  included 
not  only  imperfect  fixation  but  also  the  retention  of  apparatus  for 
immobilization  for  too  short  a  period.  Too  much  freedom  of  move- 
ment permitted  at  the  site  of  fracture  has  often  the  result  of  pulling 
upon  or  even  breaking  the  soft  early  callus,  with  the  effect  of  substi- 
tuting fibrous  for  bony  union,  while  in  still  earlier  stages  of  repair 
a  sudden  and  unguarded  movement  may  transform  end-to-end  apposi- 
tion into  overriding  with  the  interposition  of  soft  parts.  Too  much 
handling  of  the  fracture  by  an  impatient  surgeon,  with  resultant  de- 
lay in  union,  comes  under  this  head.  It  is  interesting  to  note  that 
such  a  condition  is  commoner  in  civil  than  in  military  practice.  In 
civil  life  the  surgeon  has  comparatively  few  fractures  to  deal  with,  and 
as  a  result  may  be  at  times  led  by  misdirected  zeal  to  take  down  the 
splints  from  a  fracture  and  stir  the  bones  about  at  precisely  the  time 
when  the  fragments  need  nothing  so  much  as  absolute  immobilization. 
In  times  of  war  the  surgeon  is  greatly  overworked  and  has  but  little 
time  to  spend  with  his  patients.  Let  him  but  once  have  his  fracture 
cases  splinted  and  dressed  to  his  liking  and  they  will  be  allowed  to 
heal  undisturbed. 

Immobilization  may  be  continued  for  too  short  a  time,  with  the  re- 
sult that  the  early  callus  has  not  acquired  sufficient  strength  to  with- 
stand the  shocks  incident  to  returning  function.     It  is  natural  that 


ON  DELAYED  UNION  AND  NON-UNION  OF  FRACTURES  109 

such  a  condition  should  be  found  in  connection  with  fractures  of  the 
lower  extremity.  It  is  by  no  means  uncommon  for  a  thigh  fracture 
which  has  been  thought  firmly  consolidated  to  become   ne  fractured, 

with  subsequent  danger  of  delayed  or  non-union.  Fractures  of  the 
lower  part  of  the  tibia  have  also  been  somewhat  frequent  offenders 
in  this  regard. 

In  connection  with  the  question  of  faulty  immobilization  and  its 
bearing  on  the  union  of  fractures  it  is  interesting  to  remember  Lucas- 
Championniere's  doctrine  of  the  disregard  of  fixation.  In  fact  sonic 
writers  give  too  perfect  immobilization  as  predisposing  to  delay  in 
union.  This  is  probably  an  error,  and  the  delayed  union  must  in  such 
cases  be  sought  for  in  a  restricted  circulation  brought  about  by  too 
tight  bandaging  or  splinting. 

(4)  Sepsis,  generally  acting  through  extensive  necrosis  and  bone 
abscess.  Virulent  sepsis  is  a  destructive  agent  under  whose  influence 
large  portions  of  bone  necrose,  with  resulting  gross  loss  of  substance. 
Mild  sepsis,  on  the  other  hand,  seems  to  act  as  a  stimulant  to  callus  for- 
mation, as  witness  the  extensive  osteogenesis  in  mildly  septic  fractures. 
It  may  be  recalled,  also,  that  spurs  of  bone  on  amputation  stumps  are 
found  only  in  infected  cases.  In  septic  fractures  delay  is  the  rule 
and  non-union  the  exception.  Delay  in  union  is  generally  due  to  the 
presence  of  necrotic  bone-ends  or  of  sequestra.  It  is  to  be  noted  that 
the  importance  of  mild  sepsis,  in  regard  to  its  influence  on  the  union 
of  fractures,  has  been  greatly  exaggerated  in  the  past.  It  undoubted- 
ly delays  union,  but  rarely  succeeds,  when  suitably  treated,  in  prevent- 
ing it. 

(5)  Bone  tumors,  especially  sarcoma  and  metastatic  carcinoma, 
cystic  disease,  acute  rickets,  scurvy,  osteomalacia,  and  bone  disease  of 
all  kinds  existing  at  the  site  of  fracture,  e.  g.,  gummata,  tuberculosis, 
etc. 

(6)  Defective  blood-supply  by  too  tight  bandaging  or  splinting. 
thus  producing  an  attenuated  and  bloodless  limb,  also  by  severe  trauma 
to  soft  tissue  adjacent  to  the  fracture.  Occasionally  defective  blood- 
supply  to  a  fragment,  as  a  rule  the  distal,  by  rupture  of  the  nutrient 
artery  to  the  bone.  This  is  said  to  be  especially  frequent  in  the  tibia 
and  humerus.  It  is  possible  that  defective  local  innervation  may  be  a 
cause. 

(7)  In  certain  cases  of  delayed,  but  especially  nonunion,  no  cause 
can  be  assigned.  A  good  example  of  this  is  seen  in  the  refusal  to 
unite  of  some  cases  of  osteotomy  for  bow-legs.  In  the  cases  reported 
the  bone  has  usually  been  found  to  be  very  dense,  in  consequence  of 


110  J.    APPLETON    NUTTER 

which  the  osteotomy  was  performed  by  means  of  a  saw.  The  extreme 
hardness  of  the  bone  has  been  by  some  thought  to  militate  against 
callus  formation,  by  others  the  blame  has  been  laid  at  the  door  of  one 
or  other  of  the  ductless  glands.  One  explanation,  which  has  the  merit 
of  plausibility,  is  that  the  heat  generated  by  the  use  of  the  saw  ren- 
dered necrotic  the  bone-ends  by  searing  them,  thus  preventing  union. 
The  question  cannot  be  regarded  as  settled,  though  the  relative  scarci- 
ty of  osteoblasts  in  dense  bony  tissue  undoubtedly  has  a  bearing  on  it. 
(8)  In  certain  cases  the  blame  for  non-union  may  be,  it  would  seem 
with  justice,  laid  at  the  door  of  metallic  plates,  nails,  screws,  wires,  etc. 
Even  in  the  absence  of  appreciable  sepsis,  one  can  in  many  cases  make 
out  an  area  of  bone  absorption  in  the  immediate  neighborhood  of  for- 
eign bodies  such  as  these,  with  a  corresponding  lack  of  callus  forma- 
tion. Where  such  a  condition  is  to  be  found  connected  with  delayed 
or  non-union  it  is  but  natural  to  argue  that  the  metal  plates,  screws,  etc., 
are  foreign  bodies  that  by  the  irritation  of  their  presence  are  respon- 
sible for  the  lack  of  callus  formation.  In  many  cases  of  this  nature 
the  removal  of  the  offending  plate  or  screw  has  been  followed  by  sat- 
isfactory union.  One  explanation  of  the  failure  of  union  following 
metallic  bone-plating  is  that  the  rigidly  held  fragments,  in  end-to-end 
apposition  at  the  time  of  operation,  become  separated  by  the  absorp- 
tion of  the  bone-ends  which  form  an  early  phase  of  bone  repair.  The 
gap  thus  formed  naturally  acts  as  a  bar  to  union.  It  is  interesting  to 
note  that  Sir  Arbuthnot  Lane  himself  claims  to  have  no  such  results 
following  bone-plating.  His  contention  is  that  such  areas  of  osteo- 
porosis in  the  neighborhood  of  metallic  plates  mean  flaws  in  the  opera- 
tive technique  of  the  surgeon,  and  are  the  result  of  sepsis  of  mild  de- 
gree. There  can  be  little  doubt,  whatever  may  be  the  individual  feel- 
ing with  regard  to  metallic  fixation,  that  the  use  of  plates  and  screws, 
etc.,  is  being  more  and  more  confined  to  cases  where  (1)  the  bones  are 
large  and  the  blood-supply  correspondingly  ample,  and  (2)  where, 
as  in  cases  of  malunion,  unusual  force  is  necessary  to  hold  the  bones 
in  the  desired  position.  It  is  also  fairly  well  established  that  follow- 
ing the  use  of  metallic  plates,  screws,  etc.,  the  surgeon  incurs  a  far 
greater  risk  of  sepsis  than  would  follow  the  use  of  absorbable  suture 
material. 

diagnosis. 

Delayed  union  is  to  be  diagnosed  when,  following  a  fracture,  con- 
solidation is  found  to  be  weak  after  a  period  which  usually  suffices 
tn  effect  union.    Consolidation  of  a  gunshot  spiral  fracture  of  the  femur 


ON  DELAYED  UNION  AND  NON-UNION  OP  FRACTURES  111 

has  been  observed  to  be  sufficiently  advanced  at  the  thirtieth  day  to 
allow  the  patient  to  raise  his  heel  from  the  bed.  Following  osteoclasis 
for  bow-legs  in  a  child  of  three,  beginning  union  is  easily  distinguish- 
able one  week  after  operation.  For  strong  union,  however,  in  the 
femur  two  to  three  months  are  necessary,  in  the  humerus  about  two 
months,  in  the  lower  leg  and  forearm  about  six  to  eight  weeks.  The 
diagnosis  of  delayed  union  rests  largely  on  the  discovery  of  undue  mo- 
tility, usually  accompanied  by  pain  on  movement,  at  the  site  of  frac- 
ture. There  will,  in  addition,  be  weakness  of  the  limb.  Non-union 
ordinarily  is  to  be  diagnosed  only  after  six  to  twelve  months  of  treat- 
ment directed  towards  promoting  consolidation  of  the  fracture,  in  the 
absence  of  which  treatment  the  case  is  to  be  diagnosed  as  delayed  union 
rather  than  absolute  failure  of  union.  The  diagnosis  of  non-union 
rests  on  the  persistence  of  signs  and  symptoms  of  the  original  frac- 
ture, i.  e.,  unnatural  mobility,  pain,  weakness,  etc.  It  is  to  be  insisted 
upon  that  there  often  exists  great  difficulty  in  distinguishing  between 
delayed  and  non-union.  A  very  common  error  is  to  diagnose  as  non- 
union, and  therefore  treat  by  operation,  a  condition  where  in  reality 
union  is  only  delayed  and  where,  with  patience,  consolidation  will  be 
effected  by  conservative  measures  alone. 

TREATMENT. 

An  attempt  has  been  made  to  emphasize  the  difference  between  de- 
layed union  and  the  graver  condition  of  non-union,  and  it  may  be  point- 
ed out  that  the  difference  between  them  as  regards  treatment  is  equally 
well-defined.  Speaking  broadly,  the  treatment  of  delayed  union  is  con- 
servative while  the  only  treatment  of  non-union  is  to  operate,  unless, 
of  course,  one  is  content  simply  to  furnish  some  form  of  retentive  ap- 
paratus and  let  the  fracture  go. 

TREATMENT   OF   DELAYED   UNION. 

It  is  assumed  that  any  constitutional  or  general  disease  is  to  be  treat- 
ed as  vigorously  as  possible.  The  possibility  of  syphilis  is  to  be  borne 
in  mind  especially,  and  if  there  be  the  slightest  suspicion  of  this  dis- 
ease, a  Wassermann  examination  of  the  blood  should  be  made  (Estes). 

There  is  in  fracture  work  a  great  temptation  to  have  a  look  at  one's 
results  too  early.  A  fractured  femur,  for  example,  will  be  taken  down 
at  five  or  six  weeks  and  examined.  The  surgeon,  heedless  of  the  fact 
that  this  is  precisely  the  time  when  the  strictest  immobilization  is  nee- 


112  J.    APPLETON    NUTTER 

essary,  stirs  the  leg  about  and  is  horrified  to  find  weak  consolidation 
or  none  at  all.  What  is  in  all  probability  a  simple  case  of  delayed 
union  is  thereupon  diagnosed  non-union,  with  consequent  operation. 
This  is  bad  surgery,  as  the  case,  if  allowed  to  go  on  splinted  and  un- 
touched for  another  few  weeks,  would  very  probably  have  resulted  in 
firm  consolidation.  Provided  that  bony  apposition  and  immobilization 
are  good,  taking  down  a  fracture  is  unnecessary,  and  with  sufficient 
time  the  great  majority  of  cases  will  unite.  Meddlesome  surgery  is, 
therefore,  a  factor  to  be  considered  and  avoided.  Do  not  diagnose  de- 
layed union,  and  still  less  non-union,  until  your  time  allowance  has 
been  ample. 

Another  point  to  be  remembered  is  that  recently  healed  fractures- 
should  not  be  put  to  work  too  soon.  Many  cases  of  Pott's  fracture  in 
particular  give  way  under  the  strain  of  too  early  walking.  The  tibia,, 
too,  is,  at  best,  somewhat  indolent  in  its  power  of  repair.  Whether 
or  not  this  be  due  to  the  fact  that  in  its  lower  extent  much  of  its  shaft 
lies  subcutaneously  and  hence  has  a  scanty  blood-supply,  fractures 
of  the  lower  leg  frequently  require  the  support  of  an  ambulatory  brace 
for  a  couple  of  months.  This  matter  is  even  more  to  be  emphasized  in 
the  treatment  of  hip  fractures  where,  as  a  rule,  three  months'  time 
should  be  allowed  for  consolidation.  After  this  period  weight-bearing 
may  be  cautiously  begun.  Refracture  of  a  femur,  even  with  the  pa- 
tient remaining  in  bed,  is  by  no  means  an  infrequent  occurrence  duo 
to  too  early  removal  of  splints.  At  the  same  time  it  is  of  the  highest 
importance  that  the  joints  adjacent  to  the  fracture  should  not  be  al- 
lowed to  stiffen  from  prolonged  immobilization  (Willard).  Passive  mo- 
tion of  such  joints  should  be  practised  at  as  early  a  date  as  is  con- 
sistent with  the  safety  of  the  fracture. 

After  these  negative  points  some  positive  factors  may  be  considered. 
The  principles  which  will  in  95  per  cent,  of  cases  give  union  are  of  the 
greatest  simplicity.  We  are  examining  now,  let  us  suppose,  a  simple  frac- 
tured femur  of  ten  weeks'  standing.  (1)  Has  it  good  alignment  with 
good  length,  checked  up  by  antero-posterior  and  lateral  (or  better  still, 
stereoscopic)  x-rays?  In  other  words,  has  the  fracture  been  well  re- 
duced? Try  to  get  a  certain  amount,  at  least,  of  end-to-end  apposition, 
the  fractured  bone-ends  being  engaged.  This  is  not  a  sine  qua  non 
as  regards  union,  as  consolidation  is  often  got  with  extensive  over- 
riding. In  either  case  union  should  occur  unless  there  is  tissue  be- 
tween the  bone-ends.  It  is  interesting  at  this  point  to  note  the  belief 
of  some  members  of  the  Canadian  Army  Medical  Corps  that  anatom- 
ically perfect  reduction  gives  union  which  is  not  so  strong  as  that  seen 


ON  DELAYED  UNION  AND  NON-UNION  OP  FRACTURES  113 

in  the  case  of  end-to-end  apposition  with  some  lateral  or  antero-posterior 
displacement.  They  point  out  that  callus  formation  is  much  more  ex- 
uberant in  the  latter. 

(2)  Next,  is  immobilization  goodt  See  that  the  fractured  bone- 
ends  are  kept  in  apposition  with  the  minimum  amount  of  motion. 

(3)  As  union  cannot  take  place  without  a  good  blood-supply,  are 
the  splints  or  bandages  too  tight  ?  Too  many  fractured  limbs  are  found 
tc  be  blue,  cold,  and  wasted  when  the  bandages  are  removed.  Plaster 
of  Paris  is  a  frequent  offender  in  this  matter  of  circular  compression, 
as  also  in  the  maintenance  of  good  length. 

These  then  are  the  first  points  to  be  noted  in  our  hypothetical  case 
of  delayed  union  in  a  simple  fracture — good  alignment  and  length, 
good  immobilization,  and  a  good  blood-supply.  If  any  one  of  these 
three  is  lacking  it  should  be  corrected.  If  a  fractured  femur  passes 
these  tests  at  ten  weeks  let  it  alone  and  nature  will  in  most  cases  do 
the  rest.  Where  these  rules  have  been  observed  and  union  is  still  lack- 
ing after  three  or  three  and  a  half  months,  the  old  percussion  and 
damming  treatment,  instituted  more  than  a  generation  ago  by  Thomas 
of  Liverpool,  holds  good.  Take  the  femur,  break  down  the  soft  callus 
and  turn  the  bone-ends  toward  the  skin  and  beat  them  with  a  padded 
mallet.  If  overriding  exists  put  on  strong  extension,  preferably  skeletal, 
and  hold  the  gains  with  a  Thomas  knee-splint.  Apply  a  rubber  bandage 
tightly  three  or  four  inches  above  and  below  the  site  of  fracture,  thus 
bringing  on  venous  congestion.  Leave  the  bandage  on  at  first  twenty 
minutes  per  day,  increasing  gradually  to  several  hours  daily.  This 
method  was  developed  by  Bier  of  Berlin  and  is  erroneously  termed 
Bier's  hyperemia,  as  it  originated  with  H.  0.  Thomas.  Usually  in 
two  to  three  weeks  after  this  form  of  treatment  callus  is  thrown  out. 
ll  is  to  be  noted  that  damming  both  above  and  below  the  fracture  is 
preferable  to  the  use  of  a  rubber  band  applied  above  the  fracture  alone. 

Among  the  most  popular  forms  of  local  treatment  for  delayed 
union  may  be  mentioned  baking  and  massage.  The  baking  is,  as  a  rule, 
carried  on  by  heat  from  electric  bulbs  in  suitable  holders  or  by  electri- 
cally warmed  pads  bound  over  the  site  of  fracture.  After  baking  for 
half  an  hour  there  is  an  active  congestion  of  arterial  blood,  and  the 
pain  and  tenderness  of  the  fracture  have  markedly  decreased,  thus 
permitting  massage  to  exert  its  most  stimulating  effect.  In  the  de- 
partment of  hydrotherapy  the  "em  courant"  baths  have  proved  of 
value.  The  limb  is  placed  in  these  baths,  filled  with  hot  water  in  con- 
stant agitation  and  bubbling  with  compressed  air.  These  baths  have 
much  the  same  effect  in  general  as  have  baking  and  massage:     They 


114  J.    APPLETON    NUTTER 

ii ot  only  promote  a  greater  flow  of  blood  to  the  part  immersed,  thus 
strongly  stimulating  callus  formation,  but  they  have  a  marked  effect 
in  decreasing  the  sensitiveness  of  the  limb.  In  this  way  a  valuable 
opportunity  is  given  to  manipulate  and  mobilize  the  joints  adjacent 
tc  the  fracture,  which  only  too  frequently  are  found  to  be  stiffened 
by  prolonged  splinting. 

Galvanism  and  faradism  would  seem  not  to  have  any  marked  effect 
on  stimulating  bony  consolidation.  Diathermy,  by  its  production  of 
heat  in  the  interior  of  the  limb,  should  be  of  value  along  these  lines. 
Electricity  is,  however,  of  service  in  relieving  pain,  and  so  can  be  used 
in  preparation  for  massage  or  manipulation.  Ionization  and  the  use 
of  the  high  frequency  current  are  said  to  be  of  special  value  in  this 
respect.  It  remains  to  be  proved,  however,  that  the  use  of  the  electric 
current  in  any  form  exerts  a  more  beneficial  effect  in  the  production 
of  callus  than  the  simpler  methods  of  physiotherapy  as  exemplified 
in  baking  and  massage. 

One  ancient  form  of  treatment  has  been  the  injection  of  irritants 
such  as  iodine,  alcohol,  zinc  chloride,  etc.,  between  the  bone-ends,  with 
the  supposed  object  of  promoting  bony  union  by  the  setting  up  of 
aseptic  irritation.  Such  treatment  dates  from  pre-Listerian  days,  and 
would  seem  an  excellent  method  of  promoting  fibrous  tissue  formation, 
but  not  of  advancing  the  growth  of  callus.  The  injection  of  tissue 
fluids,  suggested  in  the  first  place  by  Carrel,  has  more  to  recommend 
it.  Bier  has  advocated  the  injection  of  blood  between  the  bone-ends, 
this  to  come  from  the  patient  himself.  Bergel  injects  fibrin  from  horse 
blood  at  the  site  of  fracture.  These  methods  appear  promising  and 
even  somewhat  logical,  but  are  not  likely  to  become  popular.  At  best 
by  their  use  one  is  working  in  the  dark.  No  one  doubts  that  a  good 
blood  supply  is  essential  to  the  healing  of  a  fracture,  but  blood  without 
osteoblasts  is  of  no  avail,  and  neither  blood  nor  other  body  fluids  con- 
tain these  precious  cells.  It  is  probable  that  the  good  effects  following 
such  injections  have  been  due  to  the  opening  up  of  new  avenues  of 
escape  for  osteoblasts  imprisoned  in  the  bone-ends.  One  writer  fKauf- 
fer)  carries  the  matter  to  a  logical  conclusion  by  recommending  the 
injection  of  granulated  bone  in  vaseline  between  the  bone-ends.  This 
method  is  not  likely  to  become  popular,  and  appears  to  disre^nrd  the 
fact  that  dead  osteoblasts  introduced  in  this  way  could  be  of  no  ser- 
vice. 

The  use  of  various  ductless  gland  extracts  (pituitary,  thyroid  etc.) 
is  advocated,  but  we  have  no  definite  proof  of  their  value  in  hastening 
callus  formation. 


ON  DELAYED  UNION  AND  NON-UNION  OP  FRACTURES  115 

Drilling  down  npon  the  bone-ends  through  a  small  skin  puncture 
is  an  old  form  of  local  irritation  which  has  been  revived  of  late  by 
Wyllys  Andrews  of  Chicago.  His  claims  that  such  treatment  rapidly 
leads  to  new  bone  formation  can  be  accepted,  especially  as  his  findings 
coincide  with  the  experience  of  Surgeon-General  A.  G.  Wildey,  R.  N. 
The  latter  does  an  open  operation,  first  removing  a  thin  section  from 
each  bone-end  to  ensure  freedom  from  fibrous  tissue.  He  then  per- 
forms what  he  terms  "long-axial  drilling,' *  by  which  is  meant,  no 
doubt,  drilling  out  the  closed-up  medullary  cavity,  as  well  as  making 
longitudinal  drill-holes  into  the  cortical  bone.  An  excess  of  callus  in 
cases  described  as  non-union  has  followed  this  method,  it  is  claimed. 
As  Wildey  refreshes  the  bone-ends,  it  would  be  a  difficult  matter  to 
decide  whether  the  union  got  in  his  cases  is  to  be  attributed  to  his 
"long-axial  drilling"  alone.  However,  this  method  of  drilling  into  the 
sclerosed  bone-ends,  thereby  opening  up  an  exit  for  the  osteoblasts  im- 
prisoned in  the  medullary  cavity  and  under  thickened  periosteum,  is 
a  highly  logical  one  and,  in  fact,  seems  rapidly  growing  in  favor.  Where 
soft  parts  or  fibrous  tissue  intervene  between  the  bone-ends  it  naturally 
cannot  be  of  service,  as  also  where  there  is  great  loss  of  bony  substance. 
As  an  adjunct  to  bone  grafting  it  has  been  found  of  service,  as  it  con- 
tributes materially  to  the  successful  "taking"  of  the  graft   (Gallie). 

In  leg  cases  delayed  union  can  be  hastened  by  the  use  of  an  ambu- 
latory splint.  The  body  weight  is  transferred  to  the  tuber  ischii  by  a 
Thomas  knee-brace,  and  the  patient  is  got  out  of  bed  and  encouraged 
to  walk  about.  Whether  locomotion  has  the  effect  of  increasing  the  gen- 
eral supply  of  blood  to  the  leg,  or  whether  the  bone-ends  are  rubbed 
together  by  walking,  at  all  events  getting  the  patient  up  and  about 
has  a  splendid  effect  on  hastening  callus  formation.  Ambulatory  treat- 
ment is  to  be  emphatically  endorsed. 

The  treatment  of  delayed  union  in  compound  septic  cases  will  be 
considered  later. 

TREATMENT  OP  NON-UNION  IN  ASEPTIC  CASES. 

It  has  been  insisted  on  that  the  treatment  of  delayed  union  is  es- 
sentially conservative,  while  for  non-union  the  treatment  must  of  ne- 
cessity be  surgical.  It  has  been  pointed  out  that  the  two  main  causes 
of  non-union  are  (1)  the  interposition  of  soft  parts  between  fragments, 
the  latter  frequently  overriding,  and  (2)  the  loss  of  large  fragments  of 
bone  either  from   actual  destruction  or  by  too  zealous  debridement. 


H6  J.    APPLETON    NUTTER 

Tn  the  first  instance,  that  of  the  interposition  of  soft  parts  between  often 
overriding  bone-ends,  the  object  of  the  operation  is  to  get  raw,  bleeding, 
and  healthy  bone-ends  into  apposition  and  to  hold  them  there;  nature 
will  generally  do  the  rest.  In  the  case  of  gross  loss  of  substance  the 
bone  graft  is  the  method  of  choice  to  bridge  the  gap,  except  where  we 
are  content  to  sacrifice  considerable  length  of  limb  by  allowing  the  bone- 
ends  to  come  together.  This  latter  method  of  treatment  obtains  more 
especially  in  fractures  of  the  upper  extremity,  as  in  the  lower  extrem- 
ity length  of  limb  is  of  great  importance. 

In  operations  for  non-union  in  aseptic  cases  the  key-note  must  be 
simplicity.  The  less  manipulation  of  the  bone  fragments,  the  greater 
is  the  security  against  sepsis.  The  operation  for  non-union  of  the  femur 
is  at  all  times  a  serious  one.  The  simplest  form  of  operation  would 
be,  it  would  seem,  to  cut  down  upon  the  fracture,  remove  the  inter- 
vening tissue,  freshen  the  fractured  surfaces  until  the  bone  bleeds 
freely,  drill  the  sclerosed  bone-ends  to  insure  the  escape  of  osteoblasts, 
obtain  end-to-end  or  lateral  apposition  by  locking  or  some  simple 
method  of  joinery,  secure  by  an  absorbable  suture  such  as  kangaroo 
tendon,  and  immobilize  with  the  greatest  care  by  splint  or  plaster  of 
Paris.  In  cases  of  considerable  overriding  there  should  be  prelimin- 
ary traction,  preferably  skeletal.  By  the  use  of  the  "ice  tongs"  over- 
riding in  femur  fractures  can  be  almost  certainly  overcome  unless  union 
exists.  In  this  way  the  sacrifice  of  much  length  of  bone  is  avoided. 
The  Hawley  table  will  be  found  of  service  at  operation,  as  a  means  of 
exerting  traction.  The  bone-ends  in  aseptic  non-union  will  be  found 
sclerosed  for  possibly  several  inches  from  the  fracture.  The  ends  will 
be  rounded  off,  and  will  be  covered  with  fibrous  tissue.  The  medullary 
cavity  will  be  found  to  be  sealed  up,  thus  effectively  preventing  the 
osteoblasts  of  this  region  from  performing  their  function  of  callus 
formation.  The  sclerosed  bone-ends  have  no  further  power  of  bone 
growth  as  far  as  the  periosteal  osteoblasts  are  concerned,  as  these  latter 
lie  dormant  and  hopelessly  imprisoned  in  dense  bone  and  fibrous  tissue. 
Beyond  the  bone-ends  one  will  come  upon  healthy  bone,  with  healthy 
periosteum  and  active  osteoblasts  both  endosteal  and  periosteal.  The 
bone-ends,  their  activity  now  come  to  an  end  after  a  brief  period  of 
effort,  act  as  a  barrier.  The  problem  is  to  set  free  the  imprisoned 
osteoblasts  and  to  press  into  service  those  at  a  distance.  In  some  in-, 
stances  union  is  achieved  by  sawing  off  half  an  inch  or  more  from 
each  bone-end,  or  until  the  bone  bleeds  freely.  These  smooth,  slippery 
ends  are  now  crenated  with  the  bone-nibblers  and  the  ends  locked  in 
apposition.     Chances  of  callus  formation  are  distinctly  better  if  in  ad- 


ON  DELAYED  UNION  AND  NON-UNION  OP  FRACTURES  117 

dition  the  bone-ends  are  drilled  into  longitudinally  at  many  points 
(Wildey)  and  the  medullary  cavity  reamed  out,  as  thus  the  imprisoned 
osteoblasts  are  given  a  chance  to  escape.  Where  osteosclerosis  is  ex- 
treme in  its  density  and  extends  for  two  or  three  inches  along  each 
fragment,  there  are  too  few  osteoblasts  in  the  bone-ends,  and  what  few 
there  are  possess  too  little  vitality  to  effect  union,  as  a  rule.  One  must 
therefore  call  up  the  reserves,  namely,  the  osteoblasts  in  the  healthy 
bone  beyond  the  sclerosed  area.  As  has  been  said,  the  sclerosed  bone- 
ends  act  as  a  barrier,  and  this  barrier  must  be  removed.  This  can  be 
done  in  two  ways:  (1)  by  sawing  off  the  sclerosed  and  inert  bone-ends, 
thus  sacrificing  great  length  of  limb,  and  (2)  by  the  use  of  the  inlay 
bone  graft  (Albee)  of  great  length,  long  enough  to  bridge  across  the 
barrier  from  well  within  the  area  of  healthy  and  active  bone.  The 
groove  in  which  the  graft  is  placed  will  open  up  the  medullary  cavity, 
thus  bringing  into  action  the  osteoblasts  of  this  area.  The  graft  will 
be  from  the  tibia,  in  most  cases,  cut  from  the  subcutaneous  surface 
and  carrying  with  it  both  periosteal  and  endosteal  osteoblasts.  Two 
inches  of  the  graft  at  each  end,  if  possible,  will  lie  embedded  in  the 
healthy  bone  beyond  the  sclerosed  bone-ends,  and  in  this  way  the  graft 
will  in  all  probability  take. 

The  combination  of  overriding  and  osteosclerosis,  taken  together,  pre- 
sents rather  a  difficult  problem,  the  solution  of  which  depends  on 
whether  we  are  willing  to  sacrifice  much  or  little  length  of  limb.  Mr. 
Hey  Groves  states  that  a  patient  by  depressing  his  pelvis  on  the  short 
side  can  get  along  very  well  with  one  and  one-half  inches  of  shorten- 
ing of  his  leg,  and  that  by  the  use  of  a  high  heel  in  addition,  he  can 
make  up  for  another  one  and  one-half  inches  of  shortening.  Hence 
one  may  get  along  very  well,  according  to  Mr.  Groves,  with  a  femur 
even  three  inches  short.  Groves,  therefore,  advocates  removal  of  the 
sclerosed  bone-ends  generously  until  the  bone  is  seen  to  bleed  freely, 
getting  end-to-end  or  lateral  apposition,  with  fixation  by  plate,  bolt 
or  wire.  In  this  use  of  metallic  fixation  he  follows  Sir  Arbuthnot  Lane. 
Sir  Robert  Jones,  on  the  other  hand,  avoids,  when  possible,  the  use  of 
nlates  or  metallic  sutures.  Albee 's  method  of  inlay  bone  graft,  ex- 
tending through  the  sclerosed  areas  from  healthy  bone  above  to  healthy 
bone  below,  seems  the  most  logical  method  of  treatment  where  one 
wishes  to  avoid  shortening,  and  where  a  bone  graft  would  seem  strong 
enough  to  hold  the  bones  in  place.  His  theory  is  that  the  graft  is  in 
itself  a  stimulant  to  bone  production.  This  may  be  so,  for  although 
the  graft  promptly  dies  when  placed  in  its  bed  some  of  the  osteoblasts 
on  its  periosteal  and  endosteal  surfaces  receive  sufficient  nourishment 


118  J.    APPLETON   NUTTER 

from  the  surrounding  tissue  fluids  to  retain  their  vitality  and  live,  thus 
furnishing  additional  power  to  bone  production.  At  the  same  time 
no  reliance  is  to  be  placed  on  the  periosteum  in  regard  to  its  supposed 
and  time-honored  function  of  producing  bone  (Gallie),  and  for  this 
reason  the  presence  or  absence  of  periosteum  on  the  graft  is  of  little 
practical  importance.  Its  chief  claim  to  distinction  lies  in  the'  fact 
that  it  controls  the  nutrition  of  the  underlying  bone  through  the  com- 
munication of  its  numerous  vessels  with  the  vascular  system  of  the 
bone  to  which  it  adheres.  It  is  therefore  obvious  that  stripping  up 
of  the  periosteum  during  the  course  of  an  operation  is  to  be  done  with 
the  greatest  care  and  to  the  minimum  amount,  to  avoid  underlying 
necrosis  should  infection  ensue. 

The  placing  of  the  inlay  bone  graft,  then,  frees  many  osteoblasts 
that  would  otherwise  have  lain  dormant  and  useless.  At  the  same 
time  it  would  seem  beneficial  to  bone  production  to  treat  the  sclerosed 
bone-ends  by  drilling  into  them  in  all  directions,  thus  allowing  the 
diffusion  of  such  osteoblasts  as  still  survive  in  their  depths.  It  must 
be  remembered  that  in  the  larger  bones  (femur,  humerus,  tibia)  almost 
every  form  of  bone  graft  has  a  fair  chance  of  success,  as  the  blood  sup- 
ply is  generally  ample  and  there  is  sufficient  bony  tissue  to  provide 
an  abundance  of  osteoblasts.  Sir  Robert  Jones  in  this  connection  insists 
on  the  graft  resting  in  contact  with  the  medullary  cavity,  as  well  as, 
when  possible,  being  enveloped,  together  with  its  recipient  bone,  in  a 
petticoat  of  fascia,  transplanted  if  necessary.  Where  much  force  is 
reeded  to  keep  the  bone-ends  in  apposition  or  correct  alignment  it  may 
be  found  necessary  to  make  use  of  metallic  plates,  wire,  etc.  Gallie  in 
such  cases  has  used  plates  made  of  boiled  ox-bone,  held  in  position  by 
bone  screws  or  bolts.  It  is  to  be  noted,  however,  that  neither  boiled 
bone  nor  living  heterogenous  grafts  should  be  used  to  bridge  any  but 
short  gaps,  as  the  osteoblastic  proliferation  which  takes  place  at  either 
end  of  such  a  graft  will  almost  certainly  fail  to  reach  its  middle 
(Gallie). 

In  cases  of  considerable  loss  of  bony  substance  one  usually  waits  for 
several  months  in  the  hope  that  new  bone  may  be  produced.  Failing 
this,  one  may  sacrifice  length  of  limb  by  allowing  the  bone-ends  to 
come  together  in  the  expectation  of  union.  This  is  not  generally  done 
in  cases  of  loss  of  substance  in  the  bones  of  the  lower  extremity  amount- 
ing to  more  than  one  and  one-half  to  two  inches.  In  the  bones  of  the 
arm,  loss  of  length  is  of  little  consequence.  As  in  non-union  with  the 
bone-ends  in  apposition,  so  in  non-union  with  a  gap  to  be  bridged,  the 
method  of  choice  in  the  case  of  the  larger  bones  is  the  inlay  bone  graft 


ON  DELAYED  UNION  AND  NON-UNION  OP  FRACTURES  119 

The  graft  must  be  autogenous  and  is  best  taken  from  the  subcutaneous 
inner  surface  of  the  tibia  (not  the  crest).  Two  factors  are  of  the  utmost 
importance  here.  (1)  The  graft  must  be  sufficiently  long  to  extend 
at  least  two  inches  into  the  healthy  bone  beyond  the  sclerosed  bone- 
ends.  (2)  Immobilization  must  be  extremely  carefully  maintained 
until  the  graft  has  taken.  In  cases  of  bridging  a  gap  it  is  interesting 
to  note  the  procedure  used  and  advocated  by  Sir  Arbuthnot  Lane.  Re- 
fusing to  accept  shortening,  he  gets  the  arm  or  leg  to  normal  length 
by  extension  and  holds  the  fragments  firmly  by  a  long  metallic  plate 
which  bridges  the  gap.  The  space  between  the  fragments  he  fills  with 
a  piece  of  bone  generally  chipped  off  from  one  or  other  portion  of 
the  bone  that  is  the  subject  of  operation.  Good  results  are  claimed 
by  him.  His  criticism  of  bone  grafting  is  that  by  its  use  insufficient 
immobilization  of  the  fragments  is  provided,  with  consequent  failure 
to  unite.  He  insists  on  absolute  immobilization,  and  does  not  con- 
sider that  even  an  inlay  bone  graft  holds  the  bones  sufficiently  im- 
movably. In  the  case  of  non-union  with  much  sclerosis  of  the  bone- 
ends  it  is  difficult  to  see  how  a  considerable  gap  could  be  successfully 
bridged  by  Sir  Arbuthnot  Lane's  method,  unless  both  the  sclerosed  ends 
were  well  opened  up  by  the  chiseling  incident  to  the  making  of  the  graft. 
Nor  is  his  graft  in  contact  with  healthy  medullary  cavity,  which  Sir 
Robert  Jones  insists  should  be  done.  Granting  that  success  has  fol- 
lowed this  method  in  operations  on  the  larger  bones,  it  is  still  more 
difficult  to  understand  how  union  could  be  obtained  in  bridging  gaps 
in  the  smaller  bones  such  as  the  radius  and  ulna. 

Non-union  of  fractures  of  the  femoral  neck  is  the  rule  rather  than 
the  exception.  Where  about  ninety-five  per  cent,  of  fractures  in  gen- 
eral unite,  only  about  ten  to  sixteen  per  cent,  of  fractures  of  the  neck 
of  the  femur  acquire  bony  union  (Hunkin).  British  authorities  have 
made  the  figure  somewhat  higher,  estimating  that  union  is  obtained  in 
the  neighborhood  of  twenty-three  to  twenty-eight  per  cent,  of  cases.  One 
is  confronted,  in  cases  of  non-union  of  fracture  of  the  femoral  neck, 
not  only  by  loss  of  substance  due  generally  to  bone  absorption,  by 
poor  blood-supply  and  consequently  poor  bone-forming  power,  but 
also  considerable  deformity.  The  great  trochanter,  as  a  rule,  is  ele- 
vated, sometimes  to  such  an  extent  that  the  fractured  bone-ends  are 
not  touching.  Non-union  is  most  frequently  seen  in  cases  of  the  so- 
called  intracapsular  or  sub-capital  fracture.  Pegging  the  femoral 
neck,  together  with  refreshing  the  bone-ends  through  an  anterior  in- 
cision, seems  the  favorite  procedure,  and  one  that  has  met  with  a  con- 
siderable degree  of  success.     Whitman's  abduction  method  is  not  ad- 


120       .  J.    APPLETON    NUTTER 

vocated  by  him  in  cases  of  absorption  of  the  femoral  neck.  The  use 
of  a  bone  peg  is  to  be  recommended  rather  than  a  metallic  spike,  which 
latter  soon  loosens  owing  to  osteoporosis  of  the  bone  in  contact  with 
it.  The  bone  peg,  on  the  other  hand,  will  under  favorable  conditions 
become  an  integral  part  of  the  bone  in  which  it  lies.  It  is  not  to  be 
recommended  that  the  bone  peg  should  be  carefully  shaped  and  rounded 
off,  but  rather  that  it  should  be  driven  into  the  femoral' neck  in  the 
rough,  penetrating  well  into  the  upper  fragment  and  following  the 
track  of  a  long  hole  previously  drilled  to  receive  it.  Nor  should  perios- 
teum remain  on  the  surface  of  the  bone  peg,  as  this  would  act  as  a  bar- 
rier between  the  graft  and  the  recipient  bone.  Too  much  shaping  of 
the  bone  peg,  with  the  object  of  making  it  smooth  and  well  rounded, 
has  the  effect  of  destroying  any  osteoblasts  that  might  otherwise  remain 
on  its  surface,  to  promote  bony  union.  It  must  be  conceded,  however, 
that  a  metallic  spike  has  the  great  practical  advantage  of  being  strong- 
er than  a  bone  peg.  After  the  use  of  the  latter,  therefore,  the  greatest 
care  must  be  taken  to  insure  the  most  perfect  immobilization  of  the 
hip  region.  Pegging  of  the  fracture  alone,  without  refreshing  the  bone- 
ends,  has  been  advocated,  but  in  view  of  the  fact  that  the  bone-ends  al- 
ways show  sclerosis  and  that  fibrous  tissue  is  often  found  intervening, 
this  would  not  seem  to  be  a  correct  surgical  procedure.  The  pegging 
operation  is  to  be  preceded  by  traction  and  other  manoeuvers,  such  as 
internal  rotation  and  abduction,  with  the  object  of  getting  the  frag- 
ments of  the  femoral  neck  into  alignment  so  far  as  this  is  possible. 
It  should  be  followed  by  the  application  of  a  long  plaster  spica  extend- 
ing not  only  over  the  operated  hip  but  fixing  the  sound  hip  as  well.  It 
is  in  the  application  of  the  plaster  spica  that  the  greatest  care  must 
be  taken  not  to  break  the  bone  peg.  The  fractured  area  is  best  reached, 
to  be  explored  and  freshened,  by  the  anterior  route.  The  peg  is  in- 
troduced through  a  separate  and  more  laterally  placed  incision  over 
the  great'  trochanter.  The  long  hole  in  the  femoral  neck  extending 
into  the  upper  fragment  may  be  drilled,  but  the  bone  is  so  cancellous 
in  this  region  that  a  bradawl  will  be  found  to  work  well. 

Brackett's  method  of  transplanting  the  head  of  the  femur  to  the 
trochanter  was  published  in  The  Boston  Medical  and  Surgical  Journal 
for  September  13,  1917.  The  surgical  reputation  of  its  author  is  the 
best  guarantee  of  its  usefulness.  The  writer's  experience  with  it  has 
been   slight. 

It  should  be  noted  that  fractures  of  the  femoral  neck  involving  the 
great  trochanter,  under  which  heading  would  be  included  the  so-called 
extracapsular  fracture,  unite  with  much  greater  readiness  than  is  the 


ON  DELAYED  UNION  AND  NON-UNION  OF  FRACTURES  121 

case  with  fractures  near  the  femoral  neck.  Not  only  are  the  bones  in- 
volved of  much  larger  extent,  but  the  blood-supply  is  ample.  Osteo- 
blasts, therefore,  not  only  exist  in  great  number  but  receive  sufficient 
nourishment  to  encourage  callus  formation.  In  the  case  of  fractures 
occurring  near  the  head,  so-called  subcapital  or  intracapsular,  condi- 
tions are  very  different.  The  femoral  neck  in  this  region  is  compar- 
atively small,  while  the  fragment  consisting  of  the  head  and  the  ad- 
joining portion  of  the  neck  derives  its  nourishment  exclusively  from 
a  very  small  artery  in  the  ligamentum  teres.  As  would  naturally  be 
expected  in  consequence  of  such  a  diminutive  blood-supply,  there  is 
little  or  no  power  of  callus  formation  in  this  fragment.  Thus,  without 
impaction,  the  chances  of  union  occurring  in  a  fracture  of  this  type 
are  rather  poor. 

In  the  case  of  the  larger  bones,  the  femur,  humerus,  and  tibia,  it 
has  been  stated  that  almost  any  form  of  bone  graft  has  fair  chances 
of  taking,  there  being  an  abundant  blood-supply  and  plenty  of  bone 
substance  to  furnish  a  supply  of  osteoblasts.  In  the  case  of  the  smaller 
bones,  however,  notably  the  radius  and  ulna,  bone  grafting  has  had 
many  failures.  Some  grafts  refused  to  take,  while  others  took  for  a 
time  only  to  give  way  after  some  months.  Too  early  and  excessive 
use  of  the  arm  was  at  first  blamed  for  failures  of  the  latter  class,  but 
in  some  cases,  at  least,  this  was  found  not  to  be  the  true  solution.  Here 
the  graft  was  discovered  to  have  taken  well  at  the  ends,  but  to  have 
given  way  in  the  centre,  owing  to  the  failure  of  new  bone  formation 
to  permeate  the  graft  in  its  entirety.  In  the  case  of  refusal  of  the 
grafts  to  take,  the  mistake  seems  to  have  been  largely  one  of  disregard- 
ing the  blood-supply  and  of  overestimating  the  power  of  callus  forma- 
tion in  bones  of  small  size.  The  application  of  an  inlay  graft  of  or- 
dinary size  to  one  of  the  forearm  bones  involves  so  much  trauma  to 
the  recipient  bone  that  but  little  is  left  either  of  blood  supply  or  of 
healthy  bone.  By  the  time  the  bed  for  the  graft  has  been  made  and 
the  sutures  tied,  so  much  dissection  has  occurred  that  there  remains 
but  little  bone-forming  energy  in  the  mutilated  fragments,  too  often 
quite  insufficient  to  vitalize  the  graft.  The  same  objection  often  holds 
true  as  regards  the  application  of  metallic  plates  and  screws. 

There  are  five  methods  of  applying  the  bone  graft  in  this  region, 
as  elsewhere.  In  cases  where  the  medullary  cavity  is  to  be  easily 
reached  and  reamed  out,  bone  fragments  have  been  sprung  into  place, 
an  end  engaged  in  the  medullary  opening  of  each  fragment.  It  is  to 
be  noted  that  softer  bones,  such  as  rib  and  iliac  crest,  take  here  better 
than  the  denser  bone  from  the  tibial  crest.     At  the  same  time  grafts 


122  J.    APPLETON    NUTTER 

from  the  subcutaneous  surface  of  this  bone  have  been  found  to  give 
satisfactory  results.  To  give  the  best  results  here  the  medullary  graft, 
like  the  inlay  graft,  should  project  beyond  the  sclerosed  ends  of  the 
recipient  fragments  so  that  they  penetrate  to  the  healthy  bone  mar- 
row. As  the  fragments  are  frequently  tapering  and  with  sealed  medul- 
lary openings  this  is  not  often  possible,  nor  can  this  form  of  graft  be 
well  used  when  the  ununited  bones  lie  closely  in  apposition.  The 
method  of  choice  in  dealing  with  tapering  bone-ends  has  been  to  split 
these  with  a  saw  for  some  distance,  placing  a  graft  from  the  tibial  cor- 
tex in  such  a  manner  as  to  engage  between  the  cleft  ends.  A  third 
method  is  to  use  boiled  bone  plates  fastened  in  place  by  means  of  bone 
screws  or  bolts  (Gallie).  In  bridging  a  gap  such  procedure  is  not  to  be 
advocated,  owing  to  the  low  power  of  bone  formation  possessed  by  such 
heterogenous  and  boiled  bone  grafts.  They  are  made  of  boiled  ox-bone 
ground  to  the  shape  required,  and  are  said  to  be  satisfactorily,  though 
slowly,  replaced  by  new  bone  in  cases  where  the  recipient  healthy  bones 
are  not  much  more  than  an  inch  apart  as,  for  instance,  in  spinal  grafts. 
Autogenous  bone  grafts,  it  is  conceded,  possess  the  power  of  new  bone 
formation  to  a  comparatively  high  degree,  whether  taken,  for  instance, 
from  the  tibia  to  be  used  as  an  inlay,  or  from  one  of  the  fragments, 
preferably  the  upper  on  account  of  its  better  blood-supply,  as  a  slid- 
ing graft.  Sterilizing  such  a  graft  by  boiling  it  retards  the  rate  of 
speed  by  which  it  is  changed  into  new  and  living  bone,  and  hence  less- 
ens the  size  of  the  gap  which  it  is  capable  of  filling.  Ox-bone  grafts, 
or  those  taken  from  an  individual  not  the  one  operated  on  (so-called 
heterogenous),  will  show  a  still  slower  rate  of  bone-forming  power,  ex- 
cept when  the  donor  of  the  graft  belongs  to  the  same  blood-group  as 
the   patient. 

It  has  been  shown  that  the  use  of  the  inlay  bone  graft  has  not  proved 
so  successful  in  the  smaller  bones  as  it  has  in  the  larger,  for  reasons 
already  given.  Chutro  has  advocated  the  method  of  using  thin  slices 
of  cortical  bone  with  the  periosteum  adherent,  placing  this  in  the  space 
made  by  dissecting  back  the  periosteum  from  the  recipient  bones. 
Periosteum  is  placed  against  periosteum,  bone  against  bone.  This 
method  is  said  to  produce  the  least  amount  of  disturbance  to  the  blood 
supply,  and  to  be  a  promising  one.  It  naturally  cannot  be  used  where 
force  is  needed  to  overcome  bony  deformity,  as  the  wafer-like  grafts 
have  little  strength,  and  are  held  in  place  by  absorbable  sutures.  It 
has,  in  addition,  the  disadvantage  of  necessitating  the  stripping  bapk 
of  periosteum,  thus  jeopardizing,  to  some  extent  at  least,  an  already 
feeble  blood-supply.     It  is  not  though  that  it  will  replace  the  more 


ON  DELAYED  UNION  AND  NON-UNION  OF  FRACTURES  123 

commonly   used   methods,   particularly   that   of   grafting   between   the 
cleft  ends  of  the  fragments. 

SEPSIS    IN    DELAYED    AND    NON-UNION. 

The  war,  by  its  multiplicity  of  gunshot  wounds  complicated  by  sepsis, 
has  vastly  increased  our  knowledge  of  the  influence  of  infection  on  the 
process  of  union.  Before  the  war  sepsis  was  considered  a  most  impor- 
tant cause  not  only  of  delayed  but  of  non-union.  Experience  in  army 
hospitals  shows  that  such  is  not  the  case,  as  is  proved  by  the  compar- 
ative rarity  of  admissions  for  non-union.  Septic  fractures,  after  the 
first  flare-up  has  died  away,  show  a  great  amount  of  callus  formation, 
and,  contrary  to  our  former  belief,  union  is  readily  obtained  when  these 
often  enormous  masses  of  spongy  bone  are  placed  in  contact.  In  fact, 
sepsis  of  a  mild  nature  is  a  strong  stimulant  to  osteogenesis  and  an  as- 
sistant to  union  (Gallie).  Where  non-union  persists  in  the  presence 
of  sepsis  it  will  probably  be  found  that  either  extensive  destruction 
of  bone  has  occurred,  forming  a  gap  too  great  to  be  bridged  over,  or 
else  union  is  prevented  by  the  presence  of  necrotic  bone-ends  or  se- 
questrum formation.  These  act  in  preventing  union  both  mechanically, 
by  keeping  apart  the  masses  of  newly  formed  callus,  and  also  by  the 
continued  irritation  of  their  presence  retard  the  activity  of  the  neigh- 
boring osteoblasts,  until  fibrous  tissue  formation  mechanically  prevents 
union   from  taking  place. 

It  has  been  found  that  at  a  certain  period  after  injury  a  time  ar- 
rives particularly  favorable  to  the  union  of  septic  fractures.  At  this 
moment,  given  as  from  about  three  to  five  months  after  the  wound  was 
received  (Gallie),  osteogenesis  is  at  its  height,  vascularity  is  greatly 
increased,  callus  is  abundant  and  the  septic  infection  has  run  its  course, 
and  is  now  only  mildly  virulent,  while,  as  yet,  fibrous  tissue  growth 
is  not  sufficiently  advanced  to  form  a  mechanical  bar  to  union.  It  is 
at  this  time  that  best  results  are  obtained  in  seeking  for  union.  The 
wound  should  be  excised,  all  septic  tracts  removed,  walls  of  bone  cavi- 
ties chiseled  away,  sequestra  got  rid  of,  the  ends  of  fragments  refreshed 
and  placed  in  apposition,  and  a  very  large  drainage  opening  left,  lead- 
ing directly  down  to  the  fractured  ends,  so  that  in  fact  these  can  be 
seen.  If  any  suture  be  found  necessary  it  should  be  an  absorbable  one 
such  as  kangaroo  tendon.  Metallic  sutures,  plates,  etc.,  act  as  foreign 
bodies  and  should  not  be  used,  even  though  by  their  means  more  per- 
fect immobilization  may  be  secured.  Plaster  fixation,  with  a  window, 
may  be  applied  after  the  first  reaction  has  subsided,  in  about  a  week's 
time.     In  cases  where  there  is  so  much  loss  of  bone  .that  the  ends  can- 


124  J.    APPLETON    NUTTER 

liot  be  allowed  to  come  together  on  account  of  the  excessive  shortening 
thus  produced,  one  must  be  contented  with  simply  healing  the  wound 
and  leaving  the  question  of  promoting  union  to  a  later  date.  By  the 
recognition,  then,  that  union  is  quite  possible  in  the  presence  of  mild 
sepsis,  and  is  even  at  times  hastened  by  it  (Gallie),  much  time  can  be 
saved  in  treatment.  It  was  not  so  many  years  ago  that  one  was  con- 
tent merely  with  healing  the  wound,  considering  it  hopeless  to  expect 
any  effort  at  union  on  the  part  of  septic  bone-ends. 

SEPSIS   AND   BONE    GRAFTING. 

While  an  inadequate  blood-supply  and  lack  of  sufficient  bony  tissue 
in  a  healthy  condition  have  been  given  as  frequent  causes  of  failure 
in  bone  grafting,  it  must  be  admitted  that  above  all  other  causes  sepsis 
is  the  great  bane  of  this  operation.     Sepsis,  then,  at  all  costs  is  to  be 
avoided.    Any  surgeon  worthy  of  the  name  should  be  capable  of  oper- 
ating without  the  introduction  of  sepsis  from  without,  but  in  the  case 
cf  an  operation  to  graft  bone  for  non-union  following  a  septic  frac- 
ture one  of  our  greatest  problems  is  to  decide  whether  or  not  sepsis 
is  lurking  in  secret  directly  in  the  path  of  the  surgeon's  knife.     The 
onset  of  sepsis,  whether  from  within  or  without,  will  inevitably  de- 
stroy any  chance  of  bridging  a  gap  with  a  bone  graft,  which  at  once 
is  destroyed  by  the  infection,  all  chances  of  its  taking  being  nullified, 
and  which  now  becomes  a  foreign  body  fit  only  to  be  removed.     It 
must  be  admitted,  however,  that  at  times  union  of  the  bone-ends,  with 
taking  of  the  graft,  is  seen  even  in  the  presence  of  sepsis,  provided 
that  there  is  end-to-end  apposition  of  the  fragments.     It  is  without 
doubt  a  difficult  problem  to  decide  how  long  after  a  wound  is  healed 
it  is  safe  to  attempt  a  bone  graft  operation..    The  utmost  care  must  be 
taken  not  to  operate  in  the  presence  of  infection,  and  there  is  no  sure 
means  of  determining  whether  or  not  latent  infection  exists.     British 
surgeons  have  advocated  waiting  a  whole  year  after  the  closure  of  all 
wounds,  and  in  most  cases  such  a  course  is  to  be  recommended  in  the 
case  of  severely  comminuted  and  infected  fractures.     Other  surgeons 
not  so  conservative  and,  possibly,  with  less  experience,  have  reduced  this 
time  of  waiting  to  six  months.    It  is  perhaps  best  that  each  case  should 
be  settled  on  its  merits.     X-rays  give  valuable  information  as  to  the 
presence  or  absence  of  sepsis  in  the  bone-ends.     If  these  show  clearly, 
with  no  rarefaction  nor  sequestration  seen  and  the  bone-ends  closed 
by  a  thin  plate  of  compact  bone,  sepsis  probably  does  not  exist  and  it 
is  justifiable  to  operate.     If,  on  the  other  hand,  there  are  spots  of  in- 


ON  DELAYED  UNION  AND  NON-UNION  OP  FRACTURES  125 

creased  density  surrounded  by  osteoporosis,  these  are  probably  seques- 
tra which  by  their  presence  denote  infection.  If  the  fragment-ends 
are  surrounded  by  masses  of  callus  and  the  shadow  gradually  fades 
away  indicative  of  rarefaction,  sepsis  is  probably  still  present  and  op- 
eration should  be  deferred  (Gallie).  Before  even  considering  opera- 
tion, four  months  after  the  healing  of  the  wound  should  elapse  in  the 
case  of  small  bones,  and  six  months  when  dealing  with  large  ones.  De- 
lay is  also  imperative  on  account  of  the  greatly  increased  vascularity 
of  the  septic  area,  which  takes  place  to  such  an  extent  that  proper 
hemostasis  is  impossible.  A  large  hematoma  as  a  result  follows  too 
early  operative  interference,  and  lurking  bacteria  are  encouraged  to 
grow.  Drains,  it  is  now  generally  recognized,  are  dangerous.  Before 
operation  the  limb  is  subjected  to  a  final  test  by  being  massaged  vigor- 
ously, to  the  point  of  pain.  If  no  inflammatory  reaction  is  produced 
one  can  be  fairly  certain  that  sepsis  has  come  to  an  end.  An  operation 
in  two  stages  has  been  advocated  by  some  surgeons,  and  on  good 
grounds  when  one  considers  how  difficult,  even  at  times  impossible,  it 
is  to  determine  the  question  of  the  presence  or  absence  of  infection. 
At  the  first  stage  the  wound  is  opened  up  widely  and  all  the  dissection 
necessary  to  place  the  graft  carried  out.  The  wound  is  then  closed  and 
a  period  of  a  week  to  ten  days  allowed  to  elapse.  If  sepsis  has  been 
encountered  during  this  stage  of  the  operation  there  will  be  a  flare-up, 
which  can,  however,  be  generally  made  to  subside  with  much  greater 
readiness  than  if  the  operation  had  been  carried  on  to  its  completion. 
Drainage  will  be  much  freer  in  the  absence  of  the  graft,  which  also 
would  have  needed  removal  if  it  had  been  placed  in  position.  If  no 
reaction  follows,  the  graft  is  made  and  placed,  no  further  dissection 
being  necessary  in  the  principal  area  of  operation  and  hence  no  sup- 
puration need  be  apprehended.  Operative  interference  in  two  stages 
seems  to  be  based  on  sound  reasoning  and  is  to  be  recommended  in  the 
cases  where  the  question  of  septic  infection  cannot  be  satisfactorily 
solved.  It  is  interesting  to  note,  as  emphasizing  the  importance  of 
the  subject,  that  Sir  Arbuthnot  Lane  suggests  the  use  of  radium,  vac- 
cines or  x-rays  to  sterilize  embedded  foci  of  infection  (Lancet,  January 

5,   1918). 

Bibliography. 

Axbeb,  F.  H. :     Bone  Graft  Surgery,  1917. 

Orthopedic  and  Reconstruction   Surgery. 

Treatment   of    Fractures    of    the   Neck    of   the    Femur.    Journal    of    the 

American   Orthopedic   Association,   Aug.,   1918. 

The  Inlay  Bone  Graft  as  a  Treatment  of  Ununited  Fractures.    American 

Journal  of  Surgery,  Jan.,  1914. 

Ununited  Fractures  of  the  Patella  and  Olecranon.     Surgery,  Gynecology 

and  Obstetrics,  April,  1919. 


126  J.    APPLETON   NUTTER 

Allan,  H.  E. :  A  Plea  for  the  Conservative  Treatment  of  Fractures.  North- 
west Medicine,  April,  1916. 

Andrews,  Wyllys  :  Multiple  Drilling  of  Fractures :  an  Old-fashioned  Opera- 
tion Revived.  Surgical  Clinics  of  Chicago,  April,  1919. 

AnzIlottt:  Cure  of  Non-union  by  the  Injection  of  Gelatine.  Archiv.  di  Orto* 
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Axhatjsen:  Archiv.  f.  klin.  Chirurgie,  Bd.  lxxxviii,  1908,  d°  xciv,  1911; 
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ON  DELAYED  UNION  AND  NON-UNION  OP  FRACTURES  127 

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RECONSTRUCTION   INTERNAL   LATERAL   KNEE-JOINT  LIGAMENT  129 


RECONSTRUCTION  OF  THE  INTERNAL  LATERAL  LIGAMENT 
OF  THE  KNEE-JOINT. 

BY  JOHN  C.  WILSON,  M.D.,  LOS  ANGELES. 

Anatomy.  The  internal  lateral  ligament  of  the  knee-joint  is  a  flat, 
fibrous  band  which  extends  from  the  adductor  tubercle  to  the  upper 
medial  aspect  of  the  tibial  shaft.  Its  length  varies  between  8  cm.  and 
10  cm.  and  its  width,  8  cm.  and  1  cm.  The  ligament  is  divided  into 
superficial  and  deep  portions  and  anterior  and  posterior  fasciculi.  The 
anterior  fasciculus  passes  downward  and  is  inserted  directly  into  the 
tibia,  and  while  crossing  the  internal  meniscus  gives  off  a  few  fibrous 
bands  to  the  cartilage.  The  posterior  fasciculus  arises  from  the  common 
origin  near  the  adductor  tubercle  or  from  the  anterior  fasciculus  be- 
low the  tubercle,  passes  downward  and  backward,  and  is  inserted  into 
the  medial  meniscus.  The  semilunar  cartilage,  therefore,  is  attached 
more  securely  to  the  posterior  segment  of  the  ligament,  thereby  ac- 
counting for  the  injuries  of  the  cartilage  in  flexion  and  external  rota- 
tion of  the  knee  when  this  portion  of  the  ligament  becomes  tense.  The 
posterior  fasciculus  may  occasionally  arise  separately  just  behind  the 
adductor  tubercle  and  proceed  downward  and  backward  into  the 
meniscus. 

The  lateral  ligament  may  be  easily  differentiated  .from  the  capsule 
of  the  knee-joint.  It  is  longer  below  the  joint  than  above,  the  ratio 
being  about  3  to  7.  The  anterior  segment  is  taut  when  the  knee  is 
extended  and  relaxed  when  the  knee  is  flexed. 

The  function  of  the  internal  lateral  ligament  is  chiefly  to  stabilize 
the  knee  by  preventing  abduction  of  the  leg  in  complete  extension. 

Pathology.  The  mechanism  of  rupture  is  usually  forcible  abduction 
of  the  leg  without  rotation  when  the  knee  is  extended.  In  Case  1,  the 
laceration  was  transverse,  just  above  the  superior  border  of  the  in- 
ternal cartilage,  the  lacerated  ends  being  separated  about  .5  cm.  A  thin 
white  band  of  fibrous  tissue  which  united  the  lacerated  ends  of  the 
ligament  could  be  demonstrated.  Apparently  this  had  very  little 
tensile  strength. 

Signs  and  Symptoms.  Patients  with  rupture  of  the  internal  lateral 
ligament  of  the  knee-joint  have  one  chief  complaint,  namely,  an  un- 
stable knee  when  the  leg  is  fully  extended. 


130 


JOHN    C.    WILSON 


Fig.  1. — Photograph  of  anatomical  specimen  in  which  the  internal  lateral  liga- 
ment may  be  clearly  seen.  The  short  posterior  fasciculus  terminates  in  the 
medial  meniscus. 


If  seen  after  walking  has  been  attempted  or  after  a  slight  twist,  there 
may  be  an  effusion  into  the  joint.  Complete  or  partial  dislocation  of 
the  patella  is  likely  to  occur,  due  to  the  change  in  the  line  of  pull  of 
the  quadriceps  fe,moris  muscle  or  to  relaxation  of  the  tendon  because 
of  the  unusual  amount  of  knock-knee  that  may  be  found,  as  in  Case 
No.  2. 

Separation  of  the  internal  articular  surfaces  of  the  femur  and  tibia 
by  abducting  the  leg  in  extension  will  be  found  if  the  internal  lateral 
ligament  is  ruptured.  Pain  and  tenderness  at  the  site  of  rupture  is 
not  present  in  cases  that  are  seen  several  months  after  injury. 

Treatment.  Edwards  recommends  the  substitution  of  the  tendons  of 
the  gracilis  and  the  semitendinosus  muscles.  He  divides  these  at  the 
level  of  the  medial  condyle,  the  proximal  ends  of  the  distal  segments 
being  embedded  in  a  groove  prepared  in  the  medial  condyle  of  the 
femur.  The  divided  distal  ends  of  the  semitendinosus  and  gracilis  mus- 
cles are  sutured  together  and  the  two  secured  by  ligatures  to  the  tendon 
of  the  sartorius  muscle. 

McMurray  reports  ten  cases  in  which  the  sartorius  tendon  was  ad- 
vanced and    embedded  into  the  medial  femoral  condyle,  thereby  chang- 


Rl -CONSTRUCTION  INTERNAL   LATERAL   KNEE-JOINT  LIGAMENT 


131 


Fig.  2. — Photograph  of  an  anatomical  specimen  in  which  the  posterior  fasciculus 
arises  just  below  the  adductor  tubercle. 

Fig.    3. — Photograph   of   an    anatomical    specimen    in    which    the    anterior   and 
posterior  fasciculi  arise  separately. 

ing  the  insertion  of  the  sartorius  from  the  tibia  to  the  femur,  with 
irood  results. 

After  consultation  with  Dr.  Michael  Hoke  it  was  decided  that  the 
problem  of  repair  of  the  ligament  could  be  solved  by  means  of  a  pedunc- 
ulated flap  of  fascia  lata  which  could  be  implanted  near  the  origin  and 
insertion  of  the  ligament.  In  this  way,  the  normal  mechanical  pull 
would  be  reestablished  and  the  muscle  balance  around  the  knee 
undisturbed. 

The  medial  aspect  of  the  knee-joint  is  exposed  by  a  linear  incision 
slightly  curved  forward,  through  the  skin  down  to  the  internal  lateral 
ligament.  This  incision  is  continued  upward  to  a  point  about  15  cm. 
above  the  adductor  tubercle  of  the  femur.  After  exposing  the  origin 
snd  insertion  of  the  tendon,  cortical  flaps  2  cm.  in  diameter  are  turned 
back.  A  strip  of  fascia  lata  15  cm.  long  and  3  cm.  wide,  is  dissected 
free  from  the  inner  aspect  of  the  thigh  and  reflected  downward,  being 
doubled  on  itself  lengthwise,  so  that  the  band  shall  comprise  three 
layers  of  fascia.  In  order  to  do  this,  it  is  necessary  to  divide  the  base 
of  the  flap  one-third  of  its  distance  both  anteriorly  and  posteriorly. 


132 


JOHN    C.   WILSON 


Fig.  4. 


After  the  fascia  is  folded  it  is  passed  under  the  cortical  flaps,  which 
are  then  sutured  in  position,  and  the  fascial  band  is  further  secured  by 
a  few  sutures  to  the  divided  portions  of  the  internal  lateral  ligament 
when  possible.  The  tibial  end  of  the  transplant  extends  below  the  osteo- 
plastic flap  and  is  sutured  to  the  periosteum  and  fascia.  The  leg  is 
immobilized  in  plaster  from  the  groin  to  the  toes  for  eight  weeks,  when 
a  long  caliper  splint  is  substituted  and   worn  for   a  period  of  four 


RECONSTRUCTION    INTKKNAL    L ATKRAL    K\l  I      !«U\T   LIGAMENT 


133 


Fig. 


months.    Flexion  and  extension  of  the  knee  should  begin  immediately- 
after  the  removal  of  the  plaster. 


Case  No.  1.  A  soldier,  twenty-three  years  of  age,  was  injured  by 
a  falling  embankment  of  earth  striking  the  outer  side  of  the  extended 
leg.  Immediate  disability  followed,  with  swelling  and  tenderness 
over  the  internal  lateral  ligament.  Fixation  in  plaster  was  carried  out 
for  two  months,  at  the  end  of  which  time  pain  had  disappeared,  but 
sufficient  abnormal  lateral  mobility  in  extension  persisted  to  cause  the 
leg  to  be  insecure.  The  patient  came  under  our  observation  six  months 
after  the  accident,  complaining  of  an  unstable  knee,  the  lateral  insta- 
bility being  so  great  that  he  was  obliged  to  walk  with  crutches.  Exam- 
ination revealed  nothing  except  increased  abduction  of  the  leg  in  ex- 
tension. In  the  absence  of  signs  or  symptoms  of  internal  derangement, 
the  disability  was  considered  to  be"  entirely  due  to  laceration  of  the 
internal  lateral  ligament.  The  ligament  was  exposed  and  found  to  be 
torn  transversely  just  above  the  superior  margin  of  the  internal  men- 
iscus. It  was  repaired  by  a  pedunculated  fascial  transplant,  the  leg 
immobilized  in  plaster  for  two  months,  followed  by  protection  in  a 
long  caliper  splint  for  four  months.     It  is  now  two  years  since  this 


134  JOHN    C.    WILSON 

ligament  was  reconstructed,  and  the  patient  reports  that  he  has  a  knee 
that  allows  full  flexion  and  extension  in  which  there  is  no  abnormal 
lateral  mobility. 

Case  No.  2.  This  patient  is  a  girl,  aged  fifteen  years.  At  seven  years 
of  age  she  had  a  crushing  of  the  knee,  resulting  in  a  compound  frac- 
ture of  the  internal  femoral  condyle.  Since  this  accident,  marked  genu 
valgum  with  instability  in  flexion  or  extension  has  developed.  With 
the  leg  extended  there  is  forty-five  degrees  of  genu  valgum,  and  the 
leg  may  be  abducted  to  ninety  degrees.  The  femur  was  osteotomized 
to  correct  the  bony  alignment.  After  two  months  of  fixation,  the  union 
at  the  site  of  the  osteotomy  had  become  firm,  but  the  lateral  mobility 
at  the  knee  persisted,  due,  apparently,  to  rupture  of  the  internal  lateral 
ligament.  Consequently,  the  internal  aspect  of  the  knee-joint  was  ex- 
posed and  no  trace  of  a  lateral  ligament  could  be  found.  The  capsule 
was  rather  thin  and  somewhat  relaxed.  A  flap  of  fascia  lata  was 
turned  down  and  sutured  under  osteoplastic  flaps.  After  two  months 
of  fixation  a  long  caliper  splint  was  substituted  and  the  patient  began 
to  walk.  At  the  present  time,  fourteen  months  after  the  operation,  the 
patient  has  a  useful  knee  in  which  the  lateral  mobility  has  been  en- 
tirely   eliminated. 

CONCLUSIONS. 

1.  Persistent  abnormal  abduction  of  the  leg  in  extension  without  ab- 
normal antero-posterior  or  lateral  mobility  in  flexion  is  probably  due 
to  laceration  of  the  internal  lateral  ligament. 

2.  Persistent  instability  due  to  laceration  of  the  internal  lateral 
ligament  will  require  correction  by  surgical  procedure. 

3.  A  fascial  transplant  embedded  in  the  femur  and  tibia  near  the 
origin  and  insertion  of  the  internal  lateral  ligament  has  proven  a  sat- 
isfactory method  of  repair  in  two  cases. 

I  am  deeply  indebted  to  Dr.  M.  S.  Varian,  who  has  made  possible 
the  study  of  the  anatomical  specimens  used  in  the  preparation  of  this 
article. 

Bibliography. 

1 :     Edwards,   Alexander   H. :     British   Journal   of   Surgery,   Vol.   viii,  No.  SI. 
2:     MoMurray,  T.  P.:     British  Journal  o*  Surgery,  Vol.  vi,  No.  23. 


SHRINERS '    HOSPITALS   FOR   CRIPPLED    CHILDREN  135 

THE  SHRINERS'  HOSPITALS  FOR  CRIPPLED  CHILDREN. 
"Behold  how  great  a  matter  a  little  fire  kindleth." 

But  the  fire  must  find  material  to  inflame,  compelling  it  to  ignite  by 
its  own  energy. 

Such  a  "great  matter"  is  the  purpose  of  the  Mystic  Shrine  to  pro- 
vide hospital  accommodations  and  care  for  the  needy  crippled  children 
in  the  United  States  and  Canada. 

The  original  fire  was  one  of  the  long-standing  members  of  the  Ameri- 
can Orthopedic  Association, — Dr.  Michael  Hoke  of  Atlanta.  The  im- 
mediately inflammable  material  has  been  the  broad  sympathy  and  de- 
votion of  two  members  of  the  Shrine,  Mr.  Freeland  Kendrick  of  Phil- 
adelphia, and  Mr.  Forrest  Adair  of  Atlanta.  Kendrick  and  Adair  con- 
ceived the  idea  of  turning  the  thoughts  of  their  fellow  members  to- 
ward service.  Adair's  idea  of  this  form  of  service  had  been  given  by 
his  experience  as  organizer  and  generous  supporter  of  the  Scottish  Rite 
Hospital  for  Crippled  Children  in  Atlanta.  The  chief  surgeon  and 
guiding  spirit  of  this  institution  is  Dr.  Michael  Hoke.  His  long  orth- 
opaedic training  and  great  mechanical  and  surgical  skill  and,  more  than 
all,  his  broad  humanitarianism  had  been  furnishing  for  Mr.  Adair  a 
wonderful  example  of  the  translation  of  these  qualities  into  a  form  of 
service  of  the  most  appealing  nature. 

The  vision  was  almost  blinding  in  its  light,  and  Adair  and  Kendrick 
and  others  succeeded  in  turning  it  into  the  hearts  of  their  fellow  mem- 
bers. An  annual  assessment  was  voted  by  the  Imperial  Council  for 
this  purpose.  The  expenditure  of  this  annual  income  of  over  a  million 
dollars  has  been  entrusted  to  a  body  of  men  known  as  the  Trustees  of 
the  Shriners  Hospitals  for  Crippled  Children.  The  committee  is  made 
up  of  influential  members  of  the  Shrine,  a  third  of  its  personnel  chang- 
ing every  year.  The  present  Trustees  are :  Sam  P.  Cochran,  Chairman, 
Dallas,  Texas;  W.  Freeland  Kendrick,  Vice-Chairman,  Philadelphia, 
Pa. ;  Forrest  Adair,  Secretary,  Atlanta,  Ga. ;  Bishop  Frederick  W.  Kea- 
tor,  Tacoma,  Wash.;  Dr.  Oscar  M.  Lanstrum,  Helena,  Mont.;  John  D. 
McGilvray,  San  Francisco,  Cal.;  Philip  D.  Gordon,  Montreal,  Que.  They 
have  asked  five  orthopaedic  surgeons  to  act  as  an  Advisory  Committee 
to  the  Trustees,  to  help  them  carry  out  the  purpose  of  the  foundation. 
Doctors  Michael  Hoke,  of  Atlanta:  A.  MacKenzie  Forbes,  of  Montreal; 
Nathaniel  Allison,  of  St.  Louis:  John  C.  Wilson,  of  Los  Angeles:  and 
Robert  B.  Osgood,  of  Boston,  were  chosen  by  the  Trustees  as  an  Ad- 
visory Committee. 


J  36  THE   SHRINERS*    HOSPITALS   FOR    CRIPPLED    CHILDREN 

Ten  hospitals  of  simple  construction,  but  thoroughly  well  equipped, 
have  been  authorized,  and  more  are  apt  to  be  built  as  soon  as  the  accumu- 
lation of  funds  justifies  their  establishment  and  maintenance.  They  are 
to  be  scattered  over  the  continent  and  located  in  centers  of  population 
where  the  demand  for  such  service  to  the  crippled  child  is  most  felt. 
The  first  hospitals  are  to  be  built  in  Eastern  and  Middle  Canada,  Cal- 
ifornia, Washington,  Oregon,  Louisiana,  Missouri,  Minnesota  and  New 
England.  The  patients  are  to  include  those  children  up  to  fourteen  years 
of  age  who  need  skilled  and  free  treatment  for  their  deformities.  They 
are  to  be  teaching  hospitals,  in  so  far  as  possible,  and  the  surgeon  in 
charge,  nominated  by  the  Advisory  Committee,  is  expected  to  give  half 
of  his  time  to  the  hospital  work  and  is  to  be  paid  for  his  services. 

Suddenly,  without  any  "drive"  and  with  much  effort  on  the  part 
cf  a  few,  but  with  comparatively  little  sacrifice  on  the  part  of  many, 
the  crippled  child  is  to  be  cared  for  as  never  before.  It  is  inconceiv- 
able that  such  a  body  of  important  business  and  professional  men  will 
turn  back  after  having  put  their  hands  to  the  plow  in  all  earnestness 
and  from  the  highest  motives.  They  have  sought  specialized  profession- 
al help,  that  their  work  may  be  done  wisely  and  their  purposes  fulfilled. 
The  advice  will  be  freely  given  and  only  too  gladly. 

The  whole  movement  seems  to  us  tremendously  significant.     Charity 
has  gone  hand  in  hand  with  civilization.    We  fought  a  war  for  the  prin- 
ciple that  it  was  the  obligation  of  the  strong  to  help  the  weak,  but  the 
burden  has  been  borne  in  the  past  by  too  few  of  the  strong.    No  one  can 
read    "Philanthropic    Doubts"    in    the    September    Atlantic    Monthly 
without  being  made  acutely  aware  of  this  fact,  alike  unfortunate  for 
the  strong  and  the  weak.     Here  is  a  great  burden  distributed  among 
a  large  body  of  strong  men.    Instead  of  being  a  fatiguing  load,  it  be- 
comes an  exhilarating  service.    Perhaps  it  is  a  still,  small  voice  calling 
from  the  battlefields,  of  sacrifice  for  the  sake  of  a  principle,  and  heard 
through  the  length  and  breadth  of  the  land.  It  is  possible  that  other  or- 
ganizations will  be  stirred  by  this  example  to  dedicate  themselves  to  sim- 
ilar great  purposes.    The  adult  cripple  and  human  derelict  suffering 
from  the  effects  of  a  quiescent,  burnt-out  arthritis,  from  an  infantile  par- 
alysis, from  a  tuberculosis,  and  from  the  accidents  of  industry,  cry  for 
help  nearly  as  loudly  as  the  crippled  child.     Reconstructive  war  ser- 
vice has  made  the  profession  and  the  laity  realize  how  very  much  can 
be  accomplished  by  proper  methods  in  the  way  of  rehabilitation  and 
wage-earning  capacity. 

"Behold  how  great  a  matter  a  little  fire  kindleth." 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OP  HIP-JOINT  137 


DISCUSSION  ON  THE  OPERATIVE  TREATMKM      OF  OSTEO- 
ARTHRITIS OF  THE  HIP-JOINT.* 

Mr.  D.  McCrae  Aitken:  When  osteoarthritis  of  the  hip  joint  was 
suggested  as  a  subject  for  discussion,  I  do  not  think  the  word  "  opera- 
tive' '  was  included  in  the  title.  When  it  was  suggested  at  a  Committee 
meeting  that  I  should  have  the  honor  of  opening  a  discussion  on  this  sub- 
ject, I  asked  two  or  three  of  my  colleagues  what  we  were  going  to  dis- 
cuss. One  said  "You  must  exclude  the  general  rheumatoid  type,  where 
many  joints  are  involved,  as  we  are  not  dealing  with  the  cases  which  are 
frankly  due  to  general  infection  in  the  body,  but  it  is  the  monarticular 
type  on  which  we  ought  to  concentrate  our  attention."  Another  col- 
league said  "What  we  mean  are  cases  of  traumatic  origin";  my  reply, 
that  we  should  then  have  to  include  the  pseudo-coxalgic  and  infantile 
types,  was  immediately  objected  to,  which,  I  thought,  was  not  logical,  as 
I  shall  show  later.  Another  said  "We  must  include  cases  of  stiff  hip 
arising  from  acute  inflammatory  conditions."  Now,  if  we  reduce  these 
various  suggestions  to  their  common  measure,  we  realize  that  in  the 
minds  of  that  Committee  was  the  wish  to  get  a  discussion  on  that  type 
of  stiff  hip  which  is  amenable,  in  certain  cases,  to  operative  treatment 
for  producing  a  movable  hip.  I  think  what  the  Committee  had  in  their 
minds  was  a  discussion  of  our  present  attitude  towards  the  operation 
of  arthroplasty  of  the  hip.  But  though  all  would  like  to  hear  the  sub- 
ject discussed,  no  one  cared  to  say  directly,  "Let  us  discuss  arthroplasty 
of  the  hip, ' '  lest  he  should  be  called  on  to  open  the  debate. 

In  this  debate  we  cannot  entirely  dissociate  ourselves  from  a  dis- 
cussion of  the  conditions  before  and  after  operation.  As  you  have  said 
in  your  address,  Sir,  in  the  orthopaedic  practice  of  the  past  the  use  of 
the  knife  was  held  to  be  a  last  resort  and  an  indication  of  the  failure 
of  mechanical  effort.  At  present,  especially  in  such  operations  as  this, 
we  must  guard  ourselves  against  rushing  too  quickly  into  operative 
methods  which  are  now  open  to  us,  owing  to  advances  in  technique, 
in  asepsis,  as  well  as  in  operative  detail,  without  first  considering  the 
question  of  the  preliminary  treatment  which  is  necessary  before  re- 
sorting to  operative  measures,  and — still  more  important — how  we  are 
going  to  get  out  of  our  difficulties  afterwards  by  after-treatment  and 

*At  the  Annual.  Meeting  of  the  British  Orthopaedic  Association.  London.  No- 
vember,  1920. 


138  OPERATIVE   TREATMENT   OF   OSTEOARTHRITIS  OF   HIP-JOINT 

the  restoration  of  the  function  of  the  part,  which  is  the  real  metier  of 
■he  orthopaedic  surgeon.  Therefore,  even  if  we  take  the  title,  as  in  the 
Agenda  Paper,  "Operative  Treatment,"  we  have  to  discuss  what  cases 
are  suitable,  what  time  or  stage  is  suitable  for  the  operation,  and  what 
preliminary  treatment  and  what  after-treatment  must  be  considered. 
In  this,  as  in  all  other  disabilities,  the  surgeon  has  four  points  to  put 
before  himself.  The  first  very  important  question  is:  What  is  it  the 
patient  complains  of?  He  does  not,  of  course,  come  with  a  scientific 
diagnosis,  but  his  personal  complaint  is  a  matter  of  very  great  impor- 
tance. Second,  we  have  to  consider  its  cause,  its  original  cause,  and 
such  mechanical  or  infective  contributory  causes  as  have  helped  to  pro- 
duce the  condition  which  we  have  ultimately  to  deal  with. 

Third,  we  have  to  consider  the  possibility  of  mechanical,  operative 
or  other  means  of  eliminating  the  cause  of  complaint,  whether  the  com- 
plaint be  pain  or  stiffness.  Then,  fourthly, — and  this  I  regard  as  the 
crux  of  the  discussion, — what  probability  is  there  of  recurrence  of  the 
disability  after  our  treatment,  owing  to  the  continued  action  of  the  ac- 
cessory causes,  whether  mechanical  or  infective,  causing  a  return  of 
pain,  stiffness,  and  disability. 

Applying  these  four  points  to  osteoarthritis  of  the  hip  as  it  is  be- 
fore us,  the  complaint  of  the  patient  in  these  cases  is,  in  rising  order 
of  importance  to  the  patient,  first,  stiffness;  second,  stiffness  in  a  bad 
position  in  which  the  adduction  and  flexion  have  produced  a  short 
leg;  thirdly,  pain.  It  is  a  remarkable  thing  that  in  a  monarticular 
arthritis  of  the  hip,  stiffness  is  about  the  last  thing  a  patient  complains 
of.  It  comes  on  gradually,  and  if  he  does  not  have  pain,  he  gets  used 
to  going  about  with  a  stiff  hip.  It  is  not,  as  a  rule,  until  these  pa- 
tients have  pain  that  they  begin  to  ask  for  treatment.  If  a  patient 
has  a  painless  stiff  hip,  it  is  not  usual  for  him  to  complain.  This  has 
to  be  remembered  and  considered. 

Stiffness  with  a  bad  position  is  quite  another  matter,  because  the  pa- 
tient begins  to  limp  as  he  walks  and  because  the  bad  position  and  the 
wrong  balance  of  the  hip- joint  is  in  itself  a  contributory  cause  to  pain 
if  the  stiff  hip  is  not  absolutely  rigid.  Therefore  we  are  very  often 
asked  by  patients  that  some  treatment  may  be  carried  out  because  there 
is  adduction,  flexion,  and  sometimes  an  important  factor  is  the  pres- 
ence of  rotation.  Because  if  the  thigh  be  rotated,  the  axes  of  the  knees 
change,  and  the  patient  says  the  foot  goes  outwards,  or  inwards,  when 
the  knee  is  bent,  and  he  thinks  that  interferes  with  his  walking. 

Pain  is  in  an  entirely  different  category:  from  the  patient's  point  of 
view  it  is  an  urgent  symptom,  and  when  we  have  to  deal  with  the  ques- 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OP   HIP-JOINT  139 

tion  of  the  treatment  of  pain  it  is  always  essential  that  something  should 
be  done  for  the  relief  of  the  patient.  Patients  who  have  arthritis  of 
the  hip  and  have  suffered  from  pain  have,  in  many  instances,  before 
coming  to  an  orthopaedic  surgeon,  resorted  to  practitioners  of  every  con- 
ceivable variety,  both  qualified  and  unqualified;  they  have  been  sub- 
jected to  all,  or  many,  of  the  scientific  methods  of  treatment — balneo- 
logical, electro-therapeutical  and  other — and  often  associated  with- these 
treatments  at  watering-places  they  give  a  story  of  having  been  sub- 
jected to  active  manipulative  treatment  and  movement  with  the  object 
of  "preventing  the  joint  from  becoming  stiff."  Generally  speaking, 
we  can  lay  down  the  rule  that  a  joint  which  is  painful  on  movement 
is  demanding  rest;  it  is  an  old  law,  which  was  laid  down  by  Hilton, 
and  has  never  ceased  to  be  true  of  joints  or  anything  else.  Fortunate- 
ly for  me,  my  duty  tonight  is  to  open  this  subject  for  discussion  and 
not  to  try  to  deal  exhaustively  with  the  matter. 

We  come,  next,  to  the  causes  of  these  monarticular  hip  cases,  though 
often  the  condition  affects  both  hips  though  the  patient  may  complain 
of  only  one.  One  member  of  the  Committee  suggested  that  these  cases 
are  traumatic.  Often  they  are,  though  a  history  of  trauma  is,  in  many 
cases,  hard  to  obtain.  But  I  have  noticed  that  monarticular  cases  are 
apt  to  occur  in  men  who,  in  their  youth,  have  been  active  footballers; 
the  condition  is  common  in  hunting-men,  and  among  others  who  have 
been  much  among  horses,  especially  those  who  have  had  to  do  with 
breaking  young  horses  to  the  saddle.  Recently  I  had  as  a  patient  an 
elderly  gentleman,  who  complained  a  little  of  pain  but  chiefly  that 
his  horses  were  getting  broader  and  broader.  On  examination  his  left 
hip  was  found  to  be  adducted  with  limited  movement.  A  well-known 
bone-setter  in  Scotland  had  "manipulated  a  bone  in  the  lower  part  of 
his  back,"  and  for  a  time  thereafter  he  was  better,  he  had  some  freer 
movement.  I  have  here  the  skiagram  of  his  case,  which  shows  typical 
thickening  around  the  acetabulum,  such  as  we  usually  see  in  these  osteo- 
arthritic  hips.  If  we  are  going  to  admit  that  trauma  is  one  of  the  con- 
tributing causes,  then  we  must  remember  that  trauma  produces  at  dif- 
ferent ages  different  results.  I  have  a  skiagram  here  of  trauma  in  which 
a  child  had  the  hip  wrenched  at  nine  months  old,  and  also  one  in  which 
the  injury  occurred  at  the  age  of  eighteen  months.  In  the  x-ray  of 
the  former,  taken  at  the  age  of  eight  years,  it  is  to  be  noted  that  the 
epiphysis  is  broader  than  usual,  wThile  in  the  second,  age  twenty-three, 
the  epiphysis  is  united  to  the  shaft  and  shows  clearly  the  typical  mush- 
room head  sometimes  spoken  of  as  pseudo-coxalgia.  There  is  therefore 
to  be  considered,  that  trauma  of  the  infant  hip-joint  produces  an  in- 


140  OPERATIVE   TREATMENT   OF   OSTEOARTHRITIS  OF   HIP-JOINT 

jury  of  the  head  of  the  femur,  ending  in  a  mushroom-shaped  femoral  • 
head,  while  in  the  adult,  osteophytes  form  around  the  acetabulum. 
In  contrast  with  that,  here  is  an  x-ray  of  a  case  in  which  the  epiphysis 
of  the  head  of  the  femur  was  removed  last  March  on  account  of  an  acute 
abscess  in  the  joint.  In  all  these  cases  the  patients  arrived  with  ad- 
duction and  flexion  deformity  and  complaining  of  some  pain.  These 
cases  -are  included  among  the  hips  for  which  some  form  of  treatment 
will  be  necessary,  though  not  necessarily  as  cases  which  will  be  amena- 
ble to  treatment  by  arthroplasty.  They  all  suffer  from  the  same  dis- 
abilities, namely:  flexion,  adduction,  and  pain.  Methods  of  treating 
them,  however,  lead  us  to  consider  whether  operation  is  always  the  im- 
mediate method  which  ought  to  be  attempted. 

Having  begun  with  the  story  that  there  is  generally  some  recurrent 
injury,  such  as  produced  by  constant  riding,  we  must  never  allow  our- 
selves to  forget  that  septic  infection  of  intestinal  origin,  or  sepsis  from 
bad  teeth,  is  an  important  factor  in  many  of  these  cases,  and  changes 
due  to  infective  causes  may  be  superimposed  on  those  due  to  the  injury. 
In  a  recent  article  in  The  Bacteriologist  it  has  been  pointed  out 
that  in  those  cases'  of  monarticular  arthritis  of  the  hip  in  which  there 
are  recurrent  exacerbations,  a  certain  organism  has  been  isolated  which 
seems  to  be  pretty  frequently  associated  with  dirty  mouths  and  pain- 
ful joints  in  these  cases.  Therefore,  one  of  the  points  which  will  have 
to  arise  for  our  discussion  will  be  the  elimination  of  possible  sources 
cf  recurrent  infective  arthritis,  even  in  a  case  which  originally  was 
frankly  a  case  of  traumatic  hip.  In  this  connection  I  may  say  I  have 
a  case  which,  so  far  as  I  know,  is  not  traumatic.  When  I  first  saw  her, 
her  complaint  was  of  stiffness  of  the  right  hip,  and  on  skiagraphic  ex- 
amination, I  concluded  that  some  septic,  infective  process  had  been  at 
work,  but  of  this  I  was  unable  to  obtain  any  direct  evidence.  There 
was,  however,  some  coxa  vara  present.  I  treated  her  by  abduction,  as 
I  had  been  taught  by  my  Chief,  and  for  a  time  she  did  very  well.  Then 
both  hips  began  to  be  rather  stiff,  and  the  interesting  fact  came  out 
that  occasionally  she  was  rather  constipated.  We  had  been  trying  to 
attend  to  that,  and  on  a  day  when  she  had  been  suffering  more  than 
usual  from  pain  and  stiffness,  she  had  lavage  of  the  rectum  done,  and 
there  was  immediately  a  relief  of  the  pain,  and  within  a  few  hours  she 
felt  much  better,  and  could  move  her  hip  more  freely.  I  asked  Dr. 
John  Eyre,  of  Guy's,  to  go  into  the  case,  and  he  has  been  treating  the 
patient  with  vaccines,  and  there  has  been  an  astonishing  restoration  of 
function.  In  that  case,  as  you  will  see  by  the  skiagram,  there  has  been 
no  osteophytic  enlargement   around  the  acetabulum,  the  head  of  the 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OP   HIP- JOINT  141 

femur  is  very  firmly  in  the  socket  of  the  acetabulum,  and  there  is  no 
appearance  of  gap  between  the  head  and  the  acetabulum,  and  both  are 
well  defined.    The  condition  of  this  patient  varies  greatly  from  day  to 
clay.     Therefore  the  question  is  not  a  very  easy  one;    we  have  many 
points  to  consider  before  we  can  say  that  these  osteoarthritic  hips  will 
be  amenable  to  any  one  method  of  mechanical  or  operative  treatment. 
Returning  once  more  to  the  treatment  of  the  case,  I  shall  take,  in  the 
inverse  order,  the  points  raised.     And  first  we  will  consider  pain.    It 
is  an  established  fact  that  pain  in  these  hips  is  immediately  relieved 
when  the  hip  becomes  absolutely  stiff,  and  we  have  always  at  command 
the  simplest  and  safest  method  of  relieving  the  complaint  of  pain,  by 
fixing  the  hip   absolutely.     That   may  be  done  temporarily  in  many 
cases,  by  fixing  the  hip  in  plaster  of  Paris,  as  no  doubt  we  all  have  done 
at  times.    In  the  early  stages  a  few  weeks,  or  a  month  or  two,  of  fixa- 
tion in  a  plaster  spica  in  slight  abduction  is  essential.     In  any  posi- 
tion of  adduction  there  is  a  strain  in  the  hip-joint  every  time  weight 
is  put  on,  and  this  will  maintain  irritation  and  pain.    But  if  the  thigh 
can  be  fixed  in  abduction  the  wTeight  falls  more  directly  through  the 
head  in  the  acetabulum  and  down  the  neck  of  the  femur.    In  this  way, 
it  is  possible  to  put  these  hip- joints  into  a  state  of  rest,  because  the 
more  direct  transmission  of  body  weight  in  the  abducted  position  elim- 
inates much  of  the  mechanical  strain  on  the  joint.     This  may  ulti- 
mately lead  either  to  a  relief  of  pain  with  the  giving  of  an  increased 
range  of  movement,  or,  if  the  process  is  too  advanced,  to  relief  of  pain, 
with  a  firmer  ankylosis.     With  regard  to  the  cases  in  which  the  pa- 
tient complains  of  intolerable  pain,  the  method  of  treatment,  by  op- 
eration or  otherwise,  is  very  gravely  changed  if  both  hips  are  stiff.     I 
have  already  said  that  many  patients  with  a  single  stiff  hip,  so  long  as 
there  is  no  pain,  will  make  very  little  complaint  about  it;    they  are 
usually  people  over  middle  age,  and  they  can  perform  such  activities 
as  they  wish  to  at  their  age,  if  they  have  one  freely  movable,  flexible 
hip.     When  both  hips  are  affected,  the  mechanical  problem  of  getting 
a  functional  efficiency — I  do  not  say  competency — is  very  different,  be- 
cause, for  the  patient's  comfort,  he  must  get  at  least  one  freely  mov- 
able hip.    The  first  case  I  saw  of  operative  double  ankylosis  of  the  hip 
was  in  one  of  your  wards,  Sir,  in  Liverpool,  eighteen  years  ago.     The 
case  was  frankly  traumatic  in  origin.    WTien  working  on  a  building, 
the  man  had  slipped  off  a  scaffolding  and  had  landed  on  both  feet.    He 
got  up,  but  felt  stiff  in  both  hips.    He  went  on  with  his  work,  but  in  six 
months  he  had  been  getting  stiffer  and  stiffer,  and  when  he  came  to  hos- 
pital, x-ray  photographs  showed  firm  bony  ankylosis  of  both  hips.    This 


142  OPERATIVE   TREATMENT   OF   OSTEOARTHRITIS  OF   HIP-JOINT 

had  been  of  gradual  onset.  You  did  a  subtrochanteric  pseudo-arthrode- 
sis,  beginning  with  the  left  hip.  It  consisted  of  simple  exposure  of  the 
femur  immediately  below  the  great  trochanter,  turning  down  a  flap  of  the 
vastus  externus  from  its  upper  attachment  just  below  the  trochanter, 
excising  freely  rather  more  than  an  inch  of  the  shaft  just  below  the 
trochanter  and  turning  in  the  flap  of  the  vastus  over  the  top  of  the 
shaft.  He  was  then  given  the  ordinary  routine  treatment  in  Liver- 
pool: passive  movements  on  a  very  small  scale,  which  were  begun  at 
the  end  of  a  fortnight.  I  was  told  subsequently  that  a  year  afterwards 
he  was  doing  so  well  that  he  came  back  and  demanded  that  the  other 
hip  should  be  operated  upon.  Some  years  ago,  I  had  a  patient  who  had 
the  right  hip  ankylosed,  and  the  left  hip  was  so  painful  that  when  his 
bed  was  accidentally  touched  he  screamed  with  pain.  The  x-ray  pic- 
ture shewed  so  much  osteophytic  outgrowth  all  round,  and  the  con- 
dition was  so  acute,  that  I  did  not  think  it  was  a  case  in  wh,ich  any 
operation  on  the  joint  would  result  in  anything  but  absolute  ankylosis. 
The  operation  I  decided  on,  therefore,  was  exposing  the  upper  edge 
of  the  joint,  running  a  gouge  in  between  the  acetabulum  and  the  head, 
rawing  the  bone,  and  producing  complete  ankylosis  of  the  head  and 
acetabulum,  and  at  the  same  time  I  did  the  operation  I  have  just  de- 
scribed, dividing  the  shaft,  removing  about  1*4  inches  of  shaft,  and 
turning  in  the  vastus  over  the  end  of  the  shaft.  The  acute  pain  of 
which  he  had  been  complaining  ceased  after  the  operation,  the  leg  was 
no  longer  a  lever  jarring  that  head  in  the  acetabulum,  and  the  head 
ankylosed  firmly.  It  is  to  be  noted  that  even  if  the  joint  itself  is  not 
touched,  excision  of  portion  of  the  shaft  below  the  trochanter  usually 
relieves  the  pain  at  once.  This  patient  now  goes  into  Shrewsbury  every 
day  on  a  motorcycle,  a  distance  of  ten  miles.  He  had  an  accident  when 
on  his  motorcycle,  and  got  his  leg  rather  twisted,  and  a  bad  dislocation 
of  his  pseudo-arthrosis,  which  was  fixed  up  at  once  by  Miss  Hunt  in 
plaster,  and  he  is  now  getting  about  as  before. 

I  pass  now  to  the  question  of  arthroplasty.  I  have  already  sent 
round  the  skiagram  of  a  boy  whose  epiphysis  had  been  removed.  Ex- 
perience shows  that  in  inflammatory  cases  in  which  free  removal  of  the 
head  of  the  femur  has  been  necessary,  abduction  of  the  thigh,  adjust- 
ment of  the  remainder  of  the  neck  in  the  acetabulum,  which  is  blocked 
witli  inflammatory  fibrous  tissue,  results,  in  many  cases,  in  a  movable 
joint,  which  goes  on  to  be  a  wonderfully  effective  joint.  The  limb 
should  be  put  in  this  position  at  the  time  of  operation.  In  cases  of  acute 
local  inflammation  which  has  completely  passed  off,  but  the  head  of 
the  femur  has  been  destroyed  and  removed,  movement  often  returns 


OPERATIVE  TREATMENT  OP  OSTEOARTHRITIS  OP  HIP- JOINT  143 

Therefore  there  is  no  reason  why,  in  suitable  cases  in  which  there  is 
no  septic  condition,  we  should  not  perform  an  operation,  more  skillful, 
perhaps,  than  that  which  has  been  done  by  an  inflammatory  process, 
clearing  out  the  acetabulum  and  making  a  false  joint.  The  technique 
of  that  I  shall  leave  to  others  to  discuss  in  detail,  those  who  have  done 
the  operation  more  often  than  I  have — I  know  there  are  many  here  who 
have.  I  think  the  general  opinion  now  is,  that  the  best  access  is  obtained 
by  reflecting  the  trochanter  major  and  getting  good  access  to  the  upper 
and  posterior  parts  of  the  head  and  neck  of  the  femur,  and  gouging 
out  the  acetabulum  freely,  displacing  the  head  out,  and  afterwards 
trimming  it.  The  interposition  of  foreign  bodies,  such  as  metallic  foil, 
is,  I  think,  a  thing  of  the  past,  and  I  shall  be  interested  in  ascertaining 
whether  the  opinion  of  this  meeting  is  that  autogenous  fascial  or  mus- 
cular covering  for  the  head  is  the  material  to  be  used.  The  point  which. 
I  think,  is  absolutely  essential  before  we  attempt  any  such  operation, 
is  that  there  shall  be  absolute  care  taken  that  any  form  of  autointoxica- 
tion, from  teeth  or  intestine,  shall  first  be  eliminated,  otherwise  these 
joints  will  certainly  again  become  arthritic  and  stiff. 

Another  point  on  which  I  desire  information  is,  What  is  the  most 
appropriate  after-treatment?  In  the  upper  limb  arthroplasty  is  com- 
paratively easy,  because  the  patient  can  perform  unloaded  exercises. 
But  if  a  man  is  getting  about  on  his  hip-joint,  he  has  his  body  weight 
to  carry,  and  that  contributes  to  the  changes  which  occur  in  these  cases. 

I  hope  I  have  done  what  was  required  of  me, — introduced  the  subject 
for  discussion;  I  know  I  have  not  dealt  with  the  real  subject  itself,  so 
there  is  plenty  of  room  for  further  debate. 

Dr.  J.  B.  Mennell:  I  am  not  able  to  contribute  anything  on  the 
operative  side,  but  a  question  was  raised  about  pain  and  the  possibil- 
ities of  relieving  it.  One  point,  I  think,  we  have  overlooked,  which 
it  was  my  privilege  to  learn  last  year  in  America.  When  there  is  flex- 
ion deformity  due  to  monarticular  arthritis  of  the  hip-joint,  the  pa- 
tient, in  order  to  stand  upright,  produces  a  lordosis,  and  this  causes 
what  Dr.  Goldthwait  refers  to  as  sacroiliac  strain.  The  pain  due  to 
this  condition  can  be  relieved  to  a  marked  extent  by  the  use  of  a  sacral 
belt-support.  Many  patients  who  have  a  movable  joint,  with  perhaps 
slight  limitation  of  movement,  can  be  relieved  by  taking  off  the  strain 
from  the  sacroiliac  joint  by  wearing  a  belt  such  as  Dr.  Goldthwait  de- 
scribed. Pain  in  the  hip-joint  may  remain,  but  this  is  often  trivial 
when  compared  with  that  due  to  the  sacroiliac  strain  which  is  the  di- 
rect result  of  the  flexion  deformity  of  the  hip. 


144  OPERATIVE   TREATMENT   OF   OSTEOARTHRITIS  OF   HIP-JOINT 

Mr.  Dunn  :  I  agree  with  Mr.  Aitken  that  fixation  of  a  joint  in  plas- 
ter frequently  results  in  ankylosis  in  these  conditions.  I  think  it  is 
important,  therefore,  that  in  the  case  of  the  hip  the  position  should  not 
be  one  of  full  abduction.  Fixation  in  plaster  relieves  the  pain  in  cer- 
tain of  these  joints.  In  others  more  relief  is  afforded  by  the  wearing 
of  a  caliper.  Pain  is  certainly  the  most  difficult  thing  to  deal  with  in 
this  condition.  If  there  is  deformity,  without  pain,  it  is  usually  suffi- 
cient to  correct  this  by  trans-trochanteric  osteotomy.  If  pain  is  per- 
sistent even  after  fixation,  operation  must  be  considered. 

Any  operation  to  secure  sound  arthrodesis  or  a  movable  joint  in 
these  cases  must  be  looked  upon  as  a  serious  one.  Results  of  arthro-* 
plasty  are  uncertain,  so  that  in  most  cases  it  will  be  better  to  try  and 
procure  a  sound  ankylosis.  For  this  it  may  be  necessary  to  disarticu- 
late the  hip  and  remove  all  cartilage  from  both  surfaces. 

The  age,  general  condition  of  the  patient,  and  the  type  of  work  he 
expects  to  do  must  all  be  taken  into  consideration  before  deciding  on 
operation. 

Mr.  Bennett:  I  feel  much  interested  in  this  discussion.  I  have  at- 
tempted to  cure  some  of  the  sufferers  from  this  condition,  but  I  have 
never  done  any  formidable  operations  for  it.  I  have  done  what  Sir 
Robert  Jones  taught  me  to  do;  in  these  cases  it  is  sufficient — and  you 
must  not  try  to  do  more  than  to  relieve  the  adduction  by  dividing  the 
adductor  tendons,  stretching  them  and  getting  the  limb  into  the  ab- 
ducted position.  Mr.  Aitken  has  tried  to  explain  why  the  pain  is  pres- 
ent, and  I  think  his  explanation  is  right,  though  I  could  never  quite 
understand  why  that  should  be.  There  is  great  relief  in  the  majority 
of  cases  when  one  divides  the  tendons  and  abducts  the  limb. 

"With  regard  to  the  question  of  a  weak  sacroiliac  joint  and  its  rela- 
tion to  the  condition  which  is  under  discussion,  I  have  been  very  much 
interested  in  this,  and  I  saw  Dr.  Goldthwait 's  work  in  1913;  since  that 
date  I  have  adopted  his  method  of  giving  support  to  the  pelvic  bones. 
His  belt  is  more  elaborate  than  the  one  I  use,  but  it  really  does  not  mat- 
ter much  what  belt  one  uses  so  long  as  it  is  adjusted  well  below  the 
anterior-superior  spine,  between  it  and  the  great  trochanter,  and  very 
firmly  bound.  There  is  great  relief  of  pain  in  the  hip-joint  by  this 
method.  The  belt  also  helps  what  Goldthwait  regards  as  the  contact 
between  the  transverse  lumbar  spine  and  the  sacrum,  and  which  he 
has  so  well  described.  I  wish  to  pay  my  tribute  to  the  wonderful  work 
done  by  Dr.  Goldthwait  in  regard  to  hip  and  lumbar  spinal  conditions. 

Mr.  Harry  Platt:  Mr.  Aitken  and  Mr.  Bennett  have  spoken  of  the 
importance  of  abducting  the  hip  in  the  early  stage  of  osteoarthritis1,' 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OF   HIP- JOINT  145 

That,  I  think,  goes  without  saying.  But  the  title  of  our  discussion  is 
the  operative  treatment  of  osteoarthritis,  and  these  cases  are  generally 
in  a  condition  of  incomplete  ankylosis  after  a  year  or  two  of  severe 
sciatic  pain,  the  hip  being  ankylosed  in  the  position  of  flexion  and  ad- 
duction. I  was  looking  through  some  of  the  records  of  operations  that 
I  have  performed  in  these  cases  during  the  last  seven  years — about  25 
of  them.  I  find  I  have  been  doing  three  things:  arthrodesis,  simple 
excision  of  the  head  of  the  femur,  and  arthroplasty.  And,  from  the 
point  of  view  of  the  after-result,  the  operation  of  simple  excision  of 
the  head  of  the  femur  has  given  the  best  result  of  all.  That  operation 
is  an  easy  one;  it  relieves  the  adduction  deformity  and  gives  one  room 
to  abduct  the  hip.  And  although  you  may  not  get  a  hip-joint  which 
later  allows  much  movement,  yet  in  my  cases  the  patients  have  been 
able  to  walk  with  comfort,  with  very  slight  limp,  and  with  much  ap- 
parent mobility,  mostly  due  to  the  lumbar  spine.  Arthrodesis,  in  my 
experience,  has  been  very  unsatisfactory.  I  began  doing  it  after  I  came 
back  from  Boston,  where  Dr.  Brackett,  of  that  city,  was  working  in- 
tensively on  this  subject;  he  had  his  wards  filled  with  cases  of  mon- 
articular arthritis  of  the  hip-joint,  and  he  was  doing  arthrodesis  on 
great  numbers.  I  did  not  see,  while  I  was  there,  many  of  the  end- 
results,  but  I  believe  that  from  Boston  the  end-results,  published  last 
year,  have  been  exceedingly  disappointing.  Many  of  the  cases  failed 
to  get  a  true  bony  ankylosis,  and  in,  I  think — (quoting  from  memory) 
•--75  per  cent,  of  the  cases  the  adduction  deformity  has  returned. 
Arthrodesis,  apparently,  should  be  limited  to  younger  patients,  in  whom 
one  is  certain  of  getting  bony  ankylosis  in  a  shorter  time.  In  my  own 
experience,  it  has  been  interesting  to  see  that  the  arthrodesis,  at  the 
end  of  a  very  long  period  of  fixation  in  abduction — which  has  not  al- 
ways been  easy  to  obtain — has  given  a  result  which  has  been  character- 
ized by  a  bad  limp  and  poor  function.  The  arthroplasties  I  have  done 
have  been  merely  the  addition  of  a  fascial  flap  to  what  is  practically  a 
simple  excision  of  the  head  of  the  femur,  and  the  end-results  are  not 
quite  as  good  as  those  from  simple  excision,  leaving  a  very  good  gap 
between  the  stump  of  the  neck  and  the  deep  acetabulum.  The  essential 
feature  in  the  operation  of  excision  is  to  put  the  stump  of  the  neck  into 
the  acetabulum,  and  put  the  hip-joint  up  in  full  abduction,  keeping  it 
abducted  for  a  considerable  time,  without  any  fear  of  it  ankylosing  or 
stiffening  up.  These  cases  do  not  ankylose  completely,  they  produce  a 
kind  of  fibrous  pseudo-arthrosis  which  seems  to  offer  a  very  good  chance 
of  future  function  for  the  patient. 


146  OPERATIVE   TREATMENT  OF   OSTEOARTHRITIS  OF   HIP-JOINT 

Mr.  S.  Alwyn  Smith  :  I  was  surprised  to  hear  Mr.  Piatt  say  his  re- 
sults of  arthrodesis  in  the  usual  type  of  case  were  unsatisfactory.  I 
was  pleased  to  hear  Mr.  Dunn  say  he  made  a  bigger  job  of  it.  I  turn 
up  the  trochanter  and  clear  out  everything,  to  make  sure  there  is  good 
apposition,  and  my  results  have  been  quite  good. 

One  other  point  is  this :  where  you  have  a  case  with  bilateral  anky- 
losis of  the  hip  in  septic  arthritic  cases  in  which  there  has  been  spondy- 
litis, and  probably  ankylosis  of  knees,  in  addition — I  suppose  such  a 
case  comes  under  osteoarthritis — how  do  you  know  when  the  fire 
has,  as  it  were,  burned  out?  I  am  supposing  a  case  in  which  there 
has  been  sepsis  of  teeth,  tonsil,  gut,  or  prostate.  I  had  a  case  which 
was  very  instructive,  and  I  will  mention  it. 

A  boy,  the  son  of  a  well-known  surgeon  in  Canada,  aged  21  when  I 
saw  him,  had  all  joints  of  both  lower  extremities  ankylosed,  except  his 
two  ankles,  and,  in  addition,  ankylosis  of  all  lumbar  spines.  He  had 
to  take  up  law,  or  wanted  to,  and  so  we  had  to  enable  him  to  bend  in 
the  middle,  so  that  he  could  read.  I  went  through  his  condition  as 
carefully  as  I  could.  He  had  chronic  constipation.  We  had  him 
x-rayed,  but  the  skiagram  was  said  to  reveal  nothing.  I  had  his  pros- 
tate massaged,  and  he  had  perfect  teeth.  At  15  years  of  age,  he  was 
said  to  have  tuberculosis.  He  had  had  balneo-therapy.  The  case  was  ob- 
viously septic,  so  I  thought  it  would  be  safe  to  operate.  I  therefore 
did  the  arthroplasty  which  was  advocated  by  Sir  Robert  Jones,  taking 
a  flap  from  the  great  trochanter,  and  removing  three-fourths  of  an  inch 
of  neck,  turning  up  the  flap  of  the  trochanter  and  nailing  it  up  in  ap- 
position to  the  proximal  end  of  the  divided  neck,  so  that  there  was  a 
false  joint.  I  also  left  sufficient  soft  tissue  and  opposed  a  fascial  flap 
in  addition.  The  result  there  was  very  good.  Instead  of  his  being  on 
crutches  and  his  two  feet  progressing  together,  he  now  had  a  stride  of 
33  inches,  and  he  could  stand.  There  was  no  camouflaging  of  the  lum- 
bar spines,  Because  he  was  ankylosed;  he  could  put  his  foot  up  on  a 
chair,  but  there  was  very  little  leverage  for  his  psoas:  there  is  prob- 
ably only  one-fourth  inch  of  femur  above  the  psoas  insertion.  That 
was  done  five  years  after  any  septic  manifestations.  I  was  asked  to  do 
Murphy's  arthroplasty  on  the  second  hip,  to  get  a  better  leverage.  I 
told  them  I  did  not  know  what  the  result  would  be.  I  did  a  Murphy 
operation,  and  everything  went  well  for  ten  days,  and  then  the  whole 
condition  flared  up,  and  he  had  pains  in  every  joint.  Three  months 
afterwards,  his  other  hip,  which  I  had  done  first,  was  the  seat  of  a  very 
acute  arthritis.  At  that  time  I  was  saved  further  responsibility  be- 
cause the  date  was  August,  1914.     He  went  to  Chicago,  and  Murphy 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OP  HIP-JOINT  147 

wrote  me  when  I  was  in  France,  saying  he  did  not  know  why  it  should 
have  flared  up  in  that  way,  and  that  he  was  having  a  bad  time  with 
him.  That  is  one  of  the  tragedies  of  attempting  to  do  arthroplasty  in 
whicn  the  process  involves  the  original  joint  elements.  I  think  one 
must  ponder  over  the  matter  very  carefully,  and  be  sure  of  one's  ground 
before  one  does  such  an  operation.  And  I  would  like  to  know  if  any 
members  can  tell  me  how  to  be  sure  that  the  fire  is  dead,  and  there- 
fore there  is  likely  to  be  no  further  lighting  up.  It  will  be  a  long  time 
before  I  do  another  arthroplasty  for  a  similar  condition.  I  have  done 
three  Murphy  operations  altogether,  and  the  others  were  fairly  good. 
There  were  60°  of  voluntary  flexion  in  one,  and  nearly  a  right  angle  in 
the  other.  In  similar  cases,  I  shall  do  one  of  the  modified  excisions  of 
the  joint  which  you,  Sir,  devised.  In  that,  one  does  not  get  so  much 
rocking  as  in  removal  of  the  head  alone.  And  where  removal  of  the 
head  has  been  done,  these  are  the  cases  in  which  I  have  seen  adduction 
and  flexion  deformity  afterwards.  My  experience  has  been  different 
from  Mr.  Piatt's:  those  are  the  cases  which  come  to  you  with  adduc- 
tion and  30°  of  flexion,  possibly  owing  to  faulty  after-treatment,  not 
the  cases  which  have  had  arthrodesis  suitably  done. 

But  the  point  I  got  up  to  ask  about  is,  when  is  it  safe,  when  can 
one  be  sure  that  infection  is  not  likely  to  light  up  again?  Personally, 
I  do  not  think  one  can  ever  be  sure  about  it. 

Mr.  R.  C.  Elmslie:  I  think  Mr.  Piatt  was  quite  right  to  remind  us 
that  our  subject  is  the  operative  treatment  of  these  cases.  We  are  very 
much  indebted  to  Mr.  Aitken  for  starting  by  trying  to  differentiate 
for  us  certain  particular  types  of  cases,  because  one  cannot  regard  osteo- 
arthritis of  the  hip  as  an  entity,  and  say  the  operative  treatment  of 
osteoarthritis  is  arthrodesis,  or  arthroplasty,  or  excision.  We  must 
recognize  that  there  are  different  clinical  types,  and  that  in  every  case 
we  have  to  consider  the  particular  clinical  type  which  is  confronting 
us,  the  probable  pathology  of  the  joint  condition,  and  particularly  the 
age  and  general  constitutional  state  of  the  patient. 

I  suggest  that  we  can  divide  most  of  the  cases  upon  which  operation 
might  be  practicable  into  these  types: 

(1)  There  is  the  youngish  patient,  with  a  single  hip  affected.  Those 
cases,  I  agree  with  Mr.  Aitken,  are,  in  a  large  proportion,  traumatic, 
and  I  think  many  of  them  are  the  end-results  of  that  "mushroomed" 
condition  of  the  head  which  arises  in  early  childhood  through  some 
trouble  in  the  epiphysis  of  the  head  of  the  femur.  Thei  first  descrip- 
tion of  it  was  published  by  our  new  corresponding  member,  Dr.  Calve, 


148  OPERATIVE  TREATMENT  OF   OSTEOARTHRITIS  OF   HIP- JOINT 

as  a  particular  form  of  pseudo-coxalgia.  A  characteristic  of  the  con- 
dition and  its  end-results  is  that  the  head  and  neck  of  the  femur  are 
sometimes  enormously  big.  One  may  cut  down  on  the  end  of  the  femur 
and  have  to  deal  with  a  femoral  neck  which  is  2%  inches  thick,  and 
this  is  an  additional  problem  in  the  operation.  I  think  other  mon- 
articular cases  in  young  or  middle-aged  people  are  largely  traumatic. 
I  saw,  recently,  a  woman  with  monarticular  osteoarthritis  who  had  a 
curious  deformity,  which  I  have  never  seen  before;  the  hip  was  ab- 
ducted to  an  extent  which  produced  two  inches  of  apparent  lengthen- 
ing. In  her  case  the  trouble  is  ascribed  to  a  fall  on  the  ice,  in  which 
her  hip  was  forcibly  abducted;  this  origin  may  have  something  to  do 
with  the  position. 

(2)  The  second  type  is  that  which  Mr.  Alwyn  Smith  was  speaking 
of,  and  which  was  originally  described  as  "spondylose  rhizomelique — " 
by  Marie,  in  which  the  spine,  hips,  and  sometimes  the  shoulders  under- 
go progressive  ankylosis.  These  constitute  a  group  of  bilateral  cases 
in  which  one  feels  almost  forced  to  do  some  operation. 

(3)  There  is  a  third  definite  group,  in  which  an  older  type  of  patient 
has  osteoarthritis,  perhaps  in  one  hip,  perhaps  in  both,  in  which  there 
is  some  mobility  left  in  the  hip,  adduction  and  flexion  deformity,  and  con- 
siderable pain.  Under  what  circumstances  are  we  inclined  to  operate  in 
these  cases?  I  suppose  the  two  conditions  which  induce  operation  are: 
persistent  pain  and  progressive  deformity,  and  this  deformity  leads  us 
the  more  certainly  to  operate  if  both  hips  are  affected.  Mr.  Aitken  called 
attention  to  the  fact  that  the  patient  with  osteoarthritis  in  one  hip 
nearly  always  comes  on  account  of  pain,  or  for  shortening,  or  for 
eversion,  not  because  of  stiffening  of  the  hip.  These  patients,  who 
will,  perhaps,  acknowledge  having  had  pain  for  twelve  months,  when 
asked  how  long  it  is  since  they  could  put  on  their  own  boots,  will  re- 
ply, two  or  three  years ;  the  stiffness  had  been  present  longer  than  the 
other  symptoms  for  which  they  present  themselves  for  treatment.  This 
has  always  seemed  to  me  to  ibe  the  indication  of  the  best  method  of  treat- 
ment in  the  monarticular  type.  And  I  am  sure  the  line  of  treatment 
which  is  best  for  the  patient,  giving  the  best  functional  result,  is  to 
try  to  fix  the  hip  in  a  sound  position.  To  place  such  operations  as 
arthroplasty  or  excision  of  the  head  as  fair  rivals  of  procedures  which 
tend  to  fix  the  hip,  you  would  have  to  show  a  remarkably  good  func- 
tional result  from  your  excision  or  arthroplasty.  I  have  not  seen  any 
results  from  arthroplasty  of  the  hip  which  I.  can  put  in  the  same 
class  as  a  sound  ankylosed  hip.  Therefore,  in  the  young  type  of 
osteoarthritis  of  one  hip,  I  have,  throughout,  gone  on  the  idea  that  I 
shall  try  to  get  an  ankylosed  hip   in  a  good  position,  and  if  I  can- 


OPERATIVE  TREATMENT  OP  OSTEOARTHRITIS  OP  HIP-JOINT  149 

not  get  that  ankylosis  in  a  reasonable  time  by  fixation  in  plaster  or 
a  splint,  I  have  done  arthrodesis.  And  I  agree  with  Mr.  Piatt  that  to 
get  sound  arthrodesis  is  not  an  easy  job.  Still,  I  am  surprised  to  hear 
him  say  that  the  operation  is  an  unsuccessful  one.  I  think  he  means 
it  is  only  unsuccessful  because  it  is  difficult  to  get  arthrodesis;  I  do 
not  think  that,  having  got  fixation,  it  would  be  unsuccessful.  One  has 
to  rely  upon  that  operation,  whether  you  do  it  by  Albee's  method,  or 
by  the  more  radical  method  of  turning  out  the  head  of  the  femur  and 
removing  the  whole  cartilage,  and  clearing  out  the  acetabulum  with 
the  arthrodesis  gouge.  It  is  a  severe  operation,  and  it  takes  a  consid- 
erable time,  involving,  also,  considerable  shock.  It  also  necessarily 
involves  a  long  period  afterwards  of  fixation  of  the  joint.  So  it  is  an 
operation  which  one  would  not  lightly  undertake  on  a  patient  who 
was  not  fairly  young  and  otherwise  in  sound  health.  I  think  such 
an  operation  for  osteoarthritis  of  the  hip  in  an  old  person  is  one  which 
involves  too  much  risk. 

Then  there  are  cases  of  double  arthritis  of  the  hip,  with  progressive 
ankylosis.  I  recently  saw  a  young  man  who  is  in  the  twenties,  who 
has,  at  the  present  time,  complete  fixation  of  his  spine,  from  the  cer- 
vical region  downwards,  and  of  the  hips  in  a  flexed  position,  so  that 
when  he  stands  he  is  tilted  forwards.  One  hip  has  no  movement,  and 
is  comparatively  painless;  the  other  hip  has  a  small  range  of  move- 
ment, and  causes  him  much  pain.  I  feel  that  he  is  still  in  the  pro- 
gressive stage,  and  that  he  has,  probably,  a  septic  focus  somewhere, 
though  it  is  an  exception  to  find  a  septic  focus  in  these  cases  of  Marie's, 
imd  one  is  thus  often  left  to  deal  with  the  spine  and  the  hips  as  a 
purely  mechanical  problem.  Holding,  as  I  do,  so  poor  an  opinion  of 
arthroplasty  of  the  hip  in  general,  I  should  feel  great  reluctance  in 
admitting  that  arthroplasty  ought  to  be  attempted  on  such  a  joint, 
unless  it  is  an  arthroplasty  which  requires  so  much  removal  of  bone 
as  to  get  rid  of  all  the  joint  elements.  I  think  this  type  is  best  treated 
by  frank  excision  of  the  head  of  the  femur,  and  in  this  I  am  glad  to 
find  myself  in  agreement  with  Mr.  Piatt,  who  probably  has  consider- 
able experience  of  excision  of  the  head  of  the  femur,  and  its  results. 
I  think  the  fear  of  the  loose,  weak  joint,  following  excision  of  the  hip, 
which  I  used  to  hold  very  strongly,  is  somewhat  exaggerated;  it  de- 
pends largely  on  the  results  of  excisions  of  the  hip  done  by  surgeons 
who  could  not  be  called  orthopaedic  surgeons,  it  was  excision  of  the 
head  of  the  femur  without  proper  after-treatment.  It  has  been  my 
custom,  for  some  years  past,  to  deal  with  old-standing  cases  of  un- 
united intracapsular  fracture  of  the  neck  of  the  femur  by  excising  the 


150  OPERATIVE   TREATMENT   OF   OSTEOARTHRITIS  OF   HIP-JOINT 

head.  Every  time  I  have  done  it,  I  have  felt  justified  by  finding  that 
the  pain  is  due  to  movement  at  the  false  joint,  and  that  the  head  of 
the  femur  is  atrophic,  that  its  cartilage  has  largely  disappeared,  and 
that  to  reconstruct  the  hip -joint  itself,  if  one  could  peg  the  head  on  to 
the  trochanter  successfully,  would  be  practically  impossible.  After 
excision  of  the  head  of  the  femur,  the  only  after-treatment  necessary 
is  to  put  the  hip  up  in  an  abducted  position.  I  use  a  pair  of  Thomas ' 
splints,  slung  in  a  widely  abducted  position.  Following  six  weeks  in 
this  position,  I  put  on  a  caliper  splint,  which  is  worn  for  from  six 
to  twelve  months. 

The  real  difficulty  of  arthroplasty  of  the  hip,  in  which  the  head  is 
covered  with  fascia  and  replaced  in  the  acetabulum,  which  has  been 
cleaned  out,  is  the  same  as  in  arthroplasty  of  any  joint  in  the  lower 
limb  which  is  subjected  afterwards  to  directly  transmitted  pressure. 
It  is  very  difficult  to  get  a  permanent,  good,  false  joint  where  that  false 
joint  is  being  subjected  to  the  through  pressure  of  the  whole  of  the  per- 
son's body.  It  is  a  different  problem  to  get  arthroplasty  of  a  joint  in 
the  lower  limb  from  that  concerning  a  joint  in  the  upper  limb,  where 
no  such  considerable  pressure  passes  through  the  joint.  I  want  to  see 
a  good  deal  better  results  from  arthroplasties  by  other  people  before 
I  go  back  to  trying  to  do  it  myself. 

There  is  another  operation,  one  which  has  not  been  alluded  to  in  the 
discussion,  namely,  that  in  which  the  head  of  the  femur  is  operated 
upon  for  the  removal  of  osteophytes  around  its  margin,  which  are  lim- 
it ing  movement  in  particular  directions.  This  operation  has  a  very 
limited  scope,  but  I  have  done  it  in  one  case,  myself,  with  great  suc- 
cess. It  was  that  of  a  young  man,  aged  about  28,  probably  a  late  case 
of  pseudo-coxalgia,  with  osteophytes.  The  osteophytes  on  the  upper 
border  of  the  head  and  neck  were  preventing  abduction.  There  was 
not  much  pain  in  the  joint,  and  the  other  movements  were  of  good 
range.  I  exposed  the  joint,  and  removed  large  pieces  of  bone  from  the 
margin  of  the  head,  and  thus  secured  an  increased  range  of  movement, 
which  enabled  him  to  ride:  previously,  he  could  not  keep  on  a  horse. 
The  success  of  the  operation  was  proved  by  the  fact  that  he  took  a 
commission  in  the  A.  S.  C.  Mounted  Transport,  and  went  right  through 
the  war;    after  the  war,  he  could  ride  well. 

Mr.  A.  H.  Tubby:  I  feel  considerable  diffidence  in  speaking  on  the 
question  of  the  operative  treatment  of  arthritis  deformans,  because 
my  experience  of  it  has  been  limited.  With  regard  to  the  origin  of 
the  disease  I  crave  your  indulgence  whilst  I  say  a  word:  the  opener 
of  the  discussion  has  also  alluded  to  the  matter. 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OP   HIP-JOINT  151 

There  is  an  abundance  of  literature  which  supports  the  contention 
that  a  large  proportion  of  cases  is  due  to  defective  teeth ;  yet,  that  is 
not  the  whole  question.  We  need  to  differentiate  carefully  what  par- 
ticular lesion  in  the  teeth  it  is,  which  is  associated  with  the  more  viru- 
lent forms  of  arthritis  deformans;  and,  if  I  enter  into  personal  ex- 
periences, I  hope  you  will  forgive  me :  I  do  so  because  it  may  be  useful. 

I  had  slight  warnings  of  arthritis  deformans  for  some  years.  Last 
summer,  after  a  prolonged  stay  abroad,  under  trying  conditions,  the 
signs  were  aggravated.  The  removal  of  six  teeth  from  the  upper  jaw 
had  no  effects  upon  the  symptoms.  Skiagrams  were  then  taken,  and 
five  teeth  were  extracted  from  the  lower  jaw.  The  symptoms  abated. 
At  the  root  of  the  second  lower  right  molar,  a  granuloma  was  found 
to  be  attached  to  the  nerve,  and  came  away  with  it.  Herein  lay,  I  be- 
lieve, the  cause  of  the  trouble.  Much  work  has  been  done  by  dental 
surgeons  on  streptococcus  viridens  and  granuloma.  Their  experience 
is,  that  granulomata  are  capable  of  demonstration  by  x-rays.  They  are 
seen  as  small,  oval,  dark  masses  below  the  root,  or  roots,  of  the  teeth, 
and  it  is  of  no  avail  to  remove  the  teeth  unless  the  granulomata  ane 
extirpated  as  well.  If  the  granulomata  are  left,  there  will  be,  for  a 
long  time,  a  sinus  in  the  lower  jaw,  and  the  signs  of  arthritis  will  per- 
sist, and  even  become  aggravated. 

And  now  with  regard  to  other  questions.  Once  arthritis  deformans 
of  the  hip  is  well  developed,  the  essential  indications  are  quite  clear, 
namely,  to  take  the  weight  off  the  painful  joint  and,  at  the  same  time, 
keep  it  in  movement.  An  article  by  me,  on  the  subject,  appeared  in 
The  Practitioner,  in  November,  1920,  therefore  I  need  not  go  over 
the  points  again,  except  to  say  that  rest  in  bed,  with  weight-extension 
on  the  legs,  with  massage  and  occasional  passive  movements,  is  pre- 
scribed for  some  weeks  until  pain  and  spasm  have  subsided.  Then,  the 
patient  is  allowed  to  walk,  wearing  an  apparatus  which  is  so  contrived 
as  to  transmit  the  body-weight  directly  from  the  tuber  ischii  to  the  heel 
of  the  boot. 

With  regard  to  operations  on  the  hip-joint,  or  femur,  I  am  con- 
vinced that  their  comparative  want  of  success  is  due  to  non-recognition 
of  this  point,  viz.,  after  you  have  operated,  you  should,  by  means  of 
some  contrivance,  so  arrange  that  the  weight  of  the  body  shall  not  press 
on  the  joint  which  has  been  dealt  with  by  arthroplasty,  or  on  a  femur 
which  has  been  divided.  Movement  at  the  hip  should  be  provided  for, 
and  intra-articular  pressure  be  avoided.  This  is  effected  by  the  walk- 
ing apparatus  just  alluded  to.  My  experience  in  operating  for  arthritis 
deformans  has  been  more  extensive  in  the  knee  than  in  the  hip.     The 


152  OPERATIVE  TREATMENT  OP  OSTEOARTHRITIS  OP  HIP-JOINT 

results  after  operation  on  the  knee  have  been  satisfactory  and  pleasing 
to  the  patient  and  myself,  whereas  those  on  the  hip  leave  much  to  be 
desired. 

"Sciatica,"  wrongly  so  called,  is  often  a  sign  of  commencing  trouble 
in  the  hip.  The  pain  is  sometimes  due  to  pressure  of  osteophytes  on 
the  sciatic  nerve,  and  occasionally  you  may  remove  the  osteophytes  and 
a  small  part  of  the  subjacent  bone,  and  afford  relief.  I  embark,  only 
after  considerable  hesitation,  upon  any  extensive  operation  on  the  hip- 
joint  for  arthritis  deformans.  I  need  to  be  convinced  that  the  condi- 
tions of  pain  and  loss  of  movement  are  such  as  to  interfere  seriously 
with  the  patient's  health,  and  prevent  his  obtaining  a  livelihood.  Per- 
sons of  advanced  years  are  very  seldom  fit  subjects  for  any  severe  op- 
eration upon  the  hip. 

Dr.  J.  Adams  (Boston,  U.  S.  A.)  :  It  is  interesting  for  me,  Sir, 
coming  from  America,  to  have  the  privilege  of  being  present  at  this 
meeting  of  the  British  Orthopaedic  Association.  Originally,  we  thought 
the  centre  of  orthopaedics,  in  America,  was  Boston,  but  we  have  been 
deposed  from  that  position,  I  think,  by  the  New  York  gentlemen. 

The  question  of  osteoarthritis  has  been  very  interesting  ever  since 
the  inception  of  orthopaedic  surgery  as  a  specialty,  and  I  judge  you 
have  had  the  same  fight  in  this  country,  to  establish  orthopaedic  sur- 
gery on  the  good  basis  it  ought  to  have,  as  we  have  had  in  America.  I 
feel  that  the  subject  has  been  so  well  covered  today,  that  there  re- 
mains very  little  which  can  be  added,  except  that  I  am  very  glad  to 
hear  what  has  been  said  about  the  operation  of  arthroplasty  of  the  hip- 
joint.  I  think  we  all,  in  America — I,  personally,  certainly — have  had 
experience  of  a  succession  of  failures  after  that  operation.  Reference 
has  been  made  to  Dr.  Brackett's  series  of  cases  at  the  Massachusetts 
Hospital  and  his  thorough  investigation  of  the  subject  of  arthrode- 
sis. In  certain  selected  cases  in  which  the  patient's  condition  will  ad- 
mit of  such  a  serious  operation,  arthrodesis  has  proved  of  distinct  value, 
but  only  in  a  low  percentage  of  cases.  To  sum  up  the  treatment  of 
this  disease,  it  seems  to  me  that  if  we  could  so  teach  our  general  prac- 
titioners to  call  in  the  orthopaedic  surgeon  at  the  beginning,  in  cases 
of  rheumatoid  arthritis,  we  should  not  be  confronted  with  many  of 
the  surgical  problems  that  we  are  seeing  today.  I  feel,  and  most  of 
us  in  the  United  States  feel,  that  the  conservative  treatment  of  this 
disease,  which  is  fixation  in  plaster,  in  abduction,  until  the  patient's 
symptoms  demand  some  further  treatment,  is  all  we  can  expect  and  ac- 
cept. In  other  words,  we  fix  the  patient  in  plaster,  in  abduction,  and 
when  his   symptoms  become   so   intolerable  that  he  demands   further 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OP   HIP-JOINT  153 

treatment,  we  give  him  the  operation  of  choice,  placing  before  him  the 
statistics  which  our  experience  has  allowed  us  to  use,  as  to  the  opera- 
tion of  election.  The  results  are  not  extremely  satisfactory  along  any 
line  of  treatment  except  the  conservative  one.  I  feel  that  many  of  the 
failures  which  are  seen  following  the  radical  operation  are  due  en- 
tirely to  the  fact  that  we  have  not  allowed  the  inflammation  in  the  joint 
to  sufficiently  quiet  down  before  that  radical  operation  was  under- 
taken. At  present,  I  think  most  of  the  people  in  America  are  in  great 
danger  of  losing  most  of  their  teeth ;  we  are  passing  through  a  furore 
of  dental  abscess,  to  which  are  attributed  all  the  ills  which  result  in 
the  conditions  we  are  discussing.  A  few  years  ago  I  was  at  Los  An- 
geles, reading  a  paper  before  the  Society  there,  and  I  have  never  seen 
one  idea  taking  hold  of  a  community  as  did  the  supposed  specific  cause 
of  this,  there,  at  that  time.  Whether  that  wave  has  travelled  across 
the  country  eastwards,  and  even  arrived  at  this  country,  I  do  not  know, 
nor  do  I  know  whether  it  really  originated  in  this  country.  But  I  think 
that  in  our  attempts  to  find  the  focus  in  these  crippling  cases  we  lose 
much  valuable  time  which  should  be  occupied  in  the  treatment  of  the 
condition  which  is  present.  We  send  patients  about  to  those  practising 
different  specialties  in  the  States,  at  a  time  when  the  patient  should  be 
resting  in  bed  with  the  limb  fixed,  and  having  the  specialist  come  to 
him,  if  it  is  necessary  for  the  patient  to  be  seen,  to  investigate  the 
cause  and  the  pathology. 

Mr.  A.  B.  Mitchell  (Belfast)  :  May  I  add  my  congratulations  to 
you,  Sir,  on  the  efforts  which  you  have  made  to  establish  orthopaedies 
in  this  country  on  a  sound  basis?  One  of  the  most  valuable  results  of 
the  war  has  been  to  compel  you  to  throw  aside  your  natural  modesty 
and  come  forward  and  force  your  principles  on  the  notice  of  the  pro- 
fession. The  profession  in  this  country  has  responded  nobly.  There 
is  no  work  which  has  been  so  heartily  and  generously  recognized  by  the 
general  surgeons  in  this  country,  as  your  own.  They  truly  value  the 
principles  which  you  have  so  ardently  and  so  persistently  advocated. 

The  discussion  to  which  wTe  have  been  listening  this  morning  makes 
me  feel,  more  and  more,  that  no  man  can  undertake  to  treat  one  of 
these  cases  of  osteoarthritis  without  the  greatest  sense  of  responsibility. 
The  very  fact  that  no  one  operation  appears  to  give  the  desired  result, 
that  no  surgeon,  before  he  operates,  can  undertake  to  give  the  patient  a 
definite,  a  perfect,  even  a  moderately  satisfactory  result,  makes  it  our 
bounden  duty  to  put  the  facts  before  the  patient,  to  tell  him  exactly 
what  we  hope  to  attain,  the  possibilities  of  failure,  and  leave  him  to 
decide  whether  he  will  entrust  his  future  welfare  to  our  care. 


154  OPERATIVE  TREATMENT   OF   OSTEOARTHRITIS  OF   HIP- JOINT 

As  put  before  us  today,  the  question  of  osteoarthritis  ranges  over 
the  whole  tenure  of  life.  Mr.  Aitken  sent  round  a  very  interesting 
photograph  of  a  condition  believed  to  be  due  to  traumatism,  in  a  child 
12  months  old.  I  hope  he  will  excuse  my  saying,  I  am  in  doubt  about 
that  being  an  ordinary  case  of  osteoarthritis.  I  hardly  think  the  pos- 
sibility of  tubercular  epiphysitis,  with  destruction  of  the  head  of  the 
bone,  can  be  eliminated  in  that  case. 

We"  come  now  to  the  other  end  of  life.  A  gentleman  of  65  to  70  years 
comes  along — one  who  is  otherwise  well — and  says,  "Can  you  do  some- 
thing for  the  pain  in  my  leg,  which  is  getting  stiff?  I  cannot  lace  my 
boots."  Later,  comes  the  agonizing  pain  which  keeps  him  awake  at 
night.  As  Mr.  Aitken  has  well  said,  he  goes  to  the  general  practitioner, 
then  to  the  electrician,  then"  to  the  quack.  The  quack,  devoid  of  a  sense 
of  responsibility,  and  with  his  usual  assertion  that  he  can  certainly 
cure,  impresses  him  most  of  all.  After  a  time,  the  man  comes  back  to 
us  again.  You  find  he  has  a  hip- joint  the  seat  of  hypertrophic  osteo- 
arthritis, with  a  lip  round  the  acetabulum.  Everything  has  been  tried 
to  relieve  the  pain.  What  can  you  do  for  him?  Are  there  any  oper- 
ative measures  which  you  are  justified  in  proposing  to  him,  consider- 
ing his  years  and  the  time  he  would  be  obliged  to  be  in  bed  ?  Supposing 
his  hip-joint  is  just  commencing  to  be  involved,  and  he  is  afraid  of  be- 
ing bedridden?  He  is  prepared  to  endure  any  operation,  even  to  face 
death,  provided  he  can  get  some  relief.  I  am  satisfied  that  arthrodesis 
in  such  a  man  would  not  cure,  nor  end  his  sufferings.  The  prolonged 
after-treatment  in  these  cases  is  really  one  of  the  great  difficulties.  I 
am  pleased  to  hear,  from  Mr.  Piatt  and  others,  that  excision  of  the 
head  of  the  femur  gives  a  more  favorable  result  than  I  have  usually 
seen.  In  the  cases  I  have  had,  it  may  be  that  the  after-treatment  was 
not  sufficiently  prolonged.  I  think  the  ordinary  result  of  excision  is 
a  pathological  dislocation.  I  think  it  is  very  difficult  to  get  fibrous,  or 
any  other  form  of  ankylosis,  which  will  prevent  dislocation  in  an  up- 
ward direction  when  the  weight  of  the  body  is  thrown  on  the  leg.  If 
you  are  going  to  do  that  in  a  child,  it  will  be  much  better  to  take  away 
the  neck,  and  try  to  fix  the  head  in  the  acetabulum.  I  would  like  to 
hear  opinions  on  that  point.  I  am  speaking  from  an  experience  which 
is  not  sufficient  to  give  weight  on  a  question  of  this  importance.  The 
cases  of  excision  of  the  head  of  the  femur,  which  I  have  seen,  have  ul- 
timately got  into  a  condition  which  is  not  favorable. 

When  is  it  safe  to  open  and  deal  with  a  joint  which  has  been  the 
seat  of  arthritis  of  a  toxic  nature?  This  immediately  raises  the  ques- 
tion of  autointoxication.    No  one,  I  think,  can  deny  the  effect  of  trauma, 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OP   HIP-JOINT  15£ 

in  producing  autointoxication.  The  simplest  example  is  ordinary  acute 
septic  periostitis,  or  septic  osteomyelitis.  A  boy  gets  a  kick  on  the* 
shin ;  there  is  no  outside  wound,  yet  in  a  few  days  he  comes  with  an 
acutely  inflamed  tibia,  and  perhaps  the  whole  periosteum  stripped  from 
the  bone.  The  devitalization  of  the  tissues  produced  by  injury  has  in- 
duced the  invaders  to  attack  the  weak  spot  in  .his  defense.  It  is  impos- 
sible to  say  that  in  the  arthrodesis  a  mild  degree  of  infection  was  not 
induced,  which,  in  the  ordinary  way,  did  not  manifest  itself  early.  I 
am  not  questioning  the  care  which  was  taken,  but  we  are  dealing  with 
an  individual  whose  resistance,  probably,  to  septic  organisms  of  all 
kinds  is  rather  below  the  normal,  and  a  mild  operation,  such  as  sub- 
trochanteric osteotomy,  which  is  fairly  rapid  and  involves  a  minimum 
of  damage  to  muscular  and  other  tissue  round  the  joint,  is  less  likely 
to  be  followed  by  infection.  In  our  hospital,  in  which,  under  you.  Sir, 
I  had  the  honor  of  supervising  the  orthopedic  work,  when  joint  or 
bone  cases  were  admitted  for  treatment,  we  made  a  rule  not  to  allow 
anyone  to  operate,  to  do  a  bone  graft,  or  operate  on  a  joint,  until  all 
inflammation  and  sepsis  had  subsided. 

I  am  sorry  I  cannot  give  you  any  experiences  of  arthrodesis  of  the- 
hip- joint.  I  have  studied  the  literature  carefully,  and  I  have  not,  un- 
til now,  felt  that  the  proved  results,  after  a  reasonably  good  time,  have- 
been  sufficient  to  make  me  feel  I  ought  to  do  this  operation  of  arthro- 
desis in  an  old  patient. 

Dr.  Calve  (Paris)  :  I  accept  your  kind  invitation  to  make- 
two  observations.  First,  osteoarthritis  in  adults  is  very  rare  in  France, 
and  it  is  curious  to  us  French  orthopaedists  that  you,  in  England,  sa 
often  discuss  this  question.  In  children  it  is  very  different.  In  Amer- 
ica, there  seems  to  be  a  special  form  of  arthritis.  In  the  child,  this 
osteoarthritis  is  cured  without  surgery,  by  rest,  perhaps  for  six  months. 
Sometimes  there  is  not  more  than  a  little  pain.  I  think  the  trouble  is* 
largely  due  to  the  thickness  of  the  cartilage;  I  think  the  actual  articu- 
lar surface  is  not  involved.  In  some  cases  a  little  nucleus  forms,  and  it 
is  interesting  to  follow  and  observe  that  in  the  succeeding  radiogram, 
first,  there  is  one  nucleus  between  the  neck  and  the  acetabulum,  and 
then  two  or  three,  afterwards  uniting  to  form  one  large  one. 

Mr.  E.  W.  Hey  Groves:  I  had  not  intended  to  contribute  to  this  dis- 
cussion. I  came  with  the  object  of  gaining  information,  and  I  may  say 
I  have  done  so,  and  with  great  profit. 

I  was  much  interested  to  see  this  subject  had  been  chosen  for  discus- 
sion, because  I  think  it  is  one  which  is  becoming  more  and  more  im- 


15  b""  OPERATIVE   TREATMENT   OF   OSTEOARTHRITIS  OP   HIP- JOINT 

portant.  I  do  not  know  whether  the  war  pensioner  is  particularly  lia- 
ble to  septic  influences,  or  whether  it  is  the  late  result  of  gunshot 
wounds,  but  the  proportion  of  cases  of  severe,  crippling  osteoarthritis 
we  have  seen  lately  has  been  rather  a  painful  revelation.  They  are  be- 
coming one  of  the  biggest  problems  we,  in  the  area  I  am  associated  with, 
have  to  deal  with.  I  have  the  feeling  that  the  advantages  of  excision  of 
the  hip,  a  comparatively  simple  operation,  were  very  much  greater  than 
those  of  the  more  elaborate  operations  which  have  been  proposed  in 
the  last  decade.  But  I  have  a  rather  guilty  feeling  that  perhaps  it  was 
that  we  had  not  carried  out  the  more  elaborate  operations  in  the  way 
they  should  be  done,  and  so  I  thought  I  would  not  say  anything  about 
it.  Still,  I  am  encouraged  by  the  rather  large  consensus  of  opinion 
which  has  been  expressed  today,  to  add  my  contribution  to  the  weight 
of  that  opinion.  When  we  hear  distinguished  orthopaedists  from  this 
and  the  other  side  of  the  water  speak  about  the  importance  of  simpli- 
fying these  operations,  I  have  no  hesitation  in  adding  my  experience 
to  theirs. 

In  the  first  place,  it  seems  to  me  that  the  comparatively  elaborate  op- 
eration of  arthroplasty  has  not  made  good.  I  have  done  it;  it  is  the 
sort  of  operation  which  makes  a  strong  appeal  to  me;  it  was  carefully 
thought  out,  it  looks  good,  and  to  me  it  was  attractive,  therefore  I  set 
out  biased  in  its  favor.  I  cannot  say  in  how  many  cases  I  have  done 
it,  but  it  is  a  considerable  number.  I  have  been  very  disappointed  with 
it,  indeed.  It  is  a  long,  tedious  operation,  one  of  those  operations  in 
which  it  is  very  difficult  to  effectively  control  the  haemorrhage  by  a 
tourniquet;  there  is  much  oozing.  In  elderly  patients,  especially,  it  is 
a  serious  operation,  and  one  in  which  it  is  very  difficult  to  entirely 
avoid  sepsis;  there  is  much  exposure,  and  many  of  the  cases  have  pre- 
viously been  subjects  of  subacute  septic  absorption.  At  any  rate,  they 
are  difficult  subjects  in  whom  to  get  healing  by  first  intention.  And 
even  in  those  cases  in  which  there  has  been  no  drawback  and  no  acci- 
dent, the  functional  result  has  been  extremely  disappointing.  On  the 
other  hand,  simple  excision  of  the  head  of  the  bone  has  given  very  much 
better  results.  And  I  think  the  reason  for  that  is  two-fold.  First,  the 
inherently  simpler  character  of  the  operation  makes  very  much  more 
for  success ;  and,  secondly,  the  fact  that  after  the  head  of  the  bone  has 
been  removed  and  nothing  but  the  neck  is  left,  the  mechanical  strain  on 
that  region  of  the  femur  is  very  much  less;  that  is  to  say,  the  bone 
acts  more  like  an  axial  strut  in  the  thigh,  and  there  is  not  that  stress 
and  strain  which  normally  takes  place  at  the  neck  and  head  of  the 
bone,  owing  to  its  particular  shape.     The  third  point  is,  that,  going  on 


OPERATIVE  TREATMENT  OP  OSTEOARTHRITIS  OP   HIP-JOINT  157 

the  suggestion  which  I  first  got  from  Sir  Harold  Stiles,  after  the  head 
of  the  bone  has  been  removed,  if  the  neck  of  the  bone  is  smoothed  and 
then  rubbed  with  a  hard  variety  of  wax,  that  will  obviate  the  neces- 
sity for  interposition  of  fascia ;  and  under  those  circumstances,  I  think, 
excision  of  the  bone  gives  an  extremely  good  result.  My  feeling  now 
is,  that  in  all  cases  without  much  pain,  but  with  much  deformity,  sub- 
trochanteric osteotomy  is  the  operation  of  choice;  and  in  the  cases 
which  have  much  pain  and  it  is  desirable  to  get  some  degree  of  move- 
ment, some  simple  form  of  excision  of  bone,  followed  by  rubbing  in  of 
wax  to  the  neck,  gives  the  best  result. 

Mr.  A.  Blundell  Bankhart:  I  agree  very  strongly  with  much  of 
what  Mr.  Elmslie  said;  that  there  should  be  a  distinction  between  the 
case  in  which  one  does  excision,  and  where  arthroplasty  is  done.  If 
you  take  away  enough,  you  get  a  movable  joint ;  if  you  take  too  little, 
it  becomes  fixed.  I  have  seen  a  good  many  elbows  excised  in  children, 
and  some  got  stiff  joints,  some  had  flail  joints,  some  good  joints.  The 
same  applies  to  stiff  toe  joints.  If  you  take  enough  bone,  there  is  move- 
ment; if  you  take  too  much,  there  is  stiffness.  How  much,  then,  will 
you  excise  ?  Murphy 's  original  operation  was  not  simply  smoothing  the 
bone  and  making  the  new  articular  surfaces :  he  laid  stress  on  excising 
the  capsule  of  fibrous  tissue  and  even  baring  the  bone  and  embedding 
it  in  a  clean  muscle  bed  and  fat.  Most  of  us  who  have  tried  that,  have 
bad  a  big  wound,  which  it  has  been  difficult  to  keep  clean,  and  many 
of  the  people  have  suffered  from  infection  afterwards.  I  have  had  two 
which  were  badly  infected  and  were  suppurating,  and  they  had  better 
movement  than  did  any  of  the  cases  I  have  done  which  healed  asep- 
tically.  I  feel  it  should  be  possible  to  do  arthroplasty,  and  I  think  that 
if  we  were  talking  to  students  or  post-graduates,  and  teaching  them 
established  principles,  we  should  warn  them  against  arthroplasty.  But 
I  think  the  fact  that  other  people  have  failed  is  rather  an  incentive  to 
us  to  improve  on  the  technique  and  try  to  succeed.  I  think  past  records 
are  not  reliable  as  a  guide  to  results  of  excision  of  the  hip,  because  they 
have  not  been  treated  from  the  point  of  view  of  obtaining  a  function- 
ally good  position  afterwards;  and  personally,  I  do  excision,  and  treat 
them  afterwards  in  full  abduction,  and  later  put  on  a  caliper  splint 
to  take  the  weight  off  the  limb. 

Mr.  Fairbank:  My  experience  of  the  operative  treatment  of  osteo- 
arthritis of  the  hip  is  so  small  that  I  have  not  much  to  say,  but,  from 
seeing  results  in  my  few  cases,  and  in  other  people's,  I  am  glad  to  hear 


158  OPERATIVE  TREATMENT   OF   OSTEOARTHRITIS  OF   HIP-JOINT 

■so  many  inclined  to  put  forward  the  benefit  derived  from  excision  of 
the  hip,  which  seems  to  give  the  best  results  if  you  are  going  to  get 
any  movement  of  the  hip  at  all.  It  has  been  my  belief  that  the  result 
after  attempting  osteoplasty,  depends  very  much  more  on  the  amount 
of  bone  removed  than  on  anything  which  the  surgeon  puts  between  the 
bones,  and  also,  perhaps,  on  the  after-treatment  as  well.  Unless  you 
leave  a  sufficient  interval  between  the  bones,  you  will  not  get  a  good 
result,  no  matter  what  you  put  in  between. 

I  am  disappointed  that  we  have  not  heard  more  about  the  early,  non- 
operative  treatment,  because  it  seems  to  me  that  there  are  very  few 
cases  you  can  operate  upon :  either  they  are  not  severe  enough,  or  they 
are  too  old  and  severe,  and  in  the  latter  you  cannot  run  the  risk  of 
opening  the  hip-joint,  which  is,  as  other  speakers  have  mentioned,  a 
very  severe  operation.  With  regard  to  treatment  without  operation,  it 
seems  to  me  the  pain  is  caused  by  one  of  two  things:  either  the  move- 
ment of  the  hip-joint  or  the  weight-bearing.  In  one  instance,  the  pain 
is  not  great,  except  when  the  limb  is  walked  on,  while  in  other  cases 
any  movement  causes  agonizing  pain,  even  to  the  extent  of  interfering 
very  materially  with  sleep.  In  such  cases,  I  think,  one  has  always  to 
try  to  ascertain,  before  ordering  any  apparatus,  exactly  which  of  these 
two — movement  or  weight-bearing — inconveniences  the  patient  more.  In 
a  recent  case,  the  patient  was  unable  to  sleep  for  longer  than  a  few 
minutes  at  a  time,  being  repeatedly  disturbed  by  slight  movements  of 
the  hip-joint.  I  abducted  the  hip  first,  under  an  anaesthetic,  and  then 
I  obtained  a  plaster  model,  and  had  a  leather  support  made,  coming 
down  to  the  knee.  That  immobilized  the  hip-joint.  In  addition,  I  had 
a  walking  caliper  splint  made,  which  fitted  into  little  D-shaped  sockets 
on  the  leather  splint,  so  that  the  former  could  be  put  on  for  walking 
purposes.  When  in  bed  at  night,  she  wears  the  leather  splint  without 
the  caliper.  The  result  has  been  very  gratifying.  She  is  very  greatly 
relieved,  and  her  general  health  has  improved  enormously. 

Another  point  is  this:  when  you  abduct  the  hip-joint  and  endeavor 
to  retain  it  in  abduction  and  then  put  on  a  caliper  splint,  you  must 
thicken  the  opposite  heel.  It  is  difficult  to  maintain  abduction  unless 
you  increase  the  length  of  the  other  leg. 

The  President  (Sir  Robert  Jones)  :  This  subject  has  been  extraor- 
dinarily well  covered,  both  by  the  very  interesting  introduction  on  the 
part  of  Mr.  Aitken,  and  by  what  we  have  heard  from  subsequent 
speakers. 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OP  HIP- JOINT  159 

I  have  very  little  which  is  new  to  add  to  this  debate.  Most  of  you 
know  what  my  practice  has  been  with  regard  to  these  rheumatoid  con- 
ditions, but,  in  spite  of  many  successes,  I  have  experienced  almost  every 
variety  of  difficulty  and  disappointment  which  has  been  alluded  to  and 
described  so  graphically  by  speakers.  There  is  that  type  of  case  which 
Mr.  Mitchell  so  very  well  described — the  man  of  about  50  to  55  years 
*>f  age,  who  has  pain  in  his  hip,  not  enough  to  justify  operation,  nor 
to  do  anything  drastic.  I  think  our  inventive  faculty  is  severely  ex- 
ercised when  dealing  with  that  type  of  case.  It  is  much  easier  to  deal 
with  the  more  advanced  and  acute,  for  the  discomfort  warrants  drastic 
treatment. 

But  there  is  one  kind  of  case  which  has  not  been  referred  to  much 
today,  but  which  we  often  meet  with,  and  that  is  the  monarticular  rheu- 
matoid arthritis,  with  sharp  stalactytes  about  the  joint.  Such  a  case 
may  remain  five  or  six  years,  hardly  getting  any  worse,  but  complain- 
ing very  greatly  of  the  pain  and  the  inconvenience  of  limited  move- 
ment. In  a  very  large  number  of  such  cases  an  anaesthetic  and  very 
gentle  stretching  and  breaking  down  of  adhesions  gives  the  patient  very 
great  relief.  That  relief  does  not  necessarily  last  a  very  long  time, 
though  sometimes  it  does.  I  remember  one  case  in  which  the  patient 
had  been  bad  seven  or  eight  years,  and,  under  an  anaesthetic,  we  care- 
fully broke  down  adhesions,  and  for  four  or  five  years  afterwards  he 
was  quite  easy  and  comfortable,  only  complaining  occasionally  of  pain. 
Such  relief  is  due  to  the  fact  that  in  connection  with  the  inflammatory 
changes  which  go  on  at  the  edges  of  the  joint,  there  are  a  large  number 
of  adhesions,  which  are  very  painful. 

The  operation  of  cheilotomy  was  referred  to  in  Mr.  Elmslie's  admir- 
able address.  I  have  had  some  experience  of  this  operation:  I  remem- 
ber helping  Mr.  Sampson  Handley  in  one  such  case.  In  that  instance, 
the  patient  was  getting  distinctly  worse,  with  sharp,  big  excrescences  on 
the  posterior  part  of  the  head  of  the  femur,  and  their  removal  certainly 
gave  him  much  relief.  I  remember,  also,  another  case — that  of  a  man 
who  was  a  painter  and  had  to  climb  ladders,  in  spite  of  much  inconven- 
ience and  pain.  I  tried  to  break  down  his  adhesions,  but  without  last- 
ing effect;  and,  finally,  I  took  away  two  large  masses  at  the  back  of 
the  joint,  and  their  removal  enabled  him  to  climb  ladders  without  any 
inconvenience.  This  operation  is  t^est  performed  by  displacing  the 
trochanter,  for  in  this  way  you  get  a  good  view  of  the  osteophytes.  The 
difficulty  which  is  experienced  by  everybody  is  that  of  dealing  with  the 
masses  which  occur  below  the  joint.  As  a  rule,  those  masses  are  not  the 
ones  which  cause  the  greatest  disability. 


160  OPERATIVE   TREATMENT   OF   OSTEOARTHRITIS  OP   HIP- JOINT 

Much  has  been  said  about  arthrodesing  or  ankylosing  these  joints.  I 
have  ankylosed  a  good  number,  but  I  have  had  the  same  difficulty,  es- 
pecially early  on,  in  getting  bony  union.  There  is  a  tendency  for  anky- 
losis not  to  be  complete.  They  have  not  been  patients  in  whom  one  has 
been  justified  in  turning  out  the  head  of  the  bone  and  making  a  com- 
plete operation.  I  have  had  cases,  in  younger  people,  in  whom  I  have 
experienced  no  difficulty,  in  whom  I  could  turn  the  head  of  the  bone  out- 
completely  and  remove  the  cartilage  from  the  head  of  the  femur  and 
acetabulum.  In  such  cases  there  is  no  difficulty,  but  that  operation 
should  never  be  done  in  the  case  of  aged  persons.  As  Mr.  Hey  Groves 
and  others  have  said,  the  operation  of  turning  out  the  head  of  the  femur 
and  removing  all  the  cartilage  in  a  man  over  sixty,  is  a  very  grave  pro- 
cedure, and  one  which,  I  think,  in  the  present  state  of  knowledge,  is 
rarely  justifiable.  In  such  cases,  even  if  the  patient  survives,  he  will 
have  had  a  great  shock,  and  one  is  not  so  likely  to  get  an  ankylosis  as 
in  the  case  of  persons  with  younger  bones. 

Then  there  is  the  problem  presented  in  the  case  of  the  patient  sixty 
years  old  who  has  an  acute  and  persistent  pain,  and  who  is  willing  to 
leave  himself  unreservedly  in  an  operator's  hands  if  a  promise  of  re- 
lief is  given.  In  such  a  case,  an  operation  can,  as  a  rule,  be  performed, 
especially  if  the  person  is  thin,  with  scarcely  any  shock.  I  have  often 
described  the  operation,  which  consists  of  displacing  the  great  trochan- 
ter and,  having  previously  removed  a  large  piece  of  the  neck,  nailing  it 
to  that  part  of  the  neck  attached  to  the  head.  In  my  experience,  turn- 
ing out  the  head  of  the  bone  in  an  old  person  is  accompanied  by  con- 
siderable shock,  to  be  avoided  if  possible.  I  would  therefore  advise 
that  in  the  case  of  the  old  person,  any  operation  which  is  done  should 
be  one  in  which  you  leave  the  head  of  the  bone  in  the  acetabulum.  Not 
long  ago,  I  told  a  gentleman,  aged  60,  that  I  thought  an  operation  might 
benefit  him.  Having  said  that,  however,  I  got  rather  timid,  and  I  rested 
him  for  awhile  and  tried  to  abduct  his  hip,  doing  many  things,  indeed, 
rather  than  operate.  I  was,  however,  sent  for  by  the  patient's  friends 
who  said  he  was  prepared  to  take  any  risk  in  the  hope  of  relief.  I 
asked  a  distinguished  physician  whether  he  would  see  the  patient,  hop- 
ing that  he  would  discountenance  operation,  for  the  old  gentleman  had 
a  blue,  unhealthy  face,  and  seemed  a  most  uninviting  case.  The  physi- 
cian, who  was  an  optimist,  went  ix>  see  him,  and  gave  me  a  very  good 
report — therefore,  I  had  to  operate.  The  operation  I  chose  was  that  of 
nailing  the  trochanter  to  the  acetabulum,  and  it  scarcely  took  twenty 
minutes.  The  next  day,  the  patient  was  smoking  a  cigarette  and  think- 
ing a  miracle  had  occurred  in  his  case.    You  cannot  lay  down  a  strict 


OPERATIVE  TREATMENT  OP  OSTEOAKTI  IRITIS   OF    HIP-JOINT  161 

rule.  If  the  man  is  old,  you  must  judge  as  to  the  value  of  life  to 
him.  The  pain  in  many  is  so  great  that  some  prefer  to  die  rather  than 
to  continue  life  in  perpetual  pain. 

I  have  had  considerable  experience  of  the  operation  of  excision,  both 
in  old  dislocation  and  for  rheumatoid  arthritis.  In  old  dislocation  the 
head  being  already  displaced,  there  is  no  shock,  as  there  is  in  rheuma- 
toid arthritis. 

In  the  case  of  the  younger  men,  the  removal  of  the  head  of  the  bone, 
leaving  a  fairly  long  neck,  and  covering  the  neck  with  capsule,  makes  a 
very  good  operation  indeed,  and  the  results  of  it  are  very  good.  Again, 
as  Mr.  Tubby  said,  the  after-treatment  must  be  of  such  a  kind  that  all 
weight  must  be  removed  for  a  considerable  time  from  the  bone.  Mr. 
Hey  Groves  mentions  that  one  of  the  drawbacks  of  the  operation  is  that 
there  is  no  stability — the  femur  is  too  much  upwards.  But  this  is  no 
great  disability  when  you  remember  you  have  saved  them  from  a  good 
deal  of  misery  and  they  can  walk  without  inconvenience  and  pain. 

I  recently  saw  a  case  in  which  excision  had  been  done  for  a  man  aged 
forty-five.  He  had  a  rheumatoid  joint  which  was  septic,  and  the  x-ray 
view  showed  it  was  more  the  type  of  pseudo-coxitis,  which  Mr.  Elmslie 
alluded  to,  and  whose  theories  I  can  confirm  from  my  own  experience. 
I  have  seen  many  cases  of  rheumatoid  arthritis  in  which  the  condition 
is  more  suggestive  of  a  changed  head  of  the  bone,  very  much  the  type 
of  change  which  occurs  in  the  young,  and  which  our  distinguished  vis- 
itor, Dr.  Calve,  has  referred  to.  It  has  been  said  that  the  danger 
is  of  our  failing  to  bring  about  movement,  whatever  operation  is  prac- 
tised. The  only  way  to  prevent  this  is  to  remove  plenty  of  bone,  and 
the  orthopaedic  surgeon,  by  training  and  practice,  is  in  a  better  position 
to  secure  motion  to  the  joint  by  his  knowledge  of  the  principles  of  after- 
treatment  than  is  the  average  surgeon. 

Mr.  Alwyn  Smith  drew  attention  to  a  very  tragic  case.  Strangely 
enough,  when  I  was  in  Chicago  last  year,  I  was  asked  to  see  this  case, 
so  I  know  its  subsequent  history.  An  operation  had  been  performed 
at  the  clinic,  but,  unfortunately,  the  hip  again  suppurated.  I  advised  a 
Fabian  policy  for  some  months,  and  then  an  operation  to  produce  move- 
ment by  removing  about  an  inch  of  femur  just  below  the  trochanter. 

I  should  advise  surgeons  to  be  careful  not  to  urge  operations  for  hip 
trouble  on  the  old,  for  one  cannot  promise,  with  any  certainty,  a  pre- 
cise result.  One  should  explain  to  the  patient  the  dangers  of  failure, 
erring  on  the  side  of  pessimism ;  and  when  any  procedure  is  considered, 
let  the  element  of  shock  be  weighed  with  care. 


162  OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OF  HIP-JOINT 

Mr.  Aitken  (in  reply)  :  The  course  which  the  discussion  has  taken 
has  left  very  little  for  me  to  say.  I  am  glad  the  President  has  referred 
to  the  early  treatment  by  manipulation.  In  opening,  I  omitted  to  say 
that  I  think  movement  under  an  anaesthetic,  which  he  recommends  (1 
have  seen  many  cases  with  him)  is  most  suited  to  cases  in  which  there 
is  not  complete  fixation,  where  there  is  a  very  considerable  adduction, 
and  where  the  thrust  along  the  shaft  of  the  femur  by  the  body-weight 
on  that  hip  is  outwards,  the  characteristic  feature  being  that  those  pa- 
tients have  pain  when  walking,  they  get  stiff  after  walking,  and  they 
will  often  tell  you  that  they  are  stiff  in  the  morning!  on  rising.  In  the 
morning,  they  can  walk  a  certain  distance  and  get  better  for  a  time, 
and  then  they  become  worse  again  as  the  strain  comes  on  these  fibrous 
adhesions.  But  Sir  Robert  omitted  to  say  he  sometimes  uses  this  very 
gentle  manipulation  of  the  hip  which  he  practises  to  such  an  extent  that 
he  fractures  the  projecting  osteophytic  outgrowths,  getting  thereby  a 
greater  freedom  of  movement.  If  you' can  secure  enough  clearance  to 
get  the  hip' abducted,  to  get  a  direct  thrust,  the  result  is  satisfactory. 
Those  cases,  after  being  abducted  and  manipulated,  are  not  fixed.  The 
day  after  the  manipulation  movement  is  commenced,  if  possible,  the 
patient  should  be  got  out  of  bed  to  stand  with  legs  apart  and  practise 
abduction.  If  the  patient  has  too  much  pain  forty-eight  hours  after- 
wards to  allow  that  to  be  done,  the  indication  is  that  movement  must 
be  abandoned  and  the  hip  must  be  fixed  in  plaster,  in  an  abducted 
position. 

With  regard  to  Sir  Robert  Jones'  gentle  methods,  I  adopted  them  in 
the  case  of  a  lady  of  63  years,  who  complained  of  the  flexion,  adduction, 
and  extreme  rotation  of  the  thigh.  I  got  abduction  satisfactorily,  and 
easier  than  I  expected  to.  I  got  the  flexion  corrected,  but  the  foot  was 
still  turned  out,  and  I  knew  she  would  not  be  contented  until  I  got  the 
foot  turned  in.  I  got  hold  of  the  thigh  by  the  knee,  and  was  working 
away  with  my  hands,  when  a  snap  occurred,  and  I  found  a  spiral  frac- 
ture of  the  shaft,  immediately  above  the  knee.  The  result  was  ulti- 
Tnately  satisfactory,  because  the  lady  can  flex  her  knee  backwards  and 
forwards,  instead  of  sideways.  I  do  not  recommend  the  method,  it  is  too 
anxious  for  the  surgeon.  It  is  interesting  to  note  free  excision  is  appar- 
ently considered  more  satisfactory  than  an  attempt  at  formal  arthro- 
plasty, so  far  as  we  have  gone  in  this  debate.  In  my  Cripple  Hospital, 
I  get  a  considerable  number  of  pathological  dislocations  of  the  hips  to 
deal  with,  that  is  to  say,  acute  septic  hips  where  the  hips  were  allowed  to 
fall  backwards  while  the  patient  was  in  bed.  In  some  of  them,  after  a 
sufficiently  long  period  after  the  sepsis  has  subsided,  it  is  possible  to  re- 


OPERATIVE  TREATMENT  OF  OSTEOARTHRITIS  OP   HIP-JOINT  163 

move  the  head  of  the  bone  and  reduce  the  heck,  as  if  it  were  a  congenital 
dislocation,  into  the  region  of  the  acetabulum,  putting  them  into  an  ab- 
duction splint.  One  then  gets  a  movable  hip,  which  is  often  wonderfully- 
stable,  with  very  little  tendency  to  get  shortening  of  the  limb  afterwards, 
provided,  first,  the  position  of  abduction  is  maintained  for  a  sufficiently- 
long  time,  and  second,  the  patient  walks  in  a  caliper  splint  for  many 
months  before  attempting  to  walk  without  any  supporting  apparatus. 


164  CORRESPONDENCE 


Correspondence 


Bone  Sarcoma. 

November  22,  1921. 
To  the  Editor: 

Your  correspondent  regrets  not  having  had  the  opportunity  of  discussing 
the  excellent  paper  of  Doctors  Greenough,  Simmons  and  Harmer,  on  Bone 
Sarcoma,  read  at  the  last  meeting  of  the  American  Orthopedic  Association 
and  published  in  the  November  issue  of  the  Journal  of  Orthopcedic  Surgery. 

In  so  far  as  true  bone  sarcomata  are  concerned,  the  conclusions  reached! 
are  clear,  instructive,  and  important. 

Ewing's  classification  of  osteogenetic  sarcomata  must  be  regarded  as  a  de- 
cided step  in  advance,  and  of  special  value  to  the  surgeon,  in  that  it  simpli- 
fies our  conception  of  the  malignant  processes  encountered  in  bone. 

A  study  of  the  second  group  of  cases  is  less  clear.  It  is  rather  difficult 
to  avoid  the  impression  that  the  authors  are1  not  altogether  consistent  when 
they  report  and  classify  twelve  cases  as  being  benign  giant-cell  sarcomata, 
or  tumors,  in  one  part  of  the  paper,  and  in  another  state  that  the  giant-cells 
of  the  foreign-body  type 

"are  of  practically  no  significance  from  the  tumor  point  of  view,  how- 
ever much  they  may  impress  themselves  in  the  microscopic  section  of  the 

tissue." 

Your  correspondent  has  stressed  this  latter  fact  on  many  occasions,  in 
numerous  papers  published  on  the  subject  during  the  last  decade.  The  ap- 
pellation of  "giant-cell"  to  these  lesions  seems  to  be  as  much  out  of  place 
as  the  term  "rheumatism"  is  to  the  arthritides.  Long  usage  of  the  term 
should  not  be  an  excuse  for  continuing  the  misnomer. 

If  we  wish  to  be  scientifically  accurate,  it  is  impossible  to  regard  these 
lesions  as  "giant-cell"  tumors.  In  so  far  as  our  present-day  knowledge  goes, 
the  giant-cells  have  nothing  in  common  with  tumor  formation.  Giant-cell 
distribution  is  never  uniform  in  these  lesions,  and  may  not  be  said  to  dom- 
inate the  entire  mass.  Some  areas  may  contain  an  abundance  of  these  cells, 
while  other  areas  in  the  mass  have  few,  or  even  none. 

The  tissue  the  process  exhibits,  when  examined  in  the  gross,  gives  all  the 
criteria  we  possess  of  proliferating  granulation  regenerative  structure,  fre- 
quently containing  areas  showing  metaplasia.  Microscopic  studies  of  the 
tissue  confirm  this  evidence  of  an  inflammation. 

Masses  of  granulation  tissue  occurring  in  other  connective  tissues  in  the 
body  are  not  generally  regarded  as  tumors.  It  would  therefore  seem  that 
they  should  not  be  so  regarded  when  found  in  bone.  Should  a  blastoma 
arise  in  the  mass,  the  type  tissue  it  represents  is  the  one  to  be  recorded. 

If  the  cellular  pathology,  as  well  as  the  gross  living  pathology,  is  nega- 
tive for  autonomous  growth,  there  seems  to  be  no  escape  from  the  conclu- 


CORRESPONDENCE  165 

sion  that  the  lesion  must  be  described  and  regarded  as  an  osteomyelitis. 
Usually,  at  operative  interference,  the  process  is  found  to  be  extremely 
vascular.  The  term,  hemorrhagic  osteomyelitis,  is  used  in  describing  such 
cases.  The  lesion  may  readily  be  produced  by  aseptic  traumatic  insult  to 
bone. 

A  personal  study  of  forty  cases  (exclusive  of  the  bones  of  the  skull,  face 
or  spine)  that  have  been  observed  coincides,  in  their  clinical  pictures,  in 
most  respects,  with  the  findings  of  the  authors  of  the  paper.  In  our  series" 
trauma  appears  to  have  been  the  etiologic  factor  in  75  per  cent,  of  cases. 

In  no  instance  where  ossification  has  not  occurred,  has  there  been  pene- 
tration of  the  epiphyseal  cartilage.  Indeed,  it  has  been  one  of  our  diagnos- 
tic aids  from  the  x-ray  viewpoint,  that  if  epiphyseal  cartilage  was  pene- 
trated, a  diagnosis  of  suppurative  infection  might  safely  be  made,  providing 
other  evidences  of  malignancy  were  absent.  Where  ossification  had  occurred, 
epiphyseal  ends  of  bone  were  commonly  involved. 

The  age  of  our  patients  has  varied  from  18  months  to  63  years.  A  ma- 
jority of  the  lesions  have  occurred  in  the  lower  extremities.  Operations  were 
performed  upon  27  patients;  in  only  one  of  the  number  was  the  operation 
more  severe  than  curetting.  The  sizes  of  the  lesions  ranged  from  those  of 
H  lima  bean,  cherry,  egg,  and  orange,  to  a  grapefruit. 

George  Barrie. 
New  York  City. 


166  NEWS  NOTES 


News  Notes 


The  British  Orthopaedic  Association  has  chosen  the  following  officers  for 
the  coming  year: 

Sir  Robert  Jones,  President;  Mr.  H.  A.  T.  Fairbank,  Vice-President; 
Mr.  W.  R.  Bristow,  Treasurer;  Mr.  E.  C.  Elmslie,  Secretary;  Mr.  Harry 
Piatt,  Editorial  Secretary. 

Government  Need  for  Workers  in  Rehabilitation. 

Washington,  D.  C,  December,  1921. 

The  United  States  Civil  Service  Commission  states  that  there  is  urgent 
need  for  reconstruction  assistants  and  aides  in  physiotherapy  and  occupa- 
tional therapy,  trained  nurses,  and  physicians,  to  serve  in  hospitals  and  other 
establishments  of  the  United  States  Public  Health  Service  and  the  Veterans* 
Bureau,  in  the  care  and  rehabilitation  of  men  injured  in  the  World  War. 
The  Commission  has  announced  that  it  will  receive  applications  for  these 
positions  until  further  notice.  The  applicants  will  not  be  given  written 
scholastic  tests,  but  will  be  rated  upon  their  education,  training,  experience, 
and  physical  ability. 

The  Commission  points  out  the  importance  of  filling  these  positions 
promptly,  with  the  best  qualified  workers  available. 

Full  information  and  application  blanks  may  be  obtained  from  the  United 
States  Civil  Service  Commission,  Washington,  D.  C,  or  from  the  Secretary 
of  the  Local  Board  of  Civil  Service  Examiners  at  the  postoffice  or  custom- 
house in  any  city. 

British  Orthopaedic  Association.     Meeting  at  Oswestry. 

A  clinical  meeting  of  the  British  Orthopaedic  Association  was  held  at  the 
Shropshire  Orthopaedic  Hospital,  Oswestry,  on  September  24th,  1921.  This 
Hospital,  formerly  situated  at  Baschurch,  and  so  well  known  as  the  pioneer 
among  country  orthopaedic  hospitals,  has  recently  removed  to  larger  premises 
at  Oswestry.  Although  the  staff  has  been  considerably  increased,  Miss  Hunt, 
with  whose  name  the  hospital  has  always  been  identified  in  the  past,  remains 
the  chief  organizer. 

At  the  meeting  on  Friday,  Sir  Robert  Jones  demonstrated  a  number  of 
<*ases  in  the  wards,  the  following  being  a  few  of  those  which  were  of  special 
interest : — ■ 

(1)  Very  severe  rickety  deformities  of  the  lower  limbs,  with  extreme 
bowing  of  the  shafts  of  the  femora  and  tibiae,  which  have  been  treated  by 
osteotomies  in  the  middle  of  these  bones,  and  after  application  of  caliper 
walking  instruments.  Sir  Robert  emphasized  the  necessity  for  preliminary 
treatment  by  general  hygiene  and  by  moulding  the  badly  curved  bones  by 
fixation  upon  a  frame,  the  objection  to  correcting  an  anterior  curvature  of 
the  tibiae  fully,  because  in  so  doing  one  is  very  apt  to  produce  an  apparent 
genu  recurvatum,  and  finally  the  necessity  for  the  use  of  walking  splints 
for  a  considerable  period  after  osteotomies,  to  prevent  recurrence. 


NEWS  NOTES  167 

(2)  A  girl  of  12,  with  paralytic  dislocation  of  the  right  hip,  the  limb 
muscles  being  fairly  good  and  practically  all  active.  The  shortening  of  the 
limb  was  4%  inches.  Sir  Robert  Jones  discussed  the  possibility  of  length- 
ening the  femur  in  such  a  case  by  stepping  operation,  and  stated  that  he 
had  secured  as  much  as  three  inches  of  additional  length  in  this  way.  He 
recounted  a  story  of  how  an  operation  in  which  he  shortened  the  sound  limb 
of  a  patient  in  order  to  render  the  two  limbs  approximately  equal  in  length, 
proved  so  successful  as  to  lead  to  his  being  offered  the  post  of  surgeon  to 
the  Manchester  Ship  Canal  at  the  time  when  it  was  being  built. 

(3)  A  girl  of  17,  with  old-standing  infantile  paralysis,  involving  com- 
plete loss  of  the  deltoid  muscle,  in  which  an  arthrodesis  of  the  shoulder- joints, 
performed  four  years  before,  had  resulted  in  a  very  great  improvement  of 
function,  so  that  the  arm  was  useful  for  all  purposes  below  the  level  of  the 
ear.  The  warning  was  given  against  arthrodesing  the  shoulder  in  an  adult 
in  too  great  abduction,  so  that  the  patient]  is  unable  afterwards  to  bring  the, 
arm  to  the  side,  a  very  ugly  deformity  remaining. 

(4)  A  case  of  bi-lateral  congenital  dislocation  of  the  hips  in  a  girl  of 
13,  with  very  severe  lordosis  and  limitation  of  abduction.  X-rays  showed 
well  marked,  false  acetabula,  and  treatment  by  osteotomy  to  secure  abduc- 
tion and  lessen  lordosis,  was  suggested.  Sir  Robert  referred  to  a  case  of 
his  in  a  woman  of  32,  with  congenital  dislocation,  who  walked  extremely 
badly,  with  adducted  hips,  like  the  very  worst  type  of  coxa  vara.  S<he  wasi 
treated  first  by  a  forcible  abduction,  which  produced  a  temporary  paralysis 
of  the  sciatic  nerve;  then  a  wedge-shaped  osteotomy  was  done,  which  re- 
sulted in  a  very  great  improvement,  so  that  she  was  able  to  walk  welL  Sir 
Robert  had  several  times  shown  her  to  visiting  surgeons,  but  upon  the  last 
occasion  that  she  was  shown,  she  had  been  emphatic  in  stating  that  the 
chief  improvement  which  had  taken  place  in  her  condition  occurred  after 
she  had  become  a  Christian  Scientist! 

(5)  A  boy  with  infantile  paralysis  of  the  left  upper  limb,  in  whom  with 
a  flail  shoulder  and  elbow,  the  hand  had  been  quite  good.  He  had  been 
treated  by  arthrodesis  of  the  shoulder  and  by  the  stitching  together  of  skin 
flaps  in  front  of  the  elbow,  so  as  to  maintain  flexion  of  this  joint.  Very 
good  power  and  active  flexion  of  the  elbow  had  become  established,,  and  the 
skin  flaps  had  greatly  stretched  out,  so  that  at  the  present  time  the  elbow*  is 
actively  useful,  and  in  front  of  it  is  a  tubular  portion  of  skin  attached  to 
the  arm  and  forearm,  with  a  tunnel  between  it  and  the  elbow. 

Following  this,  Mr.  Naughton  Dunn  described  an  operation  which  he  is  at 
present  performing  for  severely  paralyzed  feet.  He  pointed  out  that  in  these 
cases  there  is  a  tendency  to  go  on  for  years  correcting  deformity  as  it  super- 
venes, and  using  instrumental  support,  and  that  the  factors  of  unequal  bal- 
ance of  muscles  and  of  the  body-weight  action  upon  lax  joints  cause  a  con- 
stant tendency  to,  or  progress  of,  deformity.  The  object  of  his  operation  is  to 
reduce  mobility  by  joint  fixation,  so  that  the  tarsal  joints  are  abolished  and 
the  foot  moves  at  the  ankle  as  one  structure  at  a  single  hinged  joint.  The 
muscles  remaining  can  then  be  re-distributed,  so  that  they  act,  as  before,  as 
flexors  or  extensors  of  this  joint.  The  operation,  consisting  of  excision  of  the 
scaphoid  and  of  the  articular  surface  of  the  os  calcis,  astragalus,  cuneiforms 
and  cuboid,  and  the  displacement  of  the  foot  backwards  beneath  the  as- 
tragalus, will  be  described  in  detail  by  Mr.  Dunn.  A  large  number  of  illus- 
trative cases  were  shown  to  the  meeting. 


168  NEWS   NOTES 

Mr.  Girdlestone  explained  the  general  principles  and  details  of  the  methods 
of  treatment  of  spinal  caries  used  in  the  Hospital,  discussing  the  period  re- 
quired before  the  patient  could  be  said  to  be  cured.  He  concluded  that  tests 
•of  mobility  of  the  spine  are  useless,  and  that,  apart  from  the  general  condi- 
tion of  the  patient  and  the  absence  of  abscess,  the  best  test  that  ai  patient  is 
in  a  safe  condition  and  may  be  allowed  to  get  up  is  an  x-ray  of  the  spine, 
which  demonstrates  that  there  is  a  sound  bone  scar  at  the  site  of  the  disease. 
Mr.  Girdlestone  showed  a  number  of  cases  in  which  the  spine  had  been  fixed 
by  a  bone  graft  or  by  a  modification  of  Hibbs'  method. 

Mr.  Macrae  Aitken  demonstrated  a  correction  in  plaster  of  a  case  of  kypho- 
lordosis  and,  a  case  of  scoliosis,  using  Abbott's  frame,  and  a  demonstration 
was  held  in  the  gymnasium,  illustrating  the  methods  of  treatment  of  scoli- 
osis by  gymnastic  exercises  adopted  in  the  Hospital.  The  most  interesting 
feature  in  these  exercises  was  the  use  of  deep  breathing  inj  positions  which, 
tended  to  fix  the  convex  side  of  the  chest  as  a  means  of  rotating  the  verte- 
brae. That  rotation  can  be  secured  by  such  breathing  movements  could  be 
clearly  seen  in  the  children  shown. 

In  the  afternoon,  visits  were  paid  to  some  of  the  After-care  Centres.  A 
number  of  these  have  been  established  throughout  the  county  of  Shropshire. 
The  children  under  observation  or  treatment  attend  one  day  in  each  week — 
preferably  on  market  day.  They  are  seen  weekly  by  the  visiting*  nurse  and 
once  a  month  by  a  medical  officer  from  the  Orthopaedic  Hospital.  Records, 
including  photographs  and  plaster  casts,  are  kept  at  the  After-care  Centres*, 
measurements  for  splints  and  appliances  made,  and  simple  plaster  applica- 
tions made  at  these  centres. 

On  September  25th,  a  series  of  operations  was  performed,  namely,  (1)  Al- 
bee's  operation  for  spinal  caries,  by  Mr.  Girdlestone;  (2)  osteotomy  for  mal- 
union  of  fracture  of  the  femur,  by  Mr.  Aitken;  (3)  stabilizing  operation 
upon  a  paralyzed  foot,  by  Mr.  Dunn ;  (4)  correction  of  a  club-foot  in  a  child 
of  seven,  with  the  wrench,  by  Sir  Robert  Jones;  (5)  Soutter's  operation  for 
displacement  of  the  anterior  superior  spine  of  the  ilium  as  a  means  of  cor- 
rection of  flexion  of  the  hip,  by  Mr.  Noble. 

The  meeting  was  attended  by  about  fifty  members  and  visitors. 


Interurban  Orthopaedic  Club  Meeting. 


The   meeting  of   the  Interurban   Orthopaedic    Club    was  held  in   Toronto, 
on  December  2d  and  3d.     The  program  was  as  follows: 

FRIDAY,    DECEMBER    2nd,    1921 
HOSPITAL    FOR    SICK    CHILDREN 

9.00  A.M.  R.     I.     HARRIS. 

A   case  of  Volkmann's   Contracture,   in   which 

no  splints  or  bandages  had  been  applied. 
Erb's   Palsy. 

D.    E.    ROBERTSON. 

A  case  of  sarcoma  of  the  scapula. 
A  case  of  sarcoma  of  the  skull. 


NEWS  NOTES  169 

Fragilitas  Ossiuni. 

Cases  of  an   unknown   epiphyseal   di>«*ase. 

Diamond   bone   grafts. 

BRUCE     ROBERTSON. 

Pedunculated  skin  grafts. 

An  undescribed  condition  of  condensing  oste- 
itis of  the  body  of  a  vertebra,  simulating 
Pott's  Disease,  resembling  Kohler's  disease 
of  the   navicular  bone. 

Rickets   extraordinary. 

Exsanguination  combined  with   blood  transfu-  ■ 
sion  in  the  treatment  of  toxaemias. 

Infantile  paralysis   involving  the  neck. 

A.    B.    LEMESURIER. 

Comparison  of  the  methods  of  treating  frac- 
tures of  the  femur  in   children, 
c.     L.     STARR. 
The  treatment  of  tuberculous  abscess. 
An  unusual  tumour  of  the  forearm. 
12.30  p.m. 

Luncheon  at  Hospital  for  Sick  Children. 
1.15  p.m. 

Executive   Session. 
2.00  p.m. 

christie  street  hospital soldiers. 

Inspection  of  sunlight  treatment  of  tuberculo- 
sis of  bones  and  joints. 

C.     L.     STARR. 

Unusual  cases  of  bone  tuberculosis. 
Bone  grafts. 
Tendon   Transfers. 

R.     I.     HARRIS. 

Sunlight  and  alpine  lamp  treatment  of  tuber- 
culosis. 

Granuloma  Inguinale. 

Difficulties  and  failures  in  the  treatment  of 
non-union    of   the   tibia. 

Cases  illustrating  the  results  of  nerve  sutures. 

W.  E.  GALLIE  AND  A.  B.  LEMESURIER. 

Operation  for  rupture  of  ligament  of  patella. 

A.    B.    LEMESURIER. 

Unusual  amputation  cases. 
4.45  p.m. 

Tea  with  the  Nurses. 
7.00  p.m. 

Resuscitation  at  the  homes  of  Dr.   Starr,  Dr. 
D.  E.  Robertson  and  Dr.  Gallic 
7.30  p.m. 

Dinner  at  York  Club. 


170  NEWS   NOTES 


SATURDAY,  DECEMBER   3rd,   1921 
HOSPITAL  FOR  SICK  CHILDREN. 

9.00   A.M.  W.    E.    GALLIE. 

Old  tendon  fixations. 

An  operation  for  infantile  paralysis  involv- 
ing  the   shoulder. 

Living  sutures  in  the  treatment  of  ptosis. 

Living  sutures  in  the  treatment  of  hernia. 

An  operation  for  the  eure  of  rupture  of  the 
ligamentum  patellae. 

An  operation  for  the  cure  of  lateral  disloca- 
tion  of  the  patella. 

An  operation  for  the  relief  of  non-union  of  the 
patella. 

The  prevention  of  forward  displacement  of  the 
foot  following  astragalectomy. 

Fractures  in  bone  grafts. 

TORONTO    GENERAL   HOSPITAL. 

11.00  A.M.  C.  L.   STARR. 

Spasmodic  torticollis. 
Sarcomas  of  femur  and  fibula. 

N.     S.     SHENSTONE. 

An  extraordinary  case  of  bone  transplantation. 

G.     E.     WILSON. 

Treatment  of  compound  fracture  of  the 
humerus. 

G.    E.    RICHARDS. 

Radium  and  high  voltage  x-ray  in  treatment  of 
tumours  of  bone. 
1.00  p.m. 

Luncheon  at  Hart  House. 

MEDICAL  BUILDING, 

DEPARTMENT    OF    PHYSIOLOGY. 
2.00  P.M.  J.   J.   R.   MACLEOD. 

Experimental  study  of  the  influence  of  local  ap- 
plications of  heat  and  cold  on  the  deep  tem- 
peratures. 

N.     B.     TAYLOR. 

Changes  in  peripheral  blood-flow,  resulting 
from  massage,  movements,  etc. 

2.00   P.M.  J.   J.   R.    MACLEOD. 

Experimental  study  of  the  influence  of  massage 
and  electrical  stimulation  of  the  muscles  in 
lesions  of  the  lower  neurone. 


NEWS  NOTES  171 

The  case  of  Volkmann's  Contracture,  demonstrated  by  Harris,  wa* 
interesting,  in  that  the  typical  symptom  complex  appeared  in  this  case- 
without  there  having  been  the  slightest  question  of  constriction  from  splints, 
in  a  case  of  fracture  of  the  elbow,  associated  with  a  large  haematoma, 
Medico-legally  the  question  is  often  raised  as  to  whether  true  Volkmann's 
Contracture  can  occur  from  the  trauma  alone  without  the  possibility  of 
too  tight  splinting  as  a  cause  of  lesion.  This  case  seems  to  demonstrate 
beyond  cavil  that  such  typical  symptoms  can  occur  from  injury  alone. 

Dr.  Starr  presented  data  to  show  that  the  treatment  of  tuberculous  ab- 
scesses by  early  free  incision  at  the  least  dependent  portion  of  the  abscess 
through  healthy  tissue,  the  curetting  of  the  sac,  and  the  swabbing  out  with 
gauze,  results  in  a  permanent  closure  in  a  great  majority  of  cases.  The 
method  has  been  continued  for  over  ten  years  at  the  Hospital  for  Sick 
Children  and  is  still  being  pursued  with  entire  satisfaction  by  members 
of  the  Staff. 

Dr.  Harris's  demonstration  of  the  value  of  sunlight  treatment  in  tu- 
berculosis of  bones  and  joints  in  adult  soldiers  was  very  convincing  and 
seemed  to  prove  beyond  question  the  great  value  of  this  treatment,  perhaps 
supplemented  during  the  winter  months  by  alpine  lamp  therapy.  It  is  his 
opinion  that  while  the  .alpine  lamp  may  be  an  adjuvant,  its  comparative  value 
with  natural  sunlight  was  much  less. 

Dr.  Starr  also  demonstrated  many  cases  where  the  diamond-shaped  bone 
graft  had  been  employed  with  great  success.  The  cone-like  ends  of  the 
host  bone  on  each  side  of  the  graft  are  split  with  a  saw,  flared  with  an 
osteotome,  and  the  diamond  bone  graft  inserted,  the  greatest  thickness  of 
the  graft  coming  at  the  center  of  the  gap  in  the  place  where  strength  is 
most  needed.  Dr.  Starr  also  demonstrated  many  cases  of  successful  ten- 
don transplantation  for  irreparable  injury  to  the  musculospjral  nerve. 

The  operation  by  Dr.  Gallie  and  Dr.  LeMesurier  for  rupture  of  the  liga- 
ment of  the  patella  convincingly  demonstrated  the  value  of  the  use  of  living 
sutures.  A  portion  of  the  tendo  Achillis  and  the  plantaris  tendon,  inserted 
into  the  patella  and  tibial  tubercle  by  firm  bony  fixation,  seemed  to  repair 
in  a  completely  satisfactory  manner  the  ruptured  ligament. 

At  the  dinner  on  Friday  evening  there  was  a  long  discussion  of  the  meth- 
ods of  teaching  Orthopaedic  Surgery  in  the  medical  schools.  A  committee- 
had  been  appointed  at  a  previous  meeting,  consisting  of  Dr.  W.  E.  Gallie, 
Dr.  W.  S.  Baer,  and  Dr.  R.  B.  Osgood.  Outlines  of  orthopaedic  teaching 
at  present  in  vogue  in  all  the  principal  medical  schools  in  the  country 
had  been  received  in  response  to  a  questionnaire  sent  out  by  this  committee. 
Expressions  of  opinion  from  the  leading  professors  in  orthopaedic  surgery 
were  also  reviewed.  As  concrete  suggestions  there  seems  to  be  a  unanimity 
of  opinion  in  the  Club  that  in  the  second  and  third  years  the  teaching]  of 
orthopaedic  surgery  should  be  as  closely  connected  with  general  surgery 
as  possible,  perhaps  even  not  being  taught  as  a  separate  subject,  but  as  a 
definite  part  of  general  surgery,  clinical  and  didactic  exercises,  these  exer- 
cises given  in  conjunction  with  the  courses  and  clinics  in  general  surgery 
by  men  specially  trained  in  extremity  and  spinal  surgery;  that  in  the  fourth 
year  there  might  well  be  a  clinico-didactic  course  covering  the  subjects 
of  congenital  malformations,  static  deformities,  old  bone  and  joint  deform- 
ities, bodily  mechanics,  the  mechanics  of  function,  etc,  and  certain  other 
conditions  which  do  not,  as  a  rule,  come  within  the  purview  of  the  general 
surgeon. 

On  Saturday  morning  Dr.  Gallie,  in  the  opinion  of  the  Club,  convinc- 
ingly demonstrated  the  permanent  value  of  his   method  of  tendon  fixation* 


172  NEWS  NOTES 

and  use  of  living  sutures  of  fascia  and  tendon  by  an  exhibition  of  many 
patients  upon  whom  operations  had  been  performed. 

A  demonstration  of  the  apparently  curative  value  of  high  voltage  roent- 
gen ray  radiation  in  certain  very  unusual  and  extensive  bone  neoplasms 
was  presented  by  Dr.  G.  E.  Richards,  roentgenologist  of  the  Toronto  Hos- 
pital. 

Professor  MacLeod's  report  of  the  experimental  study  of  the  influence 
of  local  applications  of  heat  and  cold  on  the  temperatures  of  deep  struc- 
tures was  extremely  interesting.  It  was  evident  that  the  temperature  of 
most  deeper  structures  could  be  influenced  by  the  application  of  heat  and 
cold  externally.  His  experimental  evidence  also  seemed  to  show  that  in 
cases  of  paralysis  due  to  nerve  injury  electricity  and  even  massage  was  of 
apparently  little  value  in  hastening  regeneration  of  muscle  power. 


CURRENT   ORTHOPAEDIC  LITERATURE  173 


Current  Orthopaedic  Literature 


BONE  OPERATIONS 

Cebtain  Fundamental  Laws  Underlying  Surgical  Use  of  the  Bone  Graft. 
F.  H.  Albee.    Annals  of  Surgery,  Aug.,  1921,  p.  196. 

The  author  enumerates  various  methods  which  are  being  used  for  the  treat- 
ment of  pseudarthrosis,  such  as  injection  of  blood  into  the  site  of  the  lesion, 
Bier's  hyperaemia,  deep  massage  to  promote  healthy  circulation,  and  fixation 
of  the  fragments  by  means  of  metal  appliances.  During  the  past  twelve  years 
he  has  studied  many  cases  in  which  one  or  more  of  the  above  forms  of  treatment 
have  been  carried  out,  and,  as  a  result,  he  believes  that  all  such  non-operative 
procedures,  and  particularly  operative  method  involving  the  introduction  of 
metal,  have  no  place  in  the  consideration  of  the  proper  treatment  of  pseudar- 
throsis. 

The  bone  graft  operation  is  the  only  method  offering  a  solution  of  the  problem, 
and  the  inlay  technique  is  the  most  trustworthy  one.  In  order  that  the  funda- 
mental laws  pertaining  to  tissue  transplantation  be  fulfilled,  the  graft  must 
consist  of  all  four  layers,  namely,  periosteum,  compact  bone,  endosjteum  and 
marrow. 

The  osteoperiosteal  graft  fails  because  of  its  lack  of  rigid  continuity,  and  is, 
therefore,  incapable  of  furnishing  fixation.  By  nature  of  its  removal  it  cannot 
be  a  complete  osteogenetic  unit.  Since  it  does  not  possess  rigid  continuity,  and 
is,  therefore,  incapable  of  bearing  mechanical  stress,  its  metabolism  and  bone 
growth  are  not  influenced  by  tha,t  powerful  stimulus  of  withstanding  mechanical 
stress  with  fracturing.  In  place  of  the  osteoperiosteal  graft  the  author  uses 
his  so-called  "sliver  graft"  which  consists  of  a  thin  slice  of  bone  containing  all 
layers. 

The  author  advises  that  before  deciding  to  operate  on  cases  of  pseudarthrosis, 
one  should  resort  to  rough  manipulation  of  the  fragments,  deep  massage,  possibly 
a  two-stage  operation,  in  order  to  avoid  a  recrudescence  in  cases  which  have 
been  infected.  Other  points  which  are  essential  to  success  are  that  the  operation 
should  be  of  short  duration  and  that  the  operator  should  plan  his  incision 
through  the  skin  so  that  it  does  nqt  overlie  the  bed  of  the  graft.  The  graft 
should  be  long  enough  if  possible  to  extend  into  each  fragment  for  a  distance  of 
five  cm.,  and  it  should  always  extend  beyond  the  eburnated  end  of  the  fragments. 
The  graft  should  be  held  in  place  by  absorbable  sutures. 

The  author  emphasizes  the  importance  of  post-operative  fixation  and  he  advo- 
cates a  plaster  of  Paris  spica  in  order  to  immobilize  both  shoulder  and  elbow. 
He  uses  absorbable  skin  sutures  to  avoid  disturbance  of  fixation. — LeRoy  C. 
Abbott,  Ann  Arbor,  Michigan. 


174  CURRENT  ORTHOPAEDIC   LITERATURE 


JTunction  in  Relation  to  Transplantation  of  Bone.     S.  L.  Haas.     Annals  of 
Surgery,  Sept.,  1921,  p.  425. 

In  order  to  determine  the  role  played  by  function  in  the  growth  of  bonei 
independently  of  all  other  factors,  the  author  performed  a  series  of  experiments 
on  dogs.  In  one  of  the  series  of  experiments  he  removed  the  first  metatarsal 
bone  and  replaced  it  in  its  normal  bed,  and  in  the  second  series  he  removed  the 
metatarsal  bone  and  transplanted  it  into  the  deep  muscles  of  the  back.  Function 
is  then  established  by  allowing  the  dogs  to  run  about  and  observations  were 
made  at  periods  varying  from  48  days  to  three  years.  The  conclusions  arrived 
at  were : 

1.  Function  exerts  definite  influence  on  the  viability  of  a  transplanted  bone. 

2.  Free  bone  transplants  when  subject  to  stimulation  of  normal  function 
undergo  a  slower  degeneration  than  similar  transplants  that  are  not  under  such 
functional  influence. 

3.  Bone  transplants  from  old  animals  are  more  resistant  to  absorption  and 
degenerative  processes  than  those  of  young  animals. 

4.  From  a  practical  standpoint  the  institution  of  function  at  the  earliest 
possible  moment  is  advisable  in  order  to  aid  in  insuring  success  in  the  operation 
involving  transplantation  of  bone,  but  this  early  function  should  not  be  estab- 
lished if  it  jeopardizes  the  possibility  of  bony  union  between  the  transplant  and 
the  host,  a  condition  that  is  essential  and  of  prime  importance. — LeRoy  C.  Abbott, 
Ann  Arbor,  Mich. 


The  Plastic  Substitution  of  the  Thumb,  Especially  in  Cases  of-  Loss  of 
the  Entire  Thumb  and  Metacarpal.  Perthes.  Arch.  Orch.  und  Unfallchir., 
xix,  2,  July,  1921. 

In  a  short  review  of  the  subject,  the  author  mentions  the  two  methods  of 
Nicoladoni.  In  the  first  method,  the  thumb  is  reconstructed  by  means  of 
pedicled  flaps  from  the  skin  of  the  abdomen,  into  which  a  piece  of  the  tibia,  a 
phalanx,  or  a  piece  of  a  resected  rib,  is  implanted. 

The  second  method  supplants  the  thumb  by  the  toe,  usually  the  big  toe  of  the 
contralateral  foot. 

Another  method  is  the  formation  of  cleft,  using  the  preserved  first  metacarpus 
as  a  substitute.  No  mention  is  made  in  this  connection  of  the  Italian  phalan- 
gization method  (Putti). 

Finger  exchange  is  another  method,  used  first  by  Luksch  in  1908  and  later 
perfected  by  Spitzy.  (Here  also  notable  achievements  of  technique,  especially 
the  work  of  Joyce  and  others,  is  left  unmentioned. )  Another  method,  little 
known  and  little  applied,  is  the  torsion  of  remaining  fingers  by  osteotomy  of  the 
2nd  and  5th  metacarpals,  by  which  the  index  and  little  fingers  are  twisted  so 
that  their  respective  volar  surfaces  approach  each  other.  In  the  thumb  plasty 
concerning  cases  with  preserved  first  metacarpal,  the  author  uses  the  method 
of  phalangization,  or  cleft  method  as  he  calls  it. 

Several  cases  are  reported  and  good  results  demonstrated  in  photographs. 

In  cases  of  loss  of  both  thumb  and  its  metacarpal,  of  which  the  author  reports 
three,  a  phalangization  of  the  2nd  metacarpal  is  carried  out  by  incisions  running 


CURRENT  ORTHOPEDIC   LITERATURE  175 

Tip  on  the  dorsal  and  volar  surface  in  such  a  manner  as  to  furnish  sufficient 
skin  for  the  new  thumb,  while  the  covering  of  the  surface  toward  the  third 
metacarpal  is  taken  care  of  by  a  pedunculated  flap  from  the  chest.  An  im- 
portant point  is  torsion  of  the  metacarpal  which  is  obtained  by  osteotomy. 
Careful  use  is  made  of  the  pro«orved  tonflOM  of  the  fingers,  the  flexors  being 
used  as  adductors  and  the  extensors  as  abductors.  The  operation  can  be  carried 
out  in  one  sitting. 

In  all  three  cases,  of  total  loss  of  ,thumb  and  metacarpal,  the  results  were 
so  encouraging  that  the  author  recommends  the  procedure  as  routine  for  similar 
defects.  He  considers  this  method  superior  not  only  to  the  first  Nicoladoni 
method  with  pedunculated  flap,  in  which  no  movable  thumb  is  obtained,  but  also 
superior  to  his  second  method  of  supplanting  the  missing  thumb  by  the  big  toe. — 
A.  Steindler,  Iowa  City,  la. 


Results  of  the  Supracondylar  Osteotomy  in  Flexion  Contractures  of  the 
Knee  Joint.    I,.  Aubry.    Zeit .  orth.  Chir.,  Vol.  4 ;  Nos.  1,  2 ;  April,  1921. 

Oilier  was  the  first  who  applied  supra-condylar  osteotomy  for  the  correction  of 
flexion  contractures  of  the  knee  joint. 

The  number  of  supra-condylar  osteotomies  carried  out  at  the  Munich  Ortho- 
pedic Clinic  of  Lange  in  the  last  thirteen  years  amounted  to  104.  Only  in  40 
cases  was  it  possible  to  check  up  upon  the  result  of  the  operation.  The  largest 
group,  of  ankylosis  and  contracture  of  the  knee,  is  represented  by  tuberculosis 
(63  cases)  ;  this  is  followed  by  poliomyelitis  (24  cases). 

The  time  between  the  beginning  of  the  disease  and  operation  varied  between 
one  and  20  years,  the  largest  number  falling  between  two  and  eight  years.  All 
degrees  of  flexion  contracture  were  represented. 

Before  the  operation,  the  ability  to  walk  was,  in  the  overwhelming  majority 
of  cases,  poor.  A  large  number  walked  on  crutches  and  seven  walked  on  their 
hands. 

The  osteotomy  was  carried  out  in  different  ways,  as  straight,  curved,  or 
V-shaped  osteotomy.  In  a  large  number  of  cases,  a  V-shaped  piece  was  removed 
in  order  to  facilitate  correction. 

Tenotomies  of  the  flexor  muscles  preparatory  to  the  osteotomy  were  not 
carried  out. 

The  after-treatment  consisted  in  the  usual  application  of  a  plaster  cast,  includ- 
ing ankle  and  hip  joints,  and  remaining  from  four  to  six  weeks.  Then  a  lighter 
cast  was  applied,  the  patients  being  allowed  to  walk  after  the  sixth  week. 
Complete  weight-bearing  was  gradually  permitted  before  the  completion  of  one 
year. 

Regarding  the  final  results,  reports  were  on  hand  on  94  patients.  In  63 
operations  the  position  of  180°  to  170°  remained.  In  16,  a  flexion  of  from 
170°  to  160°  developed,  and  10  went  below  160°. 

In  four  patients,  the  operation  had  to  be  repeated  because  of  the  recurrence 
of  the  flexion  contracture.    These  were  all  cases  of  tuberculous  knee  disease. 

The  ability  to  walk  was  improved  in  all  cases  and,  in  the  great  majority  of 
cases,  considerably  so. 

Of  40  cases  in  which  the  late  results  were  ascertained,  22  cases  were  observed 
not  less  than  two  years  after  the  operation ;  in  the  remainder  the  periods  varied 


176  CURRENT  ORTHOPEDIC   LITERATURE 

from  three  months  to  two  years.  Of  the  40  cases,  29  were  tuberculous.  Of 
these,  14  showed  complete  extension,  6  slight,  and  9  distinct  flexion. 

In  nine  cases  of  poliomyelitic  contracture  with  11  operations,  the  extension 
remained  completely  in  10  operations.  Twenty-two  of  the  40  cases  walked  with 
braces  and  18  without. 

Of  the  22  cases  examined  two  years  or  more  after  operation,  the  extension 
was  completely  preserved  in  16;  flexion  of  more  than  170°  secured  in  six 
cases.  There  is  a  preponderance  of  tuberculosis  cases  among  those  which  show 
a  tendency  to  recurrence. 

Conclusions :  The  supracondylar  osteotomy  in  flexion  contracture  of  the 
knee-joint  gives,  in  the  vast  majority  of  cases,  good  results.  Recurrences  were 
observed  only  in  4%  of  the  cases.  The  operative  results  wetre  preserved  by 
the  wearing  of  braces  for  several  years  after  the  operation,  and  the  author 
believes  that  this  precaution  is  absolutely  necessary.  The  osteotomy  should 
be  carried  out  as  close  as  possible  above  the  condyles.  A  correction  after 
osteotomy  is  not  altogether  accomplished  at  the  place  of  bone  operation,  but 
also  partly  intra-articular  by  compression  of  the  epiphyses.  There  is  a  danger 
of  spur  formation  by  sliding  of  the  fragments.  The  external  configuration  as 
well  as  the  internal  architecture  of  the  bone  becomes  greatly  changed  by  adaptive 
processes  consisting  in  apposition  and  absorption.  Entirely  new  trabeculae 
develop  in  the  interior  of  the  bones. — A.  Steindler,  Iowa  City,  Iowa. 


Cineplastic  Surgery  of  the  Upper  Extremity.    F.  M.  Cadenat.    Revue  d' Ortho- 
pedic, January,  1921. 

This  is  a  review  of  the  cineplastic  literature  to  date.    Historical : 

The  author  mentions,  first,  efforts  of  Vanghetti,  1896-1898,  followed  in  1900 
by  Oeci;  in  Italy;  also  those  of  de  Francesco,  Codivilla,  Fieri,  Futti,  Delitala, 
and  others;  in  Germany,  Wreden,  Sauerbruch,  Krukenberg;  in  France  the 
method  has  been  long  ignored,  the  judgment  in  1917  being  still  adverse  to  this 
method. 

Principles  of  cinematization :  The  method  may  be  carried  out  by  (a)  loop, 
(o)  club  formation.  The  loop  may  be  terminal,  that  is,  at  the  extremity  of 
the  stump  or  lateral,  that  is,  at  the  side  of  the  stump.  The  lateral  loop  may 
be  formed  by  simply  tunneling  the  muscle  masses  and  covering  the  tunnel  with 
skin;  intermuscular  canalization.  The  club  is  a  part  of  the  stump  separated 
from  the  rest  by  a  constriction  or  a  ring.  In  order  to  obtain  it,  one  may 
proceed  in  different  fashion..  A  description  of  the  different  technique  is  given 
as  follows:  (1)  cineplasties  with  terminal  loop;  (a)  single  loop,  technique 
of  Putti.  Double  parallel  incision;  elevation  of  the  bi-pedicled  skin  flap  in 
the  middle  and  deflection  of  the  lateral  flaps. 

Sub-periosteal  resection  of  3  cm. :  of  the  forearm  bones ;  in  rolling  of  the 
bi-pedicled  flap  and  by  suturing  its  free  ends  together,  (o)  Technique  of  Ceci. 
Circular  incision  of  skin  and  all  soft  parts,  1  cm.  above  carpus.  Double 
longitudinal  incision  at  the  internal  and  external  border  of  forearm  starting 
from  the  circular  incision  and  reaching  10  cm.  upward.  Dissection  of  the 
two  musculocutaneous  flaps  in  front  and  in  back  and  freeing  of  the  bone. 
Sectioning  of  the  two  forearm  bones  at  the  base  of  the  two  flaps.  In  rolling 
of  the  two  flaps  around  the  tendons,  constructing  in  this  way  two  slings,  one 


CURRENT  ORTHOPAEDIC  LITERATURE  177 

anterior  and  one  posterior,  which  contain  the  flexor  and  extensor  tendons, 
respectively. 

l>ouble  Loop:  Teolmique  of  Ceci.  The  homologous  tendons  are  sutured 
together;  flexors  with  flexors  and  extensors  with  extensors,  forming  in  this 
way  two  loops  of  antagonistic  action.  Circular  incision  of  the  skin  at  lower 
fourth  of  the  forearm.  Section  of  the  tendons.  Double  longitudinal  incision 
at  internal  and  external  border  reaching  15  cm.  upward.  Dissection  of  the 
two  skin  flaps  and  dissection  of  the  two  musculotendinous  flaps,  sectioning  of 
the  two  bones  at  the  base  of  the  flaps;  suturing  of  the  two  flaps,  the  cor- 
responding tendons  being  sewed  together,  extensors  to  extensors  and  flexors 
to  flexors.  Then  two  button-holes  are  cut  of  3  cm.  in  length.  These  have  a 
vertical  direction,  and  are  situated  one  over  the  other  in  median  line.  The 
skin  flap  is  then  turned  over  a  transverse  axis  in  such  a  way  that  the  two 
corresponding  button-holes  cover  each  other.  Then  the  skin  flaps  are  sutured 
and  the  edges  of  the  button-holes  also. 

Lateral  Loop:  Technique  of  Delitala -Pellegrini.  The  muscles  which  are  to 
be  used  for  the  establishment  of  the  lateral  loop  are  exposed  at  the  level  of 
two  transverse  incisions  parallel  to  each  other.  At;  the  extremity  of  the 
stump,  the  tendons  are  now  liberated  and  sectioned.  They  are  then  pulled 
out  through  the  inferior  transverse  incision.  The  skin  bridge  is  rolled  by 
sewing  its  free  margins  together  and  the  ends  of  the  tendons  are  slung  over  it 
and  fastened  in  a  loop  to  the  muscular  bellies.  Then  the  two  far  edges  of 
the  two  parallel  skin  incisions  are  fastened  to  each  other. 

2.  Formation  of  a  Club :  (a)  Muscle  club :  transverse  incision  of  the  extremity 
of  the  stump,  formation  of  two  flaps  by  U-shaped  incision  and  dissection  of  the 
anterior  and  posterior  flap.  Section  of  the  bone  a<t  the  base  of  the  flap.  The 
two  flaps  are  united  forming  a  club  (technique  of  Arana).  (b)  Osteomuscular 
club.  (Technique  of  de  Francesco.)  Two  incisions  of  5  cm.  length  at  the  inner 
or  outer  side  of  the  limb.  Resection  of  3  cm.  of  radius  and  ulna  leaving  two 
bony  fragments  of  2  cm.  each  at  the  extremity  of  the  stump.  Interposition  of 
muscle  tissue  to  produce  a  pseudo-arthrosis.  Suture  of  the  two  lateral  skin 
wounds. 

3.  Cineplastic  amputations  on  the  principle  of  alternating  motors.  These 
are  juxta-articular  amputations.  Cineplastic  amputation  of  the  elbow:  In  a 
lesion  necessitating  an  amputation  of  the  forearm,  the  operator  may  conserve 
the  upper  extremity  of  the  ulna  or  at  least  the  olecranon  with  the  insertion  of 
the  triceps.  Then  the  tendon  of  the  biceps  may  be  fixed  to  the  anterior  portion 
of  the  remaining  bone,  and  one  may  in  this  way  obtain  a  mobilization  of  the 
olecranon  forward  and  backward.  Similar  cineplastic  amputations  have  been 
devised  for  the  wrist.  In  this  case,  the  carpus  is  left  in  place  and  is  mobilized 
in  flexion  by  the  tendon  of  the  flexor  carpi-ulnaris  and  the  flexors ;  in  extension, 
by  the  extensors  of  the  fingers. 

Cineplasties  by  Individualization  of  Bones:  In  this  group,  the  author  classifies 
such  operations  which  individualize  certain  bones  which  normally  are  united 
in  function,  viz.,  the  two  hones  of  the  forearm  and  the  metacarpals.  It  is 
possible  on  the  forearm  to  effect  a  pineher-aetion  between  radius  and  ulna. 
This  is  being  done  in  Krukeuherg's  operation,  first  presented  by  Krukenberg 
at  the  thin!  congress  of  war  surgery  in  Brussels  in  February,  1918.  The 
operation    of    Krukenherir   conatsta    in    separation    of    radius   and    ulna    up    to   a 


178  CURRENT  ORTHOPEDIC  LITERATURE 

certain  level  and  in  epidermisation  of  the  .two  prongs.     This  operation  is  very 
disfiguring  and  hideous  and  for  this  reason  often  opposed  by  the  patients. 

4.  The  Phalangization :  The  method  is  a  method  of  Italian  authors  (Putti), 
as  is  the  forcepization  of  the  metacarpals.  By  a  longitudinal  section  of  the 
interior  metacarpal  tissue,  it  is  possible  to  give  a  certain  individuality  to  the 
metacarpals,  especially  to  the  first  and  fifth,  which  are  more  movable.— A. 
Steindler,  Iowa  City,  la. 


Permanent  Results  of  the  Operation  of  the  Semilunar  Cartilages  of  the 
Knee.    Baumann.    Archiv  Orth.  und  Unfallchir.,  Vol.  19,  No.  2;  July,  1921. 

Among  94  patients  who  were  re-examined  following  operation  on  the  semi- 
lunar cartilages  of  the  knee,  four  were  excluded  on  account  of  complications 
with  tabes,  polioarthritis,  and  arthritis  deformans.  Among  the  remaining  90 
patients,  the  results  were  as  follows: 

Absolutely  free  from  disturbance  or  complaint 32 

Functional  cure 15 

Complete  functional  efficiency  as  regards  patient's  occupation.  .37 

Slightly  diminished  functional  efficiency 4 

Considerably  diminished  functional  efficiency 2 

These  statistics  show  that  52%  of  the  patients  had  splendid  results,  and 
only  6.6%  were  unfavorable.  The  resumption  of  work  may  be  undertaken  as 
early  as  four  or  five  weeks  after  the  operation,  and,  almost  without  exception, 
in  eight  or  ten  weeks.  In  more  than  one-half  of  the  operated  cases,  a  complete 
return  of  functional  ability  may  be  expected  as  early  as  two  months  after 
the  operation.  On  the  basis  of  his  experience,  the  author  maintains  that  the 
functional  disability  caused  by  dislocation  of  the  semi-lunar  cartilage  may  be 
remedied  safely  by  surgical  interference,  and  that  absolute  indication  for  removal 
exists  in  those  cases  in  which  conservative  treatment  with  fixation,  heat  or 
massage,  carried  on  for  several  weeks,  does  not  definitely  cure  the  condition. — 
A.  Steindler,  Iowa  City,  la. 


The  Biology  of  Bone  Development  in  Its  Relation  to  Bone  Transplanta- 
tion. Philip  William  Nathan,  M.D.  New  York  Medical  Journal,  October 
19,  1921. 

This  paper  summarizes  our  knowledge  regarding  bone  development  and  bone 
regeneration.  It  especially  emphasizes  the  fact  that  ossification  takes  place 
only  in  the  presence  of  the  cells  known  as  osteoblasts,  which  are  neither  changed 
cartilage  cells  nor  changed  connective  tissue  cells  but  cells  of  independent  origin, 
probably  brought  to  the  area  to  be  ossified  by  the  blood  vessels.  These  cells 
occur  in  only  two  localities,  viz.,  the  cambium  layer  of  the  periosteum  and  of 
the  endosteum. 

There  is,  at  present,  a  difference  of  opinion  regarding  bone  development, 
particularly  as  related  to  bone  transplantation.  The  point  in  debate  concerns 
the  viability  of  the  periosteum  and  its  ability  to  produce  new  bone  when 
transplanted. 


CURRENT  ORTHOPAEDIC  LITERATURE  179 

If  the  transplanted  periosteum  carries  with  it  the  cambium  layer,  with  its 
osteoblasts,  it  will  produce  bone.  If  it  consists  only  of  the  connective  tissue 
sheath  without  osteoblasts,  it  will  not. 

Even  under  most  favorable  circumstances,  bone  transplanted  with  osteoblasts 
is  invariably  absorbed,  the  bone  serving  merely  as  a  scaffolding  for  the  building 
of  new  bone  by  the  osteoblasts.  This  is  what  happens  when  grafts  without 
periosteum  or  endosteum,  or  when  grafts  of  boiled  bone  or  ivory  are  implanted, 
osteoblasts  from  adjacent  healthy  bone  invading  the  graft  and  building  new 
bone  on  it  as  a  scaffolding. — C.  L.  Lowman,  Los  Angeles. 


BONE    DISEASES 


Sclerosing  Nonsuppurative  Osteomyelitis  as  Described  by  Gabre.     S.  Fosdick 
Jones.    Journal  A.  M.  A.,  September  24,  1921. 

The  rarity  of  this  type  of  sclerosing  nonsuppurative  osteomyelitis  as  described 
by  Garre,  prompts  the  author  to  present  a  case  which  had  come  recently  under 
his  observation.  These  sclerosing  types  of  osteomyelitis  are  characterized  by 
enlargement  and  thickening  of  bone  without  the  occurrence  of  suppuration  or 
fistulous  formations.     Garr6  first  described  this  condition  in  1891. 

In  the  large  majority  of  cases,  the  onset  is  acute,  accompanied  by  high 
fever,  swelling,  pain  at  the  site  of  bone  lesion,  and  considerable  infiltration  of 
the  soft  parts.  The  skin  is  not  reddened,  and  there  is  no  formation  of  pus. 
Among  555  cases  of  osteomyelitis  observed  at  the  Tubingen  clinic,  only  20  cases 
were  of  the  sclerosing  nonsuppurative  type.  Lange  in  1904  referred  to  these 
cases,  which  are  characterized  by  an  absence  of  suppuration,  as  periostitis 
albuminosa,  reporting  a  case  in  a  lad  of  12  years.  The  differential  diagnosis 
between  sclerosing  osteomyelitis  and  bone  sarcoma  is  frequently  very  difficult 
There  is  also  the  possibility  of  confusing  this  lesion  with  syphylitic  lesions. 

The  syphilitic  osteitis  and  periosti,tic  infections  of  bones  results  in  fusiform 
enlargement  of  the  shaft  and  lead  to  a  diffused  hyperostosis,  closely  resembling 
the  chronic  stages  of  nonsuppurative  osteomyelitis.  Night  pain  is  common  to 
both  conditions.  The  absence  of  other  syphilitic  manifestations,  the  gradual 
subsidence  of  the  pain,  and  the  finding  of  a  negative  blood  and  spinal  fluid 
Wassermann  reaction,  should  establish  the  diagnosis.  In  bone  sarcoma,  the 
problem  is  even  more  difficult  as  there  is  frequently  a  previous  history  of  trauma. 
Again  the  absence  of  glandular  enlargement,  of  cachexia,  and  repeated  loss 
of  weight  are  important  points  in  differentiating  this  type  from  malignant 
bone  disease.  The  case  of  the  author  concerned  a  boy  nine  years  old  who,  in 
June,  1918,  had  sustained  a  slight  injury  to  the  right  leg  and  who  was  free 
from  symptoms  from  June  to  December,  1918,  with  exception  of  a  slight  swelling 
over  the  anterior  surface  of  the  leg.  In  December,  he  had  another  trauma, 
and  following  this,  there  was  a  rise  of  temperature  to  100.8°  and  persisting 
pain  over  the  site  of  the  injury.  The  x-ray  pictures  showed  distinct  enlargement 
of  the  right  tibia.  He  was  operated  upon,  and  the  periosteum  was  found  normal 
in  appearance.  It  was  not  adherent.  No  pus  was  found  in  the  medullary 
oanal.      The    microscopic    examination    showed    no    evidence    of    sarcoma,    and 


180  CURRENT  ORTHOPEDIC  LITERATURE 

cultures  taken  from  the  medullary  canal  showed  no  growth  at  the  end  of  48 
hours.    There  was  no  evidence  of  any  tumor  formation. 

Conclusions:  Sclerosing  nonsuppurative  osteomyelitis  as  described  by  (Jarre  is 
a  distinct  entity.  The  differentiation  between  sarcoma  of  bone,  bone  syphilis, 
and  osteitis  fibrosa  is  freqxiently  very  difficult.  In  some  instances  amputations 
for  supposedly  malignant  diseases  of  the  extremities  have  been  performed  in 
cases  which  clearly  presented  the  nonsuppurative  sclerosing  form  of  osteomyelitis. 
In  doubtful  cases  of  bone  disease  an  exploratory  excision  should  be  made. 

In  the  discussion  of  this  paper,  Sir  Robert  Jones,  of  Liverpool,  remarked  that 
he  had  not  seen  the  original  article  by  Garr€,  and  that  since  1900  he  had 
observed  those  fusiform  swellings,  which  at  first  sight  may  be  taken  as  syphilitic. 
The  difference,  he  thinks,  is  very  obvious.  It  is  very  marked  in  the  periosteum. 
The  little  depressions  and  corrugations  in  the  bones  and  the  firm  attachment 
of  the  periosteum  to  the  tibia  are  characteristic  of  syphilis,  while  the  periosteum 
strips  off  very  easily  from  the  smooth  bone  surface  in  Giarre  affection.  Sir 
Robert  Jones  has  adopted  a  similar  treatment  to  that  of  the  author,  namely, 
a  deep  incision,  even  gutting  of  the  bone.  The  condition  once  healed  may 
recur  and  Sir  Robert  had  a  case  in  which  the  swelling  recurred  18  months  after 
the  first  operation,  necessitating  a  second  operation.  In  some  cases  the  pain 
is  very  severe,  and  he  has  been  accustomed  in  various  types  of  bone  thickening, 
especially  also  in  Paget's  disease,  to  relieve  discomfort  by  a  linear  osteotomy 
into  the  medulla. — A.  Steindler,  Iowa  City,  la. 


Disease  of  the  Tarsal  Scaphoid  in  Young  Children.     Abrahamsen.     Revue 
d'Orthopedie,  July,  1921,  p.  313, 

This  paper  is  a  brief  report  of  a  case  of  Kohler's  disease  which  showed 
improvement  under  thyroid  treatment.  A  boy  of  seven,  born  of  healthy  parents 
and  with  no  previous  history  of  illness  or  injury,  began  to  limp  and  to 
complain  of  getting  tired  easily,  although  he  walked  without  support  of  any 
kind.  Symptoms  were  in  the  right  foot.  This  foot  was  normal  in  appearance. 
There  was  no  pain  on  pressure  and  no  limitation  of  motion.  The  calf  muscle 
showed  an  atrophy  of  2  cm.  The  roentgenogram  showed  that  the  scaphoid 
was  almost  absent. 

Powdered  thyroid  gland  was  given  15  centigrams  a  day.  At  the  end  of  three 
months  the  bony  part  of  the  scaphoid  with  7  mm.  thick,  and  in  two  months 
more  it  was  9  mm.  The  disease  is  regarded  as  an  anomaly  in  development. — 
William  Arthur  Clark,  Pasadena. 


Kohler's  Disease.     George  I.  Bauman,  M.D.  Journal  A.  M.  A.,  October  1,  1921. 

The  author  gives  a  brief  resume  of  Kohler's  description  of  the  disease  in 
1908.  Dr.  Bauman  concludes  that  "the  most  one  can  say  is  that  it  is  probably 
an  osteitis  due  to  trauma  or  absorption  from  some  focus  of  infection,  and 
that  this  osteitis  interferes  with  the  normal  development"  of  the  scaphoid 
bone.  He  reports  two  cases,  and  the  paper  is  illustrated  with  two  excellent 
half-tones  of  skiagrams.  The  treatment  consists  of  plaster  splints  and  crutches 
for  two  or  three  months.— H.  A.  Pingree,  Portland,  Me. 


CURRENT  ORTHOPAEDIC  LITERATURE  181 


ROENTGEN-RAY     THERAPY     l.N      ClIUoNK       DISEASES     OF     THE     BONES,      JOINTS,      AND 

Tendons.     Herman   B.   Philips,    M.D.,   and   Harry   Fiuklestein,   M.D.     New 
York  Medical  Journal,  October  19,  1921. 

For  the  past  two  years  the  authors  have  been  developing  a  technique  for 
treatment  of  chronic  bone  and  joint  diseases  by  x-ray.  This  has  been  attempted 
before  but  has  often  failed,  probably  because  of  too  intensive  and  destructive 
application.  The  authors'  plan  of  treatment  consisted  of  rounds  of  exposure, 
repeated  monthly.  The  conditions  reported  as  treated  include  tuberculous 
arthritis  and  osteomyelitis  and  ganglia  chronic  tenosynovitis,  in  both  of  which 
conditions  the  results  were  prompt  and  very  satisfactory;  chronic  pyogenic 
osteomyelitis,  in  which  separation  of  sequestra  and  closure  of  sinuses  seemed 
fo  be  materially  hastened,  and  chronic  arthritis,  in  which  no  actual  changes 
in  the  joint  were  produced  by  the  x-ray,  but  relief  from  pain  was  prompt. 
In  summary,  the  authors  feel  that  "Roentgenotherapy  is  available  as  probably 
the  greatest  but  least  used  therapeutic  agent  in  the  orthopaedist's  armamen- 
tarium."— C.  L.  Lowman,  M.D.,  Los  Angeles. 


SCOLIOSIS 


Treatment  of  the  Sharp  Costal  Gibbosity  in  Scoliosis  by  Open  Operation" 
as  Supplement  to  Orthopaedic  Treatment.  Gaudier  and  Swynghedauw. 
Revue  d' Orthopedic,  July,  1921,  p.  265. 

The  orthopaedic  treatment  of  scoliosis  has  been  very  satisfactory  in  the 
majority  of  cases  of  the  past  few  years.  However,  there  are  some  inveterate 
irreducible  forms  accompanied  by  a  sharp  angulation  of  the  ribs  upon  which 
the  most  careful  orthopaedic  procedures  produce  no  notable  effect.  In  such 
cases  this  angulation  of  the  ribs  is  a  distinct  obstruction  to  correction  of  the 
vertebral  curvature,  and,  although  it  is  secondary  to  the  curvature,  it  constitutes 
the  most  prominent  visible  deformity,  and  is  more  of  a  hindrance  to  respiration 
than  the  curve  itself.  Osteotomy  and  resection  of  parts  of  ribs  would  seem 
to  render  the  curvature  more  amenable  to  correction.  This  was  first  done  by 
Volkmann,  who  resected  the  entire  twelfth  rib  and  the  salient  part  of  the  tenth 
and  eleventh  in  a  girl  of  15,  after  which  the  scoliosis  was  much  improved  by 
orthopaedic  measures  which  produced  no  result  before  the  resections.  Later 
he  obtained  a  very  interesting  result  by  resection  of  the  lower  seven  ribs  in 
another  case.  Hoffa  also  obtained  results  which  exceeded  his  hopes  in  a  child 
of  10  by  resection  of  the  third  to  the  eighth  ribs  from  near  the  vertebra  to 
the  axillary  line.  Casse,  a  Belgian  surgeon,  has  also  had  encouraging  success 
with  the  same  method. 

The  authors  report  two  cases : 

1.  Girl  of  14  V£  with  no  sign  of  rickets  and  a  negative  previous  history.  Right 
dorsal  scoliosis  with  a  marked  angulation  of  the  ribs  displacing  the  scapula 
outward  and  causing  an  unsightly  hump,  readily  noticeable  under  the  clothing. 


182  CURRENT   ORTHOPEDIC   LITERATURE 

The  fourth  to  tenth  ribs  were  most  involved.  Neither  suspension  in  extension 
nor  treatment  by  acute  flexion  had  any  effect  on  the  curve.  In  May,  1920,  subperi- 
osteal resection  of  the  fifth  to  ninth  ribs  was  done,  8  to  10  cm.  of  each  rib  being 
removed  at  the  most  prominent  part  of  the  curve.  The  angulation  is  now  scarcely 
apparent  and  the  scapula  lies  in  its  normal  position.  The  gaps  in  the  ribs  are 
filling  in  from  periosteum  and  some  of  the  ribs  have  rejoined. 

2.  Patient,  age  15,  right  dorsal  curve  with  angulation  of  last  six  ribs,  summit 
at  the  ninth.  It  did  not  yield  to  extension  or  flexion  treatment.  Resection  of 
sixth  to  eleventh  inclusive  in  August,  1920,  through  a  U  incision  of  which  the 
horizontal  lines  were  about  20  cm.  in  length.  Length  of  resected  portions  about 
12  cm.  Patient  able  to  be  up  the  eighth  day  and  to  breathe  without  difficulty. 
In  September  it  was  possible  partly  to  correct  the  spinal  curve  and  a  plaster 
jacket  was  applied  to  produce  corrective  pressure. 

The  preferred  incision  for  the  operation  is  a  U  with  limbs  horizontal.  The 
resection  is  done  according  to  the  classical  technique.  The  angulation  renders 
the  dissection  of  the  pleura  more  difficult  than  usual,  but  an  accidental  puncture 
is  easily  covered  by  a  flap  of  neighboring  muscle.  It  is  wise  to  insert  a  filiform 
drain  for  48  hours.  As  soon  as  the  wounds  permit,  a  plaster  corset  is  applied  with 
spine  in  slight  flexion.  Through  windows  in  the  cast,  progressive  pressure  is 
made  to  correct  the  curvature. 

The  authors  have  also  made  some  investigations  on  anatomic  specimens  and 
have  found  that  by  multiple  rib  resections  a  deformed  thorax  can  be  reformed 
practically  to  normal. — William  Arthur  Clark,  Pasadena. 


Result  of  Extensive  Rib  Resection  on  the  Concave  Side  in  Severe  Scoliosis. 
Fritz  Lange.    Ze4t.  orth  Chir.,  Vol.  41,  (No.  3,  May,  1921. 

Although  only  one  case  is  quoted  by  the  author,  general  conclusions  are  drawn 
from  it.  The  author  believes  that  in  some  of  the  severest  types  of  scoliosis  one 
may  obtain  considerable  improvement  by  increasing  secondary  curves  above  and 
below  in  the  course  of  a  preoperative  treatment. 

The  experiments  made  by  Sauerbruch  with  resection  of  the  thorax  seem  to 
offer  a  favorable  opportunity  for  attacking  the  problem  of  scoliosis  in  an  operative 
way.  The  author  refers  to1  the  experiences  of  Hoessly,  who  has  reported  two 
cases  of  rib  resection  in  scoliosis.  He  refers  also  to  the  question  of  tenotomy  of 
the  concave  side  muscles,  which,  in  his  opinion,  is  to  be  condemned  uncondi- 
tionally. The  cutting  of  these  muscles,  especially  of  the  erector  spinae  muscles, 
will  prevent  the  important  function  of  these  muscles  in  opposing  the  tilt  of  the 
whole  body  toward  the  side  of  the  convexity. 

The  author's  patient  was  a  19-year-old  boy  who  had  a  right  dorso-lumbar  sco- 
liosis. The  operation  was  performed  by  Sauerbruch.  An  incision  ten  inches  in 
length  was  made  above  and  parallel  with  the  vertebral  border  of  the  shoulder 
blade,  as  is  used  for  lung  plasty.  Resection  of  5  cm.  of  the  eighth  rib  was  per- 
formed. From  jthe  ninth  rib  down  difficulties  arose  due  to  the  overlying  muscu- 
lature so  that  incisions  of  the  musculature  were  frequently  necessary.  Following 
the  operation,  the  tilt  to  the  right  was  possibly  a  little  less.  The  mobility  of  the 
spine  was  (the  same  as  before,  but  there  was  a  distinct  flattening  of  the  dorsal 
curve.    The  gymnastic  treatment  which  followed  operation  improved  the  posture 


CURRENT  ORTHOPAEDIC  LITERATURE  183 

but  did  not  produce  any  further  improvement.  In  order  to  obtain  greater 
mobility  of  the  spine,  a  second  operation  was  performed  through  an  incision  as 
for  plasty  of  the  upper  lobe  of  the  lung.  This  time  there  were  resected  pieces  of 
4  and  5  cm.  in  length  from  the  first  and  seventh  rib.  After  the  removal  of  the 
seventh  rib,  the  left  side  of  the  thorax  collapsed,  and  improvment  of  the 
condition  was  not  noticed  either  in  regard  to  posture  or  in  regard  to  mobility. 

There  was,  shortly  after  the  operation,  an  improvement  in  that  the  tilt  to  the 
right  was  further  corrected.  But  when  the  patient  presented  himself  six  months 
after  the  second  operation,  it  was  found  that  the  increase  of  mobility  obtained 
after  the  first  operation  which  had  persisted  for  two  months  of  his  hospital 
observation,  had  been  lost  entirely. 

The  author  believes  that  the  posture  at  large  has  been  improved  by  the 
operation  owing  to  the  fact  that  the  convex  side  tilt  of  the  entire  body  was 
considerably  improved.  He  also  believes  that  a  loosening  of  the  rigid  section 
of  the  dorsal  spine  was  due  to  the  operation.  The  second  rib  resection  did  not 
bring  an  increase  in  mobility  of  the  rigid  section  of  the  spine.  Taking  it  all  in 
all,  the  resection  of  ribs  in  cases  of  rigid  scoliosis  does  not  offer  any  great  hope 
for  correcting  or  improving  the  deformity.  The  author  warns  against  an  indis- 
criminate adoption  of  this  operation. — A.  Steindler,  Iowa  City,  la. 


Is  an    Operative  Treatment  of    Scoliosis   Possible?     H.   Hoessly.   Zeit.   orth 
Chir.,  Vol.  41,  No.  3,  May,  1921. 

Two  cases  are  reported  in  which  a  thoracoplasty  of  the  concave  side  was  per- 
formed. 

(1)  Girl,  16  years,  with  right  convex  dorsal  scoliosis  and  low  rotation.  A 
thoracoplasty  was  performed  under  local  anaesthesia,  five  ribs  being  resected  to 
the  extent  of  1  to  V/2  cm.  each. 

(2)  Boy  of  13  years,  with  a  left  dorsal  scoliosis  of  the  upper  and  the  right 
dorsal  of  the  mid-dorsal  region.  A  thoracoplasty  was  performed,  with  section 
of  three  ribs  (three  to  nine),  and  the  removal  of  small  pieces  from  each. 

In  both  cases  there  was  a  very  slight  stretching  of  the  spine  nqticeable  follow- 
ing operation.  The  author  says  that  he  has  no  definite  idea  how  many  ribs  and 
to  what  extent  they  are  to  be  resected  in  the  different  cases,  since  such  knowl- 
edge would  have  to  come  from  a  larger  experience.  He  also  mentions  the  clinical 
experiences  following  the  Albee  and  de  Quervain  transplantation  of  bone  into  the 
spinous  processes,  citing  one  case.  This  case  showed  that  the  correction  obtained 
before  the  operation  had  persisted  following  transplantation,  and  he  concludes 
that  the  transplantation  of  bone  into  the  spine  is  very  apt  to  secure  the  improved 
position  obtained  by  preoperative  methods.  It  is,  according  to  the  author,  the 
method  of  choice. 

He  further  opens  the  question  of  direct  attack  upon  the  spine  through  the 
abdominal  cavity,  but  aside  from  general  considerations,  nothing  definite  is  said. 
Only  for  the  lumbosacral  regions  the  author  believes  that  such  a  method  will 
become  practicable. — A.  Steindler,  Iowa  City,  la. 


184  CURRENT   ORTHOPAEDIC   LITERATURE 


CONGENITAL  DEFORMITIES 

Three  Cases  of  Coraco-clavicular  Articulation  Observed  in  Living.    F.  Fras- 
seto.    Chir.  Org.  Movim.,  Vol.  5,  No.  1,  Feb.,  1921. 

Observations  of  three  cases  from  the  radiological  laboratory  of  Dr.  F.  H. 
Baetjer  of  the  Johns  Hopkins  Hospital  in  Baltimore.  The  x-ray  picture  showed 
an  anomalous  osseous  process  arising  from  the  inferior  surface  of  the  clavicle. 
It  had  a  trapezoid  shape  with  its  base  directed  toward  the  clavicle  and  its  apex 
toward  the  coracoid  process.  This  bony  prominence  carries  an  articular  facet 
which  articulates  with  the  tip  of  the  coracoid  process.  The  form  of  this  anom- 
alous process  corresponded  in  site,  size  and  form  to  the  two  coraco-clavicular 
ligaments  (conoid  and  trapezoid),  as  well  as  to  the  less  known  ligament  of 
the  superior  surface  of  the  clavicle  named  the  bicorne  ligament  of 
Caldoni.  This  distribution  demonstrates  the  existence  of  a  true  articulation  due 
to  ossification  of  these  ligaments.  From  the  standpoint  of  comparative  anatomy, 
it  is  mentioned  that  such  an  articulation,  analogous  to  the  coraco-clavicular 
articulation  of  man,  has  been  found  in  the  gorilla  and  hylobates.  According 
to  recent  investigation,  especially  in  studies  of  English  and  American  authors, 
this  so-called  Caldoni's  ligament  or  coraco-costal  ligament  represents  part  of  a 
skeletal  element.  Starting  from  the  marsupialia,  the  coracoid  enters  in  a  process 
of  regression  until  it  has  reached  the  rudimentary  form  found  in  man.  This 
bicorne  ligament  of  Caldoni,  therefore,  represents  the  caudal  end  of  the  disap- 
pearing coracoid  process.  The  coraco-clavicular  ligaments  represent  the  lateral 
portion  of  the  pro-coracoid  or  the  cranial  coracoid. 

In  regard  to  the  clinical  significance  of  this  anomaly,  it  is  mentioned  that  in 
one  of  the  three  cases,  there  was  a  fracture  of  the  surgical  neck  of  the  humerus ; 
according  to  the  author  this  fracture  was  considerably  enhanced  by  the  presence 
of  the  coraco-clavicular  articulation.  The  coraco-clavicular  ligaments  have  for 
their  principal  function  the  fixation  of  two  bones,  namely,  the  scapula  and  the 
clavicle,  but  because  these  ligaments  are  long  and  elastic,  they  admit  of  some 
amount  of  displacement  between  the  two  bones.  In  case  of  ossification  of  these 
ligaments  or  in  case  of  articulation  between  the  two  bones,  the  union  between 
scapula  and  clavicle  is  much  more  solid.  It  can  easily  be  seen  that  in  these 
instances,  the  counter-coup,  which  transmitted  from  the  head  of  the  humerus  to 
the  glenoid  fossa  could  not  be  lessened  by  the  elasticity  of  the  ligaments  and  the 
lack  of  give  between  the  two  bones,  causes  or  contributes  to  the  fracture  of  the 
head. 

The  author  also  found  that  in  two  of  the  three  cases  the  anomaly  was  asso- 
ciated with  tuberculosis.  From  this  it  may  be  inferred  that  one  deals,  possibly, 
with  the  subjects  of  phthisical  habitus.  The  higher  frequency  of  the  articulation 
in  women  is  also  noted  by  the  author,  although  no  explanation  is  ventured  for 
this  fact. — A.  Steindler,  Iowa  City,  la. 


Progressive  Foot  Deformities  in  Spina  Bifida  Occulta.     L.  Roeren.  Archiv. 
Orth.  u.  Unfall.  Chir.,  Vol.  19,  No.  1,  May,  1921. 

In  this  study,  the  author  refers  to  the  investigations  of  Duncker  and  Bibergeil, 
both  of  whom  have  tried  to  establish  definitely  the  connection  of  the  foot  de- 


CURRENT  ORTHOPAEDIC  LITERATURE  185 

formities  with  clefts  of  the  spinal  column.  Bibergeil  modifies  his  statements 
by  saying  that,  in  spite  of  the  numerous  relations  existing  between  spina  bifida 
occulta  and  pes  cavus,  an  etiological  connection  between  these  two  conditions 
cannot  be  assumed  under  all  circumstances.  Duncker,  however,  goes  farther 
and  concludes  from  the  defects  of  the  spine  that  there  exist  primary  develop- 
mental errors  in  the  spinal  cord  itself.  But  the  often  late  beginning  and  the 
slow  progression  of  the  deformity,  together  with  the  frequent  unilaterality  of 
the  condition,  call  for  further  explanation.  Duncker  and  others  describe  strands 
of  scar  tissue  starting  from  the  skin  and  reaching  through  the  vertebral  cleft 
into  the  vertebral  canal.  This  fibrous  strand  is  supposed  to  impede  the  normal 
ascent  of  the  medulla  in  the  vertebral  canal.  Recklinghausen  described  a  case 
of  a  man  25  years  old  with  hypertrichosis  in  the  sacral  region  and  left  club-foot, 
in  whom  the  conus  medullaris  was  at  the  level  of  the  second  sacral  vertebra 
and  not,  as  normally,  at  the  level  of  the  second  lumbar  vertebra.  Such  cases 
might  explain,  upon  a  mechanical  basis,  the  failure  of  the  medulla  to  ascend. 
A  second  type  of  pathological  changes  are  tumors  lying  between  medulla  and 
the  bone  and  exerting  pressure  upon  the  former.  These  tumors  are  mostly  or 
purely  lipomatous;  but  even  these  findings  are  not  likely  to  explain  to  satis- 
faction the  syndrome  of  spina  bifida  occulta  with  progressive  foot  deformities,  as 
there  are  no  instances  in  which  a  complete  paralysis  developed,  such  as  should 
be  expected  with  the  growth  of  a  tumor.  Malformation  in  the  medulla  is  not 
progressive  but  stationary  and  consists,  according  to  some  observers,  in  localized 
defects  and,  in  more  advanced  degrees,  the  anterior  tracts  and  anterior  horns 
themselves  as  well  as  the  posterior  roots,  may  be  involved.  In  contrast  with 
poliomyelijtic  paralysis,  the  paralysis  is  here  more  disseminated  affecting  only 
single  muscles  or  single  muscle  bundles  or  fibers  so  that  it  is  often  very  difficult 
to  establish  the  presence  of  paralysis  clinically.  This  abnormal  condition  of  the 
medulla  is,  in  the  opinion  of  the  author,  to  be  considered  the  pathological  basis 
in  the  mild  and  moderate  cases  of  spina  bifida  occulta  with  progressive  foot  de- 
formities. 

It  seems  that  certain  epochs  of  life  are  especially  prone  to  develop  these  de- 
formities. Aside  from  the  condition  at  birth,  there  are  certain  periods  when  the 
deformity  makes  decided  progress.  One  of  these  is  the  third  year  and  another 
Lhe  seventh  year  of  life.  Under  the  influence  of  disturbed  muscle  equilibrium, 
the  formerly  normal-shaped  foot  may  begin  to  turn  at  this  age.  The  author  then 
proceeds  with  a  rather  lengthy  explanation  of  the  muscle  mechanics  leading  to 
the  peculiar  deformities  of  spina  bifida  occulta.  He  is  especially  desirous  to 
show  that  the  transformation  of  the  foot  from  the  normal  into  the  equinus 
position  with  increase  of  the  arch  is  the  result  of  the  play  of  the  flexor  muscles 
under  conditions  of  disturbed  equilibrium.  The  consideration  of  the  musculo- 
mechanical  conditions  will  readily  explain  why  the  three  types,  namely,  the 
equinus,  varus,  and  cavus,  are  so  predominant.  The  topography  of  the  anterior 
horn  columns  from  which  the  motor  nerve  fibers  take  their  origin  teaches  that 
the  columns  for  those  muscles,  whose  function  is  the  plantar  flexion  of  the  foot 
and  the  increase  of  its  arch,  are  situated  more  caudally  than  are  the  cell  columns 
which  supply  the  extensors  of  the  toes  and  the  tibialis  anticus.  By  elimination 
or  weakening  of  their  antagonists,  these  muscles,  namely,  the  flexors  and  height- 
eners  of  the  foot,  go  into  contracture  and  give  rise  to  the  progressive  foot  de- 
formity in  spina  bifida  occulta.    It  is  pointed  out,  furthermore,  that  in  any  condi- 


186  CURRENT   ORTHOPAEDIC   LITERATURE 

tion  of  irritation  of  all  muscles  such  as  would  be  the  case  in  medullary  lesion 
higher  up  (upper,  neurone),  such  positions  of  contractures  might  easily  occur, 
especially  if  enhanced  by  slight  external  causes  such  as  position  or  pressure  of 
the  covers,  etc.  From  these  considerations,  it  will  become  clear  why  the  vast 
majority  of  the  foot  deformities  observed  in  spina  bifida  occulta  present  a  com- 
bination or  variation  of  the  tyjpes  of  equinus,  varus,  or  cavus. 

In  conclusion,  the  author  assumes  that  spina  bifida  occulta  is  a  malformation 
having  its  seat  in  the  lowest  part  of  the  spine.  It  becomes  established  in  the 
first  weeks  of  intrauterine  life  when  the  closure  of  the  medullary  trough  should 
occur,  but  is  then  disturbed  for  some  reason.  The  conus  medullaris  often  is 
adherent  to  the  posterior  surface  of  the  canal  by  adhesions,  and  this  is  a  factor 
which  might  bring  about  progressive  damage  or  injury  to  the  medulla. 

Since,  due  to  the  distribution  of  musculature  and  the  configuration  of  the 
joints,  conditions  are  very  propitious  for  the  formation  of  an  equino-cavus,  and 
since  the  functional  disturbance  in  most  of  the  cases  is  of  spastic  character,  it  is 
easily  explained  that  in  the  majority  of  the  cases  the  above-mentioned  deformities 
occur,  enhanced  by  conditions  of  contracture  on  the  part  of  the  hypertonic  mus- 
cles, and  relaxation  on  the  part  of  their  antagonists.  The  treatment  has  to 
consider  the  condition  of  the  medulla  in  the  first  place;  that  is,  the  removal  of 
adhesions  or  tumor  in  the  vertebral  canal.  The  local  condition  of  foot  deformity 
demands  operative  interferences  upon  the  structures  and  deformed  bones. — 
A.  Steindler,  Iowa  City,  la. 


Contribution  to  the  Pathology  and  Therapy  of  the  Congenital  Pes  Adductus. 
W.   Jareschy.  Zeit.   orth.  Chir.,   Vol.  41,  No.  4,  June,  1921. 

Cases  of  this  type  have  first  been  described  by  Kramer  in  1904.  They  represent 
a  typical  congenital  deformity  of  the  foot.  Helbing  found  among  5,000  orthopaedic 
cases  five  times  metatarsus  varus  congenitus.  The  characteristic  point  of  this 
deformity  is  the  deviation  of  the  second  to  fifth  metatarsals  which  form  an  arc 
curved  outward,  the  metatarsals  being  adducted  and,  to  a  slight  degree,  plantar 
flexed.  There  is  also  a  typical  broadening  of  the  region  of  the  metatarso- 
phalangeal joints  caused  by  the  fan-shaped  deviations  of  the  metatarsi.  The 
first  metatarsal  bone  is  not  curved  but  simply  adducted. 

The  posterior  part  of  the  foot,  in  cases  which  already  have  walked,  is  in 
position  of  pronation  so  that  the  foot  seen  from  behind  looks  like  a  pronated  foot. 
In  the  cases  of  Froelich,  there  was  an  unusual  development  of  the  big  toe  and 
extraordinary  mobility.  Cramer  distinguishes  between  the  pes  adductus  and 
the  metatarsus  varus,  the  latter  being  characterized  by  the  general  curving  of 
the  foot  already  mentioned.  In  the  metatarsus  adductus,  the  curving  of  the 
metatarsals  is  missing,  and  there  is  simply  a  medial  deviation  of  the  metatarsi. 

The  mobility  of  the  foot  in  both  instances  is  limited  in  regard  to  pronation 
and  abduction.  There  is  also  a  flattening  of  the  arch  and  secondary  deformities 
of  the  toes  to  be  considered  as  complicating  symptoms. 

A  case  of  this  type  is  described  by  the  author.  In  this  case,  there  was  also  a 
spina  bifida  occulta  which,  in  view  of  the  progressive  character  of  the  deformity,, 
leads  one  to  assume  a  causal  connection  between  the  deformity  of  the  spine  and 
the  deformity  of  the  foot,  similar  to  what  has  been  described  in  regard  to  spina 
bifida  and  hollow  clawfoot  by  Bibergeil  and  Duncker.     It  is  quite  possible  that 


CURRENT  ORTHOPAEDIC  LITERATURE  18T 

the  adduction  of  the  forefoot  will  be  brought  about  by  pure  muscle  action  such 
as  might  be  at  work  in  conditions  of  muscular  unbalance  due  to  spina  bifida 
occulta.  In  this  case,  however,  there  was  such  an  extensive  displacement  of 
the  scaphoid  toward  the  lateral  side  of  the  foot  that  the  author  doubts  that  it 
could  have  been  brought  about  by  muscle  action  alone. 

In  this  particular  point,  the  case  of  the  author  is  rather  unique,  as  the  dis- 
placement of  the  scaphoid  has  not  yet  been  described  (with  the  possible  exception 
of  Terterianz'  case). 

Manual  redressment  is  the  generally  employed  measure  for  correction  of  the 
deformity.    Redressment  should  be  carried  out  at  an  early  age. 

A  description  of  the  technique  has  been  furnished  by  Froelich.  He  adds  to  the 
redressment  in  cases  with  pronounced  abduction  of  the  big  toe  the  osteotomy  of 
the  first  metatarsal  and  oblique  section  of  the  extensor  hallucis.  Other  methods 
described  have  been  the  reefing  of  the  peroneal  tendons  and  the  transplantation 
of  the  tibialis  anticus  to  the  lower  median  surface  of  the  scaphoid  and  the 
tendon  of  the  abductor  hallucis  from  the  median  to  the  lateral  sesamoid  bone. 
In  the  case  described  by  the  author,  another  operative  procedure  was  adopted 
which  is  described  as  follows: 

A  piece  of  bone  taken  from  the  tibia  was  implanted  into  the  fissure  between, 
the  head  of  the  astragalus  and  the  inner  cuneiform  bone.  The  operation  was 
successful  and  the  correction  complete.  Plaster  of  Paris  dressings  were  applied 
and  worn  for  about  three  months  and  were  then  followed  by  a  celluloid  arch, 
support.  One  year  after  the  operation,  the  mobility  of  the  foot  had  increased 
and  the  patienit  was  able  to  be  on  her  feet  all  day  long. — A.  Steindler,  Iotoa 
City,  la. 


METABOLIC  DISEASES 

Etiological    Treatment   of   the    Rachitic    Deformities  of   the   Thorax.      R. 
Boeckh.    Archiv  Orth.  und  Unfall.  Chir.,  Vol.  Id,  No.  2,  July,  1921. 

Quisling  found  among  1000  rachitic  children,  rickets  of  the  skull  316  times, 
rickets  of  the  spine  47  times,  rickets  of  the  extremities  592  times,  dentitions 
rickets  233,  and  rickets  of  the  thorax  694.  In  the  rachitic  .thorax  there  is  a 
decided  difference  in  the  sagittal  diameter  in  the  upper  half  as  compared  with 
the  lower  half.  While  the  sagittal  diameter  in  the  upper  part  of  the  thorax  is 
unusually  large,  it  becomes  very  much  shorter  in  the  lower.  There  is  also  a 
prominence  of  the  sterno-clavicular  portion  of  the  upper  aperture,  a  depression! 
of  the  parasternal  region  and  a  spreading  of  the  lateral  portion  of  the  lower 
aperture.  In  the  normal  child,  in  each  expiration,  the  abdomen  protrudes  slowly 
while  the  thorax  shows  no  or  little  movement.  In  the  rachitic  child,  the 
thoracic  movements  are  vastly  different  The  dome  of  the  diaphragm  moves 
more  in  lateral  direction  than  up  and  down  and  the  lateral  portion  of  the  thorax 
shows  a  very  distinct  inspiratory  depression.  Both  the  pressure  of  the  arms 
touching  the  thorax  laterally  and  the  action  of  the  diaphragm  are  made  responsi- 
ble for  the  deformities  of  the  thorax,  which,  in  short,  consists  in  the  protrusion 
of  the  anterior  thorax,  the  chicken  breast,  the  retraction  of  the  parasternal 
portions  of  the  thorax,  the  transverse  furrow  around  the  thorax,  and  finally* 


188  CURRENT   ORTHOPAEDIC   LITERATURE 

the  spreading  of  the  lower  aperture  and  the  protrusion  of  the  abdomen.  It  is 
a  matter  of  experience  that  a  large  percentage  of  the  rachitics  have  adenoids, 
and  the  author  believes  that  these  contribute  in  a  large  measure  to  the  thoracic 
deformities.  The  child  with  adenoids  has  to  call  upon  his  auxiliary  respiratory- 
muscles,  of  which  the  scaleni  and  the  sternocleido  mastoid  are  especially  im- 
portant. The  action  of  these  muscles  pulls  the  upper  aperture  of  the  thorax 
upward. 

In  accordance  with  these  views,  the  author  endeavors  to  direct  the  therapy 
towards  the  causative  agents  of  this  deformity,  namely,  the  removal  of  adenoids 
and  other  obstacles  in  the  upper  air  passages,  such  as  nasal  polyps  and  hyper- 
trophic tonsils.  In  addition  to  this,  he  also  uses  an  abdominal  binder  which 
reduces  the  protrusion  of  the  abdomen  and  supports  the  weakened  abdominal 
muscles.  It  is  the  author's  opinion  that  the  physical  therapy  of  rickets  of  the 
thorax  should  begin  as  soon  as  the  diagnosis  is  made  and  as  soon  as  the  general 
treatment  of  rickets   is  being  instituted. — A.   Steindler,  Iowa   City,  la. 


Schlatter's   Disease   and   Frequent    Symptoms   of   Late   Rickets.      Bernard 
Hinrichs.    Zeit.  orth.  Ghir.,  Vol.  41,  No.  3,  May,  1921. 

The  ossification  of  the  tibial  apophysis  occurs  mostly  between  the  12th  and 
15th  year.  Between  the  first  appearance  of  the  bone  nucleus  and  the  completion 
of  ossification,  not  more  than  three  to  four  months  are  required.  Only  a  thin 
cartilage  zone  remains  between  the  tuberosity  and  the  tibial  diaphysis  to  about 
the  18th  year.  The  apophysis  sends  a  process  over  the  anterior  surface  of  the 
head  of  the  tibia  while  from  below  an  independent  bone  nucleus  grows  against 
it  until,  at  the  level  of  the  epiphyseal  disk,  the  fusion  occurs.  According  to 
Bergmann,  there  exists  even  in  the  normal,  an  extraordinary  irregularity  of  the 
ossification.  Schlatter  concludes  that  there  are  extrinsic  factors  which  contribute 
to  the  condition,  for  instance,  that  the  ossifying  apophysis  is  easily  exposed  to 
direct  or  indirect  traumatism,  especially  at  the  point  of  junction  between  the 
upper  or  the  lower  apophysis.  However,  in  the  majority  of  the  cases  reported, 
there  is  no  mention  of  a  trauma. 

Thompson  reports  a  periostitis  at  the  point  of  insertion  of  the  ligamentum 
patellae  caused  by  pull  of  the  quadriceps.  Kienbock,  upon  the  basis  of  his 
radiological  findings,  concludes,  at  least  for  part  of  the  cases,  that  there  exists 
an  active  destruction  of  the  bone  of  the  tuberosity  together  with  an  inflammatory 
reactive  swelling;  in  other  words,  an  osteochondritis.  Ebbinghaus  considers  the 
condition  as  an  epiphysitis  desiccans  traumatica.  So  it  appears  that  the  views 
on  the  etiology  of  this  deformity  are  by  no  means  in  harmony.  It  was  Joachims- 
thal  who  pointed  out  that,  aside  from  inflammatory  changes,  pathological  changes 
of  ossification  analogous  to  those  seen  in  late  rickets  are  to  be  found.  Similarly, 
Fromme,  in  a  large  clinical  material,  found  that  a  number  of  cases  afflicted  with 
late  rickets  showed  the  signs  of  Schlatter's  disease, — deducing  from  it  that 
Schlatter's  disease  occurs  in  the  majority  of  cases  in  patients  afflicted  with  late 
rickets.  The  author  has  subjected  the  reports  in  the  literature  to  a  critical 
study.  He  points  out  that  if  severe  changes  are  seen  on  the  long  pipe  bones  in 
regard  to  ossification  and  growth,  in  an  individual  afflicted  with  late  rickets, 
such  would  also  have  to  be  expected  to  occur  in  the  tibial  apophysis  where  a 
comparatively  thin  bone  plate  rests  upon  a  thick  layer,  of  cartilage.     The  pull 


CURRENT   ORTHOPAEDIC   LITERATURE  189 

of  the  quadrh »J *  tendon  may  easily  lift  the  process  off  its  cartilage  base  and 
cause  a  kinking  of  the  base  of  the  apophysis.  Severe  signs  of  late  rickets  ex- 
isted in  all  cases  which  were  studied.  The  author  concludes  that  Schlatter's 
disease,  in  many  eases  at  least,  is  merely  a  symptom  of  late  rickets. 

It  occurs  in  a  portion  of  the  tibia  which  by  virtue  of  its  anatomical  configura- 
tion and  its  exposed  situation  is  especially  open  to  direct  or  indirect  traumatism. 
But  in  all  cases  in  which  the  changes  occur  without  traumatic  influence,  one 
should  think  of  late  rickets:  (It  is  to  be  regretted  that  the  author  does  not  use 
the  term  Osgood-Schlatter's  disease). — A.  Steindltr,  Iowa  City,  la. 


The  Origin  of  the  Genu- Valgum  from  the  Pes  Valgus.    Elizabeth  E.  Schmidt. 
Zeit.  orth.  Ch.,  Vol.  41,  Nos.  1,  2 ;  April,  1921. 

Hueter's  explanation  of  the  genu-valgum  was  based  upon  difference  of  growth 
in  the  outer  and  inner  halves  of  the  epiphysis.  According  to  his  view,  there  is 
increased  pressure  on  the  outside  of  the  joint  while  the  pressure  on  the  inside  is 
diminished.  In  consequence,  there  is  atrophy  of  the  outer  and  hypertrophy  of 
the  inner  condyle  of  the  femur  (the  assumption  of  the  relation  between  atrophy 
and  pressure  is,  for  the  cartilaginous  tissue,  open  to  grave  doubt).  Mikulicz 
pointed  out  that  deformity  is  not  situated  in  the  epiphysis,  but  rather  in  the 
diaphysis.  He  considers  the  abnormal  slenderness  of  the  femur  and  constitu- 
tional changes  akin  to  rickets  as  the  cause  of  the  deformity.  Julius  Wolff  sees 
the  cause  of  the  transformation  in  the  change  of  the  static  condition  under 
which  the  extremity  functionates  so  that  the  genu-valgum  represents  nothing 
else  but  the  functional  readaptation  of  bene  and  soft  parts  of  the  extremity  to 
the  repeated  outward  rotation  of  the  leg. 

Schanz  pointed  out  that  the  abnormal  position,  such  as  over-extension,  out- 
ward rotation  and  abduction  in  the  knee,  is  already  an  effect  of  genu-valgum. 
All  these  theories  have  been  criticized  by  Lange,  who  remarks  that  it  is  by  no 
means  clear  why  an  extraordinary  strain  of  the  knee  joint  causes  genu-valgum. 
Thigh  and  leg  formed  under  normal  conditions  have  already  an  angle  which 
opens  laterally.  It,  therefore,  could  be  expected  that  any  abnormal  weight- 
bearing  upon  the  leg  wdll  increase  this  angle  and  cause  knock-knee  deformity. 
Of  interest  is  the  observation  of  Francke,  who  established  by  investigations  on 
1,099  people,  that  usually  the  bow-legged  and,  more  rarely,  the  normal  shaped 
legs  of  the  children  become  knock-kneed  when  walking  is  begun. 

In  order  to  establish  the  static  conditions  which  lead  to  knock-knee  deformity, 
the  author  has  made  studies  upon  a  model  in  which  the  effect  of  pes  valgus  u'pon 
the  knee-joint  was  investigated. 

She  finds  that  in  all  cases  the  genu-valgum  presupposes  a  pes  valgus,  that 
it  only  appears  in  combination  with  knock-ankle.  From  the  third  year  on,  the 
most  common  deformity  is  the  knock-knee. 

Fifty-five  per  cent,  of  the  children  suffering  from  pes  valgus  also  showed  more 
or  less  knock-knee  deformity;  consequently,  the  treatment  should  be  directed 
toward  the  correction  of  the  pes  valgus.  This  is  accomplished  by  insoles,  wedges, 
and  especially  by  active  exercises  which  develop  the  varus  position  of  the  foot 
To  these  are  added  passive  manipulations  by  means  of  straps  which  hold  the 
legs  in  middle  rotation  and  the  foot  in  varus  position.     The  author  believes 


190  CURRENT  ORTHOPEDIC  LITERATURE 

that  the  treatment  is  so  effective  that  if  continued  too  long,  the  opposite  deform- 
ity may  develop.  ( ! ) 

She  concludes  that  the  genu-valgum  represents  an  adaptation  of  the  extremity 
to  the  shifting  of  the  plumb  line  outward  which  is  caused  by  the  existing  pes 
valgus.  The  changes  in  the  joint  consist  in  stretching  of  the  capsular  apparatus 
of  the  knee-joint,  causing  a  flail  joint  and  leading  subsequently  to  characteristic 
changes  of  the  bone. 

The  X-ray  shows  that  the  bony  changes  are  situated  mostly  in  the  diaphysis 
of  femur  and  tibia,  while  the  epiphyses  are  not  changed. 

In  a  large  number  of  the  cases  examined,  there  was  found  hypertrophy  of  the 
lateral  portion  of  the  cortical  bone  of  the  tibia,  which  is  considered  as  an 
expression  of  the  adaptation  of  the  deformity,  conforming  to  Wolff's  Law. 

The  treatment  which  is  directed  toward  the  correction  of  the  pes  valgus  results 
in  complete  cure  of  the  knock-knee  deformity  and  proves,  according  to  the 
author,  that  the  knock-knee  is  secondary  to  pes  valgus. — A.  Steindler,  Iowa  City, 
Iowa. 


TRAUMATISMS. 

Injuries  of  the  Feet.     U.  V.  Portmann  and  F.  C.  Warnshuis.     Jour.  A.  M.  A., 
April  30,  1921,  p.  1214. 

This  is  a  very  instructive  paper  and  merits  the  attention  of  any  one  who  is 
engaged  in  industrial  work.  The  authors  state  that  of  all  industrial  accidents 
20  per  cent,  are  of  the  feet,  and  they  are  usually  looked  upon  as  minor  injuries, 
a  short  convalescence  is  expected,  and  we  are  always  disappointed.  The  follow- 
ing management  of  foot  injuries  is  advised ;  immediate  rest  and  elevation,  x-ray, 
early  motion  if  joints  are  involved,  every  wound  treated  as  infected,  but  care 
is  to  be  exercised  in  making  incisions. — C.  B.  Francisco,  Kansas  City,  Mo. 


Dislocation  of  the  Sacro-iliac  Joint.    Alexander  Gibson.    Jour.  A.  M.  A.,  May 
28th,  1921,  p.  1487. 

One  case  is  reported  in  a  boy  eight  years  old  who  was  in  an  automobile  that 
was  struck  by  a  train  and  he  was  generally  severely  injured.  Three  days  later 
the  diagnosis  of  dislocation  of  the  left  sacro-iliac  was  made,  and  a  week  later  the 
x-ray  confirmed  it  and  did  not  show  any  fractures.  Three  weeks  later  at  opera- 
tion the  projecting  posterior  ilium  was  sawed  through,  the  adjacent  sacrum  was 
freshened,  the  dislocation  reduced,  the  piece  of  ilium  replaced  and  the  child 
made  a  perfect  recovery. 

The  statement  is  made  that  these  conditions  are  rare. — C.  B.  Francisco,  Kansas 
Oity,  Missouri. 


A  Case  of  Bilateral  Dislocation  of  the  Hip-Joint.     Walter  G.  Stern.     Jour. 
A.  M.  A.,  May  28,  1921,  p.  1496. 

Stern's  case  was  a  woman  22  years  old,  who  was  thrown  from  a  speeding 
automobile  and  hurled  across  ,the  pavement,  striking  the  curb  feet-foremost. 
She  at  first  complained  so  much  of  pain  in  her  right  foot  and  leg,  in  which  she 
had  a  complete  peroneal  palsy,  that  her  hips  were  overlooked  for  seven  weeks, 


CURRENT  ORTHOPAEDIC  LITERATURE  191 

at  which  time  she  was  placed  on  the  Hibbs  table  for  reduction  of  the  right  hip 
and  it  was  discovered  that  the  left  hip  was  also  dislocated.  She  had,  however, 
never  complained  of  the  left  leg  or  hip.  No  difficulty  was  encountered  in  the 
reduction.    This  is  the  fortieth  case  recorded. — C.  B.  Francisco,  Kansas  City,  Mo. 


Dislocation  of  Radius  Forward  at  Inferior  Radio-Ulnab  Joint.     L.  Rogers. 
British  Med.  Jour.,  April  30,  1921. 

One  case  is  reported,  this  being  a  man  39  years  old  who  received  an  injury 
while  cranking  his  car.  A  fractured  carpal  bone  was  suspected  bu,t  x-ray  re- 
vealed only  a  forward  dislocation  of  the  radius  at  its  ulnar  articulation.  Reduc- 
tion was  easy  and  a  good  result  reported. — C.  B.  Francisco,  Kansas  City. 


Observations   Based  on   a  Study   of   Injury   to  the   Elbow.     Isidore   Oohn. 
Annals  of  Surgery,  Sept.,  1921,  p.  357. 

i 

A  careful  study  of  x-ray  plates  in  the  normal  elbow  shows  that  if  (the  joint 
be  flexed  to  a  right  angle  a  lateral  view  shows  the  capitellum  occupying  the 
sigmoid  cavity.  In  early  life  there  seems  to  be  a  wide  separation  between  the 
articular  surface  of  the  capitellum  and  the  great  sigmoid  cavity,  but  with  growth 
the  capitellum  comes  to  occupy  the  entire  cavity.  In  cases  of  injury  there  is  a 
disturbance  of  this  relationship  between  the  capitellum  and  the  greater  sigmoid 
cavity. 

A  plane  passed  through  the  middle  of  the  long  axis  of  the  humerus  prior  to 
about  the  eighth  year  passes  behind  the  posterior  border  of  the  capitellum ;  after 
this  period  the  plane  bisecting  the  shaft  of  the  humerus  has  approximately  two- 
thirds  of  the  lower  epiphysis  anterior  to  it.  A  plane  at  right  angles  to  the  base 
of  the  capitellum  and  bisecting  it  intersects  the  plane  through  the  middle  of 
the  long  axis  of  the  shaft  at  an  angle  of  about  130°.  With  the  forearm  extended 
on  the  arm  and  supinated,  a  plane  passed  through  the  long  axis  of  the  humerus 
is  intersected  by  a  plane  through  the  middle  of  the  axis  of  the  ulna  at  an  angle 
of  approximately  170°.  A  careful  history  and  thorough  clinical  examination 
plus  the  use  of  these  planes  in  the  study  of  the  x-rays  will  aid  greatly  in  estab- 
lishing the  diagnosis  in  cases  of  supracondylar  fractures  and  separation  of  the 
lower  humeral  epiphysis.  They  are  also  of  great  value  in  determining  if 
accurate  reduction  has  been  obtained. 

In  treatment  of  injuries  to  the  condyle  and  separation  of  the  epiphysis,  the 
acutely  flexed  position  is  used  whenever  it  is  possible.  Emphasis  is  placed  on 
position  of  the  forearm  with  reference  to  the  arm.  In  fractures  of  the  internal 
condyle  the  forearm  should  be  placed  in  pronation  because  contraction  of  the 
pronator  teres  tends  to  pronate  the  arm  and  to  pull  the  bony  fragment  away 
from  the  shaft  of  the  humerus.  In  fractures  of  the  external  condyle,  the  position 
of  greatest  stability  is  hyperflexion  and  supination. 

The  after-treatment  is  important,  and  as  hyperflexion  results  in  contracture 
of  the  flexor  group  of  muscles,  it  is  essential  to  diminish  flexion  as  early  as  it 
is  safe.  Usually  extension  is  begun  on  the  tenth  day  but  should  be  limited  by 
pain.  The  position  of  flexion  with  the  arm  across  the  chest  leads  to  weakness 
of  the  external  rotators  of  the  arm,  and  therefore  exercise  of  these  muscles 
should  begin  early. — LeRoy  C.  Abbott,  Ann  Arbor,  Michigan. 


192  CURRENT  ORTHOPEDIC   LITERATURE 


The  Retention  of  Difficult  Cases  of  Hip  Dislocation  by  Intercapsulab 
Injections  of  Alcohol.  H.  Graetz.  Zeit.  orth.  Chir.,  Vol.  41,  Nos.  1,  2; 
April,  1921. 

Absolute  alcohol  was  used  for  injection  into  the  joint  cavity.  The  amount 
injected  was  3  c.cm.  Injection  was  made  in  redislocated  position  in  order  to 
facilitate  the  introduction  of  the  needle.  Altogether  12  cases  were  treated  in 
this  way.  The  alcohol  injections  were  used  in  all  redislocations  which  occurred 
during  the  period  of  fixation  and  also  in  all  cases  in  which  there  appeared  a 
great  tendency  to  redislocation  immediately  after  reposition. 

Ideal  anatomical  and  functional  cures  were  obtained  in  seven  cases.  A  good 
functional  result  was  obtained  in  two  cases.  In  two  more  cases,  the  head 
redislocated.  Considering  the  uncertainty  which  is  peculiar  to  any  new  method 
due  to  the  deficiencies  of  the  technique,  the  author  thinks  that  the  results  are 
favorable  and  that  the  method  should  be  recommended  in  all  cases  in  which 
reduction  is  difficult.  He  has  not  observed  any  untoward  effects  of  the  alcohol 
injection  provided  certain  measures  of  precaution  were  used  such  as  the  avoid- 
ance of  the  injection  of  air. — A.  Steindler,  Iowa  City,  Iowa. 


TUBERCULOSIS. 


The  Statistics  of  Bone  and  Joint  Tuberculosis  in  the  Last  Five  Years. 
From  the  Orthopedic  Clinic  of  Dr.  Gocht.  L.  Frosh.  Archiv.  Orth.  u.  Unfall 
Chir.,  Vol.  19,  No.  2,  July,  1921. 

Among  15,000  patients,  1159  or  7.7%  were  suffering  from  bone  and  joint 
tuberculosis.  Author's  figure  is  lower  than  the  statistics  of  Biesalski  (15%) 
or  Lange  (12%).  Of  the  1159  patients,  538  or  46.4%  were  males,  and  621  or 
53.6%  females. 

Distribution  according  to  age: 

Males  Females 

1    to     5   years  133  or  24.7%  147  or  23.6% 

5   to    10      "  204  or  38.8  157  or  25.6 

10    to   15      "  93  or  16.5  126  or  20.2 

15    to   20      "  52  or    9.5  83  or  13.2 

The  predominance  of  the  first  two  quinquennia  is  evident  in  both  sexes. 
In  regard  to  localization,  the  distribution  among  the  1159  cases  was  as  follows: 

Spine     501  or  43.2% 

Hip     268  or  23.2 

Knee    199  or  17.2 

Ankle     95  or     8.2 

Wrist     50  or     4.3 

Elbow    25  or     2.2 

Shoulder     12  or     1.0 

Sacro-iliac  joint  4  or     0.3 

Diaphyseal    tuberculosis    5  or     0.4 


CURRENT  ORTHOPAEDIC  LITERATURE  193 

The  frequency  of  the  disease  of  tin-  spinr  is  noteworthy. 

I.  Tuberculosis  of  the  Spine.     Distribution: 

Of  501  cases  of  Pott's  Disease,  38  or  7*6%  involved  the  cervical  spine. 

321,  or  64.7%,  the  Dorsal  Spine. 

117,  or  22.9%,  the  Lumbar  Spine;  and 

25,  or  4.9%,  several  sections  of  the  Spine. 

The  male  sex  represented  44.5% ;  the  female,  55.5%,  of  the  cases. 

The  figures  of  the  author  are  higher  than  those  of  Nedder  in  regard  to  the 
distribution  during  different  periods  of  life. 

The  tuberculous  spondylitis  is  preeminently  a  disease  of  the  first  decade  with 
preponderance  of  the  female  sex. 

II.  Tuberculosis  of  the  Hip. 
268  cases,  of  which 

125,  or  46.6%,  were  in  the  right,  and 
143,  or  53.4%,  in  the  left  hip. 
Distribution  as  to  age: 

Males  Females 

1    to     5   years  26  or  20.8%  25  or  17.6% 

5    to    10      u  53  or  41.7  48  or  34.1 

10   to   15      "  26  or  20.8  25  or  17.6 

15   to   20      "  13  or  10.4  19  or  13.3 

All   Ages  128  or  47.8  140  or  52.2 

There  is  no  noticeable  preponderance  of  either  of  the  sexes.  The  majority  of 
the  cases  belong  to  the  first  three,  especially  the  second  quinquennia. 

III.  Tuberculosis  of  the  Knee : 
199  cases,  of  which 

133,  or  69.9%,  were  in  the  right,  and 
60  cases,  or  30.1%,  in  the  left  knee. 

This  is  a  very  remarkable  preponderance  of  Jthe  right  side  which  is  not  paral- 
leled by  the  conditions  in  the  hip. 
Distribution  according  to  age: 

Males  Females 

1   to     5   years  11  or  12.2%  20  or  18.1% 

5   to   10      "  26  or  28.4  36  or  32.7 

10   to   15      "  21  or  23.3  16  or  14.5 

15   to   20      "  17  or  18.9  12  or    9.8 

Summary :  89  males  or  44.8% ;  and  females,  110  or  55.2%,  showing  a  not 
inconsiderable  majority  in  favor  of  the  female  sex. 

IV.  Tuberculosis  of  the  Ankle,  95  cases,  with  preponderance  in  the  first  three 
quinquennia.  In  this  group,  there  are  59  males  or  62.1%,  and  only  36  females 
or  37.9%. 

V.  Tuberculosis  of  the  Wrist. 

Fifteen  cases,  of  which  the  left  wrist,  in  30% ;  the  right  in  70%. 

Distribution  according  to  age  also  shows  predominance  of  the  disease  in  the 
first  two  decades.  The  female  sex  again  is  in  prominence;  40%  males  and  60% 
females. 

VI.  In  the  series  of  tuberculosis  of  the  shoulder,  the  total  is  too  small  to 
allow  of  analysis  on  a  percentage  basis. 


]94  CURRENT  ORTHOPAEDIC   LITERATURE 

VII.  The  social  status  of  the  patients.  Of  the  1159  patients,  12.3%  belonged 
to  the  class  of  small  government  employes,  24.7%  to  the  class  of  small  business 
men,  24.0%  to  the  craftsmen,  and  26.9%  to  the  working  classes. 

Considering  the  first  three  as  middle  classes,  then  61%  of  the  patients  belong  to 
the  latter  class,  whereas  39%  belong  to  the  working  classes. 

According  to  the  author,  these  figures  again  prove  the  financial  deterioration 
of  the  middle  classes,  which  is  expressed  in  their  hygienic  condition  and  ulti- 
mately results  in  the  greater  percentage  of  these  classes  in  surgical  tuberculosis. 
The  bone  and  joint  tuberculosis  reached  its  highest  frequency  in  this  series  of 
cases  during  the  years  1918-1919. — A.  Steindler,  Iowa  City,  Ioiva. 


The  Operative  Treatment  of  Surgical  Tuberculosis.     F.  Koenig.     Arch.  kiln. 
Chir.,  Vol.  116,  No.  3,  Sept.,  1921. 

The  statistics  of  this  author  are  based  upon  a  selection  from  about  100  publi- 
cations, which  comprise  altogether  4,000  cases  with  2,000  resections. 

1.  Bier,  in  his  uncompromising  conservatism,  stands,  according  to  the  author, 
entirely  isolated.  This  surgeon  considers  that  the  resection  of  tuberculous  joints 
is  not  justified.  Amputation  might  occasionally  be  indicated  where  there  is 
concomitant  pulmonary  tuberculosis  or  a  state  of  sepsis  starting  from  the  joint. 
Since  1913,  Bier  has  performed  only  one  amputation. 

2.  Another  group  are  those  surgeons  who  first  start  conservatively  and  then 
proceed  operatively  if  conservative  treatment  fails. 

3.  A  third  group  is  formed  by  those  surgeons  who  proceed  conservatively  with 
a  number  of  cases,  but  who  in  certain  definite  cases  believe  in  primary  operations. 
Garrg  and  others  are  numbered  in  this  group. 

The  author  considers  the  questions  of  how  many  permanent  cures  are  obtained 
by  successful  resection  and  what  is  the  function  of  the  limb.  The  study  of  the 
statistical  table  involving  2,000  resections  performed  by  twenty  authors  shows 
that  in  over  68%  of  the  cases  a  permanent  cure  was  obtained,  all  joints  con- 
sidered. As  far  as  the  function  of  the  cured  joints  is  concerned,  the  author 
considers  the  flail  joint  as  the  poorest  result.  This  was  seen  three  times  in 
148  cases  of  elbow  resection,  several  times  in  over  700  cases  of  heel-knee  resec- 
tions, and  twice  in  the  ankle  joint.     It  was  noticed  once  in  hip  joint  resection. 

Shortening  is  a  much  dreaded  complication,  especially  in  children,  after 
resection  of  the  knee.  Garre's  report  on  114  resections  in  children  showed  an 
average  shortening  of  2.8  cm.  As  regards  the  wrist,  opinions  are  divided. 
Kocher  reports  75%   of  good  results. 

The  functional  results  do  not  only  depend  upon  the  operative  technique,  but 
also  upon  a  long-continued  and  carefully  carried  out  mechanical  after-treatment. 
Summing  up  his  conclusions,  the  author  states  that  reliable  statistics  on  the 
permanent  results  of  the  purely  conservative  treatment  in  severe  joint  and  bone 
tuberculosis  do  not  exist  on  a  larger  scale.  On  the  other  hand,  we  know  from 
the  study  of  the  investigations  mentioned  that  truly  permanent  cures  may  be 
obtained  by  resection  in  a  remarkably  high  percentage  of  the  severest  cases. 
In  view  of  these  facts,  the  author  feels  inclined  to  formulate  the  indications 
for  operation  in  bone  and  joint  tuberculosis  as  follows: 

1.  Find  the  tuberculous  foci,  especially  in  the  neighborhood  of  the  joints.  In 
case  of  perforation  into  the  joint,  resection  is  justified. 


CURRENT  ORTHOP-fiDlC  LITERATURE  195 

2.  One  should  also  operate  in  cases  of  severe  secondary  infection. 

3.  In  cases  of  synovial  tuberculosis  which  progress  in  spite  of  conservative 
treatment,  and  penetrate  into  the  neighborhood,  one  should  not  wait  until 
nothing  else  is  left  for  the  amputation,  but  the  decision  for  operation  should  be 
made  much  sooner. 

4.  In  adults,  the  decision  to  resect  should  generally  be  made  much  quicker 
than  in  children. 

Nevertheless,  in  many  cases,  the  conservative  method  is  exclusively  indicated, 
and  even  in  resected  cases,  the  conservative  means  must  be  employed  before 
and  after,  since  the  operation  accomplishes  not  the  removal  of  the  tuberculous 
focus,  but  rather  a  localizing  of  the  tuberculous  disease.  All  in  all,  he  believes 
that  at  the  present  time  resection  in  the  treatment  of  bone  and  joint  tuberculosis 
is  a  necessary  factor  in  a  large  number  of  cases. — A.  Steindler,  Iowa  City,  Iowa. 


The  Conservative  Treatment  of  the  So-Called  Surgical  Tuberculosis.  A.  Bier. 
Arch.  klin.  Chir.,  Vol.  116,  No.  1,  July,  1921. 

The  author  assumes  an  almost  unique  attitude  in  regard  to  the  treatment  of 
surgical  tuberculosis.  In  the  first  place,  he  turns  against  such  operative 
indications  as  are  recognized  even  by  followers  of  the  conservative  trend  of 
treatment. 

He  does  not  admit  the  indication  for  operation  in  cases  of  extracapsular  foci 
in  the  neighborhood  of  a  joint,  because  he  thinks  that  these  foci  heal  under 
conservative  treatment  with  considerable  certainty. 

2.  He  does  not  recognize  larger  sequestra  as  indications  for  operation.  Here 
he  thinks  the  operation  superfluous,  because  under  conservative  treatment  seques- 
tra become  absorbed;  occasionally  they  even  regenerate  and  take  part  in  thp 
formation  of  new  bone.  The  absorption  of  sequestra  takes  place  not  only  in 
closed  but  also  in  open  forms  of  tuberculosis  with  mixed  infection. 

3.  He  does  not  recognize  subluxation  of  the  joint,  especially  of  the  knee-joint, 
as  indication  for  resection  because,  as  he  says,  such  subluxation  can  easily  be 
remedied  by  simple  conservative  measures. 

4.  He  does  not  recognize  the  operation  in  cases  of  spina  ventosa,  considering 
that  these  manifestations  do  not  represent  the  only  focus  and  therefore  with 
their  removal  no  complete  cure  is  obtained. 

5.  He  does  not  consider  deep  cold  abscesses  as  operative  indications,  as  they 
disappear  spontaneously.    He  only  attacks  superficial  abscesses  by  puncture. 

He  condemns  the  costo-transversectomy  on  the  grounds  that  ,the  abscesses  of 
the  thorax  disappear  under  conservative  treatment. 
He  never  performs  Albee's  operation,  which  he  considers  useless. 

6.  Advanced  age  is,  according  to  Bier,  no  contraindication  to  conservative 
treatment.  He  admits,  however,  that  in  rare  cases  it  might  be  indicated  in  very 
old  and  decrepit  patients  to  amputate  a  leg  in  sufferers  from  tuberculosis  of 
the  foot  or  knee. 

Bier  has  religiously  refrained  from  operation  in  surgical  tuberculosis.  He 
has  operated  (amputated)  only  once  in  seven  years,  in  one  case.  This  case  was 
amputated  in  the  leg  because  one  patient  insisted  upon  it.  Half  a  dozen  further 
operations  were  carried  out  in  the  clinic  because  of  the  diagnosis  being  undecided 
between  sarcoma  and  tuberculosis  or  because  the  patients  refused  conservative 


396  CURRENT  ORTHOPAEDIC  LITERATURE 

treatment.     The  author  then  proceeds  to  a  description  of  his  method  of  con- 
servative  treatment. 

1.  Heliotherapy  as  developed  by  Bernhard  and  Rollier.  Rollier's  contention 
that  the  pigment  produced  by  the  sun  transforms  the  short-wave  ultra-violet 
into  long-wave  rays  which  penetrate  deeply  into  the  body,  is,  for  reason  of 
physics,  untenable.  As  a  matter  of  fact,  there  is  no  proof  that  the  sun's  rays 
have  a  specific  curative  influence  upon  tuberculosis  foci.  It  is  to  the  pigment  to 
which  such  an  action  is  ascribed  generally.  Pigmentation  is  proportionate,  ac- 
cording to  Bernhard  and  Rollier,  to  the  individual  resistance,  and  proportionate 
to  the  latter,  is  the  curative  action  of  the  sun.  For  this  reason,  it  is  maintained 
that  dark-complexioned  people  respond  better  than  blondes.  However,  all  these 
theories  are  more  or  less  problematical  and  exact  scientific  proof  is  still  lacking. 

Artificial  light  is  used  by  Bier  in  substitution  for  sunlight.  He  does  not  recog- 
nize specific  and  favorable  action  of  the  violet  and  ultra-violet  rays,  but  considers 
all  colors  of  the  spectrum  effective. 

2.  The  second  conservative  method  used  by  the  author  in  the  treatment  of 
tuberculosis  is  a  passive  hyperaemia.  As  early  as  1913,  the  author  was  in 
position  to  present  a  number  of  cases  of  a  very  severe  joint  tuberculosis  which 
were  healed  by  application  of  passive  hyperaemia  and,  internally,  of  iodides. 

3.  The  third  means  which  is  used  in  conjunction  with  the  two  first  mentioned 
are  the  iodides,  given  daily  in  doses  of  about  50  grains,  as  potassium  iodide. 
Iodine  is  an  old  remedy  for  tuberculosis,  especially  does  it  act  very  favorably  in 
conjunction  with  passive  hyperaemia,  inasmuch  as  it  avoids  or  obviates  the 
disagreeable  effects  of  the  hyperaemia,  consisting  in  the  formation  of  cold  ab- 
scesses and  the  proliferation  of  granulation  tissue.  The  author  has  used  tubercu- 
lin in  his  institute  at  Hohenlychen  only  in  the  after-treatment  and  for  the 
prevention  of  recurrences,  but  has  abandoned  it  now  entirely.  He  has  nothing 
to  say  about  Friedmann's  serum  and  does  not  consider  it  in  any  way  effective. 

Bier  states  emphatically  that  he  has  abandoned  all  plaster  of  Paris  and  other 
immobilizing  bandages  or  apparatus,  having  entertained  a  violent  opposition  to 
these  measures  for  many  years.  He  says  that  joint  tuberculosis  demands  avoid- 
ance of  weight-bearing,  but  not  immobilization.  The  immobilizing  casts  are  not 
only  superfluous,  he  says,  but  also  harmful,  because  they  lead  to  stiffening  of  the 
joints.  He  eliminates  weight-bearing  simply  by  bed  rest.  Contractures  and 
faulty  positions  are  remedied  by  traction,  which  acts  with  absolute  certainty 
and  perfection,  so  that  the  so-called  orthopaedic  operations  are  only  rarely  indi- 
cated,— except  in  such  cases  as  reach  his  clinic  already  in  a  state  of  ankylosis. 

Active  motion  is  carried  out  in  all  diseased  joints  as  soon  as  the  pain  sub- 
sides. He  considers  it  a  rule  that  such  motion  should  never  cause  pain.  In  the 
same  way  as  weight-bearing,  so  also  pain  acts  destructively  upon  bone  and  joints, 
and  provokes  ankylosis  because  it  causes  muscle  spasm  and  contractures, 
which  press  the  diseased  joint  bodies  against  each  other.  Nothing,  he  says,  is 
as  destructive  as  harmful  pressure.  If  you  relieve  the  pain,  you  stop  the  destruc- 
tive pressure,  the  contractures  disappear,  and  careful  movements  may  be 
carried  out  with  impunity.   ( ! ) 

He  then  proceeds  to  state  that  with  the  treatment  outlined  above,  he  is  able 
po  remove  what  he  calls  ankylosing  pain  in  a  period  of  one  to  two  weeks.  Then 
he  allows  motion,  and  he  never  encounters  ankylosis  any  more  in  cases  which 
show  even  a  small  remainder  of  mobility.     So  the  three  remedies  which  this 


CURRENT  ORTHOPAEDIC  LITERATURE  197 

author  considers  as  effective  and  legitimate  are:  the  sun  cure,  and,  incidentally, 
artificial  light;  passive  hyperaemia;  and,  lastly,  the  internal  use  of  iodides. 
By  far  the  most  potent  of  these  factors  is  the  sun  cure,  the  efficiency  of  which 
is  not  approached  by  any  of  the  others. 

According  to  Bier  the  sun  cure  is  not  necessarily  limited  to  high  altitudes 
or  to  dry  climate,  but  it  can  be  carried  out  under  less  selected  climatic  conditions. 
(Inasmuch  as  this  point  has  already  been  noted  by  Rollier  himself,  it  is  not 
necessary  to  dwell  upon  it) 

In  his  institute,  xthe  author  has  treated  in  the  last  seven  years,  1,389  cases 
of  tuberculosis.  His  statistics  show  that  although  the  patients  were  recruited 
from  the  poorest  classes,  over  70  per  cent,  were  cured  and  20  per  cent  improved. 
The  author  concedes,  however,  that  without  doubt  there  are  a  number  of  cases 
which  show  recurrences  although  discharged  as  cured;  just  as,  on  the  other 
hand,  many  discharged  as  improved  ultimately  will  be  cured.  He  does  not 
state  what  became  of  the  other  10  per  cent. 

Turning  to  the  pathological  details,  the  author  discusses  the  effect  of  the 
conservative  treatment  upon  different  structures  involved: 

1.  Sequestra  do  not  have  to  be  operated  upon,  because  they  disappear  sponta- 
neously, almosjt  without  exception,  or  are  often,  as  it  seems,  used  for  the  forma- 
tion of  new  bone.  That  tuberculous  sequestra  frequently  heal,  author  knows 
from  findings  in  so-called  orthopaedic  resections  of  healed  tuberculous  joints, 
in  which  one  frequently  finds  sequestra  imbedded  in  granulation  and  *connective 
tissue.  Bernhard  and  Rollier  point  out  .that  the  heliotherapy  causes  the 
extrusion  of  sequestra  through  sinuses.  Bier,  however,  says  that  he  observed 
an  extrusion  only  in  exceptional  cases,  and  that  the  resorption  of  the  sequestra 
is  a  regular  occurrence.  At  any  rate,  under  his  treatment,  there  never  occurred 
the  necessity  of  removing  even  large  sequestra. 

2.  Extracapsular  foci  heal  spontaneously  even  if  the  joint  is  already  infected. 
On  the  other  hand,  even  the  operative  removal  of  the  focus  before  invasion  of 
the  joint,  does  not  protect  the  latter  from  becoming  infected. 

3.  Bier  states  that  his  x-rays  show  the  disappearance  of  spondylitic  abscesses 
of  the  spine.    He  considers  for  this  reason  Albee's  operation  entirely  useless.  (  ! ) 

A  further  assertion  of  Bier's  is  that  deformities  of  joints,  existing  during  the 
course  of  tuberculosis  and  before  the  cure  is  accomplished,  can  be  remedied  by 
his  conservative  means,  as  the  tuberculous  bone  is  soft  and  pliable.  By  this 
he  means  the  correction  of  knock-knees,  bow-legs,  in  or  outward  rotation, 
subluxation,  etc.  He  furthermore  aims  to  show  that  there  is  a  high  degree  of 
completeness  in  the  regeneration  of  joints  and  bones;  but  even  if  regeneration 
is  incomplete  following  severe  destruction,  the  function  is  often  very  excellent. 

Bier  further  states  that  one  should  not  hasten  with  the  establishment  of  new 
joints  by  arthroplasties,  in  these  cases  of  ankylosis  from  tuberculosis.  He  has 
produced  nearthroses  after  30  years  of  ankylosis.  If  one  operates  too  soon, 
there  is  danger  of  recurrence  of  tuberculosis. 

He  has  healed  by  heliotherapy  also  several  forms  of  lupus,  especially  erythe- 
matoses. 

He  has  healed  the  capsular  fungus  of  the  knee-joint  considered  so  extremely 
refractory  to  treatment.  And  he  has  also  healed  the  indurated  form  of  tuber- 
culous glands. 


198  CURRENT  ORTHOPEDIC  LITERATURE 

One  of  the  difficulties  of  the  treatment  is  its  long  duration  during  which  the 
patient  is  condemned  to  idleness. 

Of  his  1389  patients  treated  in  his  institute,  54  or  3.8  per  cent.  died.  Cause 
of  death  was  as  follows: 

Amyloid  degeneration  18 

Meningitis  . 14 

Miliary  tuberculosis 1 

Pulmonary    6 

The  rest  divided  among  different  conditions. 

In  defense  of  his  high  rate  of  amyloid  death,  this  author  maintains  that  most 
of  these  probably  reached  his  institute  when  already  afflicted  with  amyloidosis. 

Inasmuch  as  70  per  cent,  of  all  his  cases  had  open  sinuses,  the  large  number 
of  amyloidoses  may  be  easily  explained. 

When  the  disease  has  healed  both  clinically  and  radiologically,  the  diseased 
joints  were  encased  in  Hessing  apparatus,  but  without  permanent  immobiliza- 
tion. They  are  merely  exempt  from  weight-bearing.  In  spinal  cases,  a  corset 
is  applied. 

The  author  concludes  by  pointing  out  the  difficulty  of  the  differential  diagnosis 
which  seems  to  be  increasing  the  more  experience  one  gathers  in  the  field  of 
tubercular  disease  of  bones  and  joints.  This  is  because  of  the  number  of  cases 
of  syphilis,  gonorrheal  arthritis,  and  Perthes'  disease,  which  constantly  simulate 
the  clinical  picture  of  tuberculosis.  (This  abstract  is  given  here  on  account  of 
the  most  unusual  and  strange  view  held  by  this  prominent  surgeon ;  the  abstractor 
cannot  suppress  a  feeling  of  comfort  in  the  thought  that  he  is  not  responsible 
for  any  of  these  statements.) — A.  Steindler,  Iowa  City,  la. 


PARALYSIS 


Paralysis  in  Children  Due  to  the  Bite  of  Wood-ticks.    P.  D.  McCornack,  M.D. 
Journal  A.  M.  A.,  July  23,  1921. 

Adults  are  rarely  affected,  practically  all  cases  reported  being  children.  The 
tick  season  is  from  February  to  August.  The  ticks  are  found  in  British  Colum- 
bia, Washington,  Oregon,  Idaho,  Montana,  Minnesota,  Colorado,  Iowa,  and  cases 
also  reported  from  Cape  Colony  and  Australia.  The  wood-tick  mostr  commonly 
found  is  Dermacentor  venustus  which  is  also  responsible  for  the  transmission  of 
Rocky  Mountain  spotted  fever.  No  parasites  have  been  found  and  bouillon 
cultures  from  diseased  animals  have  remained  sterile.  Experimentally,  paralysis 
has  always  been  produced  through  the  agency  of  tick  bites,  but  it  has  been 
impossible  to  transmit  the  disease  by  inoculations. 

The  nature  of  the  disease  has  not  been  determined.  The  inoculation  period 
is  from  six  to  eight  days.  The  paralysis  may  be  explained  as  resulting  from 
toxins  absorbed  from  the  ticks  and  elaborated,  especially  at  the  time  when 
engorgement  is  complete.    One  attack  seems  to  confer  a  lasting  immunity. 

At  the  point  of  attachment  of  the  tick  subcutaneous  hemorrhages  are  found 
resembling  those  seen  in  hemophilia. 


CIRRENT  ORTHOPAEDIC  LITERATURE  199 

The  symptoms  come  on  suddenly  in  a  previously  healthy  child.  Weakness  of 
the  muscles  of  the  extremities,  rapid  pulse,  slight  rise  of  temperature  and,  in 
a  few  hours,  more  or  less  complete  motor  paralysis. 

Most  of  the  children  recover  entirely  in  less  than  48  hours  after  the  tick  is 
removed.  Death  sometimes  occurs  from  respiratory  failure.  It  is  necessary  to 
remove  the  entire  tick.  The  direct  diagnosis  depends  on  finding  an  engorged 
wood-tick.  The  only  case  in  which  a  complete  blood  examination  was  made 
showed  an  eosinophilia,  being  indicative  of  animal  parasitic  infection. 

The  tick  may  be  found  buried  in  the  scalp,  external  ear,  axilla  or  some  other 
protected  region.  Kerosene  or  chloroform  may  be  used  to  force  the  tick  to 
loosen  its  hold.  In  the  cases  in  which  the  tick  has  been  classified,  it  has  been 
the  female. 

Among  the  14  cases  whose  histories  are  given  by  the  author  there  were  three 
deaths. — W.  O.  Elmer,  Philadelphia. 


The  Etiology  of  the  Plexus  Paralysis  of  the  Newborn.    Weil.    Archiv.  Orth. 
und  Unfall-Chir.,  Vol.  19,  No.  2,  Jan.,  1921. 

The  author  reviews  the  various  theories  which  have  been  advanced  in  ex- 
planation of  birth  palsy. 

He  begins  with  the  dislocation  theory,  which,  in  his  opinion,  does  not  come 
into  consideration  for  the  vast  majority  of  cases  of  birth  palsy. 

In  regard  to  the  so-called  subluxation  of  the  shoulder,  a  condition  lately 
pointed  out  by  Fink,  he  states  that  in  three  of  his  cases,  he  distinctly  noted  an 
abnormal  mobility  of  the  head  of  the  humerus,  but  he  believes  that  this  symptom 
is  to  be  regarded  as  the  effect  of  paralysis  and  not,  as  Fink  believes,  as  its  cause. 

Lange  has  been  sponsoring  the  theory  of  distortion  of  the  shoulder  joint, 
estimating  that  in  the  vast  majority  of  his  cases,  namely,  in  76  per  cent,  there 
is  a  so-called  pseudo-paralysis,  the  cause  of  which  is  a  distortion  of  the  shoulder 
joint  during  birth.  The  author,  however,  points  out  that  on  the  newborn  such 
a  distortion  cannot  be  demonstrated. 

The  theory  of  Kuestner  is  that  a  separation  of  the  epiphysis  at  the  upper  end 
of  the  humerus  is  responsible  for  the  condition.  The  author  believes,  on  the 
basis  of  his  personal  experience,  as  well  as  upon  the  findings  in  the  literature, 
that  the  so-called  osteo-articular  forms  of  birth  palsy,  the  pseudo-paralysis, 
have  been  greatly  over-estimated  in  regard  to  frequency  as  compared  with 
true  paralysis.  In  the  nine  cases  of  his  own  observation,  eight  times  paralysis 
could  be  demonstrated  and  only  in  one  case  a  pseudo-paralysis  could  be  con- 
sidered present.  He  believes  that  in  all  cases  the  nerve  paralysis  is  the  principle 
factor  and  that  a  large  part  of  the  non-paralyzed  cases  develop  from  originally 
true  lesions  of  the  plexus.  In  regard  to  the  direct  cause  of  birth  palsy,  the 
author  states  that  the  pressure  of  the  forceps  can  only  be  responsible  in  excep- 
tional cases,  since  the  instrument  hardly  ever  reaches  Erb's  point,  but  is  usually 
applied  higher  up.  Also  regarding  the  pressure  of  the  finger,  such  an  explanation 
is  forced  and  cannot  be  considered  of  great  moment.  The  large  majority  of 
cases  of  pressure  paralysis  could  only  be  explained   by   the  pressure   of  the 


200  CURRENT  ORTHOPiEDIC  LITERATURE 

clavicle,  but  the  usual  case  is  not  caused  by  pressure  but  by  tension  upon  the 
plexus,  causing  a  strain  of  the  nerve  roots,  especially  the  fifth  and  sixth  cervical 
nerve. 

However,  in  disregard  of  all  former  explanation,  the  author  advances  a  new 
theory  for  the  pathogenesis  of  birth  palsy.  He  believes  that  at  least  a  part 
of  these  paralyses  are  not  to  be  considered  as  birth  palsies  in  the  stricter  sense, 
but  are  really  due  to  intrauterine  pressure,  occuring,  therefore,  not  during  birth, 
but  in  utero.  He  reasons  as  follows :  Birth  palsy  is  not  infrequently  observed 
in  cases  of  entirely  normal  and  spontaneous  delivery.  Also  in  cases  in  which 
operative  interference  during  birth  was  necessary,  it  is  not  infrequent  that 
the  arm  which  is  paralyzed  offered  little  difficulty  in  delivery,  whereas,  the 
other,  non-paralyzed  arm  was  difficult  to  deliver.  He  also  points  out  that  there 
have  been  observed  cases  of  birth  palsies  in  brothers  and  sisters.  The  local 
findings  on  the  paralyzed  extremities  are  also  of  importance.  Pressure  marks, 
swelling,  and  haemorrhages  are  rarely  found.  On  the  other  hand,  signs  of  flail 
joint  are  often  seen  on  the  second  and  third  day  after  birth.  The  head  of  the 
humerus  on  the  paralyzed  side  can  be  displaced  forward  to  an  abnormal  degree. 
Furthermore,  the  x-rays  often  reveal  an  abnormal  curving  of  the  clavicle  and  a 
greater  distance  between  the  head  of  the  humerus  and  the  glenoid  fossa.  He 
considers  it  impossible  that  the  flail  joint  due  to  paralysis  sustained  during 
birth,  could  develop  as  early  as  two  or  three  days  later.  He  also  advances  the 
argument  that  he  has  found  very  slight  differences  in  the  circumference  of  the 
arm,  amounting  to  about  one-sixth  of  an  inch,  which  according  to  his  view, 
could  not  be  explained  unless  the  paralysis  had  taken  place  in  uterine  life. 

Of  special  importance  seems  to  him  the  fact  that  birth  palsy  is  often  com- 
plicated with  other  congenital  deformities.  Among  his  own  material,  he  has 
found  a  child  with  birth  palsy  who  had  a  double  hip  dislocation.  One  case  had 
a  congenital  defect  of  the  abdominal  musculature.  In  another  case,  the  birth 
palsy  was  combined  with  a  marked  congenital  scoliosis.  Deformities  of  the  head 
were  seen  in  three  cases.  Furthermore,  combinations  of  wry-neck  were  observed 
in  birth  palsy  by  Schuller  and  Sippel.  The  author  also  considered  wry-neck 
as  a  coordinate  congenital  deformity.  Lange  called  attention  to  contractures 
of  the  elbows  in  these  cases,  and  Koenig  found  in  his  case  a  manus  valga 
complicating  the  paralysis;  of  the  right  arm.  To  the  author,  this  case  proved 
with  certainty  that  the  paralyzed  arm  or  its  nerve  supply  had  been  exposed  to 
abnormal  pressure  during  intrauterine  life.  He  considers  the  contractures  in 
extension  or  flexion  of  the  elbow, — the  inhibition  of  pro-  and  supination,  the 
contractures  of  hand  and  fingers  likewise  as  proofs  of  the  intra  uterine  char- 
acter of  this  deformity.  As  far  as  the  fractures  of  the  clavicle  and  the  humerus 
are  concerned  which  are  occasionally  observed,  he  believes  these  to  be  a  kind 
of  spontaneous  fracture  due  to  an  abnormal  fragility  of  the  bone. 

In  explanation  of  the  mechanism  of  the  intra  uterine  development  of  this 
deformity,  the  author  is  forced  to  assume  the  action  of  two  deforming  forces: 
(1)  A  component  acting  upon  the  arm  and  causing  the  various  position  of  con- 
tracture; (2)  A  more  important  component  which  causes  the  paralysis.  Beyond 
this  theoretical  explanation,  the  author  does  not  venture  into  the  details  of 
explaining  bow  this  deformity  comes  about.  (It  is  to  be  regretted  that  the 
author  is  n<  t  familiar  with,  or  at  least  has  not  mentioned,  the  work  of  American 


CURRENT  ORTHOPAEDIC  LITERATURE  201 

authors  such  as  T.  T.  Thomas,  Taylor,  and  Sever.  The  questions  of  the  import- 
ance of  the  forceps,  of  the  significance  of  the  flail  joint,  and  many  other  points 
mentioned  in  this  paper  have  been  thoroughly  discussed  by  these  authors.  Espe- 
cially has  it  been  shown  by  Sever  in  rejection  of  Lange's  joint  theory  that  no  flail 
joint  has  ever  been  observed  earlier  than  one  month  after  birth.)— A.  Steindler, 
Iowa  City,  la. 


MISCELLANEOUS 


Treatment  of  Abthbitis.    Arthur  F.  Chace,  M.D.,  Victor  C.  Myers,  Ph.D.,  and 
John  A.  Killian,  Ph.D.,  Journal  A.  M.  A.,  Oct.  15,  1921. 

The  authors  give  a  brief  consideration  to  the  use  of  the  sodium  salicylate, 
cinchophen  and  neocinchophen  in  the  treatment  of  acute  and  chronic  arthritis 
as  well  as  of  gout. 

A  report  of  eleven  cases  of  acute  and  chronic  arthritis  gives  the  impression 
that  at  least  in  the  acute  ones  neocinchophen  did,  in  a  few  days,  produce  cessation 
of  pain  and  increased  ability.  In  their  experience  cinchophen  and  neocinchophen 
are  much  more  easily  tolerated  by  the  stomach  and  irritate  the  kidneys  much 
less  than  the  salicylates.  The  dose  of  neocinchophen,  as  employed  by  them,  was 
50  grains  daily. — H.  A.  Pingree,  Portland,  Maine. 


Infantile    Deforming    Osteochondritis    of   the    Upper    Femoral    Epiphysis. 
Feutelais.    Revue  d'Orthopidie,   July,  1921,  p.  315. 

A  child  with  negative  family  and  personal  history  began  to  limp  when  about 
3%  years  old  and  at  the  same  time  an  appreciable  atrophy  of  the  left  leg  and 
buttock  was  noticed.  No  pain,  except  for  a  very  short  period  at  the  beginning. 
The  limp  resembled  that  of  a  dislocated  hip  or  a  coxa  vara.  Motion  in  the  ^ft 
hip  to  normal  limits  except  that  abduction  is  very  sharply  limited.  (Rotation 
is  not  mentioned.)  The  roentgenogram  showed  a  slight  coxa  vara  and  the 
epiphysis  reduced  to  a  thin  plate  of  tissue  in  three  pieces.  The  acetabulum 
showed  roughening  on  its  superior  surface. 

The  child  had  no  immobilization  of  the  hip  but  went  about  as  a  normal  child. 
After  two  years  there  was  no  more  limping  except  perhaps  in  wet  weather. 
The  child  was  so  well  that  the  mother  did  not  worry  any  more  about  it. 

In  this  case  there  was  no  trace  of  infection  found  and  no  history  of  trauma. 
It  was  not  congenital.  The  affection  is  regarded  by  the  author  as  a  defect 
in  osteogenesis  and  as  probably  analogous  to  imperfect  development  of  the  tarsal 
scaphoid  which  is  frequently  seen  in  young  children. — William  Arthur  Clark, 
Pasadena. 


Loose  Bodies  in  Joints.     A.  G.  T.  Fisher,  Lancet,  April  23,  1921. 

Loose  bodies  of  cartilage  or  cartilage  and  bone  may  be  divided  in  three  groups : 
1.    Loose  bodies  occurring  in  connection  with  some  general  pathological  process 
affecting  the  joint  such  as  {a)  osteo-arthritis,  (o)  tabes,  (c)  tuberculous  disease 
accompanied  by  an  necrotic  caries,  (d)  acute  arthritis  due  to  infection. 


202  CURRENT   ORTHOPEDIC   LITERATURE 

2.  Loose  bodies  occurring  in  joints  that  are  otherwise  apparently  normal ;. 
(a)  bodies  having  the  microscopic  appearances  of  detached  portions  of  the 
articular  surfaces,  (6)  bodies  derived  from  inter-articular  fibrocartilages,  (c) 
bodies  formed  from  detached  epiphyses  not  forming  portions  of  an  articulating 
area. 

3.  Synovial  chondromata :    (a)  single,  (&)  multiple,  (c)  diffuse. 

In  cases  of  loose  bodies  formed  from  detached  osteophytes,  they  may  be  recog- 
nized if  seen  early,  but  later  this  fractured  surface  may  be  covered  by  an  out- 
growth from  the  surrounding  cartilage.  A  section  through  the  entire  body 
shows  that  the  periphery  consists  of  well  developed  flbro-cartilage  with  com- 
paratively few,  but  uniformly  distributed  cells.  The  bone  in  the  center  is  quite 
dead.  The  lacunae  are  empty,  and  devoid  of  any  staining  elements.  Detached 
epiarticular  ecchondroses  grow  from  the  articular  margins  and  might  arise  in 
the  substance  covering  the  normal  bone.  This  takes  place  by  local  hyperphasia 
of  the  cartilage,  in  which  central  ossification  subsequently  occurs. 

The  loose  bodies  in  tabes  involve  the  formation  of  bone  in  the  planes  of  con- 
nective tissue  between  the  capsule  and  the  synovial  membrane  so  that  the  joint 
may  be  surrounded  eventually  by  bony  masses. 

Loose  bodies  are  rare  in  tuberculosis,  and  are  formed  most  frequently  from 
the  articular  end  of  the  femur  and  are  probably  due  to  the  interference  with  the 
blood  supply. 

Loose  bodies  in  otherwise  normal  joints  are  most  frequently  found  in  adults 
between  the  ages  of  fifteen  and  twenty-five.  The  joints  affected  in  order  of 
frequency  are  knee,  elbow,  shoulder,'  hip,  ankle,  and  wrist.  These  are  usually 
single  but  may  be  multiple.  The  condition  may  be  bilateral  and  in  most  cases 
there  is  a  definite  history  of  trauma. 

When  a  loose  body  has  been  detached  recently,  microscopic  examination  shows 
the  cartilage  and  bone  to  be  living.  When  less  recently  attached  the  bone  cells 
are  dead  but  the  cartilage  cells  usually  show  marked  proliferative  changes.  If 
detachment  is  incomplete  or  if  secondary  adhesions  have  formed  new  bone  may 
develop.  Loose  bodies  may  also  be  derived  from  inter-articular  fibrocartilage, 
especially  the  semilunars. 

The  synovial  chondromata  are  intimately  connected  with  neoplasms.  They 
originate  from  the  cartilage  cells  in  the  synovial  villi. 

After  a  study  of  clinical,  pathological,  and  experimental  data,  trauma  is  found 
to  be  a  very  frequent  and  in  most  cases  the  exciting  cause  of  the  condition.  The 
interval  between  time  of  injury  and  the  onset  of  the  symptoms  may  be  explained 
by  incomplete  detachment  of  the  body  or  its  subsequent  detachment  elsewhere. 
Only  when  free  to  impinge  between  joint  surfaces  does  the  loose  body  cause 
symptoms  of  pain  and  locking. 

The  cartilage  cells  retain  their  vitality — bone  cells  do  not.  It  is  important 
to  remember  this  in  cases  of  grafting.  The  author  suggests  the  preservation 
of  periosteum  in  order  that  an  early  vascular  connection  may  be  established. 

The  treatment  advised  is  removal  of  the  loose  body.  The  prognosis  is  good 
in  the  young  and  middle-aged  where  the  joint  is  otherwise  normal.  If  the 
traumatic  loose  body  has  been  allowed  to  remain  in  the  joint  long  enough  to 
cause  chronic  villous  arthritis  or  commencing  osteorthritis,  although  we  may 


CURRENT  ORTHOPAEDIC  IJTERATURE  203 

cure  the  sudden  attacks  of  pain  due  to  the  body  becoming  impinged  between  the 
articular  surfaces,  yet  the  operation  may  be  followed  by  pain,  swelling,  and  a 
feeling  of  weakness  in  the  joint  due  to  the  superimposed  condition.  The  results 
of  operation  in  the  synovial  chondromata  are  also  good,  provided  the  condition  is 
not  progressive. 

At  operation  a  liberal  incision  should  be  used,  and  an  x-ray  examination  taken 
in  two  planes  will  show  us  how  and  where  to  open  the  joint.  The  author  advises 
again  the  older  method  of  transfixion  of  the  loose  body  and  removal  through  a 
small  incision. — LeRoy  C.  Abbott,  Ann  Arbor,  Michigan. 


Diagnostic  and  Therapeutic  Point  in  Retrocalcanean  Bursitis.     A.  L.  Niel- 
son,  M.D.,  Journal  A.  M.  A.,  Aug.  6,  1921. 

The  cause  of  the  disease  is  an  inflammation  of  the  bursa  lying  between  the 
insertion  of  the  Achilles  tendon  and  the  tuberosity  of  the  os  calcis.  Of  special 
infections,  tuberculosis  occurs  and  readily  extends  to  the  bone.  Gonorrheal 
infection  attacks  this  bursa,  as  do  rheumatic  infection.  In  chronic  infections 
there  is  thickening  of  the  endothelial  lining,  cartilaginous  hypertrophy  and 
periostitis,  with  formation  of  exostoses. 

The  causes  of  the  disease  are  overuse  of  the  foot,  pressure  of  shoes  and 
bacterial  infection.  There  is  local  pain  on  motion  and  tenderness  over  the  bursa. 
There  may  be  a  swelling  on  each  side  of  the  Achilles  tendon.  The  pain  is  caused 
by  pinching  the  bursa  between  the  tendon  and  the  os  calcis  on  flexion  of  the 
ankle. 

The  treatment  consists  in  adding  ^-inch  rubber  heels  to  the  ordinary  low- 
heeled  shoes  and  careful  fitting  of  the  shoes  to  prevent  pressure.  If  this  does 
not  succeed  the  bursa  must  be  dissected  out. — W.  G.  Elmer,  Philadelphia. 


Some  Observations  on  the  Static  Influence  of  Shortened  Pelvic  Muscles. 
John  Joseph  Nutt,  M.D.    New  York  Medical  Journal,  Oct.  19,  1921. 

The  author  reports  five  cases  with  complaint  of  pain  in  the  back,  hips,  and 
thighs,  made  worse  by  any  exercise,  in  which  there  was  limitation  of  thigh 
flexion  and  extension,  of  thigh  abduction,  and  in  some,  shortening  of  the  gas- 
trocnemius, without  any  structural  changes.  He  comments  that  he  has  in  a 
number  of  cases  found  the  cause  of  round  shoulders  and  other  postural  faults 
to  be  limitations  of  normal  movements  of  the  pelvis. 

In  the  cases  reported  the  symptoms  were  relieved  by  systematic  passive 
stretching  of  the  contracted  muscles. — Dr.  C.  L.  Lowman,  Los  Angeles. 


204  CURRENT  ORTHOPEDIC  LITERATURE 


Bursitis  Calcaeea  of  the  Epicondylus  Externus  Humeri;  A  Contribution  to 
the  Pathogenesis  of  Epicondylitis.  J.  Schmidt.  Archiv.  Orth.  und  Unfall- 
Chir.,  Vol.  19,  No.  2,  Jan.,  1921. 

• 

In  1896,  Bernhardt  described  an  affection  of  the  external  epicondyle  of  the 
humerus  which  he  classified  as  occupational  neuralgia.  The  principle  symptom 
was  a  sharply  defined  tenderness  upon  pressure  on  the  external  epicondyle. 
Other  symptoms  were  a  feeling  of  weakness  of  the  forearm  and  functional  dis- 
turbance, especially  in  regard  to  rotatory  and  extensory  movement.  The  con- 
dition was  described  and  recognized  by  others.  Franke  regarded  it  as  a  localized 
ostitis  of  the  external  epicondyle.  Clado  explained  the  condition  as  a  tear  in 
the  supinator  brevis.  Baehr  considered  it  as  due  to  a  tear  in  the  ligamentous 
apparatus.  Preiser  regarded  it  as  a  lesion  of  the  ligamentum  collaterale  radiale 
caused  by  simultaneous  and  violent  contraction  of  the  brachialis  internus  and 
supinator  brevis. 

The  author  describes  a  case  of  his  own  observation:  a  woman  34  years  old 
complained  of  violent  pain  on  the  outer  surface  of  the  left  elbow.  Four  years 
previously  she  strained  her  elbow  by  lifting  a  heavy  object.  Two  years 
later  there  appeared  on  the  outer  surface  of  the  left  elbow  a  node,  which  a 
short  time  later  became  painful.  The  pain  appeared  on  extension  of  the  forearm 
as  well  as  on  rotatory  motions,  and  radiated  into  the  dorsum  of  the  hand. 

He  found  on  the  outer  surface  of  the  left  elbow  joint  over  the  external 
epicondyle  a  painful  fluctuating  tumor  the  size  of  a  bean.  The  x-ray  picture 
showed  a  shadow  separated  from  the  epicondyle  and  sharply  defined.  Under 
local  anaesthesia,  an1  incision  was  made  over  the  tumor  which  appeared  to  be 
a  cyst  filled  with  detritus.  It  was  separated  from  the  external  epicondyle  and 
removed.  Examination  of  the  cyst  showed  its  contents  to  be  masses  of  calcium 
carbonates  and  phosphates.  The  walls  of  the  cyst  were  in  a  condition  of  chronic 
inflammation. 

Of  the  subcutaneous  bursae  of  the  elbow,  only  the  bursa  olecrani  is  a  constant 
structure.  A  bursa  over  the  internal  condyle  is  found  according  to  Gruber  in 
one  out  of  ten  adults.  A  bursa  over  the  external  condyle  is  still  more  infrequent, 
being  found  in  only  one  out  of  60  individuals. 

In  the  case  described,  the  eliciting  cause  seems  to  be  a  trauma  sustained  four 
years  previously. 

The  formation  of  the  bursa  with  calcareous  contents  may  be  explained  upon 
this  basis:  the  chronic  inflammation  of  the  neighboring  structures, — in  this 
case,  a  circumscribed  periostitis  at  the  external  epicondyle, — causes  a  chronic 
inflammation  of  the  walls  of  the  bursa-  or  a  chronic  bursitis.  In  this  respect, 
there  is  a  considerable  analogy  with  the  subacromial  bursitis  which  is  responsi- 
ble for  the  periarthritis  humeri ;  on  the  basis  of  a  strain  of  the  arm  from  lifting 
in  the  position  of  flexion  and  supination.  It  may  then  come  to  a  distortion  of  the 
collateral  ligament  of  the  radius,  followed  by  periosteal  bone  apposition  and 
involvement  of  the  bursa  in  a  calcifying  bursitis  over  the  external  epicondyle  of 
the  humerus.  i 

(The  author  is  not  aware  that  a  condition  of  this  kind  has  been  described 
lately  by  Osgood  under  the  name  of  tennis  elbow.) — A.  Steindler,  Iowa  City,  la 


CURRENT  ORTHOPEDIC  LITERATURE  205 


Multiple  Osteochondbomata.     Bernard  Pierre  Widmann,  M.D.     Am.  Jour,  of 
Roentgenology,  August,  1921. 

The  author  reports  one  case  of  this  condition,  which  he  defines  as  "The  occur- 
rence of  multiple,  more  or  less  symmetrical,  cartilaginous  and  osteo-cartilaginous 
growths,  within  and  on  the  skeletal  system,  generally  benign  and  resulting 
from  a  disturbance  in  the  proliferation  of  bone  forming  cartilage." 

Heredity  evidently  plays  a  considerable  rOle  in  the  transmission,  and  tubercu- 
losis is  frequently  associated,  which  association  may  be  significant. 

In  the  case  reported,  a  boy  of  13,  there  was  neither  hereditary  nor  tubercular 
element,  nor  any  significant  previous  sickness.  He  began  to  present  bony  enlarge- 
ments at  four  years  of  age  at  the  wrists,  knees,  ankles,  over  the  clavicles  and 
the  inferior  angles  of  the  scapulae.    There  were  no  subjective  symptoms. 

The  roentgenologic  examination  showed  disturbance  in  the  ends  of  the  diaphyses 
of  all  the  long  bones,  even  the  ribs,  in  the  nature  of  thickening  or  tumor  forma- 
tion, having  the  characteristics  of  bone:  t.  e.,  cancellous  tissue,  regularly  ar- 
ranged, with  no  destructive  effects  and  none  of  the  appearances  of  true  tumors. 

Two  cases  of  multiple  exostoses  are  on  record,  in  which  there  were  endostoses 
pressing  on  the  central  nervous  system,  causing  pressure  symptoms. 

The  author's  conclusion  is  that  this  condition  is  a  constitutional  disease, 
primarily  a  disease  of  the  endocrine  system,  and  with  an  hereditary  tendency.— 
C.  L.  Lowman,  Los  Angeles. 


Vol.  IV,  No.  2  APRIL,  1922  JSST&i 


The  Journal   of 
Bone  &  Joint  Surgery 


SPONTANEOUS    HEALING    INHERENT    IN    TRANSPLANTED 

BONE. 

BY   S.   L.   HAAS,   M.D.,  SAN   FRANCISCO. 

From  the  Surgical  Pathological  Laboratory  of  Leland  Stanford,  Jr., 
University  School  of  Medicine. 

It  is  still  contended  by  some  investigators  and  surgeons  that  bone 
after  transplantation  dies  and  takes  no  share  .in  the  process  of  restor- 
ation, but  functions  merely  as  an  inert  body,  by  serving  as  a  framework 
for  the  ingrowth  of  live  bone  with  which  it  is  in  contact.  By  those 
who  hold  this  view  it  is  further  claimed  that  it  is  immaterial  whether 
one  uses  live  or  dead  bone,  from  the  same  or  some  other  animal  or  even 
a  foreign  substance  for  the  transplantation  material.  This  idea  per- 
sists, in  spite  of  the  fact  that  it  has  been  repeatedly  shown  that  there 
takes  place  in  bone  after  transplantation  definite  signs  of  proliferation 
from  the  periosteum,  endosteum,  and  from  the  lining  cells  of  the  Haver- 
sian canals.  This  non-acceptance  of  the  doctrine  that  a  live  bone  trans- 
plant shares  in  the  regenerative  processes  must  be  due  to  the  fact  that 
the  evidence  thus  far  submitted  is  not  sufficiently  convincing  to  those 
who  hold  the  opposite  view.  Therefore,  in  order  to  unify  our  con- 
ception regarding  this  important  principle  concerned  with  bone  sur- 
gery, additional  proof  must  be  submitted  of  the  independent  activity 
of  osteoblastic  tissue  after  transplantation. 

The  healing  of  a  fracture  calls  into  play  practically  every  component 
part  of  bone  ancl  makes  as  severe  a  demand  upon  the  reconstructive 
activities  of  its  various  cellular  elements  as  any  pathological  process 


210 


S.    L.    HAAS 


Fig.  1. — Roentgenograms,  in  planes  at  right  angles,  of  a  phalanx  which  was 
completely  fractured  and  then  buried  in  muscle.  The  bone,  which  was  re- 
moved at  the  end  of  73  days,  shows  complete  union  of  the  fracture.  Notice 
the  absorption  of  the  bone,  resulting  from  lack  of   functional  stimulation. 


of  bone.  It  was,  therefore,  considered  as  a  suitable  test  to  determine 
if  the  cells  of  bone  possess  an  independent  power  of  proliferation  after 
transplantation,  by  studying  the  behavior  of  the  cellular  elements  and 
their  response  toward  the  healing  of  a  fracture  in  transplanted  bone. 
In  order  to  guard  against  the  influence  of  any  other  osseous  tissue, 
it  was  essential  that  the  transplant,  after  fracture,  be  placed  so  as  not 
to  be  in  contact  with  other  bones.  Therefore,  if  an  entire  bone  is  re- 
moved and  after  being  fractured,  placed  in  the  muscles  of  the  back, 
any  tendency  toward  healing  of  the  fracture  must  be  ascribed  to  the 
independent  proliferative  power  of  the  cells  of  the  transplant;  and 
should  there  be  a  definite  union  of  such  a  fracture  in  a  transplant  to 
muscle,  then  I  believe  that  the  most  skeptical  will  have  to  admit  the 
importance  of  the  inherent  activity  possessed  by  osteoblastic  tissue 
after  transplantation. 

"With  the  above  object  in  view  a  number  of  experiments  were  per- 
formed upon  dogs,  two  of  which  will  be  briefly  reported  at  this  time. 
All  of  the  experiments  were  performed  under  general  anaesthesia  with 
the  usual  aseptic  technique. 


SPONTANEOUS  HEALING 


211 


Fig.  2— Microphotograph  of  a  section  through  the  site  of  union,  of  the  healed 
fracture  in  the  transplanted  phalanx,  removed  from  the  muscles  of  the  back 
at  the  end  of  73  days.  Notice  the  old  bone  at  B,  with  the  intervening  new 
bone,  C,  which  is  the  result  of  the  inherent  proliferating  power  of  the  cells 
of  the  transplant.  This  section  is  through  the  narrow  neck  of  bone  shown 
in  the  roentgenogram,  Fig.  1. 

Experiment  1. — Dog  1. — Full  grown.  Duration  of  experiment, 
seventy-three  days. 

Operation. — The  first  phalanx  of  the  fourth  toe  of  the  left  hind  foot 
was  removed  intact.  It  was  then  fractured  completely  through  the 
center  and  after  the  fragments  were  placed  in  apposition  they  were 
transplanted  to  the  muscles  on  the  left  side  of  the  spine. 

Macroscopical  Findings. — Seventy-three  days.  The  bone  was  found 
encapsulated  in  the  muscles  of  the  back.  It  was  considerably  thinner 
than  normal  and  had  evidently  undergone  absorption.  The  two  frag- 
ments appeared  to  have  firmly  united.  The  roentgenogram  (Fig.  1) 
shows  two  views  taken  at  right  angles,  and  one  can  see  a  definite  os- 
seous bridge  connecting  the  two  fragments. 

Microscopical  Examination. — A  study  of  the  sections  shows  a  defi- 
nite continuous  osseous  tract  from  one  articular  cartilage  to  the  other. 
The  minute  cellular  changes  will  not  be  discussed  in  this  paper,  but  one 
can  distinguish  the  old  and  new  bone  at  the  site  of  union.  The  micro- 
photograph  (Fig.  2)  shows  a  section  through  the  field  of  union  of  the 
fragments. 


212 


S.   L.    HAAS 


Fig.  3. — Roentgenograms,  in  planes  at  right  angles,  of  a  metatarsal  bone  that 
had  been  fractured  in  the  center  and  transplanted  to  the  muscles  of  the  back. 
The  bone  was  removed  at  the  end  of  71  days  and  showed  firm  union.  Notice 
the  bridging  of  the  bone  at  the  fracture  plane.  The  bone  is  undergoing 
absorption. 

Deductions. — The  two  fragments  of  bone  after  transplantation  pos- 
sessed the  same  tendency  toward  healing  as  two  fragments  of  a  frac- 
ture in  a  normal  position.  From  the  study  of  other  experiments  it 
can  be  stated  that  the  process  is  identical,  and  union  takes  place  after 
the  formation  of  a  cartilaginous  callus,  which  later  undergoes  ossifi- 
cation. Because  of  the  fact  that  the  bone  is  transplanted  to  muscle, 
is  removed  from  any  possible  influence  of  extraneous  osseous  tissue,  any 
changes  taking  place  must  be  ascribed  to  the  energy  that  is  stored  in 
the  cells  of  transplant  itself.  On  account  of  the  bone  being  removed 
from  the  influence  of  normal  functional  stimulation,  there  will  take 
place  a  slow  degeneration  after  the  initial  active  response. 

Experiment  2. — Dog  3. — Young,  full  grown.  Duration  of  experi- 
ment, seventy-one  days. 

Operation. — Removed  the  entire  fourth  metatarsal  bone  from  the 
right  hind  foot.  The  bone  was  fractured  completely  across  the  cen- 
ter, except  for  a  small  strip  of  periosteum,  and  then  buried  in  the 
muscles  on  the  left  side  of  the  spine. 

Macroscopical  Findings. — At  the  end  of  seventy-one  days,  the  bone 
was  found  encapsulated  in  the  muscles  and  was  smaller  than  when  it  was 
inserted.  The  union  of  the  fragments  is  firm  and  there  is  very  little 
evidence  of  any  callus.  The  roentgenogram  (Fig.  3)  shows  the  line 
of  fracture,  which  in  places  is  bridged  by  new  bone. 

Microscopical  Examination. — A  section  through  the  bone  at  the  site 
of  the  fracture  (Fig.  4)  shows,  on  one  side,  a  definite  osseous  connec- 


SPONTANEOUS  HEALING 


213 


Fig.  4. — Microphotograph  of  a  section  through  the  site  of  union  of  a  fracture 
in  a  transplanted  metatarsal  bone  removed  from  the  muscles  of  the  back!  at 
the  end  of  71  days.  A,  A',  the  old  bone  fragments.  Notice  the  loss  of  nuclear 
staining  and  degenerated  appearance.  C,  C,  new  bone  at  the  fracture  line. 
This  is  also  undergoing  degeneration.  After  the  initial  degeneration  with 
union  of  the  fragments  there  takes  place  a  secondary  degeneration  because  of 
the  lack  of  functional  stimulation.  • 

tion  between  the  two  fragments.  In  spite  of  the  union  and  evidence 
of  proliferation,  the  osseous  tissue  of  the  original  bone,  as  well  as  of 
the  callus,  has  lost  the  greater  part  of  its  nuclear  staining.  This  is 
undoubtedly  due  to  a  secondary  degeneration. 

Deductions. — The  condition  here  suggests  that  there  was  an  early 
regeneration  and  formation  of  a  callus.  Then,  again,  because  of  the 
lack  of  functional  stimulation  a  final  degeneration  took  place. 

GENERAL    SUMMARY. 


Bone  when  transplanted  into  a  muscular  bed,  and  thereby  removed 
from  any  possible  influence  of  other  osseous  tissue,  shows  definite  signs 
of  cellular  activity.  It  has  been  previously  shown,1  that  even 
though  there  is  an  initial  degeneration  of  the  greater  part  of  a  trans- 
planted bone,  that  a  sufficient  amount  of  osteoblastic  tissue  survives 


214  S.  L.  HAAS 

in  the  region  of  the  periosteum,  endosteum,  and  about  the  Haversian 
canals,  to  regenerate  the  new  bone.  Furthermore,  if  the  transplanted 
bone  is  not  subjected  to  functional  stimulation2  it  will  gradually 
undergo  a  second  and   permanent  degeneration. 

In  the  case  of  transplanted  bones  in  which  fractures  have  been  pro- 
duced, there  is  made  an  additional  demand  upon  the  regenerative 
powers  of  osteoblastic  tissue.  This  demand  is  complied  with  in 
just  such  a  way  as  normal  bone  responds  to  the  call  for  the  repair  of  a 
fracture,  namely:  the  formation  of  cartilaginous  callus  which  later  be- 
comes ossified.  This  response  takes  place,  even  though  the  bone  is 
removed  from  the  normal  functional  stimulation,  but  on  account  of 
the  lack  of  functional  demand  it,  too,  undergoes  degeneration. 

In  view  of  the  fact  that  the  osteoblastic  components  of  a  transplant- 
ed bone  possess  sufficient  energy  to  produce  the  union  of  a  fracture, 
even  when  buried  in  muscle,  there  must  be  ascribed  a  considerable  im- 
portance to  the  regenerative  powers  of  the  cells  of  such  a  live  piece  of 
bone. 

conclusions. 

1.  There  is  sufficient  energy  stored  in  the  osteoblastic  cells  of  a  live 
bone  transplant,  placed  in  a  muscle  and  removed  from  all  osseous  con- 
tact, to  form  a  union  between  two  fragments  of  a  fracture  produced 
in  such  a  transplant. 

2.  Because  of  this  very  active,  independent,  regenerative  and  re- 
parative property  innate  in  the  live'  bone  transplant  it  is  advisable 
to  utilize  living  bone,  whenever  possible,  for  any  purpose  where  a 
transplant   is   indicated. 

(I  wish  to  extend  my  thanks  to  Professor  Blaisdell  for  the  privi- 
leges granted  to  me  during  this  experimental  study.) 

REFERENCES. 

1.  Haas,  S.  L. :    The  Transplantation  of  the  Articular  End  of  Bone  Including 

the  Epiphyseal  Line.  Surg.,  Gynec.,  and  Obst.,  xxiii,  301,  Sept.,  1916. 

2.  Haas,  S.  L. :     Function  in  Relation  to  Transplantation  of  Bone.  Arch,  of 

Surg.,   iii,  425,   Sept.,  1921. 


FIFTH    LUMBAR    VERTEBRA  215 


NOTE  ON  SACRALIZATION  OF  THE  FIFTH  LUMBAR 
VERTEBRA.* 

BY    C.    THURSTAN    HOLLAND,    D.L.,    M.R.C.S., 

Lecturer  on  Radiology,  The  University  of  Liverpool. 

Of  late  years  the  condition  known  as  Sacralization  of  the  Fifth  Lum- 
bar Vertebra  has  come  into  considerable  prominence  on  account  of 
the  fact  that  radiography  has  thrown  its  beam  of  light  upon  a  condi- 
tion about  which  previously  very  little  was  known,  and  which  most 
certainly  is  entirely  undiagnosable  without  an  x-ray  examination  and  is 
rarely  if  ever  suspected  of  being  present  from  any  symptoms  which  may 
be  complained  of. 

Until  recent  years  there  was  very  little  literature  on  the  subject, 
and  practically  all  there  was  was  purely  anatomical.  Thus  the  Index 
Medicus  from  1917  to  1920,  inclusive,  gives  no  references  under  the  head- 
ing of  Sacrum  or  Sacralization,  but  in  1921  a  considerable  number  of 
papers  are  recorded. 

The  late  Professor  Paterson,  of  Liverpool  University,  published  a 
monograph  in  the  Scientific  Transactions  of  the  Royal  Dublin  Society 
in  1893,  on  the  Sacrum — i.e.,  two  years  prior  to  the  discovery  of  x-rays. 
He  points  out  in  this  paper,  which  is  a  very  elaborate  one,  that  the 
lateral  mass  of  the  sacral  region  equals  (or  represents)  the  transverse 
processes  and  ribs  of  the  thoracic  portion  of  the  spine ;  he  figures  two 
unilateral  and  three  bilateral  cases  of  sacralization,  and  one  embryo 
of  seven  months  with  the  unilateral  condition. 

Young,  in  the  American  Journal  of  Orthopaedic  Surgery,  in  1916, 
on  the  x-ray  examination  of  the  lumbo-sacral  region,  notes  that  con- 
genital irregularities  have  long  been  recognized  and  that  irregular  for- 
mation of  one  or  both  transverse  processes  of  the  fifth  lumbar  vertebra 
has  been  considered  as  a  frequent  etiological  factor  in  scoliosis.  He 
also  notes  that  the  irregularities  of  the  deposit  and  development  of  the 
centers  of  ossification  of  the  fifth  lumbar  vertebra  are  so  variable  that 
the  late  Professor  Thomas  Dwight  was  doubtful  as  to  what  should  be 
considered  the  normal. 

Japiot,  in  1914,  when  reporting  two  cases  of  sacralization,  states  that 

at  that  time  he  could  find  only  fiive  references  in  literature.     Since 

that  time,  however,  there  have  been  a  large  number  of  cases  reported. 

*  Paper  read  before  the  British  Orthopaedic  Association  at  the  Annual 
Meeting,   held   in   Liverpool    on    December   2nd,   1921. 


216  C.    THURSTAN    HOLLAND 

For  instance:  Rossi  (Italy)  in  1917-1918  reported  22  cases;  Richard 
(America)  in  1918,  54  cases;  Nove-Josserand  et  Rendu  (France)  in 
1919-1920,  19  cases;  Japiot  (France)  has  radiographed  at  least  20 
cases,  whilst  during  the  last  twelve  months  a  great  many  authors — 
chiefly  French — have  placed  on  record  numerous  cases. 

The  condition,  as  far  as  I  know,  has  received  little  or  no  attention 
in  England,  and  I  have  not  been  able  to  find  any  reports  of  cases  or 
any  radiographs  of  this  condition  in  our  journals.  In  Ireland,  how- 
ever, Hayes  (Dublin)  has  reported  four  cases  in  the  Dublin  Journal 
of  Medical  Science,  in  the  April  number,  1921.  He  also  states  that  no 
case  of  operative  treatment  resulting  in  a  complete  cure  has  been 
reported. 

It  is  evidently  a  common  condition,  and  one,  I  think,  which  requires 
a  certain  amount  of  surgical  consideration,  in  view  of  the  undoubted 
fact  that  pain  of  some  kind  or  another  is  so  frequently  present  in  the 
cases  in  which  the  deformity  is  found.  Always  admitting  the  some- 
what voracious  appetites  of  the  orthopaedic  surgeons  during  the  past 
few  years,  I  take  it  that  this  condition  may  be  justly  considered  as  a 
part  of  their  regular  diet;  this  mlust  be  my  excuse  for  bringing  it  be- 
fore you. 

I  have  seen  ten  cases  during  the  present  year,  and  produce  radio- 
graphs of  these  cases :  eight  in  females,  two  only  in  males.  The 
ages  vary  from  2%  years  up  to  59  years,  three  in  children  of  10  years 
and  under,  the  remainder  in  adults.  The  one  in  a  child  of  2%  years  is 
of  interest  inasmuch  as  it  shows  the  development  of  the  lateral  masses 
of  the  sacrum  from  separate  centers,  and  complete  fusion  has  not 
yet  taken  place.  Five  cases  are  symmetrically  bilateral.  Five  cases  are 
unilateral.  In  four  of  these  there  is  an  abnormal  appearance  of  the 
transverse  process  on  the  opposite  side. 

The  symptomatology  is  of  some  interest.  Pain  in  the  region  of  the 
back  is  what  is  usually  complained  of  in  most  of  the  cases  in  which 
this  condition  has  been  discovered  radiologically,  but  in  one  of  my 
cases  the  discovery  was  entirely  accidental,  as  no  pain  whatever  which 
could  have  had  any  relationship  to  the  presence  of  sacralization  was  com- 
plained of.  The  radiograph  was  taken  because  pus  had  been  discov- 
ered in  the  urine.  Others  have  also  noted  that  the  condition  may  be 
painless.  We  also  have  the  fact,  of  course,  that  existing  from  the  time 
of  development,  the  condition  may  be  painless  for  a  large  number  of 
years  and  the  history  frequently  given  is  pain  for  a  few  years  only> 
or  for  even  much  less. 


FIFTH    LUMBAR    VERTEBRA  217 

Probably  the  usual  diagnosis  in  these  cases  at  first,  at  any  rate,  is 
lumbago,  and  no  doubt  many  continue  for  years  and  have  the  usual 
treatments  given  for  this  complaint.  Osteoarthritis  of  the  lumbar 
spine  would  also  have  to  be  considered.  However,  by  far  the  larger 
number  of  cases — all  mine  except  one — are  sent  to  the  radiologist  with 
a  request  for  an  x-ray  examination  of  the  kidneys,  ureters,  or  bladder, 
the  suspicion  being  that  the  pain  may  be  caused  by  stone.  In  none  of 
my  cases  was  a  stone  present. 

It  does  not  necessarily  follow  that  the  pain  in  these  cases  is  due  to 
the  sacralization,  but  that  after  all  is,  and  can  be,  only  an  inference; 
but  the  cause  of  the  pain  is  generally  obscure  and  the  pain  itself  is  indefi- 
nite in  character,  so  that  in  the  absence  of  any  other  known  cause, 
and  in  the  presence  of  an  otherwise  negative  x-ray  examination,  it 
seems  fair  to  suspect  the  only  abnormality  which  can  be  found,  namely, 
the  sacralization,  as  a  probable  cause  of  the  trouble. 

Two  questions  arise:  "Why  should  it  give  rise  to  pain?  "Why  can  it 
exist  for  many  years  without  pain  and  then,  in  some  cases,  give  rise 
to  a  pain  which  begins  slowly,  and  gradually  gets  worse  and  worse, 
and  in  others  commences  with  an  attack  of  acute  pain? 

Various  causes  have  been  put  forward,  and  these  may  be  summarized 
as  follows: 

1.  Actual  pressure  on  nerves  or  nerve  trunks. 

2.  Ligamentous  strain. 

3.  Compression  of  soft  tissues  between  bony  joints. 

4.  By  an  actual  arthritis  if  a  joint  is  present. 

5.  By  a  bursitis  if  a  bursa  is  present. 

There  is  the  additional  point  that  a  trauma  may  be  the  exciting  cause, 
especially  in  those  cases  of  sudden  and  acute  pain. 

In  one  of  my  cases,  which  I  shall  refer  to  again,  I  consider  that  the 
radiograph  distinctly  suggests  a  definite  joint,  and  also  indicates  an 
osteoarthritis.  This  was  a  unilateral  case,  with  pain  on  the  side  of,  and 
in  the  region  of,  the  abnormality. 

As  to  the  treatment  of  this  condition:  Els  (of  Bonn)  advises  opera- 
tion in  pain  from  definite  sacralization;  Merklen  and  de  Gery  (Paris) 
advise  resection,  but  state  that  up  to  the  present  (1920)  the  results 
are  not  very  striking;  Japiot  (Paris),  1921,  states  that  in  four  op- 
erations performed  in  America,  only  amelioration,  and  not  cure,  re- 
sulted. He  himself  has  treated  the  pain  by  x-ray  therapy  with  prom- 
ising results.  (As  a  comment  of  this,  it  is  extraordinary  what  a  lot 
of  conditions  have  been  treated  with  x-rays  with  "promising  results.") 


218  C.    THURSTAN    HOLLAND 

I  take  it  that  cases  for  operation  should  be  very  carefully  selected, 
and  that  to  jump  at  operation  merely  on  the  x-ray  findings  would  be 
absurd.  There  should,  at  any  rate,  be  some  definite  grounds  for  the 
assumption  that  the  condition  in  each  individual  case  was  the  prob- 
able source  of  the  pain.  My  material  bearing  on  this  matter  is  small 
but,  at  the  same  time,  significant.  One  case,  a  woman  aged  30  years, 
in  a  medical  ward  of  the  Royal  Infirmary,  was  referred  to  me  by  Dr. 
Abram  for  an  examination  of  the  kidneys.  In  the  routine  of  this  ex- 
amination, nothing  was  found,  but  a  unilateral  sacralization  plus  a 
somewhat  abnormal  transverse  process  on  the  other  side,  were  shown. 
This  is  the  case  already  alluded  to  as  suggesting  a  joint  plus  osteo- 
arthritis. The  pain — twelve  months'  duration — was  definitely  on  the 
side  of  the  sacralization.  Knowing  at  that  time  nothing  about  the  sub- 
ject, I  naturally  rushed  in  where  angels  fear  to  tread  (I,  of  course, 
refer  to  yourselves,  gentlemen),  and  suggested  an  operation. 

A  few  weeks  later  an  osteotomy  and  removal  of  bone  was  done  by 
Mr.  Jeans.  Four  months  later,  in  reply  to  enquiries,  I  received  the 
following  letter:  "I  am  pleased  to  say  that  I  have  had  no  return  of 
pain  since,  and  have  been  much  better  in  health.  I  will  take  this  op- 
portunity of  thanking  all  those  who  helped  to  restore  me  to  health, 
and  I  cannot  say  how  grateful  I  am." 

One  case  of  success  is,  of  course,  not  very  much  to  go  upon,  and  even 
in  this  case  no  great  length  of  time  has  elapsed  since  the  operation. 
At  the  same  time  it  has  its  significance,  and  I  suggest  that  the  con- 
dition of  sacralization  deserves  your  attention. 

BIBLIOGRAPHY. 

Paterson  :     Scientific  Transactions  of  the  Royal  Dublin  Society,  Vol.  v  (series 

.11),  p.  123,  1803. 
Adams:    American  Journal  of  Orthopaedic   Surgery,   Nov.,  1910. 
Goldthwait:    Boston  Medical  and  Surgical  Journal,   1911. 
Klein schmidt:     Ztrbl.  fur  Chir.,  May  11,  1912. 
Dennie:     Revue  d'Orthopedie,  December,  1913. 
Calve  :     Orthopedie  et  Tuberculose  Chirurg.,  Jan.,  1914. 
Japiot  et  Santy:    Revue  d'Orthopedie,  (May,  1914. 
Japiot:    Lyon  Medical,  May,  1914. 

Young:     American  Journal  of  Orthopaedic  Surgery,  November,  1916. 
Els:     Beitr.  z.  klin.  Chir.,  Vol.  95. 
Bertolotti:     La  Radiologia   Medica,   1917. 
Rossi:     La  chirg.  degli  Organi  di  Movimento,  1919. 
Richards:     American  Journal  of  Roentgenology,  1919. 
NovE-JossERAND :     Lyon  Chirg,  1919. 
Rendu  et  Arcelin:     Lyon  Medical,  1920. 
Japiot:     Lyon  Medical,  1920-1921. 
Nove-Josserand  et  Rendu:     Presse  Medicale,  19(20. 


FOOT    DEFORMITIES  219 

Mauclaire:     Soc.  de  Chirg.  de  Paris,  1920,  April,  June,  December. 
Mauclaire,   Delherm,  Thoyer-Rozat  :     Bull,  et  Mem.   de  la   Soc.   de   Chirg.,. 

1920. 
Clap:  Bull,  et  Mem.  de  la  Soc.  Anatomique  de  Paris,  1920. 
Olivier:     Ibid.,  1920. 
Soundat:     Gaz.   Med.   de   Picardie,   1920. 
Georget:     These  de  Lyon,   1920. 
Keating-Hart:     devolution  Medico-Chirurg.,  1920. 
Merkijn   and  Fevrier:     Bull,  et   Mem.  de  la  Soc.  Medicale  des  HOpitaux  de 

Paris,  1920. 
Ledoux  and  Catt.tode:     Presse  Med.,  Paris,  1921. 
Delherm   et   ThoyerhRozat  :     Bull.    Medicale,   1921. 
Mauclaire:     Bull,  de  la  Soc.  de  Chirg.,  1921. 
Hayes:     Dublin  Journal  Med.   Science,  1921. 
Michel:     Gaz.   des  Hopitaux,   1921. 

Olivier  et  Darbois:     Bull.  Soc.  Radiolog.  Med.  de  France,  1921. 
Lupo:     La  Chirg.  degli  Organi  de  Movimento,  1921. 


A  NEW  METHOD  OF  OPERATIVE  TREATMENT  OF 
FOOT  DEFORMITIES. 

BY   O.   E.   SCHULZ,    M.D.,   PRAGUE,    CZECHOSLOVAKIA, 

Yedlicka's  Institute  for  Crippled  Children. 

The  correction  of  a  faulty  position  of  calcaneus  is  a  matter  of  greatest 
difficulty  in  both  congenital  and  acquired  deformities  of  the  foot.  The 
correction  of  the  heel  might  be  performed  instrumentally  or  manually, 
but  it  is  the  retention  of  the  corrected  or  overcorrected  position  which 
is  so  extremely  difficult. 

In  correcting  the  deformity  of  the  forefoot  by  redressement,  we  force 
the  small  bones  of  the  forefoot  one  against  the  other  one,  but  in  the 
heel  we  find  only  one  hard  and  very  solid  bone,  deformed  in  its  structure 
and  form,  joined  by  means  of  strong  ligaments  to  the  astragalus,  fibula, 
and  tibia.    Such  a  bone  is  not  easy  to  correct. 

Unfortunately,  a  recidive  of  club  or  flatfoot  begins  always  in  the  heel, 
which  first  goes  back  to  its  former  wrong  position.  For  this  reason  a 
perfect  cure  is  secured  only  by  an  overcorrection  and  retention  in  the 
overcorrected  position  of  the  calcaneus. 


220  O.    E.    SCHULZ 

In  flatfoot  we  have  corrected  the  deformity  by  osteotomy.  Gleich 
made  an  oblique  osteotomy  of  the  calcaneus  from  the  front  and  inside 
to  outside  and  backward.  Then  he  pushed  the  rear  fragment  forward 
and  inside  and  finished  the  operation  by  achillotenotomy.  Brenner 
performed  the  same  operation  from  the  inside.  Frisch  proceeds  from 
the  outside  and  nails  the  processus  posterior  calcanei  from  behind. 
Perthes  cuts  out  a  piece  of  the  os  naviculare  and  implants  it  in  a  linear 
osteotomy  in  the  processus  anterior  calcanei.  Wilms  does  a  similar 
operation,  implanting  the  piece  between  the  os  cuboideum  and  the  cal- 
caneus. 

Lorenz,  four  years  ago,  recommended  a  simple  operation.  He  made 
a  skin  incision  against  the  Achilles  tendon,  stripped  the  skin  out  and 
.  inside  of  the  tendon,  chiseled  away  the  insertion  of  the  tendon  with 
the  epiphysis  of  the  os  calcaneum,  pushed  the  tendon  with  the  fragment 
outward  in  case  of  a  clubfoot,  inward  in  a  flatfoot,  and  finally  fixed 
the  bone  in  the  overcorrected  position  by  a  nail. 

The  purpose  of  all  these  operations  is  the  supination  and  adduction  of 
the  heel.  Following  the  same  purpose  Franke  Frank,  Vulpius  and 
others  shortened  the  tendon  of  the  muse,  tibialis  posterior,  Hubscher 
shortened  the  tendons  of  the  flexors  of  the  toes,  Byerson  transplanted 
the  muse,  peronaeus  longus  on  the  os  cuneiforme;  T.  B.  W.  Armour, 
C.  B.  Edin  and  Naughton  Dunn  excised  a  portion  of  the  peronaeus 
tendon  and  paralyzed  artificially  the  nervus  peronaeus. 

All  these  transplantations  have  only  an  indirect  influence  upon  the 
heel,  the  new  insertion  of  the  transplanted  tendon  working  directly  in 
the  elevation  of  the  inside  of  the  foot  and  only  indirectly  in  the  supina- 
tion of  the  heel. 

My  aim  was  to  produce  a  supination  of  the  heel  by  means  of  a  strong 
tendon  and  at  the  same  time  to  secure  the  important  adduction  and 
inward  rotation  of  the  heel.  For  this  reason  I  worked  out  the  following 
method : 

I  cut  the  tendon  of  the  musculus  peronaeus  longus  in  the  sole,  pull 
out  the  dissected  tendon  behind  the  malleolus  externus  and  conduct  it 
inside  between  the  gastrocnemius  and  the  flexor  of  toes  to  the  hind  part 
of  malleolus  internus.  Then  I  make  a  canal  between  the  plantar  side 
of  calcaneus  and  ligamentum  plantare  longum  and  carry  the  tendon 
backward  under  the  calcaneus  to  the  outside,  where  I  fix  it  to  the  peri- 
osteum of  the  lateral  side  of  the  calcaneus.  At  the  same  time  I  produce 
an  inward  rotation,  adduction,  and  supination  of  the  heel.  The  tendon 
of  the  muse,  peronaeus  longus  has  now  its  route  from  outside  to  inside, 


FOOT     DEFORMITIES 


221 


Tendon  Operation  for  Foot  Deformity. 


222  o.  e.  schulz 

returning  back  to  the  outside  under  the  calcaneus.  A  contraction  of 
the  transplanted  tendon  will  produce  a  strong  adduction,  supination, 
and  inward   rotation. 

OBSERVATIONS. 

I.  Girl,  12  years.  Poliomyelitis  at  the  age  of  four  years.  Right  foot 
is  in  abduction,  heel  in  abduction  and  outward  rotation.  Muse,  tibialis 
posterior  and  flexor  digitorum  are  paralyzed.  Tibialis  anterior,  ex- 
tensor digitorum  and  both  peronaei  in  a  pretty  good  condition.  Opera- 
tion :  1.  Incision  on  the  outside  of  the  foot ;  both  peronaei  cut.  2.  Long 
incision  behind  the  malleolus  externus.  3.  A  similar  incision  behind  the 
malleolus  internus.  4.  The  tendon  of  the  peronaeus  longus  pulled  out 
behind  the  malleolus  externus.  Both  tendons  carried  through  the  space 
between  the  musculus  gastrocnemius  and  the  flexors  to  the  inside.  The 
peronaeus  longus  tendon  conducted  back  to  the  outside  under  the  calca- 
neus. The  heel  adjusted  to  a  maximum  of  adduction  and  supination. 
The  free  end  of  peronaeus  brevis  fixed  with  silk  to  the  periosteum  of 
the  inner  side  of  calcaneus,  peronaeus  longus  to  the  outside  of  the  same 
bone.  Incisions  sewn  with  catgut.  Plaster  dressing  in  the  overcorrected 
position.  Two  months  later :  Foot  in  a  good  position ;  patient  walks  with 
her  foot  in  supination.    Eight  months  later :  Condition  same. 

II.  Girl,  5  years.  Poliomyelitis  when  one  year  old.  Left  foot  in 
abduction,  outward  rotation,  and  pronation.  Musculi  tibialis  anterior, 
flexor  hallucis  longus,  and  tibialis  posterior  paralyzed.  Extensor  digi- 
torum and  peronaei  in  an  excellent  condition.  The  last  named  muscle  is 
very  well  developed  and  dislocated  to  the  front  of  malleolus  externus. 

The  same  operation  performed  with  the  exception  that  only  the  pero- 
naeus longus  was  cut. 

Three  months  later:  The  child  walks  without  difficulty  in  orthopae- 
dic shoes  with  a  light  support  (inlay) .    Foot  in  good  position. 

If  we  now  turn  to  consider  the  question  of  clubfoot  we  find  that  the 
calcaneus  deformity  is  here  also  of  the  same  importance.  Hansen  rec- 
ommended the  excision  of  a  wedge  from  the  lateral  portion  of  the  cal- 
caneus with  the  angle  to  the  inside  and  infraction  of  the  calcaneus  in 
an  overcorrected  position.  The  operations  of  Perthes,  Wilms,  and  Lorenz, 
can  easily  be  modified  to  the  treatment  of  a  clubfoot.  Also  the  opera- 
tion which  I  suggest  in  this  paper  can  be  applied  to  a  clubfoot.  The 
tendon  of  the  muse,  flexor  hallucis  longus  is  cut  in  the  sole,  conducted 
behind  the  malleolus  externus  and  back  to  the  inside  of  the  heel  under 
the  calcaneus. 


FOOT     DEFORMITIES  223 

Observation:  Female,  28  years.  Poliomyelitis  at  the  age  of  4  years. 
Double  clubfoot.  Operated  at  the  age  of  18  years  by  redressement. 
Fibula  was  broken  in  both  extremities  and  its  distal  fragment  became 
dislocated  so  much  that  the  malleolus  was  too  large  for  the  astralgalus. 
A  few  weeks  later  both  feet  returned  to  the  same  position.  Walking 
possible  only  with  the  help  of  a  strong  and  elaborate  apparatus. 

I  first  made  an  instrumental  and  manual  redressement  of  both  feet 
and  applied  a  long  plaster  dressing  in  an  overcorrected  position  for 
ten  weeks.  After  this  time  the  patient  could  walk  without  any  appa- 
ratus, in  orthopaedic  shoes  only.  Foot  was  in  a  good  position  while  the 
patient  was  standing.    During  walking  the  unfirm  foot  turned  outwards. 

Six  months  later  the  transplantations  were  made. 

Operation  on  the  right  foot : 

(1)  Incision  in  the  sole,  2  inches  long,  in  the  center  of  the  first  met- 
atarsal. The  tendon  of  the  flexor  hallucis  cut  near  the  junctura 
tendinum.  The  distal  fragment  of  the  tendon  attached  with  silk  to 
the  flexor  communis,  the  proximal  end  loosened  from  the  junctura 
tendinum. 

(2)  Long  incision  behind  malleolus  internus.  Ligamentum  lancini- 
atum  cut.    The  free  end  of  the  tendon  pulled  out. 

(3)  Long  incision  behind  malleolus  externus.  The  tendon  carried 
between  muse,  gastrocnemius  and  flexor  digitorum  to  the  outside. 

(4)  The  canal  under  the  plantar  side  of  the  calcaneus  prepared. 
The  tendon  carried  through  the  canal  under  the  calcaneus  to  the  inner 
side  of  this  bone  and  fixed  there  with  silk.  Overcorrection  of  the  heel 
position  at  the  same  time. 

(5)  The  tendon  of  the  muse,  tibialis  ant.  was  transplanted  to  the 
lateral  side  of  the  foot. 

Operation  on  the  left  foot  performed  in  a  similar  way.  Here  the 
tendon  was  too  short  and  allowed  a  fixation  to  the  outside  of  the  cal- 
caneus only. 

Plaster  dressing  on  both  extremities  for  10  weeks. 

After  10  weeks:  The  patient  walked  without  any  apparatus  for 
three-fourths  to  one  hour  without  difficulty.  Only  walking  up  hill  was 
painful. 

The  position  of  the  right  foot  is  better  than  of  the  left  foot,  as  was 
expected. 

Summary:  A  new  operative  treatment  of  foot  deformities  is  de- 
scribed, based  on  tendon  transplantation  of  the  heel. 


224  PHILIP    D.    WILSON 


EARLY  WEIGHT-BEARING  IN  THE  TREATMENT   OF 
AMPUTATIONS  OF  THE  LOWER  LIMBS. 

BY  PHILIP  D.  WILSON,   M.D.,  BOSTON. 

A  sufficient  time  has  passed  since  the  termination  of  the  war  to 
allow  us  to  draw  definite  conclusions  as  to  the  real  value  of  certain 
surgical  procedures  which  were  introduced  at  that  time.  Of  these 
the  use  of  weight-bearing  in  the  after  treatment  of  amputations 
of  the  lower  limb  seems  definitely  to  have  proved  its  value  and  de- 
serves to  be  applied  to  the  surgery  of  peace. 

Early  weight-bearing  is  obtained  by  the  use  of  peg  legs  or  articu- 
lated limbs  of  such  simple  type  and  construction  that  their  rapid 
manufacture  is  possible  by  almost  anyone  after  a  little  practice  with- 
out the  necessity  of  elaborate  training  or  equipment.  The  apparatus 
consists  essentially  of  two  parts,  a  socket  which  is  moulded  to  the 
stump  in  order  to  obtain  an  accurate  fit,  and  a  skeleton  frame  which 
transmits  the  body  weight  from  the  socket  to  the  ground. 

The  chief  bearing  points  utilized  are  the  bony  prominences:  the 
tuberosity  of  the  ischium  for  thigh  amputations,  and  the  shelving 
under  surface  of  the  upper  end  of  the  tibia  in  below-the-knee  cases. 
Secondarily,  the  weight  is  borne  by  the  soft  parts,  but  always  in  a 
manner  to  relieve  the  wound  of  pressure,  the  lower  end  of  the  socket 
being  left  open  for  this  purpose. 

The  socket  may  be  made  of  papier  mache,  leather,  or  plaster  of 
Paris;  the  frame  is  usually  of  wood  or  light  iron.  To  work  success- 
fully the  apparatus  must  combine  the  following  features, — adapta- 
bility to  various  types  of  stump,  strength,  lightness,  and  ease  of  man- 
ufacture. 

With  such  forms  of  apparatus  it  is  possible  to  get  patients  out  of 
bed  and  walking  without  other  support  very  shortly  after  amputa- 
tion. When  the  wound  is  clean,  weight-bearing  may  be  begun  at  the 
end  of  two  to  three  weeks.  In  the  writer's  experience  the  time  has 
often  been  less.  Only  serious  complications  should  prolong  it  more 
than  four  weeks.  Crutches  delay  progress  and  should  not  be  allowed. 
When  support  is  necessary,  canes  suffice  and  are  not  productive  of 
bad  habits.  There  is  no  pain  when  the  apparatus  is  properly  designed 
and  fitted,  other  than  moderate  soreness  of  the  bony  prominences 
until  they  become  accustomed  to  pressure. 


EARLY     WEIGHT-BEARING 


225 


Thigh   peg  leg.   Stump   covered   with   stockinette  ,and  cardboard   cuff   at  end. 
Crutch   frame  being   applied  for  preliminary   fitting. 

Because  of  this,  however,  and  also  because  of  the  great  muscular 
weakness,  use  should  be  begun  gradually.  At  first  the  patient  is  en- 
couraged to  take  a  few  steps  supported  by  attendants.  Later,  as  he 
becomes  stronger,  he  may  push  a  chair  about  the  room  until  he  has 
obtained  sufficient  confidence  to  walk  unaided  or  with  a  cane.  Short 
and  frequent  periods  of  exertion  with  long  intervals  of  rest  are  better 
llian  prolonged  efforts  and  over-fatigue.  During  the  first  few  days 
the  patient  is  timid  and  discouraged  and  it  is  essential  that  the  sur- 
geon should  maintain  close  supervision  in  order  to  give  the  patient 
confidence  and  stimulate  him  to  further  effort.  The  ability  to  walk 
is  usually  acquired  within  a  week,  and  thereafter  progress  is  rapid. 
Little  attention   is  required  from  the  surgeon  beyond  changing  the 


226 


PHILIP    D.    WILSON 


II. 

Thigh  peg  leg.  Plaster  has  been  applied  to  stump  while  traction  was  being 
exerted  on  the  long  end  of  the  stockinette.  Upper  ends  of  the  crutch  frame 
have  been  covered  with  plaster  ready  for  incorporation  in  the  cast. 


III. 

Thigh  peg  leg.    Cast  finished.    Note  roller  bandage  in  fork  of  crutch  to  prevent 
it  from  springing  together  and  indenting  the  plaster. 

socket  when  it  becomes  too  large,  and  restraining  the  patient  from 
acquiring  his  permanent  artificial  limb  too  early.  The  use  of  the 
temporary  prosthesis  is  continued  until  the  permanent  limb  has  been 
obtained. 

The  benefits  derived  from  this  method  of  treatment  are  varied  and 
may  be  considered  as  either  physiologic,  economic,  or  psychologic. 

I.  Physiologic.  The  results  may  be  noted  here  as  they  affect  first 
the  wound  and  second  the  stump. 

1.  Effect  on  the  wound.  Following  amputation  there  is  always 
marked  edema  of  the  stump,  chiefly  noticeable  about  the  wound  or 
distal  portion.     Wound  healing  is  notoriously  slow  and  sinuses  often 


EARLY     WEIGHT-BEARING 


227 


IV.  v. 

Thigh   peg   leg.     Cast    dried,  Application   of   traction  to   thigh   stump   to 

trimmed,    and    applied.  protect    wound    when   pressure    is   borne. 

The  ends  of  the  straps  are  pulled  down 
and  buckled  tightly  to  the  lower  end  of 
the  peg  leg. 

persist  for  a  surprisingly  long  period.  This  condition  is  due  to  cir- 
culatory stasis  and  may  be  partially  relieved  by  elevation  of  the 
part,  massage,  and  tight  bandaging.  Active  weight-bearing  in  a 
temporary  limb  with  carefully  fitted  socket  gives  far  more  effective 
stump  compression,  however,  than  the  most  carefully  applied  bandage, 
and  the  alternate  application  and  withdrawal  of  pressure  in  walking 
constitutes  one  of  the  best  forms  of  massage.  In  addition,  active  use 
of  the  stump  restores  the  conditions  necessary  for  normal  functioning 
of  the  circulation.  It  is  certain  that  with  this  method  of  treatment 
the  edema  quickly  disappears,  the  circulation  becomes  normal,  and 
wounds  and  sluggish  sinuses  quickly  take  on  a  healthy  appearance  and 
heal  rapidly. 


228 


PHILIP    D.    WILSON 


VII. 

Front  view  of  thigh  peg  leg  for  long       Same    as    Fig.    VI,    rear    view.      The 
stump.     Note   suspender.  cast  has  been  varnished  with  shellac. 

Special  measures  must  be  taken  to  protect  the  wounds  in  certain 
cases,  particularly  thigh  amputations  where  the  conical  shape  of  the 
socket  tends  to  crowd  the  soft  parts  up  from  the  end  of  the  bone  and 
thus  produce  possible  separation  of  the  flaps.  This  accident  can  al- 
ways be  prevented  by  the  application  of  traction  and  has  never  hap- 
pened in  the  writer's  experience.  Broad  adhesive  straps  with  tapes 
are  applied  to  the  soft  parts  of  the  stump  and  the  tapes  passed  down 
through  the  open  end  of  the  socket  and  buckled  tightly  to  the  lower 
portion  of  the  apparatus  in  such  position  as  to  exert  downward  pull 
on  the  parts  about  the  wound  and  protect  it.  These  traction  strips 
serve  also  to  fix  the  leg  to  the  stump  and  may  be  used  in  lieu  of  other 
form  of  suspenders. 

The  presence  of  an  open  wound  at  the  end  of  the  stump  is  not  a 
contraindication  to  early  weight-bearing.  Frequently  during,  the  war 
cases  of  amputation  by  the  no-flap   or  guillotine  method  were  fitted 


EARLY    WEIGHT-BEARING  229 


VIII. 

Peg  leg  for  short  thigh 
stump,  showing  the  T 
side  bar  and  pelvic  band. 
A  suspender  is  also  used, 
as  shown  in  Fig.  VI. 


with  temporary  legs  during  a  fairly  early  stage  of  their  convalescence. 
They  were  able  to  walk  without  pain  and  it  was  noted  that  their 
wounds  healed  more  rapidly  with  this  method  of  treatment  than  with- 
out.   Traction  was  always  provided  in  such  cases. 

Improvement  has  particularly  been  noted  following  weight-bearing 
in  old  infected  amputation  stumps  with  localized  osteomyelitis  and 
sinuses.  Such  cases  ordinarily  drag  along  many  months  and  are 
often  subjected  to  secondary  operations  before  active  use  of  the  stump 
is  allowed.  Weight-bearing  after  the  acute  infection  has  subsided 
hastens  the  separation  and  discharge  of  sequestra,  improves  the  circu- 
lation of  the  part,  and  favorably  influences  the  course  of  the  disease 
in  the  majority  of  such  cases.  Backing  up  of  the  discharge  and  ab- 
scess formation  occasionally  compel  the  temporary  abandonment  of 
the  method,  but  it  should  be  resumed  as  soon  as  the  condition  of  the 
wound  permits  it. 


230 


PHILIP    D.    WILSON 


EARLY     WEIGHT-BEARING 


231 


x. 

Below-knee  leg.     The  frame  is  fitted  and  the  side  bars  bent  to  conform  to  the 

shape  of  the  stump. 

2.  Effect  on  the  stump.  In  order  to  understand  the  effect  on  the 
stump  of  treatment  by  early  weight-bearing,  it  is  first  necessary  to 
consider  the  changes  that  should  normally  take  place  in  it,  following 
amputation.  The  operation  deprives  the  larger  part  of  the  muscles 
in.  the  sectioned  limb  of  their  insertion.  Suture  across  the  end  of 
the  bone  of  the  groups  antagonistic  to  each  other  is  useful  in  pre- 
venting retraction,  but  will  only  preserve  function  in  the  relatively 
few  muscles  that  originate  above  the  proximal  joint.  The  remainder 
no  longer  have  work  to  perform  and  therefore  atrophy,  with  resulting 
decrease  in  the  stump  diameter.  In  general,  the  longer  the  stump 
the  greater  the  amount  of  atrophy,  because  the  muscles  arising  from 


232 


PHILIP    D.    WILSON 


Below-knee  leg.     The  stump  is  covered  with  stockinette  and  the  end  protected 
with  a  pasteboard  cuff.    Traction  is  maintained  on  the  stockinette. 

the  next  higher  hone  segment  are  usually  inserted  in  the  stump  close 
to  the  articulation.  Another  factor  in  producing  stump  shrinkage  is 
the  pressure  of  the  socket  of  the  artificial  limb  against  the  soft  parts. 
This  causes  atrophy  of  the  subcutaneous  and  intramuscular  fat  tissue 
and  very  considerable  change  in  size.  A  stump  that  has  been  used 
actively  for  several  years  is  often  smaller  by  half  than  the  normal 
limb. 

From  this  it  may  be  seen  that  stump  shrinkage  is  entirely  normal,, 
that  it  is  in  part  physiologic  and  in  part  due  to  weight-bearing.  From 
the  standpoint  of  function  it  is  greatly  desirable  because  the  artifi- 
cial limb  can  obtain  a  much  better  grip  on  an  atrophied  than  a  fat 
stump,  with  resulting  increase  in  stability  and  leverage  power. 

Normal  stump  shrinkage  is  interfered  with  by  the  usual  methods 
of  treatment  or,  rather,  lack  of  treatment.  When  a  patient  is  allowed 
about  on  crutches  without  apparatus  fitted  to  utilize  the  stump,  the 
dependent  position  of  the  latter  greatly  favors  an  increase  of  the 
venous  congestion  and  circulatory  stasis  produced  by  the  operation. 
Instead  of  shrinkage  in  size  there  is  increase  in  size  on  account  of 
edema.     Only  active  use  can  produce  complete  disappearance  of  the 


EARLY     WEIGHT-BEARING 


233 


XII. 

ISelow-knee  leg.     Plaster  is  applied,  covering  the  stump  from  its  end  to  the 

middle  of  the  patella. 

swelling  and  the  longer  it  persists  the  more  difficult  it  is  to  bring 
tfbout  restoration  of  the  normal  circulation.  With  time  there  is  ab- 
sorption of  some  of  the  exudate,  with  increase  in  the  amount  of  fibrous 
tissue.  But  the  stump  still  remains  large  because,  not  serving  any  other 
useful  purpose,  Nature  utilizes  it  as  a  convenient  storehouse  for  fat 
just  as  she  does  any  other  inactive  part  of  the  body. 

In  such  a  stump  nothing  will  produce  shrinkage  but  active  weight- 
bearing  in  an  artificial  limb.  Tight  bandaging  or  the  use  of  laced 
leather  '  *  shrinkers, ' '  to  be  obtained  of  artificial  limb  makers,  will  help 
but  will  not  furnish  a  solution.  Furthermore,  shrinkage  will  occur 
only  in  so  far  as  the  socket  of  the  artificial  limb  remains  tight  enough 
to  cause  firm,  even  compression  of  the  stump.  This  inevitably  entails 
the  changing  of  the  socket  two  or  three  times  during  the  process  of 
evolution.  On  the  other  hand,  this  shrinkage  does  not  go  on  indefi- 
nitely and,  sooner  or  later,  the  length  of  time  depending  upon  how 
soon  weight-bearing  is  begun,  the  moment  arrives  when  further  decrease 
in  size  does  not  occur  and  the  stump  has  reached  the  stage  of  com- 
plete evolution. 


234  PHILIP    D.    WILSON 

It  is  customary  in  present  practice  to  wait  three  to  six  months  after 
the  amputation  before  beginning  weight-bearing.  The  permanent  type 
of  limb  is  then  fitted  without  any  preliminary  treatment  to  prepare  the 
stump  for  its  use.  The  stump  under  such  conditions  is  fat,  boggy 
and  sensitive;  the  muscles  which  should  activate  it  are  atrophied  and 
powerless,  and  important  limitation  of  joint  motion  is  commonly  pres- 
ent. On  the  other  hand,  the  leg  used  is  relatively  heavy  and  diffi- 
cult to  control.  Close  fit,  freedom  from  pain,  muscular  strength,  good 
coordination,  and  full  range  of  joint  motion  are  essential  to  its  proper 
use.  Learning  to  walk  with  an  articulated  limb  is  not  easy  at  best; 
under  the  above  conditions  it  becomes  almost  impossible. 

In  England  and  France  during  the  first  two  years  of  the  war  it 
was  impossible  to  supply  artificial  limbs  in  quantity  sufficient  to  meet 
the  demand.  The  great  majority  of  the  amputation  patients  had  to 
wait  many  months  before  receiving  them.  During  this  period  they 
went  about  on  crutches  without  treatment,  as  it  was  before  the  pos- 
sibility of  using  simpler  forms  of  apparatus  had  been  recognized. 
The  condition  of  these  men  was  lamentable  indeed  when  they  were 
finally  examined  for  the  fitting  of  their  artificial  limbs.  The  vast 
majority  presented  fat,  congested  stumps  with  powerless  muscles  and 
serious  joint  contractures.  Practically  all  of  them  had  to  go  back  to 
the  hospital  for  long  periods  of  treatment  before  the  limbs  could  be 
fitted.  Many  had  to  undergo  serious  operation  for  the  correction  of 
joint  deformity.  All  made  very  slow  progress  and  many  never  suc- 
ceeded in  learning  to  walk. 

That  such  cases  are  very  frequent  in  the  surgery  of  peace,  where 
the  surgical  supervision  of  the  patient  so  commonly  ends  when  wound 
healing  has  been  obtained,  is  borne  out  by  the  cases  seen  by  the  writer 
in  hospital  and  private  practice.  The  application  of  some  temporary 
apparatus  such  as  described  later,  which  permits  weight-bearing  soon 
after  the  amputation,  hastens  stump  shrinkage,  prevents  congestion 
and  edema,  maintains  tone  and  strength  in  the  muscles  which  con- 
trol the  stump,  and  by  normal  use  of  the  joints  prevents  limitation  of 
motion. 

II.  Economic.  The  economic  factor  is  of  no  small  importance. 
Early  weight-bearing  reduces  the  period  of  convalescence  by  at  least 
one-half.  Convalescence  ends  when  maximum  functional  restoration 
has  been  obtained.  In  the  case  of  amputations  of  the  lower  limb  this 
is  represented  not  by  the  moment  when  the  patient  has  been  fitted 
with  his  permanent  artificial  limb,  but  wThen  the  stump  has  reached  the 


EARLY     WEIGHT-BEARING 


235 


XIII. 
Below-knee  leg.    The  skeleton  leer  is  applied,  the  side  bars  being  covered  with 
plaster  and  incorporated  in  the  cast. 


XIV. 

The  cast  is  finished  and  the  upper  margin  of  the  socket  is  being  marked  out, 
in   preparation    for   trimming. 


236  PHILIP    D.    WILSON 

stage  of  complete  evolution  and  no  further  improvement  in  walking 
can  be  expected.  By  the  methods  commonly  followed  this  is  usually 
nine  to  twelve  months,  often  longer.  By  the  use  of  early  weight-bearing 
it  may  be  reduced  to  three  to  six  months,  seldom  longer.  Not  only 
this,  but  the  functional  end  result  is  better.  When  one  considers  the 
thousands  of  amputations  performed  in  this  country  annually  and 
multiplies  this  by  the  number  of  months  of  productive  labor  lost  by 
old  methods  of  treatment,  figures  quite  fantastic  in  their  economic 
importance  are  obtained. 

Another  advantage  growing  out  of  the  use  of  the  principle  of  early 
weight-bearing  is  more  concrete,  because  it  touches  the  pocketbook  of 
the  patient  himself.-  The  provisional  apparatus  used  is  very  cheap. 
Change  of  socket,  in  order  to  keep  pace  with  stump  shrinkage,  may 
be  made  at  small  expense.  When  maximum  shrinkage  has  been  ob- 
tained, the  permanent  limb  is  fitted  and  no  further  alteration  is  required. 

On  the  other  hand,  when  weight-bearing  is  only  begun  with  the  fit- 
ting of  the  permanent  leg,  stump  shrinkage  very  quickly  makes  the 
socket  too  large  for  use.  The  only  satisfactory  method  of  altering 
£.  wooden  socket  is  to  make  a  new  one.  As  this  is  a  highly  skilled  op- 
eration it  is  also  very  costly,  and  as  it  must  be  repeated  once  or  twice 
before  the  evolution  of  the  stump  is  complete,  this  represents  in  its 
totality  an  expense  that  is  usually  but  ill  afforded. 

III.  Psychologic.  Following  the  loss  of  a  limb  there  is  always  a 
period  of  profound  mental  depression.  The  reaction  to  this  usually 
takes  one  of  two  forms.  Either  the  patient  resigns  himself  to  a  life 
of  invalidism  and  helplessness  or  he  tries  vigorously  to  resume  his 
normal  activities,  fixing  his  hopes  upon  eventually  becoming  inde- 
pendent. The  first  means  drifting,  and  if  the  pension  is  small  may 
end  in  mendicancy.  The  second  means  maximum  functional  restora- 
tion, normal  life,  and  economic  freedom.  The  prolonged  period  of 
idleness,  coupled  with  the  consciousness  of  conspicuous  deformity  re- 
sulting from  lack  of  treatment  and  the  use  of  crutches,  seriously  favors 
the  former,  while  early  weight-bearing,  even  with  a  peg  leg,  by  answer- 
ing in  a  practical  manner  the  question,  "How  am  I  going  to  walk?" 
gives  a  great  impetus  in  the  direction  of  normalcy. 

Froelich  of  Nancy  and  Spitzy  of  Vienna  share  the  credit  of  having 
been  the  first  to  apply  the  principle  of  early  weight-bearing  to  the 
treatment  of  amputation  cases.  They  used  very  simple  forms  of 
j>eg  legs  with  plaster-of -Paris  sockets.  After  them  Martin  at  La  Panne 
■adopted  the  idea.     He  quickly  saw  its  value  and  at  the  Ambulance 


KAKI.Y      WKKillT   UKAJCINi; 


237 


xv. 

Below-knee    leg.      The    leg    finished, 

trimmed,    and   ready   to   wear. 


XVI. 
Temporary  plaster  peg  leg  for  hip  dis- 
articulation. 


de  l'Ocean,  extended  its  applications  to  all  cases  as  routine.  The  French 
and  English  Medical  Departments  were  by  this  time  beginning  to 
understand  that  the  treatment  of  the  amputation  cases  constituted 
a  problem  special  to  itself.  After  seeing  the  results  of  delayed  weight- 
bearing  it  required  but  a  little  time  for  them  to  see  the  advantages 
of  the  new  method.  Special  amputation  centers  were  formed  at  which 
the  cases  were  concentrated  and  provisional  apparatus  supplied.  One 
and  all  adopted  the  principle  of  early  weight-bearing,  only  the  types 
of  apparatus  used  differed.  Difficulty  was  encountered  in  making  the 
plaster-of-Paris  sockets  rapidly  enough  to  take  care  of  all  the  cases. 
Certain  countries  (Canada  and  Germany),  therefore,  developed  appar- 


238 


l'HILIP    D.    WILSON 


XVII. 

Mesial   aspect  of  peg   leg 

for  hip  disarticulation. 


XVIII. 

Syme  amputation  and  tem- 
porary  peg  leg. 


XIX. 

Syme  amputation.  Patient 
using  end  weight-bearing 
in  his  peg  leg. 


atus  capable  of  being  constructed  in  quantity,  in  different  sizes,  so 
that  the  stump  might  be  fitted  as  a  shoe  is  fitted  to  the  foot.  These 
served  a  good  purpose,  but  never  met  all  the  indications  in  the  way  the 
individually  fitted  plaster  peg  leg  did. 

In  the  American  Expeditionary  Force  the  plaster-of-Paris  socket 
was  used  as  a  routine,  but  the  apparatus  incorporated  into  it  was 
quite  special  and  was  developed  only  after  a  good  deal  of  experi- 
ment. It  was  found  possible  to  train  men  to  make  the  plaster  sockets 
under  the  supervision  of  a  trained  leg  fitter,  and  nearly  fifteen  per 
cent,  of  the  two  thousand  amputation  cases  involving  the  lower  limb 
sent  home  from  overseas  were  fitted  with  this  tjrpe  of  apparatus  be- 
fore they  left.  The  large  number  of  the  unfitted  cases  is  explained 
by  the  fact  that  they  were  either  bed  cases,  on  account  of  complicating 
injuries,  or  stayed  too  short  a  time  at  the  special  centers  to  be  fitted. 
It  was  recognized  as  useless  to  supply  provisional  legs  unless  the  men 
could  be  kept  a  sufficient  time  to  train  them  in  their  use. 


EARLY     WEIGHT-BEARING  239 

In  private  and  hospital  practice  for  the  last  two  years  the  writer 
has  applied  the  principle  of  early  weight-bearing  in  the  treatment  of 
all  cases  of  amputation  seen  by  him.  The  results  have  been  even  more 
gratifying  than  in  the  Army  because  individual  attention  can  be  given 
and  it  is  less  difficult  to  get  the  patient's  cooperation  and  arouse  his 
enthusiasm. 

For  thigh  cases  the  simple  peg  leg  made  from  a  wooden  crutch 
frame  with  plaster  socket  has  been  found  best  to  meet  the  indica- 
tions. It  is  extremely  light  and  there  is  no  difficult  knee  control  to 
be  learned,  both  advantages  of  great  importance  when  the  weak  and 
sensitive  condition  of  the  stump  at  this  early  period  after  operatio)i 
is  considered.  A  knee-joint  and  foot  put  weight  at  a  distance  from 
the  stump  and  this  position  multiplies  in  direct  ratio  to  the  length  of 
the  lever  the  force  necessary  to  move  it.  On  the  other  hand,  most 
patients  object  to  a  peg  leg  for  cosmetic  reasons.  It  is  necessary 
thoroughly  to  convince  them  of  the  benefit  to  be  derived  from  its  use 
before  their  cooperation  can  be  obtained. 

For  below-the-knee  amputations  the  regular  Army  model  with  articu- 
lated foot  has  been  used.  The  presence  of  the  foot  does  not  complicate 
early  weight-bearing  in  these  cases  as  fit  does  with  thigh  ampu- 
tations. Only  an  ankle  articulation  is  involved  and  the  motion  of 
this  is  blocked  in  such  a  manner  that  the  presence  of  the  foot  really 
increases  the  stability  of  the  leg.  Added  to  this  is  the  great  advantage 
that  the  patient's  deformity  is  completely  masked  by  the  apparatus. 
The  patient  walks  with  scarcely  any  limp  and  functionally  is  quickly 
able  to  do  almost  as  much  as  when  fitted  with  his  permanent  limb. 
The  skeletal  leg  can  be  quickly  made  by  any  artificial  leg  maker  at 
a  cost  of  about  fifteen  dollars.  The  only  measurements  required  are 
a  tracing  of  the  outline  of  the  stump  and  thigh  with  the  level  of  the 
knee-joint  indicated,  the  length  of  the  sound  leg  (from  the  knee  to  the 
sole),  and  the  size  of  the  shoe.  In  addition  two  circumferences  of  the 
thigh,  above  the  knee  and  near  the  perineum,  should  be  given. 

METHOD   OF   MAKING  THE  PEG  LEG  FOR  THIGH  AMPUTATIONS. 

A  frame  is  first  prepared  by  sawing  off  an  ordinary  wooden  crutch 
at  a  height  corresponding  to  the  length  of  the  leg  from  slightly  below 
the  perineum.  The  handle  is  removed  and  the  cut  ends  of  the  crutch 
frame  tapered  down  with  a  knife. 

The  patient  may  either  lie  on  a  table  or  stand.     The  latter  position 


240 


PHILIP    D.    WILSON 


XX. 

Temporary  peg  legs  used  at  first  for  below-knee  amputations  in  the  A.  E.  F. 


is  slightly  more  convenient  for  the  surgeon.  The  stump  is  first  cov- 
ered with  tubular  stockinette,  the  upper  end  of  which  is  pinned  to  the 
clothing  and  the  lower  end  left  long  enough  to  hang  below  the  stump. 
An  assistant  holds  this  end  and  makes  downward  traction  throughout 
the  operation  so  as  to  compress  the  edematous  soft  parts  about  the 
end  of  the  stump  and  give  it  a  conical  shape.  A  strip  of  cardboard 
six  inches  wide  and  long  enough  to  encircle  the  thigh  is  next  applied  to 
the  end  of  the  stump  in  the  form  of  an  overhanging  cuff  and  fastened 
with  adhesive  strips.  This  serves  as  a  form  on  which  the  lower  end  of 
the  socket  can  be  made  and  prevents  pressure  against  the  wound  and 
surrounding  tissues  when  weight  is  borne.  Plaster  bandages  are  then 
applied  as  in  making  an  ordinary  cast,  the  plaster  being  rubbed  in  well. 
Three  to  four  bandages  usually  suffice.  Special  attention  should  be 
given  to  moulding  the  plaster  about  the  ischial  tuberosity,  perineum, 
and  gluteal  fold.  Care  should  also  be  taken  that  the  stump  is  not  ab- 
ducted while  waiting  for  the  plaster  to  harden,  otherwise  space  will 
be  found  to  exist  between  the  sockets  and  the  trochanter  when  weight 
is  borne. 


EARLY     WEIGHT-BEARING  241 

The  wooden  crutch  frame  is  now  applied,  the  upper  ends  of  the 
uprights  being  first  covered  with  a  few  turns  of  plaster  bandage  so 
that  they  will  adhere  to  the  socket.  The  frame  is  held  by  an  assistant, 
and  pains  must  be  taken  to  see  that  it  points  in  the  axis  of  the  limb  and 
that  the  side  pieces  lie  at  the  center  of  the  mesial  and  lateral  aspects 
of  the  socket.  The  uprights  may  be  prevented  from  springing  into  the 
socket  and  indenting  it  by  first  separating  them  to  the  desired  width 
and  holding  them  in  this  position  by  forcing  a  roller  bandage  into  the 
fork  of  the  crutch.  The  frame  is  now  fixed  to  the  socket  by  applying 
one  or  two  more  plaster  bandages  in  a  circular  manner,  a  few  turns  being 
taken  also  around  the  wooden  uprights  at  the  bottom  of  the  socket. 

When  the  plaster  has  set,  the  line  of  the  top  of  the  socket  is  marked 
out.  It  extends  in  front  from  the  top  of  the  great  trochanter  obliquely 
downward  to  the  perineum  where  it  is  notched  out  to  avoid  the  descend- 
ing ramus  of  the  pubis  which  is  always  sensitive  to  pressure.  It 
then  ascends  obliquely  under  the  ischial  tuberosity  outward  to  the 
starting  point  at  the  trochanter.  This  line  corresponds  exactly  in 
shape  and  angle  to  the  ring  of  the  well-known  Thomas  leg  splint.  The 
leg  is  now  removed  from  the  stump  and  the  stockinette  and  cardboard 
pulled  out  from  the  inside  of  the  socket.  The  top  of  the  socket  is 
trimmed  with  a  sharp  knife  along  the  line  previously  marked  and  the 
cut  edge  of  the  plaster  smoothed  over  by  rubbing  into  it  a  little  plaster 
paste. 

The  leg  is  now  set  aside  to  dry  and  later  finished  up  by  reinserting 
the  wooden  crutch  handle  between  the  wooden  uprights  below  the  socket 
and  painting  the  latter  with  shellac  to  make  it  more  durable.  It  is 
fitted  for  length  and  the  end  sawed  off  so  that  when  weight  is  borne 
the  leg  is  one-half  inch  shorter  than  the  normal  leg.  A  rubber  tip 
is  applied  to  the  end. 

The  stump  is  covered  with  a  woolen  stump  sock  when  the  leg  is  worn, 
and  this  gives  all  the  padding  necessary.  When  the  leg  is  put  on,  the 
end  of  the  sock  is  seized  from  underneath  through  the  open  lower  end 
of  the  socket  and  strong  downward  pull  made  as  the  stump  is  inserted. 
This  secures  relaxation  of  the  soft  parts  about  the  wound  and  protects 
the  latter  from  tension  when  weight  is  borne.  If  traction  strips  are 
used  an  opening  is  made  in  the  end  of  the  sock  through  which  the  tapes 
are  passed  and  these  are  secured  by  buckles  to  the  cross  piece  in  the 
frame. 

Suspension  of  the  leg  from  the  body  is  obtained  by  means  of  a  two- 
inch  webbing  band  with  a  piece  of  elastic  inserted  in  the  middle  passing 


242  PHILIP  D.  WILSON 

beneath  the  cross  piece  in  the  leg  and  over  the  opposite  shoulder,  the 
two  ends  being  buckled  together  in  front. 

If  the  amputation  is  above  the  middle  third  of  the  thigh  the  socket 
tends  to  slip  off  the  stump  when  the  leg  is  slightly  abducted  and  causes 
instability.  This  may  be  largely  prevented  by  riveting  a  "T"  shaped 
iron  extension  to  the  top  of  the  socket  on  its  lateral  surface  and  se- 
curing this  to  the  pelvis  by  means  of  a  webbing  belt.  The  vertical  limb 
of  the  iron  should  be  jointed  at  the  level  of  the  top  of  the  great  tro- 
chanter in  order  to  permit  flexion  and  extension  and  should  extend  up- 
ward to  just  below  the  level  of  the  anterior  superior  spine  of  the  ilium. 
The  horizontal  limb  of  the  iron  is  about  five  inches  long  and  is  curved 
to  conform  to  the  shape  of  the  pelvis.  It  is  this  portion  to  which  the 
belt  is  attached  by  rivets. 

METHOD  OP  MAKING  PROVISIONAL  LEG  FOR  BELOW-THE-KNEE  AMPUTATION. 

As  previously  stated,  the  skeleton  leg  for  this  type  of  amputation  is 
made  by  an  artificial  limb  maker.  It  can  usually  be  obained  a  week  after 
placing  the  order.  It  is  then  fitted  to  the  patient 's  stump  and  thigh  to 
determine  if  the  length  is  correct  and  the  iron  side  bars  properly  bent 
to  conform  to  the  outline  of  the  limb.  The  side  pieces  are  sufficiently 
malleable  so  that  changes  can  be  made  if  necessary  without  special  tools 
or  skill. 

If  it  is  not  possible  to  secure  a  provisional  leg  of  the  type  described, 
one  may  substitute  a  simple  form  of  peg  leg.  In  this  case  malleable 
strap  iron  is  cut  to  the  proper  length  and  bent  to  the  shape  of  the  stump. 
Two  pieces,  one  on  the  lateral  and  one  on  the  mesial  side  of  the  stump, 
are  used  as  uprights,  and  after  the  socket  has  been  made,  a  wooden  peg 
is  fitted  between  their  protruding  lower  ends  and  fastened  with  screws. 

The  application  of  the  plaster  is  most  easily  made  with  the  patient 
seated.  The  stump  is  covered  with  the  stockinette  and  if  the  end  is 
bulbous,  traction  must  be  made  as  in  the  thigh  cases  by  an  assistant  to 
compress  and  pull  down  the  soft  parts.  The  end  of  the  stump  is  like- 
wise protected  from  the  direct  pressure  of  the  socket  by  a  circular  cuff 
of  cardboard.  Pressure  of  the  socket  on  the  external  popliteal  nerve 
lying  on  the  head  of  the  fibula  is  apt  to  be  painful  and  may  be  prevented 
by  fixing  a  small  felt  pad  in  this  region  with  a  strip  of  adhesive  plaster. 

With  the  knee  extended,  two  to  three  plaster  bandages  are  now  applied 
covering  the  stump  in  a  circular  manner  and  extending  from  the  middle 
of  the  patella  to  the  bottom  of  the  pasteboard  cuff.  The  plaster  should 
be  carefully  moulded  about  the  upper  end  of  the  tibia  as  most  of  the 


EARLY     WEIGHT-BEAK  I  Ni; 


XXI. 

Temporary  peg  legs  with  lock  knee  joint,  permitting  flexion  when  sitting. 

weight  is  transmitted  to  the  socket  here.  When  the  plaster  has  hardened, 
the  skeleton  leg  is  applied  and  the  upper  end  held  by  lacing  the  thigh 
corset.  The  lower  end  is  held  by  an  assistant  who  also  steadies  the  ex- 
tremity of  the  stump  by  holding  the  loose  end  of  the  stockinette.  Care 
must  be  taken  that  the  iron  frame  is  in  the  axis  of  the  stump,  that  the 
joints  for  the  knee  are  centered  on  a  line  with  the  middle  of  the  patella, 
and  that  the  tip  of  the  wooden  foot  is  in  line  with  the  center  of  the 
patella  and  the  anterior  superior  spine  of  the  ilium.  If  any  space  exists 
between  the  side  bars  and  the  previously  applied  portion  of  the  socket 
it  should  be  filled  with  folded  pieces  of  plaster  bandage,  so  that  the 
irons  are  everywhere  in  contact  with  the  plaster  surface.  Two  or  three 
plaster  bandages  are  now  applied,  solidly  fixing  the  frame  in  place. 

The  line  of  the  top  of  the  socket  is  next  marked  out  with  a  skin  pencil. 
This  line  runs  in  front  from  the  lateral  surface  of  the  joint  line  down- 
ward and  under  the  lower  border  of  the  patella,  then  upward  to  the 


244 


PHILIP    D.    WILSON 


I  V    JA 


.*« 


*! 


XXII. 

Group  of  soldier  patients  overseas,  equipped  with  different  types  of  legs- 
joint  line  on  the  mesial  aspect  of  the  knee.     Behind  the  knee  it  curves 
down  and  then  goes  up  to  the  starting  point,  forming  a  hollow  in  the 
popliteal  space,  so  that  the  top  of  the  socket  will  not  cat  into  the  ham- 
string muscles  when  the  knee  is  flexed. 

When  the  plaster  has  set,  the  leg  is  removed  from  the  stump,  the  upper 
edge  of  the  socket  trimmed  with  a  sharp  knife,  and  the  cut  edge  smoothed 
over  with  plaster  paste.  The  apparatus  is  then  set  aside  to  dry. 
Occasionally,  when  the  iron  frame  has  not  been  properly  fitted,  there 
is  a  tendency  of  the  uprights  to  spring  apart  and  deform  the  socket 
before  the  plaster  has  solidified.  This  may  be  avoided  by  winding 
bandage  about  the  uprights  just  above  their  point  of  attachment  to  the 
wooden  ankle  piece. 

During  this  period  one  must  take  the  precaution  to  keep  the  stump 
tightly  bandaged  with  elastic  material,  otherwise  swelling  may  occur, 
and  it  would  be  difficult  to  get  the  leg  on  again.  In  this  connection  one 
should  remember  that  it  is  much  easier  to  pull  the  stump  into  the  socket 
from  below  by  reaching  up  and  grasping  the  end  of  the  sock,  rather 
than  push  it  in  from  above.  The  latter  crowds  the  soft  parts  up  from 
the  extremity  and  this  not  only  enlarges  the  stump  but  causes  tension ' 
over  the  end  of  the  bone  and  makes  walking  painful. 

If  the  extremity  of  the  stump  is  particularly  bulbous  it  may  prove 
impossible  to  withdraw  it  from  the  socket  after  making  the  leg.  In 
that  case  one  may  split  the  plaster  posteriorly  and  spring  it  apart  until 


EARLY     WEIGHT-BEARING  245 

sufficient  room  is  obtained.  The  same  procedure  is  used  in  inserting  the 
stump,  and  the  socket  is  then  drawn  together  with  buckle  straps  or 
bandage.  With  weight-bearing  the  terminal  swelling  quickly  subsides 
and  then  a  new  socket  may  be  made  which  does  not  require  splitting. 
Fixation  of  the  leg  to  the  body  is  secured  by  means  of  the  leather 
corset  which  laces  about  the  thigh.  Other  suspension  is  usually  unneces- 
sary. When  required,  a  webbing  band  two  inches  wide  is  used,  arranged 
in  the  form  of  a  loop  passing  over  the  opposite  shoulder  and  under  the 
axilla  of  the  affected  side.  The  ends  of  the  loop  are  fastened  together 
in  front  near  the  groin  and  from  their  junction  an  elastic  webbing 
band  of  the  same  width  descends  to  be  fastened  to  the  front  of  the  thigh 
corset  or  to  the  leg  itself  below  the  knee.  If  traction  is  required  to 
protect  the  wound  it  may  be  obtained  in  the  same  way  as  with  the  thigh 
peg  leg. 

METHOD  OF   MAKING  PROVISIONAL  APPARATUS  FOR 
SPECIAL  TYPES  OF  AMPUTATION. 

Disarticulation  of  the  Hip. 

The  crutch  peg  leg  is  used  with  a  plaster-of-paris  socket  shaped  like 
the  half  of  a  basin.  It  encloses  half  of  the  pelvis  and  extends  slightly 
above  the  anterior  superior  spine.  It  is  moulded  accurately  to  the  bony 
contour  and  may  be  padded  with  felt.  In  it  the  patient  sits  as  in  a 
deep  Mexican  saddle. 

The  wooden  crutch  is  cut  so  that  one  side  piece  is  about  three  inches 
longer  than  the  other.  The  long  upright  is  fixed  to  the  lateral  surface 
of  the  socket  while  the  short  piece  extends  to  the  under  surface  in  the 
region  of  the  perineum.  Fixation  is  secured  by  means  of  plaster  band- 
ages as  with  the  apparatus  previously  described. 

Suspension  is  obtained  by  means  of  a  webbing  strap  passing  under 
the  plaster  socket,  buckling  in  front.  A  webbing  belt  fixes  the  socket 
to  the  pelvis  and  prevents  lateral  displacement. 

Patients  with  this  type  of  amputation  learn  to  walk  very  well  with  a 
provisional  peg  leg.  Not  only  is  there  comfort  but  good  stability  and 
power.  Sitting  is  difficult  but  can  be  managed,  and  progress  is  so  rapid 
that  it  is  scarcely  worth  while  to  provide  the  necessary  joints  and 
unlocking  device  to  allow  flexion  in  sitting. 

Syme  Amputation. 

A  simple  form  of  peg  leg  has  been  used  in  these  cases  and  has  proved 
of  great  value  in  developing  the  all-essential  end  weight-bearing  ability 


246  PHILIP    D.    WILSON 

of  the  stump.  A  good  Syme  is  so  satisfactory  that  no  pains  should  be 
spared  in  achieving  this  result. 

A  plaster  cast  is  applied  enclosing  the  stump  to  below  the  knee.  Light 
iron  side  pieces  are  fixed  in  the  plaster  on  the  mesial  and  lateral  sur- 
faces, the  ends  projecting  two  inches  below  the  bottom  of  the  cast.  An 
oval-shaped  window  is  then-  cut  out  of  the  front  of  the  plaster  to  allow 
the  withdrawal  of  the  stump  with  its  enlarged  distal  portion. 

After  the  cast  has  dried  the  projecting  irons  are  drilled  for  the  pass- 
age of  screws,  and  a  wooden  block  of  the  necessary  length  is  fitted. 
Fixation  of  the  cast  to  the  stump  is  obtained  by  replacing  in  its  opening 
the  plaster  door  previously  removed  and  fastening  it  with  buckle  straps 
or  bandage. 

The  patient  walks  in  this  plaster  peg  at  first  with  the  weight  distrib- 
uted between  the  usual  bearing  surfaces  and  the  end  of  the  stump. 
Later,  as  sensitiveness  disappears,  felt  pads  are  inserted  at  the  bottom 
of  the  socket,  and  their  thickness  is  gradually  increased  until  the  entire 
weight  is  borne  on  the  end  of  the  stump.  The  top  portion  of  the 
socket  may  then  be  removed  and  the  patient  walks  in  this  small  plaster 
boot  until  the  permanent  type  of  limb  is  fitted. 

Summary. 

1.  Experience  gained  during  the  war  in  the  treatment  of  patients 
with  amputations  of  the  lower  limb  has  shown  that  it  is  possible  to  get 
such  patients  out  of  bed  without  crutches  and  actively  bearing  weight 
in  peg  legs  or  simple  forms  of  artificial  limbs  at  a  period  two  4o 
three  weeks  after  amputation. 

2.  Early  weight-bearing  is  of  great  advantage  to  the  patient  because 
{a)  It  promotes  healing  of  the  wound  by  improving  the  circulation,  and 

in  cases  with  terminal  localized  osteomyelitis  favors  the  separation  and 
spontaneous  discharge  of  sequestra,  (b)  It  hastens  stump  shrinkage 
and  prevents  muscle  atrophy  and  the  development  of  joint  contractures. 
(c)  It  favorably  influences  the  patient's  morale,  (d)  It  greatly  shortens 
the  period  until  the  permanent  artificial  limb  can  be  fitted  and  reduces 
the  need  of  frequent  alterations  in  the  socket,  and  thereby  much  expense 
to  the  patient. 


EXAMINATION    OF    YALE    FRESHMEN  247 

3.  Provisional  apparatus  to  secure  early  weight-bearing  may  be 
made  to  best  advantage  of  simple  materials,  in  the  use  of  which  the  sur- 
geon is  already  skilled. 

4.  With  understanding  of  the  advantages  of  early  weight-bearing  in 
the  treatment  of  amputations  of  the  lower  limb,  and  of  the  little  difficulty 
involved  in  its  application,  the  method  should  be  universally  applied. 


REPORT  OF  THE  ORTHOPAEDIC  EXAMINATION  OF  1393 
FRESHMEN  AT  YALE  UNIVERSITY. 

ROBERT  J.  COOK,  M.D.,  NEW  HAVEN,  CONN. 

In  the  past  two  years  as  Orthopaedic  Surgeon  to  the  Department  of 
University  Health  of  Yale  University,  I  have  been  privileged  to  examine, 
in  the  two  entering  classes  of  1923  and  1924,  a  total  of  1393  men. 

A  university  such  as  Yale  draws  a  selected  group  of  men,  who  come 
from  families  where  no  little  attention  is  paid  to  the  physical  welfare 
of  the  children.  Furthermore,  in  the  case  of  the  larger  number  of  men, 
considerable  interest  has  been  taken  in  their  athletic  development  during 
the  years  of  their  preparatory  schooling.  These  young  men,  therefore, 
certainly  show  a  physical  development  as  high  or  probably  higher  than 
any  other  group  selected  at  random.  The  purpose  of  this  survey  has 
been  to  detect  the  possible  correctible  deformities,  any  defects  in  posture 
or  body  carriage,  or  any  evidence  of  faulty  development  at  a  period 
when  there  is  still  time  to  correct  them  before  the  developmental  period 
of  the  individual  is  past. 

While  the  object  of  this  examination  has  been  to  find  those  individuals 
who  have  some  body  defect  and  to  undertake  its  correction,  it  must  be 
kept  in  mind  that  at  the  same  time  this  survey,  including  as  it  does  all 
the  students  of  the  entering  class,  offers  an  excellent  opportunity  to 


248  ROBERT   J.   COOK 

determine,  from  a  group  of  so-called  normal  physical  men,  the  percentage 
which  have  some  postural  or  bodily  mechanical  defect.  The  examination 
of  such  a  group  of  men  affords  us  insight  into  the  incidence  of  the  minor 
as  well  as  of  the  major  body  defects. 

This  report  is  a  study  of  the  postural  or  the  body  mechanical  condition 
of  a  group  of  men  in  transit  from  preparatory  schools  to  college  life.  The 
majority  have  had  considerable  attention  given  to  their  athletic  develop- 
ment, but  few,  except  those  entering  from  military  schools  or  those 
recently  discharged  from  the  army,  have  had  their  attention  drawn  to 
the  mechanical  set-up  of  their  body.  Instead,  almost  all  have  been 
under  the  instruction  and  care  of  individuals  whose  object  was  directed 
entirely  to  the  development  of  muscular  strength  or  athletic  skill,  and 
not  to  the  correction  of  the  abnormalities  in  the  postural  set-up  or  the 
mechanical  relationship  of  the  several  component  body  parts. 

It  seems  desirable  to  urge  the  correction  of  such  faulty  body  attitude 
as  round  shoulders,  round  and  hollow  backs,  lateral  curvatures  of  the 
spine,  flat  chest,  prominent  abdomen,  and  weak  feet.  Such  corrective 
work  among  college  men,  when  directed  either  toward  improving  exist- 
ing mechanical  faults  of  the  body  or  toward  preventing  those  likely  to 
occur,  aside  from  improving  the  physical  appearance  of  the  man,  should 
improve  the  efficiency  and  general  health  of  the  individual  throughout 
life. 

The  orthopaedic  examinations  were  conducted  in  conjunction  with 
the  mensuration  examinations  given  to  the  students  by  the  Director  of 
the  Gymnasium.  During  the  first  year,  individuals  needing  special  work 
were  discussed  with  him  and  placed  under  his  supervision  to  carry  out 
the  necessary  corrective  exercises,  but  for  the  men  of  the  class  of  1924 
the  Director  of  the  Gymnasium  has  designated  a  man  who  gives  his 
entire  time  to  corrective  work.  Those  who  needed  such  work  were  formed 
into  small  classes,  varying  from  10  to  12,  and  in  this  way  we  have  been 
able  to  give  them  intensive  training  leading  to  the  correction  of  their 
individual  body  defect — a  marked  improvement  over  the  previous  general 
gymnastic  instruction. 

As  may  be  seen  from  the  record  inserted  below,  the  age  of  the  indi- 
vidual was  obtained;  he  was  questioned  about  bone  and  joint  injuries, 
foot  trouble,  backache,  his  past  athletic  work,  and  his  future  athletic 
intentions.      The   routine   orthopaedic    examination    follows: 


EXAMINATION    OF    YALE    FRESHMEN  249 

Name    Class    Age    Date      

Athletics  in  preparatory  school   In    Yale    

Describe  any  bone  or  joint  injury   any  backache  or  back  injury   

Any  trouble  with  your  feet   any  muscle,  tendon,  ligament  or  nerve 

injury      

Fill  in  Above.    Do  Not  Write  Below  Tkte  Line.     Use  Back  of  Card  If  Necessary. 


Abnormalities  of   head Neck,   chest:    normal,   flat,   prominent, 

funnel,   pigeon    

Spine.     Deviation,  none,  right,  left   ...   Rib  margin:  level,  flat,  flaring 

Antero-posterior    curvature    Right,   left,  side,  forward ;   right,   left. 

side,   back    

Kyphosis  :    0,  1,  2,  3,  4  ;     Lordosis  :  0,   Abdomen  :     scaphoid,     flat,     prominent^ 

1,  2,  3, 4 protuberant     

Kypho-lordosis :  0,  1,  2,  3.  4 ;  Fiat-back,  Upper  extremity    

0. 1,  2,  3,  4 

Scoliosis     None     

Postural :  left,  right,  distance  from  perpendicular  at   spinous  process 

Left,  right,  shoulder,  hi^h :  right,  left,  shoulder,  back Ijower  extremity 

Rotation,    right,    left 

Structural :  distance  from  perpendicular  to  left  at   

Spinous  process :  to  right  at    . .   sp.  process   . .   Length    . .    right  leg  left   . . 

Left,  right,  phoulder.  high :   right  left,  shoulder,  back    Foot    

Rotation  right   left   Longitudinal  arch :  high,  medium,  low. 

absent    

Pelvis  level,  tilted  down  on  left,  right    ...  degrees Transverse  arch,  average, 

low,   absent    

Neck  forward   ....   degrees  from  per- 
pendicular     Pronation  :    0, 1H  2,  3,  4     

Round  shoulders :  0,  1,  2,  3,  4 Flexibility ;  normal,  fair,  poor,  absent. 

Motion  of  spine:   forward  bend    backbend . . . Dorsiflexion    ..    degrees    .. 

rightside  bend,  left   Abnormalities    of   foot    

Muscle  spasm   ..    Paralysis  back    ....Toes:  hammer,  hallux,  valgus,  absent. 

Sacro-iliac  joint    Strength    in    pounds    ► 

right  adduction  left. . . 

right      abduction      left 

dorsal   flexion   plantar. 

flexor       long       hallux 

Treatment Foot  tracing    

Photograph    

Summary    


In  order  to  record  the  condition  of  the  individual  at  the  time  of  the 
examination,  photographs  were  taken.  This  photographic  record,  taken 
at  the  beginning  and  repeated  at  the  end  of  the  school  year,  shows  the 
progress  during  the  period  of  corrective  work.  In  recording  the  class 
of  1923,  a  profile  view  was  taken,  showing  the  man  in  his  natural 
standing  position  and  in  his  best  standing  position.    At  the  end  of  the 


250  ROBERT   J.   COOK 

year  it  was  found  that  many  of  the  men  who  were  given  individual  work 
could  hold  naturally  and  without  constraint  a  poise  the  equal  of  their 
best  possible  standing  position  in  the  fall.  The  records  of  the  class 
of  1924  were  taken,  one  in  profile  and  one  posterior  view.  These  photo- 
graphs have  been  difficult  to  take  in  exact  profile  and  have  been  difficult 
to  repeat  exactly,  due  to  the  swaying  and  shifting  of  the  student  after 
he  has  been  posed.  With  the  photograph  and  the  record,  the  mechanics 
of  the  trunk  were  then  studied  with  reference  to  kyphosis,  lordosis,  and 
flat  back,  conditions  that  are  grouped  in  the  tables  under  the  topic  of 
increased  antero-posterior  curvature,  postural  and  structural  scoliosis, 
flat  chest  and  prominent  abdomen.  The  grouping  of  kyphosis,  lordosis, 
and  kypho-lordosis  has  presented  a  considerable  difficulty,  since  the  pres- 
ence of  either  kyphosis  or  lordosis  is  usually  associated  with  the  other. 
Consequently,  the  more  marked  defect  is  listed.  The  tilting  of  the 
pelvis  was  recorded  in  cases  where  present,  and  the  length  of  the  legs 
was  taken  to  note  the  relation  to  scoliosis  when  it  existed. 

In  the  foot  the  varying  heights  of  the  longitudinal  arch  are  recorded . 
Pronation  is  recorded  in  groups  according  to  severity.  Pain  in  the  foot 
was  investigated  and  was  discovered  to  have  been  present  in  the  past 
in  some  cases,  but  at  the  time  of  examination  it  was  present  in  only  a 
few;  and  in  all  cases,  both  past  and  present,  in  less  than  10%.  The 
flexibility  of  the  foot  was  noted,  the  dorsiflexion  of  the  foot,  and  the 
presence  or  absence  of  a  short  heel  cord  was  recorded. 

The  shoulders  and  spinal  curves  were  recorded  as  normal  or  grouped, 
according  to  the  severity  of  their  abnormality,  as  falling  in  the  first, 
second,  third,  or  fourth  group,  these  groups  being  in  sufficient  number 
to  record  the  seriousness  of  the  defect. 

The  grouping  of  round  shoulders,  increase  in  the  antero-posterior 
curvature  of  the  spine*,  pronation  of  the  feet,  and  height  of  the  longi- 
tudinal arch  of  the  foot,  has  been  arbitrarily  classified.  While  it  would 
be  desirable  to  classify  each  case,  mathematically  the  slight  variation 
of  the  several  individuals  in  the  group  do  not  make  it  worth  while  at 
present. 

These  statistics  are  derived  from  the  tabulation  of  the  examination 
records  of  1393  men,  giving  a  group  large  enough  so  that  it  is  felt  that 
their  presentation  is  worth  while.  In  some  of  the  smaller  divisions,  as 
backache  and  scoliosis  with  inequalities  of  the  feet,  it  is  not  thought  that 
there  are  enough  cases  from  which  conclusions  can  be  drawn,  and  such 
tables  are  presented  for  what  they  may  be  worth.  The  results  are 
tabulated  as  follows: 


EXAMINATION    OP    YALE    FRESHMEN  251 

GENERAL   TABLE.  Percent 

Bachache    present    5.2 

Backache  absent    94.8 

Spinal  deviation — none  80.3 

spinal  deviation — to  the  right 9.8 

Spinal  deviation— to  the  left 9.9 

Bound  Shoulders — none   3.5 

Bound  shoulder! — first  group  27.1 

Round  shoulders — second  group   43.0 

Round  shoulders — third  group 24.3 

Round    shoulders — fourth    group 2.1 

Normal    antero-posterior    curvature 44.1 

Increased  antero-g)  isterior  curvature,  lirst  group 19.0 

Increased  antero-posterior  curvature,  second  group 24.7 

Increased  antero-posterior  curvature,  third  group 10.6 

Increased  antero-posterior  curvature,  fourth  group 1.6 

Increased  antero-posterior  curvature,  total 55.9 

No  lateral  curvature  49.7 

Postural  scoliosis  to  the  left 39.1 

Postural  scoliosis  to  the  right 1.2 

Structural  scoliosis    10.0 

Scoliosis,   total    50.3 

Scoliosis  and  increased  antero-posterior  curve  combined 34.0 

Normal  spinal  curvature 24.8 

Chest  normal    43.7 

Chest  flat   56.0 

Pigeon  breast    0.1 

Funnel  breast   0.2 

Abdomen  prominent    41.7 

Abdomen,  normal  contour 58.3 

Legs — equal  length    85  4 

Leg — right   short    0.8 

Leg — left  short   13.8 

Pelvis  level 83.1 

Pelvis — right  side  low 0.8 

Pelvis — left   side  low 16.1 

Foot   trouble,    past    and   present    7.2% 

Pronation   of  feet    . .    none 17.9 

Pronation  of  feet  . .  first  group  42.3 

Pronation  of  feet  . .  second  group  29.5 

Pronation  of  feet   . .   third  group    9.8 

Pronation  of  feet    . .    fourth   group    0.5 

Longitudinal  arch  high    5.6 

Longitudinal  arch    medium    5S.3 

Longitudinal  arch    low    35.8 

Longitudinal  arch   gone    0.3 

Dorsiflexion  of  foot   . .   right  angle  or  less   3.0 

Dorsiflexion  of  foot  . .   5°   13.9 

Dorsiflexion  of  foot    . .    10°    02.3 

Dorsiflexion  of  foot    . .    15°    20.8 

Short  Tendo  Achillis 3.0 

Flexibility   of  foot,   normal    90.0 

Flexibility  of  foot,  limited   10.0 

YALE  UNIVERSITY :  DEPARTMENT  OF  HEALTH.    Orthopaedic  examination. 


252  ROBERT   J.   COOK 

The  forward  droop  or  rounding  of  the  shoulders  has  been  recorded 
separately  from  the  curvature  of  the  spine,  because,  while  frequently 
occurring  together  in  relatively  equal  degree,  there  are  many  cases  in 
which  the  two  are  dissociated.  The  shoulder  girdle  does  not  follow  the 
contour  of  the  chest  wall  in  a  similar  manner  in  all  cases ;  in  some,  as 
Kyphosis  increases  and  the  chest  wall  flattens,  the  shoulder  seems  to 
be  carried  straight  forward,  while  in  other  cases  the  shoulder  seems  to 
follow  around  on  the  lateral  and  upper  side  of  the  chest  wall;  in  the 
first  instance,  the  posterior  aspect  of  the  scapula  slopes  directly  back- 
ward, while  in  the  second  instance  it  will  be  found  sloping  laterally  as 
well  as  posteriorly. 

The  deviation  of  the  spinal  column  at  the  level  of  the  seventh  cervical 
vertebra  to  the  right  or  left  of  a  plumb-line  passing  over  the  cleft  of 
the  buttocks  was  recorded.  Such  deviation  occurs  in  cases  in  which  no 
scoliosis  exists,  though  it  is  usually  associated  with  it.  It  is  of  interest 
to  note  that  approximately  20%  showed  a  spinal  deviation  under  the 
.above  definition,  while  about  50%  showed  some  type  of  scoliosis. 

The  scoliosis,  postural  or  structural,  when  present,  was  recorded  at 
the  level  or  levels  where  the  curve  was  the  greatest.  The  motions  of 
the  spine,  in  cases  of  scoliosis,  as  a  rule,  were  very  slightly  limited  in 
bending  against  the  convexity  of  the  curve.  This  may  be  due  to  the 
rather  slight  curvatures,  and  to  the  physical  activity  of  the  individual. 
In  the  more  marked  cases  of  increase  in  the  antero-posterior  curvature, 
.a  moderate  amount  of  stiffening  of  the  spine  has  been  noted. 

Chests  varied  from  normal  to  the  usual  grades  of  flatness.  It  is 
found  that  a  flat  chest,  while  usually  associated  with  an  increase  in  the 
antero-posterior  curvature  of  the  spine,  was  occasionally  found  among 
those  having  an  approximately  normal  spinal  contour. 

Abdomens  among  these  students  are  usually  full,  some  are  scaphoid, 
and  a  few  are  beginning  to  protrude. 

If  one  glances  through  the  general  table,  he  cannot  fail  to  be  impressed 
with  the  low  percentage  of  normal  students.  But  3.5%  had  no  rounding 
of  the  shoulders;  but  44.1%  have  a  normal  antero-posterior  curvature; 
but  49.7%  have  no  scoliosis;  while  only  24.8%  have  a  normal  spinal 
contour.  The  chest  is  normal  in  43.7%  of  cases,  while  in  over  half  it 
is  flattened  to  some  extent.  Of  interest  in  the  feet  is  the  fact  that  but 
7.2%  have  had  foot  trouble.  Less  than  one-fifth  of  this  group  have  no 
pronation  of  the  feet.  The  height  of  the  longitudinal  arch  is  satisfac- 
tory in  the  majority  of  cases;  in  fact,  in  only  .3%  of  the  cases  was  the 
arch  found  to  be  gone.     Dorsiflexion  of  the  foot  is  limited  to  a  right 


EXAMINATION  OP  YALE  FRESHMEN  253 

angle  or  less  in  but  3%  of  the  cases,  while  the  flexibility  of  the  foot  is 
free  in  90%  of  cases.  In  general,  the  defects  are  those  of  poor  trunk 
posture,  carrying  of  the  head  and  neck  too  far  forward,  rounding  ot 
the  shoulders,  increase  in  the  antero-posterior  curvature  and  lateral 
curvature  of  the  spine,  flat  chest,  prominent  abdomen,  pronation  of  the 
ieet,  and,  in  some  cases,  relaxed  ligaments  and  muscles  of  the  feet. 

A  topical  study  of  the  more  interesting  subjects  of  the  general  table 
is  of  interest.  If  we  consider  the  trunk  first,  we  find  that  5.2%  gave 
a  history  of  backache,  of  which  1.9%  gave  physical  exertion  as  the 
exciting  cause;  .6%  were  associated  with  disease,  while  in  2.7%  no 
cause  is  known  for  the  existence  of  the  complaint. 

BACKACHE. 

Thirty-one  of  these  cases  of  backache  gave  as  a  cause  of  their  back- 
ache exertion  in  either  work  or  sport.  In  five  cases  we  find  that  backache 
has  been  associated  with  rheumatism,  cardiac  deficiency,  lumbago,  or 
an  old  empyema  scar.  Thirty-six  of  these  cases  had  backache,  but  could 
give  no  reason  for  it.  They  complained  of  discomfort  in  the  back,  of  a 
tired  feeling  or  of  pain  in  the  small  of  the  back,  or  in  the  thoracic 
region.     The  total  number  of  these  cases  of  backache  is  seventy-two. 

Dr.  Brown  (Am.  Jour,  of  Orth.  Surg.,  Vol.  xv,  No.  11,  pp.  774-787), 
in  his  report  on  the  examination  of  Harvard  freshmen,  found  that  15.1% 
complained  of  backache,  and  that  these  men  were  in  the  group  bearing 
a  notably  poor  posture.  In  the  Yale  examination,  5.2%  complained  of 
backache ;  and  it  is  of  interest  to  note  that  backache,  among  athletes  or 
those  accustomed  to  work  (in  which  cases  the  injury  could  be  traced), 
is  found  in  the  majority  of  cases  among  the  half  of  the  class  who  have 
a  relatively  good  posture,  while  those  individuals  who  could  give  no 
reason  for  backache  were  found  to  be  classed  more  frequently  in  the 
half  of  the  class  having  a  relatively  poorer  posture. 

Of  the  thirty-one  cases  in  which  backache  has  come  on  following 
exertion,  strain  or  trauma,  eight  fall  into  the  first  group,  fifteen  in  the 
second,  five  in  the  third,  and  one  in  the  fourth  group  of  round  shoulders : 
the  shoulders  and  antero-posterior  curvature  of  the  spine  are  normal  in 
two,  and  nine  cases,  respectively,  while  ten  cases  fall  into  the  first  group, 
seven  into  the  second  group,  three  in  the  third  group,  and  two  in  the 
fourth  group  of  increase  in  the  antero-posterior  curvature  of  the  spine ; 
in  twenty-three  cases  scoliosis  is  present,  while  in  thirteen  cases  scolio- 
sis and  an  increase  in  the  antero-posterior  curvature  are  combined.  In 
this  group  of  traumatic  backache  several  have  received  the  primary 
injury  in  football,  others  have  either  strained  or  sprained  their  backs 


254 


ROBERT    J.   COOK 


while  working;  in  single  cases  the  injury  was  from  a  fall,  from  diving, 
and  from  a  machine  shop  accident  in  which  the  individual  was  struck 
by  machinery.  It  is  of  interest  to  note  in  these  cases  of  traumatic  back- 
ache that  while  the  discomfort  is  not  severe,  it  is  lasting;  further,  that- 
in  these  cases  the  postures  in  general  are  fairly  good.  Note  that  the 
round  shoulders  and  the  increases  in  the  antero-posterior  curvature  are 
in  the  milder  groups  mainly ;  the  scoliosis,  though  present  in  a  large 
number  of  cases,  is  usually  of  the  postural  type.  One  thing  that  may 
be  worth  noting  is  that  these  back  injuries,  at  the  time  they  were  re- 
ceived, were  treated  rather  lightly  or  not  at  all,  and  this  may,  in  some 
cases,  explain  their  continuation  to  the  present  time. 

There  are  five  cases  associated  with  disease, — one  of  rheumatism,  two 
of  cardiac  disease,  one  of  lumbago,  and  one  with  Pott's  disease.  The 
postural  changes  in  this  group  suggest  little. 

Of  the  cases  in  which  no  known  cause  is  given  for  backache,  there 
are  thirty-six.  Among  these  there  is  a  deviation  of  the  spinal  column 
from  the  vertical  in  six  cases.  The  first  degree  of  round  shoulders  oc- 
curs in  five  cases,  the  second  and  the  third  in  fourteen  each,  and  the 
fourth  degree  in  three  cases.  As  regards  the  increase  in  the  antero- 
posterior curvature  of  the  spine,  it  may  be  said  to  be  but  moderately 
accentuated.  Postural  scoliosis  occurs  seventeen  times  and  structural 
scoliosis  five  times.  Twenty-five  cases  have  flat  chests  and  nineteen 
have  prominent  abdomens.  The  pelvis  tilts  in  six  cases,  a  short  leg 
is  present  in  three.  Pronation  of  the  feet  is  present  in  the  first  degree 
eighteen  times,  in  the  second  degree  eleven  times,  and  in  the  third  de- 
gree five  times.  In  this  group  with  unexplained  backache,  foot  trouble 
had  been  complained  of  in  the  past  in  but  three  in  the  total  of  thirty- 
six  cases. 


a 

Increased 

Antero- 

d 
I 

& 

BOUND 

posterior 

Scol- 

Shoulders 

Curvature 

7? 

iosis 

1 

Pronation 

BACKACHE 

o 

_ 

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i-i 

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8 

4* 

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s 

Oroi 
j 

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1 

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I 

Group 

• 
I 
o 
JJ       1       2       S 

4 

From  work 

1.95? 

1.0 

0.1 

0.5 

0.9 

0.3 

0.1 

0.5 

0.4 

0.6 

0.3 

0.1 

1.2 

1.1 

1.0 

0.2 

0.3 

0.1 

0.2 

0.9  0.7 

0.1 

0.0 

Associated 

with 

0.6^ 

0.1 

D.l 

0.1 

0.2 

0.2 

0.0 

0.2 

0.2 

0.1 

0.0 

0.1 

0.4 

0.4 

0.3 

0.1 

0.2 

0.1 

0.1 

0.3  0.1 

0.1 

0.0 

bisease 

Ho    known 

pause 

2.7#  Q.5 

D.l 

0.4 

1.0 

1.0 

0.2 

o.e 

0.6 

0.5 

0.4 

0.4 

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1.1 

1.4 

0.3 

0T8 

0.3 

0*2. 

1.4 

0.8 

0f3 

o»0 

EXAMINATION    OP    YALE    FRESHMEN  255 


The  following  three  plates  show  photographs  of  men  'taking  correc- 
tional work. 

The  upper  row  shows  the  man  in  his  natural  standing  position  in  the 
Fall ;  the  lower  row  shows  the  man  in  his  natural  standing  position  in 
the  Spring,  following  a  course  of  correctional  training. 

In  column  the  photographs  are  of  the  same  man. 


256 


ROBERT  J.   OOOK 


EXAMINATION    OF    YALE    FRESHMEN 


257 


258 


ROBERT   J.   COOK 


i  \  \: mi: nation   OP   valk  freshmen  209 

J ii  the  group  of  backachi-s.  taken  as  a  whole,  it  is  to  be  noted  that. 
round  shoulders  of  a  mild  degree  occur  in  the  group  of  traumatic  back- 
ache and  of  a  more  marked  degree  in  the  backache  of  unexplainable 
origin.  This  same  statement  would  hold  true,  to  a  slightly  less  degree, 
when  applied  to  increase  in  the  antero-posterior  curvature  of  the  spine. 
The  flat  chest  of  individual  predominates.  Scoliosis  is  present  in  but 
little  less  than  one-half  of  the  cases.  Pronation  of  the  feet  is  present 
usually  in  the  milder  degrees,  though  it  is  found  that  it  occurs  more 
commonly  among  those  cases  in  which  the  backache  is  unexplained. 
Generalizing,  we  may  say  that  the  body  posture  or  mechanics  is  not 
as  good  in  the  group  of  unexplained  backaches  as  among  those  in  which 
trauma  is  a  factor. 

ROUND  SHOULDERS. 

Round  shoulders  are  found  either  with  or  without  increase  of  the 
antero-posterior  curvature  of  the  spine.  In  2.7%  of  the  total  cases 
normal  shoulders  occur  with  a  normal  antero-posterior  curvature  of  the 
spine,  while  in  41.4%,  in  which  the  antero-posterior  curvature  of  the 
spine  is  normal,  the  occurrence  of  round  shoulders  in  varying  degree 
is  noted,  being  more  common  among  the  milder  grades.  In  .8%  of  the 
cases  in  which  the  antero-posterior  curvature  of  the  spine  was  increased, 
the  shoulders  remained  normal.  In  the  cases  in  which  both  round 
shoulders  and  kyphosis  occur,  the  round  shoulders  show  a  greater  degree 
of  severity,  proportionately,  than  does  the  kyphosis.  When  compared 
with  lateral  curvature  of  the  spine,  round  shoulders  are  not  found  in 
proportion  to  the  type  of  severity  of  scoliosis,  though  both  commonly 
occur  together.  The  frequency  of  flatness  of  the  chest  parallels  the 
rounding  of  the  shoulders,  as  it  also  does  the  increased  antero-posterior 
curvature  of  the  spine,  on  which  it  seems  the  more  dependent.  The 
prominence  of  the  abdomen  increases  proportionately  with  the  severity 
of  the  round  shoulders,  though  its  presence  is  found  in  more  true  associ- 
ation with  an  accentuation  of  the  antero-posterior  spinal  curvature,  and 
a  flattened  chest. 

As  pointed  out  by  Bradford  (Orth.  Trans.,  Vol.  x,  p.  162),  and  by 
Hasebrook  (Zeitschr.  f.  orth.  Chir.,  xii,  p.  612),  a  shortening  of  the  soft 
parts  anteriorly,  as  well  as  a  relaxation  of  the  posterior  muscles  moving 
the  shoulder  girdle,  is  usual lv  found. 


260 


ROBERT   J.   COOK 


1 

' 

o 

Increased  Antero- 

Scoliosis 

Fist 

Prominent 

Pronation 

1 

posterior  Curvature. 

Chest 

Abdomen 

Bound 

Shoulders 

P. 

% 

j 

S 

I 

s 

o        1 

W        .J 

Or 
2 

oup 
3 

4 

Jj 

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• 
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2        8 

4 

Sons 

8.5 

0.3 

0.4 

2.7 

0.4 

0.2 

0.1 

0.1 

1.0 

0.3 

2.2 

0.7 

2.8 

0.8 

2.7 

0.8 

1.5 

0.9 

0.8 

O.O 

27fl 

1.0 

6,2 

17.3 

6.8 

2.4 

0,6 

0.0 

11.2 

2.7 

13.2 

8.3 

18.8 

12.1 

15tp 

4,7 

12.3 

7.8 

2,5 

OtO 

Group  2 

43.0 

2.1 

8.0 

IQ.3 

8.5 

12.3 

1.8 

Otl 

18.4 

2.9 

21t7 

22.0 

21.0 

18t0 

25.0 

7.4 

18,7 

13.2 

3,5 

0,2 

SrouD  3 

24.3 

1.5 

5.0 

5.8 

3t2 

?t* 

M 

0.5 

8.9 

3.8 

11.6 

15.7 

8.6 

10.3 

14t0 

4.8 

8t7 

6.9 

8.6 

Of3 

fcroup* 

2,* 

0,3 

fixL 

0.0 

Ofl 

0,4, 

0,7 

0*9 

0.8 

0.3 

1.0 

1.9 

0.2 

0.5 

1.6 

0,2 

0.6 

0.9 

0t3 

fill. 

ANTERO-POSTERIOR  CURVE  OF   THE  SPINE. 


The  present-day  idea  of  posture  or  body  mechanics  seems  to  depend 
largely  upon  the  conception  of  the  normal  antero-posterior  curvature 
of  the  spine.  If  the  spine  has  a  normal  forward  curve  in  the  cervical 
region,  a  normal  backward  curve  in  the  dorsal  region,  and  a  normal 
forward  curvature  again  in  the  lumbar  region,  we  feel  fairly  certain 
that  the  individual  is  carrying  his  head  at  the  proper  angle,  that  his 
shoulders  are  carried  back,  his  chest  forward,  and  that  his  abdominal 
wall  is  flat.  On  the  other  hand,  if  the  individual  has  a  dorsal  kyphosis 
of  any  degree,  we  usually  find  it  associated  with  an  increase  in  the  other 
regional  spinal  curves,  with  the  head  carried  forward,  the  chest  flat- 
tened, and  the  abdomen  prominent  or  protuberant,  while  the  rounding 
or  forward  droop  of  the  shoulders  is  increased. 

In  this  series  of  cases,  44.1%  of  the  cases  have  an  approximately 
normal  antero-posterior  spinal  contour;  but  of  this  number  only  2.7% 
have  normal  shoulders,  while  41.4%  have  round  shoulders  of  varying 
degree,  thus  showing  that  a  normal  antero-posterior  curvature  is  not 
necessarily  accompanied  by  shoulders  normally  carried;  a  flat  chest 
was  found  in  17.4%  in  association  with  a  normal  spinal  curvature, 
while  the  abdomen  was  prominent  in  11.8%  of  the  cases,  and  backache 
was  complained  of  in  1.6%  of  the  cases  in  this  group.  Of  the  remaining 
cases,  the  majority  fall  into  the  moderately  marked  groups  of  increased 
spinal  curvature.  Only  1.6%  fall  into  the  poorest  group  associated 
with  the  more  marked  degree  of  round  shoulder. 


EXAMINATION    OP    YALE    FRESHMEN 


261 


Increased 
antero- 
posterior 
Currature 
55.9# 

Vt 

o 

1, 

9)    3 

o  o 

i 

1 
None 

ound 
I 

Should 

Grot 
2 

IP 
7 

4 

Flat 
Chest 

pre- 
sent 

ab- 
sent 

Prominent 
Abdomen 

pre-  ab- 
sent sent 

Backache 

pre-  ab- 
sent sent 

normal 

44.1 

2.7 

17.3 

20.3 

3.8 

OtO 

17.4 

26,7 

11.8 

32.3 

1.5 

42,6 

Group  1 

19,0 

0t4 

6.6 

6.5 

3,2 

Pfl 

10.2 

8.8 

14.3 

4t7 

1.2 

17f8 

Group  2 

24.7 

0.2 

M 

12.3 

M 

0,4 

13t4 

11.3 

10.3 

14,4 

1.2 

23,5 

Group  3 

10.6 

0,1 

0,6 

1,8 

7.4 

0t7 

6.6 

4,0 

4.4 

6.2 

0.7 

9,9 

[ 

Group  4 

1.6 

o,; 

otP 

0.1 

0.5 

0t9 

1.0 

0.6 

0.9 

0,7 

0,6 

*f0 

SCOLIOSIS. 


As  regards  scoliosis,  49.7%  have  no  scoliosis,  1.2%  have  a  right  pos- 
tural, and  39.1%  a  left  postural  scoliosis,  while  10%  have  a  structural 
scoliosis.  Bounding  of  the  shoulders  is,  of  course,  associated  with 
scoliosis,  both  being  evidence  of  body  weakness;  however,  the  presence 
of  round  shoulders  in  association  with  scoliosis  does  not  occur  in  propor- 
tion to  the  type  of  scoliosis  or  its  severity.  It  is  to  be  noted  that  31% 
have  scoliosis,  and  increased  antero-posterior  curvature;  that  24.8% 
have  a  normal  spinal  contour;  that  24.9%  have  an  increased  antero- 
posterior curvature  without  scoliosis;  that  19.3%  have  scoliosis  alone. 

Comparing  the  statistics  given  by  Lovett  (Lateral  Curvature  of  the 
Spine — Blakiston,  1907),  we  find  that  of  our  cases  of  functional  scoliosis 
97%  are  to  the  left  and  3%  to  the  right,  as  against  90%  and  10%, 
respectively,  as  cited  by  him.  Luning  and  Schulthess  (Orthop.  Chir., 
J.  F.  Lehmann,  1901)  give  the  relationship  of  left  functional  scoliosis 
to  the  right  as  5:1. 

Estes  (Jour.  A.  M.  A.,  Vol.  75,  No.  21,  p.  1411),  in  seven  yearly  exam- 
inations of  the  students  at  Lehigh,  in  five  years  of  which  the  examination 
was  done  by  the  Physical  Director  of  the  Gymnasium,  and  in  the  two 
later  years  being  done  by  himself,  finds  the  percentage  of  scoliosis  to 
vary  from  9.5  to  43.6%  in  the  seven  different  classes.  This  compares 
with  50.3%  of  the  class  here. 


262 


ROBERT   J.   COOK 


The  relationship  of  the  types  of  scoliosis  as  found  by  Estes  were: 
Left  total,  69.8%;  right  total,  12.6%;  and  structural,  17.5%.  It  is  to 
be  regretted  that  Estes  could  not  have  examined  these  several  classes 
himself,  since  it  is  quite  evident  that  the  wide  variation,  as  found  by 
the  Director  of  the  Gymnasium  (as  low  as  9.5|%)  and  his  own  estimate 
(as  high  as  43. 6%),  Represents  wide  divergencies  of  opinion  as  to  what 
constitutes  scoliosis. 

The  collected  figures  of  Scholer,  as  given  by  Lovett,  a  total  of  9483 
cases,  observed  by  eight  men,  show  37%  of  eases  with  scoliosis. 

Scoliosis  has  usually  been  regarded  as  a  disease  of  females,  the  rela- 
tionship of  cases  in  females  to  males  being  4 :1  (Whitman,  Orth.  Surg., 
Lea  &  Febiger,  1919).  These  figures  are  probably  based  on  clinical 
statistics,  and  as  more  girls  than  boys  are  usually  brought  to  a  clinic 
for  correction  of  scoliosis,  the  difference  may  be  explained.     When, 


Postural 

Scoliosis 

None 

Bight 

Left 

Structural 

5o.a£ 

49.7 

1.2% 

39. 1# 

io.o£ 

Backache 

!       1.9 

t         0.0 

2.7 

0.6 

Deviation  of  splne-none 

44*2 

0.9 

27.9 

7.3 

right 

2.8 

0.2 

5.4 

1.4 

left 

2.7 

0.1 

5.8 

1.3 

Bound  shoulders-none 

2.2 

0.0 

1.0 

0.3 

group  1 

13.2 

0.2 

11.0 

2.7 

group  2 

21.7 

0.5 

17.9 

2.9 

group  3 

11.6 

0.4 

8.5 

3.8 

group  4 

1.0 

0.1 

0.7 

0.3 

Increased             none 

24.8 

0.5 

14.9 

3.9 

antero-                 group  1 

6.8 

0.3 

10.6 

1.3 

posterior              group  2 

12.3 

0.2 

9.3 

2.9 

ourvature              group  3 

4.9 

0.2 

3.9 

1.6 

ktoud  4 

0.9 

0f0 

0.4 

0.3 

Pelvis  level 

48.3 

1.0 

28.8 

7.0 

low  on  right  side 

oa 

0.2 

0.1 

0.4 

low  on  left  side 

1.3 

0.0 

32.2 

2.6 

Plat  chest 

26.4 

0.8 

24.1 

4.7 

Prominent  abdomen 

15.3 

0.7 

22.1 

3.6 

Legs  -    equal  length 

49.0 

1.0 

26.6 

6.8 

right  short 

0.2 

0.2 

0.1 

0.3 

left  short 

0.5 

0.0 

12.4 

0.9 

Pronation  -  none 

9.3 

0.1 

6.1 

2.4 

group  1 

23.2 

0.6 

14.1 

4.4 

group  2 

12.4 

0.3 

14.5 

t* 

group  3 

4.5 

0.2 

4.2 

0.9 

«rout»  4 

0.3 

Q.p 

0.2 

0.0 

Arch-high 

2.4 

0.2 

2.4 

0.6 

medlua 

28.3 

0.7 

24.0 

5.3 

low 

18.8 

0.3 

12.6 

4.1 

._.     eon-> 

0.2 

0.0 

0.1 

OtQ 

EXAMINATION    OF     YALE    FRESHMEN 


263 


in  a  group  of  nearly  1400  men,  one-half  are  found  with  scoliosis,  it 
looks  as  if  scoliosis  occurred  in  men  about  as  frequently  as  in  women. 
A  short  leg  occurs  in  cases  where  no  scoliosis  is  present  in  .7%  of  all 
cases.  In  right  postural  scoliosis,  a  short  leg  occurs  in  .2%  of  cases; 
in  left  postural,  in  12.4'/  of  cases  on  the  left,  and  in  one  case  on  the 
right ;  while  in  structural  scoliosis  a  short  leg  occurs  in  1.2%  of  cases. 
With  the  idea  that  unequal  pronation  or  unequal  height  of  the  arch  of 
the  foot  might  have  some  bearing  on  scoliosis,  the  results  of  these  cases 
are  tabulated  below.  It  is  of  course  probable  that  if  one  foot  pronates 
more  than  its  mate,  or  if  the  height  of  the  longitudinal  arch  varies  much, 
the  pelvis  will  be  tilted  down  to  the  affected  side,  and  a  scoliosis  may 
be  the  result ;  on  the  other  hand,  it  is  possible  to  have  a  badly  pronated 
foot  or  a  lowered  longitudinal  arch  compensate  for  shortening  in  the 
length  of  the  opposite  limb.  As  the  table  shows,  we  found  inequalities 
of  the  feet  in  5%  of  all  cases,  and  in  3.7%  of  cases  of  scoliosis,  in  which, 
with  a  single  exception,  the  lowered  foot  is  on  the  side  of  the  scoliosis 
in  postural  cases,  and  on  the  side  of  the  lumbar  curve  in  structural 
cases. 


Unilateral 

Scoliosis  with 

unequal  prona- 

Inequalities of 

tion  or 

Feet 

Inequality  of 
height  of 
longitudinal 
arch 

Length  of  Legs 

% 

lower  on 

1 

5.0 

ri«ht    I 

left 

equal 

unequal 

Ho  scoliosis 

1.3 

0.4 

0.9 

1.2 

0.1 

Postural  —  left 

2.8 

o.i 

2.7 

2.8 

0*0 

right 

0.4 

0.4 

0*1 

0.4 

0.0 

Structural 

0.5 

0.1 

0*4 

0f5 

0,9 

FEET. 


Very  few  cases  gave  a  history  of  foot  trouble,  but  this  group  of  men 
is  of  an  age  and  of  a  type  of  life  where  a  considerable  use  of  the  foot 
is  unnecessary.  As  college  or  preparatory  school  students,  they  are 
not  called  upon  to  walk  more  than  four  or  six  hours  daily.  Possibly 
this  reason,  as  well  as  their  youth,  furnishes  the  explanation  of  their 
freedom  from  foot  trouble.  The  great  majority  of  them  have  a  freely 
flexible  foot.  The  relationship  of  pronation,  height  of  longitudinal 
arch,  and  the  degree  of  dorsiflexion  of  the  foot  are  shown  in  the  table. 
It  may  be  worth  noting  that  about  one-fifth  of  these  cases  show  no 


264 


ROBERT   J.   COOK 


pronation,  while  two-fifths  show  pronation  of  the  first  degree;  that 
about  95%  have  an  average  arch,  i.  e.,  either  medium  or  low;  and  that 
the  dorsiflexion  in  80%  is  over  10  degrees. 

In  looking  over  the  individual  cases  of  foot  trouble,  moderate  or 
unequal  pronation,  low  arch,  diminished  flexibility  of  the  foot,  limita- 
tion of  dorsiflexion,  hallux  valgus,  hammer  toes,  anterior  metatarsalgia, 
and  warts  on  the  sole  of  the  foot  were  found.  There  are,  to  be  sure, 
other  cases  in  which  no  definite  foot  disability  is  evident,  which  have 
given  the  usual  symptoms  of  foot  strain. 


Foot  Table 

s 

1 

Prona 

Gro 
2 

tion 

up 
3 

4 

I 

1 

n 

ongil 
Ax 

1 

•udina 
•oh 

I 

1 

S 
S 

I 

li 

orsii 
5° 

1exi< 
IP* 

m 
15* 

Backache 

0.5 

2.6 

1.6 

0.5 

0.0 

0.8 

2.6 

1.6 

0.2 

0.3 

0.9 

2.6 

1.4 

Foot  trouble  past-ankle 
arch 
metatarsals 

00.0 
0.8 
0.0 

0.1 
0.3 

0f2 

0.0 
1.1 
0.0 

0.0 
0.9 
0.0 

0.0 
0.2 
0.0 

0.0 

0.3 
0.0 

0.1 
0.3 
0.0 

0.0 
0.4 
0.1 

0.0 
0.1 
0.0 

0.0 
0.5 
0,0 

0.0 
1.0 

oto 

0.1 
0.5 
0.1 

0.1 
0.1 
0.0 

present-ankle 
arch 
metatarsals 

0.0 
0.2 
0.0 

0.1 

o.e 

0.0 

0.2 
1.1 
0.1 

0.0 
1.0 
0.0 

0.0 
0.1 
0.0 

0.0 
0.1 
0.0 

0.0 
1.6 
0.0 

0.2 

1.8 
0tl 

0.0 
0.1 
0.0 

0.0 
0.2 
0f0 

0.0 

0.8 
0.0 

0.1 
1.8 
0tl 

0.1 
0.7 
0.0 

Pronation  —  none 

group  1 
group  2 
group  3 
group  4 

17.9 

42.3 

29.5 

9.8 

0,5 

2.7 
2.2 
0.6 
0.1 
0.0 

13.1 

28.5 

13.4 

3.2 

0.1 

2.1 

11.5 

15.5 

6.4 

0t3 

0.0 
0.1 
0.0 
0.1 
0tl 

1.2 
0.4 
0.8 
0.6 
0f0 

2.7 
4.7 
4.4 
1.9 
0f2 

9.8 
29.1 
18.2 

5.0 
0.2 

4.2 
8.1 
6.1 
2.3 

0.1 

Longitudinal  arch-high 

medium 

low 

Kone 

1.9 

14.0 

2.0 

0.0 

2.6 
27.6 
12.0 

0.1 

0.8 
13.4 
15.3 

0.0 

0.2 
3.2 
6.3 
0.1 

0.1 
0.1 
0.2 
0.1 

5.6 

58.3 

35.8 

0.3 

0.3 
1.4 
1.2 
0,1 

1.4 
8.2 
4.2 

2.8 
36.8 
22.7 

0,0 

1.1 

11.9 

7.7 

0.1 

Dorsiflexion-right  angle 
five  degrees 
ten  degrees 
fifteen  degrees 

1.2 
2.7 
9.7 
4.3 

0.4 

4.6 

29.3 

8.0 

.0.9 

4.6 
18.0 

1    6.0 

0.5 
2,0 
5.0 
2.3 

0.0 
0.0 
0.3 
0.2 

0.3 
1.2 
3.0 

1.1 

1.4 
8.3 
37.0 
11.6 

1.2 

4.4 

22.2 

8,0 

0.1 
0.0 
0.1 
0.1 

3.0 

13.9 

62.3 

20,8 

TREATMENT. 


The  treatment  of  the  body  defects  has  been  carried  out  in  the  gym- 
nasium under  supervision  in  classes  of  10  or  12.  The  student  has  been 
shown  his  defect  —  whether  round  shoulders,  abnormal  spinal  curv^, 
flat  chest,  prominent  abdomen,  or  weak  feet.  Following  this,  he  has 
had  demonstrated  the  improvement  in  physique  when  he  assumes  the 
correct  bodily  mechanical  posture.  After  this,  he  has  been  given  cor- 
rective exercises  to  overcome  or  improve  his  body  defect. 

Photographs  have  been  of  great  help  in  pointing  out  to  the  indi- 
vidual his  defect.  The  photograph  taken  in  his  natural  standing  posi- 
tion, when  compared  with  the  one  taken  in  his  best  standing  position, 
shows  him  the  defect  to  be  overcome,  and  these  pictures  repeated  dur- 


EXAMINATION   OP   YALE  FRESHMEN  265 

ing  or  at  the  end  of  his  course  in  corrective  training  show  him  how 
much  he  has  accomplished.  The  man  has  been  urged  to  carry  out  these 
exercises  both  in  the  gymnasium  and  in  his  room.  For  weak  feet  mus- 
cle exercises  have  been  given;  the  individual  has  been  taught  the 
more  desirable  way  of  walking;  and,  when  necessary,  alterations  of 
shoes  have  been  advised. 

results. 

With  the  help  of  the  instruction  in  the  gymnasium  these  men  have 
been  able  definitely  to  improve  their  body  posture.  Should  his  case 
have  fallen  in  the  third  group  of  round  shoulders  or  in  the  third  group 
of  increased  antero-posterior  curvature  he  can  improve  his  abnormal- 
ity so  that  his  case  falls  in  the  second  or  first  group  or,  in  some  cases, 
within  normal  limits,  but  this  position  he  is  not  able  to  hold  naturally. 
However,  when  we  study  the  photographs  taken  after  he  has  under- 
taken to  correct  himself,  following  a  course  of  corrective  exercise,  it  is 
seen  that  he  has  so  improved  himself  that,  in  many  cases,  that  which 
was  formerly  his  best  corrected  attitude  has  now  become  his  normal 
way  of  carrying  himself. 

conclusions. 

Students  entering  college  are  at  an  age  when  bodily  defects  can  be 
corrected.  The  type  of  defect  is  one  which  can  be  improved  in  prac- 
tically all  cases,  and  corrected  in  many.  The  improvement,  as  shown 
in  the  photographs,  where  there  are  present  round  shoulders,  increase 
in  the  antero-posterior  spinal  curvature,  flat  chest,  or  prominent  ab- 
domen, is  sufficient  to  urge  that  more  time  and  effort  be  expended  in 
this  field  of  orthopaedics. 

Accurate  records  should  be  taken  and  kept  which  will  show  the  value 
of  this  form  of  therapy. 

The  value  of  photography  in  showing  to  the  student  his  physical  de- 
fect is  evident.  By  this  means  his  posture  can  be  accurately  recorded 
more  satisfactorily  than  by  any  other  method. 


266  ARMITAGE   WHITMAN 


ASTRAGALECTOMY  AND  BACKWARD  DISPLACEMENT  OF 
THE  FOOT.  AN  INVESTIGATION  OF  ITS  PRACTICAL  RE- 
SULTS.* t 

BY    ARMITAGE    WHITMAN,    M.D.,    F.A.C.S.,    NEW    YORK. 

The  value  of  any  operative  procedure  must  be  judged  from  three 
points  of  view — first,  that  of  its  originator;  second,  that  of  others  who 
might  be  expected  to  possess  sufficient  skill  properly  to  carry  it  out; 
and  third,  that  of  the  subjects  upon  whom  it  has  been  practised. 

It  is  conceded  that  many  operations  have  given  brilliant  results  in 
the  hands  of  their  originators,  while  the  results  when  the  sake  opera- 
tion was  performed  by  others  have  not  been  equally  gratifying  Aside 
from  the  element  of  personal  bias,  this  may  be  due  to  the  exceptional 
skill  of  the  operator  or  the  exceptional  difficulties  of  the  operation. 
Finally,  there  is  the  unhappy  result  of  the  performance  which  theo- 
retically was  correct,  but  which  practically  the  patient  did  not  like. 
AVe  may,  therefore,  legitimately  require  that  to  be  judged  successful  an 
operation  may  be  properly  performed  by  one  possessed  of  no  extra- 
ordinary degree  of  skill,  and  that  its  result,  if  satisfactory  to  the  sur- 
geon, should  at  the  time  be  appreciated  by  the  patient. 

Of  all  the  operations  at  the  Hospital  for  the  Ruptured  and  Crippled 
for  the  relief  of  paralytic  deformities  of  the  foot,  the  one  performed 
by  far  the  most  often  is  the  Whitman  operation  —  astragalectomy 
and  backward  displacement  of  the  foot.  It  has  gradually  and  steadily 
outnumbered  arthrodesis,  tendon  transplantation,  tendon  implantation, 
etc. 

Originally  devised  for  the  relief  of  paralytic  talipes  calcaneus,  its 
i  sefulness  has  become  so  apparent  that  it  is  now  employed  in  the  treat- 
ment of  paralytic  valgus  and  varus,  for  dangle-foot,  for  club-foot,  and 

*Read  before  the  American  Orthopedic  Association  at  Toronto,  June,  1920. 

tin  preparing  the  following  report  upon  end  results  of  the  Whitman  opera- 
tion, it  was  my  intention  to  examine  one  hundred  cases,  taking  twenty  from 
each  of  the  past  five  years.  The  work  of  tracing  the  cases  proved  so  unex- 
pectedly difficult,  and  the  date  for  finishing  my  paper — April  28— gave  me  so 
little  time,  that  T  have  been  forced  to  base  this  report  upon  sixty  cases  only, 
twenty  from  1919,  and  ten  from  each  of  the  other  four  years.  I  hope  later, 
for  my  own  satisfaction,  to  complete  the  series  of  one  hundred,  but  I  am  con- 
vinced that  the  present  number  presents  a  fair  average  from  which  to  draw 
conclusions. 


BACKWARD   DISPLACEMENT   OP    THE   FOOT  267 

occasionally  for  tuberculosis  and  osteomyelitis.  In  this  connection  it 
is  interesting  to  note  in  passing  that  Dr.  Whitman's  technique  was 
described  in  almost  identical  detail  by  Dr.  Chutro  in  his  address  be- 
fore the  American  Orthopedic  Association  in  1919,  in  dealing  with 
the  proper  treatment  of  war  wounds  of  the  ankle-joint.  It  has,  then, 
finally  become  in  one  hospital  the  universal  standby,  and  is  looked 
upon  as  the  operation  that  will  succeed  where  all  others  have  failed — 
that  may  be  held  in  reserve  for  the  relief  of  almost  any  paralytic  de- 
formity of  the  foot,  and  that  will  promise,  even  in  the  worst  cases,  a 
painless,  stable,  and  fairly  sightly  foot. 

Upon  examining  the  hospital  records  and  finding  a  striking  pre- 
ponderance in  favor  of  one  operation  (see  Table  1),  one  is  naturally 
led  to  enquire  the  cause.  One  would  hope  to  find  this  due  solely  to  the 
excellence  of  the  results  following  its  use,  but  one  is  also  bound  to  take 
into  consideration  ignorance  of  other  procedures  that  may  be  as  good 
or  better;  the  force  of  insularity,  or  local,  institutional  or  civic  preju- 
dice; the  purely  personal  influence  of  the  originator;  or  finally  the 
sffcength  of  tradition. 

I  therefore  determined  to  investigate  the  end-results  of  the  oper- 
ation by  examining  one  hundred  cases,  twenty  from  each  of  the  past 
five  years,  1915,  1916,  1917,  1918,  1919.  The  cases  were  taken  in  order 
as  they  appeared  on  the  operating  record.  If  the  first  case  in  1915 
could  not  be  traced,  or  refused  to  return,  the  twenty-first  case  was  then 
sent  for,  and  so  on,  thus  obviating  the  possibility  of  the  results  being, 
as  it  were,  hand  picked.  They  were  all  taken  from  Dr.  Whitman's  ser- 
vice, but  were  by  no  means  all  done  by  him,  as  will  be  seen  in  the  sta- 
tistics. 

As  the  operation  was  devised  originally  solely  for  the  relief  of  talipes 
calcaneus,  it  might  seem  fair  to  confine  a  criticism  of  its  results  to-  that 
type  alone,  but  as  its  application  has  been  so  widely  expanded  I  de- 
cided to  investigate  an  equally  wide  range  of  its  results.  As  I  was  ab- 
sent on  military  service  from  May,  1917,  to  February.  1919,  I  had  no 
intimate  personal  connection  with,  or  knowledge  of  any  number  of 
the  cases,  nor  were  they  themselves,  nor  their  parents,  acquainted  with 
me.  They  therefore  had  no  hesitation  in  freely  expressing  their  opin- 
ion of  the  result.  As  a  number  of  the  patients  lived  at  a  great  distance, 
and  it  was  obviously  impossible  for  them  to  return,  a  questionnaire  was 
included  with  the  original  letter,  with  the  idea  of  getting  from  the 
replies  no  accurate  technical  information,  but  a  fair  idea  of  what  the 
patients  and  patients'  families  thought  of  the  results  of  their  operative 
treatment.     The  replies  to  this  form  have  been  gratifying. 


268 


ARMITAGE    WHITMAN 


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BACKWARD   DISPLACEMENT  OP   THE  FOOT  269 

It  will  be  seen  from  a  study  of  the  table  of  operations  that  the 
number  of  arthrodesis  operations  has  been  slowly  and  steadily  decreas- 
ing. I  may  safely  say  that  it  is  here  the  current  impression  that  in 
\oung  subjects,  and  particularly  those  suffering  from  paralysis,  whose 
bones  are  notoriously  soft,  it  is  impossible  to  obtain  a  true  bony  anky- 
losis. A  deceptive  degree  of  stiffness  may  be  evident  for  months  after 
operation,  and  combined  with  other  procedures,  such  as  tendon  trans- 
plantations, this  stiffness  may  be  utilized,  and  even  prove  sufficient 
to  its  subsidiary  role.  Corrective  operations  depending  solely  for 
their  success  upon  the  formation  of  a  bony  ankylosis  have  been  ob- 
served to  be  failures.  Indeed,  one  of  the  strongest  bits  of  corrobora- 
tive evidence  lies  in  the  results  of  the  Whitman  operation.  Were  bony 
ankylosis  to  be  expected  from  removal  of  cartilage  and  the  apposition 
of  bleeding,  bony  surfaces,  one  would  certainly  find  it  in  astragalecto- 
my,  where  it  is  our  custom  to  reshape  both  malleoli  and  insert  them 
in  beds  prepared  by  removing  sufficient  cartilage  and  bone  to  per- 
mit of  their  snug  reception.  Their  stability  in  this  position  is  main- 
tained by  suture  and  by  plaster  of  Paris.  That  it  is  the  wide  impres- 
sion that  such  technique  must  result  in  ankylosis  may  be  evidenced 
by  the  following  quotations:  *" Although  it  would  seem  that  a  suffi- 
ciently destructive  removal  of  joint  surfaces  would  surely  result  in 
anchylosis,  the  fact  remains  that  skillful  and  experienced  surgeons 
will  occasionally  fail  to  secure  a  stiff  joint.' '  Later,  speaking  of  astrag- 
alectomy  itself,  *"  because  in  the  modified  operation  as  performed  in 
the  Children's  Hospital,  Boston,  an  ankylosed  ankle  is  not  aimed  at." 

As  a  matter  of  fact,  in  not  one  of  this  series  of  cases  examined  has 
there  been  ankylosis  at  the  ankle  joint.  The  limitation  of  motion  has 
been  entirely  dependent  on  the  degree  of  backward  displacement  of 
the  foot  upon  the  leg,  and  failure  of  the  operation  has  been  due  to  too 
much  motion  rather  than  to  stiffness. 

The  purposes  for  which  the  operation  has  been  done  are  as  follows: 
1. — For  calcaneus.     The  object  here  is  to   check  deformity,  to  at- 
tain stability,  to  dispense  with  apparatus,  and  to  provide  a  functionally 
passive  foot  with  propulsive  power. 

2. — For  dangle-foot.  The  object  of  the  operation  in  this  condition 
varies  according  to  the  degree  of  paralysis.    If  the  weakness  be  chiefly 

*R.  W.  Lovett.  Treatment  of  Infantile  Paralysis,  p.  118,  2nd  Edition,  P. 
Blakiston's  Son  &  Co.,  Philadelphia. 


270  ARMITAGE  WHITMAN 

below  the  knee,  the  operation  will  provide  a  symmetrical  extremity 
and  enable  the  patient  to  discard  apparatus.  If  the  paralysis  involves 
the  entire  extremity,  the  operation  has  frequently  been  done  simply 
to  give  a  stable  foundation  and  to  permit  brace- wearing  with  comfort. 
Also  in  paralysis  of  the  quadriceps  extensor,  when  the  resistance  to 
dorsal  flexion  will  lock  the  knee  in  extension  and  thereby  assure  sta- 
bility of  the  limb. 

3.— For  advanced  varus  or  valgus  deformity.  It  has  usually  been 
done  in  this  class  after  the  failure  of  other  operative  procedures  and 
is  looked  upon  as  a  last  resort.  It  should,  as  a  rule,  be  combined  with 
tendon  transplantation. 

It  is  thus  evident  that  the  result  which  we  may  expect  from  the 
operation  will  vary  according  to  the  class  of  case  in  which  it  was  per- 
formed. In  reviewing  the  series,  I  have,  however,  grouped  them  all 
together.  To  class  a  result  successful  I  have  required  that  dorsal 
flexion  should  be  checked  at  a  right  angle,  that  there  should  be  no 
appreciable  lateral  deformity  when  weight  is  borne,  and  that  appar- 
atus, when  it  is  worn,  should  be  worn  with  comfort.  The  opinion  of 
the  patient  must  also  be  satisfactory.  There  have  been  cases  puzzling 
to  classify:  for  example,  in  which  the  patient  was  satisfied  with  a  de- 
gree cf  varus  deformity,  for  which  the  surgeon  would  recommend 
correction  (Case  No.  22).  In  such  cases  the  surgeon's  opinion  has 
been  given  the  greater  authority.  In  fact,  as  such  research  as  this 
should  be  definitive,  the  emphasis  throughout  has  been  placed  on  crit- 
icism rather  than  appreciation. 

As  the  audience  for  which  this  paper  is  written  represents  the  dis- 
criminating few,  it  is  well  to  take  into  consideration  all  the  points 
which  here  influence  our  judgment  in  the  choice  of  operation.  It  will 
be  evident  at  once  that  we  regard  the  Whitman  operation  as  the  ul- 
timate resource,  and  that  its  preponderance  over  other  operations,  and 
the  number  of  conditions  for  which  it  is  being  done,  is  constantly  in- 
creasing. At  the  same  time  it  must  be  remembered  that  the  circum- 
stances of  the  patient  greatly  influence  the  choice  of  operation,  and 
that  hospital  and  private  practice  must  always  differ.  This  is  also 
true  in  contrasting  the  methods  of  a  large  and  very  busy  institution 
with  one  treating  a  smaller  number  of  cases.  An  operation  that  may 
be  satisfactory  in  private  may  be  a  failure  in  hospital  practice.  We 
have  found,  for  example,  that  certain  tendon  transplantations  give 
beautiful  results  when  they  can  be  assisted  by  accessories,  such  as 
built-up  shoes,  foot  plates,  and  muscle  training;  or,  in  other  words, 
proper  postoperative  supervision.     The  identical  condition  minus  post- 


BACKWARD   DISPLACEMENT   OF    THE  FOOT  271 

operative  care  will  result  in  failure.  Such  a  statement  sounds  so 
bTutal  in  this  generation  of  Social  Service  and  Follow-Up  Work,  that 
I  cannot  let  it  stand  unqualified.  Orthopaedic  postoperative  care 
should  end  at  the  grave,  and  patients  intelligent  enough  to  appreciate 
that  fact,  and  sufficiently  persevering,  and  in  adequate  circumstances 
to  act  upon  it  are  few.  At  least  the  intelligence  and  the  circumstances 
are  rarely  found  in  combination,  and  postoperative  care  that  in  gen- 
eral surgery  may  be  taken  for  granted,  in  orthopaedics  practically 
comes  under  the  head  of  luxury;  as  we  found  in  collecting  this  series 
cf  cases,  those  who  lived  at  a  distance  simply  could  not  come.  They 
v»ere  not  necessarily  indifferent,  as  their  replies  showed,  but  they 
could  not  afford  the  time  and  money  to  visit  the  hospital.  This  fact, 
then,  has  led  us  to  choose  the  Whitman  operation  in  a  number  of  cases 
which  elsewhere  might  be  regarded  as  proper  subjects  for  other  pro- 
cedures. 

In  spite  of  the  fact  that  the  members  of  the  American  Orthopedic 
Association  are  probably  all  thoroughly  familiar  with  the  details  of 
the  operation,  in  order  to  avoid  any  possible  misconception,  I  think 
it  best  to  describe  briefly  its  technique. 

' 'The  line  of  incision  begins  at  a  point  about  an  inch  above  the  ex- 
tremity of  the  external  malleolus  midway  between  it  and  the  tendo 
Achillis,  and  is  continued  downward  and  forward  about  three  quar- 
ters of  an  inch  below  the  malleolus  over  the  dorsum  of  the  foot  to  the 
external  surface  of  the  head  of  the  astragalus. 

The  sheaths  of  the  peronei  tendons  are  opened  and  the  tendons  are 
cut  below  the  malleolus  and  drawn  backward.  The  bands  of  the  external 
lateral  and  interosseous  ligaments  are  divided  and  the  head  of  the  as- 
tragalus is  freed  from  its  attachments  to  the  tibia  and  the  scaphoid. 
An  elevator  is  then  inserted  between  it  and  the  os  calcis,  and  the  foot, 
being  forcibly  inverted,  the  head  of  the  astragalus  is  drawn  from  the 
wound,  and,  the  attachments  on  its  inner  and  posterior  borders  hav- 
ing been  cut  or  broken,  it  is  removed. 

One  then  prepares  the  new  articulations.  A  thin  section  of  bone  is 
cut  from  the  adjoining  external  surfaces  of  the  cuboid  and  the  os  calcis 
and  turned  back  to  form  a  flap.  On  the  inner  side  a  knife  is  passed  about 
the  superior  and  internal  surface  of  the  scaphoid,  and  the  tissues  are 
separated  by  an  elevator.  The  foot  is  then  displaced  inward  and  the 
malleoli  are  laid  bare  by  dissection  from  their  ligamentous  attach- 
ments and  are  reshaped  somewhat  on  their  internal  surfaces  to  fit  the 
new  articulations.  The  peronei  tendons,  freed  from  the  lower  extrem- 
ity of  the  fibula,  are  passed   through  a  slit  at  the  base  of  the  tendo 


272 


ARMITAGE    WHITMAN 


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BACKWARD   DISPLACEMENT   OP   THE  FOOT  273 


KEY    TO    DOCTORS     INDICATED    IN     SIXTH    COLUMN    OF    TABLE    2. 


1 

Strickler. 

2 

Cilley. 

3 

Wolcott. 

4 

O'Neil. 

5 

Kleinberg. 

tf 

Wallace. 

7 

Raia. 

8 

Whitbeck. 

9 

Zadek. 

10 

O'Brien. 

11 

Dupuy. 

REFERENCES    IN    TABLE    2. 

i&)  Tendon  transplantation. 

<b)  1912 — Ext.  Comm.  Dig.  attached  to  scaphoid — 1914 — Davis  operation. 

(c)  Dorsal  flexion  limited  at  80  degrees. 

<d)     1.     Tendon  transplantation.    2.   Astragalectomy,  resulting  in  insufficient 

backward  displacement,  for  which  a  third  operation  was  done. 

\e)  Insufficient  backward  displacement,  although  dorsal  flexion  is  checked 

at  a  right  angle — slight  valgus. 

<f)  Tendon  transplantation. 

<g)  Insufficient  backward  displacement,  although  dorsal  flexion  is  checked 

at  a  right  angle — slight  varus. 

<h)  Child  easily  tired. 

<i)  Forty-five  degrees  equinus. 

(j)  Failure, 

(k)  Slight  equino varus. 

(1)  Fair. 

(m)     Dorsal  flexion  to  135  degrees, 

(n)  Improved, 

(o)  Gallie  operation, 

(p)  Slight  varus. 

(q)  Insufficient  backward  displacement, 

(r)  Insuflicient  backward  displacement, 

(t)  Tendon  transplantation. 


274  ARMITAGE   WHITMAN 

Achillis,  sewn  firmly  to  it,  and  then  drawn  forward  and  reunited  to 
their  distal  extremities  to  serve  as  ligaments. 

The  foot  is  now  displaced  backward,  the  external  malleolus  covers 
the  external  aspect  of  the  calcaneocuboid  articulation,  the  internal"  over- 
laps the  navicular.  The  above  mentioned  flap  is  turned  upward  and 
sutured  to  the  external  malleolus  by  a  mattress  suture  of  chromic  gut. 

The  wound  is  then  closed  with  catgut  sutures  and  the  foot  is  fixed 
by  a  plaster  splint  in  an  attitude  of  moderate  plantar  flexion  and  ab- 
duction. Except  in  older  subjects  and  in  extreme  cases,  the  peroneal 
tendons  are  now  neither  divided  nor  transplanted,  as  the  loss  of  the 
peroneus  longus  tends  to  induce  varus  deformity  if  the  tibial  muscles 
are  active. 

In  the  routine  of  hospital  practice  the  operation  is  performed  under 
the  Esmarch  bandage.  The  tendons  are  sutured  with  kangaroo  tendon. 
The  wound,  having  been  cleansed  with  warm  saline  solution,  is  closed 
without  drainage.  The  foot  and  limb  are  bandaged  with  sterilized  sheet 
wadding,  over  which  a  light  plaster  is  applied,  holding  the  foot  in 
the  attitude  described,  and  the  leg  at  a  right  angle  to  the  thigh.  The 
limb  is  afterwards  suspended  between  tapes  running  from  the  head 
+o  the  foot  of  the  bed.  Great  care  is  taken  to  avoid  constriction.  To 
this,  and  to  the  rest  assured  by  the  plaster  splint,  and  to  suspension,  is 
ascribed  the  very  slight  discomfort  following  the  operation,  and  the  ab- 
sence of  complications. 

At  the  end  of  about  three  weeks  the  first  support  is  removed,  and 
the  walking  plaster  splint  is  substituted,  extending  to  the  knee,  and 
fixing  the  foot  in  the  same  attitude  of  moderate  equinovalgus,  the  sole 
being  equalized  by  the  incorporation  of  a  wedge  of  cork.  The  patient 
is  encouraged  to  walk  with  equal  steps,  and  to  bear  weight  on  the  for- 
ward part  of  the  foot.  At  the  end  of  from  two  to  four  months  the  new 
joint  will  have  become  stable,  and  the  fixed  support  may  be  discarded  for 
a  shoe  arranged  with  a  cork  wedge  beneath  the  heel,  of  sufficient  thick- 
ness to  compensate  for  the  slight  equinus,  and  if  necessary,  the  outer 
border  of  the  sole  is  thickened  somewhat  to  prevent  a  tendency  to 
inversion. 

The  patients  are  directed  to  report  at  stated  intervals  for  supervi- 
sion. As  time  goes  on,  the  heel  may  be  raised,  if  necessary,  more  and 
more,  to  compensate  for.  any  preexisting  shortening  of  the  limb.  As 
a  rule,  the  thickening  of  the  outer  border  of  the  sole  may  be  discarded 
in    a    comparatively    short    time.     When    it    is    discarded,    however. 


BACKWARD   DISPLACEMENT   OP    THE   FOOT 


275 


Table  No.3 

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1916-ten  cases.         (Nos. 11-20) 
1917-ten  cases.        (Nob. 21-30) 
1918-ten  cases.         (Nos. 31-40) 
1919-twenty   cases. (Nos. 41-60) 

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parents  are  instructed  in  daily  manipulations  of  the  foot,  and  told  that 
they  must  be  continually  on  their  guard  against  the  development  of 
a  tendency  to  varus  deformity. 

The  total  of  sixty  cases  examined  shows  satisfactory  results  in  fifty- 
one.  Eight  patients  are  improved,  and  one  operation  was  a  failure. 
Fifty-four  of  the  parents,  or  patients  themselves,  were  satisfied  with 
their  condition.  From  the  surgeon's  standpoint  85%  of  the  results  were 
satisfactory — from  the  personal  standpoint  90%    (see  Table  No.  3). 

The  conclusions  derived  from  the  investigation  are  as  follows. 

1.  The  operation  gives  the  best  results  functionally  and  cosmetically 
— i.e.,  the  percentage  of  improvement  is  greater — in  the  class  of  cases 
for  which  it  was  originally  designed — talipes  calcaneus.  It  corrects 
deformity  and  changes  the  most  crippling  variety  of  talipes  into  a  func- 
tionally useful  foot.  In  this  field  it  comes  as  near  being  a  curative 
performance  as  any  operation  for  the  relief  of  paralysis  can  be. 

2.  In  dangle-foot,  with  or  without  varus  or  valgus  deformity,  it 
provides  a  symmetrical  and  stable  foot,  and,  unless  the  paralysis  of  the 
extremity  is  so  severe  as  to  require  the  use  of  a  long  brace,  enables  the 
patient  to  dispense  with  apparatus.  It  does  not  correct  the  degree  of 
drop-foot  which  may  take  place  at  the  mediotarsal  joint,  but  as  the 


276  ARMITAGE   WHITMAN 

Table  No.  4. 
analysis  of  unsatisfactory  results. 

1  Florence  C.  Case  43 — Operated  June  23,  1919, — left  calcaneus,  slight  tend- 
ency to  varus.  Has  had  no  after-treatment  whatever,  owing  to  toad  home 
conditions. 

2  Richard  G.  Case  49 — Operated  June  23,  1919, — calcaneus,  dorsal  flexion 
checked  at  80  degrees.     Insufficient  backward  displacement. 

3  Mary  McC.  Case  53 — Operated  May  19,  1919, — right  valgus,  secondary  op- 
eration. Dorsal  flexion  checked  at  80  degrees,  still  has  considerable  valgus 
deformity. 

4  Gladys  B.  Case  31 — .Dangle  foot  in  equinovarus — operated  June  24,  1918. 
Has  a  resistant  equinus  deformity — operation  a  failure.  Has  had  no  post- 
operative supervision. 

5  Catherine  C.  Case  35 — Right  varus  deformity — operated  September  9,  1918. 
Still  has  varus  deformity,  due  to  slight  power  in  the  tibialis  anticus  and 

posticus.     Should  have  a  supplementary  tendon  transplantation. 

6  Nathan  R.  Case  39 — Right  calcaneus — operated  January  21,  1918.  Has 
dorsal  flexion  to  45  degrees  in  spite  of  good  backward  displacement  of  the 
foot.  Result  classed  as  unsatisfactory,  though  the  patient  prefers  his  pres- 
ent state  to  that  before  the  operation. 

7  Martin  D.  Case  32 — Dangle  foot — operated  October  29,  1917.  Slight  valgus 
and  insufficient  backward  displacement  of  the  foot,  though  dorsal  flexion  is 
checked  at  a  right  angle. 

8  Minnie  S.  Case  26 — Left  dangle  foot  in  equinus,  operated  March  31,  1917. 
Very  slight  tendency  to  varus,  not  quite  sufficient  backward  displacement. 

9  Annie  L.  Case  16 — Left  calcaneo-varus — operated  1916.  Dorsal  flexion 
limited  at  80  degrees — insufficient  backward  displacement. 

extremity  is  usually  short  anyway,  requiring  of  itself  the  wearing  of 
a  high  heel,  this  degree  of  drop-foot  has  not  in  any  case  been  severe 
enough  to  require  the  wearing  of  apparatus  for  its  correction. 

3.  For  varus  or  valgus  deformity  the  operation  has  usually  been 
done  as  a  last  resort.  The  cosmetic  results  are  not  as  satisfactory  as 
in  the  former  classes,  nor  is  the  cure  of  deformity  likely  to  be  per- 
manent unless  the  operation  be  supplemented  by  tendon  transplantation 
or  implantation.  I  feel  that  it  should  be  recommended  in  these  cases 
only  when  other  procedures  have  failed,  or  when  we  know  that  any 
after-care  is  out  of  the  question. 

From  a  study  of  the  bad  results  (see  Table  No.  4)  we  have  proved 
two  major  causes  of  failure.  The  first  is  insufficient  backward  displace- 
ment of  the  foot,  which,  with  one  exception  in  this  series,  is  accepted 
as  evidence  that  the  original  operation  was  improperly  performed. 

The  second  is  varus  deformity.     This  may  result  from: 

(a)  Faulty  operation — failure  to  place  the  external  malleolus 
sufficiently  far  forward. 

(b)  Persistence  of  the  original  deforming  factor,  be  it  only  a  trace 
of  power  in  either  the  tibialis  anticus  or  posticus. 

(c)  The  removal  of  the  support  afforded  by  the  head  of  the  as- 
tragalus to  the  scaphoid,  which  occasionally  will  produce  varus  de- 
formity in  even  completely  paralyzed  extremities. 


BACKWARD   DISPLACEMENT   OP   THE  FOOT  277 

The  first  case  is  too  simple  to  need  comment.  For  Class  B  we  are 
inclined  to  recommend  transplantation  of  the  deforming  agent  at  the 
time  of  or  shortly  following  the  original  operation.  All  cases  should 
be  treated  with  the  development  of  this  deformity  in  mind,  with  a  shoe 
raised  on  the  outside,  and  with  the  parents  instructed  in  the  daily 
manipulations  of  the  foot.  It  is  only  where  these  simple  precautions 
have  been  neglected  that  deformity  in  Class  C  has  occurred. 

It  will  be  seen,  that  while  the  average  age  of  the  1919  cases  is  no 
less  than  that  of  preceding  years,  there  is  a  greater  proportion  six 
years  or  under  (55%),  than  in  any  of  the  other  groups.  This  fact  rep- 
resents a  new  departure  in  treatment,  as  the  youngest  operative  cases 
are  those  of  the  1916  epidemic.  It  may  be  said  that  whereas  it  was 
the  custom  formerly  to  delay  operation  for  almost  an  indefinite  period 
following  the  onset  of  the  disease,  we  now  feel  that  a  delay  of  more 
than  two  years  is  unnecessary.  We  realize  that  there  is  always,  under 
operative  treatment,  massage,  muscle  training,  or  electricity,  the  pos- 
sibility of  a  certain  regeneration  of  muscles  that  at  a  primary  exam- 
ination might  have  appeared  to  be  totally  paralyzed.  The  return  of 
power  to  the  flexors  of  the  toes  following  astragalectomy,  for  example, 
has  become  a  familiar  phenomenon  in  this  hospital.  Except  in  cases 
which  have  been  absolutely  neglected  and  been  suffered  to  run  wild, 
with  resultant  deformity  or  manifest  constant  over-fatigue,  there  is  not 
likely,  after  two  years,  to  be  a  return  of  power  to  a  muscle  sufficient 
to  be  of  practical  value  from  a  locomotive  point  of  view. 

Upon  this  premise,  then,  we  are  now,  April,  1920,  starting  the  opera- 
tive treatment  of  the  1916  cases,  upon  the  theory  that  a  proper  operative 
result  will  permit  the  discarding  of  apparatus  and  result  in  the  greater 
functional  efficiency  of  the  limb.  It  is  our  hope  and  belief,  that  the  earlier 
the  functional  use,  the  less  will  be  the  eventual  atrophy  of  t'ie  entire 
extremity.  Particularly  do  we  hope  to  check  the  extreme  atrjphy  and 
distortion  incident  to  talipes  calcaneus. 

One  of  the  most  striking  facts  brought  out  by  the  investigation  is  in 
relation  to  the  patient's  brace-wearing.  The  operation  enabled  the 
discarding  of  all  apparatus  upon  the  affected  limb  in  twenty-six  cases. 
Only  fourteen  out  of  sixty  wear  apparatus  at  all,  and  in  all  of  these  it 
is  worn  because  of  paralysis  above  the  knee. 

The  removal  of  the  astragalus  causes  an  average  shortening  of  half 
an  inch,  for  which  it  is  our  custom  to  compensate  by  the  wearing  of 
an  inner  heel.  None  of  the  patients  mentioned  this  shortening  as  a 
cause  of  dissatisfaction.  This  is  of  interest  chiefly  because  a  writer  of 
some  prominence  has  characterized  the  operation  as  "mutilating." 


278  ARMITAGE   WHITMAN 

A  study  of  statistics  will  doubtless  be  of  more  value  than  my  personal 
opinion.  As  the  study  of  statistics  is  sometimes  deferred  until  a  time 
never  attained,  I  may,  perhaps,  be  excused  for  ending  this  paper  with 
a  simple  statement: 

Sixty  cases  were  examined,  of  which  twenty-eight  were  operated  on 
by  Dr.  Whitman  and  thirty-two  by  other  surgeons  on  his  service. 
Eighty -five  per  cent,  of  the  results  were  successful.  Sixty  five  per  cent, 
of  the  patients  wearing  apparatus  were  enabled  to  discard  it.  One 
patient  regarded  the  operation  as  a  failure.  Ninety  per  cent,  were  sat- 
isfied with  their  condition. 

Those  who  are  really  interested  in  the  subject  can  gain  satisfactory 
information  from  a  study  of  the  case  records.  They  will  there  find  that 
all  but  three  of  the  bad  results  may  be — and  indeed  several  have  al- 
ready been — corrected  by  measures  varying  from  simple  manual  stretch- 
ing to  secondary  operation  for  further  backward  displacement  of  the 
foot  upon  the  leg.  They  will  observe  that  most  of  these  procedures 
might  have  been  obviated  by  elementary  postoperative  care. 

The  fact  in  the  study  of  these  patients  that  is  to  me  most  striking 
is  that  in  spite  of  the  variety  of  disabilities  to  which  the  application 
of  this  operation  has  been  expanded,  and  in  spite  of  the  hard  condi- 
tions of  this  particular  hospital  practice,  its  results  are  so  satisfactory 
to  the  patients  themselves.  That  its  results  are  also  good  from  the 
standpoint  of  technical  criticism  is  only  further  testimony  to  the  theo- 
retical soundness  of  its  conception. 


LENGTHENING    Of    THE    QUADRICEPS    TENDON  279 


LENGTHENING  OF  THE  QUADRICEPS  TENDON. 

BY  GEORGE  E.   BENNETT,   M.D. 

Associate  in  Clinical  Orthopaedic  Surgery  Johns  Hopkins  Medical  School, 

Assistant  Visiting  Orthopaedic  Surgeon  Johns  Ilopkins 

Hospital 

In  the  September,  1919,  issue  of  the  Journal  of  Orthopaedic  Surgery 
we  published  a  paper  entitled  ''Preliminary  Report  of  Lengthening  of 
the  Quadriceps  Tendon. ' '  In  this  article  we  called  attention  to  the  part 
the  quadriceps  tendon  played  in  the  loss  of  mobility  of  the  knee  joint, 
following  lesions  of  the  femur,  such  as  fractures,  simple  and  compound, 
osteomyelitis  of  the  femur,  fractures  of  the  tibia  and  fibula,  and  ununited 
fractures  of  bones  above  and  below  the  knee  joint,  requiring  long  im- 
mobilization. 

It  is  a  well-known  fact  that  in  a  small  percentage  of  cases  such  as 
have  been  enumerated,  one  sees  a  permanent  loss  of  complete  or  partial 
flexion  of  the  knee  joint,  notwithstanding  the  fact  that  the  lesion  has 
been  entirely  an  extra-articular  affair. 

Attention  was  also  called  particularly  to  the  part  the  quadriceps 
rjlays;  contractures,  adhesions,  and  other  conditions  to  which  muscles 
may  be  subjected,  and  three  cases  were  reported  in  which  we  had  suc- 
ceeded in  increasing  the  range  of  motion  by  lengthening  the  tendon, 
and  the  methods  of  procedure  were  described.  Since  that  time  the 
number  of  cases  has  increased  to  eight,  seven  of  which  have  unquestion- 
ably had  very  satisfactory  results,  while  the  eighth  case  only  showed  no 
improvement. 

Even  at  the  expense  of  being  accused  of  reiteration,  we  think  it 
would  be  well  to  touch  lightly  on  the  anatomy  of  the  anterior  thigh, 
since  in  a  description  of  the  operation  itself,  it  is  very  necessary  that 
this  point  should  be  perfectly  understood.  The  relationship  between 
the  crureus  and  vastus  internus  and  externus  muscles  is  very  close 
in  the  lower  third  of  the  femur,  and  their  tendons  are  inseparable. 
The  crureus,  lying  deepest  of  the  three  and  on  the  anterior  surface  of 
the  shaft  of  the  femur,  is  easily  tied  down  by  adhesions,  thereby  render- 
ing absolutely  inert  the  function  of  the  other  three  muscles  forming 
the  quadriceps.  We  feel  perfectly  free  in  making  this  rather  startling 
assertion,  as  we  have  seen  a  case  where  the  rectus,  by  adhesions  high 


280 


GEORGE   E.    BENNETT 


up  in  the  thigh,  had  produced  a  complete  loss  of  motion  of  the  knee 
joint.  If  this  can  be  true  of  the  most  independent  section  of  the 
quadriceps  group,  why  should  it  not  be  true  of  the  less  independent 
members,  that  is,  the  vastus  internus  and  externus  and  crureus? 


Fig.  A. 


LENGTHENING    OF    THE    QUADRICEPS    TENDON 


281 


In  our  former  article  no  note  was  made  of  changes  in  the  capsule 
of  the  knee  joint,  because  we  were  very  much  surprised  to  find,  in 
the  first  two  cases  on  which  we  operated,  very  little,  if  any,  evidence 
of  contraction,  hardly  as  much  as  one  would  anticipate  from  lesions 


Vastus  Externu: 


Rectus  femori 


Vastus  intermedius 


Vastus  internus 


Fig.  B. 


282 


GEORGE   E.    BENNETT 


which  had  existed  over  a  period  of  from  six  months  to  seventeen  years. 
Our  third  case  did  demonstrate,  in  a  mild  degree,  certain  changes  in 
the  capsule,  but  not  as  marked  as  one  had  been  led  to  believe!  in  older 
instructions. 

We  believe  that  the  changes  within  the  knee  joint  itself  are  com- 
parable with  the  changes;  which  one  would  expect  to  find  in  the  ankle 
joint,  if  the  tendo  Achillis  was  lengthened  to  correct  an  equinus  deform- 
ity that  had  persisted  for  a  long  time.  In  other  words,  we  recognize 
capsular  changes.  There  is  a  certain  amount  of  obliteration  of  the 
quadriceps  pouch,  but  we  wish  to  emphasize  that  the  chief  offender 
in  the  production  of  this  condition  is  the  contraction  of  the  quadriceps 
tendon  and  adhesions.  The  capsule  is  entirely  a  secondary  affair,  and 
will  take  care  of  itself,  —  will,  in  fact,  be  totally  relieved,  when  the 
tendon  contraction  has  been  overcome. 

We  believe  that  this  problem  can  be  more  clearly  understood  by 
following  a  rather  detailed  recital  of  the  histories  of  the  cases  which 
have  been  operated  on;  a  study  of  the  problems  which  presented  them- 
selves with  each  case,  of  the  changes  noted,  and  of  the  end  result. 


X-ray  of  knee  before  operation.    Case  1. 

Case  No.  1.  N.  C.  Age  34.  (Previously  reported  in  Journal  of 
Orthopaedic  Surgery,  September,  1919.)  Admitted  to  Johns  Hopkins 
Hospital  June  19,  1917. 

Diagnosis:  Old  healed  osteomyelitis  of  upper  third  of  femur.  Old 
healed  osteomyelitis  of  the  clavicle.  Contraction  of  the  quadriceps 
tendon. 

Complaint:  Stiff  knee. 

Family  History:  Unimportant. 

Past  History:  Unimportant. 


LENGTHENING    Of    Tin:    QUAMUGEPS    TENDON  283 


X-ray.     Osteomyelitis   upper   third    femur,   which    tied    down    the    tihres   of  the 

rectus.     Case  1. 


Photograph  before  operation.    Case  I. 


284  GEORGE   E.    BENNETT 

Present  Illness:  Onset  after  injury  to  spine  at  the  age  of  six  or 
seven.  Following  this  injury,  the  patient  was  unable  to  sleep  at  night 
for  about  one  month.  Right  leg  became  swollen,  and  there  was  marked 
pain.  Patient  was  confined  to  bed  six  or  seven  weeks.  After  this  he- 
walked  with  crutches.  In  the  meantime  abscesses  had  formed  and 
broken  down.  Relief  from  pain  after  the  evacuation  of  the  abscesses 
was  marked.  Abscesses  continuing  to  form  at  the  rate  of  about  twa 
each  year  for  several  years.  At  the  age  of  ten,  an  abscess  appeared 
on  the  left  clavicle;  this  was  treated  surgically,  as  well  as  one  on  the 
right  arm.  Several  pieces  of  bone  came  from  the  thigh  abscesses  at 
different  times.  At  the  age  of  fifteen,  the  right  knee  became  stiff, 
and  has  remained  so  ever  since.  Reaching  the  age  of  twenty-one,  the 
patient  has  had  no  more  abscesses.  He  comes  to  the  hospital  to  see  if 
motion  can  be  obtained  in  the  knee. 

Previous  Operation:  January  17,  1914,  was  admitted  to  Johns  Hop- 
kins Hospital.  Exploration  of  upper  thigh  and  attempt  to  relieve 
contracture  and  adhesions  was  without  result.  Re-admitted  to  Johns 
Hopkins  Hospital  on  June  19,  1917,  for  operation  reported  in  this 
article. 

Physical  Examination:  (Reported  from  Johns  Hopkins  Hospital  His- 
tory.) There  is  rather  marked  atrophy  of  the  muscles  of  the  right 
thigh.  Calves  appear  the  same  size.  There  is  a  long  scar  just  below 
the  greater  trochanter  on  the  right  thigh,  which  is  adherent  to  the  bone- 
Normal  motion  in  right  hip.  Flexion  of  knee  is  limited  to  fifteen  degrees, 
with  marked  contraction  of  the  quadriceps  tendon  when  knee  is  forcibly 
flexed.  Lateral  motion  of  knee  seems  fairly  free.  Scar  of  former 
operation  over  left  clavicle.  Atrophy  of  right  thigh  is  thirteen  cms. 
Atrophy  of  right  calf  is  one-half  cm. 

Operative  Note:  (Report  from  Johns  Hopkins  Hospital  History.) 
Operation  June  25,  1917.  Manipulation  of  right  knee.  Lengthening 
of  quadriceps  femoris  tendon,  right.  Iodine  technique.  After  patient 
was  fully  anesthetized,  the  right  leg  was  brought  over  the  end  of  the 
stretcher,  and  with  the  pelvis  firmly  held  to  the  table  the  leg  was  flexed 
on  the  thigh  for  several  minutes  in  an  effort  to  break  up  joint  adhesions. 
Approximately  five  degrees  of  flexion  were  gained  in  the  manoeuvre. 
It  was  noticed  that,  although  the  knee  could  not  be  flexed  more  than 
twenty  degrees,  lateral  motion  in  the  knee  joint  appeared  quite  free, 
and  that  the  patellar  and  quadriceps  tendons  were  apparently  contracted 
and  limiting  joint  motion.  The  thigh  was  then  cleaned  up  with  iodine- 
and  alcohol  and  a  long  incision  was  made  over  the  quadriceps  tendon. 
The  knee  was  allowed  to  flex  over  a  pillow.     The  tendon  of  the  rectus 


IJ5NGTHENING    OP    THE    QUADRICEPS    TENDON 


285 


Case  1.     N.  C.     End  result. 

femoris  was  tightly  contracted.  This  was  divided  and  the  fibres  of 
the  vastus  interims  and  externus  dissected  loose.  The  leg  could  now 
be  flexed  ninety  degrees,  and  motion  was  quite  free.  The  vastus  externus 
and  interims  tendons  were  sutured  to  the  distal  end  of  the  cut  rectus 
femoris  tendon  with  several  sutures  of  heavy  braided  white  silk.  Sub- 
cutaneous tissue  was  closed  with  interrupted  sutures  of  plain  catgut 
and  the  skin  with  continuous  fine  black  silk  suture.     Sterile  dressing. 

DISCUSSION 


Patient  made  an  uneventful  recovery  from  operation,  and  at  the  end 
of  four  weeks  was  walking  about  with  eighty-five  degrees  of  motion. 
This  has  continued  until,  at  the  time  of  writing,  he  has  approximately 
one  hundred  and  twenty  degrees  of  free,  painless  motion,  with  a  quadri- 
ceps tendon  in  full  power.  This  enables  him  to  perform  his  occupation 
as  carpenter.  He  states  that  he  is  able  to  carry  one  hundred  and  fifty 
pounds  on  his  shoulder,  going  up  stairs  foot  over  foot  without  any 
discomfort. 

The  points  of  particular  interest  in  this  case  are  the  duration  of 
the  loss  of  motion  in  the  knee  over  a  period  of  seventeen  years  before 


286  GEORGE    E.    BENNETT 

operation,  no  contraction  of  the  capsule  noted  at  the  time  of  operation, 
and  that  the  structures  of  the  knee  joint  were  in  very  good  condition 
prior  to  operation.  The  rectus  tendon  was  the  element  at  fault,  with 
adhesions  in  the  upper  thigh,  and  contraction  of  the  quadriceps  tendon. 


X-ray  before  operation.     Case  2. 

Case  No.  2.  Mrs.  M.  B.  (Previously  reported  in  Journal  of  Ortho- 
paedic Surgery,  September,  1919.) 

Comminuted  fracture  of  right  patella.  August  17,  1917 — Open  opera- 
tion and  wiring.  Immobilization  in  extension.  Massage  begun  October 
20, 1917. 

Manipulated  under  anesthesia  and  continued  treatment  until  operation 
February  4,  1918,  at  which  time  patient  had  thirty-five  degrees  of  motion, 
as  shown  in  X-ray  taken  with  leg  held  in  forced  flexion. 

DISCUSSION 

This  patient  had  ideal  treatment  following  removal  of  plaster  splint, 
constant  massage  and  apparatus  work,  but  in  spite  of  this:  only  thirty- 
five  degrees  of  motion  were  obtained  at  the  end  of  four  months. 

A  full  normal  range  of  motion  came  four  months  after  operation.  Ap- 
proximately one  year  after  operation  motion  in  the  knee  became  painful 


!  I  NGTHENJNG    I  V    THE    Ql  AiuiICEPS    TENDON 


287 


X-ray  ten  weeks  after  operation.    Case  2. 

from  a  thickening  of  synovia,  caused  by  a  large  patella.  A  reduction 
of  the  size  of  the  patella  relieved  all  discomfort.  Patient  is  able  to  ride 
horseback  and  lead  an  athletic,  active  life. 

No  capsular  contraction  was  noted  at  time  of  operation.  It  is  our 
opinion  that  this  was  an  example  of  contraction  of  the  quadriceps  group. 

Case  No.  3.  G.  J.  G.  Age  23.  White  male.  (Previously  reported  in 
Journal  of  Orthopaedic  Surgery,  September,  1919.)  Admitted  to  Johns 
Hopkins  Hospital  March  13,  1919.     Discharged  April  29,  1919. 

Case  No.  4.  G.  J.  G.  Age  23.  White  male.  Admitted  to  Johns  Hop- 
kins Hospital  June  29,  1919.    Discharged  August  23,  1919. 

Family  History:     Unimportant. 

Past  History:     Unimportant. 

Present  illness:  In  an  automobile  accident  June  25,  1915,  patient 
sustained  a  compound  fracture  of  the  right  femur,  eight  inches  above 
the  knee,  and  a  simple  fracture  of  the  left  femur,  six  inches  above  the 
knee.  Both  limbs  were  put  up  in  traction  and  the  wound  on  the  right 
thigh  irrigated  daily.  At  the  end  of  three  weeks  an  open  reduction  of 
the  fracture  on  the  left  was  done,  the  fragments  being  plated  and  the 
limb  being  put  up  in  a  long  plaster  hip  spica.  The  wound  on  the  right 
closed  at  the  end  of  nine  weeks,  at  which  time  a  plating  operation  was 


288 


GEORGE   E.    BENNETT 


Photograph  four  months  after  operation.     Case  2. 


done  on  this  side,  and  a  long  spica  applied.  The  cast  on  the  left  side 
was  cut  an  inch  or  so  shorter  at  various  times,  so  that  it  was  not  until 
October  of  that  year  that  the  knee  joint  was  exposed.  By  the  end  of 
December,  1915,  the  right  knee  was  also  free  for  motion;  massage  and 
later  manipulation  were  instituted.  However,  the  legs  remained  stiff 
at  the  knees.  In  August,  1918,  several  manipulations  under  anesthesia 
were  unsuccessful.  On  September  12th,  the  bone  plate  of  the  right  was 
removed  without  improvement.  Stiff  knee  condition  remains  as  on 
admission. 

Physical  Examination:  Right  leg:  The  patient  walks  with  both  knees 
stiff.  There  is  a  large  scar  over  the  middle  of  the  lower  end  of  the  femur 
extending  over  the  external  condyle  to  the  patellar  tendon,  evidence  of 
operation  for  relief  of  adhesions  and  plating  operation  for  compound 
fracture. 

Left  leg :  Scar  on  the  outer  border  of  the  lower  third  of  femur,  result 
of  operation  for  fracture.    Some  thickening  of  the  femur.    Patella  freely 


LENGTHENING    OF    THE    QUADRICEPS    TENDON  289 

movable.     Fifteen  degrees  of  flexion  can  be  obtained,  when  a  sudden 
shock  is  felt  and  the  quadriceps  tendon  becomes  taut. 

Operative  Note:  Left  leg— March  13,  1919.  Iodine  technique.  In- 
cision was  about  nine  inches  long,  beginning  at  the  patella  and  extending 
upward  parallel  to  the  femur.  The  subcutaneous  tissues  were  divided 
and  dissected  laterally.  These  were  then  retracted,  exposing  the  quadri- 
ceps tendon.  There  was  found  to  be  considerable  scar  tissue  about  the 
quadriceps  tendon,  and  it  was  firmly  adherent  to  the  femur  about  four 
inches  above  the  patella.  These  longitudinal  incisions  were  then  carried 
laterally,  so  as  to  divide  the  tendinous  portion  of  the  vasti  muscles.  This 
left  about  four  inches  of  the  quadriceps  tendon,  three-quarters  of  an  inch 
wide,  attached  to  the  patella.  The  tendons  of  the  vasti  muscles  were  then 
dissected  free  where  they  were  tied  down,  and  with  considerable  force 
the  leg  was  flexed  almost  at  right  angles.  Dissection  was  made  with  con- 
siderable difficulty,  as  all  the  tissues  were  tied  down  very  firmly  to  the 
femur.  The  capsule  was  also  quite  adherent  to  the  tendon,  so  that  in 
making  the  dissection  the  capsule  was  punctured  in  one  place  near  the 
upper  portion  of  the  patella.  With  the  leg  flexed  almost  at  right  angles, 
the  central  portion  of  the  tendon  which  was  still  attached  to  the  patella 
was  sutured  to  the  vasti  muscles  in  a  lengthened  position,  leaving  a  space 
of  nearly  three  inches  above  the  central  portion  open.  The  vasti  were 
then  sutured  across  the  open  space,  and  sutured  also  firmly  to  the  central 
portion  of  the  quadriceps  tendon.  This  gave  a  lengthening  of  the  quad- 
riceps tendon  of  about  three  inches.  Chromic  catgut  and  braided  silk 
were  used  in  this  suturing  of  the  tendon.  The  deep  tissues  were  sutured 
over  the  quadriceps  tendon  with  chromic  catgut.  The  superficial  tissues 
wrere  closed  with  plain  catgut.  The  skin  was  closed  with  silk.  Plaster 
cast  was  applied  from  toes  to  groin  with  knee  flexed  at  eighty  degrees. 
Patient  left  the  table  in  good  condition. 

Post-operative  Note:  The  post-operative  course  on  the  whole  was  un- 
eventful. Some  ecchymosis  appeared  about  the  thigh.  The  temperature 
went  up  to  as  high  as  101  on  several  occasions  the  first  week.  After  that, 
however,  the  condition  was  excellent.  On  the  27th  day  of  March  the  cast 
was  removed.  The  wound  was  found  healed  per  primam.  The  knee  could 
be  flexed  to  100  degrees  without  any  discomfort.  Following  this,  a  mild 
course  of  massage,  with  later  manipulation,  was  begun.  At  the  time  of 
discharge,  the  patient  was  able  to  actively  extend  his  knee  to  within 
fifteen  degrees  of  normal.  Limb  could  be  flexed  to  eighty  degrees.  There 
was  practically  no  local  discomfort. 


290 


GEORGE    E.    BENNETT 


Cases  3  and  4.     G.  J.  G, 


Right  leg  in  forced  flexion  before  operation,  showinj 
degree  of  motion. 


Operative  Note:  Right  leg — June  30,  1919.  Case  No.  4.  Iodine 
technique  to  the  skin.  An  incision  was  made  on  the  anterior  aspect  of 
the  thigh  from  about  the  middle  of  the  thigh  running  down  longitudi- 
nally to  a  point  just  over  the  lower  margin  of  the  patella.  It  was  carried 
through  the  skin  and  the  subcutaneous  tissues  to  expose  the  quadriceps 
tendon.  There  was  a  lateral  dissection  of  the  skin,  permitting  an  ex- 
posure of  the  entire  width  of  the  rectus  femoris  muscle,  together  with 
the  insertion  of  the  vasti  into  its  lateral  border.  Owing  to  the  numerous 
adhesions  between  the  various  tissues,  the  dissection  proved  to  be  more 
difficult,  and  there  was  more  bleeding  than  usual.  With  the  muscles 
exposed,  efforts  at  flexion  showed  that  most  of  the  restriction  of  flexion 
was  due  to  the  binding  down  of  the  tendon  by  the  lower  fibres  of  the 
vastus  internus  muscle.  In  freeing  the  quadriceps  tendon  from  these 
restricting  bands,  an  incision  was  made  from  the  middle  of  the  lateral 
margin  of  the  patella  to  the  junction  of  the  rectus  tendon  to  the  body 
of  the  muscle.    A  similar  incision  was  made  on  the  inner  aspect  of  the 


LENGTHENING    OP    THE    QUADRICEPS    TENDON 


291 


Cases  3  and  4.     G.  J.  G.     Left  leg  in  forced  flexion  before  operation,  showing 

degree  of  motion. 

rectus  f  emoris,  the  upper  end  of  the  incisions  being  connected  by  a  curved 
incision  line.  This  left  the  patella  with  its  upper  portion  attached  to  a 
tongue  of  tendinous  tissue,  free  from  the  vasti  on  either  side,  and  from 
the  belly  of  the  rectus  muscle  above.  This  flap  was  then  dissected  up 
from  the  underlying  tissues,  care  being  taken  not  to  enter  the  joint 
cavity.  Flexion  then  proved  to  be  restricted  by  intra-capsular  adhesions. 
With  a  little  forceful  manipulation,  however,  these  adhesions  could  be 
broken,  and  120  degrees  of  flexion  of  the  knee  obtained.  The  problem  of 
resuturing  the  tendon  into  its  lower  position  was  then  begun.  With  the 
leg  flexed  at  80  degrees  at  the  knee,  the  tendon  was  sewed  rather  tautly 
to  the  vastus  internus.  In  order  to  further  facilitate  the  slipping  of  the 
tendon,  a  pad  of  fat  about  three  inches  in  diameter  was  dissected  out 
from  the  subcutaneous  layers  of  the  outside  of  the  thigh,  and  placed 
underneath  the  rectus  tendon.    The  outer  side  of  this  was  then  pulled  up 


292 


GEORGE    E.    BENNETT 


Cases  3  and  4.    G.  J.  G.     End  result. 


as  high  as  could  be,  with  the  knee  in  the  flexed  position,  and  then  sewed 
firmly  to  the  tissues  of  the  externus  vastus  which  had  previously  been 
dissected  up.  The  upper  portion  of  the  tendon  was  pulled  as  far  as  could 
be  managed  to  the  belly  of  the  rectus  muscle.  The  cavity  left  was  closed 
over  by  the  joining  together  of  the  lateral  margins  of  the  space.  All  the 
suturing  was  done  with  chromic  catgut,  and  the  skin,  by  means  of  a 
locking  silk  continuous  suture.  It  was  found,  however,  on  effort  to  close 
the  skin,  that  the  contracture  of  the  skin  had  been  so  great  that  the  in- 
cision edges  would  not  unite  in  the  newly  flexed  position  without  extreme 
tension  being  made  on  the  skin.  To  relieve  some  of  this  tension,  two 
longitudinal  incisions  were  made  about  an  inch  to  either  side  of  the 


LENGTHENING  OF  THE  QUADRICEPS  TENDON 


293 


Cases  3  and  4.     G.  J.  G.    End  result 


incision  line.  The  improvement  in  the  circulation  of  the  tissues  was  quite 
noticeable  when  these  incisions  were  made.  These  relaxation  incisions 
were  just  through  the  skin.  Dry  dressings  were  applied  and  a  plaster 
cast  put  on  with  the  knee  flexed  80  degrees.  Patient  stood  the  operation 
well. 

Post-operative  Note:  July  1,  1919.  Patient  feels  fairly  comfortable. 
Temperature  100.2.    Cast  in  good  shape.    Circulation  in  toes  good. 

July  2,  1919.  Because  of  rise  of  temperature  to  101.2,  a  white  count 
was  done.  This  showed  11,000  leukocytes.  Patient  feels  fairly  well. 
Appetite  has  not  yet  returned.    Circulation  in  toes  good. 

July  5,  1919.  A  window  was  cut  in  the  cast  at  the  knee.  There  were 
several  blood  clots  at  the  side  of  the  two  lateral  incisions.  Slight  oozing 
of  these  wounds  took  place.  Incisions  were  washed  with  alcohol  and 
dressed  with  gauze.    Patient's  temperature  fell  to  99.8  after  the  dressing, 


294  GEORGE    E.    BENNETT 

but  at  7  p.  m.  was  up  to  100.4.    Patient  feels  well.    The  tissues  about  the 
knee  are  black  and  blue. 

July  7, 1919.  Hot  boric  compresses  applied  to  knee.  Patient  feels  well. 
Highest  temperature  99.8.  The  area  of  discoloration  is  more  evident  on 
the  lateral  aspect  of  the  knee. 

July  10,  1919.  Skin  in  very  good  condition,  ecchymosis  cleared  up. 
Stitches  removed.    Temperature  normal. 

July  20,  1919.  Anterior  half  of  cast  removed :  posterior  half  padded 
and  bandaged  to  the  leg. 

July  22,  1919.  Leg  extended  until  it  lacked  thirty  degrees  of  full 
extension. 

July  25,  1919.  Patient  getting  around  on  crutches.  Feels  that  right 
leg  is  weaker  possibly  than  the  left  leg  at  the  corresponding  time  after 
operation. 

July  29,  1919.     Massage  commenced. 

July  31,  1919.  Patient  awoke  to  find  a  small  amount  of  dark  blood  had 
escaped  from  one  of  the  stitches  which  has  apparently  healed.  Several 
c.c.  of  old  blood  was  squeezed  out.  Iodoform  drain  inserted.  Pocket  is 
at  least  2.5  cms.  deep. 

August  2,  1919.  Considerable  amount  of  old  blood  and  necrotic 
material  was  expressed  today.    Massage  discontinued. 

August  7,  1919.  Sinus  completely  healed.  Patient  took  a  few  steps 
unaided  in  any  way. 

August  16,  1919.    Walks  gradually. 

August  23,  1919.  Patient  has  only  25  degrees  of  active  extension  on 
the  right  leg,  10  degrees  less  than  full  passive  extension.  70  degrees  of 
flexion,  no  pain.  Patient  is  improving  under  massage  and  manipulation. 
To  continue  with  this.     May  be  discharged. 

DISCUSSION. 

Special  points  of  interest  in  this  patient :  On  the  left  leg,  which  was 
rather  the  better  of  the  two,  there  was  a  great  deal  of  difficulty  in  bring- 
ing the  knee  down  to  a  flexed  position,  and  this  difficulty  was  due  to 
contractures  of  the  capsule.  However,  there  was  a  quick  return  to  func- 
tion, and  the  patient  reports  at  this  time  a  very  good,  satisfactory  leg, 
with  110  degrees  of  motion. 

The  right  leg — operation  June  30th.  Here,  the  scars  and  adhesions 
between  the  thigh  and  quadriceps  group  were  so  great  that  it  was  only 
with  extreme  difficulty  that  we  were  able  to  detach  them  from  the  bone. 
The  tendons  had  to  be  freed  at  the  lateral  borders  of  the  vasti  and 
brought  anterior.     A  large  piece  of  fat  was  placed  under  the  newly 


LENGTHENING    OP    THE    QUADRICEPS    TENDON  295 

sutured  tendon,  and  a  great  deal  of  resistance  was  met  with  in  the  cap- 
sule. Adhesions  about  the  anterior  thigh  were  so  great,  and  the  tension 
of  the  skin  so  marked,  as  to  interfere  with  circulation.  It  was  necessary 
to  make  linear  incisions  either  side  of  the  patella  to  relieve  the  tension 
when  the  knee  was  flexed  at  an  angle  of  eighty  degrees.  The  post- 
operative notes  will  show  the  marked  ecchymosis  which  occurred  with  a 
slight  rise  of  temperature.  The  patient  went  on  to  an  uneventful  re- 
covery, with  rather  a  slower  return  to  power  than  in  the  former  operation. 
A  few  months  after  the  operation  he  was  able  to  walk  up  and  down 
stairs,  foot  over  foot,  as  a  normal  individual.  He  now  swims  and  leads 
an  athletic  life,  having  well  over  100  degrees  of  motion  in  both  legs. 

This  w^as,  in  my  opinion,  a  severe  test  case  for  this  operation,  for  this 
case  presented  contraction  of  the  muscles  from  long  immobilization, 
dense  adhesions  from  primary  plating  operation  and  suppuration,  and 
from  operation  for  the  removal  of  plate  and  freeing  of  adhesions.  The 
incision  of  the  latter  extended  from  the  middle  third  of  the  thigh  over 
the  external  condyle  and  across  the  patellar  tendon. 

This  may  seem  a  great  deal  of  detail  in  history,  but  a  careful  perusal 
of  such  detail  will  answer  questions  that  have  been  asked  on  many 
occasions. 

Case  No.  5.  Age  24.  White  male.  S.  M.  Admitted  to  Johns  Hopkins 
Hospital  October  15,  1919.    Discharged  November  30,  1919. 

Complaint:     Stiff  knee. 

Family  History:     Unimportant. 

Past  History:     Unimportant. 

Present  Illness:  On  June  25th,  1915,  patient  fractured  the  left  thigh 
in  an  automobile  accident.  The  fracture  was  about  six  inches  above  the 
level  of  the  knee.  Patient  did  not  know  whether  it  was  compound  or  not. 
Was  taken  to  a  hospital  shortly  after  accident,  traction  was  applied  for 
three  weeks,  and  then  an  open  reduction  was  done,  in  which  both  frag- 
ments were  plated.  Limb  was  put  up  in  full  extension  at  the  knee  in  a 
plaster  cast.  Six  months  after  this  all  immobilizing  agencies  were  re- 
moved and  massage  and  manipulation  were  begun.  At  first  manipulation 
was  mild  in  character,  but  later  more  violent.  Knee  did  not  yield  to 
treatment.  About  the  middle  of  October  of  1916,  an  operation  was  again 
performed  in  which  the  bone  plates  were  removed  in  the  hope  that  the 
adhesions  which  had  formed  around  them  would  be  sufficiently  relieved 
to  permit  flexion  at  the  knee.  This  operation,  however,  was  of  no  avail. 
With  the  exception  of  mild  manipulation  by  the  patient  himself,  nothing 
was  done  after  this  until  January  25th,  1918.  At  this  time  an  operation 
was  performed  by  Major at  the  Walter  Reed  Hospital  at  Washing- 


296 


GEORGE    E.    BENNETT 


Case  5.     S.  M.     Movement  in  knee  before  operation. 


ton,  D.  C,  the  operation  consisting  of  an  attempt  to  relieve  the  adhesions 
which  had  formed  about  the  fracture  and  the  removal  of  some  of  the 
extensive  callus  which  had  formed  about  the  point  of  union.  After  this 
operation,  the  patient  was  again  put  in  plaster  for  about  one  month. 
After  this,  manipulation  was  again  attempted,  with  the  result  that  about 
five  or  ten  degrees  of  motion  were  obtained.  Subsequent  to  this,  patient 
went  about  with  his  knee  practically  stiff.  No  further  attempts  at  cor- 
rection were  made.  It  is  noteworthy  that  following  the  operation  of 
January,  1918,  the  thigh  wound  became  infected,  with  subsequent  irri- 
gations with  Dakin's  solution  over  a  period  of  several  days.  Patient 
comes  in  for  operative  correction  of  the  deformity. 

Physical  Examination:  All  extremities,  bones  and  joints,  are  negative, 
except  for  the  left  leg,  upon  which  all  interest  centers.  The  left  leg  shows 
an  apparent  shortening,  with  some  slight  atrophy  and  a  scar  above  the 
knee  on  the  outer  side.  At  full  extension  the  knee  looks  almost  normal, 
although  there  is  not  the  usual  hollow  above  the  knee  in  front.  The 
patella  is  freely  movable.  All  muscles  seem  to  be  in  good  tone,  both  thigh 
and  calf.    On  motion,  flexion  at  the  knee  is  possible  only  20  degrees,  when 


LENGTHENING       I     THE    QUADRICEI'S    TENDON 


297 


the  tendon  tension  prevents  further  extension.  There  does  not  seem  to 
be  any  bony  ankylosis  or  any  bone  change  in  the  joint.  Above  the  knee 
at  the  scar  level  and  at  the  seat  of  the  old  fracture  there  is  a  bony  increase 
in  width,  almost  twice  normal.  The  quadriceps  tendon  is  tied  to  the 
scar  in  one  small  area.  Xo  pain  on  motion.  Flexion  beyond  20  degrees 
is  impossible  even  with  force. 

Operative  Note:  October  23,  1919.  Lengthening  of  quadriceps  tendon 
on  left  side  for  partial  ankylosis  of  the  knee  joint.  Iodine  skin  technique, 
patient  in  supine  position  on  table  permitting  flexion  of  the  knee  joint. 

A  longitudinal  incision  was  made  over  the  middle  of  the  anterior  aspect 
of  the  left  thigh,  reaching  from  above  the  middle  to  about  the  middle  of 
the  patella.  Skin  was  dissected  up  from  either  side  with  the  subcutane- 
ous fascia  so  as  to  expose  the  quadriceps  tendon  below.  The  rectus 
femoris  and  the  internal  and  external  vastus  muscles  were  laid  clear, 
together  with  the  insertion  into  the  upper  end  of  the  patella.  Flexion  of 
the  knee  joint  then  showed  clearly  that  the  restricting  bands  were  in  the 
region  of  the  vastus  externus.  An  incision,  therefore,  was  made  from  the 
outer  border  of  the  patella  upward  along  the  line  of  insertion  of  the 
vastus  externus  into  the  rectus,  so  as  to  separate  the  patella  from  the 
restricting  fibres.     Mild  efforts  at  manipulation  of  the  knee  joint  then 


Case  5.    S.  If.     Movement  in  knee  before  operation. 


298 


GEORGE    E.    BENNETT 


showed  considerable  resistance  to  flexion  on  account  of  contracture  of 
the  rectus  femoris  and  vastus  internus,  though  some  relaxation  was  ob- 
tained. The  incision,  therefore,  was  made  on  the  inner  aspect  of  the 
patella,  running  upward  along  the  course  of  the  insertion  of  the  internus 
to  the  rectus,  incision  running  up  the  attachment  of  the  tendon  to  the 
muscular  portion  of  the  muscle.  A  transverse  incision  then  connected 
the  blind  ends  of  the  lateral  and  median  incision  lines.  The  distal  por- 
tion of  the  rectus  femoris  was  dissected  up  from  the  bone  beneath  it  and 
reflected  back.  Flexion  was  then  made  and  the  knee  brought  through  an 
angle  of  somewhat  more  than  a  right  angle.  The  first  efforts  at  flexion 
after  the  muscle  had  been  cut  loose  were  met  with  considerable  resistance^ 


Case  5.    S.  M.    Forced  flexion  before  operation. 


LENGTHENING    OF    THE    QUADRICEPS    TENDON 


29<> 


apparently  due  to  internal  capsular  adhesions.  These  were  broken  as  the 
knee  was  bent,  and  the  upper  portion  of  the  capsule,  which  was  tacked 
down  to  the  femur,  seemed  definitely  to  pull  loose  from  the  bone  beneath 
it.  Apparently,  therefore,  the  entire  limitation  of  motion  could  not  be 
blamed  upon  the  muscular  tissue,  although  the  muscular  tissues  had 
brought  about  the  greater  element. 

The  knee  was  then  put  up  in  flexion  of  90  degrees,  the  quadriceps 
tendon  was  sewed  as  high  up  as  possible  with  this  ingle  to  the  vastus 
internus  by  means  of  kangaroo  tendon.  The  tendon  was  then  allowed  to 
resume  the  place  it  had  held  naturally,  and  the  lateral  border  of  it  sewed 
to  the  vastus  externus,  likewise  with  kangaroo  tendon.    A  gap  of  about 


Case  5.    S.  M.    Extension  before  operation. 


300 


GEORGE    E.    BENNETT 


Case  5.    S.  M.     End  result. 


U:\t.TIII.MNG    OF    THE    QUADRICEPS    TENDON  301 

one  inch  was  left  between  the  upper  end  of  the  tendon  and  the  lower  end 
of  the  rectus  muscle  from  which  it  had  been  severed.  Efforts  were  made 
to  occlude  this  gap  by  drawing  down  the  muscle  tissues  of  the  rectus  and 
by  pulling  together  the  vastus  externitt  and  interims.  The  subcutaneous 
tissues  were  then  closed  with  plain  eatgut  sutures  and  the  skin  closed 
with  sutures  of  fine  silk.  A  plaster  cast  was  then  applied  from  groin  to 
toes  with  the  knee  in  90  degrees  of  flexion.  Patient  lost  but  little  blood 
and  stood  the  operation  very  well. 

DISCUSSION. 

The  point  of  particular  interest  in  this  case  is  the  duration  from  the 
time  of  original  injury,  June  25th,  1915,  to  time  of  operation,  October 
23rd,  1919.  Patient  had  a  few  degrees  of  painless  motion.  Leg  had  been 
functioning  for  approximately  three  years.  Some  capsular  resistance 
was  met  with,  but  not  as  marked  as  in  cases  three  and  four.  Patient 
developed  a  post-operative  infection,  probably  due  to  the  lighting  of  a 
latent  infection  from  former  operation.  The  quadriceps  tendon  behaved 
very  much  as  one  would  expect  of  a  mildly  infected  tendon.  Patient  went 
on  to  an  uneventful  recovery,  and  at  the  time  of  leaving  our  care  had 
well  over  90  degrees  of  motion,  and  was  able  to  walk  up  and  down  stairs 
four  months  after  operation.  Since  that  time,  motion  has  increased  to 
extent  shown  in  illustration. 

Case  No.  6.  H.  W.  G.  Age  38.  White  male.  Admitted  to  Johns 
Hopkins  Hospital  October  14th,  1919.     Discharged  December  9th,  1919. 

Family  History:     Unimportant. 

Previous  History:     Unimportant. 

Present  Illness:  In  an  automobile  accident  April  26th,  1917,  sustained 
a  compound  fracture  of  the  right  and  left  leg  below  the  knee  (lower  third 
of  the  tibia  and  fibula).  June  9th,  1917,  had  operation  to  clear  up  in- 
fection and  adjust  fractures.  Several  small  detached  pieces  of  bone 
removed.  Following  this  the  leg  improved,  but  had  second  operation 
January  1,  1918,  for  removal  of  sequestrum  on  right  leg.  This  leg  has 
had  ulcerations  on  several  occasions  since.  Was  able  to  be  up  and  began 
to  walk  with  knees  stiff  about  August,  1918,  assisted  with  crutches.  Since 
this  has  had  massage,  etc. 

Physical  Examination:  Patient  has  a  marked  bowing  outward  of  both 
legs.  This  is  particularly  pronounced  on  the  left  side.  The  bowing  is 
found  chiefly  below  the  knee.  On  the  left  side,  the  joint  permits  of  about 
fifteen  degrees  of  flexion,  has  full  extension,  but  no  hyperextension.  No 
abnormal  lateral  mobility.     The  extremes  of  the  arc  of  motion  do  not 


302 


GEORGE    E.    BENNETT 


seem  to  be  caused  by  any  bone  limitation.  Palpation  of  the  knee  joint 
produces  no  pain,  nor  is  there  any  thickening  of  the  synovial  membrane. 
The  patella  slides  freely  over  the  joint  surface.  There  is  no  increase  in 
joint  fluid.  The  bones  of  the  leg  are  apparently  firmly  united  in  the 
position  of  varus  deformity,  the  skin  over  the  point  of  fracture  being  well 
healed. 

On  the  right  side  there  is  a  similar  picture  with  the  following  excep- 
tions :  45  degrees  of  flexion  is  permitted  and  the  bowing  is  less  marked. 
Over  the  middle  of  the  tibia  there  is  a  small  sinus  from  which  a  drop  or 
two  of  pus  exudes.    X-ray  examinations  of  both  knees  are  negative. 

Impression:  Contracture  of  the  peri-articular  structures  of  the  knees, 
as  a  result  of  abnormally  long  fixation  of  the  knee  joints  in  full  extension. 

Operative  Note:  October  15,  1919.  Lengthening  of  the  quadriceps 
tendon  for  contraction  with  immobilization  of  the  knee  joint,  left. 

Iodine  skin  technique.  A  longitudinal  incision  was  made  on  the  an- 
terior aspect  of  the  left  thigh  from  about  its  middle  to  the  middle  of  the 


Case  6.     K.  W.  G.     Flexion  before  operation. 


LENGTHENING    OP    THE    QUADRICEPS    TENDON 


303 


patella  below.  The  incision  was  deepened  to  expose  the  rectus  femoris 
muscle.  Later  dissection  then  facilitated  an  examination  of  the  vastus 
internus  and  externus.  The  knee  was  flexed  to  its  maximum,  and  the 
effect  of  this  flexion  was  noted  on  the  various  branches  of  the  quadriceps 
muscle.  Apparently  the  chief  restricting  factor  was  the  rectus  femoris. 
An  incision  was  then  made  transverse  to  the  rectus  femoris  tendon,  just 
at  its  point  of  insertion  into  the  patella,  cutting  the  tendon  in  its  entire 
width.  Longitudinal  incisions  were  then  made  from  either  end  of  this 
transverse  section  along  the  course  of  the  rectus  tendon  at  the  point  of 
insertion  of  the  vasti  into  this  tendon.  The  incision  was  carried  up  on 
the  thigh  for  a  distance  of  about  four  inches.  Forcible  flexion  then  per- 
mitted an  angle  of  90  degrees  to  be  obtained.  The  flexion  was  rather 
difficult  to  obtain,  apparently  due  to  adhesions  in  the  knee  joint  and  con- 
traction of  the  inner  band  of  the  vastus  externus.    To  relieve  some  of  the 


Case  6.    H.  W.  G.     Extension  before  operation. 


304 


GEORGE   E.    BENNETT 


tension  when  the  knee  was  flexed  at  right  angles,  the  fibres  of  this  re- 
stricting band  of  the  vastus  externus  muscle  were  cut  transversely  at  the 
proximal  portion  of  the  incision  made  previously.  With  the  knee  flexed 
nt  a  right  angle,  there  was  a  gap  left  between  the  insertion  of  the  patellar 
tendon  and  the  distal  cut  portion  of  about  two  inches.  To  cover  this  gap 
the  border  of  the  vastus  internus  and  externus,  which  had  been  cut,  were 
sewed  together  so  as  to  practically  obliterate  the  space  left  by  the  re- 
traction of  the  f  emoris.  The  rectus  f  emoris  in  its  new  position  was  sewed 
to  either  side  of  the  muscle  tissue,  the  entire  incision  line  being  joined 
to  the  adjoining  muscle  with  kangaroo  tendon.  The  fascia  was  then 
sewed  over  this  by  means  of  chromic  catgut,  the  subcutaneous  plain  catgut 
suture  line  was  inserted,  and  a  long  continuous  lockstitch  silk  suture 
completed  the  closure  of  the  skin. 

Post-operative  Note:    Plaster  was  removed  at  the  end  of  three  weeks. 
Patient  had  an  uneventful  post-operative  recovery.     Massage  was  insti- 


Case  G.    H.  W.  G.     Forced  flexion  before  operation. 


LENGTHENING    OP    THE    QUADRICEPS    TENDON 


305 


tuted  in  the  fourth  week.    Patient  was  discharged  on  December  9th  with 
60  degrees  of  painless  motion,  which  has  increased  to  90  degrees  since. 


discussion. 

This  case  shows  a  true  contraction  of  the  muscles  of  the  anterior  thigh, 
due  to  long  immobilization  in  full  extension  for  a  lesion  below  the  knee. 

Case  No.  7.  A.  L.  Age  21.  White  male.  Operated  on  at  Ruptured 
&  Crippled  Hospital,  New  York,  December  30,  1919. 

Family  History:     Unimportant. 

Past  History:  Pneumonia  when  two  years  old.  Diphtheria  when  eight 
years  old.  Following  diphtheria,  patient  developed  pain  in  right  thigh, 
which  continued  for  ten  weeks,  when  it  subsided,  not  to  return  until  a 
lapse  of  one  year.  Then  a  growth  developed  on  the  inner  aspect  of  the 
thigh  at  its  highest  point.    This  growth  was  about  the  size  of  an  orange. 


Case  6.    H.  W.  G.    Extension  bef< 


'ration. 


306 


GEORGE    E.    BENNETT 


After  a  year  this  tumor  ruptured  and  drained  for  a  whole  year.  In  1911 
patient  was  operated  on  and  about  forty-five  pieces  of  splintered  bone 
were  removed.  Six  weeks  later  was  discharged  from  the  hospital.  Two 
weeks  after  discharge  from  hospital  developed  pleuro-pneumonia,  which 
proved  severe.  Was  sick  for  six  weeks.  In  1912,  a  year  after  operation, 
there  was  a  discharge  at  the  site  of  tumor.  Since  then  there  has  been  no 
return  of  symptoms  in  thigh. 

Present  Illness:  On  October  26th,  1918,  without  apparent  cause, 
patient  had  pain  in  right  knee  and  leg  was  fixed  in  flexion.  Was  treated 
first  as  rheumatism.  Later  condition  was  diagnosed  as  septic  arthritis, 
and  treated  by  application  of  plaster  cast  and  extension  for  three  months. 
This  treatment  failed  to  give  the  desired  results  and  pain  and  stiffness 
remained.     Nothing  has  been  done  since,  but  patient  is  better  able  to 


Case  0.     H.  W.  G.     Flexion  after  operation. 


LENGTHENING    Of    THH    QUADRICKI^    TENDON 


307 


Case  7.     A.  L».     X-ray  taken  before  operation. 

get  around,  having  to  avoid  sudden  jars  or  becoming  fatigued.    Is  now 
admitted  for  forcible  correction  under  anesthesia. 

Physical  Examination:  Patient  admitted  without  apparatus,  walking 
with  a  stiff  knee  on  the  right  side. 

R.  A.,  38%.     R.  T.,  16%.     R.  K.,  13ji,  13^,  12%.     L.   A.,  38% 
L.  T.,  20y2.    L.  K.,  14,  14,  12%,    R.  C,  12%.    L.  C,  12%. 

Moderate  infiltration  about  the  right  knee  joint,  most  marked  in  the 
subcrural  pouch  about  the  patella.    The  patella  is  slightly  movable. 

A.  G.  F.,  165. 

A.  G.  F.,  160. 

With  this  amount  of  motion  there  is  no  pain  or  muscle  spasm.  The 
limitation  seems  to  be  a  mechanical  block.  The  x-ray  picture  shows 
thinning  of  the  cartilage  and  general  rarefaction  of  the  bones.  Slight 
thickening,  more  marked  on  the  inner  side  of  the  head  of  the  tibia  and 
condyles  of  the  femur.    No  erosion  of  the  joint  surfaces. 

Operative  Note:  November  10,  1919,  manipulation  under  anesthesia. 
Thirty  degrees  of  motion  obtained  followed  by  considerable  joint  reaction. 


30& 


GEORGE   E.    BENNETT 


Case  7.    A.  L.     End  result. 


LENGTHENING    OF    THE    QUADRICEPS    TENDON  309 

DISCUSSION. 

On  December  29,  1919,  patient  was  examined  by  the  author  and  was 
not  thought  to  be  a  suitable  case  for  operation,  as  it  was  the  author's 
opinion  that  there  was  an  active  arthritis.  The  point  was  brought  up 
1>\  Dr.  V.  P.  Gibney,  that  if  contraction  of  the  quadriceps  tendon  oc- 
curred from  immobilization  in  extension  from  fractures,  etc.,  the  same 
could  occur  from  immobilization  from  inflammatory  Lesion.  In  his 
opinion  there  was  no  active  arthritis  in  this  case. 

At  the  request  of  the  patient  a  lengthening  of  the  quadriceps  was 
done  on  December  30,  1919  (by  method  shown  in  cuts  demonstrating 
operation).  With  very  little  effort  the  knee  was  flexed  to  a  position  of 
90  degrees,  after  the  tendon  had  been  detached.  It  was  the  opinion 
of  the  author  at  this  time  that  a  violent  reaction  would  be  started  in 
the  knee  by  operation.  So  he  attempted  to  keep  on  the  safe  side  by 
sewing  the  tendon,  and  fixing  it  in  a  position  of  forty-five  degrees, 
instead  of  the  usually  eighty  degrees  of  flexion. 

At  the  request  of  the  author  an  early  inspection  of  the  leg  was  made 
and  passive  motion  begun.  The  author  was  surprised  to  hear  that  only 
a  moderate  joint  reaction  had  occurred.  Under  rather  vigorous  manipu- 
lation and  post-operative  treatment  this  patient  made  a  good  recovery, 
and  on  October  21,  1920,  has  approximately  ninety  degrees  of  painless 
motion  (as  shown  in  illustration)  and  walks  without  limp. 

This  case  demonstrated  clearly  the  two  points  made  by  Dr.  Gibney : — 
that  there  was  no  active  arthritis  in  this  case,  and  that  a  contraction  of 
the  anterior  thigh  group  is  sometimes  associated  with  immobilization 
from  inflammatory  disease  of  the  joint,  as  well  as  from  extra-articular 
lesions.  It  is  the  opinion  of  the  author  that  the  operation  should  not  be 
done  unless  one  is  sure  that  no  active  inflammation  is  present. 

Case  No.  8.  R.  C.  W.  Age  30.  White  male.  Admitted  to  Johns 
Hopkins  Hospital,  January  8,  1920.    Discharged  April  6,  1920. 

Family  History:     Unimportant. 

Past  History:     Unimportant. 

Present  Illness:  October  15,  1918,  was  struck  in  the  right  hip  with 
a  piece  of  high  explosive  shell  and  sustained  a  fracture  of  the  ilium  and 
anterior  hip  joint.  Was  operated  on  twenty  hours  later  and  foreign 
bodies  removed.  December,  1918,  operation  on  the  right  hip  joint  with 
immobilization.  At  this  time  there  was  no  evidence  of  any  lesion  about 
the  knee  joint  or  foot.  Leg  immobilized  in  plaster  which  was  removed 
on  February  15th,  with  many  excoriations — knee  stiff  and  foot  drop. 


310  GEORGE    E.    BENNETT 

Thomas  splint  was  then  applied  for  a  period  of  four  weeks,  followed 
by  second  immobilization  in  plaster.  During  this  time  there  was  con- 
siderable  discharge  from  the  hip  joint.  In  May,  1919,  several  abscesses 
were  opened  down  the  thigh  extending  to  a  few  inches  above  the  knee. 
Hip  joint  and  all  draining  sinuses  were  cleared  up  by  July  10,  1919, 
leaving  a  painful  knee  joint  and  toe  drop. 

Physical  Examination:  Patient  complains  of  stiff  knee  and  hip.  The 
right  hip  is  absolutely  ankylosed  in  full  extension,  in  neither  abduction 
or  adduction,  and  in  neutral  position  as  far  as  rotation  is  concerned. 
There  are  numerous  scars  of  old  incisions  about  the  hip.  One  of  these 
over  the  front  of  the  thigh  seems  to  be  attached  to  the  bone  at  about 
the  level  of  the  junction  of  the  middle  and  lower  thirds.  The  knee 
joint  is  likewise  in  full  extension,  but  permits  of  a  few  degrees  of  flexion, 
so  as  to  rule  out  bony  ankylosis.  Passive  flexion  stops  when  the  tissues 
below  the  scar  mentioned  become  taut.  Active  efforts  at  extension  are 
likewise  visibly  embarrassed  by  the  attachment  of  the  quadriceps  at  the 
scar.  Palpation  of  the  knee  joint  reveals  considerable  tenderness  to  pres- 
sure over  the  anterior  portion  of  the  internal  semilunar  cartilage.  No 
abnormal  lateral  mobility  is  obtained.    The  patella  is  freely  movable. 

Neurological  note.     January  10,  1920. 

Apparently  the  ham  string  muscles  are  active.  Internal  stronger  than 
the  external.  Below  the  knee  the  calf  muscles  act  strongly  in  extension. 
Can  flex  the  ankle  with  fair  strength.  No  evidence  that  the  popliteal 
muscles  are  active.  No  movement  of  the  great  toe  on  extension.  Ankle 
reflex  active.  There  seems  to  be  some  numbness  over  the  dorsum  of  the 
right  foot.    Nowhere  is  there  absolute  loss  of  sensation. 

Impression:  Case  impresses  me  as  a  recovering  pressure  paralysis  of 
the  external  popliteal  nerve. 

Operative  Note:  Lengthening  of  the  quadriceps  tendon  for  loss  of 
motion  in  the  right  knee. 

Iodine  skin  technique.  An  anterior  longitudinal  incision  was  made  on 
the  right  thigh  from  its  middle  third  to  the  knee  joint,  and  deepened  to 
expose  the  quadriceps  tendon.  The  skin  and  subcutaneous  layers  were 
then  dissected  up  to  either  side,  so  as  to  show  the  superficial  component 
parts  of  the  muscle  at  their  tendinous  insertions.  The  rectus  f  emoris  was 
cut  transversely  at  its  point  of  union  with  the  tendon,  the  ends  of  the 
incision  being  carried  down  to  the  patella  on  their  respective  sides,  in 
such  a  way  as  to  sever  the  connection  of  the  tendon  from  the  vasti 
muscles.  The  tendinous  flap  was  dissected  up  from  the  underlying 
bone  to  the  level  of  the  upper  part  of  the  patella.    Very  little  force  was 


LENGTHENING    OF    THE    QUADRICEPS    TENDON  311 

thru  needed  to  flex  the  knee  joint,  but  in  doing  this  the  capsule,  which 
was  very  adherent,  was  torn.  After  the  first  manipulation  was  made 
the  normal  movements  of  the  knee  from  full  extension  to  almost  70  de- 
grees of  flexion  were  obtained  freely.  Considerable  bleeding  from  the 
capsule  was  encountered  The  knee  was  held  flexed  80  degrees  and  the 
patellar  tendon,  being  drawn  up  as  far  as  possible  in  flexed  position, 
was  resutured  to  the  vasti  with  kangaroo  tendon.  The  gap  left  between 
the  upper  end  of  the  tendinous  Hap  and  the  rectus  femoris,  about  an 
Inch  Long,  was  closed  by  drawing  together  t he  lateral  borders  and  sutur- 
ing them  with  kangaroo  tendon.  Subcutaneous  layers  were  then  closed 
with  plain  catgut  and  skin  with  silk.  A  plaster  knee  cast  was  applied 
with  the  leg  in  80  degrees  of  flexion.  The  patient  lost  a  fair  amount  of 
blood,  but  stood  the  operation  well. 

DISCUSSION. 

The  notes  on  this  case  are  of  particular  importance,  since  this  case 
marks  a  failure.  The  clinical  and  X-ray  examinations  showed  definite 
knee  joint  changes,  with  some  local  reaction  in  the  knee,  at  the  time 
of  operation.  This  young  man  was  in  such  a  pitiable  condition,  with  an 
ankylosis  of  the  hip,  only  a  few  degrees  of  motion  in  the  knee,  and  an 
external  popliteal  paralysis,  that  an  attempt  was  made  to  relieve  the 
evident  adhesions  in  the  thigh.  His  post-operative  findings  show  that 
we  had  irritated  an  inflamed  joint,  and  caused  marked  reaction,  with 
the  result  that  at  the  present  time  he  has  30  degrees  of  painful  motion. 
In  post-operative  treatment  he  sustained  a  fracture  through  the  con- 
dyles due,  probably,  to  rather  vigorous  massage  to  a  joint  that  had  not 
functioned  in  fifteen  months  and  was  very  atrophic. 

I  believe  the  reporting  of  this  case  to  be  as  important  as  any  of  the 
series,  and  hope  that  perhaps  the  report  will  prevent  others  from  at- 
tempting an  operation  of  this  type  on  very  atrophic  and  actively  inflamed 
joints. 

SUMMARY. 

Certain  rather  definite  findings  are  to  be  noted.  First: — contraction 
of  the  quadriceps  without  adhesions  will  produce  a  loss  of  function  of 
the  knee. 

Second: — contraction  and  adhesion  between  the  muscles  themselves, 
or  between  muscle  and  bone,  will  produce  loss  of  flexion  of  the  knee. 

Third: — the  capsular  changes  are  not  as  constant  a  finding  as  the 
muscular  changes.  Knee  joints  that  cannot  be  forcibly  flexed  before 
the  releasing  of  the  tendon  can  be  easily  flexed  afterwards. 


312  GEORGE   E.    BENNETT 

Fourth : — contraction  of  the  muscular  tissue  following  long  immobili- 
zation for  inflammatory  knee  joint  disease,  probably  is  present,  but  it  is 
rot  advisable  to  operate  in  the  presence  of  a  sensitive  joint. 

Time  is  an  important  factor.  It  is  better  to  operate  on  a  patient  who 
has  walked  for  five  years  with  ten  degrees  of  motion,  than  on  one  who 
has  walked  for  five  months  with  thirty  degrees  of  motion.  In  the 
former,  joint  and  muscle  tissue  are  in  good  tone:  therefore,  they  lend 
themselves  better  to  operation  and  they  return  to  function  much  more 
rapidly. 

DESCRIPTION    OF    OPERATION. 

Patient  should  be  placed  in  a  position  to  allow  free  movement  of  the 
leg,  and  to  permit  flexion  to  100  degrees.  This  can  be  most  easily 
accomplished  by  extending  the  leg  over  the  end  of  the  operating  table. 

A  straight  incision  is  made  on  the  anterior  surface  of  the  thigh, 
extending  from  the  middle  of  the  patella  to  approximately  the  junction 
of  the  central  and  lower  thirds  of  the  femur,  passing  through  the  sub- 
cutaneous tissue  and  fascia.  A  lateral  blunt  dissection  gives  an  expo- 
sure of  the  vasti,  the  attachment  of  the  rectus,  and  the  capsule  of  the 
knee  joint.  If  adhesions  are  present,  exposure  should  extend  to  a 
point  at  least  two  inches  above,  permitting  a  thorough  inspection  of  the 
entire  field. 

When  dealing  with  a  simple  contraction  not  associated  with  adhesions 
of  the  tendon  and  muscle  to  the  femur,  only  the  tendinous  section  is 
cut  free  from  its  muscular  attachments.  This  is  accomplished  by  a 
linear  incision  on  each  side  of  the  tendon,  extending  from  the  attachment 
of  the  rectus  femoris  to  the  patella,  following  closely  to  the  muscle 
margin,  and  broadening  at  the  patella,  leaving  its  normal  strong  attach- 
ment at  this  point.  These  parallel  incisions  should  be  deep  enough  to 
include  the  tendinous  section  of  the  vastus  intermedins  (crureus)  (see 
Fig.  No.  I).  These  are  connected  by  a  short  incision  and  the  entire 
tendon  is  dissected  free  from  the  underlying  structures,  from  the  rectus 
to  the  patella  (Fig.  II.)  With  the  tendon  completely  detached  from 
its  muscular  attachments,  the  knee  is  carefully  flexed,  cutting  any  ad- 
herent points  in  the  capsule,  or  about  the  lateral  margin  of  the  knee. 
Flexion  is  carried  to  a  point  of  at  least  ninety  degrees.  The  leg  is 
then  brought  to  a  position  of  eighty  degrees  of  flexion,  and  the  tendon 
re-attached  to  its  muscle  at  this  level,  as  shown  in  Fig.  Ill,  by  means 
of  kangaroo  tendon  or  heavy  braided  silk. 


LENGTHENING    OP    THE    QUADRICEPS    TENDON 


313 


FIG.  I. 


In  the  presence  of  marked  adhesions  in  the  lower  thigh,  it  may  be 
necessary  to  dissect  the  vasti  free  from  the  femur,  thus  permitting  them 
to  be  drawn  toward  the  median  line,  and  attached  to  the  tendon.  If 
necessary,  fascia  or  fat  can  be  placed  between  the  bone  and  the  muscular 
structures.  With  the  tendon  in  its  new  position,  a  space  is  open  at  the 
lower  end  of  the  rectus  (Fig.  IV).  This  is  closed  by  mattress  suture 
through  the  vasti. 

The  operation  as  above  described  has  been  modified  by  attaching 
the  muscle  to  the  tendon  at  different  levels,  and  by  utilizing  the  tendon 


314 


GEORGE    E.    BENNETT 


Fig.  II. 


fibres  of  the  rectus  to  fill  in  the  space  mentioned  above.  But  this  com- 
plicates the  operation  and  does  not  hasten  the  convalescence  or  improve 
the  end  result.  However,  occasionally  one  finds  a  rectus  tendon  that 
is  independent  until  it  reaches  a  point  about  one  inch  above  the  patella, 
where  it  becomes  a  part  of  the  quadriceps.  When  this  occurs,  it  is  well 
to  cut  it  free  at  its  lowest  point,  retract,  and  proceed  with  the  operation 
as  described.  After  the  lengthening,  the  rectus  tendon  is  then  attached 
to  the  quadriceps.  The  fasciae  are  closed  with  catgut  and  non-absorbable 
skin  suture.  Plaster  of  Paris  is  used  to  immobilize  in  a  position  of  eighty 
degrees  of  flexion  for  a  period  of  three  weeks.    The  plaster  dressing  is 


LENGTHENING    OP    THE    QUADRICEPS    TENDON 


315 


Fig.  III. 


then  cut,  removing  the  upper  half,  and  passive  motion  is  begun.  Gradual 
passive  extension  of  the  knee  is  then  begun  during  the  day,  and  the 
knee  is  placed  back  in  the  splint  in  its  flexed  position  at  night.  At  the 
end  of  the  fourth  week  the  author  encourages  active  contraction  of  the 
muscles  with  the  leg  held  firmly  in  an  extended  nosition.  In  mild  cases 
active  use  of  the  leg  during  the  fifth  week  is  advised,  and  the  patient  is 
encouraged  to  walk  with  crutches  and  bend  the  knee  to  its  full  extent, 
out  not  to  place  any  weight  on  it.  Active  extension  of  the  knee  when  in 
a  standing  position  is  also  encouraged,  but  care  should  be  used  in  the 
effort  to  extend  the  leg  when  in  a  sitting  position.  Massage  is  usually 
begun  at  the  end  of  five  weeks,  but  should  be  mild  until  all  of  the  acute 
trauma  has  subsided. 

A  common  post-operative  finding  is  an  extreme  degree  of  ecchymosis 
on  a  part  or  the  entire  anterior  thigh.    Particularly  is  this  true  in  the 


316 


GEORGE   E.    BENNETT 


Fig.  IV. 


cases  with  adhesions  as  well  as  contraction.  No  skin  necrosis  has  oc- 
curred in  any  of  the  cases. 

The  return  of  power  to  extend  the  leg  to  a  normal  position  is  slow, 
particularly  the  last  fifteen  degrees,  and  in  some  instances  was  not 
accomplished  until  a  year  after  the  operation.  The  quadriceps  tendon 
often  cannot  be  palpated  for  two  or  three  months,  but  gradually  fills  in 
and  becomes  normal  in  size. 

Since  the  writing  of  this  paper,  approximately  one  year  ago,  the 
author  has  operated  on  four  additional  cases,  all  of  which  have  recovered 
with  not  less  than  ninety  degrees  of  motion. 


BONE   PEGS,   BONE  SCREWS,   ETC.  317 


PRACTICAL  THOUGHTS  ON  BONE  PEGS,  BONE  SCREWS,  ETC. 

IIAKVKY    (.    MAH.AND,    M.D.,    PHILADELPHIA. 

Recent  literature  relating  to  bone  screws  and  bone  pegs  inclines  me 
to  believe  that  certain  practical  principles  underlying  their  use  have  not 
been. appreciated.  There  is  indication  that  operators  are  having  diffi- 
culty in  the  easy  utilization  of  these  valuable  aids.  Their  inability  to 
make  and  use  pegs  and  screws  quickly,  easily,  and  with  perfect  certainty 
of  accomplishment  has  delayed  the  recognition  of  the  fact  that  pegs 
and  screws  are  the  logical  and  the  best  binding  material  we  have  in  the 
vast  majority  of  cases  for  plastic  bone  work. 

In  my  experiments  in  the  cutting  of  small-diametered  pins  I  quickly 
found  that  the  high  speed  universal  motors  burned  and  burnished  all 
the  pins  made.  The  dowelling  tools  commonly  used  have  numerous 
shallow  cutters.  These  quickly  choke,  then  chafe,  with  the  result  that 
seventy-five  per  cent,  of  the  bone  pins  are  broken  in  the  making. 

I  substitute  a  low  speed  selective  current  motor.  Instead  of  the  four- 
teen cutters  on  the  dowelling  tool  I  use  three.  This  combination  will  cut 
a  bone  cylinder  one  and  a  half  inches  long  in  a  few  seconds  with  no 
heat,  binding,  or  breaking. 

In  the  making  of  bone  screws  the  gauge  of  the  tools  that  are  correct 
in  a  machine  shop  for  metal  is  worthless.  It  is  not  practical  to  attempt 
to  cut  on  bone  as  deep  and  clean  a  thread  as  can  be  made  on  iron.  Unless 
such  a  thread  be  cut  in  successive  stages  the  bone  will  inevitably  break. 
Further,  such  a  screw  is  difficult  to  turn  into  a  threaded  bone  hole  with- 
out binding  and  breaking.  I  made  my  dowelling  tool  of  such  a  gauge 
that  the  die  will  cut  a  sufficiently  deep  thread  by  hand.  By  hand  this 
screw  can  be  turned  into  a  threaded  hole  and  have  sufficient  bite  to  hold 
rigidly  for  all  practical  purposes.  The  head  of  the  screw  is  nothing  but 
the  rough  uncut  end  of  the  bone  pin.  With  the  fingers  or  a  hemostat 
it  can  be  handled  both  in  its  manufacture  and  its  use.  One  bone  screw 
one  and  a  half  or  one  and  three-quarter  inches  long  is  sufficient  for  four 
holes.  It  is  turned  through  the  compact  layers  of  the  first  holes,  cut  off 
flush  and  so  utilized  for  the  remaining  holes. 

There  are  certain  underlying  principles  that  should  decide  us  as  to 
whether  bone  screws  or  bone  pins  should  be  used.  It  might  be  put  in  the 
form  of  a  general  statement  that  where  the  strain  is  along  the  line  of 
insertion  a  bone  screw  should  be  used.     Where  the  strain  comes  at  an 


318 


HARVEY    C.    MASLAND 


Fig.  1. — The  point  of  the  bone  strip  placed  in  the  bore  of  the  dowelling  tool. 
Start  the  point  right  to  make  a   true  cylinder. 


Fig.  2. — Cutting  a  thread  on   a  bone  pin.     Fresh  bone  is  less  likely  to  chip. 


angle  a  bone  pin  is  most  practical.  Where  a  bone  plate  is  applied  after 
the  Lane  method  bone  screws  should  be  used.  In  a  bevelled  slide  graft, 
however,  the  drill  should  be  directed  to  catch  the  margin  of  the  graft 
and  penetrate  the  compact  bone  of  the  shaft  to  be  plated  at  a  transverse 


BONE   PEGS,   BONE  SCREWS,  ETC. 


319 


Fig.  3, 


-The  bone  pin  is  engaged  in  the  chuck  tool  and  can  be  filed  down  to  any 
desired  diameter. 


Fig.  4. — A,  Bone  plate  and  bone  screws  holding  fracture.  B,  Slide  graft  with 
appropriately  reduced  bone  pins  obliquely  placed  at  the  margins  of  the  graft. 
1,  bone  screws.    2,  bone  pins. 

oblique  angle.  The  bone  pin  need  be  just  a  snug  fit  under  such  condi- 
tions. Pressed  into  place  by  hand  the  cross  strain  against  it  will  hold 
it  and  the  graft  in  place. 

The  dowelling  tool  in  my  equipment  makes  a  pin  that  allows  for  a 
thread  and  would,  therefore,  be  too  large  for  the  drill  that  makes  a  hole 
requiring  a  mating  thread.  To  make  the  pins  fit  the  hole  made  by  the 
drill  the  bone  pin  is  fitted  into  the  chuck  tool  and  while  rotated  by  the 
motor  is  filed  down  to  the  diameter  desired. 

This  ability  to  turn  the  bone  pins  down  to  any  smaller  diameter  is 
valuable  where  we  have  the  smaller  bones  of  the  limbs  to  operate  upon. 
One  would  not  use  the  same  size  bone  pins  in  plating  an  ulna  that  he 
would  use  for  a  femur. 


320  HARVEY    C.    MASLAND 

In  the  tool  holder  which  I  use,  drills,  taps  and  dies  of  varying  diam- 
eters can  be  procured  from  the  nearest  hardware  store.  These  unnick- 
elled  tools  are  really  superior  cutters  in  that  their  edges  have  not  been 
dulled  by  the  deposit  of  nickel.  Quick  drying  and  oiling  is  all  that  the 
unnickelled  tool  needs  to  preserve  it  a  better  instrument.  I  would  em- 
phasize here  the  necessity  of  requiring  of  the  nurse  proper  after  care  of 
bone  instruments.  Some  of  the  tools  are  expensive.  Incomplete  drying 
and  oiling  will  in  a  short  time  damage  an  instrument  that  should  last 
indefinitely. 

The  objection  will  be  raised  that  this  class  of  bone  work  is  nice  theo- 
retically but  is  not  practical.  This  is  because  we  have  not  submitted 
ourselves  to  learn  the  practical  way.  It  is  surprising  how  quickly  these 
things  can  be  done  at  the  operating  table  with  a  proper  equipment  and 
the  acquisition  of  the  necessary  technique.  In  this  connection,  however, 
I  feel  that  the  making  of  bone  pins  or  screws  at  the  time  of  operation  is 
quite  unnecessary.  I  look  upon  bone  pins  and  screws  solely  in  the  light  of 
suture  material.  There  is  no  valid  reason  why  they  cannot  be  hetero- 
genous. One  can  make  a  supply  of  beef  bone  screws  and  pins  of  varying 
diameters  and  threads  at  his  leisure.  This  is  a  saving  of  time  and  of 
autogenous  bone.  These  can  be  cleaned,  boiled,  and  kept  sterile  until 
needed. 

Finally,  the  different  power  equipments  now  supplied  offer  varying 
degrees  of  facility  in  operation,  but  none  of  them  should  be  used  till  the 
operator  learns  how  to  use  them.  Those  who  are  willing  to  learn  how  to 
use  and  how  to  care  for  these  modern  equipments  will  be  amply  repaid 
in  the  increased  facility  at  operation  and  the  quality  of  the  work 
performed. 


THE  STANDARD  PLASTER   BANDAGE  321 

THE    STANDARD   PLASTER    BANDAGE. 

BY   WILTON   H.    ROBINSON,    M.D.,   PITTSBURGH. 

When  applying  a  plaster  cast  one  wishes  it  to  look  well  and  to  be 
efficient.  With  other  minor  considerations,  it  should  be  of  an  even 
thickness  throughout  (except  at  those  places  where  it  is  reinforced) 
and  all  layers  should  cohere  closely.  It  is  difficult  to  obtain  these  two 
most  important  considerations  unless  the  bandages  are  properly  made. 
It  seems  to  the  writer  that  a  very  important  factor  in  consistent  plaster 
work  is  uniformity  of  the  bandages  used.  This  uniformity  may  be 
obtained  and  maintained  by  the  occasional  use  of  a  scale  to  weigh  the 
completed  bandages.  It  is  not  necessary  to  weigh  each  bandage,  as  the 
person  doing  this  work  easily  becomes  familiar  with  the  standard  band- 
age in  each  size.  Any  scale  which  has  a  capacity  of  from  one  to  six- 
teen ounces  will  do. 

The  following  table  of  lengths  and  weights  has  been  found  satisfac- 
tory : — 

Two  inches  wide  by  one  yard  long  should  weigh  two  ounces. 

Four  inches  wide  by  four  yards  long  should  weigh  eight  ounces. 

Six  inches  wide  by  four  yards  long  should  weigh  ten  ounces. 

Each  bandage  is  wrapped  in  a  paper  napkin,  except  the  two-inch 
size,  for  which  one-quarter  napkin  is  sufficient. 


'V22  BEVERIDGE  H.  MOORE 

A  CASE  OF  SPONTANEOUS  FRACTURE  OF  THE  TRANS- 
VERSE PROCESS  OF  A  LUMBAR  VERTEBRA— DUE  TO 
TUBERCULOSIS. 

BY    BEVERIDGE    H.    MOORE,    M.D.,    CHICAGO,    ILLINOIS. 

The  following  case  presents  unusual  features  which  seem  to  justi- 
fy reporting  it. 

H.  McC,  negro,  male,  aged  27  years,  was  first  seen  at  the  Ortho- 
pedic Clinic  at  Northwestern  University  Medical  School,  on  Novem- 
ber 29,  1920.  His  complaint  was  pain  in  the  left  thigh  and  lumbar 
region.  It  had  come  on  suddenly  about  four  months  previously  while 
he  was  doing  some  light  work  at  a  grinding  machine.  There  had  been 
no  unusual  strain  nor  could  he  recall  any  trauma. 

The  pain  at  the  onset  was  so  severe  that  he  was  unable  to  stand 
or  walk,  but  this  severe  pain  gradually  left,  and  was  replaced  by  a 
dull  aching  pain  which  had  persisted.  A  few  weeks  after  the  onset, 
he  noticed  that  the  left  thigh  and  leg  were  becoming  weaker  than 
the  right,  and  he  thought  they  were  "falling  off"  in  size. 

The  pain  complained  of  radiated  down  the  inner  side  of  the  thigh 
to  the  knee.  Walking  or  stooping  caused  severe  pain  to  shoot  down 
the  thigh. 

The  family  history  and  previous  history  were  unimportant.  He 
had  lost  some  weight  but  had  had  no  night  sweats  or  cough. 

Examination  showed  a  muscular  young  negro. 

The  spine  showed  the  normal  antero-posterior  curves.  In  the  left 
lumbar  muscles  there  was  a  swelling  near  the  spinous  processes,  which 
gave  deep  fluctuation  but  was  only  slightly  tender.  There  was  no 
local  heat.     No  spasm  of  these  muscles  was  present. 

The  entire  spine  showed  a  slight  list  to  the  right. 

Forward,  backward,  and  lateral  bending  all  caused  severe  pain 
which  radiated  down  the  thigh.  Lateral  bending  to  the  right  caused 
specially  severe  pain. 

Both  hips  and  knees  showed  normal  motion,  passively.  Active  flex- 
ion of  the  left  hip,  especially  acanist  some  resistance,  caused  severe 
pain  both  in  the  back  and  the  thigh. 

The  left  thigh  was  one  inch  smaller  than  the  right  and  the  calf 
was  %  inch  smaller  than  the  right.  There  was  decidedly  less  strength 
in  the  muscles  of  the  left  thigh  and  leg. 

X-ray  showed  the  entire  transverse  process  on  the  left  side  of  the- 
third  lumbar  vertebra  separated  from  the  vertebral  body  and  lying 
about  1  cm.  from  it.  The  bodies  of  the  vertebrae  and  the  interverte- 
bral discs  appeared  entirely  normal. 

The  patient  was  referred  to  Cook  County  Hospital,  where  he  was- 
admitted  to  the  Orthopedic  Service  on  December  8,  1920. 

The  swelling  in  the  lumbar  region  had  increased  somewhat  in  size 
and  was  more  fluctuant.     It  was   aspirated  and  a  thin  grayish  pus. 


A    SPONTANEOUS    FRACTURE 


323 


Showing  abscess   pointing   in   left   lumbar   region,   and   atrophy   of   left   thigh. 


X-ray  tracing  showing  detached   transverse  process  of  third  lumbar  vertebra. 


324  BEVERIDGE    H.    MOORE 

containing  floceulent  material  was  removed.     This  was  sterile  on  cul- 
ture, and  a  guinea-pig  was  inoculated. 

The  abscess  was  opened  and  drained.  The  transverse  process  was 
found  lying  free  in  the  abscess  cavity  and  was  removed. 

The  appearance  of  the  pus  in  the  abscess  cavity  was  typically  tu- 
berculous. 

After-  the  removal  of  the  bone  fragment  and  the  evacuation  of  the 
abscess  the  leg  pains  ceased.  A  sinus  opened  in  about  three  weeks 
which  drained  profusely. 

Later  the  patient  began  to  lose  weight  and  developed  signs  of  a 
generalized  miliary  tuberculosis. 

He  died  on  March  31,  1921. 

Autopsy  was  performed  by  Dr.  D.  J.  Davis,  on  April  5,  1921. 

There  was  a  marked  miliary  tuberculosis  of  nractically  all  the 
internal  organs.  The  lungs,  liver,  spleen,  adrenals,  kidneys,  pancreas, 
peritoneum,  and  brain  showed  miliary  tubercles  and  caseous  nodules. 

The  bodies  of  the  third  and  fourth  lumbar  vertebras  showed  con- 
siderable necrosis,  and  appeared  to  be  full  of  minute  foci  which  had 
not  yet  coalesced.  The  first  and  second  vertebrae  showed  the  same 
process  but  in  a  less  advanced  stage. 

The  sinus  in  the  lumbar  region  was  characteristically  tuberculous, 
with  its  base  at  the  root  of  the  affected  transverse  process. 

Sections  of  the  bone  were  characteristic  of  tuberculosis. 

It  seems  fair  to  conclude  that  the  primary  bone  focus  in  this  case 
was  in  the  transverse  process,  since  this  lesion  was  much  more  ad- 
vanced than  the  process  in  the  vertebral  bodies. 

The  weakened  process  probably  gave  way  under  some  slight  mus- 
cular strain. 

Tubby,  in  his  book  on  "Deformities,"  speaks  of  the  transverse 
processes  being  a  rare  location  of  the  tuberculous  process  but  he  does 
not  cite  any  cases. 

Speed,  in  his  book  on  ' '  Fractures, ' '  cites  several  cases  of  fracture 
of  the  transverse  processes.  These  were  all,  except  one,  due  to  mus- 
cular action,  but  no  mention  of  any  previous  pathological  process  in  the 
bone  is  made. 

The  symptoms  are  easily  accounted  for  on  an  anatomical  basis. 

The  radiation  of  the  pain  to  the  thigh  and  knee  is  due  to  pres- 
sure either  of  the  fragment  or  of  the  abscess  on  the  obturator  nerve, 
which  takes  its  principal  origin  from  the  third  lumbar  nerve. 

The  pain  on  flexion  of  the  hip  is  probably  due  to  the  action  of  the 
psoas  muscle,  which  has  one  origin  from  the  transverse  processes  of 
the  lumbar  vertebrae. 

While  rare,  tuberculosis  is  a  condition  to  be  considered  in  frac- 
tures of  the  transverse  processes.  Aspiration,  in  the  cases  which  show 
fluctuation,  is  useful  in  differentiating  between  hematoma  and  abscess. 


SUBASTRAGALOID    EXTERNAL    DISLOCATION  325 

SUBASTRAGALOID   EXTERNAL   DISLOCATION. 

BY   ELLIS   JONES,    M.D.,   LOS   ANGELES,   CALIFORNIA. 

Lateral  subastragaloid  luxations  of  the  foot  to  the  outer  side  are 
not  common.  A  review  of  the  literature  indicates  that  their  pathologi- 
cal anatomy  has  been  reconstructed  for  the  most  pari  Ml  the  bi 
of  the  clinical  findings,  and  it  is  not  surprising,  therefore,  that  the 
mechanism  of  this  displacement  is  disputed  and  the  causes  of  its  ir- 
reducible behavior  are  variously  explained. 

Recent  textbooks  on  fractures  and  dislocations  make  bare  mention 
of  the  subject.  To  Verneuil,1  Poinsot,2  Quenu,3  Broca,4  Malgaigne,"* 
Nelaton,6  Cowell,7  Kaufmann,8  Deetz,9  Thienhaus,10  and  Lossen11  the 
student  is  referred  for  modern  light  on  an  ancient  subject.  Quenu 
ascribed  a  failure  of  reduction  to  the  interposition  of  an  intact  an- 
nular ligament  between  the  articular  cavity  and  the  head  of  the  as- 
tragalus. Cowell  explained  the  mechanism  of  the  dislocation  as  being 
identical  with  the  ordinary  Pott's  fracture.  Pick12  ascribed  the  dif- 
ficulty of  reduction  to  displacement  of  one  or  the  other  of  the  tibial 
tendons  behind  the  neck  of  the  astragalus. 

Broca  and  Poinsot  collected  twenty-three  simple  cases  of  all  types 
of  subastragaloid  dislocations  in  which  reduction  was  attempted.  Re- 
duction was  successfully  accomplished  in  fourteen,  and  the  ultimate 
result  was  good ;  in  two,  the  reduction  was  incomplete,  and  one  of  these 
died  of  septicaemia.  There  were  four  secondary  amputations  with 
three  deaths,  three  secondary  removals  of  the  astragalus  with  one  death, 
and  one  good  functional  result,  notwithstanding  the  persistence  of  the 
deformity. 

In  seven  additional  cases  in  which  reduction  was  not  attempted,  four 
of  the  patients  had  apparently  good  function.  In  one  case  reduction 
was  made  after  six  months;  in  two  cases  the  disability  was  such  that 
the  patient  sought  relief;  Sinnigen13  removed  the  astragalus  and  ex- 
ternal malleolus,  and  at  the  time  of  the  report  death  by  septicaemia 
was  expected;  Raffa14  chiselled  away  the  head  and  the  neck  of  the 
astragalus  and  was  then  able  to  straighten  the  foot;  recovery  without 
suppuration ;  good  result. 

In  two  cases  primary  excision  of  the  astragalus  was  done  with  good 
results.  In  Verneuil 's  there  was  fracture  of  the  astragalus  and  rup- 
ture of  the  peroneal  artery;  in  Ore's15  an  attempt  to  reduce  had  failed 
and  gangrene  of  the  tense  skin  was  imminent. 

Of  compound  dislocations  seventeen  cases  were  collected  by  Broca  and 
six  additional  by  Poinsot  in  1884;  and  to  these,  two  cases  reported  by 
Jackson10   and   Stimson17   are  to  be  added.     Of  these,   reduction    was 


326  ELLIS   JONES 

made  in  eleven,  with  two  deaths,  with  persistent  suppuration  in  two, 
and  with  secondary  removal  of  the  astragalus  in  one.  In  fourteen  re- 
duction was  not  made ;  in  three  of  these  primary  amputation  was  done, 
in  ten,  removal  of  the  astragalus,  with  two  deaths,  and  in  one  the 
head  of  the  astragalus  became  necrosed  and  was  spontaneously  extruded, 
the  patient  recovering.  The  results  of  primary  removal  of  the  as- 
tragalus are  rather  better  than  those  of  reduction,  but  the  value  of 
these  statistics  as  a  basis  for  the  choice  of  a  method  of  treatment  has 
been  greatly  diminished,  as  Stimson  suggests,  by  the  improvement  in 
the  methods  of  treatment  of  open  wounds  that  has  taken  place  in  the 
last  few  years. 

More  recently  (1913)  Viannay18  and  Fayard19  observed  two  cases 
of  subastragaloid  luxation  of  the  foot  outward.  In  the  first  case  an 
astragalectomy  was  required  on  account  of  the  irreducible  character 
of  the  lesion.  In  the  other  case  reduction  was  obtained  on  the  day 
of  the  accident  by  manipulation  so  planned  as  to  first  exaggerate 
the  luxation  by  hyper-abduction  and  a  reduction  by  sudden  forcible 
adduction  of  the  foot. 

The  above  statistics  emphasize  the  seriousness  of  the  lesion  and  the 
need  of  early  reduction  and  appropriate  treatment  in  this  type  of  dis- 
location. 

The  forms  known  as  dislocations  backward,  inward,  and  outward  of 
the  os  calcis  and  scaphoid  from  the  astragalus  were  recognized  in 
Broca's  plan  of  sub-division.  Malgaigne  added  a  fourth  variety,  dis- 
locations forward.  The  dislocation  thus  presents  four  varieties,  oc- 
curring at  the  astragalo-scaphoid  and  astragalo-calcaneoid  joints:  dis- 
placement of  the  os  calcis  and  scaphoid  inward  and  somewhat  back- 
ward, with  the  head  of  the  astragalus  projecting  on  the  outer  part 
of  the  dorsum  of  the  foot,  their  displacement  directly  forward  or  back- 
ward and  downward  and  finally  their  displacement  outward.  The  oc- 
currences of  the  first  two  varieties,  while  uncommon,  are  of  equal  fre- 
quency and  comprise  the  greater  number  of  cases.  The  last  two  va- 
rieties are  of  less  frequent  occurrence. 

Two  varieties  of  the  dislocation  outward  have  been  described  clini- 
cally by  Malgaigne,  distinguished  by  marked  abduction  of  the  toes  in 
one  and  its  absence  in  the  other.  It  is  possible  that  such  a  clinical 
distinction  is  based  upon  the  degree  of  the  dislocation  itself  rather 
than  indicating  a  distinct  variety. 

Recent  opportunity  for  a  study  of  the  mechanism,  pathological  an- 
atomy, clinical  and  radiographic  findings,  was  afforded  the  writer  in 
the  study  of  the  following  case  of  subastragaloid  external  dislocation 
complicated  by  fracture  of  the  neck  of  the  astragalus. 


SrBASTK.UiALOlI)    EXTKKNAL    DISLOCATION 


327 


Plate   1. — Subastragaloid    external   dislocation   with    comminuted    fractnre    of 

neck   of   astragalus. 


Plate   2. — Subastragaloid   external   dislocation    with    comminuted    fracture   of 

neck  of  astragalus. 


328 


ELLIS   JONES 


Plate  3. — Subastragaloid  external  dislocation  after  reduction. 


J.  T.,  male,  aged  39.  Examination,  October  6,  1920,  three  days  after 
accident.  Patient  had  fallen  sixty  feet  into  arroyo,  striking  on  left 
foot.  The  local  physician  had  attempted  reduction,  believing  the  in- 
jury a  Pott's  fracture.  The  foot  was  in  extreme  valgus  with  the  con- 
cavity of  the  sole  obliterated  and  a  well-marked  depression  admitting 
three  finger  tips  under  the  internal  malleolus  where  the  edge  of  the 
inferior  margin  of  the  body  of  the  astragalus  was  easily  palpable.  The 
relation  of  the  body  of  the  astragalus  to  the  internal  malleolus  was 
unchanged  and  this  sign,  together  with  the  extreme  valgus,  was  suffi- 
cient for  the  clinical  diagnosis  of  external  subastragaloid  luxation.  The 
skin  over  the  head  of  the  astragalus  was  taut  and  ecchymotic  and  lacer- 
ated where  the  patient  had  attempted  with  pocket-knife  incisions  to 
relieve  the  pain  of  internal  bleeding.  Beneath  the  skin,  over  the  front 
of  the  ankle  joint,  was  a  firm,  hard  tumor,  presumably  the  head  of  the 
astragalus.  Flexion  and  extension  were  demonstrable  at  the  ankle,  but 
the  foot  was  held  in  rigid  enuino  valgus.  Stereoscopic  radiographs 
(Plates  1  and  2)  confirmed  the  diagnosis.  Reduction  was  easily  ob- 
tained, after  a  tenotomy  of  the  tendo  Achillis,  by  direct  skeletal  traction 
with  a  Steinmann  pin  through  the  tubercle  of  the  oscalcis  (Plate  3). 
The  comminuted  fragments  of  the  head  and  neck  of  the  astragalus 
were  excised  through  an  anterior1  incision.  The  astragalo-scaphoid  lig- 
ament was  found  intact.  Carrel-Dakin  tubes  were  introduced  and 
the  patient  given   an   immunizing  dose   of  tetanus  antitoxin. 


SlBASTKUiAUUI)    EXTERNAL    DISLOCATION 


829 


Plate  4. — Astragalectomy   following   external   subastragaloid   dislocation. 


On  the  third  day,  because  of  extending  infection,  a  curved  incision 
was  made  over  the  internal  malleolus  and  extending  to  the  base  of  the 
internal  cuneiform  bone.  A  four-inch  external  incision  was  made  sim- 
ilarly from. the  external  malleolus  to  the  head  of  the  fifth  metatarsal  and 
Dakin  tubes  placed.  Culture  showed  streptococcus  haemolyticus  in  al- 
most pure  culture.  The  convalescence  was  stormy  and  the  temperature 
ranged  from  97  to  105.  At  no  time  was  a  sterile  count  obtained  and  the 
radiographs  showing  an  increasing  necrosis  of  the  astragalus,  an  as- 
tragalectomy was  done  on  November  29th.  Thereafter,  convalescence 
was  relatively  uneventful,  and  a  sterile  bacteria  count  was  obtained 
on  the  eighteenth  post-operative  day.  A  transfusion  was  done  because 
of  a  haemoglobin  of  38%  and  red  cells  of  3,200,000.  No  attempt  at 
wound  closure  was  made  and  on  January  10th  all  wounds  were  healed 
and  Bristow  coil  work  and  physiotherapy  were  begun.  Five  months 
after  the  original  injury  and  four  months  after  the  astragalectomy,  the 


330 


ELLIS  JONES 


Plate  5. — End-result  after  astragalectomy. 


Plate  6. — End-result  after  astragalectomy 


SUBASTRAGALOID    EXTERNAL    DISLOCATION  331 

patient  walks  with  a  cane  and  slight  limp,  with  function  increasing 
and  with  25°  of  motion  in  the  ankle  joint  (Plate  4). 

Astragalectomy  furnished  little  opportunity  for  study  of  the  lesions 
complicating  the  dislocation.  The  extensor  and  peroneal  tendons  were 
in  their  proper  places.  The  internal  lateral  ligament  and  the  anterior 
annular  ligament  were  intact.  It  is  difficult  to  conceive  how  either  the 
extensor  or  peroneal  tendons  could  act  as  obstacles  to  reduction. 

In  experiments  on  the  cadaver  the  writer  was  able  to  reproduce  sul> 
astragaloid  external  luxations  in  the  following  manner.  The  foot  was 
placed  in  strong  pronation.  In  this  position  the  astragalus  butts  against 
the  post -surface  of  the  anterior  process  of  the  os  calcis,  the  joint  gaping 
inwards.  The  astragalus  is  now  enabled  to  move  or  luxate  over  the  os 
calcis  and  from  the  hollow  of  the  scaphoid  inwards.  An  increase  in 
the  forced  pronation,  together  with  forcible  eyersion  of  the  os  calcis, 
completes  the  dislocation.  It  was  possible  to  obtain  fracture  of  the 
neck  of  the  astragalus  (as  in  the  writer's  case)  only  by  direct  violence 
while  forced  and  rigid  pronation  was  being  maintained. 

A  few  practical  conclusions  seem  justified: 

The  mechanism  of  external  subastragaloid  dislocation  is  that  of  strong 
pronation  with  eversion. 

Apparently,  tenotomy  of  the  tendo  Achillis  facilitates  reduction  of 
a  subastragaloid  external  dislocation  and  permits  easy  lateral  replace- 
ment of  the  dislocated  os  calcis.  Traction  on  the  os  calcis  should  be 
accompanied  by  strong  supination  of  the  fore  foot. 

In  a  compound  fracture-dislocation,  early  astragalectomy  should  be 
considered  because  of  the  almost  inevitable  necrosis  of  the  astragalus. 

REFERENCES. 

1.  Verneuil:     Bulletin  de  la  Societe  Anatomique,  1S72,  p.  493. 

2.  Poinsot:      ^'intervention   chirurgicale   dans   les   luxations   compliquees    du 

coup-de-pied.  Paris.  1877. 

3.  Quenu:    Progres  Medical.  1894,  xix,  25,  p.  385. 

4.  Broca:     Gaz.  Hebdom.,  1874,  p.  316. 

5.  Malgaigne:     Quoted  by  Stimson,  Fractures  and  Dislocations,  1910,  p.  845. 

6.  Nelaton  :  Bull,  de  la  Soc.  Anatomique,.  1835,  p.  38. 

7.  Cowell:     Lancet,  1802,  i,  p.  138. 

8.  Kaufmann:     Zentralblatt  fur  Chir..  1888,  p.  369. 

9.  Deetz:     Deutsche  Zeitschrift  fiir  Chir..  vol.  lxxiv.  p.  581. 

10.  Thienhaus:     Annals  of  Surg.,  Feb.,  1906,  p.  295. 

11.  Lossen:     Deutsche   Chirurgie,   Lieferung   65,   1880,   p.   204. 

12.  Pick:     Lancet,  1880.  vol.  1,  p.  170. 

13.  Sinnigen  :     Quoted  by  Stimson,  p.  849. 

14.  Raffa:     Zentralblatt  fur  Chir.,  1885,  p.  211. 

15.  Ore:     Quoted  by  Stimson,  p.  849. 

16.  Jackson:     Lancet,   1881,  ii,  p.   590. 

17.  Stimson:     Page   849. 

18-19.     Viannay  anu  Fayard  :     Revue  de  Chirurgie,  1913,  vol.  xlvii,  p.  273. 


332  ROBERT    R.    COFIELD 

HYPERTROPHIC  BONE   CHANGES  IN  TUBERCULOUS 
SPONDYLITIS. 

BY    RORERT    B.    COFIELD,    M.D.,    CINCINNATI,    OHIO. 

From  the  Orthopaedic  Department  of  the  Cincinnati  General  Hospital. 

Tuberculous  osteitis  has  generally  been'  considered  a  destructive 
pathologic  process  producing  a  carious  degeneration  with  little  or  no 
tendency  toward  bone  regeneration  during  the  acute  or  active  stage 
of  the  disease.  Limitation  of  the  destructive  process  is  usually  con- 
trolled by  the  formation  of  fibrous  tissue,  into  which  the  deposit  of 
lime  salts  is  strikingly  absent.  Some  observers1  contend  that  ankylo- 
sis of  tuberculous  joints  is  always  fibrous,  bony  union  never  taking 
place,  except  after  a  resection  of  the  joint,  or  in  children  after  a  mixed 
infection  has  occurred.  Tuberculous  spondylitis  affecting  the  bodies 
of  the  vertebrae  has  been  no  exception  to  this  rule  and,  until  a  com- 
paratively recent  time,  the  author  has  been  inclined  to  doubt  the  diag- 
nosis of  spinal  tuberculosis  in  those  cases  in  which  hypertrophic  bone 
changes  were  shown  to  exist  during  the  acute  stage  of  the  disease. 

LITERATURE. 

The  literature  dealing  with  tuberculous  spondylitis  has  been  searched 
in  vain  for  any  accurate  description  of  this  condition.  John  Fraser2 
states  "that  it  is  an  interesting  fact,  and  one  which  has  never  been 
explained,  that  in  tuberculosis  of  the  vertebras  the  periosteum  rarely 
forms  any  degree  of  new  bone."  However,  it  has  long  been  a  com- 
mon observation  that  bony  ankylosis  of  the  vertebrae  does  often  occur 
in  the  later  stages  of  those  cases  in  which  sinuses  have  existed  for 
some  time  and  in  which  secondary  infection  has  been  allowed  to  creep 
in. 

Willis  C.  Campbell3  reports  four  cases  of  localized  spondylitis  in 
which  the  roentgenograms  show  crescent-shaped  lamellae  of  bone  ex- 
tending from  the  body  of  one  vertebra  toward  its  adjacent  fellow 
and  which  may  completely  encapsulate  the  disk,  producing  a  solid 
external  fixation  of  the  two  vertebrae.  His  conclusion  is,  that  the 
etiologic  factor  is  probably  the  same  as  in  monarticular  osteoarthritis, 
and  while  he  does  not  rule  out  the  possibility  of  a  tuberculous  in- 
fection in  all  his  cases,  he  evidently  does  not  consider  it  likely  that  he 
was  dealing  with  tuberculous  spondylitis  in  which  hypertrophic  bone 
changes   had   taken   place. 


HYPERTROPHIC    BONE    CHANGES  333 

French  contributors  have  described  a  condition,  under  the  caption  of 
Spondylitis  rhizomSlique,  which  occurs  in  phthisical  subjects  in  whom 
the  whole  spine  slowly  becomes  stiff  and  fixed  throughout  its  entire 
length.  A.  H.  Tubby4  considers  that  this  form  may  be  a  superficial 
caries  of  the  bodies  of  the  vertebra1  which  is  accompanied  by  inflam- 
matory and  otteophyfie  changes  in  the  inter  vertebral  articulations. 
He  is  inclined  to  believe  that  this  type  is  a  discrete  tuberculous  in- 
fection of  the  entire  spinal  column. 

CLINICAL    CONSIDERATION. 

A  study  of  one  hundred  consecutive  cases  of  tuberculous  spondyli- 
tis occurring  on  the  orthopaedic  service  of  the  Cincinnati  General  Hos- 
pital has  disclosed  ten  subjects  in  whom  hypertrophic  bone  changes 
were  present  during  the  active  stage  of  the  disease.  The  condition 
in  five  patients  was  confined  to  monarticular  lesions,  the  other  five 
showing  two  or  more  attempts  at  bony  bridging  in  contiguous  areas 
of  the  spine.  In  six  of  the  ten  subjects  a  cold  abscess  was  present, 
but  in  only  one  had  drainage  of  the  abscess  been  performed  previ- 
ous to  the  roentgenologic  examination  and  therefore  the  possibility 
of  extraneous  infection  could  be  eliminated.  In  the  six  patients  with 
cold  abscesses,  aspiration  or  drainage  operations  were  performed  and 
typical  tuberculous  pus  was  evacuated.  Hypertrophic  bone  changes 
have  invariably  been  confined  to  individuals  over  twenty  years  of 
age  and  have  accompanied  lesions  located  in  the  lower  dorsal,  dorso- 
lumbar,  and  lumbar  vertebra?.  This  would  indicate  an  effort  to  limit 
motion,  as  a  part  of  the  healing  process,  in  these  regions  of  the  spine 
which  sustain  the  strain  of  greatest  weight-bearing  and  motion.  Only 
those  subjects  in  which  the  least  possible  doubt  existed  concerning 
the  tuberculous  nature  of  the  disease  have  been  included  in  this  study, 
find  while  it  has  been  difficult  in  many  instances  to  secure  confirmatory 
laboratory  findings  in  all  cases,  there  were  two  with  abscess  in  which 
the  tubercle  bacillus  wras  found  in  the  pus  and  positive  inoculation 
of  the  guinea-pig  was  performed.  In  five  of  the  subjects  there  was 
positive  evidence,  of  pulmonary  phthisis  and  in  none  was  there  a  posi- 
tive Wassermann  reported.  Seven  patients  have  improved  with  con- 
servative orthopaedic  treatment,  which  has  included  immobilization  of 
the  spine  with  some  external  fixation;  three  have  died  following 
complications. 


334  ROBERT    B.    COFIELD 

GROSS    PATHOLOGY. 

From  one  subject  who  died  and  came  to  autopsy,  the  spine  was 
removed  and  careful  dissection  made  (Case  No.  6).  There  was  a  large 
sinus  on  the  right  side  leading  into  the  body  of  the  second  lumbar 
vertebra;  the  entire  lumbar  spine  was  rigid,  no  collapse  having  taken 
place.  Hypertrophic  bone  changes  were  found  extending  from  the 
second  to  the  third  lumbar  vertebra,  both  anteriorly  and  laterally. 
Further  dissection  revealed  that  the  twelfth  dorsal  was  firmly  fixed 
to  the  first  lumbar  and  that  the  second,  third,  and  fourth  lumbar 
were  firmly  ankylosed  by  periosteal  over-production  of  new  bone, 
all  of  which  did  not  appear  distinct  in  the  roentgenogram.  The  lamel- 
la of  new  bone-  took  the  same  course  as  the  ligamentous  fibers  of  the 
anterior  and  lateral  spinal  ligaments,  the  fibers  being  firmly  attached 
to  the  hypertrophic  bone  formation,  suggesting  the  possibility  that 
the  new  bone  deposit  had  occurred  within  the  ligaments,  to  some  ex- 
tent at  least.  The  body  of  the  second  lumbar  vertebra  showed  an 
extensive  carious  degeneration.  A  firm  ankylosis  was  produced  em- 
bracing that  section  of  the  spine  extending  from  two  vertebrae  above 
the  tuberculous  lesion  to  two  below.  The  entire  specimen  very  strik- 
ingly portrayed  a  natural  attempt  toward  spinal  fixation  such  as  we 
attempt  to  produce  surgically,  either  by  the  spinal  fusion  operation  of 
Hibbs  or  by  the  Albee  bone  graft. 

conclusions. 

Tuberculous  spondylitis  shows  a  natural  attempt  toward  spinal  fix- 
ation by  hypertrophic  bone  changes  in  at  least  ten  per  cent,  of  cases. 

This  natural  attempt  toward  spinal  fixation  by  bony  bridging  is 
most  likely  to  occur  in  that  portion  of  the  spine  in  which  there  is  the 
greatest  freedom  of  movement,  i.  e.,  the  lumbar  region. 

Bony  ankylosis  of  the  spine  may  occur  in  tuberculous  spondylitis 
without  the  presence  of  a  mixed  infection. 

It  is  possible  that  many  cases  of  spondylitis,  diagnosed  monarticular 
osteoarthritis,  are  of  tuberculous  origin. 

This  condition  has  not  been  found,  except  in  those  who  have  at- 
tained adult  age. 

Since  spinal  fixation  has  long  been  considered  the  most  rational 
treatment  for  tuberculous  spondylitis,  and  since  bony  fixation  occurs 
naturally  in  a  certain  percentage  of  cases,  it  would  seem  justifiable 


EIYPBBTBOPHIC    BONE    CHANGES 


335 


to  recommend  internal  fixation  by  bone  graft  or  spinal  fusion  as  a 
most  rational  aid  toward  recovery,  especially  in  the  adult. 


CASE    REPORTS. 

Case  1,— A-5716.  Age  29,  saleslady.  Admitted,  August  23,  1916; 
discharged,  December  18,  1917. 

Complaint — Swelling  in  the  back  and  thigh. 

Family  History — Negative,  except  one  sister  died  at  the  age  of  three 
months  of  pneumonia.    No  history  of  tuberculosis  in  family. 

Past  History — Diphtheria  at  the  age  of  six,  typhoid  at  eighteen, 
otherwise  always  been  well. 

Present  Illness — Began  five  years  ago  with  severe  cramps  in  the 
lower  region  of  the  abdomen.  Was  operated  on  for  a  strangulation 
of  the  bowel  at  this  time.  Eight  months  afterwards  a  large  abscess 
formed  in  left  groin  and  was  drained.  Six  months  later  another  ab- 
scess formed  in  the  lumbar  region  which  was  drained.  Wassermann 
negative. 

X-ray — August,  1916,  shows  a  bony  bridging  connecting  the  3rd 
and  4th  lumbar  vertebrae  on  the  left  side.  There  is  also  seen  the  for- 
mation of  bone  connecting  right  transverse  process  of  the  5th  lumbar 
vertebra  with  the  sacrum. 

Case  2. — B-7565.  Age  24,  Italian,  laborer.  Admitted,  November 
22,  1917;  died,  May  29,  1919. 

Complaint — Pain  in  the  region  of  the  hip  joint. 


Case  No.  2. — B-7565.     X-ray  shows  firm  bony  bridging  between  2nd  and  3rd 
lumbar   vertebne   on   the  right   side. 


336  ROBERT    B.     COFIELD 

Family  History — Negative. 

Past  History — Has  always  been  well.  Never  had  any  illness  to 
cause  him  to  stop  work  until  one  year  ago  when  he  was  injured  by 
being  crushed  by  a  steel  crane.  Was  in  the  hospital  for  two  weeks. 
Habits  are  good.     Never  had  any  venereal  diseases. 

Present  Illness — Began  about  five  months  ago  with  occasional  pain 
in  the  front  of  the  thigh,  in  the  lower  portion  of  the  back.  Intervals 
of  pain  gradually  became  more  frequent  and  more  severe.  Stiffness 
of  the  muscles  around  the  right  hip  noticed.  He  gradually  lost  his 
ability  to  bend  forward  and  to  the  right.  Abscess  in  right  lumbar 
region  was  aspirated  and  later  drained  by  operation.  Pus  was  in- 
oculated into  a  guinea-pig  and  tuberculosis  found  on  autopsy.  Wasser- 
mann  negative. 

X-ray — October,  1917.  Bone  destruction  in  the  2nd  and  3rd  lumbar 
vertebrae  with  bridging   on  right  side. 

Case  3. — Age  44,  married,  laundress,  colored.  Admitted,  March 
16,  1919;  discharged  to  Branch  Hospital  for  Consumptives,  Septem- 
ber 4,  1919. 

Complaint — Pain  in  the  lower  part  of  the  back. 

Family  History — Mother  living  and  in  good  health.  Father  died 
of  bronchitis.  Three  brothers  and  two  sisters  living  and  well.  One 
sister  died  of  heart  trouble. 

Past  History — Had  operation  for  fibroids  several  months  ago.  Usual 
diseases  of  childhood.  Has  suffered  with  rheumatism.  One  year  ago 
first  noticed  a  bulging  in  the  spine  and  has  had  severe  pain  in  th* 
abdomen  for  several  months.  The  limbs  gradually  lost  their  power; 
has  not  been  able  to  walk  for  about  one  month.  Legs  stiff  and  numb. 
Has  been  going  about  the  house  on  her  hands  and  knees.  Husband 
has  been  massaging  her  back  over  the  prominent  vertebra.  No  history 
of  cough  but  she  has  night  sweats. 

Present  Illness — Legs  are  spastic,  but  can  still  move  them  volun- 
tarily.    "Wassermann  negative. 

X-ray — March  18,  1919,  taken  of  the  dorso-lumbar  spine  shows  a 
deposit  of  bone  almost  amounting  to  complete  bridging  on  both  sides 
of  the  inter-vertebral  joint  of  the  11th  and  12th  dorsal  vertebrae. 
There  is  also  fusion  in  the  region  of  the  7th  and  9th  dorsal  vertebrae1, 
with  some  bony  destruction  and  absorption  of  the  intervertebral  disk. 

Case  4. — D-3601.  Age  60,  married,  housewife.  Admitted,  June 
1,   1919;   died,   September   11,   1919. 

Complaint — Pain  in  the  back  and  legs;  numbness  extending  from 
the  abdomen  to  the  feet. 

Family  History — Mother  and  father  dead.  Mother  died  of  asthma, 
one  brother  died  at  the  age  of  fifty-seven,  of  asthma. 

Past  History — Usual  diseases  of  childhood,  rheumatism  since  age 
of  fifty-two.  Has  had  two  children,  one  died  at  age  of  four  years  of 
brain  fever,  second  child  died  when  born.  Denies  any  venereal  in- 
fection.    Habits  good. 


HYPERTROPHIC    BONE    CHANGES 


337 


Case  No.  6— D-S013.  X-ray  taken  of  spine  after  removal  at  autopsy,  showing 
destruction  of  the  2nd  lumbar  vertebra  and  bony  bridging  between  2nd  and 
3rd  lumbar  on  the  right  side. 


Present  Illness — Began  twenty-six  weeks  ago  with  pain  in  the  back 
and  legs  and  has  gradually  increased  and  is  now  unable  to  walk  or 
stand.  Wassermann  negative. 

Was  operated  upon  by  surgical  service  July  28th.  Incision  made  at 
the  level  of  the  10th  and  11th  dorsal  vertebrae.  Some  yellowish  pur- 
ulent fluid  was  evacuated  and  somewhat  cheesy  pus  appeared  in  the 
wound.  Dura  was  exposed,  the  cord  revealed  an  abnormal  appear- 
ance. Cigarette  drain  applied  and  the  wound  was  closed.  Slight 
improvement    followed   laminectomy. 

X-ray — Examination,  June  9,  1919,  showed  bridging  between  2nd 
and  3rd  lumbar  vertebrae.  Lateral  view  shows  no  evidence  of  bone 
destruction.  August  22nd,  x-ray  shows  marked  destruction  of  the 
body  of  the  3rd  lumbar  vertebra. 


338 


ROBERT    B.     COPIELD 


Case  No.  6. — D-8013.  X-ray  shows  destruction  of  the  body  of  the  2nd  lumbar 
vertebra  and  inter-vertebral  disk  between  the  2nd  and  3rd  lumbar.  Bony 
bridging  between  the  2nd  and  3rd  lumbar  on  the  anterior  surface. 


Case  5. — D-3861.  Age  25,  single,  gardener.  Admitted,  May  19, 
1919 ;  transferred  to  War  Risk  Service,  May  29,  1919. 

Complaint — Abscess  in  the  back  following  a  sprain  two  years  pre- 
vious, caused  by  heavy  lifting. 

Family  History — Negative. 

Past  History — Negative.    Denies  venereal  diseases. 

Present  Illness — About  May  5th,  1919,  began  to  have  pain  and  swell- 
ing in  the  left  lumbar  region  and  unable  to  bend  forward.  Abscess 
was  aspirated  and  pus  obtained  which  was  sterile.  Guinea-pig  inocu- 
lation negative.     Wassermann  negative. 

X-ray — August  25,  1919,  shows  bony  lipping  between  the  bodies  of 
the  4th  and  5th  lumbar  vertebrae,  also  bony  outgrowth  at  the  right  side 
of  the  body  of  the  4th  lumbar  vertebra.  Lipping  also  between  12th 
dorsal  and   1st  lumbar. 


HYPERTROPHIC    BONE    CHANGES 


339 


No.  6. — D-8013.  X-ray  taken  of  spine  after  removal  at  autopsy,  showing 
destruction  of  the  2nd  lumbar  vertebra  and  bony  bridging  between  1st  and 
2nd  lumbar  vertebra*. 

Case  6. — D-8013.  Age  23,  laborer,  colored.  Admitted,  December 
8,  1919;  died,  September  30,  1920. 

Complaint — Mass  in  the  right  side  of  the  back. 

Family  History — Reveals  no  evidence  of  tuberculosis. 

Past  History — Patient  had  the  usual  diseases  of  childhood  and  has 
always  been  well  until  the  Fall  of  1918,  at  which  time  he  states,  he 
was  in  the  hospital  with  a  fever.  Has  always  been  regular  and  mod- 
erate in  all  his  habits. 

Present  Illness — Began  March,  1919,  at  which  time  he  fell  from  a 
step-ladder,  landing  on  his  right  side.  Following  morning  began  to 
suffer  with  severe  pain  in  the  right  side,  increased  on  any  movement 
of  the  spine.  Swelling  first  appeared  in  June,  1919.  December  12, 
1919,  170  c.c.  of  greenish -yellow  pus  was  aspirated  and  sent  to  the 


340  ROBERT    B.    COFIELD 

laboratory.  On  February  24,  1920,  abscess  was  drained.  December 
13,  1919,  acid  fast  bacillus  found  in  pus;  culture  negative.  Wasser- 
mann  negative. 

X-ray — December  12,  1919,  showed  marked  bony  destruction  of  the 
2nd  and  3rd  lumbar  vertebrae  and  thinning  of  intervertebral  disk 
with  bony  bridging  extending  between  2nd  and  3rd  lumbar  vertebra. 
Findings  suggested  tuberculosis  involving  chiefly  the  second  lum- 
bar vertebra. 

Case  7.— E-1908.  Age  23,  single,  clerk.  Admitted,  March  1,  1920; 
discharged,  March  27,  1920,  to  return  later. 

Complaint — Pain  in  the  back,  especially  on  bending  forward. 

Present  Illness — Began  about  January  28,  1919,  while  riding  on  a 
truck  in  Germany.  Patient  lay  in  a  hay  loft  in  a  barn  over  three  days 
without  being  able  to  move.  Back  was  then  strapped  and  he  was  taken 
to  a  hospital  where  he  remained  for  six  months. 

Examination — No  deformity  present.  Limitation  of  spinal  move- 
ments in  all  directions.     Wassermann  negative. 

X-ray — Made  March  5th,  1920,  shows  new  bone  formation  project- 
ing from  the  edges  of  the  body  of  the  5th  lumbar  vertebra,  also  slight 
lipping  of  the  body  of  the  3rd  lumbar  vertebra.  Between  the  bodies 
of  the  1st  and  2nd  lumbar  vertebra?  on  the  left  side  there  is  evidence 
of  bridging;  also  a  rarefaction  in  the  5th  lumbar  vertebra  suggesting 
a  tuberculous  condition.  Patient  was  treated  with  cast  and  referred 
to  War  Risk  Ward. 

Case  8. — E-3215.  Age  46,  married,  laborer.  Admitted,  April  17, 
1920 ;  dismissed,  June  6,  1920. 

Complaint — Chronic    lame   back. 

Family  History — Mother  and  father  living.  Two  brothers  living 
and  well. 

Past  History — Had  pneumonia  twenty-five  years  ago  at  Bellevne 
Hospital.  Influenza,  1918  and  1919.  Ordinary  diseases  of  childhood. 
History  of  chancre  when  seventeen  years  of  age.  Has  had  gonorrhea. 
Has  lost  about  forty  pounds  since  1918.    Regained  some  weight. 

Present  Illness — Started  in  December,  1919.  Attempted  to  swing 
on  a  car  and  felt  something  give  way  in  his  back.  Was  examined  at 
the  out-patient  department  and  referred  to  Branch  Hospital  for  Tu- 
berculosis where  he  stayed  until  February,  1920.  Is  unable  to  stoop 
over  or  bend  to  either  side  without  great  pain.  Is  better  when  rest- 
ing in  bed.     Wassermann  negative. 

Diagnosis — Spinal   tuberculosis.     Pulmonary  tuberculosis. 

X-ray — April  21,  1920,  shows  marked  bony  destruction  of  body  of 
2nd  lumbar  and  lesser  bone  destruction  of  body  of  1st  lumbar  verte- 
brae. There  is  a  bridging  between  bodies  of  1st  and  2nd  lumbar  ver- 
tebrae, on  the  right  side. 

Roentgenologist's  opinion,  tuberculosis  of  spine. 

Patient  returned  for  body  jackets.     Condition  improved. 


HYPERTROPHIC    BONE    CHANGES  341 

Case  9.— E-5397.  Age  45,  single.  Admitted,  July  20,  1920;  dis- 
charged to  Branch  Hospital  for  Consumptives,  August  10,  1920. 

Patient  sent  into  the  General  Hospital  from  the  Tuberculosis  San- 
itarium where  he  has  been  for  eight  years  suffering  from  pulmonary 
tuberculosis. 

X-ray — Plates  of  the  dorso-lumbar  spine  show  a  gross  bone  destruc- 
tion of  the  bodies  of  the  10th,  11th,  and  12th  dorsal  and  1st  and  2nd 
lumbar  vertebrae.  There  is  bony  bridging  between  the  bodies  of  the 
1st  and  2nd  lumbar  vertebra?,  on  the  right  side.  There  is  an  area  of 
increased  density  extending  about  the  dorsal  vertebrae  laterally  on 
either  side  about  one  inch,  giving  an  appearance  of  an  abscess 
formation. 

Case  10. — E-8076.  Age  42,  male,  clothing  cutter.  Admitted,  No- 
vember, 1920;  has  not  been  discharged. 

Complaint — Pain  in  the  lower  part  of  the  back. 

Family  History — Mother  living  and  well.  Father  died  at  age  of 
sixty-eight,  cause  unknown.     One  sister  living  and  well. 

Past  History — Has  had  cough  for  the  past  two  years,  which  has 
decreased  somewhat  at  the  present  time.  Does  not  have  night  sweats. 
Has  lost  eighteen  pounds  in  weight.  Denies  venereal  infection.  Had 
influenza  two  years  ago. 

Present  Illness — Pain  began  as  a  dull,  continuous  ache  in  the  lower 
part  of  the  back  in  October,  1919.  Began  very  gradually  but  contin- 
uously increased  in  severity.  Coughing  or  sneezing  increases  the  pain 
in  the  back.  Patient  has  observed  difficulty  in  putting  on  his  shoes 
and  socks,  or  when  bending  over  to  pick  up  anything  from  the  floor. 
At  night  when  asleep  he  is  often  awakened  suddenly  by  severe  pain 
in  the  back. 

Examination — Patient  moves  very  carefully,  sitting  down  or  getting 
up  very  cautiously.  There  is  limitation  in  all  movements  of  the  lum- 
bar spine.  Muscles  are  tense.  The  4th  lumbar  vertebra  shows  a  prom- 
inence, but  there  is  no  tenderness  on  pressure.    Wassermann  negative. 

X-ray — Taken  January  25,  1921,  shows  destruction  of  the  4th  and 
5th  lumbar  vertebrae  with  bridging  connecting  the  left  sides  of  the 
bodies  of  the  4th  and  5th  lumbar  vertebrae. 

REFERENCES. 

1.  Ely,  Leonard  W. :    Diseases  of  the  Bones  and  Joints,  1914,  p.  59. 

2.  Fraser,  John  :     Tuberculosis  of  the  Bones  and  Joints,  1914,  p.  114. 

3.  Campbell,  Willis  C. :     Jour.  A.  M.  A.,  Aug.  19,  1916,  p.  572. 

4.  Tubby,  A.  H. :    The.  Deformities,  Including  Diseases  of  the  Bones  and  Joints, 

1912,  Vol.  2,  p.  198. 


342  EDGAR   D.    OPPENHEIMER 

EARLY  SYMPTOMS  OF  SPINAL  CANCER. 

-  • 

BY  EDGAR  D.   OPPENHEIMER,  M.D.,   NEW  YORK. 

Carcinoma  of  the  spine,  that  is,  of  the  bodies  of  the  vertebras,  is  not 
a  very  unusual  condition.  Indeed  the  spongy  bones,  particularly  the 
bodies  of  the  vertebrae,  are  probably  the  most  favored  sites  for  the  lo- 
cation of  metastases.  "With  increased  facilities  for  autopsies  and  more 
thorough  examination  of  the  skeleton  in  patients  having  died  of  car- 
cinoma, the  pathologist  has  come  to  recognize  this  connection  as  a  matter 
of  course. 

The  clinician,  however,  not  so  favored,  still  fails  to  appreciate  this 
coincidence  and  frequently  fails  to  recognize  metastatic  carcinoma  of 
the  spine  and  other  bones  until  he  has  had  to  undergo  the  mortifica- 
tion of  an  incorrect  diagnosis  and  prognosis.  Such  failures  are.  not, 
however,  always  due  to  superficial  examination.  It  is  true,  of  course, 
that  those  who,  like  orthopaedic  surgeons,  are  insistently  concerned  with 
anomalies,  infections,  tuberculosis,  and  syphilis  of  the  spine,  are  apt 
to  bear  these  in  mind  more  or  less  to  the  exclusion  of  much  more  un- 
usual pathological  processes.  The  mistaken  diagnosis  cannot,  however, 
be  wholly  attributed  to  this  cause.  For  though  in  well  advanced  cases 
with  evident  primary  foci  the  diagnosis  is  obvious,  the  correct  in- 
terpretation of  the  symptoms  in  the  early  stages  is  often  fraught  with 
difficulty,  even  with  suspicions  aroused  and  in  spite  of  the  most  pains- 
taking examination. 

The  difficulty  is  due  to  the  fact  that  all  pathological  conditions — and 
this  applies  particularly  to  carcinoma — cause  no  definite  objective 
symptoms  as  long  as  they  remain  confined  within  the  substance  of  the 
bones.  In  tuberculosis  and  other  infections  it  is  true  the  focus  soon 
leads  to  an  inflammatory  reaction  on  or  near  the  surface,  and  this  is 
usually  manifested  by  muscular  spasm,  and  as  a  consequence  spinal 
rigidity.  But  spinal  rigidity  occasionally  accompanies  malignant  dis- 
ease of  the  spine,  and  there  are  cases  in  which  pain  and  restricted  mo- 
tion of  the  spine  are  the  only  symptoms  over  a  period  of  months.  When 
a  primary  focus  cannot  be  discovered,  and  the  radiograph  is  negative  or 
doubtful  (not  a  very  usual  happening  in  such  cases),  the  differential 
diagnosis  will  sometimes  try  the  skill  of  the  most  expert. 

Even  at  a  later  stage,  when  there  are  definite  signs  of  bone  destruc- 
tion, the  character  of  the  change  in  the  conformation  of  the  spine  is 
not  always  decisive,  as  is  generally  supposed.  A  well-rounded  kypho- 
sis that  extends  over  a  number   of  vertebrae,  accompanied  by  rather 


EARLY   SYMPTOMS  OP   SPINAL   CANCER  343 

slight  and  ill-defined  pain,  may  appear  in  Pott's  disease;  on  the  other 
hand,  an  acute  angular  kyphosis  is  occasionally  the  earliest  manifesta- 
tion of  carcinoma.  We  have  seen  cases  in  which  it  was,  in  the  absence 
of  a  primary  focus  and  other  symptoms,  very  difficult,  or  quite  impos- 
sible, to  differentiate  these  conditions  even  with  the  aid  of  an  expert 
radiographer.    This,  of  course,  is  a  very  unusual  coincidence. 

Symptoms  of  root  invasion,  in  the  absence  of  the  bony  changes  of 
tuberculosis  or  other  infections,  are  for  the  most  part  characteristic  of 
carcinoma.  They  are  not,  however,  absolutely  pathognomonic,  for 
these  symptoms  sometimes  present  themselves  as  early  manifestations 
of  tumors  or  other  diseases  of  the  spinal  meninges.  The  appearance 
of  the  segmental  symptoms  of  spinal  compression  soon  leads  to  the  dif- 
ferentiation of  meningeal  tumor,  etc.,  from  carcinomatosis;  in  one  case 
under  observation  the  segmental  symptoms  of  a  tumor  of  the  meninges 
were  late  in  appearing  and  the  diagnosis  remained  in  doubt  for  a  period 
of  two  months. 

It  is  needless  to  enter  into  a  detailed  discussion  of  all  the  difficulties 
that  may  be  encountered  in  the  differentiation  of  spinal  cancer.  What 
has  been  said  suffices  to  bring  out  the  fact  that  even  in  the  late  stages, 
when  the  symptoms  are  usually  quite  definite  and  generally  appre- 
ciated, we  may  occasionally  be  unable  to  make  a  proper  diagnosis,  am! 
this  in  spite  of  the  most  painstaking  and  expert  examination. 

This  being  true,  it  is  not  surprising  that  cancer  of  the  spine  is  often 
entirely  unsuspected  during  the  early  stages.  At  this  period  there  is 
little  danger  of  mistaking  the  condition  for  mycotic  or  tuberculous 
spondylitis  or  other  organic  lesions,  but  there  is,  not  a  possibility,  but 
a  great  probability,  that  the  condition  be  misinterpreted  as  functional. 
Vague  back  pains,  ill-defined  pain  on  pressure  over  the  spine  or  the 
sacro-iliac,  and  negative  x-ray  report,  too  readily  tempt  one  to  con- 
sider the  condition  functional.  No  doubt  many  of  us  remember  such 
cases. 

With  this  circumstance  in  mind,  I  decided  to  examine  critically  the 
rather  numerous  cases  of  carcinomatosis  that  have  come  under  my 
notice  in  the  Montefiore  Home  and  elsewhere,  in  an  attempt  to  discover 
a  train  of  objective  symptoms  so  characteristic  that  one  could  make 
the  diagnosis  of  cancer  of  the  spine  earlier  and  more  definitely. 

Pathological  processes  within  the  vertebrae  apparently  cause  no 
symptoms  as  long  as  they  remain  within  the  interior  of  the  bone. 
Symptoms  appear, —  (a)  when  the  process  begins  to  emerge  from  within 
and  invade  the  extramedullary  tissues,  or,  (b)  when  the  bodies  of  the 


344  EDGAR    D.    OPPENHEIMER 

vertebras  have  been  undermined,  and  give  way,  and  the  spine  under- 
goes changes  in  contour. 

The  methods  of  differentiating  cancer  from  other  lesions  of  the  spine 
must  therefore  be  founded  upon, — (a)  a  characteristic  manner  of  in- 
vading the  surrounding  tissues,  i.  e.f  the  spinal  cord  or  roots  and,  (b) 
characteristic  changes  in  the  contour  of  the  spine. 

The  symptoms  of  actual  invasion  of  the  spine  or  the  spinal  roots  are 
of  course  striking;  the  continuous  indescribable  agony  that  attends 
the  carcinomatosis  of  the  spine  is  fortunately  characteristic  of  no  other 
pathological  process.  Before  extensive  root  irritation  has  occurred  the 
symptoms  and  objective  findings  are  not  so  definite  and,  in  the  absence 
of  a  demonstrable  primary  focus,  are  often  difficult  to  interpret.  Ac- 
cording to  the  leading  authorities,  marked  continuous  neuralgic  pains, 
especially  bilateral  or  segmental  in  character,  not  influenced  by  the 
usual  therapeutic  remedies,  should  lead  one  to  suspect  cancer.  In  con- 
nection with  other  signs  and  symptoms,  however,  they  are  often  of  ser- 
vice in  making  the  diagnosis;  thus,  continuous  bilateral  sciatica  often 
leads  to  the  search  for  and  the  discovery  of  a  heretofore  unsuspected 
primary  cancer.  It  should  lead  to  a  search  for  cancer  in  situations 
■where  primary  carcinoma  is  sometimes  overlooked,  unsuspected  or  dif- 
ficult to  demonstrate;  viz.,  the  lungs,  thyroid,  and  prostate.  When, 
however,  the  cancer  cannot  be  demonstrated  elsewhere,  then  the  root 
symptoms,  as  the  following  case  history  illustrates,  are  difficult  to  in- 
terpret. 

A.  B.  Aged  52.  Previous  history :  For  the  past  six  months  has  been 
complaining  of  pain  in  the  hypogastrium,  which  has  gradually  in- 
creased in  severity  until  now  it  is  difficult  to  relieve,  and  then  only 
temporarily  by  morphine.  He  was  in  the  care  of  a  gastroenterologist 
for  some  months  and  was  treated  for  gastric  or  duodenal  ulcer.  As  he 
was  not  relieved  he  sought  advice  from  a  number  of  others  and  the 
removal  of  the  appendix  was  advocated.  Examination  shows  a  fairly 
well  nourished  individual ;  complains  of  pain  in  the  pit  of  the  stomach, 
which  is  continuous,  and  not  relieved  by  heat  or  change  of  position,  and 
only  partially  by  opiates.  Abdomen  flaccid  with  no  signs  of  abnormal- 
ity of  the  contained  organs.  Suggestion  prompts  him  to  describe  the 
pain  as  radiating  from  the  spine  forward.  Medical,  physical,  Wasser- 
mann,  etc., negative.  Spine  rigid  but  without  local  tenderness;  x-ray 
shows  no  definite  abnormality  in  the  spine,  other  bones  not  taken.  The 
rigidity  of  the  spine  and  the  pain  radiating  to  the  hypogastrium  sug- 
gested a  spondylitis,  and  cancer  was  not  suspected.  For  this  reason 
the  spine  was  immobilized  in  a  plaster  of  Paris  jacket.  Instead  of  the 
expected  relief,  the  pain  increased  to  such  an  extent  that  after  a  few 


EARLY    SYMPTOMS   OP   SPINAL   CANCER  M  5 

days  the  jacket  was  removed.  Subsefjuently  he  suffered  spontaneous 
fracture  of  the  ribs  and  developed  the  symptom  complex  of  general 
carcinomatosis. 

This  case,  which  resembles  a  number  of  others  which  have  come  under  ' 
observation  is  instructive  in  a  number  of  ways.  It  illustrates  not  only 
the  difficulties  in  the  way  of  diagnosis,  but  it  suggests  some  differen- 
tiating factors;  thus  for  us,  continuous  pain  more  or  less  segmental 
in  character,  indefinite  or  negative  x-ray  findings  with  spinal  rigidity, 
particularly  when  the  condition  is  exaggerated  by  immobilization,  al- 
ways leads  to  a  search  for  a  primary  carcinoma  and,  even  when  this 
is  absent,  strongly  suggests  malignant  disease.  We  have  not  been  able 
to  discover  why  immobilization  increases  the  pain  in  these  cases  (it  is 
likely  that  it  prevents  the  patient  from  assuming  an  attitude  that  some- 
what alleviates  the  suffering),  but  in  a  number  of  cases  this  aggrava- 
tion of  the  symptoms  has  occurred  and  we  now  consider  this  coincidence 
as  definitely  suggestive  of  carcinomatosis. 

We  have  concluded,  from  an  examination  of  the  cases,  that  the  early 
signs  of  root  involvement  from  carcinoma  have  the  following  clinical 
manifestations.  The  symptoms  are  those  of  sensory  root  irritation  as 
distinguished  from  a  peripheral  nerve  lesion.  What  is  usually  des- 
ignated as  a  bilateral  sciatica  is  not  a  sciatica,  but  the  pain  and  its 
distribution  will,  on  careful  examination,  be  found  to  correspond  to  one 
or  more  roots  of  the  sacral  plexus.  When  the  spine  higher  up  is  in- 
volved, the  symptoms  are  clearly  segmental  in  character;  usually  other 
sensations  are  intact  and  the  motor  sphere  is  only  involved  late  in  the 
disease.  The  pain  is  always  greatly  exaggerated  by  immobilization;  is 
more  or  less  continuous;  it  prevents  but  does  not  interrupt  sleep  as 
does  the  pain  in  spondylitis.  These  symptoms  appear  with  or  with- 
out spinal  rigidity  and  are  not  infrequently  present  when  the  radio- 
graph of  the  spine  is  negative.  They  are  in  themselves  not  character- 
istic but  should  always  arouse  suspicion  and  encourage  the  search  for 
primary  carcinoma,  and,  in  conjunction  with  other  suspicious  signs, 
often  secure  the  diagnosis. 

Tn  many  of  the  individuals  seen  early,  that  is,  before  the  disease  has 
reached  the  extension  of  the  vertebra?,  the  subjective  symptoms  are  vague. 
The  patient  complains  of  pain  in  the  back,  over  the  sacrum  or  the  sacro- 
iliac joint,  and  frequently  is  unable  definitely  to  localize  it.  In  such 
cases  we  have  tried  to  discover  the  earliest  changes  in  the  spme.  That 
is,  we  have  searched  for  the  objective  changes  that  precede  the  charac- 
teristic x-ray  findings  and  the  actual  gross  deformation  of  the  spine 
of  extensive  cancer  invasion. 

Until  recently  our  histories  show  that  we  had  not  demonstrated  these 


346  EDGAR   D.    OPPENHEIMER 

changes.  This  was  due  to  the  fact  that  we  made  no  careful  search  for 
them  or,  as  it  is  true  of  the  root  symptoms  in  many  of  our  earlier  cases, 
we  did  not  properly  interpret  or  lay  sufficient  stress  upon  them.  Since 
we  have  studied,  the  subject  more  intensively  we  have  found  that  it  is 
often  possible  to  foretell  the  ultimate  vertebra  breakdown  long  before 
it  actually  occurs  and  not  so  rarely  before  the  radiograph  gives  posi- 
tive results. 

Of  these  changes,  most  typical  is  slight  dislocation  forward,  so  that 
there  appears  a  more  or  less  definite  recession  of  particularly  one  or 
a  few  spinous  processes  as  they  are  successively  palpated  from  above 
downward.  In  some  of  the  more  marked  cases  the  palpating  finger 
suddenly  meets  with  a  sharp  depression  as  it  reaches  the  subluxated 
vertebra. 

In  another  group  of  cases  we  have  been  able  to  discover  the  presence 
of  slight  later  displacements  which  only  months  afterward  became  pro- 
nounced. This  change  is  due  to  carcinomatous  invasion  of  the  lateral 
processes  and  the  ligaments  of  the  lateral  joints  of  the  spine.  In  two 
eases  we  have  found  slight  lateral  displacement  the  only  symptom  ex- 
cept vague  back  pains.  In  the  absence  of  demonstrable  primary  car- 
cinoma, the  diagnosis  in  these  cases  remained  in  doubt  for  some  months, 
and  was  not  definitely  confirmed  until  symptoms  of  general  carcinomato- 
sis appeared.  In  two  others,  marked  lateral  dislocation  and  other 
changes  soon  followed  the  discovery  of  the  slight  displacement. 

In  another  group  of  cases  we  have  been  able  to  demonstrate  the  com- 
pression of  the  bodies  of  individual  vertebrae  as  it  occurs  very  early  in 
the  disease  and  before  it  is  apparent  in  the  radiograph,  by  what  we 
think  is  a  change  in  the  relation  between  the  adjacent  spinous  processes 
of  the  affected  vertebrae.  Rarely,  the  only  change  is  a  shortening  of 
the  distance  between  the  adjacent  spinous  processes;  more  often  the 
change  in  the  height  of  the  vertebrae  is  complicated  by  a  variable 
amount  of  torsion. 

These  changes  in  the  contour  are,  of  course,  not  absolute,  criteria  in 
the  absence  of  other  symptoms.  They  are,  however,  very  suggestive 
in  connection  with  other  symptoms  not  in  themselves  definite.  In  prac- 
tically all  the  cases  that  we  have  been  able  to  follow  up,  the  diagnosis 
was  substantiated.  And  though  we  are  far  from  assuming  that  these 
slight  objective  differences  in  the  contour  of  the  spine  are  path- 
ognomonic of  cancer,  we  feel  that  slight  lateral  displacements,  dis- 
crepancies in  the  relation  between  adjoining  spinous  processes,  with 
©r  without  lateral  deviation  or  torsion,  are  very  significant  symptoms. 


EARLY   SYMPTOMS   OF   SPINAL   CANCER  347 

At  least  they  should  lead  one  to  suspect  cancer,  and  therefore  strongly 
stimulate  the  most  thorough  search  for  other  evidence  of  carcinomato- 
sis. 

With  the  facilities  for  thorough  search  for  primary  cancer  and  the 
expert  radiography  at  our  command  in  all  general  hospitals,  why,  it 
may  be  asked,  is  it  necessary  to  seek  new  clinical  data,  or  magnify  the 
significance  of  the  changes  we  have  here  described?  But  it  has  been  our 
experience  that  if  we  except  the  more  common  carcinomata  the  primary 
focus  is  not  always  easy  to  demonstrate.    Indeed,  in  some  of  our  cases 
the  primary  carcinoma  in  the  prostate,  thyroid  or  lungs  had  not  been 
demonstrated  in  patients  with  general  carcinomatosis  until  they  came 
to  autopsy.     Nor  does  the  radiograph  always  clear  up  the  diagnosis 
in  the  early  stages.    We  have  seen  cases  in  which  the  radiograph  was 
apparently  negative  three  or  four  weeks  before  the  characteristic  de- 
formation and  symptoms  of  advanced  carcinomatosis  supervened.     Of 
course  the  advanced  cases  show  characteristic  changes  with  which  all 
are  familiar.    The  early  pictures  are,  however,  often  negative,  or  can- 
not be  definitely  interpreted  without  additional  clinical  data.    We  have 
carefully  re-examined  a  great  number  of  the  plates  taken  at  the  Monte- 
fiore  Hospital,  where  there  is  a  large  cancer  service,  without  being  able 
to  find  definite  and  characteristic  findings  for  the  earliest  stages.  Slight 
changes  in  the  outline  of  bodies,  sometimes  shown  only  in  the  oblique 
pictures,  are  the  usual  first  signs.     The  only  additional  assistance  we 
have  derived  from  this  source  was  obtained  by  radiographs  of  the  other 
bones  when  the  plates  of  the  spine  were  negative,  because  we  can,  for 
technical  reasons,  demonstrate  more  easily  the  lesion  in  the  femur,  hu- 
merus or  skull.     In  this  we  have  been  able  to  confirm  the  observations 
of  others  that  at  times  cancer  of  the  femora  or  other  bones  could  be 
remonstrated  when  the  symptoms  apparently  originated  in  the  spine, 
but  the  plates  of  this  region  were  negative.     The  characteristic  small, 
well-defined  shadows  due  to  multilocular  growths  are  striking,  but  oc- 
cur late,  and  the  early  x-ray  diagnosis  must  usually  rest  on  a  careful 
study  of  all  ill-defined  shadows  so  often  described  as  "picture  unsat- 
isfactory/*     These  lesions  are  rapid  in  growth  and  the  comparison  of 
weekly  radiographs  will  show  an  increase  of  a  suspected  lesion   and 
allow  us  to  state  that  real  atrophy  exists,  not  comparative  atrophy. 

On  the  whole,  then,  according  to  my  investigation,  the  early  diagnosis 
cf  cancer  must  be  in  many  cases  tentative.  It  can  be  verified  by  the 
search  and  demonstration  of  primary  foci  elsewhere.  In  conjunction 
with  other  symptoms,  in  themselves  not  decisive,  the  peculiar  character 


348  EDGAR   D.    OPPENHEIMER 

of  the  root  or  segmental  symptoms,  or  the  early  changes  in  the  con- 
formation of  the  spine  here  described,  will  often  greatly  aid  in  securing 
the  diagnosis. 

I  herewith  append  an  abstract  and  an  analysis  of  the  history  of 
thirty-two  cases  of  cancer  of  the  spine  under  observation  at  the  Monte- 
fiore  Hospital  on  whom  satisfactory  data  were  obtainable.  I  am  in- 
debted to  Dr.  I.  Levine  who  has  charge  of  the  Cancer  Service  for  per- 
mitting me  to  use  his  cases. 

The  site  of  the  primary  lesion  was  found  to  be  in  the  breast  eighteen 
times,  lung  four,  prostate  five,  thyroid  three,  kidney  one,  pancreas  one, 
in  a  total  of  thirty-two  carcinomata.  The  metastatic  symptoms  appeared 
before  the  primary  focus  could  be  determined  in  twelve  cases.  Three 
cases  in  addition,  presenting  spinal  symptoms,  had  breast  operations 
eight  years  previous  without  recurrence,  and  the  symptoms  of  the  me- 
tastases took  that  length  of  time  to  become  evident.  The  primary  lesion 
was  not  found  at  all  clinically  in  six  cases  and  proved  at  autopsy  to  be 
in  the  breast  one,  thyroid  two,  lung  one,  prostate  two.  Pathological  frac- 
tures were  present  before  the  diagnosis  of  carcinoma  was  established 
in  the  spine  four  times,  femur  three,  humerus  two,  elsewhere  two.  The 
first  symptoms  in  seven  cases,  in  which  there  had  been  no  local  pains, 
were  fractures  following  slight  trauma.  Local  spinal  symptoms  were 
present  in  twenty  cases  early  in  the  history;  ten  showed  pain  on  local* 
pressure,  and  fourteen  deformity.  In  no  case  was  there  tumor  present 
on  the  spine,  and  sacral  tumors  in  three  cases  appeared  only  late  in  the 
disease.  Spinal  pains  were  complained  of  in  nineteen  cases  and  were 
an  early  symptom  in  nine  cases.  In  fifteen  cases  the  lower  extremities 
were  the  seat  of  pain  and  in  thirteen  cases  this  was  an  early  symptom. 
Symptoms  of  metastases,  other  than  spinal,  were  present  in  sixteen 
cases  and  early  in  thirteen  cases.  Sensation  of  cold  was  complained 
of  in  thirteen  cases,  and  herpes  zoster  was  found  in  two  cases.  We 
found  positive  spinal  x-rays  in  fifteen  cases  and  in  eight  they  were 
negative.  Of  the  eight  negative  cases,  three  showed  lesions  in  other 
bones.  The  cases  with  early  cord  and  root  symptoms,  as  a  rule,  gave 
negative  pictures  at  the  time  of  onset  and  some  even  at  the  end.  Our 
cases  presenting  metastatic  bone  and  cord  symptoms  gave  an  average 
duration  of  fourteen  months.  The  duration  of  nerve  symptoms  in 
seventeen  cases  averaged  ten  months,  and  fifteen  cases  had  no  symptoms- 
referable  to  the  central  nervous  system. 

Case  1. — 01207.    E.  H.,    female,    aged    60    years.     Admitted  April 
9,  1917 ;  died  April  13,  1917.     October,  1915,  had  pain  in  right  foot 


EARLY    SYMPTOMS  OF   SPINAL   CANCER  349 

and  knee  grew  gradually  worse  and  was  bedridden  all  winter.  April, 
1916,  was  seven  weeks  at  C.  N.  Hospital  for  constant  pain  in  lower  por- 
tion of  spine  and  weakness  of  both  lower  limbs.  X-ray  diagnosis — 
Pott's  disease.  Six  weeks  in  plaster  corset;  after  removal  of  corset 
developed  hematuria.  October,  1916,  was  sent  to  Mount  Sinai  Hospital 
where  hematuria  was  controlled  and  examination  showed  round  dif- 
fuse kyphos  in  upper  dorsal  region  with  immobility  but  no  acute  spasm. 
Vertebrae  not  sensitive.  Paralysis  of  lower  extremities.  X-ray  showed 
almost  complete  destruction  of  second  and  third  lumbar  and  changes 
in  the  1st,  4th,  and  5th  lumbar  vertebra.  Diagnosis,  T.  B.  C.  or  malig- 
nant. On  admission  to  Home  — for  last  six  months  increased  frequency 
of  urination — for  one  month  complete  transverse  myelitis.  X-ray — 
large  neoplasm  entire  lumbar  spine,  metastases  in  dorsal  spine,  femora, 
ribs,  signs  of  arthritis  deformans.  Autopsy — Carcinoma  breast, 
metastases  in  spine  7  to  11  D,  2  to  5  L,  skull,  bones,  liver,  glands. 

Case  2.— PP  14.  H.  McM.,  age  79  years.  Admitted,  May  30,  1917 ; 
died  September  11,  1917.  For  several  months  indefinite  pains  in  back, 
sticking  in  character  and  fairly  constant,  not  influenced  by  treatment 
or  medication.  X-rays, — kidneys  negative,  spine  moderate  arthritic 
changes.  Spinal  brace  for  arthritis  made  pains  worse.  Unable  to 
wear  brace.  On  admission  severe  pains  in  back  and  shoulders,  pains 
in  legs,  and  weakness.  X-ray  in  July,  1917,  showed  aneurysm  in  arch 
of  the  aorta,  heart  enlarged,  lungs  negative,  no  bone  changes.  The 
paralysis  of  legs  gradually  increased,  followed  by  a  transient  Brown- 
Sequard  crossed  paralysis,  and  on  September  5th  complete  paraplegia 
below  the  waist  and  a  gradual  kyphos  at  dorso-lumbar  region.  Pros- 
tate enlarged  with  hard  nodules.  Diagnosis:  carcinoma  of  prostate, 
metastases  of  spine  and  cord. 

Case  3.— 02150.  H.  H.,  male,  age  48  years.  Admitted,  March  12, 
1919;  died  April  12,  1919.  September  10,  1918,  on  jumping  from  a 
street  car  had  severe  pain  in  heel  and  toes  of  right  foot.  A  week  later 
was  told  he  had  a  fracture.  Massage  and  baking  ordered  but  discon- 
tinued on  account  of  excessive  pain.  In  plaster  of  Paris  for  five  weeks. 
Removal  of  plaster  aggravated  the  pain.  Then  pills  and  five  intraven- 
ous because  blood  was  positive.  January  20,  1919,  amputation  of  leg 
was  made;  since  that  time  noticed  swelling  at  groin  and  at  finger.  On 
admission,  has  a  sacro-iliac  tumor,  apparently  osseous.  March  23d, 
cerebral  thrombosis,  facial  palsy  followed  by  partial  recovery. 
Autopsy — primary  carcinoma  lungs,  metastases  of  bones,  sacrum, 
skull,  hands,  liver,  adrenal,  lymph  glands,  dura,  scoliosis. 

Case  4.— 0943.  Male,  age  62.  Admitted,  April  11,  1916;  died, 
September  7,  1916.  For  seven  months  had  chills,  weakness,  dyspnoea, 
loss  of  weight.  On  admission: — expectoration,  pain  in  chest,  lung 
signs.  July  21,  1916,  painful  nodule  on  clavicle,  later  pathological 
fracture.     X-ray:— April  24,  1916— cavities  and  fluid  in  lungs.    July 


350  EDGAR  D.    OPPBNHEIMER 

25,  1916, — pathological  fracture  of  clavicle.  Autopsy: — carcinoma  of 
lung  with  extension  of  mediastinum,  involving  4th  and  5th  dorsal  ver- 
tebrae.    Collapse  of  bodies  and  extension  into  outer  layer  of  dura. 

Case  5. — 0841.  Male,  age  52  years.  Admitted,  December  16,  1915; 
died  May  6,  1916.  Two  years  ago  had  cutting  pain  in  left  lower  ex- 
tremity from  pelvis  radiating  down  the  inner  side  to  ankle,  and  six 
months  later  similar  pains  in  right  limb.  Plaster  jacket  for  six  months 
did  not  relieve  the  pain.  Pain  not  constant  and  not  definitely  located ; 
most  of  the  pain  in  legs  down  to  ankles.  No  pain  in  feet  and  could 
not  walk  or  sit.  Turning  in  bed  gave  sharp  pain  in  back  of  pelvis; 
only  when  on  either  side  did  he  find  comfort.  On  admission — com- 
plains of  pain  in  pelvis  and  both  lower  extremities;  consequent  inabil- 
ity to  walk  any  distance.  Thyroid  negative,  neurological  negative; 
spine  not  tender;  no  deformity  or  rigidity.  Pains"  considered  func- 
tional. January  25,  1916 — pains  vague  and  irregular,  at  times  severe 
and  frequently  absent.  On  rotation  intense  sacral  pains;  prostate 
somewhat  hard  and  enlarged.  X-ray — slight  defect  in  the  outline  of 
the  body  of  the  4th  lumbar  vertebra  not  clear.  April  16,  1916 — very 
severe  pain  in  both  hips;  motion  left  lower  limb  limited  and  very  pain- 
ful; knee  jerks  absent.  X-ray,  April  20,  1916 — defect  in  4th  lumbar, 
also  3rd  and  5th.  Retention  of  urine  and  feces  developed,  also  loss  of 
weight.  Spine  shows  no  deformity  or  tumor  but  has  extreme  tender- 
ness on  pressure  over  3d,  4th,  and  5th  lumbar  spine  and  both  sacro- 
iliac joints.  Later  followed  symptoms  of  cord  involvement.  Autopsy: 
— malignant  adenoma  thyroid  with  metastases  to  lumbar  vertebrae. 
Body  of  4th  lumbar  replaced  by  fleshv  tumor  mass  penetrating  through 
disc  to  3rd  and  5th  lumbar,  tumor  encroaching  on  canal  though  it  does 
not  project  through  the  meninges.    Hemorrhage  of  lumbar  nerve  root. 

Case  6.— 01129.  F.  G.  Male,  age  63  years.  Admitted,  August  24, 
1916;  died,  February  9,  1917.  Since  January,  1916,  had  pains  in  left 
thigh  which  were  constant,  but  at  times  so  severe  that  he  could  not  walk. 
On  admission, — lumbar  and  sacral  spine  painful  on  pressure,  rno'-e 
marked  on  left  side.  Muscular  rigidity  but  no  tumor  present.  Deep 
and  superficial  tenderness  of  left  lower  extremity;  rectal  negative. 
X-ray,  August  31,  1916,  general  carcinomatosis  lumbar  spine,  sacrum 
and  left  femur.  Autopsy: — carcinoma  of  prostate,  metastases  in  bones, 
femur  friable,  replaced  by  tumor. 

Case  7.— 0591.  B.  F.  Female,  age  56  years.  Admitted,  July  6, 
1915:  died,  July  25,  1915.  One  and  one-half  years  ago  patient  fell 
and  was  unable  to  raise  herself.  Was  put  in  plaster  corset  for  five  months. 
Since  March,  1915,  was  unable  to  walk.  On  admission, — marked  tender- 
ness dorso-lumbar  spine ;  entire  spine  rigid ;  marked  lateral  curvature  at 
2nd  lumbar.  Entire  left  lung  dull.  Autopsy: — primary  adeno-car- 
cinoma  lung,  metastases  in  pleural,  liver,  adrenal,  ribs,  vertebrae, 
glands,  suppurative  pericarditis,  duodenal  ulcer,  slight  compression 
of  cord  equina  by  metastasis  at  2nd  lumbar. 


EARLY    SYMPTOMS   OF    SPINAL   CANCER  351 

Case  8.— 01782.  B.  K.  Male,  age  40  years.  Admitted,  June  9,  1918 ; 
died,  September  9,  1918.  July,  1917,  cutting,  cramplike  pain  in  left 
inguinal  region,  radiating  to  testicle,  so  severe  that  patient  was  un- 
able to  walk.  Ten  months  ago  pain  in  left  lumbar  region,  then  pain 
in  left  axilla,  radiating  to  spine.  Pain  constant,  made  worse  without 
cause;  no  relief  from  medication  or  therapeutic  treatments.  Tender- 
ness over  left  chest;  herpes  zoster  along  course  of  intercostal  nerve. 
Teeth  extracted,  February,  1918.  Gave  streptococcus  viridans  in  pure 
culture  as  did  the  tonsil.  Wassermann  negative,  spinal  fluid  nega- 
tive. X-rays,  February  25,  1918, — sinuses,  cloudiness  of  both  anterior 
ethmoids.  X-ray  of  spine  unsatisfactory.  Considered  a  pernicious 
neurotic.  For  past  two  weeks  pains  in  right  hip,  increased  by  mo- 
tion. Small  swellings  over  ribs  anteriorly  and  behind  ears.  On  ad- 
mission,— pains  in  back,  shoulders,  hip,  stiffness  of  neck;  masses  over 
chest  and  hip  painful  on  pressure.  Loss  of  weight,  fifty  pounds  in 
year.  Small,  hard  mass  in  front  of  neck,  not  painful.  On  examina- 
tion, patient  very  sensitive;  flexion  left  thigh  causes  severe  pain,  as 
does  any  motion.  No  tenderness  of  vertebrae  or  femur.  Feeling  of 
cold  in  right  lower  extremity.  June  28,  1918,  prostate  negative.  Very 
hard  tumor  size  of  nut  adherent  to  fascia  and  laryngeal  cartilage ;  not 
painful.  X-ray,  June  18,  1918, — small  diffuse  spots  throughout  bodies 
of  vertebrae  and  12th  rib.  Multiple  fractures  of  ribs.  Irregular  bone 
destruction  along  S.  I.  joints,  pelvis,  and  left  femur.  Infiltration  of 
lungs  with  carcinoma  of  thyroid.     Metastases  of  bones  and  lungs. 

Case  9. — 0734.  F.  E.  Female,  age  56  years.  Admitted,  November 
10,  1914;  died,  January  1,  1916.  Onset,  1911,  with  pains  in  thighs. 
Breast  amputated,  September,  1913.  After  one  year,  recurrent,  fol- 
lowed by  marked  weakness;  no  muscle  atrophy.  Could  not  raise  heel 
off  bed.  Neurological  examination  negative.  December  24,  1915,  fell 
off  a  chair,  fracturing  lower  one-third  of  femur.  X-ray  showed  car- 
cinoma.    Autopsy: — ribs,   femur,   spine  showed  carcinoma. 

Case  10.  0753.  Female,  age  45.  Admitted,  October  1,  1915;  died, 
January  22,  1916.  One  year  ago  had  pain  in  left  arm,  and  breast  was 
removed.  Then  developed  pains  elsewhere;  these  grew 
worse  and  the  patient  weaker.  On  admission, — atrophy,  small  mus- 
cles right  hand;  painful  spots  on  spine;  swelling  on  lumbar  region; 
bed  sore;  increased  reflexes;  later,  signs  of  cord  compression.  X-ray, 
October  14,  1915, — metastases  show  in  all  bones,  best  in  hips,  shoul- 
ders, ribs  and  skull. 

Case  11.— 03041.  B.  B.  Female,  age  69.  Admitted,  July  30,  1918; 
died,  November  19,  1920.  Five  years  ago  bloody  expectoration,  ill 
four  weeks.  Well  for  two  years,  then  pain  in  right  foot  and  leg.  Pain 
beginning  in  hips  and  radiating  downwards,  then  pain  in  both  legs, 
edema  of  legs.  Stiffening  and  weakness  of  right  hand.  Diagnosis: — 
Mitral   regurgitation,    arteriosclerosis,   chronic    arthritis,    facial   palsy, 


352  EDGAR   D.    OPPENHEIMER 

October  14,  1920,  recurrent  carcinoma  right  breast,  ulcerations  on 
cuirasse.  X-ray: — Marked  hypertrophic  anthritis  of  spine,  metastases 
not  evident. 

Case  12. — 0761.  R.  R.  Female,  age  43.  Admitted,  January  1,  1916 ; 
died,  February  3,  1916.  May,  1915,  noticed  tumor  in  breast.  Oper 
ated  in  August.  Then  followed  pains  in  thighs,  later  in  spine,  also 
of  piercing  character.  Pain  on  pressure  along  spinal  processes.  Kyphos 
evident  and  thickened  trochanters.  X-ray,  January  20,  1916, — worm- 
eaten  appearance  11  and  12  D  and  lumbar  vertebrae,  also  femora. 
Autopsy : — Dorso-lumbar  vertebrEe  crumble  under  saw,  no  definite  meta- 
stases seen,  body  of  12th  dorsal  almost  gone,  metastases  in  liver  and 
glands;   brain  and  spinal  cord  negative. 

Case  13.— 02817.  H.  M.  Female,  age  43.  Admitted,  December  9, 
1919;  died,  June  13,  1920.  July,  1918,  operation  right  breast.  June, 
1919,  stabbing,  right  thigh  medially,  when  walking  gradually  became 
worse.  Last  three  weeks  pain  steady  in  knee  and  in  right  hip.  Sleep- 
lessness due  to  pain;  five  weeks  internal  strabismus  left  eye.  On  ad- 
mission : — two  bony  nodules  in  left  parietal  region,  are  not  tender. 
Tenderness  of  right  thigh,  cannot  lift  knee  off  bed  although  motions 
are  free.  Reflexes  normal,  no  spinal  tenderness  or  deformity.  X-ray, 
December  20,  1919,  metastases,  skull  and  right  femur,  slight  erosion 
at  fourth  lumbar  vertebra.  April  11,  1920,  irregular  bone  destruction 
throughout  body  of  fourth  lumbar  and  both  femora  where  there  is 
periosteal  reaction  in  some  places. 

Case  14. — 02758.  I.  K.  Female,  age  36.  Admitted,  January  8, 
1920;  died,  May  8,  1920.  Four  years  had  mass  at  suprasternal  notch 
and  right  supraclavicular  fossa  which  never  troubled  her.  Ten  months 
had  mass  in  right  parietal  region,  never  painful.  Five  months  ago 
stumbled  while  walking  and  had  severe  pains  but  managed  to  walk 
for  a  month.  For  increased  pain,  went  to  hospital,  where  cast  was 
applied  for  fractured  femur.  On  admission: — hard  thyroid  mass, 
soft  mass  at  third  and  fourth  rib  anteriorly  and  at  parietal,  not  ten- 
der; in  plaster  cast.  January  23,  1920,  paralysis  of  left  leg  with  in- 
creased K.  J.,  ankle  clonus  and  Babinsky  both  sides.  February  17, 
cast  removed,  decubitus  present  and  signs  of  complete  transverse  mye- 
litis. X-ray,  January  13,  dorso-lumbar  spine  negative;  January  29, 
extensive  bony  destruction  upper  right  femur,  skull,  lower  lumbar 
spine.     Carcinoma  thyroid,  metastases  skull,  femur,  ribs,  lumbar  spine. 

Case  15.— 02873.  J.  D.  Female,  age  26.  Admitted,  January  14, 
1920;  left,  July  28,  1920;  died,  December,  1920.  Five  years  ago  oper- 
ated,^ left  breast ;  five  months  ago  pain  left  hip  which  interferes  with 
walking.  Later,  pain  in  hip  less,  but  pain  in  lower  end  of  spine ;  when 
in  bed,  pains  less.  On  admission: — complaining  bitterly  of  pain  in 
left  thigh  with  weakness  that  is  progressively  worse.     X-ray,  January 


EARLY   SYMPTOMS   OP   SPINAL   CANCER  353 

2,  diffuse  metastatic  involvement  in  pelvis,  lumbar  spine,  skull,  lungs; 
collapse  second  lumbar  vertebra.  April  11,  large  area  of  bone  de- 
struction on  upper  part  of  right  sacro-iliac  and  both  pubic  bones;  hips 
negative.  July  8,  1920,  no  complaints;  pain  on  pressure  fourth  and 
fifth  lumbar  and  ribs. 

Case  16:— 02811,  S.  R.  Male,  age  60.  Admitted,  January  3,  1917; 
died,  June  11,  1920.  March,  1915,  total  excision  of  bladder  for  car- 
cinoma. Later,  general  weakness  and  lung  signs,  no  spinal  symptoms. 
X-ray,  February,  1920,  pelvis  negative,  marked  lung  shadows,  slight 
metastatic  changes  of  the  fifth  lumbar  vertebra. 

Case  17.— 02518.  Female,  age  54.  Admitted,  May  1,  1919;  died, 
November  24,  1919.  May,  1918,  noticed  lump  in  breast,  marked  loss 
of  weight,  for  three  months  pain  in  left  eye  led  to  its  destruction.  On 
admission: — cancer,  right  breast,  with  axillary  glands;  right  upper 
extremity  edematous;  August  14,  right  eye  also  involved.  X-ray, 
May  13,  second  lumbar  vertebra  somewhat  collapsed  and  small  area  of 
bone  destruction  in  lumbar  spine,  sacrum  and  skull. 

Case  18.— 02568.  R.  R.  Female,  age  50.  Admitted,  August  22, 
1919;  died,  January  8,  1920.  November,  1917,  breast  removed;  April, 
1919,  for  pain  in  leg  went  to  hospital,  while  there  spontaneous  frac- 
ture humerus.  On  admission: — tumor  left  clavicle;  no  glandular  in- 
volvement; fracture  humerus;  lower  dorsal  spine  shows  sharp  kyphos. 
left  gluteal  bed  sore,  neurological  examination  negative.     October  29, 

1919,  patient  rather  apathetic  and  complains  of  cramps.     January  2, 

1920,  no  complaints  but  weaker.  X-ray,  November  6,  1919,  moder- 
ate diffuse  bony  destruction  spine,  sacrum,  pelvis,  femora,  scapula,  hu- 
merus and  other  bones. 

Case  19.— OX.  A.  F.  Female,  age  40.  Admitted,  October  12,  1920; 
died,  January  1,  1921.  Nine  years  ago  breast  operated  on,  one  year 
ago  recurrence,  operated;  for  three  weeks  weakness  of  lees,  unable  to 
walk;  swelling  of  legs.  On  admission, — carcinoma  on  cuirasse;  re- 
flexes normal,  edema  left  hip,  spine  shows  marked  tenderness  of  7 
dorsal.     X-ray: — spine,  pelvis,  hips,  shoulders  negative  for  metastases. 

Case  20. — OX.  M.  M.  Female,  age  54.  Admitted,  December  9, 
1920;  died,  December  10,  1920.  Eight  years  ago  lump  in  breast;  op- 
erated on  April,  1919;  well  one  year,  then  pain  in  chest;  grew  weaker 
and  worse.  Five  months  ago  pain  more  severe;  increased  weakness 
and  incontinence ;  one  month  cannot  stand ;  now  transverse  myelitis 
with  bed  sores  and  complete  paralysis  below  hips. 

Case  21.— 02924.  B.  K.  Male,  age  56.  Admitted,  July  29,  1920; 
died,  September  4,  1920.  Eighteen  months  ago  influenza;  cough  per- 
sistent and  became  more  constant.     Four  months  drawing  pain  right 


354  EDGAR   D.    OPPENHEIMER 

arm  and  pain  right  chest  anteriorly.  August  18,  1920,  pain  left  gluteal 
region,  pain  and  marked  tenderness  left  sacro-iliac.  No  symptoms  of 
spine.  X-ray,  August  4,  1920,  beginning  bone  rarefaction  left  sacro- 
iliac and  right  humerus.  Other  bones  negative.  Autopsy: — primary 
tumor  right  lung,  metastases  left  lung,  ribs,  lower  spine,  direct  ex- 
tension of  tumor  into  superior  vena  cava. 

Case  22.— 02251.  J.  D.  Female,  age  56.  Admitted,  May  22,  1919; 
died,  June  21,  1919.  Nine  years  ago  amputation  of  left  breast;  one 
year  ago  pain  across  back ;  absent  when  lying  down ;  on  standing,  pain 
down  thighs  and  calves.  March  6,  1919,  tenderness  over  mid-lumbar, 
sacrum,  and  sacro-iliac  joints.  Diminished  power  in  wasting  right 
thigh.  K.  J.  absent,  no  tenderness  on  stretching  sciatic.  X-ray  showed 
extensive  involvement  of  lumbar  and  sacral  vertebrae.  On  admission: 
— inability  to  walk,  pain  in  back,  radiating  down  both  lower  extrem- 
ities. Incontinence,  edema  lower  extremities;  slight  scoliosis,  abdom- 
inal negative;  axillary  glands  palpable;  mass  above  sacrum;  vertebra 
not  tender  to  pressure;  sacrum  sensitive,  paraplegia  dolorosa.  X-ray, 
June  18,  1919,  pelvis  marked  rarefaction  and  destruction  throughout 
entire  pelvis,  process  most  marked  in  the  spine.  Marked  bilateral  hilus 
shadows  in  the  lungs. 

Case  23.— 02256.  R.  B.  Female,  age  40.  Admitted,  March  27,  1919; 
died,  June  23,  1919.  Ten  months  ago  amputation  right  breast;  three 
weeks  thereafter  sudden  sharp  pain  in  back  of  neck,  next  pain  in  right 
shoulder,  then  in  right  thigh,  so  severe  patient  could  not  walk.  Pain 
progressed  to  entire  back,  abdomen  and  into  left  thigh;  later,  chest 
and  entire  body  became  affected.  On  admission: — pain  all  over  body, 
sleeplessness,  constipation.  On  deep  palpation  back  of  neck,  abdo- 
men, chest  painful;  axilla  free  of  glands.  X-ray,  April  18,  1919, 
marked  evidence  of  small  areas  of  bone  destruction  throughout  bony 
system,  greatest  amount  in  bodies  of  10,  11,  12  dorsal. 

Case  24.— 01293.  Y.  D.  Female,  age  42.  Admitted,  January  7, 
1918 ;  discharged  July  8,  1918.  April  16,  1916,  noticed  lump  in  breast 
which  was  operated  on  in  June;  then  pain  in  right  leg.  X-ray  showed 
carcinoma.  Pains  in  right  hip  and  right  shoulder;  active  motion  lost 
due  to  pain.  Right  leg  one  and  one-half  inches  short.  February  27, 
1917,  pathological  fracture  humerus.  Tenderness  left  of  lumbar  spine. 
X-ray,  right  shoulder,  absorption  of  bone;  right  hip,  fracture  at  neck; 
much    destruction. 

Case  25.--01291.  R.  W.  Female,  age  40.  Admitted,  June  14,  1917 ; 
discharged,  July  7,  1917.  Two  years  ago  lump  in  left  axilla  noticed. 
Breast  operated  on  one  month  later;  second  operation,  January  12, 
1917.  On  admission: — pain  all  over  body,  especially  in  both  humeri, 
left  knee  and  back.  Local  recurrence  at  breast;  both  upper  extremi- 
ties edematous.  Abdominal  negative ;  shoulders,  hips,  and  spinous  proc- 
esses all  painful  on  pressure;  no  deformity,   slight  limitation  flexion 


EARLY   SYMPTOMS  OP   SPINAL   CANCER  355 

right  hip.    X-ray, — spine  and  shoulders  negative;  hips,  left  slight  de- 
struction below  acetabulum, — right,  slight  arthritic  changes. 

Case  26.— 01418.  M.  B.  Female,  age  48.  Admitted,  October  22, 
1917 ;  died,  October  27,  1917.  September,  1915,  vomiting  attacks.  Op- 
erated for  tumor  of  left  kidney;  five  months  ago  sitting  in  chair,  was 
unable  to  get  up,  had  pain  in  dorso-lumbar  region.  On  being  helped 
up  was  unable  to  straighten  back;  four  weeks  later  feet  began  to  swell; 
could  not  move  feet ;  sleeplessness  from  pain  in  back ;  last  ten  weeks 
lost  control  of  bladder,  then,  also  bowels.  On  admission: — right  but- 
tock ulcer,  paraplegia,  cystitis,  metastatic  carcinoma  dorsal  and  lum- 
bar spine  from  left  kidney. 

Case  27.— 02324.  R.  S.  Female,  age  35.  Admitted,  June  17,  1919; 
died,  July  28,  1919.  Nine  months  ago  severe  pain  in  region  of  stomach, 
and  headache.  Constant  pain  radiating  down  sides  of  legs.  Examin- 
ation shows  palpable  mass. attached  to  liver;  spinal  column  very  tender 
to  touch  at  8th  dorsal  and  below.  June  20,  complains  bitterly  of 
pains  in  back;  June  26,  incontinence,  pain  all  over  body.  Autopsy: — 
carcinoma  pancreas,  liver,  and  stomach,  involving  spinal  column. 

Case  28.— C2.  S.  T.  Female,  age  40.  Admitted,  June  17,  1920. 
Four  and  one-half  months  ago  while  stooping  found  that  she  could  not 
lift  her  lower  extremity  and  the  next  day  her  right.  Difficult  walk- 
ing, weak;  later,  stabbing  pain  and  burning  over  entire  back;  contin- 
uous sticking  pain  in  lower  part  of  right  chest.  May  12,  1920,  oper- 
ation, breast,  for  inoperable  carcinoma.  Angulation  to  left  at  3rd  and 
4th  dorsal.  On  admission: — weakness,  arms  and  legs,  reflexes  in- 
creased. June  25,  1920,  local  pain  in  first  and  second  lumbar;  no  sen- 
sory changes.  January  16,  1921,  no  pains  now  in  back;  spine  some- 
what sensitive;  gradual  kyphos.  X-ray,  June  21,  1920,  rarefaction 
of  bones  of  spine,  rather  indefinite. 

Case  29.—  C2.  S.  L.  Female,  age  42.  Admitted,  September  22, 
1920.  Breast  operation  two  years  ago;  four  months  ago  feeling  of 
cold  all  over  body ;  three  months  ago  edema  of  left  arm,  weakness,  left 
facial  palsy,  left  knee  swollen  and  tender.  On  admission: — local  re- 
currence, left  knee  swollen  and  tender.  X-ray,  October  4,  1920,  left 
tibia,  fibula,  femur  show  a  few  spots  of  rarefaction.  Moderate  irreg- 
ular rarefaction  throughout  upper  sacrum. 

Case  30.— C3.  J.  S.  Male,  age  57.  Admitted,  April  21,  1920.  De- 
cember 29,  1919,  suprapubic  operation  for  bladder  stone.  Adenoma 
with  carcinomatous  changes,  also  carcinoma  prostate.  June  19,  pain 
left  loin  downward  to  thigh, — urinary  disturbance.  On  admission: — 
weakness,  especially  legs,  constipated,  pain  side  of  thigh,  inoperable 
prostate  carcinoma.  July  7,  1920,  pain  left  femur,  local  tenderness. 
January  17,  1921,  spine  tender  at  places,  but  can  walk.     X-ray,  July 


356  EDGAR    D.    OPPENHEIMER 

15,   1920,   cervical  spine  negative.     August  10,   1920,  small  areas  de 
struction  third  cervical.     Extensive  diffuse  rarefaction  upper  part  of 
femur. 

Case  31.— Wl.  S.  G.  Male,  age  88.  Admitted,  July  23,  1920. 
About  six  months  ago  weakness  of  both  legs,  progressive  until  unable  to 
stand,  followed  in  one  month  by  inability  to  urinate.  Three  months 
ago  prostatectomy  for  enlarged  prostate.  On  admission : — inability 
to  stand  or  walk,  no  bladder  or  rectal  disturbance,  no  pain,  paresthe- 
sia or  swelling  of  extremities.  Later,  there  developed  signs  of  local 
cord  lesion  with  a  zone  of  hyperesthesia  across  chest  and  paresthesia 
of  left  lower  extremity  more  than  right.  Distinct  depression  at 
height  of  tenth  dorsal  vertebra,  slight  sensitiveness  over  entire  spine. 
Hard  nodule  region  of  prostate  now  felt.  X-ray: — Arthritis  of  second 
and  third  lumbar,  otherwise  negative. 

Case  32.— E2.  E.  O'G.  Female,  age  27.  Admitted,  October  4,  1920. 
September,  1918,  breast  amputation.  October,  1919,  to  hospital  for 
back  complaints,  pain  and  weakness  in  lumbar  region.  Spinal  corset 
gave  no  relief.  Several  x-rays  were  negative;  January,  1920,  at  an- 
other hospital,  x-rays  diagnostic.  Radium  treatments  given.  June  and 
July,  well  again.  On  admission : — complaint  for  sixteen  months  of 
stiffness  in  back  and  pains  in  back  radiating  down  thighs.  Cannot 
walk,  but  can  stand.  X-rays  show  very  marked  bone  destruction  of 
pelvis  and  spine.  January,  1921,  free  from  pain  and  has  no  tenderness 
on  local  pressure  of  spine  and  pelvis;  sensorium  intact;  distinct  de- 
pression fifth  dorsal  vertebra  and  kyphos  upper  dorsal.  Increased  re- 
flexes and  spasticity  of  legs;  marked  loss  of  weight,  signs  of  cord  com- 
pression. 


LOWER  BACK  PAIN  357 


A  STUDY  OF  206  CASES  OF  LOWER  BACK  PAIN. 

BY    J.    R.    KITH,    M.D.,    DULUTH,    MINNESOTA. 

Complaint  of  pain  in  some  area  of  the  lower  back  is  a  very  com- 
mon one  in  many  conditions.  In  many  cases  it  is  the  sole  complaint,  is 
chronic,  and  the  etiology  is  more  or  less  obscure.  After  thorough  phy- 
sical examination  the  objective  findings  are  so  meagre  and  indefinite 
that  one  is  unable  to  point  to  a  definite  area  or  to  a  definite  lesion  and 
say  the  symptoms  are  due  to  such  an  injury  or  to  such  a  disease  located 
in  this  or  that  tissue.  These  patients  form  a  large  class  commonly  seen 
in  private  practice  and  in  the  practice  of  the  various  specialties.  The 
chronicity  of  these  cases  and  the  eagerness  with  which  these  patients 
seek  relief  indicate  the  seriousness  of  the  condition  and  the  difficulty 
of  its  successful  treatment. 

The  present  study  concerns  itself  with  208  cases  of  low  back  pain. 
It  does  not  include  cases  of  obvious  or  manifest  disease  or  injury  of 
the  lower  back  structure  such  as  tuberculous,  typhoid  or  syphilitic  dis- 
ease of  the  spine ;  gross  traumatic  lesions  of  the  spine  or  cord  or  lesions 
of  the  cord  itself.  During  the  period  in  which  these  cases  were  ob- 
served, many  women  with  low  back  pain  were  examined  and  followed 
for  a  time.  These  rightfully  belong  in  this  series  but  are  not  included 
because  of  insufficient  data. 

There  were  in  the  series  136  males  and  72  females.  The  average  age 
of  the  patients  was  37  years  (the  youngest  was  12  and  the  oldest  70). 
In  180  cases,  previous  attacks  during  the  preceding  years  were  admit- 
ted by  80,  and  denied  by  100.  In  75  cases,  possible  trauma  was  given 
as  a  cause  for  the  trouble,  in  77  there  was  no  knowledge  of  any  injury. 
Tn  6,  the  trouble  preceded  or  followed  childbirth. 

In  182  individuals,  in  which  the  general  build  and  their  physical 
characteristics  were  noted,  93  were  classed  as  tall  or  short  but  strong 
and  muscular,  55  as  very  fleshy  or  overweight,  7  as  small  and  thin 
but  strong,  27  were  noted  as  tall,  thin,  and  weakly.  Ninety-nine  males 
followed  so-called  arduous  occupations  (farmers,  factory  and  ordinary 
laborers,  miners,  dock  and  railroad  laborers) ,  37  were  classed  as  clerks 
or  professional.  Of  the  72  females,  56  were  housewives  and  the  re- 
mainder followed  the  more  or  less  exerting  occupations  of  women. 

Pain  in  the  lower  half  of  the  back  was  the  chief  complaint  in  all 
cases.  It  was  localized  by  the  patient  either  in  the  middle,  or  to  one 
or  both  sides.  The  most  frequent  site  (see  Figs.  1  and  2)  was  the  sacro- 
iliac area  (97  times).  Next  in  frequency  were:  the  lumbar  area  (55 
times),  lumbo-sacral  area   (31  times),  gluteal  area   (19  times),  dorso- 


358 


J.    R.   KUTH 


AREA 

GROUP  ! 

P 

L    i 

E  &  L 

MID 

TOTAL 

Doraal 

I 

0 

0 

0 

2 

2  ) 

II 

0 

0 

0 

0 

0  ) 

Dprso-lumbar 

I 

0 

0 

0 

6 

6  ) 

II 

0 

0 

0 

5 

5  ) 

Lumbar 

I 

2 

2 

20 

0 

24  ) 

II 

7 

8 

16 

0 

31  ] 

Lumbo-caoral 

I 

1 

0 

0 

10 

11  ) 

II 

4 

0 

0 

16 

20  ] 

Sacro -iliac 

I 

7 

4 

3 

14  ) 

II 

37 

40 

6 

83  ) 

Midsacral 

I 

a 

0  ) 

II 

1 

1  J 

Goocra 

I 

4 

4  ) 

II 

0 

0  ) 

Gluteal 

I 

1 

0 

0 

1  ) 

II 

6 

10 

2 

18  1 

11 


55 


31 


97 


lumbar  area  (11  times),  coccygeal  area  (4  times),  dorsal  area  (2  times), 
and  in  the  midsacral  area,  once.  In  a  little  over  one-half  the  cases 
pain  was  noted  as  being  in  one  area  only.  In  the  others  several  areas 
were  complained  of  at  the  same  time,  these  as  a  rule  on  the  same  side 
(Figs.  1  and  2). 

Aside  from  the  pain  in  the  lower  back,  149  cases  complained  of  other 
pains  radiating  into  the  lower  extremities;  in  140,  the  pain  followed 
down  the  posterior  thigh  and  often  into  the  outer  aspect  of  leg  and 
foot.  Five  of  these,  together  with  9  others,  who  complained  of  no  pos- 
terior thigh  pains,  complained  of  pain  in  the  anterior  thigh.  These  thigh 
and  leg  pains  were  noted  as  appearing  on  the  right  side  53  times,  and 
the  left  side  60  times,  and  in  both  lower  extremities  23  times ;  in  4  cases 
the  side  was  not  noted.  .  These  pains  were  always  found  on  the  same 
side  as  back  pain  or  on  the  side  where  the  back  pains  were  severest. 
In  59  cases  there  were  no  complaints  of  leg  pains. 

When  pains  were  present  in  more  than  one  area  there  was  noted  a 
variation  in  the  time  of  the  onset.  As  examples  of  this  these  extracts 
from  the  following  case-histories  may  serve. 


LOWER  BACK  PAIN 


359 


Fig.  1. 


Case  1.  S.  Male,  age  36.  A  dull  lumbar  ache  for  one  year,  followed 
gradually  by  pain  localized  over  the  left  sacro-iliac  area. 

Case  2.  G.  Male,  age  43.  (1)  Left  lumbar  pain.  (2)  After  some 
weeks,  a  left  gluteal  pain.  (3)  Some  days  later,  posterior  thigh  pain. 
(Following  slight  trauma.     Marked  static  abnormality.) 

Case  3.  G.  Female,  age  26.  (1)  General  backache  following  a  fall. 
(2)  Some  days  later,  pain  over  the  left  sacro-iliac  area.  (3)  This  was 
followed  one  week  later  by  left  posterior  thigh  pain.    (Trauma.) 

Case  4.  D.  J.  Male,  age  41.  (1)  Pain  in  left  lumbar  area  following 
a  strain  from  lifting.  (2)  Suddenly,  four  days  later,  pain  in  the  left 
sacro-iliac  and  gluteal  areas  and  shortly  thereafter  pain  in  the  posterior 
thigh.    (Trauma.) 

Case  5.  R.  Male,  age  35.  (1)  Pain  midlumbar  area,  gradual  onset. 
(2)  Three  days  later  pain  in  the  left  sacro-iliac  area.  (3)  Somewhat 
later,  pain  in  left  posterior  thigh.  No  trauma.  (Static  from  an  old 
fracture  of  the  right  leg  three  and  one-half  years  previously.)  Dura- 
tion of  symptoms,  six  months. 

Case  6.  T.  Male,  age  26.  (1)  Sudden  pain  in  the  right  gluteal  area 
following  a  jump.  (2)  Ten  days  later  sudden  pain  in  right  posterior 
thigh.    (Trauma.) 


360 


J.    R.    KUTH 


Case  7. 
ing  hard. 
(Strain.) 

Case  8. 
left  foot. 


Fig.  2. 


G.   Male,  age  42.    (1)    Pain  in  right  gluteal  area  after  pull- 
(2)    Gradually,  after  four  days,  pain  in  posterior  right  thigh. 


M.  Female,  age  42.  (1)  Four  months  ago  a  bed  fell  on  her 
(2)  Ten  hours  later  pain  along  outer  aspect  of  left  leg  and 
posterior  left  thigh.  (3)  Shortly  after  this,  lumbo-sacral  pain.  Some- 
time later  this  patient,  a  very  intelligent  woman,  while  sitting  in  a  bath 
tub,  found  that  flexing  her  left  thigh  with  the  leg  extended,  relieved 
the  lumbo-sacral  pain.  She  persisted  in  this  exercise  and  states  that 
this  cured  her  lumbo-sacral  pain.  Her  posterior  thigh  and  leg  pain, 
however,  persisted.    (Static?) 

Case  9.  K.  Male,  age  43.  (1)  Dull  ache  over  the  sacrum,  gradual 
onset,  no  trauma.  (2)  Gradually,  two  weeks  later,  left  posterior  thigh 
pain.    (Occupational  strain?) 

Case  10.  M.  Female,  age  42.  (1)  Lumbar  pain,  gradual  onset. 
(2)  Two  weeks  later  sudden  posterior  thigh  pain.  (Heavy,  overhang- 
ing abdomen,  very  fleshy,  static;    chronic  nephritis.) 

Case  11.     M.   Male,  age  29.    (1)    Sudden  pain  in  left  sacro-iliac  area 


LOWER  BACK  PAIN  361 

followed  immediately  by  pain  in  left  posterior  thigh,  after  lifting  a 
piano.    (Strain.) 

Case  12.     M.   Male,  age  32.    (1)    Lumbo-sacral  pain,  gradual  onset 
five  years  ago.    (2)    One  week  later,  gradual  onset  of  pain  in  left  p« 
terior  thigh  and  leg.    At  present,  complete  left  paralytic  drop-foot.    So 
far  as  patient  knows,  the  drop-foot  has  developed  gradually.     Lumbo- 
sacral pains  persist.  (Underground  miner,  static.) 

Case  13.  H.  Male,  age  45.  (1)  Chronic  backache  for  many  years, 
off  and  on  at  short  intervals.  (2)  High  lumbar  pain,  bilateral,  sudden- 
ly, two  months  ago.  (3)  Disappearance  of  this  lumbar  pain  for  two 
weeks  after  a  rest.  (4)  Sudden  pain  in  the  right  sacro-iliac  area  and 
in  posterior  thigh.    (Osteoarthritis  of  lumbar  spine.) 

For  purposes  of  further  analysis,  the  cases  are  separated  into  three 
groups  according  to  the  distribution  of  pain : 

Group  I.     59  cases,  those  with  back  pains  only. 

Group  II.  140  cases,  those  with  low  back  pains  and  posterior  thigh 
and  leg  pains. 

Group  III.  14  cases,  those  with  low  back  pains  and  pains  distributed 
other  than  down  the  posterior  thigh  and  leg.  Five  of  these  later  cases 
are  also  included  in  Group  II. 

Table  No.  2  shows  the  character  of  pain  as  noted  in  the  case  histories. 
Pain  aggravated  by  turning  in  bed  or  by  rising  from  the  lying  or  sit- 
ting position,  or  by  lifting,  stooping  or  walking  and  relieved  by  lying 
down  is  noted  under  the  heading,  "Pain  worse  on  movement."  Pain 
aggravated  when  lying  down  or  sitting  still  and  better  when  moving  or 
walking  is  noted  under,  "Pain  worse  when  quiet."  One  woman 
claimed  relief  from  a  chronic  low  back  pain  only  when  pregnant. 

Movement  in  the  back  or  lower  extremities  was  found  limited  in  many 
cases.  In  many  this  limitation  was  only  in  flexion  of  the  spine,  exten- . 
sion  being  free.  In  others  both  movements  were  more  or  less  limited. 
In  others  again,  lateral  movements  were  mostly  affected.  By  placing 
the  patient  on  his  hands  and  knees, — "on  all  fours" — flexion  and  exten- 
sion of  the  lumbar  spine  could  be  easily  obtained  in  many,  actively 
and  passively,  demonstrating  the  condition  to  be  one  of  short  or  spastic 
muscles.  In  the  definitely  arthritic  spines  the  movements  remained 
limited  under  these  same  conditions. 

When  the  thigh,  with  leg  fully  extended,  was  flexed  at  the  hip,  limi- 
tation of  this  movement  was  noted  in  many  cases.  In  many  it  was  ac- 
companied by  a  pain  in  the  posterior  thigh  and  leg  or  in  the  lower, 
back.  Hyperextension  of  the  thigh  at  the  hip  was  also  limited  in  many 
of  these  cases. 

A  strikingly  flat  back,  or  a  backward  curve  in  the  lumbo-sacral  area, 


362  J.   R.   KUTH 

was  noted  in  some  of  the  cases.  In  others,  again,  there  was  present  a 
definite  list  of  the  body  to  one  side  or  the  other. 

Table  No.  3  shows  the  relative  absence  and  frequency  of  the  above 
findings. 

In  twenty-eight  cases  of  Group  II,  all  of  the  above  mentioned  findings 
were  present.  In  thirteen  of  this  group  there  were  no  other  signs  than 
the  localized  back  pain  and  tenderness  and. the  posterior  thigh  and  leg 
pain. 

Findings  having  a  bearing  on  the  etiology  of  these  cases  are  listed 
under  various  headings  in  Table  No.  6. 

1.  Under  static  factors  were  listed  the  following  when  at  all  marked : 
a  short  leg  on  one  side ;  old  fractures  of  the  lower  extremities  with  mal- 
alignment; deformity  of  the  feet;  excessively  fleshy  persons  with  large 
pendulous  bellies;  and  very  manifest  cases  of  general  fatigue,  weakness 
and  anemia.  There  were  also  included  four  cases  in  which  the  x-ray 
showed  a  definite  lipping  on  one  side  of  the  body  of  the  5th  lumbar 
vertebra.  In  the  absence  of  any  previous  injury  or  signs  of  infection, 
these  were  interpreted  as  being  static  in  character. 

Case  14.  Mrs.  B.  Female,  age  36.  Short,  fleshy,  housewife.  Dura- 
tion of  symptoms  five  months.  No  previous  attack.  No  known  trauma. 
Pain  in  the  right  sacro-iliac  and  in  posterior  right  thigh  and  outer  leg. 
Straight  leg  raising  restricted  and  painful  on  both  sides.  Slight  limi- 
tation of  motion  in  the  lower  back.  Trendelenburg  phenomenon  pres- 
ent on  the  right  side.  Marked  degree  of  flaccid  flat-foot  and  ankle 
valgus  on  both  sides.  X-ray  examination  of  spine  and  pelvis  negative. 
Both  hip  joints  normal.  Operation  for  hyperthyroidism  one  year  pre- 
viously. A  well-fitting  corset;  shoe  alterations  and  gradual  exercises 
were  followed  by  a  gradual  but  steady  improvement.     See  also  Case  5. 

2.  Those  cases  were  considered  traumatic  in  which  symptoms  fol- 
lowed upon  falls,  direct  blows  or  upon  sudden  strains  from  heavy  lift- 
ing. Also  cases  in  which  symptoms  followed  suddenly  upon  slight  move- 
ment and  those  cases  in  which  x-ray  gave  evidence  of  trauma. 

Case  15.  Mrs.  C.  Female,  age  45.  Strong,  large,  and  fleshy.  Dur- 
ation of  symptoms  one  month.  No  previous  attacks.  Following  im- 
mediately on  a  fall  on  left  lower  back,  large  hematoma  over  left  sacro- 
iliac area.  Pain  and  tenderness  over  left  sacro-iliac  area.  Limitation 
of  straight  leg  raising,  left  more  than  right.  Lower  back  movements 
limited  in  all  directions.  Pain  radiating  down  left  posterior  thigh; 
pain  very  severe  and  worse  on  slightest  movement.  X-ray  examination 
negative.  Treatment  by  heat,  massage,  and  graduated  active  exercises. 
Litigation.     Gradual  improvement  in  four  months. 


LOWER  BACK  PAIN  363 

Cvse  16.  T.  Malf.  aire  37.  Teacher,  tall,  thin.  Duration  one  day. 
Previous  attacks  five,  ten,  fifteen  years  ago.  Regan  suddenly  and  was 
caused  hy  bending  over  to  pick  something  from  floor.  Sudden  pain  ii: 
the  right  sacro-iliac  area  and  posterior  thigh  pains.  Straight  leg  rais- 
ing restricted  and  painful,  lower  back  movements  slightly  restricted. 
A  narrow  belt  around  hips  above  trochanters  gives  instant,  complete 
relief. 

3.  Infections  were  considered,  when  local  and  general  signs  point- 
ing to  an  inflammatory  lesion  of  osseous,  ligamentous,  muscle  or  joint 
structures  were  present.  Included  were  cases  following  cold  and  ex- 
posure; those  in  which  osteoarthritic  changes  were  found  in  the  ver- 
tebral or  pelvic  joints  by  x-ray. 

Furthermore,  infection  was  suspected  in  those  cases  where  definite 
foci  of  infection  (tonsils,  teeth,  genito-urinary,  etc.)  were  present  and 
in  all  cases  with  complete  limitation  of  joint  movement  in  all  directions. 

Case  17.  M.  Male,  age  12.  Tall;  thin  boy.  Duration  of  symptoms 
two  weeks.  Severe  pain  in  lower  back  and  left  posterior  thigh  and  leg. 
No  previous  attack.  No  trauma.  Pain  in  the  left  sacro-iliac  area. 
Straight  leg  raising  very  limited  and  causes  pain  in  left  sacro-iliac  area. 
Rack  movements  limited  in  all  directions.  Rackward  curve  in  lumbo- 
sacral area.  Pain,  tenderness,  and  swelling  in  lower,  left  lumbar  area. 
A  short  time  previously  he  had  been  operated  upon  for  mastoid  disease 
and  this  was  later  followed  by  sinus  thrombosis,  and  a  little  later  by  the 
present  low  back  symptoms.  Draining  of  a  small  abscess  of  the  left 
erector  spina?  muscle  caused  prompt  and  permanent  disappearance  of 
symptoms. 

Case  18.  J.  M.  Male,  age  25.  Medium  size,  short,  muscular.  Dur- 
ation of  symptoms  one  month.  Regan  suddenly,  worse  at  night  and 
when  lying  down,  more  comfortable  when  up.  No.  previous  attacks, 
no  injury.  Pain,  tenderness,  swelling  and  increased  local  heat  over 
right  sacro-iliac  area  and  down  the  right  posterior  thigh.  Straight  leg 
raising  restricted  and  painful  on  the  right  side.  Walks  with  a  forward 
stoop  and  stands  with  a  list  of  the  body  to  the  left.  Was  given  one  dose 
of  morphine  sulphate,  large  doses  of  sodium  salicylate,  local  applica- 
tions and  bed  rest.  This  was  followed  by  prompt  improvement  within 
a  few  days. 

Case  19.  W.  Male,  age  28.  Medium  build,  thin,  but  fairly  muscular. 
Pain  very  severe  on  movement  in  lumbar  area  to  both  sides.  Dura- 
tion two  months.  Previous  attack  three  years  ago.  No  trauma.  Pain 
alternately  in  right  and  left  posterior  thigh.  Movements  of  the  lower 
back  limited.  Leucocyte  count  10,000.  X-ray  shows  osteoarthritis  in 
the  body  of  the  5th  lumbar  vertebra.  Plaster  of  Paris  jacket  worn 
with  relief  for  a  time.  This  was  followed  by  a  modified  Taylor  brace. 
Patient  later  went  elsewhere  and  had  a  bone  graft  inserted  into  the 


364  J.   R.   KUTH 

lower  back.    Improvement  was  slow  when  last  seen  about  eight  months 
after  the  bonegraft  operation. 

4.  Cases  following  pelvic  disease  in  women,  or  after  operation  for 
pelvic  troubles,  and  those  associated  with  pregnancy  or  parturition, 
are  classed  as  gynecologic. 

Case  20.  Mrs.  F.  Female,  age  35.  Married,  music  teacher,  large 
frame,  muscular,  poorly  nourished.  History  of  many  miscarriages. 
Pain  and  tenderness  over  both  sacro-iliac  areas  with  posterior  thigh 
and  leg  pains  for  a  long  time  and  more  or  less  steady.  No  trauma.  No 
restriction  of  motion  or  pain  on  straight  leg  raising.  No  limitation 
of  movement  in  the  back.  No  deformity  or  deviation  of  body.  States 
that  she  is  free  from  these  pains  only  when  she  is  pregnant.  Pelvic 
examination  negative,  Wassermann  negative.  Marked  improvement 
after  wearing  properly  fitting  corset  and  a  short  course  of  anti-luetic 
treatment. 

5.  Five  cases  were  associated  with  demonstrable  nerve  lesions. 

Two  cases  had  paralytic  drop-foot  (see  Case  12),  one  of  these  fol- 
lowing a  severe  injury  with  traumatic  lesion  in  the  5th  lumbar  verte- 
bra. One  case  (spina  bifida)  of  mild  paralytic  pes  equino-varus.  One 
case  had  recurrent  attacks  of  sudden  pain  and  blanching  in  each  great 
toe.  One  case  with  recurrent  attacks  of  stiffness  and  pain  in  the  lumbar 
area  and  with  pain  and  weakness  in  both  posterior  thighs  very  much 
resembling  an  infectious  arthritis.  Symptoms  of  transverse  myelitis  of 
the  cord  gradually  developed.  At  operation  this  proved  to  be  a  cystic 
(hemorrhagic)  degeneration  below  the  lumbar  enlargement  of  the  cord. 

6.  In  five  cases  malignancy  was  considered  as  the  probable  cause. 
In  one  case  (M.,  age  49,  operated  upon  for  carcinoma  of  the  stomach  one 
\ear  previously)  symptoms  of  pain  and  tenderness  in  the  right  lower 
back  and  opposite  the  right  5th  lumbar  transverse  process,  and  in  the 
left  sacro-iliac  area,  and  pain  in  the  left  posterior  thigh  of  eight  weeks' 
duration  became  progressively  worse  and  death  from  metastases  fol- 
lowed two  months  later.  In  a  similar  case  the  symptoms  followed  nine 
months  after  an  operation  for  carcinoma  of  the  breast,  and  continued 
progressively  until  death  eight  months  later.  In  one,  symptoms  began 
some  time  after  operation  for  suspected  malignancy  (ovarian  tumor) 
and  became  progressively  worse  while  the  patient  was  under  observa- 
tion. The  patient  was  later  lost  sight  of.  In  two  other  cases  the  symp- 
toms were  those  of  marked  osteoarthritis  of  the  lumbar  spine.  In  one 
of  these  the  x-ray  was  typical  of  an  extensive  osteoarthritis  but  the  pa- 
tient became  progressively  worse  and  died  of  metastases  ten  months 


LOWER  BACK  PAIN  365 

later  (sarcoma).    In  the  other  case  death  occurred,  after  symptoms  had 
progressed  steadily,  in  four  months  (no  autopsy.) 

7.  Of  the  cases  in  which  lues  was  a  possible  factor  (history  or  posi- 
tive Wassermann)  two  are  given. 

Case  21.  Mrs.  V.  Female,  age  25.  Married,  housewife,  large,  strong, 
muscular.  A  fall  off  a  step  one  year  previously  was  followed  by  pain 
in  the  posterior  left  thigh  and  pain  and  tenderness  in  the  right  lower 
abdomen.  (Appendectomy  had  been  performed  some  two  months  b$- 
fore  for  this  pain.)  Similar  attack  some  years  previously.  Straight 
leg  raising  was  restricted  and  painful.  Lower  back  movements  free. 
Indication  of  Trendelenburg  phenomenon  on  the  right  side;  atrophy  ia 
the  left  calf.  Wassermann  4+  repeatedly.  X-ray  examination  was 
negative.     Vigorous  anti-luetic  treatment  was  without  effect. 

Case  22.  M.  Male,  age  40.  Married,  salesman,  large,  fleshy,  hypo- 
pituitary  type.  Five  months  ago  pain  gradually  developed  in  the 
left  gluteal  area  and  extended  down  the  posterior  left  thigh.  No  in- 
jury. No  previous  attacks.  Fifteen  years  ago,  chancre.  Pain  severe 
and  continuous ;  worse  on  movement.  Straight  leg  raising  very  limited 
and  painful  on  both  sides.  No  limitation  of  lower  back  (joint)  move- 
ment, marked  list  of  body  to  the  right.  Reflexes,  inclusive  of  pupillary, 
normal.  No  pathological  reflexes.  Both  lower  extremities  normal. 
Very  apprehensive  mental  state.  Blood  Wassermann  negative.  Spinal 
fluid:  cell  count  11,  Wassermann  3+,  no  globulin.  Short  anti-luetic 
treatment  without  any  effect.     Three  weeks  later,  suicide. 

8.     Tuberculosis  was  a  positive  factor  in  two  cases. 

Case  23.  Mrs.  J.  Female,  age  31.  Tall,  very  emaciated.  Pain  and 
tenderness  in  the  right  sacro-iliac  area  and  in  the  right  posterior  thigh. 
Began  gradually  four  weeks  ago.  No  previous  attacks.  No  trauma. 
Straight  leg  raising  limited  on  the  right  side.  All  movements  of  the 
lower  back  absent.  Walks  stooped  forward.  No  deviation  of  body  to 
the  side.  Trendelenburg  phenomenon  present  on  the  right  side.  Walk- 
ing and  coughing  causes  pain  over  the  sacro-iliac  area.  A  soft  swelling 
over  the  right  sacro-iliac  area.  Active  pulmonary  tuberculosis.  X-ray 
shows  destruction  at  the  right  sacro-iliac  joint. 

Case  24.  R.  Male,  age  23.  Gradual  onset  two  months  ago  with 
symptoms  of  low  lumbar  pain  of  an  indefinite  character.  Moderate 
limitation  of  movement  of  the  lower  back.  Negative  x-ray  (Group  1). 
There  appeared  eight  months  later  a  large  lumbar  abscess  showing  the 
true  nature  of  the  process  which  had  not  been  suspected. 

X-ray  examinations  were  made  in  all  but  thirty-four  cases.  In  most 
cases  the  plates  were  found  to  be  negative.  Positive  findings  were  noted 
as  follows:  Osteoarthritis  of  the  lumbar  spine,  ten  cases  (seven  in 
Group  II)  ;  arthritic  changes  (lipping)  in  body  of  5th  lumbar  vertebra, 


366  J.    R.   KUTH     ■> 

nine  cases  (eight  in  Group  II)  ;  anomaly  of  transverse  processes  of  fifth 
lumbar  vertebra,  nine  cases  (five  in  Group  II)  ;  spina  bifida  occulta,  one 
case  (Group  II)  ;  arthritic  change  in  one  sacro-iliac  joint  (lipping  of 
lower  edge)  in  one  case  (Group  II)  ;  and  a  roughening  or  spur  forma- 
tion on  one  iliac  crest,  one  case  (Group  I).  In  three  cases  of  Group  II 
there  was  present  an  apparent  widening  of  the  sacro-iliac  joint  of  one 
side.  In  one  case  (Group  I)  there  was  present  a  tear  fracture  of  the 
end  of  the  transverse  process  of  the  first  lumbar  vertebra. 

Anomalies  of  the  transverse  process  of  the  5th  lumbar  vertebra  in- 
cluded clubbing,  sacralization,  and  impingement  of  the  process.  The 
following  are  brief  case  reports  of  these. 

Case  25.  D.  Male,  age  38.  Troubled  off  and  on  for  three  years. 
Pain  in  the  right  and  left  sacro-iliac  areas.  No  posterior  leg  pains. 
Clubbed  5th  lumbar  transverse  process. 

Case  26.  R.  Female,  age  34.  Four  days'  duration,  similar  attack 
two  years  ago.  Present  symptoms  brought  on  by  a  very  slight  move- 
ment, reaching  for  something.  Pain  over  the  fifth  right  lumbar  trans- 
verse process.  Very  free  leg  movements.  Flexion  and  extension  of  the 
lower  back  limited.  Pain  constant,  severe,  on  slightest  movement.  En- 
larged right  transverse  process.  This  patient  was  very  short  and 
fleshy. 

Case  27.  S.  Female,  age  23.  Duration  four  years.  Began  grad- 
ually, following  birth  of  last  baby.  Lumbo-sacral  pain.  Appendix  re- 
moved for  this  trouble  a  short  time  ago.  Very  fleshy.  Steady  pain  day 
and  night,  worse  on  walking.  No  muscle  spasm.  Left  5th  lumbar 
transverse  process  clubbed  with  articular  facet  for  sacrum. 

Case  28.  P.  Female,  age  26.  Tall,  stooped,  thin,  enteroptotic. 
Many  miscarriages.  Lower  backache.  No  limitation  of  straight  leg 
raising.  Movement  limited  in  left  lower  back.  Back  flat.  Body  list 
to  the  left.  Flexion  causes  prominence  in  left  lower  back.  Flat-foot. 
Splay  foot.  Feet  functioned  well.  Pelvis  negative.  Wassermann  neg- 
ative.   Sacralized  5th  left  lumbar  transverse  process. 

Case  29.  Female,  age  33.  Tall,  thin,  bony,  poorly  nourished.  Six 
months'  duration.  Previous  attack  ten  years  ago.  No  trauma.  Pain 
in  left  lower  back.  No  limitation  of  straight  leg  raising.  No  symptoms 
of  muscle  spasm.  Pelvic  operation  some  years  ago.  At  times  lying 
down  aggravates  the  trouble.  Impingement  of  the  left  5th  lumbar 
transverse  process. 

Case  30.  C.  Male,  age  39.  Three  months'  duration.  No  previous 
attack.  No  trauma.  Trouble  followed  cold  and  exposure.  Pain  in 
the  right  sacro-iliac  area.     limitation  of  straight  leg  raising  on  the 


LOWER  BACK  PAIN  367 

eight    Back  movements  limited.    List  to  the  left.    Sacralized  5th  right 
lumbar  transverse  process. 

Case  31.  P.  Male,  age  31.  Tall  and  muscular.  Two  months '  dura- 
tion. Pain  in  the  right  and  left  sacro-iliac  areas.  Posterior  thigh  pains 
right  and  left  alternately.  Straight  \v<:  raising  limited,  right  and  left. 
Back  movements  limited.  Flat  back.  Very  marked  list  to  left.  No 
trauma.  Prompt  relief  followed  Buck's  extension  and  plaster  jacket. 
Enlarged  5th  lumbar  transverse  process.  (Six  months  later  appendix 
removed.) 

Case  32.  W.  Female,  age  38.  Duration  twelve  years  "most  all  the 
time."  A  direct  injury  fourteen  years  previously  in  which  the  coccyx 
was  traumatised.  Pains  in  the  lumbo-sacral  and  left  sacro-iliac  areas. 
No  limitation  of  straight  leg  raising.  Back  limited  in  flexion  only.  De- 
formed coccyx  could  be  felt.  A  large  club-shaped  5th  lumbar  trans- 
verse process  right  and  left.  Coccyx  removed  under  local  anesthetic. 
Complete  immediate  relief.     No   other  treatment. 

Case  33.  K.  Male,  age  34.  Duration  three  months.  Similar  attack 
seven  years  ago.  Sudden  onset,  no  injury.  Pain  in  the  sacro-iliac 
area,  the  right  worse  than  the  left.  Limitation  of  back  movement.  Tall 
and  muscular.  Sacralized  5th  lumbar  transverse  process  on  the  right 
side. 

The  following  are  other  cases  in  which  abnormalities  were  noted  on 
radiographic  examination. 

Case  34.  C.  Male,  age  40.  Medium  size  and  build,  poorly  nourished 
and  poor  general  musculature.  Duration  of  symptoms  four  weeks. 
No  previous  attack.  Began  suddenly  with  no  known  trauma.  Low 
lumbar  back  pain.  Straight  leg  raising  much  limited  on  the  right  side 
and  some  pain  over  the  area  of  the  right  5th  lumbar  transverse  pro- 
cess. Back  movements  all  limited.  Walks  with  a  forward  stoop.  Re- 
cent acute  attack  of  tonsillitis.  X-ray  examination  shows  spur  forma- 
tion on  the  right  iliac  crest.  A  fewT  days  later  man  returned  stating 
that  immediately  after  the  examination  his  symptoms  left  him.  No 
sudden  phenomenon  was  noted  by  him  during  the  examination.  •He 
has  remained  well  since. 

Case  35.  L.  Male,  age  30.  Tall,  muscular.  Pain  and  tenderness 
over  the  right  sacro-iliac  area,  six  months'  duration.  Began  grad- 
ually following  a  tonsillar  abscess.  Had  an  attack  much  like  the  pres- 
ent one  some  years  ago.  No  trauma.  Straight  leg  raising  limited  on 
the  right  side.  Lower  back  movements  all  limited.  ^Marked  list  of  body 
to  the  left.  Tonsils  pathological.  X-ray  examination  shows  definite 
lipping  of  the  lower  edge  of  the  right  sacro-iliac  joint.  Case  not 
followed. 


368  J.    R.    KUTH 

Treatment  of  these  cases  was  carried  out  by  various  means:  13$ 
were  treated  by  some  form  of  mechanical  support  (pelvic  and  back 
braces,  abdominal  supports,  corsets,  canvas  belts,  and  plaster  jackets)  ; 
25  by  correction  of  static  abnormalities  in  the  feet  (shoe  alterations)  ; 
18  by  hyperflexing,  under  general  anesthesia,  the  extended  leg  and 
thigh  on  the  abdomen;  17  by  leg  extension  (weight  and  pulley).  In 
a  few  other  cases  bed  rest  and  internal  medication  were  used.  In  one, 
au  abscess  on  a  lumbar  muscle  was  drained  and  in  three  a  dislocated 
coccyx  was  removed  (Case  32).  All  cases,  except  those  definitely 
arthritic,  were  given  active  exercises  for  the  back  and  lower 
extremities. 

Improvement  was  at  times  very  rapid  and  pronounced.  This  was 
especially  true  of  all  cases  after  forcible  manipulation  under  ether, 
and  twice  by  simple  manipulation  during  examination.  At  other  times 
the  application  of  a  simple  strap  above  the  trochanters,  or  a  low,  snug 
fitting  corset  or  brace,  gave  relief  no  less  prompt  and  complete. 

In  two  cases,  after  forcible  manipulation  under  ether,  there  followed 
no  relief  (one  a  probably  malignant  ovarian  tumor,  the  other  was  later 
found  to  have  osteoarthritis  demonstrable  by  x-ray).  In  two  other 
cases  improvement  was  gradual  and  slow.  In  some  cases  treated  in 
this  manner  there  was  noted  a  soft  tearing  (like  tearing  tissue  paper), 
in  others  there  was  felt  a  sudden  thud  and  a  giving  away  of  something. 

These  phenomena  were  usually  followed  by  considerable  local  sore- 
ness, swelling,  and  ecchymosis  in  the  posterior  thigh.  In  two  cas'.?s 
there  was  a  sudden  recurrence  of  the  acute  symptoms  after  a  period 
of  complete  relief.  In  such  instances  the  recurrence  was  brought  on 
by  a  slight  movement  in  leaning  forward. 

In  most  cases  the  improvement  was  very  slow  and  gradual.  In  about 
25%  of  all  cases  the  patients  were  lost  from  observation  after  a  short 
time  and  the  improvement,  therefore,  not  known.  In  ten,  there  was 
noted  no  improvement. 

Death  occurred  in  six  cases,  four  were  from .  malignant  growths, 
one  was  from  tuberculous  meningitis  and  one  was  from  degenerative 
spinal  cord  lesion. 

COMMENT. 

The  proportion  of  males  to  females  is  nearly  two  to  one  (Table  No.  4). 

This  is  probably  not  a  true  proportion,  because,  as  stated  before,  there 

were  examined  many  women  (belonging  mostly  to  Group  I)   of  whom 

no  records  are  available.* 

♦These  comprise  a  series  of  cases,  occurring  in  the  practice  of  a  gynecologist, 
in  which  the  pelvic  examination  was  negative. 


LOWER  BACK  PAIN 


369 


• 

o 

• 

| 

• 

to 

P*  • 

it 

i 

■ 

1 

| 

H 

o 

E  S 

if 

•  © 

>-    * 

u 
o 

M 

9 

a 

u  £ 
0  g> 

5-3 

• 

M 
Vi 
4 

• 

8 

*S 

d 

■ 

a 
I 

3 

GROUP 

31 

-H     -t-» 

4   ® 
pj  x> 

55 

i 

o 

I 

16 

9 

6 

4 

4 

18 

II 

57 

11 

14 

13 

2 

41 

III 

3 

1 

0 

3 

U 

6 

TOTAL    -a 

76 

21 

20 

20 

6 

65 

i 

Table  No.  J. 

The  cases  were  separated  into  groups  because  of  symptoms  only. 
Cases  in  Group  II  were  generally  more  severe  than  those  in  Group  I 
In  this  series  the  males  predominate  in  all  groups.  The  greater  chron- 
icity  in  Group  I  is  probably  due  to  the  relatively  greater  number  of 
Traumatic  cases  in  Group  II  and  because  the  cases  in  this  latter  group 
were  of  a  more  severe  character,  and  therefore  sought  relief  earlier. 
The  physical  characteristics  of  cases  as  noted  in  Table  No.  5  show  a 
very  close  parallel  between  Groups  I  and  II.  There  is  nothing  note- 
worthy in  the  character  of  the  pain  (Table  No.  2).  It  runs  fairly  par- 
allel in  Groups  I  and  II.  In  most  cases  it  is  worse  on  movement.  Re- 
lative to  the  location  of  pain  (Table  No.  1),  it  will  be  noted  it  lies  in 
the  area  occupied  by  the  erector  spinae  group  of  muscles  (origin,  body, 
and  insertion),  196  times  in  220.  The  most  frequent  site  is  the  sacro- 
iliac area,  especially  in  Group  II.  Study  of  the  cases  here  given  shows 
that  there  is  nothing  typical  in  the  site  of  the  pain,  which  would  en- 
able one  to  locate  a  lesion  accurately.  At  times  it  was  definitely  shown 
that  the  lesion  was  at  some  other  point. 

It  is  interesting  to  note  the  sequence  of  the  pain  as  given  in  Cases 
1  to  13.  These  show  the  successive  involvement  of  groups  of  muscles 
until  several  groups  of  one  system  of  muscles  have  been  involved.  Very 
interesting  in  this  connection  is  Case  8,  in  which  the  pain  and  limita- 
tion of  movement  extended  upward,  and  not  downward,  as  occurred 
in  all  other  cases.  This  woman,  after  sustaining  an  injury  to  a  foot 
in  the  forenoon,  walked  much  while  shopping  all  the  afternoon,  and 


170 


J.   R.   KUTH 


GROUP 

Lim.  of  movt 
in  lower 
back. 

.  Lim.  of 
str.  leg 
raising. 

Flat  back,  1 
backward  curv. 
lower  back. 

Body  List. 

No 

Yes 

No 

Yes 

No 

Yes 

Uo 

Yes 

I 

39 

15 

42 

7 

43 

3 

42 

2* 

II 

38 

84 

35 

93 

61 

39 

72 

39** 

III 

5 

7 

9 

2 

8 

5 

11 

3 

TOTAL 

82 

106 

86 

102 

112 

47 

125 

44  . 

*  Once  toward  the  painful  side. 

**  4  times  toward  the  painful  side. 
Table  No.  3. 

felt  the  pain  in  the  posterior  thigh  come  on  ten  hours  after  the  pri- 
mary injury. 

In  Table  No.  3  it  will  be  noted  that  there  is  a  definite  parallel  be- 
tween cases  having  limitation  of  lower  back  movement  and  those  having 
limitation  of  straight  leg  raising,  and  between  these  cases  and  those 
with  posterior  thigh  pains  (Group  II).  The  occurrence  of  flat  back 
and  backward  curve,  as  well  as  of  the  list  of  the  body  to  one  side,  is 
characteristic  of  Group  II.  All  positive  findings  in  Table  No.  3  are 
manifestations  of  muscle  spasm  or  of  muscle  shortening.  They  were 
present  under  varying  conditions  and  their  presence  gave  no  clue  to 
the  underlying  cause  (e.g.  traumatic,  infectious,  static). 

The  association  of  posterior  thigh  pains  with  low  back  pains  is  welt 
known.  These  pains  are  often  spoken  of  as  being  sciatic  in  origin.  The 
list  of  the  body  to  one  side  which  is  frequently  found  in  these  cases 
has  been  called  sciatic  scoliosis,  the  list  or  "scoliosis"  being  consid- 
ered secondary  to  the  sciatic  pain. 

The  posterior  thigh  pains,  while  very  suggestive  of  a  sciatic  nerve 
distribution,  in  nearly  all  cases,  give  positive  evidence  of  sciatic  origin 
in  only  very  few  cases — (Case  12  and  four  others  briefly  noted  on  page 
360  //) .  Of  these  cases,  Case  12  is  the  only  one  not  associated  with  a  se- 
vere traumatic  lesion  of  the  lower  spine  or  with  a  primary  nerve  or 
cord  lesion.  A  few  other  cases  complained  of  paresthesia  on  the  outer  as- 
pect of  a  leg  or  foot,  but  in  these  there  was  no  objective  sign  of  nerve 
lesion.  In  only  thirteen  cases  of  the  whole  series  in  which  these  pos- 
terior thigh  pains  were  present,  was  an  absence  of  muscle  spasm  noted. 


LOWER  BACK  PAIN 


371 


Males 

Female  8 

Duration 
i   to  date 

Previous 
attacks 

Trauma 

Isaoolated  with 
childbirth. 

GROUP 

res  I.'o 

Yes 

J.'o 

I 

36 

23 

27  mos. 
(53  cases) 

18   31 

15 

27 

5 

II 

96 

44 

ll£  Q08. 

(121  cases) 

57-   63 

55 

44 

0 

III 

.  (9)* 

(5)»» 
3 

10  mos. 

5    6 

5 

6 

1 

6 

TOTAL 

138 

70 

80  100 

75 

77 

6 

*  3  counted   twice. 
••  2  counted  twice 


Table  $fo.  4. 


Bilateral  leg  pains  in  cases  with  osteoarthritis  were  undoubtedly  of 
nerve  root  origin.    Case  22  may  have  been  one  of  cord  lesion. 

In  the  greatest  number  of  cases  these  leg  pains  followed  after  all 
other  symptoms  (muscle  spasm)  had  put  in  their  appearance,  and  were 
relieved  as  these  other  symptoms  disappeared.  In  many  cases  the  ham- 
string muscles  were  often  noted  as  being  tender  on  palpation. 


GROUP 

i 

*»  o 
d  u 

&  *» 

CO 

U   T3 

&   3 

M 

u  a 

o  >-« 
d 

r-t  O 

d  d 
En  S 

4-> 

« 

© 

> 
o 

£ 

10 

5 

d 
d 

EH 

■ 
p 

3 

a 

r-l 
r-t 
1 
E-i 

I 

21 

15 

2 

13 

II 

66 

35 

5 

12 

III 

6 

5 

0 

2 

TOTAL 

93 

55 

7 

27 

TABLE  NO.   5. 


372 


J.   R.  KUTH 


GROUP 

o 
id 

CO 

o 

id 
u 

a 
P» 
o 

+» 

o 
a> 

3 

o 

rH 
O 

o 

! 

a 
o 

i 

55 

|j 

rH    O 

a  u 

S4  <)0 

■ 
i 
pi 

CO 

■ 
o 

o 

u 

0) 

S 

■4-> 
-r«>» 

is 

I 

26 

z 

11 

2 

0 

1 

1 

0 

II 

30 

24 

20 

7 

5 

5 

4 

1 

l 

III 

6* 
4 

1 

2 

0 

2* 

0 

0 

0 

TOTAL 

60 

27 

33 

9 

5 

5         J        5 

^ 

l 

2  counted  twice. 


Table  No.  6. 


Reference  to  Table  No.  6  shows  that  in  one  hundred  and  forty-seven 
eases  in  which  the  records  were  complete,  over  80%  are  classed  as  static, 
traumatic,  or  infectious  in  origin.  Of  these,  over  one-half  are  classed  as 
static,  and  the  other  half  nearly  evenly  divided  between  the  traumatic 
and  the  infectious. 

The  static  group,  in  the  writer's  opinion,  is  probably  greater  than 
here  stated.  Thus,  most  cases  classed  as  gynecologic  and  obstetric  are 
really  static  in  origin  and  nature.  In  a  severe  case,  manifesting  all 
the  typical  symptoms  that  have  been  discussed,  one  may  elicit  a  history 
somewhat  as  follows:  From  the  sixth  month  of  pregnancy  on,  a  more 
or  less  gradual  but  insistent  low  backache  followed  by  posterior  thigh 
and  leg  pains;  parturition  follows  normally  and  the  pains  improve 
and  disappear;  two  weeks  later  the  new  mother  leaves  her  bed,  and 
after  a  further  two  weeks  the  nurse  is  discharged  and  the  mother  takes 
over  the  care  of  the  baby  with  all  the  bending  over  and  stooping  for- 
ward which  such  care  demands.  The  symptoms  all  gradually  develop 
anew.  During  the  latter  months  of  pregnancy  the  posterior  back  mus- 
culature is  overtaxed  by  the  rapidly  increasing  anterior  load,  and  is 
not  functionally  fit  to  cope  with  the  new  demands  made  upon  it.  In 
Case  14  the  previous  hyperthyroidism  probably  played  an  important 
role  in  weakening  musculature  to  a  considerable  degree.  The  term 
"insufiicientia  vertebrae' '  is  very  apt.  It  is  probable  that  not  a  few 
individuals  go  through  life  handicapped  by  this  condition.  About 
44%  of  all  cases  give  a  history  of  previous  attacks   (Table  No.  4). 


LOWER  BACK  PAIN  373 

While  trauma  was  given  by  the  patient  as  a  cause  in  about  one-half 
of  the  cases,  it  was  considered  to  be  the  chief  cause  in  a  little  over  18% 
(Table  No.  6).  Nearly  all  cases  belonged  to  Group  II.  It  is  possible, 
as  Lovett  suggested,  that  cases  following  very  slight  trauma  may  be 
really  arthritic.  In  the  absence  of  positive  x-ray  evidence,  there  is 
nothing  to  indicate  the  exact  site  of  injury,  or  the  tissues  injured. 

In  this  series  there  was  no  case  which  the  writer  felt  was  due  to 
sacro-iliac  relaxation  or  subluxation.  If,  following  muscle  insufficiency 
(as  in  weak  foot),  the  strain  is  thrown  upon  ligamentous  structures, 
there  would  follow  a  strain  not  only  in  the  sacro-iliac  structures,  but 
also  in  the  structures  of  other  joints  equally  involved.  It  is  probable 
that  this  occurs  frequently.     (Insufficientia  vertebrae.) 

The  frequency  of  anomalies  of  the  5th  lumbar  transverse  processes 
has  been  variously  estimated.  Thus,  Nove-Josserand  and  Rendu1  in 
four  hundred  cases  in  which  x-rays  were  made  at  random,  found  such 
anomalies  present  in  7  or  1.7%.  In  eight  hundred  cases  with  lumbar 
pains,  they  believe  the  symptoms  might  be  attributed  to  the  anomaly  in 
twenty-two,  or  2.7%.  In  the  two  hundred  and  eight  cases  of  this  series 
they  were  present  in  more  than  4.3%. 

In  the  nine  cases  (25  to  33)  there  is  none,  except  possibly  Case  26, 
in  which  the  symptoms  can,  with  any  degree  of  probability,  be  at- 
tributed directly  to  such  an  abnormality.  The  symptoms  in  Case  32 
certainly  had  nothing  to  do  with  the  anomaly  which  existed. 

Cases  in  which  the  arthritic  manifestations  are  slight,  are  difficult 
of  detection.  It  is  probable  that  these  cases  are  the  ones  most  chronic 
and  most  subject  to  recurring  attacks. 

Cases  in  which  lues  was  suspected  were  uninfluenced  by  anti-luetic 
treatment,  and  were  undoubtedly  of  other  etiology.  Case  22  may  have 
been  one  of  beginning  spinal  cord  lues.  Aside  from  the  very  meagre 
findings  in  the  spinal